HANDBOOK OF
PSYCHOTHERAPY INTEGRATION
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HANDBOOK
OF PSYCHOTHERAPY
INTEGRATION
JOHN C. NORCROSS, PH.D.
AND
MARVIN R. GOLDFRIED, PH.D
EDITORS
New York
Oxford
OXFORD UNIVERSITY PRESS
2003
OXFORD
UNIVERSITY PRESS
Oxford New York
Auckland Bangkok Buenos Aires Cape Town Chennai
Dar es Salaam Delhi Hong Kong Istanbul Karachi Kolkata
Kuala Lumpur Madrid Melboume Mexico City Mumbai Nairobi
Sao Paulo Shanghai Taipei Tokyo Toronto
Copyright © 2003 by Oxford University Press, Inc.
Published by Oxford University Press, Inc.
198 Madison Avenue, New York, New York 10016
www.oup.com
First published in 1992 by Basic Books
Oxford is a registered trademark of Oxford University Press
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,
electronic, mechanical, photocopying, recording, or otherwise,
without the prior permission of Oxford University Press.
Library of Congress Cataloging-in-Publication Data
Handbook of psychotherapy integration / edited by John C. Norcross, Marvin R. Goldfried
p. cm. Previously published: New York: Basic Books, 1992.
Includes bibliographical references and index.
ISBN 0-19-516704-X
Eclectic psychotherapy. I. Norcross, John C., 1957 - II. Goldfried, Marvin R.
[DNLM: 1. Psychotherapy—methods—handbooks.]
RC489.E24H36 2003
616.89'14—dc21
2003048689
1 3 5 7 9 8 6 4 2
Printed in the United States of America
on acid-free paper
Contents
Preface
About the Editors
About the Contributors
ix
xiii
XV
PART I: CONCEPTUAL AND HISTORICAL
PERSPECTIVES
1 Psychotherapy Integration: Setting the Context
John C. Norcross and Cory F. Newman
2 A History of Psychotherapy Integration
Marvin R. Goldfried and Cory F. Newman
3 Psychotherapy Outcome Research: Implications for
Integrative and Eclectic Therapists
Michael J. Lambert
4 A Critical Examination of Belief Structures in Integrative
and Eclectic Psychotherapy
Stanley B. Messer
3
46
94
130
vi
CONTENTS
PART II: INTEGRATIVE AND ECLECTIC
PSYCHOTHERAPY MODELS
A. Common Factors
5 Eclectic Psychotherapy: A Common Factors
Approach
Sol L. Garfield
6 Integration Through Fundamental Similarities and
Useful Differences Among the Schools
169
202
Bernard D. Beitman
B. Technical Eclecticism
7 Multimodal Therapy: Technical Eclecticism with
Minimal Integration
231
Arnold A. Lazarus
8 Systematic Eclectic Psychotherapy
Larry E. Beutler and Andres ]. Consoli
264
C. Theoretical Integration
9 The Transtheoretical Approach
300
James O. Prochaska and Carlo C. DiClemente
10 Cyclical Psychodynamics and Integrative
Psychodynamic Therapy
335
Paul L. Wachtel and Mary K. McKinney
PART III: INTEGRATIVE
PSYCHOTHERAPIES FOR SPECIFIC
DISORDERS
11 Integrative Psychotherapy of the Anxiety Disorders
373
Barry E. Wolfe
12 A Common Factors Therapy for Depression
Hal Arkowitz
402
Contents
13 Integrative Therapy for Borderline Personality
Disorder: Dialectical Behavior Therapy
Kelly Koemer and Marsha M. Linehan
vii
433
PART IV: INTEGRATIVE TREATMENT
MODALITIES
14 Differential Therapeutics: Macro and Micro Levels of
Treatment Planning
John F. Clarkin, Allen Frances, and Samuel Perry
463
15 Integrating Therapeutic Modalities
Larry B. Feldman and Sandra L. Powell
503
16 Integrating Pharmacotherapy and Psychotherapy
Bernard D. Beitman, Molly J. Hall, and Bums Woodward
533
PART V: TRAINING AND RESEARCH
DIRECTIONS
17 Training in Psychotherapy Integration
John D. W. Andrews, John C. Norcross, and Richard P. Halgin
18 Core Issues and Future Directions in Psychotherapy
Integration
Marvin R. Goldfried, Louis G. Castonguay, and Jeremy D. Safran
563
593
Name Index
617
Subject Index
629
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Preface
A
./ATTEMPTS TO INTEGRATE diverse approaches to psychotherapy
have captured the imagination of mental health professionals for well over
half a century. For example, Thomas French 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 recently, however, integration has appeared only as a latent theme
(if not conspiratorially ignored altogether) in a field organized around
discrete theoretical orientations. While psychotherapists secretly recognized that their paradigms 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.
Within the past two decades, the field of psychotherapy has been
subjected to another set of forces that have weakened rigid theoretical
boundaries. From outside the field, several groups have launched sobering
attacks. Consumer groups and insurance companies have been pressuring
psychotherapists to demonstrate the efficacy of their methods. Biologically
oriented psychiatrists have been questioning the psychosocial paradigm of
psychotherapists. Moreover, from inside the field, the failure of research
findings to demonstrate a consistent superiority of any one school of
thought over another and the shifting focus to specific clinical problems
(often requiring the expertise of different professions and orientations)
x
PREFACE
have led an increasing number of clinicians to search seriously for solutions
outside their own particular paradigm.
The ideological cold war and "dogma eat dogma" ambience in psychotherapy have abated as clinicians acknowledge the inadequacies of any
one system and the potential value of others. During the past decade
psychotherapy integration has crystallized into a formal movement, 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. Whether considered a paradigm shift or a metamorphosis in
mental health, psychotherapy integration will be a therapeutic mainstay of
the 21st century.
The formation of the Society for the Exploration of Psychotherapy
Integration (SEPI) in 1983 helped spark the integration movement. An
organization dedicated to dialogue among therapists of disparate theoretical orientations, and also between clinicians and researchers, SEPI's operative term is "exploration." Given the complexity of human behavior and
the change process, it is unlikely that any one individual can propose an
all-purpose integrative system that will suffice for all situations, disorders,
and clients. At the same time, we are convinced that the time is ripe tor
serious and thoughtful attempts at exploring common ground, working
toward theory integration, and blending clinical and research efforts that
are not encumbered by individual schools of thought. It is within this spirit
that our handbook has been prepared.
We believe that this volume provides, for the first time, a state-of-theart, comprehensive description of psychotherapy integration (the most
popular orientation of mental health professionals) and its clinical practices
by some of the leading proponents of the movement.
The Handbook is divided into five sections. Part I considers the concepts (Norcross & Newman), history (Goldfried & Newman), research
(Lambert), and belief structures (Messer) of psychotherapy integration. Part
II presents two exemplars of each of the movement's predominant thrusts:
common factors (Garfield, Beitman), technical eclecticism (Lazarus, Beutler,
& Consoli), and theoretical integration (Prochaska & DiClemente, Wachtel
& McKinney). Part III describes integrative psychotherapies for specific
disorders: anxiety (Wolfe), depression (Arkowitz), and borderline personality disorder (Koerner & Linehan). Part IV reviews integrative treatment
modalities, specifically, differential therapeutics (Clarkin, Frances, & Perry),
combining individual and family therapy (Feldman & Powell), and integrating pharmacotherapy and psychotherapy (Beitman, Hall, & Woodward).
Part V concludes the volume by addressing both training (Andrews, Norcross, & Halgin) and future directions (Goldfried, Castonguay, & Safran) in
integration.
Preface
xi
Contributors to part II (Integrative and Eclectic Psychotherapy Models) and part III (Integrative Psychotherapies for Specific Disorders) were
asked to address a list of central topics in their chapters. Chapter guidelines
were designed to facilitate comparative analyses and to ensure comprehensiveness. The focal issues were: background of the approach; patient assessment; applicability and structure; interventions and relationships; mechanisms of change; case example; research on the approach; clinical training;
and future directions. As expected, the authors did not always use the
suggested headings; while most of the requested topics were addressed in
some fashion in the respective chapters, we did not insist on identical
headings or formats. Further, in instances where chapter length became
burdensome, we were reluctantly forced to omit the section on clinical
training. The belief that one chapter format—or for that matter, one
integrative psychotherapy model—will suffice for all occasions is one that
is antithetical to therapeutic rapprochement and informed pluralism.
A large and integrative volume of this nature requires considerable
collaboration. Our efforts have been aided immeasurably by our families
and our SEPI colleagues; the former giving us time and inspiration, the
latter providing intellectual stimulation, professional affirmation, and social
support. We acknowledge the truly responsive and collaborative efforts of
the staff at Basic Books, particularly Jo Ann Miller, senior editor; Stephen
Francoeur, assistant editor; and Susan Zurn, project editor. Based on these
interactions we fully anticipate a debt to Lois Shapiro and her colleagues
for their marketing efforts for this book. We thank Ann Brust and Betty
Nebesky at the University of Scranton and Cecily Osley at SUNY-Stony
Brook for their clerical assistance.
We also gratefully acknowledge the permission to reprint selected
portions of several contributions that originally appeared elsewhere. Certain sections of chapters 3 (Lambert), 4 (Messer), 5 (Garfield), 7 (Lazarus),
8 (Beutler & Consoli), and 9 (Prochaska & DiClemente) first appeared in the
Handbook of Eclectic Psychotherapy (1986), published by Brunner/Mazel Inc.
and edited by John C. Norcross. All the chapters in question, however,
contain new material and have been revised and updated. Certain sections
of chapter 2 (Goldfried & Newman) first appeared in Behavior Therapy
(Goldfried, 1982, 13, 572-593), published by the Association for the
Advancement of Behavior Therapy.
Lastly, we are indebted to the contributors. Most of them are SEPI
members, and all are eminent psychotherapists in their own right. We are
pleased to be in their company and to present their integrative work.
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About the Editors
John C. Norcross, Ph.D., is Professor and Chair of Psychology at the University of Scranton and a clinical psychologist in part-time independent practice. He has published more than 100 articles and has coauthored or edited
seven monographs, the most recent being Therapy Wars: Contention and
Convergence in Differing Clinical Approaches (with Nolan Saltzman), A Dialogue with John Norcross: Toward Integration (with Windy Dryden), and the
centennial issue of Psychotherapy devoted to the future of psychotherapy.
Dr. Norcross is an editorial board member of numerous scholarly journals, and is associate editor of the Journal of Psychotherapy Integration, the
official publication of the Society for the Exploration of Psychotherapy
Integration.
Marvin R. Goldfried, Ph.D., is Professor of Psychology and Psychiatry at
the State University of New York at Stony Brook. In addition to his
teaching, clinical supervision, and research, he maintains a limited practice
of psychotherapy in New York City. A diplomate of the American Board
of Professional Psychology, a Fellow of the American Psychological Association, and editorial board member of several journals, he is coeditor of
Behavior Change Through Self-control, coauthor of Clinical Behavior Therapy,
and editor of Converging Themes in Psychotherapy. Trends in Psychodynamic,
Humanistic, and Behavioral Practice. Dr. Goldfried is cofounder of the Society for the Exploration of Psychotherapy Integration.
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About the Contributors
John D. W. Andrews, Ph.D., is Director of the Center for Teaching
Development at the University of California, San Diego, and Adjunct
Research Professor at the California School of Professional Psychology. He
is author of The Active Self in Psychotherapy: An Integration of Therapeutic
Styles.
Hal Arkowitz, Ph.D., is Associate Professor of Psychology at the
University of Arizona, where he directs the Depression Clinic. He also
maintains a part-time independent practice in psychotherapy. He coedited
Psychoanalytic Therapy and Behavior Therapy: Is Integration Possible? (with
Stanley Messer) and the Comprehensive Handbook of Cognitive Therapy (with
Arthur Freeman, Karen Simon, and Larry Beutler). Currently, he is editor
of the Journal of Psychotherapy Integration.
Bernard D. Beitman, M.D., is Professor of Psychiatry and Medicine at
the University of Missouri. He is the author of The Structure of Individual
Psychotherapy and senior editor of Integrating Pharmacotherapy and Psychotherapy. He has a major research interest in studying chest pain of unexplained etiology with particular reference to panic disorder.
Larry E. Beutler, Ph.D., is Professor of Education and Psychology and
Director of the Counseling/Clinical/School Psychology Program at the
University of California, Santa Barbara. He is a graduate of the University
of Nebraska at Lincoln in clinical psychology and a diplomate of the
American Board of Professional Psychology. He is also the editor of the
xvi
ABOUT THE CONTRIBUTORS
Journal of Consulting and Clinical Psychology, a past international president
of the Society for Psychotherapy Research, and author of numerous articles
and books on psychotherapy.
Louis George Castonguay, M.A., is completing his doctorate in clinical
psychology at SUNY at Stony Brook and conducting an internship at the
University of California, Berkeley. He coedited a book (in French) concerning the rapprochement and integration of psychoanalysis, behavior therapy, and humanistic therapy.
John F. Clarkin, Ph.D., is Professor of Clinical Psychology in Psychiatry, Cornell University Medical College, and Director of Psychology, New
York Hospital-Cornell Medical Center. He coedited Affective Disorder and
the family and coauthored Systematic Treatment Selection: Toward Targeted
Therapeutic Interventions.
Andres ]. Consoli, M.A., is a bilingual/bicultural therapist and doctoral
student at the University of California, Santa Barbara. He received his
Licenciatura in clinical psychology from the Universidad de Belgrano,
Buenos Aires, Argentina, in 1984 and subsequently has worked as a youth,
school, and family counselor. He currently serves as a graduate supervisor
in the Ray Hosford Counseling Training Clinic and is a member of the
Psychotherapy Research Project team, both at the University of California,
Santa Barbara.
Carlo C. DiClemente, Ph.D., is Associate Professor of Psychology and
Director of the Change Assessment Research Program at the University of
Houston. He is an investigator on several national collaborative intervention studies and maintains a small psychotherapy practice in addition to his
extensive supervision at the UH Psychology Research and Services Center.
He is coauthor of The Transtheoretical Approach: Crossing the Traditional
Boundaries of Therapy.
Larry B. Feldman, M.D., is Clinical Associate Professor in the Department of Psychiatry at Loyola University. He has a part-time private practice and is a consultant to mental health agencies and individual therapists.
He is the author of Integrating Individual and Family Therapy and of numerous journal articles and book chapters on individual and family therapy
integration.
Allen Frances, M.D., is Chair of the Department of Psychiatry at Duke
University and also Chair of the DSM-IV Task Force, appointed by the
About the Contributors
xvii
American Psychiatric Association to revise the current DSM system. He
has written numerous volumes, including Differential Therapeutics: A Guide
to the Art and Science of Treatment Planning in Psychiatry.
Sol L. Garfield, Ph.D., is Professor Emeritus of Psychology at Washington University. A former editor of the Journal of Consulting and Clinical
Psychology, he has authored Clinical Psychology, Psychotherapy: An Eclectic
Approach, and The Practice of Brief Psychotherapy; with Allen E. Bergin he is
the editor of the Handbook of Psychotherapy and Behavior Change. He is an
American Board of Professional Psychology diplomate, a fellow of the
American Psychological Association, a former president of the Division of
Clinical Psychology, and a former president of the Society for Psychotherapy Research.
Richard P. Halgin, Ph.D., is Professor of Psychology at the University
of Massachusetts at Amherst and holds a diplomate in Clinical Psychology
from the American Board of Professional Psychology. He has published
several dozen articles and book chapters on various topics in psychology,
including psychotherapy integration, clinical training and supervision, and
the provision of clinical services to underserved populations. He is coauthor of an undergraduate textbook entitled Abnormal Psychology: The
Human Experience of Psychological Disorder. Dr. Halgin also maintains a
part-time independent practice of psychotherapy.
Molly J. Hall, M.D., is Assistant Professor of Psychiatry at the Wright
State University School of Medicine and Residency Training Director at
the United States Air Force Medical Center, Wright-Patterson AFB. As a
flight surgeon/psychiatrist she serves as a member of the NASA Astronaut
Selection Board. She has participated as a faculty member of the American
Psychiatric Association course on treatment integration and has authored
papers on brief psychotherapy and personality disorders in the military
population.
Kelly Koerner is a staff therapist at the Suicidal Behaviors Research
Clinic and a doctoral candidate in clinical psychology at the University of
Washington. She teaches workshops on Dialectical Behavior Therapy and
conducts research to identify the processes of change in psychotherapy
with difficult patients.
Michael ]. Lambert, Ph.D., is Professor of Psychology at Brigham
Young University. He maintains a part-time independent practice in psychotherapy and has been an executive officer of the Society for Psychother-
xviii
ABOUT THE CONTRIBUTORS
apy Research. He is the author of numerous articles on psychotherapy
outcome, coeditor of The Assessment of Psychotherapy Outcome, and editor
of Psychotherapy and Patient Relationships.
Arnold A. Lazarus, Ph.D., is Distinguished Professor in the Graduate
School of Applied and Professional Psychology, Rutgers University. He
also has a private practice in Princeton, New Jersey, and serves as a
consultant to several institutions and agencies, as well as being on ten
editorial boards. He has authored over 200 articles and chapters, and has
written seven books and edited five. His major work is The Practice of
Multimodal Therapy.
Marsha Linehan, Ph.D., is Professor of Psychology, Adjunct Professor
of Psychiatry, and Director of the Suicidal Behaviors Research Clinic at the
University of Washington. She is an active clinical researcher, maintains a
clinical practice, and has published widely, including the book, CognitiveBehavioral Treatment of Borderline Personality Disorder: The Dialectics of Effective Treatment.
Mary K. McKinney, M.A., is completing her Ph.D. in clinical psychology at the City University of New York. She is presently a clinical
psychology intern in the Department of Child Psychiatry of the Montefiore Medical Center, Albert Einstein College of Medicine.
Stanley B. Messer, Ph.D., is Professor of Clinical Psychology at the
Graduate School of Applied and Professional Psychology of Rutgers University. He has been an associate editor of American Psychologist and a
consulting editor of Journal of Consulting and Clinical Psychology. Dr. Messer
is currently on the editorial boards of Contemporary Psychology, Psychotherapy Research, and Journal of Psychotherapy Integration. He is coeditor and
contributor to Psychoanalytic Therapy and Behavior Therapy: Is Integration
Possible? and Hermeneutics and Psychological Theory.
Cory F. Newman, Ph.D., Clinical Director of the Center for Cognitive
Therapy, is also Assistant Professor of Psychology in Psychiatry at the
University of Pennsylvania. In addition to his activities as psychologist,
supervisor, and administrator, Dr. Newman has presented numerous workshops on schema-focused cognitive therapy at local, national, and international conferences. He is coauthor of two books in preparation—Cognitive Therapy of Substance-Use Disorders and Cognitive Therapy of the
Borderline Patient.
About the Contributors
xix
Samuel Perry, M.D., is Professor of Psychiatry at Cornell Medical
College, Associate Director of the Consultation-Liaison Division at The
New York Hospital, and Training and Supervising Psychoanalyst at the
Columbia University Psychoanalytic Center for Training and Research. His
most recent book (with A. Frances and J. Clarkin) is A DSM-III Casebook
of Treatment Selection.
Sandra L Powell, M.S. W., is a private practitioner, teacher, and consultant to mental health agencies and individual therapists. She has conducted
numerous workshops and in-service educational programs on integrating
individual therapy with family and group therapy in the treatment of
children, adolescents, and adults.
James O. Prochaska, Ph.D., is Professor of Psychology and Director of
the Cancer Prevention Research Consortium at the University of Rhode
Island. He also serves as a consultant to numerous institutions and maintains a part-time independent practice in psychotherapy. He is author of
Systems of Psychotherapy: A Tmnstheoretical Analysis and coauthor of The
Transtheoretical Approach: Crossing the Traditional Boundaries of Therapy.
Jeremy D. Safran, Ph.D., is Associate Professor at the Derner Institute
of Advanced Psychological Studies at Adelphi University. He is coauthor
of Interpersonal Process in Cognitive Therapy and coeditor of Emotion, Psychotherapy, and Change. In addition to his teaching responsibilities, he maintains a part-time private practice in New York and Long Island.
Paul L. Wachtel, Ph.D., is Distinguished Professor of Psychology at
City College and the Graduate Center of the City University of New York,
where he teaches in the Ph.D. program in clinical psychology. He is the
author of Psychoanalysis and Behavior Therapy: Toward an Integration, The
Poverty of Affluence, and Action and Insight, as well as coauthor with Ellen
F. Wachtel of Family Dynamics in Individual Psychotherapy. Dr. Wachtel is
one of the founders of the Society for the Exploration of Psychotherapy
Integration.
Barry E. Wolfe, Ph.D., is Chair of the Psychotherapy and Rehabilitation Research Consortium at the National Institute of Mental Health. He
also conducts a part-time private practice in Rockville, Maryland, specializing in the integrative treatment of the anxiety disorders. He is currently
preparing a book tentatively entitled Psychotherapy Integration in the Treatment of the Anxiety Disorders.
xx
ABOUT THE CONTRIBUTORS
Burns Woodward, M.D., is Clinical Instructor in Psychiatry at Boston
University School of Medicine and Assistant Medical Director at Westwood Lodge Hospital in Westwood, Massachusetts. He has written and
lectured on the collaboration between psychotherapists and pharmacotherapists and on integrating psychiatric and chemical dependency treatment
for dually diagnosed substance abusers. He has an active practice of individual and group psychotherapy and pharmacotherapy.
PART I
CONCEPTUAL AND
HISTORICAL PERSPECTIVES
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CHAPTER 1
Psychotherapy Integration: Setting the Context
JOHN C. NORCROSS AND CORY F. NEWMAN
IXlVALRY 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 (Goldfried, 1980).
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. Kuhn (1970) has
described this period as a preparadigmatic crisis. Another philosopher of
science, Feyerabend (1970), 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" (p. 209).
As the field of psychotherapy has matured, integration has emerged
as a developing climate of opinion (Murray, 1983). The last 15 years in
particular have witnessed both a general decline in ideological struggle and
the stirrings of rapprochement. The debates across theoretical systems
appear to be less polemical, or at least more issue-specific. The theoretical
substrate of each system is undergoing intensive reappraisal, as psychotherapists acknowledge the inadequacies of any one system and the potential value of others (Norcross, 1986a).
4
HANDBOOK OF PSYCHOTHERAPY INTEGRATION
Current conceptualizations of the nature of therapeutic change are
more complex and multifaceted than ever, both within and between theoretical camps. What seems to be distinctive of the present era is the
tolerance for and assimilation of formulations that were once viewed as
deviant (Arkowitz, 1992; Norcross & Freedheim, 1992). Even those who
believe that the call for rapprochement is unlikely to herald either scientific
progress or patient benefit do generally advocate a spirit of tolerance of
vigorously promulgated positions. That is, mutual acceptance and openness are preferable alternatives to destructive antagonism (Franks, 1984).
The dramatic growth of interest in psychotherapy integration during
the past decade has crystallized into a formal "movement," or more dramatically, a "metamorphosis" in mental health (London, 1988; Moultroup,
1986). While various labels are applied to this movement—eclecticism,
integration, convergence, rapprochement—the goals are similar indeed.
Psychotherapy integration is characterized by a dissatisfaction with singleschool approaches and a concomitant desire to look across and beyond
school boundaries to see what can be learned from other ways of thinking
about psychotherapy and behavior change (Norcross & Arkowitz, 1992).
The ultimate outcome of doing so, not yet fully realized, is to enhance the
efficacy and applicability of psychotherapy (Goldfried, Castonguay, &
Safran, 1992).
Any number of indicators attest to the unprecedented interest in
psychotherapy integration. Eclecticism, or the increasingly favored term
integration (Norcross & Prochaska, 1988), is the modal theoretical orientation of English-speaking psychotherapists (Norcross, Dryden, & Brust,
1992; Norcross, Prochaska, & Gallagher, 1989), and the prevalence may be
rising (Jensen, Bergin, & Greaves, 1990). Leading psychotherapy textbooks
increasingly identify their theoretical persuasion as eclectic (Brabeck &
Welfel, 1985), and an integrative or eclectic chapter is routinely included
in compendia of various treatment approaches. The publication of books
that synthesize various therapeutic concepts and methods continues unabated, now numbering more than 75, and the field has matured to a point
where entire handbooks, such as this one, are deemed useful. The National
Institute of Mental Health (NIMH) recognized the importance of the
movement by sponsoring a workshop on research in psychotherapy integration (Wolfe & Goldfried, 1988). It was their belief "that treatments of
greater efficacy, efficiency, and safety will result from efforts to integrate
the best elements from different schools of psychotherapy. In addition,
research on integrated treatment models may lead to the development of
a comprehensive model of psychotherapy process that will have solid
empirical backing."
Reflecting and engendering the burgeoning field have been the establishment of interdisciplinary psychotherapy organizations devoted to
Psychotherapy Integration
5
integration—notably the Society for the Exploration of Psychotherapy
Integration (SEPI)—and of international publications, including SEPI's journal of Psychotherapy Integration, the Journal of Integrative and Eclectic Psychotherapy, and Integrative Psychiatry. The surge of integrative fervor will
apparently persist well into the 1990s: a recent panel of psychotherapy
experts portended its escalating popularity throughout this decade (Norcross, Alford, & DeMichele, 1992).
A spirit of open inquiry and lively debate pervades the entire field of
psychotherapy, as evidenced by the appearance of several series of integrative articles in "pure-form" or discipline-specific journals. Representative
journals include: Behavior Therapy (Kendall, 1982; Wachtel, 1982; Goldfried, 1982; Garfield, 1982); the British journal of Clinical Psychology (Yates,
1983; Davis, 1983; Messer, 1983; Murray, 1983; Wachtel, 1983); the British
Journal of Guidance and Counselling (Dryden & Norcross, 1989; Norcross &
Grencavage, 1989; Lazarus, 1989b; Beitman, 1989; Messer, 1989); and
Psychiatric Annals (Babcock, 1988; Birk, 1988; London & Palmer, 1988;
Rhoads, 1988; Powell, 1988). A major article on psychotherapy integration
appeared in the American Journal of Psychiatry (Beitman, Goldfried, & Norcross, 1989), and theoretical integration figured prominently in an Annual
Review of Psychology chapter on individual psychotherapy (Goldfried,
Greenberg, & Marmar, 1990). While psychotherapy integration has indeed
come of age, we clearly have not yet attained consensus or convergence.
As Lazarus (1992) notes, the field of psychotherapy is still replete with cult
members, devoted followers of a particular school of thought. High priests
of psychological health are still engaged in competitive strife and internecine battles. These battles have receded but have not been extinguished.
We do not intend to imply that all adverse reactions and cautionary
pleas in response to integration represent mere stubbornness (Allport,
1968; Henle, 1986; Messer, 1992). Many clinicians express considerable
satisfaction with their respective "schools" of therapy (Norcross & Prochaska, 1983). Profound epistemological and ontological differences also
impede rapid or wholesale integration. But even here, most antagonists
believe the movement "deserves a fair hearing and a substantial trial"
(Messer, 1983, p. 132).
A consensus has been achieved, however, in support of the idea that
neither extreme of traditional fragmentation or premature unification will
wisely serve the field of psychotherapy or its clients. At present, we are in
no position to judge, once and for all, which single theory, single technique,
or single unification scheme is best. In view of the early stage of the
integration movement and in view of fundamental philosophical differences separating therapists, it is unrealistic to advance exclusively any one
metatheoretical monolith (Norcross, 1991). Although it might be more
satisfying and elegant if the psychotherapy world were not a multiverse,
6
HANDBOOK OF PSYCHOTHERAPY INTEGRATION
but a universe, the pluralists assure us that this quest will not be realized,
at least not soon (Messer, 1992).
In the meantime, numerous psychotherapists are exploring and working toward integration in the Zeitgeist of informed pluralism. There is also
a promising and growing number of clinicians who, while maintaining their
own theoretical identities, are nonetheless willing to explore potential
sources of enrichment and convergence. This coterie of integration enthusiasts are examining multiple paths toward integration, as is evident throughout this book. Divergent but testable perspectives are required to combat
the ingrained, "one-truth," unitary conceptions of psychotherapy practice.
Plan of the Chapter
The present chapter explicates the broad context of psychotherapy integration and sets the stage for the subsequent chapters in the volume. As our
chapter title indicates, we provide an overview of the salient issues rather
than an exhaustive treatment; "breadth over depth," a motto of many
eclectics (see Lazarus, 1992), characterizes our objective. We begin by
describing the converging reasons for the recent preoccupation with psychotherapy integration, after which we review three predominant modes
of contemporary integration and delimit the parameters of the nascent
integration movement. This segues into a brief consideration of the varieties of integration, which includes summaries of recent studies on the
prevalence and subtypes of eclectic/integrative therapies. The chapter
concludes with discussions of recurrent obstacles to, and emerging themes
of, 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 (French, 1933).
Although the notion of integrating various therapeutic approaches
has intrigued mental health professionals for some time (Goldfried &
Newman, 1992), it has only been within the past 15 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
Psychotherapy Integration
7
number of publications (Arkowitz, 1992) and development of organizations and journals (Goldfried & Newman, 1992), reveals occasional stirrings before 1970, a growing interest during the 1970s, and rapidly accelerating interest from 1980 to the present.
The recent and rapid increase in integrative psychotherapies leads one
to inquire, Why now? What present conditions have encouraged the field
to give specific attention and credence of late to an elusive goal that has
been around for over half a century? At least eight interacting, mutually
reinforcing factors have fostered the development of integration in the past
two decades:
1.
2.
3.
4.
5.
6.
7.
Proliferation of therapies
Inadequacy of single theories
External socioeconomic contingencies
Ascendancy of short-term, problem-focused treatments
Opportunities to observe and experiment with various treatments
Paucity of differential effectiveness among therapies
Recognition that therapeutic commonalities heavily contribute to outcome variance
8. Development of a professional network for integration
The sheer proliferation of diverse schools has been one important
reason for the surge of integration. The field of psychotherapy has been
staggered by too many choices and fragmented by future shock. Which of
400-plus therapies should be studied, taught, or bought? Conflicting and
untested theories are advanced almost daily, and no single theory has been
able to corner the market on utility. London (1988, pp. 5-6) wryly observes
that the hyperinflation of brand-name therapies has produced narcissistic
fatigue: "With so many brand names around that no one can recognize, let
alone remember, and so many competitors doing psychotherapy, it is
becoming too arduous to launch still another new brand."
A related and second factor is the growing awareness that no one
approach is clinically adequate for all cases. Beutler (1983) suggests that the
proliferation of theories is both a cause and symptom of the problem—that
neither the theories nor the techniques are adequate to deal with the
complexity of psychological problems. Kazdin (1984, p. 139) writes that
underlying the ecumenical spirit is the "stark realization" that narrow
conceptual positions and simple answers to major questions do not begin
to explain current evidence in many areas of psychotherapy. Clinical
realities have come to demand a more flexible, if not integrative, perspective. Surveys of self-designated eclectic clinicians reveal that their alignment is motivated in part by disillusionment with single-therapy systems
(Garfield & Kurtz, 1977; Norcross & Prochaska, 1988). Indeed, very few
8
HANDBOOK OF PSYCHOTHERAPY INTEGRATION
therapists adhere tenaciously to a single therapeutic tradition (Jensen,
Bergin, & Greaves, 1990; Smith, 1982).
The proliferation of therapies and the inadequacies of single models
were in part precipitated by a matrix of economic and social pressures in
the 1970s. London (1983) suggests that integration was spurred along by
such occurrences as the advent of legal accreditation of psychologists, with
a resultant surge in professional practice and growth of psychological trade
schools; the destigmatization of psychology services, spurred by the
human potential movement; the onset of federal financial support for
clinical training; and insurance companies' financing of psychotherapeutic
treatment.
Attacks from outside the mental health professions have started to
propel them together. Psychotherapy has experienced mounting pressures
from such not easily disregarded sources as the courts, government policymakers, informed consumers, insurance companies, and national health
insurance planners. Third parties and the public started to demand crisp and
informative answers regarding the quality, durability, and efficiency of
psychosocial treatments (Parloff, 1979, 1981). Without some drastic
changes (not the least of which is the movement for therapeutic integration), psychotherapists stand to lose prestige, customers, and money. As
Mahoney (1984a) puts it, there is something to be said for having the
different therapies "hang together," rather than "hang separately."
Related to these escalating socioeconomic realities has been the rising
interest in short-term, problem-focused psychotherapies during the past 20
years. Standard professional review of treatment, tightening insurance
reimbursement, and declining federal support for mental health services
began to startle clinical practitioners out of their long-term—model complacency. Managed mental health care portends a future discontinuous with
our expansive past; short-term therapy has become the model of 1990s
psychotherapy.
The interest in short-term therapies has been accompanied by the
development of more problem-focused therapies. A common emphasis on
a problem focus has brought formerly different therapies closer together
and has created variations of different therapies that are more compatible
with each other. Integration, particularly in the form of technical eclecticism, responds to the pragmatic time-limited injunction of "which therapy
works better (and quicker) for this patient with this problem in this setting."
In one study of 294 HMO therapists, for instance, Austad, Sherman, and
Holstein (1991) discovered that the prevalence of eclecticism/integration
as a theoretical orientation nearly doubled as a function of their employment in HMOs favoring brief, problem-focused psychotherapy.
A fifth factor in the promotion of psychotherapy integration over the
last two decades has been the increasing opportunities for clinicians of
Psychotherapy Integration
9
disparate orientations actually to observe and experiment with various
treatments (Arkowitz, 1992). Since the 1970s, the establishment of specialized clinics for the treatment of specific disorders—sexual dysfunctions,
agoraphobia, obsessive-compulsive disorders, depression, and eating disorders, to name just a few—have afforded exposure to other theories and
therapies, and stimulated some to consider other orientations more seriously (London & Palmer, 1988). These clinics are often staffed by professionals of different orientations and disciplines, with greater emphasis on
their expertise about the clinical problem than on their theoretical orientation per se. Moreover, a number of specific treatment manuals have been
produced of late (e.g., Beck, Rush, Shaw, & Emery, 1979; Luborsky, 1984;
Strupp & Binder, 1984), which Luborsky and DeRubeis (1984) have labeled
a "small revolution." The availability of more clearly described therapy
procedures has permitted more accurate comparisons and contrasts among
them, providing further impetus for various approaches to psychotherapy
integration (Norcross & Arkowitz, 1992). In behavioral terms, these developments 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.
Despite a noticeable increase in the quantity and quality of psychotherapy outcome studies, research has revealed surprisingly few significant
differences in outcome among different therapies; with several exceptions,
there is little evidence to recommend the use of one type over another in
the treatment of specific problems (Lambert, Shapiro, & Bergin, 1986;
Smith, Glass, & Miller, 1980). Luborsky, Singer, and Luborsky (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." While we must be cautious in
accepting the null hypothesis (Beutler, 1991), and while there are many
possible interpretations of such findings (Stiles, Shapiro, & Elliott, 1986),
they very likely served as a catalyst for many who began to consider
integrative interpretations of these results.
A paradox has emerged from the equivalence conclusion: no consistent differential effectiveness despite technical diversity (Stiles et al., 1986).
A number of resolutions to this paradox have been advanced, including the
unspecificity of outcome measurement, the poor integrity of treatments,
and the inadequate statistical power to detect treatment differences (regarding the latter, see Kazdin & Bass, 1989). The two most common responses
seem to be a specification of factors common to successful treatments and
a synthesis of useful concepts and methods from disparate therapeutic
traditions.
10
HANDBOOK OF PSYCHOTHERAPY INTEGRATION
The field has slowly shifted to a new direction toward determining
therapeutic commonalities (Gomes-Schwartz, Hadley, & Strupp, 1978)—a
seventh contributor to the rise of integration. It has been suggested that
therapeutic success can best be predicted by the properties of the patient
and the working alliance—all transtheoretical features of psychotherapy
(e.g., Arkowitz, I992a; Beutler & Crago, 1991; Frank, 1979; Frieswyk et al,
1986; Horvath & Symonds, 1991, Lambert, 1992). Only 10 to 15 percent
of outcome variance is generally accounted for by technique variables
(Beutler & Clarkin, 1990; Lambert, 1989, 1992; Smith, Glass, & Miller,
1980).
In his classic Persuasion and Healing, Frank (1973) posits 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 the pluralistic,
competitive American society. Since the prestige and financial security of
psychotherapists hinge on their being able to show that their particular
approach is more successful than that of their rivals, little glory has been
traditionally accorded the identification of shared or common components.
Last but not least, the development of a professional network has
been both a consequence and cause of interest in psychotherapy integration. During the 1970s the strands of psychotherapy integration were
available, but they did not yet form a connected and unified body of
thought. In 1983, the interdisciplinary Society for the Exploration of Psychotherapy Integration (SEPI) was formed (see description by Goldfried &
Newman, 1992) to bring together those who were intrigued by the various
modes of rapprochement among the psychotherapies. The organization
has brought together integration enthusiasts through a newsletter, annual
conferences, regional networks, and a quarterly journal, thus simultaneously reflecting and promulgating the integrative spirit throughout the
therapeutic community.
Three Routes to Integration
There are numerous pathways toward the integration of the psychotherapies (Mahrer, 1989). The three most popular routes at present are (1)
technical eclecticism, (2) theoretical integration, and (3) common factors
(Arkowitz, 1989; Norcross & Grencavage, 1989). All three directions 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. They do
so, however, in rather different ways and at different levels.
Psychotherapy Integration
11
TECHNICAL ECLECTICISM
Eclecticism is the least theoretical of the three, 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 data 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 eclectic models of Beutler (1983; Beutler & Clarkin,
1990; Beutler & Consoli, 1992) and Lazarus (1971, 1976, 1989a, 1992) are
exemplars of this form of integration.
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 metabeliefs 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).
THEORETICAL INTEGRATION
In this 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 on integrating the underlying
theories of psychotherapy—what London (1986) has eloquently labeled
"theory smushing"—along with the integration of therapy techniques
from each—what London has called "technique melding." The various
proposals to integrate psychoanalytic and behavioral theories illustrate this
direction, most notably the work of Wachtel (1977, 1987; Wachtel &
McKinney, 1992), and grander schemes to meld all the major systems of
psychotherapy, for example, the transtheoretical approach of Prochaska
and DiClemente (1984, 1986, 1992). Other writers have focused on different hybrids (e.g., Appelbaum, 1976; Feldman & Pinsof, 1982; Gunman,
1981; Held, 1984; LeBow, 1984; Segraves, 1982; Thoresen, 1973; Wachtel
& Wachtel, 1986; Wandersman, Poppen, & Ricks, 1976).
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, however, aspires to more than
a simple combination; it seeks an emergent theory that is more than the
12
HANDBOOK OF PSYCHOTHERAPY INTEGRATION
sum of its parts, and that leads to new directions for practice and research.
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? The NIMH Workshop (Wolfe & Goldfried, 1988) and
two studies (Norcross & Napolitano, 1986; Norcross & Prochaska, 1988)
have clarified these questions. 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
early 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):
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 constant
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.
TABLE 1.1
Eclecticism vs. Integration
Eclecticism
Integration
Technical
Theoretical
Divergent (differences)
Convergent (commonalities)
Choosing from many
Combining many
Applying what is
Creating something new
Collection
Blend
Applying the parts
Unifying the parts
Atheoretical but empirical
More theoretical than empirical
Sum of parts
More than sum of parts
Realistic
Idealistic
Psychotherapy Integration
13
Further consideration of the relative merits of theoretical integration versus
technical eclecticism can be found in Goldfried and Wachtel (1987), Beutler
(1989), and Arkowitz (1989), as well as Lazarus (1989a) and Beitman (1989).
COMMON FACTORS
The common factors approach seeks to determine the core ingredients that different therapies share in common, with the eventual goal of
creating more parsimonious and efficacious treatments based on those
commonalities. This search is predicated on the belief that commonalities
are more important in accounting for therapy outcome than the unique
factors that differentiate among them. The long considered "noise" in
psychotherapy research is being reconsidered by some as the main "signal"
elements of treatment (Omer & London, 1988). The work of Arkowitz
(1992a), Beitman (1987, 1992), Frank (1973, 1982), and Garfield (1980,
1986, 1992) have been among the most important contributions to this
approach.
One way of determining common therapeutic principles is by focusing on a level of abstraction somewhere between theory and technique.
This intermediate level of abstraction, known as a clinical strategy or a
change process, may be thought of as a heuristic that implicitly guides the
efforts of experienced therapists. Goldfried (1980, p. 996) argues:
To 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.
Nonetheless, more than commonalities are evident across the therapies; there are unique or specific factors attributable to different therapies
as well. One of the important achievements of psychotherapy research,
observe Lambert and Bergin (1992), is demonstration of the differential
effectiveness of a few therapies with specific disorders, such as behavior
therapy for child conduct disorders, conjoint therapy for marital conflict,
and cognitive therapy for panic disorder. As Lambert (1992) concludes in
chapter 3, eclectic therapies should emphasize those factors common across
therapies highlighted in research while capitalizing on the contributions of
specific techniques.
The nascent consensus on the specific versus common factors controversy is that it is not either/or, not a dualism. The proper use of common
14
HANDBOOK OF PSYCHOTHERAPY INTEGRATION
and specific factors in therapy will probably be most effective for clients
and most congenial to practitioners (Garfield, 1992). To invoke the title of
Beitman's (1992) chapter, we will gradually integrate by combining fundamental similarities and useful differences across the schools. Treasure our
sameness, but respect our differences.
In clinical work, the distinctions among these three thrusts of psychotherapy integration are not so apparent. The distinctions may be largely
semantic and conceptual, not particularly functional, in practice. Few clients
experiencing an "integrative" therapy would be able to distinguish among
them (Norcross & Arkowitz, 1992).
Moreover, we hasten to add that these integrative strategies are not
mutually exclusive. No technical eclectic can totally disregard theory, and
no theoretical integrationist can ignore technique. Without some commonalties among different schools of therapy, theoretical integration would be
impossible. And even the most ardent proponent of common factors
cannot practice "nonspecifically" or "commonly"; specific techniques must
be applied.
DEFINING THE PARAMETERS OF INTEGRATION
By common decree, technical eclecticism, common factors, and theoretical 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, family,
group—and the combination of medication and psychotherapy? In both
cases, a strong majority of clinicians—80 percent plus—consider these to
be within the legitimate boundaries of integration (Norcross & Napolitano,
1986). Of course, the inclusion of psychopharmacology enlarges the scope
to integrative treatment, rather than integrative psychotherapy per se.
Integrative treatments have begun to consider seriously the role of psychosocial and psychopharmacological interventions (Beitman, Hall, & Woodward, 1992) and combined therapy formats (Allen, 1988; Clarkin, Frances,
& Perry, 1992; Feldman & Powell, 1992; Wachtel & Wachtel, 1986).
Another thrust recently proposed as a part of psychotherapy integration is the infusion of theory and research in the behavioral sciences to
inform psychotherapy. This type of integration aspires to enhance our
knowledge of change processes by turning to basic knowledge on cognition, affect, development neuroscience, biological substrates, interpersonal
influences, and community interventions (see Goldfried, Castonguay, &
Safran, 1992). This direction is illustrated by the work of Arkowitz (199lb),
Greenberg and Safran (1987), Horowitz (1988, 1991), Mahoney (1991),
Psychotherapy Integration
15
Schwartz (1991), Stein (1992), and Wolfe (1989, 1992), among others. It
may be considered to be a form of theoretical integration, but the theories
to which this approach turn are not psychotherapy theories per se, but any
empirically supported theory that would serve to elucidate aspects of the
change process (Arkowitz, 1992b).
Varieties of Integrative Experience
Integration, as is now evident, comes in many guises and manifestations
(Mahrer, 1989; Schacht, 1984). It is clearly neither a monolithic entity nor
a single operationalized system; to refer to the integrative approach to
therapy falls prey to the "uniformity myth" (Kiesler, 1966). The goals of
this section are to explicate the immense heterogeneity in the psychotherapy integration movement, and to review studies on self-identified integrative and eclectic therapists. As our research and practice evolve, it is
expected that much of this information will be supplemented and revised.
PREVALENCE OF INTEGRATION
Approximately one-third to one-half of contemporary American clinicians disavow an affiliation with a particular school of therapy, preferring
instead the label of "eclectic" or "integrative." Some variant of eclecticism
or integration is routinely the modal orientation of responding psychotherapists. Summarizing 10 studies conducted in the 1980s on the membership
of general psychotherapy organizations, Norcross (1986b) reported the
incidence varied from 30 percent to 55 percent. Reviewing 25 studies
performed between 1953 and 1990, Jensen, Bergin, and Greaves (1990)
reported a range from 19 percent to 68 percent, the latter figure being their
own finding. It is difficult to explain these variations in percentages, but
differences in the organizations sampled, the questions asked, and the years
of the investigation probably account for some of the variability.
Nor is eclecticism restricted to members of general American psychotherapy organizations. Surveys of dues-paying members of orientationspecific 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 percent in the former and 31 percent in the latter (Norcross
& Wogan, 1983; Swan, 1979). Results from Western Europe and nonEuropean, English-speaking countries also indicate eclecticism is a popular
approach; for example, among British clinical psychologists, the primary
theoretical orientations are eclectic (27 percent), behavioral (27 percent),
and cognitive (21 percent; Norcross, Dryden, & Brust, 1992).
16
HANDBOOK OF PSYCHOTHERAPY INTEGRATION
While relatively easy to ascertain self-reported prevalence of eclecticism, 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 (Goldfried, 1991;
Lambert, 1992). Until greater precision is attained in descriptions and
practices, the crucial question of whether outcomes are enhanced by integrative approaches will remain unanswered. "Thus the many efforts to
understand the diversity in therapist orientations will have been wasted
unless it can be shown that specific combinations of techniques produce
superior outcomes with given disorders" (Jensen, Bergin, & Greaves, 1990,
p. 129).
INTEGRATIVE
THERAPISTS
With such large proportions of contemporary therapists embracing
integration/eclecticism, it would be informative to identify distinctive characteristics or attitudes of eclectics as compared to noneclectics. Demographically, there do not appear to be any consistent differences between
the two groups, with the exception of clinical experience (Norcross &
Prochaska, 1982; Norcross & Wogan, 1983; Walton, 1978). Clinicians
ascribing to eclecticism tend to be older and, concomitantly, more experienced. Inexperienced therapists are more likely to endorse exclusive theoretical orientations (Norcross & Prochaska, 1982; Smith, 1982). 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, Crago, & Arizmendi, 1986; Parloff, Waskow, &
Wolfe, 1978).
Attitudinally, eclectic clinicians differ from their noneclectic colleagues in several respects. First, eclectics report relatively greater dissatisfaction with their current conceptual frameworks and technical procedures
(Norcross & Prochaska, 1983; Norcross & Wogan, 1983; Vasco, GarciaMarques, & 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, consistent
with the prescriptive ideology, eclectics rate themselves as less influenced
in practice than noneclectics by particular theories but more influenced by
their clientele and by pragmatic considerations (e.g., setting and length of
treatment).
From a personal-historical perspective, Robertson (1979) identifies six
factors that may facilitate the choice of eclecticism. The first is the lack of
Psychotherapy Integration
17
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 making a philosophy of life; Robertson asserts that eclecticism is
more likely to follow the former. In the words of several distinguished
scientist-practitioners (Ricks, Wandersman, and 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 are personality variables: an obsessivecompulsive 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 common training
experiences and the personal histories of prominent clinicians represented
in this volume (see chapters 5—13).
SURVEY GLIMPSES
Definitions of psychotherapy integration do not tell us what individual psychotherapists actually do or what it means to be an eclectic or
integrative therapist. In an early survey of eclectic psychologists, 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 psychoanalytic and learning theory,
neo-Freudian and learning theory, neo-Freudian and Rogerian theory,
learning theory and humanistic theory, and Rogerian and learning theory.
Most combinations, however, were blended and employed in an idiosyncratic fashion. It could not be determined whether the most efficacious
procedures were indeed selected from the combined perspectives. The
investigators concluded that the designation of eclectic covers a wide range
of views, some of which are apparently quite distinct from others.
Garfield and Kurtz (1977) found that almost half their sample indicated that they employed "whatever seemed best for the client." These
pragmatic clinicians—resembling our definition of technical eclectics—
reportedly select procedures according to the requirements of individual
18
HANDBOOK OF PSYCHOTHERAPY INTEGRATION
clients. Two groups of respondents, accounting for 26 percent of the
sample, replied that they basically combine two or three theories in their
clinical work. These therapists—representing theoretical integrationists—
considered themselves eclectic because they did not adhere to just one
theoretical perspective. Five percent, representing a fourth vantage point,
responded rather vaguely that "no theory is adequate and some are better
for some purposes than others" (Garfield & Kurtz, 1977, p. 82).
A ten-year "revisitation" of eclectic views by Norcross and Prochaska
(1988) enlarged and updated the seminal Garfield and Kurtz (1977) results.
Forty-two percent of 113 self-designated eclectics had not previously adhered to a particular theoretical perspective, whereas 58 percent indicated
that they had. Similar findings—46 percent and 49 percent, respectively—
were secured in the original study (Garfield & Kurtz, 1977). Of those with
prior theoretical allegiances, 44 percent followed psychodynamic viewpoints, and 27 percent adhered to a behavioral orientation. Other previous
viewpoints included client centered (12 percent), cognitive (6 percent), and
psychoanalytic (6 percent). Thus, as with the 1977 findings and other
studies (e.g., Jayaratne, 1982; Jensen, Bergin, & Greaves, 1990), the largest
shift occurred from the psychodynamic persuasion, accounting for about
one-half of the sample with previous alliance.
The eclectic clinicians rated their frequency of use of six theories (i.e.,
behavioral, cognitive, humanistic, interpersonal, psychoanalytic, systems)
in clinical practice. The resulting six theoretical views formed a matrix of
15 possible nonredundant dyadic combinations, each of which was selected
by at least one respondent. The evolving prototypical combinations of
theoretical orientations are shown in table 1.2, along with the earlier
findings of Garfield and Kurtz. The three most frequent combinations
accounted for 32 percent of the respondents in the 1980s study but only
5 percent in 1976. Although all 15 possible combinations were represented,
a cognitive-behavioral integration was the most common, followed closely
by humanistic-cognitive and psychoanalytic-cognitive syntheses. Interestingly, the three most frequent combinations all involve cognitive theory
(see Alford & Norcross, 1991, and Beck, 1991, for related accounts). The
modal combination in the 1970s was psychoanalytic-behavioral, accounting for 25 percent of the sample; however, this combination, advocated by
4 percent of the newer sample, ranked as the ninth most frequent in the late
1980s.
This study and other research (Norcross & Napolitano, 1986; Norcross & Prochaska, 1983) demonstrates an emerging preference for both
the term integration and the practice of theoretical integration, as opposed
to technical eclecticism. Clinicians prefer the self-identification of integrative over eclectic by an almost two-to-one margin. This preference for
integration over eclecticism probably represents a historical shift. In the
19
Psychotherapy Integration
TABLE 1.2
Mosf Frequent Combinations of Theoretical Orientations
1986
1976*
Combination
%
Cognitive and behavioral
12
1
Humanistic and cognitive
11
2
Psychoanalytic and cognitive
10
3
Rank
%
Rank
5
4
8
4
11
3
Interpersonal and humanistic
8
4
3
6
Humanistic and systems
6
6
Psychoanalytic and interpersonal
5
7
Systems and behavioral
5
7
Behavioral and psychoanalytic
4
9
25
1
Behavioral and humanistic
'Percentages and ranks were not reported for all combinations in the 1976 study (Garfield
& Kurtz, 1977).
1976 investigation (Garfield & Kurtz, 1977), most favored eclecticism; in
the 1986 study (Norcross & Prochaska, 1988), most favored integration.
There seems to have been a theoretical progression analogous to social
progression: one that proceeds from segregation to desegregation to integration. Eclecticism has represented desegregation, in which ideas, methods, and people from diverse theoretical backgrounds mix and intermingle.
Currently, we appear to be in transition from desegregation to integration,
with increasing efforts directed at discovering viable integrative principles
for assimilating and accommodating the best that different systems have to
offer.
Sophisticated integrative practice obviously is more complex than
these brief survey glimpses can provide. To echo the authors of the original
study, "Some value psychodynamic views more than others, some favor
Rogerian and humanistic views, others clearly value learning theory, and
various combinations of these are used in apparently different situations by
different clinicians" (Garfield & Kurtz, 1977, p. 83). However, eclecticism
seems to have gradually lost some of its negative definition as a nondescript brand name for those dissatisfied with orthodox schoolism. Instead, these clinicians actively and positively endorsed eclecticism as much
as for what it offers as for what it avoids. In other words, integration "by
design" is steadily replacing eclecticism "by default."
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HANDBOOK OF PSYCHOTHERAPY INTEGRATION
ECLECTICISM VERSUS SYNCRETISM
The term eclecticism has acquired an emotionally ambivalent, if not
negative, connotation for some clinicians due to its previously 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). Dryden (1984) observes that many of these
psychotherapists wander around in a daze of professional nihilism, experimenting with new "fad" methods indiscriminately. Indeed, it is surprising
that so many clinicians admit to being eclectic in their work, given the
negative valence the term has acquired (Garfield, 1980).
But much of the opposition to eclecticism should be properly redirected to syncretism—uncritical and unsystematic combinations (Norcross, 1990; Patterson, 1990). This haphazard "eclecticism" is primarily an
outgrowth of pet techniques and inadequate training, an arbitrary, if not
capricious, blend of methods "by default." Eysenck (1970, p. 145) characterizes this indiscriminate smorgasbord as a "mish-mash of theories, a huggermugger of procedures, a gallimaufry of therapies," having no proper rationale or empirical verification. This muddle of idiosyncratic and ineffable
clinical creations is the antithesis of effective and efficient psychotherapy
(Lazarus, Beutler, & Norcross, 1992).
Systematic eclecticism, by contrast, is the product of years of painstaking clinical research and experience. It is truly eclecticism "by design,"
that is, clinicians competent in several therapeutic systems who systematically select interventions based on patient need and comparative outcome
research (Norcross, I986a). The strengths of systematic integration lie in
its ability to be taught, replicated, and evaluated. Rotter (1954, p. 14), years
ago, summarized the matter as follows: "All systematic thinking involves
the synthesis of pre-existing points of views. It is not a question of whether
or not to be eclectic but of whether or not to be consistent and systematic."
This distinction between eclecticism (by design) and syncretism (by
default) can be illustrated by quilt making, a metaphorical representation
of the process of blending diverse methods. The selection of materials
and the construction of a quilt are reciprocally determined by the craftsperson's training, experiences, and preferences. Quilt makers do not mechanically select their swatches from the entire universe of possible materials. Instead, the possible materials are restricted to those in their
possession, to remnants of old projects, and to those that can be readily
acquired (in psychological terms: psychoanalytic, behavioral, experiential,
etc.). And it is certainly the case that one cannot include materials that
one does not possess. Furthermore, one can construct a quilt out of incomplete materials and scraps (by default) or, alternatively, from an abun-
Psychotherapy Integration
21
dance of rich and diverse materials (by design). Because quilt makers
must peddle their wares in the public marketplace, they create products
to match consumers' desires. Increasingly, quilts are tailored to the recipient, not the artisan. Each recipient's needs differ, however, resulting in
greater demands on the quilt maker. Some quilt makers refuse to sacrifice
their own preferences to cater to others' needs. These craftspeople continue in their own tradition, although to a smaller and narrower range of
clientele. The new line of quilt makers strive to acquire the necessary
resources to meet varied consumer demands and extend their wares to a
growing segment of the market.
THREE STAGES
Werner's (1948; Werner & Kaplan, 1963) organismic-developmental
theory is instructive for conceptualizing psychotherapists' development of
a sophisticated integrative stance (also see Kaplan et al., 1983; Rebecca,
Hefner, & Oleshansky, 1976). In the first of three developmental stages,
one perceives or experiences a global whole, with no clear distinctions
among component parts. Unsophisticated laypersons and undergraduates
probably fall into this category.
In the second stage, one perceives or experiences differentiation of
the whole into parts, with a more precise and distinct perspective of
components within the whole. However, one no longer has a perspective
on the whole, and subsequently loses the "big picture." Most psychotherapy courses, textbooks, and clinically inexperienced practitioners fall into
this category.
In the third stage, the differentiated parts are organized and integrated
into the whole at a higher level. Here, the unity and the complexity of
psychotherapy are appreciated. It is to this level, we believe, that psychotherapy should aspire in practice, theory, research, and training.
ROLE OF PURE-FORM THERAPIES
Conspicuously absent from this overview chapter on integration has
been acknowledgment of the conventional, "pure-form" (or brand-name)
therapy systems, such as psychoanalytic, behavioral, and experiential.
While perhaps not immediately apparent, pure-form therapies are part and
parcel of the integration movement. In fact, integration could not occur
without the constituent elements provided by the respective therapies—
their theoretical systems and clinical methods.
In a narrow sense, conventional therapies do not contribute to the
integration movement because they have not generated paradigms for
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HANDBOOK OF PSYCHOTHERAPY INTEGRATION
synthesizing various interventions and conceptualizations. But in broader
and more important ways, they add to our therapeutic armamentarium,
enrich our understanding of the clinical process, and produce the process
and outcome research from which integration draws. One cannot integrate
what one does not know (Norcross & Grencavage, 1989).
In this respect, we should be reminded that the so-called pure-form
psychotherapies are themselves "second-generation" integrations (Alford
& Norcross, 1991). In factor analytic terms, virtually all neo-Freudian
approaches would be labeled "second order" constructs—a superordinate
result of analyzing and combining the original components (therapies). Just
as Freud necessarily incorporated methods and concepts of his time into
psychoanalysis (Frances, 1988), so, too, do newer therapies. All psychotherapies may, therefore, be viewed as products of an inevitable historical
integration—an oscillating process of assimilation and accommodation
(Sollod, 1988).
This conceptualization of the historical process can temper the judgmental flavor frequently expressed toward opponents of integration. These
antagonistic characterizations—for instance, "rigid," "inveterate," "narrow," "close-minded"—are likely to result in a win-lose, zero-sum encounter, in which the integrative "good guys" seek victory over the separatistic
"bad guys." As Andrews, Norcross, and Halgin (1992) note, this will do
little to promote a welcoming attitude toward integration on the part of
the "opposition," and even less to build on the documented successes of
pure-form therapies. The objective of the integration movement, as is
repeatedly emphasized in this volume's final chapter, is to improve the
efficacy of psychotherapy; to obtain this end, the valuable contributions of
pure-form therapies must be collegially acknowledged and their respective
strengths collaboratively enlisted.
Recurrent Obstacles
The accelerated development of integrative psychotherapies has not always been paralleled by serious consideration of their potential obstacles
and tradeoffs (Arkowitz & Messer, 1984; Dryden, 1986). If we are to avoid
uncritical growth or fleeting interest in eclectic/integrative psychotherapy,
then some honest recognition of the barriers we are likely to encounter is
sorely needed (Goldfried & Safran, 1986). Caught up in the excitement and
possibilities of the movement, we have neglected the problems—the
"X-rated topics" of integration. Healthy maturation, be it for individuals or
for movements, requires self-awareness and constructive criticism.
What is stopping psychotherapy integration now? Norcross and
Thomas (1988) conducted a survey of Society for the Exploration of
23
Psychotherapy Integration
Psychotherapy Integration (SEPI) members to answer this question. Fiftyeight prominent integrationists rated the severity of twelve potential obstacles using a 5-point, Likert-type scale. The top five obstacles and their
mean scores are presented in table 1.3.
The most severely rated obstruction centered around the partisan
zealotry and territorial interests of "pure" systems psychotherapists. Representative responses here were: "egocentric, self-centered colleagues"; "the
institutionalization of schools"; and "ideological warfare, factional rivalry."
Unfortunately, professional reputations are made by emphasizing the new
and different, not the basic and similar. In the field of psychotherapy, as
well as in other scientific disciplines, the ownership of ideas gets far too
much emphasis. Although the idea of naturally occurring, cooperative
efforts among professionals is engaging, their behavior, realistically, may
be expected to reflect the competition so characteristic of our society at
large (Goldfried, 1980).
Inadequate training in eclectic/integrative therapy was the secondranked impediment. Training students to competence in multiple theories
and interventions is unprecedented in the history of psychotherapy. Understandable in light of its exacting and novel nature, the acquisition of
integrative perspectives has occurred quite idiosyncratically and perhaps
serendipitously to date (see Andrews et al., 1992; Robertson, 1986). Needless to say, designing an integrative training program is a near overwhelm-
TABLE 1.3
Obstacles to Psychotherapy Integration
Severity Rating
Obstacle
Intrinisic investment of individuals in
their private perceptions and theories
Inadequate commitment to training in
more than one psychotherapy system
Approaches have divergent assumptions
about psychopathology and health
Inadequate empirical research on the
integration of psychotherapies
Absence of a "common" language for
psychotherapists
1 = not an obstacle; 3 = moderate obstacle; 5 = severe obstacle
Mean
Rank
3.97
1
3.74
2
3.67
3
3.58
4
3.47
5
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HANDBOOK OF PSYCHOTHERAPY INTEGRATION
ing task; trying to master such a program (as a student) may be even more
intimidating.
Starting in the 1980s a fair amount of emphasis has begun to be
placed on this topic of vital importance for the future of the field. For
example, three special sections of the journal of Integrative and Eclectic
Psychotherapy have addressed integrative training and supervision (Beutler
et al, 1987; Halgin, 1988; Norcross et al., 1986). As another example, a
substantial majority of the contributors to the Handbook of Eclectic Psychotherapy put forth their ideas on a suitable integrative curriculum for graduate students and trainees. By and large, the individual authors of the
Norcross (I986a) text collectively argue that the trainee needs some or all
of the following: (1) rigorous training in the scientific method and the
development of critical thinking skills; (2) significant exposure to a number
of the major models of psychotherapy (sequentially or simultaneously);
(3) an apprenticeship model, working closely with, observing, and being
supervised by expert clinicians; (4) intensive training in developing skills
for facilitating therapeutic relationships; and (5) substantial practical experiences with a wide range of populations. Clearly, these are goals to span an
entire career.
The third-ranked obstacle concerned differences in ontological and
epistemological issues. These entail basic and sometimes contradictory
assumptions about human nature, determinants of personality development, and the origins of psychopathology (Messer, 1992). For instance, are
people innately good, evil, both, neither? Do phobias represent learned
maladaptive habits or intrapsychic conflicts? Interestingly enough, it may
be precisely these diverse world views that make psychotherapy integration valuable in that it brings together the individual strengths of these
complementary orientations (Beitman, Goldfried, & Norcross, 1989;
Messer, 1986).
We have not conducted sufficient research on psychotherapy integration: the fourth obstacle to be addressed here. Comparative outcome
research has been a limited source of direction with regard to selection of
method and articulation of prescriptive guidelines. If our empirical research
has little to say, and if collective clinical experience has divergent things
to say, then why should we use one method and not another? Again, we
may be guided by selective perception and personal preference, a situation
the integrative movement seeks to avoid.
We have reached a point where the need to justify psychotherapy
integration as a legitimate area of interest is now being replaced by the
need for relevant research findings (Goldfried, 1991). The adequacy of
various integrative and eclectic approaches remains to be proven (Lambert, 1992; Mahalik, 1990; Norcross, 1986b; Wolfe & Goldfried, 1988).
Psychotherapy Integration
25
The evidence supporting integration is still largely anecdotal and preliminary (Yates, 1983). It is important to note, however, that there is no
evidence of the clinical superiority of any "pure-form" therapy over an
integrative approach (Wachtel, 1983) and that efforts to rectify this
research deficiency are currently under way (see chapters 5—13 in this
volume).
A seemingly intractable obstacle to the establishment of clinically
sophisticated and consensually validated integrative psychotherapies is the
absence of a common language (Norcross, 1987). This was rated the fifth
most serious impediment to progress. Each psychotherapeutic tradition has
its own jargon, a clinical shorthand among its adherents, which widens the
precipice across differing orientations. Goldfried, Castonguay, and Safran
(1992) review the linguistic as well as epistemological and social barriers
to rapprochement.
The "language problem," as it has become known, confounds understanding and, in some cases, leads to active avoidance of each other's
constructs. Many a behaviorist's mind has wandered when case discussions
turn to "transference issues" and "warded-off conflicts." Similarly, psychodynamic therapists typically tune out buzz words like "conditioning procedures" and "discriminative stimuli." Isolated language systems encourage
clinicians to wrap themselves in semantic cocoons from which they cannot
escape and which others cannot penetrate. As Lazarus (1986) concludes,
"Basically, integration or rapprochement is impossible when a person
speaks and understands only Chinese and another converses only in
Greek!" (p. 241).
The purpose of a common language is to facilitate communication,
comprehension, and research (Norcross, 1987). It is not intended to establish consensus. Before an agreement or a disagreement can be reached on
a given matter, it is necessary to ensure that the same phenomenon is in
fact being discussed. Punitive superego, negative self-statements, and poor
self-image may indeed be similar phenomena, but that cannot be known
with certainty until the constructs are defined operationally and consensually (Strieker, 1986).
To be sure, this is a demanding task (Messer, 1987). In the short run,
using the vernacular—descriptive, ordinary natural language—might suffice (Driscoll, 1987). One metaphor for a common metalanguage is the
lingua franca that grows up in marketplaces, where communication among
people of many cultures and languages is honed down to the essentials
needed for transacting essential business (Andrews, 1989). In the long run,
a common language may profit from being linked to a superordinate theory
of personality or derived from an empirical database (e.g., Ryle, 1987;
Strong, 1987).
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HANDBOOK OF PSYCHOTHERAPY INTEGRATION
Emerging Themes
As one examines the modern writings and historical literature on psychotherapy integration, a number of recurring themes emerge. These include:
the complementarity of divergent approaches; the interaction of cognition,
behavior, and affect; the need for empirically based therapies; the advantages of common language(s); and the phenomenon of clinical convergence. The following sections summarize recent views regarding these
emerging themes.
COMPLEMENTARITY OF DIVERGENT APPROACHES
No therapy or therapist is immune to failure. It is at such times that
experienced clinicians often wonder if the therapeutic methods from orientations other than their own might more appropriately have been included
in the treatment program, if another orientation's strength in dealing with
the particular therapeutic problems might complement the therapist's own
orientational weakness in this area.
Even those skeptical about the value of "technique melding" or "theory smushing" in psychotherapy can be enthusiastic about theoretical
complementarity; as we suggested earlier, theoretical schools may not be
contradictory but complementary (cf. Norcross, 1991). Allegedly rival
systems of psychotherapy are not viewed as an adversity but as a healthy
diversity (Landsman, 1974). From this point of view, various orientations
complement each other and enrich the ability of clinicians to understand
and work effectively with their clients. This idea is the basis of Pinsof's
(1983) "Integrative Problem-Centered Therapy," which "rests upon the
twin assumptions that each modality and orientation has its particular
'domain of expertise,' and that these domains can be interrelated to minimize their deficits" (p. 20).
The potential for inter-orientation complementarity among psychodynamic and behavior therapy has been raised repeatedly. Consistent with
Wachtel's (1977, 1987) thesis that people are helped when they are guided
toward translating their insights into action, Fensterheim (1983) suggests
that the therapist can make use of the psychoanalytic style to formulate
hypotheses concerning the way patients organize their perceptions of the
world and to select behavior patterns that pertain to their particular problem. Following this, a behavior therapy style may be applied to change
these behaviors in a systematic and verifiable manner. Another theme of
complementarity, expressed by Messer (1984, 1986), Rhoads (1984), and
Salzman (1984), is that behavioral interventions may be able to provide
some measure of symptomatic relief at the beginning of therapy, thereby
Psychotherapy Integration
27
gaining the client's trust and cooperation to discuss broader lifestyle problems and to engage in greater introspection. As insight is gained, behavior
therapy can be utilized once again to teach the client more adaptive
behaviors, so as to test out the everyday-life effects of this heightened
self-awareness.
Relatedly, the stages or phases of treatment seem to be a particularly
useful conception (e.g., Beitman, 1992; Beutler & Consoli, 1992; Garfield,
1992). The transtheoretical approach of Prochaska and DiClemente (1992)
posits a complementary relationship in which each theory has its own
particular domain of expertise, and these are interrelated to maximize their
assets and minimize their deficits. Specifically, psychoanalytic and strategic
therapies are preeminent in dealing with precontemplators—clients unable
or unwilling to recognize maladaptive behaviors. These therapies are particularly adept at expanding awareness, locating defenses, and addressing
the resistances. Once into the contemplation stage, where clients recognize
the problem but are not yet prepared to alter it, cognitive, existential, and
Bowenian therapies come to the fore. Behavioral and structural strategies
are the most effective for clients who are ready for action. Complimentary,
not contradictory, theories of psychotherapy.
INTERACTION OF COGNITION, BEHAVIOR, AND AFFECT
Depending on the theoretical perspective being taken, the cognitions,
behaviors, and emotions of the patient have been given varying degrees
of relative emphasis. Generally speaking, cognitive therapy has focused on
the more consciously accessible side of the cognitive continuum, psychoanalytic therapy has delved into the unconscious aspects of cognitive processing, experiential orientations have tended to focus more on emotionality, and behavior therapy has been well known for its emphasis on action.
Lazarus's (1967, 1976, 1992) work on a "multimodal" therapy may
have paved the way for some of the questions that the integrative psychotherapist seems to be asking, such as, "Why not be prepared to give strong
emphasis to the interaction of cognitions, behavior, and affect?" (e.g., Mahoney, 1984b; Schwartz, 1982), and "Shouldn't the choice to concentrate
on one component more than the others be a function of patient characteristics instead of the therapist's training?" (e.g., Driscoll, 1984). A threedimensional affective-cognitive-behavior schema in therapy may be a more
parsimonious guide in the selection of specific theories for conceptualization and intervention (Ward, 1983). Steinfield (1980) and Staats (1981)
have similarly supported the adoption of a unified-interactive framework
that includes cognition, behavior, and affect, adding that there must be an
accompanying theoretical model as well as a systematic program of
research.
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HANDBOOK OF PSYCHOTHERAPY INTEGRATION
Safran (1984; Safran & Segal, 1990) deals with the interaction of
cognition, behavior, and affect in incorporating Sullivanian principles into
cognitive-behavioral treatment. He suggests that Sullivanian concepts (of
self-perception and perception of others), if translated into a language
consistent with experimental cognitive and social psychology, can supplement a cognitive-behavioral assessment by providing the conceptual
framework within which to examine "hot" information processing occurring within an emotional and/or interpersonal context. Greenberg and
Safran (1984, 1987, 1989) go on to make a serious attempt at conceptualizing the integration of affective and cognitive processes, based on experimental data and models of information processing. Although this is a
rigorous undertaking, they are quick to acknowledge that "it is essential to
recognize the complex interdependence of the thinking, feeling, and action
systems" (1984, p. 561).
NEED FOR EMPIRICALLY BASED THERAPIES
Clinicians and researchers of differing orientations have long called
for the development of psychotherapies with a strong empirical base, and
psychotherapy integrationists have rallied around this call. Early on, Lazarus (1967, 1971) recommended an eclectic therapy as most potent when
clinicians made use of (and further experimented with) a set of empirically
useful methods. Beutler's (1983), Dryden's (1984), Fensterheim and Glazer's
(1983), Garfield's (1980), and Segraves's (1982) respective volumes on
eclectic psychotherapy also aspire to an empirical approach.
An empirical base for practice has at least two meanings (Fischer,
1986). The first is the use of research to inform practice, as in the selection
of clinical techniques and interpersonal stances; the second is in the careful,
objective evaluation of the effects of the psychotherapies. The latter is
particularly urgent because there is little unambiguous evidence of the
clinical superiority of an integrative approach over existing systems (Lambert, 1992; Yates, 1983).
We need to discover, in functional terms, which therapist behaviors
and treatment strategies are more effective with which types of clients
(Cross & Sheehan, 1981; Paul, 1967). In this respect, a natural affinity exists
between process research and psychotherapy integration (Beutler & Clarkin, 1990; Goldfried and Safran, 1986; Wolfe & Goldfried, 1988). Processoutcome research can contribute to all three thrusts of the integrative
movement—by stimulating theory (theoretical integration), by identifying
effective methods for that disorder and that client (technical eclecticism),
and by delineating transtheoretical elements (common factors).
Although many authors have enumerated common therapeutic strategies that transcend different orientations, the generation of these strategies
Psychotherapy Integration
29
has been based primarily on what therapists say they do, not on direct
observations of what they actually do (Grencavage & Norcross, 1990). It
has been repeatedly suggested that the identification of general mechanisms of change can be facilitated by the investigation of those similarities
that exist across different orientations (Goldfried & Padawer, 1982). Unfortunately, a commonly expressed concern among contemporary authors is
that such research is sorely lacking (e.g., Arkowitz, 1984; Goldfried, 1991;
Jensen et al., 1990; Lambert, 1992; Prochaska & Norcross, 1986; Yates,
1983). A direct result of this concern is the emergence of a new theme in
the literature, that of the push for the development of workable methodologies for the study of psychotherapy integration (e.g., Goldfried & Safran,
1986; Norcross & Thomas, 1988; Wolfe & Goldfried, 1988). It has also
been suggested that psychotherapy integration needs to be rooted in an
empirical, unified understanding of psychopathology (Arkowitz, 1989;
Guidano, 1987; Millon, 1988; Wolfe, 1989; Wolfe & Goldfried, 1988),
since clinical decision making is often based on knowledge of the etiology
and course of a given disorder; one type of therapeutic approach may be
more efficacious than others with regard to a particular disorder.
Despite the consensus on the desirability of empirically based therapies and the encouraging starts, we have a long way to go. Several years
ago Norcross and Prochaska (1983) found that of a list of 14 possible
reasons that psychologists selected their interventions, research ranked a
disappointing tenth. The average rating fell between "weak influence" and
"some influence." Our hope for a future survey is that, as a result of the
emerging empirical base in psychotherapy, the influence of outcome research will rank much higher. In the words of Appelbaum (1979, p. 501):
"If any of us are to benefit from the ideas and experiences of others, then
the whole has to be defined ... as knowledge. Only knowledge can unite
disparate schools, techniques, and views of man and change. Only knowledge is boundaryless and infinite."
ADVANTAGES OF COMMON LANGUAGE(s)
As we mentioned previously, each psychotherapy orientation has its
own jargon, which presents obstacles to bridging the gap across schools.
The problem is manifested not only by difficulty in understanding the
various concepts, but also by active tuning out when one hears certain buzz
words associated with another orientation (e.g., "warded off conflict,"
"negative reinforcement," or "self-actualization"). Jargon impedes communication (Gurman, 1978) and, without a common language, the field resembles a Tower of Babel (cf. Messer, 1987).
Although the use of the vernacular may be helpful in facilitating
communication (Brady et al., 1980; Driscoll, 1987; Messer, 1987), the field
30
HANDBOOK OF PSYCHOTHERAPY INTEGRATION
of psychotherapy ultimately needs a language system that is tied to a
database (Goldfried, 1987; Norcross & Grencavage. 1989; Strong, 1987).
A number of contemporary writers have independently suggested the
possibility that a common language may ultimately come from the field of
experimental cognitive psychology and social cognition (Goldfried, 1987;
Kazdin, 1984; Landau & Goldfried, 1981; Ryle, 1978, 1987; Safran, 1984;
Sarason, 1979; Segraves, 1982; Shevrin & Dickman, 1980; Wolfe & Goldfried, 1988). Concepts such as "schema," "scripts," and "metacognition"
have the potential for covering therapeutic phenomena observed by clinicians of varying orientations. Kazdin (1984, p. 163) writes that the concepts
of cognitive psychology
deal with the meaning of events, underlying processes, and ways of structuring
and interpreting experience. They can encompass affect, perception, and behavior. Consequently, cognitive processes and their referents probably provide the
place where the gap between psychodynamic and behavioral views is the least
wide.
In the meantime, while the field decides whether and how it will
implement a common research language, Messer (1987, 1992) reminds us
that there is much to be learned by becoming fluent in a number of current
theoretical languages. He argues that "this way, we can better appreciate
the concepts, ideology, and terms of other viewpoints. This will surely lead
to the permeation of ideas from one theory to another" (p. 198).
CLINICAL CONVERGENCE
There is a pernicious misconception in our field that certain processes
and outcomes are the exclusive property of particular therapy systems.
Norcross (1988) labeled this fallacy the "exclusivity myth." Cases in point
are the behaviorist's contention of exclusive ownership of behavior change,
the experientalist's presumed monopoly on intense affective expression,
and the psychoanalyst's assertion of unique historical insights. The exclusivity myth is part and parcel of the hostile, ideological cold war. The
profession has encountered a proliferating number of therapies—each purportedly unique and superior.
There is a great deal of clinical evidence, however, and a small but
corroborating amount of experimental data, to the effect that the activities
of experienced therapists of differing orientations are becoming similar,
even though their conceptualizations of cases may be articulated quite
differently (e.g., Friedling, Goldfried, & Strieker, 1984; Goldfried &
Padawer, 1982; Karasu, 1977; Kazdin, 1984; Marmor, 1980; Saltzman &
Norcross, 1990; Sloane, Staples, Cristol, Yorkston, & Whipple, 1975). In
Psychotherapy Integration
31
other words, therapists of varying orientations are making use of clinical
activities that are successful, but not necessarily congruent with their
theoretical persuasions and mandates. Wachtel (1977) speaks of a therapeutic "underground," reflecting an unofficial consensus of what experienced
clinicians know to be true. Many of these factors are not associated with
any particular school, and one rarely sees them described in the literature.
Recent studies of clinical practitioners point to many areas of convergence as well as remaining points of contention. In one study (Mahoney,
Norcross, Prochaska, & Missar, 1989), 486 clinical psychologists representing five major theoretical orientations responded to 40 standardized questions about optimal practices in psychotherapy. The results indicated considerable transtheoretical convergence on the importance of novel
exploratory activity, self-examination, and self-development in psychotherapy. Behaviorists rated psychological change as significantly less difficult than did their colleagues of other persuasions unless they had been
in psychotherapy themselves. In another study (Friedling et al., 1984), 85
psychodynamic and 110 behavioral psychologists reported on their use of
operationally defined therapy activities. Over one-half of these methods
were used by both groups, 15 percent were mutually rejected, and only 29
percent were employed exclusively by members of either orientation.
Convergence refers to individual psychotherapists becoming more
similar with accumulated experience, as well as disparate systems of psychotherapy growing alike with age. An assimilative or evolutionary process is occurring, according to Messer (1992), whereby therapy paradigms
are incorporating specific clinical methods and certain perspectives from
one another. Behavior therapy, for instance, has become more integrative
by bringing cognitive and affective factors into its purview. Certain variants of psychoanalytic therapy have decidedly shifted toward interpersonal, time-limited treatment, and have been supplemented with actionoriented techniques. An emphasis on the importance of external reality,
long a cardinal concept of behavior therapy, has now been taken much
more seriously by psychoanalytic therapists. Likewise, cognitive and behavior therapists are now more willing to accept and incorporate the
notion of unconscious processing.
Be it individual psychotherapy practitioners or entire psychotherapy
systems, many signs now point to a gradual deepening rapprochement, a
coming together, of the psychotherapies.
Concluding Comment
Psychotherapy integration, as presented in this Handbook, is a vibrant and
promising movement that has begun to make encouraging contributions to
32
HANDBOOK OF PSYCHOTHERAPY INTEGRATION
the field. Integrative perspectives have been catalytic in the search for new
ways of conceptualizing and conducting psychotherapy that go beyond
the confines of single schools. They have encouraged practitioners and
researchers to examine what other theories and therapies have to offer.
Transtheoretical dialogue and cross-fertilization fostered by the integrative
spirit have produced new ways of thinking about psychotherapy and
change. In short, the historical sibling rivalry and "dogma eat dogma"
ambience of psychotherapy are gradually abating (Norcross & Arkowitz,
1992).
The early success of the integration movement, however, raises a
critical question for its future: Will there be competition and proliferation
of various schools of integrative therapy, just as there has been intense
competition among "pure-form" schools? Several observers (e.g., Arnkoff
& Glass, 1992; Arkowitz, 1991a, 1992; Lazarus, Beutler, & Norcross, 1992;
Wachtel & McKinney, 1992) have cautioned recently that partisanship and
competition among developing integrative models would simply be repeating the same old historical mistakes of psychotherapy. Integrative
therapies could, ironically, become the rigid and institutionalized perspectives that psychotherapy integration attempted to counter in the first place.
Rather, our view of—and hope for—the integration movement is that it
will engender an. open system of informed pluralism, deepening rapprochement, and empirically grounded practice, one that leads to improved
efficacy of psychosocial treatments. The telltale sign of the success of a
movement is not how long it lasts, but what it leaves.
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CHAPTER 2
A History of Psychotherapy Integration
MARVIN R. GOLDFRIED AND CORY F. NEWMAN
The progress of science is the work of creative minds. Every creative mind that contributes
to scientific advances works, however, within two limitations. It is limited, first, by
ignorance, for one discovery waits upon that other which opens the way to it. Discovery
and its acceptance are. however, limited also by the habits of thought that pertain to the
culture of any region and period, that is to say, by the Zeitgeist: an idea too strange or
preposterous to be thought in one period of Western civilization may be readily accepted
as true only a century or two later.
—E. G. Boring
THE IDEA OF BEING ABLE to integrate the psychotherapies has intrigued mental health professionals for over a half century. It is only since
the 1980s, however, that the issue of psychotherapy integration has developed into a clearly delineated area of interest. Prior to that, it was more of
a latent theme that ran through the literature.
As is the case with any attempt to trace the historical origins of
contemporary thought, one never knows for certain the influence that
earlier contributions have made to later thinking. More often than not,
innovative ideas and findings are initially ignored, only to become assimilated into the mainstream at a later point in time (Barber, 1961). It is
possible that the ultimate contribution of an idea lies in its consciousnessraising function. Thus, quite apart from their specific merits, new ideas
sensitize us to otherwise neglected areas of thought. With regard to
psychotherapy, some notions have continued to live on over the years,
whereas others have failed to pass the test of time. Still others disappear
after their introduction only to reappear at a later time when the Zeitgeist
has become more hospitable. The dramatic interest in developing a rapprochement across the psychotherapies fits into this last category.
In the present chapter, we begin with a historical review of past
efforts at psychotherapy integration, covering the work that has been done
A History of Psychotherapy Integration
47
through the 1980s. The concerns of the anti-integrationists are discussed,
such as the differing perspectives on reality, the role of the unconscious,
the importance of transference and the therapeutic alliance, and the goals
of therapy. Finally, we describe the development of a professional reference
group whose purpose is to support continued work in this area.
Early Attempts at Integration
In what perhaps represented one of the earliest attempts at integrating the
psychotherapies, French delivered an address—at the 1932 meeting of the
American Psychiatric Association—in which he drew certain parallels between psychoanalysis and Pavlovian conditioning (e.g., the similarities
between repression and extinction). The following year, the text of
French's presentation was published, together with comments by members
of the original audience (French, 1933). As one might expect, French's
presentation resulted in very mixed audience reaction. As one of the most
unabashedly negative responses by a member of the audience, Myerson
acknowledged:
I was tempted to call for a bell-boy and ask him to page John B. Watson, Ivan
Pavlov, and Sigmund Freud, while Dr. French was reading his paper. I think
Pavlov would have exploded; and what would have happened to Watson is
scandalous to contemplate, since the whole of his behavioristic school is
founded on the conditioned reflex. . . . Freud . . . would be scandalized by such
a rapprochement made by one of his pupils, reading a paper of this kind. (French,
1933, p. 1201)
Meyer was not nearly so unsympathetic. Although he stated that the field
should encourage separate lines of inquiry and should not attempt to
substitute any one for another too prematurely, Meyer nonetheless suggested that one should "enjoy the convergences which show in such
discussions as we have had this morning" (French, 1933, p. 1201). Zilboorg,
who was also in the audience at the time, took an even more favorable
stand, noting:
I do not believe that these two lines of investigation could be passed over very
lightly. . . . There is here an attempt to point out, regardless of structure and
gross pathology, that while dealing with extremely complex functional units
both in the physiological laboratory and in the clinic, we can yet reduce them
to comparatively simple phenomena. (French, 1933, pp. 1198-1199)
In an extension of French's attempts, Kubie (1934) maintained that
certain aspects of psychoanalytic technique itself could be explained in
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terms of the conditioned reflex. Noting that Pavlov hypothesized that
certain associations might exist outside of an individual's awareness because they took place under a state of inhibition, Kubie suggested that free
association might serve to remove the inhibition and allow such unconscious association to emerge.
In 1936 Rosenzweig published a brief article in which he argued that
the effectiveness of various therapeutic approaches probably had more to
do with their common elements than with the theoretical explanations on
which they were based. Rosenzweig suggested three common factors:
(1) the therapist's personality has much to do with the effectiveness of the
change process, since it may function to inspire hope in patients or clients;
(2) interpretations are helpful because they provide alternative and perhaps
more plausible ways of understanding a particular problem; and (3) even
though varying theoretical orientations may focus on different aspects of
human functioning, they can all be effective because of the synergistic
effects that one area of functioning may have on another.
At the 1940 meeting of the American Orthopsychiatric Association
(Watson, 1940), a small group of therapists got together to discuss areas
of agreement in psychotherapy. Commenting on the points of commonality (e.g., the importance of the therapeutic interaction), Watson observed
that "if we were to apply to our colleagues the distinction, so important
with patients, between what they tell us and what they do, we might find
that agreement is greater in practice than in theory" (p. 708).
In his book Active Psychotherapy, Herzberg (1945) described how
systematically prescribed "homework" assignments might be used within
the context of psychodynamic therapy. Anticipating an important behavioral contribution to the field by over a decade, Herzberg proposed the use
of graded tasks, particularly in those cases where the clients' avoidance
behavior was based on anxiety.
Woodworth's 1948 text, Contemporary Schools of Psychology, explored
the development and substantive content of the then existing schools of
psychological thought, such as behaviorism, Gestalt psychology, and the
psychoanalytic schools. He recognized that although each school had made
gains in its own respective chosen direction, "no one [school] is good
enough" (p. 255). Observing that psychology was advancing in many
different directions, Woodworth wondered "whether synthesis of the different lines of advance [might] not sometime prove to be possible" (p. 10).
Close on the heels of this thesis was a landmark work in the history
of psychotherapy integration, namely Dollard and Miller's classic book
Personality and Psychotherapy, published in 1950 and dedicated to "Freud
and Pavlov and their students." The importance of Dollard and Miller's
work in the history of psychotherapy can be attested to by the fact that
this book remained in print for over 30 years. Although behavior therapists
A History of Psychotherapy Integration
49
have traditionally argued that Dollard and Miller's thinking had little
impact on the development of behavior therapy, the fact that the work is
continually referred to suggests that it has been widely read. In their work,
Dollard and Miller described in detail how such psychoanalytic concepts
as regression, anxiety, repression, and displacement may be understood
within the framework of learning theory. For the most part, Dollard and
Miller merely translated one language system into another. Nonetheless,
they did point to certain factors that may very well be common to all
therapeutic approaches, such as the need for the therapist to support an
individual's attempt at changing by expressing empathy, interest, and
approval for such attempts.
Even though Dollard and Miller (1950) stayed fairly close to the
intervention procedures associated with psychoanalytic therapy, they
made continual reference to principles and procedures on which contemporary behavior therapy is based. Thus, Dollard and Miller suggest the
following: (1) the value of modeling procedures (e.g., "watching a demonstration of the correct response may enable the student to perform perfectly on the first trial," pp. 37-38); (2) the use of hierarchically arranged
tasks (e.g., "the ideal of the therapist is to set up a series of graded
situations where the patient can learn," p. 350); (3) reinforcement of gradual
approximations toward a goal (e.g., "if a long and complex habit must be
learned, the therapist should reward the subunits of the habit as they
occur," p. 350); (4) the principle of reciprocal inhibition (e.g., "like any other
response, fear apparently can be inhibited by responses that are incompatible with it," p. 74); (5) the significance of the reinforcing characteristic of
the therapist (e.g., "the therapist uses approval to reward good effort on
the part of the patient," p. 395); (6) the importance of teaching the individual self-control or coping skills to be used following therapy (e.g., "it is
theoretically possible that special practice in self-study might be given
during the latter part of a course of therapeutic interviews. The patient
might be asked to practice solving particular problems . . . [under conditions] as similar as possible to those to be used after therapy," p. 438);
(7) the treatment of orgasmic dysfunctions via masturbation (e.g., "at one
point in a therapeutic sequence, the therapist might have to reward masturbation so that the patients may experience the sexual orgasm for the first
time," p. 350); and (8) the importance of environmental contingencies for
maintaining behavior change (e.g., "the conditions of real life must be
favorable if new responses are to become strong habits," p. 427).
Like Herzberg, Dollard and Miller also emphasized yet another behavioral tenet, the importance of between-session assignments (e.g., "behavioral changes must be made in the real world of the patient's current
life. If benevolent changes are to occur, the patient must begin doing
something new," p. 319). All the more striking is the source that they cite
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in support of this notion. Freud himself is quoted as writing, "Actually it
is quite unimportant for his cure whether or not the patient can overcome
this or that anxiety or inhibition in the institution; what is of importance,
on the contrary, is whether or not he will be free from them in real life"
(Freud, 1924, Vol. 2, p. 320).
Unlike Dollard and Miller (1950), whose primary emphasis was on the
integration of different theoretical orientations, Thorne (1950) was interested in pursuing therapeutic integration on the basis of what we know
empirically about how people function and change. From the time that he
was a medical student, Thorne was struck by the fact that medicine was not
divided up into different schools of thought, but rather that basic principles
of bodily functioning were what guided clinical practice.
Like Thorne, Garfield had long been interested in an empirically based
approach to therapy, and in 1957 he outlined what appeared to be common
points among the psychotherapies. In an introductory clinical psychology
text, Garfield noted such universal factors as an understanding and supportive therapist, the opportunity for emotional catharsis, and the provision of
self-understanding.
Glad's (1959) Operational Values in Psychotherapy took issue with the
relative inflexibility of psychotherapy when practiced, to the letter, according to any given theoretical persuasion. He felt that the value systems
instilled by doctrinaire approaches posed major limitations, and therefore
recommended that the practicing therapist be exposed to (if not specifically
trained in) systematic operations of psychotherapists from the major theoretical approaches of the time.
More Recent Trends Toward Rapprochement
The topic of therapeutic rapprochement was seriously addressed by only
a handful of writers in the 1950s, due, no doubt, to the fact that no single
approach to psychotherapy had yet gained enough momentum to challenge psychoanalytic therapy. Perhaps it was also the conservative social
and political climate of the 1950s that served to discourage therapists from
questioning their paradigms. The 1960s, along with the broad array of
societal challenges that came with it, brought a sharp increase in the
number of books and articles dealing with rapprochement.
THE 1960s
The most significant contribution to the integration of psychotherapies made in the early 1960s was Frank's (1961) Persuasion and Healing. This
book addressed itself to commonalities cutting across varying attempts at
A History of Psychotherapy Integration
51
personal influence and healing in general. Frank suggested that psychotherapy serves to correct people's misconceptions about themselves and others. Similar change processes, Frank observed, can be seen in such diverse
methods as religious conversion, primitive healing, brainwashing, and the
placebo effects that occur in the practice of medicine. When distressed
individuals are placed in any of these contexts, an expectancy for improvement and an arousal of hope results in a concomitant increase in self-esteem
and improved functioning. It should be pointed out that although Frank
continued to stress common factors across the psychotherapies in his later
writings, in one of his more recent reviews of the field (Frank, 1979), he
acknowledged that certain clinical problems (e.g., fears, phobias, compulsive rituals) may be effectively dealt with by methods that go beyond the
general nature of the therapeutic interaction.
Thirty years after the publication of French's landmark article, a
colleague of his, Alexander (1963), suggested that psychoanalytic therapy
might profitably be understood in terms of learning theory. Based on an
analysis of tape recordings of psychoanalytic therapy sessions, Alexander
concluded that many of the therapeutic changes that occurred "can best be
understood in terms of learning theory. Particularly the principle of reward
and punishment and also the influence of repetitive experiences can be
clearly recognized" (p. 446). A therapist who was dedicated throughout his
career to the advancement of the field, Alexander suggested that "we are
witnessing the beginnings of a most promising integration of psychoanalytic theory with learning theory, which may lead to unpredictable advances in the theory and practice of the psychotherapies" (p. 448). A year
later, Marmor, involved in the same program of research on psychotherapy, described in detail the learning principles that he believed to underlie
psychoanalytic therapy (Marmor, 1964).
About this time, Carl Rogers (1963) published an article dealing with
the current status of psychotherapy. He noted that the field was "in a
mess," but that the theoretical orientations within which therapists had
typically functioned were starting to break down. He stated that the field
was now ready to shed itself of the limitations inherent in specific orientations—including client-centered therapy—and that it was essential to
observe more directly exactly what goes on during the course of psychotherapy.
London (1964), in a short but insightful book entitled The Modes and
Morals of Psychotherapy, pointed to the inherent limitations associated with
both the psychodynamic and behavioral orientations, suggesting, "There
is a quiet blending of techniques by artful therapists of either school: a
blending that takes account of the fact that people are considerably simpler
than the Insight schools give them credit for, but that they are also more
complicated than the Action therapists would like to believe" (p. 39).
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Marks and Gelder (1966) also compared behavioral therapy and
psychodynamic procedures. Although acknowledging that there was probably common ground between the two approaches, Marks and Gelder also
underscored certain differences. They further suggested that the two approaches should be viewed as potentially contributing to each other, rather
than necessarily being antagonistic in nature. Arguing for the integration
of learning theory with psychoanalysis, Wolf (1966) suggested that "their
integration is sooner or later inevitable, however passionately some or
many of us may choose to resist it" (p. 535).
The very important concept of "technical eclecticism" was introduced in 1967 by Lazarus, who maintained that clinicians can use techniques from various therapeutic systems without necessarily accepting
the theoretical underpinnings associated with these methods. Starting
from this pragmatic/clinical point of view, Lazarus maintained that the
ultimate standard of utility should rest on empirical, not theoretical
grounds. His views were eventually expanded and revised into the development of multimodal therapy (Lazarus, 1992). Appearing in that same
year as Lazarus's landmark paper was an article by Patterson (1967) on
divergent and convergent elements across the psychotherapies, a paper
by Whitehouse (1967) on the generic principles underlying a variety of
therapeutic interventions, and a discussion by Weitzman (1967) of how
systematic desensitization may profitably be used within a psychoanalytic context.
Brady (1968), responding to the practical demands of doing actual
clinical work, argued that behavioral and psychodynamic approaches were
not necessarily contradictory in nature but could, in certain cases, be used
in combination. He described the treatment of a preorgasmic woman with
systematic desensitization and short-term psychodynamic therapy focusing on the woman's relationship with her husband. In a similar vein,
Leventhal (1968) described a case of a woman experiencing anxiety over
sexuality who was successfully treated with combined behavioral and
traditional therapeutic interventions.
Developing this line of reasoning, Bergin (1968) asserted that systematic desensitization could be made into an even more powerful treatment
procedure if accompanied by therapist warmth, empathy, and moderate
interpretation. Bergin reasoned that such extrabehavioral activities were
important because they elicited cognitive and emotional responses that are
intimately tied to the behavioral situations addressed in the desensitization
hierarchies. He maintained that a theory of therapy that addressed a more
universal set of psychological events would be less likely to lead therapists
to conceptual dead-ends in the face of particularly complex cases. Along
these same lines, in an article offering a rationale for "psychobehavioral
therapy," Woody (1968) observed that the integration of behavior therapy
A History of Psychotherapy Integration
53
and psychodynamic therapy was particularly relevant for cases that were
unresponsive to treatment.
The following year, Kraft (1969) presented clinical evidence that
systematic desensitization could help patients gain insight into a wealth of
unconscious material through both imagery and relaxation in the face of
previously feared objects or situations. In a theoretical paper examining the
similarities among psychoanalytic, behavioral, and client-centered therapy,
Sloane (1969) maintained that common factors ran through all three orientations, and that the underlying process of therapeutic change probably
involved principles of learning. Commenting on Sloane's paper, Marmor
(1969) agreed that all therapies involve some application of learning principles, either directly or unwittingly, but argued that the simple S-R model
could not explain some of the more complex aspects of human functioning.
Moreover, like London (1964), Marks and Gelder (1966), Lazarus (1967),
Brady (1968), Bergin (1968), and others, Marmor concluded that behavioral
and psychodynamic therapies are probably best viewed as complementary
in nature, with neither model being totally applicable to all cases. Cautioning against a haphazard piecing together of techniques from different
orientations, Brammer (1969) maintained that what was needed was an
eclecticism based on research findings about the effectiveness of various
clinical procedures.
THE 1970s
The year 1970 marked the inauguration of a new journal, Behavior
Therapy. Given the enthusiasm that had been building among those who
associated themselves with this orientation, one might have expected the
first articles to contain grandiose statements about the "proven" effectiveness of behavior therapy over all other approaches. Such was not at all the
case. Instead, editors and contributors devoted serious attention to aspects
of theory and therapy that were not strictly "behavioral." Thus, Birk (1970)
described two clinical cases to illustrate the potential integration of behavior therapy with psychodynamic theory. Bergin (1970a) followed his earlier
treatise on nonbehavioral "adjuncts" to systematic desensitization with a
paper that went so far as to claim that desensitization proper was, in fact,
much more than a simple counterconditioning process, drawing heavily
upon cognitive and relationship variables. Bergin (1970b), in applauding
the introduction of cognitive methods into behavior therapy, observed:
The sociological and historical importance of the movement should not be
underestimated for it has three important consequences. It significantly reduces
barriers to progress due to narrow school allegiances, it brings the energies of
a highly talented and experimentally sophisticated group to bear upon the
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intricate and often baffling problems of objectifying and managing the subjective, and it underscores the notion that a pure behavior therapy does not exist,
(p. 207)
As it turned out, Bergin's observations were very much on the mark; many
of the behavior therapists who became involved in the development of
cognitive procedures (e.g., Davison, Goldfried, Lazarus, Mahoney, Meichenbaum) later moved on to an interest in therapeutic integration.
In a consideration of the importance of the therapeutic relationship
within a behavioral approach, Truax and Mitchell (1971) noted that the
successful procedures of behavior therapy were not being delivered in an
interpersonal vacuum. Although they lamented the evident difficulties
involved in conducting research on the therapy interaction, they suggested—as Rosenzweig (1936) had done some 35 years earlier—that there
existed important therapist characteristics that contributed to the change
process, regardless of therapeutic orientation.
Commenting on how existing cultural values contribute to the development of different schools of therapy, Frank (1971) outlined features that
nonetheless were common to all approaches. Marmor published an article
on therapeutic integration in that same year (Marmor, 1971), in which he
suggested:
The research on the nature ot the psychotherapeutic process in which I participated with Franz Alexander, beginning in 1958, has convinced me that all
psychotherapy, regardless of the techniques used, is a learning process. . . .
Dynamic psychotherapies and behavior therapies simply represent different
teaching techniques, and their differences are based in part on differences in their
goals and in part on their assumptions of the nature of psychopathology. (p. 26)
Many contemporary behavior therapists probably would now agree with
Marmor's clinical observation that not only simple conditioning but also
cognitive learning occurs during the course of therapy.
In a scholarly review of the psychotherapy outcome literature, Bergin
(1971) recognized the important empirical contributions that behavior
therapy had begun to make. Nonetheless, he concluded that the field
needed to remain open to the "many fertile leads yet to be extracted from
traditional therapy" (p. 254). Responding to Bergin's clinical observations
that behavior therapy alone was not always effective clinically, Lazarus
(1971) described in Behavior Therapy and Beyond a wide array of both
behavioral and nonbehavioral techniques that may be employed by broadspectrum behavior therapists. In the same year, Woody (1971) also published a book integrating behavioral and insight-oriented procedures. Echoing Lazarus's concept of technical eclecticism, Woody suggested that the
A History of Psychotherapy Integration
55
practicing clinician is capable of selecting and integrating procedures from
varying sources based purely on pragmatic grounds. Marks (1971) similarly noted the beginning trends toward rapprochement, observing that
therapists "are growing less reluctant to adopt methods with pedigrees
outside their own theoretical systems" (p. 69).
Houts and Serber's (1972) edited book After the Turn On, What?
described the experiences of seven researchers and practitioners who spent
a weekend together in an encounter group. Ranging from radical behaviorism to cognitive learning in orientation, the participants described what
they saw to be both assets and liabilities of their group experience. As part
of a larger project to try to determine the future course of psychotherapy
research, Bergin and Strupp (1972) reported on their contacts with researchers throughout the country. Among those interviewed was Neal
Miller of Dollard and Miller fame, who predicted that as behavior therapy
began to become involved with more complicated types of cases, and as
psychodynamic therapy focused more on ego mechanisms and the working-through process, the two therapeutic approaches would eventually
start to converge in some interesting ways.
In a provocative article on the "end of ideology" in behavior therapy,
London (1972) asked his behavioral colleagues to declare a truce in their
strife with other orientations and to look more realistically and pragmatically at what we are able to do clinically. Very much the clinical pragmatist,
London cautioned against becoming too enamored with theories, noting
that "the first issue, scientifically as well as clinically, is the factual one—do
they work? On whom? When? The how and why come later" (p. 919).
Other efforts at therapeutic integration that appeared in 1972 included a book by Martin that attempted to integrate learning theory with
client-centered therapy; a description of universal healing processes, seen
among psychotherapists and witchdoctors alike (Torrey, 1972); and a set
of papers dealing with the theoretical and clinical aspects of the integration
of psychodynamic and behavior therapies (Feather & Rhoads, 1972a,
1972b). Feather and Rhoads (1972a) argued that in psychology, as in
medicine, the existence of many treatments for a given disorder probably
signaled a poor understanding of the disorder, and that none of the
separate individual treatments was likely to be adequate.
Commenting on one of Feather and Rhoads's articles appearing the
previous year, Birk (1973) noted that one area of complementarity between
a behavioral and psychodynamic approach was that the former dealt more
with external stimuli, whereas the latter tended to focus on stimuli that are
more internal in nature. Garfield (1973) extended his thesis on common
factors that appeared in the late 1950s, and Strupp (1973), stressing the
common elements underlying all psychotherapies, underscored the therapeutic relationship as a vehicle for change, providing the patient with a
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corrective learning experience. Thoresen (1973) suggested that many of
the philosophical underpinnings of behaviorism and humanism were in
agreement, and that it was possible to view a behavioral approach as
providing the technology by which certain humanistic goals might be
achieved. Appearing that same year was a report of two cases of sexual
deviance (Woody, 1973), in which successful treatment was accomplished
by aversion therapy and short-term psychodynamic therapy, administered
concurrently by separate therapists.
A fair number of articles appeared in 1974 on the issue of therapeutic
rapprochement. In an intriguing discussion of behavioral and psychodynamic approaches as "complementary" rather than mutually exclusive,
Ferster (1974)—a well-known Skinnerian—described what he considered
to be some of the merits of psychoanalytically oriented therapy. The
complementary nature of different approaches was demonstrated by Lambley (1974) in the treatment of an obsessive-compulsive disorder. Birk and
Brinkley-Birk (1974) provided a conceptual integration of psychoanalysis
and behavior therapy, suggesting that insight can set the stage for change,
whereas behavior therapy provides some of the actual procedures by
which the change process may be brought about. Birk (1974) also illustrated how intensive group therapy might be implemented by combining
behavioral and psychoanalytic principles, and Rhoads and Feather (1974)
described cases treated with desensitization procedures that were modified
along psychodynamic lines.
Kaplan (1974), in her book The New Sex Therapy, outlined how a
psychodynamic approach to therapy may be integrated with performance-based methods, and Sollod's (1975) article expounded on the merits
of this structured and synergistic integrative approach to sex therapy. In
a report of the Menninger Foundation Psychotherapy Research Project,
Horwitz (1974, 1976) noted that inasmuch as supportive treatment procedures were just as effective as insight-oriented therapy, the psychodynamic approach needed to consider alternative methods of producing
therapeutic change that might not readily fit into its usual conceptual
model. Similarly, Silverman (1974) made suggestions to his psychoanalytic colleagues that there is much to learn from "other approaches that
can make (unmodified) psychoanalytic treatment more effective" (p. 305).
In a paper delivered at the 1974 meeting of the American Psychological
Association, Landsman (1974) urged his humanistically oriented colleagues to attend to some of the contributions of behavior therapy, such
as "attention to specifics, to details, careful quantification, modesty in
claims, demonstrable results" (p. 15).
In his incisive book Misunderstandings of the Self, Raimy (1975), like
Frank (1961), suggested that various approaches to therapy all seem to be
directed toward changing clients' misconceptions of themselves and of
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57
others. All therapies are alike in that they "present evidence" to assist
individuals in changing these misconceptions; the type of evidence and the
way it is presented, however, vary across different therapeutic orientations.
An article by the German psychologist Bastine (1975), and amplified upon
a few years later (Bastine, 1978), likewise outlined common strategies,
together with the specific techniques by which they may be implemented.
In his clinically oriented book on the therapeutic change process, Egan
(1975) modified his original humanistic orientation to acknowledge that
there comes a time when the therapist must assume a more active role in
helping a client to change. Although the contributions of Rogers (1963)
and others are essential for establishing the type of therapeutic relationship
in which change can take place, Egan suggested, behavior therapy may
offer the clinician methods to implement specific action programs.
Also in 1975 Sloane, Staples, Cristol, Yorkston, and Whipple published their classic findings on psychodynamic and behavior therapists'
activities. Although the title of their book, Psychotherapy Versus Behavior
Therapy, connoted a confrontation, their results actually underscored a
theme of rapprochement. Sloane et al. reported that behavior therapists and
psychodynamic therapists demonstrated comparable degrees of warmth
and positive regard, and that patients of both types of therapists exhibited
the same depth of self-exploration.
On a theoretical level, Shectman (1975) suggested that behavioral
principles might provide psychoanalysis with a more adequate theory of
learning. Wachtel (1975), in the first of his many writings on therapy
integration, cited the contributions made to psychodynamic therapy by
Alexander, Horney, and Sullivan as evidence that behavioral approaches,
which attempt to deal directly with problematic behaviors, could readily be
incorporated into a psychodynamic framework. This is a two-way street,
argued Wachtel, in that many instances of relapse following behavior
therapy might possibly be linked to the client's maladaptive patterns that
might more readily be identified when viewed from within a psychodynamic framework. Wachtel (1977) went on to explore such integration at
greater length in his well-known and challenging book, Psychoanalysis and
Behavior Therapy, in which he maintained that the convergence of clinical
procedures from each orientation would likely enhance the effectiveness of
our intervention attempts.
In 1976 a number of articles and books touched on therapeutic
integration. Strupp (1976) criticized psychoanalytic therapy for not keeping up with the times, using therapeutic procedures more on the basis of
faith than data. Fortunately, observed Strupp, younger therapists seem less
constrained by orthodoxy and are more willing to experiment with newer
techniques. In a commentary on Strupp's article, Grinker (1976) underscored the need for a therapeutic approach based on research findings and
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noted that with added clinical experience, even the most orthodox of
psychoanalysts learn that other methods are needed to help facilitate
change. As a practicing psychoanalyst with personal experience in the
human potential movement, Appelbaum (1976) suggested that some Gestalt therapy methods may complement more traditional psychoanalytic
techniques. Appelbaum's excursion into more humanistically oriented activities were described in fascinating detail in a later book (Appelbaum,
1979).
Wandersman, Poppen, and Ricks's (1976) Humanism and Behaviorism
offered discussions by members of each orientation, which attempted to
acknowledge points of potential integration. In Burton's (1976) edited
volume, What Makes Behavior Change Possible?, 16 representatives of diverse therapeutic orientations addressed themselves to some of the basic
questions about the essential ingredients of therapeutic change. Noting
that behavior therapy was a useful framework for dealing with clinical
cases, but still incomplete in and of itself, Hunt (1976) argued that there
exists no single orientation that can deal with all clinical material. Just as
separate laser beams function together to obtain a three-dimensional holographic image, observed Hunt, so too are different therapeutic orientations
required in order to provide us with a comprehensive treatment approach.
In their book Clinical Behavior Therapy, Goldfried and Davison (1976)
maintained that behavior therapy need no longer assume an antagonistic
stance vis-a-vis other orientations. Acknowledging that there is much that
clinicians of different orientations have to say to each other, they suggested: "It is time for behavior therapists to stop regarding themselves as
an outgroup and instead to enter into serious and hopefully mutually
fruitful dialogues with their nonbehavioral colleagues" (p. 15). That many
clinicians were in effect already doing this was reflected in Garfield and
Kurtz's (1976) findings that approximately 55 percent of clinical psychologists in the United States considered themselves eclectic. Most frequently
used in combination were the psychodynamic and learning orientations, a
combination that was based on the pragmatics of doing clinical work
(Garfield & Kurtz, 1977).
Integration at a clinical level was dealt with in several articles (Lambley, 1976; Levay, Weissberg, & Blaustein, 1976; Murray, 1976; Segraves &
Smith, 1976). Also Lazarus's (1976) book Multimodal Behavior Therapy
extended and refined his broad-spectrum approach to behavior therapy so
as to systematically take into account the individual's behaviors, affects,
sensations, images, cognitions, interpersonal relationships, and drugs/
physiological states (the "BASIC I.D.").
The following year Lazarus (1977), having by then practiced behavior
therapy for approximately 20 years, questioned whether behavior therapy,
as a delimited school of thought, had "outlived its usefulness." He
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59
recognized the need to "transcend the constraints of factionalism, where
cloistered adherents of rival schools, movements, and systems each cling
to their separate illusions" (p. 11). An editorial comment appearing in the
journal of Humanistic Psychology (Greening, 1978) applauded Lazarus's 1977
paper and urged readers of the journal to be open to such suggestions for
rapprochement.
Commenting on the gap that frequently exists between theory and
practice, Davison (1978) delivered a talk at the Association for Advancement of Behavior Therapy (AABT) convention in which he suggested that
behavior therapists consider the possibility of using certain experiential
procedures in their clinical work. Krasner (1978) outlined the history of
both behaviorism and humanism, noting that the two orientations shared
some common view of human functioning (e.g., the importance of situational factors, the uniqueness of the individual). He looked forward to the
time when representatives in "both camps will decrease mutual battling and
recriminations."
Gurman (1978) challenged the usefulness of approaching a psychological problem through the eyes of one of many existing theories. He
argued that theories are generally biased toward a single presentation of
the human condition, and that human experience is more accurately conceptualized as the result of multiple factors. Underscoring what we all too
often forget, Gurman went on to suggest that "therapy is not viewed as
a reified set of procedures, but as an evolving science" (p. 131). Diamond,
Havens, and Jones (1978) independently came to the same conclusion,
stressing the need for an eclectic approach to therapy that would be tied
to research and theory yet flexible enough to provide highly individualized
treatment. In that same year, Baer and Stolz (1978) provided a behavioral
analysis of est, Fischer (1978) outlined an eclectic approach to social casework, and O'Leary and Turkewitz (1978) described how a communications
analysis of marital interaction might be used within the context of behavioral marital therapy. Some of the points of overlap between behavior
therapy and Zen Buddhism were outlined by Mikulas (1978) and Shapiro
(1978).
A symposium on the compatibility and incompatibility of behavior
therapy and psychoanalysis, chaired by Arkowitz (1978), was held at the
1978 AABT Convention. In a subsequently published 1978 convention
paper entitled "Are Psychoanalytic Therapists Beginning to Practice Cognitive Behavior Therapy or Is Behavior Therapy Turning Psychoanalytic?",
Strupp (1983) commented on some of the converging trends that seem to
be occurring within each of these orientations. In a reanalysis of agoraphobia, Goldstein and Chambless (1978) described some of the complicating
features in dealing with this problem clinically, outlining a comprehensive
treatment plan that went beyond the straightforward methods typically
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associated with a behavioral approach. Also in the same year, Brown (1978)
presented case material reflecting the integration of psychodynamic and
behavior therapies, and Ryle (1978) suggested that experimental cognitive
psychology might provide a common language for the psychotherapies.
Prochaska (1979), in a textbook describing various approaches to
psychotherapy, concluded with a chapter that made the case for ultimately
developing a transtheoretical orientation that would encompass what may
have been found to be effective across different approaches to psychotherapy. Presenting some interesting parallels between cognitive therapy and
psychodynamic therapy, Sarason (1979) suggested that experimental cognitive psychology may provide us with a conceptual system for understanding both orientations. Goldfried (1979) proposed that cognitive behavior therapy might be construed as often dealing with an individual's
implicit meaning structures, and that use of association techniques from
experimental cognitive psychology to study such phenomena should be
equally acceptable to clinicians and theorists of a psychodynamic orientation. It is interesting to note that Sarason and Goldfried drew their conclusions independently and without any apparent knowledge of Ryle's (1978)
very similar conclusion the year before.
Robertson (1979) speculated on some of the reasons for the existence
of eclecticism, such as lack of pressure in one's training or professional
setting to take a given viewpoint; the tendency for clinical experience to
make a therapist more open to other procedures; a personal tendency to
be a nonjoiner; and a therapeutic orientation reaching a point where "the
bloom is off the rose." Related to this last point are the results of Mahoney's (1979) survey of leading cognitive and noncognitive behavior
therapists. Among the several questions asked of the respondents was: "I
feel satisfied with the adequacy of my current understanding of human
behavior." Although there were no statistically significant differences between the two groups on this item, the absolute rating was indeed instructive. Using a 7-point scale, Mahoney found that the average rating of
satisfaction was less than 2!
THE 1980s
During the 1980s, psychotherapy integration made a significant advance as a defined area of interest—indeed, a movement. There was a
geometric increase in the number of publications and presentations on the
topic, making it unwieldy and impractical for us to offer an adequate
description of the more than 200 publications that appeared during the
decade. However, we will attempt to highlight some of these contributions
in the limited space available.
Noting past attempts to find commonalities across psychotherapies,
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61
Goldfried (1980) argued that a fruitful level of abstraction at which such a
comparative analysis might take place would be somewhere between the
specific technique and theoretical explanation for the potential effectiveness of that technique. He maintained that it is at this intermediate level of
abstraction—at the level of clinical strategy—that potential points of
overlap may exist. One clinical strategy that may very well cut across
orientations entails providing the client/patient with "corrective experiences," particularly with regard to fear-related activities. For example,
Fenichel (1941), on the topic of fear reduction, noted that "when a person
is afraid but experiences a situation in which what was feared occurs
without any harm resulting, he will not immediately trust the outcome of
his new experience; however, the second time he will have a little less fear,
the third time still less" (p. 83). This very same conclusion was reached by
Bandura (1969), who observed: "Extinction of avoidance behavior is
achieved by repeated exposure to subjectively threatening stimuli under
conditions designed to ensure that neither the avoidance responses nor the
anticipated adverse consequences occur" (p. 414). Relevant to this general
theme of parallels across theoretical orientations was Nielsen's (1980)
description of how certain psychoanalytic concepts are reflected in the
practice of Gestalt therapy.
In a 1980 special issue of Cognitive Therapy and Research, therapists of
various orientations answered a set of questions about what they believed
to be the most effective ingredients in therapeutic change (Brady et al,
1980). At the 1980 AABT Convention, Goldfried and Strupp (1980) held
a dialogue on the issue of rapprochement in which they agreed that in the
final analysis, any attempt at finding points of commonality must be based
on what clinicians do, rather than what they say they do. Dryden (1980)
discussed the differences in therapeutic styles across orientations, particularly as they relate to the concept of transference; Bastine (1980) observed
that a problem-oriented approach to intervention is likely to facilitate
psychotherapy integration; and Linsenhoff, Bastine, and Kommer (1980)
emphasized that the field of psychotherapy could benefit most from an
integration that would be both theoretical and practical.
Messer and Winokur (1980), in an article examining the potential
benefits and pitfalls of psychotherapy integration, suggested that both
action-oriented and introspective therapeutic approaches may be used in
combination to help patients to translate their insights into action. Mahoney (1980) noted that behaviorists had begun not only to adopt a
position that accepted a person's thoughts as useful data, but also to pay
attention to "implicit" cognitions. In this manner, cognitive-behavioral
theorists and therapists were beginning to examine "unconscious" events.
Marmor and Woods's (1980) edited book The Interface Between Psychodynamic and Behavioral Therapies illustrated the theme that no single
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approach to therapy can deal with all of human functioning. This general
theme was reflected in a case report by Cohen and Pope (1980), in which a
single client was significantly helped by two cooperating therapists, one
behavioral and the other analytic. A survey by Larson (1980) found that
although therapists typically used a single orientation as their primary
reference point, 65 percent acknowledged that their clinical work included
contributions from a number of other therapeutic approaches. Ryle (1980)
reported the findings of a series of case histories, in which an integrated,
cognitive-dynamic intervention was found to be clinically effective. Garfield
(1980), drawing on different therapeutic orientations in his Psychotherapy: An
Eclectic Approach, described an empirically oriented view of psychotherapy.
Like Bergin before him, he viewed the introduction of cognitive variables
into behavior therapy as a particularly important advance.
In 1981 a number of writers furthered the argument that each distinct
orientation presents different strengths that can be combined into a more
broad-based and useful approach. For example, Arnkoff (1981) reported
combining cognitive therapy with the Gestalt empty-chair technique in
order to increase affect and to elicit meaningful cognitions from the patient.
The positive therapeutic results seemed greater than would be expected
when either approach was used in isolation. The multimodal therapy of
Lazarus (1981) essentially maintained that the therapist's choice of therapy
techniques must be data driven, not theory driven.
Schwartz (1981) reported that therapists who led groups in psychotherapy were moving toward "technical and theoretical eclecticism" in
increasing numbers. Addressing the issue of integrative conceptual models,
Landau and Goldfried (1981) described in detail how certain concepts from
experimental cognitive psychology (e.g., schema, scripts) can offer the field
a consistent framework within which cognitive, behavioral, and psychodynamic assessment may fit. Also addressing himself to the need for a
framework, Staats (1981) remarked that the field of psychology had the
means for creating empirical knowledge in abundance, but that the lack of
conceptual unification in the field was creating greater confusion, not
clarity. There appeared in the same year an article by Rhoads (1981)
outlining and illustrating the clinical integration of behavior therapy and
psychoanalytic therapy; a chapter by Gurman (1981) that described how
different therapeutic orientations may be fitted into a multifaceted empirical approach to marital intervention; and a convention presentation by
Sears (1981) relating his own personal observations of the early attempts
to link behavior theory with psychoanalytic therapy.
As the discussion of therapeutic integration was becoming increasingly widespread, it became desirable for concerned professionals to arrange meetings, so as to facilitate a more efficient and meaningful exchange
of views. For example, in 198! a small group of clinicians and clinical
A History of Psychotherapy Integration
63
researchers (Garfield, Goldfried, Horowitz, Imber, Kendall, Strupp, Wachtel, and Wolfe) held an informal, two-day conference to determine whether
clinicians of different orientations could communicate with each other
about actual clinical material. This group did not attempt to derive any
particular product as their goal; their primary objective was to have the
opportunity to initiate a dialogue with each other.
Communication between psychotherapy practitioners and researchers
of diverse orientations became a worldwide phenomenon in the following
years. For example, in 1982, the Adler Society for Individual Psychology
dedicated their World Congress (held in Vienna) to the exchange of views
between representatives of many of the major therapy models. The following year, an International Congress in Bogota, Columbia, led by Augosto
Perez Gomez, focused on the prospects for the convergence of psychotherapies and a cross-fertilization of ideas. As a way of illustrating how such
rapprochement might be implemented, Anchin (1982) described an integration of interpersonal and cognitive-behavioral constructs, Bohart (1982)
discussed the points of overlap between cognitive and humanistic therapy,
Dryden (1982) indicated how rational-emotive therapy had selected techniques from other orientations, and Mahoney and Wachtel (1982) presented a day-long dialogue and discussion of actual clinical material.
Goldfried and Padawer (1982) argued that the activities of therapists
of differing theoretical orientations are highly similar, even though their
conceptualizations of cases may be articulated quite differently. Their review of the literature revealed a number of strategies that seem to guide
the efforts of most therapists.
Focusing on the process of therapeutic change that occurs between
sessions, Kazdin and Mascitelli (1982) noted that the study of "extratherapy practice" might be a fruitful area in which to find commonalities
across orientations. Whether such practice occurs via prescribed homework
assignments or as a result of client initiative, the processes by which clients
convert insight into action are relevant to any psychotherapy.
In 1982 the issue of theoretical integration acquired still greater
visibility through the publication of a number of relevant books on the
topic, authored by clinicians and researchers from diverse backgrounds. In
Converging Themes in Psychotherapy, Goldfried (1982a) provided a compendium of articles dealing with the issue of rapprochement, together with an
overview of the current status and future directions in psychotherapy
integration. In Resistance, Wachtel (1982a) elicited the views of experienced
and well-known therapists in an attempt to explore the possibility that a
synthesis of the psychodynamic and behavioral approaches might shed
light on resistance to therapeutic change. In Psychotherapy: A Cognitive
Integration of Theory and Practice, Ryle (1982) assimilated theories and
methods of a heterogeneous set of orientations into a common language
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system: cognitive psychology. In Marital Therapy, Segraves (1982), like
Ryle, attempted to integrate elements of seemingly disparate theoretical
systems by translating them into the language of cognitive social psychology. The utility of his cognitive-social psychology terminology is exemplified by the persuasive presentation of the concept of "interpersonal schemas," analogous to the analytic concept of "transference," to explain the
influence of early-life significant relationships on a person's perceptions of
his or her spouse.
In 1983 the frequently asked question of "what therapy activities are
most appropriate for what type of problem, by which therapist, for what
kind of client/patient?" was addressed by Beutler in his book Eclectic
Psychotherapy. This volume suggested ways of maximizing therapeutic
effectiveness by reviewing what is known about the optimal matching of
patients to therapists and techniques. Fensterheim and Glazer (1983), in
Behavioral Psychotherapy, highlighted the complementarity of psychoanalytic and behavioral treatment methods. Consistent with the thesis outlined
by Wachtel (1977), the contributors to this volume suggested that a
psychoanalytic style be used to formulate assessment hypotheses and to
select target behaviors, and a behavioral style be employed to change these
problematic behaviors. Also appearing that year was a book on psychotherapy integration in German (Textor, 1983), reflecting the growth of the
movement on an international level.
Evidence of a rapprochement between biological and psychological
approaches to therapy appeared in the work of Gevins (1983), and in the
theme of the 1983 meeting of the Society of Biological Psychiatry, "The
Biology of Information Processing." The following year, Beck (1984) and
Beitman and Klerman (1984) presented guidelines for the integration of
psychotherapies and pharmacotherapy.
A number of authors began to suggest that the field of psychotherapy
needed to develop a new, higher-order theory that would help us to better
understand the connections between cognitive, affective, and behavioral
systems (Beck, 1984; Dryden, 1984; Greenberg & Safran, 1984; Mahoney,
1984b; Ryle, 1984; Safran, 1984). These writers maintained that attempts
to answer the question of how affective, behavioral, and cognitive systems
interact would move the field toward the development of a more adequate,
unified paradigm.
Another framework for organizing and integrating various approaches to psychotherapy was offered by Driscoll (1984) in Pragmatic
Psychotherapy. Substituting the vernacular for theoretical jargon, Driscoll
presented a method (the pragmatic "survey") by which any given psychological problem can be elucidated and conceptualized in a diversity of
ways. In Arkowitz and Messer's (1984) edited volume, Psychoanalytic Therapy and Behavior Therapy: Is Integration Possible? they, along with ten
A History of Psychotherapy Integration
65
contributing authors, explore the clinical, theoretical, and empirical issues
and implications of a serious attempt at rapprochement. Although there is
no clear consensus on such matters, it is apparent that Arkowitz and
Messer have provided an invaluable opportunity for the generation and
exchange of fruitful philosophical and practical ideas toward the advancement of the field as a whole.
In addition to the aforementioned books, numerous others on therapeutic integration appeared in the early 1980s (e.g., Guidano & Liotti,
1983; Hart, 1983; Meyer, 1982; Palmer, 1980; Papajohn, 1982; Prochaska
& DiClemente, 1984; Wittman, 1981). Moreover, journals started to feature discussions on this topic. A special 1982 issue of Behavior Therapy
contained a series of articles examining the potential benefits and drawbacks of complementing a behavioral approach with those of other orientations (Garfield, 1982; Goldfried, 1982b; Kendall, 1982; Wachtel, 1982b),
and a 1983 issue of the British Journal of Clinical Psychology presented
spirited "point-counterpoint" commentary between Yates (1983a, 1983b)
and Davis (1983), Messer (1983), Murray (1983), and Wachtel (1983) on
the subject of the plausibility of psychotherapy integration.
A particularly significant event in the history of psychotherapy integration has been the formation of an organization devoted specifically to
this endeavor. Formed in 1983, the Society for the Exploration of Psychotherapy Integration (SEPI) was established as a way of bringing together
the growing number of professionals interested in this area. An interdisciplinary organization that has grown to be international in scope, SEPI holds
yearly conferences at which many of the most active clinicians and researchers present their current work, and where attendees are provided
with the opportunity to discuss and exchange ideas. We shall have more
to say about SEPI later in this chapter.
In the mid- to late 1980s, it became apparent that the movement
toward psychotherapy integration had succeeded in reaching an everbroadening and receptive audience. There was a significant increase in the
number of authors who became active in contributing to the advancement
of the field. In order to provide adequate forums for these many voices,
new journals appeared that directly addressed clinical and research issues
pertinent to integration. One such journal was the International Journal of
Eclectic Psychotherapy, later renamed the Journal of Integrative and Eclectic
Psychotherapy in 1987. Also started in 1987 was the Journal of Cognitive
Psychotherapy: An International Quarterly, which openly invites papers that
discuss and explicate the integration of cognitive psychotherapy with
other models of treatment. Because of space limitation, we are unable to
identify and summarize each and every publication (e.g., all those that
appeared in the above journals) within the scope of this chapter.
In 1985 Mahoney cast a critical eye on the sociopolitics of academia,
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saying in effect that current systems foster and reward conformity and
static viewpoints. He vehemently argued that knowledge would be best
advanced if there were an openness to views that went beyond mainstream
thinking. The movement toward psychotherapy integration was presented
as an important new area of exploration that the field would do well to
support.
The following year Messer (1986) drew a comparison between psychoanalytic and behavioral approaches to treatment, using various clinical
choice points to highlight where they were similar and where they differed.
Thus, when dealing with a patient's distorted view of the world, the
psychodynamic therapist would place more of a focus on the nature of the
distortion, whereas the behavior therapist would be quicker to help the
patient to incorporate the reality. Which of these two strategies is more
effective clinically remains to be demonstrated empirically. Dealing with
the psychotherapy research findings to date, Stiles, Shapiro, and Elliott
(1986) concluded that the failure to find consistent superiority of any one
approach over another should lead us to carry out more work on studying
the process of change. This point was similarly made by Goldfried and
Safran (1986), who pointed to future research directions in psychotherapy
integration. Acknowledging that the change process with certain complex
clinical disorders requires a comprehensive intervention, Chambless, Goldstein, Gallagher, and Bright (1986) outlined and provided some preliminary
evidence for an integrative program for the treatment of agoraphobia.
If the movement toward psychotherapy integration is to help the field
as a whole to progress, it becomes vital to define clearly the parameters of
such a therapeutic approach, and to suggest methods and modes of teaching the therapy to trainees (Halgin, 1985). An important edited volume by
Norcross (1986) made valuable headway in this regard. Contributing authors spelled out their conceptualizations of eclectic psychotherapy, and
shared their views on how to teach students the vast amount of information needed to understand and integrate various models. By and large, the
individual authors of the Norcross text collectively argued that the trainee
would need some or all of the following: (1) rigorous training in the
scientific method and the development of critical thinking skills; (2) significant exposure to a number of the major models of psychotherapy (in
sequence, or simultaneously); (3) an apprenticeship model, working closely
with, and being supervised by, expert clinicians; (4) intensive training in
developing skills for facilitating therapeutic relationships; (5) substantial
practical experiences with a wide range of client/patient populations; and
(6) training in designing and performing psychotherapy process research.
The authors acknowledge that these are goals to span an entire career.
Also in 1986, a special issue of the International Journal of Eclectic
Psychotherapy was devoted to a discussion of the training and supervision
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67
of integrative-eclectic psychotherapists (Norcross et al, 1986). It was clear
that this would be a formidable task with which to grapple, and that
ongoing communication and development would be necessary in order to
begin to approach satisfactory answers. Therefore, later issues of the same
publication, the newly named Journal of Integrative and Eclectic Psychotherapy, would carry on the dialogue on training and supervision (Beutler et
al., 1987; Halgin, 1988; Norcross, 1988).
A glance at some of the major books on integration in 1987 reminds
us that interest in this area had become worldwide. From Italy we have
Guidano's (1987) Complexity of the Self, which presented a developmental
model of psychopathology, and examined cognitive dysfunction across
individual disorders and interpersonal contexts. From English-speaking
Canada, Greenberg and Safran (1987) published Emotion in Psychotherapy;
from French-speaking Canada we see Lecomte and Castonguay's (1987)
edited work, Rapprochement et Integration en Psychotherapie. From the United
States came Wachtel's (1987) Action and Insight, Beitman's (1987) The
Structure of Individual Psychotherapy, and Norcross's (1987) Casebook of
Eclectic Psychotherapy, Wachtel (1987) presented a therapeutic method that
meshed the goals of greater self-awareness and subjective relief with objective therapeutic changes in observable behavior, Beitman (1987) presented
a four-stage model of therapy that cut across orientations and used a
common language, and Orlinsky and Howard (1987) described a generic
model of therapy on the basis of their review of therapy research.
A 1987 issue of the Journal of Integrative and Eclective Psychotherapy
addressed the problem of overcoming the theoretical language barrier that
would otherwise impede communication and collaborative study between
clinicians and researchers of differing theoretical training backgrounds
(Messer, 1987). A number of writers expounded on the merits of such
language systems as the vernacular (Driscoll, 1987), experimental cognitive
psychology and social cognition (Goldfried, 1987; Ryle, 1987), and interpersonal theory (Strong, 1987).
Elaborating on the theme that diverse therapeutic orientations are
needed for a multidimensional method of intervention, Bergin (1988)
pointed out that nobody attempting to understand the workings of the
human body would ever try to invoke a single set of rules. For example,
principles of fluid mechanics are needed to understand how the heart
operates, whereas electrochemical principles are needed for an understanding of neural transmission. A true rapprochement across the psychotherapies is needed, suggested Bergin, if we are to deal effectively with those
complex human problems requiring psychotherapeutic intervention.
At one time, therapists who used methods culled from a number of
different schools of thought might have been risking ridicule. A prevailing
attitude held that such a therapeutic stance indicated a lack of in-depth
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expertise in one solid area. The eclectic approach was considered to be a
"grab-bag" or "trial-and-error" therapy. Norcross and Prochaska (1988)
wrote that this viewpoint has changed considerably as the field of eclecticism and integration has sought to become more systematic and databased. They observed that "integration 'by design' is steadily replacing
eclecticism 'by default' " (p. 173).
Another series of articles on the subject of psychotherapy integration
appeared in Psychiatric Annals in 1988: Rhoads's (1988) contribution addressed the dual use of psychotherapy and psychotropic medication; Babcock (1988) and Powell (1988) independently pointed out that many
behavioral interventions will provoke clinically meaningful emotional and
cognitive insights in clients; London and Palmer (1988) argued that cognitive therapies represent viable integrative therapies in and of themselves,
because these models have presented the most structured attempts to date
to synthesize psychodynamic and behavior therapy principles; and Birk
(1988) reminded us of the need to explore the integration of individual
psychotherapy with marital and family therapy.
The integration of therapeutic modalities, such as individual and
family therapy, was typified by the work of Allen (1988), Beach and
O'Leary (1986), Duhl and Duhl (1980), Feldman (1979, 1989), Feldman and
Pinsof (1982), Friedman (1980a, 1980b, 1981), Grebstein (1986), Gurman
(1981), Hatcher (1978), Lebow (1984), Pinsof (1983), Rosenberg (1978),
Segraves (1982), Steinfeld (1980), and Wachtel and Wachtel (1986). A
common phenomenon that these authors discussed is the vicious cycle that
results when a member of an interpersonal system expects and assumes the
worst about a significant other, resulting in acting in such a way so as to
provoke the very same negative reactions that "confirm" the original
dysfunctional belief. As testimony to the momentum the cited works have
gathered, a special interest group within the American Family Therapy
Association has been organized to support these integrative efforts.
Toward the end of the 1980s, the call for the development of an
empirical methodology for the study of psychotherapy integration became
quite pronounced (e.g., Goldfried & Safran, 1986; Norcross & Grencavage,
1989; Norcross & Thomas, 1988; Safran, Greenberg, & Rice, 1988; Wolfe
& Goldfried, 1988), while others (Messer, Sass, & Woolfolk, 1988) underscored the benefits of alternate epistemological approaches to understanding the therapy process. Safran et al. (1988) posited that psychotherapists
ultimately would learn more about the process of therapy via the intensive
study of successful and unsuccessful cases, rather than through the extensive study of groups of clients categorized by broad diagnostic labels.
Glass and Arnkoff (1988) found evidence for common as well as specific
factors in clients' explanations for change, and Omer and London (1988)
concluded that the nonspecific variables in therapy were no longer "noise,"
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but have achieved the status of "signal." Cashdan (1988) described the role
of the therapeutic relationship within an object relations framework, and
Andrews (1988, 1989) offered a model of change that emphasized the
importance of self-confirming feedback cycles.
Wolfe and Goldfried (1988), reporting on a National Institute of
Mental Health research conference dealing with psychotherapy integration, stated that the establishment and growth of an accessible archive of
tapes and transcripts would be a major boon to empirical studies relevant
to integration. Another subtheme related to the need for integration to be
based in empirical findings was the call for a better, more unified understanding of psychopathology (Arkowitz, 1989; Guidano, 1987; Wolfe,
1989; Wolfe & Goldfried, 1988).
One of the first research programs specifically designed to develop a
new methodology for the exploration and advancement of psychotherapy
integration began to emerge from the work of Goldfried and his associates
(e.g., Castonguay, Goldfried, Hayes, & Kerr, 1989; Goldfried, Newman, &
Hayes, 1989; Goldsamt, Goldfried, Hayes, & Kerr, 1989; Kerr, Goldfried,
Hayes, & Goldsamt, 1989). These authors developed a coding system,
composed in the language of the vernacular, to compare and contrast the
feedback that cognitive-behavioral and psychodynamic therapists give
their patients. Their database consists of transcripts and audiotapes of
actual therapy sessions, thus facilitating the study of what the therapists
actually do in session (Goldfried & Newman, 1986).
Another issue that gained momentum in the late 1980s was the
examination of the narrowing gap between cognitive-behavioral and psychodynamic viewpoints on the nature of the therapeutic relationship. For
example, Linehan's (1987; Koerner & Linehan, 1992) dialectical behavior
therapy for borderline personality disorder characterized the therapeutic
relationship as being central to the success of the treatment. Westen's
(1988) intriguing article conceptualized the transference phenomenon in
terms of information processing, while acknowledging its vital emotional
component. Goldfried and Hayes (1989) argued that—even in behavior
therapy—the therapeutic relationship frequently elicits a sample of the
client's most clinically relevant thoughts, emotions, and behaviors as they
pertain to the self and others. Newman (1989) authored a treatise on the
phenomenon of countertransference, as experienced and conceptualized
from the perspective of the cognitive-behavioral therapist.
In 1989, the final year of our "historical review" (we consider a review
of the 1990s to be more appropriate for an update on current events in the
field), Lazarus (1989) published a revision of his influential book The Practice
of Multimodal Therapy. Simek-Downing's (1989) International Psychotherapy,
a book that took cross-cultural factors into account in examining the
process of therapy, addressed elements of successful interpersonal helping
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that appear to be universal. Mahrer's Integration of Psychothempies (1989)
expressed the sentiment that "integrationists are dealing with many of the
crucial questions for our field," and spelled out his recommended responsibilities for the integrative therapist, teacher, supervisor, and researcher.
Beitman, Goldfried, and Norcross's (1989) overview article in the American
Journal of Psychiatry recommended that process researchers focus more of
their attention on the vicissitudes of the therapeutic alliance, such that
"prescriptive treatment [will be] based primarily on patient need and empirical evidence rather than on theoretical predisposition" (p. 141). Beginning
work in this area has come from Sheffield, England (Barkham, Shapiro, &
Firth-Cozens, 1989), where it was found that a combined intervention that
went from psychodynamic to cognitive-behavior therapy worked better
than one in which the sequence was reversed.
Although not originally intended to be an integrative text, the Comprehensive Handbook of Cognitive Therapy (Freeman, Simon, Beutler, & Arkowitz, 1989) nonetheless comprised many chapters that seemed to create
conceptual and technical bridges between cognitive therapy and other
approaches (e.g., experiential therapy, Piagetian theory, behavior therapy,
psychodynamic therapy, the use of Gestalt imagery, marital therapy, and
pharmacotherapy). Reading through this surprising volume is both a curious and a satisfying experience, and calls to mind London and Palmer's
(1988) contention that cognitive-behavior therapy is one of the field's best
integrative treatment options—that is, at this time.
Points of Contention: Is Integration
Unachievable?
Ever since Myerson's horrified response to French's (1933) presentation on
the commonalities between behaviorism and psychoanalysis, staunch supporters of circumscribed orientations have argued that rapprochement is
neither possible nor desirable. For the most part, these viewpoints have not
been expressed in publications specifically designated to attack the concept
of integration (perhaps it was deemed unnecessary to address such a
"preposterous" notion). Instead, this sentiment has been largely communicated implicitly, by authors writing on the exclusive merits of their
own theoretical persuasions. As the field has become more intrigued with
the possibility of therapy integration, we have been witnessing the emergence of publications that are making explicit those long-standing implicit
reservations toward rapprochement (e.g., Franks, 1984; Haaga, 1986;
Schacht, 1984; Yates, 1983a). Moreover, there now appears to be a willingness among enthusiasts and skeptics to have open dialogues concerning
A History of Psychotherapy Integration
71
the plausibility of rapprochement (e.g., miniseries in 1983 issue of British
Journal of Psychiatry; Arkowitz & Messer, 1984; Lazarus & Messer, 1988;
Wachtel, 1982a). Such communication can only be helpful. It encourages
an exchange of ideas between dedicated professionals of all persuasions, it
helps clarify the important issues as viewed from varying perspectives, and
it raises important questions that must be addressed by supporters of
integration.
The following is an overview of some arguments concerning those
aspects of psychotherapy that traditionally have been considered to represent fundamental points of contention between behavioral and psychoanalytic approaches to therapy. We have chosen these two particular contrasting models because much of the literature on the problems associated with
psychotherapy integration has focused on these two schools of thought.
DIFFERING PERSPECTIVES ON REALITY
Although the list of publications discussing similarities across differing theoretical orientations is impressive (cf. Grencavage & Norcross,
1990), some authors express great concern that the search for commonalities is a trivial pursuit. For example, in referring to the work of Sloane and
associates (1975), Farkas (1981) writes that they
have taken a microscopic look at the commonalities of behavior therapy and
psychotherapy. Their list included taking a history, showing interest, correcting
misperceptions, answering questions, and elucidating objectives. However, they
neglected to mention talking, sitting, walking, and hearing, and one wonders
when an analysis of commonalities has reached infinite regress. As Garfield
(1973) has questioned, are we considering mere common factors as opposed to
fundamental ingredients? (p. 14)
Authors such as Lazarus and Messer (1988), Messer and Winokur
(1980), Yates (1983a), and Schacht (1984) maintain that the fundamental
ingredients represent points of considerable divergence. One of these is the
"world view" that is taken respectively by members of behavioral and
psychodynamic orientations. Yates (1983a) finds little hope for rapprochement between orientations that stereotypically have such different perspectives on reality. Whereas behavior therapy may be characterized as emphasizing realism (the world existing independently of its observers), objectivity
(the existence of a common frame of reference for all), and extraspedion
(seeking the external motivators of behavior), psychoanalytic therapy reflects idealism (the world is of one's own making), subjectivity (each person's
frame of reference is unique), and introspection (searching for the internal
motivators of behavior). Additionally, Messer and his associates (Messer,
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1992; Messer & Winokur, 1980) view a behavioral approach as being
consonant with a "comic" vision of reality, whereby happiness can be
obtained if environmental barriers and complications are identified and
removed. A psychoanalytic approach, by contrast, follows a "tragic" vision, whereby internal conflicts rage, and all one can ever hope for is an
enlightened acceptance of the human psychological condition.
According to Yates (1983b), such marked differences in basic philosophical viewpoints result in contrasting notions as to what constitute
appropriate therapeutic goals. For example, the behavior therapist would
stress changes in readily observable client behaviors, and would view
sorrow as a negative affect to be extinguished rapidly. The psychoanalytic
therapist, on the other hand, would focus on the feeling of sorrow, view
it as a natural concomitant of the person's life history and current circumstances, and would strive to help the client/patient more fully experience,
accept, and work through this emotionality with an understanding of
associated real and perceived losses.
Wachtel's (1983) reply to the above issue is straightforward. He notes
that these differences in philosophy are real and that, indeed, an integrative
effort would be pointless were there an absence of such difference. Wachtel
goes on to suggest, "What makes an integration interesting is its bringing
the strengths, the different strengths, of each together in a new combination that is more comprehensive" (p. 129). Echoing this very sentiment is
Beck (1984), who writes, "The various perspectives have varying degrees
of explanatory power. By relating them to each other we can attempt to
construct an integrated model that will have greater explanatory power
than the individual perspectives" (p. 115). Mahoney (1984a) similarly
commented on the differences in world view between behavior therapy
and psychoanalytic therapy, and concludes that the incompatibility does
not diminish the value of an exchange of ideas, nor does it eliminate the
possibility that "both behaviorism and psychoanalysis are both contributing to the evolution of a more adequate paradigm" (p. 320). Also relevant
are articles by Messer (1986) and Andrews (1989), who suggest that there
are points of convergence between the world views of the various schools
of psychotherapeutic thought. The upshot is that the differences in perspectives on reality need not be significant obstacles to integration.
It is important to bear in mind that philosophical differences represent
a barrier to integration only at a theoretical level of abstraction, not at the
lower levels of abstraction, such as clinical techniques (Lazarus, 1992) and
clinical strategies (Goldfried, 1980). Goldfried has maintained that, at a
level of abstraction somewhere between theory and technique, these strategies may be thought of as clinical heuristics that implicitly guide the efforts
of most experienced therapists. More recent attempts to identify commonalities among psychotherapies increasingly turn to this intermediate
A History of Psychotherapy Integration
73
level of abstraction (Grencavage & Norcross, 1990). The significance of
delineating such common strategies has been underscored by Goldfried
(1980): "To 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 (italics in original)" (p. 996).
A review of the literature dealing with points of commonality across
different therapeutic approaches reveals a number of similarities that have
been described at this intermediate level of abstraction (Goldfried &
Padawer, 1982). Among these are the initially induced expectations that
therapy can be helpful, the client's/patient's participation in a therapeutic
relationship, the possibility of obtaining an external perspective on one's
problems, the encouragement of corrective experiences, and the opportunity to repeatedly test reality. Although the specific techniques that are
used to implement each of these strategies may vary from orientation to
orientation, the strategies themselves nonetheless represent common
threads.
ROLE OF THE UNCONSCIOUS IN THERAPY
It has been argued that a discussion of "the unconscious mind" clearly
separates a psychodynamic approach from a behavioral approach. Psychodynamic theory and practice has given considerable attention to the complex network of intrapsychic motivators that lie out of the patient's awareness, whereas behavior therapy traditionally has cast doubt on the very
existence of such unconscious processes.
Thus, at first glance, the concept of the unconscious would appear to
represent an irreconcilable point of divergence between psychodynamic
and behavior therapy. However, this is so only if we adhere to the
traditional tenets of classical psychoanalysis and radical behaviorism. Authors such as Arkowitz and Messer (1984), Goldfried (1979, 1988),
Mahoney (1980, 1991), Meichenbaum and Gilmore (1984), Messer (1986,
1992), Safran (1984), Safran and Segal (1990), and Wachtel (1977) point out
that dynamic psychotherapists have grown to recognize the importance of
conscious thoughts and environmental factors, whereas behaviorists have
adopted a position that accepts a person's explicit (and even implicit)
thoughts as useful data.
As cognitive processes have come to be introduced into the behavioral camp, the consideration of "unconscious" events has become inevitable (Mahoney, 1980, 1991). Meichenbaum and Gilmore (1984) explain
how conscious thoughts and actions, once practiced and learned, become
more integrated and automatic. Such "automatic thinking" (Beck, 1976) is
latent and/or unobserved, and may fruitfully be construed in terms of
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cognitive schemas (Goldfried, 1988). Beck (1984) suggests that a cognitive
focus involves more than consciousness, with cognitive organization existing at several levels, only the highest of which are characterized by
rationality, objectivity, and free decision making. These views are reminiscent of Kelly's (1955) conceptualization of a "complicated unverbalized
meaning" and Polanyi's (1958) notion of "tacit knowledge," whereby
persons know a great deal more than they can articulate, and act on this
knowledge as a trusted and important clue to reality.
Meichenbaum and Gilmore (1984) believe that, to some extent, all
psychotherapy deals with the client's hypothesized cognitive structures.
One such structure (in experimental cognitive psychology) is the "schema,"
which is construed as an unconscious entity that can be accessible to
awareness. The authors point out that the psychodynamic therapist's attempt to bring the unconscious to awareness is analogous to the cognitivebehavior therapist's attempt to have the client look for negative automatic
assumptions, and that each of these represents an endeavor to make sense
out of client's/patient's verbalizations and behaviors that on the surface
seem bewildering.
Mahoney (1984a) presents a thought-provoking conceptualization of
the unconscious:
More recent advances in clinical science and some of its associated psychobiology have suggested that the more central and core features of our nervous
system tend to precede and potentiate our conscious experience in such a way
that they would be more aptly termed "metaconscious" rather than "unconscious." [Meta-consciousness refers to] interdependent preconscious processes
that limit the range and nature of potential experiences, (p. 313)
Although there are differences between the cognitive-behavioral and
the psychodynamic view of the unconscious (e.g., the psychodynamic
premise that the unconscious is maintained by the energies of repression,
as contrasted with a cognitive-behavioral view of unconscious processes in
terms of information-processing mechanisms), we seem to be witnessing a
convergence between traditionally opposing orientations regarding the
clinical phenomena that are given emphasis and attention.
IMPORTANCE OF TRANSFERENCE AND THE THERAPEUTIC ALLIANCE
A strict psychoanalytic edict prohibits therapists from intervening on
the patient's behalf in a direct behavioral fashion, lest they hamper or
contaminate the development of the patient's idiosyncratic attitudes and
feelings toward the analyst (Gill, 1984). With more direct intervention, the
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75
transference phenomena are altered, as patients can attribute their feelings
for the therapist to actual, as opposed to perceived or fantasized, therapist
demands. In light of these transference considerations, Gill (1984) expressed doubts that classical psychoanalysis can be combined with interventions that are more directive. Acknowledging that analysis is quite
different from psychoanalytic psychotherapy, however, Gill admits that
the possibility of advantageously implementing behavioral techniques
within a psychodynamic framework is still an open issue.
Writing from within a Sullivanian conception of the therapeutic interaction, Wachtel (1977) suggests that the therapist can never really be a
totally "blank screen" onto which clients project aspects of their past
relationships. The therapist's role as participant-observer needs to be acknowledged as creating the actual context within which therapy takes
place. Consequently, the therapist "is as much a part of the context if he
is silent and invisible as if he is face to face with the patient and overtly
discernibly responding to him" (Wachtel, 1977, p. 69). It is within this
context, argues Wachtel, that direct interventions—sometimes in the form
of procedures suggested by behavior therapy—reasonably can be made.
Segraves (1982) has discussed transferencelike issues within the context of marital therapy. As we noted earlier, he broadens the analytic
definition of transference to include any systematic misperception of a
significant other, whereby individuals learn a tacit set of "rules" or "interpersonal schemas" earlier in life about what to expect in interpersonal
relationships with persons of varying characteristics. This conceptualization is closer to Sullivan's (1954) notion of "parataxic distortion," in that
such prototypic expectations do not necessarily require the existence of
unresolved conflicts in order to be present.
Arnkoff (1983) examined the definition of transference, and concluded
that similarities do exist between psychodynamic therapy and cognitivebehavior therapy in the use of the therapeutic relationship. She notes that
cognitive-behavior therapy focuses on relationship issues and agrees with
Beck, Rush, Shaw, and Emery (1979) that there are times when such an area
of exploration provides in vivo information that can be used therapeutically. The same argument has been made by Goldfried and Davison (1976),
Goldfried (1985), and Goldfried and Hayes (1989), who have conceptualized the therapeutic relationship as frequently offering a sample of the
client's relevant thoughts, emotions, and behaviors.
Further evidence of the narrowing gap between cognitive-behavioral
and psychodynamic viewpoints on the importance of the therapeutic relationship is seen in articles that conceptualize transference in terms of
information processing (Singer, 1985; Westen, 1988). It is important to
note that in neither of these publications does the author "reduce" the
client's perceptions of the therapeutic relationship to a cold, arid, cognitive
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process. On the contrary, the aforementioned writers view the transference
phenomena as being a vital and emotional component of therapy.
The convergence of schools of thought on the centrality of the
therapeutic relationship also comes from the cognitive-behavioral literature
on the treatment of personality disorders (e.g., Linehan, 1987; Koerner &
Linehan, 1992; Newman, 1989). These cognitive-behavioral writers view
the interactions in the therapeutic relationship as being central to assessment and treatment, not merely a prerequisite to treatment. Linehan's
dialectical behavior therapy places great emphasis on establishing stable
therapeutic relationships with clients who suffer from borderline personality disorder. Similarly, Newman (1989) contends that cognitive therapists
do indeed fall prey to countertransference reactions with difficult personality disordered clients. He notes that the therapist's recognition of such
thoughts, feelings, and behaviors toward the client will lead to the uncovering of vital therapeutic material that may then be (carefully) addressed.
GOALS OF THERAPY
Beutler (1983) has maintained that theories of psychotherapy probably do not direct the application of specific treatment techniques as much
as they determine the therapeutic goals. If this is indeed the case, one may
say that it is fruitless to strive for therapeutic integration, as each therapy
has its own set of objectives about what needs to be changed.
Wachtel (1977) points out that behavior therapists are more likely
than dynamic psychotherapists to conceptualize the patient's problems as
involving difficulties in obtaining conventional and socially acceptable aims
in life. In contrast, dynamic therapists are apt to see their patients as having
conflicting wants and needs, some socially censured. As a result, the goals
of treatment are likely to differ. Thus, a behavior therapist may help
patients obtain their conventional desires, whereas a psychodynamic therapist assists patients in understanding the development of their personalities
and concomitant problems in living. In an analytic approach, the assessment—in the sense of increased understanding—and the goals of therapy
are one and the same. Wachtel goes on to add, however, that there is
nothing to prevent a therapist from intervening with regard to presenting
problems, and then assisting the patient in further self-exploration. Concurring viewpoints are held by Llewelyn (1980) and Murray (1983), to the
effect that both extraspective and introspective changes can be achieved in
therapy, and by Messer (1986, 1992), who has argued for the complementarity between psychodynamic and behavior perspectives.
Other authors have found similarities in therapeutic goals across
orientations. Bastine (1975) observes that psychoanalytic and behavior
therapies converge at the level of therapeutic subgoals. Farkas (1981)
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77
understands that a dynamic approach attempts the modification of personality, but sees this as inextricably tied to a modification of the person's overt behaviors. Prochaska and DiClemente (1982, 1992) view all
therapy modalities as involving a consciousness-raising experience,
where therapists increase the information available to individuals so that
they can make effective responses and decisions in the face of internal
and external demands.
Lazarus and Messer's (1988) overview of a case from cognitivebehavioral and psychodynamic viewpoints respectively does show some
initial divergence in their treatment goals, prior to their summary discussion. However, after they had a chance to "compare notes," they achieved
a great deal more agreement than they had anticipated originally. Here,
differences in world views were quickly reduced in importance once open
communication was established.
The Development of a Professional Network
Recognizing the need to provide a reference group oriented toward rapprochement among the therapies, Goldfried and Strupp, in 1979, compiled a list of professionals who were likely to be interested in efforts
toward therapeutic integration and wrote to all of these individuals, inviting them to add their names to an informal "professional network."
Little was done with this list until 1982, when Wachtel and Goldfried
decided to poll those included in the network about potential future
directions. Taking the existing network list, and expanding it on the basis
of correspondence each had with other professionals over the years on
the topic of therapy integration, they mailed out a questionnaire. A total
of 162 individuals completed the survey. The respondents expressed
their continued interest in rapprochement and offered their views on
what should be done next—namely, the establishment of a newsletter
and the formation of an organization.
In the summer of 1983, an organizing committee, consisting of Lee
Birk, Marvin Goldfried, Jeanne Phillips, George Strieker, Paul Wachtel, and
Barry Wolfe, met to discuss the results of the questionnaire. It was immediately apparent to all six that the time was ripe to do something with this
rapidly growing network, and it was agreed that a newsletter was in order.
The group discussed the advisability of creating an organization, especially
in light of some of the comments on the questionnaire expressing reservations about formalizing something that might best be dealt with informally.
It finally was decided that without the existence of some sort of organization, it would be difficult to maintain any sense of continuity. As later
noted by Goldfried and Wachtel (1983), "It was concluded that we needed
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to achieve a delicate balance: a formal organization that would facilitate
informal contacts among the members" (p. 3). Hence, the Society for the
Exploration of Psychotherapy Integration (SEPI) was formed.
SEPI members represent diverse orientations and interests. Some are
professionals who clearly identify themselves with a particular theoretical
framework but openly acknowledge that other schools have something to
offer; some are people who are interested in finding commonalities among
the therapies; some would like to find a way to integrate existing approaches; some would like eventually to develop a totally new approach
based on research findings; and some are professionals who have gradually
drifted away from their original orientation and are interested in developing clearer guidelines that are more consistent with their clinical experience.
A common thread that runs through this diversity is a respect for research
evidence and an openness to procedures found to be clinically effective.
An interdisciplinary organization that has grown to be international
in scope, SEPI holds annual conferences at which many of the most active
clinicians and researchers present their current work, and where attendees
are provided with the opportunity to discuss and exchange ideas. As of
1991, it began publication of its official journal, the Journal of Psychotherapy
Integration, which includes the SEPI Newsletter.
The hope is that SEPI will serve to further raise our consciousness
about the field's need for a more comprehensive model of therapeutic
intervention, and will encourage the clinical and research efforts of an
increasing number of professionals interested in pursuing this goal. The
Zeitgeist is more receptive to integrative efforts than it has ever been before;
psychotherapy integration is no longer an idea that is "too strange or
preposterous" to consider (cf. Boring, 1950). It is our hope that within this
hospitable context, significant advances will be made.*
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A History of Psychotherapy Integration
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135-136.
CHAPTER 3
Psychoiherapy Outcome
Research: Implications for
Integrative and Eclectic Therapists
MICHAEL J. LAMBERT
J.VESEARCH INTO THE EFFECTS of therapy now spans over six
decades and has typically been aimed at examining the efficacy of schoolbased approaches to helping people change. The results of this research, as
well as the process of engaging in research, have had a modest impact on
the practice of psychotherapy. This impact ranges from the dramatic increase in behavior therapies due to the success of some behavioral interventions to the identification of particular treatment methods that are harmful
to particular clients.
Although considerable effort has been expended on specific schoolbased therapies, far less has been devoted to the study of eclectic and
integrative approaches. Despite the fact that the plurality of therapists
subscribe to an eclectic approach (Jensen, Bergin, & Greaves, 1990; Norcross & Newman, 1992) there is not sufficient outcome research on eclectic
psychotherapies to base a chapter on these data. Nevertheless, the decades
of past research have many implications for the practice of eclectic therapy.
This chapter focuses on the implications of psychotherapy research for the
practice of eclectic psychotherapy. First, several controversial issues, such
as the general effects of therapy, are addressed. Then the factors that have
been identified as causing therapeutic improvement are discussed. Finally,
directions for future research are suggested.
Psychotherapy Outcome Research
95
Eclectic Therapies and Research
This Handbook, the many systems highlighted herein, and other compendiums appearing before it (e.g., Norcross, 1986) are evidence of the growth
and sophistication of eclectic practice. For many reasons, this is an exciting
development in the field of psychological interventions. In the first place,
eclectic therapies, in general, are very friendly toward research. Eclectic
therapy, like psychotherapy research, is preoccupied with practical results—with what is most helpful. Thus many eclectic therapists, like psychotherapy researchers, maintain a commitment to the pursuit of data
wherever they lead, unencumbered by conceptual, doctrinal, or prior professional commitments. Perhaps eclecticism will be the broad base needed
for the integration of research findings that will facilitate reliably effective
treatments. Psychotherapy research may make its strongest contribution to
practice in eclectic approaches that combine diverse techniques and concepts into a comprehensive and pragmatic approach to treatment; one that
avoids strong allegiances to narrow theories or schools of thought.
Many authors (e.g., Goldfried & Wachtel, 1987; Norcross & Grencavage, 1989) have discussed the proper conception of eclectic and integrative
therapy. Eclectic therapies are relatively atheoretical, pragmatic, and empirical, made up from a collection of divergent techniques (Norcross & Grencavage, 1989). Integration-based therapies, on the other hand, are invested
in a conceptual and theoretical creation beyond a technical blend of methods, so that higher order constructs are offered to account for change and
to direct interventions. It appears from these definitions that it would be
easier for the eclectic approach than the integrative one to use research
findings readily. Some who take the integrative position may be as uninterested in research results as single-school practitioners, their primary interest being in theoretical elegance.
Despite the seemingly natural compatibility and affinity for research
that is obvious in systematic, eclectic approaches, there is clear evidence
that many eclectic approaches are developed and advocated without reference to studies of efficacy. So the desired consequence of the researchpractice compatibility (i.e., reliably effective, empirically based approaches)
is more of a fantasy than a reality. It has not proved easy to identify a
limited set of salient techniques from across schools. Thus, not much
agreement has been reached with regard to which treatment techniques are
most effective and which should be chosen for incorporation in eclectic
practice. Many of the reviews of eclectic therapy have supported this
conclusion (Garfield & Kurtz, 1977; Larson, 1980; Norcross & Prochaska,
1982; Mahalik, 1990). All of these studies suggest that there are many
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HANDBOOK OF PSYCHOTHERAPY INTEGRATION
kinds of eclectic combinations and great diversity in the techniques selected
as "most beneficial" by eclectic therapists.
Jensen, Bergin, and Greaves (1990), for example, conducted a study
that attempted to discover how many therapists claim to be eclectic
therapists, and of those, what forms of therapy they most often used. In
order to accomplish these goals, the authors sent questionnaires about
theoretical orientation to 800 therapists from within the fields of clinical
psychology, marriage and family therapy, social work, and psychiatry.
They found that 68 percent of the therapists who responded claimed to be
eclectic in orientation. They further discovered that eclectic therapists most
often claimed their theoretical orientation to be primarily dynamic, cognitive, or behavioral. The authors determined that, within the sample, eclectic
therapists used 4.4 different theories in their practices. The most common
combination of theoretical approaches was found to be the use of dynamic
theories, cognitive-behavioral techniques, humanistic, and systems approaches. (See Norcross & Newman, 1992, for a review of similar studies.)
Because of the wide variability of techniques used by eclectic therapists, it is extremely difficult to assess the effectiveness of standard eclectic
therapies. In order to improve the ability to assess the effectiveness of
therapy, several researchers have discussed the need to develop more
systematic approaches to incorporating eclectic techniques into general
practice (Held, 1984; Duncan, Parks, & Rusk, 1990; Mahalik, 1990). It
appears, however, that new eclectic approaches are being invented and
advocated just as rapidly as new school-based approaches. Despite this, it
seems that the most commonly applied eclectic approaches are based on
traditional theories with at least a modicum of empirical support.
It is hoped that the emergence and impact of eclectic treatments will
continue to be enhanced through synthesis of empirical findings. But just
what findings should be focused on and integrated into eclectic therapies?
What are the implications of outcome research for eclectic and integrative
psychotherapies?
Conclusions and Implications of
Outcome Research
Based on reviews of psychotherapy outcome research (Lambert, Shapiro,
& Bergin, 1986), figure 3.1 is an illustration of what empirical studies
suggest about psychotherapy outcome. This research literature is extensive, covering decades, and diverse in that it deals with a large range of
adult disorders and a variety of research designs, including naturalistic
observations, epidemiological studies, comparative clinical trials, and
Psychotherapy Outcome Research
97
FIGURE 3.1
Percent of Improvement in Psychotherapy Patients as a Function of
Therapeutic Factors.
a. Extratherapeutic Change: Those factors that are a part of the client (such as ego
strength and other homeostatic mechanisms) and part of the environment (such as
fortuitous events, social support) that aid in recovery regardless of participation in
therapy.
b. Expectancy (placebo effects): That portion of improvement that results from the
client's knowledge that he/she is being treated and from the differential credibility
of specific treatment techniques and rationale.
c. Techniques: Those factors unique to specific therapies (such as biofeedback, hypnosis, or systematic desensitization).
d. Common Factors: Include a host of variables that are found in a variety of therapies
regardless of the therapist's theoretical orientation: such as empathy, warmth,
acceptance, encouragement of risk taking, et cetera.
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HANDBOOK OF PSYCHOTHERAPY INTEGRATION
experimental analogues. However, no statistical procedures were used to
derive the percentages that appear in figure 3.1, which appears somewhat
more precise than is perhaps warranted. The figure, nevertheless, conveys
several of the conclusions to be drawn in this chapter.
Conclusion 1: A substantial number of outpatients improve without formal
psychological intervention. The first conclusion apparent from psychotherapy
research is that a portion of patients improve "spontaneously" without the
benefit of psychotherapy. The available literature on extratherapeutic improvement, using any of the research methods currently available to us, has
been summarized elsewhere (Lambert, 1976; Bergin & Lambert, 1978). The
studies reviewed are the best this area has to offer in answer to the question
of spontaneous-remission rates. The data include subjects who had minimal
treatment, but not extensive psychotherapy, as well as subjects who were,
for the most part, untreated. The median rate for extratherapeutic improvement for all available studies was 43 percent, with a range of 18 percent
to 67 percent. This figure is far from the original estimate of two-thirds
suggested by Eysenck (1952) and more recently supported by Rachman
and Wilson (1980). The figure of 43 percent represents a rough estimate
of spontaneous remission; however, it is an average figure that obscures
considerable variation. The evidence reviewed suggests that rates vary
from 0 percent to 90 percent at follow-up, and that very low rates of
extratherapeutic improvement do not necessarily mean that the course of
treatment will be long and difficult. Thus, low rates do not invariably lead
to low predictions of success with treatment. Also, high spontaneous
recovery rates for a particular disorder do not always imply that patients
referred for treatment will recover quickly or at all.
In general, it seems that several factors have a marked effect on
spontaneous improvement, such as the number of organ systems involved
in a disorder; the length of time the disorder has persisted; the presence of
an underlying personality disorder; and the nature, strength, and quality of
social supports—especially the marital relationship (Lambert, 1976; Andrews & Tennant, 1978; Mann, Jenkins, & Belsey, 1981). There would also
appear to be differential rates of improvement within the general category
of neurosis. There is some evidence to suggest that these rates vary as a
function of diagnosis, with depression having the highest remission rates,
followed by anxiety and hysterical, phobic, obsessive-compulsive, and
hypochondriacal disorders (Schapira, Roth, Kerr, & Gurney, 1972).
The substantial limitations of the research on spontaneous remission
have been elaborated on elsewhere (Lambert, 1976; Rachman & Wilson,
1980). Despite these limitations, it is apparent that a number of patients
improve without formal treatment. Unfortunately, many persons with
psychological disorders, especially those referred for treatment, will
not improve over a short period of time without professionally guided
Psychotherapy Outcome Research
99
interventions. The extratherapeutic improvement rate for most disorders is not so high as to make it impossible to demonstrate the efficacy of
psychotherapy.
The existing large number of controlled research studies permits a
more exact comparison of treated and untreated cases; as a result, comparing treated persons with baseline or "spontaneous remission" estimates is
no longer as important as it once was. Nevertheless, these data should
remind us that a significant proportion of patients improve without undergoing formal therapy. It is important, therefore, not only to examine the
effective ingredients of psychotherapy, but to examine the supportive
aspects of the natural environment. Both areas contain useful information
about psychological health and adjustment. Not only do we find that
significant numbers of people are helped by friends, family, and the clergy,
who employ a variety of supportive acts, but people with disorders are also
helped by the indirect influence of psychological techniques.
For example, in the United States people readily have available to
them a wide variety of self-help literature and self-help groups. These
resources often employ behavioral, cognitive, and insight-oriented material
from a variety of formal psychotherapy systems. Some of this material,
such as self-help books, has been shown to reduce symptomatology (cf.
Ogles, Lambert, & Craig, 1991). Thus, some of what appears to be helpful—independent of psychotherapy techniques and theory—may, in fact,
derive specifically from psychological theory and technique. This contamination or confusion is even more apparent in the realm of self-help groups
for specific disorders, because the structured material used in these groups
is often developed by psychologists and applied by people with some
training and supervision (e.g., Lewinsohn, Antonuccio, Breckenridge, &
Teri, 1984).
Implication 1: While many patients improve without formal therapy, extratherapeutic events are not so powerful that formal therapies are unnecessary.
Eclectic therapists can draw upon the natural helping systems that are abundant
in the environment to assist them in their efforts to improve psychological
therapies.
Conclusion 2: Psychological treatments are in general beneficial. A wide
variety of treatment methods have been empirically tested in controlled
outcome studies, usually undertaken by advocates of a particular school of
therapy. Ordinarily, however, particular systems of therapy are developed
and advocated long before empirical evidence supports their use. This is,
unfortunately, true for eclectic and integrationist systems as well. As a
result, we have today perhaps as many as 250 different therapies (Herink,
1980), most of which have not been tested. Nevertheless, most of the major
therapeutic systems have been tested empirically in controlled research.
The available research has led to one basic conclusion: Psychotherapy,
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HANDBOOK OF PSYCHOTHERAPY INTEGRATION
in general, has been shown to be effective. Positive outcomes have been
reported for a wide variety of theoretical positions and technical interventions. Much of this research has been summarized in past reviews (Lambert,
Shapiro, & Bergin, 1986; Lambert, 1982; Bergin, 1971; Bergin & Lambert,
1978; Meltzoff & Kornreich, 1970) and in meta-analytic summaries (Smith,
Glass, & Miller, 1980; Andrews & Harvey, 1981; Shapiro & Shapiro, 1982).
These reviews represent outcome literature on literally thousands of patients and hundreds of therapists across the Western world. The reviews
represent data on mildly disturbed persons with specific limited symptoms,
as well as on severely impaired patients whose disorders are both personally intolerable and socially dysfunctional. These data average changes in
patients across diverse and comprehensive measures of improvement. The
measures of improvement that are employed include a variety of perspectives of importance to patients, patients' families, mental health professionals, and society in general.
A summary of meta-analytic studies of psychotherapy outcome research comparing, for the most part, untreated to treated patients is presented in table 3.1.
As can be seen from the table, the average effect associated with
psychological treatment approaches one standard deviation unit. The first
application of meta-analysis to psychotherapy outcome (Smith & Glass,
1977; Smith, Glass, & Miller, 1980) addressed the general question of the
extent of benefit associated with psychotherapy and found an average
effect size of 0.85 standard deviation units over 475 studies comparing
treated and untreated groups. This implies that, at the end of treatment, the
average treated person is better off than 80 percent of the untreated
sample. By the standards developed by Cohen (1977) for the quantitative
evaluation of empirical relations in behavioral science, this is a large effect.
The results of this meta-analysis suggest that the assignment to treatment
versus control conditions accounts for some 10 percent of the variation
among individuals assessed in a typical study. As Rosenthal (1983) has
pointed out, this is equivalent to changing the success rate from 34 percent
of the cases to 66 percent. Smith, Glass, and Miller (1980) illustrated the
clinical meaning of this effect size by contrasting effect sizes derived from
therapy outcome studies to those achieved in other situations. For example,
in elementary schools the effects of nine months of instruction in reading
is about 0.67 standard deviation units. The increments in mathematics
achievement resulting from the use of computer-based instruction is 0.40
standard deviation units.
The effect sizes produced in psychotherapy can also be compared to
those derived from the use of psychoactive medication. For example,
Andrews (1982, 1983) found that treatments of agoraphobics involving
graded exposure produced a median effect size of 1.30, whereas antidepres-
101
Psychotherapy Outcome Research
TABLE 3.1
Meta-Analytic Reviews and the Effects of Therapy
Patient
Diagnosis/ Treatment
Smith, Glass, & Miller
(1980)
Mixed
Number
of Studies
Effect
Size
475
.85
Andrews & Harvey (1981) Neurotic
81
.72
Landman & Dawes (1982) Mixed
42
.90
Prioleau et al. (1983)
Mixed
32
.42a
Shapiro & Shapiro (1982)
Mixed
143
1.03
b
Nicholson & Berman
(1983)
Neurotic
47
.70
Andrews, Guitar, &
Howie (1980)
Stuttering
29
1.531.65C
Blanchard et al. (1980)
Headache
35
% improved
Quality Assurance
Project (1982)
Agoraphobia
25
1.20C
Quality Assurance
Project (1983)
Depression
200
.65
Steinbrueck, Maxwell, &
Howard (1983)
Depression
56
1.22
Dush, Hirt, & Schroeder
(1983)
Self-statement
modification
69
.74
Miller & Berman (1983)
Cognitive-behavior
therapy
38
.83
Stein & Lambert (1984)
Professional vs.
paraprofessional
28
.00
Wampler (1982)
Marital communication
20
.43
e
9
.82C
Depression
37
.73e
Hahlweg & Markman
(1988)
Behavioral marital
therapy
17
.95°
Dobson (1989)
Depression
10
2.15C
Benton & Schroeder
(1990)
Social skills training with
schizophrenics
23
.76°
Hazelrigg, Cooper, &
Borduin (1987)
Family therapy
Behavioral therapy
7
6
.45
.50
Asay et al. (1984)
Mixed mental health
Robinson, Berman, &
Neimeyer (1990)
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HANDBOOK OF PSYCHOTHERAPY INTEGRATION
TABLE 3.1 (continued)
Patient
Diagnosis/Treatment
Christensen et al. (1987)
OCD/ Exposure based
treatment
Nonspecific treatments
Behavioral treatments
Number
of Studies
Effect
Size
5
1.37
5
5
-.14
1.19
lore (1989)
Trait anxiety & neuroticism
63
.53
Quality Assurance
Project (1985)
Anxiety/ behavioral
treatments
81
.98
Quality Assurance
Project (1985)
Obsessive-compulsive/
exposure therapies
38
1.37
Scogin et al. (1990)
Self-administered treatments
Therapies
40
.96
1.19
a = Psychotherapy vs. placebo
b = Number of comparison groups
c = Based on pre-post gains rather than control group comparison
d = Improved 40-80% in psychological treatments and 20^10% in placebo controls
e = Number of mental health centers studied
f = Obsessive-compulsive disorder
sant medication produced an average effect size of 1.10. With depression,
the effect sizes produced for antidepressants ranged from 0.81 to 0.40,
depending on the type of antidepressant and on patient population. Thus,
the effect sizes produced through the application of psychotherapies are
generally as large as or larger than those produced by a variety of methods
typically employed during educational and medical interventions.
It is important to reiterate that the changes occurring in patients as
a result of therapy are neither trivial nor just cold statistics; rather, they are
substantial. A considerable number of people who might be classified as
"cases" before treatment would be considered enough improved to no
longer be so classified following treatment, although the exact proportion
who leave the ranks of the dysfunctional is open to interpretation (Jacobson, Follette, & Revenstorf, 1984; Tingey, Burlingame, Lambert, & Barlow,
1990). Research on psychotherapy outcome suggests that patients with a
variety of problems are helped by many methods that may have been put
to the empirical test. The results of psychotherapy outcome research by no
means suggest, however, that every participant gains to a clinically meaningful extent. The results are also compatible with the suggestion that
Psychotherapy Outcome Research
103
some clients may deteriorate during therapy (Lambert, Bergin, & Collins,
1977).
Implication 2: To the extent that eclectic therapies provide treatment that
includes substantial overlap with traditional methods that have been developed
and tested, they rest on a firm empirical base, and they should prove to be at least
as effective as traditional school-based therapies and certainly more effective than
no-treatment controls.
Conclusion 3: Although there are a large number of therapies, each containing its own rationale and specific techniques, there is little evidence to suggest the
superiority of one school or technique over another.
Evidence for this conclusion has been summarized elsewhere (Lambert, Shapiro, & Bergin, 1986; Luborsky, Singer, & Luborsky, 1975; Smith,
Glass, & Miller, 1980). And while there are exceptions, the equivalence
among seemingly highly diverse therapies has numerous implications for
eclectic practice. The general findings of no-difference in the outcome of
therapy for clients who have participated in highly diverse therapies has
a number of alternative explanations: (a) different therapies can achieve
similar goals through different processes; (b) different outcomes do occur
but are not detected by past research strategies; and (c) different therapies
embody common factors that are curative although not emphasized by the
theory of change central to a particular school. At this time, any of the
above interpretations can be advocated and defended, since there is not
enough evidence available to rule out alternative explanations.
Clearly, different therapies require the client to undergo different
experiences and engage in different behaviors. Diverse therapies could be
effective for different reasons. But we do not yet know enough about the
boundaries of effectiveness for each therapy to discuss alternative (a) and
its merits. Alternative (b), the inadequacy of past research, will not be fully
discussed here. Suffice it to say that there are many methodological reasons
for failing to reject the null hypothesis. Kazdin and Bass (1989), for example, have questioned the value of the majority of past comparative studies
on the basis of a "lack of statistical power." There are also as yet serious
problems in accurately measuring behavioral change (Lambert, Christensen, & Dejulio, 1983). Any of a host of methodological problems could
result in a failure to detect differences between therapies. The third alternative (c), emphasizing common factors in different therapies, is the possibility that has received the most research attention and the one that has the
clearest implications for practice. It is not only an interpretation of the
comparative outcome literature, but is based on other research aimed at
discovering the active ingredients of psychotherapy. This interpretation
also has a relationship to the placebo literature alluded to in figure 3.1.
A variety of factors common across therapies account for a substantial
amount of improvement found in psychotherapy patients (see figure 3.1).
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HANDBOOK OF PSYCHOTHERAPY INTEGRATION
These so-called common factors may account for most of the gains that
result from psychological interventions. It is important, therefore, for eclectic therapies to intentionally incorporate them. What are these common
factors, and what empirical support has been found to suggest their contribution to therapeutic outcome?
Common factors can be conceptualized in a variety of ways (see
Grencavage & Norcross, 1990). To clarify the differences between them,
they have been grouped into Support, Learning, and Action categories in
table 3.2. These categories were chosen to represent a possible developmental sequence that is presumed to operate in many psychotherapies. The
developmental sequence is at least partially mediated through factors common across therapies. The developmental nature of this sequence presumes
that the supportive functions precede changes in beliefs and attitudes,
which precede attempts by the therapist to encourage patient action.
A variety of common factors attributable to the therapist, therapy
procedures, and the client are listed in this table. As already mentioned,
these factors would seem to operate most potently during the process of
therapy. Together they provide for a cooperative working endeavor in
which the patient's increased sense of trust, security, and safety, along with
decreases in tension, threat, and anxiety, lead to changes in conceptualizing
his or her problems and ultimately in acting differently by refacing fears,
taking risks, and working through problems in interpersonal relationships.
Several studies emphasize the importance of many of these common
factors. Among the common factors most frequently studied have been
those identified by the client-centered school as "necessary and sufficient
conditions" for patient personality change: accurate empathy, positive
regard, nonpossessive warmth, and congruence or genuineness. Virtually
all schools of therapy accept the notion that these or related therapist
relationship variables are important for significant progress in psychotherapy and, in fact, fundamental in the formation of a working alliance
(Lambert, 1983).
Studies showing both positive and equivocal support for the
hypothesized relationship have been reviewed elsewhere (cf. Levant &
Shlien, 1984; Patterson, 1984; Gurman, 1977; Lambert, Dejulio, & Stein,
1978; Mitchell, Bozarth, & Krauft, 1977). Reviewers are virtually unanimous in their opinion that the therapist-patient relationship is critical;
however, they point out that research support for this position is more
ambiguous than was once thought. Studies using ratings of client-perceived relationship factors, rather than objective raters' perceptions, obtain
consistently more positive results, and the larger correlations with outcome
are often between client process ratings and client self-reports of outcome.
Nevertheless, there is considerable support for the positive effect of therapist attitudes on clients and their posttherapy adjustment.
Psychotherapy Outcome Research
105
TABLE 3.2
Sequential Listing of Factors Common Across Therapies
That Are Associated with Positive Outcomes
Support Factors
Learning Factors
Action Factors
Catharsis
Advice
Behavioral regulation
Identification with
therapist
Affective experiencing
Cognitive mastery
Mitigation of isolation
Assimilation of
problematic experiences
Encouragement of
facing fears, taking risks,
mastery efforts
Positive relationship
Modeling
Changing expectations
for personal effectiveness
Reassurance
Cognitive learning
Release of tension
Corrective emotional
experience
Practice
Structure
Exploration of internal
frame of reference
Reality testing
Therapeutic alliance
Feedback
Success experience
Therapist-client active
participation
Insight
Working through
Therapist expertness
Rationale
Therapist warmth,
respect, empathy,
acceptance, genuineness
Trust
For example, Miller, Taylor, and West (1980) investigated the comparative effectiveness of various behavioral approaches aimed at helping
problem drinkers control their alcohol consumption. Although the focus of
the study was on the comparative effects of focused versus broad-spectrum
behavior therapy, the authors also collected data on the contribution of
therapist empathy to patient outcome. One finding—surprising to the
authors and important for our discussion—was the discovery of a strong
relationship between empathy and patient outcome obtained from the sixto eight-months follow-up interviews used to assess drinking behavior.
Therapist rank on empathy correlated (r = 0.82) with patient outcome,
thus accounting for 67 percent of the variance on the criteria. These results
argue for the importance of therapist communicative skills even with
behavioral interventions. They were also presented in a context where
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HANDBOOK OF PSYCHOTHERAPY INTEGRATION
variations in specific techniques did not prove to have a similar powerful
effect on outcome.
The importance of the therapeutic relationship has been bolstered in
recent years by investigations of the therapeutic alliance (Frieswyk et al.,
1986). This construct has been conceptualized and defined differently by
a host of interested investigators. And like the client-centered dimensions,
it has been measured by client ratings, therapist ratings, and judges' ratings.
Ratings of the alliance have been undertaken with a wide variety of adult
patients who have been diagnosed with a broad spectrum of disorders.
There is more disagreement about the therapeutic alliance construct
than there was with the client-centered conditions. This may prove to be
a hindrance in drawing conclusions in this area because there are now
several popular methods for measuring this construct, rather than the
limited number of scales evidenced in the client-centered literature. In
addition, the alliance is seen as a necessary, but not sufficient, condition for
personality change, and so assumes a less important theoretical position in
dynamic therapies and certainly other therapies than the facilitative conditions did in client-centered therapy. In addition, ratings of the therapeutic
alliance contain a heavy emphasis on patient variables, mainly their ability
to participate in therapy. They go well beyond measuring therapist behavior and should correlate more highly with outcome because they take into
account important patient variables as well as therapist behavior.
Gaston (1990), in trying to integrate the various constructs that have
been offered to describe the therapeutic alliance, has suggested that some
of the following components of the alliance are measured by some but not
all current rating scales: (a) the patient's affective relationship to the therapist, (b) the patient's capacity to purposefully work in therapy, (c) the
therapist's empathic understanding and involvement, and (d) patienttherapist agreement on the goals and tasks of therapy.
That therapeutic alliance is not the same as the facilitative conditions
hypothesized by Rogers is clear from the above definition, the operationalization of the constructs in rating scales, and some empirical research. For
example, Johnson (1988) correlated relationship inventory ratings (based
on Rogers's conception of the relationship) with two alliance scales and
found no significant association.
A sample of studies on the alliance is presented in table 3.3, reflecting
the current status of research in this area. Clearly the alliance is related to
therapy outcome although there are instances where it fails to predict
outcome and related instances where only a few associations are found and
others are rather small.
The work of Windholz and Silberschatz (1988) is typical of research
in this area. These authors attempted to replicate the findings of the
Vanderbilt research group as reported by O'Malley, Suh, and Strupp
Psychotherapy Outcome Research
107
TABLE 3.3
Percentage of Outcome Variance
Accounted For by Therapeutic Alliance Ratings
% of Outcome
Accounted For
Scale
Used
Outcome
Gomes-Schwartz
(1978)
VPPSa
Global ratings of gains
Morgan et al.
(1982)
PHASb
Composite residualized
gain scores
Luborsky et al.
(1985)
PHASb
Indices of social functioning
Marziali (1984)
TARS"
Symptomatic change
Patient-therapist evaluations
Eaton et al. (1988)
TARSb
Improvement in
symptoms of bereavement
19%-35%
Marmar et al.
(1989)
CALPAS"
Symptomatic change,
interpersonal functioning
9%-16%
Horvarth &
Greenberg (1989)
WAI1*
Variety of outcome measures
Tichenor & Hill
(1989)
VTASa
Variety of outcome
0%-50%
Johnson (1988)
VPPS"
PHASa
Symptom levels at
termination
No
association
Gaston et al. (in
press)
CALPASa
Symptomatic improvement
Author
WAI"
27%-38%
20%
25%-51%
9%-14%
9%-35%
18% -27%
CALPASa
PHAS"
36%-57%
Key Terms Defined: VPPS = Vanderbilt Psychotherapy Process Scale; VTAS = Vanderbilt
Therapeutic Alliance Scale; TARS = Therapeutic Alliance Rating Scale; CALPAS = California
Psychotherapy Alliance Scale; PHAS = Perm Helping Alliance Scale; WAI = Working Alliance
Inventory.
= Rated by clinical judges
= Rated by patient
= Rated by therapist
d
= Patient working capacity subscale only, rated by patient and therapist
= When outcome was based on residual gain scores (initial levels of disturbance accounted
for), no significant relation was found
= Initial levels of symptoms not accounted for
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HANDBOOK OF PSYCHOTHERAPY INTEGRATION
(1983). The Vanderbilt researchers had reported that two process variables,
"patient involvement" and "therapist-offered relationship," predicted outcome in an outpatient college population. Using a larger sample of therapists, and a more typical adult outpatient sample, the authors replicated the
Vanderbilt findings. Ratings on 10 minutes of therapy from a single session
correlated with the outcome of 16 weeks of brief dynamic psychotherapy
based on therapist ratings of change (but not client ratings).
Using the Vanderbilt Psychotherapy Process Scale (VPPS) to study
the active ingredients of therapy, the Vanderbilt group found differences
in behavior between therapists from different orientations. The analytic
therapists were observed to use more exploratory techniques, the Rogerian
therapists were warmer and more empathetic, and the nonprofessionals
gave more advice and engaged in more informal conversations (GomesSchwartz, 1978). Despite these differences in behavior and theory, no
substantive differences in outcome were found between therapies. Drawing
on the same database, O'Malley et al. (1983) examined the active ingredients of therapy in the first three sessions. In this study they revised the
VPPS and still found that it correlated mainly with therapist ratings of
psychotherapy outcome. The predictive variables were patient involvement and therapist-offered relationship.
Both the Vanderbilt group and Windholz and Silberschatz (1988)
were puzzled over the failure of the process variables to correlate more
highly with patient ratings of change. And these failures weaken the
conclusions from both sets of studies. Neither group found much in the
way of specific techniques that were unique to particular theories of
change, strengthening the conclusion that common factors are central.
Research on the therapeutic alliance has, as yet, generated far less
research than that generated by client-centered theory. Still, it has advanced to the stage of trying to show that the alliance is actually something that not only precedes therapeutic change but is also an active ingredient of psychotherapy. Gaston, Marmar, Thompson, and Gallagher (in
press), for example, used hierarchical regression analysis to examine the
alliance in elderly depressed patients who received dynamic, cognitive, or
behavioral therapy. Initial symptomatology, symptomatic improvement up
to time of alliance measurement, and patient and therapist CALPAS (California Psychotherapy Alliance Scale) scores were used to predict symptoms
at termination. The alliance assessed near termination accounted for 36
percent to 57 percent of outcome variance over and above initial symptomatology and in-treatment symptomatology change.
Another approach to understanding the contribution of the therapist
to effective outcome has involved the use of behavioral and adjective
checklists filled out by clients following their therapeutic contacts. Lorr
(1965), for example, had 523 psychotherapy patients describe their thera-
Psychotherapy Outcome Research
109
pists on 65 different statements. A subsequent factor analysis identified five
factors: understanding, accepting, authoritarian (directive), independenceencouraging, and critical-hostile. Scores on these descriptive factors were
correlated with improvement ratings, with the result that client ratings of
understanding and accepting correlated most highly with client- and therapist-rated improvement.
In a more recent study, Cooley and Lajoy (1980) attempted to replicate the Lorr study. In addition, they studied the relationship between
therapist ratings of themselves and of outcome, as well as the relationship
of discrepancies between patient and therapist ratings and outcome ratings.
The patients were 56 adult community mental health outpatients who had
been treated by one of eight therapists at the clinic. As with the Lorr study,
patient ratings of therapist understanding and acceptance correlated most
highly with client-rated outcome. On the other hand, when self-ratings of
therapists attributes were compared to therapist-rated patient outcome, the
correlations were insignificant, suggesting that therapists did not perceive
their personal attributes as a factor influencing therapeutic outcome.
Similar findings have been reported in group treatment. Glass and
Arnkoff (1988) examined common and specific factors in client descriptions
and explanations of change. The clients were shy and consequently treated
in one of three structured group therapies for shyness or in an unstructured
therapy group. Each group was based upon a different theory of change
and differed in its content and focus. Nevertheless, content analysis revealed that in addition to specific treatment factors, all groups contained
considerable emphasis on group process and common factors such as
support. They suggest that "the role of common group process factors
appeared to be at least as important to subjects as the specific therapy
program content" (p. 437).
Murphy, Cramer, and Lillie (1984) studied common factors by having
outpatients generate a list of curative factors that they believed to be
associated with their cognitive behavioral therapy. Those factors suggested by a significant portion of patients were advice (79 percent), talking
to someone interested in my problems (75 percent), encouragement and
reassurance (67 percent), talking to someone who understands (58 percent),
and installation of hope (58 percent). The two factors that correlated most
highly with outcome, as assessed by both therapist and patient, were
talking to someone who understands, and receiving advice. It is interesting
to note that the patients in this study were predominantly from the lower
socioeconomic class, and past research has shown that these patients
expect advice (Goin, Yamamoto, & Silverman, 1965).
Patients frequently attribute their success in treatment to personal
qualities of the therapist. That these personal qualities bear a striking
resemblance to each other across studies and methodologies is evidence
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HANDBOOK OF PSYCHOTHERAPY INTEGRATION
that they are highly important in psychotherapy outcome. This notion was
also emphasized by Lazarus (1971) in an uncontrolled follow-up study of
112 patients whom he had seen in therapy. These patients were asked to
provide information about the effects of their treatment and the durability
of improvement, and their perceptions of the therapeutic process and
characteristics of the therapist. With regard to therapist characteristics,
those adjectives most often used to describe Lazarus were sensitive, gentle,
and honest. Patients clearly felt the personal qualities of the therapist were
more important than specific technical factors, about which there was little
agreement.
In their study comparing behavioral and more traditional insightoriented therapy, Sloane, Staples, Cristol, Yorkston, and Whipple (1975)
reported a similar finding and elaborated upon the place of therapist
variables in positive outcome. Although they failed to find a relationship
between judges' ratings of therapists' behavior during the third therapy
session (on empathy) and later outcome, they did find that patients tended
to emphasize the personal qualities of their therapists as causing personality change.
The notion that common factors are important in producing positive
outcomes is also supported by the failure to find differential outcomes in
studies comparing therapies that use highly divergent techniques. This
finding has been documented in several reviews (Bergin & Lambert, 1978;
Luborsky, Singer, & Luborsky, 1975), and has been dramatically illustrated
in the NIMH multisite collaborative study of depression (Elkin et al, 1989),
which compared a standard reference treatment (imipramine plus clinical
management) with two psychotherapies (cognitive-behavior therapy and
interpersonal psychotherapy, a kind of dynamic therapy). These three
treatments were contrasted with a drug placebo plus clinical management
control group. The study was the first head-to-head comparison of these
two psychotherapies that had been shown in previous research to be
specifically effective with depression. Both these therapies had been extensively tested by their developers, but less was known about the degree to
which their effectiveness could be replicated by therapists outside of the
groups that developed these treatments.
The 250 patients seen in this study were randomly assigned to the
four treatments that were offered in Pittsburgh, Oklahoma City, and Washington, D.C. They met research diagnostic criteria for a major depressive
episode and a score of 14 or more on the 17-item Hamilton Rating Scale
for Depression. A host of exclusion criteria were also applied so as to leave
the sample who were treated as free from other disorders as possible.
The therapists were 28 psychiatrists and psychologists who were
carefully selected, trained, and monitored in the specific treatment they
offered. Each therapist saw between one and eleven patients. The treat-
Psychotherapy Outcome Research
111
ments were carefully defined and intended to reflect a manual that spelled
out theoretical issues, general strategies, major techniques, and methods of
managing typical problems. Those who completed therapy averaged 16.2
sessions. The battery of outcome measures included symptomatic and
adjustment ratings from multiple perspectives.
Numerous comparisons were made and the results of this study are
very complex. Among the more interesting findings were comparisons of
the two psychotherapies with the medication placebo plus clinical management (PLA-CM). This latter condition was intended to control for the
effects of regular contact with an experienced and supportive therapist, the
general support of the research setting, and the effects of receiving a drug
that was thought to be helpful. Did the psychotherapies have any effects
beyond what could be achieved through this rather extensive placebo?
There was limited evidence of the specific effectiveness of the interpersonal psychotherapy (IPT) and no evidence for the specific effectiveness
of cognitive-behavioral therapy (CBT). In general there was little evidence
for superiority of the therapies in contrast to the placebo. The therapies
were effective, but the patients who received the placebo also improved.
Interpersonal psychotherapy, however, was more impressive with the
more severely disturbed patients.
In head-to-head comparisons of IPT and CBT, no significant differences were found in any of the major analyses or in comparisons with more
and less severely disturbed patients. This similarity held up even on measures that were thought to be differentially sensitive to the two therapies.
The authors conclude: "The general lack of differences between the two
psychotherapies, together with the good results for the PLA-CM condition, suggests once again the importance of common factors in different
types of psychologically mediated treatment" (Elkin et al., 1989, p. 979).
Similar conclusions were reached by Zeiss, Lewinsohn, and Munoz
(1979). These authors compared (a) interpersonal-skills training, (b) a reinforcement-theory program to increase pleasant activities (and the enjoyment of potentially pleasant activities), and (c) a cognitive approach to the
modification of depressive thoughts. They found that all treatments were
associated with reduction in depression, without any differential changes
specific to aspects of the patient's problems targeted by the three treatments. Zeiss et al. (1979) note the improvements also recorded by the
waiting list group and cite Frank's (1974) demoralization hypothesis as the
most parsimonious explanation for the results. These researchers suggest
that the impact of treatment was due to the enhancement of self-efficacy
via training self-help skills, thus increasing expectations of mastery and
perception of greater positive reinforcement as a function of the patient's
greater skillfulness. Therefore, the common components of therapy for
depression emerge as important. On the other hand, it should be noted that
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HANDBOOK OF PSYCHOTHERAPY INTEGRATION
the experience level of the therapists was not high (counseling psychology
graduate students and M.A.'s), and there was no monitoring of the therapists' contributions to therapy; thus treatment delivery according to the
design is not assured. In addition, patients' and therapists' perceptions of
curative factors were not studied, so that the attribution of causality to
them is purely hypothetical.
Implication 3: In general, eclectic therapies should stress commonalities,
including the therapist's contribution to outcome, by emphasizing those factors
common across therapies highlighted in empirical research. To the extent that they
are present in therapy positive personality change is likely.
What Techniques Can Be Chosen on the
Basis of Demonstrated Superiority?
Given the improvement that results from homeostatic mechanisms, fortuitous events, social supports, expectations, and common factors, there has
not been any general, clear demonstration of the power and differential
impact of specific techniques on patient functioning. Nevertheless, technique effects sometimes show themselves in particular studies; unfortunately, replication of technique effects has proved difficult.
COMPARATIVE OUTCOME STUDIES
Traditional reviewing procedures of the earliest comparative studies
have not resulted in conclusions that favor the superiority of a particular
therapy across the broad categories of anxiety, depression, and interpersonal problems to which they have been applied (Meltzoff & Kornreich,
1970; Luborsky, Singer, & Luborsky, 1975; Bergin & Lambert, 1978). The
newer quantitative reviews (see table 3.1) based on meta-analysis have
been more likely to reflect small differential outcomes, albeit with little
consistency.
Data from several meta-analytical reviews (Dush et al., 1983; Nicholson & Berman, 1983; Shapiro & Shapiro, 1982; Smith, Glass, & Miller,
1980; Quality Assurance Project, 1983) tend to yield a small but consistent
advantage for cognitive and behavioral methods over traditional verbal
and relationship-oriented therapies. The most reliable data coming from
within-study comparisons suggest some advantage for cognitive and behavioral therapies over dynamic-humanistic ones.
To examine this issue more carefully, let us consider Shapiro and
Shapiro's (1982) extensive meta-analysis, which focused exclusively on
Psychotherapy Outcome Research
113
studies comparing two or more active treatments with control conditions.
In consequence, their data contained more replicated comparisons between
treatment methods than found in the Smith et al. (1980) review, and
permitted more definitive statements concerning the comparative efficacy
of treatments. Based on an examination of 143 studies, Shapiro and Shapiro
(1982) found that cognitive and various behavioral treatments yielded
more favorable outcomes (1.00 and 1.06 effect sizes, respectively) than
other treatments with which they were compared, whereas dynamic and
humanistic therapies tended to yield inferior outcomes (effect size 0.40).
Like Smith, Glass, and Miller (1980), however, Shapiro and Shapiro (1982),
also attributed the larger effect sizes to strong biases in the behavioral and
cognitive literature toward analog studies, mild cases, and highly reactive
criteria. They stated that the treatments and cases studied were unrepresentative of clinical practice but very representative of the simple experiments
on those techniques that are frequently conducted in university settings.
An interesting sidelight of the Shapiro and Shapiro report was the
finding of a significantly larger effect size for cognitive-behavior therapy
over systematic desensitization. This conclusion has, however, been challenged by another meta-analysis. Berman, Miller, and Massman (1984),
using a larger, but overlapping, sample of studies, showed no difference
between cognitive-behavior and desensitization therapies (effective size
difference 0.06). It also revealed that the larger effect sizes for cognitivebehavior therapy occurred in studies conducted by investigators having an
allegiance to that method. Also of interest was the finding that the combination of desensitization with a cognitive-behavior method did not increase effects beyond that obtainable by either treatment alone.
Dobson (1989) reported a meta-analysis of 28 studies that compared
Beck's cognitive therapy with no treatment, other behavior therapy, drug
treatment, or other psychotherapy with depressed patients. In each study
the Beck Depression Inventory was used as the outcome measure. Cognitive therapy was two standard deviations better than no treatment, and half
a standard deviation was better than drug treatment, behavior therapy, or
other psychotherapy.
Robinson, Berman, and Neimeyer (1990) in a broader and more
diverse sampling of the literature found cognitive, cognitive-behavioral,
and behavioral psychotherapies to be a half standard deviation superior to
general verbal therapies (which appeared to be no more effective than
placebo controls). However, when allegiance of the experimenter was
taken into account, the differential effects of treatments washed out.
The foregoing meta-analyses reveal a mixed picture. There is a strong
trend toward no differences between techniques in amount of change
produced, with occasional superiority for a particular method.
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HANDBOOK OF PSYCHOTHERAPY INTEGRATION
EFFECTS OF BEHAVIORAL THERAPY WITH SPECIFIC SYMPTOMS
A variety of psychotherapy research strategies have confirmed the
powerful and superior effects of some behavior therapies with certain
specific problems. The most clear superiority for a particular treatment is
with phobic disorders. Research has suggested the necessary steps to
facilitate rapid reduction of anxiety to phobic situations. These procedures
involved selecting patients with clearly identified fears that are evoked by
specific stimuli. In addition to identifying the evoking stimuli, the patient
must be motivated to seek and complete treatment. Early reports indicated
that as many as 25 percent of patients may refuse or drop out of treatment
(Marks, 1978), although this is not a high figure for a research protocol. In
order for the treatment to work, clients must be willing to "make contact"
with the evoking stimuli until their discomfort subsides.
Numerous behavioral approaches are based on this "exposure" paradigm. Desensitization involves repeated brief exposure in fantasy or in
vivo with a counteracting response, such as relaxation, during and between
exposure. Flooding involves rapid, prolonged approach into the phobic
situation in fantasy or in vivo. Operant approaches have been used via
systematic rewards for moving toward or staying in the feared situation.
Modeling follows a similar paradigm in which the therapist models approach behaviors and then encourages the patient to do the same. Even in
cognitive rehearsal and self-regulation approaches, the patient is encouraged to face feared situations and attain mastery of those situations
through the use of effective coping strategies. Therapies for some other
anxiety-based disorders such as sexual dysfunctions and compulsive rituals
are dealt with through the use of similar exposure techniques. These
include gradual practice in sexual situations, and response prevention following exposure to the anxiety that precedes and accompanies rituals.
Although the exposure principle does not explain the reasons for
improvement, it does suggest the necessary conditions for improvement
and the therapeutic strategy that is to be used: identify the provoking
stimuli, encourage exposure, help the patient remain exposed until the
anxiety subsides, and assist in mastering thoughts and feelings linked with
the disordered responses. Given enough contact with the feared situation,
patients cease to respond with avoidance, anxiety, or rituals. Contrary to
the expectations of some professionals and the patients themselves, increased sensitization to the anxiety-provoking situation is rare. Marks
(1978) suggests such sensitization occurred in only 3 percent of the cases
that were expected to be successful (i.e., had adequate motivation, absence
of serious depression, no attempts to escape exposure in fantasy or reality,
and completed a reasonable amount of treatment).
Psychotherapy Outcome Research
115
Numerous studies have tried to sort out the specific procedures
necessary for successful treatment. Is deep muscle relaxation necessary? Is
gradual exposure through a hierarchy required? Is high arousal necessary
(as in implosion)? Should exposure be in vivo or through mental images?
Does modeling enhance other exposure methods? Should exposure be
prolonged or brief? Will the addition of cognitive coping strategies enhance the effects of exposure treatments? The bulk of evidence on these
and similar questions suggests that achieving lasting reductions in fears and
rituals is a function of exposure. Time spent with deep muscle relaxation,
the use of tranquilizers, and high levels of arousal, add little or nothing to
treatments that focus on any effective means of encouraging exposure until
anxiety reduction occurs (Marks, 1978; Emmelkamp, 1986). Likewise, interactional exposure without modeling produces fear reduction, but modeling without interactional exposure does not (Marks, 1978, p. 505).
Exposure-based therapies play a major role in the treatment of panic
disorder with agoraphobia (Barlow, 1988; Michelson & Marchione, 1991).
Clearly they are superior to alternative techniques, with conservative estimates of clinically significant improvement approximating 50 percent and
full recovery occurring in less than a third of patients (Jacobson, Wilson,
& Tupper, 1988).
Cognitive-behavioral treatments for panic with agoraphobia have
also received considerable research attention in recent years. It is a bit early
to draw definitive conclusions, but evidence is accumulating that combining cognitive therapy (aimed at cognitive restructuring and changing core
beliefs, misperceptions, and misattributions related to the disorder) with
gradual, therapist-guided exposure produces results superior to gradual
exposure alone or in combination with other treatments (Michelson,
Marchione, & Greenwald, 1989). This seemingly synergistic combination
is especially interesting for eclectic practice because it strongly supports
the basic premise of eclectic practice.
Conclusion 4: Although the earliest studies on anxiety reduction were
undertaken with simple phobias and nonclinical populations such as speech
phobics, there is now an abundance of studies on clinical populations that
substantiate the specific effects of exposure treatments when contrasted with other
therapeutic modalities and specific techniques that don't include an exposure
component. Still, research has identified boundaries to these effects; exposure treatments, although effective with agoraphobia, simple phobias, and
compulsions, are not as effective nor as uniquely effective with social
phobias, generalized anxiety disorders, or combinations of the above. The
exposure principle seems to have more limited specific applicability with
sexual dysfunctions, where the short-term effects are not followed with the
same long-term effects as exposure for agoraphobics (Emmelkamp, 1986).
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The specific importance of cognitive therapy for panic and agoraphobia
with panic appears promising but is in need of further investigation (Michelson & Marchione, 1991).
Implication 4: Eclectic therapies that capitalize on the contributions of
specific techniques are likely to be especially effective and should be recommended
for practice. Since there is some evidence for the usefulness of particular
techniques, eclectic therapies may be effective either because clinicians with
this orientation are flexible enough to use techniques that directly address
a problem or because eclectics are more open to the value of referral to
clinicians skilled in the use of a particular technique. In either case, because
of its flexibility in use of technique, eclectic therapy may be less likely to
produce negative outcomes in patients.
Overall Conclusions and Future Research
Although most eclectic therapies are based on empirically tested therapies,
their foundation has been borrowed from research work on specific therapy
schools. Very little research has been produced by the emerging systematic
eclectic approaches.
Garfield (1986), in reference to his own theory, states: "Unfortunately,
no systematic research has been conducted on the approach. . . . The only
evidence that exists to support the efficacy of this approach are clinical
observations and anecdotes, and this is not really adequate" (pp. 157—158).
Mahalik (1990) has reviewed the status of four distinct (systematic)
eclectic approaches on five dimensions ranging from theoretical adequacy
to empirical support. By evaluating the approaches of Beutler, Howard,
Lazarus, and Prochaska, Mahalik has focused on four of the most fully
developed and described representatives of eclecticism. His review clearly
reflects the status of research in this area:
None of the models have been well evaluated and none have received more than
the beginnings of empirical support. Additionally, the great majority of research
on the models has been conducted by the authors. If the systematic eclectic field
is going to attain greater credibility, research outside the labs of the model's
advocates must replicate and extend these findings, (p. 675)
In my view the picture is, if anything, more bleak than Mahalik points
out. With the exception of the Beutler and Prochaska models, Mahalik's
review showed that only two outcome studies had been conducted on the
other models, and no comparative or control group studies were among
these.
Psychotherapy Outcome Research
117
For example, Lazarus (1992) has suggested that his approach is not
intended to be added to the hundreds in existence but rather is an attempt
to be at the cutting edge of clinical effectiveness by incorporating the
findings of current research and practice. Despite his commendable efforts
to be empirical, it is disappointing to see so little systematic effort directed
toward a controlled investigation of the effects of a multimodal therapy
that purports to be at the "cutting-edge" of therapy. What kind of improvement rate can one expect as a result of this application of technical
eclecticism? Are there patients for whom this approach is more appropriate? Would this eclectic approach offer clients anything more than the
cognitive-behavioral therapy to which it is most indebted? These and a
host of similar questions remain unanswered at this time. But it would be
surprising if the unsubstantiated reports of superiority held up in a comparative outcome study!
The Beutler model (Beutler & Consoli, 1992) has generated considerably more outcome research as he has initiated several studies of his
matching hypothesis and has begun to study interventions according to his
theory of systematic eclecticism. Despite this, he has encountered significant difficulty in applying his matching scheme successfully, leaving important aspects of his theory without confirmation (e.g., Calvert, Beutler, &
Crago, 1988). Matching patients, therapists, and therapies is no small
achievement, and it continues to elude those who have the confidence to
attempt it.
Prochaska and DiClemente's (1992) model, the transtheoretical approach, has also generated considerable research. As compared with other
eclectic systems, it rests on a more substantial base of empirical research,
a good deal of which is based on a narrow sample of clients who were
attempting to give up smoking. Nevertheless, empirical support for some
of the most important postulates of this model (e.g., how the needs of
clients change over time as they improve, how this interacts with interventions) is slowly being accumulated. The outcome research has used manuals
aimed at facilitating self-change, finding that with and without a therapist
present, it proved more effective at helping people quit smoking than a
traditional self-change approach not based on the principles and assumptions of the transtheoretical approach. These initial steps toward evaluation
of the transtheoretical approach must be followed by systematic research
aimed at sorting out the advantages, if any, of this approach over singleschool or other eclectic procedures.
Recent research conducted in England by Stiles et al. (1990) may be
of special interest to eclectic practitioners and theoreticians. This research
also has implications for eclectic, stage-model of change (e.g., Beitman,
1992; Prochaska & DiClemente, 1992). Stiles and his associates have proposed an assimilation model of change, which proposes that an important
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common change mechanism across therapies is the assimilation of problematic experiences. Eight stages of problem solution are proposed. These
include (I) warded off, (2) unwanted thoughts, (3) vague awareness,
(4) problem recognition, (5) insight/understanding, (6) application of understanding, (7) problem solution, and (8) mastery. As with the Beitman
and with the Prochaska and DiClemente's models, the assimilation model
suggests that dynamic-humanistic therapies are most suitable at the early
stages of therapy, while cognitive-behavioral therapies are best suited for
the issues that arise in the latter stages of problem solution and assimilation, such as mastery.
Results of other research conducted in the Sheffield University project
(Shapiro & Firth, 1987), similarly, have several implications for eclectic
practice. These researchers, who undertook a comparative outcome study,
employed an unusual research design to maximize sensitivity to technique
effects. They used a crossover design in which 40 outpatients received
eight sessions of cognitive-behavioral therapy and eight sessions of humanistic-dynamically oriented psychotherapy. These therapies were offered by the same therapists, but the order ot exposure was varied. This
procedure allowed for a comparison of the effectiveness of both therapies
while reducing the variance in outcome as a result of different therapies
offered by different therapists. It also allowed for the examination of order
effects; does combining therapy in a set order enhance the effects of
therapy? This design thus tests the assimilation model and has implications
for the transtheoretical model as well.
Results of the analysis showed few differences between the two
treatments, although a slight superiority for the cognitive-behavioral treatment was noted. Of greater importance in the present analysis was their
study of sequencing of treatments. In view of the models just presented,
and the widespread belief in establishing a relationship prior to requiring
activities outside of therapy (as required in many behavior therapies), it is
surprising to see no differences in outcome due to the order of receiving
treatment. Although Stiles et al. (1990) have proposed the importance of
sequencing interventions, it would not appear that starting therapy with a
method that emphasizes reducing defenses, increasing awareness of feelings, and facilitating insight, was any more helpful than beginning therapy
with cognitive-behavioral procedures that focus more on active problem
solving and mastery of problems.
In many ways the Sheffield Psychotherapy Research Project reflects
the conclusions of meta-analytic reviews and summaries of comparative
studies: slight superiority for cognitive-behavioral psychotherapies in contrast to dynamic-humanistic ones. The methodological issues noted in past
reviews tended to balance out in this study. On the one hand, the dynamic
therapy was offered in only eight sessions, a decision that could be seen
Psychotherapy Outcome Research
119
as favoring the cognitive-behavioral therapy. At the same time, the allegiance of the researchers, if any, favored the dynamic-humanistic intervention. On balance, one would have to conclude that if therapists were
choosing a therapy on the basis of efficacy, they have grounds, from this
study, to consider adapting the cognitive-behavioral techniques, but in so
doing they cannot expect to show much superiority over dynamic-humanistic practitioners.
Also of considerable interest to eclectic therapists is a report on
"therapist effects" arising out of this same research. Could therapists offer
both therapies equally well? Shapiro, Firth-Cozens, and Stiles (1989) examined the effects of specific therapists on the outcome of therapy in the
Sheffield project. The 40 patients were seen by four therapists who offered
both a cognitive-behavioral and dynamic therapy to patients. Although the
project used manuals and supervision to minimize the effect of individual
therapists on treatment outcome, the authors discovered that the two
therapists who saw the majority of patients had different outcomes. One
of the therapists was more effective than the other in cognitive-behavioral
therapy and less effective in the dynamic. The results of this study suggest
that even with intensive supervision and training, therapists can still show
differential effectiveness under the most controlled of circumstances. This
appears to be true even when the therapists have an interest and a commitment to both modalities. There may well be limits to the variety of
techniques that some clinicians can employ.
One implication of this research is the serious demands that can be
put on eclectic practitioners. The effective use of any given therapy, of
course, requires considerable skill. But the effective use of many methods,
the timing of their use, and the continued updating on techniques is
especially challenging for the eclectic. This book responds in part to the
need to organize and systemize the demanding task of the eclectic therapist.
Despite the openness of eclectic theorists to knowledge derived from
clinical practice and basic research, the eclectic approach has not yet
produced a distinguishable body of research that supports its claims of
superior efficacy. In the short run, therefore, projects aimed at demonstrating the effectiveness of eclectic approaches are sorely needed. Since eclectic
theorists' most persuasive argument for effectiveness lies in their claim for
flexibility in dealing with a variety of patient problems, an initial study
would call for the random assignment of patients to practitioners who
advocate treatment within the confines of a single-school approach and to
practitioners of an eclectic approach (cf. Wolfe & Goldfried, 1988). Such a
study would need to make recordings of the therapies offered in order to
clarify the nature of therapeutic interventions. The patients in such a study
should not be homogeneous with regard to their disorder. Instead, they
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should represent a cross section of patients typical of outpatient clinical
practice.
The central disadvantage of such research is that it repeats the competitive polarizing pattern that has characterized past comparative research.
Unfortunately, this research may lead to the solidification of yet another
therapy school rather than to agreement about the most effective intervention practices. Thus, the consequences of such research may go against the
basic values of an eclectic approach, but at least it could illustrate the
advantages of systematically combining treatments.
One attempt to focus future research on psychotherapy integration
was forged by the participants of a National Institute of Mental Health
workshop reported by Wolfe and Goldfried (1988). The workshop participants developed a list of 23 recommendations, which fell into four domains: (1) conceptual clarification, (2) psychotherapy process research,
(3) efficacy studies on integrative and systematic eclecticism, and (4) the
training and supervision of integrative therapists. The two issues of greatest relevance to this chapter are efficacy research and process research. The
need for more studies of efficacy have already been addressed. There is also
an urgent need for process studies that link therapist and patient actions to
positive change. Two studies will be highlighted to provide the reader with
intriguing strategies that illuminate the process-outcome connection.
Jones, Gumming, and Horowitz (1988) attempted to demonstrate that
there are, indeed, specific factors (not common across therapies) that lead
to therapeutic change. They studied the effects of therapist actions and
techniques, as well as patient attitudes and behaviors, on psychotherapy
outcome. They examined Psychotherapy Process Q-Sort ratings of brief
(12-session) psychodynamic psychotherapy with patients suffering stress
response syndromes following traumatic events or bereavement. The authors found that different factors predicted success with more and less
disturbed patients. Those patients who were initially more seriously disturbed seemed to respond better to supportive interventions such as direct
reassurance, avoidance of threatening interpretations, directing the dialogue, and support of defenses (rather than analysis of defenses). Those
patients who were less disturbed tended to do better with the aggressive
approaches. These patients were more aware of conflicts surrounding their
dependency needs, were more clear in their ability to express problems,
and were more organized. The therapists more often drew connections
between the patients' current relationships and their past relationships and
experiences. The here and now was also more emphasized within therapy
sessions.
Although Jones and colleagues emphasize the importance of their
results for highlighting specific techniques in contrast to common factors,
the implications for eclectic therapy are limited. First, the divergence of
Psychotherapy Outcome Research
121
effective techniques is easily handled within a pure-school approach. Thus,
this process research does not suggest the need for techniques outside of
a dynamic theory of change. Second, the nature of the report makes it
impossible to assess the accuracy of their interpretation of results, since the
items that did not correlate with outcome in either group were not reported and their analysis was post hoc. It remains to be seen if more or less
disturbed clients can be systematically identified before treatment and then
assigned to ideal and unideal matches. Nevertheless, this research strategy
allows for a complex analysis of therapy process and it can be recommended for further use in studies that investigate the active ingredients of
psychotherapy.
A second illustrative study was reported by Richards, Burlingame,
Barlow, and Lambert (1990). These authors examined the interpersonal
style of a select set of six patients who manifested clinically significant
improvement or deterioration following 16 weeks of group psychotherapy. All group interactions that involved the patient, the therapist, and
group members were selected from three sessions: early, middle, and late
in the therapy. In all, nearly 4,000 interaction units were analyzed using the
Structured Analysis of Social Behavior (SASB) developed by Benjamin
(1982). A stable pattern emerged for patients regardless of who in the
group they were speaking to, and who was speaking to them. Those who
improved were self-reflective and self-accepting, and their therapists related to them in an accepting manner. Those who deteriorated tended to
avoid self-reflection, were warded off and closed up, had many more hostile
interactions, and often had interactions in which they were hostilely compliant. In addition, therapists related to them in more parental ways. The
patients tried to befriend their therapist, and therapists were friendly in
return. Thus, it was not therapist hostility that was related to deterioration
but rather that therapists failed to draw patients out of their defensive and
placating style.
These results are similar to those of Henry, Schacht, and Strupp
(1986), who found that nonimprovers in individual therapy had approximately the same high levels of hostile behaviors. Both process studies
identify patient styles that suggest the need for interventions that were not
offered, and both suggest ways of increasing the effectiveness of psychotherapy quite apart from a single-school approach. In this sense they
illustrate the natural affinity between process research and psychotherapy
integration (Goldfried, Castonguay, & Safran, 1992).
Despite the seeming compatibility of psychotherapy research and
eclectic psychotherapy, there is little evidence that eclectic therapies are
being carefully researched. Before claims of superiority based on integration of the best from single-school approaches can be supported, empirical
investigations will need to be conducted. Until such investigations have
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been conducted, eclectic practitioners would do well to be more modest in
their claims for superiority. It may be that eclectics are far too eager to
integrate the least important aspects of treatment (techniques) while neglecting the central facilitating forces within treatments (common factors).
In so doing they may even produce therapies that are less efficacious than
the single-school approaches from which they are often derived.
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Psychology, 47, 427-439.
CHAPTER 4
A Critical Examination of Belief Structures in
Integrative and Eclectic Psychotherapy
STANLEY B. MESSER
SURVEYS
OF CLINICAL AND COUNSELING psychologists conducted over the past three decades have revealed that a substantial proportion of the respondents (from 19 percent to 65 percent) regard themselves
as integrative or eclectic in their practice of psychotherapy (Jensen, Bergin,
& Greaves, 1990). In their own recent poll, which included clinical psychologists, marriage and family therapists, social workers, and psychiatrists,
Jensen et al. (1990) found that an even higher percentage of these professional groups (from 59 percent to 72 percent, with an average of 68
percent) endorsed eclecticism as their preferred orientation. Interpreting
similar survey results in the strongest terms, Smith (1982) declared that
"the days of individual schools in counselling and therapy are drawing to
a close" (p. 805). Along with such empirical surveys affirming the popularity of eclectic practice have come books, articles, conferences, and journals
furthering the cause of eclecticism (see Norcross & Newman, 1992). Psychotherapy integration and eclecticism, it would seem, are on the march.
Nevertheless, not all is tranquil on this psychotherapy frontier. To
begin with, the figures quoted above do not show a neat, linear rise in the
incidence of eclecticism. To take the most current and dramatic example,
whereas Jensen et al. (1990) reported that 68 percent of practitioners are
eclectic, the corresponding figure determined by Norcross, Prochaska, and
Gallagher (1989) was only 29 percent. This large discrepancy could not be
explained on the basis of either the year of the study or the group polled.
Jensen and colleagues quite rightly concluded that until empirical studies
examine exactly what self-declared eclectics do in practice, such results will
remain ambiguous.
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A further problem with what to make of these figures lies in the
definition of eclecticism. The College Dictionary (1972) defines eclectic as
"not following any one system, as of philosophy, medicine, etc., but
selecting and using what are considered the best elements of all systems"
(p. 418). The surveys, however, typically include under the rubric of
eclecticism a substantial proportion of therapists who selectively employ
a single (not combined) theory or method that they regard as best suited
for the client and/or problem at hand. In the survey by Garfield and Kurtz
(1975), for example, 55 percent could be so described, as could 47 percent
in a survey by Norcross and Prochaska (1988). Since it appears that such
practitioners employ individual theories or methods for particular clients
one at a time, they are not being integrative or eclectic at any one time, in
the definition's sense of selecting and using the best elements of several
approaches (Slife, 1987). Thus, statements such as, "The basis for eclectic
practice is the contention that different clients and different problems
require different treatments" (Patterson, 1989, p. 158) are mistaken. More
accurate terms for this mode of practice are prescriptive selection (Beutler
& Clarkin, 1990), differential therapeutics (Frances, Clarkin, & Perry, 1984;
Clarkin, Frances, & Perry, 1992), or "diagnose-the-problem and prescribethe-treatment" (Mahrer, 1989), but not eclecticism. In addition, as Slife
(1987) points out, one must have (or, at least should have) a system for
making such prescriptive judgments, which itself is a theory, but it is not
one that includes several theories at once.
The net effect of this argument is a marked reduction in the incidence
of eclecticism, at least as that term has been traditionally defined and
understood. Another implication is that we should discriminate as much as
possible among different kinds of "eclecticism," as the rationale for and
practices within each type are likely to differ substantially. Since it has
become common practice in discussions of integration and eclecticism to
include prescriptive matching, I will do so as well by referring to prescriptive matchers as "selective" eclectics. As I will try to show, the belief
system that underlies this approach is quite different from that of integrative eclectics.
In this chapter, I present several different, largely independent perspectives on eclecticism, each of which can be evaluated on its own
particular merits. Although I have discussed some of these issues elsewhere
(e.g., Messer, 1986a, 1987; Messer & Winokur, 1984, 1986) I expand upon
and update them below. First, I take up three philosophical notions that aid
our understanding of the beliefs that fuel eclecticism. The first, the unitydiscovery model, argues that underlying the appearance of diversity and
contradiction in the world is a basic unity. When we organize data at a
superordinate level, the integrative eclectics claim apparent contradictions
disappear and the integrated fabric of knowledge emerges. A second belief,
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which drives what I have referred to above as selective (vs. integrative)
eclecticism, is that we do not merely discover what is already present in
nature but, rather, we create our categories and impose them on the world.
That is, there are different ways of construing our observations of human
behavior, each having a certain legitimacy. As a result, the selective eclectic
advocates the use of different approaches for different clients (selective or
prescriptive matching), compared with the integrative eclectic who proposes a single, comprehensive, adequate, and unified therapy for all clients.
A third belief underlying eclecticism is that we can share a common, neutral
language in psychology, replacing the diversity of theoretical and ideological terms we currently employ. I question whether this is possible.
The second topic is a consideration of how each psychotherapy
embodies a vision of life of mythopoetic proportions. The literary forms
described include the tragic, romantic, ironic, and comic, and the systems
of therapy to which they are applied include psychoanalysis, behavior
therapy, and experiential-humanistic therapy. This forms a backdrop to
consider both the prospects and problems of eclecticism as a function of the
change in visions of reality that eclecticism necessarily brings about.
The third section takes up the issue of what constitutes evidence or
knowing in different therapeutic frameworks. The empirical-experimental
method is contrasted with the hermeneutic attitude toward truth-seeking.
The ways in which this split create certain potential obstacles to eclecticism are discussed. In the fourth section, I briefly consider how the value
framework of therapists affect their attitude toward eclecticism and integration, since, in the final analysis, it is they who must implement the
therapy. Finally, the fifth section presents an alternative to present forms
of integration, which 1 call "assimilative integration." It consists of incorporating perspectives or practices from other approaches within one's
primary theoretical or therapeutic outlook, while taking their new context into account.
Philosophical Considerations
Different forms of eclecticism are related to certain philosophical attitudes that psychotherapists rarely recognize or acknowledge. In this section I try to show that integrative eclecticism is closest to the philosophical belief called "organicism"; that selective eclecticism views the process
of knowledge acquisition as discovery rather than invention; and that
integrationists conceive of the (questionable) possibility of a language of
description that is neutral and therefore acceptable to proponents of different therapies.
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ORGANICISM AND THE UNITY-DISCOVERY MODEL
In a far-reaching philosophical treatise, Pepper (1942) spelled out four
"world hypotheses" into which all explanations are said to fall: mechanism,
contextualism, formism, and organicism. Each has a root metaphor that
provides the basic analogy by which we can get a grip on that world
hypothesis. Thus, for mechanism, the root metaphor is the machine. In
psychology we embrace mechanism when we conceive of psychological
data as consisting of individual, independent parts or pieces existing in a
spatiotemporal configuration, and which are governed by a set of universally valid laws. The British empiricists Locke, Berkeley, and Hume are
most closely connected with this tradition insofar as they emphasized the
existence of separate ideas that get linked up by association. Behaviorism
falls within the mechanistic world hypothesis.
Contextualism, unlike mechanism, is synthetic rather than analytic. The
root metaphor is the historical event as seen within a setting or context.
An act or event is explained by revealing the specific relationship it bears
to other events occurring in its psychosocial sphere. The point is not to
integrate all events in the field, nor to presume that there are timeless laws
governing the data, but to limit the explanation to the specific domain and
time period studied (White, 1973). As stated by Pepper (1942), "The
quality of an event is the fused qualities of its strands, and the qualities of
its strands come partly out of its context" (p. 249). That is, unlike the case
in mechanism, there is no separation of detail from context. Psychobiography is contextualist in that it stresses the uniqueness and individuality of
its subject matter. The phenomenological approach is contextualist, too, in
its emphasis on a description of the world of experience with full allowance
for detail embedded in context. This world hypothesis takes us in an
interpretive or hermeneutic direction as opposed to a causal-exploratory
(mechanistic) one (Smith, 1988).
A third world hypothesis is formism, the root metaphor of which is
similarity. It seeks classes of things or events whose similarity to or
difference from others can be described. "The formist considers an explanation to be complete when a given set of objects has been properly identified, its class, generic and specific attributes assigned, and labels attesting
to its particularity attached to it" (White, 1973, p. 14). In psychology, when
we set about to construct a personality typology, such as Jungian archetypes, or a stage theory that presupposes ideal forms, such as Piaget's, we
are encountering formism.
Finally, organicism is the most integrative world hypothesis within
which a philosophical (vs. pragmatic) eclecticism can find a home. The
organicist believes that in the world, we encounter fragments of experience, such as observations of a school of therapy; these appear with certain
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connections that inevitably encounter contradictions, gaps, or opposition
from other fragments of experience, such as the observations of other
theories of therapy. The various fragments have a tendency to be resolved
by incorporation into an organic whole that, all the while, was implicit in
the fragments and that transcends the previous contradictions by means of
a coherent totality (Pepper, 1942, p. 283)—or, we might say, by an
integrative eclecticism. By organizing the data at a higher level, the appearance of conflict is dissolved into the reality of the organic whole. Progress
is achieved by including more and more of the fragments into a better
integrated whole.
In terms of integrating parts of one therapy with parts of another, the
integrative eclectic, like the organicist, would argue that the apparent
contradictions were never really contradictions at all because they vanish
when the integrated system is constructed (see Beitman; Garfield; Prochaska & DiClemente; Wachtel & McKinney; all 1992). Nothing is lost in
such a system because it takes in the pieces of one therapy and joins them
to another. Individual pieces get aggregated into wholes that are greater
than the sum of their parts.
Organicism is linked to belief in unity of knowledge. Some scholars
proceed from the premise that unity of knowledge is possible because "the
connections were really there all the time, working in nature. . . . There was
nothing to do but let them come together. . . . These are immediately
discoverable in observation" (Pepper, 1942, p. 292). Now, if this is the case,
we have a powerful argument at hand in favor of integrative eclecticism:
In joining parts of different theories or therapies, we are contributing to
that unity which is, in fact, the natural order of the psychological (and
physical) universe.
Within psychology, the most fervent spokesperson for this viewpoint
is Arthur Staats (1983, 1988), who argues that our field is in a crisis of
disunity and that a unified science of psychology is now possible and
desirable. He has suggested "that psychology marshall itself toward establishing an interest in such unification which will demand development of
the need for unified theory" (Staats, 1981, p. 253). In the therapeutic realm,
those integrationists (e.g., Beitman, 1992; Garfield, 1992; Goldfried, 1980;
Omer & Alon, 1989; Omer & London, 1989; Orlinsky & Howard, 1987)
who view the power of the different psychotherapies as lying within their
shared elements (such as a good therapeutic relationship, emotional release,
exposure to conflicts, explanations of some sort), implicitly are making the
same claim—that the different schools of psychotherapy, in fact, share a
commonality of viewpoint beneath the surface diversity. So have those
theoretical integrationists who construct a superstructure encompassing
various systems of psychotherapy (e.g., Prochaska & DiClemente, 1992;
Wachtel & McKinney, 1992; Safran & Segal, 1990). Norcross (1986, 1992)
A Critical Examination of Belief Structures
135
applauds such eclectic therapists for recognizing how differentiated parts
of psychotherapy can be organized and integrated into the whole at a
higher level, and for appreciating the unity and complexity achieved
thereby. By referring to such theorists as having "successfully reached the
summit," he is, in effect, strongly endorsing the value of unity.
If the reader is persuaded that there is an affinity between integrative
eclecticism and organicism, he or she should note that, in Pepper's scheme,
organicism is but one of four world hypotheses. In fact, behaviorism,
psychoanalysis, and existential-phenomenology are not basically organicist in outlook: philosophical eclectics share one particular philosophical
outlook on the best way to view psychological data, whereas adherents of
specific schools of therapy prefer others. Consciously or otherwise, we
operate within a particular world view but tend to lose sight of the
existence of other, equally viable alternatives.
In the field of psychotherapy, at the current time, we are in no
position to judge, in a once-and-for-all fashion, which world hypothesis or
theory is best. It can be argued that what is best at present is the continued
existence of a dynamic tension among these models, rather than a unimodel, organicist view. Royce (1982) calls this "constructive dialectics,
where dialectic has to do with maintaining the tension between viable
conceptual alternatives" (p. 259). Of course, one of the possible outcomes
of such a dialectic is some form of rapprochement or integration of the
models. Although Pepper insists that we should not compromise or combine these root metaphors or world hypotheses, Smith (1988) challenges
this view, arguing that in psychology we "cannot avoid dealing with our
topic in both the causal [mechanistic] and the interpretative [contextualist]
mode . . . we seem indeed to be creatures intrinsically linked to mixed
metaphors" (p. 11).
PERSPECTIVISM AND PLURALISM
The counterpart of the unity-discovery model and, hence, of an
integrative eclecticism, is that psychology, by its very nature, is pluralistic,
and "is not a single or coherent discipline but rather a collectivity of studies
of varied cast. . . . Paradigms, theories, models (or whatever one's label for
conceptual ordering devices) can never prove pre-emptive or preclusive of
alternate organizations" (Koch, 1981, p. 268). There is no single truth out
there to discover. Similarly, Royce (1982) argues that psychology is conceptually pluralistic, multiworld view and multitheoretic. Note that this is
not the older way of viewing systems of therapy, in which only one
system—"the true one"—was expected to emerge victorious. In fact, to
quote Omer and London's (1988) pithy phrase: "Pluralism waives exclusivism in favor of relativism" (p. 178).
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In discussing these issues in the context of the integratability of the
therapies, Schacht (1984) viewed the pluralistic outlook on psychology as
related to the idea that we do not merely discover what is inherent in
nature, but invent our categories and theories and view nature through
them. For Gergen (1982) this dichotomy is captured by a comparison of
exogenic with endogenic thinking. In the latter, "recordings of reality are
not so much correct or incorrect as they are creations of the observer.
. . . Multiple interpretations of experience are usually held to be both legitimate
and desirable" (pp. 176-177; italics added). Schacht (1984) points out that
"the pluralistic position cherishes contradictions as spurs to the creation of
knowledge and as antidotes to the suffocating intellectual effects of an a
priori assumption of unity" (p. 125). He contends that insofar as efforts at
eclecticism lead to a truly new and creative theory of therapy, such efforts
are to be valued. But insofar as they attempt merely to summarize and
unify current therapies, they may tend to stultify, not enrich our discipline.
In this connection, Walsh and Peterson (1985) concluded, after considering
the merits of a synthesis among major theoretical viewpoints, that "the
most cognitively responsible yet comprehensive view available at this time
is the position of pluralism" (p. 152), insofar as it encourages a crossfertilization of ideas and healthy cross-school competition.
Rychlak (1987) believes that unification of theoretical outlook is
deadly and reminds us that it is certainly not the norm in the physical
sciences. Similarly, William James (1909/1977) embraced a pluralistic philosophy in which "nothing includes everything, or dominates everything.
. . . The pluralistic world is thus more like a federal republic than like an
empire or kingdom" (p. 145). However, James would not have discouraged
efforts at integration, as long as alternative viewpoints could receive a fair
hearing (Viney, 1989). Even within a single theoretical domain, psychoanalysis, Mitchell (1991) has written, "We need to learn to regard differences in theoretical perspectives not as unfortunate deviations from one
accurate understanding, but as fortunate expressions of the countless ways
in which human experience can be organized" (p. 6). Although it might be
more satisfying and elegant if the world were not a multiverse, but a
universe (Wertheimer, 1988), the pluralists assure us that, alas, this quest
will never be realized.
Given that different ways of conceptualizing reality are always possible and even desirable from perspectivist and pluralist standpoints, there
will continue to be several extant theories of therapy. Some therapists will
choose to practice within a single-school approach. Others will attempt to
unite two or more therapies, as integrative eclectics do. Selective eclectics
seem to take a bird's-eye view of the therapies and are prepared, in
pragmatic fashion, to use any that seem suited to the purpose at hand, even
if they presume different theories of human nature or change. Of course,
A Critical Examination of Belief Structures
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one can also be a hybrid eclectic, that is, selective in practice but singleminded in theory (see Lazarus, 1992).
PROSPECTS FOR A COMMON, NEUTRAL LANGUAGE
There is a recognition among those attracted to integration and
eclecticism that therapists holding different theoretical outlooks employ
different psychological languages. If a truly integrative therapy is to be
proposed and developed, how are the different languages to be joined? If
the phenomenologist uses terms like "the phenomenal sense of self," the
psychoanalyst, "the self-system" or "selfobject," and the social learning
theorist, "self-efficacy," how are we to understand each other, and develop
a common framework? The suggestion made by some is that we abandon
our familiar language communities and develop a "genuinely neutral metalanguage" (Murgatroyd & Apter, 1986, p. 280), or "a superordinate language system in order to separate real differences among approaches from
label differences" (Beutler, 1986, p. 94). Others suggest that we agree to
speak in the vernacular or, in order to preserve a link to the broader
discipline of experimental psychology, adopt the language of cognitive
psychology (Goldfried, 1979, 1983; Goldfried & Newman, 1986; Ryle,
1978, 1987; Sarason, 1979; Wolfe & Goldfried, 1988). Goldfried (1983) has
suggested that such a language offers us "a set of relatively neutral concepts, having a minimal theoretical superstructure, (one that is) closely
related to the kinds of phenomena that we see in our clinical work" (p. 103).
This position presumes the possibility of a psychological Esperanto that
would draw the world of psychotherapy closer together.
But is such a proposal possible or desirable? Even within established
sciences such as physics, there are specialized subfields employing different
languages suited to their own purposes. "Language is at best a feeble
instrument, even among members of a highly trained language community
having quite limited problematic interests. None of the currently institutionalized sciences form single homogeneous language communities"
(Koch, 1964, p. 27; see also Keller, 1985). Are cognitive concepts and
language with their own unique set of suppositions and presuppositions,
their own theoretical superstructures and substructures, any more neutral
than those of phenomenology, behaviorism, or psychoanalysis (Messer,
1984)? I believe not. While terms like script or schema may not carry the
same negative connotations for behavior therapists as unconscious fantasy,
or the same negatively conditioned association for psychoanalysts as behavioral chain, they are not in any absolute sense neutral terms, nor can they
be. "No natural language and no scientific one of any richness can be
regarded as organized into logical levels such that all terms are reducible,
or definable upon, a common definition base" (Koch, 1964, p. 26). Whether
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we recognize it or not, as psychologists we are always viewing phenomena
from one angle or another, none of which is ever free from theoretical bias.
As the literary critic, Richard Rorty (1979) stated it, "We have not yet a
language which will serve as a permanent neutral matrix for formulating
all good explanatory hypotheses, and we have not the foggiest notion of
how to get one" (p. 348).
Rorty's statement is not surprising since "language is itself the vehicle
of thought" (Wittgenstein, 1953, p. 107). Therefore, in order to have a
common language, we would also need to have an agreed-upon mode of
thinking about things. However, as we know, there are always multiple
ways of viewing and conceptualizing any cultural or social phenomenon,
including psychotherapy. Such diversity of theory and language is bound
to continue, as long as people continue to think freely and creatively. In
fact, such divergent thinking is an advantage in that it promotes the
generation and clash of new ideas, each of which is expressed in terms of
its own linguistic form (Messer, 1987).
Andrews (1989a) has pointed to a disadvantage of the use of a
common language in a setting where eclecticism and congeniality of staff
relationships was prized: "the common language solution may sometimes
be a protection from confronting the rough edges of conceptual differences
that would be revealed more sharply by the use of theory-based technical
language" (p. 299). What is gained in ease of communication among staff
with different theoretical and language preferences by seeking common or
neutral ground is lost by sacrificing the complexity and utility of theorybased and theory-bonded languages. Would that we could have it both
ways.
In his more recent writings on this topic, Goldfried (1987) has acknowledged that there are limits to the use of the terms of experimental
cognitive psychology as a common language. Because the latter may be
insufficiently comprehensive, he advocates only selected translations that
will allow incorporation of advances from related fields of psychology. He
suggests the use of different common languages for different purposes,
such as discourse within one theoretical school, across different schools of
therapy, with other psychologists and social scientists, and for research
purposes (Goldfried, 1987; Wolfe & Goldfried, 1988).
Mahrer (1989) also expressed agreement with my stance, stating that
terms cannot be translated without doing harm to their real meaning.
"Watch out," he says, "for terms that appear to be neutral, for they either
are so generalized that they have little or no meaning or they mask a
particular theoretical approach" (p. 104). His solution is to restrict efforts
at a common, neutral language to the increased clarification of special terms
that refer to observable events in psychotherapy, such as the client slapping the arm of the chair.
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Would this work? While we might agree on a language for describing
the latter event, the trouble would begin as soon as we imputed meaning
to the act. Is slapping the arm of the chair the client's way of releasing
tension, expressing anger, or being exuberant? How long would it take
before we brought our broader theoretical framework and specialized
languages to bear on its meaning? Could we really set aside our theoretical
and linguistic presuppositions that guide us in doing so? I think not. And
even if we could, the result would be rather bland, a lowest common
denominator not satisfying to anyone.
To illustrate the difficulty of extracting theory from observations, I
will draw upon a recent exchange between Lazarus and Messer (1991). To
support his claim that "observations simply reflect empirical data without
offering explanations," Lazarus offered the statement, "Adolescents tend to
imitate the behavior of their peers whom they respect" (p. 147). Let us
examine whether this fulfills the requirement of a neutral language of
observation, the kind also sought for some terms by Mahrer. Imitation, I
suggest, is a theoretical term used by social learning theorists to imply a
social influence process. It is not neutral. After all, one could have said that
adolescents identify with their peers, implying a belief that they feel that
they are like their peers, which is a more cognitively laden phrase. It is the
language that provides the clue to the underlying theoretical premise.
In a like vein, I have examined (Messer, 1987, 1988) the definition of
"resistance" that Driscoll (1987, 1988) offered as an exemplar of common
or ordinary language. "Resistance indicates opposition to something with
clear intent or purpose to oppose" (Driscoll, 1987, p. 190). This definition
is couched in the language of intention, which is a mental or cognitive
construct that classical behaviorists would oppose (resist?). It also implies
a conscious attitude, thereby not readily encompassing a theory of unconscious motivation. As such, it allows for one kind of discrimination and
sensitivity but not for others. To avoid theory-laden constructs in our
definitions is appealing from the viewpoint of parsimony and ease of
communication, but is constraining and unsatisfying from the standpoint of
richness, complexity, and the particular sensitivities of many language and
theoretical communities. Within a hermeneutic perspective (Messer, Sass,
& Woolfolk, 1988), language, definition, and theory are inextricably intertwined, and the effort to disentangle them typically leads to impoverished
definitions and concepts. It follows that
In psychology we must have many language communities: Many subgroups of
individuals equipped with diverse stocks of discriminations and differently
specialized sensitivities. By definition, we must have a greater number of language communities in psychology than perhaps in any other field of inquiry
currently institutionalized. (Koch, 1964, p. 28)
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In addition, we should note that psychological meanings only make
sense by virtue of their interrelations to other terms within a broad context.
Even a staunch behavior therapy advocate like Franks (1984) pointed out
that a term like symptom substitution has meaning within a psychoanalytic
context but not for a behaviorist, who may use the term response substitution. Are they the same? According to Franks, "the difference between
symptom substitution and response substitution is far more than semantic.
Each has a specific contextual meaning and intimately interwoven series of
conceptual linkages that make the two notions incompatible. Each becomes
logically meaningful only within its own context" (p. 238). It would seem
that the logical positivist's dream of a neutral data language has been
largely abandoned.
The emergent viewpoint is a version of the Whorfian hypothesis that
what we perceive around us and how we experience it are a function of the
language we employ. There is no bedrock language of definitions to which
we can point and nod in agreement. The particular sensitivities of the
observers will determine the extent to which high interobserver agreement
is possible. There is no immaculate perception! In the phraseology of the
modernist writers, we do not speak language; language speaks us. Beutler,
Goldfried, and others are right in one sense: we are prisoners of language.
But they are wrong if they think that escape from that prison is possible.
How then can we breach the barriers among the different language
communities in order to learn from one another? My suggestions are as
follows:
1. Multilingualism. In order to appreciate the insights of orientations
other than our own, we should become fluent in more than one psychotherapy language. Just as knowing a foreign language allows us to connect
more intimately with a culture not our own, so does learning a "foreign"
psychotherapy tongue allow for an appreciation of its concepts and ideology. We often return from a lengthy visit abroad with a new way of
looking at things, and a recognition that our homebred habits are not the
only ones possible. Regarding psychotherapy integration, this can lead to
the assimilation of concepts or attitudes into our preferred theoretical
system, to its potential benefit. Multilingualism, however, requires that
professional training provide the opportunity for exposure to more than
one language of psychotherapy.
2. Clarity in language and thought. We must strive to avoid unnecessary jargon, especially when communicating with proponents of other
schools of psychotherapy. Use of ordinary language, as Driscoll proposed,
or the vernacular, may be the most expedient, although we should remain
aware of the tradeoffs involved. Another way to promote a readier integration and assimilation of foreign concepts is through empirical research. The
advantage of engaging in research is that it requires us to operationalize
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our terms, making them clearer and thus more accessible to everyone
(Wolfe & Goldfried, 1988).
Visions of Reality: Mythic Forms in
Psychotherapy
Every system of psychotherapy contains an underlying thematic structure
emboding its way of viewing life's possibilities, which are as integral to it
as its theory or technical procedures. Although there are different ways of
classifying such broad outlooks, I have found one scheme to be particularly
useful. It was developed by the literary critic Northrop Frye (1957, 1965)
to categorize different genres or mythic forms in literature, and was subsequently applied by Schafer (1976) to psychoanalysis. The four visions are
called the romantic, the ironic, the tragic, and the comic. To these, Andrews
(1989b) has added the Darwinian and combative visions and the visions of
order and faith, showing how they reflect characteristic styles and patterns
of psychopathology. Winokur and I (Messer & Winokur, 1980, 1984,
1986) have employed Frye's taxonomy to spell out the contrasting visions
of reality in psychoanalytic, behavioral, and humanistic forms of treatment.
After illustrating the intersection of each of these therapeutic modes with
the four visions, I will discuss the difficulties and the possibilities of psychotherapeutic integration that such a framework reveals.
THE ROMANTIC VISION
From the romantic viewpoint, life is an adventure or quest in which
the person as hero transcends the world of experience, achieves victory
over it, and is liberated from it. "It is a drama of the triumph of good over
evil, of virtue over vice, of light over darkness, and of the ultimate transcendence of man over the world in which he was imprisoned by the Fall"
(White, 1973, p. 9). The romantic vision emphasizes exploration and conquest of the unknown, the mysterious, the irrational. It is more the world
as we would like it to be, than the world as we find it.
Humanistic therapists, such as Maslow (1971) and Rogers (1961),
view life primarily as an adventuresome quest. In emphasizing peoples'
potential for continued psychological growth, their willingness to take
risks, and the ability to self-actualize, humanistic therapies are operating
with a romantic outlook. Rogers, in fact, claims that we are born with an
"organismic valuing" process that allows us to appreciate and strive for
that which is life-enhancing.
The romantic vision idealizes individuality and what is "natural"
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since, by its lights, human nature is intrinsically good. To express oneself
freely and impulsively is prized. "The fully developed individual is characterized by true spontaneity, by the richness of his subjective experience"
(Strenger, 1989, p. 595). In a strongly romantic spirit, those therapies
considered part of the human potential movement, stress "doing one's own
thing," acting naturally, and being authentic. Similarly, they advocate the
pursuit of a unique lifestyle and the continuous search for self-realization.
Psychoanalytic therapy also partakes of the romantic vision, but with
a different emphasis. In stressing an exploration of the unconscious, of the
irrational and the unknown, psychoanalysts are influenced by the romantic
attitude. Psychoanalysis is also viewed as a journey, a quest for redemption. The therapeutic process encourages a regression away from everyday
reality and into the world of dreams, free associations, and fantasies. Unlike
humanistic therapy, however, it envisions more obstacles enroute and is
much less optimistic about the possibilities for ultimate self-actualization
and liberation. Nor does it value as strongly as some humanistic therapies,
acting "naturally" and, what it might term, narcissistically.
In contrast to both the psychoanalytic and humanistic therapies, the
behavior therapies are much more reality-oriented and practical than they
are romantic. While behavior therapists may hold an attitude of curiosity
and openness to the unexpected and the unknown, exploration of irrational
fantasies is not encouraged in behavior therapy. Rather, problems are
operationally defined, carefully measured on objective scales, and pragmatically treated. In some forms of cognitive behavior therapy, for example, irrational thoughts are disputed rather than explored and understood
(e.g., Ellis, 1984; Ellis & Grieger, 1977). Since there is no objective, rational
reason for clients needing to be perfectionistic or to be liked by everyone,
the therapist wants to disabuse them of these irrational ideas. The romantic
notion of the quest—so prominent in psychoanalytic and humanistic therapy—is almost entirely absent in behavior therapy.
THE IRONIC VISION
The ironic attitude is the enemy of romance. It is an attitude of
detachment, of keeping things in perspective, of recognizing that there is
another side of the coin. It challenges our beliefs, traditions, and (romantic)
illusions. Like the tragic vision, it emphasizes the inherent difficulties of
human existence, the impossibility of mastering the world, and even of
truly knowing its mysteries.
"The ironic perspective in analytic work results in the analysand's
coming to see himself or herself as being less in certain emotional respects
than was initially thought—less, that is, than the unconscious ideas of
omnipotence and omniscience imply" (Schafer, 1976, p. 52). Interestingly,
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143
humanistic therapy is linked in a dialectical fashion to psychoanalysis in
that it results in clients seeing themselves and life's possibilities as more
than they initially thought.
Psychoanalytic therapists adopt the ironic attitude in therapy when
they take a position of relative detachment (Stein, 1985). They do so in
order to detect the flip-side of the client's utterances and behavior—the
hidden meaning, contradictions, and paradoxes—how cheerfulness may
cover sadness, and well-wishing, murderous thoughts. By contrast, in their
therapeutic demeanor, behavior therapists and humanistic therapists are
more apt to be friendly, self-disclosing, transparent, and affectively expressive, which may lessen the possibility of discerning irony. Behavior therapists are also more likely to accept client complaints at face value, including
their stared therapeutic objectives (Wilson & O'Leary, 1980), and humanistic therapists tend to accept most client feelings as authentic expression. It
is the essence of the ironic posture to take nothing for granted and, in this
sense, such accepting attitudes are a breach of the ironic position.
THE TRAGIC VISION
The tragic and ironic visions are linked insofar as they both include
a distrust of romantic illusions and happy endings in life. Furthermore, they
are reflective in attitude, whereas the romantic and comic views are more
action oriented. Tragedy, however, unlike irony, involves commitment. In
a tragic drama, the hero has acted with purpose and in so doing, has
committed, at least in his or her mind, an act causing shame or guilt. He
or she suffers by virtue of the conflict between passion and duty and, after
considerable inner struggle, arrives at a state of greater self-knowledge.
What interests us in the work of the tragic poet "is the glimpse we get of
certain profound moods or inner struggles. Now, this glimpse cannot be
obtained from without" (Bergson, 1937/1956, p. 167). Such a mode of
knowing may be contrasted with "the kind of observation from which
comedy springs. It is directed outwards" (Bergson, 1937/1956, p. 169).
In the tragic vision the limitations in life are accepted—not all is
possible, not all is redeemable, not all potentialities are realizable. The clock
cannot be turned back, death cannot be undone, human nature cannot be
radically perfected. Tragedy "requires one to recognize the elements of
defeat in victory and of victory in defeat; the pain in pleasure and the
pleasure in pain; the guilt in apparently justified action; the loss of opportunities entailed by every choice and by growth in any direction . . ."
(Schafer, 1976, p. 35).
Among the three major therapeutic orientations, the humanistic therapies are most dyssynchronous with the spirit of tragedy. In viewing people
as fundamentally good, innocent, and unfallen (e.g., Rogers, 1961), the
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beliefs of humanistic therapy fly in the face of the tragic vision. To espouse
the view that all the potentialities of human beings are in the service of
maintaining and enhancing life falls squarely within the romantic and not
the tragic mode. To encourage risk taking without taking cognizance of the
potentially dire consequences is to operate within the comic, not tragic,
perspective. To posit an inborn "striving toward superiority or perfection"
(Adler, 1927) or to emphasize the possibility of "unselfish love" and
"unbiased understanding" (Maslow, 1962) is to accentuate the romantic
and to downplay the tragic. For both Rogers and Maslow, if the environment provides love, respect, and acceptance, along with satisfaction of
basic physiological needs, that is enough for the natural unfolding process
of self-actualization to take place (Maddi, I960). Transposing this principle
to psychotherapy, the therapist's warmth, genuineness, and unconditional
positive regard are considered sufficient for therapy to progress.
Psychoanalysis, more than humanistic or behavior therapy, falls
within the tragic vision. People are viewed as caught within early fixations,
which themselves are subject to repression and thus lie beyond their ken.
The fixations result from our sexual and aggressive nature and the conflicts
such a nature gives rise to, conflicts from which we never can be entirely
free. The psychoanalytic therapist recognizes "that suffering while learning
and changing cannot usually be avoided, nor can the analysand realize
himself or herself most fully and resume growth in the absence of adversity
and deprivation" (Schafer, 1976, p. 42). Even then, the kind of reconciliation
that occurs at the end of a psychoanalytic therapy is not unmixed joy and
happiness. It is a fuller recognition of what one's struggles are about, the
conditions of life one must work within. These conditions "set the limits
on what may be aspired to and what may be legitimately aimed at in the
quest for security and sanity in the world" (White, 1973, p. 9). "Freud's
vision resides in his emphasis that humankind cannot achieve fulfillment at
a low price" (Strenger, 1989, p. 598). Only through suffering can our
consciousness be illuminated (Mujeeb-ur-Rahman, 1990).
Behavior therapy has a far less somber outlook than psychoanalysis,
and the kind of hope for cure it holds out is greater. Its emphasis on
learning through modeling and reinforcement, direct and vicarious, allows
for greater optimism regarding people's ability to change. For example, in
a study assessing therapists' beliefs about practice, behavioral therapists
were much less likely to view psychological change as difficult than psychoanalytic therapists (Mahoney & Craine, 1991). In research comparing
the process of psychotherapy as it was conducted by therapists of different
theoretical orientations, Goldfried (1991) found that cognitive-behavioral
therapists conveyed the message that things were not as bad as they
appeared, whereas psychodynamic therapists communicated that things
were not as good as clients thought.
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Similarly, cognitive therapists, in focusing on the correction of irrational cognitive constructions and attributions, imply a malleable and improvable subject. In Ellis's rational-emotive therapy, however, there is a recognition of people's necessity to accept imperfections and limitations, which is
compatible with the tragic vision. That it differs from the full tragic vision
is apparent from Hyman's (1957) comment on the tragic hero's situation:
A person is locked in struggle with "inner forces of evil and must win
through to some private redemption and true-seeing by means of his own
suffering" (p. 169). In behavior or cognitive therapy, by contrast, clients are
helped to feel better or to change their behavior or thoughts rather than
to reach an inner reconciliation based on self-knowledge.
THE COMIC VISION
Whereas in tragedy things go from bad to worse, in comedy the
direction of events is from bad to better, or even best. True, there are
obstacles and struggles in a comedy, but these are ultimately overcome and
there is a reconciliation between hero and antagonist, between the person
and his or her social world. Harmony and unity, progress and happiness
prevail. For this reason, dramatic comedies often end with festive celebrations. Note that the conflicts portrayed in a comedy are ones between
people and the unfortunate situation in which they find themselves, and not
the kind of inner struggles or implacable oppositions encountered in dramatic tragedy.
In behavior therapy, too, conflict is often ascribed to external situations or forces that can be mastered through application of behavioral
principles. Behavior therapists are not as interested as psychoanalysts in
their clients' internal struggles but more in the direct alleviation of suffering
and a rapidly achieved positive outcome. A phobia of crossing bridges, or
a complaint of lack of assertiveness, is approached head-on with a spirit of
optimism and laboratory-tested techniques from the behaviorist's repertoire. By contrast, struggles over separation issues symbolically expressed
in difficulty crossing a bridge, or over fear of aggressive impulses in the
unassertive client, are explored by the psychoanalyst not only with the
goal of their remediation (psychoanalysis does have some comic thrust),
but with the view that increased consciousness of one's condition is itself
worthwhile.
Humanistic therapies do not strive for happy endings in quite the way
behavior therapies do, nor are they as basically contemplative about inevitable warring and discordant factions of the mind as is psychoanalysis. But
they do emphasize the substantial possibilities for gratifying impulses that
Kris (1937/1952) has described as an essential aspect of the comic view. For
them, a freer, more joyful, laughter-filled existence is attainable. Our
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fondest hopes and daydreams can be achieved. The true self one comes to
know in a humanistic therapy is not one fraught with struggle, nor is it one
seeking reduction of tension, but rather it is an authentic self, free of
conditions of worth, in touch with its natural, organismic valuing, and
satisfied with life's enormous possibilities for self-enhancement. Insofar as
the humanistic therapist's job is to penetrate the false self, and reveal the
good, innocent, unfallen, romantic beneath, it partakes of the comic vision.
ECLECTICISM AND THE VISIONS OF REALITY
Certain changes that have occurred in each of the three psychotherapeutic modes have brought about a certain degree of therapeutic
eclecticism. Such modifications, however, involve alterations in the therapies' visions of reality. For example, in a sphere of psychoanalytic therapy
known as "short-term," "brief," or "time-limited," a focus is established at
the outset and goals are set, thus delimiting the purview of the therapy (see
Rasmussen & Messer, 1986; Winokur, Messer, & Schacht, 1981). In so
doing, the romantic vision—with its emphasis on a time-unbounded journey into the unknown—is curtailed in favor of a pragmatic, problemsolving attitude (psychoanalytic style), more comic in outlook than
romantic.
Within both the theory and practice of behavior therapy, a major
change has been the development of cognitive approaches with an emphasis on concepts such as expectancies, plans, schemas, and scripts (Mahoney
& Freeman, 1985; Persons, 1989). This has led to a relatively greater
interest in cognitive conflict that lies within the tragic mode. Humanisticexperiential therapy, on the other hand, continues to view people in
process-oriented terms such as exchanging, emerging, unfolding, flowing, and
experiencing (Greenberg & Safran, 1987; Levant & Shlien, 1984; Rice &
Greenberg, 1992). There is an even greater emphasis in humanistic theory
now than in the past on human beings' actively seeking stimulation and
novelty, and on their vast resources for self-understanding and growth
(Raskin, 1985). In this way, it persists in upholding the romantic vision.
TRADE-OFFS IN THE SERVICE OF ECLECTICISM
Variants of psychoanalysis, such as ego psychology, neo-Freudianism, and brief psychodynamic therapy, bring psychoanalytic therapy closer
in its outlook and practice to behavior therapy, whereas self-psychology
brings it closer to humanistic therapy. All thereby become more integrative. Whether or not this is viewed as desirable depends on the relative
value one places on the particular blend of the four visions. In emphasizing
sociocultural influences (as does neo-Freudianism) and the power of the ego
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(as does ego psychology) versus the immutable drives, and the curative
power of the client-therapist relationship (as does self-psychology) versus
self-knowledge through interpretation, the full force of the tragic viewpoint is muted (Fox, 1984; Waldron, 1983). In recommending action along
with psychic exploration (e.g., Wachtel & McKinney, 1992), the ironic
vision is tempered by closing off avenues to further and deeper meaning
and intention. And in setting goals and a focus in advance (as in brief
dynamic psychotherapy), the romantic vision is curtailed. In short, there is
no free lunch, which anyone with a tragic view of life would be quick to
discern.
Behavior therapy has become more comprehensive or integrative by
bringing cognitive, affective, and even unconscious factors into its purview. By so doing, it reduces its appeal of clearly measurable goals and
specifiable environmental triggers. The attractiveness of eliminating problems like phobias, compulsions, or headaches in a rather straightforward
way is traded-off for a more complicated and subjective view of client
problems. It should be noted, however, that not all behaviorists or behavior
therapists agree that such an integrative shift is necessarily for the better
(e.g., Ledwidge, 1978; Skinner, 1987; Wolpe, 1976).
In viewing the three modes of therapy together, it would seem that
both behavior therapy and psychoanalytic therapy have become more
humanistic in outlook, whereas humanistic therapy has deepened and
refined its concepts even while remaining basically romantic in both its
theory and therapeutic process. It is probably true to say that humanistic
therapy has had more impact on behavior therapy (e.g., Curtiss, 1976), on
cognitive therapy (e.g., Safran & Segal, 1990), and on psychoanalytic
therapy (e.g., Appelbaum, 1979; Kahn, 1985; Stolorow, 1976) than it has
been influenced in any fundamental way by them. It appears that humanistic therapists generally have been willing to forego the potential advantages of an integrative vision. They have not compromised on their strong
allegiance to the romantic vision but instead have concentrated on developing even further within it.
The Debate over Evidence
In most of the chapters of this volume, there is a strong value placed on
empirical research in determining what shall be included in an integrated
or eclectic therapy. The alternative in the minds of several authors seems
to be reliance on unsupported speculation and conjecture. This empiricalexperimental method of truth seeking, which psychologists have adopted
from the natural sciences, relies heavily on observation, laboratory studies,
elementism, and objectivism (Kimble, 1984; Krasner & Houts, 1984). It
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stems from the philosophy of scientific modernism, which includes the
belief that nature has an existence independent of the observer and is
accessible to the operations of the human mind (Schrodinger, 1967). Findings are typically context-free and presumably lead to universal, nomothetic laws.
For some time, however, there has been a call for methodological
pluralism in psychology (Messer, 1985; Polkinghorne, 1984). Cook (1985),
for example, recommends a "postpositivist critical multiplism," in which
agreement from independent epistemological perspectives is our best
grounding for approximating truth (cited in Howard, 1991). Similarly,
Bevan (1991) warns us to be wary of rule-bound methodology. "Use any
method with a full understanding of what it does for you but also what
constraints it may place on you. ... Be mindful of the potential value of
methodological pluralism" (p. 479). And Woolfolk, Sass, and Messer (1988)
have stated, regarding the different sources of knowledge:
Most contemporary psychology researchers write as if they believe themselves
to be accumulating neutral, objective facts in a value free, transhistorical, epistemological arena. From a hermeneutic perspective, such an approach ignores the
extent to which such facts are inextricably interwoven with theory, with the
researchers' biases, with the choice of language used to describe the terms
employed, and with sociocultural and historical influences—all of which preclude the notion of facts existing apart from the interpretative process. This is
not to say that traditional psychological data-gathering approaches are without
value in the study of personality, psychopathology, and psychotherapy. It does
say, however, that such methods have no epistemic pedigree that renders them
superior to other methods, including clinical case analysis, phenomenological
description, anthropological field studies, metaphorical comparisons, narrative
forms, and literary studies, (pp. 24-25)
Whereas the experimental approach is referred to as paradigmatic and
logicoscientific (Bruner, 1984), and as leading to historical truth or empirical
truth, the alternative typically leads to what is variously called narrative
truth (Bruner, 1984, 1986; Spence, 1982; Howard, 1991), hermeneuticdialectical truth (Barratt, 1976, 1984; Chessick, 1990; Gadamer, 1975), or,
in Bruner's (1984) words, "truth-likeness" or "verisimilitude." It comes in
the form of good stories (Sarbin, 1986; Vitz, 1990), believable historical
accounts, and a good narrative fit. It stresses meaning of experiences and
their interpretation. Rather than seeking generality, it opts for an account
of uniqueness, of "personal events in their full comprehensible richness"
(Bruner, 1984, p. 8).
How are we to judge the adequacy of a narrative? Sherwood (1969)
offers three criteria. To satisfy the first, self-consistency, the general
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statements made must be logically consistent with each other. The second,
coherence, requires a fit between parts of the narrative and the whole, in
which the narrative hangs together by virtue of its resolving the apparent
incongruities in the material to be understood. The third, comprehensiveness,
is the extent to which the narrative account covers the ground; for example, the various portions of a case history are all included (see also Ricoeur,
1981). As should be apparent, this method is akin to textual interpretation
employed in history, literature, and biblical exegesis. It is hermeneutic in
that it involves meaning, interpretation, and disciplined subjectivity more
so than fact, causal explanation, and strict objectivity.
While the above account of the distinction between these two ways
of knowing is necessarily brief, it is sufficient to make the following point:
Insofar as eclectic or integrative therapy systems place sole value on
behavioral science criteria for truth, it will be very difficult for them to
incorporate psychoanalytic and phenomenological-existential approaches.
As Franks (1984) has stated in regard to behavior therapy, "For data to be
acceptable, they must conform to the hypothetico-deductive or some
related methodology of the behavioral scientist. ... it is conformity to a
generally accepted set of rules that constitutes one essential unity of
contemporary behavior therapy" (pp. 233-234).
Is it possible to accept both modes of knowing and, therefore, to
include both sets of criteria? Franks's response is a categorical "no":
It needs to be reaffirmed, that the fact that such alternative intellectual styles
cannot be ruled out is no reason for behavior therapists to abandon their
conviction that, for behavior therapy to progress, it is an objectivist methodology that is more likely to yield fruitful results rather than an alternative system
or some form of integration of the behavioral and psychoanalytic approaches,
(p. 237)
Nevertheless, others do see a complementarity of these two modes of
truth-seeking:
Psychology needs to incorporate both modes of discourse, and hermeneutics
can make a substantive and essential contribution to the understanding of
human systems. I can readily accept Apel's (1967) argument that the human
sciences should involve an interplay between hermeneutic-dialectical and naturalistic discourse, that is, in another sense between hermeneutics and empirics.
These approaches should be complementary. (Barratt, 1976, p. 473)
Similarly, Blight (1981) argues, "We must give up the view that
science seeks verified, ultimate explanations while the humanities settle for
mere conjecture. On the contrary, all knowledge is conjectural and
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permanently so" (p. 191). The implementation of this complementarity
remains to be accomplished, but if and when it is achieved, the prospects
for integration, at least among certain therapies, will brighten.
The Epistemological Values of the Therapist
The distinction between a hermeneutic and natural science approach to the
psychotherapeutic enterprise may also constitute a therapist's epistemological preferences, which in turn have an impact on their attitude toward
psychotherapeutic eclecticism. That is, by virtue of their strong allegiance
to a particular way of truth-seeking, many therapists will reject eclecticism.
For example, Schacht and Black (1985) compared the epistemological commitment of behavioral and psychoanalytic therapists using the PsychoEpistemological Profile developed by Royce and Mos (1980). It yields the
relative standing of subjects on the variables Metaphorism, Empiricism, and
Rationalism. Metaphorism resembles the hermeneutic approach insofar as
it involves testing of one's beliefs in terms of the way in which they fit into
meaning structures. It emphasizes analogical reasoning and the construction of meaning rather than observation per se. Eighty-six percent of the
psychoanalytic therapists showed a profile with Metaphorism as the highest score, which was significantly higher than the 33 percent attained by
the behavior therapists. Behavior therapists had somewhat higher mean
Rationalism scores and were much more likely than psychoanalysts to rate
Empiricism as their preferred way of knowing (36 percent vs. 6 percent).
Similarly, in comparing the values of behavioral scientists with nonbehavioral scientists in psychology, Krasner and Houts (1984) found the
former to endorse quantitative, empirical, and objectivist approaches to the
study of human behavior, whereas the latter endorsed humanistic and
subjectivist approaches. As Norcross (1981) has pointed out, "clinical investigators have repeatedly encountered numerous and predictable differences in both the activities and beliefs of therapists of differing theoretical
orientations" (p. 1544; e.g., see McGovern, Newman, & Kopta, 1986;
Plutchik, Conte, & Karasu. 1988).
These studies cited are meant merely to illustrate that many therapists
will likely remain strongly attracted to a specific way of knowing their
clients, to specific visions of reality, and to specific values. For them,
eclecticism and integration will hold little attraction. Others—perhaps
those whose value system, personality structure, or epistemological stance
are more fluid—will be more comfortable integrating features of more than
one therapy without feeling that they are violating deeply held philosophical outlooks. It is interesting to note that in the study by Schacht and Black
(1985), behavior therapists were more evenly distributed among the three
A Critical Examination of Belief Structures
151
epistemological styles than the psychoanalytic therapists, suggesting, perhaps, their greater openness to eclecticism in therapy.
Assimilative Integration
My own approach to integration can be described along the dimensions
discussed above. It encompasses a language based in any one theory versus
common or ordinary language; a pluralistic attitude regarding the validity
of different systems of psychotherapy; the recognition of a constellation of
visions of reality specific to each school; a way of knowing that acknowledges metaphoric, interpretive, and narrative modes of truth-seeking as
legitimate, along with traditional empiricism; and, in Pepper's terms, a
contextualist world hypothesis. It is pluralistic insofar as it acknowledges
the relative adequacy and comprehensiveness of each school of psychotherapy, even in comparison to a full eclecticism (see Messer, 1986a, pp.
380—382, for a discussion of this point). It is contextualist in that it
emphasizes, when incorporating elements of other therapies into one's
own, that a procedure takes its meaning not only from its point of origin,
but even more so from the structure of the therapy into which it is
imported. In plain terms, this mode of integration favors a firm grounding
in any one system of psychotherapy, but with a willingness to incorporate
or assimilate, in a considered fashion, perspectives or practices from other
schools.
The concept of contextualism requires further elaboration. It is closely
wedded to the notion of the hermeneutic circle that speaks to the relationship between the whole and its parts. Consider the meaning of a sentence,
for example:
The sentence derives its meaning from the individual words it comprises, but
our interpretation of word meanings within a sentence is also governed by their
relations within the sentence and the meaning of a sentence as a whole. Thus,
interpretation occurs within a circle in which parts are always interpreted within
some understanding of the whole, which in turn is understood by coming to
understand constituent parts. The hermeneutic circle describes the contextual
nature of knowledge. A "fact" does not stand on its own independent from its
context or its interpreter, but rather is partially constituted by them. A fact can
be evaluated only in relation to the larger structure of theory or argument of
which it is a part. At the same time, this larger structure is dependent on its
individual parts, as well as on other related information. In explicating the circle
of understanding, we move back and forth between the part and whole. (Woolfolk, Sass, & Messer, 1988, p. 7)
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To understand people or events, from the contextualist's standpoint,
we must take account of the network or context in which they are embedded (Gergen, 1982). As applied to the clinical situation, it follows that one
cannot import a technique from one therapy to another without recognizing that it has become something else within its new setting or context.
The technique gets "recontextualized" and thereby its meaning gets revised (Schafer, 1980).
ADAPTING A GESTALT TECHNIQUE TO A BEHAVIORAL THERAPY
A good example of how the meaning of a therapeutic practice
changes in a different setting is the use of the empty- or two-chair technique. Within experiential-Gestalt therapy, the therapist encourages the
client to experience two parts of a conflict in two different chairs and then
helps to create contact between the sides (Greenberg, 1979). The process
of conflict resolution involves expressing a felt desire from one side of the
conflict in the first chair, and criticizing the self from the opposite side of
the conflict in the second chair, which lead, according to research studies
(Greenberg, 1984), to a softening attitude of the internal "critic." When
Lazarus adopted the technique in the spirit of technical eclecticism, however, he used it, at least in this particular instance, to help a client develop
a more assertive position with her employer by having her engage in
behavioral rehearsal—role-playing her boss in one chair and herself in the
other (Lazarus & Messer, 1991). In this way, it fit within the social learning
stance that he adopts as a theoretical underpinning for multimodal therapy.
But note that the technique takes on a very different coloring in the
two therapies. Whereas Greenberg, as a Gestalt therapist, was most concerned with the client's felt experience, Lazarus, in the behavioral tradition,
focused on the client's external behavior. Clearly, the technique was used
differently by the two therapists and, undoubtedly, was experienced differently by the clients according to the context in which it was employed—a context that included the theoretical outlook of the therapist. In
assimilative integration, one makes the borrowed technique one's own by
fitting it into a preferred theoretical approach. Assimilative integration
avoids dogmatism by recognizing the value of the practices of others while
permitting relative consistency in one's own theory and practice.
ASSIMILATING COGNITIVE OR BEHAVIORAL PRACTICES INTO
PSYCHOANALYTIC THERAPY
In the foregoing example, a Gestalt technique was adopted within a
broad, multimodal therapy. Following is an example of incorporating a
A Critical Examination of Belief Structures
153
cognitive approach within the framework of psychoanalytic therapy. I am
treating a young, professional man who experiences severe anxiety bordering on panic in his new work setting, the first since his recent graduation
from professional school. He feels that he will not succeed at his work,
thinks of himself as less able and less prepared than his colleagues, and
worries that he will be fired. We had been exploring the roots of the
problem both in his relationship to a demanding and critical father, who
had very high expectations of him, and in a life-threatening illness contracted when he was 11 years old, leaving him with the feeling that doom
and catastrophe always lay around the corner. The illness also markedly
increased his dependency on his parents.
In line with the goals of psychoanalytic therapy, my work was aimed at
freeing him from the no-longer present dangers to which he was psychically
held hostage, and that he generalized to the work situation. Nevertheless, he
was having trouble getting through the day at work without becoming
overtly anxious and inhibited in pursuing his work. Therefore, I decided to
adopt some procedures from cognitive therapy. We discussed his "selective
negative focus" on the worst aspects of the work setting, his "magnification"
of them, and "catastrophizing" about them (Beck, Emery, & Greenberg, 1985;
Persons, 1989). I asked what he could say to himself at such times to counter
his dysfunctional thinking, and together we came up with strategies that
turned out to be helpful to him. These included reminding himself that he had
succeeded in similar situations in the past; that he was only a beginning
professional and need not expect so much of himself; and that he could focus
on just getting started on the task without "predicting the future" (Persons,
1989), namely, a failed conclusion.
Within a psychodynamically oriented therapy, my effort was to be
helpful to him without becoming overly directive and thereby setting
myself up as an authority like his father (Berman, 1985). While a nondirective, neutral stance is generally considered important in psychoanalytic
therapy, it was of specific relevance in the case of this client who, in work
situations, became overly dependent on the guidance and advice of older
men. The danger was that he would enact the role of the helpless child, and
I, the powerful, rescuing parent. The way in which I finessed this problem
was to try to have him come up with the solutions as much as possible,
and to follow up on the psychological meaning of my more active, less
neutral, exploratory stance. Following the session with the cognitive interventions, he acknowledged his wish for more of this kind of direct guidance, a wish that I proceeded to explore in terms of his felt dependency and
inadequacy.
This raises a second important principle of assimilative integration,
namely, the subsequent processing of the imported procedure. Insofar as the
integrative effort changes the nature of the relationship of client to therapist,
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or is jarring in some other respect, it is necessary to discern its meaning to the
client in its new context. In a clarifying example of assimilative integration,
Frank (1990) introduced a relaxation technique in the context of psychoanalytic therapy, to which the client responded angrily, saying that it felt like
submitting or losing herself. Further exploration revealed that her mother
had encouraged the client's dependence, only to let her down by not
protecting her from her assaultive father. For her, then, the relaxation
technique posed specific dangers, leading the therapist to explain that, in
taking a more directive role, he seemed to have threatened her feelings of
autonomy. Frank pointed out how her "reactions of anxiety, anger, hopelessness, and pulling back, might all have been dictated by a view of the potential
for hurt, not for gain" (p. 747). Feeling understood and gaining this insight,
she was then able to use the relaxation technique to good effect. For other
useful examples of seamlessly incorporating behavioral techniques into
psychodynamic therapy, see Wachtel (1991).
In discussing importations, or "parameters," within psychoanalytic
practice, Eissler (1953) offered the following recommendations: (1) a parameter should not be used unless there is a very strong reason for doing so;
(2) it should be introduced in a conservative way; (3) it should be allowed
to operate only as long as necessary to achieve a particular goal; and
(4) it should be introduced only if it can be analyzed later. Although this
is a rather restricted view of the uses of integration, its thrust is in
accordance with the cautious attitude 1 am proposing regarding a contextually sound integration.
INTEGRATIVE PRACTICE AS EVOLUTIONARY
Assimilative integration also can be viewed as an evolutionary process in which therapy systems incorporate not only specific clinical practices, but also certain perspectives from one another (Messer, 1986b). For
example, an emphasis on the importance of external reality has long been
a cardinal concept of behavior therapy that is now taken much more
seriously by psychoanalytic therapists. In this connection, Langs (1973) has
written:
We already know that human beings function basically by reacting and adapting
to stimuli; only if we correctly ascertain the stimulus can we correctly understand their response on any level. . . . Context defines the problem with which
the patient is dealing, the reality event (or internal upheaval) which has
prompted the patient's adaptive responses, (p. 31 H
Note how the external context is emphasized by Langs. Self-psychologists such as Kohut (1977), and object relations theorists like
A Critical Examination of Belief Structures
155
Winnicott (1965), have also emphasized the critical role of environment
(vs. primarily drive-related fantasy) in personality development, and have
applied this emphasis in advocating that therapists provide an "empathically attuned" or "holding" environment. In a parallel fashion, behavioral
and cognitive therapists are now more willing to accept and incorporate
the notion of unconscious processing into their purview (Mahoney, 1991;
Meichenbaum & Gilmore, 1984). However, it is not quite the concept of
a dynamic unconscious that is assimilated, since the latter does not readily
fit within the context of a social learning or cognitive therapy. In this way,
each school is influenced by developments in the broader field, thus maintaining its status as adequate and comprehensive.
TEACHING AND LEARNING ASSIMILATIVE INTEGRATION
In a paper describing the ways in which psychotherapy integration
may be learned and fostered, Schacht (1991) observed that the thinking
processes of expert (vs. novice) psychotherapists tend to "support disciplined improvisation ('integrative process')." Experts represent their domain on a semantically deeper level than novices and operate according to
principles, learned through practice, that may not be readily verbalized.
Several therapies are deconstructed within the therapist (Kramer, 1989),
who adapts them to the client at hand. Thus, an assimilative integration
may take place only partly through the novices' conceptual learning that
allows them to represent problems in terms of surface features only. For
therapists to integrate on a deeper level, they must first understand and
integrate within each individual therapy and, only then, across therapies.
This leads to the recommendation that, in training, we "agree to teach
multiple techniques and many theories to everyone who studies psychotherapy" (London, 1988, p. 10). This is similar to the recommendation I
came to previously regarding language use in psychotherapy integration,
namely, multilingualism. In the present case, it refers to the advantages of
training students in a plurality of theories and methods that will lead,
ultimately, to deep structure integration. This is not to say that teaching
psychotherapy integration directly is not useful, but only that we recognize that the most meaningful integration will take some time and probably
come about only after some years of experience. (Also see Andrews,
Norcross, & Halgin, 1992, for a discussion of training issues).
Concluding Comments
None of the analyses of the basic assumptions, beliefs, world hypotheses,
or visions of reality of eclecticism presented in this chapter are meant to
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imply that some degree of integration in practice is not desirable. It is. For
purposes of validating theories of therapy, however, the intrusion of
foreign elements breaks up the structure of corroboration. Kuhn (1977)
makes a similar point in distinguishing between the basic scientist and
applied scientist, whose "decision to seek a cure ... must be made with little
reference to the state of the relevant science" (p. 236). Pepper (1942)
contends that in the interest of intellectual clarity we want our theories
pure and not eclectic. In matters of practice, however, we want to be able
to draw upon any theoretical ideas or techniques that are backed by
evidence, are potentially useful, and can be assimilated in a contextually
meaningful way. We want to be rational and reasonable, not dogmatic.
This is exemplified in the work of various authors in this volume who
borrow from a diversity of sources in the service of an efficacious therapy.
Nevertheless, we may ask, what should be the proper degree of
integration to introduce into practice? For some of the very reasons already
set forth, this will remain a subject of debate. Some will see the resulting
integrative therapy as more comprehensive and adequate, but others will
protest that it is no more so than a present, existing therapy. Where some
will see virtue in the expansion of the visions of reality in an integrative
therapy, others will see an abrogration of the purer vision of its progenitors. There are those who will find intellectual satisfaction in the steps taken
toward a unified theory of therapy, and others who will protest that such
a view is neither possible nor desirable. Whereas some will embrace a
diversity of social science methods to obtain corroborating evidence, others will remain wedded to a particular philosophy of science. And, finally,
whereas some therapists by virtue of their personal dispositions, beliefs,
ways of knowing, and visions of reality will embrace full integration or
eclecticism, others will stick closer to a favored outlook even while slowly
assimilating some diverse elements from the panoply of existing therapeutic approaches.
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PART II
INTEGRATIVE AND ECLECTIC
PSYCHOTHERAPY MODELS
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CHAPTER 5
Eclectic Psychotherapy: A Common Factors
Approach
SOL L. GARFIELD
A
NUMBER OF FACTORS have influenced my views of the psychotherapeutic process over the years and have led me to assume an eclectic
stance. During the time that I was a graduate student at Northwestern
University, 1938-1942, the only truly influential therapeutic orientation,
apart from a somewhat directive form of counseling, was that of psychoanalysis. I was introduced to Adlerian, Jungian, and Lewinian theories of
personality, but Freud was the significant figure when it came to psychotherapy—a rather awesome and psychiatrically dominated area of clinical
practice in the early 1940s. Like most other beginning psychotherapists,
probably, I attempted to use psychoanalytic theory and techniques at the
outset of my career as a therapist during World War II. However, I was not
particularly impressed with the results of my attempts at applying analytic
procedures.
Another early important influence, and one that has persisted, was my
expectation that empirical evidence should be provided in support of a
given clinical or therapeutic procedure. Although Freudian theories were
interesting and provocative, they were also speculative. They provided a
great many interesting hypotheses for both clinical practice and research
but little in the way of empirical evidence in support of the theories. This
was certainly true as far as the efficacy of psychoanalytically oriented
therapy was concerned. Although I did find several published reports by
well-known psychoanalysts on failures in psychoanalysis and some critical
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discussions of the need for evaluations of psychotherapy (Obendorf, 1943;
Obendorf, Greenacre, & Kubie, 1948), actual research studies were limited.
Another important influence was the publication of Counseling and
Psychotherapy by Carl Rogers in 1942. I did not get a copy of this work
until two or three years later, but it did have an impact. As far as I know,
Rogers was the first psychologist to author a text on psychotherapy.
Furthermore, his whole approach, criticizing the "expert" role of the psychotherapist, was diametrically opposed to that of the psychoanalysts.
Also, Rogers was more likely to refer to research studies and to formulate
statements as hypotheses requiring study and verification. For example, in
his 1942 book, Rogers made reference to "a research program in which
counseling and therapeutic interviews have been phonographically recorded. . . . This procedure holds much promise for the future" (pp. viii—ix).
Frederick Allen's Psychotherapy with Children, also published in 1942,
was yet another early influence. The active and responsible role of the
therapist, with the emphasis on the current behaviors of the child in the
therapy situation, made a definite impression on my thinking.
Gordon Allport, in quite a different way, also influenced my thinking.
Allport was not a psychotherapist or clinician, but an academic psychologist who published one of the first scholarly books on personality (1937).
His emphasis on the idiographic view of personality as compared to the
nomothetic view made a profound impression. Whether it was related to
my own view of the limited value of psychiatric diagnosis (Garfield, 1957,
1983, 1986), I do not know; however, my clinical experience appeared to
support the idiographic emphasis and also made me critical of the generalizations applied to patients with specific diagnoses. Although there has
been an increased emphasis on psychiatric diagnosis and specific treatments
for specific disorders in recent years, I still perceive too much variability
among patients to follow the current emphasis uncritically.
Without question, my scientific research training has influenced my
views of clinical practice throughout my life. I have always wanted to see
sound empirical data in support of any clinical procedure, and I have never
been able to accept authorities who do not provide such supporting data.
As a result, I generally tried to keep an open mind about the process and
outcome of psychotherapy and to see what research data were available to
support a given view. The lack of such data for psychotherapeutic approaches was somewhat surprising since, in the area of psychological
testing, psychologists usually required information on the reliability, standardization, and validity of such instruments. However, it became clear to
me that at least a number of dynamically oriented psychologists took the
view that psychotherapy was an art and therefore could not be subject to
empirical research—a view that is still held by some (Lehrer, 1981).
Consequently, the fact that even in the 1940s there were a number
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171
of different theoretical orientations and approaches to psychotherapy suggested that there were different and opposing explanations concerning
what were the therapeutic variables in psychotherapy. There were also
some publications that suggested the possibility of some common factors
operating in the various approaches to psychotherapy. Rosenzweig (1936)
had actually discussed the possibility of a few common factors in psychotherapy. Levine (1948) also discussed a number of so-called supportive
therapeutic techniques that to me appeared as potential variables common
to most of the different forms of psychotherapy.
Finally, an important supporting influence on my thinking was the
study conducted by my long-time friend, Ralph Heine (1953). Heine studied the evaluations provided by patients treated by three different groups
of therapists: client-centered, psychoanalytic, and Adlerian. These patients
tended to account for comparable changes in very similar ways and led
Heine to conclude that a common factor (or factors) was operating in the
different forms of therapy investigated.
The net impact of these influences, as well as my own clinical experience in an army hospital, a V.A. hospital, two V.A. outpatient clinics,
several university clinics, and a medical school, led me to reach certain
conclusions. One was that it was not wise to adhere rigidly to one
psychotherapeutic system. The second was to consider seriously the possibility that there were common factors operative in most forms of psychotherapy that actually might be among the most important variables in
psychotherapy. And third, that the research available for evaluating psychotherapy was too limited for drawing any really solid conclusions. Only
research in the future would allow us to be more definitive in our appraisals
of what was of consequence in psychotherapy. These thus constituted the
bases for my views of the psychotherapeutic process and led me early to
an eclectic orientation. My first published reference to possible common
factors, however, did not appear until 1957, when I devoted 10 pages to
this topic in my first book, Introductory Clinical Psychology.
My earlier views of potential common factors among the different
forms of psychotherapy were reinforced over time by the accumulating
body of research data resulting from comparative studies of psychotherapy
(Bergin, 1971; Bergin & Lambert, 1978; Luborsky, Singer, & Luborsky,
1975; Smith, Glass, & Miller, 1980). The fact that such studies for the most
part did not show marked differences in outcome between such supposedly
different schools of psychotherapy as psychoanalytically oriented therapy
and behavior therapy (Sloane, Staples, Criston, Yorkston, & Whipple,
1975) provided some empirical support for my views and strengthened my
conviction that it was not wise to adhere strictly to one therapeutic
approach.
Consequently, I chose an eclectic approach as my means of going
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beyond adherence to one theoretical system. This allowed me the freedom
to use techniques and procedures from practically any orientation and to
use them as I saw fit in the individual case. Although this type of approach
allows the therapist the greatest flexibility and range of procedures, there
are fewer specific guidelines to follow as compared with adherence to some
of the well-known schools of psychotherapy. Also, since an eclectic approach can be used with a variety of patients, there is not the specificity
to be found in a manual for a specific disorder.
Before proceeding to a discussion of some of the emphases in my
eclectic approach, I want to make a brief reference to a study of a sample
of clinical psychologists who had identified themselves previously as eclectics (Garfield & Kurtz, 1977). In this study, 154 therapists completed and
returned the study questionnaires. Apart from a considerable variability
among the sample in the various theoretical orientations they usually
combined in their clinical work, one theme appeared to be most prominent.
These eclectic clinicians tended to emphasize that they used the theory or
methods they thought were best for the individual client. In essence,
procedures were selected for a given patient in terms of that client's
problems, instead of trying to make the client adhere to a particular form
of therapy. An eclectic therapy thus allows the therapist potentially to use
a wide range of therapeutic techniques, a view similar to my own in most
respects.
Thus there is a large degree of freedom in an eclectic approach. One
does not have to adhere to one theoretical orientation or keep from using
procedures that are inconsistent or frowned upon from that particular
orientation. This approach is clearly opposite to the emphasis on using
psychotherapy manuals to train psychotherapists to adhere strictly to a
specific form of therapy in order to ensure the integrity of the type of
psychotherapy being evaluated. In the past, psychotherapies were simply
named or labeled without specifying what was involved in the therapy and
without any monitoring of the therapy being conducted. The new emphasis,
therefore, is an attempt to operationalize the forms of psychotherapy being
studied and appraised. To the extent that this practice will tend to particularize the forms of therapy being investigated, it would appear to be going in a
direction opposite to both the spread of eclecticism and the more recent
move toward integration in psychotherapy (Garfield, 1982; Goldfried, 1980,
1982; Marmor & Woods, 1980; Norcross, 1986). It will be interesting to see
what develops in the future in terms of these different emphases.
SOME GUIDING PRINCIPLES
As mentioned earlier, one of my guiding principles is that most of the
accepted and apparently successful forms of psychotherapy rely on com-
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173
mon therapeutic factors for much of the positive outcomes attained. Each
of the psychotherapies may have some individual components that have
been emphasized by them and that are of some potential utility. However,
these unique aspects have been overemphasized at the expense of the
potentially important common factors. It is understandable that therapists
who have been trained in a given form of therapy and have been identified
with it are reluctant to acknowledge the importance of common factors—
factors they essentially share with other forms of psychotherapy.
Because the different forms of psychotherapy are derived from different theoretical orientations and use different terms and concepts, the
various forms of psychotherapy appear more different than may actually
be the case. Consequently, some common variables or processes are
viewed as different even when they are essentially similar. Even potentially
more significant is the fact that some basic and important processes are
overlooked because they are not stressed in the formal descriptions of the
individual forms of therapy. Investigators tend to investigate the processes
and procedures hypothesized to be of significance in the particular orientations. Others tend to be disregarded, or are considered to be "nonspecific"
and of lesser importance.
In most of the presentations on psychotherapy, the emphasis also has
tended to be on particular forms of psychotherapy. These have been
descriptions of a specific form of psychotherapy such as psychoanalysis or
client-centered therapy, or they have been catalogues of a number of
different approaches to psychotherapy (Binder, Binder, & Rimland, 1976;
Corey, 1991; Corsini & Wedding, 1989; Morse & Watson, 1977. Although
each of the therapies may be characterized as having some unique features
that distinguish them from the others, for the most part they are viewed
as alternative approaches to psychotherapy. One is expected to select that
form of therapy that appears best or most appealing to the individual, and
that one form of therapy is supposed to be adequate to handle all or most
types of psychological disorders. The possibility of common factors among
the psychotherapies, or the possibility of combining aspects of several of
the therapies generally has received little emphasis until fairly recent times
(see Goldfried & Newman, 1992).
However, if one shifts one's focus from the differences among the
psychotherapies to possible commonalities among them, some intriguing
possibilities become apparent. Certainly, without trying too hard, one can
note at least some superficial commonalities. Practically all forms of psychotherapy consist of at least one therapist and one patient who meet
together for a stipulated amount of time for one or more scheduled therapy
sessions. Furthermore, most use an interview type of format in which talk
or verbal interchange takes place. The therapist generally is a socially
designated and sanctioned healer with all the powers, status, and privileges
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accorded to such individuals. The patient, on the other hand, is a person
with some psychological discomfort or affliction, generally anxiety, depression, or both, who is seeking to be helped and relieved of discomfort by
the therapist.
In addition to the above, there are some other potentially common
aspects of many therapies that can be suggested. Patients seek out therapy
because of feelings of demoralization and the hope of being helped (Frank,
1971, 1973, 1979). In meeting with a therapist, they will also have an
opportunity to talk about their problems, hopes, and fears, regardless of the
therapist's theoretical orientation. Most therapists will have some ideas or
formulations about how to conduct therapy. Although these may differ,
they will tend to provide the therapist with a way of proceeding and
generally give the patient the feeling that the therapist knows what he or
she is doing. This may heighten the patient's confidence and acceptance of
the therapy and the therapist. The therapist also can be expected to say
something about the patient's disturbance and the treatment to be received.
The explanations offered, even though they may differ from one orientation to another, may be comforting to the patient. In essence, such communication indicates the therapist's knowledge and skill as well as a familiarity
with the patient's problems, all of which may have a positive influence on
the patient. More will be said about other possible common factors in
psychotherapy in subsequent sections.
Patient Assessment
Compared to many psychotherapists, I probably devote relatively little
emphasis to patient assessment in any formal sense. I am opposed to
routine diagnostic testing and assessment except for research purposes. A
number of factors have contributed to my views in this area and I will
mention them briefly.
Early in my career, patient assessment meant an intensive battery of
psychological tests that required at least two visits by the patient. After the
testing was completed, several weeks were required for the scoring, interpretation, and write-up of the results. This generally was followed by a
staff conference. This whole process usually took a month and, in my view,
mainly delayed the beginning of therapy. Whether the emphasis was on
psychiatric diagnosis or on intrapsychic dynamics, I saw the assessment
process as primarily a ritual that delayed therapy, increased the costs of
professional services, and generally contributed little to the efficacy or
efficiency of treatment.
The preceding critical statements are based in great part on empirical
research in the areas of psychological assessment (Garfield, 1957, 1974,
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1983), and psychotherapy (Garfield, 1978, 1986). The reliability of clinical
diagnosis in the past left much to be desired, and the validity of psychological tests for both clinical diagnosis and psychodynamic predictions was
distinctly unimpressive. Furthermore, prediction of therapeutic outcome on
the basis of pretherapy appraisals is disappointingly low.
I should make clear that the above statements refer to the routine
assessment of every patient, not to the intensive assessment required for
very difficult diagnostic cases where such problems as possible brain pathology or incipient psychotic disorders need to be clarified. In most
instances, the initial interview generally suffices as both the assessment
interview and the first therapeutic interview. Instead of postponing treatment, this procedure allows therapy to begin immediately. Actually, assessment and treatment are intertwined and continue throughout therapy.
In the first interview, however, there are a number of areas that need
to be assessed and discussed. These include such items as the patient's
reasons for seeking help now, the patient's personal and social problems,
the duration of the difficulties, previous therapy, and the patient's expectations about psychotherapy. The extent to which each of these areas are
pursued and clarified will depend on the particular patient. I, personally, do
not attempt to make a formal psychiatric diagnosis, since this is not critical
in my judgment; however, it is generally required where third-party payments are involved. Of greater concern are variables that are potentially
related more closely to psychotherapy process and outcome. One aspect
concerns the estimate of positive outcome—in other words, is psychotherapy a viable therapy for the patient and can I be of help.
It is not easy to be precise in amplifying the preceding paragraph,
particularly the prediction of positive outcome. In fact, if approximately
two-thirds of the patients improve by means of psychotherapy, then our
predictive measures would have to do considerably better if the base rates
are to be exceeded. One, therefore, may state his or her opinions or beliefs
but should not be too strongly attached to them.
In many respects, my views are probably not very different from
most that have appeared in the research literature. I prefer patients who
have "reasonably" clear problems, are not psychotically impaired, exhibit
some degree of anxiety or depression, appear to want to work on their
problems, and show no serious occupational or social disorganization.
Such individuals are usually referred to in psychotherapeutic lore as
"good patients." I also pay close attention to how the patient interacts
with me in the initial session, as characteristic patterns of behavior typically play an important role in the therapeutic process. I recognize that
predictions of outcome based on evaluations at intake or the first therapy
interview may not add much to the base rates, but the therapist must
strive to make as good an appraisal as possible. At the same time, I also
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recognize that psychotherapy is not a panacea for extremely severe psychological disorders.
During the first interview, I also attempt to clarify the person's
expectations about therapy, including such matters as what may take place,
the possible length of therapy, the problem or problems considered most
important, and the probabilities for, and extent of, positive change. I allow
the person to ask any questions he or she may have, and 1 may indicate
that we can take stock of how therapy is progressing after a few sessions.
There does seem to be some empirical research on both behavioral and
psychodynamic psychotherapy that indicates that, beginning with the
third interview, signs of progress are positively correlated with some
criteria of outcome (Bandura, Jeffrey, & Wright, 1974; Mathews, Johnston,
Shaw, & Gelder, 1974; O'Malley, Suh, & Strupp, 1983; Sachs, 1983).
Consequently, one can reappraise some of the issues that were not particularly clear at the initial session. It is also possible that at a later session the
patient may present what seems to be the "real" problem, the one that
appears to be the cause of the person's current discomfort. Some individuals need to have more than one session before they feel free to trust the
therapist with their innermost problems.
I do not have any set scheme for prioritizing treatment goals. In
general, it is my view that we attempt to deal with the problems that the
patient presents to us, not some goals set by the therapist. If, in terms of
the general criteria mentioned earlier, it appears that the patient's difficulties can be ameliorated by means of psychotherapy, I would be guided by
the patient's ranking of the problems and by which one might be handled
most quickly. Where the patient mentions several problems, making some
tangible progress quickly on one problem may have an overall positive
effect. It demonstrates that change is possible, it increases hope and possibly self-efficacy, and may also increase the patient's active cooperation in
working on other problems.
Applicability and Structure
As far as I can tell, an eclectic approach of this type can be used in most
typical clinical settings, particularly outpatient settings. I have only used
it for individual and couples therapy, but I see no reason why it couldn't
be adapted for work with families. Obviously, in the latter instance the
family would be the unit to consider, and particular attention would have
to be paid to the family system and its interactions. However, I have not
worked much with families and thus my statements should be viewed as
speculative.
The therapy is essentially brief and sometimes time-limited. As indi-
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177
cated earlier, I believe the client should be given some reasonably clear idea
of how long therapy will last. After all, the client's time and money are
considerations here as well as the client's desire for improvement as quickly
as possible. Most of my cases have taken between 15 and 20 sessions, and
I usually indicate this amount of time in the first session. In a few cases,
sometimes determined by the reality needs of the patient (e.g., having to
make a decision quickly, moving away, not sure about therapy), 1 have set
or agreed to a specific time limit.
I tend to see my therapy clients on a once-per-week basis for the usual
50-minute period. However, when it appears warranted, or as the termination of therapy approaches, I usually modify this to once every two weeks.
This change in the arrangement hopefully signifies to the client that progress is being made, there is less need for dependence on the therapist, and
the end of therapy is close at hand. I view this as a desirable practice for
most forms of psychotherapy, since it prepares the client for the termination of therapy and makes this process a gradual and natural one. It also
tends to reduce the more-or-less abrupt ending of therapy.
In most instances I do not see patients on a more frequent basis than
once a week, for several reasons. I believe that increasing the frequency
of therapy increases the dependency of the client on the therapist and thus
is undesirable. I also feel that spaced learning is more effective than massed
learning. Related to this is my clinical belief or bias that significant change
in the client occurs or is achieved in the client's actual social environment
and not in the consulting room. To the extent also that "time heals all
wounds," it seems best to space appointments in a moderate or reasonable
fashion. A final reason for my own preference in this instance is the matter
of the cost of therapy to the client. Meeting with a client two or three times
a week leads to a greatly increased cost for therapy, since usually there
does not appear to be a corresponding decrease in the length of therapy.
Interventions and Relationships
It is difficult to specify precisely the amount of structure I provide in the
therapy sessions; it depends on the particular patient and the specific
circumstances. Even though this sounds too general and evasive, I must
admit, there is no consistent plan that I follow strictly.
The first session is probably the most highly structured, in that there
are several specific topics or areas that I try to cover. At the beginning I
ask patients to tell me about the problem or problems that have been
troubling them and that have led them to seek therapy. I then proceed to
discuss some of the other topics mentioned earlier in the section on patient
assessment. From that point on, the type and extent of therapeutic inter-
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vention is determined by the presenting problem, the individual patient,
and not infrequently, by the amount of time available for therapeutic work.
However, after the initial interview, which is structured to a great extent
by the therapist, clients are given considerable opportunity to discuss their
problems and to express or ventilate feelings. For the most part, I allow
them to determine the content of the sessions in these interviews.
There are several considerations that 1 view as important during these
early sessions. First, I do not want to indicate or reinforce a passive role
for the client, so I try to create the expectancy that the client will be
participating actively in the therapy. Second, I believe that empathic listening on the part of the therapist helps to convey the therapist's sincere
interest in the client and a genuine desire to help. This, in turn, is of some
importance in facilitating a positive relationship in therapy and in motivating the client to collaborate in the therapeutic enterprise. Third, at least
some patients need to develop trust in the therapist before they really
reveal the problem that is most disturbing to them. The pattern of therapy
described here thus may facilitate this process and allow a greater potentiality for positive change.
In addition to the considerations already mentioned, there are at least
two features or processes that may occur when the client is encouraged to
discuss personal problems or feelings in a favorable therapeutic climate.
One is the opportunity for emotional release or catharsis. This may take
place with only a small percentage of clients, but when it does, it is a most
impressive phenomenon. I have hypothesized that this may occur and be
most therapeutic for individuals experiencing acute guilt. Another process
that may occur as the client discusses difficulties is that of desensitization.
The client has the opportunity to discuss problems at some length and as
a result, they may not appear to be as troublesome as the client originally
viewed them.
Consequently, the emphasis in the early sessions is on encouraging
the patient to discuss personal problems and to express feelings openly in
therapy. New material and concerns may be brought up in these sessions,
which may influence the plan and direction of therapy. Although therapists
should have a flexible stance, it is best if they have some general plan in
mind as a guide for intervention. As new material and observations are
secured, plans can be modified. It is also conceivable, and even possible,
that some patients will not make use of the opportunity to express themselves and to explore possible difficulties. In such instances, the therapist
has to try to overcome this problem and to engage the patient in therapy
if at all possible.
The kind of patient behavior referred to above has been called "resistance" by psychodynamic therapists. Regardless of what it is called, it may
have different causes and be a hindrance to progress in therapy. I do not
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believe there is any simple solution to the problem. The therapist can offer
explanations to the patients and encourage them to try to express their
thoughts and feelings. However, I do not attempt to "wait out" the
patient's lack of participation or resistance, which some therapists may do.
Such a procedure tends to drag out therapy, increasing its length and cost,
but not necessarily its efficacy.
Psychotherapy does require the cooperation of the client. Although
it is possible to force-feed individuals and to administer medical injections
against a person's will, the situation in psychotherapy is quite different.
Consequently, the patient's attitudes and behaviors during the early sessions are important indicators of later progress in therapy and of developing problems. If the patient appears unresponsive, this should be discussed
without undue delay. Such talks may also reveal more clearly the patient's
expectations about therapy, feelings toward the therapist, and early dissatisfactions with therapy. Hopefully, these matters can be resolved by
such open discussion, and therapy should resume on a more positive basis.
On the other hand, if this is not possible, perhaps a mutual decision to
terminate therapy at this point can be reached with the understanding that
therapy can be reinstituted when the patient feels inclined to do so. My
own bias is to try to handle such matters early in therapy, at least by the
fifth interview or so, in order that long impasses do not develop and the
patient does not drop out of therapy.
Thus far, our discussion has focused on the early sessions. Although
the emphasis has been on the patient discussing problems and expressing
thoughts and feelings—with the therapist as an empathic listener—other
therapist behaviors can begin to be brought into play as deemed appropriate for the given case. The therapist may ask the client for clarification of
certain points, may ask direct questions, may offer suggestions, and may
assign specific tasks to be performed by the client in the interval between
therapy sessions. Unfortunately, I cannot spell out concretely and in specific detail the precise and orderly behaviors the therapist will use for each
specific kind of patient. My approach to therapy is simply not that refined
or methodical. I have no detailed therapy manual that spells out precise
procedures for each session. I can only offer some general guidelines that
I believe have some utility (Garfield, 1980, 1989).
Apart from showing sincere interest in the client and in evaluating the
client and his or her problems as adequately as possible, the therapist does
not, and should not, respond in exactly the same way to each and every
client. Clients vary in a number of ways that may influence the process of
therapy and the therapist's behavior. They vary in age, sex, family situation, socioeconomic status, education, motivation, personality, and type of
psychopathology. What might be indicated as important or useful for one
client may not be of much value for a different client. Thus, the therapist
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usually cannot follow one specific set of procedures for all patients, even
if they appear to have similar diagnoses. Rather, the therapist continually
has to evaluate and reevaluate the client and the process of therapy,
selecting procedures that appear useful, and discarding ones that do not
appear to be aiding the progress of therapy.
In this process, the therapist should make use of any procedures or
techniques that appear applicable to the problem at hand and that have
received research support. For example, if a client has a specific phobia as
one feature of the reasons for seeking help, exposure or desensitization can
be used as one part of the therapeutic plan. If this works out satisfactorily,
it will have potentially positive effects not only on the phobic behavior, but
also on other aspects of the client's total functioning. First, it demonstrates
to the client that positive change is possible, thus increasing the client's
hope and confidence in the therapeutic process and in further progress.
Second, it tends to increase the client's self-esteem and self-efficacy. As a
result of these changes, the client is both better equipped and more highly
motivated to work on the other problems that present difficulties.
In a similar fashion, other cognitive or behavioral techniques that
have been shown on the basis of empirical research to produce positive
outcomes can also be employed as deemed appropriate. Attempts to
modify distorted cognitions, providing information, practicing social skills,
modeling, homework assignments, daily logs, and similar techniques may
be of use in individual cases. A primary difference in my use of such
techniques and what appears to be their use by more cognitively and
behaviorally oriented therapists is the emphasis placed on these procedures
and how they are viewed theoretically. In my view, the application of these
procedures may produce positive results even though the theoretical explanation advanced by the originators may not explain adequately the actual
process of change. For example, Wolpe's (1958) theory of reciprocal inhibition has not been widely accepted by his fellow behaviorists, although they
accept generally the finding that systematic desensitization produced positive results. Part of the success of the procedure could be due to the
expectancies brought by the patient, the confidence of the therapist, the
rationale given to the patient, and the fact that the patient does confront
his or her problem to some extent by means of the procedure.
I would also tend to see such procedures as one part of the therapeutic
process, in which the therapeutic relationship and potential common factors provide the essential frame of reference. As a consequence, I would not
emphasize them as much as their originators and would not use them in
quite as rigid a manner. For example, in an instance where mild obesity was
mentioned as one problem, I had the client keep a detailed log of all she
ate and the time and place of eating. After several sessions in which she
failed to bring the log to the therapy session, 1 did not force the issue with
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181
the client nor offer any dynamic interpretations. I pointed out this rather
unusual pattern and asked her what she made of it. It became clear that the
weight problem was not a major concern and by not stressing it, I was
accepting this fact. These sessions, however, gave her the necessary time
to develop trust in me and to finally bring forth her main concerns—the
ones that led her to seek therapy. Later, on her own, she told me that she
had lost 10 pounds and was seemingly proud of the fact that it was of her
own doing.
A final aspect of the therapist's work that I want to mention here is
the importance of observing patients' behavior in the therapy hour. Although they may have one or more specific symptoms or problems, the
patients' style of interpersonal behavior is of some importance in their
overall adjustment—whether it be a cause or a result of the current
difficulties. In either case, an attempt to modify the behavior may be
worthwhile. As the therapist observes the client's behavior in the clinical
situation, he or she should be able to note certain characteristic patterns
that may account, at least in part, for the client's difficulties. Focusing on
these patterns and discussing them with the client becomes more than a
mere verbal interaction, since the focus is on actual behavior that can be
pointed out by the therapist. Obviously, this has to be done in a sensitive
and understanding manner. However, since the intent is to help the client
function in a more satisfying manner, and as such discussion can be followed by attempts to modify the behaviors in question, the client can
respond positively. In such instances, use can be made of role play and of
exercises and tasks carried out in the client's social environment.
In this approach, therefore, the therapist is considered to play an
active role, even by ostensibly just listening to the verbalizations of the
client. The therapist has the responsibility to evaluate the client, to plan the
therapy, to guide the process, and to evaluate it and institute changes
where possible. I emphasize this point even though the type of client
clearly has an important influence on the process of therapy and its outcome. Still, we have too frequently blamed the client when therapy has not
progressed in the manner we would have liked. Some clients may be
difficult or recalcitrant, and the possibility of helping them by means of
psychotherapy may be extremely limited. Nevertheless, the therapist, as
the professional, is responsible for what takes place. If the prognosis for
positive outcome is poor, this should be made explicit at the start and an
appraisal made at that point regarding the value of initiating therapy. A
responsible therapist should not continue to see a client over a long period
of time with no significant change, and then place the responsibility for lack
of progress on the client.
This leads rather naturally into the topic of termination. The client,
the goals of therapy, and the particular kind of therapy all may influence
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the actual process of termination. In dynamically oriented long-term psychotherapy, the dependency of the client on the therapist appears to be
increased, and consequently termination has been viewed as a problem. In
relatively short-term therapy of the type described here, this does not
appear to be the case.
References to termination are made in a natural manner at various
stages of therapy. In the initial session some reference is made to the
possible length of treatment, which gives the client some potential termination dates. As therapy proceeds and as some of the goals of therapy are
being reached, mention of the impending termination of therapy can also
be made. Termination can then be discussed with the client and an agreedupon date set. I generally discuss termination about two or three sessions
before the end of therapy. In addition, I usually stagger the final couple of
sessions so that we meet every two weeks instead of weekly.
What I have just described, of course, applies to the "normal" or
modal cases of psychotherapy, those cases in which there are no unusual
problems. Although the problems of termination in short-term eclectic
therapy do not appear to be as frequent or serious as they seemingly have
been in therapy that lasts for several years, a few potential problems may
be mentioned here.
Probably the most serious issue is presented where there is an obvious lack of progress in therapy. The reasons may be diverse or obscure, but
the fact remains that satisfactory progress has not been made. This is
clearly a disappointment to most therapists and frequently is difficult to
face. Nevertheless, as emphasized earlier, the therapist has a responsibility
to evaluate the progress of therapy and to face the facts, unpleasant though
they may be. In some cases, there may be good reasons for shifting to a
different therapeutic strategy and trying some other potentially helpful
procedures. In other instances, however, this does not seem reasonable, and
steps should be taken to terminate the therapy. In this process I would be
open and frank with such patients, indicating that our goals have not been
reached and that it is probably not worth continuing. Unless you feel
confident that someone else has a high probability of helping them, it does
not seem wise to refer them elsewhere, for they may again experience
failure and incur added expenses. I would express my disappointment and
suggest that they see how they get along for a few months and then
contact me for other recommendations if needed.
Sometimes a problem in terminating therapy may occur with an
unusually dependent patient. The therapist, of course, should be alerted
early to such a problem by the behavior of the patient in therapy. Reference
to future termination, therefore, should be made at the first appropriate
opportunity, and earlier than would otherwise be the case. Furthermore, in
such cases, it is particularly important to begin spacing out the last few
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visits. Usually, the staggered visits send a message to the patients that they
are fully capable of getting along without the therapist. In one instance, I
agreed to see a patient an additional time one month after what was to
have been the last therapy session. However, before the time of the
appointment the patient called to say that he no longer felt the need for
the extra session.
Termination, in general, should be determined by the progress (or
lack of progress) of the patient. When the goals of therapy have been
reasonably met and the patient's comments in therapy are generally of a
positive nature, it is time to think of terminating therapy. Sometimes, this
situation may occur in a relatively brief period of time. Although some
therapists, particularly in training, are reluctant to face up to this positive
trend and to release the patient from therapy, I believe this is clearly
counterproductive. When a patient reports consistent progress, has little
to discuss pertaining to the initial reasons for seeking therapy, or asks the
therapist when therapy will end, it is time to discuss termination! I see no
reason to continue therapy when there are no real problems that
are bothering the patient, even when therapy has only lasted for a few
sessions.
Mechanisms of Change
Earlier in this chapter, reference was made to the potential importance of
common therapeutic factors in facilitating client change. Such factors have
been referred to by some as "nonspecific" because an understanding of
their role was unclear and because factors other than those hypothesized
by a particular orientation apparently had some therapeutic impact. I prefer
to refer to such potential therapeutic variables or factors as common
factors, since they appear to be present in most forms of psychotherapy.
It is difficult to spell out precisely the relative contribution of the
various hypothesized therapeutic variables. What exist at present are, for
the most part, opinions or formulations and not clearly demonstrated
empirical facts. Thus, many statements should be viewed as hypotheses,
although some postulated variables have received empirical support (Orlinsky & Howard, 1986). Within this context, I believe some aspects, such
as a "good" therapeutic relationship, are a prerequisite for potential progress in psychotherapy. However, a good relationship alone does not ensure
positive change; it is only a prerequisite.
The skill of the therapist is of potential importance in my view,
although we have not clearly defined skill in psychotherapy, nor have we
conducted much in the way of systematic research. We have compared
therapists in terms of theoretical orientation, gender, years of experience,
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professional discipline, adherence to training manuals, and personal therapy, but not on skill. This is an interesting commentary on psychotherapy.
In a related fashion, I am inclined to hypothesize that the personality
and psychological health of the therapist also play a role in effective
therapy, although data to support my hypotheses are hard to come by. The
personality of the therapist, however, has to be evaluated in terms of
interactions with different clients. It is a commonly accepted belief in the
field of psychotherapy that each therapist works more successfully with
some clients than with others. Thus, one cannot speak only of the therapist's personality, but must consider it in relation to client variables (Strupp,
1980).
With respect to the mental health or integration of the therapist, we
unfortunately lack sound empirical data. On a clinical level, I believe a
disturbed therapist is capable of producing negative results. Some years
ago, Allen Bergin and I conducted a small study of student therapists and
did find a positive relationship between the adjustment level of the therapists as measured by the MMPI and the outcomes of the clients treated
(Garfield & Bergin, 1971). While this is encouraging, the finding cannot be
viewed as truly robust without more systematic replication.
On the other hand, there has been little disagreement that patient
variables are extremely important as far as outcome in psychotherapy is
concerned. Although prediction of outcome on this basis is usually only
slightly better than chance, many well-known psychotherapists have
stated that the client is the most important variable as far as outcome is
concerned (Frank, 1979; Strupp, 1973). I have been somewhat critical of
this view because it allows us to place the blame for therapeutic failure
too easily on the client (Garfield, 1973), but the latter does influence the
outcome. The cooperation of the client is a necessary prerequisite for
practically all psychological work. However, once such cooperation is
secured, other variables or mechanisms of change are necessarily involved.
The therapist, who is perceived favorably by the client, first of all
provides a source of hope for the client. If a positive relationship develops,
the initial hope is reinforced and increases the client's confidence in the
therapist and in himself. This, in turn, helps to foster the possibility or
release of a number of other potentially therapeutic variables. Which ones
come into play in a particular instance depend to some extent on the
particular client and her problems. In some instances, some of these changeinducing variables have appeared to play a critical role in fostering change.
In other instances, it has sometimes been difficult to specify clearly the
change mechanisms. In what follows, only a brief presentation of some of
the potential therapeutic variables will be made. A more detailed exposition is available elsewhere (Garfield, 1980, 1989).
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THE RELATIONSHIP IN PSYCHOTHERAPY
The relationship in psychotherapy has been accorded a place of
importance in practically all forms of psychotherapy, including behavioral
approaches (Goldfried & Davison, 1976; Emmelkamp, 1986; O'Leary &
Wilson, 1987). First, a positive relationship is necessary if therapy is to
continue beyond the first few interviews. The relationship affects both
participants. The patient in a positive relationship is more highly motivated
to participate constructively in therapy, and the same holds to some degree
for the therapist. If the latter perceives the client as motivated and willing to
collaborate in the therapeutic endeavor, there is a higher probability of a
desirable therapeutic relationship developing. Some research has provided at
least some support for the importance of the therapeutic relationship and of
the patient's involvement in therapy (Luborsky, Crits-Christoph, Alexander,
Margolis, & Cohen, 1983; O'Malley, Suh, & Strupp, 1983). If the patient is
involved in therapy and feels that something positive is under way, there is
a greater likelihood of positive outcome.
If the evaluations of therapy offered by patients are viewed as one
means of appraising the relationship, certain perceived qualities of the
therapist are of great importance. In one study, the patients stressed the
personal qualities of the therapist and the opportunity to discuss the
personal problems that were bothering them as the important factors in
their psychotherapy (Feifel & Eels, 1963). In a study of behavior therapy,
"The patients felt . . . that the most universally helpful elements of their
experience were the therapists' calm, sympathetic listening, support and
approval, advice and 'faith' " (Ryan & Gizynski, 1971, p. 8).
The factors emphasized by the successful patients in the study conducted by Sloane and his colleagues (1975, p. 206) are also pertinent. The
five items considered "extremely important" or "very important" by at
least 70 percent of the successful patients who received either analytically
oriented psychotherapy or behavior therapy were the following:
1.
2.
3.
4.
5.
The personality of your doctor
His helping you to understand your problem
Encouraging you gradually to practice facing the things that bother you
Being able to talk to an understanding person
Helping you to understand yourself
Thus, the patient's perception of the therapist is exceedingly important. If the therapist is perceived as interested in the client's welfare, as
competent, and as trustworthy, a positive relationship between therapist
and client is more likely to develop, and there is a greater likelihood of
progress, regardless of the form of therapy used.
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EMOTIONAL RELEASE, OR CATHARSIS
Besides the central role of the therapeutic relationship, there are other
potential variables that appear important in psychotherapy. One of these,
long recognized in psychotherapy, has been designated as emotional release, catharsis, or abreaction. Some forms of therapy have deliberately
sought to induce or foster such strong emotional reactions in patients
(Nichols, 1974), whereas such reactions have occurred more or less spontaneously in more conventional forms of psychotherapy. Where a patient
is in a state of tension or turmoil, the opportunity to fully confide and
express one's feelings and emotions to a trusted and accepting therapist
may lead to a strong emotional discharge, with positive consequences. This
has only happened a few times in my own clinical experience, but when
it does, it is noticeable and sometimes dramatic. One brief example can be
given here.
A young man wanted to discuss a problem that involved his relationship with his girlfriend. When he came into the office he was acutely upset,
and as he described his relationship with her, he began to talk very quickly
and quite emotionally. My interactions were limited primarily to listening,
nodding, and trying to be empathic. The few times I tried to offer some
therapeutic wisdom to the client, he ignored me and continued with his
emotional outpouring. As he described his difficulties, the solution to his
problem, which he was unable to face earlier, became clear to him. He now
saw clearly that his planned marriage was not a good decision. Although
he had strong feelings of guilt about this, these seemed to be fully expressed in the session, and he ended with a great sigh of relief. Before I
could offer another bit of therapeutic wisdom, he thanked me profusely,
and quickly departed.
Of course, not all cases will respond as the preceding case did.
However, I have noted significant improvement in several cases where the
emotional release or catharsis was not anywhere near as vivid or evident.
Nevertheless, in two cases that come to mind, the bringing out and
discussing something that was decidedly guilt producing in the individual
gave evidence of some relief and marked the beginning of positive change.
EXPLANATION, RATIONALE, AND INTERPRETATION
Another aspect of psychotherapy that appears to contribute to positive change is the therapist's providing the patient with some explanation
of the latter's difficulties and how psychotherapy may improve the situation. Again, this is a common factor in practically all forms of psychotherapy, although it has been viewed and labeled differently within the differ-
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ent therapeutic systems. Whether one emphasizes interpretation of unconscious conflicts, distorted perceptions, or irrational beliefs, the patient is
being given an explanation for his or her behavior. Even behavior therapists, who pay no attention to such dynamic concepts as interpretation and
insight, do provide their patients with some explanation of how their
behavioral difficulties have arisen, as well as a rationale for the procedures
they will employ in therapy. The emergence of cognitive-behavior therapy
is also an indication of how explanatory concepts are being incorporated
into behavioral approaches.
One of the fascinating aspects of interpretation and explanation in
psychotherapy is that they appear to vary tremendously among the diverse approaches to psychotherapy. This need not be spelled out here in
any detail. It is apparent that the explanations offered by Freudians, Adlerians, Jungians, Sullivanians, Skinnerians, cognitive therapists, and rationalemotive therapists differ greatly, but, supposedly, they all are therapeutic.
Frank (1971, 1973) has also described this as a process of providing the
patient with a rationale or myth, but a process of some importance in
psychotherapy.
It is also interesting that in the study of encounter groups by Lieberman, Yalom, and Miles (1973), the groups that secured better outcomes
tended to emphasize explanations and cognitions. It thus appears that the
explanations offered by therapists during psychotherapy have a potentially
positive impact on the patient. Consequently, whether the explanation or
interpretation given is "true" in the theoretical or scientific sense is really
of little significance in the therapeutic situation. This is a strong pronouncement on my part, and it tends to be rather cooly received by therapists—
and understandably so. It challenges their own professional-scientific belief
system and would appear to denigrate their professional work. Nevertheless, the implications of comparable outcomes among the major forms of
psychotherapy, and the emphasis placed on the importance of cognitions
in psychotherapy (particularly recently), should make us face this issue in
a forthright manner.
It is suggested, therefore, that providing the patient with a rationale
or belief system is of some therapeutic value. I have explained this in the
following way:
The fact that the therapist appears to understand the patient's problems and is
able to provide this understanding to the patient appears to reduce the letter's
anxiety about his problems and to engender hope for alleviating them. When
an individual is experiencing discomfort and does not understand what his
symptoms signify, what has caused this unhappy state of affairs, or how serious
his condition may be, it is reassuring to contact a professional therapist who
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seems to know what the problem is, what factors are responsible for it, and who
also offers a treatment which supposedly can alleviate the patient's situation.
(Garfield, 1980, p. 101)
Thus, the particular explanations or interpretations offered by the
therapist do not seem to be of primary importance. Rather, the critical
factor appears to be whether the patient finds them to be credible and
acceptable. If the explanation is unconvincing or incomprehensible, it is
likely that the patient will not accept it. In such instances, the proffered
rationale will have little positive effect. On the other hand, if the patient
fully accepts the explanation, several positive effects may take place: uncertainties and doubts may be lessened, the patient may be reassured, and
hopes and expectations about therapy may be increased. In addition, the
patient may be motivated to collaborate more intensively with the therapist and to try out new behaviors. All of this includes a lot of "maybe's,"
but it appears to be a reasonable hypothesis.
Some support for the preceding supposition is apparent in the way
some prospective clients shop around for specific kinds of therapy. Because
of the increasing popularity of psychotherapy, people have become more
sophisticated about it than they were in the past. It is possible that certain
clients are more receptive to certain rationales than others, and that therapy
would be more effective if the proper matching of rationale and client
occurred. However, it seems reasonable to believe that the quality of the
therapeutic relationship may also influence the client's receptivity to the
therapist's explanations and rationale. Although it is not fully understood
how the process actually works, I believe we should try to give the clients
some explanation of their difficulties, together with some rationale for the
approach to be undertaken in therapy.
REINFORCEMENT IN PSYCHOTHERAPY
Although many nonbehavioral approaches make no specific theoretical reference to reinforcement in psychotherapy, it would appear that
reinforcement is a commonly used therapeutic technique. All therapists
respond positively to verbal reports or behaviors that appear positive to
them and thus reinforce both in-therapy and out-of-therapy behaviors.
Such therapist behaviors as nodding, smiling, frowning, and verbal responses of selected kinds can influence the behavior of the client. Even
client-centered therapists such as Carl Rogers tend to reinforce certain
client responses (Murray, 1956; Truax, 1966).
To say that the therapist is capable of influencing the behavior of the
patient should not be a surprising statement. Certainly, most therapeutic
approaches would assume this to be possible, but how the influence process
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works or how it can be used most effectively gets into more controversial
areas. Behaviorally oriented therapists do make more conscious use of
reinforcement principles than do humanistic or dynamically oriented therapists, and in a sense the comparison is between structured learning and
incidental learning. Theoretically, however, all therapists are desirous of
promoting positive change in the client, thereby reinforcing certain behaviors and "modifying" or "extinguishing" others.
Therapists should therefore be aware of their role in influencing
patients by means of reinforcement, and should also use such knowledge
to secure changes in patients. The strongest reinforcement effects, however, are achieved when clients under the guidance of the therapist attempt
behaviors that are personally and socially rewarding for them.
DESENSITIZATION
Desensitization has become a well-known behavioral technique, usually referred to as systematic desensitization. However, even before the
latter procedure was described by Wolpe (1958), a more general description of desensitization had been presented by others (Dollard & Miller,
1950; Garfield, 1957; Levine, 1948; Rosenzweig, 1936). It was noted that
as patients discuss their problems in the understanding and accepting
climate of therapy, over time these problems appear less threatening. It is
as if the process of bringing out concerns into the open and examining
them or sharing them with the therapist lessen their impact. Problems
may be perceived differently as the client discusses them. By having to
communicate items that are disturbing, the individuals have to organize
their experience and to be somewhat more objective and realistic in appraising their life situation. In terms of a learning orientation, clients'
anxieties about their difficulties are gradually extinguished as they discuss them in the security of the therapeutic setting, with no negative
consequences following.
Whether this process is actually one of gradual extinction or whether
other processes are also involved is not clear. However, it does seem as if
a process of desensitization occurs with at least some patients. As is the
case with the other therapeutic mechanisms hypothesized to operate in
successful psychotherapy, it may be just one of many operating in any
given case. Nevertheless, its potential importance should not be overlooked by the therapist.
Wolpe's (1961) approach, systematic desensitization, is a more structured and focused emphasis on desensitization. Although his theoretical
formulations have been criticized, the practical results of systematic desensitization have, for the most part, been positive (Davison & Wilson, 1973).
Thus, although, in vivo exposure treatment has been more heavily favored
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for phobias in recent years (Emmelkamp, 1986; Marks, 1978; Mathews,
Gelder, & Johnston, 1981), systematic desensitization can be used with
positive effect in the outpatient setting as one aspect or component of the
overall treatment.
FACING OR CONFRONTING A PROBLEM
This particular aspect of the psychotherapeutic process has something
in common with exposure treatment but is not synonymous with it. It does
not have to be limited to the treatment of phobic behaviors, and it can
begin on the basis of verbal discussions in therapy. In fact, the term
confrontation has been used for some time in strictly verbal psychodynamic
psychotherapy, where the therapist confronts the patient with matters that
the patient has avoided facing or about which he or she needs to be
informed. These include such matters as interpretation of content, behaviors in therapy, problems of resistance, and the like.
It is certainly true that many people tend to avoid certain situations
that make them feel uncomfortable or inadequate, even if the behaviors are
not pronounced enough to be labeled as clinical phobias, such as shyness.
However, if the avoidance behaviors can be pointed out to the patient in
a sympathetic manner as the source of much of the discomfort, the patient
may gradually acknowledge this. More important, the patient may then be
willing to enter situations that have been avoided. If these experiences are
successful, both anticipations of negative consequences and actual discomfort should decrease, and more socially adaptable behaviors should result.
The last sentence does indicate the similarity between "facing one's
problem" and in vivo exposure, but I would point out that several other
therapeutic techniques such as systematic desensitization, flooding, implosion, and modeling have also reported positive results when applied to
different fears and avoidance behaviors. Thus, there appears to be some
common factor operating in all of these approaches, namely that the client
in some way is confronted with the negative situation and learns that it can
be faced without any catastrophic consequences.*
I have made use of this procedure after at least a few sessions of
therapy, when I felt that I had an understanding of the client's problem and
that some confidence and trust in me had developed. Suggestions can then
be made that the client is willing to accept. I favor beginning with activities
that are less threatening and that the client is more likely to attempt. One
can then go on to activities that are more important for the client's overall
*I am indebted to Marvin Goldfried for pointing out the relevance of an old Chinese
proverb: "Go to the heart of danger, for there you will find safety."
Eclectic Psychotherapy
191
adjustment. Nothing succeeds like success, and positive feedback is the
strongest form of reinforcement. As the client succeeds in situations that
previously were avoided or caused discomfort, increases in self-confidence
and self-esteem are likely to occur. Furthermore, "visible evidence of improvement also facilitates an increased expectancy of positive outcome in
psychotherapy on the part of the client, which is also of some benefit"
(Gar-field, 1980, p. 122).
INFORMATION AND SKILLS TRAINING IN PSYCHOTHERAPY
At least a certain number of individuals who seek out psychotherapy are poorly informed about topics of importance or are deficient in
desired social skills. In such instances, providing information or attempting to improve social skills can be beneficial. In fact, some recent approaches to psychotherapy have emphasized developing certain personal skills by focusing on social skills training and assertiveness
training (Becker, Heimberg, & Bellack, 1987; Liberman, DeRisi, &
Mueser, 1989; Matson & Ollendick, 1988). The main difference between
these approaches and my eclectic approach is that the former tend to
focus on a specific type of problem and to emphasize skills training as
the form of therapy, whereas I might use such procedures as one aspect
of therapy at a particular time.
Traditional, dynamically oriented therapists have been reluctant to
provide information or to answer questions asked by the patient for fear
this would foster excessive dependence. Although there is some validity
to this view, I believe that it has been too rigidly adhered to in the past.
If the patient asks a question about something of real concern, a direct
answer may be very therapeutic. This would appear to be particularly the
case if the patient had false fears about his condition, which correct information might dispel. I can recall two patients with excessive anxiety and
guilt about masturbation, who improved noticeably when relevant information was provided in an empathic manner.
Similar comments can be made for the training of certain social skills.
Again, this would be just one component of psychotherapy and would be
used to help the person become more adept and self-confident in her social
adjustment. If certain social inadequacies or skills are not fully acknowledged by the patient initially, then the process would be one of confronting her with this problem, as described in the earlier section. However, if
it were clearly seen by the patient as a personal deficiency, no confrontation is necessary and the focus would be on improving the patient's skills.
Some role playing can be used along with suggestions for activities to be
attempted in the social environment.
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TIME AS A VARIABLE IN PSYCHOTHERAPY
A final variable that I want to mention is time. Although we all
recognize that a certain amount of time is required for therapy to be
conducted, experts disagree about the optimum time for treating different
kinds of problems. However, time per se is not given much emphasis,
despite the old folk saying that "time heals all wounds." The concept of
spontaneous remission in medicine also involves time. It is, of course,
difficult to appraise the role of time in psychotherapy because it appears
as a "given" and as a background variable for the introduction and interaction of other variables. In some cases, maturational or recuperative processes may occur within the individual and account largely for the positive
changes evident. Anyone who has worked with children is aware of the
changes that take place as a result of growth and maturation. It is also
possible that very positive (or negative) events may occur in the patient's
life that affect the process and outcome of psychotherapy. Some people
have more favorable social support systems and recover more quickly from
crises and stress situations.
Case Example
I accepted a woman as a patient whose major complaint centered around
marital difficulties. She had been seen twice before at the outpatient clinic
by different therapists for periods ranging from 18 to 24 sessions, and
although she had been a cooperative patient, she had made relatively little
progress. She complained mainly of depression and fears centering around
her marital difficulties. Apparently, her husband was abusive at times and
because there were two young children in the family, leaving her husband
or attempting to dissolve the marriage were not seen as adequate solutions.
Despite the fact that the marital situation appeared to be central in terms
of this woman's difficulties, apparently little attempt had been made to
involve the husband in therapy. Consequently, I insisted that her husband
had to participate as well.
It was apparent to me that the wife was highly motivated to try to
improve her situation and was a reasonably good case for psychotherapy.
It was also apparent that the husband was essentially the opposite. The
wife indicated that she had wanted her husband to participate in therapy
previously, but he had refused; she had thus undertaken therapy herself.
The husband did appear at our first session because I had insisted on it as
a condition for accepting the wife as a patient, and the wife in turn had
threatened to leave him if he did not comply.
Both patients were in their early thirties, ran a small business, and had
Eclectic Psychotherapy
193
been married for about eight years. The difficulties between them were
largely related to the husband's drinking, sometimes stimulated by economic pressures. His drinking bouts were episodic, and his abusive treatment of his wife was related to them. They were high school graduates,
appeared to be of average intelligence, and both wanted to avert a marital
breakup.
Although the husband clearly displayed little interest in participating
in therapy and stated that his wife was the one who had this interest, I
emphasized that two people were involved in the current difficulties, so
treatment had to be conducted with both of them. We started on a weekly
basis. Although the wife participated actively and the husband only defensively or in response to questions or reflections from me, I felt it was
important to have the therapy oriented to the two of them. There were
several reasons for this. The husband had avoided therapy previously, and
I felt it was important to have him see that he was involved in this problem
and had a responsibility in this regard. I also took the view that marital
problems are best resolved when both partners participate in therapy.
Moreover, the different perceptions or appraisals of husband and wife can
be most directly handled when both are in therapy. And last, the previous
therapy of the wife alone had not resulted in real or sustained progress.
The patients were seen on a weekly basis for eight sessions. During
this period therapy progressed satisfactorily, but I felt this was mainly
because the husband "behaved himself" in therapy. During these sessions
the same behavior was noted in therapy as mentioned earlier. The wife
seemed to welcome the opportunity to express her concerns and feelings,
demonstrated a strong interest in therapy, and was responsive to my
comments and suggestions. Her husband said relatively little, appeared to
be uncomfortable, and showed little interest in the therapy sessions.
Consequently, I instituted a change at this point. I noted their different attitudes and said that I thought the wife would like to continue in
therapy and to talk about her situation and her feelings. On the other hand,
it was clear that the husband now realized his role in the marital problems
but was somewhat uncomfortable in talking about himself and his feelings.
I tried to present this in an understanding and empathic manner, and both
agreed with my appraisal. From that point on I said I would see the wife
individually for two weekly sessions and then the husband for one weekly
session. This was agreed to and became the plan we followed for a couple
of months. Using the same rationale, after some progress was made, I saw
the wife every two weeks and the husband once a month.
My goals were to clarify the patients' patterns of interactions, to
increase the wife's self-esteem, confidence, and assertiveness, to confront
the husband with the implications of his behavior, to help him accept his
positive features, and to make their life a more harmonious one if possible.
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In line with what has been described earlier, I attempted to develop a good
relationship with both patients, but succeeded mainly with the wife. I
avoided partiality to either patient, communicated interest and sincerity in
helping them, allowed each of them an opportunity to express their
thoughts and feelings, reinforced positive statements and behaviors, provided some explanations about the causes of their difficulties, made suggestions, and where appropriate, offered encouragement and reassurance. I
also had the patients attend particularly to events that appeared to precipitate conflict and abusive behavior, and to work out behaviors to avoid this
kind of buildup.
I saw the wife for a total of 30 individual sessions and the husband
for 13 sessions. The wife clearly appeared to profit from our sessions. She
expressed her concerns, discussed different ways of responding to her
husband, and tried to be consistent and confident in her reactions. Therapy
seemed to have a very reassuring effect on her. Although the degree of
change in the husband was not as pronounced, he did appear less defensive
and was somewhat better able to accept his share of responsibility in the
problems discussed. There were fewer abusive incidents, the mood of both
parties seemed much more positive, and the marriage appeared more
stable.
The wife made what I regarded as significant progress—which is one
reason I remember this case. She was much more self-confident, was no
longer depressed, and said that she had profited a great deal from therapy.
She also stated that she felt she could cope better with future problems. In
our final session, she mentioned that I was the first man that she felt she
could trust, and that this was an important aspect of therapy for her. I agree
that trust is a feature of a desirable therapeutic relationship and is particularly important with patients whose lives have been deficient in adequate
interpersonal relationships.
Research
As I see it, eclecticism is a stage in the development of more efficient and
effective psychotherapeutic treatment. It has become the most popular
approach to the practice of psychotherapy (Garfield & Kurtz, 1976; Jensen,
Bergin, & Greaves, 1990; Prochaska & Norcross, 1983; Smith, 1982) because many therapists have discovered that adherence to just one system
or approach is not the most effective way to best meet the needs of
individual clients (Garfield, 1980, 1982, 1990b; Garfield & Kurtz, 1977). As
a result, individual psychotherapists have tended to develop their own
eclectic approach on the basis of their clinical experience and, to some
extent, also on the available research literature on psychotherapy outcome
Eclectic Psychotherapy
195
(e.g., Beitman, 1992; Beutler & Consoli, 1992; Lazarus, 1992). This, of
course, means that there is no one universal form of eclectic psychotherapy
and that considerable variability undoubtedly exists. In fact, several different types or categories of eclecticism have been delineated in the Casebook
of Eclectic Psychotherapy (Norcross, 1987): "Systematic Technical Eclecticism," "Structural-Phenomological Eclectic Psychotherapy," "Functional
Eclectic Psychotherapy," "Radical Eclecticism," "Multi-Modal Therapy,"
and my own form of just plain unadulterated "Eclectic Psychotherapy."
Consequently, it is difficult to provide systematic research data on "an
eclectic approach," since there is considerable uniqueness and variation
among eclectic practitioners. Perhaps more than is true of such other
approaches to psychotherapy as psychoanalysis, behavior therapy, or
client-centered therapy, there is more individuality among eclectic practitioners in how they conduct their psychotherapy. Because of this, although
some of the early research studies did report evaluations of eclectic psychotherapy and Eysenck, in his famous 1952 review reported a much higher
rate of improvement for eclectic therapy than for psychoanalysis, no really
strong conclusions should be drawn. These were very early studies. There
was no precise operational definition of eclectic therapy, no training manuals were used, and there were no detailed observations or recordings of
what individual therapists actually did in the studies reviewed. These
limitations, of course, apply to most of the research conducted on psychotherapy until very recent times. Furthermore, if one attempts to evaluate
any given eclectic approach to psychotherapy, the potential problems are
even greater, for the specific therapy not only is confounded with the skill
and personality of the therapist, but problems of objectivity, subject samples, clinical problems, and related issues illustrate the additional difficulties
involved.
Thus far psychotherapy researchers have focused almost exclusively
on type of psychotherapy, as if psychotherapy consisted solely of a set of
standard technical skills and the individual application of the therapist was
of little consequence. Research on the reliability of psychiatric diagnosis
(Garfield, 1986) and on the accuracy of psychological test interpretation
(Garfield, 1983), let alone the vast research literature on the psychology of
individual differences, clearly should raise strong doubts about such an
assumption.
Whether or not the variability within samples of psychotherapists has
influenced the results obtained, the comparative studies of psychotherapy
outcome have reported few differences among the different forms of psychotherapy (Lambert, Shapiro, & Bergin, 1986; Stiles, Shapiro, & Elliot,
1986). It is this research that lends support to the views expressed here
concerning the importance of common factors in psychotherapy. It is
interesting to point out, also, that there appears to be an increasing
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acknowledgment of common factors in psychotherapy (Kazdin, 1986; Lambert, Shapiro, & Bergin, 1986), and my own eclectic approach is characterized in this fashion in the present volume and in the one recently edited
by Zeig and Munion (Garfield, 1990b).
Clinical Training
At present, it appears that the training of psychotherapists generally tends
to emphasize one form of psychotherapy exclusively (e.g., psychoanalysis
or behavior therapy) or consists of a cursory review of a dozen different
orientations. I personally regard the former as a form of indoctrination that
limits critical evaluation and flexibility. I also tend to be critical of the
second approach, since it presents a menu of therapies without a true
critical appraisal of them or of the possible reasons for this state of affairs.
In some cases the view is presented that students simply need to select the
form of therapy that appeals to them and "run with it." Although it is
important that the therapist get some feelings of satisfaction when engaged
in psychotherapy, the satisfaction should result from helping the patient
improve and not from other considerations.
My own approach is to focus on the potentially important therapeutic
variables in psychotherapy—a less clear-cut or dogmatic approach to
follow, perhaps, but it can be done. After discussing patient and therapist
variables, I proceed to a discussion of possible therapeutic variables. Following a brief presentation of the therapeutic variables emphasized by
psychoanalysts, Rogerians, and behavior therapists, I go on to discuss the
therapeutic variables, or mechanisms of change, more broadly, as illustrated
earlier in this chapter.
I have been teaching graduate students and conducting postdoctoral
workshops on this approach for many years, and more recently have
published some books that I hope facilitate such teaching (Garfield, 1980,
1989). Former students have also told me that they have incorporated
many of my views into their practice and teaching.
Future Directions
At the present time, I am inclined to view eclecticism as an intermediate
development between the reliance on one therapeutic approach and a more
advanced stage, where a synthesis or integration of psychotherapeutic
methods and theories is developed. One aspect of this development will
be a greater consideration of the role that common, as well as specific,
factors play in securing positive outcome. Such research will be difficult,
Eclectic Psychotherapy
197
but as studies of the therapeutic relationship have indicated, it can be
accomplished. Recently, Glass and Arnkoff (1988) conducted a study of
four different types of group therapy and attempted to appraise common
and specific factors. Although the specific emphases of the three structured
group therapies were reflected in the clients' explanations of why changes
occurred, evidence for the existence of common factors also was evident.
"It is important to note that approximately half of the subjects in each of
the structured conditions emphasized common group process factors as
accounting for their improvement, citing these factors as often or more
often than factors specific to the methods used in their treatment program"
(Glass & Arnkoff, 1988, p. 435).
Another interesting finding that is relevant here comes from the
NIMH Collaborative Study of the Treatment of Depression in which a
cognitive therapy was compared with a form of interpersonal therapy
(Elkin et al., 1989). In line with most other comparative studies, no differences were found between the two forms of therapy on the general
measures of outcome. However, of particular interest is the lack of difference found between specialized measures of cognitive functioning and
social adjustment hypothesized to differentiate the two forms of psychotherapy. Although we can point to clear differences in the manuals used
and in the behaviors of the two groups of therapists, the comparable
findings obtained suggests both the likely possibility of underlying common factors and the need to describe and verify these factors. The latter
task will not be an easy one (Garfield, 1990a; Stiles, Shapiro, & Elliot, 1986).
Although an effective, systematic, and integrated formulation of psychotherapy awaits the future, I am confident it will be secured and will
include a proper emphasis on common therapeutic factors. This, of course,
does not preclude appropriate attention to specific factors or variables that
are particularly effective with specific problems.
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(1975). Psychotherapy versus behavior therapy, Cambridge, MA: Harvard
University Press.
SMITH, D. (1982). Trends in counseling and psychotherapy. American Psychologist, 37, 802-809.
SMITH, M. L., GLASS, G. V., & MILLER, T. I. (1980). The benefits of psychotherapy.
Baltimore: Johns Hopkins University Press.
STILES, W. B., SHAPIRO, D. A., & ELLIOTT, R. (1986). Are all psychotherapies
equivalent? American Psychologist, 41, 165—180.
STRUPP, H. H. (1973). On the basic ingredients of psychotherapy. Journal of
Consulting and Clinical Psychology, 41, 1—8.
STRUPP, H. H. (1980). Success and failure in time-limited psychotherapy. Further evidence (Comparison 4). Archives of General Psychiatry, 37, 947—954.
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WOLFE, J. (1958). Psychotherapy by reciprocal inhibition. Stanford, CA: Stanford
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of Nervous and Mental Disease, 132, 189-203.
CHAPTER 6
Integration Through Fundamental Similarities
and Useful Differences Among the Schools
BERNARD D. BEITMAN
Fo
L OUNDERS AND FOLLOWERS OF SCHOOLS of psychotherapy
have constructed ideals toward which others are asked to aspire. Despite
having lost much popularity, both rigid psychoanalysts and rigid behavior therapists continue to deny the value of each others' findings and to
insist that their pieces of truth are the entire truth. Some therapists have
developed manuals for their approaches (e.g., Beck, Rush, Shaw, &
Emery, 1979; Luborsky, 1984; Klerman, Weissman, Rounsaville, & Chevron, 1984; Kernberg, Selzer, Koenigsberg, Carr, & Applebaum, 1989),
which are believed to be useful for research purposes. Each requires its
practitioners to follow strict formats. However, most psychotherapy
practitioners are not interested in manuals or in following psychotherapy
ideologies. Instead, they are interested in discovering what works for the
patient in front of them.
In response to the obvious value of a variety of approaches to
psychotherapy, several psychotherapists have created integrative approaches. Unfortunately, the forms of many of these integrative
approaches bear strong resemblance to those created by rigid psychoanalysts, rigid behavior therapists, and manual-driven psychotherapists (e.g.,
Hart, 1983; Lazarus, 1986). Like their predecessors, these integrative psychotherapists have created ideals to which practitioners are asked to aspire.
An alternative approach to psychotherapy integration is to create a
model with sufficient flexibility so that (3) it will continue to assimilate new
ideas generated from patients, other psychotherapies, other psychotherapists, colleagues, personal life experiences, and research; (2) it can be
accommodated to the psychotherapy schemas of each individual therapist;
Integration Through Fundamental Similarities
203
and (3) it can ultimately be adapted to the schemas of each patient. Rather
than being a solid form, the ideas of this approach would be like the
molecules of a liquid in that they would fit the cognitive containers of their
users.
The Approach
In 1970 I was an angry first-year psychiatric resident. I wanted to become
a psychotherapist but was frustrated with the claims for correctness from
each of the many existing schools of psychotherapy. They were too much
like fundamentalist religions, each complaining about the other's blasphemy while claiming to possess the truth. I was disturbed by the Vietnam
conflict and the terrible effect it was having on our culture and society. I
wanted to find a way to bring an end to these conflicts. I had a "saviorlike"
self-image at the time. The Beatles had a song with the phrase "Come
Together Right Now Over Me," which summarized my aspirations.
I also had been reading in a variety of different areas. General systems
theory, for example, had described the possibility of constructing a model
that was applicable to a variety of systems (von Bertalanffy, 1964). These
confusing but intriguing and hopeful writings had influenced me to look for
the underlying common structures in a variety of different settings. Similarly, my reading in mysticism stirred me to search for unity in complexity,
and encouraged me to believe that modern science had missed some crucial
aspects of knowledge (e.g., Crowley, 1944).
When I was in college, I began reading George Kelly's The Psychology
of Personal Constructs (1955). I kept trying to understand his primary axiom:
A person's processes are psychologically channelized by the way he anticipates events. Although he denied he was a cognitive therapist, he was
obviously interested in how the mind influenced experience and behavior.
In medical school and during my internship, psychoanalysis and Sigmund
Freud were raised as ideals toward which to aspire. During that time I came
to know personally a well-respected psychoanalyst who married one of his
patients and subsequently committed suicide. This personal experience
helped me see the limits of these idealizations. (See Beitman, 1990, for
further biohistorical details.)
Guiding Principles
Consistent with the above, I would like to offer the following eight guiding
principles for implementing this approach to integration.
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Triflexibility of Integration
The term integration has several applications to psychotherapeutic practice:
(I) integrate the multiple schools of psychotherapy; (2) integrate this
integration with the personal and psychotherapeutic concepts of each
individual therapist; (3) integrate this integration with the concepts, selfdefinitions, and world views of the patients currently in front of the
therapist. This three-dimensional notion of integration is based upon the
suggestion from psychotherapy research that the patient is the most crucial
variable in outcome, that the relationship-establishing ability of the therapist is the second most crucial influence on therapeutic outcome, and that
technique is the least important of the three (Lambert, 1986). Therefore,
any effective, pragmatic integration must be conceptualized in ways that
permit its concepts to be adapted readily to the world view of each
individual patient, couple, or family.
Similarities and Differences Among the Schools
One of the more difficult challenges to the human mind while viewing
multiple entities is to perceive simultaneously their similarities and differences. The world tends to be divided into "lumpers" or "splitters," but
psychotherapy integration requires therapists simultaneously to see differences and similarities. Integration should define fundamental similarities
and incorporate useful differences among the schools.
Cause and the Personal Future
Theories developed by schools of psychotherapy are designed to offer
causal explanations for psychological difficulty. However, cause is a philosophically problematic issue (see the section on mechanisms of change). In
keeping with the need to focus on the patient's world view, therapists
should frame causal statements in terms that imply or suggest change
alternatives. This goal is best fulfilled by adopting a teleological perspective; that is, human beings can be considered to be drawn by their future
conceptions rather than created by their past (although future conceptions
are formed by past experiences). When the future view is reconstructed by
new alternatives, change can be attributed to these reconstructions. Since
the future is moldable and the past is "passed," the future offers the clearest
avenue for causal explanations that lead to change.
Symptom Relief Versus Core Schematic Change
While patients and most therapists seek symptomatic relief at first, many
therapists and fewer patients want to get to the "cause" of the difficulties
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so that they do not recur. Change in core schemas is usually required for
enduring results, a point that will be developed in the section that follows.
Although there are often clear relationships between symptoms and underlying core schemas, the treatment distinctions between them is crucial for
both therapist and patients. Techniques useful for symptom relief (e.g.,
placebo response, relaxation training, hypnosis, medication, behavioral
suggestions) are less likely to bring about enduring change in basic schemas than are direct approaches to them. But isn't symptom remission often
enough? Each patient-therapist pair must answer this question.
The 70-percent Rule of Technical
Efficacy
No concept or technique is always useful or correct. In psychopharmacology, it has been concluded that antidepressants, for example, are effective
in approximately 70 percent of cases with major depression, according to
many research studies (Manning & Frances, 1990). Furthermore, many of
the study patients judged to be improved continue to have difficulties. To
expect any psychotherapy technique to be more frequently effective is to
expect too much.
Keep It Simple
One of the attractions to some therapists of psychoanalytic, behavioral,
and more recent cognitive theories is their complexity. For the practicing
psychotherapist, however, simple models of psychopathology and change
are more easily remembered and used. Simple flexible models are more
easily communicated and adapted to the mind sets of patients as well. In
this context, "simple" refers to the difficult explication of basic psychotherapeutic principles that may be applied in various combinations to
individual patients, couples, or families.
Self-observation Is Crucial to Change
To self-observe is to record one's own thoughts, emotions, and behaviors.
Therapists have differed primarily about what is to be observed. To selfobserve is to be able to report very personal experiences as targets for
pattern analysis and change. Through reports of their intrapsychic and
behavioral lives, therapists can direct patients to optimal fulcrums for
change.
Exposure Is the Key to Most Change
Although first emphasized in behavior therapy, exposure in its many forms
is central to both intrapersonal and interpersonal change. In psychody-
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namic thinking, anxiety and avoidance are central to repression, the treatment of which involves "uncovering" (exposing patients to) feared images,
emotions, and/or thoughts often in a stepwise fashion (Greenson, 1967),
as suggested by Wolpe's (1973) systematic desensitization. Marital therapy
usually involves conflict resolution, a central aspect of which is exposing
each partner to the thoughts and feelings of the other (Heitler, 1990). Often
this exposure is feared because it leads to increased vulnerability to hurt by
the other. Exposure seems to mean "controlled exposure to reality" so that
new information helps to correct old distorted schemas. More will be said
about this in the next section.
Stages in Psychotherapy
Since psychotherapy is a series of events through time, it may be called a
process. This process may be divided into four stages: engagement, pattern
search, change, and termination. The change stage has three substages,
including giving up the old pattern, beginning a new pattern, and maintaining the new pattern (Beitman, 1987).
Central Tenets
Enduring psychotherapeutic change may be achieved by directing the
therapeutic focus to unresolved traumatic experiences and to the core
interpersonal schema. The core interpersonal schema is the chief architect
of interpersonal loops, and exposure in its many forms is usually necessary
for change. These concepts are further described below.
UNRESOLVED TRAUMA
Often patients have failed to resolve the effects of traumatic events
and processes, including sexual abuse, physical abuse, emotional abuse,
rape, and early caregiver loss through death or separation. The painful
emotions are walled off from consciousness but enter consciousness indirectly when some environmental event bears sufficient similarity to the
old hurtful situations to trigger its associated feelings. Patients usually
have no idea about the origin of these feelings, which usually present as
symptoms.
Patients may build their self-identities on their abilities to deny the
terrible influence of these past events. "I'm so strong because it wasn't a
problem and does not bother my life." In fact these events did affect their
lives and helped to create problematic self-other representations—core
schemas.
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CORE INTERPERSONAL SCHEMA
Schemas are maps by which people interpret and construct reality.
Inherent in Korzybski's (1958) pithy phrase, "The map is not the territory,"* is a crucial objective of psychotherapeutic change. While schemas
organize a wide spectrum of interactions between self and environment,
the focus for major psychotherapeutic change may be called "the core
interpersonal schema." This schema is based upon early experiences with
caregivers and modified by subsequent intimate relationships. It represents
the self in relationship to others and carries with it both self-identity and
the manner in which interpersonal relationships are to be formed.
Partial descriptions of this idea are scattered throughout the writings
of a wide variety of psychotherapy schools (Stiles et al., 1991). A crucial
implication of the core interpersonal schema is that intrapersonal and interpersonal events are derived from the same source. Therefore, both intrapersonal
and interpersonal data provide information about this core psychic
structure.
The core schema provides self-definition and the manner by which
close interpersonal relationships are to be formed. Structurally, the schema
may be thought to have "buttons" and "scripts." When "buttons are
pushed," emotion and/or cognition (automatic thoughts) and/or behavior
may be evoked. These products, often appearing as symptoms, may be
used to flesh out the specific details of the schema. For example, excessive,
inappropriate anxiety may be accompanied by the automatic thought, "I
might fail and might lose my job." This pairing suggests a core schema in
which the person is continually vulnerable to rejection. These two responses (the automatic thought and the anxiety) may help to flesh out the
details of the schema. While the core schema may be construed as a still
photograph, the script is the movie based upon the theme of the core
schema. The script of the previously mentioned "self as imminent failure"
schema may be one in which the person is rejected because of failure, is
abandoned, and lives forever alone.
The basic elements of the core interpersonal schema are two figures
in relationship to each other. Usually one of the two figures is dominant
and the other is submissive. Although one pole may appear dominant,
therapists may assume that its opposite is present but submerged, suggesting support for the ancient idea that "everything contains its opposite."
This duality appears under multiple labels throughout the psychotherapy
schools: superego-id and grandiose-depreciated self (psychoanalysis),
parent-child (transactional analysis), topdog-underdog (Gestalt), ultimate
rescuer-supplicant (existential) as well as angel-devil from various religions
'Quote appears in Handler & Grinder (1975, p. 7).
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(see Zalaquett, 1989, for a review). The poles are in a dynamic equilibrium
creating a dialectic tension seeking resolution, and the degree of psychopathology appears to be dependent upon the degree of this power differential. In addition, more severely disturbed people fluctuate more rapidly
between the two poles (Gabbard, 1990). Borderline personalities, for example, fluctuate between the two states, whereas narcissistic patients are more
stable in either one or the other. The more extreme the difference, the
greater the psychopathology. Both intrapersonal and interpersonal conflict
are usually based on these two aspects of the self, and information about
the schema may therefore be derived from both intrapersonal and interpersonal information.
INTERPERSONAL LOOPS
The core schema is played onto the environment through expectations and behavior. Human beings are remarkably skilled in inducing others
to fit their role expectations through a variety of subtle clues that fall under
the term "metacommunication" (Watzlawick, Beavin, & Jackson, 1967;
Strong, 1987). These metacommunications from one person interact with
the metacommunications from another person, thereby developing loops
that may be called vicious cycles, virtuous cycles, or cyclical psychodynamics (Wachtel & McKinney, 1992; Wachtel & Wachtel, 1986). These
loops possess multiple intervention points, some of which the various
schools of psychotherapy have selected for their interventions. Behavior
therapists emphasize changing environmental responses or initiating new
behaviors; psychoanalysts look for past influences on core intrapersonal
schemas; interpersonal therapists try to change behavior with others; and
cognitive therapists try to alter automatic thoughts. Each of these intervention points has the potential for altering the loops and thereby influencing
core interpersonal schemas.
PATTERNS ARE STILL LOGICAL BUT NO LONGER REALISTIC
The more the patient accepts the intentions and the aims of the
therapist, the more quickly therapeutic change is likely to proceed. Changing a core interpersonal schema requires the patient to self-observe the core
interpersonal schema in enough detail so that change points can be clarified. A therapist may offer a broad description of the schema, but details
provide the patient with the focus for change. For example, the "self as
imminent failure" person mentioned earlier required delving into his own
history to find out how he learned to be so afraid of rejection. He could
identify early caregivers who trained him to be fearful of making an error.
In such cases it is often useful to explain to patients that their core
Integration Through Fundamental Similarities
209
interpersonal schemas are still logical but are no longer realistic. In other
words, they have a logic of their own derived from early relationships, but
this logic is carried forward into a present where that logic no longer
applies.
A key aspect of changing a core schema is for the patient to selfobserve while new information is available in the environment. A kind of
dual vision is required with one eye on new information and the other eye
on the core schema, so that the new light exposes the darkness of old
thinking. This "psychotherapeutic periscope" is formed through the working alliance with the therapist, whose other-observer aligns with the selfobserver of the patient. Insight is in this way coupled with "outsight."
When presenting the details of the core interpersonal schema to the
patient, the pattern should be described in terms of the future. It is insufficient
to say, "You got this way because your mother acted a certain way and
this made you think a certain way"; rather, that "certain way" must be
defined in terms that imply an alternative, another way of thinking or
another way of behaving. For example: "You are afraid of failure because
your mother threatened you with rejection and abandonment each time
you did something slightly wrong. Therefore, you must examine each
present and future situation to see if that same threat exists. If it does not,
you have other alternatives."
The examination of the script associated with the schema is a crucial
aspect of change. The expectation of certain events, however unconsciously construed, may be addressed and then changed. For those patients
who develop strong transference responses to their therapists, the playing
out of the transference in imagination becomes a here-and-now method by
which the script may be analyzed. For instance, a patient wishing to have
sex with her therapist discovered that she was simply trying to prove that
all men are like her father, who had a history of affairs. She concluded at
an early age that all men want sex only and are untrustworthy and
unreliable, creating multiple sexual contacts with men to continue to prove
this hypothesis. By playing out this script in imagination to discover that
it doesn't end as expected—she could be in a relationship without sex and
still be cared for—she allowed the script to be altered.
EXPOSURE IS A CENTRAL CHANGE MECHANISM
There are a variety of methods by which a psychotherapist can bring
about change in core schemas and unresolved trauma. Fundamental to all
of them is letting new, more realistic information alter them. New information to dysfunctional schemas is like oxygen to a wound. Once the oxygen
reaches the malfunctioning area, healing can begin. Acceptance of the
devastation of traumatic events leads to their resolution.
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Exposure comes in a variety of forms, each of which is intended to
get new information to the core schemas. Both Wolpe (1973) and Freud
(1963) exposed patients to irrationally feared entities. Wolpe's tended to
be external (phobias, self-assertion), whereas Freud's tended to be internal
(negative emotion, fantasies). This process is ubiquitous among the other
schools. Following is a list of some forms of exposure:
1. Education by others. Patients can see their own patterns in others,
whether it be in a group therapy context or in the form of bibliotherapy.
This experience of "not being the only one" helps them to elucidate and
face their cognitive and behavioral limitations.
2. Education by the therapist. Therapists have the opportunity to present much new information. For instance, descriptions of general patterns
may invite patients to fill them in with details from their own minds. Here
the idea of exposure is expanded beyond desensitization to fears. In effect,
exposure is desensitization ignorance, on which excessive fear is often
based.
3. Insight. This term has been often abused. Insight refers to looking
in, but more than just looking in is required. Insight coupled with "outsight" can provide change. The intimacy phobic must be able to look at the
dysfunctional schema and at the partner simultaneously in order to discover that intimacy need not be so frightening.
4. Instructions to act differently. Behavior therapists, strategic therapists, and others strongly encourage people to act differently. If the patient is consciously looking for different responses in self and others
while behaving differently, then change is likely (see, Fixed Role Therapy
of George Kelly, 1955). For example, a young woman firmly believed
she needed eye makeup in order for people to talk with her. She was
asked to not wear it to see if people talked to her, which indeed they did.
She was then able to change her notion of why people interacted with
her.
5. Grief work. Since "the only constant is change," much therapy
has to do with loss and therefore grief work. Grief is the pain of a lost
future. Grief work requires that the present be confronted while the lost
future is held in mind. Often people do not want to grieve because it is
so painful, just as phobics do not like to expose themselves to feared
objects or ideas.
6. Look for the positive. With much psychotherapeutic focus on psychopathology, few therapists have been trained to look for the positive.
Patients and therapists both seem phobic of the strong and the capable in
the patient. This bias appears to be changing. Islands of power, adaptability, and cleverness within schemas provide foundations for constructing
better lives. Looking for and finding these strengths may require overcoming unexpected fears in both patient and therapist.
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The Major Schools of Psychotherapy:
Useful Differences
The following is a summary of the useful contributions of the schools of
psychotherapy, in which the emphasis is on differences among them. Many
of these ideas will be used in the ensuing case presentation.
HUMANISTIC
1. Basic goodness. Each human being is basically good.
2. Acceptance. If a person is received by another with warm, positive
regard and nonjudgmental, accurate empathy and genuineness, that person
will individuate (come closer to the true self) through which the inherent
goodness will appear (Rogers, 1951).
3. Imagine the other. Therapists may be accurately empathic by actively imagining the ongoing experience of the patient (Havens, 1974).
4. Paraphrase with patient's emotion. To express accurate empathy, the
therapist may paraphrase, while speaking with a similar emotion, what the
patient has just said (Rogers, 1942).
EXISTENTIAL
1. Death anxiety. Death anxiety is a central problem of Western
culture. The failure to accept death by facing it creates multiple problems
including psychiatric disturbance. Acceptance of death allows one to live
(Becker, 1973).
2. Isolation. Social isolation is terrifying and represents a death in
society. Many people will make many compromises to avoid it, including
attachment to "saviors" or to "supplicants" (Yalom, 1980).
3. Authenticity. Life in society requires the development of "personae" (false fronts), which achieve desired social goals but can inhibit
self-development. The courage to be oneself, to express one's own true
essence, is beyond the potential of many. Yet the distortion of this selfexpression leads to much discontent. The most satisfying relationships are
ones in which participants are able to express and be accepted for who they
are in the here-and-now.
4. Free will. Does free will exist? Each person has zones of responsibility, areas of interpersonal and intrapersonal life, that are potentially under
that person's influence. Human influence is limited by biology and culture
and the accidents of birth. Within these constraints the therapist helps
patients unbridle or constrain their wants and needs within their zones of
responsibility.
5. Boundary experiences. Each person confronts loss with great regularity, which can trigger intimations of personal mortality. Death of a loved
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one, major injury to a friend, or a promotion at work can trigger a sense
of loss. These boundary experiences assault us with the irrepressible force
of time, the limits of human power, and the inevitability of death. Anniversary reactions represent one common form of this experience (Yalom,
1980).
6. The here-and-now. Perhaps the past forms us and the future pulls
us, but we live only in the eternal present. The "now" extends forever and
may be beautiful to enter (Perls, 1973; Yalom, 1980).
7. Existence precedes essence. Humans may recreate themselves because
there is no absolute meaning or purpose to life. Positive or negative is
every person's choice.
BEHAVIORAL
1. Operant conditioning. Behavior is conditioned by its consequences.
The possibility that a desired behavior will be repeated is increased if it is
followed by positive consequences or the redirection of negative consequences. The possibility of its not being repeated is increased if a behavior
is followed by negative consequences or no consequence.
2. Associative learning. If a new stimulus is paired with an effective
stimulus, the new stimulus can trigger, on its own, the response associated
with the effective stimulus (classical conditioning). The pairing of the
stimuli transfers the value of the consequences to the new stimulus.
3. Modeling. Observation of an effective model performing feared or
unlearned tasks in a graded fashion can accelerate behavior change.
4. Exposure. Anxiety, which leads to avoidance and is central to
neurosis, can be extinguished through exposure to feared stimuli. A key
objective of treatment is defining these stimuli, since some may be external
and some may be intrapsychic.
5. Homework. Patients should work outside the therapy session.
Homework assignments include careful recording of target behavior and
their associated stimuli.
6. Suggestions. Behavior change is the focus of therapy. Direct behavioral suggestions may be useful in promoting behavior change.
COGNITIVE
1. Maps for the territory. Human beings create in their own minds
"maps for the territory" of external reality. The distortions of and deletions
from these maps are associated with psychological difficulties (Bandler &
Grinder, 1975).
2. Schemas. Schemas, representations of specific aspects of reality, are
the focus of change. Key schemas are those representing the self in close
interpersonal relationships (Horowitz, 1988).
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213
3. Automatic thoughts. Automatic thoughts, internal statements to the
self and often out of awareness, are triggered by external stimuli that
activate specific schemas (Beck et al, 1979).
4. A—B—C. Patient and therapist identify the stimuli that are associated with symptoms (anxiety, depression, anger, suicidal thinking, etc.)
and look for the automatic thoughts connecting them. (Antecedent
>
Belief
> Consequence.)
5. Symptoms as clues. Symptoms are viewed "positively" since they
can lead to identification of automatic thoughts that are associated with
dysfunctional schemas (Beck et al., 1979).
6. Schema change. Patients can change their schemas in several interrelated ways: (a) by examining their own thinking for evidence of distortion or missing knowledge; (b) by accepting evidence or information from
the therapist and others; (c) by entering situations that are likely to provide
contradictory evidence (e.g., exposure to feared situations); and (d) by
observing another person doing that which the patient feels unable to
do—modeling (Raimy, 1975).
7. New self-talk. Self-statements may be modified by logic and experience (e.g., black-white thinking becomes gray), or self-statements may be
replaced by soothing, positive, encouraging words such as "I can do it; I
am loved" (Meichenbaum, 1977).
PSYCHODYNAMIC
1. The past influences the present. Past experiences with childhood
caregivers form schemas by which current intimate relationships are understood and by which the self is judged. Knowing the general outline by
which previous experience influences responses in the present has two
practical effects: (a) patients believe that they have discovered a "cause" for
their problems; and (b) they tell themselves, "The past is not the present,"
thereby learning to alter current responses based on past experiences.
2. Transference. Symptoms and other unwarranted responses may be
activated in close interpersonal relationships including the psychotherapeutic relationship (transference). These signals can help to elucidate
the schemas.
3. Grandiose-depreciated self. The degree of individual psychopathology is based upon extremes of the grandiose and depreciated selves.
As suggested earlier, the greater the grandiosity (or the greater the depreciation), the greater the psychopathology. More disturbed people also tend
to shift between these states (e.g., borderline patients). A corollary is: the
greater the psychopathology, the poorer the self-other boundaries (Kohut,
1968; Kernberg, 1975).
4. Boundary violations. The poorer the patient's self-other boundaries,
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the more carefully must the therapist monitor and set limits to patient
"boundary violations" such as coming late, repeated telephone calls, unwarranted requests for medications or extra visits or contact outside the
office (Langs, 1973, 1974).
5. Countertransference. Therapists also have interpersonal schemas
that may result in distorted thinking or behavior and can interfere with
their carrying out effective treatment.
6. Resistance. The manner in which patients thwart therapeutic expectations may reflect basic neurotic styles. Attention to these avoidances can
therefore provide signal behavior needing change.
INTERPERSONAL
1. Interpersonal needs. People seek to satisfy their interpersonal needs
by developing relationships with others. The failure to secure certain
interpersonal needs can lead to psychological distress (Strong, 1987).
2. Metacommunication. When talking with each other, people are
unconsciously communicating rules and directives about how they would
like the receiver to respond (Watzlawick et al., 1967).
3. Gender roles. Gender role stereotypes in most cultures socialize and
teach males to be dominant and females to be submissive. In Western
society, marriage seems to promote the health and happiness of males
while reducing the health and happiness of women. Being unmarried has
the opposite effect for each gender (Klerman et al., 1984).
4. Dominant-submissive roles. Dysfunctional relationships are often
characterized by rigid asymmetrical power relationships: someone is always in power and someone is always helpless. The person in each role
may shift but the rigid imbalance remains.
5. Reducing vulnerability to hurt. Personality disorders and many other
ineffective interpersonal strategies are established, in part, by their effectiveness in successful adaptation to early caregivers. Their function is to
hold others in relationships to the self while reducing vulnerability to hurt
(Cashdan, 1973).
6. Grief and interpersonal loss. Most relationships do not endure for a
lifetime, and if they do, their character changes; therefore, people must be
able to adapt to interpersonal loss and transition. Interpersonal psychotherapy may focus on grief generated from interpersonal change.
MARITAL SYSTEMS (COUPLES)
1. Not a school. No school dominates marital therapy, since concepts
from each school may sometimes be successfully applied to marital
therapy.
2. Danger to marriages. Individual psychotherapy may be dangerous
Integration Through Fundamental Similarities
215
for marriages, since change in the patient is likely to create demand for
change in the spouse. If the spouse does not change, the patient may
become symptomatic again or the marriage may become strained.
3. Marital developmental stages. Like individuals and families, marriages have predictable developmental stages that foretell the problems
facing them: (a) courtship, (b) the first year, (c) parenting and young
children, (d) adolescence and middle marriage, (e) letting children go, and
(f) alone again (Haley, 1973; Jacobson & Gurman, 1986).
4. Level of commitment. Therapists must quickly evaluate the level of
commitment to continuing the marriage. Problem categories in order of
increasing disintegration are (a) major problems but no question of divorce,
(b) ambivalence in one partner about continuing the marriage, and
(c) definite decision by one partner to divorce but wants therapy to smooth
the exit from marriage.
5. Countertransference. Therapists must be careful to avoid the temptation to "save" marriages. Divorce may sometimes be the best solution.
6. 50-50 rule. Therapists must assume that each partner is contributing equally to the current problem until proven otherwise.
7. Better communication. Marital problems usually involve inability to
communicate accurately to, and be understood by, each other. This failure
leads each one to act negatively to the other, which spirals on itself and
leads to painful withdrawal and stalemates (Heitler, 1990).
8. Multiple intervention points. Interventions may take place in several
places along the vicious spiral created by the couple. The intervention
points are determined by the mutual predispositions of therapist and
couple; highlight past-present distortions; incorporate homework to behave more positively with each other; and involve strategic interventions
that involve reframing, such as, "She yells at you so much because she
loves you" (Jacobson & Gurman, 1986).
FAMILY SYSTEMS
1. Transgenerational patterns. Across the generations families form
cultures that contain rules by which the current family unconsciously
operates. Genograms can elucidate them by identifying repeated patterns
of behavior over the generations (Bowen, 1978). Patients often have great
difficulty accepting the impossibility of changing their dysfunctional
parents.
2. Enmeshed or disengaged. Families may be too enmeshed or too
disengaged. These states create poor role definitions for the family members, leading to symptomatic expression by one of them. One approach to
change is to establish clear subsystems with the parents in charge (Minuchin, 1974).
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3. Triangulation. Triangulation involves the use of a third person to
reduce anxiety between two others. Commonly a child becomes the stabilizer for marital conflict by forming a cross-generational alliance with one
parent. The child may become symptomatic, but the focus of therapy is
often on the marriage.
4. Sexual abuse. Sexual abuse of girls is so common among psychologically disturbed patients that therapists must ask every female patient
about it (Russell, 1986). It is not as uncommon in males as was once
believed and therefore must be asked of them as well.
5. Motivated parents. A child's opinion about, or direct negative
reaction to, specific dysfunctional marital patterns is likely to add impetus
to change because parents want the best for their children. Including
children in the interview not only offers new information but also can
accelerate change.
6. Culture, gender roles, and values. Families contain the rules of the
greater culture as well as of the genetic family. One great problem in our
culture is that girls are considered inferior to boys, and women are considered inferior to men. The movement toward equality by women (and
concerned men) creates a conflict in families that predisposes them to
dysfunction. Therapists who encourage the independent equality of
women are agents of cultural change. In this and other areas, therapists
must clarify their own values (Goldfried & Davison, 1976; Leupnitz, 1988).
Patient Assessment
Before seeing the therapist, each patient fills out several self-report questionnaires, including the Zung Anxiety Scale (Zung, 1971), the Beck Depression Inventory (Beck, Ward, & Mendelson, 1961), the Brief Symptom
Inventory (Derogatis & Melisaratos, 1983), the Michigan Alcohol Screening Test (Selzer, 1971), and the Marks Mathews Fear Inventory (Marks &
Mathews, 1979). With this information, the therapist overviews the symptoms experienced by the patient, particularly those that the patient does
not describe as the most important. If the patient presents with anxiety, the
Beck Depression Inventory picks up depression that might otherwise be
missed because of the patient's concern about anxiety. Therapists are
notoriously unwilling to ask about alcohol or drug abuse; the Michigan
Alcohol Screening Test forces the therapist to confront this information.
The Brief Symptom Inventory provides a long list of symptoms that might
otherwise be overlooked. In addition, our clinic is beginning to ask each
patient before coming to the first interview to complete a computerized
diagnostic interview schedule, the C-DIS (Blouin, 1990). This procedure,
Integration Through Fundamental Similarities
217
which takes from one to one and a half hours, provides the therapist with
an extensive inclusive list of diagnostic possibilities, which can be refined
by direct interviewing. While some may see these instruments as intrusions
on the therapeutic relationship, it is my view that when these mechanical
questions are put aside, the relationship can begin more quickly.
DSM-III-R diagnostic categories for which research has shown treatment responsiveness and other prognostic indicators must be defined first.
For example, when seeing a patient diagnosed as having panic disorder, the
therapist may then assume that there is a 50 percent chance that one
first-degree relative also has panic disorder (Crowe, 1990). This information
encourages therapists to consider the patient's children at greater risk for
shyness, school phobia, and perhaps panic disorder and agoraphobia (Biederman et al, 1990). In addition, since panic disorder has been shown to be
responsive to medications (Ballenger, 1986) as well as cognitive behavior
therapy (Barlow, 1988), the therapist can then offer predictions about
treatment outcomes. Diagnosis can often help educate the patient about
the disorder and instill hope and confidence in the therapist. The MMPI
and other personality inventories are useful in diagnostic assessment when
there are questions about personality disorders.
The presenting symptoms provide clues to the problems in the patient's intrapersonal and interpersonal life. Symptoms can be followed
intrapersonally into distorted schemas and interpersonally into difficulties
with others. The nature of the marital relationship is a crucial aspect of
assessment, since this relationship often influences the beginning symptomatic behavior as well as maintains it (Hafner, 1986). Assessments are made
at the individual, dyadic, and family levels as well as the work system,
under the assumption that core problems are likely to be played out in any
interpersonal sphere. Multiple environments provide different contexts to
highlight the basic consistencies of maladaptive patterns.
A symptom is a dramatic example of the generic "discrepancy" between normal responses and the patient's response. Investigations into
such discrepancies are not done in a linear or categorical way. Instead,
symptoms and discrepancies are assessed throughout the patient's interpersonal and intrapersonal life as signals for the underlying pattern in need of
change.
Assessment and treatment are integrated in two ways related to the
sequential goals of therapy. Some patients simply want symptomatic relief.
Whether to aim for symptom relief alone is a question for the assessment.
Symptoms may be relieved in a variety of ways, including the placebo
response, medications, systemic interventions, relaxation techniques, and
education. As symptoms are being relieved, they become reframed as
signals for information about distorted schemas.
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Applicability and Structures
The approach I am advocating has been developed through work with
patients having both panic disorder and major depression, who also have
relatively disabling personality disorders. This approach appears useful for
those with neurotic conditions and moderately severe personality disorders, as well as those with lesser conditions, who seem to be responsive
to most types of interventions (Elkin et al., 1989).
Although it has been developed in outpatient psychiatric settings, this
form of treatment is likely to be applicable to similar patients in any
outpatient setting. The typical frequency of sessions is once per week, and
the typical length of session is 50 minutes. Therapy is not time limited but
usually runs between 10 to 30 sessions. Combined modalities are an
integral part of this treatment, especially if the patient is married. Medications are also a vital treatment option (Beitman, Hall, & Woodward, 1992;
Beitman & Klerman, 1991).
Although psychotherapy has been tried for a broad range of psychological dysfunctions, more recent work has made it clear that some patients
are better served by educational and rehabilitation programs. Schizophrenics, chronic bipolar patients, and drug abusers have often missed
crucial developmental challenges. They have not learned basic social and
work skills. Psychotherapy can unleash already existing potentials in less
disabled people through anxiety reduction and the incorporation of new
information, while the chronic populations require structured learning and
experience. It is very important, therefore, that psychotherapists recognize
the limits of our scientific craft.
Interventions and Relationships
It is the therapist's task to engage patients in therapy and to help them
define patterns for change after symptoms are relieved. As the patterns to
be changed are defined and the alternatives for change are understood by
the patient, the therapist's responsibility becomes reduced somewhat
(cf. Goldfried & Davison, 1976).
Some methods for engagement work synergistically are (1) empathic
reception, (2) suggestions that usually work (including medications and
relaxation training), (3) clear explication and education about the problem,
and (4) finding strengths and other positives in the patient (Beitman, 1987).
Resistances and blocks to treatment usually exist when therapists
have specific notions of what the patient is supposed to do. Resistances
Integration Through Fundamental Similarities
219
function like symptoms in that they signal dysfunctional schemas. For
example, when assigning patients homework, failure to comply could be a
possible outcome. The reasons for such failure provide information about
parallel struggles within the patient and between the patient and people in
the environment.
Perhaps the most common errors of therapists operating within
this approach are related to countertransference difficulties. If this were a
highly systematic approach, there would be little chance for the personality of the therapist to interfere with the operation of therapy. But because it is intended to be integrated with each therapist's personal schemas, idiosyncratic distortions are more likely to affect decision making
adversely.
In regard to therapist activity, much is dependent on the activity of
the patient. Although the therapist must actively engage the patient and
help to define patterns to be changed, once the patient understands what
is to be changed, activity level shifts to the patient.
The therapeutic relationship is a precondition of change, as the
therapist uses the leverage gained by engagement to help the patient
consider changing maladaptive schemas. The therapeutic relationship can
provide information about schemas to be changed and can provide a
context in which schemas can be altered. Although psychoanalysts have
overemphasized transference, it is not to be discarded, since dramatic
here-and-now behavioral changes may take place through discussions of
the relationship between patient and therapist, which generalize to other
settings.
There are a wide range of intimacy levels possible. Clinicians need to
be very careful about maintaining boundaries while still being therapeutically close. Beginners may have the most difficulty, but as one becomes
more mature and understands therapeutic role definitions, intimacy, closeness, laughter, joking, and making fun with each other can become part of
therapy. As the patient takes more and more control over change, the
relationship can become quite friendly. The dysfunctional schemas become
problems more and more external to them personally as they keep challenging their sometimes resistant and resilient nature.
The lack of problems to discuss often provides a signal for termination. Patients may rattle on about a variety of inconsequential ideas, or may
describe problems they have already solved. At such times, termination is
obviously something to be discussed. Another time to bring up termination is when the patient initiates changes—when it is obvious that major
change in thinking and behavior are beginning to take place. This early
mention of termination can elicit transference reactions for discussion, as
change is practiced and maintained.
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Mechanisms of Change
In 19th-century philosophy of science, cause was unidirectional (e.g., X
caused Y). Since those simple early days, causal statements have become
more complex. Although Einstein objected to the idea that God plays dice
with the universe, probabilities seem more related to the association between discrete events than does any linear cause. The term variance so
common in statistical analyses reflects our limited ability to explain temporal links in any but probabilistic means.
Further complication in causal understanding has been added by
notions of interactive causation (e.g., vicious or virtuous spirals). These
principles are beginning to inform psychotherapy thinking about mechanisms of change (e.g., Pentony, 1981).
Attempts to describe the mechanisms of change in psychotherapy
must take into consideration the limits of other scientific causal explanations. In psychopharmacology current knowledge cannot explain how our
antidepressants work despite several decades of intense work. Partial contributing factors are being uncovered for the mechanism of action of
neuroleptics on dopamine receptors in schizophrenics (Seeman, 1991), but
much more remains to be understood.
The placebo response further confounds the change mechanisms of
psychopharmacology. How is this crucial, yet usually overlooked, response
to be understood? Horvath (1988) has suggested that patients learn to alter
their self-talk in more encouraging directions. Understanding of the placebo response will increase our knowledge of the relationship between the
"active ingredients" of psychotherapy and outcome.
Psychotherapists need targets for change, as do their patients. When
the "magic" of pills and placebo is insufficient, when intriguing paradoxical
suggestions do not seem to work, then the hard labor of direct psychological change is necessary. The target of enduring change is the hypothetical
core interpersonal schema, a simple idea whose complexity may only be
realized as its crevices and textures are elucidated through the hard work
of homework and self-observation.
Change is "caused" by somehow providing both insight and outsight
through paying attention to the inner schema and the outer matched
aspects of reality. Somehow, with the patient's necessary acquiescence, the
new information alters the old and change takes place. Several repetitions
or repeated exposures are necessary. Rarely is the dramatic "aha" experiences sufficient. But to answer the question about how exposure of a
distorted schema to new relevant information changes the schema is to go
beyond current knowledge.
Integration Through Fundamental Similarities
221
Case Example
In order to illustrate the preceding descriptions of this approach, I present
a detailed case report.*
SUMMARY
Laura is a 30-year-old woman with a 15-year history of intermittent
panic disorder and major depression. Treatment was focused first on symptoms using medications (imipramine and alprazolam), cognitive-behavioral
diaries, diagnostic education, and looking for the positive. The core interpersonal schema centered around the need to be perfect for (1) her father,
who was always threatening to leave the family and finally did get a
divorce, and (2) her mother, who was a heavy smoker and emotionally
dependent on Laura. The patient feared independence and self-assertion.
Change was stymied through unconscious efforts by her husband to maintain the familiar equilibrium. Couples therapy, which focused on his difficulties as well as theirs, accelerated each of them to change. Session
frequency was once weekly for approximately one year, with two early
months of twice weekly individual psychotherapy. Follow-up frequency
was biweekly or monthly.
INITIAL ASSESSMENT
Laura, a mother of two girls ages 5 and 2, was accompanied by her
husband, Keith, at her first session in January 1990. She was referred by a
psychologist who knew of my interest in treating patients with panic
disorder and depression. She had seen another psychiatrist, who had
started her on 4 mg. of alprazolam. Self-report questionnaires revealed the
following information: (1) no drugs of abuse, no caffeine use; (2) Beck
Depression Inventory was 22, suggesting moderate depression; (3) Zung
Anxiety Scale was 38, suggesting moderate anxiety; (4) Marks-Mathews
Fear Inventory yielded scores of over 30 on both social phobia and
agoraphobia, which suggested not only agoraphobia but great sensitivity
to criticism by authority figures (including possibly the therapist); and
(5) Brief Symptom Inventory yielded many symptoms scored 3 or 4,
suggesting anxiety, depression, agoraphobia, and fears of mental illness.
The patient noted that her anxiety would have been higher if she had not
been taking alprazolam.
The patient did not want to continue with alprazolam for very long,
'Both "Laura" and "Keith" read this report and provided consent for its publication.
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but was frightened to stop it. I suggested that she try imipramine.* As she
increased the imipramine, the alprazolam would be reduced; she accepted
this suggestion. I spent much of the first session describing panic disorder,
depression, and their treatments. I suggested to her that panic disorder has
several different overlapping psychological causes, which include (1) illness
fears, (2) unresolved grief reactions, (3) fears of one's own anger, and
(4) unresolved reactions to traumatic events, including sexual and physical
abuse. I suggested to her that depression has multiple causes and one of
them has to do with excessive perfectionism and negative self-talk. Since
there are biological causes of depressivelike symptoms, I suggested that we
get a thyroid screen, especially since her mother had had thyroid difficulties. It was normal.
ENGAGEMENT AND SYMPTOMATIC TREATMENT
The patient readily accepted the possible explanations for panic disorder and depression and willingly proceeded with a diary for panic attacks
and depression. She also willingly developed a hierarchy for adventures
out of the home. She was able to reach 150 mg of imipramine, the target
dose, and in parallel spent increasingly more time away from the house by
herself, with decreasing anxiety. In confronting these fears, she noticed and
reported additional data about her intrapersonal life. The MMPI summary
suggested that "she forms deep emotional attachments and tends to be
quite vulnerable to hurt. She avoids confrontation and seeks nurturances
from others, often at the price of her own independence." This suggestion
was confirmed by details from her diary. Indeed, she was very dependent
upon her husband's attention to her. She began to wonder how she used
her agoraphobia to control him. She soon was able to taper off her
alprazolam by April 10, 1990.
CORE SCHEMA
During Christmas, about a month before she came to see me, she had
several severe panic attacks. Her father was visiting at her house, accompanied by a woman only two years older than the patient. Some persistent,
gentle digging helped the patient admit to herself that she was angry about
'Alprazolam (Xanax), like diazepam (Valium), a benzodiazepine, had received much negative media attention because of its supposed "addiction" potential. It is safe and effective
in early treatment, but for people with drug or alcohol abuse histories, it is likely to be
misused. As with many panic patients, Laura feared losing control, so she wanted a
medication easier to taper. Imipramine, an inexpensive antidepressant with several potentially uncomfortable side effects, could reduce her depression while also blocking her panic
attacks.
Integration Through Fundamental Similarities
223
her father's being there, especially with "that other woman." This information suggested to both of us that perhaps anger avoidance had something
to do with triggering her panic attacks. Further investigation over four to
five months revealed many details around her relationship to her parents,
which seemed central to her panic attacks and passive character. Her father
was continually threatening to leave and actually separated from the family
when the patient was 7, only to return. He finally obtained a divorce when
the patient was age 15. She found herself trying to keep him happy at all
costs. Her mother, who was a constant smoker, used the patient as her sole
source of emotional support. Her mother eventually contracted lung cancer, despite the patient's protestations against smoking, and died when
Laura was 28.
Laura had not fully grieved her mother's death. This unresolved grief
was another contributor to her panic attacks, since abnormal physical
sensations reminded her of her mother's death and tended to trigger panics.
Therapy involved attempts to have her visualize, despite her great resistances, her mother on her death bed. The patient's repeated phobic responses to her own bodily sensations, which sometimes became panic
attacks, were based on her identification with her mother's suffering.
She viewed herself as a "balancer" who was responsible for the
emotional well-being of her parents. It was she who kept the marriage
together by keeping her father happy. It was she who supplied emotional
support for her mother. On the other hand, her needs remained unaddressed for, in fact, she was the emotional servant to both. She had been
trained to stay home and became afraid to leave both because she did not
want to abandon her mother by acting like her father and because she had
so little experience in the world.
In her marriage, Laura assumed the helpless needy role her mother
had modeled for her, while feeling responsible for everything bad that
happened or could happen. She gave Keith great power over her while also
demeaning him through his lack of "perfect caring." Her self-opinion
moved between great power and great helplessness (usually the latter), as
did her relationship with Keith.
TRANSFERENCE AND COUNTERTRANSFERENCE
During the first month of therapy, the patient called me three weeks
in a row at my office on late Friday afternoons. She described many
symptoms and many fears, and only later was able to admit that she was
afraid she would never get me during the weekend when she "most
needed" me. She was becoming deeply dependent upon me and terrified
that I might abandon her. This was a reflection of her reality-based fear that
her father and mother would leave her. I found these calls irritating, but she
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responded to firm limit setting. When she became confident that I wouldn't
abandon her, these calls ceased. When, after a few months, she asked for
twice-weekly psychotherapy, I felt she might be asking for unlimited time
with me. But she was able to clearly state her strong desire to get through
this difficulty, be a better mother for her children so they would not have
to suffer from her unnecessary anxieties. This argument seemed genuine,
although 1 suspected some other, more distorted reasons, including a need
to feel closer and more dependent. The only other times these desires for
additional attachment appeared were during termination discussions. Slow
tapering of termination sessions seemed to desensitize her to these fears of
loss.
A major countertransference response was triggered in me when I
was told that she had become pregnant, as will be described later. I had
great hopes that she would follow her wish not only to be a mother but
also to continue her schooling. By becoming pregnant again I felt "that she
and her husband had ruined my great work." I could laugh at myself later,
but 1 was also responding empathically to her.
There was much in Laura and Keith that attracted me to them, that
made me want to help them. She came from the East Coast and spoke with
an accent reminiscent of my high school friends. She was intelligent and
motivated and wanted to do the right thing. I shared many of her values.
Her husband was a hardworking, sincere young man engaged in graduate
studies in psychology. He reminded me of some of my classmates in
college and medical school.
CHANGE TARGETS AND CHANGE TECHNIQUES
The target for change was her core interpersonal schema, the details
of which we tried to elucidate. As noted above, she described herself as "a
balancer"; she tried to reduce her father's unhappiness with the family and
her mother's own personal unhappiness. Some of the anxiety-generating
self-statements associated with this core schema included: "I'd better not do
anything because something bad might happen;" "Anything that goes
wrong is my fault." The latter self-statement held her responsible for her
mother's death and any other awful occurrences.
In her relationship with her husband, Laura had adopted many of the
earlier characteristics of those relationships. She was afraid he would leave
her, and needed to control him with her symptoms as her mother had
controlled her. She feared her own anger because it could upset the mental
equilibrium. In addition to continuing education about her panic disorder
and depression, I used several other techniques:
1. Simple instruction to do something different. This included an
attack on her belief that things always turned out badly whatever she did.
Integration Through Fundamental Similarities
225
I suggested that she begin a garden. She gained some satisfaction from
seeing this belief in her own incompetence challenged as her garden grew.
2. Exposure in its various forms became a critical part of therapy.
Exposure to images of her mother's death was most crucial.
3. Addressing her grandiose-depreciated self, particularly the notion
that "I am responsible for everything." I approached this by suggesting in
various ways that there were many events in the world about which she
had nothing to do, including the choice of her own mother. I formulated
her interpersonal sensitivity as a "phobia of slights" to which she needed
to be exposed.
4. I helped her modify her internal dialogue both by permitting
herself to be more flexible about her thinking and by adding soothing
self-talk in situations where she needed to be able to encourage herself,
instead of inducing her husband to encourage her.
THE BEGINNING OF RELAPSE
By May 18 she had reduced her imipramine and was directly confronting her self-talk about perfectionism. On May 22 she found herself
pregnant. She quickly withdrew from the imipramine and became immediately afraid of the delivery. As she discussed this, it became clear that lying
on the delivery table reminded her of her mother's pain during her last days
of life in the hospital bed. She did not want to break this connection to her
mother but saw that it was disrupting her ability to live now. She could
begin to see the positive in her mother's death: freeing her of the caretaking. Yet she feared (1) the empathic reexperiencing of her mother's pain,
(2) the guilt for having not stopped her from dying, and (3) the associated
grief of her mother's death.
Within a month of her becoming pregnant, Keith almost forced her
into a situation in which she was very likely to have a panic attack. He
wanted her to return to a park in which she had already had several panic
attacks. Furthermore, he began to discuss with her the need for him to sell
the car she used to get around town. By July she was becoming more
anxious and afraid of seeing people or going out by herself. She did not
want to talk about Keith's contribution to any problems; she was afraid he
might leave. During our July sessions she became overly obsessional,
asking such questions as "Why?" "What should I do?" "What does this
mean?" I became irritated. I insisted that Keith come into treatment. She
had difficulty telling him why we had asked him to return. She was starting
to slip back into her old self.
I listed the suspicious events by which Keith had kept her at home—
pregnancy, encouraging her into a situation likely to trigger a panic attack,
and wanting to sell her car. Intellectually he understood that these events
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indicated his resistance to her changing, but emotionally he could not take
responsibility. He was quite happy with the way she was now. It seemed
that after many years, she now was again the same person he had married.
Gradually the focus shifted to Keith and his problems. His mother had had
panic attacks. As a teenager he had seen her through a very difficult
divorce. He could almost admit that he was afraid that if Laura changed,
she might leave him. He was struggling with school while trying to
support his family on a limited income. He wanted to keep things the way
they were.
We tried to help him stop monitoring her symptoms and encouraged
Laura to monitor his difficulties. As she focused more on his problems, she
became less symptomatic and more able to go out on her own. She became
more confident that she could get angry at him, and it became clear that
he could accept it. In the office, we practiced her listening to him and asking
him questions. It was difficult for her at first, but with some instruction and
guidance, she was able to move her attention to him and away from herself.
Keith also could monitor himself more as he paid less attention to her.
A year after we started, their third child, Mike, was born. The birth
went very smoothly. She felt in control of the whole process by gathering
around her friends upon whom she felt she could lean, including her
husband. Her mother hardly entered into her consciousness. She had told
herself when she knew she was pregnant that nine months later she would
be psychologically liberated. Indeed, this self-programming seemed to
have taken place. Her husband still had problems with his own mother,
especially with the manner in which she interfered with their marriage. We
would address these issues in once-monthly meetings. They had a child to
bring through the first few months of his life.
In March 1991, Laura stated that she was better. An "invisible hand"
was moving her to do what she would not have done before. She felt
anxious and went shopping instead of staying home. She casually told
people about her anxiety problems and made fun of her illness fears.
I predicted for them that her anxiety would return, but with decreasing frequency and intensity. She could use alprazolam to abort incipient
panic attacks. Keith remained defensively skeptical, fearing that her intense
neediness would return. By her steady improvement, he could allow himself to be convinced and no longer needed to be her ultimate rescuer. He
too could become more himself as a result.
Laura developed the "Chicken Little theory" of her problems. When
she felt a strong sensation in her body, it became a catastrophe, just like
Chicken Little in the children's tale, who, when hit by an acorn, feared the
sky was falling.
"What should I do now?" she asked me. "I feel good; I have more to
learn. I know if I do things, I'll do more things." "Keep doing," I said. "You
Integration Through Fundamental Similarities
227
need to learn to find, test, and trust your intuition. That 'still small voice'
is often hard to find but is your best source of advice."
Research and Future Directions
No formal research is being undertaken to test these ideas. The informal
research on this approach resembles the search for effective ideas, which
characterize any psychotherapist willing to challenge personal beliefs when
confronted with apparent anomalies or surprises.
The need to integrate the psychotherapies through the discovery of
similarities and the respect for differences harbingers the even greater
necessity to break down other ideological boundaries in the same way.
Religious, ethnic, racial, gender, and nationalistic belief systems provide the
justification for terrible cruelty. I hope that the psychotherapy integration
movement can provide a model by which the human beings of earth can
embrace their similarities while also respecting their differences.
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CHAPTER 7
Multi-modal Therapy. Technical Eclecticism
with Minimal Integration
ARNOLD A. LAZARUS
A,
A LTHOUGH RIGID SCHOOL ADHERENCE in psychotherapy is by
no means passe, it has become increasingly clear to most theorists and
practitioners that no single orientation can shed light on the vast range of
problems and issues for which people consult psychotherapists. When I
called for a technically eclectic approach over 25 years ago (Lazarus, 1967)
the response was anything but favorable or supportive. For example,
immediate expulsion from the editorial board of Behaviour Research and
Therapy was followed by a vitriolic attack by the recondite Eysenck (1970),
who railed that eclecticism "would lead us to nothing but a mishmash of
theories, a huggermugger of procedures, a gallimaufry of therapies, and a
charivaria of activities having no proper rationale, and incapable of being
tested or evaluated" (p. 145).
This is not the place to offer an extensive rebuttal of Eysenck's
position (for a comprehensive critique of Eysenck's controversial contributions to behavior therapy, see Lazarus, 1986), but it is worth emphasizing
how far the field has progressed during the past 20 to 25 years. Today, 59
to 72 percent of counselors and clinicians endorse an eclectic stance (Jensen,
Bergin, & Greaves, 1990). Many would now agree that a systematic,
prescriptive, eclectic approach offers the greatest opportunities for clinical
practice and psychotherapy research (Norcross, Alford, & DeMichele,
1992).
I wish to thank, in addition to the editors, Drs. Allen Fay, Clifford Lazarus, and Stanley
Messer for their helpful suggestions.
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Systematic (Technical) Eclecticism
There are vast differences between a haphazard, subjective, smorgasbord
conception of eclecticism (known as syncretism), and one that rests on the
practical application of psychological science (Norcross, 1986). Systematic
(technical) eclecticism borrows or imports techniques from diverse sources
without subscribing to the theories that spawned them. Nevertheless,
technical eclecticism is neither antitheoretical nor atheoretical.
As a technical eclectic, I subscribe mainly to a social and cognitive
learning theory (Bandura, 1986) because its tenets are open to verification
or disproof. The efficacy of any technique from free association to behavioral shaping will be accounted for in social learning theory terms. The
active ingredients of techniques as diverse as the empty-chair, projected
imagery, cognitive restructuring, relaxation, assertiveness training, abreaction, biofeedback, flooding, structured daydreams, and so forth, are readily
explained by social and cognitive learning principles (Lazarus, 1989). Thus,
a rhythmic breathing technique to offset certain anxiety-inducing cues may
be adopted from yoga practice, but its efficacy does not require one to
subscribe to yoga principles. I have yet to administer an effective technique
that was not readily explicable in terms of conditioning, vicarious learning,
modeling, identification, self-talk, and other parameters of social and cognitive learning processes.
Technical eclectics may draw ideas, strategies, and observations from
Adlerian, Rogerian, and Ericksonian schools, or from any other approach—
for example, psychodrama, Gestalt, reality, transactional—without embracing any of the diverse theoretical positions. Blending bits and pieces of
different theories is likely to obfuscate matters. Remaining theoretically
consistent but technically eclectic (see Dryden, 1987) enables therapists to
spell out precisely what procedures they use with various clients, and the
means by which they select those particular methods.
Integration: Proceed with Caution
Those who favor an integrative over an eclectic viewpoint are apt to employ
techniques from various sources, while also seeking to harness greater
power by combining different theories or aspects of particular schools of
thought. Some theoretical positions can readily be amalgamated with
others. For example, general systems theory (von Bertalanffy, 1974) seems
to be compatible with social learning theory. Indeed, Franks (1982), a
vociferous opponent of the eclectic or integrative movement, concedes
that to combine systems theory with the precepts of behavior therapy
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"offers considerable promise" (p. 5). Kwee and Lazarus (1986) addressed
some clinical avenues that may be enriched by a systems/social learning
theory merger. But for the most part, one cannot be too cautious about the
dangers of combining elements from two or more theories. Close scrutiny
will show that many theoretical positions that appear to be interchangeable
are actually irreconcilable, intrinsically incompatible, if not antithetical
(Messer & Winokur, 1981). Let us address one of the most prevalent errors
in this connection.
Many clinicians have contended that when treating phobias, they
employ desensitization to get rid of the symptoms, while drawing on
psychodynamic concepts to achieve insight (e.g., Fensterheim & Glazer,
1983; Wachtel, 1987). On the face of it, this psychobehavioral hybrid
combines the best of two worlds, but if one understands that phobias, from
a psychodynamic perspective, entail conflicting urges, symbolic processes,
and often serve hidden (unconscious) purposes, desensitization would violate the very essence of the "real" problem and its attendant functions.
So-called symptomatic treatment is at odds with psychoanalytic drive
theory, ego psychology, object relations theory, and self-psychology.
Conversely, from a social learning perspective, most psychodynamic
insights draw on putative processes that are not verifiable or capable of
disproof and are therefore outside the realm of science. A cognitivebehavioral conception of phobias rests on entirely different assumptions
from those embraced by psychodynamic thinkers, both from the viewpoint
of the origin of the disturbance and from the point of view of their
appropriate method of treatment (Bandura, 1986; Lazarus & Messer, 1988;
O'Leary & Wilson, 1987).
Nevertheless, a thorough assessment may reveal that a given phobia
patient is riddled with conflict, is struggling with triangulated and enmeshed familial relationships, and is deriving secondary gains from his or
her avoidant behaviors. A salubrious treatment outcome calls for attention
to, and remediation of, each of these aspects of the problem. Similarly, as
emphasized elsewhere (Lazarus, 1991), if a person is claustrophobic and he
or she feels trapped in an untenable marriage, it is unlikely that treatments
addressed only to the external stimuli will be adequate. But when enabling
patients to resolve their conflicts, or undo unfortunate familial collusions,
it is wise to avoid the quagmire of psychodynamic theorizing, and it is
equally expedient to keep away from theoretical assumptions offered by
Bowen, Haley, Minuchin, Watzlawick, or other members of a family systems perspective (since the views of these personages are often untestable
and are often directly opposed to one another).
Instead of drawing on potentially incompatible theories, many of
which, over time, may be proved inaccurate, a technical eclectic may draw
quite freely on observations from many and diverse sources. For example,
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psychodynamic thinking, when stripped of its excess theoretical baggage,
enables one to appreciate the observation that people are capable of
denying, projecting, disowning, displacing, splitting, and repressing their
emotions, and that unconscious motivation is often important for the full
understanding of behavior—which should not be confused with reified
versions of "the unconscious mind" and "defense mechanisms" (see Lazarus, 1989).
Can Observations Be Separated from
Theories?
How do theories differ from observations? Theories are essentially speculations that attempt to account for or explain various phenomena. A theory
endeavors to answer how and why certain processes arise, are maintained,
can be modified, or can be eliminated. Observations simply reflect empirical
data without offering explanations. Given the fact that observations do not
occur in a vacuum but are influenced by our viewpoints (we bring our
theoretical ideas to what we observe), is it, in fact, possible to separate
observations from theories? According to extreme views of social constructionism (Gergen, 1982), we create what we observe to the extent that we
cannot discover what is inherent in nature; rather, we invent our theories
and categories, and view the world through them. From this perspective,
it is impossible to separate observation from theory. A less extreme view
would concede that therapists probably have no "hard" facts, "brute" data,
or "pure" observations, but that the distinction between observations and
theories is nevertheless worth upholding—even though observations cannot be entirely separated from theory (Lazarus & Messer, 1991).
"Observations" refer to notions that call for minimal speculation.
Compare the following two statements: "People overheard him arguing
with his boss, and when he came home he kicked the dog." "He did so
because of displaced conflictual impulses toward his boss, a father figure
who exacerbated his castration anxiety based on ego-dystonic homosexual
fantasies." The first statement (the observation) contains some low-level
inferences and is not 100 percent theory-neutral, but the range of assumptions conveyed in the second statement makes it quantitatively and qualitatively different from the first. The point at issue is that observations do not
have to constitute pure facts in order to be separable from theories. If it
were deemed impossible ever to separate the two, how would we ever test
our theories?
It is futile to garner bits of information and blend theoretical elements
from the hundreds of different psychotherapeutic schools in the hopes of
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constructing a superordinate umbrella under which disparate ideas can be
reconciled. This type of theoretical integration only breeds confusion. But
the effective practice of psychotherapy requires a basis from which we can
draw to account for the vagaries and idiosyncrasies of human temperament, personality, and behavior. What concepts and observations (not
theories) from any source are necessary to provide a basis for understanding human psychology and creating a comprehensive and scientific approach to psychotherapy? Wielding Occam's razor, we would want only
those concepts that are absolutely necessary.
The following list of basic concepts is one that I consider necessary
and sufficient to account for the factors that shape and maintain human
personality: (1) associations and relations among events (i.e., operant and
Pavlovian conditioning—see Rescorla, 1988); (2) modeling and imitation
(see Bandura, 1986); (3) nonconscious processes (not to be confused with
"the unconscious," but drawing solely on the observation that people have
different levels and degrees of awareness, and that unrecognized—subliminal—stimuli can influence one's thoughts, feelings, and behaviors);
(4) defensive reactions (not to be equated with the Freudian theory of
"defense mechanisms"); (5) private events or idiosyncratic perceptions
(addressing the fact that people do not respond to some real environment,
but rather to their perceived environment, thus factoring in the personalistic
use of language, semantics, expectancies, encoding, and selective attention); (6) metacommunications (we communicate about our communications); and (7) thresholds (people have different frustration-tolerance
thresholds, different stress-tolerance thresholds, different pain-tolerance
thresholds, and so forth, all of which are largely innate and account for a
good deal of interpersonal variance). The foregoing all rest on a biochemical-neurophysiological substrate. (For a detailed account of the role these
concepts play in multimodal assessment and therapy, see Lazarus, 1989).
To recapitulate, whereas rigid adherence to competitive schools of
psychotherapeutic thought is rapidly being replaced by a systematic, eclectic, and integrative climate, one must guard against the temptation to
merge notions that are intrinsically incompatible. By operating from a
consistent, testable, theoretical base, it is possible to draw on techniques
and observations from diverse sources, thereby enriching one's clinical
armamentarium without violating the integrity and testability of one's
underlying assumptions. But while this technically eclectic and cautiously
integrative stance will enable therapists to bypass the many prohibitions
and limitations that individual systems may impose, it does not provide
practitioners with any guidelines for clinical decision making. Eclecticism
per se, offers no modus operand! for selecting treatments of choice, matching therapy styles to particular client variables, or choosing the type of
relationship stance that is most likely to facilitate growth and change.
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Multimodal assessment is presented as a method within a systematic,
technically eclectic position that offers a "blueprint" for attaining these
objectives.
The Multimodal Approach
In keeping with the foregoing technically eclectic framework, resting
mainly on social and cognitive learning theory, the goal of multimodal
therapy (MMT) is to reduce psychological suffering and promote personal
growth as rapidly and as durably as possible. Its practice is based on the
view that an effective way to think about people and to assess their
psychological strengths and weaknesses is in terms of their various actions
and interactions across seven discrete but interactive modalities of functioning: Behavior, Affect, Sensation, Imagery, Cognition, Interpersonal
relationships, and Biological processes. By referring to the biological modality as "Drugs/Biology," the convenient acronym BASIC I.D., derived
from the first letters of each dimension, creates a useful mnemonic.
As a model for clinical practice, the BASIC I.D. embodies the following principles:
1. Human beings act and interact across the seven modalities.
2. These modalities exist in a state of reciprocal transaction and flux,
connected by complex chains of behavior and other psychophysiological processes.
3. Accurate and thorough assessment often requires systematic assessment
of each modality and its interaction with every other.
4. Durable treatment outcomes are more likely if significant problems
throughout the BASIC I.D. are specifically corrected.
5. Psychological disturbance is a product of one or more of the following:
conflicting or ambivalent feelings and reactions, misinformation, missing information, maladaptive habits, biological dysfunctions, interpersonal inquietude, issues pertaining to negative self-acceptance, external
stressors, and existential concerns (see Lazarus, 1989, for a full exposition of these factors).
The multimodal approach evolved mainly from follow-up inquiries
showing that durable outcomes seemed to be a function of how much
patients had learned during therapy, moving from a somewhat rigid behavioral perspective into a broad-spectrum approach, before finally emerging
as distinctly multimodal per se (Dryden, 1991a). It seems straightforward
to assume that the more useful and relevant information a person leams in
Multimodal Therapy
237
therapy, the greater will be the range of his or her coping responses, and
that it is thus less likely that relapse will occur.
The advantages of breadth over depth became clear when people who
consulted me after receiving psychotherapy elsewhere (sometimes for several years) still displayed significant excesses and deficits in many areas of
their BASIC I.D. For example, patients who had received "cognitive therapy" often remained at the mercy of intrusive images and untoward
sensations that had not been adequately addressed and that overwhelmed
their best attempts at cognitive restructuring. Those who had been in
psychodynamic therapy were often armed with insight but remained devoid of social and interpersonal skills and other adaptive behavioral responses that called for explicit training, coaching, and modeling. Patients
who had been in existential analyses, or had received affectively charged
treatments (e.g., bioenergetic, primal, or various forms of psychodrama)
had never learned how to challenge specific cognitive errors and dysfunctional beliefs, or overcome a variety of maladaptive behavioral and interpersonal difficulties. Many had been seen by biologically oriented psychiatrists who seemed to think that adequate treatment of the "D" modality
would ipso facto take care of problems throughout the BASIC I.
Nevertheless, it should not be concluded that MMT advocates the
complete assessment and treatment of the BASIC I.D. in virtually every
case. Indeed, there are those for whom the correct antidepressant will solve
90 percent of their difficulties; others need no more than a shoulder to cry
on, a confidant to lean on, or a nonjudgmental and empathic listener whom
they can respect. Perhaps the most important skill in any therapeutic
endeavor is the ability to determine who and what each individual is most
likely to find particularly helpful. In MMT the emphasis throughout is on
(1) treatments of choice (i.e., knowing what the research literature has to
say about specific remedies for particular problems); (2) tailored interventions (i.e., selecting psychotherapeutic strategies to fit patients' goals, coping behaviors, situational contexts, affective reactions, "resistances," and
basic beliefs); and (3) therapists' styles (i.e., going beyond formal diagnoses
to match treatment styles to specific client characteristics).
Beutler and Clarkin (1990) discuss prescriptive decisions that enable
therapists to match technical interventions as well as interpersonal styles
according to several parameters. Many writers pay lip service to individual
uniqueness and aver that therapy must be tailored to the personalistic
needs of each patient. Having stated this, the practitioners proceed to fit
all-comers into the confines of their (usually narrow) system of therapy.
The polar opposite of the prescriptive emphasis of MMT is exemplified by the work of the late Carl Rogers and his person-centered followers
(Lazarus & Lazarus, 1991a). Strict Rogerians never ask: "What type of
relationship will be best-suited to this client's personality and problems?"
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"How much direction and support will best meet the demands of this
person's needs at various times throughout therapy?" "What specific techniques will facilitate change; when and how should these methods be
introduced and implemented?" Instead, the entire counseling process rests
on the therapeutic alliance, wherein the therapist endeavors to communicate genuine empathy and unconditional positive regard, which is deemed
both necessary and sufficient for constructive personality change (Bozarth,
1991). Multimodal clinicians regard the patient-therapist relationship as the
soil that enables the techniques to take root—it is not the complete means
to the end (Lazarus & Fay, 1984). The multimodal view is that within the
context of a warm, caring therapeutic relationship, it is necessary to remedy
maladaptive behaviors, faulty cognitions, and other problems throughout
the BASIC I.D., and that effective therapy often calls for coping skills
training (communication skills, relationship skills, health maintenance skills,
problem-solving skills, sexual skills, and career development skills—to
name a few).
Some of the main hypothesized mechanisms of change, from a multimodal perspective, may be listed as follows:
• Behavior: Positive reinforcement; negative reinforcement; punishment;
counterconditioning; extinction
• Affect: Acknowledging, clarifying, and recognizing feelings; abreaction
• Sensation: Tension release; sensory pleasuring
• Imagery: Coping images; change in self-image
• Cognition: Cognitive restructuring; heightening awareness
• Interpersonal Relationships: Modeling (developing assertive and other
social skills); dispersing unhealthy collusions
• Drugs/Biology: Identifying medical illness; substance abuse cessation;
better nutrition and exercise; psychotropic medication when indicated
A point worth emphasizing is that one cannot elicit or change affects
or emotions directly; this modality can be worked with only indirectly
(Lazarus & Lazarus, 1990). One can deal directly with behavior ("Do this;
say that; act like this; don't stand there; don't say that"). The sensory
modality is open to direct stimulation ("Hear that; see this; touch that; smell
this; taste that"). In the interpersonal modality, direct interventions such as
imitation, modeling, and role playing are among the most common. The
biological modality lends itself to numerous direct interventions, drugs and
surgery being the most obvious. Even inferred constructs such as cognitions and images are amenable to direct intervention: "Dispute that false
belief," "Think about it this way," "Imagine yourself sitting under a palm
tree," "Picture an elephant running across a field." But affect can only be
accessed or reached through behavior, sensation, imagery, cognition, inter-
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239
personal relationships, and biological processes. While many people seek
therapy because they feel bad (i.e., they are experiencing negative affective
states such as anxiety, depression, and guilt), the multimodal position is
that the most elegant and thorough way of reducing anxiety, lifting
depression, and assuaging guilt is to eliminate the specific and interrelated
dysfunctional patterns of behavior, sensation, imagery, cognition, interpersonal relationships, and possible biological processes.
Initial Interviews
In multimodal assessment there is no slavish attention to order. A person
in crisis needs a good listener and someone who can offer immediate
support, reassurance, and perhaps guidance and technical intervention.
There are those who enter therapy with many misgivings, such as low
levels of basic trust, so that a sensitive period of rapport building is
essential before any specific measures can be applied. Some patients are
"window shoppers," whose uncommited attitude can be very trying but
who need a nonthreatening environment, because these potential consumers are easily scared away. And then there are those who come mainly to
complain. Most rewarding, of course, are those "customers" who are
willing to work and are ready for change. Irrespective of the patient's
readiness for change, two basic questions need to be thought through in
every case: (a) What has led to the current situation? (b) Who or what is
maintaining it?
Any good clinician will be on the alert for signs of psychosis, intellectual impairment, homicidal or suicidal tendencies, and other indications of
serious psychopathology. And any astute therapist will note what patients
say, and how they say it—being on the lookout for hesitations, blocks,
changes in affect, significant gestures and movements, rapid breathing,
frequent swallowing, and other minutiae (without reading too much into
them).
A major emphasis throughout MMT is on flexibility and versatility.
Initial interviews provide a neutral, accepting, and open atmosphere. It is
then necessary to gauge how best to augment the level of rapport with
each individual. For some, gentle clarification of their affective reactions is
a necessary precursor to any specific training or assignments, and a reflective ambience is made to order. Others grow impatient with purely supportive tactics and respond best to immediate cognitive disputation. How
can a therapist determine when it is advisable to remain silent, pensive, and
quietly reflective, versus being active, directive, and distinctly didactic? By
using his or her clinical judgment and studiously observing the impact of
each intervention (Lazarus, 1989). Howard, Nance, and Myers (1987) have
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discussed the need for therapists to vary the extent of directiveness and
supportiveness throughout therapy, and they provide interesting choice
points for reaching these decisions.
Whenever there is a definite discrepancy between the client's apparent presymptomatic stress and the severity of the ongoing disorder, particular attention should be paid to biological considerations. A typical mentalstatus examination is performed. If this examination suggests neurological
impairment, a thorough testing of the client's comprehension, attention,
grasp, reasoning, judgment, and other neuropsychological factors is called
for. When in doubt, a neurological consultation is strongly recommended.
The patient's interests are best served when the therapist has a network of
competent physicians for consultation (psychiatrists, neurologists, endocrinologists, internists).
In essence, initial interviews are used to arrive at 12 determinations:
1. Are there signs of psychosis (e.g., delusions, thought disorder, bizarre
or inappropriate behavior, incongruity of affect)?
2. Are there signs of organicity (e.g., disorientation, memory lapses, rigid
posture, untoward mannerisms)?
3. Is there evidence of depression, or suicidal or homicidal tendencies?
4. What are the presenting complaints and their main precipitating
events?
5. Why is the patient seeking therapy at this time—why not last week,
last month, or last year?
6. What appear to be some important antecedent factors?
7. Who or what seems to be maintaining the patient's overt and covert
problems?
8. What does the patient wish to derive from therapy?
9. Are there clear indications or contraindications for the adoption of a
particular therapeutic style? (Does a basic directive or nondirective
initial stance seem preferable?)
10. Are there any indications that it would be in the patient's best interests
to be seen individually, as part of a dyad, triad, family unit, and/or in
a group?
11. Is it likely that a facilitative therapeutic relationship will be established,
or should the patient be referred elsewhere?
12. What are some of the patient's positive attributes and strengths?
While the foregoing typifies the multimodal approach during the
early stages of therapy, it is not distinctly different from most broad-based,
eclectic practices. Yet MMT has several unique assessment procedures that
set it apart from other approaches.
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241
How Multimodal Therapy (MMT) Differs
from Other Eclectic Approaches
MMT has been used with inpatients (Brunell & Young, 1982; Kwee,
Duivenvoorden, Trijsburg, & Thiel, 1986; Roberts, Jackson, & Phelps,
1980), children (Keat, 1979, 1990), adolescents (Edwards & Kleine, 1986),
and with specific populations in various settings (Brickner, 1984; Greenburg, 1982; Kertesz, 1988; O'Keefe & Castaldo, 1985; Ponterotto, 1987;
Ridley, 1984; Rudolph, 1985; Sank, 1979; Slowinski, 1985; Smith &
Southern, 1980). The present account will deal with the treatment of
adult outpatients.
MODALITY PROFILES
Information derived from initial interviews and the 15-page Multimodal Life History Inventory (Lazarus & Lazarus, 199lb) usually provide the
therapist with information sufficient to design a comprehensive treatment
program. The inventory, in addition to obtaining routine background
information, contains a "Modality Analysis of Current Problems" via behavior, affect, sensation, imagery, cognition, interpersonal relationships,
and biological factors. In tandem with observations obtained during the
first couple of interviews, after the patient completes the Multimodal Life
History Inventory, the therapist is in a position to construct a BASIC I.D.
chart, or Modality Profile—a distinctive feature of multimodal assessment.
The Modality Profile lists salient problems in each dimension of the BASIC
I.D. with recommended treatments. Table 7.1 is the Modality Profile of a
37-year-old man in treatment for generalized anxiety.
Some MMT practitioners use these problem checklists routinely, but
I construct them only when therapy is not proceeding apace and when
unforeseen problems arise. The discipline and time (seldom more than 15
or 20 minutes) required to construct these profiles is usually well worth the
effort, and they often enable the therapist to pinpoint specific issues and
interactions that may have eluded other avenues of inquiry. C. N. Lazarus
(1991) has provided clear-cut and vivid examples of the ways in which
Modality Profiles are far superior to traditional psychiatric diagnoses for
facilitating treatment selection.
Given a Modality Profile, how does one proceed to select and prioritize treatment goals? A basic rule is to start with items that are likely to
respond to one's ministrations, thereby augmenting one's credibility. In
many instances, certain problems call for immediate attention. For example,
an individual who is unduly tense may require some form of relaxation
training before other measures can be introduced. Another person with a
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TABLE 7.1
Modality Profile
Modality
Behavior
Problem
Intervention
Procrastination
Contingency contracting
Modeling and role playing
of assertiveness skills
Tends to pout or
withdraw when
frustrated
Volatile and explosive
Affect
Anxiety
Depression
Sensation
Imagery
Cognition
Interpersonal
relationships
Drugs/ biology
Jealousy
Tension (esp. in jaws
and neck)
Lower-back pain
Lonely images
Images of failure
Perfectionism
Negative scanning
Dichotomous thinking
Self-downing
Passive-agressive
Unassertive
Has few friends
Insufficient exercise
Overweight
Relaxation and
communication training
Breathing and deep muscle
relaxation; stress inoculation
training
Coping imagery; increase
rewarding activities
Flooding and cognitive disputation
Relaxation training
Orthopedic exercises
Picturing various coping responses
Cognitive restructuring
Social skills and assertiveness
training
Healthy lifestyle program
clearly dysfunctional belief that undermines several areas of discourse may
require "cognitive disputation" as an initial intervention. Generally, the
choice of problem areas to be addressed, and the techniques to be administered are discussed with the patient, and decisions are made in concert with
his or her input. When deciding upon the interactive cadence that is most
likely to yield respect, compliance, or treatment adherence by the patient,
multimodal therapists pay close attention to three items on the Multimodal
Life History Inventory (p. 4). "In a few words, what do you think therapy
is all about?" "How long do you think your therapy should last?" "What
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243
personal qualities do you think the ideal therapist should possess?" Someone who thinks that therapy is all about the past and its current implications is likely to be displeased with an exclusively here-and-now inquiry.
A person who anticipates a three-to-six-month course of treatment may be
nonplused in the hands of a long-term psychotherapist. A patient who
considers a good therapist "someone who is an active listener, who says
very little but takes in a whole lot," will probably take unkindly to an
active-directive, task-oriented clinician.
It would be naive to assume that patients necessarily know what is
best for them or that the therapist must comply with each of their expectations. Nevertheless, I have found that it is wise, initially, to follow the
patient's script fairly closely so that adequate rapport is established. Thereafter, it is more acceptable and less threatening when the therapist rewrites
parts of the scenario and develops a modus operandi that seems better suited
to overcome the patient's fundamental problems.
Most patients elect to terminate therapy before all the entries on their
problem profile have been addressed and successfully resolved. When the
more debilitating or disturbing features have been overcome, some patients may decide to "go it alone." They usually feel capable of living with
the remaining problems, or have acquired sufficient coping skills to apply
them in a self-help capacity and thereby further attenuate residual difficulties. Others may elect to undergo several different courses of therapy,
preferring to deal with different problems at different times (and perhaps
with different therapists). The task-oriented nature of MMT seems to avert
the development of undue dependency, wherein treatment termination
becomes a problem in and of itself. The goal of MMT is to deal with as
many specific problem areas as seem feasible, cost-effective, and worthy of
attention. Thus, the Modality Profile provides an overall "blueprint" of
major and minor problem areas, so that specific treatment goals can be
selected from the total list. It is important to avoid suggesting treatment
goals that patients are unlikely to attain.
STRUCTURAL PROFILES
In addition to the Multimodal Life History Inventory and the use of
Modality Profiles, another assessment procedure that is unique to MMT is
the use of Structural Profiles—quantitative ratings across the BASIC I.D.
The following instructions (p. 14 on the Multimodal Life History Inventory) are sufficient for drawing up these Structural Profiles:
Directions: Rate yourself on the following dimensions on a 7-point scale,
with 1 being the lowest and 7 being the highest.
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BEHAVIORS
Some people may be described
as "doers"—they are action
oriented, they like to busy
themselves, get things done,
take on various projects. How
much of a doer are you?
1 234567
FEELINGS
Some people are very emotional
and may or may not express
it. How emotional are you?
How deeply do you feel
things? How passionate are
you?
1 23 45 67
PHYSICAL SENSATIONS
Some people attach a lot of
value to sensory experiences,
such as sex, food, music, art,
and other "sensory delights."
Others are very much aware
of minor aches, pains, and
discomforts. How "tuned in
to" your sensations are you?
1 23 4567
MENTAL IMAGES
How much fantasy or
daydreaming do you engage
in? This is separate from
thinking or planning. This is
"thinking in pictures,"
visualizing real or imagined
experiences, letting your mind
roam. How much are you into
imagery?
1 23 4 567
THOUGHTS
Some people are very analytical
and like to plan things. They
like to reason things through.
How much of a "thinker" and
"planner" are you?
1 23 4 567
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245
INTERPERSONAL
RELATIONSHIPS
How important are other people
to you? This is your
self-rating as a social being.
How important are close
friendships to you, the
tendency to gravitate toward
people, the desire for
intimacy? The opposite of this
is being a "loner."
1234567
BIOLOGICAL FACTORS
Are you healthy and
health-conscious? Do you
avoid bad habits like smoking,
too much alcohol, drinking a
lot of coffee, overeating, etc.?
Do you exercise regularly, get
enough sleep, avoid junk
foods, and generally take care
of your body?
123 4 5 67
These ratings are easily depicted on a graph. Despite their subjective
nature, they often enable one to obtain useful clinical information. Important insights may be gained when the therapist explores the meaning and
relevance of each rating. With couples, when husband and wife each fill out
a Structural Profile, important differences and areas of potential incompatibility are readily discerned. When seeing couples, it is also helpful to obtain
"metacommunicative" scores; they are asked to rate how they think their
spouse will depict them. These scores often provide additional inputs that
can be put to good effect. Thus, in couples therapy, it is useful to determine
the way a person rates himself or herself and to compare this with the way
he or she rates his or her spouse.
There is also a 35-item Structural Profile Inventory (SPI); see appendix
4 in Lazarus (1989). The merits of a standardized instrument are selfevident. The development of the SPI was achieved by generating a variety
of questions that, on the basis of face validity, appeared to reflect essential
components of the BASIC I.D. Factor analytic studies gave rise to several
versions of the questionnaire until one with good factorial stability was
obtained. Additional research (Herman, 1991; Landes, 1988) has borne out
the reliability and the validity of this instrument. Again, the SPI has been
particularly useful with couples because the scores frequently generate
meaningful discussions and promote better mutual understanding while
pinpointing areas of misunderstanding.
When necessary, MMT practitioners may call for other standardized
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tests and additional diagnostic and assessment procedures (in the same
technically eclectic spirit as a therapeutic method may be employed), but
the mainstay of multimodal assessment centers on Modality Profiles and
Structural Profiles.
TRACKING THE FIRING ORDER
Another specific feature of the multimodal approach is the observation that a fairly reliable pattern may be discerned behind the way in which
people generate negative affect. Different people tend to arouse feeling
states through individualistic perceptions of the BASIC I.D. For example,
some dwell first on aversive images (I) (pictures of dire and catastrophic
events), followed by unpleasant sensations (S) (shortness of breath, palpitations, sweating, tremors), to which they attach negative cognitions (C)
(ideas about their impending death), leading to maladaptive behavior (B)
(avoidance, withdrawal, and isolation). This I-S-C-B firing order (ImagerySensory-Cognitive-Behavioral) may require a different treatment strategy
from that employed with say a C-I-S-B sequence (Cognitive-ImagerySensory-Behavioral), or from yet a different firing order. Our clinical findings suggest that it is usually better to select techniques in accordance with
the patient's chain reaction.
A man who could not account for his frequent "anxiety attacks"
was encouraged through self-observation to track his modality firing
order during the course of a week. He stated: "My anxieties usually
begin to develop when I tune into the fact that my body is feeling a little
'off,' such as a queasy feeling in my stomach, or a little tension in my
neck. This sets off the chain. These feelings grow stronger as I attend to
them, and then new ones develop, and pretty soon I start thinking that
something dreadful is going to happen to me. These thoughts stir up a
whole series of memories and pictures of the time I came down with pneumonia—which went undiagnosed for six weeks." In this case we have a
Sensory-Cognitive-Imagery sequence. Since the patient's anxieties were
triggered first by sensations, the therapist selected several sensory techniques (rhythmic breathing exercises, deep muscle relaxation, biofeedback) as the initial antianxiety regimen. Next, the cognitive modality was
addressed (e.g., providing instructions in positive self-talk), followed by
imagery methods (e.g., specific pictures wherein the patient saw himself
being healthy, warding off disease).
Alternatively, if a patient's anxiety commences with cognitive inputs ("I'm doing fine, when suddenly I start thinking of all the things that
could possibly go wrong in my life"), followed by unpleasant images
("Then I picture myself, quite vividly, passing out and making a complete
fool of myself"), leading to negative sensations ("My hands get clammy,
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247
my chest tightens up, and I get butterflies in my stomach"), the use of
biofeedback and relaxation as a first line of attack may not be effective,
since the sensory mode is the third sequence in the chain. As already
stated, clinical impressions suggest that the end result is enhanced by
matching patients' specific firing orders to the treatments selected, although the active ingredient may well be the power of suggestion—the
aura of a therapist who appears to be implementing a "scientific" and
"custom made" trajectory. A multimodal maxim, however, is that if
something proves helpful, use it, don't analyze it!
BRIDGING
A strategy that is probably employed by most good intuitive therapists can readily be taught to novices via the format of the BASIC I.D.
Typically, a therapist is interested in a patient's emotional responses—his
or her fundamental feelings about various events—but may be receiving
only defensive and perhaps irrelevant intellectualizations. In response to
the question, "How did you feel about your father's decision to leave
home?" the therapist receives a cognitive appraisal of the situation: "My
father tended to place his needs first, and neither my mother nor I were
factored into the equation." "Yes, but how did you feel about that?" "Well,
you have to understand his own family background in order to appraise the
significance of his actions." Clearly, for reasons known or unknown, the
patient is reluctant to address his feelings, and it may be counterproductive
to point this out. Even the tactful comment, "You seem to be avoiding my
questions regarding how you feel about these matters," may prove too
confrontational for some. Unfortunately, it is not uncommon for some
therapists to strongly upbraid (if not attack) patients for providing intellectualizations rather than discussing their feelings.
In the foregoing instances, the multimodal practitioner uses "bridging" to ensure that relevant information is obtained, thereby allowing
therapy to remain on target. Bridging refers to a procedure in which the
therapist deliberately tunes into the patient's preferred modality before
branching off into other dimensions that seem likely to prove more productive. Thus, when confronted with intellectual barriers rather than emotional
reactions, the therapist will join the patient in his or her cognitive modality.
For example:
THERAPIST: So your father's family background predisposed him to put his
needs first.
PATIENT: He seemed to identify with his very selfish mother, and ended up
being the opposite of his own father.
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T: I wonder if he saw his mother as strong and his father as weak?
P: I think it had more to do with the fact that he did not respect his father.
Comment: Instead of challenging the patient's intellectualizations or
interpreting his "resistance," the therapist joins him in the cognitive modality. Thus, the patient does not feel hurt, misunderstood, criticized, or
attacked. The therapist may go along with the patient's cognitive content
for about five minutes and then bridge into a modality that is less threatening than the affective domain, for example, the sensory area:
T: By the way, can you tune into some sensations anywhere in your body?
I'm wondering if this conversation has made you feel tense or if you are
in touch with any other sensations?
Comment: If the patient is unaware of any tension or discomfort, the
therapist may then ask him to dwell for a few minutes on various parts of
his body. Thus, one has bridged out of the cognitive modality into the
sensory modality. From a discussion of sensations (or the absence of
sensations), it is usually possible to bridge into the affective modality. At
this juncture, a question such as "I really wonder how you feel about the
things your father has done" is less likely to evoke the same cognitive
defenses. If the patient does not avoid or disavow his sensory reactions, the
interchange may continue as follows:
P: I have quite a nasty headache. Also, my shoulders and my jaws feel
tight.
T: Let's pay attention to your headache and those tense sensations. Would
you mind closing your eyes and studying those sensations for a few
moments?
P: (Sits with eyes closed for about 40 seconds) The tension is mainly in my
neck.
T: Try rubbing your neck, massage it gently and see if that helps at all.
P: (Rubbing his neck) When I press here, it is quite painful.
T: Is this pain connected to any feelings?
P: How do you mean?
T: Well, the things we were discussing about your dad sounded rather
painful.
P: (Emotionally) Although I try to understand the reasons behind his
actions, I still feel he is a selfish bastard.
T: What else do you feel?
Comment: It should be reemphasized that a therapist's failure to tune
into the patient's presenting modality can lead to feelings of alienation—
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the patient may feel misunderstood, or may conclude that the therapist
does not speak his or her language. Thus, it is recommended that therapists
start where the patient is and then bridge into more productive areas of
discourse.
SECOND-ORDER BASIC I.D. ASSESSMENTS
Yet another advantage of working from a multimodal perspective is
the degree of precision that becomes possible. The initial BASIC I.D. chart
(Modality Profile) translates vague, general, or diffuse problems (e.g., depression, anxiety, unhappiness) into specific, discrete, and interactive difficulties. Thereafter, while avoiding push-button panaceas, the initial selection of techniques is usually straightforward. When undue physical tension
is evident, relaxation training is applied; dysfunctional beliefs will call for
the correction of misconceptions; timid and unassertive behaviors usually
require the application of assertiveness training.
Nevertheless, treatment impasses arise—for example, when a patient's unassertive reactions are not being changed despite the diligent
application of role playing, behavior rehearsal, modeling, and other relevant training. When this occurs, a more detailed inquiry into associated
behaviors, affective responses, sensory reactions, images, cognitions, interpersonal factors, and possible biological considerations may shed light on
the situation. This recursive application of the BASIC I.D. to itself adds
depth and detail to the macroscopic overview afforded by the initial
Modality Profile. Thus, a patient who was not responding to assertiveness
training, when asked to examine in detail the repercussions of assertiveness
responses across the BASIC I.D., revealed a significant "cognition" that
seemed to account for his "resistance." In essence, it seemed that he did not
feel entitled to certain rights and privileges. Consequently, "cognitive restructuring" was required before role playing and other behavioral measures proved effective.
Another case in which a Second-Order BASIC I.D. shed light on
issues that had not emerged previously concerned a young man who felt
a strong but puzzling fear at the prospect of being promoted at work.
Cliches regarding his presumed "fear of success" had been offered by
others, but this made no sense to him. "I see myself as very ambitious
. . . I'm a go-getter." Analysis of his reactions through a Second-Order
BASIC I.D. revealed nothing significant in Behavior, Affect, or Sensation
when picturing himself having attained a significant advancement (apart
from minor and understandable concerns about having to put in longer
hours, and some trepidation about working under the scrutiny of senior
executives). But when traversing the Imagery Modality, he first stated, "I
picture myself impressing the Board Members," and after a long pause
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came up with an image that called a halt to the inquiry: "I picture my father
dying and my brothers blaming me." This peculiar image called for closer
attention. It was shown to fit into a convoluted pattern of reasoning that
proceeded more or less as follows:
The youngest son, with three older brothers, the patient had already
exceeded his own expectations regarding his station in life. He was the
only college graduate in a blue-collar family, and he sensed real or imagined envy from his siblings, especially his oldest brother. A rebellious child,
he had a turbulent relationship with his father, who disapproved of his
academic aspirations and often accused him of wanting to look down on
the entire family. Nevertheless, he had "written his own script" and had
obtained a liberal arts education instead of following the family tradition
of becoming a tradesman. In part, he had missed the camaraderie that his
brothers had with one another and with their father, but he also felt
superior to them—a feeling that was tainted with guilt.
All of this information had been obtained from the Multimodal Life
History Inventory, but only while focusing on the Second-Order BASIC I.D.
did he realize to what extent additional achievements on his job symbolized the demise of his father and signaled total alienation from his siblings.
This opened up a productive discussion of his family attachments and
obligations and eventuated in a decision to "go full steam ahead." Later he
said: "I knew I wasn't afraid of the added responsibility and new demands
that would be placed on me, but i couldn't figure out what was holding me
back." The therapist pointed out that he may have adopted a standoffish
attitude toward his family, and recommended that he make deliberate
overtures to participate with them in mutually enjoyable activities—family
dinners, picnics, bowling, and other sporting events. The outcome was
decidedly positive. The Second-Order BASIC I.D. rapidly brought to the
fore some important issues that had been elusive and enabled the therapist
to intervene effectively.
SUMMARY
There are six distinctive features that set MMT apart from all other
approaches:
1.
2.
3.
4.
5.
6.
The specific and comprehensive attention given to the entire BASIC I.D.
The use of Second-Order BASIC I.D. assessments
The use of Modality Profiles
The use of Structural Profiles
Tracking the modality firing order
Deliberate bridging procedures
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251
MMT places primary emphasis on the uniqueness of each and every
person. Hence, there is no typical treatment format. When tuning into the
expectancies and demand characteristics of one patient, the therapist may
adopt a passive-reflective stance. At other times, or with a different patient,
the therapist may be extremely active and directive. Bearing in mind the
fundamental question of who or what is best for this individual, the first
issue is whether the therapist should work with the patient or refer him or
her to someone else. Although the therapist will endeavor to function as
an "authentic chameleon," in assessing and respecting the needs of each
individual, there are obvious limits to everyone's versatility. Hence, a
judicious referral to a more compatible resource may be necessary (see
Dryden, 199lb). Obviously, patients who display grossly bizarre behaviors, active delusions, thought disorder, and other signs of psychosis, are
probably best seen in a psychiatric facility, and those who are clearly
homicidal or suicidal often require medical and custodial intervention.
MMT practitioners are drawn from the full range of health service
providers. Psychiatrists, psychologists, social workers, psychiatric nurses,
pastoral counselors, and other mental health workers each have members
within their disciplines who employ multimodal methods. Some multimodal therapists have a strong background in health psychology and behavioral medicine; many are clinically adept with substance abusers, sexual
offenders, or with specific problem populations (e.g., bulimia nervosa,
obsessive-compulsive disorders, posttraumatic stress disorders).
Case Example
Ken, aged 23, complained that for the past year he had been suffering from
anxiety and depression, and he expressed frustration over his inability to
sustain erections during sexual intercourse, a difficulty he had experienced
for approximately five years. He was good looking and neatly groomed,
but conveyed an aura of defeat and agitation. Ken had recently dropped
out of law school, a fact that produced additional tensions with his "reticent" father, a 47-year-old attorney who specialized in tax law and real
estate closings, and his "overprotective" 43-year-old mother, an elementary school teacher. His 28-year-old sister, a certified public accountant,
was married to an architect and had a 2-year-old daughter upon whom the
entire family doted. Ken stated with some passion: "I'd like to get married
and have kids myself some day." Regarding his sister, Ken emphasized that
his parents seemed to prefer her to him, usually sided with her against him,
and that her outstanding academic record contrasted sharply with his own
rather average scholastic performance.
Two additional factors were mentioned during the initial interview:
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(1) at age 16 he was extremely upset over the death of his maternal
grandmother of whom he was especially fond; (2) at age 18, the tragic
demise of his girlfriend as the result of a cerebral aneurysm (his first sexual
relationship) had a profoundly negative impact. After the initial interview,
Ken took home the Multiniodal Life History Inventory (Lazarus & Lazarus,
199lb) and mailed it to the therapist before his second session. It provided
the following list of salient interactive problems:
Behavior
"Can't get going."
Procrastination
Avoidance, tends to withdraw
Affect
Anxiety, depression, guilt feelings
Sensation
Tension in head and shoulders
Headaches and bouts of dizziness
Dryness in mouth
Imagery
Vivid pictures of grandmother's funeral
Events of his girlfriend's demise
Images of failure
Vivid pictures of parental censure
Cognition
Self-downing and self-blaming tendencies
Demands (shoulds, oughts, musts)
Catastrophic thinking
Thoughts about personal failure
Interpersonal relationships
Familial tensions
Has withdrawn from most friends
Avoids sexual encounters
"My mother tries to control and restrain me."
Drugs /biology
Drinks up to a six-pack of beer some nights
Has stopped playing tennis and jogging
The questionnaire also indicated that Ken expected therapy to last no
more than six months, and that he favored a cognitive-behavioral approach
that would be didactic rather than purely exploratory. Describing Ken as
a young man suffering from anxiety, depression, and sexual problems
provides a succinct description of his major difficulties, but does not point
the way to the selection and implementation of specific treatment strate-
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253
gies. The Modality Profile outlined above provides a "blueprint" for personalized and immediate remedies (see C. N. Lazarus, 1991).
Given his pervasive tension, Ken was taught basic relaxation skills
and given cassette recordings for home use. He also responded favorably
to a simple meditation technique wherein, while sitting in a quiet room, he
would repeat a "mantra" and focus on rhythmic breathing. He was encouraged to practice relaxation and meditation daily. At the same time, his
"cognitive modality" was addressed, and in addition to the initial entries
on his Modality Profile, it soon became clear that he had a penchant to
disqualify the positive (only negative events "counted," while positive
happenings were dismissed or forgotten). He was also prone to all-ornothing thinking, interspersed with a negative filter (i.e., dwelling on
particular negative events to the extent that his vision of life became bleak
and dark). Thus, broadly speaking, the first five sessions focused on relaxation, meditation, and cognitive restructuring. His dysfunctional thinking
was disputed (Ellis, 1989), and he was urged to monitor self-destructive
thinking and to challenge his own faulty inferences and false conclusions.
His anhedonic philosophy and eschewal of pleasure prompted the
application of a Second-Order BASIC I.D. assessment, which brought two
additional factors to light: (1) he irrationally blamed himself for his grandmother's death ("I should have persuaded my parents to take her to better
doctors"); (2) given the tragic ending of his first love-sex relationship, he
had acquired a superstition that future romantic liaisons would follow the
same trajectory. This called for an active-directive-persuasive-cognitive
realignment and occupied the bulk of the next five sessions. In essence, his
irrational ideas were parsed and challenged, and paradoxical interventions
were added to the regimen. "If you try really hard, I'm sure you'll manage
to invent some other things apart from your late grandmother and girlfriend for which you can castigate yourself!" Ken chuckled appreciatively
at these kinds of remarks and soon began to see how ridiculous his
self-blaming really was.
Behavior rehearsal and role-playing methods were used to offset his
inept dealings with his parents, especially his "controlling mother," and a
highly significant focus became the fact that in his overzealous desire to
please them, he was not leading his own life. He drew up a list of parental
put-downs and pejorative remarks and embarked on a successful course of
self-desensitization. At the same time, positive and coping images (wherein
he pictured himself succeeding, be it sexually, in dealings with his parents
and other significant individuals) were added to his "homework package"
(Lazarus, 1984; Zilbergeld & Lazarus, 1987).
By the 10th session, Ken was eager to share various insights he had
acquired into many facets of his life, and he was excited over "forgotten
memories" he had retrieved. For example, he reported with great astonish-
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ment and some consternation how he had remembered that, when 10 or
11 years old, he had wished to be a girl. It soon became evident that this
was related to the favoritism that his parents had shown toward his sister.
This brought our attention back to the salient realization that Ken continued to march to his parents' drum, instead of asking himself, What do
/ want out of life? For example, he had downplayed the fact that he was
extraordinarily dexterous and could perform wonders with his hands. He
demeaned these talents in favor of aspiring to develop a brilliant legal
mind.
He declined the suggestion that some family therapy sessions with his
parents, and perhaps even his sister, might readily resolve some lingering
familial tensions. "I'd feel like a kid, like a schoolboy at a parent-teacher
conference," he said, and added that he felt fully confident at this juncture
that he could deal with them himself.
It took over four months for Ken to emerge significantly less anxious,
euthymic, and sexually potent. He no longer appeared to have any regrets
about dropping out of law school and had decided to apply to dental
school instead. He had undergone 14 sessions in all.
Approximately a year later, he consulted me again, in the company
of a young woman whom he described as a "potential fiancee." He complained of intermittent erectile inadequacy, a problem that was overcome
in one session by emphasizing that performance anxiety was behind his
difficulty, and stressing that instead of dwelling on his own erections (or
lack thereof), he would be better advised to focus on the pleasures he could
bestow on his partner via manual, digital, and oral stimulation. He was
attending dental school, a fact that had earned him "unexpected respect"
from his family.
Ken was not a difficult patient. He was intelligent, cooperative, competent, and willing to change. This particular case was selected in order to
illustrate how the multimodal framework, with its emphasis on breadth,
permits one to address significant interactive elements in a person's life in
an immediate, comprehensive, and systematic fashion.
Research Findings
Several dissertations have explored the clinical utility of MMT suppositions and findings (e.g., Aigen, 1980; Ferrise, 1978; Olson, 1979; Schaut,
1991). Lawler (1985) found a significant degree of interrater reliability in
terms of problem identification, and the extent of agreement regarding the
relevant modalities for treatment. Mann (1985) showed that therapists'
personal BASIC I.D. profiles did not appear to influence their assessment
of others. Rosenblad (1985) studied Structural Profiles given to distressed
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255
and nondistressed couples. Among the dysfunctional couples, spouses
tended to estimate incorrectly the way that the other person would rate
them (i.e., their metacommunications were faulty). As noted earlier, Herman (1991) and Landes (1988, 1991) have obtained data on the reliability
and validity of the Structural Profile Inventory. Several studies are presently under way, exploring the relevance of multimodal approaches in
industrial and organizational contexts.
Kwee (1984) conducted a controlled outcome study using multimodal
therapy with 44 severe obsessive-compulsive patients and 40 extremely
phobic individuals in a general psychiatric hospital. Of these patients, 90
percent had previously undergone psychiatric treatment without success,
and 70 percent had suffered from their disorders for more than four years.
Various measures were administered at intake, on admission, after 12
weeks, at discharge, and at follow-up nine months later. The follow-up
showed that 64 percent of the obsessive-compulsive people remained
significantly improved. Among the phobic patients, 55 percent had maintained or had proceeded beyond their treatment gains.
Williams (1988), in a carefully controlled outcome study, compared
multimodal assessment and therapy with other treatments in helping children with learning disabilities. The study took several years to complete
and emerged with clear data pointing to the efficacy of the multimodal
approach in comparison to other treatments.
Perhaps it should be emphasized again that MMT is an approach that
tries to incorporate state-of-the-art research findings into its framework. It
is not intended as yet another "system" to be added to the hundreds in
existence. Rather, it is an approach that attempts to be at the cutting edge
of clinical effectiveness by continually scanning the field for better assessment and treatment methods. Whether this augments clinicians' overall
effectiveness remains an empirical question.
Clinically, the writer has conducted several outcome and follow-up
inquiries. A three-year follow-up of 20 "complex cases" who had responded favorably to the writer's ministrations (e.g., people who had
overcome extreme agoraphobia, pervasive anxiety, panic disorder, obsessive-compulsive rituals, or enmeshed marital or family problems) showed
that 14 maintained their gains or had made additional progress without
further therapy. In another survey, 100 patients who had not responded
to at least three therapists before seeking multimodal therapy, revealed
that 61 achieved objective and unequivocal benefits. Many of these patients were considered intractable by their former therapists. The patients
who fared poorly in this series suffered either from anorexia nervosa or
chronic alcoholism. Although this is not meant to imply that these are
the results of comparative outcome studies, it seems reasonable to suggest that there are clinical findings supporting the notion that MMT
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usually succeeds where less comprehensive approaches have previously
failed.
Clinical Training
One of the major aims of effective clinical training should be to prevent
formal coursework from undermining the talents and skills with which
most trainees are endowed naturally. It is most unfortunate that many
therapists, during their courses of training, seem to acquire a stylized
professionalism replete with pejorative labels and questionable proscriptions (Lazarus, 1990). It is debatable whether therapists, before becoming
technically eclectic or multimodal, should be steeped in several systems
(e.g., Gestalt, behavioral, psychoanalytic) so that they attain competence in
many different approaches. My opinion is that it is counterproductive to
study the theoretical underpinnings of different systems, but, as already
discussed, it can be fruitful to cull observations, methods, and techniques
from many sources.
My experiences at the Graduate School of Applied and Professional
Psychology at Rutgers University, where, since 1974, I have trained selected Psy.D. and Ph.D. students in the multimodal orientation, suggest
that certain theories undermine effective therapy. In short, students who
have learned to approach clinical phenomena from a psychoanalytic viewpoint are inclined (from my perspective) to spend too much time exploring
mental conflicts rather than promoting action; they often fail to direct
therapeutic tasks or initiate topics of discussion; and instead of challenging
irrational ideas, they are apt to explore them (see Messer, 1992). The
well-trained MMT practitioner asks when, with whom, and under what
circumstances it seems better to delve into nonconscious fantasies than to
modify irrational beliefs (and vice versa). In keeping with social learning
theory, performance-based methods will usually be preferred to purely
verbal or cognitive inputs.
Students who are especially enamored of family systems approaches
are prone to see the woods but miss the individual trees. In MMT, the
focus swings back and forth from the individuals and their parts, to the
people in their social milieu. Students enamored of a particular unimodal,
bimodal, or trimodal approach are apt to pursue a favorite line of inquiry,
or to continue employing a particular procedure despite the absence of
change. For example, those who are particularly devoted to cognitive
therapy are inclined to dispute, challenge, explain, argue, interpret, and
reframe, even when it seems obvious that their words are falling on deaf
ears. Because they often regard a change in cognition as the be-all and
Multimodal Therapy
257
end-all, they are reluctant, if not unwilling, to switch to a different
modality.
It would seem that some of the better students are those who have
majored in psychology, with extensive course work in sociology, anthropology, and biology. Their graduate training seems best devoted to
courses in behavioral medicine, psychopathology, tests and measurements,
interviewing skills, research design, and various electives that afford the
opportunity to undergo several apprenticeships. In other words, a most
valuable learning experience is derived from working closely with expert
therapists—observing them in action, sitting in on sessions, serving as
cotherapists, and receiving formal supervision. This affords students the
opportunity of appreciating the nuances of interpersonal style and seeing
what works, regardless of the ways in which different therapists rationalize
their results.
MMT calls for as much breadth as the individual clinician can muster.
It is not difficult for most students to learn and apply MMT methods—
drawing up Modality Profiles, constructing Structural Profiles, formulating
assessments and strategies in BASIC I.D. terms, using bridging and tracking maneuvers when necessary. Nevertheless, considerable attention has to
be paid to more subtle aspects of therapy. Thus, a useful and frequently
employed training tactic is the analysis of response couplets. Whenever a
patient makes a response, the therapist is obliged to react. For example, if
a patient asks, "Do you think I should tell my mother how I feel about my
brother's divorce?" the therapist has to respond. He or she may respond
simply by saying nothing, by repeating the patient's question (e.g., "You
want to know if you should discuss your feelings about your brother's
divorce with your mother"), by deflecting the issue back to the patient (e.g.,
"Do you think it would be beneficial to discuss it with your mother?"), by
making an interpretation (e.g., "Perhaps you are more concerned about the
way your mother feels about the divorce"), or by offering advice (e.g., "I
think it would be better if you first discussed the way your father reacted").
The range of possible responses is great, but the goal is to rate and seek
group consensus of the therapist's response in terms of its negative, neutral,
or positive potential. Thus, during group supervision, trainees play tape
recordings of ongoing sessions, and at judicious points, the recorder is
switched off and various response couplets are examined. It is particularly
helpful to stop the recording at the point where the therapist is required
to make a response, and before hearing what was actually said and done,
to discuss a variety of facilitative reactions.
The analysis of response couplets enables supervisors to discern
instances wherein the trainee fails to appreciate the patient's feelings, is
inappropriate in timing his or her remarks, is angry or defensive, or even
worse, shows disdain, impatience, disrespect, intolerance, or induces guilt.
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HANDBOOK OF PSYCHOTHERAPY INTEGRATION
This process primes the supervisor to zero in on irrelevant questions,
confusing remarks, and false reassurance. On the positive side, it enhances
the trainer's capacity to model concise and accurate phrasing, display
sensitivity to relevant and highly charged emotional issues, underscore the
virtues of profound respect and significant understanding, and discuss the
appropriate use of humor.
How important is personal therapy? If personal problems are likely to
interfere with trainees' successful implementation of accurate assessment
and effective treatment, it is necessary to remedy the situation. I disagree
with those who contend that personal therapy should be mandatory, and
that all trainees should be encouraged to undergo psychotherapy. Of
course, in keeping with the multimodal philosophy, if it is considered
necessary or advisable for some students to receive personal therapy, it is
important to help them find the type of therapy and therapist who would
most likely be the best for them.
Future Directions
The multimodal framework is eclectic without being fragmented; it provides integration of salient observations without a futile rapprochement of
conflicting theories; and it calls for broad-based clinical training without
sacrificing "depth." It is essentially an approach (not a system) that seeks
to incorporate into its purview helpful diagnostic and treatment procedures
garnered from many disciplines. It is the polar opposite of cultism. Thus,
despite requests to do so, I have refused to launch a journal of multimodal
therapy, because this would foster the very thing to which I am opposed—
an in-group mentality.
But the field of psychotherapy is still replete with cult members,
devoted followers of a particular school of thought. Various gurus and their
disciples only reiterate findings that fit their own needs and tie into the
perceptions of their flock. As mentioned at the start of this chapter, these
tendencies have receded but have not extinguished. High priests of psychological health are still engaged in competitive strife and internecine
battles. Many have such desperate needs for a leader and a sense of
belonging that virtually anyone with a tinge of charisma and an appealing
party line can attract overzealous adherents.
There are those who believe that the foregoing state of affairs is on
the verge of its demise, and to bolster their position, they point to books
such as this one, to the existence of journals devoted to psychotherapy
integration, and especially to the Society for the Exploration of Psychotherapy Integration (SEPI). Yet if one looks closely at the SEPI conference
contents, it becomes clear that those who search for "common ingredients"
Multimodal Therapy
259
are at loggerheads with members who espouse specific points of emphasis.
Many resort to an arbitrary fusion of two or more systems (e.g., behavioral-Gestalt, systems-psychodynamic), and others are strongly committed
to one school of thought while paying lip service to being open to input
from others. Norcross and Prochaska (1988) conducted a survey of selfidentified eclectics and found considerable divergence and little convergence. Thus it would appear that the integration movement has done little
(if anything) to diminish the chaos that surrounds the hundreds of different
schools of psychotherapeutic thought, and that differences among various
integrationists may even surpass those of the most rigid school adherents.
This state of affairs seems unlikely to change in the near future.
Yet few would disagree that we require greater rigor; that we need
to operationalize and concretize therapist decision-making processes; that
we would do well to broaden our theoretical bases; and that systematic,
differential, and prescriptive therapeutic strategies are called for. The question is how best to achieve these worthy ends, and herein lies the problem:
people cannot agree on an acceptable modus operandi. Perhaps mounting
socioeconomic pressures for rapid and effective short-term therapies, the
availability of pharmacotherapeutic remedies, and the impact of managed
health care may induce otherwise recalcitrant theorists to seek compelling
solutions for psychological disturbances.
One can but hope that more professionals will appreciate the limitations of theoretical integration, that treatments of choice and different
therapies will be accurately matched to patients' needs, and that clinical and
programmatic research will yield answers that are desperately needed (see
Lazarus, Beutler, & Norcross, 1992). The establishment of training institutes that offer courses on technical eclecticism, articulate the value and
limitations of integration, provide technically eclectic supervision, and
address many of the issues and concerns noted throughout this chapter
would move the enterprise of psychotherapy into the 21st century.
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(Paperback 1988. New York: Ivy Books)
CHAPTER 8
Systematic Eclectic Psychotherapy"
LARRY E. BEUTLER AND ANDRES ]. CONSOLI
.HERE ARE THREE OBSERVATIONS that have underwritten the deTH
velopment of systematic eclectic psychotherapy (s.e.p.t Beutler, 1983).
First, the past three decades have seen an exponential growth in the
number of psychotherapies being offered and the variety of theories underlying them. The proliferation of theories suggests that all of these constructions have failed to respond adequately to the spectrum of human behavior
that characterizes both therapists and patients. This failure, in turn, suggests the need for integrative approaches, wherein specific interventions
can be designed for specific populations.
Second, although a preponderance of the literature on psychotherapy
theory is devoted to justifying the use of theory-specific methods and
procedures, most of the effectiveness of psychotherapy can be attributed
to factors that are common to most effective therapists (Lambert, 1992;
Shapiro & Shapiro, 1982). Most of contemporary literature is devoted to
understanding the factors that account for a very small percentage of
therapeutic change.
Third, there has been a persistent lack of communication between
practitioners and psychotherapy researchers (Barlow, 1981; Strupp, 1981a).
While the advent of treatment manuals (Luborsky & DeRubeis, 1984) in
research, and their translation to clinical practice, promises to reduce the
•Research for this chapter was supported by NIAAA grant No. I ROl AA08970.
tWe have elected to use the abbreviation s.e.p. for systematic eclectic psychotherapy, both for
the sake of simplicity and space. It is our intention neither to introduce a new acronym nor
a new therapy. For this reason, our abbreviation appears in lowercase letters.
Systematic Eclectic Psychotherapy
265
significance of this point, it remains true that most psychotherapy theories
have little or no foundation in research.
With the appearance of this volume, undertaking to describe different
integrative and eclectic psychotherapies, there is a danger that we "eclectics," like the theoreticians before us, may become so concerned with our
pet viewpoints that we will fail to provide a truly eclectic approach.
Integration and advancement can come only with continued discussion. It
is often as important to be wrong as to be right, as long as theories are
constructed in such a way as to allow one to tell the difference through
empirical research.
Background
S.e.p., as it has evolved and expanded during the past decade (see Beutler,
1979a; Beutler, 1983; Beutler & Clarkin, 1990), has its roots both in clinical
practice and in empirical research. From practitioners have come an appreciation for the need for a pragmatic form of eclecticism and the accompanying belief that different interventions are effective for different types of
patients (Garfield & Kurtz, 1977; Norcross & Prochaska, 1983). It is also
from practitioners that we have adopted a degree of skepticism regarding
the value of diagnosis for planning psychosocial interventions. Nearly
three decades ago, Cole and Magnussen (1966) observed the low relationship that existed between diagnosis and treatment assignment, and argued
for a diagnostic system that was predictive of treatment outcome. The
magnitude of the relationship between diagnosis and treatment assignment
has not improved much in the ensuing years (Beutler, 1989; Gillis, Lipkin,
& Moran, 1981).
From empirical research has come an appreciation of the power of the
therapeutic bond. Numerous investigators have asserted that the relative
inability to distinguish the outcomes of different psychotherapies suggest
that they all work through the same basic mechanisms—the therapeutic
bond, or alliance (Luborsky, Singer, & Luborsky, 1975; Sloane, Staples,
Cristol, Yorkston, & Whipple, 1975; Smith, Glass, & Miller, 1980). In turn,
work on therapist-patient matching has convinced us that good therapeutic
relationships arise from a complex of initial similarities and dissimilarities
between patients and therapists (Beutler, 1981; Beutler & Bergan, 1991;
Kelly, 1990).
At the same time, we are aware that some of these research-based
observations conflict with the assumptions of clinical practitioners. For
example, on one hand, respected scientists who have reviewed large bodies
of research have frequently reiterated the conclusion that training in specific therapies and their associated procedures does not enhance the likeli-
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HANDBOOK OF PSYCHOTHERAPY INTEGRATION
hood or magnitude of outcomes (cf. Luborsky et al, 1975). On the other
hand, the sociopolitical emphasis placed upon technical proficiency by
training institutions and licensing boards, as well as the parochial arguments lodged by different practitioners, implies that special skills and
techniques do matter. Responding to these disparate conclusions, we have
turned to a search for conditions under which certain procedures do and
do not work, the conditions largely being defined both by patient transient
reactions and enduring characteristics (e.g., Beutler, 1991; Beutler & Clarkin, 1990).
S.e.p. represents an attempt to bridge the gap between these polar
views, and to do so by translating contemporary research into a model of
treatment selection that accepts both the value of common therapeutic
qualities and the reality of indicators and contraindicators for the use of
certain procedures. Bolstered by the work of Frank (1973), Goldstein
(Goldstein & Simonson, 1971; Goldstein, Heller, & Sechrest, 1966), and, to
a lesser extent, by that of Strong (1968) and Brehm (Brehm, 1976; Brehm
& Brehm, 1981), we have adopted a philosophy that psychotherapy is a
social-influence or persuasion process in which the therapist's operational
theory forms the content of what is persuaded, and the therapist's technology functions as the means of influence. The quality of the therapeutic
relationship is thought to define the limiting influence of the procedures
used.
S.e.p. represents an effort to define relevant variables from which
differential effects may be predicted. This effort has proceeded, first, from
a retrospective review of empirical work (Beutler, 1979a), progressed to a
construction of a theoretical model of treatment decision making (Beutler,
1983; Beutler & Clarkin, 1990), and has finally been manifested in prospective empirical tests of that model (Beutler, Engle, Shoham-Salomon et al.,
1991; Beutler & Mitchell, 1981; Beutler, Mohr, Grawe, Engle, & MacDonald, 1991; Calvert, Beutler, & Crago, 1988). From the outset, it has
been a commitment of s.e.p. to seek knowledge upon which changes in the
system can be made. Accordingly, a number of changes have occurred in
s.e.p. that correspond with the extensions and modifications of the first
(Beutler, 1983) and of the most recent (Beutler & Clarkin, 1990) renditions.
Concepts of Systematic Eclectic
Psychotherapy
To be practical, an eclectic psychotherapy must emphasize three working
principles. First, it must consider all or most psychotherapy approaches as
potentially beneficial to some individuals. Second, it must act on the
assumption that therapeutic procedures are capable of being implemented
Systematic Eclectic Psychotherapy
267
independently of their originating theories. Third, eclecticism must operate
from a theory of change that gives credence to a variety of technical
procedures. This is a tall order and may seem impossible to those who
maintain that certain procedures are, per force, incorrect and inappropriate.
However, most psychotherapists identify themselves as eclectic (Garfield
& Kurtz, 1977; Norcross & Prochaska, 1983; Norcross, 1986; Norcross &
Newman, 1992) and thereby advocate the use of those procedures that fit
the patient best, regardless of the theoretical origins of those procedures.
It is the operationalization of this point of view that we pursue.
To this end, three questions are faced by s.e.p.: (1) On what dimensions should patients and therapists be matched to be maximally effective?
(2) Within compatible patient-therapist matches, what is the best combination of patient and procedure? (3) What considerations can best dictate the
alteration of therapeutic procedures in treatment across time? The promise
of eclectic psychotherapy rests in the faith that one can extract, from
research and theory, dimensions, characteristics, and patterns that will
allow one to make maximally effective and reliable decisions.
In response to this challenge, s.e.p. addresses theories at two levels.
The first of these levels is as an attribute of the given therapist. From this
view, the therapist's formal theory provides both the foundation for communicating with other professionals and constitutes the philosophy of life
that is taught to the patient or client. In this context, one theory is
considered as "true" as another, the value resting more on its usefulness
and believability than upon its truth. At the second level, theory represents
a pragmatic description of the dimensions and criteria for making treatment
decisions. At this level, theory is not explanatory but descriptive and
closely follows clinical and empirical data that defines relationships between patients and environments, on one hand, and treatment contexts
(settings, modalities, formats, frequencies, duration) and methods (i.e., procedures), on the other.
At the first level of theory, s.e.p. suggests that therapists develop and
use their own life experiences to inform their explanatory philosophies. At
the second level of theory, s.e.p. proposes that identifiable patient and
environmental qualities can be used as indicators and contraindicators for
assigning treatment components (Beutler & Clarkin, 1990).
The social-persuasion theoretical formulation on which s.e.p. is
loosely based, unlike most that are applied to psychotherapy, does not
address the nature of psychological disturbance (psychopathology) but the
nature of the interpersonal forces and mechanisms that instigate or inhibit
change. At this level of abstraction, each therapist's personal theory of
symptom development provides (1) an explanation of change that may be
understood by the patient and (2) a formulation of treatment objectives
that provides a focus for the interventions employed.
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In comparing various psychotherapy approaches, Luborsky, CritsChristoph, Alexander, Margolis, and Cohen (1983) and Shaw (1983) have
observed that treatment effectiveness is more a function of whether therapists consistently follow their particular theories of intervention than of
what techniques or philosophies they employ. Theoretically, at least, a
therapist's view of human behavior and psychopathology provides such a
focus and directs the therapeutic interventions to "relevant" patterns of
behavior (Strupp, I98lb). Because it is more a collection of empirical
observations than of explanatory constructs, models of social influence are
sufficiently flexible to encompass a broad array of explanatory theories (i.e.,
psychodynamic, behavioral, and systems orientations), thus (potentially)
circumventing some of the problems of intertheory communication. Moreover, exploring psychotherapy from the larger perspective of persuasion or
social-influence theory leads to certain predictions about matching patients
with therapy procedures. To wit:
1. The collection of procedures that induce desired persuasion is
partially dependent upon how these procedures "fit" with the recipient's
characteristics. Persuasion methods that affect people who use one style of
coping with stressors may work poorly tor those who use others. Persuasion is effective to the degree to which it manages arousal levels and
focuses efforts.
2. Other things being equal, discrepancies between the point of view
taken by a valued persuader (the therapist) and the point of view held by
a willing recipient (the patient) of a persuasive message will be predictive
of the amount of attitude change or persuasion initiated. The strength of
this relationship, however, will be limited by the degree to which the
therapist is perceived as a safe, knowledgeable, trustworthy, and credible
individual. Discrepancy of viewpoints induces motivation (i.e., arousal),
and the content of the message provides a direction for intended change.
3. Recipients of persuasive communications vary in their receptivity
to direct persuasive efforts. Hence, an important aspect of persuasive
strategies is the degree to which they alter or adapt to these variations in
receptivity.
Patient-Therapist
Compatibility
Most authors (Guidano, 1987; Bowlby, 1979; Larson, 1987; Mahoney,
1991) concur in asserting the imperious necessity of developing a therapeutic alliance, a bond that will ultimately be the vehicle tor the therapeutic
achievements, yet few authors elaborate on what the components of such
an alliance or bond are (Atkinson & Schein, 1986; Beutler 1979c; Beutler
& Bergan, 1991; Bordin, 1976; Talley, Strupp, & Morey, 1990). As qualities
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of a process of persuasion and influence, the therapeutic alliance is understood as representing unavoidable imprints of its participants. Two types
of variables—demographic characteristics (age, ethnicity, gender, socioeconomic status) and interpersonal response patterns (attributions, beliefs/values,
strivings) of the participants—will partially give form and determine the
quality of their relationship. The question then is, what similarities and
dissimilarities along these dimensions are most conducive to developing a
successful treatment relationship and outcome?
Among the demographic dimension, ethnic similarity has been amply
researched and reviewed by Atkinson and collaborators, among others
(Atkinson, 1983; Atkinson & Schein, 1986; Wampold, Casas, & Atkinson,
1981), with some mixed results. Black patients appear to prefer black
therapists, but such preference has not been connected to therapeutic
effectiveness, nor has it been replicated consistently among other ethnic
groups. The clinical practice of assigning ethnically similar therapists to
minority clients may fail to account for more important sources of diversity
(i.e., age, gender, socioeconomic status).
Findings regarding demographic similarity, although not solid, allow
some preliminary statements (cf. Beutler & Clarkin, 1990). Demographic
similarities tend to facilitate positive perceptions of the treatment relationship, retention in therapy, and treatment adherence, especially among
minority and disenfranchised patients. These process findings are not directly seen in outcome gains, however. Beutler and collaborators (Beutler,
Crago, & Arizmendi, 1986) have concluded that attitudinal flexibility and
perceived similarity, rather than actual similarity, account for the modest
effects observed on outcome.
Patterns of interpersonal response may be more directly involved in
outcome than demographic ones. S.e.p. identifies two domains in which
patient-therapist matching is important for facilitating the therapeutic relationship. The first of these reflects interpersonal strivings or needs for
interpersonal attachment and affiliation, qualities that have been found to
represent stable characteristics that transcend diagnostic groupings (e.g.,
Widiger, Trull, Hurt, Clarkin, & Frances, 1987). At one end of this dimension may be individuals who desire affiliation, dependency, relatedness,
recognition, and twinship (Kohut, 1977), while at the other are individuals
whose lives are committed to the pursuit of individuality, distinction and
autonomy from others. Berzins (1977) suggests that therapists who are
unlike their patients on dimensions that reflect dependency and autonomy
needs are most likely to produce positive therapeutic change, regardless of
whether the patient or the therapist places the highest value on these
dimensions.
The second domain of interpersonal-response pattern matching consists of attitudes, beliefs, and values. Several lines of investigation have
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suggested that patients who acquire their therapists' belief systems over
the course of treatment tend to have a higher likelihood of improvement
than those who do not change or who diverge from the belief systems of
their therapists (Beutler, 1981; Beutler & Bergan, 1991; Beutler et al, 1986;
Hamblin, Beutler, Scogin, & Corbishley, 1988; Kelly, 1990; Tjelveit, 1986).
In turn, a number of clinically relevant studies (e.g., Beutler, Johnson,
Neville, Elkins, & Jobe, 1975; Mendelsohn & Geller, 1963) have suggested
that the patient-therapist convergence process is facilitated by the presence
of initial dissimilarity between the two.
To summarize, demographic and background similarities between
patients and therapists may serve to facilitate the patients' adherence to
treatment regimens early in the treatment process (Beutler el al., 1986). As
treatment progresses, however, the attitudinal and conceptual changes that
we frequently call "improvement" are based on the patients' efforts to
assimilate the discrepant views of a valued therapist. From the standpoint
of therapeutic process, it seems prudent to attempt case assignments that
have the lowest number of patient-therapist background mismatches. Mismatches are minimized by demographic and background similarities and
dissimilarities in relevant attitudes. Likewise, the therapist may do well to
introduce attitudes about which the members of the dyad may have
different views, somewhat later in treatment.
Matching Therapy Technique to Patient
Characteristics
The field of patient-therapy interaction research is not a new one, and its
contributions are being reassessed. Shoham-Salomon's (1991) adaptation of
an old familiar saying, "different folks benefit from different strokes," has
been an appealing call to renew the search for preferable patient-therapy
matching. To address the task of discovering "what kind of therapy, or
elements thereof, benefits what kind of client" (Shoham-Salomon & Hannah, 1991, p. 219), one must assume a framework designed to make
effective interventions specific to certain patient characteristics and qualities. Hence, both procedures and patient qualities must be addressed in
more treatment-relevant ways than that captured either by therapy brand
names or by diagnostic labels. For example, while formal diagnoses have
a role in the derivation of medical treatments (Frances, Clarkin, & Perry,
1984), psychological interventions must be tailored to more specific qualities of patients' personalities, styles of coping, and knowledge repertoires
than these clinical diagnoses allow. Faced with the endless and unattainable
task (cf. Beutler, 1991) of exploring every possible interaction between
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psychotherapy variables (therapy, patient, therapist), we propose the study
of selective patient variables and associated classes of interventions with
which they interact, and the study of patient-therapist compatibility.
IDENTIFYING AND MEASURING PATIENT VARIABLES
Assessment of treatment-relevant patient dimensions relies on a combination of both formal and informal procedures. In most cases, the evaluation process is not clearly distinct from the therapeutic one. Hence, it makes
little sense to separate the definition of these variables from the means used
for assessing them.
There are numerous patient dimensions that may enhance the predictive efficacy of psychotherapy. Beutler's (1979a) initial efforts extracted
from comparative psychotherapy studies those dimensions that were present when one theoretical approach emerged as more effective than another.
While the list has expanded since that time, here we will restrict our
discussion to four dimensions: problem severity, problem complexity,
reactance level, and coping style.
Problem Severity
Problem severity is a concept constructed to express how successful the
patient's coping styles are. This concept is used to refer to the ways in
which coping methods have or have not being able to maintain anxiety and
distress within manageable limits. Severity can be conceptualized as a
continuum, ranging in extremes from reflecting minimal symptoms to the
presence of symptoms that are incapacitating.
The severity of the problem is indicated by impairments in the
patient's capacity to relate in the social, occupational, and interpersonal
demands of daily life. A final evaluation of each of these subvariables
considers their dynamic interaction and their response to stress. Stressful
events or situations challenge the individual's coping mechanisms. The
result is a multidetermined response that is sensitive to the complexity of
the situation and the patient's diverse strengths. These strengths include
intellectual capacity, levels of ego integrity, and quality of family and social
network and support systems (Beutler & Clarkin, 1990).
Special consideration is given to problem seventy when formulating
a treatment plan, since the acuteness and intensity of the problem will affect
motivation and investment in treatment. It will also determine the format,
duration, and immediate goals of the treatment planned.
The suitable assessment methods to evaluate problem severity include, but are not limited to, detailed clinical interview, drawing of the
patient's human resources and social network map, a life-history question-
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naire, mental status exam, review of current assets, and use of objective
tests (Beutler & Clarkin, 1990).
Problem Complexity
We believe that it is both necessary and consistent with current research
to distinguish between problem severity and problem complexity. While
problem severity is easily conceptualized as a continuum of impairment, we
find it useful to think of problem complexity as a simple dichotomy,
expressing on one hand, "generalized habits or transient responses" and, on
the other, "complex problems" that are symbolized in recurrent themes or
patterns of behavior (Beutler & Clarkin, 1990). Complex problems, therefore, represent a clinical judgment of the degree to which the presenting
problem(s) are both repeated as themes of underlying dynamics across
situations and are represented symbolically in the patient's manifest
complaints.
The two concepts, problem complexity and problem severity, are
among the most significant patient dimensions for predicting effectiveness
of treatment. The concept of problem severity captures the acute, intense,
situation-specific aspects of the patient's difficulties that require immediate
attention, while problem complexity addresses the more enduring, less
situation-specific characteristics of the patient's complaints—those that
require long-term attention. The designation of a problem along a dimension of complexity and the definition of those themes that are manifest
when the complexity of problems is high are necessary in order to select
the focus of treatment. Complex problems, or thematic issues, merit a
broad-band treatment—one that is aimed at conflict resolution—while
situation-specific problems and habits warrant a treatment that is symptom
oriented.
The degree to which a presenting problem represents a linear generalization from the conditions under which it was initiated allows us to
determine if it is a simple habit or a symbolic expression of an associated
conflict. If given symptoms bear only an indirect, obscure, or symbolic
relationship to the events that initiated them, one must elect in favor of
identifying the problem as "complex" rather than the symptoms as "habitual." In this case the feared punishment that gave rise to the reaction
pattern is frequently no longer in evidence, and the behavioral symptoms
themselves are discomforting and result in pain or anguish. Indeed, one of
the major indices of a complex problem is that the associated behaviors are
not conducive to pleasure or satisfaction but to a prolonged suffering and
continuing interpersonal impairment (Bond, Hansell, & Shevrin, 1987).
The clinician has to evaluate different sources of information when
assessing the dimension of problem complexity. First, he or she must
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explore the way in which relevant, recurrent patterns develop in the
patient's life history. Second, the therapist should assess unconscious needs
and wishes that might be represented symbolically in these patterns. Finally, a close look and assessment of the relative roles that social reinforcements and conflictual needs play in the maintenance of the symptom
pattern is warranted (Beutler & Clarkin, 1990).
The SCL-90R (Derogatis, Rickels, & Rock, 1976) is particularly useful
for assessing symptom severity and complexity, because it presents estimates of both intensity of distress and symptom generality or spread.
Monosymptomatic symptoms and habits often can be separated from
multisymptomatic and complex ones by this means.
When one determines that a complex pattern is being presented, the
next major task is to define the focal theme in terms of a dynamic interaction. The exact framework by which one formulates a dynamic focus,
however, though not irrelevant, is not specifically dictated by s.e.p. The
eclectic approach simply emphasizes the importance of explicitly defining
a theme or conflict, using whatever terminology one finds compatible with
one's own theory, and then using this theme to maintain treatment consistency. The theory from which this conflict is defined reflects one's beliefs
both about mental health and the life philosophy that is taught to the
patient in the course of therapy.
We find the empirically based methods of defining interpersonal
themes elucidated by dynamic theorists (e.g., Strupp, 198lb; Strupp &
Binder, 1984; Luborsky, 1984) to be helpful. The Core Conflictual Relationship Theme (CCRT) (Luborsky, McLellan, Woody, O'Brien, & Auerbach,
1985) encourages the therapist to make a global judgment about the
principal needs or wishes that guide the patient's interpersonal behavior.
Once defined, the most frequently observed motive or behaviorally expressed "want" is then considered along with other patient qualities such
as coping style, reactance against loss of autonomy, and expectations, to
complete a thematic formulation. This formulation then is used to alert the
therapist to important issues in the patient's life, as a model against which
to test patient responses in therapy, as the basis of interventions designed
to facilitate self-understanding, and as a framework from which the intermediate and immediate goals of specific interventions are selected.
Reactance Level
The concept of interpersonal reactance derives directly from persuasion
theory, models of interpersonal influence, and concepts of behavior change
(Brehm, 1976; Brehm & Brehm, 1981; Goldfried & Davison, 1976). Reactance is the tendency to respond oppositionally to external demands, and
the potential for such reaction is thought to represent a trait that varies in
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strength from person to person. This trait is related to an individual's
acquired sensitivity to perceived interpersonal threats to one's autonomy
and is indexed by one's ability to comply with externally imposed
demands.
Tolerance of external demands varies along a continuum, reflecting
the level of therapeutic directiveness that will be tolerated without rebellion. Those who are easily threatened by a perceived loss of autonomy
respond more positively both to low levels of therapeutic directiveness and
to the use of paradoxical interventions (e.g., prescribing the symptom or
symptom exaggeration) than those who have high tolerance for such
threats (Ollendick & Murphy, 1977; Shoham-Salomon, Avner, & Neeman,
1989). Mismatching the use of highly directive procedures with reactanceprone patients may result in worsening of one's symptoms (e.g., Forsyth
& Forsyth, 1982). Recently, we have used a combination of MMPI scales
reflecting defensive anxiety (Edwards Social Desirability Scale + Taylor
Manifest Anxiety Scale) to predict therapeutic response to directive and
nondirective procedures (Beutler, Engle, Mohr et al., 1991).
Coping Style
One's efforts to cope include an array of specific defense mechanisms (e.g.,
American Psychiatric Association, 1987; Hinshelwood, 1989; Laplanche &
Pontalis, 1973), and characteristic preferences come to be expressed in
patterns of interrelated defenses, called coping styles. Although there have
been numerous attempts to classify coping styles, four categories are
sufficient to capture treatment-related distinctions (Beutler & Clarkin,
1990).
An internalizing coping style is characterized by self-blame and selfdevaluation, accompanied by compartmentalization of affect and idealization of others. Jnternalizers attribute faults and mishaps to their lack of skills
or abilities, and then try to compensate by engaging in ritualistic behavior
with the intention of undoing the faulty behavior. Those with a low
reactance potential are prone to be intrapunitive and to constrict their
emotional responses to the point of impoverishment. On the other hand,
those with a high reactance level are prone to overcontrol impulses and
feelings, masking high levels of underlying anger and periodically expressing this anger through explosive outbursts. These outbursts may be followed by profuse apologies and guilt. These variations may parallel the
diagnostic groupings of avoidant and obsessive personality disorders.
Externalizers, in sharp contrast to internalizers, attribute responsibility for their lack of well-being and discomfort to external objects or to
others. Among those who have low reactance proneness, symptoms
rather than people may be blamed for the externalizers' problems, and
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one may expect those patients to express feelings of being unable to
control what happens to them. Specific defense mechanisms that might
be expected to characterize these low reactant, externalizing persons include diversion, distraction, displacement, and passive-aggressiveness. On
the other hand, externalizers with high reactance potential tend toward
more direct and person-centered blame and acting out, including overt
oppositionalism and extrapunitiveness. Diagnoses frequently associated
with high reactant externalizers include paranoid and antisocial personality, whereas narcissistic and passive-aggressive personalities often are associated with lower reactant levels.
We believe that two other patterns also have implications for treatment planning: repressive and cyclic coping styles. Repressive individuals
invest their resources in maintaining a generalized level of ignorance, a
process through which the harmful components of a situation are not
recognized, even at the expense of ignoring the situation altogether.
Repressive style persons who have high reactance potentials tend to
respond to threatening situations by relying on the defense mechanisms of
repression and reaction formation, whereas those with low reactance tendencies may be more reliant on denial and negation.
Cyclic coping styles are characterized by instability and mutability,
fluctuating between internalization to externalization or from passive to
active defenses. People with low reactant, cyclic coping styles present
rationalization as their common defense mechanism, and those whose
reactance levels are more dominant tend to become hypersensitized to
indications of threat. The first group tends to receive diagnoses such as
impulse and dysthymic disorders, as well as passive-aggressive personality.
The second group frequently presents diagnoses that include borderline,
cyclothymic, and sometimes unstable paranoid personalities.
The MMPI (Dahlstrom, Welsh, & Dahlstrom, 1972)—and we believe
the MMPI-2—is especially helpful in obtaining an estimate of the patient's
coping style. Moreover, when the MMPI-2 is combined with clinical
history a determination of reactance level is also possible. We have found
that the relative constellation of scores described by Welsh (1952) distinguishes among patients with externalizing and internalizing coping styles
(Beutler, Engle, Mohr et al, 1991).
INTERVENTIONS
The avenue to effective change in s.e.p. lies in the potential of employing procedures from any and all available schools on the basis of their
fit to the patient rather than on the basis of their fit with the theoretical
model of change that is unique to any single theory. In order to match
specific procedures with corresponding patient qualities, Beutler and
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Clarkin (1990) identified the functional goals and demand characteristics
around which different therapeutic procedures clustered. This analysis indicated that while they had many qualities in common, each school of
psychotherapy had developed identifiable and specific procedures that
seemed to fit its peculiar objectives. Beutler and Clarkin (1990) concluded
that specific procedures, from whatever school, varied in breadth of objectives, the level of experience addressed, the amount of therapist directiveness required, and preference for intratherapy versus extratherapy material.
For example, psychoanalytic therapy espouses broad-band (conflictual) goals, relies on evocative procedures (e.g., engaging transference
reactions), focuses on unconscious experiences (e.g., defenses), and addresses extratherapy material (e.g., early experiences). On the other hand,
experiential therapy, while also addressing conflictual goals, uses a preponderance of directive interventions, focuses on emotional and sensory experiences, and addresses intratherapy material; cognitive therapy addresses
more narrow-band (symptomatic) goals, while utilizing directive interventions, focusing dominantly on manifest cognitive experiences, and addressing extratherapy material; and behavior therapy has symptomatic goals,
uses directive interventions, focuses on behavioral experiences, and addresses extratherapy material. By assessing the functional use of procedures
that differ in these qualities, the procedures can be matched to the needs
of different patients
MATCHING
Beutler and Clarkin (1990) cross-matched therapy procedures with the
relevant patient qualities. They suggest the following guidelines for matching these treatment dimensions to the patient characteristics discussed in
the foregoing paragraphs:
1. Problem complexity directs us to differentiate between conflictual and
symptomatic treatment goals.
2. Problem severity helps us define some of the intermediate objectives of
our intervention and to plan on the order to which symptoms and
themes will be addressed.
3. Patient coping style specifies the level of functioning most affected, and
effective interventions are selected to correspond with this level. Four
subgroupings of procedures roughly correspond to the four-fold categorization of coping styles: (a) procedures that facilitate emotional
arousal and awareness with internalizing coping styles; (b) procedures
that facilitate uncovering and insight with repressive coping styles;
(c) procedures that facilitate cognitive self-control with cyclic coping
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styles; (d) procedures that facilitate behavioral change with externalizing coping styles.
4. Defining patient reactance proneness pinpoints the amount of therapist
directiveness that may be tolerated in implementing interventions.
Imagine, for example, that Jack is a patient whose ubiquitous symptoms of depression and anxiety are judged to arise from symbolized and
persistent fears of losing dependency attachments (i.e., complex problem
associated with dependency/attachment needs). Moreover, he has a history of avoiding or resisting interpersonal demands (i.e., high reactance
potential) by social withdrawal, emotional inhibition, overcontrolled expression of affect, and extensive self-criticism (i.e., he copes by internalizing). Under these circumstances, the therapist may elect to focus on interpersonal themes and conflicts because of the level of problem complexity
presented; to use emotional focusing and imagery exercises that enhance
emotional awareness on the basis of the internalizing coping style presented; to employ nondirective or evocative questions and reflections
because of the level of reactance expected; and to draw out these fears by
exploring feelings that arise in situations that are imbued with the threat
of loss and separation. The degree of Jack's impairment may be used to
determine how quickly one may begin focusing upon thematic patterns
rather than symptomatic behaviors to restore immediate functioning. Severity may also help us assess the level of motivational arousal present to
support the targeted changes and lead us to use either procedures for
increasing or reducing arousal levels.
Modifying Treatment Strategy as Patients
Change
Two separate factors underlie the need to modify the therapeutic procedures that are used at different points in therapy. First, many patients do
not maintain a consistent level of either reactance or coping style and may
vary on these dimensions when stressed. Hence, one must modify the
therapeutic procedure from moment to moment as the patient vacillates on
these dimensions. Second, with effective treatment, patients may be expected to move on all four major character dimensions. Patterning of
interventions across time is a function of matching the phases of problem
resolution to the mediating goals of treatment. Beitman (1992) has observed that psychotherapy ordinarily proceeds along four stages: relationship enhancement, pattern identification, change efforts, and termination
planning. These stages define the mediating goals of therapy toward which
the patient and therapist work.
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However, the mediating goals of treatment must also reflect the
patients' progress in solving their problems. Prochaska and DiClemente
(1992) have described four stages people ordinarily go through when
resolving difficult problems: precontemplation, contemplation, action, and
maintenance. The principal goals of the therapist in working with patients
who have achieved the precontemplative phase is relationship enhancement. If successful, the relationship propels them to the phase of contemplation and invokes the therapist's goals of assessing patterns of problematic behavior. In turn, as the patient moves to the action phase, the
therapeutic goal becomes facilitating intrapersonal and interpersonal
change, thus setting the stage for the patient to move to the phase of
maintenance. In this latter phase of problem resolution, the mediating goals
of therapy become planning for termination and relapse prevention. Moreover, as one moves toward the phase of maintenance, the value of group
and family interventions is thought to increase as a way of providing
needed social support.
Patient Assessment
Among most patients who are referred specifically for psychotherapy from
trusted professional sources, intake assessment dimensions overlap almost
completely with those used for selecting specific psychotherapy procedures. Based on this observation, we have considered the specific methods
for assessing relevant patient dimensions in the previous sections. However, if not determined in advance by the referral process, one must become
satisfied that the patient does not represent a current risk, is suitable for
psychotherapy, and that other aspects of treatment assignment (e.g., setting, modality, and patient-therapist match) are appropriate.
Three fundamental questions must be asked when a patient enters the
consultation relationship with a prospective therapist: "Why are you here?"
"Why are you here?" and "Why are you here now?" In the context of
answering questions about safety and suitability for psychotherapy, one
must explore relevant history. The latter can also be used to determine if
the patient's difficulty represents a habit pattern or a thematic problem.
In making an initial assessment of the patient's ability to respond to
psychotherapy, one must address history, previous treatment, and the
nature of the disturbance. In certain disorders, psychotherapy must be
supported through other forms of intervention (e.g., group therapy, psychoactive medication, hospitalization). There may even be conditions in
which psychotherapy is directly contramdicated. It is at this stage of the
decisional process that formal diagnoses may have a place. Assessment of
the patient's mental status, family history, medication history, and health
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status, as well as of the nature of the problem and the events that have
brought the patient to treatment are all critical Once suicide risk, bipolar
disorder, psychoses, organicity, and major medical problems have been
ruled out as primary problems, one can make a better decision about the
patient's potential for effecting a helpful psychotherapy relationship.
We prefer to have patients send or bring with them to the first
appointment pertinent medical records, including recent physical examination findings that may be relevant to their specific complaints. If patients
initially present with suicidal ideation, the first decisional alternative must
address the control of this behavior and the protection of the patient, rather
than the resolution of the distressing conflict. If a patient is sufficiently
intact and the intensity of the problem is such that he or she is willing to
make a nonsuicide contract, the potential for a helpful therapeutic relationship is more certain.
In a similar way, patients presenting with psychotic ideation, dementia, or major physical complaints must be considered for alternative forms
of treatment first. Frances et al. (1984) have described some of the indicators and contraindicators for such protective interventions and externally
controlled treatments.
Initial assessment is facilitated by the use of formal psychological
devices that can be integrated with background material and clinical impressions. The differentiation among organic versus functional, psychotic
versus nonpsychotic, or complex versus noncomplex disturbances may
entail either relatively little or a great deal of intensive psychological
investigation for ultimate clarification. Among most patients, however, the
initial decisions about working diagnosis and treatment appropriateness
can be made within the first one or two treatment sessions, especially if the
therapist has pertinent medical history at hand, and the patient is supplied
with self-administered psychological assessment devices at the time of the
first appointment. We find instruments such as the Shipley Institute of
Living Scale (Paulson & Lin, 1970), the SCL-90R (Derogatis et al., 1976),
the Locus of Control Scale (Rotter, 1966), and the MMPI-2 (Butcher,
Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) particularly useful in
defining various aspects of functioning that are significant in global treatment planning. History and direct observations both supplement these
decisions and define primary conflictual themes.
Treatment Applicability
The avowed purpose of eclectic psychotherapy is to affect a broad range
of patients by differentially altering the therapeutic procedure applied.
However, the value of psychotherapy itself is subject to some question for
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some populations. Psychotherapy seems least relevant for individuals with
active thought disorders, those with bipolar affective disorders, and those
whose psychiatric and psychological symptoms are the result of some
biological impairment.
Although the concepts of s.e.p. were originally applied primarily to
individual treatment, Beutler and Clarkin (1990) extended the concepts to
the selection of medical modalities and formats, settings of various levels
of restrictiveness, and to short- and long-term interventions. Indicators and
contraindicators for various forms of group and family therapy and for
short- and long-term therapy include (1) problem severity, (2) availability
of external support systems, (3) phase achieved in problem-solving efforts,
(4) coping style, and (5) reactance proneness (for treatment prescription, see
Feldman & Powell, 1992; Clarkin, Frances, & Perry, 1992).
One must ordinarily expect that psychotherapy will be relatively
short term, being limited either by external requirements or by the patient's
decision to terminate. While the therapist must work with this assumption,
recommendations for long-term treatment are often appropriate and are
made upon observing the degree of problem severity and complexity, and
the nature of the setting. The more focal the problem to be addressed, the
less severe its manifestation, and the more oriented the treatment setting
to brief therapy, the more appropriate it is to set predetermined time limits.
We find it useful to establish an initial contract for 20 sessions, with an
understanding that a new contract can be negotiated at the end of that time.
A few patients do not accept a contract of this length, and adjustments to as
few as five sessions are occasionally made. By the end of 10 sessions the
therapist should have an idea of how rapidly the patient is moving through
the phases of therapy, initially resolving symptoms and progressing on to
explorations of interpersonal, behavioral, cognitive, and affective environments. This awareness can help in the assessment of treatment goals and,
eventually, in the establishment of another contract, if the patient is willing.
Psychotherapy should not be considered as a process with a given
beginning and a final end. Patients are best prepared to face the world
when they understand their difficulties within the context of an ongoing
life struggle. This is true as much of symptomatic behaviors as it is of
complex patterns. The door to therapy is advisably left open, even though
planned vacations and terminations may occur. Termination may thus best
be seen as a phase of treatment, rather than the end of treatment.
Treatment Structure
The limitations placed on the duration, setting, frequency, or structure of
eclectic psychotherapy are those that are also placed on psychotherapy
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generally. The duration and structure of the intervention as well as the
setting depend largely on the contract of mutual expectation that is entered
into with the patient. The critical features, rather than setting, frequency,
or duration, are the patient's compliance, the therapist's flexibility, the
indications of common expectations, and a compatible patient-therapist
match. Beyond this, the therapist's ability to assess adequately the patient's
needs and to apply a suitable treatment menu that maintains the patient's
investment in the treatment process are limiting factors.
Research on the power of interpersonal influences that characterize
different learning environments (e.g., Corrigan, Dell, Lewis, & Schmidt,
1980) suggests that one does well to vary interpersonal distance, posture,
emotional expressions, self-disclosure, and even office decor as a function
of various patient characteristics. For example, highly reactive, externalizing patients respond poorly to therapists' self-disclosures of emotional
experience and even to therapists' expressions of liking (Tennen, Rohrbaugh, Press, & White, 1981; Kolb, Beutler, Davis, Crago, & Shanfield,
1985). As a result, such patients' treatment may require a formal and
nondisclosing verbal pattern by the therapist. Highly reactant patients tend
to respond best if their therapist is seen as distant, occasionally unsure, and
without a great deal of emotional or charismatic appeal. In contrast, patients with relatively low levels of reactance are tolerant of a broad range
of therapist behaviors and therapeutic interventions. They tend to respond
best to individuals who emphasize personal contact, who disclose positive
feelings, and who may even engage in supportive physical contact. A
forward-balanced posture and relatively informal attire and environment
might satisfy their need for relationships with benign, egalitarian, and
friendly authorities.
The therapist's assigned power, which is derived from the title, the
office, and the expectancy inherent in the term psychotherapist, carries a
great deal of weight if it is not severely discordant with the patient's desires
and expectancies (e.g., Corrigan et al, 1980). As treatment proceeds, however, the therapist's individual style emerges and begins exerting increasing influence on the treatment process and outcome (Martin, Moore, &
Sterne, 1977). To maximize therapeutic impact, therapists should be comfortable with a wide range of interpersonal relationship styles.
Persuasion theory argues that patients will more easily be persuaded
to adopt a new viewpoint or set of behaviors if the technical procedures
used in the persuasion effort are consistent both with preexisting expectations and needs for control, ascendance, and power. This match between
patient styles and technical interventions must be accomplished with great
care so that the strategies that are used enable patients to attain greater
attitudinal consonance without impeding their ability to adapt to a changing environment.
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Mechanisms of Change
S.e.p. is an integration of therapy procedures, not of personality theories.
Although one needs a superordinate theory of human functioning to direct
and guide one's interventions, the nature of this theory is directed by one's
personal preferences, not by any specific aspects of eclecticism. Theories of
interpersonal influence offer some understanding of the process of change
that is convenient and still compatible with the particular explanations that
characterize most theories that are constructed for psychotherapy. Within
this framework, a fundamental concept in understanding change is cognitive dissonance.
Therapeutic dissonance may occur when patients become aware that
their attitudinal system is discrepant from that of a valued therapist. When
confronted with this situation, they have a choice of either changing their
own attitudinal construct in order to become similar to that of the valued
other, devaluing the significant other, or exiting the system. The therapist's
task in this process is to maintain sufficient value and influence in the
patients' eyes so as to seriously question their own attitudinal systems
when such dissonances arise, rather than prematurely exiting the system or
disregarding the therapist's viewpoint. This process is analogous to "working through" a problem and relies on the therapist's ability to keep the
patient in cognitive contact with the conflict.
It is noteworthy that patients tend to use their therapists as attitudinal
models, not only for defining the internal constructs that will supplant old,
unworkable ones, but also for modeling the methods of resolution. That is,
values tend to change over the course of psychotherapy and to become
increasingly similar to those of the therapist (Arizmendi, Beutler, Shanfield,
Crago, & Hagaman, 1985; Beutler, Arizmendi, Crago, Shanfield, & Hagaman, 1983). A relationship that balances the ability to maintain interpersonal attachment with the ability to confront and model attitudes provides
the basis for a corrective emotional experience (Frank, 1973).
For most volunteer patients, termination is at the patient's initiation,
and our own preference is to gradually experiment with reducing the
frequency of sessions rather than engage in abrupt termination. This tends
to facilitate generalization and allows the patient to reenter treatment
without a sense of failure.
Case Example
Jorge, a 34-year-old male from a civil-war-ridden Central American country, requested help with his two older children's school performance and
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social skills. He had been married to Silvia, a compatriot woman his age,
for 12 years and they had four children; two girls, aged eight and six, and
two boys, aged ten and seven.
Jorge was born into a family of three brothers and two parents, and
lived in a large city. His youngest brother, aged 26, had been diagnosed
with schizophrenia five years before. Jorge left his country 14 years ago,
searching for a better economic situation in San Diego, where he met Silvia,
who had also recently immigrated to the United States.
Over the phone, Jorge mentioned being unemployed for the last six
months and "not feeling good about it." He complained about "health
problems" and "feeling in no condition to look for a job." He had seen a
number of physicians, who found "nothing wrong" with him. We scheduled an intake interview for Jorge and his family and requested that Jorge
bring in school records of his children (all four), the children's teachers'
names, his medical records, along with the names, addresses, and telephone
numbers of the physicians he had visited (the compliance or noncompliance
of patients to such a request gives important clinical information about
their reactance level as well as their motivational state).
When Jorge and his family came in for the intake interview, they
impressed us as a traditional, conservative family. They were all wellgroomed, looking ready for "Sunday mass." Jorge, although attentive,
appeared exhausted. The student records of the children did not reveal any
out-of-the-ordinary situation, and their teachers expressed satisfaction in
their comments. Jorge's medical records showed no pathological conditions. We excused the children and asked Jorge and Silvia to tell us in what
way we could be of help. Silvia complained about the economic hardships
that the family was facing. They were currently living on Silvia's income
as a part-time housecleaner, were behind in their rent payments, and were
facing imminent eviction by the landlord. Silvia expressed concern about
Jorge's health, about his "problems." We asked Jorge about his "problems"
and got the following description.
He enjoyed driving buses and trucks, and was at one time employed
in a parcel service company, but the job was too hard on his body. He
started to worry about his job performance and to question his ability to
support his family financially. In a couple of weeks he began to feel restless,
irritable, tense, dizzy, short of breath, and to have difficulties falling asleep,
symptoms that were still present at intake. He learned about openings in
a local bus company and decided to apply. After an intensive screening
process to become a bus driver, he made it to the final ten candidates. All
that was left was a month of training, and for that Jorge quit his other job.
Throughout the selection process Jorge's symptoms intensified. On the
first training day, Jorge went into the classroom, sat down, and within a
few minutes started to feel "uncomfortable," with most of his symptoms
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reactivated, and had what he named "un ataque" (an attack). He excused
himself from the meeting, went home, and since the feeling didn't subside,
went to the hospital. A thorough check-up revealed nothing abnormal, but
Jorge felt in no condition to go back to the training. He asked for consecutive medical leaves, but after a week of absence he was discharged from the
program.
After this incident, Jorge saw a number of physicians without receiving a diagnosis for his condition. He had attempted to regain employment
but had felt tired, depressed, and had feared that another "ataque" would
"take over." He expressed being desperate for a job, not wanting to be at
home all the time, feeling isolated, and worrying about his behavior with
his children. He said he was being harsher with the children, compulsively
checking their homework, although no physical abuse was involved. During the intake interview it was noted that the marital relationship was tense
and strained. Jorge and Silvia weren't making eye contact, sat apart, and did
not seem to pay much attention to each other. The therapist attempted to
explore these dynamics, but the couple expressed no interest.
Following are the therapist's initial impressions on the four salient
dimensions of the patient's conflict. With respect to problem severity,
Jorge's condition was judged to be moderately severe since his coping
mechanisms had been unsuccessful in keeping his anxiety level within
manageable limits for the past several months. His present symptoms were
interfering with his ability to secure a job and were affecting his family life
(potential eviction from a housing complex) and social network. Jorge had
abandoned contact with many of his friends and felt little desire to keep
in touch with his closest friends, saying, "Nobody wants to be friends with
a bum."
With respect to problem complexity, Jorge's maladaptive responses
were deemed as transient, reactive behaviors. They appeared to have a
direct relationship with situational and environmental stressors that allowed a linear generalization. A symptomatic therapeutic intervention that
addressed his presenting complaints (generalized anxiety, panic attack,
depressed mood) seemed warranted (for the systematic eclectic treatment
of a case presenting nonlinear symptomatology, see Beutler, 1986). These
procedures needed to be tailored to Jorge's needs, taking into account his
personal and interpersonal patterns of self-doubt, self-defeating statements,
and psychosomatization tendencies.
With respect to reactance level, Jorge seemed very compliant and
submissive to authority. Based on his personal history, psychological assessments, and the therapist's clinical impressions, Jorge's reactance level
was estimated low, facilitating the implementation of relatively directive
therapeutic procedures. It was anticipated that Jorge would follow the
therapist's suggestions and directions, but a delicate balance through accu-
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285
rate clinical judgment needed to be found between Jorge's anticipated high
levels of compliance and his depleted energies.
With respect to coping style, Jorge's predominant style could be
defined as internalizing. Such a pattern, accompanied by Jorge's low reactance, set the stage for his defense system: constriction of affect, intropunitive cognitions, withdrawing, and isolation. Jorge also presented externalizing coping characteristics that were expressed in passive-aggressive
interpersonal interactions with his wife, and overcontrol of their children.
The basic characteristics of understanding, caring, and respect in the
therapeutic relationship were assured by the therapist's previous training
and current supervision. Also, the therapist-patient cultural, ethnic, gender,
and age similarities were all demographic affinities that are associated with
moderately positive perceptions by the patient of the treatment relationship. Differences between therapist and patient on the dimensions of
personal autonomy and attachment were present, favoring the development of a successful working alliance. The therapist's etiological framework, based on a rational-cognitive understanding of the patient symptomatology, contrasted with Jorge's animistic and self-depreciating
perspective.
FORMULATION AND TREATMENT PLAN
Jorge's somatic complaints, minority status, and low income are all
factors associated with high dropout and premature termination. These
characteristics and Jorge's linear symptomatology made him a candidate
for time-limited therapy. The focus of the treatment could be narrow,
mainly aimed at symptom alleviation. Given his level of distress and type
of coping style, the procedures also needed to consist of those that reduced
arousal while increasing awareness of internal cues of stress. Many cognitive interventions reflect these interests.
We proposed the following plan to the family. First, we would work
with Jorge on his symptoms, and for that we needed to contact his
physicians to determine his current and past medical history. We would see
him once a week at the beginning and every other week as he progressed,
for a total of 20 sessions. Second, we would contact the children's teachers
to evaluate their school performance, and based on their impressions, we
would be making arrangements as needed. Third, we needed to enlist
Silvia's cooperation to create a resource network for the family, given their
critical economic situation. Because of their immigration status (temporary
residency), the family did not want to claim any "official aid." We offered
a number of private resources, and although reluctant at the beginning (an
expected culturally syntonic reaction), Silvia accepted them. She had already filed an application with the district housing office to receive a
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subsidy for which the family qualified. We committed ourselves to do our
best to speed up that process, which was successful within a month. We
contacted Jorge's physicians and learned that it was the last one, a psychiatrist, who had suggested to Jorge to see a psychotherapist after Jorge's
tests indicated no signs of physical abnormality.
The systematic eclectic treatment combined a cognitive/behavioral
model of symptom relief, social skills training, and family-social networking. The first few sessions were devoted to the development of rapport and
to the understanding of the precise nature of Jorge's symptoms and how
he interpreted them. From Jorge's description it could be concluded that he
had experienced generalized anxiety for at least two months prior to a
single panic attack. Subsequent to this, the anxiety symptoms continued
and a depressive mood secondary to his unemployment set in.
In the exploration of the panic attack, automatic thoughts and prodromic symptoms were explained as follows: While he was in the office of the
bus company on the first morning of the final training, he felt a reactivation
of his month-long anxiety symptoms including some perspiration on his
forehead and palms. His hands felt cold, and he didn't want to shake his
"sweaty and cold" hand with the trainer. A few moments later, he found
himself breathing shallowly, feeling dizzy and disoriented. All of a sudden
he felt a brief, sharp pain under his left rib, and said to himself, "My heart
is about to stop; I am about to have a heart attack." He stood up and left,
feeling very scared and confused. He went back home but later to a
hospital. The situations in which panic was likely to be feared were explored in therapy, and some commonalities among the situations allowed
the therapist to consider Jorge's problems in the realm of social anxiety.
This phenomenon was expressed by Jorge's perception and expectation of
disapprobation and critical regard by others and low self-esteem; he had
rigid ideas of appropriate social behavior, and reported having uncomfortable bodily sensations in social situations (Beck, Emery, & Greenberg,
1985).
In subsequent sessions, a process of reattribution was started, offering
Jorge a different interpretation of anxiety and the symptoms leading to the
panic attack. In spite of the medical reports, Jorge maintained that his
problem was a physical one that the physicians had not "been able to figure
out yet." The therapist persisted on the nonpathological nature of the
symptoms, addressing them one by one, and offering a reinterpretation, a
strategy in which Jorge was willing to engage. For example, the morning
of the panic attack was explored in detail. Jorge recalled thinking, "I don't
want to be late," and decided to run the last few blocks. Once he sat down,
he was agitated and out of breath. The sharp pain below his left rib was
interpreted as "gas," something that Jorge had complained about. Since his
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symptoms involved breathing anomalies, he was taught corrective breathing techniques.
The therapist proposed to Jorge role plays that would simulate job
interviews, which were used as in vitro exercises, gradually increasing
exposure. These activities allowed the production of "minipanic attacks"
within the context of treatment, which afforded the opportunity to teach
Jorge coping practices such as breathing into a brown bag. It was also at
this time that Jorge's social image, both as perceived by him and as he
thought he was being perceived by others, was addressed.
Jorge was taught distraction techniques, his favorite one being "talking with people," something he found extremely comforting, since he
enjoyed it as a regular activity but he had not done much of since he had
started feeling depressed. Jorge started to regain confidence as anxiety
seemed more under his control.
Jorge was instructed on different methods to cope with anxiety
(Beck, 1988; Beck et al, 1985) and a process of systematic exposure was
started. Jorge complied when the therapist asked him to go to a county
facility that offered vocational orientation and training, but came out
disappointed. As Jorge came in for his next appointment, he noticed an
advertisement in Spanish and pointed out that it was misspelled. The
therapist pulled out a copy of a Spanish newspaper and asked Jorge to
identify misspellings and grammatical errors, which Jorge did with noticeable ease and enjoyment. Jorge said that he had never thought highly
of those skills, although he enjoyed reading very much. We brainstormed
with him about job placements where his abilities could be put to use. By
this time, Jorge's systematic exposure process needed in vivo exposures,
so job interviews were assigned to him. He stated feeling eager and
ready.
Jorge was quite successful in his job interviews, finding a job with the
local Spanish newspaper. He was able to identify the prodromic symptoms
during the interviews, and managed to keep the anxiety at bay. Future
sessions were spread over a period of two months, one session every other
week. As treatment was ending, Jorge raised a number of different issues,
the first one having to do with painful memories that depicted his father
in a mental hospital, the place where his father eventually died. Jorge's
father seemed to have suffered a form of schizophrenia that presented
similar symptoms to those that Jorge's brother was experiencing. At this
point, Jorge remembered that while having the panic attack he had feared
going crazy "like my brother and my father." A second issue was related
to the relationship with his wife, whom he "had not kissed for at least 8
years." The therapist asked Jorge whether he would be interested in
working on the relationship, to which he replied, "Right now." After
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contacting Silvia, who stated her interest, arrangements were made with
them for marital therapy.
Research
Research in s.e.p. has been in two fundamental areas. The first area has
addressed the matching of patients and therapists; the second area has
emphasized matching of patients to therapeutic procedures. This second
area is only now achieving a level of sophistication that is sufficient to draw
conclusions.
Research on patient-therapist matching has emphasized the roles of
similarities and dissimilarities in belief and value systems. Two related
programs of investigation have been undertaken in this regard. The first
applies to similarities and dissimilarities between the belief systems of
patients and therapists. The second applies to the acceptability of belief
systems, a concept that is only indirectly associated with similarity. Both
of these lines of research rely in part on the demonstration that effective
psychotherapy is accompanied by attitudinal convergence between the
two participants. This latter point of view is supported by a large number
of research studies that have used a wide variety of personality, attitudinal,
and value concepts (cf. reviews by Beutler, 1981; Kelly, 1990; Tjelveit,
1986).
Our investigations have confirmed the observation that initial (pretreatment) patient-therapist dissimilarity on global attitudinal value dimensions is positively associated with the development of productive therapeutic processes (Beutler, 1971a; Beutler, 197 lb; Beutler, Jobe, & Elkins,
1974; Beutler et al, 1975; Beutler et al., 1983). Its relationship to therapy
outcome is more complex and difficult to assess. Attitudinal acceptability
must be considered along with the dimension of attitude similarity in order
to understand therapeutic improvement. In our investigations of this issue,
for example, we (Beutler, 1971a; Beutler et al., 1974; Beutler, 1979b)
determined that if the therapist's attitudes were acceptable to the patient,
the patient was more likely to adopt the therapist's belief systems about
sex, authority, and discipline. Not surprisingly, we have also discovered
that if the therapist's latitudes of acceptance are broad enough to encompass the preferred viewpoints of the patient, both therapeutic process and
outcome are facilitated even if the patient finds the therapist's preferred
viewpoint unacceptable.
A fewer number of studies have been devoted to the matching of
specific therapeutic technologies with patient dimensions, but research in
this area is growing in visibility (Shoham-Salomon, 1991). The derivation
of the treatment-matching dimensions was based on an intensive reanalysis
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of psychotherapy outcome studies (Beutler, 1979a; Beutler, 1983; Beutler
& Clarkin, 1990), and subsequent research has been directed at exploring
and expanding these relationships (Beutler & Mitchell, 1981; Beutler, 1989;
Beutler, Engle, Mohr et al., 1991; Beutler, Mohr et al., 1991; Calvert et al.,
1988).
Four foundation studies have provided support for the predictive
utility of patient coping style and resistance potential as predictors of
differential response to various qualities of psychotherapy procedures.
These studies have demonstrated significant patient characteristic by treatment interaction effects, one of which comprised a cross-validation on an
international sample. Two of these studies (Beutler & Mitchell, 1981;
Calvert et al., 1988) used naturalistic designs and heterogeneous outpatient
samples. These studies provided the foundation for a larger and more
tightly controlled randomized clinical trial on patients with major depressive disorder, to which most of our attention here will be devoted.
Two studies have provided by far the strongest foundation for the
current investigation, since they both provided criteria-controlled treatments, random assignment, refined measurements of coping style and
resistance potential, and demonstrated that both patient dimensions
yielded differential responses to different therapies.
The central study (Beutler, Engle, Mohr et al., 1991) employed three
manualized treatments designed to vary along two dimensions: insight
focused (focused-expressive psychotherapy, or FEP, and supportive, selfdirected procedures, or S/SD) to symptom focused (cognitive therapy, or
CT), and directive (FEP and CT) to nondirective (S/SD).
The three treatments revealed a very clear interaction effect between
coping style and outcome. Among patients assigned to cognitive therapy,
treatment outcomes (reduction of depression) were greater among patients
whose initial MMPI configurations consisted of high scores on indices of
sociopathic and impulsive qualities (externalization) as compared to those
whose scores indicated fewer of these latter qualities. Conversely, among
patients seen in the two insight-oriented treatments (FEP, S/SD), the reverse was true. While mean outcomes for this latter group were nearly
identical to those in CT, it was those whose MMPI indicators of externalizing patterns were relatively low who experienced the greatest amounts of
symptom reduction.
The results also indicated that patients who were initially assessed to
have high levels of anxious defensiveness (high reactance potential) did
better when assigned to the nondirective treatment (S/SD) than when
assigned to either of the other, directive treatments. Conversely, those
with low levels of initial defensiveness, as assessed at intake, performed
comparably well when assigned to either of the two treatments that
employed therapist directives (Beutler, Engle, Mohr et al., 1991).
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The pattern of results for both patient variables and both types of
treatment were subsequently cross-validated in the fourth study, using
several different measures of coping style and resistance potential. In this
study, a sample of anxious and depressed patients from the Bern (Switzerland) Psychotherapy Research Program (Beutler, Mohr et al., 1991) was
studied using a randomized clinical trial design. Coping style significantly
predicted the differential value of symptom-focused (behavior therapy) and
insight-focused (client-centered therapy) interventions. Likewise, resistance
potential was differentially predictive of the use of directive and nondirective procedures. The zero order correlations indicated differences both in
the magnitude and direction of the relationships between improvement and
patient characteristic in the two treatments.
Implications for Clinical Training
Eclectic psychotherapy maintains that therapists should be simultaneously
trained to competency levels in a variety of highly specific models.
Whether therapists can, in fact, become equally or even minimally proficient in such a broad range of procedures is uncertain. We are currently
exploring this issue, but it is too early to provide definitive results. The
eclectic model proposes, however, that at least some therapy procedures
should be learned from different categories of objectives (such as insight
enhancement, emotional awareness, emotional escalation, emotion reducing, behavioral control, perceptual change). Moreover, these procedures
should be learned in a way that allows their implementation through both
high and low therapist directiveness.
Training programs for eclectic psychotherapy would ideally be based
on competency criteria for procedures representing all of the six categories
of objectives. The alternative is to consider psychotherapists specialists and
to determine those skill areas in which they are able to achieve competence
or with which they are most comfortable. In this model, eclectic approaches
would encourage therapists to define and limit their practices to those
patient groups for whom their particular strategies and orientations will be
most productive. It is rather naive to assume that therapists will thereafter
only treat the patients for whom they and their skills are most fitted. It is
somewhat reassuring to observe, however, that there may be an automatic
selection process that directs patients to therapists by whom they are likely
to be most helped (cf. King & Blaney, 1977).
If nothing else is certain, literature to date suggests that training
programs that emphasize accreditation and credentialing on the basis of
time spent and classes taken, rather than competence, are outmoded. Even
highly trained and experienced therapists from such programs do not
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291
achieve the ability to define appropriate therapeutic foci or to adjust
treatment strategies appropriately (Strupp, 198lb). The importance of
competency-based programs is seen in recent observations that therapists'
ability to comply with the procedures they say they implement are
stronger contributors to treatment outcome than the procedures themselves (Shaw, 1983; Luborsky et al., 1985). Competency-based programs
with criteria levels of performance will be necessary in order to implement
any eclectic psychotherapeutic treatment.
To be an effective eclectic psychotherapist, one must be familiar with
a wide range of therapeutic procedures. One must have demonstrated
competence in implementing those procedures, and one must be trained to
observe and assess conflictual themes in a way that allows these themes to
be the focus of concentrated treatment. Additionally, and even more
important, the therapist should be able to facilitate and use relationshipenhancement procedures, which are generally characteristics of effective
therapists, independent of any particular therapeutic school. These tasks are
probably best accomplished in a training program that first and foremost
emphasizes the development of skills for establishing and maintaining
therapeutic relationships. Active listening skills, methods of exploring
interpersonal relationships, and a solid foundation in relationship-oriented
procedures should be established. Only subsequently should specific technologies be emphasized. A well-rounded eclectic psychotherapist will receive ample supervision in the development of behavioral methodologies,
cognitive change interventions, and the many techniques for exaggerating
or escalating affective states that are borrowed from Gestalt therapies. The
therapist will also receive supervised experience with interventions that
highlight interpersonal processes and psychoanalytically oriented procedures for enhancing and interpreting transference relationships. In each of
these areas the therapist should be exposed to the foundations of theory
as well as to a sampling of the technologies employed. Thereafter, and as
a final step in the training process, the therapist should concentrate on
exploring integrative models such as the one proposed here.
Although research experience and training may be important to the
training endeavor, it is probably not a necessary ingredient for becoming
an effective, integrative therapist. Nonetheless, a research orientation assists one to perceive relationships between therapeutic strategies and subsequent changes, and to be a thinking therapist. Research training may also
give one an appreciation for methods of questioning, measuring, and
assessing one's impact. Hence, such a research perspective should be acquired during training. A guiding model such as that proposed here is
useful in developing therapeutic menus for directing research and clinical
efforts.
Finally, in addition to the formal training requirements previously
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outlined, we consider it important to emphasize the significance of
a healthy lifestyle and personal development exercises as part of the
training of future therapists and the continuing education of experienced
practitioners.
Future Directions
The most pressing needs in s.e.p., as in psychotherapy generally, are (1) the
validation of therapeutic efficacy and (2) the delineation of the processes
that portend therapeutic changes. The past seven years has seen a substantial (not yet dramatic) increase in the number of empirical studies on
therapy-patient-therapist matching. Yet much needs to be done in extracting, from the hundreds of variables that have been touted by various
authors as matching dimensions, those that do serve as indicators and
contraindicators. Our own research has successfully moved from correlational demonstrations of the efficacy of various matching dimensions to
prospective studies. These studies are beginning to demonstrate the differential predictive power of three patient dimensions: motivational distress, coping style, and reactance. The evidence is strongest for the value
of coping style and reactance level (resistance) as differential indicators for
insight versus behaviorally oriented procedures, and directive versus nondirective procedures, respectively. But there are numerous other variables
in our model of treatment decision making whose hypothesized role in
treatment selection is still unknown. Work is needed to make operational
the concepts of problem complexity and severity, as well as to develop
measures for assessing reactance, coping style, and motivational distress.
S.e.p. suggests that the concepts of treatment matching should generalize across diagnostic groups, but no research is currently available to
support this contention. Hence, research is sorely needed to see how well
the relationships that have been observed between coping style and level
of focus, and between reactance level and directiveness translate from
major depression and general anxiety symptoms to other diagnostic
groups. At this point, it is still not certain whether all patients or disorders
can be efficaciously matched with specific therapy procedures. Systematic
research is needed in order to determine if the procedures presently available are sufficiently broad and flexible to encompass most patient patterns.
Work with the seriously mentally ill, alcohol and drug populations, and
anxiety disorders is needed to complement existing research findings. Our
current research, under sponsorship of the National Institute on Alcohol
Abuse and Alcoholism, is now testing the relationship between patient
coping style and behavioral versus insight-oriented procedures among
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293
alcoholics. This work concentrates on invoking family interventions as
well.
There is also the question of what to do to enhance outcome when
therapist and patient are incompatible and referral is not possible. Are there
behaviors and methods that will help the therapist to enhance the quality
of therapeutic contacts in those cases where patients and therapists cannot
be suitably matched?
Finally, a great deal of research is still needed on training effective
therapists. The questions of whether one can become equally or minimally
proficient in employing the variety of therapeutic strategies proposed as
necessary by the s.e.p. model is yet to be answered. Of equal concern to
the issue of training is the question of the degree to which proficiencybased training enhances therapeutic outcome. Chiefly, what are the
methods that will best teach therapists to apply definite therapeutic procedures in ways that include both common and specific variables that enhance
outcome?
Beyond these research questions, it is expected that the future will see
a continuation of interest among therapists in the clinical application of
eclectic methods. As research questions are addressed, the methods for
assisting clinicians directly in developing effective treatment plans are
likely to become available. Ultimately, if any eclectic approaches to psychotherapy prove to be more beneficial than the theories they attempt to
integrate, they must stand the empirical as well as the clinical test. The
concepts derived must be useful to the clinician, verifiable to the scientist,
and acceptable to a diversity of practitioners and theoreticians.
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(1985). Client-therapist value similarity and psychotherapy outcome: A
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CHAPTER 9
The Transtheoretical Approach
JAMES O. PROCHASKA AND CARLO C. DICLEMENTE
I
MPETUS FOR THE TRANSTHEORETICAL APPROACH came from
several different sources. First and foremost was a discontent with the
state of affairs in psychotherapy theory, research, and practice. The narrowness and frequent dogmatism of the proponents of many therapies,
the consistent research findings of a few, and the differences in outcome
among therapy systems encouraged a search for alternatives. Each therapy system focused more on theories of psychopathology and single
mechanisms of change than an exploration of the process of change.
Unconditional positive regard, authenticity, living in the here and now,
confrontation of beliefs, social interest, conditioning, and contingencies
are valuable rules for human functioning but are not sufficient to explain
therapy change.
In 1977 Prochaska, with the help of his students, embarked on a
journey through the various systems of therapy, seeking the commonalities
across the rigid boundaries of the most popular theories of psychotherapy.
Systems of Psychotherapy: A Transtheoretical Analysis (Prochaska, 1984)
represents the culmination of this journey. The map used for the journey
indicated that theories of psychotherapy can be summarized by 10 separate
processes of change. Although the framework used in this analysis appeared to have face validity, it remained a theoretical construct with no
empirical basis. Since that initial work, we and a number of collaborators
applied the model, expanded its scope, and explored its limitations in
studies of intentional change, surveys of practitioners and patients, and the
creation of assessment instruments. This research supported and expanded
our theorizing and encouraged us to continue the development of what we
The Transtheoretical Approach
301
have called The Transtheoretical Approach: Crossing the Traditional Boundaries
of Therapy (Prochaska & DiClemente, 1984).
A final impetus for our work was found in the general Zeitgeist among
practitioners and theorists of psychotherapy. We heard clearly the pleas of
the participants of a 1981 APA symposium (e.g., Marvin Goldfried and
Hans Strupp) who called for a more integrated and comprehensive approach to psychotherapy. What seemed to be needed was an approach that
would take into account the differences in the experiences of therapists and
clients (Sloane, Staples, Cristol, Yorkston, & Whipple, 1975). Moreover, in
our thinking, an integrative approach should be able to account for how
individuals change on their own (unaided by psychotherapy) as well as
how they change as the result of psychotherapy.
The Transtheoretical Approach
The proliferation of psychotherapy systems reflects the complex, interactive nature of psychotherapy. The daily dilemma facing the clinician is
what to do, when to do it, with whom, in what way, and with which
problem. Both in the research literature and in clinical experience, it has
become clear that no one system of therapy addresses adequately all these
questions.
From our perspective, an integrative perspective will accomplish the
following goals:
1. Preserve the valuable insights of major systems of psychotherapy.
Trying to reduce all therapy systems to their least common denominator removes the richness of the major therapy systems.
2. Provide some practical answers to the questions faced by clinicians.
However theoretically elegant it might be, an impractical, oversimplistic, or irrelevant integration would never be adopted.
3. Bring some order to the chaotic diversity in the field of psychotherapy.
However, if we act like children ordered to clean up their rooms,
throwing an assorted collection of techniques into the toy box may
offer some relief, but will only hide the chaos.
4. Offer a researchable alternative to single-system and comparative types
of research. Explanation without experimentation will not silence the
critics of both eclecticism and psychotherapy.
5. Generate a systematic approach, a structure or set of principles and
constructs that are comprehensive enough to include the critical dimensions of psychotherapy and, at the same time, that are adequately
flexible to promote collaboration, creativity, and choice.
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PROCESSES OF CHANGE
An analysis of the 24 most popular theories of psychotherapy (Prochaska, 1984) yielded the first of the three basic elements of the transtheoretical approach—the processes of change. Transtheoretical therapy
began with the assumption that integration across a diversity of therapy
systems most likely would occur at an intermediate level of analysis
between theory and technique, the level of processes of change. Coincidentally, Goldfried (1980, 1982) in his well-known call for a rapproachment,
independently suggested that the principles of change were the appropriate starting point at which rapprochement could begin.
The processes of change, then, may be best understood as a middle
level of abstraction between the basic theoretical assumptions of a system
of psychotherapy and the techniques proposed by the theory. A process
of change represents types of activity initiated or experienced by an
individual in modifying thinking, behavior, or affect related to a particular
problem. Although there are a large number of coping activities, there
appear to be a finite set of processes that represent the basic change
principles underlying coping activities. In a similar manner, techniques of
therapy can be analyzed to see which type of process they would draw
upon or promote. Thus, confrontation by the therapist would provide new
information, challenge current thinking about the problem, and offer feedback. All these therapist activities would enable the individual to engage
in more accurate information processing. From a transtheoretical perspective, these activities represent the process of change called consciousness
raising.
Subsequent modifications of our original formulation through research yielded 10 separate and distinct processes of change:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Consciousness raising
Self-liberation
Social liberation
Counterconditioning
Stimulus control
Self-reevaluation
Environmental reevaluation
Contingency management
Dramatic relief
Helping relationships
Our studies indicate that people in the natural environment generally use
these 10 different processes of change to modify problem behaviors. Most
major systems of therapy, however, theoretically employ only two or three
The Transtheoretical Approach
303
processes (Prochaska, 1984). One of the assumptions of the transtheoretical
approach is that therapists should be at least as cognitively complex as
their clients. They should be able to think in terms of a more comprehensive set of processes and be able to apply techniques to engage each
process when appropriate.
STAGES OF CHANGE
A second basic element of the transtheoretical approach is the stages
of change, which reflect the temporal and motivational aspects of change.
Intentional change is not an all-or-none phenomenon, but a gradual movement through specific stages (cf. Beitman, 1987; Egan, 1986). Lack of
awareness of this staging phenomenon has led some theories of therapy to
assume that all clients presenting for therapy are in the same stage of
change and are ready for the same change processes.
Studies of various outpatient populations (McConnaughy, Prochaska,
& Velicer, 1983; McConnaughy, DiClemente, Prochaska, & Velicer, 1989;
DiClemente & Hughes, 1990) have found a variety of profiles on the Stages
of Change Scale. Clearly, all individuals who come to therapy are not at
the same stage of change. We have been able to identify five basic stages
of change: precontemplation, contemplation, preparation, action, and
maintenance.
In our approach, a stage of change represents both a period of time
and a set of tasks needed for movement to the next stage. While the time
spent in each stage may vary, the tasks to be accomplished in order to
achieve successful movement to the next stage are assumed to be invariant.
In the move from precontemplation to contemplation, an individual must
become aware of the problem, make some admission or take ownership of
the problem, confront defenses and habit aspects of the problem that make
it difficult to control, and begin to see some of the negative aspects of the
problem in order to move to the next stage of seriously contemplating
change.
One of the most helpful findings to emerge from our research is that
particular processes of change are emphasized during particular stages of
change (Prochaska & DiClemente, 1983). The integration of stages and
processes of change can serve as an important guide for therapists. Once
a client's stage of change is clear, the therapist knows which processes to
apply in order to help the client progress to the next stage of change.
Rather than apply change processes in a haphazard or trial-and-error approach, integrative therapists can begin to use change processes much
more systematically.
Table 9.1 presents a diagram showing the integration that was revealed from our exploration of the stages and processes of change (Pro-
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TABLE 9.1
Processes of Change Emphasized at Particular Stages of Change
Precontemplation
Contemplation
Preparation
Action Maintenance
Consciousness
raising
Dramatic relief
Environmental
reevaluation
Self-reevaluation
Self-liberation
Contingency
management
Helping
relationship
Counterconditioning
Stimulus control
chaska & DiClemente, 1983; in press). During precontemplation, individuals use change processes significantly less than people in any other stage.
It was found that precontemplators process less information about their
problems; spend less time and energy reevaluating themselves, experience
fewer emotional reactions to the negative aspects of their problems, are less
open with significant others about their problems, and do little to shift their
attention or their environment in the direction of overcoming their problems. In therapy these are clients who are labeled resistant.
What can help assist people from precontemplation to contemplation?
Table 9.1 suggests several change processes that are most helpful. First,
consciousness-raising interventions, such as observations, confrontations,
and interpretations, can help clients become more aware of the causes,
consequences, and cures of their problems. To move to the contemplation
stage, clients have to become more aware of the negative consequences of
their behavior. Often we have to first help clients become more aware of
their-defenses before they can become more conscious of what they are
defending against. Second, the process of dramatic relief provides clients
with helpful affective experiences (e.g., psychodrama or the Gestalt intervention using the empty chair), which can raise emotions related to problem behaviors. Life events such as the disease or death of a friend or lover
can also move precontemplators emotionally, especially if such events are
problem related.
The Transtheoretical Approach
305
Clients in the contemplation stage are most open to consciousnessraising interventions such as observations, confrontations, and interpretations. Contemplators are much more likely to use bibliotherapy and other
educational interventions. As clients become increasingly more aware of
themselves and the nature of their problems, they are freer to reevaluate
themselves both affectively and cognitively. The self-reevaluation process
includes an assessment of which values clients will try to actualize, act
upon, and make real, and which they will let die. The more central problem
behaviors are to the core values, the more will their reevaluation involve
changes in their sense of self. Contemplators also reevaluate the effects
their behaviors have on their environments, especially the people they care
most about. Addicts, for example, may ask, "How do I think and feel about
living in a deteriorating environment that places me and my family at
increasing risk of disease, death, poverty, or imprisonment?" For some
addictive behaviors, like heroin addiction, the immediate effects on the
environment are much more real. For other addictions, like smoking, the
emphasis may need to be on longer-term effects.
Movement from precontemplation to contemplation, and movement
through the contemplation stage, involves increased use of cognitive,
affective, and evaluative processes of change. To better prepare individuals
for action, changes are required in how they think and feel about their
problem behaviors and how they value their problematic lifestyles.
Preparation indicates a readiness to change in the near future and
acquisition of valuable lessons from past change attempts and failures.
They are on the verge of taking action and need to set goals and priorities
accordingly. They often develop an action plan for how they are going to
proceed. In addition, they need to make firm commitments to follow
through on the action option they choose. In fact, they are often already
engaged in processes that would increase self-regulation and initiate behavior change (DiClemente et al., 1991). People typically begin by taking some
small steps toward action. They may use counterconditioning and stimulus-control processes to begin reducing their problem behaviors. Addicted
individuals, for instance, may delay their use of substances each day or may
control the number of situations in which they rely on the addictive
substances.
During the action stage it is important that clients act from a sense
of self-liberation. They need to believe that they have the autonomy to
change their lives in key ways. Yet they also need to accept that coercive
forces are as much a part of life as is autonomy. Self-liberation is based,
in part, on a sense of self-efficacy (Bandura, 1977, 1982), the belief that
one's own efforts play a critical role in succeeding in the face of difficult
situations.
Self-liberation, however, requires more than just an affective and
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cognitive foundation. Clients must also be effective enough with behavioral processes, such as countercondiHoning and stimulus control, to cope with
those external circumstances that can coerce them into relapsing. Therapists can provide training, if necessary, in behavioral processes to increase
the probability that clients will be successful when they do take action. As
action proceeds, therapists provide a helping relationship in which they serve
as consultants to the clients-as-self-changers, assisting them to identify any
errors they may be making in their attempts to change their behavior and
environment in healthier directions. Since action is a particularly stressful
stage of change that involves considerable opportunities for experiencing
coercion, guilt, failure, rejection, and the limits of personal freedom, clients
are also particularly in need of support and understanding. Knowing that
there is at least one person who cares and is committed to helping serves
to ease some of the distress and dread of taking life-changing risks.
Just as preparation for action is essential for success, so too is preparation for maintenance. Successful maintenance builds on each of the processes that has come before, and also involves an open assessment of the
conditions under which a person is likely to be coerced into relapsing.
Clients need to assess the alternatives they have for coping with such
coercive conditions without resorting to self-defeating defenses and pathological responses. Perhaps most important is the sense that one is becoming
more of the kind of person one wants to be. Continuing to apply counterconditioning and stimulus control is most effective when it is based on the
conviction that maintaining change maintains a sense of self that is highly
valued by oneself and at least one significant other (cf. Wolfe, 1992).
LEVELS OF CHANGE
At this point in our analysis, it appears that we are discussing only
how to approach a single, well-defined problem. However, as all of us
realize, reality is not so accommodating, and human behavior change is not
so simple a process. Although we can isolate certain symptoms and syndromes, these occur in the context of complex, interrelated levels of human
functioning. The third basic element of the transtheoretical approach addresses this issue. The levels of change represent a hierarchical organization
of five distinct but interrelated levels of psychological problems that can
be addressed in psychotherapy:
1.
2.
3.
4.
5.
Symptom/situational problems
Maladaptive cognitions
Current interpersonal conflicts
Family systems conflicts
Intrapersonal conflicts
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307
Historically, systems of psychotherapy have attributed psychological
problems primarily to one or two levels and focused their interventions on
these. Behavior therapists have focused on the symptom and situational
determinants; cognitive therapists on maladaptive cognitions; family therapists on the family systems level; and analytic therapists on intrapersonal
conflicts. It appears to us to be critical in the process of change that both
therapist and client agree as to which level they attribute the problem and
at which level or levels they are willing to engage in together as they work
to change the problem behavior.
In the transtheoretical approach, we prefer to intervene initially at the
symptom/situational level because change tends to occur more quickly as
this level and often represents the primary reason for which the individual
entered therapy. The further down the hierarchy we focus, the further
removed from awareness are the determinants of the problem, and the
more historically remote and more interrelated the problem is with the
sense of self. Thus, we predict that the "deeper" the level that needs to be
changed, the longer and more complex therapy is likely to be and the
greater the resistance of the client (Prochaska & DiCIemente, 1984).
These levels, it should be emphasized, are not completely isolated
from one another; change at any one level is likely to produce change at
other levels. Symptoms often involve intrapersonal conflicts, and maladaptive cognitions often reflect family systems beliefs or rules. In the transtheoretical approach, the complete therapist is prepared to intervene at any
of the five levels of change, though the preference is to begin at the highest
most contemporary level that clinical assessment and judgment can
justify.
INTEGRATING LEVELS, STAGES, AND PROCESSES
In summary, the transtheoretical approach sees therapeutic integration as the differential application of the processes of change at specific
stages of change, according to identified problem level. Integrating the
levels with the stages and processes of change provides a model for
intervening hierarchically and systematically across a broad range of therapeutic content. Table 9.2 presents an overview of the integration of levels,
stages, and processes of change.
Three basic strategies can be employed for intervening across multiple levels of change. The first is a shifting-levels strategy. Therapy would
typically focus first on the client's symptoms and the situations supporting
the symptoms. If the processes could be applied effectively at the first level,
and if the client could progress through each stage of change, therapy
could be completed without shifting to a more complex level of analysis.
If this approach were not effective, therapy would necessarily shift to other
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FABLE 9.2
Interaction of Levels, Stages, and Processes of Change
Stages
Levels
Precontemplation Contemplation Preparation Action Maintenance
Symptom/
situational
Consciousness
raising
Dramatic relief
Environmental
reevaluation
Self-reevaluation
Self-liberation
Contingency
management
Helping
relationship
Counterconditioning
Stimulus control
Maladaptive
cognitions
Interpersonal
conflicts
Family systems
conflicts
Intrapersonal
conflicts
levels in sequence in order to achieve the desired change. The strategy of
shifting from a higher level to a deeper one is illustrated in table 9.2 by the
arrows moving first across one level and then down to the next level. The
second option is the key-level strategy. If the available evidence points to
one key level of causality of a problem, and the client can be effectively
engaged at that level, the therapist would work almost exclusively at this
key level. The third alternative is the maximum-impact strategy. With many
complex cases, it is evident that multiple levels are involved as a cause, an
effect, or a maintainer of the client's problems. Interventions can be created
to affect clients at multiple levels of change in order to establish a maximum impact for change in a synergistic rather than a sequential manner.
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COMPLEMENTARITY OF THERAPY SYSTEMS
Theoretical complimentarity and integration are the keys to synthesizing the major systems of psychotherapy. Table 9.3 illustrates where
leading systems of therapy fit best within the integrative framework of the
transtheoretical approach. The therapy systems included in table 9.3 have
been the most prominent contributors to the transtheoretical approach.
Depending on which level and at which stage we are working, different
therapy systems will play a more or less prominent role. Behavior therapy,
for example, has developed specific interventions at the symptom/situational level for clients who are ready for action. At the maladaptive
cognition level, however, Ellis's rational-emotive therapy and Beck's cognitive therapy are most prominent for clients in the contemplation and action
stages.
By definition we have not excluded any therapy systems from the
transtheoretical approach. Our approach is an open framework that allows
for integration of new and innovative interventions, as well as the inclusion
of existing therapy systems that either research or clinical experience
suggest are most helpful for clients in particular stages at particular levels
of change.
A major therapy system that is not included in table 9.3 is Rogers's
(1951, 1959) client-centered therapy, a system that has been most prominent in articulating and demonstrating the importance of the therapeutic
TABLE 9.3
Integration of Major Tlierapy Systems Within
the Transtheoretical Framework
Stages
Levels
Precontemplation Contemplation Preparation
Symptom/
situational
Action Maintenance
Behavior therapy
Maladaptive
cognitions
Adlerian
therapy
Rational-emotive therapy
Cognitive therapy
Interpersonal
conflicts
Sullivanian
therapy
Couples communication
Transactional analysis
Family systems
conflicts
Strategic
therapy
Bowenian therapy
Intrapersonal
conflicts
Gestalt therapy
Psychoanalytic
Existential therapy
therapies
Structural therapy
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relationship as a critical process of change. Our own thinking and research
on the helping relationship as a major process of change has been most
influenced by client-centered therapy, even though we do not rely just on
client-centered techniques for developing a helping relationship. Thus,
Rogers's influence on the transtheoretical approach cuts across the levels
of change.
Patient Assessment
Accurate assessments of the client's stage, level, and processes of
change are critical to the transtheoretical approach. Therapy would be
most effective if patient and therapist were matched and working at the
same stage and level of change. The joining of the patient and the therapist is centered around the structure and process of intentional change.
The therapist's role is one of maximizing self-change efforts by facilitating neglected processes, deemphasizing overused processes, correcting
inappropriately applied processes, teaching new or unknown processes,
and redirecting change efforts to the appropriate stages and levels of
change.
Clinical assessment of the stages, levels, and processes requires some
modification of the traditional interview. Knowledge of both the attitude
toward a problem, as well as the actions taken with regard to it, is needed
for assessment of the stages of change. It is important to know that a man
stopped drinking one week ago, when his wife left him. Equally important,
however, is knowing whether this is the first step in taking significant
action toward intentional change of his problem drinking, or an attempt to
change his wife's behavior. Another method of assessing the current stage
of change is to evaluate both time and energy used in accomplishing the
tasks of any prior stage of change. If someone has contemplated changing
only casually for a couple of weeks, for example, then that person would
not be prepared to take action.
Assessment of the levels of change requires a clinical interview that
addresses each of the levels. In a case of vaginismus, we must know the
symptomatic expression and situational determinants of the sexual dysfunction, but we should also explore self-statements, the couple's interpersonal functioning, family-system involvement, and any possible intrapersonal conflicts regarding identity, self-esteem, and so on. In this assessment
it would be important to establish at which level or levels the patient
perceives the problem, as well as the levels that the clinician assesses are
integrally involved in the problem.
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311
Evaluating the processes of change being employed by the patient
can be an extensive task. Therapists should explore what the patient is
currently doing with regard to the problem, how often these activities are
occurring, and what has been done in the past in attempts to overcome the
problem. An obsessive patient may be relying heavily on consciousness
raising as the most important process, while neglecting self-liberation and
more action-oriented processes.
In our research, we have begun to develop assessment instruments to
aid in the evaluation of the stages, levels, and processes of change. The
University of Rhode Island Change Assessment Scale (URICA) is a 32-item
questionnaire with four subcomponents; profiles are based on scores on the
four subcomponents. Research on these profiles continues, with some of
the profiles needing more empirical interpretation. However, the existing
profiles can be used clinically to direct therapy interventions based on
patient scores on the precontemplation, contemplation, action, and maintenance subscales.
Several forms of a questionnaire to assess the processes of change
have also been developed. The questionnaires typically contain four to five
questions about activities that would represent each of the processes, and
clients are asked to indicate how frequently each activity occurs on a
5-point Likert Scale (1 = not at all; 5 = very frequently). Since changeprocess activity is somewhat different for diverse problems, we have
attempted to adapt this basic format to problems of alcoholism, overeating,
distress, and smoking; a more general form for psychotherapy has also
been developed. These questionnaires have shown remarkable consistency
across problem areas (Prochaska & DiClemente, 1986), and principal component analyses have yielded 10 or more consistent components in their
use with both clients and therapists. This type of questionnaire can be used
to assess change processes used before and during therapy to examine how
therapy interventions affect the use of the processes. Change-process activity has been found to relate to therapist theoretical orientation (Prochaska
& Norcross, 1983) and client activity in the various stages of change, and
to be predictive of successful movement through the stages of change.
Questionnaires have also been developed to assess the levels of
change. The questionnaires typically contain four questions representing
each of the five levels of change used in the transtheoretical model. In
addition, five other levels are assessed, since people do not attribute their
problems only to psychosocial sources. The other levels include bad luck,
spiritual determinism, biological determinants, insufficient effort, and preferred lifestyle. The levels have been developed for use with psychotherapy clients and with health-related behaviors like smoking (Norcross,
Prochaska, & Hambrecht, 1985).
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Treatment Applicability
We are attempting to develop a transtheoretical framework applicable to
all clinical problems of psychological origin. The levels of change represent
a means of categorizing patient problems, which is compatible with current
DSM-III-R diagnosis but is somewhat more comprehensive, since it includes systems and interpersonal problems. Thus, we envision the framework as appropriate for all types of psychopathology and health-related
problems. In addition, the framework can be used to categorize treatment
delivery systems according to the kind of clients and problems they
primarily address.
Since we often intervene first at the symptom/situational level, the
transtheoretical approach can be used in both a short-term and long-term
format. Length of therapy, setting, and modality are determined more by
the stage of change, level of problem involvement, and type of processes
employed rather than a predetermined set on the part of the therapist.
Thus, a family intervention that brings family members together to make
an effective confrontation of the patient can be used for a precontemplative
alcoholic. Individual and couples therapy can be used to work through
contemplation issues to achieve effective action when working with sexual
dysfunctions.
Duration and timing of therapy would also depend on the problem
levels and the stage of change. Individuals who have rather circumscribed
problems and are in the action stage often modify the problem in a
relatively brief period of time. Someone with multiple problems, who may
be at the precontemplation stage with several of them, would necessarily
require significantly longer treatment. In this context, several important
considerations should be kept in mind. Action and maintenance are separate and important stages of change. Discontinuation of therapy when the
client has taken action could do a disservice to the client, especially one
who is at high risk for relapse.
Since our approach concentrates on intentional change, contraindications for the use of the transtheoretical approach would indicate any
setting or problem where intentional change was not the primary goal. In
a correctional setting or in managing the self-destructive behavior of a
child, control, not intentional change, may be the primary goal. In this
context, being aware of the stages and levels of change may nonetheless
be desirable. However, external behavioral control appears to be the treatment of choice, using the processes of contingency control and stimulus
control. Once the immediate threat to self or others has been managed,
therapists can work to bring the problem behaviors under intentional
self-control rather than external control. In fact, this should be an important
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313
secondary goal if treatment or incarceration goals are to be maintained
after the person is released into the community.
In working with intentional change, the transtheoretical approach is
quite compatible with the traditional treatment structure of psychotherapy.
Weekly, hour-long sessions can be used to implement the treatment process. Since we envision psychotherapy as an adjunct to self-change, what
occurs between therapy sessions is as important as what happens within
therapy sessions. However, modifications of the traditional treatment
structure may be negotiated with a client, depending on the stage and level
being addressed. A longer, more intense therapy session that includes
significant others may be needed for an individual in precontemplation to
overcome defenses. Less frequent sessions may be more appropriate for
those in contemplation and maintenance. For the former, more time between sessions can allow clients time to use the processes of consciousness
raising and self-reevaluation in the service of decision making. For the
latter, time between sessions can be used to monitor temptation levels and
encounter any obstacles to continued action or maintenance, which occur
less frequently. Thus, in effect, therapy sessions become booster sessions.
Treatment Specificity
The goal of our clinical and research work on intentional change is to
identify the variables that are most effective in helping clients move
through the stages of change with regard to a particular problem. In this
context, treatment: selection is too generic a term. The more specific issue is
to identify which process would be most effective in helping to move a
person from one particular stage of change to the next with regard to a
certain level or levels of change. The decision to use a particular process
is multiply determined. Rather than stating a priori that counterconditioning is the treatment of choice for phobic problems, we prefer to analyze
first the stages and levels of change, then the processes currently being
used, before making prescription.
We realize that this approach places a sizable burden on the therapist.
However, in the case of psychotherapy, we believe that simplicity can be
a source of mediocrity and confusion. We have found, for example, that
insufficient use of consciousness raising in the contemplation stage forces
individuals to rely excessively on self-liberation or willpower in their
efforts to change, and opens the way to what Janis and Mann (1977) have
called "post-decisional regret." The overuse of self-reevaluation during
maintenance, on the other hand, is predictive of relapse (DiClemente &
Prochaska, 1985). Thus, matching patients with processes requires a general knowledge of the stages, processes, and levels of change and how they
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interact, as well as specific knowledge about individual clients and what
they have been doing to effect changes in their lives.
While matching is a complex process that has not yet been adequately
researched, mismatches (from our perspective) are more readily apparent.
A therapist committed to consciousness raising and exploration of all the
levels of change prior to taking action will frustrate a client ready to take
action at the symptomatic level. An action-oriented behavior therapist will
be constantly disappointed by precontemplative clients who fail to implement the suggested behavioral techniques. The family therapist, who insists that change take place at the family systems level with the whole
family present, may be unable to engage a system that has a critical
member who is in precontemplation.
Therapists must become aware of their preferences for particular
stages, processes, and levels of change. Certain therapists, by constitution
or training, do not have the temperament or skills to address adequately
certain stages, processes, or levels. Awareness of these limitations is essential in approaching the question of patient-therapist matching. If a
therapist does not have the patience to handle what may be experienced
as endless contemplation on the part of the client, it is unlikely that a
therapeutic relationship will be developed. Respecting a client's position
on the stages of change is an important first step in the joining of therapist and client.
Treatment matching should not simply focus on disorders, which
amounts to a continuation of the medical model. From our perspective,
the problem with using this model as the framework for psychotherapy
is that it is not applicable to intentional change. Even with physical problems that require some health-behavior modification, the medical model
has been problematic. Compliance, diet control, and exercise all require
intentional change and are extremely difficult problems for a medical
model that relies on processes of change, such as surgery, which are
invasive, externally applied procedures. Disorder is an important concept
for developing a taxonomy that enables us to bring together certain
symptoms and syndromes for classification. While this information is important in understanding a problem, knowledge of a disorder by itself
has limited value in prescribing therapy interventions (Beutler, 1983;
Beutler & Consoli, 1992).
Therapeutic Relationship
Although therapists have not struggled with all the particular problems
faced by different clients, all therapists have had some experience with the
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315
processes of change. This is the common experiential ground that forms
the basis of the relationship between therapist and client. In general, the
therapist is seen as the expert on change—not in having all the answers,
but in being aware of the critical dimensions of change and being able to
offer some assistance in this regard. Clients have potential resources as
self-changers, which must be used in order to effect a change. In fact, clients
need to shoulder much of the burden of change and look to the therapist
for consultation on how to conceptualize the problem and ways to free
themselves to move from one stage to another.
As with any interactive endeavor, rapport must be built to accomplish
the work. However, the type of relationship needed for the work of
psychotherapy can vary somewhat with the stage and level of change
being addressed. Thus, the consultant-client relationship needs to be modulated according to the client's particular issues. Initiation of therapy with
a precontemplation client, for example, takes on a different flavor. A client's
unwillingness to see or own a problem is not viewed as resisting the
therapist or being uncooperative, but rather as resisting change. Therapists
must become aware of how frightening and anxiety provoking the prospect of change can be. With this shift in perspective, the therapist can take
on the role of a concerned adviser who can help the client explore the
problem (DiClemente, 1991). The therapist becomes an ally rather than
another person attempting to coerce change.
For a person contemplating change, the therapist should take care not
to be too impatient. Contemplation can be a lengthy, frustrating stage of
change. While therapists should not support chronic contemplation, they
must also avoid blame, guilt, and premature change. In order to make a
decision to change a problem behavior, individuals must see that change
is possible and in their own best interests. The therapist can challenge
clients by making explicit the pros and cons of both the problem behavior
and the change. Support, understanding, and a relationship that would
enable the therapist to make explicit the fears and concerns of the client is
needed during this time.
During the action and maintenance stages, the therapist can assume
a more formal teaching relationship, since at these stages, the client is likely
to idealize the therapist. When initiating action, the client needs the support of a helping relationship and may need to rely on the confidence of
the therapist rather than a self-generated sense of efficacy. Initial efforts are
likely to be tentative, and seeing the therapist as the expert on change can
be comforting. However, as soon as is feasible, it is important to have the
client develop more self-confidence and independence from the therapist.
For therapists who need to be needed, this can pose a problem. Letting go
and allowing the client to take ownership of the change are the final stages
of the therapist-client relationship.
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Mechanisms of Change
As already noted, a central principal of the transtheoretical approach is that
different processes are most important in producing change at different
stages. The mechanisms that move someone from precontemplation to
contemplation are different from the processes that move someone from
preparation to action.
What moves people from precontemplation into the contemplation
stage of change? What facilitates or forces people to become aware that
previously acceptable patterns of behavior are now problematical or pathological? To respond to these questions, we have had to go beyond research
data and rely more on clinical experience and clinical theory (Prochaska &
DiClemente, 1984).
The important theoretical issue here is that intentional change, such
as occurs in therapy, is only one type of change that can move people.
Developmental and environmental changes are other events that can cause
people to alter their lives. The transtheoretical approach focuses primarily
on facilitating intentional change, but it recognizes and, at times, relies on
other types of change when working with clients. It is assumed, however,
that unless developmental or environmental changes produce intentional
change as well, clients can feel coerced by forces not of their choosing, and
will be likely to revert to previous patterns once the coercion is removed.
Therapists can help clients progress more freely into the contemplation stage of change if they can help their clients accept the developmental
or environmental forces that are pressuring them to change. Clients may,
for example, have difficulty identifying with the developmental process of
aging, even though it comes from within their skin. Whether entering a
new age becomes a life crisis or an opportunity for growth may be
determined by whether we experience aging as imposed on us or as part
of us. Most of us, for example, identify with aging when we become 21.
Our sense of self includes becoming more independent, mature, and adult.
Becoming 40 or 50, on the other hand, is more often experienced as an
imposition in a society that identifies with youth. As clients and therapists
begin to develop a shared identity that is the essence of a therapeutic
relationship, clients become much more open to influence from therapists,
much freer to respond to feedback and education about the alienated
aspects of their lives.
Once clients begin to move into the contemplation stage, their insight and understanding are critical for further progress. Whether the
insight is historical-genetic, interactive, cognitive, or situational depends
on the level of change that is needed. For clients working at the symptom/
situational level, a functional analysis of the immediate antecedents and
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317
consequences of troubled behavior may be all the understanding that is
needed. Clients attempting to change troubled relationships, however, will
need insight into the interactive nature of their problems. Clients who are
not free enough from their family of origin or who are plagued by internalized interpersonal conflicts are more likely to need insight into the
historical-genetic causes of their conflicts.
Moving from contemplation to action involves both consciousnessraising (e.g., confrontation) and self-reevaluation (e.g., value clarification)
processes. Helping clients to work through a decisional balance, for example, can clarify which course of action is most likely to reflect the kind of
person the client wants to become. Balancing the pros and cons of a
particular course of action also prepares clients to pay the price that comes
with any major change in life and moves them to develop the solid
commitment and plans needed in the preparation.
When it comes to action, skill acquisition and/or utilization are most
important for therapeutic progress. Applying such behavioral skills as
desensitization, assertion, communication, or negotiation are important
aspects of the action stage. Which skills are employed depends on the
clients level of change. Desensitization, for example, is used most often at
the symptom/situational level, whereas communication training is much
more important for the interpersonal level. Renegotiating dysfunctional
family rules can be particularly liberating at the family systems level. An
existentially based assertiveness can be one of the most liberating means
for expressing the enhanced sense of self that emerges when interpersonal
conflicts are being resolved.
Case Example
By its very nature, an integrative therapy cannot be illustrated by a single
case. Rather, it would take a long series of cases to reflect the full range of
stages, levels, and processes of change used with a diversity of clients. One
of the essential values of integration is that it encourages therapists to be
rich, diverse, and creative in their choice of interventions with each person.
Thus, if the reader were looking over the shoulder of a transtheoretical
therapist, the therapist's interventions would be seen to vary tremendously, depending on the needs of particular clients. Nevertheless, we will
try to illustrate some of the richness of our approach through the treatment
of a psychologically distressed client, partially within the context of marital
therapy.
Tom, a 50-year-old schoolteacher, was referred for marital therapy by
a colleague who had been working with Torn's wife, Barbara, in individual
therapy for about a year. Barbara's therapist did not believe that Tom
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would stay in treatment for more than three sessions, even though he was
quite distressed. Barbara's therapist actually thought her husband needed
individual therapy, but Tom agreed to go to therapy only if they went as
a couple.
Tom and Barbara were seen together in the first session to assess their
problems and their ability to work together at the interpersonal level.
Usually we begin by talking about the problems that bring people to
therapy, but the first problem at hand in this case was Tom's resistance to
therapy. Confronting the problem directly communicates to the client that
we are going to try to deal with problems in a straightforward and direct
manner. It communicates that the therapist cares about the client's resistance and that the client need not be defensive about it. It also communicates the therapist's hope that maybe there is something the client and/or
the therapist can do to make it easier for the client to be a more willing
participant. Many spouses have said that their partners would never come
to therapy, and if they did, they would not stay. But we have found that
almost all reluctant partners would come in for at least one session if the
therapist asked, and most would continue in therapy.
Tom said, "I don't believe therapy is worthwhile. My wife has been
going to therapy for a year, and she's still always lying and spending
money like it's going out of style."
"Sounds like you might be angry at her therapist," the therapist
responded.
"You're damn right! He just feeds into her wasting money," said Tom.
"Have you let him know you're angry?" the therapist asked.
"No, he doesn't want to talk to me," Tom said.
"Would you like me to let him know you're angry?" the therapist
asked.
"Yeah, I would appreciate that," said Tom.
So we're off and running. Tom's resistance to therapy is being addressed, if only at the situational level. But at least he does not have to be
defensive about his defensiveness. He may be able to experience the
therapist as someone who cares about his defensiveness and is trying to
understand it. He may, to his surprise, experience the therapist as being
helpful, both in dealing with his resistance and with his anger.
At the same time, the therapist has to be concerned with Barbara
experiencing the therapist as Tom's ally. The therapist could have addressed Tom's anger toward his wife for what he labels "lying and wasting
money." But this would have risked putting Barbara on the defensive, and
if she counterattacked, the couple could slip into the blame game that
involves partners quickly shifting from the offensive to the defensive
position.
"It must be hard to have your husband accusing you of lying and
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319
wasting money." I said this to Barbara, knowing I was still risking the
blame game but feeling that I wanted to empathize with her as well as with
Tom. I also wanted to communicate that I appreciated that there are two
sides to every marital conflict, and that her perspective was as important
as Tom's.
These opening segments of therapy indicate that treatment usually
begins immediately, with no formal assessment period, although assessment occurs right from the start. In the course of the first two therapy
sessions, the following information was shared: Tom's mood was usually
depressed; he couldn't relax; he was having trouble sleeping; he was
irritable and often verbally abusive; he felt lousy about himself; and he was
having trouble relating to his students, his colleagues, and the customers
who sought his services in his after-school job. Tom's distress increased
whenever he approached Barbara sexually and she refused, which happened at least once a day.
Barbara was really angry at Tom. She was angry about his constant
accusations about her lying, spending money behind his back, and having
affairs when she went out on Friday night with her women friends. He
would check the phone bill to see whom she had been calling; he would
open mail addressed to her to see what money she owed; and he would
sometimes follow her out with her friends to see if she was seeing other
men. How could she want to make love, when they were so embroiled in
a game of cops and robbers? Tom had coerced her into having sexual
intercourse a couple of times and she resented it.
Barbara also resented Tom's preoccupation with money. If he wasn't
preoccupied about her spending money, he was preoccupied with his
compulsive gambling. Tom denied that his gambling was a problem. If they
lost everything on his gambling, it would come to $1,000 a year, and
between the two of them, they were making over $80,000.
What is a therapist to believe? At worst, we have a compulsive
gambler and an obsessive and possessive lover married to a compulsive liar
and an impulsive spender. We may have classic character disorders who
have trouble managing their own lives let alone managing marriage effectively. Character disorders either do not stay in therapy or they stay
forever.
From the transtheoretical perspective, it appeared that Tom was in the
precontemplation stage in regard to most of his problems. The exception
was his gambling, which Tom had changed on his own to relatively
controlled gambling. Barbara, on the other hand, was prepared to take
action. She had been contemplating changes in her marriage for the past
year while in therapy. The problem was that the action she most likely was
going to take—although she did not say so directly—was divorce. Unfortunately, few couples present asking for divorce therapy. Most couples
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present asking for marital therapy. Assessing whether a couple is likely to
be a divorce case rather than a marital case can make a considerable
difference in therapeutic outcomes. Elsewhere, we present in detail the
subtle, and not so subtle, signs of impending divorce, which we use to
assess a couples case (Prochaska & DiClemente, 1984).
In the present case, among the obvious signs was the fact that Barbara
had been contemplating divorce for some time. More important, she had
told some of her family and friends that she was contemplating a divorce.
When people go public with their contemplations, they are moving much
closer to action. She had also lost her excess weight and engaged in some
other self-improvement activities. Making oneself more marketable is often
preparatory action for people heading for divorce. Furthermore, Barbara
had been in individual therapy for a year, with the theme being increased
independence and autonomy.
Tom, on the other hand, was psychologically distressed. He had not
been contemplating divorce, although he knew that Barbara was. On the
contrary, he was obsessed with trying to control Barbara's actions to
prevent losing her. Tom was resistant to change, as if he knew the ultimate
change in their marriage was going to be divorce. He was also distressed
by the prospect of having the drastic change of divorce imposed upon him.
The imposition of change is one of the most common causes of psychological distress.
Psychological distress caused by imposed change is likely to lead to
people resisting change (cf. Beutler & Consoli, 1992). Change can be
experienced as a threat, not an opportunity, and they defend against any
awareness of needs to change as they dig more deeply into the precontemplation stage. Moreover, they have trouble contemplating change as they
become cognitively impaired by distress (Mellinger et al, 1983), trouble
making decisions, and trouble taking action, even action that could lead to
self-enhancement.
What do we do when we have spouses in two different stages of
change, which is common in marital therapy? What do we do when we
have spouses in two different stages of divorce, which is even more
common in divorce therapy? The most common pattern is to have one
spouse in precontemplation and one who is ready for action, like Tom and
Barbara. When we are treating psychological distress precipitated by an
impending and imposed divorce, we need to slow down the spouse who
is ready for action and speed up the spouse who is resisting change.
Barbara was willing to spend some time trying to resolve some of their
interpersonal problems. The therapist made it clear that they were going
to work at the interpersonal level to improve their relationship whether
they stayed together or got divorced. Either way, they were going to have
a long-term relationship, in part because they shared two lovely daughters.
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321
The couple needed to become more conscious of the interactive
nature of their conflicts. Tom and Barbara agreed that their struggles over
control produced the most conflict. The therapist presented feedback based
on the therapist's assessment of what was going on at the interpersonal
level. Tom's actions appeared to be based on his intention to keep the
marriage going, and his actions were based on values of closeness and
togetherness. Barbara, on the other hand, had developed an increased need
for independence; her actions were based on values of individualness and
separateness. The problem was that the more Tom tried to control their
being together, the more Barbara felt a need to be apart. Barbara agreed.
Conversely, the more Barbara pulled apart, the more Tom felt the need to
control her to keep them together. Tom agreed. The needs and values that
Tom was expressing set off opposite needs and values in Barbara. The
blame game is based on our preference for linear causality—she acts and
I react. Circular causality, on the other hand, can help couples appreciate
that they both act and react—that their behavior is both a cause and an
effect of their ongoing relationship (cf. Wachtel & McKinney, 1992).
Tom and Barbara were becoming more conscious of what they personally contributed to their control struggles. They were going beyond
the blame game. They were also able to reevaluate their partner's behavior to some extent. Togetherness is somewhat more positive than dependence. Separateness is something different from selfishness. With the help
of the therapist's minilectures based on his experience with family life
education (Prochaska & Prochaska, 1982), Tom and Barbara became
aware that a more mature relationship includes both togetherness and
separateness. They were taught that individuals mature in their relationships from dependence to independence to interdependence, with interdependence being the caring and sharing of two independent individuals
with separate identities.
The problem was that Tom was entirely in charge of togetherness and
Barbara was standing just for separateness. They were, however, willing to
risk acting differently. The therapist recommended that Tom be in charge
of separate activities and Barbara be in control of shared activities. Tom
was going to liberate himself from a vicious circle by acting more like
Barbara, and vice versa. The longer they could continue such reversal of
roles, the more they would condition themselves to respond with new
alternatives.
This action worked for a while. Tom took charge of recording on the
calendar Barbara's nights out with her friends and his golfing dates. Barbara
recorded their dates together on the calendar and was in charge of initiating shared activities. They were communicating better and feeling better.
Tom's chief complaint was that Barbara was not initiating any sex.
Because they were doing better, the therapist recommended that
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gradual involvement in sexual relating could help them overcome anxieties
they may have about sexual performance. They had been avoiding sex for
quite a while, and the first steps of sensate focusing (Masters & Johnson,
1970) might give Barbara, in particular, a chance to deal with her feelings
about gradually getting close again. They agreed with the idea and agreed
that they would start with light massage.
Tom came alone to the next session. "Barbara is not coming back
again. She said she knows she just wants out of the relationship." The
therapist probably had made a mistake in too quickly encouraging the
couple to move to action in their sexual relationship. After the session, the
therapist called Barbara and expressed his concern that he might have made
a mistake and inquired if she would be willing to come in to talk about how
she was feeling.
Barbara actually came in for a couple of sessions. She said that the
only thing the therapist's recommendation had done was force her to
realize that she just didn't want to be close to Tom anymore. The fact that
their relationship had improved somewhat made her even more aware that
she just didn't feel the same about Tom. She was still concerned that Tom
would not be able to handle a divorce, but she wanted out.
Tom was distressed but not devastated. Fortunately, therapy had
become a place where he could be open about his feelings. He wasn't all
alone as he had feared. He allowed himself to relive the memories of losing
his first love. He had felt more rejected then than he felt now. He had so
many regrets about not having tried harder in that relationship. But this
time he had been trying. Back then, he withdrew from everyone. He stayed
in his room, unable to eat or work. His parents were concerned, but they
left him alone.
No wonder he avoided contemplating divorce. He never, ever
wanted to go through such emotional hell again. He did not think he would
make it—that he could handle another rejection—but he realized he did
not have to go through it alone this time. Not only was therapy available,
but he had other helping relationships. Now, Tom could talk more openly
and rely more on the social supports in his natural environment.
The therapist encouraged Tom to explore fully why that rejection as
a young man had been so distressing. Eventually, he focused on the
rejection he had experienced from his parents. When Tom was about 7 or
8, his parents had lost their business and did not have the financial resources to take care of him. Tom had gone to live with an aunt and uncle
who had no children. They weren't particularly loving, but they did give
him a lot of money. After a couple of years, Tom's parents were on their
feet again and were able to have him back. Tom recalled not wanting to
go back, and not wanting to give up all that money. He had forgotten how
rejected he had felt as a child. The therapist suggested that perhaps he had
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substituted all that money for the love he had lost. Yes, maybe that was
why money had come to mean so much to him. Gambling was fun but he
also felt more lovable when he won. And when he lost? Well, maybe he
was getting used to losing love.
After that early separation, Tom had closed off his relationship with
his parents, or maybe it had always been too closed. The therapist took a
lead from Bowen (1978) and encouraged Tom to act on his emerging
feelings. He encouraged Tom to talk to each of his parents individually
about how they had experienced that time in their lives.
Tom's mother was especially pleased with the opportunity to talk.
She had never told Tom how much it had hurt her to give him up and how
much it hurt when he didn't want to return home. She felt that he was
always angry at her after that. Tom began to realize that his hurt and his
anger had caused him to close off close contact with others. But now Tom
was risking new ways of relating—with his parents, his daughters, and his
friends. He was communicating more spontaneously and openly, and felt
more sensitive to the needs of others. He was asserting himself more at
work without having to get angry.
Tom was making many self-changes after a total of 22 therapy
sessions, but was puzzled by his reluctance to take action and move out and
get a place of his own. He told himself that it was because he wanted to
be close to his daughters, but he knew he was really afraid that Barbara
might turn them against him. He also realized that he was still concerned
about money and didn't want to spend the money on an apartment if he
could help it. Furthermore, staying in the house was a safe way of expressing his resentment at Barbara for rejecting him. At a deeper level, Tom
became aware that leaving his home stirred up painful feelings about when
he had had to leave his family's home. And at an intrapersonal level, Tom
became aware that he really did have some unresolved dependency problems. He had, for example, never lived alone.
The therapist helped Tom to appreciate that moving out and living
on his own was a maximum impact action that could facilitate further
progress at each level of his life. At a situational level, Tom would be
moving into an entirely new environment that would reflect the new era
of his life, free from all the reminders that elicited so many painful thoughts
and feelings. At a cognitive level, Tom would be challenging his "awfulizing" tendencies that added to his distress, such as his belief that it was awful
that he was the one to have to move when he didn't want the divorce in
the first place (cf. Ellis, 1973).
At the interpersonal level, Tom could further let go of his desire to
remain in control of his relationship with Barbara. As long as Barbara
wanted him out and he refused to leave, Tom felt in control. But he could
let go of this need to control and accept that Barbara was getting the house.
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At the family level, Tom was very tempted to move back with his parents.
Moving on his own, however, would enable him to further separate from
his parents without rejection or resentment. And at the intrapersonal level,
Tom could experience himself as becoming more fully adult. He would be
moving beyond dependence to independence and would be better preparing himself for an interdependent relationship.
After a couple of months of encouragement in therapy and additional
harassment at home, Tom was ready to leave his nest. This was a major move
in his life. It evoked a variety of countertransference feelings in his therapist,
who felt like a parent watching his 50-year-old son going off to college.
Would he be distressed by loneliness and homesickness, or would he spread
his wings and fly, enjoying his new-found freedom. Needless to say, Tom
soared. He felt more fully connected to life than he had ever known. For the
first time in his life he began to appreciate activities like concerts and plays.
He asserted himself and found women responding rather than rejecting.
Certainly he felt lonely at times, but never alone. He even felt a spiritual
awakening, for which his atheist therapist takes no credit whatsoever.
Therapy was already terminating when Tom met a special woman.
Ironically, she too had just come out into the world in the past few years.
She had hidden in a nunnery while Tom had hidden within himself and his
home. She had had several years of therapy, struggling with intrapersonal
issues both before and after leaving the nunnery; Tom was terminating
after nine months of therapy.
Tom had made a remarkable transformation from a distressed and
defensive man preoccupied with a small portion of his existence to a
growth-oriented person able to function more freely and fully at each level
of life. What process or processes account for such rewarding changes?
First, Tom had been facing turning 50, and he probably had the benefit of
developmental changes urging him on to a new stage of life. He also faced
dramatic but distressing environmental changes being imposed upon him.
Therapy had helped Tom shift from a resentful and resistant position in the
precontemplation stage to becoming more conscious of and committed to
the self-liberating qualities of intentional change. Tom, the gambler, would
also attribute some of his good fortune to lady luck. The last time the
therapist talked to Tom, not only was he doing well with his woman friend,
his family, his daughters, his friends, and himself, he also had just won $750
in the lottery two weeks in a row. Tom was on a roll!
Research on the Approach
Considerable care has been taken to operationalize and validate each of
the core constructs of the transtheoretical approach. The stages of
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325
change, for example, have been identified and validated with a questionnaire applied to a range of patients entering psychotherapy (McConnaughy et al, 1983, 1989; Medeiros & Prochaska, 1991), alcoholics entering treatment (DiClemente & Hughes, 1990), and obese patients entering
behavior therapy (Prochaska, Norcross, Fowler, Follick, & Abrams, in
press). Brief algorithms have been used to validate stages of change for a
broad range of problems (see Prochaska & DiClemente, in press). The
processes of change also have been replicated and validated across a
broad range of problems. These include smoking (DiClemente & Prochaska, 1982; Prochaska & DiClemente, 1983; Prochaska, Velicer, DiClimente, & Fava, 1988), psychological distress (Norcross & Prochaska,
1986; Prochaska & DiClemente, 1985; Prochaska et al., in press), weight
control (Prochaska & DiClemente, 1985; Prochaska et al., in press), alcoholism (Snow, 1990), cocaine abuse (Rosenbloom, 1990), heroin abuse
(Tejero, Trujols, & Hernandez, 1991), exercise acquisition (Marcus, Rossi,
Selby, & Niaura, in press), and a mixture of mental health disorders
(Medieros & Prochaska, 1991). The levels of change have received less
empirical attention but have been replicated and validated with such
problems as alcohol abuse (Begin, 1988), cocaine abuse (Rosenbloom,
1991), smoking (Norcross, Prochaska, Guadagnoli, & DiClemente, 1984),
and a mixture of DSM-III-R disorders (Penny, 1987; Medeiros & Prochaska, 1991). The systematic relationship between the stages and processes of change have been well supported in cross-sectional studies
(Prochaska & DiClemente, 1983; DiClemente et al., 1991; Marcus et al.,
in press).
In a longitudinal analysis of subjects who progressed, regressed, and
remained the same over a six-month period, discriminant functions predicted movement for the groups representing the precontemplation, contemplation, action, and relapse stages. Predictors included the ten processes, two decision-making variables and measures of self-efficacy and
temptation, all variables that are open to change (Prochaska, DiClemente,
Velicer, Ginpil, & Norcross, 1985). When more static variables such as age,
education, smoking history, withdrawal symptoms, reasons for smoking,
and health problems were used as predictors, the results were much less
significant (Wilcox, Prochaska, Velicer, & DiClemente, 1985). The point is
that dynamic measures are much better predictors of change than are the
more commonly used static measures, like client characteristics.
At least five longitudinal studies have found that the amount of
progress individuals make following intervention is directly related to the
stage they are in prior to intervention. Over an 18-month follow-up,
smokers who were in the precontemplation stage initially were least likely
to progress to the action or maintenance stages following intervention.
Those in the contemplation stage were more likely to make such progress,
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and those in the preparation stage made the most progress (DiClemente et
al., 1991; Prochaska & DiClemente, in press). In an intervention study with
smokers with heart disease, Ockene and her colleagues (in press) found that
22 percent of the smokers who were in the precontemplation stage prior
to treatment were not smoking at a six-month follow-up. Of those who
were in the contemplation stage, 44 percent were not smoking at six
months, and approximately 80 percent of those in preparation or in action
were not smoking at six months. With a household sample of MexicanAmericans in small towns in Texas who smoked, Gottlieb, Galavotti,
McCuan, & McAlister (1990) replicated most of the cross-sectional relationships between stages and processes and other dynamic variables such
as decisional balance and self-efficacy. Furthermore, over a 12-to-18-month
follow-up, they found that smokers who were originally in the contemplation stage progressed to the action and/or maintenance stages four times
as frequently as smokers who were originally in the precontemplation
stage. The amount of progress head injury adults made in rehabilitation
was directly related to their stage of change prior to treatment (Lam,
McMahon, Priddy, & Gehred-Schultz, 1988).
Dropout is a major problem for psychotherapy patients in general,
and for addictive patients in particular. In some studies for addictive
problems, as many as 80 percent of participants drop out (Abrams et al.,
1988). In a study of therapy dropouts using variables such as SES, age, and
gender, we were unable to predict the 40 percent of patients who terminated prematurely. Using stage-related variables such as the stages-ofchange questionnaire, however, we were able to predict these drop-outs
with 93 percent accuracy (Medeiros & Prochaska, 1991). In a cognitivebehavior therapy intervention for weight control, the stages and processes
of clients early in therapy were the best predictors of both premature
termination and progress at follow-up (Prochaska et al., in press).
The only comparative outcome research to date on the transtheoretical approach involves efforts to facilitate change with smokers. A transtheoretical (TTT) action manual was tested in pilot studies with smokers,
many of whom had not been able to quit on their own during the past two
years. These pilot studies included a comparison of the TTT materials with
the sophisticated American Lung Association (ALA) action manual, which
have been accepted as the "gold-standard" manuals for smoking cessation
(Glasgow & Rosen, 1978) under both self-administered (manual) and fourweek therapist-administered (clinic) conditions.
Results of these pilot studies were encouraging. In the clinic, at the
four-week posttest, the percentage of subjects who had taken action in the
TTT clinic groups was much higher than in the ALA clinic groups (58
percent vs. 23 percent). At the six-month follow-up for these subjects, 17
percent of the TTT clinic subjects (n = 4) reported they were not smoking,
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327
compared to only 3 percent (n = 1) of the ALA subjects. Similar six-month
results were found in a second site. Five of 12 subjects (42 percent) in the
TTT clinic group were not smoking at six months, compared to one of 16
subjects (6 percent) for the ALA group. In the self-administered manual
studies, 42 subjects received the TTT manual and 42 subjects the ALA
manual. At the four-week follow-up, only three TTT subjects and two ALA
subjects reported quitting in the past month. However, the delayed quitting effect was striking. At the six-month follow-up, 38 percent of the TTT
manual subjects reported taking action in the past month, compared to
only 17 percent of the ALA manual subjects.
In a recent study we randomly assigned 770 smokers in Rhode Island
by stage to one of four treatment conditions: standardized, individualized,
interactive, and personalized (Prochaska, DiClemente, Velicer, & Rossi,
1992). The standardized treatment involved the best self-help program
currently available, namely, the American Lung Association's action and
maintenance manuals. The individualized self-help manuals were individualized to the stage of change of each participant. The interactive (ITT)
condition involved computer-generated progress reports that included
feedback about the participant's stage of change, decisional balance measures regarding the pros and cons of quitting smoking (Velicer, DiClemente, Prochaska, & Brandenburg, 1985); up to six processes of change
that were being underutilized, overutilized, or utilized appropriately (Prochaska et al, 1988); temptations and self-efficacy across the most important
smoking situations (Velicer, DiClemente, Rossi, & Prochaska, 1990); and
techniques for coping with specific situations. The personalized (PITT)
condition included the stage-based manuals, computer reports, and four
counselor calls. The calls were proactive, initiated by the counselors rather
than reacting to calls from the participants. Except for one call, counselors
had the computer reports to help counsel clients about changes they were
making on key process variables.
The results were revealing. The two manual conditions basically
replicated each other through the 12-month follow-up. At the 18-month
follow-up, however, the individualized transtheoretical (TTT) manuals
(18.5 percent abstained) appeared to be performing better than the standardized (ALA + ) manuals (11 percent). The interactive (ITT) computer
reports outperformed both manual conditions at each of the four followups. The computer reports produced more than twice as much quitting at
each follow-up than did the gold standard ALA manuals (e.g., 25.2 percent
vs. 11 percent at 18 months). The personalized counselor-call condition
nearly doubled the quit rates of the two manual conditions up to the
12-month follow-up. By the 18-month follow-up, effects from the PITT
condition appeared to have plateaued (18 percent for PITT). At 18 months,
the PITT condition only outperformed the ALA+ manuals, while the
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transtheoretical manual condition seemed to have caught up with the
counselor-call condition.
These results suggest that interactive computer feedback on stagerelated variables has the potential to outperform the best self-help program
currently available. These results also suggest that the field may now have
self-help programs that are appropriate and effective for the vast majority
of smokers who are not prepared to take action. Providing smokers interactive feedback about their stages of change, decisional balance, processes of
change, self-efficacy, and temptation levels in critical smoking situations
can produce greater success than just providing the best self-help manuals
currently available.
Preliminary data from 4,200 smokers indicate that only about 17
percent of smokers are in the preparation stage. This highlights the importance of offering interventions for all smokers, not just those ready to take
action. Unfortunately, in the health psychology area, the vast majority of
interventions are action oriented.
If only a minority of individuals are ready to take action, it helps to
account for why participation rates are so low for behavior problems related
to health and mental health. In the health area, less than 10 percent of people
with risk behaviors participate in professionally developed programs. In the
mental health area, only about 25 percent of people with DSMTII-R
disorders seek psychotherapy. In the smoking cessation area, for example,
only 1 to 5 percent of eligible smokers typically participate in home-based or
self-help programs (Schmid, Jeffrey, & Hellerstedt, 1989). In our randomdigit dialing study using stage-matched interventions and proactive recruitment, we have been able to produce 75 to 80 percent participation rates.
Research to date has been highly supportive of the core constructs of
the transtheoretical approach and the hypothesized integration of constructs such as stages and processes. Longitudinal studies have supported
the relevance of these constructs for predicting premature termination and
short-term and long-term outcomes. Comparative outcome studies support
the potential of stage-matched interventions to outperform the best alternative treatments available. Population-based studies support the importance of developing interventions that match the needs of individuals at all
stages of change. These same studies suggest the relevance of this approach for generating participation rates that are dramatically higher than
traditionally reported.
Future Directions
Psychotherapy is probably 10 to 20 years away from its heyday. This
prediction is based on what has happened in biology and medicine for the
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329
past 30 years. As biology made breakthroughs in understanding different
levels of organisms, from basic genetic processes to cellular processes to
organ functioning, medicine has benefited immensely. The dramatic increases in basic knowledge of biological processes lead to equally dramatic
increases in medicine's ability to apply this knowledge. Medicine has been
experiencing its heyday in recent years, with the development of creative
interventions ranging from genetic engineering to biochemical controls for
diseased cells to transplants of entire organs.
Fortunately, as society begins to turn more and more to behavior
changes and lifestyle changes as the best preventions and interventions for
many health problems, psychology is likely to replace biology as the
hottest science, just as biology once surpassed chemistry. Psychology has
already been making major strides toward understanding different levels of
human behavior.
The most important issue that integrative therapists will need to
address is how we can best apply the knowledge that will emerge from
research on each of the basic levels of human functioning. Psychotherapy
practitioners and researchers are in a position to contribute to our knowledge of how change can best be facilitated in troubled situations, cognitions, interactions, systems, and intrapersonal dynamics. Integrative psychotherapists can contribute to our understanding of how changes at one
level can lead to changes at other levels, even though no direct intervention was made at the other levels. Eclectic psychotherapists are in a unique
position to discover the best ways to integrate change processes derived
from diverse therapy systems that are seen as inherently incompatible.
To improve integrative approaches, we need comparative studies to
assess what advantages, if any, there are to adopting a technical eclectic,
as opposed to a theoretical, integration. Alternatively, should therapists be
encouraged to take the easier alternative of becoming specialists in just one
therapy system? We need to demonstrate empirically what those advantages are and how different forms of integration vary in the degree to
which they contribute to these advantages.
To improve integrative theory, we need to know much more about
the processes and patterns of change. What techniques, for example, are
best for applying each of the basic processes of change? Have interpretations been overused in the past, at the expense of confrontations and
observations that may facilitate greater reliance on self-change and less
reliance on therapy? Or perhaps feedback from computers may get processed with less resistance than similar feedback from therapists. What are
the patterns of change that we can expect with different problems at
different levels of change? Is it true, for example, that little change can be
expected at the intrapersonal level when we are working with character
disorders?
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The transtheoretical approach seeks to facilitate a movement toward
integrating self-change and therapy-change processes. We are working to
create a more complete spectrum of change alternatives for specific problems, ranging from people choosing to change entirely on their own to
choosing to rely on longer-term therapy. Between these alternatives, individuals could choose to use self-help materials based on the transtheoretical approach; correspondence courses that are individualized and interactive according to the person's stage and level of change; and short-term
therapy that is more personalized and individualized, allowing them to
progress in therapy while learning a model of change they can use on their
own once therapy is over.
Future directions include more work on developing the key-level and
maximum-impact strategies for intervening at different levels of change.
This work will involve further development of the levels of change test for
assessing the clients' problem levels. The more therapists are able to
identify a key level that is involved in maintaining a client's problem, the
more therapists will be able to use the limited time they have with clients
effectively and efficiently.
One of our most creative challenges will be to develop the maximum
impact strategy for work with clients with multilevel problems. If clients
know that therapeutic interventions or homework assignments have the
potential for facilitating changes at the symptom/situational, cognitive,
interpersonal, family systems, and intrapersonal levels, we would expect
them to be willing to spend more time and energy on such therapeutic
activities. The purpose here is to use our integrative model to produce a
synergistic effect that can help clients progress more fully and efficiently
at each level of change.
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DiCLEMENTE, C. C., PROCHASKA, J. O., FAIRHURST, S., VELICER, W. F., VELASQUEZ,
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EGAN, G. (1986). The skilled helper (3rd ed.). Montery, CA: Brooks/Cole.
ELLIS, A. (1973). Humanistic psychotherapy: The rational-emotive approach. New
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GLASGOW, R. E., & ROSEN, G. (1978). Behavioral bibliotherapy: A review of
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GOLDFRIED, M. (Eo.). (1982). Converging themes in psychotherapy. New York:
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MARCUS, B., Rossi, J. S., SELBY, V. C., & NIAURA, R. S. (in press). The stages and
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change in psychotherapy: Measurement and sample profiles. Psychotherapy:
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MEDIEROS, M., & PROCHASKA, J. O. (1991). Predicting premature termination from
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MELLINGER, G. D., BAITER, M. B., UHLENHUTH, E. H., CISIN, 1. H., MANHEIMER,
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NORCROSS, J. C., & PROCHASKA, J. O. (1986). Psychotherapist heal thyself: The
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CHAPTER 10
Cyclical Psychodynamics and Integraiive
Psychodynamic Therapy
PAUL L. WACHTEL AND MARY K. MCKINNEY
c
-YCLICAL PSYCHODYNAMICS is the theoretical basis for an integrative therapy that seeks to synthesize key facets of psychodynamic,
behavioral, and family systems theories. The therapy that derives from this
theoretical perspective is known as integrative psychodynamic therapy.
The first statements of this theoretical point of view appeared in 1977
(Wachtel, 1977a, 1977b), and significant revisions and additions were
incorporated in two later books (Wachtel & Wachtel, 1986; Wachtel,
1987). A major restatement of the clinical applications of the theory is
currently in progress (Wachtel, in press).
Cyclical psychodynamics seeks to provide an internally consistent
theoretical approach to personality functioning, as well as a way of preceding clinically within the therapy hour. In contrast to a technically eclectic
approach, which might consist of a hodgepodge of techniques selected
probabilistically because they have seemed to work with patients possessing similar characteristics, cyclical psychodynamics seeks to develop a
coherent theoretical structure that can guide both clinical decision making
and general principles.
As an integrative theory, cyclical psychodynamics rejects the assumption of fundamental incompatibility among the theoretical viewpoints it
attempts to integrate. This does not deny differences among perspectives
with different labels; the theoretical differences are real. Cyclical psychodynamic theory, however, selects from among these various competing perspectives, choosing those aspects of each that can be put together in a new
synthesis. Each of the theoretical perspectives that cyclical psychodynamics draws upon is attuned to a different, and only partially overlapping, set
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of observations and clinical interventions. Cyclical psychodynamics attempts to forge a new, more inclusive synthesis—a synthesis that can
encompass the full range of observations addressed by its contributory
sources and also provide a context for as wide a range of clinical interventions as can be coherently employed.
As the name implies, cyclical psychodynamics, although drawing
upon multiple contributions and perspectives, has been most influenced by
the psychodynamic point of view. Many of Freud's basic concepts, such as
the emphasis on unconscious processes and inner conflict, and the importance of understanding the patient's relationship with the therapist, are
maintained, though with modifications. The neo-Freudian and interpersonal traditions that followed Freud have also shaped cyclical psychodynamic theory considerably, especially the ideas of Horney, Sullivan, Alexander, and Erikson.
In applying its psychodynamic perspective, cyclical psychodynamics
places its primary emphasis not on the notion of fixation upon traumatic
past events and relationships, but on the vicious cycles set in motion by
those events and relationships and on the ways those cyclical patterns
persist into the present. Its analyses show how problematic patterns are
sustained and strengthened not in spite of, but precisely because of, our
current reality.
Behavioral and family systems traditions have also enriched and
expanded the theoretical premises of cyclical psychodynamics by contributing to the focus on a detailed account of how and when neurotic
patterns are evoked, and on the patient's current social and cultural context.
Both external and internal realities are critical. Indeed, from the perspective
of cyclical psychodynamic theory, the distinction between them breaks
down; they continually define and redefine each other (Wachtel, 1987). On
a concrete level, both behavioral and systemic models provide therapeutic
change techniques to complement the psychoanalytic emphasis on insight
and examination of the transference. Rather than assuming that change will
follow insight automatically, the cyclical psychodynamic therapist views
change as a synergistic process in which new behaviors and feedback
promote new insights, and such insights in turn generate increased motivation to try new behaviors.
Cyclical Psychodynamics: Origins and Key
Concepts
In order to avoid awkward locutions and referring to oneself in the third
person, this section of the chapter, written by the first author, will be in the
Cyclical Psychodynamics and Integrative Psychodynamic Therapy
337
first person singular. It describes the origins of the cyclical psychodynamic
approach and, in the process, addresses a number of key theoretical and
clinical issues.
I was originally trained in the psychodynamic tradition, first at Yale
in psychoanalytic ego psychology, later complemented in my postdoctoral
training by an interest in the interpersonal point of view. These influences
have remained considerable in my own thinking, indeed so much so that
I still tend to think of my approach to psychotherapy as best described
as "integrative psychodynamic therapy" (Wachtel, 1985). As will be evident both from the present chapter and from my other writings, there
remain many ways in which I remain committed to psychoanalytic
ideas.
Nonetheless, as my psychoanalytic training proceeded, a number of
dissatisfactions slowly developed, which eventually shaped a central concern with developing a psychodynamic model that was not limited by the
problems I will shortly note. It might well be said that the development of
such a psychodynamic model and the development of a model for therapy
integration are two perspectives on the same task. The psychodynamic
model described here is one that by its very nature points to a wider range
of therapeutic interventions and incorporates observations whose origins
lie outside the psychodynamic tradition.
OVEREMPHASIS ON EARLY EXPERIENCE
One of the most significant sources of dissatisfaction with standard
psychodynamic accounts was what I experienced as an excessive emphasis
on very early experiences, and in particular an emphasis on early experience formulated in a way that made it seem as if those early experiences
remained lodged in the psyche as a foreign body, unchanged by later
experience. Such an emphasis leads a therapist to pay relatively little
attention to the influence of ongoing events in the person's life, and indeed
places theoretical obstacles to full consideration of such influences. Both
daily personal observation and my reading of the results of empirical
research persuaded me of the importance of ongoing life events. Both our
behavior and our experience vary greatly in different contexts, and a
theory that did not fully and readily accommodate this obvious fact was
unnecessarily limited. I sought an alternative that could retain the important insights and surprising observations deriving from the psychoanalytic
tradition, yet could integrate into its account of personality development
and psychological distress the important role of environmental context (cf.
Mischel, 1968, 1973; Wachtel, 1973a, 1973b).
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OVEREMPHASIS ON INSIGHT
Around the same time, I began to be skeptical that knowing something
about oneself was the major source of change. The idea of insight seemed
an inexorably cognitive notion, and although the distinction between
intellectual and emotional insight was clearly rooted in sound and important clinical observation, it was conceptually extremely problematic. It
seemed to me that judgments about whether an insight was intellectual
rather than emotional were very frequently post hoc decisions that reflected
rather circular reasoning. With hindsight, insights were accorded the status
of merely intellectual insights if not followed by clinical change, and of
emotional insights if the results were more favorable. This made the theory
relating insight to change invulnerable, but not very useful.
The basically negative attitude of the psychoanalytic community
toward Alexander's notion of the corrective emotional experience (e.g.,
Alexander & French, 1946) seemed to me unfortunate. In my own clinical
experience, it seemed that the experiential component was a critical one, and
that not only new experiences in the relationship with the therapist but also
new experiences more generally, which disconfirmed neurotic expectations, were of greater import than insights that were of a more cognitive
sort.
As I began to become more familiar with the methods of behavior
therapists, it became clear to me that, however they were formulating what
they were doing, providing opportunities for such corrective experiences
was very much at the center of what good behavior therapists were doing.
Even now, I find that in my own practice I am more likely to use traditional
behavioral methods than to borrow from more cognitive-behavioral approaches, even though the formulations of more cognitively oriented therapists are closer in many ways to my own than are S-R formulations. I
believe this is due both to my own preference for the mediating variables
from the psychodynamic tradition and to the fact that my move in an
integrative direction was to a substantial degree sparked by what I perceived to be an overly cognitive (if less explicitly and avowedly cognitive)
emphasis in traditional psychoanalytic approaches.
UNCLARITY ABOUT THE PROCESS OF CHANGE AND INSUFFICIENT
EXPLOITATION OF FREUD'S REVISED ANXIETY THEORY
Having been trained at Yale during the days when John Dollard and
Neal Miller were there (Dollard & Miller, 1950), I was alerted early to see
alternative ways of understanding the process of change that seemed to me
more clearly formulated. In particular, 1 began to feel that the concept of
extinction of anxiety as a major source of change, while it probably would
Cyclical Psychodynamics and Integrative Psychodynamic Therapy
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not have met with a warm reception from Freud, actually captured better
the implications of Freud's (1926/1959) later insights into the role of
anxiety in neurosis than anything in the psychoanalytic literature.
The extinction concept was closely linked to an important procedural
variable—exposure to the cues that were previously fearfully avoided.
Avoidance as a consequence of fear prevents new encounters that might
demonstrate that the fear is no longer warranted. Dollard and Miller's
analysis suggested that the cues being avoided were not limited to external
cues of the sort typically emphasized by behavior therapists. They could
include as well what Dollard and Miller called "response-produced cues"—
cues associated with the person's own thoughts and affective reactions.
Thus they forged a potential link between psychoanalytic concepts of
repression and the avoidances addressed by more behaviorally oriented
therapists. As implied in a different but related way in Freud's notion of
signal anxiety, when the individual begins to perceive cues that are even
marginally associated with a thought that has become a source of anxiety,
there is a strong inclination to avoid those cues. Whether described in
terms of "repression" or "defense" in traditional psychoanalytic terminology, in terms of "selective inattention" in Sullivan's terminology (e.g.,
Sullivan, 1953), or in terms of the response of "not-thinking," in Dollard
and Miller's conceptualization, what is being addressed is a tendency to not
notice, to reinterpret, to change the subject, or in other ways to avoid or
attenuate the experience of the forbidden.
Everything we know about extinction of anxiety associated with
more overtly observable cues suggests that what is crucial is repeated
exposure to the frightening stimulus, in circumstances where the expected
harmful consequences does not occur. Almost always this exposure must
occur on many occasions, and the reduction of anxiety occurs only gradually. If the reader is following the logic of the argument being developed
here, it will be apparent that what is being described is another perspective
on what in psychoanalytic terms is referred to as "working through."
Psychoanalytic accounts of working through are often rather vague.
Freud sensed early that singular flashes of insight are unlikely to lead to
permanent change, that something more arduous and less dramatic was
usually required. This observation has been confirmed so readily in clinical
practice by others that therapists reading or talking about working through
feel they know precisely what is being referred to. But while the experience
of working through is a familiar one, the process that is represented is not
nearly as clear. Psychoanalytic accounts tend to discuss it in terms of
examining the newly discovered thoughts, feelings, and experiences from
a variety of different perspectives until it is fully understood. The emphasis,
in other words, is again often cognitive.
The extinction concept, together with Freud's revised theory of anxi-
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ety, suggests another explanation. Working through is needed because
what is most essential in therapeutic change is the overcoming of anxieties
learned early in life, which are no longer appropriate (if they ever were).
Fears and inhibitions resulting from the cognitive and motor limitations of
children, their misunderstanding and overgeneralization of parental prohibitions, and the restrictions placed on children that are not applied to adults
(for example, about sexuality) must be unlearned. The unlearning of these
fears, however, is impeded by the avoidance they engender, which makes
impossible the needed experience of encountering the source of fear and
discovering it is no longer a danger. And once the therapist does manage
to bring about exposure to the previously avoided cues, repeated exposure
to them is necessary. In the case of formulations guided by psychoanalytic
thought, this implies bringing the patient back into contact with the
thoughts and affects that have been repressed—that is, avoided. Thus, it
is not enough merely to "see" what you have blinded yourself to; it is
essential to see it again and again, to undergo repeated extinction trials for
the anxiety to these cues or, in psychodynamic terminology, to participate
in working through.
From this perspective, one of the key functions of "interpretations" is
that they are comments that either interrupt the person's way of avoiding
cues associated with the feared thought (defense interpretations) or, by
stimulating associations and/or saying out loud the thought that can't be
spoken, increase the likelihood that the patient will begin to be exposed to
the therapeutically relevant cues. When psychoanalytic treatment is successful, it is likely that a good deal of its success is due to its effectiveness
in bringing the patient into contact with thoughts and images that have
theretofore been fearfully avoided. The process of working through, however, may be approached inefficiently if it is conceived of as a quasicognitive process of exploration and understanding rather than as a reflection of the repetition necessary for extinction of the maladaptive anxiety.
Rather than looking for "new material" or new perspectives or new understanding, the therapist might more deftly accomplish the therapeutic task
by helping the patient to be exposed to the same cues over and over until
an efficient, focused extinction process is effected.
INSUFFICIENT ATTENTION TO THE ROLE OF SOCIAL SKILLS
A further important consequence of the anxiety and avoidance so
regularly associated with psychological disorders is that it generally leads,
in the course of development, to the bypassing or truncating of important
developmental experiences. The complex social skills required of every
adult in an advanced society take many years to learn, and their effective
learning requires both careful observation of others and much practice and
Cyclical Psychodynamics and Integrative Psychodynamic Therapy
341
honing of one's interactional style. That much of this observation and
practice goes on automatically, without self-consciousness or even awareness that one is doing such things, does not in any way diminish its
ubiquity or importance. If anxieties and conflicts make it more comfortable
to avoid certain kinds of experiences early in life, and the countless practice
sessions that life offers are not encountered, there will be an impact on
one's ability to negotiate the shoals of social interaction.
This does not necessarily mean that the individual will be grossly
inappropriate or a social outcast. To begin with, the deficits are often quite
focused, showing up only in very specific contexts. Thus the patient might
in many ways be a highly skilled participant in social interactions, showing
just a few odd lacunae in an otherwise general picture of competence. The
lacunae in each case would be related to specific areas of anxiety and
avoidance, but the relationship is not necessarily a simple one-to-one.
Many dimensions of life experience, including just where one is forced to
sink or swim despite one's anxiety, and where, in contrast, well-rationalized
avoidance is possible, will influence where reasonable skillfulness develops
and where avoidance takes its toll.
THE IMPORTANCE OF ACTIVE INTERVENTION
These and other considerations led me to believe that much more
active intervention into people's difficulties was both possible and desirable
than I was taught by my psychodynamic teachers. I began to be struck by
the possibilities inherent in the interventions developed by behavior therapists, whose conceptions did not prevent them from intervening actively.
And as I will discuss shortly, I began to see that their overall approach did
not need to be viewed as thoroughly incompatible with a psychodynamic
view, as was commonly believed.
THE CONTINUED IMPORTANCE OF THE PSYCHODYNAMIC PERSPECTIVE
Despite the aforementioned dissatisfactions, my basic outlook continues to be best characterized as a version of psychodynamic thought, and
various features of the psychodynamic approach have seemed to me crucial
to retain. Perhaps most important, I continue to be struck by the pervasiveness of conflict and by how readily people can deceive themselves about
their own motives and feelings. Self-deception is really the very heart of
the psychodynamic point of view, and instances of self-deception seem to
me prevalent enough that I regard it as one more instance of the phenomenon to develop a view of human psychology that is not centrally rooted
in this reality.
The psychodynamic perspective not only alerts us to conflict and to
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the ubiquity of self-deception, it also provides guidelines about where and
how to look for inclinations and experiences that are being disavowed.
Although the rules of inference that countenance analytically oriented
therapists' claims have still not been sufficiently spelled out, the situation
is not as arbitrary as the most implacable critics of psychoanalysis would
have it. Close examination of the logic of inference among responsible
psychoanalytic clinicians reveals a variety of useful rules that can be
followed with reasonable consistency. It is certainly true that eschewing
the kinds of inferences that analysts make can protect the clinician from
numerous errors of overinterpretation, but a state of affairs exists that is
akin to the unavoidable tradeoff in statistical inference between Type I and
Type II errors: Avoidance of the danger of erroneous inferences that the
psychoanalytic interpretive method does indeed present can only be
achieved by increasing the danger of missing crucial areas of conflict and
self-deception, a danger whose clinical consequences may be even more
serious. Relying too preponderantly on what the patient can consciously
report increases the danger of misformulations of the patient's aims and
difficulties.
It is very easy to assume that what people want and feel are the things
that society teaches us they should want and feel. When one looks and
listens closely, however, in the way that the psychodynamic tradition
teaches us to look and listen, one may be struck by how often people's
effective motives and assumptions do not correspond to what is socially
expected or normative. Naturally, it is just such nonnormative motives and
experiences that are most likely to be inaccessible to the person's conscious
awareness.
It is interesting to note—and this bears quite relevantly on the issue
of the potential compatibility of psychodynamic and behavioral perspectives—that the inferences on which psychoanalytic formulations are based
are often most essentially rooted in paying attention to people's behavior,
to how what they do differs from what they say. It is in noticing contradictions between patients' avowed intentions and the consistent consequences
of their actions that dynamic inferences are frequently born.
BEHAVIORAL CONTRIBUTIONS
As I began to be more familiar with the work being done by behavior
therapists—I had earlier been taught to be rather dismissive toward this
approach and had paid little attention to it—I was struck by several things.
First, behavior therapy was particularly strong in some key areas where the
psychodynamic tradition was particularly weak. For example, behavior
therapists had available to them active intervention methods frankly designed to produce change. The psychoanalytic tradition, in contrast, had
Cyclical Psychodynamics and Integrative Psychodynamic Therapy
343
few specific interventions. The process of exploration, which might well be
thought to be primarily a diagnostic rather than a therapeutic process, was
forced to serve double duty, as it were.
It seemed to me entirely consistent with the substantive empirical
discoveries deriving from the psychoanalytic method to develop intervention procedures based on the understanding of motivation and conflict
achieved in the early exploratory and diagnostic work with the patient.
The work of Alexander and his colleagues, as I read them, was based on
a similar estimate (e.g., Alexander et al, 1946; Alexander, 1956, 1961). The
impetus behind Alexander's efforts was a view that Freud's work was too
valuable to be embalmed in a method that was essentially a preliminary,
early 20th-century stab at how to apply the new insights, and that explicit
efforts to take Freud's ideas and develop new therapeutic methods based
on them would likely prove more fruitful. Despite the largely rejecting
attitude that greeted Alexander's work, I think he was basically correct, and
I regard my own efforts as, in a sense, carrying on in this tradition.
Part of the resistance to explicit intervention methods on the part of
psychoanalysts seems to reflect an ideological commitment to a highly
individualistic worldview in which autonomy is the supreme value and in
which healthy interdependency and problematic dependency are confused
(cf. Wachtel, 1989). Part also is due to an affirmation of the emphasis Freud
placed on psychoanalysis as a research method. Freud's research interests
shaped the psychoanalytic method in ways that were useful for the research enterprise but placed significant and unacknowledged constraints on
the clinical side (Wachtel, 1987, chap. 12).
Variability and Context
A second area of strength for behavior therapy that filled (and highlighted)
a gap in the psychoanalytic approach was its considerably greater attention
to the role of context in human behavior and, as a consequence, to the
variability of our behavior and experience in different contexts. This
seemed to me consistent with my own experience, both in observing
others and in observing myself, of quite significant range in both level and
mode of functioning, depending on the situation and the other people
involved. Such a recognition of variability with context need not lend itself
to what Bowers (1973) has called "situationism"—an overemphasis on the
determining influence of situations that excludes or underestimates the
concurrent role of the perceptions, motives, and prior experiences of the
people who find themselves in the situation. Rather, in its more sophisticated versions, it points to an appreciation of how characteristics of the
individual and the situation interact to jointly codetermine what occurs (see
also Magnusson & Endler, 1977; Wachtel, 1973a).
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This emphasis on the contextual nature of human behavior provided
an important corrective to formulations that emphasized the person's fixation or arrest at a particular developmental level and that, in effect, treated
the enormous variability in the actual level of functioning of almost every
individual as "noise." Moreover, it provided a much better handle on
appreciating and building on the patient's strengths rather than focusing
the therapist's attention almost exclusively on pathology. In addition, it
pointed much more readily to the way changes in patients' ongoing
behavior and changes in the situations they encountered could codetermine each other, introducing the possibility of synergistic circles of therapeutic change (Wachtel, 1985, 1987).
Validation and Research Commitment
Another feature of the behavioral tradition that drew my attention was its
emphasis on the need to validate concepts and procedures. From its inception, psychoanalysis has been weak in this area. The emphasis on privacy,
the corollary resistance to tape recording as it developed as a potentially
powerful research tool, and the indifference to—or even antipathy toward—the experimental method shown by many analysts all contributed
to an atmosphere in which clinical lore and private convictions predominated. The vulnerability of uncontrolled clinical observations to bias and
selective perception and memory seemed to me greatly underestimated by
the psychoanalytic community; the possibility of adding techniques that
were being seriously evaluated by strenuous methods was very appealing.
COMPATIBILITY OF DYNAMIC AND BEHAVIORAL APPROACHES:
THE DEVELOPMENT OF CYCLICAL PSYCHODYNAMICS
As I began to examine closely and seriously the work of leading
behavior therapists, I found to my surprise that there were ways of understanding what they were doing that suggested considerably greater compatibility with a psychodynamic view than I had thought possible. The
possibilities for a fruitful merger seemed particularly enticing with regard
to the interpersonal version of psychodynamic thought which was increasingly coming to characterize my views.
The key to reconciling the two views was appreciation of the largely
circular nature of causality in human affairs: The events that have a causal
impact on our behavior are very frequently themselves a function of our
behavior as well. If situations have a greater impact on our functioning than
most psychodynamic formulations tend to acknowledge, it is also the case
that the situations we encounter are not simply independent variables, as
they might seem from the perspective of the experimental studies to which
Cyclical Psychodynamics and Integrative Psychodynamic Therapy
345
early behavior therapists largely attended (cf. Wachtel, 1973a). Rather,
they can themselves be understood as a function of the extant personality
organization. By choosing to be in certain situations and not others, by
selectively perceiving the nature of those situations and thereby altering
their psychological impact, and by influencing the behavior of others as a
result of our own way of interacting, we are likely to create for ourselves
the same situation again and again. The situations we find ourselves in are
not just what the world throws us into, but are very largely consequences
or expressions of our personalities.
Both the reality of the impact of the situation on our behavior and
experience, and the reality of our capacity to choose and alter the situations
we encounter, must be taken into account by a fully satisfactory theory.
Neither is more basic or correct. By and large, psychodynamic theorists
have given greater weight to what might be called the "inside-out" direction of causality, and behavioral theorists to the "outside-in." Interpersonal
versions of the former and social learning and cognitive versions of the
latter tend to treat the causal sequences less unidirectionally (e.g., Sullivan,
1953; Horney, 1939, 1945; Bandura, 1978), providing further footholds
and handholds for the theorist seeking an integrative model.
In attempting to sketch out the outlines of a more fully integrative
picture of personality development, I have increasingly relied upon the
analysis of vicious circles that maintain consistency in personality functioning over time despite the considerable forces potentially pushing for
change. The term cyclical psychodynamics reflects the dual emphasis of this
point of view on elucidating the cyclical nature of causal processes in
human affairs and elucidating the unconscious motives, fantasies, and conflicts that are so crucial in almost everything we do (cf. Strupp & Binder,
1984, who also present a perspective that they describe as cyclical psychodynamics).
From a cyclical psychodynamic perspective, it became clear that (1) the
active intervention methods of behavior therapists (and later of therapists
from other perspectives; see, for example, Wachtel & Wachtel, 1986) could
be of significant value in promoting the changes dynamic therapists were
working toward, and (2) those methods could be employed logically and
consistently within a modified psychodynamic context. The key to the
latter point was the recognition that the transference phenomena that were
at the heart of much of the psychoanalytic therapist's concerns were being
conceptualized in most psychoanalytic accounts in a needlessly constricting way.
From a cyclical psychodynamic perspective, transference reactions are
understood as the individual's idiosyncratic way of construing and reacting
to experiences, rooted in past experiences, but always influenced as well by
what is really going on. The therapist's interventions do not "muddy" or
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"distort" the transference because all transference reactions are reactions
to something. Moreover, it is as important to understand what occurrences
the patient is reacting to as to understand why, based on past history, he
reacts to the situation in the particular way he does. From this vantage
point there is no neutral point from which, if the therapist just gets out of
the way and doesn't interfere or distort, the real transference will "emerge"
or "unfold" (cf. Wachtel, 1987. chap. 3). Rather, transference is a complex
set of responses, varying with context, but highly informative about the
patient's key interpersonal experiences and maneuvers. Whatever therapists
do (whether they remain silent and restrict themselves to interpreting,
actively direct the treatment, or assist the patient in devising a regimen of
therapeutic experiences) their behavior with the patient will have an impact. And whatever they do, the meaning of that impact is essential to
understand (cf. Sullivan's [1953] conception of participant observation and
also Gill's and Hoffman's formulations [Gill, 1982; Gill & Hoffman, 1982;
Hoffman, 19831).
As this point of view emerged clearly for me, I began to get training
in behavior therapy and to study closely the work of leading behavior
therapists. I also began experimenting with ways to incorporate behavioral
methods into my clinical work. At first my use of behavioral methods was
fairly orthodox—even if the setting in which 1 employed them was not.
That is, when I used these methods I looked pretty much the way a
traditional behavior therapist looked when he or she used them (though it
was not long before at least some variations began to become evident—the
consequence of my having had psychoanalytic training and retaining a
strongly psychodynamic point of view in many respects). Before long,
however, I began to notice that the dividing line between which aspects
of my clinical work represented the behavioral side of my work and which
represented the psychodynamic side began to blur. Not only did 1 begin
to give a psychodynamic flavoring to my use of behavioral methods, but
my style of carrying through the psychodynamic side of the work—of
interpreting, of communicating my understanding, and even of listening—
began to be influenced by my increasing immersion in the behavioral point
of view.
Much of this is communicated and illustrated in Psychoanalysis and
Behavior Therapy (Wachtel, 1977b) and Action and Insight (Wachtel, 1987).
In those books are illustrations both of the use of standard behavioral
procedures and of some of the ways they have been modified in the effort
to incorporate them into a dynamically oriented therapy. In the present
chapter, we will illustrate the further evolution of the cyclical psychodynamic approach to integration. Originally, the emphasis was on combining
methods derived from different theoretical perspectives, or incorporating
methods from one viewpoint into work essentially informed by another.
Cyclical Psychodynamics and Integrative Psychodynamic Therapy
347
More recently, cyclical psychodynamic efforts have moved toward a fuller
synthesis or integration. In much of the work presently approached from a
cyclical psychodynamic viewpoint, it is hard to say which is the psychodynamic part and which is the behavioral. The work, one might say, is
becoming more seamless. At this point we would like to elaborate with a
clinical vignette that illustrates the fruitful merging of frames of reference.
Case Example
John N. was a quite prominent member of his profession, who had never,
to his great consternation, passed the licensing examination. He had taken
the exam five times before and had failed each time, despite the fact that
his professional stature was such that his own work was occasionally
addressed on the exam.
Although he presented himself as a case of "test anxiety," and informed me of that self-diagnosis in the first session, it quickly became clear
that more was involved. John had grown up in a prominent Boston family
and had been taught by his parents, who were quite demanding and
status-conscious, that he must not only excel but also appear to do so
effortlessly.
This was not something that John was able at the outset to say
directly. At first I was merely struck by his various efforts to let me know,
indirectly but most assuredly, who it was I was dealing with. He worked
very hard at conveying both his stature in the profession and his social
status, and seemed very uncomfortable with being in the role of patient.
In looking for a way to inquire into this tendency that did not leave John
feeling criticized or put down (cf. Wachtel, in press), I wondered out loud
if his parents had been very concerned about status and what the impact
on him might have been. At this he seemed to experience a good deal of
relief and immediately relaxed some. He said yes, they were like that and
it was very oppressive.
John's conscious views were much more liberal than his parents', and
this added still further to his dilemma: He could not readily acknowledge
his concerns about status, or appreciate the role those concerns played in
his life, because he had struggled hard to disavow them and, as far as he
knew, he had done so. By raising them as his parents' concerns, I made it
possible for him to begin addressing them while still maintaining his view
that he himself did not endorse them, indeed while expressing his distaste
for them.
Attempting to open further a path for John's exploration of attitudes
I sensed were an important part of his difficulties, I then added that it must
have been difficult growing up in such an environment not to adopt some
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of their views simply in self-defense; with their relentless emphasis on
status and success it would have been extremely painful not to attend to
this himself. This comment seemed to make it a bit easier for John to take
a look at his own concerns about status, most likely because it implicitly
conveyed that it was not his fault that he felt this way.
Through this process of gentle and gradual confrontation with his
disavowed status concerns, John began to recognize that he had felt
defensive and humiliated by having to take the exam, and had as a
consequence not prepared seriously enough. This was somewhat the case
even the first time he took it: He felt he had to be very cool and casual
about his preparation despite considerable anxiety—anxiety largely
prompted by the internal necessity not just to pass but to do spectacularly
well and to do so without "sweating it." Needless to say, the pressure
became even greater as he took and failed the exam over and over.
This initial bit of "insight-oriented" work modified the program of
behavioral interventions that was to be employed. Although, as I will
describe shortly, I did indeed use systematic desensitization to help John
overcome his test anxiety, I also concentrated more than I otherwise would
have on his preparing more thoroughly for the challenge the exam represented. By helping him to see the unacknowledged feelings and ideas that
had led him to treat the exam dismissively, the initial work enabled John
to address the situation more seriously this time around. As he came to see,
it was not just a matter of anxiety that had to be overcome. The anxiety,
while in certain respects excessive, and certainly interfering with his performance, was not entirely unrealistic: It was based in part on his unacknowledged perception that he had not taken the exam seriously enough
to be properly prepared.
After working a good deal on the internal pressures that had led John
to be dismissive toward the exam, and on how he could study for it more
seriously this time, we did turn to desensitization. Initially, the major
dimension for the development of a hierarchy was a temporal one. The
images moved from a period considerably before the test, through increasingly close approaches to his actually appearing at the door, to his sitting
down at his desk, to his confronting various experiences he would encounter when actually taking the examination.
As we went through these images, the nature of his discomfort
became clarified in a number of specific situations. Thus, when he pictured
walking into the room, he became aware of the crowd of exam takers
pressing in together, and he experienced a strong sense of indignity at being
pushed and at having his identity checked. This, more than any concern
about failure, was his primary source of distress with these images. We
discussed this in relation to the legacy of his upbringing, and it led to an
important discussion of his strategy lor studying for the test. He was
Cyclical Psychodynamics and Integrative Psychodynamic Therapy
349
struggling with dual inclinations to study much harder than anyone else
and to study much less. We worked on images of his being just one of the
crowd until he could imagine this with little discomfort, and he found that
this enabled him, as well, to have a much clearer sense of what would be
an appropriate amount of preparation: He could do it "just like everyone
else."
Similarly revealing was his reaction to the image of approaching the
door of the building. It became clear as he immersed himself in the image
that another source of discomfort was seeing the guard at the door. He
recalled that the same man had been on duty on several occasions and felt
very uncomfortable at the idea that this man would see that he was taking
the test still one more time. He worked on this image for much of a session,
finally overcoming the anxiety when he pictured himself taking the bull by
the horns and saying "good morning" instead of trying to slink in unnoticed (as he realized at some point he was doing in the image).
The most interesting developments occurred when John imagined
himself visiting the room the day before the exam. The aim in this set of
imagery exercises was initially for him to acclimate himself to the setting
in which the test would take place. He was asked to look carefully around
the room, to touch the various surfaces such as the desk and walls, to
experience the lighting, and so forth. It was hoped that thereby some
portion of the anxiety he tended to experience in the exam situation could
be eliminated.
When he began the imaging, however, a fascinating series of associations and new images came forth. At first he spontaneously had the
association that the room seemed like a morgue, and then that the rows of
desks seemed like countless graves covering the site of a battlefield. Then
he felt overcome with a feeling of impotence. I asked him if he could picture
himself as firm and hard, ready to do battle. He did so (I left it ambiguous
whether he should take this specifically to mean having an erection or as
an image of general body toughness and readiness). He said he felt much
better, stronger, and then spontaneously had an image of holding a huge
sword and being prepared to take on a dragon. He associated this image
to our various discussions of his treating the exam as a worthy opponent,
taking it seriously yet being able to master it. He was exhilarated by this
image and I suggested he engage in such imagery at home between
sessions, a suggestion he endorsed with great enthusiasm.
In the next session we began with his again picturing himself visiting
the exam room the day before the test. For a while, as he checked out the
various features of the room, he felt quite calm and confident. But suddenly
he felt a wave of anxiety, as if something was behind him. I asked him to
turn around and see what was there. He reported seeing a large cat, a
panther. Here I made a kind of interpretation. I offered that the panther
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represented his own power and aggression and that it was a threat to him
only so long as he kept it outside of him or out of sight. I asked him if he
could reappropriate the panther part of him, adding that what he was
feeling threatened by was his own power, his own coiled intensity.
He pictured the panther being absorbed into himself, and the anxiety
receded. I then elaborated—quite speculatively, to be sure, but in a way
rooted in the understanding we had achieved together about the dynamics
of his difficulty with the exam—on why it might be that he had chosen a
panther in particular to represent the part of himself that needed to be
reappropriated. I noted that panthers were not only strong and purposeful
but were also meticulous and supremely respectful of their prey. Despite
being awesome creatures, 1 suggested, panthers did not take their prey
lightly. They did not just casually leap out whenever they saw a potential
source of nourishment. They did not act as if it were beneath their dignity
to stalk for hours, crawling on their bellies. Panthers, 1 said, were diligent
students who became experts on the habits of the creatures they tracked—
experts whose expertise was the result not just of instinct or superb natural
equipment but of attention to detail and a respect for the difficulty of the
task of conquest nature required of them. Their grace might look effortless,
but it was far from casual; panthers were supremely serious.
Now in all this it is impossible for me to distinguish how much
reflected an empathic grasp of the actual layers of meaning that led to
John's experiencing that particular image, and how much was simply
suggestion on my part. The "interpretation" seems plausible, but at the
very least I was gilding the lily, using the panther image to point toward
attitudes I felt it would be useful for him to incorporate, whether they were
the actual sources of the image or not.
What is important is that my comments were meaningful to the patient.
Whether or not they accurately depicted the origins of the image, they did
resonate with the ripples of meaning that the image engendered, and they
helped to amplify and consolidate the utility of the image itself, which was,
after all, John's creation. In further work on the test anxiety and—significantly—later on his own in dealing with a range of other concerns,
John, for whom imagery turned out to be a very salient modality, made
great use of the panther image and its variants (cf. Lazarus, 1992). He aided
his efforts at relaxation, for example, by imagining himself as a big cat,
relaxing and licking himself. When faced with a difficult challenge, he again
imagined himself and the panther as one, and felt that he didn't have to be
overtly aggressive, since he knew deep inside he was capable of whatever
was necessary. Sometimes he would even imagine himself emitting low
murmuring sounds deep in his throat, which, as he put it, "remind the
panther that it's a panther."
One of my favorites of his spontaneous creative uses of the panther
Cyclical Psychodynamics and Integrative Psychodynamic Therapy
351
image came later in the desensitization work. We were at the point of his
imagining actually sitting and taking the test, when a wonderful smile
appeared on his face. He told me he had just had an image that the point
of the pencil with which he was writing the exam was actually the claw of
the panther; that the panther was firmly within him, incorporated and
channeled, and as the claws came through the tips of his fingers they were
pencils that were writing out the answers with very sharp points.
This time around, his points were indeed sharp. After having failed
the exam five times previously, he not only passed but did very well. I
cannot, of course, determine whether he would have passed even without
therapy of any kind, or whether a more orthodox course of either behavior
therapy or psychoanalytic therapy alone (or of any other approach for that
matter) would have done just as well. Only systematic research can enable
us to sort out with confidence the many questions that cases like this raise.
Conceptualizing and implementing such research, and ensuring that it
addresses the complexities that cases such as this present, will be a considerable challenge that will tax our powers of persistence and methodological
innovation.
COMMENT ON THE CASE
In one sense, the case just described is atypical. The patient, to begin
with, turned out to be unusually adept and creative with imagery. Moreover, the degree of synthesis of differing methods, the extent of the
"seamlessness" of the therapeutic effort, was greater than it is often possible to achieve. In this sense, the experiences with John described here are
noteworthy less for their representativeness than for their providing a
model of the kind of full synthesis toward which the cyclical psychodynamic perspective aims. In daily practice, therapy conducted from this
perspective often is limited to a less complete form of integration, in which
procedures deriving from one tradition or another are used at different
times. Although they fit together into a coherent framework, they are
nonetheless clearly identifiable as separate parts. The integration in this
case is more seamless in that what emerged were procedures that were not
quite what most behavior therapists would do and not quite what analysts
would do, but rather emergent procedures reflecting the integrative intent
of the therapy.
The case differs, as well, from most cases seen from a cyclical psychodynamic perspective in that it had a narrowly defined goal. Rather than
being directed primarily at a set of characterological features that were
manifested in various aspects of the patient's life (as is more common in this
approach to therapy), the work here focused rather sharply and pointedly
on John's difficulty with the test.
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Nonetheless, the case nicely illustrates a number of features of the
cyclical psychodynamic point of view. To begin with, we may see a
number of vicious circles evident in John's difficulties, which interweave
influences from his past, from his motivational conflicts and internal necessities, and from his daily transactions with the world of actual events.
John's conflicting needs to be outstanding and to appear to do everything
effortlessly made it difficult for him to study sufficiently to do well on the
test, and made the first failure especially painful. These influences then fed
on themselves. Feeling so humiliated and embarrassed, John's anxiety
increased, making still further failure more likely. Moreover, his need
defensively to deride the exam, and also not to appear shaken and therefore
not to study too hard, both repeated the state of affairs associated with the
first failure and set the stage for the next.
An additional circular process, reinforcing the interlocking set of
influences just described, involved the excessively high standards that John
had absorbed from his parents in his youth. Those standards were maintained as a continuing psychological irritant, not just by his attachments to
the objects and images of his earlier days, but by the new relationships he
continually established with others. By presenting himself as special, John
evoked expectations of being special and created a life structure that replicated the circumstances of his childhood in this way. That he was in fact
a very talented individual enabled this potentially fragile structure to be
maintained, but at a very high psychic cost. As they became enmeshed
with his difficulties with the exam, and with the other circles described
above, these influences further exacerbated John's difficulties. It was not
really enough for him to pass the exam; he had to do extraordinarily well.
This pressure increased as the number of his failures mounted and, of
course, it interacted toxically with his anxiety.
Thus we may see that even in a therapy focused on a relatively simple
and narrowly defined problem, the cyclical psychodynamic perspective
points us to seeing how interacting circular processes tie together past and
present and internal and external influences.
We also see in this case a number of characteristic features of the
approach to therapeutic intervention that is associated with the cyclical
psychodynamic point of view. We see, for example, the emphasis on
exposure to what one has been afraid of and on structuring that exposure
in such a way that it will be both vivid and able to provide the patient with
an experience of mastery. In addition, the therapist's efforts were directed
toward helping John change his overt behavior with regard to the exam
and his preparation. At various points, John's strategies for studying were
examined quite explicitly and suggestions made, both implicitly and explicitly, for ways to achieve a better synthesis of his competing aims. Illustrated, too, is the concern with skills that have been impaired by anxiety
Cyclical Psychodynamics and Integrative Psychodynamic Therapy
353
and avoidance, and with helping the patient explicitly to improve those
skills. The primary focus here was on study skills (in keeping with the more
limited aims of this particular case), but even here, other dimensions were
brought to bear. In working with John on his attitudes about other people
who might notice that he was taking the exam again, at least some work
was done on his more general assumptions about what others would think
of him and on how he dealt with those attitudes.
It should also be apparent from this case illustration how a therapy
rooted in the cyclical psychodynamic perspective integrates the exploration of warded-off experiences and inclinations with direct and active
efforts at promoting change. Although various active intervention methods were employed, the direction toward which the therapeutic efforts
were addressed depended considerably on the initial exploratory work
done with John. Enabling John to acknowledge and understand how he had
kept himself from appreciating the extent of his status concerns, and why
he had needed to do so, was important in developing the focus of the
overall approach. Appreciation of his conflict over working hard to prepare
for the exam, as well as the unrecognized need he had to make it all appear
effortless (not only to others but to himself), led to further active intervention efforts directed toward helping John study more effectively and take
the exam more seriously. Moreover, understanding the importance of the
indignity John experienced in the process and his embarrassment at taking
the exam still again provided another focus for desensitizing efforts, as well
as for further explorations of the impact of these feelings on his life more
generally.
The case also illustrates some of the concerns about the therapist's use
of language that have increasingly been at the center of the therapeutic
effort from a cyclical psychodynamic point of view. The inquiry into John's
status concerns—concerns that at first were vigorously disavowed by
him—began by addressing his parents' concerns, and proceeded only gradually to inviting him to explore his own. Moreover, the latter exploration
was undertaken in a way carefully designed to enable John to examine
these concerns in a manner that permitted him to maintain his self-respect.
Ultimately, the aim was for John to be able to acknowledge and take
responsibility for his attitudes, and the general evolution of the case
indicates that he indeed was able to do so. The path toward doing so,
however, led initially through a preliminary disavowing of responsibility: It
was his parents' attitudes that were really at issue, and he could not help
absorbing some of them. Such a strategy for enabling people to recognize
and take responsibility for their experiences by initially placing the responsibility outside themselves has been described in recent cyclical psychodynamic explorations of therapeutic language as "externalization in the service of the therapy." It is one of a number of strategies we have recently
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developed to ensure that the fostering of insight enhances, rather than
diminishes, the patient's self-esteem. The exploration of the language used
by the therapist in communicating his understanding to the patient has
become increasingly central in the evolution of the cyclical psychodynamic
approach. The modes of communication we have been developing aim at
synthesizing cognitive, behavioral, and psychodynamic considerations to
enable patients to hear the therapist's message with less defensiveness and
to use the therapist's comments to take the steps necessary for change (see
Wachtel, in press).
Relevant Research
The research evidence supporting cyclical psychodynamic theory is still
only indirect. Studies have not yet been done comparing the outcome of
therapy conducted from this point of view with that of other approaches.
Nor has explicit testing of cyclical psychodynamic propositions been undertaken thus far. There is, however, a significant body of research, especially in social and developmental psychology, that supports the basic
tenets of the theory described here. Studies about self-fulfilling prophecies,
also called expectancy effects or behavioral confirmations, are perhaps
more strikingly relevant to the concepts underlying cyclical psychodynamics. Social psychologist E. E. Jones (1986) summed up the findings of this
line of investigation as follows: "We are not passive observers of our
respective social worlds, but active forces in the shaping of those worlds.
To an important extent, we create our own social reality by influencing the
behavior we observe in others" (p. 41).
Numerous studies of expectancy effects have shown results consistent with the major thrust of cyclical psychodynamics—that the patterns
of our lives are sustained and strengthened not in spite of, but precisely
because of, our current reality. To use the terminology of cyclical psychodynamic theory (e.g., Wachtel, 1977a, 1977b, 1987), in subtle and unconscious ways we induce others to act as unwitting "accomplices" in maintaining the beliefs that support our life structure, including those that
maintain neurotic or maladaptive patterns.
The research cited below demonstrates both the range of situations
in which accomplices may be found and the subtlety of our recruitment
methods. Much of the research cited is about first impressions and the
interactions of strangers. But as Jones (1986) points out, there is reason to
think that such patterns are found in long-term relationships as well. He
argues that the increasing contact can "generate patterns of behavioral
escalation" (p. 46), a conclusion quite congruent with the conception of
vicious cycles at the heart of cyclical psychodynamic theory.
Cyclical Psychodynamics and Migrative Psychodynamic Therapy
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THE SELF-FULFILLING PROPHECY
First defined by sociologist Robert Merton (1948, 1957), a selffulfilling prophecy is an understanding of a situation, originally incorrect,
which leads to behavior that causes the false assumption to come true. We
respond not to an objective reality but to the meaning we ascribe to our
perceptions. Thus, "the specious validity of the self-fulfilling prophecy
perpetuates a reign of error. For the prophet will cite the actual course of
events as proof that he was right from the very beginning" (Merton, 1957,
p. 477).
Sociologists and psychologists have followed Merton's lead to show
how self-fulfilling prophecies may explain a host of social problems, especially ethnic and sexual prejudices (e.g., Snyder, 1981, 1982). Expectancies
perpetuate negative stereotypes about race (Word, Zanna, & Cooper,
1974), social class (Darley & Gross, 1983), mental health problems (Farina,
Gliha, Boudreau, Allen, & Sherman, 1971), and homosexuality (Snyder &
Uranowitz, 1978). As early as 1978, Rosenthal and Rubin conducted a
meta-analysis of 345 studies of expectancy effects and concluded that the
phenomenon exists "beyond doubt" and is substantial in its impact.
One of the most controversial and frequently replicated studies of a
self-fulfilling prophecy, called "Pygmalion in the Classroom," was reported
by Rosenthal and Jacobson in 1968. In this study, elementary school
teachers were led to believe that IQ tests indicated that a few of their
students would "bloom" academically during the course of the year. Although the targeted children had been randomly selected, at the end of the
school year they performed significantly better on the same intelligence
tests. Fulfilling the prophecy, chosen children bloomed in comparison with
their peers, presumably because the teachers' expectations somehow led to
subtle changes in teaching behavior that benefited those target students.
In another influential study, Snyder, Tanke, and Berscheid (1977)
wanted to see whether stereotypes about physical attractiveness would
affect dyadic interactions, since it has been found that attractive people are
assumed to possess more desirable social skills (Berscheid & Walster, 1974).
Before making a getting-acquainted phone call, male undergraduates were
shown a Polaroid snapshot of either a very pretty or a rather plain woman.
The photo was presented as the person he was about to call, although in
fact, each photo was of a woman not in the study. As expected, male
subjects who had seen a photo of a pretty woman were judged more
sociable and friendly than those talking to presumably plain women. Perhaps more important, raters listening only to the women's end of the
conversation found that when women were talking to men who assumed
they were attractive, they were judged to be more confident, animated,
friendly, and likable than the women who were imagined to be plain.
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Although the women were told nothing about their conversation partner's
false preconceptions, they behaved in a manner consistent with being
physically "attractive" or "unattractive."
In addition to school performance and social traits linked with attractiveness, cycles of self-perpetuating bias have been generated and examined for a wide variety of personality traits. Experiments have shown that
when target subjects are expected to act more hostile (Snyder & Swann,
1978), competent (Feldman & Prochaska, 1979), or competitive (Kelley &
Stahelski, 1970a, 1970b), their behavior tends to confirm the perceiver's
expectation.
That people enter an interaction with certain preconceptions, act in
manner geared to elicit behaviors congruent with their conceptions, and
then perceive the behavior as confirming their assumption, was nicely
demonstrated in a study by Curtis and Miller (1986). They found that by
falsely leading subjects to think that another person liked or disliked them,
a subsequent interaction between the partners led the subjects to actually
be liked or disliked correspondingly. Moreover, when expecting to be
liked, subjects disclosed more, used a more pleasant tone of voice, and
engaged in fewer distancing behaviors, such as disagreeing with their
partner. As Curtis and Miller point out, their research demonstrates how
those who believe they will be disliked contribute to their own unpopularity.
Self-fulfilling prophecies appear to be especially powerful when they
involve the maintenance of an individual's self-image. Swann and Read
(1981) report research that strongly suggests people seek out and attend
to information that will preserve their vision of themselves, whether that
vision be as likable or dislikable. Subjects also behaved in ways that
reinforced their self-concept, and they selectively remembered social feedback that confirmed their view of themselves. Thus, confirmation bias
occurred before, during, and after interactions. This was true even with the
subjects who had negative self-images. Subjects who thought of themselves as dislikable, and were interacting with a partner whom they had
been led to believe had a favorable impression of them, tended to
act especially unpleasantly and were actually more disliked by their partners than subjects in other conditions. Swan and Read concluded
that self-verification can be an even more powerful motivation than
self-enhancement.
Keisner (1985) points out how this kind of negative self-fulfilling
prophecy can be played out during the course of psychotherapy. He
describes treating a patient who, from the beginning of their work together, accused Keisner of being selfish, without compassion, and abusive
"just like anyone else." With more candor than shown in many case
histories, Keisner admits that he indeed came to dislike the patient and at
Cyclical Psychodynamics and Megrative Psychadynamic Therapy
357
times wished that the patient would follow through on repeated threats to
end treatment. "In other words," concludes Keisner, "he was successfully
inducing me to feel toward him the way he expected me to feel" (p. 443).
Considerable research supports the view that the expectations of both
patients and therapists inevitably influence the therapeutic relationship and
its success. In Jerome Frank's classic work Persuasion and Healing (1973) and
in the latest revised edition coauthored with his daughter (Frank & Frank,
1991), the role of expectations is linked with placebo effects, symptom
relief, and treatment duration. The authors review studies that show that
inert medications or placebo-attention therapy can be as effective as psychotherapy because the placebos arouse hope in demoralized patients (e.g.,
Arkowitz, 1992; Bootzin & Lick, 1979; Elkin et al, 1989). Symptom relief
after six weeks of therapy has been correlated with patients' optimism
about therapy results measured before treatment begins (Uhlenhuth &
Duncan, 1968). According to Frank, self-fulfilling prophecies play a greater
than average role for people with limited or inflexible social repertoires,
such as the paranoid patient who antagonizes others with a surly, suspicious manner. "Breaking these vicious circles by confronting patients with
the discrepancies between their preconceptions and the world around them
is [an] important goal of psychotherapy" (Frank & Frank, 1991, p. 33).
DEVELOPMENTAL STUDIES OF CYCLICAL PROCESSES
Recent studies in infant development have raised questions about the
conception of infants as passively reacting to environmental forces or inner
drives, and have suggested, instead, that the infant is an active participant
in the creation of its interpersonal world. The new infant research also
describes the infant as shaped and guided particularly by interpersonal
expectancies. Studies have shown that even neonates have the capacity to
detect contingencies between actions and environmental events and to
develop causal expectations (Finkelstein & Ramey, 1977; Millar & Watson,
1979; Watson, 1985). By 3 months of age, an infant needs only two
encounters with a novel event to form expectancies about whether that
event will recur (Fagen, Morrongiello, Rovee-Collier, & Gekoski, 1984).
The cognitive capacity to form expectations develops early, and the
expectancies that the child forms about social interactions with the mother
and other caretakers are thought to form the basis of early inner representations of self and other, even before verbal representation becomes possible
(Beebe & Lachman, 1988; Lamb, 1981). Stern (1985) speaks of the child's
formation of expectations about social interactions as important from the
second or third month in forming a core sense, and he calls such interpersonal expectancies "Representations of Interactions that have been Generalized (RIGs)" (p. 97).
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The terms used by these researchers all highlight the cyclical nature
of the interactions of focal interest. For example, Brazelton and colleagues
refer to "reciprocity" (Brazelton, Kozlowski, & Main, 1974), Beebe and
Lachman (1988) write about the implications of "mutual influence," and
"bidirectional" impact is the focus of work by Cohn and Tronick (1988).
The findings of contemporary infant research suggest that in normal
mother-child dyads, there is a continual exchange of cues in which each
member has an impact on the expressive state of the other (e.g., Cohn &
Tronick, 1987; Jaffe, Stern, & Peery, 1973; Jasnow & Feldstein, 1986; Stern,
1977; Tronick, Als, & Brazelton, 1977).
The study by Cohn and Tronick (1988) of face to face interactions
between mothers and infants used time-series statistical analyses to focus
specifically on whether mothers were generally responding to their infants
or vice versa. These researchers found that mother and child influence was
bidirectional; the mother's positive affective state often induced the child
to join her in a smile, and the child's expressions, in turn, led to shifts in
the mother's state. At ages 3 months and 9 months, mothers and infants
were equally likely to influence the directions of the interaction. However,
when the baby was 6 months old, the mother was more likely to follow
the child's lead, a finding that the authors suggest may be due to developmental changes resulting in increased interest in objects at this age. Cohn
and Tronick also found that at all ages, babies were more likely to respond
to changes in their mother's behavior if the mother was responsive to
changes in their behavior. Within a matrix of sensitive caretaking, babies
quickly learn to attend to and read social cues that lead to positive cycles
of interpersonal exchange.
On the other hand, infants with unresponsive parents may learn that
their social cues are ineffective, as appears to be the case when parental
psychopathology interferes with caretaking skills. Studies of depressed
mothers and their infants have shown that such mothers are less able to
respond appropriately to their babies' signals, and thus the infants experience themselves as having little impact on their social environments (Cohn,
Matias, Tronick, Cornell, & Lyons-Ruth, 1986; Field, 1984, 1986). This
may be one reason why infants and young children of depressed mothers
are at increased risk for developmental problems (Tronick & Gianino,
1986). From the first month, the child develops expectations with regard
to the effectiveness of its interpersonal signals and whether social interactions will be satisfying and enjoyable.
The dyadic reciprocity found by developmental researchers, and the
cyclic impact of expectations, is having growing impact within the psychoanalytic community on therapeutic work with adults. In a paper on
the implications of infant development research for psychodynamic theory and therapy, Zeanah, Anders, Seifer, and Stern (1989) come to con-
Cyclical Psychodynamics and Integrative Psychodynamic Therapy
359
elusions remarkably similar to those on which cyclical psychodynamics is
founded.
[A] major paradigmatic shift away from the fixation-regression model of psychopathology and development is indicated. A new model that better fits
available data is proposed instead. In this continuous construction model, there
is no need for regression, and ontogenetic origins of psychopathology are no
longer necessarily tied to specific critical or sensitive periods in development.
... In the continuous construction model, patterns of internal subjective experience and patterns of relating to others are derived from past relationship
experiences but are continuously operating in the present, (p. 657)
The "continuous construction model" proposed by these authors prompts
them to call for multimodal treatment that focuses more explicitly on the
here and now, especially through the transference relationship.
The view of child development as a continual, interactive, and mutual
influencing process between the child and its environment also makes it
possible to reconcile theorists who insist on the importance of early life
events—the view of the vast majority—with the vociferous minority (e.g.,
Clarke & Clarke, 1976) who argue that negative events that occur during
the first few years of life do not inevitably and irrevocably mar later
development. For example, Kagan (1976, 1979a, 1979b) has argued that
children have an enormous capacity for change throughout life, and that
there is little evidence that events during the first year of life produce
irreversible consequences—what he calls the "tape recorder theory of
development" (1979, p. 886). To support a theory of discontinuity in
development, Kagan presents a comparative study of the cognitive
capabilities of Guatemalan children and American children of the same
ages, who show very different rates of cognitive development in early
childhood, but who end up at similar levels of cognitive functioning by
adolescence (Kagan & Klein, 1973; Kagan, 1976). Kagan attributes this
apparent absence of a predictive relationship between cognitive functioning during infancy and pubescence to the specific cultural expectations of
the Guatemalan parents. In these isolated villages, infants were not generally held or played with and were kept indoors for the first year of life
because the outside sun, air, and dust were considered unhealthy. Kagan's
point is that childrearing practices that in our country would be considered
extreme deprivation, and that would indeed lead to severe and permanent
retardation, have very different outcomes where a lack of stimulation
during the first year of life is the norm. Since the expectations for these
children in later years differ from the dire expectations that would prevail—and be fulfilled—here, the consequence of the early experience is
very different.
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Kagan's view of potential discontinuity in development and the traditional psychoanalytic views of the vital importance of early experience can
be reconciled within the cyclical psychodynamic framework. In our framework, early interactions are important not because they permanently "fix"
or "arrest" development, but because they start an individual on a life
course in which further such interactions are made more likely. They
"skew" development and perpetuate themselves by recreating over and
over again the circumstances for their repetition. This is not a matter of a
"repetition compulsion," an inner force driving one to repeat, but a dynamic in which people are at once author and victim, in which what
happens to them leads them to act in ways that make it likely the same
thing will happen again.
American children reared in as "deprived" a way as Kagan's Guatemalan children are an exception, a specially deprived subclass, and they are
likely to continue in a deprived environment for many years. Moreover,
they are likely to be perceived by those outside their family or social group
as damaged, and to be treated as damaged even by those who treat other
children in a facilitative way. In contrast, the Guatemalan children who are
"understimulated" in the first few years of life, and who are perceived by
American observers as "apathetic," "passive," or "timid," are not a special
subgroup of their own society. They are "normal" children of "normal"
parents and are perceived that way. They are thus in a position to respond
adaptively and effectively to the stimulating experiences that their culture—with a different agenda and timetable—provides in later childhood.
DISCONFIRMATION OF PATHOGENIC EXPECTATIONS:
BREAKING VICIOUS CIRCLES
In contrast to the large body of research about self-fulfilling prophecies, there are relatively few studies that have explored the conditions
necessary for expectations to be broken (Darley & Fazio, 1980; Miller &
Turnbull, 1986). A self-disconfirming prophecy occurs when the original
belief leads to behavior that prevents that expectation from coming true. For
example, falsely expecting someone to be shy and withdrawn might lead
one to act especially solicitous and comforting, thus inducing that person
to open up and behave more gregariously than usual.
Snyder (1984) and Swann and Snyder (1980) suggest that the key
to whether a prophecy is confirmed or disconfirmed lies in the link between the expectation and the individual's hypothesis about how best to
behave, given that expectancy. For instance, teachers may have different
theories about how best to instruct a gifted student. One teacher may
believe that students with naturally high abilities will achieve their potential only with effective instruction, thus generating a self-fulfilling
Cyclical Psychodynamics and Migrative Psychodynamic Therapy
361
prophecy by lavishing attention on the presumably gifted students. Another teacher may believe that gifted students are most likely to bloom if
left alone to develop their natural abilities. In this scenario, the students
may perform more poorly than those believed to be less gifted because
they are never taught the academic skills they need. The teacher's "hands
off" policy may thus lead to a disconfirming prophecy. Empirical investigation (Swann & Snyder, 1980) supports this analysis of teacher hypothesis and student performance.
Motivation also appears to be a key factor in whether prophecies are
confirmed or disconfirmed. Darley, Fleming, Hilton, and Swann (1988)
found that the motivational set with which individuals approached an
interaction influenced whether or not negative expectations were confirmed. These researchers asked college students to interview someone
who they had been led to believe performed poorly under pressure and
became highly emotional during stressful situations. Half the subjects were
told that the goal of the interchange was to choose a partner for a
cooperative, high-stress game, while the other half were told that the goal
was to have casual conversation. The subjects who were motivated to find
a game partner chose to ask questions that would help them find out
whether the targets were calm or frantic, while the subjects choosing
questions for casual conversation did not ask questions that would allow
their expectations to be disconfirmed, and thus continued to view the other
person as frantic, whether or not this was true.
Negative stereotypes may be especially prone to perseverance in the
face of contradictory evidence. For example, Farina and Ring (1965) led
perceivers to believe falsely that a coworker was mentally ill, and found
that the perceivers then behaved in a manner that led the targets to work
more competently than when they were believed to be "normal"—an
example of behavioral di'sconfirmation. However, despite objective measures of competence, the targets were still perceived by their coworkers as
performing poorly. We sometimes see what we expect to see rather than
reality.
Swann and Ely (1984) looked at what happens when two people in
an interaction have conflicting expectancies with regard to the self-image
of one of them. Prior to a social interaction between female undergraduates, Swann and Ely manipulated the perceivers' expectancies so that some
women were certain that their target partner would be introverted, some
were certain of extroversion, and others were relatively uncertain whether
their partner would be introverted or extroverted. Firmly held or not, the
perceivers' expectancies were always the opposite of their partners' true
self-image. The researchers found that target women who started with a
strong view of themselves as extroverted tended to be outgoing and
gregarious during the conversations, continued to view themselves as
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HANDBOOK OF PSYCHOTHERAPY INTEGRATION
extroverted at the end of the experiment, and managed to change the mind
of those perceivers who had expected an introverted partner. However,
when the perceiver was certain of a particular level of extroversion, and the
target was uncertain of her own self-image, behavioral confirmation of the
perceiver's expectations occurred. If the perceiver, for example, expected
the target woman to be introverted, and the target entered the experiment
with a view of herself as extroverted, but with no great certainty about this
view, she tended to act more and more introverted over the course of the
conversations and to modify her own self-image by the end. When we are
unsure of ourselves, we are much more easily swayed by the expectations
of others.
These findings are congruent with the cyclical psychodynamic emphasis on interaction cycles as dependent on the characteristics and actions
of both partners. They provide further understanding of why it is that
patients may sometimes learn to interact in new and adaptive ways within
the therapy hour, yet may revert back to old patterns in interacting with
friends and family, whose expectations and ways of interacting differ from
those of the therapist. The cyclical psychodynamic approach to therapy is
keenly attentive to these phenomena. It is one of the key reasons that work
on the transference is usually complemented by explicit attention to the
patient's interactions in his or her daily life.
Generally, it is necessary to rework over and over again the processes
of skewed perception and behavioral induction that maintain the patient's
vicious circles. Both the patient and significant others in the patient's life
have long-held expectations that are not likely to yield instantly to changes
in the actual events and behaviors encountered. The schemas that are most
central in our psychological difficulties tend to be characterized by an
overemphasis on assimilation and a slowness to accommodate to new
perceptual input (Wachtel, 1987, chap. 2). We continue to see what we
expect to see long after the circumstances that led to that expectation have
changed.
Because all of the schemas by which we grasp reality and interact with
the world—no matter how skewed or rigid—inevitably have elements of
accommodation as well as of assimilation (cf. Piaget, 1952; 1954), eventually our perceptions will accommodate to real changes in our experiences
with others. But because the behavior of others is itself responsive to our
expectations of them, it can often happen that before the patient has
sufficiently recognized the changes that have begun, those changes have
been undermined by the effects of the still persisting old perceptions. That
is, if the other person were to continue acting in new ways toward the
patient, the patient would eventually notice it. But because the patient's
slowness to notice it has consequences, the new circumstances have dis-
Cyclical Psychodynamics and Integrative Psychodynamic Therapy
363
solved before they have been effectively perceived. Thus once again the
expectation is confirmed despite its initial "objective" disconfirmation. And
before they are subjectively and adequately registered, the data of experience themselves accommodate; by the end of the process the "objective"
reality once again matches the reality expected.
The tenacity with which beliefs are held (see Jelalian & Miller,
1984, for a review) also points to the conclusion that insight may not
be enough to lead to change in most cases. A number of lines of research point to limits in the capacity of understanding, however emotionally charged, to shift opinions. Many studies have shown, for example, that when research subjects are misled, their erroneous beliefs
persist even after debriefing (Nisbett & Ross, 1980; Ross, Lepper, &
Hubbard, 1975). If these newly formed self-concepts are so difficult to
modify, how much more impervious are long-standing beliefs about the
self? It is interesting to note in this context that even most "cognitive"
therapies include considerable effort to bring about changes in behavior
and to induce patients actively to test out the assumptions by which
they have been living.
DIRECTIONS FOR FUTURE RESEARCH
While the self-fulfilling prophecy paradigm has influenced research
in the classroom, the workplace, the laboratory, and in casual social
situations, it has not tended to be incorporated into studies of psychotherapy. It is appropriate at this time to test directly how cycles of behavioral confirmation and self-verification are played out within the
therapy hour. It is also time to test the techniques and interventions
deriving from cyclical psychodynamics. As such research is conducted,
we suggest that it should be guided by an awareness of how interactive
patterns and expectations may shape research methodology, and we
find the guiding principles of family therapy process research helpful in
this regard (e.g., Gunman, 1983; Gurman, Kniskern, & Pinsof, 1986;
Wynne, 1984). Specifically, the conceptual framework and methodological guidelines suggested by Pinsof (1989) include an emphasis on the
interaction between therapist and patient systems, "which is nonlinear
and implies bidirectional mutual causality or influence" (p. 55). According to this point of view, therapy process research must be aware not
only of how the therapist influences the patient(s), but how the patient
subtly sways the therapist, how a supervisor makes an impact, and how
the patient's system—not only family of origin but friends and coworkers—maintain the status quo or push for change.
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Future Directions
The cyclical psychodynamic approach to theory and to clinical practice
developed as an integrative effort to incorporate the observations and
concepts of diverse perspectives into a coherent conceptual framework.
Over the years, this point of view has evolved so that in certain respects
it now resembles a "theory of personality" in its own right. This is both
a sign of progress and a signal of danger. The increasing coherence and
comprehensiveness of this point of view are encouraging, as is its fertility
in generating new ideas for how to proceed clinically (e.g., Wachtel, in
press). But it is essential that theorists who are integrative in their intent
not lose track of the spirit of the integration movement. Nothing could be
more alien to this spirit than the development of separate "schools" of
integration, replicating the very parochialism they were designed to transcend (also see Norcross & Newman, 1992).
Further progress in developing the cyclical psychodynamic approach,
therefore, may be expected to derive not only from efforts to incorporate
perspectives from still other established orientations (much as the approach
moved from the integration of psychodynamic and behavioral approaches
to the further incorporation of ideas and methods from family systems
approaches); they will derive, as well, from efforts to synthesize the ideas
and methods of cyclical psychodynamics with those of other integrative
efforts, such as those described in this volume. An integrative theory such
as cyclical psychodynamics is continually evolving and seeking new
sources of nourishment from other viewpoints, at the same time that it
seeks to bring order and coordination into these assimilative efforts.
Cyclical psychodynamics is by its very nature an open-ended approach. It can be expected to change not only as a result of examining and
attempting to integrate other theoretical perspectives, but also from efforts
to come to grips with new empirical observations—those deriving from
controlled research in clinical, developmental, social, and other branches of
psychology, and those based on clinical observation. One of the most
likely sources of new ideas and of changes in the theory is the inevitable
failures and difficulties that will arise in new clinical cases. Failures in clinical
work are humbling, but are also perhaps the most potent potential source
of theoretical development. Nothing is quite as effective in combating
complacency and premature closure as the daily challenges of clinical work.
Finally, one further direction in which the cyclical psychodynamic
point of view is likely to evolve is in the examination of the broader social
context within which people's difficulties develop. This framework has
already been applied in a number of works of social criticism (e.g., Wachtel,
1989), and further explorations of the interface between social and psycho-
Cyclical Psychodynamics and Integrative Psychodynamic Therapy
365
logical processes from a cyclical psychodynamic point of view are in
progress. Because this perspective probes deeply into unconscious fantasies
and unarticulated wishes and expectations without positing a separate
"inner world" cut off from the world of everyday experience, and because
it emphasizes context in all psychological processes, cyclical psychodynamics lends itself readily to psychologically oriented examination of
social processes. Questions of race, class, poverty, quality of life, environmental deterioration, and social values are extremely pressing ones in our
society. It is one of the aims of the cyclical psychodynamic point of view
to address these questions in a way that brings together our understanding
of their psychological foundations and of the social context in which they
are manifested. Such an agenda may be the most demanding of all the
challenges an integrative effort can assume. In today's world, it may also
be the most essential.
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657-668.
PART III
INTEGRATIVE
PSYCHOTHERAPIES FOR
SPECIFIC DISORDERS
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CHAPTER 11
Integmtive Psychotherapy of the
Anxiety Disorders
BARRY E. WOLFE
G
IROUNDLESS EXPECTATIONS have been the chief formative influence in the development of my integrative perspective on the anxiety
disorders. Like so many of my friends in the Society for the Exploration of
Psychotherapy Integration (SEPI), I had the experience of being trained in
a particular orientation, only to be rudely confronted with its limitations
when applied to particular patients or problems. Patients often refuse to
accept the parts assigned to them by the dictates of a given therapy
orientation. Instead, they respond in very individual ways and, in the
process, decimate any grand theory that may be imposed upon them.
Background of the Approach
My training as a therapist served to generate a number of expectations
regarding how patients develop and maintain their emotional problems.
Perhaps the best way to describe the therapeutic approach in which I was
trained is that I learned to talk "psychodynamic" but to practice an eclectic
blend of Rogerian and Gestalt therapy. A patient's problem might be
formulated in psychodynamic terms, but the actual awareness-heightening
therapeutic operations might include "evocative reflection" (Rice & Greenberg, 1984) or the "two-chair technique" (Greenberg, 1979).
As useful as this combined approach has been in the treatment of
some patients, its benefits for many others were limited. I found with
phobic patients, for example, that it provided little resolution of the avoidance behavior, since it lacked a performance-based, confrontative approach
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to the treatment of phobias, which was being touted in the research
literature (Barlow & Wolfe, 1981). Particularly in the area of phobias, I
believed that behavior therapists had a lock on effective treatment. I then
made the popular logical error in thinking that effective treatment necessarily implies an accurate conceptualization of the problem being treated;
therefore, I eagerly received some training in a variety of behavioral
techniques, including a number of exposure-based procedures.
When I attempted to employ traditional exposure therapy, however,
my expectations were unsubstantiated once again. The application of
imaginal exposure to the phobic patient's feared object or situation led to
a series of recurring clinical observations that profoundly altered my conceptualization of the formation, maintenance, and treatment of phobic
disorders. The following observations serve as the empirical foundation for
my etiological model of anxiety disorders.
Exposure-Induced Catastrophic Imagery
I had assumed that anxiety somehow becomes conditioned to the phobic
object and that imaginal exposure would allow the patient to experience the
habituation of that anxiety by means of continual exposure. What I serendipitously discovered, however, was that imaginal exposure uniformly elicited
images of catastrophe associated with the experience of extremely painful
emotions. The imaginal scenes that spontaneously arose would find the
patient in a powerless position, about to be humiliated or badly harmed by
the phobic object. As my patients and I would explore their catastrophic
imagery, we would find that they were either recapturing long-forgotten
traumatic events in their own history or that these images were constructed
prototypes that symbolized their sense of helplessness, powerlessness, and
doom originally experienced much earlier in their lives (cf. Weitzman, 1967).
As the serendipitous discovery of catastrophic imagery became a
routine occurrence in my treatment of phobias, I was increasingly struck by
the irony that unconscious conflicts were being elicited by a therapeutic
approach that denied their existence. Of course, this was not new. Feather
and Rhoads (1972a, 1972b) had demonstrated something like this phenomenon 20 years ago when they attempted to employ systematic desensitization
to previously elicited unconscious fears. Even before that, Stampfl and Levis
(1967) and Weitzman (1967) originally highlighted the importance of
psychodynamic issues in the development and maintenance of phobias.
Anxiety as Signal of Surfacing Painful Emotions
With phobic patients, for example, images of confrontation with the phobic
object would result initially in very high anxiety. If the patient was able to
Integrative Psychotherapy of the Anxiety Disorders
375
experience the anxiety associated with the catastrophic imagery, rather
than trying to avoid or interrupt it, the anxiety eventually would give way
to a variety of feared emotions, including rage, humiliation, shame, hopelessness, and despair.
A similar phenomenon occurred with panic patients for whom there
may not be an external phobic object. These patients typically fear their
body sensations, particularly the sensations of anxiety (Reiss, 1987). Such
patients would be asked to focus on the most prominent body site of
anxiety. Once a patient was able to maintain a continual focus on the
experience of his or her anxiety, one or more of the aforementioned
frightening and painful emotions would be experienced.
It was through such experiences that a patient would come to realize
that the anxiety appeared to function as a signal or an alarm of very
threatening emotions. For example, one patient who suffered from a severe
fear of flying experienced his anxiety predominantly in his throat. He
would feel a severe constriction whenever he imagined himself on a plane.
When we were able to induce this constriction through imaginal exposure,
I would instruct him to maintain a strict attentional focus on his throat.
After doing this for a few minutes, he suddenly burst into sobs as he
reexperienced his long-dormant rage at his mother, which would eventually segue into an intense feeling of extreme sadness over her apparent
neglect. As he experienced and explored the meaning of these feelings, his
anxiety disappeared.
This particular patient, however, found depressive sorrow to be as
painful as the anxiety and panic, and the anxiety reappeared upon the next
trial of imaginal exposure. Repeated episodes of imaginal exposure demonstrated to the patient, beyond doubt, that his anxiety signaled the surfacing of depressive sorrow, a feeling for which he possessed virtually no
tolerance.
Painful Meanings, Painful Sensations
The fear of pain, particularly emotional pain, can be observed in virtually
all anxiety patients. As patients begin to allow themselves to experience
some emotions connected to their phobogenic catastrophes, they discover
that they fear both the sensations associated with the emotion as well as
the meanings embedded in the feeling. The patient mentioned above, for
example, had so little tolerance for negative affect that he terminated therapy for a brief period so that he would not have to encounter the painful affect. Anxiety patients fear both the medium and the
message.
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Symbolic Connection of the Phobia
When phobic patients explore their catastrophic imagery elicited by imaginal exposure to their feared object, they are able quite frequently to
discover the connection between the phobic object and the catastrophe.
One driving phobic patient whose central fear was of being lost, recaptured
the memory of being kidnapped by her father when she was 4 years old
and placed in a house full of strangers. Feelings of isolation, abandonment,
terror, and rage were reexperienced during her imaginal exposure work,
the same feelings that she experiences whenever she gets lost while driving. "Being lost" while driving appears to symbolize her childhood trauma.
But for other patients, the phobic object may be an adventitious element
of the catastrophic scene. For example, another driving phobic had felt his
world coming apart when his wife, while driving him from Sacramento to
San Francisco, told him she was ending their marriage. In such instances,
the phobic object appears to function more as a sign than a symbol.
Experiencing the Dreaded Emotions
Another frequently observed phenomenon involves the diminution of
anxiety that results when phobic and panic patients are able to experience
the emotions they fear. When such patients can maintain a strict attentional
focus on what they fear, whether it be a specific external object or an
internal sensation, they will contact the rage, humiliation, and despair that
appear to be obscured by the anxiety. Often, but not always, patients will
notice that experiencing these feelings is actually less painful than the
anxiety.
All of these observations, I hasten to mention, are predicated on the
patient's being able to experience the anxiety long enough for the catastrophic imagery and the painful emotional processing to occur. But what
if the patient is unable to experience the anxiety? Another set of recurring
clinical observations were made in conjunction with some patients' inability to experience their anxiety.
Metappraising
Perhaps the most frequently observed phenomenon with patients suffering
from an anxiety disorder is their tendency to experience an emotional
reaction to their anxiety. Most frequently emphasized in the published
literature is what Goldstein and Chambless (1978) have called "fear of fear."
Reiss (1987) has investigated the similar phenomenon of anxiety sensitivity. Both constructs describe a two-step emotional reaction that anxiety
patients, in particular, experience: First, they become anxious either for
some unknown reason or because of the situation in which they currently
Integrative Psychotherapy of the Anxiety Disorders
377
find themselves; second, they become anxious about being anxious. As
most clinical investigators have noticed, the fear of fear rapidly escalates
the intensity of the original fear and may well be a specific catalytic process
by which anxiety spikes into panic (Goldstein, 1982).
While my observation of patients becoming fearful of their fear was
ubiquitous, I also began to notice that these patients experience a variety
of emotions in reaction to their first-order fear. They would become angry,
depressed, ashamed, and humiliated by their fear. This form of emotional
processing seemed to be a general phenomenon that uniformly resulted in
the experience of intensely negative affect. In an earlier article, I called this
form of emotional processing "metappraising," an emotional appraisal of a
first-order emotional appraisal (Wolfe, 1989). It was further apparent that
while patients metappraised their fear, they could not experience it directly.
Reflexive Focus of Attention on Self
As I began to ponder the phenomenon of metappraising, it occurred to me
that patients were using their attention in a particular way. Instead of
remaining in contact with their direct experience of the world, they were
focusing on themselves as a person in the ad of being fearful—almost as if
they were watching another person in the throes of fear. As a form of
self-awareness, this way of focusing attention had some properties that
distinguished it from a more immediate perception of one's reactions to
what is happening outside one's skin. Duval and Wicklund (1972) had
described two forms of self-awareness in their social psychological theory
that were distinguished only by the way in which the individual focused
his or her attention. According to their theory, there were two options:
subjective self-awareness, which described a focus on the environment, and
objective self-awareness, which described an attentional focus on self as
object. In short, they were describing a distinction between a nonreflexive
and a reflexive focus of attention. Their description of objective selfawareness comported well with my clinical experience with anxiety patients. Their notion of subjective self-awareness, however, obscures two
different attentional foci.
Reflexive, Sentient, and Exterior Awareness
Reflexive self-awareness is perhaps the easiest attentional focus to define.
Attention is focused on self as object. To achieve this focus, however, we
must remove ourselves from our immediate, direct experience of the world.
Instead of experiencing the world, we are replaying thoughts, beliefs,
images, and fantasies that we have internalized about ourselves. But our
attention apparently can be focused in two other directions, either
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(a) wholly on the environment, with virtually no self-awareness, or (b) on
our in-the-moment experiences of our interactions with the physical and
social world. I have called the former attentional focus exterior awareness,
and the latter focus, sentient awareness. Duval and Wicklund's subjective
self-awareness seems to encompass these two attentional foci (Wolfe,
1992).
An example may clarify. A young man is on a date listening to the
animated conversation of the young woman sitting next to him. His
attention might be wholly absorbed by what she is saying and how she is
saying it, that is, in exterior awareness. Or it might be on his current
emotional reactions arising spontaneously as he listens to her; this is
sentient self-awareness. Finally, he may be wondering what she thinks
about him or whether he is giving the impression that he is listening closely
enough to her; this would be reflexive self-awareness. One's attention, in
reality, shifts back and forth among the three foci.
The point is that our experience of self varies significantly with the
focus of attention. Reflexive thinking, for example, is a self-contained
cognitive-affective process that involves only internal stimuli and our
reactions to those stimuli. If we become fixated in reflexive awareness, we
literally lose contact with the outside world. Sentient awareness is the
direct experience of our felt meanings (Gendlin, 1962), which can include
our in-the-moment "senses of self" or our own personal, emotional reactions to what we perceive outside our skins. Exterior awareness is akin to
direct perception without self-awareness.
Reflexive Self-awareness and Self-endangerment Experiences
Another set of clinical observations ties together the experience of anxiety
and the focus of attention. I have observed that when patients feel themselves significantly endangered, their attention automatically shifts to reflexive self-awareness. At such times, they cannot seem to focus their
awareness on either the task at hand or on their direct experience of the
environment. A case in point is the person suffering from test anxiety who
cannot focus on the examination because he or she seems literally stuck in
catastrophic thoughts about failure and its implications. In the published
literature, an almost identical phenomenon has been labeled "self-focused
attention" (Barlow, 1988; Ingram, 1990). In my model, however, reflexive
awareness represents only one way of focusing attention on the self.
The Nature of Self-endangenneut
Finally, I would like to sketch the nature of this experienced sense of danger
to the self. Quite clearly, it is rarely, if ever, associated with actual physical
Integrative Psychotherapy of the Anxiety Disorders
379
harm posed to the individual. Self-endangerment experiences appear to be
confined to the psychological realm; to fears associated with interpersonal
rejection and loss; to experiences of "self loss"; and to the processing of
extremely painful emotions, particularly shame, humiliation, or despair.
Interestingly, panic patients, for whom many of these fears operate at a
tacit level, and who are habitually hypervigilant for the experience of
unusual body sensations, will convert a nebulous psychological danger into
an imagined physical one with catastrophic thoughts relating to these
sensations.
Upon reflection, I was struck with how closely these self-endangerment experiences mirrored those mentioned by Freud (1926) and several
psychoanalysts who followed him. In his paper on anxiety, Freud proposed
that anxiety is the experience of helplessness, or a signal of impending
helplessness, with further content specification varying according to developmental phase. He referred to this phenomenon as the "epigenetic unfolding of danger situations," which included, in developmental progression,
• Fear
from
• Fear
• Fear
• Fear
• Fear
• Fear
of being overwhelmed by traumatic excitation, from without or
within
of loss of the object of primary care and attachment
of the loss of the object's love
of castration or other bodily punishment or hurt
of superego, conscience, or social condemnation
of abandonment by the powers of fate
Anna Freud (1946) spoke of several types of "narcissistic catastrophes," such as fear of fusion, fear of ego disintegration (self loss?) in the face
of excessively strong drives, fear of humiliation, fear of loss of self-esteem.
All of these fears have been observed clinically in anxiety patients when
they have been confronted with the objects and situations that they
consciously fear. It should be noted that the perception of a danger
situation is always relative to the person's ability to cope with that particular situation. The danger may be specific to the situation or may be a more
general problem relating to a deflated sense of coping ability.
ETIOLOGICAL ODYSSEY
These observations of what happens when anxiety patients can and
cannot experience their anxiety for any length of time progressively altered my sense of the etiology of these disorders. While there was no
denying the potency of exposure-based therapy, the behavioral conception
of the acquisition and treatment of phobias left much to be desired. In fact,
considering the kind of material that continually turned up in imaginal
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HANDBOOK OF PSYCHOTHERAPY INTEGRATION
exposure, I began to wonder what was so wrong with the original psychoanalytic conception of the development of a phobia. The information
obtained from the imaginal exposure work appeared to confirm several
aspects of the psychoanalytic model of phobia acquisition: (1) that catastrophic, unconscious conflicts were at the root of the phobia; (2) that an
internal danger had been displaced onto a concrete, external reality (i.e., the
phobic object or situation); (3) that the phobic object or situation bore some
relationship to the conflict, usually a symbolic one; and (4) that an unmanageable internal danger was made manageable by displacement and projection onto an external object or situation.
But the Freudian model of phobia deemphasizes the emotional processing of personal meaning in favor of drive or instinctual dynamics. The
Freudian drive metapsychology is, by common consensus, the least compelling aspect of this theoretical orientation. The corrections in emphasis
offered by the recent theoretical developments in the self psychology and
object relations versions of psychoanalysis move it closer to a psychology
of meaning that, in my view, offers a more accurate picture of the phenomena of anxiety disorders.
What was also surprising was the frequency of childhood traumas
that phobic patients apparently experienced at the hands of their caretakers. Although, these traumas were occasionally sexual in nature, more
often they concerned disillusioning experiences of abandonment by—or
the unreliability of—the patient's caretakers. The question of whether
psychopathogenic traumas are real or imagined is one that has been
debated since Freud's time. As is well known, the course of psychoanalytic
history and theory experienced a sea-change when Freud abandoned his
own sexual trauma hypothesis in 1897. I would suggest—as Bowlby
(1988) frequently has—a second look at the possibility that there are many
more real traumas happening to our patients than is typically believed.
Whether or not these catastrophes were "real" in any veridical sense,
they had a profound effect upon the anxiety patient's self-experiencing, in
terms of both the patient's immediate self-experience and self-beliefs. The
price of such childhood trauma is the recurring, jolting experience of
self-endangerment or loss of safety. Although such self-experiences are
most prominently felt when confronted with the phobic object, they reflect
more enduring self-beliefs and unresolved conflicts about one's self. Exposure therapy has been found to be most helpful in dealing with the phobic
avoidance behavior in the short run. But for long-term, durable change, it
appears that these underlying issues of self-experience have to be addressed.
Exploration of patient self-experiencing began to show the importance of tacit emotional processing, or, put more simply, the difficulties that
phobic patients generally have with the experience and expression of
Integrative Psychotherapy of the Anxiety Disorders
381
particular painful feelings. Such issues, however, seemed to be tailor-made
for an experiential therapeutic approach, which brought me full circle back
to the virtues of my original orientation.
In summary, I started from an experiential-dynamic frame of reference, flirted with behavioral conceptions, returned to a more psychodynamic view of the phenomena, and most recently see much potential in a
cognitive-experiential perspective. This is to say, of course, that all of these
perspectives contribute insights into the phenomena of anxiety disorders.
But their limitations also highlight the need for an integrative framework.
Treatment Approach
Groundless expectations have been as instrumental in the development of
my treatment approach as they were in shaping my current thinking
regarding the etiology of anxiety disorders. As mentioned earlier, I had
been led to believe that the application of exposure therapy for simple
phobias, for example, would lead to a fairly rapid reduction or elimination
of phobic symptoms in at least 60 to 70 percent of the cases (Barlow &
Wolfe, 1981). In fact, for the phobic patients that I see in private practice,
simple phobias are not so simple. Sometimes, exposure therapy would lead
to a rapid reduction in symptomatology. Often, however, patients experienced at least three other outcomes: (1) they found the exposure therapy
too frightening, however gradual it might be, and were not able to complete the treatment; (2) they would experience symptomatic relief, which
would not last; and (3) they were able to reduce their avoidance behavior,
but would continue to experience substantial anxiety whenever they confronted their feared object or situation.
Thus it became apparent that it was necessary to treat more than just
the phobic symptomatology and thus to do more than just exposure
therapy. And to do that one had to discover whether the phobia existed
as an independent, circumscribed disorder or whether it was connected to
other issues and problems in the patient's life. In the small and biased
sample of patients that I see in my practice, it is the rare individual who
presents with a circumscribed simple phobia. In the majority—but not
all—of cases that I have treated, simple phobias turn out to be quite
complex disorders involving dysfunctions in a variety of areas in the
patient's life, and these dysfunctions turn out to be integrally connected to
the patient's phobia.
The limits of exposure therapy and the serendipitous discovery of
tacit catastrophic emotional processing suggested that an integrative therapy was necessary for the resolution of a phobic disorder and the various
issues associated with it. The two major therapeutic approaches to the
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treatment of phobias have dealt with only a subset of the issues involved
in these disorders. The psychoanalytic error was to focus only on the
underlying issues, ignoring the phobic symptoms. The error of behavior
therapists has been to focus only on the phobic symptoms, ignoring the
underlying issues. It was apparent that both symptoms and associated
issues need to be addressed. The two foci appear to be united by a concern
with the endangered self, that is, the patient's anticipation of a state of
helplessness.
THE GOALS OF TREATMENT
In the case of a complex phobia, the overall goal of treatment is
self-repair, which involves both alterations in the individual's self-concept
and in the process of self-experiencing. The subsidiary goals of self-repair
include
• Enhancing the individual's sense of agency, or self-efficacy
• Increasing the individual's tolerance for emotional experience, but particularly negative affects
• Reducing the various defensive interruptions to sentient selfexperiencing
• Restoring a better balance between reflexive and sentient self-awareness
• Increasing the patient's ability to engage in authentic relationships (i.e.,
relationships in which one allows oneself to be known and to know the
other)
• Restructuring toxic self-representations
In an earlier article (Wolfe, 1989), I outlined a treatment approach
involving a sequence of four basic steps:
1.
2.
3.
4.
Establish the working alliance.
Elicit phobogenic and panicogenic conflicts.
Teach anxiety-management techniques.
Resolve conflicts.
These four treatment stages simultaneously targeted phobic and panic
symptoms as well as the phobogenic and panicogenic traumas and conflicts. With an increasing focus on issues of self-experiencing, I began to see
how each of these treatment stages contributed to the repair of specific
aspects of self-experiencing, both the contents of self-experiencing (e.g.,
immediate senses of self and self-representations) and the processes of
self-experiencing (attentional focus, emotional processing, and defensive
interruptions).
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ESTABLISHING THE THERAPEUTIC ALLIANCE AND REPAIRING TRUST
Phobic and panic patients often begin therapy quite distrustful of both
the therapist and themselves. The personal and interpersonal dynamics of
trusting have their source in the close relationship between how one is
treated by others and how one sees oneself (Guidano, 1991). If the actions
and communications of others toward us suggest that we are not trustworthy, or if our general experience with others is that they are not
trustworthy, then the task of coming to trust ourselves is made all the more
difficult. So repairing the patients' ability to trust another contributes to
their ability to trust themselves. The source of distrust in both cases is often
childhood interpersonal traumas inflicted by caretakers. The evolution of
trust, therefore, is a difficult process for phobic and panic patients. Consequently, trust is usually the first issue that is negotiated in therapy, either
as an explicit or a tacit issue.
A frequently occurring phobogenic conflict in agoraphobic patients,
for example, involves the bipolar dimension of freedom versus security.
Each pole possesses both a positive and a negative valence. Freedom
connotes autonomy and isolation; security connotes being cared for and
being controlled. With such patients, therapists will be called upon to pass
very specific tests of trustworthiness (Friedman, 1985; Weiss & Sampson,
1986). Can therapists care for without controlling agoraphobic patients? By
the same token, can therapists allow patients to function autonomously
without abandoning them? Unless the therapists pass such tests, agoraphobic patients cannot make use of any of the specific therapeutic techniques, including imaginal or in vivo exposure. The first therapeutic task
then is for therapists to establish their trustworthiness, and for patients to
acknowledge to themselves this trustworthiness.
To the extent that the therapist is being trustworthy, he or she is
providing the patient with important information to be assimilated. But
because of past disillusionments and resultant fears of disappointment,
the patient may find it difficult to acknowledge the therapist's care and
concern. Part of the alliance-building phase of therapy will include identifying the various ways the patient defensively interrupts his or her sentient experiencing of the therapist's trustworthiness. As these defenses
are identified and found to be inapplicable in the present context, the
patient may begin to experience sentiently the therapist's trustworthiness. The resurrection of sentient experiencing will begin to lead to a
corrective emotional experience regarding the dependability of a significant other.
The sentient experiencing of the therapist's trustworthiness indirectly
contributes to the rebuilding of the patient's sense of self-efficacy. With the
therapist as ally, the patient feels more confident of his or her ability to face
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HANDBOOK OF PSYCHOTHERAPY INTEGRATION
the phobic object or situation, and to endure the automatically occurring
anxiety.
ELICITING THE TACIT CATASTROPHIC IMAGERY
When some modicum of trust has been established by the therapist
and acknowledged by the patient, we are ready to move to the next stage
of treatment. In the case of phobics, this entails imaginal exposure to the
feared object. In the case of panic patients, it involves a strict attentional
focus (i.e., interoceptive exposure) on the bodily sites of fearful sensations.
In both instances, the procedure begins the same way, with a breathinginduction exercise. This induction procedure helps the patient tune out
competing stimuli from the external environment, allowing him or her to
focus attention inwardly.
The patient is then invited to be receptive to his or her internal
productions, that is, to any thoughts, feelings, images, or ideas that arise
automatically. In the case of phobias, the patient is asked to imagine the
feared object or situation, and while intensively focusing attention on the
phobic scene, to notice any automatically arising feeling or thought. In the
case of panic disorders, the patient is asked to identify the most prominent
bodily sites of anxiety or fearful body sensations and to maintain a strict
attentional focus on these sites. Typically, within one or two sessions,* this
procedure results in the appearance of several thematically related and
emotionally laden images. The imagery is imbued with themes of conflict
and catastrophe that the patient is helpless to prevent or terminate. One
interesting feature of applying this procedure with panic-disorder patients
is that whereas, consciously, their fears are about physical destruction, the
tacit catastrophic imagery is most often about psychological destruction.
The goals of this version of imaginal exposure depart somewhat from
those of the more behavioral version. The experience of anxiety is not only
for the purpose of learning that the feared disaster will not take place or
that the anxiety will habituate, but also for the patient to uncover the felt
catastrophe and to experience the associated feelings.
Imaginal and interoceptive exposure have the potential to benefit all
of the various senses of self; redress the imbalance between reflexive and
sentient self-experiencing; enhance the processing of painful emotions;
identify the tacit, negative self-representations; and elicit the various ways
in which patients defensively interrupt their immediate experiencing. By
staying focused on the body site of anxiety until the conscious emotional
*H usually takes longer with panic-disorder patients because they have great difficulty
contacting emotionally laden imagery. Despite this, however, the procedure is almost
uniformly successful in eliciting the panicogenic, catastrophic imagery.
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processing begins, panic-disorder patients experience several positive
senses of self: they learn that they do not fall apart (coherence), are not
destroyed (continuity), can tolerate negative affects (coherence and
agency), and can master their fear and expand their behavioral horizons
(agency). Once they begin to experience the various dysphoric emotions,
we can identify the toxic self-representations that need to be modified as
well as the conflicts that need to be resolved.
A content analysis of the modal conflicts of phobic and panic patients
tempts me to offer the following generalization: in the broadest sense, the
issues of conflict are existential. By that I mean that the conflicts involve
confrontations with difficult, unavoidable human realities. While the conflicts were probably developed in the context of historical interpersonal
traumas, then and now they relate to several realities that we all must face:
the inevitability of loss; the experience of a separate consciousness; the
yoke of personal responsibility; the ubiquity of anxiety; the struggle for
self-esteem; the unavoidability during that struggle of experiencing selfdenigrating emotions such as humiliation, guilt, and shame; the awareness
and acceptance of our mortality; the need to equilibrate our actions and our
expressiveness in the face of sociocultural demands; and, finally, the need
to engage in painful negotiations between the quest for freedom, autonomy, and novelty, on the one hand, and comfort, security, and safety, on
the other (cf. Koerner & Linehan, 1992).
TEACHING ANXIETY-MANAGEMENT TECHNIQUES
In addition to exploring the feelings that underlie anxiety, patients
need a sense of increasing control over the anxiety when it begins to
escalate. In other words, patients need to be taught ways to turn off the
alarm switch, and to cope with their anxiety when they encounter the
phobic object, or, in the case of panic patients, when they experience
frightening body sensations. One effective technique now generally used
for modulating the levels of anxiety is diaphragmatic breathing. Patients
are taught this slow, deep-breathing procedure for use during in vivo
exposure. Generally, it has been successful in bringing an immediate decrease in the level of anxiety.
A second procedure attempts to deal with the catastrophic thinking
that usually accompanies the experience of frightening body sensations.
Didactic prompts are used to reassure patients that the anxiety they are
experiencing, while unpleasant, will not lead to any life-threatening
cardiovascular dysfunction, will not make them go crazy, and will eventually dissipate. Patients are told to reflect on recent experiences of anxiety or panic attacks to verify that these catastrophes do not usually take
place.
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HANDBOOK OF PSYCHOTHERAPY INTEGRATION
RESOLVING CONFLICTS
Once the tacit, catastrophic conflicts have been identified, a major
focus in therapy concerns their resolution. Conflict resolution essentially
involves the creation of a synthesis between incompatible aims. The steps
in resolving conflict include (J) identifying the poles of the conflict,
(2) employing the two-chair technique in order to heighten the experience
of each pole, (3) beginning a dialogue between the two poles in an effort
to create a synthesis, and (4) making a provisional decision to take specified
steps toward change. Once a decision has been made regarding specific
behavioral changes, the next step is to take action and allow sentient
experience to inform the patients of the results of the change steps taken.
Successful outcomes that result from these self-fashioned choices increase
the likelihood of a change in dysfunctional self-representations. As the
patients try to change, they will encounter the specific ways in which
sentient experience is defensively interrupted, and additional work will be
necessary to limit the impact of these defenses and thereby enhance sentient self-experiencing.
Other Treatment Modalities
Since the generative context of phobic and panic disorders is frequently, if
not always, interpersonal, it is often the case that interpersonally formatted
therapies are quite helpful in the resolution of these disorders. Marital and
family therapies often play a significant role in changing interpersonal
patterns that have influenced the anxiety-disorder patients' war against
their own sentient self-experiencing. Marital therapy, for example, is often
the context in which new patterns of self-experience are forged.
While the patterns of self-experiencing may have developed independent of their marriage, the marital relationship of panic patients often
reinforces these patterns. Even in relatively untroubled marriages in which
the panic/agoraphobic patient's spouse is quite supportive, the patient will
often employ the spouse in the service of protecting him or her from
painful feelings. Thus, for example, one patient would call her husband and
ask him to leave work and come home whenever she began to feel bad. His
arrival often did have the effect of reducing her anxiety or other dysphoric
feelings, but it also allowed her to avoid confronting whatever issues were
keeping her agoraphobic. In this instance, marital therapy was instrumental
in helping the patient assu