Psychotherapy Integration: The Attitudes of the Integrative Therapist

By Elizabeth Dickson, LCSW




Using Theories and Concepts Responsibly

Not only is the eclectic or integrative therapist always on the lookout for feedback on what works in order to help navigate, there is also the challenge of how to work flexibly with a variety of theories and concepts, some of which we can become very attached to. How do we hold them lightly and use them effectively without oversimplifying what is going on or cutting off opportunities for the client to pursue something important that may not fit into our predetermined views?

At the most basic level, the integrative therapist must believe in, cherish, welcome and invite that completely unique intricacy that is hidden under the surface for each client (and for all of us). And if we keep this goal in mind, then we can feel more free to use all of our theories and approaches without doing something counterproductive or stifling the aliveness and opportunity for forward movement that is the essence of the psychotherapy process. We can be comfortable about opening the door and inviting in all the theories and concepts as long as we are committed to handling them with great care and wisdom.

As therapists, we want to cultivate what I would call “optimal responsiveness”. And this is not just being empathic and passive. Just because we are focused on “emergence” in the therapy process does not mean that we must always be in a listening or validating posture. If we are to be truly present and create a relationship with our clients where real intimacy can develop, we as therapists need the freedom and the skills to be proactive in creative ways when the situation calls for it. And we can always remember to check every move we make to see how our client is responding.

One of my complaints about the psychoanalytic community in New York City is that I feel there can be an assumption that, because certain types of theories or approaches are potentially dangerous in the wrong hands, it is safer not to study them at all. When I was a student in the mid 1990s, I had the sense that Cognitive Therapy and/or Behavioral Therapy were not fully approved of, maybe because they sometimes require the therapist to challenge thoughts or behaviors rather than staying in a more “exploratory” mode.

Possibly the most “dangerous” might be approaches that apply to particular categories of clients, from the more benign versions, such as cognitive and behavioral approaches for clients with OCD (Obsessive Compulsive Disorder), to the more controversial ones such as guidelines for clients with particular schemas, such as abandonment, defectiveness, emotional deprivation, subjugation, dependency, etc. The most controversial might be psychoanalytic and other approaches for different personality styles or disorders. In fact, Nancy McWilliam’s book, Psychoanalytic Diagnosis, Understanding Personality Structure in the Clinical Process, was “banned” by at least one institute when it first came out in the mid 1990s.


An Integrative Sensibility

Rather than having to avoid the more controversial approaches or feeling “politically incorrect” about secretly using certain of our favorite concepts or techniques, my hope would be that we could entertain all types of approaches that we feel are potentially helpful, as long as we use them responsibly. As Donna Orange has written, “The mistake is not to have categories, but to imagine that people belong to them.”

In their paper, “Toward An Integrative Sensibility: A Post Postmodern Challenge,” Lynn Preston and Ellen Shumsky introduce the concept of an “integrative sensibility” and suggest three necessary attitudes: openness, curiosity, and “fallibilism”. To these three they add “complexification”, which refers to our willingness to stay in complexity and to bear the inevitable anxiety and disorientation that “unknowability” can create. If a therapist is holding these four attitudes, then they will be open to exploring different approaches, but they will do so with caution and will guard against clinging too tightly to any of their theories or techniques.

Eugene Gendlin’s statement, “All interpretations are really only hypotheses,” offers a helpful way to remember how to maintain a “complexification” attitude. For Gendlin, “Only when one of them opens the felt sense and carries it forward, is it then more than a mere hypothesis.”  He also emphasizes that we must be flexible enough to alter our hypotheses based upon our clients’ responses, which will always reflect each client’s own unique intricacy, beyond anything that we could ever precisely anticipate. According to Gendlin, “By the time the felt sense opens and a flood of detail spills out, there can no longer be any doubt. But what comes also alters and augments the hypothesis. The result could not have been deduced from the hypothesis that helped to bring it about.”

As we gain more experience as therapists, it becomes easier to see “complexification” and the resulting unknowability as more of a friend than an enemy. With experience we are less inclined to interpret the “disorienting” quality as meaning that we are not doing therapy correctly or that we don’t know enough or that we are failing to have a sufficient understanding of a particular client. Rather than have it be a signal of a problem, that familiar “disoriented” feeling can be a friendly reminder that reality is more complex than we can imagine and that we have to take in new information and regroup. Complexity theory does not suggest that we should empty our minds or stay in a place of mental chaos and just feel our way blindly in our work, but that we can expect to follow a kind of rhythm of creating structure, dismantling (to various degrees) what we have created, and restructuring.