Psychotherapy Integration

The practitioner's theoretical orientation shapes the work of psychotherapy. Theory is the lens the therapist uses to see and understand as well as to decide when and how to intervene. It determines what is looked for, what is found, and what happens from there.

Although there are said to be 400 or so schools of psychotherapy, they can all be assigned to one of two basic classifications: 1) insight-oriented and 2) action-oriented (George Stricker, Psychotherapy Integration , 2010).  Of the 400, Psychodynamic Therapy (PDT), representing the insight orientation, and Cognitive Behavior Therapy (CBT), representing the action orientation, are the most comprehensive of the two fundamental approaches.

PDT originated with Sigmund Freud, the father of psychoanalysis. He explored the psychology of meaning. His techniques were designed to facilitate his understanding, often based on past developmental history, and then to transfer that understanding to the patients themselves. He tried to impart self-understanding in the least intrusive, least directive manner possible, which he called interpretation. Patients, now armed with much more insight, were then expected to change in ways not designed or even suggested by Freud himself. Self-determination based on self-understanding was the ultimate goal. But however clearly he set forth his methods, he was not nearly as rigid as some of his followers became as they tried to follow him to the letter. In 1905, he acknowledged that "there are many ways and means of practicing psychotherapy. All that lead to recovery are good."

CBT was born in the laboratory, where psychology is defined as the science of human behavior. At first, however, it began with animal behavior in the labs of such scientists as Pavlov. Stimulus-response paradigms were then generalized to humans, which gave rise to behavior therapy. But the generalizations had serious limitations because humans have capabilities far beyond those of lab animals. When Aaron Beck's Cognitive Theory of Depression (1979) added cognitive science to learning theory, the human mind was included as an active and more complex variable. This addition of thought to observable behavior led to better clinical results yet allowed the goal to stay the same: behavioral change through the most efficient, structured, and time-limited methods possible. The CBT therapist has no trouble being direct and directive by prompting actions to change behavior in specific ways.

Beginning with Dollard and Miller's Personality and Psychotherapy (1950), theorists and clinicians have been interested in reconciling PDT and CBT. The challenge is great because the differences are many and some make the two look very far apart indeed. To illustrate, they represent diametrically opposed philosophical positions; that is, PDT, the tragic and CBT, the comedic. Nevertheless, Paul Wachtel's Psychoanalysis and Behavior Therapy (1977) managed to bridge the gap, even while acknowledging the problems and downright incompatibilities. By taking a position well outside the competition between the advocates of each approach, he found enough common space by seeing the similarities between concepts and techniques with ostensibly different origins and referents. For example, he recognized that PDT's interpretation of defense is a variety of CBT's response prevention, how interpretations in general are a way to effect CBT's exposure therapy, and that PTD's defense can be translated into CBT's selective inattention. He gave rationales for the PDT therapist to reinforce constructive behavior change in the present while still honoring the patient's wishes and the disavowed motivations that arose from the past. He offered a new focus when he proposed that the therapist attend most closely to old issues that are enacted and sustained in the present by current, repetitive interactional patterns.

Even more importantly yet, Wachtel (1977) recognized the reciprocal influence of the unconscious, conscious, and behavior. With cyclical interactions, for example, behavior change can alter conscious thought, which impacts unconscious fantasy, and back and forth, and in and out. Change can begin at any level. There are reverberations between such artificial divisions as past and present, intrapsychic and interpersonal, events and perceptions, and the internal and external worlds. All are interwoven: effect can become cause.

Over the last decades, the two theoretical orientations have evolved and become ever more easily blended. The development and growing popularity of the relational and interpersonal perspectives in PDT theory include a  here-and-now, directive dealing with psychological issues, including behavioral ones. CBT's growing appreciation of the relationships between cognition, behavior, and emotion has given more room for the behaviorist to enfold conscious thoughts and even, occasionally, unconscious dynamics into their work. Sometimes it is hard to distinguish CBT from PDT therapists in their day-to-day practices.To further illustrate, both CBT and PDT practitioner's use mindfulness, the acceptance of moment-to-moment experiences. But CBT and PDT are still sufficiently different in theory to represent two distinct approaches, and many therapists are loyal to only one of them.

To maximize therapeutic responsiveness, I deliberately blend both of what seem to me to be complementary approaches. I agree with the conclusion : "Increasingly it is becoming clear that most effective and lasting therapeutic change requires both increased understanding and behavior change" ( Stricker, 2010, p. 12). Using PDT and CBT allows for this two-pronged approach. Still and all, when the patient's goal is symptomatic change, I practice CBT. When the patient's complaints are more general and there is an interest in understanding and meaning, I emphasize PDT. But for most clients, I try to use a judicious mixture of the two.

If you are interested in reading a bit more about Cognitive Behavior Therapy and Psychodynamic Therapy, please look at The Role of Theory on my page Individual Psychotherapy .

REFERENCES

Beck, A.T., Rush, A.J., Shaw, B.F., & Emery, G. (1979). Cognitive therapy of depression . New York: Guilford Press.
Dollard, J., & Miller, N.E. (1050). Personality and psychotherapy. New York: Mcgraw-Hill.
Stricker, G. (2010). Psychotherapy integration . Washington D.C.: American Psychological Association.
Wachtel, P. (1977). Psychoanalysis & behavior therapy:Toward an integration. New York: Basic Books.


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