ArticlePDF Available
OPINION
published: 11 January 2016
doi: 10.3389/fpsyg.2015.02021
Frontiers in Psychology | www.frontiersin.org 1 J
anuary 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
1
Department of Human and Social Science, University of Bergamo, Bergamo, Italy,
2
Department of Psychiatry, University of
Ottawa, Ottawa Hospital, Ontario, ON, Canada,
3
Department 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
a
nd 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 worlds 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;
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 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
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 expec tations; 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., 20 11). 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 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 (
Norcross and
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).
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 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
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Previous meta-analyses comparing the efficacy of psychotherapeutic interventions for depression were clouded by a limited number of within-study treatment comparisons. This study used network meta-analysis, a novel methodological approach that integrates direct and indirect evidence from randomised controlled studies, to re-examine the comparative efficacy of seven psychotherapeutic interventions for adult depression. We conducted systematic literature searches in PubMed, PsycINFO, and Embase up to November 2012, and identified additional studies through earlier meta-analyses and the references of included studies. We identified 198 studies, including 15,118 adult patients with depression, and coded moderator variables. Each of the seven psychotherapeutic interventions was superior to a waitlist control condition with moderate to large effects (range d = -0.62 to d = -0.92). Relative effects of different psychotherapeutic interventions on depressive symptoms were absent to small (range d = 0.01 to d = -0.30). Interpersonal therapy was significantly more effective than supportive therapy (d = -0.30, 95% credibility interval [CrI] [-0.54 to -0.05]). Moderator analysis showed that patient characteristics had no influence on treatment effects, but identified aspects of study quality and sample size as effect modifiers. Smaller effects were found in studies of at least moderate (Δd = 0.29 [-0.01 to 0.58]; p = 0.063) and large size (Δd = 0.33 [0.08 to 0.61]; p = 0.012) and those that had adequate outcome assessment (Δd = 0.38 [-0.06 to 0.87]; p = 0.100). Stepwise restriction of analyses by sample size showed robust effects for cognitive-behavioural therapy, interpersonal therapy, and problem-solving therapy (all d>0.46) compared to waitlist. Empirical evidence from large studies was unavailable or limited for other psychotherapeutic interventions. Overall our results are consistent with the notion that different psychotherapeutic interventions for depression have comparable benefits. However, the robustness of the evidence varies considerably between different psychotherapeutic treatments. Please see later in the article for the Editors' Summary.
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The second edition of The Great Psychotherapy Debate has been updated and revised to expand the presentation of the Contextual Model, which is derived from a scientific understanding of how humans heal in a social context and explains findings from a vast array of psychotherapies studies. This model provides a compelling alternative to traditional research on psychotherapy, which tends to focus on identifying the most effective treatment for particular disorders through emphasizing the specific ingredients of treatment. The new edition also includes a history of healing practices, medicine, and psychotherapy, an examination of therapist effects, and a thorough review of the research on common factors such as the alliance, expectations, and empathy.
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Integration has become an important and influential movement within psychotherapy practice, reflected by the fact that many treatment providers now identify as integrative. However, integration has not had as great an influence on psychotherapy research. The goal of this paper is to highlight the growing body of research on psychotherapy integration, and to identify future directions for research that may strengthen the integration movement as well as the field of psychotherapy as a whole. We first summarize the past 25 years of research on integration, with a focus on four approaches to integration: theoretical integration, systemic eclectic, common factors, and assimilative integration. Next, we identify directions of research within these four areas that could strengthen and support integrative practice. We then propose ways in which the open-minded and exploratory perspective of integrationists could contribute to psychotherapy research in the critical areas of harmful effects, therapist effects, practice oriented research, and training. We end this paper by suggesting that a greater collaboration between integrationists and psychotherapy researchers will help to create a unified landscape of knowledge and action that will benefit all participants and advance the field.
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The rapid development of picosecond technology has allowed us to examine fundamental processes in materials. The following chapters will review these developments. Here we shall first investigate some historical concepts that underly the measurement of rapid phenomena. We shall see that some concepts are very old and that many are included in present technology, although in a most sophisticated form. We shall also attempt to discover why investigators have been interested in rapid phenomena in the past, and how some of their motivations and procedures differ from those of today. We shall try to answer the question why picosecond light pulses have become so attractive in such a short period of time, what some of the main research directions are, and what we can expect in the future. We hope to succeed in this general overview in our attempt of outlining the objectives and providing perspective into picosecond studies, although we shall only briefly survey that field; the new concepts are discussed in great detail in subsequent chapters.
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The evidence-based practice movement has become an important feature of health care systems and health care policy. Within this context, the APA 2005 Presidential Task Force on Evidence-Based Practice defines and discusses evidence-based practice in psychology (EBPP). In an integration of science and practice, the Task Force's report describes psychology's fundamental commitment to sophisticated EBPP and takes into account the full range of evidence psychologists and policymakers must consider. Research, clinical expertise, and patient characteristics are all supported as relevant to good outcomes. EBPP promotes effective psychological practice and enhances public health by applying empirically supported principles of psychological assessment, case formulation, therapeutic relationship, and intervention. The report provides a rationale for and expanded discussion of the EBPP policy statement that was developed by the Task Force and adopted as association policy by the APA Council of Representatives in August 2005
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Originally published in Contemporary Psychology: APA Review of Books , 1991, Vol 36(7), 574-575. Reviews the book, Cognitive-Analytic Therapy: Active Participation in Change: A New Integration in Brief Psychotherapy by Anthony Ryle, Amanda M. Poynton, and Bee J. Brockman (see record 1990-97237-000 ). Ryle has written a book describing his approach to treatment, cognitive-analytic therapy (CAT), an attempt to meld the understanding derived from a psychodynamic conception of behavior with a technique that blends cognitive approaches with psychoanalytic ones. The result is intended to provide a short-term approach that will be useful with a wide variety of patients, many of whom are economically disadvantaged, and that will be applicable by therapists from a wide variety of backgrounds, including some with limited training. The cognitive approach is broadly interpreted so as to include both emotion and unconscious processes, and the psychoanalytic understanding is based on an object-relations approach that is stripped of much metapsychology to make it more accessible. A great deal of clinical material is presented to illustrate the theoretical and technical points that are made. The task is a formidable one, and the effort is impressive in its promise. (PsycINFO Database Record (c) 2012 APA, all rights reserved)