published: 11 January 2016
Frontiers in Psychology | www.frontiersin.org 1 J
anuary 2016 | Volume 6 | Article 2021
Susan G. Simpson,
University of South Australia, Australia
Anima Research Institute, Italy
Alpert Medical School of Brown
This article was submitted to
Psychology for Clinical Settings,
a section of the journal
Frontiers in Psychology
Received: 18 October 2015
Accepted: 17 December 2015
Published: 11 January 2016
Zarbo C, Tasca GA, Cattaﬁ F and
Compare A (2016) Integrative
Front. Psychol. 6:2021.
Integrative Psychotherapy Works
, Giorgio A. Tasca
, Francesco Cattaﬁ
and Angelo Compare
Department of Human and Social Science, University of Bergamo, Bergamo, Italy,
Department of Psychiatry, University of
Ottawa, Ottawa Hospital, Ontario, ON, Canada,
Department of Psychology, University of Chieti, Chieti, Italy
Keywords: integrative, psychotherapy, common factors, eclecticism, clinical psychology
A range of psychotherapy approaches have been recognized as eﬀective and even the treatment
of choice across the range of psychiatric diagnostic categories (e.g., see https://www.nice.org.
uk/guidance/cg123 or https://www.nice.org.uk/guidance/conditions-and-diseases/mental-health-
and-behavioural-conditions). However, in clinical practice, the choice of the most eﬀective
psychotherapy for each mental disorder is complicated by the existence of over 400 varieties
of psychotherapy approaches that can be deﬁned and classiﬁed in several ways according to
their theoretical model (i.e., behavioral, systemic, cognitive, psychodynamic, etc.), format (i.e.,
individual, family, group), temporal length and frequency of the sessions, as well as any possible
combination of these elements (
Garﬁeld and Bergin, 1994). Due to their diﬀerent epistemologies
nd attempts to create rigid boundaries around the theories, dialog among these models has been
In part to bridge this historical division, a number of leaders in the ﬁeld have proposed an
integrative approach to psychotherapy, which since the 1990s has been gaining wider acceptance
(Norcross and Goldfried, 2005). For example, the Society for the Exploration of Psychotherapy
Integration (SEPI; http://www.sepiweb.org/) is an international organization with a growing
membership that includes some of the world’s leaders in psychotherapy practice and research.
More commonly, psychotherapists choose one theoretical model and apply it in a ﬂexible
and integrative way in their therapy practice. In recent decades, an increasing number of
psychotherapists do not prefer to identify themselves completely within a single approach, but
prefer to deﬁne themselves as integrative or eclectic (Feixas and Botella, 2004). In a recent large
survey of over 1000 psychotherapists, only 15% indicated that they used only one theoretical
orientation in their practice, and the median number of theoretical orientations used in practice was
four (Tasca et al., 2015). According to the integrative psychotherapy movement, a new research ﬁeld
is evolving toward the search for common goals, aiming at selecting theories and techniques among
psychotherapy models and developing a new ﬁeld in a collaborative and integrative manner. The
integrative psychotherapy movement does not aim at combining all the psychotherapeutic models
into one, but its purpose is to develop a new framework for dialog among diﬀerent approaches
(Feixas and Botella, 2004).
The term “integration” may denote diﬀerent meanings. The so-called “inte grative perspective”
indicates a general ﬂexible and inclusive attitude toward the diﬀerent psychotherapeutic models
(Greben, 2004). It aims to see what can be learned and introduced from various perspectives in
practice. Integration in psychotherapy involves four possible approaches: theoretical integration
(i.e., transcending diverse models by creating single but diﬀerent approach), technical eclecticism
(i.e., using eﬀective ingredients from diﬀerent approaches), assimilative integration (i.e., working
primarily from within one model but integrating aspects of others when needed), and common
factors approach (i.e., focusing on eﬀective therapeutic practices that are common to all approaches;
c, 2008; Castonguay et al., 2015).
Zarbo et al. Integrative Psychotherapy Works
WHY INTEGRATIVE PSYCHOTHERAPY
Integrative Psychotherapy Fits Different
Patients, Problems and Contexts
There is a growing agreement among psychotherapists and
researchers that no single psychotherapeutic approach can
be eﬀective and appropriate for all patients, problems,
and contexts. Each existing psychotherapeutic model and
approach is inadequate for some individuals (
Goldfried, 2005). Evidence-based research has demonstrated
that psychotherapeutic treatments that are integrative in their
nature (e.g., Interpersonal Psychotherapy, Schema Therapy,
Cognitive analytic therapy) are eﬀective for several psychiatric
disorders (e.g., Depression, Post-partum depression, Social
Anxiety disorders, Generalized Anxiety Disorders, Personality
Disorders, Dissociative Identity) (
Reay et al., 2003; Kellett, 2005;
Hamidpour et al., 2011; Stangier et al., 2011; Masley et al., 2012;
Roediger and Dieckmann, 2012; Clarke et al., 2013; Miniati et al.,
Integrative Psychotherapy Includes
Effective Common Factors
At the heart of psychotherapy integration is the important
research ﬁndings that despite the varying theoretical rationales
and approaches of diﬀerent schools of psychot h erapy, they
produce similar outcomes (
Barth et al., 2013). What has
lead psychotherapists to integrate psychotherapy models is the
evidence that common factors across psychotherapy approaches
(e.g., therapeutic alliance, client expectations, t herapi st empathy,
etc.) likely account for more outcome variance than the speciﬁc
eﬀects attributed to each psychotherapeutic approach (e.g.,
interpretations in dynamic therapies or cognitive restructuring
in cognitive behavioral therapies) (Wampold and Imel, 2015).
Speciﬁc therapeutic techniques contribute about 7% on the
outcome variance in psychotherapy, while the common f actors
account for almost 20% of the outcome variance (Lambert and
). In recent decades, clinicians and researchers have
been coming to a growing consensus about the existence of
common factors that are shared among several psychotherapeutic
approaches (Norcross and Goldfried, 1992; Wampold and Imel,
2015). Common factors among psychotherapy approaches that
have been associated with positive outcomes and therapeutic
changes include: the ability of the therapist to inspire hope
and to provide an alternative and more plausible view of the
self and the world; the ability to give patients a corrective
emotional experience that helps them to remedy the traumatic
inﬂuence of his previous life experiences; the therapeutic alliance;
positive change expec tations; and beneﬁcial therapist qualities,
such as attention, empathy and positive regard (
Gold, 2001; Feixas and Botella, 2004; Norcross and Goldfried,
2005; Constantino et al., 2011; Horvath et al., 20 11). Among
the cited common factors, therapeutic alliance has the most
evidence as a predictor of patient change (
Feixas and Botella,
Integrative Psychotherapy is Flexible to
Patients’ Needs and Sensitive to
One key value of integrative psychotherapy is its individualized
Norcross and Goldfried, 2005). The integrative
psychotherapy model aims to respond to the person, with
particular attention to aﬀective, behavioral, cognitive, and
physiological levels of functioning, and to spiritual beliefs.
Integrative psychotherapy allows for a better adaptation of the
therapy to the distinctive characteristics and needs of each
client, by allowing the therapist to tailor their knowledge of
evidence-based treatments and approaches. The main emphasis
of integrative psychotherapy is on the individual characteristics
of the patient and on the therapeutic relationship, both
considered as key elements of therapeutic change (
and Botella, 2004), as well as on client motivation. This
approach is in line with the recent guidelines by the American
Psychological Association on what constitutes Evidence-Based
Practice (American Psychological Association, 2006). In those
guidelines, EBP are deﬁned by research evidence, clinical
judgment, and client factors. Consistent with this deﬁnition,
integrative psychotherapy is not a technique applied to a passive
patient, but the client is seen as an active participant in the
therapy, and the therapist adjusts his or her approach depending
on client characteristics and preferences. It is within the context
of the therapeutic relationship that changes can be promoted and
clients can most beneﬁt from a caring and empathic therapist
(Feixas and Botella, 2004).
BE INTEGRATIVE, NOT ECLECTIC
Psychotherapists commonly practice diﬀerent types of
psychotherapy integration, applying the common factors
approach as well as assimilative integration or theoretical
integration. The common factors approach tends to
downplay the importance of speciﬁc eﬀects or techniques
of psychotherapies (i.e., two-chair technique, exposure, Socratic
questioning, etc.), in favor of working with common factors
known to be related to positive outcomes (e.g., therapeutic
alliance, therapist empathy, client expectations, etc.;
and Goldfried, 2005). On th e other hand, assimilative integration
involves working primarily from one theoretical approach
(e.g., cognitive behavioral therapy) but also incorporating
techniques from other psychotherapeutic approaches as needed
for any given client or context (e.g., interpreting transference;
Stricker and Gold, 2001). Finally, theoretical integration aims
to bring together theoretical concepts from several diﬀerent
psychotherapeutic approaches and to develop a “Grand Uniﬁed
Theory” of psychotherapy (Stricker and Gold, 2001).
The psychotherapy integration movement h ighlights that
psychotherapy integration is not only the process of taking some
techniques from various models and applying them as needed
(i.e., technical eclecticism), but it involves also the focus on
the link between theory, evidence, and technique (
Goldfried, 2005). In other words, integrative psychotherapy is
Frontiers in Psychology | www.frontiersin.org 2 January 2016 | Volume 6 | Article 2021
Zarbo et al. Integrative Psychotherapy Works
diﬀerent from technical eclecticism. An e clectic therapist chooses
a te chnique because it may work or may be eﬃcient, without
concern for its theoretical basis or resea rch evidence. If an
eclectic psychotherapist’s client experiences positive outcomes
after receiving a speciﬁc technique, the therapist does not
necessarily investigate why the positive change occurred in order
to develop a generalizable model of treatment. In contrast,
psychotherapy int e gration focuses on the relationship between
an eﬀective practice and its theoretical and empirical basis
Norcross and Goldfried, 2005). For example, e vidence-based
psychotherapy relationship practi ces (i.e., alliance, therapist
empathy, congruence, positive regard, etc.), which are integrative
in nature and based on common factors, have been the focus of a
recent APA task force report (Norcross, 2011).
In conclusion, the evidence indicates that integration
in general psychotherapeutic practice is desirable, even if
clariﬁcation needs to emerge at the level of theory. In order
to overcome this limitation of psychotherapy integration,
psychotherapy orientations should cultivate integration
and work closely together while maint a ining their separate
identities. International organizations like SEPI or the Society
of Psychotherapy Research (h ttp://www.psychotherapyresearch.
org/) represent a good example of the possibilities of
collaboration and integration among psychotherapists of
diﬀerent orientations. Moreover, a strong collaboration between
integrationists and psychotherapy researchers could lead to
the development of a uniﬁed background of knowledge and
action that, in turn, will advance the promising integrative
psychotherapy ﬁeld (
Castonguay et al., 2015).
We declare that the manuscript has been seen and reviewed by all
authors which have contributed to it in a meaningful way.
American Psychological Association (2006). Evidence-based practice in
psychology. Am. Psychol. 61, 271 –2 85. doi: 10.1037/0 00 3 -0 66 X.61 .4.27 1
Barth, J., Munder, T., Gerger, H., Nüesch, E., Trelle, S., Znoj, H., et al. (2013).
Comparative eﬃcacy of seven psychotherapeutic interventions for patients
with depression: a network meta-analysis. PLoS Med. 10:e1001454. doi:
Castonguay, L. G., Eubanks, C. F., Goldfried, M. R., Muran, J. C., and Lutz, W.
(2015). Research on psychotherapy integration: building on the past, looking
to the future. Psychother. Res. 25, 365–382. doi: 10.1080/10503307.2015.1
Clarke, S., Thomas, P., and James, K. (20 13 ). Cognitive analytic therapy for
personality disorder: randomised controlled trial. Br. J. Psychiatry 202,
129–134. doi: 10.1192/bjp.bp.112.108670
Constantino, M. J., Arnkoﬀ, D. B., Glass, C. R., Ametrano, R. M., and Smith,
J. Z. (2011). Expectations. J. Clin. Psychol. 67, 184–192. doi: 10.1002/jclp.
Feixas, G., and Botella, L. (2004). Psychotherapy integration: reﬂections and
contributions from a constructivist epistemology. J. Psychother. Integr. 142,
192–222. doi: 10.1037/1053-04126.96.36.199
Garﬁeld, S., and Bergin, A. (1994). “Introduction and historical overview,” in
Handbook of Psychotherapy and Behaviour Change, eds A. Bergin and S .
Garﬁeld (Chichester: Wiley), 3–18.
Greben, D. H. (2004). Inte g rative dimensions of psychotherapy training. Can. J.
Psychiatry 49, 238–248.
Hamidpour, H., Dolatshai, B., Shahbaz, A. P., and Dadkhah, A. (2011). The eﬃcacy
of schema therapy in treating women’s generalized anxiety disorder. Iran. J.
Psychiatry Clin. Psychol. 16, 420–431.
Horvath, A. O., Del Re, A. C., Flückiger, C., and Symonds, D. (2011).
Alliance in individual psychotherapy. Psychotherapy (Chic). 48, 9–16. doi:
Kellett, S. (2005). The treatment of dissociative identity disorder with cognitive
analytic therapy: experimental evidence of sudden gains. J. Trauma Dissociation
6, 5 5–8 1. doi: 10.1300/J22 9 v06n0 3_0 3
c, D. (2008). Integrative psychotherapy. Psychiatr. Danub. 20,
Lambert, M. J., and Bergin, A. E. (1992). “Achievements and limitations of
psychotherapy research,” in History of Ps ychotherapy: A Century of Change,
ed D. K. Freedheim (Washington, DC: American Psychological Association),
Masley, S. A., Gillanders, D. T., Simpson, S. G., and Taylor, M. A. (2012). A
systematic re view of the evidence base for Schema Therapy. Cogn. Behav. Ther.
41, 18 5–2 0 2. doi: 10.1080/1650 60 7 3.20 1 1.61 4 27 4
Miniati, M., Callari, A., Calugi, S., Rucci, P., Savino, M., Mauri, M., et al. (2014).
Interpersonal psychotherapy for postpartum depression: a systematic review.
Arch. Women’s Ment. Health 17, 257–268. doi: 10.1007/s00737-014-0442-7
Norcross, J. C. (ed.). (2011). Psychotherapy Relationships that Work: Evidence-
Based Responsiveness. Oxford: Oxford University Press.
Norcross, J. C., and Goldfried, M. R. (1992). Handbook of Psychotherapy
Integration. New York, NY: Basic Books.
Norcross, J. C., and Goldfried, M. R. (2005). Handbook of Psychotherapy
Integration, 2nd Edn. Oxford: Oxford University Press.
Reay, R., Stuart, S., and Owen, C. (2003). Implementation and eﬀectiveness
of interpersonal psychotherapy in a community mental health service. Aus.
Psychiatry 11, 284–289. doi: 10.1046/j.1440-1665.2003.00574.x
Roediger, E., and Dieckmann, E. (2012). Schema therapy: an integrative approach
for personality disorders. Psychother. Psychosom. Med. Psychol. 62, 142–148.
doi: 10.10 5 5/s -0 0 32 -1 30 4 61 5
Stangier, U., Schramm, E., Heidenreich, T., Berger, M., and Clark, D. M.
(2011). Cognitive therapy vs interpersonal psychotherapy in social anxiety
disorder: a randomized controlled trial. Arch. Gen. Psychiatry 6 8, 692–700. doi:
Stricker, G., and Gold, J. R. (2001). An introduction to psychotherapy integration.
Psychiatr. Times 28. Available online at: http://www.psychiatrictimes.com/
Tasca, G. A., Sylvestre, J., Balfour, L., Chyurlia, L., Evans, J., Fortin-Langelier, B.,
et al. (2015). What clinicians want: ﬁndings from a psychotherapy practice
research network sur vey. Psychotherapy (Chic). 52, 1–11. doi: 1 0.1 03 7/ a003 82 5 2
Wampold, B. E., and Imel, Z. E. (2015). The Great Psychotherapy Debate: The
Evidence for What Makes Psychotherapy Work. London: Routledge.
Conﬂict of Interest Statement: The authors declare that the research was
conducted in the absence of any commercial or ﬁnancial relationships t hat could
be construed as a potential conﬂict of interest.
Copyright © 2016 Zarbo, Tasca, Cattaﬁ and Compare. This is an open-access article
distributed under the terms of the Creative Commons Attribution License (CC BY).
The use, distr ibution or reproduction in other forums is permitted, provided the
original author(s) or licensor are credited and that the original publication in this
journal is cited, in accordance with accepted academic practice. No use, distribution
or reproduction is permitted which does not comply with these terms.
Frontiers in Psychology | www.frontiersin.org 3 January 2016 | Volume 6 | Article 2021