Handbook of Psychotherapy Integration [3 ed.] 0190690461, 9780190690465

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HANDBOOK OF PSYCHOTHERAPY INTEGRATION

Handbook of Psychotherapy Integration Third Edition

Edited by John C. Norcross Marvin R. Goldfried

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1 Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and certain other countries. Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America. © John C. Norcross and Marvin R. Goldfried 2019 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by license, or under terms agreed with the appropriate reproduction rights organization. Inquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above. You must not circulate this work in any other form and you must impose this same condition on any acquirer. Library of Congress Cataloging-​in-​Publication Data Names: Norcross, John C., 1957– editor. | Goldfried, Marvin R., editor. Title: Handbook of psychotherapy integration / edited by John C. Norcross and Marvin R. Goldfried. Description: Third edition. | New York, NY : Oxford University Press, [2019] | Includes bibliographical references and index. Identifiers: LCCN 2018056131 (print) | LCCN 2018057695 (ebook) | ISBN 9780190690472 (UPDF) | ISBN 9780190690489 (EPUB) | ISBN 9780190690465 (hardcover : alk. paper) Subjects: LCSH: Eclectic psychotherapy. Classification: LCC RC489.E24 (ebook) | LCC RC489.E24 H36 2019 (print) | DDC 616.89/14—dc23 LC record available at https://lccn.loc.gov/2018056131 9 8 7 6 5 4 3 2 1 Printed by Sheridan Books, Inc., United States of America

Contents

Preface  vii Summary Outline  xiii The Editors  xv The Contributors  xvii Part I: Conceptual and Historical Perspectives 1. A Primer on Psychotherapy Integration  3 John C. Norcross and Erin F. Alexander 2. A History of Psychotherapy Integration  28 Marvin R. Goldfried, John E. Pachankis, and Brien J. Goodwin Part II: Integrative Psychotherapy Models A. Common Factors/​Processes 3. Integration of Common Factors and Specific Ingredients  69 Bruce E. Wampold and Pål G. Ulvenes 4. A Principle-​Based Approach to Psychotherapy Integration  88 Catherine F. Eubanks and Marvin R. Goldfried 5. Feedback Informed Treatment  105 Cynthia L. Maeschalck, David S. Prescott, and Scott D. Miller B. Technical Eclecticism 6. Multimodal Therapy  125 Clifford N. Lazarus and Arnold A. Lazarus 7. Systematic Treatment Selection  141 Andrés J. Consoli and Larry E. Beutler

vi Contents C. Theoretical Integration 8. The Transtheoretical Approach  161 James O. Prochaska and Carlo C. DiClemente   9. Cyclical Psychodynamics and Integrative Relational Psychotherapy  184 Paul L. Wachtel and Gregory J. Gagnon D. Assimilative Integration 10. Assimilative Psychodynamic Psychotherapy  207 George Stricker and Jerry Gold 11. Cognitive-​Behavioral Assimilative Integration  228 Louis G. Castonguay, Michelle G. Newman, and Martin grosse Holtforth Part III: Integrative Psychotherapies for Specific Disorders and Populations A. Specific Disorders 12. Dialectical Behavior Therapy for Borderline Personality Disorder  257 Heidi L. Heard and Marsha M. Linehan 13. Integrative Psychotherapy for Generalized Anxiety Disorder  284 Henny A. Westra and Michael J. Constantino 14. Cognitive Behavioral Analysis System of Psychotherapy for Chronic Depression  303 James P. McCullough, Jr. and Elisabeth Schramm B. Specific Populations and Modalities 15. Integrative Psychotherapy with Culturally Diverse Clients  325 Jeff E. Harris, Natasha Shukla, and Allen E. Ivey 16. Integrative Psychotherapy with Children  341 Athena A. Drewes and John W. Seymour 17. Integrating Self-​Help and Psychotherapy  357 Amanda Edwards-​Stewart and John C. Norcross Part IV: Training, Research, International, and Future Directions 18. Training and Supervision in Psychotherapy Integration  377 John C. Norcross and Marcella Finnerty 19. Outcome Research on Psychotherapy Integration  405 James F. Boswell, Michelle G. Newman, and Lata K. McGinn 20. Integrating Research and Practice  432 Louis G. Castonguay, Michael J. Constantino, and Henry Xiao 21. International Themes in Psychotherapy Integration  448 Beatriz Gómez, Shigeru Iwakabe, and Alexandre Vaz 22. Future Directions in Psychotherapy Integration  474 Catherine F. Eubanks, Marvin R. Goldfried, and John C. Norcross Name Index  487 Subject Index  509

Preface

From its beginnings, psychotherapy integration has been characterized by a dissatisfaction with single-​school approaches and the concomitant desire to look across and beyond school boundaries to see what can be learned—​and how patients can benefit—​from other forms of behavior change. Improving the efficacy, efficiency, and applicability of psychotherapy is the raison d’etre of integration. The 28  years between publication of the inaugural edition of the Handbook of Psychotherapy Integration and this third edition have been marked by memorable growth. In 1992, psychotherapy integration was relatively new and novel, just entering its pre-​teen years. Integration had only recently crystallized into a formal movement. Our original Handbook was the first compilation of the major integrative approaches (in the English language) and was hailed by one reviewer as “the bible of the integration movement.” Few empirical studies had

yet been conducted on the comparative effectiveness of integrative or eclectic approaches. The formal integration movement was small and concentrated in the United States. In 2019, psychotherapy integration has entered young adulthood, no longer an immature or novel approach to clinical work. Integration—​or the older term, eclecticism—​is now well established as the modal orientation of mental health professionals, and this book is now only one of many volumes on the subject. Literally hundreds of books around the globe are now published with the term integrative in their titles. Research evidence attesting to the effectiveness of integrative psychotherapies has mushroomed. Integration has grown into a mature and international movement. For these and related reasons, the second edition of the Handbook of Psychotherapy Integration became dated and incomplete. It was time for a new edition.

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viii Preface OUR AIM What has not materially changed is the purpose of our book. The aim of this third edition continues to be a state-​of-​the-​art, comprehensive description of psychotherapy integration and its clinical practices by some of its distinguished proponents. Along with these integrative approaches, we feature the concepts, history, training, research, international themes, and future of psychotherapy integration as well. Our intended audiences are practitioners, students, and researchers. Psychotherapists of all persuasions and professions will be attracted to these premier integrative psychotherapies and integrative treatments. Earlier editions of the Handbook were widely adopted for courses and seminars on psychotherapy integration, and we anticipate that this version will again serve this purpose. The contributors’ use of Chapter Guidelines and our Summary Outline facilitate a systematic and comparative analysis of the integrative approaches. We worked hard to maintain the delicate balance between authors’ individual preferences and readers’ desire for uniformity in chapter content and format. And researchers will find that each chapter summarizes the outcome research associated with that particular approach. THE CHANGES The contents of this third edition reflect both the evolution of psychotherapy integration and the continuation of our original aims. We have deleted several dated chapters that appeared in the earlier edition, and all remaining chapters have been revised and updated. We added six new chapters:  common factors therapy, principle-​based integration, integrative psychotherapy with children, mixing psychotherapy and self-​ help, integrating research and practice, and international themes. The latter two chapters constitute contemporary thrusts in the integration movement:  blending research and practice and recognizing its international nature. We have also purposefully added more diversity in our contributors:  fully half of the

authors are now women, and many authors represent countries beyond North America. Additionally, we updated the Chapter Guidelines (see below) in two significant ways. First, we required in each chapter a new section on diversity considerations to address how integrative approaches operate in a multicultural world. Second, we revised the section headings and the desired content on research in the chapters to highlight the outcome research; that is, research on the success (and failures) of the integrative treatments, especially in comparison to alternative forms of psychotherapy. All these welcome changes reflect the maturation of psychotherapy integration itself. CONTENT AND ORGANIZATION The Handbook is divided into four substantive parts. Part I  presents the concepts (Norcross and Alexander) and history (Goldfried, Pachankis, and Goodwin) of psychotherapy integration. Part II features exemplars of each of the movement’s four predominant thrusts:  common factors/​processes (Wampold and Ulvenes; Eubanks and Goldfried; Maeschalck, Prescott, and Miller), technical eclecticism (Lazarus and Lazarus; Consoli and Beutler), theoretical integration (Prochaska and DiClemente; Wachtel and Gagnon), and assimilative integration (Stricker and Gold; Castonguay, Newman, and Holtforth). Part III presents integrative psychotherapies for specific disorders, populations, and modalities: borderline personality (Heard and Linehan), anxiety (Westra and Constantino), chronic depression (McCullough and Schramm), culturally diverse clients (Harris, Shukla, and Ivey), children (Drewes and Seymour), and self-​ help (Stewart and Norcross). Part IV concludes the volume by addressing clinical training (Norcross and Finnerty), outcome research (Boswell, Newman, and McGinn), synthesis of research and practice (Castonguay, Constantino, and Xiao), international considerations (Gómez, Iwakabe, and Vaz), and future directions in integration (Eubanks, Goldfried, and Norcross).

Preface

No single volume—​even a hefty one like this—​can canvass all consequential concerns or clinical situations. Two regrettable gaps in our coverage are the absence of chapters on integrating pharmacotherapy and psychotherapy and on blending therapy formats/​ modalities (individual, couple, family, group). Moreover, space considerations restricted us to five examples of integrative therapies for specific disorders and populations. In making the precarious choices of which material would receive coverage and which would be passed over, we opted to keep the book clinically useful and student accessible. CHAPTER GUIDELINES Contributors to Part II (Integrative Psychotherapy Models) and Part III (Integrative Psychotherapies for Specific Disorders and Populations) addressed the same central topics in their chapters. We constructed Chapter Guidelines to facilitate comparative analyses and to ensure comprehensiveness. As expected, the authors did not cover every item in the guidelines, but all authors used the suggested headings and all addressed the requested topics. The Chapter Guidelines were: The Integrative Approach Aim: To outline the historical development and guiding principles of the approach. ◆ What were the primary influences that contributed to the development of the approach (e.g., people, experiences, research, books, conferences)? What were the direct antecedents of the ◆ approach? What are the guiding principles and central ◆ tenets of your approach? Are some theoretical orientations more ◆ prominent contributors to your approach than others? What is the basis for selecting therapy ◆ interventions (e.g., proven efficacy, theoretical considerations, clinical experience, patient characteristics)?

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◆ How does your integrative approach prove more effective than single-​system therapies? Assessment and Formulation Aim:  To describe the methods used to understand patient functioning, to construct a case formulation, and to track client progress. ◆ What are the formal and informal systems for diagnosing or typing patients? Do you employ tests or questionnaires in ◆ your assessment? What major client and/​or environmental ◆ variables are assessed? At which levels (e.g., individual, dyadic, ◆ system) are the assessments made? What role does case formulation play in the ◆ approach? How do you select and prioritize ◆ treatment goals? How do you monitor or track client progress ◆ over the course of therapy? How do you integrate assessment and ◆ treatment? Applicability and Structure Aim:  To describe those clinical situations and patients for which the approach is relevant. ◆ For which types of patients (e.g., diagnostic types, client characteristics) is the approach useful? For which types of patients is the approach ◆ not appropriate or of uncertain relevance? For what situations (e.g., clinical settings, ◆ time limitations) is/​is not the approach relevant? What are the clinical settings for the ◆ approach? Are there any contraindicated settings? What is the typical frequency and length of ◆ sessions? Is the therapy typically time-​limited or ◆ unlimited? What is the typical duration of therapy (mean number and range of sessions)? Are combined therapy formats used (e.g., ◆ individual therapy plus family therapy)?

x Preface ◆ Where and when does psychotropic medication fit into the approach? Processes of Change Aim: To identify the mechanisms or processes that produce changes in therapy and to assess their relative impact. ◆ What are the central mechanisms of change in your approach? What is the relative importance of insight/​ ◆ awareness, skill/​action acquisition, transference analysis, and the therapeutic relationship in the approach? What are the relative contributions of ◆ “common” factors to outcome? Does the therapist’s personality ◆ and psychological health play an important role? What other therapist factors influence the ◆ course and outcome of therapy? Which patient variables enhance or limit ◆ the probability of successful treatment? Therapy Relationship Aim:  To depict the ideal therapeutic relationship in the approach and the therapist behaviors contributing to it. ◆ How do you view the therapeutic relationship (e.g., as a precondition of change, as a mechanism of change, as content to be changed)? What are the most important ingredients of ◆ the therapy relationship in the approach? On what grounds is the therapy relationship ◆ adjusted or tailored to the individual patient? Does the therapist’s role change as therapy ◆ progresses? Methods and Techniques Aim: To delineate the methods and techniques frequently employed in the approach. ◆ What are some of the interventions used to engage patients? What is the therapist’s work in treatment? ◆ What is the client’s work in treatment?

◆ What therapy methods are typically employed? Which would typically not be used? How do you deal with resistances and ◆ blocks in treatment? What are the most common and the most ◆ serious technical errors a therapist can make in your approach? How active and directive is the therapist in ◆ the approach? How are maintenance sessions and relapse ◆ prevention addressed in the approach? Diversity Considerations Aim:  To outline the treatment considerations and potential adaptations for clients of historically marginalized ethnic/​racial, gender, sexual, and other dimensions of diversity. ◆ How does the approach apply to diverse patients in a multicultural world? Are there any particular adaptations for ◆ clients of diverse cultural identities? What are the most common culturally ◆ competent and culturally challenging elements of your approach? Case Example Aim:  To illustrate the initiation, process, and outcome of the integrative approach with a single case example. ◆ To maintain comparability among the examples, the cases in Part II should deal with the treatment of a client with general anxiety and unipolar depression (psychological distress). The case example should illustrate and discuss the initiation of treatment, patient assessment, case formulation, treatment methods, therapy relationship, termination, and outcome. Cases in Part III will pertain, of course, to the specific disorder and population discussed in the respective chapters. Outcome Research Aim:  To summarize the outcome research on the integrative approach.

Preface

◆ What research has been conducted on process–​outcome linkages of the approach? What outcome research has been ◆ performed on the approach? Does any controlled outcome research ◆ suggest that the integrative approach is comparable or superior to other forms of psychotherapy? What are the average percentages of ◆ dropouts and negative outcomes? Future Directions Aim:  To explicate the future directions and needs of the approach. ◆ What further work (clinical, research, theoretical, training) is required to advance your approach? In what directions is your integrative ◆ approach heading in the next decade? ACKNOWLEDGMENTS A large and integrative volume of this nature requires considerable collaboration. Our efforts have been aided immeasurably by our families and our Society for the Exploration of Psychotherapy Integration (SEPI) colleagues;

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the former giving us time and inspiration, the latter providing intellectual stimulation and professional affirmation. We are deeply indebted to the contributors. Most of them are SEPI members, and all are eminent psychotherapists in their own right. They are “beyond category”—​a phrase that Duke Ellington used as a high form of praise for artists who transcend the normal theoretical boundaries. We are pleased to be in their company and to privilege their integrative work. We also appreciate the dozens of emails and letters with advice on preparing the third edition of this Handbook. In particular, we are grateful for Gary VandenBos’s detailed feedback on the second edition. Thank you to his 2016 and 2017 Integrative Psychotherapy students at Uniformed Services University for their systematic feedback. Last, we reciprocally acknowledge each other for the pleasure and success of our editorial collaboration. We have a long history of collaborating on multiple projects and consider ourselves fortunate to continue to do so. John C. Norcross Clarks Summit, PA Marvin R. Goldfried Stony Brook, NY

Integrative Approach

Assessment and Formulation

Applicability and Structure

Processes of Change

Therapy Relationship

Methods and Techniques

Diversity Considerations

Case Example

Outcome Research

Future Directions

Summary Outline (for Parts II and III)

Common Factors plus Specific Ingredients

70

77

77

71

71

78

78

78

80

80

Principle-Based Integration

88

89

92

92

96

92

96

97

100

101

106

108

110

111

111

111

112

113

117

118

Multimodal Therapy

125

127

131

132

133

133

135

135

137

138

Systematic Treatment Selection

141

142

143

145

147

148

150

151

153

154

Transtheoretical Therapy

162

168

170

172

171

172

173

177

179

Cyclical Psychodynamics

185

188

190

191

191

191

195

198

Assimilative Psychodynamic Therapy

207

209

211

212

214

216

218

219

223

223

Assimilative CBT Integration

229

230

232

233

234

235

241

241

243

246

Common Factors/Processes

Feedback-Informed Treatment Technical Eclecticism

Theoretical Integration

Assimilative Integration

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Methods and Techniques

Diversity Considerations

Case Example

Outcome Research

Future Directions

258

262, 261, 272 263 265

273

268

274

275

277

279

Generalized Anxiety

284

286

288

288

290

291

293

293

297

298

Chronic Depression

303

306

308

310

312

312

315

315

318

319

Culturally Diverse Clients

325

327

328

329

330

331

335

336

337

Integrative Therapy with Children

342

346

348

349

349

350

352

352

Processes of Change

Borderline Personality

Integrative Approach

Therapy Relationship

Applicability and Structure

Summary Outline Assessment and Formulation

xiv

Disorders and Populations

350

The Editors

John C. Norcross, PhD, ABPP, is Distinguished Professor of Psychology at the University of Scranton, Adjunct Professor of Psychiatry at SUNY Upstate Medical University, and a board-​ certified clinical psychologist in limited independent practice. Dr.  Norcross has co-​written or edited 22 books, including Psychotherapy Relationships That Work, Psychologists’ Desk Reference, Clinician’s Guide to Evidence-​Based Practice, Self-​Help That Works, the five-​volume APA Handbook of Clinical Psychology, Insider’s Guide to Graduate Programs in Clinical & Counseling Psychology, and Systems of Psychotherapy: A Transtheoretical Analysis, now in its 9th edition. Dr. Norcross has served as president of the American Psychological Association (APA) Society of Clinical Psychology, the APA Society for the Advancement of Psychotherapy, the International Society of Clinical Psychology, and the Society for the Exploration of Psychotherapy Integration. He edited the Journal of Clinical Psychology:  In

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Session for a decade and has been on the editorial boards of a dozen journals. Dr. Norcross has received multiple professional awards, such as APA’s Distinguished Career Contributions to Education and Training Award, Pennsylvania Professor of the Year from the Carnegie Foundation, and election to the National Academies of Practice. Dr.  Norcross has conducted workshops and lectures in 30 countries. He lives in northeast Pennsylvania. Marvin R.  Goldfried, PhD, ABPP, is Distinguished Professor of Psychology at Stony Brook University. In addition to his teaching, supervision, and research, he maintains a limited practice of psychotherapy in New  York City. He is a diplomate in clinical psychology and recipient of distinguished psychologist awards from APA divisions 8, 12, 29, and 44, the APA/​ American Psychological Foundation lifetime achievement award for the application of

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The Editors

psychology, the Distinguished Career Award from the Society for Psychotherapy Research, and awards for both education/​training and clinical contributions from the Association for Behavioral and Cognitive Therapies. Dr. Goldfried is past president of the Society for Psychotherapy Research, Society for the Exploration of Psychotherapy Integration, Society of Clinical Psychology, and Society for the Advancement of Psychotherapy. He is author, co-​author, or editor of several

books, including Behavior Change Through Self-​ Control, Clinical Behavior Therapy, Converging Themes in Psychotherapy, From Cognitive-​Behavior Therapy to Psychotherapy Integration, How Therapists Change, and Transforming Negative Reactions to Clients. Dr. Goldfried is cofounder of SEPI, founder of Psychologists Affirming Their Gay, Lesbian, and Bisexual Family (AFFIRM), and founder of the Two-​ Way Bridge Between Research and Practice. He lives in New York City.

The Contributors

Erin F. Alexander, BS Department of Psychology, University of Scranton Department of Psychology, Binghamton University Larry E. Beutler, PhD Clinical Psychology Program, Palo Alto University (emeritus) School of Education, University of California, Santa Barbara (emeritus) James F. Boswell, PhD Department of Psychology, State University of New York at Albany Louis G. Castonguay, PhD Department of Psychology, Pennsylvania State University, University Park

Andrés J. Consoli, PhD Counseling, Clinical, and School Psychology, University of California, Santa Barbara Michael J. Constantino, PhD Department of Psychological and Brain Science, University of Massachusetts, Amherst Carlo C. DiClemente, PhD Department of Psychology, University of Maryland at Baltimore County Athena A. Drewes, PsyD Astor Services for Children and Families Amanda Edwards-​Stewart, PhD National Center for Telehealth and Technology Psychological Health Center of Excellence

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xviii The Contributors Catherine F. Eubanks, PhD Ferkauf Graduate School of Psychology, Yeshiva University Mount Sinai Beth Israel Psychotherapy Research Program, Mount Sinai School of Medicine

Arnold A. Lazarus, PhD (deceased) Graduate School of Applied and Professional Psychology, Rutgers University (emeritus)

Marcella Finnerty, DPsych IICP College, Dublin

Marsha M. Linehan, PhD Department of Psychology, University of Washington Behavioral Tech, Seattle, WA

Gregory J. Gagnon, MPhil Department of Psychology, Graduate Center of the City University in New York Jerry Gold, PhD Department of Psychology, Adelphi University Marvin R. Goldfried, PhD Department of Psychology, Stony Brook University Beatriz Gómez, PhD Aigle Foundation, Buenos Aires Brien J. Goodwin, BA Department of Psychological and Brain Science, University of Massachusetts, Amherst Jeff E. Harris, PhD Department of Psychology and Philosophy, Texas Women’s University

Clifford N. Lazarus, PhD The Lazarus Center, New Jersey

Cynthia L. Maeschalck, MA International Center for Clinical Excellence James P. McCullough, Jr., PhD Departments of Psychology and Psychiatry, Virginia Commonwealth University Lata K. McGinn, PhD Ferkauf Graduate School of Psychology, Yeshiva University Scott D. Miller, PhD International Center for Clinical Excellence Michelle G. Newman, PhD Department of Psychology, Pennsylvania State University

Heidi L. Heard, PhD Behavioral Tech, Seattle, WA

John C. Norcross, PhD Department of Psychology, University of Scranton Department of Psychiatry, SUNY Upstate Medical University

Martin grosse Holtforth, PhD Department of Psychology, University of Bern

John E. Pachankis, PhD School of Public Health, Yale University

Allen E. Ivey, EdD Department of Counseling, University of Massachusetts, Amherst (emeritus)

David S. Prescott, LICSW International Center for Clinical Excellence

Shigeru Iwakabe, PhD Faculty of Core Research, Ochanomizu University

James O. Prochaska, PhD Department of Psychology, University of Rhode Island



Elisabeth Schramm, PhD Department of Psychiatry and Psychotherapy, University Medical Center Freiburg John W. Seymour, PhD Department of Counseling and Student Personnel, Minnesota State University, Mankato Natasha Shukla, MA Department of Psychology and Philosophy, Texas Women’s University

The Contributors

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Alexandre Vaz, MSc ISPA—​University Institute, Portugal Paul L. Wachtel, PhD Department of Psychology, City College and Graduate Center of City University in New York Bruce E. Wampold, PhD Research Institute, Modum Bad Psychiatric Center, Norway Department of Counseling Psychology, University of Wisconsin–​Madison

George Stricker, PhD Clinical Psychology Program, Argosy University, Northern Virginia

Henny A. Westra, PhD Department of Psychology, York University

Pål G. Ulvenes, PhD Research Institute, Modum Bad Psychiatric Center, Norway

Henry Xiao, MS Department of Psychology, Pennsylvania State University, University Park

HANDBOOK OF PSYCHOTHERAPY INTEGRATION

PART I

Conceptual and Historical Perspectives

1 A Primer on Psychotherapy Integration JOHN C. NORCROSS AND ERIN F. ALEXANDER

Rivalry among theoretical orientations has a long and undistinguished history in psychotherapy dating back to Freud. In the infancy of the field, therapy systems, like battling siblings, competed for attention and affection in a “dogma eat dogma” environment (Larson, 1980). Clinicians traditionally operated from within their own particular theoretical frameworks, often to the point of being blind to alternative conceptualizations and potentially superior interventions. The field was organized into “tribes” in which therapists derived their identities from belonging to certain subgroups, identities that often entailed opposition to other groups (Wachtel, 2017). Mutual antipathy and exchange of puerile insults between adherents of rival orientations were very much the order of the day. This ideological Cold War may have been a necessary developmental stage toward sophisticated attempts at rapprochement. Thomas

Kuhn (1970) has described this period as a “pre-​ paradigmatic crisis.” Feyerabend (1970, p. 209), another philosopher of science, concluded that “the interplay between tenacity and proliferation is an essential feature in the actual development of science. It seems that it is not the puzzle-​solving activity that is responsible for the growth of our knowledge, but the active interplay of various tenaciously held views.” As the field of psychotherapy has matured, integration (or eclecticism) has become a therapeutic mainstay. Since the early 1990s, we have witnessed both a general decline in ideological struggle and a movement toward rapprochement. Psychotherapists now widely acknowledge the inadequacies of any one theoretical system and the potential value of others. Integration gathers, in the words of Abraham Lincoln, “strange, discordant, and even, hostile elements from the four winds.”

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4

Conceptual and Historical Perspectives

What is distinctive of the present era is tolerance for and assimilation of formulations that were once viewed as deviant. Indeed, many young students of psychotherapy express surprise when apprised of the ideological Cold War of the preceding generations. Psychotherapy integration has crystallized into a formal movement or, more dramatically, a “revolution” (Lebow, 1997)  and a “metamorphosis” in mental health (London, 1988; Moultrup, 1986). Although various labels are applied to this movement—​eclecticism, integration, rapprochement, convergence—​ the goals are similar. Integration is characterized by dissatisfaction with single-​school approaches and a concomitant desire to look across school boundaries to see what can be learned from other ways of conducting psychotherapy. The ultimate outcome of doing so is to enhance the efficacy, efficiency, and applicability of psychotherapy. The latter point deserves reiteration:  the goal of integration is to boost therapeutic success, not for academic or aesthetic satisfaction. Proposing another integrative treatment or advancing a neglected element in psychotherapy may prove interesting, but the bottom line is whether it leads to improved outcomes of some sort. Simply adding elements—​a “more is better” strategy—​does not necessarily enhance treatment effectiveness. Psychotherapy integration has come of age since the first edition of this Handbook in 1992. Any number of indicators attest to the maturation of psychotherapy integration. Integration or the earlier preferred term, eclecticism, is the modal theoretical orientation of English-​speaking psychotherapists and in many countries throughout the world (see Gómez, Iwakabe, & Vaz, Chapter  21, this volume). Leading psychotherapy textbooks routinely identify their theoretical persuasion as integrative, and an integrative or eclectic chapter is regularly included in compendia of treatment approaches. The publication of books that synthesize various therapeutic concepts and methods continues unabated, now numbering in the hundreds. Handbooks on integration, such as this one, have been published in at least a dozen countries. Reflecting and engendering

the movement have been the establishment of interdisciplinary organizations devoted to integration, notably the Society for the Exploration of Psychotherapy Integration (SEPI), and of international publications, including SEPI’s Journal of Psychotherapy Integration. And the integrative fervor will apparently persist well into the 2020s: a panel of psychotherapy experts portend integration’s escalating popularity (Norcross, Pfund, & Prochaska, 2013). Although psychotherapy integration has indeed come of age, we have not yet attained consensus or convergence. As Lazarus and Lazarus (Chapter  6, this volume) note, the field of psychotherapy is still replete with cult members—​ devoted followers of a particular school of thought. High priests of psychological health persist in competitive strife and internecine battles. These battles have receded but have not been extinguished. A consensus has been achieved, however, in support of the idea that neither traditional fragmentation nor premature unification will wisely serve the field of psychotherapy or its clients. We are in no position to determine conclusively which single theory, single treatment, or single unification scheme is best. Although it might be more satisfying and elegant if the psychotherapy world were not a multiverse but rather a universe, the pluralists assure us that this quest will not be realized, at least not soon (Messer, 1992). In the meantime, psychotherapy is progressing toward integration in the zeitgeist of informed pluralism. PLAN OF THE CHAPTER This chapter explicates the broad context of psychotherapy integration and sets the stage for the subsequent chapters in the volume. As the chapter title indicates, we offer a primer on integration in the dual sense of a primer (soft i) as a small introduction to the subject and of a primer (hard i) as a basecoat or undercoat for the following applications. This chapter begins by describing the converging reasons for the growth of psychotherapy integration, after which we review the four primary routes to integration. This segues into the varieties of



Primer on Psychotherapy Integration

integration, which includes summaries of recent studies on the prevalence, subtypes, and practices of integrative therapists. The chapter concludes with a discussion of recurrent obstacles to psychotherapy integration. WHY INTEGRATION NOW? 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 a.d. (Lunde, 1974). In psychotherapy, Freud consciously struggled with the selection and integration of diverse methods (Frances, 1988). More formal ideas on synthesizing the psychotherapies appeared in the literature as early as the 1930s (Goldfried, Pachankis, & Goodwin, Chapter 2, this volume). For example, Thomas French (1933) stood before the 1932 meeting of the American Psychiatric Association and drew parallels between certain concepts of Freud and Pavlov. In 1936, Sol Rosenzweig published an article that extracted commonalities among various systems of psychotherapy. Until recent decades, however, integration has appeared only as a latent theme (if not conspiratorially ignored altogether) in a field organized around discrete theoretical orientations. Although psychotherapists privately recognized

5

that their orientations did not adequately assist them in all they encountered in practice, a host of political, social, and economic forces—​ such as professional organizations, training institutes, and referral networks—​ kept them penned within their own theoretical school yards and typically led them to avoid clinical contributions from alternative orientations. It has only been within the past 40  years that integration has developed into a clearly delineated area of interest. Indeed, the temporal course of interest in psychotherapy integration, as indexed by both the number of publications (Arkowitz, 1992)  and development of organizations and journals (Chapter 2), reveals occasional stirrings before 1970, a growing interest during the 1980s, and rapidly accelerating interest from 1990 to the present. Figure 1.1 depicts the frequency trends of the three interrelated terms psychotherapy integration, integrative psychotherapy, and eclectic psychotherapy from 1960 to 2010 in volumes archived by Google Books. The frequency graphs have been moderately smoothed for easier interpretation. The term “eclecticism” experienced its heyday during the 1980s and has gradually declined thereafter. By contrast, “psychotherapy integration” has become the preferred or at least the most frequently used terminology. The slopes for both integrative titles continued to move upward into the late 2010s. The rapid increase in integrative psychotherapies of late leads one to inquire,

0.00000400% 0.00000350% psychotherapy integration

0.00000300% 0.00000250% 0.00000200% 0.00000150% 0.00000100%

integrative psychotherapy eclectic psychotherapy

0.00000050% 0.00000000% 1960

1965

1970

1975

1980

1985

1990

1995

2000

2005

(click on line/label for focus)

FIGURE  1.1 Frequency of occurrence of “psychotherapy integration,” “integrative psychotherapy,” and “eclectic psychotherapy” in the Google Books Archive from 1960 to 2010.

6

Conceptual and Historical Perspectives

“Why now?” What conditions encouraged the field to give specific attention and credence of late to an elusive goal that has been around for more than half a century? At least eight interacting, mutually reinforcing factors have fostered the development of integration in the past two decades:

integrative clinicians reveal that their alignment is motivated in part by disillusionment with single-​therapy systems (Garfield & Kurtz, 1977; Norcross, Karpiak, & Lister, 2004). The ecumenical spirit reflects the stark realization that narrow conceptual positions and simple answers to major questions do not begin to explain current evidence in many areas of psycho 1. Proliferation of therapies therapy (Kazdin, 1984). Clinical realities have 2. Inadequacy of single theories and treatments come to demand a more flexible, if not integra 3. External socioeconomic contingencies tive, perspective. 4. Ascendancy of short-​term, problem-​focused No therapy or therapist is immune to failure. treatments It is at such times that seasoned clinicians often 5. Opportunity to observe various treatments, wonder if the clinical methods from orientations particularly for difficult disorders other than their own might more appropriately 6. Recognition that therapeutic commonalities have been included in the treatment—​if anheavily contribute to outcome other orientation’s strength in dealing with 7. Identification of specific therapist effects the particular therapeutic problems might and evidence-​based treatments complement the therapist’s own orientational 8. Development of a professional network for weakness. The twin assumptions are that each integration orientation has its particular domain of expertise and that these domains can be interrelated The sheer proliferation of diverse schools to minimize their deficits (Pinsof, 1995). has been one important reason for the surge The proliferation of therapies and the of integration. The field of psychotherapy has inadequacies of single models were in part been staggered by over-​choice and fragmented precipitated by a matrix of economic and social by future shock. Which of 500-​plus therapies pressures. In the 1970s and 1980s, integration should be studied, taught, or bought (Prochaska was spurred along by such occurrences as the & Norcross, 2018)? Conflicting and untested advent of legal accreditation of psychotherapists, theories are advanced on a regular basis, and no with a resultant surge in professional practice single theory has cornered the market on utility. and growth of psychological trade schools; the The hyperinflation of brand name therapies has destigmatization of psychotherapy, spurred by produced narcissistic fatigue:  “With so many the human potential movement; the onset of fedbrand names around that no one can recognize, eral financial support for clinical training; and let  alone remember, and so many competitors insurance companies’ financing of psychologdoing psychotherapy, it is becoming too arduous ical treatment (London, 1983). Psychotherapy to launch still another new brand” (London, also experienced mounting pressures from 1988, pp.  5–​6). This might also be called the such not easily disregarded sources as govern“exhaustion theory” of integration: Peace among ment policymakers, informed consumers, and warring schools is the last resort. insurance payors who started to demand crisp A related and second factor is the growing and informative answers regarding the effectiveawareness that no one approach is clinically ade- ness of psychosocial treatments. More broadly, quate for all patients and situations (Fernandez-​ the culture of the 1970s and 1980s created Alvarez, Consoli, & Goemez, 2016). The an intellectual and sociopolitical climate for proliferation of theories is both a cause and con- psychotherapists in which experimentation and sequence of the problem—​neither the theories heterodoxy could flower more easily than at nor the techniques adequately deal with the other times (Gold, 1990). complexity of psychological problems (Beutler, In the 1990s, another set of forces weakened 1983). Surveys of self-​designated eclectic and the field’s rigid theoretical boundaries.



Consumer groups and insurance companies were pressuring psychotherapists to demonstrate the efficacy of their methods. Biologically oriented psychiatrists questioned the psychosocial paradigm. The failure of research findings to demonstrate a consistent superiority of any one school over another and the shifting focus to specific clinical problems (often requiring the expertise of different professions and orientations) led an increasing number of clinicians to search seriously for solutions outside their own particular paradigm. Attacks from outside the mental health professions started to propel psychotherapists together. Without some drastic changes (not the least of which is integration), psychotherapists to lose prestige, customers, and money. As Mahoney (1984) put it (paraphrasing Benjamin Franklin), there is something to be said for having the different therapies “hang together” rather than “hang separately.” In recent decades, short-​ term, problem-​ focused psychotherapies have been in the ascendancy. Treatment reviews, tightening insurance reimbursement, and mandated brief treatment began to startle clinical practitioners out of their complacency with long-​term treatment. With 90% of all patients now covered by some variant of managed care, short-​term therapy has increasingly become the de facto treatment. Short-​term therapy invariably means more problem-​focused therapy. The brief problem focus has brought formerly different therapies closer together and has created variations of therapies that are more compatible with each other. Integration, particularly in the form of technical eclecticism, responds to the pragmatic time-​ limited injunction of “whatever therapy works better—​ and quicker—​ for this patient with this problem.” In one early study of 294 health maintenance organization (HMO) therapists, for instance, the prevalence of eclecticism/​integration as a theoretical orientation nearly doubled as a function of their employment in HMOs favoring brief therapy (Austad et al., 1991). A fifth factor in the promotion of psychotherapy integration has been clinicians of diverse

Primer on Psychotherapy Integration

7

orientations observing and experimenting with diverse treatments (Arkowitz, 1992). The establishment of specialized clinics for the treatment of specific disorders has afforded exposure to other theories and therapies. These clinics are often staffed by professionals of multiple orientations and disciplines, with greater emphasis on their expertise about the clinical problem than on their theoretical orientation per se. These clinics focus on treating patients and disorders that have not historically responded favorably to pure-​form psychotherapies:  personality disorders, eating disorders, substance abuse, trauma, obsessive-​ compulsive disorders, and the severely mentally ill, to name a few. Moreover, the publication of detailed treatment manuals and the release of numerous videotapes of actual psychotherapy have permitted more accurate comparisons and contrasts among the therapies. Many clinicians reading manuals or watching videotapes are surprised by the immense commonality among practitioners of diverse orientations in spite of their differing vocabulary (Norcross & VandenBos, 2011). Even when actual differences remain, in behavioral terms, observing practices of different orientations may have induced an informal version of “theoretical exposure”: previously feared and unknown therapies were approached gradually, anxiety dissipated, and the previously feared therapies were integrated into the clinical repertoire. At the same time, controlled research has revealed surprisingly few significant differences in outcome among different therapies. Luborsky and associates (1975), borrowing a phrase from the Dodo bird in Alice in Wonderland, wryly observe that “everybody has won and all must have prizes.” Or, in the words of London (1988, p.  7), “Meta-​ analytic research shows charity for all treatments and malice towards none.” Though there are many interpretations of such findings, the two most common responses seem to be a specification of factors common to successful treatments and a synthesis of useful methods from disparate therapeutic traditions. The recognition that the so-​called common factors play major roles in determining therapy

8

Conceptual and Historical Perspectives

effectiveness served as another contributor to the rise of integration. The common factors or change processes most frequently proposed are the development of a therapeutic alliance, opportunity for catharsis, acquisition and practice of new behaviors, and clients’ positive expectancies (Grencavage & Norcross, 1990; Tracey et  al., 2003). Empirically speaking, therapy outcome can best be predicted by the properties of the patient and the therapy relationship (see Norcross & Lambert, 2019, for reviews):  only 10–​ 15% of outcome variance is generally accounted for by the particular technique. Nonetheless, more than commonalities are evident across the therapies—​ there are occasionally specific factors attributable to different treatments and different therapists (the so-​called therapist effects; Castonguay & Hill, 2017). Psychotherapy research has demonstrated the differential effectiveness of a few therapies with specific disorders; for example, parent management therapy for child conduct disorders, conjoint therapy for partner conflict, and some form of exposure for trauma disorder. Psychotherapy research has also demonstrated the differential effectiveness of particular relationships with specific types of patients; for example, less directive therapies for highly resistant patients (Consoli & Beutler, Chapter 7, this volume) and insight-​oriented therapies for people in the contemplation stage of change (Prochaska & DiClemente, Chapter 8, this volume). We now have more information by which to selectively prescribe different treatments, or combinations of treatments, for some clients and problems. Practitioners have learned to emphasize those factors common across therapies while capitalizing on the contributions of specific treatments. The proper use of common and specific factors in therapy will probably be most effective for clients and most congenial to practitioners (Garfield, 1992). We integrate by combining fundamental similarities and useful differences across the schools. The identification of specific effects in psychotherapy relates closely to the recent

promulgation of research-​based treatments in mental health. These tend to be manualized, single-​theory treatments for specific disorders that are supported by controlled research in clinical trials. At first blush, the compilation of single-​theory or pure-​form treatments would seem antithetical to the integration movement (Glass & Arnkoff, 1996). The promotion of such compilations might lead to training programs teaching only the listed pure-​form therapies, insurance companies funding only these, and practitioners conducting only these. Yet the emergence of research-​ based treatments in mental health has, paradoxically, furthered the breakdown of traditional schools and the escalation of informed pluralism. The particular decision rules for what qualifies as evidence remain controversial, but the emerging evidence-​based lists reveal a pragmatic flare for “what works for whom.” The clear emphasis is on “what” works, not on “what theory” applies. The evidence-​based movement is compatible with theoretical integration and essential to technical eclecticism (Shoham & Rohrbaugh, 1996). In fact, several commentators believe that evidence-​ based compilations herald the final dismantling of traditional theoretical categories and will yield a new metatheory of therapy (Smith, 1999). Finally, the development of a professional network has been both a consequence and cause of interest in psychotherapy integration. In 1983, the interdisciplinary SEPI was formed to bring together those who were intrigued by the various routes to rapprochement among the psychotherapies. SEPI promotes the integrative spirit throughout the therapeutic community through annual conferences, regional networks, a quarterly journal, and professional networking. Integrationists (and eclectics) now have a professional home. FOUR ROUTES TO INTEGRATION There are numerous pathways toward the integration of the psychotherapies; many roads lead to Rome. The four most popular routes are



technical eclecticism, theoretical integration, common factors, and assimilative integration. Each of the four routes is embraced by considerable proportions of self-​identified eclectics and integrationists but with some definite preferences. Recent research on SEPI members (Norcross et al., 2017) indicates that the preferred routes or subtypes entail assimilative integration, theoretical integration, and common factors, followed by technical eclecticism. That rank order generally aligns with those of US clinical psychologists (Norcross, Karpiak, & Lister, 2005), who endorsed theoretical integration (27.5%), common factors (27.5%), assimilative integration (26%), and technical eclecticism (19%). In both studies and populations, technical eclecticism ranked last in frequency. All four routes are characterized by a general desire to increase therapeutic efficacy, efficiency, and applicability by looking beyond the confines of single theories and the restricted techniques traditionally associated with those theories. However, they do so in different ways and at different levels. Here, we define each route, comment on its integrative strategy, and consider how it professes to improve patient outcomes—​the ultimate goal of all integration. Technical Eclecticism Eclecticism is the least theoretical of the four routes but should not be construed as either atheoretical or antitheoretical (Lazarus, Beutler, & Norcross, 1992). Technical eclectics seek to improve our ability to select the best treatment for the person and the problem. This search is guided primarily by research evidence and clinical observation on what has worked best for others in the past with similar problems and similar characteristics. Eclecticism focuses on predicting for whom interventions will work: the foundation is actuarial rather than theoretical. The multimodal therapy of Lazarus (1989, 1997; Lazarus & Lazarus, Chapter 6, this volume) and the systematic treatment selection (STS) of Beutler (1983; Beutler & Clarkin, 1990; Consoli & Beutler, Chapter  7, this volume) exemplify technical eclecticism.

Primer on Psychotherapy Integration

9

The term eclecticism has acquired an emotionally ambivalent, if not negative, connotation for some clinicians due to its alleged disorganized and indecisive nature. In some corners, eclecticism connotes undisciplined subjectivity, muddle-​headedness, the “last refuge for mediocrity, the seal of incompetency,” or a “classic case of professional anomie” (quoted in Robertson, 1979). Eysenck (1970, p.  145) characterized this indiscriminate smorgasbord as a “mish-​mash of theories, a hugger-​mugger of procedures, a gallimaufry of therapies” having no proper rationale or empirical verification. Indeed, it is surprising that so many clinicians admit to being eclectic in their work, given the negative valence the term has acquired. But much of the opposition to eclecticism should properly be redirected to syncretism—​ uncritical and unsystematic combinations (Norcross, 1990; Patterson, 1990). This haphazard stew is primarily an outgrowth of pet techniques and inadequate training, an arbitrary, if not capricious, blend of methods by default (Smith, 1999). This muddle of idiosyncratic clinical creations is the antithesis of effective eclecticism. Proponents of technical eclecticism use procedures drawn from different sources without necessarily subscribing to the theories that spawned them, whereas the theoretical integrationist draws from diverse systems that may be epistemologically or ontologically incompatible. For technical eclectics, no necessary connection exists between theoretical underpinnings and techniques. “To attempt a theoretical rapprochement is as futile as trying to picture the edge of the universe. But to read through the vast amount of literature on psychotherapy, in search of techniques, can be clinically enriching and therapeutically rewarding” (Lazarus, 1967, p. 416). Prescriptive matching of psychotherapy to the client’s goals, problems, and context promises to enhance treatment outcomes. Historically, the match was a research-​ based method to the presenting diagnosis or disorder, say, cognitive therapy for depression, exposure therapy for trauma, communication skills training for couples, psychodynamic therapy for

10

Conceptual and Historical Perspectives

personality disorders. Increasingly, the match is to the patient’s transdiagnostic characteristics, such as adaptations to culture, preferences, religion/​spirituality, reactance level, and stage of change. The outcome research generally shows stronger effect sizes for these transdiagnostic adaptations or responsiveness than to specific disorders (Norcross & Wampold, 2019). In all cases, the point is to improve success by fitting or personalizing psychotherapy to the individual client. Theoretical Integration In the theoretical integration form of synthesis, two or more therapies are integrated in the hope that the result will be better than the constituent therapies alone. As the name implies, there is an emphasis placed on integrating the underlying theories of psychotherapy (“theory smushing”) along with the integration of therapy techniques from each (“technique melding”). Proposals to integrate psychoanalytic and behavioral theories illustrate this direction, most notably the cyclical psychodynamics of Wachtel (1977, 1987; Wachtel & Gagnon, Chapter 9, this volume), as do efforts to blend cognitive and psychoanalytic therapies, notably Ryle’s (1990, 2001) cognitive-​analytic therapy. Grander schemes have been advanced to meld most of the major systems of psychotherapy, such as the transtheoretical approach of Prochaska and DiClemente (1984, Chapter 8). Even more ambitious are proposals for a unified psychotherapy (Magnavita, 2012; www.unifiedpsychotherapyproject.org), which seeks to integrate all of psychotherapy and the clinical sciences. Such unifications claim that they would leave behind the pre-​paradigmatic past of traditional theoretical orientations to explain many features of psychopathology and psychotherapy; instead, psychotherapy would graduate to a paradigmatic clinical science (Melchert, 2016). Theoretical integration involves a commitment to a conceptual or theoretical creation beyond a technical blend of methods. The goal is to create a conceptual framework that synthesizes the best elements of two or more

approaches to therapy. Integration aspires to more than a simple combination; it seeks an emergent theory that is more than the sum of its parts and that leads to new directions for practice and research. The rationale is that such integrative treatments may prove more effective because they are more adaptable to different types of patients, address client functioning in multiple ways or levels, or are more comprehensive than single-​ theory therapies (Wampold, 2005). The preponderance of professional contention resides in the distinction between theoretical integration and technical eclecticism. How do they differ? Which is the more fruitful strategy for knowledge acquisition and clinical practice? Table 1.1 summarizes the consensual distinctions between integration and eclecticism. The primary distinction is that between empirical pragmatism and theoretical flexibility. Integration refers to a commitment to a conceptual or theoretical creation beyond eclecticism’s pragmatic blending of procedures, or, to take a culinary metaphor (cited in Norcross & Napolitano, 1986, p. 253): “The eclectic selects among several dishes to constitute a meal, the integrationist creates new dishes by combining different ingredients.” A corollary to this distinction, rooted in theoretical integration’s earlier stage of development, is that current practice is largely eclectic; theory integration represents a promissory note for the future. In the words of Wachtel (1991, p. 44):

TABLE 1.1  Eclecticism versus integration Eclecticism

Integration

Technical Divergent (differences)

Theoretical Convergent (commonalities) Combining many Creating something new; blend Unifying the parts More theoretical than empirical More than sum of parts Idealistic

Choosing from many Applying what is; collection Applying the parts Atheoretical but empirical Sum of parts Realistic



Primer on Psychotherapy Integration The habits and boundaries associated with the various schools are hard to eclipse, and for most of us integration remains more a goal than a daily reality. Eclecticism in practice and integration in aspiration is an accurate description of what most of us in the integrative movement do much of the time.

Common Factors The common factors approach seeks to determine the core ingredients of change that different therapies share in common, with the eventual goal of creating more parsimonious and efficacious treatments based on those commonalities. This search is predicated on the belief that the commonalities are more important in accounting for therapy success than the unique factors that differentiate among them. The long considered “noise” in psychotherapy research is now considered by many as the main “signal” elements of treatment (Omer & London, 1988). The work of Jerome Frank (1973; Frank & Frank, 1993), Bruce Wampold (2010; Wampold & Imel, 2015; Wampold & Ulvenes, Chapter  3), and Scott Miller and colleagues (Hubble, Duncan, & Miller, 1999; Maeschalck, Prescott, & Miller, Chapter 5, this volume) have been among the most important contributions to this approach. Commonalities may be expressed in terms of essential components of psychotherapy, such as the therapeutic relationship and an active client, or in terms of common principles of change. In this volume, such a change principle approach is presented by Eubanks and Goldfried (Chapter 4) and, to a lesser extent, by Consoli and Beutler (Chapter 7). In his classic Persuasion and Healing, Frank (1973) 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 pluralistic, competitive American society. Because the prestige and financial security of psychotherapists hinge on their ability to show that their particular approach is more successful than that of their rivals, little glory has

11

traditionally been accorded the identification of shared or common components. It is a familiar rendition of the “tragedy of the commons”—​ all therapy systems “own” the pantheoretical commonalties but few care for and tout them. One means of determining common therapeutic principles is to focus on a level of abstraction somewhere between theory and technique. This intermediate level of abstraction, known as a clinical strategy or a change principle, may be thought of as a heuristic that implicitly guides the efforts of experienced therapists. Goldfried (1980, p. 996, italics in original) argues that [t]‌ o the extent that clinicians of varying orientations are able to arrive at a common set of strategies, it is likely that what emerges will consist of robust phenomena, as they have managed to survive the distortions imposed by the therapists’ varying theoretical biases.

In specifying what is common across disparate orientations, we may also be selecting what works best among them, be they common factors or change principles. Assimilative Integration This form of integration entails a firm grounding in one system of psychotherapy but with a willingness to selectively incorporate (assimilate) practices and views from other systems (Messer, 1992). In doing so, assimilative integration combines the advantages of a single, coherent theoretical system with the flexibility of a broader range of technical interventions from multiple systems. A  cognitive-​ behavior therapist, for example, might use the Gestalt two-​ chair dialogue in a course of treatment focusing on the reevaluation of distorted thinking and maladaptive behavior. In addition to Messer’s (1992, 2001)  original explication of it, exemplars of assimilative integration are Gold and Stricker’s assimilative psychodynamic therapy (Stricker & Gold, 1996, Chapter  10, this volume), Castonguay and associates’ (Castonguay, Newman, & Grosse Holtforth, Chapter  11, this volume) cognitive-​behavioral assimilative therapy, and Safran’s (1998; Safran

12

Conceptual and Historical Perspectives

& Segal, 1990) interpersonal and cognitive assimilative therapies. Assimilative integration may well prove more efficacious than its single-​theory base by virtue of combining fidelity with flexibility. Fidelity to a theoretically cohesive, empirically informed treatment promises that psychotherapy “works” but not necessarily with that particular client in that particular context. Flexibility to the patient’s preferences, values, and cultures promises that psychotherapy “fits” but not necessarily with research support or conceptual cohesiveness. Borrowing from other systems on occasion can capitalize on both fidelity and flexibility and can produce the optimal balance for many practitioners. To its proponents, assimilative integration represents a realistic waystation to a sophisticated integration; to its detractors, it is more of a delayed half-​way station for those unwilling to commit to a full integration. Both camps agree that assimilation is a tentative step toward an ambitious integration: most therapists have been trained in a single approach, and most therapists gradually incorporate parts and methods of other approaches once they discover the limitations of their original approach. The odysseys of seasoned psychotherapists (e.g., Dryden & Spurling, 1989; Goldfried, 2001; Karasu, 2016) suggest that this is how therapists modify their clinical practice and expand their clinical repertoire. Therapists do not discard original ideas and practices but rather rework them, augment them, and cast them all in new form. They gradually, inevitably integrate new methods into their home theory (and life experiences) to formulate the most effective approach to the needs of patients. In clinical work, the distinctions among these four routes to psychotherapy integration are not so apparent. The distinctions may largely prove semantic and conceptual, not particularly functional, in practice. Few clients experiencing an “integrative” therapy would likely distinguish among them (Norcross & Arkowitz, 1992). Moreover, these integrative strategies are not mutually exclusive. No technical eclectic can totally disregard theory, and no theoretical

integrationist can ignore technique. Pluralistic psychotherapy (Cooper & McLeod, 2011), to take a prominent example from the United Kingdom, blends the technical eclectic (use the method that works), theoretical integrative (use a combination of theories), and common factors (use powerful pantheoretical elements, especially the relationship) pathways. Systematic treatment selection and the transtheoretical model, to take prominent examples from the United States, match the individual patient to a particular treatment by stage of change, reactance level, or coping level (in the eclectic tradition) while simultaneously emphasizing change principles (in the common processes/​factors tradition). Without some commonalities among different schools of therapy, theoretical integration would prove impossible. Assimilative integrationists and technical eclectics both believe that synthesis should occur at the level of practice, as opposed to theory, by incorporating therapeutic procedures from multiple schools. And even the most ardent proponent of common factors cannot practice “nonspecifically” or “commonly”; specific techniques must be applied. DEFINING THE PARAMETERS OF INTEGRATION By common decree, technical eclecticism, common factors, theoretical integration, and assimilative integration are all assuredly part of the integration movement. However, where are the lines to be drawn—​if drawn at all—​concerning the boundaries of psychotherapy integration? What about the combination of therapy formats—​individual, couples, family, group—​ and the combination of medication and psychotherapy? In both cases, a strong majority of clinicians—​80% plus—​consider these to be within the legitimate boundaries of psychotherapy integration (Norcross & Napolitano, 1986). Of course, the inclusion of psychopharmacology enlarges the scope to integrative or combination treatment rather than integrative psychotherapy per se. Two recent thrusts proposed as parts of psychotherapy integration are the infusion of



multicultural theory and self-​help resources into clinical practice. These are receiving increased attention in the literature and in this Handbook (see Harris, Shukla, & Ivey, Chapter  15; Edwards-​Stewart & Norcross, Chapter 17) but probably less so in daily clinical practice. It routinely takes several years for new developments to be widely practiced in the field. The integration movement as a whole, and SEPI in particular, is embracing the synthesis of research and practice in addition to the blending of diverse schools of psychotherapy. Integration appears well positioned to narrow the infamous practice–​research gap and to facilitate their mutual enrichment. This third edition again features a chapter on outcome research on psychotherapy integration (Boswell, Newman, & McGinn, Chapter 19) and, for the first time, a chapter on integrating research and practice (Castonguay, Constantino, & Xiao, Chapter 20). Psychotherapy integration, like other maturing movements, is frequently charact­ erized in a multitude of confusing manners. One routinely encounters references in the literature and in the classroom to integrating spirituality and psychotherapy, integrating Occidental and Oriental perspectives, integrating social justice with psychotherapy, and so on. All are indeed laudable pursuits, but we restrict ourselves in this volume to the two meanings of integration as the blending of diverse theoretical orientations and the synthesis of research and practice.

VARIETIES OF INTEGRATIVE EXPERIENCE Integration, as is now clear, comes in many guises and manifestations. It is clearly neither a monolithic entity nor a single operationalized system; to refer to the integrative therapy is to fall prey to the “uniformity myth” (Kiesler, 1966). The twin goals of this section are to explicate the immense heterogeneity of the psychotherapy integration movement and to review studies on self-​ identified integrative therapists.

Primer on Psychotherapy Integration

13

Prevalence of Integration Approximately one-​quarter to one-​half of contemporary American clinicians disavow an affiliation with a particular school of therapy and prefer instead the label of integrative or eclectic. Some variant of integration is routinely the modal orientation of responding psychotherapists. Reviewing 25 studies performed in the United States between 1953 and 1990, Jensen et al. (1990) reported a range from 19% to 68%, the latter high figure being their own finding. It is difficult to explain these variations in percentages, but differences in the organizations sampled and in the methodology used to assess theoretical orientations account for some of the variability (see Arnkoff, 1995; Poznanski & McLennan, 1995). More recent studies confirm and extend these results. Table 1.2 summarizes the prevalence of integration found in 10 English-​ language studies published during the past decade. The frequency of integration as a discrete orientation ranged from a low of 18% to a high of 47% in these studies. The findings make it clear that integration is the most common or modal orientation in most studies, but not the majority orientation, as is occasionally (and erroneously) argued. Integration is not restricted to members of general or secular psychotherapy organizations. Older surveys of dues-​paying members of orientation-​specific organizations—​both behavioral (Association for Advancement of Behavior Therapy) and humanistic (APA Division of Humanistic Psychology) associations—​ reveal sizable proportions who endorse an eclectic orientation; 42% in the former and 31% in the latter (Norcross & Wogan, 1983; Swan, 1979). At the same time, cognitive-​ behavioral therapy (CBT) is rapidly challenging integration for the modal theory, at least in the United States. CBT lags only a few percentage points behind integration in several studies or actually supersedes it in other studies. Given that CBT is the most popular theoretical orientation of core faculty in US training programs (Norcross et  al., 2018), CBT will rival integration as the modal orientation in the future as well.

14

Conceptual and Historical Perspectives

TABLE 1.2  English-​language studies published in the past decade reporting prevalence of the integrative orientation

Authors Bike, Norcross, and Schatz

Cassin et al.

Garland et al. Goodyear et al.

Year Published

Response Rate (%)

Sample Size

2009

33

232

2007

34 37 NR

234 261 498

Point Prevalence of Integrative/​ Eclectic (%)

Countries

Professional Discipline

United States

Counselors

40

Social workers Psychologists Graduate students in Clinical psychology Counseling psychology Child therapists Counselling psychologists

39 35

United States

25 27

2010 2016

80 28

96 253

United States Australia

McClure et al.

2005

36 NR NR NR NR NR NR 35

81 47 225 398 124 144 347 279

Canada New Zealand South Africa South Korea Taiwan United Kingdom United States United States (TX)

Norcross and Karpiak Norcross and Rogan Rihacek and Roubel Thoma and Cecero Vasco

2012

46

488

United States

2013

43

428

United States

2017

NR

373

Czech Republic

Clinical psychologists Primarily psychologists Multiple

2009

18

209

United States

Multiple

26

2008

22

186

Portugal

Psychologists, psychiatrists and others

18

The studies reviewed so far have directly ascertained the prevalence of integration by therapist endorsement of a discrete orientation from a given list. It can also be gleaned indirectly by therapist endorsement of multiple orientations. For example, among UK counselors, 85–​87% did not take a pure-​form approach to psychotherapy (Hollanders & McLeod, 1999). Among clinical psychologists in the United States, for another example, fully 92% of psychologists embraced several orientations (Norcross & Karpiak, 2012). In a study of New Zealand psychologists, for a final

Counselors psychologists

25 46 40 35 22 47 37 47 31 30 31 22 25 33

example, 86% indicated that they used multiple theoretical orientations in the practice of psychotherapy (Kazantis & Deane, 1998). Indeed, very few therapists adhere tenaciously to a single therapeutic tradition. The results of the massive collaborative study of the Society for Psychotherapy Research (SPR) bear this out dramatically (Orlinsky & Rønnestad, 2005). Nearly 5,000 psychotherapists from 20 countries completed a detailed questionnaire, including questions on theoretical orientations. Orientations were assessed from therapist responses to the



question “How much is your current therapeutic practice guided by each of the following theoretical frameworks?” Responses were made to six orientations on a 0–​5 scale. Twelve percent of the psychotherapists were uncommitted in that they rated no orientations as 4 or 5; 46% were focally committed to a single orientation (rating of 4 or 5); 26% were jointly committed; and 15% were broadly committed, operationally defined as three or more orientations rated 4 or 5. As the authors conclude (Orlinsky et al., 1999, p. 140), “While there is a substantial group whose theoretical orientations are relatively pure, they are a minority in the present data base.” The results point to “a rather extensive amount of eclecticism” (Orlinsky & Rønnestad, 2005, p. 29). A related method of determining the relative mix is to have participants assign percentages on how much a given theoretical orientation comprises their total approach. One study of 2,156 psychotherapists using this method found that only 2% identified themselves completely with a single orientation by rating it 100% (Cook, Biyanova, Elhai, Schnurr, & Coyne, 2010). Few therapists proved purists; 98% were non–​pure  form. The research or measurement method strongly influences the resulting prevalence of integration. A  creative study of 373 Czech therapists employed four different methods of identifying an “integrative” therapist. The corresponding percentages ranged from 22% to 99%:  22% integrative by formal training, 33% integrative by endorsement of multiple orientations as a 4 or 5 on a scale from 0–​5, 88% integrative by endorsement of the multiple orientations as 2–​5 on the same scale, and 99% integrative by use of techniques from several orientations (Rihacek & Roubal, 2017). Likewise, in a study of Portuguese therapists (Vasco, 2001), the prevalence of integration varied widely depending on the way integration is defined. There was a value of 18% when using a demanding criterion:  choosing values above 3 (on a 0–​5 scale) simultaneously for two or more orientations (“same family” orientations were not considered; e.g., cognitive and behavioral). If the criterion was not so demanding, as

Primer on Psychotherapy Integration

15

in rating more than one orientation, the value rose to about 80%! These results exemplify how the measurement method produces dramatic differences in the reported popularity of psychotherapy integration. The prevalence of integration in countries outside North America (see Gómez, Iwakabe, & Vaz, Chapter  21) also seems to be steadily rising. The surveys of psychotherapists reviewed in the international chapter show that integrative psychotherapy is widely endorsed and used across the globe. It is no longer restricted to the United States and Western Europe. In many countries, the integration movement gave rise to a great diversity of models, in many cases within their own training programs. These multiple methods of determining the prevalence of integration fuel debate on whether certain brand name therapies can be rightfully called integrative. CBT is explicitly a hybrid of two approaches, but not all would characterize it as integrative. If one adds acceptance and mindfulness approaches to CBT, such as in dialectical behavior therapy (Heard & Linehan, Chapter  12), then the boundary into integration seems to have been crossed. The clinical reality is that most theories did not spring de novo from Zeus’s head: they inevitably represent assimilation of previous theories. Emotion-​focused couples therapy is a case in point; it proclaims itself an amalgam of experiential, systemic, person-​centered, relational, and attachment theories (Greenberg & Johnson, 2010). Although integration’s measurement and boundary permeability may occasionally prove confusing, it does illustrate the inevitable thrust toward sophisticated integration. Integrative Therapists With such large proportions of psychotherapists embracing integration, it would prove informative to identify their distinctive characteristics or attitudes. Demographically, there do not appear to be any consistent differences between the two groups, with the exception of clinical experience in several older studies (Norcross & Prochaska, 1982; Norcross & Wogan,

16

Conceptual and Historical Perspectives

1983; Smith, 1982; Walton, 1978). Clinicians ascribing to integration or eclecticism tended to be older and, concomitantly, more experienced. Inexperienced therapists are more likely to endorse exclusive theoretical orientations. Several empirical studies have suggested that reliance on one theory and a few techniques may be the product of inexperience or, conversely, that with experience comes diversity and resourcefulness (see reviews by Auerbach & Johnson, 1977; Beutler, Machado, & Neufeldt, 1994). In more recent studies (e.g., Mullins et al., 2003; Norcross et al., 2004), the age and experience differential of eclectics has disappeared, probably owing to the fact that a greater percentage of psychotherapists are being explicitly trained as integrationists in graduate school. Attitudinally, integrative or eclectic clinicians differ from their nonintegrative colleagues in at least two respects. First, eclectics report greater dissatisfaction with their current conceptual frameworks and technical procedures (Norcross & Prochaska, 1983; Norcross & Wogan, 1983; Vasco, Garcia-​Marques, & Dryden, 1992). This increased dissatisfaction may serve as an impetus to create an integrative approach, or it may have resulted from the elevated expectations that integration has engendered. Second, practitioners seem to embrace integration more frequently than academic and training faculty (Friedling, Goldfried, & Stricker, 1984; Norcross et  al., 2004; Tyler & Clark, 1987). Integrationists are more involved in conducting psychotherapy than are their pure-​ form colleagues. From a personal-​ historical perspective, Robertson (1979) identified six factors that may facilitate the choice of eclecticism. The first is the lack of pressures in training and professional environments to bend to a doctrinaire position. Also included here would be the absence of a charismatic figure to emulate. A second factor, which we have already discussed, is length of clinical experience. As therapists encounter heterogeneous clients and problems over time, they may be more likely to reject a single theory. A  third factor is the extent to which doing psychotherapy is making a living or reflecting a philosophy of life; Robertson asserts

that integration is more likely to follow the former, consistent with the research reviewed earlier. In the words of several distinguished scientist-​practitioners (Ricks, Wandersman, & Poppen, 1976, p. 401): So long as we stay out of the day to day work of psychotherapy, in the quiet of the study or library, it is easy to think of psychotherapists as exponents of competing schools. When we actually participate in psychotherapy, or observe its complexities, it loses this specious simplicity.

The remaining three factors underlying why some therapists are integrative seem to be personality variables:  an obsessive-​compulsive drive to pull together all the interventions of the therapeutic universe, a maverick temperament to move beyond some theoretical camp, and a skeptical attitude toward the status quo. Although these factors require further confirmation, they are supported by our training experiences and the personal histories of prominent clinicians represented in this volume and elsewhere (see Chapters  3–​ 14; Goldfried, 2001). Integrative Practices Although it is relatively easy to ascertain its self-​reported prevalence, it is much more difficult to determine what “integrative” practice precisely entails. Far more process research is needed on the conduct of eclectic or integrative psychotherapies. Such investigations will probably need to make audio, video, and transcript recordings of the therapy offered in order to clarify the nature of therapeutic interventions. Definitions of psychotherapy integration do not tell us what individual psychotherapists actually do or what it means to be an integrative therapist. Several studies, however, have attempted to do just that. In an early survey of psychologists in the United States, Garfield and Kurtz (1977) discerned 32 different theoretical combinations used by 145 eclectic clinicians. The most popular two-​ orientation combinations, in descending order of frequency, were



Primer on Psychotherapy Integration

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psychoanalytic and learning theory, neo-​ Over time, the behavioral and psychoanFreudian and learning theory, neo-​ Freudian alytic combination as well as the behavioral and Rogerian theory, learning theory and hu- and humanistic combination have slipped conmanistic theory, and Rogerian and learning siderably. They have gradually dropped from theory. Most combinations were blended and the first and third most frequently combined employed in an idiosyncratic fashion. The theories in 1977 to the ninth and fourth in 1988 investigators concluded that the designation of and now to thirteenth and fourteenth in 2004. “eclectic” covers a wide range of views, some of The behavioral and psychoanalytic hybrid—​ which are quite distinct from others. accounting for 25% of the combinations in the Replications of the seminal Garfield and 1970s and only 1% on the 2000s—​has firmly Kurtz study in 1988 and again in 2004 enlarged been replaced by cognitive hybrids. and updated the findings. In the most recent This study and other research demonstrate a study (Norcross et  al., 2004), exactly one-​ half preference for both the term “integration” and of the 187 self-​ identified eclectic/​ integrative the practice of theoretical or assimilative intepsychologists adhered to a specific theoretical ori- gration, as opposed to technical eclecticism. entation before becoming explicitly integrative. Fully 59% preferred the term “integrative” This 50% is similar to the two previous studies in compared to 20% who favored “eclecticism.” which 58% (Norcross & Prochaska, 1988)  and This preference for integration over eclecti49% (Garfield & Kurtz, 1977)  had previously cism represents a historical shift. There seems adhered to a single orientation. The previous the- to have been a theoretical progression analooretical orientations were varied but were prin- gous to social progression, one that proceeds cipally psychodynamic (41%), cognitive (19%), from segregation to desegregation to integraand behavioral (11%). Thus, as with the earlier tion. Eclecticism represented desegregation, in findings and other studies (e.g., Jayaratne, 1982; which ideas, methods, and people from diverse Jensen et al., 1990), the largest shift continues to theoretical backgrounds mix and intermingle. occur from the psychodynamic and psychoan- We have now transitioned from desegregation alytic persuasions and the next largest from the to integration, with increasing efforts directed cognitive and behavioral traditions. at discovering viable integrative principles for Integrative psychologists rated the frequency assimilating and accommodating the best that of the use of six major theories (behavioral, different systems have to offer. cognitive, humanistic, interpersonal, psychoSophisticated integrative practice obviously analytic, and systems, and “other”) in their is more complex than these survey glimpses practice. To permit historical comparisons with can provide. To echo the authors of the original the earlier studies, we examined the individual study, “Some value psychodynamic views more ratings to determine the most widely used than others, some favor Rogerian and humanistic combinations of two theories. The most fre- views, others clearly value learning theory, and quent combinations of theoretical orientations various combinations of these are used in apparconstituting eclectic/​ integrative practice are ently different situations by different clinicians” summarized in Table 1.3. All 15 possible (Garfield & Kurtz, 1977, p.  83). However, eccombinations of the six theories presented were lecticism has gradually lost some of its negative endorsed by at least one self-​identified eclectic/​ definition as a nondescript brand name for those integrationist. As seen in the table, cognitive dissatisfied with orthodox schoolism. Instead, therapy predominates; in combination with these clinicians actively and positively endorsed another therapy system, it occupies the first 5 eclecticism/​ integration as much for what it of the 15 combinations and accounts for 42% offers as for what it avoids. When asked if they of the combinations. Put differently, cognitive considered eclecticism/​integration the absence therapy is the most frequently and most heavily of a theoretical orientation or the endorsement of used contributor to an integrative practice, at a broader one in its own right (or both), the vast least in the United States. majority of eclectics—​85%—​conceptualized

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Conceptual and Historical Perspectives TABLE 1.3  Most frequent combinations of theoretical orientations among eclectic and integrative psychologists in the United States Combination

Behavioral and cognitive Cognitive and humanistic Cognitive and psychoanalytic Cognitive and interpersonal Cognitive and systems Humanistic and interpersonal Interpersonal and systems Psychoanalytic and systems Interpersonal and psychoanalytic Behavioral and interpersonal Behavioral and systems Humanistic and psychoanalytic Behavioral and humanistic Behavioral and psychoanalytic Humanistic and systems

1976

1985

2004

%

Rank

%

Rank

%

Rank

5 NR NR NR NR 3 NR NR NR NR NR NR 11 25 NR

4

12 11 10