By Elizabeth Dickson, LCSW
When the Way is Not Clear
What does it mean to be a psychotherapist today? Certainly not the same thing that it meant in the earlier or middle parts of the 20th Century when the expectations for what happens in therapy were more clearly defined. Today we are more likely than ever before to consider ourselves integrative or eclectic, and even those of us who identify with one particular tradition have probably ventured well beyond our home base and exposed ourselves to readings, seminars or trainings from some of the hundreds (if not thousands) of competing schools out there—many with their own theories about what constitutes the healing process and which approaches best accomplish these goals.
Few would doubt that this explosion of perspectives represents progress, but the progress does come with certain challenges. If we stick to one school and identify with that community, such as a more traditional psychoanalytic approach, a Self-Psychology approach or a Jungian approach, we may be concerned that we are not sufficiently diversified and that our technique might benefit from trying out other methods. (For example, we may want to explore Focusing, Relational Psychoanalysis, Cognitive Therapy, Emotionally Focused Therapy, Gestalt Therapy, or spiritually-oriented therapy, just to name a few.) Yet if we open ourselves up to philosophies, theories and techniques from a wide variety of schools, how do we integrate them into our belief systems and our practices? At the most basic level, how do the different parts become a whole?
It is not simply about knowing how to flow seamlessly from one approach to another, which can be challenging in and of itself. There is also the challenge of mixing paradigms, and with that the possibility that we may lose touch with our basic beliefs about what is healing in psychotherapy. Of course, we may never have had these beliefs in the first place, or maybe they are still in the evolutionary stage.
The Inevitability of Pluralism
This increased complexity and confusion is probably inevitable and actually appropriate given the magnitude and nature of the task that we are taking on as psychotherapists–to attempt to gain some kind of knowledge base, skill and expertise to better understand and help facilitate human growth and development. We are now in a postmodern world, no longer the modernist world where we assumed that scientific methods could ultimately reveal “truths” about human behavior that would lead us to find one right way to approach the psychotherapy process.
Unlike modernism, which attempts to define themes or truths, a postmodern point of view emphasizes the ways that reality is fragmented or not unified. There is less concern with discovering truths and more concern with what is happening at the local or individual level. We no longer have the same faith that we can uncover laws of human nature that apply across multiple contexts, and the goal of creating such laws is received with more skepticism than in “modern” times.
Our current psychotherapy world mirrors these philosophical trends. Increasingly, therapists are finding “truth value” in a much broader range of theories, and this embrace of pluralism gives us more opportunities to respond to the specific context that we find ourselves in with our clients. A pluralist approach to theory and technique can enhance our sensitivity to the uniqueness of the psychotherapy moment by providing us with multiple perspectives to gauge what is happening and, if we are truly integrative, also offers a wide range of possible approaches to address whatever we encounter.
The “Black Box” of Psychotherapy Integration
So we find ourselves more sensitive than ever before to the complexity inherent in each moment in our work with clients and more aware than ever before of the many competing ways that we might conceptualize what is happening and how to respond. But where does this leave us as therapists? Are we feeling more secure or more insecure? Have we been successful in bringing together all the pluralistic elements that are meaningful to us in a way that feels whole and integrated? Or is a sense of integration even necessary? And how can we begin to generalize about what the actual practice of psychotherapy is when so many of us are undertaking our own unique versions of integration or eclecticism that even we as individuals would be hard pressed to describe?
The difficulty of making generalizations about what constitutes the practice of psychotherapy today is also reflected in the contrast between the typical psychotherapist (who claims to be integrative or eclectic) and the institutions that serve us. In New York City, for example, many graduates of Social Work or PhD Psychology programs attend psychoanalytic institutes as a way to continue their education. And even though the institutes cover more than one school or theory, most continue to focus on a rather narrow spectrum of theories that fall under the “psychoanalytic” umbrella. These typically include Freudian Drive Theory, Psychoanalytic Ego Psychology, Object Relations Theory, Interpersonal Psychoanalysis, and Kohut’s Self-Psychology.
Any therapist who wants to study cognitive or behavioral approaches or techniques such as guided imagery, mode work, or EMDR, or who wants to learn more about approaches designed for specific types of problems (including depression, anxiety, trauma, panic, OCD, ADHD, personality disorders, or specific “schemas”, for example), may have to undertake those studies on their own. And anything in the spiritual realm also tends to be excluded, including mention of the word “love”, even though, in my experience, the majority of therapists would agree that many, if not most, successful therapy experiences (especially longer term therapy) are “all about love”.
In addition, in my institute experience there seemed to be a disconnect between the theories that we were reading about and the application of those theories to actual practice. The practice side of these programs generally takes place in the context of group or individual supervision meetings, where the fine distinctions of practice are left to the individual or group supervisor to determine based upon student presentations of individual clients. This approach has some major advantages, as it honors the uniqueness of each client and avoids the danger of attempting to establish “context-free” laws that students could apply incorrectly in their work. But it does not necessarily help therapists link theoretical concepts with actual practice, and it runs the risk of relying heavily on the proclivities and styles of the individual supervisors involved.
As a result of all of this, what ends up being created is what I call the “black box” of psychotherapy integration. We have some sense of the inputs that go into the “box” (all the various theories and approaches out there), but how they come together for therapists in general or even for any individual therapist in particular remains somewhat of a mystery that seems to defy our attempts at illumination. Maybe it is not surprising that many therapists feel alone in their quest to integrate and that it can be difficult to establish a sense of community as an integrative therapist. The nature of our work requires that, to some degree, each of us take the journey on our own and make sense of our pluralistic psychotherapy world in ways that resonate and feel right to us at the very deepest levels.
Why There Can Be No One Grand Integrative Approach
One response to the dissatisfaction with separate schools of psychotherapy is the creation of a multitude of what can be called “integrative approaches”. Some are more specific to particular types of clients and circumstances, such as Marsha Linehan’s assimilation of concepts form Zen thinking into a cognitive-behavioral framework as part of her Dialectical Behavior Therapy (DBT) for borderline personality disorder. Others might be more broadly applied, such as Paul Wachtel’s “circular psycho-dynamics” where he assimilates “cognitive-behavioral and systems approaches into an interpersonal psychoanalytic framework” that offers a way to conceptualize and address the vicious cycles that people tend to fall into that end up perpetuating their pathology.
While these integrative approaches have greatly enriched our field, no one system has emerged as the psychotherapy integration that ties everything together and can serve as a template for all of psychotherapy. One could argue that the emergence of all of these integrative approaches has had the opposite effect in that they add to the number of concepts and theories out there that we may wish to study and ultimately integrate into our ways of doing therapy.
And this is as it should be; it is generally acknowledged today that it is not possible to create any one grand integrative system that could point us to the choices we should make as therapists (or the procedures that we should use). In fact, the authors in the field of psychotherapy integration do not claim to try to produce one grand integrative system or approach. I am a great believer in the movement to develop integrative approaches, but the reality is that we are still left with the “black box” of psychotherapy integration.