By Elizabeth Dickson, LCSW
PART I: THE CHALLENGE OF THE INTEGRATIVE THERAPIST
(Looking at Psychotherapy Integration From the Top Down)
- Why have a course about psychotherapy integration?
- What is currently offered in the psychotherapy community and how it evolved that way.
- What that means for therapists who are searching or want to combine different modalities.
- How creating a course on psychotherapy integration helps us see ourselves and our process from a different vantage point. It puts us on a new “cutting edge”. It is exciting to think about what we can discover on this new cutting edge.
- “Psychotherapy Integration: Peering Into the Black Box” by Elizabeth Dickson
- “Toward an Integrative Sensibility: A Post-Postmodern Challenge” by Lynn Preston and Ellen Shumsky
- “More Than a Hammer: Psychoanalytic Skills In An Age of Complexity” by Lynn Preston and Ellen Shumsky
The Parts and the Whole
Discuss Our Reactions to Eugene Gendlin’s quote:
“…One begins without understanding the parts or the whole very well. Only the whole gives the parts their roles and meanings. But of course we arrive at an understanding of the whole only part by part. A better grasp of any part can change the sense of the whole…The meaning of the parts is not fixed; they must grow in meaning…”
Our Own Experience With Integration
- What is our unique experience of integration as therapists?
- Do we prefer the term “eclectic” or “integrative”?
- Did we start with a home base?
- Do we have an underlying philosophy about the healing process?
- What are the most important “parts” (theories, concepts, approaches) in our process?
- Have we brought these parts together to form a “whole”, and, if so, how?
- Have we struggled in this process, or has our journey been more smooth or consistent?
- Does our integration process as therapists parallel our personal integration process?
PART II: CREATING A FRAMEWORK FOR PSYCHOTHERAPY INTEGRATION
(Looking at Psychotherapy Integration From the Bottom Up)
The Concept of the Navigation System
- How do we actually make choices as therapists on a moment by moment basis?
- Introduce the concept of “the navigation system” as a phenomenological perspective—an attempt to put a lens up to the actual process of how a therapist navigates through the psychotherapy hour.
- Look at the infinite complexity of all the inputs that go into our making choices or taking actions as therapists in any given moment.
- Seeing our process this way, it becomes clear why no one theory or no one integrative system or approach can ever fully explain our actions.
The Power and Limitations of Theories and Concepts in the Psychotherapy Process
- Looking at theories, ideas and concepts as just one type of input in our navigation systems.
- Using theory as “a good mother”.
- The experience of seemingly conflicting theories and ideas.
- How do we manage our conflicting theories and ideas? How have we addressed this challenge in our work as therapists?
The Role of Personal Values in Guiding Our Choices as Therapists
- Much has been written about how our counter-transference influences our choices as therapists, but there has been little attention paid to how our values (often implicit rather than explicit) can influence our choices and behavior.
- Implicit values as another type of input in our navigation systems.
- Our values include not only what we find most meaningful in life, but also what we most want to avoid doing (or being) as therapists.
- And of course our values influence which theories or schools we are attracted to as well as how much priority we give to one theory or approach over another and under what circumstances.
- Can we each identify the implicit values that are most important in determining what we most want to do or not do as therapists?
- “Implicit Theories of Technique and the Values that Inspire Them” by Donnell Stern
The Role of Our “Passions” in Guiding Our Choices as Therapists
- We can extend our discussion of values to consider our passions as another input to our navigation systems. Of course our passions are very much related to our values and also to the ideas, theories and concepts that we hold dear.
- Introduce the notion of “ideas that we love”. Can we identify ideas and concepts that we truly love? How do these ideas that we love influence how we work as therapists?
- How does it feel to explore and discuss the ideas that we love? This is such a powerful part of our experience as therapists, yet we are not accustomed to discussing our choices of ideas and approaches using the word “love”.
- How might we describe how our passions influence our work as therapists? For example, a therapist who is most passionate about the power of relationship or connection may operate differently than a therapist who is most passionate about personal autonomy or the ability to freely express ones own unique voice.
An Example of How Our Passions Can Influence Us: The Positive Spiritual Emotions
- One subset of passions that I would like to consider here are emotions that we might associate with a personal experience of meaning. For example, what about positive spiritual emotions such as awe, love, compassion, faith, joy, and gratitude? Most analytic institutes do not focus on this aspect of our work, yet many therapists (though certainly not all) would claim to feel passionate about all (or most) of the above emotions.
- We might think of a spiritually-oriented therapist as tapping into their passions to uncover and cultivate the uplifting positive spiritual emotions in the therapy process and use them as a source of healing. (This is in contrast to a therapist who may be more passionate about the dangers and vicissitudes of life and who might establish a tone that feels quite different.)
- To what extent are these emotions a source of passion for us, and how might that influence the tone that we establish as therapists? For example, Lynn Preston has written about the experience of felt meaning and the experience of the healing power of relationship as “miracles”. How would seeing these as “miracles” affect our approach?
- “Two Interwoven Miracles: The Relational Dimension of Focusing-Oriented Psychotherapy” by Lynn Preston
- “Psychotherapy and the Poetry of Spirituality: Introduction” by Elizabeth Dickson
- “Psychotherapy and the Poetry of Spirituality: Making Room for Awe” by Elizabeth Dickson
- “Psychotherapy and the Poetry of Spirituality: The Healing Power of Love” by Elizabeth Dickson
PART III: “WHAT WORKS” IN PSYCHOTHERAPY
(How We Take In and Respond To Feedback From the Client)
The Concept of What Works
- Of course it makes no sense to discuss the concept of the therapist’s navigation system without also discussing the bigger system that it is a part of, namely the system of the therapist and client working together.
- In our postmodern time of multiple truths, our ability to be sensitive to and correct our course based upon client responses is essential in guiding our way. Since we don’t have any one approach that represents the ultimate truth, how else can we navigate but to have some way of determining if what we have done “works”?
- Yet our training does not tend to focus directly on this concept of what works.
- In this section we explore what is happening when we look to the client to see what works. And in doing this we are not just examining the client’s reactions in an objective, scientific way. We are also using our own visceral reactions as well as our experience of the psychotherapy relationship as guides to what is working.
Using Client Responses in the Moment to See What Works
- When we ask, “Is therapy working?” we tend to think over the longer term. For example, is the client feeling better, more fulfilled, are they coming closer to meeting their goals?
- Yet ultimately our actions as therapists are based more upon the client’s reactions in the here and now. One of the most important inputs to our navigation systems is the way our client is experiencing our input from moment to moment.
- What kind of experience are we hoping that our clients will have? For experiential therapists, we might say that we want our clients to be “touched” in the process in a way that leads to growth and development. The word “touched” has the advantage of being very broad. It can mean emotionally touched, touched by the truth of a new insight, touched in the context of the psychotherapy relationship, etc.
- To explore this further we will introduce the work of Eugene Gendlin who has devoted much of his career to exploring the experiential dimension of psychotherapy, why it is necessary for successful therapy, and how therapists can utilize this experiential component in their work with clients.
- Gendlin’s approach to what works is based upon his understanding of “felt meaning”—when something becomes meaningful to us, not just in an intellectual way, but more as if our whole being senses that something is meaningful. He describes this as the forward movement of a felt sense. When clients are touching in to the felt sense, thoughts, feelings, images and reactions emerge out of the lived experience of the therapy process.
- Studying Gendlin can help us recognize, encourage and evoke this felt sensing and process of forward movement. We can think of it as learning to “facilitate emergence”. Identifying what works in this way can give therapists more of a map of how to proceed; we can check each move we make to see if it carries the client’s felt sense forward or not.
- Focusing-Oriented Psychotherapy: A Manual of the Experiential Method by Eugene Gendlin
Utilizing Multiple Theories and Approaches
- One advantage of focusing on what works for the client is that we can be open to a variety of theories and approaches, as long as we continue to evaluate what we do based upon our criteria of what is working for the client.
- Gendlin encourages therapists to incorporate a wide range of orientations (including cognitive approaches, role play, dream analysis, imagery, emotional catharsis, action steps, working with the body, etc.) as long as it is all predicated on the therapist’s ability to read the client’s responses to their interventions.
- For Gendlin, “All interpretations are really only hypotheses.” He emphasizes that we must always be flexible enough to alter our hypotheses based upon our client’s responses, which will always reflect each client’s unique intricacy, beyond anything that we could ever precisely anticipate.
- What is the type of attitude that would be required of a therapist who wishes to integrate multiple approaches? Lynn Preston and Ellen Shumsky introduce the concept of an “integrative sensibility” and suggest four necessary attitudes: openness, curiosity, “fallibilism”, and a comfort with “complexification”. This latter term refers to our willingness to stay in complexity and to bear the inevitable anxiety and disorientation that “unknowability” can create.
- “A Unified View of the Field Through Focusing and the Experiential Method” in his book Focusing-Oriented Psychotherapy: A Manual of the Experiential Method by Eugene Gendlin
- “Toward An Integrative Sensibility: A Post Postmodern Challenge” by Lynn Preston and Ellen Shumsky
Observing the Psychotherapy Relationship to See What Works
- But we are not just observing the client in isolation when we attempt to see what works. We are observing the client in relationship to us. We can be aware of all three dimensions: our own thoughts and feelings, our sense of what the client is experiencing, and how the two of us are together.
- Just as we observe whether therapy is helping a client heal and grow, we can also observe how the psychotherapy relationship is evolving.
- Lynn Preston and Ellen Shumsky have proposed that we look to the evolution of the analytic partnership as “one lens through which the analyst can envision the movement of therapy”. How well the relationship is developing can inform us as to whether or how the therapy is working.
- To extend this idea, what might be the qualities of a dyad that suggest that therapy is working? Preston and Shumsky believe that the growth of the psychotherapy relationship can be measured by “increasing intimacy, aliveness, vitality, resiliency, flexibility, depth, the capacity to negotiate conflict and difference, the building of trust and openness, the capacity to include a wider spectrum of feelings, and the expansion of each individual’s relational repertoire”.
- And in any given moment, we as therapists can become aware of how the relationship feels. What is the sense of the “us” in any given moment, and how might that determine the decisions we make as therapists? And what kind of “us” moments are we inclined to see as working or not working?
- Do we agree that the success of the therapy can be evaluated based upon the evolution of the dyad?
- “The Development of the Dyad: A Bidirectional Revisioning of Some Self Psychological Concepts” by Lynn Preston and Ellen Shumsky
PART IV: DEVELOPING SKILLS AS AN INTEGRATIVE THERAPIST
The Concept of Skills
- The word “skills” can have a negative connotation. It implies technique, which is sometimes associated with a rigid application of an approach without the proper sensitivity to nuance and context. We would like to reintroduce the word “skills” as representing something of great value for therapists. When we are using our navigation systems, the effectiveness of how we ultimately navigate will have a great deal to do with the range and quality of our skills.
- Therapists are often taught theories rather than specific skills, even though theories almost always imply certain types of therapeutic actions. Yet if the therapeutic actions are not made explicit, students may fail to make the leap between the theories they read about and what they actually do in a session with a client.
- Learning theories without skills is merely an intellectual exercise, but applying skills or technique without an in depth understanding of the theories behind them can be mechanistic.
- Ideally our skills are embodied. We have digested the theories behind them such that we understand their power in a visceral way. Often this happens most effectively when the therapist is able to relate the theory and skills to their own lives and experiences. This, combined with years of practice honing our skills in our work with clients, is what enables us to navigate with the greatest ease and confidence.
The Importance and Challenge of Having Multiple Skills
- One can make the case that our ability to navigate as therapists requires multiple skills, not just the skills from one particular theory. This may account for why the vast majority of therapists identify themselves as “integrative” or “eclectic” rather than identifying with any one tradition.
- To illustrate, Kohut and Winnicott each focus on aggression from a different perspective. Kohut describes anger as a “disintegration byproduct”, resulting from rupture or narcissistic injury. Kohut’s theory gives us the skills of healing ruptures, empathic attunement (de-centering), and “going under” the anger to address the core vulnerability. Alternatively, Winnicott speaks about anger as a type of expression that is necessary in the development of a true self. Winnicott’s theory implies the skill of allowing clients to safely express their anger with us (the use of the object) without our retaliating or collapsing.
- Experienced therapists will likely utilize both of these skill sets in their work with clients—which raises another issue: How do integrative therapists decide which theories or skill sets apply in which situations? When is the moment a Kohut moment and when is it a Winnicott moment? Just having a large “bag of tricks” is not sufficient. An integrative therapist must also determine what the moment calls for and how to prioritize multiple approaches and possibilities. And because everything in therapy happens so fast, much of this prioritizing is done outside of our awareness.
Reviewing the Skill Sets for Different Theoretical Approaches: Beginning With FORP
- Since we are often taught theories without understanding the actions that are implied by those theories, it might be useful to explicate the implied skill sets for some of the more popular psychotherapy approaches. But because we do not want to do this in a mechanistic way, we hope to combine a discussion of the theory and the implied therapeutic actions in a way that makes both the theory and the skills come alive for us.
- We begin by reviewing the theory and selected skill sets from three key theoretical traditions that have been integrated in The Focusing-Oriented Psychotherapy Program (FORP). They are Focusing, Self-Psychology, and Relational Psychoanalysis. While there are considerable overlaps between the skill sets implied by the three different schools, there are certain skills that are uniquely emphasized by each school.
- In addition to reading theory and discussing implied therapeutic actions, we will also illustrate this by showing videos and reading cases that demonstrate these skills.
Reviewing the Skill Sets for Different Theoretical Approaches: Beyond FORP
- We will include a look at some theories and implied skills for other approaches such as Emotionally Focused Therapy (EFT), spiritually-oriented psychotherapy, Cognitive Therapy, motivational therapy or coaching, classical psychoanalysis, Behavioral Therapy, trauma work (such as EMDR), Gestalt therapy, Existential Psychotherapy, etc.
- How much do we find ourselves using these types of skills or therapeutic movements, even if we have not formally studied these approaches or do not identify with these schools or traditions? If we do incorporate some of these skills, do they feel like embodied skills? And, if so, what kind of process did we go through that helped us deeply resonate with these skills and make them our own?
The Skills of Integration: Identifying “Fault Lines”
- Fault lines are examples of certain types of tensions between competing approaches where therapists must decide which way to proceed. While experienced therapists tend to make most of these choices automatically, it can be valuable to conceptualize some common types of fault lines.
- For example, common fault lines or decision points include the decision of whether to stay close to the client (and listen, empathize and/or validate) versus the decision to attempt to guide, educate, interpret, provide direction, confront, or otherwise introduce a different point of view. We might call this “client-centered versus providing direction”.
- Another familiar fault line is the decision of whether to continue to explore and stay with the client’s reality versus introducing ourselves in a more relational way. Is the moment a focusing moment where the client needs time and space to explore—or is the moment more of a relational moment where the therapist needs to bring in the “us”? We might call this “client-centered versus relational”.
- Can you identify other fault lines that you have encountered in your work as a therapist?
PART V: CONCLUSIONS
- Case studies provide a focal point for observing and discussing many of the challenges and opportunities faced by an integrative therapist. One case that serves this purpose well is the case presented by Elizabeth Carr (“You Can Call Me Al”) at the 2012 IAPSP Conference, which includes discussions by Frank Lachmann and Malcolm Slavin.
- The discussions are particularly helpful in illustrating how two therapists with different orientations, values and passions find points of agreement along with some very different interpretations. Part of what makes the discussion so rich is the breadth of the range of theoretical orientations that the two discussants call upon in their responses to the case.
- Do you have a case (or cases) from your work as a therapist that you believe illustrates some of the themes that we have brought up throughout this course on integration?
The Notion of Optimal Responsiveness
- In creating a course on integration we are hoping to provide several valuable functions, one being to offer a port in the storm for therapists who in their effort to integrate different schools or traditions find themselves without a home base or community that they can identify with.
- Another function is to celebrate the richness that comes from bringing together many diverse perspectives. One of the problems of having a variety of competing schools all claiming (to some degree) to have the “right” approach is that therapists are left with the impression that there is a right approach and that they should commit or choose one path. A course on integration celebrates the paradox of “multiple truths” while acknowledging the challenges this poses.
- Optimal responsiveness might be conceptualized as the ability to find the best response for the moment, which implies the ability to draw from a wide range of theories and skills. Even though different theories or traditions can sometimes feel like they are at war or competing for our attention, we ultimately can embrace them all (or at least the ones that we resonate with); we do not need to choose between them.
Allowing Our Clients to Teach Us: The Ultimate Integration
- Over the years of practice as therapists we develop a style of working that takes into account not only our own personalities, passions and values, but also integrates what our clients have taught us.
- So the process is reciprocal—our values and passions influence how we work, but our experience with our clients over time very much influences our values and passions. If we are fortunate we have allowed our work to bring us greater wisdom.
- What are some of the most valuable lessons that you have learned from your work with clients?