Scientific Validation Criteria

Scientific Validation Criteria for Integrative psychotherapy

Document submitted by the European Association for Integrative Psychotherapy, Supervision and Training for accreditation as a European-wide accrediting organization for Integrative psychotherapists

Introduction:

Integrative psychotherapy embraces first and foremost a particular attitude towards the practice of psychotherapy which affirms the importance of a unifying approach to persons. Thus a major focus is on responding appropriately and effectively to the person at the emotional, spiritual, cognitive, behavioural and physiological levels. The aim of this is to facilitate integration such that the quality of the person’s being and functioning in the intrapsychic, interpersonal and socio-political space is maximized with due regard for each individual’s own personal limits and external constraints.

Within this framework it is recognized that integration is a process to which therapists also need to commit themselves. Thus there is a focus on the personal integration of therapists. However, it is recognized that while a focus on personal growth in the therapist is essential there needs also to be a commitment to the pursuit of knowledge in the area of psychotherapy and its related fields. Therefore the EAIP defines as “Integrative” any methodology and Integrative orientation in psychotherapy which exemplifies, or is developing towards, a conceptually coherent, principled, theoretical combination of two or more specific approaches, and/or represents a model of integration in its own right. In this regard there is a particular ethical obligation on integrative psychotherapists to dialogue with colleagues of diverse orientations and to remain informed of developments in the field,

A central tenet of Integrative psychotherapy is that no single form of therapy is best or even adequate in all situations- Integrative psychotherapy therefore promotes flexibility in its approach to problems but also subscribes to the maintenance of a standard of excellence in service to clients, in supervision and in training. Thus when integrative therapists draw on different strategies, techniques and theoretical constructs when dealing with particular situations, this is not done haphazardly but in a manner informed both by clinical intuition and a sound knowledge and understanding of the problems at hand and the interventions to be applied.

In the final analysis Integrative psychotherapy, while affirming the importance of foregrounding particular approaches or combinations of approaches in regard to specific problems, nevertheless places the highest priority on those factors which are common to all psychotherapies, especially the therapeutic relationship in all its modalities. In regard to the therapeutic relationship however, particular emphasis is placed on the maintenance of an attitude of respect, kindness, honesty and equality in regard to the personhood of the client in a manner which affirms the integrity and humanity both of the self and the other. Integrative psychotherapy affirms the importance of providing a holding environment in which growth and healing can take place in an intersubjective space which has been co-created by both client and therapist.

Philosophical Aspects of the Approach:

1. Does the approach have clearly defined areas of enquiry, application and research?

In 1986, the Affective and Anxiety Disorder Research Branch at the National Institute of Mental Health in the U. S, held a 2-day workshop to examine research on psychotherapy integration. The findings of this meeting, which outlined recommended research directions, offered 23 areas of inquiry for psychotherapy integration (Wolfe & Goldfried, 1988). These specific areas of study fell into four general domains: (a) conceptual clarification (eg., the difference between technical eclecticism vs conceptual integration, the need for knowledge-acquistion strategies. the role of integrated theories of psychopathology); (b) psychotherapy process research (e g-.studying the process of change, the role of the therapeutic alliance in different schools of thought, problems associated with school-specific jargon); (c) efficacy studies on integrative therapies (e.g.,, development of empirically based integrative interventions, clinical problems appropriate for an integrated therapy, issues in the assessment of process and outcome); and (d) the training and supervision of integrative therapists (e.g., training in pure form therapies vs an integrative approach).

Within the past decade or so, work has proceeded along each of these lines. For example, Wiser, Goldfried, Raue and Vakoch (1996) have outlined a program of comparative process research, whereby the mechanisms of change were studied in psychodynamic and cognitive-behavioural interventions. Other research has studied the relationship between process and outcome, uncovering such unexpected findings that even in the treatment of cognitive therapy for depression, contributions from other orientations (e.g.,, focusing on developmental and interpersonal issues and enhancing client emotional experiencing) helped to facilitate successful outcome (Castonguay et al., 1996; Hayes. Castonguay & Goldfried, 1996). As will be seen in the responses to the questions that follow, many of the issues raised in the 1986 workshop (e.g., the role of the therapeutic alliance) have been the subject of inquiry over the years.

2. Does the approach demonstrate its claim of knowledge and competence within its field’s tradition regarding assessment/diagnosis and treatment/intervention?

During the 1986 conference on psychotherapy integration, the existence of different language systems was considered as being an obstacle to psychotherapy integration. Although theoretical jargon may be seen as being useful in communicating with like-minded colleagues, it prevents those from another theoretical system from benefiting from a school’s clinical insights and research findings. Recognizing the need for a common language in a theoretically integrated approach to assessment and therapy, integrative therapists have chosen to translate various theoretical constructs into the vernacular. This provides not only a common ground for communicating across theoretical orientations, but allows for a clearer integration of contributions from different schools of thought.

For example, Benjamin’s Structural Analysis of Social Behavior (SASB) provides a transtheoretical approach for classifying interpersonal behavior, classifying an action according to its level of affiliation and control. Using a circumplex coding scheme, a message a person sends to another, and the way this other person reacts to it, can be assessed along these dimensions. The assessment procedure can also be used to evaluate how individuals deal with themselves intrapersonally, as when they are excessively self-critical and demanding of themselves (i.e., low in affiliation and high in control). This system has applicability to a variety of theoretical orientions, and consequently lends itself particualry well to psychotherapy integration.

3. Does the approach have a theory of the human being, the therapeutic relationship and health and illness, which is clear and self consistent?

A consistent research finding has been that the therapeutic relationship contributes significantly to successful outcome (Horvath & Greenberg. 1994). This has been found to be the case in various forms of therapy, be it psychodynamic, experiential or cognitive-behavioural in orientation- Consequently, it is believed to represent a common change factor, reflecting the fact that people are more likely to change when in the context of an interpersonally safe haven Based on this finding, Safran and his colleagues (Safran et al., 1990) have specified how to recognize points within the therapeutic interaction where there may be a threat to the therapeutic alliance, and what might be done to alleviate this rupture. On the basis of the finding that alliance strains in cognitive therapy are associated with poorer outcome in cognitive therapy for depression (Castonguay et al., 1996), Castonguay and Safran are currently collaborating on a research project to test the enhanced effectiveness of cognitive therapy when it includes guidelines for dealing with strains in the alliance.

Other research findings on the process of change in different orientations have yielded results with important implications for developing more effective interventions- For example, Beutler and Consoli (1992) have found that cognitive interventions were more effective than insight-oriented treatment with externalizing patients, and that defensive individuals responded better to nondirective than directive treatments,, Also relevant is the work of Prochaska and DiClemente (1992), which suggests that an intervention that takes into account where a patient exists within the general phase of the change process can be more effective than treatment procedures that do not.

Methodological aspects :

4. Do the methods specific to this approach generate developments in the theory of psychotherapy, demonstrate new aspects in the understanding of human nature and lead to ways of intervention/treatment?

As indicated in response to the previous question, the comparative study of the change process across orientations, and the investigation of the relationship between process and outcome, can have important implications for developing more effective methods of therapy, inasmuch as these studies make use of transtheoretical constructs (i.e., described in the vernacular), the findings can be readily used to develop improved, integrative treatments- The example given above in the collaborative efforts of Castonguay and Safran offer a case in point, whereby findings on strains in the therapeutic alliance were used to expand the scope of cognitive interventions for depression.

Another important example of how an integrative approach to therapy has led to more effective treatments is Linehan’s (1993) Dialectical Behavior Therapy (DBT) in the treatment of borderline personality disorder. A treatment approach that is receiving widespread recognition on an international basis, DBT is specifically designed for patients who paradoxically need to be validated and accepted for who they are and at the same time need to change. In a clinical tour de force, Linehan has integrated a person-centered approach (for validation) with a cognitive-behavioral coping skills model (for facilitating change), finding that it is more effective with this patient population than other currently available, theoretically pure treatments.

5. Does the approach include processes of verbal exchange, alongside an awareness of non-verbal sources of information and communication?

Of necessity, a comprehensive, integrative approach to therapy requires attention to the complexities of human interaction. For example, the SASB coding system, a procedure that has successfully informed the field about therapeutic interaction from a transtheoretical perspective, takes into account not only what is said, but also how it is said (e.g.,voice quality, facial expression). Thus, depending upon nonverbal sources of communication, the statement “You are free to do it any way you’d like” can be categorized as high in affiliation and low in control, or low in affiliation and high in control Experienced clinicians, regardless of orientation, can readily make this distinction, and can reliably make use of this coding system. In addition to being a research tool for studying the process of therapy, it clearly is also useful for purposes of clinical training, and has been used to train beginning therapists in the subtleties of communication-

Also of relevance is the work of Greenberg, Rice and Elliot (1993), which has studied “markers” in the therapeutic interaction. These markers represent points in the therapeutic discourse where a client reacts in a way that has important implications for how the therapist should proceed clinically. Such markers can be informed by a variety of theoretical orientations, and may be used to develop integrative clinical guidelines,, Still another integrative approach to the analysis of interpersonal communication is the Coding System of Therapeutic Focus (CSTF), which highlights aspects of the client’s functioning (e.g., thinking, emotions, actions) on which the therapist places a focus within the therapeutic interaction, and can be used to provide an integrative case formulation (Goldfried, 1995),

6. Does the approach offer a clear rationale for intervention/treatment and assessment/diagnosis, faciliatating constructive change over factors provoking or maintaining illness or suffering?

The various transtheoretical assessment procedures used in integration-oriented process research and clinical practice (e.g., the Structural Analysis of Social Behavior, Coding System of Therapeutic Focus) have been used to address the question: “What did the therapist do in a session that was effective?” Inasmuch as these procedures are not linked to a particular theoretical school, the research findings coming from such process research can readily be used by professionals who integrate several different orientations. Moreover, these findings have direct applicability to clinical practice, as they readily address the question raised by practicing therapists, namely: “What can I do in a session that can be effective?”

These various assessment systems essentially serve as maps to deal with different aspects of the therapeutic territory. Different maps have different clinical uses. depending on the nature of the terrain it details the most (i.e., intrapersonal issues or interpersonal relations). They are used to formulate clinical cases in such a way as to point to treatment directions, and can be used to monitor progress during ongoing therapy- And while the map is not the territory, knowledge of both can greatly enhance the clinical effectiveness of the integrative therapist.

7. Does the approach include clearly defined strategies to enable clients to develop new organization of experience and behaviour?

On the basis of an analysis of different theoretical approaches to change, Goldfried and Padawer (1982) have outlined certain clinical strategies that are common to the different schools of thought and therefore capture the integrative approach to treatment. These common strategies may be conceptualized as reflecting a level of abstraction between theory and technique, and consist of the encouragement of hope, the facilitation of a good therapeutic alliance, the enhancement of client awareness, the encouragement of corrective experiences, and the presentation of ongoing reality testing.

The use of such common factors guides the integrative therapist at a strategic level. With these common strategies in mind, the therapist is then able to select more specific interventions without being limited by the dictates of a specific school of thought,, instead, the requirements of the case at hand determine which intervention method would be used as a means of implementing a given strategy. Thus, the “encouragement of client awareness” might involve an increased awareness of thoughts, feelings, desires, actions, or interpersonal impact on others, drawing on methods traditionally associated with different theoretical orientations- In their comprehensive perspective, integrative therapists focus on the eigenvelt (using psychodynamic methods), the mitvelt (using interpersonal and systems interventions) and the umvelt (using behavioural procedures).

Professional aspects:

8. Is the approach open to dialogue with other psychotherapy modalities about its fields of theory and practice?

Psychotherapy integration is characterized by a dissatisfaction with single-school approaches and by a concomitant desire to look across theoretical boundaries to see what can be learned from other ways of conducting therapy. By its very nature, this approach to therapy requires open, ongoing and collegial dialogue across the therapy modalities. Integrative therapy maintains that the awareness-enhancing process of psychodynamic therapy and the action-producing processes of behavior therapy-plus many others-are the curative factors in psychotherapy,, In order to arrive at such a comprehensive, integrative approach to treatment, collaborative dialogue is essential.

The roots of psychotherapy integration go back to the 1930s, at which point it was only a latent theme- Since the 1980s, however, this theme emerged into a salient movement, due in large part to the formation of the Society for the Exploration of Psychotherapy Integration (SEPI). Formed in 1983, SEPI was established as a way of bringing together the growing number of professionals interested in this approach to treatment. An interdisciplinary organization that is now international in scope, SEPI holds yearly conferences at which many of the most active clinicians and researchers present their current work, and where the attendees are provided with the opportunity to discuss and exchange ideas. It is this spirit of open dialogue, where professionals go to listen and learn, that is the strength of this approach,

9. Are the chosen fields of study and methods of treatment/intervention of this approach methodologically described in a way that can be used by other colleagues?

As suggested above, the strength of psychotherapy integration is the desire to reach across boundaries and bridge the traditional gap between orientations. The field of psychotherapy has been characterized over the years by competing factions, each of which tends to go its own way. With its own unique jargon, any contributions that might be made are all too often available only to members of the particular school,. The very essence of the integrative approach is to enhance the development of the field. which can only be done so by facilitating communication among professionals,, As mentioned earlier, the use of the vernacular-instead of theoretical jargon” as a way of describing clinical and research findings is the hallmark of an integrative approach to therapy.

SEPI, the organizing force behind psychotherapy integration, serves an educational function by having clinical workshops at its annual meetings (held in Madrid in 1998), publishes a journal and a newsletter, and supports the existence of Regional Networks worldwide. The JOURNAL OF PSYCHOTHERAPY INTEGRATION, a quarterly publication, includes clinical, research, and theoretical articles relevant to psychotherapy integration., The journal also includes a NEWSLETTER, which serves as a source of information for members, and contains announcements of regional network activities, training opportunities, and a bulletin board where professionals can present relevant announcements,, It has also recently developed a web page, and makes a list available to those interested in internet communication.

10. Is the information associated with this approach the result of conscious self-reflection and critical reflection by other professionals within the approach?

The long history of psychotherapy integration has involved considerable self-reflection over the years,, It has crossed theoretical boundaries, has encompassed various professional groups (psychology, psychiatry, social work), and has been international in scope. In the UK. Dryden (1980) has dealt with with differences in therapeutic style across theoretical orientations. In Germany, Bastine (1980) has discussed the methods for accomplishing an integration of the therapies, as well as its theoretical and practical benefits. In English-speaking Canada, Greenberg and Safran (1987) published EMOTION IN PSYCHOTHERAPY; from French-speaking Canada, Lecomte and Castonguay (1987) edited RAPPROCHEMENT ET INTEGRATION EN PSYCHOTHERAPIE. From Italy, Guidano (1987) contributed COMPLEXITIES OF THE SELF,, Among the numerous books appearing in the United States, Norcross and Goidfried (1992) and Stricker and Gold (1993) edited extensive handbooks on psychotherapy integration.

In their thoughtful and extensive review of research in psychotherapy, commissioned by the National Health Service Executive of the English Department of Health, Roth and Fonagy (1996) have concluded that one of the more promising directions for future investigation is with those approaches that “attempt to integrate models of therapy. These provide a more formal theoretical framework for the ‘eclecticism’ that often characterizes everyday clinical practice, with clear implications for efficacy” (p. 375). It is our distinct impression that there is a growing consensus that integrative approaches to treatment represent the future of psychotherapy.

11. Does the approach offer new knowledge, which is differentiated and distinctive, in the domain of psychotherapy?

What is new and distinctive about psychotherapy integration is that it approaches the question of how people change from a vantage point that has not been taken before, namely the common factors that cut across different schools of thought. To the extent that commonalities may be found across therapeutic orientations, it is likely that these will represent robust phenomena, as they have emerged despite the different theoretical starting points. In addition to looking at commonalities, however, psychotherapy integration also acknowledges the importance of technical eclecticism, whereby different intervention procedures coming from different orientations may be used, depending upon what is needed in any given case at hand. A third theme within psychotherapy integration is work being done to achieve an integration at the theoretical level.

It should be pointed out that these three approaches to the study of psychotherapy integration are not mutually exclusive, but rather are closely interrelated. For example, common factors inform us about what different theoretical models have in common and, as a result, highlight the areas in which more detailed empirical and clinical examination is required. In looking for greater specificity in our clinical and research efforts, we thus move into a clarification of the parameters of these genera! principles. This represents the technical eclecticism thread of the orientation, in which we examine the specific techniques that are effective in certain clinical situations. Once we have obtained information of the effectiveness of several techniques, it is possible to engage in a bottom-up approach to theory construction. Thus. while theoretical constructs associated with a given school of thought may have generated specific interventions, the existence of a technically eclectic array of effective methods may require us to regroup what we have found to be effective into a new conceptual mode! involving a form of theoretical integration-

12. Is the approach capable of being integrated with other approaches considered to be part of scientific psychotherapy so they can be seen to share with them areas of common ground?

By looking at common principles (e.g., the therapeutic alliance, increasing awareness, encouraging corrective experiences), we are in the position of having the contributions of different theoretical orientations converge, thereby increasing the likelihood of advancing the field. Moreover, by translating theory-based jargon into the vernacular, we have at our disposal a common language for dialoguing across the orientations. In using this approach to bridge the gap across theoretical orientations, our hope is that”,.. some members of each community may also begin vicariously to understand how a statement previously opaque could seem an explanation to members of the opposing group” (Kuhn, 1970, p. 203).

Take, for example, the common principle of the corrective experience (or new learning), which involves clients taking a risk in their lives by saying or doing something they have previously feared or avoided. Therapists from different orientations recognize the importance of this phenomenon, but may implement it in different ways. Thus, within a psychodynamic orientation, this risk-taking may be more likely to occur in the way the client interacts with the therapist, whereas the corrective experience in a behavioural therapy may be more likely to take place between sessions, as when the therapist encourages clients to assert themselves to a significant other. The overall principle is the same, but the method of implementing it may vary according to orientation (hence the technical eclectism)

Research aspects:

13. Does the approach describe and display a coherent strategy to understand human problems and a coherent relation between methods of intervention/treatment and results?

The overriding research strategy for developing and confirming effective integrative interventions involves the comparative study of the therapeutic process and its relationship to outcome, In conducting such research, therapy sessions are evaluated using a transtheoretical coding procedure (e.g., SASB, CSTF, measures of the therapeutic alliance), which are then related to outcome. The process analysis may involve one or more different theoretical orientations, depending upon the outcome study that is the focus of the investigation. For example, in a study of cognitive therapy for depression, a process-outcome analysis has revealed that the therapeutic alliance and client emotional experience level were both positively related to symptom reduction (Castonguay, et al, 1996). in another study with the same data set, it was found that therapists who focused on clients’ developmental issues were more likely to be successful (Hayes et al,,, 1996). It should be noted that the treatment manuals did not focus on these factors, even though they proved to be clinically important. This research strategy therefore is able to uncover effective aspects of a therapeutic intervention, regardless of whether or not it is derived from the theoretical underpinnings of the intervention procedure.

14. Are the theories of normal and problematic human behaviour adopted by the approach explicitly related to effective methods of diagnosis/assessment and intervention/treatment and research?

An excellent illustration of the relationship between the theory of human behavior and the success of the intervention within psychotherapy integration is the dialectical behavior therapy approach that Linehan (1993) has taken in the treatment of borderline personality disorder. On the basis of clinical experience and research evidence, it has been found that borderline patients are particularly sensitive to criticism. It has been hypothesized that there may be some constitutional/biochemical factors that contribute to their unstable emotional state, which has been exacerbated by early experiences of non acceptance and abuse. In addition to their sensitivity to criticism, they also manifest unstable and conflictual interpersonal relationships. As most practicing clinicians well know, this makes them a most difficult patient population with which to work,.

In originally attempting to use a behavioral orientation with this patient population, Linehan found that encouraging borderline patients to learn better ways of coping with their emotions and interpersonal problems proved to be unsuccessful Given their sensitive to criticism, the patients reacted to the therapist’s suggestion that they needed to change as invalidating who they were. Upon this realization, Linehan developed an integrated intervention, whereby the therapy begins with a person-focused approach, accepting patients just as they are-This empathic. validating approach continues until patients reach the point where they ask to learn new ways of coping, at which point the therapist can suggest the option of implementing behaviorally oriented coping skills. This dialectic stance continues throughout the therapy, where the therapist maintains the delicate balance between acceptance and change. The available research findings are very promising, indicating that this integrated therapy is more effective than other available approaches in dealing with this patient population.

15. Are the investigative procedures of this approach defined we!! enough to indicate possibilities of research?

As illustrated in the response to several of the earlier questions, an integrative approach to therapy lends itself most readily to research. Given the premise that psychotherapy integration is committed to using therapy procedures that are effective clinically-regardless of their theoretical origin-psychotherapy research is essential to the system. Indeed, the development of integrative interventions may be readily derived from process analyses of clinically effective interventions, such as the finding that patient level of emotional experience is positively related to successful cognitive therapy for depression. What this suggests is that cognitive therapy procedures should be modified so that they include affect-arousal interventions, which might be integrated from experiential approaches to therapy. Once having done this, the “enhanced” cognitive therapy can be directly compared to standard cognitive therapy within the context of a controlled clinical trial, In short, there is an intrinsic interface between research and practice in psychotherapy integration, where each feeds into the other

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