Psychotherapy Volume 37/Winter 2000/Number 4 - … · Psychotherapy Volume 37/Winter 2000/Number 4...

Psychotherapy Volume 37/Winter 2000/Number 4

EVOLVING PSYCHOTHERAPY INTEGRATION: ECLECTICSELECTION AND PRESCRIPTIVE APPLICATIONS OF

COMMON FACTORS IN THERAPY

GEORGIOS K. LAMPROPOULOSBall State University

Since its inception 65 years ago, thepsychotherapy integration movement hasundergone much development along itsmajor thrusts: technical eclecticism,common factors, and theoreticalintegration. Based on findings fromdecades of exploration of psychotherapyintegration, this article attempts toadvance the movement one step furtherby (a) reviewing the pros and cons ofeclecticism and common factors, and(b) integrating the two approaches intoa new conceptual scheme. The newintegrative scheme aspires to improvetreatment selection and application, aswell as facilitate integrative trainingand research.

Introduction: Celebrating the Evolution of thePsychotherapy Integration Movement

The psychotherapy integration movement hasan unofficial history of more than 65 years, andan official presence since 1983. The Society forthe Exploration of Psychotherapy Integration

An earlier version of this article was the recipient of thePsychotherapy Division of the American Psychological Asso-ciation's Freedheim Student Development Award.

The author is thankful to the anonymous reviewers for theircomments, as well as to Carol Chalk for her assistance withthe English language.

Correspondence regarding this article should be addressedto Georgios K. Lampropoulos, Department of CounselingPsychology and Guidance Services, Teachers College 622,Ball State University, Muncie, IN 47306. E-mail:[email protected]

(SEPI) presently numbers hundreds of membersin several countries (SEPI, 1999) and has gener-ated more than 150 training programs, courses,and workshops in psychotherapy integrationworldwide (Norcross & Kaplan, 1995). A generalsatisfaction with the movement has been reportedin a recent survey of its membership (Figured& Norcross, 1996), and a proposal to replace"Exploration" with "Evolution" in the society'stide was recently considered.

What exactly has been explored so far? In sum,major areas of attention have been (a) the theoreti-cal integration route; (b) the technical eclecticismroute; (c) the common factors approach; (d) theassimilative integration route; (e) the empiricallysupported (manualized) treatments (ESTs) move-ment (as a form of eclecticism); (f) the develop-ment of integrative treatments for specific disor-ders and specific populations; (g) the developmentof integrative-eclectic systems of treatment selec-tion, and the integrative exploration of psycho-therapy case formulation methods; and (h) train-ing and supervision in eclectic and integrativetherapies (all reviewed in Gold, 1996; Hawkins& Nestoros, 1997; Lampropoulos, in press-a;Norcross & Goldfried, 1992; Stricker & Gold,1993; see also Nestoros & Vallianatou, 1990).

Initial explorations have been conducted in allthese areas of integrative focus. While develop-ments in integrative theory, practice, and researchare clearly evident, definitive answers are notavailable for most integrative questions. Fourteenyears after the 1986 National Institute of MentalHealth (NIMH) conference issued research rec-ommendations for the society (Wolfe & Gold-fried, 1988), many of the designated areas ofresearch have not yet received appropriate atten-tion. Obviously, the end of the exploration erais more distant than integrationists might wish.Nevertheless, a period of evaluation, redefinition,and empirical research in the application of integ-

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Georgios K. Lampropoulos

rative therapies and ideas is necessary for the move-ment to evolve (Beitman, 1994; Norcross, 1997).This author, along with others in the field, be-lieves that future efforts of the society shouldfocus on (a) theory-driven programmatic aptitudeby treatment interaction (ATI)' research focusingon small intervention packages rather than wholetherapies (Beutler, 1991; Shoham & Rohrbaugh,1995); (b) the development and empirical testingof integrative models of psychotherapy for spe-cific populations, preferably against theoreticallypure ESTs (Goldfried & Wolfe, 1998); (c) thedevelopment, evaluation, and dissemination ofintegrative-eclectic psychotherapy training; and(d) the development of integrative-eclectic sys-tematic treatment-selection methods.

The improvement of integrative treatment-selection systems is the focus of this article. Theplethora and diversity of integrative developmentsand findings mentioned above raises a need foran organizational scheme to guide integrative cli-nicians. This organization is necessary, consider-ing that the integration movement is experiencinga problem that it meant to address in the firstplace: the proliferation of different therapeuticmodels, now in the form of various integrative-eclectic approaches (Lazarus, in Lazarus & Mes-ser, 1991). To organize the existing integrativeclinical findings, integration within the integra-tion movement is attempted here. Specifically, aneffort to integrate two of the major thrusts ofpsychotherapy integration (i.e., common factorsand eclecticism) follows. The proposed integra-tion is also fueled by the need to compensatefor existing weaknesses of eclecticism and thecommon factors approach (reviewed below).

Common Factors and Eclecticism as GuidingSystems in Therapy

The Common Factors Approach: Pros and ConsThe common factors approach has been pro-

posed as a guiding model to describe clinical prac-tice in terms of ingredients common in all thera-pies, despite the varying terminology that is used.It has been identified as one of the major routesto psychotherapy integration and one of the mostimportant trends in psychotherapy in the last few

decades (Grencavage & Norcross, 1990). Themajor advantage of this approach is that it focuseson the "heart and soul of change," that is, themost important factors associated with positiveoutcomes in various therapies (for detailed de-scriptions see the edition by Hubble, Duncan, &Miller, 1999a). Lambert (1992; Asay & Lambert,1999) estimates that only 15% of change can beattributed to specific techniques used by varioustherapies (with some exceptions); the other 85%of clients' improvement can be attributed to fac-tors such as the therapeutic relationship, placeboeffects, and other client factors.

Proponents of this thrust have offered differentlists of common factors to be followed in clinicalpractice. Among them are common factors mod-els proposed by Garfield (1986), Beitman (1992),Frank and Frank (1991), Arkowitz (1992), Orlin-sky and Howard (1987), and Weinberger (1993).Commonly cited common factors include the ther-apeutic alliance, empathy and support, positiveexpectations about therapy, emotional catharsis,problem exploration and insight, exposure andconfrontation of the problem, and learning of newbehaviors (Grencavage & Norcross, 1990). Thisauthor counts at least a dozen psychotherapy re-search programs that continue to provide data oncommon factors worldwide (for more on researchissues see Castonguay, 1993; Goldfried, 1991;Norcross, 1993a, 1995a). In addition, authorswho review common factors in therapy usuallyconclude that therapists should incorporate andemphasize those common factors in their practice,in order to enhance clinical effectiveness (e.g.,Asay & Lambert, 1999; Fischer, Jome, & Atkin-son, 1998; Hubble, Duncan, & Miller, 1999b).Examples of how common factors can be em-ployed in therapy are also available (e.g., Hubbleet al., 1999b). Other authors add that a combina-tion of common and specific factors might benecessary for optimal therapeutic effects (e.g.,Beitman, 1992; Lambert, 1992). Clearly, com-mon factors do exist and are important contribu-tors to therapeutic outcome. They also appear tobe the major explanation for the Dodo bird verdict(i.e., that all therapies produce equivalent out-comes; Lambert & Bergin, 1994; Luborsky,1995; Luborsky, Singer, & Luborsky, 1975).

Despite the obvious importance of commonfactors in therapy, several weaknesses exist inthis approach. In sum, (a) common factors areobscurely defined; (b) common factors in differ-ent theories are not as similar as they are claimed

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l Aptitude by treatment interactions can be found whendifferent interventions are matched to client variables ac-cording to a clinically meaningful hypothesis.

Eclectic Applications of Common Factors in Therapy

to be; (c) common factors provide only a minimaldescription of change (least common denomina-tor) that may overlook valuable clinical informa-tion; (d) common factors proposals are insensitiveto client, problem, and therapist individual differ-ences; (e) the proposed common factors are toogeneral and abstract to guide clinical practice (be-cause of the aforementioned two weaknesses,i.e., c and d); and (f) common factors are oftenerroneously considered sufficient change agents;some specific factors and effects also exist (seeEmmelkamp, 1994; Ogles, Anderson, & Lunnen,1999). The final point is further supported byliterature that reveals several additional explana-tions besides common factors for the outcomeequivalence phenomenon (Lampropoulos, 2000;Luborsky, 1995; Norcross, 1995b). Such expla-nations include the lack of adequate statisticalpower to reveal differences between therapies,inappropriate research designs, the use of insensi-tive outcome measures, and the lack of psycho-logically meaningful hypotheses in ATI research.For additional discussion on common factors is-sues, the reader is referred to relevant roundtables(Norcross, 1993a, 1995a), a monograph (Wein-berger, 1995), and other publications (e.g., Ar-kowitz, 1995; Butler & Strupp, 1986; Caston-guay, 1993; Goldfried, 1991; Grencavage &Norcross, 1990; Hubble et al., 1999a; Lampro-poulos, 2000; Messer & Winokur, 1981; Omer& London, 1989).

It is obvious that the common factors approachalone cannot be used as an adequate treatmentplan at this point in its development. To furtherillustrate the foregoing six weaknesses and theneed to eclectically choose and prescriptivelymatch common factors in therapy, the exampleof "support" is used: How exactly is support beingdefined in different therapies? Do we define it asa process, or do we include the content of whatis being supported as well (Arkowitz, 1997)? Issupport in psychoanalytic psychotherapy (Wal-lerstein & DeWitt, 1997) the same thing as sup-port in cognitive therapy (Alford & Beck, 1997)and support in existential-humanistic therapy(Yalom & Bugental, 1997)? Can we define itat a commonly accepted level without omittingimportant aspects that are unique to various theo-ries? Is support as necessary and important forthe treatment of depression (where support is con-sidered to be the cornerstone of therapy; Arkow-itz, 1992) as it is for the treatment of other prob-lems? Is support therapeutic or equally important

in all phases of therapy, such as the phase ofclient vague awareness of the problem and thephase where clients are attempting a new solu-tion? Should support have the same form andintensity in all phases of change? When shouldit be alternated with challenge, interpretation,confrontation, and insight-oriented, exploratoryinterventions? Is support equally necessary for alltypes of clients (e.g., clients with strong vs. poorsocial support systems, constrictive and inter-nalizing vs. impulsive and externalizing clients,highly distressed vs. low distressed and unmoti-vated clients; Beutler, Goodrich, Fisher, & Will-iams, 1999)? In order to answer those kinds ofquestions, an eclectic approach to therapy isneeded. Next, the pros and cons of eclecticismare discussed followed by a specific proposal asto how common factors and eclecticism can com-plement each other.

The Eclectic Approach: Pros and ConsTechnical eclecticism has been described as the

Zeitgeist of counseling and psychotherapy in the21st century (Lazarus, Beutler, & Norcross, 1992).Technical eclecticism advocates the selectivecombination of the most efficient techniques, re-gardless of their theoretical origin, in order toachieve optimal therapeutic results for a specificclient. It is largely guided by Paul's (1967) ques-tion "What treatment, by whom, is most effectivefor this individual with that specific problem, andunder which set of circumstances?" Indeed, eclec-ticism by definition covers major variables per-taining to clients (175 variables), therapists (40variables), and therapies (50 variables), and itsfinal aim is to match them with the appropriateintervention (Beutler, 1991). Eclecticism has thepotential to describe optimal change in exhaustivedetail; however, this task will take decades ofintense effort to be completed, if ever. Further-more, the eclectic movement has experiencedboth successes (e.g., Beutler, Engle et al., 1991;Beutler et al., 1999; for a review see Dance &Neufeld, 1988) and failures (e.g., Project MATCHResearch Group, 1997) in demonstrating differen-tial therapeutic effectiveness. Failures occasion-ally include research that has utilized prospectiveATI designs and evidence-generated hypotheses.Thus, the use of robust theory-driven hypotheseshas been suggested for future ATI research (Beu-tier, 1991; Shoham & Rohrbaugh, 1995). Suchexamples have been discussed in Henry (1996),and Piper, Joyce, McCallum, and Azim (1998).

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A closer look at the major types of eclecticismsuggests the following pros and cons: "Stages ofchange" eclecticism suggests that clients(a) change by progressing through continuousstages, and (b) respond optimally to treatment iftheir stage of change is matched to the appropriateintervention. The best example of this type ofeclecticism is the transtheoretical model, whichhas been modestly supported by research (Pro-chaska & DiClemente, 1984, 1992). For exam-ple, in Matching Alcoholism Treatments to ClientHeterogeneity (project MATCH), the expectedaptitude-treatment interaction between clientstage of change and type of treatment was con-firmed for clients at the earlier stages of changebut not at the later stages (Project MATCH Re-search Group, 1997). Along with modest researchsupport, this type of eclecticism is also somewhatinsensitive to personality and problem differ-ences. However, sensitivity to client clinicalproblems in the transtheoretical approach has in-creased with the consideration of client levels ofchange (symptom-situational problems, maladap-tive cognitions, interpersonal, intrapersonal, andfamily conflicts; Prochaska & DiClemente,1992).

"Level of problem assimilation" eclecticism issimilar to the transtheoretical approach with re-gard to conceptualization of client change. Devel-oped and researched by Stiles and associates(1990, 1997a, 1997b), the assimilation modelproposes that (a) client problems progress throughseven levels until they become assimilated intoclient schemata (i.e., problem is solved), and(b) clients respond differentially to treatments basedon their level of problem assimilation. It has alsoreceived modest research support. For instance,the expected differential effectiveness ofpsychodynamic-interpersonal treatment in thefirst three levels of assimilation was not confirmedin a recent study (Stiles, Shankland, Wright, &Field, 1997a). The assessment of problem-assimila-tion level takes into consideration some client andproblem variables (as measured by the Early As-similation Research Scale; Stiles, Shankland,Wright, & Field, 1997b). However, this kind ofeclectic practice can also be considered insensi-tive to other important personality and problemdifferences (i.e., it differentiates clients only bygrouping them in one of the seven assimilationlevels). Further, it has been researched mainly intwo types of treatments: cognitive-behavioral andpsychodynamic-interpersonal therapies.

Psychopathology-matched eclecticism is sim-ply the empirically supported treatment move-ment. Although some might argue against its in-clusion in eclecticism (since complete treatmentsand pure theoretical models are tested for specificproblems), this movement can be included in abroader definition of eclectic practice. Further-more, if we consider using empirically supportedtechniques for specific problems (e.g., empty-chair dialogue for unfinished business; Paivio &Greenberg, 1995) as portable interventions to beincorporated and used eclectically in larger treat-ment packages (Lampropoulos, in press-a),psychopathology-matched eclecticism gets itsown place in the integration movement. Needlessto say, its major disadvantage is that it too ne-glects client personality differences as well asother diagnostic variables (e.g., disorder subtypesand comorbidity). For example, in terms of per-sonality differences, not all clients are suitable orwilling to participate in the empty-chair tech-nique; further, clients with greater need for thera-pists' direction and advice will probably benefitmore from a different type of treatment for unfin-ished business (Greenberg, Rice, & Elliott, 1993).For these clients, an expressive-interpretive ap-proach to the resolution of unfinished businesshas been proposed as an integrative-eclectic alter-native to the empty-chair intervention (Lampro-poulos, 1999).

Personality-matched eclecticism has been thefocus of attention of Beutler and his associatesfor more than 30 years (Beutler, 1983; Beutler &Clarkin, 1990; Beutler et al., 1999; Beutler &Williams, in press). Their work has resulted inthe development of an eclectic model called Sys-tematic Treatment Selection (STS). One of itsmajor advantages is empirical support for its ma-jor dimensions. Second, it has the goal of devel-oping a data-based theory of psychotherapy andchange, due to the inadequacy of the existingtheories of personality and psychopathology inthat domain (Beutler, 1995). Next, it considersboth nondiagnostic client personality variables(e.g., resistance, coping style) and diagnosticvariables, such as functional impairment, subjec-tive distress, and problem complexity (Beutler etal., 1999; Beutler & Williams, in press; Fisher,Beutler, & Williams, 1999); thus, it has becomean advanced eclectic approach to systematic,empirically-based treatment selection. Finally, ithas been significantly developed to allow specificeclectic recommendations for specific disorders,

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such as depression (Beutler, Clarkin, & Bongar,2000) and alcoholism. It is worth noting that inthe Couples Alcoholism Treatment (CAT) project(where four of the seven dimensions of Beutler'smodel were tested together for the first time),three of the matching dimensions alone were ableto predict collectively 76% of the variance inchange (Beutler et al., 1999). Nevertheless,STS's weaknesses are that (a) only a small num-ber of client variables are used from many poten-tially important ones, and (b) some assumptionshave not always been supported by research (e.g.,client coping style or impulsivity in the CAT proj-ect; Beutler et al., 1999).

A general weakness of eclecticism as an ap-proach to treatment is the lack of a basic guidingstructure to the essence of psychotherapy. Eclecti-cism focuses on meaningful details and specificdifferences, while neglecting common factors.Eclectic therapists may be aware of differentialeffects and guidelines, but they also have to makesure that all important common factors have beenapplied in their therapy. Clinicians should not losesight of the "forest" (common factors) by payingattention to the "tree" (individual differences andeclecticism). The common factors approach, bothreferring to important relationship variables (i.e.,alliance, support, empathy) and important thera-peutic structure variables (i.e., catharsis, remora-lization, exploration, insight, problem confronta-tion, learning, test and mastery of new behavior),can be a guiding map for eclectic therapists. Thiscommon-factors map will allow them to see theimportant therapeutic qualities and processes theyneed to include in therapy. The eclectic map willallow them to match these qualities and processesto individual clients and situations in order tomaximize therapeutic results. A detailed descrip-tion of the proposed integration of common fac-tors and eclecticism follows.

Some Factors Are More Common (andNecessary) Than Others: Eclectic Selection

More than two decades after the Dodo birdverdict first announced the equivalence of thera-peutic outcomes (Luborsky et al., 1975), thisfinding continues to receive empirical support(Shapiro et al., 1994; Wampold et al., 1997).However, research supporting this equivalencehas been strongly criticized (e.g., Crits-Christoph,1997; Kazdin & Bass, 1989; Norcross, 1995b;Norcross & Rossi, 1994; Shadish & Sweeney,1991). Although most researchers agree about the

contribution of common factors to the equivalentoutcomes phenomenon, the presence of additionalexplanations for this phenomenon (Luborsky,1995; Norcross, 1995b) suggests that (a) therapiesmay not be as equal as they appear, and (b) commonfactors may not be sufficient or the only changeagents (Lampropoulos, 2000). Specific factors existand account for some demonstrated differential out-comes among therapies (see also Asay & Lambert,1999; Ogles et al., 1999).

It should, therefore, be expected that futureresearch findings will include (a) some widelycommon and therapeutic elements (e.g., an effec-tive working alliance), (b) additional therapeuticelements that are common only in some (but notall) of these therapies (e.g., the rehearsal and testof new behaviors), and (c) a few unique elementsin some treatments, particularly with specificproblems (Lampropoulos, 2000). The last twotypes of therapeutic agents will be responsible forspecific effects and should be researched amongtherapies that have already demonstrated differen-tial outcomes with specific clients and problems(i.e., empirically supported treatments and othereclectic therapies). Consistent with these expecta-tions is the observation that certain common fac-tors might be more relevant and important forsome problems than others (i.e., social supportfor depression; Arkowitz, 1995; see also Gar-field, 1986).

Some therapeutic factors are common and nec-essary. For instance, therapists should always tar-get a good working alliance. However, as it con-cerns the treatment of some specific problems,the therapist might consider an eclectic use ofcommon factors. For instance, learning, testing,and performing new behaviors are not necessaryin the treatment of unfinished business with adeceased significant other. Therefore, it is appro-priate to choose common factors to include intherapy according to each individual case. Em-ploying lists of common factors should not be-come the Procrustean bed either, as is the casewith many inflexible pure-form therapies. In sum,a selective combination of common and specificfactors should be employed in the treatment ofeach client.

Common Factors Are Not (and Should NotAlways Be) the Same: PrescriptiveApplications

Some researchers have suggested exploringdifferent functions of hypothesized common fac-

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tors in various therapies, as well as studying theirinteractions with specific factors and in certaincontexts (Elkin, 1995; Glass & Arnkoff, 1993;Shoham, 1993; see also Arkowitz, 1997; Caston-guay, 1997). The view that common factors existand operate in different forms in various therapiesdictates a flexible conceptualization of the com-mon factors approach. Thus, a recommendationfor prescriptive application of specific forms ofcommon factors is in order. At this point, itshould be noted that recommendations for botheclectic selection and prescriptive application arebased on (a) observations of what actually hap-pens in various therapies, and (b) predictions ofwhy and how the integration of common factorsand eclectic models will enhance clinical practice.The rationale of why this will happen has alreadybeen presented in reviewing the strengths andweaknesses of the two approaches. Followingare specific suggestions of how this will happenin clinical practice. Several available categoriesof therapy variables can be identified as com-mon factors (e.g., client variables, therapistvariables, techniques, change events; Lampro-poulos, 2000). Due to space limitations, discus-sion is limited to common factors from two ma-jor combined categories: relational variablesand therapeutic structure variables (phases ofchange).

Relational Variables as Common Factors:Prescriptive Applications

Therapeutic Relationships of Choice

The therapeutic relationship and the workingalliance have been unanimously accepted as themost important common factors in therapy, andthey make a major contribution to the therapeuticoutcome (Horvath & Greenberg, 1994; Sexton &Whiston, 1994). As the single most importantfactor in therapy, the therapeutic relationship de-serves at least as much attention as other therapeu-tic variables. Thus, eclectic applications and pre-scriptive matching in treatment (Norcross, 1991)have now been extended to include the therapeu-tic relationship. Expert therapists have recentlydiscussed issues pertaining to tailoring relation-ship styles to client variables (Norcross, 1993b).There are several questions to ask regarding pre-scriptive applications of the therapeutic relation-ship (see also Mahoney & Norcross, 1993).

How should therapists choose the appropriaterelational style? The first concern for eclectic ther-

apists is to identify the client variables for whichthey need to tailor their relational style. Consider-ing that a great number of client variables couldbe considered for that purpose (Garfield, 1994),clinical attention should focus on those that havereceived some empirical support and have beenproposed by expert integrative therapists. The fol-lowing are some of the most important variablesto consider:

1. Client expectations about therapist behaviorand relational style (Lazarus, 1993). When thereare no serious therapeutic considerations for notdoing so, the therapist should honor client expec-tations about, for instance, the level of formality,activity, and structure, and the degree of personaldisclosure, directiveness, warmth, and emotionaldepth. This author's experience in watching othertherapists has convinced him that therapists caneven adjust the way they empathize, either beingmore emotional and warm or intellectual and for-mal, according to client style or situational needs.That is, the therapist should take both client ex-pectations and real characteristics and needs intoaccount when adopting a relational style.

2. Client reactance and coping style (introspec-tive vs. externalizing) (Beutler et al., 1999; Laza-rus, 1993). These client variables should not onlydictate the choice of the appropriate intervention,but also constantly inform the therapist's way ofrelating to the client. For example, the employ-ment of a paradoxical or a self-change techniquewith a highly resistant client will not be as effec-tive if the therapist's relational style remains di-rective, controlling, instructional, or confronta-tional. The entire therapeutic style, includingtechniques selected, should be matched to theindividual client.

3. Other important variables might include(a) client attachment style (in which therapistsmatch their stance in order to disconfirm clientmaladaptive patterns; Dolan, Arnkoff, & Glass,1993); (b) client motivational arousal and readi-ness for change (Beutler et al., 1999); and(c) client intellectual and educational level (i.e.,use of client's language and frames of reference tocommunicate). However, a couple of cautionarynotes should be made. First, all basic micro-counseling skills and qualities are necessary insome form in the relationship, regardless ofwhether or not they will be prescriptively applied.Second, because the therapeutic relationship isnot a static phenomenon, therapist relational stylemay also change throughout therapy.

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How similar should the client and therapist be?A certain degree of difference and dissimilarityin the therapist-client relationship in variablessuch as problem-solving experience (Mahoney &Norcross, 1993) or attitudes about attachment andintimacy (Beutler, Zetzer, & Williams, 1996)might be necessary for therapeutic change. Itseems that a complex pattern of initial similaritiesand differences exists in the optimally matchedtherapeutic relationship (see Beutler, Clarkin,Crago, & Bergan, 1991; Beutler, Machado, &Neufeldt, 1994). In sum, in successful therapy,the client and therapist should be initially similarin some variables (e.g., demographics) and dis-similar in others (e.g., attitudes), while some con-vergence in the latter should appear at the endof treatment.

How flexible can the therapist be? Althoughmaster therapists seem to have a more flexiblerepertoire than novices, an ability to control them-selves, and a talent to improvise when necessaryto fit different clients, this variability has its lim-its. Even when therapists are aware that a differ-ent stance is needed, their personality may limittheir flexibility. This author recalls an experi-enced therapist (with a natural client-centeredstyle) admitting how difficult and awkward it wasfor him to be strategically nonsupportive attimes to a client he treated with a manualizedempirically supported treatment for obsessive-compulsive disorder, even though both therapistand client knew that this stance was required bythe treatment.

To conclude, although there are certain limitsin therapists' flexibility in relating to differentclients, the following training recommendationsseem helpful: (a) educate therapists to identifyand be aware of their relationship styles; (b) traintherapists to explore and attempt varying thera-peutic styles, when necessary; (c) train therapiststo recognize important criteria for adopting differ-ent relationship styles; (d) educate them to iden-tify and maintain an optimal level of fit or differ-ence in the relationship; and (e) train them tomake appropriate referrals when there is a clearincompatibility and mismatch in the relationshipthat cannot be fixed. Empirical research is alsoneeded to clarify and guide clinical practice inthese areas.

Support

Issues regarding the complexities and varietiesof support have already been raised (see also Cas-

tonguay, 1997). With a conventional Rogeriandefinition of support in mind, some of the dilem-mas of an informed eclectic therapist includethe following:

Support versus challenge. This is the most im-portant decision the therapist has to make ac-cording to a variety of client variables. For exam-ple, high distress indicates an increased level ofsupport. Usually the average talented therapistwill respond instinctively in the right directionwhen the client arrives at the first session tearfulor anxious. More difficult but equally importantis to challenge the low distressed, unmotivatedclient. A similar client variable that requires adecision regarding the support versus challengedilemma is client readiness for change.

Supportive versus exploratory (insight-oriented) treatment. Client functional impairmentand ego strength may also dictate the treatmentof choice. Supportive interventions are requiredin severe situations and when few client resourcesare available. Exploratory behavior is feasible,useful, and recommended to the degree that theclient is strong and able to benefit from it. Theclients' internal versus external attributions oftheir problems may also dictate the treatment ofchoice.

Amount and duration of support. This dependson client objective and subjective (perceived) lev-els of social support (Beutler et al., 1999), bothcurrently and in the past, as well as the type ofthe client's presenting problem (e.g., a great dealof support for long periods of time might be nec-essary for the chronically depressed client). Theamount of support might also depend on the cli-ent's perceived self-efficacy to perform a specificbehavior in therapy.

Type and content of support. This should alsobe determined by client problem or disorder. Dif-ferent kinds of support might be necessary for thedepressed client, the client with various anxietydisorders, and the client with personality disor-ders. Pure therapies also differ in the content oftheir support (Arkowitz, 1997). For example,cognitive therapy supports client efforts to correctmaladaptive cognitions (Alford & Beck, 1997).It is argued that this seems optimal only whenmaladaptive cognitions are the main causal reasonfor the psychological dysfunction (e.g., depres-sion). Similarly, the existential-humanistic em-phasis is on supporting client self-exploration(Yalom & Bugental, 1997). However, supportshould not only be available where theory says it

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is necessary, but also in areas where particularclients need that support. Psychopathology and itsetiology, rather than theoretical orientation per se,should decide the content of support in therapy.

Timing and conditions of support. Progress intherapy can also be mediated and conditioned bythe provision of therapeutic support. Even in theclient-centered tradition, therapists use supportselectively to guide their clients. Further, specificphases and tasks in therapy require more supportthan others, regardless of client strengths. Forexample, a certain amount of support is helpfulfor all clients when they attempt to confront aproblem, apply a solution, or try a new behavior.

Therapeutic Structure Variables as CommonFactors: Prescriptive Applications

Phases or stages of therapy (Beitman, 1987;Howard, Lueger, Maling, & Martinovich, 1993),stages of change (Prochaska & DiClemente,1992), and level of problem assimilation (Stiles etal., 1990) are three somewhat different constructsthat represent comparable conceptualizations ofthe therapeutic process. The first emphasizes ther-apy as an encounter; the second focuses on clientself-change; and the third describes how clientsprogress in assimilating each single problem intherapy. These descriptions of the therapeuticstructure, all well researched and useful from dif-ferent perspectives, can serve both as eclectic andcommon-factors dimensions. Their importance aseclectic variables consists of matching the appro-priate intervention to client stage or level ofchange in order to maximize therapeutic efficacyand minimize time in therapy. For example, moti-vated clients who enter therapy with relativelyclearly formulated ideas of what the problem isand what needs to be changed will probably spendless time in motivational, goal-setting, andproblem-exploration activities. For these clients,the focus of therapy should turn to problem-solving processes rather quickly. They will proba-bly progress faster compared to less psychologi-cally minded clients with limited self-awarenessand insight into their problems, who will requirean initial therapeutic focus that emphasizes ex-ploratory activities.

Besides choosing interventions based on clientreadiness for change (i.e., eclectic applications),the stage-like concepts have important common-factors applications. Since they describe commonchange pathways that people follow regardless oftheir therapist's theoretical orientation, they have

high heuristic value to guide therapeutic effortsin a common direction. Among the stage models,Stiles' assimilation model (seven levels of assimi-lation of problematic experience: warded off, un-wanted thoughts, vague awareness-emergence,problem statement-clarification, understanding-insight, application-working through, problemsolution, and mastery) seems promising. The as-similation model describes the change of prob-lems through a series of sequential therapeuticprocesses (or better, change events). It appearsmore concrete and specific compared to other gen-erally defined stage models, and thus has a higherguiding value in clinical practice.

Specifically, it is argued that the seven levelsof the assimilation model can be used as commonstages through which all therapists should guidetheir clients. In order to facilitate client progressthrough these stages, a variety of individual (eclec-tic) variables should be taken into account in treat-ment selection. Examples of how interventionscan be tailored to individual clients in differentlevels of assimilation follow. Similar treatmentselection decisions can and should be made forall seven levels of client change.

The Exploration Phase of Treatment-The EarlyLevels of Problem Assimilation

This phase of change is generally described asan effort to facilitate client progress from a stateof vague awareness to a state of understandingand insight into problems and behaviors. In thisexploratory period of treatment, both theory andempirical research suggest that there are differentroads (i.e., cognitive vs. experiential) towardawareness and insight (Elliott et al., 1994; Maho-ney, 1991; Stalikas, Rogan, & Berkovic, 1996)that capitalize on either cognitive or emotional-experiential aspects, respectively. As an exampleof eclectic practice, Lampropoulos and Spengler(1999) proposed the respective use of cognitiveand experiential interventions in the awarenessphase of treatment of clients with a correspondingpredominant thinking style (rational vs. experien-tial; Epstein, 1990). Indeed, testing comparabletechniques from different therapies in specificstages of change through meaningful ATI designsseems promising. This is consistent with the 1986NIMH workshop recommendation for research inpsychotherapy integration (Wolfe & Goldfried,1988), which suggests, "Inasmuch as change pro-cesses are likely to vary with the particular stageor phase of treatment, comparative research on

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change processes should focus on a comparablephase across orientations" (p. 449).

Besides client thinking style, other variables toconsider in the exploratory phase of treatmentinclude but are not limited to the following:

Problem complexity. Mild and simple behav-ioral or interpersonal difficulties might be satis-factorily limited to the exploration of the problemand its dynamics. However, the existence of un-derlying unresolved intrapsychic conflicts may re-quire psychodynamic and insight-oriented, in-depth self-explorations (Beutler & Clarkin, 1990;Wolfe, 1992).

Resistance. Interpretations, confrontations,and highly directive and controlling techniquesshould be avoided with high-resistance clients.These clients may respond better to self-directedand self-change interventions, as well as to client-centered approaches or paradoxical techniques(Beutler, Engle et al., 1991; Beutler et al., 1999).

A variety of other important personality, nondi-agnostic client variables. Variables such as cog-nitive complexity, psychological-mindedness,dependency, emotional control, coping style, per-ceptual style, developmental level, neuroticism,extroversion, conscientiousness, agreeableness,and openness to experience may dictate that thetherapist needs to choose specific exploratory in-terventions. The eclectic selection might be madeaccording to the following dimensions: directiveversus evocative, systemic versus person-centered,symptom versus relationship focused, plannedversus spontaneous, homework versus in-sessionexploration, and so on (Anderson, 1998; Beutler,1991; Garfield, 1994).

Client diagnostic variables and therapist per-sonality variables. Client diagnostic variables(e.g., external attributions of problems; Stiles etal., 1997a; co-existing personality disorders) andtherapist personality variables are also importantto consider in prescriptive matching in this phase(Beutler et al., 1994). The interactions betweentherapist and client variables may also be takeninto account (e.g., therapist difficulty to be direc-tive and client need for direction, or a discrepancybetween therapist-client levels of cognitive com-plexity).

The Action Phase of Treatment-The LaterLevels of Problem Assimilation

This phase of change is generally described asan effort to facilitate client progress from the levelof problem clarification to problem solution and

then to control of the problem and mastery of thenew learning experience. Action-oriented inter-ventions are used in this phase, which focuseson exposure to and active confrontation of theproblem, as well as acquisition, testing, and prac-tice of new learning (interpersonal, cognitive,emotional, behavioral, etc.) during and betweensessions. Practice helps the client master the newbehaviors (and thoughts and feelings), which re-place the old, maladaptive, and problematic pat-terns. Client internal attributions of change arealso targeted.

Similar to the exploration phase, client, thera-pist, and problem (diagnostic) variables shoulddictate treatment selection. For example, clientcognitive complexity and cognitive style may beimportant for choosing between imaginal versusin vivo exposure. A client's preexisting deficitsor reasons, say, for depression, can determine asymptom versus relationship focus of the activeintervention. The level of client conscientiousnessis important for the degree of structure of action-oriented techniques (i.e., low conscientiousnessrequires high structure). Client self-efficacy, re-actance, and need for guidance and advice alsodictate the therapist's level of support and direc-tiveness in exposing the client to the problem,modeling the new behavior, and testing it in andoutside the session. Interactions between therapistand client variables should be considered in thetreatment selection in the action phase of ther-apy, too.

Implications for Psychotherapy Theory,Practice, Research, and Training

Psychotherapy practice is the first area that canbenefit from the integration of common factorsand eclectic approaches. Clinicians, regardless ofwhether they (a) practice integratively based ona common factors or a technical-eclectic approach,or (b) practice integratively from a specific theoreti-cal standpoint through an assimilative integrativefashion (Lampropoulos, in press-a), should alwaysbe aware of important commonalities and differ-ences in problems, therapies, clients, and them-selves. By applying as many common factors asnecessary in an individualized and prescriptivefashion, a small but important step toward theevolution of psychotherapy integration is taken.Until the integration of common factors and tech-nical eclecticism is thoroughly mapped, therapistscan use the principles discussed in this article toguide treatment selection and integrative practice.

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Psychotherapy research can also use these prin-ciples to explore this integration empirically andconceptually. It is hoped that detailed models thatplot common and eclectic dimensions in matriceswill be available in the future. The numerousclient, therapist, and process variables reviewedin the Bergin and Garfield handbook (1994) andthe various common factors proposed in variouslists (Grencavage & Norcross, 1990) provide richmaterial to be studied. Following the examplesdiscussed in this article, integrative researcherscan further explore how each of these commonfactors can be most effectively applied andmatched to different individual and situationalcharacteristics. Existing empirical data and theo-retical hypotheses can also help prioritize this re-search. However, work on defining common fac-tors more clearly should precede these explorations.

Psychotherapy theory will be the next naturaldevelopment. Following empirical research, theo-ries of psychotherapy and change could be cre-ated. One of the most common critiques of eclec-ticism is that it is atheoretical. Although it maynot be guided by a specific theory of personalityand psychopathology, eclecticism's final goal isto develop empirical theories of change (Beutler,1995). The same may be true for the common-factors approach. For example, Lampropoulos (inpress-b) proposed a common-factors frameworkto describe and explain change in psychotherapyand other human interactions, such as parenting,education, religion, sales, politics, friendships,and mentoring and coaching of any kind (e.g.,sports, acting).

Psychotherapy training should focus on teach-ing important eclectic and common-factors vari-ables; these must be the first lessons in theeducation of novice integrative-eclectic therapists(Lampnpoulos, Moahi-Gulubane, & Dixon, 1999).Beutler (1999) recently offered eight basic guide-lines for the training of eclectic therapists. Theseguidelines cover major areas of treatment selec-tion and matching (e.g., optimal format, type,and length of treatment; ESTs; indications andcontraindications). By adding recommendationsfor (a) training in the identification and applica-tion of common factors, and (b) training in theforegoing integrative treatment selection system,we have the first "ten commandments" for thetraining of integrative therapists. Although theseten commandments may not be irreplaceable,their goal will always be sacred: to train therapists

to provide clients with the optimal and cost-effective services they are looking for.

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