Systems of Psychotherapy: A Transtheoretical Analysis

1. Systems of Psychotherapy:A Transtheoretical Analysis Chapter 16. Integrative Therapies

2. Integrative Therapies • Look beyond confines of single schools to see what can be learned & how patients can benefit • Goal: enhance the effectiveness and efficiency of psychotherapy • Characterized by a spirit of transtheoretical inquiry • Avoid the “dogma eat dogma” history of psychotherapy

3. Sketch of Integrative Motives • Response to proliferation of therapies • Inadequacy of single theory for all patients • External socioeconomic contingencies • Ascendancy of short-term, problem-focused txs • Therapists observing multiple treatments • Commonalities contribute strongly to outcome • Development of professional societies (e.g., SEPI) devoted to psychotherapy integration

4. Common Factors • Determine the core ingredients that different therapies share • Commonalities across therapies probably produce most benefits of psychotherapy • Common factors include the client, the relationship, hope/expectancy, and novel techniques

5. Reports of Superior Outcomes of Certain Treatments are Misleading Bruce Wampold notes 3 reasons: • Comparative therapy studies ignore therapist effects and thus overestimate treatment effects • Comparison treatments are often not bona fide; lack of structural equivalence • Reported outcome differencesare often due to allegiance effect (researcher’s favorite)

6. Technical Eclecticism • Seeks to improve ability to select best treatment for client & problem • Guided by research on what has worked best on others with similar problems • Actuarial rather than theoretical • Do not need to subscribe to underlying theory to use effective methods • Not to be confused with syncretism

7. Theoretical Integration • Two or more theories are integrated so that composite will be more effective than its parts • Blend both theory & technique • Hybrid examples: psychoanalytic & behavioral; cognitive & interpersonal • Most integrated theory is cognitive therapy • Unified protocol: incorporates common CBT principles for specific emotional disorders

8. Eclecticism vs. Integration Technical Theoretical Divergence Convergence Collection Blend More empirical More theoretical Realistic Idealistic Lazarus Wachtel Multimodal tx Integrative therapy

9. A Sketch of Paul Wachtel • 1940 - • Ushered in sophisticated attempts at theoretical integration • Trained in psychoanalytic therapy and then incorporated behavioral & systemic • Began as effort to portray behavior therapy as foolish, superficial, & possibly immoral

10. Theory of Psychopathology • Anxiety is core -- common to both psychoanalysts & behaviorists • Bridges can be built to connect the chasms that separate them • Cyclical psychodynamics: powerful conflicts can be understood as both cause & effect • Vicious self-perpetuating cycles maintain psychopathology

11. Therapeutic Processes • Need for active intervention for neurotic patterns to change • Insight is one way of disrupting the destructive cycle of events • Employ behavioral methods such as assertion training • Insight & action are mutually facilitative

12. Therapeutic Relationship • Affirmative and active relationship required • “You don’t go far in neutral” • Viewed as both a precondition of change and a process of change • Centrality of non-pejorative, therapeutic communication

13. Effectiveness of Integrative Psychodynamic-Behavior Therapy • Research supports central tenets of cyclical psychodynamics • Controlled research and outcome studies have not been conducted • Other integrative txs found more effective than no therapy & placebo, but rarely more effective then single-theory treatment

14. Multimodal Therapy:Arnold Lazarus • 1932 - 2013 • Born, raised, & educated in South Africa • Originally trained in behavioral tradition • Introduced multimodal therapy in 1973 • One of most influential psychologists • Expanded horizons of therapeutic practice

15. Multimodal Theory of Psychopathology • Complex interplay of genetic endowment, social- learning history, & physical environment • Most disorders emanate from perceived associations (cognitive) rather then actual conditioning (behavioral) • Occam’s razor: the simplest explanation is often the best • A precise explanation of psychopathology is not required to remedy it

16. Therapeutic Processes • Patients are troubled by multitude of specific problems that are remedied with a similar multitude of specific techniques • Comprehensive assessment of patient’s deficits & excesses (BASIC I.D.) • Patient’s problems (not therapist’s theory) determine the change processes • Employ any & all change processes as the case demands

17. BASIC I.D. B = Behavior A = Affect S = Sensation I = Imagery C = Cognition I = Interpersonal relationships D = Drugs/biology

18. Representative Techniques • Behavior: positive/negative reinforcement, counterconditioning, extinction, stimulus control • Affect: acknowledging and recognizing feelings • Sensation: tension release, sensory pleasuring • Imagery: coping images, change in self-image • Cognition: cognitive restructuring, heightening awareness, education • Interpersonal relationships: modeling, assertion, developing social skills • Drugs/biology: identifying illnesses, exercise, psychotropic medications

19. Therapeutic Relationship • Warm caring relationship is a precondition of change, but not the central process • Empathy and positive regard prove useful, but not necessary or sufficient • Each client is unique & so should the relationship; therapist as authentic chameleon • Flexibility in and outside session

20. Effectiveness of Multimodal Therapy • Few controlled studies performed; supportive but not definitive • Eclecticism uses research-proven techniques for each problem • Difficult to evaluate effectiveness of eclectic treatments because of their variations, but in general, they show effectiveness

21. Practicalities of Integrative Therapies • Psychotherapy integration and brief treatments are simpatico • Share a pragmatic & flexible outlook • Places significant demands on the therapist • A lifelong process of becoming competent in multiple techniques and/or theories

22. Criticisms of Integrative Therapies • From a Psychoanalytic Perspective (do not add much, many trade-offs) • From a Cognitive-Behavioral Perspective (lack of outcome research, fails to add anything new) • From a Humanistic Perspective (does not integrate humanistic theories) • From a Cultural Perspective (needs to find a way to bring culture into the mix)

23. Future Directions • Short-term integrative treatments on the rise • Incorporating neuroscience & cognitive science into psychotherapy • Continued reliance on empirical findings to select treatment (evidence-based practices) • Therapies will be matched to not only clinical diagnosis but also transdiagnostic features • Cognitive-behavioral-acceptance therapies will rival and perhaps overtake integrative

24. Key Terms action and insight allegiance effect assimilative integration authentic chameleon BASIC I.D. change process (or principle) common factors cyclical psychodynamics Dodo bird verdict externalization in the service of therapy integrative psychodynamic-behavior therapy modality profile multimodal therapy Occam’s razor outcome monitoring and feedback systems prescriptive matching Procrustean bed psychotherapy integration relationship of choice schema

25. Key Terms (cont.) structural profiles syncretism systematic treatment selection technical eclecticism theoretical integration therapist effects treatment of choice Unified Protocol vicious cycles woolly mammoth view of pathology

26. Recommended Websites • Heart & Soul of Change Project: www.heartandsoulofchange.com • International Center for Clinical Excellence: www.centerforclinicalexcellence.com/ • Lazarus Institute: www.thelazarusinstitute.com • Society for the Exploration of Psychotherapy Integration (SEPI): www.sepiweb.org/ • Systematic Treatment Selection:www.larrybeutler.com/systematic-treatment-selection/