Ch. 9 – Integrative Approaches to Psychotherapy

1. Ch. 9 – Integrative Approaches to Psychotherapy PSYC E-2488 12/10/07

2. Exercise (15 minutes) • Divide into groups of 3-4 • Pick one member to be the patient • Pick out a presenting problem • Take an integrative model, e.g., theoretical assimilative or common factors/technical eclecticism • Present the patient and approach

3. Historical Background • 1. An Introduction to Integrative Approaches to Psychotherapy: - A product of integrating constructs and interventions from 2+ traditional therapies; - Hope is an increase in efficacy; • 2. Integrative Psychotherapy and Psychotherapy Integration: A Distinction - A clinical, conceptual, and philosophical openness to guide integration rather than another sectarian school of therapy; • 3. Historical Antecedents to Contemporary Psychotherapy Integration - French (1933) Psychoanalysis should integrate Pavlov’s work; - Rosenzweig (1936) Many schools have common factors; - Dollard and Miller (1950) integrated psychoanalytic ideas about UCS motivation and conflict, with learning theory work by Hull, Spence, Mowrer, Tolman; - Alexander and French’s (1946) concept of the correctional emotional experience; - 1960s integration of systems, primarily behavioral and psychoanalytic; - Beck et al.,(1979) - Marmor (1971) and Feather & Rhodes (1973) – Eclectic approaches. - Wachtel (1977) Psychoanalysis and Behavior Therapy: Toward an Integration. - SEPI founded in the 1980s and 1st Journal of Eclectic and Integrative Psychotherapy, replaced by Journal of Psychotherapy Integration in 1991 and two handbooks by Norcross and Goldfried and Stricker and Gold.

4. Historical Background – con’d. • 3. The Modes of Psychotherapy Integration: - Technical Eclecticism: Most clinical, least theoretical. Broad and comprehensive assessment followed by strategies and techniques from two or more therapies to describe and address the interconnections between cognitive, behavioral, emotional, and interpersonal aspects of patient. Lazarus’ Multi-Modal Therapy (BASIC ID) is best example. - Common Factors Approach to Integration: Began with Rosenzweig (1936) and Jerome Frank’s (1961). Messer & Wampold (2002) studies and meta- analysis conclude common factors account for most of critical therapeutic effect. Goal of treatment is to maximize patient’s exposure to unique combination of factors (insight, exposure, and provision of new experience) - Theoretical Integration: Most complex, sophisticated and difficult. Integrates various personality theories, models of psychopathology, and various mechanisms of psychological change. Subtle interactions between levels of behavior, interpersonal; motivational, cognitive, affective, internal states and processes. Wachtel’s cyclical psychoanalysis is first good example.

5. Historical Background – con’d. • Assimilative Integration: Suggested by Messer (1992) and refers to the observation that actions are defined and contained by the interpersonal, historical, and physical context in which they occur. - Therapeutic interventions are highly complex interpersonal actions that mean different things to different people, especially when one considers that techniques are being assimilated in the context of other models.

6. The Concept of Personality • 1. “Attention to personality is omitted from most integrative models that are based on common factors integration or on technical eclecticism.” • 2. “Personality is a much more important concept in the integrative psychotherapies that are based on theoretical or assimilative integration.” • 3. “Integrative theories substitute circular conceptualizations of causation for the linear views of causation that are typical of traditional personality theories.” - They guide structures and other features that need to be influenced by psychotherapy; - They integrate facts and processes neglected by traditional theories.

7. Psychological Health and Psychopathology • Few integrative theories have specific comprehensive models of health, though many have spoken about the “dis-ease model”. • Generally psychological health is seen as adaptive freedom from constraints on choice and definition of goals; successfully choosing and modifying goals based on individual and social adaptive benefit; actively developing and seeking out goals; learning from self-generated feedback; without intrapersonal or interpersonal interference. • Focus of model is on development(al) and maintenance of psychological and environmental factors that inhibit responsiveness and foster redundancy in functioning.

8. Psychological Health and Pathology – con’d. • Childhood and adolescence lay down the foundations of perception, thinking and motivation that are at the heart of psychopathology. • Painful interactions are internalized and form the cognitive and emotional representational system. • These negative representational systems feedback loops form the basis for CS/UCS predictions of psychological danger and lead to defensive and self-defeating feedback loops. • Such linked sequences of motivation, conflict, emotion, cognition, conflict and interpersonal behavior maintain underlying meaning structures (schemata, object representations, narratives reflected in the theories) • Diagnostic systems vary: See BASIC ID, Trans-Theoretical Model (Prochaska & DiClemente, 2002), DSMs

9. The Process of Clinical Assessment • Based on methods that make up the particular therapies. • Example: Assimilative Psychodynamic Psychotherapy – Focus on conflict, character, resistance, object representations, etc. Assessment is ongoing and involves all levels of processing. Parameters of assessment include the possibility that parameters of technique may be borrowed from other systems to augment the base system. • Unit of assessment is the individual. Forms of assessment extend beyond base therapy, include cultural and SES factors, and +/-s. • Few such systems rely heavily on tests or formal diagnostic categories.

10. The Practice of Therapy • Basic Structure of Therapy - Generally variable (as components in base are heterogeneous/variable); - Psychodynamic tend to be longer and met 1+/X per week but there are exceptions (see Malan and Basch); CBT and Humanistic-Experiential shorter and meet less frequently; - Sessions 45-60 minutes; - Trend in recent years has been toward shorter/time-limited models; • Goal Settings - Nota Bene: Integrative models allow goals to be established at any level; - Quite variable with psychodynamic/humanistic-experiential goals more broadly defined (e.g., meaning, representational structures, character, open to new integration and symbolization of experience; symptom/function focused models are focused on symptom reduction/control/elimination - Goal setting is collaborative (based on core need for trust and respect for experience); - Therapist-driven are most likely short-term and patient-driven more psychodynamic/H-E

11. The Practice of Therapy – con’d. • Process Aspects of Therapy: - Generally any accepted form of intervention is a potential tool in the integrative therapy armamentarium; - Theory/Needs is assimilative-theoretical model; Clinical Assessment/Process Matching is technical eclectic and common factors approach; - Homework, cognitive re-structuring, interpretation; exposure techniques; empty-chair, etc., are all options for incorporation into treatment; - Critical question is when to use what and when/how to switch orientations from one model to another (use example of tween using PR and the chaotic emergence of dynamically colored hypno-gogic imagery; and rural immigrant Hispanic patient seeing deceased relative); framing makes critical difference; - Such switches in theoretical-assimilative models usually guided by therapist’s here-and-now observation of the process; often rationale is when one approach is judged not to be working; - Concrete, active, and solution driven approaches are often used when patient is fragile and less psychologically sophisticated (see old psychoanalytic idea of parameters of technique and supportive-re-educational-re-constructive categorizations of Wolberg); - Resistance is understood differently by models (e.g., fear of internal state vs. contributions of each to dyad); how worked with is determined by how it is understood;

12. Curative Factors or Mechanisms of Change • Integrative models incorporate as many change factors as are possible, broadening the likelihood that patient will be exposed to as much that is therapeutic as is possible; - Me: how this is understood is complex and depends on understanding both levels and contexts; • Emphasis is determined by the model; • “Many roads to Rome” (see example of different schools of yoga and modes of meditative experience); • Client/patient factors important (JAVIS) and personality and therapeutic relationship emerge in common factors research; • Little about approach is unique; • Uniqueness rests in the breadth of the process, rather than any single aspect;

13. Treatment Applicability and Ethical Considerations • Uniquely suited to a diverse group of patients and problems; • Patient’s issues guides the therapy and emphasizes the uniqueness of the approach; • See McCullough’s CBASP , Chambless et al., and Linehan’s DBT as examples of integrative approaches applied to frequent and refractory disorders/problems; • The problem, integrative model, and patient’s goals determine the limits of the treatment; • Example: Iris Fodor’s integration of Feminist, CBT and Gestalt Therapies

14. Research Support • Models with support include Linehan’s DBT, Beutler’s Prescriptive Therapy, Prochaska and DiClemente’s Trans-theoretical Therapy, Klerman’s Interpersonal Therapy for Depression, Greenberg’s Process-experiential therapy, McCullough’s CBSP