Creating a Framework for Psychotherapy Integration

By Elizabeth Dickson, LCSW

 

Creating A Framework

 

Introduction: Looking at Psychotherapy Integration from the Bottom Up

Given that there can be no one integrative approach that can dictate (in advance) the interventions or approaches that we should use as therapists, where does that leave us with regard to understanding psychotherapy integration? Rather than conclude that this is just a natural consequence of the healthy pluralism of our field and leave the “black box” of psychotherapy integration unexamined, I suggest that we try looking at it from a somewhat different angle. In addition to looking at integrative approaches, I suggest that we look at the process of integration from the standpoint of the individual therapist and use more of a phenomenological approach. We could ask what actually happens when a therapist sits across from a client and is juggling (either consciously or not) all the various theories they have internalized, along with all of the other variables that determine the moves we make as therapists.

My goal here is to propose a framework: some concepts and vocabulary to describe the integration process as it unfolds in our interaction with clients. In doing so, I am attempting to be aware of complexity theory, with its emphasis on systems within systems, and am trying to capture as much of the true intricacy of the process as possible. But I also realize that, as with integrative approaches, there is more than one way to try to structure or conceptualize the psychotherapy process. Ideally this structure can provide a basis for other therapists to describe their processes and for deeper conversations about psychotherapy integration to emerge.

 

The “Navigation System”

The psychotherapy process can be conceptualized as a series of overlapping systems, or systems within systems, rather than a linear process. And if we think of it this way, it becomes more clear why it is unlikely that anyone will produce one overriding framework for integration. I would make the case that any theoretical approach, no matter how broad, will, at best, become one of many guidelines that therapists use. This is because any specific framework is likely to become only one more input into a much bigger and more complex system that, by its nature, is constantly adjusting to take into account a vast number of inputs and perspectives, much of which is outside of our conscious awareness.

So, rather than attempting to establish rules or guidelines for how to conduct therapy under different circumstances, I will propose a framework that describes the decision-making process. At the core of this framework is the concept that we are guided by a kind of implicit, felt sense navigation system that incorporates all the various inputs in the psychotherapy process and ends up determining how we proceed. For an integrative therapist, we might think of our navigation system as the rudder of our ship that steers our course through the psychotherapy hour and ultimately determines how we integrate across our different theories, concepts and approaches to come up with a response that is best suited for any given moment.

But our navigation systems do much more than integrate our theories, concepts and approaches. Because they operate in the “now”, our navigation systems take into account the infinite complexity of the moment that we find ourselves in with our clients, including the tone, body language, the sense of our potential and limitations as a dyad, of what feels comfortable and safe for the two of us, our history with this particular client, and what we have learned both explicitly and implicitly about how to work with them. They also include all the facets of our personalities, predilections and idiosyncrasies that will push for expression (or lack of expression) in one way or another within the psychotherapy process. All of this is in addition to our factoring in the various theories, concepts and approaches (both explicit and implicit) that we have internalized or otherwise made our own that would apply to this particular client and our particular dyad at this particular moment.

And since our conceptual brains cannot process all of this information, so much of this processing is not done consciously. For the most part, our words, gestures and expressions “just come”, guided by priorities or beliefs that we may be unaware of or that have not been put into words. Sometimes there is a feeling of flow or conviction, as if our navigating is coming from a strong “felt sense” that knows the way. At other times we may draw a “felt sense blank”, but we must navigate nonetheless.

 

Theories, Concepts, and Approaches as Inputs

“All theories are sometimes wrong. If you really believe a theory, then it’s wrong. If you have many and they conflict, then you are in good shape.”  ~ Eugene Gendlin

 

Thinking of our theories and approaches as inputs to our navigation systems can help clarify how we actually use them as therapists and how multiple theories, concepts, and approaches can make sense. No one theory is acting alone, but instead is part of a much larger context that is working together to determine our choices, and ultimately our style and technique. So, when it comes to choosing between different theories, the challenge for today’s integrative therapist is not so much to choose which school or tradition to commit to, but rather to digest elements of multiple theories and to rely upon our navigation systems to make the more subtle, and sometimes difficult, tradeoffs as to where we place our emphasis for different clients or, equally important, in different moments for the same client.

Being an eclectic or integrative therapist is all about bringing potentially competing paradigms, theories, concepts and techniques together under one roof. We want our theories to feel like “good mothers”; we want them to be nurturing parents that guide us, not punishing parents that make us feel like we are transgressing in some way. Our theories can feel like a punishing, authoritarian parent if they claim to be the truth rather than a truth. For example, Focusing can become a bad parent if it perpetually leaves us questioning anything we do that is not directly intended to help the client to go deeper and lift out a “felt sense”. Similarly, a more traditional psychoanalytic position can become a bad parent if any self-disclosure or spontaneous exchange with a client feels like a potential counter-transference acting out or a boundary setting violation.

The “parents” can also feel like they are fighting, which can be healthy as long as the arguments are not too heated and are resolved in a constructive manner. In my case, for example, I sometimes perceive a “fight” between my “Carl Rogers side” that is inclined to believe that with a good therapy relationship and attuned exploration the client will tend to find their own way in the process, versus my more “interpretive side” that is inclined to believe that the client is likely to have certain blind spots and needs my interpretations and/or suggestions in order to facilitate or hasten the process of growth and change. Even though they fight, I can see the truth value in each theory and the importance of holding both views simultaneously.

Extending the family analogy to include the concept of a navigation system, we might think of our theories, concepts and approaches as siblings in a large family where we as therapists must rely on our navigation systems to take responsibility and serve as the good parent. Our attitude towards our theories and concepts could then be that we love each of them, that they all belong in their own special way, each with their particular strengths and limitations. It is impossible to imagine life without them, since they have each brought so much to the family and opened up and enlivened the dynamic in such unique ways. So, when they fight with each other, which is not uncommon, we accept that it is a necessary reality for all families and trust that we will do our best to manage the disputes as wisely as possible (with the help of our clients, of course). Ultimately our theories must be parts of a greater whole.  It would be irresponsible to go on vacation and leave any one of them in charge.

 

Implicit Values as Inputs

“Theories about how to do psychoanalysis, in other words, not only our implicit theories but our explicit ones as well, are not the idealized, rational products of detached, objective minds; they are instead the rather direct expressions of our values, many of which are both unarticulated and very close to our hearts.”  ~Donnel Stern

 

As the above quote suggests, a big part of why we choose the theories we do, and how we integrate and prioritize the ones that we have chosen, is not just a function of what is called upon by our clients in the therapy process. It is also very much a reflection of our own personal values, both articulated and unarticulated, many of which feel very “close to our hearts”—the type of values that can seem as if they have always been with us rather than learned along the way. Implicit, unarticulated values imply that we must discover them, even though they can also be influenced by life experience and teachings.

In his paper, “Implicit Theories of Technique and the Values That Inspire Them,” Donnel Stern uses Self Psychology and contemporary Ego Psychology to illustrate how theories can actually have quite different goals and are often shaped by different values. According to Stern, in Self Psychology, “The ultimate value is the integrity and stability of the self,” while in Ego Psychology it is “the effectiveness of the ego in its dealings with drives, affects, self-punitive trends in the personality, and the external world.” He goes on as follows:

“Self Psychology grows from the value of secure, realistic self-regard, and it emphasizes the significance of whole persons (self objects) in the attainment and maintenance of that goal. Contemporary Ego Psychology’s primary value, on the other hand, is the mature functioning of the personality, and so that theory emphasizes the role of other people less as particular, whole persons than as contributors, via the nature of their interactions, to the growth or deterioration of ego functioning in the patient. The values of these two theories often overlap and neither theory ignores the goals of its competitor. But to argue the superiority of one theory over the other, we must come to terms with the fact that each theory begins with a vision of what is most important in human living, and its practitioners promote that vision by practicing according to their theory of technique.”

For integrative therapists who work with both of these theories, our values will be reflected in the tradeoffs we make as we practice and how much priority is given to one theory or approach over another and under what circumstances. Because our values are such a defining feature of who we are, it is hard to imagine any psychotherapist just “buying” some prepackaged version of theories, concepts or approaches without making some effort to tailor these theories and approaches to match with their personal priorities, including what they find most meaningful in life and also what they most want to avoid doing as therapists. (In fact, what we are trying to avoid doing or being as therapists is often just as powerful, if not more powerful, in influencing our technique and style than what we aspire to be.) This process of trying out and adjusting theories to see what fits for each of us is undoubtedly a big part of what psychotherapy integration is all about.