“Speaking Frankly”

Psychotherapy Integration: Why and How?

Kenneth A. Frank, Ph.D.

Why can’t we simply decide to change and then make it so? Declare it and then, do it? Often, we cannot even get ourselves to bed on time or end our overdone late-night snacking. If we cannot manage even these simple behaviors, how can we possibly change complex responses that seem so deeply rooted within us that they are called up reflexively and automatically? Psychoanalysts call this “character”—all the habitual ways of feeling and reacting that distinguish one individual from another.

Becoming who you are is the product of a lifetime of learning—a practice you conducted, and still conduct 24/7, largely unconsciously. It continues no matter what is going on in your life. You learned, and continue to learn to be you, through the action of many psychological and biobehavioral processing systems. These include emotion, cognition, (like constructing meaning), sensation, imagery, and behavior, all coextensive with synaptic brain and other bodily changes that form your biological foundation. Invoking all these systems, you explored by watching, listening, thinking, feeling, imagining, making sense of, and doing; you processed and, ultimately, learned. Especially during your early years, little self-reflection was involved. And just as the project of becoming you seldom required you to focus on it, being you rarely requires premeditation. Adult life has become improvisation; it is as if, moment to moment, within certain parameters, you make it up as you go along.

Because your “youness” generally works adaptively, you remain constant and display a relatively narrow range of personality variability. As the saying goes, wherever you go, you take yourself with you. You manifest yourself in the most fundamental ways—how you walk and talk, as well as through rarified habits like your favorite books and music, your preferred cocktail (and whether you like it on the rocks), or whether you enjoy oysters. Being thoroughly practiced, you are good at being you. Exceptionally good. And wonderfully efficient. Moreover, beyond familiarity, you have grown to feel attached to the way you are, and if you are fortunate, you are pleased with it, at least mostly. No one else can do you. But you can—consistently, effortlessly, and mindlessly. You literally can do you in your sleep. When it comes to you, you are the world’s foremost expert!

II

By now I’m sure you have learned that your expertise is a two-edged sword. That is, when it serves you well, you can thank the heavens for it; but when it malfunctions, like losing your temper repeatedly with your spouse or kids, or becoming preoccupied with an irrational fear, then you learn just how difficult it is to change. Once, as a novice therapist, I consulted with a favorite supervisor. I was afraid a patient of mine was “decompensating,” deteriorating from a previously contained form of psychopathology and I needed to know what to do to stem her decline. He reminded me how difficult it is for us to help people change for the better, and pointed out that the personality’s forces of stability, of remaining the same, are formidable whether they are opposing healthy growth or negative decline. He was wise, indeed.

See for yourself. Just try putting on the other shoe first one morning. Or try to improve your tennis serve or golf swing and watch things come apart before they come together. Change is difficult, even with the help of an expert psychotherapist. There are multiple motives, conscious and unconscious, driving who you have become and why you are the same person each morning when you wake up. These forces include powerful physical survival strategies, fundamental attachment needs, and sociocultural pressures, among other influences. Those synaptic brain pathways I mentioned, many formed in early life, are well practiced, and become highly efficient and stable.

III

Did you know that despite all biased claims to the contrary, research has failed to demonstrate that any one school of psychotherapy is superior to the others? Remarkably, the American Psychological Association has identified over 400 forms of therapy, classified into 5 basic categories. There is no single best way to help people change, but many. And so, I have become an integrative psychotherapist.

The psychotherapy of today is not the psychotherapy your grandmother knew. Many newer schools, including mindfulness-based, body-based, imagery-based, emotion focused, trauma therapies, and others have generated insights and methods that can usefully complement one another. And many of these methods can be integrated with “single” orientations, psychodynamic and others, to enhance psychotherapy’s effectiveness. It is important for therapists like me, trained traditionally, to keep abreast of these new developments.

As an integrative therapist, I consider the research finding that therapies are equivalent intriguing. It is hard for me to accept the equivalencies of therapies as a complete truth since different therapies so obviously differ in what they set out to achieve. Psychoanalysts, for example, ambitiously seek to help patients achieve systemic change in their personality organization. That is nothing less than personal transformation. But behavior therapists try to create change more superficially, by engineering limited behavioral changes. Granted, the research itself is limited. For instance, most psychotherapy research fails to distinguish skill levels among therapists, naively assuming uniformity among them. In addition to broad outcome criteria in psychotherapy research, like the question, “Do you believe psychotherapy helped you?” we need differentiated and nuanced outcome criteria to identify what changed, and how, and how different therapies and therapists brought these results about. We should examine main effects and indirect effects, changes that therapy targets and therefore are readily identifiable and measurable, and subtle changes that are not foreseen or result as ripple effects. The latter, although not anticipated or measured specifically, may involve profound and meaningful changes beyond the readily quantifiable, mundane changes that research so often measures.

IV

Once we agree that learning plays a crucial role in forming us, and that we eventually become creatures of habit, with some will mixed in, then it stands to reason that we could learn to be another way. And that is exactly what neuroscience is demonstrating on a very fundamental level. The brain’s neuroplasticity—its ability to form and reorganize synaptic connections, especially in response to learning—exists lifelong. Of course. It would have to be that way. We are adaptive organisms and must be able to meet changing conditions to survive.

Rather than looking at change through any single therapy’s purview, it is useful to look at it through a multi-systemic, wide-angle lens. This is the clinical vision of the integrative therapist. Such an inclusive view encompasses, first, the several processing systems I mentioned (feeling, thinking (and constructing meaning), sensing, imagining, and doing; second, varied insights and methods drawn from a range of diverse psychotherapies—object relations configurations from psychoanalysis and exposure hierarchies from CBT, for example; and third, insights from related disciplines like cognitive science and neuroscience. Considering clinical problems from a multifactorial perspective of this sort helps therapists discover many creative ways of thinking about and helping people change that narrow views cannot.

Most therapists define themselves as eclectic or integrative, rather than as adherents of a single approach. That is entirely understandable, for only the most narrow-minded and doctrinaire therapist would see a singular, closed way of practicing as being sufficient for all patients and all problems. Some psychoanalysts think of themselves as integrative because they see value in more than one analytic approach—Stephen Mitchell’s relational orientation as well as Heinz Kohut’s self psychology, for example. However, surprisingly relatively few of these so-called integrative therapists have made the effort to study approaches other than that in which they first trained. Rather than fumbling about in a willy-nilly fashion to stumble upon or jerry rig what might work from the point of view of another therapy system, formal studies facilitate efficiency and enable one to consider differently conceptualized but established views and proven methods. As pioneering integrationist George Stricker glibly asserted, until you know a minimum of two approaches well, you may think of yourself as an integrationist, but please do not call yourself one. In that sense, relatively few therapists or analysts are truly integrative and can think in terms of a multisystemic causation and change model that blends multiple methods to address the many interacting processes that create problematic personality and behavioral patterns.

V

Consider a straightforward case illustration: “Emily,” an intellectually gifted young woman, was struggling with depression when she came to therapy for help with “underachieving.” We reached an early understanding of the sources of her problem. She described how during her growing up, her intellectual abilities and strivings were ridiculed, especially by her formidable father, who was, she left little doubt, a bullying sexist. Her parents encouraged her to become a wife and mother, but she had other aspirations.

One day in session, Emily reacted extremely negatively to a well-intended but apparently ambiguous comment I made. She had always felt me as supportive, but on this occasion, she took my words as disparaging. Because her emotional reaction was, we agreed, disproportionate, we explored her response in relation to what I had said, how I said it, and my intent. Through this process of mutual self-exploration, we came to recognize an important self-defeating pattern of hers. She had been seeking and finding the needle in the haystack; affirming comments would pass right by her unnoticed, but potentially negative ones, however small, immediately captured her focus and she would exaggerate them and feel them as deeply wounding.

We understood her problematic reaction in terms of learned sensitivities developed through her history. Based on experience, her expectations were not unreasonable. This interpersonal pattern, driven by negative expectations of criticism and hurt, had long reinforced her difficulties, and evaded her awareness. She felt most strongly attached, if painfully, when in an interaction that diminished her. The familial had become the familiar. But now that was becoming conscious, understandable, and, hopefully, amenable to change. Our reaching this knowledge together also “repaired” the temporary rupture in our relationship, a process known by therapists to have strong therapeutic benefits associated with corrective emotional experiences that “surprise” patients by disconfirming expected responses.

Emily had achieved a new understanding, or insight. That can be both illuminating and satisfying. But insight is not always sufficient or even required for change. I could recognize and commented on self-protective actions associated with this pattern in sessions—how she would maintain a low profile through her slouched, closed posture and softly spoken, tentative words. She described noticing this behavior outside, too—that she would often shrink or hide from fear of causing harsh responses from others. She had developed this “armor” unconsciously to conceal and protect herself from anticipated, painful criticism.

But now she had reached self-awareness, “made the unconscious conscious,” as analysts used to say. We now recognized and understood that dynamic. And here is where many therapies fall short and integrative therapy stands out. Insight, alone, if not harnessed to further action and change, is not necessarily useful and can even become a source of self-criticism. (“I know what I’m doing wrong but can’t help it.”) Instead of leaving further developments to trial and error, through psychotherapy integration, I helped Emily apply this insight to her outside life. A stepwise behavioral approach—asking her to practice expressing herself forthrightly between sessions, first in unthreatening situations with strangers, then in increasingly threatening ones until eventually with her father—worked directly to embolden her, lessen her anxiety, and reduce self-defeating aspects of her character.

We also explored some empowering bodily exercises. I asked her to open her posture, standing tall with head erect, chest expanded, and shoulders drawn back. This postural shift helped her contact underlying resources that she rarely acknowledged. She noted her intelligence, persistence, resilience, and, she reported jokingly, if proudly, “I’m also unusually strong physically for a woman.” In some sessions, we practiced vocal exercises. I prompted her to express herself as loudly and forcefully as she could to encourage her to strengthen and experience the power beneath her usually stifled voice. Trying out a new persona in this way can bring contact with inner resources and spearhead further changes based on new insight.

My approach is called assimilative integration. Based on relational psychodynamic psychotherapy, it is opened to importing insights and methods from other approaches and disciplines when they can facilitate the work of therapy. Emily’s and my work together was mainly psychodynamic, discovering old ways of being and their sources, and making room for new ways. But I introduced two outside modalities, behavioral and body approaches. These methods allowed us to introduce change potentials that likely would not have otherwise presented themselves. In addition to being practically oriented, they also engaged additional processing channels by destabilizing and shifting automatic bodily experiences and promoting adaptive behavioral actions. What I described in this brief case vignette is a simple, straightforward example. There are many, many other ways of engaging the multiple systems that participate in change, some quite subtle and complex.

Why base the approach on relational psychodynamic therapy? Research has repeatedly shown what practicing clinicians always have known—that a critical factor in the success of all forms of psychotherapy, likely the most critical factor aside from resources the patient brings to the task, is a strong therapeutic relationship, or alliance. And among all the therapy approaches, the relational psychodynamic approach most helps us understand and cultivate the relationship’s power to promote change.

We also know that emotional activation (versus intellectual knowledge) is essential for meaningful change, and the psychodynamic approach is emotionally evocative. Whether through lived experience with the therapist (as we saw with Emily) or others, or through narrative description, it activates and provides access to many of the emotionally charged processes needed to modify problematic patterns. Finally, I want to mention that Emily discovered what is often found—changes in behavior and in self-understanding interact, leading to reciprocal changes that play off one another in a recursive virtuous cycle. New behaviors lead to new interpersonal outcomes that, in turn, help bring awareness to, and shift the internal dynamics of how one sees oneself, the world, and the future—a kind of changing from the outside in.

VI

It is important to know that success rates in psychotherapy studies typically run around 75 percent. Rather than specific methods, it is usually found that common factors that act in virtually all therapies (good quality relationship; collaborative goal setting; therapists’ empathy, warmth, and positive regard; and others) account for most of change. But I believe researchers will perfect a model that does not yet exist to show that effectively applied integrative methods produce success, both gross and subtle, at higher rates. In any event, since there is no need to worry about changes so great that afterward you will not recognize yourself, be grateful that even small changes often go a long way.

The days of waiting for that lightning bolt from the heavens—the grand, transformative insight delivered by the psychoanalyst—are gone. The truth is that insight, alone, is rarely transformative. We become ourselves largely effortlessly; but changing ourselves, quite the opposite, demands sustained effort. It requires self-examination, much of which focuses on what we avoid and would prefer not to know about ourselves. Being a patient in any, especially, integrative therapy, is a challenging, active process. Sessions themselves can be fun, interesting, even exciting; but, overall, for all the reasons we have discussed, the work of change is challenging. An integrative therapist will engage many of your resources, and likely will ask you to actively try out and practice new ways of looking at things and behaving that initially will feel unnatural, like the early, disruptive results of working on your tennis serve, but that ultimately pay off.