PSYC 8343: Psychotherapy Interventions II “Integrative Therapy” Program Transcript NARRATOR: Doctor Norcross begins this video program by describing four major types of integrative therapies. He then explains the strong relationship between integrative therapies and evidence-based practice. JOHN NORCROSS: Psychotherapy integration is characterized by dissatisfaction with single school approaches, and then a concomitant desire to look past school boundaries to see how patients can benefit from other ways of conducting psychotherapy. So psychotherapy integration, or integrative therapy, begins with the realization that any singular treatment will not suffice for the multitude of patients and complaints that we encounter daily. Then after that, we begin looking around saying, well perhaps there's a better treatment method, a different therapy relationship, a different treatment format, that would be effective for this particular patient. In the psychotherapy integration movement, we identify four major paths to the integrative summit. The first, and probably the oldest, is common factors. And this is shown in the work of Jerome Frank, Sole Garfield, and early proponents of looking for what different therapy share in common. Insofar as they were able to survive the distortions in each approach, there's something surely curative and important about those. Some of the most commonly cited therapeutic commonalities include a warm and supportive therapeutic relationship, cultivating positive expectations of the clients, using some novel or experimental behavioral measures so that the client experiences something new and different. A second major path to psychotherapy integration is technical eclecticism. And here, the founder of technical eclecticism is Arnold Lazarus, followed by Larry Beutler and other people. They, like other technical eclectics, seek to use effective techniques in a given case. It doesn't matter where those particular techniques may have originally hailed from, because they don't endorse the underlying theoretical or epistemological commitments. They're just the pragmatists among us that say, this works for this disorder and patient. Let me try it in this case. So as the name indicates, it's technical eclecticism. They're taking specific techniques or treatment methods and using them in a given case, largely based upon the research and past experience and what's worked. © 2012 Laureate Education, Inc. 1 The third major path is theoretical integration, and as that term designates, this is more theoretical. Here, we try to blend entire theories or systems of psychotherapy. So the work, for example, of Paul Wachtel, trying to bridge psychoanalytic and behavioral, or the work of Jim Prochaska and Carlo DiClemente, transtheoretical, trying to combine many different systems of psychotherapy. And fourth and final, there's what's known as assimilative integration. This is somewhat more recent and a little more controversial in that the psychotherapist maintains their theoretical commitment, let's say it's psychodynamic or cognitive behavioral. And then they selectively integrate or assimilate into that home theory particular techniques or methods that may be indicated. Now, it's somewhat controversial because some people see this as a way station. These are the people who haven't really committed to full-bodied integration. They hold onto their treasured theoretical proficiency, but gradually assimilate. So it's certainly a movement toward full integration. Many paths to an integrative summit, or many roads to Rome. Integrative therapy can accommodate all of these paths. Over the years, I've thought long and hard about optimal practices of cultivating an integrative perspective. First, it begins with a systems of psychotherapy course like this one that exposes you to multiple theories. It gets you thinking pluralistically, flexibly, integratively about the various options available. Then that should be followed with some sort of course that helps you develop helping skills. These are the relationship skills. All too often these days in training we simply talk about, well, I'll try to be empathic, I'll be supportive. I'm talking about one of the good, old-fashioned skills-based courses that teach one how to be empathy, how to ask questions, reflect, and clarify. These need to be established skills, not just paper ideals. We move on forward to other courses, naturally enough. But then, we're looking for a seasoned, flexible supervisor, someone who can help you appreciate when specific treatment methods, formats, and techniques might be indicated for someone. So a non-doctrinaire, non-purist. In fact, that supervisor doesn't even have to declare that he or she is integrative, just that it's someone who can see the bigger picture. © 2012 Laureate Education, Inc. 2 From there, personal therapy. In many ways, personal therapy occupies the center of the psychotherapy universe. How we become committed to change, what we learn from our therapist, what it's like to be on the other side of the couch, so to speak, and that sensitivity. And for an integrative person, I always encourage people, if they have the time and the financial opportunity, to seek at least two personal treatment experiences, people from different theoretical orientations so they can see how they're touched in different ways. Because each theoretical orientation, and indeed each person of the therapist, has a way of reaching us that perhaps in other ways wouldn't. In the same way in the humanistic tradition we would be touched differently by Carl Rogers than, say, Fritz Perls, in the psychodynamic tradition, Freud may be different than one of the short-term dynamic therapists. So we encourage people to seek at least two. And then finally, we actually ask people, in developing an integrative perspective, to get out of psychotherapy into the broader world, to enhance themselves through a training experience or course outside of psychotherapy proper. So with that, we are reminded that people change in lots of different ways, not just through psychotherapy. This could be yoga, this could be martial arts, it could be a group encounter, it might be a spiritual pilgrimage of some type, it may be through a series of self help books. The point is to cultivate this understanding that integration surpasses the melding of individual psychotherapy theories. It's part of a broader, inclusive, allencompassing behavior change. And when we experience that ourselves as psychotherapists, we immediately translate and bring that back into the immediacy with our patients. Integrative or eclectic psychotherapy is the most popular theoretical orientation of United States psychotherapists, and in fact, those in the Western European nations. We've conducted a series of studies over the last 20 years and eclecticism-- or increasingly, the favored term, integration-- consistently emerges as the modal, the most popular. Now, it's not the majority, but is the modal. 30% to 35% of psychotherapists routinely endorse eclecticism or integration as their primary theoretical orientation. © 2012 Laureate Education, Inc. 3 But the actual number may be even higher. While only about a third of psychotherapists will say this is my primary theoretical orientation, if you ask the question differently, you get about 90%. If you ask them, our treasured colleagues, our psychotherapy colleagues, do you only use one theory in your practice, only 10% respond in the affirmative. 90% will say, of course I use multiple theories, or the techniques that have spawned from them. So there are very few, probably 10%, theoretical purists around. In practice, most of us are eclectics or integrationists. Most of us deal with the daily reality of clinical practice, which requires a pragmatic, if not integrative, perspective. Many students of psychotherapy are confused about these distinctions, particularly between technical eclecticism on the one hand, and theoretical integration on the other. Technical eclecticism uses demonstrably effective procedures from diverse theoretical perspectives, and uses them at different times, in different sessions, with different patients. It is technical. What is being combined are different treatment methods, independent of the theoretical heritage. By contrast, theoretical integration tries to combine entire theories, and while it may be impossible to theory smush, at least we can build bridges between the two of them. So one is more technical, one is more theoretical. One's more realistic and pragmatic-- technical eclecticism-- one is a little more grandiose, some people even argue, idealistic. Let's think of it this way. If you had some friends over for dinner and you served different dishes throughout the evening, you would be a technical eclectic. You might have a Mediterranean salad, you might have a Norwegian salmon, and then a desert from Mexico. That would be technical eclectic, different things all wrapped together. But if you were a theoretical integrationist, you would try to create one mega-dish with the ingredients from different countries. That's, in essence, the difference between technical eclecticism and theoretical integrationists. And even as we say that, it should be clear that they all get to the same place. And if you were to watch a technical eclectic versus a theoretical integrationist, as you may not see that many observable differences in actual therapist behavior. There's a natural affinity between psychotherapy integration and evidence-based practice, because the ultimate outcomes of doing both of these are to enhance © 2012 Laureate Education, Inc. 4 the effectiveness, be that for an individual client or be that for the populace as a whole. We don't simply integrate for fun, or wouldn't that be interesting? We pursue integrative therapy because we're convinced, in many cases anyway, that borrowing and begging from different schools enhances the success of psychotherapy. Well of course, that's precisely the overarching goal of evidencebased practice. We take the best available research, we combine that with clinical expertise in the context of patient characteristics, culture, and preferences, in order to enhance psychotherapy. So they really are quite simpatico in that regard. In the end, we do all this to increase the success of psychotherapy. Once we access the research literature and identify a research-supported treatment, we don't automatically apply that to the case at hand. Instead, we go through a clinical decision making process in which we say, does this fit the current case? We call this the three A's. A clinician can decide, once they have in hand a research-supported treatment, to adopt that particular treatment method, to adapt it in some way, or to just abandon it because it doesn't seem to fit for various reasons. Of course, we want to adopt it whenever possible, because the research suggests it's safe, effective, and it outperforms either nothing or some other treatment method. But sometimes, we need to adapt it. Most of the research in this area have been done on cultural adaptations, that the research has been performed on a population that doesn't match the patient or patient population with which we're working at the moment, so we may need to adapt it to their language, to their icons, their symbols, to their spiritual faith, to their sexual orientation. So that's what we mean by adaptation. And fortunately, the research shows that these treatments adapted work just as well, whether to the pure forms of it. So cultural adaptation doesn't necessarily make it more effective, but at least it's no more ineffective. So they're comparable. And in many cases, you're going to need to adapt it, or the client will find it just unsatisfactory. And the third A, of course, is we can abandon it. We may come in with a particularly good treatment, say for anxiety disorders, say panic control therapy, which is certainly a leading entry on all the evidence-based lists. But the patient may say, I tried that before, I don't like it. That's not my goal. There may be no one within a low-income mental health clinic that can immediately provide that © 2012 Laureate Education, Inc. 5 therapy and there's no other options. The patient may say, but I want to be in group therapy, where perhaps that's not offered. So the three A's, the adopt the research-supported treatment, the adapt, or the abandon, is always up to the psychotherapist. We start with research. We want to be guided and informed by research, but we cannot be shackled by the research. And that's why, of course, there's three pillars, not one, of evidencebased practice. Psychotherapy integration, or some variant of it, certainly constitutes the future of psychotherapy. That is the developmental growth of any scientific and applied field. When we think about psychotherapy integration in the future, we can think or conceptualize this as two steps, and we're currently finishing just the first step. Psychotherapy integration is the first step in that it has been fabulous in removing our theoretical blinders, opening ourselves up to new treatment methods, formats, and theories. The second step, which we're just beginning now, is to know exactly when and with whom to use those multiple treatment methods, formats, and theories. This will embody Gordon Paul's classic question, what treatment, by whom, with which presenting problem, is most applicable in this situation? So psychotherapy integration constitutes that first step. It's liberated us, it's pluralistic, it's pragmatic. Let's not be bound by the ideological cold wars of 20 years ago. It says, let's move forward. But now, in concert with evidence-based practice, we need to know specifically when to do what. This is the mandate of prescriptive matching, and it coincides beautifully with evidence-based practice, to match to the patient's characteristics, cultures, and preferences. In the future, psychotherapy integration will insist that we follow the broadened definition of evidence-based practice. Most people immediately think about treatment methods when we refer to evidence-based practice, but this process refers to everything we do as psychotherapists, how we assess a client, how we formulate a case, how we establish and maintain the therapeutic alliance, how we monitor patient progress, how we make mid-treatment adjustments, how we terminate, how we consult, how we teach. It isn't simply treatment method. © 2012 Laureate Education, Inc. 6 And of course, as a pluralistic movement, psychotherapy integration wants to be inclusive. It would say look, it's just not looking at the research a treatment method, let's look at everything we do. In fact, if you truly a good scientist, you'll begin with the therapy relationship-- you'll eventually end up at the treatment method, it's not either/or-- but one needs to look at both of them. Psychotherapy integration predictably says, let's have a broad, inclusive tent. Let's use the correct definition of evidence-based practice that refers to every clinical practice. In the future as well, psychotherapy integrationists will remind us that we need to conceptualize the behavior change enterprise a little more broadly than simply saying, which psychotherapy theory? That is, we should be thinking about all of these ways in which people can successfully change, with and without psychotherapy. So integration, in this enlarged sense, can refer to the synthesis of different treatment formats, individual, couple, family, network. It can refer to using Eastern and Western, integrating self help into psychotherapy, medication with psychotherapy, combining faith and religion with psychotherapy. Psychotherapy is only one means of effective behavior change. Now of course, many of us have devoted our lifetimes to this, but it doesn't mean it's the only effective way to change. In the future, psychotherapy integration will insist, if not demand, that we look at all effective means of behavior change and not be so therapist-centric to think it's only what happens in 50-minute sessions. Why isn't everyone an eclectic or integrative therapist? Because it's awful hard work on many levels. It's difficult to become a competent practitioner in a single theoretical orientation. Now in integrative eclectic, we're asking for two or more theories in which you would be competent. So it's additional commitment to training, additional hard work. On the level of an individual session, that means each session will necessarily be different depending upon the patient, the problem, the personality, the preferences. That's a lot of work for a therapist hour to hour. It is incontrovertibly easier to do the same brand of therapy for six hours a day than to go through the mental work of telling treatment each patient, even moment to moment. So it's hard on even a societal level. To say I'm an eclectic or integrative therapist doesn't exactly brand you into a prestigious camp. In fact, many people will say, well you just can't commit. One of my colleagues once commented that an eclectic therapist is best defined as a © 2012 Laureate Education, Inc. 7 muddle-headed person with both feet straddling a fence. So it has an emotionally ambivalent connotation. There are organizations that support the development of integration, principally the Society for the Exploration of Psychotherapy Integration, SEPI, S-E-P-I. But it's not the same as the multitude of journals and professional organizations, that coherent identity one has by saying, I'm a psychoanalyst, or I'm cognitive behavior, or I'm a humanist. It's still a little diffuse identity. So it's hard work on many levels to be an eclectic. On the other hand, we obviously think it's worth it, because eclecticism is all about effectiveness. At the end of the day, we are eclectic, we integrate, because we believe it's the best for our patients. As we move into a new health care economy, it's no longer about the therapist's preferences or theoretical identity. It's supposed to be about, what will work best for this particular client? That's the mandate for eclecticism and integration in psychotherapy. © 2012 Laureate Education, Inc. 8
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