Ch. 9

1
Ch. 9 Integrative Approaches to Psychotherapy

• PSYC E-2488
• 12/10/07

2
Exercise (15 minutes)

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

3
Historical Background

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

4
Historical Background cond.

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

5
Historical Background cond.

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

6
The Concept of Personality

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

7
Psychological Health and Psychopathology

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

8
Psychological Health and Pathology cond.

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

9
The Process of Clinical Assessment

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

10
The Practice of Therapy

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

11
The Practice of Therapy cond.

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

12
Curative Factors or Mechanisms of Change

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

13
Treatment Applicability and Ethical Considerations

• Uniquely suited to a diverse group of patients
  and problems
• Patients issues guides the therapy and
  emphasizes the uniqueness of the approach
• See McCulloughs CBASP , Chambless et al., and
  Linehans DBT as examples of integrative
  approaches applied to frequent and refractory
  disorders/problems
• The problem, integrative model, and patients
  goals determine the limits of the treatment
• Example Iris Fodors integration of Feminist,
  CBT and Gestalt Therapies

14
Research Support

• Models with support include Linehans DBT,
  Beutlers Prescriptive Therapy, Prochaska and
  DiClementes Trans-theoretical Therapy, Klermans
  Interpersonal Therapy for Depression, Greenbergs
  Process-experiential therapy, McCulloughs CBSP