Psychotherapy Integration: An Assimilative, Psychodynamic Approach
Jerold R. Gold
Original citation: Stricker, G., & Gold, J.R. (1996). Psychotherapy
integration: An assimilative, psychodynamic approach. Clinical Psychology:
Science and Practice, 3, 47-58.
Electronic citation: Retrieved from http://cyberpsych.org/SEPI /stricker.htm
Psychotherapy integration is an approach
to treatment that goes beyond any single theory or set of techniques.
The history of the psychotherapy integration movement is described,
along with several approaches that have been developed to integration.
We then describe our assimilative approach, based on a psychodynamic
model but incorporating techniques from various active approaches
to treatment. A case history is provided illustrating the model
that we described.
Key words: Psychotherapy integration; Assimilative integration
Electronic reprint permission:
Oxford University Press
Psychotherapy Integration: An Assimilative, Psychodynamic Approach
Psychotherapists always have been interested in, and have
attempted to use, new developments in the natural and social
sciences, philosophy, theology, the arts, and literature. However,
for the most part, we have refused to learn psychotherapy from
each other if our ideologies and allegiances are different.
This isolationism has been contradicted by a small, but growing,
group of scholars and clinicians who have been able to cross
sectarian lines. These integrationists have aimed at establishing
a useful dialogue among members of the various sectarian schools
of psychotherapy. Their goal has been the development of the
most effective forms of psychotherapy possible. The integration
of therapies involves the synthesis of the "best and brightest"
concepts and methods into new theories and practical systems
of treatment. Given the rise of publications, journals, and
professional societies concerned with psychotherapy integration,
it seems that, as Arkowitz (1991) has announced, psychotherapy
integration has come of age.
The first approach to psychotherapy integration involved the
translation of concepts and methods from one psychotherapeutic
system into the language and procedures of another. A brief
historical overview1 of this movement might begin with an attempt
to convert Freudian psychoanalytic concepts into the terms of
learning theories. As noted by Arkowitz (1984), whose fine history
of psychotherapy integration has influenced extensively this
more concise attempt, perhaps the first article of this type
was written by Ischlondy (1930), and his work was expanded upon
by French (1933) and by Kubie (1934). French was concerned with
the correspondences between the Pavlovian constructs of inhibition,
differentiation, and conditioning and the analytic concepts
of repression, object choice, and insight. Kubie's expansion
of these ideas moved him to consider the possibility of such
phenomena as conditioning and disinhibition playing an important
role in the relationship between the analyst and the analysand.
These early pioneers in integration were following a trend
introduced into psychoanalysis by Freud (1909/1955). He had
noted the importance of compelling the phobic patient to face
the phobic object actively--a preview of in vivo desensitization--and
also experimented with setting time limits on the treatment
in order to promote conflict and to gain access to deeper unconscious
As learning theorists began to include operant conditioning
principles and organismic and complex psychological variables
in their systems, such ideas were applied to the dominant psychotherapeutic
approaches of the era. Sears (1944), Shoben (1949), and Dollard
and Miller (1950) recast psychodynamic and client-centered therapies
in the language and concepts of reinforcement and the internally
mediated learning that had been studied by neobehaviorists such
as Hull (1952). These studies emphasized the reinforcement value
of the therapist and, particularly in the case of Dollard and
Miller (1950), preceded modifications in psychoanalytic technique
that emphasized activity and instruction on the part of the
therapist. Procedures that are commonplace today in cognitive-behavioral
therapy and in many forms of integrative therapy were introduced
by Dollard and Miller, and included the use of homework, role
playing, and modeling, as well as active and graded confrontation
of fearful situations and internal states. Wachtel (1977) and
Arkowitz (1984) have noted that the work of Dollard and Miller
was much more influential in general psychology and in learning
theory than in psychotherapy studies, and that their direct
impact on psychotherapy integration was not felt until much
later. Alexander (1963; Alexander & French, 1946) modified
his psychoanalytically oriented approach to therapy by experimenting
with active approaches to the induction of change that were
informed by the then contemporary learning theories. A point
crucial to later developments in psychotherapy integration was
his introduction of the idea that insight into unconscious processes
often followed behavioral change, rather than exclusively being
the antecedent to change. This move away from a unidirectional
view of change was highly influential in the thinking of many
later students of integration.
A very important trend that was occurring throughout this
same time period was the search for generic change factors that
were common to all psychotherapies. Although not aimed at integration
or theoretical translation in themselves, these studies were
crucial in breaking down barriers between adherents of specific
theories and methods. Fiedler (1950) demonstrated that observers
were unable to differentiate between psychoanalytic, Adlerian,
and client-centered therapies, or to identify the therapeutic
ideology of different practitioners. Such research, as well
as the investigations of Frank (1961) and of London (1964),
pointed to the commonalties among the variety of contemporary
therapies, and collectively became a voice arguing for a nonsectarian
and generalist approach to psychotherapy. These arguments proved
to be extremely generative of the more specifically integrative
work that followed.
As behavior therapy became more sophisticated and more oriented
toward complex clinical problems, some of its theorists and
practitioners came to look to psychoanalysis, humanistic therapies,
and systems approaches for guidance, ideas, and methods. Some
pertinent examples of these truly integrative studies include
the works of Beier (1966), Marks and Gelder (1966), Weitzman
(1967), Sloane (1969), Marmor (1971), and Birk and Brinkley-Birk
(1974) among many others. These students shared a concern for
searching out the underlying theoretical links and similarities
among behavioral, humanistic, and dynamic methods. Brady (1968),
Birk (1970), and Feather and Rhoades (1972) experimented with
the technical integration of psychodynamic, systems, and behavioral
methods within single cases. Goldfried and Davison (1976) acknowledged
the utility of, and the need for, concepts and methods drawn
from other systems of therapy.
If the history of psychotherapy integration had a single watershed
moment, it was the publication of Wachtel's (1977) Psychoanalysis
and Behavior Therapy. This volume remains the most frequently
cited work in psychotherapy integration, and has served as a
model of integration at both a theoretical and a technical level.
Wachtel offered a theory of personality and psychopathology
that fully integrated critical aspects of psychodynamic and
behavioral theory into a unique and synergistic model. Just
as important, this new and integrative theory also allowed interventions
from a broad range of positions to be used clinically in a way
that was predictable and comprehensible.
Norcross and Newman (1992) identified eight interacting variables
that have encouraged the growth of psychotherapy integration.
These include: 1. the enormous expansion in the number of separate
psychotherapies; 2. the failure of any single therapy or group
of therapies to demonstrate remarkably superior efficacy; 3.
the correlated lack of success of any theory adequately to explain
and to predict pathology, personality, or behavioral change;
4. the growth in number and importance of shorter term, focused
psychotherapies; 5. greater communication between clinicians
and scholars that has resulted in increased willingness and
opportunity for therapeutic experimentation; 6. the intrusion
into the consulting room of the realities of limited socioeconomic
support by third parties for traditional, long term psychotherapies,
accompanied by an increased demand for accountability and documentation
of the effectiveness of all medical and psychological therapies;
7. the identification of common factors in all psychotherapies
that are related to successful outcome; and 8. the development
of professional organizations2, networks, conferences, and journals
that are dedicated to the discussion and study of psychotherapy
Recently, there has been an explosion of integrative works,
and of impassioned debate about the possibility and advisability
of integrative efforts. Of particular note during this period
was a collection of dialogues between supporters and opponents
of psychotherapy integration (Arkowitz & Messer, 1984).
A final sign of the evolving maturity of psychotherapy integration
was the almost simultaneous publication of two recent handbooks
that collected the work of the major contributors in single
volume sources (Norcross & Goldfried, 1992; Stricker &
The Modes of Psychotherapy Integration
There are three generally accepted ways in which the methods
and concepts of two or more schools of psychotherapy may be
combined or synthesized. These modes differ from each other
with regard to the hypothesized point at which the component
therapies meet and meld with each other. They also differ in
terms of the respective emphasis placed at each level on technique,
change factors, or broader theory (Norcross & Newman, 1992).
The three most commonly discussed forms of integration are
technical eclecticism, the common factors approach, and theoretical
integration. Technical eclecticism is the most clinical and
technically oriented form of psychotherapy integration. Techniques
and interventions drawn from two or more psychotherapeutic systems
are applied systematically and sequentially. The series of linked
interventions usually follows a comprehensive assessment of
the patient. This assessment allows target problems to be identified
and then clarifies the relationships among different problems,
strengths, and the cognitive, affective, and interpersonal characteristics
of the patient. Techniques are chosen on the basis of the best
clinical match to the needs of the patient, as guided by clinical
knowledge and by research findings. Technical eclecticism need
not be guided by an original or integrative theory of personality
or of psychopathology. Instead, it usually is based on existing
theories and goes beyond this conceptual foundation on a case
by case, clinical basis, by adding new techniques and clinical
strategies as they are needed. When theory is not involved,
this style of psychotherapy integration converges with an eclectic
The common factors approach to integration stems from the
assumption that all effective methods of psychotherapy share
to some degree certain critical, curative factors. Common factors
approaches start from the attempt to identify the specific effective
ingredients of any group of therapies. This effort is followed
by exploration of the ways that particular interventions and
psychotherapeutic interactions promote and contain those ingredients.
The integrative therapies that result from this process are
structured around the goal of maximizing the patient's exposure
to the unique combination of therapeutic factors that best will
ameliorate his or her problems.
The search for common curative factors in cross-sectional
studies of psychotherapy has a long and distinguished history.
The research and scholarship of such leaders in psychotherapy
as Jerome Frank, Carl Rogers, and Hans Strupp were central to
the establishment of the common factors approach as viable and
important. Rogers (1961) attempted clinically and empirically
to identify the necessary and sufficient factors that led to
therapeutic growth. According to Rogers, personality change
for the patient followed from a relationship in which the therapist
reacted to the patient with accurate empathy, unconditional
positive regard, and self-congruence. Frank's (1961) work contained
a cross- cultural perspective on healers and psychotherapists
and led to the conclusion that the remoralization of a defeated
patient and the provision of hope were central to all psychological
and moral helping relationships. Strupp and his colleagues (e.g.,
Strupp, Wallach, & Wogan, 1962) pioneered the empirical
study of psychodynamic psychotherapy. They (Strupp, Hadley &
Gomes-Schwartz, 1977) came to very similar conclusions with
regard to the effective ingredients of analytic therapies.
Contemporary common factors investigators have built on these
earlier efforts and have been able to demonstrate that most
therapies do share a pool of curative ingredients. These common
factors are relational and supportive, in that they stem from
the therapeutic relationship. They also are technical, deriving
from the provision of new learning experiences and the opportunities
to test new skills in action (Lambert, 1992; Lambert & Bergin,
1994). Each school of psychotherapy capitalizes on certain common
effective factors, and neglects or excludes others (Weinberger,
1995). The advantage of this common factors integration, then,
is to increase the number of these curative factors, common
and unique, to which the patient systematically may be exposed.
The last type of psychotherapy integration to be considered
here is theoretical integration. This form of integration has
been described as the most sophisticated and important by some
writers, but has been criticized as overly ambitious and essentially
impossible by others (Franks, 1984; Lazarus, 1992; Messer, 1992)
because of the scientific incompatibilities and philosophical
differences among the various schools of psychotherapy. Those
who argue in favor of this form of integration do so because
of the new perspectives it offers at the levels of theory and
of practice. Theoretical integration involves the synthesis
of novel models of personality functioning, psychopathology,
and psychological change out of the concepts of two or more
traditional systems. Integrative theories of this kind generally
attempt to explain psychological phenomena in interactional
terms, by looking for the ways in which environmental, motivational,
cognitive, and affective factors influence and are influenced
by each other. Causation usually is assumed to be multidirectional
and to include conscious and covert factors, and most theoretical
integrations include a focus on the ways that individual's recreate
past patterns and experiences in the present.
The systems of psychotherapy that follow from such theoretical
integration use interventions from each of the component theories,
as well as leading to original techniques that may "seamlessly
blend" two or more therapeutic schools (Wachtel, 1991).
At times, the clinical efforts suggested within a theoretically
integrated system substantially may resemble the choice of techniques
of a technically eclectic model. The essential differences may
lie in the belief systems and conceptual explanations that precede
the clinical strategies selected by the respective therapists.
Theoretical integration goes beyond technical eclecticism in
clinical practice by expanding the range of covert and overt
factors that can be addressed therapeutically. Subtle interactions
between interactional experiences and internal states and processes
can be assessed and targeted for intervention from a number
of complementary perspectives. Expected effects of any form
of intervention in one or more problem areas can be predicted,
tested, and refined as necessary. This conceptual expansion
offers a framework in which problems at one level or in one
sphere of psychological life can be addressed in formerly incompatible
ways (Gold, 1990).
The Assimilative, Psychodynamic Model of Psychotherapy Integration.
Our model of psychotherapy integration is one of theoretical
integration. It relies heavily on contemporary psychodynamic
theories of personality structure, psychopathology, and psychological
change, while freely using methods and interventions from other
therapeutic systems. This approach to theoretical integration
is described best as assimilative (Messer, 1992) because a single
theoretical structure is maintained, but techniques from several
other approaches are incorporated within that structure. As
new techniques are employed within a conceptual foundation,
the meaning, impact, and utility of those techniques are changed
in powerful ways. In his discussion of assimilative integration
of psychotherapies, Messer (1992) points out that all actions
are defined and contained by the interpersonal, historical,
and physical context in which those acts occur. Therapeutic
interventions are complex interpersonal actions, so that interventions
are defined by the larger context of the therapy. A behavioral
method such as systematic desensitization will mean something
entirely different to a patient whose ongoing therapeutic experience
has been defined largely by psychodynamically oriented exploration
than it will to a patient in traditional behavior therapy. The
process of accommodation is an inevitable partner of assimilation.
Psychodynamically oriented ideas, styles, and methods are recast
and experienced differently in an integrative system as compared
to traditional dynamic therapies. When we choose to intervene
actively in a patient's cognitive activities, behavior, affect,
and interpersonal engagements, we change the meaning and felt
impact of our exploratory work and of our emphasis on insight
These assimilative and accommodative changes have been detailed
extensively in the recent psychotherapy integration literature.
In earlier writings we have presented a "three tier"
model of personality structure and change (Gold & Stricker,
1993; Stricker & Gold, 1988). These tiers refer respectively
to overt behavior (Tier 1), conscious cognition, affect, perception,
and sensation (Tier 2), and unconscious mental processes, motives,
conflicts, images, and representations of significant others
(Tier 3). We emphasize theoretically and clinically the exploration
of this last sphere of experience, but recognize and use therapeutically
the complex and multidetermined interconnections between different
levels of experience. Unlike traditional psychoanalysis, which
treats behavior and conscious experience as epiphenomenal and
as important only in symbolizing underlying issues, we embrace
the realms of behavior and consciousness as areas of important
work in themselves.
Our evolving psychodynamic theoretical base inherits the contributions
of such psychoanalytic innovators as Ferenczi (1930) and Alexander
and French (1946), and interpersonalists such as Sullivan (1953)
and Fromm (1955). These authors all challenged the hegemony
of insight and interpretation within psychoanalytic therapy,
instead arguing that new experience and the corrective interaction
between patient and therapist were as important, if not more
important, than insight in bringing about change. Our thinking
closely resembles, and has been influenced deeply by, innovative
psychodynamic theories such as Wachtel's (1977, Gold & Wachtel,
1993) Cyclical Psychodynamics, Ryle's (1990) Cognitive-Analytic
Therapy, and Andrews' (1993) Active Self model. These theorists
observe that insight and new patterns of relating to the self
and to others are linked in circular, varied and shifting ways,
with insight following new emotional, interpersonal, and representational
processes as often as it causes those shifts in function and
style. Insistence on a unidirectional model of change (Gold,
1991) suggests, erroneously, that psychological life and psychotherapeutic
effect are straightforward and simple.
One also must rethink a psychodynamic model of the mind when
assimilative integration is employed (Stricker, 1994). In particular,
the unidimensional theory of change that is emblematic of classical
psychoanalysis must be jettisoned in favor of a multidirectional,
circular model (Gold & Wachtel, 1993; Stricker & Gold,
1988). We understand change to occur and to begin at any of
the three tiers of psychological life, rather than always being
caused by changes in unconscious conflict, structure, and motive.
We also argue that insight can be the cause of change, the result
of new experiences and ways of adaptation, or a moderator variable
that intervenes in the effects of other change processes. Often,
it is difficult, if not impossible, to identify the places of
insight and active interventions in the causal chain of events
that preceded a patient's gains.
In attempting to achieve assimilative integration, the selection
among alternative interventions is among the most difficult
decisions that face the therapist. Most frequently, these decisions
are made on the basis of clinical factors, such as theoretical
orientation or prior experience. This leads to highly individualistic
decisions that rarely are reliable, but often appear to be effective.
Nonetheless, the lack of reliability warns us that validity
may be suspect, no matter how much faith each individual clinician
has in his or her own decision. An alternative approach has
been suggested by Beutler (e.g., Beutler & Hodgson, 1993),
who is attempting to develop a research-driven basis for matching
interventions with therapeutic issues. Clearly this is a superior
basis for action, but the literature currently does not allow
a broad enough foundation for action and therefore many clinical
situations are returned to the clinician for decision on the
theoretical and experiential grounds that always have marked
The assimilative use of active interventions is based primarily
on the therapist's ongoing assessment of the patient's psychodynamic
status. This evaluation includes an emphasis on the tone of
the therapeutic relationship and alliance, as well as consideration
of the most pressing conflicts, defenses, self and object representations,
and emotional states with which the patient is struggling. Active
methods are chosen and are suggested with two or more simultaneous
and compatible objectives in mind: (1) to promote changes in
the person's current functioning that (2) will impact on central
intrapsychic and characterological processes as well.
When indicated, either on the basis of clinical experience
or research evidence, cognitive, behavioral, systemic, or experiential
techniques may be introduced to intervene in any or all of these
psychodynamic issues. For example, we sometimes will use an
exposure based method such as systematic desensitization or
assertiveness training to assist a patient in the task of reducing
social anxieties. Although the change in overt behavior is highly
desirable in itself, it also represents a way to work with resistances
and defenses that may not yield to interpretation. When the
patient is engaged more completely in previously feared relationships,
the underlying intrapsychic contributions to those fears will
be accessible to dynamic exploration in an immediate, emotionally
vital manner. Similarly, an impasse in the therapeutic relationship
that might be brought about by a patient's unconscious, paranoid
representation of the therapist's intentions may be resolved
only partially by interpretation of the immediate and historical
roots of those perceptions. Active testing of the accuracy of
the patient's ideas, as practiced in traditional cognitive therapy,
often can be highly effective in such a situation. As a final
example, interpretive work with a tightly controlled, overly
intellectualized person may be helped immensely by introducing
affectively oriented, experiential methods from gestalt therapy,
such as the two chair technique. The goal here is to combine
expanded intellectual awareness of the emotions that were repressed
with immediate and powerful experiences of those emotions. This
active expansion of the patient's affective life often synergizes
with psychodynamic exploration by creating a blend of insight
and experience that is less likely to be worked into the patient's
intellectualizing defensive structure in a redundant, isolated
The therapist takes an expanded perspective on the variety
of events and process that may affect intrapsychic life. Interpretation
and insight still are accorded a central place, but interpersonal,
cognitive, and emotional variables are seen as maintaining or
provoking wishes, representations of self and others, and complex
states of internal conflict (Ryle, 1990; Stricker & Gold,
1993; Wachtel, 1977). As Wachtel (1977; Gold & Wachtel,
1993) has pointed out, disowned intrapsychic states sometimes
may reflect the patient's unconscious perceptions of real events
and relationships in the here and now, rather than being remnants
of early experiences. Whether their derivation is past or present,
dynamic issues are shaped, reinforced, and sometimes are modified
by the participation of the significant people in the patient's
life. This applies to all patients, but especially is germane
to therapeutic work with patients whose pathology results from
deviations in development. These "character disordered"
individuals lack the internal structure necessary for such adaptive
tasks as affect tolerance, regulation of self esteem, or self
generated initiative (Stricker & Gold, 1988). These gaps
in development manifest themselves in severe impairment in behavior,
cognition, affect, and interpersonal relationships (Tiers 1
Work on these issues must address pathology at all three tiers.
To work only at the psychodynamic level would ask the patient
to go too far beyond his or her pre-existing adaptive capacities.
However, if one ignores the intrapsychic, the therapy may remain
superficial and overly simplified. When Tier 3 issues cannot
be addressed advantageously through interpretation, this expanded
framework allows the therapist to work indirectly on those issues
by using them as a "map" for change in the other tiers.
Work on overt behavior and conscious ideation and emotion can
proceed from any of the three tiers, but will be most effective
when the meaning of the behavior or thought is understood completely
and the selected interventions are presented and used in ways
that are experienced as benign and acceptable to the patient.
Additionally, ideas, affects, behaviors, defenses, and symptoms
do not exist in isolated ways or meaningless states. These Tier
1 and 2 phenomena frequently are invested with much symbolism
and meaning that is unknown to the patient and to the therapist.
For example, a particular cognitive structure, belief, or way
of processing emotion can unconsciously be perceived as a crucial
part of one's identity, or as a way of identifying with a parent.
Thus, active interventions may be experienced as forced wedges
that are aimed at prying loose a cherished self representation
or object relationship. A complete psychodynamically oriented
exploration of these phenomena is necessary to appreciate fully
the patient's needs in these matters, and then to introduce
active methods in ways that will seem most benign and helpful
to the patient (Gold & Stricker, 1993).
This conceptualization of the mutual influence and interpenetration
of the intrapsychic, interpersonal, experiential, and behavioral
spheres of life brings our psychodynamic theory closer to recent
developments in psychotherapy and clinical and developmental
psychology than its traditional psychoanalytic predecessors
(see, for example, Greenberg, Rice, & Elliot, 1993; Guidano,
1987; Safran & Segal, 1990; or Stern, 1985).
A Case of Assimilative Integrative Psychotherapy
In the case presentation that follows we attempt to illustrate
the use of active techniques. Three of the several assimilated
techniques that marked this essentially psychodynamic psychotherapy
are mentioned. This therapy lasted for about 32 months with
the frequency of sessions moving from once weekly to twice weekly
after about one year. The final six months of the therapy also
was conducted on a once weekly basis.
Mr. S. was a 37 year old single man who came to therapy complaining
of severe anxiety symptoms that had begun at about the time
the small company at which he worked had merged with a larger
and more impersonal firm. Mr. S. was an accountant who increasingly
felt isolated at work, especially after his supervisor retired.
He had formed an attachment to this older person that he described
as parental, and felt that he had been protected and supported
in this relationship. He was preoccupied with the prospect of
being fired by his new supervisor, although his evaluations
had been more than satisfactory. As a result of this concern,
he had been working longer and harder, had ignored any of his
few social connections and sources of recreation, and had fallen
into a reactive state of irritation and pessimism that bordered
on depression. Mr. S's father, with whom he had had a distant
and mutually unhappy relationship, had died suddenly about eight
months prior. The patient reported this in the first session
in a seemingly disinterested way, stating that he had felt little
about the loss. However, his associations, the few dreams he
remembered having near the time he sought therapy, and his description
of his relationships with his supervisor all pointed to repressed
grief reactions that were complicated by pre-existing unconscious
issues of loss, rage, and unrequited love.
The first phase of the therapy involved a broad inquiry into
all relevant experiences necessary to complete an assessment
at Tiers 1, 2, and 3. Tier 1 (overt behavior) was marked by
repetitive patterns of compulsive involvement with work, impulsive
and hasty actions and choices, and avoidant patterns of interaction
wherein Mr. S. took care to limit contact with people to an
excessive degree. Tier 2 (conscious cognition and affect) contained
rigid and moralistic demands for intellectual control over himself
and other people, affective constriction, and a long list of
"shoulds" and "musts." His compulsive preoccupation
with work yielded a conscious sense of perfectionism, pride
and ideas about being better than other people, but he also
suffered worries about his self worth and a dimly perceived
but ever present sense of shame that he could not explain. Tier
3 (intrapsychic representations) had been shaped by Mr. S.'s
relationships with an obsessive and distant father, and a depressed
and passive mother. His father had focused exclusively on his
highly successful and lucrative career, rarely displaying any
interest in his wife or children, whereas his mother cared for
the patient in a dispirited and dutiful manner. Mr. S.'s inner
world was composed of fragmentary andconflicting identifications
with these parents. He unconsciously was caught between a sense
of isolated grandiosity and a portrayal of himself as vulnerable,
without energy, and unworthy of a father's attentions.
The assessment also revealed the multidirectional relationships
among issues at the three tiers. Mr. S.'s psychodynamic issues
were symbolized and expressed in his behavior and thoughts,
but the way he acted and understood his experiences also confirmed
and reinforced his self and object relationships. For example,
each time someone made an attempt to befriend him, he felt caught
between his shameful sense of unworthiness and his identification
with his father's scorn of intimate connections. These conflicts
and the defensive need to avoid were then reinforced by the
other person's discomfort with Mr. S's ambivalent reactions.
When his compulsive behavior and perfectionistic ideas were
unrewarded at work, his rage and his sense of failing to achieve
the love and approval of a father figure also were reinforced.
As the therapy proceeded, Mr. S. became subtly but increasingly
combative, bringing his affectless, perfectionistic, and avoidant
style into the therapy. He could not use interpretations effectively
and, instead, challenged the scientific validity of the therapist's
formulations, general approach, and in particular the therapist's
ideas about the connections between the loss of his supervisor,
his relationships with his father, his reactions to his father's
death, and his current symptoms. These resistive interactions
severely threatened an already shaky therapeutic relationship,
as an increasingly unworkable hostile atmosphere developed.
The therapist became aware that, in his attempts to reach Mr.
S., he had become an accomplice to Mr. S: the patient needed
to keep the therapist at bay in order to ward off the very psychodynamic
issues that the therapist was concerned with. An assimilative
shift was proposed. The two chair technique from gestalt therapy
was suggested in order to help Mr. S. test his ideas about the
lack of validity of the therapist's formulations. If, as Mr.
S. argued, he had no other feelings about his father, his death,
and the loss of his supervisor, then these techniques probably
would be ineffective as well, demonstrating the therapist's
uselessness to him. On the other hand, if some change did occur,
perhaps Mr. S. would consider some change in his outlook on
his psychological situation and on therapy.
Thus followed an extended period of gestalt work in which
Mr. S. uneasily involved himself in the enactment of dialogues
with his former supervisor, with his father, and, eventually,
with himself as a child and with his mother. Gradually, his
affective constriction was loosened, and he became aware of
tremendous anger, coupled with a deep longing for contact and
a pervasive sense of shame, anxiety, and unworthiness of the
love of his parents.
The success of the experiential exercises had tremendous impact
beyond the expansion of Mr. S's emotional range. As hoped, he
began to review his ideas and feelings about the therapist,
psychotherapy, and his relationships in a new and more positive
light, with a strengthened bond with the therapist being one
result. The hostile transference that had developed diminished
significantly, and became the source of fruitful psychodynamic
investigation and insight that now could be integrated. As Mr.
S. now had experienced success in psychotherapy, and perceived
directly that the therapist was effective and on his side, other
implications of the transference (such as aspects of mother's
helplessness) became apparent. Mr. S. felt himself to have been
worthy of help, and in this experience found a basis for making
conscious, and for actively testing cognitively and interpersonally,
his fears that others would reject him as did his father.
A second example of assimilative integration in Mr. S's therapy
occurred when he suffered a severe panic attack when notified
of an unexpected internal audit of some of his work. Dynamic
inquiry and interpretation were impossible given the paralysis
that Mr. S. displayed in the next session. As a result, a move
was made toward active instruction in relaxation techniques,
cognitive measures for self-soothing, and calming imagery. These
techniques were very helpful. As Mr. S. became less anxious,
he realized that he was both exhilarated and saddened by these
events: the therapist had demonstrated an immediate concern
for Mr. S. and an ability to help him that evoked deeply painful
memories and images of father and mother. At times when the
patient had been distressed in the past, his father's disinterest,
and his mother's passive ineffectuality, had convinced Mr. S.
of the hopelessness of nurturance and help from others, and
had imprinted a vision of himself as isolated and reactively
self-contained. As these issues were explored, he became able
to acknowledge and to integrate a full range of affects that
he had long avoided. At the same time that he began to cast
off these self and object images, he used this helpful interaction
with the therapist as the source of new intrapsychic representations
A final example of our approach to the integration of active
methods is drawn from a situation in which the patient asked
for help in designing exercises to be used to overcome his interpersonal
distancing behaviors. A series of sessions were devoted to behavioral
rehearsal, anxiety management, and to the construction of an
in vivo hierarchy of social situations. These procedures had
three goals: first and most obvious, the reduction of his social
anxiety and improvement in social skills; second, to gain greater
access to the psychodynamic issues that were warded off through
his avoidance of intimacy with others; and lastly, support for,
and reinforcement of, his newly emerging sense of being able
to ask for help, and to be deserving of it. Correspondingly,
such a request signalled the presence of a benign image of the
therapist that required whatever confirmation was possible.
The results of this behavioral sequence were analyzed and led
to an ongoing expansion of the psychodynamic part of the therapy.
In these and all of the other instances when active techniques
were introduced to Mr. S., they were mentioned tentatively and
always with concern for his intrapsychic construal of their
meanings. The effects of these suggestions on his perceptions
of the therapist, their relationship, the therapist's understanding
of Mr. S's needs, and Mr. S's reactions all were explored repeatedly
before, during, and after the interventions were attempted.
These discussions often stood as among the more enriching part
of the therapy, as they highlighted all three tiers of psychological
life in an immediate and vital way. Empirical Considerations
If our assimilative model of integrative psychotherapy is
to be influential and long lasting, it must pass the tests of
scientific validation and reliability by which we evaluate all
therapies. We hope that our case study is clearly illustrative
of our thinking and methods. However, it does not itself demonstrate
anything about the model's efficacy, generalizability, or potential
for replication by other therapists.
At this point in our work we have been concerned exclusively
with clinical and theoretical issues, and have not been able
to subject this model to the empirical tests that it requires.
Nonetheless, it behooves us to raise the critical questions
that only can be answered by research, and also to consider
extant research findings that may speak indirectly to the status
of our work.
First, and probably foremost, are the questions concerning
treatment effectiveness and specificity. Is this therapy as
or more effective than its component therapies (psychodynamic,
cognitive-behavioral, or experiential) or any other systems
of treatment? Linked to this question are the issues of prescription
and patient matching: are there particular persons, problems,
diagnoses, or psychological characteristics for whom or which
this therapy can be empirically demonstrated to be most effective?
Inquiry also eventually must be directed at such theoretical
issues as our hypothesized revisions of psychodynamic theory
and the assumed circular relationships between psychodynamics,
behavior, cognition, and affective experience. In particular,
this model must be studied in terms of the incremental validity
of our expansion of the psychodynamic perspective when compared
to its traditional conceptualization. Finally, issues of generalizability
must be raised and tested. Will this therapy work, or even exist,
when conducted by therapists other than the authors of this
report? Can the model be taught? Can we formalize and offer
data driven guidelines for when and how to move from one intervention
to the next, or must clinical intuition dictate exclusively?
Although we do not yet possess direct and data derived answers
to these questions, the research literature does offer some
suggestions and reasons for cautious optimism. For example,
research on prescriptive psychotherapies (Beutler & Hodgson,
1993) and on the stages of change in psychotherapy (Prochaska
& DiClemente, 1992) have demonstrated the maximized effectiveness
of psychotherapies that include interventions that are drawn
from several different dimensions of psychological life, as
does our model. These groups of studies impressively support
the idea that technique serves the patient best when interventions
are matched to the patient's immediate clinical need and psychological
state. This view is central to our model. Clinical trials of
integrative psychotherapies that resemble ours in their fusion
of psychodynamic formulations and exploration with active interventions
have yielded preliminary but positive results. For instance,
the integrative, interpersonal psychotherapy for depression
developed by Klerman, Weissman, Rounsaville, and Chevron (1984)
has outperformed medication and other psychological interventions
in a number of studies. Ryle (1990) reports that both short
term and long term versions of Cognitive Analytic Therapy (CAT)
have been found emphatically to be more effective than purely
interpretive or behaviorally oriented approaches. Omer (1992)
offers empirical support for integrative interventions that
heighten the patient's awareness of his or her participation
in psychotherapy, thus improving the impact of the basic exploratory
stance of the psychotherapist. Glass, Victor, and Arnkoff (1993)
point out that several systems of integrative psychotherapy
have been demonstrated, albeit in limited numbers of studies,
to outperform either strictly psychodynamic or cognitive- behavioral
Perhaps the most impressive and important collection of studies
of integrative psychotherapy have been carried out by Shapiro
and his colleagues at the Sheffield Psychotherapy Project (e.g.,
Shapiro & Firth, 1987; Shapiro & Firth-Cozens, 1990).
These workers studied the impact of two sequences of combined
psychodynamic and cognitive-behavioral therapy: dynamic work
followed by active intervention or vice versa. They found that
the greatest gains were made, and the smoothest experience of
treatment were reported, by those in the dynamic-behavioral
sequence. Patients in the behavioral- dynamic sequence more
frequently deteriorated in the second part of the therapy, and
did not maintain their gains over time as often as did patients
in the other group. These findings seem to echo and confirm
the guidelines of our model, in which psychodynamic work usually
precedes and prescribes more active interventions.
Other research can be found that points to the possibility
of empirically validating expansions of psychodynamic theory,
and of the construct validity and reliability of clinically
generated integrative psychodynamic formulations. One central
source of these findings is the work of Andrews (1993) on the
Active Self model of personality and psychotherapy. This system,
like ours, posits feedback and feedforward relationships between
events in various psychological domains, with behavior, affect,
cognition, and interpersonal relatedness all serving to express
and to reinforce pre-existing representations of self and of
others. Content analysis of therapy transcripts has yielded
much support for this theory, and for its utility in guiding
the selection of interventions in an integrated psychotherapy.
Kiesler (1992) points out that work in personality theory
that is derived from the variety of interpersonal circles inventories
is supportive of many of the personality theories that drive
integrative models of psychotherapy. He notes that much data
exist to confirm hypotheses about the back and forth nature
of the relationship between intrapsychic and interpersonal variables,
and also to support the central focus of many integrative therapies
upon interrupting the processes that confirm and maintain pathological
representations of self and of others.
Empirical verification for psychodynamic formulations may
now be found in a variety of well designed and extensive research
projects. Methods such as the Core Conflictual Relationship
Theme (CCRT) developed in the Penn Psychotherapy Project (Luborsky
& Crits-Cristoph, 1990) can yield valid and reliable assessment
of central dynamic themes. The Mt. Zion psychotherapy project
(Weiss & Sampson, 1986) has generated the Plan Formulation
Method that yields an assessment of conscious and unconscious
goals, pathogenic beliefs and conflictual emotions, plans for
testing those beliefs, and necessary insights. These formulations
have been employed in a number of studies that impressively
have validated therapist and judges predictions about process
changes in psychodynamics over the course of psychotherapy (Weiss,
1994). Strupp and his colleagues at the Vanderbilt Psychotherapy
Project (Strupp, 1993; Strupp & Binder, 1984) also have
demonstrated the capacity to develop valid and replicable psychodynamically
informed formulations of a patient's psychological functioning
that drive and guide the therapist's interventive strategies.
These formulations are organized around a concept called the
Cyclical Maladaptive Pattern (CMP), a concept that expands the
view of psychodynamic processes in ways that are identical to
ours: internal variables are assumed both to influence and to
be influenced by interpersonal, cognitive, and emotional states
through feed back and feed forward processes.
The findings of these last few research projects also address
the questions of generalizability and teachability that we noted
above. The Penn Psychotherapy Project, the Mt. Zion group, and
the Vanderbilt Psychotherapy Project all have resulted in the
production of psychotherapy manuals (see Gold, 1995, for a more
extensive review of this work). These manuals offer any psychotherapist
explicit and data driven guidelines for formulation of the patient's
problems and current functioning. Studies indicate (Weiss &
Sampson, 1986; Luborsky & Crit-Cristoph, 1990; Strupp, 1993)
that compliance to the manual can be demonstrated and that the
level of compliance is linked positively to process variables
and to outcome. There is virtually no direct empirical evidence
concerning the model we propose, but there are many encouraging
developments to suggest that this and other models may become
of demonstrable validity, generalizability, and teachability.
An assimilative approach to psychotherapy integration combines
the organizing principle of a theoretical system of understanding
with the range of technical interventions available to the gamut
of schools of treatment. It has the advantages of access to
an expanded set of techniques and of the understanding that
comes from a coherent set of propositions to justify those interventions.
It also stretches the theoretical system in order to understand
better the impact of interventions that ordinarily would not
be available within that system.
Our approach begins with a psychodynamic system of understanding,
but incorporates behavioral and affect arousing procedures that
ordinarily do not follow from such an approach. The success
of these techniques lead us to favor an interpersonal rather
than a solely intrapsychic psychodynamic formulation, as these
techniques are more consistent with such a theory. However,
colleagues can begin with any other theory and also will find
it helpful to incorporate an expanded range of interventions.
This leads us back to our three tier approach. Behavior, the
first tier, is the province of the behavioral approaches. The
second tier, conscious cognition and affect, often draws the
cognitive- behavioral and the experiential theorists. The third
tier, dynamics, is the concern of the psychodynamic therapists.
However, patients function and malfunction at all three tiers,
and it behooves a responsive therapist to draw interventions
from all three. We have illustrated one among many possible
approaches to assimilative integration, and would recommend
that other therapists experiment with alternative combinations
of theory and technique, and then test these experiments empirically
so that the science and the practice of clinical psychology
and psychotherapy can be advanced.
Alexander, F. (1963). The dynamics of psychotherapy in
the light of learning theory. American Journal of Psychiatry,
Alexander, F., & French, T. (1946). Psychoanalytic therapy.
New York: Ronald Press.
Andrews, J. D. (1993). The active self model: A paradigm for psychotherapy
integration. In G. Stricker & J. R. Gold (Eds.), The comprehensive
handbook of psychotherapy integration (pp. 165-186). New York:
Arkowitz, H. (1984). Historical perspective on the integration
of psychoanalytic therapy and behavior therapy. In H. Arkowitz
& S. Messer (Eds.), Psychoanalytic therapy and behavioral
therapy: Is integration possible? (pp. 1-30). New York: Plenum.
Arkowitz, H. (1991). Introductory statement: Psychotherapy integration
comes of age. Journal of Psychotherapy Integration, 1, 1-4.
Arkowitz, H., & Messer, S. (Eds.) (1984). Psychoanalytic therapy
and behavioral therapy: Is integration possible? New York: Plenum.
Beier, E. G. (1966). The silent language of psychotherapy. Chicago:
Beutler, L. E., & Hodgson, A. B. (1993). Prescriptive psychotherapy.
In G. Stricker & J. R. Gold (Eds.), Comprehensive handbook
of psychotherapy integration (pp. 151-163). New York: Plenum.
Birk, L. (1970). Behavior therapy: Integration with dynamic therapy.
Behavior Therapy, 1, 522-526.
Birk, L., & Brinkley-Birk, A. (1974). Psychoanalysis and behavior
therapy. American Journal of Psychiatry, 131, 499-510.
Brady, J. P. (1968). Psychotherapy by combined behavioral and
dynamic approaches. Comprehensive Psychiatry, 9, 536-543.
Dollard, J., & Miller, N. E. (1950). Personality and psychotherapy.
New York: McGraw-Hill.
Feather, B. W., & Rhodes, J. W. (1972). Psychodynamic behavior
therapy I: Theory and rationale. Archives of General Psychiatry,
Ferenczi, S. (1930). The principles of relaxation and neocatharsis.
In S. Ferenczi, Final contributions to the problems of psychoanalysis
(108-125). New York: Basic Books
Fiedler, F. E. (1950). The concept of an ideal therapeutic relationship.
Journal of Consulting Psychology, 14, 239- 245.
Frank, J. D. (1961). Persuasion and healing. Baltimore: Johns
Franks, C. M. (1984). On conceptual and technical integration
in psychoanalysis and behavior therapy: Two incompatible systems.
In H. Arkowitz,. & S. Messer, (Eds.), Psychoanalytic therapy
and behavioral therapy: Is integration possible? (pp. 223 - 248).
New York: Plenum.
French, T. M. (1933). Interrelations between psychoanalysis and
the experimental work of Pavlov. American Journal of Psychiatry,
Freud, S. (1955). Notes upon a case of obsessional neurosis. In
J. Strachey (Ed. and Trans.), The standard edition of the complete
psychological works of Sigmund Freud (Vol. 10, pp. 153-318). London:
Hogarth Press. (Original work published 1909)
Fromm, E. (1955). Man for himself. New York: Henry Holt.
Glass, C. G., Victor, B. J., & Arnkoff, D. B. (1993). Empirical
research on integrative and eclectic psychotherapies. In G. Stricker
& J. R. Gold (Eds.), Comprehensive handbook of psychotherapy
integration (pp. 9-26). New York: Plenum.
Gold, J. R. (1990). The integration of psychoanalytic, interpersonal,
and cognitive approaches in the psychotherapy of borderline and
narcissistic disorders. Journal of Integrative and Eclectic Psychotherapy
, 9, 49-68.
Gold, J. R. (1991). Repairing narcissistic deficits through the
use of imagery. In R. Kunzendorf, (Ed.), Mental imagery (pp. 227-232).
New York: Plenum Press.
Gold, J. R., & Stricker, G. (1993). Psychotherapy integration
with personality disorders. In G. Stricker & J. R. Gold (Eds.),
Comprehensive handbook of psychotherapy integration (pp. 323-336).
New York: Plenum.
Gold, J. R. (1995). The place of process oriented psychotherapies
in an outcome oriented psychology and society. Applied and Preventive
Psychology, 4, 61-74.
Gold, J. R., & Wachtel, P. L. (1993). Cyclical psychodynamics.
In G. Stricker & J. R. Gold, (Eds.), Comprehensive handbook
of psychotherapy integration (pp. 59-72). New York: Plenum.
Goldfried, M. R., & Davison, G. C. (1976) Clinical behavior
therapy. New York: Holt.
Goldfried, M. R., & Newman, C. (1992). A history of psychotherapy
integration. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook
of psychotherapy integration (pp.46-93). New York: Basic.
Greenberg, L. S., Rice, L., & Elliot, R. (1993). Process-
experiential therapy: Facilitating emotional change. New York:
Guidano, V. F. (1991). The complexity of the self. New York: Guilford.
Hull, C. E. (1952). A behavior system. New Haven: Yale.
Ischlondy, N. E. (1930). Neuropsyche und hirnride: Physiologische
grundlagen der tiefenpsychologie unter besonder berucksichting
der psychoanalyse. Berlin: Urban und Schwarzenberg. Cited in Arkowitz,
Kiesler, D. J. (1992). Interpersonal circles inventories: Pantheoretical
applications in psychotherapy research and practice. Journal of
Psychotherapy Integration, 2, 77-100.
Klerman, G. L., Weissman, M. M., Rounsaville, B. J., & Chevron,
E. S. (1984). Interpersonal psychotherapy of depression. New York:
Kubie, L. (1934). Relation of the conditioned reflex to psychoanalytic
technique. Archives of Neurology and Psychiatry, 32, 1137-1142.
Lambert, M. (1992). Psychotherapy outcome research: Implications
for integrative and eclectic therapists. In J. C. Norcross &
M. R. Goldfried (Eds.), Handbook of psychotherapy integration
(pp. 94-129). New York: Basic.
Lambert, M., & Bergin, A. E. (1994). The effectiveness of
psychotherapy. In A. E. Bergin & S. L. Garfield, (Eds.), Handbook
of psychotherapy and behavior change, 4th Ed, (pp. 143-189). New
Lazarus, A. A. (1992). Multimodal therapy: Technical eclecticism
with minimal integration. In J. C. Norcross & M. R. Goldfried
(Eds.), Handbook of psychotherapy integration. (pp. 231 -263).
New York: Basic.
London, P. (1964). The modes and morals of psychotherapy. New
York: Holt, Rinehart, and Winston.
Luborsky, L., & Crits-Cristoph, P. (1990). Understanding transference:
The CCRT method. New York: Basic.
Marks, I. M., & Gelder, M. G. (1966). Common ground between
behavior therapy and psychodynamic methods. British Journal of
Medical Psychology, 39, 11-23.
Marmor, J. (1971). Dynamic psychotherapy and behavior therapy:
Are they reconcilable? Archives of General Psychiatry, 24, 22-28.
Messer, S. (1992). A critical examination of belief structures
in integrative and eclectic psychotherapy. In J. C. Norcross &
M. R. Goldfried (Eds.), Handbook of psychotherapy integration
(pp. 130-168). New York: Basic. (pp. 63-100). New York: Plenum.
Norcross, J. C., & Goldfried, M. R. (Eds.), (1992). Handbook
of psychotherapy integration. New York: Basic.
Norcross, J. C., & Newman, C. (1992). Psychotherapy integration:
Setting the context. In J. C. Norcross & M. R. Goldfried (Eds.),
Handbook of psychotherapy integration (pp. 3-46). New York: Basic.
Omer, H. (1992). Theoretical, empirical, and clinical foundations
of the concept of "therapeutic impact." Journal of Psychotherapy
Integration, 2, 193-206.
Prochaska, J. O., & DiClemente, C. C. (1992). The transtheoretical
approach. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook
of psychotherapy integration (pp 300-334). New York: Basic.
Rogers, C. R. (1961). On becoming a person. Boston: Houghton Mifflin.
Ryle, A. (1990). Cognitive-analytic therapy: Active participation
in change. Chichester: John Wiley & Sons.
Safran, J., & Segal, Z. (1990). Interpersonal processes in
cognitive therapy. New York: Basic Books.
Sears. R. R. (1944). Experimental analysis of psychoanalytic phenomena.
In J. McV. Hunt (Ed.), Personality and the behavior disorders
(pp. 191-206). New York: Ronald Press.
Shoben, E. J. (1949). Psychotherapy as a problem in learning theory.
Psychological Bulletin, 46, 366-392.
Sloane, R. B. (1969). The converging paths of behavior therapy
and psychotherapy. American Journal of Psychiatry, 125, 877-885.
Stern, D. (1985). The interpersonal world of the infant. New York:
Stricker, G. (1994). Reflections on psychotherapy integration.
Clinical Psychology: Science and Practice, 1, 3-12.
Stricker, G., and Gold, J. (1988). A psychodynamic approach to
the personality disorders. Journal of Personality Disorders, 2,
Stricker, G., & Gold, J. R. (Eds.). (1993). Comprehensive
handbook of psychotherapy integration. New York: Plenum.
Strupp, H. H. (1993). Psychotherapy research: Evolution and current
trends. In T. K. Fagan & G. R. VandenBos (Eds.), Exploring
applied psychology: Origins and critical analyses. Washington,
D.C.: American Psychological Association.
Strupp, H. H., & Binder, J. L. (1984). Psychotherapy in a
new key: A guide to time limited dynamic psychotherapy. New York:
Strupp, H. H., Hadley, S., & Gomes-Schwartz, B. (1977). Psychotherapy
for better or worse. New York: Wiley.
Strupp, H. H., Wallach, M. S., & Wogan, M. (1964). Psychotherapy
experience in retrospect: A questionnaire study of former patients
and therapists. Psychological Monographs, 78, 3-78.
Sullivan, H. S. (1953). The interpersonal theory of psychiatry.
New York: W. W. Norton.
Wachtel. P. L. (1977). Psychoanalysis and behavior therapy: Toward
an integration. New York: Basic.
Wachtel. P. L. (1991). From eclecticism to synthesis: Toward a
more seamless psychotherapeutic integration. Journal of Psychotherapy
Integration, 1, 43 - 54.
Weinberger, J. (1995). Common factors aren't so common: The common
factors dilemma. Clinical Psychology: Science and Practice, 2,
Weiss, J. (1994). How psychotherapy works. New York: Guilford.
Weiss, J., & Sampson, H. (1986). The research: A broad view.
In J. Weiss & H. Sampson, The psychoanalytic process. (pp.
337-348). New York: Guilford.
Weitzman, B. (1967). Behavior therapy and psychotherapy. Psychological
Review, 74, 300-317.
1 - Readers who desire a more extensive discussion of the history
of psychotherapy integration are referred to the excellent works
by Arkowitz (1984) and Goldfried and Newman (1992).
2 - Anyone interested in information about the Society for the
Exploration of Psychotherapy Integration (SEPI) may obtain it
by writing to George Stricker, The Derner Institute, Adelphi University,
Garden City, NY 11530.