Integrative Psychotherapy Works

Full text

OPINION
published: 11 January 2016
doi: 10.3389/fpsyg.2015.02021
Frontiers in Psychology | www.frontiersin.org 1January 2016 | Volume 6 | Article 2021
Edited by:
Susan G. Simpson,
University of South Australia, Australia
Reviewed by:
Stefano Manzo,
Anima Research Institute, Italy
Beth Jerskey,
Alpert Medical School of Brown
University, USA
*Correspondence:
Cristina Zarbo
cristina.zarbo@unibg.it
Specialty section:
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
Citation:
Zarbo C, Tasca GA, Cattafi F and
Compare A (2016) Integrative
Psychotherapy Works.
Front. Psychol. 6:2021.
doi: 10.3389/fpsyg.2015.02021
Integrative Psychotherapy Works
Cristina Zarbo 1*, Giorgio A. Tasca 2, Francesco Cattafi 1, 3 and Angelo Compare 1
1Department of Human and Social Science, University of Bergamo, Bergamo, Italy, 2Department of Psychiatry, University of
Ottawa, Ottawa Hospital, Ontario, ON, Canada, 3Department of Psychology, University of Chieti, Chieti, Italy
Keywords: integrative, psychotherapy, common factors, eclecticism, clinical psychology
INTEGRATIVE PSYCHOTHERAPY
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
and attempts to create rigid boundaries around the theories, dialog among these models has been
limited.
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 “integrative 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;
Kozari´
c-Kovaci´
c, 2008; Castonguay et al., 2015).

Zarbo et al. Integrative Psychotherapy Works
WHY INTEGRATIVE PSYCHOTHERAPY
WORKS
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 (Norcross and
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.,
2014).
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 psychotherapy, 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, therapist 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 factors
account for almost 20% of the outcome variance (Lambert and
Bergin, 1992). 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 expectations; and beneficial therapist qualities,
such as attention, empathy and positive regard (Stricker and
Gold, 2001; Feixas and Botella, 2004; Norcross and Goldfried,
2005; Constantino et al., 2011; Horvath et al., 2011). Among
the cited common factors, therapeutic alliance has the most
evidence as a predictor of patient change (Feixas and Botella,
2004).
Integrative Psychotherapy is Flexible to
Patients’ Needs and Sensitive to
Therapeutic Alliance
One key value of integrative psychotherapy is its individualized
approach (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 (Feixas
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.; Norcross
and Goldfried, 2005). On the 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 highlights 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 (Norcross and
Goldfried, 2005). In other words, integrative psychotherapy is
Frontiers in Psychology | www.frontiersin.org 2January 2016 | Volume 6 | Article 2021

Zarbo et al. Integrative Psychotherapy Works
different from technical eclecticism. An eclectic therapist chooses
a technique because it may work or may be efficient, without
concern for its theoretical basis or research 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 integration focuses on the relationship between
an effective practice and its theoretical and empirical basis
(Norcross and Goldfried, 2005). For example, evidence-based
psychotherapy relationship practices (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 maintaining their separate
identities. International organizations like SEPI or the Society
of Psychotherapy Research (http://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).
AUTHOR CONTRIBUTIONS
We declare that the manuscript has been seen and reviewed by all
authors which have contributed to it in a meaningful way.
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Conflict of Interest Statement: The authors declare that the research was
conducted in the absence of any commercial or financial relationships that could
be construed as a potential conflict of interest.
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Frontiers in Psychology | www.frontiersin.org 3January 2016 | Volume 6 | Article 2021