Key Concepts in Psychotherapy Integration

APPLIED CLINICAL PSYCHOLOGY

Series Editors:

Alan S. Bellack University of Maryland at Baltimore, Baltimore, Maryland

Michel Hersen Nova Southeastern University, Fort Lauderdale, Florida

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Key Concepts in Psychotherapy Integration

Jerold R. Gold Long Island University Brooklyn, New York

Springer Science+Business Media, LLC

Library of Congress Cataloging-in-Publication Data

On file

ISBN 978-1-4899-1871-0 ISBN 978-1-4899-1869-7 (eBook) DOI 10.1007/978-1-4899-1869-7

© 1996 Springer Science+Business Media New York Originally published by Plenum Press, New York in 1996 Softcover reprint of the hardcover 1st edition 1996

10 9 8 7 6 5 4 3 2 1

All rights reserved

No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the Publisher

For Natan, Roseann, and Daniel

Preface

This book has been 20 years or more in the making. When I began my training as a psychologist and psychotherapist in 1975, the idea of integrating psychotherapies was barely alive, and far from well. My professors and supervisors seemed convinced of the certainty of their theories and methods. Clinicians and scholars who identified with any of the dominant therapeutic schools were intolerant of al­ternative points of view and were clearly unwilling and unable to converse cordially about any overlap in approach. Yet, my experi­ences with patients did not teach me the way to orthodoxy. If any­thing, I became, and remain today, puzzled by the ability of others to identify any psychological or behavioral event as proof of any par­ticular conceptual system or therapeutic ideology.

A few years ago I had the good fortune to coedit, with George Stricker, the Comprehensive Handbook of Psychotherapy Integration (Stricker & Gold, 1993). This volume was one of the many indications that the field of psychotherapy integration had made it through rougher times and now had reached a point of "coming of age" (Ark­owitz, 1991). However, the handbook raised many questions for me about the status and future of psychotherapy integration. The con­tributors all wrote worthwhile and valuable chapters, and I learned a great deal. But there was little cross-referencing in these contribu­tions: It seemed that integrators of psychotherapy were not learning very much from each other. Instead, there appeared to be emerging a new set of sectarian psychotherapies that shared a common interest in synthesizing elements of preexisting treatments and theories.

Do we really need, and will we benefit from, a new group of therapies, be they sectarian or integrative? Or, I asked myself, have

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viii Preface

I set out, with others, to add to the clinical Tower of Babel? Where was the larger view of integration in the field of psychotherapy in­tegration? And in what language or metaphor can and should it be expressed?

This book is an attempt to answer these questions. By reviewing psychodynamic, cognitive-behavioral, and humanistic therapies with regard to certain key psychotherapeutic concepts, and then by looking at integrative contributions to the same variables, I hope to set the stage for a larger, more general level of integrative discourse and prac­tice. In borrowing the theoretical framework of narrative from many disciplines, my goal is to offer one alternative for theory building that allows many models to be synthesized without preference or ex­clusion. The central point of this book is to redirect the path of in­tegrative efforts in specific, and of the broader field of psychotherapy in general, toward the search for fewer and more powerful therapies. I leave it to the reader to judge the worth of this effort.

Acknowledgments

I would like to thank a number of people, without whose efforts this book would never have made it into print. Eliot Werner at Plenum, Alan S. Bellack, and Michel Hersen were involved in this project when it was just an idea. Their encouragement, interest, and editorial acumen helped to turn an unwieldy and cumbersome proposal into a more streamlined and reader-friendly volume. Mariclaire Cloutier and her staff at Plenum ushered the manuscript through the process of editing and production efficiently and painlessly. Many thanks are due to Margaret Ritchie for her superb copyediting.

To Gary Kose, Chairman of Psychology at Long Island University, I owe many thanks for good friendship, hours of good talk, and a great deal of professional support and freedom. Joseph Newirth, Di­rector of the Postdoctoral Program in Psychotherapy and Psychoanaly­sis at the Derner Institute of Adelphi University, helped me to find the magic and joy associated with writing and being productive.

George Stricker, Distinguished Research Professor at the Derner Institute, was as always a source of collegial advice and encourage­ment. Able and invaluable research assistance was contributed by An­nie Chanler, David Baldwin, Elizabeth Potter, and Isabel Sanchez of the Doctoral Program in Clinical Psychology at Long Island University.

Part of Chapter 1 appeared in an article in Clinical Psychology: Science and Practice. Parts of Chapter 9 appeared in earlier forms in articles in the Journal of Psychotherapy Integration and Applied and Preventive Psychology.

This book is dedicated to three people, who represent three criti­cal elements in my narrative: the past, the present, and the future. Natan Sarotzkin, my grandfather, was my first storyteller and my most

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X Acknowledgments

important caretaker. He taught me the value of the examined life and of caring for others and was a model of quiet courage and strength. Roseann Ungaro has shared and created a story with me for almost 20 years. She has been a better companion, lover, friend, and col­league than I could ever have imagined for myself. Daniel Gold is the future and the point of the story. Each day his tale unfolds a little more with great joy and energy, and with the promise of more magic to come.

Contents

PART I. THEORETICAL FOUNDATIONS

Chapter 1. The Status of Psychotherapy Integration. 3

A Brief History of Psychotherapy Integration 3 The Need for an Integrated Psychotherapy . . . . 7 The Modes of Psychotherapy Integration . . . . . 11 The Major Systems of Psychotherapy Integration . 14

Technical Eclecticism . . . . . . . . . . . . . . . 14 Common-Factors Approaches to Psychotherapy Integration 16 Theoretically Integrated Systems of Psychotherapy. 17

Toward a Metaintegration: The Plan of This Work . . . . 24

Chapter 2. Theories of Personality and Psychopathology . . . . 25

Contributions of Traditional Theories to an Integrated Theory of Personality and Psychopathology . . . . . 25

Integrative Theories of Personality and Psychopathology 31 A Metatheory of Personality and Psychopathology: The

Organizing Role of Personal Narratives . . . . 37 Clinical Application of the Metatheoretical Model 43

Chapter 3. Theories of Psychotherapeutic Change . 49

Traditional Approaches to Change 49 Integrative Theories of Change . . 54

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A Narrative-Based Synthesis of Integrative Theories of Change ..... .

Case Example: James . . . . . . . . . . . . . . . . . . .

PART ll. CLINICAL CONCEPTS

. 62

. 65

Chapter 4. The Therapeutic Relationship . . . . . . . . . . . . . 71

Traditional Definitions of the Roles of Patient and Therapist . . . . . . . . . . . . . . . . . . . . . 71

Traditional Conceptualizations of the Therapeutic Relationship . . . . . . . . . . . . . . . . . . . . 75

Transference and Countertransference in Traditional Psychotherapies . . . . . . . . . . . . . . . . . . 80

Resistance in Traditional Therapies . . . . . . . . . 85 Integrative Approaches to the Psychotherapeutic

Interaction . . . . . . . . . . . . . . . . . . . . . 90 The Emotional Climate of the Therapeutic Interaction . 90 Interactional Stance . . . . . . . . 92 The Role of Interactional Data . . . . . . . . . . . . . . . 94 Implications . . . . . . . . . . . . . . . . . . . . . . . . . 98

The Narrational Approach to the Integrative Therapeutic Relationship . . . 100

Case Example: James . . . . . . . . . . . . . . . . . . . . . 102

Chapter 5. Insight, Interpretation, and Unconscious Processes 107

The Role of Insight and Interpretation in Traditional Therapies . . . . . . . . . . . . . . . . . . . . 107

The Varied Roles of Insight and Interpretation in Integrative Therapies . . . . . . . . . . . . . . 111

Traditional Uses of Insight in Integrative Psychotherapy 111 Insight as a "Cognitive Map" for Change. . . . 113 Prescriptive Uses of Insight and Interpretation . . . . . 114 Insight as a Consequence of New Experience . . . . . . 116 The Cyclical Use of Interpretation and Insight: Toward

a Seamless Integration . . . . . . . . . . . . . . . . . 118 A Narrative-Based Approach to the Integration of Insight

and Interpretation 118 Case Example: James . . . . . . . . . . . . . . . . . . . . . 123

Contents xiii

Chapter 6. Experiential Interventions 127

The Traditional Therapeutic Uses of Emotional Experience 127 Integrative Theories of Emotional Experience . . . . . 135 Integrative Interventions . . . . . . . . . . . . . . . . . 140

The Role of Emotion and Experience in Integrative Psychotherapies . . . . . . . . . . . . . . 140

Technical Approaches in the Here and Now . . . . 144 A Synthesis of Integrative Approaches . . . . . . . . . 150

Directed Inquiry as a Source of Experiential Exploration 152 Experiential Markers and Integrative Clinical Decisions 152

Narrative and Experience 155 Clinical Example: James . . . . . . . . . . . . . . . . 158

Chapter 7. Active Interventions for Behavioral and Cognitive Change . . . . . . . . . . . . . . . . . . . . . 163

Traditional Therapeutic Uses of Active Intervention 163 Integrative Approaches to the Use of Action-Oriented

Interventions . . . . . . . . . . . . . . . . . . . . . 168 Focal and Prescriptive Uses of Action-Oriented Interventions 169

Using Action-Oriented Methods to Promote Structural, Dynamic, and Representational Change . . . . . . . . 170

Active Intervention in Intrapsychic Processes . . . . . . . 171 Active Intervention in Contextual Theoretical Integration 175 The Narrative Approach to Action 180 Case Example: James . . . . . . . . . . . . . . . . . . . . . 183

PART III. PillLOSOPillCAL CONCERNS

Chapter 8. The Worldview of an Integrated Psychotherapy. . . 189

The Mythology of Natural Science or a Science of Mythology? . . . . . . . . . . . . . . . . . . . 189

Bridging the Gap between Process and Outcome Orientations in Psychotherapy . . . . . . . . 192

Patient-Initiated Integration: Toward a First-Person Point of View for Psychotherapy and Psychotherapy Integration . . . . . . . . . . . . . . . . . . . . . . . . 199

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Mode 1: The Integration of a Sequence of Therapies 203 Mode 2: Concurrent Integration of Two Separate

Therapies . . . . . . . . . . . . . . . . . . . . . . 204 Mode 3: The Integration of Self-Therapy with Ongoing

Therapy . . . . . . . . . . . . . . . . . . . . . 206 Mode 4: In-Session Integrations of Interventions 207

The Implications of Patient-Initiated Integration 208 The "Inside-Out" Psychotherapist . . . . . . . . . . 212

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219

Index ................................. 233