Integrative/Eclectic Therapy

Eclecticism, or integration, is now the most common theoretical orientation among counselors and psychotherapists in the United States. This has not always been the case. In the mid-20th century, three dominant theories of counseling and psychotherapy were often viewed as distinct and incompatible: psychoanalysis, behaviorism, and humanism. Less contradictory forms of therapy evolved during the second half of the century, and counselors began to combine strategies from diverse theories in an eclectic manner. Early eclecticism was often criticized for its lack of an underlying theory and the absence of formal guidelines to help counselors make decisions. In response, more formal models of integrative psychotherapy were developed, and today four general routes to integration are recognized: (1) common factors, (2) technical eclecticism, (3) theoretical integration, and (4) assimilative integration. In this entry, formal models of integration are described that exemplify each of these general routes.

Common Factors

The common factors route to integration identifies core ingredients that most forms of psychotherapy share. The advantage of common factors is the emphasis on therapeutic actions that have been demonstrated to be effective. The disadvantage is that common factors may overlook specific techniques that have been developed within particular theories.

Jerome Frank and Julia Frank analyzed cross-cultural approaches to healing and identified the following common factors: (1) an emotionally charged, confiding relationship with a helping person; (2) a healing setting; (3) a rational, conceptual scheme, or myth that provides a plausible explanation for the client’s symptoms; and (4) a ritual or procedure that requires the active participation of client and therapist and that both believe to be the means of restoring the client’s health. The analysis concluded that the active ingredients in psychotherapy are not unique or new but have been used by healers around the world for many centuries. Research has demonstrated the importance of the therapeutic alliance as well as other common factors.

Scott Miller and his colleagues have described a contemporary common factors approach that ensures that clients experience the kind of changes they desire. This approach is based on research demonstrating common factors related to the client’s role in extratherapeutic change, the therapeutic relationship, and expectancies for change. Miller emphasized the importance of working within the client’s frame of reference as the defining “theory” for psychotherapy, in order to support active participation in shared goals. The therapeutic alliance is strengthened when counselor and client come to a consensus on the methods of treatment and share an emotional bond. There is also ongoing attention to the client’s experience of the therapeutic relationship and active attempts to address problems in the relationship when they arise.

Technical Eclecticism

Technical eclecticism is designed to improve the therapist’s ability to select the best treatment for the person and the problem. This route to integration is guided by empirical data on the efficacy of different methods. The advantage of technical eclecticism is that it encourages the use of diverse strategies without being hindered by theoretical differences. A disadvantage is the lack of a clear conceptual framework describing how techniques drawn from divergent theories fit together.

The most well-known model of technical eclectic psychotherapy is Arnold Lazarus’s multimodal therapy. This approach begins with a thorough assessment of seven modalities: behavior, affect, sensation, imagery, cognition, interpersonal relationships, and drugs/biology. Multimodal therapy represents an ongoing attempt to adapt therapy to the individual. The form and style of therapy are adapted to each client’s particular needs.

Larry Beutler’s model of systematic treatment selection represents another model of technical eclecticism. His approach uses research-based conclusions to describe principles of treatment and to identify the best interventions for particular clients. Clients are assessed on variables such as coping style, resistance level, and emotional arousal. Therapists choose a treatment focus and specific strategies that are consistent with these client characteristics. For example, psychotherapy strategies that focus on symptoms or skill building, structured problem solving, correcting dysfunctional thought patterns, homework assignments, and relaxation training may work best with clients with an externalizing coping style. In contrast, clients who use an internalizing coping style benefit most from strategies that emphasize insight and awareness, such as identifying interpersonal themes and following client affect.

Theoretical Integration

In theoretical integration, two or more therapies are integrated to create an approach that is better than the constituent therapies. Some models of theoretical integration focus on combining and synthesizing a small number of theories at a deep level. Other models combine elements from several systems of psychotherapy at a more superficial level.

Paul Wachtel’s cyclical psychodynamics integrates psychodynamic, behavioral, and family systems theories. These systems are seen as complementary because psychodynamic theories focus on internal change and behavioral theories focus on the external environment. The family system is seen as a crucial environment that often reinforces interpersonal patterns. Wachtel’s approach to integration depends on dynamic insight and behavioral action to recognize and change vicious cycles that are often shaped by early family experiences but maintained by current behavior.

Anthony Ryle’s cognitive analytic therapy integrates ideas from psychoanalytic object-relations theory and cognitive psychotherapy. This approach is based on a cognitive description of relational patterns and describes target problems that often include mal-adaptive patterns. This reformulation is used as an ongoing reference point to help clients recognize and modify problematic patterns. Ryle encourages the use of cognitive-behavioral methods and an examination of the therapy relationship to understand the way clients enact reciprocal role patterns.

James Prochaska and Carlos DiClemente’s trans-theoretical approach describes the relationship among several theories. This approach assumes that many systems of psychotherapy are complementary and that different theories tend to target different stages and levels of change. Prochaska and DiClemente used five stages of change (precontemplation, contemplation, preparation, action, or maintenance) and five levels of change (symptom/situational problems, maladaptive cognitions, current interpersonal conflicts, family systems conflicts, or intrapersonal conflicts) to create a two-dimensional matrix that is used to organize 15 theories of psychotherapy and to illustrate their relative emphases. For example, at the symptoms/ situational level, motivational interviewing is located at the precontemplation stage and behavior therapy and exposure are located at the action stage. At the level of intrapersonal conflicts, psychoanalysis is suggested for the precontemplation stage, existential therapy is appropriate during contemplation, and Gestalt therapy is suggested for the preparation stage.

Assimilative Integration

Assimilative integration starts with a firm grounding in one system of psychotherapy, but then incorporates or assimilates ideas or methods from other theories. Many psychotherapists feel comfortable selecting a primary theoretical orientation that serves as their foundation but, with experience, incorporate ideas and strategies from other sources into their practice.

Increasingly, integrationists are acknowledging that most counselors prefer the security of using one primary theory as they begin the process of exploration and integration.

George Stricker and Jerold Gold proposed an assimilative model based on relational psychoanalytic therapy but selectively incorporating more active interventions drawn from cognitive, behavioral, experiential, and systemic approaches. This approach is organized around a three-tiered model of psychological functioning that includes (1) behavior and interpersonal relatedness; (2) cognition, perception, and emotion; and (3) psychodynamic conflict, self-representations, and object representation. Psychotherapists are encouraged to look for links between these tiers and to be aware that interventions aimed at one tier may affect other levels of functioning.

Louis Castonguay’s assimilative model rests on a cognitive-behavioral foundation that also includes techniques designed to facilitate interpersonal functioning and emotional deepening. This interpersonal focus on the therapeutic relationship allows clients to receive feedback about their actions and to understand the cause-and-effect links between the environment, cognitive and emotional processing, and the consequences of interpersonal behavior. From a behavioral perspective, emotional deepening can be seen as an exposure method that helps clients overcome a cognitive avoidance of affect.

Emerging Models

In addition to these established approaches to integration, there are newer models that embrace ideas from more than one of the four established routes. The emerging models described next are also aimed at training counselors to begin thinking and acting in an integrative fashion from the very beginning of graduate school.

Clara Hill’s three-stage model of helping skills combines theoretical integration and technical eclecticism; it encourages counselors to emphasize skills from different theories during different stages of helping. First, exploration is based on Rogers’s person-centered theory, and it emphasizes skills like attending, listening, and reflection of feelings. Second, insight is based on psychoanalytic theory and uses skills such as challenge, interpretation, and immediacy. Third, action is based on cognitive-behavioral theory and emphasizes skills like giving information and direct guidance.

Glenn Good and Bernard Beitman’s integration of common factors and technical eclecticism highlights both core components of effective therapy and specific techniques designed to target clients’ particular issues or areas of concern. Counselors are encouraged to learn key concepts from a variety of psychotherapy theories. This approach emphasizes the importance of core processes related to therapeutic communication, working alliance, identifying patterns, and encouraging change. Attention is given to the specific skills that are most helpful when dealing with common concerns like depression, anxiety, and substance abuse.

Jeff Brooks-Harris’s multitheoretical approach, a combination of technical eclecticism and theoretical integration, allows counselors to make informed choices when combining theories and intervention strategies. First, counselors are encouraged to systematically assess seven dimensions of functioning (thoughts, actions, feelings, biology, interpersonal patterns, social systems, and cultural contexts) and to choose the most salient dimensions on which to focus. Next, conceptualization is formulated using two or more theories corresponding to the selected focal dimensions. Finally, specific interventions are chosen from a catalogue of key strategies that are drawn from the theoretical approaches corresponding to each focal dimension.

Therapy Relationships and Personal Integration

Most models of integration focus on the choice of intervention strategies, but the therapeutic relationship has even more impact on outcome than the choice of techniques. In response to this discrepancy, John Norcross and his colleagues described ways that the therapeutic relationship can be customized based on client characteristics including resistance, coping style, expectations, and attachment style. This integrative focus on the therapeutic relationship reminds counselors that any form of psychotherapy should be implemented within an interpersonal relationship based on a phenomenological understanding of the client.

Experienced counselors develop their own individualized and integrated conceptual systems and intervention styles over time. This process of personal integration involves an integration of the therapist’s personal beliefs with formal theory, clinical experience, and therapeutic methods. Integrative psychotherapy can be seen as an art, and experienced therapists develop their own consistent, personal integrative approach over time. Personal integration often begins as a form of assimilation with a foundation in one theory and takes on a unique appearance as it is adapted to the personal strengths of different counselors and implemented with different clients.

Future Directions

Although integrative psychotherapy has become more popular, there are still obstacles to its further growth. Some persistent obstacles include continued allegiance to pure systems of psychotherapy and the difficulty of providing integrative training to graduate students. A more recent obstacle comes from those in the field who advocate the use of manualized treatments whose efficacy has been empirically supported using randomized clinical trials. Many of the integrative approaches described here are implemented in a flexible manner, based on the individual needs of clients. These types of treatment are difficult to manualize and are not consistent with the idea of randomized assignment to structured treatment protocols. In response to the need to document the efficacy of integrative treatments, there has been an increase in outcome research on psychotherapy integration. Although many counselors agree that psychotherapy should be evidence based, there is not always agreement about what evidence is most important.

It is likely that integrative/eclectic therapy will continue to be an important movement throughout the 21st century. New perspectives are likely to emerge that capitalize on the strengths of earlier approaches. Integrative psychotherapy will benefit from empirical research testing its usefulness, as well as continued clarity about how to balance research evidence and clinical wisdom. The consistent strength of integrative therapy will continue to be the recognition that complex individuals can be understood from a variety of vantage points, and effective counselors can combine therapeutic tools drawn from diverse theoretical sources.

References:

Beutler, L. E., Consoli, A. J., & Lane, G. (2005). Systematic treatment selection and prescriptive psychotherapy: An integrative eclectic approach. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (2nd ed., pp. 121-143). New York: Oxford University Press.
Brooks-Harris, J. E. (2008). Integrative multitheoretical psychotherapy. Boston: Houghton Mifflin.
Castonguay, L. G., Newman, M. G., Borkovec, T. D., Holtforth, M. G., & Maramba, G. G. (2005). Cognitive-behavioral assimilative integration. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (2nd ed., pp. 241-260). New York: Oxford University Press.
Frank, J. D., & Frank, J. B. (1991). Persuasion and healing: A comparative study of psychotherapy (3rd ed.). Baltimore, MD: Johns Hopkins University.
Good, G. E., & Beitman, B. D. (2006). Counseling and psychotherapy essentials: Integrating theories, skills, and practices. New York: Norton.
Hill, C. E. (2004). Helping skills: Facilitating exploration, insight, and action (2nd ed.). Washington, DC: American Psychological Association.
Lazarus, A. A. (2005). Multimodal therapy. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (2nd ed., pp. 105-120). New York: Oxford University Press.
Miller, S. D., Duncan, B. L., & Hubble, M. A. (2005). Outcome-informed clinical work. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (2nd ed., pp. 84-102). New York: Oxford University Press.
Norcross, J. C. (Ed.). (2002). Psychotherapy relationships that work: Therapist contributions and responsiveness to patients. New York: Oxford University Press.
Norcross, J. C., & Goldfried, M. R. (Eds.). (2005). Handbook of psychotherapy integration (2nd ed.). New York: Oxford University Press.
Prochaska, J. O., & DiClemente, C. C. (2005). The transtheoretical approach. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (2nd ed., pp. 147-171). New York: Oxford University Press.
Ryle, A. (2005). Cognitive analytic therapy. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (2nd ed., pp. 196-217). New York: Oxford University Press.
Stricker, G., & Gold, J. (2005). Assimilative psychodynamic psychotherapy. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (2nd ed., pp. 221-240). New York: Oxford University Press.
Wachtel, P. L., Kruk, J. C., & McKinney, M. K. (2005). Cyclical psychodynamics and integrative relational psychotherapy. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (2nd ed., pp. 172-195). New York: Oxford University Press.