Psychotherapy integration is defined as an approach to psychotherapy that includes a variety of attempts to look beyond the confines of single-school approaches in order to see what can be learned from other perspectives. It is characterized by an openness to various ways of integrating diverse theories and techniques. Psychotherapy integration can be differentiated from an eclectic approach in that an eclectic approach is one in which a therapist chooses interventions because they work (the therapist relies solely on supposed efficacy) without looking for a theoretical basis for using the technique. The rationale of efficacy is reasonable, but it often is based on imprecise memories of past experience without any reference to theory or research data. In contrast, psychotherapy integration attends to the relationship between theory and technique.
The term psychotherapy integration has been used in several different ways. The term has been applied to a Common Factors approach to understanding psychotherapy, to Assimilative Integration, to Technical Integration, and to Theoretical Integration.
Common Factors refers to aspects of psychotherapy that are present in most, if not all, approaches to therapy. These techniques cut across all theoretical lines and are present in all psychotherapeutic activities. Because the techniques are common to all approaches to psychotherapy, the name Common Factors has been given to this variety of psychotherapy integration. There is no standard list of common factors, but if a list were to be constructed, it surely would include:
- a therapeutic alliance established between the patient and the therapist
- exposure of the patient to prior difficulties, either in imagination or in reality
- a new corrective emotional experience that allows the patient to experience past problems in new and more benign ways
- expectations by both the therapist and the patient that positive change will result from the treatment
- therapist qualities, such as attention, empathy, and positive regard, that are facilitative of change in treatment
- the provision by the therapist to the patient of a reason for the problems that are being experienced
No matter what kind of therapy is practiced, each of these common factors is present. It is difficult to imagine a treatment that does not begin with the establishment of a constructive and positive therapeutic alliance. The therapist and the patient agree to work together and they both feel committed to a process of change occurring in the patient. Within every approach to treatment, the second of the common factors, the exposure of the patient to prior difficulties, is present. In some instances the exposure is in vivo (occurs in real life), and the patient will be asked directly to confront the source of the difficulties. In many cases, the exposure is verbal and in imagination. However, in every case, the patient must express those difficulties in some manner and, by doing so, re-experiences those difficulties through this exposure. In successful treatment, the exposure usually is followed by a new corrective emotional experience. The corrective emotional experience refers to a situation in which an old difficulty is re-experienced in a new and more positive way. As the patient re-experiences the problem in a new way, that problem can be mastered and the patient can move on to a more successful adjustment.
Having established a therapeutic alliance, and being exposed to the problem in a new and more positive context, both the therapist and the patient always expect positive change to occur. This faith and hope is a common factor that is an integral part of successful therapy. Without this hope and expectation of change, it is unlikely that the therapist can do anything that will be useful, and if the patient does not expect to change, it is unlikely that he or she will experience any positive benefit from the treatment. The therapist must possess some essential qualities, such as paying attention to the patient, being empathic with the patient, and making his positive regard for the patient clear in the relationship. Finally, the patient must be provided with a credible reason for the problems that he or she is undergoing. This reason is based in the therapist's theory of personality and change. The same patient going to different therapists may be given different reasons for the same problem. It is interesting to speculate as to whether the reason must be an accurate one or whether it is sufficient that it be credible to the patient and not remarkably at variance with reality. As long as the reason is credible and the patient has a way of understanding what previously had been incomprehensible, that may be sufficient for change to occur.
The second major approach to psychotherapy integration is Assimilative Integration. Assimilative Integration is an approach in which the therapist has a commitment to one theoretical approach but also is willing to use techniques from other therapeutic approaches.
As an example, a therapist may try to understand patients in terms of psychodynamic theory, because he or she finds this most helpful in understanding what is going on in the course of the treatment. However, the therapist may also recognize that there are techniques that are not suggested by psychodynamic theory that work very well, and these may then be used in the treatment plan. The psychodynamic therapist can occasionally use cognitive-behavioral techniques such as homework, and may occasionally use humanistic approaches, such as a two-chair technique, but always retains a consistent psychodynamic understanding. The treatment can take place in a way that is beneficial to the patient and is not bound by the restrictions of the therapist's favorite way of intervening. The patient may not be aware that integration is taking place, but he or she does feel that a consistent approach is being maintained. Most patients are not familiar with theory, don't realize that different techniques are generated by different theoretical understandings, and only are concerned with whether or not the treatment is helpful.
Inherent in psychotherapy integration is the conviction that there is no one approach to therapy that is suitable to every patient. Both in single-school approaches and in psychotherapy integration, the treatment must be suitable for the individual patient. In making the treatment suitable for the individual patient, the therapist must understand the patient, and that establishes a place for theory. Assimilative Integration is particularly useful in that theory helps in the understanding of the needs of the patient, but then several different approaches to technique can help to design a treatment that fits that particular understanding. The treatment plan then must undergo continuous revision as the understanding of the patient gets fuller and deeper over the course of the treatment.
Technical Eclecticism is a variation of Assimilative Integration and is most common among those practitioners who refer to themselves as eclectic. In Technical Eclecticism, the same diversity of techniques is displayed as in Assimilative Integration, but there is no unifying theoretical understanding that underlies the approach. Rather, the therapist relies on previous experience and on knowledge of the theoretical and research literature to choose interventions that are appropriate for the patient.
The obvious similarity between Assimilative Integration and Technical Eclecticism is that both rely on a wide variety of therapeutic techniques, focusing on the welfare of the patient rather than on allegiance to any particular school of psychotherapy. The major difference between the two is that Assimilative Integration is bound by a unifying theoretical understanding whereas Technical Eclecticism is free of theory and relies on the experience of the therapist to determine the appropriate interventions.
The fourth approach to psychotherapy integration is called Theoretical Integration. This is the most difficult level at which to achieve integration because it requires integrating theoretical concepts from different approaches, and these approaches may differ in their fundamental philosophy about human behavior. Whereas Assimilative Integration begins with a single theory and brings together techniques from different approaches, Theoretical Integration tries to bring together those theoretical approaches themselves and then to develop what in physics is referred to as a "Grand Unified Theory." Neither psychotherapists nor physicists have been successful to date in producing a Grand Unified Theory. It is difficult to imagine a theory that really can combine an approach that has one philosophical understanding with another approach that has a different philosophical understanding. For example, a psychodynamic approach believes that an early difficulty leads to a pattern of behavior that is repetitive, destructive, and nearly impossible to resolve. In contrast, behavior therapy sees problems as much more amenable to change. This difference may represent a basic incompatibility between the two theories. Therefore, theoretical integration would be faced with the task of integrating a theory about the stability of behavior with a theory about the ready change ability of behavior, and unless this obstacle can be overcome, Theoretical Integration will not be achieved.
In any case, the general point in three of these approaches, Common Factors, Assimilative Integration, and Theoretical Integration, is that there is a clear value to the role of theory in psychotherapy integration, whether the theory deals with the way integration works (Theoretical Integration), the framework that governs the choice of interventions (Assimilative Integration), or the organizing principle for understanding the Common Factors that are present in all psychotherapy. The fourth approach, Technical Eclecticism, is not concerned with theory, but does view the benefit of the patient to be of more significance than the adherence to any single theory.
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Stricker, G., and J. Gold. (Eds.) Comprehensive handbook of psychotherapy integration. New York: Plenum, 1993.
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Stricker, G., and J. R. Gold. "Psychotherapy integration: An assimilative, psychodynamic approach." Clinical Psychology: Science and Practice 3 (1996): 47-58.
Weinberger, J. "Common factors aren't so common: The common factors dilemma." Clinical Psychology: Science and Practice 2 (1995): 45-69.
George Stricker, Ph.D.