Bridging Technical Eclecticism and Theoretical Integration: Assimilative Integration

Assimilative integration is a new type of psychotherapy integration introduced by Messer in 1992. This paper explains the where, what, when, and how of this integrative route, outlines its advantages and weaknesses, and discusses areas for potential assimilative practice in various models of therapy. Following a brief review of the current status of psychotherapy integration and its practices, assimilative integration is conceptualized as a mini theoretical integration and as theoretical eclecticism it is offered as a bridge between theoretical integration and technical eclecticism. Assimilative integration is proposed as the best theoretically and empirically based integrative approach available at this time, particularly for therapists who have been trained in a single mode of therapy before they became integrationists.     

Introduction to the Special Issue on Assimilative Integration

This issue of Journal of Psychotherapy Integration includes a set of articles that explore and apply the concept of assimilative integration. They do so from different theoretical perspectives, including psychodynamic, cognitive–behavioral, family systems, and Yogic/Buddhist, as well as from broad conceptual standpoints. The articles are followed by 3 commentaries that offer an appreciation and critique of assimilative integration and recommendations for its further development.     

Commentary: Further Thoughts About Assimilative Integration

The models for assimilative integration presented in this issue are considered. It is concluded that some grounding theories may be too structured, or one's interpretation of them too rigid, stifling psychotherapeutic flexibility and creativity by excluding potentially useful interventions. Alternatively, models may be too unstructured, or one's interpretation of them too loose, leading to treatment forms lacking specificity, direction, and coherence. As noted originally by Messer, assimilative integration operates most beneficially when practitioners address the limitations of their therapeutic models, or tap their models' progressive implications in ways that respect the fundamentals of their shared clinical theories. Practiced in this balanced way, assimilative integration can offer a useful, flexible way of navigating a creative yet disciplined psychotherapeutic course between unbridled technical eclecticism and technical and theoretical rigidity. The author also examines and extends some of the integrative ideas put forth in this issue, from a two-person or intersubjective perspective based on a relational psychodynamic treatment model.     

A Relational Psychodynamic Perspective on Assimilative Integration

In this paper we discuss recent advances in relational psychoanalytic thinking, and demonstrate how an assimilative approach to integration can be based on this theoretical and clinical model. We describe 3 instances in which active interventions may be used to enhance relationally oriented, psychoanalytic work: by impacting on relationships outside of therapy that maintain pathological patterns, by filling in intrapsychic deficits, and by supporting the patient's active efforts at change. We provide clinical examples to illustrate each of these points.     

Assimilative and Accommodative Integration: The Basic Dialectics

Two basic styles in psychotherapy integration can be described, in which respectively the assimilative or the accommodative mode of proceeding preponderate. The first is chosen by those who wish to keep a firm grounding in any one theoretical system, into which they incorporate perspectives or practices from other schools, reinterpreted and reformulated in their own terms. The second is favored by those who prefer to practice eclectically, without worrying too much about the contradictions and incompatibilities among the different approaches. The latter therapists can remain at this purely eclectic level, or move on towards a proper integration. In this case the integration does not usually happen on the base of a preferred system, as in theoretical integration, but rather follows the line of the common factors approach. This integration mode has a prevalent accommodative character. It points to a basic structure that is common to the different methods, and becomes clearer the more the relation is freed of the constriction of theoretical models. An attempt is made to show the substantial complementarity and the dialectical relation that links the two fundamental modes of psychotherapy integration.     

Psyche and System: On Progress in the Integration of Individual Psychotherapy and Family Psychotherapy

This article addresses the frequency with which the same group of patients utilizes individual and family therapies, and at the same time do not constitute actual integration. The conditions under which such serial or concurrent utilization of the two forms of psychotherapy may be considered to be integrative are discussed.     

The Freudian Antecedents of Cognitive–Behavioral Therapy

The writings of Sigmund Freud are reviewed, showing the similarities of many of his concepts with those of cognitive–behavioral therapy (CBT). Automatic thoughts, core beliefs, and the desire to please the therapist are shown to have parallels in Freud's ideas about involuntary thoughts, the preconsdous, the unconscious, and transference. Similarities in technique are noted, especially in light of Freud's original ideas about suggestion and influence as well as latter-day discoveries regarding Freud's actual practices. In certain ways, CBT is closer to Freud than is classical psychoanalysis. A brief history of the attempts to integrate behaviorism with Freud is given, showing how Freud's objectifying of dream reports presaged the viewing of verbal reports as behavior. Other developments in cognitive psychology are also discussed with regards to Freud's ideas about information processing and the production of memories.     

Cost-Effectiveness and Health Care Utilization in a Multidisciplinary Pain Center: Comparison of Three Treatment Groups

Recent literature supports the efficacy of multidisciplinary pain management in treating persons suffering from chronic pain. However, the components of multidisciplinary pain management need to be evaluated in terms of effects on patients' quality of life as well as saving of future health care dollars. Therefore, cost-effectiveness of three treatment groups was compared by examining treatment outcome, posttreatment health care costs, and posttreatment health care visits. Results revealed that patients receiving both medical and psychological treatment (multidisciplinary pain management) exhibited the largest improvements in functional capacity, while being the least costly after their treatment program had ended. In contrast, patients who received only medical treatment exhibited significant deterioration in outcome after their treatment ended, and consumed substantially more posttreatment health care dollars.     

Randomized Controlled Trial of Cognitive–Behavioral Group Therapy for Irritable Bowel Syndrome in a Medical Setting

Standard medical treatments have not been effective for irritable bowel syndrome (IBS) patients. Though individualized cognitive–behavior therapy is an empirically supported treatment option, cognitive–behavioral group therapy (CBGT) has yet to be established as an effective alternative in a randomized controlled trial. This study compared the efficacy of a 10-session CBGT with a home-based symptom monitoring with weekly telephone contact (SMTC) treatment for IBS, extending previous quasi-experimental research in this area. Twenty-eight refractory IBS patients, evaluated and referred by gastroenterologists using the Rome criteria, participated in the study. IBS symptoms, psychological functioning, and health-related quality of life were assessed pre- and posttreatment, and at 3-month follow-up. CBGT patients reported significantly more gastrointestinal (GI) symptom improvement than SMTC patients on posttreatment global measures and had significantly reduced daily diary pain scores at 3-month follow-up. Based on MANOVA, there was significant improvement in psychological distress and health-related quality of life for the CBGT patients in comparison to the SMTC patients. These improvements were also maintained at the 3-month follow-up. Reductions in GI symptoms, psychological distress, and improved health related quality of life may contribute to less behavioral avoidance, disability, and health care utilization in refractory IBS patients.     

An Overview of Directions in Psychotherapy Integration Research

In general, empirical research in psychotherapy integration has lagged behind the growing theoretical and clinical interest in the field. Even though many of the theoretically integrative treatment models currently available are based on empirical findings and clinical observations, the models themselves remain, for the most part, untested. Rigorous examination of integrative psychological theories and therapeutic programs is a necessary and useful way to increase our understanding of the process of psychotherapy and establish the efficacy and effectiveness of integrative therapies. The present article explores five different research areas in the field of psychotherapy integration, discussing several published studies in each area. The utility of this research for practicing clinicians is also discussed. Additional investigations in these areas and others are encouraged, with the goals of greater understanding of psychotherapy, as well as the further development and acceptance of integrative approaches.     

Clinical Exchange: The Architectural Failure

The Clinical Exchange invites eminent clinicians of diverse persuasions to share, in ordinary language, their clinical formulations and treatment plans of the same psychotherapy patient—one not selected or nominated by those therapists—and then to discuss points of convergence and contention in their recommendations. This Exchange concerns a Mr. L, a 47-year-old, married man presenting for outpatient individual psychotherapy with chief complaints of depression, anxiety, and a lengthy history of vocational underachievement. Drs. Herbert Fensterheim, Leslie Greenberg, and Leigh McCullough, who anchor their practices in the cognitive-behavioral, experiential, and psychodynamic orientations, respectively, are the featured commentators. Finally, Dr. Jerold Gold, the case contributor and Mr. L's psychotherapist, provides a few closing comments.     

Cognitive change and enhanced coping: missing mediational links in cognitive behavior therapy with anxiety-disordered children

In this review, we examine the recent cognitive behavior therapy (CBT) outcome literature with anxiety-disordered children and, specifically, explore the status of cognitive change and increased coping ability as (1) specific treatment effects, and (2) possible mediators of the efficacy of CBT. In the past decade, the number of controlled CBT studies with clinically diagnosed anxiety-disordered children has increased substantially. CBT aims to restructure distorted or maladaptive cognitions and teach the anxious child to effectively use diverse coping strategies. Our review shows that in recent CBT research with anxiety-disordered children the use of domain-specific measures like cognitive and coping measures is, unfortunately, not common practice. Furthermore, only one study examined the issue of treatment mediation. Generally, recent CBT research has not been designed to test mediational issues and does not clarify whether cognitive change and enhanced coping—the presumed central components of CBT—are in fact responsible for its efficacy. Implications for the direction of future CBT research with anxiety-disordered children are discussed.     

Towards a cognitive-behavioral model of PTSD in children and adolescents

Posttraumatic stress disorder in children and adolescents has been studied only for the past 15–20 years and is the subject of a burgeoning corpus of research. Much research has focused on examining whether children and adolescents have the same responses to trauma as those experienced by adults. Many of the research tools used to investigate children's responses are taken from measures designed for use with adults, and these measures have proven to be useful. However, it has not been established that children's responses to traumatic events are related to the same underlying processes as are adults' responses. The possible application of 2 recent cognitive models of PTSD in adults to understanding PTSD in children and adolescents is discussed in this paper, within the context of what is already known about children's reaction to trauma and existing theoretical accounts of childhood PTSD. Particular attention is paid toward the nature of children's memories of traumatic events and how these memories relate to the reexperiencing symptoms of PTSD, and cognitive processes that may play a role in the maintenance of PTSD. It is proposed that the adoption of a more specific cognitive–behavioral framework in the study of this disorder may be beneficial and lead to better treatment outcomes.     

Longitudinal Assessment of Pain, Coping, and Daily Functioning in Children with Sickle Cell Disease Receiving Pain Management Skills Training

Objective. To conduct intensive pain management skills training (IST) in children with sickle cell disease (SCD) and their parents and to comprehensively evaluate pain, coping, and daily functioning in children pre, immediately post, and 3 months following treatment. Methods. Three children who received IST in nonpharmacological and pharmacological pain management strategies completed a Coping Strategies Questionnaire (CSQ) at pre, post, and follow-up assessments, and daily pain and activity diaries for 18 weeks, spanning from 1 week pretreatment to 11 weeks posttreatment. Results. From pre- to posttreatment, 1 child receiving IST indicated increased report of active coping attempts and all 3 children indicated decreased report of negative thinking on the CSQ. Participants in IST used coping skills on 90% of days with pain and reported the skills to be moderately helpful on the daily diaries. For daily activities such as eating dinner, playing with friends, and hours slept, children participated similarly on days with pain and days without pain during the posttreatment period. Given the small number of participants in this study, individual cases are discussed to highlight similarities and differences in how participants responded to the treatment and during the 3-month follow-up period. Conclusions. In this pilot study, each participant showed improvement in coping and daily functioning after completing the IST program. Individual differences in response to treatment indicate the need for more targeted intervention programs that incorporate pharmacological and nonpharmacological components. The results of this study highlight both the promise and the complications of conducting comprehensive pain intervention and functional outcome studies in children with SCD.     

Cognitive–Behavioral-Interpersonal Scenarios: Interformulator Reliability and Convergent Validity

Although a clinical case formulation can help focus treatment, little is known about the reliability and convergent validity of independently generated, cognitive–behavioral or cognitive–interpersonal formulations. Using videotapes of a semi-structured interview, pairs of clinicians independently formulated 2–3 cognitive–behavioral–interpersonal scenarios (CBISs) on each of 4 women with mood or comorbid mood and anxiety disorders. Ten licensed psychologists then rated each CBIS on 15 dimensions involving cognition, affect, symptoms, and interpersonal functioning. Reliability of the mean ratings (aggregated over the 10 raters) was >.83 for all dimensions. The set of CBISs formulated by a clinician for a patient generally demonstrated good convergent (same patient/different formulator) and discriminant (different patient/same or different formulator) validity on three factor-analytically derived general dimensions of depression, anxiety, and interpersonal functioning. Within each of three patients, pairs of formulators generally agreed on the situational components of the CBISs and demonstrated adequate to very good convergent validity of corresponding CBIS content. These results contribute to accumulating evidence for the reliability and validity of clinical scenarios as an idiographic, situation-level case formulation. Such formulations can help identify multiple cognitive, behavioral, or interpersonal intervention points in the causal chain leading to distress or dysfunction.     

Some Thoughts on the Integration of Narrative and Humanistic/Existential Approaches to Psychotherapy

Although humanistic and narrative approaches to psychotherapy make some different assumptions about the nature of the human condition and emphasize different aspects of human functioning in their therapeutic endeavors, I argue here that the underlying assumptions of these two approaches reflect a common view of humanness, thus making these two approaches candidates for attempts at integration. Four areas of commonality are discussed in detail: (a) life as a process of continual development, (b) the nature of experience and the process of meaning creation, (c) the nature of psychological dysfunction, and (d) the nature and importance of human relationships. The implications of these commonalities for the practice of therapy from an integrated perspective are explored in an extended case example.     

The Challenges of Qualitatively Coding Ancient Texts

We respond to several important and valid concerns about our study (“The Prevalence of Folk Dualism in Early China,”Cognitive Science 35: 997–1007) by Klein and Klein, defending our interpretation of our data. We also argue that, despite the undeniable challenges involved in qualitatively coding texts from ancient cultures, the standard tools used throughout the cognitive sciences—large quantities of data, coders as blind to the hypothesis as possible, intercoder reliability measures, and statistical analysis—allow the noise of randomly distributed interpretative differences to be distinguished from the signal of genuine historical patterns.     

Logotherapy-Enhanced REBT: An Integration of Discovery and Reason

Viktor Frankls Logotherapy and Albert Elliss Rational Emotive Behavior Therapy (REBT) are at seemingly opposite ends of the psychotherapeutic spectrum. However, a close review of the assumptions and philosophy of each school of therapy reveals that these two systems are compatible. We propose that a Logotherapy-enhanced REBT can increase human achievement and happiness by balancing the individual discovery of meaning with the pursuit of reason. This integrated and enhanced therapy will help human beings participate in positive life experiences and take greater responsibility for change. Fruitful and beneficial aspects of a Logotherapy enhanced-REBT are explored with respect to cognitions, emotions, and the reduction of rumination. Conclusions are drawn, limitations are discussed, and future recommendations are outlined.     

心理治疗两种范式的对立及其整合

心理治疗有两种不同的范式:科学主义治疗范式和人文主义治疗范式。前者主要由行为疗法和认知—行为疗法的诸种治疗形式所构成;后者则包括当事人中心疗法、存在疗法等。两种范式在人性观、心理诊断、治疗关系、治疗方法和治疗目的等方面存在着明显的对立。对此进行分析,并提出两者整合的构思,以期裨益于心理治疗实践。