There’s a way of doing psychotherapy that’s known as integrative, because it is supposed to integrate other ways of doing psychotherapy. You get the best of them all that way…or do you?
The various different approaches to psychotherapy are known as orientations, an innocent-sounding word that makes it seem they are just different ways of looking at the same thing, different points of view. When you look deeper, though, there are deep and irreconcilable differences between the various orientations.
While different orientations do have some elements in common, it’s because of their irreconcilable elements that they have separate bands of followers and separate jargon. The key question is whether the common elements alone are sufficient to deliver effective psychotherapy. If the common elements are sufficient, then an integrative approach would work. But if the irreconcilable elements are essential to effective psychotherapy, then an integrative approach cannot work.
It’s difficult to know which orientations to consider, because there are so many, so I’ll use a loose interpretation of the list of talking therapies provided by SANEline: Talking Treatments
The SANEline list is not really a list of orientations, though. It starts with Counselling, which I’ll reinterpret as person-centred therapy. Towards the end of the list you’ll see Group therapy, Relationship counselling and family therapy, Support Groups and Self-help groups, but these are not orientations at all because they do not have their own separate views of how therapy works.
So, together with person-centred, that leaves CBT, mindfulness and psychodynamic approaches to consider. Four orientations — can they be integrated?
The common elements of the orientations are mostly trivial. For example, the therapist generally sits on a chair. Therapy involves a lot of talking, and strong emotions can be expressed. Therapy happens in regular planned sessions that have a time limit. It’s private and confidential. I could go on listing things like this, but none of them gets to the heart of what psychotherapy really is.
A little closer to the heart of the matter, there are three qualities of psychotherapy commonly known as the ‘core conditions’. They are derived from the work of Carl Rogers, whom I mentioned recently in The list.
The third of the core conditions is briefly summarized as ’empathy’. Here’s how Rogers described it in On Becoming a Person, Chapter 4:
When the therapist is sensing the feelings and personal meanings which the client is experiencing in each moment, when he can perceive these from “inside,” as they seem to the client, and when he can successfully communicate something of that understanding to his client, then the third condition is fulfilled.
But the other two core conditions are more problematic, because some orientations rule them out.
The person-centred or humanistic orientations are the most directly related to the work of Carl Rogers, so all three of the core conditions generally apply. The other two conditions are briefly summarized as ‘genuineness’ and ‘warmth’.
Rogers describes genuineness as (original emphasis):
…when the psychotherapist is what he is, when in the relationship with his client he is genuine and without “front” or façade, openly being the feelings and attitudes which at that moment are flowing in him.
It means that the therapist cares for the client, in a non-possessive way. It means that he prizes the client in a total rather than a conditional way… It means an outgoing positive feeling without reservations, without evaluations.
Person-centred theory is based on the observation that when a patient becomes aware of these three qualities in the therapist, an inner change starts to take place in the patient. The change is not directed by the therapist (which gives rise to the description ‘non-directive’ for this kind of technique), but instead is self-directed by the patient.
I’m going to take this kind of psychotherapy as the baseline and examine how well other therapies integrate with it. It’s an arbitrary choice of baseline.
CBT is very closely related to person-centred therapy, but with one tiny difference. The difference lies in the last two words of the quotation above: “without evaluations”
Suppose a therapist incorporates all three core conditions in his relationship with patients, including unconditional non-possessive warmth, but he ignores those last two words. Evaluations become possible. However, with the therapist making evaluations, the therapy ceases to be non-directive. The patient’s progress in therapy is no longer completely self-directed, but instead is directed in collaboration with the therapist.
Aaron T. Beck, the principal originator of CBT, described the collaboration like this in Cognitive Therapy and the Emotional Disorders, Chapter 9:
It is useful to conceive of the patient-therapist relationship as a joint effort. It is not the therapist’s function to try to reform the patient; rather, his role is working with the patient against “it,” the patient’s problem… Investigators…have found that if the therapist shows the following characteristics, a successful outcome is facilitated: genuine warmth, acceptance, and accurate empathy.
So CBT is fundamentally irreconcilable with the person-centred approach, even though they have a huge amount in common. A therapist must decide in advance whether the patient directs the course of therapy or it’s a joint effort. There’s no in-between. It’s one or the other. Integration is not possible.
Several orientations are known as psychodynamic because they are based more or less on Sigmund Freud’s theories about psychological energy. (‘Dynamic’ originally meant having to do with energy, although in modern everyday usage it tends to have a different meaning.) There are many variations on how to go about doing therapy using these theories, and thus there are many psychodynamic orientations.
In order to adapt Freud’s theories for use as therapy, psychodynamic therapists create a very unusual environment for their patients. The intention is that the therapist observes the patient’s use of psychological energy, and helps the patient to interpret it. The patient gains a deep understanding and insight into their own thoughts, feelings and unconscious drives, and uses that insight to resolve any problems that they have.
To make this work, the therapist must not interfere by interacting in ways that would distort flow of the patient’s psychological energy. For example, a psychodynamic therapist is frequently silent, expressionless and unresponsive to the patient, forcing the patient to conduct the session as if alone (even though the therapist is physically present in the room).
That’s why I wrote, above, that the therapist sitting on a chair is a common feature of psychotherapies. The patient sitting on a chair is not — in classical psychoanalysis, one of the psychodynamic orientations, the patient lies on a couch so that the therapist can abstain from human interaction.
Integration with other orientations is a problem, because the therapist’s withdrawal from being a fully-interacting person in the therapy sessions conflicts directly with Rogers’ first two core conditions, the ones I summarized briefly as ‘genuineness’ and ‘warmth’.
Being warm and genuine towards a patient destroys any possibility of psychodynamic work. Failing to be warm and genuine towards a patient destroys any possibility of using any other orientation. This makes psychodynamic orientations impossible to integrate with other orientations. There is an irreconcilable conflict.
Mindfulness summarizes a wide range of what are known as ‘third-wave’ behavioural approaches to psychotherapy. They include DBT (‘dialectical behaviour therapy’), MCBT (mindfulness-based cognitive behaviour therapy), and many others.
The ‘first wave’ of behavioural approaches focussed on observable behaviours. It was based on the idea that if you can change someone’s behaviour, then their mind will look after itself. In other words, if you can simply ‘act normal’, then your thoughts and emotions will fall into line. My phrase ‘act normal’ belittles behaviour therapy unfairly — there’s a huge quantity of technique and theory available to behaviour therapists. Nevertheless, there is a sense in which it is not psychotherapy at all, because it does not work with the mind directly, so there is some justification for its omission from the SANEline list.
The ‘second wave’ of behavioural approaches is what I tend to call ‘fake CBT’ in this blog. It’s not worth serious consideration.
The ‘third wave’ employs a behavioural approach to the mind. That is, it teaches patients to control their own minds in the same kind of way that they control their own behaviours. What really happens is that patients learn to split their consciousness into two parts. One part, the mentally ill part, remains mentally ill in the background. The other part, the mentally well part, becomes the dominant part in the patient’s consciousness.
The patient’s split-off mentally well consciousness observes the mentally ill consciousness with a kind of detachment. This detached observing of oneself is known as ‘mindfulness’.
In these third-wave approaches, and indeed in all the behavioural ‘waves’ the therapist is really a trainer. Like CBT, behavioural approaches discard the non-directive quality of person-centred approaches. But they go further than CBT, because the therapist/trainer has an evaluative role that is not collaborative.
The goal is to teach the patient certain mental techniques. The therapist/trainer evaluates how well the patient is learning the techniques, even if this conflicts with the patient’s own evaluation. Integration with person-centred or CBT approaches is made impossible by this requirement.
The conclusion has to be that integrative psychotherapy is a fake. The different orientations are different orientations for good reason, not just for fun. There are irreconcilable differences between them that it is not possible to fudge.
That’s not to say that any orientation must be in some way kept pure. Elements of theory certainly enrich the practice of psychotherapy and (I would say) make it more effective. I would never hesitate to incorporate theoretical elements of other therapies into CBT. For example, I might readily draw on the ideas of Freud, Jung, Perls (Gestalt), Berne (transactional analysis), and many others.
However, elements of theory are not any kind of integration. They are different ways of conceptualizing human experience that can be useful in working towards a CBT formulation in collaboration with a patient. They are definitely not a distraction from the methodology of CBT.
The risk with any so-called integrative approach is that it’s just a huge pile of theoretical fragments that don’t come together in any meaningful way, that don’t have any structure or purpose. Patients who are offered integrative psychotherapy should be very skeptical, and are entitled to wonder whether their therapist is Jack of all trades but Master of none.