HANDBOOK OF PSYCHOTHERAPY INTEGRATION

Handbook of Psychotherapy Integration

Third Edition

Edited by
John C. Norcross
Marvin R. Goldfried
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© John C. Norcross and Marvin R. Goldfried 2019

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Library of Congress Cataloging-in-Publication Data

Names: Norcross, John C., 1957– editor. | Goldfried, Marvin R., editor.
Title: Handbook of psychotherapy integration / edited by John C. Norcross and Marvin R. Goldfried.
Description: Third edition. | New York, NY : Oxford University Press, [2019] |
Includes bibliographical references and index.
Identifiers: LCCN 2018056131 (print) | LCCN 2018057695 (ebook) | ISBN 9780190690472 (UPDF)
|
ISBN 9780190690489 (EPUB) | ISBN 9780190690465 (hardcover : alk. paper)
Subjects: LCSH: Eclectic psychotherapy.
Classification: LCC RC489.E24 (ebook) | LCC RC489.E24 H36 2019 (print) | DDC 616.89/14—
dc23
LC record available at https://lccn.loc.gov/2018056131
 Contents

Preface
Summary Outline
The Editors
The Contributors

Part I: Conceptual and Historical Perspectives

1. A Primer on Psychotherapy Integration
John C. Norcross and Erin F. Alexander
2. A History of Psychotherapy Integration
Marvin R. Goldfried, John E. Pachankis, and Brien J. Goodwin

Part II: Integrative Psychotherapy Models

A. Common Factors/Processes
3. Integration of Common Factors and Specific Ingredients
Bruce E. Wampold and Pål G. Ulvenes
4. A Principle-Based Approach to Psychotherapy Integration
Catherine F. Eubanks and Marvin R. Goldfried
5. Feedback Informed Treatment
Cynthia L. Maeschalck, David S. Prescott, and Scott D. Miller
B. Technical Eclecticism
6. Multimodal Therapy
Clifford N. Lazarus and Arnold A. Lazarus
7. Systematic Treatment Selection
Andrés J. Consoli and Larry E. Beutler
 C. Theoretical Integration
8. The Transtheoretical Approach
James O. Prochaska and Carlo C. DiClemente
9. Cyclical Psychodynamics and Integrative Relational Psychotherapy
Paul L. Wachtel and Gregory J. Gagnon
D. Assimilative Integration
10. Assimilative Psychodynamic Psychotherapy
George Stricker and Jerry Gold
11. Cognitive-Behavioral Assimilative Integration
Louis G. Castonguay, Michelle G. Newman, and Martin grosse
Holtforth

Part III: Integrative Psychotherapies for Specific Disorders and Populations

A. Specific Disorders
12. Dialectical Behavior Therapy for Borderline Personality Disorder
Heidi L. Heard and Marsha M. Linehan
13. Integrative Psychotherapy for Generalized Anxiety Disorder
Henny A. Westra and Michael J. Constantino
14. Cognitive Behavioral Analysis System of Psychotherapy for Chronic
Depression
James P. McCullough, Jr. and Elisabeth Schramm
B. Specific Populations and Modalities
15. Integrative Psychotherapy with Culturally Diverse Clients
Jeff E. Harris, Natasha Shukla, and Allen E. Ivey
16. Integrative Psychotherapy with Children
Athena A. Drewes and John W. Seymour
17. Integrating Self-Help and Psychotherapy
Amanda Edwards-Stewart and John C. Norcross

Part IV: Training, Research, International, and Future Directions

18. Training and Supervision in Psychotherapy Integration
 John C. Norcross and Marcella Finnerty
19. Outcome Research on Psychotherapy Integration
James F. Boswell, Michelle G. Newman, and Lata K. McGinn
20. Integrating Research and Practice
Louis G. Castonguay, Michael J. Constantino, and Henry Xiao
21. International Themes in Psychotherapy Integration
Beatriz Gómez, Shigeru Iwakabe, and Alexandre Vaz
22. Future Directions in Psychotherapy Integration
Catherine F. Eubanks, Marvin R. Goldfried, and John C. Norcross

Name Index
Subject Index
 Preface

From its beginnings, psychotherapy integration has been characterized by a

dissatisfaction with single-school approaches and the concomitant desire to
look across and beyond school boundaries to see what can be learned—and
how patients can benefit—from other forms of behavior change. Improving
the efficacy, efficiency, and applicability of psychotherapy is the raison
d’etre of integration.
The 28 years between publication of the inaugural edition of the
Handbook of Psychotherapy Integration and this third edition have been
marked by memorable growth. In 1992, psychotherapy integration was
relatively new and novel, just entering its pre-teen years. Integration had
only recently crystallized into a formal movement. Our original Handbook
was the first compilation of the major integrative approaches (in the English
language) and was hailed by one reviewer as “the bible of the integration
movement.” Few empirical studies had yet been conducted on the
comparative effectiveness of integrative or eclectic approaches. The formal
integration movement was small and concentrated in the United States.
In 2019, psychotherapy integration has entered young adulthood, no
longer an immature or novel approach to clinical work. Integration—or the
older term, eclecticism—is now well established as the modal orientation of
mental health professionals, and this book is now only one of many
volumes on the subject. Literally hundreds of books around the globe are
now published with the term integrative in their titles. Research evidence
attesting to the effectiveness of integrative psychotherapies has
mushroomed. Integration has grown into a mature and international
movement.
For these and related reasons, the second edition of the Handbook of
Psychotherapy Integration became dated and incomplete. It was time for a
new edition.
OUR AIM
What has not materially changed is the purpose of our book. The aim of this
third edition continues to be a state-of-the-art, comprehensive description of
psychotherapy integration and its clinical practices by some of its
distinguished proponents. Along with these integrative approaches, we
feature the concepts, history, training, research, international themes, and
future of psychotherapy integration as well.
Our intended audiences are practitioners, students, and researchers.
Psychotherapists of all persuasions and professions will be attracted to these
premier integrative psychotherapies and integrative treatments. Earlier
editions of the Handbook were widely adopted for courses and seminars on
psychotherapy integration, and we anticipate that this version will again
serve this purpose. The contributors’ use of Chapter Guidelines and our
Summary Outline facilitate a systematic and comparative analysis of the
integrative approaches. We worked hard to maintain the delicate balance
between authors’ individual preferences and readers’ desire for uniformity
in chapter content and format. And researchers will find that each chapter
summarizes the outcome research associated with that particular approach.

THE CHANGES
The contents of this third edition reflect both the evolution of
psychotherapy integration and the continuation of our original aims. We
have deleted several dated chapters that appeared in the earlier edition, and
all remaining chapters have been revised and updated. We added six new
chapters: common factors therapy, principle-based integration, integrative
psychotherapy with children, mixing psychotherapy and self-help,
integrating research and practice, and international themes. The latter two
chapters constitute contemporary thrusts in the integration movement:
blending research and practice and recognizing its international nature. We
have also purposefully added more diversity in our contributors: fully half
of the authors are now women, and many authors represent countries
beyond North America.
Additionally, we updated the Chapter Guidelines (see below) in two
significant ways. First, we required in each chapter a new section on
diversity considerations to address how integrative approaches operate in a
multicultural world. Second, we revised the section headings and the
desired content on research in the chapters to highlight the outcome
research; that is, research on the success (and failures) of the integrative
treatments, especially in comparison to alternative forms of psychotherapy.
All these welcome changes reflect the maturation of psychotherapy
integration itself.

CONTENT AND ORGANIZATION

The Handbook is divided into four substantive parts. Part I presents the
concepts (Norcross and Alexander) and history (Goldfried, Pachankis, and
Goodwin) of psychotherapy integration. Part II features exemplars of each
of the movement’s four predominant thrusts: common factors/processes
(Wampold and Ulvenes; Eubanks and Goldfried; Maeschalck, Prescott, and
Miller), technical eclecticism (Lazarus and Lazarus; Consoli and Beutler),
theoretical integration (Prochaska and DiClemente; Wachtel and Gagnon),
and assimilative integration (Stricker and Gold; Castonguay, Newman, and
Holtforth). Part III presents integrative psychotherapies for specific
disorders, populations, and modalities: borderline personality (Heard and
Linehan), anxiety (Westra and Constantino), chronic depression
(McCullough and Schramm), culturally diverse clients (Harris, Shukla, and
Ivey), children (Drewes and Seymour), and self-help (Stewart and
Norcross). Part IV concludes the volume by addressing clinical training
(Norcross and Finnerty), outcome research (Boswell, Newman, and
McGinn), synthesis of research and practice (Castonguay, Constantino, and
Xiao), international considerations (Gómez, Iwakabe, and Vaz), and future
directions in integration (Eubanks, Goldfried, and Norcross).
No single volume—even a hefty one like this—can canvass all
consequential concerns or clinical situations. Two regrettable gaps in our
coverage are the absence of chapters on integrating pharmacotherapy and
psychotherapy and on blending therapy formats/modalities (individual,
couple, family, group). Moreover, space considerations restricted us to five
examples of integrative therapies for specific disorders and populations. In
making the precarious choices of which material would receive coverage
and which would be passed over, we opted to keep the book clinically
useful and student accessible.

CHAPTER GUIDELINES
Contributors to Part II (Integrative Psychotherapy Models) and Part III
(Integrative Psychotherapies for Specific Disorders and Populations)
addressed the same central topics in their chapters. We constructed Chapter
Guidelines to facilitate comparative analyses and to ensure
comprehensiveness. As expected, the authors did not cover every item in
the guidelines, but all authors used the suggested headings and all addressed
the requested topics. The Chapter Guidelines were:
The Integrative Approach
Aim: To outline the historical development and guiding principles of the
approach.

◆ What were the primary influences that contributed to the development

of the approach (e.g., people, experiences, research, books,
conferences)?
◆ What were the direct antecedents of the approach?
◆ What are the guiding principles and central tenets of your approach?
◆ Are some theoretical orientations more prominent contributors to your
approach than others?
◆ What is the basis for selecting therapy interventions (e.g., proven
efficacy, theoretical considerations, clinical experience, patient
characteristics)?
◆ How does your integrative approach prove more effective than single-
system therapies?

Assessment and Formulation

Aim: To describe the methods used to understand patient functioning, to
construct a case formulation, and to track client progress.
◆ What are the formal and informal systems for diagnosing or typing
patients?
◆ Do you employ tests or questionnaires in your assessment?
◆ What major client and/or environmental variables are assessed?
◆ At which levels (e.g., individual, dyadic, system) are the assessments
made?
◆ What role does case formulation play in the approach?
◆ How do you select and prioritize treatment goals?
◆ How do you monitor or track client progress over the course of
therapy?
◆ How do you integrate assessment and treatment?

Applicability and Structure

Aim: To describe those clinical situations and patients for which the
approach is relevant.

◆ For which types of patients (e.g., diagnostic types, client

characteristics) is the approach useful?
◆ For which types of patients is the approach not appropriate or of
uncertain relevance?
◆ For what situations (e.g., clinical settings, time limitations) is/is not the
approach relevant?
◆ What are the clinical settings for the approach? Are there any
contraindicated settings?
◆ What is the typical frequency and length of sessions?
◆ Is the therapy typically time-limited or unlimited? What is the typical
duration of therapy (mean number and range of sessions)?
◆ Are combined therapy formats used (e.g., individual therapy plus
family therapy)?
◆ Where and when does psychotropic medication fit into the approach?

Processes of Change
Aim: To identify the mechanisms or processes that produce changes in
therapy and to assess their relative impact.
◆ What are the central mechanisms of change in your approach?
◆ What is the relative importance of insight/awareness, skill/action
acquisition, transference analysis, and the therapeutic relationship in
the approach?
◆ What are the relative contributions of “common” factors to outcome?
◆ Does the therapist’s personality and psychological health play an
important role?
◆ What other therapist factors influence the course and outcome of
therapy?
◆ Which patient variables enhance or limit the probability of successful
treatment?

Therapy Relationship
Aim: To depict the ideal therapeutic relationship in the approach and the
therapist behaviors contributing to it.

◆ How do you view the therapeutic relationship (e.g., as a precondition

of change, as a mechanism of change, as content to be changed)?
◆ What are the most important ingredients of the therapy relationship in
the approach?
◆ On what grounds is the therapy relationship adjusted or tailored to the
individual patient?
◆ Does the therapist’s role change as therapy progresses?

Methods and Techniques

Aim: To delineate the methods and techniques frequently employed in the
approach.
◆ What are some of the interventions used to engage patients?
◆ What is the therapist’s work in treatment? What is the client’s work in
treatment?
◆ What therapy methods are typically employed? Which would typically
not be used?
◆ How do you deal with resistances and blocks in treatment?
◆ What are the most common and the most serious technical errors a
therapist can make in your approach?
◆ How active and directive is the therapist in the approach?
◆ How are maintenance sessions and relapse prevention addressed in the
approach?

Diversity Considerations
Aim: To outline the treatment considerations and potential adaptations for
clients of historically marginalized ethnic/racial, gender, sexual, and other
dimensions of diversity.

◆ How does the approach apply to diverse patients in a multicultural

world?
◆ Are there any particular adaptations for clients of diverse cultural
identities?
◆ What are the most common culturally competent and culturally
challenging elements of your approach?

Case Example
Aim: To illustrate the initiation, process, and outcome of the integrative
approach with a single case example.
◆ To maintain comparability among the examples, the cases in Part II
should deal with the treatment of a client with general anxiety and
unipolar depression (psychological distress). The case example should
illustrate and discuss the initiation of treatment, patient assessment,
case formulation, treatment methods, therapy relationship, termination,
and outcome. Cases in Part III will pertain, of course, to the specific
disorder and population discussed in the respective chapters.

Outcome Research
Aim: To summarize the outcome research on the integrative approach.
◆ What research has been conducted on process–outcome linkages of the
approach?
◆ What outcome research has been performed on the approach?
◆ Does any controlled outcome research suggest that the integrative
approach is comparable or superior to other forms of psychotherapy?
◆ What are the average percentages of dropouts and negative outcomes?

Future Directions
Aim: To explicate the future directions and needs of the approach.

◆ What further work (clinical, research, theoretical, training) is required

to advance your approach?
◆ In what directions is your integrative approach heading in the next
decade?

ACKNOWLEDGMENTS
A large and integrative volume of this nature requires considerable
collaboration. Our efforts have been aided immeasurably by our families
and our Society for the Exploration of Psychotherapy Integration (SEPI)
colleagues; the former giving us time and inspiration, the latter providing
intellectual stimulation and professional affirmation. We are deeply
indebted to the contributors. Most of them are SEPI members, and all are
eminent psychotherapists in their own right. They are “beyond category”—
a phrase that Duke Ellington used as a high form of praise for artists who
transcend the normal theoretical boundaries. We are pleased to be in their
company and to privilege their integrative work.
We also appreciate the dozens of emails and letters with advice on
preparing the third edition of this Handbook. In particular, we are grateful
for Gary VandenBos’s detailed feedback on the second edition. Thank you
to his 2016 and 2017 Integrative Psychotherapy students at Uniformed
Services University for their systematic feedback.
Last, we reciprocally acknowledge each other for the pleasure and
success of our editorial collaboration. We have a long history of
collaborating on multiple projects and consider ourselves fortunate to
continue to do so.
John C. Norcross
Clarks Summit, PA
Marvin R. Goldfried
Stony Brook, NY
 Summary Outline (for Parts II and III)

Integrative Assessment Applicability Processes Therapy Methods Diversity Case Outcome Future
Approach and and of Relationship and Considerations Example Research Directions
Formulation Structure Change Techniques
Common Factors/Processes
Common 70 77 77 71 71 78 78 78 80 80
Factors plus
Specific
Ingredients
Principle-Based 88 89 92 92 96 92 96 97 100 101
Integration
Feedback- 106 108 110 111 111 111 112 113 117 118
Informed
Treatment
Technical Eclecticism
Multimodal 125 127 131 132 133 133 135 135 137 138
Therapy
Systematic 141 142 143 145 147 148 150 151 153 154
Treatment
Selection
Theoretical Integration
Transtheoretical 162 168 170 172 171 172 173 177 179
Therapy
Cyclical 185 188 190 191 191 191 195 198
Psychodynamics
Assimilative Integration
Assimilative 207 209 211 212 214 216 218 219 223 223
Psychodynamic
Therapy
Assimilative 229 230 232 233 234 235 241 241 243 246
CBT Integration
Disorders and Populations
Borderline 258 262, 263 261, 265 272 273 268 274 275 277 279
Personality
Generalized 284 286 288 288 290 291 293 293 297 298
Anxiety
Chronic 303 306 308 310 312 312 315 315 318 319
Depression
Culturally 325 327 328 329 330 331 335 336 337
Diverse Clients
Integrative 342 346 348 349 349 350 350 352 352
Therapy with
Children
 The Editors

John C. Norcross, PhD, ABPP, is Distinguished Professor of Psychology at

the University of Scranton, Adjunct Professor of Psychiatry at SUNY
Upstate Medical University, and a board-certified clinical psychologist in
limited independent practice. Dr. Norcross has co-written or edited 22
books, including Psychotherapy Relationships That Work, Psychologists’
Desk Reference, Clinician’s Guide to Evidence-Based Practice, Self-Help
That Works, the five-volume APA Handbook of Clinical Psychology,
Insider’s Guide to Graduate Programs in Clinical & Counseling
Psychology, and Systems of Psychotherapy: A Transtheoretical Analysis,
now in its 9th edition. Dr. Norcross has served as president of the American
Psychological Association (APA) Society of Clinical Psychology, the APA
Society for the Advancement of Psychotherapy, the International Society of
Clinical Psychology, and the Society for the Exploration of Psychotherapy
Integration. He edited the Journal of Clinical Psychology: In Session for a
decade and has been on the editorial boards of a dozen journals. Dr.
Norcross has received multiple professional awards, such as APA’s
Distinguished Career Contributions to Education and Training Award,
Pennsylvania Professor of the Year from the Carnegie Foundation, and
election to the National Academies of Practice. Dr. Norcross has conducted
workshops and lectures in 30 countries. He lives in northeast Pennsylvania.
Marvin R. Goldfried, PhD, ABPP, is Distinguished Professor of Psychology
at Stony Brook University. In addition to his teaching, supervision, and
research, he maintains a limited practice of psychotherapy in New York
City. He is a diplomate in clinical psychology and recipient of distinguished
psychologist awards from APA divisions 8, 12, 29, and 44, the
APA/American Psychological Foundation lifetime achievement award for
the application of psychology, the Distinguished Career Award from the
Society for Psychotherapy Research, and awards for both education/training
and clinical contributions from the Association for Behavioral and
Cognitive Therapies. Dr. Goldfried is past president of the Society for
Psychotherapy Research, Society for the Exploration of Psychotherapy
Integration, Society of Clinical Psychology, and Society for the
Advancement of Psychotherapy. He is author, co-author, or editor of several
books, including Behavior Change Through Self-Control, Clinical Behavior
Therapy, Converging Themes in Psychotherapy, From Cognitive-Behavior
Therapy to Psychotherapy Integration, How Therapists Change, and
Transforming Negative Reactions to Clients. Dr. Goldfried is cofounder of
SEPI, founder of Psychologists Affirming Their Gay, Lesbian, and Bisexual
Family (AFFIRM), and founder of the Two-Way Bridge Between Research
and Practice. He lives in New York City.
 The Contributors

Erin F. Alexander, BS
Department of Psychology, University of Scranton
Department of Psychology, Binghamton University
Larry E. Beutler, PhD
Clinical Psychology Program, Palo Alto University (emeritus)
School of Education, University of California, Santa Barbara (emeritus)
James F. Boswell, PhD
Department of Psychology, State University of New York at Albany
Louis G. Castonguay, PhD
Department of Psychology, Pennsylvania State University, University Park
Andrés J. Consoli, PhD
Counseling, Clinical, and School Psychology, University of California,
Santa Barbara
Michael J. Constantino, PhD
Department of Psychological and Brain Science, University of
Massachusetts, Amherst
Carlo C. DiClemente, PhD
Department of Psychology, University of Maryland at Baltimore County
Athena A. Drewes, PsyD
Astor Services for Children and Families
Amanda Edwards-Stewart, PhD
National Center for Telehealth and Technology
Psychological Health Center of Excellence
Catherine F. Eubanks, PhD
Ferkauf Graduate School of Psychology, Yeshiva University
Mount Sinai Beth Israel Psychotherapy Research Program, Mount Sinai
School of Medicine
Marcella Finnerty, DPsych
IICP College, Dublin
Gregory J. Gagnon, MPhil
Department of Psychology, Graduate Center of the City University in New
York
Jerry Gold, PhD
Department of Psychology, Adelphi University
Marvin R. Goldfried, PhD
Department of Psychology, Stony Brook University
Beatriz Gómez, PhD
Aigle Foundation, Buenos Aires
Brien J. Goodwin, BA
Department of Psychological and Brain Science, University of
Massachusetts, Amherst
Jeff E. Harris, PhD
Department of Psychology and Philosophy, Texas Women’s University
Heidi L. Heard, PhD
Behavioral Tech, Seattle, WA
Martin grosse Holtforth, PhD
Department of Psychology, University of Bern
Allen E. Ivey, EdD
Department of Counseling, University of Massachusetts, Amherst
(emeritus)
Shigeru Iwakabe, PhD
Faculty of Core Research, Ochanomizu University
Arnold A. Lazarus, PhD (deceased)
Graduate School of Applied and Professional Psychology, Rutgers
University (emeritus)
Clifford N. Lazarus, PhD
The Lazarus Center, New Jersey
Marsha M. Linehan, PhD
Department of Psychology, University of Washington
Behavioral Tech, Seattle, WA
Cynthia L. Maeschalck, MA
International Center for Clinical Excellence
James P. McCullough, Jr., PhD
Departments of Psychology and Psychiatry, Virginia Commonwealth
University
Lata K. McGinn, PhD
Ferkauf Graduate School of Psychology, Yeshiva University
Scott D. Miller, PhD
International Center for Clinical Excellence
Michelle G. Newman, PhD
Department of Psychology, Pennsylvania State University
John C. Norcross, PhD
Department of Psychology, University of Scranton
Department of Psychiatry, SUNY Upstate Medical University
John E. Pachankis, PhD
School of Public Health, Yale University
David S. Prescott, LICSW
International Center for Clinical Excellence
James O. Prochaska, PhD
Department of Psychology, University of Rhode Island
Elisabeth Schramm, PhD
Department of Psychiatry and Psychotherapy, University Medical Center
Freiburg
John W. Seymour, PhD
Department of Counseling and Student Personnel, Minnesota State
University, Mankato
Natasha Shukla, MA
Department of Psychology and Philosophy, Texas Women’s University
George Stricker, PhD
Clinical Psychology Program, Argosy University, Northern Virginia
Pål G. Ulvenes, PhD
Research Institute, Modum Bad Psychiatric Center, Norway
Alexandre Vaz, MSc
ISPA—University Institute, Portugal
Paul L. Wachtel, PhD
Department of Psychology, City College and Graduate Center of City
University in New York
Bruce E. Wampold, PhD
Research Institute, Modum Bad Psychiatric Center, Norway
Department of Counseling Psychology, University of Wisconsin–Madison
Henny A. Westra, PhD
Department of Psychology, York University
Henry Xiao, MS
Department of Psychology, Pennsylvania State University, University Park
HANDBOOK OF PSYCHOTHERAPY INTEGRATION
PART I

Conceptual and Historical Perspectives

 1

A Primer on Psychotherapy Integration

JOHN C. NORCROSS AND ERIN F. ALEXANDER

Rivalry among theoretical orientations has a long and undistinguished

history in psychotherapy dating back to Freud. In the infancy of the field,
therapy systems, like battling siblings, competed for attention and affection
in a “dogma eat dogma” environment (Larson, 1980). Clinicians
traditionally operated from within their own particular theoretical
frameworks, often to the point of being blind to alternative
conceptualizations and potentially superior interventions. The field was
organized into “tribes” in which therapists derived their identities from
belonging to certain subgroups, identities that often entailed opposition to
other groups (Wachtel, 2017). Mutual antipathy and exchange of puerile
insults between adherents of rival orientations were very much the order of
the day.
This ideological Cold War may have been a necessary developmental
stage toward sophisticated attempts at rapprochement. Thomas Kuhn (1970)
has described this period as a “pre-paradigmatic crisis.” Feyerabend (1970,
p. 209), another philosopher of science, concluded that “the interplay
between tenacity and proliferation is an essential feature in the actual
development of science. It seems that it is not the puzzle-solving activity
that is responsible for the growth of our knowledge, but the active interplay
of various tenaciously held views.”
As the field of psychotherapy has matured, integration (or eclecticism)
has become a therapeutic mainstay. Since the early 1990s, we have
witnessed both a general decline in ideological struggle and a movement
toward rapprochement. Psychotherapists now widely acknowledge the
inadequacies of any one theoretical system and the potential value of others.
Integration gathers, in the words of Abraham Lincoln, “strange, discordant,
and even, hostile elements from the four winds.”
What is distinctive of the present era is tolerance for and assimilation of
formulations that were once viewed as deviant. Indeed, many young
students of psychotherapy express surprise when apprised of the ideological
Cold War of the preceding generations.
Psychotherapy integration has crystallized into a formal movement or,
more dramatically, a “revolution” (Lebow, 1997) and a “metamorphosis” in
mental health (London, 1988; Moultrup, 1986). Although various labels are
applied to this movement—eclecticism, integration, rapprochement,
convergence—the goals are similar. Integration is characterized by
dissatisfaction with single-school approaches and a concomitant desire to
look across school boundaries to see what can be learned from other ways
of conducting psychotherapy. The ultimate outcome of doing so is to
enhance the efficacy, efficiency, and applicability of psychotherapy.
The latter point deserves reiteration: the goal of integration is to boost
therapeutic success, not for academic or aesthetic satisfaction. Proposing
another integrative treatment or advancing a neglected element in
psychotherapy may prove interesting, but the bottom line is whether it leads
to improved outcomes of some sort. Simply adding elements—a “more is
better” strategy—does not necessarily enhance treatment effectiveness.
Psychotherapy integration has come of age since the first edition of this
Handbook in 1992. Any number of indicators attest to the maturation of
psychotherapy integration. Integration or the earlier preferred term,
eclecticism, is the modal theoretical orientation of English-speaking
psychotherapists and in many countries throughout the world (see Gómez,
Iwakabe, & Vaz, Chapter 21, this volume). Leading psychotherapy
textbooks routinely identify their theoretical persuasion as integrative, and
an integrative or eclectic chapter is regularly included in compendia of
treatment approaches. The publication of books that synthesize various
therapeutic concepts and methods continues unabated, now numbering in
the hundreds. Handbooks on integration, such as this one, have been
published in at least a dozen countries. Reflecting and engendering the
movement have been the establishment of interdisciplinary organizations
devoted to integration, notably the Society for the Exploration of
Psychotherapy Integration (SEPI), and of international publications,
including SEPI’s Journal of Psychotherapy Integration. And the integrative
fervor will apparently persist well into the 2020s: a panel of psychotherapy
experts portend integration’s escalating popularity (Norcross, Pfund, &
Prochaska, 2013).
Although psychotherapy integration has indeed come of age, we have not
yet attained consensus or convergence. As Lazarus and Lazarus (Chapter 6,
this volume) note, the field of psychotherapy is still replete with cult
members—devoted followers of a particular school of thought. High priests
of psychological health persist in competitive strife and internecine battles.
These battles have receded but have not been extinguished.
A consensus has been achieved, however, in support of the idea that
neither traditional fragmentation nor premature unification will wisely serve
the field of psychotherapy or its clients. We are in no position to determine
conclusively which single theory, single treatment, or single unification
scheme is best. Although it might be more satisfying and elegant if the
psychotherapy world were not a multiverse but rather a universe, the
pluralists assure us that this quest will not be realized, at least not soon
(Messer, 1992). In the meantime, psychotherapy is progressing toward
integration in the zeitgeist of informed pluralism.

PLAN OF THE CHAPTER

This chapter explicates the broad context of psychotherapy integration and
sets the stage for the subsequent chapters in the volume. As the chapter title
indicates, we offer a primer on integration in the dual sense of a primer
(soft i) as a small introduction to the subject and of a primer (hard i) as a
basecoat or undercoat for the following applications. This chapter begins by
describing the converging reasons for the growth of psychotherapy
integration, after which we review the four primary routes to integration.
This segues into the varieties of integration, which includes summaries of
recent studies on the prevalence, subtypes, and practices of integrative
therapists. The chapter concludes with a discussion of recurrent obstacles to
psychotherapy integration.

WHY INTEGRATION NOW?

Integration as a point of view has probably existed as long as philosophy
and psychotherapy. In philosophy, the third-century biographer Diogenes
Laertius referred to an eclectic school that flourished in Alexandria in the
second century a.d. (Lunde, 1974). In psychotherapy, Freud consciously
struggled with the selection and integration of diverse methods (Frances,
1988).
More formal ideas on synthesizing the psychotherapies appeared in the
literature as early as the 1930s (Goldfried, Pachankis, & Goodwin, Chapter
2, this volume). For example, Thomas French (1933) stood before the 1932
meeting of the American Psychiatric Association and drew parallels
between certain concepts of Freud and Pavlov. In 1936, Sol Rosenzweig
published an article that extracted commonalities among various systems of
psychotherapy.
Until recent decades, however, integration has appeared only as a latent
theme (if not conspiratorially ignored altogether) in a field organized
around discrete theoretical orientations. Although psychotherapists
privately recognized that their orientations did not adequately assist them in
all they encountered in practice, a host of political, social, and economic
forces—such as professional organizations, training institutes, and referral
networks—kept them penned within their own theoretical school yards and
typically led them to avoid clinical contributions from alternative
orientations.
It has only been within the past 40 years that integration has developed
into a clearly delineated area of interest. Indeed, the temporal course of
interest in psychotherapy integration, as indexed by both the number of
publications (Arkowitz, 1992) and development of organizations and
journals (Chapter 2), reveals occasional stirrings before 1970, a growing
interest during the 1980s, and rapidly accelerating interest from 1990 to the
present.
FIGURE 1.1 Frequency of occurrence of “psychotherapy integration,” “integrative psychotherapy,”
and “eclectic psychotherapy” in the Google Books Archive from 1960 to 2010.

Figure 1.1 depicts the frequency trends of the three interrelated terms
psychotherapy integration, integrative psychotherapy, and eclectic
psychotherapy from 1960 to 2010 in volumes archived by Google Books.
The frequency graphs have been moderately smoothed for easier
interpretation. The term “eclecticism” experienced its heyday during the
1980s and has gradually declined thereafter. By contrast, “psychotherapy
integration” has become the preferred or at least the most frequently used
terminology. The slopes for both integrative titles continued to move
upward into the late 2010s.
The rapid increase in integrative psychotherapies of late leads one to
inquire, “Why now?” What conditions encouraged the field to give specific
attention and credence of late to an elusive goal that has been around for
more than half a century? At least eight interacting, mutually reinforcing
factors have fostered the development of integration in the past two
decades:
1. Proliferation of therapies
2. Inadequacy of single theories and treatments
3. External socioeconomic contingencies
4. Ascendancy of short-term, problem-focused treatments
5. Opportunity to observe various treatments, particularly for difficult disorders
6. Recognition that therapeutic commonalities heavily contribute to outcome
7. Identification of specific therapist effects and evidence-based treatments
8. Development of a professional network for integration
 The sheer proliferation of diverse schools has been one important reason
for the surge of integration. The field of psychotherapy has been staggered
by over-choice and fragmented by future shock. Which of 500-plus
therapies should be studied, taught, or bought (Prochaska & Norcross,
2018)? Conflicting and untested theories are advanced on a regular basis,
and no single theory has cornered the market on utility. The hyperinflation
of brand name therapies has produced narcissistic fatigue: “With so many
brand names around that no one can recognize, let alone remember, and so
many competitors doing psychotherapy, it is becoming too arduous to
launch still another new brand” (London, 1988, pp. 5–6). This might also be
called the “exhaustion theory” of integration: Peace among warring schools
is the last resort.
A related and second factor is the growing awareness that no one
approach is clinically adequate for all patients and situations (Fernandez-
Alvarez, Consoli, & Goemez, 2016). The proliferation of theories is both a
cause and consequence of the problem—neither the theories nor the
techniques adequately deal with the complexity of psychological problems
(Beutler, 1983). Surveys of self-designated eclectic and integrative
clinicians reveal that their alignment is motivated in part by disillusionment
with single-therapy systems (Garfield & Kurtz, 1977; Norcross, Karpiak, &
Lister, 2004). The ecumenical spirit reflects the stark realization that narrow
conceptual positions and simple answers to major questions do not begin to
explain current evidence in many areas of psychotherapy (Kazdin, 1984).
Clinical realities have come to demand a more flexible, if not integrative,
perspective.
No therapy or therapist is immune to failure. It is at such times that
seasoned clinicians often wonder if the clinical methods from orientations
other than their own might more appropriately have been included in the
treatment—if another orientation’s strength in dealing with the particular
therapeutic problems might complement the therapist’s own orientational
weakness. The twin assumptions are that each orientation has its particular
domain of expertise and that these domains can be interrelated to minimize
their deficits (Pinsof, 1995).
The proliferation of therapies and the inadequacies of single models were
in part precipitated by a matrix of economic and social pressures. In the
1970s and 1980s, integration was spurred along by such occurrences as the
advent of legal accreditation of psychotherapists, with a resultant surge in
professional practice and growth of psychological trade schools; the
destigmatization of psychotherapy, spurred by the human potential
movement; the onset of federal financial support for clinical training; and
insurance companies’ financing of psychological treatment (London, 1983).
Psychotherapy also experienced mounting pressures from such not easily
disregarded sources as government policymakers, informed consumers, and
insurance payors who started to demand crisp and informative answers
regarding the effectiveness of psychosocial treatments. More broadly, the
culture of the 1970s and 1980s created an intellectual and sociopolitical
climate for psychotherapists in which experimentation and heterodoxy
could flower more easily than at other times (Gold, 1990).
In the 1990s, another set of forces weakened the field’s rigid theoretical
boundaries. Consumer groups and insurance companies were pressuring
psychotherapists to demonstrate the efficacy of their methods. Biologically
oriented psychiatrists questioned the psychosocial paradigm. The failure of
research findings to demonstrate a consistent superiority of any one school
over another and the shifting focus to specific clinical problems (often
requiring the expertise of different professions and orientations) led an
increasing number of clinicians to search seriously for solutions outside
their own particular paradigm.
Attacks from outside the mental health professions started to propel
psychotherapists together. Without some drastic changes (not the least of
which is integration), psychotherapists to lose prestige, customers, and
money. As Mahoney (1984) put it (paraphrasing Benjamin Franklin), there
is something to be said for having the different therapies “hang together”
rather than “hang separately.”
In recent decades, short-term, problem-focused psychotherapies have
been in the ascendancy. Treatment reviews, tightening insurance
reimbursement, and mandated brief treatment began to startle clinical
practitioners out of their complacency with long-term treatment. With 90%
of all patients now covered by some variant of managed care, short-term
therapy has increasingly become the de facto treatment.
Short-term therapy invariably means more problem-focused therapy. The
brief problem focus has brought formerly different therapies closer together
and has created variations of therapies that are more compatible with each
other. Integration, particularly in the form of technical eclecticism, responds
to the pragmatic time-limited injunction of “whatever therapy works better
—and quicker—for this patient with this problem.” In one early study of
294 health maintenance organization (HMO) therapists, for instance, the
prevalence of eclecticism/integration as a theoretical orientation nearly
doubled as a function of their employment in HMOs favoring brief therapy
(Austad et al., 1991).
A fifth factor in the promotion of psychotherapy integration has been
clinicians of diverse orientations observing and experimenting with diverse
treatments (Arkowitz, 1992). The establishment of specialized clinics for
the treatment of specific disorders has afforded exposure to other theories
and therapies. These clinics are often staffed by professionals of multiple
orientations and disciplines, with greater emphasis on their expertise about
the clinical problem than on their theoretical orientation per se. These
clinics focus on treating patients and disorders that have not historically
responded favorably to pure-form psychotherapies: personality disorders,
eating disorders, substance abuse, trauma, obsessive-compulsive disorders,
and the severely mentally ill, to name a few.
Moreover, the publication of detailed treatment manuals and the release
of numerous videotapes of actual psychotherapy have permitted more
accurate comparisons and contrasts among the therapies. Many clinicians
reading manuals or watching videotapes are surprised by the immense
commonality among practitioners of diverse orientations in spite of their
differing vocabulary (Norcross & VandenBos, 2011). Even when actual
differences remain, in behavioral terms, observing practices of different
orientations may have induced an informal version of “theoretical
exposure”: previously feared and unknown therapies were approached
gradually, anxiety dissipated, and the previously feared therapies were
integrated into the clinical repertoire.
At the same time, controlled research has revealed surprisingly few
significant differences in outcome among different therapies. Luborsky and
associates (1975), borrowing a phrase from the Dodo bird in Alice in
Wonderland, wryly observe that “everybody has won and all must have
prizes.” Or, in the words of London (1988, p. 7), “Meta-analytic research
shows charity for all treatments and malice towards none.” Though there
are many interpretations of such findings, the two most common responses
seem to be a specification of factors common to successful treatments and a
synthesis of useful methods from disparate therapeutic traditions.
 The recognition that the so-called common factors play major roles in
determining therapy effectiveness served as another contributor to the rise
of integration. The common factors or change processes most frequently
proposed are the development of a therapeutic alliance, opportunity for
catharsis, acquisition and practice of new behaviors, and clients’ positive
expectancies (Grencavage & Norcross, 1990; Tracey et al., 2003).
Empirically speaking, therapy outcome can best be predicted by the
properties of the patient and the therapy relationship (see Norcross &
Lambert, 2019, for reviews): only 10–15% of outcome variance is generally
accounted for by the particular technique.
Nonetheless, more than commonalities are evident across the therapies—
there are occasionally specific factors attributable to different treatments
and different therapists (the so-called therapist effects; Castonguay & Hill,
2017). Psychotherapy research has demonstrated the differential
effectiveness of a few therapies with specific disorders; for example, parent
management therapy for child conduct disorders, conjoint therapy for
partner conflict, and some form of exposure for trauma disorder.
Psychotherapy research has also demonstrated the differential effectiveness
of particular relationships with specific types of patients; for example, less
directive therapies for highly resistant patients (Consoli & Beutler, Chapter
7, this volume) and insight-oriented therapies for people in the
contemplation stage of change (Prochaska & DiClemente, Chapter 8, this
volume). We now have more information by which to selectively prescribe
different treatments, or combinations of treatments, for some clients and
problems.
Practitioners have learned to emphasize those factors common across
therapies while capitalizing on the contributions of specific treatments. The
proper use of common and specific factors in therapy will probably be most
effective for clients and most congenial to practitioners (Garfield, 1992).
We integrate by combining fundamental similarities and useful differences
across the schools.
The identification of specific effects in psychotherapy relates closely to
the recent promulgation of research-based treatments in mental health.
These tend to be manualized, single-theory treatments for specific disorders
that are supported by controlled research in clinical trials. At first blush, the
compilation of single-theory or pure-form treatments would seem
antithetical to the integration movement (Glass & Arnkoff, 1996). The
promotion of such compilations might lead to training programs teaching
only the listed pure-form therapies, insurance companies funding only
these, and practitioners conducting only these.
Yet the emergence of research-based treatments in mental health has,
paradoxically, furthered the breakdown of traditional schools and the
escalation of informed pluralism. The particular decision rules for what
qualifies as evidence remain controversial, but the emerging evidence-based
lists reveal a pragmatic flare for “what works for whom.” The clear
emphasis is on “what” works, not on “what theory” applies. The evidence-
based movement is compatible with theoretical integration and essential to
technical eclecticism (Shoham & Rohrbaugh, 1996). In fact, several
commentators believe that evidence-based compilations herald the final
dismantling of traditional theoretical categories and will yield a new
metatheory of therapy (Smith, 1999).
Finally, the development of a professional network has been both a
consequence and cause of interest in psychotherapy integration. In 1983,
the interdisciplinary SEPI was formed to bring together those who were
intrigued by the various routes to rapprochement among the
psychotherapies. SEPI promotes the integrative spirit throughout the
therapeutic community through annual conferences, regional networks, a
quarterly journal, and professional networking. Integrationists (and
eclectics) now have a professional home.

FOUR ROUTES TO INTEGRATION

There are numerous pathways toward the integration of the
psychotherapies; many roads lead to Rome. The four most popular routes
are technical eclecticism, theoretical integration, common factors, and
assimilative integration.
Each of the four routes is embraced by considerable proportions of self-
identified eclectics and integrationists but with some definite preferences.
Recent research on SEPI members (Norcross et al., 2017) indicates that the
preferred routes or subtypes entail assimilative integration, theoretical
integration, and common factors, followed by technical eclecticism. That
rank order generally aligns with those of US clinical psychologists
(Norcross, Karpiak, & Lister, 2005), who endorsed theoretical integration
(27.5%), common factors (27.5%), assimilative integration (26%), and
technical eclecticism (19%). In both studies and populations, technical
eclecticism ranked last in frequency.
All four routes are characterized by a general desire to increase
therapeutic efficacy, efficiency, and applicability by looking beyond the
confines of single theories and the restricted techniques traditionally
associated with those theories. However, they do so in different ways and at
different levels. Here, we define each route, comment on its integrative
strategy, and consider how it professes to improve patient outcomes—the
ultimate goal of all integration.

Technical Eclecticism
Eclecticism is the least theoretical of the four routes but should not be
construed as either atheoretical or antitheoretical (Lazarus, Beutler, &
Norcross, 1992). Technical eclectics seek to improve our ability to select
the best treatment for the person and the problem. This search is guided
primarily by research evidence and clinical observation on what has worked
best for others in the past with similar problems and similar characteristics.
Eclecticism focuses on predicting for whom interventions will work: the
foundation is actuarial rather than theoretical. The multimodal therapy of
Lazarus (1989, 1997; Lazarus & Lazarus, Chapter 6, this volume) and the
systematic treatment selection (STS) of Beutler (1983; Beutler & Clarkin,
1990; Consoli & Beutler, Chapter 7, this volume) exemplify technical
eclecticism.
The term eclecticism has acquired an emotionally ambivalent, if not
negative, connotation for some clinicians due to its alleged disorganized
and indecisive nature. In some corners, eclecticism connotes undisciplined
subjectivity, muddle-headedness, the “last refuge for mediocrity, the seal of
incompetency,” or a “classic case of professional anomie” (quoted in
Robertson, 1979). Eysenck (1970, p. 145) characterized this indiscriminate
smorgasbord as a “mish-mash of theories, a hugger-mugger of procedures, a
gallimaufry of therapies” having no proper rationale or empirical
verification. Indeed, it is surprising that so many clinicians admit to being
eclectic in their work, given the negative valence the term has acquired.
But much of the opposition to eclecticism should properly be redirected
to syncretism—uncritical and unsystematic combinations (Norcross, 1990;
Patterson, 1990). This haphazard stew is primarily an outgrowth of pet
techniques and inadequate training, an arbitrary, if not capricious, blend of
methods by default (Smith, 1999). This muddle of idiosyncratic clinical
creations is the antithesis of effective eclecticism.
Proponents of technical eclecticism use procedures drawn from different
sources without necessarily subscribing to the theories that spawned them,
whereas the theoretical integrationist draws from diverse systems that may
be epistemologically or ontologically incompatible. For technical eclectics,
no necessary connection exists between theoretical underpinnings and
techniques. “To attempt a theoretical rapprochement is as futile as trying to
picture the edge of the universe. But to read through the vast amount of
literature on psychotherapy, in search of techniques, can be clinically
enriching and therapeutically rewarding” (Lazarus, 1967, p. 416).
Prescriptive matching of psychotherapy to the client’s goals, problems,
and context promises to enhance treatment outcomes. Historically, the
match was a research-based method to the presenting diagnosis or disorder,
say, cognitive therapy for depression, exposure therapy for trauma,
communication skills training for couples, psychodynamic therapy for
personality disorders. Increasingly, the match is to the patient’s
transdiagnostic characteristics, such as adaptations to culture, preferences,
religion/spirituality, reactance level, and stage of change. The outcome
research generally shows stronger effect sizes for these transdiagnostic
adaptations or responsiveness than to specific disorders (Norcross &
Wampold, 2019). In all cases, the point is to improve success by fitting or
personalizing psychotherapy to the individual client.

Theoretical Integration
In the theoretical integration form of synthesis, two or more therapies are
integrated in the hope that the result will be better than the constituent
therapies alone. As the name implies, there is an emphasis placed on
integrating the underlying theories of psychotherapy (“theory smushing”)
along with the integration of therapy techniques from each (“technique
melding”). Proposals to integrate psychoanalytic and behavioral theories
illustrate this direction, most notably the cyclical psychodynamics of
Wachtel (1977, 1987; Wachtel & Gagnon, Chapter 9, this volume), as do
efforts to blend cognitive and psychoanalytic therapies, notably Ryle’s
(1990, 2001) cognitive-analytic therapy.
 Grander schemes have been advanced to meld most of the major systems
of psychotherapy, such as the transtheoretical approach of Prochaska and
DiClemente (1984, Chapter 8). Even more ambitious are proposals for a
unified psychotherapy (Magnavita, 2012;
www.unifiedpsychotherapyproject.org), which seeks to integrate all of
psychotherapy and the clinical sciences. Such unifications claim that they
would leave behind the pre-paradigmatic past of traditional theoretical
orientations to explain many features of psychopathology and
psychotherapy; instead, psychotherapy would graduate to a paradigmatic
clinical science (Melchert, 2016).
Theoretical integration involves a commitment to a conceptual or
theoretical creation beyond a technical blend of methods. The goal is to
create a conceptual framework that synthesizes the best elements of two or
more approaches to therapy. Integration aspires to more than a simple
combination; it seeks an emergent theory that is more than the sum of its
parts and that leads to new directions for practice and research. The
rationale is that such integrative treatments may prove more effective
because they are more adaptable to different types of patients, address client
functioning in multiple ways or levels, or are more comprehensive than
single-theory therapies (Wampold, 2005).
TABLE 1.1 Eclecticism versus integration
Eclecticism Integration
Technical Theoretical
Divergent (differences) Convergent (commonalities)
Choosing from many Combining many
Applying what is; collection Creating something new; blend
Applying the parts Unifying the parts
Atheoretical but empirical More theoretical than empirical
Sum of parts More than sum of parts
Realistic Idealistic

The preponderance of professional contention resides in the distinction

between theoretical integration and technical eclecticism. How do they
differ? Which is the more fruitful strategy for knowledge acquisition and
clinical practice? Table 1.1 summarizes the consensual distinctions between
integration and eclecticism. The primary distinction is that between
empirical pragmatism and theoretical flexibility. Integration refers to a
commitment to a conceptual or theoretical creation beyond eclecticism’s
pragmatic blending of procedures, or, to take a culinary metaphor (cited in
Norcross & Napolitano, 1986, p. 253): “The eclectic selects among several
dishes to constitute a meal, the integrationist creates new dishes by
combining different ingredients.”
A corollary to this distinction, rooted in theoretical integration’s earlier
stage of development, is that current practice is largely eclectic; theory
integration represents a promissory note for the future. In the words of
Wachtel (1991, p. 44):
The habits and boundaries associated with the various schools are hard to eclipse, and for most
of us integration remains more a goal than a daily reality. Eclecticism in practice and integration
in aspiration is an accurate description of what most of us in the integrative movement do much
of the time.

Common Factors
The common factors approach seeks to determine the core ingredients of
change that different therapies share in common, with the eventual goal of
creating more parsimonious and efficacious treatments based on those
commonalities. This search is predicated on the belief that the
commonalities are more important in accounting for therapy success than
the unique factors that differentiate among them. The long considered
“noise” in psychotherapy research is now considered by many as the main
“signal” elements of treatment (Omer & London, 1988). The work of
Jerome Frank (1973; Frank & Frank, 1993), Bruce Wampold (2010;
Wampold & Imel, 2015; Wampold & Ulvenes, Chapter 3), and Scott Miller
and colleagues (Hubble, Duncan, & Miller, 1999; Maeschalck, Prescott, &
Miller, Chapter 5, this volume) have been among the most important
contributions to this approach.
Commonalities may be expressed in terms of essential components of
psychotherapy, such as the therapeutic relationship and an active client, or
in terms of common principles of change. In this volume, such a change
principle approach is presented by Eubanks and Goldfried (Chapter 4) and,
to a lesser extent, by Consoli and Beutler (Chapter 7).
In his classic Persuasion and Healing, Frank (1973) posited that all
psychotherapeutic methods are elaborations and variations of age-old
procedures of psychological healing. The features that distinguish
psychotherapies from each other, however, receive special emphasis in
pluralistic, competitive American society. Because the prestige and
financial security of psychotherapists hinge on their ability to show that
their particular approach is more successful than that of their rivals, little
glory has traditionally been accorded the identification of shared or
common components. It is a familiar rendition of the “tragedy of the
commons”—all therapy systems “own” the pantheoretical commonalties
but few care for and tout them.
One means of determining common therapeutic principles is to focus on
a level of abstraction somewhere between theory and technique. This
intermediate level of abstraction, known as a clinical strategy or a change
principle, may be thought of as a heuristic that implicitly guides the efforts
of experienced therapists. Goldfried (1980, p. 996, italics in original) argues
that
[t]o the extent that clinicians of varying orientations are able to arrive at a common set of
strategies, it is likely that what emerges will consist of robust phenomena, as they have managed
to survive the distortions imposed by the therapists’ varying theoretical biases.

In specifying what is common across disparate orientations, we may also

be selecting what works best among them, be they common factors or
change principles.

Assimilative Integration
This form of integration entails a firm grounding in one system of
psychotherapy but with a willingness to selectively incorporate (assimilate)
practices and views from other systems (Messer, 1992). In doing so,
assimilative integration combines the advantages of a single, coherent
theoretical system with the flexibility of a broader range of technical
interventions from multiple systems. A cognitive-behavior therapist, for
example, might use the Gestalt two-chair dialogue in a course of treatment
focusing on the reevaluation of distorted thinking and maladaptive
behavior. In addition to Messer’s (1992, 2001) original explication of it,
exemplars of assimilative integration are Gold and Stricker’s assimilative
psychodynamic therapy (Stricker & Gold, 1996, Chapter 10, this volume),
Castonguay and associates’ (Castonguay, Newman, & Grosse Holtforth,
Chapter 11, this volume) cognitive-behavioral assimilative therapy, and
Safran’s (1998; Safran & Segal, 1990) interpersonal and cognitive
assimilative therapies.
Assimilative integration may well prove more efficacious than its single-
theory base by virtue of combining fidelity with flexibility. Fidelity to a
theoretically cohesive, empirically informed treatment promises that
psychotherapy “works” but not necessarily with that particular client in that
particular context. Flexibility to the patient’s preferences, values, and
cultures promises that psychotherapy “fits” but not necessarily with
research support or conceptual cohesiveness. Borrowing from other systems
on occasion can capitalize on both fidelity and flexibility and can produce
the optimal balance for many practitioners.
To its proponents, assimilative integration represents a realistic
waystation to a sophisticated integration; to its detractors, it is more of a
delayed half-way station for those unwilling to commit to a full integration.
Both camps agree that assimilation is a tentative step toward an ambitious
integration: most therapists have been trained in a single approach, and
most therapists gradually incorporate parts and methods of other approaches
once they discover the limitations of their original approach. The odysseys
of seasoned psychotherapists (e.g., Dryden & Spurling, 1989; Goldfried,
2001; Karasu, 2016) suggest that this is how therapists modify their clinical
practice and expand their clinical repertoire. Therapists do not discard
original ideas and practices but rather rework them, augment them, and cast
them all in new form. They gradually, inevitably integrate new methods into
their home theory (and life experiences) to formulate the most effective
approach to the needs of patients.
In clinical work, the distinctions among these four routes to
psychotherapy integration are not so apparent. The distinctions may largely
prove semantic and conceptual, not particularly functional, in practice. Few
clients experiencing an “integrative” therapy would likely distinguish
among them (Norcross & Arkowitz, 1992).
Moreover, these integrative strategies are not mutually exclusive. No
technical eclectic can totally disregard theory, and no theoretical
integrationist can ignore technique. Pluralistic psychotherapy (Cooper &
McLeod, 2011), to take a prominent example from the United Kingdom,
blends the technical eclectic (use the method that works), theoretical
integrative (use a combination of theories), and common factors (use
powerful pantheoretical elements, especially the relationship) pathways.
Systematic treatment selection and the transtheoretical model, to take
prominent examples from the United States, match the individual patient to
a particular treatment by stage of change, reactance level, or coping level
(in the eclectic tradition) while simultaneously emphasizing change
principles (in the common processes/factors tradition).
Without some commonalities among different schools of therapy,
theoretical integration would prove impossible. Assimilative integrationists
and technical eclectics both believe that synthesis should occur at the level
of practice, as opposed to theory, by incorporating therapeutic procedures
from multiple schools. And even the most ardent proponent of common
factors cannot practice “nonspecifically” or “commonly”; specific
techniques must be applied.

DEFINING THE PARAMETERS OF INTEGRATION

By common decree, technical eclecticism, common factors, theoretical
integration, and assimilative integration are all assuredly part of the
integration movement. However, where are the lines to be drawn—if drawn
at all—concerning the boundaries of psychotherapy integration?
What about the combination of therapy formats—individual, couples,
family, group—and the combination of medication and psychotherapy? In
both cases, a strong majority of clinicians—80% plus—consider these to be
within the legitimate boundaries of psychotherapy integration (Norcross &
Napolitano, 1986). Of course, the inclusion of psychopharmacology
enlarges the scope to integrative or combination treatment rather than
integrative psychotherapy per se.
Two recent thrusts proposed as parts of psychotherapy integration are the
infusion of multicultural theory and self-help resources into clinical
practice. These are receiving increased attention in the literature and in this
Handbook (see Harris, Shukla, & Ivey, Chapter 15; Edwards-Stewart &
Norcross, Chapter 17) but probably less so in daily clinical practice. It
routinely takes several years for new developments to be widely practiced
in the field.
The integration movement as a whole, and SEPI in particular, is
embracing the synthesis of research and practice in addition to the blending
of diverse schools of psychotherapy. Integration appears well positioned to
narrow the infamous practice–research gap and to facilitate their mutual
enrichment. This third edition again features a chapter on outcome research
on psychotherapy integration (Boswell, Newman, & McGinn, Chapter 19)
and, for the first time, a chapter on integrating research and practice
(Castonguay, Constantino, & Xiao, Chapter 20).
Psychotherapy integration, like other maturing movements, is frequently
characterized in a multitude of confusing manners. One routinely
encounters references in the literature and in the classroom to integrating
spirituality and psychotherapy, integrating Occidental and Oriental
perspectives, integrating social justice with psychotherapy, and so on. All
are indeed laudable pursuits, but we restrict ourselves in this volume to the
two meanings of integration as the blending of diverse theoretical
orientations and the synthesis of research and practice.

VARIETIES OF INTEGRATIVE EXPERIENCE

Integration, as is now clear, comes in many guises and manifestations. It is
clearly neither a monolithic entity nor a single operationalized system; to
refer to the integrative therapy is to fall prey to the “uniformity myth”
(Kiesler, 1966). The twin goals of this section are to explicate the immense
heterogeneity of the psychotherapy integration movement and to review
studies on self-identified integrative therapists.

Prevalence of Integration
Approximately one-quarter to one-half of contemporary American
clinicians disavow an affiliation with a particular school of therapy and
prefer instead the label of integrative or eclectic. Some variant of
integration is routinely the modal orientation of responding
psychotherapists. Reviewing 25 studies performed in the United States
between 1953 and 1990, Jensen et al. (1990) reported a range from 19% to
68%, the latter high figure being their own finding. It is difficult to explain
these variations in percentages, but differences in the organizations sampled
and in the methodology used to assess theoretical orientations account for
some of the variability (see Arnkoff, 1995; Poznanski & McLennan, 1995).
TABLE 1.2 English-language studies published in the past decade reporting prevalence of the
integrative orientation
Authors Year Response Sample Countries Professional Point Prevalence of
Published Rate (%) Size Discipline Integrative/Eclectic
(%)
Bike, 2009 33 232 United Counselors 40
Norcross, and States
Schatz
34 234 Social workers 39
37 261 Psychologists 35
Cassin et al. 2007 NR 498 United Graduate students
States in
Clinical 25
psychology
Counseling 27
psychology
Garland et al. 2010 80 96 United Child therapists 25
States
Goodyear et 2016 28 253 Australia Counselling 46
al. psychologists
36 81 Canada 40
NR 47 New 35
Zealand
NR 225 South 22
Africa
NR 398 South 47
Korea
NR 124 Taiwan 37
NR 144 United 47
Kingdom
NR 347 United 31
States
McClure et 2005 35 279 United Counselors 30
al. States psychologists
(TX)
31
Norcross and 2012 46 488 United Clinical 22
Karpiak States psychologists
Norcross and 2013 43 428 United Primarily 25
Rogan States psychologists
Rihacek and 2017 NR 373 Czech Multiple 33
Roubel Republic
Thoma and 2009 18 209 United Multiple 26
Cecero States
Vasco 2008 22 186 Portugal Psychologists, 18
psychiatrists and
others
 More recent studies confirm and extend these results. Table 1.2
summarizes the prevalence of integration found in 10 English-language
studies published during the past decade. The frequency of integration as a
discrete orientation ranged from a low of 18% to a high of 47% in these
studies. The findings make it clear that integration is the most common or
modal orientation in most studies, but not the majority orientation, as is
occasionally (and erroneously) argued.
Integration is not restricted to members of general or secular
psychotherapy organizations. Older surveys of dues-paying members of
orientation-specific organizations—both behavioral (Association for
Advancement of Behavior Therapy) and humanistic (APA Division of
Humanistic Psychology) associations—reveal sizable proportions who
endorse an eclectic orientation; 42% in the former and 31% in the latter
(Norcross & Wogan, 1983; Swan, 1979).
At the same time, cognitive-behavioral therapy (CBT) is rapidly
challenging integration for the modal theory, at least in the United States.
CBT lags only a few percentage points behind integration in several studies
or actually supersedes it in other studies. Given that CBT is the most
popular theoretical orientation of core faculty in US training programs
(Norcross et al., 2018), CBT will rival integration as the modal orientation
in the future as well.
The studies reviewed so far have directly ascertained the prevalence of
integration by therapist endorsement of a discrete orientation from a given
list. It can also be gleaned indirectly by therapist endorsement of multiple
orientations. For example, among UK counselors, 85–87% did not take a
pure-form approach to psychotherapy (Hollanders & McLeod, 1999).
Among clinical psychologists in the United States, for another example,
fully 92% of psychologists embraced several orientations (Norcross &
Karpiak, 2012). In a study of New Zealand psychologists, for a final
example, 86% indicated that they used multiple theoretical orientations in
the practice of psychotherapy (Kazantis & Deane, 1998). Indeed, very few
therapists adhere tenaciously to a single therapeutic tradition.
The results of the massive collaborative study of the Society for
Psychotherapy Research (SPR) bear this out dramatically (Orlinsky &
Rønnestad, 2005). Nearly 5,000 psychotherapists from 20 countries
completed a detailed questionnaire, including questions on theoretical
orientations. Orientations were assessed from therapist responses to the
question “How much is your current therapeutic practice guided by each of
the following theoretical frameworks?” Responses were made to six
orientations on a 0–5 scale. Twelve percent of the psychotherapists were
uncommitted in that they rated no orientations as 4 or 5; 46% were focally
committed to a single orientation (rating of 4 or 5); 26% were jointly
committed; and 15% were broadly committed, operationally defined as
three or more orientations rated 4 or 5. As the authors conclude (Orlinsky et
al., 1999, p. 140), “While there is a substantial group whose theoretical
orientations are relatively pure, they are a minority in the present data
base.” The results point to “a rather extensive amount of eclecticism”
(Orlinsky & Rønnestad, 2005, p. 29).
A related method of determining the relative mix is to have participants
assign percentages on how much a given theoretical orientation comprises
their total approach. One study of 2,156 psychotherapists using this method
found that only 2% identified themselves completely with a single
orientation by rating it 100% (Cook, Biyanova, Elhai, Schnurr, & Coyne,
2010). Few therapists proved purists; 98% were non–pure form.
The research or measurement method strongly influences the resulting
prevalence of integration. A creative study of 373 Czech therapists
employed four different methods of identifying an “integrative” therapist.
The corresponding percentages ranged from 22% to 99%: 22% integrative
by formal training, 33% integrative by endorsement of multiple orientations
as a 4 or 5 on a scale from 0–5, 88% integrative by endorsement of the
multiple orientations as 2–5 on the same scale, and 99% integrative by use
of techniques from several orientations (Rihacek & Roubal, 2017).
Likewise, in a study of Portuguese therapists (Vasco, 2001), the
prevalence of integration varied widely depending on the way integration is
defined. There was a value of 18% when using a demanding criterion:
choosing values above 3 (on a 0–5 scale) simultaneously for two or more
orientations (“same family” orientations were not considered; e.g.,
cognitive and behavioral). If the criterion was not so demanding, as in
rating more than one orientation, the value rose to about 80%! These results
exemplify how the measurement method produces dramatic differences in
the reported popularity of psychotherapy integration.
The prevalence of integration in countries outside North America (see
Gómez, Iwakabe, & Vaz, Chapter 21) also seems to be steadily rising. The
surveys of psychotherapists reviewed in the international chapter show that
integrative psychotherapy is widely endorsed and used across the globe. It
is no longer restricted to the United States and Western Europe. In many
countries, the integration movement gave rise to a great diversity of models,
in many cases within their own training programs.
These multiple methods of determining the prevalence of integration fuel
debate on whether certain brand name therapies can be rightfully called
integrative. CBT is explicitly a hybrid of two approaches, but not all would
characterize it as integrative. If one adds acceptance and mindfulness
approaches to CBT, such as in dialectical behavior therapy (Heard &
Linehan, Chapter 12), then the boundary into integration seems to have
been crossed. The clinical reality is that most theories did not spring de
novo from Zeus’s head: they inevitably represent assimilation of previous
theories. Emotion-focused couples therapy is a case in point; it proclaims
itself an amalgam of experiential, systemic, person-centered, relational, and
attachment theories (Greenberg & Johnson, 2010). Although integration’s
measurement and boundary permeability may occasionally prove
confusing, it does illustrate the inevitable thrust toward sophisticated
integration.

Integrative Therapists
With such large proportions of psychotherapists embracing integration, it
would prove informative to identify their distinctive characteristics or
attitudes. Demographically, there do not appear to be any consistent
differences between the two groups, with the exception of clinical
experience in several older studies (Norcross & Prochaska, 1982; Norcross
& Wogan, 1983; Smith, 1982; Walton, 1978). Clinicians ascribing to
integration or eclecticism tended to be older and, concomitantly, more
experienced. Inexperienced therapists are more likely to endorse exclusive
theoretical orientations. Several empirical studies have suggested that
reliance on one theory and a few techniques may be the product of
inexperience or, conversely, that with experience comes diversity and
resourcefulness (see reviews by Auerbach & Johnson, 1977; Beutler,
Machado, & Neufeldt, 1994). In more recent studies (e.g., Mullins et al.,
2003; Norcross et al., 2004), the age and experience differential of eclectics
has disappeared, probably owing to the fact that a greater percentage of
psychotherapists are being explicitly trained as integrationists in graduate
school.
Attitudinally, integrative or eclectic clinicians differ from their
nonintegrative colleagues in at least two respects. First, eclectics report
greater dissatisfaction with their current conceptual frameworks and
technical procedures (Norcross & Prochaska, 1983; Norcross & Wogan,
1983; Vasco, Garcia-Marques, & Dryden, 1992). This increased
dissatisfaction may serve as an impetus to create an integrative approach, or
it may have resulted from the elevated expectations that integration has
engendered. Second, practitioners seem to embrace integration more
frequently than academic and training faculty (Friedling, Goldfried, &
Stricker, 1984; Norcross et al., 2004; Tyler & Clark, 1987). Integrationists
are more involved in conducting psychotherapy than are their pure-form
colleagues.
From a personal-historical perspective, Robertson (1979) identified six
factors that may facilitate the choice of eclecticism. The first is the lack of
pressures in training and professional environments to bend to a doctrinaire
position. Also included here would be the absence of a charismatic figure to
emulate. A second factor, which we have already discussed, is length of
clinical experience. As therapists encounter heterogeneous clients and
problems over time, they may be more likely to reject a single theory. A
third factor is the extent to which doing psychotherapy is making a living or
reflecting a philosophy of life; Robertson asserts that integration is more
likely to follow the former, consistent with the research reviewed earlier. In
the words of several distinguished scientist-practitioners (Ricks,
Wandersman, & Poppen, 1976, p. 401):
So long as we stay out of the day to day work of psychotherapy, in the quiet of the study or
library, it is easy to think of psychotherapists as exponents of competing schools. When we
actually participate in psychotherapy, or observe its complexities, it loses this specious
simplicity.

The remaining three factors underlying why some therapists are

integrative seem to be personality variables: an obsessive-compulsive drive
to pull together all the interventions of the therapeutic universe, a maverick
temperament to move beyond some theoretical camp, and a skeptical
attitude toward the status quo. Although these factors require further
confirmation, they are supported by our training experiences and the
personal histories of prominent clinicians represented in this volume and
elsewhere (see Chapters 3–14; Goldfried, 2001).

Integrative Practices
Although it is relatively easy to ascertain its self-reported prevalence, it is
much more difficult to determine what “integrative” practice precisely
entails. Far more process research is needed on the conduct of eclectic or
integrative psychotherapies. Such investigations will probably need to make
audio, video, and transcript recordings of the therapy offered in order to
clarify the nature of therapeutic interventions.
Definitions of psychotherapy integration do not tell us what individual
psychotherapists actually do or what it means to be an integrative therapist.
Several studies, however, have attempted to do just that.
In an early survey of psychologists in the United States, Garfield and
Kurtz (1977) discerned 32 different theoretical combinations used by 145
eclectic clinicians. The most popular two-orientation combinations, in
descending order of frequency, were psychoanalytic and learning theory,
neo-Freudian and learning theory, neo-Freudian and Rogerian theory,
learning theory and humanistic theory, and Rogerian and learning theory.
Most combinations were blended and employed in an idiosyncratic fashion.
The investigators concluded that the designation of “eclectic” covers a wide
range of views, some of which are quite distinct from others.
Replications of the seminal Garfield and Kurtz study in 1988 and again
in 2004 enlarged and updated the findings. In the most recent study
(Norcross et al., 2004), exactly one-half of the 187 self-identified
eclectic/integrative psychologists adhered to a specific theoretical
orientation before becoming explicitly integrative. This 50% is similar to
the two previous studies in which 58% (Norcross & Prochaska, 1988) and
49% (Garfield & Kurtz, 1977) had previously adhered to a single
orientation. The previous theoretical orientations were varied but were
principally psychodynamic (41%), cognitive (19%), and behavioral (11%).
Thus, as with the earlier findings and other studies (e.g., Jayaratne, 1982;
Jensen et al., 1990), the largest shift continues to occur from the
psychodynamic and psychoanalytic persuasions and the next largest from
the cognitive and behavioral traditions.
TABLE 1.3 Most frequent combinations of theoretical orientations among eclectic and integrative
psychologists in the United States
Combination 1976 1985 2004
% Rank % Rank % Rank
Behavioral and cognitive 5 4 12 1 16 1
Cognitive and humanistic NR 11 2 7 2 (Tie)
Cognitive and psychoanalytic NR 10 3 7 2 (Tie)
Cognitive and interpersonal NR <4 12 6 4 (Tie)
Cognitive and systems NR <4 14 6 4 (Tie)
Humanistic and interpersonal 3 6 8 4 (Tie) 5 6
Interpersonal and systems NR 5 7 (Tie) 4 7
Psychoanalytic and systems NR 4 9 (Tie) 3 8 (Tie)
Interpersonal and psychoanalytic NR <4 15 3 8 (Tie)
Behavioral and interpersonal NR <4 13 2 10
Behavioral and systems NR 5 7 (Tie) 2 11 (Tie)
Humanistic and psychoanalytic NR <4 12 2 11 (Tie)
Behavioral and humanistic 11 3 8 4 (Tie) 1 13 (Tie)
Behavioral and psychoanalytic 25 1 4 9 (Tie) >1 14 (Tie)
Humanistic and systems NR 6 6 >1 14 (Tie)
NR, not reported.
a
Percentages and ranks were not reported for all combinations in the 1976 study (Garfield & Kurtz,
1977).

Integrative psychologists rated the frequency of the use of six major

theories (behavioral, cognitive, humanistic, interpersonal, psychoanalytic,
and systems, and “other”) in their practice. To permit historical comparisons
with the earlier studies, we examined the individual ratings to determine the
most widely used combinations of two theories. The most frequent
combinations of theoretical orientations constituting eclectic/integrative
practice are summarized in Table 1.3. All 15 possible combinations of the
six theories presented were endorsed by at least one self-identified
eclectic/integrationist. As seen in the table, cognitive therapy predominates;
in combination with another therapy system, it occupies the first 5 of the 15
combinations and accounts for 42% of the combinations. Put differently,
cognitive therapy is the most frequently and most heavily used contributor
to an integrative practice, at least in the United States.
Over time, the behavioral and psychoanalytic combination as well as the
behavioral and humanistic combination have slipped considerably. They
have gradually dropped from the first and third most frequently combined
theories in 1977 to the ninth and fourth in 1988 and now to thirteenth and
fourteenth in 2004. The behavioral and psychoanalytic hybrid—accounting
for 25% of the combinations in the 1970s and only 1% on the 2000s—has
firmly been replaced by cognitive hybrids.
This study and other research demonstrate a preference for both the term
“integration” and the practice of theoretical or assimilative integration, as
opposed to technical eclecticism. Fully 59% preferred the term
“integrative” compared to 20% who favored “eclecticism.” This preference
for integration over eclecticism represents a historical shift. There seems to
have been a theoretical progression analogous to social progression, one
that proceeds from segregation to desegregation to integration. Eclecticism
represented desegregation, in which ideas, methods, and people from
diverse theoretical backgrounds mix and intermingle. We have now
transitioned from desegregation to integration, with increasing efforts
directed at discovering viable integrative principles for assimilating and
accommodating the best that different systems have to offer.
Sophisticated integrative practice obviously is more complex than these
survey glimpses can provide. To echo the authors of the original study,
“Some value psychodynamic views more than others, some favor Rogerian
and humanistic views, others clearly value learning theory, and various
combinations of these are used in apparently different situations by different
clinicians” (Garfield & Kurtz, 1977, p. 83). However, eclecticism has
gradually lost some of its negative definition as a nondescript brand name
for those dissatisfied with orthodox schoolism. Instead, these clinicians
actively and positively endorsed eclecticism/integration as much for what it
offers as for what it avoids. When asked if they considered
eclecticism/integration the absence of a theoretical orientation or the
endorsement of a broader one in its own right (or both), the vast majority of
eclectics—85%—conceptualized it as the endorsement of a broader
orientation (Norcross et al., 2004). In other words, integration “by design”
is steadily replacing eclecticism “by default.”
A host of studies have asked psychotherapists of diverse orientations to
self-report their in-session activities. Integrative or eclectic therapists
typically evidence a more comprehensive or balanced profile of therapeutic
activity than their single-system colleagues. In one early study, for example,
on 13 scales of therapeutic activity, reported therapy interventions varied as
a function of the therapist’s orientation. Eclectics had either the highest or
second-highest mean scores on each of the 13 scales, indicating a varied
therapeutic arsenal (Wogan & Norcross, 1985). In a more recent study, 24
psychotherapists who were experts in psychotherapy integration completed
a 100-item psychotherapy process Q sort. The findings demonstrated a
diversity of theoretical influences and self-reported practices among the
experts (Hickman et al., 2009). Indeed, that is what self-report study after
study reveals: psychotherapists use a substantial number of techniques from
outside their respective orientations (Thoma & Cecero, 2009).
Several studies have progressed past self-report to what integrative
psychotherapists actually do in their sessions. Ratings of videotaped
demonstration sessions of nine psychotherapy experts from different
therapeutic orientations and from different generations were examined to
determine the extent of integration (Solomonov et al., 2016). Psychotherapy
integration was observed in all the demonstration sessions, with experts
blending techniques from other approaches, especially within their own
family of theories.
Another study of actual in-session behavior analyzed 34 sessions from
the APA Psychotherapy Videotape Series (Norcross & VandenBos, 2011).
The integrative therapists utilized significantly more cognitive-behavioral
techniques than the psychodynamic-relational therapists, and significantly
more psychodynamic-interpersonal techniques than the cognitive-
behavioral therapists (Pitman et al., 2017). Both self-report and actual
behaviors of integrative practitioners suggest a wider clinical repertoire and
probably more responsiveness to the needs of the individual patient and the
specific session.

The Journey to Integration

Werner’s (1948; Werner & Kaplan, 1963) organismic-developmental theory
is instructive for conceptualizing psychotherapists’ development of a
sophisticated integrative stance. In the first of three developmental stages,
one perceives or experiences a global whole, with no clear distinctions
among component parts. Unsophisticated laypersons and undergraduates
probably fall into this category.
In the second stage, one perceives or experiences differentiation of the
whole into parts, with a more precise and distinct perspective of
components within the whole. However, one no longer has a perspective on
the whole and subsequently loses the big picture. Most psychotherapy
courses, textbooks, and clinically inexperienced practitioners fall into this
category.
In the third stage, the differentiated parts are organized and integrated
into the whole at a higher level. Here, the unity and complexity of
psychotherapy are appreciated. It is to this level, we believe, that
psychotherapy should aspire.
Several studies have examined the process by which psychotherapists
arrive at an integrative orientation. In one study (Rihacek & Danelova,
2016), researchers analyzed 22 autobiographies published by integrative
psychotherapists; in another study (Rihacek et al., 2012), the same
researchers conducted interviews with seven experienced practitioners.
Adoption of an integrative perspective was found usually to be a
consequence of developing an autonomous personal therapeutic approach
rooted in congruence with the person of the therapist and perceived efficacy
of the approach. The integrationists typically, but not invariably, progressed
through three stages: adherence (to a particular single-system therapy),
destabilization, and consolidation (in an integrative therapy). The research
findings generally correspond with Werner’s three-stage theory and attest
that, to date, relatively few psychotherapists have been trained from the
beginning in a systematic integrative model (Chapter 18).

Role of Pure-Form Therapies

Conspicuously absent from this primer on integration has been
acknowledgment of the conventional, “pure-form” (or brand name) therapy
systems, such as psychoanalytic, CBT, experiential, and systems. Although
it may not be immediately apparent, pure-form therapies are part and parcel
of the integration movement. In fact, integration could not occur without the
constituent elements provided by the respective therapies—their theoretical
systems and clinical methods.
In a narrow sense, pure-form or single-theory therapies do not contribute
to the integration movement because they have not generated paradigms for
synthesizing various interventions and conceptualizations. But, in broader
and more important ways, they add to our therapeutic armamentarium,
enrich our understanding of the clinical process, and produce the process
and outcome research from which integration draws. One cannot integrate
what one does not know.
 In this respect, we should be reminded that the so-called pure-form
psychotherapies are themselves “second-generation” integrations. In factor
analytic terms, virtually all neo-Freudian approaches would be labeled
“second-order” constructs—a superordinate result of analyzing and
combining the original components (therapies). Just as Freud necessarily
incorporated methods and concepts of his time into psychoanalysis
(Frances, 1988), so do newer therapies. All psychotherapies may, therefore,
be viewed as products of an inevitable historical integration—an oscillating
process of assimilation and accommodation (Sollod, 1988).
An appreciation of this historical process can temper the judgmental
flavor frequently expressed toward those who may be antagonistic toward
psychotherapy integration. These antagonistic characterizations—“rigid,”
“inveterate,” “narrow,” “close-minded,” for instance—are likely to result in
a win-lose, zero-sum encounter in which the integrative “good guys” seek
victory over the separatist “bad guys.” Such an attitude will do little to
promote a welcoming attitude toward integration on the part of the
“opposition” and even less to build on the documented successes of pure-
form therapies. The objective of the integration movement, as we have
repeatedly emphasized, is to improve the effectiveness of psychotherapy. To
obtain this end, the valuable contributions of pure-form therapies must be
collegially acknowledged and their respective strengths collaboratively
enlisted.

OBSTACLES TO INTEGRATION
Enthusiasts of psychotherapy integration have not always seriously
considered its potential obstacles and tradeoffs. If we are to avoid uncritical
growth in integrative psychotherapy, then some honest recognition of the
barriers we are likely to encounter is sorely needed. Caught up in the
excitement and potential of the movement, we have neglected the problems
—the “X-rated topics” of integration. Healthy maturation, be it for
individuals or for movements, requires self-awareness and constructive
criticism.
What is stopping psychotherapy integration from progressing? Survey
research of prominent integrationists (e.g., Norcross & Thomas, 1988),
special journal sections (e.g., Norcross & Goldfried, 2005), chapters in this
Handbook, and contributors to the Journal of Psychotherapy Integration
converge in highlighting several obstacles.
Probably the most severe obstruction centers on the partisan zealotry and
territorial interests of “pure” systems psychotherapists. Representative
responses in the survey research (Norcross & Thomas, 1988) were
“egocentric, self-centered colleagues,” “the institutionalization of schools,”
and “ideological warfare, factional rivalry.” A recent study of Brazilian
therapists from closely related schools of psychotherapy (gestalt and
psychodrama) found that both schools employed an adversarial attitude and
depreciated their “neighboring” school (Vieira & Vandenberghe, 2016).
Understanding and overcoming resistance to integration must first consider
the dynamics of in-group and out-group tribalism.
Unfortunately, professional reputations are made by emphasizing the new
and different, not the basic and similar. “One’s career is advanced by
making history, not knowing it” (Goldfried, 2011, p. 324). In
psychotherapy, as well as in other scientific disciplines, there is far too
much emphasis on the ownership of ideas. Although the idea of naturally
occurring, cooperative efforts among professionals is engaging, their
behavior, realistically, may be expected to reflect the competition so
characteristic of our society at large (Goldfried, 1980).
Inadequate training in integrative therapy is another recurrent
impediment. Training students to competence in multiple theories and
interventions is unprecedented in the history of psychotherapy.
Understandable in light of its exacting nature, the acquisition of integrative
perspectives has occurred quite idiosyncratically and perhaps
serendipitously to date (Norcross & Finnerty, Chapter 18). Designing an
integrative training program is an arduous task; gathering support for such a
program from all faculty members is probably even more intimidating.
A third obstacle concerns differences in ontological and epistemological
issues. These entail basic and sometimes contradictory assumptions about
human nature, determinants of personality development, and the origins of
psychopathology (Messer, 1992). For instance, are people innately good,
evil, both, or neither? Do phobias represent learned maladaptive habits,
intrapsychic conflicts, both, or neither? Is the primary purpose of
psychotherapy to facilitate insight, restructure relationships, modify overt
behavior, or promote self-actualization? Interestingly enough, it may be
precisely these diverse worldviews that make psychotherapy integration
interesting, in that it brings together the individual strengths of these
complementary orientations. Profound epistemological and ontological
differences impede rapid or wholesale integration (Allport, 1968). But even
here, most antagonists believe the movement “deserves a fair hearing and a
substantial trial” (Messer, 1983, p. 132).
Another obstacle to a consensually supported integration—widely
discussed in the 1990s but not lately—is the absence of a common
language. Each psychotherapeutic tradition has its own jargon, a clinical
shorthand among its adherents, which widens the chasm between differing
orientations. The language problem, as it has become known, confounds
understanding and, in some cases, leads to active avoidance of each other’s
constructs. Many a cognitive-behaviorist’s mind has wandered when case
discussions turn to “transference issues” and “warded-off conflicts.”
Similarly, psychodynamic therapists typically tune out buzzwords like
“conditioning procedures” and “discriminative stimuli.” Isolated language
systems encourage clinicians to wrap themselves in semantic cocoons from
which they cannot escape and which others cannot penetrate.
Before an agreement or a disagreement can be reached on a given matter,
it is necessary to ensure that the same phenomenon is, in fact, being
discussed. Punitive superego, negative self-statements, and poor self-image
may indeed prove similar phenomena, but that cannot be known with
certainty until the constructs are defined operationally and consensually.
Without a common language, the field resembles a Tower of Babel (Messer,
1987).
In the short run, using the vernacular—descriptive, ordinary, natural
language—might suffice (Driscoll, 1987). One metaphor for a common
metalanguage is the lingua franca that grows up in marketplaces, where
communication among people of many cultures and languages is honed
down to the essentials needed for transacting essential business (Andrews,
1989). In the long run, the field of psychotherapy probably needs a
language system that is tied to a database. Such an evidence-based common
language may hail from cognitive psychology or interpersonal psychology.
In the meantime, while the field decides whether and how it will implement
a common language, there is much to be learned by becoming fluent in a
number of current theoretical languages. Messer (1992) argues that in “this
way, we can better appreciate the concepts, ideology, and terms of other
viewpoints. This will surely lead to the permeation of ideas from one theory
to another” (p. 198).
Then there is the glaring obstacle of differential efficacy: What is to be
gained from integration in an era of evidence-based practice? Where is the
hard proof of integration’s incremental effectiveness vis-à-vis established
single-system treatments? (Wampold, 2005). Reviews of the outcome
research (Boswell, McGinn, & Newman, Chapter 19) indicate that at least
30 explicitly integrative therapies have been subjected to rigorous
controlled research. The results consistently and persuasively attest to their
safety, feasibility, and effectiveness. Several integrative therapies, including
the stage-matching of the transtheoretical approach (Chapter 8) and the
person-matching of systematic treatment selection (Chapter 7), have
repeatedly proved superior in efficacy or applicability to single-system
therapies. Most of the other integrative models featured in this volume
prove promising or are in the early phases of comparison to pure-form
therapies, so the jury is still out on whether they prove equivalent or
superior.
Controlled outcome research is only one form of research evidence, of
course, and other research traditions point to the clinical value of
psychotherapy integration. To the extent that an advantage of integrative
approaches is that they intentionally emphasize common factors, then the
meta-analytic evidence on the curative power of the therapeutic relationship
is supportive indeed (Norcross & Lambert, 2019). To the extent that
integrative treatments are more adaptable or responsive to a greater number
of patients, then other meta-analyses favor the integrative path. For
example, a meta-analysis of 587 studies on psychotherapy dropout found
that integrative therapies experienced the lowest rates (Swift & Greenberg,
2014). Phrased positively, integrative was the most robust model for
retaining clients of all other therapy approaches for 11 out of the 12
disorders examined. Or, for another example, integrative therapists have
pioneered the clinical use of research-supported treatment adaptations (or
responsiveness) to individual patients. Meta-analyses indicate that tailoring
therapy to the patient’s transdiagnostic characteristics (e.g., culture,
religion, preferences, coping style, reactance level, stage of change)
demonstrably improves patient outcomes compared to nonadapted
treatments (Norcross & Wampold, 2019). In short, psychotherapy
integration is supported by decades of both clinical experience and research
evidence.
A final obstacle to be addressed here is the challenge of continually
expanding integrative therapies to incorporate newer elements and clientele.
Early eclectic therapies needed to be revamped to include family systems,
feminist, and cognitive therapies, and, in some cases, narrative or
constructivist therapies. Later integrative therapies needed to reckon with
acceptance strategies (as opposed to change strategies) and gender-
nonconforming patients (as opposed to cisgender patients). A contemporary
case in point is multiculturalism. For too long, we have treated patients,
disorders, and their goals outside the context of their cultures. Yet most
integrative therapies have been slow in incorporating a multicultural
dimension. If the integration movement ignores these key additions, the end
point will be insulated, albeit newly packaged versions of psychotherapy
that do not challenge the narrow traditions and that do not address the needs
of the populations we serve.

CONCLUDING COMMENTS
Psychotherapy integration, as presented in this Handbook, is an
intellectually vibrant, clinically popular, demonstrably effective, and
maturing international movement. Integrative perspectives have been
catalytic in the search for new ways of conceptualizing and conducting
psychotherapy that go beyond the confines of single schools. They have
encouraged practitioners and researchers to work together to examine what
other therapies have to offer, particularly when confronted with difficult
cases and therapeutic failures. Rival systems are increasingly viewed not as
adversaries, but as a welcome diversity (Landsman, 1974); not as
contradictory, but as complementary. Transtheoretical dialogue and cross-
fertilization fostered by the integrative spirit are very much the order of the
day. Whether considered a revolutionary paradigm shift or an evolutionary
arc of all sciences, psychotherapy integration will most certainly be a
therapeutic mainstay of the twenty-first century.
Centuries ago, Hegel famously explained the progress of human
knowledge by means of thesis, antithesis, and synthesis. Decades ago,
Rotter (1954, p. 14) summarized the matter as follows: “All systematic
thinking involves the synthesis of pre-existing points of views. It is not a
question of whether or not to be eclectic but of whether or not to be
consistent and systematic.” Integration thus has an illustrious and
established history, now fully established in psychotherapy as well.
At the same time, the ultimate goal of integration to make therapy more
effective has not been realized yet in many of its self-identified
psychotherapies. Most integrative treatments continue to be promulgated in
the absence of any rigorous outcome research. The calls for rapprochement
prove intellectually and clinically appealing, but in an era of accountability
and evidence-based practice, such appeals fall short of the mark unless
accompanied by compelling research attesting to the effectiveness,
efficiency, and applicability of integrative psychotherapies.
Finally, we end the chapter by wondering whether there will be
competition among and proliferation of various schools of integrative
therapy, just as there has been intense competition among “pure-form”
schools. Partisanship among integrative models would largely repeat the
same old historical mistakes of psychotherapy. Integrative therapies could,
ironically, become the rigid and institutionalized perspectives that the
movement attempted to counter in the first place. Rather, our view of—and
hope for—psychotherapy integration is that it will engender an open system
of informed pluralism, deepening rapprochement, and evidence-based
practice, one that leads to improved effectiveness of psychosocial
treatments. The tell-tale sign of a movement’s success is not how long it
lasts, but what it leaves.

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 2

A History of Psychotherapy Integration

MARVIN R. GOLDFRIED, JOHN E. PACHANKIS, AND BRIEN J. GOODWIN

The progress of science is the work of creative minds. Every creative mind that contributes to
scientific advances works, however, with two limitations. It is limited, first, by ignorance, for
one discovery waits upon that other which opens the way for it. Discovery and its acceptance
are, however, limited also by the habits of thought that pertain to the culture of any region and
period, that is to say, by the Zeitgeist: an idea too strange or preposterous to be thought in one
period of Western civilization may be readily accepted as true only a century or two later.
—Edwin G. Boring (1950)

Although the idea of attempting to integrate different therapeutic

approaches met with mixed enthusiasm in the twentieth century, it has
received far greater acceptance in recent years. Indeed, on entering the term
“integrative psychotherapy” to explore available books on the Amazon
website, no fewer than 460 published books appear. Although the term
“integration” might not always accurately reflect attempts to blend diverse
therapies, it nonetheless illustrates that the concept enjoys widespread
acceptance. What follows in this third edition of the Handbook is not a
revision of history, but an update of the status of psychotherapy integration
in the twenty-first century.
As is the case with any attempt to trace the historical origins of
contemporary thought, one never knows for certain the influence that earlier
contributions have had on later thinking. More often than not, as Edwin G.
Boring noted in the epigraph, innovative ideas and findings are initially
ignored only to become assimilated into the mainstream at a later point in
time (Barber, 1961). It is possible that the ultimate contribution of an idea
lies in its consciousness-raising function. Thus, quite apart from their
specific merits, new ideas sensitize us to otherwise neglected areas of
thought. With regard to psychotherapy, some notions have continued to live
on over the years, whereas others have failed to pass the test of time. Still
others disappear after their introduction only to reappear at a later time
when the zeitgeist has become more hospitable. The marked interest in
developing a rapprochement across the psychotherapies dramatically
illustrates the latter phenomenon.
In this chapter, we begin with a historical review of past efforts at
psychotherapy integration, covering in detail the work that has been done
during the twentieth century. We highlight the development of professional
networks and scholarly journals whose purpose is to support continued
work in this area. Finally, we conclude with a brief overview of several key
developments in the twenty-first century.

EARLY ATTEMPTS AT INTEGRATION

In what represented one of the earliest attempts at integrating the
psychotherapies, French delivered an address at the 1932 meeting of the
American Psychiatric Association in which he drew certain parallels
between psychoanalysis and Pavlovian conditioning (e.g., the similarities
between repression and extinction). The following year, the text of French’s
presentation was published, together with comments by members of the
original audience (French, 1933). As one might expect, French’s
presentation resulted in a mixed reaction from his audience. One of the
most unabashedly negative responses acknowledged that
I was tempted to call for a bell-boy and ask him to page John B. Watson, Ivan Pavlov, and
Sigmund Freud, while Dr. French was reading his paper. I think Pavlov would have exploded;
and what would have happened to Watson is scandalous to contemplate, since the whole of his
behavioristic school is founded on the condition reflex . . . Freud . . . would be scandalized by
such a rapprochement made by one of his pupils, reading a paper of this kind. (Meyerson, in
French, 1933, p. 1201)

Adolph Meyer was not nearly as unsympathetic. Although he stated that

the field should encourage separate lines of inquiry and should not attempt
to substitute any one for another too prematurely, Meyer nonetheless
suggested that one should “enjoy the convergences which show in such
discussions as we have had this morning” (French, 1933, p. 1201). Gregory
Zilboorg, who was also in the audience at the time, took an even more
favorable stand, noting that
 I do not believe that these two lines of investigation could be passed over very lightly. . . . There
is here an attempt to point out, regardless of structure and gross pathology, that while dealing
with extremely complex functional units both in the physiological laboratory and in the clinic,
we can yet reduce them to comparatively simple phenomena. (French, 1933, pp. 1198–1199)

It is of significance that French not only proposed a rapprochement between

two seemingly different conceptual orientations, but also highlighted a
possible bridge between clinical practice and research findings.
In an extension of French’s attempts, Kubie (1934) maintained that
certain aspects of psychoanalytic technique itself could be explained in
terms of the conditioned reflex. Noting that Pavlov hypothesized that
certain associations might exist outside of an individual’s awareness
because they took place under a state of inhibition, Kubie suggested that
free association might serve to remove the inhibition and allow such
unconscious association to emerge.
In 1936, Rosenzweig published a brief article in which he argued that the
effectiveness of multiple therapeutic approaches probably had more to do
with their common elements than with their theoretical explanations. In this
article, which had as its subtitle, “At last the Dodo said, ‘Everybody has
won and all must have prizes,’ ” Rosenzweig suggested three common
factors: (1) the therapist’s personality has much to do with the effectiveness
of the change process as it may function to inspire hope in patients or
clients, (2) interpretations are helpful because they provide alternative and
perhaps more plausible ways of understanding a particular problem, and (3)
even though varying theoretical orientations may focus on different aspects
of human functioning, they can all be effective because of the synergistic
effects that one area of functioning may have on another.
At the 1940 meeting of the American Orthopsychiatric Association
(Watson, 1940), a small group of therapists got together to discuss areas of
agreement in psychotherapy. Commenting on the points of commonality
(e.g., the importance of the therapeutic interaction), Watson astutely
observed that “if we were to apply to our colleagues the distinction, so
important with patients, between what they tell us and what they do, we
might find that agreement is greater in practice than in theory” (p. 708).
In his book Active Psychotherapy, Herzberg (1945) described how
systematically prescribed “homework” assignments might be used within
the context of psychodynamic therapy. Anticipating an important behavioral
contribution to the field by more than a decade, Herzberg proposed the use
of graded tasks, particularly in those cases where the clients’ avoidance
behavior was based on anxiety.
Woodworth’s 1948 text, Contemporary Schools of Psychology, explored
the development and substantive content of the then existing schools of
psychological thought, such as behaviorism, gestalt psychology, and the
psychoanalytic schools. He recognized that although each school had made
gains in its own respective chosen direction, “no one [school] is good
enough” (p. 255). Observing that psychology was advancing in many
directions, Woodworth wondered “whether synthesis of the different lines
of advance [might] not sometime prove to be possible” (p. 10).
Close on the heels of this thesis was a landmark work in the history of
psychotherapy integration, namely Dollard and Miller’s Personality and
Psychotherapy, published in 1950 and dedicated to “Freud and Pavlov and
their students.” Although behavior therapists have argued that Dollard and
Miller’s thinking had little impact on the development of behavior therapy,
the fact that the work is continually referenced suggests that it has widely
been read. In their work, Dollard and Miller described in detail how such
psychoanalytic concepts as regression, anxiety, repression, and
displacement can be understood within the framework of learning theory.
For the most part, Dollard and Miller merely translated one language
system into another. Nonetheless, they did point to certain factors that may
well prove common to all therapeutic approaches, such as the need for the
therapist to support an individual’s attempt at changing by expressing
empathy, interest, and approval for such attempts.
Even though Dollard and Miller (1950) stayed fairly close to the
interventions associated with psychoanalytic therapy, they made continual
reference to principles and procedures on which contemporary behavior
therapy is based. Thus, Dollard and Miller suggest the value of modeling
procedures (e.g., “watching a demonstration of the correct response may
enable the student to perform perfectly on the first trial,” pp. 37–38), the
use of hierarchically arranged tasks (e.g., “the ideal of the therapist is to set
up a series of graded situations where the patient can learn,” p. 350),
reinforcement of gradual approximations toward a goal (e.g., “if a long and
complex habit must be learned, the therapist should reward the subunits of
the habit as they occur,” p. 350), the principle of reciprocal inhibition (e.g.,
“like any other response, fear apparently can be inhibited by responses that
are incompatible with it,” p. 74), the significance of the reinforcing
characteristic of the therapist (e.g., “the therapist uses approval to reward
good effort on the part of the patient,” p. 395), the importance of teaching
the individual self-control or coping skills to be used after therapy (e.g., “it
is theoretically possible that special practice in self-study might be given
during the latter part of a course of therapeutic interviews. The patient
might be asked to practice solving particular problems . . . [under
conditions] as similar as possible to those to be used after therapy,” p. 438),
the treatment of orgasmic dysfunctions via masturbation (e.g., “at one point
in a therapeutic sequence, the therapist might have to reward masturbation
so that the patients may experience the sexual orgasm for the first time” p.
350), and the importance of environmental contingencies for maintaining
behavior change (e.g., “the conditions of real life must be favorable if new
responses are to become strong habits,” p. 427).
Unlike Dollard and Miller (1950), whose primary emphasis was on the
integration of two orientations, Frederick Thorne (1950) was interested in
pursuing integration on the basis of what we know empirically about how
people function and change. From the time that he was a medical student,
Thorne was struck by the fact that medicine was not divided up into schools
of thought, but rather that basic principles of bodily functioning guided
clinical practice.
Like Thorne, Garfield has long been interested in an empirically based
approach to therapy, and in 1957 he outlined what appeared to be common
points among the psychotherapies. In an introductory clinical psychology
text, Garfield noted such universal factors as an understanding and
supportive therapist, the opportunity for emotional catharsis, and the
provision of self-understanding.

MORE RECENT TRENDS TOWARD RAPPROCHEMENT

The topic of therapeutic rapprochement was seriously addressed by only a
handful of writers in the 1950s, due, no doubt, to the fact that no single
approach to psychotherapy had yet gained enough momentum to challenge
psychoanalytic therapy. Perhaps it was also the conservative social and
political climate of the 1950s that discouraged therapists from questioning
their paradigms. The 1960s, along with the broad array of societal
challenges that came with them, brought a sharp increase in the number of
books and articles dealing with rapprochement.
The 1960s
Probably the most significant contribution to the integration of
psychotherapies made in the early 1960s was Jerome Frank’s (1961)
Persuasion and Healing. This book addressed itself to commonalities
cutting across attempts at personal influence and healing in general. Similar
change processes, Frank observed, can be seen in such diverse methods as
religious conversion, primitive healing, brainwashing, and the placebo
effects that occur in medicine. When distressed individuals are placed in
any of these contexts, an expectancy for improvement and an arousal of
hope result in a concomitant increase in self-esteem and improved
functioning. Frank continued, in his later writings, to stress common factors
across the psychotherapies, but in one of his later reviews of the field
(Frank, 1979), he also acknowledged that certain clinical problems (e.g.,
fears, phobias, compulsive rituals) may effectively be dealt with by methods
that go beyond the general nature of the therapeutic interaction.
Thirty years after the publication of French’s landmark article, a
colleague of his, Alexander (1963), suggested that psychoanalytic therapy
might profitably be understood in terms of learning theory. Based on an
analysis of tape recordings of psychoanalytic therapy sessions, Alexander
concluded that many of the therapeutic changes that occurred “can best be
understood in terms of learning theory. Particularly the principle of reward
and punishment and also the influence of repetitive experiences can be
clearly recognized” (p. 446). Alexander suggested that “we are witnessing
the beginnings of a most promising integration of psychoanalytic theory
with learning theory, which may lead to unpredictable advances in the
theory and practice of the psychotherapies” (p. 448). A year later, Marmor,
involved in the same program of psychotherapy research, described in detail
the learning principles that he believed to underlie psychoanalytic therapy
(Marmor, 1964).
About this time, Carl Rogers (1963) published an article dealing with the
current status of psychotherapy. He noted that the field was “in a mess” and
that the theoretical orientations within which therapists had typically
functioned were starting to break down. He stated that the field was now
ready to shed itself of the limitations inherent in specific orientations—
including client-centered therapy—and that it was essential to observe more
directly exactly what transpires during the course of psychotherapy.
 London (1964), in a short but insightful book entitled The Modes and
Morals of Psychotherapy, pointed to the inherent limitations associated
with both the psychodynamic and behavioral orientations. He suggested
that
[t]here is a quiet blending of techniques by artful therapists of either school: a blending that
takes account of the fact that people are considerably simpler than the Insight schools give them
credit for, but that they are also more complicated than the Action therapists would like to
believe. (p. 39)

Other clinicians and researchers began comparing and integrating

behavior therapy and psychodynamic procedures. Although acknowledging
their common ground, Marks and Gelder (1966) also underscored certain
differences. They suggested that the two approaches should be viewed as
potentially contributing to each other, rather than necessarily being
antagonistic in nature. Arguing for the integration of learning theory with
psychoanalysis, Wolf (1966) suggested that “their integration is sooner or
later inevitable, however passionately some or many of us may choose to
resist it” (p. 535).
The influential concept of “technical eclecticism” was introduced in 1967
by Arnold Lazarus, who maintained that clinicians could use techniques
from multiple therapeutic systems without necessarily accepting their
theoretical underpinnings. Starting from this pragmatic point of view,
Lazarus maintained that the ultimate standard of utility should rest on
empirical, not theoretical grounds. His views were eventually expanded and
revised into the development of multimodal therapy (Lazarus, 1989;
Lazarus & Lazarus, Chapter 6, this volume).
Appearing in that same year as Lazarus’s landmark paper were several
articles of integrative import. One (Patterson, 1967) outlined divergent and
convergent elements across the psychotherapies; another (Whitehouse,
1967) identified the generic principles underlying therapeutic interventions;
and another (Weitzman, 1967) on how systematic desensitization could
profitably be used within a psychoanalytic context.
Brady (1968), responding to the practical demands of doing actual
clinical work, argued that behavioral and psychodynamic treatments were
not necessarily contradictory in nature but could, in certain cases, be used in
combination. He described the treatment of a preorgasmic woman with
systematic desensitization and short-term psychodynamic therapy focusing
on the woman’s relationship with her husband. Colleagues similarly
described successfully treating anxiety with combined behavioral and
insight-oriented interventions (e.g., Leventhal, 1968).
Developing this line of reasoning, Bergin (1968) asserted that systematic
desensitization could be made into an even more powerful treatment if
accompanied by therapist warmth, empathy, and moderate interpretation.
Bergin reasoned that such extra-behavioral activities were important
because they elicited cognitive and emotional responses intimately tied to
the behavioral situations addressed in the desensitization hierarchies. He
maintained that a theory of therapy that addressed a more universal set of
psychological events would be less likely to lead therapists to conceptual
dead ends in the face of complex cases.
In the following year, Sloane (1969) maintained that common factors ran
through psychoanalytic, behavioral, and client-centered therapy and that the
underlying process of therapeutic change probably involved principles of
learning. Commenting on Sloane’s paper, Marmor (1969) agreed that all
therapies involve some application of learning principles, either directly or
unwittingly, but argued that the simple stimulus-response (S-R) model
could not explain some of the more complex aspects of human functioning.
Moreover, like London (1964), Marks and Gelder (1966), Lazarus (1967),
Brady (1968), Bergin (1968), and others, Marmor concluded that behavioral
and psychodynamic therapies are probably best viewed as complementary
in nature, with neither model being applicable to all cases.

The 1970s
The year 1970 marked the inauguration of a new journal, Behavior
Therapy. Interestingly enough, editors and contributors devoted serious
attention to theories and therapies that were not strictly “behavioral.” Thus,
one article described two clinical cases to illustrate the potential integration
of behavior therapy with psychodynamic theory (Birk, 1970). Bergin
(1970a) followed his earlier treatise on nonbehavioral “adjuncts” to
systematic desensitization with an article that claimed that desensitization
proper was, in fact, much more than a simple counterconditioning process,
drawing heavily on cognitive and relationship variables. Bergin (1970b, p.
207), in applauding the recent introduction of cognitive methods into
behavior therapy, observed that
 [t]he sociological and historical importance of the movement should not be underestimated for it
has three important consequences. It significantly reduces barriers to progress due to narrow
school allegiances, it brings the energies of a highly talented and experimentally sophisticated
group to bear upon the intricate and often baffling problems of objectifying and managing the
subjective, and it underscores the notion that a pure behavior therapy does not exist.

As it turned out, Bergin’s observations were very much on the mark; many
of the behavior therapists who became involved in the development of
cognitive procedures (e.g., Davison, Goldfried, Lazarus, Mahoney,
Meichenbaum) later moved on to an interest in therapeutic integration.
In a consideration of the importance of the therapeutic relationship within
a behavioral approach, humanistic therapists noted that the successful
procedures of behavior therapy were not being delivered in an interpersonal
vacuum. Although Truax and Mitchell (1971) lamented the evident
difficulties involved in conducting research on the therapy interaction, they
suggested—as Rosenzweig (1936) had done some 35 years earlier—that
there existed key therapist characteristics that contributed to the change
process, regardless of theoretical orientation.
Marmor published an article on therapeutic integration in that same year
(1971, p. 26), in which he suggested that
[t]he research on the nature of the psychotherapeutic process in which I participated with Franz
Alexander, beginning in 1958, has convinced me that all psychotherapy, regardless of the
techniques used, is a learning process. . . . Dynamic psychotherapies and behavior therapies
simply represent different teaching techniques, and their differences are based in part on
differences in their goals and in part on their assumptions of the nature of psychopathology.

Most contemporary behavior therapists probably would now agree with

Marmor’s clinical observation that not only simple conditioning but also
cognitive learning occurs during the course of therapy.
In a scholarly review of the psychotherapy outcome literature, Bergin
(1971) recognized the important empirical contributions that behavior
therapy had begun to make. Nonetheless, he concluded that the field needed
to remain open to the “many fertile leads yet to be extracted from traditional
therapy” (p. 254). Responding to Bergin’s observations that behavior
therapy alone was not always effective clinically, Lazarus (1971) described
in Behavior Therapy and Beyond a wide array of both behavioral and
nonbehavioral techniques that may be employed by broad-spectrum
behavior therapists. In the same year, Woody (1971) also published a book
integrating behavioral and insight-oriented procedures; Woody suggested
that the practicing clinician is capable of selecting and integrating
procedures from varying sources based purely on pragmatic grounds.
An edited book—After the Turn On, What?—described the experiences
of seven researchers and practitioners who spent a weekend together in an
encounter group (Houts & Serber, 1972). Ranging from radical behaviorism
to cognitive learning in orientation, the participants described what they
saw to be both assets and liabilities of their group experience.
As a part of a larger project to try to determine the future course of
psychotherapy research, Bergin and Strupp (1972) reported on their
contacts with researchers throughout the country. Among those interviewed
was Neal Miller, who predicted that as behavior therapy began to become
involved with more complicated types of cases, and as psychodynamic
therapy focused more on ego mechanisms and the working-through process,
the two therapeutic approaches would eventually start to converge in some
interesting ways.
In a provocative article on the “end of ideology” in behavior therapy,
London (1972) asked his behavioral colleagues to declare a truce in their
strife with other orientations and to look more realistically and
pragmatically at what we are able to do clinically. Perennially the
pragmatist, London cautioned against becoming overly enamored with
theories, noting that “the first issue, scientifically as well as clinically, is the
factual one—do they work? On whom? When? The how and why come
later” (p. 919).
Other efforts at therapeutic integration that appeared in 1972 included a
book that attempted to integrate learning theory with client-centered therapy
(Martin, 1972), a description of universal healing processes as seen among
psychotherapists and witch doctors alike (Torrey, 1972), and a set of papers
dealing with the theoretical and clinical aspects of the integration of
psychodynamic and behavior therapies (Feather & Rhoads, 1972a, 1972b).
Feather and Rhoads (1972a) argued that in psychology, as in medicine, the
existence of many treatments for a given disorder probably signaled a poor
understanding of the disorder and that none of the separate treatments was
likely to prove adequate.
Commenting on one of Feather and Rhoads’s articles appearing in the
previous year, Birk (1973) noted that one area of complementarity between
the behavioral and psychodynamic approaches was that the former dealt
more with external stimuli, whereas the latter tended to focus on stimuli that
are more internal in nature. Strupp (1973), stressing the common elements
underlying all psychotherapies, underscored the therapeutic relationship as
a vehicle for change through providing the patient with a corrective learning
experience. Thoresen (1973) suggested that many of the philosophical
underpinnings of behaviorism and humanism were in agreement and that it
was possible to view a behavioral approach as providing the technology by
which certain humanistic goals might be achieved.
A fair number of articles appeared in 1974 on the issue of therapeutic
rapprochement. In an intriguing discussion of behavioral and
psychodynamic approaches as “complementary” rather than mutually
exclusive, Ferster (1974)—a well-known Skinnerian—described what he
considered to be some of the merits of psychoanalytic therapy. The
complementary nature of different approaches was demonstrated in the
treatment of an obsessive-compulsive disorder (Lambley, 1974). Birk and
Brinkley-Birk (1974) offered a conceptual integration of psychoanalysis
and behavior therapy, suggesting that insight sets the stage for change,
whereas behavior therapy provides the actual procedures by which the
change process may be brought about.
Kaplan (1974), in her book The New Sex Therapy, outlined how
psychodynamic therapy could be integrated with performance-based
methods. Likewise, Sollod’s (1975) article expounded on the merits of this
structured and synergistic integrative approach to sex therapy.
In that same year, suggestions resurfaced that there is much to learn from
“other approaches that can make (unmodified) psychoanalytic treatment
more effective” (Silverman, 1974, p. 305). In a paper delivered at the 1974
meeting of the American Psychological Association (APA), Landsman
(1974) urged his humanistic colleagues to attend to the contributions of
behavior therapy, such as “attention to specifics, to details, careful
quantification, modesty in claims, demonstrable results” (p. 15).
In his incisive book, Misunderstandings of the Self, Raimy (1975), like
Frank (1961), suggested that various therapies all seem directed toward
changing clients’ misconceptions of themselves and others. All therapies
are alike in that they “present evidence” to assist individuals in changing
these misconceptions; the type of evidence and the way it is presented,
however, differ across therapeutic orientations. An article by the German
psychologist Bastine (1975), amplified upon a few years later (Bastine,
1978), likewise outlined common strategies together with the techniques by
which they may be implemented. In his book on the therapeutic change
process, Egan (1975) modified his original humanistic orientation to
acknowledge that although the contributions of Rogers (1963) and others
are essential for establishing the therapeutic relationship in which change
can take place, behavior therapy offers methods to implement specific
action programs.
Also in 1975, Sloane, Staples, Cristol, Yorston, and Whipple published
the results of their influential comparative trial of psychodynamic and
behavior therapists. The results showed that therapists from both
orientations demonstrated comparable degrees of warmth and positive
regard and that patients of both types of therapists exhibited the same depth
of self-exploration and experienced similar treatment outcomes.
Paul Wachtel (1975), in the first of his many writings on therapy
integration, cited the contributions made to psychodynamic therapy by
Alexander, Horney, and Sullivan as evidence that behavioral approaches,
which deal directly with problematic behaviors, could readily be
incorporated into a psychodynamic framework. This is a two-way street,
argued Wachtel, in that many instances of relapse following behavior
therapy might possibly be linked to the client’s maladaptive patterns that
might more readily be identified when viewed from within a
psychodynamic framework. Wachtel (1977) went on to explore such
integration at greater length in his well-known and challenging book,
Psychoanalysis and Behavior Therapy, in which he maintained that the
convergence of clinical procedures from each orientation would likely
enhance clinical effectiveness.
In 1976, a number of publications touched on therapeutic integration or
directly endorsed it. Several prominent psychoanalytic clinicians criticized
psychoanalytic therapy for not keeping up with the times, using therapeutic
procedures more on the basis of faith than data (Strupp, 1976). Many
underscored the need for psychotherapy to be predicated on research
findings and noted that, with added clinical experience, even the most
orthodox of psychoanalysts learn that other methods are needed to facilitate
change (Grinker, 1976). As a practicing psychoanalyst with personal
experience in the human potential movement, Appelbaum (1976) suggested
that some gestalt therapy methods may complement more traditional
psychoanalytic techniques. Appelbaum’s excursions into more
humanistically oriented activities were described in fascinating detail in a
later book (Appelbaum, 1979).
In that same year, two edited books provided multitheoretical discussions
and acknowledged points of potential integration: Humanism and
Behaviorism (Wandersman, Poppen, & Ricks, 1976) and What Makes
Behavior Change Possible? (Burton, 1976).
In their book Clinical Behavior Therapy, Goldfried and Davison (1976)
maintained that behavior therapy need no longer assume an antagonistic
stance vis-à-vis other orientations. Acknowledging that there is much that
clinicians of different orientations have to say to each other, they suggested:
“It is time for behavior therapists to stop regarding themselves as an
outgroup and instead to enter into serious and hopefully mutually fruitful
dialogues with their nonbehavioral colleagues” (p. 15). That many
clinicians were in effect already doing this was reflected in Garfield and
Kurtz’s (1976) findings that most clinical psychologists in the United States
considered themselves eclectic. Most frequently used in combination were
the psychodynamic and learning orientations, a combination that was based
on the pragmatics of doing clinical work (Garfield & Kurtz, 1977).
Integration at a clinical level was also dealt with in several articles (e.g.,
Lambley, 1976; Levay, Weissberg, & Blaustein, 1976; Murray, 1976;
Segraves & Smith, 1976).
Lazarus’s (1976) book, Multimodal Behavior Therapy, extended and
refined his broad-spectrum approach to behavior therapy to systematically
take into account the individual’s behaviors, affects, sensations, images,
cognitions, interpersonal relationships, and drugs/physiological states. In
the following year, Lazarus (1977), then having practiced behavior therapy
for approximately 20 years, questioned whether behavior therapy, as a
delimited school of thought, had “outlived its usefulness.” He recognized
the need to “transcend the constraints of factionalism, where cloistered
adherents of rival schools, movements, and systems each cling to their
separate illusions” (p. 11). An editorial comment appearing in the Journal
of Humanistic Psychology (Greening, 1978) applauded Lazarus’s 1977
paper and urged readers of the journal to be open to such suggestions for
rapprochement.
Increasingly in the 1970s, psychotherapists acknowledged that no single
orientation can deal successfully with all clinical cases (Hunt, 1976) and
challenged the usefulness of approaching a psychological problem through
the eyes of any single theory. Underscoring what we all too often forget,
Gurman (1978) suggested that “Therapy is not viewed as a reified set of
procedures, but as an evolving science” (p. 131). Diamond, Havens, and
Jones (1978) independently came to the same conclusion, stressing the need
for eclecticism that would be tied to research and theory, yet be flexible
enough to provide highly individualized treatment. In that same year,
Fischer (1978) outlined an eclectic approach to social casework, and
O’Leary and Turkewitz (1978) described how a communications analysis of
marital interaction might be used within the context of behavioral marital
therapy. Some of the points of overlap between behavior therapy and Zen
Buddhism were outlined as well (Mikulas, 1978; Shapiro, 1978).
In a 1978 article entitled “Are Psychoanalytic Therapists Beginning to
Practice Cognitive Behavior Therapy or Is Behavior Therapy Turning
Psychoanalytic?” Strupp (1983) commented on several converging trends
occurring within each of these orientations. In a reanalysis of agoraphobia,
Goldstein and Chambless (1978) described some of the complicating
features in dealing with this problem clinically, outlining a comprehensive
treatment plan that went beyond the straightforward behavioral methods.
Also in the same year, Ryle (1978) suggested that experimental cognitive
psychology might provide a common language for the psychotherapies.
That paper instigated and reinforced years of scholarly literature on the
search and value for a generic language or Esperanto for psychotherapists to
enhance communication across theories.
Prochaska (1979), in a textbook describing the diverse systems of
psychotherapy, concluded with a chapter that made the case for ultimately
developing a transtheoretical model that would encompass what may have
been found to be effective across different approaches to psychotherapy. In
that same year, Knobloch and Knobloch (1979) presented their integrated
psychotherapy in a book.
Presenting some interesting parallels between cognitive therapy and
psychodynamic therapy, Sarason (1979) suggested that experimental
cognitive psychology may provide a conceptual system for understanding
both orientations. Goldfried (1979) proposed that cognitive-behavior
therapy might be construed as often dealing with an individual’s implicit
meaning structures and that use of association techniques from
experimental cognitive psychology to study such phenomena should be
equally acceptable to psychodynamic practitioners. It is interesting to note
that Sarason and Goldfried drew their conclusions independently and
without any apparent knowledge of Ryle’s (1978) similar conclusion made
the year before.
Robertson (1979) speculated on some of the reasons for the existence of
eclecticism, such as lack of pressures in one’s training or professional
setting to take a given viewpoint and a therapeutic orientation reaching a
point where “the bloom is off the rose.” Related to this last point were the
results of Mahoney’s (1979) survey of leading cognitive and noncognitive
behavior therapists. Among the several questions asked of the respondents
was: “I feel satisfied with the adequacy of my current understanding of
human behavior.” Using a 7-point scale, Mahoney found that the average
rating of satisfaction was less than 2!

The 1980s
During the 1980s, psychotherapy integration made a significant advance as
a defined area of interest—indeed, a movement. There was a geometric
increase in the number of publications and presentations on the topic,
making it unwieldy and impractical for us to offer an adequate description
of the hundreds of publications that appeared during this decade and the one
that followed.
In an oft-cited article published in the American Psychologist, Goldfried
(1980) argued that a fruitful level of abstraction for a comparative analysis
of psychotherapy would be somewhere between the specific technique and
its theoretical explanation. He maintained that it is at this intermediate level
of abstraction—at the level of clinical strategy—that points of overlap may
exist. One clinical strategy that may very well cut across orientations entails
providing the patient with “corrective experiences,” particularly with regard
to fear-related activities. For example, Fenichel (1941, p. 83), on the topic
of fear reduction, noted that
when a person is afraid but experiences a situation in which what was feared occurs without any
harm resulting, he will not immediately trust the outcome of his new experience; however, the
second time he will have a little less fear, the third time still less.

The same conclusion was reached by Bandura (1969, p. 414), who observed
that
 [e]xtinction of avoidance behavior is achieved by repeated exposure to subjectively threatening
stimuli under conditions designed to ensure that neither the avoidance responses nor the
anticipated adverse consequences occur.

Relevant to this general theme was Nielsen’s (1980) description of how

certain psychoanalytic concepts are reflected in the practice of gestalt
therapy.
In a 1980 special issue of Cognitive Therapy and Research, therapists of
various orientations answered a set of questions about what they believed to
be the most effective ingredients in therapeutic change (Brady et al., 1980).
Dryden (1980) discussed the differences in therapeutic styles across
orientations, particularly as they relate to the concept of transference,
Bastine (1980) observed that a problem-oriented approach to intervention is
likely to facilitate psychotherapy integration, and Linsenhoff, Bastine, and
Kommer (1980) emphasized that the field of psychotherapy could benefit
most from an integration that would be both theoretical and practical.
Messer and Winokur (1980), in an article examining the potential
benefits and pitfalls of psychotherapy integration, suggested that both
action-oriented and insight-oriented approaches may be combined to help
patients to translate their insights into action. Mahoney (1980) noted that
behaviorists had begun not only to adopt a position that accepted a person’s
thoughts as useful data, but also to pay attention to “implicit” cognitions. In
this manner, cognitive-behavioral theorists and therapists were beginning to
examine “unconscious” events.
Marmor and Woods’s (1980) edited book, The Interface Between the
Psychodynamic and Behavioral Therapies, illustrated the theme that no
single approach to therapy can deal with all of human functioning. This
theme was reflected in a case report (Cohen & Pope, 1980), in which a
single client was significantly helped by two cooperating therapists, one
behavioral and the other analytic. A national survey found that although
therapists typically used a single orientation as their primary reference
point, 65% acknowledged that their clinical work included contributions
from a number of other therapeutic approaches (Larson, 1980). Ryle (1980)
reported the findings of a series of cases in which an integrated, cognitive-
dynamic intervention was found to be clinically effective. Garfield (1980),
drawing on different therapeutic orientations in his Psychotherapy: An
Eclectic Approach, described an empirically oriented view of
psychotherapy. Like Bergin before him, he viewed the introduction of
cognitive variables into behavior therapy as a particularly important
advance.
In 1981, a number of writers furthered the argument that each orientation
presents distinctive strengths that can be combined into a more broad-based
and useful approach. For example, Arnkoff (1981) reported combining
cognitive therapy with the gestalt empty-chair technique to increase affect
and to elicit meaningful cognitions from the patient. The multimodal
therapy of Lazarus (1981) essentially maintained that the therapist’s choice
of therapy techniques must be data-driven, not theory-driven.
Individual therapists were not the only mental health professionals
subject to the integrative fervor. Group psychotherapists were moving
toward “technical and theoretical eclecticism” in increasing numbers
(Schwartz, 1981). Gurman (1981) described how different orientations may
be fitted into a multifaceted empirical approach to marital therapy that
enhances effectiveness.
As the discussion of therapeutic integration was becoming increasingly
widespread, it became desirable for concerned professionals to arrange
meetings to facilitate a more efficient and meaningful exchange of views.
For example, in 1981, a small group of clinicians and researchers (Garfield,
Goldfried, Horowitz, Imber, Kendall, Strupp, Wachtel, and Wolfe) held an
informal, 2-day conference to determine whether clinicians of different
orientations could communicate about actual clinical material. This group
did not attempt to generate any particular product; their primary objective
was to initiate a dialogue with each other.
Communication between psychotherapy practitioners and researchers of
diverse orientations became a worldwide phenomenon in the following
years. For example, in 1982, the Adler Society for Individual Psychology
dedicated their World Congress (held in Vienna) to the exchange of views
between representatives of the major therapy models. The following year,
an International Congress in Bogota, Colombia, led by Augosto Perez
Gomez, focused on the prospects for the convergence of psychotherapies
and a cross-fertilization of ideas.
As a way of illustrating how such rapprochement might be implemented,
multiple authors launched proposals for theoretical hybrids: integration of
interpersonal and cognitive-behavioral constructs (Anchin, 1982), points of
overlap between cognitive and humanistic therapy (Bohart, 1982), and how
rational-emotive therapy had selected techniques from other orientations
(Dryden, 1982). Goldfried and Padawer (1982) argued that the activities of
psychotherapists of differing theories are quite similar even though their
conceptualizations of cases may be articulated quite differently. Their
review of the literature revealed a number of strategies that seem to guide
the efforts of most therapists.
In 1982 and 1983, the issue of theoretical integration acquired still
greater visibility through the publication of a number of books on the topic
authored by clinicians and researchers from diverse backgrounds. In
Converging Themes in Psychotherapy, Goldfried (1982) provided a
compendium of articles dealing with the issue of rapprochement together
with an overview of the current status and future directions in
psychotherapy integration. In Resistance, Wachtel (1982) elicited the views
of experienced and well-known therapists in an attempt to explore the
possibility that a synthesis of the psychodynamic and behavioral approaches
might shed light on resistance to therapeutic change. In Psychotherapy: A
Cognitive Integration of Theory and Practice, Ryle (1982) assimilated
theories and methods of a heterogeneous set of orientations into a common
language system—cognitive psychology. Fensterheim and Glazer (1983), in
Behavioral Psychotherapy, highlighted the complementarity of
psychoanalytic and behavioral treatment methods.
In Marital Therapy, Segraves (1982), like Ryle, attempted to integrate
elements of seemingly disparate theoretical systems by translating them into
the language of cognitive social psychology. The utility of his cognitive-
social psychology terminology is exemplified by the persuasive
presentation of the concept of “interpersonal schemas,” analogous to the
analytic concept of “transference,” to explain the influence of early-life
significant relationships on a person’s perceptions of his or her spouse.
In 1983, the frequently asked question of “what therapy activities are
most appropriate for what type of problem, by which therapist, for what
kind of client/patient?” was addressed by Beutler in his book, Eclectic
Psychotherapy. This volume suggested ways of maximizing therapeutic
effectiveness by reviewing what is known about the optimal matching of
patients to therapists and techniques. Also appearing in this year was a book
on psychotherapy integration in German (Textor, 1983) reflecting the
growth of the movement on an international level.
Evidence of a rapprochement between biological and psychological
approaches to therapy appeared in the work of Gevins (1983) and in the
theme of the 1983 meeting of the Society of Biological Psychiatry—“The
Biology of Information Processing.” The following year, several
psychiatrists (e.g., Beck, 1984; Beitman & Klerman, 1984) presented
guidelines for integrating psychotherapy and pharmacotherapy.
A number of authors began to suggest that the field of psychotherapy
needed to develop a new, higher order theory that would help us to better
understand the connections between cognitive, affective, and behavioral
systems (Beck, 1984; Greenberg & Safran, 1984; Mahoney, 1984; Ryle,
1984; Safran, 1984). These writers maintained that attempts to answer the
question of how affective, behavioral, and cognitive systems interact would
move the field toward the development of a more adequate, unified
paradigm.
Systemic therapists soon followed in their insistence that any thoughtful
integration necessarily included family and societal forces and in their
synthesis of therapeutic formats/modalities, such as individual and family
therapy. This thrust was typified by dozens of books and articles in the
1980s (e.g., Allen, 1988; Beach & O’Leary, 1986; Duhl & Duhl, 1981;
Feldman, 1979, 1989; Feldman & Pinsof, 1982; Friedman, 1980a, 1980b,
1981; Grebstein, 1986; Gurman, 1981; Hatcher, 1978; Lebow, 1984; Pinsof,
1983; Rosenberg, 1978; Segraves, 1982; Steinfeld, 1980; Wachtel &
Wachtel, 1986). A common phenomenon these authors discussed was the
vicious cycle that results when a member of an interpersonal system expects
and assumes the worst about a significant other, resulting in acting in such a
way to provoke the very negative reactions from the significant other that
“confirm” the original dysfunctional belief. As testimony to the momentum
the preceding works have gathered, a special interest group within the
American Family Therapy Association was organized to support these
integrative efforts.
Another framework for organizing and integrating various approaches to
psychotherapy was presented by Driscoll (1984) in Pragmatic
Psychotherapy. Substituting the vernacular for theoretical jargon, Driscoll
presents a method (the pragmatic “survey”) by which any given
psychological problem can be elucidated and conceptualized in a diversity
of ways.
In Arkowitz and Messer’s (1984) edited volume, Psychoanalytic Therapy
and Behavior Therapy: Is Integration Possible?, they, along with 10
contributing authors, explore the clinical, theoretical, and empirical issues
of a serious attempt at rapprochement. Although there was no clear
consensus, the book provided a valuable opportunity for the exchange of
fruitful philosophical and practical ideas toward the advancement of the
field as a whole.
In addition to the aforementioned books, numerous others on therapeutic
integration appeared at this time (e.g., Guidano & Liotti, 1983; Hart, 1983;
Meyer, 1982; Palmer, 1980; Papajohn, 1982; Prochaska & DiClemente,
1984; Wittman, 1981). Moreover, journals started to feature discussions on
this topic. A special 1982 issue of Behavior Therapy contained a series of
articles examining the potential benefits and drawbacks of complementing a
behavioral approach with those of other orientations, and a 1983 issue of
the British Journal of Clinical Psychology presented spirited “point–
counterpoint” commentary on the subject of the plausibility of
psychotherapy integration.
A significant event in the history of psychotherapy integration was the
formation of an international organization devoted specifically to this
endeavor. Formed in 1983, the Society for the Exploration of
Psychotherapy Integration (SEPI, n.d.) was established as a way of bringing
together the growing number of professionals interested in this area. An
interdisciplinary organization that has grown international in scope, SEPI
holds yearly conferences at which both clinicians and researchers present
their current work and where attendees discuss and exchange ideas. We
shall have more to say about SEPI later in this chapter.
In the mid to late 1980s, it became apparent that the integration
movement had succeeded in reaching a broadening and receptive audience.
There was a significant increase in the number of authors who contributed
to the advancement of the field. To provide forums for these many voices,
new journals appeared that directly addressed clinical and research issues
pertinent to integration. One such journal was the International Journal of
Eclectic Psychotherapy, later renamed the Journal of Integrative and
Eclectic Psychotherapy in 1987.
In 1985, Mahoney cast a critical eye on the sociopolitics of academia,
saying in effect that current systems foster and reward conformity and static
viewpoints. He vehemently argued that knowledge would best be advanced
by an openness to views that went beyond mainstream thinking. The
movement toward psychotherapy integration was presented as an important
new area of exploration that the field would do well to support.
 In the following year, Messer (1986) drew a comparison between
psychoanalytic and behavioral approaches to treatment, using various
clinical choice points to highlight where they were similar and where they
differed. Thus, when dealing with a patient’s distorted view of the world,
the psychodynamic therapist would focus more on the nature of the
distortion, whereas the behavior therapist would be quicker to help the
patient to incorporate the reality. Which of these two strategies is more
effective clinically remains to be demonstrated empirically. Dealing with
the psychotherapy research findings, Stiles, Shapiro, and Elliott (1986)
concluded that the failure to find consistent superiority of any one approach
over another should lead us to carry out more work on studying common
processes of change. This point was similarly made by Goldfried and
Safran (1986), who pointed to future research directions in psychotherapy
integration.
If the movement toward psychotherapy integration is to help the entire
field to progress, it becomes vital to define clearly the parameters of such a
therapeutic approach and to suggest methods and modes of teaching the
therapy to trainees (Halgin, 1985). An edited volume by Norcross (1986)
made valuable headway in this regard. Contributing authors spelled out
their conceptualizations of eclectic psychotherapy and shared their views on
how to teach students the vast amount of information needed to understand
and integrate various models. Also in 1986, a special issue of the
International Journal of Eclectic Psychotherapy was devoted to a
discussion of the training and supervision of integrative/eclectic
psychotherapists (Norcross et al., 1986). It was clear that this would be a
formidable task with which to grapple and that ongoing development would
be necessary to approach satisfactory answers. Therefore, later issues of the
same publication, the newly named Journal of Integrative and Eclectic
Psychotherapy, would carry on the dialogue on training and supervision
(Beutler et al., 1987; Halgin, 1988; Norcross, 1988).
A glance at some of the major books on integration in 1987 reminds us
that interest in this area had become worldwide. From Italy, we had
Guidano’s (1987) Complexity of the Self: A Developmental Approach to
Psychotherapy and Theory. From English-speaking Canada, Greenberg and
Safran (1987) published Emotion in Psychotherapy; from French-speaking
Canada, we see LeCompte and Castonguay’s (1987) edited work,
Rapprochement and Integration in Psychotherapy, and from the United
States came Wachtel’s (1987) Insight and Action, Beitman’s (1987) The
Structure of Individual Psychotherapy, and Norcross’s (1987) Casebook of
Eclectic Psychotherapy. Beitman (1987) presented a four-stage model of
therapy that cut across orientations and used a common language, and
Orlinksy and Howard (1987) described a generic model of therapy on the
basis of their review of therapy research.
A 1987 issue of the Journal of Integrative and Eclectic Psychotherapy
addressed the problem of overcoming the theoretical language barrier that
would otherwise impede communication and collaborative study between
clinicians and researchers of differing theoretical training backgrounds
(Messer, 1987). A number of writers expounded on the merits of such
language systems as the vernacular (Driscoll, 1987), experimental cognitive
psychology (Goldfried, 1987; Ryle, 1987), and interpersonal theory (Strong,
1987). Elaborating on the theme that diverse therapeutic orientations are
needed for a multidimensional method of intervention, Bergin (1988)
pointed out that nobody attempting to understand the workings of the
human body would ever try to invoke a single set of rules. For example,
principles of fluid mechanics are needed to understand how the heart
operates, whereas electrochemical principles are needed for an
understanding of neural transmission. A true rapprochement across the
psychotherapies is needed, suggested Bergin, if we are to deal effectively
with those complex human problems requiring psychotherapeutic
intervention.
In 1988, Norcross and Prochaska updated Garfield and Kurtz’s 1977
study on eclectic views. The results demonstrated that the majority of
clinical psychologists now preferred the label of integrative over eclectic.
Although the integrative/eclectic orientation continued to be the modal
orientation among American psychotherapists, the frequency of theoretical
contributions was changing. Whereas the most frequent combination in the
1970s was psychoanalytic and behavioral, the most common combinations
in the 1980s were cognitive and behavioral and then humanistic and
cognitive. The authors observed that “integration by design is steadily
replacing eclecticism by default” (p. 173).
Another series of articles on the subject of psychotherapy integration
appeared in Psychiatric Annals in 1988. The contributions addressed the
dual use of psychotherapy and psychotropic medication (Rhoads, 1988),
pointed out that many behavioral interventions will provoke clinically
meaningful emotional and cognitive insights (Babcock, 1988; Powell,
1988), argued that cognitive therapies represent viable integrative therapies
in and of themselves (London & Palmer, 1988), and reminded us of the
need to explore the integration of individual psychotherapy with marital and
family therapy (Birk, 1988).
Toward the end of the 1980s, the call for the development of an empirical
methodology for the study of psychotherapy integration became quite
pronounced (e.g., Goldfried & Safran, 1986; Norcross & Grencavage, 1989;
Norcross & Thomas, 1988; Safran, Greenberg, & Rice, 1988; Wolfe &
Goldfried, 1988), whereas others (e.g., Messer, Sass, & Woolfolk, 1988)
underscored the benefits of alternate epistemological approaches to
understanding the therapy process. Safran, Greenberg, and Rice (1988)
posited that psychotherapists ultimately would learn more about the process
of therapy via the intensive study of successful and unsuccessful cases
rather than through the extensive study of groups of clients categorized by
broad diagnostic labels. Cashdan (1988) described the role of the
therapeutic relationship within an object relations framework, Andrews
(1988, 1989) offered a model of change that emphasized self-confirming
feedback cycles, Glass and Arnkoff (1988) found evidence for common as
well as specific factors in clients’ explanations for change, and Omer and
London (1988) concluded that the nonspecific variables in therapy were no
longer “noise” but had achieved the status of “signal.”
The National Institute of Mental Health (NIMH, n.d.) held a research
conference dealing with psychotherapy integration (Wolfe & Goldfried,
1988). The conferees stated that the establishment and growth of an
accessible archive of tapes and transcripts would be a major boon to
empirical studies relevant to integration. Another subtheme related to the
need for integration to be based in empirical findings was the call for a
better, more unified understanding of psychopathology (Arkowitz, 1989;
Guidano, 1987; Wolfe, 1989; Wolfe & Goldfried, 1988).
One of the first research programs specifically designed to develop a new
methodology for the advancement of psychotherapy integration began to
emerge from the work of Goldfried and his associates (e.g., Castonguay,
Goldfried, Hayes, & Kerr, 1989; Goldfried, Newman, & Hayes, 1989).
These authors developed a coding system, composed in the language of the
vernacular, to compare and contrast the feedback that cognitive-behavioral
and psychodynamic therapists give their patients. Their database comprised
transcripts and audiotapes of actual therapy sessions, thus facilitating the
study of what the therapists actually do in session (Goldfried & Newman,
1986).
Another issue that gained momentum in the late 1980s was the
examination of the narrowing gap between cognitive-behavioral and
psychodynamic viewpoints on the nature of the therapeutic relationship
(Goldfried & Hayes, 1989). For example, dialectical behavior therapy for
borderline personality disorder characterized the therapeutic relationship as
being central to the success of the treatment (Heard & Linehan, 2005;
Linehan, 1987). Westen’s (1988) intriguing article conceptualized the
transference phenomenon in terms of information processing while
acknowledging its vital emotional component. Newman (1989) authored a
treatise on the phenomenon of countertransference as experienced and
conceptualized from the perspective of the cognitive-behavioral therapist.
In 1989, Lazarus published a revision of his influential book, The
Practice of Multimodal Therapy, while International Psychotherapy, a
book that took cross-cultural factors into account in examining the process
of therapy, addressed elements of successful interpersonal helping that
appear to be universal (Simek-Downing, 1989). Mahrer’s The Integration of
Psychotherapies (1989) expressed the sentiment that “integrationists are
dealing with many of the crucial questions for our field” and spelled out his
recommended responsibilities for the integrative therapist, teacher,
supervisor, and researcher. Beitman, Goldfried, and Norcross’s (1989)
overview article on psychotherapy integration in the American Journal of
Psychiatry underscored the importance of research findings on this topic so
that “prescriptive treatment [could be] based primarily on patient need and
empirical evidence rather than on theoretical predisposition” (p. 141).
Beginning work in this area came from Sheffield, England (Barkham,
Shapiro, & Firth-Cozens, 1989), where it was found that a combined
intervention that went from psychodynamic to cognitive-behavior therapy
(insight to action) worked better than one in which the sequence was
reversed.

The 1990s
If the 1980s witnessed the establishment of integration as a movement, then
the 1990s saw its ideas embraced, recognized, and adopted by a wide
variety of researchers and clinicians alike. Indeed, integrative themes
became part of the prevailing zeitgeist and were increasingly incorporated
into mainstream writing. Multiple surveys found again that a majority of
psychotherapists subscribed to integrative/eclectic forms of therapy (e.g.,
Jensen, Bergin, & Greaves, 1990).
Interpersonal Process in Cognitive Therapy by Safran and Segal (1990)
outlined how the clinical effectiveness of cognitive therapy could be
enhanced by incorporating principles and techniques associated with
interpersonal theory. In their UK edited volume, Eclecticism and
Integration in Counseling and Psychotherapy, Dryden and Norcross (1990)
included a consideration of potential obstacles to integration as well as
emerging themes that could potentially lead to contention, noting that since
integration was still in its early stages of development, different authorities
have had different views. In another edited book, Client-Centered and
Experiential Psychotherapy in the Nineties (Lietaer, Rombauts, &
VanBalen, 1990), Bohart contributed a chapter in which he brought an
integrative approach to client-centered therapy, describing the common
underlying factors in psychotherapy and how these are related to client-
centered therapy. In their review of the burgeoning common-factors
literature, Grencavage and Norcross (1990) discerned that these factors
could be classified according to client characteristics, therapist attributes,
change processes, treatment structure, and therapy relationship. The latter
was, by far, the most frequently proposed commonality across the
psychotherapies.
Several psychotherapists admitted that theoretical integration may offer
the greatest intellectual appeal, but technical eclecticism may be the more
practical solution, allowing the clinician to avoid having to find a
connection between techniques and theoretical underpinnings (Duncan,
Parks, & Rusk, 1990). As one prominent example, Beutler and Clarkin
(1990) proposed a systematic eclectic therapy that allows for the selection
of a treatment approach based on client predisposing variables, such as
problem complexity/severity, motivational distress, coping style, and
resistance level. Discussing their identification as a technical eclectic and a
common-factors integrationist, respectively, Lazarus (1990) and Beitman
(1990) debated their differing stances.
Expanding on work begun in the 1980s, Ryle (1990) discussed how
cognitive-analytic therapy integrates aspects of cognitive, psychodynamic,
and behavior therapies. Also in 1990, Lazarus urged integrationists to avoid
training students in one particular approach to therapy and instead to
present them with various options in an unbiased manner so that they could
learn to recognize the values of each approach.
Two landmark books appeared in 1991. One (Frank & Frank, 1991) was
a revision of the classic Persuasion and Healing by Frank that was
published three decades earlier (Frank, 1961) and the other a
comprehensive analysis by Mahoney (1991) on the process of change.
Also of particular significance in 1991, SEPI began publishing its own
journal, the Journal of Psychotherapy Integration. The goal of the journal
was to offer a forum for articles that moved beyond the confines of single-
school approaches to psychotherapy and behavior change. Much of the
work in the area of integration throughout the 1990s was published in this
journal.
The first articles published in the Journal of Psychotherapy Integration
dealt with the current state and trends of psychotherapy integration. In a
dialogue between Lazarus and Messer (1991), Lazarus lamented the
fragmentation that exists among psychotherapies and called for “fewer
theories and more facts” (p. 146), arguing for a data-based technical
eclecticism rather than an integration that is informed solely by theory.
Messer countered by noting that all data are informed by theory but also
acknowledged that imported techniques must be tried out in their new
contexts and be validated through use and experimentation. Writing about
multicultural counseling and therapy, Ramirez (1991) observed the regular
use of contributions from different orientations. Alford (1991) called for
integrationists to find the various systems that are worthy of integration,
noting a continued lack of consensus regarding criteria for the selection and
incorporation of elements from various therapies. Horowitz (1991)
proposed “deep” formulations such as emotionality, relationships, self-
control, and development that may potentially offer an entry to integration.
Wachtel (1991) similarly proposed moving beyond simply combining
elements, suggesting that we try to achieve a more seamless
psychotherapeutic integration. Goldfried (1991) proposed a research
enterprise that could lead to such an integration. He described
“desegregation” research across pure-form treatment modalities, one that
involves a comparative analysis of the change process. He proposed that by
focusing on clinical principles that are common across orientations,
research would have a greater likelihood of focusing on the most important
mechanisms of change. Commenting on this article, Shoham-Salomon
(1991) added that only therapies that are different from each other in clearly
identifiable ways can be integrated.
Writing in 1991, Schacht suggested that the manner in which clinicians
learn therapy influences their ability to employ integrative concepts,
observing that integration has different meanings for beginning therapists
than for expert therapists. He proposed that those who train students in
integrative approaches need to take note of the developmental path that
therapists follow as they move from novice to expert therapists. In the same
year, Mahoney and Craine reported on a survey of 177 members of SEPI
and the Society for Psychotherapy Research (SPR) regarding optimal
therapeutic practice. The only difference found among theoretical
orientations was that behaviorists rated psychological change as less
difficult than did nonbehaviorists. Of particular interest was the finding that
most psychotherapists exhibited considerable belief change over the course
of their careers.
In an edited volume, History of Psychotherapy: A Century of Change
(Freedheim et al., 1992), Arkowitz presented a chapter that traced the
development of psychotherapy integration across the twentieth century.
Significant was the reality that inclusion of such a chapter was regarded as
essential for a complete portrayal of the past 100 years of psychotherapy. In
the same volume, Arnkoff and Glass (1992) devoted a substantial portion of
their chapter on cognitive therapy to psychotherapy integration, noting that
the development of cognitive therapy sparked interest in eclectic and
integrative approaches to therapy.
Integration was met with receptivity in the early 1990s. As an example,
Duncan (1992) offered the use of integrative techniques for ameliorating the
criticisms of strategic family therapy, suggesting ways for improving
strategic therapy that are clearly integrative in nature. Writing in the same
year, Norcross and Newman (1992) discussed the multitude of factors that
contributed to the growing interest in psychotherapy integration. These
entailed (1) the proliferation of different schools of thought within
psychotherapy, which led to increasing fragmentation and confusion; (2) the
realization that no theoretical orientation was sufficient to handle all clinical
issues; (3) the rise of managed healthcare and the consequent pressure for
accountability and consensus; (4) the growing focus on specific clinical
problems and practical ways of dealing with them; (5) increasing
opportunities to observe and experiment with clinical approaches other than
one’s own; (6) the interest in common factors that cuts across all forms of
treatment; and (7) SEPI, which provides an educational, clinical, and
scientific forum in which to consider integration.
Commensurate with its maturation, psychotherapy integration began to
differentiate more clearly into separate paths or subtypes: common factors,
theoretical integration, and technical eclecticism (Arkowitz, 1992). In a
special issue of Psychotherapy devoted to the future, Goldfried and
Castonguay (1992) opined on the future of theoretical integration, while
Lazarus, Beutler, and Norcross (1992) discussed the future of technical
eclecticism. In the early 1990s, eclecticism became a more deliberate
combination of interventions stemming from more appropriate training in
various orientations, a systematic assessment of client needs, and a use of
outcome research.
The first edition of the Handbook of Psychotherapy Integration, edited
by Norcross and Goldfried (1992), offered a comprehensive examination of
the theory and practice of integrative psychotherapy, including a conceptual
and historical perspective, models of psychotherapy integration, approaches
to specific clinical problems, different modalities of intervention, and issues
related to training, research, and future directions. Norcross and Goldfried
concluded that it was unlikely that the psychotherapy integration movement
would provide the field with a grand, overarching theoretical orientation.
Instead, they proposed that integrative efforts can lead to increased
consensus on the interventions that are indicated for certain clinical
problems. They called for process and outcome studies of both pure-form
and integrative interventions to be complemented by research findings on
the determinants of specific clinical disorders. In the same year, Dryden
(1992) edited a volume on clinical and research contributions to integration
in the United Kingdom and included a valuable bibliography of relevant
articles appearing in British journals between 1966 and 1990.
During the next year, Stricker and Gold (1993) published their
Comprehensive Handbook of Psychotherapy Integration. It included
contributions on a variety of topics such as individual approaches to
integration, the integration of traditional and nontraditional approaches,
psychotherapy integration for specific disorders and specific populations,
teaching psychotherapy integration, and a review of relevant research.
 That same year, the Journal of Psychotherapy Integration featured a
roundtable discussion by prominent scientist-practitioners (Norcross, 1993).
The panelists (Glass, Arnkoff, Lambert, Shoham, Stiles, Shapiro, Barkham,
and Strupp) dealt with the two central influences in the current integration
movement: common factors and technical eclecticism. They covered the
empirical investigation of therapeutic commonalities, the value of research
programs determining “treatments of choice,” and alternatives to
comparative designs. They concluded by proposing additional research
directions to advance integration.
One such study reported on both the similarities and differences in
therapy methods between cognitive-behavioral and psychodynamic therapy
(Jones & Pulos, 1993). Other studies compared these same two orientations
with regard to the working alliance (Raue, Castonguay, & Goldfried, 1993)
and client emotional experiencing (Wiser & Goldfried, 1993).
Castonguay (1993) called attention to the unfortunate tendency to equate
“nonspecific” factors with “common” factors. The former refers to
unspecified relational contributions, whereas the latter refers to techniques
(e.g., reinforcement) or strategies (i.e., facilitating corrective experiences)
that are shared by different orientations. Gradually, over the 1990s and
2000s, the global accumulation of common factors was unpacked to
delineate principles, processes, and strategies shared by many theoretical
approaches.
Mahoney, also writing in 1993, maintained that the goal of integration is
not to eliminate differences among the various approaches to therapy, but to
consolidate the unique aspects of each school of therapy (1993a). Given the
complexity of human nature, he suggested that it is necessary and, in fact,
unavoidable to establish an integrative movement that can allow for both a
common factors approach as well as a more dialectical integration. In a
separate article that same year, Mahoney (1993b) traced the theoretical
developments in cognitive psychology since the 1950s. As others had
indicated before him, he noted the large involvement of cognitive therapists
in the integration movement. Schwartz (1993) considered his work on
social cognition and cognitive-affective balance in the development of
psychopathology as an integrative construct. He discussed how balance is
an ideal central construct for an integrative cognitive-dynamic therapy and
noted that dialectical behavior therapy attempts such balance in teaching
clients to transcend artificial polarities through the dialectical process. It
was also in 1993 that Linehan published her landmark book on dialectical
behavior therapy, in which she describes in detail how this approach can be
implemented clinically.
In the edited book Beyond Carl Rogers (Brazier, 1993), several
contributors discussed the frequent move toward eclecticism by therapists
trained in a client-centered mode. Clinicians trained in an “antidogmatic”
approach such as Rogers’s may naturally seek out integration in order to
buttress the effectiveness of their therapy (Hutterer, 1993). Goldfried and
Castonguay (1993) suggested that this openness also characterized
practicing behavior therapists, who have been shown to complement
behavioral methods with contributions from other orientations.
Integrative theories of personality and psychopathology were popular in
the 1990s as well. Writing about the feasibility of integrative approaches to
the study of personality, Millon, Everly, and Davis (1993) suggested that
psychotherapy integration is a sign of a mature clinical science that allows
for a coherent taxonomy of personality disorders. Along with Gaston
(1995), the authors called for such an integrative model of personality.
Others (e.g., Goldfried, 1993) suggested that psychopathology research can
inform integrative therapy by uncovering relevant determining variables
associated with mental disorders. The clinician can then use these
determinants to understand the core issues that need to be addressed in
therapy.
Dutch psychologists Lemmens, deRidder, and vanLieshout (1994)
discussed empirical, conceptual, and linguistic strategies of
psychotherapeutic integration. They propose that these strategies offer ways
to approach integration from a neutral stance. The empirical strategy seeks
to find common factors through research, the conceptual strategy attempts
to develop superordinate constructs, and the linguistic strategy is rooted in
the notion that a common language must exist across orientations to better
understand psychotherapy.
The potential for integration inherent in contemporary behaviorism was a
repeated theme (e.g., Jacobson, 1994). Several integrative therapies derived
from a behavioral orientation—acceptance and commitment therapy,
dialectical behavior therapy, and functional analytic psychotherapy. In this
regard, Goldfried and Davison’s (1976) integration-friendly Clinical
Behavior Therapy was reissued in an expanded edition (Goldfried &
Davison, 1994).
 Further calls came for the integration of psychotherapy into the science
of psychology. Sechrest and Smith (1994) held up behavior therapy as a
fitting example of the successful integration of a psychotherapeutic
approach into mainstream psychology. They went on to say that the
successful integration of psychotherapy into the broader field of psychology
would address the conceptual and scientific limits of psychotherapy.
Weinberger (1995) criticized technical eclecticism as lacking a
theoretical base, which Beutler (1995) countered by stating that the absence
of a single theory of psychopathology and therapeutic change is indeed a
strength, not a weakness. He also stated that traditional theories do not
adequately address mechanisms of change and that individual theories
within a larger theoretical framework vary too much. Also in response to
Weinberger, Gaston (1995) noted that theoretical (not technical) eclecticism
has the ability to “fuel conceptual creativity” by encouraging therapists to
learn all major theoretical approaches.
Proponents of individual theories continued to experiment with the select
incorporation of methods from other, once rival, orientations. In his volume
on rational-emotive behavior therapy, for example, Dryden (1995)
discussed the issues that rational-emotive therapists consider when
choosing to undertake more integrative approaches. With regard to gestalt
therapy, Resnick (1995) maintained that integration is intrinsic to the
approach. Greenberg (1995) pointed out that Wolfe’s (1995) self-
psychopathology can serve as a potential basis for psychotherapy
integration in that it contains a set of integrative treatment principles for
repairing various forms of pathologies that are conceptualized as being
rooted in issues involving the self (see Wolfe, 2005). Acknowledging the
importance of promoting integration at the training level, Robertson (1995)
published a text designed to assist those who are involved in training
clinicians within a theoretically and pedagogically integrative framework.
Goldfried’s (1995) book, From Cognitive-Behavior Therapy to
Psychotherapy Integration: An Evolving View, traced the development of
cognitive-behavior approaches and their eventual implications for therapy
integration. Davison (1995), an important figure in the history of cognitive-
behavior therapy, similarly offered a personal and professional account of
the past 20 years of his career. He elaborated on the therapeutic benefits of
taking a broader therapeutic approach and discussed how his early cases
may have had better outcomes if such a perspective had been taken.
 Two important books to psychotherapy integration were published in
1995. One was McCullough’s (1995) manual for his cognitive behavioral
analytic system of psychotherapy, an intervention developed to treat chronic
depression. It comprises a clinically sophisticated integration of cognitive,
behavioral, and interpersonal approaches (McCullough, 2000) with
empirical support. The other was the publication of Pinsof’s Integrative
Problem-Centered Therapy, in which he describes an approach for
integrating theoretical approaches associated with individual, family, and
biological interventions.
In the mid-1990s, there was evidence that psychiatry continued to take
notice of the psychotherapy integration movement. As one example,
Albeniz and Holmes (1996) noted in the British Journal of Psychiatry that
integration at the level of practice is common and desirable and called for
more clarification of integrative principles at the level of theory. They
concluded that the different orientations should work closely together while
retaining their separate identities.
At about the same time, proponents of integration began to speak out
against wholesale incorporation of lists of manualized, “empirically
supported” therapies. Integration may prove difficult for clinicians working
from a manual (e.g., Goldfried & Wolfe, 1996; Stricker, 1996), and
empirically supported treatments that use such manuals have the potential
to obstruct the integration movement (Fensterheim & Raw, 1996). All of
these authors suggested that because empirically supported treatments have
little to do with actual clinical practice, the flexibility (and potentially
integrative stance) of the clinician is undermined by such treatments.
Several other integration enthusiasts (e.g., Rigazio-Digilio, Goncalves, &
Ivey, 1996) re-emphasized the need for the integration movement to include
cultural and interdisciplinary domains (see Harris, Shukla, & Ivey, this
volume). Historically, individuals interested in psychotherapy integration
have failed to address such issues, and authors suggested that this
constitutes a vital next step for the movement (Perez, 1999).
Books with integrative themes continued to appear in 1996. These
included Gold’s (1996) review of key concepts on psychotherapy
integration and Gilbert and Shmukler’s (1996) volume on how humanistic,
psychodynamic, and behavioral contributions may be used in couples
therapy. In addition, the topic of psychotherapy integration became
increasingly salient in books on psychotherapy theory and technique (e.g.,
Patterson & Watkins, 1996).
In a survey of 268 members of SEPI, respondents ranked the provision of
a forum for the systematic investigation and discussion of integrative
themes as the central priority of that organization (Figured & Norcross,
1996). In addition to continuing as is, the most frequent recommendations
for SEPI were to increase its membership, advocate for integration, offer
training, and produce more research. Overall, the results revealed that
although different benefits of SEPI were endorsed, members were largely
satisfied with both SEPI and its journal.
In 1997, Safran and Messer discussed trends in the integration movement
from the perspective of pluralism and contextualism. They noted that
because therapeutic approaches are rooted in a particular framework, these
concepts might not make sense once they are removed from their context.
Thus, they proposed that the proper goal of integration is to maintain an
ongoing dialogue among the proponents of diverse orientations while
allowing for the discussion and clarification of differences.
Patterson (1997) argued for the use of an integrative approach to
ameliorate the divisiveness that characterizes family therapy. Specifically,
he uses integrative concepts to establish a substrate upon which various
techniques can be added in a coherent fashion. He suggested that doing so
can allow the public and third-party insurers to understand family therapy
more clearly.
The multiple goals of integration came into clearer relief as the
movement developed. Some saw the movement as advancing the
integration of science and practice, maintaining that the psychotherapy
integration model is a step toward the reduction in the incommensurability
of science and practice (e.g., Stricker, 1997). Yet Norcross (1997), writing
that same year in a more pragmatic tone, observed that although integration
is the most common theoretical orientation among psychotherapists, it
continues to lack practical coherence. He underscored the need for outcome
research to establish the effectiveness of integrative treatments, for training
programs that ensured competence in integrative approaches, and for a
clearer delineation of the integration movement’s mission and goals.
Integrative therapy with children also gained traction in the 1990s. Lewis
(1997) emphasized interpersonal and experiential aspects in his discussion
of integrated psychodynamic therapy with children. He noted that the use of
nonpsychodynamic methods does not minimize the psychodynamic theme
but instead enhances it. Likewise, Shirk (1999) drew from the empirical
literature to propose the utility of integrative child therapy. In a commentary
on a special section on psychotherapy integration with children in the
Journal of Clinical Child Psychology, Goldfried (1998) lamented the fact
that integrationist work did not always reflect a broader historical and
conceptual perspective, thereby at times “rediscovering the wheel.” Still,
the significance that an entire issue of such a journal was devoted to
integrative approaches was noteworthy.
Alford and Beck (1997) provided an entire volume on cognitive therapy
as an integrative paradigm for psychotherapy. They maintained that it had
evolved into a multidimensional approach that incorporates interpersonal,
behavioral, and psychodynamic techniques.
In Wachtel’s (1997) update of his original book, Psychoanalysis and
Behavior Therapy, he offered an integrative construct, cyclical
psychodynamics, which addresses fundamentals of both psychoanalytic and
behavioral orientations (see Wachtel & Gagnon, Chapter 9, this volume).
The expanded book, Psychoanalysis, Behavior Therapy, and the Relational
World, deals with how behavior therapy may usefully complement the
intrapersonal and interpersonal contributions of psychoanalytic therapy.
Into the later part of the decade, the call for more research continued,
with relatively little evidence that it was being undertaken. Glass, Arnkoff,
and Rodriquez (1998) noted that empirical research in psychotherapy
integration seriously lagged behind the widespread clinical and theoretical
interest that it had received. They observed that even though some of the
theoretically integrative treatments are based on research, the effectiveness
of the therapeutic models remains, for the most part, unsubstantiated by
empirical investigation. They mentioned four promising integrative
approaches that have received initial empirical support: the transtheoretical
approach, cognitive analytic therapy, process-experiential/emotion-focused
therapy, and eye movement desensitization and reprocessing. However, just
a few years later, the same authors noted that there had recently been a
dramatic increase in outcome research on psychotherapy integration. They
nominated more than a dozen research-based or “evidence-based”
integrative treatments (Schottenbauer, Glass, & Arnkoff, 2005).
Toward the end of the 1990s, integrative themes continued to take root
internationally. For instance, 87% of counselors in the United Kingdom do
not take a pure-forms approach to therapy (Hollanders & McLeod, 1999).
Trijsburg, Colijn, Collumbien, and Lietaer (1998), writing from The
Netherlands; Eagle (1998), writing from South Africa; Carere-Comes
(1999) and Giusti, Montanari, and Montanarella (1995), writing from Italy;
Christoph-Lemke (1999), writing from Germany; and Caro (1998), writing
from Spain, all proffered integrative perspectives from an international
perspective.
In 1999, Jacobson presented an outsider’s perspective on psychotherapy
integration. He suggested that by taking note of the social psychology of
psychotherapy and integration, integrationists might find that they have
heretofore been exaggerating the progress of integration. Some
integrationists took umbrage at Jacobson’s article (Cullari, 1999; Goldfried,
1999), noting that his perspective was tainted with a pessimistic view of the
potential for human change and contained a misunderstanding of the goal of
integration.
Smith (1999) noted that the growing emphasis placed on evidenced-
based treatments might paradoxically lead to a breakdown of traditional
theoretical approaches. He stated that this could have the advantage of
yielding a new kind of “meta-theory” of therapy, which will increase the
applicability of clinical research. Beitman and Yue (1999) presented such a
data-based approach to therapy in a training manual.

Development of a Professional Network

Recognizing the need to provide a reference group oriented toward
rapprochement among the therapies, Goldfried and Strupp, in 1979,
compiled a list of professionals who were likely to be interested in efforts
toward therapeutic integration and wrote to all of these individuals, inviting
them to add their names to an informal “professional network.” Little was
done with this list until 1982, when Wachtel and Goldfried polled those in
the network about potential directions. The respondents expressed their
continued interest in rapprochement and offered their views on what should
be done next: namely, the establishment of a newsletter and the formation
of an organization.
In the summer of 1983, an organizing committee, consisting of Lee Birk,
Marvin Goldfried, Jeanne Phillips, George Stricker, Paul Wachtel, and
Barry Wolfe, met to discuss the results of the questionnaire. It was
immediately apparent that the time was ripe to do something with this
rapidly growing network, and it was agreed that a newsletter and
organization were in order. As later noted by Goldfried and Wachtel (1983,
p. 3), “It was concluded that we needed to achieve a delicate balance: a
formal organization that would facilitate informal contacts among the
members.” Hence, SEPI was formed.
SEPI (sepiweb.org) has evolved into an interdisciplinary and
international organization with annual conferences, a quarterly Journal of
Psychotherapy Integration, and a quarterly newsletter, The Integrative
Therapist. SEPI has also been integral in the development of avenues of
communication among individuals in the same geographical areas who are
interested in psychotherapy integration through its Regional Network
Program. Some meet regularly, and these meetings are open to all interested
therapists, researchers, and scholars in their geographical area. Others are
made up of preexisting groups of mental health professionals from clinics,
universities, and research institutes. There are now SEPI Regional
Networks operating in four states and some 19 countries.
A recent electronic survey of all SEPI members (55% response rate)
found an increasingly demographically and internationally diverse
association (53% women, 39% non-US members) of mental health
professionals employed largely in university settings and independent
practices. Psychodynamic, humanistic, and cognitive-behavioral theories
most influenced respondents’ integrative practices. The most frequent
subtypes of integration were assimilative integration, theoretical integration,
and common factors. Members expressed satisfaction with progress on
most priorities, including providing a “home” for integration (88% member
satisfaction), supplying a forum for discussion (82%), promoting exchange
of information among integration enthusiasts (77%), and offering
conferences and workshops (75%; Norcross, Nolan, Kosman, & Fernández-
Alvarez, 2017).
Although the notion of lowering the boundaries that have existed among
different schools of thought had been a latent theme for some 50 years, the
formation of SEPI has provided the impetus for psychotherapy integration
to become established as a definite and visible movement. It is no longer
novel to hear mental health professionals acknowledge the value of
psychotherapy integration. As indicated at the outset of this chapter, books
have routinely been published in the past decade or two with the term
“integration” in their titles. Many of these have been noted in our historical
overview.
Other publication outlets founded in the twentieth century within the
integrative tradition consist of journals dedicated to that purpose. In
addition to the Journal of Psychotherapy Integration, there is Integrative
Psychiatry and In Session, which appears quarterly as part of the Journal of
Clinical Psychology. In Session offers a state-of-the-art overview of
research and clinical advances on various topics (e.g., posttraumatic stress
disorder, anger, coping with infertility, panic disorder, resistance,
therapeutic alliance). A particularly unique feature is that it not only
describes and illustrates different approaches to a given clinical problem,
but it also highlights the potential for integrating research findings and
clinical practice—a theme that has become more salient in the twenty-first
century.

DEVELOPMENTS IN THE TWENTY-FIRST CENTURY

Extending French’s recommendation in 1932, the twenty-first century saw a
renewed attention to the possibility of closing the gap between research and
practice and its relevance to psychotherapy integration. As will be described
in greater detail later, this concern was addressed by a renewed call for
practice-oriented research and increased involvement of therapists at every
level of the research process. To these ends, task forces were formed, often
in collaboration between different psychotherapy organizations, to foster
clinical research, glean transtheoretical change mechanisms, and provide
pragmatic heuristic recommendations for therapists As well, psychotherapy
integration has expanded to countries well beyond North America. Finally,
there were a number of conceptual developments in psychotherapy
integration, and these new approaches stretched the definition of integration
beyond its four traditional types (i.e., common factors, technical
eclecticism, theoretical integration, and assimilative integration; see
Chapter 1 for fuller description).

Minding the Gap

To address the science–practice gulf, the integration movement has
increasingly expanded its purview beyond the synthesis of diverse schools
of psychotherapy to the integration of practice and research. There have
been renewed calls for clinically relevant research that positions therapists
as integral collaborators in the research process. Castonguay (2013) offered
a comprehensive review of the different approaches within the umbrella
category of practice-oriented research, which has been updated in Chapter
20 of this Handbook.
Practitioners and researchers from around the globe offered their
experiences in conducting practice-oriented research in a special issue of
Psychotherapy Research (vol. 25). Following are several ideas for
narrowing the research–practice gap. For example, Boswell, Kraus, Miller
and Lambert (2015) described their experiences implementing routine
outcomes monitoring and providing feedback and tools to therapists to
improve treatment outcome. Fernández-Alvarez, Gómez, and García (2015)
offered their experiences in developing a patient-oriented research program
within a naturalistic setting where psychotherapy is provided and
psychotherapists are trained through international collaboration with
researchers, therapists, agencies, and universities.
With the same goal of bridging the practice–research gap, the Journal of
Psychotherapy Integration began a recurring series of practice-oriented
evidence reviews. The goal of this series is to glean both clinical and
research implications from basic research findings in such areas as
psychopathology, cognitive science, and social psychology. Articles in this
series connected research findings with clinical practice. For example,
Andersen and Przybylinski (2014) reviewed the research on the social-
cognitive process of interpersonal perception and the clinical implications
of this process in addressing maladaptive interpersonal patterns in therapy.
Pinel, Bernecker, and Rampy (2015) reviewed the social psychology
research on I-sharing as a means to ameliorate existential isolation and how
findings from this body of literature can be applied in clinical practice.
The integration of practice and research has been repeatedly advanced by
interspeciality and interdisciplinary cooperation. Here, we briefly review
three such collaborative efforts: the two-way bridge initiative, the evidence-
based relationships task forces, and the Penn State Conferences. To foster
collaboration between therapists and researchers, a two-way bridge
initiative sought to develop a mechanism through which therapists can
provide feedback about their experiences using empirically supported
treatments modeled after the US Food and Drug Administration’s (FDA’s)
feedback system that facilitates the sharing of physician’s experiences using
approved drugs in the treatment of their patients (Goldfried et al., 2014). In
2011, this two-way bridge initiative became a collaborative effort between
Division 12 and Division 29 of the APA.
As part of this two-way bridge initiative, therapists were surveyed about
their frontline experiences delivering empirically supported
psychotherapeutic treatments to their clients (Goldfried et al., 2014). The
first of these surveys focused on therapist’s experiences providing
psychotherapy for panic disorder, social anxiety disorder, generalized
anxiety disorder, and obsessive-compulsive disorder.
A similar venture among the psychotherapy, clinical, and counseling
divisions of the APA was designed to reduce the practice–research gulf by
identifying and disseminating effective therapy relationships. Virtually all
practitioners agree that the therapeutic relationship proves crucial to
treatment success, but few can reliably identify those relationship elements
that contribute to and predict that success. A series of interdivisional APA
task forces on Evidence-Based Psychotherapy Relationships and
Responsiveness produced original meta-analyses on (1) what works in the
therapy relationship in general and (2) what works in psychotherapy for
particular patients (adaptations/responsiveness). The research results and
clinical practices were widely disseminated in multiple editions of the
ensuing book Psychotherapy Relationships that Work (Norcross, 2011;
Norcross & Lambert, 2019), several special issues of journals
(Psychotherapy, Journal of Clinical Psychology), and hundreds of
presentations and workshops.
As a final example, Castonguay and Hill organized a series of
conferences at Penn State University to spark meaningful debate about
principles of change between clinicians and researchers of differing
orientations (Castonguay, 2011). Each of the three-conference series
focused on a specific change process. The first series focused on insight,
culminating in the publication of Castonguay and Hill’s (2007) Insight in
Psychotherapy. The second Penn State Conference focused on corrective
experiences as a principle of change, with the capstone publication of
Transformation in Psychotherapy: Corrective Experiences Across Cognitive
Behavioral, Humanistic, and Psychodynamic Approaches. Emerging from
the third Penn State conference was How and Why Are Some Therapists
Better Than Others?: Understanding Therapist Effects (Castonguay & Hill,
2017), which explored the often contentious topic of therapist effects.

Conceptual Developments
In accordance with a shifting research climate, conceptual developments
seek to incorporate findings from the broad science knowledge base. As one
example, Magnavita (2008) called for a new type of integrative
psychotherapy—the Unified Psychotherapy Project. Magnavita sought to
widen the scope of sources of knowledge beyond clinical psychology to
incorporate findings from all realms of clinical science, including
developmental psychology, psychotherapy research, neuroscience, and
personality psychology. To further this project, an online Journal of Unified
Psychotherapy and Clinical Science was started in 2012, committed to
forging connections between different realms of clinical science. In
addition, a web-based Wikipedia called Psychotherapedia was created
where researchers and therapists can document current psychotherapeutic
techniques with the ultimate goal of creating a public database for
therapists, researchers, and academics (Magnavita, 2014).
Another conceptual development in psychotherapy integration has been
Brooks-Harris (2008) approach, which seeks to integrate seven theoretical
approaches (cognitive, behavioral, experiential-humanistic,
biopsychosocial, psychodynamic-interpersonal, systematic-constructivist,
and multicultural-feminist) in conceptualizing and treating individual
clients. He argues that synergistic relationships between these seven
orientations originate in their foci on different dimensions of psychological
functioning. For example, cognitive therapy focuses on thoughts, while the
focus of behavioral therapy is actions. Experiential therapy focuses on
feelings, while multicultural therapy focuses on cultural contexts. Brooks-
Harris describes 100 strategies drawn from these seven theories that
therapists can use in response to strategy markers.
In the pragmatic spirit of determining what works best for whom,
conceptual development and empirical research continue to identify specific
client behaviors and transdiagnostic markers that call for specific therapist
methods. The best known and researched in this tradition are the
transtheoretical model (DiClemente & Prochaska, Chapter 8, this volume)
and systematic treatment selection (Consoli & Beutler, Chapter 7, this
volume). The former emphasizes tailoring the change processes and
therapeutic relationship to the patient’s stage of change; in the past 20 years,
hundreds of studies have demonstrated that stage-matching enhances the
effectiveness of self-help and psychotherapy. The latter adapts
psychotherapy to multiple patient features, such as coping style, reactance
level, and functional impairment; recently, it became the first integrative
treatment (to our knowledge) to demonstrate superior client outcomes of
trainees specifically supervised in and following its principles.
In this tradition, Constantino and colleagues developed a clinical marker–
driven transdiagnostic modular approach to psychotherapy integration,
context-responsive psychotherapy integration (CRPI; Constantino, Boswell,
Bernecker, & Castonguay, 2013). CRPI provides a model with which
therapists can adjust their treatment approach to the specific client’s
characteristics, psychopathology, and clinical scenarios that emerge
moment to moment during treatment. Five common markers are alliance
ruptures, low client outcomes, client resistance, client self-strivings, and
information garnered through routine outcomes monitoring. CRPI does not
require that a therapist alter her theoretical orientation or make major
changes to her clinical approach, but allows for assimilation of specific
modules into her existing practice.
For example, it may be prudent for a therapist, when faced with client
negative beliefs about treatment outcome, to employ evidence-based
strategies to foster client outcome expectation. Or, when faced with a
client’s ambivalence about change and/or resistance, the treatment course
may benefit from integrating motivational interviewing strategies—before
returning to the primary treatment. The efficacy of this latter modular
strategy (if client ambivalence/resistance, then motivational interviewing
techniques) has been successfully tested in small pilot studies (Westra,
Aviram, & Doell, 2011) and in a randomized controlled clinical trial for
severe generalized anxiety disorder (Westra, Constantino, & Antony, 2016).

International Growth
In what was primarily started by mental health professionals in the United
States as a need to break down the conceptual and clinical boundaries that
separated different schools of thought, the psychotherapy integration
movement has become international in scope. Indeed, an increasing number
of mental health professional throughout Europe, Latin American, Asia,
Australia, and Africa have become actively involved in psychotherapy
integration. A detailed description of this goes well beyond the scope of our
overview of what is happening in the twenty-first century, but international
efforts are described in detail by Gomez, Iwakabe, and Vaz in Chapter 21 of
this volume.

CONCLUSION
It is now well over eight decades since Thomas French stood before the
1932 meeting of the American Psychiatric Association and suggested that it
might be time to integrate different theoretical approaches and to draw on
empirical research to inform practice. Over the years, his call for integration
has been slow to develop momentum. However, the field has clearly come a
long way, and an increasing number of professionals are actively pursuing
this goal. The zeitgeist is clearly more receptive to integrative efforts than it
has ever been before. Indeed, psychotherapy integration is no longer an idea
that is “too strange or preposterous” to consider (cf. Boring, 1950). It is our
hope that, within this hospitable context, significant advances will continue.

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PART II

Integrative Psychotherapy Models

A. Common Factors/Processes
 3

Integration of Common Factors and Specific

Ingredients
BRUCE E. WAMPOLD AND PÅL G. ULVENES

The history of psychotherapy is characterized by arguments between those

who are convinced that various treatments are superior to others and those
who claim that factors common to all psychotherapies are responsible for
the benefits produced by psychotherapy (Wampold & Imel, 2015).
However, as we discuss in this chapter, this dichotomy is false. Stefan
Hofmann and David Barlow (2014), two vocal advocates of specific
treatments for particular disorders (e.g., Barlow, 2004; Hofmann et al.,
2012), had this to say about common factors: “We do not agree and never
have that so called ‘common factors’ are unimportant, nor do other clinical
scientists” (Hofmann & Barlow, 2014, p. 511). On the other hand, common
factor proponents, at least since Jerome Frank’s work in the 1960s (Frank,
1961), have stressed the importance of particular therapeutic actions to
address the client’s distress: “Jerome Frank discussed the importance of
providing an explanation for the patient’s distress and concomitant specific
therapeutic actions to overcome the distress” (Yulish et al., 2017, p. 329).
Our point is that specific ingredients and common factors are not
mutually exclusive but work together to make psychotherapy effective.
Focusing on the debate between specific ingredients and common factors
ignores their integration, which results in treatment outcomes superior to
approaches that emphasize either the therapeutic actions of a particular
treatment or the common factors.
In this chapter, we describe and illustrate a psychotherapy that integrates
common factors and specific ingredients. Our overall message is that it is
impossible to conceptualize psychotherapy by emphasizing either common
factors or specific ingredients to the exclusion of the other. However, to
make psychotherapy optimally effective, the manner in which the common
factors and specific ingredients are integrated is critical.

THE INTEGRATIVE APPROACH

To understand the contextual model (Wampold & Budge, 2012; Wampold
& Imel, 2015; Wampold et al., 2006), which integrates common factors and
specific ingredients, it is important to consider the historical context.
Although the antecedents of psychotherapy existed in the United States and
Europe prior to Freud’s development of psychoanalysis (Caplan, 1998;
Makari, 2008), psychoanalysis was the first unified theory of
psychotherapy. From the inception of psychoanalysis, there were heated
arguments about the theory and the correct way to practice it. Indeed,
Alfred Adler and Carl Jung were expelled from Freud’s inner circle due to
disagreements about theory and practice (Makari, 2008). This might be said
to be the beginning of the idea that some forms of treatments were superior
to others—implicit in that idea was that treatments have specific and unique
therapeutic actions and that these actions are of paramount importance for
the effectiveness of the treatment. The idea that some therapies are superior
to others due to the potency of their specific therapeutic actions has
continued over the years. As said eloquently by Norcross and Newman
(1992):
Rivalry among theoretical orientation has a long and undistinguished history in psychotherapy
dating back to Freud. In the infancy of the field, therapy systems, like battling siblings,
competed for attention and affection in a “dogma eat dogma” environment. . . . Mutual antipathy
and exchange of puerile insults between adherents of rival orientations were much the order of
the day. (1992, p. 3)

Interestingly, the notion of relationship components and other factors that

are often labeled as common factors was recognized by advocates of the
specific treatments. Indeed, the idea of the alliance, which is probably the
most widely discussed and researched common factor, emanated from
psychoanalytic theory (Horvath, 2017). When making a distinction between
generic psychotherapy and psychological treatments, Barlow (2004) noted
that psychological treatments contained common factors such as “the
therapeutic alliance, the induction of positive expectancy of change, and
remoralization,” much in the way that generic psychotherapy would, but
importantly also contain “specific psychological procedures targeted at the
psychopathology at hand” (p. 873). That is, according to this view, what
makes treatments work are the specific procedures that remediate a
psychological deficit and thus render the patient healthier, even if common
factors are necessary for their delivery.
There are now more than 400 purportedly different therapies (Dattilio &
Norcross, 2006), which would seem to indicate that treatment developers
believe that the specific therapeutic actions of their newly developed
treatment have an effect not obtainable with existing treatments—or so they
lead us to believe. With the possible exception of motivational interviewing
(Moyers et al., 2016; Moyers, Miller, & Hendrickson, 2005) and, of course,
integrative therapies that emphasize common factors, treatments emphasize
what makes them different from other treatments (Goldfried, 1980).
The warrants for claims of superiority have increasingly relied on
outcomes of treatments produced in clinical trials as estimated by meta-
analyses (Tolin et al., 2015; Wampold, 2013; Wampold & Imel, 2015). The
initial meta-analysis of psychotherapy outcomes found that there were few
differences among treatments, particularly after confounds were controlled
(Smith & Glass, 1977; Smith, Glass, & Miller, 1980). Not surprisingly, this
was a conclusion that distressed advocates of behavioral treatments who
contended that their treatments were more effective because they relied on
“scientific” ingredients (e.g., Eysenck, 1978, 1984, 1995; Wilson, 1982;
Wilson & Rachman, 1983). Disputes about the conclusions from meta-
analyses continue (Baardseth et al., 2013; Tolin, 2010, 2014, 2015;
Wampold, Flückiger, et al., 2017) and illustrate that claims of superiority of
treatments and of the importance of specific therapeutic ingredients have
saturated the field of psychotherapy since the beginning. The false
dichotomy continues unabated.
There is a countervailing strand to the specific ingredient perspective in
the development of psychotherapy. In 1936, Saul Rosenzweig observed in a
brief article that advocates claimed that their treatments were beneficial and
that the specific ingredients were responsible for these benefits—and they
provided an explanation for this:
 The proud proponent, having achieved success in the cases he mentions, implies, even when he
does not say it, that his ideology is thus proved true, all others false. . . . [However] it is soon
realized that besides the intentionally utilized methods and their consciously held theoretical
foundations, there are inevitably certain unrecognized factors in any therapeutic situation—
factors that may be even more important than those being purposefully employed. (Rosenzweig,
1936, p. 412)

Referring to the race in Alice in Wonderland in which participants started

when they wanted and ended when they wanted, Rosenzweig used the
metaphor “At last the Dodo bird said, ‘Everybody has won and all must
have prizes’ ” as the subtitle to his article. This refers to both the
competition among the psychotherapies and the generally equivalent
outcomes among them. The equivalence of the benefits of psychotherapy
has even been called the Dodo Bird effect. Rosenzweig’s “unrecognized”
factors have become known as common factors, as they are aspects of
therapy that are common to all, or at least most, psychotherapies and
include such aspects of therapy as hope, expectation, therapeutic
relationship, treatment ritual, and corrective experiences.
Since Rosenzweig introduced the notion of common factors, many
researchers and theoreticians have discussed them, developed taxonomies,
and proposed theories about how they work (e.g., Castonguay, 1993; Frank
& Frank, 1991; Garfield, 1992; Grencavage & Norcross, 1990; Orlinsky &
Howard, 1986; Tracey et al., 2003; Wampold & Imel, 2015). Jerome
Frank’s model has been arguably the most grounded in a theory of change
(Wampold & Imel, 2015). His (and the last one co-authored with Julia
Frank) editions of Persuasion and Healing (Frank, 1961, 1973, Frank &
Frank, 1991) provided a model of how change occurs in various healing
practices. The model presented here is in many ways an extension of
Frank’s model.

CHANGE PROCESSES AND THERAPEUTIC RELATIONSHIP

The contextual model (Wampold & Imel, 2015) is a meta-model of how
psychotherapy works. Central to the model are three pathways to change:
(1) the real relationship, (2) expectation through explanation and treatment,
and (3) specific ingredients. Its basic premise is that humans are evolved to
heal in a social context (Humphrey, 2002). For example, there is evidence
that the facial expression of pain, which is culturally and time invariant,
evolved to signal the need for social support to assist the person with pain
(Steinkopf, 2016). There are social healing practices in all societies, with
designated healers and healing rituals, and these have existed since the
earliest Homo sapiens (Frank & Frank, 1991; Shapiro & Shapiro, 1997;
Wilson, 1978). In fact, eusocial insects heal through social means (e.g.,
ants; Konrad et al., 2012).
Most psychotherapy theories delineate how a therapy works,
emphasizing particular therapeutic actions or change processes. The
contextual model recognizes the importance of these therapeutic actions,
but integrates them with the relationship between therapist and the client.
Healing properties of the relationship can provide a foundation or vehicle
for delivering the specific ingredients. Providing an explanation and a
means to overcome one’s difficulties elicit healing responses, most likely
through the creation of positive expectation and hopefulness. And, finally,
enacting specific therapeutic actions has benefits for the client.
The multiple pathways to change can be active simultaneously during the
course of therapy, as shown in Figure 3.1. Some theories will emphasize
one pathway more than others, but the contextual model suggests that the
benefits of psychotherapy are optimized when all three pathways are
activated and utilized.

FIGURE 3.1 The Contextual Model.

The client comes to therapy with distress—he or she is having difficulties

in life and likely has tried many strategies to overcome his or her problem,
all of which have failed to produce the desired changes. In Jerome Frank’s
term, the client feels demoralized (Frank & Frank, 1991). Of course, the
client is more than a human with symptoms—the client has a personality, a
racial/ethnic identity, a social network (or lack of), economic resources (or
lack of), an occupation/vocation/work history and situation, a history, and
current life events (e.g., recent death of a family member). The therapist
also comes to the initial meeting with a personality, a racial/ethnic identity,
a history, and current life events, as well as professional training and a
theoretical orientation. It is a meeting of strangers imbedded in a
professional context.
The patient is seeking immediate answers to some questions: Can this
therapist understand me and my problems? Can I trust the therapist? Does
the therapist have the capacity and expertise to help me? Bordin (1979),
who developed the pantheoretical concept of the therapeutic alliance, noted
that an initial bond was necessary before beginning therapeutic work:
“Some basic level of trust surely marks all varieties of therapeutic
relationships, but when attention is directed toward the more protected
recesses of inner experience, deeper bonds of trust and attachment are
required and developed” (p. 254).
The formation of the initial bond is a combination of top-down and
bottom-up processing. Clients presenting to psychotherapy have some
notion of what will be involved. They may have received therapy
previously, read about therapy, received information from friends and
family, or assimilated cultural conceptualizations of therapy. Hopefully, this
top-down processing involves the belief that therapy will prove effective. It
appears that patients experience significant benefit from the time they make
the initial appointment to the time they present for the initial meeting with
the therapist (Frank & Frank, 1991), as they are remoralized because they
believe their involvement in the impending psychotherapy will be helpful.
In addition, there is bottom-up processing of information from the
therapy experience. Having viewed another person’s face, humans make
quick judgments about the trustworthiness of another person (Willis &
Todorov, 2006). But the therapist (or the face of the therapist) is not the
only sources of information processed. The psychotherapy context itself is
critical—the warmth and efficiency of the clinic staff, the attractiveness and
comfort of the waiting room, the therapy room itself, including diplomas
and pictures hung on the wall, will create strong feelings about the
psychotherapy experience. There is emerging evidence that the clinic at
which therapy is conducted has an influence on outcome (Falkenström,
Grant, & Holmqvist, 2018). It is clear that the initial interaction and patient
engagement early in therapy is critical to the success of therapy, if for no
other reason than the fact that most patients who drop out of therapy
prematurely do so after the first session or two (Connell, Grant, & Mullin,
2006; Simon & Ludman, 2010; Swift & Greenberg, 2012).

The Real Relationship

The client and the therapist have distinct roles in treatment—the client has a
problem, complaint, or disorder that he or she wants resolved, and the
therapist is the healer, providing something of value to the client based on
his or her training and experience. Despite these roles, psychotherapy
involves an intimate interpersonal relationship between two human beings.
This relationship can be described psychodynamically as the transference-
free genuine relationship based on realistic perceptions (Gelso, 2009),
where genuineness is defined by Gelso and Carter (1994) as “the ability and
willingness to be what one truly is in the relationship—to be authentic, open
and honest” (p. 297) and realistic perceptions as “those perceptions that are
uncontaminated by transference distortions and other defenses . . . [the
therapist and patient] see each other in an accurate, realistic way” (p. 297).
In therapy, the real relationship involves a therapist who is warm, caring,
and empathic with an understanding that this relationship will continue
regardless of the material discussed (albeit with exceptions; e.g., for clients
reporting they are a danger to themselves or others).
The real relationship is therapeutic in and of itself. According to the
literature, the real relationship is thought to be fundamental to humanistic
approaches, important for dynamic therapies, but generally not emphasized
by most behavioral and cognitive therapies. However, there is a compelling
clinical and empirical case to be made that the real relationship is critical to
the benefits of all types of psychotherapy (Gelso, Kivlighan, & Markin,
2018).
Humans evolved as social animals, and attachment is fundamental to the
survival of humans, as discussed by many prominent theorists (Cacioppo &
Cacioppo, 2012; Holt-Lunstad, Robles, & Sbarra, 2017; Lieberman, 2013;
Wilson, 2012). Indeed, there is compelling evidence that perceived
loneliness places an individual at as great or greater risk for mortality than
smoking, obesity, environmental pollutants, and physical inactivity (for
general populations or those at risk of cardiac events; Holt-Lunstad et al.,
2017; Luo et al., 2012). Indeed, holding the hand of a loved one or even
having a beloved person in the room increases tolerance of pain, with
expected concomitant neural processes (Benedetti, 2011; Coan, Schaefer, &
Davidson, 2006), suggesting that individuals in higher quality relations
benefit from greater regulatory effects on neural systems involved in
negative emotions (Butler & Randall, 2013).
The impact of empathy on healing in medicine has been discussed
extensively (e.g., Decety & Fotopoulou, 2015). This effect has been shown
in research on placebos, where the evidence indicates that the placebo effect
for a number of conditions is augmented when the placebos are
administered by a warm and caring clinician who is perceived as competent
(Fuentes et al., 2014; Howe, Goyer, & Crum, 2017; Kaptchuk et al., 2008;
Kelley et al., 2009).
An empathic relationship is healing in itself and augments the
effectiveness of other aspects of psychotherapy (Elliott et al., 2018).
Treatments without any therapeutic actions other than meeting with a warm,
caring, and empathic therapist are remarkably effective (Honyashiki et al.,
2014; Smits & Hofmann, 2009). Fortunately, practitioners need not rely
only on the real relationship for all clients, but it serves as the foundation
for other therapeutic processes and actions.
Some clients will benefit more from the real relationship than others.
Clients with problematic attachments styles, poor social support,
impoverished social networks, chaotic interpersonal relations, and features
of borderline personality disorder will benefit more from the real
relationship than patients with relatively supportive interpersonal
relationships. However, it may be that an intense and emotional
interpersonal relationship could be detrimental, at least initially. Clients
with paranoid features or autism spectrum disorders, for example, might
find the intensity of such a relationship stressful and avoid psychotherapy as
a result.

Creation of Expectation Through Explanation and Treatment

Patients may come to therapy with an explanation for their distress, but
typically the explanation does not directly lead to solutions. These
maladaptive explanations, sometimes called “folk” psychology, are beliefs
about the cause of distress and solutions for overcoming difficulties. These
beliefs are culturally influenced and are often acquired from family, friends,
and influential others, as well as from the larger society (e.g., in
advertisements for psychotropic medications; Hutto, 2004; Stich &
Ravenscroft, 1994; Thomas, 2001). These explanations are not labeled as
“maladaptive” because they are unscientific—although surely many are—
but because they fail to lead the patient to find solutions to what is
distressing (Wampold & Imel, 2015; Wampold et al., 2006).
In psychotherapy, the clinician provides the client with an adaptive
explanation for his or her distress and a means for overcoming difficulties.
That is, the client comes to believe that participating in and successfully
completing the therapeutic tasks will be helpful in coping with his or her
problems, which then further creates the expectation that the patient has
“control” over his or her problems. These expectations and beliefs are
central to theories of how individuals change and behave, including theories
involving mastery (Frank & Frank, 1991), self-efficacy (Bandura, 1999),
and response expectancies (Kirsch, 1985, 1999).
It is well known, scientifically as well as clinically, that outcome
expectations have a large effect on what is experienced. Compelling
evidence for the power of expectations is found most profoundly in the
placebo literature (see Benedetti, 2014; Kirsch, 1985; Price, Finniss, &
Benedetti, 2008). A few perspicuous results will be convincing of the power
of expectations. Taking a placebo analgesic with the expectation that the
substance or procedure will reduce pain reduces the experience of pain
(Benedetti, 2014; Price et al., 2008, for a comprehensive review).
Furthermore, taking the placebo results in the release of endogenous opioids
into the brain, indicating that the placebo effect is not simply a subjective
response but is mediated by physiological processes. Moreover, in an
“open-hidden” paradigm, surreptitiously administering a postsurgical
patient a dose of morphine (the hidden condition; e.g., by an intravenous
infusion from a machine out of the awareness of the patient) is less effective
than when the patient is aware that the drug is being administered (open
condition; e.g., a clinician indicates to the patient that the drug is being
delivered) (Benedetti et al., 2003). What is clear from hundreds of other
studies is that the patient’s expectation for pain relief results in pain relief
and that the expectations are created by what is said to the patient—that is,
in a verbal interaction with a healer.
Demonstrable placebo effects are not limited to pain. Parkinson patients
benefit from placebos both in terms of symptoms (viz., motoric activity) but
also in levels of dopamine in the brain (Benedetti, 2014). In another
interesting study, female hotel room attendants were told that their everyday
work was good exercise. Compared to hotel workers who were not
provided any information, the informed workers reported that they got more
exercise and they had better health indicators (lower weight, lower blood
pressure, and less body fat), even though they did not do more exercise
(Crum & Langer, 2007). More than 90% of the effect of antidepressants is
probably due to the placebo effect (Kirsch, 2009; Kirsch et al., 2008).
Positive expectations about the effectiveness of chamomile extract for
generalized anxiety created symptom relief after receiving the extract
(Keefe et al., 2017).
Expectations in psychotherapy have a strong influence on the benefits
experienced. For example, many studies show that expectations about
therapy are determinants of the final outcome in the treatment of anxiety
(Borkovec & Costello, 1993; Brown et al., 2014; Chambless, Tran, &
Glass, 1997; Kirsch et al., 1983; Newman & Fisher, 2010; Rutherford et al.,
2015; Westra, Dozois, & Marcus, 2007). Meta-analyses of psychotherapy
studies examining the relation of expectations and outcome find medium-
sized effects (Constantino et al., 2018), and reviews suggest that it is
important for therapists to deliberately create positive expectations for
change (Constantino, Ametrano, & Greenberg, 2012; Yulish et al., 2017).
As well, psychotherapy clients who attribute their therapeutic gains to their
own efforts rather than to a medication they had taken (which was actually
a placebo) were significantly less likely to relapse (Liberman, 1978; Powers
et al., 2008).
Simply creating expectations through providing the patient an
explanation for the distress and describing the treatment are not sufficient.
The client must actually enact the therapeutic procedure—explaining that a
pill will decrease pain must be accompanied by taking the pill. The
explanation and procedure/ritual work together; the client must believe that
therapeutic progress is a result of his or her own efforts, providing a sense
of control over the person’s distress.
A critical aspect of explanation and therapeutic actions is acceptance of
the explanation and agreement about the tasks of therapy. This aspect is
embodied in the tripartite concept of the therapeutic alliance: the bond
between the patient and the therapist, agreement about the goals of therapy,
and agreement about the tasks of therapy (Bordin, 1979; Hatcher &
Barends, 2006; Horvath, 2006). More than 300 studies have investigated the
correlation of alliance with outcome across all forms of psychotherapy and
found meta-analytically that there is a strong association between the
alliance, measured early in psychotherapy, and the final outcome (Flückiger
et al., 2012, 2018; Horvath et al., 2011). The alliance capitalizes on the
collaborative effort undertaken in the therapeutic relationship, and, as
already indicated, the therapist and patient work together toward mutually
agreed upon goals using means that the patient agrees are relevant for the
problem at hand.

The Specific Ingredients

The power of therapeutic procedures is not limited to their created
expectations. The first two pathways in the contextual model set the stage
for the client to collaborate with the therapist to do something that is good
for the client. Different treatments will utilize different therapeutic actions.
Cognitive-behavioral therapists work with clients to reduce dysfunctional
thinking and behavior, interpersonal therapists work to improve the quality
of relationships, and dynamic therapists encourage the expression of
avoided emotions. For most disorders, different treatment actions have
proved effective (Wampold & Imel, 2015).
Of course, every approach to psychotherapy has a different explanatory
system for disorders, as Laska, Gurman, and Wampold (2014) describe in
reference to posttraumatic stress disorder (PTSD):
Each [treatment] posits a specific mechanism of change based on a given scientific theory. For
example, prolonged exposure (PE) for PTSD (Foa, Hembree, & Rothbaum, 2007) is
conceptually derived from emotional processing theory (Foa & Kozak, 1986), and the specific
ingredients of PE (viz., imaginal and in vivo exposure) (a) activate the “fear network,” (b)
whereby clients habituate to their fears, and thus, (c) extinguish the fear response. On the other
hand, interpersonal therapy (IPT) for PTSD (Markowitz, Milrod, Bleiberg, & Marshall, 2009) is
derived from interpersonal and attachment theory (Bowlby, 1973; Sullivan, 1953) and “focuses
on current social and interpersonal functioning rather than exposure” (Bleiberg & Markowitz,
2005, p. 181). (p. 468)

Several features of the specific ingredients probably account for their

contribution to successful psychotherapy. The first is that there is evidence
that the particular ingredient used is not important, as long as the ingredient
is credible to the patient (Constantino et al., 2018; Devilly & Borkovec,
2000). There is little evidence that any one treatment is superior to another
(Wampold & Imel, 2015); even when there are differences, they are small,
are limited to targeted symptoms, disappear at follow-up, and are probably
due to methodological aspects rather than to the ingredients themselves
(Wampold, Flückiger, et al., 2017). The second point is that when the
specific ingredients are removed from treatments (in dismantling designs),
treatments without the removed ingredient generally prove as effective as
the entire treatment (Ahn & Wampold, 2001; Bell, Marcus, & Goodlad,
2013). A third point is that adherence (or fidelity) to a treatment protocol is
not consistently related to outcome (Boswell et al., 2013; Webb, DeRubeis,
& Barber, 2010) whereas flexibility seems to be related to better outcomes
(Owen & Hilsenroth, 2014; Wampold & Imel, 2015).
Some would take the evidence about particular theoretical ingredients to
infer that having specific ideas about what actions maintain and what
actions can change a condition is not necessary or that a therapist can do
anything and it will be effective. This is wrong. For therapy to be optimally
effective, the patient must work toward goals that are meaningful to him or
her based on a credible explanation and convincing means to achieve those
goals. Jerome Frank (1961, 1973; Frank & Frank, 1991) made it clear that a
therapeutic “ritual” was one of the most important—if not essential—
common factors. The client’s dedicated work toward a goal and attribution
that such work is beneficial is a vital component of successful therapy (i.e.,
the third pathway of the contextual model). The results of clinical trials
show that a particular ingredient may not be critical—what is important is
the client’s work toward his or her goal (Yulish et al., 2017).
From our viewpoint, the scientific validity of the explanation of distress
and the therapeutic actions is not what is important; rather, it is the client’s
acceptance and engagement in these aspects that is needed. That is, the
explanations must be credible to the patient.
This point can be understood by examining the literature on panic
disorder. Cognitive-behavior therapy (CBT) for panic contain various
actions derived from a theoretical understanding of panic disorder (Barlow
et al., 1989; Clark et al., 1994), yet the theoretical models proposed for
panic disorder have not been empirically verified, and it is questionable
whether they are verifiable (Roth, Wilhelm, & Petit, 2005). Furthermore,
opposite breathing techniques (viz., hypoventilation and hyperventilization)
have the same effect on panic symptoms as they do on control of blood
levels of carbon dioxide (Pco2)and respiration rates (Kim, Wollburg, &
Roth, 2012). The effect of breathing exercises for anxiety seems to be due
to the therapeutic relationship, expectancy, and credibility (Kim, Roth, &
Wollburg, 2015), the latter two derived from having credible tasks that
make sense to the client and that create positive expectations. Finally,
psychoanalytic treatments for panic are effective (Busch, Milrod, &
Sandberg, 2009; Milrod et al., 2007).
A final point is that there is evidence to support focusing on the client’s
problems and working toward their solution. In clinical trials, control
treatments without any specific therapeutic actions (i.e., the therapist is
proscribed from actions that would be classified as “specific” to a
treatment) perform remarkably well (Honyashiki et al., 2014; Smits &
Hofmann, 2009), capitalizing on the first pathway of the contextual model.
Interestingly, several treatments were believed to be inactive controls, but,
when given structure, therapeutic actions that the therapist and client
believed were effective and that involved psychoeducation were found to be
as effective as the first-line treatments. For example, interpersonal therapy
for depression and present-centered therapy for PTSD were designed as
nonspecific controls but now are designated as psychological treatment with
research evidence (see Wampold & Imel, 2015). Thus, focusing on the
client’s problem, providing an explanation for the problem, and instituting
specific therapeutic actions (the second two pathways of the contextual
model) seem to render the treatments more effective, particularly for
targeted symptoms (Yulish et al., 2017).
The contextual model is not a common factor therapy as such, but rather
an explanation of why specific interventions may be effective. Thus, CBT,
psychodynamic approaches, emotion-focused treatments, and so forth are
consistent with the contextual model. Rather than saying “I am a Contextual
therapist,” practitioners might say “I am a [fill in the blank . . . CBT,
dynamic, emotion-focused] therapist who delivers the treatment in a
contextual model manner.” Or, even more to the point, “I choose a
treatment that I am confident can provide a convincing explanation and
prescribe therapeutic actions that are logically coherent with my
explanation in a convincing way (i.e., that will be accepted by the client).”
The contextual model is integrative in that the actions endemic to a
particular treatment are put into relationship context. In this way, the
common factors give potency to the specific ingredients.

ASSESSMENT AND FORMULATION

There are several ways to think about assessment and case formulation in
the contextual model. The first involves the assessment of the client in the
usual sense that this term is used (e.g., by doing diagnostic assessments
according to the Diagnostic and Statistical Manual of Mental Disorders
[DSM-5] or the International Classification of Disease [ICD-10] codes).
Different approaches to psychotherapy place different emphasis on client
assessment. The same can be said for case formulations—a CBT case
formulation will probably differ from a psychodynamic formulation. The
contextual model is agnostic with regard to these assessments and case
formulations as concerns their usefulness in planning and delivering
treatment.
From the contextual model point of view, what is important is the client’s
experience of the assessment, although information from the assessment
itself might be useful. The client should experience the assessment as the
genuine interest of the therapist to know more about the client—the client
should, as a result of the assessment, feel better understood. As well, the
client should believe that this knowledge will help the therapist develop a
treatment that will be more effective and congruent with the client’s
presenting problems. On the other hand, if the assessment is experienced as
impersonal, routine, or otherwise unhelpful, the relationship with the
therapist may be harmed and psychotherapy may not be optimally effective.
The formulation that the therapist develops might well be useful for
developing an effective intervention for the client. But critical to the success
of therapy is the acceptance of the explanation for distress and the treatment
actions. No matter how cogent the formulation, what is important from a
contextual perspective is how it is communicated to the client and whether
it makes sense and is accepted.
In the contextual model, ongoing assessment of the relationship
components of psychotherapy is important. There are assessment devices
for most of the common factors, such as the alliance, expectations,
treatment credibility, and positive regard/affirmation (Norcross & Lambert,
2018). Several routine outcome monitoring systems have incorporated
relationship variables into their assessments, so that therapist have
information about client progress (outcome) as well as about the
relationship factors that might account for client progress (Chow et al.,
2015; Duncan & Reese, 2015; Lambert et al., 2005).
APPLICABILITY AND STRUCTURE
The contextual model is a meta-model in that it applies to all types of
treatments with all types of clients. Some treatments focus on one aspects of
the contextual model. For example, a long-term humanistic treatment would
probably emphasize the real relationship, whereas a short-term CBT for a
particular disorder would rely on the specific ingredients and treatment
procedures. It is our contention that both those treatments, despite their
obvious differences, would benefit from emphasizing all pathways of the
contextual model. The same applies to every other treatment. The
humanistic therapist should give thought to the structure of the treatment,
how the client connects what is done in therapy to achieving his or her
goals, and how various actions in therapy as well as between sessions
promote psychological growth and distress reduction. On the other hand,
the CBT therapist should understand that the real relationship, feeling
understood and cared for, and expectations that are created through
explanation are important determinants of outcome in psychotherapy. In the
integrative tradition, adherence to the contextual model would suggest more
structure and focus for traditionally unstructured treatments and more focus
on relationship and expectations in more structured treatments.

METHODS AND TECHNIQUES

As discussed earlier, the contextual model integrates common factors and
specific ingredients, but it is not a treatment protocol that guides treatment
in the way that a manual for a particular treatment would. Nevertheless,
attention to the contextual model can be used to assess and improve the
quality of just about any treatment. The therapist should monitor the quality
of each pathway by asking the following questions:
◆ What is the quality of the real relationship?
◆ Does the client feel understood and cared for?
◆ Is there a sufficient bond to do the difficult work of therapy?
◆ Does the therapist understand the folk psychology or explanatory
model of the client?
◆ Does treatment privilege or take into account cultural practices, life
context, and other factors?
◆ Was a cogent and convincing explanation for the client’s distress
provided (i.e., psychoeducation), and was it accepted by the client?
◆ Has the therapist persuasively presented a cogent treatment plan
consistent with the explanation for distress? Was the plan accepted by
the client?
◆ Are the therapist and client working collaboratively on the treatment
plan toward consensual goals?
◆ Is the client participating in the therapeutic actions?
◆ Is therapy progressing? That is, is there less distress, progress toward
goals, improved relationships, greater well-being? If not, make sure
there is sufficient attention paid to other components of the contextual
model.

DIVERSITY CONSIDERATIONS
By its nature, the contextual model is transcultural because it applies to
most healing practices and to clients of various ethnicities, genders, sexual
orientations, religions, and other cultural identities. As noted earlier,
endemic to the therapy process is that the folk psychology of the client
needs to be assessed and explanations and treatment design must be
congruent with the patient’s understanding of the problem, but the therapy
process must also have an adaptive component so that there will be
opportunities to change. A client who believes that his or her failure is due
to poor genes from his or her parents, which conferred low intelligence,
must come to have an alternative explanation that involves something that
can be changed.
Care must be taken in this process. Many manualized therapies have
psychoeducation components, a feature that is consistent with the
contextual model. However, “canned” psychoeducation is often composed
of Western rational and scientific-sounding components and consequently
will not be congruent with the cultural values of many groups. A meta-
analysis of culturally adapted, evidence-based treatments found that those
treatments that adapted the explanation given to various racial, ethnic,
language, and cultural groups had better outcomes (Benish, Quintana, &
Wampold, 2011; Duncan & Reese, 2015). A component of the contextual
model is an assessment of whether therapy is progressing and the patient
improving. If not, one of the things the therapist should consider is whether
cultural factors are part of the reason for lack of progress.

CASE EXAMPLES

Case Example 1: Abby: A Case of Sudden Deterioration

Abby is a 22-year-old white American who grew up on a farm where both
of her parents struggled with opioid addiction, and she had a history of
physical abuse from both parents. Abby attempted to “leave her bad family”
behind by attending college. She felt disoriented at college (a large land-
grant institution), which she attributed to her being different from other
undergraduates who seemingly grew up in functional families. She met the
criteria for major depressive disorder. She had been seeing a CBT therapist
and had been making adequate progress. But, in the fifth session, she
presented in a rather disheveled manner, her affect was flat, and she did not
appear engaged (e.g., had difficulty making eye contact).
The therapist, who noticed the change in demeanor and presentation,
summarized the progress in therapy and asked Abby about the assigned
homework. She responded as follows:
Abby: I did not feel like doing it. So, I didn’t do it.
According to the contextual model, there is no “right” way to proceed but
the therapist should consider each of the model’s pathways. Suppose that
the therapist hypothesized that something, either external or internal, has
led to this sudden worsening. The therapist could decide to accept this
situation:
Therapist(in empathic manner): Abby, you seem really sad and discouraged
today. You look like someone piled a sack of bricks on your back and asked
you to walk up the hill to class.
 Alternatively, the therapist might be thinking that the bond between them
was sufficient when they were working successfully, but now whatever has
happened is too difficult to talk about with this therapist.
Therapist: I sense that something has happened with you but you find it
difficult to talk with me about it.
The therapist might have assessed that the agreement about the tasks
related to changing dysfunctional thoughts was not agreeable to Abby but
that she went along with it, thinking that it might help anyway.
Therapist:I am thinking that you don’t find the work on dysfunctional
thinking all that helpful. I think we should talk about whether these
exercises are useful to you so that I could clarify why they are helpful or we
might change them or do something different.
Then again, the therapist might have concluded that there was a strong
enough bond to do the work and sufficient agreement on tasks to proceed.
The therapist might not have wanted to reinforce the depressive mood and
recognized the ups and downs of depressive disorder:
Therapist:
It is not unusual for those with depression to experience ups and
downs. We were making good progress, so I am wondering whether there
was anything about this particular assignment that turned you off? It would
be helpful to complete it, so are you agreeable to giving it another go?
On the other hand, the therapist might have felt that Abby was feeling
profoundly alone, had little or no social connection, felt alienated both from
family and those at the university, and what she really wanted and needed
was someone to understand her.
Therapist:Abby, I get the sense that your loneliness is overwhelming
sometimes—there is no one in your life right now who supports you, cares
for you, and wants to see you succeed. Doing these exercises might seem
like putting a Band-Aid on a deep wound to your soul. We certainly can
come back to them another time, when you feel like they would be helpful.
Therapists have a variety of options to determine which tack to take with
any client. Some are determined by the theoretical orientation, but what the
contextual model makes clear is that the therapist has to consider the
multiple ways that clients make use of therapy.

Case Example 2: Tshua: A Hmong Gentleman Without a Soul

Tshua is a 69-year-old male Hmong American who was referred by his
physician for depression after a heart transplant. Many of Tshua’s family
members were killed during the secret war in Laos, and the remainder have
passed away since then. His therapist was a young Hmong woman training
to be a psychologist. Tshua discussed with the therapist that, in his
experience of Hmong culture, his heart was where his soul was and that
through the transplant he had lost his soul. The therapist, trained in the
importance of the alliance, worked diligently to establish goals of therapy,
but Tshua was not inclined to be goal-directed.
Tshua: You know, Kiab [the name of the therapist], I am lonely. I come here
to talk to you. I am too old to have goals, there is nothing I want to change.
Please let me just come and talk about life.
The psychologist trainee was frustrated because she wanted this therapy
to be successful, to document that she delivered treatment in an optimal
way. She was required to document in the client’s chart his goals of therapy,
the treatment plan, and clinical progress. On the other hand, culturally, the
trainee was expected to honor her elders, which would be contradictory to
pushing her client to agree on measurable treatment goals if he did not want
to do so. She consulted her supervisor, who encouraged her to emphasize
the real relationship (the first pathway of the contextual model). In the next
session, the therapist told the client the following.
Therapist: Tshua, I want you to get what you want from coming to
counseling. Your stories are terribly sad, but I learn much about you and our
people from your wisdom. Sometime in the future, we can come back to
having goals to work on if we want, but for now, please tell me more about
your life.
Tshua: [with tears in his eyes] Thank you.
Some might say that the trainee was not doing psychotherapy, but,
according to the contextual model, she was certainly providing
psychotherapy through the first pathway of the model. However, the
psychotherapy could also be understood to encompass all three pathways of
the Contextual model, and, as such, there are reasons to be hopeful for the
progression of Tshua’s therapy. Through the assessment, it is clear that the
patient was depressed, and clearly loneliness was central to his distress. At
this stage in therapy, the goal may be to help Tshua feel understood and less
lonely. The means for achieving this was to meet with the therapist weekly
and share experiences and stories that he does not have anyone else to share
with. Through this understanding it may be possible for Tshua to expect that
his loneliness and depression can disappear. Working toward achieving this
goal, new goals might appear, such as Tshua finding ways to connect with
other people in addition to his therapist.

OUTCOME RESEARCH
The research supporting the contextual model was reviewed extensively by
Wampold and Imel (2015) as mentioned earlier, and the relationship
components of the contextual model were investigated and supported by
multiple meta-analyses in Psychotherapy Relationships That Work
(Norcross & Lambert, 2018). Here, the major conclusions are summarized.
◆ All treatments intended to be therapeutic and which contain elements
of the contextual model are approximately equally effective, in general
and for specific disorders.
◆ Psychotherapies composed of only the first pathway (i.e., without an
explanation for distress or specific therapeutic actions) are effective.
◆ However, treatments without a focus on the patient’s distress, without
explanations for distress, and without actions focused on the patient’s
problems are less effective than treatments than contain these
ingredients.
◆ Expectations created in an interpersonal relationship have a strong
association with outcomes, as shown in placebo and psychotherapy
studies.
◆ The alliance, including the bond, agreement on therapy goals, and
consensus on the tasks of therapy, is robustly related to psychotherapy
outcome.
◆ Warmth, empathy, positive regard, and genuineness (real relationship)
are associated with outcome in psychotherapy.
◆ Tailoring psychotherapy to the patient’s culture and preferences
reliably increases the effectiveness of psychotherapy (Norcross &
Wampold, 2018).

FUTURE DIRECTIONS
The contextual model was constructed based on research and theory across
the social sciences, including anthropology, social psychology,
neuroscience, placebo studies, and evolutionary psychology, as well as
psychotherapy research. The continued development and refinement of the
model requires additions to all the pathways of the model as research
accumulates. For example, the model currently and rightfully considers
patient expectations but does not capitalize on recent research showing that
client preferences exert at least as strong, and probably stronger, an effect
on therapy outcome (Swift, Callahan, & Vollmer, 2011; Swift et al., 2018).
In addition to cultural adaptation, contextual therapists can also profit from
tailoring therapy to a client’s stage of change, reactance level, and coping
style (Norcross & Wampold, 2018).
Work needs to be done on the utility of applying the contextual model to
train and guide therapists. That is to say, the model is based on robust
behavioral evidence, but whether it proves useful to psychotherapists is
untested.
The contextual model suggests that relationship skills are critical to the
success of psychotherapy. There is evidence that more effective therapists
have a sophisticated set of interpersonal skills that are demonstrated in
challenging interpersonal environments (Anderson et al., 2009; Schöttke et
al., 2017; Wampold, Baldwin, Holtforth, & Imel, 2017). A vital question is
whether such skills can be taught and practiced and whether increasing
competence in these skills will improve a therapist’s outcomes. There is a
burgeoning movement in psychotherapy that claims that deliberate practice
of these interpersonal skills in the psychotherapy context will improve
outcomes (Rousmaniere et al., 2017), but there is only preliminary evidence
that therapist deliberate practice will improve therapist’s outcomes (Chow
et al., 2015; Goldberg et al., 2016) and more research on this idea is needed.
There is another complexity involved here. It may well be that many of
the relationship factors work differently in different therapies (Hoffart et al.,
2012; Ulvenes et al., 2012; Webb et al., 2011). Thus, using the contextual
model to guide therapy may depend on the type of therapy being delivered.
Three major ways have been suggested to improve the quality of
psychotherapy: (1) dissemination of evidence-based treatments, (2) use of
routine outcome monitoring and feedback to therapists (and patients), and
(3) improving the outcomes of individual therapists by deliberate practice
of clinical skills. Although not fully examined, option (3), which is based
on the contextual model, offers an innovative alternative or addition to other
attempts to improve mental health services.

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 4

A Principle-Based Approach to Psychotherapy

Integration
CATHERINE F. EUBANKS AND MARVIN R. GOLDFRIED

A principle-based approach to psychotherapy grew out of a desire to

enhance clinicians’ abilities to help their clients by integrating ideas from
different schools of thought. This approach facilitates such integration by
focusing on principles of change shared across orientations. In addition to
lowering the barriers between theoretical schools, this approach also
facilitates the integration of research and practice by privileging change
principles that have empirical support. In doing so, it provides a
transtheoretical framework that encourages therapists to enact these
evidence-based principles in a flexible, responsive, and hopefully more
effective way. Keeping the principles in mind is much more feasible and
practical than trying to integrate across hundreds of potential techniques.

THE INTEGRATIVE APPROACH

Early in his career, the second author (Goldfried) found that, although his
preferred theoretical orientation of behavior therapy seemed to be an
effective means of helping many patients, focusing solely on overt behavior
and learning models limited his conceptualization of clients’ difficulties and
his ability to successfully intervene. Along with other behavior therapists,
he became one of the early advocates of enhancing behavior therapy by
integrating cognitive processes. He also began to draw on psychodynamic
and experiential ideas that complemented cognitive-behavioral therapy
(CBT) (Goldfried, 2015). The rationale behind this rapprochement was that
if one set aside the jargon employed by various approaches, it might be
possible to identify a set of change principles that were shared by the major
theoretical orientations.
In 1980, the second author proposed that a useful way to identify these
commonalities would be to focus on an intermediate level of abstraction
(Goldfried, 1980). With theoretical frameworks or orientations at the
highest level of abstraction and specific techniques at the lowest level of
abstraction, at the intermediate level are change principles. By focusing on
this intermediate level and describing these principles in clear language that
eschews jargon, the goal was to step outside of the contentious competition
between orientations and recognize how seemingly disparate techniques
actually serve similar clinical functions.
In a 1980 article and in subsequent writings (e.g., Goldfried, 2012),
Goldfried delineated five principles that he argued are common across
orientations:
1. Fostering the patient’s hope, positive expectations, and motivation
2. Facilitating the therapeutic alliance
3. Increasing the patient’s awareness and insight
4. Encouraging corrective experiences
5. Emphasizing ongoing reality testing

This set of principles is based on the clinical, theoretical, and research

literature of major orientations, especially the cognitive-behavioral,
psychodynamic, and experiential/humanistic traditions. For example,
compare how the general approach to the reduction of fearful behavior is
described from these three orientations.
From a psychoanalytic point of view:
when a person is afraid but experiences a situation in which what was feared occurs without any
harm resulting, he will not immediately trust the outcome of his new experience; however, the
second time he will have a little less fear, the third time still less. (Fenichel, 1941, p. 83)

Couched in heavy jargon, from a cognitive-behavioral viewpoint:

Extinction of avoidance behavior is achieved by repeated exposure to subjectively threatening
stimuli under conditions designed to ensure that neither the avoidance responses nor the
anticipated adverse consequences occur. (Bandura, 1969, p. 414)

Referred to as “directive behavior” within an experiential/humanistic

approach, the goal is to provide the client with
 the opportunity for relevant practice in behaviors he may be avoiding. Through his own
discoveries in trying out these behaviors, he will uncover aspects of himself which in their turn
will generate further self-discovery. (Polster & Polster, 1973, p. 252)

Each of these instances, stated in a somewhat different language and

perhaps implemented technically in different ways, may be seen as
reflecting the principle of “encouraging corrective experiences.”
These five common principles of change are not presumed to be
exhaustive: additional principles can be identified, particularly as new
treatment approaches are developed, as existing approaches evolve, and as
the research literature identifies additional predictors of positive treatment
outcome. In this chapter, we feature and illustrate only these five principles,
recognizing that others would probably expand and revise our list.

ASSESSMENT AND FORMULATION

It is important to recognize that principles of change, by definition, involve
general strategic approaches to intervention. They say nothing about the
specific techniques that are used to achieve these objectives and also
nothing about what aspects of the client’s functioning are to be the focus of
the intervention. For example, with regards to the strategies just indicated,
what should the client become aware of? What is the nature of the
experiences that can be corrective? What is the target of the ongoing reality
testing? These are the issues that are the focus of clinical assessment and
case formulation.
Based on a coding system for the process of change that proves common
to more than one therapy approach, the second author developed a
transtheoretical approach to clinical assessment and case formulation
(Goldfried, 1995). The acronym STAIRCaSE refers to those variables
involved in a person’s interaction with the environment that can be the
focus of intervention. They are: Situation, Thought, Affect, Intention,
Consequence, and Self-Evaluation.
◆ Situation: Refers to something external to the individual, be it an event,
circumstance, or interaction with another person.
◆ Thought: May be of various sorts, such as an interpretation of the
external situation, an expectation, or an attribution of the motive
behind another person’s action.
Affect: Refers to an emotional reaction that could be conditioned to the
◆ situation or one mediated by a thought.
◆ Intention: Refers to what the person wants and/or needs in this
particular situation.
◆ Response: Represents an action that is observable, which may be
something a person does or avoids doing.
◆ Consequence: Refers to what results from the action or avoidance, be it
consequences to the individual or the impact it makes on someone else.
◆ Self-evaluation: How the individual judges how well he or she
responded to the situation.

The following is an example of how STAIRCaSE is used in the

assessment and case formulation of unassertive behavior and how this
information guides the principles of change. “Unassertiveness” here is
broadly defined as the client having difficulty in verbalizing or acting on
what she or he wants, feels, or thinks. This unassertiveness may be the
result of fear and/or lack of ability. In essence, this is what we frequently
see clinically, where a patient’s problematic behavior is more a function of
anxiety or inability than what she or he wants and needs.
Because this assessment and case formulation approach is
transtheoretical in nature, the specific clinical methods of assessment and
intervention, by definition, are not specified. Our principle-based
integration directs clinicians to what information to acquire, not how to
acquire it. The particular assessment methods (e.g., interview, observation,
psychological testing) should be determined by the specific details of the
case, clinical judgment, and the existing empirical evidence.
Gathering Assessment Information Relevant to Current Life Situation.
In assessing unassertiveness, the therapist looks for difficulty in refusing
requests from others, people-pleasing and trying to be “nice,” and
reluctance in taking the initiative in requesting what the client wants or
needs. These can occur generally or only within specific classes of stations,
such as work, school, friends, family, or intimate relationships. Client may
be more attuned to “shoulds” than “wants.”
Observing markers in session. Passivity, being apologetic, reassurance-
seeking; putting oneself down; worrying about what one said or did in the
past and/or what one will say or do in the future.
Obtaining client history. Past history of criticism, abuse, trauma,
neglect, difficulty in forming relationships, strict rules and role constraints
(e.g., religion, culture).
Selecting possible targets. Anxiety, depression, interpersonal conflict,
outbursts of anger following period of passivity, lack of confidence/self-
efficacy, excessive concern about impact on others, external locus of
control, uncertainty and hesitancy.

Case Formulation
Situations: Request by another person; client needing something from
another person.
Intention: What client would like to say about what he or she needs or
wants, thinks, or feels.
Thought: Thought that one can’t say what one wants; explicitly or
implicitly expects negative reaction from other.
Affect: Anxiety at thought of saying what one needs or wants, thinks,
or feels, often as the result of feared consequences.
Response: Behaviorally avoids saying what one needs or wants, thinks,
or feels.
Consequence: Inconvenienced; doesn’t get what one wants; others may
view client negatively.
Self-Evaluation: Negative thoughts and feelings about self; feelings of
inefficacy; regret about not self-asserting.

Providing client with rationale for intervention. The goal here is to

help clients gain a preliminary understanding of why they are having the
problem (concurrently and historically), what needs to be done
therapeutically to make changes, and how they can work with the therapist
to bring this about.
1. Present formulation to client, together with any relevant history leading to current vulnerability,
in-session markers, and therapy targets.
2. Use case formulation described earlier to clarify the STAIRCaSE links that need to be broken:
(e.g., “You are afraid [affect] to say what you really want to say [intention] because you think
[thought] that it will be taken badly by the other person. The problem is that by remaining silent
[response], you end up not only failing to get what you want [consequence], but the other person
may see you in a negative way [consequence]. And you also then feel lousy about yourself.”
[self-evaluation]).
3. Clarify links that need to be made in therapy: S—I—R—C—SE [e.g., “When you are in a
situation where you want or don’t want something, the goal is be able to focus on your intention
rather than your fearful thoughts and emotions, to notice the consequences of what you say or do
for yourself and the impact it makes on others and see if you can give yourself credit for what
you’ve done.”

Clinical assessment and case formulation naturally lead to goal

specification. There are three associated principles of change for clinically
pursuing the goal of facilitating assertive behavior.
 Increasing awareness: The goal here is to help clients become more
aware in their day-to-day interactions of the connections between
the external situation; their thoughts, feelings, intentions/needs,
actions; the consequences of their actions for themselves and
others; and how they evaluate the way they dealt with the situation.
An ultimate goal is to help them develop a more efficacious view or
expectation of their ability to deal with future situations. Although
the therapist can point these out, the eventual goal is to have clients
make use of their executive functioning to step back and observe
these connections themselves in life situations.
Corrective experience: The goal here is to create behavior change by
speaking up and saying what they want, think, and feel in specific
situations. This new behavior will also have an impact on thoughts,
feelings, intentions, consequences, and how they evaluate the way
they responded in this life situation. There is a certain amount of
risk-taking involved (and the client should be informed of this
explicitly) where the goal—based on their increased awareness—is
for them to behave in a new way that is more effective (e.g., having
positive consequences) and satisfying (e.g., positive self-
evaluation).
Ongoing reality testing: The goal here is to facilitate a synergy
between increased awareness and corrective experiences. Once they
have a corrective experience by acting in a more self-assertive way,
clients become more aware of new links between the external
situation, their thinking, feelings, and intentions. Thus, they focus
more on what they want to say rather than on being inhibited by
excessive concerns about the reactions of others. They also
recognize that what they have done differently results in better
consequences and makes them feel more positive about what they
have done. This increase in awareness resulting from a corrective
experience may then be used to encourage more corrective
experiences, resulting in an ongoing synergistic process between
cognition and behavior.

APPLICABILITY AND STRUCTURE

This principle-based approach is a framework that addresses the general
therapy change process and that therefore can be applied to multiple clinical
situations and populations. In fact, we would argue that these principles are
relevant for all patients, settings, and modalities and can be applied in either
short- or long-term treatments. The five principles provide general
guidelines for what needs to be accomplished in therapy. Drawing on these
organizing principles, the therapist can then identify subgoals for each
principle and select specific methods or techniques that will enable him or
her to achieve those subgoals over the course of treatment. Future research
may identify certain principles that therapists should emphasize more with
specific patient populations or clinical settings. At this point, we see no
reason that these principles cannot be utilized with patients undergoing
couples or family therapy or who are also receiving psychotropic
medication. With patients on medication, clinicians will need to be mindful
of how they interpret their corrective experiences: if patients attribute all of
their success experiences to medication, they may miss an opportunity to
develop a more positive and empowered self-evaluation.

PROCESSES OF CHANGE AND REPRESENTATIVE TECHNIQUES

In this section, we describe each of the five principles of change in greater
detail, together with representative research on and methods using each. As
noted earlier, the principle-based approach does not prescribe a specific set
of methods and techniques; any technique can be utilized as long as it
supports one or more of the principles of change, is within the therapist’s
skill set, and is responsive to the client’s needs and preferences.

Fostering Hope, Positive Expectations, and Motivation

Psychotherapy often proves more effective when patients have hope that
their lives can improve, positive expectations that therapy can facilitate this
improvement, and motivation to do the work of therapy. The idea that
therapists need to take steps to foster this sense of hopefulness and
motivation in patients has long been an important principle of many
therapeutic approaches. For example, Frank (1961) proposed that patients
seek therapy because they are demoralized, and the restoration of their hope
and positive expectations is an important part of treatment. Research on
patients’ expectations about the benefits of therapy shows a small but
significant relation with positive outcome in treatment. This research also
shows that unmet patient expectations are related to premature dropout
from therapy (Constantino, Vîslă, Coyne, & Boswell, 2018).
The importance of patient motivation to change is underscored by the
transtheoretical model, which conceptualizes change as progressing through
the five stages of precontemplation, contemplation, preparation, action, and
maintenance. Research on these stages of change has found that patients in
the precontemplative stage, who lack awareness of their problems or
motivation to change their behavior, are far less likely to make progress in
therapy than patients who are more motivated and thinking more actively
about making changes (Prochaska & DiClemente, Chapter 8, this volume;
Krebs, Norcross, Nicholson, & Prochaska, 2018).
In order to have hopeful, positive expectations about treatment and the
motivation to engage in it, it is important that patients know what the
treatment entails. Role induction is the process of orienting patients to
treatment by giving them a general idea of what will happen in therapy and
the roles of each participant (Orne & Wender, 1968). Several studies have
found that the use of role induction is associated with less dropout and
better therapy outcome (Strassle, Borckardt, Handler, & Nash, 2011; Swift
& Greenberg, 2015). Useful role induction strategies include helping clients
understand the general behaviors of an ideal client and the general
behaviors the client can expect from the therapist, providing a credible
treatment rationale, and also supplying logistical information about the
length and frequency of sessions and how payment is handled.
Therapists seeking to increase client motivation can look to the
techniques of motivational interviewing (MI; Miller & Rollnick, 2013), a
client-centered approach that addresses ambivalence about change. In MI,
when a patient resists making changes, the therapist does not directly
challenge or confront this resistance, but rather seeks to “roll with
resistance” by viewing it as valuable information to understand rather than
as an obstacle to progress. Using person-centered techniques, but with some
leading as well as following, the therapist helps the patient to recognize the
consequences of changing and not changing. Outcome research on MI has
demonstrated efficacy and effectiveness across a range of outcomes,
particularly alcohol and drug use (Hettema, Steele, & Miller, 2005; Lundahl
& Burke, 2009; Lundahl et al., 2013), and a recent meta-analysis found that
therapist skills consistent with MI were correlated with more change talk
from clients (Magill et al., 2017).
Finally, in order to help their patients have hope, therapists themselves
need to maintain their own hope. Given research that mental health workers
report relatively high levels of burnout (e.g., Morse, Salyers, Rollins,
Monroe-DeVita, & Pfahler, 2012; Paris & Hoge, 2010), it is important that
therapists practice good self-care (Wise & Barnett, 2016).

Facilitating the Therapeutic Alliance

The alliance is one of the most robust predictors of outcome in therapy
(Flückiger, Del Re, Wampold, & Horvath, 2018). Many theorists and
researchers draw on Bordin’s (1979) conceptualization of the working
alliance as agreement between patient and therapist on the goals of therapy,
collaboration on the tasks of therapy, and the presence of a positive
emotional bond. Although therapeutic approaches may differ regarding the
extent to which the alliance is regarded as a mechanism of change (e.g.,
Safran & Muran, 2000) or as a precondition of change (e.g., Beck, 2011),
there is widespread agreement that a “good-enough” alliance is essential for
effective therapy. In addition, when problems or ruptures in the alliance
arise, if these are not addressed and resolved, patients may quit therapy or
fail to achieve good outcomes (e.g., Samstag, Batchelder, Muran, Safran, &
Winston, 1998). Conversely, successful resolution of ruptures is moderately
related to improved outcome (Eubanks, Muran, & Safran, 2018).
One way to build a strong alliance is to help the patient actually move
closer to achieving his or her treatment goals: in other words, effective
therapy facilitates a good alliance. In addition, therapists can facilitate
agreement and collaboration on goals and tasks by negotiating the goals of
treatment with the patient and by giving patients some agency with respect
to the tasks. An example of this would be collaborating with the patient to
decide on a homework assignment rather than simply telling the patient
what the therapist wants the patient to do. Therapists can work to build a
strong bond by being empathic and respectful and validating the patient’s
experience. The empathic style of the client-centered tradition is well-suited
to building a strong bond (Elliott, Bohart, Watson, & Murphy, 2018).
Focusing on the alliance is clearly a crucial task early in treatment so that
the patient is willing to engage in the work of therapy. Research on alliance
ruptures points to the importance of monitoring the alliance throughout
treatment and intervening when a rupture emerges (Eubanks et al., 2018).
Useful alliance rupture repair strategies include both direct strategies in
which the therapist draws attention to the rupture, such as inviting the
patient to express his or her thoughts and feelings about an impasse, and
indirect strategies, in which the therapist resolves the rupture without
explicitly acknowledging it—such as changing a homework task that a
patient finds too challenging.
Rupture resolution strategies can be immediate as well, such as providing
a rationale for a task that the patient did not understand so that the dyad can
quickly resolve the rupture and resume the therapeutic task. Rupture repair
strategies can also be more expressive or exploratory and aim to shift the
focus of treatment to exploring the rupture and the patient’s needs or
concerns that underlie it. This form of resolution may entail exploring not
only the patient’s experience of the rupture, but also disclosure of the
therapist’s experience and nondefensive acknowledgment of how the
therapist has contributed to the rupture.

Increasing Patient Awareness and Insight

Patients often begin psychotherapy in a state of unconscious incompetence
—unaware of exactly how they are contributing to their difficulties. An
important step in therapy is to help the client move to a stage of greater
awareness or insight that can be described as conscious incompetence.
As illustrated earlier, a clear case formulation helps therapists identify the
thoughts, feelings, intentions, and/or behaviors of which the client needs to
become more aware. For example, a client who is unaware of her anger at
others may also be unaware of how she inadvertently expresses her anger
through indirect slights and pained facial expressions. She then may also be
unaware of how her behavior aggravates others and leads them to withdraw
from her. A task for the therapist would be to help this client recognize her
feelings of anger, how she manifests her anger, and how these
manifestations impact those around her. The therapist could draw upon
STAIRCaSE to help the client increase her awareness of the links between
specific challenging encounters with her employer [situation], her belief
that she is being treated unfairly but “must not cause a scene” [thought], her
feelings of anger and frustration [affect], and her attempts to “say
something nice” while clenching her jaw [response]. As the client becomes
more aware of these factors and the links between them and how they are
interfering with her ability to achieve her career goals [intention], she will
start to recognize opportunities for positive change.
All of the major therapeutic approaches embrace techniques for
enhancing patient awareness. Increasing patient insight has always been a
central aim of psychodynamic approaches and, certainly, interpretations,
when accurate and well-timed, can facilitate greater awareness in patients of
the relational patterns that contribute to their difficulties. Reflections,
observations, and feedback have long been employed in insight-oriented
therapies for this purpose. The CBT technique of having patients complete
thought records can help patients to become more aware of connections
among thoughts, feelings, and behaviors. Two-chair exercises, a hallmark of
experiential approaches, can help patients to become more aware of implicit
feelings and unmet needs (Elliott, Watson, Goldman, & Greenberg, 2004).

Encouraging Corrective Experiences

In 1946, Alexander and French proposed that a client’s experience of
interacting with a therapist in a way that differed from the client’s
experiences with significant figures in the client’s early life could, in itself,
produce therapeutic change. This concept has been extended to include
experiences outside of the therapeutic relationship: a corrective experience
is any experience in which the patient takes a risk and engages in a new
behavior that leads to a shift in cognitions and emotions (Goldfried, 2012).
Corrective experiences can be conceptualized as a form of learning—the
patient engages in a new way of behaving that is more effective. For
example, exposure in fear reduction is one type of corrective experience.
When patients begin to engage in new, more adaptive behaviors, they move
into the stage of conscious competence: they are choosing to act more
effectively and competently through deliberate and conscious efforts.
As Alexander and French observed, the therapeutic relationship can also
provide a corrective experience. A patient who is accustomed to being
criticized or abandoned by significant others can have a corrective
experience when a therapist is supportive, empathic, validating, and willing
to address and work through alliance ruptures (Eubanks, 2019). A
corrective experience is the heart of change—it is the most essential of the
change principles.
 Therapists can encourage corrective experiences both between and within
sessions. Between sessions, therapists and patients can collaborate on
identifying possible between-session situations in which clients can attempt
to have corrective experiences, such as facing situations that they may have
been avoiding. The very process of exploring such experiences in session
can also lead clients to consider doing things differently. Questions the
therapist raises in the process of exploring a patient’s experience (e.g.,
“Have you ever told her how that makes you feel?”) may, even without the
therapist’s awareness or intent, plant a seed that subtly encourages the
patient to try a new behavior. This indirect approach may be particularly
well-suited to high-reactance patients who do not respond well to being told
what to do (Beutler, Edwards, & Someah, 2018).
Corrective experiences within the session can be facilitated through in-
session tasks, such as patients reporting more open and expressive reactions
about their experiences, or by role-plays in which the patient tries out a new
behavior. An empty chair exercise can provide an opportunity for a patient
to have the experience of a new interpersonal interaction with a significant
other, even someone who has died, as a means of processing unfinished
business. Therapists can facilitate corrective experiences by using their case
formulation to help them identify what kind of relational experience would
be most beneficial for a particular patient (Eubanks, 2019). For example, if
a hostile patient is accustomed to encountering hostility from others, the
therapist might provide a different experience by being validating and
nondefensive. If a hostile patient is accustomed to others fleeing from or
cowering before his aggression, a therapist might meet the patient’s
aggression with active engagement and healthy self-assertion.
Indeed, the therapeutic relationship can provide a corrective experience
for the patient even when the therapist is not intentionally trying to do so.
For example, once when the first author was giving a client a handout in
session, she mentioned that she had come across the handout during the past
week and thought the client would find it useful. The client’s face lit up and
she said, “You were thinking about me!” What the therapist had intended to
be a psychoeducational intervention had a relational significance that took
the therapist by surprise.

Emphasizing Ongoing Reality Testing

The ultimate goal of therapy is to help patients move to the stage of
unconscious competence, in which adaptive behaviors become so well-
learned that they no longer require deliberate effort. To reach this stage,
patients need to engage in repeated corrective experiences. Patients may
also need the therapist’s help to process these new experiences: they may
fail to detect, accept, or recall their success experiences because these
experiences are inconsistent with their long-standing views of themselves.
Clients can see how their present functioning differs from their past, less
effective functioning and align their expectations of situations, the emotions
they anticipate experiencing, the consequences they deem most likely, and
their subsequent self-evaluations (Goldfried & Robins, 1982). The client’s
reality has changed, and the client recalibrates his or her expectations
[thought] and self-view [self-evaluation] to be in line with this new reality.
This process of ongoing reality testing represents the consolidation of
change.
As patients make positive changes, therapists can help patients process
their corrective experiences by using the STAIRCaSE acronym to help
patients recognize how each component of their functioning is changing.
When altering one’s negative self-schema proves difficult, therapists can
offer affirmation by celebrating their patients’ successes. Therapists can
also encourage patients to find or strengthen positive interpersonal
relationships that will be a source of support when therapy ends. Finally,
therapists can encourage patients to develop healthy habits such as
mindfulness, engagement in the arts, or regular exercise. Such heathy
behaviors will likely increase their sense of mastery and pleasure and will
help them cope with future stressors.

THERAPY RELATIONSHIP
In our principle-based approach, the therapy relationship can contribute to
the change process both indirectly and directly. A good therapy relationship
will enable the therapist and client to collaborate on tasks of treatment that
are helpful to the client. As noted earlier, facilitation of the alliance, which
is an important aspect of the therapy relationship, is a key principle in our
approach. A “good-enough” alliance, in which the patient is willing to
collaborate with the therapist, is a necessary precondition for the work of
therapy. The “real relationship” component of the patient–therapist
relationship, characterized by a genuine and realistic perception of the other
(Gelso, 2014), can also foster a sense of connection and trust that increases
patients’ willingness to engage in the tasks of therapy. Within the context of
therapy research, the therapy relationship in this instance is said to
“moderate” the change process, which may be occurring outside the
session.
At the same time, the experience of being in a relationship with a
supportive, empathic, and reliable therapist who encourages the patient’s
growth can also challenge the patient’s negative beliefs about relationships
and provide a new interpersonal experience of what is possible in an
adaptive relationship with another person. Patients who are fearful of being
vulnerable with others due to a history of being rejected and neglected by
their parents may have the experience of opening up to a therapist who is
respectful and attentive. Through this relationship, the patient learns that it
is possible to be vulnerable with another person and thus gains a new
appreciation of his or her own worth. In this second instance, the
relationship can be considered a mediator of change.
In our principle-based approach, therapists should strive to be attuned to
both possibilities: particularly in early sessions, they should focus on
developing a good-enough relationship with the client in order to lay the
foundation for collaboration. As treatment progresses, they should be
mindful of the patient’s past and current relationships with significant
figures, and they should think actively about what kind of relational
experience with the therapist would facilitate a corrective emotional
experience for the patient. Therapists may find it challenging at times to
provide the positive relational experience the client needs as the patient may
“pull for” negative responses similar to those the patient has received in
past relationships. By closely attending to their own internal experience of
the patient—including ways in which they contribute to alliance ruptures by
pushing against or pulling away from the client—therapists can identify
opportunities to “pause” the therapeutic tasks they are engaging in and turn
to actively exploring the therapy relationship. This kind of exploration is
necessary if problems in the therapeutic relationship are hindering
collaboration between patient and therapist.

DIVERSITY CONSIDERATIONS
A strength of a principle-based approach to integration is its flexibility with
respect to specific techniques when working with patients from diverse
cultures, backgrounds, and identities. As we have indicated earlier, in
viewing therapy from within the perspective of principles of change,
therapists can choose from an array of techniques in support of one of the
principles. The therapist’s choice of techniques is informed by the research
literature on multicultural competence but should also be tailored to the
specific needs and preferences of the individual client because
accommodating patient preferences typically enhances treatment outcome
and decreases premature termination (Swift, Callahan, Cooper, & Parkin,
2018). There is strong research evidence that therapies adapted for religious
clients and for patients of color offer additional benefits compared to
nonadapted secular therapies (Captari, Hook, Hoyt, Davis, McElroy-
Heltzel, & Worthington, 2018; Soto, Smith, Griner, Domenech Rodríguez,
& Bernal, 2018). For example, a therapist can tailor treatment for a
religious client by encouraging the client to draw on his or her faith
tradition, such as encouraging the client to attend religious services,
including the client’s favorite verses of Scripture, or by incorporating
prayer.
By closely attending to subtle shifts in the alliance, the therapist can
quickly detect therapy ruptures that can arise from differences between
patients and therapists with respect to aspects of their identities such as
gender, race, religion, sexual orientation, and class (Muran, 2007).
Microaggressions, or direct and indirect disrespectful, insulting, dismissive
communications about another individual’s cultural group, can be
understood as a type of alliance rupture (Hook, Davis, Owen, & DeBlaere,
2017), and there may be value in drawing on alliance rupture resolution
strategies to address microaggressions (Gaztambide, 2012; Spengler, Miller,
& Spengler, 2016).
A principle-based approach to integration proceeds from an assumption
that certain principles of change are universal. However, it is certainly
possible that this assumption is wrong—certain principles may not be
relevant for all patients, or there may be important principles missing from
our list. It is important that we approach our work with cultural humility,
appreciating how much we do not know about the lived experiences of our
clients and how much we may be blinded by our implicit cultural
assumptions (Hook et al., 2017). As more principle-based research is
conducted with diverse samples of patients and therapists, we expect and
indeed hope that additional principles will be identified so that therapists
have a rich array of clinical strategies to draw upon when tailoring
treatment to a particular patient.

CASE EXAMPLE

To illustrate our principle-based approach, we present a case example based

on clients in our clinical practices. The patient, Greg, was a white,
heterosexual male in his mid-40s who worked as an attorney at a
prestigious law firm. He presented with anxiety that he linked to work
stressors, his distant relationship with his wife, and his frustrations with his
teenage daughter who was performing poorly in her academics. Greg met
diagnostic criteria for generalized anxiety disorder.
The psychologist was a white, heterosexual female in her early 40s. At
the first session, the therapist asked the patient to complete the Outcome
Questionnaire (OQ; Lambert, 2015), which indicated that he was
experiencing a moderate level of distress.

Fostering Hope, Positive Expectations, and Motivation

In the first session, the therapist inquired about Greg’s expectations for
treatment. Greg’s answer included the unrealistic hope about what the
therapist could do— “I am hoping that you have something in your
therapist bag of tricks that will put all my demons to rest once and for all. I
want a life with no setbacks.” He also expressed resignation about his own
helplessness— “I think it’s something in how I’m wired; I just can’t stop
thinking this way and feeling this way.” The therapist tried to encourage
more balanced expectations by orienting Greg to the treatment. She
explained that this treatment would be a collaborative effort, with both
parties contributing to the work; that it was possible for him to feel better,
but it would take some time; and that therapy might not entail exorcising all
of his demons but rather helping him develop skills to cope with his demons
more effectively. The therapist inquired about Greg’s past experience in
therapy to gain a better understanding of what he did and did not find
helpful. She also observed that Greg brought several strengths to therapy:
his awareness that things were not going well in his life, his motivation to
seek treatment, and his willingness to share his difficulties fairly readily
with the therapist. By drawing attention to these strengths, the therapist not
only fostered Greg’s positive expectations, but also bolstered her own
personal sense of hope.

Facilitating the Therapeutic Alliance

In the first session, the therapist introduced the concept of the therapeutic
alliance to Greg by using Bordin’s (1979) tripartite conceptualization of the
alliance as (1) agreement between the patient and the therapist on the goals
of treatment, (2) collaboration between the patient and the therapist on the
tasks of treatment, and (3) the existence of a positive affective bond
between the patient and the therapist. She encouraged Greg to let her know
if at any point he disagreed with the direction in which they were going.
She also shared that she might at times draw his attention to their
interaction as a better understanding of how they were relating to each other
could help them better understand his interactions with others; in this way,
she provided a rationale for any future efforts to attend to and explore
alliance ruptures.
Throughout the first few sessions, the therapist paid close attention to the
development of her alliance with Greg. As she and Greg spoke about his
goals for therapy, she directly noted that she and Greg had different
perspectives on the best ways to achieve some of Greg’s goals. Greg wanted
to include winning more legal cases as a treatment goal because he believed
that this would mean that he would make more money and that his
difficulties with anxiety would be relieved if he were wealthier. The
therapist was concerned that there were many external variables outside
Greg’s control that contributed to whether he won or lost a case and that
making more money would not resolve Greg’s difficulties with anxiety. She
thought that focusing on the ways in which Greg’s own behavior, thoughts,
feelings, intentions, and self-evaluation were contributing to his anxiety was
a better way to proceed. Greg’s tendency to tie his personal worth to his net
worth was part of his problem, and she did not want to reinforce this.
Knowing that agreement on treatment goals is a key component of the
alliance, the therapist spoke explicitly with Greg about their differing views
and engaged in a collaborative discussion about whether they could find a
treatment goal with which they were both comfortable. Greg agreed that
they could start with focusing on how his thoughts, feelings, intentions,
behaviors, and self-evaluation contributed to his anxiety. He said that he
still hoped that this would help him be more effective at work and make
more money. The therapist agreed to help Greg reflect on his behaviors at
work and to identify whether his anxiety was interfering with his ability to
do his job effectively, but she also said that increasing his income would not
solve his problems. Greg felt that this was fair, and said “OK, we can agree
to disagree on that.”
In addition to negotiating an agreement on goals, the therapist worked to
collaborate with Greg on tasks and to develop a bond. Greg made several
references to his former therapist who was “very perceptive and insightful”
based on his “years of experience with hundreds of patients.” Greg drew
contrasts with the current therapist’s relative lack of experience: he noted
that since she was an academic, her private practice was probably small and
that there were things she would know more about “once you’ve seen more
patients.” The therapist felt that Greg was challenging her at times by
rejecting some of her interpretations and homework suggestions in a
slightly confrontational way. She drew Greg’s attention to this dynamic,
trying to be nondefensive and curious about their interaction: “I feel like
you are testing me.” Greg laughed and said, “Oh, there you go, talking
about our relationship, just like you said you would,” in a teasing manner.
When the therapist tried to further explore Greg’s potential concerns about
her ability, he made more jokes and kept the conversation light.
The therapist believed that while Greg was determining if she passed
muster, he was simultaneously eager for her approval. As Greg seemed
uncomfortable exploring this aspect of their interaction directly at this
point, the therapist decided to back off for the time being.
The therapist reflected to herself on how the therapeutic relationship
could provide a corrective experience for Greg. Greg was raised by parents
who pressured him to succeed, and he now lived with frequent criticism
from his wife, hostile competition from his work colleagues, and numerous
demands from his 16-year-old daughter. The therapist hypothesized that
experiencing validation, support, and acceptance in the therapy relationship
could be a healing experience for Greg. She tried to keep this as a guiding
principle in her interactions with Greg.
For example, in one session, Greg was relating an argument he had with
his daughter. He acknowledged losing his temper with his daughter and
“yelling and doing everything wrong.” The therapist stopped him and
asked, “What do you think I think about all of this?” Greg responded, “I
hope you are figuring out what parenting techniques I should be using to
communicate better with her, set limits better, be more patient—all these
things that I keep messing up.” The therapist replied, “I do think there are
some things that could be helpful, which I’ll share with you, but that’s not
what I was thinking just now. I was thinking, ‘this is really hard.’ ” Greg
looked surprised for a moment, then put his face in his hands, and, for the
first time in the treatment, he began to cry. The therapist sat with him for
several minutes and listened as Greg slowly began to speak about his
sadness and pain as a failing parent. This moment felt like a turning point in
the therapeutic relationship.

Increasing Patient Awareness and Insight

Based on his prior therapy, Greg could speak fluently about many of his
difficulties. However, his insights remained intellectualized—sounding
almost like he was talking about someone else when he spoke of his
tendency to worry and his history of self-defeating behaviors. The therapist
suspected that Greg needed to become more self-aware in an experiential
fashion that linked his thoughts with his emotions.
The therapist employed the two-chair technique to facilitate this link.
During a session in which Greg was being highly self-critical, the therapist
pulled up a chair and facilitated a dialogue between Greg and his critical
voice by having Greg go back and forth between the two chairs. This
dialogue helped to increase Greg’s awareness of the origins of his inner
critic: as he later observed, pointing at the critic chair, “That’s my father.”
Greg also shared that highlighting his inner critic increased his sense of
self-compassion: “I really felt something—it really activated something
emotional for me. I wanted to give myself a hug.” Greg had long known at
an intellectual level that he was self-critical; now he seemed to have a
deeper, affective understanding of it and an appreciation for how much his
self-criticism was hurting him.
Throughout treatment, the therapist periodically reviewed Greg’s
progress by readministering the OQ and discussing how Greg felt that he
was changing. She also prepared a diagram of her formulation of Greg’s
case and shared this with him. Greg agreed with the therapist’s formulation
and reported that he found this diagram helpful. The diagram laid out the
vicious cycle Greg was stuck in: a sense of inadequacy leading to anxiety
that he found difficult to tolerate, leading to efforts to escape the anxious
feelings through avoidant thoughts and behaviors, which then contributed to
difficulties in his life that fueled his personal sense of inadequacy. Greg
reported that he knew many of the pieces of this cycle but had never really
connected them. This case formulation increased his awareness of what was
operating and became a useful way to track Greg’s progress and to explain
the rationale for various interventions by linking them to the stage in the
cycle they were meant to address.

Encouraging Corrective Experiences

In addition to facilitating corrective experiences within the alliance, as
described earlier, the therapist encouraged Greg to pursue corrective
experiences outside of session. The therapist introduced Greg to
mindfulness exercises and encouraged Greg to practice these daily to help
him be more aware of the present moment and less consumed by his
anxious thoughts. Greg found that his mindfulness practice helped him have
new kinds of interpersonal interactions. For example, he reported that he
was waiting for his wife to get ready for an event they were attending
together, and he was getting frustrated that she was taking too long. Usually,
this kind of occurrence would be the beginning of an argument that would
overshadow the entire evening. However, Greg realized that he could
practice mindfulness while he waited for his wife. As he paid attention to
his breathing and felt himself grow calmer, he realized that he had skills
that he could utilize to manage the anxiety and anger he usually felt when
he was helpless to control a situation. He—and his wife—were both
surprised at how much they enjoyed their evening together and how much
this positive experience subsequently impacted their entire weekend. As
Greg relayed this experience to the therapist, she enthusiastically
highlighted what an important experience this was and how the
accumulation of many of these experiences could help not only Greg’s
symptoms of anxiety, but also could positively impact his marriage.

Emphasizing Ongoing Reality Testing

Greg began to report more corrective experiences outside session in
managing his anxiety, and the therapist processed these experiences with
him. At times, Greg needed encouragement to recognize his gains: for
example, after he proactively addressed a difficult task at work by
appropriately asking for help from a colleague, he tried to minimize what he
had done: “I was lucky; he was in a good mood that day.” The therapist
noted that Greg’s proactive and skillful handling of the situation had
contributed to the positive outcome and highlighted the contrast between
this success experience and his previous, negative interactions with this
particular colleague. Drawing on the STAIRCaSE concept, she pointed out
how his different response was leading to a new consequence, and she
encouraged Greg to incorporate this feedback into his self-evaluation. She
also linked this to the case formulation, observing that by tolerating
uncomfortable feelings, such as the discomfort of acknowledging his
limitations to his colleague and taking proactive steps rather than avoiding
the task, he broke his old cycle.
The therapist also drew links between this situation and Greg’s behavior
in therapy. She noting how Greg’s willingness to be open and vulnerable
with the therapist had not made him look foolish or weak, but rather had
helped her to understand him, had strengthened their bond, and had
facilitated their work together. Moreover, it provided him with a corrective
experience whereby he could show vulnerability without being criticized.
After approximately 40 individual sessions, Greg’s scores on the OQ
moved into the normal range. Greg reported that he was feeling anxious less
often and felt better equipped to tolerate and manage his anxious feelings
when they did arise. He also reported that his relationship with his wife was
greatly improved. He felt that he and his wife were working together better
as parents, and this was leading to improvements in their relationship with
their daughter.
The therapist introduced the idea of termination. Greg was initially
reluctant to terminate, but as the therapist continued to highlight his
progress, Greg agreed to a gradual tapering off of therapy sessions. He
terminated with definite improvement and with the understanding that he
could return for booster sessions should the need arise.

OUTCOME RESEARCH
In presenting this principle-based approach to integration, the goal was not
to create yet another brand of therapy to compete in horse races with other
treatments, but rather to provide a conceptual framework for how to think
about integrating empirically supported principles into clinical practice.
There are no formal or controlled clinical trials on the effectiveness of this
integrative approach. Because flexibility—the ability to use a variety of
techniques to enact a particular principle—is integral to this approach, it
would prove challenging to study principle-based integration via traditional
means such as randomized controlled trials.
At the same time, there is some outcome research to support most of the
principles. Castonguay and Hill have brought together researchers to collect
supporting research on increasing clients’ awareness (Castonguay & Hill,
2007) and on corrective experiences (Castonguay & Hill, 2012). A task
force sponsored jointly by the Society for Clinical Psychology (Division 12
of the American Psychological Association) and the North American
Chapter of the Society for Psychotherapy Research identified research-
supported principles for the treatment of four categories of psychological
disorders: dysphoric disorders, anxiety disorders, personality disorders, and
substance abuse disorders (Castonguay & Beutler, 2006). Principles
common across at least two disorders included, for example, providing
structure and a clear focus throughout therapy and helping clients to accept,
tolerate, and, at times, fully experience their emotions.
Several of the principles in the approach we have described have also
been identified by an interdivisional American Psychological Association
(APA) Task Force to be elements of the therapy relationship that are
probably or demonstrably effective. The most recent compendium featured
meta-analyses of the literature to demonstrate the relationship between
several of these principles and patient outcomes (Norcross & Lambert,
2019): specifically, client expectations, the alliance, collaboration,
facilitating positive expectations, and alliance rupture repair.

FUTURE DIRECTIONS
One promising direction is to use principle-based integration as a way of
training therapists and to compare the clinical outcomes of therapists
trained in this approach to those of therapists trained in other approaches.
Beginning trainees can quickly grasp the five principles and use them to
organize their thinking so that they are not overwhelmed by the vast array
of possible therapeutic interventions. It is far easier to keep in mind a
handful of operating principles than to identify which of hundreds of
techniques might be relevant in any given case. As they progress through
their training, trainees can learn possible techniques nested within each
principle and thereby gradually accumulate a larger repertoire of methods
for facilitating each principle. Early controlled studies of principle-based
training in systematic treatment selection (Consoli & Beutler, Chapter 7,
this volume) and transtheoretical therapy (Prochaska & DiClemente,
Chapter 8, this volume) have demonstrated its viability and promising
results. The context responsive integration model (Constantino, Boswell,
Bernecker, & Castonguay, 2013) is an example of a practical and useful
way to structure principle-based training with clinical markers and related
strategies. Thus, if a marker occurs, such as a rupture in the alliance, one
should consider using certain rupture repair strategies.
In the future, as the field becomes more aware of the importance of the
therapist in treatment (e.g., Castonguay & Hill, 2017), we will address the
burden that a principle-based approach to integration places on therapists: it
requires that therapists think flexibly and creatively to move outside the box
of one orientation, to gain familiarity with a variety of techniques, to look
beyond superficial differences between seemingly disparate techniques to
recognize common underlying functions, to stay abreast of the research
literature, and to tolerate a degree of uncertainty because there is no clear
script for the next therapy session other than focusing on principles of
change and being responsive to the patient’s needs (Stiles, Honos-Webb, &
Surko, 1998). It also provides researchers with robust phenomena on which
to focus their research efforts—as opposed to clinical trials involving
complex interventions designed to treat heterogeneous disorders as defined
in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5;
American Psychiatric Association, 2013).
Perhaps most important, this approach requires therapists to be open to
recognizing their limits and receptive to continually learning new ways to
help their patients. An important future direction is to identify how best to
inculcate such openness, flexibility, and skill at integrating research
findings into clinical practice in therapist trainees. For example, should
trainees develop competence in employing these principles within one
orientation first, in order to gain a secure foundation, or would early
exposure to how different theoretical orientations implement these
principles help maximize trainees’ openness and agility? Does the best
training approach depend on the trainee and his or her level of anxiety or on
other therapist characteristics? Another important future direction for our
principle-based approach is to determine whether additional principles
should be added to the five discussed in this chapter. A related future
direction is the need for more research on applying the principles to work
with specific populations, as it may be that certain principles are more
critical for specific types of patients or clinical situations. An exciting
potential future direction is the possibility that we may one day know
enough about the interactions among some patient characteristics, clinical
principles, and the effectiveness of particular techniques to develop
empirical algorithms to tailor treatment to the patient. One example is the
Personalized Advantage Index that DeRubeis and colleagues have
developed for determining whether a patient is a better match for cognitive
therapy or medication for depression (DeRubeis et al., 2014). Another,
broader example is the list of effective treatment adaptations to patients’
transdiagnostic characteristics from the intradivisional APA task force on
evidence-based relationship and responsiveness (Norcross & Wampold,
2019). Extensive meta-analyses have determined that several patient
characteristics serve as markers for doing something particular: when the
patient presents with this feature, then the research indicates this method
typically proves most effective. Those six client characteristics are
reactance level, stages of change, patient preferences, culture
(race/ethnicity), religion/spirituality, and coping style. Not coincidentally,
our principle-informed integration already addresses many of them.
As indicated in Chapter 1 of this Handbook, there have been four major
approaches to psychotherapy integration: common factors, assimilative
integration, technical eclecticism, and theoretical integration. A principle-
based approach encompasses aspects of all of these approaches. It is clearly
aligned with a common factors approach in that it identifies
principles/change processes that are common across different therapeutic
approaches. As the five principles described earlier are present in all the
major orientations, the principle-based approach is also conducive to
assimilative integration: therapists can conceptualize a case using the five
principles from within their primary orientation and then integrate
techniques from other orientations into that primary approach in service of
those principles as needed. Similar to the technical eclectic approach, a
principle-based approach also gives therapists the freedom to select
different techniques from different orientations without remaining tied to
one school. Consistent with theoretical integration, it does have an
integrating, overarching conceptualization of what is necessary for change
that guides the selection of various approaches. Thus, a principle-based
approach is not only a way to integrate different approaches to therapy, but
it also has the potential to facilitate movement toward greater future
consensus in the field of psychotherapy integration.

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 5

Feedback Informed Treatment

CYNTHIA L. MAESCHALCK, DAVID S. PRESCOTT, AND SCOTT D. MILLER

A recent newspaper headline, “Human Rights Complaint: Atheist Nurse

Fights AA Edict” led into an article describing a nurse’s claim that his
employer violated his human rights by forcing him to attend Alcoholics
Anonymous (AA) meetings. Three years previously, the nurse had been
admitted into a hospital after he experienced a psychotic break brought on
by withdrawal from a combination of alcohol, medications, and street
drugs. Following the recommendations of the nurse’s doctor, his employer
and union developed a plan that, prior to returning to work, he would
complete a residential treatment program, attend AA meetings, and submit
to random drug tests.
The nurse took issue with the plan but eventually submitted and
completed the 5-week, 12 step–based residential treatment program they
chose for him. While there, he tried to explain that he was an atheist but
found that “If [he] questioned the 12-step philosophy or tried to discuss
scientific explanations and treatments for addiction, [he] was labelled as ‘in
denial’ . . . [and] told to admit that he was powerless, and must submit to a
higher power . . . [and] encouraged to pray” (Van Manan, 2016, p. 3). The
nurse told the reporter that the experience “was unhelpful and humiliating.”
After completing the treatment program, he refused to continue attending
the mandated three AA meetings per week and was consequently fired.
Ultimately, he filed a human rights complaint based on the doctor, union,
and employer’s disregard for his feedback regarding his religious views and
treatment preferences.
The result had serious, if not tragic, consequences. The nurse lost his job
and potentially his career. The doctor, employer, and union were now facing
legal action for human rights violations. Furthermore, the likelihood of the
nurse reaching out for help in the future was questionable. Clearly, AA has
helped millions of individuals struggling with alcoholism. The treatment
plan might have made sense and been a good fit for someone else.
However, forcing people into any treatment approach could lead to similar
results. This story highlights the importance of integrating client feedback
into care, a core principle of the integrative approach known as feedback
informed treatment (FIT). Had those charged with the nurse’s treatment
been open and willing to act on his feedback, the outcomes may have been
very different.

THE INTEGRATIVE APPROACH

A substantial body of evidence demonstrates that psychotherapy is effective
in reducing distress and improving well-being. Consistently, the average
effect size for psychotherapy is robust, coming in reliably between 0.8 and
1.2 standard deviations above the mean of no treatment or control
conditions (Lambert & Ogles, 2004; Smith, Glass, & Miller, 1980;
Wampold, 2001). The effectiveness of psychotherapy equals or exceeds
many medical treatments (such as coronary bypass surgery for heart
problems and chemotherapy for breast cancer) with the added benefits of
being cost effective and avoiding the negative side effects of many medical
treatments (Schuckard, Miller, & Hubble, 2017; Wampold, 2007).
Beyond these generally positive results, a more complicated picture
emerges. Amid progressing cases, mental health professionals experience
client no-shows, dropouts, and those who remain stuck in despair despite
the best efforts to help them. Yes, psychotherapy is effective, but it is
impossible to ignore the facts. Dropout rates average about 25% for adults
and 35% for adolescents and children (Swift & Greenberg, 2012; Weisz et
al., 2005). With 5–10% of adult clients and 12–20% of child and youth
clients actually getting worse in therapy, the picture begins to look quite
different, if not grim (Lambert, 2010; Warren et al., 2010). The financial
implications for healthcare systems for clients who are not successfully
helped are enormous, eating up an estimated 60–70% of total expenditures
in the healthcare system (Miller, 2011).
Adding to the problem, there is evidence that clinicians are not accurately
identifying clients at risk for premature termination or negative outcomes.
Clinicians are frequently overly optimistic about their clients’ treatment
satisfaction and progress. In a 2005 study, researchers looked at how well
clinicians predicted treatment outcomes. The results are sobering.
Clinicians were accurate in their prediction of client negative outcome in
less than 5% of the cases (Hannan et al., 2005). The researchers conclude
that “therapists tend to over predict improvement and fail to recognize
clients who worsen in therapy” (Hannan et al., 2005, p. 161). Comparing
clinicians’ and clients’ views of how therapy is progressing frequently
reveals quite different perceptions (Schuckard et al., 2017). These concerns
beg the question: How can psychotherapists improve at identifying clients
at risk of dropping out or treatment failure and engage more clients in
achieving successful outcomes?
In the past two decades, numerous studies have documented the benefits
of routine outcome measurement (ROM). Gathering and utilizing ongoing
client feedback about the alliance and progress in treatment has been shown
to improve the effectiveness of therapy. In a meta-analysis of 15
randomized clinical trials (RCTs), Lambert and colleagues (2018) found
that providing therapists with ongoing feedback and clinical support tools
reduced deterioration rates in at-risk patients from an average of 30% to
12%; feedback improves by half the likelihood of at-risk patients
experiencing positive outcomes.
Consistent with these findings, that same meta-analysis (Lambert et al.,
2018) of nine additional RCTs (2,272 clients) using a different measure
(PCOMS) found that feedback produced an average effect size of .40 on
client outcomes. To illustrate, in a study of 6,424 clients, Miller and his
colleagues provided therapists with ongoing, real-time feedback regarding
the client’s experience of the alliance and progress (Miller et al., 2006). The
results included higher retention rates and a doubling of the effect size of
services offered (baseline ES = .37 vs. final phase ES = .79). Providing
mental health professionals with ongoing consumer feedback regarding the
working relationship and progress in treatment markedly increased success
rates and the cost-effectiveness of services.
Availability, frequency, and immediacy of feedback have also been
shown to be instrumental in improving the outcome of therapy. For
example, immediate feedback had a larger impact on outcomes than
feedback that was delayed by 2 weeks (Slade et al., 2008). Sharing outcome
data with clients and actively engaging them in discussion about their
progress has been shown to contribute to improved outcomes. (Hawkins et
al., 2004; Schuckard et al., 2017).
Moving from research to practice, FIT has evolved to embrace not only
the use of ROM and client feedback to inform treatment, but also to look
beyond individual client outcomes toward improving the effectiveness of
individual therapists. FIT is an evidence-based approach that translates the
best available research about what works in therapy into a practical system
by which clinicians measure their outcomes, enhance their chances of
achieving positive treatment effects, and improve performance across their
career. In keeping with the American Psychological Association (APA)
Task Force on Evidence-Based Practice, FIT promotes “the integration of
the best available research with clinical expertise in the context of patient
characteristics, culture, and preferences” (APA Presidential Task Force on
Evidence-Based Practice, 2006, p. 273). Furthermore, FIT provides a
practical method for “monitoring of patient progress (and of changes in the
patient’s circumstances—e.g., job loss, major illness) that may suggest the
need to adjust the treatment . . . (e.g., problems in the therapeutic
relationship or in the implementation of the goals of the treatment)” (APA
Presidential Task Force on Evidence-Based Practice, 2006, pp. 276–277).
Beyond these, FIT encourages a growth mindset, encouraging clinicians to
pursue ongoing improvement of their performance.

Guiding Principles
Research indicates that the therapeutic alliance is a strong predictor of
outcome (Del Re et al., 2012; Miller et al., 2005). The therapeutic or
working alliance involves the relational bond between therapist and client
and—taking client preferences into account—agreement on the goals of
therapy, as well as the means and methods to be used to achieve those goals
(Bordin, 1979). Research on the power of the therapeutic alliance has been
well established in more than 1,100 research findings (Horvath et al., 2011)
and steadfastly emerges as one of the strongest predictors of eventual
patient success—or failure.
The client’s rating of the alliance has a higher correlation with outcome
than therapists’ ratings (Horvath et al., 2011). Research consistently
indicates that therapists are relatively poor judges of the client’s view of the
alliance. On top of this, therapists and clients tend to perceive the
therapeutic relationship differently—clients may not see the therapist’s
behaviors in the same light as they were intended. For the most part, clients
and therapists tend to attribute change to different factors (Horvath et al.,
2011). Monitoring the client’s view of the alliance helps clinicians identify
divergent perspectives that may have a negative impact on the alliance and
heighten the risk of dropout or null or negative outcomes.
In addition to the therapeutic alliance, early change is a strong predictor
of client engagement and, in turn, of therapeutic outcome. Numerous large
research studies suggest that, on average, the bulk of change in successful
therapy occurs earlier rather than later (Owen, Adelson, Budge, et al., 2015;
Stulz et al., 2007). With as many as 30% of people remaining in treatment
while experiencing no measurable benefit and a 90% chance of failure if
there is no change between the second and eighth visits (Lambert, 2013),
obtaining real-time feedback from clients regarding their experience of
change is especially important—not only early in treatment but throughout
the treatment process. Maintaining engagement and ensuring that change
continues is key to successful therapy outcomes.
FIT involves the use of reliable and valid methods to monitor and track
client progress and identify clients at risk of unsuccessful treatment.
Feedback provides insight into clients’ subjective experience of the therapy
alliance and the impact that treatment is having on their functioning. This
feedback guides service delivery to best meet each client’s needs. Thus, FIT
involves routine collection of client feedback through alliance and outcome
measures administered at each session and engaging clients in discussions
about their progress. This information is used to inform and refine practice
decisions. Furthermore, FIT encourages clinicians to use aggregate outcome
data to establish their personal baseline of effectiveness, then develop
strategies to improve their effectiveness and monitor the impact that these
strategies have on their outcomes. FIT is a transtheoretical approach that
can be applied by psychotherapists no matter which theoretical orientation
they endorse.
In 2011, Miller and colleagues established four core competencies for
FIT, laying out knowledge and skills associated with outstanding clinical
performance and the components essential to FIT practice (Miller et al.,
2011; Prescott, 2017). The following is a summary of the FIT core
competencies.
Competency 1, Research Foundations, includes:
◆ familiarity with the research on the therapeutic alliance
◆ familiarity with research on behavioral healthcare outcomes
◆ familiarity with the general research on expert performance and its
application to clinical practice
◆ familiarity with the properties of valid, reliable, and feasible alliance
and outcome measures

Competency 2, Implementation, includes:

◆ integration of consumer-reported outcome and alliance data into

clinical work
◆ collaboration and transparency in interactions with consumers about
collecting feedback
◆ using the resulting information to inform and tailor service delivery
◆ ensuring that the course and outcome of behavioral healthcare services
are informed by consumer preferences

Competency 3, Measurement and Reporting, includes:

◆ measuring the therapeutic alliance and the outcome of clinical services

on an ongoing basis with consumers
◆ providing details in reporting outcomes sufficient to assess the
accuracy and generalizability of the results

Competency 4, Continuous Professional Improvement, includes

clinicians:

◆ determining their baseline level of performance

◆ comparing their level of performance to the best available norms,
standards, or benchmarks
◆ developing and executing a plan for improving their performance
◆ seeking performance excellence by deliberate practice

ASSESSMENT AND FORMULATION

FIT does not designate specific outcome and alliance measures to gather
client feedback other than the requirement that they be valid and reliable
measures. While there are numerous options to measure alliance and
outcomes, longer formats have proved cumbersome, taking too much time
to administer and making them impractical for regular use. Indeed,
utilization rates suffer when measures take more than 5 minutes to
administer (Brown, Dreis, & Nace, 1999). Moreover, several feedback
instruments and ROMs are proprietary and costly, putting them out of reach
for some clinicians and clinics.
The Outcome Rating Scale (ORS; Miller & Duncan, 2000) and the
Session Rating Scale (SRS; Johnson, Miller, & Duncan, 2000) are brief
measures that have proven feasible for regular use and are commonly used
by therapists implementing FIT. Designed to minimize content and
complexity, each of the measures consists of four visual analog scales. The
client marks the scale nearest to whichever “pole” best describes his or her
experience. Visual analog scales tend to have good face validity.
The ORS developed out of the third author’s long-standing use of the
Outcome Questionnaire 45 (OQ-45; Lambert et al., 2003). Miller was
teaching a workshop on routine outcome measurement in Israel and
mentioned the time that the measure took to administer as well as how its
literacy level created difficulty for many of his clients. A psychologist in
attendance, Haim Omer, suggested bypassing the language-dependent items
and using a visual analog scale to capture the major domains assessed by
the longer tool. Miller had experience with the Line Bisection Test
(Schenkenberg, Bradford, & Ajax, 1980) during his neuropsychology
internship and developed scaling questions at the Brief Family Therapy
Center (Berg & Miller, 1992; Miller & Berg, 1995). This prompted him to
suggest a measure with four lines, each 10 centimeters in length,
representing the four domains of client functioning assessed by the OQ-45
(Miller, 2010). A similar process led to the creation of the SRS (Miller,
2010).
Miller’s mentor and supervisor, Johnson (1995), had developed a 10-
item, Likert-type scale for assessing the quality of therapeutic interactions
(including alliance). Miller had used the scale but wanted a simpler, briefer
version to fit with the demands of an inner-city clinic. The measure was
shortened and converted into a visual analogue scale that captures the major
elements of a good therapeutic alliance as originally defined by Bordin
(1979; Miller, Duncan, & Hubble, 2004).
The ORS and SRS provide a broad snapshot of client functioning and
view of the alliance. The ORS measures change in three areas of client
functioning: individual (or symptomatic) functioning, interpersonal
relationships, and social role performance (including work and quality of
life). The SRS measures four interrelated domains of the therapeutic
alliance: the quality of the relational bond, the degree of agreement between
the therapist and client on goals, agreement on methods, and agreement on
overall approach to therapy.
Versions of the ORS and SRS are available for use with adults,
adolescents, and children, thus making the measures versatile with diverse
client populations. A group session rating scale (GSRS) measures the
client’s alliance with the group facilitator and other group members. Oral
versions of ORS and SRS are available for use over the phone and with
clients who have literacy or visual problems or who prefer not to complete
paper or electronic versions of the measures. To date, the measures have
been translated into 19 different languages and used in many countries
across the globe.
The adult versions of the ORS and SRS are designed for administration
to clients with a grade six reading level or higher and are normed for people
13 years and older. The Child Outcome Rating Scale (CORS) and Child
Session Rating Scale (CSRS) are designed for use with children aged 6–12
with about a grade two or higher reading level. Due to the simplified
language on the measures, they can also be used with adolescents or with
adults who have literacy or language challenges. Versions of the measures
are available for use with very young children who lack literacy skills
(usually under 6 years old). These are called the Young Child Outcome
Rating Scale (YCORS) and the Young Child Session Rating Scale
(YCSRS). They use three “feeling face” pictures representing a happy or
smiley face, a neutral face, and a frowning or unhappy face that young
children choose to represent their experience. A fourth blank feeling face
provides an option to draw their feeling if the other three faces do not
adequately capture their experience. Since these measures do not have any
numeric assignment, they do not provide a numerical measure of change.
However, they engage young children in providing feedback.
Adding to the utility of the FIT measures, computerized systems are
available for administration and for tracking client scores. These systems
save time by allowing clients to complete the measures electronically. If
clients prefer paper or oral versions, therapists can input scores following
administration of the measures. The computer systems automatically score
the measures and plot the scores on a graph that provides a comparison of
the client’s score to a normative sample of 427,744 administrations of the
ORS, in 95,478 unique episodes of care, provided by 2,354 different
clinicians (Miller, 2011). This provides immediate feedback on the client’s
progress compared to change trajectories formulated from the normative
sample, indicating whether the client’s progress is similar to clients whose
therapy outcome was successful, uncertain, or unsuccessful. Access to the
trajectories has the added benefit of making it possible to assess under- and
overreporting of change, thereby facilitating a discussion with clients in real
time. Finally, computerized systems calculate aggregate outcome data for
both individual therapists and agencies, allowing a comparison of
effectiveness to agency and national norms.
Unlike many therapy models, FIT discourages theoretical interpretations.
Instead, it puts the focus on client progress (based on outcome and alliance
scores). Treatment efforts prioritize goals according to client preferences,
and treatment decisions derive from feedback generated from monitoring
the client’s progress and his or her view of the alliance via ongoing
administration of measures and client discussions regarding scores.
Clinical cutoffs for the ORS and SRS provide essential assessment
information to therapists. The clinical cutoff of outcome measures defines
the boundary between a normal and clinical range of distress and provides a
reference point for evaluating the severity of distress in a particular client or
client sample. The clinical cutoff of the ORS is 25 for clients18 years and
older. Scores below 25 indicate lower satisfaction in areas such as personal
relationships and acquaintanceships, while those over 25 imply a level of
distress that is not significant enough to seek out psychotherapy.
Adolescents and children tend to score the ORS higher, so the cutoff for
these clients is higher (adolescents 13–18 years old = 28; children 6–12
years old =32). A quarter to a third of clients who present for treatment
have normal scores typical of those not seeking psychotherapy—falling
above the clinical cutoff for the ORS. This is usually because they are
mandated for treatment or because they are seeking assistance for a focal
problem with limited impact on their well-being. Initial scores that indicate
a low level of distress (i.e., above the clinical cutoff) may give cause for
concern because normative studies show that when clients’ initial scores are
high, with therapy they tend to decrease over time. However, when clients
present with initial scores on the ORS in the “normal” range, therapists
should explore their reason for seeking therapy. For example: “From your
score on the ORS it looks like things are going pretty well. I am curious
about why you decided to come to see me now?”
Typically, clients will score high on alliance measures, and the SRS is no
exception. It asks clients to rate the session in terms of how understood and
respected the client felt, how well the therapist’s approach addressed their
needs, and to what extent the client and therapist agreed on the goals of
treatment. Only about 24% of clients score lower than 36/40 on any version
of the SRS. Thus, the clinical cutoff for all versions of the SRS is 36; scores
below this cutoff clearly warrant discussions about how to ensure the best
possible alliance. FIT therapists watch for any change in alliance scores. A
drop of even 1 point during the course of therapy can indicate a problem
with the alliance that could lead to the client dropping out or continued
services being ineffective (Miller & Duncan, 2004).

APPLICABILITY AND STRUCTURE

As a transtheoretical approach, FIT can apply to almost all treatment
settings (outpatient, inpatient, crisis), therapy formats (individual, couple,
family or group), and patient ages (adults, adolescents, children, young
children) regardless of presenting concerns or referral source (voluntary,
mandated). In some situations, FIT may seem inappropriate or of uncertain
relevance. For example, clients with cognitive impairments may have
difficulty assessing changes in their well-being over time. In these cases,
although trends in scores on the measures may be more open to
interpretation, the usefulness of the measures as tools for clinical dialog
remains. Some argue that FIT may also not be appropriate for planned
single-contact situations since clients would not be returning for a second
appointment and a second session score is needed to measure change.
However, obtaining an initial ORS score can nonetheless provide a
snapshot when assessing clients, and it is generally useful to obtain
feedback regarding a client’s experience.
Typically, the frequency of sessions and length of treatment depend on
client progress. When positive change occurs rapidly, more frequent and
intense treatment maximizes gains. When positive change slows or
diminishes, sessions are less frequent and intensity of treatment decreases
with a focus on consolidating change and transitioning out of therapy.
Psychotherapy goes on as long as meaningful change is evident and the
client wants to continue.

PROCESSES OF CHANGE
Therapists’ attitudes toward soliciting and using patient feedback vary and
may influence change. Therapists who value feedback achieve better
outcomes (Miller, 2014). From a FIT perspective, change is measured by
outcome data and client feedback.
Clinicians can use any theoretical approach to achieve patient change, but
if the data indicate that the approach is not working, the onus is on the
therapists not the client, to adjust the approach. Lack of change within the
first few sessions (typically by the third session) merits evaluating the
frequency and intensity of treatment. Therapists should explore the alliance
more carefully and adjust their approach as needed. If, despite adjustments,
lack of significant change continues, it may be time to consider referral to a
different therapist or changing the treatment approach.

THERAPY RELATIONSHIP
FIT involves not only the administration of outcome and alliance measures,
but also the creation of a transparent and open environment that encourages
clients to provide honest and useful feedback. In FIT this is known as
creating a “culture of feedback.” Specifically, clients are told that providing
feedback is critical to success, enabling the clinician to tailor services to
meet their needs. Typical scripting and suggestions for processing feedback
are illustrated in the case example at the end of this chapter as well as the
FIT Treatment and Training manuals (Bertolino & Miller, 2013).
Surveys regularly indicate that more than 90% of adult psychotherapy
patients report having lied to their therapists (Blanchard & Farber, 2015).
According to this research, one of the most common lies is that the client
likes or benefits from his or her therapist’s interventions more than he or
she actually does. Naturally, fears and the desire to be viewed positively can
make people reluctant to provide negative feedback. Evidence indicates that
creating an environment where clients feel able to share such feelings is a
skill that can be learned. Studies using the ORS and SRS indicate, for
example, that the most effective practitioners receive more negative
feedback (e.g., low SRS scores) than their more average counterparts
(Miller, Duncan, & Hubble, 2007; Owen, Miller, Seidel, & Chow, 2016).
Clinical experience reveals that many therapists experience discomfort in
obtaining patient feedback. Reasons range from fears about receiving
negative feedback to concerns that low outcome or alliance scores could
threaten their job security and fears that administering measures could
dampen the therapeutic alliance. Managing such worries, consulting the
research to differentiate worry from reality, and being transparent with
clients can prove essential.

METHODS AND TECHNIQUES

Clients are diverse; no single treatment works for all clients. From a FIT
perspective, outcome takes precedence over technique. The choice of
therapy approach depends on the probable effect the approach will have on
the client’s outcomes. When feedback scores indicate a lack of progress
and/or problems with the alliance, therapists can adjust their treatment plan
(e.g., type, frequency or intensity of treatment).
One of the biggest technical errors in implementing FIT happens when
therapists use feedback measures in a perfunctory fashion (e.g.,
administering the measures but failing to discuss scores with clients or not
using the feedback to guide therapy). Charts of client progress should be
shared with the client and act as a springboard for discussion around the
alliance and progress in therapy. Based on clients’ input, therapists can
align better with clients’ preferences and adjust their approach accordingly.
At their initial contact, therapists can introduce clients to FIT by presenting
the measures with a rationale for clients to complete them, emphasizing the
importance of detailed and honest feedback in the outcome of their therapy.
Once clients understand its purpose, therapists should administer the ORS
as early as possible and at each session thereafter unless there is a specific
reason not to, such as frequency of sessions. In order to avoid measurement
fatigue, clients should not be expected to complete the measure any more
frequently than once per week. Administering the ORS as early as possible
—at first contact—is useful because it provides a baseline of client
functioning.
We recommend that the SRS be administered near the end of each
session, leaving enough time to discuss the client’s scores with them in case
concerns are present that require attention. Since the alliance is associated
with and predicts treatment outcome, therapists should promptly address
any indication of an alliance problem or rupture. Taking swift action may
prevent the premature termination or deterioration of treatment.
Some change patterns warrant special consideration and action. When a
client’s initial score indicates functioning in the normal rage of distress,
therapists should proceed with caution. In the case of a voluntary client
seeking help with a specific concern, depth-oriented techniques may not be
useful, and problem-solving techniques focused on the presenting concern
may be more appropriate. When dealing with involuntary clients, consider
asking them to complete the ORS based on how the person who referred
them would score the measure. This provides an opportunity to compare the
clients’ self-perception to that of the referrer and also opens up discussion
on what kind of change the referrer would need to see in order to resolve
the referrer’s concerns.
Although having clients remain in psychotherapy longer may consolidate
behavior change (and prevent relapses), treatment starts to have a
diminishing return when essential goals are met and clients continue
treatment in absence of further change (scores plateau). When clients have
made positive changes and their scores plateau, therapists can talk with
them about spreading out sessions and begin planning for termination.
When treatment frequency and intensity are not decreased during
maintenance sessions, client scores can begin to fluctuate dramatically. This
pattern in scores can indicate everyday ups and downs rather than
meaningful changes over time.
Sometimes, ORS scores will drop dramatically after positive change has
occurred—a phenomenon known as “ditching.” Often this is due to an
event external to therapy (an “extratherapeutic” variable). When this
happens, we advise clinicians to review each domain of the ORS carefully
to determine if there are any external variables affecting the scores and to
monitor change to ensure quick recovery of gains.

DIVERSITY CONSIDERATIONS
Race, ethnicity, nationality, gender, age, sexual orientation, gender identity,
religion, physical ability, socioeconomic status, and body size are all
examples of human diversity that have led to people and groups being
marginalized. Failing to consider the impact of such marginalization can
result in power imbalances that contribute to clients’ distrust and feeling
unsafe to disclose feedback regarding their psychotherapy. The essence of
FIT is providing feedback to clinicians so they can tailor services to the
individual client. The process includes specific guidelines for creating a
“culture of feedback” that maximizes opportunities for attending to diverse
client backgrounds, experiences, and ways for making sense of the world
(Bertolino & Miller, 2013). The SRS in particular is designed to alert
therapists to differences in understanding, goal consensus, and preferences
related to identity so they may be discussed and addressed directly.
Although FIT has proved versatile, as evidenced by its use in many
countries and cultures, providing direct feedback to health professionals
may not be the norm and, in some cases, may conflict with deeply held
values. Even the outcome being measured may present challenges. For
example, the idea of “personal well-being,” included on many outcomes
measures, may not be relevant in cultures where well-being is experienced
in the context of relationships (Bertolino & Miller, 2013; Koo, Dion, &
Rice, 2016). Making room for the client’s perspective in this case would
mean choosing a method and measure for seeking feedback in which well-
being refers to the feeling of the group close to the client.
In another example, older adults in the United States have frequently
been conditioned not to critique or evaluate a professional’s activities. Still
other patients will resist providing alliance and outcome measures at every
session. Cultural adaptations in the use of feedback should follow the same
fundamental FIT principles of therapist flexibility and client preferences. To
help in this regard, Miller and colleagues have produced a comprehensive
and detailed series of FIT manuals. Manual 5 is specifically designed to
guide therapists in applying FIT across diverse settings, cultures, and clients
(Bertolino & Miller, 2013).
With ORS and SRS measures available in multiple languages, there are
several FIT implementation projects under way where FIT is being applied
in diverse settings and populations. Unlike other measures, to date,
comparisons of clients from different countries and cultures have not shown
differences in either the psychometric properties of the measures or the
predictive trajectories (Koo et al., 2016; Miller, Bargmann, & Wampold, in
preparation; Schuckard et al., 2017).
CASE EXAMPLE

Thirty-year-old Natalie and her partner, Andrea, had been seeing a couple’s
therapist. Andrea was addicted to alcohol and street drugs, and she
completed a residential treatment program. She was now engaged in
outpatient treatment to continue working on her recovery. Andrea and her
therapist invited Natalie to attend couple sessions, during which Andrea had
expressed that Natalie’s ongoing marijuana use was putting her at risk for
relapse. Indeed, the couple had experienced an escalation of conflict with
Natalie defending her right to recreational marijuana use, saying she was
not responsible for Andrea’s problem and therefore should not have to
change her behavior because Andrea decided to pursue abstinence from all
substances. Ultimately, the relationship deteriorated, and Andrea moved
out. Andrea’s therapist recommended that Natalie seek help from another
therapist to deal with the aftermath of the breakup.
Natalie presented for individual therapy as angry and depressed. She felt
heartbroken and betrayed by a bitter ending to a loving relationship.
According to Natalie, as a result of her addiction, Andrea had accumulated
massive debt. She was unemployed and now on a disability pension, and
she was unable to pay anything toward the debt. Natalie found herself
saddled with the debt, a huge financial burden. She was working full-time
yet struggling to make ends meet. Preoccupied with worry about debt, not
sleeping, and becoming socially isolated, Natalie was angry, perceiving
herself as having been dumped and left to clean up Andrea’s financial mess.
The following is a reconstruction of Natalie’s psychotherapy based on the
recollection of her therapist (first author). At the initial session, Natalie’s
therapist introduces her to FIT.
Therapist:I want to be certain that the work we do together has the best
chance for success. To help me with this, I’d like to ask if you would
complete two very brief measures each time we meet. Usually, if change is
going to happen, it should happen sooner rather than later. These measures
will help us see if the work we are doing together is working for you. If
things aren’t getting better, then we’ll talk about what we can do to get
things moving in the right direction. The first measure is one that I’d like
you to fill in at the beginning of each session and will tell us if change is
happening. The second one is the one I’d like you to complete at the end of
each session. It will ask you questions about how you think the session
went and whether I am in sync with what you are wanting. It’s kind of like
when your doctor gives you medicine to reduce high blood pressure and
then monitors it regularly to make sure the medicine is working. Would you
be willing to do this with me?
Natalie: Sure. Sounds like a good idea.
Therapist:Great. Now, we have a couple of options. If you like, you could
complete the measures on my tablet here, or, if you prefer, I have paper
versions that you could use. Do you have a preference?
Natalie: Well, may as well go green. I’ll use the tablet.
Therapist:Okay. So here is the first measure. I am going to ask you to
complete this one at the beginning of each session. It’s the one that helps us
to see if change is happening. When you complete this, it’s not based on
how you are doing at this moment, it’s based on how things have been
going over the past week or since the last session we’ve had together.
Things can fluctuate day to day, but what we need to know is how things
are going over time. So, you see it asks: “Looking back over the last week,
including today, help us understand how you have been feeling by rating
how well you have been doing in the following areas of your life, where
marks to the left represent low levels and marks to the right indicate high
levels.” Now, to mark each of the scales, all you do is just move the cursor
where you want to and then click on the line. Make sense?
Natalie:Yeah, I think so. (Takes the tablet and completes the measure then
hands it back to therapist.)
Therapist:Great, thanks. Okay, let’s take a look (holding the tablet so that
they both see it). You see, each of these scales has a value of 10. So, if you
marked it way over to the left here, the score would be zero and if you score
it way over to the right, the score would be 10. What the computer does is it
takes each of the scores and adds them up to get a score out of 40. Then it
plots your score on this graph (shows the client the graph). Then the
computer compares your scores to a huge sample of people who started
therapy with a similar score to you. First, we look to see if your score falls
above or below this line (points to the line on the graph that represents the
clinical cut off, in this case for the ORS the score is 25). When someone’s
score falls above the line usually it means things are going pretty well for
them. If their score is below the line, it means there may be some things that
aren’t going so well, in which case therapy might help. It looks like you had
a score of 19 indicating that there may be some things that you aren’t
feeling too good about. Is that right?

Figure 5.1 below represents Natalie’s initial score on the ORS once it was
entered into MyOutcomes, a computerized system used in the
administration of the ORS and SRS. The chart displays the ORS score
relative to the clinical cutoff for the ORS (represented by the solid black
line). The shaded areas on the chart provide a guide to indicate where
subsequent scores would fall if the client’s progress were similar to clients
whose treatment was successful (light gray zone), uncertain (white zone), or
unsuccessful (dark gray zone).
FIGURE 5.1 Expected treatment response based on initial Outcome Rating Scale (ORS) score.
Natalie: Yes, that’s right.
Therapist:As you can see, there are shaded areas on the chart, a light gray
one, a white area, and a dark gray area. As I mentioned, I’m going to ask
you to complete this measure at each session to see if and how things are
changing. So, as we progress, we’ll track your scores. If your score lands in
the light gray area it means you are responding to therapy similar to people
who ended therapy successfully. If your scores are in the white area, it
means you are responding like people whose outcome of therapy was
uncertain. And if your scores are in the dark gray area, well, it means that
your scores are similar to those where the outcome wasn’t successful. Does
that make sense?
Natalie: Yes, I think so.
Therapist:So if we think of this as a kind of traffic light, if you are in the
light gray zone, then everything is on track to keep going as we are. On the
other hand, if the scores are in the white zone, we should proceed with
caution and pay careful attention and consider if we should change things
up. If the scores are in the dark gray area, then we should take pause and
talk about what changes I should make to help you get back on track. When
therapy is successful, usually change takes place sooner rather than later, so
if we are not seeing progress soon then we’ll want to talk when we notice
that.
Natalie: Okay, that makes sense.

Had the client opted to complete the paper version, the therapist would
use a metric ruler to score the measure, putting the 0 on the far left pole and
then taking the measurement to the nearest centimeter where the client
marked on each of the scales. The score is either plotted on a paper graph or
is entered manually into one of the computer tracking systems designed for
managing ORS and SRS data. The limitation with paper graphs is that it
does not provide comparison of client scores to the normative sample. In
addition, it does not allow for easy calculation of aggregate therapist
outcome data.
Therapist:Now, I noticed that you marked a couple of the scales on the
measure lower than the others. I see you have marked the “Interpersonally”
and the “Individually” scales lower than the other two scales. Would you
like to start by telling me about that? Why are these two lower? What’s
been going on?

Natalie and her psychotherapist proceeded to discuss the meaning of the

scores, and the treatment unfolded based on their conversation. The
therapist eventually chose a treatment plan indicated by the clients’
preferences, problems, and personality.
At the end of the session, the therapist introduced the SRS and left
enough time to discuss Natalie’s answers.
Therapist:If you’ll recall, when we started today I mentioned that I would be
asking you to complete another brief measure at the end of the session.
Here it is (showed Natalie the measure on the tablet). As you can see, it is
similar to the last measure, only this time, it’s asking you for feedback
about how you thought the session went. If you felt heard and respected by
me, if we worked on or talked about what you wanted to today, if my
approach was a good fit for you or not, and finally how the session was for
you overall. You fill it in the same as before, by clicking on the line. Before
you do this, though, it is important for you to know that I need you to be
honest with me when you do this. If there is something, even the smallest
thing, that I missed, it is important that your score reflects that. I am not
perfect, no one is, so don’t be afraid to mark the scales honestly. I won’t be
offended, and it will help us to stay on track. How I learn what works best
for you is when you let me know what felt right and what didn’t. Okay?
Natalie: Okay, sure (therapist handed her the tablet and she filled it in).
Therapist: Thanks Natalie. Now let’s take a look at your scores.
Whether the alliance scores are high or low, it is important to seek
additional information. Asking task questions can generate actionable
feedback.
Therapist:
Okay, I see all of the scores were pretty high. It looks like the
session was good for you.
Natalie: Yes, thanks, it was good.
Therapist:
That’s good to hear. Now, if there was one thing that might have
made the session even better, what would that be?
Natalie:(Thought for a minute). Well, maybe if we could spend a bit more
time talking about my debt. I really need some concrete ideas about how I
can get a handle on them.
Therapist:Okay, great. How about next time we make sure to check in about
that. I have some ideas and resources that may be of interest to you.
Natalie: Sounds good. Thank you. When I can see you next?

The therapy continued, with the therapist asking Natalie at each session
to complete the measures. However, ORS scores indicated little progress,
even though alliance scores remained high (refer to Figure 5.2). The
therapist talked to Natalie about this pattern.
Therapist:Natalie, I notice that since we started to work together, your scores
have not changed much. As you can see, they are about the same as when
you began to see me. If you recall, when we first met I explained that
usually, if therapy is working, we’ll notice change sooner, rather than later.
Based on your scores it looks like not much is changing.
Natalie: I hate this measure.
Therapist: Wow, I feel surprised. You never mentioned this to me before.
Natalie:Well, it’s not really the measures. It’s just that when I fill them in
and see my scores, I realize I need to change some things in my life if I am
going to feel better. I’ve been thinking about it, and since we did that work
on budgeting I am realizing that a lot of my money is going to buying pot.
That’s not helping with the debt problem, and I think it’s probably not
helping with my sleep problems either. But pot is like one of the only things
that gives me a bit of relief and helps me relax and focus on something
other than Andrea and the mess I’ve been left with.
Therapist: So where do we go from here then?
Natalie: Well, I think it would help if I cut down a bit on the pot.

Natalie and her therapist started in a new direction, monitoring her

progress as they went. They agreed to shift the focus of psychotherapy to
strategies aimed at reducing and eventually eliminating her use of
marijuana. Natalie attended weekly one-to-one sessions as well as Narcotics
Anonymous meetings. When she first stopped using marijuana, her scores
on the ORS increased. However, after a couple of weeks, her score
decreased, indicating that she was having more trouble coping. Despite this,
SRS scores remained high. Figure 5.2 shows the drop in Natalie’s ORS
scores into the dark gray zone indicating that she was at risk for an
unsuccessful treatment outcome.
Once again, her therapist discussed the declining ORS scores with
Natalie. Natalie said she was having trouble coping without marijuana and
needed help with that. Her therapist referred her to a relapse prevention
program consisting of weekly group sessions focused on helping clients
develop coping strategies, such as stress and anger management. Biweekly
one-to-one sessions continued while she attended the group program.
During this time, her ORS scores increased, indicating decreasing distress.
SRS scores remained high, suggesting no issues with the alliance. After her
ORS scores moved into the light gray zone and plateaued (indicating she
was on track for successful treatment outcome), her therapist adjusted the
frequency of sessions to once a month, and the focus shifted to maintaining
gains and eventual termination.
Natalie’s treatment took place over the course of 6 months (13 sessions).
At last contact, Natalie reported improved mood, sleep, and ability to cope
without marijuana. Although still in debt, she was making headway paying
it down. She had also decided to proceed with a divorce from Andrea and
had started dating. Natalie said she felt ready to end psychotherapy and
expressed her appreciation and gratitude to her therapist. In this case,
continuous monitoring of Natalie’s feedback about her progress and
adjusting the approach when Natalie was not progressing resulted in the
eventual successful outcome to her psychotherapy. Figure 5.2 shows the
pattern of Natalie’s progress from start of psychotherapy to termination.

FIGURE 5.2 Client progress based on Outcome Rating Scale (ORS) scores over the course of
treatment.
OUTCOME RESEARCH
In 2012, FIT was formally recognized as an evidence-based practice and
listed on the Substance Abuse and Mental Health Services Administration’s
National Registry of Evidence-Based Programs and Practices
(https://www.samhsa.gov/nrepp). Since that time, the number of RCTs on
FIT, whether using the ORS/SRS or another combination of measures, has
been accelerating with clinically, culturally, and economically diverse
clients. The effectiveness of FIT has been impressive: routine outcome
monitoring and feedback reliably increases the rate of clinically significant
change, consistently decreases dropout and deterioration rates, and
significantly reduces the cost of mental healthcare (Lambert et al., 2018). In
non–feedback groups, the costs increased (Schuckard et al., 2017).
Questions remain, however. Is it simply the use of measures to assess
outcome and alliance that helps improve treatment outcomes, or is it the
process of engaging people in their care that produces the most
improvement?
Research suggests that focusing too closely on the measures themselves
proves risky and distracts focus away from outcome (Miller, Duncan, &
Hubble, 2004). A dismantling by study found that using both alliance and
outcome measures did not translate into any significant increase in feedback
effects when compared to using only an alliance or an outcome measure to
solicit feedback (Mikeal et al., 2016). This study suggests that the process
of asking clients about their experience of therapy may prove more
important than which measures are used to collect feedback. This finding
speaks to the importance of creating a culture that engages the client in
collaboration, dialogue, and the process of change itself.
Therapy without both outcome and alliance feedback presents
limitations. For example, opting to administer only alliance measures
hinders the ability to track client progress along with valuable aggregate
data, including session-to-session change. Using outcome measurement
alone may limit insight into fluctuations in the strength of the alliance,
which hold predictive value in terms of engagement and retention.

FUTURE DIRECTIONS
FIT has potential in three principal directions: increased dissemination and
implementation, more investigation into the boundary conditions of when
FIT does and does not work well, and employment of therapist deliberate
practice in conjunction with client feedback. Given the clinical and research
evidence of its benefits and the fact that psychotherapists can adopt FIT
with virtually any theoretical orientation, it is no wonder that many
psychotherapists are implementing formal feedback systems to monitor
their clients’ progress and view of the alliance. However, FIT is a relatively
new approach and, at this point, not all mental health professionals are
using ROM in their practices. Some are not familiar with FIT, others are
hesitant to implement FIT into their practice. For example, Babins-Wagner
(2017) found that after research was presented on the value of outcome and
alliance measurement, only 60% of therapists in an agency opted to
administer the measures. When asked, therapists offer many reasons for
opting not to use the measures (Babins-Wagner, 2017). Objections such as
“it will take too much time,” “it will conflict with my style,” or “my clients
won’t like it” prevent therapists from implementing FIT. Even when
therapists administer such measures, Lutz found in Germany that about
60% of the time when the feedback suggests a client is deteriorating,
therapists do not discuss this with clients. Furthermore, therapists attempt to
assist clients with other treatment resources about 27% of the time and only
adjust therapeutic interventions 30% of the time, varying the intensity or
dose of services 9% of the time and consulting with others (e.g., supervision
or education) 7% of the time (Lutz, 2014; Miller, 2014). Even though some
mental health professionals are reluctant to implement formal measurement
processes, 92% of people in healthcare say they like the use of outcome
measures (Lutz, 2014). It seems that therapists’ attitudes are more likely
than clients’ to create barriers to implementation. Such findings suggest a
need to overcome therapist reluctance to implement FIT as intended. The
goal of dissemination and implementation is to share the value and methods
of FIT and then ensure that it is conducted appropriately.
Despite early encouraging evidence that ROM and client feedback
improve outcomes, recent studies show more modest results (Lambert et al.,
2019). Chow (2017) notes that “ROM and feedback studies are not immune
to the decline effect . . . earlier studies have demonstrated therapeutic
benefits of using feedback measures, but more recent studies have shown
contrary results” (Chow, 2017, p. 325). Several recent studies show
predictable evidence of this decline effect. This ubiquitous effect may be
attributable to a confluence of the enthusiasm and allegiance of its
developers and early proponents, the regression toward the mean in
scientific studies, probable publication bias, and the paucity of treatment
fidelity in later studies. In other words, future researchers will examine the
boundary conditions of the efficacy of FIT more closely, including when,
how, and with whom it works.
Convinced that feedback alone is not sufficient to generate substantial,
sustainable gains in treatment outcomes, Miller and colleagues (2013) have
begun to look more closely at a growing body of evidence suggesting that
therapist factors influence outcomes. “Available evidence documents that
the therapist is one of the most robust predictors of outcome among factors
studied. Indeed, the variance of outcomes attributable to therapists (5%–
9%) is larger than the variability among treatments (0%–1%), the alliance
(5%), and the superiority of an empirically supported treatment to a placebo
treatment (0%–4%)” (Miller et al., 2013, p. 90). They looked to studies of
research on experts and expertise in a number of fields such as sports,
music, and medicine. Here, they found a large body of research outside of
psychotherapy that provided a clearer direction that could drive better
outcomes. They concluded that the common avenue to superior
performance consists of three steps: (1) determining a baseline level of
effectiveness; (2) obtaining systematic, ongoing feedback; and (3) engaging
in deliberate practice. Deliberate practice involves individualized training
activities especially designed to improve specific aspects of an individual’s
performance through repetition and successive refinement. To receive
maximum benefit from feedback, individuals have to monitor their training
with active concentration on a regular basis (Ericsson & Lehmann, 1996).
FIT strives to enhance outcomes at two levels. First, it informs the work
client by client. Second, aggregate outcome data informs therapists about
their level of effectiveness (relative effect size) compared to national norms.
By establishing a baseline for their performance and by analyzing outcome
and alliance data, therapists can identify areas for professional
development.
Engaging in deliberate practice includes creating and executing a plan for
improving one’s performance. Early research indicates that therapists with
superior outcomes are characterized by professional self-doubt, focusing
more on their mistakes and what they can do to change than on their
successes (Chow, 2017). In fact, highly effective therapists spend, on
average, two to three times more hours per week engaged in deliberate
practice activities than do other therapists (Chow, 2017). The ideal path to
developing expertise in psychotherapy is still hazy. In going forward,
deliberate practice merits greater attention.

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B. Technical Eclecticism
 6

Multimodal Therapy
CLIFFORD N. LAZARUS AND ARNOLD A. LAZARUS

THE INTEGRATIVE APPROACH

At the time when rival factions were dominating the field of psychotherapy,
Arnold A. Lazarus (AAL) was prompted to write a brief note, “In Support
of Technical Eclecticism” (Lazarus, 1967). Specific schools of thought were
actively competing for dominance and prominence—each claiming its own
superiority over all others. It seemed obvious that no one school could have
all the answers and that many approaches had something worthwhile to
offer. AAL was strongly influenced by London’s (1964) observation that
techniques, not theories, are actually used on people and that the “study of
the effects of psychotherapy, therefore, is always the study of the
effectiveness of techniques” (p. 33)*.
AAL recommended that we cull effective techniques from many
orientations without subscribing to the theories that spawned them. He
argued that to combine different theories in the hope of creating more
robust methods would only furnish a mélange of incompatible notions,
whereas technical eclecticism (not theoretical integration) would permit one
to import and apply a broad range of potent strategies. Subsequently, in
addition to developing the multimodal approach to assessment and therapy
(which will be explicated in this chapter), he wrote at length about the pros
of technical eclecticism and the cons of theoretical integration (A. Lazarus,
1986, 1987, 1989, 1992, 1995, 1996; Lazarus & Beutler, 1993; Lazarus,
Beutler, & Norcross, 1992; Lazarus & Lazarus, 1987).
In 1983, the Society for the Exploration of Psychotherapy Integration
(SEPI) was founded, held annual international conferences, and launched
the Journal of Psychotherapy Integration. It was AAL’s view that the
much-needed emphasis on eclecticism and integration had served a useful
purpose but that it is now passé. The narrow and self-limiting consequences
of adhering to one particular school of thought are now self-evident to most.
It seems that the current emphases on evidence-based methods and the use
of manuals in psychotherapy (Wilson, 1998, 2006) have much to commend
them.
As will now be underscored, the multimodal approach provides a
framework that facilitates systematic treatment selection in a broad-based,
comprehensive, and yet highly focused manner. It respects science and
data-driven findings, and it endeavors to use evidence-based methods when
possible. Nevertheless, it recognizes that many issues still fall into the gray
area in which clinical artistry and judgment are necessary, and it tries to fill
the void by offering methods that have strong clinical support. In essence,
owing to its emphasis on technical eclecticism instead of theoretical
integration, multimodal therapy (MMT) aims to be a synergistic synthesis
rather than a syncretistic stew.

History of Multimodal Therapy

AAL’s undergraduate and graduate training exposed him to several schools
of psychotherapeutic thought—Freudian, Rogerian, Sullivanian, Adlerian,
and behavioral—but, for several reasons, he became a strong advocate for
behavior therapy (Wolpe & Lazarus, 1966). Most of his conclusions about
the conduct of therapy were derived from careful outcome and follow-up
inquiries. Twice a year, he made a point of studying his treatment outcomes.
He’d ask, in essence, “Which clients derived benefit? Why did they
apparently profit from therapy? Which clients did not derive benefit? Why
did this occur, and what could be done to rectify matters?”
Follow-up investigations proved to be especially pertinent. They led to
the development of AAL’s broad-spectrum outlook because, to his chagrin,
he found that about one-third of his clients who had attained their
therapeutic goals after receiving traditional behavior therapy backslid or
relapsed. Further examination led to the obvious conclusion that the more
people learn in therapy, the less likely they are to relapse. There is a clinical
point of diminishing returns: So what are people best advised to learn to
have minimal emotional problems?
 Clearly there are essential behaviors to be acquired—acts and actions that
are necessary for coping with life’s demands. The control and expression of
one’s emotions are also imperative for adaptive living—to correct
inappropriate affective responses that undermine success in many spheres.
Untoward sensations (e.g., the ravages of tension), intrusive images (e.g.,
pictures of personal failure and ridicule from others), and faulty cognitions
(e.g., toxic ideas, as well as important missing information) also play a
significant role in diminishing the quality of life. Each of the foregoing
areas must be addressed to remedy significant excesses and deficits.
Moreover, the quality of one’s interpersonal relationships is a key ingredient
of happiness and success, and, without the requisite social skills, one is
likely to be shortchanged in life. Finally, consideration that we are
biological entities, governed by the myriad physiological processes of our
brains and bodies, is also vital in a complete and comprehensive paradigm.
The aforementioned considerations led to the development of what AAL
initially termed multimodal behavior therapy (Lazarus, 1973, 1976) and
what was soon changed to multimodal therapy or MMT (A. Lazarus, 1981,
1986, 1997, 2000a, 2000b). Emphasis was placed on the fact that, at base,
we are biological organisms (neurophysiological/biochemical entities) who
behave (act and react), emote (experience affective responses), sense
(respond to tactile, olfactory, gustatory, visual, and auditory stimuli),
imagine (conjure up sights, sounds, and other events in our mind’s eye),
think (entertain beliefs, opinions, values, and attitudes), and interact with
one another (enjoy, tolerate, or suffer various interpersonal relationships).
Most psychological problems are multifaceted, multidetermined, and
multilayered; comprehensive therapy calls for a careful assessment of
seven, reciprocally transactional dimensions or “modalities” in which
individuals operate: Behavior, Affect, Sensation, Imagery, Cognition,
Interpersonal relationships, and Biological processes. Given that the most
common biological intervention is the use of psychotropic drugs, the first
letters from the seven modalities can be combined to produce the
convenient acronym “BASIC I.D.” although the “D” modality actually
represents the complete range of physiological and biological factors
beyond the use of substances, prescribed or otherwise. In addition to its use
as a template for conducting therapy, the BASIC I.D. stands alone as a
model of human personality and phenomenology (Lazarus & Lazarus,
2015; C. Lazarus, 2017).
 The BASIC I.D. or multimodal framework rests on a broad social and
cognitive learning theory because its tenets are open to verification or
disproof (Bandura, 1977, 1986). Instead of postulating putative complexes
and unconscious forces, social learning theory rests on testable
developmental factors (e.g., modeling, observational learning, acquisition
of expectancies, operant and respondent conditioning, self-regulatory
mechanisms).
While drawing on effective methods from any discipline, the multimodal
therapist does not embrace divergent theories but remains consistently
within social-cognitive learning theory. The virtues of technical eclecticism
(Lazarus, 1967, 1992; Lazarus et al., 1992) over the dangers of theoretical
integration is a cardinal presumption of MMT. The major criticism of
theoretical integration is that it inevitably tries to blend incompatible
notions and breeds confusion.
The polar opposite of the multimodal approach is any unimodal therapy.
Case in point is the Rogerian or person-centered orientation, which is
conversational and virtually unimodal. Although, in general, the
relationship between therapist and client is highly significant and
sometimes sufficient, in most instances, the doctor–patient relationship is
but the soil that enables the techniques to take root. A good relationship,
adequate rapport, and a constructive working alliance are “usually
necessary but often insufficient” (Fay & Lazarus, 1993; Lazarus & Lazarus,
1991a).

ASSESSMENT AND FORMULATION

The elements of a thorough assessment involve the following range of
questions:
 B: What is this individual doing that is getting in the way of his or her
happiness of personal fulfillment (self-defeating actions, maladaptive
behaviors)? What does the client need to increase and decrease? What
should he or she stop doing and start doing?
A: What emotions (affective reactions) are predominant? Are we dealing
with anger, anxiety, depression, or combinations thereof, and to what extent
(e.g., irritation vs. rage; sadness vs. melancholy)? What appears to generate
these negative affects—certain cognitions, images, interpersonal conflicts?
How does the person respond (behave) when feeling a certain way? It is
important to look for interactive processes: What impact does various
behaviors have on the person’s affect and vice versa? How does this
influence each of the other modalities?
S: Are there specific sensory complaints (e.g., tension, chronic pain,
tremors)? What feelings, thoughts, and behaviors are connected to these
negative sensations? What positive sensations (e.g., visual, auditory, tactile,
olfactory, and gustatory delights) does the person report? This includes the
individual as a sensual and sexual being. When called for, the enhancement
or cultivation of erotic pleasure is a viable therapeutic goal. The importance
of the specific senses is often glossed over or even bypassed by many
treatment approaches.
I: What fantasies and images are predominant? What is the person’s
“self-image?” Are there specific success or failure images? Are there
negative or intrusive images (e.g., flashbacks to unhappy or traumatic
experiences)? And how are these images connected to ongoing cognitions,
behaviors, affective reactions, and the like?
C: Can we determine the individual’s main values, beliefs, and opinions
—his or her cognitions? What are this person’s predominant shoulds,
oughts, and musts? Are there any definite dysfunctional beliefs or irrational
ideas? Can we detect any untoward automatic thoughts that undermine his
or her functioning?
I.: Interpersonally, who are the significant others in this individual’s life?
What does he or she want, desire, expect, and receive from them, and what
does he or she, in turn, give to and do for them? What relationships give
him or her particular pleasures and pains?
D.: Is this person biologically healthy and health conscious? Does he or
she have any medical complaints or concerns? What relevant details pertain
to diet, weight, sleep, exercise, alcohol, and drug use?
 The foregoing are some of the main domains that multimodal clinicians
traverse while assessing the client’s BASIC I.D. A more comprehensive
problem identification sequence is derived from asking most clients to
complete a Multimodal Life History Inventory (MLHI; Lazarus & Lazarus,
1991b). This 15-page questionnaire facilitates treatment when
conscientiously completed by clients as a homework assignment, usually
after the initial session. Seriously disturbed clients will obviously not be
expected to comply, but most outpatients who are reasonably literate will
find the exercise useful for speeding up routine history taking and to readily
provide the therapist with a BASIC I.D. analysis.
Such a BASIC I.D. analysis is referred to as a Modality Profile: a list, or
matrix, of identified problems across the BASIC I.D. and the best
therapeutic interventions to address them. While several problems may be
discovered within an individual’s BASIC I.D. because of the “the ripple
effect,” it is not usually necessary to address them all in therapy (i.e.,
because significant improvement with one or a few central problems often
results in positive, compensatory changes in other problems, even if they
were not directly focused on in treatment).
A primary postulate of MMT is that the most robust and durable
outcomes are positively correlated with the number of BASIC I.D.
modalities addressed in treatment. Moreover, given their structured and
comprehensive nature, modality profiles allow novice therapists to achieve
a level of thoroughness and effectiveness usually associated with more
experienced practitioners. What’s more, by virtue of their highly
individualized nature, Modality Profiles transcend standard diagnostic
nomenclature because many people with the same diagnosis (from the
Diagnostic and Statistical Manual of Mental Disorders [DSM] or
International Classification of Disease [ICD] codes) often have very
different symptom constellations and, thus, unique Modality Profiles with
corresponding individualized treatment plans (C. Lazarus, 1991).
Despite all people having all seven modalities of the BASIC I.D., no two
people are alike in how they experience their psychological life. Indeed, just
as all musical compositions can be reduced to seven notes in the musical
scale, no two musical works are exactly the same in spite of being based on
the same fundamental notes. In this way, the BASIC I.D. can be thought of
as a person’s unique “basic identity” in addition to the fundamental
dimensions of his or her psychological makeup.
 In addition to Modality Profiles, there are three other important
assessment procedures employed in MMT: second-order BASIC I.D.
assessments, a method called bridging, and another called tracking.

Second-Order BASIC I.D. Assessments

If and when treatment impasses arise, a more detailed inquiry into
associated behaviors, affective responses, sensory reactions, images,
cognitions, interpersonal factors, and possible biological considerations
may shed light on the situation. For example, a client was making almost no
progress with assertiveness training. He was asked to picture himself as an
assertive person and was then asked to recount how his behavior would
differ in general, what affective reactions he might anticipate, and so forth,
across the BASIC I.D. This brought a central cognitive schema to light that
had eluded all other avenues of inquiry: “I am not entitled to be happy.”
Therapy was then aimed directly at addressing this maladaptive cognition
before assertiveness training was resumed.

Bridging
Let’s say a psychotherapist is interested in a client’s emotional responses to
an event. “How did you feel when you first discovered that your wife was
seeing another man?” Instead of discussing his feelings, the client responds
with defensive and irrelevant intellectualizations. “My wife was always
looking for affirmation. It stemmed from the fact that her parents were less
than forthcoming with praise or affection.” It is often counterproductive to
confront the client and point out that he is evading the question and seems
reluctant to face his feelings.
In situations of this kind, bridging is usually effective. First, the therapist
deliberately tunes in to the client’s preferred modality—in this case, the
cognitive domain. Thus, the therapist explores the cognitive content: “So
you see it as a consequence of your wife’s own lack of self-confidence and
her excessive need for love and approval. Please tell me more.” In this way,
after perhaps a 5- to 10-minute discourse, the therapist endeavors to branch
off into other directions that seem more productive. “Tell me, while we
have been discussing these matters, have you noticed any sensations
anywhere in your body?” This sudden switch from Cognition to Sensation
may begin to elicit more pertinent information (given the assumption that,
in this instance, Sensory inputs are probably less threatening than Affective
material). The client may refer to some sensations of tension or bodily
discomfort, at which point the therapist may ask him to focus on them,
often with an hypnotic overlay. “Will you please close your eyes, and now
feel that neck tension. (Pause.) Now relax deeply for a few moments,
breathe easily and gently, in and out, in and out, just letting yourself feel
calm and peaceful.” The feelings of tension, their associated images and
cognitions may then be examined. One may then venture to bridge into
Affect. “Beneath the sensations, can you find any strong feelings or
emotions? Perhaps they are lurking in the background.” At this juncture, it
is not unusual for clients to give voice to their feelings. “I am in touch with
anger and with sadness. I feel betrayed.” By starting where the client is and
then bridging into a different modality, most clients are willing to traverse
the more emotionally charged areas they had been avoiding.

Tracking the Firing Order

A fairly reliable pattern may be discerned in the way that many people
generate negative affect. Some dwell first on unpleasant sensations
(palpitations, shortness of breath, tremors), followed by aversive images
(pictures of disastrous events), to which they attach negative cognitions
(ideas about catastrophic illness), leading to maladaptive behavior
(withdrawal and avoidance). This S-I-C-B firing order (Sensation, Imagery,
Cognition, Behavior) may require a different treatment strategy from that
employed with, say, a C-I-S-B sequence, an I-C-B-S, or yet a different
firing order.
Clinical findings suggest that it is often best to apply treatment
techniques in accordance with a client’s specific chain reaction. A rapid
way of determining someone’s firing order is to have him or her in an
altered state of consciousness—deeply relaxed with eyes closed—
contemplating untoward events and then describing their reactions. This
tracking procedure can also have an immediate positive effect.
Thus, a 67-year-old woman who had responded well to a course of
cognitive restructuring for depression nevertheless complained that she was
prone to what she termed “panic attacks.” As she explained it, “I am
inclined to feel somewhat nervous and jittery at times, but for no reason at
all, this often develops into a massive sense of anxiety. I have no idea where
this comes from.” She was asked to identify the thoughts that preceded and
accompanied her next attack and to jot them down.
Subsequently, she outlined the following sequence: “I was waiting at
home for my friend Betty to come over. I really like her and was looking
forward to her visit. Suddenly, I noticed that my nervous feeling was
coming on. I did what you said and asked myself what I was thinking, and
how I was bringing it on. But I drew a blank. I then became aware that my
heart was beating rather fast and took my pulse—it was over 90 beats per
minute. Then I started feeling overheated, as if I had a temperature. But
when I took it, my thermometer showed that my temperature was below
normal—98.3 degrees. Then I noticed that my right knee was throbbing and
felt painful, so I started massaging it. Because I was scrutinizing and
following my thoughts as you had recommended, I immediately realized
that I was picturing myself in the rehab center right after my knee
replacement surgery and dwelling on how I had developed an infection that
almost killed me. Ever since then, I know I have been panicky whenever I
have a fever or whenever my knee hurts. So I told myself not to be stupid
because my temperature was in fact below normal, I had no fever, and I was
actually creating fear out of nothing, and this calmed me down.”
This woman’s firing order appeared to follow a Sensory (becomes aware
of nervous reaction, develops tachycardia, feels overheated), Behavioral
(measures her temperature), Sensory (pain in her knee), Behavioral
(massages her knee), Imagery (recalling her life-threatening postoperative
infection), and then Cognition (turns to rational, self-calming thoughts)
order. Many clients have reported that using this “tracking” procedure tends
to furnish them with a useful self-control device.
Another client who reported having panic attacks “for no apparent
reason” put together the following string of events. She had initially
become aware that her heart was beating faster than usual. This brought to
mind an episode where she had passed out after imbibing too much alcohol
at a party. This memory or image still occasioned a strong sense of shame.
She started thinking that she was going to pass out again, and, as she
dwelled on her sensations, this cognition only intensified and culminated in
her feelings of panic. Thus, she exhibited an S-I-C-S-C-A pattern
(Sensation, Imagery, Cognition, Sensation, Cognition, Affect).
 Thereafter, she was asked to take careful note whether any subsequent
anxiety or panic attacks followed a similar “firing order.” She subsequently
confirmed that her two “trigger points” were usually Sensation and
Imagery. This alerted the therapist to focus on sensory training techniques
(e.g., diaphragmatic breathing, deep muscle relaxation) followed
immediately by Imagery training (e.g., the use of coping imagery and the
selection of mental pictures that evoked profound feelings of serenity).
A Structural Profile Inventory (SPI) has been developed and tested (C.
Lazarus, 1986). This 35-item survey provides a quantitative rating of the
extent to which clients favor specific BASIC I.D. areas. The instrument
measures action-oriented proclivities (Behavior); the degree of emotionality
(Affect); the value attached to various sensory experiences (Sensation); the
amount of time devoted to fantasy, daydreaming, and “thinking in pictures”
(Imagery); analytical and problem-solving propensities (Cognition); the
importance attached to interacting with other people (Interpersonal); and the
extent to which health-conscious habits are observed (Drugs/Biology). The
reliability and validity of this instrument has been borne out by research
(Herman, 1992; Landes, 1991). Herman (1991, 1994, 1998) showed that
when clients and therapists have wide differences on the SPI, therapeutic
outcomes tend to be adversely affected. In addition, preliminary research
demonstrated that it is possible to predict which forms of treatment will be
most effective and preferred on the basis of clients’ scores on the SPI
(Herman, 2004).
Beyond the SPI, owing to its emphasis on technical eclecticism, MMT is
open to any other validated psychometric instrument (e.g., MMPI-II, WAIS-
IV) provided its use is rational and therapeutically indicated (e.g.,
demonstrating that a person who denigrates him- or herself for “stupidity”
has at least average, objectively measured intelligence).
Students and colleagues frequently inquire whether any particular BASIC
I.D. areas are more significant, more heavily weighted, than others. For
thoroughness, all seven require careful attention, but perhaps the biological
and interpersonal modalities are especially significant.
The biological modality wields a profound influence on all the other
modalities. Unpleasant sensory reactions can signal a host of medical
illnesses; excessive emotional reactions (anxiety, depression, and rage) may
all have biological determinants; faulty thinking and images of gloom,
doom, and terror may derive entirely from chemical imbalances; and
untoward personal and interpersonal behaviors may stem from many
somatic reactions ranging from toxins (e.g., drugs or alcohol) to intracranial
lesions. Hence, when any doubts arise about the probable involvement of
biological factors, it is imperative to have them fully investigated. A person
who has no untoward medical/physical problems and enjoys warm,
meaningful, and loving relationships is apt to find life personally and
interpersonally fulfilling. Hence, the biological modality serves as the base,
and the interpersonal modality is perhaps the apex. The seven modalities
are by no means static or linear but, as previously noted, exist in a state of
reciprocal transaction.
A question often raised is whether a “spiritual” dimension should be
added. In the interests of parsimony, AAL pointed out that when someone
refers to having had a “spiritual” or a “transcendental” experience, typically
their reactions point to, and can be captured by, the interplay among
powerful cognitions, images, sensations, and affective responses.
Another question that is often asked is why a particular problem is
assigned to a specific modality when it could be as accurately applied to
another. For example, social avoidance is a behavior as well as an
interpersonal difficulty. Similarly, excessive drinking is a behavior, but it is
also a biological consideration. In essence, where an identified problem is
placed in a Modality Profile is not crucial. What is vital, however, is that the
problem is identified and that it receives the best therapeutic intervention.
Most people to enter therapy with explicit problems in two or more
modalities—“I have headaches that my doctor tells me are due to tension. I
also worry too much, and I feel frustrated a lot of the time. And I’m very
angry with my brother.” Initially, it is usually advisable to engage the
patient by focusing on the issues, modalities, or areas of concern that he or
she presents. To deflect the emphasis too soon onto other matters that may
seem more important is only inclined to make the patient feel discounted.
Once rapport has been established, however, it is usually easy to shift to
more significant problems.
Thus, any good clinician will first address and investigate the presenting
issues. “Please tell me more about the aches and pains you are
experiencing.” “Do you feel tense in any specific areas of your body?”
“You mentioned worries and feelings of frustration. Can you please
elaborate on them for me?” “What are some of the specific clash points
between you and your brother?” Any competent therapist would flesh out
the details.
A multimodal therapist goes further. She or he will carefully note the
specific modalities across the BASIC I.D. that are being discussed and
which ones are omitted or glossed over. The latter (i.e., the areas that are
overlooked or neglected) often yield important data when specific
elaborations are requested. And when examining a particular issue, the
BASIC I.D. will be rapidly but carefully traversed.

APPLICABILITY AND STRUCTURE

One cannot point to specific diagnostic categories for which MMT is
especially suited. MMT offers practitioners a broad-based template, several
unique assessment procedures, and a technically eclectic armamentarium
that permits the selection of effective interventions from any sources
whatsoever.
Clinicians of any persuasion are likely to report that noncharacterological
disorders are typically more responsive than personality disturbances. Like
any other approach, MMT can point to many individual successes with
patients diagnosed as schizophrenic or with those who suffered from mood
disorders, anxiety disorders, sexual disorders, eating disorders, sleep
disorders, substance use disorders, and the various adjustment disorders.
But there is no syndrome or symptoms that stands out as being most
strongly indicated for a multimodal approach. Instead, MMT practitioners
will endeavor to mitigate any clinical problems that they encounter, drawing
on the scientific and clinical literature that shows the best way to manage
matters.
But they will also traverse the BASIC I.D. spectrum in an attempt to
leave no stone unturned. Moreover, they may refer out to an expert, a
resource better qualified to treat the entire problematic disorder or one (or a
few) specific foci of it. This is routinely done, for instance, when
psychotropic medication is indicated. And, while some clinicians prefer to
refer to a psychiatrist or psychopharmacologist for these needs, others with
the requisite training and expertise are happy to engage in collaborative
medical management with internists, primary care, or family physicians. In
other cases, a referral to an expert in addictions, insomnia, or obsessive-
compulsive disorder (OCD), for example, can be made. In these cases,
either a co-therapy approach can be employed or the client may choose to
work exclusively with the clinician to whom he or she was referred. In this
way, in MMT, the act of referral itself can be seen as a therapeutic
intervention.
To reiterate, MMT is not a unitary or closed system. It is basically a
clinical approach that rests on a social and cognitive learning theory
foundation and uses technical eclectic and evidence-based procedures in an
individualistic manner.
The overriding question is, “Who and what is best for this client?”
Obviously, no one therapist can be well versed in the entire gamut of
methods and procedures or populations that exist. Some clinicians are
excellent with children, whereas others have a talent for working with
geriatric populations. Some practitioners have specialized in specific
disorders (e.g., OCD, eating disorders, sexual dysfunctions, posttraumatic
stress disorder, panic, depression, substance abuse, or schizophrenia). Those
who employ MMT will bring their talents to bear on their areas of special
proficiency and employ the BASIC I.D. as per the foregoing discussions
and, by so doing, possibly enhance their clinical impact. If a problem or a
specific client falls outside their sphere of expertise, they will endeavor to
effect a referral to an appropriate resource. But, as will be further explicated
later, because all people have BASIC I.D.’s, there are no problems or
populations per se that are excluded. The main drawbacks and exclusionary
criteria are those that pertain to the limitations of individual therapists.

PROCESSES OF CHANGE
Ultimately, all psychological experience of human phenomenology is based
on brain activity. Hence, changes attributable to psychotherapy are likely
due to various alterations in neurophysiology. Since the mind (or
psychology) and body (or biology) are different sides of the same coin, they
influence each other in many reciprocal ways. What’s more, a primary goal
of most psychotherapy is to help people feel better. Yet the Holy Grail of
direct affect modification remains elusive. By virtue of its seven
transactional modalities, however, MMT has six points of entry into affect,
and five into biology, each of which is believed to influence psychological
experience and thus allows for numerous synergistic effects.
 Multimodal therapists view psychotherapy as a mostly psychoeducative
endeavor that aims to help clients acquire specific skills they may be
lacking. By enhancing people’s repertoires of techniques for behavioral
management and emotional regulation, it is believed that they will feel and
function better. For example, anxiety management, mood regulation,
assertiveness and relaxation training, and cognitive reframing are a few of
the skills typically emphasized in MMT. By providing clients with missing
information, correcting misinformation, encouraging specific behavioral
changes, and addressing various response deficits and excesses across the
BASIC I.D., it is believed that desirable emotional shifts will result.
In essence, corrective thinking and corrective action while traversing the
BASIC I.D. is thought to bring about corrective emotional experiences by
altering cortical and subcortical activity. On a global scale, this translates
into changes in the BASIC I.D. insofar as behavioral patterns are more
adaptive, the sensorium is positively affected, imagery is improved,
cognitive schemata and ideation are more rational, social functioning is
better, physiology improves, and desirable shifts in emotional functioning
result.
Hence, unlike in traditional psychotherapy, insight per se is not seen as
necessary for therapeutic change, provided, of course, some degree of self-
awareness is present. Similarly, while transferential processes are de-
emphasized, it is maintained that a good therapeutic relationship and strong
alliance can greatly enhance positive outcomes. Indeed, MMT sees the
relationship as the soil in which the methods and techniques of
psychotherapy take root.
It is a fundamental postulate of MMT that the more knowledge and skills
a person acquires within and across his or her BASIC I.D., the more robust
and durable progress and change will be. Therefore, the more versed a
therapist is with a variety of methods, strategies, and techniques, and the
more flexible and adaptable he or she is, the more thoroughly he or she can
therapeutically traverse a given client’s BASIC I.D., thus producing
enhanced outcomes.

THERAPY RELATIONSHIP
The multimodal orientation is not yet another system of psychotherapy to
be added to the hundreds already in existence. It is an approach that uses
techniques that are likely to prove helpful regardless of their point of origin,
and it contends that the larger the clinician’s repertoire of methods and
procedures, the more likely treatment will prove to be effective.
In addition to techniques of choice, the multimodal clinician is well
aware that the relationship between client and therapist is often the sine qua
non of salubrious outcomes. Thus, emphasis is placed on trying to be an
authentic chameleon who also selects relationships of choice (Lazarus,
1993). Decisions regarding different relationship stances or styles include
when and how to be directive, supportive, reflective, cold, warm, tepid,
gentle, tender, tough, earthy, chummy, casual, informal, or formal.
How does the clinician determine or arrive at specific relationships of
choice? By carefully observing the client’s reactions to various statements,
tactics, and strategies. One begins neutrally by offering the usual facilitative
conditions—the therapist listens attentively, expresses caring, exudes
empathy, and notes the client’s reactions. If there are clear signs of progress,
one offers more of the same; if not, the clinician may take a more active or
directive position and note whether this proves effective.
Moreover, those who complete the MLHI (Lazarus & Lazarus, 1991b)
are asked to describe their “Expectations Regarding Therapy” including
their views of the personal qualities of the ideal therapist. A client who
describes the ideal therapist as “a good listener” will probably respond to a
treatment trajectory that differs from a patient who wants “a good teacher
and coach.”
Sometimes the client’s expectancies leap out at one. Once AAL used the
word “ephemeral” with a client who was a philosophy professor. She
immediately said, “Ephemeral? Did you say ephemeral? Or did you mean
to say abstruse, evanescent, transient, cursory, or illusive—and do you
know the difference?” She made it very clear that she was uninterested in
advice or opinions but wanted a sounding board, an active listener. This was
one of the few cases in which a strictly person-centered approach seemed
indicated.
MMT practitioners endeavor to provide what the client appears to desire,
especially the relational ambiance from which he or she is most likely to
benefit. In essence, no matter how knowledgeable and skillful a therapist
might be, it is the therapeutic relationship that allows the methods and
techniques to take root.
METHODS AND TECHNIQUES
As noted previously, MMT is a theoretically consistent, technically eclectic
approach to “broad-spectrum” cognitive-behavior therapy (CBT) that rests
on a foundation of social cognitive learning theory. While the specific
methods of MMT have already been discussed (i.e., use of the MLHIs,
Modality Profiles, structural profiles, bridging, tracking, firing orders, and
second-order BASIC I.D’s), some elaboration of the process and techniques
of MMT might prove helpful.
MMT endeavors to be flexible, thus tailoring treatment to the unique
needs of a given individual. Once specific problems across the BASIC I.D.
have been identified (which is accomplished by interviewing, discussion,
and, when desirable, the use of the MLHI), a Modality Profile is
constructed noting the identified problems and the interventions of choice
for them. This, again, depends heavily on the therapist’s personal repertoire
of knowledge, skill, and experience. Since MMT evolved from CBT, most
multimodal therapists are well-practiced with methods such as cognitive
reframing/restructuring, exposure-based methods, behavioral assignments,
and assertiveness and various types of relaxation training, as well as a range
of interpersonally focused approaches, such as marital and family therapy.
Basically, given its eclectic stance, any and all methods that are thought to
be helpful will be employed, but preference is always placed on empirically
supported ones first. The few methods that most multimodal therapists
would eschew are those based on analytic or psychodynamic approaches
that rely on purported transferential phenomena or those involving as of yet
unproved methods such as “energy” work and past-life regression.
Moreover, MMT is versatile, and an experienced therapist will routinely
transition between degrees of active-directive and supportive-nondirective
styles and interventions both within a given client’s therapy and among
different individuals. Thus the therapist’s work will at times be quite active
and intensive (e.g., during exposure, role-playing, participant modeling,
hypnosis, etc.) while at other times much less active (e.g., while
supportively listening to someone in grief who is sharing a narrative).
On those occasions when noncompliance is encountered, rather than
positing factors such as “resistance,” multimodal therapists conceptualize
such “road blocks” in terms of readiness on the part of the client or
appropriate selection of techniques on the part of the therapist. That is,
perhaps the assignment or therapeutic process did not make sense to the
client, he or she did not understand the assignment or task, or the therapist
expected more from the client than he or she was ready to deliver.
A patient requesting therapy may point to any of the seven modalities as
his or her entry point. Affect: “I suffer from anxiety and depression.”
Behavior: “My checking and cleaning routines are getting to me.”
Interpersonal: “My husband and I are not getting along.” Sensory: “I have
these tension headaches and chest pains.” Imagery: “I can’t get the picture
of my mother’s funeral out of my mind, and I often have disturbing
dreams.” Cognitive: “I know I set unrealistic goals for myself and expect
too much from others, but I can’t seem to help it.” Biological: “I need to
remember to take my medication, and I should start exercising and eating
less junk.”
Yet, given the emphasis placed on established treatments of choice for
specific disorders and the weight attached to using evidence-based methods,
in most instances, MMT typically draws on methods employed by most
cognitive-behavior therapists. The cognitive-behavioral literature has
documented various treatments of choice for a wide range of afflictions
including maladaptive habits, fears and phobias, stress-related difficulties,
sexual dysfunctions, depression, eating disorders, OCDs, and traumatic
stress disorders. We can also include substance use disorders, somatization
disorders, personality disorders, psychophysiological disorders, and pain
management. Hence, cognitive-behavioral therapies have by far produced
the most empirically supported or evidence-based methods. Moreover CBT
and its derivatives, more than other approaches, have provided research-
based data for matching particular methods to explicit problems.
It is our view that some of the current approaches that have garnered
increasing interest and some degree of empirical support (e.g., dialectical
behavior therapy [DBT], eye movement desensitization and reprocessing
[EMDR], acceptance and commitment therapy [ACT], mindfulness based
stress management [MBSR]) are essentially derivatives of CBT. By virtue
of its technically eclectic stance and BASIC I.D. formulation, MMT can
incorporate and subsume any other therapeutic approach. For example, if a
client’s Modality Profile included intrusive images as an identified problem,
EMDR might be strategically employed (Lazarus & Lazarus, 2002). MMT
can, and routinely does, utilize methods like EMDR, ACT, MBSR, and
DBT.
DIVERSITY CONSIDERATIONS
The matter of diversity considerations is often raised with respect to MMT.
While gaining an understanding of the varied cultural aspects of clients
from differing backgrounds is up to individual therapists, since all people
have a BASIC I.D., MMT is practically universally applicable. How a
multimodal therapist “sells” and thus utilizes the MMT approach is entirely
dependent on his or her knowledge of, familiarity with, and sensitivity for
both the unique aspects of a specific individual as well as the diverse
cultural factors relevant to that person.
Thus, some multimodal practitioners are very knowledgeable and
experienced with transgender populations, others with members of
particular racial or ethnic groups, while some are more limited in their
knowledge or breadth of cultural diversity. Since the goodness of fit and
therapeutic relationship prove important for success, it is hoped that a
multimodal therapist—indeed any therapist for that matter—will refer to a
more suitable colleague if certain diversity or cultural obstacles are seen as
impediments to therapy.

CASE EXAMPLE

Kevin was referred for therapy by his primary care physician whom Kevin
consulted for vague physical complaints such as back pain and generalized
muscle tension. A 46, a single white male, Kevin was an information
technology professional at a nearby university. He was raised in a middle-
class suburb, did well at school, graduated from college, but tended to be
rather anxious, obsessional, prone to bouts of depression, and suffered from
work-related stress. After an initial session that consisted of establishing
rapport, the usual exploration of the client’s situation, background
information, and an inquiry into antecedent events and their consequences,
C. Lazarus asked Kevin to complete an MLHI and bring it with him to the
next session. Clients who comply tend to facilitate their treatment trajectory
because this usually reflects motivation for change and thus serves as a
good predictor of a client’s willingness to complete homework assignments.
After the second session, upon a perusal of his MLHI, coupled with some
in-session discussion of it, the following therapeutic considerations were
explored and relevant information was obtained.
 B: What is Kevin doing that is getting in the way of his happiness or
personal fulfillment (e.g., self-defeating actions, maladaptive behaviors)?
What does he need to increase and decrease? What should he stop doing
and start doing?
A: What emotions (affective reactions) are predominant? Are we dealing
with anger, anxiety, depression, or combinations thereof, and to what extent
(e.g., irritation vs. rage; sadness vs. profound melancholy)? What appears to
generate these negative affective states—certain cognitions, images,
interpersonal conflicts? And how does Kevin respond (behave) when
feeling a certain way? We discussed what impact various behaviors had on
his affect and vice versa and how this influenced each of the other
modalities.
S: We discussed Kevin’s specific sensory complaints (e.g., tension,
chronic lower back discomfort, frequent headaches) as well as the feelings,
thoughts, and behaviors that were connected to these negative sensations.
Kevin was also asked to comment on positive sensations (e.g., visual,
auditory, tactile, olfactory, and gustatory pleasures). This included sensual
and sexual elements.
I: Kevin described some of his main fantasies and mental images. He
described self-images full of failure.
C: We explored Kevin’s main values, beliefs, and opinions and looked
into his predominant cognitions: his shoulds, oughts, and musts. It was clear
that he was too hard on himself and embraced a perfectionistic viewpoint
that was bound to prove frustrating and disappointing. Moreover, he had a
lot of anxious ideation, including worry about his job security, financial
future, and interpersonal confrontation.
I.: Interpersonally, we discussed his relationships with significant others;
he was fearful of commitment, inclined to avoid confrontations, and often
felt short-changed and resentful.
D.: In addition to his minor aches and pains, Kevin was about 20 pounds
above his ideal weight, often skipped lunch, drank 6 to 10 cups of coffee
during the work week, and exercised infrequently. Nevertheless, his
drugs/biology profile showed him to be in generally good health, never
smoked cigarettes, and never used recreational drugs or drank alcohol to
excess.
 The foregoing assessment pointed immediately to four issues that called
for remediation (or attention?). (1) His images of failure had to be altered to
images of coping and succeeding. (2) His perfectionism needed to be
changed to a generalized anti-perfectionistic philosophy of life, and his
anxiogenic cognitions required reduction. (3) His interpersonal reticence
called for an assertive modus vivendi wherein he would discuss his feelings
and not harbor resentments, and his avoidance of social challenges called
for gradual exposure. And, (4) he would benefit from a shift toward more
health-conscious patterns of eating and physical activity. To achieve these
ends, the techniques selected were standard methods—positive and coping
imagery exercises, disputing irrational cognitions, assertiveness training,
exposure, and relaxation-based, sensory relabeling.
To look at Kevin’s therapy under a “higher magnification,” a review of
his (simplified) Modality Profile is useful. (Keep in mind that these are the
broad brush strokes used to convey the essential features of a Modality
Profile.)
Problems identified in Therapeutic recommendations
Behavior:
Avoids confrontation Exposure
Works too many hours Leave work at quitting time
Affect:
Anxiety MMT*
Depression MMT*
Anger MMT*
Sensation
Generalized muscle tension Relaxation training
Back pain and headaches Mindfulness techniques
Imagery
Failing Visualizing success
Getting fired Coping imagery
Being criticized Visualizing assertiveness
Cognition
Various categorical imperatives Rational disputation
Perfectionism Deliberate, substandard performance
Anxious ideation (i.e., “what if’s”) Calming self-statements
Interpersonal:
Lacks assertiveness Assertiveness training
Avoids confrontation Graded exposure
Fears commitment Emotional risk-taking
Drugs/Biology
Overweight and poor nutrition Referral to nutritionist
Excessive coffee consumption Gradual reduction
Sedentary Increase physical activity
 The astute reader will notice that no specific therapeutic
recommendations are noted for affective problems. Rather, “MMT” for
multimodal therapy is noted. This is because the current state of the art and
science of psychological therapy lacks the means and methods for direct
affect modification. There appears to be no way to access affect directly
and, hence, technically, no interventions exist that allow one to work
directly with it. Even direct brain stimulation that activates or produces
emotional phenomena is not direct affect modification but, rather, enters the
system at the level of biology—the D. modality. Similarly, psychotropic
medication works to change or ameliorate aversive affective states through
the conduit of the biological modality. Nevertheless, since all of the other
six modalities of the BASIC I.D. can be accessed and modified directly, and
since all the modalities are transactional and reciprocally influential, the
MMT model provides six potentially synergistic portals into affect, albeit
indirectly.
Kevin took well to the multimodal model, saying “It makes a lot of sense
to me.” He was highly motivated and felt comfortable in the therapy owing
to the great respect he had for his referring physician. Hence, a solid
therapeutic relationship was quickly cultivated and paved the way for the
process of therapy, which was mostly an active-directive undertaking.
Given his comfort in the therapeutic setting, Kevin was initially introduced
to some relaxation and visualization techniques as well as asked to monitor
and record his cognitions during negative affective states.
Building on that, Kevin was asked to keep a journal of his avoidance
behavior while he was introduced to the methods of identifying and
challenging his irrational thoughts. This segued to some mindfulness
methods, imaginal exposure, and then in vivo exposure. Concurrently,
assertiveness training was undertaken using some role-playing and role-
reversal techniques. Kevin was also referred to a nutritionist and
encouraged to increase his general physical activity.
After six consecutive weekly sessions, Kevin agreed to reduce the
frequency of his visits to every 2 weeks. Following four biweekly sessions,
it was decided to meet on a monthly basis. After three monthly meetings,
regular therapy was terminated, and we agreed that Kevin would follow-up
as needed. Six months after his last session, Kevin was contacted and
reported that he was continuing to enjoy the gains he made in active
treatment and that he had also started working out at a local gym and had
lost 20 pounds.
This case has been presented to demonstrate how MMT provided a
template (the BASIC I.D.) that pointed to four discrete but interrelated
components that became the main treatment foci. In a sense, the term
“multimodal therapy” is a misnomer because, while the assessment is
multimodal, the treatment is largely cognitive-behavioral and draws,
whenever possible, on evidence-based methods. The main claim is that by
assessing clients across the BASIC I.D., one is less apt to overlook subtle
but important problems, and the overall problem identification process is
significantly expedited.

OUTCOME RESEARCH
MMT is so broad, so flexible, and so personalistic that tightly controlled
outcome research is difficult to conduct. Nevertheless, the Dutch
psychologist Kwee (1984) organized a treatment outcome study on 84
hospitalized patients suffering from OCDs and extensive phobias, 90% of
whom had received prior treatment without success. More than 70% of
these patients had suffered from their disorders for more than 4 years.
Multimodal treatment resulted in substantial recoveries and durable 9-
month follow-ups. This was subsequently replicated and amplified (Kwee
& Kwee-Taams, 1994).
In Scotland, Williams (1988), in a carefully controlled outcome study,
compared multimodal assessment and treatment with less integrative
approaches in helping children with learning disabilities. Clear results
emerged in support of the multimodal procedures compared to treatment as
usual.
Although the multimodal approach per se has not become a household
term, recently, the vast literature on psychosocial treatment has borrowed
liberally from MMT, with authors referring to multidimensional,
multimethod, or multifactorial treatment procedures. The recent surge in
combining modular treatments, especially in the personality disorders (e.g.,
Livesley, Dimaggio, & Clarkin, 2016), was predated by MMT approach by
almost 50 years. Identical, unimodal treatment for all patients is now
considered unwise at best, malpractice at worst.
 Follow-up studies that have been conducted since 1973 (see Lazarus
1997, 2000a) have consistently suggested that durable outcomes are in
direct proportion to the number of modalities deliberately traversed. To
reiterate an important point made at the start of this chapter, although there
is obviously a point of diminishing returns, it is a multimodal maxim that
the more someone learns in therapy, the less likely he or she is to relapse.
In this connection, circa 1970, it became apparent that lacunae or gaps in
people’s coping responses were responsible for many relapses. This
occurred even after they had been in various (non-multimodal) therapies,
often for years on end. Follow-ups indicate that teaching people how to
cope with problems across the BASIC I.D. ensured far more compelling
and durable results (Lazarus, 2000a). MMT takes Paul’s (1967, p.111)
mandate seriously: “What treatment, by whom, is most effective for this
individual with that specific problem and under which set of
circumstances?”
There are serious limitations of group designs in comparative therapy
research, and a strong case can be made for the idiographic analyses of
individual cases (Davison & Lazarus, 1994). One cannot study identical
cases (because everyone is unique), but there are often sufficient similarities
and obvious dissimilarities to permit the evaluation of treatment effects on
the basis of various related and unrelated features. Be that as it may, from a
research perspective, the major thrust in MMT is to attempt to unravel the
complex interplay among personal biases, professional allegiances,
epistemological assumptions, theoretical preferences, and familiarity with
the use of certain bodies of data. A sustained and widespread emphasis on
the documentation of clinical research, with special reference to objective
ratings and a thorough account of the course of a given patient’s treatment
—in concrete and operational terms—may yet transform psychotherapy
into a clinical science.

FUTURE DIRECTIONS
Cost-effective MMT underscores the notion that treatment should be
custom-made for each client. The client’s needs come before the therapist’s
theoretical framework. Instead of placing clients on a Procrustean bed and
treating them alike, multimodal therapists look for a broad but tailor-made
panoply of effective techniques to bring to bear upon the problem.
 Flexibility is the major impetus. Thus, as already indicated, if an
assessment reveals the need to listen attentively and reflect the client’s
feelings, a multimodal therapist will do just that. If the situation calls for a
directive stance involving role-playing and other active strategies, that is
what will be implemented. In searching for the best match in terms of the
therapeutic relationship and the specific treatment trajectory, a multimodal
practitioner is quite willing to refer a client to someone else—a colleague
who may be a more effective resource. This stands in stark contrast to many
clinical schools of thought wherein the client will receive what the therapist
offers—whether or not that is what is required.
In terms of future directions, beyond adding to research that further
validates its effectiveness, employing MMT in primary care and inpatient
settings could greatly reduce unnecessary medical healthcare costs as well
as enhance the outcomes of patients treated in levels of care that are higher
than community-based outpatient settings. This too, of course, is grist for
the research mill.

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*
Author Note: Arnold Lazarus (1932–2013) authored earlier incarnations of this chapter in previous
editions of this Handbook but died before the third edition was initiated.
 7

Systematic Treatment Selection

ANDRÉS J. CONSOLI AND LARRY E. BEUTLER

THE INTEGRATIVE APPROACH

Contemporary research that compares manualized psychotherapies has
minimized the roles of the patient, the therapist, the therapy relationship,
the environment, and treatment fit that both cut across theoretical
approaches and that form effective treatments (Wampold & Imel, 2015).
The result is a considerable discordance between what works from the
perspective of the clinician and what variables occupy the attention of the
researcher. These collective limitations underscore a need for integrative,
evidence-based therapies that facilitate human change by eschewing the
broad definitions of treatment type and patient diagnosis in favor of
matching narrower treatment interventions to specific problems, patients,
and populations.
Systematic treatment selection (STS) is an evidence-based, principle-
driven approach that arose from three converging observations extracted
from psychotherapy practice and research: (1) there has been an exponential
growth in the number of psychotherapies touted as “empirically supported”
(Chambless & Ollendick, 2001); (2) there is strong evidence that most
treatment packages/interventions produce equivalent effects, suggesting that
the effects of treatment are heavily influenced by nonprocedural factors,
such as the therapy relationship and treatment fit (e.g., Castonguay, 2000;
Luborsky et al., 2002; Wampold & Imel, 2015); and (3) there is a persistent
disparity between what clinicians consider to be important to effect change
and what researchers seek to confirm in clinical trials (Beutler, Williams,
Wakefield, & Entwhistle, 1995). The foregoing suggests that the methods
for evoking meaningful change are broad ranging, interactive, and are not
indelibly yoked to specific theories or treatment models.
STS, as it has evolved and expanded during the past decades, has its roots
jointly planted in clinical practice and empirical research. From
practitioners have come an appreciation for the cross-cutting nature (i.e.,
relevant to all psychotherapy approaches) of the therapeutic relationship, an
awareness of the need for a pragmatic form of intentional eclecticism, and
skepticism regarding the value of traditional diagnoses for treatment
planning (Castonguay, Constantino, & Beutler, in press; Machado &
Beutler, 2017). From researchers have come an appreciation of the power of
controlled observations, the relative advantages of both efficacy and
effectiveness research, and the strangely contrasting views that exist about
the contributors to psychotherapy benefit.
STS seeks to provide the clinician with an intentional framework for
identifying, recognizing, and facilitating the optimal conditions for
therapeutic change. This effort began with a representative review of
outcome literature (Beutler, 1979) and proceeded to more comprehensive
reviews and the construction of a model of treatment decision-making
(Beutler, 1983; Beutler & Clarkin, 1990). STS has been subjected to
prospective empirical tests (Beutler et al., 2000; Beutler, Mohr, Grawe,
Engle, & MacDonald, 1991), which has led to a refinement of ways to
apply psychotherapy (e.g., Beutler & Harwood, 2000).
STS is based on three cardinal assumptions.
1. All or most psychotherapy approaches are beneficial for some individuals, but none is effective
for all.
2. Therapists can implement multiple therapeutic strategies and techniques that go beyond the
theories that originated them if therapists follow empirically derived principles that determine
when and how they should be used.
3. An inordinate focus exists on problem etiology among psychotherapists, which has proven to be
less important to the process of change than a focus on improving the quality of clinical
decision-making used by psychotherapists.

ASSESSMENT AND FORMULATION

Reliable and valid assessment of treatment-relevant patient characteristics
benefits from the use of a semi-structured intake battery of standardized
psychometric instruments. However, few clinicians employ standardized
assessment in their intake procedures. Often, and potentially to the
detriment of the patient, therapists rely solely on unstructured and
unstandardized clinical interviews to inform their judgments. This can
frequently prove to be unfortunate because therapists are often called on to
make life-changing decisions, such as whether to hospitalize a patient or
refer for medication consultation, without an informative historical context.
Often, clinicians are unsure of what constructs to measure and uncertain
about what to do with the information they gather from psychological tests
(Harwood, Beutler, & Groth-Marnat, 2011). Since most tests of personality
and cognitive functioning are keyed to help establish the diagnosis and a list
of problem areas, clinicians often resort to using those that will help them
identify a reliable diagnosis. Although clinicians may establish a diagnosis
that satisfies the insurance carrier—no mean feat in itself—they still may be
uncomfortable because rendering a diagnosis has not helped them much in
tendering a meaningful and empirically grounded treatment plan (Beutler &
Malik, 2002).
Diagnosis is usually a weak contributor to finding a distinctive path for a
given patient’s improvement. It may provide targets of needed change, but
it does not offer direct information about how to reach these targets. Thus,
even if one knows some identifying principles of treatment that might suit a
given individual, one has still to face the task of finding a test or a test
battery that will elucidate the relevant principles.
To address the questions of what to measure, how to measure it, and how
to use it in treatment planning, we utilize and recommend consideration of
two related instruments. If there is need (e.g., mandated, adolescent, and
psychotic patients) and time to provide a clinician-based assessment, we use
the Systematic Treatment Selection-Clinician Rating Form (STS-CRF) that
reliably assesses most of the well-validated patient characteristics
associated with planning for change (Fisher, Beutler, & Williams, 1999).
In most cases, we prefer and use a patient self-report instrument that is a
derivation and expansion of the STS-CRF. The STS/innerlife
(www.innerlife.com; Beutler, Williams, & Norcross, 2009) includes reliable
measurement of most patient-based predictors of change identified in the
research literature (Beutler et al., 2000; Norcross, 2011). The roles of these
patient qualities have been translated into a list of evidence-based principles
of effective psychotherapy from which is generated a set of narrative and
graphic reports that are easily understood and translated into a practice plan
by clinicians.
 The STS/innerlife is a cloud-based measure of patient and environmental
characteristics that has proved to contribute to change and from which we
developed a method of tracking symptom changes over time. The measure
consists of 22 reliable and culturally sensitive symptom scales, six of which
are global indicators of distress and dysfunction (depression, anxiety,
chemical abuse, somatic symptoms, thought disorder, and risk of self-
harm). In addition, independently validated questions which address the
client’s cultural stress, coping styles, resistance traits, preferences, readiness
for change, and many others are included. The STS/innerlife is listed as a
reliable and valid psychological test by Division 12 of the American
Psychological Association, and STS (the therapy developed from this
assessment) is recognized as an evidence-based treatment by Substance
Abuse and Mental Health Services Administration (SAMHSA) (M.
Bejarano, personal communication, 2016).
Innerlife produces both a narrative report for patients and one for the
clinician that suggests treatment approaches and prognoses. It has been used
successfully to facilitate therapist compliance with empirically established
principles (Harwood et al., 2011) and to improve the efficacy of acquiring
psychotherapy skills in supervision (Holt et al., 2015; Stein, 2015).
The STS practitioner adheres closely to the clinical maxim, “the
outcomes of the assessments guide the interventions.” Case formulations
are based on the results of the assessments and expressed as treatment fit.
This responsiveness is a finely tuned aspect of case formulation and
treatment planning and hinges on identifying key patient characteristics and
then selecting and implementing a fitting treatment. The eight principles
that are core to the current practice of STS and that are detailed in the next
section focus on maximizing the blending of interventions and patient
qualities (Beutler et al., 2000; Holt et al., 2015).

APPLICABILITY AND STRUCTURE

STS consists of clinically and empirically informed principles that guide
practitioners in their decision-making process of how best to treat patients.
The principles apply to the use of multiple person therapy (e.g., couples,
family, group), different settings and levels of care, psychoactive
medication, and to factors that reduce patient risk. Furthermore, the
principles identify the conditions that take place within the treatment
relationship to maximize the fit between patient and therapist.
These principles were identified empirically through repeated surveys of
literature (Beutler et al., 2000; Castonguay & Beutler, 2006). Among 39
empirically grounded principles (Castonguay et al., in press; Holt et al.,
2015), eight core principles were selected because of their empirical
strength and their practical fit with the usual developmental sequence of
establishing a therapeutic relationship and selecting an intervention strategy.
The principles are introduced here as they describe clinical situations and
patients for which STS is most relevant.
Functional Impairment
1. For all patients with moderate to severe impairment, the therapist should identify social service
or medical care needs and arrange for attention to these needs. Those with low social support
systems, in particular, need assistance from the therapist to develop social support and support
services.

Psychotherapeutic Relationship
2. Psychotherapy is likely to be beneficial if a strong working alliance is established and
maintained during the course of treatment.
3. The qualities of a good working alliance are likely to be facilitated if the therapist relates to
clients in an empathic way and adopts an attitude of caring, warmth, and acceptance, as well as
one of congruence or genuineness.
4. Therapists are likely to resolve alliance strains and ruptures when addressing them in an
empathic and flexible way.

Resistance
5. In dealing with clients exhibiting resistance, the therapist’s use of directive treatments should be
planned to inversely correspond with the patient’s manifest level of resistant traits and states.

Coping Styles
6. Clients whose personalities are characterized by relatively high “externalizing” styles (e.g.,
impulsivity, social gregariousness, emotional lability, and external blame for problems) benefit
more from direct behavioral change and symptom reduction efforts, including building new
skills and managing impulses, than they do from procedures that are designed to facilitate
insight and self-awareness.
7. Clients whose personalities are characterized by relatively high “internalizing” styles (e.g., low
levels of impulsivity, indecisiveness, self-inspection, and overcontrol) tend to benefit more from
procedures that foster self-understanding, insight, interpersonal attachments, and self-esteem
than they do from procedures that aim at directly altering symptoms and building new social
skills.

Readiness
8. Clients who are in more advanced stages of readiness for change (preparation, action,
maintenance) are more likely to improve in psychotherapy than those at lower stages of
readiness (precontemplation, contemplation).
 The structure of treatment is predicated on these eight principles. To
expand on them, we will review the clinical implications for each of these
principles. For example, the first principle asserts that the more severe the
patient’s impairment, the more intensive the planned treatment must be to
effect change. Functional impairment is often inversely related to the degree
of social support available to the patient from family and reference groups.
Low levels of social support are indicative of the need to provide assistance
in developing attachments and social outlets (Longabaugh et al., 1993). In
such cases, referral of the patient to group and family therapy may be useful
to consider. Impairment is a complex construct and is comprised of the
interrelation among variables like the severity of the symptoms, extant
levels of social isolation, and problem chronicity (Holt et al., 2015). For
example, a patient who has high levels of anxiety, depression, and daily
impairment of function, and who lacks social support is considered to be
highly impaired. The salience of this determination is increased if the
patient has had the condition or its recurrence over a long period of time,
making them a poor candidate for psychotherapy. The trajectory of severity
for such a patient is likely to worsen. But by improving the patient’s access
to systems that provide social support and by working to relieve symptoms
that have reduced the patient’s functioning, this negative trajectory can be at
least partially ameliorated. As a therapist shifts the focus of treatment from
one stage (e.g., precontemplation) to foster the next (contemplation),
patients are most likely to benefit if that shift includes enhanced social
support.
Principles 2–4 are used to initiate, maintain, and repair the therapeutic
relationship. They are discussed in detail in a later section titled “Therapy
Relationship.” Suffice to say here that, in STS, as in most psychotherapies,
the therapeutic relationship consists of a collaboration between patient and
therapists that is built on trust and reflects personal interest in the patient by
the therapist. At the same time, these principles suggest a progression of
relationship qualities over the course of treatment and a need for the
therapist to be skilled both in fostering a helping relationship and in healing
strains and ruptures.
Principle 5 addresses ways in which one may most effectively structure
treatment to deal with patient resistance. Resistance is considered to have
both state and trait qualities, but in STS the focus is on trait-like qualities
that jeopardize one’s long-term change prospects. The effects of resistance
as a moderator of outcomes are of central importance. Patients with high
propensities to resist the efforts of others to change them are less likely to
benefit from directive treatments and goal-driven therapists. These patients
are more responsive to therapy methods that emphasize patient self-
direction and that de-emphasize therapist control and guidance (Beutler et
al., 2000). The effective therapist in this instance is more evocative than
directive, more empathic than assertive, and more gentle than challenging.
The exception to this rule is in the use of paradoxical procedures, which can
prove quite effective among highly resistant patients in whom fear of the
loss of freedom and control dominate (Beutler & Harwood, 2000). By way
of contrast, patients who are low on resistance are more likely to find
comfort in therapists who assume directive and guiding functions. These
patients generally experience good results and retain these effects when
treated by a structured and directive therapist using targeted goals,
homework, and instruction.
Principles 6 and 7 address the role of patient coping styles in treatment
implementation. The fact that the effects of internalization and
externalization as coping patterns are expressed in two principles is a
reminder that they are separate but related dimensions; they do not exist on
a continuum and are weakly but positively correlated with one another.
Thus, there is often great variation among the ways in which they are
expressed. Treatments must account not only for which of the two patterns
are dominant but also for the overall levels of their expression. Being low
on both coping scales reflects low levels of energy and social engagement.
High levels on both scales suggest the degree of ambivalence and instability
with which one approaches and handles change. In most instances, a patient
tends to prefer either an externalizing or internalizing stance when facing
new situations or impending threat. That stance is one that either is blaming
and openly defensive or one that is self-punitive and inhibited. Internalizing
styles of adjustment are typically best addressed by insight- and emotion-
focused treatments. Conversely, those with externalizing coping styles are
guided to procedures that emphasize the development of problem-solving
strategies and direct behavioral change.
Principle 8 comes into play throughout treatment and again when one
anticipates transferring or terminating a patient. The higher one’s stage of
readiness, the easier the shift will be, and this adaptation process can be
enhanced by inclusion of social support and, progressively, by a focus on
emotional expression through a progression of decision-making and taking
action. The therapist notes the patient’s level of readiness and guides the
patient toward experiences that will enhance the movement from
contemplation to action and maintenance of change. We address processes
and stages of change in more detail next.

PROCESSES OF CHANGE
Beyond the impact of the therapeutic relationship (covered more
extensively in the next section), there are several mechanisms that are used
to facilitate change processes in STS. To begin with, there are important
therapist characteristics that contribute to change, including but not limited
to trust, acceptance, acknowledgment, collaboration, support, respect,
awareness of self and others as cultural beings, cultural competence, and
humility. These characteristics are likely to be represented in the behaviors
of most effective therapists, perhaps many of whom have chosen this
“impossible profession” because of consistent praise that they received to
indicate their skills precisely in expressing these interpersonal abilities.
Therapists’ psychological well-being and personality play important roles
to the extent that they are likely to significantly mediate their capacity to
resonate empathically with their patients’ struggles and accomplishments.
Furthermore, therapists’ personal styles and match or mismatch with those
of each of their patients are also likely to influence significantly the
outcome of psychotherapy (Beutler, Moleiro, & Talebi, 2002; Fernández-
Álvarez, 2001).
Although the well-being of therapists plays an important role in the
quality of service provision (i.e., be well to serve well), so does patients’
character traits. These two domains of experience (clinician experience and
patient traits) tend to interact to jointly move the process along and enhance
outcomes of psychotherapy. Moreover, high problem complexity, marked
chronicity, significant functional impairment, maladaptive coping styles,
high reactance levels, and extreme distress all are likely to have a negative
impact on treatment and perhaps make difficult the actualization of a caring
relationship (Beutler & Consoli, 1993).
STS emphasizes the importance and generality of exposure as a process
that brings about human change while curtailing the potentially harmful
influence of avoidance. Treatment success is likely to be brought about if
patients can be persuaded to expose themselves to objects or targets of
behavioral and emotional avoidance.
STS operationalizes the adage, “different folks benefit from different
strokes.” It identifies procedural emphases that may contribute to
individualized change among patients. At a general level, patient variability
is based on the identification of externalizing contrasted with internalizing
coping styles. For the former, the relative balance of interventions ought to
favor the use of skill-building and symptom reduction procedures, whereas
for the latter, the balance should tip toward insight- and relationship-
focused procedures.
Concomitantly, the principles emphasize that therapeutic change is most
likely to occur when therapeutic procedures do not evoke patient resistance.
In other words, STS emphasizes the importance of tailoring treatments to
address the level of resistance that is present. When patient resistance is
high, treatments most likely to facilitate change are those that are the least
directive or those that are paradoxical in nature, such as prescribing the
continuation of symptomatic behavior.
Another contributor to the nature of the relationship is seen in the way
that STS urges the therapist to underscore the importance of a personalized
strategy for moderating a patient’s emotional distress. Therapeutic change is
maximized when the distress experienced by patients is moderate, and
therapists may respond to this level by assuming the roles of emotional
managers who seek to facilitate change by activating an optimal level of
emotional arousal. Therapists are called on to use therapeutic strategies that
will modulate emotional arousal, such as structure and support when
emotional level is too high; and confrontation, experiential, and open-
ended/unstructured procedures when emotional level is too low.
To optimally benefit from treatment, patients must be ready to make
changes. A powerful heuristic that therapists may want to systematically
consider in honoring patient differences in readiness is that of stages of
change (DiClemente & Prochaska, Chapter 8, this volume; Norcross, Krebs,
& Prochaska, 2011; Prochaska & DiClemente, 1983): precontemplation,
contemplation, preparation, action, maintenance, and termination.
Precontemplation is a stage in which one is not engaging in active change
and typically is not considering change. In contrast, the movement a patient
makes to enter the contemplation stage is indexed by the initiation of
thoughts about change and the need for making a change. The preparation
stage follows contemplation and signals a stage of readiness that may
include making some tentative efforts to change. The patient’s behaviors
indicate that change is wanted and motivates the patient to take the next
step in the change process. In this action stage, one begins to take the task
of changing seriously by actively engaging in the process and trying to
change. In this stage, if one is successful, the acts of “trying” are replaced
by a commitment to change. At the end of the process of making a change,
one enters the maintenance stage. Maintenance is a stage of living with and
refining the changes made and coping with the environmental changes they,
themselves, evoke. Put simply, therapists may consider the question of what
the patient is a customer for based on what stage of change they are at and
then tailor interventions that would move the patient along in the
corresponding stages of change.
STS emphasizes the importance of sustained emotional arousal until
problematic responses diminish. Finally, positive change is more likely to
occur when the initial foci of treatment is to build new skills and to alter
disruptive symptoms.

THERAPY RELATIONSHIP
The therapeutic relationship occupies an important role in STS, accounting
for three of the eight core principles detailed previously. The therapeutic
relationship, or working alliance, has been described as “the quintessential
integrative variable” (Wolfe & Goldfried, 1988, p. 449). Much of what will
happen in therapy as well as outside of therapy will be influenced by the
persuasive qualities of not only the therapeutic relationship but also of those
relationships that are most significant in the patient’s life. The therapeutic
relationship is critically involved at the beginning of therapy, but it is also a
cardinal process in maintaining the therapeutic work and healing the wound
when the relationship is strained or ruptured.
STS considers the roles of patient’s preparation and the process of role
induction together with the therapist’s preparation. In this interplay, the
therapist is encouraged to observe role activation as a variable that is most
relevant to the initial development and facilitation of the therapeutic
relationship. Therapists formally prepare patients and themselves for
therapy; present and actualize therapy as a process characterized by
alliance, mutuality, and collaboration; and, ultimately, seek to engage
patients in change and stabilizing activities.
A patient’s preparation serves the purpose of not only putting the patient
at ease but of also setting the stage for change. Congruent with the adage
that an informed consumer makes for a better one, the likelihood of positive
psychotherapy outcomes is significantly increased when patients are
properly informed of how to make best use of the services offered to them.
It is of particular importance to evaluate issues related to expectations that
patients bring to treatment, including personal and cultural values, beliefs
and attitudes toward the presenting complaint and its etiology, and attitude
toward help-seeking, treatment, and possible stigma associated with
psychological difficulties. Time needs to be spent redressing any
misperceptions or unrealistic prospects while educating patients on the roles
and activities to be expected of them. Furthermore, patient preparation at
the beginning of treatment and again when strains or ruptures are being
addressed involves explaining confidentiality and its limitations, the
purposes and potential length and outcomes of therapy, billing procedures,
and informed consent to treatment.
Therapists’ preparation involves education, training, and supervised
experience. It also involves the development of what Laing described as a
“harmless, inviting, cultivated” state (in Tougas & Shandel, 1989), refined
not only through personal therapy but also through lifelong exercises that
expand the therapist’s acceptance (Beutler, Consoli, & Williams, 1995),
cultural competence, and humility (Consoli et al., 2017). This caring
relationship is likely to engender a safe and respectful environment that
could be described as “a secure base” (Bowlby, 1988). Such base is not an
end in itself but a sine qua non foundation that will permit meaningful
exploration and important risk-taking by the patient, the therapist, and their
relationship. In partial agreement with Rogers (1957), we view these
therapists and potentially therapeutic relationship characteristics as
necessary although not, in and of themselves, sufficient conditions for
change.
Incipient ruptures in the therapeutic alliance, flagged by signs of hostility,
negativism, criticism, intolerance, or anger, are to be redressed through
reparative healing. Reparation may require an active consultation with a
supervisor or colleague because, many times, patient hostility may
inadvertently drag therapists into negative complementary sequences
expressed through hopelessness, belittling, and criticism, which may prove
quite difficult to overcome. Coldness, distancing, counterhostility, and
rejection toward patients are the markers of serious potential disruptions to
a fruitful therapeutic alliance. Unaddressed, these feelings are likely to
evolve into strains and then possibly ruptures in the alliance (Safran,
Muran, & Shaker, 2014; Wolf, Goldfried, & Muran, 2013).
Ultimately, establishing a warm and caring therapeutic relationship is
crucial. As Norcross put it, in a wordplay based in a spinoff of Bill
Clinton’s unofficial presidential campaign slogan, “It is the economy,
stupid!,” in psychotherapy, “It is the relationship, stupid!” (Norcross, 2011,
p. 347). Yet, with all its healing properties, the therapeutic relationship is
not an end to itself. As we see it, the therapeutic relationship ought to
evolve from therapists’ actions reflecting acceptance and affirmation to
those processes that complement the relationship qualities with a chain of
interactions that expand the repertoire of emotions experienced by patients
and their associated meanings (Wachtel, 1997). In the context of this secure
base, patients are appropriately encouraged to take the necessary risks to
face avoided material, emotions, and circumstances. We now turn to the
methods and techniques involved in such risk-taking activities.

METHODS AND TECHNIQUES

STS methods and techniques are those acts of the therapist that come in
response to one or more patient behaviors that, in turn, arise from the
characteristic traits that are used in treatment planning. These therapist acts
and the patient behaviors from which they arise should exist in a pattern
that operationalizes one or more principles of change. In this section, we
discuss the most frequently used methods and techniques when addressing
patient dimensions such as functional impairment, resistance level, coping
style, and readiness for change. We will not discuss principles 2, 3, and 4 on
the therapeutic relationship again, as they were addressed in the prior
section.

Principle 1: Functional Impairment

Functional impairment may be seen in the spread or overlap of
dysfunctional behavior across environments, the frequency of reoccurrence,
and the degree to which the patient has access to people and institutions that
can provide the needed levels of social support that will sustain change.
Functional impairment ranges from behaviors that reflect minimal
disturbance of life patterns or acute disturbance in one area of life to those
in which behavior is impaired in all areas of function. The antidote to the
negative influence of the patient’s impairment level is treatment intensity.
The greater the impairment, the more intense the treatment needs to be. The
diagnosis of a personality disorder, for example, typically indicates the
presence of an enduring and cross-situational disturbance in interpersonal
functioning that can be predictive of one’s long-term response to change
efforts. If the destructive influence of this disorder can be moderated by
intensifying and varying the interventions, positive change is more likely.
Treatment intensity, as used in this context, most often includes the use of
adjunctive interventions like group therapy, family therapy, couple therapy,
employment training, self-help groups, substance abuse treatment, and
psychoactive medication. With few exceptions, adding treatments works
through a process of increasing the patient’s involvement with treatment
resources and pushes change forward. While it probably is true that some of
the adjunctive treatments (e.g., mood elevators, antimanic medication, drug
abuse titration) have some direct and specific effects, at least part of the
action of intensifying treatment is to call on the patient to get involved and
committed to the process of change (Beutler et al., 2000). Patients with
complex and chronic problems require longer term and more intensive
treatments, with a therapeutic focus kept on interpersonal domains. Use of
psychoactive medication is recommended in cases of patients with very
high levels of problem complexity and chronicity (Beutler et al., 2000).

Principle 5: Resistance
Resistance is a concept that has widely been applied to explain all types of
patient behavior, both therapeutic and social. A narrower concept,
reactance, has been applied by social psychologists and cognitive theorists
to explain both trait- and state-like behavior within the context of social
persuasion theories (Brehm & Brehm, 1981; Goldfried & Davison, 1976).
Reactance can be viewed as an extreme case of resistance. It is the tendency
to respond oppositionally to external demands. Reactance, in contrast to
lesser forms of resistance, has clear trait-like (as well as state-like)
properties—an attribute whose likely expression varies from person to
person and one that is related to an individual’s acquired sensitivity to
perceived interpersonal threats to one’s autonomy. Reactance can be
indexed by a given individual’s ability to comply with externally imposed
demands.
A patient’s intolerance for external demands indicates the level of
therapist directiveness that likely will be needed and accepted by the patient
without eliciting oppositional resistance. Those who are easily threatened
by a perceived loss of autonomy respond more positively both to low levels
of therapy directives and to the use of paradoxical interventions (e.g.,
prescribing the symptom, symptom exaggeration) compared to those who
have high tolerance for such threats (Ollendick & Murphy, 1977).
Mismatching the use of highly directive procedures with patients who are
prone to reactance frequently results in worsening of symptoms (e.g.,
Forsyth & Forsyth, 1982). Highly resistant patients do best in the context of
methods that are evocative and self-directed and that generate in the patient
a sense of autonomy and self-reliance. If such straightforward, first-order
change strategies are not sufficient to catalyze the necessary or desired
changes, then therapists are encouraged to use paradoxical or second-order
change strategies. Low patient resistance is expressed by a tendency to
avoid confrontation and to be obedient to authority. Patients who are low in
resistance tend to benefit more from guidance, assignments, and
interpretations. Therapists may resort to structured homework, including
self-monitoring and direct suggestions that redress presenting complaints.

Principles 6 and 7: Coping Styles

A coping style is defined as “the typical and usual way an individual
interacts with others and responds to a threatened loss of safety and
wellbeing” (Beutler & Harwood, 2000, p. 74). Coping styles reflect the
patient’s efforts to adjust to anticipated or past change and related
discomfort. Although coping styles are trait-like characteristics, they are not
in themselves pathological. All individuals resort to coping strategies in
order to navigate the usual changes that occur in one’s life while seeking
constancy and freedom from pain. Coping styles, among patients, therefore
can turn into a problem when the individual becomes either unstable or
inflexible in the use of certain coping strategies. The degree to which this
kind of rigidity is expressed adds further to the problems that stimulate
coping and the negative effects of the coping style itself.
Although we have come to identify coping styles categorically as either
dominantly “internalizing” or “externalizing,” each can have different
levels of adaptability and functioning. Internalization is a more complex
expression of coping than is externalization, thus warranting the
independence of these constructs. Internalizing coping styles include self-
criticism, feelings of guilt and fear, inhibition of impulses, somatic
symptoms, introversion, and agitated or low activity levels. An internalizing
patient is most often described as being self-blaming, timid, and engaging
in self-devaluation accompanied by compartmentalization of affect and
idealization of others. Clinical signs that can indicate internalization include
a greater tendency toward suppressed negative affect and avoidance of
expressing outward anger. Internalizers attribute faults and mishaps to their
lack of skills or abilities and then try to compensate by engaging in
ritualistic behavior that is initiated with the intention of undoing the faulty
behavior. They are prone to be intropunitive and to restrict their emotional
response to the point of being constrained and stilted in emotional
expression. This style parallels some of the traits associated with diagnostic
groupings of avoidant and obsessive-compulsive personality disorders.
When one determines that an internalizing coping style is present and
insight-oriented treatment is indicated, the next major task is to define a
focal theme to guide and organize the relevant interventions. The
formulation of the issue is best done by using a theoretical orientation with
which the therapist is most familiar. Within cognitive therapy (CT) and
cognitive-behavior therapy (CBT), a theme that focuses on schematic
cognitions would fit, and within the psychodynamic tradition, either an
object relations theme or a social dynamic theme works well.
Externalizers, in sharp contrast to internalizers, attribute responsibility
for their distress and discomfort to external objects or to others.
Externalization includes such behaviors as acting out, blaming others for
one’s own mistakes, projection, social gregariousness, extraversion, and
direct avoidance. Externalizers tend to behave in a manner easily
characterized as aggressive; they tend to actively avoid blame or
responsibility and to exhibit denial. They also tend to avoid taking
responsibility for change, leaving their future well-being in the hands of
others or fate. Externalizers tend to respond best to symptom-oriented
procedures and those treatments that provide structure, feedback, and
enhance behavioral coping skills.

Principle 8: Readiness for Change

The readiness principle not only applies to the point of entry into
psychotherapy, but at the point of exit when follow-up and continuing work
is needed. A patient who remains in the precontemplation stage will find it
difficult to commit to further treatment. Listening and understanding the
patient’s investment in avoiding change may reveal some avenues to
pursue, and negotiating a level of intervention to which the patient can
make a commitment is often the goal at this point. When patients achieve
higher levels of readiness, the recommendations for further treatment
become more varied and the treatments suggested become more flexible. As
the patient enters the action phase and has made a commitment to change,
then the specificity of any needed referral and follow-up becomes of greater
importance again. Until the patient has experienced the benefits of change,
their follow-through and autonomy in seeking out other treatment sources
will be weak. Therapists can vary their degree of directiveness and focus to
fit the patient’s coping style and resistance levels at every stage of change.
Of course, treatment methods do not exist independently of the
practitioners who use them, and patients are more than diagnoses and
character traits. It is as important to know the patient who has a given
clinical problem as it is to know the disorder the patient is experiencing.
Therefore, the effectiveness of treatment is predicated on therapist skills to
adapt treatment to the most salient patient dimensions beyond diagnosis.
Though methods are important, even more important is the systematic
selection of those interventions that are most likely to make a difference for
a given patient.

DIVERSITY CONSIDERATIONS
Psychotherapy is a culturally sanctioned approach within the healing arts.
Moreover, psychotherapy as a professional culture has its own aspirational
values expressed in general principles such as nonmaleficence, beneficence,
fidelity, and the like (www.apa.org/ethics/code/ethics-code-2017.pdf), as
well as practices such as confidentiality. These values and practices may be
familiar to, congruent with, and expected by some patients while possibly
awkward and incongruent to others.
Clinicians employing a culturally grounded psychotherapy such as STS
work toward mutual understandings with their patients. The concept of
fitting treatment to one’s cultural behaviors and beliefs is absorbed within
the larger goals of fitting treatment to specific qualities and characteristics.
Culture specific attitudes and beliefs are simply another way of
characterizing some of the compatibilities of treatment that therapists must
address. They do so by maintaining a respectful and listening attitude
toward their patients, one in which they actively join with them in
discerning the influence that historical, sociocultural, and contextual
dimensions have on presenting complaints, patients’ strengths and
difficulties, and ways to redress their difficulties while furthering their
strengths.
The Cultural Assessment of Risk for Suicide and the Minority Stress
Scale (Chu et al., 2013) are included within the STS/innerlife to broaden the
nature of factors that are the object of a treatment fitting process. These are
specific scales to assess minority suicidality and stress among ethnically
diverse populations. This assessment is activated at the discretion of the
clinician or when some key questions are scored in the direction of minority
stress. Research is in the process of identifying indicators for different
treatments within these stressed minority communities. Early results
indicate that coping styles and stages of change are identifiable across many
different cultures, but their expression may differ as a function of one’s
culture. For example, internalization is the modal coping style in some
countries, and some behaviors that appear to be “externalizing” in one
country may in fact be strongly infused with internalizing guilt and blame.
We believe these embedded measures will prove useful in identifying risk
among minority groups and in helping therapists struggling with issues
related to cultural competence and humility.
STS emphasizes the person of the therapist as the most fundamental tool
in psychotherapy. The development of the therapist is fostered through
awareness of our own privileges, such as our education and profession,
while considering the influence of intersecting cultural dimensions in
ourselves and our patients (e.g., race, ethnicity, culture, (dis)abilities,
sexuality, and gender, among others). An STS approach is mindful of the
impact that xenophobia, discrimination, racism, ethnocentrism, ableism,
and other human shortcomings are likely to have on the therapist’s ability to
be of service as well as the impact they may have on patients’ presenting
complaints and experiences. Due to the implicit nature of many of our
biases, STS therapists welcome supervision and consultation concerning
diversity matters while engaging in the lifelong endeavor of fostering
cultural competence and humility.
STS honors diversity by appreciating the power differential in the
therapeutic relationship and in the variety of interventions utilized to
establish and maintain the therapeutic contract (e.g., informed consent,
confidentiality, mandated reporting, involuntary hospitalization).
Specifically, in STS, diversity is recognized through honoring the adage
“one size does not fit all.” STS practitioners personalize treatment to the
unique patients and systematically select interventions tailored to the
client’s singular context.

CASE EXAMPLE

HG is a 45-year-old, white married male who voluntarily participated in a

research study on the treatment of comorbid stimulant abuse and
depression. He was seen in a psychology training clinic by a master-level
drug counselor certified by the state of California. The patient completed
the initial 20 planned sessions and a 6-month extension.
The patient reported that he had been a poly-drug abuser off and on for
several decades. His preferred drug was heroin, but he also abused cocaine,
methamphetamines, and alcohol, as well as various “downers.” He had been
through rehabilitation several times and on one occasion had remained
drug-free for 5 years. At the time he was referred, he was using heroin and
cocaine on a weekly basis, as well as engaging in daily marijuana use.
HG was recently unemployed and was trying to support himself and his
family (one child) as a telephone solicitor. His work had been negatively
affected by frequent absenteeism; finally, he had been terminated because
of drug use at work. His wife vowed support for him, but no longer trusted
that he could take care of the family or that he would stay chemical-free as
he promised.
In the initial assessment, the patient presented a chaotic family history in
which both parents were alcoholics and frequent drug users. The patient
began drug use at age 13 under the tutelage of his older brother who
supplied him with marijuana and heroin for the next 4 years until he was
arrested for the first time for possession. Asked about his own explanations
for his difficulties HG responded, “You are what you see.”
Assessment with the STS-CRF computer-based system (Harwood &
Williams, 2003) revealed the patient to have chronic problems, to have both
a polysubstance abuse disorder and major depression, and to have a
probable personality disorder. Characteristics ascribed to him by the intake
clinician included moodiness, impulsivity, limited foresight and insight,
impatience, anger, resentment of authorities, and irritability. These qualities
were judged to be present across situations, suggesting their trait-like
qualities. Thus, problem complexity and chronicity were both high.
Likewise, functional impairment was high, with impaired work, social, and
intimate functioning. At the same time, but somewhat surprisingly, HG felt
social support was moderate, with the patient placing much reliance on the
support of his wife and one other friend. Though the patient was depressed,
there were no indicators of current suicidality.
These findings supported intensive outpatient care. A program of daily
contact via electronic means and three times per week treatment sessions,
occasionally supplemented by collateral treatment with his wife, was
initiated. Weekly blood tests for drugs complemented this work.
Collectively, the patient’s status on chronicity, complexity, impairment,
and social support suggested that treatment should be intense. Inpatient care
was considered but rejected because of insurance coverage. An externalized
coping style led to the targeting of symptom change and interpersonal skill
development, especially in the area of impulse control. The patient’s
reactance level required that strong assertions and control on the part of the
therapist and the patient’s family be avoided. The initial treatment focus
was on achieving symptomatic change in drug use.
The initial treatment plan called for little emphasis to be placed on
insight, given HG’s impulsive and externalizing coping style. Thus, daily
monitoring, assisted by the patient’s wife, provided the degree of oversight
needed to help him transition off of drugs. His preferences for outpatient
care and self-monitored drug withdrawal were accepted in order to fit the
treatment to the patient’s resistance. However, a contingency plan of
involuntary hospitalization was presented in the event that these initial self-
care efforts proved unsuccessful. This was presented paradoxically, as a
fallback position that would be employed if the patient demonstrated that he
could not control his impulses. We anticipated that this paradoxical
presentation might strengthen his resolve to be self-controlling.
A working relationship was slow to develop. The patient, initially, was
distrustful and guarded, saying little without being prompted. His
attendance was spotty at first, but the patient gradually became more open
and, by the eighth session, had come to seek advice and showed other
indicators of active participation. The therapist, accordingly, initiated
treatment with reflections, open but nonthreatening questions, and
statements of support. As the patient became more invested and his
attendance improved, the therapist began to introduce some homework
assignments. The sessions remained supportive and nonconfrontative,
however, and the patient accepted the weekly blood tests without resistance.
Honoring HG’s views on what brought about his difficulties, we
encouraged the development of social contacts and role models as ways of
improving social support and facilitating commitment to a healthier life
style. HG selected Al-Anon from among a list of potential social referrals
and support groups provided by the therapist, again trying to work with,
rather than against, the patient’s resistance tendencies. Thus, homework
assignments encouraged monitoring of abstinence, urges, effective
cognitive and behavioral coping strategies, increased social activities (HG
chose to join a hiking club for families), job-seeking behaviors, and
support-seeking from his wife and a friend.
Telephone contact was initiated as a way of maintaining low-demand
contact during the early phase when he missed sessions. These calls were
made to inquire about and then to encourage attendance. Eventually, they
were instrumental in implementing a program that required him to call the
therapist or his closest friend each morning. This program was instituted to
ensure his ongoing compliance and continued throughout his treatment.
With the overall program, drug use began to decline under the initial
suggestion that he monitor urges and avoid change, then monitor urges and
delay use, and then monitor urges and reduce use. As the patient’s
resistance would allow, self-monitoring skills and symptom maintenance
homework instructions (e.g., “Don’t try to quit your drug use, just keep it at
the same level for a while”) were the focus of training and homework
assignments until about session 13. At that point, he was challenged to
reduce his drug use, “but not too rapidly.”
 Drug withdrawal was complete by the eighteenth session, and he
remained substance-free through the duration of the treatment and a 6-
month, planned follow-up period. HG terminated successfully with two
clean urine tests and was referred to a therapist in the community for
follow-up as needed.

OUTCOME RESEARCH
A psychotherapy like STS, which is built on principles of change rather
than on circumscribed theories, offers certain advantages to those who seek
to implement outcome research. First, since principles are independent, they
can be separately validated as well as validated as part of a large treatment
package. Second, psychotherapies frequently comply with some of the STS
principles without specifically intending to do so. Hence, it usually is
possible to identify which principles were employed in a given treatment
plan and to determine if their usage may have been related to positive
outcomes. What is perhaps the most unique contribution of STS is that it
has sought empirical support on how it works and when to intervene and
then expressed the findings in the form of principles of change that inform
therapists’ actions regardless of theoretical leanings.
Six randomized controlled trials (RCT), at least three quasi-experimental
studies, and multiple meta-analyses provide empirical support for STS. We
will review one RCT to illustrate the methods and some of the typical
findings. The first RCT to test some of the core STS principles employed a
sample of moderately depressed patients (Beutler, Engle et al., 1991) and
concentrated on testing the principles of resistance and coping styles. In this
case, three therapies to be compared with one another were selected
because they systematically differed in the implicit principles on which they
relied. CT, as a directive approach focused on symptom change, was
expected to perform best among patients who were low on resistance and
who were characterized by externalizing coping styles. Self-directed
therapy was a low direction, insight-oriented approach and was expected to
perform best with patients who were highly resistant. Finally, focused
expressive psychotherapy was selected as a moderately directive approach
that focused on current experience and emotional awareness. It was
expected to do best among those with internalizing coping styles.
 A test of the outcomes associated with the three treatments was
undertaken. Not surprisingly, few main effect differences emerged for the
three treatments; the “Dodo bird verdict” of equivalent outcomes was
supported. The next step in the analysis assessed the interaction effects
resulting in an effect size (d) of .75 associated with coping style ×
insight/symptom focus and one of .88 (d) associated with compliance with
directiveness × resistance. A follow-up (Beutler et al., 1993) was
undertaken at 12 months post discharge. The match between patient trait-
resistance and therapist directiveness then generated a strong effect size (d)
of 1.40, and the match between coping style × insight/symptom focus
earned a 1.64 (d), indicating that the match enhanced maintenance effects.
Subsequently, a cross-cultural replication (Switzerland) was undertaken
comparing two therapies, one based on behavioral principles (high
directiveness and symptom focused) and one on client-centered therapy
(low directiveness and insight focused; Beutler, Mohr et al., 1991). Main
effect differences modestly favored the behavior therapy, but a within-
groups comparison showed that resistance and coping style matching
significantly added to treatment gains. Similar results were found across
other studies with different populations, including patients with co-
occurring depression and stimulant abuse (Beutler et al., 2003), substance
dependence (Beutler et al., 1993; Karno, Beutler, & Harwood, 2002),
alcohol dependence/abuse (Karno & Longabaugh, 2004, 2005a, 2005b),
and mixed diagnostic samples (e.g., Beutler et al., 2012; Watzke et al.,
2010).
Our most recent study (Holt et al., 2015) demonstrated that training in
STS produced greater improvement among patients receiving care from
therapists supervised through STS compared to those who received
supervision as usual (SAU). The SAU group of graduate student therapists
achieved good results among their patients but were outperformed by
students who received STS-assisted supervision (SAS). The effect sizes,
which were expressed as percentages of a standard deviation (d) drawn
from pre-post differences were (d) = 0.72 (SAU) and 1.37 (SAS) and
revealed a d = .65 increase over students receiving SAU supervision. More
than 80% of the patients in the SAS group returned to “normal” functioning
by the end of treatment.
In addition to individual studies, of which we have reviewed only a few,
the core principles have been subjected to several meta-analyses. Here, and
for the purpose of illustration, we will briefly report only on a meta-analysis
that has addressed the principles of patient reactance levels. A meta-
analysis of 15 studies that reviewed the impact of treatment when a good fit
(i.e., an inverse relationship between patient resistance and therapist
directiveness) occurred compared to when a poor fit was present (i.e., a
positive relationship occurred between patient resistance levels and
therapist directiveness) reported a mean d across studies of .81, a strong
effect in support of the match (Edwards, Beutler, & Someah, in press).
The significance of this study as well as others for which these served as
illustrations (e.g., Beutler, Edwards, Kimpara, & Miller, in press; Edwards
et al., in press) is threefold. First, they have consistently found positive
effects of STS, suggesting that the efficacy of STS among mixed patient
groups is comparable to that obtained among diagnostically pure groups of
depressed and chemically dependent patients. Second, the meta-analyses
support the matching principles identified earlier in this chapter. And third,
emerging studies on supervision using the STS principles have provided a
clinically convincing demonstration that the STS skills and principles can
be learned in supervision to the benefit of the client, outperforming
supervision as usual. That, we reiterate, is the mandate and the goal of STS:
enhanced patient outcomes.
The cumulative research on STS, as we have noted, has included both
inpatients and outpatients, alcoholics, co-occurring conditions, depressed
and anxious outpatients, and European and South American samples in
addition to many from North America. Moreover, the research has failed to
reveal a specific effect of patient diagnosis on treatment outcome when the
effects of FI and other STS factors are controlled (Beutler et al., 2012). We
think these results are promising for the generalization of STS principles.
We conclude that STS treatment matching does enhance the effects of
psychotherapy. Even compliance with a single principle produces
substantial increases in the proportion of change variance contributed by
treatment. Moreover, the higher effect sizes observed when STS is applied
as a multiprinciple package provides indirect evidence that the components
are additive in their effects.

FUTURE DIRECTIONS
The most pressing needs in STS are the validation of its therapeutic efficacy
and the delineation of the principles of therapeutic change. The past two
decades have seen a substantial increase in the number of research studies
on therapy-patient-practitioner matching. Yet much needs to be done in
extracting—from the many clinically relevant variables that have been
touted as matching dimensions—those that do serve as indicators and
contraindicators. Our own research has moved from correlational
demonstrations of the efficacy of matching dimensions to prospective
studies that focus on causality and guidelines for the practicing clinician.
Prospective research continues to be needed, however, to determine how
well the relations that have been observed between coping style and
treatment focus, and between reactance level and therapist’s directiveness,
translate from major depression and anxiety symptoms to other diagnostic
groups. Likewise, systematic research is needed to determine if the
treatment procedures currently available are sufficiently broad and flexible
to encompass most patient patterns.
Finally, more research is needed on training effective psychotherapists.
Our recent studies (Holt et al., 2015; Stein, 2015) provide encouraging
support for the conclusion that trainees’ effectiveness (and patient
outcomes) can be improved by using STS-assisted supervision over the
usual supervision methods. However, both studies were performed at the
same training clinic and led by the primary developer of STS. Replication
in multiple sites is sorely needed.
Beyond these research questions, we believe that the future will see a
continuation of interest among psychotherapists in integrative, principle-
driven, evidence-based methods of responsively fitting psychotherapy to the
individual patient. The methods for assisting clinicians directly in
developing effective treatment plans will become more widely available,
such as that offered in electronic assessments. Ultimately, if any integrative
psychotherapies prove more beneficial than the approaches they integrate,
they must stand the empirical as well as the clinical test. The matching
concepts must be useful to the clinician, verifiable to the scientist,
acceptable to a diversity of practitioners, and relevant to a pluralistic
society.

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C. Theoretical Integration
 8

The Transtheoretical Approach

JAMES O. PROCHASKA AND CARLO C. DICLEMENTE

Impetus for the transtheoretical approach came from several sources. First
and foremost was a discontent with the state of affairs in psychotherapy
theory, research, and practice. The narrowness and frequent dogmatism of
the proponents of many therapies and the consistent research findings of
few differences in outcome between therapy systems encouraged a search
for alternatives. Therapy systems focused more on theories of
psychopathology and single mechanisms of change than on an exploration
of the more extensive process of intentional behavior change. Positive
regard, authenticity, living in the here and now, confrontation of beliefs,
social interest, conditioning, and contingencies are valuable rules for human
functioning but are not sufficient to explain psychotherapy change.
In 1977, Prochaska, with the help of his graduate students, embarked on a
journey through the major systems of therapy to seek the commonalities
across the boundaries of the most popular theories of psychotherapy.
Systems of Psychotherapy: A Transtheoretical Analysis (Prochaska, 1979;
Prochaska & Norcross, 2018) represents the culmination of this journey.
The map used for the journey indicated that active ingredients identified by
theories of psychotherapy can be summarized by 10 processes of change.
Although the framework used in this analysis appeared to have face
validity, it remained a conceptual integration with no empirical basis.
Since that initial work, we and many collaborators applied and studied
the transtheoretical model, created assessment instruments, expanded its
scope, and explored its limitations. This research supported our model of
change and encouraged us to continue the development of The
Transtheoretical Approach: Crossing the Traditional Boundaries of
Therapy (Prochaska & DiClemente, 1984). As our applications expanded
beyond office-based psychotherapy of psychopathology in individuals to a
proactive treatment of health problems in entire populations, we have
expanded the model. Changing for Good (Prochaska, Norcross, &
DiClemente, 1994) and Changing to Thrive (Prochaska & Prochaska, 2016)
are apt titles for helping individuals and populations progress across the
stages of change. Hundreds of outcome studies using the transtheoretical
model have now been conducted around the world on dozens of health and
behavioral problems.
A final impetus for our work was the zeitgeist among psychotherapy
practitioners and theorists. We heard the pleas for a more integrated and
comprehensive approach to psychotherapy that would take into account the
differences in the experiences of therapists and clients. Moreover, in our
thinking, an integrative approach should account for how individuals
change on their own (unaided by psychotherapy) as well as how individuals
change with the assistance of psychotherapy.

THE INTEGRATIVE APPROACH

The proliferation of psychotherapy systems reflects the complex, interactive
nature of psychotherapy. The daily dilemma facing the clinician is what to
do, when to do it, with whom, in what way, with which problem. Both in
the research literature and in clinical experience, it has become clear that no
one system of therapy addresses adequately all these questions.
From our perspective, an integrative perspective will accomplish the
following goals:
1. Preserve the valuable insights of major systems of psychotherapy. Trying to reduce all therapy
systems to their least common denominator removes their richness.
2. Provide practical answers to pressing questions faced by clinicians. However elegant a theory
might be, an impractical, simplistic, or clinically irrelevant integration will never be adopted.
3. Bring some order to the chaotic diversity and divisiveness in psychotherapy but not by merely
throwing a collection of techniques into a toolbox to hide the chaos.
4. Offer a researchable alternative to single-system and comparative research designs. Explanation
without experimentation will not silence critics of integration or psychotherapy.
5. Generate a systematic approach: a structure or set of principles that are comprehensive enough
to include crucial dimensions of the work of psychotherapy and behavior change and, at the
same time, provide a perspective that promotes collaboration, creativity, and choice.
 The transtheoretical approach attempts to meet these goals by means of
four critical dimensions: the processes of change, the stages of change, the
pros and cons of change, and the levels of change. In the following sections,
we review these four dimensions and their important interconnections.

Processes of Change
An analysis of the 24 most popular theories of psychotherapy (Prochaska,
1979) yielded the first of the four dimensions of the transtheoretical
approach: the processes of change. Transtheoretical therapy began with the
assumption that integration across a diversity of therapy systems most
likely would occur at an intermediate level of analysis, somewhere between
overarching theory and specific techniques. Coincidentally, Goldfried
(1980, 1982), in his well-known call for a rapprochement, independently
suggested that principles of change were the appropriate starting point for
integration.
The processes of change, then, may best be understood as a middle level
of abstraction between the global theoretical assumptions of a system of
psychotherapy and its specific techniques. A process of change represents
the activities initiated or experienced by an individual in modifying
thinking, behavior, or emotion related to a particular problem. Although
there are many coping activities, there appear to be a finite set of processes
that represent change principles. In a similar manner, techniques of therapy
can be analyzed to see which change process they would draw on or
promote. Thus, therapist feedback would provide new information and
challenge current thinking about the problem. These therapist activities
would enable the individual to engage in more accurate information
processing. From a transtheoretical perspective, these activities activate the
process of change known as “consciousness raising” in the client.
Subsequent research has driven modifications of our original
formulations. That research has consistently yielded 10 distinct processes of
change: consciousness raising, self-liberation, social liberation,
counterconditioning, stimulus control, self-reevaluation, environmental
reevaluation, contingency management, helping relationships, and dramatic
relief/emotional arousal.
Our studies indicate that people in the natural environment generally use
these 10 processes of change to modify problem behaviors (DiClemente &
Prochaska, 1982). Most major systems of therapy, however, theoretically
employ only two or three processes (Prochaska & Norcross, 2018). One of
the assumptions of the transtheoretical approach is that therapists should be
at least as cognitively complex as their clients. They should think in terms
of a more comprehensive set of processes and apply techniques to engage
each process when appropriate.

Stages of Change
A second dimension of the transtheoretical approach is the stages of
change, which reflect the temporal and intentional aspects of change.
Intentional change is not an all-or-none phenomenon but a gradual
movement through specific stages. Lack of awareness of the stages led
some theories of therapy to assume that clients arriving at therapy present in
the same stage of change and are ready for the same change processes.
Studies of various outpatient populations (e.g., Carbonari & DiClemente,
2000; DiClemente & Hughes, 1990; McConnaughy, DiClemente, et al.,
1989; McConnaughy et al., 1983) have found a variety of profiles on a
Stages of Change measure. Clearly, all individuals who come to therapy are
not at the same place in terms of their stage of change.
We have identified five stages of change: precontemplation,
contemplation, preparation, action, and maintenance. A stage of change
represents both a period of time and a set of tasks needed for movement to
the next stage. Although the time spent in each stage may vary, the tasks to
be accomplished to achieve successful movement to the next stage are
assumed to be invariant. In the move from precontemplation to
contemplation, an individual must become concerned and aware of the
problem, make some acknowledgment of or take ownership of the problem,
confront defenses and habitual aspects that make it difficult to control, and
see some of the negative aspects of the problem or positive aspects of
change in order to move to the next stage of seriously contemplating
change.
One of the most helpful findings to emerge from our research is that
specific processes of change are emphasized during particular stages of
change. The integration of stages and processes of change has been well
supported across problem areas. In fact, a meta-analysis of 47 cross-
sectional studies (Rosen, 2000) examining the relation between the stages
and processes found moderate to large effect sizes: .70 for variation in
cognitive-affective processes by stage and .80 for variation in behavioral
processes by stage.
This integration serves as an important guide for therapists. Once a
client’s stage of change is clear, the therapist likely knows which processes
to activate to optimally help the client complete critical tasks and progress
to the next stage of change. Rather than try to engage change processes in a
haphazard or trial-and-error approach, integrative therapists can use change
processes more systematically.
Table 8.1 summarizes the integration that emerged in our research
explorations of the stages and processes of change (DiClemente, 2018;
Prochaska & DiClemente, 1983). During precontemplation, individuals use
change processes significantly less than people in any other stage.
Individuals in precontemplation process less information about their
problems, spend less time and energy reevaluating themselves, experience
fewer emotional reactions to the negative aspects of their problems, are less
open with significant others about their problems, and do little to shift their
attention or their environment in the direction of overcoming their
problems. In therapy, these are clients who are labeled “resistant.”
TABLE 8.1 Processes of change emphasized at particular stages of change
Precontemplation Contemplation Preparation Action Maintenance
Consciousness raising
Emotional arousal
Environmental reevaluation
Self-reevaluation
Self-liberation
Contingency management
Counterconditioning
Stimulus control

What can help people move from precontemplation to contemplation?

Table 8.1 suggests several change processes that prove most helpful. First,
consciousness raising interventions, such as observations, feedback, and
interpretations, can help clients become more aware of the causes,
consequences, and cures of their problems. To move to the contemplation
stage, clients have to become more aware of the negative consequences of
their behavior. Often, we must help clients become more aware of their
defenses before they can become more conscious of what they are
defending against. Second, the process of dramatic relief or emotional
arousal provides clients with helpful affective experiences (e.g.,
psychodrama, gestalt empty chair), which offer emotional experiences
related to problem behaviors. Life events, such as illness or death of a
friend or lover, can also move individuals in precontemplation emotionally.
As clients become increasingly more aware of themselves and the nature
of their problems, they are freer to reevaluate themselves both affectively
and cognitively. The self-reevaluation process includes an assessment of
which values clients will try to actualize. The more central problems are to
their core values, the more their reevaluation will involve their sense of self.
Contemplators also use environmental reevaluation to reevaluate the effects
that their behaviors have on their environments, especially the people they
care about most. Addicted individuals, for example, may ask, “How do I
think and feel about living in an environment that places me and my family
in increasing risk of disease, death, poverty, and/or imprisonment?”
Movement through the contemplation stage involves increased use of
cognitive, affective, and evaluative processes of change leading to a
decision to change. To better prepare individuals for action, changes are
required in how people think and feel about their problem behaviors and
how they value their problematic lifestyles.
Preparation indicates a readiness to change in the near future and
realization of valuable lessons from past change attempts and failures. They
are on the verge of taking action and need to set goals and priorities
accordingly. Patients in preparation often develop an implementation
intention and action plan for how they will proceed. In addition, they build
firm commitments to follow through on the action option they choose. In
fact, they are often already engaged in processes that would increase self-
regulation and initiate behavior change (DiClemente et al., 1991). People
typically begin by taking some small steps toward action.
During the action stage, clients act from a sense of self-liberation. They
need to believe that they have the autonomy and to take responsibility to
change their lives in key ways. Yet they also accept that coercive forces are
as much a part of life as is autonomy. Self-liberation is based in part on a
sense of self-efficacy (Bandura, 1977, 1982), the belief that one’s own
efforts play a crucial role in succeeding in the face of difficult situations.
Self-liberation, however, requires more than an affective and cognitive
foundation. Clients must also be effective using behavioral processes, such
as counterconditioning and stimulus control, to cope with those external
circumstances that can coerce them into relapsing. If necessary, therapists
can provide training in behavioral processes to increase the probability that
clients will be successful when they do implement plans and take action.
Successful maintenance builds on each of the change processes that has
come before and involves a candid assessment of the conditions under
which a person is likely to be encouraged or coerced into relapsing. Clients
assess the alternatives they have for coping with such coercive forces
without resorting to self-defeating defenses and pathological responses.
Perhaps most important is the sense that one is becoming more of the kind
of person one wants to be. Continuing to apply counterconditioning,
stimulus control, and reinforcement management is most effective when it
is based on the conviction that maintaining change maintains a self that is
highly valued by oneself and at least one significant other.
The amount of progress patients typically make in treatment is a function
of their pretreatment stage of change. A meta-analysis of 76 psychotherapy
studies (encompassing 21,424 patient) found that stages robustly predict (d
= .41) distal outcomes (Krebs, Norcross, & Prochaska, 2018). Several
longitudinal studies illustrate this meta-analytic finding. In an intervention
study with smokers with heart disease, Ockene and her colleagues (1992)
found that 22% of smokers in precontemplation prior to treatment were not
smoking at a 6-month follow-up. However, of those in contemplation, 44%
were abstinent and approximately 80% of those in preparation or in action
were not smoking at 6 months. With a household sample of Mexican
American smokers in Texas (Gottlieb et al., 1990), at a 12- to 18-month
follow-up, smokers originally in contemplation progressed to the action
and/or maintenance stages four times as frequently as smokers originally in
the precontemplation stage. The amount of progress head-injury adults
made in rehabilitation also was directly related to their stage of change prior
to treatment (Lam et al., 1988).

Pros and Cons of Changing

A third dimension of the transtheoretical model is the pros and cons of
changing, which represent the decisional and motivational aspects of
change. Janis and Mann’s (1977) model of decision-making inspired our
original work on the pros and cons of change. They identified four types of
“pros” or benefits of decisions and a similar set of “cons” or costs:
instrumental benefits/costs to self, instrumental benefits/costs to others,
approval/disapproval from self, and approval/disapproval from others.
Questionnaires assessing the pros and cons included items to represent
each of these eight categories. Principle components analyses consistently
demonstrated that decision-making could be reduced to two core constructs:
pros and cons of changing (Velicer et al., 1985). When weighing important
life changes, people do not differentiate benefits to self from those for
others or instrumental benefits from affective or evaluative. They do clearly
differentiate the pros from the cons.
Most importantly, there are clear and consistent associations between the
stages of change and the pros and cons of changing across all types of
problems. A meta-analysis was performed on the relation of the pros and
cons and stages of change across 43 behaviors in more than 60,000 people
from nine nations (Hall & Rossi, 2003). The problem behaviors included
depression, stress, anorexia, alcohol abuse, heroin addiction, cocaine abuse,
obesity, smoking, partner abuse, and more. Figure 8.1 demonstrates how
clear integration can be even in the face of so many differences.

FIGURE 8.1 Integration of pros and cons by stages of change across 43 behaviors.

Across 43 behaviors, the cons of changing outweigh the pros by .7

standard deviations (SD) for people in precontemplation. The opposite is
true for people in maintenance where the pros of changing are .7 SD higher
than the cons. The pros of changing are clearly higher in contemplation than
in precontemplation. In contemplation, the pros and cons are about equal,
reflecting the profound ambivalence that characterizes the contemplation
stage. The pros and cons cross over for people in the preparation stage who
are more convinced that the huge efforts needed during the action stage are
likely to be worth it. The further along people are in the stages, the more
convinced they are that the struggles to change are worthwhile.
It might be helpful here to briefly apply these change dynamics to
people’s decisions to participate in treatment. We need to keep in mind that
the weighing of the pros and cons of changing is not fully conscious or
rational. The clear patterns in Figure 8.1 only emerge if standardized scores
rather than raw scores are used. If raw scores were used, then the pros of
changing would outweigh the cons at each stage.
Imagine clients in the precontemplation stage who are prescribed
psychotherapy or medication for depression. Their cons of treatment would
clearly outweigh the pros. So, if they started treatment, they would likely be
among the 40% who would discontinue treatment quickly and prematurely.
That is exactly what we found in predicting more than 90% of premature
termination from psychotherapy: those in precontemplation were highly
likely to discontinue. Those in the action stage were likely to finish therapy
quickly but appropriately, as judged by their therapists (Brogan et al.,
1999). A growing number of studies indicate that by matching processes of
change to stage of change, patients in precontemplation can complete a
treatment program at the same high rates as those in preparation (e.g.,
Prochaska et al., 1993; Prochaska, Velicer, Fava, Rossi, & Tsoh, 2001;
Prochaska, Velicer, Fava, Ruggiero, et al., 2001).

Levels of Change
At this point in our analysis, we appear to be discussing how to approach a
single, well-defined problem. However, as clinicians know, reality is not so
accommodating. Although we can isolate certain symptoms and syndromes,
these occur in the context of complex, interrelated levels of human
functioning. In changing any one behavior there is the life context
surrounding that change. The fourth dimension of the transtheoretical
approach addresses this issue.
 The levels of change represent an organization of five distinct and
interrelated levels of psychological problems that can be addressed in
psychotherapy:

◆ Symptom/situational problems
◆ Maladaptive cognitions
◆ Current interpersonal conflicts
◆ Family/Systems conflicts
◆ Intrapersonal conflicts

Historically, systems of psychotherapy have attributed psychological

problems primarily to one or two levels and focused their interventions on
these levels. Behavior therapists have focused on the symptom and
situational determinants, cognitive therapists on maladaptive cognitions,
family therapists on the family/systems level, and psychoanalytic therapists
on intrapersonal conflicts. It is crucial that both therapists and clients agree
as to which level they attribute the problem and at which level or levels
they are willing to target as they work to change the problem (Begin, 1988).
In the transtheoretical approach, we consider intervening initially at the
symptom/situational level because change tends to occur more quickly at
this level and symptom/situational problems are often primary reasons for
entering therapy. The further down the levels we focus, the further removed
from awareness are the determinants of the problem and the more
historically remote and more interrelated the problem is with the sense of
self. Thus, we often predict that the “deeper” the level that needs to be
changed, the longer and more complex therapy is likely to be and the
greater the resistance of the client (Prochaska & DiClemente, 1984).
These levels, it should be emphasized, are not independent: change at any
one level is likely to produce change at other levels. Symptoms often
involve intrapersonal conflicts, and maladaptive cognitions often reflect
family/system beliefs or rules. In the transtheoretical approach, the
complete therapist is prepared to intervene at any of the five levels of
change, although the preference is to begin at the highest, most
contemporary level that clinical assessment and judgment can justify.

Integrating Levels, Stages, and Processes

In summary, the transtheoretical approach sees therapeutic integration as the
differential application of the processes of change at specific stages of
change according to identified problem level. Integrating the levels with the
stages and processes of change provides a model for intervening
hierarchically and systematically across a broad range of therapeutic
content. Table 8.2 presents an overview of the integration of levels, stages,
and processes of change.
TABLE 8.2 Interaction of levels, stages, and processes of change

Three basic strategies can be employed for intervening across multiple

levels of change. The first is a shifting levels strategy. Therapy would
typically focus first on the client’s symptoms and the situations supporting
those symptoms. If processes could be applied effectively at this level and
the client could progress through each stage of change, treatment could be
completed without shifting to a more complex level of analysis. If this focus
proved ineffective or incomplete, therapy should shift to other levels in
sequence to achieve desired change. Table 8.2 illustrates the strategy of
shifting from a higher to a deeper level by the arrows moving first across
one level and then down to the next level.
The second strategy is the key level strategy. If clinical assessment points
to one key level of causality and the client can effectively be engaged at that
level, the therapist could work almost exclusively at that level. The key
level may also represent the problem area where the client has the most
motivation or is in the most active stage of change.
The third alternative is the maximum impact strategy. With many
complex cases, it is evident that multiple levels are involved as a cause, an
effect, or a maintainer of the client’s problems. Interventions in these cases
need to address multiple levels of change in order to establish a maximum
impact for change in a synergistic rather than a sequential manner.
TABLE 8.3 Integration of psychotherapy systems within the transtheoretical framework
Stages
Levels Precontemplation Contemplation Preparation Action Maintenance
Symptom/situational Motivational Solution-focused Behavior therapy
interviewing
Exposure therapy
Maladaptive cognitions Adlerian therapy Third-wave Therapies Rational emotive
therapy
Cognitive therapy
Interpersonal therapy Sullivanian Interpersonal
conflicts therapy
Transactional analysis
Family/ systems Strategic therapy Bowenian Structural therapy
conflicts therapy
Intrapersonal conflicts Psychoanalytic Gestalt therapy
therapies
Existential Dialectic behavior therapy
therapy

Each system of psychotherapy has distinctive strengths within the

transtheoretical model. Table 8.3 illustrates where leading systems of
therapy fit best within the integrative framework of the transtheoretical
approach. Depending on the patient’s level and stage of change, different
therapy systems will play a more or less prominent role. Behavior therapy,
for example, has developed specific interventions at the
symptom/situational level for clients who are ready for action. At the
maladaptive cognition level, however, Ellis’s rational-emotive therapy and
Beck’s cognitive therapy are most prominent for clients in the
contemplation and action stages.
We have not excluded any therapy systems from the transtheoretical
approach. Our approach is an open framework that allows for integration of
new and innovative interventions, as well as the inclusion of existing
therapy systems that either research findings or clinical experience suggest
are most helpful for clients in particular stages at particular levels of change
(DiClemente, 2018).

ASSESSMENT AND FORMULATION

Accurate assessments of the clients’ stage, level, and processes of change
are crucial to the transtheoretical approach. Therapy should prove most
effective if patient and therapist are matched and working at the same stage
and level of change. The joining of the patient and therapist is centered
around the structure and process of intentional change. The therapist’s role
is one of maximizing self-change efforts by facilitating neglected processes,
de-emphasizing overused processes, correcting inappropriately applied
processes, teaching new processes, and redirecting change efforts to the
appropriate stages and levels of change.
Clinical assessment of the stages, levels, and processes requires a specific
focus within the clinical interview. Knowledge of both the attitudes and
intentions toward a change, as well as the actions taken about it, are needed
for accurately assessing the stages of change. It is important to know that an
individual stopped drinking 1 week ago when his partner left him.
However, equally important is knowing whether this is the first step in
taking significant action toward intentional change of his drinking or an
attempt to change his partner’s behavior. Another method of assessing the
current stage of change is to evaluate how adequately an individual
accomplished the tasks of any prior stage of change. If someone has
contemplated changing only casually or briefly, for example, then that
person often would not have made a decision strong enough to support the
commitment and plan needed to take action.
Assessment of the levels of change requires a clinical interview that
addresses each of the levels. In a case of vaginismus, we must know the
symptomatic expression and situational determinants of the sexual
dysfunction but should also explore explicit and implicit thoughts, the
couple’s interpersonal functioning, family system involvement, and any
possible intrapersonal conflicts regarding identity, self-esteem, and so on. In
this assessment, it is important to establish at which level or levels the
patient perceives the problem, as well as the levels that the clinician
assesses are integrally involved in the problem. For one couple it could be
related to a religious or moral belief, for another an issue of interpersonal
control or anger, and for another a physiological anxiety symptom.
Evaluating the processes of change being employed by the patient can be
a rather extensive task. Therapists should explore what the patient is
currently doing about the problem, how often these activities are occurring,
and what has been done in the past in attempts to overcome the problem.
An obsessive patient may be relying heavily on consciousness-raising as the
most important process while neglecting more action-oriented processes.
In our research, we developed assessment instruments to evaluate the
stages, levels, and processes of change. The University of Rhode Island
Change Assessment Scale (URICA), or Stages of Change Questionnaire, is
a 32-item questionnaire with four scores: precontemplation, contemplation,
action, and maintenance (DiClemente & Hughes, 1990).
Several forms of a questionnaire to assess the processes of change have
also been developed (www.uri.edu/cprc; www.umbc.edu/psyc/habits). The
questionnaires typically contain two to four questions about activities that
would represent each of the processes, and clients are asked to indicate how
frequently each activity occurs. Because change processes differ somewhat
for diverse problems, we have adapted this format to a variety of problems,
such as alcoholism, overeating, depression, and exercise. These
questionnaires have shown robust consistency across problem areas
(Prochaska & DiClemente, 1986), and principal component analyses have
yielded 10 or more consistent components in their use with both clients and
therapists. Processes of Change Scales can be used to assess change
processes before, during, and after therapy to examine how therapy
interventions affect utilization of processes (Prochaska & DiClemente,
1985). Change process activity has been found to relate to therapist
theoretical orientation (Prochaska & Norcross, 1983) and client activity in
the various stages of change (DiClemente & Hughes, 1990; Snow et al.,
1992; Tejero et al., 1997) and to be predictive of successful movement
through the stages of change (Carbonari & DiClemente, 2000).
The Level of Attribution and Change (LAC) Scale contains four or more
questions representing each of the five levels of change used in the
transtheoretical model. In addition, five other levels are assessed because
people do not attribute their problems only to psychosocial sources.
Individuals often blame bad genes, bad luck, or bad karma for their inability
to change. Other levels of attribution include spiritual determinism,
biological determinants, insufficient effort, and preferred lifestyle (Norcross
et al., 1984,1985; Norcross & Magaletta, 1990; Penny, 1987).

APPLICABILITY AND STRUCTURE

The transtheoretical model applies to all clinical problems of psychological
origin as well as to many health problems that require behavior change
(Marcus et al., 1992; Prochaska, Norcross et al., 1992). Thus, the approach
is applicable to psychopathology and health-related problems. In addition,
the framework can categorize treatment delivery systems according to the
types of clients and problems they primarily address.
Because we often intervene first at the symptom/situational level, the
transtheoretical approach can be used in both a short-term and a long-term
format. Ideally, length of therapy, setting, and modality will be determined
more by the stage of change, level of problem involvement, and type of
change processes employed rather than a predetermined set on the part of
the therapist. A family intervention that brings family members together to
make an effective intervention with the patient can be used for an alcohol-
dependent individual in precontemplation. Individual and couples therapy
can work through contemplation and achieve effective action when working
with sexual dysfunctions. Group therapy can be tailored to patients in all
stages of change (Velasquez et al., 2015).
Because the transtheoretical approach concentrates on intentional change,
contraindications are settings or problems where intentional change is not
the primary goal. In a correctional setting or in managing the self-
destructive behavior of a child, control, not intentional change, may be the
primary goal. However, external behavioral control appears to be the
treatment of choice using the processes of contingency control and stimulus
control. Once the immediate threat to self or others has been managed,
therapists can bring the problem behaviors under intentional self-control
rather than external control. In fact, this should be an important secondary
goal if treatment or incarceration goals are to be maintained after the
individual is released into the community.
In working with intentional change, the transtheoretical approach is quite
compatible with the traditional structure of psychotherapy (Connors et al.,
2013). Weekly, hour-long sessions can implement the treatment process.
Because we envision psychotherapy as an adjunct to self-change, what
occurs between therapy sessions is as important as what happens within
therapy sessions. A longer, more intense therapy session with the inclusion
of significant others may be needed for an individual in precontemplation to
overcome defenses. Less frequent sessions can be used for individuals in
contemplation and maintenance. For the former, more time between
sessions can allow clients time to use the processes of consciousness-raising
and self-reevaluation in the service of decision-making. For the latter, time
between sessions can be used to monitor temptation levels and encounter
any obstacles to continued action or maintenance that occur less frequently.
Thus, in effect, therapy sessions become booster sessions.
The goal of our clinical and research work is to identify the variables
most effective in helping clients move through the stages of change
regarding a particular problem. In this context, treatment selection is too
generic a term. In the best spirit of using case formulation, we identify
which tasks of a particular stage need to be addressed and which processes
will prove most effective in helping an individual move from one stage to
the next. The decision to engage a particular process is multiply determined.
Rather than stating a priori that counterconditioning (e.g., exposure,
cognitive therapy, behavioral activation) is the treatment of choice for
phobic or depressive problems, we prefer to analyze first the stages and
levels of change before making prescriptive matches.
We realize that this approach places a sizable burden on the therapist.
However, simplicity can be a source of mediocrity and confusion. We have
found, for example, that insufficient use of consciousness raising in the
contemplation stage forces individuals to rely excessively on self-liberation
or will power in their efforts to change and leads to what Janis and Mann
(1977) have called post-decisional regret. The overuse of self-reevaluation
during maintenance and while abstinent, on the other hand, is predictive of
relapse (DiClemente & Prochaska, 1985). Thus, matching patients with
change processes requires both a general knowledge of the stages,
processes, and levels of change as well as specific information about
individual clients and what they have been using, underusing, or overusing
to effect changes in their lives.
Although stage matching is a complex process, mismatches are readily
apparent. A therapist committed to consciousness raising and exploration of
all the levels of change prior to taking action may frustrate a client ready to
take action at the symptomatic level. An action-oriented therapist may be
constantly disappointed by clients in precontemplation who drop out
quickly or fail to implement suggested behavioral techniques. A family
therapist insisting that change take place at the family systems level with
the whole family present may be unable to engage a system with a key
member in precontemplation.
Treatment matching should be to the process of change and not simply to
the problem being addressed. From our perspective, the problem with using
a more medical model in psychotherapy is that it focuses on diagnosis and
cure rather than process and intentional change. Even with most physical
health problems and chronic conditions that require health behavior
modification, the medical model has proved problematic. Medication
compliance, diet control, and exercise all require intentional change and are
not simply solved with a prescription or advice. Disorder is an important
concept for developing a taxonomy that enables us to bring together certain
symptoms and syndromes for classification. Although this information is
valuable in understanding a problem, knowledge of a disorder by itself has
limited value in prescribing therapy interventions when intentional behavior
change is an important part of the remedy (Consoli & Beutler, Chapter 7,
this volume).

THERAPY RELATIONSHIP
Although psychotherapists have not struggled with all the problems faced
by their clients, all therapists have experience with the processes of change.
This is the common experiential ground that forms the basis of the
relationship between therapist and client. In general, the therapist is the
expert on change—not in having all the answers, but in being aware of the
crucial dimensions of change and offering assistance. Clients have potential
resources as self-changers that must be actualized to effect a change. In fact,
clients shoulder much of the burden of change and look to the therapist for
consultation on how to conceptualize the problem and on methods to free
themselves to move from one stage to another.
As with any interactive endeavor, rapport must be built to accomplish the
work. However, the type of relationship will vary with the stage and level of
change being addressed. Initiation of therapy with a precontemplation
client, for example, takes on a different flavor. A client’s unwillingness to
see or own a problem is not viewed as resisting the therapist or being
uncooperative but as resisting change and preserving autonomy. Therapists
must become aware of how frightening and anxiety-provoking the prospect
of change can be. With this shift in perspective, the therapist can take on the
role of a concerned advisor or nurturing parent who can help the individual
explore the problem (DiClemente, 1991). The therapist becomes an ally
rather than another person attempting to coerce change.
For a person contemplating change, the therapist takes care not to be too
impatient. Contemplation can be a lengthy, frustrating stage—not only for
the patient, but also for the therapist. Although therapists should not support
chronic contemplation, they must tolerate ambivalence and avoid blame,
guilt, and premature action. To decide to change, patients must see that
change is possible and in their own best interests. The therapist, like a
Socratic teacher, can challenge clients by making explicit the pros and cons
of both the problem behavior and the change. Support, understanding,
compassion, and a relationship that enables the therapist to make explicit
the hopes, fears, and concerns of the client are needed during this time.
During the action stage, the therapist assumes a more formal teaching
and coaching relationship. During these stages, the client is likely to
idealize the therapist. When initiating action, the client needs the support of
a helping relationship and may need to lean on the confidence of the
therapist rather than a self-generated sense of efficacy. Initial efforts are
likely to be tentative, and seeing the therapist as a change expert can prove
comforting. However, as soon as is feasible, it is important for the client to
develop more self-confidence and independence. For therapists who need to
be needed, this can pose a difficult problem.
In the maintenance stage, the therapist becomes an occasional consultant
—preventing relapse, consolidating gains, and identifying potential trouble
spots. Letting go, saying goodbye, and helping the client assume ownership
of the change are the final tasks of the therapy relationship.

PROCESSES OF CHANGE
As already noted, the transtheoretical approach identified the processes that
are most effective in producing change at different stages. The mechanisms
that move someone from precontemplation to contemplation are different
from the processes that move someone from preparation to action
(Velasquez et al., 2015).
 The important issue here is that intentional change, such as occurs in
psychotherapy, is only one type of change that can move people.
Developmental and environmental changes can also cause people to alter
their lives. However, imposed change often is not sustained (Stotts et al.,
1996). The transtheoretical approach focuses primarily on facilitating
intentional change, but it recognizes and, at times, relies on other types of
change when working with clients. We assume, however, that unless
developmental or environmental changes produce intentional change as
well, clients can feel coerced by forces not of their choosing and will likely
revert to previous patterns once the coercion is removed.

DIVERSITY CONSIDERATIONS
Intentional change is a universal human phenomenon, and the concepts and
approaches described in this chapter have been translated and are being
used in a wide range of countries and cultures. Researchers and
practitioners from around the world—including Britain, Brazil, France,
Poland, South Korea, Australia, India, New Zealand, the Philippines, China,
Mexico, and Japan—have found these concepts useful, which supports
focusing on process and not simply problems.
At the same time, it is important to consider cultural diversity for clients
of historically marginalized backgrounds related to sex, gender, ethnicity,
race, poverty, education, and heritage when using this approach. Here are
some examples and suggestions for incorporating diversity into the
application of the transtheoretical model.
1. Empowerment, resilience, and taking responsibility are important elements of the process of
change and represent values of a more individualistic culture. In more collectivist cultures,
processes and tasks may have to be broadened to include involvement of family and community.
Conversations about change will include cultural considerations and understanding how the
cultural context will impact the process as well as the problem.
2. The process of change requires cultural humility. Pros and cons, emotional experiences, and
values that move individuals through precontemplation and contemplation are culturally
influenced and must be respected. Action plans and coping activities also need to be acceptable
and accessible to clients and may need to be adapted (reinforcement, counterconditioning).
Some emotional and re-evaluation processes may need to be adapted to include different
experiences and values.
3. Racism, poverty, stigma, and ethnic alienation create unique barriers to engaging in the process
of change. Often, these forces keep people in precontemplation and contemplation, making it
difficult to see the pros of change. These systemic forces also tend to promote coercive rather
than intentional change, thus further undermining choice and the ability to move through the
intentional process of change.
4. Poverty, lack of education, and lack of opportunity create a maelstrom of problems that
overwhelm the capacity of the client to address change effectively. Lack of resources and
multiple problems interfere with contemplation and preparation activities and make it difficult
for individuals to use processes of change. Multiple problems overwhelm the self-regulation
system needed to accomplish tasks of the stages. These individuals tend to be reactive and not
proactive and are often labeled unmotivated rather than overwhelmed. These clients will require
structural and well as relational support.
5. Beliefs systems in cultures and subcultures about sex, gender, and race influence the
opportunities for change and can limit the capacity of individuals in these cultures to make
change decisions that go against the cultural norms. Therapists must proceed cautiously in
imposing views about change that are not cognizant of cultural views.

Behavioral change described in this chapter can be used to understand

change at an individual as well as a system level. Culture can constrain and
can liberate the potential for intentional change. As with all issues of
diversity, understanding the individual, the context, and the culture as
experienced by that individual is the only certain way to address differences
and diversity competently and to support empowerment and resilience.

CASE EXAMPLE

By its very nature, an integrative therapy cannot be illustrated by a single

case. Rather, it would take a series of cases to reflect the full range of
stages, levels, and processes of change used with a diversity of patients.
Thus, if the reader were looking over the shoulder of a transtheoretical
therapist, the therapist’s interventions would vary tremendously depending
on the needs of specific clients. Nevertheless, we will illustrate our
approach through the treatment of a distressed client partially within the
context of couple therapy.
Tom is a 50-year-old white heterosexual school teacher referred for
marital therapy by a mental health colleague who had been working with
Tom’s wife, Barbara, in individual therapy for about a year. Barbara’s
therapist did not believe that Tom would stay in treatment for more than
three sessions, even though he was quite distressed and needed individual
therapy. Tom agreed to go to therapy only if they went as a couple.
Tom and Barbara were seen together in the first session to assess their
problems and ability to work together at the interpersonal level. The first
problem at hand in this case was Tom’s resistance to therapy. Addressing
the problem directly communicates that the therapist cares about the client’s
concerns and that the client need not be defensive. It also communicates the
therapist’s hope that there may be something to make it easier for the client
to become a more willing participant. Many spouses have said that partners
would never come to therapy or stay. And yet we have found that almost all
reluctant partners will come in for at least one session if the therapist asked,
and most would continue.

Tom: I don’t believe therapy is worthwhile. My wife has been going to

therapy for a year, and she’s still always lying and spending money like it’s
going out of style.
Therapist: Sounds like you might be angry at her therapist.
Tom: You’re damn right! He just feeds into her wasting money.
Therapist: Have you let him know you’re angry?
Tom: No, he doesn’t want to talk to me.
Therapist: Would you like me to let him know you’re angry?
Tom: Yeah, I would appreciate that.

So, we’re off and running. Tom’s resistance is being addressed, and he
does not have to be defensive about his defensiveness. He may learn to
experience the therapist as someone who cares about his defensiveness and
is trying to understand it. He may, to his surprise, experience the therapist
as being helpful in dealing both with his resistance and with his anger.
At the same time, the therapist has to be concerned with Barbara
experiencing the therapist as Tom’s ally. The therapist could have addressed
Tom’s anger toward his wife for what he labels “lying and wasting money.”
But this would have risked putting Barbara on the defensive, and, if she
counterattacked, the couple could slip into the blame game.

Therapist:
It must be hard to have your husband accusing you of lying and
wasting money.

I knew I was still risking the blame game but I felt that I wanted to
empathize with her as well as with Tom. I also wanted to communicate that
I appreciated that there are two sides to every marital conflict, and her
perspective was as consequential as Tom’s.
These opening segments indicate that transtheoretical treatment usually
begins immediately. There usually is not a formal assessment period,
although assessment occurs right from the start. In the course of the first
two sessions, the following information was shared. Tom’s mood was
usually depressed, he couldn’t relax, had trouble sleeping, was irritable and
often verbally abusive, felt lousy about himself, and was having trouble
relating to his students, his colleagues, and the customers that sought his
services in his after-school job. Tom’s distress increased whenever he
approached Barbara to be sexual and she refused.
Barbara was incensed with Tom. She was angry about his constant
accusations about her lying, spending money behind his back, and having
affairs when she went out on Friday night with her female friends. He
would check the phone bill to see whom she had been calling, open her mail
to see what money she owed, and sometimes follow her to see if she was
seeing other men. How could she want to make love when they were in a
game of “cops and robbers?” Tom coerced her into having intercourse a
couple of times, and she resented it.
Barbara also resented Tom’s preoccupation with money. If he wasn’t
preoccupied about her spending money, then he was preoccupied with his
compulsive gambling. Tom denied that his gambling was a problem.
From the transtheoretical perspective, it appeared that Tom was in
precontemplation about most of his problems. The exception was his
gambling, which Tom had changed on his own to relatively controlled
gambling. Barbara, on the other hand, had been contemplating changes in
her marriage for the past year in psychotherapy that most likely would be
divorce.
Few couples present asking for divorce therapy. Assessing whether a
couple is likely to be a divorce case rather than a marital case can make a
considerable difference in therapeutic approach and outcomes. Elsewhere,
we present in detail the subtle and not so subtle signs of impending divorce
that we use to assess a couple’s case (Prochaska & DiClemente, 1984).
In the current case, obvious signs included the fact that Barbara had been
contemplating divorce for some time and told some of her family and
friends. When people go public, they are moving closer to action. Barbara
had also lost excess weight and engaged in other self-improvement
activities, often a preparatory action when heading for divorce. Barbara had
also been in individual treatment for a year working on increased
independence and autonomy.
Tom, on the other hand, was psychologically distressed. He had not been
contemplating divorce, although he knew that Barbara was. On the contrary,
he was obsessed with trying to control Barbara’s actions to prevent losing
her. Tom was resistant to change and distressed by the prospect of having
the drastic change of divorce imposed on him. Imposition of change/the
loss of control is one of the most common causes of psychological distress.
Psychological distress caused by imposed change is likely to lead to
people resisting change (DiClemente, 2018) since change is experienced as
a threat, not an opportunity, and people may dig more deeply into
precontemplation. Moreover, as they become cognitively impaired by
distress, they have trouble contemplating change, making decisions, and
taking action, even action that could lead to self-enhancement (Mellinger et
al., 1983).
What to do with spouses in different stages of change, which is common
in couple therapy? What do we do when we have spouses in different stages
for divorce, which is even more common in divorce therapy (DiClemente &
Wiprovnick, 2017)? The most common pattern is one spouse in
precontemplation and one ready for action, like Tom and Barbara. When we
are treating psychological distress precipitated by an impending and
imposed divorce, we need to slow down the spouse who is ready for action
and speed up the spouse who is resisting change. Barbara was willing to
spend some time trying to resolve their interpersonal problems. The
therapist made it clear that they were going to work at the interpersonal
level to improve their relationship whether they stayed together or got
divorced. Either way, they were going to have a relationship because they
shared two lovely daughters.
The couple needed to become more conscious of the interactive nature of
their conflicts. The therapist presented feedback based on his assessment of
what was transpiring at the interpersonal level. Tom and Barbara agreed that
their struggles over control produced the most conflict. Tom’s actions
appeared to be based on his intention to keep the marriage going and was
based on values of closeness and togetherness. Barbara, on the other hand,
had developed an increased need for independence; her actions were based
on values of individuality and separateness. The problem was that, in a
vicious cycle, the more Tom tried to control their being together, the more
Barbara felt a need to be apart. Barbara agreed. Conversely, the more
Barbara pulled apart, the more Tom felt the need to control her to keep them
together. Tom agreed. The needs and values that Tom was expressing set off
opposite needs and values in Barbara.
The blame game rests on our preference for linear causality—one partner
acts, and the other partner reacts. Circular causality, on the other hand, can
help couples appreciate that they both act and react—that their behavior is
both a cause and an effect of their ongoing relationship (cf. Wachtel &
Gagnon, Chapter 9, this volume).
Tom and Barbara became more conscious of how they personally
contributed to their control struggles. They were also re-evaluating their
partner’s behavior to some extent. Togetherness is more positive than
dependence. Separateness is something different from selfishness. With the
help of the therapist’s mini-lectures based on his experience with family life
education (Prochaska & Prochaska, 1982), Tom and Barbara became aware
that a more mature relationship includes both togetherness and
separateness. They were taught that individuals mature in their relationships
from dependence to independence to interdependence, which is the caring
and sharing of two independent individuals.
As they moved into preparation, the therapist recommended that Tom be
in charge of separate activities and Barbara be in control of shared
activities. Tom was going to liberate himself from a vicious circle by acting
more like Barbara and vice versa. The longer they could continue such
reversal of roles, the more they would condition themselves to respond with
new alternatives.
This plan worked for a while. Tom took charge of recording on the
calendar Barbara’s nights out with her friends and his golfing dates. Barbara
recorded their dates together on the calendar and was in charge of initiating
shared activities. They were communicating better and feeling better. Tom’s
chief complaint was that Barbara was not initiating sex.
Because they were doing better, the therapist recommended that gradual
involvement in sexual relating could help them overcome anxieties about
sexual performance. They had been avoiding sex for quite a while, and the
initial steps of sensate focusing (Masters & Johnson, 1970) might give
Barbara, in particular, a chance to deal with her feelings about gradually
getting close again. They agreed with the idea that they would start with
light massage.
Tom came alone to the next session. “Barbara is not coming back again.
She said she knows she just wants out of the relationship.” The therapist
probably had made a mistake in too quickly encouraging them to move to
action in their sexual relationship. After the session, the therapist called
Barbara, expressed his concern that he might have made a mistake, and
inquired if she would be willing to come in to talk about how she was
feeling.
Barbara came in for a couple of sessions. She said that the only thing the
therapist’s recommendation had done was force her to realize that she did
not want to be close to Tom anymore. The fact that their relationship had
improved made her even more aware that she did not feel the same about
him. She was concerned that Tom would not handle a divorce, but she
wanted out.
Tom was distressed but not devastated. Fortunately, psychotherapy had
become a place where he could be open about his feelings. He was not
alone as he had feared. He allowed himself to relive the memories of losing
his first love as a young man. He had felt more rejected then than he felt
now. He had so many regrets about not having tried harder in that
relationship. But this time he had been trying. Back then, he withdrew from
everyone. He stayed in his room. He wasn’t able to eat. He couldn’t work.
No wonder he avoided contemplating divorce with Barbara. He never,
ever wanted to go through such emotional hell again. He thought he could
not handle another rejection, but now realized that he did not have to go
through it alone this time. Not only was therapy available, but he had other
helping relationships. Now, Tom could talk more openly and rely on the
social supports in his natural environment.
Tom was making many self-changes after 22 therapy sessions but was
puzzled by his reluctance to move out and get a place of his own. He told
himself that it was because he wanted to be close to his daughters, but he
knew he was really afraid that Barbara might turn them against him. He
also realized that he was still concerned about money and did not want to
spend the money on an apartment. Furthermore, staying in the house was a
safe way of expressing his resentment at Barbara for rejecting him. At a
deeper level, Tom became aware that leaving his home stirred up painful
feelings about when he had to leave his family of origin’s home. And, at an
intrapersonal level, Tom became aware that he did have unresolved
dependency problems. He had, for example, never lived alone.
The therapist helped Tom to appreciate that moving out and living on his
own was a maximum impact action that could facilitate further progress at
each level of his life. At a situational level, Tom would be moving into a
new environment that would reflect the new era of his life, free from all the
reminders that elicited so many painful thoughts and feelings. At a
cognitive level, Tom would be challenging his catastrophizing tendencies
that added to his distress, such as his belief that it was awful that he was the
one to have to move when he did not want the divorce in the first place.
At the interpersonal level, Tom could let go of his desire to control his
relationship with Barbara. As long as Barbara wanted him out and he
refused to leave, Tom felt in control. But he could let go of this need to
control and accept that Barbara was getting the house. At the family level,
Tom was tempted to move back with his parents. Moving on his own,
however, would enable Tom to separate further from his parents without
rejection or resentment. And, at the intrapersonal level, Tom could
experience himself as becoming more fully adult. He would be moving
beyond dependence to independence.
After a couple of months of encouragement in therapy and additional
harassment at home, Tom was ready to leave the nest. This was a major
move in his life. Moving out was transformative. Tom felt more fully
connected to life than he had ever known. For the first time in his life he
began to appreciate activities like concerts and plays. He asserted himself
and found women responding rather than rejecting. Certainly, he felt lonely
at times, but never alone. He even felt a spiritual awakening.
Tom made a remarkable transformation from a distressed and defensive
individual preoccupied with a small portion of his existence to a growth-
oriented person functioning more freely and fully at each level of life. What
process or processes account for such rewarding changes? First, Tom had
been facing turning 50 and had the benefit of developmental changes urging
him to a new stage of life. Second, he faced dramatic but distressing
environmental changes being imposed upon him. Third, psychotherapy had
helped Tom shift from a resentful and resistant position in precontemplation
to becoming more conscious of and committed to the self-liberating
qualities of intentional change. The last time the therapist talked to Tom, not
only was he doing well with his woman friend, his family, his daughters, his
friends, and himself; he also won $750 in the lottery two weeks in a row.

OUTCOME RESEARCH
One influential line of research has examined the stages and processes of
change in substance abuse treatment. Patients entering alcohol and
substance abuse treatment have different profiles on the stages of change
(Carney & Kivlahan, 1995; DiClemente & Hughes, 1990; Heather et al.,
1993). Using a motivational readiness score based on the stages of change
scales, Project MATCH investigators found that baseline readiness scores
were one of the strongest predictors of posttreatment drinking outcomes for
the 952 outpatients in this large multisite alcoholism treatment matching
trial (DiClemente et al., 2003; Project MATCH, 1997, 1998). Baseline stage
predicted outcomes when treatment type did not (DiClemente et al., 2001).
Client motivation at baseline also related to how individuals engaged with
the therapist (working alliance) and how active they were in using the
processes of change and other external resources to modify their drinking
(DiClemente et al., 2003). Finally, post-treatment stage and process of
change activities during treatment, particularly behavioral process activity,
predicted drinking outcomes (Carbonari & DiClemente, 2000; Heather &
McCambridge, 2013). Results indicate that outcomes are probably due
more to what clients do than what therapists do (DiClemente et al., 2003).
During the past 25 years, we have conducted a series of clinical trials on
the effectiveness of the transtheoretical model. In our first clinical trial, we
randomly assigned 770 smokers in Rhode Island by stage to one of four
treatment conditions: standardized, individualized, interactive, and
personalized (Prochaska et al., 1993). The standardized treatment used the
best self-help program available, the American Lung Association’s (ALA’s)
action and maintenance manuals. The self-help manuals were
individualized to the stage of change. The interactive condition (ITT)
involved computer-generated progress reports with feedback about stage of
change; decisional balance measures regarding quitting smoking (Velicer et
al., 1985); up to six processes of change that were being underutilized,
overutilized, or utilized appropriately (Prochaska et al., 1988) temptations
and self-efficacy across the most important smoking situations (Velicer et
al., 1990); and techniques for coping with specific situations. The
personalized condition (PITT) included the stage-based manuals, computer
reports, and four proactive counselor calls. Except for one call, counselors
had the computer reports to counsel clients about changes they were making
on key process variables.
The results were revealing. The two manual conditions replicated each
other through the 12-month follow-up. At the 18-month follow-up,
however, the individualized transtheoretical manuals (18.5% abstained)
were performing better than the standardized (ALA) manuals (11%). The
interactive computer reports outperformed both manual conditions at each
of the four follow-ups, producing more than twice as much quitting at each
follow-up than the gold standard ALA manual (e.g., 25.2% vs. 11% at 18
months). The personalized counselor calls doubled the quit rates of the two
manual conditions up to the 12-month follow-up. By the 18-month follow-
up, effects from the PITT condition appeared to have plateaued (18%) and
only outperformed the ALA manuals, whereas the transtheoretical manual
condition seemed to have caught up with the counselor call condition.
These results suggest that interactive computer feedback on stage-
matched variables can outperform the best self-help program currently
available. Providing smokers interactive feedback about their stages of
change, decisional balance, processes of change, self-efficacy, and
temptation levels in crucial smoking situations can produce greater success
than just providing the best self-help manuals currently available.
The next controlled trial demonstrated the efficacy of the expert system
applied to an entire population recruited proactively. With more than 80%
of 5,170 smokers participating and fewer than 20% in the preparation stage,
we demonstrated significant benefit of the expert system at each 6-month
follow-up (Prochaska et al., 2001). Furthermore, advantages over proactive
assessment alone increased at each follow-up for the full 2 years assessed.
The implications here are that expert system interventions in a population
can continue to demonstrate benefits long after the intervention has ended.
In more recent research, we have been enhancing our expert system to
produce even better outcomes. In one trial, we added a personal handheld
computer designed to bring the behavior under stimulus control (Prochaska
et al., 2001) in a population of smokers in a health maintenance
organization (HMO). This innovation was an action-oriented intervention
that did not enhance our expert system program on a population basis. In
fact, our expert system alone was twice as effective as the system plus the
enhancement. There are two major implications: (1) more is not necessarily
better, and (2) providing interventions mismatched to stage can make
outcomes markedly worse.
These results also support our assumption that the most powerful
behavior change programs for entire populations will be interactive (Velicer
et al., 1999). In the reactive clinical literature, interactive interventions like
behavioral counseling produce greater long-term abstinence rates (20–30%)
than do noninteractive ones such as self-help manuals (10–20%). Providing
assessment-driven interactive interventions via computers is likely to
produce greater outcomes than relying on noninteractive communications,
such as newsletters, media, or self-help manuals.
We next extended the stage-matched expert systems to treatments for
populations with alternative problems, like psychological stress. With a
national sample suffering from stress symptoms, we recruited more than
70% (N = 1,085) to a single behavior change program (Evers et al., 2006).
The transtheoretical program involved assessments on each of the
constructs to derive three expert system–tailored communications for 6
months and a stage-based self-help manual. At the 18-month follow-up, the
transtheoretical program group had more than 60% of the at-risk sample
reaching action or maintenance in terms of stress reduction compared to
42% for the control group. This outcome was maintained during the next 12
months.
Finally, we offer some studies that focus on the effectiveness of
transtheoretical therapy for mental health disorders. Primary care patients
experiencing major depression or subclinical depression and not receiving
treatment (n = 480) and those nonadherent with antidepressant medications
were randomized to receive transtheoretical-based treatment (TTM) or
usual care. TTM condition participants were more likely to have clinically
significant improvement compared to usual care (35% vs. 25%) with an
odds ratio of 1.79. Patients with major depression also had greater
improvement (22% vs. 6%). This depression program received recognition
as an evidence-based practice by Substance Abuse and Mental Health
Services Administration (SAMHSA) (Levesque et al., 2011).
In school-based trials examining TTM-based Internet programs
compared to controls in reducing bullying and violence, the TTM
conditions outperformed the control condition with both middle and high
school youth. There were decreases in the three roles of bully, victim, and
passive bystander, with a 40% decrease compared to 19% in middle school
and 40% compared to 22% in high school youth (Evers et al., 2007).
A meta-analysis of 88 prospective, tailored interventions delivered by
mail or computer across smoking cessation, physical activity, healthy diet,
and mammography screening demonstrated an effect size of d = 0.18 for
TTM-tailored interventions. This represents a 39% increase over
assessment or usual care (Krebs, Prochaska, & Rossi, 2010).
With a population of patients in Canada with diabetes, we proactively
recruited 1,040 patients to a multiple behavior change program for diabetes
self-management (Jones et al., 2001, 2003). With this population, self-
monitoring for blood glucose (SMBG), diet, and smoking were targeted.
Patients were randomly assigned to standard care or TTM. The TTM
program involved monthly contacts that included three assessments, three
expert system reports, three counseling calls, and three newsletters targeted
to the participant’s stage of change. At 12-month assessments, the TTM
group had significantly more patients in action or maintenance for diet
(41% vs. 32%) and for SMBG (38% vs. 25%). With smoking, 25% of the
TTM group were abstinent compared to 15% of usual care. Similar results
were found in a population-based study in Hawaii (Rossi et al., 2002).
We believe that the future of behavior change interventions lies with
stage-matched, proactive, and interactive interventions driven by sensitive
assessments that focus on client stages, processes, and levels of change
(DiClemente, 2018; Heather et al., 2009). Interventions should offer what
the client needs to achieve the tasks of the specific stages and to engage in
critical processes of change. Our research demonstrates that interventions
can promote change in interpersonal settings like therapy as well as in
telephone- and Internet-based programs that include feedback and tailored
interventions. At a population level, interventions generate greater impacts
with proactive programs because of much higher participation rates, even if
efficacy rates are lower. But we also believe that proactive programs
reaching out to individuals in various stages of change can produce
comparable outcomes to traditional reactive programs that wait until clients
request help.

FUTURE DIRECTIONS
The health of our nation and the health of our healthcare systems cannot
wait 25 more years for the dissemination of psychotherapy integration. The
top priority for the transtheoretical approach is the rapid dissemination of
available science and systems. The first problems that are likely to be
treated on a population basis are high-cost conditions, such as depression,
addiction, and stress. Populations with multiple behavior problems are also
high-risk and high-cost and are major candidates for population-based
treatments. We are working with healthcare systems, employees,
governments, and other organizations to bring the most effective and cost-
efficient therapies to these populations.
One clinical strategy that we are studying is a stepped care approach,
where we begin with the least intensive and least costly of treatments, such
as computer-based TTM programs. Participants who are progressing with
these programs would continue with them. Those who are not progressing
would be stepped up to a more intensive treatment, such as telephone
counseling. Those not progressing with this help would then be stepped up
to face-to-face psychotherapy with TTM-trained therapists. Another is to
focus on the self evaluations of individuals related to decision making,
processes of change and self efficacy (Shaw & DiClemente, 2016;
Velasquez et al., 2015).
We also need to test the limits on how many behavior problems can be
treated simultaneously without reducing effectiveness. To date, we have
effectively treated three behaviors on a population basis with no decreased
efficacy but with increased impacts on health and healthcare costs. Even
single behavioral targets, such as smoking, could benefit from multiple
behavior therapies that can treat major barriers to successful cessation, such
as stress, depression, alcohol abuse, and weight gain.
There are hopeful trends that encourage integrated care and precision
medicine in the future. Those trends view patients across differing stages of
change and in need of comprehensive treatments for multiple health
disorders (DiClemente et al., 2016; Prochaska & Prochaska, 2016).
Focusing on the individual’s process of change will empower healthcare
practitioners of all professions and persuasions to provide targeted yet
integrative strategies.

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 9

Cyclical Psychodynamics and Integrative

Relational Psychotherapy
PAUL L. WACHTEL AND GREGORY J. GAGNON

Cyclical psychodynamics is a theoretical approach that seeks to reconcile

the seemingly conflicting formulations of psychoanalytic, cognitive-
behavioral, systemic, and humanistic-experiential orientations. A key
element in this integrative effort is a focus on the vicious and virtuous
circles that are prominent in personality dynamics and development and
that largely account for how early experiences and interpersonal patterns
can be powerfully influential even decades later. Rather than viewing the
residues of these early experiences as fixed and buried “internal”
representations, the cyclical psychodynamic perspective traces the ways in
which the perceptual and motivational schemas that have their origins in
earlier experiences lead to new actions and relational experiences that, often
ironically and unwittingly, end up strengthening those very schemas and
setting the stage for still another repetition of the cycle.
Cyclical psychodynamic theory focuses especially sharply on the
relational events and experiences that constitute the center of most people’s
emotional life and aims to incorporate in a consistent theoretical
formulation both the powerful role of early experiences and the powerful
role of what is happening in the present. The implications of the past must
be understood by the kind of present that past experiences make likely, and
the impact of the present must be understood in terms of the sensitivities,
proclivities, and perceptual tendencies the person brings to the present on
the basis of past experiences (Wachtel, 2014a, 2014c, 2017d).
 This integrative conceptualization highlights both the importance of what
are often called “internal” structures and the equally crucial role of what are
often described as “external” variables. Among the putatively internal
sources of our behavior and experience are the unconscious motivations and
fantasies emphasized by psychoanalytic thinkers (especially as
reconceptualized by D. B. Stern [1997] in terms of unformulated
experiences); the kinds of schemas and cognitive processes variously
conceptualized by Piaget, by cognitive therapists, and by contemporary
cognitive psychology and cognitive neuroscience; and the emotional
schemas and processes emphasized by experiential and interpersonal
therapists. Among the influences often depicted as external or
environmental are discriminative stimuli and reinforcement contingencies,
the immediate relational context of intimate interactions with others, and
the larger social and cultural context (Wachtel, 1999, 2014a, 2017b). From
the vantage point of the cyclical psychodynamic perspective, these past and
present and internal and external influences are seen as different facets of a
larger explanatory web (Wachtel, 2017c).
As the name implies, cyclical psychodynamics, although drawing on
multiple perspectives, has at its core the psychodynamic point of view, into
which it assimilates ideas deriving from other sources. It can, in that sense,
be seen as a clear example of assimilative integration (Messer, 1992;
Stricker & Gold, 1996). In addition to its reworked emphasis on such
traditionally psychoanalytic ideas as unconscious motivation, conflict,
defense, and transference, it draws on interpersonal conceptualizations (e.g.,
Horney, Sullivan), social and cultural explorations (e.g., Fromm and
Erikson), the impact of new relational experience (e.g., Alexander &
French, 1946; Christian, Safran, & Muran, 2012; Frank, 1999; Kohut, 1977,
1984; Weiss & Sampson, 1986), and the emerging relational synthesis in
psychoanalytic thought (e.g., Aron, 1996; Mitchell, 1988, 1993).
Complementing its psychodynamic emphasis, cyclical psychodynamics
includes as well such behavioral and cognitive-behavioral concepts as
reinforcement and exposure. Thus, what psychodynamic clinicians call
“interpretations” can be seen as interventions bringing the person into
contact with thoughts, feelings, and modes of interaction that had been
fearfully avoided, thereby promoting exposure. In this way, these thoughts
and feelings can become less frightening and can be reassimilated into the
person’s evolving sense of self (for more detail on how this perspective
modifies the ways that interpretations are offered and integrated into the
overall therapeutic strategy, see Wachtel, 1997, 2008, 2011a, 2011b).
In cyclical psychodynamics, the distinction between the person’s “inner
world” and his or her “external” reality breaks down, and they are seen as
continually defining and redefining each other in recursive fashion
(Wachtel, 2017c). Behavioral, experiential, and systemic treatment elements
complement the psychoanalytic emphasis on insight, exploration, and
articulation of feelings and desires. Rather than assuming that change will
follow insight rather automatically, cyclical psychodynamics conceptualizes
change as a synergistic process in which new behaviors and feedback
promote new insights, and such insights in turn generate increased
motivation to try new behaviors.

THE INTEGRATIVE APPROACH

In order to avoid awkward locutions and referring to oneself in the third
person when discussing the origins of cyclical psychodynamics, this section
of the chapter, written by PLW, will be in the first-person singular: I was
originally trained in the psychodynamic tradition. My doctoral training at
Yale emphasized psychoanalytic ego psychology, complemented by a
strong dose of Hullian learning theory, as mediated by the work of Dollard
and Miller (1950). My psychoanalytic training, in the New York University
postdoctoral program in psychoanalysis and psychotherapy, combined a
further grounding in classical psychoanalytic theory and ego psychology
with a strong exposure to interpersonal and existential-phenomenological
models. These experiences proved seminal for me; I have remained strongly
interested in and committed to psychoanalytic ideas to this day. Over time,
however, I became increasingly dissatisfied with a number of features of
psychoanalytic thought, which seemed to me both problematic and far less
essential to the psychoanalytic point of view than is commonly assumed.

Overemphasis on Early Experience

One of the most significant sources of dissatisfaction was an excessive
emphasis on very early experiences formulated in a way that made it seem
as if those experiences remained unchanged by later events and
circumstances, preserved in their original form like woolly mammoths
buried under the Arctic ice (see Wachtel, 1997, 2008, 2011b, 2014a). Such
an emphasis leads the therapist to pay insufficient attention to the influence
of ongoing events in the person’s life and, indeed, places theoretical
obstacles to full consideration of such influences. Both daily personal
observation and my reading of the results of empirical research (see later
discussion) persuaded me of the powerful and continuous impact of
ongoing life events. Both our behavior and our experience vary greatly in
different contexts, and a theory that did not fully and readily accommodate
this obvious fact was unnecessarily limited. I sought an alternative that
could retain the important insights and observations deriving from the
psychoanalytic tradition, yet could integrate into its account the important
role of environmental context (Wachtel, 1973).

Overemphasis on Insight
Around the same time, I began to be skeptical that insight was the major
source of therapeutic change, as psychoanalytic accounts of that era
emphasized. The insights patients achieved could too readily remain
abstract and cognitive, and although the distinction between intellectual and
emotional insight reflected an appreciation of this issue, it was conceptually
problematic. Later, as behavior therapy evolved into cognitive behavior
therapy, I became similarly skeptical about its overly cognitive,
intellectualized features as well (Wachtel, 1997). More recently, deriving
from clarifications that first emerged in cognitive psychology and cognitive
neuroscience, I have come to see my initial interest in behavior therapy (in
contrast to the cognitive approach of Beck and Ellis), as part of a broader
shift in emphasis from the declarative/explicit dimension of language and
symbolic thought as the key to therapeutic change to the procedural/implicit
dimension of nonverbal, directly experiential, and “how-to” learning (see,
in this regard, Boston Change Process Study Group, 2010). Relatedly, I
began to view behavioral methods as a means of providing corrective
emotional experiences (cf. Alexander & French, 1946), an important
component of therapeutic change that mainstream psychoanalytic thought
had problematically disparaged.
As behavior therapy evolved into cognitive-behavior therapy, it seemed
to me that this more experiential and procedural way of working that
behavior therapy offered was shunted aside by an excessively rationalistic
approach that at times seemed to treat emotion as a mere epiphenomenon.
Focusing on the half-truth that how we feel about something depends on
how we think about it, this rationalistic viewpoint seemed to virtually
ignore the equally important ways that how we feel about things powerfully
influences how we think about them (cf. Fosha, 2000; Greenberg, 2016). As
I observed videos of the work of behavior therapists from whom I had
learned a great deal in the early years of my integrative efforts, it seemed to
me that, under the sway of this rationalistic philosophy, they were
essentially trying to talk clients out of their feelings, to demonstrate that if
only the client would learn to think “rationally,” there would be no need to
feel distressing emotions.
More recently, as cognitive and cognitive-behavioral therapists have
themselves increasingly articulated differences between “rationalist” and
“constructivist” approaches to cognitive therapy (Arnkoff & Glass, 1992;
Neimeyer, 2009; Neimeyer & Mahoney, 1999; Winter, 2008), I have found
myself increasingly interested in the convergences between the
constructivist branch of cognitive therapy and the relational approaches to
psychoanalysis (Wachtel, 1997, 2008). I have as well been interested in
convergences with “third-wave” cognitive-behavior therapies such as
dialectical behavior therapy (DBT) and acceptance and commitment
therapy (ACT) (Hayes, Follette, & Linehan, 2004) and in the ways that my
initial interest in the more experiential encounters that were part of
behavioral methods such as exposure, behavior rehearsal, and graded
challenges in daily life could be further complemented by the methods of
the humanistic-experiential tradition, especially emotion-focused therapy
(Greenberg, 2016).

Insufficient Exploitation of Freud’s Revised Anxiety Theory

Having been trained at Yale during the days when John Dollard and Neal
Miller were there, I was alerted early to the possibilities of understanding
the observations of Freud and later analysts in ways that differed somewhat
from standard psychoanalytic language and that opened up new
possibilities. In particular, I saw their discussions of extinction of anxiety as
better capturing the implications of Freud’s (1926/1959) late insights into
the role of anxiety in neurosis than did the standard psychoanalytic
literature (Dollard & Miller, 1950).
 Dollard and Miller’s analysis, rooted in psychoanalytic observations as
well as those deriving from the laboratory, suggested that the cues patients
avoided were not limited to external cues of the sort typically emphasized
by behavior therapists. They could include as well what Dollard and Miller
called “response-produced cues”—cues associated with the person’s own
thoughts and affective reactions. In this way, Dollard and Miller forged a
link between the psychoanalytic concept of repression and the avoidances
addressed by behavior therapists. As implied in a related way in Freud’s
notion of signal anxiety, when the individual begins to perceive cues that
are even marginally associated with a thought that has become a source of
anxiety, there is a strong inclination to avoid those cues. Whether described
in terms of “repression” or “defense” in psychoanalytic terminology, in
terms of “selective inattention” in Sullivan’s (1953) terminology, or in
terms of the response of “not-thinking” in Dollard and Miller’s
conceptualization, what is being addressed is a tendency to not notice, to
reinterpret, to change the subject, or in other ways to avoid or attenuate the
experience of the forbidden.
Everything we know about the extinction of anxiety associated with more
overtly observable cues suggests that what is crucial is repeated exposure to
the frightening stimulus in circumstances where the expected harmful
consequence does not occur. Generally, this exposure must occur on many
occasions, and the reduction of anxiety occurs only gradually. Such a
perspective offers a different way of understanding what in the
psychoanalytic literature is referred to as “working through.” It should be
noted, however, that research on the phenomenon of memory
reconsolidation holds out the intriguing possibility that therapeutic
reworking may eventually be more rapid and decisive (Lane et al., 2014).
From the perspective of this integration of psychodynamic and
behavioral viewpoints, one of the key functions of “interpretations” is that
they are comments that either interrupt the person’s way of avoiding cues
associated with the feared thought or feeling (defense interpretations) or, by
stimulating associations and/or saying out loud the thought that can’t be
spoken, increase the likelihood that the patient will begin to be exposed to
the therapeutically relevant cues. It is not enough merely to “see” what you
have blinded yourself to; it is essential to undergo repeated exposures to the
forbidden or frightening experience.
Active Intervention and Attention to the Role of Social Skills
The complex social skills required of every adult in an advanced society
take many years to learn, and their effective learning requires both careful
observation of others and much practice of one’s interactional style. That
much of this observation and practice goes on automatically, without self-
consciousness or even awareness that one is doing such things, does not
diminish its ubiquity or importance. If anxieties make it more comfortable
to avoid certain kinds of experiences early in life, and the countless practice
sessions that life offers are not encountered, there will be an impact on
one’s ability to negotiate the shoals of social interaction.
These and other considerations led me to believe that much more active
intervention into people’s difficulties was both possible and desirable than I
was taught by my psychodynamic teachers. I began to be struck by the
possibilities inherent in the interventions developed by behavior therapists,
whose assumptions did not prevent them from intervening actively. The
cyclical psychodynamic perspective was in large measure a
reconceptualization aimed at enabling these interventions to be employed in
a way that retained the different and equally important strengths of the
psychodynamic approach.

Vicious Circles and the Recursive Dynamics of Personality-in-

Context
Attention to vicious circles originally was a means to reconcile the largely
environmental emphasis of behavior therapy and the predominantly
intrapsychic emphasis of psychoanalysis. Over time, however, both
approaches evolved. Behavior therapy became more cognitive and
mediational, psychoanalysis more relational and contextual. But, as it
turned out, attention to how ways of thinking, feeling, and acting are
maintained by the consequences they generate remained illuminating,
pointing to sequences and interactions that are at the heart of how
personality patterns and clinical problems persist over time (Wachtel, 1994,
2009, 2010b, 2014c, 2017d). As a consequence, it continued to be central to
the effort to create a more comprehensive therapeutic strategy that could
draw on both the distinctive and the overlapping strengths of the separate
orientations that currently dominate clinical practice.
 The key to moving beyond the particular siloed viewpoints that seem to
their proponents to be competing and incompatible was attention to the
largely circular nature of causality in human affairs: the events that have a
causal impact on our behavior are frequently also a function of our behavior
and the impact of that behavior on others. Thus, a therapy grounded in
attention to the subtleties and complexities of emotional experience,
fantasy, perception, cognition, or fearful expectations is not antithetical to a
therapy focused on the relational systems in which the patient participates
(Wachtel & Wachtel, 1986) or in which detailed examination of behaviors
in daily life or the employment of modeling, role-playing, or graduated
opportunities to practice were prominent. Expanding beyond the original
interest in integrating behavioral methods into a therapy grounded in
psychodynamic principles (Wachtel, 1977) and the subsequent efforts to
integrate systemic perspectives and interventions (Wachtel & Wachtel,
1986), more recent explorations have included attention to “third-wave”
cognitive-behavioral approaches (Hayes et al., 2004), methods deriving
from an experiential or emotion-focused perspective (e.g., Greenberg,
2016), attention to processes of rupture and repair in the therapeutic
relationship (Safran, Muran, & Shaker, 2014), and attention to attachment
(Wachtel, 2010b, 2017a; Wallin, 2007).

ASSESSMENT AND FORMULATION

Treatment from a cyclical psychodynamic point of view requires a clear
understanding of the sources of the patient’s problems and the dynamics
that maintain them. The process of assessment and the development of a
formulation that can guide the treatment effort may be more prominent
early in the therapy, but it in fact takes place over the entire course of
treatment as new understandings continue to emerge. The inquiry and the
formulation share many of the features typically found in other approaches
(e.g., inquiry into the frequency, chronicity, and severity of symptoms;
current social support; history of loss and trauma).
We will forgo a discussion of these more general or common dimensions
of assessment and formulation and will instead address those components
that are particular to cyclical psychodynamics; namely, identifying vicious
circles, identifying accomplices, finding strengths as well as weaknesses,
and contextualization. By contextualization, we mean identifying the
circumstances under which a particular problem or way of interacting is
most likely to be manifested and those under which it is less likely. Critical
as well is the clinician’s immersing herself in the patient’s experience in
order to grasp his subjectivity as fully as possible. (For purposes of clarity,
throughout this chapter, when, as in this sentence, “the patient” or “the
therapist” is referred to in general or abstract ways, the therapist will be
referred to as “she” and the patient as “he.”)
During the assessment phase, as throughout therapy, the therapist
searches particularly for indications of thoughts, feelings, perceptions,
memories, hopes, and fears that have been excluded from awareness or
warped and constrained because they have become associated with anxiety,
guilt, or shame. The cyclical psychodynamic formulation of this pattern of
avoidance builds on psychodynamic concepts of defenses and unconscious
conflict. But, in contrast to versions of psychodynamic thought that regard
the aspects of experience that are excluded from awareness as “buried” in
the unconscious, we view them primarily as being dissociated or
unformulated (Stern, 1997) as a result of a self-perpetuating cycle of
avoidance. The very avoidance deprives the patient of opportunities to learn
that the thought or feeling experienced as forbidden in childhood can be
safely integrated into his adult life, especially because the avoidance also
prevents the practicing and sharpening of skills that enable the feeling to be
expressed in appropriate and effective ways.

Identifying Vicious Circles

The vicious circle is a critical psychological unit and a phenomenon often at
the heart of the patient’s problems. Unacknowledged and unintegrated
aspects of the personality remain frightening and subjectively unacceptable
because of the very kinds of real-life experiences their dissociation is likely
to bring about. The vicious circles that underlie the patient’s difficulties
include cognitive, affective, behavioral, and systemic elements, and the
cyclical psychodynamic account integrates these into a single formulation
without privileging any one dimension by assigning it primary causal status.
Instead, the aim is to identify the self-reinforcing pattern that organizes
these diverse elements in order to find points of intervention to break the
cycle.
Identifying Accomplices
Complementing and extending the cyclical psychodynamic focus on
identifying vicious circles, the identification of accomplices—those people
in the patient’s life whose ways of interacting with him end up maintaining
the vicious circles undergirding his experience of distress—is a critical
feature of the formulation (Wachtel, 2011b, 2014a). Much time can be spent
articulating the intrapsychic, cognitive, and affective aspects of the patient’s
difficulties, but it is essential as well to understand how others in the
patient’s life are pulled, often unwittingly, to confirm the expectations that
contribute to perpetuating the problem. Appreciation of the ways in which
the patient’s suffering is not simply a result of “distortions,” but a response
to things that are really happening—though perhaps happening for reasons
that the patient may not understand well—is an essential feature of the
approach. To be sure, there are ways in which the patient’s perception of
events is likely to be idiosyncratic and problematic—perceiving rejection,
say, when it is not intended by the other or anger when it is not there. But
the irony often evident in these vicious circles includes ways in which what
was initially a distortion or misperception becomes, through the dynamics
of mutual interaction, a self-fulfilling prophecy. Much of this process goes
on with little or no awareness, but it is no less powerful for this. Indeed, the
absence of clear awareness is an important element in how the pattern can
be repeated over and over despite its problematic consequences.

Finding Strengths as Well as Weaknesses

Central to our way of understanding and working with patients is an
emphasis on the patient’s strengths and not only his problems.
Understanding the patient’s problems in depth, in a clear-eyed way that
does not shrink from difficult truths and yet does so without pathologizing,
is a central aim, both with individuals (Wachtel, 2011a, 2011b) and with
couples (Wachtel, 2016). In part, this reflects the aim of a fully
comprehensive evaluation—people have strengths as well as weaknesses.
But it reflects, as well, a view that, to promote change effectively, the
patient must be engaged in a collaborative enterprise in which he feels the
therapist is on his side and understands how the world looks through his
eyes. The skills of a good therapist lie significantly in broaching difficult
truths with the patient—whether those be feelings and desires the patient
may initially view with shame or ways in which he has been an active
contributor to the patterns in his life that plague him—in a way that is not
accusatory (Wile, 1984) and that enables him to maintain his self-respect
(Wachtel, 2011b). Without an appreciation for the patient’s potential for
change, for his capacity to develop new ways of being and experiencing,
the therapist will likely encounter difficulty in her efforts to bring about that
change.

Contextualizing Formulations
Parallel to the emphasis on strengths—and often a critical part of it—is
attention to the ways the patient’s behavior and experience can vary from
one context to another. Pathologizing formulations tend to be monolithic—
the patient is narcissistic, angry, avoidant. The cyclical psychodynamic
formulation certainly attends to these phenomena and experiences, but it
also seeks to notice how exceptions to the general tendency can be obscured
by overly broad trait descriptions. When is the “angry” person gentle or
caring? When is the “avoidant” person ready to pick up on a challenge? We
find that almost always those exceptions can be found and that they are a
key element in building toward new ways of living.
The point is not a bland “you’re not so bad, there are good things, too.”
Rather, it is to understand when things are different, in what circumstances
does another side of you show? This helps as well to understand what is
going on when the person does act angrily or timidly or self-centeredly.
Those behaviors and attitudes can then be understood not as a taint but as a
response to experiences one is encountering and ways of construing those
experiences that one has learned. In understanding better what enables the
patient to act more adaptively or feel more confident in some situations than
others, we help break the monolithic perceptions that can plague not only
patients but therapists, too.

APPLICABILITY AND STRUCTURE

Cyclical psychodynamic psychotherapy is typically practiced as a long-term
outpatient treatment although, given the incorporation of active
interventions, treatment may also in some cases be briefer, as in the case
presented later, which lasted about 8 weeks. Rapid change, when it occurs,
is viewed as a desirable consequence of the treatment, rather than as a
“flight into health.” Upon resolution of the problem that brought the patient
to therapy, patient and therapist may explore together whether there are
other issues the patient wishes to address.
Cyclical psychodynamic treatment can be applied to a broad range of
neurotic and characterological difficulties. As in the case example presented
later, it is also applied fairly commonly to a range of symptomatic
complaints, particularly involving anxiety and interpersonal difficulties. It
can be applied alongside psychopharmacological treatment when such
treatment is likely to help the patient to participate more successfully in
breaking the vicious circles in which he is caught. Though most often
applied to individual treatment, the cyclical psychodynamic perspective can
be applied to couple therapy as well (E. F. Wachtel, 2016). Even in an
individual treatment, occasional sessions with a spouse or partner to address
a particular impediment are common, as are occasional sessions, primarily
for the purpose of gaining additional perspective, with other individuals
who play a significant role in the patient’s life (Wachtel & Wachtel, 1986).

THERAPY RELATIONSHIP
In keeping with the findings of a vast quantity of research (see, for example,
Norcross & Lambert, 2018), we view the therapy relationship as a key
element in successful psychotherapy. The impact of the relationship is
viewed from a number of different vantage points, drawing, for example,
from Alexander’s concept of the corrective emotional experience
(Alexander & French, 1946); broader relational reformulations of that
concept (e.g., Aron, 1996; Frank, 1999); the notion of epistemic trust
(Fonagy & Allison, 2014); rupture and repair in the therapeutic alliance
(e.g., Safran et al., 2014); and implicit relational knowing and moments of
meeting (Boston Change Process Study Group, 2010).
In contrast with many approaches that highlight the impact of the
therapeutic relationship, however, the cyclical psychodynamic perspective
equally highlights processes of change occurring outside of the consulting
room or the specific relationship with the therapist (Wachtel, 2008, 2017d).
The relationship is not only a direct source of change-generating
experiences, but is as well a powerful catalyst for promoting experiences
outside the relationship that are critical to change.
Consistent with the differentiated understanding of personality that
highlights the significance of different experiences of self, other,
relationship, and affect in different contexts, it is assumed that some
important features of the patient’s personality are especially well engaged in
the context of the transference but that, in contrast to many psychodynamic
formulations, not all important relationship configurations are engaged in
that context. The therapist, as a specific person rather than a “universal
donor,” will elicit only a portion of the potentially relevant emotional
reactions. Consequently, attention to how other people in the person’s life
elicit different reactions and are implicated in different therapy-relevant
patterns is an important part of the work.

DIVERSITY CONSIDERATIONS
The cyclical psychodynamic perspective applies to people of all
backgrounds. The therapy is not manualized to create a different treatment
package for every potential patient group, but rather relies on a set of
principles that guide the therapeutic work. This reliance on broad principles
and processes of change rather than narrowly specified protocols for each
different group applies as well to work with people of diverse sexual
orientations or ethnic, racial, and class backgrounds.
As a highly contextual approach, cyclical psychodynamics treats
socioeconomic and cultural dimensions of the person’s psychological
makeup as highly relevant in understanding the challenges the patient faces
(see, e.g., Wachtel, 1999, 2014a, 2017b). This is the case whether the
person has considerable wealth and privilege or is disadvantaged by reason
of social inequity. Thus, there is not a separate version of cyclical
psychodynamic therapy for each racial, ethnic, or socioeconomic group, but
rather these dimensions of people’s lives are a central concern of clinical
work with all patients.

CASE EXAMPLE

John N is a quite prominent member of his profession who had, to his great
consternation, never passed the licensing exam. He had taken the exam five
times and had failed each time, despite the fact that his professional stature
was such that his own work was occasionally addressed on the exam.
Although he presented himself as a case of “test anxiety” and informed me
(PLW) of that self-diagnosis in the first session, it quickly became clear that
more was involved. John had grown up in a prominent Boston family and
had been taught by his parents, who were quite demanding and status-
conscious, that he must not only excel but also appear to do so effortlessly.
This was not something that John could say directly at the outset. At first,
I was merely struck by his various efforts to let me know, indirectly but
most assuredly, who it was I was dealing with. He worked very hard at
conveying both his stature in his profession and his social status and
seemed uncomfortable with being in the role of patient. In looking for a
way to inquire into this tendency that did not leave John feeling criticized or
put down (see Wachtel, 2011b; Wile, 1984), I wondered out loud if his
parents had been concerned about status and what the impact on him might
have been. At this, he seemed to experience a good deal of relief and
immediately relaxed some. He said yes, they were like that and it felt very
oppressive to him.
John’s conscious views were much more liberal than those of his parents,
and this added further to his dilemma: he could not readily acknowledge his
concerns about status or appreciate the role those concerns played in his life
because he had struggled hard to disavow them and, as far as he knew, he
had done so. By raising them as his parents’ concerns, I made it possible for
him to begin addressing them while still maintaining his view that he
himself did not endorse them—indeed, while expressing his distaste for
them.
Attempting to open further a path for John’s exploration of attitudes that I
sensed were a crucial part of his difficulties, I added that it must have been
difficult growing up in such an environment not to adopt some of their
views simply in self-defense. With their relentless emphasis on status and
success, it would have been extremely painful not to attend to this himself.
This comment seemed to make it a bit easier for John to look at his own
concerns about status, most likely because it implicitly conveyed that it was
not his fault that he felt this way.
Through this process of gentle and gradual confrontation with his
disavowed status concerns, John began to recognize that he had felt
defensive and humiliated by having to take the exam and had, as a
consequence, not prepared seriously enough. This was somewhat the case
even the first time he took the exam: he felt he had to act cool and casual
about his preparation despite considerable anxiety—anxiety largely
prompted by the internal necessity not just to pass but to do spectacularly
well and to do so without “sweating it.” Needless to say, the pressure
became even greater as he took and failed the exam over and over.
This initial bit of insight-oriented work modified the behavioral
interventions that were to be employed. Although, as I will describe shortly,
I did indeed use imaginal systematic desensitization to help John overcome
his test anxiety (the treatment John had expected), I also, on the basis of the
exploratory aspects of this initial work, concentrated more than I otherwise
might have on his preparing more thoroughly for the challenge the exam
represented. By helping him to see the unacknowledged feelings and ideas
that had led him to treat the exam dismissively, the initial work enabled
John to address the exam more seriously this time. As he came to see, it was
not only a matter of anxiety that had to be overcome. The anxiety, while in
certain respects excessive and certainly interfering with his exam
performance, was not entirely unrealistic: it was based in part on his
unacknowledged perception that he had not taken the exam seriously
enough to be properly prepared.
After working a good deal on the internal pressures that had led John to
be dismissive toward the exam and on how he could study for it more
seriously this time, we did conduct desensitization. Initially, the major
dimension for the development of a hierarchy was a temporal one. The
images moved from a period considerably before the exam, through
increasingly close approaches to actually appearing at the door, to his sitting
down at the desk, to his confronting the experiences he would encounter
when actually taking the exam.
As will be apparent later, the “insight” part of the work did not come to
an end once systematic desensitization began. Indeed, some of the most
useful and interesting insights came during the course of the systematic
desensitization itself. If the therapist approaches systematic desensitization,
or any other intervention, in a spirit of openness to the patient’s experience,
there is not a sharp dichotomy between insight-oriented work and active
interventions (Frank, 1999).
For example, as we went through the images in John’s original hierarchy,
the nature of his discomfort became clarified in a number of specific
situations. Thus, when he pictured walking into the exam room, he became
aware of the crowd of exam takers pressing in together, and he experienced
a strong sense of indignity at being pushed and at having his identity
checked. This, more than any concern about failure, was his primary source
of distress with these images. We discussed this in relation to the legacy of
his upbringing, and it led to an important discussion of his strategy for
studying for the exam. He was struggling with dual inclinations to study
much harder than anyone else taking the exam and to study much less. We
worked on images of his being “just one of the crowd” until he could
imagine this with little discomfort. He found that this image/thought
enabled him as well to have a much clearer sense of what would be an
appropriate amount of preparation: he could do it “just like everyone else.”
Similarly revealing was John’s reaction to the image of approaching the
door of the exam building. It became clear as he immersed himself in the
image that another source of discomfort was seeing the guard at the door.
He recalled that the same man had been on duty on several occasions and
felt pain at the idea that this man would see that he was taking the exam still
again. He worked on this image for much of a session, finally overcoming
the anxiety when he pictured himself taking the bull by the horns and
saying “Good morning” instead of trying to slink in unnoticed (as he
realized at some point he was doing in the image).
The most interesting developments occurred when John imagined
himself visiting the exam room the day before the exam. The goal in this set
of imagery exercises was for him to acclimate himself to the setting in
which the exam would take place and thereby to experience a reduction in
anxiety. He was asked to look carefully around the room, to touch the
various surfaces such as the desk and walls, to experience the lighting, and
so forth.
When he began the imaging, however, a fascinating series of associations
and new images came forth. At first, he spontaneously had the association
that the room seemed like a morgue and then that the rows of desks seemed
like countless graves covering the site of a battlefield. Then he felt
overcome with a feeling of impotence. I asked him if he could picture
himself as firm and hard, ready to do battle. (I left it ambiguous whether he
should take this specifically to mean having an erection or as an image of
general body toughness and readiness.) He did so and said he felt much
better, stronger, and then spontaneously had an image of holding a huge
sword and being prepared to take on a dragon. He associated this image to
our multiple discussions of his treating the exam as a worthy opponent,
taking it seriously yet mastering it. He was exhilarated by this image, and I
suggested he engage in such imagery at home between sessions, a
suggestion he endorsed with great enthusiasm.
In the next session, we began with his again picturing himself visiting the
exam room the day before the exam. For a while, as he checked out the
various features of the room, he felt calm and confident. But suddenly he
felt a wave of anxiety, as if something was behind him. I asked him (staying
in the realm of imagery) to turn around and see what was there. He reported
seeing a large cat, a panther. Here, I made a kind of interpretation. I offered
that the panther represented his own power and aggression and that it was a
threat to him only so long as he kept it outside of him or out of sight. I
asked him if he could reappropriate the panther part of him, adding that
what he was feeling threatened by was his own power, his own coiled
intensity.
He pictured the panther being absorbed into himself and the anxiety
receded. I then elaborated—quite speculatively, to be sure, but in a way
rooted in the understanding we had achieved together —on why he had
chosen a panther in particular to represent the part of himself that needed to
be reappropriated. I noted that panthers were not only strong and purposeful
but were also meticulous and supremely respectful of their prey. Despite
being awesome creatures, I suggested, panthers did not take their prey
lightly. They did not act as if it were beneath their dignity to stalk for hours,
crawling on their bellies. Panthers, I said, were diligent students who
became experts on the habits of the creatures they tracked—and whose
expertise was the result not just of instinct or superb natural equipment but
of attention to detail and a respect for the difficulty of the task of conquest
nature required of them. Their grace might look effortless, but it was far
from casual; panthers were supremely serious.
Now in all this it is impossible for me to distinguish how much reflected
an empathic grasp of the actual layers of meaning that led to John’s
experiencing that particular image (what Freud might call the “latent
content”) and how much was simply suggestion on my part (Wachtel,
2011b). The “interpretation” seems plausible, but I was at the very least
gilding the lily, using the panther image to point toward attitudes I felt it
would be useful for him to incorporate in light of his conflicts, whether they
were the actual sources of the image or not.
What was key was that my comments proved meaningful to the patient.
They resonated with the ripples of meaning that the image engendered, and
they amplified and consolidated the utility of the image itself, which was,
after all, John’s creation. In further work on the test anxiety and—
significantly—later on his own in dealing with a range of other concerns,
John made great use of the panther image and its variants. He aided his
efforts at relaxation, for example, by imagining himself as a big cat,
relaxing and licking himself. When faced with a challenge he imagined
again himself and the panther as one and felt that he knew deep inside he
was capable of whatever was necessary. Sometimes he would even imagine
himself emitting low murmuring sounds deep in his throat that, as he put it,
“remind the panther that it’s a panther.”
One of my favorites of his spontaneous creative uses of the panther
image came later in the desensitization work. We were at the point of his
imagining sitting and taking the exam when a wonderful smile appeared on
his face. He told me he had just had an image that the point of the pencil
with which he was writing the exam was actually the claw of the panther;
that the panther was firmly within him, incorporated and channeled, and as
the claws came through the tips of his fingers they were pencils which were
writing out exam answers with sharp points.
This time around, his points were indeed sharp. After having failed the
exam five times, he not only passed but excelled. I cannot, of course,
determine whether he would have passed even without therapy of any kind,
or whether a more orthodox course of either behavior therapy or
psychoanalytic therapy alone (or of any other approach for that matter)
would have done just as well. Only systematic research can enable us to
sort out with confidence the many questions that cases like this raise.

Further Comment on the Case

This case was in certain respects a turning point, or at least a marker along
the way, in the evolution of cyclical psychodynamic practice. The degree of
synthesis of differing methods, the extent of the “seamlessness” of the
therapeutic effort, was greater than had typically been achieved in my
previous efforts. Previously, therapy often was characterized by
incorporating procedures derived from different therapeutic traditions at
different times in the work. Although they fit together into a coherent
framework, they were nonetheless still clearly identifiable as separate parts.
Increasingly, as in this case, what has evolved is a more seamless
integration in which the procedures at any given moment are not quite what
most behavior therapists would do and not quite what psychoanalysts would
do, but rather emergent procedures more fully integrative in their form and
implementation.
The case differs from most seen in cyclical psychodynamic
psychotherapy in that it had a rather narrowly defined goal. A variety of
intriguing characterological issues, fantasies, and conflicts became evident
during the work, but John made it clear that what he was coming for was
simply to overcome the anxiety that had impeded his passing the exam. Had
John been interested in pursuing further how these attitudes and anxieties
influenced his life in other ways, the therapy would have addressed them
more extensively and more in depth. This is the more typical course of the
work from a cyclical psychodynamic perspective. But it is another essential
feature that one must understand and respect the goals of the patient; there
is a difference between a therapist and a missionary.
John’s case, nonetheless, illustrates well a number of features of the
cyclical psychodynamic point of view. To begin with, we see a number of
vicious circles evident in John’s difficulties, which interweave influences
from his past, from his motivational conflicts and internal necessities, and
from his daily transactions with the world. John’s conflicting needs to be
outstanding and to appear to do everything effortlessly made it difficult for
him to study sufficiently to do well on the exam and made the first failure
especially painful. These influences then fed on themselves. Feeling so
humiliated and embarrassed, John’s anxiety increased, making still further
failure more likely. Moreover, his need defensively to deride the exam and
also not to appear shaken and therefore not to study too hard both repeated
the state of affairs associated with the first failure and set the stage for the
next.
An additional circular process, reinforcing the interlocking set of
influences just described, involved the excessively high standards that John
had absorbed from his parents. Those standards were perpetuated as a
continuing psychological irritant, not only by his attachments to the objects
and images of his earlier days, but by the new relationships he established
with others. By presenting himself as special, John evoked expectations of
being special and created a life structure that replicated the circumstances of
his childhood in this way. That he was in fact highly talented enabled this
potentially fragile structure to be maintained, but at a high psychic cost.
It should also be apparent from this case illustration how a cyclical
psychodynamic therapy integrates the exploration of warded off
experiences and inclinations with direct and active efforts at promoting
change. Although active interventions were employed, the target of the
therapeutic efforts depended considerably on the initial exploratory work.
Enabling John to acknowledge and understand how he had kept himself
from appreciating the extent of his status concerns, and why he had needed
to do so, was critical in developing the treatment focus. Attending to his
conflict over working hard to prepare for the exam and to the unrecognized
need he had to make it all appear effortless (not only to others but to
himself), led to further active interventions directed toward helping John
study more effectively and take the exam more seriously. Moreover,
understanding the indignity John experienced in the process and his
embarrassment at retaking the exam provided another focus for
desensitization, as well as for further explorations of how these feelings
(and how he dealt with them) affected his life more generally. John’s
spontaneous panther imagery and the (partly whimsical, but deeply serious)
discussion we had about its meaning were both a marker of his having
engaged these issues and an indicator of the anxiety they still aroused and
the potential for change and expanded personal power they represented.
The case illustrates, as well, some of the subtleties of the therapist’s use
of language that have increasingly been at the center of the cyclical
psychodynamic approach (Wachtel, 2011b). The inquiry into John’s status
concerns—concerns which at first he vigorously disavowed—began by
addressing his parents’ concerns and proceeded only gradually to inviting
him to explore his own. Moreover, the latter exploration was undertaken in
a way designed to enable John to examine these concerns in a manner that
maintained his self-respect. Ultimately, the aim was for John to
acknowledge and sympathetically examine his attitudes. The way the
therapy proceeded suggests that he indeed did so.

RELEVANT RESEARCH
The research foundations for both cyclical psychodynamic theory and the
therapeutic approach that derives from it are broad and diverse. The cyclical
psychodynamic approach to therapy has not been characterized by a fixed,
manualized set of procedures designed to be employed in randomized
controlled trials or targeted to a single diagnosis derived from the
Diagnostic and Statistical Manual of Mental Disorders (DSM) or the
International Classification of Disease (ICD). In fact, the logic of the
cyclical psychodynamic viewpoint has led to critiques of the overemphasis
on this approach to so-called empirically supported or evidence-based
treatment (Wachtel, 2010a, 2018). The evidence for this approach rests
instead on a range of basic research areas and on research on the basic
principles and processes applied in the therapeutic effort. (For
complementary discussions of a principles-based, rather than a
package/brand name–based approach to therapy and its evidence base, see
also, Castonguay & Beutler, 2006; Pachankis & Goldfried, 2007).
The principles and processes relevant to cyclical psychodynamic therapy
derive from all of the current major therapeutic orientations. Thus, within
the integrative framework of cyclical psychodynamic theory, the vast body
of research demonstrating the efficacy of exposure in diminishing anxiety
(e.g., Abramowitz, Deacon, & Whiteside, 2011) is brought to bear on
understanding not only how patients overcome anxiety associated with
specific phobic objects or traumatic events, but how anxiety associated with
the person’s own thoughts and feelings can similarly be overcome (Dollard
& Miller, 1950; Wachtel, 1997, 2011b). These latter anxieties, emphasized
more by psychodynamic approaches, have been thought of from that
perspective as primarily addressed via interpretations and insights. But from
the cyclical psychodynamic perspective, a key characteristic of a good
interpretation is that it promotes exposure to the previously avoided thought
or feeling. Thus, both the extensive empirical literature on exposure and the
domain of research on the problematic consequences of retreating from
feelings, yearnings, and ways of interacting with others that have come to
be associated with anxiety (e.g., Chawla & Ostafin, 2007; Cramer, 2006)
bear on the integrative approach under discussion here. Relatedly, the very
substantial body of research conducted by proponents of emotion-focused
therapy (Greenberg, 2016, 2017) can be understood both as pointing to the
critical importance of short-circuited emotional experience and as
highlighting alternative means of promoting effective exposure to emotional
cues that have been associated with anxiety.
The enormous research literature on attachment points to an additional
factor leading people to experience some of their own thoughts and feelings
as threatening. In addition to the more familiar explanations (from both
behavioral and psychodynamic sources) in terms, essentially, of aversive
conditioning, research on the dynamics of attachment and attunement
(Cassidy & Shaver, 2016; Mikulincer & Shaver, 2016; Obegi & Berant,
2010) suggests that thoughts and feelings can become associated with
anxiety if they do not elicit responsive, attuned behavior from the caregiver.
Even when the thought or feeling is not overtly forbidden or criticized, the
developmental need for attunement can give rise to discomfort when an
aspect of the self does not elicit parental engagement and responsiveness
(Wachtel, 2017a).

Expectancies and the Self-Fulfilling Prophecy

One area of research that is particularly relevant to cyclical psychodynamic
theory concerns the related topics of self-fulfilling prophecies, interpersonal
expectancy effects, and behavioral confirmation (Bandura, 1997; Jussim,
2012; Madon et al, 2011; Snyder & Klein, 2005; Trusz & Bąbel, 2016).
Studies in this area elucidate the variables contributing to the vicious circles
at the heart of cyclical psychodynamic theory in which problematic
expectations lead us (often unwittingly and contrary to our intentions) to
elicit from others the very responses that are most likely to reinforce those
expectations.
Self-fulfilling prophecies were first defined by sociologist Robert K.
Merton (1948) and have since been investigated for their role in a host of
social problems, including those related to race (Snyder, 2016; Wachtel,
1999), social class (Darley & Gross, 1983), mental health (Clement et al.,
2014), and sexual orientation (Dasgupta & Rivera, 2006). Although the
effects of expectancies in inducing behavior in others have appeared to be
modest in some research on the phenomenon (Jussim, 2012), there are
circumstances in which they grow in importance. For example, self-
fulfilling prophecies become especially powerful when they involve the
maintenance of an individual’s self-image, a phenomenon termed “self-
verification” (Swann, 2012). According to self-verification theory, people
seek out information that confirms their self-view, whether positive or
negative, because a stable self-view lies at the heart of an individual’s
knowledge about the world. Strikingly, people with negative self-views may
exhibit anxiety and physiological arousal in response to positive—and
therefore inconsistent—feedback (Ayduk et al., 2013) and report poorer
health after positive life events (Shimizu & Pelham, 2004). In intimate
relationships, the effects of self-verifying processes increase over time
(Campbell, Lackenbauer, & Muise, 2006). Further indicating the important
role of expectancies within close relationships, parents’ expectancies for
their children’s maladaptive alcohol use have been found to shape
children’s later drinking (Madon et al., 2004; Madon, Willard, Guyll, &
Scherr, 2011).
Another clinically relevant form of expectancy is rejection sensitivity
(RS), “the disposition to anxiously expect, readily perceive and overreact to
rejection” (Downey & Feldman, 1996, p. 1338). Rejection expectancies
lead people to interpret ambiguous events as rejections. Crucially, these
perceptions ironically elicit the very behavior that high RS people are
attempting to avoid, thus creating a self-fulfilling prophecy (Downey,
Freitas, Michaelis, & Khouri, 2004; Romero-Canyas & Downey, 2013;
Romero-Canyas et al., 2010). The findings of this research, discussed
largely in terms of the attachment and social cognition literatures, converge
substantially with the premises of cyclical psychodynamic theory.
In a separate line of research, which applies the methodologies of social
cognitive researchers to the phenomenon psychoanalysts call transference,
Andersen and colleagues (e.g., Andersen & Przybylinski, 2014; Chen et al.,
2013; Miranda, Andersen, & Edwards, 2013) have focused on situations in
which individuals’ representations of significant others from the past
influence the way they interact with new people in the present. Consistent
with cyclical psychodynamic premises, these perceptions can then
perpetuate these early, emotion-laden expectations by inducing behavior
that “confirms” them in the present (e.g., Berk & Andersen, 2000). In
understanding these and similar findings, occurring without either perceiver
or target being aware of what was being evoked or stirred, Andersen and
colleagues note resemblances to the psychoanalytic concepts of
transference and countertransference.

Developmental Studies of Cyclical Processes

Decades of developmental research have demonstrated that humans are
attuned to interpersonal experience from the earliest moments of life. At the
same time, the influence of the caretaker, rather than simply an “external”
or “environmental” shaper of behavior and experience, is itself responsive
to the evolving properties of the infant. Several influential lines of infant
research have demonstrated the pervasiveness of processes between infants
and their caregivers that parallel the conceptualization of cyclical
psychodynamic theory. These processes have variously been described in
terms of “reciprocity” (Brazelton, Koslowski, & Main, 1974), “mutual
influence” (Beebe & Lachmann, 1988, 2014), and “bidirectional influence”
(Cohn & Tronick, 1988).
As evident from this research, each member of a mother–child dyad is
attuned (if always imperfectly) to the expressive state of the other and
responds to the expressive state of the other in a dynamically evolving
system. Infants rely on this attunement for regulation of their emotions and
level of arousal, and repeated experiences of attunement (or misattunement)
with mothers and other caregivers shape the infant’s later interpersonal
expectancies and symbolic functioning (Beebe et al., 2016; Beebe & Steele,
2013; Bigelow et al., 2010; Markova & Legerstee, 2006). A similar process
is evident as well in the evolution and maintenance of models of
attachment, what Bowlby called internal working models. There, too, rather
than the infant’s (or older child’s or adult’s) attachment representations
simply being fixed or “internal,” they are a continuing product of mutual
interaction, self-fulfilling prophecies, and cyclical dynamic processes
(Wachtel, 2010b).
The findings by developmental researchers of dyadic reciprocity in
mother–infant interaction and the ways that expectations become self-
replicating and self-sustaining have had increasing impact within the
broader therapeutic community on therapeutic work with adults. The
Boston Change Process Study Group (2010) has been in the forefront of
this translation from infant research to clinical practice. Extrapolating from
a wide range of developmental and interactional studies, both by members
of their group and by others, they argue that “conflicts and defenses are
born and reside in the domain of interaction,” that understanding people in
depth requires understanding of “specific exchanges at the local level of the
interaction,” and that “the past is carried forward into the present at the
level of lived experience” (Boston Change Process Study Group, 2007, p.
856).

Psychotherapy and Psychopathology Research

Consistent with the focus of such developmental studies and with the
premises of cyclical psychodynamic theory, both process research in
psychotherapy and research in psychopathology have become increasingly
attuned to the subtle, moment-to-moment, verbal and nonverbal exchanges
that occur between patient and therapist or between the patient and his
accomplices. As part of this, methods of data collection and analysis are
being continually refined to better model these reciprocal, interactive
phenomena. These models and research designs have great relevance to the
cyclical psychodynamic point of view (e.g., Bolger & Laurenceau, 2013;
Sadler, Ethier, & Woody, 2011). Thanks in part to these methodological
advances, researchers are now able to illuminate such clinically relevant
questions as how changes in therapeutic alliance over time predict
therapeutic outcome (Zilcha-Mano et al., 2016), what sequences of
emotional expression lead to improvement in distressed couples (McKinnon
& Greenberg, 2017), and what sequences of self-states characterize a
patient’s depression (Osatuke et al., 2011). While the complexity of human
interaction is daunting, these developments represent a significant increase
in our ability to study in systematic fashion the reciprocal and often self-
perpetuating processes that are at the center of the cyclical psychodynamic
point of view.

FUTURE DIRECTIONS
The cyclical psychodynamic perspective originally developed in the effort
to integrate psychoanalytic and behavioral approaches (Wachtel, 1977). It
then became apparent that its emphasis on reciprocal causal influences and
the role of vicious and virtuous circles had much in common with many of
the core premises of family therapy, and the integrative effort was extended
to include attention to and work with family systems (Wachtel & Wachtel,
1986). A direction currently being pursued aims to enhance the scope and
effectiveness of the integrative effort by incorporating methods from
experiential and emotion-focused approaches (Greenberg, 2016) and
attending to the procedural dimension in therapeutic change (Lyons-Ruth,
1998; Stern et al., 1998).
From the beginning, the impetus for the integrative effort was to promote
greater experiential contact with desires, thoughts, and feelings that had
been fearfully avoided. The aim was to move beyond what seemed like an
excessive emphasis in the therapeutic approaches of the time on knowing
about those warded-off aspects of the self and to enable the patient to
directly experience and reassimilate their potential into his evolving
experiential and behavioral repertoire. As part of this experiential emphasis,
the patient was also encouraged to try out new modes of interacting with
others that gave more direct expression to those previously unexpressed
yearnings and that, through direct experiential learning, enabled him to
modify the interpersonal feedback central to maintaining the problematic
patterns. Behavioral methods were viewed, in this context, not as the
application of a behavioristic methodology, but as a means of achieving this
more experiential aim. The increasing employment of methods from
therapeutic approaches more explicitly defined in terms of an experiential,
emotion-focused point of view is thus a natural extension of the original
integrative agenda. So, too, is the current emphasis on exploring the
therapeutic implications of the distinction between semantic/declarative
learning and more procedural dimensions of learning and memory. In
contrast to the emphasis in many therapeutic approaches on the explicit
recovery of memories and the promotion of conscious insights (Fonagy,
1999), a procedural emphasis highlights change promoted through lived
experience. It is this procedural emphasis, including attention to the subtle,
often out-of-awareness exchanges that promote implicit relational knowing
(Lyons-Ruth, 1998), that represents one of the key directions toward which
cyclical psychodynamic practice is moving.
A second major vector in the evolution of the cyclical psychodynamic
point of view is the continuing elaboration of its focus on the therapist’s use
of language (Wachtel, 2011b). This strong interest in language and attention
to how small differences in the words and phrases the therapist uses can
advance or impede progress might at first seem inconsistent with the shift in
emphasis from declarative/semantic to procedural dimensions of the
therapeutic change process. The aim of this focus on language, however, is
not so much to promote verbalized (declarative) insights as it is to take
account of language’s being a critical medium of relationship and human
interaction. Language contributes to evoking emotions, to creating trust or
mistrust, to generating confidence or hesitancy, and to promoting new ways
of acting and experiencing or to strengthening old ways. Viewing language
in this way, and attending to how common phrases and linguistic habits of
therapists can unwittingly create shame and discouragement in the patient,
the cyclical psychodynamic therapist thus approaches language itself in a
fashion consistent with the shift from a declarative to a procedural
emphasis.
Part of that shift includes attending not just to the content of the message
but to the meta-messages (Wachtel, 2011b)—the emotional tone, the
implied message about how the therapist feels about the patient, the
promptings to action, the implicit generation of alternative meanings, and
so forth. These dimensions and strategies of therapeutic communication
contribute to change in many of the same ways that behavioral interventions
do (e.g., by generating exposure or promoting new, more adaptive
behaviors), but they fit more comfortably and less intrusively into an
exploratory or psychodynamic approach.
A third vector of cyclical psychodynamic theory is its applications to
larger social questions. The integrative framework points to the importance
of attending not just to the immediate interpersonal context but to the larger
social, economic, and cultural context as well (Wachtel, 2014a).
Applications have included explorations of phenomena of race and racism
(Wachtel, 1999), greed and materialism (Wachtel, 2003, 2005), and the
psychological factors that impede our ability to address the challenges of
climate change, environmental degradation, and economic inequality
(Wachtel, 2017b). The well-being of our patients depends not only on their
individual psychological inclinations or the quality of their personal
relationships but also on the culture and society in which they live.
Psychotherapists have tended to leave out this broader foundation of well-
being. A current and future goal of cyclical psychodynamics is to move
these social and cultural considerations increasingly to the center of
psychotherapists’ concerns. Such a shift does not represent a retreat from
understanding individuals in depth or from attention to the intimate
relationships that contribute so powerfully to shaping who we become.
Rather, it reflects the view that it is in attending to the ways that individuals
both shape and are shaped by their contexts that we gain the most effective
understanding for helping people live richer and fuller lives.
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D. Assimilative Integration
 10

Assimilative Psychodynamic Psychotherapy

GEORGE STRICKER AND JERRY GOLD

Our patients and our work as psychotherapists have puzzled us, tantalized
us, humbled us, and ultimately taught us to question the validity of a “one
truth” position in the world of psychotherapy. We both were trained as
psychodynamic psychotherapists and remain committed to that orientation.
Yet we have learned much from colleagues of all orientations and have
found that our psychodynamic ideas and methods can be empowered by,
and can synergize with, concepts and techniques from several therapeutic
schools.

INTEGRATIVE APPROACH
The Assimilative Psychodynamic model refers to a broadly psychodynamic
therapy into which active interventions (cognitive-behavioral, experiential,
and family-systems techniques) are assimilated, producing an altered
purpose and expanded impact of those interventions and an enlarged view
of psychodynamic functioning (Gold & Stricker, 2001, 2013, 2015;
Stricker, 2010; Stricker & Gold, 2002). Our approach to psychotherapy
integration grew out of a number of experiences, individual and shared,
academic, collegial, and clinical, that taught us about psychotherapy
integration in general and about its role in psychodynamic psychotherapy in
particular.
One of us (GS) was an initial organizer of the Society for the Exploration
of Psychotherapy Integration (SEPI; /www.sepiweb.org/) and, as such, has
been involved in this scholarly and clinical movement since its beginnings.
Stricker has been privy to, and a contributor to, the central conversations
about psychotherapy integration for more than 30 years and has presented at
almost all of the SEPI conferences during that period. A particularly
formative experience occurred at Iguazu Falls, a beautiful spot in Argentina.
He was excited to be there but uncomfortable with the heights, and he
challenged one of the editors of this book (MG) to help him with it. A
combination of some breathing exercises and a great deal of support made
the event a memorable one and underlined the potential value of cognitive-
behavior therapy (CBT) to a confirmed psychodynamic psychotherapist
(Stricker, 1995).
The second author (JG) was editor of the Journal of Psychotherapy
Integration and, in that role, examined many scholarly contributions to
psychotherapy integration. Gold was Stricker’s doctoral student just prior to
the founding of SEPI, and during our work together on what would become
Gold’s (1980) doctoral dissertation, we discussed early papers and books on
psychotherapy integration, which remain shared influences. These included
Dollard and Miller’s (1950) seminal integration of learning theory and
Freudian psychoanalysis; Alexander and French’s (1946) radical revision of
psychoanalytic therapy, in which the concept of the corrective emotional
experience was introduced; and classic articles on the integration of various
psychotherapies. Some of the more influential papers were French’s (1933)
examination of the relation between Pavlovian conditioning and Freudian
theory; Rosenzweig’s (1936) description of common factors in
psychotherapy; Alexander’s (1963) description of the therapist as a source
of rewards, punishments, and corrective learning experiences; Beier’s
(1966) description of the way in which therapists reinforce unconscious
mental processes; and the psychodynamic behavior therapy contributed by
Feather and Rhodes (1972).
A critically important influence on both authors was the seminal book by
Paul Wachtel (1977), Psychoanalysis and Behavior Therapy: Towards an
Integration, which we read together soon after its publication and which
was a serendipitous find as we struggled to conceptualize the research
questions that shaped Gold’s (1980) dissertation. The theoretical model of
cyclical psychodynamics contained in this book, and the integrative
intervention strategies therein, remain important foundations of our
integrative model.
The relative flood of integrative writing that followed Wachtel’s (1977)
watershed publication has influenced us as well. Important contemporary
integrative writers who have taught us much include Ryle (cognitive-
analytic therapy; Ryle &Kerr, 2002), Beutler (Beutler et al., 2013), and
Lambert (2007). We also have been influenced by Messer’s (1992) seminal
writing on assimilative integration; our integration of active interventions
from therapies other than psychoanalysis conforms to this contextual
perspective.
This collective of innovators all demonstrated that psychodynamic
changes can and do follow from behavioral changes as frequently and as
powerfully as when insight precedes change. Essentially, all of these
therapists place insight and psychodynamic variables within a
multidirectional and multidimensional model of psychological change. It
then follows that new learning and the provision of new experiences and
new relationships, as well as interpretation and insight, are crucial in a
psychoanalytically informed integrative therapy. It was from this conceptual
and technical foundation that our approach grew.
Another “brick” in the foundation of our model was our own effort
(Stricker & Gold, 1988) to conceptualize personality and personality
disorders within an expanded psychodynamic theory that would take into
account conscious cognitive and perceptual processes, as well as overt
behavior and interpersonal relationships. Although not meant as an overtly
integrative theory at the time, we have returned to this model repeatedly
(Gold & Stricker, 1993, 2001; Stricker, 2010; Stricker & Gold, 1996) and
have explored its integrative implications in the development of
Assimilative Psychodynamic Psychotherapy. This “three-tiered” theory
(behavior, cognition and emotion, and psychodynamics) allowed us to
consider how to incorporate nonanalytical ideas and methods in a flexible
but systematic way.
Our conceptual foundation fits best into the relational group of
psychoanalytic therapies (Greenberg & Mitchell, 1983; Wachtel, 2007).
That is, we believe that each person’s psychological structures and ways of
consciously and unconsciously remembering and representing our
experiences accrue in the context of significant interpersonal relationships.
Central to our model is the traditional psychoanalytic notion that those
memories and experiences that are painful and that contradict our cherished
notions of who we are and of who our parents and other loved ones were
are excluded from consciousness yet continue to influence our thinking,
behavior, and emotional experience.
 As integrative theorists and therapists, and following our own three-
tiered model, we believe that consciousness and its components (emotion,
cognition, and perception) and behavior play significant roles in
psychopathology and often require direct intervention as well. Furthermore,
we assume that there are dynamic linkages among the tiers that reinforce
and maintain phenomena at all levels. In other words, we have found that
problematic thinking and troubling interpersonal relationship patterns often
express and stabilize unconscious conflicts and prevent interpretive work
from being completely effective.
As a result, there are times when we must intervene directly in the
patient’s behavior and consciousness, in much the same ways as do
cognitive, behavioral, experiential, and systemic therapists. This leads to the
assimilative nature of this therapy. When employing an intervention that is
meant to change thinking, emotional processing, or behavior, we do so with
two purposes: to change the targeted psychological issue and, at the same
time, to intervene in the psychodynamic sphere that is connected to that
issue.
Our selection of interventions is guided primarily by clinical experience
and necessity and by our reliance on psychodynamic principles, but we are
aware of, and use whenever possible, empirical guidelines. In doing so, we
rely on evidence-based interventions rather than empirically supported
techniques, as the latter are more narrow and restrictive. Our psychoanalytic
interventions reflect our training and ongoing experience as clinicians, yet
we also rely on research findings that substantiate the clinical effectiveness
of psychodynamic exploration and of interpretation of transference (cf.
Luborsky, 1996; Shedler, 2010; Weiss & Sampson, 1986). Similarly, when
an active intervention is assimilated into our psychodynamic approach, we
do so first with an eye toward the immediate and long-term clinical needs of
the patient, but also with awareness of the literature on prescriptive
matching of patient, problem, and evidence-based methods (Beutler et al.,
2013; Consoli & Beutler, Chapter 7, this volume). Finally, and of crucial
importance, we are cognizant of the compelling research support for the
impact of the therapeutic relationship (Norcross & Lambert, 2018) as well
as of the therapy technique. Interestingly, this brings us full circle, as that
was the crucial finding of Gold’s (1980) dissertation.

ASSESSMENT AND FORMULATION

Although we assign patients diagnoses for record keeping and for insurance
purposes, we have not found any diagnostic typology to be of much use in
the complex environment of ongoing psychotherapy. Our assessment begins
with the first contact with the patient and continues throughout the
treatment. It usually is interwoven in a relatively seamless way with the
psychotherapeutic process. This is inherent in an exploratory,
psychodynamically informed psychotherapy, wherein a central goal of the
treatment is the progressive expansion of our understanding of the patient.
We do not separate the treatment into phases of formal assessment and
psychotherapy, but, as new material and understanding emerges, we revisit
our initial assessment and formulation. We are not adverse to the use of
formal tests or questionnaires to answer specific questions about issues such
as diagnosis, risks, or psychological abilities and disabilities, but our
assessment is not linked to such instruments, and we use them only as a
particular need emerges with an individual patient. We do rely on outcome
assessments (Lambert, 2007).
Our assessment and formulation of each patient relies heavily on the
three-tiered model of psychological functioning that we introduced earlier
in this chapter (Stricker & Gold, 1988). These tiers are behavior and
interpersonal relatedness (Tier 1); cognition, perception, and emotion (Tier
2); and psychodynamic conflict, self-representations, and object
representation (Tier 3). We evaluate the patient’s functioning, strengths, and
weaknesses at each tier and look in particular for the linkages between
variables in each tier and for the ways in which problems and processes in
one tier may express or maintain a problem in another tier. We also evaluate
deficits and skills at each level of experience and try to identify how filling
in these gaps, or using specific strengths, might support change at the other
levels.
In general, we try to spot those issues in Tiers 1 and 2 that would prevent
effective psychodynamic work and that, if ameliorated, could serve as the
kernels of “corrective emotional experiences” and thus as the seeds of new
images of self and of others (Gold & Stricker, 2001). That is, current
interactions with others (Tier 1) are motivated, skewed, and limited by
unconscious perceptions, motives, conflicts, and images (Tier 3) yet can be
and are limiting factors in the patient’s ability to change these issues.
Similarly, one’s conscious thinking and perception (Tier 2) exist in an
ongoing, circular interaction with the people in one’s life. Finally, each
patient’s set of character traits, or enduring patterns of adapting to the
interpersonal world, limits the chance for new interaction with others and
for new experiences at Tiers 1 and 2. At the same time, these traits are not
carved in stone but seem inflexible and enduring, at least in part due to the
contributions of others in the patient’s life who channel his or her actions
down well worn, familiar paths.
The three-tier individual, usually represented by a triangle, is placed in a
field that includes many other triangles. Our index patient, in an expansion
of the three-tier theory, is shown as relating, through mutual influence, to
each of the other triangles (Stricker, 2010) and doing so within a larger
circle representing the culture in which we function. This amplification
captures the relational functioning crucial to our model and the cultural
impact necessary for any model.
As an example, consider the patient who suffers from a Tier 2 problem of
self-critical thinking. In addition to thinking about ways to help this person
to test these thoughts and to modify them, we explore the possible role of
Tier 3 (psychodynamic) factors in motivating such thinking, and we
consider such thoughts to be a potential defense against unconscious
conflicts such as hostility toward a loved one with whom the patient is
identified. Then, we ask ourselves—and attempt to explore clinically—the
question of whether these thoughts can and need be changed through
exploration of their unwitting symbolic and defensive role or whether their
modification via the use of active, cognitive techniques would be a more
effective step that would lead us to the same exploratory goal. Additionally,
we consider how the people in the patient’s world are relating to them in a
way that maintains this problem.
Another component of this assessment piece would be to think about the
interpersonal or transferential impact of the active intervention. Will the
patient experience our active intervention in their problematic thinking to
be an expression of concern or an intrusion? Will the patient take away a
sense of being worthy of care and of the therapist as being caring, which
will help the patient to revise old self and object representations? Or, will
our attempt to help unwittingly reinforce the patient’s sense of vulnerability
and images of authorities who are arbitrary and condescending? Will we be
providing a corrective emotional experience or a repetition of a previous
experience (participating in an enactment)?
 We begin to develop a case formulation at the beginning of the treatment
and add to or revise this formulation on an ongoing basis. Our formulation
serves as a general, cognitive-experiential roadmap that allows us to
organize the vast array of data that emerges in each session and during the
course of many sessions. However, we do not go into each session with an
agenda based on this formulation and are quite willing to abandon its
guidance when the clinical situation dictates otherwise. This follows from
our belief, common to most psychodynamic and humanistic therapies, that
it is the patient who determines the course of the therapy, and it is from the
patient that we take the lead in prioritizing goals (Bohart & Tallman, 1999;
Hubble, Duncan, & Miller, 1999). We are willing to live with this tension
but, at the same time, consider there to be a difference between the long-
term goals of the therapy, which are set by the patient, and the clinical needs
of the patient, which are to be identified and met by the therapist.

APPLICABILITY AND STRUCTURE

We believe that assimilative psychodynamic psychotherapy is suitable for a
broad range of patients and that, in fact, it extends the range of applicability
of traditional psychodynamic therapies beyond their usual limits. We have
found that most adult patients who are seen in private therapy offices or in
outpatient clinics can benefit from and are successfully treated with this
psychotherapy. We do not believe that this approach would be particularly
useful in a hospital or other confined institutional setting as we present it
here. However, it is very likely that therapists working in inpatient units or
residential settings might use our assimilative perspective, especially if their
models are psychodynamic. As such, we conclude that it is indicated for
adults who have anxiety disorders, stress-related disorders, mood disorders,
and personality disorders.
Due to both its psychodynamic foundation and its integrative assimilation
of active techniques, this model permits and encourages easy shifting
between a more immediate, symptomatic focus and a more extended,
exploratory, personality-oriented focus. These parallel tracks allow the
therapist to assist the patient in lessening the patient’s current suffering, as
well as in exploring and changing the underlying patterns implicated in that
suffering.
 The decision to start off with a symptom reduction focus or an
exploratory focus is based on the therapist’s assessment of patients’
beginning psychological state, including their level of suffering, ability to
tolerate that suffering, capacity to delay gratification, psychological
sophistication, and interest in self-understanding. With patients who are
relatively high on these variables, we usually begin the treatment in a fairly
standard psychodynamic mode, using integrative, active techniques as
indicated. With those patients whose suffering is too great to delay
symptom reduction, or for whom psychological exploration is too great a
strain, we begin the therapy in a more active, cognitive-behavioral or
experiential mode and move gradually toward psychodynamic work as the
patient improves. We have found that this approach allows more fragile or
volatile patients (perhaps those who might be diagnosed with personality
disorders, especially borderline and narcissistic disorders) to experience
early success in therapy. This contributes to improvement in the patient’s
self-esteem, to the attainment of an expanded sense of competence and
mastery, and to the perception of the therapist as a positive and helpful
presence. These experiences in turn lend themselves to the establishment of
a solid therapeutic alliance and to the lessened likelihood of destructive
hostility and negative transference.
We do not believe that this approach is particularly useful with patients
whose primary problems are substance abuse, schizophrenia, other active
psychotic disorders, organic disorders, or acute relationship (e.g., marital
conflicts) disturbances. This therapy probably is contraindicated in acute
emergencies and crises when management and safety are crucial. We have
not tested this approach with children, but others (Grehan & Freeman,
2009) have applied it to adolescent patients. The effectiveness of the short-
term psychodynamic psychotherapies are likely to be enhanced by the type
of assimilative integration that we propose. Indeed, certain of the more
influential and demonstrably effective therapies of this type, such as
Levenson’s (1995) time-limited dynamic psychotherapy, are highly similar
to our model in their integrative perspectives.
This therapy usually is conducted on a once weekly basis for 45–50
minutes, though not infrequently we see people twice weekly for extended
periods. The therapy usually is designed as long-term and open-ended,
though more and more often we find that third-party issues, such as
insurance and managed care limits, force therapy to be constructed as short-
term or to end sooner than we would like. The typical therapy lasts a year to
2 years and consists of approximately 40–100 sessions, though both authors
have had several patients with whom we have worked for many years and
for many hundreds of sessions, usually with a great deal of mutual
satisfaction.
We often work in combined formats where a patient in individual therapy
is referred to couple, family, or group therapy or to a psychiatrist for
medication. Usually, these supplementary treatments are carried out by
colleagues. We conceptualize these referrals within the same assimilative
framework as we do when using an active intervention in the patient’s
individual therapy. That is, we make these referrals for at least two
simultaneous purposes: first, to assist the patient in changing troublesome
symptoms and patterns of relating at Tiers 1 and 2; and second, to remove a
problem that may be expressing, reinforcing, and warding off Tier 3
(psychodynamic) phenomena that we have not been able to reach within the
context of psychotherapeutic exploration.

PROCESSES OF CHANGE
Among the main reasons for our ongoing interest in psychotherapy
integration is our shared goal of enlarging the range of change factors that
can be used in the comprehensive therapy. At the same time, we hope to
preserve the inclusion of insight, in all of its myriad forms, as a crucial
change factor.
The literature on psychotherapy integration (Prochaska & DiClemente,
1992; Wachtel, 1977) has emphasized repeatedly that change accrues from
many factors. We are happy to make use of as many of those factors as is
possible, noting that each person changes somewhat differently and that, as
a result, each therapy is constructed somewhat differently as well. We
believe that change can and does result from insight, from exposure to
fearsome internal and external stimuli, from the modification of cognition
and perception, from observational learning and via operant conditioning,
from the ability to access and to symbolize emotional experiences, and from
the internalization of benign, corrective interpersonal contacts.
We emphasize exploratory work in which insight in its broadest sense is a
central mechanism of change. We believe that an enhanced and expanded
awareness of the warded off, unconscious meanings of one’s life
experience, of the effects of intrapsychic conflict, and of an appreciation for
the ways in which we unwittingly repeat our histories and find our parents
and significant others in current relationships often leads to therapeutic
outcomes. We try to accomplish this expansion and deepening of meaning
in typical psychodynamic ways. This is done through a detailed inquiry into
past and present relationships, fantasies, dreams, behavior, and feelings, and
through the gradual building up of a series of hypotheses and inferences
about the connections between past and present, intrapsychic and
interpersonal, desire and fear that eventually leads to clarification and
interpretation. We thus rely on historical insight and interactional insight in
a mutually influential way. Understanding the role of the past in shaping the
present can inform, and is informed by, patients attaining a more complete
understanding of their current interactions and the ways in which these
relationships keep the past alive (Wachtel, 1977).We do not prize one
source of insight above any other. Therefore, at times, we work with
patients to better understand the past and its role in determining their
current sense of self, whereas at other times the work focuses exclusively
on the present and on clarifying what is going on in the patient’s significant
contacts with others. At other times, we work within the therapeutic
relationship, trying to unravel the ways in which we have stepped into the
patient’s intrapsychic and interpersonal world and the symbolic
manifestations of transference, countertransference, resistance, and
interpersonal enactment as they emerge.
To this point, our description of assimilative psychodynamic
psychotherapy does not differentiate it clearly from any other variant of
psychoanalytic treatment. The differences emerge most clearly when we
approach the limits of insight as a change factor or when we discover that
our exploratory, interpretative approach is not the best way to get to certain
conflicts, meanings, or other (Tier 3) psychodynamic issues. We understand
that people often need to learn new skills or to unlearn maladaptive skills in
order to change. We often are humbled by the power of old images of
significant others and their staying power in the face of interpretation and
insight and by the need for the therapist to do something different from
those figures from the past for the patient to change. We have repeatedly
seen how helping patients to expose themselves to a feared situation,
experience, or emotion can lead to new discoveries, which neither the
patient nor the therapist had learned about through exploratory work.
 When we find that we are stuck temporarily, that exploration has led to a
dead end, that the patient is too pained by a symptom or problem to
continue, or when the transference seems too real and too hot to explore, we
make an assimilative, technical shift. We attempt to use other change
factors for a dual purpose: to change the immediate problem situation and
to clear the way for the emergence of the potential new meanings and other
psychodynamic factors that may be implicated in the current problem or
stalemate.
Traditional psychodynamic therapists consider the points at which insight
and exploration stall to be those moments during which the patient’s
conflicts and pain have stimulated defenses, the manifestation of which are
the source of resistance to the therapy. These therapists explore and
interpret such conflicts, defenses, and resistance much as they do any other
material or phenomena, often with success. We often use this approach as
well, but find that an unvarying interpretive approach can be unsuccessful
and sometimes reflects an unwitting enactment of a past relationship in
which the patient was misunderstood, hurt, or neglected (Frank, 1999; Gold
& Stricker, 2001).
For example, it is not uncommon for psychodynamic work to stall around
a “crisis” in a relationship for which the patient demands immediate help, or
when a symptom, such as a fear of air travel, comes to dominate the
sessions leading up to the patient’s vacation. These issues often reflect the
impact of defenses against warded-off conflicts, self-images, object
representations, and transference reactions. Yet they are real concerns as
well, and they may be worsened by the therapist’s refusal to intervene
actively because of allegiance to theoretical principles, even though he or
she knows how to do so.
Such an interaction may represent a reenactment of a parental disregard
of or refusal to respond to the patient’s need and may reinforce an
underlying pessimism on the part of the patient. It also may provide
convincing evidence to patients that they are not deserving of help.
Frequently, these issues only become accessible after the therapist has made
an assimilative shift, introducing a technique that can help quiet a conflict
in a relationship or lessen severe anxiety. The therapist’s willingness to
respond, to be flexible, and to demonstrate immediate concern often
constitutes a powerful corrective emotional experience. Such a powerful
interpersonal event may allow the patient to access, express, and resolve old
feelings about that past relationship and to use this new positive experience
as the kernel of a new self-image and images of others.
We (Gold & Stricker, 2001; Stricker, 2006; Stricker & Gold, 2002) have
identified several clinical situations in which we have found it to be
advantageous to make such an assimilative shift. These situations include
those mentioned earlier (exposure and extinction of anxiety, resolution of
transference that cannot be handled though interpretation alone, and
provision of a corrective emotional experience) as well as two others:
correction of developmental deficits through skill building and success
experiences, and support of a patient’s active attempts to change through
active intervention (Gold, 2000).
We use cognitive-behavioral and other didactic methods when
exploration reveals that the patient suffers from a faulty learning history and
that the necessary Tier 1 and Tier 2 skills cannot easily be gained in the
context of the therapeutic relationship. Systematic and purposeful filling in
of cognitive, behavioral, and experiential deficits leads to new successes,
enhanced self-esteem, and internalization of the therapist as an effective,
benign, and helpful parent substitute. Similarly, making suggestions about
ways of thinking or behaving and then standing by as a supportive audience
often allows the patient to actively and creatively experiment with new
ways of relating outside of therapy and provides the patient with the
experience of being encouraged to explore his or her own creative powers.
This type of experience also can modify and correct many of the more
malignant self- and object images with which the patient has been
burdened.
Assimilative psychodynamic psychotherapy places considerable demands
on the psychotherapist as a person and as a professional. Any treatment that
is psychoanalytic in nature requires a considerable amount of self-
awareness and of self-reflection, as well as the ability to delay gratification,
to remain silent for relatively long periods, and to tolerate high levels of
ambiguity and uncertainty for extended stretches of time. In addition to
these characteristics, the assimilative psychodynamic therapist must be able
to acknowledge and to be aware of the limits of the psychodynamic
approach, must be familiar with theories and methods from other therapies,
and must not get caught up in ideological conflicts or “clan loyalties” at the
patient’s expense. Unresolved issues about being true to one’s family of
origin that express themselves in the therapist’s behavior as interfering with
assimilative shifts or in too rapid shifting away from psychodynamic
exploration when it is called for will compromise this psychotherapy.
Success in assimilative psychodynamic psychotherapy seems more or
less likely depending on the patient’s interest in and ability to tolerate and
enjoy a depth-oriented, developmentally influenced psychotherapy in which
the expansion of awareness is a central goal. Such patients typically have,
or develop during therapy, a certain level of psychological mindedness, an
interest in their own history, a curiosity about their own minds and their
psychological development, and some capacity for delay of gratification
and tolerance of frustration. If the patient is interested in this type of work,
a relative lack of these capacities (as might be found with patients suffering
from personality disorders) can be overcome by starting with active
interventions and then moving toward a more exploratory approach.
But even highly intelligent and socially successful persons may not make
good use of this therapy if they simply “want results” (symptom relief,
interpersonal change) without caring about the intrapsychic journey toward
those results. For example, a talented, mature man of significant financial
means recently sought out psychotherapy with one of the authors. He came
to therapy due to the great pain that he was in because of his wife’s recently
disclosed infidelity. He stated that he wanted “some psychological
techniques that would work like pills, that will make me able to handle this
pain and go on functioning.” He worked diligently with cognitive-
behavioral techniques, such as relaxation and self-soothing, and obtained
some relief. Yet he also made it clear that he had no interest in exploring
anything other than the obvious meanings of this event and that he
considered his developmental history to be off-limits and irrelevant. As
such, once he had achieved the maximal, but far from complete, relief from
the circumscribed techniques in which he was interested, he ended the
treatment.

THERAPY RELATIONSHIP
The therapeutic relationship consists of a unique interpersonal environment
that patients may experience as a supportive safe haven from which they
may embark on the tasks of psychodynamic exploration and participation in
potentially mutative experiences (Stricker & Gold, 2002). In spite of the
inevitability of transference and countertransference that press the therapist
to repeat or to enact past, pathogenic relationships with the patient, it is the
therapist’s job to observe, identify, and understand the phenomena in which
they have been ensnared. Furthermore, the therapist must find a way to
react differently and correctively, allowing exploration of new intrapsychic,
behavioral, experiential, cognitive, and interpersonal possibilities and
pathways.
As noted earlier, we rely on the exploration and analysis of the
transference–countertransference matrix. We have found that acceptance,
warmth, and concern also are powerful antidotes to the past. In this way,
our ideas about the relationship converge with client-centered therapy
(Rogers, 1961) and more closely with self-psychology (Kohut, 1977).
However, the impact of the relationship goes further than described in a
non-psychodynamic system of therapy, and we are equally concerned with
the provision of new experiences within the therapeutic relationship.
We have found that, as patients feel accepted, secure, and understood in
the context of therapy, they are more willing and better able to explore life
in new ways: to take chances, to question previously drawn conclusions,
and to own and tolerate painful emotions, perceptions, and other previously
unacknowledged internal states. As Bowlby (1980) noted, exploration is
only possible when one has a secure base of attachment figures to whom to
return. We suggest that most patients, regardless of their diagnosis or
presenting problems, were and are lacking in this foundation. If the
therapist can supply a substitute for this lack, then the task of psychotherapy
can proceed more confidently and with a much greater chance of success.
As we have and will stress repeatedly, new experience with the therapist
becomes the stimulus for change at all three tiers of experience. When a
patient tries out a new way of thinking or acting with the therapist and
meets with acceptance and approval, those changes are likely to be
experimented with outside of therapy. At a deeper level (Tier 3), the
therapist’s (perhaps) unanticipated positive reaction can go a long way to
correct powerful, unconscious images of the self and of others that have
been maintained by the patient’s fears and inhibitions and by interpersonal
responses from others who are ambiguous or as negative as the patient had
anticipated, thereby providing a corrective emotional experience.
The relational stance of the therapist is a crucial variable in determining
the emotional valence of the therapeutic alliance and of the effectiveness of
the therapeutic process. A cartoon suggested by Stricker and featured in an
article by Goldfried (1999) illustrates our point very well: A patient and
therapist meet for the first time. In the thought bubble above the patient’s
head is the worrisome idea, “I hope he treats the problem I have,” while the
therapist frets, “I hope she has the problem I treat.” Goldfried used this
cartoon to help explain his movement toward psychotherapy integration.
We refer to it to underscore our attempt to tailor the therapeutic interaction
to the needs of the patient rather than to the dictates of any particular
therapeutic ideology.
We attempt to ascertain quickly whether patients would benefit most
from active interventions that are symptom-focused, and, if so, is this the
best approach to solidify their trust and confidence in the therapist and the
therapy? Or, are these patients for whom active interventions would be
experienced as pressured and intrusive and therefore would be met best
with a more gentle, empathic, and reflective approach? Or, are these people
who can and are interested in “diving into” the relative depths of the
unconscious nuances of transference analysis, dream interpretation, and free
association? We consider all of these approaches potentially to be equally
valid and possible starting points, and we move from one relationship path
to the other as the therapy unwinds and reveals itself.
For example, we would not typically start with active interventions with
a patient whose presenting complaints are clustered around chronic
dissatisfaction with intimate relationships or with work and who has some
sense that these problems are connected to his or her developmental history.
To start with active interventions with this person might contribute to the
patient feeling belittled, infantilized, or disrespected and could interfere
greatly with the establishment of an effective alliance. With such a person,
the therapeutic sequence may be characterized by long periods of inquiry,
interpretation, and transference analysis interspersed with occasional
episodes of active intervention when the need to alleviate a symptom
emerges or when the development of new skills might help the exploratory
work move forward.
In psychodynamic psychotherapy, the analysis of transference and
countertransference is a crucial, if not the crucial, ingredient. Because we
believe that the provision of corrective emotional experiences is a central
change process, it is an important goal for us to adjust our interaction with
the patient in such a way as to provide new, ameliorative experiences. This
requires us to be thinking about the potential impact of our behavior and
language on patients, to study their associations for clues about that impact,
to interpret our hypotheses about the relationship when indicated, and to
find ways to correct the interaction when it has become an enactment (i.e.,
unconscious repetition) of a past relationship.
The therapist’s role may change considerably as therapy continues, or it
may stay relatively constant. To be most effective, the therapist’s role
should be a reflection of the predominant clinical issues, needs, goals, and
intentions of the patient, including the patient’s latent and overt sense of
what types of interactions and techniques would be most helpful (Bohart &
Talman, 1999; Hubble, Duncan, & Miller, 1999). When a particular patient
can be served best by more radical shifts in understanding and technique,
then the therapist’s activity will be quite different at various points in
therapy: in the case of a more fragile patient, the therapist may start out in a
very active, structuring, and didactic role (much like a cognitive-behavioral
therapist) and only later shift into a less active psychodynamic position in
which her or his tasks are empathic reflection, questioning, and occasional
interpretation. We have found that, with most patients, active interventions
occur most frequently in the middle phase of the therapy, with the
beginning being dominantly based on inquiry, empathic reflection, and
some tentative interpretative work, and the final phase being characterized
by deeper psychodynamic exploration and transference analysis.

METHODS AND TECHNIQUES

We rely on questioning, clarification, confrontation (pointing out of an
immediate behavior or experience about which the patient seems to be
unaware), and interpretation as standard interventions that occur during
psychodynamic therapy. At those times when active intervention is called
for, we use such methods as behavior rehearsal, social skills training,
relaxation in many of its forms, cognitive monitoring, guided imagery,
systematic and in vivo desensitization, response cost, and experiential
techniques such as the empty chair and two-chair methods.
Patients differ to some degree with regard to which of these methods they
find most engaging. Patients with different personality structures, relational
styles, and psychological capacities seem to be best engaged with different
techniques. In this perspective, we are in agreement with those (e.g.,
Consoli & Beutler, Chapter 7, this volume; Lazarus & Lazarus, Chapter 6,
this volume) who argue for prescriptive matching of patient and
intervention. Patients who are more thoughtful, internally focused, and
concerned with the “whys” of their behavior seem to be best engaged, at
least at first, by the traditional methods of person-centered therapy and
psychoanalysis: empathic exploration, reflection of feelings, and detailed
inquiry into the historical sources and current manifestations of intrapsychic
events. More action-oriented, externally directed patients may be more
interested in the “whats” of life and often are engaged more effectively by
action-oriented, skill-directed interventions: cognitive restructuring, social
skills training, in vivo- and imagery-based desensitization, or gestalt
techniques such as the empty chair technique.
However, we also believe that matching patient and technique is only
part of effective engagement. The patient’s sense of the therapist’s genuine
commitment to being helpful to the patient may be the most important
effective ingredient or common factor in all therapies. Commitment
probably is demonstrated in any number of ways, including the therapist’s
warmth, genuineness, and positive regard (Rogers, 1961), as well as by his
or her ability to recognize and to respond to the individuality of the patient,
free of the constraint of any therapeutic ideology. It may be that willingness
on the part of the therapist to assimilatively integrate new techniques is
more helpful in engaging the patient because it demonstrates concretely the
therapist’s commitment than because of the utility of those or any other
techniques.
It is the therapist’s job, first and foremost, to listen to the patient.
Listening is a skill that is in short supply in the world. Listening conveys
and expresses commitment, warmth, and prizing, and only through
empathic, committed listening can effective assessment and formulation
occur. From listening follows questioning, which also is a commodity that
is in short supply in most lives.
Out of listening and questioning grow understanding on the part of both
participants in the therapy. When the therapist’s understanding outpaces or
precedes the patient’s understanding, it is the therapist’s job to share that
understanding in the form of interpretation (if what is understood is some
possible meaning of an interaction or event) or suggestion of an active
intervention (if what is comprehended is some way for the patient to gain
new skills or to overcome a particular symptom). It is also the therapist’s
job to accept the patient’s existing and newly attained insights, to help the
patient to articulate and to make use of the patient’s theory of change
(Hubble, Duncan, & Miller, 1999), and to accept and to use the patient’s
feedback and observations of the therapist’s impact on the therapy. This is
enhanced by formal outcome assessment (Lambert, 2007).
Our usual approach to a patient’s resistance to exploration is to explore
the meaning and the utility of such phenomena for the patient. Resistance
signals potential self-discoveries for which patients feel unprepared and
about which they are frightened. We look for the survival value in these
defensive efforts (Singer, 1965); that is, how, in past and present
relationships, did the patient benefit from not knowing or accepting some
piece of experience, some wish, fear, or interpersonal perception? How, in
the transference relationship, we ask also, are these issues being replayed?
This type of inquiry often enables the resistance to be resolved, as insight
into its sources allows patients relief from the fear that brought it about and
enables them to consider taking the risk of expanding their self-experience
in a new relationship with the therapist.
Sometimes, resistances are manifested or are caused by problems and
deficits in Tiers 1 (behavior) and 2 (conscious experience) and can best be
resolved by active intervention at those levels. A socially phobic patient
may use psychodynamic exploration, the need to know more about the
historical sources of their interpersonal discomfort, as a way of avoiding
trying out new social behaviors. This may keep new insights from being
pursued. This point was made first by Freud (1912/1958), who argued that,
at certain crucial points in psychoanalysis, the analyst had to compel the
phobic patient to face the object of his fears lest the treatment become stale
and intellectualized. (We are not the first to think that Freud might have
been the first integrative therapist!) Thus, it is crucial to suggest an active
intervention, such as social skills training combined with in vivo
assignments to try out these new skills, in order to avoid or overcome this
resistive pattern.
We explore with the patient the meaning of the active intervention before,
during, and after its introduction and have found that such exploration
enhances the patient’s ability to cooperate with these techniques. In our
experience, a good deal of noncompliance with or resistance to experiential,
cognitive, and behavioral interventions can be avoided or undone by
exploring the psychodynamic meanings and defensive purposes of the
symptoms at which these interventions are aimed and by understanding the
interpersonal and transferential impact of the suggestion of such techniques.
As many symptoms and problematic ways of functioning are maintained
because they ward off anxiety and other dysphoric feelings, there are times
when patients find symptom-oriented techniques threatening and painful
rather than helpful. For example, we (Gold & Stricker, 1993) have found
that certain patients are reluctant to use cognitive restructuring to change
depressogenic thoughts because these thoughts unconsciously represent and
defend against awareness of the patient’s attachment to and identification
with a parent. Similarly, patients sometimes are embarrassed by experiential
techniques or by behavioral methods in which role-playing is required,
often because these scenarios are connected unwittingly to situations in
which the patient was shamed or felt exposed. Alternation between active
use of these interventions at Tiers 1 and 2 and psychodynamic exploration
seems to allow more compliance in work at all three levels. Recognition
that the tiers are played out within an interpersonal matrix, as captured by
our expanded model (Stricker, 2010), is also crucial to our approach.
The assimilative psychodynamic therapist is prone to the same kinds of
mistakes as is any psychotherapist in terms of failing to listen well or to be
tactful and considerate in responding to the patient, and to overlook
important psychodynamic material in and outside of the transference
relationship. The most serious errors that are unique to this approach
involve too rapid or too infrequent shifts from one therapeutic stance and
technique to another. There are important times when “staying the course”
is the most crucial, useful approach, and a shift from psychodynamic
exploration to active intervention may reflect a misunderstanding of the
patient’s need or a countertransference issue that is “too hot” and is thus
avoided by shifting the therapeutic focus. At other times, the therapist may
err by overlooking the opportunity to expand or deepen the therapy by
moving from exploration to active intervention. At times, this may be
experienced as a repetition of a parental failure to respond to the patient’s
distress and may therefore have serious but undisclosed consequences
(Frank, 1999). In particular, this lack of responsiveness may deepen the
patient’s conviction that help is unavailable or undeserved and thus
represent an enactment of previous difficulties.
We try to announce or prepare the patient for shifts to experiential,
cognitive, and behavioral techniques in a tentative, experimental way,
allowing the patient to decide whether to use them. We have found that a
patient’s decision to use or not use an active intervention can be as or more
important than the impact of that intervention. These decisions can tell us
much about patients’ real and transferential perceptions of the therapist,
their lack of trust, their motivation for change, and about conflicts and
memories that are stimulated by the therapist’s assumption of a more active
and directive stance.
We have not developed any explicit guidelines with regard to relapse
prevention and maintenance sessions; however, these are included
frequently. For example, as termination of any therapy nears, we often taper
down the frequency of sessions (from weekly to biweekly to monthly) and
then discuss with the patient the possibility of follow-up sessions after the
official termination session. Quite often, these are issues that are brought up
first by the patient, and, as frequently as possible, we follow the patient’s
suggested changes in schedule and desire for posttermination contacts. With
patients who have made specific gains that seem tenuous (such as having
overcome shyness or other social inhibitions or who have modified long-
standing dysfunctional thoughts), we may engage in relapse prevention
practice sessions (Marlatt & Gordon, 1985). Finally, especially in these
days of time-limited psychotherapy because of insurance limitations, it is
important to prepare the patient for a possible return to treatment so that any
potential future difficulties are viewed as a natural occurrence rather than a
failure of treatment.

DIVERSITY CONSIDERATIONS
Diversity, as we understand it, embraces all of the dimensions of human
difference. As such, it refers to differences in race and ethnicity, culture and
social class, sex, gender, and orientation, religious and political beliefs,
physical appearance and abilities, age, and myriad other dimensions that are
not listed. Sensitivity to diversity requires sensitivity to what makes the
patient a human being and implies a high level of empathy.
Assimilative psychodynamic psychotherapy is well-suited to deal with
issues of diversity, as are any other integrative approaches that do not rely
on a manual. As long as the therapist is free to respond to the patient in a
flexible and empathic manner, diversity will be taken into account.
Assimilative psychodynamic psychotherapy is particularly well-suited
because our revised three-tier model understands the full range of human
response, including behavioral, conscious, and unconscious factors; places
them in a bidirectional relational context; and views everything within a
cultural context. The ability to shift interventions according to patient needs
also allows for a response to any human dimension that may be present.
However, it must be noted that this depends on the ability of the therapist
to be aware of inevitable blind spots and not to allow these to disrupt an
empathic relationship. This can lead to a rupture, and it is important that
such ruptures be identified as early as possible. For that reason, outcome
assessment is an important component of our approach.

CASE EXAMPLE

This young adult was treated on a once-per-week basis for approximately

17 months by one of us (JG). The presentation of this case will focus on the
specific points in the therapy at which active interventions were assimilated
into a standard psychodynamic approach. These interventions were selected
to accomplish the simultaneous purposes of furthering psychodynamic
exploration while alleviating symptoms and building new skills.

Presenting Problems and Background

Ms. M is a 30-year-old married Caucasian woman who presented for
therapy complaining of chronic anxiety and periods of moderate depression.
She was particularly concerned with periods of what she called “fuzziness,”
during which she experienced accelerating anxiety, physical distress that
included rapid heartbeat, intense perspiration, and an altered state of
perception in which things seemed vague and out of focus to her. Ms. M
described herself as a chronic “worrywart,” to the point that “if I can’t
remember what I was just worrying about, I worry about that.” She stated
that most recently her worries had clustered around fears that her
“fuzziness” meant that she was going to lose her mind and around the
health and well-being of her 2-year-old son.
Ms. M was a college graduate who recently had returned to work as an
accountant in a small tax firm. She had been married for 6 years to a middle
school teacher, whom she described as kind and loving, but who was
increasingly concerned about her emotional state. Their son had been
planned, and the couple hoped to have another child in a few years.
Ms. M was the older of two children born to a small business owner and
his stay-at-home wife. She described her childhood as horrific. Her father
spent many hours at his store and, when not working, was absent from their
home. These absences were explained simply as being “out” and were the
source of ongoing bitterness and screaming fights between her parents. Her
mother often accused the patient’s father of having affairs, which he neither
admitted nor denied. He in turn told his wife that she was crazy and unfit to
be a mother. Ms. M reported that her father rarely spent time with her or
spoke to her and that her mother’s approach to her was critical and
demeaning. Ms. M had few friends and coped with her family life by
retreating into television programs, books, and schoolwork. A good student,
she had attended an out-of-state college where she had met her future
husband. Once married, they settled in a town about an hour’s drive from
her parents. She reported that her parents visited once or twice a month, and
she visited them at about the same frequency. These visits were described as
awful: her parents argued and fought with each other, and her mother
criticized Ms. M’s parenting, home, and husband on a constant basis. Ms. M
reported that her anxiety, “fuzziness,” and depression worsened in the days
prior to and after these visits, which she anticipated with dread.

Beginning the Treatment

The treatment began with an attempt at engaging Ms. M in a standard
psychodynamic framework. Ms. M was encouraged to speak freely while
the therapist conducted a detailed inquiry in a gradual and supportive way.
It soon became apparent that this approach would not be useful and in fact
might lead to grave problems. Weeks 1 through 15 encompassed
assimilative use of cognitive and behavioral techniques to establish an
alliance and manage resistance.
Ms. M had never been in psychotherapy and was quite frightened and
ashamed at the prospect of beginning this treatment. She believed that a
need for help indicated that she was in danger of losing her mind and was a
sign of weakness and failure. Her discussion of these fears also seemed to
point to an unconscious identification with the criticisms her father had
hurled at her mother. Ms. M was tentative and uncomfortable with the
therapist and seemed to have rapidly developed a negative transference that
combined elements of the worst aspects of both of her parents: her father’s
neglectful lack of presence and her mother’s critical, demeaning attacks.
These issues clearly presented major obstacles toward the establishment
of a therapeutic alliance and were the sources of immediate and powerful
resistances in the sessions. Ms. M could not make eye contact, frequently
was silent for long periods, and when she did speak seemed either to be
defending herself from criticism or to be pleading for attention.
Psychodynamic exploration seemed both counterproductive and impossible.
Exploration of her fear and shame seemed to come across as critical and
shaming. Instead, it seemed necessary to use active interventions to change
her experience of psychotherapy and to help her to view the therapist as
different from her parents.
To alleviate Ms. M’s shame and fear over her need for therapy, the
therapist suggested that she do some research about successful and famous
people who had been public about their own psychological treatment. As
noted, reading had been an important source of solace during her troubled
childhood. She also had mentioned that she was a fan of rock music, and so
the therapist advised her to look into the autobiographies written by such
celebrities as Bruce Springsteen and Eric Clapton, and to read interviews
with other musicians such as John Lennon and Sting, all of whom described
the positive role of psychotherapy in their lives. She also was encouraged to
do some research about anxiety disorders, their prevalence, and the
frequency of use of psychotherapy in the general populations. These
interventions were chosen as ways of acknowledging Ms. M’s intellectual
strengths, the comfort she took from reading, and as a way of reassuring her
without directly challenging her doubts and fears.
Along with these and other psychoeducational efforts came the use of
self-talk, imagery, and acceptance-based techniques to assist the patient in
managing her anxiety. These techniques were emphasized for purposes that
included but went beyond the standard benefits that might accrue from their
use. Certainly, symptomatic relief for the patient was of central importance.
The therapist hoped that improvement in the patient’s symptoms would also
lead to an improved therapeutic relationship. If the patient were to
experience the therapist as accepting, kind, and helpful, then perhaps this
would increase her ability to see him more clearly, thus reducing her fearful
transference reactions and her need to defend herself in the sessions.
 Ms. M experienced “a bit” of relief from her shame about psychotherapy
through her reading and research. She had concluded that her concerns
about therapy and the prospect of “losing her mind” probably were
exaggerated and that her form of psychological disorder was in the range of
the “common cold.” She expressed some gratitude for the book
recommendations and also reported that she had read interviews with
former President Carter and (then current) First Lady Michelle Obama that
recounted their positive experiences in psychotherapy. These interviews
also reassured her and offered positive figures with whom to identify as
well.
As a result of the reduction of Ms. M’s discomfort, she spoke more
openly and made active use of specific cognitive techniques to work on her
anxiety. The first technique used was a simple “mantra-like” phrase of
saying, “focus on what is going on, rather than what could be,” whenever
she started to worry. She also was taught how to use distraction and
distancing techniques, such as imagining her worries on a television screen
and then changing the channel. Another technique involved imagining her
worries being enveloped in a large soap bubble and then floating away.
These techniques were practiced in sessions and in homework assignments.
As the patient developed more comfort and competence with these
methods, she found herself somewhat less anxious and more positive about
being in therapy. She seemed more comfortable, spoke more freely, made
eye contact, and reported that she had started to look forward to her
sessions. She also began to bring up questions about her reactions to
therapy and the therapist, wondering about why she had been so fearful and
uncomfortable, when in fact she could now see him in a more realistic way.
An alliance had been established, and the interfering parental transferences
and subsequent resistances had been resolved enough to allow the work to
proceed. In particular, Ms. M discussed her new perceptions of the therapist
as a potential ally and accepting parental figure. It was at this point, through
mutual agreement, that fruitful psychodynamic exploration was begun.

Middle Phase of Treatment

Sessions 16–47 were characterized by periods of active intervention to
enhance and expand psychodynamic change. Ms. M’s involvement in
therapy and her curiosity about her mind and its workings increased as her
anxiety symptoms diminished. She was most concerned with the causes and
meanings of the “fuzziness” and eventually reached the understanding that
this altered state of experience was the result of unacknowledged anger,
particularly at her parents. She became aware of the correlations between
being “fuzzy” and the times she found herself thinking about her parents or
interacting with them. She frequently asked herself, in and out of sessions,
“If I’m angry, why don’t I feel it?” Interpretations of possible guilt and fear
interfering with awareness of anger made sense to her but did not lead to
changes in her experience.
At this point, the therapist suggested the use of a mindfulness technique
to circumvent this situation. Ms. M was instructed to use her “fuzzy” states
as a signal to explore what was going on in her mind and body as fully as
possible, rather than trying to change them. After much practice, she was
able to fully immerse herself in these states and reported feeling the
beginnings of an urge to break things, scream, and insult whoever was
around. The similarities to her mother’s behavior during fights with the
patient’s father became apparent to Ms. M She concluded that one reason
anger was so difficult for her was that it made her seem, to herself, that she
and her mother were more alike than she could tolerate.
This identification with the worst aspects of her mother’s personality was
very troubling to Ms. M, who asked if she could learn to use anger more
effectively and appropriately than had her parent. To accomplish this goal,
and to promote separation of her view of herself from this old and painful
identification, we employed a series of social skills exercises. These
exercises allowed Ms. M to experience and express angry feelings in
moderate and appropriate ways while differentiating her self-perception
from her view of her parents, thus allowing psychological maturation to
proceed in a positive direction.
As Ms. M developed greater tolerance for anger and continued to
perceive herself as a distinct individual, she brought to her sessions dreams,
memories, and fantasies that yielded a deeply felt understanding of the
depth and extent of the hurt, rage, and fear that had accumulated during her
childhood and adolescence. She came to realize that her worries and her
“fuzzy” states of mind served as ways of avoiding and disconnecting from
these feelings and the murderous and destructive fantasies that they
provoked. She also became aware of the guilt and fear that she harbored
about these fantasies and feelings, particularly in connection to wishes to
hurt or kill her parents. She also gradually learned that her worries about
her son were an expression of her unconscious identification with the
hurtful characteristics of her parents: she unknowingly feared that she
would do to him as they had done to her. So, as her view of herself changed
in a more individuated and positive way, the frequency and intensity of her
worry diminished as well.
It is difficult to convey, in this short space, the full extent of the interplay
between psychodynamic work and active intervention during this long
phase of the therapy. Even during the most intense moments of exploration,
there were frequent references to the use of cognitive techniques, which
allowed Ms. M to stay with the work. These brief digressions allowed her to
tolerate long-avoided wishes, feelings, thoughts, and memories, and
modified the destructive meanings with which they were connected. In a
similar vein, longer periods of active intervention were infiltrated with
moments of interpretation of unconscious meanings, often following the
spontaneous emergence of an unexpected feeling, memory, or fantasy that
seemed to be “liberated” by active change on the patient’s part.
One of the more important changes in Ms. M that occurred during this
part of the therapy accrued in about equal measure from the psychodynamic
and cognitive-behavioral interventions. Ms. M developed a mature sense of
pride and confidence in her new-found abilities to accept anger in all of its
extreme—even murderous—forms and in her corresponding ability to
express these feelings in mature ways. She emphatically connected
improvements in her self-esteem to her new insights and abilities, especially
as these changes provided her with an identity distinct from her parents.
It also is worth noting that the patient’s comorbid depression improved
significantly without much direct work on that problem. She and the
therapist both came to understand that these mood problems were driven by
her anxiety and its intrapsychic and interpersonal sources. The alleviation in
depression was probably due to the gains she had made in these primary
problems.
Ms. M also frequently discussed her sense of being accepted and
approved of by the therapist and of her sense that his attitude toward her
served as a permanent “antidote” to the destructive familial experiences.
She reported that it was particularly important to her that the therapist had
been willing to work in both an exploratory and active, instructional way as
her needs changed. As the therapy progressed, she had educated herself
about the various debates in psychotherapy and, on her own, had come to
the conclusion that a therapist who stuck to one approach, in spite of the
demonstration of her needs to the contrary, might have unwittingly
recreated some of the negative aspects of her childhood experiences.

The Final Phase

After about a year of treatment, Ms. M’s functioning was markedly
improved, and she had begun to think about ending the therapy. She
decided to put off this ending because she was troubled by occasional flare-
ups of anxiety and worry, usually, if not always, connected to a visit or
phone conversation with her parents. Ms. M was aware that her now 3-year-
old son, and her parenting of him, had become the targets of her mother’s
criticisms, which hurt Ms. M deeply. Ms. M also was distressed by her
father’s indifference to his grandson, expressed by an unwillingness to play
with the boy or to show affection to him.
Ms. M’s ability to manage her feelings about these interactions and to
make any changes were complicated by her relationship with her husband.
She described him as generally supportive and affectionate, but also as
bullied by her parents and as fearful of any confrontation. He often advised
her to “not rock the boat,” especially as her parents had been helpful to the
couple financially and he seemed afraid of losing that monetary support.
Ms. M used the final phase of the therapy to explore these interactions
and, specifically, her fears of confronting her parents, of setting limits on
their critical and indifferent behaviors, and of differing with her husband.
These sessions yielded considerable insight into core feelings and fear of
abandonment, her long-warded-off sense of being worthless and unlovable
in her parents’ eyes, and much anger and disappointment. In addition, a
pervasive sense of grief for the love and well-being she had been deprived
of emerged into awareness and was painfully worked though.
As these issues were explored and integrated, in-session work often
incorporated active practice in assertive limit-setting and confrontation of
unacceptable behavior on the part of her husband and parents. Ms. M was
able to “rock the boat” and to tolerate her husband’s initial disapproval and
concern, leading eventually to a better connection between the two. She
also made it clear to her parents that any criticism or neglect of her son
would lead to visits ending and to less frequent contact with her and the
boy. She demonstrated this to them on several occasions; the result was that
their behavior moved in a more positive direction.
Most importantly, Ms. M found that her bouts of anxiety had decreased
significantly in frequency and intensity, and while she often felt “unhappy”
before and after visits to her parents, her level of distress was quite
manageable. She took great pride in having protected her son and
separating her own sense of self-worth from the old feelings of
worthlessness that had become conscious in this last part of therapy.
It was at this point that the therapy was ended with plans for follow-up
sessions at intervals of 2 months and 6 months beyond the termination date.
Ms. M was seen at those two times and reported that she had maintained her
gains with regard to her anxiety. She had, with sadness but with resolve,
greatly limited her contact with her parents due to their failure to live up to
her (minimum) standards for their behavior toward her and her son. She
was enjoying her work and being a parent, and her marriage was stable.
She and the therapist agreed that no regular meetings need be scheduled,
though she could call if the need did arise. There have been no meetings
since this last one, and the only contact was a holiday card in which Ms. M
described continued well-being and life satisfaction.

OUTCOME RESEARCH
There is only a little empirical evidence concerning the effectiveness of
assimilative psychodynamic psychotherapy, but there is ample support for
the efficacy of psychodynamic therapy. Multiple meta-analyses find that
psychodynamic therapy, in general, proves effective for many disorders. A
meta-analysis of 42 treatment samples, totaling 1,615 patients, found a large
effect size of d of 1.01 between pretreatment and posttreatment across all
studies (Town et al., 2012). A recent meta-analysis tested the efficacy of
psychodynamic therapy in 39 randomized controlled trials (Leichsenring et
al., 2015). It showed that, by rigorous criteria used to define what works,
psychodynamic therapy can be considered efficacious for major depression,
social anxiety disorder, borderline personality disorder, and somatoform
pain disorder. It can be considered possibly efficacious for complicated
grief, panic disorder, substance abuse, and generalized anxiety disorder. The
empirical evidence has steadily accumulated on its efficacy for multiple
disorders routinely encountered in daily practice.
 Lilliengren has posted a comprehensive compilation of randomized
controlled trials (RCTs) involving psychodynamic treatments
(www.researchgate.net/publication/317335876). That list, as of November
2017, has 200 entries, making it clear that psychodynamic treatment is both
testable and efficacious.
There is a notion that CBT represents the gold standard for effective
psychotherapy, a conclusion that has been based on researcher allegiance
and limitations in the quality of the studies (Leichsenring & Steinert, 2017).
Although a bias against psychodynamic therapy (Abbass et al., 2017) may
be present, it is belied by the evidence. Sophisticated meta-analyses
repeatedly demonstrate the equivalence of psychodynamic therapy to other
established treatments (Steinert et al., 2017).
There also have been a series of studies that directly look at the impact of
psychotherapy integration in general and assimilative psychodynamic
psychotherapy in particular. A study of videotaped sessions by master
therapists found that integrative therapists used more psychodynamic
techniques than CBT therapists and more CBT interventions than
psychodynamic therapists (Pitman et al., 2017), showing that integration
does occur. The integration of CBT and psychodynamic techniques has
been repeatedly related to a more positive therapeutic alliance (e.g.,
Goldman et al., 2013, 2016; Zilcha-Mano & Errazuriz, 2015).

FUTURE DIRECTIONS
Assimilative psychodynamic psychotherapy rests on a foundation of
psychodynamic theory and practice, as well as the practice (and perhaps the
theory) of many other treatment approaches. Further developments,
therefore, will rely on each of these areas.
Perhaps the most important questions we must ask concern effectiveness.
Is this therapy equally as effective as, or is it more effective than, the
component therapies (psychodynamic, cognitive-behavioral, or
experiential) that are assimilated? Equally important is the question of
whether this therapy is more effective than any other systems of treatment.
Associated with these queries are such concerns as the degree to which this
therapy can be prescribed for particular diagnoses, psychological
characteristics, problems, and persons. Research that is guided by, and can
test, theoretical issues such as our assimilative modifications of
psychoanalytic theory also is necessary. We believe there is an important
need for research that can investigate the incremental validity of our
expansion of the psychodynamic perspective when compared to its
traditional conceptualization. Finally, questions of generalizability come to
the fore. For example, can we identify and offer empirical guidelines that
instruct us as to when and how to move from one technique to the next, or
must clinical intuition remain our guide?
Psychodynamic theory is an area of evolving development (Wachtel,
2007). In previous years, there has been a change from a one-person
treatment that emphasized the internal processes of the patient to a two-
person treatment that gave much more emphasis to relationship issues. Our
approach has kept stride with this change and is based on a theoretical
model that emphasizes relationships with others. It is difficult to foresee
future areas of growth in theory, but every step toward integration that is
based on assimilation should be complemented by a step that produces an
accommodation of the theory to the new clinical observations. Perhaps it
was the clinical observations of the importance of relationship issues (e.g.,
the corrective emotional experience) that led to the expansion of
psychodynamic models (e.g., interpersonal psychoanalysis, self-
psychology). As the success of assimilation becomes clear, the need for
accommodation opens an exciting path to theory development.
Psychodynamic technique also has changed as the underlying theory has
changed. The silent therapist of prior years has been replaced by a more
active therapist who deals with relationship issues inside and outside the
consulting room. Our model, particularly when behavioral, cognitive, and
experiential techniques are being employed, calls for even more therapist
activity, and we expect that the future will move in this direction while
continuing to retain the value of silent listening and empathy during the
course of treatment.
As we indicated at the outset of this chapter, assimilative psychodynamic
psychotherapy relies on the incorporation of techniques from other
orientations to treatment. Techniques that are used today either were not
available or were little known during our earlier training. As the other
orientations grow, we must remain aware of these developments and be
alert to the possibility that they may offer to our work with our patients.
Two areas of current research must be taken into account when looking to
the future. The first is outcome assessment, as exemplified by the influential
research programs of Lambert (e.g., 2007, 2018) and Duncan (e.g., Duncan
& Sparks, 2017). This research has repeatedly demonstrated the value of
frequent evaluation of both the therapeutic relationship and treatment
outcome. The integration of outcome measures into assimilative
psychodynamic psychotherapy represents an important addition. The
second research challenge is that one approach to therapy is not reliably
better than any other (the Dodo Bird effect; e.g., Laska, Gurman, &
Wampold, 2014). This latter finding has often been attributed to common
factors that account for the majority of outcome variance. Whether we are
discussing assimilative psychodynamic psychotherapy or any other
integrative approach, it is necessary to show that the approach has some
value added as compared to single-school approaches, which themselves
have not differentiated from each other.
Finally, although we have detailed directions that are more specific to
assimilative psychodynamic psychotherapy, other research issues clearly
exist. Issues related to the relative value of different approaches, the
generalizability of clinical observations, and the potential disentangling of
assimilative methods all remain to be studied. During this time, it behooves
every practitioner to adopt the stance of a local clinical scientist (Stricker &
Trierweiler, 1995; Trierweiler & Stricker, 1998), treating each patient as a
small research project and learning from each clinical encounter something
that will be of use with the next patient.

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 11

Cognitive-Behavioral Assimilative Integration

LOUIS G. CASTONGUAY, MICHELLE G. NEWMAN, AND MARTIN GROSSE
HOLTFORTH

The three authors of this chapter define themselves, with more or less
conviction, as cognitive-behavior therapists. Operationally, this means that
we believe that distressing behaviors, cognitions, and emotions should be
primary targets of our interventions. We also assume that both situational
(e.g., external contingencies) and intrapersonal (e.g., inaccurate cognitions)
factors are involved in the etiology and/or maintenance of our clients’
impairments. As cognitive behavior therapists, we further believe that a
fruitful clinical strategy is to identify the determinants of clients’ difficulties
by conducting comprehensive functional analyses and case formulations
that are grounded in known empirical knowledge.
However, while it is clear to us that psychotherapy can reduce clients’
impairments, we are convinced that cure is not a possibility. Even after
successful therapy, the difficulties of life will likely continue to trigger
vulnerabilities that are linked to years of complex learning, implicit
meaning structures, biological processes, and genetic predispositions. In our
opinion, the ultimate goal of therapy is to facilitate the acquisition of coping
skills (emotional, cognitive, and behavioral) that will help clients cope with
life’s stressful demands.
Along with the theoretical writing of leading figures in cognitive-
behavioral therapy (CBT), our clinical experience has suggested that the
traditional techniques of this orientation are not always sufficient to treat
clients’ distress and to help them develop better ways of dealing with life’s
difficulties. On more than one occasion, we have found it helpful to let
clients talk extensively about early relationships with their parents, to
encourage them to experience and “stay with” painful feelings, or to draw
links between what is taking place in the therapy relationship and what has
occurred in their interpersonal relationships outside of therapy.
The beneficial use of what many would consider “non-CBT”
interventions has raised the question of how best to incorporate techniques
derived from (or consistent with) humanistic, psychodynamic,
interpersonal, or systemic approaches into our CBT practice. The
integrative approach described in this chapter represents our effort to
improve the efficacy of CBT via a systematic and theoretically cohesive
assimilation of treatment procedures typically associated with other
psychotherapy orientations.

THE INTEGRATIVE APPROACH

Our integrative approach is based on the assumption that clients’
improvement is due in part to principles of change that cut across different
forms of therapy (Castonguay, 2000). As described by Goldfried (1980;
Goldfried & Padawer, 1982), we believe that most techniques associated
with particular orientations are idiosyncratic manifestations of common
principles. These principles include the fostering of positive expectations
toward therapy, the increase in awareness about self and others, the
establishment of a therapeutic alliance, the facilitation of new and/or
corrective experiences, and the generalization of therapeutic change in the
client’s daily life. More about principles of change can be found in Eubanks
and Goldfried (Chapter 4, this volume).
From a clinical standpoint, our approach is based on the premise that the
repertoire of interventions of a particular orientation (e.g., CBT) can be
increased by adding techniques that reflect general principles of
intervention while allowing this specific approach to address more directly
or adequately certain dimensions of human functioning. Based on research
findings, as well as on conceptual critiques and modifications of CBT, we
believe that a fruitful way to improve CBT’s efficacy is to add techniques
aimed at facilitating interpersonal functioning and emotional deepening.

Interpersonal Focus
Several authors have criticized CBT (and especially cognitive therapy) for
not paying sufficient attention to interpersonal factors involved in
psychopathology (e.g., Coyne & Gotlib, 1983; Goldfried & Castonguay,
1993; Robins & Hayes, 1993). There is convincing evidence that cognitive-
behavioral therapists focus less on interpersonal experience than do
psychodynamic-interpersonal (PI) therapists (e.g., Blagys & Hilsenroth,
2000). In addition, while one preliminary study found that CBT therapists
tended to focus more on interpersonal issues than intrapersonal issues (Kerr
et al., 1992), the reverse was found in two later studies (Castonguay et al.,
1995; Castonguay, Hayes et al., 1998). More importantly, interpersonal
focus in CBT has been found to be unrelated to client’s improvement in two
studies (Castonguay, Hayes et al., 1998; Kerr et al., 1992).
Moreover, one study found that the therapist’s focus on interpersonal
cognitions is negatively related to outcome in cognitive therapy (Hayes,
Castonguay, & Goldfried, 1996). By contrast, evidence suggests that when
PI therapists focus on interpersonal issues, such focus is positively linked
with outcome (Castonguay, Hayes, et al., 1998; Kerr et al., 1992).
Furthermore, process studies suggest that clients do improve when
cognitive-behavior therapists focus on the kinds of interpersonal issues
typically emphasized in psychodynamic treatment. For instance, Hayes et
al. (1996) found a positive relationship between the therapist’s focus on
early attachment patterns and client’s improvement in CBT. Other studies
(Ablon & Jones, 1998; Jones & Pulos, 1993) also found that the therapist’s
connections between the therapeutic relationship and other relationships
were among a set of psychodynamic techniques positively related to
therapeutic change in CBT. Taken together, these findings suggest that
adding techniques from the psychodynamic and interpersonal traditions to
address client’s maladaptive relationship patterns might increase the
therapeutic impact of CBT.

Emotional Deepening
Prominent authors in the field have criticized CBT for approaching
emotions as phenomena to be controlled rather than experienced (e.g.,
Mahoney, 1980). One study (Wiser & Goldfried, 1993) provided evidence
to suggest that cognitive-behavior therapists see the reduction of emotional
experiencing as a significant event during the session, whereas PI therapists
view good sessions as involving an increase in emotional experiencing.
Recent studies lend very strong support for the notion that PI focuses more
than CBT on the expression of patients’ emotions. As noted by Blagys and
Hilsenroth (2000, p. 172), these empirical findings also
support the notion that PI therapy attempts to evoke the expression of patients’ emotion while
CB therapy attempts to control or reduce patients’ feelings. The propensity of PI therapy to
focus on affect not only conveys a greater emphasis on cathartic expression, but also a greater
focus on emotional insight and a greater encouragement to identify, stay with and/or accept
emotions.

Interestingly, a number of studies have found that the client’s emotional

experience in CBT is positively linked with outcome (Castonguay et al.,
1996; Castonguay, Pincus et al., 1998). Indeed, a recent meta-analysis of 42
studies (N = 925) found that patient affective experiencing and expression
in session was robustly associated with and predictive of (d = .85) favorable
outcomes in psychotherapy (Peluso & Freud, 2018). That was the case with
all types of psychotherapy, including CBT (Ablon & Jones, 1998, 1999;
Coombs, Coleman, & Jones, 2002; Jones & Pulos, 1993).
The decision to emphasize both interpersonal and emotional issues when
attempting to improve CBT has also been influenced by Safran’s expansion
of cognitive therapy (Safran, 1998; Safran & Segal, 1990). Although
endorsing the concept of schema, Safran has argued that such mental
representation of self is intrinsically interpersonal. Relationships with others
are implicitly or explicitly embedded in our understanding of who we are.
In addition, core schemas are not purely cognitive. Rather, they are
cognitive-affective structures, or “hot” cognitions. The interpersonal and
emotional nature of our core schema reflect the fact that our views of self
are deeply shaped by our relationships with significant others. The ways we
perceive and treat ourselves are based on the way important others (past and
current) have viewed and treated us.
Within this context, an emotionally immediate exploration of the clients’
problematic relationships with important others (parents, spouse, therapist)
provides a unique opportunity to better understand their interpersonal needs
and fears, as well as to correct their maladaptive schema of self and others
and their behavioral relationship patterns. Safran’s model has provided us
with a conceptual framework accounting for and addressing interpersonal
and emotional dimensions of human functioning when, as cognitive-
behavioral therapists, we attempt to provide a new perspective of self, to
facilitate positive experience, foster more adaptive ways of dealing with
reality, and to enhance or repair our therapeutic alliances.
Having described the bases of our integrative approach, we now turn to a
more pragmatic question: How do we actually combine traditional CBT
techniques with interpersonally and emotionally focused interventions that
are derived from (or consistent with) interpersonal, psychodynamic, and
humanistic orientations?

APPLICABILITY AND STRUCTURE

The main efforts described in this chapter to increase the effectiveness of
CBT have evolved via the development and empirical testing of treatments
for depression (Castonguay et al., 2004) and generalized anxiety disorders
(GAD; Newman et al., 2004). Because it is the most comprehensive of the
two, the GAD treatment will be the main focus of this chapter.
CBT includes multiple techniques that directly address situational and
intrapersonal factors involved in the etiology or maintenance of GAD.
Numerous studies have demonstrated that this treatment leads to
statistically and clinically significant change in the short and long term
(Borkovec & Ruscio, 2001). As summarized in an overview of both
psychopharmacological and psychosocial treatments for mental disorders,
“[r]ecent studies suggest that CBT approaches are most successful for
generalized anxiety disorder” (Nathan & Gorman, 2015, page xxi). Yet,
there is also evidence that a substantial number of clients with GAD still
show clinical symptoms after CBT (Borkovec & Ruscio, 2001; Borkovec &
Whisman, 1996).
The evolution of integrative therapy for GAD had its origins in the
seminal work of Thomas Borkovec, especially the basic and therapy
outcome research on GAD he conducted from 1984 to 1995 (Borkovec,
1996). The fact that many clients in these earlier therapy trials were not
returned to normal levels of anxiety by the end of treatment suggested that a
therapeutic focus solely on intrapersonal processes proves insufficient.
On the other hand, evidence has indicated, both then and now, that
interpersonal as well as intrapersonal processes are likely involved in the
origins and maintenance of GAD (Newman & Erickson, 2010).
Specifically, worry is most closely associated with social-evaluative fears
(Borkovec et al., 1983) and interpersonal topics (Roemer, Molina, &
Borkovec, 1997). In addition, social phobia is the most common comorbid
diagnosis among GAD clients (Brown & Barlow, 1992). GAD clients also
report elevated levels of attachment problems with their primary caregivers
in childhood (Cassidy, 1995; Newman, Shin, & Zuellig, 2016; Schut et al.,
1997), suggesting potential interpersonal problems with others. Moreover,
several studies have found that a majority of GAD clients report
interpersonal problems related to being intrusive, cold, exploitable and
nonassertive that likely cause difficulties for them in their current
relationships (Przeworski et al., 2011; Salzer et al., 2008). More recent
studies also suggest that whereas hostile interpersonal problems of GAD
individuals are reported by significant others, those with GAD tend to
report more affiliative problems (Erickson et al., 2016; Shin & Newman,
2017) and that those with GAD under- or overestimate their hostile impact
(Erickson & Newman, 2007). Dimensions of interpersonal problems also
significantly predict posttherapy and follow-up clinical improvement
(Borkovec et al., 2002; Newman et al., 2017; Salzer et al., 2011).
To address interpersonal difficulties experienced by several clients with
GAD, the integrative approach added interpersonal and experiential
techniques to CBT based, in part, on Safran and Segal’s (1990) work.
Despite the incorporation of techniques from different theoretical
orientations, Borkovec was comfortable with the fact that empirical
knowledge allowed such techniques to be used from within CBT.
Interpersonal therapy can be viewed from within CBT as an approach that
examines and then attempts to modify by emotionally focused and
interpersonally focused methods the cause-and-effect links that exist among
(a) environmental events; (b) the client’s cognitive, affective, behavioral,
and interpersonal processes; and (c) the consequences of the client’s
interpersonal behaviors. Moreover, the use of the therapeutic relationship to
provide feedback to the client about his or her interpersonal effect on the
therapist is fully in line with CBT principles of change (e.g., Kohlenberg &
Tsai, 1991).
Finally, the use of emotional deepening techniques (prescribed in both
experiential and interpersonal therapies) turned out to fit the behavioral
learning view quite well once empirical advances were made concerning
GAD and the emotional process in general. Specifically, evidence has
indicated that GAD clients largely ignore some of their emotions and
indeed may be fearful of many of them, including positive ones (Borkovec,
Alcaine, & Behar, 2004). These findings suggested that worry, the cardinal
symptom of GAD, may actually serve the role of cognitive avoidance of
affect. From a CBT perspective, therefore, emotional deepening techniques
can be used as exposure methods for the sake of full emotional processing
of fear (Foa & Kozak, 1986).
The structure of the GAD treatment is unique. Rather than involving a
simultaneous blend of theoretically diverse intervention, our assimilative
intervention involves a sequential application of two “pure” forms of
therapy. Specifically, therapists are trained to conduct a 50-minute segment
of CBT, which is immediately followed by a 50-minute segment of
interpersonal/emotional processing (I/EP) therapy (Newman et al., 2004).
This structure has been dictated by a specific scientific purpose. If this
treatment combination (CBT + I/EP) can be shown to be superior to the
combination of CBT and a supportive listening (SL) condition (CBT + SL),
then research could not only provide evidence that CBT can be improved
but also that such incremental improvement might be causally attributable
to the added interventions. Such an additive design is one of the few
process research designs that can adequately address a major question that
drives science: Causality (Borkovec & Castonguay, 1998).
The concern with internal validity comes at a price of external validity.
This integrative treatment, the way it has been structured, is not easily
transportable to the clinical setting. Effectiveness research will hopefully be
conducted to assess the feasibility and impact of a treatment structure more
in sync with the way psychotherapy is typically conducted (e.g., a 1-hour
session involving a more permeable implementation of the two treatments).
However, we should mention that during the studies described later in
this chapter, our therapists and clients did not find it onerous to work within
a particular orientation for 50 minutes and then shift to a different treatment
approach for another 50 minutes (with the exception of having to schedule a
2-hour appointment every week). In fact, our therapists frequently
mentioned that the sequential structure helped them to focus on the tasks
specific to each segment and had on many occasions prevented them from
prematurely shifting to an “off-task” intervention.
Although we have developed the integrative approach specifically for
GAD, we believe that it could be applied to other clinical problems. We
predict that CBT may be improved by adopting parts of our treatment when
targeting any problems for which the etiology and maintenance involve
interpersonal difficulties or the avoidance of painful emotions. On the other
hand, we would assume that this assimilative approach might not be
relevant or sufficient to adequately address a number of clinical problems,
such as psychotic diagnoses and severe substance dependence.
We have no evidence to suggest that the addition or removal of
psychoactive medication can be either beneficial or detrimental when
implementing this approach. In the two studies that we conducted thus far
(see later discussion), we did not exclude clients who were currently using a
stable dose of medication for anxiety as long as they consented (and their
prescribing physician approved) to maintain their dose constant during the
treatment. In general, however, we do believe that the use or increase of
psychotropic medication to reduce anxiety has the risk of reducing the
client’s full exposure to both internal and interpersonal triggers of his or her
worry—and thus may potentially interfere with the corrective mechanism
assumed to underlie both CBT and the interpersonal/emotional components
of the integrative approach.

ASSESSMENT AND FORMULATION

Because the GAD treatment was developed and used in the context of
clinical trials, the clients were assessed by two independent administrations
of a semi-structured interview—the Albany Anxiety Disorder Interview
Schedule - IV (ADIS; Brown, DiNardo, & Barlow, 1994). The ADIS
determined whether an individual suffered from the clinical disorder
targeted by the treatment and identified the specific content of the client’s
worries. Moreover, it systematically assessed comorbid conditions that were
likely to influence case formulation. For instance, knowing that a client also
struggled with social phobia helped determine intervention targets (e.g.,
social skills) when addressing interpersonal issues.
The assessment also involved a number of questionnaires that the
therapists used to identify negative cognitions that may reflect and
contribute to the client’s worry and anxiety (i.e., Dysfunctional Attitude
Scale; Beck et al., 1991), as well as to better understand the client’s
relationship patterns (e.g., Inventory of Interpersonal Problems; Alden,
Wiggins, & Pincus, 1990). The daily monitoring of clients’ anxiety and the
systematic monitoring of their relationships also helped therapists conduct
functional analyses of clients’ problematic reactions.
 During treatment, the information derived by such an extensive
assessment was used to construct case formulations, which in turn guided
an idiographic application of the CBT and I/EP techniques. In CBT,
therapists developed their case formulations around the following
questions: What are the early cues (situational and internal) of the client’s
anxiety reaction? What are the maladaptive elements (cognitive, imaginal,
physiological) of such reaction that could be replaced by more adaptive
responses? In I/EP, the case formulations were centered around the
following questions: What are the clients’ most central interpersonal
schema (i.e., core views of self in relation to others)? What do clients want
and fear from others? What do they do to get their needs met? What is the
impact they have on others? Are there specific emotions that they are
avoiding and that might tell them what they want from others?

PROCESSES OF CHANGE
We assume that a substantial part of the process of change can be attributed
to general principles that cut across different forms of psychotherapy
(including CBT and I/EP). However, the ways in which these principles
were implemented vary from one segment to another.
Early in therapy, therapists work toward creating positive expectations
for the clients. This is accomplished by providing a rationale explaining
factors that might have contributed to their difficulties, as well as a
description of techniques that will be used to address these factors. In CBT,
the rationale focuses on situational and intrapersonal issues. Specifically,
clients are informed that their experiences of uncontrollable worry and
anxiety are learned responses to threat cues, which involve maladaptive and
habitual interactions among cognitive, behavioral, and physiological
systems. For example, GAD patients frequently have a preattentive bias to
indications of danger that can trigger images of negative events, which can
in turn lead to defensive somatic reactions. As one component in the
spiraling intensification of anxiety, such somatic responses can result in
greater attention to physiological activity, which can interfere with a client’s
attention to (and realistic appraisal of) external reality and further increase
his or her internal response of worry and rumination. The goal of CBT is to
identify early cues that indicate that an anxiety spiral is beginning and to
help the client replace these maladaptive reactions with adaptive coping
responses.
In the I/EP segment, the rationale focuses on both interpersonal and
emotional issues. Clients are informed that chronically anxious individuals
frequently develop interpersonal styles that contribute to their anxiety.
Therapists tell their clients that when they interact with others, anxious
people tend to focus more on avoiding what they fear rather than trying to
get what they need. Unfortunately, attempts to avoid what one fears
sometimes lead to the specific—and anxiety-provoking—reactions from
others that one tried to avoid (e.g., being extra-attentive to another’s need in
order to not be ignored can lead the other to move away from the
relationship because he or she is feeling intruded upon). The attention to
what they fear has become such an automatic focus for chronically anxious
persons that they are frequently unaware of many of their interpersonal
needs. Clients are informed that one way to become aware of what they
need from others is to explore their emotions. Accordingly, the goal of I/EP
is to help clients become aware of—and then change—the maladaptive
ways in which they interact with others, including the therapist. By
exploring and owning emotions that are triggered by their relationship
difficulties, clients will increase their abilities to get what they want and
better deal with what they fear from others.
Another principle of change underlying each segment of this integrative
treatment is the provision of a new perspective. By offering an explanation
of the etiology and maintenance of GAD symptoms, the rationales
described earlier intrinsically serve this principle. As described in the next
section, each segment of the treatment includes additional procedures to
foster a new understanding, such as (a) helping the client challenge
inaccurate thoughts, cognitive errors, and maladaptive attitudes; (b)
experiencing and expressing previously implicit emotions and meanings;
and (c) exploring wishes and fears about others, interpersonal schemas, and
maladaptive relationship patterns. While implementing the same general
principle of change, these interventions focus on different dimensions of
human functioning (i.e., cognitive, emotional, interpersonal). Our clinical
observations suggest that clients recognize multiple types of determinants
involved in their difficulties, as well as establish meaningful connections
among them. For example, they realize that some of their ways of thinking
at times parallel their ways of relating with others or that being more open
about their emotions will help them to become less rigid about their
appraisal of themselves.
Several of the techniques described later in this chapter directly serve the
principles of corrective experience and continued testing with reality. For
example, relaxation and self-control desensitization techniques are used
during CBT segments and between sessions to help the client to learn and
rehearse new, more adaptive coping responses to anxiety-provoking cues.
Similarly, attempts at fostering new and more meaningful ways of relating
with others are made by paying attention to the interaction with the
therapist during I/EP segments, as well as between the client and others in
his or her daily life.
Interestingly, while different techniques are used to foster these two
principles of change, some of the techniques are based on the same learning
processes. For instance, exposure in CBT is designed to help the client gain
control over his or her anxiety. In I/EP, it is aimed at helping the client to
stay with and own his or her painful emotions. In both situations, the
mastery of previously intolerable situations is experienced as a positive
corrective event.
Modeling and problem-solving skills are also involved in the techniques
in each segment to correct maladaptive responses, learn more adaptive
reactions, and implement them in situations outside the sessions. For
example, such learning processes are at play when therapists help clients to
react more adaptively to anxiety-provoking cues or when they help them to
find better ways to get what they want from others.
Finally, as in all forms of psychotherapy, the use of the therapeutic
relationship reflects a core principle of change in this integrative treatment.
The ways in which therapists attend to the working alliance in each of the
segment are described in the next section.

THERAPY RELATIONSHIP
In both segments of the integrative treatment, therapists pay careful
attention to the development and maintenance of a positive therapeutic
relationship. There is, of course, a good reason for this, as different aspects
of the therapeutic relationship stand as robust predictors of change in
psychotherapy (Norcross, 2011). Thus, during the whole course of the
treatment, therapists make all possible efforts to be empathic, warm, and
supportive toward their clients and to foster mutual agreement on the goals
and tasks of therapy.
However, there is a theoretical and clinical difference in how the
relationship plays a role in the process of change underlying the two
segments of this integrative therapy. In the CBT segment, the relationship is
primarily viewed as a precondition for change. Therapists, in other words,
adopt a supportive attitude mainly to build the client’s trust in the treatment
rationale and procedures, as well as to foster the client’s willingness to do
what he or she needs to do to develop better coping skills. It is assumed that
if a good therapeutic bond (based on mutual respect and affection for each
other) is created, that if the therapist genuinely understands the client’s
subjective experience, if he or she is flexible and tactful in the use of the
prescribed technique, and if he or she encourages and reinforces the client’s
engagement in the treatment task, then it is likely that the client will face
what he or she had avoided in the past and will implement, during and
between sessions, new ways of reacting to anxiety cues.
The same assumption is held in the interpersonal and emotional
processing segment of the intervention. A good relationship is viewed as
necessary for the client’s engagement in the demanding and anxiety-
provoking tasks prescribed in this therapy segment. In this segment,
however, the therapeutic relationship is also used as a change process.
Therapists use what takes place during the session to help clients gain
awareness of, and change, their maladaptive patterns of interpersonal
interaction. Therapists, in other words, not only attempt to build a positive
relationship in I/EP but also work with the relationship to deepen authentic
emotions and to modify interpersonal habits that have contributed to
clients’ anxiety.
In addition, specific techniques are included in I/EP to deal with alliance
ruptures. Although therapists are asked to pay attention to markers of
alliance ruptures in both the CBT and I/EP segments, these markers are
addressed only during the I/EP portion.

METHODS AND TECHNIQUES

Although some principles of change cut across the two segments of this
integrative treatment for GAD, the techniques used to implement these
principles differ. Before describing these various techniques, however, it is
important to mention that the stance of the therapist in both segments is
fairly directive. Specifically, therapists ensure that the session is in line with
the respective goals of each segment. While focusing on different aspects of
functioning in each segment, therapists help clients to be more cognizant of
what they perceive as dangers (e.g., specific external events, internal
images, negative emotions, interpersonal issues) and to replace their earlier
coping responses (e.g., catastrophizing, scanning physiological reactions,
avoidance of emotion, engaging in fear-reducing interpersonal behaviors)
with ones that are more effective and less maladaptive. Helping clients to
develop new skills to deal with anxiety requires that the therapist be task-
oriented and directive, irrespective of the stimuli feared and the skills to be
taught.

Cognitive-Behavioral Work
The CBT segment is primarily aimed at modifying and reducing internal
responses to specific threats. Following is a brief overview of standard
methods employed in the CBT segment to achieve this therapeutic task
(Newman, 2002)

Self-Monitoring and Early Cue Detection

Clients are taught to identify their earliest reactions to perceived threats and
their reactions to these early reactions, as well as the spiraling chain of
internal events (attention, thoughts, images, bodily sensations, emotions,
and behaviors) that then occur. Clients can begin to discover early signs of
anxious responding by describing typical worry and anxiety experiences
and/or imagining situations involving different components of their anxiety
responses. Therapists can also help clients detect early cues of anxiety by
asking them to intentionally worry about a personal concern. Therapists
also pay great attention to noticeable shifts in the clients’ affective states as
they occur during the therapy session. Immediately pointing out such a shift
can sharpen the client’s own early cue detection.
In addition to these in-session experiences, the client is asked to self-
monitor his or her worrying and anxiety responses on a daily basis. As
sessions progress, clients are increasingly asked to attend to and process
immediately available experiences, both in the environment and internally.
The goal is to help clients shift attention to present-moment reality and
away from the illusions of the future and of the past that their worrying and
rumination create.

Stimulus Control Methods

Once clients have learned to detect early cues for anxiety, stimulus control
is used to reduce the amount of time spent worrying and to decrease the
habit strength of worrying. For example, clients are instructed to postpone
any early-detected worrying during the day to a fixed period of worrying—
30 minutes at the same time and in the same place every day—during which
they can engage in problem-solving about the worry or apply cognitive
restructuring skills to it. Such a deliberate postponement of worry enables
clients to refocus attention to the present environment and the task at hand.

Relaxation Methods
As part of the natural response to perceived threats (“fight or flight”),
anxiety reactions are closely associated with the activation of the
sympathetic nervous system. One way to attenuate the sympathetic nervous
system at the early detection of anxious responding is by activating the
parasympathetic system through learning and repeatedly using applied
relaxation methods (Bernstein, Borkovec, & Hazlett-Stevens, 2000).
Multiple relaxation methods are taught to encourage flexibility in the use
of coping resources and to find those that are most helpful for clients in
different situations or in response to different internal cues. Slowed, paced,
diaphragmatic breathing is an ideal starting point to provide the client with
an immediate and noticeable effect of treatment and to teach him or her
ways to reach a rapid relaxation response that is easy to learn and readily
applicable in daily living. The client is instructed to slow down breathing
and to shift it from the chest to the stomach by letting the diaphragm rise
and fall without expanding the chest. Progressive muscle relaxation is
aimed at reducing muscle tension and sympathetic activation via systematic
tensing and releasing various muscle groups. Meditational techniques can
be combined with relaxation to facilitate the client’s shift away from
anxiety-provoking cues and toward pleasant internal stimuli.
At the end of each relaxation practice session, the client can be instructed
to focus on a meaningful, pleasant internal stimulus (an image, a word) that
is associated with safety, comfort, security, love, and/or tranquility. A
related technique, guided imagery, can be used to deepen the relaxation by
leading the patient through a sequence of tranquil and pleasant images.
The use of applied relaxation allows the client to cultivate a more relaxed
life style and to cope adaptively with perceived threats as they occur in day-
to-day living. It is applied on a moment-to-moment basis during the course
of the day whenever clients recognize early cues of anxiety (and,
eventually, any time clients are aware of the absence of a calm or tranquil
state), and it is intended to shift attention away from tension/anxiety and
toward relaxation. The therapist helps clients to acquire and practice this
coping skill during the session by frequently asking them to apply the
relaxation response whenever therapists or clients observe signs of
increased anxiety.

Self-Control Desensitization
Self-control desensitization (Goldfried, 1971) involves the rehearsal of
relaxation responses (and, later in therapy, cognitive perspective shifts)
while imagining frequently occurring anxiety-provoking situations (both
environmental cues and internal cues). First, the client is asked to imagine
him- or herself in a situation in which he or she detects anxiety cues.
Second, the therapist repeatedly guides the client through imagining
successfully applying relaxation techniques in that situation. In the course
of therapy, self-control desensitization is practiced with several sets of
anxiety cues in order to generalize this adaptive coping response to various
situations. Clients are also asked to include this coping skill at the end of
their daily relaxation practice. Finally, in the course of cognitive therapy
(described next), images of the most likely outcomes for worrisome topics
are created, and these are to be imagined vividly as soon a worry is
detected.

Cognitive Therapy
Clients’ inaccurate perceptions are important components of their worry
and anxious experiences. As such, numerous cognitive techniques are used
to help them develop cognitions that more closely correspond with
environmental information. Clients are first instructed to observe their
environment, as well as to monitor the content of their anxious thoughts on
a daily basis. Clients’ inaccurate perceptions and/or interpretations are then
challenged by diverse methods, such the search for evidence to support and
reject clients’ cognitions, the generation of alternative perspectives, and the
identification of core beliefs (or nonadaptive attitudes) underlying many of
their specific inaccurate thoughts and negative images. Because worry
frequently involves an exaggeration of the negative implications of specific
events, the cognitive technique of decatastrophizing (i.e., a step-by-step
analysis of what it is that the client fears might happen, including the
probability of each of these steps and the client’s coping resources to deal
with them) is particularly useful for GAD clients. Perhaps differing from
some CBT approaches, special emphasis is placed on the creation of
multiple perspectives for any given situation to maximize flexibility in
thinking.
Clients also complete a Worry Outcome Diary, wherein they write down
(a) their worries when detected, (b) what they fear will happen, and (c) the
actual outcome once it occurs. The purpose of this information is to help
clients to build a new history of evidence of the way things actually are and
to facilitate their processing of all available information from their
environments, instead of only the negatively biased information.
Behavioral experiments are also use to test unrealistic cognitions as well
as to provide additional exposure to feared situations and opportunities to
practice applied relaxation and perspective shifts. On the basis of the data
collected in these exercises, the clients learn to treat their perceptions as
hypotheses and revise inaccurate predictions or assumptions involved in the
spiraling intensification of their anxiety. By learning to pay less attention to
negative environmental cues and by focusing less on the past or the future,
the client also learns to be fully immersed in his or her present reality, to
process environmental information as needed, and to be confident that he or
she can deal with smaller or bigger challenges to come. Indeed, the eventual
goal in therapy is to move from inaccurate expectations about the future to
relatively more accurate expectations and, ultimately, to no expectations at
all. Such expectancy-free living is our cognitive therapy method for
contributing to the goal of living in the present moment, wherein there can
be little anxiety or depression.
Finally, clients are encouraged increasingly to make use of intrinsically
motivated behaviors for approaching worrisome or anxiety-provoking
situations and for taking an active approach to daily living to maximize joy
in life. Thus, drawing from the values that clients hold near and dear to their
hearts, the therapist helps them to create emotional and cognitive sets
reflective of those values and facilitative of a true, whole-organism
approach to each life situation that they are about to enter.

Interpersonal/Emotional Processing
I/EP has been added to CBT so that therapists can address clients’
problematic relationships and facilitate emotional deepening. Briefly put,
the goals pursued in this segment are to facilitate clients’ identification of
interpersonal needs, fears, and schemas and to help them develop behaviors
that will better satisfy their personal needs. Although the focus of
interventions and the techniques used differ from CBT, the general goal is
the same: to help clients to live in the present—to focus on their immediate
experience with others. Rather than paying attention to the past or the future
(the bad things that happened and/or could happen), clients learn to focus
on what they currently want from others, as well as on what others want
from them. A greater awareness of their contributions to maladaptive
patterns of relating and the acquisition of new social skills will also help
clients to reduce their negative impact on others.
As in the CBT segment, I/EP directly targets the GAD clients’ tendency
to avoid. Clients are encouraged to expose themselves to feared emotions,
feared critical feedback about their impact on others, and their fear of being
vulnerable to other people by showing who they are. By trying to confront
their immediate fear, clients become aware of how their avoidance of
negative emotions in the short term comes at a great cost in the long term.
The therapist also helps clients to shift their attentional focus away from
danger anticipation and toward openness, spontaneity, and vulnerability
with others as well as toward a greater empathic attention to the needs of
others.

Exploring and Changing Interpersonal Functioning

Early in the I/EP segment, the task of the therapist is to get a sense of the
client’s interpersonal history. Responses to open-ended questions about
relationships with past and current significant others provide the therapist
with a general understanding of clients’ perceptions of their interpersonal
needs and fears, as well as their typical attempts to deal with them. As early
as in the second or third session, the primary focus of treatment shifts away
from a description of these past and/or current relationships to an
exploration, in an emotionally immediate way, of the therapeutic
relationship.
It is assumed that clients’ maladaptive patterns of relating are likely to be
repeated in the therapeutic relationship. As such, an important task for the
therapist is to identify when and how they have been participating in
clients’ interpersonal schemata. Safran and Segal (1990) have suggested
that therapists actually need to be “hooked” into clients’ maladaptive ways
of relating to others—to be pulled by clients into behaving consistently with
clients’ expectations—to help them change the way they interact with
others. Adopting an attitude of a participant-observer (Sullivan, 1953),
therapists pay constant attention to signs of having been hooked, such as a
feeling of being emotionally detached from the client or the realization of
having frequently let the client tell long tangential stories. Another indicator
of therapists being hooked is when they and/or their clients are trying to
find out why clients are reacting (or not reacting) in a particular way instead
of helping clients to become aware, own, or deepen their emotional
experiences.
Once hooked, the therapist stops acting in ways that are consistent with
the client’s expectations. Instead, he or she is ask to explore what is taking
place in the relationship to help the client gain awareness of his or her
maladaptive ways of relating, as well as the rigid construal of interpersonal
relationships that underlies these patterns. Such exploration first requires
the therapist to disclose, in an open and nondefensive manner, his or her
reaction to what transpired in the relationship, such as saying “I feel pushed
away when you don’t answer my questions.” In some cases, the therapist’s
self-disclosure immediately leads clients to being open to their own
emotional experience.
With GAD clients, however, we have rarely observed such an ability or
willingness to be vulnerable with another person. What is typically required
is gentle but repeated invitations for the client to identify, experience, and
express emotions triggered by the therapist’s self-disclosure and/or the
event that preceded it. The therapist’s role is then to empathize with and
validate the affective experiences expressed by the client, as well as to share
his or her own reactions to the client’s self-disclosures, such as saying “Of
course, you would want to avoid a topic that made you uncomfortable.
However, not answering my question also has an impact on me and makes
me feel as though what I am asking for isn’t important.” Therapists are also
encouraged to observe and communicate whether clients’ responses to their
openness help them feel understood by clients.
When used with warmth and support, these interventions can help the
client become aware of his or her impact on another person. In addition,
such an exploration of the therapeutic relationship allows the therapist to
model an open communication style. By disconfirming the validity of the
client cognitive-interpersonal schema (i.e., “It is dangerous to openly
communicate with others”), this way of working with the therapeutic
relationship—of meta-communicating (Kiesler, 1996)—can provide the
client with a unique corrective experience (Alexander & French, 1946;
Goldfried, 1980).
Similar techniques of meta-communication are also used in I/EP to repair
alliance ruptures. In fact, the enactment of client interpersonal schema
during sessions, as when the client walls off the therapist or pulls for his or
her hostility, will at times create alliance ruptures. This in no way suggests
that clients are always responsible for alliance problems. Such strains in the
alliance can be caused or exacerbated by the therapist’s less than adequate
level of engagement, attention, empathy, warmth, tact, or attunement to the
client’s needs. The therapist may frustrate the client’s desire to be helped by
not using an effective technique, by failing to competently execute a
perfectly adequate intervention, or by being blinded by his or her own
interpersonal schema and its accompanying emotion. Thus a therapist may
avoid dealing with core therapeutic issues because of his or her own fears of
hurting the client or because of personal frustration or annoyance (Wolf,
Goldfried, & Muran, 2017). From a cognitive-interpersonal perspective
(Safran & Segal, 1990), alliance ruptures can be expected when two
individuals are involved in a complex, demanding, and emotionally
meaningful relationship such as therapy.
Accordingly, therapists are trained to recognize markers of alliance
ruptures, such as clients’ overt expressions of dissatisfaction, indirect
expressions of hostility, disagreements about the goals or tasks of therapy,
overly compliant behavior, evasive behavior, and self-esteem–boosting
maneuvers (Safran et al., 1990). Therapists are asked to attend to the
markers of alliance ruptures during both the CBT and I/EP segments but,
because of the additive research design noted earlier, these markers are only
addressed during the I/EP segment which has an interpersonal focus.
Attempts are made to repair the alliance by following three steps (Burns,
1989; Safran & Segal, 1990). First, therapists invite clients to talk about
their negative reactions (e.g., “I have a sense that you aren’t as engaged as
you have been in other sessions. Is that how you are feeling?”). Second, the
therapist empathizes with the client’s perception and emotions and invites
him or her to express additional emotions and thoughts about what was
unhelpful or invalidating in the treatment. When the therapist believes that
the client feels understood, the therapist should then recognize and
comment on his or her own contribution to their relationship difficulty. His
last step, elegantly captured by Burns (1989) as a “disarming” technique,
requires the therapist to find some truth in the client’s reaction, even when
the reaction may seem unreasonable. The use of this technique is based on
the assumption that the therapist has invariably contributed in some way to
the lack of synchrony between client and therapist. It is also based on the
assumption that the therapist’s openness to his or her own experiences can
lead to the client’s openness to his or her experience, which may in turn
help them to exit an unproductive cul-de-sac in their relationship
(Castonguay, 1996).
Contrary to the client’s expectation, he or she learns that being
emotionally vulnerable can lead to stronger and safer relationships. The
client also learns that when “living in the moment” (such as when
experiencing and exploring in an emotionally immediate way what is taking
place in a relationship), he or she ceases to pay attention to the past and the
future. Worries and ruminations dissipate as one becomes real and present
with others.
In addition to paying attention to the therapeutic relationship, therapists
help clients to draw links between interaction patterns observed in the
session and patterns in clients’ past or current relationships with significant
others. Therapists, however, are reminded that such connections are
sometimes drawn (by the client or themselves) as a way to avoid processing
negative events taking place in the therapeutic relationship. Such defensive
maneuvers may prevent the client from fully experiencing his or her
emotions and further reinforce long-standing avoidance strategies (e.g.,
intellectualizing or “staying in his or her head” as opposed to being open
and vulnerable with another person). When part of an emotionally
immediate exploration of the client’s experience, such connections with
outside interpersonal events frequently help clients gain a deeper awareness
of their rigid constructions of relationships and maladaptive ways of
relating.
Therapists also ask clients to monitor and record between sessions events
taking place with significant others. Specifically, clients are asked to
describe specific interactions and to take note of the emotions they felt
during these interactions, what they wanted and feared from the other
person, what they did, and what happened next. Such functional analyses of
intrapersonal and interpersonal factors frequently help clients to identify
what they need and what they actually get from others (McCullough, 2005;
McCullough & Schramm, Chapter 14, this volume). In particular, these
analyses reveal the negative impacts that some of the client’s behaviors
have on others. When indicated, behavioral strategies (e.g., social skills
training) are then used to teach clients better ways to satisfy their
interpersonal needs.

Facilitating Emotional Deepening

Helping the client to experience, deepen, and express his or her emotions is
aimed in part at extinguishing fear and avoidance (including worry as a
cognitive avoidance response) of emotion. As mentioned earlier, research
has suggested that when individuals with GAD worry, they do so in part to
avoid painful events (future bad outcomes or distressing emotions). As
such, worry is maintained, at least in part, by its negative reinforcement
(e.g., suppression of somatic aspects of anxiety or the eventual
nonoccurrence of low-probability, but feared, negative events). By exposing
the client to his or her emotional experience, he or she learns that although
some emotions can be painful, they are not dangerous (e.g., sadness and
anger over another’s betrayal). As such, the safety of the therapeutic
relationship provides clients with yet another unique opportunity for
corrective experiences. Indeed, if the experience with and exploration of
feeling repeatedly fails to be intolerable, they learn that there is nothing to
fear from their emotional experience. And when there is nothing to fear,
there is no reason to avoid. Worry, as a consequence, loses its reinforcing
impact, and clients begin to gain access to primary affects that can motivate
and direct adaptive behaviors, as described later.
 Emotions are an important source of information for what we need in life
(Grawe, 2002; Greenberg & Safran, 1987). As such, emotional deepening is
also used in I/EP to help clients better understand what they need from
others. Guided by the work of Greenberg, Rice, & Elliott, (1996), therapists
track markers of emotionality in order to decide when to use techniques
aimed at deepening feelings. Examples of such markers are changes in
voice quality, the sound of sadness in the voice, and a slowing or
quickening of conversational pace. When such markers are noted, clients
are encouraged to stay with their emotions and to allow themselves to fully
experience them.
Therapists also pay attention to moments of emotional disruption or
disengagement. When clients stop emoting and/or being attentive to their
affective experience, therapists invite them to focus on their immediate
experience. For example, “What just happened? You were allowing yourself
to cry, and you quickly moved away from your feeling.”
When markers of a self-evaluative split—internal conflict experienced by
clients—are observed, clients are invited to take part in a two-chair
exercise. In the exercise, clients distinguish the two parts of themselves—as
though they were two separate people—and then embody each one
separately and repeatedly as one part speaks to the other until clients have
gained greater insight into their feelings and their own needs in the internal
conflict.
In contrast, markers of unfinished business—unresolved feelings toward
a significant other—are dealt with in an empty-chair exercise. Here, the
client expresses his or her feelings while imagining another person sitting
across in an empty chair.
The technique of systematic evocative unfolding is also used to address
markers of problematic reactions—when clients experience surprise or
confusion about one of their own reactions. Clients are asked to close their
eyes and imagine themselves back in the situation that evoked the reaction
and play the scene in slow motion in their imagination. They are asked to
vividly remember every aspect of the scene, describe in detail the events
and their feelings during the situation, and to pay attention to every internal
cue as they repeatedly describe the situation. By reexperiencing fine-
grained details and their reactions to them, clients can better express and
own the emotions that first surprised them, as well as gain access to
previously implicit emotions.
 Therapists also encourage clients to focus on and own their emotions as
they occur in their day-to-day lives. It is indeed important to help clients
generalize the corrective experiences of expressing feelings in the safe
environment of the session to interpersonal relationships outside of therapy.
Continued attention to clients’ experience and behavior in the real world
may well be crucial to help them overcome their fear of vulnerability and
achieve a lasting change in their habitual avoidance of emotion.

DIVERSITY CONSIDERATIONS
Our integrative approach was developed and used in the context of clinical
trials. One of the limitations of these trials (which are described later) is that
they have involved a very large majority of Caucasian clients. As a
consequence, we have no observations and evidence to rely on to make
reliable statements and inferences about whether our approach applies to
underrepresented ethnic and racial populations. It thus remains an open
question as to whether procedural modifications (cultural adaptations)
should be made to the treatment to optimize its impact for clients of non-
Caucasian identity and whether some elements of our current treatment are
particularly attuned to or unresponsive to the needs of a diversity of client
populations. Needless to say, future investigations of this integrative
approach, within and/or outside of our own research program, should pay
close attention to these and other crucial diversity considerations. At the
same time, as with most approaches to psychotherapy, our treatment entails
personalization and making use of client goals, strengths, and limitations to
tailor our approach to individual needs.

CASE EXAMPLE

The following case was chosen because it illustrates the major thrust of our
assimilative integrative treatment. It demonstrates how the addition of
specific techniques to CBT allows therapists to work with material not
directly or adequately addressed in traditional CBT. As such, the case
description will mostly focus on the I/EP segment of the therapy.
“Wendy” is a female, Caucasian undergraduate seen within the context of
an National Institute of Mental Health (NIMH)-funded study aimed at
providing preliminary evidence for the feasibility and impact of the CBT +
I/EP treatment for GAD (this study is presented in detail in the next
section). Although Wendy’s primary diagnosis was GAD, she was also
diagnosed with comorbid social phobia, obsessive compulsive disorder, and
a specific phobia. She reported that she had previously received 2 months of
psychotherapy for an interpersonal problem. She was not currently taking
any medications nor had she taken any psychiatric medications in the past.
In terms of her GAD symptoms, she reported that the current bout of GAD
had been chronically ongoing for 7 years. She reported that she was not
aware of any formal diagnoses of any mental health problems in her
immediate family but that she would characterize her mother as a worrier.
Wendy was treated by a Caucasian male psychologist who was primarily
trained in CBT. In addition to his full-time private practice, the therapist had
served as a therapist in several CBT trials (e.g., Borkovec & Costello, 1993;
Borkovec et al., 2002).
Wendy felt very comfortable during the CBT segments. She took the
therapist’s directives to heart and actively complied with the therapeutic
tasks prescribed during and between sessions. On the other hand, the I/EP
segments proved much more difficult for her, at least initially. She was
reluctant to reveal herself, expressing minimal emotion and, when she did,
only in response to the therapist’s persistent requests. Although she wanted
to please the therapist, he felt discounted by her lack of authentic
interpersonal and emotional behavior toward him, probably due to her fear
of being vulnerable. While she tried hard to understand and follow the
therapist’s instructions (as the perfect client that she wanted to be—and felt
that she could be in CBT), the therapist did not believe that she wanted to
connect with him or allow herself to be emotionally close during the I/EP
segment.
What was happening during therapy paralleled what had been taking
place in Wendy’s interpersonal relationships. Early on in I/EP, she reported
that she felt that she had to be perfect with others. Her view of relationships
was that she felt obligated to take care of others’ happiness. Not
surprisingly, she felt burdened by what she perceived to be the expectations
of others, became angry when friends asked her to socialize because it was
taking time away from her studies, and frequently avoided being with them.
As therapy progressed, it became clear that she had a hard time being
empathic with others. In part, because her attention was on her own
behavior (her attempt to please others), she did not fully listen to others.
She was so focused on her fear of failure in meeting their needs that she had
little energy left to listen to the needs they actually expressed. She thus
found herself trapped in an unfortunate paradox: she spent so much time
trying to do everything for others that she feet burdened by others and thus
discarded them.
At the same time she was surprised to learn that she did not meet their
needs. For example, when she asked the therapist after several sessions
whether he liked her, she was quite surprised by his reply that he did not
know whether he liked her or not because he had not yet met the real her.
She thought that she was doing everything he wanted her to do, including
self-disclosing.
Wendy was also expecting significant others in her life, including her
boyfriend, to have a similar view of relationships. Specifically, she expected
others to be vigilant and attentive to her needs. She expressed considerable
frustration at the fact that her boyfriend was not always anticipating what
she wanted from him. As therapy helped her to focus on her interpersonal
needs, she became aware that she had difficulty being spontaneous with
others. One of her first realizations was that she felt angry at others. This
led her to be more assertive with her boyfriend, but it also made it more
difficult for her to be vulnerable, as well as to be attentive to his needs.
Wendy’s interactions with her boyfriend led the therapist to focus on her
impact on others, including on the therapist himself, which in turn led her to
become more emotionally expressive. The therapist then used emotional
deepening techniques to explore the origins of her fear of being vulnerable
with others. The therapist used a systematic evocation technique and
allowed her to reexperience her feeling of being betrayed by another person
when she was in high school. This incident appeared to play a formative
role in her fear of trusting others, of letting her guard down, of being
herself, of not worrying about (and therefore being burden by) others. The
use of an empty chair (where she expressed her feeling of being betrayed
and hurt) in the same session helped her to become aware that the price paid
for not being herself was social isolation, loneliness, and sadness. She
realized that she had missed her previous connections.
At the same time, Wendy was genuinely surprised by the therapist’s
acceptance of her tears and sadness (of her vulnerability) expressed during
the evocation of these memories: “You like me when I’m like this, really?
This is what you were looking for?” Because the therapist’s reaction to her
first authentic emotional reaction in therapy was opposite to what she
expected, it led to a corrective emotional experience.
In the following sessions, the client became more emotionally present,
displayed a wider range of and more intense emotions, and began making
numerous and adaptive changes in the way she was relating to others
outside of therapy.
After completing the 14 sessions prescribed by the treatment (plus an
additional “booster” session planned in the research study), Wendy was
followed-up for 2 years. At pre-therapy, her GAD severity level was 6; by
follow-up it was 1. Also, the client demonstrated clinically significant
change and high end-state functioning (i.e., her score was within the range
of a normative sample) on all six of GAD-associated symptoms (e.g., self-
reported worry, self-reported trait anxiety, assessor-rated severity of GAD,
and self-reported diary measure of worry). She showed at least 20% change
and was within the range of a normative sample on all measures.

OUTCOME RESEARCH
This integrative treatment for GAD has been the object of two NIMH-
funded clinical trials. The first was a preliminary study aimed at
determining whether it could be implemented and if its outcome would
suggest improvement over traditional CBT for GAD (Newman et al., 2008).
Eighteen clients with GAD received the CBT + I/EP described earlier.
The treatment was delivered by three experienced therapists (one originally
trained in CBT and two primarily trained as psychodynamic therapists).
Numerous process findings and adherence checks suggested that what took
place during each segment of therapy was consistent with the treatment
manuals. An observer-rated measure of the therapist interventions, for
example, showed that while therapists focused more on interpersonal issues
in I/EP than in CBT, they focused more on intrapersonal issues in CBT than
in I/EP (Castonguay et al., 2002). In addition, both self-report (client and
therapist) and observation measures showed that, as predicted, higher levels
of negative emotions (e.g., sadness) were found in I/EP. For a number of
positive emotions (e.g., confidence, joy), however, higher levels of intensity
were found in CBT (Castonguay et al., 1999, 2001), which is consistent
with its focus on building skills and increasing self-efficacy.
 The outcome findings obtained in this open trial were promising.
Pre-/posttreatment effect sizes indeed appeared to be superior to those
obtained by previous studies conducted with traditional CBT. In fact, the
average within-participant effect size from previous CBT studies was 2.44,
whereas our pilot study obtained a 3.5 effect size.
Based on these preliminary findings, we conducted a second NIMH-
funded study (Newman et al., 2011). In this randomized clinical trial, 83
GAD clients were assigned to either CBT + I/EP or CBT + SL (i.e.,
supportive listening). As previously mentioned, such an additive design was
adopted not only to assess whether our integrative treatment was superior to
traditional CBT, but also to determine, if this was the case, whether the
improvement was specifically due to the addition of specific components
(i.e., interpersonal focus and emotional deepening techniques). Contrary to
our prediction, however, the analyses showed no statistically significant
difference between the integrative and the CBT + SL conditions (Newman
et al., 2011).
Because the integrative treatment showed higher percentages of clients
having reached clinically significant change on almost all outcome scores, it
is possible that the lack of statistical difference was due to the study’s
relatively small sample size. Another interpretation, more empirically and
clinically sound in our view, is that the analyses of main effects (i.e., the
comparisons of the two conditions) might have actually masked more
nuanced but real differences. Inasmuch as CBT has been repeatedly shown
to be efficacious for a substantial number of GAD clients, it may be that
adding components to CBT may increase it efficacy for some clients but not
for others.
To test this possibility, secondary analyses were conducted to assess the
moderating impact of clients’ attachment problems (Newman et al., 2015).
The findings of these analyses revealed that clients with one particular type
of attachment style (i.e., dismissive) benefitted significantly more from the
integrative therapy than the CBT + SL condition, both at the end of therapy
and at follow-up assessments. In contrast, clients with a primary angry
attachment style showed the reverse results—but only at posttreatment.
Because dismissively attached individuals tend to avoid both emotion and
intimacy, it makes sense, conceptually and clinically, that they might gain
more from a treatment that helps them to recognize their affective needs and
to develop interpersonal connections. In contrast, an emphasis on emotional
deepening may have interfered with improvement (at least in the short term)
of angrily attached individuals, who tend to be emotionally reactive.
These results suggest that, although it is legitimate and important to
investigate whether integrative therapies achieve better outcomes than pure
forms of therapy, it may be more fruitful to examine for whom such
treatments are more appropriate than traditional approaches. These findings
have also clinical implications as they suggest that while some clients may
benefit more from an integrative therapy, others may improve less—in least
in the short term—than they would have if they had received a pure form of
therapy. In our effort to improve therapy, and especially with the current
emphasis on harmful effects (Castonguay et al., 2010), it is thus crucial to
recognize an obvious reality: clients matters.
It is also clear that therapists matters. Research findings have indicated
that some therapists are better than others, and that, inversely, other
therapists are less effective than the majority of practitioners (Castonguay &
Hill, 2017). These findings have led us to explore whether the main effects
presented earlier did not also mask other subtle differences. Preliminary
analyses conducted on the randomized controlled trial (RCT) revealed that
the clients of one of the therapists showed poorer outcomes than the clients
of the other two therapists involved in the study (Youn et al., 2017).
Furthermore, when new analyses were conducted on the outcome data with
the first therapist removed, results showed significant differences in the
predicted directions between the two conditions compared. In other words,
these findings suggest that there was a therapist effect and that this effect
may have hidden real and predicted advantages of the integrative therapy
over CBT.
Based on these findings, intense (both quantitative and qualitative)
analyses were conducted on videotaped sessions involving three clients: a
client who failed to benefit from the integrative treatment and who was seen
by the less effective therapist, and two clients who responded to treatment
and were treated, respectively, by one of the other two therapists. The
results indicated that the less effective therapist committed two types of
errors. One type were errors of omission, when, for example, the therapist
failed to use (as a response to clear markers of interventions) prescribed
social skills training to help his client to be more assertive in her
interpersonal relationships. The second type of mistake were ones of
commission. These took the form of relational problems, as manifested by
the therapist’s frequent interruptions of the client disclosure. These errors
were also technical in nature. In the I/EP segment, in particular, therapists
repeatedly used interpretations when working with client worries. Rather
than exploring and deepening the client’s emotion that may have triggered
such worry, the therapist’s interpretations replaced one type of thought with
another—essentially encouraging the client to “stay in her head.” In doing
so, the therapist appeared to reinforce the client’s cognitive avoidance of
emotion, which the I/EP segment was specifically aimed at correcting.
Taken together, the studies conducted thus far on the integrative therapy
of GAD suggest that this treatment is promising but that understanding its
helpful impact requires a complex interaction of client, therapist, relational,
and technical variables—which most certainly mirrors what therapists
encounter in routine practice.
Preliminary outcome studies on an integrative treatment for depression
have also been conducted. In this treatment, only one of the components of
the I/EP package is added to traditional CBT. Specifically, alliance ruptures
are addressed in cognitive therapy. Conducted with inexperienced therapists
(graduate students), the findings of the first pilot study showed that this
integrative cognitive treatment (ICT) was superior to a waiting-list
condition (Castonguay et al., 2004). As a whole, the findings also compared
favorably with findings of previous results obtained with traditional CT.
The effect size obtained for the Beck Depressive Inventory (Beck et al.,
1961), for example, was twice that estimated in a meta-analysis of control
studies comparing cognitive therapy (CT) and wait-list or placebo condition
(Gloaguen et al., 1998).
In a subsequent pilot study, Constantino and colleagues (2008) examined
the efficacy of ICT by comparing it to CT. The findings showed that ICT
patients evidenced greater posttreatment improvement regarding
depressiveness and global symptomatology (with small to medium effects),
and ICT patients displayed more clinically significant change than did CT
patients. Furthermore, ICT clients also showed higher alliance and empathy
scores across treatment than CT clients. Because they have been conducted
with small samples of depressed clients (N = 21 and 22, respectively), the
results of these two studies should be considered with caution. Taken
together, however, they provide preliminary support for the potential
viability and effectiveness of integrating rupture–repair interventions into a
standard CT for depression.
 Further support for the enhancement of CBT via an assimilation of
theoretically “foreign” interventions toward the therapeutic relationship
comes from empirical studies on Brief Relational Therapy (BRT; Safran &
Muran, 2000). Based on Safran’s seminal contribution on the exploration
and repair of alliance ruptures, BRT shares strong conceptual and clinical
roots with the I/EP segment of the integrative therapy for GAD and even
stronger (foundational) links with ICT for depression. In a study with a
sample of personality-disordered clients, Muran, Safran, Samstag, and
Winston (2005) found that BRT was as effective as CBT and short-term
dynamic therapy on outcome measures, but more successful at retaining
clients in therapy. In a more recent study aimed at improving interpersonal
interactions between clients and therapists in CBT for outpatients with
comorbid with Axis I and II disorders, Muran, Safran, Eubanks, and
Gorman (2018) trained novice therapists in a two-step protocol. First,
therapists were trained to fidelity standards in CBT, and, subsequently (after
either 8 or 16 sessions), therapists underwent alliance-focused training
(AFT) that draws on the same principles as BRT. The results of this training
provide further support to supplementing CBT with alliance-focused
components.
Although not the main focus of this chapter, several other ways of
enhancing CBT in line with principles of assimilative integration have been
developed (Castonguay et al., 2015). These approaches vary by diagnostic
specificity and theoretical background, as well as by relative research
support. Two diagnosis-specific approaches with strong interpersonal
components are the cognitive-behavioral analysis system of psychotherapy
for patients with chronic depression (CBASP; McCullough & Schramm,
Chapter 14, this volume) and the dialectic behavior therapy for patients
with borderline personality disorder (DBT; Heard & Linehan, 1993;
Chapter 12, this volume).
Support has also been gained for schema therapy (Young, Klosko, &
Weishaar, 2003), which was created to treat patients with challenging
interpersonal problems by integrating principles of CBT with object
relations theory and gestalt therapy. Developed in the United Kingdom,
cognitive analytic therapy (Ryle et al., 2014) integrates psychodynamic
therapy with CBT principles in a brief, user-friendly relational therapy and
has received empirical evidence for its effectiveness for the treatment of a
range of clinical disorders. Other assimilative treatments have focused on
specific dimensions of psychological functioning, such as resistance,
emotional processing, or outcome expectation. For example, responsively
integrating motivational interviewing (MI) to address emerging patient
resistance to standard CBT for GAD has been shown to outperform CBT
alone on long-term worry and distress reduction (Westra, Constantino, &
Antony, 2016). Furthermore, and consistent with MI’s target, MI-CBT
versus CBT patients experienced less during-treatment resistance, which
mediated the superior treatment effect (Constantino et al., 2019; Westra &
Constantino, Chapter 13, this volume).
Built to enhance cognitive-emotional processing in the depressed client,
exposure-based cognitive therapy (EBCT) systematically integrates
principles of exposure therapy for anxiety disorders with interventions of
emotion-focused therapy (Hayes et al., 2005, 2015). At this time, evidence
for the efficacy of EBCT has been obtained in an RCT and two pilot trials
(grosse Holtforth et al., 2011, 2019; Hayes et al., 2005). Assimilating
strategies for increasing patients’ positive outcome expectations (identified
by Goldfried [1980] as a general principle of change) has also been shown
to improve CBT for depression in a small pilot trial (see Constantino,
2012).

FUTURE DIRECTIONS
CBT is by far the psychotherapy that has received the most research
support, so it is encouraging, both from a scientific and a clinical
perspective, that several attempts have been made to improve it based on
the integration of complementary constructs and techniques derived from
other traditions. More is needed, however, to expand and solidify the
empirical bases of these CBT-assimilative treatments. We have envisaged a
number of future directions for our own integrative efforts—directions that
we believe might also prove beneficial for the other CBT assimilations
briefly mentioned in this chapter.
Based on the moderating findings reported earlier, it is clinically relevant
to assess experimentally whether or not integrative therapy is superior to
CBT with particular clients suffering from GAD. These moderating
variables may be associated with attachment problems and/or other
individual differences. With these specific clients and/or with GAD
individuals in general, the next empirical steps should also include the
investigation of our own integrative treatment at different sites, with
different investigators, and with more diverse ethnic clients. Moreover, it
would be useful to conduct investigations in more naturalistic settings in
order to investigate the effectiveness of the integrative treatment. Directly
relevant to effectiveness is the question of whether it would be possible and
advantageous to combine the techniques involved in the integrative
treatment within the same sessions—as opposed to dividing them into
different segments of therapy sessions. It would also be interesting to
examine whether the treatment developed for GAD can be applied
successfully to other clinical problems. Depression, for instance, is likely to
be an appropriate target as many of the process findings and theoretical
arguments that guided our selection of the techniques to be added to
traditional CBT emerged from the depression literature.
Much more research should also be done on the less comprehensive
protocol that has begun to be tested on depression. In particular, studies
with large sample sizes comparing ICT and CT are required before it can be
confidently asserted that adding techniques to repair alliance ruptures
improves the efficacy of CT for depression. As with GAD, future research
should not be restricted to efficacy studies. For example, plans are being
made to determine if training therapists to use alliance repair techniques in
their day-to-day practice (irrespective of their theoretical orientation and
across a variety of clinical populations) can improve their effectiveness.
We plan to continue to develop and test treatment methods that might
improve the effectiveness of therapy. In particular, we hope that the studies
supporting the new model of worry and GAD proposed by one author of
this chapter (i.e., contrast model; Newman & Llera, 2011) will provide
fruitful heuristics for the potential improvement of CBT and other treatment
approaches.
In addition to these research directions, we believe that clinical
developments could be beneficial for most GAD clients and/or for specific
types of individuals—such as ethnic/racial minority clients. In particular,
we believe that the recent literature on therapist effects might provide
insightful ways to improve our treatment (as well as many others) without
imposing major changes in its general structure. We know that therapist
effects explain between 5% and 8% of outcome variance (Barkham et al.,
2017). Research has also identified a number of factors that explain why
some therapists are better than others, such as the ability to establish a good
working alliance, facilitative interpersonal skills, and deliberate practice
(Wampold et al., 2017). Based primarily on clinical observations, clinical
guidelines have been derived from those and other therapist factors with the
goal of enhancing treatment outcomes (Castonguay & Hill, 2017). These
guidelines address issues such as how to deal with cultural
microaggressions, how to regulate and use negative emotions for
therapeutic purposes, and how to foster engagement during treatment. As
we look to the future, we can and should assimilate, in clinically cohesive
ways, many of these guidelines into our integrative efforts—in the same
way that these efforts have integrated methods from diverse theoretical
orientations.

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PART III

Integrative Psychotherapies for Specific Disorders

and Populations
A. Specific Disorders
 12

Dialectical Behavior Therapy for Borderline

Personality Disorder
HEIDI L. HEARD AND MARSHA M. LINEHAN

Psychotherapy integration synthesizes different theories and techniques to

develop a maximally efficacious therapy. In this way, the goal and process
of psychotherapy integration parallel the goal and process of psychotherapy
itself. Practitioners from various schools strive to foster synthesis within
their clients, whether by targeting the incorporation of new skills into a
client’s behavioral repertoire or by guiding the client toward the integration
of disparate aspects of the self.
In dialectical behavior therapy (DBT; Linehan, 1993a, 2015a, 2015b), the
emphasis on observing and creating syntheses within therapy has developed
into an integral part of helping clients achieve their ultimate goals. DBT is
integrative in the “dialectical/developmental” sense of the word (Stricker &
Gold, 1993), meaning that it emphasizes the “open-ended dialogical process
in which differences are examined and novel integrations are welcomed” (p.
7). Thus, while at any given moment DBT constitutes a single, unified
psychotherapy, it is also in a continuous process of change in which new
developments are accepted rather than avoided, rather like a client
effectively participating in therapy.
This chapter elaborates on the integrative aspects of DBT by describing
its application to individuals who meet criteria for borderline personality
disorder (BPD), the population on whom the treatment was originally
tested. First, it identifies the theoretical and philosophical principles of the
approach and the history of their integration. It discusses “dialectics” in
greater detail and describes some of the ways in which the dialectical
philosophy performs multiple integrating roles throughout the therapy. The
chapter describes the initial assessment, case formulation, and treatment
modes. It focuses on the strategies and process that occur within a therapy
session, as well as how the therapy relationship contributes to change. A
case example illustrates the integration of the various strategies. Finally, the
chapter summarizes the results of outcome research that examines the
efficacy of DBT for BPD and considers future directions for the treatment
approach.

INTEGRATIVE APPROACH

Development of Approach
Linehan (1993a, 1993b) originally developed DBT as a cognitive-
behavioral intervention to treat individuals with a high risk for suicide and
other difficult-to-treat problems. Linehan then focused particularly on
clients who had a diagnosis of BPD because this patient population best fit
the focus of the treatment with respect to suicidal and other severe
behaviors, and research funding favored focusing on a specific mental
disorder. To explain the etiology and maintenance of problematic behaviors
associated with BPD, she combined capability deficit and motivational
models of behavioral dysfunction. Individuals who meet criteria for BPD
lack important skills (e.g., emotion regulation, interpersonal effectiveness),
and personal and environmental factors both inhibit skillful behavior and
reinforce problematic behavior. Linehan further proposed a transactional
theory of the etiology and maintenance of BPD that combines biological,
social, and developmental causes.
To change the problematic behaviors, DBT applies the principles of
behaviorism (e.g., Skinner, 1974) and social behaviorism (an integrative
model itself; Staats, 1975) and the traditional practices of cognitive-
behavior therapy (CBT; e.g., Barlow, 1988; Goldfried & Davidson, 1976;
Masters et al., 1987; Wilson & O’Leary, 1980) that led to the development
of efficacious treatments for many other disorders. To facilitate case
conceptualizations and interventions capable of addressing the multiplicity
and complexity of behaviors associated with BPD, DBT integrates and
adapts traditional problem-solving strategies such as skills training,
exposure, and contingency management.
 Clinical experience, however, suggested that these practices alone would
prove insufficient when treating BPD clients. Compared to most clients
who successfully complete behavioral programs, these clients had
significantly more behaviors to target, poorer treatment compliance, and
higher treatment dropout. Developing and maintaining a collaborative
relationship and a stable set of treatment goals while encountering high
suicidality, conflict in therapy, and other crises made the straightforward
application of CBT extremely challenging.
Therapy-interfering behaviors occur as a result of CBT’s perceived focus
on changing behaviors, ranging from emotions and cognitions to overt
behaviors. Linehan suggested that the focus on change was experienced by
the client not only as invalidating specific behaviors but as invalidating the
client as a whole. Research (e.g., Swann, Stein-Serussi, & Giesler, 1992)
may explain how such perceived invalidation leads to problematic behavior
in therapy. When an individual’s basic self-constructs are not verified, the
individual’s arousal increases. The increased arousal then leads to cognitive
dysregulation and the failure to process new information. The biosocial
model suggests that BPD clients are particularly sensitive to any potentially
invalidating cues and more likely to become highly aroused.
To balance the emphasis on change, Linehan began to integrate the
principles of Zen (e.g., Aitken, 1982) and the associated practice of
mindfulness (e.g., Hanh, 1987), which describe “acceptance” at its most
radical level. Zen encourages radical acceptance of the moment without
change. Practice includes focusing on the current moment, seeing reality as
it is without “delusions,” and accepting reality without judgment. The
practice also encourages students to let go of attachments that obstruct the
path to enlightenment, to use skillful means, and to find a middle way. Zen
teaches that each moment is complete by itself and that the world is perfect
as it is (Aitken, 1982). Zen focuses on acceptance, validation, and tolerance
instead of change. In contrast to the experimental evidence required in
psychology, Zen emphasizes experiential evidence as a means of
understanding the world. Although Kabat-Zinn (1990, 1994) was
developing a mindfulness-based approach to treat stress in behavioral
medicine at about the same time, Linehan was the first to integrate
mindfulness into a psychotherapy (Swales, 2018).
The tensions arising from Linehan’s attempt to integrate the principles of
behaviorism with those of Zen required a framework that could house
opposing views. The dialectical philosophy, which highlights the process of
synthesizing oppositions, provides such a framework. Through the
continual resolution of tensions between theory and clinical experience as
well as between Western psychology and Eastern practice, DBT evolved in
a manner similar to the theoretical integration described by psychotherapy
integration researchers (Arkowitz, 1989; Norcross & Alexander, Chapter 1,
this volume).

Dialectical Principles
Dialectics describes the process by which the development and progress of
therapy occurs and by which conflicts that impede progress are resolved.
The American Heritage Dictionary (1979, p. 363) defines dialectics, in part,
as “The Hegelian process of change whereby an ideational entity (thesis) is
transformed into its opposite (antithesis) and preserved and fulfilled by it,
the combination of the two being resolved in a higher form of truth
(synthesis).” Linehan’s application of dialectics was influenced by
evolutionary biology (Levins & Lewontin, 1985), cognitive development
(Basseches, 1984), and the evolution of self (Kegan, 1982). Based on such
sources, Linehan draws several assumptions about the nature of reality that
are particularly relevant to psychotherapy with BPD clients. Three of these
assumptions—that reality is (1) interrelated or systemic, (2) oppositional or
heterogeneous, and (3) continuously changing—are discussed in greater
detail.

Interrelatedness
Dialectics stresses the fundamental interrelatedness and unity of reality by
emphasizing relationships within and between systems. “Parts and wholes
evolve in consequence of their relationship, and the relationship itself
evolves. These are the properties of things that we call dialectical: that one
thing cannot exist without the other, that one acquires its properties from its
relations to the other” (Levins & Lewontin, 1985, p. 3). Behaviorism and
Zen both recognize the importance of interrelatedness. Though all CBT
therapists are trained to include the external environment in their search for
controlling stimuli and to evaluate the effect of behavioral antecedents and
consequences, the contextualist position described by Hayes (1987) most
clearly resembles the dialectical emphasis on attention to interrelatedness
and the whole. Zen and other Eastern practices (Wilber, 1979) highlight the
experience of connectedness to the universe and letting go of personal
boundaries.
One of the most pervasive ways in which the principle of interrelatedness
influences treatment is that it encourages a systemic approach to the
analysis of behavior. The DBT therapist considers two levels at which the
client may experience dysfunction. The first level encompasses mutually
influential systems within the individual, such as biochemical systems,
affective regulation systems, and information processing systems. For
example, if a client’s serotonin uptake is dysregulated, this may lead to
affective instability. Affective dysregulation often interferes with cognition.
If the cognitive dysregulation includes a disruption of problem-solving
abilities, then this disruption could lead to a crisis that further dysregulates
affect. Although multiple dysregulations may require multiple treatments, a
systemic approach also foresees how any single intervention may influence
multiple systems. For example, effective pharmacotherapy may regulate
serotonin intake such that the chain just described never begins.
Alternatively, enhancing emotion regulation skills may help the client to
manage biological changes such that information processing and problem-
solving are not impaired.
The second level of systemic dysregulation involves the interpersonal
systems, such as family, culture, and other environmental systems. To
obtain an accurate understanding of the client’s behavior, DBT therapists
assess these influences as well as biological and psychological factors.
Many clients live in or interact with systems that reinforce problematic
behavior or punish skillful behavior. For example, the hospitalization of a
client for attempting suicide may actually reinforce the behavior if the
hospitalization provides desirable consequences, such as more warmth and
caring from staff than the client received elsewhere or fewer onerous
responsibilities (e.g., finding housing) that the client cannot otherwise
avoid. Decreasing the likelihood of attempting suicide may involve, in part,
the therapist and client working to diminish the likelihood that
hospitalization leads to such desirable consequences. Alternatively, a
client’s attempts to search for employment may be punished by a family in
which everyone else lives on unemployment benefits. One of the most
critical interpersonal systems is, of course, the therapeutic relationship,
which will be discussed later.

Opposition
Dialectics also highlights the complexity of nature by suggesting that reality
is composed of opposing forces, the thesis and the antithesis, in tension
with each other. Development occurs as these oppositions proceed toward
synthesis and as a new set of opposing forces emerges from the synthesis.
In psychotherapy, tensions can arise within the client, within the therapist,
between the client and therapist, or between the client and/or therapist and
the larger treatment system. Here, we focus on what DBT has identified as
the central opposition for the therapist: the tension between accepting the
client and changing the client.
The relation between change and acceptance forms the basic paradox and
context of treatment. Therapeutic change can occur only in the context of
acceptance of what is, and the act of acceptance itself is change. The ability
of the DBT therapist to balance change and acceptance is enhanced through
combining aspects of CBT and Zen practices. CBT provides the technology
of change, Zen provides the technology of acceptance. To maximize
therapeutic progress, the DBT therapist continuously interweaves
acceptance strategies—which acknowledge the client as in the moment—
and change strategies, which attempt to alter the client’s behavior.
The therapy strives to help the client understand that certain behaviors
may prove both valid and problematic. For example, anxiety about not
having sufficient skills to cope when the therapist leaves town for a holiday
is a valid response from a client who has few coping skills and functions
better when the therapist remains in town. On the other hand, the therapist
will leave town, so learning relevant skills will be the most effective way
forward for the client. To validate the client while also solving a problem,
the therapist may offer the client an extra session prior to the holiday and
then focus exclusively during that session on skills to help the client cope
with the therapist’s absence.

Change
Dialectics stresses change as a fundamental aspect of reality. All therapies
foster change, but they differ in the type and degree of change they
promote. As noted earlier, both behaviorism and Zen discuss change,
though in slightly different ways. CBT promotes change by using
interventions that require the client and/or the therapist to actively change
emotions, thoughts, overt behavior, or the environment. In contrast, neither
the Zen student nor the master tries intentionally to change but instead to
mindfully observe experiences as they occur. Whereas the cognitive-
behavior therapist teaches the client how to actively decrease dysfunctional
behavior, the Zen master helps the student learn to observe how emotions,
cognitions, and urges, both pleasant and aversive, naturally come and go
without making any attempts to change them. According to Zen, everything
is impermanent and comes and goes like waves in the ocean, thus the
important emphasis on acceptance.
CBT and Zen practice therefore offer two approaches to change. For
example, whereas cognitive-behavioral procedures can reduce suicidal
behavior by teaching the client how to actively reduce suicidal urges, Zen
practice can reduce such behavior by teaching the client how to allow and
observe the urges without acting on them. These behavioral and Zen
approaches reciprocally enhance each other. On the one hand, an important
step in reducing suicidal urges is to increase awareness of those variables
that control the urges. On the other hand, if one observes the urges without
reinforcing them through action, the urges will naturally decrease over time.
In addition to promoting change in the client’s behavior, DBT allows
therapists extensive freedom to change their own behavior and some
aspects of the treatment’s structure. For example, as the therapy relationship
develops, the therapist may expand various limits (e.g., willingness to
accept phone calls, using examples of self as a coping model) as one would
expand limits in any other relationship over time. This natural change is
allowed to occur so that the therapeutic context matches, as closely as
possible, the “real world.” Alternatively, such limits may also contract as a
result of changes in the therapy relationship (e.g., client begins to phone the
therapist too often or shares the therapist’s self-disclosure with other
clients) or the therapist’s life (e.g., therapist has a baby, is studying for
exams). The therapist does not try to protect the client from natural change
but instead tries to help the client learn to respond effectively to change,
viewing such changes as opportunities for the therapy to actively address
deficits in the client’s ability to adapt. For example, when DBT group skills
trainers rotate into and out of an ongoing group, the trainers may directly
target the clients’ distress by helping them to practice some of the relevant
skills that they have learned during skills training.

APPLICABILITY
The first randomized controlled trial (RCT; Linehan et al. 1991, 1994)
examining the applicability of DBT occurred in an outpatient treatment
program for women who had a history of attempted suicide, nonsuicidal
self-injurious behavior, or both and who met criteria for BPD. This trial
excluded individuals who met criteria for schizophrenia, bipolar disorder,
substance dependence, and intellectual disability, but included individuals
who presented with comorbidity for other disorders. Because treatment
programs for substance dependence often excluded borderline individuals,
Linehan (Linehan & Dimeff, 1997) decided to develop DBT to treat
borderline clients who also met substance dependence or abuse criteria.
More recently, an adaptation of Foa’s exposure treatment for posttraumatic
stress disorder (PTSD) has been integrated into standard DBT for clients
with comorbid PTSD, BPD, and suicidal behavior (Harned, Korslund, &
Linehan, 2014). The RCTs examining the efficacy of standard,
comprehensive DBT for BPD are reviewed later in this chapter.
In addition to the developments in DBT for BPD, treatment developers
and clinicians have applied DBT, either in its original version or in an
adapted form, to a range of mental disorders, across the age spectrum, and
in several clinical settings. Only those developments with favorable results
in RCTs are identified as having demonstrated applicability for the purposes
of this chapter. Unlike the original DBT trial, many of these trials included
male clients. Diagnoses with evidence of efficacy include bulimia and binge
eating disorder (summarized in Safer, Telch & Chen, 2009; see Lenz et al.,
2014 for a meta-analysis), mood disorders (e.g., Lynch et al., 2003),
comorbid clinical depression and personality disorder (Lynch et al., 2007),
clinical anxiety (Neacsiu et al. 2014), and attention deficit disorder (e.g.,
Fleming et al., 2015).
Regarding age, the age range for DBT has been extended by adapting the
treatment for suicidal adolescents (McCauley et al., 2018; Mehlum et al.,
2014; Miller, Rathus & Linehan, 2007; Rathus & Miller, 2015). The
adaptation also appears efficacious for adolescents with bipolar disorder
(Goldstein et al., 2015). More recently, DBT has been adapted for even
younger clients, specifically children with disruptive mood dysregulation
disorder (Perepletchikova et al., 2017). At the other end of the age
spectrum, DBT has been adapted for depressed elderly clients (Lynch et al.,
2003, 2007).
Although adaptations have extended its applicability, DBT has
emphasized the importance of implementation research before adapting the
treatment. For example, research on innovative treatments has supported
first adopting a treatment as originally developed and then adapting only as
necessary or as data suggest will not harm clinical outcomes. Considering
the principle-guided nature of DBT and the types of changes made in its
empirically supported adaptations, another way to approach the issue may
be to adopt the principles wholeheartedly and adapt the practical aspects as
needed.

ASSESSMENT
Standard DBT initially assesses potential clients during a screening phase to
determine whether they meet the program’s diagnostic, behavioral, and
other inclusion criteria and do not meet any of the exclusion criteria.
Programs are encouraged to use standardized assessments whenever
possible. Though DBT emphasizes the importance of objective,
standardized diagnostic assessments, the treatment maintains a behavioral
view that suggests that a diagnosis of BPD is simply a term to summarize a
particular pattern of behaviors. If the behaviors cease, so too does the
diagnosis.
Further, DBT therapists approach the application of the diagnosis of BPD
from a utilitarian perspective. That is, DBT does not “believe in” the
diagnosis per se but uses it because it has been demonstrated to be effective.
A diagnosis of BPD functions to predict the prognosis of various types of
treatments and allows the therapist to develop a treatment plan.
In standard DBT programs, clients who successfully complete the
screening phase receive a DBT individual therapist who completes several
“pretreatment” tasks, including additional assessments. The therapist first
assesses the client’s treatment goals, including short- and long-term, clinical
and nonclinical goals, and orients the client to how the treatment will
address these goals. The therapist then assesses the client’s mental disorders
and behavioral problems not included in the screening and any other
presenting problems. The therapist also obtains a detailed history of the
client’s most severe behaviors.
Borderline individuals often present with severe lack of behavioral
control, engaging in multiple unsafe or destabilizing behaviors or both. A
single individual may be suicidal, abuse substances, physically threaten
others, and dissociate. Because BPD clients often engage in behaviors that
either directly interfere with therapy (e.g., not attending, not completing
homework, remaining mute) or that lower the therapist’s motivation to
provide treatment (e.g., insulting the therapist, threatening to complain
about the therapist to management, stalking the therapist), an assessment of
the individual’s past treatment experiences may prove valuable as well.
For clients at this stage of dysfunction, DBT focuses on moving from
severe dyscontrol to behavioral control. The initial assessment of the severe
behaviors enables the therapist to develop a hierarchy of behaviors to target.
These target behaviors are as specific and as clearly defined as possible.
The target hierarchy is as follows: (1) decreasing suicidal (e.g.,
nonsuicidal self-injurious acts, suicidal urges, suicide threats) and other
imminently life-threatening behaviors (e.g., homicidal behaviors); (2)
decreasing therapy-interfering behaviors of both patient and therapist; (3)
decreasing severe, quality of life-interfering behaviors (e.g., mental
disorders, impulsive spending leading to bankruptcy, behaviors leading to
homelessness); and (4) increasing behavioral skills such as distress
tolerance, emotion regulation, interpersonal effectiveness, and mindfulness.
The client tracks the target behaviors on a weekly diary card, along with
other variables related to those behaviors (e.g., emotions, thoughts, use of
DBT skills). The therapist and client use the most recent diary card to
identify an episode of the highest target for the week and then conduct a
thorough assessment of that episode (see section on “Behavioral Chain
Analysis”). Outcome variables in DBT commonly consist of the top targets
in the hierarchy.
The identification of treatment targets a tension between behavior
therapy and Zen and a paradox within Zen itself. Whereas the cognitive-
behavior therapist helps the client to define where the client wants or needs
to go, the Zen master helps the student to realize that the student is already
there. The paradox within Zen is that, although one enters the practice to
achieve enlightenment, the more one focuses on enlightenment as a goal
during practice, the less likely one is to experience it. DBT therapists
balance requiring clients to work on treatment targets with appreciating
clients’ inherent strengths. Of course, therapists also attend to the many
ways in which attention to treatment targets can interfere with achieving
them. For example, the client’s fears of not being able to stop drinking may
actually cause anxiety that leads to more drinking.

CASE FORMULATION
Formulation in DBT may be viewed as occurring on two overlapping
levels, a general case formulation and specific behavioral formulations. The
therapist first develops a formulation of the case as a whole. Based on
behavioral and dialectical principles and the biosocial model, the case
formulation provides a general understanding of the development of the
client’s behaviors and general guidelines for treatment, as well as the target
hierarchy. This formulation slowly evolves across sessions as the therapist
first addresses the same problem in various contexts and then moves on to
address other problems.
Within a single session, a therapist first selects an episode of the client’s
most severe behavior (e.g., cutting, bingeing, dissociating) to target and
then develops a behavioral formulation for that specific episode. If the
behavior reoccurs the following week, the therapist will develop a
behavioral formulation of the new episode, incorporating information from
both an assessment of the current episode and from past formulations. Thus,
the DBT therapist develops a single case formulation that slowly evolves
and a series of behavioral formulations that may change more quickly from
session to session.

Biosocial Model
To explain the development of the behaviors associated with BPD, Linehan
(1993a; Crowell, Beauchaine, & Linehan, 2009) proposes a biosocial model
in which BPD results primarily from a disorder within the system of
emotion regulation. She hypothesizes that the problems with emotion
regulation result from a dialectical transaction between a biologically based
proclivity toward emotion dysregulation and impulsivity on one side and an
invalidating social environment(s) on the other. This hypothesis suggests
that not only does the interaction of the individual’s biology and
environment lead to problematic behaviors, but also that the biology and
environment reciprocally influence each other such that the emotional
dysregulation creates more invalidation and vice versa.
The pervasive emotion dysregulation experienced by borderline
individuals results from a biologically based emotional vulnerability
combined with insufficient emotion regulation. “Emotional vulnerability”
refers to a physiological predisposition to be highly sensitive to emotional
stimuli, to respond intensely to such stimuli, and to return slowly to a less
emotional baseline. Emotional vulnerability alone would not necessarily
prove problematic if the individual managed the emotions well. To
conceptualize emotion regulation, DBT has incorporated the work of
Gottman and Katz (1990), who have suggested that emotion regulation
requires the ability to (a) inhibit inappropriate behavior related to strong
negative or positive emotion, (b) decrease physiological arousal induced by
the affect, (c) refocus attention away from the affect, and, finally (d)
organize one’s behavior toward coordinated action to achieve the external
goal (i.e., solve the problem that initially elicited the affect).
Though emotion dysregulation may cause some form of behavioral
problems by itself, only when such dysregulation occurs within an
invalidating environment over a period of time, and the dysregulation and
environment shape each other, does BPD develop. An invalidating
environment is “one in which communication of private experiences is met
by erratic, inappropriate and extreme response” (Linehan, 1993a, p. 49).
Such environments chronically reject or otherwise punish the individual’s
communication of private experiences (e.g., emotions, cognitions, physical
sensations) or self-generated behaviors and oversimplify the ease of
resolving problems. Furthermore, these environments then intermittently
reinforce the escalation of emotional behavior. For example, an invalidating
environment may ignore expressions of distress until it leads to suicide
attempts, substance dependence, or bulimic behavior.
Though individuals diagnosed with BPD first encounter invalidating
environments during childhood, many find themselves in such
environments (e.g., marriages, employment, treatment systems) during
adulthood as well. The potential consequences of continual invalidation
include difficulties in effectively labeling and regulating emotions and
distrusting one’s own experiences as valid responses. Additionally, the
environment fails to adequately teach the individual how to solve problems,
to self-regulate, and to tolerate distress. Finally, the intermittent
reinforcement of escalated emotional reactions teaches the individual to
fluctuate between inhibition of emotions and extreme emotional behavior.
Recently, Linehan has clarified the concept of traumatic invalidation to
describe the severest type of invalidation and its consequences. As with the
traumatic events involved in PTSD, objective elements of an invalidating
event are used to define “traumatic,” rather than just an individual’s
response to the event. Invalidation events are, however, interpersonal rather
than physical. Traumatic invalidation events are events that are reasonably
capable of causing serious psychological injury to the individual. The injury
may be to the individual’s integrity or fundamental experience of self. For
example, the event may lead to confronting a belief that one is lovable, to
destroying confidence about having the skills to accomplish a goal, or to
denigrating trust in one’s emotional responses. Alternatively or additionally,
the injury may be to the individual’s perception of how essential others
value or view the individual. For example, the event may lead to destroying
the perception that one is loved by parents, liked by friends, or appreciated
by colleagues.
In addition to the extremity of the invalidating act, several other aspects
of the act determine whether the invalidation warrants the label of
“traumatic.” One critical factor is the salience of the invalidator to the
individual (e.g., parent, leader of relevant social organization, boss). For
example, some clients who experienced sexual abuse as children reported
the abuse to their mothers only to have their mothers respond in
invalidating ways, such as accusing them of lying. Several of these clients
have described these interactions as traumatic, not so much because of the
implications for the abuse itself, but because the invalidation indicated to
them that the parent did not love them or value them enough to believe
them or take care of them. Other relevant aspects include the frequency or
repetition of the invalidation and the pervasiveness of it by different
invalidators.
Although traumatic invalidation commonly involves invalidating the
valid, in some instances the invalidator’s communication or other action has
some validity regarding the individual’s problematic behavior or inaccurate
cognitions. The traumatic aspect of the invalidation in these circumstances
results from the invalidator demeaning the individual about the behavior or
belief. In verbal communications, this usually involves strong negative
judgments or overgeneralizations (e.g., “You’re so fat, no one will ever love
you”). For example, during their youth, some clients experienced bullying
that involved no physical threats, but instead involved a valued social group
repeatedly making extreme invalidating statements about the client that
caused the client reasonably to perceive that no one would befriend him or
her because of personal traits. In several cases, the invalidating statements
highlighted socially problematic traits that the client did have and needed to
change to achieve his or her social goals, but the demeaning style of the
communications, often public, transformed potentially useful information
into traumatic invalidation.
Traumatic invalidation has both psychological and behavioral
consequences. Some of these consequences resemble those associated with
physical trauma, including reexperiencing the event through memories,
images, thoughts, and even dreams and reacting with intense emotions to
any invalidating cue. The individual may experience higher levels of shame
or anger, or oscillate between the two. Paradoxically, the individual may
alternately avoid the invalidator as well as similar situations and yet
intensely attempt to obtain validation from the invalidator.

STRUCTURE
In standard DBT for BPD, clients commit to an initial year of treatment that
includes weekly, hour-long individual psychotherapy sessions, weekly 2.5-
hour group skills training classes, and between-session telephone
consultation. Inpatient programs often have a shorter duration but more
frequent sessions than outpatient programs. Although DBT encourages
“skills rather than pills,” the treatment emphasizes using all effective
means, which sometimes involves improving medication compliance.
Similarly, DBT emphasizes problem-solving and skills-coaching rather than
hospitalization as the response to outpatient clients’ suicidal crises. To
facilitate applying DBT in such crises, when the therapist may be
emotionally dysregulated and less able to think clearly, the intervention
involves the suicide crisis protocol (Linehan, 1993a) and the more recent
addition of the Linehan Risk Assessment and Management Protocol
(Linehan, Comtois, & Ward-Ciesielski, 2012).
If a client continues to engage in his or her top target behavior, the
therapist continues to target that behavior throughout the year rather than
ending the treatment for that behavior. By the end of a year of DBT,
however, if the client has not demonstrated notable progress regarding the
top target, the program will conclude that DBT does not help the client and
consequently will not extend the treatment. In many programs, clients can
renew their contract if they have demonstrated notable progress during the
year yet have other clinical problems to address. Thus, DBT establishes
programmatic contingencies to reward progress rather than stagnation or
deterioration.
To enhance its generalizability, DBT is organized around treatment tasks
or functions, rather than around inflexible treatment modes (e.g., group
skills training, phone consultation). There are five primary treatment tasks
based on the capability deficit/motivational model. These tasks consist of
(1) enhancing client capabilities, (2) improving client motivation, (3)
generalizing client capabilities, (4) structuring the environment, and (5)
treating therapists. The dialectical model suggests that although tensions
may arise among the various tasks, the successful completion of any task
depends on how well it is integrated with the others.

Enhancing Client Capabilities

To address the assumed capability deficit, the treatment first requires a
mode that enhances the client’s capabilities. Various modes, ranging from
self-help books and videos to pharmacotherapy, may address this task.
Standard DBT employs psychoeducational skills training groups (Linehan,
2015a, 2015b) as a key mode to enhance capabilities. The DBT skills
trainer teaches modules or sets of skills that can be divided into those that
promote change, consisting of the emotion regulation and the interpersonal
effectiveness modules, and those that promote acceptance, consisting of the
mindfulness and the distress tolerance modules. To develop these skills,
DBT integrates research and applications not only from CBT but from both
the wider field of psychology (including social psychology, biological
psychology, and emotion research) and Eastern practices.
In skills training, the client first learns a wide variety of skills and then
works to integrate these skills into a repertoire. The client’s job resembles
that of a technically eclectic practitioner who may select from a variety of
techniques to solve a therapeutic problem. For both, the key question is
what is effective in this situation.
 Though the section that follows later in this chapter on outcome research
will review RCTs of comprehensive DBT for BPD, three studies focusing
on skills are relevant here. An analysis (Neacsiu, Rizvi, & Linehan, 2010)
of data from three of Linehan’s studies with BPD clients supports the
importance of skills training. The analysis revealed that DBT skills use
mediated clients’ decrease in suicide attempts and depression and increase
in anger control. Two RCTs have assessed the impact of “skills only” (i.e.,
no DBT individual therapy or other individual psychotherapy) interventions
for suicidal BPD clients. The first study (Soler et al., 2009) compared 13
weeks of DBT skills training to nonbehavioral group therapy with
psychodynamically trained therapists. The second study (McMain et al.,
2017) compared 20 weeks of DBT skills training to a wait list control.
Although neither adaptation is as integrative as standard, comprehensive
DBT, both studies obtained sufficiently favorable results to warrant
attempts to replicate with more rigorous research designs.
From an integrative perspective, mindfulness skills may be of particular
interest. These skills teach clients to observe, describe, and participate
without judgment, with a focus on the present moment and with an
emphasis on being effective. These skills help clients to enhance their
awareness of reality and are an inherent part of the other skill modules.
Before one can change what is, one must first be aware of what is. As one
of their early assignments in the emotion regulation module, for example,
clients practice observing and describing the prompting event,
interpretations, facial expressions, actions, and so forth associated with a
particular emotional episode. Becoming aware of the many factors
contributing to a single emotional episode facilitates learning skills to
change those factors and thus better manage the corresponding emotion.

Enhancing Client Motivation

As behavior is determined by motivational factors as well as capabilities,
DBT also focuses on improving motivation. Again, a variety of modes,
including inpatient milieus (e.g., settings that provide incentive systems,
peer support/pressure), couple sessions, and pharmacotherapy (e.g.,
anxiolytics may decrease fear that inhibits interpersonal skills), may address
this function. For example, DBT for substance abusers (Linehan & Dimeff,
1997) replaces illegal drugs with legal medications (e.g., methadone for
heroin users) to decrease the motivation to use the illegal drugs.
Standard DBT primarily addresses the task of improving motivation in
individual psychotherapy, where the therapist conducts an extensive
analysis of the factors that motivate the client’s behavior and employs
strategies to improve the client’s motivation. The individual therapist also
integrates the skills training described earlier into the individual therapy
(e.g., suggesting skills as solutions to problems, rehearsing the
implementation of those skills, and reinforcing the use of skillful behavior).
Also, if the client has a problem with the skills training group (or any other
mode), the individual therapist consults with the client as to how the client
can best solve the problem. Similarly, the client could seek consultation
from the group therapist regarding a problem with the individual therapist.

Ensuring Generalization and Structuring the Environment

Just as the DBT therapist does not assume that the client will have sufficient
motivation to apply new skills, the therapist also does not assume that skills
practice will automatically generalize from therapeutic settings to real-life
settings. The context of applying skills may differ substantially from the
context of learning skills, particularly in terms of the client’s degree of
emotional dysregulation and the environment’s likelihood of providing a
reinforcing response. As a behavioral treatment, DBT emphasizes the
importance of in vivo treatment so that learning will generalize beyond the
therapeutic context. Possible treatment modes include inpatient milieus,
occupational therapy, and in vivo practice/exposure with the DBT therapist
or a case manager.
Outpatient DBT programs provide clients with the opportunity to phone
or otherwise contact their individual therapist or another designated DBT
team member for brief coaching interventions between individual therapy
sessions. Skills coaches accept phone calls whenever possible, within their
natural rather than arbitrary limits. These coaching interventions help
clients apply skillful solutions to an immediate problem. Clients also learn
how to ask for help in a more socially effective way.
The treatment’s fourth function focuses on helping the client to structure
his or her environment in a way that promotes progress in other contexts.
Structuring the environment may involve removing environmental cues that
elicit problematic target behaviors, adding cues that elicit skillful behavior
and environmental consequences that reinforce it, subtracting consequences
that punish skillful behavior, and removing reinforcing consequences for
target behaviors. To address this function, the therapist and client may
involve other individuals, such as family, inpatient staff or case managers.

Enhancing Therapists’ Capabilities and Motivation

Finally, dialectical principles guide the treatment to also attend to the
capabilities and motivation of DBT therapists. Linehan observed that
clients’ behaviors sometimes emotionally dysregulate therapists to the
extent that the therapists experience excessive stress and urges to quit and
that they either ineffectively tried to control patients or reject them entirely.
At other times, she observed therapists experiencing excessive empathy for
clients to the extent that they became despairing and noticed impulses to
abandon these clients. Also, with borderline clients, the transaction between
client and therapist may be such that the client punishes therapeutic
behavior and rewards iatrogenic behavior.
Treating the therapist as well as the client thus reinforces the dialectical
frame of the therapy by attending to the two primary subsystems within the
therapeutic context. In standard DBT programs, consultation meetings
among therapists address these issues. Rather than focusing on clients, as is
done in traditional case management meetings, these consultation meetings
focus on the therapists, enhancing their DBT adherence and competence
and minimizing their distress. Implementation research finds that such team
supervision typically improves therapists’ adherence and sometimes
improves clients’ outcomes as well. It might be noted that DBT was one of
the first to integrate such team supervision as a standard part of the
treatment (Swales, 2018).
One of the consequences of having multiple professionals involved in the
care of a single client is that tensions can arise among them. Therapists on
DBT consultation teams adhere to a set of agreements, several of which
help to reduce the likelihood of such tensions and increase a sense of shared
responsibility. Unsurprisingly, consultation team members agree to remain
dialectical in their interactions with each other as well as with clients. The
consultation-to-the-client agreement states that therapists do not instruct
each other about how to interact with a client; instead, they coach the client
on how to interact effectively with members of the team. This removes one
of the greatest causes of tension—practitioners telling each other how to do
the other’s job. Similarly, the consistency agreement states, in part, that all
team members need not have a consistent response to a client. For example,
a therapist covering for an individual therapist on leave may provide more
hours of phone availability but may hospitalize more quickly if the client
threatens suicide. Such inconsistencies offer the client an opportunity to
learn, with the therapist’s coaching, how to respond effectively when
inconsistencies and changes occur outside of therapy. The fallibility
agreement assumes that therapists will make mistakes. This encourages
therapists to present their own clinical problems to the team rather than hide
them for fear of being judged and to accept rather than defend their clinical
errors that other team members have identified. The agreement also requires
team members to identify and treat each other’s errors.

METHODS AND TECHNIQUES

DBT is an integrative therapy that embraces many techniques adapted from
a variety of sources. Each technique, however, fits within the therapy’s
theoretical framework. The primary techniques or strategies are organized
into sets of pairs, with one member of the pair most strongly emphasizing
change and the other most strongly emphasizing acceptance. A dialectical
set of strategies facilitates the synthesizing of the other strategies. The
relation between the strategies resembles a figure skating pair in a rink. The
members of the pair have different steps, but the steps flow together and
balance each other, with one member’s moves enhancing, not competing
with, the moves of the other. Attaining balance is difficult, of course,
particularly as the balance point continuously changes across clients and
across time for a single client. That the session is no longer progressing is
the primary indicator that one or more of the pairs of strategies have
become imbalanced. The most frequently used strategies—problem-
solving, validation, stylistic and dialectical strategies—are described next.

Problem-Solving Strategies
DBT views the problem-solving strategies as central to changing
dysfunctional behaviors. Within DBT, problem-solving targets a specific
problematic behavior, applies behavioral principles to understand that
behavior, and focuses on current variables that maintain the behavior.
Furthermore, problem-solving applies empirically supported interventions
to treat the problematic behavior, integrates multiple CBT procedures, and
emphasizes behavioral rehearsal.
Problem-solving can be divided into two interconnected components: (1)
a behavioral chain analysis, which assesses the presenting problem(s), and
(2) a solution analysis, which generates and implements more effective
solutions in response to the problem(s). It is in the application of the
problem-solving strategies that therapists may appear at their most “active,”
as they are asking questions, analyzing answers, generating solutions, and
helping clients to implement solutions. Though most of this activity
involves thinking and verbalizing actions, DBT therapists often engage in
physical activity when modeling skills. How directive the therapist becomes
during problem-solving usually depends on the client’s level of
dysregulation.

Behavioral Chain Analysis

As described earlier in the section on case formulation, DBT emphasizes
the development of a behavioral formulation within each session. To
achieve this formulation, the therapist conducts a behavioral chain analysis,
which involves defining a behavior to target, conducting a chain analysis of
that behavior, and identifying the function and other variables that control
that behavior. Using the target hierarchy, the therapist and client first choose
a specific incident of a defined behavior. The therapist then assesses, in
detail, the links in the chain surrounding the target behavior, from the
environmental event that prompted the behavior through to the
consequences that followed the behavior. Other variables of interest include
the client’s cognitions, emotions, sensations, urges, and overt behaviors.
The therapist also analyzes the relations among these links. With respect to
assessing the consequences of the behavior, the therapist is interested in
both the short- and long-term psychological and environmental
consequences.
The following is an example of a brief chain of an overdose. A client
asked her husband to spend more time with her. His refusal precipitated an
argument followed by his departure. The client’s anger began to decrease
and be replaced by a sense of loneliness. This sense elicited thoughts that
the husband would never return and that she would not be able to cope by
herself. These thoughts then prompted fear, which escalated over time as
the client continued to ruminate. The escalating fear led to thoughts that she
might go crazy, which led the client to having suicidal thoughts and urges
and eventually to overdosing on prescribed medication. Later, her husband
found her unconscious and rushed her to the hospital. During her stay in the
hospital, the nursing staff was very validating while her husband visited her
often and apologized profusely for having left during their argument. The
client enjoyed her husband’s visits and hoped that things would change
when she returned home.
During the behavioral chain analysis, the therapist identifies variables
that control the target behavior. Behaviorists particularly focus on factors
maintaining the behavior in the current context as opposed to factors that
initially developed the behaviors. Because of the biosocial model, DBT
therapists also attend especially to the impact of emotions, such as the
anger, fear, and joy in the preceding example. Most importantly, behavioral
chain analyses help the therapist and client to gain insight into the function
of the target behavior. The client here overdosed with the intent of escaping
from extreme fear, and the behavior functioned in this way. She did not
expect the nurses to validate her nor her husband to visit and apologize; she
had expected to die, after all. This couple, however, had a pattern of
fighting, overdosing, and repairing, such that overdosing increased the time
spent with her husband more effectively. Over time, the husband’s attentive
response to the overdosing had become a secondary function. Once the
function(s) is identified, along with other controlling variables in the chain,
then the therapist and client can generate alternative solutions that will help
the client to more effectively achieve his or her goals. The behavioral chain
analysis should not stand alone but always be followed by a solution
analysis.

Solution Analysis
A solution analysis involves generating, evaluating, and implementing
more effective responses to problems. The first step, generating solutions,
requires the therapist and client to identify as many potential responses as
possible. Borderline clients frequently have a tendency to generate solutions
that require someone else (e.g., therapists, social services, family) to solve
the problem for them (Linehan, 1993a). For example, one client’s only
proposed solution to his drinking problem was to ask his psychiatrist for
medication, and another’s only suggested solution to forgetting therapy
appointments was to ask staff to remind him. To solve this problem,
solution generation should particularly search for options that require the
client’s involvement.
DBT also searches for the opportunity to integrate a variety of CBT
interventions. These interventions include skills training, exposure,
contingency management, and cognitive restructuring. If the client does not
have the requisite skills to solve the problem, the therapist teaches the
necessary skills. Alternatively, if skillful behavior in the client’s repertoire
is inhibited by unwarranted emotions, then the therapist applies exposure
procedures. If the skillful behavior has been either punished or not
reinforced in the client’s environment, or if problematic behavior has been
reinforced, the therapist applies contingency management procedures.
Finally, if maladaptive cognitions interfere with skillful behavior, then the
therapist uses cognitive modification procedures. A single behavioral
analysis usually offers an opportunity to use several CBT interventions.
Solution generation itself presents a problem for many borderline clients.
As a result of growing up in an invalidating environment, some clients
never received adequate modeling of how to generate solutions. Other
clients have acquired the basics of solution generation, but the behavior
remains weak or inhibited because in the past their solutions have failed or
have been punished by others. For example, when one client suggested
higher education as a way to improve her quality of life, her uneducated
parents responded by asking “Who do you think you are? Do you think that
you are better than us?” To shape solution generation, the DBT therapist
reinforces any reasonable attempt by the client to generate solutions and
encourages the client to generate as many solutions as possible before
trying to evaluate potential solutions.
The behavioral chain analysis offers an opportunity to demonstrate how a
therapist and client may generate multiple solutions for a single episode of
behavior. Interpersonal effectiveness skills may increase the likelihood that
the client’s husband agrees to spend more time with her when she initially
asks. To manage that anger if the husband refuses, the client might use
emotion regulation skills and, to decrease cognitions that perpetuate the
anger, mindfulness skills. The therapist may also use cognitive restructuring
to change problematic cognitions. Distress tolerance skills may decrease the
sense of loneliness, while mindfulness and/or cognitive restructuring may
decrease the subsequent worry thoughts. With respect to addressing the fear,
which provided the primary motivation for the overdose, the therapist might
suggest a combination of additional emotion regulation skills and exposure.
If these strategies fail and the client has urges to overdose, having
aversive contingencies in place may help to prevent the client from acting.
For example, in standard DBT, clients lose their telephone privileges for 24
hours following an episode of self-harm. In case the client does overdose,
the therapist and client might alter the contingencies, particularly the
husband’s response to the overdose. Through consultation with the husband,
they may try to change the husband’s behavior such that he becomes more
attentive when she engages in skillful behavior and less attentive when she
engages in suicidal behavior.
After generating solutions, the therapist and client evaluate the potential
efficacy of the various solutions. The solution evaluation should attend to
long-term as well as short-term solutions. For example, many clients report
that they attempt suicide because it so immediately reduces their negative
emotions. In the long term, however, attempting suicide creates more
problems that lead to more negative emotions. The evaluation should also
identify potential obstacles to implementing solutions. Like suicidal clients
(Williams & Pollock, 2000), borderline clients seem to emphasize the
potential negative outcomes of potential solutions. Though this emphasis
may result from an information processing bias, the client’s worries may
also result from an actual lack of skills related to the solution, the
anticipation or experience of extreme affect, or the fact that the client’s
natural environment will punish or at least not reward adaptive solutions.
CBT interventions can again be used to resolve these obstacles.
Finally, the client and therapist select a set of solutions and then
implement those solutions. If the solutions include new or difficult skills,
the client rehearses those skills during the session. This rehearsal
strengthens the skills, challenges the client’s expectations of failure, and
allows the therapist and client to identify and solve problems that might
interfere with the successful implementation of the skills outside of therapy.
If the solutions include any of the other CBT interventions, the therapist
conducts the appropriate procedures during the session. DBT generally
interweaves these procedures informally into the treatment rather than
following the more structured formats of traditional cognitive and
behavioral therapies. For example, if a client avoids asking the therapist for
help because the client fears that the therapist will respond with rejection,
exposure would probably serve as the primary intervention. Prior to the
exposure, however, some interpersonal skills training might increase the
likelihood that the client asks for help in a way that the therapist can
reinforce, while a cognitive modification of expectations might increase the
client’s collaboration with the exposure procedure. Finally, the therapist
would reinforce the client’s appropriate request for help.

Validation Strategies
Balancing the change focus of problem-solving strategies, validation
strategies focus on acceptance. Validation occurs when “the therapist
communicates to the patient that her responses make sense and are
understandable within her current life context or situation” (Linehan, 1993a,
pp. 222–223). There are at least six levels of validation: (1) listening and
observing, (2) accurately reflecting, (3) articulating the unverbalized, (4)
validating in terms of sufficient causes, (5) validating as reasonable in the
moment, and (6) treating the person as valid or radically genuine (Linehan,
1997a).
Levels 5 and 6 are most definitional of validation in DBT. Level 5
validation requires the therapist to communicate how a client’s response
makes sense or is normal in terms of the current context rather than in terms
of the client’s mental disorder or learning history. For example, in response
to a new client who indicates some distrust of the therapist, the DBT
therapist might say, “It makes sense that you have difficulty trusting me
considering that we have just met and you don’t know me well.”
Level 6 requires the therapist to interact with the client simply as a fellow
human being, rather than as a fragile or volatile individual who is incapable
of learning. For example, a therapist may notice that a female client who
complains that the male clients in her skills training group stare at her wears
very revealing clothing to group. If the therapist hypothesizes that the
clothing contributes to the stares, a radically genuine response would
require the therapist to share this hypothesis with the client. The therapist
may then validate both the client’s “right” to dress as she wants and the
normalcy of the male clients’ responses to her dress. These last two levels
of validation most clearly reflect the Zen emphasis on the current moment,
on searching for truth, and on the inherent capability of discovering it.
Though validation is an end in itself, it also facilitates change. The
development of validation was strongly influenced by research indicating
that the verification of an individual’s beliefs about the self tends to
enhance the processing of new information (Linehan, 1997b; Swann, Stein-
Seroussi, & Giesler, 1992). This research indicates that interweaving
problem-solving with validation might increase the likelihood that the client
will process the information provided by the problem-solving. For example,
a therapist may validate the function of a target behavior (“It makes sense
that you want to stop feeling so anxious, and drinking is very effective at
immediately numbing your feelings”), challenge the use of the target
behavior (“But drinking perpetuates your anxiety in the long run”), and then
suggest alternative skills to achieve the same function (“We must find more
effective ways to help you decrease your anxiety”). In addition to balancing
problem-solving strategies, validation may function directly as a change
strategy by providing information about what is valid, modeling how clients
can self-validate, and reinforcing skillful behavior.

Stylistic Strategies
Stylistic strategies refer to the manner in which the therapist interacts with
the client. These strategies attend to the how, as opposed to the what, of the
therapist’s communications to the client. The therapist balances the tension
between two opposing sets of strategies, reciprocal communication and
irreverent communication.
The reciprocal strategies refer to those that communicate the therapist’s
interest in and attachment to the client and that foster a collaborative
relationship. Part of reciprocal communication requires mindfully attending
to the client by noticing responses by the client and by not allowing
preconceptions or judgments to interfere with the attention. Zen applies a
similar responsive approach to achieving a state of the mind at rest:
“Nothing carries over conceptually or emotionally . . . we do not react out
of a self-centered position. We are free to apply our humanity appropriately
in the context of the moment according to the needs of people” (Aitken,
1982, p. 42).
 In contrast to the reciprocal strategies, the irreverent strategies include
techniques designed to attract the client’s attention and temporarily
“unbalance” a client engaged in dysfunctional behavior. Procedures include
reacting matter-of-factly to a client’s extreme communication and directly
confronting dysfunctional behavior. Therapists also reframe behaviors and
situations in unorthodox ways. For example, if a client commits to
decreasing judgmental thinking, the therapist might respond to in-session
judgmental statements by lightheartedly saying, “Did you notice that you
were judging? We know that you already have that skill, so you don’t need
to practice it any more. Let’s practice a skill that you don’t have yet. Try
just describing what happened.” The irreverent strategies integrate
techniques from Whitaker’s (1975) irreverent style in experiential family
therapy and were influenced by Ellis’s (1962, 1987) style in his rational-
emotive therapy. The irreverent strategies also reflect the style of
unorthodox responses employed by Zen masters with their students
(Braverman, 1989). Such responses function to interrupt habitual thinking
patterns that interfere with a student achieving enlightenment.

Dialectical Strategies
The dialectical strategies permeate the application of all other DBT
strategies. Dialectical strategies refer both to a specific set of techniques,
which inherently include elements of acceptance and change, and to
strategies that facilitate dialectical processes within the session (i.e., the
development of syntheses in place of tensions). With respect to developing
syntheses, the therapist and client attend to the entire context of a problem,
frequently asking what has been forgotten or ignored. As discussed earlier
under dialectical assumptions, when tensions arise, the therapist and client
search for the validity of various viewpoints and the syntheses between
them. The therapist also responds to dialectical tensions by interweaving
change strategies with acceptance strategies (e.g., problem-solving with
validation, irreverence with reciprocal communication). Furthermore, the
therapist balances adherence to the treatment manual with responsiveness to
the client, just as dancers follow both the steps of the dance and the
movements of their partners.
Dialectical techniques all share an inherent synthesis of acceptance and
change. Though some of the techniques, such as metaphor (Barker, 1985;
Rosen, 1982) and “playing devil’s advocate” (Goldfried, Linehan, & Smith,
1978), are traditional psychotherapy interventions, other techniques are
adapted from Eastern practices. For example, extending is a translation of a
technique used in Aikido, a Japanese martial art (Saposnek, 1980; Windle
& Samko, 1992). The therapist produces change by extending or taking
more seriously than the client a problematic position originally taken by the
client. The intent is to unbalance the client so that the therapist can shift the
client away from the problematic position without direct confrontation that
could produce conflict. The therapist joins with the client, allows the
behavior to progress naturally to the point intended by the client, and then
extends the behavior beyond the point intended by the client. For example,
a client may say, “You are a horrible therapist, I’m going to write a
complaint about you,” with little intent of writing a complaint but with the
expectation that the therapist will resist the client’s threat and will focus on
repairing any damage to the therapy relationship to prevent the client from
writing. A therapist using extending, however, would accept the client’s
desire to write such a letter and, extending the client’s threat, may offer to
spend the session time helping the client to write the letter because it is the
therapist’s job to help the client to be as effective as possible.

PROCESSES OF CHANGE
As in other aspects of DBT, a dialectical perspective influences the
understanding of the processes of change. Indeed, dialectics itself may be
viewed as a theory of change. As described earlier, change occurs
continuously. Thus, an individual’s behaviors will change, for better or
worse and regardless of whether the individual receives treatment or not.
The role of treatment is to direct and propel change along the most effective
path toward a client’s long-term goals and to facilitate the client’s
acceptance of such change.
Dialectics highlights the occurrence of oppositional positions and the
creation of syntheses between these positions. Indeed, the creation of such
syntheses may be viewed as one mechanism of change. DBT itself was
created by integrating behavioral principles of learning with Zen principles
of acceptance.
Insight and behavioral rehearsal are two mechanisms of change that
sometimes have been polarized. One or the other may prove sufficient (e.g.,
interpersonal contingencies often shape behavior out of awareness), but,
more often, the DBT therapist interweaves them to enhance the impact of
each. For example, insight about self-blaming thoughts may increase the
client’s motivation to rehearse more effective ways of thinking.
DBT also incorporates several theories regarding principles of learning
(e.g., classical conditioning, operant conditions), as well as each theory’s
corresponding techniques (e.g., exposure, contingency management).
Though the theories could compete with each other, in DBT, each theory
and its techniques solve a particular part of the clinical puzzle. Principles to
determine which solution fits where were described in the section on
solution analysis.
The emphasis in dialectics on the transactional nature of development
underlines the importance of attending to the interdependence of
mechanisms of change, as well as to their opposition. The success of
problem-solving strategies, for example, depends partly on interweaving
them with validation strategies. Problem-solving strategies also rely on, or
at least support, each other. For example, a client’s tolerance for behavioral
and solution analyses depends on one following the other. Either alone is
experienced as invalidating or otherwise aversive. Examples of
interweaving the solutions themselves was described in the earlier section
on solution analysis.

THERAPY RELATIONSHIP
The DBT therapist attends to the therapy relationship and to the tensions
and the consequent therapy-interfering behaviors that can arise. Dialectical
principles direct the therapist’s attention toward transactions that occur
within the therapeutic context and accept that the therapist is part of and,
therefore, influenced by the therapeutic context. The DBT therapist views
therapy as a system in which the therapist and client reciprocally influence
each other. Thus, the client’s experience of and behavioral responses toward
the therapist are examined for their validity within the context of the current
relationship and not only as transferences from past relationships.
Just as the therapist shapes the client’s behavior, so the client shapes the
therapist’s behavior. For example, one can easily imagine that if a client
became verbally aggressive every time the therapist tried to address a
presenting problem, the therapist may become less likely to target that
problem. In this scenario, the client would have punished the therapist’s
therapeutic behavior, and the therapist may have reinforced the client’s
aggressive behavior. It is the borderline client’s tendency to shape the
therapist’s behavior in a detrimental direction that necessitates therapist
supervision/consultation. In this way, DBT reflects a crucial element of Zen
that requires the student to practice overcoming the delusions that interfere
with practicing Zen or attaining enlightenment (Aitken, 1982). DBT
therapists do not view therapy-interfering behaviors simply as obstacles to
be avoided or removed so that therapy can proceed, but instead view them
as examples of the very behaviors that occur in clients’ lives outside of
therapy and as the most immediate opportunities to change problematic
patterns.
As within any system, tensions will arise between the therapist and client.
Three examples of relationship tensions are the client’s belief that taking
drugs is the solution and the therapist’s belief that taking drugs is the
problem; the client’s belief that only hospitalization will prevent suicide
now and the therapist’s belief that hospitalization may increase the
probability of a future suicide; and the client’s wish for more contact with
the therapist and the therapist’s wish to observe natural limits.
To resolve such conflicts, the therapy searches for syntheses. The most
effective syntheses are generally those that validate some aspect of both
sides of the debate and move toward more effective behavior. For example,
in the first example, if the client considers drugs as a solution because they
decrease overwhelming anxiety, the therapy may achieve a synthesis by
identifying anxiety reduction as a valid therapy goal. With this as the
accepted goal, drug abuse would no longer be a valid solution as it will tend
—directly and indirectly—to increase, not decrease, anxiety in the long
term. The therapy would instead focus on the client developing more
skillful means to prevent and manage anxiety.
When therapy tensions have not been successfully resolved, they often
result in therapy-interfering behaviors. For example, if a therapist simply
confronted a client about the use of drugs but never offered alternative
solutions that could achieve the client’s goal of regulating affect, the client
may begin to lie to the therapist about drug use. When such behaviors
occur, the therapist targets the behavior and applies the problem-solving,
dialectical, and other strategies described in earlier sections (Heard, 2018).
 Though balancing, integrating, or synthesizing may prove the most
effective ways forward, how to balance or integrate in any particular
situation is not always obvious or easy. Success requires comprehensive and
detailed assessments, rapid movement among the strategies, and rigorous
application of the therapy as a whole. Such demands can be intellectually
and emotionally exhausting for the therapist and client alike. The therapy
can stop or even reverse if the therapist then becomes emotionally
dysregulated or cognitively distracted by worries of what may happen next,
by beliefs that the therapist should find a synthesis more easily, or by
judgments that the client should not have placed the client and therapist
together in this situation in the first place.
Perhaps the most crucial element in not becoming overwhelmed by the
demands of therapy is conducting therapy as mindfully as possible.
Mindfulness requires the therapist to nonjudgmentally focus on the moment
and what is effective, to be aware of unmindful thoughts and urges, and to
refocus on solving the problem at hand. Also drawing from Zen practice,
the therapist strives toward balancing compassion and detachment. Of
course, therapists also use for themselves any or all of the skills and
interventions that they teach their clients.

DIVERSITY CONSIDERATIONS
The biosocial model and other DBT principles provide a solid base from
which to adapt the treatment to a wide range of cultures, including
marginalized cultures. Indeed, the treatment is often adopted by other
cultures without any changes other than language. As described in the
biosocial theory, the treatment was developed for individuals with
experiences of severe and persistent invalidation, who were often judged as
being “wrong” even when their behavior wasn’t pathological. Moreover,
they may also have been frequently rejected by their communities as well as
their families. Indeed, for many years, clients with a diagnosis of BPD often
were marginalized by their mental health systems by being considered
untreatable.
As a behavioral treatment, DBT considers any environmental variable as
a possible controlling variable for a target behavior and also considers a
wide range of solutions for problematic environmental variables. For
example, if an adult client’s suicidal urges are partially controlled by a
parent’s judgmental statements about the client’s sexuality, the client might
use interpersonal skills to change the parent’s behavior, refocus attention
away from the parent or topic, challenge inaccurate interpretations
regarding the parent being judgmental, use self-validation, seek validation
from someone else, or minimize contact with that parent.
As a principle-guided treatment, DBT is designed to be applied flexibly
in various settings while still maintaining fidelity to the model. For
example, the content and style of an irreverent statement may sound
different in one culture than another, but every culture has ways of being
irreverent and consequently capturing clients’ attention in a way that stops
problematic behavior in that moment. Over the years, DBT has developed
across a number of diverse cultures. Indeed, every continent has countries
that have developed DBT programs. Within Europe, DBT programs range
from Ireland to Istanbul and from Scandinavia to Italy. A review of the
international implementation of DBT (Dubose, Botanov, & Ivanov, 2018)
describes the extent of implementation beyond the United States, lists the
empirical trials of DBT contributed by various countries, and discusses
some of the challenges of implementing DBT in other cultures.
With respect to subcultures within the United States, some studies have
occurred within communities that have large minority populations or have
directly targeted minority subcommunities as part of their participant
recruitment efforts. A recent pre-/post study (Beckstead et al., 2015)
focused on American Indian and Alaska Native populations. Integrating
DBT with local cultural, traditional, and spiritual beliefs, the study
successfully applied DBT to adolescents diagnosed with substance use
disorders.

CASE EXAMPLE

C is a woman in her late twenties who met criteria for BPD. She had
completed college and, at the beginning of therapy, was a married
homemaker with no children. She was referred for treatment following a
suicide attempt by overdose.
C reported a history of overdosing with varying degrees of suicidal intent
during the previous 3 years. On average, she overdosed every other month,
but only half of these required medical treatment. Early in her history of
overdosing, most episodes requiring medical treatment also led to brief
psychiatric inpatient stays, but during the year prior to entering DBT, the
client had only been hospitalized twice.
C reported no other types of suicidal behavior but did meet criteria for
recurrent major depressive disorder, panic disorder, and subclinical bulimia.
C described a history of supportive therapy as helping “me to feel better but
nothing really changed.” She stated that she had not had any problems with
the therapy, but her past therapist had described her as “dependent” and
“occasionally manipulative” in sessions.
During pretreatment sessions, C identified several goals for therapy,
including no longer being suicidal, having a “better relationship” with her
husband, and “feeling better” about herself. She initially contracted for 1
year of treatment. The DBT therapist and C developed the following target
hierarchy: (1) decreasing suicidal overdoses and urges to overdose; (2)
decreasing therapy-interfering behaviors; (3) decreasing bingeing and
purging, panic attacks, and depression; and (4) increasing skills, including
mindfulness, emotion regulation, distress tolerance, and interpersonal
effectiveness skills. The therapy-interfering behaviors emerged over time
and included frequently phoning the therapist prior to the therapist’s out-of-
town trips, missing the session following the therapist’s trips, sobbing when
the therapist challenged passive problem-solving, and impulsively
responding with “That won’t work” to suggested solutions.
Several factors may have initially transacted to shape C’s problematic
behavior. She was an only child whom her mother described as “colicky”
and difficult to soothe as an infant. Her mother had recurrent episodes of
major depression throughout the client’s childhood. C described her
relationship between her mother and father as “conflicted.” Her father left
the family when C was 8 years old, though he maintained regular but
infrequent contact with her. Her mother accused the father of being an
alcoholic, but C believed him only to be heavily drinking. She also
described his occasional outbursts of anger. After her father departed, her
mother became more depressed and irritable and less tolerant of emotions
expressed by C, though she never abused or neglected C.
Though it would prove difficult to differentiate the relative impact of
nature versus nurture, some of the sequelae of their transactions are clearer.
The client presented as emotionally vulnerable, with a particularly high
reactivity to emotional stimuli. Her mother failed to model emotion
regulation and tended to either ignore or otherwise punish C’s emotional
communications unless they became extreme (e.g., sobbing). C believed
that her father used alcohol to manage his emotions but also remembers that
he did try “to reassure” her when she worried. When possible, he would
also solve problems for her (e.g., financial). C learned to inhibit her
emotions as much as possible, to become extreme when she failed to
manage them, and to depend on others to solve problems. Also, she did not
learn either to tolerate or to resolve interpersonal conflict. These patterns
were maintained in her relationship with her husband.
The client received all of the traditional DBT modes during the first year
of treatment. She attended individual psychotherapy and group skills-
training regularly, missing approximately eight sessions of each during the
course of the first year. She also regularly used after-hours phone contact
for skills coaching. When the therapist became aware of the extent to which
the husband’s responses influenced C’s motivation, the therapist and C
arranged several conjoint sessions with the husband. These sessions focused
on changing the husband’s responses that reinforced target behaviors,
particularly overdoses and panic attacks. They appeared effective, in part,
perhaps, because the husband shared his wife’s treatment goals and was
motivated to help. Her psychiatrist had prescribed a variety of
antidepressants and anxiolytics prior to C’s entry into DBT. By the end of
the treatment year, C had stopped using anxiolytics.
During individual therapy sessions, the therapist and client targeted the
highest behavior in the hierarchy that had occurred during the past week. If
C had not overdosed or had strong urges to overdose during the past week,
the therapy focused on one of the quality-of-life–interfering behaviors.
Therapy-interfering behaviors topped the agenda only in the case of missing
a session or phoning beyond the therapist’s limits. Other therapy-interfering
behaviors, such as sobbing or passive problem-solving, usually occurred
while targeting suicidal or quality-of-life–interfering behaviors. If these
behaviors occurred, the therapist would briefly shift the focus to the in-
session behavior, solve the problem, and return to the original target. For
example, when the client sobbed in session, the therapist would usually
coach the client on mindfulness and emotion regulation skills until the
client had stopped sobbing and would then proceed with engaging the client
in actively solving problems related to the original target. This response not
only encouraged the client to use skills, but it also functioned as a
contingency management intervention in which the therapist did not
reinforce the client’s avoidance (via sobbing) of active problem-solving.
After selecting a target behavior, the therapist and client completed
behavioral and solution analyses of the target behavior. An example of a
behavioral chain analysis and the corresponding solution analysis for one of
C’s overdoses is provided in the previous section on problem-solving. Most
of her overdoses were precipitated by a disagreement with her husband that
led to strong emotions, with fear as the predominant emotion. Solution
analyses included the full range of skills and other interventions, with
mindfulness and emotion regulation seemingly the most crucial skills.
Major therapy-interfering behaviors and quality-of-life–interfering
behaviors received similar treatment. For example, panic attacks sometimes
occurred in the chain leading to overdosing, and, if so, they received
treatment like other links in the chain. In the absence of overdosing or
strong urges to overdose, panic attacks often served as the primary target.
Analyses of this behavior revealed a similar chain of events. Standard
behavioral treatment, interwoven with mindfulness skills, served as the
main intervention for the panic attacks themselves, while a range of skills
and interventions, similar to those used to treat overdosing, addressed the
other links in the chain.
By the end of 1 year of treatment (approximately 44 individual sessions
and 40 group skills-training sessions), C had become notably more stable.
She had not required hospitalization at any time during the year. During the
last 4 months, she only infrequently had a strong urge to overdose and never
acted on this urge. C stopped missing sessions in response to the therapist’s
travels and seldom exceeded the therapist’s limits on telephone calls. The
frequency of panic attacks decreased from weekly to monthly, and their
intensity and duration were significantly less. Bingeing and purging
decreased in a similar way. By the end of the year, C reported a notable
decrease in depression, as measured by the Beck Depression Inventory
(BDI), though her score remained within the clinical range.
C decided to renew her treatment contract for another year. During this
second year, DBT focused on continuing to decrease quality-of-life–
interfering behaviors and to increase skillful behavior. By the end of the
second year, the bingeing, purging, and panic attacks had stopped. C no
longer met criteria for major depression but did have occasional periods of
“low mood.” The therapy also moved into a more advanced stage of
treatment where targets included emotionally processing issues from her
childhood, finding and maintaining employment, and improving the way
she related to her husband. Therapy ended after 2 years because the
therapist relocated.

OUTCOME RESEARCH
This section reviews the RCTs of DBT for clients diagnosed with BPD.
Linehan and colleagues have published five clinical trials of DBT for BPD,
three involving clients with suicidal behaviors and two involving clients
with substance-related disorders. The initial trial of DBT compared 1 year
of the therapy to treatment-as-usual (TAU) in the community (Linehan et
al., 1991, 1994). The participants were women who met criteria for BPD
and had a recent history of “parasuicidal” (i.e., suicide attempts and
nonsuicidal self-injurious) behavior. The results suggested that, after 1 year,
participants receiving DBT had significantly fewer parasuicides, less
medically severe parasuicides, higher treatment retention rates (DBT = 83%
vs. TAU = 42%), fewer psychiatric inpatient days, lower anger, and higher
social and global functioning than TAU. The two groups did not differ,
however, with respect to depression or suicidal ideation. Additional
analyses suggested that DBT is also a cost-effective treatment (Heard,
2000). Outcome results were weaker but generally maintained during a 1-
year follow-up (Linehan, Heard, & Armstrong, 1993).
Linehan and colleagues (2006) later replicated the initial trial although
with a more rigorously controlled design. All participants in the control
condition (CTBE) received treatment from nonbehavioral therapists
identified as local experts in treating this population. DBT participants were
significantly less likely to make a suicide attempt and more likely to remain
in treatment (DBT = 81% vs. CTBE = 57%). DBT participants also had
significantly fewer psychiatric hospitalizations and psychiatric emergency
department visits, and their suicide attempts and nonsuicidal self-injuries
had significantly less medical risk. Analyses (Harned et al., 2008) of
outcomes for those Axis I disorders experienced by many of the participants
indicated that those receiving DBT had significantly more drug and alcohol
abstinent days and a significantly greater probability of achieving full
remission. The two conditions did not differ in anxiety disorders, eating
disorders, or major depressive disorder.
 Following the replication trial, Linehan and colleagues (2015) dismantled
the treatment to evaluate the importance of the skills training component for
the same client population evaluated in the two previous studies. This trial
compared two treatments to standard, comprehensive DBT. In the DBT-S
condition, participants received the standard skills training group plus case
management, to provide participants in this condition with the same access
to individual treatment time that participants in the standard DBT condition
received. The case managers received training in the DBT crisis protocol
and assisted “with solving problems.” In the DBT-I condition, participants
received a modified version of DBT individual psychotherapy that did not
include DBT skills. Participants in this condition also received an activity-
based support group equal in time to DBT skills training groups. The results
of the trial revealed no difference among the conditions in the frequency
and severity of suicide attempts. Compared to DBT-I, however, the other
two conditions did report significantly fewer episodes of nonsuicidal self-
injury.
After the initial trial of DBT for suicidal behaviors, Linehan (Linehan et
al., 1999) evaluated the efficacy of modifications to standard DBT for the
treatment of substance disorders. The participants in this trial were women
who met criteria for BPD and either substance abuse or substance
dependence. After a year of treatment, DBT participants had significantly
greater reductions in substance abuse compared to TAU participants. The
treatment retention rate was 55% for DBT and 19% for TAU. The
conditions did not differ with respect to psychiatric inpatient treatment,
anger, social functioning, or global functioning. During a 4-month follow-
up, however, DBT participants had significantly greater gains in global and
social adjustment as well as significantly greater reductions in substance
abuse.
Linehan and associates (2002) then examined the efficacy of this
modified form of DBT with women who met criteria for BPD and opioid
dependence. All participants received levomethadyl acetate hydrochloride
as replacement medication, while half received DBT and the other half
received a control treatment consisting of comprehensive validation plus
12-step program (CVT + 12S). The control treatment consisted of
individual therapy and Narcotics Anonymous (NA) meetings. Individual
therapists used all of the DBT acceptance-based strategies (e.g., validation,
reciprocal communication, and environmental intervention) as their primary
strategies and used problem-solving only to reduce imminent suicide risk
and to ensure treatment attendance and medication compliance. The control
treatment also encouraged participants to meet weekly with a 12-step
sponsor and to attend as many NA meetings as possible. The results of this
trial suggested that both treatments effectively reduced opioid use.
Interestingly, the validation plus 12-step participants were more likely to
remain in therapy (DBT = 64% vs. CVT + 12S = 100%), but the DBT
participants were more likely to maintain treatment gains.
Several other researchers also have published RCTs examining the
efficacy of DBT with BPD. Three RCTs involving comprehensive DBT
included a standardized assessment of therapist adherence to DBT. In the
first of these studies, Koons and colleagues (2001) conducted an RCT
comparing standard DBT to a predominantly CBT control condition. The
participants were female veterans who met criteria for BPD, only 40% of
whom had a recent history of parasuicidal behavior. After 6 months of
treatment, DBT participants had a significantly greater reduction in suicidal
ideation, depression, hopelessness, and anger expression than TAU
participants. The two conditions did not differ with respect to treatment
retention (DBT = 77% vs. TAU = 82%), parasuicidal acts, anger
experienced, and dissociation.
Next, van den Bosch and colleagues (2002; Verheul et al., 2003)
examined the efficacy of 12 months of DBT versus treatment as usual for
borderline women referred through either addiction or psychiatric services.
At the end of this trial, DBT participants had significantly higher treatment
retention rates (DBT = 63% vs. TAU = 23%) and greater reductions in self-
mutilating and self-damaging impulsive behaviors (e.g., substance misuse,
binge eating, gambling) when compared to TAU participants. Additional
analyses suggested that DBT had the greatest impact on self-mutilating
behavior among those patients who had reported higher baseline
frequencies for the behavior.
McMain and colleagues (2009) conducted an RCT involving individuals
diagnosed with BPD and having engaged recently in suicidal behavior.
Participants received 12 months of either comprehensive, outpatient DBT
or general psychiatric management. Psychiatric management consisted of
weekly psychodynamic individual therapy, case management, and
medication management. No differences between conditions appeared in
any of the primary outcome variables, including suicidal behavior and
utilization of health care services.
Three other RCTs (Carter et al., 2010; Clarkin et al., 2007; Turner, 2000)
included comprehensive DBT conditions. These studies, however, either
described significant deviations from the model or did not assess adherence
to the model using a standardized assessment (Miga et al., 2018). The
findings from these studies present a more mixed picture, with DBT having
better outcomes compared to another psychotherapy in the first study
(Turner, 2000), better outcomes compared to one psychotherapy but not
another in the second study (Clarkin et al., 2007), and mixed outcomes
compared to a wait-list in the third study (Carter et al., 2010).
In summary, both individual studies and meta-analyses for BPD clients
(Cristea et al., 2017; Kliem et al., 2010) demonstrate the superior
effectiveness of DBT in treating individuals diagnosed with BPD compared
to no treatment and TAU. Of particular note are the favorable outcomes for
treating suicide attempts, nonsuicidal self-injurious behavior, substance
abuse, and general psychopathology in BPD clients. The RCTs also suggest
that DBT may prove efficacious for other comorbid mental disorders, but
thus far these disorders have been assessed only as secondary outcomes,
with some participants never having the disorder, or have been examined as
a primary outcome in only a single study.

FUTURE DIRECTIONS
In the previous edition of this Handbook, we divided the future directions
for DBT into three pathways: development of the treatment, dissemination
to clinicians, and delivery in clinical settings. Though these directions are
divided here for the purposes of discussion, they may be considered
integrative in that they transact with each other.
With respect to treatment development, DBT principles are expected to
remain the same, although techniques and modes will continue to evolve as
new data become available from research. A few areas of development,
however, seem to warrant particular attention. First, a review of DBT RCTs
(Miga et al., 2018) identified several areas for future development that
apply to studies of DBT for clients with BPD: the need for systematic
assessment of therapist competency, for operational definitions, for delivery
of evidence-based training and supervision, and for clarity on treatment
adaptations. Second, treatment development will need evaluations of the
relative impact of the treatment modes, their combinations, and their doses.
For example, many programs provide “DBT skills-only” despite the lack of
RCTs comparing skills-only to standard DBT for clients with BPD. How
does this significant change impact client outcomes? Similarly, many
programs do not provide after-hours skills coaching. Does the notable
reduction in therapist availability result in significantly higher rates of
suicidal behavior, emergency room visits or hospitalizations, or in slower
progress? How does using text, email, or phone skills apps rather than
phone calls effect skills generalization or primary clinical outcomes?
Third, the treatment’s development may benefit from attention to
improving the treatment of DBT therapists themselves. In particular, a
notable number of therapists persist in their emotionally controlled therapy-
interfering behaviors, especially in response to suicidal behaviors, despite
attending the consultation team. How can the consultation team better treat
such therapists’ behaviors and their related emotions?
Fourth, artificial intelligence may offer an opportunity for healthcare
systems to deliver DBT programs at a high quality with more consistency
and less cost. Clients have welcomed phone apps for skills generalization as
an addition to their DBT treatment programs, but artificial intelligence
could be developed to identify which skills a client needs to learn and then
to teach those skills, to identify controlling variables leading to a target
behavior, and to analyze and help implement appropriate solutions for those
variables. Indeed, artificial intelligence likely would excel at the pattern
recognition aspect of problem-solving.
Though not as prolific as treatment development research, a notable
amount of research evaluating the effectiveness of DBT dissemination has
begun to appear. An early research (Hawkins & Sinha, 1998) examined the
impact of introductory and advanced education in DBT on clinician’s DBT
conceptual knowledge. The study reported that performance on an
examination of DBT knowledge correlated specifically with DBT training.
The study also reported that background education generally did not predict
performance, except that psychologists scored significantly higher than
other professions.
Another set of investigators (Dimeff et al., 2009) conducted an RCT on
three methods of teaching DBT skills to practitioners. The practitioners
experienced significantly greater satisfaction with online and instructor-led
training compared to reading the treatment manual and found that online
training resulted in a significantly greater increase in skills knowledge
compared to the other two conditions. Dissemination would benefit,
however, from research analyzing which types of DBT training produce the
greatest adherence and competence in therapists and the greatest fidelity in
programs.
The delivery of DBT in clinical settings offers several future directions
for research on the treatment’s effectiveness. Walton and Comtois (2018)
have suggested analyzing why routine clinical settings have notably lower
treatment retention rates compared to rigorous RCTs and what can be done
to alter this. She also highlights the importance of learning how program
restrictions on skills coaching effects client outcomes. Much work also
remains to be done in the future respecting how to maximize the cost-
effectiveness of DBT.
Though progress over the next decade is difficult to predict with any
precision, it is hoped that several DBT principles will continue to guide this
progress. DBT has behavioral science as a foundation, and scientific
principles apply to each of the three main future directions. Dialectics is
another foundational principle. Thus, transactions among the various future
directions, in addition to change in each direction, are to be expected. Most
importantly, the ultimate goal of every future direction is the enhanced
functioning and reduced suffering of clients.

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 13

Integrative Psychotherapy for Generalized

Anxiety Disorder
HENNY A. WESTRA AND MICHAEL J. CONSTANTINO

THE INTEGRATIVE APPROACH

When facing change, people are often fraught with competing and even
contradictory motives and feelings. Familiarity is seductive and compelling
despite the suffering it may promote. Psychopathology often represents
efforts at self-protection and cohesion (Mahoney, 2003); thus, whereas
people might desire change, they often simultaneously fear and resist it.
For instance, individuals who worry excessively typically see worry both
as a problem and an asset (e.g., “my worry is motivating,” or “worrying
protects me and prepares me for negative events”) and are therefore
ambivalent about relinquishing it (Borkovec, 1994; Westra & Arkowitz,
2010). Appreciating this bind, motivational interviewing (MI) is a person-
centered approach in which the therapist strives not to direct clients toward
change, but rather to support clients’ own self-efficacy and personal
advocacy for change (Miller & Rollnick, 2002). Recognizing that clients
are the best experts on themselves, the central tenet of MI is to have the
therapist work from a “spirit” of empathy, collaboration, evocation, and
preservation of client autonomy while employing strategies that assist
clients to work through their ambivalence and ultimately argue for self-
change.
The first author’s (HW) attraction to MI arose from working primarily
within a cognitive-behavioral orientation early in my career to treat clients
with anxiety disorders. I realized that although cognitive-behavioral therapy
(CBT) could benefit many clients, it fell flat for others. Realizing that CBT
strategies worked well if clients used them, I began advocating vigorously
for their adoption with my less engaged clients, with predictably (in
retrospect) poor results. Rather than facilitating change, my strong CBT
advocacy seemed to distance further these already minimally engaged
clients. Such interactions would often end in argument, frustration (on both
sides), and stalemates. It turns out that my experiences were shared by
many CBT practitioners. For example, in a survey of CBT experts, the most
frequently cited reasons for clients’ insufficient treatment response were
“lack of engagement in behavioral experiments” and “noncompliance”
(Sanderson & Bruce, 2007).
At the same time, MI was emerging as an evidence-based treatment for
addictions, and it seemed to me that its methods might be equally applicable
to my disengaged anxious clients who were “stuck.” Integrating MI into
CBT offered a more satisfying way of viewing and working in harmony
with clients, rather than wrestling with them. With its complementary
supportive, reflective methods and ways of being, MI balanced CBT’s
action orientation.
Since those early days of my practice, the integrated approach presented
in this chapter has evolved substantially, and the position of MI within CBT
has become increasingly clear to us. This evolution has been primarily in
response to the growing insights derived from systematic component
studies and process-outcome research (on ambivalence and resistance; on
mediators and moderators of MI + CBT vs. CBT alone), clinical experience
in training others in MI + CBT, and the developments in context-responsive
psychotherapy integration (Constantino et al., 2013; Constantino, Westra et
al., 2017). We regard the assimilation of MI into CBT as a responsive
solution to a specific process challenge of client resistance (tensions in the
alliance, noncollaboration, working at cross-purposes)—a pernicious
challenge that relates to poorer treatment outcomes. Resistance arises from
a mismatch between a client factor (being ambivalent about change) and
therapist action in this context (taking control, advising, and persuading, as
opposed to supporting, understanding, preserving autonomy, and evoking).
Thus, sustained resistance is a result of the clinician’s skill error (Miller &
Rollnick, 2002). Such a mismatch is most likely to arise in more directive,
or action-oriented approaches, like CBT, that require a high degree of
change motivation and is less likely in approaches, like MI, that are
foundationally person-centered. Although integrating MI has various
beneficial impacts on therapy process, the most important impact is
reducing levels of resistance, which in turn improves outcomes relative to
CBT alone (Aviram & Westra, 2011; Constantino, Westra et al., 2017).
Our MI + CBT approach has, to date, focused on generalized anxiety
disorder (GAD), the least CBT-responsive of the anxiety disorders (Cuijpers
et al., 2014). This relatively poor response rate perhaps owes partly to
traditional CBT’s failure to address the interpersonal problems that
characterize GAD (Newman et al., 2013), such as being under-agentic and
overly communal, often to the point of exploitability (Gomez Penedo et al.,
2017; Przeworkski et al., 2011). In session, resistance can represent a
client’s rare risk-taking attempt at agency/assertiveness, initiated to protect
one’s need to retain worry and to make one’s own choices about change
(Westra, 2012). It is plausible that a CBT therapist pushing for change in
the face of client resistance would inadvertently recapitulate the common
interpersonal pattern in GAD of pulling for, and deferring to, others’
dominance (Constantino & Westra, 2012; Coyne et al., in press). Such
reinforcement might render CBT methods less effective, whereas
preserving clients’ autonomy when they resist and encouraging exploration
of this experience might redress these interpersonal dynamics and enhance
the agency that is typically lacking in persons with GAD.
From this perspective, MI’s benefit resides in its ability to help therapists
learn a specific interpersonal skill of “rolling with” ambivalence and
resistance. When applied contextually over time, this approach should
reduce client deference, thereby reducing an etiological characteristic of
GAD and facilitating healthier social interactions. This corrective
experience notion has been corroborated by several qualitative studies of
clients with GAD receiving MI + CBT versus CBT (Khattra et al., 2017;
Macaulay et al., 2017; Morrison et al., 2017).
The second author (MC) also has a history of administering and studying
CBT for GAD. However, his connection to MI + CBT came not from
loyalty to either brand or from a sole interest in GAD pathology, but rather
from a broader dissatisfaction with the idea that evidence-based practice (or
therapist expertise) reflects adherence to standardized treatment packages.
Drawing on research demonstrating that when therapists perseverate in
adhering to the treatment model in the face of negative process, it correlates
negatively with patient outcome (e.g., Castonguay et al., 1996), I became
interested in clinical flexibility and how therapists can most effectively
“depart” when a given treatment, and the relationship on which it is built,
are not working. This if-then focus, the hallmark of the context-responsive
framework, was a conceptual fit for MI: if client resistance to the direction
of the therapist presents itself, then depart (at least temporarily) to MI to
address it (Constantino et al., 2009).The biggest bang for our clinical buck
may boil down to therapists using responsive behaviors (e.g., MI and its
spirit) known to have a therapeutic impact in precise moments (e.g., when
clients resist).
In this chapter, we elaborate on our systematic integration of MI into
CBT for GAD. We present assessment and formulation methods;
summarize the application and structure of MI interventions; describe the
processes of change, therapeutic relationship, and core techniques in MI +
CBT; consider diversity elements; and provide a case example. We review
supporting research both throughout the chapter and in a devoted section on
the central findings from two randomized controlled trials (RCTs), and we
then highlight future directions for this integrative treatment.

ASSESSMENT AND FORMULATION

The Case for Observation

A prerequisite for responsively using MI skills, especially evoking clients’
own motivations, is to identify the key moments and markers that call for
the person-centered approach. In this sense, assessment is ongoing and
inexorably tied to treatment. Research on client motivational language and
resistance has indicated that not all moments are equally significant, and
some, such as disagreements and misattunements in the therapy
relationship, are more likely to predict poor response (Hunter, Button, &
Westra, 2014; Sijercic et al., 2016). It is during these moments when an MI
stance/spirit may be especially therapeutic (Aviram et al., 2016), though this
runs counter to traditional psychotherapy training and research designs that
have largely focused on intervention (doing) more than observation
(seeing). In MI, which is predicated on matching action to the moment-to-
moment context, the ability to observe key process markers accurately is
paramount.
Such observation is challenging as signals of disharmony or
misattunement are often subtle, with complex interpersonal cues reflecting
opposition (tone, inflection, pauses, posture, gestures, etc.). Difficulties in
detecting such signals are further complicated by clients’ reluctance to
express openly their concerns about therapy (Rennie, 1993), as well as
therapists’ own blind spots for negative processes in which they are
participating (Binder & Strupp, 1997). Indeed, resistance has been found to
be associated with outcome when rated by observers, but not therapists
(Hara et al., 2015). Such findings indicate that therapist observation is a
needed and presumably trainable skill (considering that research observers
are generally also clinicians).
In essence, a therapist striving to be a good participant-observer is
collecting vital feedback on a moment-to-moment basis about research-
supported process markers (e.g., How engaged is this person? Are there
signals of disharmony or opposition? Are there markers of ambivalence or,
alternatively, signals of readiness to begin changing?). In contrast, reliance
on self-report measures of motivation is discouraged, given their proneness
to ceiling effects and response bias and their generally weak and
inconsistent relation to outcome (Westra, 2011, 2012). Accordingly, we
have adapted and successfully applied two observational coding systems,
discussed next, that facilitate the identification of ambivalence and
resistance markers.

Observing Ambivalence from Client’s In-Session Language

The Motivational Interviewing Skills Code (MISC 1.1; Hagen Glynn, &
Moyers, 2009) assesses client motivational statements as either change talk
(arguments for change) or counter-change talk (arguments against change).
Often, a client will indicate ambivalence about change by expressing a
reason to change and then immediately expressing reluctance or fear of
doing so. These statements capture competing motives of approach and
avoidance, such as yes-but (e.g., “I want to relax, but I’m afraid that I’ll
become lazy,” or “I know worry doesn’t help, but I feel like I have to do
it”). They can also be expressions of the benefits of the status quo (e.g.,
“Part of the reason things turn around is because I do worry and as I’m
worrying, I’m coming up with the strategic alternatives on how to approach
something”). Relatively more counter-change talk statements reflects
resistance to change or “stuckness,” whereas relatively more change talk
indicates a client who is more decided on change and its benefits.
Observing Resistance in Patient–Therapist Interpersonal Process
In addition to client language, which is more intrapersonal, direct resistance
—which is more interpersonal—represents a signal that the interaction or
alliance is in jeopardy. We have adapted a version (Westra, Aviram, et al.,
2009) of the Client Resistance Code (CRC: Chamberlain et al., 1984) to
codify resistance as any behavior that opposes, blocks, diverts, or impedes
the direction set by the therapist. The CRC proper includes multiple
categories of resistant behavior, but our adapted version collapses these
categories into one global rating capturing the presence or absence of any
resistance.
Resistance can manifest as the therapist making a suggestion and the
client responding with silence or little enthusiasm. Or, the therapist might
make a reflection that the client protests or ignores. Each example reflects
resistance that is stimulated and sustained by the presence of therapist
direction or demand in the context of a client who is ambivalent about
changing. In these exchanges, the client and therapist are in essence “acting
out” the ambivalence relationally (vs. helping the client work through the
ambivalence intrapersonally), with the therapist typically advocating for
change and forcing the ambivalent client to defend the status quo with
counter-change talk. Thus, a good question for clinicians to ask themselves
is: “Who is making the arguments for change?” If it’s the therapist, the
process is likely off track.
The presence of resistance in the therapy relationship can operate as a
type of stop signal that indicates that the therapist is working ahead of the
client’s level of readiness; that is, placing demands on the client to do, be,
think something for which he is not ready. Continuing to put one’s foot on
the gas (direct), instead of the brake (slow down, support), when the signal
is red is an unresponsive, ineffective, and potentially harmful process. In
such instances, resistance to therapist demands represents clients’ efforts to
protect their autonomy to explore personally valid counter-change
positions. The onus is on the therapist to attend to and support such
messages in order to reestablish collaborative attunement and to address
ambivalence more productively.
Ongoing attentiveness to and observations of the therapy process can
provide valuable information about a client’s engagement in therapy and
level of readiness to change. Given our focus on using MI as a contextual
process intervention embedded in change-oriented CBT, this attention to
emerging process informs the short-term process goal of matching clinical
style (supportive or directive) to client motivation level. Such matching
more effectively addresses client resistance (Beutler et al., 2011; Westra &
Norouzian, 2018). This in turn facilitates the long-term outcome goals of a
corrective interpersonal experience (i.e., having an important other—the
therapist—defer to the client’s atypical resistant behavior), interpersonal
change (i.e., taking more autonomy in directing oneself toward
improvement), and corresponding worry reduction in clients with GAD.

APPLICABILITY AND STRUCTURE

As our approach remains grounded in CBT, the applicable clinical
situations are any in which CBT is traditionally administered. With our
focus on clients with GAD, the present descriptions predominantly apply to
individual outpatient psychotherapy of a time-limited nature. Consistent
with CBT length parameters, the latest clinical trial that we conducted on
MI + CBT included 15 weekly sessions, with MI integrated responsively
vis-à-vis markers of client ambivalence/resistance (Westra, Constantino, &
Antony, 2016). Such a treatment approach can be adapted to lengthier
psychotherapy contacts and to more intensive treatment settings, such as
partial hospitalization programs, but we are unaware of any published
studies conducted on CBT + MI in those settings yet.
As noted, our integrative approach has centered on GAD for three central
reasons: (1) CBT generates relatively humble success rates for this
particular anxiety disorder (i.e., < 50%; Cuijpers et al., 2014); (2)
individuals with GAD are often ambivalent about relinquishing the cardinal
feature of their condition—worry—as it can be experienced both as
problematic and functional; and (3) the interpersonal underpinnings of
GAD pathology (i.e., low agency and excessive communion) set the stage
for MI to be a corrective interpersonal experience that shifts relational
patterns and reduces worry.
However, the responsive MI principles are not limited to this client
population. As perseverative therapist adherence in the face of client
resistance or alliance tensions can adversely affect any psychotherapy for
most types of problems, we argue that MI can be widely applied for
effectively addressing the disruptive process of client resistances. Put
differently, MI can be a transtheoretical and transdiagnostic strategy to use
for many types of disorders (e.g., substance use, health behaviors,
gambling) when a current treatment is not working (Lundahl et al., 2010).
Although applying the person-centered principles of empathy,
collaboration, and evocation would seem universally facilitative, it is
possible that clients need to have a minimum level of reality testing,
psychological mindedness, some connection to emotional experience, and
communication abilities to capitalize on what often amounts to a process
dialogue. That being said, we are hard pressed to identify clinical scenarios
where being validating and supportive of client agency is contraindicated.
Unless future research uncovers clear contraindications, the current
evidence base compellingly supports the clinical utility of MI in context, as
well as the associated alliance and Rogerian facilitative conditions
(Norcross & Lambert, 2018).
Also, whereas our discussion centers on individual therapy, client
resistance certainly manifests in other formats, such as couple, family,
group, or Internet-mediated therapies. We suspect that the current
considerations for MI would remain applicable in these other formats,
though the dynamics would be more complex when expanded beyond a
two-person psychology.

PROCESSES OF CHANGE
For our integrative approach, CBT change mechanisms remain foundational
in treating GAD (e.g., psychoeducation about anxiety and worry, self-
monitoring, physiological change via relaxation, cognitive restructuring).
However, the essence of our integrative model is to create an additive effect
that improves client response beyond traditional, change-oriented CBT. To
this end, the primary purported mechanism is the superior resolution of
resistance via MI versus standard CBT. Achieving this effect requires the
therapist to use both the MI spirit and specific MI strategies for resolving
emergent resistance in the therapy relationship.

MI Spirit
Applying MI begins with its underlying spirit, which is particularly useful
at times of client opposition and/or ambivalence (Aviram et al., 2016). More
than simply being a directive intervention where clients are told what to do,
and consistent with its origins in person-centered therapy, MI is
fundamentally a way of being with clients that promotes a safe,
collaborative atmosphere in which clients can resolve their conflicting
feelings about change, moving toward their most valued self.
MI therapists operate as evocative consultants in the client’s journey,
consistently communicating the message, “I don’t have what you need, but
you do. And I will help you find it.” In supporting client autonomy, MI
helps clients recognize themselves as the authority. Accordingly, the MI
therapist resists the temptation to supply expertise to correct client
deficiencies when markers of ambivalence and resistance are present.
Indeed, in client accounts of their experiences of MI, therapist empathy, the
provision of safety, and the freedom to explore have emerged as prominent
recollections (e.g., Marcus et al., 2011).
Although MI is decidedly person-centered, it is also directive in several
ways. First, the MI therapist focuses on the exploration of clients’ feelings
and ideas about change. Second, an active therapist deliberately listens for
motivational process markers (e.g., ambivalence, resistance, change talk).
Thus, our approach involves “learning to hear” process markers that signal
the therapist to use specific skills and to move in particular directions. In
this sense, the therapist complements the client’s expertness on their own
content (i.e., problems or their resolution) by being an expert on the therapy
and relational process.

Working with Resistance to Change

Ambivalence is the tension between perceived benefits of the status quo and
perceived benefits of change. In working with the status quo voice, the
therapist helps the ambivalent or stuck client explore and understand the
needs that are being met (e.g., “What’s good about worrying?”) and the
arguments against change (e.g., “What would be bad about not worrying?”).
Asking about the developmental origin of the behavior is also useful in
developing understanding of and compassion for the motives to worry (e.g.,
“Where did you get the idea that it was important to worry about others? To
be perfect?” etc.). What appears maladaptive on the surface is often driven
by core needs, such as the desire for comfort, safety, connection, control,
familiarity, success, freedom from aversive consequences, and so forth. The
status quo often offers familiarity, predictability, and a sense of control,
whereas change, and the steps to produce it, are fraught with risk,
uncertainty, unfamiliarity, discomfort, and ambiguity (e.g., “Can I do it?
Who will I be? What if I fail? How will others regard me?”). Stated
differently, it is naïve to assume that “change is all good”; if a client is
stuck, there is typically a dominant voice that warns against and fears
change—a voice that needs to be heard and validated. Then (typically later),
in working with the change voice, the therapist helps the client understand
“What are the costs of staying the same?” (e.g., problems created, excessive
distress) and “What would be good about change?” (new opportunities,
desired ways of being, freedom from distress). Such change talk is often
“emergent” when the therapist backs away from coercive attempts to
promote change and seeks to genuinely hear and validate the needs,
motives, and fears being expressed by the status quo position. And thus
change talk represents the client’s attempts to intrapsychically understand
and resolve his or her own resistance to change.
Exploration of ambivalence is not a linear, straightforward process. There
is a natural ebb and flow as exploration of one side naturally evokes
consideration of the other side. At any given moment, the therapist works to
capture what is most alive. For example, if clients express substantial
change-talk, the therapist explores, elaborates, and empathically
understands the part of the person that wishes to change. Even if the
therapist suspects that the client is ambivalent about change, she can
nonetheless explore what is most salient for the client at that moment,
trusting that if significant ambivalence about change is there, it will surface.
Working within the MI spirit, therapists avoid pejorative perceptions of
clients as unmotivated or difficult. Rather, ambivalence and resistance are
viewed as a normal part of the vicissitudes of change, but, even more so,
they are regarded as meaningful therapeutic opportunities. Ambivalence
and resistance contain important information that needs to be attended to,
understood, and integrated. Rather than trying to defeat resistance to
change, the therapist “rolls with it.” The therapists’ curiosity about and
openness to exploring resistance translates into clients developing a more
complex and compassionate view of the beliefs, motives, and behaviors that
often frustrate them and keep them stuck. In MI, the therapist works with,
rather than against, resistance (Miller & Rollnick, 2002).
Having helped clients achieve a fuller understanding of the forces for and
against change, opportunities arise to develop discrepancy between these
positions. For example, parents who value their relationship with their
children may find it unsettling to consider if their overprotectiveness
alienates the children. Discrepancy also arises between the reasons for the
status quo on the one hand and the consequences or outcomes on the other
(e.g., “Worrying is a way of gaining control, yet I also hear it makes you
feel out of control”). Therapists seek to identify such discrepancies, not to
confront the client, but rather to invite the client to wrestle with and
ultimately resolve these discrepancies for themselves, given that such
discrepancies naturally pull for resolution to reestablish value–behavior
alignment (Miller & Rollnick, 2002).
Although MI spirit and strategies are grounded in a specific orientation
(i.e., person-centered therapy), we see the responsive use of MI in moments
of client resistance as a common factor. That is, no matter what type of
therapeutic approach is being applied, its effectiveness will be hindered
when clients resist its intended direction and helped when a therapist
validates and supports client autonomy during such moments (vs. persisting
with misaligned treatment directions). In this sense, MI can be viewed as
both a theory-specific process for addressing low change readiness, as well
as a nondenominational process for supporting clients’ own agency and
direction toward change.

THERAPY RELATIONSHIP
In MI + CBT, the quality of the patient–therapist relationship facilitates the
work of therapy. Our perspective fits Bordin’s (1979) notion of the alliance
as a common factor representing treatment goal and task agreement in the
context of an affective bond. When considered this way, the outcomes for
higher alliance clients/dyads are better than lower alliance clients/dyads
(Flückiger, Del Re, & Horvath, 2018).
The patient–therapist relationship is also an interpersonal dynamic to be
changed in our integrative approach. That is, resistance may represent an
alliance rupture in the form of the client and therapist no longer agreeing on
the goals or tasks of therapy. Such misalignment can also cause the bond to
suffer. To the extent that therapists try to combat the resistance by doubling
their change efforts, not only may a maladaptive pattern of other
dominance–patient submission get enacted, but also the core elements of
the alliance may rupture. In this sense, the alliance is truly dyadic in that it
represents two people coming to see the relational universe more similarly
over time, or what has been referred to as dyadic convergence.
In one study of MI + CBT for GAD, early alliance convergence was
associated with subsequent greater reductions in worry and distress (Coyne
et al., 2017). That is, when client and therapist become more attuned over
time, in whatever treatment is being delivered, the client shows greater
improvement. Again, this perspective allows for the alliance (and
convergence on it) to be a facilitative factor for CBT strategies applied
outside of resistance tensions and relational ruptures, but also a relational
change factor in its own right within MI + CBT.
Beyond the alliance, the impact of resistance on the relational element of
empathy is substantive as therapist behavior tends to become markedly less
supportive in times of resistance. For example, in an experimental study,
Francis and colleagues (2005) randomly assigned practitioners to interview
the same actor who was portraying an individual either high or low in
resistance to quitting smoking. Therapists in the high-resistance condition
increased their confrontational behavior, offered significantly less praise
and encouragement, and asked fewer open-ended questions that sought to
understand the client’s perspective. These findings demonstrate that, during
moments of resistance to change, therapists become increasingly dismissive
of the client’s position (see Consoli & Beutler, Chapter 7, this volume).
Moreover, there is evidence that this behavior impacts the client’s
experience of therapist empathy (Hara et al., 2018)—a key process variable
that has been shown to relate positively to client improvement (Elliott,
Bohart, & Watson, 2018; Moyers & Miller, 2013). Moreover, Aviram and
colleagues (2016) found that being more empathic precisely at the moment
of disagreement was 10 times more positively impactful on client outcomes
than being more empathic generally. Thus, identifying resistance that
adversely impacts empathy may be an important step toward facilitating
sustained positive relational climates in psychotherapy.

METHODS AND TECHNIQUES

With Low Ambivalence and Resistance

When motivation to change is present, the MI + CBT therapist supports
clients in the process of planning for, experimenting with, executing, and
supporting their efforts to change. Essentially, when the client moves from
greater to lesser resistance to change (and complementary lower to higher
motivation to change), the therapist’s focus shifts from why change to how
to change. In these latter stages of change readiness, clients tend to
welcome and engage readily with CBT as it provides explicit guidance,
direction, and support for worry reduction.
MI is probably unnecessary in this context, and research supports that
clients with high levels of initial motivation fare equally well, if not better,
in reducing their worry with CBT alone versus MI + CBT (Button et al.,
2016). Furthermore, for clients with less marked problematic
unassertiveness or low agency at baseline, CBT yields comparable worry
reduction to MI + CBT (Gomez Penedo et al., 2017) as these clients may
not have required their therapist deferring to them (by supporting agency
and granting autonomy) to help alter their typical deference to others. It is
also noteworthy that the major additive benefit of possessing MI skills
(empathy, MI spirit) lies in deploying them at the “right time” of client
ambivalence and resistance (Aviram et al., 2016). However, a benefit of
maintaining an MI frame at any point in therapy, even when the client is
taking action to change, may be the therapist’s readiness to observe signs of
reemerging ambivalence or resistance (misattunement), which can then
precipitate full MI responsivity to reestablish collaboration (attunement).
Learning MI can change the way a therapist practices “standard” CBT as
MI has much to offer in terms of informing the process of any treatment.
Extending the MI relational stance into the action (CBT) phase of therapy
might preempt some of the pernicious problems of resistance and
noncompliance that more directive approaches can create while also
enhancing client agency. Indeed, in our trial comparing MI + CBT to CBT
alone for severe GAD, MI + CBT therapists demonstrated higher levels of
patient-perceived empathy and observer-rated MI spirit compared to CBT-
alone therapists (Westra et al., 2016). Next, we outline several specific ways
that MI is generally infused into CBT in our approach, outside of the
pointed moments of ambivalence and resistance.

Being Evocative
Instead of moving quickly to supply expertise or problem-solve, the MI +
CBT therapist continuously searches for opportunities to evoke, develop,
and work with client expertise (e.g., “How do you think this problem could
be handled?”). Letting clients do more of the work can increase the
likelihood that they will implement the planned steps to change, in large
part because they generated them. Perhaps even more significantly, it
represents important opportunities to support clients’ previously
unrecognized capabilities for self-determination and enduring self-efficacy
resources that can be tapped long after treatment ends.
Another juncture where using MI spirit and evocation can be helpful is in
processing the results of the client’s efforts to take action toward change.
Here the MI + CBT therapist brings an attitude of curiosity to the client’s
experience, which promotes discovery. For example, when a client shows
willingness to take action, therapists have an opportunity to explore the
effort/activity as an illustration of the client’s potential for and ability to
change. It is important not to (a) assume that the client will continue with
the changes, (b) move in with praise or reinforcement (e.g., “That’s great
that you did that”), and, in general, (c) communicate an attitude of “I told
you this would work/help.” Such responses would likely undercut client
self-discovery, instead promoting therapist conditions of worth that must be
met to receive approval. Rather, the MI + CBT therapist suspends her own
judgments to make space for the client to discover and process his or her
own sense of worth and learning of the experience (e.g., “What did you like
or not like about what you did?” “What did you learn, if anything?”). When
the therapist supports such autonomy, the client is much more likely to
internalize the change and to articulate the benefits of the change effort (i.e.,
change-talk).

Integrating Therapist Suggestion and Psychoeducation

A common question of CBT trainees who consider integrating MI into CBT
is: “What about the role of therapists’ expertise in treating anxiety and their
knowledge about factors that perpetuate it?” From our perspective, these
inputs are essential but can have unintended consequences if they are
applied in a scripted vacuum. Therapist suggestions and information can be
introduced in ways that enhance the probability of client engagement. Of
particular importance is their timing to align with client change readiness
and the style (spirit) of explicitly reinforcing client autonomy when
introducing these ideas. Also, explicit monitoring of client receptivity and
level of engagement with such offerings is important (Westra, 2012). Thus,
the MI spirit means recognizing that it is the therapist’s perspective and not
currently the client’s, holding it tentatively for the client to consider if he or
she so chooses and being prepared to back off from a suggestion if the
client resists it.
Infused by MI, Socratic questioning and suggesting a homework
assignment are not exercises in persuasion, but rather communications of
the therapist’s efforts to brainstorm collaboratively with the client about
possibilities, with the client as the sole arbiter of whether the possibilities
are retained. For example, a therapist could say, “Your anxiety says that if
you worry you can prevent bad things from happening. Is there a part of
you that disagrees with that? There may not be.” With the same idea in
mind, the therapist could note, “I’m not sure about this, and it could be
wrong, but I wonder if there is another way of thinking about this situation?
For example, could it be possible that . . .? Only you can know.” It needs to
be clear in the therapist’s communications (both verbally and nonverbally)
that the client is free to go his or her own way, even if that means
disagreeing with the therapist. When presented in this manner, the therapist
is explicitly communicating a respect for the client’s authority in making
choices.

Rolling with Homework Noncompliance

A focus on establishing and achieving compliance can often create a
battleground between client and therapist, which can end in stalemate.
Homework noncompliance need not be cause for alarm and is often just one
way of expressing resistance. And, as we have seen, pushing for change in
the context of client resistance inadvertently creates more resistance and
risks alienating clients and stalling their progress. In such situations, even if
the therapist is “successful” in persuading the client to do the homework,
such acquiescence may be won at the expense of undermining the client’s
self-determination and may jeopardize the safety of the therapeutic
relationship on which so much depends. Moreover, taking action in the
context of lack of belief in the value of such steps is typically ineffective.
Rolling with and reframing such resistance represent important
opportunities to learn more about the client’s concerns about change and to
build motivation. For example, noncompliance could signal high
ambivalence (indicating a need to shift to full-on MI mode), it could signal
that the client does not accept what the therapist is suggesting (indicating a
need for an open discussion of more effective ways of working together), or
it could mean that there is a problem in the therapy relationship (indicating
a need for empathic listening and rupture repair). Underscoring this point,
GAD clients receiving MI + CBT in which therapists rolled with homework
noncompliance completed just as much homework (and had better long-
term outcomes) as their counterparts receiving CBT alone (Westra et al.,
2016).

DIVERSITY CONSIDERATIONS
The efficacy of MI + CBT for diverse subgroups has yet to be examined. It
is possible that the entire integrative approach, and/or the ways in which MI
is integrated into CBT, would need to be adapted for clients with different
multicultural identities. Such applications and adaptations will require
future focus both clinically and empirically.
MI alone has been found to be particularly effective with ethnic minority
clients (Hettema, Steele, & Miller, 2005; Lundahl et al., 2010). MI
incorporates quintessential cultural respect—empathic reflection and
unconditional support. Supporting this perspective, meta-analytic research
has demonstrated a positive correlation among clients’ rating of their
therapist’s multicultural competence, their therapist’s expressed empathy,
their therapist’s support or affirmation, and their treatment outcomes (e.g.,
Soto et al., 2018). It is possible that a substantive element of cultural
competence may reside in the therapist’s ability to adopt a person-centered
approach emphasizing reflective listening, empathic reflection, and support
for the client’s own expertise on self, even without the therapist being
thoroughly schooled in culture-specific methods. The use of such person-
centered approaches may be particularly useful when ethnic differences
between a client and therapist may render the relationship most vulnerable
to poor engagement or resistance.
Using MI to address such vulnerable moments is also consistent with a
recent formulation of multicultural competence that emphasizes (1)
therapist cultural humility, or a stance of openness, curiosity, and a
suspension of cultural preconceptions; and (2) an awareness of and
responsivity to moments that offer avenues for further collaborative
exploration of a client’s cultural identities (Owen et al., 2016). The first
point is quite consistent with a therapist using MI spirit in general, as well
as the MI strategy in the face of resistances or relational tensions. The
second point is consistent with the notion that resistance or alliance rupture
can represent an opportunity for change. Although future research will need
to confirm this, it may be that adding MI to CBT is one way to be culturally
competent.

CASE EXAMPLE

Meghan is a 24-year-old, white, cisgender female who received individual

MI + CBT in one of our research studies for GAD (Westra et al., 2016). We
selected this case because of her high levels of counter-change talk in the
first session and her inordinately low outcome expectation (10% expected
improvement), perhaps because of several failed attempts at counseling and
medications, including a prior course of CBT. Meghan was living at home
with her parents and younger siblings, going to school part-time, and
running her own business. She had a roughly 10-year history of severe
GAD. At the time of intake, she had severe GAD (78/80 on self-reported
worry via the Penn State Worry Questionnaire [PSWQ], Meyer et al.,
1990). Meghan also met criteria for several other anxiety disorders,
including obsessive compulsive disorder (OCD) and panic disorder with
agoraphobia.
Meghan’s therapist was a 29-year-old, cisgender female who was trained
in MI + CBT and was serving as a research therapist in the clinical trial.
She was supervised by the first author (HW), and session recordings were
reviewed regularly as part of that supervision.
Meghan received 15 sessions; the first 4 focused exclusively on MI,
followed by 11 integrative MI + CBT sessions. In the first session, she
described multiple sources of fear and anxiety, including her own health
and the health of others, undergoing any medical procedure, being late,
being productive, and procrastination, with her anxiety at school being the
most debilitating. She reported being easily overwhelmed with details and
pressures to perform, noting that having an assignment precipitated “World
War III in my head.” She presented as highly driven, perfectionistic, and
obsessed with using time effectively and productively. She noted having
some hyperproductive, “good” days and then other “waste of time” days
when she felt depressed, had no energy, and was physically unable to get
going. She was critical of having these “bad” days and characterized them
as nonsensical, useless, and irrational. This intolerance was notable
throughout Meghan’s speech, in which she would frequently descend into
becoming self-critical and intolerant of her emotions, her limitations, and
her struggles. She described needing a “tough love” approach to her
anxiety, such as the one her mother used. As one example, Meghan
recounted that when helping her endure getting an injection, her mother
would say “Suck it up. A 5-year-old can get a needle and you are 24. Just
stop whining!”
Early in treatment, when prompted by the therapist, Meghan articulated
change talk, including disliking her avoidance, feeling unwell and unhappy
most of the time, and being constantly preoccupied. Despite these
incentives for change, by listening carefully, the therapist also observed
numerous instances of counter-change talk in Meghan’s initial sessions.
These statements had a quality of defending her high standards and the
necessity of motivating herself through harsh rebukes. For example, when
the therapist pointed out her self-critical tendencies, she responded “Yes. I
am my biggest critic, but this is why I am able to excel at work. I just need
to get better at doing it when it comes to school. I need someone to push
me.” When asked about her feelings about treatment, Meghan noted being
excited, but quickly articulated many objections. For example, she
recounted a story about how much work CBT is and concluded “I guess it’s
not impossible but. . . .”
Given Meghan’s high level of ambivalence, the MI + CBT therapist
sought to identify the needs being met by the status quo and to
communicate compassionate understanding, validation of, and resonance
with (siding with or rolling with) the reasons for not changing. The
following excerpts demonstrate these:
Therapist:
This may seem like a bit of a strange question but “What’s good
about having high standards?” What works about that?
Meghan: My whole life is a portfolio. I want to go into medicine and it’s
ultra-competitive. So, I have to bring the best of the best to the table . . . to
be not just good, but better than everyone else. And that’s a good way to
think.
Therapist: There’s a lot on the line here.
Meghan: Absolutely.
Therapist:And it makes a lot of sense to drive yourself so hard because there
is so much at stake . . . you are so invested in it. Having a lot of anxiety
about it really fits almost. It drives you to do better.
Meghan: Absolutely. It’s crucial to my success.
Therapist:
And there is almost a kind of fear there . . . I’m guessing . . . that if
you didn’t drive yourself, things would really go off the rails and there is no
way you would be successful.
Meghan: There is no way that is happening . . . I would just . . . I know
myself . . . I would just be lazy and get depressed. If I let up absolutely
nothing will get done.

The therapist continued to use supportive strategies responsively, such as

empathy and evocation, to elaborate more fully Meghan’s ambivalence. In
doing so, she opened the dialogue, particularly the motives underlying the
patient’s strong defense of the status quo/perfectionism. This was done to
elaborate these motives, so that, armed with greater self-awareness, Meghan
could decide for herself whether to risk changing.
The exploration continued until the therapist heard change-talk,
indicating self-confrontation, reevaluation, and protest of the status quo. In
Meghan’s case (as with many GAD clients), the motives for worry included
a familiar sense of control by worrying; uncertainty about not worrying;
strong fears of relaxing, including fears of failure/erosion of ambition; and
identity concerns (“Who would I be if I didn’t worry? I’ve never been that
person. Would it be okay?”). These are all critical areas to explore and
excellent questions before proceeding with behavior change.
Later in the dialogue, when exploring her feelings about being self-
critical, a strategy Meghan used constantly to reach her high standards,
change-talk eventually began to emerge.
Meghan: My aunt is a psychologist and she says that you have to talk to
yourself like you were your own mother or something . . . like be nice to
yourself. But that feels so stupid . . . (client becomes very animated)
because I’m not my mother. And the way I feel is a bit harsh yeah, but I
don’t see that as a flaw. I feel fine with the way I approach it. (counter-
change talk)
Therapist:So rationally, there could be some downsides, but it’s way (with
emphasis) more valuable than hurtful. I’d much rather have it than not have
it. (therapist rolling with resistance . . . continues to resonate with the
wisdom of the status quo).
Meghan: (pauses) I mean it motivates me, but it also kind of makes me
anxious because I have to do everything to a certain standard. (change talk
emerges; self-confrontation)
Therapist: Say more. (elaborating change talk)
Meghan:I have a need to do everything really well, and it can be exhausting.
For example, it takes me 3 hours to get 30 minutes of productive work
because it’s 2 and a half hours of me disciplining myself. With every single
assignment, every single task, every single sentence I read, I tell myself,
“Okay, read it, pay attention, what does it mean. Think!” And I have to look
up every word or phrase I don’t know. So, it takes a long time. And I spend
so much time preparing to get into it that I don’t get into it.
Therapist: That does sound exhausting . . . and frustrating!
Meghan: Incredibly frustrating.
Therapist: And so not fun!
Meghan: Totally. I hate studying! Like I want to learn . . . I like the material .
. . but I hate it, too.
Therapist:
So, it sounds like it almost works against you in a way. Like on the
one hand your high standards drive you to do things really well . . . but on
the other hand, it almost sounds like that drive also gets in the way a bit,
too. Ironically, it almost sounds like sometimes it might make you less
productive rather than more. But I’m guessing. Would that be right?
(developing discrepancy between the positive ‘intent’ of the behavior and
the actual outcome)
Meghan:That’s true. I get discouraged, you know? I feel like other people
skim more. Like I do 4 hours of reading for every normal person’s 1 hour.
Therapist: You’re saying, “What I do is too much. It’s over the top.” Is that
right?
Meghan: Right.
Therapist:And I could be wrong, but you might also be wondering, “Maybe
there’s another way?” . . . Like it’s possible to not exhaust yourself . . . other
people seem to do it.
Meghan: Yeah . . . that’s true.
Therapist: What do you think others do?
Meghan: Well, they don’t go crazy like I do. They don’t obsess about getting
it right.
Therapist: So, everything is not “on the line” all the time.
Meghan: Right.
Therapist:And only you can know whether this would be true, but maybe
they seem to be okay with not absorbing every single word. They allow for
that. (Socratic questioning/suggesting in MI spirit)
Meghan: That’s true.

As Meghan elaborated the motives and benefits of her status quo, a

process ensued whereby she began to reexamine it and the therapist sought
to help her elaborate this emergent change talk. Given this new context of
reduced ambivalence, the MI + CBT therapist then worked to introduce
change-oriented (CBT) strategies (presenting them in the spirit of MI) in
order to join Meghan in her growing resolve. The MI + CBT therapist,
however, seeks to avoid coercion and is at the ready for any reemergent
ambivalence or resistance in this process.
Therapist:
So, one of the ways we can combat the anxiety is by activating the
soothing system. (Client smirks). “What’s your reaction to that?” (Therapist
notices client smirk and probes for possible resistance)
Meghan: I have a feeling it’s going to be like, “Find five brown things and
listen to this and where are you, what are you doing, that kind of stuff”
(laughs)

Noticing that this interchange has the potential to develop into more
resistance, however, the therapist invites the client to talk about her
reluctance.
Therapist: Right. So, what has been your experience with that . . . helpful or
no?
Meghan:It just seems so . . . like it happened one time when I drank like four
cups of coffee and had really bad heart palpitations and I went to the
counseling office and some guy sat me down and said “what do you see,
what do you hear . . . ,” and it just seemed really silly.
Therapist:That makes sense . . . there is something silly about being asked
such basic questions . . . you know who you are. . . . (laughing together) So
part of this is just trying different things and deciding what works for you.
So, if there are some things you absolutely hate, then we won’t do that.
You’re the boss. You are the one to decide if it’s going to be beneficial or
not to try. (therapist reinforcing autonomy) And if it’s not, then we can
move on. (client nods) So, one of the ways we can soothe is to focus on our
breathing . . .
Meghan: (interrupts): I’ve done that before and found the opposite. . . . Like
on the subway I had an anxiety attack and I tried to breath in and out . . .
and I couldn’t feel the air doing anything for me, and it freaked me out even
more. (resistance)
Therapist: Sometimes focusing on your breath can actually contribute to
anxiety. . . . Like there you were attending to your breathing and thought,
“Oh my goodness, my breathing is not automatic anymore. I am not getting
any air.” (Therapist rolling with resistance)
Meghan: That’s it. Exactly (both laughing). The other thing I had once . . .
you know when you go to your doctor and they tell you to breath in and out
. . . that makes me want to pass out . . . like I can only do it twice and then
“get away from me” . . . so breathing for me . . . I am scared to focus on it .
. . I feel like it’s better off automatic. (ambivalence)
Therapist:Okay, so we can definitely not go that route. There is also
something called progressive muscle relaxation. (therapist explains a bit)
That might be helpful for addressing tension and restlessness. Does that
sound like maybe it might be a better fit?
Meghan: Oh, that’s good. Yes, much better fit.
 Note that if they could not identify a CBT technique the client was ready
to engage with, the therapist would go back to a fuller exploration of the
ambivalence; lack of engagement is a sign that something about change
continues to be threatening. With Meghan, this was not the case, and the
therapist and client moved on to implementing progressive muscle
relaxation, thought records, and behavioral experiments to challenge the
worry and try on new ways of being. The next example again illustrates the
benefits of infusing MI into CBT, even when the client is in the action
phase, and demonstrates the process of supporting autonomy.
Therapist:So, we talked about identifying some action tendencies in anxiety
and worry. Some of the behaviors you see in yourself that you listed are
things like checking and planning. So maybe today we can start to address
those behaviors, and you can decide which ones you want to hold on to and
which ones might be worth trying to let go of a bit. . . .
Meghan: Well, here is the thing, I did try it . . . for our appointment today, I
didn’t write down our appointment. I thought I could write it or I could not.
So, I made an effort not to write it down and just kind of see.
Therapist:
And what was that like? (open question designed to explore the
experiment with a new behavior)
Meghan: It was interesting. Like when you rely on something so much you
don’t tend to use your head to figure out what do I have to do . . . so it got
me thinking. . . . (pause) And it wasn’t bad . . . it’s one thing, it’s not like it
was a hundred things . . . so it was manageable.
Therapist:
And does it feel like you want to attempt it again? It’s up to you.
(supporting autonomy/choice)
Meghan: Yes (quickly). Because it sucks relying on something, you know.
Therapist:
And what specifically did you notice about not writing down the
appointment?
Meghan: I thought about it more in an effort to not forget . . . (pause) But I
kind of liked not writing it down, but just knowing . . . like organizing it in
my head as opposed to visually. (change talk)
Therapist: It sounds like you were able to trust yourself a bit. . . .
Meghan: Right! (enthusiastically)

Here the therapist is fully prepared to address, and accept, either outcome
(experiment worked or it did not). The exchange has more of a feel of
exploration and is less compliance-oriented than CBT alone might be at
times. Notice that the therapist did not step in quickly to praise Meghan as
this might indicate the therapist’s attachment to a preferred outcome and
interfere with the client deciding for herself what she thought of the change
step. It also prevents resistance that might occur, especially early in the
process of experimenting with change when the patient is still unsure about
its merits.
Over the course of the 15 sessions of MI + CBT, Meghan’s scores on
alliance quality and outcome expectancy showed steady improvement, with
a particular jump occurring early. Despite her high ambivalence at the
outset, at midtreatment Meghan showed evidence of resistance in just 5% of
total session time. Comparatively, the average midtreatment resistance
score among the CBT-alone patients was three times higher than Meghan’s
(again suggesting Meghan had high levels of collaboration despite her high
initial change ambivalence). On posttreatment and 1-year follow-up
diagnostic interviews, Meghan no longer met criteria for GAD, and she had
no clinically significant symptoms of GAD. Her self-reported worry
dropped markedly and was clearly in the normal range (pre 78/80, post
18/80; 1-year follow-up 19/80). In terms of diagnostic comorbidity, at
posttest and follow-up, she no longer met criteria for OCD or panic disorder
with agoraphobia. And on the Inventory of Interpersonal Problems
(Horowitz et al., 1988) her relational functioning showed the largest
improvements in the areas of self-sacrificing, nonassertiveness, and being
overly accommodating.

OUTCOME RESEARCH
The research attesting to the effectiveness of MI alone and CBT alone is
voluminous and compelling. In this section, we summarize the central
findings from our team’s RCTs that have established the additive efficacy of
integrating MI into CBT for GAD.
We have tested MI + CBT’s efficacy in two GAD trials. In the first pilot
trial, clients were randomly assigned to receive either a pretreatment of 4
MI sessions followed by 14 hours (8 sessions) of individual CBT (MI +
CBT) or 14 hours (8 sessions) of CBT with no pretreatment (Westra,
Arkowitz, & Dozois, 2009). MI + CBT clients demonstrated greater
posttreatment worry reduction than CBT clients, with this superior effect
being more pronounced for severe worriers (d = .97) than for moderate
worriers (d = .20). Moreover, the differential treatment effect was mediated
by lower levels of rater-observed resistance early in MI + CBT compared to
CBT (Aviram & Westra, 2011). However, these results warranted some
caution, given several notable confounds: MI + CBT clients had more
sessions, had two different therapists (one delivering the MI pretreatment,
another the CBT), were inherently aware of being in the experimental
condition, and had MI delivered to them sequentially versus fully
responsively.
Addressing these limitations, the second trial compared the efficacy of 15
sessions of CBT alone to 4 sessions of MI followed by 11 sessions of fully
integrated MI + CBT for clients with high worry severity GAD (Westra et
al., 2016). This integration was accomplished in two ways: (1) by
continuously using MI spirit in conducting CBT and (2) by responsively
shifting into primary MI strategies in response to markers of client
ambivalence or resistance. When MI + CBT therapists judged the resistance
to be resolved, they would then shift back into primary CBT, though still
with the MI spirit. Although MI + CBT and CBT achieved comparable
posttreatment outcomes, MI + CBT patients evidenced greater worry and
distress reduction and also had a greater likelihood of clinically significant
change at 12-month follow-up. The authors posited that this delayed or
“sleeper” effect might be due to the long-term benefits of therapists
promoting the client-as-expert stance, especially when they take the risk of
asserting their own needs in session, which could help clients develop trust
in their own change directions and resources that would enable continued
improvement even after treatment ends. In contrast, it is possible that CBT
clients attributed their posttreatment change more to the treatment
techniques or the therapist, potentially leaving them more vulnerable to
relapse after termination.
Probing these trial results, a follow-up study examined both MI theory-
relevant (i.e., empathy, resistance) and common treatment processes (i.e.,
homework compliance, alliance) as potential mediators of MI + CBT’s
superior long-term effect (Constantino, Westra et al., 2017). Greater
homework compliance and better quality alliances (the two common
processes) correlated with more positive outcomes across both treatments,
but only empathy and resistance significantly mediated the treatment effect.
Specifically, MI + CBT clients exhibited significantly lower midtreatment
resistance and perceived greater therapist empathy compared to CBT
patients, which in turn related to lower worry levels at 12-month follow-up.
However, when both empathy and resistance were included in the same
statistical model, only patient resistance remained significant, accounting
for 76% of the comparative treatment effect. These results support that
using MI to address resistance is the primary mechanism through which
integrative MI + CBT outperforms standalone CBT, at least over the long
term. That is entirely consistent with the origins and intentions of MI: to
reduce patient resistance, to prepare them for an action-oriented treatment,
and to help them learn to trust themselves in bringing about change.

FUTURE DIRECTIONS
Regarding practice directions, we suggest that therapists routinely assess
interpersonal problem types, ambivalence, and resistance, even if
informally. Such measurement can guide the use of MI, especially for those
clients who need it the most (e.g., those with high resistance, low
assertiveness, and high exploitability). Clinicians can also generate
practice-based evidence to test the immediate and longer term impacts of
using MI + CBT with clients suffering from disorders beyond GAD.
Regarding research directions, we believe it is important to test
interpersonal change as an outcome in GAD clients and clients with other
presenting problems, to follow the corrective interpersonal experiences
posited here through to their natural endpoint. Researchers can also test the
reach of MI beyond GAD clients and beyond integration with individual
CBT—to other clinical populations, other psychotherapies, varied treatment
formats. As noted, researchers can also test whether MI + CBT requires
adaptations for clients with different multicultural identities. Finally, future
research can also investigate whether training therapists to use MI in the
face of negative process markers improves therapists’ general efficacy; that
is, whether MI training not only improves treatment efficacy, but also
therapist efficacy (Constantino, Boswell et al., 2017).
Another future direction of our approach is to adapt deliberate practice
(Rousmaniere, 2016) to a workshop focused on repeated practice with
numerous video vignettes and recreated material of ambivalence and
resistance (e.g., ambivalent/resistant statements trainees have encountered
or fear encountering). Trainees engage with multiple exercises, from
identifying ambivalence/resistance to responding to clients with varying
presentations of ambivalence and resistance, as well as anger. They receive
feedback on their responses and also compare their responses to ideal ones
to shape skill development. We are planning to conduct an RCT examining
this deliberate practice format to a traditional MI workshop (i.e., more
didactic, demonstration, discussion, and some practice but little feedback).
Outcomes will include pre- and postresponding to video vignettes of
resistance and ambivalence, as well as posttraining interviews of actors
portraying difficult clients.
We recently conducted a pilot study to test the feasibility of a 2-day
deliberate practice workshop with 21 graduate students in clinical
psychology (Singer-Nussbaum et al., 2018). Findings indicated significant
improvements, pre- to post-workshop, in MI-consistent responses to video
vignettes depicting ambivalent and resistant clients. Moreover, trainees also
showed significant improvement in their “positivity” toward resistant
clients who were hostile and angrily expressing dissatisfaction with therapy.
Given that research has indicated that the positive effects of traditional
didactic workshops typically erode over time (Miller et al., 2004), it will be
important to assess the durability of these gains in follow-up assessments
and to improved outcomes in clinical settings.
If successful, translating the methods of deliberate practice to an efficient
workshop format may be one step in improving clinical skills, which tend to
remain static or even erode with time and experience (Goldberg et al.,
2016). Moreover, using process research to inform these efforts is important
in ensuring that training is focused on client markers and therapist actions
that have been explicitly linked to outcomes. This is especially relevant
given the lack of evaluated training methods in our field and the fact that
therapist adherence to a specific psychotherapy model (the focus of most
workshops) tends to be unrelated to client outcomes (Webb, Derubeis, &
Barber, 2010). In short, process-informed deliberate practice may be
particularly promising in training therapists to navigate specific and
contextually bound moments of client resistance, ambivalence, and even
criticism or negative feedback. Doing so not only has a reasonable chance
of improving therapist performance, but also, most importantly, enhancing
clinical outcomes.

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 14

Cognitive Behavioral Analysis System of

Psychotherapy for Chronic Depression
JAMES P. MCCULLOUGH, JR. AND ELISABETH SCHRAMM

THE INTEGRATIVE APPROACH

The cognitive behavioral analysis system of psychotherapy (CBASP) is an
acquisition-learning behavioral model of psychotherapy constructed
specifically to treat chronic depression, now diagnosed as persistent
depressive disorder, dysthymia (PDD). CBASP is administered by
clinicians who utilize a unique therapist interpersonal role known as
disciplined personal involvement (DPI; McCullough, 2000, 2006;
McCullough, Schramm, & Penberthy, 2015). CBASP development (from
1980 to the present) evolved under the guiding aegis of Gordon Paul’s
(1967) optimal goal for psychotherapy research: Paul advocated that
psychotherapy research must investigate outcome results where patient
diagnoses are matched with operationalized treatments under particular
therapists.
CBASP patients learn-to-criterion operationalized goals of therapy. In
many chronically depressed patients (hereafter referred to as PDD patients)
—and particularly those whose depression onset occurred during
adolescence—there are two core internal dilemmas (Wakefield, 1992) that
remain unresolved: (1) a pervasive interpersonal fear-avoidance reaction
toward others and (2) a perceptual disconnection to interpersonal
encounters that make it difficult for them to be informed by the
interpersonal consequences of their behavior. CBASP learning goals are
specifically designed to address both internal mechanism dilemmas. The
first learning goal, dyadic safety, teaches patients to discriminate the person
of the therapist from maltreating significant others (SOs)—designed for
later generalization to other persons. The second goal teaches individuals to
recognize the interpersonal-environmental consequences they produce
which connect them perceptually to the person-by-environmental (P × E)
relationship—a CBASP learning goal labeled perceived functionality
(McCullough, 2000; McCullough et al., 2015).
The depression follow-up data we have indicate that patients frequently
relapse (>50%) following treatment (Klein et al., 2004; Klein, Shankman,
& Rose, 2006; Steinert et al., 2014). These data suggested two things: (1)
patients must learn the “subject matter” (learning goals) of treatment to self-
protect them during the posttreatment period, and (2) PDD is an lifetime
illness (McCullough et al., 2015). Patients may learn to manage PDD
effectively but, like diabetes and high blood pressure, maintaining wellness
during posttreatment is a lifelong task.
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5;
American Psychiatric Association [APA], 2013) published the first chronic
depression category in its nomenclature by consolidating chronic major
depression and dysthymic disorder. This separation of chronic depression
from its “specifier status” in previous editions of the DSM was the result of
chronic depression research (e.g., Klein, 2008; McCullough et al., 2003;
McCullough et al., 2000). The essential feature of PDD is a depressed mood
that continues for 2 years or longer (1 year for children and adolescents).
CBASP, focusing on the chronic depressive disorders since the mid-1970s
(Doverspike, 1976), has been shown to treat effectively all subtypes of
PDD, types that are more alike than different (Klein, 2008; Klein et al.
2006; McCullough et al. 2000; McCullough et al., 2003b).
One of the novel features of CBASP that distinguishes it from other
psychotherapy models is that clinicians become personally involved with
patients. For more than a century, psychotherapists have been trained to
avoid personal involvement with patients (McCullough, 2006). The
proscription banning therapist personal involvement originated with
Sigmund Freud (1963) early in the twentieth century.
A present-day analyst writes (Hoffer, 2006): “The analyst’s responsibility
is to enhance the patient’s capacity for conscious and unconscious conflict
elucidation while conflict resolution remains both the prerogative and
responsibility of the analysand” (p. 37). Expecting chronically depressed
patients to behave in novel ways, ex nihilo, without being taught to behave
in an alternative fashion, is unrealistic. Such logic applied to chronic
patients poses this question: How can patients be responsible for modifying
their behavior when they have never been exposed to a loving and caring
environment? It is the assumption of CBASP that patients cannot and will
not spontaneously produce loving and caring behavior without learning to
do so in a relationship with a loving and caring human being. If one has
never experienced positive and facilitative experiences with others, no
positive neural or interpersonal potentialities exist for the individual. In
short, persons cannot do what they’ve never learned to do! This realization
led us to rethink the entire therapist role with the chronically depressed
patient as well as to review the century-old proscription prohibiting
personal involvement in psychotherapy.

Disciplined Personal Involvement

CBASP is fully cognizant of certain dangers that countertransference
strategies present; that is, using dyadic treatment to meet one’s own
personal needs (Spotnitz, 1969)—always a destructive strategy. Why is the
DPI role important in treatment of chronic depression? Because many
early-onset PDD patients report that they have never experienced
interpersonal trust or felt safe around others. Without the learning
experiences of trust and safety in the presence of clinicians with whom they
trust, patients usually remain quite resistant to efforts to modify their
pervasive fear-avoidance lifestyle.
DPI is administered from an objective countertransference perspective
(Winnicott, 1949); that is, therapists’ DPI reactions involve the verbal
articulation of the restricted feelings, attitudes, and reactions practitioners
experience and that are evoked by patient behaviors (e.g., “I can’t say this
or the patient will think I’m negatively judging him”). DPI “objective
countertransference” reactions also include instances when therapists
express caring feelings for patients who need to hear it. Examples of such
statements are ones that express acceptance, respect, and concern toward
those individuals who fear being verbally, sexually, or physically abused by
the clinician.
In summary, many chronic patients present for treatment severely
traumatized developmentally, cognitive-emotionally, and behaviorally.
CBASP therapists frequently treat preoperational and primitive-functioning
adults who, in the beginning, behave like “little boys and girls”
(McCullough, 2006; McCullough et al., 2015); however, these immature
individuals have the capacity to grow and maturate within a safe dyadic
relationship. DPI facilitates this potential as it gives therapists permission to
be disciplined and personally involved. The role, administered
appropriately, enables clinicians to behave toward patients as interpersonal
partners, where felt safety and interpersonal trust are actualized and
problem-solving skills are learned.

Historical Origins
The first author’s long-standing interest in chronic depression and in finding
ways to modify the disorder stems from multiple sources. These include (1)
JPM’s own struggles with PDD; (2) the desire to establish CBASP on
empirical foundations, operationalize the techniques, and research its
effectiveness; (3) interest in the contributions of B. F. Skinner, Albert
Bandura, Donald Kiesler, and Jean Piaget that have informed our theoretical
views and praxis; and, last, (4) JPM’s long-standing interest in chronic
depression. What follows is a more detailed description of each of these
four influences.
1. During early adolescence, JPM experienced an early-onset PDD that lasted more than a decade.
Today, he would be diagnosed with early-onset PDD dysthymia with intermittent major
depressive episodes (or “double depression”). During his mid-twenties, he underwent
psychoanalytic treatment. The disorder remitted, and the process of the illness and its recovery
played a significant role in the conceptualization of the chronic disorder and its treatment. For
example, JPM places high value on the disciplined personal involvement of the therapist, a
salient characteristic of his analyst. Learning to trust the analyst was a facilitative experience
that resulted in remission of the disorder.
2. Because CBASP is an operationalized model, therapy is structured so that patient performance
data are obtained session-to-session throughout treatment. The goal of the “learning content”
seeks to correct two essential learning problems that we opine maintain the PDD disorder (see
McCullough et al., 2015). Thus, we want to determine how much learning patients are acquiring
across sessions. The assumption underlying this approach is that patients who achieve the best
learning performance should also obtain the best outcome of treatment results. We answer two
questions with this approach: (a) How much learning content is acquired? And, (b) What
relationship does the amount learned have with the outcome of treatment and follow-up indices
(e.g., Beck Depression Index [BDI-II] score [Beck, 1996], Kiesler’s Impact Message Inventory
profile, etc.)?

As noted earlier, CBASP is an interpersonal psychotherapy based on a

person × environment causal determinant model of behavior (Bandura,
1977; Kiesler, 1996), and therapists following this model assist patients in
addressing two dysfunctional internal mechanisms (Wakefield, 1992). The
first is to countercondition the patient’s pervasive interpersonal fear,
replacing the fear with felt interpersonal dyadic safety. The technique used
to do this is labeled the Interpersonal Discrimination Exercise (IDE). This is
considered learned by patients when they experience felt interpersonal
safety with the clinician and when they can successfully discriminate the
psychotherapist from maltreating SOs. Over time, patients learn to make
this discrimination without assistance from the clinician.
The second learning goal is achieved when patients’ interpersonal
avoidance behaviors are replaced with approach behaviors, allowing them
to interact with others in a more effective manner. To accomplish this goal,
patients are administered and learn to self-administer a situational analysis
(SA) which teaches assertive behavior and assists patients in obtaining their
situational desired outcomes with others. Achieving desired outcomes in
interpersonal situations also reflects the acquisition of perceived
functionality. Perceived functionality means that patients are now
perceptually connected to others because they can recognize the
consequences their behavior has on others. Over the course of treatment,
patients learn to self-administer and perform to criterion the SA task. To
date, there is some preliminary evidence that the outcome of CBASP
treatment is dependent on the amount of learning acquired (Manber et al.,
2003).
3. The third historical feature is the synthesis of theoretical models that have influenced the
construction of CBASP. For example, Skinner’s views on the importance of informing
behavioral consequences (Skinner, 1953), his approach to teaching (Skinner, 1968), and his
understanding of the therapist’s (experimenter’s) role in choreographing of contingencies during
the session are foundations of CBASP. Also part of CBASP is Bandura’s (1977)
conceptualization of reciprocal interaction, which is achieved during the latter stages of
treatment (not in the beginning) when patients learn to identify the interpersonal impacts they
exert on the therapist and others; Beckian cognitive psychology influences (Beck et al., 1979)
are reflected in the structure of the CBASP model particularly in the SA exercise. In addition,
CBASP incorporates the interpersonal psychotherapy views of Kiesler (e.g., Anchin & Kiesler,
1982; Kiesler, 1983, 1996). Kieslerian interpersonal theory, as well as his experimental data,
strengthened our assumption that the therapist role can be used as a major interpersonal change
variable. Finally, Piaget’s (1923/1926; 1954/1981) theory of cognitive-emotive development,
elegantly described in Intelligence and Affectivity (1954/1981), provides the foundations for our
etiological views of preoperational functioning of PDD patients.
4. The last historical feature that has impacted the method is the evolution of the mood disorder
nomenclature in the various editions of the DSM. In the 1960s and 70s, DSM-II (APA, 1968)
defined chronic affective illness as a personality disorder; at that time, the mental health field
considered personality disorders to be untreatable. Such views turned out to be patently
erroneous. Robert Spitzer’s creative work with the Research Diagnostic Criteria (RDC; Spitzer,
Endicott, & Robins, 1978) moved mental health in the direction of diagnostic reliability. In
1980, the first chronic Axis I affective category (viz. dysthymia) appeared in DSM-III (APA,
1980), with Spitzer serving as its chair. In April, 2013, the American Psychiatric Association
published DSM-5, and, for the first time, chronic depression was uncoupled from its “specifier
status” with major depression and became an independent diagnostic entity, PDD (dysthymia).
Paralleling these developments, my 45-year research program has been divided between
constructing an effective treatment program and developing a valid diagnostic nomenclature for
the chronic disorders (e.g., Keller et al., 1995; Klein, 2008; Klein et al., 2006; McCullough,
1980, 2000; McCullough et al., 2000; McCullough et al., 2003b).

ASSESSMENT AND FORMULATION

CBASP conceptualizes PDD as an evolutionary-social disorder (Wakefield,
1992). The chronic mood disorders illustrate a multiple risk factor
phenomenon (Kendler, 2012). They are as follows: (1) biological risk
factors (molecular genetic and neurological), (2) person-interacting-with-
environment risk factors (P × E), and (3) social risk factors (peer influences,
social norms, and customs, laws.). The biological and P × E domains
constitute the major risk factors for PDD, with the P × E domain having the
greatest influence (Kendler, 2012).
An early paper by Wakefield (1992), one that has strongly influenced the
present authors’ conceptualization of PDD, proposed an alternative to
DSM-III-R’s (APA, 1987) definition of disorder. Wakefield defined
disorder as harmful dysfunction, describing “dysfunction” as an
evolutionary biological construct signifying an internal mechanism that was
not working or performing as it was intended, in contrast to a normal
organismic state of affairs that is operating as intended. He further defined
an internal mechanism including both biological structures (e.g., excessive
presynaptic reuptake in the serotonin tracts in depressive reactions) as well
as mental structures, such as motivational, cognitive, affective, behavioral,
and perceptual variables. Finally, Wakefield hypothesized that dysfunctional
internal mechanisms are the mediating causes of disorder and lead to the
resultant harm domain in his definition. Applying Wakefield’s definition of
disorder to PDD, the psychological symptoms of PDD and the reported felt
harm/distress represent the results of the dysfunctional cognitive,
emotional, behavioral, and physiological internal mechanisms. They are not
performing as biologically intended, and the PDD patient experiences a
concomitant harmful dysfunctional state of psychological functioning.
In summary, the risk factors in the biological and P × E domains in PDD
impact in dysfunctional ways on the patient’s internal mechanisms, which
are hypothesized to mediate the harm/symptom condition. The internal
mechanisms are the focus of CBASP treatment and its learning
requirements.
The two learning goals that form the foundation of CBASP are designed
to correct two dysfunctional internal mechanisms that we hypothesize
maintain the chronic disorder (McCullough et al., 2015). As stated earlier,
two corresponding CBASP techniques rectify the patient’s dysfunctional
internal processes. The IDE is designed to correct interpersonal fear-
avoidance, and SA is designed to correct the person × environment
perceptual disconnection. These two learning goals are mastered during
treatment and modify the dysfunctional mechanisms: the harm/symptom
state is replaced with felt interpersonal safety, and the patient’s perceptual
disconnection with the interpersonal environment is remedied with the
learned ability to recognize the consequences of his or her behavior.
CBASP prioritizes two treatment goals: Patient performance on the IDE
and the SA. As noted earlier, the first involves determining the degree to
which patients discriminate successfully the person of the therapist from
abusive SOs. The exercise is designed to create dyadic safety. Criterion
performance is attained when the person can self-administer the exercise,
without assistance, during two subsequent sessions. The second, SA,
enables patients to recognize the interpersonal consequences of their
behavior. As with the first goal, criterion performance requires correct self-
administration without assistance for two sessions in a row. The Patient
Performance Rating Form (PPRF), completed by the therapist, rates the
patient’s performance in the SA exercise. Early data on the use of this
measure were reported in 14 single-case replications (McCullough, 1984,
1991), in which therapy was terminated when patients performed the
problem-solving procedure (i.e., SA) to criterion.
The acquisition-learning of goals and the relationship of these learning
tasks to treatment outcome are illustrated in Figure 14.1. Specifically, the
second curve representing treatment outcome is determined by the amount
of learning.
FIGURE 14.1 Graphic illustration of the acquisition-learning and the Symptom Intensity Ratings in
the cognitive behavioral analysis system of psychotherapy (CBASP) model across sessions involving
the average of the two learning curves (Interpersonal Discrimination Exercise [IDE] Technique Felt
Safety; situational analysis [SA] Technique Perceived Functionality) and the Symptom Intensity
Ratings across several measures.

CBASP uses several measurement indices: pre-/postdiagnosis using the

DSM-5 diagnostic nomenclature; the BDI-II, and the Impact Message
Inventory (IMI; Kiesler, 1983; Kiesler & Schmidt, 1993). Optimal outcome
results are as follows: patients achieve diagnostic remission, patients report
zero or no BDI-II depression intensity levels, and patients are rated as
changing their interpersonal impact scores in facilitative directions. These
changes will be discussed in more detail later.
APPLICABILITY AND STRUCTURE

Session One Diagnosis of PD

It is unacceptable today to speak of depression in the “generic” sense
(McCullough, 2003b). Differences between the unipolar chronic and
nonchronic depressions have been shown to be quite profound. Numerous
factors are involved in the different manifestations of depression: the
clinical course of the chronic disorders, modal age of onset, outcome of
treatment, time-to-response, recurrence and relapse rates, psychosocial
functioning, concomitant Axis III involvement, family history among first-
degree relatives, developmental history and abuse, and the prevalence rates
of Axis II comorbidity have all been well documented as differentiating
variables separating the depressive subtypes (Klein, 2008; Klein et al.
2006). Finally, the chronic depressive disorders are usually lifetime
disorders with low rates of spontaneous remission (e.g., Klein et al., 2006;
McCullough et al., 2015). This is not the case with acute major depression,
which is usually a time-limited disorder frequently remitting within 9
months even without treatment (Tollefson, 1993).
When CBASP clinicians initially interview a depressed patient in session
one, they must determine whether the disorder is PDD or a case of acute
major depression. We recommend graphing the historical course of chronic
depression to answer whether the patient has presented with an acute or
chronic course (McCullough et al., 1996, 2016). An example of course
graphing is shown in Figure 14.2.
FIGURE 14.2 Clinical course graph of persistent depressive disorder (PDD) working back in time
from present to the past with intermittent major depressive (MD) episodes, without current episode of
major depression.
Source: McCullough et al., 2016.

Procedure During Session 1

1. The patient is assessed using the DSM-5 criteria to established a current diagnosis.
2. A clinical course graphing procedure (McCullough et al., 2016) is administered to differentiate
between a case of acute major depression and PDD.
3. BDI-II is administered at every session.
4. The Childhood Trauma Questionnaire; A Retrospective Self-Report (Bernstein & Fink, 1998) is
administered if the patient meets PDD criteria.
5. The therapist describes the Significant Other History (SOH) procedure (McCullough et al.,
2011, 2015) explaining that the exercise will be administered during the next session. Patients
are asked to bring a list of 5–6 SOs to the next session.

Procedure During Session 2

1. BDI-II administered.
2. The SOH is administered. Patients provide a list of 5–6 SOs who have shaped them to be the
kind of person they are. These SOs will be the patient’s major life players and individuals who
have left their “stamp of influence.” Patients describe what it was like growing up or being
around these persons. The contributions of the SOs may either be positive or negative. After a
brief period of discussion on each SO, patients are requested to construct the stamp or source of
influence in one sentence—these descriptions are called causal theory conclusions (CTCs).
Examples might be: “From my mother I learned that I could never trust a man”; “Both parents
taught me that I must always be self-sufficient, that it is wrong to need anything from anyone”;
“Growing up around my father left me with the feeling that I always had to be perfect—I should
never make a mistake”; “I can’t ever get mad or feel any anger, even today. This comes from my
mother.”

After Session 2 ends, the clinician examines the CTC list looking for
themes or motifs that run through the SO material. From the content, one
transference hypothesis (TH) is derived describing the hypothesized core
fear that is likely to influence the behavior of the patient in the dyadic
relationship. These themes will usually be reactions that patients have made
to toxic SOs who have hurt them. For example, core fear THs might be: “If
I have a relationship with Dr. JPM, then he will reject me and remind me
how inadequate I am”; “If I disclose my innermost thoughts and feelings to
Dr. JPM, then he will dismiss what I say and tell me I’m stupid”; “If I make
a mistake around Dr. Schramm (e.g., be late to an appointment, forget an
appointment, mess up my homework), then she will get mad and refuse to
see me again.”
The TH is used in the session whenever a “hot spot” appears. Hot spots
are dyadic events practitioners and patients encounter that suggest that the
TH subject is present. For example, when patients disclose personal
memories that they have never disclosed before, then the “disclosure” TH is
implicated. When a hot spot arises in the session, the clinician stops and
administers the IDE.
3. The SA procedure (described in detail later) is explained, and patients are given multiple copies
of the Coping Survey Questionnaire (McCullough, 2000; McCullough et al., 2015) that is used
for the SA exercise. One CSQ is completed prior to every session.
4. Last, the Patient’s Manual for CBASP (McCullough, 2003a) is distributed and the patient is
asked to read the Manual and come to the next session ready to discuss it.
5. After Session 2 ends, the therapist completes an IMI (Kiesler & Schmidt, 1993) on the patient.
In order to evaluate modification of the patient’s interpersonal style, the IMI is administered
again at the midpoint and at the end of treatment. An example of successful changes on the IMI
is demonstrated when a patient’s peak scores on the hostile side of the Interpersonal Circle (e.g.,
Hostile and Hostile-Submissive Octants) shift to the friendly side at treatment endpoint, as the
last IMI revealed peak scores on the Friendly and Friendly-Dominant Octants.
Procedure After Session 2
1. BDI-II administered at the beginning of every session.
2. Patient begins his or her SA training from Session 3 on.
3. Patient is rated on his or her SA performance during every session using the PPRF.
4. Patient is rated on his or her IDE performance during sessions when the IDE is administered.
5. Therapist completes one IMI on the patient between sessions 10 and 15 and at the end of
treatment.
6. Patient is rediagnosed for PDD, by DSM-5 criteria, at the end of treatment.

PROCESSES OF CHANGE
Although CBASP was developed specifically for the treatment of PDD,
several comorbid personality disorders have also been successfully treated
(avoidant, dependent, obsessive compulsive, and mild-moderate borderline
personality disorders; Keller et al., 2000). CBASP has not been successfully
administered to severe borderline patients who present with chronic
suicidality, self-mutilation patterns, extreme cognitive splitting, and
frequent hospitalizations (McCullough, 2002). Seven successive failures
were reported with these patients (McCullough, 2002).
The recommended number of acute phase sessions needed to obtain a
positive treatment response averages 16. Intent-to-treat data from a recent
national study (Keller et al., 2000) showed that the average number of
sessions was 16 for psychotherapy alone and psychotherapy with
medication, respectively (Keller et al., 2000). Probably a better indicator of
the typical number of required sessions for a positive outcome was seen
with those patients who “completed” the 12-week acute phase of treatment.
Patients with successful outcome receiving psychotherapy in combined
treatment received a mean number of 18 sessions. The optimal number of
acute phase sessions needed for a therapeutic response seems to be 18–20
sessions.
Two exceptions to the optimal number of sessions involve adults who are
diagnosed with early-onset dysthymia and with intermittent major
depressive episodes, without current episode (double depression). Early-
onset pure dysthymic syndrome, although described in DSM-5 as a milder
disorder than major depression, is also one of the most difficult chronic
disorders to treat to remission (McCullough et al., 2015). Eighteen to 20
sessions will probably not be enough. Outcome data on 10 pure dysthymic
disorder patients who completed CBASP averaged 31 sessions
(McCullough, 1991). The mean treatment duration was 8 months, with
cases seen on a weekly basis. Patients were followed for 16–96 months
after treatment termination. One hundred percent of the patients responded
to treatment, and all but one remained in remission at the follow-up visit.
Some of the pathology features of PDD that therapists confront when
treating the chronically depressed patient are described here and will serve
as an important context in understanding the processes of change.

Perceptual-Interpersonal Psychopathology
Chronic depression denotes structural–perceptual psychopathology whereby
patients are unable to generate formal operational cognitive-emotive
behavior in the social–interpersonal sphere (McCullough, 2000; Piaget,
1954/1981). Patients enter therapy functioning interpersonally and socially
in a preoperational mode and thinking in a prelogical/precausal manner. In
essential ways, their cognitive-emotive functioning mimics the behavior of
4- to 6-year-old preoperational children (Piaget, 1954/1981). Severe early
trauma, sexual and physical abuse, emotional and physical neglect, and
chronic “psychological insults” (McCullough et al., 2015) confronting
young children are the maltreatment etiological causes of chronic
depression. Cognitive-emotional (maturational) retardation resulting from
early maltreatment is the catastrophic outcome of a toxic developmental
history where “surviving the hell of the family,” and not growth, has been
the major goal (Cicchetti, Ackerman, & Izard, 1995; McCullough, 2000;
McCullough et al., 2015; Piaget, 1954/1981; Spitz, 1946). In a study of
chronic depression, one-third of the sample reported abuse: 34% reported
parental loss, 44% reported physical abuse, 16% said they had been
sexually abused, with 10% reporting they were neglected (Nemeroff et al.,
2003; Keller et al., 2000). The abuse had occurred before 15 years of age.
In contrast to the early-onset patient, late-onset patients usually describe
a milder developmental history (Horwitz, 2001; McCullough, 2000). One or
more SO relationships have frequently played a salutary role. Current
research shows that 20% of late-onset adults who are treated for their first
major episode do not fully recover; hence, they go on to develop a chronic
course (Keller & Hanks, 1994; Keller et al., 1983).
The consequences of the unremitting major depression are realized as the
person progressively adopts the attitude: “It really doesn’t matter what I do,
I will always be depressed.” Heightened-chronic emotionality washes away
the late-onset individual’s normal cognitive-emotive regulatory functions
(Cicchetti et al., 1995; McCullough, 2000; Piaget, 1954/1981), and the
dysfunctional internal mechanisms fall into place (i.e., fear-avoidance and P
× E disconnection) producing a return to preoperational functioning in the
social–interpersonal domain.
Over sessions of treatment and once the consequences of behavior are
consistently recognized, both early- and late-onset patients begin to view
themselves in a perceived functional manner; it is then that they report a
sense of gaining control of their lives. It is also at this point that several
other perceptual-intrapersonal changes occur: (1) primitive preoperational
functioning is replaced by formal operational (abstract) thought, (2)
depressive symptom intensity decreases, (3) the patient learns how to
generate interpersonal empathy, (4) patients report emitting assertive coping
skills with others, and last, (5) the PDD diagnostic status is modified in
remission directions (note: PDD diagnosis requires a 2-year duration).

Inability to Generate Authentic Empathy

The second pathological feature clinicians face is seen in the patient’s
inability to generate authentic empathy. Empathy requires one to use
language in a reciprocal manner in order to understand another individual as
well as to make oneself understood. Generating empathy also assumes that
one can employ formal operational thought. Extreme egocentrism, not
empathy, is one of the hallmarks of preoperational functioning. As noted
earlier, egocentrism is often symptomatic of the patient’s perceptual
disconnection from the environment. CBASP teaches patients to generate
empathy with their therapists and later with others, This achievement occurs
in patients as a perceived functional mode replaces their preoperational
patterns.

Gross Interpersonal Skill Deficits

Third, patients present with serious interpersonal skill deficits, and these
deficits involve an inability to emit assertive behavior with others. For
example, many have difficulty telling others what they need, what they
want, and what they don’t want. Assertive training is universally required
with this patient.

THERAPY RELATIONSHIP
As noted earlier, the therapist DPI role in CBASP is novel in the field of
psychotherapy. The authors know of no other model that requires therapists
to develop and utilize a personal countertransference role (Winnicott, 1949).
DPI means teaching preoperational patients to be human by interacting with
therapists who demonstrate that they can be interpersonally normal and
natural with patients (i.e. “It is okay to be yourself with patients”). The
word “discipline” is the critical component of DPI. The role must be
delivered with the well-being of the patient uppermost in mind.
Requirements for DPI training are fourfold, with the majority of
supervision time spent in this arena of therapy administration. First,
therapists are trained to be aware of their emotional reactions moment to
moment and at optimal change points in the session and are trained to
disclose their emotions to evoke change. Second, therapists need to learn to
think of themselves as a “comrade” who walks side by side with patients
through technique administration (i.e., IDE, SA, skill training). Third,
therapists learn to administer interpersonal consequences when
inappropriate behavior occurs. The fourth requirement is learning to walk at
the pace of the patient (in regard to making changes): trainees learn not to
“walk ahead” with their demands for change or to push, preach, or pull.
Examples of the DPI role follow. One patient told of the sexual abuse she
received at the hands of her biological father. After listening, the therapist
exclaimed: “What you told me your father did to you makes me want to
puke!” Another DPI moment is seen when the psychotherapist discloses
pride and joy over what an emotionally deprived-neglected patient does:
“I’m delighted about what you told me you did!” One patient who never
looked at the therapist but instead stared at the floor received the followed
reaction: “You make me feel that I do not exist with you.” One trainee
exclaimed during a workshop, “In CBASP, patients come to psychotherapy
to learn to relate interpersonally to psychotherapists!” They do.
One caveat, however, must be stated. DPI is not for all those who seek
training in CBASP. Some are not willing to step from behind the “warm
blank slate” wall and interact interpersonally and reciprocally with patients.
These individuals are not effective CBASP training candidates.

METHODS AND TECHNIQUES

As we have already noted, SA, the IDE, and social skill/role rehearsal
training constitute three techniques used to bring about change. All
techniques are designed to move patients toward formal operational
functioning, to assist them to generate authentic empathy, and to ensure that
they have the necessary assertive social skills to manage their lives
effectively. A fourth interpersonal-emotional exercise, the SOH, is also
administered during the second session to identify the core interpersonal
fear of the patient.

Situational Analysis
SA is a multistep social problem–solving exercise designed to attack the
helplessness/hopelessness of the chronically depressed patient by
demonstrating repeatedly that one’s misery is produced and maintained by
the patient. The impact of this message becomes a paradoxical word of
hope: if you don’t like what you’re producing and the misery you feel, then
change your behavior! Patients begin to assume radical responsibility for
their lives when they recognize that their behavior has self-destructive
consequences. What started out during the first session as a
helpless/hopeless individual protesting that “nothing I do matters” is
transformed by SA into a self-affirming person who admits that “everything
I do matters.” Making behavioral consequences explicit in SA moves the
patient to this perceptual stance. This is the reason CBASP therapists are
rigorously trained to arrange in-session contingencies to modify the
patient’s behavior (McCullough, 2000). The two phases of SA, labeled the
elicitation phase and the remediation phase, are described next.
During the elicitation phase of SA, patients address an interpersonal
problem by pinpointing one situational event where some difficulty
occurred (“Tell me when this last happened to you”). Once the event is
pinpointed, the person describes it in terms of a slice of time which entails
describing a beginning point, an exit/end point, and a story in between.
During the exercise, patients are not allowed to move outside the slice of
time or talk about other things. Rigid and destructive patterns of
psychosocial functioning, when analyzed carefully in one situation, often
turn out to be a microcosm of the universe of interpersonal problems. Thus,
the single SA is easily generalized to other areas of the patient’s life.
Generalization learning constitutes the last step of the SA exercise.
SA highlights specific behavioral consequences (the exit/end point of the
situation) that are labeled the actual outcome (AO). After pinpointing it,
patients are then asked to construct a desired outcome (DO) for the exit/end
point. During the early sessions, DO formulations highlight the fact that the
AO was not what the person wanted. This is made explicit during SA when
the patient is asked: “Did you get what you wanted here?” Discrepancies
between what one produces (AOs) and what one wants (DOs) often
noticeably increase felt discomfort. Distress at this point is desirable.
Now, the administration of negative reinforcement becomes possible
(reducing the distress by substituting more appropriate behavior) during the
remediation phase, where the mismanaged situation is “fixed.” When
patients see what must be done differently cognitively and behaviorally to
produce their DOs, they often feel better. The therapist then assists the
patient to recognize that the alleviation of discomfort is connected to
solution strategies. In this way, patient learning is reinforced (Skinner,
1968).
Over time, patients begin to bring in situations where the AO matches the
DO. Such successes are cause for celebration, particularly when they first
occur. Successful situational management will be subjected to the same
intensive scrutiny as mismanaged situations. SA also prevents patients from
overlooking consequences resulting from successful behavior.

Significant Other History

By the end of second session, the therapist role is defined. The role
definition stems from the TH that clinicians generate from the SOH and the
interpersonal impact data derived from the IMI.
The SOH data result in patients describing the stamp or legacy in one or
two sentences, the CTCs. From those, a TH is derived.

Transference Hypotheses
One or two consistent themes usually characterize the causal conclusions,
which then generate one hypothesis that sufficiently captures the major
interpersonal issue needing to be addressed.
Consider one example where the therapist was male and the patient’s
mother had taught her daughter that she shouldn’t trust a man; we
constructed the following hypothesis: “If I get close to Dr. Samuels, then he
will hurt/reject me.” Notice the functional way the hypothesis is stated: if
this happens . . . then that will occur. The hypothesis, when used in the
IDE, also states the name of the therapist to personalize the patient’s tacit
fear-expectancy. The TH, when used in the IDE, makes explicit what has
previously been tacit knowledge. Whenever the therapist and patient
experience moments implicated by a TH—for example, during a moment of
closeness or intimacy—the occasion is labeled a “hot spot” transference
area. The hot spot signals to the clinician that the IDE exercise should be
administered.

Interpersonal Discrimination Exercise

Preoperational patients habitually perceive their psychotherapists as
“hurtful” SOs. Patients are, for the most part, unaware of these tendencies;
thus, their misconstruals do not represent explicit knowledge; instead, they
strongly suggest tacit patterns of behavior (Polanyi, 1966). Regardless, the
consequences are the same for the therapist because his or her motives,
behaviors, thoughts, and feelings are frequently misinterpreted, meaning
that the clinician is often expected to reject, punish, abandon, or abuse.
Viewing therapists unrealistically not only decreases the probability of
change, it also decreases the patient’s motivation to change. Left
unaddressed, these perceptual distortions often preclude successful
treatment.
The IDE is designed to correct interpersonal distortions and heal early
traumatic experiences by adding a dose of interpersonal reality to the
patient’s experience. It teaches patients to make accurate discriminations
between the positive qualities of the therapist and the negative
characteristics of SOs. Unless patients are systematically and repeatedly
guided to make their misperceptions explicit, important distinctions
between hurtful SOs and the clinician are not learned (McCullough, 2000).
Said another way, persons cannot risk a cognitive-emotional alliance with
the therapist while maintaining potent negative expectancies. They profit
from specific and robust assistance to break these earlier connections; the
IDE provides such assistance.
During the IDE exercise, patients first recall a specific event where a SO
reacted to them in a hurtful way. The content of the event must fall into one
of four content domains and must describe actual encounters with SOs: an
intimacy situation that occurred between the patient and an SO, a time when
the patient personally disclosed highly private material for the first time, an
occasion when the patient made a mistake or broke some rule, or an
encounter where the individual felt or expressed negative emotions toward
an SO (e.g., frustration, anger, fear, guilt, shame, regret, etc.).
Patients are then asked to describe how the SO reacted to them in one of
the domains listed and to recall how the reaction affected them. As in the
SA comparison between the AO and DO, recalling negative past events
often potentiates emotional discomfort. Highlighting the patient’s aversive
emotions during recall makes it possible to create a negative reinforcement
condition (e.g., “This is the way it was then”).
The aversive state frequently diminishes when the patient’s attention is
directed to the therapist’s positive reactions, which is the third step of the
IDE. Thus, the interpersonal bond with the therapist is strengthened in a
dyadic safety zone. The final IDE step considers the implications for the
individual if the therapist turns out to be different from toxic SOs.
Several consequences occur over repeated IDE exercises. The IDE
highlights the positive reality of the dyadic relationship and makes it
explicit knowledge. The IDE proactively replaces negative emotional
attachments with new emotional dyadic connections. And the IDE
strengthens the person’s awareness that the practitioner is qualitatively
different from SOs and demonstrates experientially what a normal
interpersonal relationship is like.

Impact Message Inventory

The IMI assesses interpersonal impacts on eight octants, all of which
represent subdivisions within the interpersonal circle (Kiesler, 1983; Kiesler
& Schmidt, 1993). Kiesler’s interpersonal circle contains two intersecting
axes. Each axis represents an interpersonal impact dimension characterized
by polar opposites. The Dominant (D) → Submissive (S) vertical axis
designates a power dimension, whereas the Hostile (H) → Friendly (F)
horizontal axis signifies the affiliation dimension. These two impacts are
present in all interpersonal relationships and exert their influence on the
quality of a relationship as well as on the direction it takes.
Kiesler further divides the quadrants into eight octants. Chronically
depressed patients usually obtain the highest peak scores in the Submissive
and the Hostile-Submissive octants. This means that they are typically
submissive and compliant and remain detached and anxious in interpersonal
encounters. Patients pull therapists into dominant (“I’ll take charge”) and
hostile-dominant (“You can’t do anything, I’ll have to do it myself”) roles.
Even when therapists successfully resist falling into these roles, these
particular pulls are omnipresent. Identifying the stimulus value of patients
using the IMI determines the interpersonal role the clinician optimally
assumes if he or she is to help the patient move to other interpersonal
impact domains (McCullough, 2000).

DIVERSITY CONSIDERATIONS
CBASP has been administered in Australia, Canada, China, Finland,
France, Germany, Japan, Sweden, Switzerland, the United Kingdom, and
the United States. We have no process or outcome research specifically on
diversity issues, but CBASP has proved efficacious for chronic depression
across countries and cultures.
CBASP is very often administered under supervision, which places
heavy emphasis on the patient variable and adherence to treatment
variables. The chronically depressed patient presents challenges, regardless
of the cultural differences, that easily pull practitioners off protocol. Thus,
clinical supervision is recommended for all.

CASE EXAMPLE

Susan is a 41-year-old, divorced, part-time employee, with above average

intelligence; she is a single parent with an adolescent daughter. She has
been depressed “for as long as I can remember,” and, in addition to her
early-onset dysthymia, she recalled 4 or 5 major depressive episodes during
the past 25 years. The onset of the last major depressive episode began 3
months prior to the screening interview and followed the breakup with a
boyfriend. Her first husband had been an alcoholic, and her last relationship
ended when she discovered the man was also seeing another woman.
Susan’s developmental history and family of origin were characterized by
conflict, abandonment, and ostracism. Her father lived in the same city, and
they saw each other at least once a week. They had a stormy, conflictual
relationship that she always felt had been mostly her fault. Susan’s mother
died 8 years previously. The mother abandoned the family for another man
when Susan was 10. She had a brother and sister, 2 and 5 years younger,
respectively; the mother took the sister when she left home. Susan didn’t
hear from or see her mother or sister for 20 years. Her brother committed
suicide when Susan was a senior in high school. She lived with her father
until she went to college at age 18. The father severely criticized the
patient’s mistakes, and his criticism continued up to the present time. Based
on her description of the confrontations, he still treated her like a child.
During adolescence, he frequently accused her of “being a whore,” “a slut,”
“a junkie,” and many other negative labels. She made As and Bs during
high school and graduated on time, but she did report that she ran with a
“wild crowd” and did anything that would keep her out of the house.
Susan was diagnosed with PDD, an early-onset case of intermittent major
depression with current episode. At screening, she obtained a BDI-II score
of 35. On the Childhood Trauma Questionnaire, she reported severe levels
of emotional abuse and emotional neglect, indicating that a toxic
developmental environment characterized her early home life.
Her BDI-II score at the beginning of session 2 was 34. The SOH was
administered. Six SOs were listed in the following order: mother, father,
maternal grandmother, college professor, first husband, and her brother. The
causal theory conclusions centered around two salient themes: No one will
care for me or love me if they really get to know me; and I’m a screw-up,
and I can’t do anything right. From those, one TH was constructed by JPM:
“If I get close to JPM/have any kind of relationship, then he will reject me
in disgust.”
An IMI was completed post session 2, and Susan’s stimulus value style
was hostile-submissive (H-S), friendly (F), and submissive (S). Profiles of
this type may be confusing. Her moderate H-S score denotes a detached and
anxious interpersonal impact (“I’m nervous being with you”), but it is
accompanied by a peak score suggesting a friendly sociability style, “I like
being with you.” This means that JPM must not be seduced by her
friendliness; rather, he must attend more to her obvious interpersonal
distrust (hostile-submissiveness), which was congruent with the TH. The
IMI pattern provides another warning: JPM must avoid the lethal trap of
assuming a strong dominant role. Susan’s submissiveness suggests that JPM
must resist enacting a “take-charge” role but instead encourage Susan to
take the in-session lead.
At the end of session 2, Susan was given the Patient’s Manual for CBASP
as well as several Coping Survey Questionnaires for doing her SA
homework. JPM asked the patient to complete one CSQ for session 3. The
patient began taking sertraline (Zoloft) following session 2 and remained on
150 mg for the next 6 years.
The BDI-II score was 26, and the content of Susan’s fifth in-session SA
is shown here:
Situational Description (What happened?)
“I was in the house washing clothes and helping my daughter with her
algebra homework. I had not gone to work because she was sick. The
doorbell rang. I got up, and answered it. It was the air-conditioning
repairman who had come to replace the filter in our unit. I told him this was
not a good time for him to do the work. I asked if he could come back. He
insisted that he would not be long. Again I protested and asked that he come
back, but I opened the door, and he walked in. He went to the utility room,
replaced the filter, left his bill, and walked out. I didn’t even speak to him
when he left.”
Situational Interpretations (What did the situation mean to you? or, What
thoughts or feelings did you have during the event?)
1. “I can never control what happens to me.” [Global interpretation that doesn’t address the
problem at hand.]
2. “Big corporations are unfair to homeowners.” [Global interpretation.]
3. “My life is out of control.” [Global interpretation.]

Situational Behavior (What did you do in the situation?)

“I answered the doorbell and asked the repair man to come back at a better
time. I asked him twice. Oh, I almost forgot, I held the door open for him. I
didn’t speak to him when he left.”
Actual Outcome (How did the situation come out for you?)
“The repair man replaced the filter and left.”
Desired Outcome (How did you want the situation to come out for you?)
“I wanted the repair man to come back at a more convenient time.”
AO versus DO Comparison (Did you get what you wanted here?)
“No!” (Susan begins to cry while saying what a failure and screw-up she
is.)
Why Didn’t You Get What You Wanted Here?
“Because I’m stupid! I can’t do anything right!” (more crying)
Revising the Situational Interpretations
All three of her interpretations had to be revised. They did not accurately
describe what was going on; in fact, no interpretation dealt specifically with
the problem at hand. Because they were irrelevant (not anchored to the
event) and inaccurate (did not correctly describe what was going on), the
interpretations were modified to meet the relevance and accuracy criteria.
With considerable assistance, Susan revised her interpretations in such a
way that the probability of obtaining the DO was increased. The revisions
were as follows:
1. “I don’t want the filter replaced at this time” [accurate and relevant introspective
interpretation].
2. “I’ve got to request another appointment time with the repairman” [Action Interpretation
that leads to assertive behavior].

Repairing the Situational Behavior

JPM: “Had you interpreted the situation in this new way, how would your
behavior have changed?”
Susan: “I would have been more assertive and definite with the repairman.
And, i certainly would not have held the door open for him!”
JPM: “Had you managed the situation this way, do you think you would
have gotten your desired outcome? That is, for him to reschedule and come
back?”
Susan: “I would have had a better chance of getting what I wanted than I did
the first time through.” (Her crying stopped, and Susan is showing more
signs of energy and conviction about what would have happened.)

Space limitations do not permit us to discuss the final two steps of SA

(Wrap-up/Summary and Transfer of Learning Steps). But before leaving the
SA, note how Susan’s global cognitive interpretations precluded problem
resolution and how her cognitive errors inhibited her lack of assertive
behavior. Coping the old way frequently resulted in situational failure and
frustration. Her life really was really out of control, and, without realizing
it, Susan had inadvertently produced the failure she described.
 JPM administered the IDE following the SA exercise because the
situation implicated a hot spot that was suggested by the transference
hypothesis (“If I get close to Dr. McCullough, then he will reject me in
disgust”). The IDE exercise was administered in the following way:

JPM: “Susan, let me ask you a question. Had you told your dad about the
way you first handled this situation, how would he have reacted?”
Susan: “He would have laughed out loud at me and made me feel like a
stupid idiot. He would have gone on and on about how I can’t do anything,
how I’m always screwing up.” (Susan is beginning to tear up.)
JPM: “How would your first husband have reacted had you told him about
your experience with the repairman?”
Susan: “He would have poured himself a drink and told me I had driven him
to drink. He was just like daddy. He would have called me stupid, dumb, an
imbecile, and the biggest loser he had ever known. (Susan is crying softly
now.)
JPM: “Now, I want you to describe for me what my reaction was to the way
you dealt with the repairman?”
Susan: “It was okay, I guess.”
JPM: “Think back, what did I do, how did I look throughout, what did I
say? I want you to think carefully about how I behaved with you a few
moments ago.”
Susan:“You certainly didn’t make me feel stupid. You helped me see what I
could have done better, you encouraged me, and then you were pleased
when I said that the second way would have probably gotten me what I
wanted.”
JPM: “Now, I want you to compare and contrast my reactions to you with
those of your father and ex-husband. Tell me how they were similar and
how they differed.”

The IDE exercise attacks proactively the negative reactions of SOs by

focusing the patient’s attention on the contrasting salubrious behavior of the
therapist. The stable reality of this new interpersonal relationship must be
nurtured and strengthened over time so that it will acquire the capacity to
compete with and finally overthrow the old interpersonal realities and the
hold they have had on Susan’s life.
Susan ended weekly treatment after 21 sessions. The patient learned to
self-administer SA to criterion (using the PPRF as the rating scale) without
assistance from JPM by the end of session 20. At session 21, she obtained a
BDI-II score of 9. She continued to see JPM biweekly during the next 12
months. Six months after the weekly sessions ended, Susan was
rediagnosed and achieved remission from dysthymia.

OUTCOME RESEARCH

Meta-Analytic Reviews
A meta-analysis (Kriston et al., 2014) on acute treatments for PDD included
60 trials. The findings showed that several evidence-based acute
pharmacological, psychotherapeutic, and combined treatments for PDD are
available with significant differences between some of them. For CBASP
compared to medication, no significant differences were found. For the
treatment of chronic major depression, CBASP plus medication was
recommended, with weak to moderate strength due to conflicting findings.
The meta-analysis authors recommended CBASP over interpersonal
psychotherapy (Klerman et al., 1984).
A recent meta-analysis (Negt et al., 2016) was conducted on six studies
of CBASP for chronic depression. CBASP was moderately more effective
than treatment as usual (TAU) and interpersonal psychotherapy and was of
comparable effectiveness to antidepressant medication. Despite the small
number of studies, the evidence to date supports CBASP’s effectiveness for
chronic depression.
This meta-analysis included the large multicenter study of Keller et al.
(2000) that followed a total of 681 outpatients with chronic forms of major
depressive disorder at 12 sites across the United States. The trial compared
the effectiveness of nefazodone, CBASP, and the combination of both
therapies. The results at the end of the 12-week acute phase favored the
combination approach. The rates of response in the intent to treat sample
were 73% for the combined treatment, 48% for nefazodone alone, and 48%
for CBASP alone. A secondary analysis of the temporal sequence of
symptom change showed that the overall advantage of the combined group
was attributable to sharing both the earlier onset of benefit seen in the
nefazodone-alone condition and the later-emerging benefit seen in the
CBASP-alone condition.
The Keller et al. trial also implemented a crossover phase for
nonresponders to monotherapies (61 patients in CBASP; 79 patients in
nefazodone). Patients in both arms showed clinical benefits by switching so
that, at 24 weeks, their outcomes matched those of the combined group at
12 weeks (Schatzberg et al., 2005).

Recent Individual Studies

A more recent two-center study (Schramm et al., 2015), not included in the
meta-analyses, used a newer antidepressant, escitalopram, in a smaller
sample of 60 outpatients with PDD and compared it with the effects of 12
CBASP sessions over the acute treatment phase. In cases of
nonimprovement (<20% reduction in depression score), the other treatment
condition was added for the subsequent 20 weeks of extended treatment.
The intent to treat analysis revealed that depression scores decreased
significantly after 8 and 28 weeks in both conditions with no significant
differences between the approaches.
An 8-week randomized controlled trial by Michalak et al. (2015)
examined the effects of group mindfulness-based cognitive therapy
(MBCT), group CBASP, and TAU in 106 outpatients with PDD. CBASP
proved to be significantly more effective than TAU in reducing depressed
symptoms, whereas MBCT was not more effective than TAU. Despite the
fact that CBASP was adapted to the group format of MBCT (8 group
sessions of 2.5 hours) in this study, the results showed clear benefits for this
population.
In the most recently published multicenter trial of CBASP, 268
unmedicated patients with early-onset PDD (Schramm et al., 2017) were
also treated with supportive therapy (SP). Each treatment comprised 24
sessions in the acute treatment phase followed by 8 sessions of extended
treatment over 28 weeks. CBASP was found to be more effective and
acceptable at treating chronic depressive symptoms and quality of life than
SP. Rates of remission after 48 weeks of CBASP (36.7%) were similar to
the rate of remission reported by Keller et al. (2000) for CBASP or
medication (32.1%) after only 12 weeks of therapy. This study highlights
the potential use of psychotherapy without medication even though
combination treatment may remain the most efficient and most applied
treatment option.

Summary
So far, CBASP has proved to be of equivalent or superior effectiveness to
antidepressant medication, TAU, or other psychological treatments for
chronic depression. CBASP is an evidenced-based preferred treatment for
PDD, particularly for those with childhood maltreatment (Klein et al.,
2018). The European Psychiatric Association Guidance Group on
Psychotherapy in PDD (Jobst et al., 2016) and other guidelines consider
CBASP and, to a lesser degree, interpersonal therapy, to be effective in
persistent forms of depression. CBASP is recommended there as a first-line
treatment for PDD, and interpersonal therapy as a second-line treatment.

FUTURE DIRECTIONS
The most immediate need for the future is that CBASP must be compared
to another disorder-specific approach such as cognitive-behavioral therapy.
As well, we advocated for a series of dismantling studies to identify the
effectiveness of SA (when used alone) and the IDE (when used alone) and
when both CBASP components are administered in combination. An area
that has not been explored is augmentation strategies for the nonresponders
in randomized clinical trials.
Clinically, a future direction is to intervene early in high-risk groups
(e.g., depressed children, adolescents, young adults with childhood
maltreatment, etc.) to prevent a chronic course of depression. In this
context, therapists for children and adolescents will need to be trained. That
will probably entail the application of CBASP to related disorders,
including the aforementioned personality disorders.

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B. Specific Populations and Modalities
 15

Integrative Psychotherapy with Culturally

Diverse Clients
JEFF E. HARRIS, NATASHA SHUKLA, AND ALLEN E. IVEY

THE INTEGRATIVE APPROACH

The guiding assumption of this chapter is that culture is a broad social
context that has a pervasive influence on psychological functioning and
treatment. “All individuals exist in social, political, historical, and economic
contexts, and psychologists are increasingly called upon to understand the
influence of these contexts on individuals’ behavior” (American
Psychological Association, 2002, p. 1). This sociocultural environment is
internalized into beliefs and values that impact behavioral processes. Using
this inclusive definition of culture, all clients are recognized as culturally
unique, which might suggest an alternative title for this chapter:
“Integrating Culture into All Psychotherapy.”
Understanding diversity and the impact of culture on human development
has been a major emphasis in psychotherapy over the past several decades.
The multicultural movement can be described as developing across three
historic phases (Harris, 2012). First, starting in the late 1970s and
throughout the 1980s, there was an emphasis on educating psychotherapists
about racial and ethnic differences. The multicultural movement began as
an effort to help psychotherapists, a majority of whom were European
Americans, to work more effectively with clients from different racial and
ethnic backgrounds (e.g., Atkinson, Morten, & Sue, 1979; Sue, 1981).
Starting in the 1990s, during the second stage in the multicultural
movement, culture began to be defined more broadly. Instead of focusing
solely on race and ethnicity, the definition of culture was expanded to
include other personal variables, including sex and gender, sexual
orientation, age, socioeconomic status, religion, and disability status
(Pederson, 1990). Third, in the new century, culture is being addressed
within the context of evidence-based practice (American Psychological
Association, 2005). This stage of the movement involves more widespread
recognition that client variables, including cultural background and identity,
should influence the way psychotherapists select and implement treatments.
The field has increasingly articulated a sophisticated understanding about
how identity and self-definition interact and are shaped by social and
physical environments as well as by experiences of power, privilege, and
oppression (American Psychological Association, 2017).
One of the first descriptions of integrative multicultural psychotherapy
was written by Franklin, Carter, and Grace (1993), who proposed a
multisystem/racial identity perspective for working with blacks/African
Americans. This approach took into account the role of intrapersonal
dynamics, family systems, sociocultural influences, economic resources,
and community. These authors concluded that both a client’s and a
therapist’s racial identity development has a crucial impact on their
therapeutic interaction. This idea has been updated with a recognition that
multicultural practice is shaped by whether a privileged or marginalized
clinician is working with a privileged or marginalized client (Ratts et al.,
2015). This chapter will embrace and further explore these themes of
culture, identity, and integration.
Although many integrative psychotherapies have been proposed, most
have not made culture a major emphasis. One exception is multitheoretical
psychotherapy (MTP; Brooks-Harris, 2008), which is based on a
multidimensional model of human functioning, depicted in Figure 15.1.
MTP encourages psychotherapists to think about clients in a holistic
manner, focusing on both immediate psychological functioning (thoughts,
feelings, and actions) and external influences (interpersonal, systemic, and
cultural contexts). When working with culturally diverse clients, this model
reminds us that culture surrounds us and shapes the human experience in an
ongoing manner. MTP acknowledges that different theories of
psychotherapy focus on different dimensions of functioning depicted in
Figure 15.1. In the same way that cognitive therapies focus on thoughts and
experiential therapies focus on feelings, multicultural psychotherapy
focuses on cultural contexts and the way culture is internalized in the form
of worldview and identity.
Psychotherapists should identify focal dimensions that are most relevant
for each client. Culture will prove more important to explore with some
clients than with others. When culture becomes salient, then it will be
important to implement multicultural interventions. Methods and
techniques that directly examine culture will be discussed later in this
chapter.

FIGURE 15.1 Multidimensional model of human functioning.

Source: Reprinted with permission from Brooks-Harris, J. E. (2008). Integrative Multitheoretical
Psychotherapy.

Cultural competency requires therapists to develop three interrelated

areas of practice: attitudes, knowledge, and skills (Sue, Arredondo, &
McDavis, 1992; Ratts et al., 2015). First, therapists become aware of their
own assumptions, values, and biases. The development of awareness is an
ongoing process that involves training, supervision, and active self-
reflection. Second, cultural competence involves understanding and
accepting clients’ worldviews without judgment. Knowing about the
cultures that shape clients’ experiences is a prerequisite for empathy and
understanding. Third, psychotherapy will be more effective when it
involves goals and interventions that are consistent with clients’ cultural
values (Sue & Sue, 2016).
Of course, developing and maintaining cultural competence is an
ongoing process. For example, if a therapist begins working with a Syrian
refugee for the first time, he or she may become aware of personal biases
about Muslims that were previously outside of awareness. It will be useful
for the therapist to learn more about the cultural and historical forces that
have shaped this client’s life. As a result of this knowledge, clinical skills
may be adapted in a way that fits the clients’ worldview and cultural
preferences.

ASSESSMENT AND FORMULATION

To integrate culture into psychotherapy, practitioners assess and understand
the cultural variables that shape their clients’ lives. Hays (2008) suggested
10 different dimensions of culture that influence the way people function.
Together these cultural influences spell the word ADDRESSING: Age and
generational influences, Developmental disabilities, Disabilities acquired
later in life, Religion and spiritual orientation, Ethnic and racial identity,
Socioeconomic status, Sexual orientation, Indigenous heritage, National
origin, and Gender. To understand a client’s cultural experience, it will be
necessary to explore the personal meaning that these identities possess.
Each of these 10 cultural influences might impact a client’s thoughts,
feelings, actions, or all three.
It is usually helpful to explore the salience of different aspects to assess
which features are most impactful. For example, when working with an
Asian female who reports symptoms of social anxiety, it may prove useful
to look at the impact of both ethnic identity and gender socialization. This
client may report that her identity as an Asian woman impacts her thoughts
(“I should not assert myself directly”), her feelings (apprehension in social
situations with strangers), and her actions (avoiding eye contact and
remaining quiet). With a transgender man who is facing job discrimination,
the clinician can focus on the way gender identity impacts functioning.
Assessing culture with this client may reveal a pattern of thoughts (“They
are treating me unfairly because I am different”), feelings (anger about
being passed over for a promotion), and actions (becoming more
confrontational with colleagues at work) that are creating distress and
interpersonal conflict.
Psychotherapy with culturally diverse clients may or may not include
formal psychological assessment and diagnosis. If psychometric
instruments are used, or if a diagnosis is made, cultural implications must
be considered (Suzuki, Lee, & Short, 2017). Cultural barriers during the
clinical interview may include communication, language, mistrust, racism,
bias, and socioeconomic status. Behavioral observation can be difficult
because the meaning of eye contact, facial and bodily expressions, and the
use of language and speech differ so much between cultures. The same
problems exist with diagnosis because the same behavior may have a
different meaning in a different social context. Therapists should also be
cautious about using psychometric instruments that have not been normed
on diverse samples (Suzuki et al., 2017).

Identity Development
Identify development is frequently used in case formulation when working
with culturally diverse clients. Many people of color move through stages
of development that involve responses to their own ethnic or racial group
membership as well as to the dominant culture. Specific models have been
proposed to describe the experience of African Americans (e.g., Cross,
1971, 1995), Asian Americans (e.g., Sue & Sue, 1971; Kim, 2012), and
Latino/Hispanic Americans (e.g., Ruiz, 1990). Many of the cross-group
themes have been combined in the Racial/Cultural Identity Development
model (Atkinson, Morten, & Sue, 1998; Sue & Sue, 2016), which describes
five stages:
1. Conformity: People of color in the United States are often raised within a cultural environment
that values white European American culture and devalues other racial and ethnic groups.
People of color often internalize these values, resulting in a depreciation of their own group and
their own racial or ethnic identity.
2. Dissonance: People of color often have an encounter with racism or another experience that is
inconsistent with their cultural beliefs and values that moves them into a stage of dissonance.
During this stage, there is often internal conflict about whether to value one’s own group or the
dominant culture.
3. Resistance and Immersion: Some people of color will enter a stage of resistance when they
immerse themselves in their own culture and experience anger about the oppression they have
experienced. During this stage, people of color may embrace an attitude of pride that includes
culture-centric values that may devalue other groups.
4. Introspection: Some people of color will move from resistance, focused on group identity,
toward a more individualized stage of reflection that embraces individual autonomy as well as
group membership. Individuals in this stage typically reflect on their basis for judging others and
begin to view other groups with more balance.
5. Integrative Awareness: This final stage of development allows people of color to appreciate their
own group as well as members of other groups. They may develop an internal sense of security
that allows them to appreciate unique aspects of their own racial or ethnic culture as well as
aspects of the dominant US culture (Sue & Sue, 2016).

Psychotherapy can facilitate this process of racial identity development,

using strategies matched to the person’s stage. If clients are in the
conformity stage, for example, then it can prove helpful to encourage them
to explore their own identity, and psychotherapy may involve a process of
reeducation. During resistance and immersion stages, for another example,
the therapist supports clients’ feelings of anger and helps channel these
strong feelings into actions related to social justice. When working with
clients in the final stage of integrative awareness, it frequently proves useful
to focus on systemic action that values both pride and autonomy (Sue &
Sue, 2016).
Identity development models have also been identified for a variety of
other cultural groups beyond race and ethnicity. Six stages of identity
development for lesbians and gay men include identity confusion,
comparison, tolerance, acceptance, pride, and synthesis (Cass, 1979). Since
then, many psychotherapists have written about how to modify
psychotherapy for LGBT clients (e.g., Bieschke, Perez, & DeBord, 2007;
Pachankis & Goldfried, 2004). Psychotherapy with LGBT clients often
involves providing support as clients negotiate the coming-out process and
deal with prejudice, discrimination, and misconceptions (Sue & Sue, 2016).
The sociopolitical climate may discourage self-disclosure among LGBT
clients until they decide if psychotherapy feels safe.
 Similar stages of identity development have been identified for people
with disabilities: passive awareness, realization, and acceptance (Gibson,
2006). Recommendations for psychotherapy for people with disabilities
have been made by a variety of psychotherapists (e.g., Cordes et al., 2017;
Gibson, 2009). Communities of people with disabilities often create their
own cultures, such as deaf culture or blind culture, of which
psychotherapists should become aware. Working with clients with
disabilities often involves assessing the impact of discrimination and
exploring whether clients view their disability as a moral lapse, a physical
limitation, or an individual difference that society may fail to accommodate
(Sue & Sue, 2016).

APPLICABILITY AND STRUCTURE

When should therapists focus on culture? On one hand, because culture
influences all aspects of psychological functioning and treatment, therapists
should always be mindful of the way culture shapes cognitions, emotions,
and behavior. On the other hand, there are some clinical situations in which
a more overt emphasis on culture is warranted.
This chapter highlights three conditions that call for a direct focus on
culture. First, when there are salient cultural differences between the
psychotherapist and client, practitioners must monitor the impact of these
differences on the therapeutic relationship. Second, when clients present
with strong preferences for cultural content or request a practitioner of a
similar cultural background, then culture should be addressed. The third
situation in which an overt focus on culture is crucial is when psychological
problems are related to stressful cultural encounters (Harris, 2012).
Racism and discrimination are stressful events that can have a serious
impact on mental health and put people of color at greater risk for
depression and anxiety (US Department of Health and Human Services,
2001). Stressful cultural encounters might include moving to another
culture (e.g., immigration, international studies); discrimination,
oppression, and prejudice (e.g., racism, sexism, sexual harassment); moving
between cultural contexts (e.g., being closeted with family but out with
friends, working in the city but visiting family on the reservation); cultural
stressors (e.g., poverty, refugee experience, undocumented immigration);
cultural violence (e.g., hate crimes, sexual assault, terrorism); and changes
in status or privilege (e.g., moving from majority to minority, loss of
income) (Harris, 2012). These stressful cultural encounters may result in
cultural adjustment disorders involving culture shock, adjustment disorders,
posttraumatic stress, depression, or anxiety.
Since gender, gender identity, and sexual orientation are crucial parts of
cultural identity, feminist therapy and gay- and transgender-affirming
therapy are also seen as cultural-sensitive methods of treatment. Feminist
therapy entails four essential principles: exploring women’s
multidimensional identities, assisting clients with awareness of systemic
influences that impact their lives (e.g., institutional racism), fostering an
egalitarian relationship between the therapist and the client by minimizing
power differentials, and focusing on processes and language that value
clients’ strengths, emotional expression, and independence (Worell &
Remer, 2002). Gender-aware therapy is a way to address cultural
conceptions of gender when working with either male or female clients
(Good, Gilbert, & Scher, 1990). When working with transgender and
gender nonconforming clients, therapists should treat gender as a nonbinary
construct, recognizing that people experience a variety of gender identities
that may not correspond to sex assigned at birth (American Psychological
Association, 2015).
Multicultural psychotherapy does not prescribe a particular structure or
require a specific theoretical orientation. Instead, therapy is flexibly tailored
to the unique, culturally situated client. Thus, integrative psychotherapy
with culturally diverse clients will necessarily take many forms. Most
culturally sensitive therapists embrace theoretical integration or technical
eclecticism (e.g., Corey, 1996; Franklin et al., 1993; Pederson, 1990). The
only prescription is an ongoing attempt to see how culture impacts clients
and how it can inform and enhance psychotherapy.

PROCESSES OF CHANGE
Prochaska and Norcross (2018) concluded that multicultural therapy often
taps into four processes of change: consciousness-raising, catharsis,
choosing, and social liberation (a form of advocacy and social justice).
First, consciousness-raising can highlight oppression and its personal
impact on clients. Consciousness-raising is particularly important during
early stages of identity development (conformity and dissonance). For
example, with a client who has experienced racism and discrimination, it
will be helpful to ask questions that highlight the external barriers that have
been faced. Psychotherapy can address the liberation of consciousness,
which speaks to helping clients understand how oppression operates in their
lives. Liberation of consciousness goes beyond traditional therapeutic goals
related to self-actualization, insight into the past, or behavior change (Sue,
Ivey, & Pederson, 1996).
Second, therapy can support the expression of anger and other emotional
responses that clients may feel about stressful cultural experiences like
discrimination or sexual harassment (Prochaska & Norcross, 2018). This
type of catharsis may be particularly important during the resistance and
immersion stages of identity development. If a client is angry and confused
about the way he or she has been treated, practitioners can serve as a
witness for their pain by validating their experience. Culturally diverse
clients are also likely to experience feelings of fear, sadness, and shame that
may need to be explored and resolved in psychotherapy. For example, in
working with undocumented immigrants, therapists will help them deal
with realistic fears related to employment and deportation.
Third, multicultural psychotherapy often involves facilitating active
choices about how to respond to cultural encounters and how to express
cultural identity. Making active choices and participating in social action
are particularly important during the middle stage of resistance and
immersion as well as in the final stage of integrative awareness. After
exploring clients’ thoughts and feelings about their cultural experiences, it
may prove helpful to consider choices and actions that will empower them
in their broader communities. Immigrant clients face choices regarding how
to incorporate cultural traditions and roles within the norms of their new
country. Clients choose how much they want to acculturate into their new
society and, if desired, determine how they can blend aspects of both
cultures without losing important aspects of each. This, of course, is easier
said than done.
A fourth process of change is social liberation or social justice.
Awareness alone rarely promotes concrete change; active work is required
to secure freedom from oppression. Therapists can advocate for their clients
and actively intervene to transform society. Freire’s (1972) liberation
psychology argues that our interventions should be aimed at changing the
world (Ivey, 1995). Mental health professionals conduct social justice work
through varied forms and paths as activists, educators, therapists, and
community members (Toporek, Sapigao, & Rojas-Arauz, 2017). For
instance, a therapist who works with community agencies to provide low-
cost mental health services to clients who cannot afford health insurance
participates in a form of social action.

THERAPY RELATIONSHIP
The quality of the therapeutic relationship is a positive predictor of the
outcome of psychotherapy (Norcross, 2011), and this is particularly true
with culturally diverse clients (Liu & Pope-Davis, 2005). When working
cross-culturally, psychotherapists can enhance the therapeutic relationship
by acknowledging and addressing cultural differences between the client
and the therapist, understanding how microaggressions can impact the
relationship, and addressing ruptures in the therapeutic alliance when they
occur.
Discussing cultural differences with clients frequently proves challenging
or uncomfortable, and it may be difficult to initiate these discussions. Part
of building rapport is openly acknowledging differences rather than
dismissing them. By ignoring these conversations, practitioners may be
telling clients indirectly that their lived experiences are not valid or
important enough to be discussed and that the therapist is not culturally
competent.
For instance, suppose a client with a physical disability arrives to see an
able-bodied therapist. The client begins to discuss how she feels
discriminated against by able-bodied individuals when applying for jobs
and feels helpless in her situation. If the therapist does not explicitly
acknowledge the differences between herself and the client, then there is a
significant missed opportunity to fully understand the client’s worldview. In
this instance, the therapist might make a relational intervention such as, “I
am wondering what it is like for you as an individual with a physical
disability to discuss your experiences with a therapist who is able-bodied.”
This proactive exploration usually facilitates a deeper exploration into the
client’s experiences as well as how her identity has been shaped by her
cultural context.
The term “microaggression” refers to subtle, indirect messages (either
intentional or unintentional) that are perceived as derogatory or demeaning
to a target group or individual (Sue & Sue, 2016). One research study found
that more than half of racially and ethnically diverse clients in a university
counseling setting had experienced a microaggression by their
psychotherapist (Owen et al., 2014).
Microaggressions tend to fall into three categories: microassaults,
microinsults, and microinvalidations. Microassaults are similar to overt
discrimination as they are a direct attack on an individual or a group
intended to be discriminatory in nature. Microinsults are considered
insensitive insults, such as when a career counselor asks a black female
client if she wants to change her major since she failed a math course. This
therapist’s microinsult assigns intelligence to a person based on her race and
gender. A therapist who does not value the importance of a client’s racial or
ethnic identity may be guilty of microinvalidation by stating, “I don’t
believe you and me are very different. We are all humans and we should be
treated equally.” While the therapist’s intention may be to help the client
feel a sense of belonging, the opposite message may be communicated.
Ruptures in the therapeutic alliance are inevitable (Eubanks, Safran, &
Muran, in press). When working with diverse clients, therapists can
communicate directly when they may have ruptured a relationship through
a microaggression. How should a therapist repair a ruptured alliance? First,
be honest and transparent in discussing the topic with the client, openly
acknowledging that an assumption or mistake has been made. Second,
explore with the client what it was like for the therapist to make a
microaggression in session and discuss other contexts in which
microaggressions have occurred. This type of exploration can facilitate a
deeper discussion of the client’s feelings and thoughts related to her
experiences of being part of a marginalized group as well as the cumulative
cultural messages she has received about her identity. Third, offer a sincere
apology. Fourth, contract for how to address any future alliance ruptures in
the relationship. Research demonstrates that rupture repairs often enhance
the therapeutic relationship, decrease premature terminations, and improve
patient outcomes (Eubanks et al., in press).

METHODS AND TECHNIQUES

We highlight four approaches to cultural methods and techniques below:
group specific recommendations, cultural adaptations of evidence-based
treatments, exploring culture using an ideographic approach, and examining
interactions between culture and other dimensions of functioning. The first
two types of multicultural skills (group-specific skills and multicultural
adaptations) represent nomothetic approaches because they emphasize “the
prominent characteristics of the group to which an individual belongs”
(Ridley, 2005, p. 86). This nomothetic focus on group membership
represents both a strength and a weakness. A central theme of the
multicultural movement has been that knowledge about cultural group
membership should guide our work as psychotherapists. At the same time,
there is a risk in assuming that by knowing a client’s racial or ethnic
identity, we have captured their essence. The recognition that people within
the same group differ greatly in levels of acculturation and stages of identity
development creates another challenge in applying nomothetic models of
culture. Nomothetic models are most helpful when ethnocultural identity is
central to psychotherapy goals and when the client identifies clearly with a
single group (Harris, 2012).
The alternative or complement to a nomothetic approach to culture is an
ideographic perspective, which provides a method to “understand the
personal meaning that the client holds as a particular person” (Ridley,
2005, p. 86). In practice, the distinction between a nomothetic and an
ideographic perspective is a delicate balance. As noted earlier, culturally
competent therapists learn about the cultural heritage and identity of clients
and then explore the personal meaning of these influences to avoid
inaccurate stereotyping. The last two types of skills presented in this
chapter (exploring culture and examining cultural interactions) are more
ideographic, which typically proves most helpful when a client does not
clearly identify with a single group, or when race or ethnicity intersects
with other aspects of identity in influential ways (Harris, 2012).

Group-Specific Recommendations
The multicultural movement has frequently made specific recommendations
for counseling clients from different cultural groups. The first edition of D.
W. Sue’s (1981) Counseling the Culturally Different had chapters with
recommendations for counseling Asian Americans, blacks, Hispanics, and
American Indians. The seventh edition (Sue & Sue, 2016) has additional
chapters about counseling multiracial individuals, Arab and Muslim
Americans, immigrants and refugees, Jewish Americans, individuals with
disabilities, LGBT individuals, older adults, individuals living in poverty,
and women. Some recommendations about working with specific groups
include recognizing that self-disclosure is not a natural part of Asian,
Latino, or Native American cultures and that many minority clients prefer
active and directive treatments.
Another approach begins with knowledge about a specific culture and is
then applied to psychotherapy, resulting in specific methods across six
stages of treatment: connecting with clients, assessing, facilitating
awareness, setting goals, instigating change, and feedback and
accountability (Gallardo et al., 2012). For example, for American Indians
and Alaska Natives, reality is defined spiritually, giving to family and
community is the highest value, the spiritual world is seen as parallel to the
material universe, learning from experience is the best way to know
something, and action is defined by how it supports the tribe.
Based on this understanding of native culture, Trimble (2012) made
recommendations for working with American Indians across the six stages
of treatment. First, connecting with American Indian clients will include
accepting long periods of silence and discussing trust and trustworthiness.
Second, assessment should include a discussion of tribal and personal
history and recognition that clients may be mistrustful of formal testing.
Third, awareness will typically include a discussion of values and beliefs as
well as a deep openness to truth. Fourth, goal-setting should consider
gender and the context of extended family and the possibility that personal
goals may be supported by traditional healing ceremonies. Fifth, change
may involve social networks, including family, friends, and coworkers.
Sixth, feedback may include storytelling as well as behavioral records of
client change.

Cultural Adaptations of Evidence-Based Treatments

A second approach to cultural methods involves cultural adaptations of
evidence-based treatments. Cultural adaption procedures are defined as
“systemic modifications of an evidence-based treatment (EBT) or
intervention protocol to consider language, culture, and context in such a
way that it is compatible with the client’s cultural patterns, meanings, and
values” (Bernal, Jimenez-Chafey, & Rodriguez, 2009, p. 362). The
motivation to create cultural adaptations is based on research that indicates
that EBTs may not be as effective for diverse cultural groups (Benish,
Quintana, & Wampold, 2011). Multiple meta-analyses demonstrate that
cultural adaptations of EBTs work as well, and usually better, than the non-
adapted EBTs (Griner & Smith, 2006).
In culturally adapting treatments, clinicians start by inquiring about the
intervention’s acceptability, usefulness, and effectiveness with the target
population, including discussions with other practitioners who are
knowledgeable about the target population. Based on a literature review to
document barriers to treatment, a pilot study of the adapted treatment can be
used to determine if it is acceptable and valid. Finally, delivery modes that
impact how the intervention will be conducted and in what format can be
considered (Bernal & Rodriguez, 2012). Research indicates that therapists
often struggle with adapting interventions to meet their clients’ needs
(Griner & Smith, 2006). For instance, a client who identifies as an Asian
male may find the assertiveness training proposed by his therapist to be
understood as aggressive due to his cultural background.
Many models of adaptation utilize Bronfenbrenner’s (1979) ecological
systems theory addressing multiple cultural elements when working with
diverse ethnocultural groups: language, person, metaphors, content,
concepts, goals, methods, and context (Bernal, Bonilla, & Bellido, 1995).
Researchers have utilized this framework to successfully create culturally
adapted therapies for specific ethnic groups. Many frameworks also
consider how acculturative stress, discrimination, nationality status,
spirituality, customs, and values impact treatment outcomes and client
engagement (Bernal & Rodriguez, 2012).
Cultural adaptions are more effective than interventions that are not
culturally sensitive, but their effectiveness is probably impacted by patient
age and acculturation level (Griner & Smith, 2006). For instance, older
Hispanic participants are more likely to be receptive and in need of
culturally adapted interventions compared to younger Hispanic participants.
This may be due to older participants being less acculturated and thus
preferring clinicians who are matched based on language and culturally
sensitive to their clients’ worldviews.

Exploring Culture Using an Ideographic Approach

The third approach to cultural methods involves specific skills that can
explore culture with any client using an ideographic approach. Instead of
choosing methods based on group membership (nomothetic), these skills
focus on exploring the individual experience of culture and its personal
meaning (Ridley, 2005). These skills can be divided into clusters: becoming
aware of your own worldview, creating a culturally sensitive therapeutic
relationship, understanding the client’s worldview, facilitating cultural
identity development, responding to societal structures and values, and
utilizing complementary roles beyond psychotherapy (Altschul et al., 2004,
Harris, 2012). Each of these six clusters has been operationalized with
practical skills that can be learned, practiced, and implemented.

Becoming Aware of Your Own Worldview

These skills involve reflecting on one’s own cultural influences and how
they may impact diverse clients. Ideally, a foundational sense of awareness
begins before working with clients, but there is recognition that each new
client may require a different type of awareness. For example, therapists
can reflect on the societal messages about diversity variables that have been
internalized. The first time a therapist works with an elderly client, he or
she may become aware of biases about the value of youth. In work with
transgender clients, therapists can examine how their worldview defines sex
and gender.

Creating a Culturally Sensitive Therapeutic Relationship

It is essential to engage in discussions with clients about how the client’s
and therapist’s worldviews influence the relationship. The need to tailor the
relationship to the individual needs of clients has long been recognized
within the psychotherapy integration movement. Norcross and Wampold
(2011) recommended that psychotherapists responsively adapt the
therapeutic relationship to the client’s preferences, reactance level, stages of
change, religion/spirituality, race/ethnicity, functional impairment, and other
transdiagnostic factors that have been supported by the research evidence.

Understanding the Client’s Worldview

As we have emphasized throughout the chapter, a central theme in
culturally competent therapy is knowing a client’s history, worldview, and
personal experiences. Virtually all cultural experts suggest that it is not
clients’ responsibility to educate practitioners about the history of the
groups to which they belong. Understanding a client’s worldview may
involve education and consultation when a therapist encounters new
nuances of diversity. Although background knowledge is necessary, it is not
sufficient. Therapists must view clients as individuals and explore the
personal meaning of various identities (Hays, 2008).

Facilitating Cultural Identity Development

These skills encompass acknowledging differences in cultural worldviews,
processing encounters with oppression or difference, embracing culture,
cultivating pride, internalizing culture, and valuing others. An encounter
with racism and discrimination may leave clients feeling angry and
confused. Therapists can help clients process these strong emotions and
understand them using a cultural lens. Therapists may then encourage
clients to embrace social support from others in the community. Clients
may need help identifying ways to channel their strong emotions into
adaptive personal and social action.

Responding to Societal Structures and Values

These skills highlight ways that psychotherapy can help clients decide how
to respond to societal structures and values. This includes examining social
oppression, considering systems of privilege, facilitating movement toward
social action, and supporting informed choices. These skills help clients
look at the cultural messages they have been taught and to make a
conscious decision about which values to continue to embrace and which
messages to discard or modify. For example, in working with a married
Latina woman who has been taught that she should value her husband’s
career over her own, a therapist can encourage her to reflect on these
cultural messages. The goal will be to help this client make informed
choices about whether to pursue a more challenging career or to stay at
home and support her husband’s career.

Utilizing Complementary Roles Beyond Psychotherapy

Sharing personal information with a therapist is not a natural activity for
people from many cultural groups. As a result, therapists can embrace
different roles that do not heavily rely on immediate personal disclosure.
Skills that may complement traditional psychotherapy interventions include
integrating spiritual awareness, facilitating indigenous healing, and seeking
consultation with cultural experts. For example, if an unemployed client is
finding it hard to afford healthy food, it may prove more helpful to consult
about how to apply for food stamps than to explore thoughts and feelings
about being unemployed. Psychotherapy is not the only way that people
seek growth and stability; speaking to clients about other sources of wisdom
and healing will enhance treatment outcome for many clients.

Examining Interactions Between Culture and Other Dimensions of

Functioning
These skills examine the way culture interacts with other dimensions of
human functioning. Examining cultural interactions provides a method for
taking traditional therapies—cognitive, experiential, behavioral,
interpersonal, and systemic—and adjusting them to be more responsive to
clients’ cultures (Brooks-Harris et al., 2004; Harris, 2012). Practically
speaking, interventions from any theoretical orientation can by modified by
adopting a cultural lens. Within cognitive therapy, for example, therapists
can understand cognitions in their cultural context, identify culturally
sensitive alternative cognitions, explore cultural schemas, and facilitate
cultural and cognitive flexibility. Drawing from experiential therapy,
practitioners can attend to feelings within the cultural context, clarify self-
in-relation, and examine freedom and responsibility with cultural
sensitivity. Behavioral interventions can be modified to recognize the way a
different culture reinforces certain behaviors and the way clients can be
exposed to new experiences as a part of cultural adjustment.
Culture shapes the way relationships are expressed and experienced.
Modifying interpersonal interventions to be more culturally responsive
includes honoring resistance that may be culturally appropriate, exploring
cultural transference, and understanding past interpersonal conflicts within
the context of culture. As a final example, systemic interventions can be
modified by identifying culturally influenced family expectations,
illuminating cultural values transmitted through the family, and encouraging
systemic change that fits the cultural context.

CASE EXAMPLE

Joan is a 35-year-old, single, heterosexual, African American female. She

was a graduate student majoring in Theology and Religious Studies at a
Christian university when she sought psychotherapy. Joan identified as
being raised Christian-Baptist, noting that her religion was very important
to her. Her physician referred her to psychotherapy because she had been
feeling depressed and anxious about graduation.
Joan participated in a total of 26 sessions of individual therapy at the
university counseling center where she was attending graduate school.
Joan’s therapist was Natasha (second author of this chapter), a 30-year-old,
married, heterosexual, Asian American, female who was completing her
doctorate in counseling psychology and participating in practicum training
at the counseling center.
Joan indicated that her anxiety had been heightened as she neared
graduation. Joan believed that she had been experiencing an “identity
crisis” as she began to question her spirituality and her future career plans.
At the time of intake, Joan met the criteria listed in the Diagnostic and
Statistical Manual of Mental Disorders (DSM-5) for an adjustment disorder
with mixed anxiety and depressed mood. No formal assessment was used to
assess the severity of her symptoms. When asked about her therapy goals,
Joan hoped to decrease her anxiety related to graduation as well as
understand her spirituality more clearly.
A multicultural assessment determined that religion was Joan’s most
salient cultural identity. Over time, Natasha also explored how Joan’s ethnic
and racial identity and her gender interacted with her religion to impact her
depression and anxiety. Natasha developed a warm and collaborative
relationship with her client, and Joan expressed appreciation for having a
safe and nonjudgmental setting in which to discuss these sensitive matters.
Joan described how she had been taught by her family to value and honor
God by attending church on a weekly basis. She had recently started
attending church less frequently as she did not feel connected to the people
there or the topics discussed. Each Sunday, Joan would make up an excuse
for why she did not attend church, isolating herself from her community.
She expressed to the therapist that she felt ashamed for not desiring to
attend church as it no longer provided her the desired support or
encouragement. Natasha reflected on the cultural messages Joan received
from her family as well as within her church community since a young age.
Joan believed that she was no longer a “good Christian” and that she would
be “damned to hell,” messages she received from her family of origin about
people who did not attend church.
Natasha gradually formulated a cultural conceptualization to understand
Joan, one that involved integrating spiritual awareness into the sessions and
assessing how Joan’s identity had been impacted by family and social
expectations. Joan reported that her graduate courses were impacting her
thoughts and feelings regarding her religion and spirituality. The cultural
messages and values that she received from her family members were being
challenged within the classroom by her peers and professors, which created
recurring thoughts of “I don’t know what to believe in anymore” and “I
must be a bad person.” These critical self-judgments resulted in feelings of
loneliness, confusion, and anxiety. These thoughts and feelings resulted in
avoidance and social isolation.
Natasha utilized cognitive methods to explore and challenge Joan’s core
belief that she was a bad person through thought diaries and examining
evidence. Specifically, Natasha challenged Joan’s conclusion that not going
to church or interpreting the Bible differently than her family made her a
bad person. Using an experiential intervention, Natasha facilitated a two-
chair dialogue between these two cultural parts of Joan. One part of Joan
believed that “I’m a bad person,” and the other part believed that “Having
different views from others does not make me bad.” By examining her
cultural values using both cognitive and experiential methods, Joan
experienced less distress related to changes in her cultural identity as a
Christian.
Since Natasha did not identify as a Christian, she consulted with religious
leaders within the community to better understand Joan’s religious beliefs.
This consultation helped Natasha integrate spiritual awareness into
treatment by fostering knowledge and awareness regarding a specific
religious context. As a result of this consultation, Natasha inquired further
into Bible verses that Joan found emotionally confusing as well as the
cultural meaning of sin for Joan.
 As an African American woman raised in a conservative Christian
household, Joan had always perceived church as an integral part of her
community and a source of social support. However, Joan now found
herself withdrawing from church activities as she began to disagree with
other churchgoer’s views on Christianity. She believed she no longer fit in
with the community that had felt like a safe haven for so long. Natasha and
Joan discussed the role church played within Joan’s family and within the
African American community.
Natasha encouraged Joan to find a social context in which she would feel
comfortable sharing her thoughts about religion with others. Joan began to
seek support from classmates who had experienced similar cultural
messages. Joan’s classmates introduced her to other places of worship more
consistent with her new beliefs. This social support facilitated changes in
Joan’s identity development and increased her connectedness in the
community. Joan began to recognize that she could reach out to individuals
at her school for support and assistance instead of depending solely on
members of her home church. These new sources of social support
facilitated Joan’s cultural and religious awareness and validated her new
beliefs.
As Joan learned more about her religious identity, she felt more confident
about letting her family know that she was not attending church weekly.
Joan discovered a congruent outlet for her religious identity and had fewer
negative thoughts about her self being a “bad person” or being “sinful” for
not being a devout Christian. Joan experienced reduced symptoms of
anxiety and distress. At termination, Joan no longer met the DSM-5 criteria
for an adjustment disorder. During the termination process, Joan wrote a
letter to Natasha thanking her and letting her know that she felt proud of
both her racial and religious identities. After completing treatment, Joan
sustained the social connections she made with her classmates and peers at
the university.
In summary, Natasha seamlessly employed several of the cultural
approaches highlighted earlier in this chapter: using cultural adaptations of
evidence-based treatments (cognitive therapy, emotion-focused therapy),
exploring culture using an ideographic approach, and examining
interactions between Joan’s race/ethnicity and religious orientation. In
addition, Natasha pursued several general multicultural skills, such as
pursuing consultation with experienced practitioners, increasing her
knowledge of religious sources, and cultivating social support for the client
from those of similar cultural identity. Because changes in Joan’s cultural
identity were so closely related to her anxiety and depression, it was
essential to make culture a central part of her treatment.

OUTCOME RESEARCH
Of the four cultural psychotherapy methods reviewed in this chapter, only
the two nomothetic approaches have been subjected to systematic outcome
research. The effectiveness of cultural group-specific psychotherapies has
been examined in a handful of studies (e.g., Trimble, 2012), but cultural
adaptations have been extensively studied. This section thus focuses on the
effectiveness of those adaptations of evidence-based psychotherapies. Meta-
analytic research has been used to investigate the effectiveness of
multicultural competence and cultural adaptations. Soto and colleagues (in
press) conducted a meta-analysis of 27 studies that examined multicultural
competence as a therapist factor. Results indicated that therapists’
multicultural competence improved clients’ participation in treatment and
client outcomes. That is, cultural competence improves patient success in a
modest way. Their meta-analysis also revealed that clients’ ratings of
therapists’ cultural competence had a significant impact on treatment, but
therapists’ self-reported cultural competence did not have a significant
effect. Therapists’ estimates of their own cultural competence are probably
unreliable, whereas clients’ ratings predict clients’ positive outcomes in
psychotherapy (Soto et al., in press).
Several meta-analyses have examined the effectiveness of cultural
adaptations in psychotherapy. The most recent (Soto et al., in press)
analyzed 99 studies that tested cultural adaptations and found an overall
effect size of d = 0.50, a medium strong effect. That is, cultural adaptations
work better than nonadapted treatment for clients of color. Adaptations that
focused on the client’s preferred language had the greatest impact on
treatment outcome.

FUTURE DIRECTIONS
As our world becomes more culturally diverse, the field of psychotherapy
will continue to increase its understanding of the many ways that
sociocultural contexts and intersecting identities impact psychological
functioning (American Psychological Association, 2017). We will continue
to explore the impact of experiences of privilege and marginalization on the
therapeutic relationship and other aspects of treatment (Ratts et al., 2015).
Psychotherapy theories will increasingly recognize the importance of
cultural variables, and integrative theories will articulate the role of culture
and identity.
In practice, therapists will increase their ability to work with clients who
differ from themselves on a wide variety of demographic variables and
learn to address these differences openly. Therapists will continue to find
new ways to translate multicultural values into practical interventions,
especially with evidence-based cultural adaptations.
Although research has tested the effectiveness of cultural adaptations and
cultural competence, more research is needed. In addition to outcome
research comparing different treatments, process research will look at subtle
nuances within therapy sessions. Research will be used to explore the ways
that intersecting identities impact psychotherapy and how therapists can
avoid microaggressions and repair therapeutic ruptures. Psychotherapy will
increasingly view culture as an essential part of understanding each unique
client. As a result of these advances in theory, practice, and research, culture
will be integrated into all psychotherapy.

ACKNOWLEDGMENTS
The authors thank Deborah Altschul, Larisa Buhin, Winter Hamada, Andrea
Nacapoy, and Shelley Savage for developing the descriptions of skills to
explore culture in this chapter, as well as Cristina Castagnini, George
Hanawahine, Dorje Jennette, Jill Oliveira, and Kimberly Wagner for
developing the descriptions of skills to examine interactions between
culture and other dimensions of functioning.

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 16

Integrative Psychotherapy with Children

ATHENA A. DREWES AND JOHN W. SEYMOUR

Childhood psychopathology continues at a high and constant rate. Between

17% and 22% of youth (under the age of 18) have experienced a
diagnosable emotional, behavioral, or developmental problem (Kazdin &
Johnson, 1994). This translates to more than 14 million youth in the United
States suffering significant impairments (Prout & Fedewa, 2015). Children
are a critically underserved population despite ample recognition of the
growing rates of at-risk, suicidal, and antisocial behaviors, and substance
abuse (Prout & Fedewa, 2015).
To complicate matters further, treatment dropout rates for children and
youth have been found to be as high as 40–60% (Prout & Fedewa, 2015),
and there are conflicting viewpoints on whether child psychotherapy is
effective (Weisz et al., 2017). For example, a large meta-analysis covering
447 studies (30,431 youths) and synthesizing 50 years of research findings
found that youth in the treatment condition fare better than those in the
control condition (63% posttreatment probability, ES = 0.46). The strongest
treatment effect was for anxiety (0.61), weakest for depression (0.29), and
nonsignificant for multiproblem treatments (0.15). The findings
underscored the benefits of psychological treatments, as well as the need for
improved therapies and more representative, informative research (Weisz et
al., 2017). Although psychotherapy studies of children and youth show
efficacy when compared with no treatment (Lebow, 2008), effectiveness
drops when conducted in real-world settings.
Complicating child psychotherapy is the issue of development, which is
shifting and changing, making stable measurements difficult (Lebow,
2008). The child therapist must be familiar with human development
because much of what is viewed as problematic in children, with the
exception of severe psychopathology or extreme behaviors, might be
normal developmental deviation. In addition, many of the symptomatic
manifestations in normal children and in child development, such as temper
tantrums, enuresis, specific fears and anxieties and sleep disturbance tend to
disappear as a function of development and maturation.
Another factor that contributes to the differences between child and adult
therapy is that the child’s personality is less likely to be set than the adult’s.
The child’s defenses are not as well established, are more pliable, and
respond better to therapeutic intervention once a therapeutic relationship
and cooperation is established. On the other hand, because of the rapid
changes, child clients may be labile, with a wider range of normal
emotional and behavioral responses and inconsistency in responding to
therapy.
Compounding the difficulty of treatment with children still further is a
different motivation than adults have. While adults have some awareness
that a personal problem exists, children may not recognize or agree that
there is a problem, nor voluntarily initiate therapy. Other adults will make
this determination for treatment, resulting in varying degrees of acceptance,
compliance, and resistance from the child. In addition, the child usually has
little understanding of the therapeutic process and treatment objectives and
may even have a distorted view of and misinformation regarding therapy.
Another major difference between child and adult therapy is that the
child has limited verbal and linguistic development, which in turn relates to
limitations in cognition and abstract thinking. Children may not think in
abstract terms, may lack skills to articulate their thoughts and emotions, and
may not have a sufficient receptive vocabulary to fully understand what is
being asked in an interview or session. Thus, talk therapy with children
often fails unless play or play-based interventions are used as a medium of
treatment (Drewes, 2009).
These and additional complexities in child psychotherapy virtually
require integrative psychotherapies. Child clinicians trained in one
theoretical orientation or a single treatment quickly find that one size cannot
fit all of the presenting problems and complex circumstances. Since
children are not simply little adults, their treatment cannot be scaled-down
adult treatment. Developmental stages, systemic environments, referral
reasons, and a multitude of additional factors require a flexible, integrative
approach to therapy. In addition, an integrative approach with youth will
frequently involve other systems in the child’s life, such as parents, family
members, and school personnel, and require blending individual, parent,
family, and community formats as well.

THE INTEGRATIVE APPROACH

Foundational Concepts
“Psychotherapy integration is central to child treatment, although at times it
is not clearly identified or developed both in the research literature and
practice” (Krueger & Glass, 2013, p. 331). The more interventions and
systems that can be combined, the more modalities involved in the
treatment, the more likely the overall therapeutic goals are realized (Prout
& Fedewa, 2015). The treatment focus necessitates looking at “which set of
procedures is effective when applied to what kinds of patients with which
set of problems and practiced by which sort of therapists” (Barrett, Hampe,
& Miller, 1978, p. 428). Because child psychotherapy demonstrates high
levels of symptom severity and comorbidity, along with parent and family
stressors, a multidimensional approach is necessary (Kazdin, 1996, Kelley,
Bickman, & Norwood, 2010).
In addition, an integrative approach to child psychotherapy facilitates
broadening the therapist’s theoretical conceptualization of the child’s
presenting problems and helps to implement a variety of interventions
(Krueger & Glass, 2013). In contrast to linear models of psychopathology
(Gold, 1992; Pine, 1985), integrative theories of psychopathology
conceptualize it from the viewpoint of multicausation. Equal weight is
given to various aspects of personal functioning, such as motives, affects,
thoughts, images, and behaviors. These are examined through “psychic
structures, developmental needs, biological and maturational processes,
intrapsychic motives and conflicts, cognitive and perceptual processes and
contents, emotions, and overt actions” (Gold, 1992, p. 56). Each of these
components are “influencing, modifying, reinforcing, inhibiting, and
perhaps even creating each other” (Gold, 1992, p. 56), and they are seen in
a blended and unified whole. Such blending implies a circularity as well as
the containment of multiple relationships that are seen between the
cognitive, dynamic, interpersonal, and behavioral aspects of the person
(Coonerty, 1993).
 Because cognitive styles are in the process of formation in children,
interventions must be tailored to match them, as well as determining what is
developmentally appropriate for the client and for their extended systems of
family and school. An integrative approach allows for the addressing of
interpersonal challenges as well as external realities of the child client
(Krueger & Glass, 2013).
Rather than jumping from one treatment to another, the child therapist
develops a prescriptive, integrative approach that broadens the therapist’s
concept. Of course, the selection of treatments should not be ruled by a
therapist’s preferences or the staying within a comfort zone, but rather
through research evidence and clinical expertise (Schaefer, 2003). The
prospect of change in one sphere of functioning frequently leads to broad
reverberations and changes throughout multiple aspects of the client’s
maladaptive functioning (Coonerty, 1993).
In addition, the child’s family and macroenvironment (e.g., poverty, poor
housing, disintegrated family structure, alienation, and disenfranchisement)
add influential components to the child’s cognitive, dynamic, and
behavioral responses (Gold, 1992). This multiple causation model helps
move the clinician from narrow theoretical constraints to address the many
factors that may be causing or maintaining pathology and inhibiting a
young person’s ability to learn and function in a healthy manner.
Integrative treatments are not new to child therapy. Surveys indicate that
child clinicians utilize techniques and procedures from a variety of
theoretical sources in clinical work with children (Koocher & Pedulla,
1977; Shirk, 1999; Tuma & Pratt, 1982). More than half of surveyed child
and play therapists blend techniques (Fonagy et al., 2002; Phillips &
Landreth, 1998).
The extensive research conducted on child sexual abuse and trauma also
push for an integrative approach. For example, a three-prong integrated
trauma treatment (Stein & Kendall, 2004) addressed problematic behaviors
and skill development through cognitive-behavior therapy (CBT)
interventions; integrated traumatic memories, emotions, and buried parts of
the self through psychodynamic interventions; and attended to the actions
and reactions in the family system that maintain dysfunctional family
interactions. In addition, because trauma memories are imbedded in the
right hemisphere of the brain (Gil, 2006; van der Kolk, 2005), the
integrative use of nonverbal treatments and strategies utilizing symbolic
language, pretend play, and creativity will help access and activate this
portion of the child’s brain. Thus, the use expressive arts, play, and
pleasurable activities within therapy has been found to be helpful in
allowing traumatized and abused children to create their trauma narratives
(e.g., Drewes & Cavett, 2012; Gil, 2006; van der Kolk, 2005).

Defining Integrative Child Therapies

In both the child and adult literatures, psychotherapy integration typically
refers to the synthesis of diverse schools and methods of psychotherapy. As
well, integration refers to combining two or more therapy
modalities/formats, such as family, group, and individual therapy (Feldman,
1988; Reeves & Bruno, 2009). Involving the child’s parent into the
treatment process, even if only for psychoeducation, is also considered
integrative (Krueger & Glass, 2013). Still others refer to traditional talk
therapy plus play therapy as integrative. Finally, but not exhaustively,
working across systems of care (such as a school setting along with the
home environment) is sometimes called integrative (Cook, 2007). In this
chapter, we embrace all four types of integration in child work.

Exemplars of Integrative Child Therapies

Child therapy calls for the therapist to wear many hats and be skillful in
changing from one therapeutic stance to another in order to meet the needs
of the child and of others in the child’s life (Coonerty, 1993; Drewes,
2011a). At one moment, the therapist may find herself intensely involved in
a deeply evocative and often intense therapeutic relationship with the child
client in which the therapist deals with the child’s internal struggles, sets
limits, and acts as an educator or mediator with the child. Then, in the next
moment, the therapist needs to engage with a parent or school psychologist
or classroom teacher. These often conflicting and rapidly changing roles
lead many child therapists to adopt an eclectic prescriptive style in which
therapeutic interventions are chosen and then changed according to the
most pressing external demand (Coonerty, 1993; Drewes, 2011b).
Initially, child treatment consisted of taking adult models and extending
them downward to children (Krueger & Glass, 2013). In particular,
cognitive and behavioral approaches were utilized to address behavioral
management problems through use of behavior modification techniques,
along with addressing parent–child relationship issues. Examples include
modifications of the adult psychodynamic together with behavior therapy to
treat child behavior problems, using behavior modification techniques along
with parent–child relational dynamics (Feather & Rhoads, 1972; West &
Carlin, 1980), and the development of a psychodynamic understanding of
the meaning of the child’s behavior (Krueger & Glass, 2013).
One of the first integrative attempts was developmentally based
psychotherapy (Greenspan, 1997), which merged an understanding of
developmental abilities with self-regulatory abilities into a primarily
psychodynamic approach. Likewise, assimilative psychodynamic
psychotherapy maintains a strong psychodynamic base while integrating
cognitive-behavioral and family systems orientations in treating adolescents
(Grehan & Freeman, 2009; Krueger & Glass, 2013; Stricker & Gold, 1996).
There are several avenues toward developing an integrative treatment
with children. In what follows, we consider several exemplary integrative
child therapies according to the four routes: technical eclecticism,
theoretical integration, assimilative integration, and common factors
(Norcross & Alexander, Chapter 1, this volume).
Technical eclecticism is prescriptive in that it selects the best treatment
for the client and the problem. It has been described as more practical than
theoretical (Norcross, 2005), with the emphasis on predicting for whom
particular interventions work well, rather than why they work well.
Exemplars here applied to children include multimodal therapy (Lazarus,
2006) and systematic treatment selection (Beutler, Consoli & Lane, 2005;
Consoli & Buetler, Chapter 7, this volume).
Technical eclecticism, utilizing prescriptive play therapy for child
treatment, is seen in the case study of an 11-year-old autistic girl with
behavioral difficulties (Kenny & Winick, 2000). Using a sequential
approach, treatment methods were chosen that built on one another over
time, rather than blending them together within one session. In this case
study, the rapport-building component of nondirective play therapy was
used with directive techniques in targeting maladaptive behavior and
providing parent education. The rationale for using a flexible integrative
approach was due to the multidimensional aspects of the child’s behaviors
along with her developmental delays. Different treatment approaches were
combined into a coherent intervention sequence (Shirk, 1999).
 Treatment for trauma has several effective integrative approaches for
children. Trauma-focused integrative play therapy (Gil, 2009) is a
promising manualized, technically eclectic treatment for children who have
experienced complex trauma (Krueger & Glass, 2013). Evidence-based
trauma-focused cognitive behavior therapy (Cavett & Drewes, 2012;
Cohen, Mannarino, & Deblinger, 2006, 2012; Drewes & Cavett, 2012) is
integrated with expressive techniques, directive and nondirective play, and
mindfulness interventions.
Theoretical integration takes the best elements of two or more
approaches to therapy and blends them with the expectation that the result
will be more than the sum of the separate therapies. The emphasis is on
integrating the underlying theories along with an integration of therapy
techniques. Exemplars are Ellen Wachtel’s (2014) psychoanalytic-
behavioral-relational integration and the transtheoretical model, which
matches principles or processes of change to the child’s stage of change
(DiClemente & Prochaska, Chapter 8, this volume). The latter has been
subject to hundreds of outcome studies, including with children and their
families.
One of the earliest theoretically integrative treatments for children was
cognitive behavioral play therapy (Knell, 1993). It blends cognitive and
behavioral interventions into play therapy, with the child’s development
informing treatment (Drewes, 2009; Knell, 1993). Problematic behaviors
are seen as stemming from maladaptive thoughts which impact the child’s
feelings and subsequently behaviors. These maladaptive thoughts can be
modified by using play-based tasks and applications in therapy while
incorporating evidence-supported techniques from cognitive and behavioral
orientations (Krueger & Glass, 2013).
An example of theoretical integration is ecosystemic play therapy,
developed by O’Connor (2001). The clinician considers the child, his or her
problems, and the therapy process within the framework of the child’s
ecosystem. It incorporates key elements of the analytic, child-centered, and
cognitive-behavioral models of play therapy, as well as elements of
Theraplay (Jernberg, 1979; Jernberg & Booth, 1999).
Another exemplar of theory integration is flexibly sequential play therapy
for traumatized children (Goodyear-Brown, 2010). A variety of treatment
techniques give the child the space in which to disclose and adjust to the
sharing of the trauma content (continuum of disclosure), as well as to
restore the child’s lost sense of empowerment that occurs due to abuse
(experiential mastery plan). The therapist flexibly integrates directive and
nondirective approaches. Because of all the various teaching components,
knowledge of cognitive behavioral therapy, somatic therapies and
mindfulness, and family systems and attachment theories are required. The
therapist is not required to be expert in every model, but a working
knowledge of how to conduct dyadic interventions and psychoeducational
components in working with the parent is needed.
Both parent–child interaction therapy (Eyberg, 1988; Krueger & Glass,
2013) and child parent relationship therapy (Bratton et al., 2006) are
evidence-based, parent training programs that exemplify theoretical
integration for young children presenting with behavioral, emotional, and
family problems. Children’s problem behaviors are addressed by modifying
contributing negative parent–child interaction patterns (Bell & Eyberg,
2002). Nondirective play and behavioral contingencies are central to
treatment, and concepts such as attachment and social learning theories
inform the treatment approach (Krueger & Glass, 2013).
Assimilative integration has also taken root in child therapy, whereby
psychotherapists work primarily from their favorite theoretical orientation
and then selectively incorporate methods from other models. Therapists
maintain a home theory and incorporate techniques from other theoretical
orientations, often reinterpreting the meaning of the technique through the
lens of the home theory. This integrative path is frequently favored by those
child clinicians trained in a single approach. Rather than discard their
theoretical foundation as they discover its limitations, clinicians gradually
incorporate parts and methods from other approaches and mold these into a
new form.
Assimilative integration is common within child treatment but can be
difficult to identify when the integration is not explicitly acknowledged.
Many unacknowledged integrations occur in treatments that have strong
evidence base that identifies them solely as CBT but that employ play
techniques (Krueger & Glass, 2013).
Coming largely from a systemic orientation, Ellen Wachtel (2004)
integrates family systems, behavioral, and psychodynamic approaches for
the treatment of children and their families. She conceptualizes the child’s
difficulties as embedded in and reinforced by family interactions, although
the treatment focuses mainly on the child as the identified patient rather
than the family system. Similarly, an adolescent case study illustrated this
integrative model to guide child work by adapting it to the client’s
developmental age (Clement, 2011). The therapy draws from cognitive-
behavioral, person-centered, and positive psychology orientations.
A good example of assimilative integration is seen in a play therapy case
study within a school setting which blended three theories into a cohesive
treatment driven by the child’s and/or family’s needs (Fall, 2001). Child-
centered play therapy (the home theory) was buttressed with evidence-
based Adlerian play therapy and cognitive-behavioral methods along with
corresponding techniques (Fall, 2001), and this was shown to be effective.
Research has shown that play therapy interventions prove useful in meeting
the treatment needs of children and families (Landreth et al., 1996).
Common factors is an approach to integration that identifies clinical
principles or change processes shared by several psychotherapies in the
hope that these robust commonalities will form the foundation of successful
treatment. In a review of more than 50 publications, it was found that 41%
of the proposed commonalities had to do with change processes, while only
6% were attributed to client characteristics. The strongest consensus across
therapies was the development of a therapeutic alliance, opportunity for
catharsis, acquisition and practice of new behaviors, and the client’s
positive expectancies (Grencavage & Norcross, 1990). Practice Wise is a
web-based program that helps identify common factors across evidence-
based child treatments and then matches them to the clients’ needs
(Chorpita, Becker, & Daleiden, 2007; Chorpita et al., 2011).
The attachment-focused developmental psychotherapy of Hughes (1997)
encourages the use of an integrative model that utilizes play therapy within
family work with adoptive children. The commonalities across each of
these treatments are the use of play therapy principles, which are utilized
within sessions and at home with the parent and child, along with
psychoeducational principles of parenting.
Of course, these four pathways to integrative treatment are not mutually
exclusive. Consider the work of Goldenthal (2005) who created a model
that integrated psychodynamic, behavioral, and contextual theories. At first
blush it appears a classic example of theoretical integration; however, the
psychotherapy was prescriptive in recommending the right intervention to
the right child in the tradition of technical eclecticism. Furthermore, the
treatment focuses on the therapeutic relationship—the quintessential
common factor—as the central change agent (Krueger & Glass, 2013).
All told, the multiple routes to integration in child psychotherapy offer
clinicians several ways through which they can conceptualize patient
concerns, address both interpersonal issues and environmental factors, and
select from a rich array of efficacious clinical methods. Consequently, the
clinician can select interventions and use them in a coordinated and
efficient manner (Krueger & Glass, 2013).

ASSESSMENT AND FORMULATION

The basic task of assessment in child integrative psychotherapy is similar to
any other model of working with children: a comprehensive assessment
through multiple sources and methods that collects data on the child’s
development (including in utero and birth history), presenting problems and
circumstances underlying them, strengths and weaknesses of the child and
family as a whole, spiritual and community resources, cultural components,
and the family system (Coonerty, 1993; Drewes & Schaefer, 2015). A
crucial component in integrative assessment is that the child therapist
involves both the parents/caregiver and the child as active collaborators in
treatment and treatment planning. The child therapist needs to be attuned to
important connections and systemic interplay, working like a skilled
detective to piece together a coherent picture that is multilayered and
multiconnected. Indeed, each puzzle piece represents only a single
dimension (Coonerty, 1993). Thus, careful assessment, be it conducted
through formal measures or informal observations, is critical to make the
optimal selection of interventions and to coordinate communication among
those providing services.
Treatment planning is based on developmental awareness of the child in
order to provide direction throughout all stages of therapy, monitor
progress, and know when termination can occur. Having a developmental
framework prevents establishing unreachable goals and permits the
selection of appropriate content and the level of therapeutic interaction that
is best suited to the child. Furthermore, as suggested earlier, the child
therapist also needs to be sensitive to developmental delays in children,
particularly in cognition and language, that impact treatment planning and
differentiate them from behavioral or emotional disorders. Psychological
testing is not necessarily a prerequisite for treatment but frequently proves
useful and, of course, is demonstrably more reliable and valid than informal
assessment.
Verbal treatment is ineffective with young children because of their
limited abstract thinking and development; consequently, use of non-verbal
play therapy is critical for effective treatment (Coonerty, 1993). Verbal
treatment is ineffective in early childhood (4–7) because there is a primitive
level of development, egocentric thinking, a present-time orientation, along
with the child struggling to develop a constant sense of self and other. The
child uses internal fantasy without a clear fantasy/reality boundary. In
middle childhood (8–13), while children may become more verbal, there is
a fascination with rules and complexities of the real world along with the
emergence of formal operations; abstract reasoning; and problem solving
that needs to be developed and utilized through play-based activities
(Drewes & Schaefer, 2015).
Assessment instruments and the integrative process with children must be
consistent with the purpose of the assessment, acknowledging the vital
contexts and attuning to cultures of the family system. Child therapists can
utilize numerous assessment approaches including standardized tests, rating
scales, interviews, observations, projective techniques, and informal
assessment in order to develop a complete picture from multiple angles and
informants,
There are numerous formal norm-referenced, standardized psychological
assessment tools for use with children. Popular normative assessments
include the Behavior Assessment System for Children, Third Edition, which
offers a structured developmental history for ages 2–21 (Kamphaus et al.,
2014), Connors Comprehensive Rating Scales for ages 6–18 (Kollins,
Epstein, & Connors, 2014), the Achenbach System of Empirically Based
Assessment for ages 6–18 (Achenbach & Resorla, 2014); Child and
Adolescent Needs and Strengths (CANS, 1999), and the Devereaux
Behavior Rating Scale for ages 5–18 (Naglieri & Pfeiffer, 2014). These
assessments can be done during an intake with the parent/caregiver.
Observations within the initial sessions with the child can obtain data and
frequency counts, as well as provide information for informal hypotheses
generation and in vivo identification of strengths and weaknesses. Play-
based assessments allow the child therapist to look at the quality of the
child’s play and to identify consistent or clinically significant themes. The
child’s perceptions of her parents/family, events, and
environmental/systemic settings (including school) are examined. In
addition, the quality of the expression of affect, ability to regulate affective
range, and intensity and level of enjoyment, as well as the ability to soothe,
sustain, focus, shift and inhibit attention, and levels of impulsivity and
frustration are observed. The child’s maintenance of physical boundaries, as
well as the richness or paucity of play content, level of dependent versus
independent interactions, and whether the age level and developmental
level are congruent with the play and child’s physical abilities are all
assessed. Informal assessment tools include projective drawings, puppet
interviews, and sentence completions.
The formulation begins with the comprehensive assessment of the
symptoms and determinants (internal and external) of the child’s presenting
problems. An individualized case formulation describes and explains the
child client’s most important disorders and probable causal or contributor
variables, along with treatment plans and predicted obstacles as a means for
evaluating progress.
The child therapist then looks to prescribe interventions to alleviate the
client’s problems, thereby formulating defined treatment goals and detailed
“nuts-and-bolts” strategies for achieving these goals. Because the
integrative child therapist is not confined by single-school theories, the
combination of theories and techniques can strengthen a treatment plan.
Individual, group, and family strategies may be integrated, as well as
multiple systems of care. A multicomponent, multimodal intervention can
thereby address the complex and multidimensional psychological disorders
experienced by children.

PROCESSES OF CHANGE
Shirk and Russell (1996) proposed 11 change processes as the basis for an
integrative model of child therapy. They fall under three broad processes.
 Cognitive: Schema transformation, symbolic exchange, insight, and
skill development
Affective: Abreaction, emotional experiencing, affective education, and
emotional regulation
Interpersonal: Support, corrective relationship, and supportive
scaffolding (O’Connor, 2001)

Kazdin and Knock (2003) studied the mechanisms underlying therapeutic

change related to symptom improvement in child therapy. They proposed
that evidence-based practices can be improved with regard to clinical
applicability in real-world settings by studying the discrete mechanisms of
therapeutic change. Understanding how change processes work within best
practices is the critical link in moving evidence-based practices from
research to the service settings of usual care.
As noted earlier, play has a long history in child psychotherapy as it is
the natural language and mode of expression for children (Drewes, 2005).
Four broad functions of play in child work (Russ & Niec, 2011) are
providing a means of expression, communication, and relationship building;
insight and working through; practicing new forms of expression and
relating; and problem-solving. Depending on which methods are utilized in
the integrative approach, the change mechanisms probably differ. Aside
from those noted earlier, any number of the following factors may
constitute change processes.

Cognitive processes: Direct/indirect teaching, schema transformation,

symbolic exchange, interpretation-insight, skill development,
competence and self-control, accelerated development, creative
problem solving, fantasy compensation, and reality testing
Emotional processes: Self-expression and emotional experiencing,
access to the unconscious, abreaction release and sublimation,
affective education, emotional regulation, stress inoculation,
counterconditioning of negative affect
Interpersonal processes: Validation and support, supportive
scaffolding, corrective relationship and attachment and relationship
enhancement, power/control, moral judgment and empathy
(Schaefer & Drewes, 2013)
 Differential therapeutics recognizes that some interventions are more
effective than others for certain disorders and particular clients. A client
who does poorly with one type of child therapy may do well with another.
The greater our understanding of the change mechanisms, the more
effective the child therapist can be in applying them to meet the particular
needs of his or her clients (Schaefer, 1999).

THERAPY RELATIONSHIP
The therapeutic relationship remains integral to the effectiveness of child
work. Indeed, the most robust research (and clinical) finding in the child
psychotherapy literature is the strong association between the therapeutic
alliance and treatment outcome. A recent meta-analysis of 42 studies of
child and adolescent therapy (3,427 clients and parents) revealed an effect
size of (d) of 0.39 for the both therapist–child and therapist–
parent/caregiver relationship (Karver et al., 2005). The association and
prediction of treatment success did not differ by the type of treatment; that
is, the alliance “works” in all forms of child therapy.
That relationship can be enhanced by soliciting feedback from the
child/family client and by routinely monitoring outcome. This process is the
core ingredient to patient progress regardless of the therapeutic approach
taken (Duncan, 2013), as is therapist empathy, collaboration, positive
regard, and genuineness (Norcross, 2005).
Children are clearly aware that they have been brought to therapy by
others who can also force them to attend sessions. The usual adult approach
of asking questions, probing into personal feelings, or explaining behaviors
usually results in uncooperativeness or strong emotional responses. The
therapist needs to explain what the treatment process will be like, not only
verbally but also through the use of play-like techniques to communicate
the expectation that the relationship is playful, creative, and not always
based in verbalizations. Offering factual transparency about the treatment
process, collaborative creation of treatment planning, and a nonjudgmental
approach toward engagement will help the child to see how this therapeutic
relationship will differ from those with peers, teachers, parents, and others
(Prout & Fedewa, 2015).
As is most certainly the case in working with adults, creating a safe
therapeutic relationship is critical when working with children. The child
therapist’s behavior in the session, as well as his or her attitude toward the
client, are keenly perceived and reacted to by children. The relationship
needs to be fostered and built through transparency, honesty in sharing
information, nonintrusiveness, reliability, attunement, and curiosity about
the client’s internal experience, coupled with the use of play and humor
within sessions. Critical, especially with trauma work, is the sensitive
timing and depth of therapeutic interventions.
The therapist’s role will vary depending on the particular approach taken
and its application. Thus, the therapist may need to be directive and
structured when implementing a behavioral approach or nondirective when
creating rapport and a therapeutic relationship or utilizing a more child-
centered approach. That is precisely the value of psychotherapy integration.

METHODS AND TECHNIQUES

Integrative treatments offer systematized methods, with the majority
designed for specific child disorders. Treatment for trauma has by far been
the best developed, followed by treatments for behavioral disorders
(Krueger & Glass, 2013). The therapeutic menu of methods in integrative
therapies canvass the entire spectrum of interventions. In the evidence-
based tradition, we advocate that selection of particular methods be based
on all three evidentiary sources: best available research, clinical expertise,
and patient characteristics, preferences, and cultures. Research on the
efficacy of methods aids clinical decision-making but does not dictate it;
much depends on the skill of the therapist (Schaefer, 2003).
As we have indicated throughout this chapter, working with young
children includes play-based interventions that are developmentally
sensitive and geared to their abilities. Play as therapy (child-centered,
nondirective) and play in therapy (directive), includes expressive arts, use
of miniatures to create a scene or story in a sand tray, puppet play, drama
role play, music, art, therapeutic storytelling, dance, and movement
(Drewes, 2009).

DIVERSITY CONSIDERATIONS
Clearly, a child is a product of his or her nuclear family, extended family,
neighborhood, cultural and racial heritage, school, town/city,
socioeconomic status, and political situation. These systemic components
result in multiple causality and feedback loops that significantly impact
treatment choices when working with children. Poverty, poor housing,
alienation, disenfranchisement, and cultural and gender identities critically
influence the child’s cognitive, dynamic, and behavioral repertoire (Gold,
1992). Thus, child therapy attends deeply to diversity considerations and
seeks key opportunities to provide effective social intervention beyond just
changing a child’s internal chemistry or cognition (Lebow, 2008). The child
clinician needs to account for the individual differences within each client,
creating a case formulation and treatment plan unique to each child’s needs.
Play is a universal expression of children, and it can transcend
differences in ethnicity, language, and other aspects of diversity. It is
important for clinicians to be aware of cultural differences that may exist. A
study of play therapists found that they rated themselves as not being
knowledgeable about racial identity and feeling competent in using this
knowledge clinically (Drewes, 2005). This may also prove the case for
many other child therapists. All child clinicians need to be sensitive
regarding diversity in the assessments used and interventions chosen
(especially with regard to what population it was normed on), as well as
inclusive in the techniques and materials used in treatment. Having
culturally, racially, and ethnically diverse therapeutic toys and materials is
crucial (Drewes, 2005).

CASE EXAMPLE

The following case illustrates integrative child psychotherapy in that it

simultaneously blended several theoretical approaches, treatment formats,
and systems of care. Sammy is an 8-year-old Hispanic boy, in foster care,
who presented with behavioral difficulties in school due to mood
dysregulation, generalized anxiety, and depression. He struggled with his
father’s death 3 years before, along with his mother’s current wish to
surrender parental rights so he could be adopted due to the reemergence of
her cancer.
Assessment consisted of the caregiver’s completion of the Child
Behavior Checklist and Child and Adolescent Needs and Strengths (CANS)
and the child’s completion of projective drawings and an observation of
strengths and themes during play therapy sessions. Results of the CBCL
and CANS showed clinical indicators of externalizing and internalizing
behaviors (depression, aggression), with drawings and thematic play themes
reflecting concerns about death, feelings of anger, and lack of emotional
connection in his family environment. Over the first four sessions, I (AAD)
obtained a good sense of Sammy’s developmental level and emotional
conflicts, as well as built rapport and facilitated the creation of a therapeutic
relationship.
Our treatment goals were to help Sammy (1) to build rapport and a
therapeutic alliance, along with offering control in selection of materials
and tasks and a release from traumatic material; (2) to reduce his anxiety,
anger, depression, become aware of emotional triggers, and develop
alternative coping skills; and (3) to deal with unresolved grief and loss over
his father and the pending loss of his mother.
The treatment plan was to use child-led psychodynamic play therapy to
accomplish the first cluster of therapy goals, CBT methods for the second
cluster, and bereavement or trauma work for the third. Parent–child dyadic
therapy in the systemic tradition was also utilized to help Sammy and his
mother talk about the events of his father’s death and to better understand
his mother’s wishes to have him adopted. In addition, the therapist
maintained contact with Sammy’s school setting and foster home parents
for information regarding his progress and to coordinate follow-through on
treatment recommendations.
Sammy was seen in individual weekly therapy over the course of 2 years
for 75 sessions. The 45- to 55-minute sessions were structured and divided
into components which allowed for the integrative use of several treatment
approaches.
In the initial session, the therapist was transparent in sharing with Sammy
what was learned of his history and why he was being seen, as well as what
the therapy time would be like. Using a balloon to blow in all his anxious
and angry feelings, Sammy saw how the big balloon was like his head and
heart containing so many upset feelings that he felt like he would “pop.” By
letting out the air a little at a time, safely and slowly, and seeing how much
smaller the balloon was getting, Sammy better understood that this was like
the therapy time together, where he could let out his angry feelings in a
safe, slow, and manageable way with the therapist’s help.
Next, we assessed what he felt he needed to work on, and a treatment
plan was jointly created. Using strips of paper to write on, the therapist and
Sammy worked together on selecting three problems each about home,
school, and his family for a total of nine items we would take on in therapy.
One blank piece was left which would allow Sammy to spontaneously
address something not covered. Sammy wrote on each strip of paper the
goal selected and decorated an envelope in which the paper strips would be
kept. Each session when he entered, the envelope would be put out, and
Sammy would get to pick one of the pieces of paper for us to focus on. He
could put back the paper and select a different one only once before we had
to work on it. Then, after we talked about the issue or used a directive
technique, he would strip off a small piece of the paper and put it back. This
way he saw that we were making progress on the goal, but were still not yet
finished with it.
Prior to having Sammy enter the treatment room, the therapist would
meet for 5–10 minutes with the foster parent(s) regarding how Sammy was
doing in their home, at school, and on visits with his mother. We would also
discuss treatment strategies and interventions. Then, after the foster
parent(s) left, Sammy came into the session. The next 5 minutes were
“check in” time to talk about the week, share any information received from
his foster parents that needed to be conveyed, and follow-up on any CBT
homework assignments. The next 10–15 minutes allowed for work on
directive CBT-based techniques to address treatment goals. The next 20–25
minutes were child-led, which allowed Sammy to select what he wished to
play with and how and what emotional material he wished to convey. The
last 5–10 minutes were for clean-up and a closing ritual of bubble blowing
or deep breathing techniques for affect regulation and transitioning from the
session.
In this first session, Sammy used his child-led, nondirective time to
create in the sand tray, utilizing miniatures of all aspects of life (people,
houses, trees, vehicles, etc.) to create a scene showing me what his world
was like. During other sessions, Sammy often used toys, puppets, art
materials, and clay to express his feelings, often nonverbally. But he
frequently preferred to use the sand tray when there were deep conflicts
around his father’s death and worries about his mother that he did not want
to talk about, but rather wanted to show.
Over the course of treatment, Sammy delved more deeply into his
feelings and memories regarding his father and his death when he was 4½
years old. There were missing details to the narrative of his father’s death,
as well as information lacking as to what happens when someone dies and
even where his father was buried.
Once monthly, his mother joined Sammy for family therapy. His mother
discussed with him where his father was buried and details surrounding his
illness and death. The foster parents were willing to take Sammy to the
grave, where he had a closing ceremony and left a letter to his father (that
we worked on in therapy) telling him his feelings and that he missed him.
Sessions with Sammy’s mother allowed for discussion about why she
wanted him adopted, how she had only one relative available who was not a
viable resource, and that she wanted to know he was in a good home. This
was her second bout with cancer, and she was unsure that, even if she went
into remission again, she would ultimately not die from the disease in the
near future and leave her son an orphan with no place to go. His mother
also spontaneously shared the unknown fact that she had been in foster care
as a child and was adopted as well. This was a good experience for her, and
she wanted to place Sammy in a loving home. We worked out an “open”
adoption in which Sammy and his mother maintained contact around
holidays and birthdays with the consent of the adoptive parents.
Through the healing powers of play and integrative treatment, Sammy
learned and applied better coping strategies, accessed his previously
unexplored conflicts around his father’s death, experienced catharsis in
getting out his anger and rage over feeling abandoned, gained power and
control over his anxieties, and developed competence, self-control, and a
greater sense of himself. Through CBT techniques, he performed creative
problem-solving, behavioral rehearsal, and counterconditioning of negative
affect.
By the end of treatment, an adoptive family was found, and we worked
toward his successful adoption. Sammy still remains with his adoptive
family and has periodic contact with his biological mother. Just prior to
termination, the CBCL and CANS were completed by the foster parents.
Results showed Sammy’s behavioral functioning within the average or
normal range. Furthermore, his acting out behaviors in school significantly
diminished, going from daily aggressive and physical outbursts to minimal
verbal outbursts on a quarterly basis, and he reduced his sadness and
anxiety as seen in his frequent smiling, involvement in sports, and positive-
themed drawings.
OUTCOME RESEARCH
In spite of the growth of psychotherapy integration, there is little outcome
research on explicitly integrative child therapies (Schottenbauer, Glass, &
Arnkoff, 2005; Seymour, 2011), with few systematic reviews of integrative
treatment for children (Krueger & Glass, 2013). That’s the bad news. The
good news is that by using, in part or in whole, evidence-based child
therapies, integrative clinicians can harvest the fruits of that vast outcome
research. While there is moderate but clear support for the general
effectiveness of child therapies, there continues to be a need to take a
cautious and thoughtful approach to child treatment (Prout & Fedewa,
2015).
Child behavioral therapy and outcome research have begun to
incorporate a more integrative approach, with assimilative integration
becoming more commonplace within CBT (Krueger & Glass, 2013). In
general, a trend has emerged of CBT integrating aspects of other treatments,
while integrative treatments frequently utilize CBT methods.

FUTURE DIRECTIONS
Integration is clearly gaining hold in child psychotherapy, but much work
remains to be done. More outcome research is needed, especially research
identifying change mechanisms of successful child psychotherapy, as well
as the prescriptive matching of those change mechanisms to varying clinical
circumstances. Further research is needed to illuminate which specific uses
of play are most effective with specific presenting problems and within the
blending of treatment approaches. Based on our clinical observations and
those of our colleagues, we expect that future research looking into these
complex processes will wind up providing empirical support for integrative
treatments.
Clinically, many cognitive-behavioral treatments for young children
would benefit from the incorporation of other approaches, especially less
directive techniques. Treatment and research would also be better informed
if the play-based techniques included the anchoring theories behind their
application.
Perhaps the most severe obstacle to integration comes from territoriality
of the purists who hold their single theory to be the best. We advocate for
work toward common definitions and language in psychotherapy to
decrease the inconsistency of terminology. In that way, a commonly
understood experience can be implemented in practice and measured in
research (Seymour, 2011).
There still is inadequate training in integrative child therapy in university
and internship settings. Consequently, student clinicians are not fluid in
thinking about using several different approaches and do not feel well-
grounded in responding to the realistic clinical complexities of working
with children. Training in academic settings needs to furnish ample and
diverse experiences imparting technical and interpersonal skills that then
lead to establishing competence (Norcross & Halgin, 2005; Seymour,
2011).
In spite of these and other hurdles, in recent years, the clinical practice of
child integrative psychotherapy has grown considerably. It is important that
these clinical observations inform research process and outcome research to
further enhance the synergy between practice and research. Such
convergence between research and practice will not only allow the therapist
to borrow flexibly from multiple theoretical positions to tailor treatment to a
particular child, but also will result in cost-effective interventions.

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 17

Integrating Self-Help and Psychotherapy

AMANDA EDWARDS-STEWART AND JOHN C. NORCROSS

Psychotherapy is an incontestably effective pathway to personal growth and

behavior change (Wampold & Imel, 2015). However, it is not the only
effective way. Individuals change through many methods, but the principal
way is self-change or self-help. Approximately 75% of those modifying
mental and addictive disorders do so without professional help
(Klingemann et al., 2001; Swindle et al., 2000). Self-help is also the least
restrictive, intrusive, and costly option compared to psychotherapy.
The term psychotherapy integration typically refers to the synthesis of
diverse schools of psychotherapy and also the integration of research and
practice. This chapter expands that definition of integration to consider the
synthesis of psychotherapy itself with self-help materials. According to
research, practitioners already routinely use self-help materials in practice,
but they are frequently encumbered by a lack of knowledge to do so
systematically and effectively.
In this chapter, we review the prevalence of self-help with and without
psychotherapy and consider its surprisingly high effectiveness. We then
address in-depth, clinician-tested, and research-informed methods of
integrating self-help seamlessly into psychotherapy. The chapter concludes
with a few future directions and, in the end, a plea for increased integration
of these two premier paths to human improvement.

PREVALENCE OF SELF-HELP
Current statistics on the rates of untreated mental disorders are staggering.
Around 89% of American adults with mental and substance disorders will
not receive mental health treatment in a given year (Bijl et al., 2003).
Seventy percent will never receive mental health care (Kessler et al., 1997).
The percentage of those suffering from mental illness in developing
countries and receiving professional treatment is even lower and more
alarming (Kazdin & Rabbitt, 2013).
While most individuals suffering from psychopathology do not seek
professional treatment, many regularly use self-help. Self-help refers to
materials or events occurring outside of formal treatment or psychotherapy
that can be used toward education, support, monitoring, or the elimination
of mental health symptoms. Self-help resources are generally stand-alone
and include such categories as bibliotherapy (books), films, self-help
groups, websites, mobile applications, and computer programs.
Self-help, not psychotherapy, is the de facto mental health system. About
5–7% of American adults attended a self-help group in the past year
(Eisenberg et al., 1998; Kessler et al., 1997), with up to 18% having done so
in their lifetime (Kessler et al., 1999). Seventy-two percent of internet users,
and approximately half of smartphone owners looked up health-related
information in the past year. Searches generally explore specific diseases or
conditions followed by treatments (Pew Research Internet Project, 2014).
Nineteen percent of smartphone owners reported having at least one health
app (Pew Research Internet Project, 2012), while the app market is
saturated with tens of thousands of health- or medical-related applications
(Google Play Store, 2017). Furthermore, self-help books are published at a
rate of 5,000 per year (Bogart, 2011).
When self-help is guided by a mental health professional, it is typically
known as guided self-help or self-help with minimal therapist contact. In
either case, psychotherapists help clients help themselves (Bernecker,
2014). The self-help resources may prove a minor complement to the
ongoing course of weekly psychotherapy or many constitute the principal
intervention with infrequent or brief consultations with a clinician.
Recommending self-help resources to patients is something many mental
health clinicians do. Nearly 70% of Canadian mental health clinicians
suggest clients use self-help books (Adams & Pitre, 2000). More than 90%
of Norwegian clinical psychologists recommend self-help materials, and
approximately half (55%) receive requests for such materials from clients
(Nordgreen & Havik, 2011). This trend is also seen among US school
psychologists, where 36% employ self-help materials with 20–50% of their
clients (O’Conner & Kratochwill, 1999). When recommending and using
mobile technology with clients, 41% of military clinicians reported using
self-help apps in clinical care (Armstrong et al., 2017).
Table 17.1 displays the percentages of US psychologists recommending
self-help resources to clients in 2002 and 2011 (Norcross, Campbell et al.,
2013). In both 2002 and 2011, 85% recommended self-help books, and
recommendations for the use of autobiographies, films, Internet sites, and
online programs have increased. Only recommendations for self-help
support groups have decreased between the two time points. The increase in
the number of psychologists recommending Internet sites and online self-
help likely reflects the increased use and awareness of web-based resources
and the creation of such sites over time.
TABLE 17.1 Psychologists recommending self-help resources to their patients in the past 12 months
% Recommending
Year 2002 2011
Self-help/support group 82 79
Self-help book 85 85
Autobiography 24 28
Film 46 54
Internet site 34 78
Online program – 23
N = 1,229 in 2002; N = 1,306 in 2011

Despite the many clinicians who recommend such resources, the

percentage of clients being “prescribed” self-help tools is small (see Table
17.2). These small numbers are likely owing to multiple factors, including a
lack of training. Most clinicians receive only on-the-job training in the use
of self-help resources. Two studies (Adams & Pitre, 2000; Norcross et al.,
2000) found that clinicians with more years of experience were more likely
to use bibliotherapy with clients than were less experienced ones. This
difference suggests a deficiency in graduate training, few continuing
education opportunities on this topic, and growth in self-help knowledge
and skill over years of practice. In one article, when clinicians received
continuing education in the use of mobile self-help applications, 93.5% of
clinicians stated they intended to use apps with their clients following
training (Armstrong et al., 2017). Clinicians’ high reported intent-to-use
suggests that those training to use self-help tools might be more willing to
use them in practice.
TABLE 17.2 Patients “prescribed” self-help resources in the past 12 months
% “prescribed” self-help
Self-help/support group 15.9
Self-help book 27.6
Autobiography 3.6
Film 10.5
Internet site 22.8
Online program 3.8
N = 1,306 in 2011

In this chapter, we offer suggestions on the integration of such tools into

psychotherapy. Such recommendations are derived from both the research
literature and clinical experience. Literature and experience demonstrate
that clinician’s behavior can significantly enhance the effectiveness of self-
help, with or without professional treatment (Kelly, 2003). Caveats and
cautions are also offered against the wholesale incorporation of self-help
into psychotherapy.

EFFECTIVENESS OF SELF-HELP
Empirical research and meta-analyses have demonstrated the effectiveness
of self-help programs for mental health concerns. Meta-analyses
consistently show that client improvement using self-help exceeds wait-list
and no-treatment controls (e.g., Cuijpers et al., 2011; Den Boer, Wiersma,
& Van Den Bosch, 2004; Menchola, Arkowitz, & Burke, 2007; Mains &
Scogin, 2003; Reger & Gahm, 2009; Richards & Richardson, 2012).
Typical mean effect sizes (d) of self-help versus control conditions are .70
to .80 at post-treatment and .50 to .70 at follow-up (Den Boer et al., 2004).
It should be cautioned, however, that effect sizes for self-help versus
formal, therapist-assisted interventions in the same studies are not as high.
The effectiveness of self-help resources extends to bibliotherapy (i.e.,
self-help books). Meta-analyses for depression and anxiety show the
superiority of bibliotherapy to no treatment and that bibliotherapy is slightly
less effective than therapist-administered treatments (e.g., Den Boer et al.,
2004; Menchola et al., 2007). For example, a meta-analysis of 29 outcome
studies of cognitive bibliotherapy for depression reported an effect size of
.77 (Gregory et al., 2004). Another meta-analysis demonstrated a mean
effect size of .68 for 12 controlled studies of bibliotherapy for sexual
dysfunctions when compared to a no-treatment control group (van
Lankveld, 1998). In a Cochrane database systematic review of bibliotherapy
for smoking cessation, mixed evidence was found, but findings were
strongest among trials in which tailored materials (tailored for
characteristics of individual smokers or matched according to motivational
stage) were compared to no intervention or standard materials (Hartmann-
Boyce, Lancaster, & Stead, 2014). Last, a meta-analysis evaluating 22
studies of bibliotherapy for alcohol problems found modest support for
decreasing at-risk and harmful drinking (Apodaca & Miller, 2003). In
general, findings provide support for the cost-effective use of bibliotherapy
with many clients (Ritzert et al., 2016; Watkins & Clum, 2008).
Self-help groups show similar research support. Meta-analyses have
found that participation in Alcoholics Anonymous (AA) is related to
reductions in drinking (Kownacki & Shadish, 1999; Tonigan, Toscoova, &
Miller, 1995). Three controlled evaluations of 12-step programs for
addictive disorders found such groups as effective as professional treatment
(Morgenstern et al., 1997; Ouimette, Finney, & Moos, 1997; Project
MATCH Research Group, 1997). Other research shows that self-help
groups are generally beneficial (Kyrouz, Humphreys, & Loomis, 2002).
Also, self-help group attendees frequently evaluate groups as just as helpful
as psychotherapy (Seligman, 1995). Thus, clinicians can be sure that clients
will derive at least some benefit from participation.
Research on the effectiveness of online support groups is more recent
and, to date, not as methodologically rigorous as the preceding research.
One study evaluating the effectiveness of an online support group among
university students for depression did not find evidence of symptom
reduction from use. However, the authors did gather qualitative data that
might be useful for future research and technology development in this area
(Horgan, McCarthy, & Sweeney, 2013).
Meta-analyses evaluating the effectiveness of multiple forms of self-help
—namely, bibliotherapy, computer programs, web-based, and mobile
interventions—found small to moderate effect sizes when comparing the
self-help intervention to control conditions (Cuijpers et al., 2011; Cavanagh
et al., 2014). Reviews evaluating web-based and mobile interventions show
mixed but promising results. In one systematic review of web-based
interventions for smoking cessation, moderate evidence was found for
adults using web-based interventions compared to no treatment. Evidence
was insufficient to say if such interventions were more effective than face-
to-face counseling (Hutton et al., 2011). Several controlled trials found
equivalent positive outcomes for therapist-guided versus unguided use of
web-based interventions (e.g., Ivanova et al., 2016; Rozental et al., 2015).
Another randomized controlled trial evaluating a web-based problem-
solving intervention for depression found both the website and the self-help
book equally effective in reducing depression (Kenter et al., 2016).
Meta-analyses can only aggregate the results of existing studies.
Unfortunately, the vast majority of self-help materials have not been
empirically evaluated and thus are not included in these meta-analyses.
Furthermore, defining and controlling the self-help independent variable in
research is fairly complex. It proves difficult distinguishing unguided from
therapist-guided treatments and those from formal psychotherapy with self-
help recommendations.
Our point is not that self-help is as or more effective than psychotherapy.
Rather, we offered a brief review of the literature on the efficacy and
effectiveness of self-help with the goal of helping clinicians embrace it.
Clients are frequently more likely to engage with self-help than talk-
therapy, and self-help can invariably be integrated with psychotherapy.
Therapists holding a favorable view of self-help have been found to be
associated with increased goal attainment for clients (Hodges & Segal,
2002; Kelly, 2003).

INTEGRATING SELF-HELP INTO PSYCHOTHERAPY

As noted earlier, healthcare professionals often recommend self-help tools
to their clients. Questions arise, however, as to the best ways of practically
using such resources as part of, in conjunction with, and in addition to
formal psychotherapy. Here, we offer suggestions on such integrations.

Recognize the Helpfulness of Self-Help

Because clinicians rarely encounter those who recover without professional
help (Klingemann et al., 2001), it is easy to think that psychotherapy is the
only effective way to change. There are even clinicians who act as though
their self-esteem and economic survival depend on our unique and
exclusive ability to help people change (Norcross, 2000). The evidence
supporting the efficacy of self-change can be threatening (Prochaska,
Norcross, & DiClemente, 1995). Some mental health clinicians are
ambivalent or even hostile to the idea of using self-help in practice. Yet
self-help tools remain quite popular and surprisingly effective.
The first step toward integration is to cease demonizing self-help as
“trivial” or “futile” and to be aware of a tendency toward professional-
centrism—the belief that psychological expertise and practice are the
primary mechanisms of mental healthcare for the public (Salzer, Rappaport,
& Segre, 2001). Reducing such biases can increase the frequency of
clinicians recommending or referring clients to self-help resources.

Embrace Both Therapy and Self-Help

The integration of psychotherapy and self-help that we address is
“both/and,” not “either/or.” Clinicians can frame self-help participation as
exploring alternative and additional change mechanisms so that clients can
find the best combination for themselves. Combining self-help with
psychotherapy could generate more active patient participation instead of
attempting to pressure them into receiving help from only one resource or
group (Klaw & Humphreys, 2005). In many respects, this is similar to how
clinicians incorporate conjoint sessions or pharmacotherapy into ongoing
treatment; self-help can integrate just as naturally.

Broaden the Definition of Self-Help

Mental health professionals typically think of books or support groups as
the primary type of self-help, but self-help is much more. When
incorporating self-help into treatment, the options are broad, consisting of
eight major types of self-help:

Self-help books
Autobiographies
Structured workbooks
Commercial films
Expressive writing and journaling
Support groups
Websites
Mobile applications
 The integration of self-help books, autobiographies, commercial films,
support groups, and websites has been extensively discussed in other
publications (e.g., Norcross et al., 2013; Watkins & Clum, 2008; Wedding
& Niemiec, 2014). Expressive writing and structured workbooks emphasize
a person’s communicative and interactive output (Harwood & L’Abate,
2010). These have been subjected to considerable research, which has been
reviewed and compiled in a series of books (e.g., L’Abate, 2000, 2004,
2010).
Mental health professionals have recently begun to identify the best
behavioral health apps (Simmons et al., 2016) or, in the vernacular,
“evidence-based apps” (Lui, Marcus, & Barry, 2017). With the creation of
the iPhone in 2007 and the opening of the Apple app store the following
year, self-help mobile applications have become popular mental health
supports. Mobile apps are akin to websites; many products have both a
website and a mobile app, but others exist on only one platform. Mobile
apps are typically simple, condensed psychoeducation or a single
intervention. For example, PTSD Coach is a psychoeducation mobile app
that offers information about what posttraumatic stress disorder (PTSD) is,
symptom assessment, and treatment options typical for the disorder (Kuhn
et al., 2017). Virtual Hope Box is a mobile app intervention meant to help
with emotion regulation and coping through the creation of a digital hope
box (Bush et al., 2017). A hope box is a therapeutic technique that involves
the creation of a collection of personal reminders of reasons for living or
items that help ground the client in the present (e.g., photos of loved ones, a
scent they enjoy, photos of places they still want to travel to). This app
allows for the creation of a digital hope box instead of a physical one.
Another example is OurRelationship, which provides evidence-based
integrated behavioral couples therapy online (Doss et al., 2016).
Although we have been reviewing the successful use of self-help, a
Cochrane Collaboration review (Murray et al., 2004) has provided a
warning that indiscriminate use of health-related Internet materials can
prove harmful in some cases. The review of 28 studies and 4,042 people
with chronic medical disorders found that those who used the Internet to
locate information on their disorders reported feelings of social support and
greater knowledge about their disorders and treatments. However, those
same users had worse health outcomes. Worse outcomes were due, in part,
to browsing the Internet looking for alternatives, making their own health-
related decisions and often ignoring professional advice. Such studies
remind us of the need to meld self-help with professional guidance and to
review self-help resources before we use them.

Capitalize on Multiple Self-Help Benefits

Self-help is not restricted to behavior change. The most frequent reasons
given by clinicians who recommend self-help are for psychoeducation,
encouragement, empowerment, fostering a sense of universality,
reinforcement of specific points or strategies worked on in session, provide
support and knowledge for family members, and social support (Campbell
& Smith, 2003). Thus, there are a variety of reasons therapists recommend
self-help in conjunction with psychotherapy.
Consider the case of Army CPT Myers, a 35-year-old married African
American man seen in therapy by the first author, suffering from
posttraumatic stress and major depression precipitated by several
deployment-related traumas. On his own, he had purchased and read the
highly rated self-help book Trauma and Recovery (Herman, 1997), which
he found “helpful” in providing information and understanding his
experience of trauma. In the session, we discussed how his experience
might differ from the text in his lack of desire to reconstruct the traumatic
story or connect with others. I (AES) recommended the mobile app PTSD
Coach so he could better contextualize his symptoms as they relate to
military operations. In his following sessions, he talked about joining a
support group for veterans suffering from PTSD and bringing his wife with
him. He followed through on this, and we discussed how this group helped
him reconnect with others and gave him a place where he was not afraid to
share his trauma since “they could relate to it.” All these resources
supported his continuation of antidepressant medication and therapy
sessions work using prolonged exposure.

Become Familiar with Self-Help Options

There are some ways that psychotherapists can familiarize themselves with
self-help resources. Familiarization could include attending a self-help
meeting, reading a self-help book, downloading mental health apps, reading
an autobiography of a mental health client, and browsing online for a
particular mental health topic.
Familiarity will facilitate knowledgeable referrals and seamless
integration with in-session work. We, the authors, encourage our colleagues
and students to attend a meeting of a self-help group, especially if
recommending such groups to clients and to read self-help books with
mental health content. We have found that when students attend an open
AA or Narcotics Anonymous meeting, they are generally enthusiastic in
their reactions. Any initial skepticism and devaluation of self-help groups
quickly change to impressions of solidarity, support, and sincerity.
Comparably, when students rated the value of various autobiographies in an
abnormal psychology course, their responses were favorable: across three
evaluations, more than 95% rated the assignment positively (Norcross,
Sommer, & Clifford, 2001). It can also prove helpful for therapists to
download and experiment with mobile apps, rate them, and determine if an
app’s content is based on sound psychological research.
Being familiar with the self-help materials that clients may use, or that
you may recommend, can decrease the chances of inappropriate advice.
More than most other self-help categories, films require certain warnings
and preparation. Viewers are asked to suspend belief and enter a fantasy
world; they should not overidentify or overgeneralize from a single
cinematic episode. People suffering from debilitating psychological
disorders should be warned of possible negative consequences, and those
who recently suffered from traumas should be careful not to be
retraumatized by various films.
The rate at which self-help books and mobile apps appear outpaces
research on them. Familiarity with them will allow therapists to gauge the
evidence base and the psychological theory, if any, on which the self-help
tool is based.

Assess Clients’ Self-Help Experiences

It takes only a moment, early in therapy, to assess a patient’s self-help
experiences. Seasoned clinicians already thoughtfully assess clients’
previous experiences, positive and negative, in psychotherapy. Clinicians
should also assess self-help exposure. Clinicians want to avoid
recommending what clients have already tried and found wanting and build
on what was previously successful.
Therapists are likely to be surprised by the prevalence and variety of
clients’ self-help attempts in the past. One fairly representative client the
second author saw in an afternoon tried Anthony Robbins’s audiotapes,
over-the-counter supplements, a self-help group, three self-help books, and
sexual enrichment videotapes (Norcross, 2000). This example is from a
client who was himself a mental health professional; imagine what less-
informed clients have used and not shared with you!
In a survey of 262 psychotherapy clients, only 34% reported discussing
their use of alternative therapies with their therapist (Elkins et al., 2005).
When alternative therapies were discussed in session, the topic was brought
up by the client about half of the time. Clients’ information about their self-
help histories will assist in case formulation and treatment selection. For
example, some clients with depression might say they have a good grasp of
psychoeducation and their current symptoms but need help complying with
daily positive activities and keeping in touch with friends. Other clients
might say they tried cognitive-behavioral methods that helped but think the
issue goes back to an early childhood trauma that they need to process. Still,
other clients say that they have received all they can from peer support but
need concrete and specific direction on how to best approach their current
problems. Assessing these self-help experiences and client preferences
enrich case formulation and treatment selection.

Help with Problematic Self-Help Programs

Many clients enter treatment after “failures” with self-help materials. One
research review found that more than three-quarters of laypersons could not
successfully self-administer a toilet training protocol, a sexual dysfunction
treatment, or a desensitization procedure (Rosen, Glasgow, & Moore,
2003). Just because it is labeled self-help does not mean clients can
understand or perform the methods on their own; many clients need
assistance with their self-help (Andersson, Carlbring, & Grimlund, 2008).
Results from several studies support individualizing self-help
recommendations and ministrations. One controlled study (Haefferl, 2010)
investigated whether those who ruminate might get worse using self-help
programs for depression. Might such programs foster rumination by having
the user focus on his or her negative or unrealistic thoughts? They do.
Students prone to rumination became worse after recording their realistic
and unrealistic thoughts in workbooks. Another study (Febbraro et al.,
1999) cast doubt on the effectiveness of bibliotherapy and self-monitoring
for panic attacks when used with a professional. This research highlights
the need to avoid certain types of self-help tools that might be
countertherapeutic to a client’s symptom presentation.
Ineffective self-help poses many problems. Not only can it leave clients
feeling frustrated, deflated, and incapable, but it could even be harmful. It
may be innocuous in and of itself, but ineffective self-help could deprive
individuals of time and resources, diminish public credibility in the mental
health profession, and reduce the scientific foundation of our profession
(Lilienfeld, Lynn, & Lohr, 2003).
Clinicians can offer assistance with difficult self-help programs. After
psychotherapists have determined that the self-help resource is, generally,
appropriate and for a specific client, they can assist in implementing the
program and then later assist with its maintenance. Clinicians can also
reassure clients that it is not their fault if the self-help materials are difficult
to apply or not effective (Rosen et al., 2003). It is often useful to remind
clients that there is no legal or professional regulation of self-help claims.
Because a self-help resource claims it is “clinically tested,” “proven
effective,” and effective “in a single day” does not necessarily mean that it
is.

Offer Tangible Support

Specific steps by a therapist can increase client immersion in self-help
activities that supplement the work of treatment. These include:
◆ Hold favorable views toward self-help involvement. Favorable views
are associated with increased goal attainment (e.g., Hodges & Segal,
2002).
◆ Provide specific recommendations to local chapters of self-help and
support groups (a valuable national clearinghouse can be found at
www.mhselfhelp.org/). Connect with the specific self-help group
during a session and arrange for someone to accompany the client to a
meeting (100% of clients in one study attended at least one self-help
meeting when these two steps were accomplished vs. virtually 0%
attendance when a self-help meeting was just suggested; Sisson &
Mallams, 1981).
◆ If a client is open to attending a 12-step group, encourage attendance,
secure a sponsor, and engage in other 12-step–related behaviors
during and after treatment (Mankowski, Humphreys, & Moos, 2001).
◆ Distribute copies of self-help books and autobiographies you
frequently recommend during a session or make them available in the
waiting room (expect most will never reappear in your office).
◆ Give specific website URLs and titles of movies/books, and have clients
download apps in-session as opposed to making a general suggestion.

All these recommendations support the idea that a clinicians’ behavior in

session translates concretely into client involvement in self-help.

Recommend Research-Supported Self-Help

Many self-help books and technology-based treatments have proved
effective in controlled studies as stand-alone self-help. These include the
technology-based tools mentioned throughout this chapter and a growing
number of self-help books. Among the latter are Alberti and Emmon’s Your
Perfect Right, Burns’s Feeling Good (1999), Clum’s Coping with Panic
(1990), Craske and Barlow’s Mastery of Your Anxiety and Panic (2000),
Fairburn’s Overcoming Binge Eating (1995), Gordon’s Parent Effectiveness
Training (1975), Heiman and LoPiccolo’s Becoming Orgasmic (1988),
Lewinsohn, Munoz, Youngren, and Zeiss’s Control Your Depression,
Linehan’s Skills Training Manual for Treating Borderline Personality
Disorder (2015), Pennebaker’s Opening Up by Writing It Down, multiple
forms of parent management training (Elger & McGrath, 2003), and sleep
stimulus control instructions. Several published compilations offer a critical
review of which self-help resources are evidence-based (e.g., Harwood &
L’Abate, 2010; Norcross et al., 2013; Watkins & Clum, 2008) for multiple
disorders and life challenges.
Of course, hundreds of self-help books and apps are based on effective
face-to-face psychotherapies; however, research has not identified if we can
reliably know whether they can be practically and effectively implemented
with no therapist contact. According to Rosen and colleagues (2003):
The only way to know the effectiveness of well-intentioned instructional materials, when they
are entirely self-administered, is to test those specific materials in the specific context of their
intended usage. Psychologists who write self-help materials based on methods they find effective
in office settings have no assurance that the public can successfully apply these procedures on
their own. (p. 410, emphasis in original)

Thousands of such resources are vying for notice and sales. Clients
obtaining trustworthy information from a basic Internet search is like taking
a 2-year-old on a walk: they pick up a few pretty rocks but also lots of
garbage and dirt (Norcross, 2006). Clinicians may know when to dismiss
something as irrelevant or inaccurate, but the average client rarely does.
The take-home message is, whenever possible, leverage scientific research
and advance self-help materials that are empirically supported as a stand-
alone intervention.

Rely on Professional Consensus

The quantity of self-help tools far exceeds controlled trials on their efficacy.
We estimate that less than 5% of commercial self-help books and 1% of
web and mobile tools possess any research evidence on their effectiveness
or safety.
Where does this leave psychotherapists? We need to be empirically
informed, but very few self-help tools have been subjected to scrutiny as
self-administered treatments. We also cannot read 5,000 self-help books per
year, surf the more than 25,000 websites devoted to mental health, or
download the thousands of mental health-related apps. It is clear that more
research needs to be done, but, in its absence, therapists can proceed in the
tradition of evidence-based practice by integrating the best available
research with clinical expertise in the context of client characteristics,
culture, and preferences (APA Task Force on Evidence-Based Practice,
2006).
Professional consensus is the majority opinion, not unanimity. Case in
point is The Courage to Heal (Bass & Davis, 2008). This is a best-selling
self-help book rated highly by psychologists for its sensitive portrayal of
adults who were sexually abused as children. The book is not without
criticism or complaint, however. It contains research-unsubstantiated signs
of sexual abuse and inadvertently encourages erroneous memories or false
accusations of sexual abuse. Supporters of the book point out that it fosters
an acceptance of and trust in women whose abuse was denied by others.
There are few self-help tools with universal approval.
Knowing, both clinician ratings of self-help materials and the research
base is ideal. In Self-Help That Works (Norcross et al., 2013), both clinician
rating and research base are listed. The clinical expertise of the nearly 5,000
mental health professionals is contained in this text and can help guide
clinicians’ recommendations to clients. Clinician consensus is no guarantee
to the accuracy or safety of a self-help tool and is inferior to controlled
research, but it is, without question, superior to consumer choice, random
selection, best-seller lists, or app store ratings.

Tailor Recommendations to Clients Not Only Disorders

The typical way of recommending self-help tools is by focusing on the
client’s diagnosis being addressed in treatment: depression, addiction,
relationship distress, anxiety, and the like. The more sophisticated self-help
referral is to recommend based on the disorder and the person. That is, try
to tailor the self-help recommendation to the qualities of the client; their
gender, age, culture, religion, sexual orientation, occupation, and so on. As
Sir William Osler (John, 2013), father of modern medicine, said: “It is
much more important to know what sort of a patient has a disease than what
sort of disease a patient has.”
An example of this can be seen in a 28-year-old, married man with four
children who had recently relocated. He came into psychotherapy due to
increased relationship stress around this move. In his previous job, his
wife’s family lived close by and the children had many friends. He
presented with minor symptoms of depression and feelings of guilt. He
reported feeling that he had less energy and little interest in helping his wife
identify fun things for the kids to do in their new location. Psychotherapy
paired behavioral activation and a self-help mobile app, Positive Activity
Jackpot (Edwards-Stewart, 2012), in which he identified family-friendly
and pleasant local activities. Both treatment and self-help alleviated his
depression and helped familiarize his family with their new town.
It can prove difficult at times to locate self-help for clients from
marginalized populations, such as immigrants and gay, lesbian, bisexual,
and transgender patients. Specialized support groups may not be available
in the local community if they cannot be found online, and self-help books
may not be available for specific cultural populations. Moreover, web-based
programs and mobile apps rarely customize around client characteristics.
We recently searched in vain for a culture-specific resource for a
Vietnamese immigrant family struggling with bipolar disorder. More
culture-specific resources are needed.
When tailoring the self-help recommendation to clients’ characteristics
and their unique contexts, it is also helpful to consider three treatment
adaptation methods that have received research support: patient preferences,
stage of change, and theory of cause/cure (Norcross & Wampold, 2018).
Some clients struggle with reading, some do not have wi-fi at home, some
will not watch movies or television, and still others (particularly
adolescents) refuse to consult anything not found online. Match such
preferences and utilize patient strengths in recommending self-help.
Regarding stage of change, some self-help materials are appropriate for
the precontemplation and contemplation stages, whereas others are better
for the action stage. Many self-help resources are geared toward active
change but can backfire for those in earlier stages. For substance abuse, the
web-based Drinker’s Check-Up is particularly suited for an early stage of
change as it utilizes motivational enhancement that includes personalized
feedback (Hester, Delaney, & Campbell, 2012). A meta-analysis of 87
prospective, stage-matched computer interventions found a 39% increase in
effectiveness (OR = 1.39) over the nonmatched interventions or minimal
care conditions (Krebs, Prochaska, & Rossi, 2010).
Self-help resources can also be matched to clients’ (or clinicians’)
theories of cause and cure. Following with the substance use example,
clients (and clinicians) who favor a disease model and abstinence-only will
be more disposed toward the AA Big Book and Twelve Steps and Twelve
Tradition. Those inclined to ideas of moderation will respond better to
books like Controlling Your Drinking by Miller and Munoz (2013), When
AA Doesn’t Work for You by Ellis and Velton (1992), The Addiction
Workbook by Fanning and O’Neil (1997), or the web tool mentioned earlier.
Clinicians would be wise to avoid the outdated medical model that
identifies clients by pathology alone. By adapting self-help to the
individuality of the client, both applicability and efficacy are typically
enhanced (Norcross & Wampold, 2018).

Recommend Self-Help for Life Transitions

Patients come into treatment for more than their disorders. Many of their
concerns are associated with life transitions. While addressing the most
salient disorders in sessions, clients can concurrently use self-help for life
challenges. Leading the list are financial planning, marriages, pregnancy,
child rearing, career changes, grief, retirement, aging, and death. There are
also excellent self-help resources for personal growth which can include
skills like assertiveness, communication, self-management, relaxation, and
spirituality. The idea is that self-help can address both the central issues
being treated in sessions as well as those not in the treatment plan. Self-help
for transitions can help clients feel heard in all aspects of their life, even if
periphery transitions are not directly addressed every session.

Employ Self-Help During Waiting Periods and Maintenance

Self-help in all its forms can prove a powerful intervention for clients on a
wait-list. Such tools can enable natural recovery for some individuals and
increase motivation for those in need of professional treatment. Self-help
can also support clients who have already made changes and are trying to
maintain such changes after professional services have ended (Klaw &
Humphreys, 2005). In this sense, self-help should not only be considered a
part of active treatment but also as pre-therapy and maintenance
interventions.

Address Common Concerns

Many clients and clinicians pose legitimate reservations about certain
aspects of self-help. In practice with clients and while interacting with
colleagues, we have repeatedly encountered concerns about incorporating
self-help into treatment. Below we address these concerns with research
findings and clinical experiences.
◆ Self-help discourages treatment and medication. It is true that some
self-help books, websites, and many 12-step programs direct clients
away from professional treatment and medications. In years past, many
clients who were also AA members would report that fellow members
accused them of not being sober or abstinent while taking psychotropic
medications. The number of such reports, however, is decreasing, and
the empirical evidence for this cited barrier is scarce (Kelly, 2003). In
fact, in a survey of AA members, the vast majority believe that the use
of psychotropic medications intended to reduce relapse risk is a “good
idea” and deny being pressured to discontinue their medications
(Rychtarik et al., 2000). Most self-help resources tell users to seek
professional treatment, and many now invite professionals to serve on
their advisory boards. In short, this concern seems to be dated and
fading.
◆ Incompatibility with treatment philosophy. This reservation often
relates to rival theoretical orientations or 12-step theistic groups.
Patients receiving psychotherapy from a particular orientation can be
confused by self-help information or treatment guidance from another
theoretical orientation. This is not a pressing concern among
integrative therapists, but it may prove frustrating to those
professionals seeking to maintain theoretical consistency or who prize
one approach over another. In practice, we have found that many
clients can profit from 12-step, AA-modeled groups by either
accepting the teachings or reinterpreting the language into spiritual
concepts more compatible with their own beliefs. In a study of 3,018
substance abusers, both theists and nontheists were equally likely to
follow through on and benefit from referrals to AA (Winzelberg &
Humphreys, 1999). Clients high in religious involvement have not
been found to attend 12-step groups more frequently (Brown et al.,
2001) or to respond better to them (Connors, Tonigan, & Miller, 2001)
than those who are not religious. Consider referring both religious and
nonreligious clients to 12-step groups and materials. For the few clients
opposed to AA philosophy, or who have had negative experiences with
such groups, refer to non–12-step groups. There are alternatives for
every addictive disorder.
◆ Possibility of harm. Another reservation is that self-help may harm
clients. Meta-analyses of research show a low deterioration effect.
 Scogin and colleagues (1996) found a low rate of negative outcomes
for self-help across five self-help studies; the low negative outcomes
were similar to or lower than those associated with professional
treatment. In a meta-analysis of 29 clinical trials of Internet-based
cognitive-behavior therapy (CBT), only 6% of participants experienced
deterioration, compared to 17% in control conditions (Rozental et al.,
2017). Selection bias is, however, possible in the self-help materials
chosen for research, and we do not know the magnitude of this bias. It
is probable that highly implausible self-help would be less likely to be
submitted to a randomized trial than a more conventional self-help
resource. As for the self-help materials that have been scientifically
researched, we can confidently say that the possibility of harm is quite
low and probably lower than receiving no care at all. Negative
outcomes are more of a concern with purely client self-administered
treatments than with self-help integrated into psychotherapy (Schueller
et al., 2017; Scogin, 2003); put differently, self-help technologies are
more effective with human support and professional guidance.
◆ Web/mobile self-help privacy and security concerns. Many clinicians
harbor concerns around the privacy and security of using web-based
and mobile self-help. Recent, large-scale breaches in credit cards and
financial organizations accentuate these concerns, which are not to be
taken lightly or dismissed. In our experience, these concerns are
attributable to a lack of familiarity and comfort with self-help
technology, which has had minimal privacy breaches (to our
knowledge). Clinicians can learn such skills and expand their
knowledge as technology use increases with time. In recent years,
several articles have outlined the privacy/security considerations of
technology in clinical practice (e.g., Jones & Moffitt, 2016; Karcher &
Presser, 2016; Prentice & Dobson, 2014), and one offers ethical advice
and legal guidance on recommending self-help mobile apps in clinical
practice (Edwards-Stewart et al., 2017).

Monitor Progress with Self-Help

It is not enough to recommend self-help and then leave the client to read the
book, visit the website, or join a support group. Research suggests that self-
help works best when directed, reinforced, or, at least, occasionally
reviewed by psychotherapists. Regular monitoring of self-help use, such as
progress in a group or a mobile app, provides the opportunity for clients to
ask questions, clarify concerns, and correct misunderstandings. It can also
help end a client’s use of an unhelpful resource earlier on before harm can
be done; for example, a support group that is causing the client damage and
not reinforcing positive change. When the self-help material is useful,
monitoring can reinforce the benefits and remind clients that their clinician
is interested in progress in all areas of their lives. Last, if clients need
assistance in finding another self-help tool, therapists familiar with their
clients’ self-help history and clinical needs will be well equipped to do so.

FUTURE DIRECTIONS
Historically, self-help and psychotherapy developed independently, with
separate sources of theory, practice, and research. The streams of self-
change and psychotherapy rarely intersected, let alone were they integrated.
When they did intersect, it was frequently to pit one against the other rather
than to serve as complementary paths of behavior change.
In the future, we foresee a mounting rapprochement and mutual synergy.
In an era of briefer treatment and declining mental health reimbursement,
psychotherapists will necessarily need to do more with less.
Psychotherapists will naturally seek additional change mechanisms to
complement and continue the positive effects of their treatments. To reduce
the burdens of suffering and to reach the untreated, new, integrative models
are required (Kazdin & Rabbitt, 2013).
Stepped care will attempt to maximize the effectiveness and efficiency of
resource allocations. Many health organizations are already beginning
treatment of mental health disorders with the least costly assistance of self-
help, such as a support group and bibliotherapy. If these do not suffice, then
care steps up to a more intensive treatment; for example, a interactive
multimedia program delivered over the Internet. If more help is needed,
group therapy could be added. Face-to-face psychotherapy will be
increasingly reserved, we fear, for the affluent and the severe cases. We
hope, and advocate for, a thoughtful hybrid of psychotherapy and self-help.
In that future, self-help, with or without psychotherapy, will remain the
country’s de facto treatment for most behavioral disorders. A Delphi poll of
73 experts predicted that psychotherapy in the future would be
characterized by escalating computer technology (e.g., mobile apps, social
networking interventions) and increased reliance on client self-change, such
as self-help and bibliotherapy (Norcross, Pfund, & Prochaska, 2013). The
economics of healthcare along with the affordability, privacy, and
effectiveness of (tested) self-help propels its integration with
psychotherapy.
Psychotherapists are inexorably responding to these changes. As we
better understand the role that technology can play (and not play) in face-to-
face care (Schueller, Munoz, & Mohr, 2013), clinicians will utilize it more.
Prominent researchers and clinicians are turning their treatments into web-
based, patient-led applications. A web-based prolonged exposure for PTSD
is currently being tested within a military population (McLean et al., 2018).
Participants “attend” 10 online sessions of approximately 60 minutes in
length. Participants complete assessment batteries on several occasions and
have contact with a clinician for brief, 15-minute phone conversations
before session 1, after session 3, and then again after the last session.
Integrative behavioral couples therapy (IBCT; Christensen et al., 2010), as
another example, has been adapted into a web-based intervention called
OurRelationship and has been found to be effective in improving
relationship satisfaction, also with minimum clinician contact (Doss et al.,
2016).
The challenge for future research is how to reliably predict which
patients will benefit from self-help alone as compared to self-help with
therapist contact or psychotherapy alone (Baillie & Rapee, 2004). Higher
formal education seems to predict self-help improvement (Warmerdam et
al., 2013). Clinical severity and functional impairment (Castonguy,
Constantino, & Beutler, 2019) are research-supported markers for more
intensive and lengthier intervention, but even here self-help and online
social support play a curative role.
Massive open online interventions (MOOIs) have the potential to
increase the reach and affordability of psychological interventions (Munoz
et al., 2016). These have proved largely acceptable to populations in
multiple countries for several behavioral and health disorders. We anticipate
a day when therapists can routinely recommend these interventions,
augment their moderate effectiveness, and provide the in-person care and
experience that computers cannot approach.
 Technology will never replace face-to-face psychotherapy. In the
preceding examples, web-based interventions were created to address
barriers to care (e.g., affordability, privacy, availability). The future of self-
help plus psychotherapy embodies the ethical mandate to give away our
knowledge, make it available on a population-wide scale, and treat as many
suffering individuals as possible. Self-help technologies provide one way to
do so.

CONCLUDING COMMENTS
The rise of self-help is part and parcel of the transformation of healthcare
toward patient-led care. More companies and insurers are turning to
consumer-directed health plans that give more control (and responsibility)
to the patient. Professional guidance on the selection and use of self-help
increase the probability of positive outcome (Schueller et al., 2016; Scogin,
2003). Effective self-help is best embedded within a therapeutic
relationship. As clinicians, we can select, direct, and tailor preferred self-
help to lead clients toward effective resources and prevent the utilization of
ineffective ones.
Two American Psychological Association task forces on self-help praised
its enormous potential for public mental health but warned that untested
programs pose risks to consumers (Rosen, 2004). Giving psychology away
is the goal, both in disseminating evidence-based methods and in countering
what has not been tested or supported (Norcross, 2000). Popular mental
health need not be unscientific mental health (Lilienfeld, 1998). This entails
sharing the scientific process and its outcomes with the general population
in ways that can be easily and affordably consumed.
The integration of self-help and psychotherapy expands the traditional
boundaries of psychotherapy integration and promises a broader,
responsive synthesis of effective change methods. There is no need to
choose only one pathway to patient self-growth and behavior change; to
paraphrase Freud, all that work are good.

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PART IV

Training, Research, International, and Future

Directions
 18

Training and Supervision in Psychotherapy

Integration
JOHN C. NORCROSS AND MARCELLA FINNERTY

Once upon a time, psychotherapists were trained exclusively in a single

theoretical orientation and in the individual therapy tradition. The
ideological singularity of training did not always result in clinical
competence but did reduce clinical complexity and theoretical confusion
(Schultz-Ross, 1995). But, over time, psychotherapists began to recognize
that their orientations were theoretically incomplete and clinically
inadequate for the variety of patients, contexts, and problems they
confronted in practice. They began receiving training in several theoretical
orientations—or at least were exposed to multiple theories—and in diverse
therapy formats, such as individual, couple, family, and group.
The gradual evolution of psychotherapy training toward integration has
proven a mixed blessing. On the one hand, the movement addresses the
daily needs of clinical practice, satisfies the intellectual quest for an
informed pluralism, and responds to the growing research evidence that
different patients prosper from different treatments, formats, and
relationships. On the other hand, integrative training increases the student
press to obtain clinical competence in multiple methods and formats and, in
addition, challenges the faculty to create a coordinated training enterprise.
Not only must the conventional difficulties in producing competent
clinicians be resolved, but integrative training must also assist its students
in acquiring mastery of multiple treatments and then in tailoring their
therapeutic approach to fit individual patients.
 In this chapter, we begin by introducing what is, in our view, an ideal
training sequence for psychotherapy integration. We then consider training
in light of the four principal routes of integration—technical eclecticism,
theoretical integration, common factors, and assimilative integration—as
their training objectives and sequence will vary somewhat. Next, we
address questions regarding the centrality of personal therapy and the
necessity of research training in the preparation of integrative therapists. We
review integrative supervision, specifically seven of its distinctive practices.
We conclude with a discussion of organizational strategies for promoting
psychotherapy integration and offer future directions for integrative
training.

A FEW WORDS ON WORDS

Before proceeding to the chapter proper, a few words on our terminology.
The term “training” can denote a mechanistic and impersonal pursuit, such
as training seals to clap their flippers or training rats to run a maze
(Bugental, 1987; Rønnestad & Skovholt, 2012). We would prefer to retitle
psychotherapy training something along the lines of “cultivating
psychotherapists” or “developing psychotherapists.” But precedent is
against us; when we talk about the development of a psychotherapist, many
of our colleagues and students look at us quizzically. Thus, we will concede
to linguistic preference and precedent in using the conventional “training”
throughout this chapter, but we implore readers to interpret the term in a
broader and more human meaning. We try to prepare graduates who are
both competent psychotherapists and better functioning people.
A second bit of linguistic ambiguity concerns the term “integrative
training” (and “integrative supervision”). Our use deliberatively denotes
two meanings: training/supervision itself that integrates methods,
modalities, and mechanisms associated with diverse theoretical orientations,
and psychotherapy training/supervision conducted from an integrative
approach. At times, this ambiguity proves confusing, but we believe it
serves the higher purpose of underscoring the inherent parallel processes of
integrative education. The integrative teacher remains theoretically flexible
in systematically tailoring the education to the individual trainee, just as
that trainee simultaneously adapts psychotherapy to the individual client
and singular context. In this respect, the educational medium becomes
much of the message (Norcross & Popple, 2017).

INTEGRATIVE TRAINING
Psychotherapy students and practitioners are confronted with a blizzard of
theories and a fragmented training system. With so many therapy systems
claiming success, which theories should be studied, taught, or integrated
(Prochaska & Norcross, 2018)?
More specifically, psychotherapy trainers are immediately confronted
with a crucial decision regarding their training objectives. The major choice
is whether the program’s objective will be to train students to competence
in a single psychotherapy system and subsequent referral of other clients to
more specialized treatments, or whether its declared mission will be for
their students to accommodate most of these patients themselves by virtue
of the students’ competence in an integrative approach to psychotherapy. In
this section, we present consensual training models for teaching both
differential referral and psychotherapy integration. The introduction and
implementation of these models into any program will require substantive
content revisions, as well as a clinical sensitivity to the process of
successful organizational change, as described later in this chapter. Along
the way, we review several debates on the best practices in integrative
training.

Differential Referrals
Each of the single-school orientations represents a feasible structure for
practice, and essential work is being conducted under the patronage of
“purist” approaches. Many practitioners find meaning and success, over
their professional careers, with their chosen orientation (McLeod, 2017). A
single theory offers valuable assistance in case conceptualization and
treatment planning (Boswell et al., , 2009).
Psychotherapists can indeed function effectively within a single
theoretical system, although they are rarely the best judge of their own
performance (Walfish et al., 2012). Providing they have the ethics and
ability to discriminate which patients can benefit from their preferred
system and which cannot, referral of the latter patients can then
systematically be made to clinicians competent to offer the indicated
treatment.
In the words of Howard and colleagues (1987, p. 415): “Without a
therapist’s willingness and ability to engage in a range of behaviors and to
employ a range of therapeutic modalities, the therapist, by intent or default,
will have to limit his or her practice to clients who fit the specific range of
behaviors he or she has to offer.” The primary problem is not from narrow-
gauge therapists per se, but from therapists who impose that narrowness on
their patients (Miller et al., 2013; Stricker, 1988).
The two essential tasks in differential referral are to train students to
recognize the respective contraindications of their single psychotherapy
system and to educate them in making informed referral decisions. Many
evidence-based studies are now available by which to recognize the
indications and contraindications of particular therapies and formats (e.g.,
Aponte & Kissil, 2014; Beutler & Harwood, 2000; Fernandez-Alvarez et
al., 2016; Halvorsen et al., 2016; Prochaska & Norcross, 2018; Roth &
Fonagy, 1996), and the failure to make use of such information can no
longer be construed primarily as lacunae in the psychotherapy outcome
literature. On the contrary, difficulties in appreciating the limitations of
one’s treasured proficiencies now prove largely emotional and
organizational, not intellectual. Helping single-system advocates to
relinquish patients for whom another approach is better suited will entail
attention to both the prescriptions of the research evidence and the
limitations of their theoretical commitments.
In order to make differential referrals, clinicians will need knowledge of
available community and treatment resources. Because many students may
ultimately practice in geographic locations different from where they were
trained, this information cannot readily generalize from the training
location. Instead of teaching specific resources, therefore, training programs
are well advised to ensure that students know how to locate resources in any
community (Norcross, Beutler, & Clarkin, 1990).
Programs can provide several experiences to ensure students’ ability to
develop treatment and community knowledge. First, specific instruction and
course work can emphasize the value of community services, self-help
resources, and networks of private practitioners. Second, students routinely
can be provided with names and web addresses of national directories and
referral services. Third, visits to community mental health centers, family
counseling agencies, child protective services, and substance abuse
programs, among others, can give a sampling of the resources available.
Fourth, trainees can be assigned the task of locating treatment resources and
preparing an integrated treatment plan for an actual patient presented in
either case conference or a class vignette. Examples can be organized
around the client’s disorder, treatment goals, stage of change, therapy
preferences, and the like. Finally, trainees should obtain extensive
experience in evaluating a range of patients under close supervision in
differential referral and treatment assignment. These experiences are most
easily obtained in large health centers that offer a variety of treatment
programs and specialty clinics. In such a setting, too, the integration of
research and practice can be facilitated and reinforced (Castonguay et al.,
Chapter 20, this volume; Dyason et al., 2018; Jarmon & Halgin, 1987;
Miller et al., 2013).
Many colleagues in the United States complain that training in
differential referral is dated, that we have progressed well beyond referral.
We agree that indeed proves the case for most doctoral programs in the
United States, but it does not address the reality of smaller programs and
other countries where psychotherapy integration is not yet firmly
established. Some training programs may be too brief, or students too
inexperienced, or faculty too divided to tackle the integrative challenge. We
hope that, in the next volume of this book, the section on training in
differential referral can be jettisoned permanently.

Integrative Psychotherapy
Once the program faculty decide to implement training in integrative
psychotherapy, they confront a series of choices or debates on how best to
approach such education—what theories or principles should be taught and
when integration should be introduced to the student. Some educators
believe that students should be trained integratively from the outset (e.g.,
Eubanks-Carter et al., 2005) as integrative pedagogy can promote the
critical skills for effective practice: flexibility, open-mindedness, creativity,
awareness of limitations, and resourcefulness to cope with future
challenges. Such training would enable students to avoid the difficulties of
trying to unlearn years of work and practice within one orientation
(Norcross, 2011). In addition, when therapists commit early to one theory,
numerous institutions and organizations reinforce maintaining a purist
approach, which reaffirms a single-school mindset (Wachtel, 1977). An
early commitment to a single theory can impede the consideration of other
therapeutic possibilities.
Other educators (e.g., Castonguay, 2006) contend that we can only
integrate what we know well, so trainees should master one approach
before they begin to practice integration. Inexperienced students may
become anxious and confused by the daunting integrative goal; a single
system can serve as a secure base, at least initially (Norcross & Goldfried,
2005). Neophyte therapists’ needs for closure and resolution of conflict
frequently mean that they cannot value the complexities and ambiguities of
tensions between theories (Orlinsky & Rønnestad, 2005; Rønnestad &
Skovholt, 2012).
Surveys indicate that training directors are committed to psychotherapy
integration but disagree on the routes toward it. Approximately 80–90% of
directors of counseling psychology programs and internship programs agree
that knowing one therapeutic model is not sufficient for the treatment of a
diversity of problems and populations; instead, training in a variety of
models is needed. However, their views of the optimal integrative training
process differ: about one-third believe that students should be trained first
to be proficient in one therapeutic model, about half believe that students
should be trained minimally competent in a variety of models, and the
remainder believe that students should be trained in a specific integrative
model from the outset (Lampropoulos & Dixon, 2007).
Still other educators—such as the authors of this chapter—combine both
positions by introducing integration at the outset but postponing intense
integrative training until later in the training sequence. We believe
cumulative experience supports this practice, but we freely admit that there
is insufficient research on integrative training to render any definitive
judgment (Hill & Knox, 2013).
What content to teach in an integrative program is yet another choice
point for professional debate. We will cover this matter in more detail in the
next section, but for now, we note that some educators prefer to teach
singular models of therapy (e.g., psychodynamic, cognitive-behavioral,
experiential), some prefer to teach particular methods or techniques
independent of their theoretical heritage, and still others prefer to teach
overarching common factors or change principles. The theories and their
associated techniques comprise the basic building blocks of integrative
psychotherapy, but there is no consensus on which combination of these
foundational elements should be taught. As illustrated in the contents of this
Handbook, integrative therapies still retain distinctive favorites in which
theories are represented and which are largely ignored.
The recognition that, at this point, there is no single best way to teach
integration brings both liberation and apprehension, which is precisely the
conflict that our students and colleagues face every day. It also means that
educators are continually attempting to balance the tensions between
different training approaches and disparate theoretical orientations. This
entails dealing with a tremendous volume of literature and bringing
educators to the core in the ongoing debates (Gilbert & Orlans, 2011). Does
instruction and practice in several theoretical approaches from the
beginning create greater fluency in integration? Or is it better to start with
one or two approaches, which ultimately leaves the demanding task of
integration to the individual student? At what point should students be
exposed to change principles or processes common to all therapies?
The responsibility for integration is an ongoing test faced by all
practitioners, no matter what their training. Ultimately, mental health
professionals need to be competent and comfortable with a variety of
methods to face the challenges and privileges that their profession bestows.

AN IDEAL TRAINING SEQUENCE

Here we advance an integrative training sequence encompassing an
interlocking sequence of experiences that are predicated on the crucial
therapist-mediated determinants of psychotherapy outcome. This five-step
sequence draws heavily from the consensus of several journal sections on
training integrative psychotherapists (Beutler et al., 1987; Castonguay,
2000a; Journal of Psychotherapy Integration, June 2017; Norcross &
Goldfried, 2005; Norcross et al., 1986; The Integrative Therapist, October
2017).
The first step entails training in fundamental relationship and
communication skills, such as active listening, nonverbal communication,
empathy, collaboration, positive regard, feedback, and respect for patient
problems. The relationship elements that are associated with and predictive
of psychotherapy success are increasingly clear (Hill, 2014; Norcross &
Lambert, 2019). Acquisition of these generic interpersonal skills can follow
one of the systematic models that have demonstrated significant training
effects compared to controls or less specific models (see Hill & Knox,
2013, for reviews). In general, the most efficient way of maximizing
learning of facilitative psychotherapy skills is to structure their acquisition
involving instruction, demonstration (modeling), practice, evaluation
(feedback), and more practice. These interpersonal skills are crucial to the
establishment, repair, and maintenance of the therapeutic alliance.
Students would be retained in this foundation course until a predefined
level of competence is achieved in these skills. Criterion-referenced
situational tests, expert ratings, and demonstration experiments can be used
to confirm such competence. The point is that students should not be
automatically moved forward in the curriculum simply because they have
completed a course on the psychotherapy relationship; they should be
advanced because they have demonstrated minimal competence in
facilitative interpersonal skills (Anderson et al., 2016).
The second interlocking step consists of an exploration of various
systems of psychotherapy. At a minimum, the courses would examine
psychoanalytic, humanistic-existential, cognitive-behavioral, interpersonal-
systems, constructivist, and multicultural theories. Students would be
exposed to all approaches with minimal judgment being made as to their
relative contributions to truth. At the outset, multiple systems of
psychotherapy would be presented critically, but within a paradigm of
comparison and integration. Psychotherapy systems would be introduced as
tentative and explanatory notions, varying in goals and methodology. It is
possible to synthesize training in a specific theoretical model while also
cultivating an integrative mindset (Sotskova & Dossett, 2017). Integrative
frameworks and informed pluralism would thus be introduced at the
beginning of training (Halgin, 1985b), but a formal course on integration
would occur later in the sequence.
In our experience, courses and textbooks that only present “one theory a
week” are inadequate for this purpose. Rather, the psychotherapy systems
need to be presented and, at the end of the course, compared and integrated
in a clinically meaningful manner (Prochaska & Norcross, 2018). At this
point, students would be encouraged to tentatively adopt a theoretical
orientation or two that proves most harmonious with their personal values
and clinical preferences.
 The third step in the training sequence entails a series of practica,
accompanied by clinical supervision and sometimes coursework. Neophyte
psychotherapists would be expected to become competent in the use of at
least two psychotherapy systems that vary in treatment objectives and
change processes. In each case, completion of the practicum would depend
on specific criteria to ensure acquisition of the skills associated with a given
system. Relevant psychotherapy handbooks, treatment manuals, and
videotapes can outline criteria for implementing interventions.
Following satisfactory completion of these competency-based
experiences, the fourth step involves the integration of disparate models and
methods. Many educators believe that the sophisticated adoption of an
integrative perspective occurs after learning specific therapy systems and
techniques. The formal course on psychotherapy integration would provide
a decisional model for selecting the methods, formats, and relationships
from various therapeutic orientations to be applied in given circumstances
and with given clients. Several textbooks and sample syllabi for such
integrative courses are now available for psychology, psychiatry,
counseling, and social work programs (e.g.,
www.sepiweb.org/page/teach_train). This course bears the program’s
responsibility for providing “a system of analysis or a framework by which
a multiplicity of theories and methods could be organized into an integrated
understanding” (Reisman, 1975, p. 191).
Finally, and concomitantly, an intensive practicum experience, such as an
internship or residency, with a wide variety of patients would allow early-
career therapists to practice integration and to evaluate their clinical skills.
Theoretical knowledge of integration is sorely incomplete without
supervised experience in applying it to the real world of patients. In fact, the
principal complaint of psychotherapists following graduation is inadequate
clinical experience (Bhola & Raguram, 2016; Robertson, 1995).
Throughout these clinical experiences, students will be trained in
deliberate practice and reflective practice. The former derives from the
science of expertise and involves repeatedly practicing specific skills with
expert feedback (similar to methods used in other performance activities,
such as a musician, surgeon, or pilot). It shows some early promise of
improving client outcomes and enhancing therapist performance (Chow et
al., 2015; Rousmaniere et al., 2017). The latter refers to the examination of
one’s own covert and overt experiences to enhance learning and
professional development (Stedmon & Dallos, 2009). A fundamental
assumption to both forms of practice is that experience alone is insufficient
to facilitate improvement; rather, focused contemplation and supervised
practice prove necessary. That’s what ideally transpires in supervision.
These training experiences are but the beginning steps in the
development of competent integrative psychotherapists; genuine education
continues far after the internship or residency. Students would be
encouraged—nay, expected—to go forth to receive additional training in
specialized methods and preferred populations.
“Deep structure” integration will take considerable time and probably
come about only after years of clinical experience (Messer, 1992). Expert
psychotherapists represent their domain on a semantically and conceptually
deeper level than novices. Conceptual learning about psychotherapy
integration is probably necessary to achieve deep structure integration, but
it is not sufficient. For therapists to integrate at a deeper level requires that
they first understand and integrate within each individual therapy and, only
then, across therapies. Additional psychotherapy experience and disciplined
reflection on that experience is needed to attain a mature and abiding
synthesis.
Psychotherapy integration, in other words, may take two broad forms that
are differentially accessible to novice versus expert therapists (Schacht,
1991). The first form, accessible to neophytes, emphasizes conceptual
products that enter the educational arena as content additions to the
curriculum. The second form of integration, largely limited to expert
therapists, emphasizes a special mode of thinking. This form enters the
educational arena only indirectly through accumulated clinical experiences
that promote fluent performance and creative metacognitive skills.

SPECIFIC TRAINING MODELS

Since the second edition of this Handbook (Norcross & Goldfried, 2005),
we have secured considerably more experience and a bit more research to
inform the ingredients of integrative training. In particular, we and others
have learned that the training sequence and objectives are heavily
influenced by the specific type of, or path toward, psychotherapy
integration. Proponents of technical eclecticism, theoretical integration,
assimilative integration, and common factors (see Chapter 1 of this volume
for more detailed definitions) all have definite preferences in how and when
the ideal training occurs.

Four Paths
Technical eclectics seek to improve our ability to select the best treatment
for the person and the problem through use of multiple techniques.
Eclecticism focuses on predicting for whom particular methods will work:
the foundation is actuarial rather than theoretical. As such, the eclectics rely
on accumulating research evidence and the needs of individual patients to
make systematic treatment selections. The training emphasis is placed
squarely on acquiring competence in multiple methods and formats, as
opposed to pledging allegiance to theories, and pragmatically blending
these methods and formats to suit the given situation.
Technical eclectics are disinclined toward grand unifying theories and
more interested in a pragmatic blending of methods. They generally endorse
teaching psychotherapy integration from the very beginning of training.
Gradually building toward integration in mid-career is considered too
tentative and theoretical. And, for some therapists, learning integration after
working for years in a specific orientation may prove too difficult. Instead,
the eclectic mandate is to teach multiple therapy methods and treatment
selection heuristics early on so that clients receive the optimal match of
treatment, format, and relationship.
Eclectics readily acknowledge the limitations associated with faculty
composition and disposition. Graduate programs will range from those in
which the faculty embrace disparate theories and goals to programs in
which there is coordination of the training process and faculty consensus
about an integrative model (Norcross & Beutler, 2000). It will take
considerable time for many senior faculty to unlearn their own allegiance to
a single, pure-form system of conducting (and teaching) psychotherapy.
Yet, many new clinical faculty have been trained in, or at least favorably
exposed to, an integrative perspective.
Theoretical integrationists blend two or more therapies in the hope that
the result will be better than the constituent therapies alone. As the name
implies, there is an emphasis on integrating the underlying theories of
psychotherapy along with the integration of techniques from each. Some
proponents highlight the need for an emergent meta-theory, more than the
sum of its parts, which will bring elements from many theories into a
coherent and comprehensive approach to psychotherapy. As such, the
training focuses on the theoretical systems and building bridges between the
chasms that separate them.
Theoretical integration proves the most ambitious and probably the most
controversial. No theory, integrative or otherwise, can seamlessly combine
all potential approaches, so most theoretical integrations attempt to blend or
bridge two or three theories, such as psychoanalytic and cognitive.
Although theoretical integration brings together certain ideas, it
simultaneously rejects others, arriving at different endpoints and potentially
fragments the field further (McLeod, 2013). As a result, theoretical
integration is arguably the most difficult of the paths to master, with
technical eclecticism considered a more pragmatic and flexible route to
integration. Assimilative integrationists similarly embrace synthesis, but in
a more tentative manner. The approach entails a firm grounding in one
system of psychotherapy with a willingness to selectively incorporate
(assimilate) practices and views from other systems (Messer, 2012). The
imported practice is influenced by the context into which it is absorbed. As
such, the training is primarily in a single system of psychotherapy with an
understanding that the clinicians will gradually incorporate techniques from
other systems.
The assimilative integrationists frequently argue that, in early training,
students need a single theoretical system for structure, support, and
direction. Trainees internalize the theory and the contributions of their
supervisors. To be sure, educators may introduce the eventual goal of
integration, but neophyte psychotherapists focus on a manageable amount
of clinical skills and delimit their range of experiences. Otherwise, they risk
being overwhelmed by the morass of choices and the hundreds of
therapeutic methods. Later, students are expected to move in an integrative
fashion, but from a position of single-system comfort and strength.
Such assimilation is probably an inevitable part of the development of
psychotherapists. New ideas and methods are picked up, tried, and
occasionally incorporated into the repertoire of any clinician. But a
technique cannot stand alone and separate from the therapy within which it
is practised (Messer, 2012). This approach falls within a “pluralistic
tradition, which holds that one theory or model can never pre-empt or
preclude an alternate organisation of the evidence” (Norcross & Goldfried,
2005, p. 2).
Those who advocate common factors or processes seek to determine the
core ingredients that different therapies share in common, with the eventual
goal of creating more parsimonious and efficacious treatments based on
those commonalities. Psychotherapies share important similarities, notably
in the curative therapeutic relationship, responsible for therapeutic
outcomes (Duncan et al., 2010). These potent commonalities include
establishing a positive alliance, creating positive patient expectations,
mobilizing client’s resources, and helping patients acquire new skills
(Wampold & Imel, 2015).
As such, the training focuses on the acquisition of pan-theoretical skills
that research has found to account for much of psychotherapy success.
Castonguay (2000b), for example, outlines a psychotherapy training driven
by a common factors strategy. He recommends training students in “pure-
form” therapies and, using general principles of change, expecting them to
integrate contributions of the different orientations in their clinical work.
Other educators prefer to educate students in common change processes
or principles. Eubanks and Goldfried (Chapter 4, this volume), for example,
teach students five change principles that are common across orientations
and are supported by outcome research: fostering the patient’s hope,
positive expectations and motivation, facilitating the therapeutic alliance,
increasing the patient’s awareness and insight, encouraging corrective
experiences, and emphasizing ongoing reality testing. Focusing on these
principles, their students have the flexibility to select a variety of techniques
responsive to the client’s individual needs and preferences Prochaska and
DiClemente (Chapter 8, this volume), for another example, train students in
10 processes that they believe capture the essence of patient change in
psychotherapy.

Hybrid Paths
Of course, psychotherapy training is not restricted to any single path or type
of integration, and most programs appear to embrace several of them
concurrently. Systematic treatment selection (STS; Consoli & Beutler,
Chapter 7, this volume), to take one prominent example, combines training
in change principles of psychotherapy (common factors) with training in a
menu of particular techniques (technical eclecticism) to implement those
principles. To our knowledge, STS is the only integrative training to show
in a quasi-randomized trial that its training and supervision leads to better
patient outcomes among its trainees than supervision as usual (Holt,
Beutler, Kimpara, et al., 2015; Stein et al., 2017).
Following training in core relationship skills and courses in
psychotherapy systems, STS training covers eight change principles over a
10-week period when a student begins supervised psychotherapy. Training
in each pan-theoretical principle begins with a lecture and video
demonstration, and then the student is introduced to a cloud-based
assessment procedure on that principle. As an example, patients high in
reactance (resistant to being told what to do) benefit more from less
directive psychotherapies, and patients low in reactance benefit more from
more directive methods. Again, with video demonstrations and lectures, the
student is taught the difference between high- and low-directive treatments.
In the eclectic tradition, students can select which particular methods to use
as long as they remain consistent with the underlying evidence-based
change principle. These methods and treatments are practiced with one or
more patients in the student’s caseload, while the student is supervised and
given feedback to let him or her know his or her proficiency with each type
of treatment. The supervisor sets goals to help each student to improve.
When the student is deemed proficient by the supervisor, the student
performs an intake on a new case and uses the assessment and treatment
procedures for implementing that change principle.
Pluralistic training, to take another prominent exception, blends the
technical eclectic (use the method that works), theoretical integrative (use a
combination of theories), and common factors (use powerful pan-theoretical
principles) pathways. Adopting a pluralistic approach enables students and
supervisors to use a variety of theories without the need to reconcile
differences (O’Hara & Schofield, 2008). Training pluralistically emphasizes
the collaborative clinician–client relationship and privileges the client as an
expert on his or her own life. It is postmodernist insofar as truth is seen as
constructed more so than discovered: “any substantial question admits of a
variety of plausible but mutually conflicting responses” (Cooper &
McLeod, 2011, p. 137). Much of graduate training, especially in Europe,
seems to follow the pluralistic route. Integration is considered an evolving,
processual activity, as well as an implementation of specific integrative
models (Oddli & McLeod, 2017).

An Irish Example
IICP College in Dublin, Ireland, operates a suite of integrative
psychotherapy programs spanning 6 years that incorporates threads from
theoretical integration, technical eclecticism, common factors, and
assimilative integrative approaches within a pluralistic framework. The
programs hold both academic validation (from the Statutory Agency,
Quality and Qualifications Ireland) and professional accreditation from the
Irish Association for Counselling and Psychotherapy. At the end of year 4,
students are awarded an honors undergraduate degree in psychotherapy. The
degree, together with a further 450 hours of supervised clinical practice, is a
pathway for professional accreditation in Ireland.
Trainees develop a critical awareness of a variety of therapeutic
approaches within the three pillars of education: theory, skills, and personal
development. Students gain considerable knowledge and competencies
through teaching and assessment strategies such as essay writing, faculty
modeling, and reflecting (under supervision) on their own audio- and
videotaped practice as novice therapists. Students are encouraged to be
critically reflective practitioners and to evaluate the theories and clinical
cases presented to and by them.
Pluralism runs throughout the suite of programs with a more in-depth
focus during the 2-year master’s program. At the postgraduate stage, there
is a central focus on advanced research methods, which helps students
appreciate the philosophical foundations for clinical and research practice.
It affords students a practical hands-on introduction to psychotherapy
research and an opportunity to develop the core clinical, theoretical, and
research competencies.
Students learn and reflect on many psychotherapy models as opposed to
one “true” model. In the research methods modules, students encounter and
engage with different approaches to psychotherapy research. In contrast to a
monist approach, the contemporary perspectives module introduces
students a multiplicity of models for working with clients, such as
mindfulness therapies, neuroscience, and trauma work. The inputs from
psychology, sociology, neuroscience, mindfulness, philosophy, research,
and psychotherapy itself speak to the overall pluralistic nature of the
training.
As in many integrative programs, IICP students learn all four routes to
psychotherapy integration within a pluralistic frame. In reality, the four
paths all prove variations on the integrative theme. They overlap
considerably in how they educate students, with the central differences
being in the timing and level of integration.

Moderating Expectations
The excitement engendered by integrative training can give rise at times to
grandiose plans and overly optimistic predictions. We ourselves have been
guilty of such unfettered optimism at times, and we hasten to correct any
illusion that competency-based training in psychotherapy integration will be
easily or instantly attained. At the risk of fostering the opposite reaction—
pessimism or apathy—we will consider several reasons to moderate
expectations regarding integrative prospects in training. These
considerations, it should be emphasized, apply with equal cogency to
conventional psychotherapy training and not uniquely to integrative
training.
To begin with, explicit training in psychotherapy has a relatively brief
history, and research on training for psychotherapy has a briefer history
still. In early critiques of training studies (e.g., Alberts & Edelstein, 1990;
Ford, 1979), reviewers discovered that the interventions were poorly
described, the dependent variables were not well-validated, typical client
samples were composed of undergraduates, and the skills imparted were
simple and discrete. Although progress is certainly afoot (Hill & Knox,
2013), most studies on psychotherapy training have progressed little in
methodological sophistication or clinical relevance. The unhappy truth is
that professional reputations are rarely made in clinical training and
supervision; prestige and funding are accorded to developing
psychotherapies, not teaching them.
If current training programs do relatively little to ensure competence in a
single psychotherapy, how can competency be ensured if we attempt to
teach practitioners several psychotherapies or an integrative model?
Then there is the challenge of novelty—integrative training is
unprecedented in the history of psychotherapy. During the 1980s and 1990s,
when the integrative movement was emerging, educators faced the
challenge of trying to formulate integrative training curricula without the
benefit of learning such approaches in a formal context themselves. As
Robertson (1986, p. 416) put it: “Quite frankly, many of us who are trainers
teach students pretty much the way we were trained, and most of us were
not trained to be eclectic therapists.” In recent years, the situation has
improved as graduate and postgraduate programs have instituted more
formalized integrative coursework and practica. However, most of those
who teach and supervise psychotherapy integration did not have such
experiences themselves.
As with psychotherapy itself, it is increasingly difficult to speak of
psychotherapy training without reference to its demonstrated effectiveness.
Although many descriptions of integrative training programs have appeared
in the literature, empirical evaluations have not (for exceptions, see
Lecompte et al., 1993; Stein et al., 2017). The same can be said for virtually
all programs adhering to a single theoretical tradition, but this similarity is
hardly redeeming. The competence of our graduates and, indeed, the
adequacy of our clinical training are typically assumed rather than verified
(Stevenson & Norcross, 1987).
Given questions about the feasibility of training graduate students to
competencies in multiple systems of psychotherapy in just a few years, the
need for rigorous evaluation of training in psychotherapy integration is
particularly urgent. An indisputable disadvantage of multiple competences
is that they necessitate longer and more comprehensive training than a
single competency. Integrative psychotherapists, similar to bilingual
children and switch hitters in baseball, may be delayed initially in the
acquisition of skills or in the attainment of several proficiencies.
Even if an integrative training program is carefully implemented and
thoroughly evaluated, the effects of the training would probably be complex
and idiosyncratic. The findings of the Vanderbilt II project, one of the most
carefully designed psychotherapy training ventures, bear this out (Henry &
Strupp, 1991). This project was designed to investigate the manner in which
specialized training might improve the therapeutic process and outcome of
time-limited dynamic psychotherapy. The effects of training were mixed,
involving potentially positive and negative effects. No linear relationship
was found between technical adherence and psychotherapy outcome,
although the training was successful in imparting adherence to a
manualized form of therapy. The training altered some specific and general
operations associated with improving the quality of dynamic therapy, but
there was evidence that some elements not directly related to the imparted
techniques were also improved after training.
The criteria for effective training are multitudinous and individualized,
no less so than possible indications of effective psychotherapy. The
introduction of an integrative perspective does nothing to reduce the subtle
and complex effects of training and probably enlarges the task of ensuring
competence and measuring training outcome. We are aficionados of
integrative training but realistic about the probable challenges.

PERSONAL THERAPY AND RESEARCH TRAINING

Contributors to earlier editions of this Handbook addressed questions
concerning the centrality of personal therapy and the necessity of research
training in the preparation of integrative therapists. In this section, we
summarize their responses on these contentious matters and add our own
views on the basis of 60-plus collective years of psychotherapy training.
With respect to personal therapy, the contributors agreed that its
importance as a prerequisite for clinical work depends on the student’s level
of psychological functioning and the trainer’s own experience with personal
therapy. If a student’s personal problems interfere with the successful
implementation of psychotherapy, then all contributors concurred that it is
necessary to remedy the situation, probably including personal therapy.
In the United Kingdom, a certain number of hours of personal
psychotherapy or personal development activities is required for
professional certification. This is rarely the case for graduate mental health
programs in the United States outside of psychoanalytic institutes.
We also sensed a marked hesitancy to endorse mandatory personal
psychotherapy for all students, arising in part from two cardinal integrative
principles. First, the research evidence is inconclusive on the ability of
personal therapy to enhance clinical effectiveness (Geller, Norcross, &
Orlinsky, 2005), and committed integrative clinicians are reluctant to oblige
students to an activity with unproven efficacy. Second, the integrative
maxim of matching the treatment to the unique needs of the student/client
would be violated by insisting on a single modality for diverse students.
Instead, a variety of individually tailored personal development and other
life-enhancing activities are endorsed.
In both this Handbook and in research studies, the valence accorded to
personal therapy varies as a function of whether or not the psychotherapist
has undergone personal treatment him- or herself. In one representative
study (Bike, Norcross, & Schatz, 2009), only 5% of mental health
professionals who received personal therapy thought it was unimportant as
a prerequisite for clinical practice compared to 57% of those who had not
received it. Since approximately 85% have received personal treatment on
at least one occasion (Geller et al., 2005), the vast majority of
psychotherapists whole heartedly endorse it for both training purposes and
continuing development.
What might be the benefits of personal treatment for the typical
psychotherapist in general and the integrative therapist in particular? The
literature contains at least six recurring commonalities on how the
therapist’s therapy may improve his or her clinical work:

◆ By improving the emotional and mental functioning of the

psychotherapist: It makes the clinician’s life less neurotic and more
gratifying in a profession where one’s health is an indispensable
foundation.
◆ By providing therapist-patients with a more complete understanding of
themselves: The therapists will thereby conduct treatment with clearer
perceptions and fewer contaminated reactions.
◆ By alleviating the emotional stresses and burdens inherent in this
“impossible profession”: It enables practitioners to deal more
successfully with the special problems imposed by the craft.
◆ By serving as a profound socialization experience: Personal therapy
can help establish a sense of conviction about the validity of
psychotherapy, demonstrating its transformational power in our own
lives and facilitating the internalization of the healer role.
◆ By placing therapists in the role of the client: It thus sensitizes us to the
interpersonal reactions and needs of our own clients and increases
respect for our patients’ struggles.
◆ By providing a first-hand, intensive opportunity to observe clinical
methods: The therapist’s therapist models interpersonal and technical
skills.
 In particular, clinicians with integrative leanings will take away several
profound lessons about their future discipline. To wit: they will probably
discern that psychotherapy is rarely “pure-form” in practice or outcome,
that good practitioners routinely incorporate a variety of methods
traditionally associated with diverse systems, and that the therapeutic
relationship accounts for as much of treatment outcome as specific
techniques (Geller et al., 2005).
To Yalom (2002), personal psychotherapy is, by far, the most important
part of psychotherapy training. He reviews his own odyssey of personal
therapy during a 45-year career, emphasizing the diversity of theoretical
orientations he sought. He concludes (pp. 41–42):
It is important for the young therapist to avoid sectarianism and to gain an appreciation of the
strengths of all the varying therapeutic approaches. Though students may have to sacrifice the
certainty that accompanies orthodoxy, they obtain something quite precious—a greater
appreciation of the complexity and uncertainty underlying the therapeutic enterprise.

Yalom is hardly alone in his experience. Across studies and across

countries, psychotherapists rate their personal therapy or analysis as the
second most important influence on their professional development—
behind only clinical experience (Orlinsky, Botermans, & Rønnestad, 2001).
Given this and the overwhelmingly positive self-reported outcomes of
therapists’ personal therapy (Orlinsky & Norcross, 2005), we
enthusiastically recommend (but not require) personal treatment for our
trainees. A “good-enough” therapist (or multiple therapists) is necessary for
the undertaking, of course. Personal therapy is one component of ongoing
development and continuing education.
With respect to research training, the consensus is that it is a desirable,
but not necessary, ingredient for an effective integrative therapist. None of
the contributors to the earlier edition of this Handbook insisted on its
inclusion in clinical curricula, but several advocated a critical and searching
perspective to the psychotherapy enterprise. A respect for research assists
one to perceive relations between therapeutic strategies and subsequent
changes and to be a thinking therapist. Lazarus (1992) placed paramount
importance on the multimodal therapist being trained to understand the
workings of science, to appreciate the value of inquiry, and thus to become
a critical consumer of research—not necessarily a producer of research. We
concur wholeheartedly.
 A scientific orientation, not to be equated with laboratory research,
conveys a mode of thought that transcends the particular brand of therapy
being conducted. It teaches how to be inquisitive and skeptical, how to
gather data rather than opinion, how to analyze those data and draw
inferences from them. These are skills that help organize clinical knowledge
and help students select among the morass of competing therapy claims
(Meltzoff, 1984).
Many integrative therapists credit their research training for fostering the
thinking skills and methodological pluralism that enabled them to proceed
toward integration (Goldfried, 2001). Good practice, like good research,
depends on systematic decision-making, reasoning from sufficient data,
tolerance for ambiguity, and avoidance of premature assumptions (Faust,
1986; Giller & Strauss, 1984). Whether or not clinicians ever elect to
produce original research, they must learn to respect the process of
knowledge acquisition, to acquire a way of thinking about therapeutic
phenomena, and to critically read the relevant literature. In short, research
training prepares us to question and evaluate the way psychotherapy (and
psychotherapy training) is conducted.

INTEGRATIVE SUPERVISION
As beginners, many psychotherapists seek out a single theory by which they
can define their approach, manage their anxiety, and solidify their identity.
Beginners can feel a naïve security in adhering to the methods of a single,
pure-form orientation; however, such reassurance is usually short-lived as
they come to realize the clinical limitations of any singular approach. In
recent years, the lure of evidence-based treatments has led many beginners
down a path of simplistic hope that manualized treatments supported by
randomized controlled trials (RCTs) would have all the answers. In time, of
course, those who jumped on the evidence-based bandwagon quickly
realized the limitations of manualized therapies developed within laboratory
settings using research volunteers. Decades of psychotherapy research have
clearly documented that patient factors and the therapeutic relationship
prove most important to psychotherapy success (Norcross & Lambert,
2019; Wampold & Imel, 2015). If we manualize anything, it should be
flexibility and effectiveness (Beutler, 1999).
 Integrative supervisors find ways to help their supervisees feel
comfortable foregoing the pursuit of proficiency in a single, pure-form
system and instead working toward the development of a comprehensive,
multifaceted system. The following sections cover seven principles of
supervising integrative psychotherapy, culled from both the research
literature and our collective experience. These principles are probably
distinctive of, but certainly not unique to, integrative supervision (Norcross
& Popple, 2017).

Understand Trainees’ Biases and Anxieties

The word has spread to educators who have not been involved in the
integration movement about the wisdom and the pragmatics of integrative
training. Experienced faculty increasingly appreciate integrative training,
but they may be surprised to encounter some resistance in their students
about such prospects. Even in the earliest stages of graduate training,
students often come with theoretical biases that limit their openness to
integration. This situation may be compounded by the understandable
anxiety experienced by novices who are overwhelmed by the complexity of
psychotherapy and who, therefore, yearn for a simple, albeit narrow,
theoretical model.
It can be both surprising and disconcerting for a supervisor to encounter
the supervisee who professes adherence to a single-system model and is
resistant to becoming more broadly trained. In these situations, it may not
be a matter of the trainee holding on to a base of security, but rather a case
of a refusal to consider alternative methods. Some trainees apparently feel
no need to become informed about other models and methods; they
evidence complacency with their treasured singular psychotherapy.
In an early study, Heide and Rosenbaum (1988) surveyed 14
psychotherapists regarding their experiences in using single versus
combined theoretical models in psychotherapy; their results nicely
anticipate our trainee’s frequent concerns. When using a single orientation,
psychotherapists reported being significantly more self-controlled,
conventional, precise, and reserved. When using an integrative model, they
said they were more imaginative, adventuresome, spontaneous, and
changeable. That’s also our take on integrative supervision: more
imaginative, adventuresome, and changeable—and more effective.
 But if the clash of theoretical persuasions rings of adventure, it is also the
sound of occasional disequilibrium. We will phrase five of these sources of
disequilibrium in the way we often hear them: as anxious threats to
therapeutic identity and competence (Norcross, 1990):

◆ “But which of these many paths shall I take at any one point?” Should
the student promote action or explore mental content, challenge or
understand irrational cognitions, work on actual or projected
relationships, empathize or redirect during a session?
◆ “It is just too damn hard!” Students and supervisors alike complain of
additional work and of increased mental effort.
◆ “Oh, I don’t like doing this type of psychotherapy!” Therapists are not
as personally attached or psychologically comfortable with some
therapies as with other therapies, even controlling for competence in
them.
◆ “I am becoming a jack of all trades, master of none.” This concerns the
inherent conflict between depth and breadth.
◆ “I am opening myself up here to chaos! Who knows what can
happen?” The ambiguity and uncertainty of integrative practice can be
emotionally taxing even as it is exciting and spontaneous.

Integrative practice requires a cost-benefit analysis—the intellectual

challenge versus the internal conflicts, the gratifying openness versus the
anxious ambiguity. That’s also the reasoning behind our insistence that
integrative supervision be reserved for trainees already exposed to a range
of theories and techniques, with at least 2 years of clinical experience, and
nascent competence in at least one system of therapy. The integrative
journey is arduous; it is unrealistic to expect beginners to competently
plunge into integrative work early in their development.
As is the case with therapists and their patients, supervisors will find it
easier to reach beginning trainees when they approach their work with an
understanding of the stages of therapist development (Halgin, 1988). In one
widely accepted stage theory (McNeil & Stoltenberg, 2016), supervisees
progress through several stages: stagnation, confusion, and integration.
During the stagnation stage, the beginner is deceived by the illusion of
simplicity in clinical work. The confusion stage follows, during which the
trainee realizes that something is amiss and solutions seem elusive. It is
only later in training that the supervisee attains a sense of integration during
which flexibility, security, and understanding emerge. Thus, the supervisor
who impatiently expects the trainee to have attained integration early in
training is likely to engender dismay, frustration, and diminished self-
esteem in the trainee.
Research suggests that supervisory styles are differentially effective for
trainees at varying levels of experience. In the initial level, beginning
students are highly motivated and highly dependent on their supervisors,
while in the latter stage, advanced students seek more sophisticated
formulations and are more attuned to individual differences among clients.
One can immediately grasp that integrative supervision is oriented toward,
and indicated for, more advanced graduate students, as we have previously
noted.
In this regard, supervisors can often lose touch with the challenging
nature of learning integration. Some students, when first introduced to
multitheoretical approaches, are frequently puzzled by the mechanics of
technique shifts and are dismayed that their own attempts might prove to be
awkward and disruptive (Wachtel, 1991). Beginners are typically
overwhelmed by the array of possibilities. For example, a novice may be
perplexed by whether an interpretation or a directive intervention is
advisable at a given point in a session; confronted with such an imposing
choice, paralysis may set in. When apprised of such a moment in the
therapy, an insensitive supervisor may make a difficult situation even worse
for the trainee who is already feeling miserably insecure. A comment that
reflects impatience or surprise about the trainee’s handling of the therapy is
likely to intensify the student’s anxiety instead of fostering some risk-
taking, which is an indispensable part of the learning process. Experience
provides clinicians with a special sense of what should be done next in the
therapy; this reflects a complex, recursive decision-making process that is
informed by dozens, perhaps hundreds, of bits of data related to client,
therapist, and context considerations.

Integrate Supervision Methods Aligned with Multiple Theories

Integrative supervision is necessarily eclectic in therapeutic content and
pedagogical method. The supervisor’s work is determined both by the needs
of the clients being discussed and the needs of the trainee, all of whom will
call for different strokes. Thus, one supervision session might entail a
directive/educative approach in which the trainee learns specific techniques
for the treatment of a focused clinical problem, whereas another session
with the same trainee might involve a predominantly exploratory approach,
due either to the historical roots of the patient’s conflicts or because of the
therapist’s countertransference struggles (Halgin & Murphy, 1995). We
adhere to the integrative maxim: It depends.
Methodologically, integrative supervision entails a wide variety of
techniques and stances associated with diverse psychotherapy systems.
Structure follows function, but is not limited to it. As the situation dictates,
supervision might involve didactic presentations, reading assignments,
open-ended discussions, personal modeling, experiential activities, video
review, case examples, and mini-case conferences. Nothing is a priori off
the table (except unethical practices).
Importantly, we have moved away from reliance on supervisee’s self-
reports and “reconstructed tales of therapy” (Norcross, 1988) to the use of
videotape and live observation through one-way mirrors. This progression
has substantially increased the accuracy and completeness of information
about what has ensued in therapy and thereby has enhanced supervision.
Despite its intrusive nature, videotaping provides the best compromise and
has achieved a consensus as the best method for conducting supervision.
The empirical research tends to support review of videotaped therapy
sessions, supervision guidelines encourage it, and several jurisdictions now
mandate a minimum number of observations (videotaped or live) of
supervisee’s performance. Supervisees’ evaluations (Allen, Szollos, &
Williams, 1986; Nelson, 1978) and empirical research (e.g., Ellis, 2010)
indicate that direct observation and videotapes are the preferred supervisory
methods.

Tailor Supervision to the Individual Supervisee

One of the most appealing (and effective) features of integrative
psychotherapy is that an individualized treatment plan can be tailored to
each client. A similar principle holds true for integrative supervision: an
individualized supervision plan can be formulated for each trainee on the
basis of his or her style, stage, preferences, experience, complexity, and
other considerations. Just as we ask our students to behave integratively and
prescriptively in their clinical work, so, too, should we match our
supervision to their unique needs and clinical strategies.
Integrative supervision will obviously take into account a number of
trainee variables. Supervisors will assess personality characteristics, such as
introversion versus extroversion or need for challenge versus need for
support, and develop supervisory strategies that take these characteristics
into account (Lampropoulos, 2002) to help the supervisee develop and
discover her own voice. Although we cannot specify a priori all the possible
supervisee variables and permutations of those variables, our supervision
experience and the research literature (e.g., Holloway & Wampold, 1986;
McNeill & Stoltenberg, 2016; Norcross & Halgin, 1997) suggest that we
can improve supervision outcomes by tailoring it to several trainee
characteristics: supervisee preferences, developmental stage, therapy
approach, cognitive style/reactance level, cultural identities, and clinical
setting. We briefly consider three of these here.
Regarding preferences, we try to elicit supervisees’ expressed desires and
genuine needs. And as with patients, we seriously consider supervisees’
expressed desires but are not bound to them. They form the initial basis for
our discussions and eventual supervision contract. Tactful questioning and
sensitive inquiry can shed light on favored cognitive and interpersonal
styles. How do you best tolerate feedback from others? What was your
worst supervision experience like? How do you learn most effectively about
psychotherapy? What sort of supervisory relationship works well for you?
What do you hope to accomplish from our supervision sessions?
Regarding reactance level, supervisees will vary in their tendency to
respond oppositionally to external direction and perceived authority. Like
the high-reactant client who is resistant to therapist directiveness, the high-
reactant supervisee is likely to resist a directive supervisor. This student is
likely to do best with a reflective and evocative supervisor who focuses on
the student’s experience and is less direct in recommending technical
procedures (Tracey, Ellickson, & Sherry, 1989). This student is contrasted
to the low-reactant student who is likely to respond well to supervisor
directives. How directive should a supervisor be? It depends. It depends on
the supervisee’s preferences, cognitive style, reactance level, and cultural
identity.
Regarding cultural identities, much in the way that research has
demonstrated that psychological services are enhanced by fitting them to
the client’s culture (Bernal & Rodriguez, 2012), supervision is improved by
adapting it to the supervisee’s cultures. We respectfully ask supervisees
which of their cultural identities—and the intersection of those multiple
identities—are instrumental to their sense of self and their work in
supervision (Inman & Kreider, 2013). By culture, we refer to all salient
dimensions of identity, such as chronological age, disability status, race and
ethnicity, sexual orientation, gender, religion, and indigenous heritage.
We agree that “all supervision is multicultural” (Chopra, 2013) and try to
explicitly adapt integrative supervision to those cultural identities
nominated as salient by the trainee. Supervisees who feel their supervisors
are culturally responsive experience a more productive supervision
(Burkard et al., 2006).
Responsively attending to these and other supervisee characteristics
enables integrative supervisors to systematically and effectively personalize
the supervision. The trick is to know which of these supervisee features are
relevant in any given moment and which others are not of immediate
import. The second consideration is not to artificially force supervisees into
any of these cookie cutter molds; ongoing needs assessments and candid
discussions will point to those that will fit the unique supervisee–supervisor
dyad.

Fit Psychotherapy to the Individual Patient

In parallel fashion to their own supervision experience, supervisees are
asked to fit psychotherapy to their individual patient and unique context.
How they do so largely depends on the integrative therapy being conducted
and supervised, but, for the sake of concrete illustration, here we discuss
adapting or fitting to the patient’s transdiagnostic characteristics from the
perspective of systematic treatment selection (Consoli & Beutler, Chapter 7,
this volume) and transtheoretical model (Prochaska & DiClemente, Chapter
8, this volume).
In this tradition, integrative supervisors assist their trainees in assessing
diagnostic and especially transdiagnostic patient characteristics at the onset
of psychotherapy. It is, according to Sir William Osler (1906; the father of
modern medicine), “much more important to know what sort of a patient
has a disease than what sort of disease a patient has.” At least seven robust
patient features suggest a particular treatment and relational tack as judged
by meta-analyses (Norcross & Wampold, 2019): primary diagnosis,
treatment goal, reactance level, stage of change, coping style, culture, and
preferences. In our experience, a 1-year (50-session) course of individual
supervision usually manages to cover three or four of these and assists
supervisees’ in acquiring comfort and competence in assessing them in
routine practice. The supervisor’s task, then, is to instruct, coach, and
practice efficient means to accurately assess these patient dimensions most
relevant to the case at hand and then adapt them in session.
All told, these responsive matches or treatment adaptations prove far
more powerful than the match of Treatment Method A to Disorder Z. The
typical effect sizes for customizing to these transdiagnostic features are in
the .20 to .80 range (Norcross & Wampold, 2019), whereas the differential
effects of a particular treatment method to a particular disorder fall between
0 (the equivalent outcomes of the Dodo bird) and at best .20 (Wampold &
Imel, 2015).
That research evidence is strong and compelling, but what has not been
empirically known was whether integrative psychotherapy can be learned
through integrative supervision and, thereby, produce increased benefits for
patients. A recent study addressed this issue question directly for one form
of integrative supervision: STS.
The controlled study used a matched clinical trial design with quasi-
random assignment of doctoral-level students to supervisors (Holt et al.,
2015; Stein et al., 2017). The student therapists received supervision as
usual (SAU) or supervision by STS-trained supervisors (SAS). The
matching principles were those that had earned strong outcome effect sizes
in meta-analytic reviews (Norcross & Wampold, 2019; Castonguay,
Constantino, & Beutler, 2019), as reviewed earlier in these pages, such as
adapting therapy to patient reactance level, coping style, preferences, and
stages of change. The patients suffered from depressive, anxiety, and
personality disorders, averaging within the moderate range of severity.
Socioeconomic characteristics of the patients tended toward low income
and marginal employment.
Student therapists who received the integrative STS supervision
produced enhanced outcomes over those achieved by students receiving
supervision as usual. At the end of treatment, the pretest/posttest effect size
(d) of patients seeing SAU trainees was a respectable .72. However, the
effect size achieved by the SAS group was a substantially larger (d) 1.37,
with 81% of the patients in this group returning to “normal” functioning
based on final outcome. Thus, STS supervision produced increased patient
benefit over typical supervision.
These impressive results from a single setting require replication, of
course. At the same time, these results parallel the increased psychotherapy
benefits found for fitting therapy to the patient, as reviewed earlier. To our
knowledge, this is one of the first controlled studies to show differential
patient improvement for trainees receiving a particular form of supervision
—integrative supervision.

Collect Formal Feedback from Supervisees and their Patients

In integrative supervision, we strongly urge—some would say “require”—
trainees to monitor the progress and evaluate the outcome of the therapy
they render. This process occurs formatively (during therapy) and
summatively (posttherapy). In the former, we frequently use one of the
dozen or so feedback monitoring systems (December 2015 issue of
Psychotherapy). We typically use one of three feedback systems: The free
Session Rating Scale (Miller, Duncan, et al., 2003) containing four items
evaluating the quality of the relationship, goals and topics,
approach/method, and overall satisfaction; Lambert’s (2015,
www.oqmeasures.com/) computerized Outcome Questionnaire containing
30 or 45 items; or the InnerLife STS (Systematic Treatment Selection), a
100+ item, cloud-based assessment of patient problem areas, patient
transdiagnostic characteristics, and treatment recommendations. There are
many measures for collecting routine feedback from patients, but we favor
those that assess both goal attainment and relationship satisfaction.
Sometimes supervisees elect to experiment with one of the other
feedback methods. If more aligned with the therapy itself or supervisee
preferences, the supervisee will hold an explicit discussion with the client
about the quality of their relationship, goal attainment, the approach, what
is working, and what can be improved.
The important point is to explicitly collect and process client feedback in
session. Meta-analyses show that doing so leads to modest increases in
outcome for all patients and large effects for patients at risk for dropout or
deterioration (Lambert, Whipple, & Kleinstäuber, 2019). Therapists who
specifically and respectfully inquire about their client’s perceptions of
therapy and the relationship frequently enhance the alliance and prevent
premature termination.
In a parallel process, we systematically collect formal feedback from our
supervisees about the utility and fit of integrative supervision. Many of our
colleagues express surprise that we ask formally, but the process is not so
different from collecting feedback from our patients in session, from our
students in class, and from our peers in scholarship and academia.
This is particularly useful when supervisees are collecting feedback from
their clients and when students have experienced negative experiences with
clinical supervision. Most practitioners report at least one unsatisfactory
supervision—one in which the theory, the technique, or the style of
supervision was discordant with their needs (Ellis, 2006; Gray et al., 2001;
Nelson & Friedlander, 2001). We are convinced that such discordant
supervision relationships suffer from (1) inadequate explication of
supervision expectations and goals at the outset and (2) insufficient
evaluation of the supervision throughout.
A variety of supervision and alliance measures are available for this
purpose. To focus the process for supervisees and to reduce their anxiety,
we favor structured ratings and written forms. Two of our favorites are the
Supervisory Alliance Inventory (SWAI) and the Leeds Alliance in
Supervision Scale (Wainwright, 2010). Having specific content and
behavioral anchors helps launch as candid as possible discussions of
students’ feelings about the supervision. In reality, the supervisor’s
powerful position makes it difficult for supervisees to share candid
feedback with the supervisor, but, with time and genuine commitment that
the “data are always friendly,” frank evaluations do transpire. The
numerical rankings are followed by open conversation about what’s
working, what’s not, and what can be improved in supervision.

Model the Pragmatic Flexibility of Integration

Although modeling has been shown to be an effective procedure for
teaching complex behaviors, it is used surprisingly little in supervising
psychotherapy. When one reflects on it, this is a rather remarkable situation:
Can one imagine surgeons, musicians, or teachers not observing the very
skills they are expected to acquire? Most educators use consultant
techniques to pass on knowledge about the methods of psychotherapy; the
methods rely more on declarative knowledge than procedural knowledge.
Supervisors can reliably model the intellectual curiosity, pragmatic
flexibility, informed pluralism, and their own mistakes central to
psychotherapy success as well as to psychotherapy integration itself.
Trainees fruitfully observe the work of clinical supervisors and watch
videotaped segments of expert clinicians. Trainees frequently benefit by
reading about how seasoned therapists themselves have struggled in their
early attempts to develop an integrated approach to therapy (Goldfried,
2001). Supervisors can insure that therapists-in-training spend many hours
behind the one-way mirror and the videotape/DVD screen, not just in
passively watching, but also in interactive coding, responding, and
anticipating the next move (Vaillant, 1997).
Sharing our clinical work with our students initiates a magnificent
dialogue in which the supervisor becomes vulnerable. Such vulnerability
tends to beget a more trusting, mutual, and open relationship. Supervision
can focus on the difficulties encountered by the therapist/supervisor, and the
student can develop a greater appreciation of what transpires within the
integrative therapy session.
Rather than discuss the mistakes they have committed, most supervisors
in our experience are inclined to report the successes they have achieved,
thus communicating an inflated sense of competence and self-assurance. By
contrast, we prefer to disclose the anxieties and mistakes with which we
contend in clinical work. Sometimes we speak openly of the “dumb-ass”
comment or missed reflection that characterized a recent session. We all
struggle.
In integrative supervision, then, the importance of modeling informed
pluralism and synthetic thinking cannot be overemphasized. Not unlike our
children, our students learn to emulate what we do more closely than what
we say (Beutler et al., 1987). But, too often, supervisors teach integration in
the form of value statements instead of value actions. Resist the universal
temptation to primarily critique others’ behavior rather than risking
exposure and vulnerability oneself.

Provide a Systematic Model of Treatment Selection

A systematic model determines in large part whether integrative supervision
is experienced as intelligible or bewildering. Supervision within a coherent
framework is associated with a higher quality experience (Allen et al.,
2000); conversely, less valued integrative supervisors fail to ground their
clinical interventions within larger conceptual perspectives. These
unsystematic integrative supervisors may lack the “big picture”—an
encompassing integrative structure that organizes the case formulation and
prioritizes clinical intervention. That is, be integrative, not syncretic.
The task of integrating the diverse systems of psychotherapy cannot be
left entirely to the trainee (Hollanders, 1999). Many programs and
supervisors advertise themselves as integrative, offering a nonpartisan
approach that appeals to students. But what it frequently means is that the
students are taught by faculty of different orientations, leaving students to
try to integrate the systems on their own, or, the students are supervised by
faculty who respect all systems but have no systematic way of synthesizing,
sequencing, or selecting among them for a given case (Hinshelwood, 1985).
In the midst of conducting psychotherapy, many supervisees will desire
immediate and concrete guidance on the “right” treatment for their patients.
In the midst of conducting supervision, a supervisor will want to address the
student’s immediate need but also provide a more general treatment
selection heuristic for future patients. The most frequent integrative models
used in this regard appear to be multimodal therapy, the common factors
approach, the transtheoretical (stages of change) model, cognitive-
interpersonal therapy, and STS, according to directors of graduate programs
(Lampropoulos & Dixon, 2007). The inescapable take-home is that
supervisors need to offer systematic and evidence-based models.
These integrative models specify the basis for treatment selection and
guide the supervisor in enabling supervisees to determine the treatments
and relationships of choice. Decisional models are provided for selecting
the technical procedures and relationship stances from various therapeutic
orientations to be applied in given circumstances and with given clients. All
told, integrative models provide the coherence and guidance by which a
multiplicity of theories and methods can be organized into an integrated
understanding.
The integrative frame embraces both/and instead of either/or. The culture
wars of psychotherapy have pitted the therapy relationship against the
treatment method or the idiographic against the nomothetic. It is easy for
trainees to choose sides, ignore disconfirming research, and lose sight of the
superordinate commitment to patient benefit. The incontrovertible but oft-
neglected truth about psychotherapy is that it is, at once, a relationship and
a method. Integrative supervision fruitfully crafts the best of each for the
supervisee so that the supervisee may craft the best relationship stance and
technical methods for each client. Similarly, we aim to blend the
idiographic and the nomothetic, the particular and the general. Many
specious dualities, thankfully, fade away in integrative supervision. The
clinical phenomena become fuller, richer, more verdant—and more
consequential for those receiving our services.

Additional Considerations
Clinical supervision is generally rated the second most important
contribution to one’s professional development, immediately behind direct
experience working with patients (e.g., Henry, Sims, & Spray, 1971;
Orlinsky & Rønnestad, 2005). Far more than courses and books and
theories, hands-on supervision of actual clients constitutes the learning
foundation.
Despite decades of investigating (and debating) the effectiveness of
clinical supervision, there is no controlled research to identify precisely
what supervisor behaviors substantially improve the treatment outcomes of
the supervisee. The extant research has largely addressed the effects of
supervision not on patient benefit but on satisfaction with supervision, the
supervisory alliance, and supervisee self-ratings (Freitas, 2002; Milne et al.,
2008). In attempting to bridge the science and practice of clinical
supervision across 28 years of research, Ellis (2010, p. 110) concedes that
“it is a bridge under construction.”
Instead, what we have from the large body of less than methodologically
rigorous research is a finite list of best educational practices or principles on
conducting supervision. The hundreds of research reports, as distilled by
numerous reviewers (e.g., American Psychological Association, 2015;
Bernard & Goodyear, 2014; Ellis, 2010; Milne et al., 2008), boil down to
the following (Norcross & Popple, 2017):
◆ cultivating a warm, trusting supervisory alliance
◆ attending to alliance ruptures and managing countertransference
◆ using informed consent and a written contract (goal setting)
◆ observing what supervisees actually do in session
◆ focusing on supervisee competencies and attaining minimal levels of
those competencies
◆ providing plentiful formative feedback and occasional summative
feedback
◆ modeling or demonstrating skills to be learned
◆ teaching technical, relational, and conceptual skills to supervisees
◆ monitoring the progress of supervisees’ patients
◆ maintaining proper boundaries and modeling ethical conduct
◆ documenting what transpires in supervision (and any deficits in
supervisees)
◆ attending to the cultural identities of all participants in the supervisory
triad
◆ individualizing supervision to the singular supervisee and particular
context.

Of particular import: none of these research-supported practices or

principles hails from a single theoretical tradition. All can be employed by
supervisors of all theoretical models. These are robust pantheoretical or
common factors (Watkins, 2017). Perhaps we are biased, but we
characterize the cumulative results of the research as unequivocally
supporting integrative supervision!

THE ORGANIZATIONAL CONTEXT OF INTEGRATIVE TRAINING

The curricular and supervision models portrayed so far represent a growing
consensus on the outlines of effective integrative training. In our judgment,
the training need at the present time is not so much for further conceptual
refinement as for progress in institutions adopting such integrative training.
In other words, the more pressing need is less curricular than systemic.
This conclusion has led us (Andrews, Norcross, & Halgin, 1992) and
others to contemplate the necessary systemic change processes—how
innovations are adopted in organizations of higher education. How can so-
called disruptive innovations (Christensen et al., 2000) advance integrative
training? This approach represents a different stream of thinking, one that
complements the conceptual models described herein. Our objective in this
section is to outline several principles of organizational change that must
occur to implement an integrative program.
In much of the literature on psychotherapy integration, nonintegrative
programs are portrayed as showing rigidity in the curriculum, in those who
administer it (faculty), and in those who consume it (students). Programs
that teach either one orientation exclusively or a multiplicity of competing
orientations are criticized as forcing students into premature closure at the
risk of otherwise seeming to be a “wishy-washy” eclectic. It is argued that
such programs enforce indoctrination and do not teach optimal client–
therapy matching.
One difficulty with this account is that it has a judgmental flavor, as
evidenced by the use of words like rigid to characterize the opponents of
integration. When translated into interpersonal messages, such
characterizations are likely to produce an antagonistic, win–lose struggle, in
which the integrative “good guys” try to take over from the separatist “bad
guys.” This is hardly likely to promote a welcoming attitude toward
integration on the part of the “opposition!”
Moreover, one of the first principles of organizational change is to listen
to one’s opponents respectfully and seriously; they probably have some
truth on their side, and important considerations may emerge from a
dialogue among those with contrasting views. Even when the obstacles to
integration consist largely of rigidity on the part of current faculty and
students, we must work with them; we are not likely, except in unusual
circumstances, to select a body of faculty de novo. It is, of course, possible
to select students or interns according to explicitly integrative criteria (see
Lane et al., 1989, for an example), but this is only likely to happen once the
faculty themselves adopt integrative principles.
Those who study social change in higher education emphasize the
decentralization of power in a variety of overlapping sites. Rather than a
simple “line” or hierarchical authority structure, power and decision-
making are localized in many settings: the formal administrative structures
involving deans and presidents, the faculty senate and its curriculum
approval committees, the department chair, and the individual faculty
members who, within certain limits, decide on what is to be taught in their
courses. These factors make it even more imperative that we draw on a
variety of change strategies in promulgating integrative training.
In his classic monograph entitled Strategies for Change, Lindquist (1978)
reported the results of case studies involving curricular and institutional
change on various college and university campuses. He distilled four
models of influence processes that, he concludes, help to delineate the
channels through which an innovation becomes accepted and stabilized.
Innovation—integrative training, in the current case—is best introduced
through a combination of the four change processes. The (1) rational idea is
effectively stated, (2) spread by means of informal social networks, (3)
linked to solutions by means of the problem-solving model, and (4) finally
ratified by the political process. All four models hold, in varying degrees,
depending on the situation and people involved. Therefore, an effective
change agent will orchestrate all four of the change processes in a flexible
way if he or she is to be fully effective.
Often at conferences dealing with psychotherapy integration, complaints
are voiced of resistance at one’s home institution to the introduction of
integrative ideas; indeed, in some settings, the member of Society for the
Exploration of Psychotherapy Integration (SEPI) may be the only proponent
of such ideas. One reason for this frustration may be that we tend to take the
rational model or one of the three other models as our sole view of change
processes, thereby missing the opportunity to exert influence within a
combination of models. Integrative ideas are best shared and implemented
by a sage synthesis of rational information, social network, problem-
solving, and politics.

FUTURE DIRECTIONS
In the future, formal training of mental health professionals will assuredly
continue using brand-name systems of psychotherapy but increasingly
within a comparative and integrative frame. Students will still learn the
major theories of psychotherapy but with knowledge of their respective
limitations, with respect for the research evidence, and with appreciation for
integration. We also expect increased training in integrative
psychotherapies, including those featured in this Handbook, many of which
prove the most popular for training purposes (Lampropoulos & Dixon,
2007).
 Theoretical pluralism and psychotherapy integration are here to stay in
training mental health professionals. Although the particular objectives and
sequences will invariably differ across programs, the vast majority of
training programs profess a pro-integration position. Training directors
indicate that they are committed to providing their students with significant
exposure to several different treatment approaches. And, in 80–90% of
programs, the attitudes of professors and students alike are positive toward
integration (Goldner-deBeer, 1999; Lampropoulos & Dixon, 2007).
In tech speak, most integrative training to date has been in the
“sandbox”—untested practices, outright experimentation, and learning from
our trials and errors. The bar has now been raised to mainstream
development, certification, and competence. In the future, the field expects
production of competent practitioners and research-supported training.
Psychotherapy integration is both a product and a process. As a product,
integration will be increasingly disseminated through books, videotapes,
courses, seminars, curricula, workshops, conferences, supervision,
postdoctoral programs, and institutional changes. Our hope is that educators
will develop and deliver integrative products that are more pluralistic and
effective than traditional, single-theory treatments.
Our more fervent hope is that, as a process, psychotherapy integration
will be disseminated in training methods and models consistent with the
openness of integration itself (Cooper & McLeod, 2011; Norcross, 2011).
Integration, by its very nature, will be a continuing process rather than a
final destination. The intention of integrative training is not necessarily to
produce card-carrying, flag-waving “integrative” or “eclectic”
psychotherapists. This scenario would replace enforced conversion to a
single orientation with enforced conversion to an integrative orientation, a
change that may be more pluralistic and liberating in content but certainly
not in process. Instead, our goal is to educate therapists to think and,
perhaps, to behave integratively—openly, synthetically, but critically—in
their clinical pursuits. Our aim is to prepare students to develop, if they
possess the motivation and ability, into knowledgeable integrative
therapists.
We join legions of others in predicting that psychotherapy training will
broaden beyond classic mental disorders in specific disciplines to health
behaviors in an interdisciplinary or interprofessonal healthcare. The more
comprehensive repertoire and flexible style of integrative therapists prepare
them to lead in treating behavioral components of chronic diseases, such as
smoking, alcohol abuse, unhealthy eating, and inadequate exercise that
account for half of all deaths (Mokdad et al., 2004). Behavioral health
services are emerging as part of the overall healthcare system, not apart
from it. And integrative therapists can be right in the middle of it, if training
keeps apace.
Psychotherapy training, we predict, will become more specific and
modular, as contrasted with grand theories. A module in education is a unit
of knowledge or skill that is virtually self-contained; a modular approach
builds skills and knowledge in discrete, largely independent units.
Psychotherapy students will be increasingly trained in responding to
specific, transdiagnostic patient challenges, such as responding
therapeutically to an alliance rupture, an oppositional patient, someone in a
particular stage of change, and the like. The responsive decision-making
may be expressed in a series of “when . . . then” statements (Norcross &
Wampold, 2019; Westra & Constatino, Chapter 13): When the client
presents with this (feature), then consider doing this; when there is a rupture
in the alliance, then consider doing these things. Balancing effectiveness
with responsiveness, the modular approach to integrative training has
shown promising results across theoretical boundaries, including with child
clients (Chorpita et al., 2015) and for personality disorders (Livesley et al.,
2015).
In all of training, competency has emerged as a central thrust. In two
recent Delphi polls on the future of psychotherapy (Norcross et al., 2013;
Taylor et al., 2018), attention to professional competence emerged as the
single highest rated item on training. That future stands in marked contrast
to a past where competence was occasionally defined, but rarely verified.
The educational system has assumed for generations that bright-enough
graduate students will make eager, competent practitioners. And that
competent practitioners will make competent educators and supervisors.
Folie à deux!
Competency benchmarks will be controversially incorporated into the
trainee’s learning goals and into the criteria for the supervisor’s evaluation
of the trainee’s performance. The same will probably occur for trainers’
competencies as well. Integrative training and supervision will be expected
to identity, assess, and verify competencies for all parties involved.
Competency can be nurtured through constant reflective and deliberate
practice. When not working with clients, therapists can repeatedly devote
time to improving their work, such as thinking about difficult cases,
securing consultation on specific skills, preparing and reflecting on
sessions, critiquing videotapes of previous sessions, and attending training
workshops (Castonguay & Hill, 2017; Wampold, 2017).
That sustained practice will assuredly focus on facilitative relationship
skills that account for the lion’s share of outcome variance (Norcross &
Lambert, 2019)—second only to the patient’s contribution—and that serve
as the quintessential common factor in psychotherapy. The therapeutic
alliance, alliance rupture repairs, collaboration, empathy, support, gathering
client feedback, responsiveness, and other interpersonal skills can be taught
and learned (e.g., Crits-Christoph et al., 2006; Harris et al., 2016; Smith-
Hansen, 2016). Technological advancements allow psychotherapists,
neophyte and seasoned alike, to study their in-session relational behavior
and improve on it. That’s the relentless and enthusiastic lifelong learning
that we ideally inculcate in our students; that’s the adaptiveness and
openness to challenges that distinguishes the passionately committed
psychotherapist from the run-of-the-mill therapist (Dlugos & Friedlander,
2001).
As yet, there is little controlled research on integrative training and
supervision. We do not know, in an empirical sense, which training process
works best for which situation. We expect and welcome the generation of
reciprocal linkages among practitioners, trainers, and researchers on the use
of integrative approaches in mental health interventions (Cooper, 2008;
Fernández-Álvarez et al., 2016). That will enlighten our understanding of
which training process works best for which situation.
The Magna Charta Universitatum is a document signed by 388 rectors
and heads of universities from all over Europe and beyond in 1988, the
900th anniversary of the University of Bologna. Its second principle reads:
“Teaching and research in universities must be inseparable if their tuition is
not to lag behind changing needs, the demands of society, and advances in
scientific knowledge” (www.magna-charta.org/magna-charta-
universitatum). That principle encapsulates our hopes for integrative
training in the future—inseparable from the grand adventure of research.

ACKNOWLEDGMENTS
The authors gratefully acknowledge Drs. Richard P. Halgin and John D. W.
Andrews for co-authoring this chapter in previous editions of this
Handbook.

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 19

Outcome Research on Psychotherapy Integration

JAMES F. BOSWELL, MICHELLE G. NEWMAN, AND LATA K. MCGINN

Recent surveys demonstrate that approximately one-third of American

mental health professionals identify themselves as “integrative” (and,
occasionally, “eclectic”) in theoretical orientation (Norcross & Karpiak,
2012; Norcross & Rogan, 2013). Attempts to integrate ostensibly distinct
models of psychotherapy can be dated back to the 1930s (Dollard & Miller,
1950; French, 1933; Rosenzweig, 1936), yet many decades would pass
before there was outcome research conducted on psychotherapy integration.
A number of factors have motivated the development, testing, and
implementation of integrative therapies (Norcross, 2005; Norcross &
Alexander, Chapter 1, this volume). For example, many patients do not
respond to frontline treatments, and extant outcome research on “pure
form” psychotherapies points to considerable room for improvement
(Lambert, 2013). In addition, some patients decline and/or drop out of
treatment with “pure-form” psychotherapies, suggesting that adaptations
may be necessary to make these treatments more palatable. Clinicians and
researchers recognize the limits of a particular theoretical model and its
associated techniques when applied to particular types of patients and
contexts (Goldfried et al., 2014). In addition, since many therapists adopt an
integrative approach, progress in the field is dependent on identifying and
operationalizing their integrative process, subjecting it to rigorous empirical
scrutiny, and disseminating this information to stakeholders.
The second edition of the Handbook of Psychotherapy Integration
(Norcross & Goldfried, 2005) provided a review of the outcome research on
29 integrative psychotherapies (Schottenbauer, Glass, & Arnkoff, 2005).
Here, we provide an updated review of the outcome literature on
psychotherapy integration, with particular attention to studies conducted
between 2004 and 2017, as well as recent trends in psychotherapy
integration. We will summarize conclusions made in the prior review yet
direct readers to the previous volume for a more thorough review
(Schottenbauer et al., 2005). In addition, we discuss the difficulties inherent
in conducting this research and suggest future directions for outcome
research on psychotherapy integration.
In updating this chapter, we largely adopted the criteria and structure
established in the previous edition. Specifically, we do not include
integration of psychopharmacology and psychotherapy, nor do we include
integration of treatment formats/modalities. We primarily focus on
individual psychotherapy for adults, with a brief review of family, couples,
and group modalities. Less empirical research exists on bona fide
integrative therapies for children. As noted in the prior review
(Schottenbauer et al., 2005), although much of the treatment for children
may be integrative for pragmatic reasons, it is rarely identified formally as
integrative (Chorpita et al., 2002). In addition, this review is largely
restricted to studies published in the English language.
Several challenges emerge when reviewing outcome research on
psychotherapy integration. First, it is difficult to define what constitutes
integrative psychotherapy. We restricted our review to therapies that
explicitly described themselves as eclectic or integrative. For example,
some therapies may acknowledge an eclectic heritage, yet primarily retain a
pure-form identity (e.g., feminist therapy); such therapies were not included
in this review. A related challenge occurs when therapies are described
inconsistently across studies, making it difficult to ascertain if the same set
of procedures have been implemented (e.g., emotion-focused therapy (EFT)
vs. person-centered experiential therapy). We focused on integrative
treatments with some standardized “core.” This did not require the use of a
treatment manual per se; rather, an established documentation of theory,
guiding principles, and/or procedures facilitated (or could facilitate) valid
replication. Inconsistent use of terms and conflation of distinct treatments
also creates difficulties when drawing conclusions from existing systematic
reviews and meta-analyses. Consequently, we summarized reviews and
syntheses where conclusions regarding integrative treatments of interest
could be drawn with relative confidence.
 A second challenge is the multiple and diverse pathways through which
psychotherapists integrate. Similar to previous work that has attempted to
categorize different pathways or routes (Boswell & Goldfried, 2010;
Norcross, 2005), we distinguish among four types of psychotherapy
integration. The first is assimilative integration, which is defined as: “the
incorporation of attitudes, perspectives, or techniques from an auxiliary
therapy into a therapist’s primary, grounding approach” (Messer, 2001, p.
1). A second type is theoretical integration, in which a clear theory drives
the choice of techniques. Unlike assimilative integration, the theory is not
necessarily derived primarily from a single type of mainstream
psychotherapy; it may be developed from an amalgam of two or more
theories, developed anew, or imported from a relevant field (e.g., social-
ecological theory). The choice of techniques is guided by the theory and
may include techniques from one or more systems of psychotherapy. The
third type of psychotherapy integration discussed in this chapter is technical
eclecticism, which has been defined as the use of psychotherapy techniques
without regard to their theoretical origins (Norcross, 2005). A fourth type or
path toward integration is the common factors or processes approach.
However, by its very nature, common factor therapies are rarely researched
as distinctive treatments in outcome studies. Hence, they are not considered
here; more information on common factors can be found in the chapters by
other authors in this volume (Eubanks & Goldfried, Chapter 4, this volume;
Wampold & Ulvenes, Chapter 3, this volume).
Within each type of integration, we distinguish between therapies
designed for multiple disorders and those created to address a specific
disorder(s). A list of integrative psychotherapies covered in the chapter,
along with their degree of empirical support to date, is presented in Table
19.1. The three levels of empirical support are substantial empirical support
(four or more randomized controlled studies [RCTs]), some empirical
support (one to three randomized controlled studies), and preliminary
empirical support (studies with no control group or a nonrandomized
control group). As some of the treatments reviewed here have dedicated
chapters in this Handbook, more detailed information about treatment
development and outcome research can be found there.
TABLE 19.1 Level of research support for integrative psychotherapies
Substantial Some Preliminary Randomized Reviewed
empirical empirical empirical controlled in
support (4 or support (1 to support studies since previous
more 3 randomized 2004 edition
randomized controlled
Name of controlled studies)
therapy Reference studies)
Dialectical Linehan Yes -- -- Yes Yes
behavior (1993)
therapy
Cognitive Ryle & Kerr Yes -- -- Yes Yes
analytic therapy(2002)
Multisystemic Henggeler Yes -- -- Yes Yes
therapy et al. (1998)
TranstheoreticalProchaska, Yes -- -- Yes Yes
psychotherapy DiClemente,
& Norcross
(1992)
Systematic Beutler & Yes -- -- Yes Yes
treatment Harwood
selection (2000)
Emotion- Elliott et al. Yes -- -- Yes Yes
focused therapy (2004)
Emotion- Greenberg Yes -- -- Yes Yes
focused couple & Johnson
therapy (1988)
Cognitive McCullough Yes -- -- Yes Yes
behavioral (2002)
analysis system
of
psychotherapy
Outcome- Miller et al. Yes -- -- Yes Yes
informed (2005)
psychotherapy
Brief eclectic Gersons et Yes -- -- Yes Yes
psychotherapy al. (2000)
for PTSD
Behavioral Robin et al. Yes -- -- Yes Yes
family systems (1999)
therapy
Attachment Diamond Yes -- -- Yes No
based family (2014)
therapy
Schema therapy Young -- Yes -- Yes No
(1990)
CBT + Newman et -- Yes -- Yes Yes
interpersonal al. (2004)
/emotional
processing
therapy for
GAD
Brief relational Safran et al. -- Yes -- Yes Yes
therapy (2000)
MI + CBT for Westra et al. -- Yes -- Yes No
GAD (2009)
Complicated Shear et al. -- Yes -- Yes No
grief therapy (2005)
Integrative Castonguay -- Yes -- Yes Yes
cognitive et al. (2004)
therapy for
depression
Integrative Jacobson & -- Yes -- Yes Yes
behavioral Christensen
couple therapy (1996)
Multimodal Lazarus -- Yes -- No Yes
therapy (2005)
Integrative Wonderlich -- Yes -- Yes No
cognitive- et al. (2010)
affective
therapy for
bulimia nervosa
Integrative Chambless -- Yes -- No Yes
treatment for et al. (1986)
agoraphobia
Systemic Alexander -- Yes -- Yes Yes
behavioral & Parsons
family therapy (1982)
Cognitive Duignan & -- Yes -- Yes Yes
analytic group Mitzman
therapy (1994)
Pluralistic Cooper & -- -- Yes No No
therapy McLeod
(2011)
Integrative Calderon -- -- Yes No Yes
psychotherapy (2003)
for personality
disorders
Developmental Ivey (2000) -- -- Yes No Yes
counseling and
therapy
Bergen project Nielsen et -- -- Yes No Yes
(fiat model) al. (1987)
Integrative Morgan et -- -- Yes No Yes
group treatment al. (1999)
Notes: MI, motivational interviewing; CBT, cognitive-behavioral therapy; GAD, generalized anxiety
disorder. PTSD, posttraumatic stress disorder.

ASSIMILATIVE INTEGRATION
As we have noted earlier, assimilative integration consists of a home
theoretical orientation explicitly augmented by specific techniques from one
or more exogenous systems. Examples include emotion-focused (or
process-experiential) therapy, integrative cognitive therapy (ICT),
integrative cognitive-affective therapy (ICAT) for bulimia nervosa,
cognitive-behavioral therapy (CBT) plus interpersonal-emotional
processing (I/EP), motivational interviewing (MI) plus CBT, and
complicated grief treatment (CGT). In this section, we will summarize the
state of the outcome research for these respective treatments.

Therapies Originally Designed for Multiple Disorders

To our knowledge, EFT is the only assimilative treatment with controlled
research that was not originally designed to treat a specific disorder.
Although most of the controlled research has been done in depression, its
principles and techniques are intended to be broadly applicable to a wide
range of presenting problems.

Process-Experiential/Emotion-Focused Therapy
EFT, also referred to as process-experiential therapy (Elliott et al., 2004;
Watson & Greenberg, 2017) was developed for individual (Greenberg &
Watson, 1998) and couple formats (Greenberg & Johnson, 1988; Johnson,
Hunsely, Greenberg, & Schindler, 1999), both of which have been tested in
several outcome studies. Couple therapy research is included later in this
chapter. Individual EFT integrates person-centered and experiential/gestalt
methods for specific client markers. Several key experiential interventions
(e.g., empty chair) have their origins in gestalt therapy, yet, unlike gestalt
therapy, there is more explicit attention to the therapeutic relationship. As
noted, EFT is designed to be applied across a spectrum of problem areas,
yet most of the outcome research to date has focused on depression (e.g.,
Greenberg & Watson, 1998; Watson et al., 2003), as well as some recent
work on anxiety and trauma disorders.
Schottenbauer and colleagues (2005) reviewed the results of two RCTs
that compared EFT to person-centered therapy (PCT) for depression.
Overall, EFT outperformed PCT on most symptom and functioning
measures. Subsequently, another study reported results from a depression
RCT comparing EFT with PCT that included 38 treatment completers
(Goldman, Greenberg, & Angus, 2006). Although EFT and PCT
significantly increased self-esteem, reduced depression symptoms, and
improved interpersonal functioning, EFT led to more improvement on most
measures. In the same sample, EFT clients evidenced a significantly lower
relapse rate over 18 months compared to person-centered clients, as well as
maintenance of symptom and self-esteem gains (Ellison et al., 2009).
In a trial that involved socially anxious clients, EFT evidenced superior
outcomes to standard PCT (Elliott et al., 2013; Rodgers & Elliott, 2012).
There were small to large Cohen’s d effect size differences across outcome
measures, with an average effect size (d = .62) that was comparable to
previous trials (e.g., Goldman et al., 2006). However, the comparative
samples were relatively small, and EFT clients received more sessions on
average.
After controlling for researcher allegiance (Elliott et al., 2013), a meta-
analysis of humanistic psychotherapies more broadly concluded that the
efficacy of EFT was not statistically different from CBT. Outcome research
continues to support the efficacy of EFT for depression and, more recently,
social anxiety; EFT appears to be more effective than PCT yet does not
appear to be more (or less) effective than CBT when direct comparisons
have been conducted (Elliott et al., 2013). (For a more comprehensive
review of EFT literature, readers are directed to Elliott et al. [2013] and
Angus et al. [2015].)

Therapies Originally Designed for a Specific Disorder

Several assimilative treatments have been designed to target specific
disorders, including generalized anxiety disorder (GAD), major depressive
disorder, eating disorders, and complicated grief. Each of the treatments
described below has been tested in at least one RCT.

Integrative Cognitive Therapy for Depression

Castonguay and colleagues (2004) developed and initially tested ICT for
depression, which adds techniques from humanistic and interpersonal
therapies to cognitive therapy for depression to address alliance ruptures.
An alliance rupture reflects negative shifts in the patient–therapist bond or
sense of coordinated collaboration (Safran, Muran, & Eubanks-Carter,
2011). The crux of this approach involves the therapist (a) inviting patients
to speak directly about potential problems in the therapy relationship, (b)
exploring and validating patients’ experience of the rupture, and (c) taking
some responsibility for the rupture by recognizing that relational problems
are inherently dyadic processes.
In an RCT with depressed patients, the ICT group did significantly better
statistically and clinically than a wait-list control on two measures of
depression and on global functioning. A subsequent small RCT (N = 22)
showed that ICT led to greater posttreatment improvement in depression
and global symptom severity and more clinically significant change than
did standard cognitive therapy (Constantino et al., 2008).

Integrative Cognitive-Affective Therapy for Bulimia Nervosa

ICAT (Wonderlich et al., 2015) for bulimia nervosa is informed by emotion
science and self-discrepancy theory and research. ICAT integrates MI, less
traditional CBT strategies, and experiential exercises. It has many
commonalities with standard CBT, which represents its broader framework,
yet it does not include formal cognitive restructuring. Studies demonstrate
that negative emotional states often precipitate bulimic symptoms (Haedt-
Matt & Keel, 2011; Smyth et al., 2007) and that negative emotions may
temporarily subside after bulimic behaviors occur (Smyth et al., 2007). A
self-oriented cognition described as “self-discrepancy”—involving the
difference between a person’s self-perception and his or her self-evaluative
standards—may be an important aspect of eating disorder (Strauman et al.,
1991). Integrative ICAT emphasizes emotion regulation, adaptive coping,
self-directed behaviors, interpersonal relationships, and self-oriented
cognitive patterns including self-discrepancy (Wonderlich et al., 2010).
In an RCT, there were no significant differences between ICAT and a
transdiagnostic CBT (Fairburn, 2008), yet both were associated with
significant improvement in bulimia symptoms and other outcomes at end of
treatment and follow-up (Wonderlich et al., 2014). A current trial is under
way comparing ICAT with CBT-guided self-help for binge eating disorder
(https://clinicaltrials.gov/ct2/show/NCT02043496).
CBT and Interpersonal/Emotional Processing Therapy for Generalized
Anxiety Disorder
Newman and associates (2004) developed and tested the efficacy of an
interpersonal and EFT for GAD, used together with CBT. Based on findings
that some clients with GAD did not improve with typical CBT (Borkovec et
al., 2002) and have difficulty with interpersonal problems (Przeworski et
al., 2011) and emotional processing (Llera & Newman, 2010), this therapy
integrates techniques from humanistic, interpersonal, and psychodynamic
treatments with traditional CBT. One hour of CBT was followed by 1 hour
of I/EP, so that the therapies were kept as distinct components.
Targeting intrapersonal aspects of anxious experience, CBT proceeded
through the following steps: (a) identifying anxiety- and worry-associated
triggers via self-monitoring and early cue detection techniques; (b)
therapeutic rationale; (c) systematic training in diaphragmatic breathing,
progressive and applied relaxation; (d) self-control coping desensitization
(relaxation paired with worry trigger imagery); (e) cognitive restructuring;
(f) behavioral tests of alternatives; and (g) long-term maintenance of new
skills/coping. Cognitive techniques used were individualized and included
development of coping self-statements, identification of cognitive
predictions and interpretation about the threatening nature of events/cues,
cognitive challenge and logical analysis, examination of evidence, labeling
of logical errors, generation of alternative thoughts, and worry outcome
monitoring.
The I/EP segment had several goals: (a) identification of interpersonal
behavior that attempted to satisfy needs, (b) generation of more effective
interpersonal behavior to better satisfy needs, and (c) identification and
processing of avoided emotion associated with all therapeutic content. The
interventions were based on the following principles: emphasis on
emotional experience; therapists’ use of their own emotional experiences to
identify points of intervention; use of the therapeutic relationship to explore
affective processes and interpersonal patterns; provision of homework
experiments; detection of alliance ruptures and provision of emotionally
corrective experiences in their resolution; processing of patient’s affective
experiencing in relation to past, current, and in-session interpersonal
relationships using emotion-focused techniques (e.g., Greenberg, 2002);
and skill training methods to provide more effective interpersonal behaviors
to satisfy identified needs.
 In a small sample of clients, a larger percentage improved in the
integrative CBT and I/EP treatment than in CBT plus supportive listening
(SL). Improvements were maintained at 6 months and 1 year (Newman et
al., 2008). A much larger RCT found no significant difference between the
two compared conditions (Newman et al., 2011). However, in a subsequent
secondary analysis, those with a dismissive attachment style responded
significantly better to CBT + I/EP than to CBT + SL up to 2-year follow-up
(Newman et al., 2015). This finding suggested that individuals who tend to
be avoidant of emotional processing and interpersonal closeness might do
better with a structured and intense treatment that specifically focuses on
emotion and relationship issues, including with the therapist. However,
more empirical work needs to be done to strengthen this interpretation.

Motivational Interviewing and CBT for Anxiety

Westra and colleagues (e.g., Westra & Dozois, 2006) developed and tested
the integration of MI procedures into CBT for anxiety disorders. MI (Miller
& Rollnick, 2002) was designed to increase intrinsic motivation and
decrease ambivalence about change. In MI, the therapist tries to help the
client become his or her own advocate for change. The four principles of
MI are (1) express empathy, (2) develop discrepancy between the
undesirable behaviors and values that are inconsistent with those behaviors,
(3) roll with resistance rather than confronting it directly, and, (4) support
self-efficacy. Many MI skills come directly from traditional client-centered
therapy (e.g., affirming, summarizing). MI therapists also employ
decisional balance procedures to help clients explore and weigh the pros
and cons of change.
An initial study comparing a group of CBT patients who received no
pretreatment MI to a group of CBT participants who received three sessions
of “pretreatment” MI found that the pretreatment MI group had a higher
number of responders than the CBT-alone group (Westra & Dozois, 2006).
Subsequently, a similar RCT comparing MI plus CBT (MI-CBT) to CBT
alone for GAD observed significant group differences favoring the MI-CBT
group on worry reduction (Westra, Arkowitz, & Dozois, 2009). The size of
this difference was more pronounced for patients with higher worry severity
at baseline. However, neither of these studies controlled for the additional
sessions and therapist contact in the MI-CBT.
 A follow-up study replicated and extended the preceding findings in an
RCT that controlled for allegiance effects and therapist contact (Westra,
Constantino, & Antony, 2016). Patients in MI-CBT received four sessions
of MI followed by 11 sessions of CBT integrated with MI; patients in CBT
alone received 15 sessions of just CBT. In the MI-CBT condition, therapists
were trained to attend and respond to markers of patient
resistance/ambivalence and respond with MI-consistent strategies.
No between-group differences were observed between pre- and
posttreatment; however, fewer patients dropped out in the integrative
therapy condition, and outcome differences did emerge at 12-month follow-
up. Patients who received MI-CBT demonstrated a steeper decline in worry
and general distress at follow-up; they were also significantly less likely to
meet diagnostic criteria for GAD when compared to patients who received
CBT alone. In summary, the assimilation of MI strategies into CBT for
GAD is associated with better long-term outcomes than CBT alone.
Therapists who deliver CBT can be trained to identify markers of resistance
and ambivalence and to respond with MI-consistent strategies.

Complicated Grief Treatment

CGT (Shear et al., 2005) is a broadly CBT approach that incorporates
elements of interpersonal psychotherapy (IPT), experiential therapy, and
MI. For example, it incorporates the use of chair work, where the client
“interacts” with the deceased. CGT also relies heavily on attachment theory
enriched by self-compassion (Germer & Neff, 2013) and self-determination
theory (Ryan & Deci, 2000). CGT has shown strong positive outcomes in
three separate RCTs. This has been manifested by reductions in complicated
grief and depression symptoms, suicidal ideation, and global functional
impairment.
Results from the first RCT comparing CGT with IPT in a sample of 95
adults suffering from complicated grief showed that both treatments
produced symptom improvements, yet the overall response rate and
trajectory significantly favored CGT (Shear et al., 2005). A follow-up study
subsequently compared CGT with grief-focused IPT in a larger sample of
elderly persons (Shear et al., 2014). Once again, CGT produced
significantly higher response rates. In a more recent trial, CGT alone was
compared with antidepressant medication in a placebo-controlled RCT
(Shear et al., 2016). CGT with placebo outperformed placebo alone in terms
of complicated grief symptoms, and the addition of the active medication
(citalopram) did not significantly improve CGT outcomes. However, the
combination of CGT and medication evidenced significantly greater
improvements in co-occurring depression symptoms.
Recent years have witnessed the development of several efficacious
assimilative treatments, the foundational orientations of which have been
largely cognitive-behavioral and humanistic. In addition, integrative
treatments such as ICT, MI plus CBT, and CGT have outperformed a
standard pure-form treatment in at least one outcome trial. The
methodological rigor (e.g., random assignment, fidelity assessment, sample
size) of these outcome studies is also impressive.

THEORETICAL INTEGRATION
Theoretically driven integration represents an amalgam of two or more
theories. Those theories may be existing psychotherapy approaches, newly
developed perspectives, or imported from a relevant discipline (e.g., social
ecological theory, personality theory). The methods similarly hail from two
or more systems of psychotherapy.

Therapies Originally Designed for Multiple Disorders

In the following section, we summarize the outcome research for the
following integrative treatments: transtheoretical psychotherapy, cognitive
analytic therapy (CAT), brief relational therapy (BRT), and schema therapy.
Each of these therapies was developed to be applicable to a broad range of
presenting problems.

Transtheoretical Psychotherapy
The Transtheoretical Model (TTM; Prochaska & DiClemente, Chapter 8,
this volume; Prochaska & DiClemente, 2005;Norcross, Krebs, &
Prochaska, 2011) posits five stages of change (precontemplation,
contemplation, preparation, action, and maintenance), with specific
processes of change to be used at specific stages. Clients in the
precontemplation stage, which is defined as being undisturbed by or
unaware of problems, and not intending to change, are at risk for
terminating therapy prematurely. Processes of change are activities and
experiences engaged in by individuals when they attempt to change, either
within or outside of therapy, such as consciousness-raising,
counterconditioning, and helping relationships.
Multiple meta-analyses demonstrate that certain change processes are
especially beneficial at particular stages of change or to facilitate patient
progress. For example, clients in the action stage are likely to be more
receptive to directive interventions that prompt engagement in new
behaviors within and outside therapy, whereas clients in the
precontemplation stage are more likely to benefit from interventions aimed
at increasing problem awareness and motivation to change.
A considerable amount of empirical evidence has been gathered in
support of the TTM (Prochaska & Norcross, 2014; Rosen, 2000). Hundreds
of studies have focused on its efficacy on health behaviors, while fewer
have examined its applicability to mental health. A meta-analytic review of
39 psychotherapy studies (N = 8,238 patients) involving diverse diagnoses
reported that stages of change robustly predicted treatment outcomes,
including premature termination (mean effect size of d = .46; Norcross et
al., 2011). This finding highlights the importance of assessing clients’
stages of change before and throughout treatment. The therapist should take
care to match treatment goals and tasks to the client’s stage, including
refraining from premature implementation of action-oriented interventions.
A separate review of six RCTs that utilized TTM for adolescent smoking
cessation demonstrated higher quit rates for TTM compared to control
conditions; that is, the implementation of stage-based interventions was
associated with a higher likelihood of cessation (Robinson & Vail, 2012). In
RCTs, stage-matched treatments have also outperformed treatment-as-usual
for stress, depression, and partner violence. The depth and diversity of stage
of change and TTM-related research over four decades precludes a
comprehensive review in this chapter (see Prochaska & DiClemente,
Chapter 8, this volume; Prochaska & Norcross, 2018; Velicer et al., 2013).

Cognitive Analytic Therapy

CAT (Ryle, 2005) is a synthesis of CBT and psychoanalytic object
relations, and includes a series of interventions that can be applied in a
time-limited format. The main emphasis is on reformulating clients’
problems regarding problematic patterns of relating to self and others (Ryle
& Kerr, 2002). The Self States Sequential Diagram is employed to visually
depict the self-maintaining nature of clients’ sequences of beliefs,
perceptions, roles, actions, and their consequences. At the end of therapy,
therapists write a letter to clients summarizing what they have learned about
the clients (Ryle & Kerr, 2002).
RCTs of CAT have been conducted for a variety of presenting problems
(e.g., Clarke, Thomas, & James, 2013), yet most have been for personality
and eating disorders and fewer for anxiety, depression, or bipolar disorder
(Calvert & Kellett, 2014; Evans, Kellett, Heyland, Hall, & Majid, 2017). In
a systematic review of 25 CAT outcome studies, five of which were RCTs,
44% focused on personality disorders (Calvert & Kellett, 2014). A
subsequent review examined uncontrolled effect sizes across 21 studies
utilizing various designs and reported an overall effect size of d = 0.81
(Simmonds, 2016). All authors concluded that CAT is effective, but not
more efficacious than other active treatments.

Brief Relational Therapy

Safran and Muran (2000) developed BRT, which combines maintaining an
alliance and resolving alliance ruptures with elements of relational
psychoanalysis, humanistic/experiential therapy, and contemporary theories
of cognition and emotion. BRT is focused on creating the patient’s
awareness of self in the interpersonal context and relies heavily on the
identification and resolution of alliance ruptures. Alliance rupture repairs
involve a process of meta-communication about the therapeutic relationship
and the role of the therapist with regard to the patient’s needs. The alliance
rupture resolution consists of four steps: attention to markers that indicate
the alliance rupture, exploration of the experience, examination of any
avoidance of exploration of the ruptured alliance, and, finally, emergence of
a wish or need.
Several RCTs of BRT have been published to date. In a RCT of 128
personality-disordered clients, although all groups improved equally, BRT
was better at reducing dropout than short-term dynamic therapy (STDT) or
brief CBT. In addition, BRT and CBT showed more clinical improvement
than STDT (Muran et al., 2005).
Of the clients randomly assigned to STDT or CBT in another trial
(Muran et al., 2005), 18 identified as high-risk for treatment failure were
offered reassignment (Safran et al., 2005). These clients then received BRT,
STDT, or short-term CBT. Among those who opted to be reassigned (n =
10), 60% of those in BRT had good outcome, whereas 100% of those in the
dynamic and CBT treatments dropped out. In an open trial that included 30
sessions of BRT with 22 mixed-diagnosis patients, within-patient analyses
demonstrated significant, positive pre/post changes on global symptoms,
target complains, and interpersonal functioning (Rozmarin et al., 2008).
Overall, the results of BRT indicate that clinicians would do well to
attend to markers of ruptures in the alliance, as well as to integrate
strategies aimed at their repair. Such strategies may reduce the risk of
dropout and negative outcome; however, such a conclusion should be made
with caution given the relatively small sample sizes in these studies.

Schema Therapy
Schema therapy was developed by Young (1990) to meet the needs of
patients with personality disorders and characterological problems. It
combines cognitive-behavioral, interpersonal, and experiential techniques
to bring about change (Martin & Young, 2010; McGinn & Young, 1996;
Young, Klosko, & Weishaar, 2003).
Although intended for the treatment of varying personality disorders,
schema therapy to date has been evaluated for treatment of borderline
personality disorder (BPD) and has received some empirical support. It was
initially shown to be effective in a series of six single case reports (Nordahl
& Nysaeter, 2005). Since then, two RCTs have demonstrated its efficacy in
BPD and shown that it was more effective than treatment as usual and
transference-focused psychotherapy (Farrell, Shaw, & Webber, 2009;
Giesen-Bloo et al., 2006). (A more detailed account of these studies can be
found in Leahy and McGinn [2012].)

Therapies Originally Designed for a Specific Disorder

In the following section, we summarize the outcome research for the
following integrative treatments: dialectical behavior therapy (DBT),
multisystemic therapy (MST), and cognitive behavioral analysis system of
psychotherapy (CBASP). It is notable that each of these therapies was
designed to treat difficult patient populations—BPD, conduct disorder, and
chronic depression, respectively.
Dialectical Behavior Therapy
Linehan’s (1993, 2015) DBT for individuals with BPD is the most studied
integrative therapy for a particular disorder and is considered to have
“strong” research support based on empirically supported treatment criteria
(Chambless & Ollendick, 2001). DBT integrates dialectics into CBT (Heard
& Linehan, 1994; Chapter 12, this volume). Interventions such as
mindfulness, acceptance, and focusing on dialectical processes are
integrated into a framework consisting of more traditional cognitive-
behavioral interventions, such as interpersonal reinforcement and problem-
solving (Linehan, 2015). Offered as both individual sessions and in skill-
building groups, problematic interpersonal and intrapersonal processes of
the clients are addressed by an emphasis on dialectical processes to resolve
their tendency to vacillate between the extremes of the dialectical poles.
Outcome research on DBT has been extensive, and several meta-analyses
and systematic reviews of the efficacy and effectiveness of DBT for BPD
have been conducted. A meta-analysis focused on 16 BPD studies,
including eight RCTs, found a moderate global effect and a moderate effect
size for suicidal and self-injurious behaviors (Kliem, Kroger, & Kosfelder,
2010). Similar results were reported in a meta-analysis that included five
RCTs wherein DBT demonstrated significant reductions in suicide and
parasuicidal behavior compared to treatment as usual (Panos et al., 2014).
A Cochrane review of BPD RCTs found moderate to large statistically
significant effects favoring DBT versus treatment as usual on anger (d =
−0.83), parasuicidality (d = −0.54), and general mental health (d = 0.65;
Stoffers-Winterling et al., 2012). In addition, in a systematic review of
nonrandomly assigned DBT for inpatients, 11 studies reported pre- and
posttreatment BPD symptoms and noted significant heterogeneity in the
therapy components and approaches utilized. Nonetheless, most studies
reported reductions in suicidal ideation, self-injurious behavior, and
depression and anxiety symptoms (Bloom et al., 2012).
Additional studies have supported the effectiveness of DBT for
difficulties beyond BPD, including substance use (e.g., Linehan et al., 1999,
2002), eating disorders, and depression (e.g., Lynch et al., 2003). In a meta-
analysis of four DBT studies with a between-group analysis (N = 202
patients), there was a large effect size in problematic eating behavior
reduction favoring DBT (Lenz et al., 2013). Overall, DBT is efficacious for
BPD and has accumulated support for its implementation in other problem
areas.

Multisystemic Therapy
MST (Henggeler et al., 1998, 2002) is an integrative treatment for youth
with antisocial behaviors. Grounded in systems theory and social ecology,
MST uses a range of multitheoretical techniques and a positive, present-
oriented focus. Interventions are primarily CBT, structural, and systemic;
individual, family, and community sessions are employed flexibly.
Strengths in the client’s systems are used as levers for change. A
hypothesis-testing approach is used to develop theories regarding reasons
for behavioral maintenance.
Numerous studies have found empirical support for MST in the treatment
of delinquent adolescents, serious juvenile offenders, and substance-abusing
juvenile offenders in comparison to wait-lists and treatment us usual
(Schottenbauer et al., 2005). One of the larger efficacy studies of 176
violent and chronic juvenile offenders found improvements in family
relationships and reductions in recidivism (Borduin et al., 1995). A follow-
up study showed a 36% reduction in felony arrests from MST (Borduin,
Schaeffer, & Heiblum, 2009). MST has also demonstrated effectiveness in
naturalistic studies (e.g., Henggeler, Pickrel, & Brondino, 1999). A meta-
analysis of 22 MST outcome studies (N = 4,066) found small but significant
effects on delinquency, psychopathology, substance use, family
relationships, and out-of-home placements. MST was most effective with
juveniles under the age of 15 with severe baseline severity (Van der Stouwe
et al., 2014).

Cognitive Behavioral Analysis System of Psychotherapy

CBASP (see McCullough, 2002; McCullough & Schramm, Chapter 14, this
volume) was developed to treat chronically depressed clients. It understands
depression through a combination of developmental (Piagetian), cognitive,
and interpersonal theories; interventions include a mix of CBT and
interpersonal techniques. CBASP is similar to CBT approaches in that it is
structured, focuses on teaching social problem-solving skills, and utilizes
homework assignments. It has similarities with IPT in its focus on
interpersonal problems. Consistent with psychodynamic psychotherapy, the
relationship with the therapist is used to help patients become more aware
of their impact on others and distinguish between adaptive and maladaptive
relationships (McCullough, 2000).
A major technique used in CBASP is a multiple-phase situational
analysis (SA). In SA, patients identify a recent, distressing interpersonal
situation and examine it with the therapist. In the initial elicitation phase,
patients describe (a) an interpersonal event, (b) their interpretation of what
occurred, (c) their behavior, (d) the outcome of the event, (e) what they
would have liked the outcome to be, and (f) whether the desired outcome
was achieved. In the subsequent remediation phase, patients work with the
therapist to revise their interpretations, behaviors, and/or desired outcome
during the situation to increase the probability of achieving the desired
outcome. In the final generalization phase, patient and therapist review
what has been learned and explore how the patient’s new understanding and
skills can be applied to similar situations in the future.
The effectiveness of CBASP has been examined in multiple RCTs and
meta-analyses (e.g., Kocsis et al., 2009; Michalak Schultze, Heidenreich, &
Schramm, 2016; Schramm et al., 2011; 2015). Klein et al. (2004) reported
results from the psychotherapy arm of the maintenance phase of a large
multisite chronic depression trial (Keller et al., 2000) that found positive
results for both CBASP alone and combined with pharmacotherapy. Their
analysis involved 82 patients who had responded to acute and continuation-
phase CBASP and were subsequently randomized to monthly CBASP or
assessment only for 1 year. Significantly fewer patients in the CBASP than
in the assessment-only condition experienced a recurrence. The two
conditions also differed significantly on change in depressive symptoms
over time.
A meta-analysis that included 16 trials conducted on acute treatments for
chronic depression found no significant differences between CBASP and
medication (Kriston et al., 2014). For the treatment of chronic major
depression, CBASP plus medication was recommended with moderate
strength. Another meta-analysis conducted on six studies of CBASP for
chronic depression found that CBASP was moderately more effective than
treatment as usual and IPT, and of comparable effectiveness to
antidepressant medication (Negt et al., 2016).
In summary, CBASP proves an effective approach for patients with
chronic depressive disorder. CBASP has consistently outperformed
treatment as usual and is comparable to antidepressant medication. It is
unclear yet if it demonstrates differential efficacy when compared directly
to other bona fide psychotherapies for depression, such as IPT. It is
important not to miss the fact that CBASP shares elements of IPT.
Additional research is needed to determine the types of patients for whom
CBASP is likely to be particularly helpful.
To sum up: Several approaches that fall under the category of
transtheoretical integration have garnered significant research support
across multiple controlled trials. Substantial evidence supports the
effectiveness of the TTM, DBT, MST, and CBASP, specifically. Fewer
well-powered controlled investigations have been conducted on CAT, BRT,
or schema therapy, yet the results have been promising with regard to their
effectiveness across a range of disorders. The differential efficacy of these
treatments when compared to other bona fide, pure-form therapies is mixed,
however.

TECHNICAL ECLECTICISM
As noted earlier, technical eclecticism involves the use of effective methods
drawn from different schools of therapy without subscribing to their
underlying theoretical foundations. At the same time, technical eclectics
argue for a systematic approach in choosing methods and tailoring them to
individual clients. Thus, multimodal therapy (MMT; Lazarus & Lazarus,
Chapter 6, this volume) relies on empirical research and clinical experience
to determine which techniques to employ for given patient problem.
Systematic treatment selection (STS; Consoli & Beutler, Chapter 7, this
volume) uses research reviews determine which patients are most likely to
benefit from different interventions. As such, technical eclecticism is
closely tied to empiricism.
Given the flexibility and diverse nature of technical eclecticism, it proves
more difficult to subject such treatments to traditional comparative efficacy
research. A therapist’s methods and relationship stances are likely to change
patient to patient. Treatment components or change principles may have
garnered robust empirical support, yet RCTs might not have tested their
delivery in a standardized sequence. Nevertheless, several eclectic
psychotherapies have accumulated notable empirical support.
Therapies Originally Designed for Multiple Disorders
In the following section, we summarize the outcome literature for two
eclectic psychotherapies, STS and feedback-informed therapy (FIT). These
two approaches are designed to be applicable to a broad range of presenting
problems. Consistent with technical eclecticism, routine assessment to
inform treatment decisions is the lynchpin of both.

Systematic Treatment Selection

The hallmark of eclectic psychotherapy is the twin ideas that certain clients
do better in certain types of treatment and that techniques can be used from
different systems of therapy regardless of their theoretical origin (Consoli &
Beutler, Chapter 7, this volume). Beutler’s et al. (2005) STS has the greatest
empirical support of the client–treatment matching systems. It was
originally based on a comprehensive review of the research literature and
then subjected to several RCTs to validate the matches. Clients are matched
by virtue of their transdiagnostic characteristics, functional impairment,
readiness for change, reactance level, social support, and coping style
(Beutler et al., 2004).
Several RCTs have been performed on the STS matches. For example,
Beutler et al. (2003) compared standard cognitive therapy, cognitive-
narrative therapy, and STS prescriptive therapy for 40 clients with comorbid
depression and chemical dependence. STS prescriptive therapy selectively
applied interventions from the other two therapies using client functional
impairment, coping style, reactance level, and subjective distress as
variables for matching treatments. The effects of the matched therapy were
stronger than either of the other two treatments.
Another study compared treatment matching and mismatching according
to four STS variables (Karno, Beutler, & Harwood, 2002). Cognitive
therapy or family systems therapy was given to 47 couples in which one
partner was an alcoholic. Matching on the STS variables accounted for
most of the abstinence outcomes (76%), and mismatched treatment resulted
in the worst outcomes.
Two patient characteristics for which the research clearly shows
treatment matching effects are coping style and reactance level.
Externalizing styles of coping consists of acting-out or blaming others,
whereas internalizing coping consists of a client blaming himself and
generating internal distress as a result. A meta-analysis of 12 studies (N =
1,291 patients) reported a moderate mean effect size for matching treatment
approach to patient coping style (Beutler, Harwood, et al., 2011a). Patients
who externalized did better in CBT, symptom-focused, and skill-building
therapies than in insight-oriented or relationship-oriented therapies, while
internalizing patients did better in insight-oriented or relationship-oriented
therapies.
Reactance is defined as individuals’ tendency to oppose following
directives; they prefer to do things their way and maintain control (Beutler
et al., 2011b). Clients high in reactance respond more favorably to
interventions low in directiveness (such as client-centered therapy and MI),
whereas clients low in reactance respond better to interventions high in
directiveness (such as CBT). A meta-analysis of 27 studies (N = 1,102
patients) reported a large mean effect size in support of this hypothesis. (For
a thorough review of client-matching variables to outcome, see Beutler et
al. [2011a, 2011b]; Consoli & Beutler, Chapter 7, this volume).

Multimodal Therapy
Lazarus’s MMT (2005) remains one of the best-known systems of eclectic
psychotherapy. MMT is based on an assessment that identifies a client’s
problems and also predominant modalities (aspects of functioning) from
among the BASIC I.D.: Behavior, Affect, Sensation, Imagery, Cognition,
Interpersonal relationships, and Drugs/biological functioning. Treatment is
then tailored to the client’s problem, needs, and characteristic modalities.
Lazarus employs approximately four dozen techniques, including
medication, imagery and fantasy, client-centered reflection, and gestalt
empty-chair exercises, with an emphasis on cognitive and behavioral
techniques (Lazarus, 2005).
Some controlled studies of MMT have been undertaken in the area of
school counseling. In a 10-week multimodal counseling program developed
for potential middle school dropouts, attitudes of girls (but not boys) in the
treatment group became significantly more positive, whereas the control
group did not change (Gerler, Drew, & Mohr, 1990). No significant change,
however, was observed in the multimodal group on a teacher behavior-
rating scale or on academic performance. In another controlled outcome
study, clear support was observed for multimodal assessment and therapy as
compared with other approaches for children with learning disabilities
(Williams, 1988). Additional uncontrolled studies have reported favorable
response rates in inpatient settings (e.g., Kwee et al., 1986; Kwee & Kwee-
Taams, 1994).
Although MMT has certainly been the focus of empirical scrutiny, it is
difficult to draw firm conclusions regarding its efficacy given the lack of
more recent rigorous controlled research. However, it is important to
emphasize that many of MMT’s suggested techniques have been supported
by other empirical research.

Feedback-Informed Therapy
Miller and associates (2005) advocate for a technically eclectic
psychotherapy that embraces select common factors: tapping client
resources, enhancing the therapeutic relationship, and adopting the client’s
worldview regarding his or her problems. They shift from a framework in
which the therapist knows best to one in which the therapist asks the client
for feedback regularly and incorporates the client’s views about therapy into
treatment (Miller et al., 2005). Any number of interventions are then used in
service of meeting the client’s needs.
FIT relies heavily on the Partners for Change Outcome Management
System (PCOMS), which collects feedback at each session on the clients’
experience of the session and their progress toward their desired goals. This
information is immediately processed by the therapist and discussed with
the client in session. Meta-analysis (Lambert et al., 2018) supports the
efficacy of the PCOMS in individual, couple, and group psychotherapy.
Feedback modestly improves treatment outcomes for all patients but
substantially improves outcome and decreases dropout among patients
identified as at risk of deterioration. (The reader is referred to Maeschalck,
Prescott, & Miller [Chapter 5, this volume] and Lambert et al. [2018] for
further information.)

Pluralistic Therapy
Pluralistic therapy (Cooper & McLeod, 2011) combines diverse treatment
methods and strategies in a manner that is tailored directly to the client’s
goals and preferences. This approach is highly collaborative in the selection
of strategies and utilized formal feedback tools to support collaborative task
and goal negotiations. Results from a preliminary open trial showed that the
majority of clients receiving pluralistic therapy experienced clinical and/or
reliable improvement in symptoms and functioning (Cooper, 2014).
A subsequent multisite pre/post intervention (nonrandomized) study of
pluralistic therapy for depression found that the majority of treatment
completers (N = 28) demonstrated reliable improvement in self-reported
symptoms and functioning (Cooper et al., 2015). Pluralistic therapy has also
been the focus of process research and case studies.

Therapies Originally Designed for a Specific Disorder

Technical eclecticism assumes that a one-size-fits-all approach to
psychotherapy is limited, so it is not surprising that most eclectic models
are intended to be applied to a wide range of clients and presenting
problems. Brief eclectic psychotherapy (BEP) for posttraumatic stress
disorder (PTSD), however, was designed specifically for use with trauma-
related disorders.

Brief Eclectic Psychotherapy for PTSD

Gersons, Carlier, Lamberts, and van der Kolk (2000) adapted a treatment
for PTSD that uses CBT techniques (psychoeducation, imaginary guidance,
homework tasks, and cognitive restructuring), focal psychodynamic work
targeting moral emotions and the therapeutic relationship, and a farewell
ritual. In a RCT of 24 PTSD patients, the BEP group evidenced
significantly greater reductions in PTSD and general anxiety symptoms at
posttreatment than did a wait-list group (Lindauer et al., 2005). Another
RCT of PTSD patients (N = 30) with mixed traumatic events found that
those in the BEP condition demonstrated significantly greater reductions in
PTSD symptoms, as well as comorbid anxiety and depression symptoms,
than did those receiving “minimal attention” (Schnyder et al., 2011).
In what appears to be the only comparative treatment trial comparing
BEP to another active treatment, patients diagnosed with PTSD were
randomized to receive BEP (N = 70) or eye-movement desensitization and
reprocessing (EMDR) (N = 70). Treatments demonstrated similar symptom
outcomes and dropout rates; however, EMDR patients demonstrated a
steeper recovery trajectory (Nijdam et al., 2012). BEP is listed as
“conditionally recommended” in the American Psychological Association’s
(APA) practice guidelines for PTSD.
Although the term eclecticism has somewhat fallen out of favor
(Norcross et al., 2016), the technically eclectic approaches just reviewed are
on solid empirical ground. The STS approach has garnered substantial
support over decades of research; PCOMS is designated as an evidence-
based intervention by Substance Abuse and Mental Health Administration
(SAMHSA), and BEP is included in APA’s clinical practice guidelines for
PTSD.

INTEGRATIVE FAMILY, COUPLES, AND GROUP PSYCHOTHERAPY

Compared to individual therapy, fewer attempts have been made to
investigate the outcomes of integrative treatments in family, couple, and
group formats. This literature consists of two well-studied therapies,
emotion-focused couple therapy (Greenberg & Johnson, 1988) and MST
(Henggeler et al., 1998). In addition, there are a number of therapies with
only one or two empirical studies.

Integrative Family Therapies

A variety of integrative therapies have been developed for families,
including MST (Henggeler et al., 1998), a combination of individual and
family therapies that was reviewed earlier in this chapter. (A more
comprehensive review of family therapy research, including literature on
integrative family therapy, can be found in Sexton et al. [2013].)
As described earlier, MST (Henggeler et al., 1998, 2002) is an integrative
treatment for youth with antisocial behaviors that is grounded in systems
theory and social ecology. Interventions are CBT, structural, or family
therapy. A meta-analysis of 22 MST outcome studies (N = 4,066) found
significant effects on delinquency, psychopathology, substance use, family
relationships, and out-of-home placements (Van der Stouwe et al., 2014).
Another integrative family therapy that has been studied in RCTs is
systemic behavioral family therapy (SBFT; Alexander & Parsons, 1982),
which combines systemic and behavioral principles (Robin & Foster, 1989).
SBFT was compared to CBT and nondirective supportive therapy for
adolescents with major depressive disorder (Birmaher et al., 2000).
Significant improvements were observed in all treatments, with no long-
term differences between groups. Secondary analyses from this trial have
failed to find significant differences between the CBT and SBFT conditions
(Barbe et al., 2004a, 2004b), yet the nondirective therapy appears to have
been relatively less effective than the CBT and SBFT conditions for
adolescents with more severe presentations and histories.
Behavioral family systems therapy (BFST) has also been studied in RCTs
for anorexia nervosa (e.g., Robin et al., 1999) and for adolescents with
diabetes. For example, BFST plus medical treatment resulted in improved
family relationships and decreased diabetes-related conflicts at both
posttreatment and follow-up, in comparison to educational support and
treatment as usual (Wysocki et al., 2001). In a study with families of
adolescents with unstable diabetes type 1 (Wysocki et al., 2006, 2007) a
positive effect was found for an adapted form of BFST for diabetics when
compared with standard care or multifamily educational support.
Attachment-based family therapy (ABFT; Diamond, 2014) was designed
to treat adolescents with depression, suicidality, and trauma. This approach
is grounded in attachment theory and is heavily influenced by EFT and
traditional family-based therapy (Diamond, Russon, & Levy, 2016). The
first RCT of ABFT compared 12 weeks of ABFT to 6 weeks of a wait-list
control condition and found that participants in the ABFT condition were
less likely to meet criteria for depression at posttreatment (Diamond et al.,
2002). A subsequent RCT comparing ABFT to usual care for adolescents
with suicidal ideation and depression found that youth treated with ABFT
exhibited significantly greater and faster reductions in suicidal ideation at
posttreatment, and these were maintained at follow-up (Diamond et al.,
2010).

Integrative Couples Therapy

Emotion-focused couple therapy (EFCT; Greenberg & Johnson, 1988;
Johnson, 2004) blends the experiential tradition, emphasizing the role of
affect through the use of client-centered and gestalt methods and the
systemic tradition, focusing on communication and interaction patterns,
within the context of attachment theory. EFCT has received considerable
empirical support (Schottenbauer et al., 2005).
 Recent research has focused on the efficacy of EFT for couples with
specific difficulties, such as trauma and depression. An RCT examined the
efficacy of EFCT for women with a history of childhood abuse in
comparison to a wait-list control group (Dalton, Johnson, & Classen, 2009).
Couples in EFCT demonstrated significant reductions in relationship
distress compared to a wait-list control group. EFCT combined with
medication versus medication alone in depressed couples found that women
in both groups experienced significant improvements in their depressive
symptoms, yet there was no between-group difference on this outcome
(Denton et al., 2010). However, women receiving EFCT combined with
medication did experience a significantly greater improvement in
relationship quality. In summary, EFCT has received substantial attention
within the literature and is one of the two evidence-based treatments of
relationship distress, the other being behavioral couple therapy (Lebow et
al., 2012).
Integrative behavioral couple therapy (IBCT; Jacobson & Christensen,
1996) is broadly behavioral yet integrates mindfulness and acceptance
strategies. IBCT was compared to traditional behavioral couple therapy
(TBCT) in a large, multisite RCT. Couples in both conditions improved in
relationship satisfaction; however, their trajectories were significantly
different. TBCT couples improved quickly early on but then tapered off,
whereas IBCT couples improved gradually but consistently throughout the
course of treatment. For the first 2 years after termination, IBCT couples
maintained their satisfaction at significantly higher rates than TBCT
couples (Christensen et al., 2004, 2006). However, after 2 years of follow-
up, differences between the two treatments disappeared. Nevertheless, a
substantial portion of couples in both groups maintained improvements
through 5 years after treatment termination (Christensen et al., 2010).

Integrative Group Therapies

With the exception of CAT, which has been adapted for a time-limited
group format, we were unable to identify group therapies that explicitly
identify themselves as integrative in orientation. A recent study on group
CAT used a longitudinal cohort design in a sample of female survivors of
childhood sexual abuse (Calvert, Kellett, & Hagan, 2015). Moderate
pre/post effect sizes were observed in global symptoms. We were unable to
locate more recent controlled trials examining the efficacy of group CAT.
A recognition of the complexity of the process of change has been a
driving force in the development of psychotherapy integration, as well as in
clinicians’ identification with an integrative orientation. It is not, therefore,
surprising that integrative treatments have been developed and tested for
application in complex family and couples contexts. MST, in particular, is
one of the most heavily researched treatments, and it has also established an
impressive dissemination and implementation portfolio. Similarly, EFCT
has established itself as a frontline therapy for couples. Simply stated, the
gold standard therapies for families and couples are integrative therapies.
The state of the outcome literature for integrative group therapies is less
clear. This is due to a lack of bona fide group treatments that explicitly
define themselves as integrative, as well as a lack of published controlled
outcome research on approaches that some might consider integrative in
orientation (e.g., Yalom, 2005).

FUTURE DIRECTIONS
Psychotherapy integration has come of age in outcome research. At least 29
explicitly integrative therapies have been subjected to rigorous controlled
research. The results consistently and persuasively attest to their safety,
feasibility, and effectiveness. Of course, effectiveness is a relative matter,
but we can confidently declare that integrative treatments uniformly
outperform no treatment and almost uniformly outperform treatments as
usual. Few integrative therapies have been thoroughly compared to bona
fide, pure-form therapies, so the jury is still out on whether integrative
therapies prove superior in efficacy or applicability to others.

CONCLUSION
Similar to the conclusions drawn from RCTs involving any active
interventions (integrative or otherwise), it would be premature and spurious
to conclude that integrative treatments fail to confer added or unique benefit
for individual patients. As argued elsewhere (Stiles, 2009), outcome
“equivalence” is likely driven by responsiveness and the masking of
interindividual variability in treatment response. As such, it is not
necessarily the case that integrationists should go back to the drawing
board; rather, additional process–outcome studies are needed to increase our
understanding of those patients who are more likely to benefit from an
integrative therapy.
A host of other promising integrative therapies, such as Benjamin’s
(2003) interpersonal reconstructive therapy, have been developed and
received some empirical attention in recent decades. Any attempt to list
these therapies here would be admittedly selective. Nonetheless, our review
of 29 integrative psychotherapies probably underestimates the actual
number.
In addition, were we to emphasize research designs other than RCTs to a
greater degree, the number of evidence-based integrative therapies would
undoubtedly increase. Multitheoretical psychotherapy, pluralistic therapy,
several assimilative therapies, and numerous child therapies (Drewes &
Seymour, Chapter 16, this volume) have been subjected to some empirical
scrutiny yet are relatively lacking in controlled outcome research. We
acknowledge that RCTs and related designs are not without limitations and
that diverse research methods can yield results that inform evidence-based
practice (Norcross, Beutler, & Levant, 2006). Nevertheless, it is difficult to
draw substantive conclusions regarding the efficacy of a given therapy in
the absence of studies involving random assignment and adequate power.
Conclusions regarding a given therapy’s efficacy are not only connected
to the research design, but also to the operationalization and replicability of
the therapy itself. Perhaps due to their evolving nature, the labels and
methods of integrative therapies change over time, leading one to wonder if
the same treatment that was delivered in the first trial was the same
treatment delivered in the second trial. Such responsiveness may be a boon
for patients, but a curse for researchers (Norcross & Wampold, 2019). This
creates a dilemma for studying integrative treatments because, to their
credit, they emphasize the flexible application of clinical strategies based on
emerging context and client characteristics (Boswell, 2017; Constantino,
Boswell, Bernecker, & Castonguay, 2013).
Although outcome research on psychotherapy integration has progressed
dramatically in recent decades, much work is left to be done. The field still
lacks substantial knowledge regarding the effectiveness of psychotherapy
integration as it is carried out by clinicians in routine practice. This is a
difficult task to accomplish, however. Naturalistic studies examining the
improvement of clients receiving eclectic therapy in routine practice (e.g.,
Nordberg et al., 2014) are limited because they have not clearly defined
what the therapists did during treatment and therefore are not easily
translated into direct practice recommendations. Integrative therapists often
state that they tend to use what works best for the client—different
combinations of techniques, as well as different decisional processes. This
leaves a virtually infinite number of integrations that would need to be
studied.
That potential blizzard of integrations accounts in part for the recent
movement to a finite number of change processes or principles.
Practitioners—and trainers—need to delimit the universe of therapeutic
methods and systematically determine which might be optimally employed
for a given client and context. In this volume, the integrative therapies of
common factors (Wampold & Ulvenes, Chapter 3, this volume), principle-
based therapy (Eubanks & Goldfried, Chapter 4, this volume), systematic
treatment selection (Consoli & Beutler, Chapter 7, this volume), and the
transtheoretical approach (Prochaska & DiClemente, Chapter 8, this
volume) all have developed principles/processes of change to be used at
certain times.
In addition, objective characterizations of routine practice patterns are
difficult to obtain, regardless of the treatment. It cannot be taken on faith
that clinicians who identify with a specific theoretical orientation, including
an integrative one, consistently engage in orientation-specific and consistent
behaviors with their clients (Stirman et al., 2015). Researchers have
developed participant self-report measures that can provide potentially
useful information at some scale. For example, the Multidimensional List of
Therapeutic Interventions assesses the nature of psychotherapy delivered in
routine settings across broad theoretical orientation-linked domains
(McCarthy & Barber, 2009). The Comparative Psychotherapy Process Scale
assesses the presence of interventions across broad psychodynamic and
CBT domains (Hilsenroth et al., 2005), while a routine assessment tool for
child anxiety treatment was developed to assess treatment adherence
(Southam-Gerow et al., 2016). As similar multidimensional measures are
developed and implemented, the capacities to both characterize the nature
of an integrative treatment and explore the effectiveness of integrative
psychotherapy will be enhanced.
Of course, exploring the effectiveness of integrative psychotherapy must
also include targeted assessments of relevant outcomes. The increased
implementation of routine outcome monitoring offers a critical resource for
examining the outcomes of integrative psychotherapy “in the trenches.” In
addition, such feedback can aid psychotherapist decision-making and the
ability to detect when a change of approach might be indicated. For
example, feedback that a client is on course to experience a negative
outcome in the current course of treatment can function as a marker for
integration (e.g., implementing a technique from an exogenous theoretical
orientation). Future work can identify markers for integration, as well as
successful (or unsuccessful) response strategies.
Although it will be important to continue investigating integrative
therapies in both controlled and naturalistic settings, a focus on markers and
how to respond to the unfolding context might require a shift in our
approach to studying integrative psychotherapy. As the list of integrative
therapies and the associated acronym alphabet soup grow, there is a danger
that we are recapitulating the very problem integrative therapies were, at
least in part, intended to address. A marker- and context-responsive–driven
approach to studying psychotherapy process and outcome appears to be a
logical response to this dilemma as well, compared to a proliferation of
Integrative Therapy A versus Pure Form Therapy B outcome trials. In
addition to a strong likelihood of demonstrating statistical equivalence on
posttreatment outcomes, such comparative outcome trials, on their own, do
little to elucidate principles that can guide clinician decision-making with a
given patient.
It may prove more fruitful to study within- and between-patient
mechanisms, which can guide integrative practice. Matching treatments to
the patient’s stage of change (TTM) and their reactance level and coping
style (STS) illustrates one form of this matching—to patient transdiagnostic
markers. We expect additional work on in-session markers. For example,
markers of alliance ruptures: upon the identification of such a marker,
clinicians can shift into rupture repair strategies. Process–outcome research
can then examine how different markers might manifest in certain
subgroups of patients, as well as how repair strategies might be tailored to
subgroups of patients. Such research and research-derived guidelines may
be more useful to clinicians than the knowledge that Treatment A
(integrative or pure form) is generally effective.
In the United States, the National Institute of Mental Health has been the
largest funder of psychotherapy outcome research. Significant changes in its
funding priorities and requirements have taken place over the past decade.
It is much more difficult to obtain large grants for investigator-initiated
psychotherapy outcome trials, and, in the foreseeable future, there will be
far fewer funded studies involving the comparative efficacy of integrative
and pure-form psychotherapies.
Integration researchers will need to be more creative in their research
questions and methods, and researchers must consider alternative funding
sources. Given the current funding environment, the more innovative
outcome research is likely to come from researchers in countries outside of
the United States.
Finally, all of psychotherapy research needs to be conducted with more
racially, ethnically, and sexually representative populations. Several of the
research-heavy integrative therapies in this chapter have been performed
with unrepresentative populations to date. For example, the vast majority of
DBT research has been performed with entirely or primarily female patients
(Rizvi et al., 2013). Likewise, MST has been criticized for not being
sufficiently attentive to cultural norms in some settings. That will certainly
constitute a direction for future research, so that we might, one day,
confidently assert the effectiveness of integrative therapies for patients of
all cultural identities.

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 20

Integrating Research and Practice

LOUIS G. CASTONGUAY, MICHAEL J. CONSTANTINO, AND HENRY XIAO

The history of modern psychotherapy can be traced through many

discontents and dismissals. Debates have flourished for years about the
validity and usefulness of divergent theoretical models, as well as the role
of different facets of treatment, such as relationship variables, technical
factors, and participant characteristics. From our perspective, though, the
most troublesome schism in our field has been the disconnect between
researchers and practitioners. Most of these professionals belong to
different communities of knowledge seekers, with relatively few engaging
in fruitful collaboration despite converging interests and complementary
expertise (Castonguay, 2011). This disconnect reflects une indifference
maladroite (a clumsy indifference), which comes at a high price for
understanding the complexity of psychopathology and improving the
effectiveness of mental healthcare.
The consequences of this indifference, or practice–research gap, are
manifold. In one direction rests the sad realization that the field has let the
knowledge of clinicians drop through the holes of a colander (Kazdin,
2008). At its worst, this indifference might take the form of an empirical
imperialism (Castonguay, 2011), where treatment and training guidelines
rest primarily on the work of researchers. The irony, if not danger, of such
unidirectional knowledge translation is its questionable assumption that the
most valid information guiding practitioners to conduct therapy comes
almost exclusively from individuals who tend to see few, if any, patients.
In the other direction resides the disconcerting, but persistent, belief that
clinical judgment trumps empirical evidence and the corresponding notion
that systematic research is largely irrelevant to the everyday clinical
situation. Yet, the data are clear—clinical predictions based solely on
human judgment can be inaccurate, even when made by seasoned
professionals (Garb, 2005), and data-supported predictions outperform
clinical judgment alone (Hannan et al., 2005). Furthermore, naturalistic
research robustly indicates that therapists differ in their effectiveness
(Baldwin & Imel, 2013); yet therapists have been shown to overestimate
their own success (Walfish et al., 2012). This unidirectional dismissal of
research evidence can also prove dangerous to the patients we treat
(Boswell et al., 2017).
The goal of this chapter is not to describe the reasons for the practice–
research gap—much has already been written about this sad state of affairs
(e.g., Goldfried & Wolfe, 1996; Parloff, 1982). Rather, our optimistic aim is
to demonstrate the integration of research and practice by multiple efforts in
collaboration and information sharing. This aim squares with that of recent
initiatives, such as the “two-way” bridge project initiated by the American
Psychological Association’s Division 12 (Society of Clinical Psychology).
This project, among others, highlights the practitioner’s voice in the
research process by surveying their experiences in delivering empirically
supported treatments (ESTs; e.g., Goldfried, 2011a, 2011b; Teachman et al.,
2012). Through this mechanism, which mirrors the one in place in
medicine, practitioners provide feedback on empirically supported
treatments to other practitioners and researchers. This voice can illuminate
the nuances of treatment efficacy and can help adapt and test ESTs to meet
the demands of clinical reality.
We describe here several facets of practice-oriented research that rely,
more or less tidily, on bidirectional partnership between researchers and
practitioners. We believe that such partnership is an optimal vehicle to
embody and actualize the integration of research and practice—an
integration that might enhance the effectiveness and applicability of
psychotherapy. We also believe that research–practice integration may hold
promise for stimulating meaningful advances in psychotherapy integration
more broadly as the inputs from such advances will come from many
conceptual, clinical, and epistemological angles.

DEFINING PRACTICE-ORIENTED RESEARCH

Most research has been guided by the researchers’ interests, which are
largely shaped by graduate training, peer review, and institutional reward
structures. It is no wonder that researchers pursue projects that are likely to
earn them academic tenure, federal grants, and journal citations rather than
the gratitude of clinical practitioners. From the beginning, then, although
researchers and practitioners may share keen interest in the subject of
psychotherapy, the nature of psychotherapy research is often driven by
questions that may not be at the forefront of clinicians’ preocupations.
Statements of directly applicable practice implications are usually restricted
to a few aspirational lines in the discussion section of a journal article—a
section that many practitioners may never reach, if they start to read the
article at all.
With the academic landscape and reward structure, the researcher’s
overarching goal is often to maximize internal validity, which increases the
perceived scientific rigor of the work. Internal validity is inherently stronger
when research is conducted in controlled settings and under standardized
conditions. These methodological controls include specific patient inclusion
and exclusion criteria, manualized treatment protocols, and systematic
checks for therapist adherence and competence to the method under study.
Historically, when clinicians are involved in a research study, their primary
task has been to implement with fidelity (according to predetermined
parameters) procedures designed and manualized by the investigators.
Contrary to this top-down approach, practice-oriented research (POR) is
conducted within naturalistic clinical settings where clinicians are
practicing as usual. It addresses questions that are of utmost relevance to
clinicians’ concerns, and efforts are made, both in study design and
implementation, to avoid major impositions and burdens on clinical routine
(e.g., no attempted manipulations of therapist behavior, limited patient
exclusion criteria, no onerous measurement battery). To achieve these goals,
this bottom-up approach relies on various levels of practitioner involvement
beyond the delivery of externally scripted procedures. In fact, most POR
has emerged from collaboration between researchers and practitioners
where the knowledge and expertise of both participants are valued as
necessary assets for scientifically rigorous and clinically impactful studies.
Although POR represents a philosophical and methodological shift from
most traditional research on psychotherapy, these two empirical strategies
are not inherently antagonistic. To the contrary, one could argue that both
are necessary for developing a comprehensive and translatable knowledge
base (Barkham & Margison, 2007; Barkham et al., 2010; Sobell, 1996).
Because of their complementary nature, these scientific strategies can
compensate for the other’s limitations; for example, POR emphasizes
external or ecological validity, while traditional designs emphasize internal
validity. Furthermore, when similar findings are obtained (about between-
therapist effects, for example) in each of the two epistemological routes, we
can place more confidence in the results. In addition, having more research
guided by diverse sources of expertise and interest will, by necessity,
broaden the scope of our scientific radar.
Whereas practitioners can certainly learn from full-time researchers (e.g.,
about process–outcome correlations, patient factors that moderate an effect
of treatment on an outcome), there are also clinical phenomena and realities
to which full-time clinicians have unique access. Thus, POR provides
opportunities to define, measure, and investigate topics that might otherwise
remain unexplored were clinicians not involved in deciding what to study
and how best to study it.
POR can take many forms (Castonguay, Barkham, Lutz, & McLeavey,
2013). These empirical efforts have been differentiated into three, more or
less, distinct types: patient-focused, practice-based, and practice–research
network (PRN). In what follows, we provide a few examples of findings
that have emerged from the first two types of POR. We then pay special
attention to PRN studies as they tend to involve more extensive
collaboration between researchers and clinicians and fruitful integration of
psychotherapy research and practice.

PATIENT-FOCUSED RESEARCH
This type of POR centers on typically large samples of patients receiving
psychotherapy in naturalistic settings. Spurred by the work of Kenneth
Howard, it marked a departure from the predominant attention of traditional
outcome research, or what has frequently be referenced as “randomized
clinical trials.” Rather than investigating what types of therapy work
(typically in comparison to other types and in a tightly controlled and
therefore less ecologically valid manner), patient-focused research
examines how change occurs over treatment, either for a given patient or on
average across patients.
 An exemplar of patient-focused research is a study of the dose–effect
model, which examines the relation between the number of sessions
attended and patient improvement. In an early study, Howard and
colleagues (1986) found that patients, on average, demonstrated a decrease
in symptoms with every session, with 50% judged as “improved” by their
eighth session. The researchers also found that improvement occurred, on
average, more rapidly in the earlier sessions, with perhaps diminishing
returns later. These findings not only inform practitioners about a
particularly beneficial window of change in practice, but can also inform
treatment policies within healthcare systems. In fact, when the first author
of this chapter (LGC) presented these results at an administrative meeting
during the first week of his clinical internship, the clinic administrators
changed the policy on session limit from six to eight.
Further specifying change patterns in routine practice, another study by
Howard and colleagues (1993) revealed that significant improvement takes
place within two sessions with respect to patient-rated well-being.
Reductions in symptomatic distress and improvements in life functioning,
however, occur more gradually. This study also showed that change in
psychotherapy is generally contingent on the success of the previous phase
of improvement: decrease of general distress (or remoralization) precedes
the decrease of specific symptoms (or remediation), which in turn precedes
the decreases of maladaptive functioning (or rehabilitation). Clinicians
might draw on these results to shape a patient’s expectation about the
course and outcome of his or her therapy and to develop a treatment plan
that capitalizes on these change sequences.
The dose–effect and phase models have varied across later studies. They
are, for example, affected by the patient’s severity level (e.g., Lambert,
Hanson, & Finch, 2001; Stulz & Lutz, 2007). The dose–effect association
can also be moderated by treatment setting, further indicating the need to
gather data from diverse settings (Lambert et al., 2001).
The investigation of patient change patterns has also provided valuable
tools to meet clinicians’ most important ethical duty to “do no harm.”
Unfortunately, between 5% and 10% of adult patients will deteriorate
during the course of treatment (albeit not always because of treatment),
with an even higher harm rate for patients with substance abuse
(Castonguay et al., 2010; Lambert, 2010). There is also evidence that
clinicians tend to underestimate the rate of deterioration in their own
caseloads and, to make matters worse, that they are inaccurate in predicting
which of their own patients are likely to deteriorate (Hannan et al., 2005).
Multiple practice-oriented investigations, however, have shown that
providing therapists with feedback about their patients’ progress can help
mitigate the deterioration problem. In a landmark study, Lambert and
colleagues (2001) showed that routinely monitoring outcome and providing
progress feedback (including alert signals for patients at risk of
deteriorating) during routine care significantly reduced deterioration (and
increased improvement) for patients failing to progress (i.e., not-on-track
patients). In a subsequent investigation, adding clinical support tools (i.e.,
brief strategies to facilitate alliance quality, patient motivation, social
support, and possible need for medication) to the therapist feedback for
their not on track patients further decreased deterioration and promoted
improvement (Whipple et al., 2003).
These are only a few examples of studies conducted in naturalistic
settings (with no manipulation of the types of therapy) that have
demonstrated the value of outcome monitoring and clinical feedback (see
Lambert, Whipple, & Kleinstäuber, 2019). As a whole, the findings suggest
that routinely collecting a patient’s outcome data, feeding back the
information to the therapist, and offering support tools improves outcomes
for that particular case, particularly for patients at risk for deterioration. Put
differently, patient-level feedback can improve patient-level outcomes.
Although this patient-level research says little about improving
therapists’ overall effectiveness across all patients, it does point to the
ability to affect change with individual patients for whom outcomes are
routinely monitored. Such practices can be implemented without imposing
drastic changes to the way clinicians practice, such as shifting theoretical
orientations or adhering closely to manualized interventions. Rather,
therapists of all theoretical persuasions can request that their patients
regularly complete a brief measure over the course of treatment. Then, to
maximize the effect, therapists commit to using such information to
improve psychotherapy, as opposed to viewing it as ancillary, or even
irrelevant, assessment information (de Jong et al., 2012).

PRACTICE-BASED RESEARCH
Displaying a broader palette of investigations, practice-based research has
focused less intensively on how patients change and more on how different
components of clinical practice can influence such change. The first of
these components is the therapist him- or herself. In a typical RCT,
therapist differential effectiveness represents a variable (or noise) to be
reduced—or at least controlled—in order to keep everything equal except
the treatments being compared. By contrast, therapists have been viewed in
POR as legitimate contributors to outcome, with the recognition that
therapist-level results can and should inform training, practice, and
healthcare policy (Boswell et al., 2017).
Empirical research has now robustly confirmed what many have
repeatedly observed but would rarely admit publicly: therapists differ from
each other in their average effectiveness across the patients in their
caseloads. More specifically, this so-called therapist effect explains
approximately 5–8% of outcome variance (Castonguay & Hill, 2017). This
effect is even more pronounced in naturalistic settings compared with RCTs
(where standardized treatment delivery is emphasized) and for patients with
greater impairment (where the challenge of the case may render general
variability in therapist skill more clinically vital than with less severe or
more “straightforward” cases; Barkham et al., 2017). Put bluntly, not all
therapists are the highly effective generalists that they believe themselves to
be (Walfish et al., 2012).
Some studies have also suggested that therapists may possess relative
strengths and weaknesses within their own practice depending on their
patients’ presenting problem; that is, many clinicians may be particularly
effective at treating certain problems or personalities than others, even if
they are unaware of this specialization (Kraus et al., 2011). Although it
remains unclear whether therapist effects are primarily a matter of general
competence or domain-specific skills (Constantino et al., 2017; Wampold et
al., 2017), it seems reasonable to suggest that therapists (and their patients)
could benefit from identifying what therapists are particularly good at (and
perhaps what they could teach others) and what they are less good at (and
thus can learn from others). Only by knowing their outcomes can clinicians
harness information about their own efficacy in relation to other clinicians
—and their own strengths and weaknesses in relation to themselves—to
improve their practice.
 Research advances have also been made in identifying potential
determinants of between-therapist differences in effectiveness. To date, at
least four of such promising variables may account for part of the therapist
effect: facilitative interpersonal skill, self-doubt, deliberative practice, and
fostering good therapeutic relationships (Wampold et al., 2017). Although,
again, such work on therapist effects determinants is just emerging, the
following tentative implications can be derived:
As ways to increase their effectiveness, therapists should strive to become better at developing,
maintaining, and repairing the alliance with clients. They should also make use of and enhance
their verbal and emotional expressiveness, motivational skills (persuasiveness and hopefulness),
warmth and empathic attitude, and problem focus. Moreover, they should adopt and/or maintain
a sense of humility toward their ability to help their clients. When not working with clients,
therapists should also repeatedly and consistently devote time to improve their work, such as
thinking about difficult cases, preparing and reflecting upon sessions, and attending training
workshops. (Hill & Castonguay, 2017, p. 328).

It is difficult to imagine clinicians not being interested in the practice-

based findings that have emerged so far demonstrating the importance of
therapists themselves! It is also difficult to underestimate the practical
implications of these findings, including how we select candidates into
graduate programs, which competencies we teach, which videotaped
examples and live models students might emulate, who should teach
coursework, who should supervise students, and so forth.
In addition to investigating the effectiveness of therapists, practice-based
researchers have examined the effectiveness of services, centers, and
practices. Some studies conducted in the United Kingdom have focused on
the naturalistic delivery of theoretical orientations that have tended to
receive less attention in RCTs, such as person-centered and psychodynamic-
interpersonal therapies (Gibbard & Hanley, 2008; Paley et al., 2008). This is
an example of how the complementarity of practice-oriented research and
traditional research (where cognitive-behavior therapy [CBT] approaches
have been given predominant emphasis) can increase the breadth of
scientific investigations in psychotherapy. Two large studies conducted in
the United Kingdom have found the outcomes of CBT, person-centered
therapy, and psychodynamic therapy to be fairly similar in National Health
Service routine practice (Stiles et al., 2006, 2008).
Assessing the effectiveness of treatment centers or practices, however,
has not been restricted to the work of UK practice-based researchers. For
example, as part of a 40-year-old practice and training infrastructure based
in Argentina (Aiglé Foundation), clinicians have conducted several studies,
on their own and in collaboration with researchers from other countries, on
the impact of therapy (as delivered in natural settings) for specific disorders
(see Fernández-Alvarez, Gómez, & Garcia, 2015). For at least two decades,
in the United States, Persons and colleagues have examined the impact of
cognitive therapy for depression in private practice (Persons et al., 1988,
2006).
Other researchers have examined the outcomes of a residential treatment
for adolescents and young adults with substance abuse problems. They
discovered, first, that their services did not address a specific problem of
their patients (i.e., high level of anger). They then demonstrated that the
implementation of a therapeutic approach specifically targeting this
problem (rational-emotive behavior therapy) substantially improved their
therapists’ ability to reduce it (Adelman, 2006; Adelman et al., 2015).
Practice-based research, however, has not been restricted to the
measurement of treatment effectiveness. Mirroring other efforts to
understand how therapy works, process studies have drawn on datasets
collected in practice settings, examining the contribution of relationship
variables, characteristics of the therapist, characteristics of the patient, and
interactions among such factors. As a case in point, some research
conducted at the Aiglé Foundation in Argentina has investigated the role of
process and participant characteristics, such as the focus of therapy, alliance
quality, therapist personal style, and the interaction between therapist and
patient characteristics (Fernández-Alvarez et al., 2015).
Within the previously mentioned residential treatment setting where
clinicians delivered rational-emotive behavior therapy, another study
demonstrated that a positive association between alliance quality and
patient outcome was moderated by patient attachment history. Specifically,
the facilitative effect of a good alliance was stronger for patients with more
problematic attachment, thereby suggesting a corrective interpersonal
experience for patients most in need of one (Zack et al., 2015).
Underscoring the importance of such process studies conducted in practice
settings, this study suggests that two constructs historically emphasized in
psychodynamic therapy (attachment and alliance) might explain part of how
CBT works, again underscoring the way in which practice-based research
can promote treatment and theory integration.
 Practice-based research has also been conducted on training
psychotherapy. As a prime example, Koerner created a participatory
research community allowing clinicians to learn evidence-backed
interventions (e.g., behavioral activation skills, two-chair techniques) in
their own clinical settings (for details, see Koerner & Castonguay, 2015).
This type of research is particularly noteworthy considering the paucity of
studies that have been conducted on training (Hill & Knox, 2013),
especially in clinicians’ own settings.
One could argue that almost all translational research is practice-based
research. Moving research evidence from science to service, from the (lab)
bench to the bedside, necessarily involves practitioners in collaboration
with researchers. Translation(al) research inclusively refers to the process
of moving research-supported discoveries into established practice and
policy. The thousands of translational studies in healthcare and hundreds in
psychotherapy involve first dissemination, entailing raising awareness of
resources and their availability, particularly the supporting research
evidence, and then implementation, which involves getting research-
supported methods routinely used in practice. The consistent take-home
lesson from these legions of naturalistic studies is that effective translation
involves both practitioners and researchers working together from the
beginning (Norcross et al., 2017; Straus et al., 2010). Researchers
unilaterally imposing methods onto practitioners is not likely to be an
optimal way to foster therapeutic change; neither is clinicians practicing in
the absence of, or in conflict with, robust research.

PRACTICE-RESEARCH NETWORK
Practice-based research covers a broader range of topics than patient-
focused studies, but PRNs have gone even further in expanding the scope of
investigations. PRNs are defined as a formal collaboration among a system
of practitioners and clinical scientists to investigate questions of high
relevance to the practitioner while drawing on the methodological know-
how of the researchers. Networks can vary in size, but all have in common
the goal to conduct salient research in ecologically valid settings to promote
clinically actionable results (Borkovec et al., 2001).
PRNs directly address a wide array of phenomena of interest to
practitioners who, as equal partners, have a voice on the selection, design,
implementation, and dissemination of joint empirical projects. In its optimal
form, the PRN is an antidote to empirical imperialism. Going beyond
research translation (from the controlled environments of academia to the
murky ground of clinical reality), PRNs foster a synergetic combination of
expertise and experience, a shared ownership of ideas and data, and a full
respect for epistemological complementarity.
PRN infrastructures have evolved in a diversity of mental health
communities, and we describe next a sample of empirical fruits that have
emerged from four clinical settings (training clinics, private practices,
community centers, and university counseling centers) and two professional
organizations (American Psychiatric Institute for Research and Education,
National Drug Abuse Treatment Clinical Trials Network).

Training Clinic PRNs

Early in graduate school, most psychotherapy trainees learn the hard way
that research and clinical work are demanding activities and that they are
also mostly unrelated. Both of these activities require their own separate
time, each is aimed at meeting distinct academic and professional goals, and
when students are engaged in one of them they are frequently navigating in
a conceptual land foreign to the other. Conducting statistical analyses and
preparing for a therapy session do not just feel like wearing two hats; it
feels more like wearing different parts of an outfit that, for the most part, do
not match.
Such a dichotomous way of learning, however, is not necessary for the
early professional development of clinical researchers. Systematically
integrating clinical and research activities protects the most precious
commodity of graduate students (time) and fosters an early attachment to
the scientist-practitioner or scholar-practitioner model.
One way to achieve such integration is to transform psychology training
clinics into a PRN in which students can conduct their master’s and doctoral
theses (or any research) at the same time—and in the same environment—
where they complete their supervised clinical work. An example of a
training clinic PRN is the one created in the adult track of the clinical
psychology program at Penn State University (Castonguay et al., 2015).
This infrastructure is anchored in key components: (1) the adoption and
standardized implementation of assessment instruments that are helpful to
clinical case formulations and that are essential to research in many labs,
(2) the creation of a clinic/research committee to review research proposals
from the perspective of multiple stakeholders (students, faculty, clinic staff,
local practitioners), and (3) an agreement with the Office of Research
Protection, which allows for Institutional Review Board approval for
requests to access data collected in the clinic. We next describe a few
exemplar research projects emanating from the Penn State training clinic
PRN.
One master’s thesis (Nordberg et al., 2014) focused on whether specific
change patterns observed in managed care could also reflect the change
profiles of patients seen by novice therapists. Replicating previous findings
(Stulz et al., 2007), the results indicated that a substantial number of
patients begin therapy with a high level of depression, but that they
eventually split into two groups: one in which patients showed rapid
response as therapy progressed, and another in which patients maintained
their high level of distress. Furthermore, the study identified clinical factors
that predicted membership in the second group, such as high levels of
suicidality and social conflicts.
Another master’s thesis examined trainee self-reported use of empirically
supported interventions (via the Multitheoretical List of Therapeutic
Intervention; McCarthy & Barber, 2009) in relation to patient-rated session
helpfulness (Boswell, Castonguay, & Wasserman, 2010). The intervention
profiles correlated neither with their self-identified theoretical preference
nor the theoretical orientation espoused (and taught) by their supervisors.
By contrast, the use of some techniques did relate to the patients’ perceived
session helpfulness—but in a nuanced way. Specifically, patients whose
therapist typically used high levels of common factor relational
interventions (e.g., warmth, acceptance) perceived sessions to be less
helpful than when the therapist shifted to using more cognitive-behavioral
interventions in those sessions. Although these findings are preliminary and
unique to one treatment setting, they provide an example of how research
conducted within a training clinic PRN can begin to reveal ways in which
clinician behavior relates to patients’ session outcomes. Replication, of
course, is warranted.
Importantly to the core mission of PRNs, such studies were conducted
under both research and clinical oversight. The clinical research committee
approval of these studies attested that they were investigating clinically
relevant issues in a way that did not disturb the clinical routine nor impose
undue burdens to therapists, patients, and clinical staff. In addition, also
consistent with the PRN mission, such findings can directly inform future
practice in this, or perhaps similar, training settings (Castonguay, Pincus, et
al., 2015).

Private Practice PRNs

PRNs primarily involving independent practitioners form a conduit for
them to reconnect with their interest in conducting research (Borkovec et
al., 2001). This has certainly been one of the motivations of the members of
the Pennsylvania Psychological Association (PPA) PRN, which emerged
after years of friendly but heated dialogues about the value of knowledge
derived from research between Tom Borkovec, a full-time academician, and
Steve Ragusea, a full-time clinician. As a way to settle their debate, they
agreed to test whether it would be possible to find therapists interested in
collecting data in their independent practices that would also be relevant to
it. At the launch of their infrastructure, they gathered practitioners from
across the state for a meeting, created committees related to specific topics
(e.g., assessment measures, ethics), and set up a collaborative process to
select, design, and implement research projects and to analyze and
disseminate the results.
For the first PPA-PRN study, more than 50 clinicians investigated the
feasibility of adopting a standardized outcome measure in their day-to-day
practice. They also aggregated the data obtained to assess patient
improvement, as well as to examine variables related to such change. They
met their primary goal of feasibility by successfully implementing the
routine outcome monitoring process across several independent practices, a
process that has since been established as an evidence-based practice
(Boswell et al., 2015; Lambert et al., 2019). While being cautious about the
implications of their findings, they found evidence for the positive impact
of therapy conducted in private practice. They also identified factors that
may foster or interfere with therapeutic benefits, such as the number of
patients in a therapist’s caseload and patients’ interpersonal problems prior
to treatment (Borkovec et al., 2001; Ruiz et al., 2004).
For the second PPA-PRN study (Castonguay, Boswell, Zack, et al.,
2010), a smaller group of therapists designed a research project centered on
a inquiry voiced by one of the clinicians: “At the end of every session, I
would like to know if there are things that happened that my client found
helpful and/or hindering.” Then, for the next 18 months, practitioners
invited their new patients to participate in a study in which they would
document helpful or hindering events that took place during the prior
session. Therapists also documented what they saw as helpful or hindering.
Analyses of close to 1,500 events revealed that, for both therapist and
patients, the most frequent type of helpful event was an increase in patients’
self-awareness. The second most frequent helpful event for therapists (who
represented a variety of theoretical orientations) were those that involved
the strengthening of the therapeutic relationship. Results also indicated that
the most prominent focus or content of helpful events (reported by the
patients and the therapists) was the therapeutic interaction. Interestingly,
relatively few hindering events were reported, but the most prominent focus
of these events (reported by both patients and therapists) was, again, the
therapeutic interaction.
When therapists were interviewed about their participation in this PRN
study (Castonguay, Nelson et al., 2010), one of the benefits was that the
helpful/hindering event form completed by their patients provided them
with helpful feedback about how to be best attuned to those patients’ needs.
This is an example of a clinically syntonic investigation that, to us, is an
optimal characteristic of POR. (A clinically syntonic study is one that
simultaneously serves both research and clinical purposes.)
The results of the interviews conducted with the clinicians guided the
choice and design of a third PPA-PRN study: feedback provided by patients
at the end of every session. Rather than using open-ended questions about
helpfulness, a decision was made to use the Multitheoretical List of
Therapeutic Intervention as a measure of interventions used by therapists
and a brief measure of session impact. Preliminary findings showed that the
interventions (rated by the therapists and the patients) that were more
strongly and consistently related to positive impact were interventions
common to most, if not all, orientations (Castonguay et al., 2014).
The three studies conducted to date in the PPA-PRN were designed and
implemented by a relatively small number of therapists. This has imposed
obvious limitations on uncovering the scope of clinicians’ interests, not
only in terms of sample sizes and statistical power to test some questions,
but also in the variety of interests and expertise among the PRN
membership. Fortunately, a large private practice PRN has been developed
in Canada, which sheds some light on these matters (Tasca et al., 2015).
In a flagship study, 41 survey items were developed following focus
groups comprising 82 psychotherapists and then administered to more than
1,000 participants, mostly practicing clinicians, to be rated on perceived
importance to clinical work. Unsurprisingly, the respondents were most
interested in the therapeutic relationship, mechanisms of change, therapist
and patient factors, and professional development. The lowest ranked items
may have been perceived as externally driven or imposed, such as
technological interventions, progress monitoring, manuals, and matching
patients and therapists; these issues are perhaps comparatively distant from
the actual process of therapy. Thus, the use of PRNs becomes even more
clearly synergistic: just as clinicians have room to voice unique insights and
interests, dissemination of research to practitioners can become more
organic.

Community Center PRNs

Another example of partnership, the Practice & Research: Advancing
Collaboration (PRAC; Garland & Brookman-Frazee, 2015), has convened
researchers and clinicians working in publicly funded community centers.
The first phase of this project examined the treatment of children with
disruptive behavior problems in naturalistic settings. After months of work
on the questions, methods, and feasibility of the study, the collaboration
collected data on more than 3,000 therapy sessions conducted by more than
80 therapists and with more than 200 patients across six clinical sites. One
of the goals of this ambitious study was to investigate how much the
interventions used in clinical routine are consistent with evidence-based
principles of change for children with disruptive behavior problems and
their families.
Perhaps not surprisingly, the coding of more than 1,200 sessions showed
a generally low level of convergence between usual care and evidence-
based practice. A possible exception was cognitive-behavioral and
behavioral therapists who, consistent with other findings (Stewart &
Chambless, 2007), showed higher level of compliance with cognitive and
behavioral techniques, which are often considered to be empirically
supported (Brookman-Frazee et al., 2010). However, as a sign of openness
to a diversity of knowledge and action, a second-phase PRAC is focused on
the training and supervision, in community settings, of evidence-based
practices (Garland & Brookman-Frazee, 2015).

University Counseling Center PRNs

If the inclusion of six clinical sites allowed for the planning and
implementing of ambitious studies in the PRAC partnership, so, too, has the
adoption of standardized assessment instruments by more than 500
university counseling centers that are members of the Center for Collegiate
Mental Health (CCMH). CCMH is a large PRN infrastructure that has
relied on the shared interest of stakeholders (clinicians, faculty members,
graduate students, administrators, information science and technological
experts, industry partners, and funders) in understanding the mental health
difficulties of college students. It has described services delivered in
counseling centers, developed clinical tools to inform practitioners’ work,
provided information that can assist counseling centers’ self-advocacy
purposes, and conducted research relevant to the needs of and treatment
provided to college students (Castonguay, Locke, & Hayes, 2011; Locke et
al., 2012). Although each counseling center owns the data it collects as part
of its routine care, data across centers are aggregated in a repository
centrally managed at Penn State University. At this time, the aggregation
has produced a sample size of more than 150,000 new patients per year, as
well as several thousands of psychotherapists.
The early research efforts conducted in CCMH focused on the
psychometric validation of its main assessment tools, difficulties
experienced by minority students, and predictors of utilization of
counseling services (McAleavey et al., 2015). More recently, psychotherapy
has taken center stage. One study showed that students who received
counseling over a 6-week period reported a significant reduction of
academic distress (Lockard et al., 2012). Over the same period, a group of
students recruited via a research pool at the same university did not. Going
one step further, another study provided evidence—for the sake of skeptical
members in our field, as much as for the sense of self-efficacy of CCMH
stakeholders—that individual psychotherapy in a counseling centers
produces substantial improvement in a broad array of psychological
problems (McAleavey et al., 2019). Despite the fact that treatments are of
shorter duration in counseling centers, the level of change observed for
distressed patients is similar to what has been observed in RCTs, with more
change occurring for individuals experiencing the highest levels of distress.
Other CCMH studies have examined patient factors that relate to the
process of change (e.g., Boswell et al., 2012; Nordberg et al., 2016), and yet
others have investigated problems in mental care treatment: dropout and
session nonattendance (e.g., Xiao, Castonguay, et al., 2017; Xiao, Hayes, et
al., 2017).
Recent studies have also explored questions related to between-therapist
effects, and these have provided new directions to CCMH stakeholders to
improve its services. For example, Hayes and colleagues (2016) found that
some therapists are more effective with racial and ethnic minority patients
than with white patients, that others show the reverse pattern, and that some
are highly effective with both racial/ethnic groups. Another study
demonstrated that between-therapist variability explains a particularly large
amount of outcome variance in the treatment of a clinical problem that is
significant on college campuses: alcohol abuse (Youn et al., 2015).
From a research perspective, the findings of these studies help us to
specify the therapist’s contribution to outcomes above and beyond what we
can glean from the population of patients at large. From a practice
perspective, these findings can inform best therapeutic practices. We hope
to identify “super-shrinks” (those, for example, with multicultural expertise
and with particular competence in treating alcohol problems), examine their
clinical work, and use the results of these examinations as the basis for
future clinical guidelines in terms of training, practice, and research.

Professional Organization PRNs

A number of PRNs have emerged from professional and scientific
organizations, and we highlight the infrastructure (and some empirical
contributions) of two of them. The American Psychiatric Institute for
Research and Education (APIRE) was originally conceived as a means to
gather systematic and longitudinal data to inform the development of the
American Psychiatric Association’s practice guidelines (West et al., 2015).
Starting with nearly 800 psychiatrists, the APIRE is now a PRN that largely
recruits clinician participants through randomly selected samples from the
American Medical Association Physician Masterfile. As stated by West and
colleagues (2015), the engagement of practitioners in this research
partnership has led to valuable scientific benefits.
Our experience in developing the PRN and conducting practice-based research has
demonstrated that involving clinicians in the research enterprise significantly enhances the
quality of the research. In addition to their primary contribution of participating in and
implementing the actual studies which are fielded, our clinician collaborators have helped us to
strengthen our research enterprise and efforts by: (i) Identifying and selecting topics that are
clinically relevant and important; (ii) ensuring that studies are designed to optimize feasibility
and success; and (iii) facilitating dissemination of findings. The input and participation of our
clinician collaborators have proven to be particularly valuable in improving the quality,
feasibility, and strength of our studies through their generous contributions of time, expertise,
and valuable insights to strengthen our research. (p. 153).

Among its research initiatives, the APIRE PRN has fostered the
investigation of specific patient disorders and their treatments, including
treatment-resistant patients with schizophrenia and children and adolescents
with attention deficit hyperactivity disorder, depression, and posttraumatic
stress disorder (PTSD). These studies have allowed for empirical analysis
on what kinds of treatments, including therapy and medications, were being
used and where there was room for improvement in administering
evidence-based treatments. For example, among treatment-resistant patients
with schizophrenia, two-thirds of psychiatrists considered long-acting
injectable medications to be effective for treatment, but fewer than one-fifth
of their patients were actually prescribed these medications (West et al.,
2008). Additional studies have examined patient characteristics and
psychiatric treatments across public and private treatment settings,
comorbidity patterns in routine psychiatric care, and race/ethnicity
variations in diagnosis and treatment.
The National Institute on Drug Abuse (NIDA) has also maintained a
PRN in the form of its National Drug Abuse Treatment Clinical Trials
Network (Tai et al., 2010). Much of the extensive research (more than 270
published journal articles as of 2011) that has emerged from this
infrastructure focuses on the efficacy of pharmacologic treatments, but there
are also several studies providing research on psychotherapeutic and
behavioral treatments. These include research on the process and
effectiveness of brief strategic family therapy for adolescents with
substance abuse and delinquency problems (Szapocznik et al., 2015).
Research within this Clinical Trial Network is structured to be
collaborative, efficient, and effective. Projects can start with discussion and
planning at a regional “node,” such as around a clinic-based practitioner or
university-based researcher. Collaboration occurs both within these nodes
between researchers and providers and also between nodes, as many
research projects seek at least three nodes to increase external validity. This
partnership is exemplified in its steering committee, comprising equal
representation of practitioners and researchers at each node. When a
potential project is ready for implementation, the NIDA is responsible for
approval and support. Finally, clinical training for research protocols and
data/statistical efforts are overseen by a centralized management.

FUTURE DIRECTIONS
As surveyed in this chapter, POR has focused on many dimensions of
psychotherapy and a wide range of variables (e.g., patient and therapist
characteristics, relationship and technical factors). Although the complexity
of psychotherapy intrinsically calls for the investigation of many issues, we
believe that it is more important to end this chapter by emphasizing the
need to develop further practitioner and researcher partnerships than to
identify specific topics for future investigations. There are three reasons to
do so.
First, because the three authors of this chapter “live” in Babel towers of
academia, proposing a list of research topics would be a perpetuation, albeit
nonmalevolent, of empirical imperialism—where researchers have
historically driven the agenda of what should be studied. We believe that
delineating of contents of future POR is best done collaboratively by
clinicians and researchers together. And this also applies to the delineation
of directions regarding how to do future practice-oriented research.
Fortunately, the voices of both clinicians and researchers (from countries
across three continents) have been pulled together in a recent series of
papers created to guide future partnerships by identifying benefits,
obstacles, and strategies to cope with them and general recommendations
for designing and implementing POR in various clinical settings
(Castonguay & Muran, 2015).
The second reason to emphasize the need for more POR is that this type
of investigation offers a unique pathway for the actualization of scientific
knowledge about psychotherapy. As previously mentioned, POR
complements some of the restrictions and limitations of traditional research.
Encouraging this knowledge acquisition is therefore likely to be a fruitful
strategy to build more robust, broader, and more valid empirical
foundations for our field (Barkham & Margison, 2007; Barkham et al.,
2010).
The third reason is that, in the mainstream territories of practice and
training guidelines, POR may also promote the viability of psychotherapy
integration. It is well known that the credibility of a professional tradition is
based in part on its scientific foundations. It is also well established that a
large percentage of clinicians identify themselves as integrationists, but
integrative therapies have received less research attention than prominent
“pure-form” treatments. By promoting the full engagement of practitioners
in the design and implementation of research, especially within their own
work environments, many future studies will investigate topics directly
related to integrative practice. We believe that the futures of POR and
psychotherapy integration are closely linked and that such nesting can only
benefit the science-practitioner and scholar-practitioner models underlying
our field.

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 21

International Themes in Psychotherapy

Integration
BEATRIZ GÓMEZ, SHIGERU IWAKABE, AND ALEXANDRE VAZ

Integrative psychotherapies have grown significantly worldwide since the

1980s and currently hold a central place on most continents. In this chapter,
we present a landscape of practice, training, and research in psychotherapy
integration in select countries in Asia, Latin America, and Europe. This
panorama allows us to see the global similarities in integration beyond
particular contexts while also noticing the cultural differences and
idiosyncrasies influencing psychotherapy integration. In other words, we
seek to explicate both common themes as well as local characteristics
around the world.
Psychotherapy is defined by common features throughout the world and,
at the same time, is practiced differently according to geographical regions
and cultural contexts. On the one hand, the scientific tradition is worldwide.
Researchers are receptive to ideas from any place in the world, pursue long-
distance collegial ties, and disseminate their creations globally (Schott,
1993). Knowledge diffusion is highly global, more widespread than social
ties such as informal exchanges, collaboration, and bestowal of recognition
among scientists (Schott, 1991). Some theoretical concepts and procedures
in psychotherapy are strikingly similar in different regions because they
have a common source in world standards.
On the other hand, the sociocultural environment in which therapy takes
place, the ethnocultural background of clients and clinicians, and the
attitudes toward psychotherapy all profoundly affect therapy in each place it
is delivered. Attitudes toward psychotherapy vary from society to society
based on the general attitude toward mental health and illness. The client’s
style of problem presentation, complaint, and suffering, as well as the
desired goals and expectations of psychotherapy, will be shaped by cultural
factors.
A more complex phenomenon is the progressive cultural heterogeneity in
many regions. Increased migrations across national borders have altered old
categories that assumed a homology between nation-states, populations, and
cultures (Kirmayer, 2006). Cultural worlds are open systems, increasingly
shaped by forces of migration, globalization, and hybridization
(Papastergiadis, 2000). Global and local properties of knowledge and
practice are complementary and give shape to psychotherapy in different
regions of the world.
This chapter is based on brief descriptions of integrative psychotherapy
movements and contributions in different world regions in order to furnish a
view of integration at an international level. We asked contributors to
provide overviews of integration in their respective countries in terms of
specific models, training programs, and research programs, concluding with
the current state of psychotherapy integration.
Following summaries of integration in Asia-Pacific, Latin America, and
Europe and select countries therein, we highlight recurrent themes across
countries. The landscape includes considerations about incentives and
challenges to the growth of psychotherapy integration in every region as
well as obstacles to address.

PSYCHOTHERAPY INTEGRATION IN ASIA-PACIFIC

Asian countries are diverse in their religious, ethnic, linguistic, economic,
historical, and political backgrounds. Although the influence of Buddhism
is pervasive in the philosophy of life, Catholicism, Islam, and other
religions form substantial minorities in some countries. Many Asian
countries share the history of colonialization by European countries over
four centuries that significantly influenced the course of development of
commerce, politics, and culture. While it brought rapid development in
some sectors of the economy based on trading of the rich resources of these
countries, they were forcibly brought into the power struggles of Western
countries, militarized, and coerced into international economic competition.
Asian countries have for years struggled to find their own national identity.
 Many Asian countries have a rich and long history of indigenous healing
practices from Buddhist meditation, shamanism, religious rituals, and
traditional medicine. In some countries, Western psychotherapies have a
relatively long history, but, in comparison to many Western countries,
psychotherapy has not gained sufficient recognition in facilitating mental
health. In other countries, Western psychotherapies are relatively new,
introduced only recently by those academics who studied abroad. Most
commonly, biological psychiatry is considered the main provider of
treatment of mental illness, and strong stigma is attached to mental illness.
Help-seeking is largely suppressed to avoid shaming oneself and one’s
family in collectivist societies.
Adapting Western psychotherapy to the Asian worldview and lifestyle
has been one of the central themes of integrative attempts in Asian
countries. The majority of Asian psychotherapists are eclectic or
integrative. They tend to adjust their understanding of a psychotherapy
model to their own population and clinical settings. The exceptions are
Australia and New Zealand. Both are Anglophone countries with Western
cultural backgrounds.

Australia and New Zealand

Australia takes up a special place in Asia-Pacific. It is an English-speaking
country with many natural resources and a highly developed economic
system, ranking highly in per capita income and having the second-highest
human development index globally. New Zealand, located southeast of
Australia and consisting of two main islands and many small islands, is also
a developed country that ranks highly in international comparisons of
nations’ wealth and power, such as health, education, economic freedom,
and quality of life.
Psychotherapy is relatively well developed in these two countries: there
are more than 50 professional psychotherapy associations. The
Psychotherapy and Counselling Federation of Australia, which is a national
body for counsellors, psychotherapists, and professional associations,
promotes and supports the diversity of approaches within the profession and
provides a united forum for mental health professionals; therefore, its basic
nature is integrative (Schofield & Roedel, 2012).
 Several surveys have been conducted to examine the theoretical
orientations of Australian and New Zealander psychotherapists (e.g.,
Poznanski & McLennan, 1998). The most recent large survey of
psychotherapists and counselors who are members of the Psychotherapy
and Counselling Federation of Australia showed that the five most salient
theoretical approaches were humanistic (39%), interpersonal (38%),
analytic/psychodynamic (36%), experiential (35%), and family/systems
(33%) (Schofield & Roedel, 2012). When asked to what extent they
regarded their orientation as eclectic or integrative, approximately 70% of
therapists answered greatly or very greatly.
Most graduate schools in counseling takes an integrative stance when
different models of therapy are taught, and students learn to examine the
match between client problems and model characteristics. O’Hara and
O’Hara (2015), however, point out that this is relatively superficial
psychotherapy integration because the actual meaning of integration is not
developed at a deeper level, and theories are mostly combined at a
pragmatic level. There are training institutes for integrative approaches.
Emotion-focused therapy, for example, has its own training programs in
major cities of Australia. The Australian Centre for Integrative Studies
offers an original integrative training based on transactional analysis.
Australia has lagged behind in terms of representing counseling and
psychotherapy in the higher education because public mental health is
dominated by psychiatry, nursing, and psychology, all operating within a
medical model of health (Day, 2015). Common factors across approaches
might become a strong base that pushes psychotherapy and counseling to
grow in Australia. In particular, the therapeutic relationship as a common
factor in treatment effectiveness may provide a solid scaffolding for
psychotherapy and counseling (Day, 2015).

China
China has experienced rapid social and economic transformations in past 50
years. The landscape of China is dramatically changing, and its economic
development is transforming the lifestyle of many Chinese people. The
rates of common mental health problems, such as mood disorders, anxiety
disorders, and suicide, are also on the rise (Lee & Kleinman, 1997).
However, psychotherapy is still very limited in its availability and its use
(Chang et al., 2013).
Chinese psychiatrists and psychologists have attempted to import and
disseminate the Western psychotherapies (Li et al., 1994). Newer models of
psychotherapy have been introduced by those Chinese psychologists who
studied overseas. In addition, master therapists have been invited to give
professional workshops in China. Professional organizations for major
psychotherapy systems have been formed, and these host annual
conferences and provide training workshops. However, Chinese therapists
are not equipped with basic theories of psychotherapy or counseling skills;
therefore, they tend to rigidly apply the interventions that they learn without
examining the underlying values of Western psychotherapy. Western values
such as individuation, self-control, and self-efficacy are not easily accepted
in Chinese culture, though they are often well-regarded by young people.
Teaching from an integrative point of view is much needed but not yet
common.
One psychotherapy integration that is commonly attempted in China is a
version of cultural integration in which cultural values of Chinese society
are added to Western psychotherapy (Chang et al., 2013). Confucianism and
Taoism are particularly relevant because they have permeated the Chinese
people’s psychological, social, and moral life for thousands of years.
Confucianism emphasizes hierarchy, moral development, achievement, and
social responsibility, and excessive compliance with it may give rise to
rigidity and overresponsibility. In contrast, Taoism focuses on conforming
to natural laws, letting go of excessive control, and the flexible
development of personality. Extreme adherence to this approach may foster
passive compromise, resignation, and apathy (Zhang et al., 2002).
A prominent example of a psychotherapy integration that incorporates
these Chinese cultural values is Chinese Taoist cognitive psychotherapy
(CTCP), a culturally adapted cognitive therapy (Zhang et al., 2002). CTCP
is based on the assumption that when clients learn more adaptive modes of
thinking, affective and behavioral changes naturally follow; however, it
does not emphasize rationality, objectivity, and logicalness as in
conventional cognitive therapy. Clients apply Taoist analytic thinking to
evaluate their thoughts, feelings, and behavior. Outcome research in two
trials on generalized anxiety disorder demonstrated that CTCP was more
effective than medication alone.
Hong Kong
Hong Kong, officially the Hong Kong Special Administrative Region of
The People’s Republic of China, is a cosmopolitan city that was a former
British colony until it was returned to China in 1997; it is renowned for its
economic and cultural prosperity. However, it is also struggling from many
social problems, such as long working hours, large income disparity,
escalating property prices, lack of social care for the elderly, and rising
inflation. Pressures are also being put on young children: there is a strong
focus on examination results and achievement in education, thus
contributing to a high need for psychological services in educational
settings (Leung, December 13, 2017, personal communication).
Because English is the official language of Hong Kong, psychotherapy
and its research are easily introduced. Major schools of psychotherapy have
established their own associations and instituted professional training such
as gestalt therapy, psychoanalysis, EMDR, and emotion-focused therapy.
Cognitive-behavioral therapy (CBT) is the most common approach, and
other short-term problem-solving approaches are preferred over long-term
insight-oriented therapies (Leung, 2017, personal communication).
Psychotherapy is relatively underdeveloped in Hong Kong (Yuen, Leung,
& Chan, 2014), and there is a lack of public recognition of its importance in
enhancing psychological health. Help-seeking behavior is also suppressed
due to stigma against mental illness. Mental health services in Hong Kong
are dominated by psychiatrists, nurses, and social workers, while
psychologists are not included in national projects funded by the
government. Therefore, the clientele in Hong Kong is limited to a small
portion of relatively wealthy and expatriates. Indeed, many private practices
in Hong Kong are conducted by European and Anglophone therapists who
treat international clients. Many therapists in Hong Kong are integrative or
eclectic, with CBT as a primary orientation. However, there is no academic
organization or community for psychotherapy integration.

Japan
Japan is often represented as a country of intricate yet contradictory culture
in which the elements of the most advanced technology and an ancient
cultural heritage coexist. The slogan Wa-kon Yo-sai, meaning “maintaining
Japanese spirit and acquiring and integrating Western technology,” which
was central to Japan’s modernization in late 19th century, had long
mobilized Japanese people toward development while maintaining a feeling
of connection to their ancestry and spiritual core.
Psychotherapy in Japan has been rapidly expanding and developing since
the 1990s in response to problems such as the growing rates of truancy and
bullying in middle schools, depression and other mental health issues in
workplaces, the high suicide rate, and two major earthquakes (Iwakabe &
Enns, 2012). Japanese psychotherapists have translated and introduced new
approaches developed in the Western countries. There are more than 30
associations affiliated with particular theoretical approaches. The
psychodynamic approach is dominant, followed by CBT, which has grown
in past 10 years. Japanese indigenous therapies, such as Morita therapy and
Naikan therapy, form small minorities among Western approaches.
According to a survey of the Japanese Society of Certified Clinical
Psychologists (2009), more than 70% of Japanese clinical psychologists are
integrative or eclectic. Most therapists learn to be integrative through their
clinical experience of working with different populations in a myriad of
clinical settings.
There have been a few models of integrative therapy created by Japanese
therapists (e.g., Hiraki, 1996; Murase, 2003). Murase (2003), for example,
constructed an integrative, multiaxial therapy based on her work with
children and their families. Most recently, major works of integrative
therapists have been translated into Japanese, and textbooks of
psychotherapy routinely make reference to psychotherapy integration as
one of the important movements.
Probably the most common form of psychotherapy integration is cultural
adaptation (Iwakabe, 2008), in which therapists modify or adjust some
aspects of the therapy to fit Japanese clients. The most poignant example is
Doi’s (1973) theory of dependence, which proposes the capacity to
construct a mutually dependent relationship is central to healthy
psychological development in Japan. Another example is the Ajase
complex. Kosawa thought that the Oedipus complex needed to be replaced
with the Ajase complex, wherein the Buddhist legend of Prince Ajatasattu
(ajase in Japanese) reflects the strong mother-son tie in Buddhist culture
(Dale, 1987).
 There are two Japanese groups active in psychotherapy integration. One
is the Society for the Exploration of Psychotherapy Integration (SEPI)-
Japan regional group in Tokyo and Eastern Japan that started their regular
meetings in 2005; the other is the Kansai Institute of Eclectic
Psychotherapy (KIEP) in Western Japan, which was formed in 2008. The
two groups have been working toward forming a national academic
association.
In Japan, 2 years of master-level education is necessary to be a clinical
psychologist. The certification does not specify any particular theoretical
orientations; therefore, graduate students are typically exposed to more than
two approaches. Two organizations offer formal training in integration. The
Institute of Psychotherapy Integration in Tokyo, funded by Noriko Hiraki,
has provided integrative family therapy training for more than 20 years. The
Kansai Counseling Center in Osaka was established in 1965 to provide
counseling service and training to a wider population of lay counselors with
or without a graduate degree in psychology. The Center launched a 3-year
integrative training program under the leadership of Yasushi Sugihara.
The most frequent type of psychotherapy article in Japan has been the
clinical case study (Iwakabe, 2015), which comprises 60% of the articles
published in the main academic journal, the Journal of Japanese Clinical
Psychology. Many of these therapists appear to practice some form of
integrative or eclectic therapy. However, the authors usually do not report
their theoretical approach. The reluctance of Japanese therapists to discuss
their integrative attempts needs to be addressed to develop a more open
discussion about psychotherapy integration in action.

Malaysia
Malaysia is one of the fastest growing countries in the South East Asia and
a multicultural society where Malays, Chinese, Indians, and other
indigenous groups and ethnic minorities cohabitate. Reflecting these
multicultural backgrounds, there is diversity in the popular view of mental
health, ranging from the supernatural to modern Western psychiatry (Ng,
2011). The number of people suffering from mental illness rising sharply;
however, the number of mental health professionals remains small.
Psychotherapy in Malaysia did not develop until the 1970s (Azhar &
Varma, 2000). The mental health service is predominantly associated with
psychiatrists who are more biological in orientation. Many approaches to
psychotherapy were recently brought home by those psychiatrists and
psychologists trained in English-speaking countries. There is no formal
regulation or accreditation for psychological practice. A survey of 30
clinical psychologists out of a total of 42 in the country found that the
majority were younger than 35 (Ng, 2011).
There is a strong inclination toward CBT. Its collaborative and
authoritative teaching stance fits the interaction style of Malaysians, which
is characterized by a hierarchical and an expert–patient relationship with
health professionals. Psychodynamic approaches are underrepresented in
Malaysia; some believe that psychodynamic theory is incompatible with the
indigenous cultural and religious beliefs. A more formal integrative CBT
model by Azhar Zain incorporates Islamic and sociocultural elements of
Malaysian lives (Azhar & Varma, 2000).
Most therapists practice more or less integratively, though they may not
identify their primary approach as such. In addition, they do not necessarily
articulate what they practice or what guides their clinical thinking; their
integration is implicit (Ng, personal communication, December 1, 2017).
Training resources for psychotherapy integration are scarce (Ng, personal
communication, December 1, 2017). The resources to support professional
development, such as supervision and continuing education, need to be
established. Male therapists are underrepresented. In a multicultural society,
training therapists of diverse linguistic and cultural backgrounds, as well as
therapists who are equipped to work with clients of diverse backgrounds, is
an urgent task.
Another important area of training is in family therapy. The problems
that therapists in Malaysia deal with most often require family work
because all ethnic groups in Malaysia consider family as the most important
system (Ng, personal communication, December 1, 2017). Individual
therapies may not fit the client’s conceptualization of the problem, and
behavior change often involves the entire family rather than a single
individual. The combination of individual and family therapy is one of the
integrative models that is needed.

Singapore
Singapore is one of the leading economic countries in the world, located at
the southern end of the Malay Peninsula. It is a multicultural country with 5
million inhabitants: approximately 75% of the population is Chinese, 13%
Malay, and 9% Indian. English is the official language, and, among
employed persons, approximately 1 in 3 is a foreigner, many coming from
China, India, and other Asian countries.
As in many Asian countries, Singaporeans are more familiar with the
term “counseling” than “psychotherapy.” Counseling was first introduced in
the 1960s and developed most strongly in the area of school and
educational settings (Yeo, Tan, & Neihart, 2012). Commonly, counseling is
short-term, practical, and problem-focused. The average length of treatment
tends range between 3 and 5 sessions (Chuan, December 15, 2017, personal
communication). On the other hand, psychotherapy is an emergent field that
started to grow in past 10 years, and the term is used mainly by Western
private practitioners in Singapore and by those academics trained in
Anglophone countries.
Most Singaporean psychotherapists practice integrative or eclectic
therapy, though psychotherapy integration is not a topic that has caught
their attention. Some therapists, however, have made creative integrative
attempts. One is the assimilative integration of traditional Chinese medicine
into the Western model of psychotherapy (Lee, 2015). Lee found that three
cultural practices have a profound influence on the lives of Chinese
Singaporeans. One is traditional Chinese medicine, a holistic approach that
integrates mind and body in treating diseases. It is concerned more with
prevention than treatment by having a balanced diet, regulating emotions
and desires, valuing moderation and self-control, and using herbal
medicines. The second is Dang-ki, which is shamanism that relates
psychological problems to external causes such as fate, astrological forces,
and supernatural entities. The third is Feng-shui, literally translated as
“wind and water.” This is a type of fortune-telling and divination based on
the belief that human fate and fortune are largely controlled by
cosmological forces. Feng-shui addresses psychological problems by
advising the client to restructure the physical environment, such as
rearranging a building’s interior design and furniture so that the energy (qi)
in the building will flow properly. Lee maintains that these practices can be
integrated into a form of assimilative integration within the basic
framework of CBT.
 One study that has a high relevance to psychotherapy integration in Asian
countries was conducted by Lee and Bishop (2001), who examined Chinese
Singaporeans’ beliefs about the etiology and treatment of psychological
problems. The result showed that therapists, clients, and non-clients all
equally endorsed Western psychological beliefs over indigenous beliefs
based on Chinese medicine, while therapists endorsed Western
psychological beliefs more than did the clients and the non-client sample.
These findings suggest that Chinese Singaporeans tend to be quite open to
Western psychological explanations for psychological problems.

South Korea
The concept of Western psychotherapy was introduced into Korea as early
as the 1930s, but it was only in the 1950s, after the Korean War (1950–
1953), that clinicians began to practice psychotherapy. It was after 1996 that
mental health professionals other than psychiatrists were allowed legally to
practice psychotherapy in South Korea (Joo, 2009). Today, psychiatrists,
clinical psychologists, counselors, social workers, and lay practitioners are
the main providers of psychotherapy. Among these practitioners, however,
psychiatrists still have the strongest political power and professional
jurisdiction.
Many Koreans still rely on traditional practices fusing shamanistic rituals
and Oriental medicine when faced with psychological disorders. Stigma
against seeking mental health service is strong. As in many Asian countries,
people often complain of somatic symptoms when their problems are
psychological in nature. Seeking psychotherapy is the last resort after other
kinds of support have been exhausted.
Two surveys of South Korean psychotherapists found that the majority
are eclectic, with the humanistic orientation as their main foundation (Bae,
Joo, & Orlinsky, 2003; Joo, 2009). Joo (2009) gives three reasons for a
strong eclectic orientation in South Korean therapists. First, South Korean
therapists often experienced difficulty in applying psychotherapy based on a
Western worldview that in some ways conflicts with Korean values.
Second, professional organizations have not provided advanced training in
specific treatment approaches Third, Korean society is based on the
Confucian worldview (In-bon-Ju-euh Sa-sang) that has much affinity with
humanistic eclecticism, which allows therapists to flexibly work with their
clients without creating cultural and value conflicts.
This open stance is particularly suited for promoting a sense of agency
and emotional involvement in Korean clients. Many Korean clients come to
therapy with an expectation that the relationship with the therapist will
reflect the traditional hierarchical relationships in which the therapist
teaches, gives guidance, and leads, while the client’s role is that of a
student, patient, or follower who is expected to be obedient, diligent, and
faithful. It is helpful for many Korean clients to change this expectation to
take an active and agentic stance in therapy (Joo, 2009).
A growing number of Korean psychotherapists are attempting to combine
familiar traditions of Taoism, Zen Buddhism, and Korean shamanism to
better attune psychotherapy to the special needs of the Korean setting
(Craig, 2007). Korean culture is in flux, with traditional values still forming
the foundation of the society, while Western values are influencing younger
generations more strongly than ever. Thus, psychotherapy in Korea must
incorporate and balance these two value systems in working with
individuals.

Taiwan
Taiwan, located in South East Asia, is a relatively small tropical island with
a highly modernized economy that enjoys one of the highest qualities of life
in Asia. The practice of counseling and psychotherapy has traditionally
remained small, mainly in the public school system. However, the recent
passage of the Psychologist Law (Guo et al., 2013) mandated that both
central and local governments install and manage community mental health
and school counseling services for the public. Although there are still
concerns regarding government control over the provision of counseling
services (Wang, 2006), licensure enhances the recognition of professional
counselors in Taiwan. On the other hand, psychotherapy in private practice
remains rare.
Western psychotherapy theories were introduced by Taiwanese
psychologists trained in the United States and other Anglophone countries.
Therefore, some therapists in Taiwan strictly follow Western psychological
practices. Taiwanese society has been deeply affected by Western cultures,
and this sort of direct application was still considered acceptable or even
necessary. On the other hand, many psychotherapists trained domestically
practice a form of eclectic therapy that incorporates Eastern Asian
traditional values with techniques of Western psychotherapies.
Taiwan scholars have been developing indigenous psychologies that
reflect Taiwanese cultures. Hwang and Chang (2009), for example, argue
that the Western ideal of individualism and free will does not fit in the
countries where an Eastern philosophical tradition has prevailed for
centuries. Self-cultivation practices originated from Confucianism, Taoism,
and Buddhism, each of which contributed to the emphasis on the
importance of following the laws of nature and detachment from the state of
egoism. They argue that core values arising from these cultural traditions
need to be integrated into the therapeutic endeavor to fully appreciate Asian
individuals.
Hwang and Chang also suggest modifications to the therapeutic
relationship. They argue that, for many Asians, a one-to-one relationship or
a face-to-face dialogue is uncomfortable. Having to disclose one’s faults
triggers shame, making it difficult to self-disclose and explore personal
feelings. Instead, therapists should take a teaching role, passing down
tradition by word of mouth to clients who are advised to live according to
these principles. Such a relationship is in agreement with Confucian ethics
that advocates the maintenance of interpersonal harmony by respecting
those above in the hierarchy and the principle of favoring the intimate—
those with whom one has a blood relationship (Hwang, 2001).

Thailand
Thailand is a newly industrialized country with manufacturing, agriculture,
and tourism as leading sectors of the economy. Buddhism is integral to Thai
identity and culture, with approximately 95% of the population identifying
themselves as Buddhists of the Theravada tradition.
Social stigma against mental health has prevailed, and thus far the mental
health service has remained small, limited to those with severe mental
illnesses. The social climate for mental health service, however, has
dramatically changed due to major national crises. One was the HIV/AID
epidemic in the 1990s. The need for long-term support as well as
psychoeducation about HIV became an essential health goal. The economic
crisis in 1997 resulted in considerable distress due to unemployment and
also led to suicide prevention and other supports for psychological
problems. Similarly, drug problems demanded the development of
rehabilitation services. Finally, the 2004 tsunami spawned the establishment
of support for survivors and families of victims. International supports also
helped train Thai professionals (Sangganjanavanich & Nolrajsuwat, 2013).
Counseling and psychotherapy, however, are still new and foreign to
most Thai people. Psychotherapy practice is largely limited to private
settings by European and North American practitioners for expatriates and
to academic settings by psychologists who see a small number of clients
using a particular approach.
Client-centered therapy and CBT are the leading approaches in Thailand.
Thai therapists use these while endorsing Eastern philosophies and
Buddhist teaching as the guiding worldview. The Buddhist psychological
notions about human drive or motivation (desire or craving), distress and
suffering (dissatisfaction and disharmony), as well as its resolution (right
understanding, right thoughts, right action), are all blended into the clinical
training and practice.
One of the best examples of Buddhist integrative attempts is integrative
group therapy by Chongruksa and colleagues (2015). This group treatment
integrates CBT, art work using mandala drawing, and reality therapy to
reduce the risk of developing traumatization among army rangers and Thai
police officers who work in terrorist attacks. Recently, the integrative
movement, as well as basic concepts of psychotherapy integration, has been
introduced into the Thai language (Sakunpong, 2014). The more
psychotherapists in Thailand become acquainted with psychotherapy
integration, the more systematic their integrative practice may become in
the future. The number of training programs in clinical psychology and
counseling has sharply risen in recent years in Thailand. However, there are
still challenges facing the development of psychotherapy. First, there is no
regulating board for counselors, psychologists, or psychotherapists. This is
a major disadvantage because Thai psychotherapists cannot secure positions
in the health system, and salaries are not guaranteed. Second, medical
professions have the strongest influence in mental health services, and the
role of psychologists tends to be limited to assessment and testing. Finally,
the stigma against mental illness is still so strong that people do not
frequently seek psychological treatment.
PSYCHOTHERAPY INTEGRATION IN EUROPE
Europe was home to many important contributions to the philosophy of
science, such as Karl Popper’s and Michael Polanyi’s innovative works. In
this sense, integration as an inevitable driving force in scientific
development should have found a secure home in the “old continent.”
At the same time, many cultural and historical factors retarded integrative
initiatives. As the birthplace of psychoanalysis, many European countries
were for many decades almost exclusively psychodynamic. The
establishment of different approaches came later and with considerable
effort. As a consequence, most European countries have not explicitly
delved into integrative research and training, with some notable exceptions.
More frequently and more recently, multiple therapy models have co-
existed in a state of mutual existence, with no active collaboration.
Europe is home to noteworthy early integrative scholars, such as
Anthony Ryle in the United Kingdom and António Branco Vasco in
Portugal. SEPI has regularly held conferences in Europe for the past
decades, and attendance from European professionals is usually high and
steadily rising.

Austria*
Austria has had some integrative initiatives, mainly focused on the
development of theory, practice, and training. One early example of such an
initiative was Packesch’s Integrative Seminar for Psychotherapy, which was
founded in 1969 and is still offering “a psychotherapy discourse that spans
different schools and is enriched by an interdisciplinary approach”
(www.seminargleichenberg.at).
Probably the most significant Austrian contribution to the field of
integration has been the development of an approach simply named
“integrative therapy.” This approach was recognised in Austria as an
independent method of therapeutic practice in 2005, and it is an anchor-
point for psychotherapy integration in Austria. Integrative therapy was
historically closely associated with Petzold and initially linked to gestalt
therapy. It is oriented toward interdisciplinarity, being influenced by fields
such as neurobiology. It does not include influences from either local
healing traditions or religious or spiritual components (see Austrian
Psychotherapy Act; Kierein, Pritz, & Sonneck, 1991).
The Austrian Society of Integrative Therapy (Österreichische
Gesellschaft für Integrative Therapie [ÖGIT]) was founded in 1990. In
addition to a degree in psychotherapy specializing in integrative therapy, it
offers further training at Danube University Krems in the form of a
postgraduate program leading to a master’s degree in education.
Other integrative efforts exist, such as another recognized modality called
integrative gestalt therapy and more recent integrative endeavors under way
in institutes of behavior therapy. Thus, the Institut für Verhaltenstherapie
(Institute of Behavioural Therapy) now offers further training in dialectical
behavioral therapy and schema therapy. Medical psychotherapy training
also offers integrative behavioral therapy as a major subject. Despite these
initiatives, to our knowledge, no systematic research has been conducted on
integrative approaches in Austria.
Contacts with SEPI have been made mainly by Silke Birgitta Gahleitner.
From 2018 onward, the Austrian SEPI network has been coordinated by
members of the ÖGIT. As a result of international networking with SEPI,
the strengthening of the integrative movement may bring additional clinical
expertise to Austria, as well as future developments in training, practice,
and research.

Czech Republic
Historically, the Czech Republic has pioneered a number of integrative
psychotherapies. These include SUR, a Czech integrative-psychodynamic
group psychotherapy whose name is derived from the first names of its
founders: Skála, Urban, and Rubeš; integrated psychotherapy, an original
Czech integrative model; and satitherapy, a Czech mindfulness-based
approach. Psychodynamic and cognitive-behavioral therapies are also
prominent in both training and practice. More recently, a growing
community of practitioners and researchers has spawned six psychotherapy
training programs that have focused explicitly on integration. Two of these,
briefly described here, are accredited by the European Association for
Integrative Psychotherapy.
Some integrative Czech scholars have developed the concept of a
“personal therapeutic approach” (Řiháček & Roubal, 2017a), focusing on
the idiosyncratic style and person of the therapist in a research-informed
fashion. This construct drives the integrative training program based in
Brno, Training in Psychotherapy Integration (Roubal & Kostínková, 2017).
In addition, this training is grounded on a common factors approach,
emphasizing the importance of the therapeutic relationship and principles of
therapeutic change.
This endeavor has also spawned a number of integrative research
initiatives. Jan Roubal, a researcher and member of the country’s SEPI
Regional Network, and colleagues received a 5-year state grant to
investigate their training (e.g., Kostínková & Roubal, 2015; Plchová et al.,
2016). One of their studies estimated the prevalence of Czech therapists’
integrationism, which found that the proportion could range from 21% all
the way up to 99% depending on the criterion used (e.g., actual
psychotherapy training or use of psychotherapy techniques; Řiháček &
Roubal, 2017b). This study serves as an early indicator that the Czech
Republic does indeed have a growing investment in psychotherapy
integration.
A second integrative training program is called the Integrative System of
Psychotherapy (Instep). It is led by M. Jara and J. Drahota and is based on
the assimilative model of integration, with gestalt therapy as the ground
approach.
It may be that the Czech Republic’s experience as a small nation,
historically overruled by bigger nations and totalitarian regimes, may have
alerted Czech citizens to the danger of big ideologies, making them
cautious of considering any single therapeutic approach as the “truth” (J.
Roubal, personal communication, August 13, 2017). This cultural
characteristic may have played a role in the Czech Republic’s pluralistic
spirit and its integrative interests.

France
To the best of our knowledge, psychotherapy integration has not had a
significant impact in France thus far. France has historically been at the
forefront of many innovations in psychotherapy, such as the study of trauma
and dissociation (Janet), hypnosis (Liebault and Bernheim, Puysegur), and
suggestion (Coue). Psychoanalysis found a strong following there, and
France retains this strong psychoanalytic influence. Cognitive-behavioral
approaches made significant inroads over the past decades, culminating
with the creation of a French Association of Behavior and Cognitive
Therapy in 1990 (Seiden, 1994). Graduate training and research tend to
represent a single theoretical approach. As one French integrative therapist
and SEPI member jokingly stated, “We have to be radically for or against
psychoanalysis or CBT, with or without having an adequate knowledge of
either” (M. Bachelart, personal communication, August 10, 2017).
During the 1990s, a few psychotherapists contributed to psychotherapy
integration in the book The Basics of Psychotherapy: Integrative and
Eclectic Approach (Chambon & Marie-Cardine, 2010). Despite this, the
psychotherapy integration movement has not made had a long-standing
impact or resulted in training programs or research efforts.
Importantly, France has also been underrepresented at SEPI, with only a
small number of active members representing the country, and none of them
being faculty from major universities. Despite this, a younger generation of
integrationists may be on the rise. Specifically, Maximilien Bachelart,
current coordinator of the French SEPI Regional Network, has written four
papers on psychotherapy integration and the first French book devoted to
the topic (Bachelart, 2017).

United Kingdom*
The historical development of psychotherapy in Britain has been
characterized by the dominant influence of separate schools of therapy.
From the 1930s, an extensive psychoanalytic community developed, with
an organizational center at the Tavistock Institute. In the immediate postwar
years, the Institute of Psychiatry in London was a leading international
center for training and research in behavior therapy. At the same time, the
ideas of Carl Rogers began to have a strong influence within the emerging
counseling community. Until the 1970s, psychotherapy and counseling in
Britain lacked professional associations and journals that would enable
dialogue to take place across theoretical orientations.
Early signs of interest in psychotherapy integration took the form of
training in integrative models imported from the United States: Egan’s
Skilled Helper model (Wosket, 2006) and Lazarus’s Multimodal Therapy
(Palmer, 2000) approaches that continue to prove influential among UK
professionals. The beginnings of a distinctive British tradition in integrative
therapy began to crystallize in the 1990s (Hollanders, 1999). An important
source of influence during this phase was the Sheffield Psychotherapy
Project (Barkham, 1992), which investigated the additive effects of
combining exploratory and prescriptive treatments within the same
protocol. Also significant was the facilitative role of Windy Dryden (1992),
a Rational Emotive Therapist, whose intellectual curiosity enabled a
growing openness to new therapeutic ideas (Dryden, 1992). Within the
psychoanalytic community, Jeremy Holmes (2002) fulfilled a similar
function.
Surveys of psychotherapists and counselors in Britain have found that
13–50% of clinicians explicitly define themselves as eclectic or integrative
in orientation (Hollanders & McLeod, 1999). However, when asked about
the actual techniques they used in their work with clients, as many as 80%
could be categorized as informally or implicitly adopting an integrative
approach (Hollanders & McLeod, 1999).
Since the 1990s, a number of home-grown models of psychotherapy
integration have been developed in Britain. A broadly relational-
developmental form of integrative therapy evolved at the Metanoia
Institute, drawing on psychodynamics, gestalt, transactional analysis, and
phenomenology. It was originally formulated by Clarkson (2003), further
articulated by others (Gilbert, 2010), and disseminated through the British
Journal of Psychotherapy Integration. Psychodynamic-interpersonal
therapy is an evidence-based approach that includes ideas and methods
from psychodynamic, interpersonal, and humanistic psychotherapies
(Barkham et al., 2016). Cognitive analytic therapy is another evidence-
based integrative therapy that combines psychodynamic, cognitive, and
postmodern dialogical perspectives (Ryle, 1990). A more recent model of
psychotherapy integration to have originated in the UK has been pluralistic
therapy (Cooper & McLeod, 2011). This is a flexible, collaborative
approach to therapy based on shared decision-making, in which therapists
and clients work together to use methods from a variety of sources.
There are three main psychotherapy associations in the UK. The British
Psychological Society has oversight of training in clinical psychology and
counseling psychology. The United Kingdom Council for Psychotherapy
(UKCP) and the British Association for Counselling and Psychotherapy
(BACP) validate training programs for psychotherapists and counselors,
respectively. A significant proportion of trainees within BACP- and UKCP-
validated programs tend to be mature students with previous careers in field
such as education, social work, health care, and the clergy. These
individuals typically exhibit a pragmatic, open-minded stance toward
therapy, along with a desire to make use of what they already know.
UKCP, as well as BACP, accredit both single-orientation and integrative
programs. All counseling psychology and clinical psychology programs at
the doctoral level require trainees to demonstrate competence in at least two
single-theory models.
Regarding research in psychotherapy integration, substantial amounts of
research have been conducted into the process and outcomes of both
cognitive analytic therapy (Calvert & Kellett, 2014) and psychodynamic-
interpersonal therapy (Barkham et al., 2016). Over the past decade, the
pluralistic approach has been an active area of research, with exploration of
its clinical outcomes (Cooper et al., 2015), processes of change (Antoniou
et al., 2017), and the development of tools for shared decision-making in
therapy (Cooper & Norcross, 2016).
In Britain, the overall movement toward psychotherapy integration has
been supported by an awareness of international developments, by SEPI,
and by the Journal of Psychotherapy Integration. It has also been facilitated
by the institutional openness that characterizes counseling and
psychotherapy in Britain.
There are perhaps three main challenges that stand in the way of the
further development of psychotherapy integration in Britain. First, there are
few positions for tenured faculty in psychotherapy, and those holding such
positions are typically required to run training programs that leave little
time for research. Second, the government has aggressively pursued
policies, such as the Improving Access to Psychological Therapies
initiative, which have been based around the delivery of single, manualized
therapies. A third challenge is the absence of organizational structures to
support the activities of integrative therapists. Although many clinicians are
aware of SEPI, few attend meetings or read articles.

Portugal*
António Branco Vasco, who was supervised by Dianne Arnkoff and Carol
Glass in the United States, both of whom served for decades on SEPI’s
steering committee, published the first papers on psychotherapy integration
in Portugal. He also started two courses on integrative and eclectic therapies
at the University of Lisbon, in 1996 and 2007, respectively, which continue
to this day. Nuno Conceição served as SEPI President in 2017.
In Portugal, there is a rising interest in psychotherapy. The public is
making use of therapy more often, is better informed about therapy, and is
also starting to understand its preventive and personal development
potentials. The “crazy” stigma seems to be losing strength. In a recent
survey of the general population (N = 4,893), about 20% had sought the
help of a mental health professional.
This increase in psychotherapy demand also has to do with increasing
availability, in that there has been a steady increase in the number of mental
health professionals in recent years (2,000+ professionals formally doing
psychotherapy in Portugal, for a population of about 10 million).
Furthermore, as compared to 10 years ago, psychotherapists are becoming
more professionalized and have more training, supervision, personal
therapy, and, of course, more experience.
Regulations to practice psychotherapy are becoming clearer, at least for
psychologists. Following the directives of the European Association for
Psychotherapy that promotes training standards for scientifically based
practice, the Board of Portuguese Psychologists has established rules
concerning the training required for a psychologist to be also considered a
psychotherapist: namely—formal training provided by some societies or
associations of psychotherapy, which tends to foster affiliation with a
particular brand or school of treatment. However, some of the training
includes psychotherapy integration approaches. For example, formal
training in psychotherapy integration is provided in some modules by the
Portuguese Association of Cognitive, Behaviour and Integrative Therapies.
Other societies, for example, the Society of Existential Therapy, also offer
some training in integration.
Clearly, there is a growing interest in and a wider acceptance of
integrative views in Portugal. Based on a survey (Vasco, 2001), the most
influential orientations in Portugal were the analytic/dynamic and the
cognitive-behavioral—about 30% each. A smaller percentage of therapists
endorsed systemic and client-centered orientations (about 11%_. Based on
that survey, more than 25% of all therapists considered themselves
integrative. Of course, it all depends on the way one defines integration:
there was a prevalence of about 18%, when using a very demanding
criterion. And when the criterion was not so demanding, the prevalence rose
to about 80%!
Despite the growing openness to psychotherapy integration, rivalry
continues to prevent a more inclusive climate, be it in academia, in
professional associations, or even in clinical settings. Still, dialogues on
psychotherapy integration continue to be of paramount importance in
Portugal, especially if one wants to train better and more responsive
therapists. The 2007 SEPI Conference was held in Lisbon, as will be the
2019 conference.
Research studies on psychotherapy integration are intermittently
published by several investigators, but the primary source of research has
been the Paradigmatic Complementarity Lab at the University of Lisbon,
which delivers several master’s level and doctoral studies each year (Vasco,
Conceição, Silva, & Vaz-Velho, 2018). Its aim is to help therapists organize
relevant contributions from several (also integrative) approaches in order to
understand clinical situations in a more comprehensive manner.

Spain*
The first contact Spain made with the international psychotherapy
integration community was through Guillem Feixas during his stay in the
United States in the late 1980s. The connection between the Spanish
integrative community and SEPI has existed since then.
Spanish integrative efforts materialized in June 1990, when Manuel
Villegas, Luis Botella, and Guillem Feixas founded the Sociedad Española
para la Integración de la Psicoterapia (Spanish Society for Psychotherapy
Integration) as both a Spanish association in its own right and a regional
branch of SEPI. The three founding members played a significant role in a
number of psychotherapy training programs, both their own (Universitat de
Barcelona, Universitat Ramon Llull i) and others, both nationally and
internationally. Also, the active involvement of visiting researchers and
professors helped create training and research that attracted a number of
younger researchers and practitioners that continue the interest in
integration. These initial efforts produced in 1992, among other things, an
issue of the Revista de Psicoterapia devoted to psychotherapy integration.
Subsequently, there has been a growing body of publications and research
from Spanish authors in the field.
 Accreditation in clinical psychology in Spain is regulated in two ways.
The first is via an internship program and the second via a master’s degree.
It is strongly advised that both paths are complemented by specific training
in psychotherapy (not just clinical psychology) via another master’s degree.
The influence of psychotherapy integration in such programs is especially
visible here. While some of the master’s programs still align with a single
theoretical orientation, a growing number of programs explicitly emphasize
combining and/or integrating approaches. This fact is probably influenced
by the significant number of Spanish practitioners who identify themselves
as integrative and/or eclectic. In 2006, this was estimated at around 54%
(Alonso et al., 2006).
Psychotherapy integration is facing the challenge of the general
movement toward a heavy medico-biological view of mental health and
psychotherapy. Such moves are visible in the official curricula of
compulsory training programs for clinical psychologists in Spain, where
more psychological topics have been replaced with psychopathological and
medical ones.
Recent integrative publications of Spanish authors suggest several future
directions. These include transdiagnostic models and their role in
psychotherapy integration; integrating research and practice, not only
theoretical approaches; the role of mindfulness-based psychotherapies in
integration; and research on the outcome of integrated models in practice.

Sweden*
Among the pioneers of psychotherapy integration in Sweden are Bengt
Eriksson and Lars-Gunnar Lundh. Both trained as psychologists and
psychotherapists at Uppsala University, where their PhD dissertations
focused on theoretical integration in the 1980s. Both were members of SEPI
from the beginning.
In 1994, Lundh and Eriksson published a book, Psykoterapins
skolbildningar (The Schools of Psychotherapy), which included chapters on
psychotherapy integration and common factors and argued for the need of
better communication across school boundaries. This book was used as a
textbook at training programs for a number of years.
Lundh taught classes on psychotherapy integration as part of the 5-year
psychologist program in Uppsala from 1986 to 1993, and at Stockholm
University from 1993 to 2002. In 2003, he was appointed professor of
clinical psychology at Lund University, where he contributed to a more
integrative model for the psychotherapy course for both psychologists and
psychotherapists. As part of his research, Lundh has published integrative
papers (e.g., Lundh, 2014, 2017).
Eriksson, who worked as an integratively oriented psychotherapist and
supervisor from the 1980s onward, developed at Örebro University an
integrative psychotherapy course from 2004 at their new psychologist
program. This was the probably the first fully integrative psychotherapy
training in Sweden. Within an integrative frame, the students were taught
psychodynamic, cognitive-behavioral, and humanistic-existential
psychotherapies. As part of his research, Eriksson (2014) has also published
a book on conceptualization in psychodynamic therapy from an integrative
perspective.
Another integrative development came in the late 1990s and early 2000,
when Rolf Sandell, originally a psychoanalyst, implemented a common
factors–based training at Linköping University. Unfortunately, these
training activities were not complemented with integrative research efforts.
Despite these integrative initiatives, psychotherapy integration has not
had a significant impact in Sweden, which maintains a greater interest in
singular theoretical approaches (B. Philips, personal communication,
August 3, 2017). Nonetheless, in a survey of more than 400 Swedish
therapists, approximately 24% regarded themselves as “eclectic” (Sandell et
al., 2004).
A Swedish SEPI Regional Network contact describes the current climate
in Sweden as one with a clear lack of collaboration between different
therapy approaches. Although different schools are operating quite well in
university and training settings, recent national guidelines for depression
and anxiety disorders recommend a focus on cognitive-behavioral and
pharmacological treatments, discouraging other psychotherapeutic
orientations. This governmental pressure may have hindered integrative
research and practice (B. Philips, personal communication, August 3,
2017).

Switzerland
A 2012 survey reported that Switzerland had about 15,000 psychologists,
which represents 1.8 psychologists per 1,000 inhabitants. Psychologists and
psychotherapists subscribe to the following theoretical orientations: 32%
psychoanalytic, 19% cognitive-behavioral, 17% humanistic, and 12%
systemic, with the remaining 20% stating that they adhere to “several
approaches” of psychotherapy in an integrative or eclectic way (Stettler et
al., 2012).
Looking at the roots and links between Swiss psychotherapists and SEPI,
the University of Bern group of scholars centered around Klaus Grawe
(now deceased) and Franz Caspar. These two researchers attended SEPI
meetings for decades, with Franz Caspar being present at these conferences
since the early 1980s and maintaining an active involvement in SEPI
committees to this day. Through them, many Swiss students and younger
practitioners have become familiar with the psychotherapy integration
movement.
In the 1980s, this Bern group opened an outpatient university clinic based
on an original integrative model. This model integrated CBT with
interpersonal elements. These interpersonal aspects were based on the “plan
analysis” case formulation method, which has been one of the cornerstones
in integrative thinking coming from Switzerland (Caspar, 2007). The
University of Bern clearly stands out as the main integrative force in this
country, as does, more recently, the University of Lausanne. Psychotherapy
integration also materialized early on, for instance, through the work of
Klaus Grawe on “schema theory” and later in 1998 through the publication
of his landmark book presenting an integrative approach (Grawe, 2004).
In Lausanne University, there is a tradition of having several coexisting
therapy models. Only in recent years has there been discussion of having a
common base for all university psychotherapy training. This proposed
integrative training is now in place, starting with common principles of
psychotherapeutic change and promoting dialogues and case discussions
between practitioners of different approaches.
As in other countries, governmental pressure influences psychotherapy
training, research, and practice. In Switzerland, there is a legal requirement
for training programs to subscribe to a particular model. Even within
training programs that are open to ideas outside their base orientation,
priority is given to the single model. Specific laws regulating therapeutic
practice vary across cantons (Caspar, 2008). Just as there is a great cultural
and linguistic richness to Switzerland, there also exists a wide offering of
quality training for therapy models, such as CBT, psychodynamic,
humanistic, and systemic interventions.
Swiss Regional Network director Ueli Kramer has reported that
contemporary students are increasingly valuing research that is informed by
clinical observation, in contrast with an older approach where research was
“translated” more or less directly to the clinical setting. Two Swiss SEPI-
related groups exist, one in French and one in German. This has facilitated
integrative venues in which to discuss cases from multiple theoretical
perspectives, thus cross-fertilizing ideas across the boundaries. Moreover,
SEPI Regional Network meetings have occurred there since early 2017.
These meetings suggest that Swiss integrative professionals have started to
move from a generic interest in theoretical integration toward more
assimilative and eclectic forms.

Turkey*
The Psychotherapy Institute, via its president Tahir Özakkaş, was the first to
encourage psychotherapy integration in Turkey. The contacts started in
2007 and evolved into relationships at an institutional level after 2010. The
Institute has been striving to follow the efforts being made toward
psychotherapy integration and is especially interested in European and
American integration studies, but the organic bond was formed only after
2010. Since then, the Institute has contributed to SEPI activities and
become a Regional Network center.
In Turkey, psychotherapy has traditionally been a no-man’s land,
unclaimed by either psychiatrists or psychologists. Due to the absence of
legal regulation of psychotherapy, professionals other than psychiatrists are
not allowed to treat clients. Psychologists and psychological consultants
have been mostly trained to be examiners, so psychotherapy has not been
addressed in academic curricula until recently. Recent legal arrangements
and increasing public demand for psychotherapy, which could not be met
by the existing base of psychiatrists, promoted mental health professionals’
interest in psychotherapy. Currently, psychologists can see clients in state
and private hospitals as long as they work with medical doctors.
Psychotherapy has only recently been taught in psychology departments,
and psychotherapy integration has not yet made an impact in university
settings. Cognitive-behavioral therapies are the dominant force.
Consequently, the Psychotherapy Institute has offered the only integrative
training program in Turkey. Each year, 50 mental health professionals are
enrolled in a 4-year training to become integrative psychotherapists.
Institute graduates have begun to offer brief informative seminars on
integrative psychotherapy at universities, counseling centers, and research
organizations.
In select seminars at universities, there have been references made to the
integrative literature, and these have been translated and published by the
Psychotherapy Institute. Other initiatives include seminars on integrative
psychotherapy taught by academics, a recent Türkiye Bütüncül Psikoterapi
Dergisi [Integrative Psychotherapy Journal of Turkey], and a National
Integrative Psychotherapy Congress, organized annually by the
Psychotherapy Institute.
Despite this thriving integrative community, there is no appreciable
research activity on psychotherapy integration in Turkey. Only the theses of
the Institute’s trainees sometimes research psychotherapy integration.
Because there is no formal licensure of psychotherapists, the prevlance of
integrative practice can only be estimated through private societies
regarding the dominant therapy orientations. Cognitive-behavioral
approaches are dominant in the country, and the number of CBT therapists
is between 500 and 1,000. The number of integrative psychotherapists is
around 500, mostly trained at the Psychotherapy Institute. In a country of
80 million, there is a huge and increasing need for psychotherapists. Right
now, the demand is quite high and increasing.

PSYCHOTHERAPY INTEGRATION IN LATIN AMERICA

Latin America is a vast region of the American continent, populated by
approximately 650 million inhabitants (Worldometers, 2018). It includes a
heterogeneous set of nations formed under the cultural influence of Latin
countries in Western Europe. It presents common cultural features such as
language proximity (Spanish and Portuguese), religion (most are Catholic),
and political systems (republican democracies). On the other hand, it shows
great diversity due to its social composition, the various ethnic roots of its
native people, and the migratory flows that influenced each region
(Fernández-Alvarez, 2017).
 It is difficult to estimate the exact number of professionals practicing
psychotherapy on this continent due to a lack of systematic studies.
Numerous reports insist that the number is proportionally high in relation to
other regions of the world, even larger than in European countries and in
many parts of North American. This is accompanied by a large percent of
practices that are guided by the psychoanalytic model. However, this has
changed in recent years, to the extent that other theoretical approaches have
developed (Muller & Palavezzatti, 2015).
In Latin America, psychologists obtain their licensure upon the
completion of their undergraduate degree and, along with psychiatrists, are
allowed to practice psychotherapy without taking further courses. Although
there is not a formal requirement, psychologists and psychiatrists frequently
consider it necessary to obtain a qualification in psychotherapy for the
purposes of social and professional recognition. Within this context,
graduate training has flourished. Many of the more prestigious academic
and clinical centers provide graduate studies in various approaches and
methods, and there is an increasing range of opportunities for training in
integration.
The Latin American pioneers in psychotherapy integration established
training programs based on the integrative models developed by Héctor
Fernández-Alvarez (Argentina), Roberto Opazo (Chile), Lucio Balarezo
(Ecuador), and Margarita Dubordieu (Uruguay). These individuals train
both local therapists in their respective countries and foreign therapists
abroad, thereby disseminating their models. Developments are expanding in
different countries, including Bolivia, Colombia, Guatemala, Mexico, and
Paraguay, thus promoting diverse forms of exchange.
In Latin America, the integration movement rapidly gathered momentum
due to multiple conferences. The 10th SEPI conference was held in Buenos
Aires in 1994. In 2001, the Chilean Institute of Integrative Psychotherapy
organized the 17th annual SEPI conference. During the First Latin
American Conference of Integrative Psychotherapies, held in 2006 in
Ecuador, the Latin American Association of Integrative Psychotherapy was
formed. The Second Latin American Meeting took place in October 2008,
in Uruguay. In 2007, the First Argentine and Uruguayan Integrative
Psychotherapy Conference took place in Buenos Aires and resulted in the
creation of an Argentine and Uruguayan integrative movement. It was a
sign of acknowledgment for the Latin American integrative movement
when Beatriz Gómez (of the Aiglé Foundation, Argentina) was elected
SEPI president in 2016.

Argentina*
Argentina has one of the highest utilization rates of psychotherapy in the
world, and it has traditionally been psychoanalytic (Fernández-Alvarez,
2008). Its early roots were favored by the fact that several psychoanalysts
from Central Europe immigrated to Argentina in the late 1930s. The
cultural specifics of the population facilitated this process as well, since
Argentina was a heterogeneous and cosmopolitan society with a high
proportion of European immigrants (Vezzetti, 1996).
Argentina counts 93,811 active psychologists, with 226 practitioners per
100,000 inhabitants (Alonso & Klinar, 2016). In a recent study of 1,854
psychologists (Alonso, Gago, & Klinar, 2017), 84% were psychotherapists,
of whom 47% were psychoanalysts, 29% integrative, 14% cognitive-
behavioral, 8% systemic, and 3% humanistic-existential. In an earlier
survey (Muller & Palavezzatti, 2015) of 314 psychotherapists from state
hospitals, the psychoanalytic model also emerged as predominant,
representing 53% of the sample. The integrative model, at 42%, constituted
the second largest group.
Argentina has a long-standing integrative tradition, beginning with
Héctor Fernández-Alvarez in the 1980s and facilitated by the creation of a
mental health and research institution, the Aiglé Foundation, in 1976.
Fernández-Alvarez participated for the first time in a SEPI conference in
1990, and he set up the Regional Latin American Network together with the
Argentine Network of Integrative Psychotherapies in 1991.
The movement gathered momentum at the beginning of the ’90s. This
process was developed by regular visits from well-known North American
and European psychotherapists who conducted seminars and workshops at
the Foundation. Argentine therapists utilized the developments taking place
abroad as well, creating new versions of these practices in their own work
(Fernández-Alvarez, 2001,2008).
Collaborative research as well as education and supervised experience
have shaped the Aigle integrative model over time. The training is a 2-year,
graduate-level program conducted jointly with state and private universities
in Argentina and in agreement with the Ackerman Institute for the Family
(Fernández-Alvarez, Consoli, & Gómez, 2016). The training is delivered
annually to 500 students in Buenos Aires and other cities in the country.
Faculty members of Aiglé also travel regularly to teach in other countries in
Latin America and Spain.
Research work started early on. The activities in this area are
characterized by strong communication between clinicians and researchers
and efforts to translate knowledge into clinical applications and training.
Special efforts have been devoted to the development and study of the
personal style of the therapist (Fernández-Alvarez, Gómez, & García,
2015). Currently, two research projects are being carried out to study
routine outcome monitoring and short-term outcome follow-up. Since 1992,
Aiglé has published the Revista Argentina de Clínica Psicólogica
[Argentine Journal of Clinical Psychology], which in turn publishes papers
based on all theoretical orientations.
Finally, integration of psychotherapy is at work in Argentina under
conditions that differ from traditional office practice. Clinical projects are
carried out in various regions, particularly in the south of the country, where
psychotherapists work side by side with practitioners of traditional healing
methods. In some of the Patagonian provinces, health care centers
incorporate the cultural framework of indigenous groups. An active
collaboration between local healers and psychotherapists enhances client
confidence in the help they are offered (Arrúe & Kalinsky, 1991).

Chile*
As is the case for most Latin American countries, there are scant data
regarding psychotherapists’ orientations in Chile. However, psychoanalytic,
humanistic, systemic, and behavioral therapies are known to be prevalent,
with an estimated predominance of eclectic approaches (Bagladi, 2014).
In 1991, the Center for Scientific Psychological Development, directed
by Roberto Opazo, organized a Congress in Santiago de Chile under the
title “Integration in Psychotherapy.” In that context, a survey was conducted
to identify the theoretical orientation of attendees. Results indicated that
15% of the attendees subscribed to the psychoanalytic approach, 20% to the
systemic approach, 22% to the behavioral approach, and 15% to
eclecticism. Most respondents considered it important to promote
integration, and about a third considered it particularly imperative to
achieve integration in psychotherapy. These data, however, must be
evaluated within the context of an “integrative” congress.
Psychotherapy integration was introduced in Chile by Opazo and his
group. As early as 1981, members of the integrative center published an
article entitled “Towards an Integral Therapy” (Opazo et al., 1981). The
first direct contact with integration in psychotherapy occurred in a
presentation of the integrative supraparadigm by Opazo in 1983, during the
annual congress of the Association for the Advancement of Behavioral
Therapies. In 1985, the Institute presented its first graduate psychotherapy
courses, including discussing the subject of psychotherapy integration. Ten
years later, they were the first accredited institution in Chile authorized to
teach accredited courses of psychotherapy with an integrative orientation
(Opazo & Bagladi, 2010).
Connections with SEPI began in the early ’90s, through contacts
facilitated by Héctor Fernández-Alvarez and through attendance at the SEPI
conference in 1995. The The Chilean SEPI Network was created, and, in
1997, the integrative model was published in the Journal of Psychotherapy
Integration (Opazo, 1997). In 2000, CECIDEP changed its name to Chilean
Institute of Integrative Psychotherapy (ICPSI). The institution has
maintained close ties with SEPI, and, over the years, more than 10
international SEPI members taught courses at the institution. Especially
enriching have been the contributions of SEPI members Michael Mahoney,
Paul Wachtel, John Norcross, George Stricker, Jeremy Safran, Marvin
Goldfried, Barry Wolfe, and Louis Castonguay, among others.
Master’s programs in integrative psychotherapy began in 1998, in
agreement with the University of Santiago de Chile. In 2001, the Institute
signed an agreement with Adolfo Ibáñez University to create a master’s
program in clinical psychology, including the term integrative
psychotherapy. To date, more than 400 master’s students and more than 600
students from the other graduate training programs have received education
in integrative psychotherapy (Bagladi, 2002, 2014).
Most of the Chilean research in integration has been carried out within
the context of ICPSI. To date, this amounts to 300 studies on the integrative
supraparadigm. Among the topics addressed are the functions of the system
of the self, validations of comprehensive psychodiagnosis, integrative
psychotherapy in personality disorders, integrative psychotherapy and
personal development, integrative psychotherapy with youth, and
comparative results of psychotherapy.
The Institute has published numerous articles and books centered on
integrative themes. A newly released book is Integrative Psychotherapy IES
(Opazo, 2017). The institutional links with SEPI, Latin-American
Association of Integrative Psychotherapy (ALAPSI) ALAPSI, and with the
World Council for Psychotherapy have facilitated the dissemination of
Chilean integration. Furthermore, there are relationships with the Aiglé
Foundation in Argentina, which has consisted of a long and close
collaboration.

Ecuador*
The integrative movement in Ecuador was formalized in 1999, in
Argentina, during a foundational meeting among Héctor Fernández-
Alvarez, Roberto Opazo, and Lucio Balarezo at the first Latin American
Congress on Psychotherapy. This event not only solidified a friendly
exchange among the three practitioner-scholars, but also established an
academic relationship that fostered in Ecuador an integrative psychotherapy
that focuses on personality as the central organizing concept (Bautista,
2015).
With this background, the Ecuadorian Society of Integrative Counseling
and Psychotherapy (SEAPSI) was established. The Society is committed to
the dissemination and expansion of the integrative model in the country,
and it has achieved acceptance in both scientific circles and therapeutic
practice (Balarezo & Velástegui, 2014). In 2001, a group of Ecuadorian
researchers and clinicians led by Balarezo participated for the first time in a
SEPI conference in Chile, which in turn eventually spurred the organization
of the Ecuador SEPI Regional Network in 2016.
With the emergence of the integrative movement, some new training for
integrative psychotherapists occurred through the creation of a master’s
program in integrative psychotherapy and through training groups. Thus far,
five master’s programs have been developed: one in the city of Quito at the
Central University, and four at the University of Azuay. Regarding informal
training, training groups have been established in the cities of Quito, Loja,
Ambato, and Quevedo
 Undergraduate training at the university level embraces all well-
established theoretical orientations, and most universities take an integrative
stance. In fact, at the Pontifical Catholic University of Ecuador, traditionally
a psychoanalytically oriented institution, an integrative program was
established in 2016. At the graduate level and in continuing education
programs, the demand for integrative models is also high. Master’s degree
programs, courses, seminars, and workshops have been endorsed by
universities. At some universities, integrative psychotherapy has been
incorporated as a separate course or as one of the main units in the syllabus
(Balarezo, 2011).
There are currently three research groups aiming to validate personality
instruments and guidelines for psychotherapy. The studies are descriptive
and correlational in nature. Over the past 10 years, there have been
developments in guidelines on family mentoring, clients with kidney
failure, drug abuse, depression, and cancer (Balarezo, 2011). Ecuador also
publishes a primary Latin American journal on integrative orientation, the
Revista Pser-Integrativo.

Uruguay*
Although psychoanalysis has prevailed in Uruguay for decades,
psychotherapy integration has been growing and currently holds a
significant place. That is the case in undergraduate education, graduate
training, and clinical care delivered in state and private practice
(Dubourdieu, 2016).
In 1995, Margarita Dubourdieu founded the Humana Center in Uruguay,
where therapists began to be trained in an integrative model called
integrative psychotherapy. The model integrates contributions from
cognitive, interpersonal, systemic, existential, and humanistic
developments, as well as from other disciplines. In 2002, the Uruguayan
Society of Psycho-Neuro-Immuno-Endocrinology was founded and
integrates the areas of medicine, psychotherapy, and nutrition (Dubordieu,
2017).
The Uruguayan Federation of Psychotherapy was created in 2004,
bringing together 23 psychotherapy associations. This organization
developed the Psychologist Law and Code of Ethics and established the
regulation of psychotherapeutic practice under the joint jurisdiction of the
Ministry of Education and Culture and the Parliament.
In 2005, Dubourdieu contacted Opazo in Chile to initiate an exchange
about the development of integrative psychotherapy. In 2006, after a
meeting in Buenos Aires, Fernández-Alvarez invited her to participate in
the First Latin American Conference of Integrative Psychotherapies. She
attended several SEPI conferences, thereafter establishing the Uruguay
SEPI Regional Network.
Training programs in integrative psychotherapy were developed at the
undergraduate and graduate levels at the University of the Republic,
Catholic University, and San Francisco de Asis University. The Human
Center is recognized by the Ministry of Education and Culture to deliver a
2-year graduate training in integrative psychotherapy as well as a training
program at the Catholic University. Both courses must be complemented
with 100 hours of supervised internship to obtain the national and Latin
American Certificate of Integrative Psychotherapist.
Since 1995, integrative psychotherapy has been incorporated into
hospital work and also included in interventions with adolescents. This
work takes place at the Clinical Hospital of Medicine and utilizes
individual, couples, and group therapy approaches. Psychological care is
provided to adolescents at risk at a local clinic, mainly with self-injury, and
for drug abuse disorders in a population facing adverse socioeconomic
conditions. Research in psychotherapy integration is starting to develop in
Uruguay. Studies have been conducted on the impact of stress on health in
hospital populations in oncology and in gastroenterology, and on the effects
of biopsychoeducation on treatment outcome. A recent book on this subject
reflects work in this area (Dubordieu & Nasi, 2017).

RECURRENT INTERNATIONAL THEMES

In this section, we reflect on the global landscape of psychotherapy
integration and extract recurring international themes from the preceding
contributions. Specifically, we discuss and amplify seven themes.
First, the surveys of psychotherapists reviewed in this chapter show that
integrative psychotherapy is widely used across the globe. It is no longer
restricted to the United States and Western Europe. In many countries, the
integration movement gave rise to a diversity of models, in many cases with
their own training programs.
Second, psychotherapy integration spawned distinctive proposals, but
most adapt psychotherapy to particular features of their place of origin. The
models adapt strategies to differences and peculiarities of the context in
each country in terms of health needs, patient preferences, therapist
availability, and governmental requirements. This approach to integration
typically begins with research-supported treatments and then adapts them to
the cultural needs and institutions of particular countries.
At the same time, one major problem to overcoming psychotherapy
fragmentation is a persistent tendency of therapists to create new models
and to defend a particular territory, which sometimes corresponds more to
marketing than to science (Paris, 2015). Psychotherapy integration may be
at risk of falling into new divided and competing territories instead of
contributing to a common, albeit complex, mental health field.
A third recurrent theme is that socioeconomic conditions prove
fundamental in shaping both demand and supply. The harsh socioeconomic
conditions in many countries, particularly in Latin America and Asia, have
increased the demand for psychotherapy but simultaneously reduced the
resources available to meet this growing demand. In this sense,
psychotherapy faces a powerful challenge to help clients broaden their
horizons, which have shrunk not only internally but externally (Gómez,
2007).
Fourth, multiple contributors to this chapter observed the power of both
national and international organizations in providing a socioacademic home
and professional support to psychotherapy integration. Many specifically
cite the influence of SEPI and its members, although contributors were
undoubtedly aware that the chapter authors (and book editors) also have
been long-term SEPI enthusiasts. Organizations provide publications,
conferences, trainings, social forums, and reinforcing identities.
Fifth, one detects the mutual facilitation among practice, education, and
research in these integrative accounts. Collaboration between integrative
scholars and psychotherapy practitioners is fostering a greater
rapprochement between research and practice. Reciprocal collaboration and
exchanges seem to be a meaningful trend within the integration movement.
Open-mindedness, flexibility, and humility to accept the limits of our
knowledge are some of our foundational attitudes.
 Sixth, many of the integrative psychotherapies developed across the
world have not been subjected to rigorous evaluation for their comparative
effectiveness. Lack of controlled outcome research on integrative therapies
probably hindered the uptake and impact of psychotherapy integration. In
an age where evidence-based practice and randomized controlled trials
dictate much psychotherapy policy and academic relevancy, integrative
research warrants further investment (Castonguay et al., 2015).
Seventh, and final, a major constraint that prevents researchers and
clinicians alike from benefitting more from each other’s contributions
worldwide stems from a language barrier. Not everything that is produced
can realistically be translated, and even when such translations are available
in English, in many cases the therapists do not possess sufficient English
skills to benefit meaningfully from reading these contributions. Still, one
mediating factor is the existence of international organizations and
congresses, which are facilitators for exchange. In this sense, the
contributions of SEPI and the Journal of Psychotherapy Integration as
communication and information channels among countries stand out as
driving forces in facilitating the psychotherapy movement.

CONCLUSION
This chapter illustrates the variety and richness of contributions to
integration in psychotherapy in Europe, Latin American, and Asia. These
contributions are nourished by schools of thought from different regions but
emerge with their own unique features, enriched by cultural components
and social conditions of great diversity. A challenge will be to discover
creative ways to integrate the values and worldviews of multiple cultures
within the demands for efficiency and evidence that dominate psychological
care. Such integration will produce a healthier future for the field and for
populations that turn to psychotherapy for a better quality of life (Norcross,
Pfund, & Prochaska, 2013).
Another challenge for the field will be to increase the exchange between
the more developed countries and the less developed ones. This means
overcoming cultural barriers in which psychotherapies are exported from
developed countries, mainly from North America and Western Europe, to
other regions with scarce movement in the opposite direction. This
undertaking will entail mutual efforts. Psychotherapies generated in less
developed countries will need to increase controlled outcome studies and
their visibility. The greatest difficulty at this point probably lies in the
available resources, especially economic. Therapists and schools from more
developed countries will need to recognize the value of these contributions
in order to learn from them and benefit from their creativity. This will also
be true for education and training programs coming from less favored
regions, so they contribute to therapy training in the rest of the world.
At the same time, theories and treatments appropriate for the original
population of each country also require constant adjustment to the rapid
changes of a mobile and migrating world. More and more people are
moving away from their country of origin. In 1990, 150 million people
across the world were classified as international migrants; 25 years later,
that number has increased by almost 100 million (World Economic Forum,
2017).
Migration will clearly influence the training of psychotherapists.
Programs will require grounding in integrative, cultural-sensitive
psychological perspectives that view patients as cultural beings immersed in
multiple contexts, facing significant challenges, and as human beings who
bring unique strengths (Fernández-Alvarez, 2017). This is reason enough to
make greater efforts toward fuller integration.
In the future, psychotherapy around the world will undoubtedly become
more fully integrative, not only in terms of blending theoretical
perspectives, but also in mutually beneficial collaborative efforts between
practitioners and researchers. Most importantly, integration seeks to
enhance the effectiveness of psychological help in relieving human
suffering any place in the world where people happen, have to, or choose to
live.

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*
The section has been contributed by Silke Birgitta Gahleitner and colleagues.
*
This section has been contributed by John McLeod and Mick Cooper.
*
This section was contributed by António Branco Vasco and Nuno Conceição.
*
This section has been contributed by Luis Botella.
*
This section was partly contributed by Lars-Gunnar Lundh.
*
This section was contributed by Tahir Özakkaş.
*
This section was contributed by Héctor Fernández-Alvarez.
*
This section was contributed by Roberto Opazo.
*
This section was contributed by Lucio Balarezo.
*
This section was contributed by Margarita Dubordieu.
 22

Future Directions in Psychotherapy Integration

CATHERINE F. EUBANKS, MARVIN R. GOLDFRIED, AND JOHN C. NORCROSS

Any movement that merits a third edition of a handbook clearly has reached
a position of recognition and strength. In the past 40 years, psychotherapy
integration has grown into a well-established and influential movement in
mental health. Any number of objective indictors point to this fact.
Integration (or occasionally eclecticism) represents the modal theoretical
orientation of psychotherapists in most countries (see Chapter 1 for a
review). Scores of professional books and textbooks characterize
themselves as integrative in their approach. The integrative movement
boasts an international association (Society for the Exploration of
Psychotherapy Integration, or SEPI) with dozens of regional branches,
several journals (e.g., Journal of Psychotherapy Integration), and thousands
of publications in multiple languages. Students crave systemic training in
less doctrinaire and more secular psychotherapy that, ideally, proves more
efficient, applicable, and efficacious for their clients. Research on
psychotherapy integration overall is still at an adolescent stage (Castonguay
et al., 2015), but outcome research has now been published on at least 30
hybrid or integrative psychotherapies (see Boswell, Newman, & McGinn,
Chapter 19, this volume).
Psychotherapy integration is here and, by all indications, is here to stay.
A recent poll of psychotherapy experts from diverse persuasions predicted
that integration in its various forms (e.g., theoretical integration, technical
eclecticism; see Chapter 1) will continue to increase in the next decade
(Norcross, Pfund, & Prochaska, 2013). In fact, integrative therapies were
forecast to increase the third most among 31 psychotherapies, only behind
mindfulness therapies and cognitive-behavioral therapy.
 In the previous edition of this Handbook, the concluding chapter on
future directions (Eubanks-Carter, Burckell, & Goldfried, 2005) noted that
integration had not yet fulfilled its promise. It was observed that there was a
tension between action and exploration, between those who want the field
to reach a consensus about the principles or strategies that characterize
effective integrative psychotherapy and those who argued that reaching
consensus is premature and will hamper innovation. That earlier chapter on
the future expressed concern that the lack of consensus on an action plan
resulted in integration standing on the sidelines while the proliferation of
new therapies continues unabated, as some had long predicted and feared
(Goldfried, 1980).
Although many talented researchers continue to focus on “proving” that
certain therapeutic approaches are superior to others, these efforts continue
to fail to find evidence of a clear winner (Luborsky et al., 2002; Wampold
& Imel, 2015). Now, well into the 21st century, we find ourselves reaching
the same conclusion that Saul Rosenzweig reached back in 1936, when he
observed that, due to the complexity of psychological phenomena and the
presence of common processes, multiple forms of psychotherapy will prove
effective. That resulted in the verdict of the Dodo bird that “Everybody has
won and all must have prizes” (Rosenzweig, 1936).
With a humble recognition that, as Niels Bohr once observed, prediction
is very difficult, especially when it comes to the future, we endeavor in this
chapter to suggest where psychotherapy integration may be headed in the
areas of theory, practice, research, and training, as well as its status as a
formal movement. Our primary objective, however, is to advance
discussion about several future directions that seem particularly promising.
In doing so, we draw on our collective experiences and the 21 other
chapters in this volume. A content analysis of the future directions sections
of those other chapters revealed that 88% of the chapter authors addressed
the future of integrative practice and 72% research, but only 22% addressed
training directions and only 17% the future of theory. Here, we try to
redress that inequity and speak equally to all four domains of psychotherapy
integration.

DIRECTIONS IN INTEGRATIVE THEORY

Theory has always played an important role in psychotherapy integration.
For example, Wachtel’s (1977; Wachtel & Gagnon, Chapter 9, this volume)
seminal theoretical work on integrating psychodynamic and behavioral
therapies was a major contribution to the integration movement. He
subsequently (1997) added relational and interpersonal theories to the mix,
demonstrating the fluid and evolving nature of integration. Wachtel
recognized both the essential similarities and the fundamental differences
between disparate theories; identifying the similarities as potential points of
clinical convergence that can serve as bridges across the chasms of
divergence.
Virtually every combination of theories have been blended or bridged in
the literature or in practice. When 187 self-identified integrative therapists
were asked to rate their use of six theories (behavioral, cognitive,
humanistic, interpersonal, psychoanalytic, systems), the resulting 15
possible combinations of two theories were each selected by at least one
therapist (Norcross, Karpiak, & Santoro, 2005). The typical combination in
the late 1970s was psychoanalytic-behavioral; in the late 1980s, the three
most popular hybrids all involved cognitive therapy; and in the early 2000s,
cognitive and third-wave (acceptance, mindfulness, meditation) theories
dominate the list of combinations.
Which theories are the probable source of future integrations? To be sure,
neuroscience finds its way increasingly into psychotherapy book titles and
journal titles. Multicultural perspectives should be part of all
psychotherapies, but most integrative therapies do not yet have culture as a
major emphasis (Harris, Shukla, & Ivey, Chapter 15, this volume). We
foresee both neuroscience and multicultural perspectives occupying
privileged positions in coming years, in and out of integrative treatments.
Sometimes the theoretical innovation originates not from researchers or
theoreticians, but from patients. A case in point are the stages of change in
the transtheoretical model (Prochaska & DiClemente, Chapter 8, this
volume). Clients described their change methods in terms of when change
occurred, subsequently labeled the precontemplation, contemplation,
preparation, action, and maintenance stages. That conceptualization
provided a useful framework that helps practitioners of all orientations
assess and tailor their interventions in accord with the client’s readiness for
change.
 In recent years, two integrative models that seek to ambitiously
incorporate most psychotherapy systems have been advanced by numerous
writers. The first, pluralistic counseling and psychotherapy, is more popular
in the United Kingdom and Europe. It seeks to break away from the
orientation-specific way in which services and training have been
historically conducted. Different clients are likely to want—and benefit
from—different things in therapy. Hence, therapists should be open to
respecting practices from across the psychotherapy spectrum and sharing
decision-making with patients. Pluralism can be a way of thinking about
therapy, or it can be a specific practice in which the therapist draws on a
range of different understandings and methods
(www.pluralistictherapy.com). It has generated several books and a fair bit
of published process and outcome research.
More popular in the United States, unified psychotherapy is a
biopsychosocial systems model that draws from many major therapy
approaches. The aim is that such an approach could be grounded in clinical
science and would bring together the structures, processes, and mechanisms
of human functioning into one coherent model that could guide
psychotherapy. (e.g., Henriques, 2011; Magnavita & Anchin, 2014;
Melchert, 2015). Unified psychotherapy has generated a number of
publications, books, and an online journal but, to our knowledge, no process
or outcome research.
Several aspects of the quest for unification are promising. Working
toward a unified psychotherapy would entail reaching greater agreement on
language. As the jargon of each orientation forms a language barrier that
prevents us from recognizing areas where we agree (Goldfried, 1987),
efforts to use common language to express our ideas as clearly and
straightforwardly as possible could help us to reach greater consensus by
facilitating the productive exchange of ideas and by aiding the recognition
of the extent to which we already agree but simply use different words to
express the same ideas.
Recent efforts to work toward integration or unification also emphasize
basing theory on research evidence. Efforts to ground our work in research,
including not only psychotherapy research but research from the basic
sciences as well—such as social cognition, attribution, decision-making—is
laudable and could help to foster consensus in some areas.
 At the same time, voices within the integration movement have registered
concerns about the feasibility and desirability of a grand unification,
suggesting that differences in perspective are unavoidable (e.g., Messer,
2008). Indeed, the various unification proposals cannot agree on the
underlying or foundational substrate—is it systems theory, neuroscience,
developmental, evolution, cognition, empiricism, or humanism? Prioritizing
one perspective means inescapably neglecting others, which leads to
renewed quarrels about the superiority of select theories. Alternatively, the
pluralistic approach values all theories that work and relies heavily on the
client’s experiences to determine which methods to employ.
Hopes for unification need to recognize the inherent complexity involved
in understanding human behavior and the change process. Psychotherapy, in
this view, is not a universe but a multiverse. For example, even agreeing on
a commitment to empiricism to identify “what works” is a complex
proposition. Psychotherapists need to agree first on the relative proportion
or proper sequencing assigned to research evidence, clinical expertise, and
client input in treatment decisions (Norcross et al., 2017). An agreement
must then be reached on what constitutes quality research and on how to
properly interpret those research findings. The reality is that research topics
are chosen and studies are designed and conducted by complex human
beings, with assumptions and biases impacting every step of the empirical
process.
A profitable direction for integrative theory might be to shift focus from
integrative theories to integrative practitioners—the individuals using the
theories. Psychotherapists have long recognized the healing impact of the
person of the therapist and the therapeutic relationship; researchers have
now repeatedly substantiated that clinical conviction (e.g., Castonguay &
Hill, 2017; Norcross & Lambert, 2019; Wampold & Imel, 2015). Better
understanding of how therapists are (or are not) guided by theory when they
are working clinically could help point to more effective ways to integrate;
we can build better theories if we have a better understanding of clinicians’
needs and struggles. Focusing on the person who uses the theory could
direct us to focus more on areas such as therapist decision-making
(Magnavita, 2015), navigation of choice points (Messer, 1986), and
therapists’ awareness of their own experience (Gelso & Hayes, 2008) as a
means of identifying critical moments in therapy.
 Greater attention to how therapists use theory would involve recognizing
the strengths and limitations of theory—how theory helps therapists
organize their experience and navigate challenging clinical situations with
greater confidence and skill, and how theory can bias and blind us. Better
understanding of how therapists use theory could also inform our efforts to
teach and disseminate theory effectively (Norcross & Finnerty, Chapter 18,
this volume).

DIRECTIONS IN INTEGRATIVE PRACTICE AND RESEARCH

When beginning to write this chapter, we intended to have separate sections
on the future of integrative practice and the future of integrative research.
However, we have found that these are probably best discussed together as
we predict that the futures of these two domains are intertwined. As
pressures mount on practitioners to demonstrate the value of their work and
as funding opportunities diminish for psychotherapy researchers (Goldfried,
2016), practice that is informed by research and research that is informed by
and relevant for practice stand a greater chance of surviving. Indeed, the
integration of practice and research is increasingly being highlighted as a
key component of psychotherapy integration, as acknowledged in recent
mission statements of SEPI (www.sepiweb.org) and in the addition of an
entire chapter in this Handbook devoted to integrating research and practice
(Castonguay, Constantino, & Xiao, Chapter 20, this volume).
Most researchers and practitioners are united in their pursuit to determine
what works in psychotherapy. A frequent plea in psychotherapy integration
is to “stop all the theorizing and help us to better treat our patients!” That’s
a quest endorsed by virtually every clinician.
The relation between research and practice in integration frequently
proves mutually beneficial: outcome research findings can support
integrative treatments, and furthermore, the mind sets and methodologies of
integrative researchers and practitioners make them ideally suited to be at
the forefront of research critical for the advancement of psychotherapy
(Castonguay et al., 2015). Specifically, dialogues across orientations could
play a pivotal role in identifying harmful effects in therapy and ways to
address them. Advancements in the field can also be made by studying the
characteristics of effective therapists and identifying best practices for
training. Reaching across theoretical divides will increase the likelihood of
making new and innovative connections, and researchers and practitioners
interested in integration could be key figures in fostering such
collaborations.
An example of fostering collaboration between researchers and
practitioners in the spirit of integration is the Two-Way Bridge initiative. A
collaboration between Divisions 12 (Society of Clinical Psychology) and 29
(Society for the Advancement of Psychotherapy) of the American
Psychological Association, the two-way bridge is modeled after a system
used to monitor pharmaceuticals in the United States. The Food and Drug
Administration encourages medical practitioners to give feedback on drugs
based on their clinical experiences. Goldfried and colleagues (2014) took
this concept and adapted it for the field of psychotherapy. To date, several
surveys have been conducted to gather feedback from practicing therapists
on the use of CBT for various anxiety disorders (e.g., Jacobson, Newman,
& Goldfried, 2016; McAleavey, Castonguay, & Goldfried, 2014; Szkodny,
Newman, & Goldfried, 2014). This initiative aims to foster two-way
dialogue between researchers and practitioners about what works and what
does not work in real-world settings. Practicing therapists can disseminate
their clinical observations to researchers on what needs to be studied, and
researchers can disseminate to therapists the findings that result from such
research.
Another example of the integration of research and practice is feedback-
informed therapy, also referred to as routine outcome monitoring
(Maeschalck, Prescott, & Miller, Chapter 5, this volume). This involves
tracking client progress using reliable measures and immediately providing
feedback from the measures to the therapist. This approach empowers
clinicians to be true scientist-practitioners in the therapy room, drawing on
data to inform their work with their patients. Routine outcome monitoring
systems that identify patients at risk of treatment failure reduce
deterioration rates and enhance positive outcomes (Lambert, Whipple, &
Kleinstäuber, 2018).
In addition, feedback systems provide excellent opportunities to
encourage and study integration across orientations. For example, with the
Outcome Questionnaire (OQ) system (Lambert, 2015), when clients’
ratings indicate that they are not progressing as expected in psychotherapy,
the system assesses the clients’ stage of change, the therapeutic alliance,
social support, and stressful life events. The OQ system then provides
clinicians with clinical support tools and interventions that the therapist
could consider to be more responsive to the patient. This is an excellent
way to present therapists with opportunities to integrate: the system
provides feedback that the current approach may not fit this patient and also
provides recommendations for introducing new methods that research
suggests may be helpful. Further research on how therapists use this
information and what forms of integration are most effective are used to
refine the clinical support tools. In this way, routine outcome monitoring
provides an opportunity for clinicians and researchers to engage in a
continuous feedback loop, with researchers creating clinical tools and then
collaborating with clinicians to test and further refine the tools.
As detailed by Castonguay, Constantino, and Xiao (Chapter 20, this
volume), important integrative contributions are made by conducting
practice-oriented research. They review a number of ways in which this can
occur, including practice research networks, where therapists directly
collaborate with researchers in studying what actually transpires in clinical
practice.
Another future direction for integrative research and practice is to garner
research evidence for integrative treatments. Although all the integrative
treatments featured in this Handbook have research supporting their general
tenets, several do not have controlled research on their treatment outcomes
or attesting to their efficacy. Both research and practice in an era of
accountability demand such research evidence; otherwise, we fear such
integrative therapies will gradually expire.
Many evidence-based treatments are often associated with a particular
orientation but are actually quite integrative. Greater recognition of their
integrative nature could bolster the credibility of integration. In this volume
alone, dialectical behavior therapy (Chapter 12) and the cognitive-
behavioral analysis system of psychotherapy (Chapter 14) are widely
regarded as expanded CBT, but reading the chapters leaves no doubt about
their integrative nature. Similarly, schema-focused therapy (Young, Klosko,
& Weishaar, 2003) is usually associated with CBT, but it is an integrative
approach that blends elements from CBT, attachment, gestalt, object
relations, and constructivist approaches. It has garnered empirical support
for its efficacy in treating borderline personality disorder (Giesen-Bloo et
al., 2006).
 Another avenue to integrating research and practice is to focus on a
single clinical problem. Focusing on various approaches that are specific to
a clinical problem is one way to highlight common themes that underlie
different techniques. When therapists from different orientations observe
clinical issues associated with a given problem, they are often likely to see
the same things. Indeed, when asked if they would use cognitive therapy
with patients whose depression was the result of complicated grief, two
well-known cognitive therapists once indicated that they would not. Instead,
they would intervene with grief therapy—an intervention usually associated
with interpersonal therapy.
When comparing multiple approaches for one disorder, it would probably
prove useful to focus on an intermediate level of abstraction—somewhere
between theory and technique (Goldfried, 1980). At higher levels of
abstraction (e.g., psychodynamic, cognitive-behavioral, experiential,
family/systems), philosophical differences and language barriers can
obscure agreement. At lower levels of abstraction (e.g., specific
techniques), surface differences may mask functional similarities. By
focusing on an intermediate level of clinical strategies or principles (e.g.,
corrective experiences, therapeutic relationship), it is easier to recognize
how different approaches may be using different techniques in service of
the same principle. Research showing positive relations between treatment
outcome and change principles, such as client expectations, the alliance,
client awareness, and corrective experience, is growing (Eubanks &
Goldfried, Chapter 4, this volume). Beutler, Castonguay, and colleagues
have also identified principles that can be used to responsively tailor the
therapist’s approach to the patient, such as adjusting therapist directiveness
in accordance with the patient’s level of reactance (Consoli & Beutler,
Chapter 7, this volume).
Research on principles of change and treatment selection can guide
comparisons of different approaches to the same clinical problem in order
to identify common principles. For example, most research-supported
treatments for posttraumatic stress disorder (PTSD) include some form of
exposure to the painful memories of the trauma. In prolonged exposure,
patients engage in repeated imaginal and in vivo exposures to trauma-
related thoughts, feelings, and situations (Foa, Hembree, & Rothbaum,
2007). In cognitive processing therapy, patients repeatedly write about their
traumatic experience and work in therapy to change the content of their
cognitions about a trauma (Resick & Schnicke, 1993). In eye movement
desensitization and reprocessing (EMDR; Shapiro, 2001), patients recount
their traumatic experiences while focusing their eyes on an external
stimulus, often engaging in therapist-directed lateral eye movements. In
both emotion-focused therapy for trauma (Paivio & Pascual-Leone, 2010)
and in narrative exposure therapy (Schauer, Neuner, & Elbert, 2011), client
storytelling around their trauma memories is central as patients and
therapists work toward a reconstruction of the clients’ trauma narratives.
Identifying the common ingredients of these approaches strongly indicates
that exposure to traumatic memories may be a key common strategy to
address PTSD.
Research examining the different ways in which these approaches
employ exposure could identify treatment selection principles: Do specific
techniques work better for different types of patients or traumas? Or, given
how challenging exposure can be for clinicians (van Minnen, Hendriks, &
Olff, 2010), could different approaches to exposure be more appealing or
easier to implement for different types of therapists? Are any of the
techniques that accompany exposure (e.g., homework, hand movements)
extraneous, or do they serve additional functions? The specific techniques
associated with any given approach may be seen as testable parameters of
the more general principle. By starting from a principle-based appreciation
of the common ground these approaches share, comparisons of these
treatments can proceed in the spirit of fostering generative conversations
rather than zero-sum competitions.
Progress in integrative research and practice will also require attention to
the role of the cultural contexts of patients and how therapists can best tailor
treatment to be maximally effective with a diverse range of patients (Harris,
Shukla, & Ivey, Chapter 15, this volume). Here, we refer to culture writ
large and inclusively—race, ethnicity, national heritage, gender, sexual
orientation, religion, disability status, age, and so on. As recognition of the
importance of multicultural competence grows (e.g., Hook et al., 2017),
therapists and researchers with experience integrating multiple treatments
may be well-positioned to be leaders in encouraging openness to different
cultural perspectives.
That certainly proves the case in integrating research and practice in
countries around the world. In their review of global psychotherapy
integration, Gómez, Iwakabe, and Vaz (Chapter 21, this volume) repeatedly
demonstrate how a country’s cultural and historical background
significantly influenced the nurturance or hindrance of integrative
endeavors. Moreover, psychotherapy integration necessarily adapted to
particular features of their place of origin, to differences and peculiarities in
each country in terms of health needs, patient preferences, therapist
availability, and governmental requirements.
A final promising direction for advancing psychotherapy practice and
research in the integrative tradition is by embracing multiple research
methods. Fishman and Messer (2005, 2013) have proposed an innovative
way to integrate practice and research via the pragmatic case study method.
With this method, both quantitative and qualitative research methodologies
are applied to a single case, or qualitative case studies complement
quantitative analyses within psychotherapy trials (Fishman et al., 2017).
When we discard the “either/or” and embrace the “both/and,”
psychotherapy practice and research thrive. The phenomena become fuller,
richer, more verdant—and more consequential for those receiving our
services. Embracing contrasting perspectives increases our understanding of
the case at hand. As more cases are studied in this way, comparisons across
cases allow for unifying themes and theoretical generalizations to emerge
from the bottom up through meaningful dialogue.

DIRECTIONS IN INTEGRATIVE TRAINING

If we want to advance our field, we must focus on training as that will
shape the future of theory, research, and practice. Learning to be a
psychotherapist rooted in one orientation is an intellectually and
emotionally challenging task; learning to be an integrative therapist brings
particular challenges as it requires exposure to more than one orientation, as
well as knowledge of how and when to integrate across orientations. The
knowledge, skills, and flexibility integration entails place considerable
demands on a trainee.
Broad, integrative training in psychotherapy is universally desired, but
the challenge has been how to do so systematically in ways that ensure
student clinical competence. All agree that integration as a concept and as a
goal should be introduced at the beginning of clinical training, but, beyond
that, there is not a consensus in the educational community on how to train
toward that goal (Norcross & Finnerty, Chapter 18, this volume). Some
educators believe that students should first achieve minimal competence in
one or two pure-form psychotherapies and then gradually integrate
additional competencies, in the tradition of assimilative integration. Other
educators believe that training graduate students in multiple
psychotherapies and treatment formats proves unfeasible. Instead, they
advocate for principle-based training.
An early example is found in the Transtheoretical Model associated with
stages of change (Prochaska & DiClemente, Chapter 8, this volume), in
which students are trained to assess the patient’s stage of change and to
tailor treatment methods and relationship stances to that stage. What works
for a patient in precontemplation differs markedly from the patient in, say,
the action stage. Such principles or mini-models reduce the universe to a
manageable number for training and practice.
A more elaborate principle-based training occurs in systematic treatment
selection (STS; Consoli & Beutler, Chapter 7, this volume). Students are
taught and supervised to follow a series of research-fueled integrative
change principles, such as developing an alliance and matching therapy to
patient transdiagnostic features, such as reactance level, functional
impairment, and coping style. Highly reactant patients, for instance, profit
most from a less directive treatment, whereas patients who are low on
reactance fare better on average with a more directive approach. Numerous
RCTs have determined that such matching improves treatment outcomes.
Systematic treatment selection, is, to our knowledge, the only supervision,
integrative or otherwise, to demonstrate in an RCT its superiority to an
alternative method. Patients whose therapists were trained and supervised
according to the STS model demonstrated greater therapeutic gains when
compared to supervision as usual (Holt et al., 2015; Stein et al., 2017).
A similar, promising model that aims to make integration more feasible
for a trainee is context-responsive integration (Constantino et al., 2013).
This approach reframes common factors as clinical situations that therapists
will frequently encounter and to which they need to be responsive rather
than continuing with treatment as usual. To date, this approach has
proposed five context-responsive markers: low outcome expectations,
ambivalence, patient self-strivings for positivity and verification, alliance
ruptures, and outcomes monitoring. The model proposes principle-driven
and evidence-based strategies that therapists can employ when they identify
these markers in session. The “if-then” structure makes it much easier for
therapists to identify opportunities for integration. For example, in the area
of alliance ruptures, therapists can be taught to recognize markers of
ruptures (such as markers of confrontation and withdrawal) and resolution
strategies that can be employed to facilitate resolution with each of these
types of markers (Eubanks-Carter, Muran, & Safran, 2015).
Unprecedented training opportunities abound in and through technology.
Trainees can now watch hundreds of streaming videotaped psychotherapy
demonstrations. The classic “Gloria” films, once watchable only on bulky
film reels, now fit easily onto a single memory stick. Standardized patient
presentations and stimulus prompts are available at a push of a button.
Students can access the research literature with a few keystrokes.
Researchers can monitor and collect real-time client responses. Internet-
mediated supervision and psychotherapy are commonplace. Supervisors can
observe every moment of every session of a trainee’s case. We confess to
being a bit staggered and bewildered by the embarrassment of riches for
hybrid instruction, training, and supervision in integrative psychotherapy
afforded by technology. It is not clear yet which technology-enabled
training methods will flourish and which will flop, but technology will
certainly impact the future of training in psychotherapy integration.
Another promising area for training is the growing literature on
deliberate practice. Deliberate practice, or individualized training to
improve specific skills, has long been a part of improving performance in
areas such as music, chess, and sports (Ericsson & Lehmann, 1996).
Although there are only a few studies of deliberate practice in
psychotherapy, it will probably prove useful in training mental health
professionals in the future (Rousmaniere, 2017). The amount of time
therapists spend alone in deliberate practice activities, such as reviewing
recordings of one’s therapy sessions, has been linked to client outcomes
(Chow et al., 2015).
Deliberate practice exercises should target particular skills that the
therapist seeks to improve. The research highlights psychotherapists’
improving interpersonal and alliance-building skills in session and reducing
negative countertransferential reactions between sessions. Exercises geared
toward enhancing therapists’ skills with a specific technique could be
particularly valuable for therapists interested in integrating a new approach
into their clinical repertoire.
DIRECTIONS IN THE INTEGRATION MOVEMENT
A recent survey of members of the Society for the Exploration of
Psychotherapy Integration (SEPI; Norcross, Nolan et al., 2017) found that
almost a third of respondents indicated that the type of integration that best
represents their practice is assimilative integration, in which therapists are
anchored in one approach and thoughtfully integrate ideas from other
orientations into that approach (Messer, 1992). This finding indicates that
many people interested in integration still identify with a primary
orientation and manifest interest in learning about other approaches.
In the future, will more therapists begin to identify as integrative, and
will integration become another entry in the theoretical orientation horse
race? Or could we be moving toward a time when therapists do not think so
much in terms of specific schools of thought? What would a post-
orientation world look like in psychotherapy?
As some of the contributors to the previous edition of this Handbook
observed, perhaps one future direction for integration is to view it as “less
of an orientation and more of a perspective—a way of thinking (in terms of
convergence, divergence, complementarity, synergy, synthesis, and anti-
thesis) aimed at constantly challenging our conceptualizations and
improving our clinical practice” (Castonguay, Holtforth, & Maramba, as
quoted in Norcross & Goldfried, 2005, p. 457). Perhaps integration is less
about which techniques or theories one uses and more about the stance of
the therapist.
At its core, integration is an effort to work toward what Stiles and
colleagues have termed responsiveness, or therapeutic behavior that is
affected by what seems to be required therapeutically in the emerging
clinical context (Stiles, Honos-Webb, & Surko, 1998). As we have
suggested earlier, the integrative therapist is willing to change or adapt his
or her approach to meet the needs of the patient as they emerge. Multiple
meta-analyses on therapist responsiveness to clients (Norcross & Wampold,
2019) support exactly this point: that responsiveness occurs moment to
moment, session to session, and, of course, patient to patient. This attuned
flexibility—perhaps even more than the skillful use of a variety of
techniques—may be the greatest strength of the integrative therapist.
In reviews of therapist effectiveness, theoretical orientation does not
explain why some therapists are more effective than others (e.g., Anderson
et al., 2009; Schöttke et al., 2016; Wampold et al., 2017). Rather, the
research points to several factors that have received empirical support in
explaining differences between therapists. These include, most prominently,
the common factor of the therapeutic relationship: practitioners who
establish a positive alliance, demonstrate an empathic connection, manifest
support and warmth, and so on achieve better treatment outcomes across
patients. Two other nascent factors supported by the research were
therapists’ self-doubt about their skill in helping patients (Nissen-Lie et al.,
2013), and engaging in deliberate practice (Chow et al., 2015). Awareness
of the limitations of one’s approach and motivation to expend extra effort to
expand one’s skills sound like the profile of an integrative therapist.
Finally, we reiterate that the future of integration as a formal movement
will assuredly become more international and interdisciplinary in nature.
Most of the early impetus of the movement hailed from North America (see
Goldfried, Pachankis, & Goodwin, Chapter 2, this volume), but integration
has clearly taken root around the world. And, although much of the early
integrative literature and leadership came from psychologists, it is
becoming—and will increasingly grow——into an interdisciplinary force in
mental health.

CONCLUSION
Coming full circle, we conclude this chapter where we began it—by
quoting Saul Rosenzweig (1936) and his discussion of common factors and
the Dodo bird verdict. More than 80 years ago, Rosenzweig (1936)
observed that it may be of “comparatively little consequence” what
particular method a therapist uses, so long as the therapist (a) employs an
approach that she or he has mastered, (b) is responsive to the patient’s
needs, and (c) possesses an “effective personality” (pp. 414–415).
Rosenzweig declined to elaborate on what characterizes an effective
personality because the personal qualities of the good therapist “elude
description” (p. 413). Perhaps this is where integrative therapists can show
the way forward—by blending practice, research, theory, and training in
identifying and modeling the effective psychotherapist.

ACKNOWLEDGMENTS
We appreciate the assistance of Ms. Nicole G. Plantier, who performed a
content analysis on the future directions sections of the preceding chapters
in this volume.

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 Name Index

Abbas, M., 69, 74–76

Abbass, A., 223
Abelson, J. L., 231
Ablon, J. S., 73, 229–230
Abramowitz, J. S., 196
Abrams, D. B., 170
Accurso, E. C., 14t
Achenbach, T. M., 347
Ackerman, B. P., 311
Adams, S. J., 358–359
Adelman, R. W., 437
Adelson, J., 107
Agras, W. S., 230
Ahmed, M., 287
Ahn, H., 75–76
Aikins, D., 230, 244
Aitken, R., 258–259, 271, 273
Ajax, E. T., 109
Akinola, M., 196–197
Albeniz, A., 46
Alberts, G., 386
Alcaine, O. M., 231
Alden, L. E., 232–233
Alexander, F., viii, 31, 35, 94, 95, 185, 186, 191, 208, 238–239, 259, 344
Alford, B. A., 43, 47
Allen, D. M., 39, 395
Allen, G. J., 391
Allison, E., 191
Allmon, D., 261
Allport, G. W., 20
Alonso, M. M., 461, 465
Altenstein-Yamanaka, D., 245–246
Altmaier, E. M., 14t
Altschul, D., 333
Ametrano, R. M., 74–75
Amsterdam, J. D., 74–76, 81
Anastasiades, P., 76
Anchin, J. C., 38, 306, 476
Ancis, J. R., 394
Andersen, S. M., 50, 197
Anderson, T., 81, 381, 482
Andersson, G., 285, 288, 359, 360, 363, 367
Andrews, J. D. W., 21, 41, 396–397
Andrews, W. P., 77, 81, 382, 481, 482
Andrusyna, T. P., 475
Angus, L., 285, 289
Anton, B. S., 106
Antoniou, P., 459
Antony, M. M., 52, 245, 285, 286, 288–291, 293, 297–299
Apelberg, B. J., 360
Apodaca, T. R., 359
Aponte, H. J., 379
Appel, S., 358
Appelbaum, S. A., 35
Arkowitz, H. S., 7, 12, 39, 41, 43, 44, 259, 284, 297, 359
Armijo-Olivo, S., 73
Armstrong, C. M., 358–359
Armstrong, H. E., 261, 277
Arnkoff, D. B., 8, 13, 18, 37, 41, 43, 44, 48, 186–187, 352
Arnow, B. A., 306, 310, 318
Aron, L., 191
Arredondo, P., 326–327
Arrúe, W., 465
Asnaani, A., 69
Atkins, D. C., 368–369
Atkinson, D. R., 325–326, 327
Auerbach, A. H., 15–16
Austad, C. S., 7
Ávila, A., 461
Aviram, A., 52, 285–291, 297
Axelrod, S. R., 261–262
Axelson, D. A., 261–262
Axsen, R., 108
Ayduk, Ö., 196–197
Aylott, H., 396
Azhar, M. Z., 452–453

Baardseth, T. P., 70–71

Babcock, H. H., 41
Bąbel, P., 196
Babins-Wagner, R., 118, 299
Bachelart, M., 458
Backenstrass, M., 318
Bae, S. H., 454
Bagladi, V., 465, 466
Bahrick, L. E., 197
Bailer, J., 318
Bailey, R., 107
Bailey, V. S., 74–75
Baillie, A. J., 369
Baker-Ericzen, M., 441
Baker, S., 244, 435
Balarezo, L., 464, 466, 467
Balderson, B. H. K., 15–16
Baldwin, S. A., 81, 106, 246–247, 432–433, 436, 482
Balfour, L., 440
Balte, M. B., 174
Bandura, A., 37, 74, 89, 165, 196, 305, 306
Banks, P. L., 318
Barber, B., 28
Barber, J. P., 18, 299, 439
Barbui, C., 278–279
Barends, A. W., 75
Barett, S., 165
Bargmann, M. T., 113
Barker, J., 357, 360
Barker, P., 272
Barkham, M., 44, 107, 198, 246–247, 434, 436–437, 439, 443, 458, 459
Barlow, D. H., 69, 75–76, 231, 232
Barnes, J. B., 245–246
Barnett, J. E., 93
Barnett, N. P., 93
Barnhart, R., 266
Barrachina, J., 266
Barrett, C. L., 342
Barry, C. T., 361
Bass, E. B., 360, 365
Basseches, M., 259
Bastine, R., 34–35, 37
Batchelder, S. T., 93
Baucom, B., 368–369
Baurer, M. R., 178
Bausch, P., 319
Bautista, P., 466
Beach, S. H., 39
Beadnell, B., 279
Beattie, M., 144
Beauchaine, T. P., 263
Beck, A. T., 38–39, 47, 167–168, 186, 232–233, 244, 306
Beck, J. S., 93
Becker, K. D., 346
Beckstead, D. J., 275
Bedi, R., 14t
Bedics, J., 231
Beebe, B., 197
Beekman, A., 360
Beevers, C. G., 245–246
Begin, A., 167
Behar, E., 231
Beier, E. G., 208
Beitman, B. D., 38–40, 42, 48, 450
Bejarano, M., 143
Bell, A., 177
Bell, E. C., 75–76
Bell, S. K., 345
Bellido, C., 333
Belyea-Caldwell, S., 308
Bendit, N., 278
Benedetti, F., 73, 74
Benish, S. G., 78, 332
Benson, L. A., 361
Benum, K., 379
Berant, E., 196
Berenson, K., 197
Berg, I. K., 109
Bergan, J., 153
Berggraf, L., 81
Berghoff, C. R., 359
Bergin, A. E., 13, 17, 32–33, 37, 40–42
Berk, M. S., 197
Berking, M., 288
Berlin, K. S., 231, 285
Berman, J. S., 475
Bernal, G. E., 96–97, 293, 332–333, 336–337, 392
Bernard, J. M., 396
Bernecker, S. L., 50–52, 101, 285, 358, 481
Bernstein, D. A., 236
Bernstein, D. P., 309
Bertolino, B., 111–113
Berzins, S., 299
Beutler, L. E., viii, 6, 9, 11, 15–16, 38, 40, 42, 44, 46, 51, 95, 100, 101, 125, 141–149, 153–155, 171,
195–196, 208, 209, 216, 287, 290–291, 344, 369, 379, 381, 383, 384, 386, 389, 392, 393, 395,
479, 481
Beyermann, S., 245–246
Bezborodovs, N., 196–197
Bhati, K. S., 70
Bhola, P., 382
Bickman, L., 342, 349
Bieschke, K. J., 328, 441
Bijl, R. V., 357–358
Bike, D. H., 14t, 387
Binder, J. L., 286
Birk, L., 32–34, 41, 48
Birmaher, B., 261–262
Bischof, S., 462
Bishop, D. G., 454
Biyanova, T., 15
Blackard, S., 345
Blackburn, I.-M., 244
Blagys, M. D., 229, 230
Blalock, J. A., 306, 318
Blanchard, M., 111
Blasey, C., 306
Blaustein, A. B., 35
Bleich, S., 318
Blomqvist, J., 357, 360
Bockting, C. L., 245–246
Boettcher, J., 367
Bogart, D., 358
Bohart, A. C., 38, 42, 73, 93, 210–211, 216, 290–291
Bohmer, R., 396–397
Bolger, N., 198
Bologh, L., 230, 244
Bongar, B., 142–145, 148, 151
Bonilla, J., 333
Booth, P., 345
Borckardt, J. J., 92–93
Bordin, E. S., 72, 75, 93, 97–98, 107, 290
Borge, F.-M., 81
Borian, F. E., 304, 306, 318
Boring, E. G., 28, 52
Borkovec, T. D., 74–76, 230–232, 236, 241, 243, 284, 293, 438–440
Boswell, J. F., viii, 13, 21, 50–52, 74–76, 92, 101, 243, 244, 285, 298, 359, 378, 432–433, 435–436,
437, 439–441, 474, 481
Botanov, Y., 274
Botella, L., 460–461
Botermans, J., 388
Boucher, H. C., 197
Boutselis, M., 244, 435, 440
Bowlby, J., 75, 147, 197, 215
Bradford, D. C., 109
Brady, J. P., 32, 37
Brakemeier, E. L., 318, 319
Brandenburg, N., 165, 177
Bratton, S. C., 345
Braver, M., 440
Braverman, A., 271–272
Bravin, J. I., 369
Brazelton, T. B., 197
Brazier, D., 45
Brazil, L. A., 93
Brechwald, W. A. G., 437
Brehm, J. W., 148–149
Brehm, S. S., 148–149
Brinkley-Birk, A., 34
Broberg, J., 462
Brogan, M. M., 166
Bronfenbrenner, U., 333
Bronner, L., 261–262
Brookman-Frazee, L., 14t, 440–441
Brooks-Harris, J. E., 46–47, 51, 326, 333, 334
Brown, B. S., 367
Brown, C. H., 442
Brown, G., 232–233
Brown, J., 106–108
Brown, L. A., 74–75
Brown, M. Z., 277, 279
Brown, P. J., 74–75
Brown, T. A., 231, 232
Brownell, C. A., 288, 293
Bruce, T. J., 284–285
Brunet, H., 384, 386, 393, 481
Bruno, A., 343–344
Bruschweiler-Stern, N., 198
Buchheim, A., 319
Buck, K. A., 197
Budge, S. L., 70, 107
Bugati, M., 432–433, 435–436
Bugental, J. F. T., 378
Buhin, L., 333
Bullis, J., 75–76
Bunge, E. L., 369
Burckell, L. A., 380, 475
Burish, T. G., 258
Burkard, A. W., 392
Burke, B. L., 93, 288, 293, 359
Burlingame, G. A., 106
Burlingame, G. M., 109
Burns, D. D., 230, 239, 244, 364, 437
Burns, J., 361–362
Busch, F. N., 76
Bush, N. E., 358–359, 361
Butler, C., 93, 290–291
Butler, E. A., 73
Butler, S. K., 326–327, 337
Butters, R., 93
Button, M. L., 286, 291
Bystritsky, A., 74–75

Cacioppo, J. T., 73
Cacioppo, S., 73
Cahill, J., 436–437
Caldwell, D. M., 73, 76
Callahan, J. L., 80–81, 96–97
Calvert, R. D., 245, 459
Cameron, R. P., 328
Campbell, L. F., 196–197, 358–359, 361, 362, 364, 365, 399
Campbell, W., 366
Campins, M. J., 266
Canning, S. S., 359
Cao, Y., 450–451
Caplan, E., 70
Captari, L. E., 96–97
Carbonari, J. P., 163, 169, 172, 177
Cardish, R. J., 278
Carere-Comes, T., 48
Carlbring, P., 360, 363, 367
Carlile, J. A., 231
Carlin, M., 344
Carlsson, J., 462
Carney, M. M., 177
Caro, I., 461
Carroll, K. M., 177
Carter, G. L., 278
Carter, J. A., 73
Carter, R. T., 326, 329
Casas, M., 169
Cashdan, S., 41
Caspar, F., 319, 462
Cass, V. C., 328
Cassidy, J., 196, 231
Cassin, S. E., 14t
Castagnini, C., 334
Castonguay, L. G., viii, 8, 11–12, 40, 41, 44–45, 50, 51–52, 71, 100, 101, 141–143, 195–196, 229–
232, 239, 243–247, 285–286, 298, 369, 378–381, 384, 386, 393, 399, 432–443, 466, 469, 474,
477–478, 481, 482
Cavanagh, K., 360
Cavett, A., 343, 344–345
Cebria, A., 266
Cecero, J. J., 14t, 18
Cermak, I., 19
Chalk, M. B., 106–107
Chamberlain, P., 287
Chambless, D. L., 36, 74–75, 141, 441
Chambon, O., 458
Chan, R. T. H., 451
Chander, G., 360
Chaney, J. M., 15–16
Chang, D. F., 450–451
Chang, J., 455
Chapman, A. L., 277
Chawla, N., 196
Cheavens, J. S., 261–262
Chen, H., 197
Chen, K., 369
Chen, P., 73, 76
Chen, S., 197
Chevron, E. S., 318
Chiswick, N., 244, 435, 440
Chongruksa, D., 456
Chopra, T., 392
Chorpita, B. F., 346, 398–399
Chow, D. L., 77, 81, 111, 118–119, 379, 382, 481, 482
Christensen, A., 361, 368–369
Christensen, C. M., 396–397
Christian, C., 185
Christiani, K., 14t
Chu, J., 151
Chuan, Eng., 453
Chyurlia, L., 440
Cicchetti, D., 311
Cicila, L. N., 361
Cisin, I. H., 174
Ciulla, R. P., 358–359
Claiborn, C. D., 7–8, 71
Clark, D. M., 76, 81
Clark, J. A., 16
Clark, S. W., 308–309
Clarkin, J. F., 9, 40, 42, 76, 137, 142–145, 148, 278, 379, 398–399
Clarkson, P., 459
Clement, P. W., 346
Clement, S., 196–197
Clifford, J. S., 362
Cloud, W., 357, 360
Clum, G. A., 359, 361, 363, 364
Coan, J. A., 73
Coble-Temple, A., 328
Cobstanino, M. J., 141–142, 393
Cody, S., 74–75
Cohen, J. A., 344–345
Cohen, L. H., 37
Cohen, Z. D., 101–102
Cohn, J. F., 197
Colby, S. M., 93
Coleman, D., 230
Combs, D. C., 455
Comtois, K. A., 265, 277, 278, 280
Conboy, L. A., 73
Conceição, N., 459–460
Conley, K. A., 309
Connell, J., 72–73, 436–437
Connors, C. K., 347
Connors, G. J., 170, 177, 367
Connors, L., 287
Conrad, A. M., 278
Consoli, A. J., viii, 6, 9, 11, 51, 101, 145–147, 171, 209, 216, 290–291, 344, 379, 384, 392, 399, 465,
479, 481
Constantino, M. J., viii, 51–52, 74–76, 92, 101, 143, 230, 244–246, 285, 286, 288–291, 293, 297–
299, 369, 398–399, 432–433, 435–436, 477, 478, 481
Contreras-Tadyc, D. A., 392
Cook, J. M., 15
Cook, J. R., 343–344
Coombs, M. M., 230
Coonerty, S., 343, 344, 346–347
Cooper, M., 12, 80–81, 96–97, 385, 398, 399, 436–437, 459
Corbella, S., 147
Cordes, C. C., 328
Corey, G., 329
Corno, C., 179
Coryell, W., 311
Coscollá, A., 461
Costello, E., 74–75, 241
Cotet, C. D., 278–279
Cottraux, J., 244
Cottrell, D., 343
Countis, L., 442
Coyne, A. E., 74–76, 92, 285, 290, 291, 298, 436
Coyne, J. C., 15, 229
Craft, J. C., 277–278
Craig, E., 454
Cramer, P., 196
Craske, M. G., 74–75
Cremer, S., 71
Cristea, I. A., 278–279
Cristol, A. H., 35
Crits-Christoph, K., 399
Crits-Christoph, P., 399
Crocker, P., 239
Crouch, C., 170, 172, 179
Crowell, S. E., 263
Crum, A. J., 73, 74
Cucherat, M., 244
Cuijpers, C., 278–279
Cuijpers, P., 285, 288, 319, 359, 360, 369
Cukrowicz, K. C., 261–262
Cullari, S., 48
Cyr, M., 386

Dahlin, M., 360

Daldrup, R. J., 153
Dale, P., 452
Daleiden, E. L., 346
Dallos, R., 382
Damer, D., 440
Danelova, E., 19
Darley, J. M., 196–197
Dasgupta, N., 196–197
Dattilio, F. M., 70, 480
David, D., 97
Davidson, R. J., 73
Davis, D. E., 96–97, 293, 480
Davis, L., 365
Davis, R. B., 73, 358
Davis, R. D., 45
Davis, S. M., 304, 306
Davison, G. C., 33, 35, 45, 46, 138, 148–149, 258
Day, E., 450
de Graaf, R., 357–358
de Ridder, M. A. J., 278
Deacon, B. J., 74, 196
Deane, F. P., 14
DeBlaere, C., 97, 480
Deblinger, E., 344–345
DeBord, K. A., 328
Decety, J., 73
Del Re, A. C., 70–71, 75–76, 93, 107, 290
Delaney, H. D., 366
Den Boer, P. C., 359
Denneson, L. M., 361
DePree, J. A., 231
deRidder, D., 45
Dermen, K. H., 367
DeRubeis, R. J., 74–76, 81, 101–102, 229, 299
Devilly, G. J., 75–76
Dexter-Mazza, E. T., 277
Diamond, R. E., 36
Dick, B., 73
DiClemente, C. C., viii, 8, 10, 39, 40, 51, 92, 101, 146, 161–172, 174, 175, 177, 179, 212, 345, 360,
384, 392, 476, 480–481
Diener, M. J., 223
Diep, H., 151
Diep, L. M., 261–262
Diguer, L., 475
Dimaggio, G., 137, 398–399
Dimeff, L. A., 261, 266, 277–279
Dimidjian, S., 75–76, 81
DiNardo, P. A., 232
Ding, B.-K., 450
Dion, D., 113
Dirksen, C., 478–479
Dixon, D. N., 380, 395, 398
Dlugos, R. F., 399
Dobscha, S. K., 361
Dobson, K. S., 14t, 367–368
Doell, F. K., 52
Doi, T., 452
Dollard, J., 30–31, 185–187, 196, 207–208
Domenech Rodríguez, M., 96–97
Donker, T., 285, 359, 360
Donovan, D. M., 170, 177
Dörig, N., 245–246
Doss, B. D., 361
Dossett, K., 381
Downey, G., 197
Dozois, D. J. A., 74–75, 297
Drabick, D. G., 433
Drahota, J., 457–458
Dreessen, A., 261
Dreis, S., 108
Drewes, A. A., viii, 342–350
Driessen, E., 223
Drinane, J. M., 293
Driscoll, R., 21, 39
Dryden, W., 12, 16, 37, 38, 42, 44, 46, 458
Duan, C., 450
Dubose, A. P., 274, 275
Dubourdieu, M., 464, 467, 468
Duff, J. H., 442
Duffy, F. F., 442
Duhl, B., 39
Duhl, F., 39
Duncan, B. L., 11, 42, 44, 77, 78, 106–111, 118, 210–211, 216, 217, 224, 349, 384, 393–394
Dunner, D. L., 310, 318
Durgam, S., 363
Durlak, J. A., 106
Dyason, K. M., 379

Eagle, G. T., 48
Ebesutani, C., 346
Ebmeier, K. P., 319
Echemendia, R. J., 438, 439
Eckshtain, D., 341
Edelstein, B., 386
Edwards-Stewart, A., 12–13, 358–359, 365, 367–368
Edwards, C., 95, 154
Edwards, D. J. A., 480
Edwards, L., 178–179
Edwards, T., 197
Egan, G., 34–35
Eifert, G. H., 359
Eisenberg, D. M., 358
Elbert, T., 479
Elger, F. J., 364
Elhai, J., 15
Elkins, G., 363
Ellickson, J. L., 392
Ellinstad, T., 357, 360
Elliott, R. K., 40, 73, 93, 94, 240, 290–291
Ellis, A., 167–168, 186, 271–272, 366
Ellis, M. V., 391, 394, 396
Emery, G., 306
Endicott, J., 306, 311
Engle, D., 142, 153
Enns, C. Z., 451–452
Entwhistle, S. R., 141
Epstein, J. N., 347
Erbaugh, J., 244
Erickson, T. M., 231, 285
Ericsson, K. A., 119, 481
Eriksson, B., 461–462
Erkens, N., 319
Errázuriz, P., 223
Ethier, N., 198
Ettner, S. L., 358
Eubanks-Carter, C. F, 93, 95, 245, 331, 380, 438, 475, 481
Eubanks, C. F., viii, 11, 93, 198, 229, 245, 384, 438, 469, 474, 477, 479
Evans-Lacko, S., 196–197
Evans, J., 440
Everly, G., 45
Evers, K. E., 178
Eversmann, J., 81, 482
Eyberg, S. M., 345
Eysenck, H. J., 9, 70–71

Fairburn, C. G., 364

Fairhurst, S., 164
Falkenström, F., 72–73
Fall, M., 346
Fang, A., 69
Fanning, P., 366
Farber, B., 111
Farrell, E. V., 367
Faust, D., 389
Fava, J. L., 166, 177–178
Fay, A., 127
Feather, B. W., 34, 344
Febbraro, G. A. R., 363
Fedewa, A. L., 341, 342, 349, 352
Feixas, G., 460–461
Feldman, G. C., 245–246
Feldman, L. B., 39, 343–344
Feldman, S. I., 197
Fenichel, O., 89
Fensterheim, H., 38, 46
Fernández-Álvarez, H., 6, 9, 49, 50, 145, 147, 379, 399, 437, 464–467, 469, 482
Ferreira, J. F., 460
Fersch-Podrat, R. K., 261–262
Ferster, C. B., 34
Feyerabend, P., 3
Fields, S., 349
Figured, K. J., 47
Finch, A. E., 435
Fink, L., 309
Finnerty, M., viii, 20, 477, 480
Finney, J. W., 359–360
Finniss, D. G., 74
First, M. B., 308–309
Fischer, J., 36
Fisher, A. J., 74–75, 231, 243, 441
Fisher, D., 142
Fishman, D. B., 480
Fitzpatrick, H., 396
Flechner, I. S., 367
Fleming, A. P., 261
Floyd, R., 151
Flückiger, C., 70–71, 75–76, 81, 93, 107, 290, 482
Foa, E. B., 75, 231, 368–369, 479
Follette, V. M., 186–188
Follick, M., 170
Fonagy, P., 191, 198–199, 343, 379
Forand, N. R., 101–102
Ford, J. D., 386
Forder, L., 360
Fordwood, S. R., 341
Forgatch, M. S., 287
Forman, E. M., 70–71
Forrester, B., 153, 154, 209
Forsell, E., 360
Forsyth, D. R., 149
Forsyth, J. P., 359
Forsyth, N. L., 149
Fortin-Langelier, B., 440
Fosha, D., 186
Fotopoulou, A., 73
Fournier, J. C., 101–102
Fowler, J., 170
Frances, A., 5, 40
Francis, N., 290–291
Frank, J. B., 11, 43, 71, 72, 74, 76
Frank, J. D., 11, 31, 34–35, 43, 69, 71, 72, 74, 76, 92
Frank, K. R., 185, 191, 192, 213, 218
Franklin, A. J., 326, 329
Freedheim, D. K., 43
Freeman, A., 211, 344
Freire, P., 330
Freitas, A. L., 197
Freitas, G. J., 396
French, T. M., 5, 29, 49, 52, 94, 95, 185, 186, 191, 208, 238–239
Freud, S., 3, 5, 187, 194, 217, 304
Freudenberger, H. J., 43
Frey, R. M., 359–360
Friedlander, M. L., 394, 399
Friedling, C., 16
Friedman, P., 39
Frost, N. D., 69, 70–71, 74–76
Fuentes, J., 73
Fuertes, J. N., 50, 477–478
Funabashi, M., 73
Furukawa, T. A., 73, 76

Gabriel, T., 397

Gage, R., 14t
Gago, P., 465
Gahm, G. A., 359
Galavotti, C., 165
Gallagher-Thompson, D., 145, 153, 154
Gallagher, M. W., 75–76
Gallardo, M. E., 332
Gallop, R. J., 277, 399
Ganger, W., 14t
Garb, H. N., 432–433
Garcia-Marques, L., 16
Garcia, E., 361
García, F., 50, 437, 465
Gardiol, L., 462
Garfield, S. L., 6, 8, 16–18, 31, 35, 37, 38, 41, 71
Garland, A. F., 14t, 440–441
Garvert, D. W., 361
Gaston, L., 45, 46
Gaztambide, D. J., 97
Gehred-Schultz, A., 165
Gelder, M. G., 32, 76
Gelenberg, A. J., 310, 318
Gelfand L. A., 101–102
Geller, J. D., 387, 388
Gelso, C. J., 73, 96, 477
Gentili, C., 278–279
Georgia, E. J., 361
Gerberding, J. L., 398
Gevins, A., 38–39
Gibbard, I., 436–437
Gibbons, M. B. C., 399
Gibson, J., 328
Giesen-Bloo, J., 478–479
Giesler, R. B., 258, 271
Gil, E., 343–345
Gilbert, L. A., 329
Gilbert, M., 47, 380–381, 459
Gillaspy, J. A., 118
Giller, E., 389
Ginpil, S. E., 161–162
Glasgow, R. E., 363, 364
Glass, C. R., 8, 18, 41, 43, 44, 48, 74–75, 186–187, 342–345, 346, 349, 352
Glass, G. V., 70–71, 106
Glasziou, P., 437–438
Glazer, H. I., 38
Gloaguen, V., 244
Gnam, W. H., 278
Gold, J. R., viii, 11–12, 44, 47, 185, 207–210, 213–215, 217–218, 223, 257, 342–344, 350
Goldberg, D. N., 178
Goldberg, R., 165
Goldberg, S. B., 69–71, 74–76, 81, 299, 482
Goldblum, P., 151
Goldenthal, P., 346
Goldfried, M. R., viii, 5, 11, 12, 16, 20, 35–38, 40–48, 50, 70, 88–90, 94, 95, 147–149, 162, 195–
196, 215, 229–230, 236, 238–239, 244–246, 258, 272, 285–286, 328, 380, 381, 383, 384, 389,
394, 433, 438, 441, 466, 469, 474–479, 482
Goldman, R. E., 18, 223
Goldman, R. N., 94
Goldner-deBeer, L., 398
Goldsamt, L. A., 229–230
Goldstein, A. J., 36
Goldstein, T. R., 261–262
Gomez Penedo, J. M., 285, 291
Gómez, B., viii, 4, 6, 15, 50, 52, 379, 399, 437, 464, 465, 468, 480
Goncalves, O. F., 46–47
Gonzales, A. M., 278
Good, G. E., 329
Goodlad, J. K., 75–76
Goodwin, B. J., viii, 5, 285, 482
Goodyear-Brown, P., 345
Goodyear, R. K., 7–8, 14t, 71, 81, 382, 396
Gordon, J. R., 218
Gordon, T., 364
Gorman, B. S., 18, 245
Gorman, J. M., 75–76, 230–231
Gotlib, I. H., 229
Gottlieb, N. H., 165
Gottman, J. M., 263
Goyer, J. P., 73
Grace, C., 326, 329
Graham, T., 196–197
Grant, J., 72–73, 462
Grant, S., 72–73
Grawe, K., 142, 153, 240, 462
Gray, L. A., 394
Graydon, M., 179
Greaves, D. W., 13, 17, 42
Grebstein, L. C., 39
Greenberg, J., 208–209
Greenberg, L. S., 15, 39–41, 94, 186–188, 196, 198, 240
Greenberg, R. P., 21, 72–75, 92–93, 106
Greene, G., 178–179
Greening, T. C., 35–36
Greenspan, S. I., 344
Gregory, R. J., 359
Gregory, W. H., 179
Grehan, P. M., 211, 344
Grencavage, L. M., 7–8, 41, 42, 71, 346
Grimlund, A., 363
Griner, D., 96–97, 293, 332–333, 336–337
Grinker, R. R., 35
Grohol, J. M., 358, 361, 364, 365, 399
Gross, D. P., 73
Gross, P. H., 196–197
grosse Holtforth, M., 11–12, 244, 245–247, 435, 436, 482
Grossman, M., 261–262
Grosso, T., 395
Groth-Marnat, G., 142
Grothgar, B., 153
Guadagnoli, E., 169–170
Guidano, V. F., 39, 40, 41
Guimond, T., 266, 278
Guo, Y. J., 455
Gurman, A. S., 36–39, 75, 224
Guthrie, E., 459
Guyll, M., 196–197
Gyurak, A., 196–197

Haavind, H., 379

Habinski, L., 266
Hackmann, A., 76
Haefferl, G. J., 363
Haga, E., 261–262
Hagen Glynn, L., 287
Haine-Schlagel, R., 14t
Haine, R. A., 441
Halgin, R. P., 40, 352–353, 379, 381, 390–392, 396–397
Hall, K. L., 165
Halvorsen, M. S., 379
Hamada, W., 333
Hambrecht, M., 169–170
Hampe, I. E., 342
Hanawahine, G., 334
Handelsman, J., 349
Handler, L., 92–93
Hanh, T. N., 258–259
Hanks, D. L., 311
Hanley, T., 436–437
Hannan, C., 106, 432–433, 435
Hansen, N. B., 109, 435
Hara, K., 299
Hara, K. M., 286
Hardy, G. E., 198, 459
Harmon, C., 77, 106, 432–433, 435
Harmon, S. C., 107
Harned, M. S., 277, 279
Harris, J. E., viii, 12–13, 325–326, 328–329, 331–334, 399, 475–476, 480
Harrison, A. M., 198
Hart, J., 39
Härter, M., 318
Hartman, V. L., 15–16
Hartmann-Boyce, J., 359
Harvey Livingston, K., 14t
Harwood, T. M., 142–145, 149, 151–153, 287, 361, 364, 379
Hashtpari, H., 399
Hatcher, C., 39
Hatcher, N. M., 347
Hatcher, R. L., 75
Haug, N. A., 143, 144, 154, 155, 384, 386, 393, 481
Havens, R. A., 36
Havik, O. E., 358
Hawkins, E. J., 77, 435
Hawkins, K. A., 279
Hawkley, L. C., 73
Hayes, A. H., 229–230
Hayes, A. M., 41–42, 229–230, 245–246, 285–286
Hayes, J. A., 436, 441–442, 477
Hayes, S. C., 186–188, 259
Haynes, R. B., 437–438
Hays, P., 327, 333–334
Hazlett-Stevens, H., 236
Heagerty, P., 278
Heard, H. L., viii, 41–42, 245, 261, 274, 277–279
Heather, N., 177, 179
Heide, F. J., 389–390
Heidenreich, T., 318
Heim, C. M., 311
Heiman, J., 364
Heller, K., 357
Hembree, E. A., 75, 479
Hemmelstein, N., 440
Hendrickson, S. M. L., 70
Hendriks, L., 479–480
Henriques, G., 476
Henry, W. E., 396
Henry, W. P., 387
Hepple, J., 245
Herman, J., 362
Herman, S. M., 130
Hernandez, E., 169
Hershenberg, R., 433
Herzberg, A., 30
Hester, R. K., 366
Hettema, J., 93, 293
Hickman, E. E., 18
Higa-McMillan, C. K., 398–399
Hill, C. E., 8, 51, 100, 101, 244, 246–247, 380, 381, 386, 399, 436, 437, 477
Hilsenroth, M. J., 18, 70–71, 75–76, 223, 229, 230
Himawan, L., 381
Hines, C. E., 230, 243
Hinshelwood, R. D., 395
Hipolito-Delgado, C., 326–327, 337
Hiraki, N., 452
Hiripi, E., 357–358
Hirschfeld, R. M. A., 306
Hoadley, A., 93
Hodges, J. Q., 360, 364
Hoff, A. L., 15–16
Hoffart, A., 81
Hoffer, A., 304
Hoffman, J. E., 361
Hofmann, S. G., 69, 73, 76
Hogan, T. P., 437–438, 476–477
Hoge, M. A., 93
Hollanders, H., 14, 48, 395, 458–459
Holliday, C., 459
Hollon, S. D., 75–76, 81, 258
Holloway, E. L., 391–392
Holman, J., 287
Holmes, J., 46, 458
Holmqvist, R., 72–73
Holstein, L., 7
Holt-Lunstad, J., 73
Holt, H., 143, 144, 154, 155, 209, 384, 393, 481
Holt, P., 397
Holtforth, M. g., 81
Hölzel, L. P., 318
Holzer, C. E., 304, 306
Hönekopp, J., 179
Honos-Webb, L., 101, 482
Honyashiki, M., 73, 76
Hood, K., 290–291
Hook, J. N., 96–97, 293, 480
Horgan, A., 360
Hormann, M., 223, 304
Horowitz, M. J., 38, 43
Horvath, A. O., 70, 75, 93, 107, 290
Horwitz, J. A., 311
Houck, J., 70
Houts, P. S., 33
Howard, G. S., 379
Howard, K. I., 40, 71, 434–435
Howe, L. C., 73
Howell, M. K., 361
Howland, R. H., 304, 306
Hoyer, J., 231
Hoyt, T. V., 358–359
Hoyt, W. T., 81, 96–97, 299
Hubble, M. A., 11, 106, 107, 109, 111, 113, 117–119, 210–211, 216, 217, 379, 384
Huedo-Medina, T. B., 74
Hughes, D., 346
Hughes, S. O., 163, 169, 177
Huibers, M., 288
Humphrey, N., 71
Humphreys, K., 359–361, 364, 366, 367
Hungr, C., 198
Hunt, H. F., 36
Hunter, J. A., 286
Hurlburt, M. S., 14t
Hutman, H., 14t
Hutto, D. D., 74
Hutton, H. E., 360
Hwakins, E., 379
Hwang, K. K., 455

Ichikawa, K., 73, 76

Iles, B. R., 74–76
Imel, Z. E., 11, 69–71, 74–76, 80, 81, 141, 246–247, 330–331, 357, 384, 389, 432–433, 436, 475,
477, 482
Inman, A. G., 392
Ip, J., 285
Ivanov, A., 274
Ivanova, E., 360
Ivey, A. E., viii, 12–13, 46–47, 329, 330, 475–476, 480
Iwakabe, S., viii, 4, 15, 52, 451–452, 480
Izard, C. E., 311

Jackson, R., 442

Jacob, T., 153
Jacobson, E. E., 73
Jacobson, N. C., 231, 243–244, 477–478
Jacobson, N. S., 45, 48
Janis, O. L., 165, 170–171
Janis, R., 441–442
Janis, R. B., 441
Jara, M., 457–458
Jarmon, H., 379
Jayaratne, S., 17
Jennette, D., 334
Jensen, J. P., 13, 17, 42
Jernberg, A., 345
Jiménez-Chafey, M. I., 332
Jobst, A., 319
Johansson, R., 285, 359, 360
John, M., 365
Johnson Jennings, M. D., 70
Johnson, A. J., 392
Johnson, B. T., 74, 341
Johnson, J. L., 178
Johnson, L. D., 108–109
Johnson, M., 15–16
Johnson, S. M., 15
Johnson, V., 175, 455
Jones, A. C., 36
Jones, E. E., 44–45, 229–230
Jones, F., 360
Jones, H., 178–179
Jones, J., 436–437
Jones, N., 367–368
Joo, E., 454
Jürgensen, R., 153
Jussim, L., 196–197

Kabat-Zinn, J., 258–259

Kahl, K. G., 318
Kahler, C. W., 359–360
Kalinsky, B., 465
Kamphaus, R. W., 347
Kane, R. T., 77, 81, 382, 481, 482
Kang, N. J., 197
Kanter, J., 277–278
Kanuri, N., 361
Kaplan, B., 18–19
Kaplan, H. S., 34
Kaptchuk, T. J., 73
Karasu, T. B., 12
Karcher, N. R., 367–368
Karno, M. P., 153
Karpiak, C. P., 6, 9, 14, 14t, 475
Karver, M., 349
Kasoff, M. B., 231, 243, 285
Katz, L. F., 263
Kavanagh, K., 287
Kaye, A. L., 308
Kazantzis, N., 14
Kazdin, A. E., 341, 342, 348, 357–358, 368, 432
Keefe, J. R., 74
Kegan, R., 259
Kellam, T., 345
Keller, M. B., 304, 306, 310, 311, 318
Kellet, S., 245, 459
Kelley, J. M., 73
Kelley, S. D., 342
Kelly, J. F., 359, 360, 367
Kenagy, J., 396–397
Kendall, J., 343
Kendler, K. S., 306–307
Kennedy, C. L., 395
Kenny, M. C., 344
Kenter, R. M., 360
Kernberg, O. F., 278
Kerr, C. E., 73
Kerr, I. B., 208
Kerr, S., 41, 229–230
Kertes, A., 285, 287, 289
Kessler, J. W., 43
Kessler, R. C., 357–358
Khattra, J., 285
Khouri, H., 197
Kierein, M., 456–457
Kiesler, D. J., 13, 238–239, 305–307, 310, 314–315
Kikuzawa, S., 357
Kim, H., 244
Kim, J., 327
Kim, S., 76, 347
Kimpara, S., 143, 144, 154, 155, 384, 386, 393, 481
Kirmayer, L., 449
Kirsch, I., 74–75
Kissil, K., 379
Kivlahan, D. R., 177
Kivlighan, D. M., Jr., 73
Klatt, M., 71
Klaw, E., 361, 366
Klein, D. N., 304, 306, 308–310, 318
Klein, J. P., 319
Klein, O., 196
Klein, S., 223
Kleinman, A., 450
Kleinstäuber, M., 106–107, 117, 394, 435, 439, 478
Klerman, G. L., 38–39, 311, 318
Kliem, S., 278–279
Klinar, D., 465
Kline, M., 231
Klingemann, H., 357, 360
Klonsky, E. D., 70–71
Klosko, J. S., 245, 478–479
Knell, S. M., 345
Knobloch, J., 36
Knobloch, R., 36
Knock, M. K., 348
Knox, S., 380, 381, 386, 392, 437
Koch, U., 153
Kocsis, J. H., 306
Koerner, K., 279, 437
Koeter, M. W. J., 278
Kohlenberg, R. J., 231
Kohn, R., 357–358
Kohut, H., 185, 215
Kolaski, A. Z., 399
Kollins, S. C., 347
Kommer, D., 37
Konrad, M., 71
Koo, M., 113
Koocher, G. P., 343, 437–438, 476–477
Koole, S., 288
Koons, C. R., 278
Kopta, M., 107, 434
Korathu-Larson, P., 398–399
Korman, L., 278
Kornstein, S. G., 304, 306, 308
Korslund, K. E., 277
Kosfelder, J., 278–279
Koslowski, B., 197
Kosman, D. C., 49, 482
Kostínková, J., 457
Kownacki, R. J., 359–360
Kozak, M. J., 75, 231
Kozlowski, J. M., 392
Kratochwill, T. R., 358
Kraus, D. R., 50, 298, 432–433, 435–437, 439, 441
Krause, E. D., 475
Krause, M. S., 434
Krebs, P. M., 92, 146, 165, 178, 366
Kreider, D. E., 392
Kreische, R., 231
Krieger, T., 245–246
Kring, M., 69, 74–76
Kristellar, J., 165
Kriston, L., 153, 318, 319
Kröger, C., 278–279
Krueger, S. J., 342–345, 346, 349, 352
Krull, J., 398–399
Kruse, J., 223, 304
Kubie, L. S., 29
Kuhn, E., 361
Kuhn, T. S., 3
Kune, N. F., 293
Kunz, C., 288, 293
Künzi, K., 462
Kuppens, S., 341
Kuprian, N., 18
Kurtz, R., 6, 16–18, 35, 41
Kurtz, Z., 343
Kwee-Taams, M. K., 137
Kwee, M. G. T., 137
Kyrouz, E. M., 359–360

L’Abate, L., 361, 364

Labouvie, E., 359–360
Lachmann, F. M., 197
Lackenbauer, S. D., 196–197
Ladany, N., 394
Laforge, R., 166, 177–178
Lai, R., 361–362
Lam, C. S., 165
Lambert, M. J., 7–8, 21, 44, 50–51, 77, 80, 81, 97, 100–101, 106–107, 109, 117, 191, 208, 209, 217,
224, 246–247, 275, 288, 379, 381, 389, 393–394, 399, 432–436, 439, 443, 477, 478, 482
Lambley, P., 34, 35
Lampropoulos, G. K., 380, 391–392, 395, 398
Lancaster, T., 359
Landes, A. A., 130
Landreth, G. L., 343, 345
Landsman, J. T., 22
Landsman, T., 34
Lane, C., 290–291
Lane, R. D., 187, 397
Lange, J., 81, 482
Langer, E. J., 74
Lanotte, M., 74
Larson, D., 3, 37
Laska, K. M., 75, 224
Laurenceau, J.-P., 198, 230, 244–246
Lavori, P. W., 311
Laws, H. B., 290
Lazar, A., 462
Lazarus, A. A., 9, 32, 33, 35–37, 42–44, 125–128, 133, 134, 137–138, 216, 344, 388
Lazarus, C. N., 9, 32, 125–128, 130, 133–135, 216
Leach, C., 107, 439
Lebow, J. L., 4, 39, 341–342, 350
Lecompte, C., 40, 386
Lee, B. O., 453–454
Lee, E., 327
Lee, S., 450–451
Lee, T. W., 359
Lehmann, A. C., 119, 481
Leibing, E., 231
Leichsenring, F., 223, 231, 304
Lembo, A. J., 73
Lemmens, F., 45
Lenzenweger, M. F., 278
Leon, A. C., 76
Leong, S., 361
Leung, A. S., 451
Leung, S., 451
Levay, A. N., 35
Levenson, H., 211
Leventhal, A. M., 32
Levesque, D. A., 178
Levins, R., 259
Levitt, J. T., 475
Levy, K. N., 278
Levy, R., 73
Levy, S. R., 18, 223
Leweke, F., 223
Lewin, T. J., 278
Lewinsohn, P., 364
Lewis, O., 47
Lewontin, R., 259
Li, L., 450–451
Li, M.-G., 450
Li, Q. S., 74
Liberman, B. L., 74–75
Lichtenberg, J. W., 7–8, 14t, 71
Lieberman, M. D., 73
Lietaer, G., 42
Lilienfeld, S. O., 363, 369
Lin, Y. C., 455
Lindner, P., 360
Lindquist, J., 397
Linehan, M. M., viii, 41–42, 45, 186–188, 245, 257–259, 261–266, 269–272, 275, 277–278, 364
Links, P. S., 278
Linsenhoff, A., 37
Liotti, G., 39
Lister, K. M., 6, 9
Liu, D., 442
Liu, W. M., 330
Livesley, W. J., 137, 398–399
Livingston, R. B., 14t
Llera, S. J., 246, 285
Lockard, A. J., 441
Locke, B. D., 441–442
Lohr, J. M., 363
London, P., 4, 6, 7, 31–32, 34, 41, 125–126
Long, D., 231
Longabaugh, R., 70, 144, 153
Loomis, C., 359–360
Lopiano, L., 74
LoPiccolo, J., 364
Lord, B. D., 309
Lorenzo-Luaces, L., 101–102
Luborsky, L., 7, 141, 209, 475
Lucock, M., 107, 439
Ludman, E. J., 72–73
Lueger, R. J., 434–435
Lui, J. L., 361
Lundahl, B. W., 93, 288, 293
Lundh, L. G., 461
Lungu, A., 277–279
Lunnen, K., 109
Luo, Y., 73
Lutz, W., 107, 118, 245, 246–247, 434–436, 438, 439, 469, 474, 477
Luyten, P., 223
Ly, K. H., 360
Lynch, T. R., 261–262, 278
Lynn, S. J., 363
Lyons-Ruth, K., 198–199
Lytle, R., 231, 241

Macaulay, C., 285

MacDonald, R., 142, 153
Machado, P. P. P., 15–16, 141–142
Macias, S., 143, 144, 154, 155, 384, 386, 393, 481
Maddoux, J. A., 399
Madon, S., 196–197
Madson, M. B., 392
Maeschalck, C. L., viii, 11, 108, 478
Magaletta, P. R., 169–170
Maganvita, J. J., 476
Maggi, G., 74
Maggio, L. A., 437–438, 476–477
Maggioni, F., 196–197
Magill, M., 93
Magnavita, J. J., 50, 51, 477–478
Magnusson, K., 367
Mahoney, M. J., 7, 33, 36, 37, 39, 40, 43, 45, 186–187, 230, 284, 381, 395, 466
Mahrer, A. R., 42
Main, M., 197
Mains, J. A., 359
Makari, G., 70
Malik, M. L., 142, 145
Maling, M. S., 434–435
Mallams, J. H., 364
Malloy, P., 144
Manber, R., 306
Manheimer, D. I., 174
Mankowski, E. S., 364
Mann, L., 165, 170–171
Mannarino, A. P., 344–345
Mao, J. J., 74
Marcus, B., 170
Marcus, D. K., 75–76, 361
Marcus, J., 363
Marcus, M., 74–75, 289
Margison, F., 434, 443, 459
Margolis, A., 197
Marie-Cardine, M., 458
Markin, R. D., 73
Marks, I. M., 32
Marks, J. S., 398
Marlatt, G. A., 218
Marmor, J., 31–33, 37
Martin, A. M., 309
Martin, C. G., 34
Martinex, J., 299
Martinovich, Z., 434–435
Masters, J. C., 258
Masters, W., 175
McAleavey, A. A., 244, 434, 437, 440, 441–442, 477–478
McAlister, A. L., 165
McAlister, B., 379, 432–433, 436
McCambridge, J., 177, 290–291
McCarthy, G., 360
McCarthy, K. S., 439
McCarty, D., 442
McClintock, A. S., 381
McClure, R. F., 14t
McConnaughy, E. A., 163
McCrady, B. S., 359–360
McCuan, R. S., 165
McCullough, J. P. Jr., viii, 46, 240, 245, 303–315, 318
McCullough, J. R., 326–327, 337
McCullough, L., 81
McDavis, R. J., 326–327
McElroy-Heltzel, S. E., 96–97
McGinn, L. K., viii, 13, 21, 474
McGrath, P. J., 364
McKay, D ., 70–71
McKinnon, J. M., 198
McLean, C. P., 368–369
McLennan, J., 13, 450
McLeod, J., 12, 14, 48, 378, 379, 383–385, 398, 458–459
McMahon, B. T., 165
McMahon, R. J., 261
McMain, S. F., 239, 266, 278
McNeill, B. W., 390–392
Mee-Lee, D., 107
Mehlum, L., 261–262
Meichenbaum, D., 33
Meisch, L., 245–246
Melchert, T. P., 10, 476
Mellinger, G. D., 174
Mellor-Clark, J., 434, 436–437, 443
Meltzoff, J., 389
Menchola, M., 359
Mendelson, M., 244
Mendelson, T., 261–262
Mendes, W. B., 196–197
Meredith, K., 153
Merranko, J., 261–262
Merriam, P., 165
Merrill, C., 261–262
Merry, W., 153
Merton, R. K., 196–197
Messer, S. B., 4, 11–12, 20, 21, 37, 39–41, 43, 47, 185, 208, 382–384, 476, 477, 480, 482
Messinger, D., 197
Metzger, R. L., 293
Meyer, R., 39
Meyer, T. J., 293
Michaelis, B., 197
Michalak, J., 318
Michelson, A., 287
Miciak, M., 73
Mickelson, K. D., 357–358
Middleton, H., 76
Miga, E. M., 278, 279
Mikeal, C., 118
Mikulas, W. L., 36
Mikulincer, M., 196
Miller, A. L., 261–262
Miller, D. J., 97
Miller, I., 306
Miller, K., 154
Miller, L., 342
Miller, M. L., 293
Miller, N. E., 30–31, 33, 185–187, 196, 207–208
Miller, R., 18, 223
Miller, S. D., viii, 11, 50, 77, 81, 106–107, 108–113, 117–119, 210–211, 216, 217, 379, 382, 384,
393–394, 439, 481, 482
Miller, T. I., 70–71, 106
Miller, W. R., 70, 93, 177, 285, 289–291, 293, 299, 359–360, 366, 367
Millon, T., 45
Milne, D., 396
Milrod, B. L., 76
Minami, T., 107
Mintz, J., 368–369
Miranda, R., 197
Mitchell, K. M., 33
Mitchell, S. A., 208–209
Mock, J., 244
Moertl, K., 285
Moffitt, M., 367–368
Mohr, D. C., 142, 153, 285, 359, 360, 367, 368–369
Mokdad, A. H., 398
Moleiro, C., 145
Moleni, T., 93
Molina, S., 231
Molnar, C., 230–232
Mona, L. R., 328
Mondragon, S. A., 106
Monroe-DeVita, M., 93
Monsen, J. T., 482
Moore, G. A., 243–244
Moore, T. E., 363, 364
Moore, T. J., 74
Moos, R. H., 359–360, 364
Moran, L. R., 261
Morgan, A. C., 198
Morgenstern, J., 359–360
Morrison, N. R., 285
Morrissey, S. A., 379
Morse, G., 93
Morse, J. Q., 261–262, 278
Morten, G., 325–327
Mościcki, E. K., 442
Moultrup, D., 4
Moyers, T. B., 70, 287, 290–291, 299
Muir, J. A., 442
Muise, A., 196–197
Mullen, P., 172
Muller, F., 464, 465
Mullin, T., 72–73
Mullins, L. L., 15–16
Munoz, R. F., 364, 366, 368–369
Muran, J. C., 93, 95, 97, 147–148, 185, 188, 191, 198, 239, 245, 331, 438, 443, 469, 474, 477, 481
Murase, K., 452
Murphy, D., 93
Murphy, J. G., 93
Murphy, J. J., 118
Murphy, M. J., 149
Murphy, R. A., 391
Murray, A. M., 277
Murray, E., 361–362
Murray, N. E., 35
Murray, P., 239
Myers, P., 379

Nacapoy, A., 333

Nace, D. K., 108
Nadel, L., 187
Naglieri, J. A., 347
Nahum, J. P., 198
Nakamura, B. J., 346, 398–399
Nance, D. W., 379
Napolitano, G., 10, 12
Narduci, J., 399
Narrow, W. E., 442
Nash, M., 92–93
Nasi, L., 468
Nassar-McMillan, S., 326–327, 337
Nathan, P. E., 230–231
Nathanson, D., 261–262
Nazareth, I., 361–362
Neacsiu, A. D., 266, 277–279
Negt, P., 318
Neihart, M. F., 453
Neimeyer, G. J., 399
Neimeyer, R. A., 186–187
Nelson, D., 440
Nelson, G., 391
Nelson, M. L., 394
Nelson, P. L., 106
Nemeroff, C. B., 311
Neufeldt, S. A., 15–16
Neuner, F., 479
Newman, C. F., 41–42, 44, 70, 474
Newman, M. G., viii, 11–13, 21, 50, 74–75, 230, 231–232, 235, 241, 243–244, 246, 285, 477–478
Ng, M. Y., 341
Ng, W. S., 452–453
Niaura, R. S., 170
Nicholson, J. M., 92
Niec, L. N., 348
Nielsen, A. C., 37
Nielsen, S. L., 81, 106, 432–433, 435
Niemiec, R. M., 361
Ninan, P. T., 311
Nissen-Lie, H. A., 482
Noel, N., 144
Nolan, B. M., 9, 49, 482
Nolrajsuwat, K., 455
Noma, H., 73, 76
Norcross, J. C., viii, 4, 6–10, 12–18, 14t, 20, 21, 40–42, 44, 47, 49–51, 70, 71, 77, 80–81, 92, 100–
102, 125, 143, 146, 148, 161–162, 169–170, 191, 209, 234, 259, 288, 329–330, 333, 344, 346,
349, 352–353, 358–362, 364–366, 368, 369, 378–381, 383, 384, 387–393, 395–399, 437–438,
459, 466, 469, 474–475, 476–477, 480, 482
Nordberg, S. S., 243, 436, 441
Nordgreen, T., 358
Norouzian, N., 287, 299
Norwood, A. E., 179
Norwood, E., 342
Nowlan, K. M., 361
Nurco, D. N., 367

O’Conner, E. P., 358

O’Connor, K., 345
O’Donnell, P., 379, 432–433, 436
O’Grady, K. E., 367
O’Hara, D. J., 385, 450
O’Hara, E. F., 450
O’Leary, K. D., 36, 39, 258
O’Leary, W., 440
O’Neill, J., 366
Obegi, J. H., 196
Ockene, I., 165
Ockene, J., 165
Oddli, H. W., 385
Odelola, O., 360
Offord, D. R., 357–358
Ogles, B. M., 81, 106, 482
Okiishi, J., 109
Okruch, A., 243
Oleen-Junk, N. A., 69, 74–76
Olff, M., 479–480
Olieveira-Berry, J., 334
Ollendick, T. H., 141, 149
Omer, H., 41, 109
Opazo, R., 465–466
Orchowski, L., 93
Orlans, V., 380–381
Orlinsky, D. E., 14–15, 40, 71, 380, 387, 388, 396, 434, 454, 461
Orne, M. T., 92–93
Osatuke, K., 198
Osler, W., 365, 392–393
Ostafin, B., 196
Ouimette, P. C., 359–360
Overland, E., 14t
Owen, J. J., 75–76, 97, 107, 111, 223, 293, 330–331, 480
Özakkaş, T., 463

Pace, B. T., 70–71, 75–76

Pachankis, J. E., viii, 5, 195–196, 328, 482
Padawer, W., 38, 229
Padberg, F., 319
Padula, J. A., 178
Paivio, S. C., 479
Palavezzatti, C., 464, 465
Paley, G., 436–437
Palmer, J. O., 39
Palmer, M., 7, 41
Palmer, S., 458
Palomba, D., 278–279
Pansomboon, C., 456
Papajohn, J. C., 39
Papastergiadis, N., 449
Pardo, S., 151
Parham, T. A., 332
Paris, J., 468
Paris, M. Jr., 93
Park, A., 398–399
Parkin, S. R., 80–81, 96–97
Parks, M., 42
Parloff, M. B., 433
Pascual-Leone, A., 479
Pascual, J. C., 266
Pate, G. A., 437
Patrick, S., 436–437
Patterson, C. H., 9, 32, 47
Patterson, C. L., 81, 381, 482
Patterson, G. R., 287
Patterson, K. M., 153
Patterson, T., 47
Paul, G. L., 137–138, 303
Pederson, P. B., 325–326, 329
Pedulla, B. M., 343
Pelham, B. W., 196–197
Penberthy, J. K., 303–305, 307, 309–311
Penny, D., 169–170
Perepletchikova, F., 261–262
Perez de los Cobos, J., 169
Perez Gomez, A., 38
Perez-Stable, E. J., 369
Perez, J. E., 46–47
Perez, R. M., 328
Pérez, V., 266
Perlman, C., 245–246
Perloff, J. M., 437
Persons, J. B., 437
Pescosolido, B., 357
Peterson, A. L., 368–369
Peterson, A. P., 261
Peterson, D. R., 43
Petit, D., 76
Pfahler, C., 93
Pfeiffer, S. L., 347
Pfund, R. A., 4, 361, 368, 469, 474–475
Phillips, B., 462
Phillips, J., 48, 343
Phillips, R. D., 343
Piaget, J., 305, 306, 311
Pincus, A. L., 230–233, 241, 285, 378, 439
Pine, F., 342–343
Pinel, E. C., 50
Pinsof, W. M., 6, 39, 46
Pirritano, M., 299
Pitman, S. R., 18, 223
Pitre, N., 358–359
Plum, B., 107
Polanyi, M., 314, 456
Pollo, A., 74
Pollock, L. R., 270
Polster, E., 89
Polster, M., 89
Pomerantz, A. M., 13
Pope-Davis, D. B., 330
Pope, B., 37
Poppen, P. J., 16, 35
Popper, K., 456
Popple, L. M., 378, 389, 396
Pott, E., 74–75
Poulin, L., 299
Powell, D. H., 41
Powers, M. B., 74–75
Poznanski, J. J., 13, 450
Pratt, J., 343
Prentice, J. L., 367–368
Prescott, D. S., viii, 11, 108, 478
Presser, N. R., 367–368
Price, D. P., 74
Priddy, D. A., 165
Prinyapol, P., 456
Pritz, A., 456–457
Prochaska, J. M., 161–162, 166, 175, 178–179
Prochaska, J. O., viii, 4, 6, 8, 10, 15–17, 36, 39–41, 51, 92, 101, 146, 161–167, 169–171, 174, 175,
177–179, 212, 329–330, 345, 360, 361, 366, 368, 378, 379, 381, 384, 392, 395, 469, 474–476,
480–481
Prout, H. T., 341, 342, 349, 352
Pruitt, N. T., 392
Pruzinsky, T., 231
Przeworski, A., 231, 285
Przybylinski, E., 50, 197
Pulos, S. M., 44–45, 229–230

Qian, M., 450–451

Quintana, S., 78, 332

Rabbitt, S. M., 357–358, 368

Rabung, S., 223
Rachman, S. J., 70–71
Raguram, A., 382
Ragusea, S. A., 438, 439
Raimy, V., 34–35
Rainero, I., 74
Rajab, M. H., 363
Ramberg, M., 261–262
Ramirez, M. III, 43
Rampy, N. M., 50
Randall, A. K., 73
Rapee, R. M., 369
Rappaport, J., 360–361
Rathus, J. H., 261–262
Ratts, M. J., 326–327, 337
Rauch, S. A. M., 368–369
Raue, P. J., 44–45, 230, 285–286
Ravenscroft, I., 74
Raw, S. D., 46
Re, A. C. D., 107
Reese, R. J., 77, 78
Reeves, G., 343–344
Reger, M. A., 359
Regier, D. A., 442
Reid, E., 436–437
Reid, J. B., 243, 287
Reisman, J. M., 382
Remer, P., 329
Rennie, D., 286
Resick, P. A., 479
Resnick, R., 46
Resorla, L. A., 347
Reynolds, C. R., 347
Reynolds, S. K., 278
Rhoads, J. M., 34, 41, 344
Rhode, A., 245–246
Rice, A., 113
Rice, L. N., 41, 240
Rice, S. L., 70
Richards, D., 359
Richardson, T., 359
Richardson, W. S., 437–438
Rickles, K., 174
Ricks, D. F., 16, 35
Ridley, C. R., 331–333
Rigazio-Digilio, S. A., 46–47
Řiháček, T., 14t, 15, 19, 457
Rimm, D. C., 258
Riso, L. P., 304, 306
Ritzert, T., 359
Rivera, L. M., 196–197
Rivera, M., 261–262
Rizvi, S. L., 266
Roberts, N. A., 437
Roberts, W. C., 308
Robertson, M. H., 9, 16, 36, 40, 46, 381, 382, 386, 395
Robins, C. J., 95, 229, 261–262, 278
Robins, E., 306
Robinson, E., 231
Robles, T. F., 73
Roddy, M. K., 361
Rodolfa, E., 330–331
Rodríguez, M. D., 293, 332–333, 336–337, 392
Rodriguez, S., 461
Rodriquez, B. F., 48
Roedel, G., 450
Roemer, L., 231
Rogan, J. D., 14t
Rogers, C. R., 31, 34–35, 45, 147, 215–217, 458
Rohrbaugh, M., 8, 153
Rojas-Arauz, B. O., 330
Rollins, A. L., 93
Rollnick, S., 93, 177, 285, 289–291
Romanelli, R., 145
Rombauts, J., 42
Romero-Canyas, R., 197
Rompay, M. V., 358
Rønnestad, M. H., 14–15, 378, 380, 388, 396, 482
Roodman, A. A., 363
Roose, S. P., 74–75
Rose, S., 304, 308
Rosen, G. M., 163, 363, 364, 369
Rosen, S., 272
Rosenbaum, R., 389–390
Rosenberg, J., 39
Rosenthal, R., 475
Rosenzweig, S., 5, 29, 33, 71, 208, 475, 482–483
Rossi, J. S., 164–166, 169, 170, 177–179, 366
Rossi, S. R., 178–179
Roth, A., 379
Roth, W. T., 76
Rothbaum, B. O., 75, 479
Rotter, J. B., 22
Roubal, J., 14t, 15, 457
Rounsaville, B. J., 318
Rousmaniere, T. G., 81, 298–299, 382, 481
Roy-Byrne, P., 74–75
Rozental, A., 360, 367
Rüddel, H., 153
Rudden, M., 76
Ruggiero, L., 166, 177–179
Ruiz, A. S., 327
Ruiz, M. A., 438, 439
Ruscio, A., 230–231
Rush, A. J., 306, 311, 318
Rusk, G. S., 42
Russ, S. W., 348
Russell, R. L., 348
Rutherford, B. R., 74–75
Ruzek, J. I., 361
Ryan, L., 187
Rychtarik, R. G., 367
Ryle, A., 10, 36–43, 208, 245, 456, 459

Sabourin, S., 386

Saccone, A. J., 74–75
Sadler, P., 198
Safran, J. D., 11–12, 39–42, 47, 93, 95, 147–148, 185, 188, 191, 198, 230, 231, 238–240, 244, 245,
331, 466, 481
Sakunpong, N., 456
Salkovskis, P. M., 76
Salyers, M. P., 93
Salzer, M. S., 360–361
Salzer, S., 231
Samko, M., 272
Sampson, H., 209
Samstag, L. W., 93, 245
Sandberg, L. S., 76
Sandell, R., 462
Sander, L. W., 198
Sanderson, W. C., 284–285
Sandler, I. N., 106
Sangganjanavanich, V. F., 455
Santoro, S. O., 475
Santrock, J. W., 358–359, 361, 364, 365, 399
Sapigao, W., 330
Saposnek, D. T., 272
Sarason, I. G., 36
Saribay, S. A., 197
Sass, L. A., 41
Sauer-Zavala, S. E., 75–76
Savage, S., 333
Sawatsri, S., 456
Sawyer, A. T., 69
Saxon, D., 246–247, 436
Sayette, M. A., 13
Sbarra, D. A., 73
Scarsella, G. M., 231
Schacht, T. E., 43, 382–383
Schaefer, C. E., 343, 346–349
Schaefer, H. S., 73
Schamberger, M., 399
Schatz, D. M., 14t, 387
Schatzberg, A. F., 311, 318
Schauer, M., 479
Schauman, O., 196–197
Schenkenberg, T., 109
Scher, M., 329
Scherr, K. C., 196–197
Schick, M., 397
Schmidt, H., 277–278
Schmidt, J. A., 307, 310, 314–315
Schneider, R. J., 178
Schneier, F. R., 74–75
Schnicke, M. K., 479
Schnurr, P. P., 15
Schofield, M. J., 385, 450
Schott, T., 448
Schottenbauer, M. A., 18, 48, 352
Schöttke, H., 81, 482
Schramm, E., viii, 240, 245, 303–305, 307, 309–311, 318, 319
Schubert, J., 462
Schuckard, E., 106, 107, 113, 117
Schueller, S. M., 367–369
Schultz-Ross, R. A., 377
Schultze, M., 318
Schulz, H., 153
Schut, A. J., 230, 231, 243, 244
Schwalberg, M., 76
Schwartz, B. D., 37–38
Schwartz, R. M., 45
Schwartz, S. J., 442
Schweiger, U., 319
Scoboria, A., 74
Scogin, F. R., 359, 367, 369
Scoles, M. T., 118
Seals, K., 231
Sechrest, L., 45–46
See Tai, S., 361–362
Segal, S. P., 360, 364
Segal, Z. V., 11–12, 42, 230, 231, 238, 239
Segraves, R. T., 35, 38, 39
Segre, L., 360–361
Seidel, J. A., 77, 81, 108, 111, 119, 379, 382, 481, 482
Seiden, D. Y., 458
Selagea, F., 358, 361, 364, 365, 399
Selby, V. C., 170
Seligman, M. E. P., 359–360
Serber, M., 33
Sexton, H., 81
Seymour, J. W., viii, 352–353
Shadish, W. R., 359–360
Shaker, A., 147–148, 188, 191
Shandel, T., 147
Shanely, D. C., 379
Shankman, S. A., 304, 308
Shapiro, A. K., 71
Shapiro, D. A., 40, 198, 436–437
Shapiro, D. H. Jr., 36
Shapiro, E. S., 71
Shapiro, F., 479
Shaughnessy, E. A., 369
Shaver, P. R., 196
Shaw Welch, S., 278
Shaw, B. F., 306
Shaw, M. A., 179
Shear, M. K., 75–76
Shedler, J., 209
Shelton, R. C., 75–76, 81
Sherbourne, C., 74–75
Sherman, W. O., 7
Sherry, P., 392
Shi, Q., 450–451
Shiloff, N., 143, 144, 154, 155, 384, 393, 481
Shimizu, M., 196–197
Shimokawa, K., 106, 432–433, 435
Shin, K. E., 231
Shirk, S. R., 47, 343, 344, 348
Shmukler, D., 47
Shoham-Salomon, V., 43, 44
Shoham, V., 8, 153
Short, E. L., 327
Shukla, N., viii, 12–13, 475–476, 480
Siddiqui, J. R., 70–71
Siebert, E. C., 231
Siegel, D. F., 18, 223
Sijbrandij, M., 288
Sijercic, I., 286
Silva, A. N., 460
Silverman, L. H., 34
Simek-Downing, L., 42
Simmons, K., 361
Simon, G. E., 72–73
Sims, J. H., 396
Singer-Nussbaum, B., 299
Singer, A. R., 14t
Singer, B., 7
Singer, E., 217
Singh, A. A., 326–327, 337
Sinha, R., 279
Sisson, R. W., 364
Skinner, B. F., 258, 305, 306, 313
Skovolt, T. M., 378, 380
Skow, J., 364–365
Skutch, J. M., 279
Slade, K., 77, 107
Sloane, R. B., 32, 35
Smailes, D., 179
Smart, D. W., 106, 107, 432–433, 435
Smith-Hansen, L., 399
Smith, B., 45–46
Smith, D. A., 8, 9, 48
Smith, D. S., 15–16
Smith, J. L., 272
Smith, M. L., 70–71, 106
Smith, R. C., 35
Smith, T. B., 96–97, 293, 332–333, 336–337
Smith, T. P., 358–359, 362
Smits, J. A. J., 73, 74–76
Smolenski, D., 361
Snow, M. G., 169
Snyder, M., 196
Sobell, L. C., 50, 357, 360, 434, 477–478
Soeller, I., 74
Soler, J., 266
Sollod, R. M., 19, 34, 381
Sollod, R. N., 40, 395
Solomonov, N., 18
Someah, K., 95, 154, 384, 386, 393, 481
Sommer, R., 358–359, 361, 362, 364, 365, 399
Song, X., 287, 381
Sonneck, G., 456–457
Sorrell, R., 106–107
Soto, A., 96–97, 293, 336–337
Sotskova, A., 381
Sparenborg, S., 442
Sparks, J., 224
Spengler, E. S., 97
Spengler, P. M., 97
Spinhoven, P., 478–479
Spitz, R. L., 311
Spitzer, R. L., 306
Spoth, R., 196–197
Spray, S. L., 396
Spurling, L., 12
Sripada, R. K., 368–369
Staats, A. W., 258
Staples, F. R., 35
Starace, N., 346
Stasiewicz, P. R., 367
Stead, L. F., 359
Stedmon, J., 382
Steele, J., 93, 293
Steer, R. A., 232–233
Stegman, S., 143
Stein-Seroussi, A., 258, 271
Stein, M. B., 74–75, 143, 144, 154, 155, 209, 384, 386, 393, 481
Stein, P. T., 343
Steinert, C., 223, 304
Steinfeld, G. J., 39
Stephens, N., 170, 172, 179
Stern, D. B., 184–185, 189
Stern, D. N., 198
Stettler, P., 462
Stewart, R. E., viii, 441
Steyer, R., 245–246
Stich, S., 74
Stijnen, T., 278
Stiles, T. C., 81
Stiles, W. B., 40, 101, 198, 434, 436–437, 443, 482
Stock, M., 71
Stocker, D., 462
Stoltenberg, C. D., 390–392
Stotts, A., 172
Stout, R., 144
Strassle, C. G., 92–93
Straus, M. M., 442
Straus, S. E., 437–438
Strauss, C., 360
Strauss, J., 389
Streiner, D. L., 266
Stretcher, A. L., 399
Stricker, G., viii, 11–12, 16, 44, 46–48, 185, 207–210, 213–215, 217–218, 257, 344, 379, 466
Strong, S. R., 40–41
Stroup, D. F., 398
Strupp, H. H., 33–36, 38, 43, 44, 48, 286, 387
Stulz, M., 107, 439
Stulz, N., 435
Suarez, A., 261
Sue, D. W., 325–332
Sugihara, Y., 452
Sullivan, H. S., 35, 75, 185, 187, 238
Surko, M., 101, 482
Sutton, S. W., 106, 432–433, 435
Suzuki, L. A., 327
Svartberg, M., 81
Svensson, A., 360
Swales, M. A., 258–259, 267
Swann, W. B. Jr., 196–197, 258, 271
Sweeney, J., 360
Swift, J. K., 21, 72–73, 80–81, 92–93, 96–97, 106
Swindle, R., 357
Sylvestre, J., 440
Syme, M. L., 328
Symonds, D., 75, 107
Szapocznik, J., 442
Szkodny, L. E., 243, 477–478
Szollos, S. J., 391

Tai, B., 442

Tallman, K., 210–211, 216
Tan, S. Y., 453
Tanaka, S., 73, 76
Tang, E. A., 360
Tannahill, H. S., 368–369
Tao, K. W., 293, 330–331
Target, M., 343
Tasca, G. A., 440
Taylor, C. B., 361
Taylor, J. M., 399
Teachman, B. A., 433
Tejero, A., 169
Telch, M. J., 74–75
Tempier, A., 459
Tennen, H., 74–75
Textor, M. R., 38
Thase, M. E., 311
Theis, F. J., 71
Thoma, N. C., 14t, 18
Thomas, B. L., 20, 41
Thomas, E., 361
Thombs, B. D., 70–71
Thompson, L., 145, 153, 154
Thoresen, C. E., 34
Thorne, F. C., 30–31
Thornicroft, G., 196–197
Thornton, J. A., 77, 81, 382, 481, 482
Thorp, S. R., 261–262
Tiana, T., 266
Todorov, A., 72–73
Tolin, D. F., 70–71
Tollefson, D., 93, 288, 293
Tollefson, G. D., 308
Tomasino, K. N., 367, 369
Tomlins, J. B., 153, 154
Tonigan, J. S., 359–360
Tonigan, S., 367
Toporek, R. L., 330
Tørmoen, A. J., 261–262
Torrey, E. F., 34
Toscoova, R., 359–360
Tougas, K., 147
Town, J. M., 223
Tracey, T. J. G., 7–8, 71, 392
Tragust, S., 71
Tran, G. Q., 74–75
Travaglini, L., 179
Trimble, J. E., 332, 336–337
Tronick, E. Z., 197, 198
Trost, S., 245–246
Truax, C. B., 33
Trujols, J., 169
Trusz, S., 196
Tsai, K., 398–399
Tsai, M., 231
Tsoh, J. Y., 166
Tucker, J., 357, 360
Tuma, J., 343
Turkewitz, H., 36
Turner, R. M., 278
Tutek, D. A., 261
Tweed, J. L., 278
Twigg, E., 436–437
Twisk, J., 369
Tyler, J. D., 16

Ugueto, A. M., 341

Uhlenhuth, E. H., 174
Ulleberg, P., 482
Ulvenes, P. G., viii, 11, 81
Umpress, V., 109

Vaillant, L. M., 394

Vallis, T. M., 178–179
van Asselt, T., 478–479
van den Bosch, L. M. C., 278
van den Bosch, R. J., 359
van den Brink, W., 278
van der Kolk, B. A., 343
van Dyck, R., 478–479
van Lankveld, J. J. D. M., 359
Van Marter, D. F., 178
van Minnen, A., 479–480
van Rijn, B., 459
van Straten, A., 285, 359, 360, 369
van Tilburg, W., 478–479
VanBalen, R., 42
Vandenbergbhe, L., 20
VandenBos, G. R., 7, 18
vanLieshout, P., 45
Varma, S. L., 452–453
Vasco, A. B., 14t, 15, 16, 456, 459–460
Vaughn-Coaxum, R., 341
Vaz-Velho, C., 460
Vaz, A., viii, 4, 15, 52, 480
Veeser, W. R., 395
Velasquez, M. M., 164, 170, 172, 179
Velástegui, M., 467
Velicer, W. F., 161–166, 177–178
Vellegas, M., 460–461
Velton, E., 366
Verheul, R., 278
Vermeersch, D. A., 81, 435, 482
Vernmark, K., 360
Vezzetti, H., 464
Vieira, E. D., 20
Vighetti, S., 74
Villanueva, J. J., 73
Vîslă, A., 74–76, 92
Vives, A., 243
Vivian, D., 306, 433
Vollmer, B. M., 80–81
von Wolff, A., 318
Vonk, I. J. J., 69
Vyleta, M. L., 71

Wachtel, E. F., 39, 188, 190–191, 198, 345, 346

Wachtel, P. L., 3, 10, 35, 38, 39, 40, 43, 47–48, 148, 175, 184–192, 194–199, 208–209, 212, 380,
390–391, 466, 475
Wagner, K., 334
Wainwright, N. A., 394
Waite, L. J., 73
Wakefield, J. C., 303–307
Wakefield, P. J., 141
Walfish, S., 379, 432–433, 436
Walker, J. A., 261–262, 394
Wallin, D. J., 188
Walton, C. J., 280
Walton, D. E., 15–16
Wambach, K., 318
Wampold, B. E., viii, 7–11, 21, 69–71, 74–76, 78, 80–81, 101–102, 106, 107, 113, 141, 224, 246–
247, 299, 330–333, 357, 366, 382, 384, 389, 391–393, 398–399, 436, 475, 477, 482
Wandersman, A., 16, 35
Wang, C., 450–451
Wang, S. C., 455
Ward-Ciesielski, E. F., 265
Ward, C. H., 244
Ward, T., 459
Warmerdam, L., 369
Warren, J. S., 106
Warren, S., 73
Wasserman, R. H., 439
Watkins, C. E. Jr., 47, 396
Watkins, P. L., 359, 361, 364
Watson, G., 29–30
Watson, J. C., 73, 93, 94, 290–291
Watzke, B., 153
Webb, C. A., 75–76, 81, 299
Wedding, D., 361
Weinberger, J., 46
Weishaar, M. E., 245, 478–479
Weiss, J., 209
Weissberg, J. H., 35
Weissman, A. N., 232–233
Weissman, M. M., 318
Weisz, J. R., 106, 341
Weitzman, B., 32
Wender, P. H., 92–93
Wentz, R., 243
Werner, H., 18–19
West, J. C., 442
West, M., 344
Westen, D., 41–42
Westphal, A., 318
Westra, H. A., viii, 52, 74–75, 245, 284–293, 297–299, 398–399
Whipple, J. L., 77, 81, 106–107, 117, 299, 389, 394, 435, 478
Whipple, K., 35
Whisman, M. A., 230–231
Whitaker, C., 271–272
Whitehouse, F. A., 32
Whiteside, S. P. H., 196
Whitley, D., 74–75
Wickless, C., 74–75
Wiersma, D., 359
Wiggins, J. S., 232–233
Wilber, K., 259
Wild, C., 459
Wile, D. B., 190–192
Wiley, J. F., 74–75
Wilhelm, F. H., 76
Wilk, J. E., 442
Wilkey, S., 358
Willard, J., 196–197
Willcox, C. H., 278
Williams, B. E., 391
Williams, H. B., 361
Williams, J. M. G., 270
Williams, O. B., 142, 143, 151–152
Williams, R. E., 141, 147
Williams, T. A., 137
Willis, J., 72–73
Wilm, K., 245–246
Wilson, B., 440
Wilson, E. O., 71, 73
Wilson, G. T., 70–71, 125–126, 258
Wilson, L. M., 360
Windle, R., 272
Winick, C. B., 344
Winkelbach, C., 231
Winnicott, D. W., 304–305, 312
Winokur, M., 37
Winston, A., 93, 198, 245
Winter, D. A., 186–187
Winter, L., 318
Winzelberg, A., 367
Wiprovnick, A. E., 175
Wise, E. H., 93
Wise, J. C., 359
Wiser, S. L., 44–45, 230, 285–286
Wislocki, A. P., 70–71
Wittchen, H. U., 357–358
Wittman, L., 39
Wogan, M., 13, 15–16, 18
Wolf, A. W., 50, 147–148, 239, 477–478
Wolf, E., 32
Wolfe, B. E., 41, 46, 48, 147, 433, 466
Wolitzky-Taylor, K., 74–75
Wollburg, E., 76
Wolpe, J., 126
Woodcock, E., 279
Woods, S. M., 37
Woodworth, R. S., 30
Woody, E., 198
Woody, R. H., 33
Woolfolk, R. L., 41
Worell, J., 329
Worthington, E. L. Jr., 96–97
Wosket, M., 458
Wright, H., 399
Wright, J. H., 363

Xiao, H., viii, 244, 441–442, 477, 478

Xiao, Z., 450–451

Yahne, C. E., 299

Yalom, I., 388
Yamasaki, A. S., 231, 285
Yasinski, C., 245–246
Yeh, C. J., 332
Yeo, L. S., 453
Yi, J., 368–369
Yorkston, N. J., 35
Yost, E., 153
Youn, S. J., 244, 440–442
Young, C., 14t
Young, D., 450–451
Young, J. E., 245, 346, 478–479
Youngren, M. A., 364
Yu, H., 261–262
Yue, D.-M., 48, 450
Yuen, S., 451
Yulish, N. E., 69–71, 74–76

Zack, S. E., 244, 435, 437

Zalecki, C. A., 437
Zeiss, A., 364
Zhang, H., 450–451
Zhang, Y., 450–451
Zhao, S., 357–358
Zilboorg, G., 29
Zilcha-Mano, S., 18, 198, 223
Zimmermann, J., 245–246
Zinman, B., 178–179
Zobel, I., 318, 319
Zoffness, R. J., 14t, 441
Zuckerman, E. L., 358–359
Zuellig, A. R., 231
Zuelling, A., 243
 Subject Index

abstraction, 479
acceptance. See Zen, DBT applications of
acceptance and commitment therapy (ACT), 134, 186–187
Achenbach System of Empirically Based Assessment, 347
Ackerman Institute for the Family, 465
action stage, 146, 163, 165, 166, 172
actual vs. desired outcome/situational analysis, 313, 316
addictive disorders, self-help effectiveness, 359–360, 362, 366. See also substance abuse treatment
ADDRESSING mnemonic, 327
ADHD, 442
affect, 90
After the Turn On, What?, 33
aged patients, 261–262, 333, 451
agoraphobia, 36
Aiglé Foundation, 437, 465
aikido, 272
Ajase complex, 452
ALAPSI, 466
Albany Anxiety Disorder Interview Schedule - IV (ADIS), 232
Alcoholics Anonymous (AA), 105–106, 359–360, 362, 366, 367
alcoholism, 177, 359, 362, 366
American Indian clients, 332
antidepressants, placebo effect and, 74
anxiety/depression
case studies, 219–222, 335
anxiety disorders
breathing exercises for, 76
cognitive therapy, 237
early cue detection, 235
extinction, 187, 191, 194
interventions, active, 187
multimodal therapy, 32
relaxation methods, 236
self-control desensitization, 236
self-help books, 364
self-monitoring, 235
stimulus control methods, 236
APA Code of Ethics, 150
APIRE PRN, 442
applied relaxation, 236
artificial intelligence in DBT, 279
assertiveness training, 90–92, 128
assimilative integration
assimilative psychodynamic model as, 11–12, 207
children’s therapy, 345–346
cognitive-behavior assimilative therapy as, 11–12, 229
history of integration, 11
interpersonal assimilative therapy, 11–12
movement, directions in, 482
systematic treatment selection as, 12, 141
traditional Chinese medicine/Western psychotherapy, 453–454
training/supervision, 383–384
assimilative psychodynamic model
applicability, 211
assessment/formulation, 209
as assimilative integration, 11–12, 207
case studies, 219–222
change processes, 212, 215
contraindications, 211, 214
diversity considerations, 218
exploratory work in, 212, 213, 215
intervention, , 209, 210, 215–216, 217–218, 221
methods/techniques, 213–214, 215–216
outcome research, 223
patient autonomy in, 218
patient’s resistance to, 217–218
patient success factors, 214, 216–217
relapse prevention, 218
therapeutic relationship, 214
three-tiered theory, 208–210
transference/countertransference, 215, 216, 217
attachment
CBT treatment of, 243–244
expectancy, self-fulfilling prophecies and, 196
focus on, in CBT, 229–230
GAD as problem in, 231
mother–child attunement, 197
mutual influence/mother–child attunement, 197
rational-emotive behavior therapy, 437
attachment-focused developmental psychotherapy, 346
Australian Centre for Integrative Studies, 450
Austrian Society of Integrative Therapy, 457
autonomy
in assimilative psychodynamic model, 218
MI + CBT, 287, 288, 289, 292, 296–297
self-liberation, 165
systematic treatment selection, 148–149
avoidance behavior extinction, 89
avoidance patterns, cyclical psychodynamic theory. See cyclical psychodynamic theory
avoidant personality disorders, 310
BASIC I.D.
assessment, 126–127
assessment, second-order, 128
change processes, 132
Becoming Orgasmic (Heiman/LoPiccolo), 364
behavioral chain analysis, 268, 269–270
Behavioral Psychotherapy (Fensterheim/Glazer), 38
Behavior Assessment System for Children, 3/e, 347
Behavior Therapy, 32–33, 39
Behavior Therapy and Beyond (Lazarus), 33
benefits of the status quo, 287, 294–296
Beyond Carl Rogers (Brazier), 45
bibliotherapy. See self-help materials
bidirectional influence, mother–child attunement, 197
binge eating disorder, 261
biosocial model, 263, 274
bipolar disorder, 261–262
borderline personality disorders, 41–42, 211, 245, 310
Boston Change Process Study Group, 197–198
breathing, diaphragmatic, 130, 236
breathing techniques, 76, 99–100, 296, 351
bridging, multimodal therapy, 129
Brief Relational Therapy (BRT), 245
British Association for Counseling and Psychotherapy (BACP), 459
British Journal of Psychotherapy Integration, 459
Buddhism, 449, 455, 456
bulimia nervosa, 261
bullying/violence, 178

Casebook of Eclectic Psychotherapy (Norcross), 40

case studies
adjustment disorder, 335
alcoholism, 105–106
anger management, 219–222
anxiety/depression, 219–222, 335
anxiety extinction, 191, 194
assimilative psychodynamic model, 219–222
borderline personality disorder, 275
breathing techniques, 99–100, 296
CBASP, 315
children’s therapy, 350
cognitive-behavior assimilative therapy, 241
contextual model, 78
cross-culturalism, 335
cyclical psychodynamic theory, 191, 194
depression, major, 315
dialectical behavior therapy, 275
divorce/couples therapy, 173
eclecticism, technical, 344
feedback informed treatment, 113, 115f, 117f
 GAD, 241, 293
heart transplant/loss of soul, 79
interpersonal/emotional processing, 241
major depressive disorder, 78
MI + CBT, 293
mindfulness practice, 99–100
multimodal therapy, 135
polysubstance abuse/depression, 151
religion/spirituality, 335
sensation, sensory complaints, 135
social support, 335
STAIRCaSE, 97
substance abuse, 113, 115f, 117f
sudden deterioration, 78
systematic desensitization, 191, 194
systematic treatment selection, 151
transtheoretical model, 173
catharsis, 329–330
CBASP
actual vs. desired outcome/situational analysis, 313, 316
applicability, 308, 310
assessment/formulation, 306
case studies, 315
change processes, 310
described, 303–304
disciplined personal involvement, 303, 304, 305, 312
diversity considerations, 315
dyadic safety, 303–304, 307, 314
historical origins, 305
IDE, 305, 307, 314, 317
Impact Message Inventory, 314
internal mechanisms in dysfunction, 307
interpersonal skill deficits, 312
interpersonal style assessment, 310, 314, 316
learning content, 305, 307
methods/techniques, 312
objective countertransference, 304–305
outcome research, 318–319
PDD diagnosis, 308, 309f
perceived functionality, 303–304, 306
reciprocal interaction, 306
remediation phase/situational analysis, 313
sessions required, 310–311
significant other, 309, 313, 314, 315–316, 317
situational analysis, 306, 307, 310, 312, 316–317
therapeutic relationship, 312
transference hypothesis, 309–310, 313, 315–316, 317
treatment goals, 307, 308f
Center for Collegiate Mental Health (CCMH), 441–442
Center for Scientific Psychological Development, 465–466
chain analysis, 268, 269–270
change processes
assimilative psychodynamic model, 212, 215
CBASP, 310
children’s therapy, 348
cognitive-behavior assimilative therapy, 233
contextual model, 71, 72f
cross-culturalism, 173, 329
dialectical behavior therapy, 272
exposure/avoidance, 146
feedback informed treatment, 111
history of integration, 31, 32, 34, 36, 41, 43
integrative approach to, 7–8, 11
MI + CBT, 285
multimodal therapy, 132
STAIRCaSE, 92
systematic treatment selection, 145, 479
transtheoretical model, 162, 172, 173
Child and Adolescent Needs and Strengths (CANS), 347
Child Outcome Rating Scale (CORS), 109
child parent relationship therapy, 345
children’s therapy. See also attachment
adoptive children, 346
affective change processes, 348
assessment/formulation, 346
assimilative integration, 345–346
background, 341–342
case studies, 350
change processes, 348
common factors approach, 346
development, treatment and, 341–342, 346, 347
diversity considerations, 350
history of integration, 47
integrated trauma treatment, 343
integrative therapies, 343–344
interpersonal change processes, 348
methods/techniques, 349
multiple causation model, 343, 346
outcome research, 352
parent–child interaction patterns, 345, 346–347
parent–child interaction therapy, 345
parent management therapy, 8
play therapy, 345, 346, 347, 348, 350
principles of, 342
systematic treatment selection, 344
therapeutic relationship, 349
transtheoretical model, 345
trauma-focused cognitive behavior therapy, 344–345
trauma-focused integrative play therapy, 344–345
treatment effects, 341
Child Session Rating Scale (CSRS), 109
Chilean Institute of Integrative Psychotherapy, 466
Chinese Taoist cognitive psychotherapy, 451
chronicity, 144, 145–146, 148, 151–152, 188
C-I-S-B firing order, 129
Client-Centered and Experiential Psychotherapy in the Nineties (Lietaer/Rombauts/VanBalen), 42
client-centered therapy, 215, 456
Client Resistance Code (CRC), 287
clients. See also therapeutic relationship
American Indian, 332
autonomy of, 287, 288, 289, 292, 296–297
expectations, creation of, 233
in-session language, 287
lying to therapist, 111
maladaptive patterns in relapse, 35
misconceptions, changing, 34–35
motivation, enhancing, 266
resistance, 285, 286, 287, 289, 291, 295–296, 297
self-regulation systems, 173
worldview, cross-culturalism awareness of, 333
Clinical Behavior Therapy (Goldfried/Davison), 35, 45
clinical feedback, 434. See also feedback informed treatment
clinical strategy/change principle focus, 11
clinical training. See training/supervision
cognitive-analytic therapy, 208, 459
cognitive behavioral analysis system of psychotherapy. See CBASP
cognitive behavioral play therapy, 345
cognitive-behavior assimilative therapy
applicability, 230
assessment/formulation, 232
as assimilative integration, 11–12, 229
background, 228–229
case studies, 241
change, principles of, 229
client expectations, creation of, 233
cognitive therapy, 237
continued testing with reality, 234, 237
corrective experiences, 234, 238–239, 241
diversity considerations, 241
emotional deepening via, 230, 240, 242
history of integration, 46, 231
interpersonal/emotional processing, 231–232, 233–234, 235, 237–238, 240, 241, 243, 245
interpersonal focus of, 229, 233
interpersonal therapy within, 231
methods/techniques, 235
mindfulness in, 239
modeling/problem-solving skills, 234
new perspective provision, 234
outcome research, 243
schema concept in, 230, 239
 stimulus control methods, 236
therapeutic relationship, 234
worry as avoidance of affect, 231
cognitive-behavior therapy. See also MI + CBT; multimodal therapy
corrective experiences, encouraging, 89
credible explanations benefits in, 76
DBT vs., clinical trial, 278
history of integration, 36, 37, 42–43, 45, 46, 47
insight emphasis, 186
Internet-based, 367
interpersonal theory in, 42
outcomes research, 223
panic disorder, 76
practices effectiveness, 436–437
prevalence of integration in, 13, 15
psychotropic medications, 41
rational-emotive behavior therapy, 437
cognitive bibliotherapy, 359. See also self-help materials
cognitive-narrative therapy, 21–22, 134, 143, 479
Cognitive Therapy and Research, 37
commonalities/change processes. See change processes
common factors/contextual model, 69, 71, 76
community center PRNs, 440
complementary role utilization, 334
Complexity of the Self (Guidano), 40
Comprehensive Handbook of Psychotherapy Integration (Stricker/Gold), 44
conformity as cultural value, 327–328
Confucianism, 450–451, 454, 455
conjoint/couples therapy
assimilative psychodynamic model, 211
cyclical psychodynamic theory, 190–191
dialectical behavior therapy case study, 275
divorce case studies, 173
history of integration, 36
prevalence of integration in, 15
substance abuse case studies, 113, 115f, 117f
therapist effects in, 8
transtheoretical model case studies, 173
web/mobile apps, 361
Connors Comprehensive Rating Scales, 347
consciousness-raising, 329
consequence, 90, 91, 100
contemplation stage, 146, 163, 164, 164t, 165, 166, 170, 171–172
Contemporary Schools of Psychology (Woodworth), 30
context-responsive psychotherapy integration (CRPI), 51–52, 101–102, 481
contextual model. See also therapeutic relationship
applicability, 77
assessment/case formulation, 77
case studies, 78
change processes, 71, 72f
 common factors, 69, 71, 76
development/refinement of, 80–81
diversity considerations, 78
expectation, creation of, 74
integrative approach, 70
methods/techniques, 78
outcome research, 80
psychotherapy outcomes meta-analysis, 70–71
specific ingredients, 70–71, 75
therapeutic relationship roles in, 71, 73, 80
continuous professional improvement, 108
Control Your Depression (Lewinsohn et al), 364
Converging Themes in Psychotherapy (Goldfried), 38
Coping with Panic (Clum), 364
corrective experiences
CBT, encouraging via, 94, 98, 99
cognitive-behavior assimilative therapy, 234, 238–239, 241
fear-related activities, 36–37
MI + CBT, 285
STAIRCaSE, 94, 98, 99
unassertiveness, 90–92
Counseling the Culturally Different (Sue), 332
counterconditioning, 165
countertransference, 41–42
Courage to Heal, The (Bass/Davis), 365
crisis intervention, 265, 277
cross-culturalism
applicability, 328
assessment/formulation, 327
assimilative psychodynamic model, 218
case studies, 335
CBASP, 315
change processes, 173, 329
children’s therapy, 350
cognitive-behavior assimilative therapy, 241
contextual model, 78
cultural barriers, 327
cultural competency, 326–327
cultural humility, 172
cultural norms/belief systems, 173
cyclical psychodynamic theory, 191
dialectical behavior therapy, 274
evidence-based treatments, cultural adaptations of, 332, 336–337
feedback informed treatment, 112
feminist therapy, 329
gender-aware therapy, 329
group-specific recommendations, 332
history of integration, 42, 43, 46–47
identity development, 326, 327, 334
ideographic approaches, 331–332, 333
 individualistic vs. collectivist cultures, 172
as integrative approach, 325
LGBT identity, 328, 329
methods/techniques, 331
MI + CBT, 293
multimodal therapy, 135
multitheoretical psychotherapy, 326f, 326
nomothetic approaches, 331, 336–337
outcome research, 336
people with disabilities identity, 328, 330
psychotherapy integration of, 12–13
racial identity, 326, 327–328
racism/discrimination, 329
self-help materials, 365–366
societal structures/values, responding to, 334
STAIRCaSE, 96
systematic treatment selection, 150, 153
therapeutic relationship, 326–327, 328–329, 330, 333
transgender-affirming therapy, 329
transtheoretical model, 172
cultural adaptation, 452
Cultural Assessment of Risk for Suicide, 151
cultural factors. See cross-culturalism
culture of feedback, 111
cyclical psychodynamic theory
accomplices identification, 189
anxiety theory/Freud, 187
applicability, 190, 199, 208
assessment/formulation, 188
case studies, 191, 194
change as synergistic process, 185
diversity considerations, 191
early experiences emphasis, 186
experiential/emotion-focused approaches in, 198–199
exposure, 185
insight emphasis, 186
as integrative approach, 185
internal structures, 184–185, 193
interpretations, 185, 194
interventions, , 187, 195
patient goals in, 194
principles of, 184–185
procedural dimension in, 198–199
processes, developmental studies of, 197
research foundations, 195
schemas/cognitive processes, 184–185
self-fulfilling prophecy, 196
social skills role, 187
strengths emphasis, 190
therapeutic relationship, 191
 therapist’s use of language in, 195, 199
vicious circle identification, 189, 194–195

Dang-ki, 453–454
deliberate practice, 481
demoralization, 72, 92
dependent personality disorders, 310
depression
acceptance and commitment therapy, 134, 186–187
APIRE PRN, 442
case studies, 78, 315
CBT of, 244–245
dialectical behavior therapy, 261
major depressive disorder, 78, 178
pros/cons of changing, 166
transtheoretical model, 178
desensitization. See EMDR; extinction; systematic desensitization
deterioration problem, 435
developmentally based psychotherapy, 344
Devereaux Behavior Rating Scale, 347
dialectical behavior therapy (DBT)
applicability, 261
assessment, 262
aversive contingencies, 270
behavioral chain analysis, 268, 269–270
biosocial model, 263, 274
case formulation, 263
case studies, 275
change principle, 260, 272
client motivation, enhancing, 266
consultation teams, 267
convergences in, 186–187
described, 257–258
development of, 258, 279
dialectical strategies, 272
diversity considerations, 274
emotional vulnerability/regulation, 263–264
environment, structuring, 266
fallibility agreement, 267
generalization, ensuring, 266
history of integration, 41–42
as integrative approach, 245
invalidating environment, 263–264
methods/techniques, 268
opposition principle, 260
outcome research, 277, 279
principles of, 259
problem-solving strategies, 268
solution analysis, 269
stylistic strategies, 271
 systemic dysregulation, 259–260
target hierarchy, 262
therapeutic relationship, 258, 261, 273
therapy-interfering behaviors, 274
training, 279–280
traumatic invalidation, 264–265
treatment tasks, 265
validation strategies, 270
diaphragmatic breathing, 236
differential efficacy as challenge in integration, 21
differential referrals, 378
differential therapeutics, 348–349, 393
direct experiential learning, 198–199
directive behavior, 89
disciplined personal involvement, 303, 304, 305, 312
dissonance in cultural values, 328
diversity considerations. See cross-culturalism
divorce case studies, 173
Dodo Bird verdict, 71
dose–effect association, 435
double depression, 310–311
dramatic relief, 164
Drinker’s Check-Up, 366
drug abuse. See substance abuse treatment
Dysfunctional Attitude Scale, 232–233

eating disordered patients, 7, 131, 132, 134, 261, 277

eclecticism
concepts, terminology, 17–18
history of integration, 45
humanistic, 454
integration vs., 10t, 41, 127
as integrative, 3–4, 7, 9, 10
psychotherapists using, 15
therapeutic activities, 18
eclecticism, technical
case studies, 344
described, 344
four paths, 383
history of integration, 32, 35–36, 42, 46
Eclecticism and Integration in Counseling and Psychotherapy (Dryden/Norcross), 42
Eclectic Psychotherapy (Beutler), 38
ecological systems theory, 333
ecosystemic play therapy, 345
elderly patients, 261–262, 333, 451
elicitation phase/situational analysis, 313
EMDR, 134, 451, 479
emotional arousal, 164
emotional deepening, 230, 240, 242
emotion-focused therapy, 451
Emotion in Psychotherapy (Greenberg/Safran), 40
emotion regulation
cross-culturalism, 173
DBT applications, 263–264
systemic dysregulation, 259–260
transtheoretical model, 173
empathy
patient’s inability to generate, 311
in therapeutic relationship, 73
empirically supported treatment, 46, 50, 119, 433
environmental reevaluation, 164
evidence-based apps, 361
Evidence-Based Psychotherapy Relationships and Responsiveness, 50–51
evidence-based treatments, 332, 478–479
exhaustion theory of integration, 6
expectancy, self-fulfilling prophecies and, 196
expectations
client’s, regarding therapy, 133
creation of, 74, 233
positive, fostering, 92
STAIRCaSE, 92
experiential family therapy, 271–272
exposure-based cognitive therapy (EBCT), 245–246, 479
extending technique, 272
externalizers, 150
extinction
anxiety disorders, 187
avoidance behavior, 89
case studies, 191, 194
eye movement desensitization and reprocessing. See EMDR

family therapy, 44, 47, 271–272

fearful behavior reduction, 89
fear reduction. See extinction; systematic desensitization
fear-related activities, corrective experiences, 36–37
feedback informed treatment. See also Outcome Rating Scale (ORS); Session Rating Scale (SRS)
adolescents, 109, 110
applicability, 110
assessment/formulation, 108
background, 105–106, 119
case studies, 113, 115f, 117f
change patterns, 112
change processes, 111
clinical cutoffs, 110
computerized systems, 109–110
core competencies, 108
described, 107
diversity considerations, 112
implementation barriers, 118
as integrative approach, 106
 methods/techniques, 111
outcome research, 117
principles of, 107
therapeutic alliance as predictive of outcome, 107
therapist factors in outcomes, 119
therapy relationship, 111
feedback systems, 478
Feeling Good (Burns), 364
Feng-shui, 453–454
firing order tracking, 129
FIT. See feedback informed treatment
flexibly sequential play therapy, 345
focused expressive psychotherapy, 153
focusing technique, Wolfe’s, 46
From Cognitive-Behavior Therapy to Psychotherapy Integration (Goldfried), 46
functional impairment, 51, 143, 144, 145–146, 148, 151–152, 333, 369, 481

gay identity, 328, 329

generalized anxiety disorders (GAD). See anxiety disorders; cognitive-behavior assimilative therapy;
MI + CBT
gestalt therapists, integration among, 20
group designs, 33, 37–38, 138
group session rating scale (GSRS), 109
guided imagery, 236

Handbook of Psychotherapy Integration 1e (Norcross/Goldfried), 44

health maintenance organization (HMO) study, 7
helpful/hindering events studies, 439–440
helplessness, 97, 312–313
history of integration
abstraction in comparative analysis, 36–37
action-/insight-oriented approaches, 37
behavior/psychodynamic approaches, 30, 32–35, 40, 45–46
biological/psychological approaches, 38–39
children’s therapy, 47
client-centered therapy, 34, 42
client misconceptions, changing, 34–35
client’s maladaptive patterns in relapse, 35
cognitive procedures development, 32–33, 36
cognitive social psychology, 38
collaboration in, 50
common change processes, 31, 32, 34, 36, 41, 43
conceptual developments, 51
consensus/convergence in, 29–30
cross-culturalism, 42, 43, 46–47
desegregation research, 43
dialectical behavior therapy, 41–42
eclecticism, technical, 32, 35–36, 42, 46
empiricism, 9, 12, 30–31, 32, 33, 35, 37, 41, 44–45
gestalt therapy methods, 35, 37, 46
global interest in, 40, 48, 52
 goals of, 45, 47
group experiences, 33, 37–38
learning theory, 30, 31
modeling procedures, 30
multimodal therapy, 29, 32, 35–36, 37, 43
1960s, 31
1970s, 32
1980s, 36
1990s, 42
outcomes research, 47–48
overview, 28–29
performance-based methods, 34
professional networking, 38, 41, 48
psychoanalysis/Pavlovian conditioning similarities, 29
psychotropic medications, 41
rational-emotive behavior therapy, 46
science–practice gulf, 50
single orientations, limitations of, 31–32, 40, 46
strategic family therapy, 44, 47
systematic desensitization treatment, 32–33
theoretical hybrids, 38, 44
theoretical language, 40–41, 45, 47, 476
therapeutic rapprochement, 34
therapeutic relationship, 33, 34–35, 41–42, 50–51
therapy process, 41
training, 40, 43, 46
21st century, 49
universal factors in, 31, 42
History of Psychotherapy: A Century of Change (Freedheim), 43
HIV/AIDs, 455
home theory, 346
How and Why Are Some Therapists Better Than Others? (Castonguay/Hill), 51
Humana Center, 467
Humanism and Behaviorism (Wandersman, Poppen, & Ricks), 35
humanistic treatment, 77–78

I-C-B-S firing order, 129

identity development, 326, 327, 334, 335. See also schemas
disequilibrium, sources of, 390
LGBT, 328, 329
ideographic approaches, 331–332, 333
imagery, guided, 236
Impact Message Inventory, 314
implementation competency, 108
InnerLife STS, 393–394
In Session, 49
Insight and Action (Wachtel), 40
Insight in Psychotherapy (Castonguay/Hill), 51
Institute of Psychotherapy Integration, 452
integration. See history of integration; psychotherapy integration
Integration in Psychotherapy Congress, 465–466
Integration of Psychotherapies, The (Mahrer), 42
integrative awareness in cultural values, 328
integrative gestalt therapy (Austria), 457
integrative multicultural psychotherapy. See cross-culturalism
Integrative Problem-Centered Therapy (Pinsof), 46
Integrative Psychiatry, 49
Integrative System of Psychotherapy (Instep), 457
integrative theory, directions in, 475
Integrative Therapist, The, 49
intention, 90
Interface Between the Psychodynamic and Behavioral Therapies, The (Marmor/Woods), 37
internal working models, 197
International Journal of Eclectic Psychotherapy, 39–40
international therapy programs, 15, 448–449, 468–469
Interpersonal Discrimination Exercise (IDE), 305, 307, 314, 317
interpersonal/emotional processing in CBT, 231–232, 233–234, 235, 237–238, 240, 241, 243, 245
Interpersonal Process in Cognitive Therapy (Safran/Segal), 42
introspection in cultural values, 328
Inventory of Interpersonal Problems, 232–233
irreverent communication, 271–272

Journal of Integrative and Eclectic Psychotherapy, 39–41

Journal of Psychotherapy Integration, 4, 20, 43, 44, 47, 49, 50, 125–126, 208, 459, 466
Journal of Unified Psychotherapy and Clinical Science, 51

Kansai Institute of Eclectic Psychotherapy (KIEP), 452

language, 20–21, 40–41, 45, 47, 476

Lausanne University, 462
learning theory, 30, 31
Leeds Alliance in Supervision Scale, 394
Level of Attribution and Change (LAC) Scale, 169–170
LGBT identity, 328, 329
liberation of consciousness, 329
liberation psychology, 330
Linehan Risk Assessment and Management Protocol, 265
listening. See therapeutic relationship
live observation, 391

Magna Charta Universitatum, 399

maintenance stage, 146, 163, 165, 166, 170, 172
major depressive disorder, 78, 178
mandala drawing, 456
marital therapy. See conjoint/couples therapy
Marital Therapy (Segraves), 38
massive open online interventions (MOOIs), 369
Mastery of Your Anxiety and Panic (Craske/Barlow), 364
maximum impact strategy, 167, 168t
measurement/reporting competency, 108
meditation techniques, 236
mental health disorders, 178. See also specific disorders
meta-messages, 199
metaphor technique, 272
MI + CBT
action behaviors implementation, 296–297
ambivalence, working with, 289, 291, 295–296
applicability, 288
assessment/formulation, 286, 298
case studies, 293
change processes, 285
client autonomy, 287, 288, 289, 292, 296–297
client resistance, 285, 286, 287, 289, 291, 295–296, 297
corrective experiences, 285
described, 284–286
diversity considerations, 293
evocation, 291
homework noncompliance, 292
methods/techniques, 291
MI spirit, 286, 288, 292
outcome research, 297
responsive behaviors, 285–286
suggestion/psychoeducation integration, 292
therapeutic relationship, 290
training, 298–299
microaggressions, 97, 330–331
microinvalidations, 331
mindfulness, 457
DBT applications of, 258–259, 266, 269–270, 274
practice, case study, 99–100
mindfulness-based cognitive therapy (MBCT), 318
mindfulness based stress management (MBSR), 134
Minority Stress Scale, 151
Misunderstandings of the Self (Raimy), 34–35
mobile apps, 358, 360, 361–362, 365, 366, 368–369
Modality Profile, 128, 131, 136
Modes and Morals of Psychotherapy, The (London), 31
mood disorders, 261
Morita therapy, 451–452
mother–child attunement, 197
motivational interviewing, 70, 93, 245. See also MI + CBT
Motivational Interviewing Skills Code (MISC), 287
Multimodal Behavior Therapy (Lazarus), 35–36
Multimodal Life History Inventory (MLHI), 128, 133
multimodal therapy
affective reactions, 127, 135, 136
applicability, 131, 344
assessment/formulation, 127
BASIC I.D. assessment, 126–127, 128
biological health, 128, 130–131, 135–136
bridging, 129
 case studies, 135
change processes, 132
cognitions, 127–128, 135
diversity considerations, 135
firing order tracking, 129
history of integration, 29, 32, 35–36, 37, 43, 126, 458
images, 127, 130, 135
as integrative approach, 9, 125–126
interpersonal interactions, 128, 130–131, 135
methods/techniques, 133
MLHI, 128, 133
Modality Profile, 128, 131, 136
outcome research, 137
outcomes, factors affecting, 128
problems, assigning to modality, 131
relapse, 137–138
sensation, sensory complaints, 127, 129, 130, 135
SPI, 130
spirituality, 131
theoretical integration vs. eclecticism, 127
therapeutic relationship, 133, 138
training in, 388
unimodal therapy vs., 127
multiple causation model, 343, 346
Multitheoretical List of Therapeutic Intervention, 440
multitheoretical psychotherapy, 326f, 326. See also cross-culturalism
mutual influence/mother–child attunement, 197

Naikan therapy, 451–452

narcissistic disorders, 211
Narcotics Anonymous (NA), 278, 362
narrative therapy, 21–22, 134, 143, 479
National Drug Abuse Treatment Clinical Trials Network, 442–443
nefazodone, 318
New Sex Therapy, The (Kaplan), 34
NIDA PRN, 442–443
nomothetic approaches, 331, 336–337
not-thinking, 187

obsessive-compulsive disorder, 34, 310

older patients, 261–262, 333, 451
online support groups, 360, 362
open-hidden paradigm, 74
Opening Up by Writing It Down (Pennebaker), 364
oppositional behavior, 148–149, 259, 272, 392, 398–399
organic disorders, 211
organismic-developmental theory, 18
OurRelationship app, 361
outcome-informed clinical work. See evidence-based treatments; practice-oriented research
outcome monitoring, 434, 439
Outcome Questionnaire 45 (OQ-45), 109, 393–394, 478
Outcome Rating Scale (ORS)
change patterns, 112
clinical cutoffs, 110
described, 108–109
diversity considerations, 112
effective practitioners, 111
frequency of administration, 112
Overcoming Binge Eating (Fairburn), 364
ownership of ideas, 20

panic attacks
breathing techniques, 76, 99–100
firing order tracking, 129–130
self-help books, 364
self-help materials for, 363
Paradigmatic Complementarity Lab, 460
parent–child interaction therapy, 345, 364
Parent Effectiveness Training (Gordon), 364
parent management therapy, 8
Parkinson’s disease, 74
patient-focused research, 434
Patient Performance Rating Form (PPRF), 307
Patient’s Manual for CBASP (McCullough), 310
pediatrics. See children’s therapy
people with disabilities identity, 328, 330
persistent depressive disorder, dysthymia (PDD). See CBASP
personality, integrative approaches to, 45
Personality and Psychotherapy (Dollard/Miller), 30
personality disorders, 211, 214, 245, 261, 310
personality-in-context dynamics
assimilative psychodynamic model, 187
cyclical psychodynamic theory, 188
personal therapeutic approach (Czech Republic), 457
Persuasion and Healing (Frank), 11, 31, 43
placebo effect, 74
playing devil’s advocate technique, 272
play therapy, 345, 346, 347, 348, 350
pluralistic psychotherapy, 12, 459, 476
Positive Activity Jackpot, 365
posttraumatic stress disorder. See PTSD
power dimension assessment, 314–315
Practice of Multimodal Therapy, The (Lazarus), 42
practice-oriented research
background, 432–433, 478
community center PRNs, 440
definitions, 433
history of integration, 50
practice–research network, 438
practitioner/researcher partnerships, 443
private practice PRNs, 439
 professional organizations PRNs, 442
training clinic PRNs, 438
types of, 434
university counseling center PRNs, 441
Practice & Research: Advancing Collaboration (PRAC), 440–441
practice–research networks (PRNs)
community center, 440
described, 438
private practice, 439
professional organizations, 442
training clinic, 438
practice effectiveness studies, 436–437
Practice Wise, 346
pragmatic case study method, 480
Pragmatic Psychotherapy (Driscoll), 39
precontemplation stage, 146, 163–164, 164t, 165, 166
preparation stage, 146, 147, 163, 164
prescriptive matching benefits, 9–10
principle-based integration, 101–102
private practice PRNs, 439
problem-solving strategies
aversive contingencies, 270
behavioral chain analysis, 268, 269–270
cognitive-behavior assimilative therapy, 234
dialectical behavior therapy, 268
solution analysis, 269
validation strategies, 270
Processes of Change Scales, 169
professional organizations PRNs, 442
progressive muscle relaxation, 236
Project MATCH, 177, 359–360
psychiatry, history of integration, 46
Psychoanalysis, Behavior Therapy, and the Relational World (Wachtel), 35, 47–48
psychoanalytic-behavioral-relational integration, 345
Psychoanalytic Therapy and Behavior Therapy: Is Integration Possible? (Arkowitz/Messer), 39
psychodrama therapists, integration among, 20
psychodynamic-interpersonal therapy, 18, 51, 229, 436–437, 459
psychological treatments, psychotherapy vs., 70
psychopathology, cognitive-affective balance in, 45
Psychotherapedia, 51
Psychotherapy: A Cognitive Integration of Theory and Practice (Ryle), 38
Psychotherapy: An Eclectic Approach (Garfield), 37
Psychotherapy and Counseling Federation of Australia, 450
psychotherapy integration
assimilative integration, 11
common factors/change processes role, 7–8, 11
consensus/convergence in, 4, 29–30, 474–475
developmental stages of, 18
eclecticism (see eclecticism)
frequency trends in, 5f, 5
 goal of integration, 4, 22
integrative practices, 16, 18t
integrative psychotherapy/psychotherapists, 5–6, 14–15
maturation of, 4
methodological efficacy, 6–7
movement, directions in, 482
obstacles to, 20
parameters, defining, 12
pre-paradigmatic crisis, 3
prevalence of, 13, 14t
professional network development in, 8
pure-form therapies in, 8, 19
research-based treatments in, 8
routes to, 8
short-term therapy, 7
single model inadequacies, 6
specialized clinics, 7
theoretical integration, 10, 10t, 127, 345, 383–384
theoretical orientation combinations in, 16–18, 18t
therapy effectiveness/outcomes, 7–8, 9–10, 21
timing of, 5f, 5
treatment manuals, 7, 18, 46
treatment selection, 479–480
Psychotherapy Relationships that Work (Norcross), 50–51, 80
psychotic disorders, 211
PTSD
APIRE PRN, 442
dialectical behavior therapy, 261
self-help materials, 361, 362, 368–369
treatment, contextual model of, 75
treatment selection, 479
PTSD Coach, 361, 362

Racial/Cultural Identity Development model, 327–328

racial identity, 326, 327–328
Rapprochement and Integration in Psychotherapy (LeCompte/Castonguay), 40
rational-emotive therapy, 271–272, 437
reactance, 148–149
reality testing, ongoing, 95, 100
reality therapy, 456
reciprocal communication, 271
reciprocal inhibition principle, 30
reciprocity, dyadic, 197
referrals, differential, 378
reinforcement management, 165
rejection sensitivity, 197
relationships of choice, 133
relaxation methods, 236
religion/spirituality, 131, 335
remediation phase/situational analysis, 313
repression, 187
residential treatment effectiveness studies, 437
resistance
by clients, 285, 286, 287, 289, 291, 295–296, 297
systematic treatment selection, 144–145, 146, 148
Resistance (Wachtel), 38
resistance/immersion in cultural values, 328
response, 90, 91, 100
response-produced cues, 187
responsiveness, 482
role induction, 92–93
routine outcome monitoring, 106, 478

SAMHSA National Registry of Evidence-Based Programs and Practices, 117

satitherapy, 457
schemas
in cognitive-behavior assimilative therapy, 230, 239
in cyclical psychodynamic theory, 184–185
therapy, 245, 457, 478–479
schizophrenia, 211, 442
selective inattention, 187
self-control desensitization, 234, 236
self-evaluation stage, 90, 91, 95, 100, 164
self-evaluative split, 240
self-fulfilling prophecy, 196
self-help materials
benefits of, 362
books, 364
client experiences, assessment of, 363
common concerns, 366
defined, 358
diversity considerations, 365–366
effectiveness of, 359
films, 362
groups, 359–360, 362, 364
guided self-help, 358
harm, possibility of, 367
life transitions, 366
MOOIs, 369
online support groups, 360, 362
outcome prediction, 369
prevalence of, 357, 358t
progress monitoring, 368
psychotherapy integration into, 12–13, 357, 360, 368–369
research-supported, 364
resources, recommending, 358, 358t, 362, 364, 365
security/privacy issues, 367–368
stages of change, 366
therapist support of, 361, 364
training, 358–359
 treatment/medication combined with, 367
treatment philosophy incompatibility, 367
types of, 361
waiting periods/maintenance, 366
web/mobile apps, 358, 360, 361–362, 365, 366, 367–369
Self-Help That Works (Norcross), 365
self-liberation, 165. See also autonomy; liberation of consciousness
self-psychology, 215
services effectiveness studies, 436–437, 439
Session Rating Scale (SRS), 393–394
alliance measures, 110
change patterns, 112
clinical cutoffs, 110
diversity considerations, 112
effective practitioners, 111
frequently of administration, 112
sexual abuse, self-help materials, 365
Sheffield Psychotherapy Project, 458
shifting levels strategy, 167, 168t
S-I-C-B firing order, 129
Singapore, 453
situation, 90
situational analysis, 306, 307, 310, 312, 313, 316–317
Skilled Helper model, 458
Skills Training Manual for Treating Borderline Personality Disorder (Linehan), 364
smoking cessation, 165, 177–178, 359
social healing practices, 71
social liberation/social justice, 330
social phobia, social-evaluative fears, 231
social skills role, 187
Society for the Exploration of Psychotherapy Integration (SEPI), 4, 8, 13, 39, 43, 47, 48, 125–126,
207–208, 457, 459, 464, 468, 477
Society of Psychotherapy Research (SPR), 14–15, 43
solution analysis, 269
spirituality/religion, 131, 335
stages of change
assessment/formulation, 169
self-help materials, 366
systematic treatment selection, 146–147, 150, 151
therapeutic relationship, 171
transtheoretical model, 161–162, 163, 164t, 476, 480–481
Stages of Change Questionnaire, 169
STAIRCaSE
applicability, 92
assessment/formulation, 89, 94
case studies, 97
change processes, 92
corrective experiences, encouraging, 94, 98, 99
diversity considerations, 96
hope, fostering, 92, 97
 as integrative approach, 88
motivation, fostering, 92, 97
outcome research, 100
patient awareness/insight, increasing, 94, 99, 100
positive expectations, fostering, 92, 97
principles of, 89
reality testing, ongoing, 95, 100
representative techniques, 92
therapeutic alliance facilitation, 93, 97
therapy relationship, 96
status quo, benefits of, 287, 294–296
stepped care, 368
stimulus control, 165
Strategies for Change (Lindquist), 397
Structural Profile Inventory (SPI), 130
Structure of Individual Psychotherapy, The (Beitman), 40
STS. See systematic treatment selection
STS/innerlife, 143, 151
substance abuse treatment
assimilative psychodynamic psychotherapy, 211
conjoint/couples therapy case studies, 115f
DBT, 261, 278
NIDA PRN, 442–443
patient-focused research, 435
self-help materials, 362, 366, 367
stages/processes of change studies, 177
suicide crisis intervention, 265
supervision. See training/supervision
Supervisory Alliance Inventory (SWAI), 394
syncretism, 9
systematic desensitization
case studies, 191, 194
cognitive-behavior assimilative therapy, 236
history of integration, 32–33
systematic treatment selection
applicability, 143, 344
assessment/formulation, 142
as assimilative integration, 12, 141
cardinal assumptions, 142
case studies, 151
challenges in integration, 21
change processes, 145
coping styles, 144, 145, 146, 149, 151
diversity considerations, 150, 153
as eclecticism, 9
efficacy of, 154
externalization, 150
functional impairment, 143, 144, 148
history of integration, 51
internalization, 149–150
 methods/techniques, 148, 154–155
outcome research, 153
patient’s emotional distress, 146
reactance, 148–149
readiness, 144, 145, 146, 150
resistance, 144–145, 146, 148
stages of change, 146–147, 150, 151
therapeutic relationship, 143–144, 147
training in, 154, 155, 384–385, 393
treatment fit, 143, 151
treatment intensity, 148, 152
validation of, 154
Systematic Treatment Selection-Clinician Rating Form (STS-CRF), 142–143
Systems of Psychotherapy: A Transtheoretical Analysis (Prochaska/Norcross), 161

Taoism, 450–451, 455

technical eclecticism. See eclecticism, technical
termination, 146
theoretical integration, 10, 10t, 127, 345, 383–384
theoretical language, 40–41, 45, 47, 476
therapeutic relationship. See also clients.
alliance as predictive of outcome, 107, 290
alliance facilitation, 93, 96, 97, 211, 219
alliance ruptures in, 93–94, 97, 147–148, 235, 239, 244, 290, 331
assimilative psychodynamic model, 214
CBASP, 312
children’s therapy, 349
client’s lying to therapist, 111
client’s problem focus, 76
cognitive-behavior assimilative therapy, 234
complementary role utilization, 334
contextual model, 71, 80
corrective experiences, encouraging, 94, 98, 99
cross-culturalism, 326–327, 328–329, 330, 333
cultural competency, 326–327, 336–337
culturally sensitive, 333
cyclical psychodynamic theory, 191
dialectical behavior therapy, 258, 261, 273
disarming technique, 239
early experiences emphasis, 186
empathy in, 73
expectation, creation of, 74
feedback informed treatment, 111
focus on, in CBT, 229–230
history of integration, 33, 34–35, 41–42, 50–51
information processing in, 72–73
insight emphasis, 186
integrative practitioners in, 477
interpersonal skills in, 81
invalidation, perceived, 258
 as mediator of change, 96
meta-communication, 238–239
MI + CBT, 290
multimodal therapy, 133, 138
outcome/alliance correlations, 75
outcomes, therapeutic ritual in, 76
practice-based research, 435
realistic perceptions in, 73
reality testing, ongoing, 95, 100
real relationship, 71, 73, 77–78, 80, 96
responsiveness, 482
societal structures/values, responding to, 334
specific ingredients, 75
stages of change, 171
strengths emphasis, 190
systematic treatment selection, 143–144, 147
therapeutic styles, 37
therapist effectiveness, 482
therapists, integration among, 20
therapists effects, 8, 119, 133, 215, 244, 290–291, 436–437
therapy-interfering behaviors, 274
transference-free genuine relationship, 73
transtheoretical model, 163, 168–169, 171
trust/attachment in, 72, 73, 79, 93, 330
Theravada Buddhism, 455
thought, 90, 95
time-limited dynamic psychotherapy, 211
training clinic PRNs, 438
training/supervision
assimilative integration, 383–384
as challenge in integration, 20
common factors/processes, 384
competency as goal, 399
context-responsive integration, 481
cultural identities in, 392
deliberate practice, 382, 481
dialectical behavior therapy, 279–280
differential referrals, 378
discordant supervision relationships, 394
disruptive innovations, 396–397
feedback monitoring systems, 393
four paths model, 383
history of integration, 40, 43, 46, 377–378
IICP College case study, 385
individualized supervision plan, 391
integrative, 378, 398–399
integrative, directions in, 480
integrative child therapy, 352–353
integrative psychotherapy, 380, 386
integrative supervision, 389, 390–391
 integrative training sequence, 381
interpersonal skills, 381
MI + CBT, 298–299
migration influences on, 469
models, 383
modules in, 398–399
in multimodal therapy, 388
organizational context of, 396
personal therapy, 387
pluralistic training, 385, 398
practica/clinical work, 382, 396
practice-based research, 437
pragmatic flexibility modeling, 394
principle-based, 480–481
principle-based integration, 101–102
professional certification, 387
reflective practice, 382
research training, 387
scientific orientation in, 389
self-help materials, 358–359
supervisor behaviors affecting outcomes, 396
syllabi samples, 382
systematic treatment selection, 384–385, 393
in systematic treatment selection, 154, 155
systems exploration, 381
technology in, 481
theoretical integration, 383–384
trainees’ biases/anxieties, 389
transdiagnostic adaptations, 9–10
transference, 37, 38, 197
transference-free genuine relationship, 73
transference hypothesis, 309–310, 313, 315–316, 317
transtheoretical model
applicability, 170
assessment/formulation, 168
case studies, 173
change, levels of, 166, 169
change processes, 162, 172, 173
change processes assessment tools, 169–170
client consciousness raising, 163
client self-regulation systems, 173
contraindications, 170
diversity considerations, 172
expert systems in, 177–178
goal of therapy, 170–171
history of integration, 36, 51
as integrative approach, 162
key level strategy, 167, 168t
maximum impact strategy, 167, 168t
outcome research, 177
 patient motivation in, 92
relapse, predictive factors, 170–171
shifting levels strategy, 167, 168t
stage-matching, 21, 171
stages of change, 161–162, 163, 164t, 476, 480–481
stepped care approach, 179
therapeutic relationship, 163, 168–169, 171
TTM-tailored interventions, 178–179
trauma disorder therapy, therapist effects on, 8, 479–480
trauma-focused cognitive behavior therapy, 344–345
trauma-focused integrative play therapy, 344–345
traumatic invalidation, 264–265
treatment manuals, 7, 18, 46
treatment selection, 384–385, 393
12-step groups, 364
two-chair technique, 99, 240, 242, 335–336
Two-Way Bridge initiative, 50, 433, 477–478

unassertiveness, 90–92
unconscious incompetence, 94, 95
unfinished business markers, 240
unified psychotherapy, 10, 476–477
Unified Psychotherapy Project, 51
uniformity myth, 13
university counseling center PRNs, 441
URICA questionnaire, 169

validation strategies, 270

Vanderbilt II project, 387
vicious circle identification, 189, 194–195
videotape, 7, 18, 46, 391
Virtual Hope Box, 361

web/mobile apps, 358, 360, 361–362, 365, 366, 367–369

What Makes Behavior Change Possible? (Burton), 35
worldview, client’s awareness of, 333
Worry Outcome Diary, 237

Young Child Outcome Rating Scale (YCORS), 109

Young Child Session Rating Scale (YCSRS), 109
Your Perfect Right (Alberti/Emmons), 364

zeitgeist, 28, 162

Zen, DBT applications of, 258–259, 260–261, 263, 271–272, 273