Motivational interviewing (MI) techniques have been described in cognitive and behavioral terms, as means to positively resolve tension created by unresolved ambivalence about change. This view of motivation is consistent with a negative reinforcement model, in which behaviors are performed to escape from negative states. In contrast, the concept of positive reinforcement involves seeking positive states through behaviors that lead toward more satisfying conditions. From this perspective, motivation involves a desire to experience positive emotions. This paper focuses on the potential role that emotions may play in MI, particularly positive emotions. The authors posit that MI elicits positive emotions of interest, hope, contentment and inspiration by inviting clients to envision a better future, to remember past successes, and to gain confidence in their abilities to improve their lives.
This commentary considers the six papers on assimilative integration in the larger context of the significance of this specific form of integration for psychotherapy integration in general. The author begins by revealing his bias that theoretical integration is the most mature form of psychotherapy integration. In this context, he views assimilative integration as an advanced form of eclecticism that absorbs technical eclecticism into the practitioner/theorist's home orientation. Several of the papers present useful examples of assimilative integration, but they tend not to explore the implications of the successful application of foreign techniques for their home theories. The author concludes by suggesting that assimilative integrationists need to become accommodative integrationists by thinking through the implications for, and the implied modifications to, their home theoretical orientations. Accommodative integration would bring us a step closer to the author's ultimate goal—an emergent, unifying, and integrative theory of psychotherapy.
This paper presents an integrative model of treatment—family focused relational psychotherapy—and applies it to work with adult children of divorce (ACDs). Three areas of assessment are identified—(a) assessment of individual ego development, (b) assessment of family of origin functioning, and (c) assessment of the nature of the parents' divorce (e.g., level of conflict). Based on this assessment, the treatment model is presented, which integrates strategies from relational/psychodynamic therapy, family of origin work, and experiential techniques. Case examples are presented to demonstrate the appropriate integration of these techniques with clients at different levels in the assessment schema. In addition, a review of the literature on the long-term effects of divorce on children suggests several specific issues that may arise in treatment. These include low self-esteem, emotional distress, externalizing problems, and interpersonal problems such as fear of commitment, difficulty trusting, a high rate of divorce, and strained relationships with parents.
I am pleased to have been asked to respond to these excellent papers on the use of various strategies within cognitive psychotherapy. The model that these presentations demonstrate is an excellent one—the presentation of a case followed by different perceptions on its management from the proponents of several approaches. Although this model fosters integration within the various aspects of cognitive psychotherapy, it can also be useful in fostering integration across cognitive psychotherapies and other forms of psychotherapy. In my response to these papers, I will address both aspects of integration although I will not directly address the case of Silvia. I will first discuss each model, followed by a comparison of the similarities and differences among them. Finally, I will provide a few of my own thoughts on psychotherapy integration. The Linguistic Therapy of Evaluation (LTE; Caro, 2001) appears to me to be an unusually creative application of General Semantic Theory. Its fundamental postulate seems to be an assumption that the words we use in describing events or people, or the labeling, are not identical with reality itself. Put another way, the evaluation that clients (or anyone) give to an event can easily be seen as reflecting the reality itself rather than what it really is—just an evaluation. When an individual identifies the words with the reality, an intensional orientation has taken place. Furthermore, as I understand the theory, it sounds as if the use of the words tends to create the reality itself. Through the process of therapy, or perhaps through the process of living, an extensional orientation takes place, in which the individual learns to distinguish between the words used to describe a reality
When successful therapeutic experiences themselves become the focus of therapeutic inquiry and work, it becomes possible to deepen and broaden the treatment's effectiveness. The systematic exploration of phenomena associated with therapeutic change—through exploring the patient's experience of having a therapeutic experience—activates meta-therapeutic processes associated with characteristic affects of transformation. The aim is to raise the consciousness of therapists of all orientations, a fortiori those interested in integration, of the therapeutic potential inherent in the exploration of such nondenominational processes. First, three meta-therapeutic processes—acknowledging mastery, mourning-the-self, and receiving affirmation—and their respective affective markers—joy, emotional pain, and the healing affects—are identified. Then, the focus is on the dynamics of the affirmation process and the phenomenology of the healing affects. Therapeutic benefits and possible sources of resistance to receiving affirmation—in both patients and therapists—are discussed. In the last part of the paper, a transcript of a clinical vignette illustrates integrative therapeutic work with the response to affirmation and the experience of the healing affects.
The relationship between client emotional expression and therapist interventions was studied in two working alliance conditions. An events-focused methodology was used to examine a total of 8 events taken from a variety of therapeutic orientations. Results indicated that, in the presence of a good client–therapist relationship, therapists showed higher levels of empathy and effectively focused on the immediately expressed feelings; in turn, their clients were engaged in exploration of feelings. In poor-relationship dyads, clients expressed negative feelings toward the therapists. Interventions rated as effective by clinical judges were characterized by accurate therapist understanding of clients' emotional expressions and working with strains in the therapeutic relationship. Ineffective interventions were associated with inaccurate assessments of clients' emotional states. Intensive analysis of these sessions led to three distinct models of in-session emotional expression events. Theoretical and practical implications of these models will be discussed.
This patient is enacting two chronic maladaptive patterns. In one he alternates between the role of victim and abuser while inducing the therapist to play the counterrole. He tries to master the abuse he suffered passively as a child by becoming abusive with the therapist and having her experience what it feels like to be mistreated. My effort would be to interpret this pattern even while acknowledging and absorbing some degree of his anger. In a second pattern he acts like an angry, demanding child in an effort to extract nurturance and special treatment from the therapist. I would help him explore this posture in terms of his deprived background and its maladaptiveness in his current life. Finally, I present vignettes from my own practice to demonstrate how I work with patients' anger when it is expressed indirectly rather than in Mr. P's very direct manner.
Responding to patients who become angry at the therapist is difficult for many clinicians. In the case and session presented, the patient is not only angry, but devalues the therapist by not paying while asking for more frequent sessions. The therapist loses it, states she is angry, and remains insistent on the patient keeping his bills paid or reducing the frequency of sessions. The therapist is conflicted over confronting the patient with what she believes has to change in order for his symptoms to diminish—the irrational beliefs, life style, and sense of entitlement related to the personality disorder of this patient, but likely to drive him away from treatment. The therapist engages in a risky confrontation and remains unclear about the eventual benefit of this response.
This article formulates the main problem of the angry patient treated by Dr. Curtis as one of poor ego functioning. This is possibly of neuropsychological origin. Treatment would be training to strengthen ego functions and the patient–therapist relationship would be task oriented. The anger is not dealt with directly except as it interferes with the training. It is predicted that as the ego becomes stronger, the anger will become more controllable. There is some question of whether this patient would be able to cooperate with such a program.
The visions of reality refer to assumptions about the nature and content of human reality and have been used to describe different genres of literature as well as psychoanalytic, behavioral, and humanistic modes of therapy. In this paper, four visions—the tragic, romantic, comic, and ironic—are applied to a single case, spelling out the way in which each can direct the focus of a therapist's attention to different aspects of a client's problems. Each vision can also influence the process of therapy and its goals. Keeping the several visions in mind can broaden both the therapist's and the client's view of the client's life situation and problems, thereby opening up possibilities for integrative work. The paper also spells out the shift in visions of reality that is necessary when conducting brief versus long-term therapy.
The principles and procedures of Cognitive Appraisal Therapy (CAT) are applied to the case of Silvia. The assessment plan focuses on affective, behavioral, and cognitive aspects of personality. The patient evidences self-pity and anger, and rebellion and withdrawal in her interpersonal relations. Key interventions include encouraging positive methods for comforting her feelings, building self-respect by doing what she deems morally right, eliminating self-defined victim status by active pursuit of her goals, and correcting cognitive distortion of self-image and pessimistic forecasts. Other characteristic CAT interventions are also discussed and illustrated.
Although the humanistic/existential and the narrative approaches to psychotherapy are clearly distinct perspectives with some marked differences at the level of metatheory, they also show very important similarities in their conceptualization of the human condition and the processes involved in living adaptively (Richert, 1999). These similarities make these two approaches reasonable candidates for integration. The present paper examines five specific points of integration at the level of strategy and techniques (Neimeyer, 1993b): Interplay of experiential meanings and narrative structure in developing client meaning, use of existential themes in client narratives, deconstruction as a means of dealing with existential guilt, contextualization of wishes as a means of mobilizing will, and reflexivity as a way of developing the I–Thou relationship. A brief theoretical rationale is offered for each of these points of integration, and each is illustrated with clinical examples.
The Clinical Exchange invites eminent clinicians of diverse persuasions to share, in ordinary language, their clinical formulations and treatment plans of the same psychotherapy patient—one not selected or nominated by those therapists—and then to discuss points of convergence and contention in their recommendations. This Exchange concerns a Mr. L, a 47-year-old, married man presenting for outpatient individual psychotherapy with chief complaints of depression, anxiety, and a lengthy history of vocational underachievement. Drs. Herbert Fensterheim, Leslie Greenberg, and Leigh McCullough, who anchor their practices in the cognitive-behavioral, experiential, and psychodynamic orientations, respectively, are the featured commentators. Finally, Dr. Jerold Gold, the case contributor and Mr. L's psychotherapist, provides a few closing comments.
Eye Movement Desensitization and Reprocessing (EMDR) (Shapiro 1989a, 1989b, 1995) is an innovative, comprehensive approach to psychotherapy. While EMDR's use of eye movements has attracted a great deal of attention, the efficacy of the EMDR method can be explained parsimoniously in terms of many different types of therapy. Lang's (1985) information processing networks provide a way to understand the Accelerated Information Processing model proposed by Shapiro to explain EMDR. A representative EMDR session is presented to illustrate the integrative components of EMDR's procedural elements and the range of clinical effects. Therapeutic changes seen as a result of self-healing using EMDR are discussed from the perspectives of other psychotherapeutic approaches in order to understand the contribution of EMDR to the psychotherapy integration movement.
Beginning with an eastern concept of human beings rooted in the Buddhist and Yogic traditions, this paper describes a theoretical assimilation of western models and therapies into the eastern paradigm. It traces the beginning of the east–west psychotherapy dialogue in the United States, citing early examples of Buddhist and yogic practices in the west. Ken Wilber's spectrum of consciousness model is presented and its unifying value for psychotherapy is explored. An integrative model of wholistic therapy, developed by a group of eastern and western practitioners, is then described. The paper concludes with an exploration of the issues and implications for psychotherapy integration raised by this model.
This article addresses key themes in the teaching of family therapy-centered integration and describes the critical role of assimilative integration. The tenets of assimilative integration provide a framework for introducing students to multiple systemic theories and techniques while allowing them to maintain a secure base in one main theory. This form of integration is compared and contrasted to theoretical eclecticism, which guides students to become securely based in multiple theories through providing a framework for selecting which systemic approach to use when and with whom. Other issues that shape the form, content, and process of integrative training are discussed including the role of institutional culture and clinical needs, the importance of fully incorporating issues of diversity and social oppression, and the relational context within which teaching and learning take place.
The models for assimilative integration presented in this issue are considered. It is concluded that some grounding theories may be too structured, or one's interpretation of them too rigid, stifling psychotherapeutic flexibility and creativity by excluding potentially useful interventions. Alternatively, models may be too unstructured, or one's interpretation of them too loose, leading to treatment forms lacking specificity, direction, and coherence. As noted originally by Messer, assimilative integration operates most beneficially when practitioners address the limitations of their therapeutic models, or tap their models' progressive implications in ways that respect the fundamentals of their shared clinical theories. Practiced in this balanced way, assimilative integration can offer a useful, flexible way of navigating a creative yet disciplined psychotherapeutic course between unbridled technical eclecticism and technical and theoretical rigidity. The author also examines and extends some of the integrative ideas put forth in this issue, from a two-person or intersubjective perspective based on a relational psychodynamic treatment model.
Assimilative integration is a new type of psychotherapy integration introduced by Messer in 1992. This paper explains the where, what, when, and how of this integrative route, outlines its advantages and weaknesses, and discusses areas for potential assimilative practice in various models of therapy. Following a brief review of the current status of psychotherapy integration and its practices, assimilative integration is conceptualized as a mini theoretical integration and as theoretical eclecticism it is offered as a bridge between theoretical integration and technical eclecticism. Assimilative integration is proposed as the best theoretically and empirically based integrative approach available at this time, particularly for therapists who have been trained in a single mode of therapy before they became integrationists.
S. B. Messer (1992) introduced the notion of assimilative integration in psychotherapy, theorizing that integrative practitioners adhere to their preferred theoretical paradigms while judiciously blending aspects from other models. His assimilative approach offers a conceptual and clinical middle ground between technical eclecticism and a grand, unified theory of psychotherapy. However, the practice of competent assimilative integration is fraught with many challenges, both theoretical and clinical. The goal of the present paper is to explore the challenges of implementing assimilative integration. First, the theoretical and clinical barriers to assimilative approaches are considered. Second, the use of assimilative integration to avoid therapeutic failures is discussed. Finally, a case example is presented to illustrate the author's attempt to assimilate narrative, interpretive interventions within his preferred cognitive–behavioral treatment paradigm.
This issue of Journal of Psychotherapy Integration includes a set of articles that explore and apply the concept of assimilative integration. They do so from different theoretical perspectives, including psychodynamic, cognitive–behavioral, family systems, and Yogic/Buddhist, as well as from broad conceptual standpoints. The articles are followed by 3 commentaries that offer an appreciation and critique of assimilative integration and recommendations for its further development.
In this paper we discuss recent advances in relational psychoanalytic thinking, and demonstrate how an assimilative approach to integration can be based on this theoretical and clinical model. We describe 3 instances in which active interventions may be used to enhance relationally oriented, psychoanalytic work: by impacting on relationships outside of therapy that maintain pathological patterns, by filling in intrapsychic deficits, and by supporting the patient's active efforts at change. We provide clinical examples to illustrate each of these points.
The paper argues that the integrative psychotherapy approach is ideally suited to the treatment of psychological trauma. A brief term intervention model, devised by psychotherapists working with trauma in the South African context, is presented to illustrate this premise. It is asserted that posttraumatic stress represents a disorder in which dysfunction occurs both internally and externally, according to Freud at the interface of these two aspects of psychological functioning, i.e., at the ego boundary. Disturbance manifests in recognizable cognitive, behavioral, and somatic symptoms and in addition carries unconscious associations and anxieties. The ideal approach to treatment thus appears to be to draw on the relative strengths of both the psychodynamic and cognitive-behavioral schools. Existing trauma intervention models reflect the centrality of integration in many respects, although this does not seem to be explicitly recognized. The five components of the model referred to above are outlined and each component is explored in terms of its efficacy within both a cognitive-behavioral and a psychodynamic framework. Illustrative case material is provided to demonstrate the mechanisms at work in each case. The paper argues that the clinical success of the model lies in its integrative perspective and that psychotherapy integration should be recognized as the approach of choice in the treatment of traumatized individuals.
To determine the underlying values and methods in cognitive-behavioral and psychodynamic therapy and to address the implications of those values and methods for integrating the two therapies, the Process Value and Methods Survey was sent to members of The Association for Advancement of Behavior Therapy (cognitive-behavioral sample) and Division 39 of American Psychological Association (psychodynamic sample). Members were asked to endorse items based on their ideal understanding of their respective orientations. A Principal Components Analysis (PCA) of the combined samples yielded six components for values, of which four were significant according to orientation. A second PCA, for therapeutic methods, yielded six components, five of which were significant according to orientation. In both PCAs, components significant for an orientation were consistent with the corresponding constructs of that orientation. The relationship between method and value components as well as how value components may be related to clinical practice and psychotherapy integration is discussed.
Clinical experience suggests that a variety of neurotic and personality disorders are effectively treated by an approach to therapy that is relatively passive in appearance and is directed towards the development of self-knowledge. Behavior theory provides an economical, naturalistic analysis of the therapeutic effects of this approach. Punishment, a common method of controlling forbidden behavior, can result in pathologic avoidance and deficient awareness of one's own behavior and its relation to the environment. Traditional methods of psychoanalysis and behavior therapy provide circumstances that help the patient to observe acts and feelings and their relation to elements of the environment that are otherwise avoided. These procedures may work best when self-observation is (1) not selectively reinforced by the therapist, and (2) supplemented by explicit training in behavior analysis. These elements are combined in a treatment approach for generating observations of one's own behavior and its functional significance in the natural environment.
This is a response to Dr. NeilJacobson''s article, An Outsider''s Perspective on Psychotherapy Integration, which appears in this issue. It addresses the issue of the differences between eclecticism and psychotherapy integration as well as the possible advantages integration holds over a one-model therapy system. This article suggests that virtually all psychotherapy systems operate under an integrated three paradigm model, and offers some concrete examples of this explanation. It also suggests that the use of psychotherapy integration may lead to a better paradigm match between client and therapist, and ultimately to better outcome. This article concludes that psychotherapy integration possibly offers the best alternative in terms of reducing the biases of one''s underlying treatment oaradiem.
This study evaluated specific influences of a cognitive marital treatment (CMT) for depression based on an integration of cognitive theory of depression and systems theory. The effects of CMT on variables representing cognitions, emotions, and behaviors were compared with the effects of traditional cognitive therapy (CT), pharmacotherapy (PT), and no treatment (NT). Subjects were Major Depression Disorder and Dysthymic outpatients and their spouses. The changes considered were for pre–post treatment and pre-treatment–follow-up. CMT affected a wider range of variables than other treatments. In most instances it was also superior to the NT condition. Most of the gains were manifested at termination and lasted through follow-up. The variables affected by CMT were patients' and spouses' cognitions and emotions. PT had best effects on patients' emotions. CT affected patients' cognitions, but did not achieve superiority on any of the compared variables. None of the treatments produced significant changes in behaviors.
This case study describes a rather brief course of therapy with a 30-year-old woman who became clinically depressed after the birth of her child. A unique element of this presentation is that the client describes what happened to her before and during a variety of treatments, including four hospitalizations and an array of medications that iatrogenically produced seizures, prior to our therapeutic work. Proceeding the client's subjective account, I describe my clinical framework—a brief, integrative, solution-focused, client-directed therapy approach, emphasizing the integration of cognitive-behavioral and thought field therapies (Callahan, 1995)—undertaken within the context of a constructivist/spiritual metatheory. A session-by-session description of the implementation of this approach and its effects follows the client's description of her experiences. The paper concludes with the client's remarks about this therapy and its impact, followed by my own observations about treatment, including prospects for bridging Western psychology and spiritual practice with such Eastern traditions as Yoga and Buddhism.
This article reports on the integrated application of cognitive therapy, transactional analysis techniques, and the behavioral technique of response prevention using self-instructional training and behavioral substitution in a brief therapy approach. These methods were applied in the case of a young man who presented with compulsions to perform repetitive and ordering rituals with the belief that it would prevent his girlfriend from becoming pregnant. A 21-year-old white male who had performed 3 to 5 hours of rituals daily for several years was able to eliminate the majority of his compulsive behaviors and reduce his level of anxiety after eight clinical therapy sessions. Results were maintained at 6-month follow-up. The clear precipitating factors and the unusual maintaining variables for the disorder in the client are described. The author discusses the case in light of current theoretical, therapeutic, and biomedical understandings of the disorder.
I first briefly review the dodo bird verdict and suggest that we should be responding to it by looking for a new way to conceptualize how therapy works. Then I describe the dominant medical or treatment model of psychotherapy and how it puts the client in the position of a dependent variable who is operated on by supposedly potent therapeutic techniques. Next I argue that the data do not fit with this model. An alternative model is that the client is the most important common factor and that it is clients' self-healing capacities which make therapy work. I then argue that therapy has two phases—the involvement phase and the learning phase—and that the involvement phase is the most important. I next review the five learning opportunities provided by therapy. Finally, I argue that a relational model of therapy focused on consultation, collaboration, and dialogue is better than a treatment model.
Carere-Comas is concerned that I have elevated the client as a hero. I point out that what I really am arguing for is a paradigm shift from therapy as treatment to therapy as mutual, intelligent collaboration. I also discuss what it means to say that the client knows what he or she wants and needs. Finally I discuss the idea that it is the client who makes therapy happen.
Preliminary findings by the McGill Psychotherapy Process Research Team indicate that not only are interpretations used in client-centered therapy, but they are also efficient in producing in-session client change. Using the Hill Counsellor Verbal Response Category System—Revised (Friedlander, 1982) as a guide to locate interpretations, we investigated the qualitative differences between interpretations leading to different in-session client change events in six sessions conducted by Carl Rogers. The occurrence of in-session therapeutic phenomena were assessed using the Experiencing Scale (Klein, Mathieu, Gendlin, & Keisler, 1970) and the Category System of Good Moments (Mahrer & Nadler, 1986). Results indicate that significant in-session therapeutic phenomena are preceded by interpretations and that qualitative differences exist between interpretations that precede change events and those that do not. Implications for psychotherapy theory, research, and practice are discussed.
This commentary discusses the four papers from the vantage point of a cognitive-developmental view. Psychotherapeutic change involving changes in core cognitive structures is seen as threatening an individual's personal sense of identity as well as security and safety needs. Core cognitive constructs are laid down early via the principle of covariation of events and form the basis of our tacit knowledge base. Subsequent changes in this tacit knowledge is difficult because the core cognitive constructs act like a mental filter to screen in confirming data and screen out disconfirming data. Ambiguous stimuli tend to be interpreted on the basis of preexisting cognitive constructs, even when the match between event and interpretation is not ideal. Several suggestions are given for increasing the probability of changes occurring in core cognitive constructs.
Treatment choice is the decision process whereby the psychotherapeutic methods and the psychotherapist are determined when psychotherapy is recommended for a specific client. In this article the problem of treatment choice is situated within an integrative view of psychotherapy. A review of the literature confirms the usefulness of the following concepts for treatment choice: client preferences, client control of the situation of choice, and the mutual acceptability of differing views of therapists and clients. These research findings reveal the importance of four elements in the psychotherapeutic intake strategy: exploration of the client's perspective, informing the client, negotiation as a process of confrontation between the client's and the clinician's perspective, and the client's ultimate choice between alternative treatment proposals.
This paper focuses on two common misconceptions of common factors in therapy. The first misconception entails the confusion between common factors and therapeutic factors, and thus the inappropriate and misleading use of the term therapeutic common factors in various situations. The second misconception is the mixing of commonalities of different kinds and levels in proposed lists and studies of common factors. These areas are discussed and clarified, and recommendations designed to facilitate conceptual and methodological improvements relative to each misconception are offered. The selection of best levels and kinds of common factors to be studied are further explored (i.e., the study of client change events and antecedent therapist behaviors across different therapies), and specific proposals for their research are outlined.
Some of the epistemological consequences of adopting the narrative point of view in psychotherapy are explored. Attempts to apply principles and norms from the philosophy of science to psychotherapy are criticized, since psychotherapy is not a science, but a technique. In addition, those models, related to the acquisition of knowledge, that consider that knowledge could increase by apposition without transforming the subject who is knowing are discussed. Natural science and hermeneutic metaphors are not suitable for understanding the practice of psychotherapy. Traditionally, the interpretation of symptoms or problems to solve has been the main instrument in therapy. In other words, the therapist tries to look for the truth hidden under the symptom, which then becomes a sign. Our proposition is to substitute these metaphors for the paradigm of text commentary. Text commentary, instead of providing a unique truth, provides a set of meanings suggested by a commentary. Characteristics that allow one to distinguish a good and a bad commentary, and implications of the paradigm described for the training of psychotherapists, are discussed.