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There are three types of integration practiced by psychotherapists: Common Factors, Assimilative Integration and Theoretical Integration. How do they differ from each other, and how does psychotherapy integration differ from an eclectic approach to therapy?
Psychotherapy integration can be defined as an attempt to look beyond the confines of single-school approaches to see what can be learned from other perspectives (Stricker, 1994). It is characterized by an openness to various ways of integrating diverse theories and techniques. A frequent question that arises is whether psychotherapy integration is simply a different name for the popular eclectic approach. An eclectic approach is one in which a therapist chooses interventions because they work. The therapist does not need a theoretical basis for, understanding of or unnecessary concern with the reason for using the technique other than efficacy. 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.
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 and to theoretical integration. I will try to develop each of these three approaches to psychotherapy integration more fully.
Common factors refers to aspects of psychotherapy that are present in most, if not all, approaches to therapy (Weinberger, 1995). This collection of common and effective techniques cuts across all theoretical lines and is present in all psychotherapeutic endeavors. Although there is no fixed established list of common factors, consensus suggests that such a list would include: a therapeutic alliance; exposure of the patient to prior difficulties followed by a new corrective emotional experience; expectations by the therapist and the patient for positive change; beneficial therapist qualities, such as attention, empathy and positive regard; and the provision to the patient of a rationale for problems.
No matter what kind of therapy is practiced, each of these elements is present. It is difficult to imagine a treatment that does not begin with the establishment of a therapeutic alliance. The therapist and the patient agree to work together and they feel jointly 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, as a patient may be asked directly to confront the source of the difficulties. In many cases, the exposure is verbal and in the imagination. However, in every case, the patient must talk about those difficulties or express them in some form and, by doing so, experiences those difficulties again. In order for the treatment to be successful, the exposure often 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 benign way. As the patient learns to re-experience the problem in a new way, they find it is possible to master that problem and move on to a higher level of adjustment.
When the exposure occurs within the therapeutic alliance, both the therapist and the patient expect positive change to occur. This faith and hope is a common factor that is part and parcel of the change process that occurs in successful therapy. Without this hope and expectation of change on the part of the therapist, it is unlikely that they can deliver an intervention in a way that will be useful. If the patient does not have some expectation for change, it is unlikely that they will be particularly responsive to that intervention. Moving to another common factor, there must be beneficial therapist qualities, such as paying attention to the patient, being empathic with the patient's circumstances and predicament, and demonstrating a positive regard for the patient.
Finally among the common factors, the patient is provided with a rationale for the problems that are being experienced. The rationale comes directly from the therapist's theory. The same patient going to a series of therapists may be provided with a series of rationales for the same problem. This leads to the very interesting question about whether the rationale that is provided must be an accurate one or whether it is sufficient that the rationale be credible to the patient. As long as credibility is sufficient and the patient now has a way of understanding what before had been incomprehensible, that may be sufficient and we need not get into the very thorny issue of ultimate truth.
The second major approach to psychotherapy integration is assimilative integration (Messer, 1992). A variant of this approach, technical eclecticism, is most common among many practitioners who refer to themselves as eclectic. Assimilative integration is an approach in which a solid grounding in one theoretical approach is accompanied by a willingness to incorporate techniques from other therapeutic approaches. In technical eclecticism, the same diversity of techniques is displayed, but without a binding theoretical understanding.
The theoretical position with which I am most comfortable is a psychodynamic one (Stricker and Gold, 1996). I try to understand my patients in terms of psychodynamic theory and find this very helpful in understanding what is going on in the course of the treatment. Nonetheless, I also find that there are many techniques not generated by psychodynamic theory, such as assigning homework to the patient, that work very well, and I would not hesitate to use them. Using occasional cognitive-behavioral interventions, such as homework, and occasional humanistic approaches, such as a two-chair technique, but retaining the constancy of psychodynamic understanding, treatment can proceed in a relatively seamless manner.
It is important that this seamless quality be present so that the patient's experience is of an easy flow of consistent treatment. With the seamless approach, the patient is not aware that integration is taking place, but rather feels a consistent approach is being maintained. After all, most patients are not familiar with theory and do not realize that different techniques are generated by different theoretical understandings. However, the therapist does, and it remains a very important challenge for theory to try to understand why any individual theory is limited--suggesting that the use of another technique can prove to be very helpful.
Inherent in this is the idea that there is not a one-size-fits-all therapy. Both in single-school approaches and in psychotherapy integration, therapy must be tailored to the individual patient, which requires an understanding of the patient, and that is the role of theory. Assimilative integration is particularly useful in that theory can help in understanding the needs of the patient, and then several different approaches to technique can help tailor-make a treatment that fits with that particular understanding. Of course, the treatment plan must undergo continuous revision as the understanding of the patient gets fuller and more profound over the course of the treatment.
Finally, there is theoretical integration. This is the most difficult level at which to achieve integration, for it requires bringing together theoretical concepts from disparate approaches, some of which may differ in their fundamental worldview. Whereas assimilative integration begins with a single theory and brings together techniques from different approaches, theoretical integration tries to bring together those approaches themselves and to develop what in physics is referred to as a "Grand Unified Theory." Physicists have not been successful in producing a Grand Unified Theory and, to date, to my knowledge, neither have psychotherapists. It is difficult to imagine a theory that really can combine two approaches that have different worldviews.
Messer and Winokur (1984) wrote very well about this problem and characterized a psychodynamic approach as tragic and a behavioral approach as comic. They saw these differences as representing a fundamental incompatibility at the level of theory. They used the words tragic and comic in a very specific manner, one that stems from literary criticism. They considered psychodynamic approaches tragic because such approaches focus on an early difficulty leading to a pattern of behavior that is repetitive, destructive and impossible to resolve. On the other hand, behavior therapy sees problems as much more amenable to change, and it is the happy ending to behavior therapy that is akin to the comic approach to literary theory.
The important point here is that theoretical integration somehow must reconcile a theory about the stability of behavior with a theory about the ready changeability of behavior. Unless this obstacle can be overcome, theoretical integration will not be achieved. It remains an elusive Holy Grail, one that probably will be enormously rewarding if found but not a level at which most practitioners can function at the present time.
In all of these approaches, there is a clear value to the role of theory in psychotherapy integration. This holds true whether the theory is the level at which integration works (theoretical integration), the framework that governs the choice of a breadth of technical interventions (assimilative integration) or the organizing principle for understanding the common factors that are present in all psychotherapy.
Those who are interested in learning more about psychotherapy integration can refer to two major texts (Norcross and Goldfried, 1992; Stricker and Gold, 1993). In addition, the Journal of Psychotherapy Integration regularly publishes relevant articles. It is available as a benefit of membership in the Society for the Exploration of Psychotherapy Integration (SEPI).
Messer SB (1992), A critical examination of belief structures in interpretive and eclectic psychotherapy. In: Handbook of Psychotherapy Integration, Norcross JC, Goldfried MR, eds. New York: Basic Books, pp130-168.
Messer SB, Winokur M (1984), Ways of knowing and visions of reality in psychoanalytic therapy and behavior therapy. In: Psychoanalytic Therapy and Behavioral Therapy: Is Integration Possible? Arkowitz H, Messer SB, eds. New York: Plenum Press, pp63-100.
Norcross JC, Goldfried MR, eds. (1992), Handbook of Psychotherapy Integration. New York: Basic Books.
Stricker G (1994), Reflections on psychotherapy integration. Clinical Psychology: Science and Practice 1:3-12.
Stricker G, Gold JR, eds. (1993), Comprehensive Handbook of Psychotherapy Integration. New York: Plenum Press.
Stricker G, Gold J (1996), Psychotherapy integration: an assimilative, psychodynamic approach. Clinical Psychology: Science and Practice 3(1):47-58.
Weinberger J (1995), Common factors aren't so common: the common factors dilemma. Clinical Psychology: Science and Practice 2:45-69.