Psychiatric Annals

Integrative Psychotherapy 

The Integrative Trend in Psychotherapy in Historical Context

Perry London, PhD; Mary Palmer

Abstract

A great change of mood and style has come over the practitioners of different psychotherapies. It is barely one generation since "eclecticism" rose in status from a near dirty word to one of the most prominent of avowed psychotherapy orientations.1 Some advocates yearn, moreover, to go beyond merely choosing "the best" among treatment techniques, and to develop a true integration of them, ie, a conceptual continuity across theories and techniques. This has not yet happened, nor have its proponents done much more than show that there are common ingrethents of language, theory, and method across diverse therapies. But there is some convergence of techniques in the work of many therapists, for whom pragmatism in practice has replaced purism in theory. If this trend continues, there likely will be serious efforts at integration in the near future.

This article describes the historical sequence that gave rise to this trend and discusses some of its implications.

THE PREHISTORY OF PSYCHOTHERAPY INTEGRATION

Efforts to integrate psychotherapy began as early as 1932, fully half the lifespan of modern psychotherapy, dated from Breuer and Freud. At both clinical and theoretical levels, the arguments for integration were about as good then as they are now. At the 1932 meeting of the American Psychiatric Association, according to Goldfried and Padawer,2 Thomas French3 presented a paper that attempted to reconcile Freud and Pavlov, and the question was debated by Adolph Meyer, A. Myerson, and Gregory Zilboorg. Psychoanalysis was still controversial in psychiatric circles, and the behavioral treatments spawned by Pavlov's work were still not well known nor widely accepted in America at that time. Even so, scholars recognized that Freud and Pavlov had both created powerful theories for explaining neurosis, and it was important to compare, contrast, and, if possible, reconcile them. The best known subsequent attempts at unifying theory have concentrated on the same two general models, with Pavlovian theory broadened to refer to "learning" or "behavior" theory and Freudian theory to mean psychoanalysis or psychodynamic theories in a more inclusive sense than orthodox analysts might like.4-6

At the clinical level, Saul Rosenzweig7 argued in 1936 that therapeutic change may occur equally across competing brands because common personal styles of therapists may evoke common, if unvoiced, responses in clients, and because systematic interpretive labeling improves patients' personality organization whether it is accurate or not. His clinical ideas anticipated those of Franz Alexander by a decade,8 of Jerome Frank by a generation ( 1961 ), and of others by half a century.2,10

Further attempts at unifying either theory or clinical practice were rare until the 1980s. Eclecticism, which is a far cry from integration in any case, was criticized and even ridiculed as something between intellectual sloth and characteristic wishy-washiness. Therapists who were committed to a specific modality tempered their parochialism by alluding to their "orientation" rather than saying they "belonged" to a "school." But if anything, this softening was aimed more against mrranecine conflicts among psychoanalytic (or behavioral or experiential) variants in favor of the general theory, than at incorporating the truly foreign ideas of some competitors.

HISTORICAL CONTEXT FOR INTEBRATION

* Psychoanalysis and Behavior Therapy Vie for Dominance

Psychotherapy was widely recognized and long practiced in psychiatry before Sigmund Freud. But until Breuer and Freud found that their method was a good treatment for hysteria, it never had a theory. Since then, no important psychotherapy has been without one. By the end of World War II, despite opposition, psychoanalysis was widely accepted as the paragon, if not the prototype, of mental therapy. Its most important competition was Carl Rogers' client-centered therapy.11,12 Behavior therapy (under other names)…

A great change of mood and style has come over the practitioners of different psychotherapies. It is barely one generation since "eclecticism" rose in status from a near dirty word to one of the most prominent of avowed psychotherapy orientations.1 Some advocates yearn, moreover, to go beyond merely choosing "the best" among treatment techniques, and to develop a true integration of them, ie, a conceptual continuity across theories and techniques. This has not yet happened, nor have its proponents done much more than show that there are common ingrethents of language, theory, and method across diverse therapies. But there is some convergence of techniques in the work of many therapists, for whom pragmatism in practice has replaced purism in theory. If this trend continues, there likely will be serious efforts at integration in the near future.

This article describes the historical sequence that gave rise to this trend and discusses some of its implications.

THE PREHISTORY OF PSYCHOTHERAPY INTEGRATION

Efforts to integrate psychotherapy began as early as 1932, fully half the lifespan of modern psychotherapy, dated from Breuer and Freud. At both clinical and theoretical levels, the arguments for integration were about as good then as they are now. At the 1932 meeting of the American Psychiatric Association, according to Goldfried and Padawer,2 Thomas French3 presented a paper that attempted to reconcile Freud and Pavlov, and the question was debated by Adolph Meyer, A. Myerson, and Gregory Zilboorg. Psychoanalysis was still controversial in psychiatric circles, and the behavioral treatments spawned by Pavlov's work were still not well known nor widely accepted in America at that time. Even so, scholars recognized that Freud and Pavlov had both created powerful theories for explaining neurosis, and it was important to compare, contrast, and, if possible, reconcile them. The best known subsequent attempts at unifying theory have concentrated on the same two general models, with Pavlovian theory broadened to refer to "learning" or "behavior" theory and Freudian theory to mean psychoanalysis or psychodynamic theories in a more inclusive sense than orthodox analysts might like.4-6

At the clinical level, Saul Rosenzweig7 argued in 1936 that therapeutic change may occur equally across competing brands because common personal styles of therapists may evoke common, if unvoiced, responses in clients, and because systematic interpretive labeling improves patients' personality organization whether it is accurate or not. His clinical ideas anticipated those of Franz Alexander by a decade,8 of Jerome Frank by a generation ( 1961 ), and of others by half a century.2,10

Further attempts at unifying either theory or clinical practice were rare until the 1980s. Eclecticism, which is a far cry from integration in any case, was criticized and even ridiculed as something between intellectual sloth and characteristic wishy-washiness. Therapists who were committed to a specific modality tempered their parochialism by alluding to their "orientation" rather than saying they "belonged" to a "school." But if anything, this softening was aimed more against mrranecine conflicts among psychoanalytic (or behavioral or experiential) variants in favor of the general theory, than at incorporating the truly foreign ideas of some competitors.

HISTORICAL CONTEXT FOR INTEBRATION

* Psychoanalysis and Behavior Therapy Vie for Dominance

Psychotherapy was widely recognized and long practiced in psychiatry before Sigmund Freud. But until Breuer and Freud found that their method was a good treatment for hysteria, it never had a theory. Since then, no important psychotherapy has been without one. By the end of World War II, despite opposition, psychoanalysis was widely accepted as the paragon, if not the prototype, of mental therapy. Its most important competition was Carl Rogers' client-centered therapy.11,12 Behavior therapy (under other names) had enjoyed some status and interest in sophisticated academic and clinical circles in the 1920s and 1930s, but it did not catch on widely. Variants of psychoanalysis continued to dominate the field until the behavioral rebellion in the 1960s.

With the publication of Wolpe's Psychotherapy by Reciprocal Inhibition in 1958, ,3 soon followed by a swell of books and articles, behavior therapy began to come into its own, and within two decades reached its present status in the therapeutic establishment. This "establishment" consists of psychiatrists and psychologists, mostly on university faculties and hospital staffs, and mostly having access to government training and research funds.14 Behavior therapy was suited to the scientific and push-button bent of the times, claiming title to the heritage of the experimental psychology of learning and the theories of Pavlov, Thorndike, and Skinner; it claimed the streamlined cost-benefit virtues of speed and efficiency, allegedly providing successful treatment in minimum time with a maximum of cases. Behavior therapy outcome studies used scientific methodology and aimed at rigorous statistical analysis. Systematic desensitization, token economies, flooding, aversion therapies, assertiveness training, relaxation training, stress reduction, and sex therapy all became popular in this period, when their promoters claimed the superiority of these methods for the treatment of everything from simple phobias to schizophrenia.

Dynamic therapists argued that behavior therapy removed symptoms only by overlooking underlying problems; that its view of human nature was simplistic (at best); its view of therapy, manipulative; and that some of its techniques, such as aversion and token economies, were inhumane. Behavior therapists countered with outcome data and with counter-polemics to the effect that psychoanalysis and insight therapies, with their high costs, lengthy treatment and lack of efficacy data, were inhumane and ill-conceived, based on outmoded theories of physics.

Oddly, it was the results of outcome research in general, and of meta-analytic statistical methods for summarizing it in particular, that turned the tide of intellectual victory away from the militant behavioral party. Individual outcome studies tended to uphold the efficacy claims of behavior therapy methods against base rates of untreated control groups and showed their superiority to other methods in treating some conditions, such as simple phobias. But when different treatments were tested against a variety of problems across an array of studies, the overall results suggested, as in the tidy precis of Luborsky et al from Alice in Wonderland: "... everybody has won and all must have prizes" - different treatments worked equally well, showing modestly positive results of small magnitude.15

This finding was obtained by the simple "box score" method of counting which outcome studies showed significant positive treatment effects and which did not. Stronger support soon followed, however, from the powerful methods of meta-analysis, which verified psychotherapy's effectiveness with statistical precision from analysis of hundreds of \ studies. Indeed, most meta-analyses find that psychotherapy results in general are positive and large, but that the differences between treatment types are small and unimportant.16

Even before statistical parity had been shown for the warring modalities, a grudging professional truce began. Behavioral approaches gained acceptance in school guidance clinics, hospitals, and universities, especially among psychologists, and they were legitimized, if not endorsed, by most psychiatrists. They did not "do in" psychoanalytic or other insight schools, as they had once hoped to, but by the early 1970s, they were firmly seated with them in the mental health establishment.

SELF-CRITICAL MATURITY IN PSYCHOTHERAPY SCHOOLS

Even when hostility between schools was at its height, they were affecting each other and being affected by the proliferation of other therapies and the changing times. Advocates of humanistic psychology, calling themselves "the third force," "growth," or "human potential" movement, promoted encounter groups, consciousness-raising, gestalt therapy, and a variety of therapeutic games as challenges to both major orientations.17 Many practitioners were influenced by them and quietly modified their work to create what Wachtel called a "therapeutic underground."6 Scholars also began to acknowledge important ingrethents common to opposing therapies, such as interpersonal rapport,1821 and the idea that such nonspecific factors as the therapist-client relationship were critical to all treatment, regardless of theoretical orientation.9,22 A softening of positions fostered a blurring of boundaries from which rapprochement, eclecticism, or integration could evolve.

Some leading scholars of each school also began to question their own dogmas, and a wave of internally generated skeptical or revisionist writings appeared on psychoanalysis, behavior therapy, and cognitive therapy.10

Internal critiques of behavior therapy had accompanied its growth from early on. Relatively early criticism assailed behavior therapy's exaggerated connections between etiology and treatment, and its vaunted superiority to all other treatments for all conditions. 19,20,23,25 Later critics supported these or went further to admit the value of such hypothetical psychoanalytic constructs and "mentalisms" as the unconscious.26-28

Psychoanalysis was also criticized from within. The growing impact of ego psychologists and "object relationists" directed analytic practice more toward relationship and reality aspects of treatment.29-53 Some critics went further to express doubt that patients could remember early life experience or report it accurately, that the analyst could actually be a "blank slate," or that therapist interpretation need be accurate in order to be helpful.34-36

Early cognitive behavior therapists, like everyone else, claimed outstanding effectiveness.37,38 But cognitive therapies have always been the most open to change, perhaps because of their late arrival, perhaps because they have already started to synthesize some psychodynamic and behavior therapy principles.39 Soon after its genesis, a self-critical trend emerged within cognitive therapy, challenging the dominance of thoughts over emotions,40 the idea that neurotic thoughts are always irrational and lead to neurotic depression,41 that pathological cognition can be dependably retrieved in memory, and that correcting it will necessarily dispel bad feelings.42'43

These self-critical developments were uneven, of course. Psychoanalysis, probably by historical accident of early origins, was more resistant to change than the others. Having arisen later, and in an era demanding scientific publicity and public scrutiny of new ideas, behavior therapies did not become as entrenched as did orthodox psychoanalysis.

WHY THE THRUST TOWARD INTEGRATION NOW?

Most critics of behavior therapy, cognitive therapy, and psychoanalysis are not touting eclecticism or integration. Some are, however,6,17,44-45 although they may be only a small minority in each school.46 Whether or not their interest augurs large scale change in this direction, it does tend to make polemics less harsh and antagonists more respectful of each other's accomplishments.

Since the arguments for therapeutic convergence are much the same now as 50 years ago, one must ask why so many more theorists and therapists are listening now? A number of converging events account for this.

Most important may be the equalizing impact of outcome research. In addition to provoking a measure of collegiality and humility, it may also have influenced closet eclectics to "come out" and discover that they are now a plurality of psychotherapists.

Changes in therapy theory are also a factor. In addition to the critiques discussed above, some scholars have argued that cognitive psychology has bridged some gratuitous language gaps from one modality to another, showing that there is more commonality across treatments than had been realized.47,49

These explain the trend only in part. Most "equalizing" outcome research has appeared since 1980, well after the convergence trend appeared. Ecumenical arguments on theory and language were around a generation before the trend was visible, as Goldfried has nicely documented.47 Current theory and cognitive language per se are not better intellectual currency than the learning-and-psychodynamic models of Alexander or of Dollard and Miller, or the computer-dynamic models of Gerald Blum50 or of George Miller, Eugene Galanter, and Karl Pribram.51

In addition to theory and research, recent social, economic, and professional events have been major circumstantial factors helping to legitimize eclecticism in practice and ecumenism in theory. An era of free market psychotherapy practice developed in recent decades from the pressure of many simultaneous events: 1) the behaviorist rebellion; 2) a boom in professional practice from the legal accreditation of psychologists in most of the United States; 3) the mushrooming of schools of professional psychology and the expansion of social workers into psychotherapy practice; 4) specialization that throws therapists from different schools together in clinics that treat specific problems: eating disorders, sexual dysfunctions, substance abuse, etc; 5) the destigmatization of soul-searching for pay by growth centers and the encounter movement; and 6) the outpouring of third party funding on both sides of the therapeutic counter - government pays for the doctor's training and insurance pays for the patient's treatment.

These events were all set in place in the 1960s, and they bore two kinds of fruit in the 1970s - a hyperinflation of brand-named treatments (Harper counted 36 in 195952 and Karasu (quoted in GolemanJ counted 416 in 198653) on the one hand, and a tendency toward reconciliation among therapies belonging to the mental health establishment on the other.

Just such a "Who's Who" of thinkers on this topic includes the list of contributors to compendia on integration,47,54,55 the critics and innovators they cite in turn, and indeed, the membership list of The Society for the Exploration of Psychotherapy Integration, about 20% to 35% of whom have authored books on psychotherapy, if not on integration. None of them has yet gone beyond exploration to stake a claim for full achievement of this goal. The convergence of psychotherapies is a worthy idea whose time has not quite come in theory nor in practice. It is a commonsensical and conceptual striving that promotes and sanctions broader, therefore better, practice. Its value, so far, is more as apologia than as invention. As such, it makes psychotherapy a more honest craft, freer of stifling "school" protectionism and intellectual cant. Whether the continued pressure to integrate will produce important intellectual novelty as well is impossible to tell.

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10.3928/0048-5713-19880501-06

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