INTEGRATIVE THERAPY

George Strieker

Jerry Gold

We want to begin this chapter by recounting an interaction that one of us (JG) has frequently with graduate students who are learning about the practice of psychotherapy for the first time. On meeting with such a class at the beginning of the semester, he raises this question: “How many versions or types of psychotherapy exist, as defined by descriptions in the clinical and research literature?” The students take a number of reasonable guesses, but it is unusual for any answer to approach that found by Norcross and Newman (1992) in their survey of practicing psychotherapists, in which over 400 schools or types of psychotherapy were identified. The point is made to the students, and should be noted by the reader as well, that this study is well over a decade old and that the true number may be twice or more than the number found by those authors.

What can this finding mean? Is it an indication that psychotherapy is such an individualized and unique experience that it must be created over and over again? Can psychotherapists learn little or nothing from their colleagues and thus are doomed to invent the wheel over and over again? Or, does it suggest that variables are being rediscovered and reutilized, in somewhat differing configurations and with differing emphases, and with different terms to describe them? In more simple terminology, perhaps these 400 or 800 types of psychotherapy are more similar than their creators believe and would have us consider.

As the authors of this chapter, we take this latter position. Although each person’s experience in psychotherapy will have certain unique elements and features, many universal variables cut across these many schools. Psychotherapists can and should learn from each other; the division of the field into many small, squabbling, and competing versions of psychotherapy can only be harmful clinically to patients, and scientifically to scholars and practitioners.

Our goal in this chapter is to describe and discuss those forms of psychotherapy that grow out of the crossing of boundaries between the various schools of psychotherapy. These universalist forms of psychotherapy are known as Integrative Psyehotherapies and are defined as those models of psychotherapy in which the theories, principles, or techniques from two or more separate forms of treatment are combined in an organized and systematic way.

In contrast, integrative psyehotherapy refers to a new and particular form of psychotherapy with a set of theories and clinical practices that synthesizes concepts and methods from two or more schools of psychotherapy. It would be difficult, if not impossible, to conceive an integrative psychotherapy that was practiced by a therapist who was not sympathetic to the philosophy of psychotherapy integration. In this chapter, we discuss the intellectual position that is psychotherapy integration and describe some of the more important and influential versions of integrative psychotherapy. It also is important to distinguish between an integrative approach to psychotherapy, which proposes a systematic synthesis, and a purported completed integrative psychotherapy, which is a synthesis established as one more fixed school of psychotherapy. Perhaps cognitive-behavioral psychotherapy, actually a synthesis of two disparate approaches, is the best example of the latter.

Most discussion of the current status of psychotherapy integration focuses immediately on the four accepted modes or ways of conceptually understanding how psychotherapies may be combined. These modes were identified in a post hoc way: As the number of integrative models of therapy began to proliferate, those writers who studied psychotherapy integration identified conceptual commonalities between these approaches that referred specifically to the ways these therapies combined ideas and interventions from particular forms of psychotherapy. The four modes that have come into common usage in the psychotherapy integration literature are technical eeleetieism, common factors integration, assimilative integration, and theoretical integration (Gold, 1996). Each integrative psychotherapy might be thought of as an example of one of these modes, and the process of psychotherapy integration makes use of these modes as well. This framework, however, has outlived its usefulness to some extent. In our capacities as the editors of a recently published casebook of psychotherapy integration (Stricker & Gold, 2006), we attempted to group the cases according to the mode of psychotherapy integration that they represented. This was a difficult task. Some cases seemed to be examples of two or more of the modes, whereas others seemed to combine modes. We occasionally found ourselves disagreeing about the assignment of a case to a specific mode. This reflects the maturation of the field, as particular types of integrative psychotherapy have become more complex and therefore cross the boundaries of these modes. The blurring of the modes suggests that this framework may have outlived its initial usefulness in organizing our approach to psychotherapy integration in a way that replicates and is parallel to the way that sectarian approaches to psychotherapy; and thus the separation that those approaches conveyed may also have become outdated. We discuss the modes of psychotherapy integration here because of their historical importance as well as their usefulness in showing how current thinking about psychotherapy integration has developed.

TECHNICAL ECLECTICISM

Prescriptive psychotherapy (Beutler et al., 2006) is a flexible and empirically driven system in which the therapist attempts to use the research literature and clinical knowledge to match patient characteristics and the focal problems that are of immediate clinical concern with the most efficacious interventions. This therapy does not limit the schools of therapy from which it draws its techniques, aiming at the broadest application of techniques to problems.

The well-recognized and systematic technical integration of Lazarus and of Beutler stand in sharp contradistinction to the common practice of eclecticism. The latter is based on the moment-to-moment intuition of the practitioner and seems to have little theoretical, empirical, or conceptual basis to unify it. There are at least two major models of technical integration (Lazarus & Beutler), but as many approaches to eclecticism as there are eclectic practitioners.

COMMON FACTORS APPROACHES TO INTEGRATION

Suppose we were walking down the aisle in a pharmacy where many brands of toothpaste were displayed. If we were to believe the advertisements for each brand, we would conclude that each is uniquely suited to the task of preventing tooth decay and whitening teeth. However, were we to ask a dentist about the advantages of any specific brand of toothpaste, we would learn that most dentists (except those who are paid to endorse a particular product) would argue that all toothpastes are equally effective, because most are based on one or a few of the same effective ingredients.

Many psychotherapists argue that real differences between the many varieties of psychotherapy are as illusory as those claimed for toothpaste. They base this argument on reviews of the research literature that suggest no psychotherapy has been found to be more effective than any other (Luborsky et al., 1999) and on clinical observation. These students of psychotherapy further suggest that the many brands of psychotherapy work equally well because they contain certain effective factors that are present, to one degree or another, in most forms of psychological treatment.

A well-known and well-received integrative model that is based on common factors is Beitman’s (Beitman, Soth, & Good, 2006) common factors approach, which is discussed in detail in the pages that follow. Another important example of integrative psychotherapy is Garfield’s (2000) common-factors-based integrative therapy, which relies on insight, exposure, the provision of new experience, and the provision of hope through the therapeutic relationship. It is a well-known example of this mode of integrative work. These models and the other common-factors-based integrative therapies share the goal of maximizing the patient’s exposure to the most powerful combination of therapeutic factors that will best ameliorate his or her problems. Those therapists who organize their work within an integrative common factors perspective therefore aim to identify which of the several known common factors will be most important in the treatment of each individual. Once the most clinically significant common factors are selected, the therapist reviews the spectrum of techniques and psychotherapeutic interactions to locate those that promote and contain those ingredients.

In addition, Sparks, Miller, and Duncan (cf. this volume; also, Duncan, Sparks, & Miller, 2006) have developed an imaginative approach to common factors integration based on the direction to treatment provided by the patient.

THEORETICAL INTEGRATION

Just as Albert Einstein spent the final part of his career searching for a unified theory of relativity that would integrate the general and special theories, certain psychotherapists have spent their careers searching for theoretical models that would account for and synthesize two or more entire systems of psychotherapy at a conceptual level.

Theoretical integration greatly expands the vision and understanding of the therapist when attempting to work with any individual. At first glance, it may be difficult to distinguish therapies that are technically eclectic or that are based on the mode of assimilative integration (see following section) from those therapies that are based on theoretical integration. Any of these therapies, regardless of the integration that they exemplify, may specify the application of identical interventions. However, this seeming equivalence is only skin deep. Deeper and more important distinctions may emerge at the theoretical level. These differences exist in the divergence of the belief systems that guide therapists in the choice of clinical strategies and techniques. Subtle interactions between various levels and spheres of behavior, interpersonal interactions, motivational, cognitive, and affective internal states and processes can be evaluated; and interventions can be considered from several complementary therapeutic perspectives. This expanded conceptual framework allows problems at one level or in one sphere of psychological life to be addressed in formerly incompatible ways. The therapist might intervene in a problem in affect tolerance not only to help the patient be more comfortable emotionally, but also to promote change in motivation or to rid the patient of thinking about emotion in a way that maintained powerful unconscious feelings.

ASSIMILATIVE INTEGRATION

The fourth mode of psychotherapy integration is assimilative integration. This term describes an approach to psychotherapy in which the therapist maintains a central theoretical position, but incorporates (assimilates) techniques from other orientations. Assimilative integration is the most recently described mode of psychotherapy integration. It has been the focus of much interest (e.g., the March 2001 issue of the Journal of Psychotherapy Integration was devoted to this topic).

The first mention of this mode of psychotherapy integration appeared in an article by Messer (1992). Messer (1992) referred to the term assimilation as he attempted to place the stuff of behavior and of psychotherapy in a contextual framework. He pointed out that all behaviors are defined and structured by the physical, historical, and interpersonal context in which those actions occur. He went on to suggest that, because any therapeutic intervention is an interpersonal and a behavioral act (and a highly complex one at that), and because it reflects the history between therapist and patient, those interventions must be defined, and perhaps even created, by the larger context of the therapy. These background issues are constantly assimilated into the therapy, even if their influence is not consciously acknowledged by either participant.

HISTORY OF THE APPROACH

Beginnings

The earliest efforts at psychotherapy integration were not labeled as such. These pioneering contributions arose from clinical observations of psychotherapy that led a small number of therapists to question the validity and exclusivity of the theories and methods in which they had been trained. These articles were of two types: those that attempted to synthesize psychoanalytic ideas and methods with findings from academic psychology, chiefly behaviorism/learning theory; and those that attempted to find similarities or common factors across therapeutic schools.

Perhaps the earliest writing that might be identified as belonging to the psychotherapy integration literature was the article penned by Thomas French (1933), in which he challenged the psychoanalytic world to take account of, and to integrate, the concepts of classical conditioning that had become prominent in academic psychology and its dominant theories of learning. As these academic theories were expanded on and were elaborated in more complex and clinically oriented ways, certain psychoanalysts and academic psychologists with an interest in psychoanalysis built on French’s position and developed increasingly sophisticated theories that intertwined behavioral theories and psychoanalysis. These efforts were the forerunners of contemporary versions of theoretical integration, and they continue to influence integrative thinking even today. Among the more important contributions of this type were Sears’s (1944) examination of the role of reinforcement in the psychotherapeutic relationship, and a book by Dollard and Miller (1950) entitled Personality and Psychotherapy. This volume was not well received when it was published, but later students of psychotherapy integration, especially Wachtel (1977), were deeply influenced by these authors and their attempt to synthesize central psychoanalytic ideas such as unconscious motivation and conflict, anxiety, and defense mechanisms with laboratory-based learning theories that were being advanced by O. Hobart Mowrer, Edward Tolman, Clark Hull, and Kenneth Spence.

These theoretical revisions, and the perspective that interventions could be planned or prescribed for their desired impact, led to an expanded understanding of the therapist’s role in psychoanalysis, and to a retreat from the emphasis on a single concept (insight) as the exclusive unit of change, linked to a single intervention (interpretation). Alexander (1963) followed up this work with an increased interest in, and an explicit emphasis on, the role of learning factors, such as conditioning and reinforcement, in psychoanalytically oriented psychotherapy. He was especially concerned with the way interpersonal factors, such as the therapist’s approval and affection, could reinforce healthy or problematic patient behaviors. A similar argument was made at about the same time by Beier (1966), who described a theory and clinical approach (perhaps one of the earliest examples of theoretical integration) that was designed to be an integration of Skinner’s and Freud’s psychologies. Beier (1966) argued that the unconscious fantasies, motives, and conflicts described in classical Freudian psychoanalysis were subject to modification through positive and negative reinforcement, shaping, habituation, and extinction as much as any other conscious psychological processes that could be studied in the laboratory. Beier (1966) suggested that the psychotherapist’s verbalizations be constructed to maximize the desired reinforcement value of each statement, whether to promote exposure to a feared unconscious stimulus so that extinction of the associated anxiety could occur, or to promote new and more adaptive ways of behaving through verbalizations that conveyed approval.

Since the appearance of Wachtel’s (1977) book, the rate and quality of publications about psychotherapy integration and the number and utility of integrative therapies have multiplied at an unforeseen rate. By this time, therapists were game for trying all sorts of combinations of theory and method. Gone were the days when the integration of psychoanalytic and behavioral approaches was to dominate the field. Approaches that integrated the wide range of humanistic and experiential methods with other schools emerged importantly (Watson, 2006), as had integrative models that incorporated cognitive-behavioral elements (Ryle & McCutcheon, 2006), systemic contributions (Heitler, 2001), philosophical and epistemological principles (Anchin, 2006), and political and cultural variables (Consoli & Chope, 2006).

Why has psychotherapy integration made such rapid and broad inroads into the mainstream of psychotherapeutic theory and practice in the past 20 years or so? What has moved it from being an obscure and disconnected collection of poorly received efforts to becoming a well recognized and mature field that supports a journal (Journal of Psychotherapy Integration), a professional society founded by such major contributors to psychotherapy integration as Paul Wachtel, Marvin Goldfried, Barry Wolfe, and George Stricker (SEPI, the Society for the Exploration of Psychotherapy Integration), and many books, handbooks, and journal articles in established publications? Norcross and Newman (1992) reviewed the factors within the field of psychotherapy that have affected theory and practice and identified eight variables that have made psychotherapy integration attractive to a larger group of clinicians and scholars: (1) the ever-increasing number of schools of psychotherapy; (2) the lack of unequivocal scientific support for superior efficacy of any single psychotherapy; (3) the failure of any theory to completely explain and predict pathology, or personality and behavioral change; (4) the rapid growth in the varieties and importance of short-term, focused psychotherapies; (5) greater communication between clinicians and scholars that has encouraged willingness and opportunity for experimentation; (6) the effects of the grim realities of third-party support for long-term psychotherapies; (7) identification of common factors in all psychotherapies that are related to outcome; and (8) growth of professional organizations, conferences, and journals dedicated to the exploration of psychotherapy integration. Also, the proliferation of effective psychopharmacological agents, an intellectual shift toward biological explanations of psychopathology, and the economic and clinical intrusions of managed care have stripped psychotherapy of its formerly privileged position as a clinical activity within the mental health professions (Gold, 1993). This new adversity may have prompted psychotherapists of many schools to leave behind their sectarian conflicts and adopt a new willingness to learn from each other, perhaps for the first time.

Other changes that arise from more positive professional, theoretical, and clinical factors may in part have encouraged the recent and rapid expansion of interest in integrative therapies. Most of the original sectarian versions of psychotherapy (such as behavior therapy, client-centered therapy, and psychoanalysis) are two to three generations old. The originators of these models and their immediate successors are gone, and the following generations may be less devoted to these sectarian approaches and therefore more comfortable and facile about crossing boundaries and in using ideas that derive from rival psychotherapeutic systems.

Populations and Places Where Developed

As might be inferred from the preceding historical review, most of the early work in psychotherapy integration was American and British and was based on outpatient psychotherapy with relatively high functioning (neurotic) patients. This was inevitable because psychotherapy in those two areas was dominated by psychoanalysis and by client-centered therapy until the advent of behavioral methods in the 1950s and cognitive approaches in the 1960s. Even though some practitioners of psychoanalysis and of client-centered therapy worked in psychiatric institutions or with more serious forms of psychopathology (schizophrenia and affective disorders), most of the literature on integrative approaches was focused on work with the types of persons and problems that are more suitable for outpatient psychotherapy and especially the private practice of psychotherapy. So, these therapies were most often studied in relation to their effectiveness with anxiety, mild to moderate depression, sexual dysfunctions, and relationship difficulties. When the investigators were more focused on empirical trials of a new therapy, they tended to test their efforts on populations with disorders such as phobias and related anxiety issues. This narrow focus was due to the prevalence of these disorders in the easily reachable populations on which researchers are dependent, as well as their relatively well validated and reliable diagnostic criteria.

Psychotherapy integration today is international and has been investigated with most populations and treatment settings. Important contributions have been made by investigators from Argentina, Chile, Italy, Germany, Nigeria, and New Zealand, to name just a few of the venues. It also would be difficult to find a population of patients or a particular type of psychotherapy that has not been studied and treated within an integrative framework, ranging from schizophrenia (Hellcamp, 1993) to borderline personality disorder (Allen, 2006) to addictions (Cummings, 1993) to neurological disorders (Becker, 1993).

Although most integrative psychotherapies originated in the context of individual psychotherapy with adults, this limitation no longer applies. Integrative models have been developed for work with children (Gold, 1992), couples (Lebow, 2006), and families (Nichols, 2006).

Current Popular Variants

As noted, in the past 2 decades there has been an explosion of writing about psychotherapy integration, and about the myriad forms of integrative psychotherapy that have been derived from this exploration. It is impossible for us to review all the important current forms of integrative psychotherapy that are deserving of such attention. Therefore, we have chosen to discuss four current integrative therapies, each of which is representative of one of the four modes of psychotherapy integration. Technical eclecticism is represented by Lazarus (2006; cf. this volume), common factors by Beitman et al. (2006), assimilative integration by Stricker and Gold (2002), and theoretical integration by Wachtel (1997). The interested reader is referred to Norcross and Goldfried (2005) or Stricker and Gold (2006) for more extensive presentations of current integrative treatments.

Multimodal therapy evolved out of Lazarus’s background in traditional behavior therapy, and, more than 25 years after its creation, still relies heavily on traditional behavioral interventions. He (2006) has written that he became dissatisfied with the limitations of traditional behavior therapy in the 1960s and 1970s when his clinical studies revealed that many of his patients had suffered relapses of their symptoms and problems after completing therapy. Lazarus (2006) reports that these findings made him aware of the need to evaluate and intervene in the implicit psychological, interpersonal, and physiological mechanisms that caused these problems and made patients prone to relapse. He believed that behavior therapy as it was then practiced could not accomplish these tasks.

As a technically eclectic form of integrative psychotherapy, multimodal therapy is based on social learning theory, and that theoretical foundation has not been expanded or influenced by concepts from other systems. Lazarus (2006) moves beyond the standard limits of cognitive-behavioral therapy by using any appropriate intervention from any form of therapy, if that intervention has empirical support for its effectiveness with a particular condition or disorder. In the absence of such research-based validation, he selects techniques that are supported by the clinical literature and by clinical experience.

At the heart of multimodal therapy is an extensive assessment of the patient and his or her problems, strengths, and psychological, social, and biological needs. This central emphasis on assessment is shared by most other technically eclectic systems (Beutler & Hodgson, 1993). Lazarus (2006) applies the acronym BASIC ID to the areas of the patient’s function that the multimodal therapist evaluates. This label refers to B ehavior, A ffect (emotion), S ensation, I magery, C ognition, I nterpersonal relations, and D rugs (including all biophysical issues). Although Lazarus would dispute this claim, it might be argued that the BASIC ID framework is an integrative theory of personality and of psychopathology, so that multimodal therapy is not simply an example of technical eclecticism. This illustrates the difficulties in finding pure forms of the four modes of psychotherapy integration.

When the BASIC ID assessment is completed, the therapist has available a detailed evaluation that may identify the mechanisms of the patient’s presenting problems, and of the acute and chronic issues that may be contributing to their maintenance. The therapist also formulates a central clinical hypothesis called the firing order. This term refers to the component of the BASIC ID in which a symptom or problem is assumed to start, and to its progression through the other six spheres in the model. Many patients with anxiety disorders describe their anxiety symptoms as appearing when some event, such as the sound of an ambulance, triggers an image of a terrible event (Imagery), which is followed by thoughts of personal danger (Cognition), and by feelings of tension and fear (Sensation, Affect). These processes may then trigger actions (Beehavior) and interactions with others (I nterpersonal relations) that are meant to be helpful and reassuring to the patient, but that often may be reinforcing of the patient’s problems.

In some cases, the therapist may choose to intervene at the beginning of the firing order and to follow it through each step. In other cases, based on the therapist’s clinical judgment, treatment begins at a later point in the firing order, if the therapist believes that starting there will yield positive results quickly and might aid in establishing a positive therapeutic alliance. Most psychological problems do not involve each part of the BASIC ID, and not every multimodal therapy involves intervention in each component. As noted, specific interventions for problems in each area are selected on the basis of available evidence, both research and clinically based, for the suitability of the technique being matched to the specific need of the patient.

Beitman and his colleagues have presented an approach to integration based on their finding that “all schools [of psychotherapy] intersect in an ultimate concentration on the client’s future” (Beitman et al., 2006, p. 43). These authors have observed that most, if not all, forms of effective psychotherapy share a clinical focus on the way the patient thinks about and anticipates the future, and on assisting patients to develop pleasant, realistic, and attainable views of the type of life that they would like to achieve. Using the future as a central factor that drives psychopathology is an easy and effective way of understanding important causes of most disorders. Patients who suffer from anxiety do so, at least in part, because they continually imagine danger and catastrophe down the road or around the corner. Depression often is the result of predictions about the future, which patients see as no better than the present, while problems with anger are the outcome of predictions about frustration or humiliation.

The central common factor of the future then becomes the organizing concept around which integration occurs, and on which the flow of treatment is based. Working within this system, the therapist must figure out what is getting in the way of the patient’s attempts to envision and to realize a productive and rewarding future. The specific difficulties that interfere with this process then can be addressed therapeutically with techniques that were originally part of separate psychotherapeutic systems. Some patients may have a bleak and pessimistic view of the future. These images (which Beitman et al., 2006, term problematic expectation videos) might be addressed through cognitive restructuring. Other patients may populate their expectation videos with feared repetitions of past traumatic events, and healing them may require experiential or psychodynamic work. Still other patients may have a more hopeful outlook about a desirable future, but may lack the behavioral skills and interpersonal competencies that are necessary to achieve those goals. In these cases, behavioral exercises such as social skills training, interpersonal therapy, or family systems interventions may be important components of the treatment. Most patients probably will need some combination of these types of intervention, as their pathological pictures of the future are caused by both psychological and social factors.

An additional approach to common factors integration can be found in the works of Sparks, Miller, and Duncan (cf. this volume; also, Duncan et al., 2006). They base their approach on the unifying common factor of the patient, who is seen as influential in determining the direction of the course of psychotherapy.

Integrative Psychodynamic Psychotherapy

This system of integrative psychotherapy is derived from Wachtel’s (1977) pioneering efforts to synthesize psychoanalysis and learning theories. In a later expansion of his work, Wachtel (1997) incorporated conceptual elements from family systems and experiential theories as well. This example of theoretical integration is called cyclical psychodynamic theory; the therapy that it supports is known as integrative psychodynamic psychotherapy (Gold & Wachtel, 2006; Wachtel, 1997). We discuss the theory more completely in the section about personality theory that follows.

This therapy is based on the principle that a person’s manner of adapting to the environment, and his or her interactions with others, not only express his or her central psychodynamic conflicts, but also maintain those conflicts. Rather than considering that consequences of the past such as motivations, feelings, and perceptions are the sole significant determinants of present-day behavior, Wachtel (1977) suggested that past and present are locked together in a mutually influential and reinforcing way. If a man’s depression, in part, reflects his unconscious hostility toward his father, it is assumed that the patient’s present-day involvement with an employer who treats the patient in much the same way keeps that hostility active. Should the patient find a way to change his interactions with his employer, he might find that not only does he feel and function better at work, but he has softer feelings about his father as well.

This modification of psychodynamic theory allows the therapist to incorporate behavioral, family systems, cognitive, and experiential interventions to correct the behavior patterns that are maintaining and reinforcing the patient’s unconscious motivations and conflicts. Wachtel (1977) was heavily influenced by the work of Alexander and French (1946) and Dollard and Miller (1950), cited earlier. The impact of the corrective emotional experience that was introduced by the former can be observed in the working of this therapy. The therapist expands on the traditional component of psychodynamic exploration and interpretation by using this material in an additional way. The therapist gradually creates a psychodynamic formulation of the patient’s developmental history, and of the patient’s unconscious conflicts, and uses these hypotheses to collaboratively plan new experiences, in the therapeutic relationship and outside it, that will interrupt the critical vicious circles: present-day patterns of behavior that unwittingly repeat, and therefore confirm and reinforce, developmentally derived, unconscious ways of perceiving, understanding, and reacting (Gold & Wachtel, 2006).

ASSIMILATIVE PSYCHODYNAMIC PSYCHOTHERAPY

Assimilative integration might best be understood as a modest form of theoretical integration that is combined with a certain degree of technical eclecticism. It is based on an expanded version of a traditional theory (the home theory) that incorporates concepts from other models, and it uses interventions from those other models as well. In the best case, this assimilation then results in accommodation, in that the home theory is modified to explain how these nonstandard methods fit into it.

INTEGRATIVE THEORIES OF PERSONALITY AND PSYCHOPATHOLOGY

Key Aspects

Integrative models of personality are the defining characteristics of those psychotherapies that exemplify theoretical integration or assimilative integration. Assimilative integration is based on a traditional, home personality theory and theory of therapy as its organizing feature, but this theory is modified, as discussed earlier, by the assimilation of new constructs and ideas from other theories, and therefore, through a process of accommodation, evolves into a newly created personality theory (Stricker & Gold, 1996). The combination of two or more separate and traditional personality theories into a new approach to personality is the critical, defining foundation of theoretical integration, without which this form of integration is impossible. This novel, integrative personality theory is assumed to be an improvement over the original theories in its capacity to guide the therapist’s understanding of psychopathology, psychological development, and most importantly, the most effective selection of clinical techniques and methods.

Integrative theories of personality influence our understanding of the work of psychotherapy in two ways. First, in exactly the same ways that traditional theories of personality are used in traditional systems of psychotherapy, integrative theories serve as a conceptual framework for understanding the patient’s psychological organization and the structures (e.g., schemas, or long-standing patterns of thinking, feeling and behaving, and defense mechanisms, or an unconscious process by which we protect ourselves against unwelcome wishes or needs) and processes (e.g., anxiety, unconscious motivation, and affect) that need to be changed by the therapy. Second, the more creative and unique contribution of these integrative theories is their ability to explain the complex relationships between psychological phenomena that traditional theories ignore or consider to be irrelevant. These theories substitute circular explanations of causes of behavior for the linear, unidirectional explanations of psychological life that are central to traditional personality theories. Circular views of causation hypothesize that many spheres of psychological life can be crucial in understanding any behavioral phenomenon. As a result, integrative theories of personality are a corrective to the narrow determinism that characterizes most standard personality theories, which relegate important psychological variables to superficial status if they do not fit that model.

Perhaps the most widely cited example of integrative personality theory is Wachtel’s (1977, 1997) theory of cyclical psychodynamics. Wachtel’s (1977) integrative psychodynamic psychotherapy, discussed earlier in this chapter, is based on this theory. The appearance of this theory in print was a turning point in the development of psychotherapy integration because Wachtel (1977) demonstrated that a clinically useful and conceptually empowering synthesis of learning theories and psychoanalysis could be achieved. Cyclical psychodynamic theory is based on the assumption that those psychological variables usually thought about in a hierarchical and linear way (i.e., unconscious motivations are remnants of childhood experiences and wishes that cause most clinically relevant present-day behavior) are actually mutually determining. Wachtel assumed that behavior, interpersonal relationships, and unconscious motivation and conflict were equally important, and interacted with each other in ways that made the question of “which causes which” obsolete and irrelevant. The most important innovation in this theory was Wachtel’s (1977) hypothesis that the patient’s ongoing patterns of thinking, perceiving, and relating to others were key sources of reinforcement for motivations, fantasies, and conflicts that were the consequences of painful experiences in early life.

The theory guided therapists in understanding how changes in psychodynamics could lead to, or follow from, changes in behavior and in interactions with others. The latest iteration of cyclical psychodynamics has expanded the theory to include concepts drawn from family systems theory, relational psychoanalysis, experiential theories, and cognitive theory (Wachtel, 1997).

The procedural sequence object relations model (Ryle & McCutcheon, 2006) is another integrative model of personality. This model is the basis of the integrative treatment known as cognitive-analytic therapy (CAT) and is an integration of ideas that originated in cognitive therapy, psychoanalytic object-relations theory, and cognitive psychology. The procedural sequence model focuses on the complicated relationships between the way that the person consciously takes in and processes information about the self and others, and the unconscious developmental foundations of the person’s beliefs, assumptions, cognitive structures, and role definitions.

Guidano’s (1987) cognitive-developmental model is another example of an integrative theory of personality. Guidano was a careful student of Bowlby’s (1980) innovations in attachment theory, and he was perhaps the first psychotherapist to see the potential of attachment theory as a foundation for psychotherapy integration. Cognitive-developmental theory is a significant elaboration of the concept of internal working models that Bowlby introduced. Internal working models are the conscious and unconscious patterns of organizing experience and of representing the self and significant persons in the patient’s life. Internal working models are relatively realistic, highly personalized abstractions of repetitive experiences of attachment and exploration on the part of the child, and of the attachment figure’s typical responses to those behaviors. The cognitive-developmental therapist uses this framework to assess those working models that are the basis of the patient’s symptoms, and to frame interventions that will challenge and modify those ways of perceiving relationships.

The three integrative theories previously described were formulated in the context of theoretical integration. An example of a personality theory that guides, and is in part the product of, efforts at assimilative integration, is the three-tier model of personality that was developed by the authors of this chapter (Stricker & Gold, 1988, 1996). This theory originally was formulated to conceptualize the psychological causes of personality disorders, but as our approach to assimilative integration matured, we found that the three-tier model was applicable in this context as well. Assimilative psychodynamic psychotherapy (Stricker & Gold, 1996) is based on this approach to personality.

The three-tier model is an expanded version of psychoanalytic theory (Gold & Stricker, 2001b) in which psychological experience is conceptualized as occurring simultaneously at three levels or tiers. Tier 1 refers to the level of behavior and interpersonal interaction. Tier 2 refers to conscious cognition, perception, and emotion, whereas Tier 3 is the sphere of unconscious motivation, conflict, and representations of the self and of significant others. Although traditional psychoanalytic theories take these tiers into account, those theories privilege the processes that we describe as occurring in Tier 3, and suggest that behavior and conscious experience are superficial consequences of the “real stuff”: of what is going on unconsciously. In this model, all variables in all three tiers are considered to be substantial and important, and to have ongoing influence on processes in the other tiers. Therefore, no one sector is believed to be the exclusive cause of experience. This expanded theory allows for the inclusion, in therapy, of interventions that can address issues at all the tiers.

Models of Health and Pathology

How do we define psychological health and psychopathology within an integrative framework? Most writings in this area do not specifically describe a model of psychological health, but if one looks between the lines in this literature, it is not difficult to identify certain central ideas about this topic.

Integrative theories share an emphasis on successful adaptation to life’s challenges as they emerge over time. These challenges have several components: environmental (how one copes with excessive heat when the air conditioning is not working), interactional and interpersonal (how we deal with conflicts with others), or intrapsychic (how a tired parent copes with the mix of love and exasperation that yet another dirty diaper evokes) and require a broad range of abilities for the person to stay afloat cognitively, behaviorally, emotionally, and in relation to others.

As noted in the section on personality theory, integrative models are concerned with how people understand their experiences and make the flow of experience meaningful. A central adaptive mechanism that is part of the healthy personality has been named semiotic competence by Levenson (1983). This term refers to the healthy person’s ability to make sense out of experience, to trust one’s own perceptions, feelings, and motivations, and to have available the necessary behavioral repertoire that can lead to effective action. Healthy persons can discriminate between past experiences and present and future events, and between internal psychological processes (wishes, fantasies, conflicts, and feelings) and events in the outer world. They can make useful and accurate predictions about the outcome of their actions and the actions of others. Healthy persons also have at their disposal the desired interpersonal skills to reach their goals and to protect themselves when they perceive real danger.

Integrative views of psychopathology are concerned with adaptive failures. Lazarus’s BASIC ID model (Lazarus, 2006) is but one demonstration of this viewpoint. Each component of that assessment framework allows the therapist to identify adaptive failures, whether they are behavioral, cognitive, interpersonal, or otherwise. The three-tier model (Stricker & Gold, 1988) shares this comprehensive approach to psychopathology, locating the adaptive failures that generate psychological problems in all levels and spheres of psychological experience and functioning. Psychopathology results when the person has lost the ability to adapt to new situations, faces events for which he or she had never prepared, or tries to apply adaptive solutions that had worked in the past to situations for which they are not a fit.

Models of Etiology

It should come as no surprise to the reader of this chapter that integrative therapies are based on complex and inclusive ideas about the etiology of psychological disturbance. These models do not privilege any particular etiological factors, but suggest that biology, unconscious processes, cognition, emotion, and interpersonal relationships all can cause psychological development to go awry. Furthermore, integrative theories suggest that problems in any or all these areas can and will have lasting impact in other areas of the patient’s functioning. In describing the integrative model of schema therapy, Young, Klosko, and Weishaar (2003; also cf. Kellogg & Young, this volume) pointed out that the traumatic events that eventuate in relatively permanent, pathological ways of understanding close relationships also can cause permanent alterations of the functioning of the hypothalamus, amygdala, and the endocrine system’s production of the stress hormone, cortisol. These correlated psychological and physiological alterations explain the stubbornness of the emotional, cognitive, and neurological reactions that contribute to psychopathology.

THEORY OF PSYCHOTHERAPY

Goals

The goals of integrative psychotherapies typically are determined in the consultation process between patient and therapist. Therapies with a psychodynamic or experiential focus tend to have explicit goals that reflect what the patient wishes to change or to learn (usually clustered around the patient’s presenting complaints and areas of dissatisfaction), and implicit, process-oriented goals that reflect the variables and processes that the therapist believes are necessary to reach the patient’s objective. Examples would be changes in unconscious motivational conflicts or in the cognitive schema through which the patient organizes the meaning of experience. Sometimes these goals are shared with the patient, but probably most often they serve as guides and goals for the therapist, who believes that success in achieving the patient’s explicit goals is based on success in meeting these implicit ones.

Those therapies that are more cognitive-behaviorally or systemically oriented will tend to be focused on goals that are more overt and observable, such as the reduction of panic attacks, the building of competencies such as better time management, or enhancement of relationships.

Certain versions of psychotherapy integration (Bohart, 2006; Duncan et al., 2006; also cf. Sparks, Miller, & Duncan, this volume) suggest that the patient alone should determine the goals of therapy and should take the lead in promoting change. These therapies are based on the empirical finding that the patient’s active involvement in the psychotherapy is the single most important variable in determining the outcome of treatment. As Bohart (2006) put it, “. . . the client is the most important factor in making therapy work” (p. 241). These versions of psychotherapy integration are structured around this idea and around the related idea that it is the therapist’s task to provide educational opportunities for the patient. These experiences inform the patient about the options (the various psychotherapeutic techniques from any and all approaches) that are available to enable the reaching of goals.

Most key goals, and especially the more implicit, are idiographic (individualized) in the sense that they are selected by the patient, and therefore will differ from patient to patient. These therapies prescribe processes and interventions rather than particular goals. This emphasis on the idiosyncratic nature of each person’s experience in psychotherapy is one of the driving factors behind interest in psychotherapy integration, as therapists became dissatisfied with sectarian schools of therapy and the tendency of each school to impose goals, a priori, on the patient. The implicit process goals reflect the broad spectrum of potential change processes and their end products. The particular goals that are emphasized in any single form of integrative psychotherapy reflect the particular systems that are integrated. If a patient were seen by a multimodal therapist, then those areas of the BASIC ID in which problems were identified would also likely be the areas in which the most important goals were identified. A patient whose anxiety symptoms reflected dysfunctional cognitions and alarming images would most likely have the goals of restructuring those thoughts and replacing those images with neutral or calming images. In Beitman et al.’s (2006) common factors therapies, the more important goals would be derived from the particular problematic visions of the future that the patient reports.

Assessment

In any discussion of assessment, the distinction between assessment and diagnosis must be explored. We define assessment as the ongoing process of data collection and of data organization that allows the therapist to deepen and broaden his or her understanding of the patient. Diagnosis is the process of generating a label that is assigned to hypothesized pathology. It is difficult to think of any important form of integrative psychotherapy that does not rely on assessment, whereas the role of formal diagnosis, as found in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), is relatively unimportant in many of these same therapies.

Most other forms of integrative therapy, however, originated in clinics and in private practice, and were designed to be as inclusive as possible, enhancing the effectiveness of psychotherapy that was available regardless of the particular diagnoses of the patients to whom it might be offered. Formal diagnosis, in these systems, does not tell the therapist much about the patient.

Assessment, though, is a critical, ongoing component of all integrative therapies.

The preceding examples of integrative therapies demonstrate that these approaches may differ on the dimensions of formal versus informal assessment, the presence or absence of a specific assessment phase, the foci of assessment, and the methods used for assessment. All these characteristics depend on the particular system of psychotherapy integration. Some integrative models rely on a formal assessment that incorporates testing during a beginning phase. This is perhaps most typical of those examples of technical eclecticism (multimodal therapy and prescriptive psychotherapy) that substitute a structured assessment framework (such as the BASIC ID) for a guiding theory. Other integrative therapies, most often those that are examples of theoretical integration and that are more humanistic or psychodynamic, tend to use informal methods and to continually incorporate theory-guided assessment into the flow of the ongoing therapy. Examples of these therapies included integrative psychodynamic psychotherapy (Gold & Wachtel, 2006), cognitive-analytic therapy (Ryle & McCutcheon, 2006), and Goldfried’s (2006) cognitive-affective-relational behavior therapy. Assessment plays a similar role in common factors based approaches, as the patient’s condition and functioning is assessed from the perspective of the suitability and potential effectiveness of particular change factors.

Process of Therapy

The various integrative therapies each resemble their most important component therapies in terms of the ongoing process of therapy. That is, those therapies that are primarily psychodynamic or humanistic in approach will proceed in relatively unstructured ways without relying on an initial period of formal assessment and will be organized around the patient’s ongoing exploration of internal experience. The therapist will be relatively silent and inactive, asking questions, reflecting feelings, offering explanations, and making connections between past experiences, current relationships, and processes that are occurring in the therapeutic relationship. Psychodynamically informed therapists will frame discussions of the patient-therapist interaction in terms of transference and countertransference, whereas those with a humanistic-experiential slant will conceptualize this interaction from that theoretical vantage point. These unstructured therapies will become more structured when more directive and active interventions, such as behavioral, cognitive, and systemic interventions are necessary. Critically, in an integrative therapy, these additional elements will be explored with regard to their experiential impact and psychodynamic meanings. Another point of departure from the original therapies is that these integrative treatments often use homework assignments in between sessions (Stricker, 2006); in fact, homework is perhaps one of the most important characteristics shared by all types of integrative treatment.

Most integrative therapists are concerned with the inescapable problem that patients often cannot make use of what therapy has to offer. Whether this phenomenon is known as resistance by those with a more psychoanalytic approach, or as countercontrol or a failure of compliance by those clinicians who lean toward cognitive-behavioral therapies, it is understood to be a ubiquitous occurrence. Various integrative therapies will deal with these blockages differently, again usually relying on the understanding that is conveyed by the central theory of that model. So, cognitively oriented integrative therapists will look first at technical factors such as mistakes in assessment and a mismatch between the techniques offered and the needs of the patient. Experientially informed and dynamically oriented therapies will look at interpersonal events and the patient’s intrapsychic perceptions and meanings (such as unconscious anger or anxiety) as sources of resistance. What is unique about integrative therapies is that they will go beyond these typical sources of understanding and intervention if they do not prove to be useful, and they will incorporate ideas and methods from other therapies to move the therapy along. Psychodynamically oriented therapists may shift to experiential or cognitive-behavioral methods to see if these techniques might help the patient go forward, whereas more structured therapists might move toward a more depth oriented, exploratory approach.

Strategies and Interventions

Integrative psychotherapies are built around an expanded and potentially unlimited array of strategies and interventions. Psychotherapy integration was established with a value system in which no useful way of working or psychotherapeutic technique should be overly prized or excluded from consideration for theoretical or sectarian reasons. The only valid limitation on the choice of interventions in these therapies is clinical utility: The therapist does not believe, on the basis of the research literature and on clinical reports and experience, that a particular direction in therapy, or a particular intervention, would be helpful to this patient at this time.

Having said this, we must acknowledge that in practice it is impossible for any therapist to be competent with all strategies and techniques, and to know where and when to use those interventions. It also must be noted that the same intervention, when used by practitioners with different approaches, can take on different meanings. Homework has different meanings when assigned by a psychodynamic and a cognitive behavioral therapist. As discussed in the previous section, the practice of each single type of integrative psychotherapy is guided by its unique conceptual framework, be it a plan for assessment as in models that are technically eclectic or are based on common factors, or an expanded and integrative theory, as in assimilative integration or theoretical integration. The important point once again is that these conceptual systems allow for more and greater choice and flexibility in thinking about the direction of the therapy and the interventions that might be possible, and also allow for creativity and innovation on the part of the therapist.

Psychotherapy integration is based on the premise that there are a multiplicity of curative or change factors, and that most integrative models try to make use of this variety to the most realistic degree possible. Common factors approaches are built directly and openly on this idea: that many change factors cut across the various therapies, and it is most desirable to identify those common factors and to organize therapy around their inclusion. Psychodynamically oriented integrative therapies value insight, but incorporate such behavioral change principles as reinforcement, shaping of new behaviors, and exposure to and extinction of anxiety (Wachtel, 1977). Humanistically leaning treatments continue to emphasize prizing, warmth, and accurate empathy, but incorporate reliance on cognitive restructuring and changes in schemas as well (Greenberg et al., 1993).

Certain writers have made attempts to find the critical change factors that are most typical of integrative therapies. Most integrative therapies seem to rely on exposure to anxiety, on the provision of new experience, on positive reinforcement for new ways of coping, on a new way of thinking about an old problem, and on enhanced self-understanding and a greater capacity for experiencing and expressing emotions. As discussed, Beitman et al. (2006) have identified the positive changes in the patient’s vision of the future to be a central change factor. Gold (1996) suggested that changes in meanings in all parts of a patient’s narrative, or life story, make for the most complete therapeutic gain. Perhaps the most complete description of those change factors that operate across the boundaries of all therapies, integrative or otherwise, has been compiled by Prochaska and DiClemente (2005). In their transtheoretical approach, these authors identified 10 processes of change: consciousness raising (insight or the expansion of awareness), self-liberation (freedom from internal criticism and inhibitions of thought and emotion), social liberation (greater assertiveness and expanded interpersonal choices), counterconditioning (exposure, extinction, and habituation), stimulus control, self-reevaluation, reevaluation of the environment, contingency management, helping relationships, and dramatic relief (catharsis and expression of intense emotion). Prochaska and DiClemente (2005) point out that most sectarian therapies make use of two or three of these change factors. Most integrative therapies probably make use of several more. The transtheoretical model is designed to make use of all that are necessary, depending on the stage of therapy and the patient’s needs and readiness for change. This concept of stages of change is integrated with processes of change, and it is particularly important to recognize whether the patient is in a precontemplative, contemplative, preparation, action, or maintenance stage of change. These stages refer to a continuum in which the patient may vary from not yet considering change to having made a change and needing to solidify gains that have been made.

Special Issues

We are not criticizing our colleagues for these choices, nor do we think we are much different than they. Psychotherapy integration may be a desirable goal and may greatly potentiate the effectiveness of traditional therapies. But, it takes a very confident therapist, who can tolerate a great deal of ambiguity and anxiety, and who has a huge amount of knowledge and skill at his or her disposal, to work in a way that is truly free of limits.

We do not have well-worked-out answers to the questions raised about the choices faced by an integratively inclined therapist. Competence in more than one area comes with education and training that extends far beyond graduate or medical school. There now exist a fair number of graduate and postgraduate training programs in integrative therapies (Norcross & Halgin, 2005), but these are still in a small minority, and it is difficult for any one program to be long or intensive enough to avoid the trap of teaching a form of shallow eclecticism. The ability to recognize the need for an integrative shift in any therapy, to move from one set of concepts and techniques to another, may be as difficult as learning to hit a major league curve ball, or to play the violin on the stage of Carnegie Hall. We don’t know exactly how these virtuosi arrive there, but we do know that at least it is a combination of innate ability, years of practice, good teachers, a certain level of self-confidence, ambition, fearlessness, and inspiration. We need to look at these variables, and others, in the context of who makes an effective integrative therapist.

Race, Culture, Gender, and Class

Some integrative therapies have been developed specifically to work with issues and problems that are derived from social inequalities and conditions. One of the authors of this chapter (Gold, 1992) wrote about an integrative treatment that was derived from work with poor children from minority backgrounds who lived in the horrific conditions of New York City’s south Bronx neighborhood during its greatest period of social decline. This therapy developed out of the realization that the psychological problems that these children faced were caused in great part by poverty, discrimination, neglect, abuse, drug addiction, and homelessness, and that any therapy had to expand its boundaries and methods of intervening to help the children to survive in this environment. The therapy integrated cognitive-behavioral and psychoanalytic techniques with an expanded role for the therapist, who added to these traditional methods the actions of the social and political activist and advocate, assisting the patients and their families in dealing with these situational issues.

Franklin, Carter, and Grace (1993) developed an integrative therapy that was tailored to the needs of African American patients. These therapists described novel ways of identifying the contributions of social class and race on psychopathology; specifically, they were concerned with the ill effects of racism, discrimination, and poverty on personality development and on personal identity. They suggested using a multisystem approach to treatment that allows these issues to be understood and confronted, along with standard work on cognitive and psychodynamic issues.

Several integrative therapists have developed therapeutic approaches that include and synthesize spiritual and religious issues with psychotherapeutic models. Rubin (1993) demonstrated how Buddhist philosophy and meditation techniques could be successfully used within the context of psychoanalytic therapy, whereas Healey (1993) explored the ways that psychoanalytic treatment could be enriched by incorporating Christian ideas and processes. Sollod (1993) described an integrative, experientially oriented therapy into which he blended ideas and techniques that originated in folk medicine and in traditional culture. In a similar vein, Van Dyk and Nefale (2005) explored the ways in which African healing narratives and rituals could be used to promote the effectiveness of Western psychotherapies in traditional African populations.

Special Populations

Integrative approaches have been developed for just about every standard problem or group of patients for whom traditional psychotherapies exist. There are several approaches that have been described as being suitable and effective for more atypical problems and populations. These specialized integrative treatments usually are described by their advocates as being more helpful than standard therapies because the targeted problem or patient characteristics seem to make adherence to a standard model less possible.

Papouchis and Passman (1993) described one such integrative therapy aimed at the elderly. This therapy takes into account the cognitive, emotional, and social issues and concerns that are part of the aging process, and describes ways in which therapists can address these issues, making it easier for the patient to make use of standard psychodynamic and cognitive-behavioral procedures. Although the therapy is predominately psychodynamic, more emphasis is placed on current than past events, and the past is used as a source of reminiscence to highlight issues in the present.

The unique problems of patients with chronic pain is the central focus of the therapy described by Dworkin and Greziak (1993). They discuss how behavioral and cognitive methods can be combined with psychodynamic exploration in the treatment of these patients. The psychosocial antecedents and concomitants of chronic pain must be understood to develop a truly psychobiological understanding of pain.

Another specialized integrative therapy is Butollo’s (2000) treatment for the survivors of the ethnic cleansing and torture that occurred in the Balkans after the breakup of Yugoslavia. Many integrative therapies have been devised to address the needs of patient suffering from the aftereffects of trauma, but Butollo’s (2000) social interaction, multiphasic approach was designed specifically for the treatment of war trauma. It focuses on distorted self-processes caused by traumatic experiences. A similar effort was made by Pelzer (2001), who constructed an integrative therapy for victims of ethnic violence in Rwanda. Pelzer’s model combines an emphasis on the relationship and transference with several other modalities, including modeling, somatic techniques, trauma therapy, and reeducation.

Research on the Approach

Schottenbauer et al. (2005) found that 29 forms of integrative therapy had achieved at least preliminary empirical support. This status refers to the existence of positive findings of effectiveness in studies that don’t include a control group, or in which the control group is not randomized. Of the 29 integrative therapies mentioned in this review, 13 met the criteria for some empirical support, which requires the completion of one to four randomized and controlled studies in which the therapy is found to be effective. Finally, nine integrative treatments met the criteria for substantial empirical support, which is the existence of more than four randomized, controlled studies. This group included acceptance and commitment therapy, cognitive-analytic therapy, dialectical behavior therapy, emotionally focused couples therapy, eye movement desensitization and reprocessing, mindfulness based cognitive therapy, multisystemic cognitive therapy, prescriptive psychotherapy, and transtheoretical psychotherapy.

When we examine the 22 integrative therapies that had been evaluated against randomized control groups, we find that these integrative therapies were of equal or greater effectiveness across a variety of patient populations and problems. These treatments were useful for couples, patients with acute and chronic depression, depressed patients who were prone to relapsing, patients with borderline personality disorder, patients with physical disorders, generalized anxiety disorder, smokers, workplace related stress, binge eating, antisocial adolescents, personality disorders, and patients with Posttraumatic Stress Disorder (Schottenbauer et al., 2005).

In looking over these systems, it does not appear that any one type of integration (integrative therapies that are exemplars of any of the four modes of psychotherapy integration, or that are based on any particular foundation therapy such as behavior therapy) is any more likely to be empirically supported than is any other type. The easiest observation to make is that those integrative therapies that originated within an academic, research-oriented context, such as transtheoretical therapy or acceptance and commitment therapy, are most likely to have been widely studied and then to have received the most empirical support. The creators of these therapies have been clinician/researchers who were aiming to refine their psychotherapeutic work and to evaluate it simultaneously. Many of the most prominent and influential integrative models, such as multimodal therapy and cyclical psychodynamics, have been investigated in randomized controlled studies only once or twice (in the case of multimodal therapy) or not at all (cyclical psychodynamics), largely because Lazarus and Wachtel developed these models in clinical settings, and their findings were used primarily by other clinicians. This split between research and practice certainly is not limited to psychotherapy integration; rather, it has been a part of the history of the general field of psychotherapy and remains a source of heated debate today as well.

SPECIFIC APPROACH: ASSIMILATIVE PSYCHODYNAMIC PSYCHOTHERAPY

The specific approach we describe more completely in this section is assimilative psychodynamic psychotherapy, an approach that we have presented extensively in previous publications (Stricker, 2006; Stricker & Gold, 1996, 2002) and also referred to earlier in this chapter.

How the Specific Approach Implements or Modifies the Broad Theory

The heart of the theoretical approach that underlies assimilative psychodynamic psychotherapy is relational psychoanalysis. Ordinarily, the focus of relational psychoanalysis is on interpersonal relationships rather than on drives, as is the case with traditional psychoanalysis. Personality development is seen as emerging from representational structures, or templates established by early relationships with parents and other significant figures. However, that relational theoretical structure has been modified according to our three-tier model of personality (Stricker & Gold, 1988). As described previously, the three tiers concern behavior (Tier 1), cognition, perception, and affect (Tier 2), and unconscious psychodynamic processes (Tier 3). Thus, the traditional concepts of unconscious motivation, conflict, and representational structures are retained, but these variables are placed in a broader psychological and social context. In this model, unconscious processes are maintained by, influence and are influenced by, and are changed by interpersonal, cognitive, and behavioral factors as well as by intrapsychic processes. Thus, accommodation as well as assimilation has taken place and produced the final theoretical structure for assimilative psychodynamic psychotherapy. This theory now has become cyclical rather than linear, as the direction of causation among the three tiers can vary from patient to patient and even from situation to situation for the same patient.

The implementation of the theory within the therapy follows quite logically. The usual beginning approach is to adopt the stance of the psychoanalytic listener and allow the patient to unfold his or her story. A therapeutic alliance is encouraged early and forms a foundation on which all else is based. Impasses may be met by the usual analysis of resistance, but also by the introduction of interventions that have their source in Tier 1 or Tier 2, such as the assignment of homework or in session activities such as two-chair work.

Specific Strategies and Interventions That Are Highlighted in the Approach

The signal for a shift from a psychodynamic set of interventions to an intervention drawn from a foreign theory is the arrival at an impasse in the treatment. If therapy proceeds well, there is no need for assimilation, and it should not be done simply to display virtuosity. It is highly unlikely that therapy will proceed without impediments, however, and we feel that there often is value in dealing with the impediment in a direct manner rather than attempting to analyze it. It is in these cases that a choice will be made from the range of possible assimilated interventions and an appropriate one will be employed. After this is done, there will be a return to the more standard way of working, often beginning with the processing of what has just occurred (e.g., “How was it for you to have me appear more directive than usual?”).

The length of a typical episode of assimilative psychodynamic psychotherapy usually can be figured in months rather than weeks, and it is not unusual for therapy to continue for more than 1 year. This is typical of the course of psychodynamic psychotherapy in general. Our modification may include more attention to behavior change, and is likely to consume fewer sessions because patients usually are seen weekly, but it generally is consistent with the overall length of psychodynamic treatment.

Empirical Support

There is no specific empirical support for this model if one takes the traditional definition of research. Our experience with the approach has been very encouraging, but experience cannot be substituted for direct evidence. As discussed, however, there is growing evidence for the more general process of psychotherapy integration, and this has positive implications for this specific variant.