Psychotherapy Integration Research Paper

1. The Historical Context

The practice and training of psychotherapy has been historically organized around distinct and competing theoretical orientations, such as psychoanalysis, humanistic persuasions, behavior therapies, and family systems models. In the infancy of the field, therapy systems, like battling siblings, competed for attention and affection in a ‘dogma eat dogma’ environment. Clinicians traditionally operated from within their own particular theoretical frameworks, often to the point of being blind to alternative conceptualizations and potentially superior interventions.

Although this ‘ideological cold war’ may have been a necessary developmental stage for the discipline, psychotherapy since the mid-1980s has witnessed a decline in ideological struggle and the stirrings of rapprochement. The theoretical substrate of each system is undergoing intensive reappraisal, as psychotherapists acknowledge the inadequacies of any one system and the potential value of others. Distinctive of the present era is the tolerance for and assimilation of formulations that were once viewed as deviant, even heretical.

2. Integration Defined

As the field of psychotherapy has matured, integration has emerged as a dominating force. The dramatic growth of interest in psychotherapy integration during the 1990s has crystallized into a formal movement, or more dramatically, a ‘metamorphosis’ in mental health (London 1988).

Psychotherapy integration is characterized by a dissatisfaction with single-school approaches and a concomitant desire to look across and beyond school boundaries to see what can be learned—and how patients can benefit—from other ways of thinking about psychotherapy and behavior change. The ultimate outcome of doing so, not yet fully realized, is to enhance the effectiveness, efficiency, and applicability of psychotherapy.

Any number of indicators attest to the unprecedented interest in psychotherapy integration. Eclecticism or the increasingly favored term ‘integration’ is the modal theoretical orientation of English-speaking psychotherapists and is gradually increasing in prevalence throughout Europe. Leading psychotherapy textbooks increasingly identify their theoretical persuasion as integrative, and an integrative chapter is routinely included in compendia of treatment approaches. Handbooks on psychotherapy integration have appeared throughout the world, including several in Europe and two in the USA (Norcross and Goldfried 1992, Stricker and Gold 1993).

As with many relatively new movements, integration has been plagued by confusing vocabulary and multiple goals. Various labels are applied to the movement—convergence, rapprochement, treatment selection, combined therapies, prescriptionism, differential therapeutics, and eclecticism, among them—but psychotherapy integration has emerged as the over- arching consensual term. Similarly, a plethora of integrations have been advanced: combining different therapy formats/modalities (such as individual and family therapy); blending self-help and psychotherapy; integrating pharmacotherapy and psychotherapy; synthesizing research and practice; integrating Occidental and/oriental perspectives; and so on. This research paper confines itself to the traditional and primary meaning of integration as the blending of diverse theoretical orientations or schools of psychotherapy.

3. Reasons For Recent Growth

Integration as a point of view has probably existed as long as philosophy and psychotherapy. In philosophy, the third-century biographer, Diogenes Laertius, referred to an eclectic school that flourished in Alexandria in the second century AD. In psychotherapy, Freud consciously struggled with the selection and integration of diverse methods.

Formal ideas on synthesizing the psychotherapies appeared in the literature as early as the 1930s (see Goldfried and Newman 1992 for a history), but it is only within the latter decade of the twentieth century that integration has developed into a clearly delineated area of interest. A number of interacting, mutually reinforcing motives have fostered the recent growth of integration (Prochaska and Norcross 1999):

(a) Proliferation of therapies. The field of psychotherapy has been staggered by over-choice and fragmented by future shock. Which of 400 plus therapies on the market should be studied, taught, or bought? This might also be called the Exhaustion Theory of Integration: the cynical but accurate observation that peace among warring schools is the last resort.

(b) Inadequacy of single theories for all patients and problems. No single system has cornered the market on utility. Underlying the ecumenical spirit is the stark realization that narrow conceptual positions do not begin to explain the evidence in psychotherapy. Clinical realities have come to demand a more flexible, if not integrative, perspective.

(c) Ascendancy of short-term, problem-focused treatments. The brief, problem focus of psychotherapy, particularly in the US, has brought formerly different therapies closer together. Integration responds to the pragmatic time-limited injunction of ‘which therapy works better—and quicker—for this patient with this problem.’

(d) Opportunities to observe and experiment with various treatments. The introduction of treatment manuals, the availability of psychotherapy videotapes, and the establishment of specialized clinics for the treatment of specific disorders have all afforded exposure to other theories and therapies, and stimulated some practitioners to consider other orientations more seriously.

(e) Recognition that commonalties contribute heavily to outcome. The equivalent outcomes found among the empirically evaluated psychotherapies in many studies has led to increased emphasis on factors common to successful cases. Therapeutic success can best be predicted by patient characteristics and the therapeutic relationship, both transtheoretical features of psychotherapy, while only 15 percent of outcome variance is accounted for by specific techniques (Lambert 1992).

(f) Identification of specific treatments for particular disorders. While commonalties contribute heavily to therapeutic success, controlled research has identified several treatments of choice for particular disorders; for example, cognitive therapy and interpersonal therapy for depression, behavior therapy for specific phobias and childhood aggression, and exposure for PTSD. This has led to selective prescription of different treatments, and combinations of treatments, to individual patient needs.

(g) Development of a professional network for integration. Reflecting and engendering the burgeoning field have been the establishment of interdisciplinary psychotherapy organizations devoted to integration, notably the Society for the Exploration of Psychotherapy Integration (SEPI).

4. Pathways To Integration

There are numerous pathways toward the integration of the psychotherapies. The four most popular routes are technical eclecticism, theoretical integration, change processes, and common factors. All four attempt to look beyond the confines of single theories, but they do so in rather different ways and at different levels.

Technical eclecticism is the least theoretical of the four, but should not be construed as either atheoretical or antitheoretical (Lazarus et al. 1992). Eclecticism seeks to improve our ability to select the best treatment based primarily on the evidence of what has worked for others in the past with similar problems and similar characteristics. Proponents of technical eclecticism use procedures drawn from different sources without necessarily subscribing to the theories that spawned them.

In theoretical integration, two or more therapies are synthesized in the hope that the result will be better than the constituent therapies alone. This entails a commitment, as the name implies, to a conceptual or theoretical creation beyond a technical blend of methods. The various proposals to integrate psychoanalytic and behavioral theories, such as the influential work of Wachtel (1977), illustrate this path, as do the grander schemes to meld the major systems of psychotherapy, such as the transtheoretical approach of Prochaska and DiClemente (1984).

A level of abstraction down from theory is that of the change process or change strategy. This intermediate level of abstraction between global theory and specific techniques is a heuristic that implicitly guides the efforts of experienced therapists and that is increasingly guiding the teaching of psychotherapy. Instead of smushing theories fraught with epistemological incompatibilities on the one hand, or melding techniques without an overarching theory on the other, proponents of change processes suggest this intermediate level as the ideal for conceptualizing effective behavior change (Goldfried 1980).

The fourth pathway to psychotherapy integration is the common factors approach, which seeks to determine the core ingredients that different therapies share in common, with the eventual goal of creating more parsimonious and efficacious treatments based on those commonalties. This search is predicated on the belief that commonalties are more important in accounting for therapy outcome than the unique factors that differentiate among them, as eloquently maintained by Frank (1973). Literature reviews have discovered that the most consensual commonalties across theories are the development of a therapeutic alliance, opportunity for catharsis, acquisition, and practice of new behaviors, and clients’ positive expectancies (Grencavage and Norcross 1990).

Integration, as is now clear, comes in many guises and manifestations. It is neither a monolithic entity nor a single operationalized system; to refer to the integrative approach is simply a fallacy. At the same time, these multiple integrative pathways are not mutually exclusive. No technical eclectic can totally disregard theory, and no theoretical integrationist can ignore technique. Without some commonalties among different schools of therapy, theoretical integration would be impossible. And even the most ardent proponent of common factors cannot practice ‘nonspecifically’ or ‘commonly’; specific methods must be applied.

5. Future Directions

Psychotherapy integration is a vibrant international movement that has begun to make encouraging contributions to the field. Transtheoretical dialogue and cross-fertilization fostered by the integrative spirit have produced new ways of thinking about psychotherapy and researching behavior change. This closing section outlines five probable directions of the movement.

First and foremost, psychotherapy integration, in some guise, will likely emerge as the psychotherapeutic Zeitgeist. A dispassionate panel of psychotherapy experts, for example, portend its escalating popularity. Indeed, integrative and eclectic therapies were two of the four orientations (along with cognitive therapy and family systems therapy) predicted to expand the most in the future (Norcross and Freedheim 1992).

Second, integrationists will increasingly attend to the potential obstacles and tradeoffs of the process of integration. These will include establishing ambitious training programs and processes that ensure student competence in multiple theories and interventions, an unprecedented task in the history of psychotherapy; acknowledging the underlying epistemological and ontological differences embodied by the different theories of psychotherapies, which precludes facile integration; and addressing the language problem that confounds understanding of disparate jargons and, in some cases, leads to active avoidance of theoretical constructs.

A third direction for the integration movement is to document through outcome research the effectiveness of various integrative treatments. The empirical evidence supporting integration remains largely anecdotal and preliminary (Lambert 1992, Kazdin 1996, Wolfe and Goldfried 1988).

Fourth, psychotherapy integration will evolve past its initial step of widening therapeutic horizons and embracing multiple techniques and theories. The next step is to specifically know when and where to use these multiple techniques and theories in order to enhance therapeutic efficacy, a process also known as differential therapeutics or prescriptive matching. Psychotherapies will thus be matched to multiple client variables, including but not limited to diagnosis or problem.

In this matching process lies the fifth direction for psychotherapy integration: customizing the therapeutic relationship to the individual patient. While the historical emphasis has been on matching techniques to specific disorders, the integration movement is more and more committed to the prescriptive use of the therapeutic relationship. One way to conceptualize the issue, paralleling the notion of ‘treatment of choice’ in terms of techniques, is how clinicians determine the ‘relationship of choice’ in terms of interpersonal stances for individual clients. Again, this customization will occur on the basis of both diagnostic and cross-diagnostic considerations, such as the patient’s treatment goals, arousal level, coping style, personality traits, and stage of change (Beutler and Clarkin 1990).

In this manner, the psychotherapy integration movement promises to be instrumental in customizing research-informed treatment methods and therapeutic relationships to individual patients and, in so doing, enhance the effectiveness, applicability, and efficiency of psychotherapy.

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