Therapeutic Integration Strategy

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17th Jul 2017 Psychology Reference this

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Historically counsellors and psychotherapists were trained within a single theoretical orientation. In their practice, this initial theoretical orientation, would on the whole 'stick' with them throughout their career (McLeod, 2009). With several counselling and psychotherapy approaches being developed in the second half of 20th century, a substantial body of available literature to helping became available (Hollanders, 1999). The downside of so many schools existing was the division it created among practioners such as 'this against that', 'mine is better than yours' attitude (Lapworth & Sills, 2010), and each claiming to be 'the right one' (Cooper & McLeod, 2011). In the middle of such division some practitioners began asking questions such as, 'Which, if any, has the correct theory and practice for helping people in distress?' (Sanders, 1996, p.28). In general until the 1960s, theoretical purity was preferred, even though an integrationist movement was in progress providing numerous alternative models and approaches to working with clients.

In recent years, the tendency for practitioners to be exposed to different ideas, concepts and techniques have led many to attempt to overcome the problems associated with single orientation therapies (Goldfried, Pachanakis & Bell, 2005). Research supports this fact showing that many practitioners educated and trained in one orientation would have also studied variety of other approaches and tends to use them in their everyday practice. In addition, many practitioners are no longer referring to themselves as 'purist' but rather identifying themselves as integrative (Lapworth & Sills, 2010).

It can be assumed that the practitioners are attracted to counselling and psychotherapy integration for variety of reasons. One of the most important reasons is when practitioners find themselves needing to expand their range of conceptual and intervention skills in order to be fully responsive to the needs of their clients (Norcross & Goldfried, 2005). The current development towards integration was also forged with many practitioners implementing their own personal style during therapy by incorporating their life experience, cultural values and their work setting (McLeod, 2009). Some have pointed out that the reason why practitioners are more likely to react defensively when presented with different perspectives on therapeutic practice is because the field of psychotherapy is still in a 'pre-paradigmatic' state (Norcross & Goldfried, 2005). This means that psychotherapy as a scientific discipline is still in its developmental stage whereby collective understanding in its professional community is yet to be grasped (Cooper & McLeod, 2011).

It is estimated that there are approximately 400 different types of therapy (Norcross, 2005) offering numerous explanations of psychological distress and immense amount of practical techniques to help the client alleviate some of it. A steady development in eclecticism and integration has continued to flourish. It can be claimed that today they are the most widely practised theoretical orientation of English-speaking psychotherapies (Norcorss, 2005; Cooper & McLeod, 2011). However, this is still not reflected in the current therapy training. Majority of therapists within the United Kingdom are not trained in an integrative approach. Furthermore, orientation-based practices in the United Kingdom continue to be encouraged with distribution of programmes such as Improving Access to Psychological Therapies which is based on evidence-based practice and as such prescribing manualised treatments to specific psychological problems (Cooper & McLeod, 2011).

When thinking about clarifications of the words integration and eclecticism it is important to remember that in relation to each other there are no universally agreed definitions over the meaning of the terms (Hollanders, 1997). The related literature points to this confusion and Norcross and Grencavage (1990) skilfully point out that they both have similar goals and 'no technical eclectic can totally disregard theory and no theoretical integrationist can totally ignore technique' (p.11). From the very beginning of counselling and psychotherapy it could be also argued that there is no such thing as a 'pure' theory. Naturally all theoreticians have been subjected by the past.

Eclecticism can be defined as using various techniques without regard to their theoretical origins whereas integration is defined as endeavours at combining various theoretical ideas into a comprehensible new theory (Hollanders, 1997). For the purpose of this paper, I will use the word integration to refer to both eclecticism and integration. I do acknowledge that Stricker and Gold (2003) describe eclecticism as an alternative to both single orientation therapy and integrationism. However, I feel the single word 'integration' is a self-explanatory term, equipped at instantly summarising and describing the movement away from the purist approaches that have dominated the world of counselling and psychotherapy.

Integration of therapeutic approaches can be argued is a process which is constantly evolving rather than being a static position (Hollanders, 1999). In this paper, I will propose that therapy integration can be based on ethical and philosophical level which will be discussed at a later stage. However, I will now briefly present some arguments in favour of therapy integration and provide an overview of main strategies to date for achieving integration.

Strategies for achieving therapeutic integration

It can be argued that there are more parallels between theoretical approaches and effect sizes a differences (Luborsky et al., 2002). For instance, at a convention in 1940, many recognised figures (such as Saul Rosenzweig, Carl Rogers and Frederick Allen) settled that features such as support, a good client-therapist relationship, insight and behaviour change were common factors in effective therapy (McLeod, 2009).

There is no doubt that it is a significant challenge to combine ideas and methods from different therapeutic approaches and to achieve an effective balance of them in practice. At the heart of each single orientation there are underlying set of theoretical and philosophical foundations which directly inform therapy practice. Often these foundations or principles are not compatible with each other and might even be contradictory. This makes the present time for psychological therapies of great turmoil, excitement and change (Cooper, 2009). The broad aim of the therapeutic integration is not to be an enemy of the unitary-approaches but against a unitary-approach mentality (Hollanders, 1999).

Some argue that honest acknowledgement of integration difficulties and open discussion of this work may lead to substantial progress in the practice of integrated therapies. In literature more is needed on 'how difficult this work is; how imperfect our knowledge, skills and tools are and how difficult it is for patients to engage themselves in the process' (Norcross & Goldfried, 2005, p.408). In this next section I will explore different strategies for therapeutic integration which will make this challenge more apparent.

Theoretical Integration

It can be defined as a creation of a new approach by blending aspects of two or more existing approaches together (Cooper & McLeod, 2007). The fundamental tactic in attaining theoretical integration is to find a central theoretical concept or framework within which, some or all existing approaches can be incorporated. One way to achieve this is through identifying a higher-order construct which is transtheoretical or beyond any one single approach. In this way a practitioner map would be produced helping to link all the different concepts and ideas together (McLeod, 2009). Among examples of approaches that have created theoretical integration in such a manner is Egan's Skilled Helper Model which is what I will be arguing in this paper. I realise that some writers (Jenkins, 2000 and Wosket, 2006) take a different point of view on whether the model is seen as eclectic or integrative or somewhere in the middle. I will discuss Egan's Skilled Helper Model later in this paper.

Common Factors

The guiding principle of this form of integration is to identify the active ingredients across a range of therapies. Its founding father is Jerome Frank, whose talent was his ability to account for the practice of therapy in ways that go beyond the restrictions of any one single approach, nonetheless apply to all approaches (Cooper & McLeod, 2007). Frank's identification of non-specific factors that help clients deal with their problems has since been recognized as 'common factors' which according to Miller et al (2005) are extra therapeutic events (positive experiences outside of the therapy room), the therapy relationship, the instillation of hope and positive expectations for change and structure of therapeutic work (Norcross & Goldfried, 2005, p.372). Proponents of the common factors approach have been significant in providing a clear opposing argument to the supporters of the theoretical purity. The key element to this approach is monitoring what works for the individual client by asking for feedback and reflecting on the degree that the common therapeutic factors have been implemented. Many practitioners feel liberated by concepts of this approach. However; the common factors model does not detail therapists tasks other than focusing on client's perception of change and the progress made in therapy. The common factors approach operates as a meta-perspective within which it is possible to utilise a range of methods and techniques by those already competent practitioners (McLeod, 2009).

Assimilative Integration

Assimilative integration is a process which takes place on a personal level in which the practitioner integrates new techniques and ideas into their pre-existing theory (Cooper & McLeod, 2007). The secret to this method is for the therapist to develop their own approach based on their specific personal and professional development and experience. The main focus of this approach is in interpreting any new perspective and/or technique through the eyes of the single orientation they have been initially trained in. As such new ideas are either rejected or accepted into the therapists pre-existing structure of how to do therapy (McLeod, 2009).

Technical Eclecticism

A purely eclectic approach to therapy is addressing the client's needs or problems by choosing the best or most appropriate techniques from variety of orientations. Technical eclecticism is a pragmatic approach to therapy. The practitioner makes an initial assessment of the client and draws on an extensive range of techniques whilst ignoring the theoretical roots of the techniques they have selected. This is because the practitioner is concentrating solely on what works in practice. According to Lazarus (2005) effective practitioners need to be versatile with a broad and flexible repertoire which is in contrast to the single model approaches in which all clients receive the same general conditions and where the therapist creates near identical relationships with all clients. In a chameleon like way, the eclectic therapist knows that the relationship and techniques are not prescribed to clients but are out of choice to ensue clients' needs are met (Norcross & Goldfried, 2005). For example, more recluse clients need more ways to open up whereas very sensitive clients might want a more challenging approach. The major limitation of this approach is reliance on empirically supported techniques which requires a high level of mastery and competence in the central concepts of a variety of orientations and their perspective weaknesses.

A further weakness of technical eclecticism is that techniques and ideas from other viewpoints can come across as 'add-ons' chosen on weak grounds. This argument would insist on the requirement that the techniques are selected on both strict criteria and thorough principles underlying the choice of intervention (McLeod, 2009).

Summary of some well-known disagreements about therapy integration

In the midst of the debate between single school approaches and newer developments such as integration some writers would argue that little progress has been made in answering the question posed by Paul in 1967: 'What treatment, by whom, is the most effective for this individual with that specific problem, and under which set of circumstances?' (p.111).

Lapworth & Sills (2010) summarise that there are currently three main debates about ever-changing philosophical and theoretical boundaries within counselling and psychology. The first is the purist or single orientation argument for therapy, the second is the debate between eclectic and integrative approaches and the third, is between the practioners of various strands of integrative approaches. The last two debates are in my opinion more to do with disagreements about meanings and definitions then something of substance. Spending time on debating about essentially different approaches under the one umbrella of therapy integration is I think fruitless. In addition, it only encourages the division within counselling and psychotherapy universe.

One of the biggest critics of both eclecticism and integration is Eysenck (1970) who as a theoretical purist strongly believed that any attempts to combine different schools of therapy are likely to end in confusion because each approach is based on different philosophical perspectives. Famously Eysenck (1970) said that combining theories will end up in "mishmash of theories, a huggermugger of procedures, a gallimaufry of therapies and a charivaria of activities..'(1970:140-6). Szasz (1974) suggests that combining theories and practices will lead to inauthencity.

From another standpoint, Downing (2004) has claimed that attempts at integration result in replicating something quite similar to single models of theory and practice. In other words, that any form of integration (particularly theoretical and assimilative integration) end up making a new single model or theory; just one that is collected from many different sources (Cooper & McLeod, 2007).

Some theorists would claim that practitioners from single orientation have joined a long standing professional identity. According to them to refer to oneself as eclectic or integrative is indicative of lack of identity and saying that lack of commitment to a particular professional body (Hollanders, 1999).

Where does Egan's Skilled Helper Model fit with therapy integration?

As I mentioned earlier, Egan's Skilled Helper model (2010) is an example of transtheoretical approach to integration. The key integrating or 'high order' concept Egan chose is that of problem management. Essentially Egan refrained from creating impressive theories of the person and focused on the process of helping itself. He proposed that human problems were due to both internal (deficits in skills) and external factors (damaging social or interpersonal structures) and as such it was logical to help people manage their difficulties in a skills-centred way (Sanders, 1996).

To Egan clients seeking formal help from practitioners are struggling to cope with their problems. As such the key task of the counsellor or psychotherapist is to help the client discover and act on appropriate solutions in order to manage these problems (McLeod, 2009). The model breaks down the problem solving process in therapy into three stages. In the first stage, client's problem is explored through discussions about their current situation, the second stage involves brainstorming alternative solutions and the third stage, involves planning and implementing goals to achieve change in the problem presented. The fine details of each stage of the Egan's Skilled Helper Model are not covered in this paper due to lack of space. However, within each stage of the model there are sub-stages and Egan specifies the key skills needed by the therapist in order continue the helping process.

Egan has produced a practitioner 'map' that selects in his opinion the most effective elements of other approaches and hence brought together a number of techniques to be skilfully practiced through a series of stages (Sanders, 1996). For example, the model shares some features of the client-centred theory by implementing core conditions and the idea of challenging 'blind spots' (Egan, 2006) is directly influenced by a psychodynamic school of taught.

Although Egan suggests that the stages are followed in a particular order his latest version (2010) stipulates that the stages are not necessarily static and can be applied much more flexibly and collaboratively. Egan's model is user friendly, offering basic helping skills and as such is a good starting point for new counsellors and psychotherapists (Sanders, 1996). In practice the model can be used as a simple framework through which new approaches from a variety of sources can be incorporated. Another asset of Egan's model is its applicability to a range of contexts and counselling modalities (McLeod, 2009).

On the other hand there are number limitations of Egan's Model. For example, Jenkins (2000) argues that Egan's hypotheses about human nature, underpinning the model are contradictory. From one point of view the model presents people as capable of overcoming challenges, seeking new opportunities and achieving goals whilst at the same time Egan refers to human beings as incapable of pursuing their goals due to being 'bottomless pits' of self- crushing actions and continued issues with confidence, negative state of mind and use of inappropriate strategies (Jenkins, 2000). Despite the model's stages it can be argued that Egan over focuses on individual factors and as such minimises the influence of client's social structures.

In terms of client-therapist relationship Egan puts forward the idea of the collaborative working alliance. However, by referring to the client-therapist relationship in this way Egan underestimates the reparative nature of therapeutic relationship as being key factor in producing change. It flows from this, that the therapeutic relationship is seen as helpful instead of determining importance to the counselling work undertaken (Jenkins, 2000). It is therefore 'a relationship of service, not an end in itself' (Egan, 1990:57). Some helpers saw Egan's approach as reducing the human qualities of helping and trading them with practical, 'de-humanised' techniques (Sanders, 1996). However, it's important not to overlook that the contributions made by Egan and other integrative pioneers has required practitioners to become more reflective in their practice.

As mentioned earlier, Egan's Skilled Helper Model is it the most basic levels of helping or as Egan himself describes client's Problem Management. In addition, the model is not likely to be suitable for those experiencing major psychological distress and similarly would be unsuitable for those who are beginning to think about change (Jenkins, 2000) and seeking help (pre-contemplation stage of change). Although the Skilled Helper is widely used in Britain there is very little research validating the three stage model as a specific paradigm thus, the stages for now remain largely abstract.

Pluralism - An alternative integration approach based on philosophy and ethics

The pluralistic therapy was developed by McLeod and Cooper (2007). They combined and elaborated on important elements of each of the strategies of integration discussed earlier in this paper. I will re-visit these strategies of integration in comparison to pluralism later on in this section.

Pluralism is defined as 'the doctrine that any substantial question admits a variety of plausible but mutually conflicting responses' (Rescher, 1993:79). From a pluralistic standpoint, there is no one universal answer to scientific, moral or psychological questions that can be applied to all human beings. This is because people are considered to have a wide array of experiences and grouping them would be unethical as well as problematic due to the likelihood of excluding those that are different and diverse (McLeod, 2009). According to McLeod and Cooper (2011): 'That is, neither scientists, philosophers, psychotherapists not any kinds of people can claim to have a better vantage point on reality. Each of us has our own quite special and unique understanding of what is there' (p.7).

From the perspective of the therapist similarly, Schmid (2007) argues that good therapy involves refraining from categorising the other person within practitioner's pre-existing understanding but to be ready and accepting of different experiences. The goal of the therapist is not only to utilise knowledge within therapy literature but also be open to a vast number of plural possibilities such as individual's cultural and social conditions (McLeod, 2005).

The main assumption underpinning pluralist framework is that psychological difficulties may have multiple causes and that as such there is no one correct therapeutic approach that will be appropriate in all situations for all people (McLeod & Cooper, 2007). The basic belief per se is that different things are likely to help different people at different points in time. Pluralistic framework is built on two principles. First, that multiple change processes exist, none which are superior to others and second, that the most important is that any therapeutic decision about which method to follow is based on strong collaborative commitment of the client's view of what will be useful for them. It follows that this commitment needs the therapist to stretch beyond current therapeutic assumptions and interventions (McLeod & Cooper, 2011).

The pluralistic framework operates on philosophical and ethic constructs integral to practice of therapy as opposed to being built upon any psychological construct. This means that pluralism is not bound by any particular psychological model. The strong emphasis in therapy is on three domains consisting of goals, tasks and methods. According to McLeod and Cooper (2007), these domains offer a clear way by which therapeutic processes can be hypothesised, studied and empirically researched to inform future practice. At the centre of each of these domains and interactions between them is collaborative relationship between the therapist and the client. In pluralism the therapeutic relationship and being attuned to client's perception of reality is highly important.

In my quest for learning about therapy integration, I felt delight when reading about pluralistic approach to therapy. The philosophical and ethical stance described resonated with my own life and understanding. One could say it felt like 'coming home' and that for me, at least, pluralism not only represented a path forward but it truly embodied the saying, 'Jack of all trades, master of none'.

As mentioned earlier, pluralism builds on the 'goodness' of each therapy integration approach. John McLeod (2009) himself wrote, 'collaborative pluralism can be regarded as an adaptation and elaboration of central themes found in other strategies for therapy integration' (p.382). For instance, pluralism translated use of techniques in technical eclecticism by setting guidelines by which to choose them. Pluralism added to the ideas of common factors by incorporating use of individual's 'cultural resources'. Pluralism loved continuation of learning and developing of practice proposed by assimilative integration. However, it disagreed that it is necessary for practitioner's initial training to be focused on a single approach and that anything new needed to be assimilated through those pre-existing concepts. As of theoretical integration, pluralism argues that it is not sufficient to just dismantle ideas and methods only to reassemble them in the newest type of packaging. For this to be an effective process it should take place on case-by-case basis instead of one size fits all mentality.

However, pluralism does not embrace or suggest 'anything goes' approach to combining different therapies (Cooper & McLeod, 2011). Its clear structure and emphasis on in prioritising what the client wants to gain from therapy keeps it grounded in a pluralistic viewpoint. Pluralistic framework to therapy is strongly related to Kanellakis' (2009) proposition that the core of counselling psychology as a profession is its base in a set of humanistic values and ethics. These humanistic and ethical roots are what makes pluralistic therapy stand out from other integrative approaches (Cooper, 2009; Cooper & McLeod, 2011). In addition, its intense desire to respect experience and point of view of the other emphasises the fundamentally relational nature of human being (Levinas, 1969; Cooper, 2009).

Pluralism has the benefit of being able to improve on strengths and weaknesses of earlier approaches to therapy integration. The limit of being a recent approach to appear is that there is no research and practice cases to emerge as of yet.

Main areas of convergence and divergence between Egan's Skilled Helper Model and pluralistic framework

Before I begin this specific but overall comparison of Egan's Skilled Helper Model and pluralistic framework of integration its worth mentioning that throughout this paper one observes the common overlap between all integrative thought and single orientation approaches to alleviating psychological distress. This overlap is that simply most practitioners regardless of their theoretical background try to match their practice to the needs of the client (Cooper & McLeod, 2011).

There is also an overlap between the pluralistic viewpoint and specifically Egan's Skilled Helper Model. As there is nothing in literature directly comparing Egan's Skilled Helper Model and pluralistic framework this next section will be written solely on my observations and knowledge gained through reading on the matter. For the purpose of this essay Egan's Skilled Helper Model is categorised as theoretical integration of therapy.

For ease of reading, this comparative section will be divided in the following parts: theory and basic focus, value base, components of therapy, therapist involvement and therapeutic relationship, broad comparison to single orientations and other therapy integrations and research.

Theory and basic focus

Clearly both Egan's model and pluralistic therapy are integrative approaches. Pluralistic therapy endeavours to utilise all the existing concepts and models of therapy integration but without creating a new theory or particular orientation of practice (see McLeod, 2009; Cooper & McLeod, 2011).

Egan's model (2010) on the other hand has created theoretical integration by including some ideas but discarding others. As such it can be argued that Egan's integrations of previous theory have resulted in him implicitly advocating a new theory of therapy practice. For example, Egan's merging of new approaches resulted in the creation of a cognitive 'map' on which the model is built (Jenkins, 2000). In effect, the eclectic way Egan has integrated elements from a number of sources to problem management has is in the end all been founded on his perception of the change process. The change process Egan follows is that of behaviourism (Woolfe et al., 1989; Cooper & McLeod, 2009) in that he prefers external markers for outcome at the expense of more subtle internal ones such as emotions and insight gained in therapy. Although Egan acknowledges internal change his presumption in needing to identify behavioural change may, according to critics, alienate the client. Instead of haphazardly or implicitly developing a new theory, like Egan's model has, pluralism believes there is more than one truth to everything and hence focuses instead on 'what works' (Jenkins, 2000; McLeod 2009).

Value base

Pluralism is conceptualised and centred on specific philosophical and moral issues. As such its value base and set of guiding values is rooted in ethics (McLeod, 2009; Cooper & McLeod, 2011). While the value base of Egan's model is rooted in pragmatic usefulness. For instance, this would be Egan's pragmatic focus on client's problem management.

Components of therapy

Both Egan's model and pluralism follow similar stages or domains in therapy. However, the fundamental difference between the two is the main focus of each stage. In the pluralistic framework the most important is for to come to a mutual understanding of the issue that has driven the person to seek therapy (McLeod, 2009). Everyone is different as such there is no goal which is equally or most important to every person. It follows that there may not be a direct link between the components within one stage and the other (Cooper & McLeod, 2009). For pluralism, Egan's relentless problem solving or managing through the application of the stages is more important than building a collaborative therapeutic relationship. The argument might be that the Egan's model is excessively rational in its focus at each stage on task, thinking and behaviour at expense of the process of therapy and client's emotions (Jenkins, 2000).

Therapist involvement and therapeutic relationship

From a pluralist perspective, both therapist and client are sources of ideas and decisions. This is because a pluralistic framework believes that for change to happen the therapy needs to primarily concentrate on things that are meaningful to the client. A pluralist practitioner will focus on what the client believes will make effective therapy (McLeod, 2009). The therapeutic relationship is highly valued and as such is embedded in the principles underpinning the pluralistic framework. This is why in pluralism the relationship between the client and therapist is referred to as a 'collaborative' process.

Although therapeutic relationship is acknowledged as being an important part in therapy in Egan's model the intervention is more therapist orientated, meaning that the therapist is seen as a primary source of ideas and decisions (McLeod, 2009). This is reflected in Egan's choice of vocabulary in describing the therapeutic relationship as a 'working alliance'. The limitation of working alliance is in the words themselves which undervalue the relationship between the client and therapist as being one of the main factors in bringing about change (Jenkins, 2000 & McLeod, 2009).

Broad comparison to single orientations and other therapy integrations

Egan's model selects only some elements from a pool of available therapy orientations and approaches. This is unlike the pluralistic approach which is open to all possibilities. Due to the selective nature of Egan's model this has resulted in the model for instance, not benefiting from valuable knowledge of other approaches such as psychodynamic. In his book Egan (2010), recognises that: 'Effective helpers understand the limitations not only of helping theories, frameworks, and models but also of helpers, the helping profession, clients, and the environments that affect the helping process' (p.33).

The strength of a pluralistic position is acceptance that a variety of different models of psychological suffering and change can be correct. As such according to pluralism it is unnecessary to attempt to condense our understanding of human problems into one model (Cooper & McLeod, 2007). From a pluralistic perspective, it may be true that the client is distressed because of their learned behaviour (Skinner) negative self-talk (Beck), or because of his or hers repressed needs and wants (Freud). Pluralism maintains that different explanations of human experience and interventions are sufficient for different individuals at different stages of their lives.

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