Handbook of Psychotherapy Integration

HANDBOOK OF PSYCHOTHERAPY INTEGRATION

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HANDBOOK OF PSYCHOTHERAPY INTEGRATION JOHN C. NORCROSS, PH.D. AND

MARVIN R. GOLDFRIED, PH.D EDITORS

New York Oxford OXFORD UNIVERSITY PRESS 2003

OXFORD

UNIVERSITY PRESS

Oxford New York Auckland Bangkok Buenos Aires Cape Town Chennai Dar es Salaam Delhi Hong Kong Istanbul Karachi Kolkata Kuala Lumpur Madrid Melboume Mexico City Mumbai Nairobi Sao Paulo Shanghai Taipei Tokyo Toronto

Copyright © 2003 by Oxford University Press, Inc. Published by Oxford University Press, Inc. 198 Madison Avenue, New York, New York 10016

www.oup.com First published in 1992 by Basic Books Oxford is a registered trademark of Oxford University Press All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Oxford University Press. Library of Congress Cataloging-in-Publication Data Handbook of psychotherapy integration / edited by John C. Norcross, Marvin R. Goldfried p. cm. Previously published: New York: Basic Books, 1992. Includes bibliographical references and index. ISBN 0-19-516704-X Eclectic psychotherapy. I. Norcross, John C., 1957 - II. Goldfried, Marvin R. [DNLM: 1. Psychotherapy—methods—handbooks.] RC489.E24H36 2003 616.89'14—dc21 2003048689

1 3 5 7 9 8 6 4 2 Printed in the United States of America on acid-free paper

Contents

Preface About the Editors About the Contributors

ix xiii XV

PART I: CONCEPTUAL AND HISTORICAL PERSPECTIVES 1 Psychotherapy Integration: Setting the Context John C. Norcross and Cory F. Newman 2 A History of Psychotherapy Integration Marvin R. Goldfried and Cory F. Newman 3 Psychotherapy Outcome Research: Implications for Integrative and Eclectic Therapists Michael J. Lambert 4 A Critical Examination of Belief Structures in Integrative and Eclectic Psychotherapy Stanley B. Messer

3 46

94 130

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CONTENTS

PART II: INTEGRATIVE AND ECLECTIC PSYCHOTHERAPY MODELS A. Common Factors 5 Eclectic Psychotherapy: A Common Factors Approach Sol L. Garfield 6 Integration Through Fundamental Similarities and Useful Differences Among the Schools

169

202

Bernard D. Beitman

B. Technical Eclecticism 7 Multimodal Therapy: Technical Eclecticism with Minimal Integration

231

Arnold A. Lazarus

8 Systematic Eclectic Psychotherapy Larry E. Beutler and Andres ]. Consoli

264

C. Theoretical Integration 9 The Transtheoretical Approach

300

James O. Prochaska and Carlo C. DiClemente

10 Cyclical Psychodynamics and Integrative Psychodynamic Therapy

335

Paul L. Wachtel and Mary K. McKinney

PART III: INTEGRATIVE PSYCHOTHERAPIES FOR SPECIFIC DISORDERS 11 Integrative Psychotherapy of the Anxiety Disorders

373

Barry E. Wolfe

12 A Common Factors Therapy for Depression Hal Arkowitz

402

Contents

13 Integrative Therapy for Borderline Personality Disorder: Dialectical Behavior Therapy Kelly Koemer and Marsha M. Linehan

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433

PART IV: INTEGRATIVE TREATMENT MODALITIES 14 Differential Therapeutics: Macro and Micro Levels of Treatment Planning John F. Clarkin, Allen Frances, and Samuel Perry

463

15 Integrating Therapeutic Modalities Larry B. Feldman and Sandra L. Powell

503

16 Integrating Pharmacotherapy and Psychotherapy Bernard D. Beitman, Molly J. Hall, and Bums Woodward

533

PART V: TRAINING AND RESEARCH DIRECTIONS 17 Training in Psychotherapy Integration John D. W. Andrews, John C. Norcross, and Richard P. Halgin 18 Core Issues and Future Directions in Psychotherapy Integration Marvin R. Goldfried, Louis G. Castonguay, and Jeremy D. Safran

563

593

Name Index

617

Subject Index

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Preface

A

./ATTEMPTS TO INTEGRATE diverse approaches to psychotherapy have captured the imagination of mental health professionals for well over half a century. For example, Thomas French stood before the 1932 meeting of the American Psychiatric Association and drew parallels between certain concepts of Freud and Pavlov; in 1936 Sol Rosenzweig published an article that extracted commonalities among various systems of psychotherapy. Until recently, however, integration has appeared only as a latent theme (if not conspiratorially ignored altogether) in a field organized around discrete theoretical orientations. While psychotherapists secretly recognized that their paradigms did not adequately assist them in all they encountered in practice, a host of political, social, and economic forces— such as professional organizations, training institutes, and referral networks—kept them penned within their own theoretical school yards and typically led them to avoid clinical contributions from alternative orientations. Within the past two decades, the field of psychotherapy has been subjected to another set of forces that have weakened rigid theoretical boundaries. From outside the field, several groups have launched sobering attacks. Consumer groups and insurance companies have been pressuring psychotherapists to demonstrate the efficacy of their methods. Biologically oriented psychiatrists have been questioning the psychosocial paradigm of psychotherapists. Moreover, from inside the field, the failure of research findings to demonstrate a consistent superiority of any one school of thought over another and the shifting focus to specific clinical problems (often requiring the expertise of different professions and orientations)

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have led an increasing number of clinicians to search seriously for solutions outside their own particular paradigm. The ideological cold war and "dogma eat dogma" ambience in psychotherapy have abated as clinicians acknowledge the inadequacies of any one system and the potential value of others. During the past decade psychotherapy integration has crystallized into a formal movement, characterized by a dissatisfaction with single-school approaches and the concomitant desire to look across and beyond school boundaries to see what can be learned—and how patients can benefit—from other forms of behavior change. Whether considered a paradigm shift or a metamorphosis in mental health, psychotherapy integration will be a therapeutic mainstay of the 21st century. The formation of the Society for the Exploration of Psychotherapy Integration (SEPI) in 1983 helped spark the integration movement. An organization dedicated to dialogue among therapists of disparate theoretical orientations, and also between clinicians and researchers, SEPI's operative term is "exploration." Given the complexity of human behavior and the change process, it is unlikely that any one individual can propose an all-purpose integrative system that will suffice for all situations, disorders, and clients. At the same time, we are convinced that the time is ripe tor serious and thoughtful attempts at exploring common ground, working toward theory integration, and blending clinical and research efforts that are not encumbered by individual schools of thought. It is within this spirit that our handbook has been prepared. We believe that this volume provides, for the first time, a state-of-theart, comprehensive description of psychotherapy integration (the most popular orientation of mental health professionals) and its clinical practices by some of the leading proponents of the movement. The Handbook is divided into five sections. Part I considers the concepts (Norcross & Newman), history (Goldfried & Newman), research (Lambert), and belief structures (Messer) of psychotherapy integration. Part II presents two exemplars of each of the movement's predominant thrusts: common factors (Garfield, Beitman), technical eclecticism (Lazarus, Beutler, & Consoli), and theoretical integration (Prochaska & DiClemente, Wachtel & McKinney). Part III describes integrative psychotherapies for specific disorders: anxiety (Wolfe), depression (Arkowitz), and borderline personality disorder (Koerner & Linehan). Part IV reviews integrative treatment modalities, specifically, differential therapeutics (Clarkin, Frances, & Perry), combining individual and family therapy (Feldman & Powell), and integrating pharmacotherapy and psychotherapy (Beitman, Hall, & Woodward). Part V concludes the volume by addressing both training (Andrews, Norcross, & Halgin) and future directions (Goldfried, Castonguay, & Safran) in integration.

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Contributors to part II (Integrative and Eclectic Psychotherapy Models) and part III (Integrative Psychotherapies for Specific Disorders) were asked to address a list of central topics in their chapters. Chapter guidelines were designed to facilitate comparative analyses and to ensure comprehensiveness. The focal issues were: background of the approach; patient assessment; applicability and structure; interventions and relationships; mechanisms of change; case example; research on the approach; clinical training; and future directions. As expected, the authors did not always use the suggested headings; while most of the requested topics were addressed in some fashion in the respective chapters, we did not insist on identical headings or formats. Further, in instances where chapter length became burdensome, we were reluctantly forced to omit the section on clinical training. The belief that one chapter format—or for that matter, one integrative psychotherapy model—will suffice for all occasions is one that is antithetical to therapeutic rapprochement and informed pluralism. A large and integrative volume of this nature requires considerable collaboration. Our efforts have been aided immeasurably by our families and our SEPI colleagues; the former giving us time and inspiration, the latter providing intellectual stimulation, professional affirmation, and social support. We acknowledge the truly responsive and collaborative efforts of the staff at Basic Books, particularly Jo Ann Miller, senior editor; Stephen Francoeur, assistant editor; and Susan Zurn, project editor. Based on these interactions we fully anticipate a debt to Lois Shapiro and her colleagues for their marketing efforts for this book. We thank Ann Brust and Betty Nebesky at the University of Scranton and Cecily Osley at SUNY-Stony Brook for their clerical assistance. We also gratefully acknowledge the permission to reprint selected portions of several contributions that originally appeared elsewhere. Certain sections of chapters 3 (Lambert), 4 (Messer), 5 (Garfield), 7 (Lazarus), 8 (Beutler & Consoli), and 9 (Prochaska & DiClemente) first appeared in the Handbook of Eclectic Psychotherapy (1986), published by Brunner/Mazel Inc. and edited by John C. Norcross. All the chapters in question, however, contain new material and have been revised and updated. Certain sections of chapter 2 (Goldfried & Newman) first appeared in Behavior Therapy (Goldfried, 1982, 13, 572-593), published by the Association for the Advancement of Behavior Therapy. Lastly, we are indebted to the contributors. Most of them are SEPI members, and all are eminent psychotherapists in their own right. We are pleased to be in their company and to present their integrative work.

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About the Editors

John C. Norcross, Ph.D., is Professor and Chair of Psychology at the University of Scranton and a clinical psychologist in part-time independent practice. He has published more than 100 articles and has coauthored or edited seven monographs, the most recent being Therapy Wars: Contention and Convergence in Differing Clinical Approaches (with Nolan Saltzman), A Dialogue with John Norcross: Toward Integration (with Windy Dryden), and the centennial issue of Psychotherapy devoted to the future of psychotherapy. Dr. Norcross is an editorial board member of numerous scholarly journals, and is associate editor of the Journal of Psychotherapy Integration, the official publication of the Society for the Exploration of Psychotherapy Integration. Marvin R. Goldfried, Ph.D., is Professor of Psychology and Psychiatry at the State University of New York at Stony Brook. In addition to his teaching, clinical supervision, and research, he maintains a limited practice of psychotherapy in New York City. A diplomate of the American Board of Professional Psychology, a Fellow of the American Psychological Association, and editorial board member of several journals, he is coeditor of Behavior Change Through Self-control, coauthor of Clinical Behavior Therapy, and editor of Converging Themes in Psychotherapy. Trends in Psychodynamic, Humanistic, and Behavioral Practice. Dr. Goldfried is cofounder of the Society for the Exploration of Psychotherapy Integration.

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About the Contributors

John D. W. Andrews, Ph.D., is Director of the Center for Teaching Development at the University of California, San Diego, and Adjunct Research Professor at the California School of Professional Psychology. He is author of The Active Self in Psychotherapy: An Integration of Therapeutic Styles. Hal Arkowitz, Ph.D., is Associate Professor of Psychology at the University of Arizona, where he directs the Depression Clinic. He also maintains a part-time independent practice in psychotherapy. He coedited Psychoanalytic Therapy and Behavior Therapy: Is Integration Possible? (with Stanley Messer) and the Comprehensive Handbook of Cognitive Therapy (with Arthur Freeman, Karen Simon, and Larry Beutler). Currently, he is editor of the Journal of Psychotherapy Integration. Bernard D. Beitman, M.D., is Professor of Psychiatry and Medicine at the University of Missouri. He is the author of The Structure of Individual Psychotherapy and senior editor of Integrating Pharmacotherapy and Psychotherapy. He has a major research interest in studying chest pain of unexplained etiology with particular reference to panic disorder. Larry E. Beutler, Ph.D., is Professor of Education and Psychology and Director of the Counseling/Clinical/School Psychology Program at the University of California, Santa Barbara. He is a graduate of the University of Nebraska at Lincoln in clinical psychology and a diplomate of the American Board of Professional Psychology. He is also the editor of the

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Journal of Consulting and Clinical Psychology, a past international president of the Society for Psychotherapy Research, and author of numerous articles and books on psychotherapy. Louis George Castonguay, M.A., is completing his doctorate in clinical psychology at SUNY at Stony Brook and conducting an internship at the University of California, Berkeley. He coedited a book (in French) concerning the rapprochement and integration of psychoanalysis, behavior therapy, and humanistic therapy. John F. Clarkin, Ph.D., is Professor of Clinical Psychology in Psychiatry, Cornell University Medical College, and Director of Psychology, New York Hospital-Cornell Medical Center. He coedited Affective Disorder and the family and coauthored Systematic Treatment Selection: Toward Targeted Therapeutic Interventions. Andres ]. Consoli, M.A., is a bilingual/bicultural therapist and doctoral student at the University of California, Santa Barbara. He received his Licenciatura in clinical psychology from the Universidad de Belgrano, Buenos Aires, Argentina, in 1984 and subsequently has worked as a youth, school, and family counselor. He currently serves as a graduate supervisor in the Ray Hosford Counseling Training Clinic and is a member of the Psychotherapy Research Project team, both at the University of California, Santa Barbara. Carlo C. DiClemente, Ph.D., is Associate Professor of Psychology and Director of the Change Assessment Research Program at the University of Houston. He is an investigator on several national collaborative intervention studies and maintains a small psychotherapy practice in addition to his extensive supervision at the UH Psychology Research and Services Center. He is coauthor of The Transtheoretical Approach: Crossing the Traditional Boundaries of Therapy. Larry B. Feldman, M.D., is Clinical Associate Professor in the Department of Psychiatry at Loyola University. He has a part-time private practice and is a consultant to mental health agencies and individual therapists. He is the author of Integrating Individual and Family Therapy and of numerous journal articles and book chapters on individual and family therapy integration. Allen Frances, M.D., is Chair of the Department of Psychiatry at Duke University and also Chair of the DSM-IV Task Force, appointed by the

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American Psychiatric Association to revise the current DSM system. He has written numerous volumes, including Differential Therapeutics: A Guide to the Art and Science of Treatment Planning in Psychiatry. Sol L. Garfield, Ph.D., is Professor Emeritus of Psychology at Washington University. A former editor of the Journal of Consulting and Clinical Psychology, he has authored Clinical Psychology, Psychotherapy: An Eclectic Approach, and The Practice of Brief Psychotherapy; with Allen E. Bergin he is the editor of the Handbook of Psychotherapy and Behavior Change. He is an American Board of Professional Psychology diplomate, a fellow of the American Psychological Association, a former president of the Division of Clinical Psychology, and a former president of the Society for Psychotherapy Research. Richard P. Halgin, Ph.D., is Professor of Psychology at the University of Massachusetts at Amherst and holds a diplomate in Clinical Psychology from the American Board of Professional Psychology. He has published several dozen articles and book chapters on various topics in psychology, including psychotherapy integration, clinical training and supervision, and the provision of clinical services to underserved populations. He is coauthor of an undergraduate textbook entitled Abnormal Psychology: The Human Experience of Psychological Disorder. Dr. Halgin also maintains a part-time independent practice of psychotherapy. Molly J. Hall, M.D., is Assistant Professor of Psychiatry at the Wright State University School of Medicine and Residency Training Director at the United States Air Force Medical Center, Wright-Patterson AFB. As a flight surgeon/psychiatrist she serves as a member of the NASA Astronaut Selection Board. She has participated as a faculty member of the American Psychiatric Association course on treatment integration and has authored papers on brief psychotherapy and personality disorders in the military population. Kelly Koerner is a staff therapist at the Suicidal Behaviors Research Clinic and a doctoral candidate in clinical psychology at the University of Washington. She teaches workshops on Dialectical Behavior Therapy and conducts research to identify the processes of change in psychotherapy with difficult patients. Michael ]. Lambert, Ph.D., is Professor of Psychology at Brigham Young University. He maintains a part-time independent practice in psychotherapy and has been an executive officer of the Society for Psychother-

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apy Research. He is the author of numerous articles on psychotherapy outcome, coeditor of The Assessment of Psychotherapy Outcome, and editor of Psychotherapy and Patient Relationships. Arnold A. Lazarus, Ph.D., is Distinguished Professor in the Graduate School of Applied and Professional Psychology, Rutgers University. He also has a private practice in Princeton, New Jersey, and serves as a consultant to several institutions and agencies, as well as being on ten editorial boards. He has authored over 200 articles and chapters, and has written seven books and edited five. His major work is The Practice of Multimodal Therapy. Marsha Linehan, Ph.D., is Professor of Psychology, Adjunct Professor of Psychiatry, and Director of the Suicidal Behaviors Research Clinic at the University of Washington. She is an active clinical researcher, maintains a clinical practice, and has published widely, including the book, CognitiveBehavioral Treatment of Borderline Personality Disorder: The Dialectics of Effective Treatment. Mary K. McKinney, M.A., is completing her Ph.D. in clinical psychology at the City University of New York. She is presently a clinical psychology intern in the Department of Child Psychiatry of the Montefiore Medical Center, Albert Einstein College of Medicine. Stanley B. Messer, Ph.D., is Professor of Clinical Psychology at the Graduate School of Applied and Professional Psychology of Rutgers University. He has been an associate editor of American Psychologist and a consulting editor of Journal of Consulting and Clinical Psychology. Dr. Messer is currently on the editorial boards of Contemporary Psychology, Psychotherapy Research, and Journal of Psychotherapy Integration. He is coeditor and contributor to Psychoanalytic Therapy and Behavior Therapy: Is Integration Possible? and Hermeneutics and Psychological Theory. Cory F. Newman, Ph.D., Clinical Director of the Center for Cognitive Therapy, is also Assistant Professor of Psychology in Psychiatry at the University of Pennsylvania. In addition to his activities as psychologist, supervisor, and administrator, Dr. Newman has presented numerous workshops on schema-focused cognitive therapy at local, national, and international conferences. He is coauthor of two books in preparation—Cognitive Therapy of Substance-Use Disorders and Cognitive Therapy of the Borderline Patient.

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Samuel Perry, M.D., is Professor of Psychiatry at Cornell Medical College, Associate Director of the Consultation-Liaison Division at The New York Hospital, and Training and Supervising Psychoanalyst at the Columbia University Psychoanalytic Center for Training and Research. His most recent book (with A. Frances and J. Clarkin) is A DSM-III Casebook of Treatment Selection. Sandra L Powell, M.S. W., is a private practitioner, teacher, and consultant to mental health agencies and individual therapists. She has conducted numerous workshops and in-service educational programs on integrating individual therapy with family and group therapy in the treatment of children, adolescents, and adults. James O. Prochaska, Ph.D., is Professor of Psychology and Director of the Cancer Prevention Research Consortium at the University of Rhode Island. He also serves as a consultant to numerous institutions and maintains a part-time independent practice in psychotherapy. He is author of Systems of Psychotherapy: A Tmnstheoretical Analysis and coauthor of The Transtheoretical Approach: Crossing the Traditional Boundaries of Therapy. Jeremy D. Safran, Ph.D., is Associate Professor at the Derner Institute of Advanced Psychological Studies at Adelphi University. He is coauthor of Interpersonal Process in Cognitive Therapy and coeditor of Emotion, Psychotherapy, and Change. In addition to his teaching responsibilities, he maintains a part-time private practice in New York and Long Island. Paul L. Wachtel, Ph.D., is Distinguished Professor of Psychology at City College and the Graduate Center of the City University of New York, where he teaches in the Ph.D. program in clinical psychology. He is the author of Psychoanalysis and Behavior Therapy: Toward an Integration, The Poverty of Affluence, and Action and Insight, as well as coauthor with Ellen F. Wachtel of Family Dynamics in Individual Psychotherapy. Dr. Wachtel is one of the founders of the Society for the Exploration of Psychotherapy Integration. Barry E. Wolfe, Ph.D., is Chair of the Psychotherapy and Rehabilitation Research Consortium at the National Institute of Mental Health. He also conducts a part-time private practice in Rockville, Maryland, specializing in the integrative treatment of the anxiety disorders. He is currently preparing a book tentatively entitled Psychotherapy Integration in the Treatment of the Anxiety Disorders.

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Burns Woodward, M.D., is Clinical Instructor in Psychiatry at Boston University School of Medicine and Assistant Medical Director at Westwood Lodge Hospital in Westwood, Massachusetts. He has written and lectured on the collaboration between psychotherapists and pharmacotherapists and on integrating psychiatric and chemical dependency treatment for dually diagnosed substance abusers. He has an active practice of individual and group psychotherapy and pharmacotherapy.

PART I

CONCEPTUAL AND HISTORICAL PERSPECTIVES

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CHAPTER 1

Psychotherapy Integration: Setting the Context JOHN C. NORCROSS AND CORY F. NEWMAN

IXlVALRY AMONG THEORETICAL ORIENTATIONS has a long and undistinguished history in psychotherapy, dating back to Freud. In the infancy of the field, therapy systems, like battling siblings, competed for attention and affection in a "dogma eat dogma" environment (Larson, 1980). Clinicians traditionally operated from within their own particular theoretical frameworks, often to the point of being blind to alternative conceptualizations and potentially superior interventions (Goldfried, 1980). Mutual antipathy and exchange of puerile insults between adherents of rival orientations were very much the order of the day. This "ideological cold war" may have been a necessary developmental stage toward sophisticated attempts at rapprochement. Kuhn (1970) has described this period as a preparadigmatic crisis. Another philosopher of science, Feyerabend (1970), concluded that "the interplay between tenacity and proliferation is an essential feature in the actual development of science. It seems that it is not the puzzle-solving activity that is responsible for the growth of our knowledge, but the active interplay of various tenaciously held views" (p. 209). As the field of psychotherapy has matured, integration has emerged as a developing climate of opinion (Murray, 1983). The last 15 years in particular have witnessed both a general decline in ideological struggle and the stirrings of rapprochement. The debates across theoretical systems appear to be less polemical, or at least more issue-specific. The theoretical substrate of each system is undergoing intensive reappraisal, as psychotherapists acknowledge the inadequacies of any one system and the potential value of others (Norcross, 1986a).

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Current conceptualizations of the nature of therapeutic change are more complex and multifaceted than ever, both within and between theoretical camps. What seems to be distinctive of the present era is the tolerance for and assimilation of formulations that were once viewed as deviant (Arkowitz, 1992; Norcross & Freedheim, 1992). Even those who believe that the call for rapprochement is unlikely to herald either scientific progress or patient benefit do generally advocate a spirit of tolerance of vigorously promulgated positions. That is, mutual acceptance and openness are preferable alternatives to destructive antagonism (Franks, 1984). The dramatic growth of interest in psychotherapy integration during the past decade has crystallized into a formal "movement," or more dramatically, a "metamorphosis" in mental health (London, 1988; Moultroup, 1986). While various labels are applied to this movement—eclecticism, integration, convergence, rapprochement—the goals are similar indeed. Psychotherapy integration is characterized by a dissatisfaction with singleschool approaches and a concomitant desire to look across and beyond school boundaries to see what can be learned from other ways of thinking about psychotherapy and behavior change (Norcross & Arkowitz, 1992). The ultimate outcome of doing so, not yet fully realized, is to enhance the efficacy and applicability of psychotherapy (Goldfried, Castonguay, & Safran, 1992). Any number of indicators attest to the unprecedented interest in psychotherapy integration. Eclecticism, or the increasingly favored term integration (Norcross & Prochaska, 1988), is the modal theoretical orientation of English-speaking psychotherapists (Norcross, Dryden, & Brust, 1992; Norcross, Prochaska, & Gallagher, 1989), and the prevalence may be rising (Jensen, Bergin, & Greaves, 1990). Leading psychotherapy textbooks increasingly identify their theoretical persuasion as eclectic (Brabeck & Welfel, 1985), and an integrative or eclectic chapter is routinely included in compendia of various treatment approaches. The publication of books that synthesize various therapeutic concepts and methods continues unabated, now numbering more than 75, and the field has matured to a point where entire handbooks, such as this one, are deemed useful. The National Institute of Mental Health (NIMH) recognized the importance of the movement by sponsoring a workshop on research in psychotherapy integration (Wolfe & Goldfried, 1988). It was their belief "that treatments of greater efficacy, efficiency, and safety will result from efforts to integrate the best elements from different schools of psychotherapy. In addition, research on integrated treatment models may lead to the development of a comprehensive model of psychotherapy process that will have solid empirical backing." Reflecting and engendering the burgeoning field have been the establishment of interdisciplinary psychotherapy organizations devoted to

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5

integration—notably the Society for the Exploration of Psychotherapy Integration (SEPI)—and of international publications, including SEPI's journal of Psychotherapy Integration, the Journal of Integrative and Eclectic Psychotherapy, and Integrative Psychiatry. The surge of integrative fervor will apparently persist well into the 1990s: a recent panel of psychotherapy experts portended its escalating popularity throughout this decade (Norcross, Alford, & DeMichele, 1992). A spirit of open inquiry and lively debate pervades the entire field of psychotherapy, as evidenced by the appearance of several series of integrative articles in "pure-form" or discipline-specific journals. Representative journals include: Behavior Therapy (Kendall, 1982; Wachtel, 1982; Goldfried, 1982; Garfield, 1982); the British journal of Clinical Psychology (Yates, 1983; Davis, 1983; Messer, 1983; Murray, 1983; Wachtel, 1983); the British Journal of Guidance and Counselling (Dryden & Norcross, 1989; Norcross & Grencavage, 1989; Lazarus, 1989b; Beitman, 1989; Messer, 1989); and Psychiatric Annals (Babcock, 1988; Birk, 1988; London & Palmer, 1988; Rhoads, 1988; Powell, 1988). A major article on psychotherapy integration appeared in the American Journal of Psychiatry (Beitman, Goldfried, & Norcross, 1989), and theoretical integration figured prominently in an Annual Review of Psychology chapter on individual psychotherapy (Goldfried, Greenberg, & Marmar, 1990). While psychotherapy integration has indeed come of age, we clearly have not yet attained consensus or convergence. As Lazarus (1992) notes, the field of psychotherapy is still replete with cult members, devoted followers of a particular school of thought. High priests of psychological health are still engaged in competitive strife and internecine battles. These battles have receded but have not been extinguished. We do not intend to imply that all adverse reactions and cautionary pleas in response to integration represent mere stubbornness (Allport, 1968; Henle, 1986; Messer, 1992). Many clinicians express considerable satisfaction with their respective "schools" of therapy (Norcross & Prochaska, 1983). Profound epistemological and ontological differences also impede rapid or wholesale integration. But even here, most antagonists believe the movement "deserves a fair hearing and a substantial trial" (Messer, 1983, p. 132). A consensus has been achieved, however, in support of the idea that neither extreme of traditional fragmentation or premature unification will wisely serve the field of psychotherapy or its clients. At present, we are in no position to judge, once and for all, which single theory, single technique, or single unification scheme is best. In view of the early stage of the integration movement and in view of fundamental philosophical differences separating therapists, it is unrealistic to advance exclusively any one metatheoretical monolith (Norcross, 1991). Although it might be more satisfying and elegant if the psychotherapy world were not a multiverse,

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but a universe, the pluralists assure us that this quest will not be realized, at least not soon (Messer, 1992). In the meantime, numerous psychotherapists are exploring and working toward integration in the Zeitgeist of informed pluralism. There is also a promising and growing number of clinicians who, while maintaining their own theoretical identities, are nonetheless willing to explore potential sources of enrichment and convergence. This coterie of integration enthusiasts are examining multiple paths toward integration, as is evident throughout this book. Divergent but testable perspectives are required to combat the ingrained, "one-truth," unitary conceptions of psychotherapy practice.

Plan of the Chapter The present chapter explicates the broad context of psychotherapy integration and sets the stage for the subsequent chapters in the volume. As our chapter title indicates, we provide an overview of the salient issues rather than an exhaustive treatment; "breadth over depth," a motto of many eclectics (see Lazarus, 1992), characterizes our objective. We begin by describing the converging reasons for the recent preoccupation with psychotherapy integration, after which we review three predominant modes of contemporary integration and delimit the parameters of the nascent integration movement. This segues into a brief consideration of the varieties of integration, which includes summaries of recent studies on the prevalence and subtypes of eclectic/integrative therapies. The chapter concludes with discussions of recurrent obstacles to, and emerging themes of, psychotherapy integration.

Why Integration Now? Integration as a point of view has probably existed as long as philosophy and psychotherapy. In philosophy, the third-century biographer, Diogenes Laertius, referred to an eclectic school that flourished in Alexandria in the second century A.D. (Lunde, 1974). In psychotherapy, Freud consciously struggled with the selection and integration of diverse methods (Frances, 1988). More formal ideas on synthesizing the psychotherapies appeared in the literature as early as the 1930s (French, 1933). Although the notion of integrating various therapeutic approaches has intrigued mental health professionals for some time (Goldfried & Newman, 1992), it has only been within the past 15 years that integration has developed into a clearly delineated area of interest. Indeed, the temporal course of interest in psychotherapy integration, as indexed by both the

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number of publications (Arkowitz, 1992) and development of organizations and journals (Goldfried & Newman, 1992), reveals occasional stirrings before 1970, a growing interest during the 1970s, and rapidly accelerating interest from 1980 to the present. The recent and rapid increase in integrative psychotherapies leads one to inquire, Why now? What present conditions have encouraged the field to give specific attention and credence of late to an elusive goal that has been around for over half a century? At least eight interacting, mutually reinforcing factors have fostered the development of integration in the past two decades: 1. 2. 3. 4. 5. 6. 7.

Proliferation of therapies Inadequacy of single theories External socioeconomic contingencies Ascendancy of short-term, problem-focused treatments Opportunities to observe and experiment with various treatments Paucity of differential effectiveness among therapies Recognition that therapeutic commonalities heavily contribute to outcome variance 8. Development of a professional network for integration

The sheer proliferation of diverse schools has been one important reason for the surge of integration. The field of psychotherapy has been staggered by too many choices and fragmented by future shock. Which of 400-plus therapies should be studied, taught, or bought? Conflicting and untested theories are advanced almost daily, and no single theory has been able to corner the market on utility. London (1988, pp. 5-6) wryly observes that the hyperinflation of brand-name therapies has produced narcissistic fatigue: "With so many brand names around that no one can recognize, let alone remember, and so many competitors doing psychotherapy, it is becoming too arduous to launch still another new brand." A related and second factor is the growing awareness that no one approach is clinically adequate for all cases. Beutler (1983) suggests that the proliferation of theories is both a cause and symptom of the problem—that neither the theories nor the techniques are adequate to deal with the complexity of psychological problems. Kazdin (1984, p. 139) writes that underlying the ecumenical spirit is the "stark realization" that narrow conceptual positions and simple answers to major questions do not begin to explain current evidence in many areas of psychotherapy. Clinical realities have come to demand a more flexible, if not integrative, perspective. Surveys of self-designated eclectic clinicians reveal that their alignment is motivated in part by disillusionment with single-therapy systems (Garfield & Kurtz, 1977; Norcross & Prochaska, 1988). Indeed, very few

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therapists adhere tenaciously to a single therapeutic tradition (Jensen, Bergin, & Greaves, 1990; Smith, 1982). The proliferation of therapies and the inadequacies of single models were in part precipitated by a matrix of economic and social pressures in the 1970s. London (1983) suggests that integration was spurred along by such occurrences as the advent of legal accreditation of psychologists, with a resultant surge in professional practice and growth of psychological trade schools; the destigmatization of psychology services, spurred by the human potential movement; the onset of federal financial support for clinical training; and insurance companies' financing of psychotherapeutic treatment. Attacks from outside the mental health professions have started to propel them together. Psychotherapy has experienced mounting pressures from such not easily disregarded sources as the courts, government policymakers, informed consumers, insurance companies, and national health insurance planners. Third parties and the public started to demand crisp and informative answers regarding the quality, durability, and efficiency of psychosocial treatments (Parloff, 1979, 1981). Without some drastic changes (not the least of which is the movement for therapeutic integration), psychotherapists stand to lose prestige, customers, and money. As Mahoney (1984a) puts it, there is something to be said for having the different therapies "hang together," rather than "hang separately." Related to these escalating socioeconomic realities has been the rising interest in short-term, problem-focused psychotherapies during the past 20 years. Standard professional review of treatment, tightening insurance reimbursement, and declining federal support for mental health services began to startle clinical practitioners out of their long-term—model complacency. Managed mental health care portends a future discontinuous with our expansive past; short-term therapy has become the model of 1990s psychotherapy. The interest in short-term therapies has been accompanied by the development of more problem-focused therapies. A common emphasis on a problem focus has brought formerly different therapies closer together and has created variations of different therapies that are more compatible with each other. Integration, particularly in the form of technical eclecticism, responds to the pragmatic time-limited injunction of "which therapy works better (and quicker) for this patient with this problem in this setting." In one study of 294 HMO therapists, for instance, Austad, Sherman, and Holstein (1991) discovered that the prevalence of eclecticism/integration as a theoretical orientation nearly doubled as a function of their employment in HMOs favoring brief, problem-focused psychotherapy. A fifth factor in the promotion of psychotherapy integration over the last two decades has been the increasing opportunities for clinicians of

Psychotherapy Integration

9

disparate orientations actually to observe and experiment with various treatments (Arkowitz, 1992). Since the 1970s, the establishment of specialized clinics for the treatment of specific disorders—sexual dysfunctions, agoraphobia, obsessive-compulsive disorders, depression, and eating disorders, to name just a few—have afforded exposure to other theories and therapies, and stimulated some to consider other orientations more seriously (London & Palmer, 1988). These clinics are often staffed by professionals of different orientations and disciplines, with greater emphasis on their expertise about the clinical problem than on their theoretical orientation per se. Moreover, a number of specific treatment manuals have been produced of late (e.g., Beck, Rush, Shaw, & Emery, 1979; Luborsky, 1984; Strupp & Binder, 1984), which Luborsky and DeRubeis (1984) have labeled a "small revolution." The availability of more clearly described therapy procedures has permitted more accurate comparisons and contrasts among them, providing further impetus for various approaches to psychotherapy integration (Norcross & Arkowitz, 1992). In behavioral terms, these developments may have induced an informal version of "theoretical exposure": previously feared and unknown therapies were approached gradually, anxiety dissipated, and the previously feared therapies were integrated into the clinical repertoire. Despite a noticeable increase in the quantity and quality of psychotherapy outcome studies, research has revealed surprisingly few significant differences in outcome among different therapies; with several exceptions, there is little evidence to recommend the use of one type over another in the treatment of specific problems (Lambert, Shapiro, & Bergin, 1986; Smith, Glass, & Miller, 1980). Luborsky, Singer, and Luborsky (1975), borrowing a phrase from the dodo bird in Alice in Wonderland, wryly observe that "everybody has won and all must have prizes." Or, in the words of London (1988, p. 7), "Meta-analytic research shows charity for all treatments and malice towards none." While we must be cautious in accepting the null hypothesis (Beutler, 1991), and while there are many possible interpretations of such findings (Stiles, Shapiro, & Elliott, 1986), they very likely served as a catalyst for many who began to consider integrative interpretations of these results. A paradox has emerged from the equivalence conclusion: no consistent differential effectiveness despite technical diversity (Stiles et al., 1986). A number of resolutions to this paradox have been advanced, including the unspecificity of outcome measurement, the poor integrity of treatments, and the inadequate statistical power to detect treatment differences (regarding the latter, see Kazdin & Bass, 1989). The two most common responses seem to be a specification of factors common to successful treatments and a synthesis of useful concepts and methods from disparate therapeutic traditions.

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HANDBOOK OF PSYCHOTHERAPY INTEGRATION

The field has slowly shifted to a new direction toward determining therapeutic commonalities (Gomes-Schwartz, Hadley, & Strupp, 1978)—a seventh contributor to the rise of integration. It has been suggested that therapeutic success can best be predicted by the properties of the patient and the working alliance—all transtheoretical features of psychotherapy (e.g., Arkowitz, I992a; Beutler & Crago, 1991; Frank, 1979; Frieswyk et al, 1986; Horvath & Symonds, 1991, Lambert, 1992). Only 10 to 15 percent of outcome variance is generally accounted for by technique variables (Beutler & Clarkin, 1990; Lambert, 1989, 1992; Smith, Glass, & Miller, 1980). In his classic Persuasion and Healing, Frank (1973) posits that all psychotherapeutic methods are elaborations and variations of age-old procedures of psychological healing. The features that distinguish psychotherapies from each other, however, receive special emphasis in the pluralistic, competitive American society. Since the prestige and financial security of psychotherapists hinge on their being able to show that their particular approach is more successful than that of their rivals, little glory has been traditionally accorded the identification of shared or common components. Last but not least, the development of a professional network has been both a consequence and cause of interest in psychotherapy integration. During the 1970s the strands of psychotherapy integration were available, but they did not yet form a connected and unified body of thought. In 1983, the interdisciplinary Society for the Exploration of Psychotherapy Integration (SEPI) was formed (see description by Goldfried & Newman, 1992) to bring together those who were intrigued by the various modes of rapprochement among the psychotherapies. The organization has brought together integration enthusiasts through a newsletter, annual conferences, regional networks, and a quarterly journal, thus simultaneously reflecting and promulgating the integrative spirit throughout the therapeutic community.

Three Routes to Integration There are numerous pathways toward the integration of the psychotherapies (Mahrer, 1989). The three most popular routes at present are (1) technical eclecticism, (2) theoretical integration, and (3) common factors (Arkowitz, 1989; Norcross & Grencavage, 1989). All three directions are characterized by a general desire to increase therapeutic efficacy, efficiency, and applicability by looking beyond the confines of single theories and the restricted techniques traditionally associated with those theories. They do so, however, in rather different ways and at different levels.

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11

TECHNICAL ECLECTICISM

Eclecticism is the least theoretical of the three, but should not be construed as either atheoretical or antitheoretical (Lazarus, Beutler, & Norcross, 1992). Technical eclectics seek to improve our ability to select the best treatment for the person and the problem. This search is guided primarily by data on what has worked best for others in the past with similar problems and similar characteristics. Eclecticism focuses on predicting for whom interventions will work: the foundation is actuarial rather than theoretical. The eclectic models of Beutler (1983; Beutler & Clarkin, 1990; Beutler & Consoli, 1992) and Lazarus (1971, 1976, 1989a, 1992) are exemplars of this form of integration. Proponents of technical eclecticism use procedures drawn from different sources without necessarily subscribing to the theories that spawned them, whereas the theoretical integrationist draws from diverse systems that may be epistemologically or ontologically incompatible. For technical eclectics, no necessary connection exists between metabeliefs and techniques. "To attempt a theoretical rapprochement is as futile as trying to picture the edge of the universe. But to read through the vast amount of literature on psychotherapy, in search of techniques, can be clinically enriching and therapeutically rewarding" (Lazarus, 1967, p. 416).

THEORETICAL INTEGRATION

In this form of synthesis, two or more therapies are integrated in the hope that the result will be better than the constituent therapies alone. As the name implies, there is an emphasis on integrating the underlying theories of psychotherapy—what London (1986) has eloquently labeled "theory smushing"—along with the integration of therapy techniques from each—what London has called "technique melding." The various proposals to integrate psychoanalytic and behavioral theories illustrate this direction, most notably the work of Wachtel (1977, 1987; Wachtel & McKinney, 1992), and grander schemes to meld all the major systems of psychotherapy, for example, the transtheoretical approach of Prochaska and DiClemente (1984, 1986, 1992). Other writers have focused on different hybrids (e.g., Appelbaum, 1976; Feldman & Pinsof, 1982; Gunman, 1981; Held, 1984; LeBow, 1984; Segraves, 1982; Thoresen, 1973; Wachtel & Wachtel, 1986; Wandersman, Poppen, & Ricks, 1976). Theoretical integration involves a commitment to a conceptual or theoretical creation beyond a technical blend of methods. The goal is to create a conceptual framework that synthesizes the best elements of two or more approaches to therapy. Integration, however, aspires to more than a simple combination; it seeks an emergent theory that is more than the

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HANDBOOK OF PSYCHOTHERAPY INTEGRATION

sum of its parts, and that leads to new directions for practice and research. The preponderance of professional contention resides in the distinction between theoretical integration and technical eclecticism. How do they differ? Which is the more fruitful strategy for knowledge acquisition and clinical practice? The NIMH Workshop (Wolfe & Goldfried, 1988) and two studies (Norcross & Napolitano, 1986; Norcross & Prochaska, 1988) have clarified these questions. Table 1.1 summarizes the consensual distinctions between integration and eclecticism. The primary distinction is that between empirical pragmatism and theoretical flexibility. Integration refers to a commitment to a conceptual or theoretical creation beyond eclecticism's pragmatic blending of procedures. Or to take a culinary metaphor (cited in Norcross & Napolitano, 1986, p. 253): "The eclectic selects among several dishes to constitute a meal, the integrationist creates new dishes by combining different ingredients." A corollary to this distinction, rooted in theoretical integration's early stage of development, is that current practice is largely eclectic; theory integration represents a promissory note for the future. In the words of Wachtel (1991, p. 44): The habits and boundaries associated with the various schools are hard to eclipse, and for most of us integration remains more a goal than a constant daily reality. Eclecticism in practice and integration in aspiration is an accurate description of what most of us in the integrative movement do much of the time. TABLE 1.1

Eclecticism vs. Integration Eclecticism

Integration

Technical

Theoretical

Divergent (differences)

Convergent (commonalities)

Choosing from many

Combining many

Applying what is

Creating something new

Collection

Blend

Applying the parts

Unifying the parts

Atheoretical but empirical

More theoretical than empirical

Sum of parts

More than sum of parts

Realistic

Idealistic

Psychotherapy Integration

13

Further consideration of the relative merits of theoretical integration versus technical eclecticism can be found in Goldfried and Wachtel (1987), Beutler (1989), and Arkowitz (1989), as well as Lazarus (1989a) and Beitman (1989). COMMON FACTORS

The common factors approach seeks to determine the core ingredients that different therapies share in common, with the eventual goal of creating more parsimonious and efficacious treatments based on those commonalities. This search is predicated on the belief that commonalities are more important in accounting for therapy outcome than the unique factors that differentiate among them. The long considered "noise" in psychotherapy research is being reconsidered by some as the main "signal" elements of treatment (Omer & London, 1988). The work of Arkowitz (1992a), Beitman (1987, 1992), Frank (1973, 1982), and Garfield (1980, 1986, 1992) have been among the most important contributions to this approach. One way of determining common therapeutic principles is by focusing on a level of abstraction somewhere between theory and technique. This intermediate level of abstraction, known as a clinical strategy or a change process, may be thought of as a heuristic that implicitly guides the efforts of experienced therapists. Goldfried (1980, p. 996) argues: To the extent that clinicians of varying orientations are able to arrive at a common set of strategies, it is likely that what emerges will consist of robust phenomena, as they have managed to survive the distortions imposed by the therapists' varying theoretical biases.

In specifying what is common across disparate orientations, we may also be selecting what works best among them. Nonetheless, more than commonalities are evident across the therapies; there are unique or specific factors attributable to different therapies as well. One of the important achievements of psychotherapy research, observe Lambert and Bergin (1992), is demonstration of the differential effectiveness of a few therapies with specific disorders, such as behavior therapy for child conduct disorders, conjoint therapy for marital conflict, and cognitive therapy for panic disorder. As Lambert (1992) concludes in chapter 3, eclectic therapies should emphasize those factors common across therapies highlighted in research while capitalizing on the contributions of specific techniques. The nascent consensus on the specific versus common factors controversy is that it is not either/or, not a dualism. The proper use of common

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HANDBOOK OF PSYCHOTHERAPY INTEGRATION

and specific factors in therapy will probably be most effective for clients and most congenial to practitioners (Garfield, 1992). To invoke the title of Beitman's (1992) chapter, we will gradually integrate by combining fundamental similarities and useful differences across the schools. Treasure our sameness, but respect our differences. In clinical work, the distinctions among these three thrusts of psychotherapy integration are not so apparent. The distinctions may be largely semantic and conceptual, not particularly functional, in practice. Few clients experiencing an "integrative" therapy would be able to distinguish among them (Norcross & Arkowitz, 1992). Moreover, we hasten to add that these integrative strategies are not mutually exclusive. No technical eclectic can totally disregard theory, and no theoretical integrationist can ignore technique. Without some commonalties among different schools of therapy, theoretical integration would be impossible. And even the most ardent proponent of common factors cannot practice "nonspecifically" or "commonly"; specific techniques must be applied. DEFINING THE PARAMETERS OF INTEGRATION

By common decree, technical eclecticism, common factors, and theoretical integration are all assuredly part of the integration movement. However, where are the lines to be drawn, if drawn at all, concerning the boundaries of psychotherapy integration? What about the combination of therapy formats—individual, family, group—and the combination of medication and psychotherapy? In both cases, a strong majority of clinicians—80 percent plus—consider these to be within the legitimate boundaries of integration (Norcross & Napolitano, 1986). Of course, the inclusion of psychopharmacology enlarges the scope to integrative treatment, rather than integrative psychotherapy per se. Integrative treatments have begun to consider seriously the role of psychosocial and psychopharmacological interventions (Beitman, Hall, & Woodward, 1992) and combined therapy formats (Allen, 1988; Clarkin, Frances, & Perry, 1992; Feldman & Powell, 1992; Wachtel & Wachtel, 1986). Another thrust recently proposed as a part of psychotherapy integration is the infusion of theory and research in the behavioral sciences to inform psychotherapy. This type of integration aspires to enhance our knowledge of change processes by turning to basic knowledge on cognition, affect, development neuroscience, biological substrates, interpersonal influences, and community interventions (see Goldfried, Castonguay, & Safran, 1992). This direction is illustrated by the work of Arkowitz (199lb), Greenberg and Safran (1987), Horowitz (1988, 1991), Mahoney (1991),

Psychotherapy Integration

15

Schwartz (1991), Stein (1992), and Wolfe (1989, 1992), among others. It may be considered to be a form of theoretical integration, but the theories to which this approach turn are not psychotherapy theories per se, but any empirically supported theory that would serve to elucidate aspects of the change process (Arkowitz, 1992b).

Varieties of Integrative Experience Integration, as is now evident, comes in many guises and manifestations (Mahrer, 1989; Schacht, 1984). It is clearly neither a monolithic entity nor a single operationalized system; to refer to the integrative approach to therapy falls prey to the "uniformity myth" (Kiesler, 1966). The goals of this section are to explicate the immense heterogeneity in the psychotherapy integration movement, and to review studies on self-identified integrative and eclectic therapists. As our research and practice evolve, it is expected that much of this information will be supplemented and revised. PREVALENCE OF INTEGRATION

Approximately one-third to one-half of contemporary American clinicians disavow an affiliation with a particular school of therapy, preferring instead the label of "eclectic" or "integrative." Some variant of eclecticism or integration is routinely the modal orientation of responding psychotherapists. Summarizing 10 studies conducted in the 1980s on the membership of general psychotherapy organizations, Norcross (1986b) reported the incidence varied from 30 percent to 55 percent. Reviewing 25 studies performed between 1953 and 1990, Jensen, Bergin, and Greaves (1990) reported a range from 19 percent to 68 percent, the latter figure being their own finding. It is difficult to explain these variations in percentages, but differences in the organizations sampled, the questions asked, and the years of the investigation probably account for some of the variability. Nor is eclecticism restricted to members of general American psychotherapy organizations. Surveys of dues-paying members of orientationspecific organizations—both behavioral (Association for Advancement of Behavior Therapy) and humanistic (APA Division of Humanistic Psychology) associations—reveal sizable proportions who endorse an eclectic orientation; 42 percent in the former and 31 percent in the latter (Norcross & Wogan, 1983; Swan, 1979). Results from Western Europe and nonEuropean, English-speaking countries also indicate eclecticism is a popular approach; for example, among British clinical psychologists, the primary theoretical orientations are eclectic (27 percent), behavioral (27 percent), and cognitive (21 percent; Norcross, Dryden, & Brust, 1992).

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HANDBOOK OF PSYCHOTHERAPY INTEGRATION

While relatively easy to ascertain self-reported prevalence of eclecticism, it is much more difficult to determine what "integrative" practice precisely entails. Far more process research is needed on the conduct of eclectic or integrative psychotherapies; such investigations will probably need to make audio, video, and transcript recordings of the therapy offered in order to clarify the nature of therapeutic interventions (Goldfried, 1991; Lambert, 1992). Until greater precision is attained in descriptions and practices, the crucial question of whether outcomes are enhanced by integrative approaches will remain unanswered. "Thus the many efforts to understand the diversity in therapist orientations will have been wasted unless it can be shown that specific combinations of techniques produce superior outcomes with given disorders" (Jensen, Bergin, & Greaves, 1990, p. 129). INTEGRATIVE

THERAPISTS

With such large proportions of contemporary therapists embracing integration/eclecticism, it would be informative to identify distinctive characteristics or attitudes of eclectics as compared to noneclectics. Demographically, there do not appear to be any consistent differences between the two groups, with the exception of clinical experience (Norcross & Prochaska, 1982; Norcross & Wogan, 1983; Walton, 1978). Clinicians ascribing to eclecticism tend to be older and, concomitantly, more experienced. Inexperienced therapists are more likely to endorse exclusive theoretical orientations (Norcross & Prochaska, 1982; Smith, 1982). Several empirical studies have suggested that reliance on one theory and a few techniques may be the product of inexperience or, conversely, that with experience comes diversity and resourcefulness (see reviews by Auerbach & Johnson, 1977; Beutler, Crago, & Arizmendi, 1986; Parloff, Waskow, & Wolfe, 1978). Attitudinally, eclectic clinicians differ from their noneclectic colleagues in several respects. First, eclectics report relatively greater dissatisfaction with their current conceptual frameworks and technical procedures (Norcross & Prochaska, 1983; Norcross & Wogan, 1983; Vasco, GarciaMarques, & Dryden, 1992). This increased dissatisfaction may serve as an impetus to create an integrative approach, or it may have resulted from the elevated expectations that integration has engendered. Second, consistent with the prescriptive ideology, eclectics rate themselves as less influenced in practice than noneclectics by particular theories but more influenced by their clientele and by pragmatic considerations (e.g., setting and length of treatment). From a personal-historical perspective, Robertson (1979) identifies six factors that may facilitate the choice of eclecticism. The first is the lack of

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17

pressures in training and professional environments to bend to a doctrinaire position. Also included here would be the absence of a charismatic figure to emulate. A second factor, which we have already discussed, is length of clinical experience. As therapists encounter heterogeneous clients and problems over time, they may be more likely to reject a single theory. A third factor is the extent to which doing psychotherapy is making a living or making a philosophy of life; Robertson asserts that eclecticism is more likely to follow the former. In the words of several distinguished scientist-practitioners (Ricks, Wandersman, and Poppen, 1976, p. 401): So long as we stay out of the day to day work of psychotherapy, in the quiet of the study or library, it is easy to think of psychotherapists as exponents of competing schools. When we actually participate in psychotherapy, or observe its complexities, it loses this specious simplicity.

The remaining three factors are personality variables: an obsessivecompulsive drive to pull together all the interventions of the therapeutic universe; a maverick temperament to move beyond some theoretical camp; and a skeptical attitude toward the status quo. Although these factors require further confirmation, they are supported by our common training experiences and the personal histories of prominent clinicians represented in this volume (see chapters 5—13).

SURVEY GLIMPSES

Definitions of psychotherapy integration do not tell us what individual psychotherapists actually do or what it means to be an eclectic or integrative therapist. In an early survey of eclectic psychologists, Garfield and Kurtz (1977) discerned 32 different theoretical combinations used by 145 eclectic clinicians. The most popular two-orientation combinations, in descending order of frequency, were psychoanalytic and learning theory, neo-Freudian and learning theory, neo-Freudian and Rogerian theory, learning theory and humanistic theory, and Rogerian and learning theory. Most combinations, however, were blended and employed in an idiosyncratic fashion. It could not be determined whether the most efficacious procedures were indeed selected from the combined perspectives. The investigators concluded that the designation of eclectic covers a wide range of views, some of which are apparently quite distinct from others. Garfield and Kurtz (1977) found that almost half their sample indicated that they employed "whatever seemed best for the client." These pragmatic clinicians—resembling our definition of technical eclectics— reportedly select procedures according to the requirements of individual

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HANDBOOK OF PSYCHOTHERAPY INTEGRATION

clients. Two groups of respondents, accounting for 26 percent of the sample, replied that they basically combine two or three theories in their clinical work. These therapists—representing theoretical integrationists— considered themselves eclectic because they did not adhere to just one theoretical perspective. Five percent, representing a fourth vantage point, responded rather vaguely that "no theory is adequate and some are better for some purposes than others" (Garfield & Kurtz, 1977, p. 82). A ten-year "revisitation" of eclectic views by Norcross and Prochaska (1988) enlarged and updated the seminal Garfield and Kurtz (1977) results. Forty-two percent of 113 self-designated eclectics had not previously adhered to a particular theoretical perspective, whereas 58 percent indicated that they had. Similar findings—46 percent and 49 percent, respectively— were secured in the original study (Garfield & Kurtz, 1977). Of those with prior theoretical allegiances, 44 percent followed psychodynamic viewpoints, and 27 percent adhered to a behavioral orientation. Other previous viewpoints included client centered (12 percent), cognitive (6 percent), and psychoanalytic (6 percent). Thus, as with the 1977 findings and other studies (e.g., Jayaratne, 1982; Jensen, Bergin, & Greaves, 1990), the largest shift occurred from the psychodynamic persuasion, accounting for about one-half of the sample with previous alliance. The eclectic clinicians rated their frequency of use of six theories (i.e., behavioral, cognitive, humanistic, interpersonal, psychoanalytic, systems) in clinical practice. The resulting six theoretical views formed a matrix of 15 possible nonredundant dyadic combinations, each of which was selected by at least one respondent. The evolving prototypical combinations of theoretical orientations are shown in table 1.2, along with the earlier findings of Garfield and Kurtz. The three most frequent combinations accounted for 32 percent of the respondents in the 1980s study but only 5 percent in 1976. Although all 15 possible combinations were represented, a cognitive-behavioral integration was the most common, followed closely by humanistic-cognitive and psychoanalytic-cognitive syntheses. Interestingly, the three most frequent combinations all involve cognitive theory (see Alford & Norcross, 1991, and Beck, 1991, for related accounts). The modal combination in the 1970s was psychoanalytic-behavioral, accounting for 25 percent of the sample; however, this combination, advocated by 4 percent of the newer sample, ranked as the ninth most frequent in the late 1980s. This study and other research (Norcross & Napolitano, 1986; Norcross & Prochaska, 1983) demonstrates an emerging preference for both the term integration and the practice of theoretical integration, as opposed to technical eclecticism. Clinicians prefer the self-identification of integrative over eclectic by an almost two-to-one margin. This preference for integration over eclecticism probably represents a historical shift. In the

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Psychotherapy Integration

TABLE 1.2 Mosf Frequent Combinations of Theoretical Orientations 1986

1976*

Combination

%

Cognitive and behavioral

12

1

Humanistic and cognitive

11

2

Psychoanalytic and cognitive

10

3

Rank

%

Rank

5

4

8

4

11

3

Interpersonal and humanistic

8

4

3

6

Humanistic and systems

6

6

Psychoanalytic and interpersonal

5

7

Systems and behavioral

5

7

Behavioral and psychoanalytic

4

9

25

1

Behavioral and humanistic

'Percentages and ranks were not reported for all combinations in the 1976 study (Garfield & Kurtz, 1977).

1976 investigation (Garfield & Kurtz, 1977), most favored eclecticism; in the 1986 study (Norcross & Prochaska, 1988), most favored integration. There seems to have been a theoretical progression analogous to social progression: one that proceeds from segregation to desegregation to integration. Eclecticism has represented desegregation, in which ideas, methods, and people from diverse theoretical backgrounds mix and intermingle. Currently, we appear to be in transition from desegregation to integration, with increasing efforts directed at discovering viable integrative principles for assimilating and accommodating the best that different systems have to offer. Sophisticated integrative practice obviously is more complex than these brief survey glimpses can provide. To echo the authors of the original study, "Some value psychodynamic views more than others, some favor Rogerian and humanistic views, others clearly value learning theory, and various combinations of these are used in apparently different situations by different clinicians" (Garfield & Kurtz, 1977, p. 83). However, eclecticism seems to have gradually lost some of its negative definition as a nondescript brand name for those dissatisfied with orthodox schoolism. Instead, these clinicians actively and positively endorsed eclecticism as much as for what it offers as for what it avoids. In other words, integration "by design" is steadily replacing eclecticism "by default."

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ECLECTICISM VERSUS SYNCRETISM

The term eclecticism has acquired an emotionally ambivalent, if not negative, connotation for some clinicians due to its previously alleged disorganized and indecisive nature. In some corners, eclecticism connotes undisciplined subjectivity, "muddle-headedness," the "last refuge for mediocrity, the seal of incompetency," or a "classic case of professional anomie" (quoted in Robertson, 1979). Dryden (1984) observes that many of these psychotherapists wander around in a daze of professional nihilism, experimenting with new "fad" methods indiscriminately. Indeed, it is surprising that so many clinicians admit to being eclectic in their work, given the negative valence the term has acquired (Garfield, 1980). But much of the opposition to eclecticism should be properly redirected to syncretism—uncritical and unsystematic combinations (Norcross, 1990; Patterson, 1990). This haphazard "eclecticism" is primarily an outgrowth of pet techniques and inadequate training, an arbitrary, if not capricious, blend of methods "by default." Eysenck (1970, p. 145) characterizes this indiscriminate smorgasbord as a "mish-mash of theories, a huggermugger of procedures, a gallimaufry of therapies," having no proper rationale or empirical verification. This muddle of idiosyncratic and ineffable clinical creations is the antithesis of effective and efficient psychotherapy (Lazarus, Beutler, & Norcross, 1992). Systematic eclecticism, by contrast, is the product of years of painstaking clinical research and experience. It is truly eclecticism "by design," that is, clinicians competent in several therapeutic systems who systematically select interventions based on patient need and comparative outcome research (Norcross, I986a). The strengths of systematic integration lie in its ability to be taught, replicated, and evaluated. Rotter (1954, p. 14), years ago, summarized the matter as follows: "All systematic thinking involves the synthesis of pre-existing points of views. It is not a question of whether or not to be eclectic but of whether or not to be consistent and systematic." This distinction between eclecticism (by design) and syncretism (by default) can be illustrated by quilt making, a metaphorical representation of the process of blending diverse methods. The selection of materials and the construction of a quilt are reciprocally determined by the craftsperson's training, experiences, and preferences. Quilt makers do not mechanically select their swatches from the entire universe of possible materials. Instead, the possible materials are restricted to those in their possession, to remnants of old projects, and to those that can be readily acquired (in psychological terms: psychoanalytic, behavioral, experiential, etc.). And it is certainly the case that one cannot include materials that one does not possess. Furthermore, one can construct a quilt out of incomplete materials and scraps (by default) or, alternatively, from an abun-

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dance of rich and diverse materials (by design). Because quilt makers must peddle their wares in the public marketplace, they create products to match consumers' desires. Increasingly, quilts are tailored to the recipient, not the artisan. Each recipient's needs differ, however, resulting in greater demands on the quilt maker. Some quilt makers refuse to sacrifice their own preferences to cater to others' needs. These craftspeople continue in their own tradition, although to a smaller and narrower range of clientele. The new line of quilt makers strive to acquire the necessary resources to meet varied consumer demands and extend their wares to a growing segment of the market.

THREE STAGES

Werner's (1948; Werner & Kaplan, 1963) organismic-developmental theory is instructive for conceptualizing psychotherapists' development of a sophisticated integrative stance (also see Kaplan et al., 1983; Rebecca, Hefner, & Oleshansky, 1976). In the first of three developmental stages, one perceives or experiences a global whole, with no clear distinctions among component parts. Unsophisticated laypersons and undergraduates probably fall into this category. In the second stage, one perceives or experiences differentiation of the whole into parts, with a more precise and distinct perspective of components within the whole. However, one no longer has a perspective on the whole, and subsequently loses the "big picture." Most psychotherapy courses, textbooks, and clinically inexperienced practitioners fall into this category. In the third stage, the differentiated parts are organized and integrated into the whole at a higher level. Here, the unity and the complexity of psychotherapy are appreciated. It is to this level, we believe, that psychotherapy should aspire in practice, theory, research, and training.

ROLE OF PURE-FORM THERAPIES

Conspicuously absent from this overview chapter on integration has been acknowledgment of the conventional, "pure-form" (or brand-name) therapy systems, such as psychoanalytic, behavioral, and experiential. While perhaps not immediately apparent, pure-form therapies are part and parcel of the integration movement. In fact, integration could not occur without the constituent elements provided by the respective therapies— their theoretical systems and clinical methods. In a narrow sense, conventional therapies do not contribute to the integration movement because they have not generated paradigms for

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synthesizing various interventions and conceptualizations. But in broader and more important ways, they add to our therapeutic armamentarium, enrich our understanding of the clinical process, and produce the process and outcome research from which integration draws. One cannot integrate what one does not know (Norcross & Grencavage, 1989). In this respect, we should be reminded that the so-called pure-form psychotherapies are themselves "second-generation" integrations (Alford & Norcross, 1991). In factor analytic terms, virtually all neo-Freudian approaches would be labeled "second order" constructs—a superordinate result of analyzing and combining the original components (therapies). Just as Freud necessarily incorporated methods and concepts of his time into psychoanalysis (Frances, 1988), so, too, do newer therapies. All psychotherapies may, therefore, be viewed as products of an inevitable historical integration—an oscillating process of assimilation and accommodation (Sollod, 1988). This conceptualization of the historical process can temper the judgmental flavor frequently expressed toward opponents of integration. These antagonistic characterizations—for instance, "rigid," "inveterate," "narrow," "close-minded"—are likely to result in a win-lose, zero-sum encounter, in which the integrative "good guys" seek victory over the separatistic "bad guys." As Andrews, Norcross, and Halgin (1992) note, this will do little to promote a welcoming attitude toward integration on the part of the "opposition," and even less to build on the documented successes of pure-form therapies. The objective of the integration movement, as is repeatedly emphasized in this volume's final chapter, is to improve the efficacy of psychotherapy; to obtain this end, the valuable contributions of pure-form therapies must be collegially acknowledged and their respective strengths collaboratively enlisted.

Recurrent Obstacles The accelerated development of integrative psychotherapies has not always been paralleled by serious consideration of their potential obstacles and tradeoffs (Arkowitz & Messer, 1984; Dryden, 1986). If we are to avoid uncritical growth or fleeting interest in eclectic/integrative psychotherapy, then some honest recognition of the barriers we are likely to encounter is sorely needed (Goldfried & Safran, 1986). Caught up in the excitement and possibilities of the movement, we have neglected the problems—the "X-rated topics" of integration. Healthy maturation, be it for individuals or for movements, requires self-awareness and constructive criticism. What is stopping psychotherapy integration now? Norcross and Thomas (1988) conducted a survey of Society for the Exploration of

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Psychotherapy Integration (SEPI) members to answer this question. Fiftyeight prominent integrationists rated the severity of twelve potential obstacles using a 5-point, Likert-type scale. The top five obstacles and their mean scores are presented in table 1.3. The most severely rated obstruction centered around the partisan zealotry and territorial interests of "pure" systems psychotherapists. Representative responses here were: "egocentric, self-centered colleagues"; "the institutionalization of schools"; and "ideological warfare, factional rivalry." Unfortunately, professional reputations are made by emphasizing the new and different, not the basic and similar. In the field of psychotherapy, as well as in other scientific disciplines, the ownership of ideas gets far too much emphasis. Although the idea of naturally occurring, cooperative efforts among professionals is engaging, their behavior, realistically, may be expected to reflect the competition so characteristic of our society at large (Goldfried, 1980). Inadequate training in eclectic/integrative therapy was the secondranked impediment. Training students to competence in multiple theories and interventions is unprecedented in the history of psychotherapy. Understandable in light of its exacting and novel nature, the acquisition of integrative perspectives has occurred quite idiosyncratically and perhaps serendipitously to date (see Andrews et al., 1992; Robertson, 1986). Needless to say, designing an integrative training program is a near overwhelm-

TABLE 1.3

Obstacles to Psychotherapy Integration Severity Rating Obstacle Intrinisic investment of individuals in their private perceptions and theories Inadequate commitment to training in more than one psychotherapy system Approaches have divergent assumptions about psychopathology and health Inadequate empirical research on the integration of psychotherapies Absence of a "common" language for psychotherapists 1 = not an obstacle; 3 = moderate obstacle; 5 = severe obstacle

Mean

Rank

3.97

1

3.74

2

3.67

3

3.58

4

3.47

5

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ing task; trying to master such a program (as a student) may be even more intimidating. Starting in the 1980s a fair amount of emphasis has begun to be placed on this topic of vital importance for the future of the field. For example, three special sections of the journal of Integrative and Eclectic Psychotherapy have addressed integrative training and supervision (Beutler et al, 1987; Halgin, 1988; Norcross et al., 1986). As another example, a substantial majority of the contributors to the Handbook of Eclectic Psychotherapy put forth their ideas on a suitable integrative curriculum for graduate students and trainees. By and large, the individual authors of the Norcross (I986a) text collectively argue that the trainee needs some or all of the following: (1) rigorous training in the scientific method and the development of critical thinking skills; (2) significant exposure to a number of the major models of psychotherapy (sequentially or simultaneously); (3) an apprenticeship model, working closely with, observing, and being supervised by expert clinicians; (4) intensive training in developing skills for facilitating therapeutic relationships; and (5) substantial practical experiences with a wide range of populations. Clearly, these are goals to span an entire career. The third-ranked obstacle concerned differences in ontological and epistemological issues. These entail basic and sometimes contradictory assumptions about human nature, determinants of personality development, and the origins of psychopathology (Messer, 1992). For instance, are people innately good, evil, both, neither? Do phobias represent learned maladaptive habits or intrapsychic conflicts? Interestingly enough, it may be precisely these diverse world views that make psychotherapy integration valuable in that it brings together the individual strengths of these complementary orientations (Beitman, Goldfried, & Norcross, 1989; Messer, 1986). We have not conducted sufficient research on psychotherapy integration: the fourth obstacle to be addressed here. Comparative outcome research has been a limited source of direction with regard to selection of method and articulation of prescriptive guidelines. If our empirical research has little to say, and if collective clinical experience has divergent things to say, then why should we use one method and not another? Again, we may be guided by selective perception and personal preference, a situation the integrative movement seeks to avoid. We have reached a point where the need to justify psychotherapy integration as a legitimate area of interest is now being replaced by the need for relevant research findings (Goldfried, 1991). The adequacy of various integrative and eclectic approaches remains to be proven (Lambert, 1992; Mahalik, 1990; Norcross, 1986b; Wolfe & Goldfried, 1988).

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The evidence supporting integration is still largely anecdotal and preliminary (Yates, 1983). It is important to note, however, that there is no evidence of the clinical superiority of any "pure-form" therapy over an integrative approach (Wachtel, 1983) and that efforts to rectify this research deficiency are currently under way (see chapters 5—13 in this volume). A seemingly intractable obstacle to the establishment of clinically sophisticated and consensually validated integrative psychotherapies is the absence of a common language (Norcross, 1987). This was rated the fifth most serious impediment to progress. Each psychotherapeutic tradition has its own jargon, a clinical shorthand among its adherents, which widens the precipice across differing orientations. Goldfried, Castonguay, and Safran (1992) review the linguistic as well as epistemological and social barriers to rapprochement. The "language problem," as it has become known, confounds understanding and, in some cases, leads to active avoidance of each other's constructs. Many a behaviorist's mind has wandered when case discussions turn to "transference issues" and "warded-off conflicts." Similarly, psychodynamic therapists typically tune out buzz words like "conditioning procedures" and "discriminative stimuli." Isolated language systems encourage clinicians to wrap themselves in semantic cocoons from which they cannot escape and which others cannot penetrate. As Lazarus (1986) concludes, "Basically, integration or rapprochement is impossible when a person speaks and understands only Chinese and another converses only in Greek!" (p. 241). The purpose of a common language is to facilitate communication, comprehension, and research (Norcross, 1987). It is not intended to establish consensus. Before an agreement or a disagreement can be reached on a given matter, it is necessary to ensure that the same phenomenon is in fact being discussed. Punitive superego, negative self-statements, and poor self-image may indeed be similar phenomena, but that cannot be known with certainty until the constructs are defined operationally and consensually (Strieker, 1986). To be sure, this is a demanding task (Messer, 1987). In the short run, using the vernacular—descriptive, ordinary natural language—might suffice (Driscoll, 1987). One metaphor for a common metalanguage is the lingua franca that grows up in marketplaces, where communication among people of many cultures and languages is honed down to the essentials needed for transacting essential business (Andrews, 1989). In the long run, a common language may profit from being linked to a superordinate theory of personality or derived from an empirical database (e.g., Ryle, 1987; Strong, 1987).

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Emerging Themes As one examines the modern writings and historical literature on psychotherapy integration, a number of recurring themes emerge. These include: the complementarity of divergent approaches; the interaction of cognition, behavior, and affect; the need for empirically based therapies; the advantages of common language(s); and the phenomenon of clinical convergence. The following sections summarize recent views regarding these emerging themes.

COMPLEMENTARITY OF DIVERGENT APPROACHES

No therapy or therapist is immune to failure. It is at such times that experienced clinicians often wonder if the therapeutic methods from orientations other than their own might more appropriately have been included in the treatment program, if another orientation's strength in dealing with the particular therapeutic problems might complement the therapist's own orientational weakness in this area. Even those skeptical about the value of "technique melding" or "theory smushing" in psychotherapy can be enthusiastic about theoretical complementarity; as we suggested earlier, theoretical schools may not be contradictory but complementary (cf. Norcross, 1991). Allegedly rival systems of psychotherapy are not viewed as an adversity but as a healthy diversity (Landsman, 1974). From this point of view, various orientations complement each other and enrich the ability of clinicians to understand and work effectively with their clients. This idea is the basis of Pinsof's (1983) "Integrative Problem-Centered Therapy," which "rests upon the twin assumptions that each modality and orientation has its particular 'domain of expertise,' and that these domains can be interrelated to minimize their deficits" (p. 20). The potential for inter-orientation complementarity among psychodynamic and behavior therapy has been raised repeatedly. Consistent with Wachtel's (1977, 1987) thesis that people are helped when they are guided toward translating their insights into action, Fensterheim (1983) suggests that the therapist can make use of the psychoanalytic style to formulate hypotheses concerning the way patients organize their perceptions of the world and to select behavior patterns that pertain to their particular problem. Following this, a behavior therapy style may be applied to change these behaviors in a systematic and verifiable manner. Another theme of complementarity, expressed by Messer (1984, 1986), Rhoads (1984), and Salzman (1984), is that behavioral interventions may be able to provide some measure of symptomatic relief at the beginning of therapy, thereby

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gaining the client's trust and cooperation to discuss broader lifestyle problems and to engage in greater introspection. As insight is gained, behavior therapy can be utilized once again to teach the client more adaptive behaviors, so as to test out the everyday-life effects of this heightened self-awareness. Relatedly, the stages or phases of treatment seem to be a particularly useful conception (e.g., Beitman, 1992; Beutler & Consoli, 1992; Garfield, 1992). The transtheoretical approach of Prochaska and DiClemente (1992) posits a complementary relationship in which each theory has its own particular domain of expertise, and these are interrelated to maximize their assets and minimize their deficits. Specifically, psychoanalytic and strategic therapies are preeminent in dealing with precontemplators—clients unable or unwilling to recognize maladaptive behaviors. These therapies are particularly adept at expanding awareness, locating defenses, and addressing the resistances. Once into the contemplation stage, where clients recognize the problem but are not yet prepared to alter it, cognitive, existential, and Bowenian therapies come to the fore. Behavioral and structural strategies are the most effective for clients who are ready for action. Complimentary, not contradictory, theories of psychotherapy. INTERACTION OF COGNITION, BEHAVIOR, AND AFFECT

Depending on the theoretical perspective being taken, the cognitions, behaviors, and emotions of the patient have been given varying degrees of relative emphasis. Generally speaking, cognitive therapy has focused on the more consciously accessible side of the cognitive continuum, psychoanalytic therapy has delved into the unconscious aspects of cognitive processing, experiential orientations have tended to focus more on emotionality, and behavior therapy has been well known for its emphasis on action. Lazarus's (1967, 1976, 1992) work on a "multimodal" therapy may have paved the way for some of the questions that the integrative psychotherapist seems to be asking, such as, "Why not be prepared to give strong emphasis to the interaction of cognitions, behavior, and affect?" (e.g., Mahoney, 1984b; Schwartz, 1982), and "Shouldn't the choice to concentrate on one component more than the others be a function of patient characteristics instead of the therapist's training?" (e.g., Driscoll, 1984). A threedimensional affective-cognitive-behavior schema in therapy may be a more parsimonious guide in the selection of specific theories for conceptualization and intervention (Ward, 1983). Steinfield (1980) and Staats (1981) have similarly supported the adoption of a unified-interactive framework that includes cognition, behavior, and affect, adding that there must be an accompanying theoretical model as well as a systematic program of research.

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Safran (1984; Safran & Segal, 1990) deals with the interaction of cognition, behavior, and affect in incorporating Sullivanian principles into cognitive-behavioral treatment. He suggests that Sullivanian concepts (of self-perception and perception of others), if translated into a language consistent with experimental cognitive and social psychology, can supplement a cognitive-behavioral assessment by providing the conceptual framework within which to examine "hot" information processing occurring within an emotional and/or interpersonal context. Greenberg and Safran (1984, 1987, 1989) go on to make a serious attempt at conceptualizing the integration of affective and cognitive processes, based on experimental data and models of information processing. Although this is a rigorous undertaking, they are quick to acknowledge that "it is essential to recognize the complex interdependence of the thinking, feeling, and action systems" (1984, p. 561). NEED FOR EMPIRICALLY BASED THERAPIES

Clinicians and researchers of differing orientations have long called for the development of psychotherapies with a strong empirical base, and psychotherapy integrationists have rallied around this call. Early on, Lazarus (1967, 1971) recommended an eclectic therapy as most potent when clinicians made use of (and further experimented with) a set of empirically useful methods. Beutler's (1983), Dryden's (1984), Fensterheim and Glazer's (1983), Garfield's (1980), and Segraves's (1982) respective volumes on eclectic psychotherapy also aspire to an empirical approach. An empirical base for practice has at least two meanings (Fischer, 1986). The first is the use of research to inform practice, as in the selection of clinical techniques and interpersonal stances; the second is in the careful, objective evaluation of the effects of the psychotherapies. The latter is particularly urgent because there is little unambiguous evidence of the clinical superiority of an integrative approach over existing systems (Lambert, 1992; Yates, 1983). We need to discover, in functional terms, which therapist behaviors and treatment strategies are more effective with which types of clients (Cross & Sheehan, 1981; Paul, 1967). In this respect, a natural affinity exists between process research and psychotherapy integration (Beutler & Clarkin, 1990; Goldfried and Safran, 1986; Wolfe & Goldfried, 1988). Processoutcome research can contribute to all three thrusts of the integrative movement—by stimulating theory (theoretical integration), by identifying effective methods for that disorder and that client (technical eclecticism), and by delineating transtheoretical elements (common factors). Although many authors have enumerated common therapeutic strategies that transcend different orientations, the generation of these strategies

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has been based primarily on what therapists say they do, not on direct observations of what they actually do (Grencavage & Norcross, 1990). It has been repeatedly suggested that the identification of general mechanisms of change can be facilitated by the investigation of those similarities that exist across different orientations (Goldfried & Padawer, 1982). Unfortunately, a commonly expressed concern among contemporary authors is that such research is sorely lacking (e.g., Arkowitz, 1984; Goldfried, 1991; Jensen et al., 1990; Lambert, 1992; Prochaska & Norcross, 1986; Yates, 1983). A direct result of this concern is the emergence of a new theme in the literature, that of the push for the development of workable methodologies for the study of psychotherapy integration (e.g., Goldfried & Safran, 1986; Norcross & Thomas, 1988; Wolfe & Goldfried, 1988). It has also been suggested that psychotherapy integration needs to be rooted in an empirical, unified understanding of psychopathology (Arkowitz, 1989; Guidano, 1987; Millon, 1988; Wolfe, 1989; Wolfe & Goldfried, 1988), since clinical decision making is often based on knowledge of the etiology and course of a given disorder; one type of therapeutic approach may be more efficacious than others with regard to a particular disorder. Despite the consensus on the desirability of empirically based therapies and the encouraging starts, we have a long way to go. Several years ago Norcross and Prochaska (1983) found that of a list of 14 possible reasons that psychologists selected their interventions, research ranked a disappointing tenth. The average rating fell between "weak influence" and "some influence." Our hope for a future survey is that, as a result of the emerging empirical base in psychotherapy, the influence of outcome research will rank much higher. In the words of Appelbaum (1979, p. 501): "If any of us are to benefit from the ideas and experiences of others, then the whole has to be defined ... as knowledge. Only knowledge can unite disparate schools, techniques, and views of man and change. Only knowledge is boundaryless and infinite." ADVANTAGES OF COMMON LANGUAGE(s)

As we mentioned previously, each psychotherapy orientation has its own jargon, which presents obstacles to bridging the gap across schools. The problem is manifested not only by difficulty in understanding the various concepts, but also by active tuning out when one hears certain buzz words associated with another orientation (e.g., "warded off conflict," "negative reinforcement," or "self-actualization"). Jargon impedes communication (Gurman, 1978) and, without a common language, the field resembles a Tower of Babel (cf. Messer, 1987). Although the use of the vernacular may be helpful in facilitating communication (Brady et al., 1980; Driscoll, 1987; Messer, 1987), the field

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HANDBOOK OF PSYCHOTHERAPY INTEGRATION

of psychotherapy ultimately needs a language system that is tied to a database (Goldfried, 1987; Norcross & Grencavage. 1989; Strong, 1987). A number of contemporary writers have independently suggested the possibility that a common language may ultimately come from the field of experimental cognitive psychology and social cognition (Goldfried, 1987; Kazdin, 1984; Landau & Goldfried, 1981; Ryle, 1978, 1987; Safran, 1984; Sarason, 1979; Segraves, 1982; Shevrin & Dickman, 1980; Wolfe & Goldfried, 1988). Concepts such as "schema," "scripts," and "metacognition" have the potential for covering therapeutic phenomena observed by clinicians of varying orientations. Kazdin (1984, p. 163) writes that the concepts of cognitive psychology deal with the meaning of events, underlying processes, and ways of structuring and interpreting experience. They can encompass affect, perception, and behavior. Consequently, cognitive processes and their referents probably provide the place where the gap between psychodynamic and behavioral views is the least wide.

In the meantime, while the field decides whether and how it will implement a common research language, Messer (1987, 1992) reminds us that there is much to be learned by becoming fluent in a number of current theoretical languages. He argues that "this way, we can better appreciate the concepts, ideology, and terms of other viewpoints. This will surely lead to the permeation of ideas from one theory to another" (p. 198). CLINICAL CONVERGENCE

There is a pernicious misconception in our field that certain processes and outcomes are the exclusive property of particular therapy systems. Norcross (1988) labeled this fallacy the "exclusivity myth." Cases in point are the behaviorist's contention of exclusive ownership of behavior change, the experientalist's presumed monopoly on intense affective expression, and the psychoanalyst's assertion of unique historical insights. The exclusivity myth is part and parcel of the hostile, ideological cold war. The profession has encountered a proliferating number of therapies—each purportedly unique and superior. There is a great deal of clinical evidence, however, and a small but corroborating amount of experimental data, to the effect that the activities of experienced therapists of differing orientations are becoming similar, even though their conceptualizations of cases may be articulated quite differently (e.g., Friedling, Goldfried, & Strieker, 1984; Goldfried & Padawer, 1982; Karasu, 1977; Kazdin, 1984; Marmor, 1980; Saltzman & Norcross, 1990; Sloane, Staples, Cristol, Yorkston, & Whipple, 1975). In

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other words, therapists of varying orientations are making use of clinical activities that are successful, but not necessarily congruent with their theoretical persuasions and mandates. Wachtel (1977) speaks of a therapeutic "underground," reflecting an unofficial consensus of what experienced clinicians know to be true. Many of these factors are not associated with any particular school, and one rarely sees them described in the literature. Recent studies of clinical practitioners point to many areas of convergence as well as remaining points of contention. In one study (Mahoney, Norcross, Prochaska, & Missar, 1989), 486 clinical psychologists representing five major theoretical orientations responded to 40 standardized questions about optimal practices in psychotherapy. The results indicated considerable transtheoretical convergence on the importance of novel exploratory activity, self-examination, and self-development in psychotherapy. Behaviorists rated psychological change as significantly less difficult than did their colleagues of other persuasions unless they had been in psychotherapy themselves. In another study (Friedling et al., 1984), 85 psychodynamic and 110 behavioral psychologists reported on their use of operationally defined therapy activities. Over one-half of these methods were used by both groups, 15 percent were mutually rejected, and only 29 percent were employed exclusively by members of either orientation. Convergence refers to individual psychotherapists becoming more similar with accumulated experience, as well as disparate systems of psychotherapy growing alike with age. An assimilative or evolutionary process is occurring, according to Messer (1992), whereby therapy paradigms are incorporating specific clinical methods and certain perspectives from one another. Behavior therapy, for instance, has become more integrative by bringing cognitive and affective factors into its purview. Certain variants of psychoanalytic therapy have decidedly shifted toward interpersonal, time-limited treatment, and have been supplemented with actionoriented techniques. An emphasis on the importance of external reality, long a cardinal concept of behavior therapy, has now been taken much more seriously by psychoanalytic therapists. Likewise, cognitive and behavior therapists are now more willing to accept and incorporate the notion of unconscious processing. Be it individual psychotherapy practitioners or entire psychotherapy systems, many signs now point to a gradual deepening rapprochement, a coming together, of the psychotherapies.

Concluding Comment Psychotherapy integration, as presented in this Handbook, is a vibrant and promising movement that has begun to make encouraging contributions to

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the field. Integrative perspectives have been catalytic in the search for new ways of conceptualizing and conducting psychotherapy that go beyond the confines of single schools. They have encouraged practitioners and researchers to examine what other theories and therapies have to offer. Transtheoretical dialogue and cross-fertilization fostered by the integrative spirit have produced new ways of thinking about psychotherapy and change. In short, the historical sibling rivalry and "dogma eat dogma" ambience of psychotherapy are gradually abating (Norcross & Arkowitz, 1992). The early success of the integration movement, however, raises a critical question for its future: Will there be competition and proliferation of various schools of integrative therapy, just as there has been intense competition among "pure-form" schools? Several observers (e.g., Arnkoff & Glass, 1992; Arkowitz, 1991a, 1992; Lazarus, Beutler, & Norcross, 1992; Wachtel & McKinney, 1992) have cautioned recently that partisanship and competition among developing integrative models would simply be repeating the same old historical mistakes of psychotherapy. Integrative therapies could, ironically, become the rigid and institutionalized perspectives that psychotherapy integration attempted to counter in the first place. Rather, our view of—and hope for—the integration movement is that it will engender an. open system of informed pluralism, deepening rapprochement, and empirically grounded practice, one that leads to improved efficacy of psychosocial treatments. The telltale sign of the success of a movement is not how long it lasts, but what it leaves.

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APPELBAUM, S. A. (1979). Out in inner space: A psychoanalyst explores the therapies. Garden City, NY: Anchor.

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ARKOWITZ, H. (1984). Historical perspective on the integration of psychoanalytic therapy and behavior therapy. In H. Arkowitz & S. B. Messer (Eds.), Psychoanalytic therapy and behavior therapy: Is integration possible? (pp. 1-30). New York: Plenum. ARKOWITZ, H. (1989). The role of theory in psychotherapy integration. Journal of Integrative and Eclectic Psychotherapy, 8, 8—16. ARKOWITZ, H. (1991a). Introductory statement: Psychotherapy integration comes of age. Journal of Psychotherapy Integration, 1, 1—3. ARKOWITZ, H. (199lb, August). Psychotherapy integration: Bringing psychotherapy hack to psychology. Paper presented at the meeting of the American Psychological Association, San Francisco. ARKOWITZ, H. (1992a). A common factors therapy for depression. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. ARKOWITZ, H. (1992b). Integrative theories of therapy. In D. K. Freedheim (Ed.), History of psychotherapy: A century of change. Washington, DC: American Psychological Association. ARKOWITZ, H., & MESSER, S. B. (EDS.). (1984). Psychoanalytic therapy and behavior therapy: Is integration possible? New York: Plenum. ARNKOFF, D. B., & GLASS, C. R. (1992). Cognitive therapy and psychotherapy integration. In D. K. Freedheim (Ed.), History of psychotherapy: A century of change. Washington, DC: American Psychological Association. AUERBACH, A. H., & JOHNSON, M. (1977). Research on the therapist's level of experience. In A. S. Gurman & A. M. Razin (Eds.), Effective psychotherapy: A handbook of research. Elmsford, NY: Pergamon. AUSTAD, C. S., SHERMAN, W. O., & HOLSTEIN, L. (1991). Psychotherapists in the HMO. Manuscript under review. BABCOCK, H. H. (1988). Integrative psychotherapy. Collaborative aspects of behavioral and psychodynamic therapies. Psychiatric Annals, 18, 271—272. BECK, A. T. (1991). Cognitive therapy as the integrative therapy. Journal of Psychotherapy Integration, 1(3), 190—194. BECK, A. T., RUSH, A. J., SHAW, B. F., & EMERY, G. E. (1979). Cognitive therapy of depression. New York: Guilford. BEITMAN, B. D. (1987). The structure of individual psychotherapy. New York: Guilford. BEITMAN, B. D. (1989). Why I am an integrationist (not an eclectic). British Journal of Guidance and Counselling, 17, 259—273. BEITMAN, B. D. (1992). Integration through fundamental similarities and useful differences among the schools. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. BEITMAN, B. D., GOLDFRIED, M. R., & NORCROSS, J. C. (1989). The movement toward integrating the psychotherapies: An overview. American Journal of Psychiatry, 146, 138-147. BEITMAN, B. D., HALL, M. J., & WOODWARD, B. (1992). Integrating pharmaco-

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therapy and psychotherapy. In J. C. Norcross & ML R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. BEUTLER, L. E. (1983). Eclectic psychotherapy: A systematic approach. Elmsford, NY: Pergamon. BEUTLER, L. E. (1989). The misplaced role of theory in psychotherapy integration. Journal of Integratwe and Eclectic Psychotherapy, 8, 17—22. BEUTLER, L. E. (1991). Have all won and must all have prizes? Revisiting Luborsky et al.'s verdict. Journal of Consulting and Clinical Psychology, 59, 226-232. BEUTLER L. E., & CLARKIN, J. (1990). Selective treatment selection: Toward targeted therapeutic interventions. New York: Brunner/Mazel. BEUTLER, L. E., & CONSOLI, A. J. (1992). Systematic eclectic psychotherapy. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. BEUTLER, L. E., & CRAGO, M. (EDs.). (1991). Psychotherapy research: An international review of programmatic studies. Washington, DC: American Psychological Association. BEUTLER, L. E., CRAGO, M., & ARIZMENDI, T. G. (1986). Research on therapist variables in psychotherapy. In S. L. Garfield & A. E. Bergin (Eds.), Handbook of psychotherapy and behavior change (3rd ed.). New York: Wiley. BEUTLER, L. E., MAHONEY, M. J., NORCROSS, J. C., PROCHASKA, J. O., SOLLOD, R. M., & ROBERTSON, M. (1987). Training integrative/eclectic psychotherapists II. Journal of Integratwe and Eclectic Psychotherapy, 6, 296-332. BIRK, L. (1988). Behavioral/psychoanalytic psychotherapy with overlapping social systems: A natural matrix for diagnosis and therapeutic change. Psychiatric Annals, 18, 292-308. BRABECK, M. M., & WELFEL, E. R. (1985). Counseling theory: Understanding the trend toward eclecticism from a developmental perspective. Journal of Counseling and Development, 63, 343—349. BRADY, ]. P., DAVISON, G. C., DEWALD, P. A., EGAN, G., FADIMAN, J., FRANK, J. D., GILL, M., HOFFMAN, I., KEMPLER, W., LAZARUS, A. A., RAIMY, V., ROTTER, J. B., & STRUPP, H. H. (1980). Some views on effective principles of psychotherapy. Cognitive Therapy and Research, 4, 269-306. CLARKIN, J. F., FRANCES, A., & PERRY, A. (1992). Differential therapeutics: macro and micro levels of treatment planning. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. CROSS, D. G., & SHEEHAN, P. W. (1981). Classification of variables in psychotherapy research: Therapeutic change and the concept of artifact. Psychotherapy: Theory, Research and Practice, 18, 345—355. DAVIS, J. D. (1983). Slaying the psychoanalytic dragon: An integrationist's commentary on Yates. British Journal of Clinical Psychology, 22, 133—144. DRISCOLL, R. (1984). Pragmatic psychotherapy. New York: Van Nostrand Reinhold.

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FRENCH, T. M. (1933). Interrelations between psychoanalysis and the experimental work of Pavlov. American Journal of Psychiatry, 89, 1165-1203. FRIEDLING, C, GOLDFRIED, M. R., & STRICKER, G. (1984, April). Convergence in psychodynamic and behavior therapy. Paper presented at the annual meeting of the Eastern Psychological Association, Baltimore. FRIESWYK, S. H., ALLEN, J. G., COLSON, D. B., COYNE, L, GABBARD, G. D., HOROWITZ, L., & NEWSON, G. (1986). Therapeutic alliance: Its place as a process and outcome variable in dynamic psychotherapy research. Journal of Consulting and Clinical Psychology, 54, 32—38. GARFIELD, S. L. (1980). Psychotherapy. An eclectic approach. New York: Wiley. GARFIELD, S. L. (1982). Eclecticism and integration in psychotherapy. Behavior Therapy, 13, 610-623. GARFIELD, S. L. (1986). An eclectic psychotherapy. In J. C. Norcross (Ed.), Handbook of eclectic psychotherapy (pp. 132-162). New York: Brunner/Mazel. GARFIELD, S. L. (1992). Eclectic psychotherapy: A common factors approach. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. GARFIELD, S. L., & KURTZ, R. (1977). A study of eclectic views. Journal of Clinical and Consulting Psychology, 4-5, 78—83. GOLDFRIED, M. R. (1980). Toward the delineation of therapeutic change principles. American Psychologist, 35, 991-999. GOLDFRIED, M. R. (1982). On the history of therapeutic integration. Behavior Therapy, 13, 572-593. GOLDFRIED, M. R. (1987). A common language for the psychotherapies: Commentary. Journal of Integrative and Eclectic Psychotherapy, 6, 200—204. GOLDFRIED, M. R. (1991). Research issues in psychotherapy integration. Journal of Psychotherapy Integration, 1, 5-25. GOLDFRIED, M. R., CASTONGUAY, L. G., & SAFRAN, ]. D. (1992). Core issues and future directions in psychotherapy integration. In ]. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. GOLDFRIED, M. R., GREENBERG, L. S., & MARMAR, C. (1990). Individual psychotherapy: Process and outcome. Annual Review of Psychology, 41, 659—688. GOLDFRIED, M. R., & NEWMAN, C. (1992). A history of psychotherapy integration. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. GOLDFRIED, M. R., & PADAWER, W. (1982). Current status and future directions in psychotherapy. In M. R. Goldfried (Ed.), Converging themes in psychotherapy: Trends in psychodynamic, humanistic, and behavioral practice. New York: Springer. GOLDFRIED, M. R., & SAFRAN, ]. D. (1986). Future directions in psychotherapy integration. In ]. C. Norcross (Ed.), Handbook of eclectic psychotherapy (pp. 463-483). New York: Brunner/Mazel. GOLDFRIED, M. R., & WACHTEL, P. L. (1987). Clinical and conceptual issues in

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psychotherapy integration: A dialogue. Journal of Integrative and Eclectic Psychotherapy, 6, 131-144. GOMES-SCHWARTZ, B., HADLEY, S. W., & SIRUP?, H. H. (1978). Individual psychotherapy and behavior therapy. Annual Review of Psychology, 29, 435— 471. GREENBERG, L. S., & SAFRAN, J. D. (1984). Integrating affect and cognitions: A perspective on the process of therapeutic change. Cognitive Therapy and Research, 8, 559-578. GREENBERG, L. S., & SAFRAN, J. D. (1987). Emotion in psychotherapy: Affect, cognition, and the process of change. New York: Guilford. GREENBERG, L. S., & SAFRAN, J. D. (1989). Emotion in psychotherapy. American Psychologist, 44, 19-29. GRENCAVAGE, L. M., & NORCROSS, J. C. (1990). Where are the commonalities among the therapeutic common factors? Professional Psychology: Research and Practice, 21, 372-378. GUIDANO, V. F. (1987). Complexity of the self: A developmental approach to psychotherapy and theory. New York: Guilford. GURMAN, A. S. (1978). Contemporary marital therapies. In T. J. Paolino & B. S. McCrady (Eds.), Marriage and marital therapy. New York: Brunner/Mazel. GURMAN, A. S. (1981). Integrative marital therapy: Toward the development of an interpersonal approach. In S. Budman (Ed.), Forms of brief therapy (pp. 415-457). New York: Guilford. HALGIN, R. P. (1988). Special section: Issues in the supervision of integrative psychotherapy. Journal of Integrative and Eclectic Psychotherapy, 7, 152-180. HELD, B. S. (1984). Toward a strategic eclecticism: A proposal. Psychotherapy, 21, 232-241. HENLE, M. (1986). Some problems of eclecticism. In 7879 and all that: Essays in the theory and history of psychology. New York: Columbia University Press. HOROWITZ, M. J. (1988). Introduction to psychodynamics: A new synthesis. New York: Basic Books. HOROWITZ, M. J. (1991). New theory for psychotherapy integration. Journal of Psychotherapy Integration, 1, 85—92. HORVATH, A. O., & SYMONDS, B. D. (1991). Relation between working alliance and outcome in psychotherapy: A meta-analysis. Journal of Counseling Psychology, 38, 139-149. JAYARATNE, S. (1982). Characteristics and theoretical orientations of clinical social workers: A national survey. Journal of Social Service Research, 20, 476-485. JENSEN, J. P., BERGIN, A. E., & GREAVES, D. W. (1990). The meaning of eclecticism: New survey and analysis of components. Professional Psychology: Research and Practice, 21, 124—130. KAPLAN, A. G., FIBEL, B., GREIF, A. C., McCoMB, A., SEDNEY, M. A., & SHAPIRO, E. (1983). The process of sex-role integration in psychotherapy. Psychotherapy: Theory, Research and Practice, 20, 476—486.

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CHAPTER 2

A History of Psychotherapy Integration MARVIN R. GOLDFRIED AND CORY F. NEWMAN The progress of science is the work of creative minds. Every creative mind that contributes to scientific advances works, however, within two limitations. It is limited, first, by ignorance, for one discovery waits upon that other which opens the way to it. Discovery and its acceptance are. however, limited also by the habits of thought that pertain to the culture of any region and period, that is to say, by the Zeitgeist: an idea too strange or preposterous to be thought in one period of Western civilization may be readily accepted as true only a century or two later. —E. G. Boring

THE IDEA OF BEING ABLE to integrate the psychotherapies has intrigued mental health professionals for over a half century. It is only since the 1980s, however, that the issue of psychotherapy integration has developed into a clearly delineated area of interest. Prior to that, it was more of a latent theme that ran through the literature. As is the case with any attempt to trace the historical origins of contemporary thought, one never knows for certain the influence that earlier contributions have made to later thinking. More often than not, innovative ideas and findings are initially ignored, only to become assimilated into the mainstream at a later point in time (Barber, 1961). It is possible that the ultimate contribution of an idea lies in its consciousnessraising function. Thus, quite apart from their specific merits, new ideas sensitize us to otherwise neglected areas of thought. With regard to psychotherapy, some notions have continued to live on over the years, whereas others have failed to pass the test of time. Still others disappear after their introduction only to reappear at a later time when the Zeitgeist has become more hospitable. The dramatic interest in developing a rapprochement across the psychotherapies fits into this last category. In the present chapter, we begin with a historical review of past efforts at psychotherapy integration, covering the work that has been done

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through the 1980s. The concerns of the anti-integrationists are discussed, such as the differing perspectives on reality, the role of the unconscious, the importance of transference and the therapeutic alliance, and the goals of therapy. Finally, we describe the development of a professional reference group whose purpose is to support continued work in this area.

Early Attempts at Integration In what perhaps represented one of the earliest attempts at integrating the psychotherapies, French delivered an address—at the 1932 meeting of the American Psychiatric Association—in which he drew certain parallels between psychoanalysis and Pavlovian conditioning (e.g., the similarities between repression and extinction). The following year, the text of French's presentation was published, together with comments by members of the original audience (French, 1933). As one might expect, French's presentation resulted in very mixed audience reaction. As one of the most unabashedly negative responses by a member of the audience, Myerson acknowledged: I was tempted to call for a bell-boy and ask him to page John B. Watson, Ivan Pavlov, and Sigmund Freud, while Dr. French was reading his paper. I think Pavlov would have exploded; and what would have happened to Watson is scandalous to contemplate, since the whole of his behavioristic school is founded on the conditioned reflex. . . . Freud . . . would be scandalized by such a rapprochement made by one of his pupils, reading a paper of this kind. (French, 1933, p. 1201)

Meyer was not nearly so unsympathetic. Although he stated that the field should encourage separate lines of inquiry and should not attempt to substitute any one for another too prematurely, Meyer nonetheless suggested that one should "enjoy the convergences which show in such discussions as we have had this morning" (French, 1933, p. 1201). Zilboorg, who was also in the audience at the time, took an even more favorable stand, noting: I do not believe that these two lines of investigation could be passed over very lightly. . . . There is here an attempt to point out, regardless of structure and gross pathology, that while dealing with extremely complex functional units both in the physiological laboratory and in the clinic, we can yet reduce them to comparatively simple phenomena. (French, 1933, pp. 1198-1199)

In an extension of French's attempts, Kubie (1934) maintained that certain aspects of psychoanalytic technique itself could be explained in

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terms of the conditioned reflex. Noting that Pavlov hypothesized that certain associations might exist outside of an individual's awareness because they took place under a state of inhibition, Kubie suggested that free association might serve to remove the inhibition and allow such unconscious association to emerge. In 1936 Rosenzweig published a brief article in which he argued that the effectiveness of various therapeutic approaches probably had more to do with their common elements than with the theoretical explanations on which they were based. Rosenzweig suggested three common factors: (1) the therapist's personality has much to do with the effectiveness of the change process, since it may function to inspire hope in patients or clients; (2) interpretations are helpful because they provide alternative and perhaps more plausible ways of understanding a particular problem; and (3) even though varying theoretical orientations may focus on different aspects of human functioning, they can all be effective because of the synergistic effects that one area of functioning may have on another. At the 1940 meeting of the American Orthopsychiatric Association (Watson, 1940), a small group of therapists got together to discuss areas of agreement in psychotherapy. Commenting on the points of commonality (e.g., the importance of the therapeutic interaction), Watson observed that "if we were to apply to our colleagues the distinction, so important with patients, between what they tell us and what they do, we might find that agreement is greater in practice than in theory" (p. 708). In his book Active Psychotherapy, Herzberg (1945) described how systematically prescribed "homework" assignments might be used within the context of psychodynamic therapy. Anticipating an important behavioral contribution to the field by over a decade, Herzberg proposed the use of graded tasks, particularly in those cases where the clients' avoidance behavior was based on anxiety. Woodworth's 1948 text, Contemporary Schools of Psychology, explored the development and substantive content of the then existing schools of psychological thought, such as behaviorism, Gestalt psychology, and the psychoanalytic schools. He recognized that although each school had made gains in its own respective chosen direction, "no one [school] is good enough" (p. 255). Observing that psychology was advancing in many different directions, Woodworth wondered "whether synthesis of the different lines of advance [might] not sometime prove to be possible" (p. 10). Close on the heels of this thesis was a landmark work in the history of psychotherapy integration, namely Dollard and Miller's classic book Personality and Psychotherapy, published in 1950 and dedicated to "Freud and Pavlov and their students." The importance of Dollard and Miller's work in the history of psychotherapy can be attested to by the fact that this book remained in print for over 30 years. Although behavior therapists

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have traditionally argued that Dollard and Miller's thinking had little impact on the development of behavior therapy, the fact that the work is continually referred to suggests that it has been widely read. In their work, Dollard and Miller described in detail how such psychoanalytic concepts as regression, anxiety, repression, and displacement may be understood within the framework of learning theory. For the most part, Dollard and Miller merely translated one language system into another. Nonetheless, they did point to certain factors that may very well be common to all therapeutic approaches, such as the need for the therapist to support an individual's attempt at changing by expressing empathy, interest, and approval for such attempts. Even though Dollard and Miller (1950) stayed fairly close to the intervention procedures associated with psychoanalytic therapy, they made continual reference to principles and procedures on which contemporary behavior therapy is based. Thus, Dollard and Miller suggest the following: (1) the value of modeling procedures (e.g., "watching a demonstration of the correct response may enable the student to perform perfectly on the first trial," pp. 37-38); (2) the use of hierarchically arranged tasks (e.g., "the ideal of the therapist is to set up a series of graded situations where the patient can learn," p. 350); (3) reinforcement of gradual approximations toward a goal (e.g., "if a long and complex habit must be learned, the therapist should reward the subunits of the habit as they occur," p. 350); (4) the principle of reciprocal inhibition (e.g., "like any other response, fear apparently can be inhibited by responses that are incompatible with it," p. 74); (5) the significance of the reinforcing characteristic of the therapist (e.g., "the therapist uses approval to reward good effort on the part of the patient," p. 395); (6) the importance of teaching the individual self-control or coping skills to be used following therapy (e.g., "it is theoretically possible that special practice in self-study might be given during the latter part of a course of therapeutic interviews. The patient might be asked to practice solving particular problems . . . [under conditions] as similar as possible to those to be used after therapy," p. 438); (7) the treatment of orgasmic dysfunctions via masturbation (e.g., "at one point in a therapeutic sequence, the therapist might have to reward masturbation so that the patients may experience the sexual orgasm for the first time," p. 350); and (8) the importance of environmental contingencies for maintaining behavior change (e.g., "the conditions of real life must be favorable if new responses are to become strong habits," p. 427). Like Herzberg, Dollard and Miller also emphasized yet another behavioral tenet, the importance of between-session assignments (e.g., "behavioral changes must be made in the real world of the patient's current life. If benevolent changes are to occur, the patient must begin doing something new," p. 319). All the more striking is the source that they cite

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in support of this notion. Freud himself is quoted as writing, "Actually it is quite unimportant for his cure whether or not the patient can overcome this or that anxiety or inhibition in the institution; what is of importance, on the contrary, is whether or not he will be free from them in real life" (Freud, 1924, Vol. 2, p. 320). Unlike Dollard and Miller (1950), whose primary emphasis was on the integration of different theoretical orientations, Thorne (1950) was interested in pursuing therapeutic integration on the basis of what we know empirically about how people function and change. From the time that he was a medical student, Thorne was struck by the fact that medicine was not divided up into different schools of thought, but rather that basic principles of bodily functioning were what guided clinical practice. Like Thorne, Garfield had long been interested in an empirically based approach to therapy, and in 1957 he outlined what appeared to be common points among the psychotherapies. In an introductory clinical psychology text, Garfield noted such universal factors as an understanding and supportive therapist, the opportunity for emotional catharsis, and the provision of self-understanding. Glad's (1959) Operational Values in Psychotherapy took issue with the relative inflexibility of psychotherapy when practiced, to the letter, according to any given theoretical persuasion. He felt that the value systems instilled by doctrinaire approaches posed major limitations, and therefore recommended that the practicing therapist be exposed to (if not specifically trained in) systematic operations of psychotherapists from the major theoretical approaches of the time.

More Recent Trends Toward Rapprochement The topic of therapeutic rapprochement was seriously addressed by only a handful of writers in the 1950s, due, no doubt, to the fact that no single approach to psychotherapy had yet gained enough momentum to challenge psychoanalytic therapy. Perhaps it was also the conservative social and political climate of the 1950s that served to discourage therapists from questioning their paradigms. The 1960s, along with the broad array of societal challenges that came with it, brought a sharp increase in the number of books and articles dealing with rapprochement. THE 1960s The most significant contribution to the integration of psychotherapies made in the early 1960s was Frank's (1961) Persuasion and Healing. This book addressed itself to commonalities cutting across varying attempts at

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personal influence and healing in general. Frank suggested that psychotherapy serves to correct people's misconceptions about themselves and others. Similar change processes, Frank observed, can be seen in such diverse methods as religious conversion, primitive healing, brainwashing, and the placebo effects that occur in the practice of medicine. When distressed individuals are placed in any of these contexts, an expectancy for improvement and an arousal of hope results in a concomitant increase in self-esteem and improved functioning. It should be pointed out that although Frank continued to stress common factors across the psychotherapies in his later writings, in one of his more recent reviews of the field (Frank, 1979), he acknowledged that certain clinical problems (e.g., fears, phobias, compulsive rituals) may be effectively dealt with by methods that go beyond the general nature of the therapeutic interaction. Thirty years after the publication of French's landmark article, a colleague of his, Alexander (1963), suggested that psychoanalytic therapy might profitably be understood in terms of learning theory. Based on an analysis of tape recordings of psychoanalytic therapy sessions, Alexander concluded that many of the therapeutic changes that occurred "can best be understood in terms of learning theory. Particularly the principle of reward and punishment and also the influence of repetitive experiences can be clearly recognized" (p. 446). A therapist who was dedicated throughout his career to the advancement of the field, Alexander suggested that "we are witnessing the beginnings of a most promising integration of psychoanalytic theory with learning theory, which may lead to unpredictable advances in the theory and practice of the psychotherapies" (p. 448). A year later, Marmor, involved in the same program of research on psychotherapy, described in detail the learning principles that he believed to underlie psychoanalytic therapy (Marmor, 1964). About this time, Carl Rogers (1963) published an article dealing with the current status of psychotherapy. He noted that the field was "in a mess," but that the theoretical orientations within which therapists had typically functioned were starting to break down. He stated that the field was now ready to shed itself of the limitations inherent in specific orientations—including client-centered therapy—and that it was essential to observe more directly exactly what goes on during the course of psychotherapy. London (1964), in a short but insightful book entitled The Modes and Morals of Psychotherapy, pointed to the inherent limitations associated with both the psychodynamic and behavioral orientations, suggesting, "There is a quiet blending of techniques by artful therapists of either school: a blending that takes account of the fact that people are considerably simpler than the Insight schools give them credit for, but that they are also more complicated than the Action therapists would like to believe" (p. 39).

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Marks and Gelder (1966) also compared behavioral therapy and psychodynamic procedures. Although acknowledging that there was probably common ground between the two approaches, Marks and Gelder also underscored certain differences. They further suggested that the two approaches should be viewed as potentially contributing to each other, rather than necessarily being antagonistic in nature. Arguing for the integration of learning theory with psychoanalysis, Wolf (1966) suggested that "their integration is sooner or later inevitable, however passionately some or many of us may choose to resist it" (p. 535). The very important concept of "technical eclecticism" was introduced in 1967 by Lazarus, who maintained that clinicians can use techniques from various therapeutic systems without necessarily accepting the theoretical underpinnings associated with these methods. Starting from this pragmatic/clinical point of view, Lazarus maintained that the ultimate standard of utility should rest on empirical, not theoretical grounds. His views were eventually expanded and revised into the development of multimodal therapy (Lazarus, 1992). Appearing in that same year as Lazarus's landmark paper was an article by Patterson (1967) on divergent and convergent elements across the psychotherapies, a paper by Whitehouse (1967) on the generic principles underlying a variety of therapeutic interventions, and a discussion by Weitzman (1967) of how systematic desensitization may profitably be used within a psychoanalytic context. Brady (1968), responding to the practical demands of doing actual clinical work, argued that behavioral and psychodynamic approaches were not necessarily contradictory in nature but could, in certain cases, be used in combination. He described the treatment of a preorgasmic woman with systematic desensitization and short-term psychodynamic therapy focusing on the woman's relationship with her husband. In a similar vein, Leventhal (1968) described a case of a woman experiencing anxiety over sexuality who was successfully treated with combined behavioral and traditional therapeutic interventions. Developing this line of reasoning, Bergin (1968) asserted that systematic desensitization could be made into an even more powerful treatment procedure if accompanied by therapist warmth, empathy, and moderate interpretation. Bergin reasoned that such extrabehavioral activities were important because they elicited cognitive and emotional responses that are intimately tied to the behavioral situations addressed in the desensitization hierarchies. He maintained that a theory of therapy that addressed a more universal set of psychological events would be less likely to lead therapists to conceptual dead-ends in the face of particularly complex cases. Along these same lines, in an article offering a rationale for "psychobehavioral therapy," Woody (1968) observed that the integration of behavior therapy

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and psychodynamic therapy was particularly relevant for cases that were unresponsive to treatment. The following year, Kraft (1969) presented clinical evidence that systematic desensitization could help patients gain insight into a wealth of unconscious material through both imagery and relaxation in the face of previously feared objects or situations. In a theoretical paper examining the similarities among psychoanalytic, behavioral, and client-centered therapy, Sloane (1969) maintained that common factors ran through all three orientations, and that the underlying process of therapeutic change probably involved principles of learning. Commenting on Sloane's paper, Marmor (1969) agreed that all therapies involve some application of learning principles, either directly or unwittingly, but argued that the simple S-R model could not explain some of the more complex aspects of human functioning. Moreover, like London (1964), Marks and Gelder (1966), Lazarus (1967), Brady (1968), Bergin (1968), and others, Marmor concluded that behavioral and psychodynamic therapies are probably best viewed as complementary in nature, with neither model being totally applicable to all cases. Cautioning against a haphazard piecing together of techniques from different orientations, Brammer (1969) maintained that what was needed was an eclecticism based on research findings about the effectiveness of various clinical procedures. THE 1970s The year 1970 marked the inauguration of a new journal, Behavior Therapy. Given the enthusiasm that had been building among those who associated themselves with this orientation, one might have expected the first articles to contain grandiose statements about the "proven" effectiveness of behavior therapy over all other approaches. Such was not at all the case. Instead, editors and contributors devoted serious attention to aspects of theory and therapy that were not strictly "behavioral." Thus, Birk (1970) described two clinical cases to illustrate the potential integration of behavior therapy with psychodynamic theory. Bergin (1970a) followed his earlier treatise on nonbehavioral "adjuncts" to systematic desensitization with a paper that went so far as to claim that desensitization proper was, in fact, much more than a simple counterconditioning process, drawing heavily upon cognitive and relationship variables. Bergin (1970b), in applauding the introduction of cognitive methods into behavior therapy, observed: The sociological and historical importance of the movement should not be underestimated for it has three important consequences. It significantly reduces barriers to progress due to narrow school allegiances, it brings the energies of a highly talented and experimentally sophisticated group to bear upon the

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As it turned out, Bergin's observations were very much on the mark; many of the behavior therapists who became involved in the development of cognitive procedures (e.g., Davison, Goldfried, Lazarus, Mahoney, Meichenbaum) later moved on to an interest in therapeutic integration. In a consideration of the importance of the therapeutic relationship within a behavioral approach, Truax and Mitchell (1971) noted that the successful procedures of behavior therapy were not being delivered in an interpersonal vacuum. Although they lamented the evident difficulties involved in conducting research on the therapy interaction, they suggested—as Rosenzweig (1936) had done some 35 years earlier—that there existed important therapist characteristics that contributed to the change process, regardless of therapeutic orientation. Commenting on how existing cultural values contribute to the development of different schools of therapy, Frank (1971) outlined features that nonetheless were common to all approaches. Marmor published an article on therapeutic integration in that same year (Marmor, 1971), in which he suggested: The research on the nature ot the psychotherapeutic process in which I participated with Franz Alexander, beginning in 1958, has convinced me that all psychotherapy, regardless of the techniques used, is a learning process. . . . Dynamic psychotherapies and behavior therapies simply represent different teaching techniques, and their differences are based in part on differences in their goals and in part on their assumptions of the nature of psychopathology. (p. 26)

Many contemporary behavior therapists probably would now agree with Marmor's clinical observation that not only simple conditioning but also cognitive learning occurs during the course of therapy. In a scholarly review of the psychotherapy outcome literature, Bergin (1971) recognized the important empirical contributions that behavior therapy had begun to make. Nonetheless, he concluded that the field needed to remain open to the "many fertile leads yet to be extracted from traditional therapy" (p. 254). Responding to Bergin's clinical observations that behavior therapy alone was not always effective clinically, Lazarus (1971) described in Behavior Therapy and Beyond a wide array of both behavioral and nonbehavioral techniques that may be employed by broadspectrum behavior therapists. In the same year, Woody (1971) also published a book integrating behavioral and insight-oriented procedures. Echoing Lazarus's concept of technical eclecticism, Woody suggested that the

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practicing clinician is capable of selecting and integrating procedures from varying sources based purely on pragmatic grounds. Marks (1971) similarly noted the beginning trends toward rapprochement, observing that therapists "are growing less reluctant to adopt methods with pedigrees outside their own theoretical systems" (p. 69). Houts and Serber's (1972) edited book After the Turn On, What? described the experiences of seven researchers and practitioners who spent a weekend together in an encounter group. Ranging from radical behaviorism to cognitive learning in orientation, the participants described what they saw to be both assets and liabilities of their group experience. As part of a larger project to try to determine the future course of psychotherapy research, Bergin and Strupp (1972) reported on their contacts with researchers throughout the country. Among those interviewed was Neal Miller of Dollard and Miller fame, who predicted that as behavior therapy began to become involved with more complicated types of cases, and as psychodynamic therapy focused more on ego mechanisms and the working-through process, the two therapeutic approaches would eventually start to converge in some interesting ways. In a provocative article on the "end of ideology" in behavior therapy, London (1972) asked his behavioral colleagues to declare a truce in their strife with other orientations and to look more realistically and pragmatically at what we are able to do clinically. Very much the clinical pragmatist, London cautioned against becoming too enamored with theories, noting that "the first issue, scientifically as well as clinically, is the factual one—do they work? On whom? When? The how and why come later" (p. 919). Other efforts at therapeutic integration that appeared in 1972 included a book by Martin that attempted to integrate learning theory with client-centered therapy; a description of universal healing processes, seen among psychotherapists and witchdoctors alike (Torrey, 1972); and a set of papers dealing with the theoretical and clinical aspects of the integration of psychodynamic and behavior therapies (Feather & Rhoads, 1972a, 1972b). Feather and Rhoads (1972a) argued that in psychology, as in medicine, the existence of many treatments for a given disorder probably signaled a poor understanding of the disorder, and that none of the separate individual treatments was likely to be adequate. Commenting on one of Feather and Rhoads's articles appearing the previous year, Birk (1973) noted that one area of complementarity between a behavioral and psychodynamic approach was that the former dealt more with external stimuli, whereas the latter tended to focus on stimuli that are more internal in nature. Garfield (1973) extended his thesis on common factors that appeared in the late 1950s, and Strupp (1973), stressing the common elements underlying all psychotherapies, underscored the therapeutic relationship as a vehicle for change, providing the patient with a

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corrective learning experience. Thoresen (1973) suggested that many of the philosophical underpinnings of behaviorism and humanism were in agreement, and that it was possible to view a behavioral approach as providing the technology by which certain humanistic goals might be achieved. Appearing that same year was a report of two cases of sexual deviance (Woody, 1973), in which successful treatment was accomplished by aversion therapy and short-term psychodynamic therapy, administered concurrently by separate therapists. A fair number of articles appeared in 1974 on the issue of therapeutic rapprochement. In an intriguing discussion of behavioral and psychodynamic approaches as "complementary" rather than mutually exclusive, Ferster (1974)—a well-known Skinnerian—described what he considered to be some of the merits of psychoanalytically oriented therapy. The complementary nature of different approaches was demonstrated by Lambley (1974) in the treatment of an obsessive-compulsive disorder. Birk and Brinkley-Birk (1974) provided a conceptual integration of psychoanalysis and behavior therapy, suggesting that insight can set the stage for change, whereas behavior therapy provides some of the actual procedures by which the change process may be brought about. Birk (1974) also illustrated how intensive group therapy might be implemented by combining behavioral and psychoanalytic principles, and Rhoads and Feather (1974) described cases treated with desensitization procedures that were modified along psychodynamic lines. Kaplan (1974), in her book The New Sex Therapy, outlined how a psychodynamic approach to therapy may be integrated with performance-based methods, and Sollod's (1975) article expounded on the merits of this structured and synergistic integrative approach to sex therapy. In a report of the Menninger Foundation Psychotherapy Research Project, Horwitz (1974, 1976) noted that inasmuch as supportive treatment procedures were just as effective as insight-oriented therapy, the psychodynamic approach needed to consider alternative methods of producing therapeutic change that might not readily fit into its usual conceptual model. Similarly, Silverman (1974) made suggestions to his psychoanalytic colleagues that there is much to learn from "other approaches that can make (unmodified) psychoanalytic treatment more effective" (p. 305). In a paper delivered at the 1974 meeting of the American Psychological Association, Landsman (1974) urged his humanistically oriented colleagues to attend to some of the contributions of behavior therapy, such as "attention to specifics, to details, careful quantification, modesty in claims, demonstrable results" (p. 15). In his incisive book Misunderstandings of the Self, Raimy (1975), like Frank (1961), suggested that various approaches to therapy all seem to be directed toward changing clients' misconceptions of themselves and of

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others. All therapies are alike in that they "present evidence" to assist individuals in changing these misconceptions; the type of evidence and the way it is presented, however, vary across different therapeutic orientations. An article by the German psychologist Bastine (1975), and amplified upon a few years later (Bastine, 1978), likewise outlined common strategies, together with the specific techniques by which they may be implemented. In his clinically oriented book on the therapeutic change process, Egan (1975) modified his original humanistic orientation to acknowledge that there comes a time when the therapist must assume a more active role in helping a client to change. Although the contributions of Rogers (1963) and others are essential for establishing the type of therapeutic relationship in which change can take place, Egan suggested, behavior therapy may offer the clinician methods to implement specific action programs. Also in 1975 Sloane, Staples, Cristol, Yorkston, and Whipple published their classic findings on psychodynamic and behavior therapists' activities. Although the title of their book, Psychotherapy Versus Behavior Therapy, connoted a confrontation, their results actually underscored a theme of rapprochement. Sloane et al. reported that behavior therapists and psychodynamic therapists demonstrated comparable degrees of warmth and positive regard, and that patients of both types of therapists exhibited the same depth of self-exploration. On a theoretical level, Shectman (1975) suggested that behavioral principles might provide psychoanalysis with a more adequate theory of learning. Wachtel (1975), in the first of his many writings on therapy integration, cited the contributions made to psychodynamic therapy by Alexander, Horney, and Sullivan as evidence that behavioral approaches, which attempt to deal directly with problematic behaviors, could readily be incorporated into a psychodynamic framework. This is a two-way street, argued Wachtel, in that many instances of relapse following behavior therapy might possibly be linked to the client's maladaptive patterns that might more readily be identified when viewed from within a psychodynamic framework. Wachtel (1977) went on to explore such integration at greater length in his well-known and challenging book, Psychoanalysis and Behavior Therapy, in which he maintained that the convergence of clinical procedures from each orientation would likely enhance the effectiveness of our intervention attempts. In 1976 a number of articles and books touched on therapeutic integration. Strupp (1976) criticized psychoanalytic therapy for not keeping up with the times, using therapeutic procedures more on the basis of faith than data. Fortunately, observed Strupp, younger therapists seem less constrained by orthodoxy and are more willing to experiment with newer techniques. In a commentary on Strupp's article, Grinker (1976) underscored the need for a therapeutic approach based on research findings and

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noted that with added clinical experience, even the most orthodox of psychoanalysts learn that other methods are needed to help facilitate change. As a practicing psychoanalyst with personal experience in the human potential movement, Appelbaum (1976) suggested that some Gestalt therapy methods may complement more traditional psychoanalytic techniques. Appelbaum's excursion into more humanistically oriented activities were described in fascinating detail in a later book (Appelbaum, 1979). Wandersman, Poppen, and Ricks's (1976) Humanism and Behaviorism offered discussions by members of each orientation, which attempted to acknowledge points of potential integration. In Burton's (1976) edited volume, What Makes Behavior Change Possible?, 16 representatives of diverse therapeutic orientations addressed themselves to some of the basic questions about the essential ingredients of therapeutic change. Noting that behavior therapy was a useful framework for dealing with clinical cases, but still incomplete in and of itself, Hunt (1976) argued that there exists no single orientation that can deal with all clinical material. Just as separate laser beams function together to obtain a three-dimensional holographic image, observed Hunt, so too are different therapeutic orientations required in order to provide us with a comprehensive treatment approach. In their book Clinical Behavior Therapy, Goldfried and Davison (1976) maintained that behavior therapy need no longer assume an antagonistic stance vis-a-vis other orientations. Acknowledging that there is much that clinicians of different orientations have to say to each other, they suggested: "It is time for behavior therapists to stop regarding themselves as an outgroup and instead to enter into serious and hopefully mutually fruitful dialogues with their nonbehavioral colleagues" (p. 15). That many clinicians were in effect already doing this was reflected in Garfield and Kurtz's (1976) findings that approximately 55 percent of clinical psychologists in the United States considered themselves eclectic. Most frequently used in combination were the psychodynamic and learning orientations, a combination that was based on the pragmatics of doing clinical work (Garfield & Kurtz, 1977). Integration at a clinical level was dealt with in several articles (Lambley, 1976; Levay, Weissberg, & Blaustein, 1976; Murray, 1976; Segraves & Smith, 1976). Also Lazarus's (1976) book Multimodal Behavior Therapy extended and refined his broad-spectrum approach to behavior therapy so as to systematically take into account the individual's behaviors, affects, sensations, images, cognitions, interpersonal relationships, and drugs/ physiological states (the "BASIC I.D."). The following year Lazarus (1977), having by then practiced behavior therapy for approximately 20 years, questioned whether behavior therapy, as a delimited school of thought, had "outlived its usefulness." He

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recognized the need to "transcend the constraints of factionalism, where cloistered adherents of rival schools, movements, and systems each cling to their separate illusions" (p. 11). An editorial comment appearing in the journal of Humanistic Psychology (Greening, 1978) applauded Lazarus's 1977 paper and urged readers of the journal to be open to such suggestions for rapprochement. Commenting on the gap that frequently exists between theory and practice, Davison (1978) delivered a talk at the Association for Advancement of Behavior Therapy (AABT) convention in which he suggested that behavior therapists consider the possibility of using certain experiential procedures in their clinical work. Krasner (1978) outlined the history of both behaviorism and humanism, noting that the two orientations shared some common view of human functioning (e.g., the importance of situational factors, the uniqueness of the individual). He looked forward to the time when representatives in "both camps will decrease mutual battling and recriminations." Gurman (1978) challenged the usefulness of approaching a psychological problem through the eyes of one of many existing theories. He argued that theories are generally biased toward a single presentation of the human condition, and that human experience is more accurately conceptualized as the result of multiple factors. Underscoring what we all too often forget, Gurman went on to suggest that "therapy is not viewed as a reified set of procedures, but as an evolving science" (p. 131). Diamond, Havens, and Jones (1978) independently came to the same conclusion, stressing the need for an eclectic approach to therapy that would be tied to research and theory yet flexible enough to provide highly individualized treatment. In that same year, Baer and Stolz (1978) provided a behavioral analysis of est, Fischer (1978) outlined an eclectic approach to social casework, and O'Leary and Turkewitz (1978) described how a communications analysis of marital interaction might be used within the context of behavioral marital therapy. Some of the points of overlap between behavior therapy and Zen Buddhism were outlined by Mikulas (1978) and Shapiro (1978). A symposium on the compatibility and incompatibility of behavior therapy and psychoanalysis, chaired by Arkowitz (1978), was held at the 1978 AABT Convention. In a subsequently published 1978 convention paper entitled "Are Psychoanalytic Therapists Beginning to Practice Cognitive Behavior Therapy or Is Behavior Therapy Turning Psychoanalytic?", Strupp (1983) commented on some of the converging trends that seem to be occurring within each of these orientations. In a reanalysis of agoraphobia, Goldstein and Chambless (1978) described some of the complicating features in dealing with this problem clinically, outlining a comprehensive treatment plan that went beyond the straightforward methods typically

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associated with a behavioral approach. Also in the same year, Brown (1978) presented case material reflecting the integration of psychodynamic and behavior therapies, and Ryle (1978) suggested that experimental cognitive psychology might provide a common language for the psychotherapies. Prochaska (1979), in a textbook describing various approaches to psychotherapy, concluded with a chapter that made the case for ultimately developing a transtheoretical orientation that would encompass what may have been found to be effective across different approaches to psychotherapy. Presenting some interesting parallels between cognitive therapy and psychodynamic therapy, Sarason (1979) suggested that experimental cognitive psychology may provide us with a conceptual system for understanding both orientations. Goldfried (1979) proposed that cognitive behavior therapy might be construed as often dealing with an individual's implicit meaning structures, and that use of association techniques from experimental cognitive psychology to study such phenomena should be equally acceptable to clinicians and theorists of a psychodynamic orientation. It is interesting to note that Sarason and Goldfried drew their conclusions independently and without any apparent knowledge of Ryle's (1978) very similar conclusion the year before. Robertson (1979) speculated on some of the reasons for the existence of eclecticism, such as lack of pressure in one's training or professional setting to take a given viewpoint; the tendency for clinical experience to make a therapist more open to other procedures; a personal tendency to be a nonjoiner; and a therapeutic orientation reaching a point where "the bloom is off the rose." Related to this last point are the results of Mahoney's (1979) survey of leading cognitive and noncognitive behavior therapists. Among the several questions asked of the respondents was: "I feel satisfied with the adequacy of my current understanding of human behavior." Although there were no statistically significant differences between the two groups on this item, the absolute rating was indeed instructive. Using a 7-point scale, Mahoney found that the average rating of satisfaction was less than 2! THE 1980s During the 1980s, psychotherapy integration made a significant advance as a defined area of interest—indeed, a movement. There was a geometric increase in the number of publications and presentations on the topic, making it unwieldy and impractical for us to offer an adequate description of the more than 200 publications that appeared during the decade. However, we will attempt to highlight some of these contributions in the limited space available. Noting past attempts to find commonalities across psychotherapies,

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Goldfried (1980) argued that a fruitful level of abstraction at which such a comparative analysis might take place would be somewhere between the specific technique and theoretical explanation for the potential effectiveness of that technique. He maintained that it is at this intermediate level of abstraction—at the level of clinical strategy—that potential points of overlap may exist. One clinical strategy that may very well cut across orientations entails providing the client/patient with "corrective experiences," particularly with regard to fear-related activities. For example, Fenichel (1941), on the topic of fear reduction, noted that "when a person is afraid but experiences a situation in which what was feared occurs without any harm resulting, he will not immediately trust the outcome of his new experience; however, the second time he will have a little less fear, the third time still less" (p. 83). This very same conclusion was reached by Bandura (1969), who observed: "Extinction of avoidance behavior is achieved by repeated exposure to subjectively threatening stimuli under conditions designed to ensure that neither the avoidance responses nor the anticipated adverse consequences occur" (p. 414). Relevant to this general theme of parallels across theoretical orientations was Nielsen's (1980) description of how certain psychoanalytic concepts are reflected in the practice of Gestalt therapy. In a 1980 special issue of Cognitive Therapy and Research, therapists of various orientations answered a set of questions about what they believed to be the most effective ingredients in therapeutic change (Brady et al, 1980). At the 1980 AABT Convention, Goldfried and Strupp (1980) held a dialogue on the issue of rapprochement in which they agreed that in the final analysis, any attempt at finding points of commonality must be based on what clinicians do, rather than what they say they do. Dryden (1980) discussed the differences in therapeutic styles across orientations, particularly as they relate to the concept of transference; Bastine (1980) observed that a problem-oriented approach to intervention is likely to facilitate psychotherapy integration; and Linsenhoff, Bastine, and Kommer (1980) emphasized that the field of psychotherapy could benefit most from an integration that would be both theoretical and practical. Messer and Winokur (1980), in an article examining the potential benefits and pitfalls of psychotherapy integration, suggested that both action-oriented and introspective therapeutic approaches may be used in combination to help patients to translate their insights into action. Mahoney (1980) noted that behaviorists had begun not only to adopt a position that accepted a person's thoughts as useful data, but also to pay attention to "implicit" cognitions. In this manner, cognitive-behavioral theorists and therapists were beginning to examine "unconscious" events. Marmor and Woods's (1980) edited book The Interface Between Psychodynamic and Behavioral Therapies illustrated the theme that no single

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approach to therapy can deal with all of human functioning. This general theme was reflected in a case report by Cohen and Pope (1980), in which a single client was significantly helped by two cooperating therapists, one behavioral and the other analytic. A survey by Larson (1980) found that although therapists typically used a single orientation as their primary reference point, 65 percent acknowledged that their clinical work included contributions from a number of other therapeutic approaches. Ryle (1980) reported the findings of a series of case histories, in which an integrated, cognitive-dynamic intervention was found to be clinically effective. Garfield (1980), drawing on different therapeutic orientations in his Psychotherapy: An Eclectic Approach, described an empirically oriented view of psychotherapy. Like Bergin before him, he viewed the introduction of cognitive variables into behavior therapy as a particularly important advance. In 1981 a number of writers furthered the argument that each distinct orientation presents different strengths that can be combined into a more broad-based and useful approach. For example, Arnkoff (1981) reported combining cognitive therapy with the Gestalt empty-chair technique in order to increase affect and to elicit meaningful cognitions from the patient. The positive therapeutic results seemed greater than would be expected when either approach was used in isolation. The multimodal therapy of Lazarus (1981) essentially maintained that the therapist's choice of therapy techniques must be data driven, not theory driven. Schwartz (1981) reported that therapists who led groups in psychotherapy were moving toward "technical and theoretical eclecticism" in increasing numbers. Addressing the issue of integrative conceptual models, Landau and Goldfried (1981) described in detail how certain concepts from experimental cognitive psychology (e.g., schema, scripts) can offer the field a consistent framework within which cognitive, behavioral, and psychodynamic assessment may fit. Also addressing himself to the need for a framework, Staats (1981) remarked that the field of psychology had the means for creating empirical knowledge in abundance, but that the lack of conceptual unification in the field was creating greater confusion, not clarity. There appeared in the same year an article by Rhoads (1981) outlining and illustrating the clinical integration of behavior therapy and psychoanalytic therapy; a chapter by Gurman (1981) that described how different therapeutic orientations may be fitted into a multifaceted empirical approach to marital intervention; and a convention presentation by Sears (1981) relating his own personal observations of the early attempts to link behavior theory with psychoanalytic therapy. As the discussion of therapeutic integration was becoming increasingly widespread, it became desirable for concerned professionals to arrange meetings, so as to facilitate a more efficient and meaningful exchange of views. For example, in 198! a small group of clinicians and clinical

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researchers (Garfield, Goldfried, Horowitz, Imber, Kendall, Strupp, Wachtel, and Wolfe) held an informal, two-day conference to determine whether clinicians of different orientations could communicate with each other about actual clinical material. This group did not attempt to derive any particular product as their goal; their primary objective was to have the opportunity to initiate a dialogue with each other. Communication between psychotherapy practitioners and researchers of diverse orientations became a worldwide phenomenon in the following years. For example, in 1982, the Adler Society for Individual Psychology dedicated their World Congress (held in Vienna) to the exchange of views between representatives of many of the major therapy models. The following year, an International Congress in Bogota, Columbia, led by Augosto Perez Gomez, focused on the prospects for the convergence of psychotherapies and a cross-fertilization of ideas. As a way of illustrating how such rapprochement might be implemented, Anchin (1982) described an integration of interpersonal and cognitive-behavioral constructs, Bohart (1982) discussed the points of overlap between cognitive and humanistic therapy, Dryden (1982) indicated how rational-emotive therapy had selected techniques from other orientations, and Mahoney and Wachtel (1982) presented a day-long dialogue and discussion of actual clinical material. Goldfried and Padawer (1982) argued that the activities of therapists of differing theoretical orientations are highly similar, even though their conceptualizations of cases may be articulated quite differently. Their review of the literature revealed a number of strategies that seem to guide the efforts of most therapists. Focusing on the process of therapeutic change that occurs between sessions, Kazdin and Mascitelli (1982) noted that the study of "extratherapy practice" might be a fruitful area in which to find commonalities across orientations. Whether such practice occurs via prescribed homework assignments or as a result of client initiative, the processes by which clients convert insight into action are relevant to any psychotherapy. In 1982 the issue of theoretical integration acquired still greater visibility through the publication of a number of relevant books on the topic, authored by clinicians and researchers from diverse backgrounds. In Converging Themes in Psychotherapy, Goldfried (1982a) provided a compendium of articles dealing with the issue of rapprochement, together with an overview of the current status and future directions in psychotherapy integration. In Resistance, Wachtel (1982a) elicited the views of experienced and well-known therapists in an attempt to explore the possibility that a synthesis of the psychodynamic and behavioral approaches might shed light on resistance to therapeutic change. In Psychotherapy: A Cognitive Integration of Theory and Practice, Ryle (1982) assimilated theories and methods of a heterogeneous set of orientations into a common language

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system: cognitive psychology. In Marital Therapy, Segraves (1982), like Ryle, attempted to integrate elements of seemingly disparate theoretical systems by translating them into the language of cognitive social psychology. The utility of his cognitive-social psychology terminology is exemplified by the persuasive presentation of the concept of "interpersonal schemas," analogous to the analytic concept of "transference," to explain the influence of early-life significant relationships on a person's perceptions of his or her spouse. In 1983 the frequently asked question of "what therapy activities are most appropriate for what type of problem, by which therapist, for what kind of client/patient?" was addressed by Beutler in his book Eclectic Psychotherapy. This volume suggested ways of maximizing therapeutic effectiveness by reviewing what is known about the optimal matching of patients to therapists and techniques. Fensterheim and Glazer (1983), in Behavioral Psychotherapy, highlighted the complementarity of psychoanalytic and behavioral treatment methods. Consistent with the thesis outlined by Wachtel (1977), the contributors to this volume suggested that a psychoanalytic style be used to formulate assessment hypotheses and to select target behaviors, and a behavioral style be employed to change these problematic behaviors. Also appearing that year was a book on psychotherapy integration in German (Textor, 1983), reflecting the growth of the movement on an international level. Evidence of a rapprochement between biological and psychological approaches to therapy appeared in the work of Gevins (1983), and in the theme of the 1983 meeting of the Society of Biological Psychiatry, "The Biology of Information Processing." The following year, Beck (1984) and Beitman and Klerman (1984) presented guidelines for the integration of psychotherapies and pharmacotherapy. A number of authors began to suggest that the field of psychotherapy needed to develop a new, higher-order theory that would help us to better understand the connections between cognitive, affective, and behavioral systems (Beck, 1984; Dryden, 1984; Greenberg & Safran, 1984; Mahoney, 1984b; Ryle, 1984; Safran, 1984). These writers maintained that attempts to answer the question of how affective, behavioral, and cognitive systems interact would move the field toward the development of a more adequate, unified paradigm. Another framework for organizing and integrating various approaches to psychotherapy was offered by Driscoll (1984) in Pragmatic Psychotherapy. Substituting the vernacular for theoretical jargon, Driscoll presented a method (the pragmatic "survey") by which any given psychological problem can be elucidated and conceptualized in a diversity of ways. In Arkowitz and Messer's (1984) edited volume, Psychoanalytic Therapy and Behavior Therapy: Is Integration Possible? they, along with ten

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contributing authors, explore the clinical, theoretical, and empirical issues and implications of a serious attempt at rapprochement. Although there is no clear consensus on such matters, it is apparent that Arkowitz and Messer have provided an invaluable opportunity for the generation and exchange of fruitful philosophical and practical ideas toward the advancement of the field as a whole. In addition to the aforementioned books, numerous others on therapeutic integration appeared in the early 1980s (e.g., Guidano & Liotti, 1983; Hart, 1983; Meyer, 1982; Palmer, 1980; Papajohn, 1982; Prochaska & DiClemente, 1984; Wittman, 1981). Moreover, journals started to feature discussions on this topic. A special 1982 issue of Behavior Therapy contained a series of articles examining the potential benefits and drawbacks of complementing a behavioral approach with those of other orientations (Garfield, 1982; Goldfried, 1982b; Kendall, 1982; Wachtel, 1982b), and a 1983 issue of the British Journal of Clinical Psychology presented spirited "point-counterpoint" commentary between Yates (1983a, 1983b) and Davis (1983), Messer (1983), Murray (1983), and Wachtel (1983) on the subject of the plausibility of psychotherapy integration. A particularly significant event in the history of psychotherapy integration has been the formation of an organization devoted specifically to this endeavor. Formed in 1983, the Society for the Exploration of Psychotherapy Integration (SEPI) was established as a way of bringing together the growing number of professionals interested in this area. An interdisciplinary organization that has grown to be international in scope, SEPI holds yearly conferences at which many of the most active clinicians and researchers present their current work, and where attendees are provided with the opportunity to discuss and exchange ideas. We shall have more to say about SEPI later in this chapter. In the mid- to late 1980s, it became apparent that the movement toward psychotherapy integration had succeeded in reaching an everbroadening and receptive audience. There was a significant increase in the number of authors who became active in contributing to the advancement of the field. In order to provide adequate forums for these many voices, new journals appeared that directly addressed clinical and research issues pertinent to integration. One such journal was the International Journal of Eclectic Psychotherapy, later renamed the Journal of Integrative and Eclectic Psychotherapy in 1987. Also started in 1987 was the Journal of Cognitive Psychotherapy: An International Quarterly, which openly invites papers that discuss and explicate the integration of cognitive psychotherapy with other models of treatment. Because of space limitation, we are unable to identify and summarize each and every publication (e.g., all those that appeared in the above journals) within the scope of this chapter. In 1985 Mahoney cast a critical eye on the sociopolitics of academia,

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saying in effect that current systems foster and reward conformity and static viewpoints. He vehemently argued that knowledge would be best advanced if there were an openness to views that went beyond mainstream thinking. The movement toward psychotherapy integration was presented as an important new area of exploration that the field would do well to support. The following year Messer (1986) drew a comparison between psychoanalytic and behavioral approaches to treatment, using various clinical choice points to highlight where they were similar and where they differed. Thus, when dealing with a patient's distorted view of the world, the psychodynamic therapist would place more of a focus on the nature of the distortion, whereas the behavior therapist would be quicker to help the patient to incorporate the reality. Which of these two strategies is more effective clinically remains to be demonstrated empirically. Dealing with the psychotherapy research findings to date, Stiles, Shapiro, and Elliott (1986) concluded that the failure to find consistent superiority of any one approach over another should lead us to carry out more work on studying the process of change. This point was similarly made by Goldfried and Safran (1986), who pointed to future research directions in psychotherapy integration. Acknowledging that the change process with certain complex clinical disorders requires a comprehensive intervention, Chambless, Goldstein, Gallagher, and Bright (1986) outlined and provided some preliminary evidence for an integrative program for the treatment of agoraphobia. If the movement toward psychotherapy integration is to help the field as a whole to progress, it becomes vital to define clearly the parameters of such a therapeutic approach, and to suggest methods and modes of teaching the therapy to trainees (Halgin, 1985). An important edited volume by Norcross (1986) made valuable headway in this regard. Contributing authors spelled out their conceptualizations of eclectic psychotherapy, and shared their views on how to teach students the vast amount of information needed to understand and integrate various models. By and large, the individual authors of the Norcross text collectively argued that the trainee would need some or all of the following: (1) rigorous training in the scientific method and the development of critical thinking skills; (2) significant exposure to a number of the major models of psychotherapy (in sequence, or simultaneously); (3) an apprenticeship model, working closely with, and being supervised by, expert clinicians; (4) intensive training in developing skills for facilitating therapeutic relationships; (5) substantial practical experiences with a wide range of client/patient populations; and (6) training in designing and performing psychotherapy process research. The authors acknowledge that these are goals to span an entire career. Also in 1986, a special issue of the International Journal of Eclectic Psychotherapy was devoted to a discussion of the training and supervision

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of integrative-eclectic psychotherapists (Norcross et al, 1986). It was clear that this would be a formidable task with which to grapple, and that ongoing communication and development would be necessary in order to begin to approach satisfactory answers. Therefore, later issues of the same publication, the newly named Journal of Integrative and Eclectic Psychotherapy, would carry on the dialogue on training and supervision (Beutler et al., 1987; Halgin, 1988; Norcross, 1988). A glance at some of the major books on integration in 1987 reminds us that interest in this area had become worldwide. From Italy we have Guidano's (1987) Complexity of the Self, which presented a developmental model of psychopathology, and examined cognitive dysfunction across individual disorders and interpersonal contexts. From English-speaking Canada, Greenberg and Safran (1987) published Emotion in Psychotherapy; from French-speaking Canada we see Lecomte and Castonguay's (1987) edited work, Rapprochement et Integration en Psychotherapie. From the United States came Wachtel's (1987) Action and Insight, Beitman's (1987) The Structure of Individual Psychotherapy, and Norcross's (1987) Casebook of Eclectic Psychotherapy, Wachtel (1987) presented a therapeutic method that meshed the goals of greater self-awareness and subjective relief with objective therapeutic changes in observable behavior, Beitman (1987) presented a four-stage model of therapy that cut across orientations and used a common language, and Orlinsky and Howard (1987) described a generic model of therapy on the basis of their review of therapy research. A 1987 issue of the Journal of Integrative and Eclective Psychotherapy addressed the problem of overcoming the theoretical language barrier that would otherwise impede communication and collaborative study between clinicians and researchers of differing theoretical training backgrounds (Messer, 1987). A number of writers expounded on the merits of such language systems as the vernacular (Driscoll, 1987), experimental cognitive psychology and social cognition (Goldfried, 1987; Ryle, 1987), and interpersonal theory (Strong, 1987). Elaborating on the theme that diverse therapeutic orientations are needed for a multidimensional method of intervention, Bergin (1988) pointed out that nobody attempting to understand the workings of the human body would ever try to invoke a single set of rules. For example, principles of fluid mechanics are needed to understand how the heart operates, whereas electrochemical principles are needed for an understanding of neural transmission. A true rapprochement across the psychotherapies is needed, suggested Bergin, if we are to deal effectively with those complex human problems requiring psychotherapeutic intervention. At one time, therapists who used methods culled from a number of different schools of thought might have been risking ridicule. A prevailing attitude held that such a therapeutic stance indicated a lack of in-depth

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expertise in one solid area. The eclectic approach was considered to be a "grab-bag" or "trial-and-error" therapy. Norcross and Prochaska (1988) wrote that this viewpoint has changed considerably as the field of eclecticism and integration has sought to become more systematic and databased. They observed that "integration 'by design' is steadily replacing eclecticism 'by default' " (p. 173). Another series of articles on the subject of psychotherapy integration appeared in Psychiatric Annals in 1988: Rhoads's (1988) contribution addressed the dual use of psychotherapy and psychotropic medication; Babcock (1988) and Powell (1988) independently pointed out that many behavioral interventions will provoke clinically meaningful emotional and cognitive insights in clients; London and Palmer (1988) argued that cognitive therapies represent viable integrative therapies in and of themselves, because these models have presented the most structured attempts to date to synthesize psychodynamic and behavior therapy principles; and Birk (1988) reminded us of the need to explore the integration of individual psychotherapy with marital and family therapy. The integration of therapeutic modalities, such as individual and family therapy, was typified by the work of Allen (1988), Beach and O'Leary (1986), Duhl and Duhl (1980), Feldman (1979, 1989), Feldman and Pinsof (1982), Friedman (1980a, 1980b, 1981), Grebstein (1986), Gurman (1981), Hatcher (1978), Lebow (1984), Pinsof (1983), Rosenberg (1978), Segraves (1982), Steinfeld (1980), and Wachtel and Wachtel (1986). A common phenomenon that these authors discussed is the vicious cycle that results when a member of an interpersonal system expects and assumes the worst about a significant other, resulting in acting in such a way so as to provoke the very same negative reactions that "confirm" the original dysfunctional belief. As testimony to the momentum the cited works have gathered, a special interest group within the American Family Therapy Association has been organized to support these integrative efforts. Toward the end of the 1980s, the call for the development of an empirical methodology for the study of psychotherapy integration became quite pronounced (e.g., Goldfried & Safran, 1986; Norcross & Grencavage, 1989; Norcross & Thomas, 1988; Safran, Greenberg, & Rice, 1988; Wolfe & Goldfried, 1988), while others (Messer, Sass, & Woolfolk, 1988) underscored the benefits of alternate epistemological approaches to understanding the therapy process. Safran et al. (1988) posited that psychotherapists ultimately would learn more about the process of therapy via the intensive study of successful and unsuccessful cases, rather than through the extensive study of groups of clients categorized by broad diagnostic labels. Glass and Arnkoff (1988) found evidence for common as well as specific factors in clients' explanations for change, and Omer and London (1988) concluded that the nonspecific variables in therapy were no longer "noise,"

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but have achieved the status of "signal." Cashdan (1988) described the role of the therapeutic relationship within an object relations framework, and Andrews (1988, 1989) offered a model of change that emphasized the importance of self-confirming feedback cycles. Wolfe and Goldfried (1988), reporting on a National Institute of Mental Health research conference dealing with psychotherapy integration, stated that the establishment and growth of an accessible archive of tapes and transcripts would be a major boon to empirical studies relevant to integration. Another subtheme related to the need for integration to be based in empirical findings was the call for a better, more unified understanding of psychopathology (Arkowitz, 1989; Guidano, 1987; Wolfe, 1989; Wolfe & Goldfried, 1988). One of the first research programs specifically designed to develop a new methodology for the exploration and advancement of psychotherapy integration began to emerge from the work of Goldfried and his associates (e.g., Castonguay, Goldfried, Hayes, & Kerr, 1989; Goldfried, Newman, & Hayes, 1989; Goldsamt, Goldfried, Hayes, & Kerr, 1989; Kerr, Goldfried, Hayes, & Goldsamt, 1989). These authors developed a coding system, composed in the language of the vernacular, to compare and contrast the feedback that cognitive-behavioral and psychodynamic therapists give their patients. Their database consists of transcripts and audiotapes of actual therapy sessions, thus facilitating the study of what the therapists actually do in session (Goldfried & Newman, 1986). Another issue that gained momentum in the late 1980s was the examination of the narrowing gap between cognitive-behavioral and psychodynamic viewpoints on the nature of the therapeutic relationship. For example, Linehan's (1987; Koerner & Linehan, 1992) dialectical behavior therapy for borderline personality disorder characterized the therapeutic relationship as being central to the success of the treatment. Westen's (1988) intriguing article conceptualized the transference phenomenon in terms of information processing, while acknowledging its vital emotional component. Goldfried and Hayes (1989) argued that—even in behavior therapy—the therapeutic relationship frequently elicits a sample of the client's most clinically relevant thoughts, emotions, and behaviors as they pertain to the self and others. Newman (1989) authored a treatise on the phenomenon of countertransference, as experienced and conceptualized from the perspective of the cognitive-behavioral therapist. In 1989, the final year of our "historical review" (we consider a review of the 1990s to be more appropriate for an update on current events in the field), Lazarus (1989) published a revision of his influential book The Practice of Multimodal Therapy. Simek-Downing's (1989) International Psychotherapy, a book that took cross-cultural factors into account in examining the process of therapy, addressed elements of successful interpersonal helping

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that appear to be universal. Mahrer's Integration of Psychothempies (1989) expressed the sentiment that "integrationists are dealing with many of the crucial questions for our field," and spelled out his recommended responsibilities for the integrative therapist, teacher, supervisor, and researcher. Beitman, Goldfried, and Norcross's (1989) overview article in the American Journal of Psychiatry recommended that process researchers focus more of their attention on the vicissitudes of the therapeutic alliance, such that "prescriptive treatment [will be] based primarily on patient need and empirical evidence rather than on theoretical predisposition" (p. 141). Beginning work in this area has come from Sheffield, England (Barkham, Shapiro, & Firth-Cozens, 1989), where it was found that a combined intervention that went from psychodynamic to cognitive-behavior therapy worked better than one in which the sequence was reversed. Although not originally intended to be an integrative text, the Comprehensive Handbook of Cognitive Therapy (Freeman, Simon, Beutler, & Arkowitz, 1989) nonetheless comprised many chapters that seemed to create conceptual and technical bridges between cognitive therapy and other approaches (e.g., experiential therapy, Piagetian theory, behavior therapy, psychodynamic therapy, the use of Gestalt imagery, marital therapy, and pharmacotherapy). Reading through this surprising volume is both a curious and a satisfying experience, and calls to mind London and Palmer's (1988) contention that cognitive-behavior therapy is one of the field's best integrative treatment options—that is, at this time.

Points of Contention: Is Integration Unachievable? Ever since Myerson's horrified response to French's (1933) presentation on the commonalities between behaviorism and psychoanalysis, staunch supporters of circumscribed orientations have argued that rapprochement is neither possible nor desirable. For the most part, these viewpoints have not been expressed in publications specifically designated to attack the concept of integration (perhaps it was deemed unnecessary to address such a "preposterous" notion). Instead, this sentiment has been largely communicated implicitly, by authors writing on the exclusive merits of their own theoretical persuasions. As the field has become more intrigued with the possibility of therapy integration, we have been witnessing the emergence of publications that are making explicit those long-standing implicit reservations toward rapprochement (e.g., Franks, 1984; Haaga, 1986; Schacht, 1984; Yates, 1983a). Moreover, there now appears to be a willingness among enthusiasts and skeptics to have open dialogues concerning

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the plausibility of rapprochement (e.g., miniseries in 1983 issue of British Journal of Psychiatry; Arkowitz & Messer, 1984; Lazarus & Messer, 1988; Wachtel, 1982a). Such communication can only be helpful. It encourages an exchange of ideas between dedicated professionals of all persuasions, it helps clarify the important issues as viewed from varying perspectives, and it raises important questions that must be addressed by supporters of integration. The following is an overview of some arguments concerning those aspects of psychotherapy that traditionally have been considered to represent fundamental points of contention between behavioral and psychoanalytic approaches to therapy. We have chosen these two particular contrasting models because much of the literature on the problems associated with psychotherapy integration has focused on these two schools of thought. DIFFERING PERSPECTIVES ON REALITY

Although the list of publications discussing similarities across differing theoretical orientations is impressive (cf. Grencavage & Norcross, 1990), some authors express great concern that the search for commonalities is a trivial pursuit. For example, in referring to the work of Sloane and associates (1975), Farkas (1981) writes that they have taken a microscopic look at the commonalities of behavior therapy and psychotherapy. Their list included taking a history, showing interest, correcting misperceptions, answering questions, and elucidating objectives. However, they neglected to mention talking, sitting, walking, and hearing, and one wonders when an analysis of commonalities has reached infinite regress. As Garfield (1973) has questioned, are we considering mere common factors as opposed to fundamental ingredients? (p. 14)

Authors such as Lazarus and Messer (1988), Messer and Winokur (1980), Yates (1983a), and Schacht (1984) maintain that the fundamental ingredients represent points of considerable divergence. One of these is the "world view" that is taken respectively by members of behavioral and psychodynamic orientations. Yates (1983a) finds little hope for rapprochement between orientations that stereotypically have such different perspectives on reality. Whereas behavior therapy may be characterized as emphasizing realism (the world existing independently of its observers), objectivity (the existence of a common frame of reference for all), and extraspedion (seeking the external motivators of behavior), psychoanalytic therapy reflects idealism (the world is of one's own making), subjectivity (each person's frame of reference is unique), and introspection (searching for the internal motivators of behavior). Additionally, Messer and his associates (Messer,

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1992; Messer & Winokur, 1980) view a behavioral approach as being consonant with a "comic" vision of reality, whereby happiness can be obtained if environmental barriers and complications are identified and removed. A psychoanalytic approach, by contrast, follows a "tragic" vision, whereby internal conflicts rage, and all one can ever hope for is an enlightened acceptance of the human psychological condition. According to Yates (1983b), such marked differences in basic philosophical viewpoints result in contrasting notions as to what constitute appropriate therapeutic goals. For example, the behavior therapist would stress changes in readily observable client behaviors, and would view sorrow as a negative affect to be extinguished rapidly. The psychoanalytic therapist, on the other hand, would focus on the feeling of sorrow, view it as a natural concomitant of the person's life history and current circumstances, and would strive to help the client/patient more fully experience, accept, and work through this emotionality with an understanding of associated real and perceived losses. Wachtel's (1983) reply to the above issue is straightforward. He notes that these differences in philosophy are real and that, indeed, an integrative effort would be pointless were there an absence of such difference. Wachtel goes on to suggest, "What makes an integration interesting is its bringing the strengths, the different strengths, of each together in a new combination that is more comprehensive" (p. 129). Echoing this very sentiment is Beck (1984), who writes, "The various perspectives have varying degrees of explanatory power. By relating them to each other we can attempt to construct an integrated model that will have greater explanatory power than the individual perspectives" (p. 115). Mahoney (1984a) similarly commented on the differences in world view between behavior therapy and psychoanalytic therapy, and concludes that the incompatibility does not diminish the value of an exchange of ideas, nor does it eliminate the possibility that "both behaviorism and psychoanalysis are both contributing to the evolution of a more adequate paradigm" (p. 320). Also relevant are articles by Messer (1986) and Andrews (1989), who suggest that there are points of convergence between the world views of the various schools of psychotherapeutic thought. The upshot is that the differences in perspectives on reality need not be significant obstacles to integration. It is important to bear in mind that philosophical differences represent a barrier to integration only at a theoretical level of abstraction, not at the lower levels of abstraction, such as clinical techniques (Lazarus, 1992) and clinical strategies (Goldfried, 1980). Goldfried has maintained that, at a level of abstraction somewhere between theory and technique, these strategies may be thought of as clinical heuristics that implicitly guide the efforts of most experienced therapists. More recent attempts to identify commonalities among psychotherapies increasingly turn to this intermediate

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level of abstraction (Grencavage & Norcross, 1990). The significance of delineating such common strategies has been underscored by Goldfried (1980): "To the extent that clinicians of varying orientations are able to arrive at a common set of strategies, it is likely that what emerges will consist of robust phenomena, as they have managed to survive the distortions imposed by the therapists' varying theoretical biases (italics in original)" (p. 996). A review of the literature dealing with points of commonality across different therapeutic approaches reveals a number of similarities that have been described at this intermediate level of abstraction (Goldfried & Padawer, 1982). Among these are the initially induced expectations that therapy can be helpful, the client's/patient's participation in a therapeutic relationship, the possibility of obtaining an external perspective on one's problems, the encouragement of corrective experiences, and the opportunity to repeatedly test reality. Although the specific techniques that are used to implement each of these strategies may vary from orientation to orientation, the strategies themselves nonetheless represent common threads. ROLE OF THE UNCONSCIOUS IN THERAPY

It has been argued that a discussion of "the unconscious mind" clearly separates a psychodynamic approach from a behavioral approach. Psychodynamic theory and practice has given considerable attention to the complex network of intrapsychic motivators that lie out of the patient's awareness, whereas behavior therapy traditionally has cast doubt on the very existence of such unconscious processes. Thus, at first glance, the concept of the unconscious would appear to represent an irreconcilable point of divergence between psychodynamic and behavior therapy. However, this is so only if we adhere to the traditional tenets of classical psychoanalysis and radical behaviorism. Authors such as Arkowitz and Messer (1984), Goldfried (1979, 1988), Mahoney (1980, 1991), Meichenbaum and Gilmore (1984), Messer (1986, 1992), Safran (1984), Safran and Segal (1990), and Wachtel (1977) point out that dynamic psychotherapists have grown to recognize the importance of conscious thoughts and environmental factors, whereas behaviorists have adopted a position that accepts a person's explicit (and even implicit) thoughts as useful data. As cognitive processes have come to be introduced into the behavioral camp, the consideration of "unconscious" events has become inevitable (Mahoney, 1980, 1991). Meichenbaum and Gilmore (1984) explain how conscious thoughts and actions, once practiced and learned, become more integrated and automatic. Such "automatic thinking" (Beck, 1976) is latent and/or unobserved, and may fruitfully be construed in terms of

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cognitive schemas (Goldfried, 1988). Beck (1984) suggests that a cognitive focus involves more than consciousness, with cognitive organization existing at several levels, only the highest of which are characterized by rationality, objectivity, and free decision making. These views are reminiscent of Kelly's (1955) conceptualization of a "complicated unverbalized meaning" and Polanyi's (1958) notion of "tacit knowledge," whereby persons know a great deal more than they can articulate, and act on this knowledge as a trusted and important clue to reality. Meichenbaum and Gilmore (1984) believe that, to some extent, all psychotherapy deals with the client's hypothesized cognitive structures. One such structure (in experimental cognitive psychology) is the "schema," which is construed as an unconscious entity that can be accessible to awareness. The authors point out that the psychodynamic therapist's attempt to bring the unconscious to awareness is analogous to the cognitivebehavior therapist's attempt to have the client look for negative automatic assumptions, and that each of these represents an endeavor to make sense out of client's/patient's verbalizations and behaviors that on the surface seem bewildering. Mahoney (1984a) presents a thought-provoking conceptualization of the unconscious: More recent advances in clinical science and some of its associated psychobiology have suggested that the more central and core features of our nervous system tend to precede and potentiate our conscious experience in such a way that they would be more aptly termed "metaconscious" rather than "unconscious." [Meta-consciousness refers to] interdependent preconscious processes that limit the range and nature of potential experiences, (p. 313)

Although there are differences between the cognitive-behavioral and the psychodynamic view of the unconscious (e.g., the psychodynamic premise that the unconscious is maintained by the energies of repression, as contrasted with a cognitive-behavioral view of unconscious processes in terms of information-processing mechanisms), we seem to be witnessing a convergence between traditionally opposing orientations regarding the clinical phenomena that are given emphasis and attention.

IMPORTANCE OF TRANSFERENCE AND THE THERAPEUTIC ALLIANCE

A strict psychoanalytic edict prohibits therapists from intervening on the patient's behalf in a direct behavioral fashion, lest they hamper or contaminate the development of the patient's idiosyncratic attitudes and feelings toward the analyst (Gill, 1984). With more direct intervention, the

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transference phenomena are altered, as patients can attribute their feelings for the therapist to actual, as opposed to perceived or fantasized, therapist demands. In light of these transference considerations, Gill (1984) expressed doubts that classical psychoanalysis can be combined with interventions that are more directive. Acknowledging that analysis is quite different from psychoanalytic psychotherapy, however, Gill admits that the possibility of advantageously implementing behavioral techniques within a psychodynamic framework is still an open issue. Writing from within a Sullivanian conception of the therapeutic interaction, Wachtel (1977) suggests that the therapist can never really be a totally "blank screen" onto which clients project aspects of their past relationships. The therapist's role as participant-observer needs to be acknowledged as creating the actual context within which therapy takes place. Consequently, the therapist "is as much a part of the context if he is silent and invisible as if he is face to face with the patient and overtly discernibly responding to him" (Wachtel, 1977, p. 69). It is within this context, argues Wachtel, that direct interventions—sometimes in the form of procedures suggested by behavior therapy—reasonably can be made. Segraves (1982) has discussed transferencelike issues within the context of marital therapy. As we noted earlier, he broadens the analytic definition of transference to include any systematic misperception of a significant other, whereby individuals learn a tacit set of "rules" or "interpersonal schemas" earlier in life about what to expect in interpersonal relationships with persons of varying characteristics. This conceptualization is closer to Sullivan's (1954) notion of "parataxic distortion," in that such prototypic expectations do not necessarily require the existence of unresolved conflicts in order to be present. Arnkoff (1983) examined the definition of transference, and concluded that similarities do exist between psychodynamic therapy and cognitivebehavior therapy in the use of the therapeutic relationship. She notes that cognitive-behavior therapy focuses on relationship issues and agrees with Beck, Rush, Shaw, and Emery (1979) that there are times when such an area of exploration provides in vivo information that can be used therapeutically. The same argument has been made by Goldfried and Davison (1976), Goldfried (1985), and Goldfried and Hayes (1989), who have conceptualized the therapeutic relationship as frequently offering a sample of the client's relevant thoughts, emotions, and behaviors. Further evidence of the narrowing gap between cognitive-behavioral and psychodynamic viewpoints on the importance of the therapeutic relationship is seen in articles that conceptualize transference in terms of information processing (Singer, 1985; Westen, 1988). It is important to note that in neither of these publications does the author "reduce" the client's perceptions of the therapeutic relationship to a cold, arid, cognitive

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process. On the contrary, the aforementioned writers view the transference phenomena as being a vital and emotional component of therapy. The convergence of schools of thought on the centrality of the therapeutic relationship also comes from the cognitive-behavioral literature on the treatment of personality disorders (e.g., Linehan, 1987; Koerner & Linehan, 1992; Newman, 1989). These cognitive-behavioral writers view the interactions in the therapeutic relationship as being central to assessment and treatment, not merely a prerequisite to treatment. Linehan's dialectical behavior therapy places great emphasis on establishing stable therapeutic relationships with clients who suffer from borderline personality disorder. Similarly, Newman (1989) contends that cognitive therapists do indeed fall prey to countertransference reactions with difficult personality disordered clients. He notes that the therapist's recognition of such thoughts, feelings, and behaviors toward the client will lead to the uncovering of vital therapeutic material that may then be (carefully) addressed. GOALS OF THERAPY

Beutler (1983) has maintained that theories of psychotherapy probably do not direct the application of specific treatment techniques as much as they determine the therapeutic goals. If this is indeed the case, one may say that it is fruitless to strive for therapeutic integration, as each therapy has its own set of objectives about what needs to be changed. Wachtel (1977) points out that behavior therapists are more likely than dynamic psychotherapists to conceptualize the patient's problems as involving difficulties in obtaining conventional and socially acceptable aims in life. In contrast, dynamic therapists are apt to see their patients as having conflicting wants and needs, some socially censured. As a result, the goals of treatment are likely to differ. Thus, a behavior therapist may help patients obtain their conventional desires, whereas a psychodynamic therapist assists patients in understanding the development of their personalities and concomitant problems in living. In an analytic approach, the assessment—in the sense of increased understanding—and the goals of therapy are one and the same. Wachtel goes on to add, however, that there is nothing to prevent a therapist from intervening with regard to presenting problems, and then assisting the patient in further self-exploration. Concurring viewpoints are held by Llewelyn (1980) and Murray (1983), to the effect that both extraspective and introspective changes can be achieved in therapy, and by Messer (1986, 1992), who has argued for the complementarity between psychodynamic and behavior perspectives. Other authors have found similarities in therapeutic goals across orientations. Bastine (1975) observes that psychoanalytic and behavior therapies converge at the level of therapeutic subgoals. Farkas (1981)

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understands that a dynamic approach attempts the modification of personality, but sees this as inextricably tied to a modification of the person's overt behaviors. Prochaska and DiClemente (1982, 1992) view all therapy modalities as involving a consciousness-raising experience, where therapists increase the information available to individuals so that they can make effective responses and decisions in the face of internal and external demands. Lazarus and Messer's (1988) overview of a case from cognitivebehavioral and psychodynamic viewpoints respectively does show some initial divergence in their treatment goals, prior to their summary discussion. However, after they had a chance to "compare notes," they achieved a great deal more agreement than they had anticipated originally. Here, differences in world views were quickly reduced in importance once open communication was established.

The Development of a Professional Network Recognizing the need to provide a reference group oriented toward rapprochement among the therapies, Goldfried and Strupp, in 1979, compiled a list of professionals who were likely to be interested in efforts toward therapeutic integration and wrote to all of these individuals, inviting them to add their names to an informal "professional network." Little was done with this list until 1982, when Wachtel and Goldfried decided to poll those included in the network about potential future directions. Taking the existing network list, and expanding it on the basis of correspondence each had with other professionals over the years on the topic of therapy integration, they mailed out a questionnaire. A total of 162 individuals completed the survey. The respondents expressed their continued interest in rapprochement and offered their views on what should be done next—namely, the establishment of a newsletter and the formation of an organization. In the summer of 1983, an organizing committee, consisting of Lee Birk, Marvin Goldfried, Jeanne Phillips, George Strieker, Paul Wachtel, and Barry Wolfe, met to discuss the results of the questionnaire. It was immediately apparent to all six that the time was ripe to do something with this rapidly growing network, and it was agreed that a newsletter was in order. The group discussed the advisability of creating an organization, especially in light of some of the comments on the questionnaire expressing reservations about formalizing something that might best be dealt with informally. It finally was decided that without the existence of some sort of organization, it would be difficult to maintain any sense of continuity. As later noted by Goldfried and Wachtel (1983), "It was concluded that we needed

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to achieve a delicate balance: a formal organization that would facilitate informal contacts among the members" (p. 3). Hence, the Society for the Exploration of Psychotherapy Integration (SEPI) was formed. SEPI members represent diverse orientations and interests. Some are professionals who clearly identify themselves with a particular theoretical framework but openly acknowledge that other schools have something to offer; some are people who are interested in finding commonalities among the therapies; some would like to find a way to integrate existing approaches; some would like eventually to develop a totally new approach based on research findings; and some are professionals who have gradually drifted away from their original orientation and are interested in developing clearer guidelines that are more consistent with their clinical experience. A common thread that runs through this diversity is a respect for research evidence and an openness to procedures found to be clinically effective. An interdisciplinary organization that has grown to be international in scope, SEPI holds annual conferences at which many of the most active clinicians and researchers present their current work, and where attendees are provided with the opportunity to discuss and exchange ideas. As of 1991, it began publication of its official journal, the Journal of Psychotherapy Integration, which includes the SEPI Newsletter. The hope is that SEPI will serve to further raise our consciousness about the field's need for a more comprehensive model of therapeutic intervention, and will encourage the clinical and research efforts of an increasing number of professionals interested in pursuing this goal. The Zeitgeist is more receptive to integrative efforts than it has ever been before; psychotherapy integration is no longer an idea that is "too strange or preposterous" to consider (cf. Boring, 1950). It is our hope that within this hospitable context, significant advances will be made.*

References ALEXANDER, F. (1963). The dynamics of psychotherapy in light of learning theory. American Journal of Psychiatry, 120, 440—448. ALLEN, D. M. (1988). Unifying individual and family therapies. San Francisco; Jossey-Bass. ANCHIN, J. C. (1982). Sequence, pattern, and style: Integration and treatment implications of some interpersonal concepts. In J. C. Anchin & D. J. Kiesler (Eds.), Handbook of interpersonal psychotherapy. Elmsford, NY: Pergamon. ANDREWS, J. D. W. (1988). Self-confirmation theory: A paradigm for psycho*For further information about SEPI, write to Dr. George Strieker, The Derner Institute, Adelphi University, Garden City, NY I 1530, U.S.A.

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therapy integration: 1. Content analysis of therapeutic styles. Journal of Integrative and Eclectic Psychotherapy, 7, 359—384. ANDREWS, J. D. W. (1989). Psychotherapy of depression: A self-confirmation model. Psychological Review, 96, 576—607. APPELBAUM, S. A. (1976). A psychoanalyst looks at gestalt therapy. In C. Hatcher & P. Himmelstein (Eds.), The handbook of gestalt therapy. New York: Jason Aronson. APPELBAUM, S. A. (1979). Out in inner space: A psychoanalyst explores the therapies. Garden City, NY: Anchor. ARKOWITZ, H. (CHAIR). (1978, November). Behavior therapy and psychoanalysis: Compatible or incompatible? Symposium presented at the Convention of the Association for Advancement of Behavior Therapy, Chicago. ARKOWITZ, H. (1989). The role of theory in psychotherapy integration. Journal of Integrative and Eclectic Psychotherapy, 8, 8—16. ARKOWITZ, H., & MESSER, S. B. (EDs.). (1984). Psychoanalytic therapy and behavior therapy: Is integration possible? New York: Plenum. ARNKOFF, D. B. (1981). Flexibility in practicing cognitive therapy. In G. Emery, S. D. Hollon, & R. C. Bedrosian (Eds.), New directions in cognitive therapy (pp. 203-223). New York: Guilford. ARNKOFF, D. B. (1983). Common and specific factors in cognitive therapy. In M. J. Lambert (Ed.), Psychoiherapy and patient relationships. Homewood, IL: Dorsey. BABCOCK, H. H. (1988). Integrative psychotherapy: Collaborative aspects of behavioral and psychodynamic therapies. Psychiatric Annals, 18, 271-272. BAER, D. M., & STOLZ, S. B. (1978). A description of the Erhard Seminars Training (est) in the terms of behavior analysis. Behaviorism, 6, 45—70. BANDURA, A. (1969). Principles of behavior modification. New York: Holt, Rinehart & Winston. BARBER, B. (1961). Resistance by scientists to scientific discovery. Science, 134, 596-602. BARKHAM, M., SHAPIRO, D. A., & FIRTH-COZENS, J. (1989). Personal questionnaire changes in prescriptive vs. exploratory psychotherapy. British Journal of Clinical Psychology, 28, 97-107. BASTINE, R. (1975). Auf dem Wege zu einer integrierten Psychotherapie. Psychologie Heute, 53-58. BASTINE, R. (1978). Strategien psychotherapeutischen Handelns. In F. Reimer (Ed.), Moglichkeiten und Grenzen der Psychotherapie im psychiatrischen Krankenhaus (pp. 59—66). Stuttgart: Thieme. BASTINE, R. (1980). Ausbildungen in psychotherapeutischen Methoden und Strategien. In V. Birtsch & D. Tscheulin (Eds.), Ausbildung in klinischer Psychologic und Psychotherapie (pp. 71—85). Weinheim: Beltz. BEACH, S. H., & O'LEARY, K. D. (1986). The treatment of depression occurring in the context of marital discord. Behavior Therapy, 17, 43—49. BECK, A. T. (1984). Cognitive therapy, behavior therapy, psychoanalysis, and

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BOHART, A. (1982). Similarities between cognitive and humanistic approaches to psychotherapy. Cognitive Therapy and Research, 6, 24—249. BORING, E. G. (1950). A history of experimental psychology (rev. ed.). New York: Appleton-Century-Crofts. BRADY, J. P. (1968). Psychotherapy by combined behavioral and dynamic approaches. Comprehensive Psychiatry, 9, 536—543. BRADY, J. P., DAVISON, G. C., DEWALD, P. A., EGAN, G., FADIMAN, J., FRANK, J. D., GILL, M. M., HOFFMAN, I., KEMPLER, W., LAZARUS, A. A., RAIMY, V., ROTTER, J. B., & STRUPP, H. H. (1980). Some views on effective principles of psychotherapy. Cognitive Therapy and Research, 4, 271—306. BRAMMER, L. M. (1969). Eclecticism revisited. Personnel and Guidance Journal, 48, 192-197. BROWN, M. A. (1978). Psychodynamics and behavior therapy. Psychiatric Clinics of North America, I 435-448. BURTON, A. (Eo.). (1976). What makes behavior change possible? New York: Brunner/Mazel. CASHDAN, S. (1988). Object relations theory: Using the relationship. New York: Norton. CASTONGUAY, L. G., GOLDFRIED, M. R., HAYES, A. M., & KERR, S. (1989, June). An exploratory analysis of process and outcome variables in the Sheffield Psychotherapy Project. Paper presented at the 20th annual meeting of the Society for Psychotherapy Research, Toronto. CHAMBLESS, D. L., GOLDSTEIN, A. ]., GALLAGHER, R., & BRIGHT, P. (1986). Integrating behavior therapy and psychotherapy in the treatment of agoraphobia. Psychotherapy, 23, 150-159. COHEN, L. H., & POPE, B. (1980). Concurrent use of insight and desensitization therapy. Psychiatry, 43, 146—154. DAVIS, J. D. (1983). Slaying the psychoanalytic dragon: An integrationist's commentary on Yates. British journal of Clinical Psychology, 22, 133—134. DAVISON, G. C. (1978). Theory and practice in behavior therapy: An unconsummated marriage. (Audiocassette). New York: BMA Audio Cassettes. DIAMOND, R. E., HAVENS, R. A., & JONES, A. C. (1978). A conceptual framework for the practice of prescriptive eclecticism in psychotherapy. American Psychologist, 33, 239-248. DOLLARD, J., & MILLER, N. E. (1950). Personality and psychotherapy. New York: McGraw-Hill. DRISCOLL, R. (1984). Pragmatic psychotherapy. New York: Van Nostrand Reinhold. DRISCOLL, R. (1987). Ordinary language as a common language for psychotherapy. Journal of Integrative and Eclectic Psychotherapy, 6, 184—194. DRYDEN, W. (1980). "Eclectic" approaches in individual counselling: some pertinent issues. The Counsellor, 3, 24—30. DRYDEN, W. (1982). Rational-emotive therapy and eclecticism. The Counsellor, 3, 15-22.

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GOLDFRIED, M. R., & DAVISON, G. C. (1976). Clinical behavior therapy. New York: Holt, Rinehart & Winston. GOLDFRIED, M. R., & HAYES, A. M. (1989). Can contributions from other orientations complement behavior therapy? The Behavior Therapist, 12, 5760. GOLDFRIED, M. R., & NEWMAN, C. F. (1986, August). A look at what therapists actually do. Symposium presented at the annual convention of the American Psychological Association, Washington, DC. GOLDFRIED, M. R., NEWMAN, C. F., & HAYES, A. M. (1989). The coding system of therapeutic focus. Unpublished manuscript, SUNY at Stony Brook, Stony Brook, NY. GOLDFRIED, M. R., & PADAWER, W. (1982). Current status and future directions in psychotherapy. In M. R. Goldfried (Ed.), Converging themes in psychotherapy (pp. 3—49). New York: Springer. GOLDFRIED, M. R., & SAFRAN, ]. D. (1986). Future directions in psychotherapy integration. In J. C. Norcross (Ed.), Handbook of Eclectic Psychotherapy (pp. 463-483). New York: Brunner/Mazel. GOLDFRIED, M. R., & STRUPP, H. H. (1980, November). Empirical clinical practice: A dialogue on rapprochement. Panel presented at the meeting of the Association for Advancement of Behavior Therapy, New York. GOLDFRIED, M. R., & WACHTEL, P. L. (Ens.). (1983). Newsletter of the Society for the Exploration of Psychotherapy Integration, 1, 1-16. GOLDSAMT, L., GOLDFRIED, M. R., HAYES, A. M., & KERR, S. (1989, April). A comparison of three psychotherapies on the dimension of therapist feedback. Paper presented at the annual meeting of the Society for the Exploration of Psychotherapy Integration, Berkeley, CA. GOLDSTEIN, A. ]., & CHAMBLESS, D. L. (1978). A reanalysis of agoraphobia. Behavior Therapy, 9, 47—59. GREBSTEIN, L. C. (1986). An eclectic family therapy. In J. C. Norcross (Ed.), Handbook of eclectic psychotherapy (pp. 282-319). New York: Brunner/Mazel. GREENBERG, L. S., & SAFRAN, J. D. (1984). Integrating affect and cognitions: A perspective on the process of therapeutic change. Cognitive Therapy and Research, 8, 559-578. GREENBERG, L. S., & SAFRAN, j. D. (1987). Emotion in psychotherapy. New York: Guilford. GREENING, T. C. (1978). Commentary, journal of Humanistic Psychology, 18, 1-4. GRENCAVAGE, L. M., & NORCROSS, J. C. (1990). Where are the commonalities among the therapeutic common factors? Professional Psychology: Research and Practice, 21, 372-378. GRINKER, R. R. (1976). Discussion of Strupp's, "Some critical comments on the future of psychoanalytic therapy." Bulletin of the Menninger Clinic, 40, 247-254. GUIDANO, V. F. (1987). Complexity of the self: A developmental approach to psychotherapy and theory. New York: Guilford.

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GUIDANO, V. F., & LIOTTI, G. (1983). Cognitive processes and emotional disorders: A structural approach to psychotherapy. New York: Guilford. GURMAN, A. S. (1978). Contemporary marital therapies. In T. Paolino & B. McCrady (Eds.), Marriage and marital therapy. New York: Brunner/Mazel. GURMAN, A. S. (1981). Integrative marital therapy: Toward the development of an interpersonal approach. In S. Budman (Ed.), Forms of brief therapy. New York: Guilford. HAAGA, D. A. (1986). A review of the common principles approach to integration of the psychotherapies. Cognitive Therapy and Research, W, 527—538. HALGIN, R. P. (1985). Teaching integration of psychotherapy models to beginning therapists. Psychotherapy, 22, 555—563. HALGIN, R. P. (En.). (1988). Issues in the supervision of integrative psychotherapy [Special section]. Journal of Integrative and Eclectic Psychotherapy, 7, 152-180. HART, J. (1983). Modern eclectic therapy: A functional orientation to counselling and psychotherapy. New York: Plenum. HATCHER, C. (1978). Intrapersonal and interpersonal models: Blending gestalt and family therapies. Journal of Marriage and Family Counseling, 4, 63—68. HERZBERG, A. (1945). Active psychotherapy. New York: Grune & Stratton. HORWITZ, L. (1974). Clinical prediction in psychotherapy. New York: Jason Aronson. HORWITZ, L. (1976). New perspectives for psychoanalytic psychotherapy. Bulletin of the Menninger Clinic, 40, 263-271. HOUTS, P. S., & SERBER, M. (1972). After the turn-on, what? Learning perspectives on humanistic groups. Champaign, IL: Research Press. HUNT, H. F. (1976). Recurrent dilemmas in behavior therapy. In G. Serban (Ed.), Psychopathology of human adaptation. New York: Plenum. KAPLAN, H. S. (1974). The new sex therapy. New York: Brunner/Mazel. KAZDIN, A. E., & MASCITELLI, S. (1982). Covert and overt rehearsal and homework practice in developing assertiveness. Journal of Consulting and Clinical Psychology, 50, 250-258. KELLY, G. A. (1955). The psychology of personal constructs. New York: Norton. KENDALL, P. C. (1982). Integration: Behavior Therapy and other schools of thought. Behavior Therapy, 13, 559-571. KERR, S., GOLDFRIED, M. R., HAYES, A. M., & GOLDSAMT, L. (1989, June). Differences in therapeutic focus in an interpersonal-psychodynamic and cognitivebehavioral therapy. Paper presented at the Society for Psychotherapy Research, Toronto. KOERNER, K., & LINEHAN, M. (1992). Integrative therapy for borderline personality disorder: Dialectical behavior therapy. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. KRAFT, T. (1969). Psychoanalysis and behaviorism: A false antithesis. American Journal of Psychotherapy, 23, 482—487.

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KRASNER, L. (1978). The future and the past in the behaviorism-humanism dialogue. American Psychologist, 33, 799-804. KUBIE, L. S. (1934). Relation of the conditioned reflex to psychoanalytic technique. Archives of Neurology and Psychiatry, 32, 1137-1142. LAMBLEY, P. (1974). Differential effects of psychotherapy and behavioural techniques in a case of acute obsessive compulsive disorder. British Journal of Psychiatry, '125, 181-183. LAMBLEY, P. (1976). The use of assertive training and psychodynamic insight in the treatment of migraine headaches: A case study. The Journal of Nervous and Mental Disease, 163, 61—64. LANDAU, R. ]., & GOLDFRIED, M. R. (1981). The assessment of schemata: A unifying framework for cognitive, behavioral, and traditional assessment. In P. C. Kendall & S. D. Hollon (Eds.), Assessment strategies for cognitivebehavioral interventions (pp. 363-399). New York: Academic Press. LANDSMAN, T. (1974, August). Not an adversity but a welcome diversity. Paper presented at the meeting of the American Psychological Association, New Orleans. LARSON, D. (1980). Therapeutic schools, styles, and schoolism: A national survey. Journal of Humanistic Psychology, 20, 3—20. LAZARUS, A. A. (1967). In support of technical eclecticism. Psychological Reports, 27, 415-416. LAZARUS, A. A. (1971). Behavior therapy arid beyond. New York: McGraw-Hill. LAZARUS, A. A. (1976). Multimodal behavior therapy. New York: Springer. LAZARUS, A. A. (1977). Has behavior therapy outlived its usefulness? American Psychologist, 32, 550-554. LAZARUS, A. A. (1981). The practice ofmultimodal therapy. New York: McGrawHill. LAZARUS, A. A. (1989). The practice of rnultimodal therapy (rev. ed). Baltimore: Johns Hopkins University Press. LAZARUS, A. A. (1992). Multimodal therapy: Technical eclecticism with minimal integration. In j. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. LAZARUS, A. A., & MESSER, S. B. (1988). Clinical choice points: Behavioral versus psychoanalytic interventions. Psychotherapy, 25, 59—70. LEBOW, J. L. (1984). On the value of integrating approaches to family therapy. Journal of Marital and Family Therapy, 10, 127—138. LECOMTE, C., CASTONGUAY, L. G. (Eos.). (1987). Rapprochement et integration en psychotherapie. Montreal: Gaetan Morin Editeur. LEVAY, A. N., WEISSBERG, J. H., & BLAUSTEIN, A. B. (1976). Concurrent sex therapy and psychoanalytic psychotherapy by separate therapists: Effectiveness and implications. Psychiatry, 39, 355-363. LEVENTHAL, A. M. (1968)- Use ot a behavioral approach within a traditional psychotherapeutic context: A case study. Journal of Abnormal Psychology, 73, 178-182.

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MEYER, R. (1982). Le corps assui: de la psychanalyse a la somatanalyse. Paris: Maloine S. A., Editeur. MIKULAS, W. L. (1978). Four noble truths of Buddhism related to behavior therapy. Psychological Record, 28, 59—67. MURRAY, E. J. (1983). Beyond behavioral and dynamic therapy. British Journal of Clinical Psychology, 23, 127-128. MURRAY, N. E. (1976). A dynamic synthesis of analytic and behavioral approaches to symptoms. American Journal of Psychotherapy, 30, 561—569. NEWMAN, C. F. (1989). Cognitive therapy, countertransference, and the borderline patient. Unpublished manuscript. Center for Cognitive Therapy, Philadelphia. NIELSEN, A. C. (1980). Gestalt and psychoanalytic therapies: Structural analysis and rapprochement. American Journal of Psychotherapy, 34, 534—544. NORCROSS, J. C. (£D.). (1986). Handbook of eclectic psychotherapy. New York: Brunner/Mazel. NORCROSS, J. C. (£D.). (1987). Casebook of eclectic psychotherapy. New York: Brunner/Mazel.

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PROCHASKA, J. O., & DI&EMENTE, C. C. (1992). The transtheoretical approach. In ]. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. RAIMY, V. (1975). Misunderstandings of the self. San Francisco: Jossey-Bass. RHOADS, ]. M. (1981). The integration of behavior therapy and psychoanalytic theory. Journal of Psychiatric Treatment and Evaluation, 3, 1—6. RHOADS, J. M. (1988). Combinations and synthesis of psychotherapies. Annals of Psychiatry, U, 280-287. RHOADS, J. M., & FEATHER, B. W. (1974). The application of psychodynamic to behavior therapy. American Journal of Psychiatry, 131, 17-20. ROBERTSON, M. (1979). Some observations from an eclectic therapist. Psychotherapy: Theory, Research and Practice, Id, 18-21. ROGERS, C. R. (1963). Psychotherapy today or where do we go from here? American Journal of Psychotherapy. 17, 5—15. ROSENBERG, J. (1978). Two is better than one: Use of behavioral techniques within a structural family therapy model, journal of Marriage and family Counseling, 4, 31-40. ROSENZWEIG, S. (1936). Some implicit common factors in diverse methods in psychotherapy. American Journal of Orthopsychiatry, 6, 412—415. RYLE, A. (1978). A common language for the psychotherapies? British Journal of Psychiatry, 132, 585-594. RYLE, A. (1980). Some measures of goal attainment in focussed integrated active psychotherapy: A study of fifteen cases. British Journal of Psychiatry, 37, 475-486. RYLE, A. (1982). Psychotherapy: A cognitive integration of theory and practice. London: Academic Press. RYLE, A. (1984). How can we compare different psychotherapies? Why are they all effective? British Journal of Medical Psychology, 57, 261—264. RYLE, A. (1987). Cognitive psychology as a common language for psychotherapy. Journal of Integratwe and Eclectic Psychotherapy, b, 168-172. SAFRAN, ]. D. (1984). Assessing the cognitive-interpersonal cycle. Cognitive Therapy and Research, 8, 333-347. SAFRAN, J. D., GREENBERG, L. S., & RICE, L. (1988). Integrating psychotherapy research and practice: Modeling the change process. Psychotherapy, 25, 1-17. SAFRAN, J. D., & SEGAL, Z. V. (1990). Interpersonal process in cognitive therapy. New York: Basic Books. SARASON, I. G. (1979). Three lacunae of cognitive therapy. Cognitive Therapy and Research, 3, 223-235. SCHACHT, T. E. (1984). The varieties of integrative experience. In H. Arkowitz & S. B. Messer (Eds.), Psychoanalytic therapy and behavior therapy: Is integration possible? (pp. 107-131). New York: Plenum. SCHWARTZ, B. D. (1981). An eclectic group therapy course for graduate stu-

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CHAPTER 3

Psychoiherapy Outcome Research: Implications for Integrative and Eclectic Therapists MICHAEL J. LAMBERT

J.VESEARCH INTO THE EFFECTS of therapy now spans over six decades and has typically been aimed at examining the efficacy of schoolbased approaches to helping people change. The results of this research, as well as the process of engaging in research, have had a modest impact on the practice of psychotherapy. This impact ranges from the dramatic increase in behavior therapies due to the success of some behavioral interventions to the identification of particular treatment methods that are harmful to particular clients. Although considerable effort has been expended on specific schoolbased therapies, far less has been devoted to the study of eclectic and integrative approaches. Despite the fact that the plurality of therapists subscribe to an eclectic approach (Jensen, Bergin, & Greaves, 1990; Norcross & Newman, 1992) there is not sufficient outcome research on eclectic psychotherapies to base a chapter on these data. Nevertheless, the decades of past research have many implications for the practice of eclectic therapy. This chapter focuses on the implications of psychotherapy research for the practice of eclectic psychotherapy. First, several controversial issues, such as the general effects of therapy, are addressed. Then the factors that have been identified as causing therapeutic improvement are discussed. Finally, directions for future research are suggested.

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Eclectic Therapies and Research This Handbook, the many systems highlighted herein, and other compendiums appearing before it (e.g., Norcross, 1986) are evidence of the growth and sophistication of eclectic practice. For many reasons, this is an exciting development in the field of psychological interventions. In the first place, eclectic therapies, in general, are very friendly toward research. Eclectic therapy, like psychotherapy research, is preoccupied with practical results—with what is most helpful. Thus many eclectic therapists, like psychotherapy researchers, maintain a commitment to the pursuit of data wherever they lead, unencumbered by conceptual, doctrinal, or prior professional commitments. Perhaps eclecticism will be the broad base needed for the integration of research findings that will facilitate reliably effective treatments. Psychotherapy research may make its strongest contribution to practice in eclectic approaches that combine diverse techniques and concepts into a comprehensive and pragmatic approach to treatment; one that avoids strong allegiances to narrow theories or schools of thought. Many authors (e.g., Goldfried & Wachtel, 1987; Norcross & Grencavage, 1989) have discussed the proper conception of eclectic and integrative therapy. Eclectic therapies are relatively atheoretical, pragmatic, and empirical, made up from a collection of divergent techniques (Norcross & Grencavage, 1989). Integration-based therapies, on the other hand, are invested in a conceptual and theoretical creation beyond a technical blend of methods, so that higher order constructs are offered to account for change and to direct interventions. It appears from these definitions that it would be easier for the eclectic approach than the integrative one to use research findings readily. Some who take the integrative position may be as uninterested in research results as single-school practitioners, their primary interest being in theoretical elegance. Despite the seemingly natural compatibility and affinity for research that is obvious in systematic, eclectic approaches, there is clear evidence that many eclectic approaches are developed and advocated without reference to studies of efficacy. So the desired consequence of the researchpractice compatibility (i.e., reliably effective, empirically based approaches) is more of a fantasy than a reality. It has not proved easy to identify a limited set of salient techniques from across schools. Thus, not much agreement has been reached with regard to which treatment techniques are most effective and which should be chosen for incorporation in eclectic practice. Many of the reviews of eclectic therapy have supported this conclusion (Garfield & Kurtz, 1977; Larson, 1980; Norcross & Prochaska, 1982; Mahalik, 1990). All of these studies suggest that there are many

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kinds of eclectic combinations and great diversity in the techniques selected as "most beneficial" by eclectic therapists. Jensen, Bergin, and Greaves (1990), for example, conducted a study that attempted to discover how many therapists claim to be eclectic therapists, and of those, what forms of therapy they most often used. In order to accomplish these goals, the authors sent questionnaires about theoretical orientation to 800 therapists from within the fields of clinical psychology, marriage and family therapy, social work, and psychiatry. They found that 68 percent of the therapists who responded claimed to be eclectic in orientation. They further discovered that eclectic therapists most often claimed their theoretical orientation to be primarily dynamic, cognitive, or behavioral. The authors determined that, within the sample, eclectic therapists used 4.4 different theories in their practices. The most common combination of theoretical approaches was found to be the use of dynamic theories, cognitive-behavioral techniques, humanistic, and systems approaches. (See Norcross & Newman, 1992, for a review of similar studies.) Because of the wide variability of techniques used by eclectic therapists, it is extremely difficult to assess the effectiveness of standard eclectic therapies. In order to improve the ability to assess the effectiveness of therapy, several researchers have discussed the need to develop more systematic approaches to incorporating eclectic techniques into general practice (Held, 1984; Duncan, Parks, & Rusk, 1990; Mahalik, 1990). It appears, however, that new eclectic approaches are being invented and advocated just as rapidly as new school-based approaches. Despite this, it seems that the most commonly applied eclectic approaches are based on traditional theories with at least a modicum of empirical support. It is hoped that the emergence and impact of eclectic treatments will continue to be enhanced through synthesis of empirical findings. But just what findings should be focused on and integrated into eclectic therapies? What are the implications of outcome research for eclectic and integrative psychotherapies?

Conclusions and Implications of Outcome Research Based on reviews of psychotherapy outcome research (Lambert, Shapiro, & Bergin, 1986), figure 3.1 is an illustration of what empirical studies suggest about psychotherapy outcome. This research literature is extensive, covering decades, and diverse in that it deals with a large range of adult disorders and a variety of research designs, including naturalistic observations, epidemiological studies, comparative clinical trials, and

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FIGURE 3.1

Percent of Improvement in Psychotherapy Patients as a Function of Therapeutic Factors. a. Extratherapeutic Change: Those factors that are a part of the client (such as ego strength and other homeostatic mechanisms) and part of the environment (such as fortuitous events, social support) that aid in recovery regardless of participation in therapy. b. Expectancy (placebo effects): That portion of improvement that results from the client's knowledge that he/she is being treated and from the differential credibility of specific treatment techniques and rationale. c. Techniques: Those factors unique to specific therapies (such as biofeedback, hypnosis, or systematic desensitization). d. Common Factors: Include a host of variables that are found in a variety of therapies regardless of the therapist's theoretical orientation: such as empathy, warmth, acceptance, encouragement of risk taking, et cetera.

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experimental analogues. However, no statistical procedures were used to derive the percentages that appear in figure 3.1, which appears somewhat more precise than is perhaps warranted. The figure, nevertheless, conveys several of the conclusions to be drawn in this chapter. Conclusion 1: A substantial number of outpatients improve without formal psychological intervention. The first conclusion apparent from psychotherapy research is that a portion of patients improve "spontaneously" without the benefit of psychotherapy. The available literature on extratherapeutic improvement, using any of the research methods currently available to us, has been summarized elsewhere (Lambert, 1976; Bergin & Lambert, 1978). The studies reviewed are the best this area has to offer in answer to the question of spontaneous-remission rates. The data include subjects who had minimal treatment, but not extensive psychotherapy, as well as subjects who were, for the most part, untreated. The median rate for extratherapeutic improvement for all available studies was 43 percent, with a range of 18 percent to 67 percent. This figure is far from the original estimate of two-thirds suggested by Eysenck (1952) and more recently supported by Rachman and Wilson (1980). The figure of 43 percent represents a rough estimate of spontaneous remission; however, it is an average figure that obscures considerable variation. The evidence reviewed suggests that rates vary from 0 percent to 90 percent at follow-up, and that very low rates of extratherapeutic improvement do not necessarily mean that the course of treatment will be long and difficult. Thus, low rates do not invariably lead to low predictions of success with treatment. Also, high spontaneous recovery rates for a particular disorder do not always imply that patients referred for treatment will recover quickly or at all. In general, it seems that several factors have a marked effect on spontaneous improvement, such as the number of organ systems involved in a disorder; the length of time the disorder has persisted; the presence of an underlying personality disorder; and the nature, strength, and quality of social supports—especially the marital relationship (Lambert, 1976; Andrews & Tennant, 1978; Mann, Jenkins, & Belsey, 1981). There would also appear to be differential rates of improvement within the general category of neurosis. There is some evidence to suggest that these rates vary as a function of diagnosis, with depression having the highest remission rates, followed by anxiety and hysterical, phobic, obsessive-compulsive, and hypochondriacal disorders (Schapira, Roth, Kerr, & Gurney, 1972). The substantial limitations of the research on spontaneous remission have been elaborated on elsewhere (Lambert, 1976; Rachman & Wilson, 1980). Despite these limitations, it is apparent that a number of patients improve without formal treatment. Unfortunately, many persons with psychological disorders, especially those referred for treatment, will not improve over a short period of time without professionally guided

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interventions. The extratherapeutic improvement rate for most disorders is not so high as to make it impossible to demonstrate the efficacy of psychotherapy. The existing large number of controlled research studies permits a more exact comparison of treated and untreated cases; as a result, comparing treated persons with baseline or "spontaneous remission" estimates is no longer as important as it once was. Nevertheless, these data should remind us that a significant proportion of patients improve without undergoing formal therapy. It is important, therefore, not only to examine the effective ingredients of psychotherapy, but to examine the supportive aspects of the natural environment. Both areas contain useful information about psychological health and adjustment. Not only do we find that significant numbers of people are helped by friends, family, and the clergy, who employ a variety of supportive acts, but people with disorders are also helped by the indirect influence of psychological techniques. For example, in the United States people readily have available to them a wide variety of self-help literature and self-help groups. These resources often employ behavioral, cognitive, and insight-oriented material from a variety of formal psychotherapy systems. Some of this material, such as self-help books, has been shown to reduce symptomatology (cf. Ogles, Lambert, & Craig, 1991). Thus, some of what appears to be helpful—independent of psychotherapy techniques and theory—may, in fact, derive specifically from psychological theory and technique. This contamination or confusion is even more apparent in the realm of self-help groups for specific disorders, because the structured material used in these groups is often developed by psychologists and applied by people with some training and supervision (e.g., Lewinsohn, Antonuccio, Breckenridge, & Teri, 1984). Implication 1: While many patients improve without formal therapy, extratherapeutic events are not so powerful that formal therapies are unnecessary. Eclectic therapists can draw upon the natural helping systems that are abundant in the environment to assist them in their efforts to improve psychological therapies. Conclusion 2: Psychological treatments are in general beneficial. A wide variety of treatment methods have been empirically tested in controlled outcome studies, usually undertaken by advocates of a particular school of therapy. Ordinarily, however, particular systems of therapy are developed and advocated long before empirical evidence supports their use. This is, unfortunately, true for eclectic and integrationist systems as well. As a result, we have today perhaps as many as 250 different therapies (Herink, 1980), most of which have not been tested. Nevertheless, most of the major therapeutic systems have been tested empirically in controlled research. The available research has led to one basic conclusion: Psychotherapy,

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in general, has been shown to be effective. Positive outcomes have been reported for a wide variety of theoretical positions and technical interventions. Much of this research has been summarized in past reviews (Lambert, Shapiro, & Bergin, 1986; Lambert, 1982; Bergin, 1971; Bergin & Lambert, 1978; Meltzoff & Kornreich, 1970) and in meta-analytic summaries (Smith, Glass, & Miller, 1980; Andrews & Harvey, 1981; Shapiro & Shapiro, 1982). These reviews represent outcome literature on literally thousands of patients and hundreds of therapists across the Western world. The reviews represent data on mildly disturbed persons with specific limited symptoms, as well as on severely impaired patients whose disorders are both personally intolerable and socially dysfunctional. These data average changes in patients across diverse and comprehensive measures of improvement. The measures of improvement that are employed include a variety of perspectives of importance to patients, patients' families, mental health professionals, and society in general. A summary of meta-analytic studies of psychotherapy outcome research comparing, for the most part, untreated to treated patients is presented in table 3.1. As can be seen from the table, the average effect associated with psychological treatment approaches one standard deviation unit. The first application of meta-analysis to psychotherapy outcome (Smith & Glass, 1977; Smith, Glass, & Miller, 1980) addressed the general question of the extent of benefit associated with psychotherapy and found an average effect size of 0.85 standard deviation units over 475 studies comparing treated and untreated groups. This implies that, at the end of treatment, the average treated person is better off than 80 percent of the untreated sample. By the standards developed by Cohen (1977) for the quantitative evaluation of empirical relations in behavioral science, this is a large effect. The results of this meta-analysis suggest that the assignment to treatment versus control conditions accounts for some 10 percent of the variation among individuals assessed in a typical study. As Rosenthal (1983) has pointed out, this is equivalent to changing the success rate from 34 percent of the cases to 66 percent. Smith, Glass, and Miller (1980) illustrated the clinical meaning of this effect size by contrasting effect sizes derived from therapy outcome studies to those achieved in other situations. For example, in elementary schools the effects of nine months of instruction in reading is about 0.67 standard deviation units. The increments in mathematics achievement resulting from the use of computer-based instruction is 0.40 standard deviation units. The effect sizes produced in psychotherapy can also be compared to those derived from the use of psychoactive medication. For example, Andrews (1982, 1983) found that treatments of agoraphobics involving graded exposure produced a median effect size of 1.30, whereas antidepres-

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TABLE 3.1 Meta-Analytic Reviews and the Effects of Therapy Patient Diagnosis/ Treatment Smith, Glass, & Miller (1980)

Mixed

Number of Studies

Effect Size

475

.85

Andrews & Harvey (1981) Neurotic

81

.72

Landman & Dawes (1982) Mixed

42

.90

Prioleau et al. (1983)

Mixed

32

.42a

Shapiro & Shapiro (1982)

Mixed

143

1.03

b

Nicholson & Berman (1983)

Neurotic

47

.70

Andrews, Guitar, & Howie (1980)

Stuttering

29

1.531.65C

Blanchard et al. (1980)

Headache

35

% improved

Quality Assurance Project (1982)

Agoraphobia

25

1.20C

Quality Assurance Project (1983)

Depression

200

.65

Steinbrueck, Maxwell, & Howard (1983)

Depression

56

1.22

Dush, Hirt, & Schroeder (1983)

Self-statement modification

69

.74

Miller & Berman (1983)

Cognitive-behavior therapy

38

.83

Stein & Lambert (1984)

Professional vs. paraprofessional

28

.00

Wampler (1982)

Marital communication

20

.43 e

9

.82C

Depression

37

.73e

Hahlweg & Markman (1988)

Behavioral marital therapy

17

.95°

Dobson (1989)

Depression

10

2.15C

Benton & Schroeder (1990)

Social skills training with schizophrenics

23

.76°

Hazelrigg, Cooper, & Borduin (1987)

Family therapy Behavioral therapy

7 6

.45 .50

Asay et al. (1984)

Mixed mental health

Robinson, Berman, & Neimeyer (1990)

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HANDBOOK OF PSYCHOTHERAPY INTEGRATION TABLE 3.1 (continued) Patient Diagnosis/Treatment

Christensen et al. (1987)

OCD/ Exposure based treatment Nonspecific treatments Behavioral treatments

Number of Studies

Effect Size

5

1.37

5 5

-.14 1.19

lore (1989)

Trait anxiety & neuroticism

63

.53

Quality Assurance Project (1985)

Anxiety/ behavioral treatments

81

.98

Quality Assurance Project (1985)

Obsessive-compulsive/ exposure therapies

38

1.37

Scogin et al. (1990)

Self-administered treatments Therapies

40

.96 1.19

a = Psychotherapy vs. placebo b = Number of comparison groups c = Based on pre-post gains rather than control group comparison d = Improved 40-80% in psychological treatments and 20^10% in placebo controls e = Number of mental health centers studied f = Obsessive-compulsive disorder

sant medication produced an average effect size of 1.10. With depression, the effect sizes produced for antidepressants ranged from 0.81 to 0.40, depending on the type of antidepressant and on patient population. Thus, the effect sizes produced through the application of psychotherapies are generally as large as or larger than those produced by a variety of methods typically employed during educational and medical interventions. It is important to reiterate that the changes occurring in patients as a result of therapy are neither trivial nor just cold statistics; rather, they are substantial. A considerable number of people who might be classified as "cases" before treatment would be considered enough improved to no longer be so classified following treatment, although the exact proportion who leave the ranks of the dysfunctional is open to interpretation (Jacobson, Follette, & Revenstorf, 1984; Tingey, Burlingame, Lambert, & Barlow, 1990). Research on psychotherapy outcome suggests that patients with a variety of problems are helped by many methods that may have been put to the empirical test. The results of psychotherapy outcome research by no means suggest, however, that every participant gains to a clinically meaningful extent. The results are also compatible with the suggestion that

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some clients may deteriorate during therapy (Lambert, Bergin, & Collins, 1977). Implication 2: To the extent that eclectic therapies provide treatment that includes substantial overlap with traditional methods that have been developed and tested, they rest on a firm empirical base, and they should prove to be at least as effective as traditional school-based therapies and certainly more effective than no-treatment controls. Conclusion 3: Although there are a large number of therapies, each containing its own rationale and specific techniques, there is little evidence to suggest the superiority of one school or technique over another.

Evidence for this conclusion has been summarized elsewhere (Lambert, Shapiro, & Bergin, 1986; Luborsky, Singer, & Luborsky, 1975; Smith, Glass, & Miller, 1980). And while there are exceptions, the equivalence among seemingly highly diverse therapies has numerous implications for eclectic practice. The general findings of no-difference in the outcome of therapy for clients who have participated in highly diverse therapies has a number of alternative explanations: (a) different therapies can achieve similar goals through different processes; (b) different outcomes do occur but are not detected by past research strategies; and (c) different therapies embody common factors that are curative although not emphasized by the theory of change central to a particular school. At this time, any of the above interpretations can be advocated and defended, since there is not enough evidence available to rule out alternative explanations. Clearly, different therapies require the client to undergo different experiences and engage in different behaviors. Diverse therapies could be effective for different reasons. But we do not yet know enough about the boundaries of effectiveness for each therapy to discuss alternative (a) and its merits. Alternative (b), the inadequacy of past research, will not be fully discussed here. Suffice it to say that there are many methodological reasons for failing to reject the null hypothesis. Kazdin and Bass (1989), for example, have questioned the value of the majority of past comparative studies on the basis of a "lack of statistical power." There are also as yet serious problems in accurately measuring behavioral change (Lambert, Christensen, & Dejulio, 1983). Any of a host of methodological problems could result in a failure to detect differences between therapies. The third alternative (c), emphasizing common factors in different therapies, is the possibility that has received the most research attention and the one that has the clearest implications for practice. It is not only an interpretation of the comparative outcome literature, but is based on other research aimed at discovering the active ingredients of psychotherapy. This interpretation also has a relationship to the placebo literature alluded to in figure 3.1. A variety of factors common across therapies account for a substantial amount of improvement found in psychotherapy patients (see figure 3.1).

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These so-called common factors may account for most of the gains that result from psychological interventions. It is important, therefore, for eclectic therapies to intentionally incorporate them. What are these common factors, and what empirical support has been found to suggest their contribution to therapeutic outcome? Common factors can be conceptualized in a variety of ways (see Grencavage & Norcross, 1990). To clarify the differences between them, they have been grouped into Support, Learning, and Action categories in table 3.2. These categories were chosen to represent a possible developmental sequence that is presumed to operate in many psychotherapies. The developmental sequence is at least partially mediated through factors common across therapies. The developmental nature of this sequence presumes that the supportive functions precede changes in beliefs and attitudes, which precede attempts by the therapist to encourage patient action. A variety of common factors attributable to the therapist, therapy procedures, and the client are listed in this table. As already mentioned, these factors would seem to operate most potently during the process of therapy. Together they provide for a cooperative working endeavor in which the patient's increased sense of trust, security, and safety, along with decreases in tension, threat, and anxiety, lead to changes in conceptualizing his or her problems and ultimately in acting differently by refacing fears, taking risks, and working through problems in interpersonal relationships. Several studies emphasize the importance of many of these common factors. Among the common factors most frequently studied have been those identified by the client-centered school as "necessary and sufficient conditions" for patient personality change: accurate empathy, positive regard, nonpossessive warmth, and congruence or genuineness. Virtually all schools of therapy accept the notion that these or related therapist relationship variables are important for significant progress in psychotherapy and, in fact, fundamental in the formation of a working alliance (Lambert, 1983). Studies showing both positive and equivocal support for the hypothesized relationship have been reviewed elsewhere (cf. Levant & Shlien, 1984; Patterson, 1984; Gurman, 1977; Lambert, Dejulio, & Stein, 1978; Mitchell, Bozarth, & Krauft, 1977). Reviewers are virtually unanimous in their opinion that the therapist-patient relationship is critical; however, they point out that research support for this position is more ambiguous than was once thought. Studies using ratings of client-perceived relationship factors, rather than objective raters' perceptions, obtain consistently more positive results, and the larger correlations with outcome are often between client process ratings and client self-reports of outcome. Nevertheless, there is considerable support for the positive effect of therapist attitudes on clients and their posttherapy adjustment.

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TABLE 3.2

Sequential Listing of Factors Common Across Therapies That Are Associated with Positive Outcomes Support Factors

Learning Factors

Action Factors

Catharsis

Advice

Behavioral regulation

Identification with therapist

Affective experiencing

Cognitive mastery

Mitigation of isolation

Assimilation of problematic experiences

Encouragement of facing fears, taking risks, mastery efforts

Positive relationship

Modeling Changing expectations for personal effectiveness

Reassurance

Cognitive learning

Release of tension

Corrective emotional experience

Practice

Structure

Exploration of internal frame of reference

Reality testing

Therapeutic alliance

Feedback

Success experience

Therapist-client active participation

Insight

Working through

Therapist expertness

Rationale

Therapist warmth, respect, empathy, acceptance, genuineness Trust

For example, Miller, Taylor, and West (1980) investigated the comparative effectiveness of various behavioral approaches aimed at helping problem drinkers control their alcohol consumption. Although the focus of the study was on the comparative effects of focused versus broad-spectrum behavior therapy, the authors also collected data on the contribution of therapist empathy to patient outcome. One finding—surprising to the authors and important for our discussion—was the discovery of a strong relationship between empathy and patient outcome obtained from the sixto eight-months follow-up interviews used to assess drinking behavior. Therapist rank on empathy correlated (r = 0.82) with patient outcome, thus accounting for 67 percent of the variance on the criteria. These results argue for the importance of therapist communicative skills even with behavioral interventions. They were also presented in a context where

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variations in specific techniques did not prove to have a similar powerful effect on outcome. The importance of the therapeutic relationship has been bolstered in recent years by investigations of the therapeutic alliance (Frieswyk et al., 1986). This construct has been conceptualized and defined differently by a host of interested investigators. And like the client-centered dimensions, it has been measured by client ratings, therapist ratings, and judges' ratings. Ratings of the alliance have been undertaken with a wide variety of adult patients who have been diagnosed with a broad spectrum of disorders. There is more disagreement about the therapeutic alliance construct than there was with the client-centered conditions. This may prove to be a hindrance in drawing conclusions in this area because there are now several popular methods for measuring this construct, rather than the limited number of scales evidenced in the client-centered literature. In addition, the alliance is seen as a necessary, but not sufficient, condition for personality change, and so assumes a less important theoretical position in dynamic therapies and certainly other therapies than the facilitative conditions did in client-centered therapy. In addition, ratings of the therapeutic alliance contain a heavy emphasis on patient variables, mainly their ability to participate in therapy. They go well beyond measuring therapist behavior and should correlate more highly with outcome because they take into account important patient variables as well as therapist behavior. Gaston (1990), in trying to integrate the various constructs that have been offered to describe the therapeutic alliance, has suggested that some of the following components of the alliance are measured by some but not all current rating scales: (a) the patient's affective relationship to the therapist, (b) the patient's capacity to purposefully work in therapy, (c) the therapist's empathic understanding and involvement, and (d) patienttherapist agreement on the goals and tasks of therapy. That therapeutic alliance is not the same as the facilitative conditions hypothesized by Rogers is clear from the above definition, the operationalization of the constructs in rating scales, and some empirical research. For example, Johnson (1988) correlated relationship inventory ratings (based on Rogers's conception of the relationship) with two alliance scales and found no significant association. A sample of studies on the alliance is presented in table 3.3, reflecting the current status of research in this area. Clearly the alliance is related to therapy outcome although there are instances where it fails to predict outcome and related instances where only a few associations are found and others are rather small. The work of Windholz and Silberschatz (1988) is typical of research in this area. These authors attempted to replicate the findings of the Vanderbilt research group as reported by O'Malley, Suh, and Strupp

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TABLE 3.3

Percentage of Outcome Variance Accounted For by Therapeutic Alliance Ratings % of Outcome Accounted For

Scale Used

Outcome

Gomes-Schwartz (1978)

VPPSa

Global ratings of gains

Morgan et al. (1982)

PHASb

Composite residualized gain scores

Luborsky et al. (1985)

PHASb

Indices of social functioning

Marziali (1984)

TARS"

Symptomatic change Patient-therapist evaluations

Eaton et al. (1988)

TARSb

Improvement in symptoms of bereavement

19%-35%

Marmar et al. (1989)

CALPAS"

Symptomatic change, interpersonal functioning

9%-16%

Horvarth & Greenberg (1989)

WAI1*

Variety of outcome measures

Tichenor & Hill (1989)

VTASa

Variety of outcome

0%-50%

Johnson (1988)

VPPS" PHASa

Symptom levels at termination

No association

Gaston et al. (in press)

CALPASa

Symptomatic improvement

Author

WAI"

27%-38%

20% 25%-51% 9%-14% 9%-35%

18% -27%

CALPASa PHAS"

36%-57%

Key Terms Defined: VPPS = Vanderbilt Psychotherapy Process Scale; VTAS = Vanderbilt Therapeutic Alliance Scale; TARS = Therapeutic Alliance Rating Scale; CALPAS = California Psychotherapy Alliance Scale; PHAS = Perm Helping Alliance Scale; WAI = Working Alliance Inventory. = Rated by clinical judges = Rated by patient = Rated by therapist d = Patient working capacity subscale only, rated by patient and therapist = When outcome was based on residual gain scores (initial levels of disturbance accounted for), no significant relation was found = Initial levels of symptoms not accounted for

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HANDBOOK OF PSYCHOTHERAPY INTEGRATION

(1983). The Vanderbilt researchers had reported that two process variables, "patient involvement" and "therapist-offered relationship," predicted outcome in an outpatient college population. Using a larger sample of therapists, and a more typical adult outpatient sample, the authors replicated the Vanderbilt findings. Ratings on 10 minutes of therapy from a single session correlated with the outcome of 16 weeks of brief dynamic psychotherapy based on therapist ratings of change (but not client ratings). Using the Vanderbilt Psychotherapy Process Scale (VPPS) to study the active ingredients of therapy, the Vanderbilt group found differences in behavior between therapists from different orientations. The analytic therapists were observed to use more exploratory techniques, the Rogerian therapists were warmer and more empathetic, and the nonprofessionals gave more advice and engaged in more informal conversations (GomesSchwartz, 1978). Despite these differences in behavior and theory, no substantive differences in outcome were found between therapies. Drawing on the same database, O'Malley et al. (1983) examined the active ingredients of therapy in the first three sessions. In this study they revised the VPPS and still found that it correlated mainly with therapist ratings of psychotherapy outcome. The predictive variables were patient involvement and therapist-offered relationship. Both the Vanderbilt group and Windholz and Silberschatz (1988) were puzzled over the failure of the process variables to correlate more highly with patient ratings of change. And these failures weaken the conclusions from both sets of studies. Neither group found much in the way of specific techniques that were unique to particular theories of change, strengthening the conclusion that common factors are central. Research on the therapeutic alliance has, as yet, generated far less research than that generated by client-centered theory. Still, it has advanced to the stage of trying to show that the alliance is actually something that not only precedes therapeutic change but is also an active ingredient of psychotherapy. Gaston, Marmar, Thompson, and Gallagher (in press), for example, used hierarchical regression analysis to examine the alliance in elderly depressed patients who received dynamic, cognitive, or behavioral therapy. Initial symptomatology, symptomatic improvement up to time of alliance measurement, and patient and therapist CALPAS (California Psychotherapy Alliance Scale) scores were used to predict symptoms at termination. The alliance assessed near termination accounted for 36 percent to 57 percent of outcome variance over and above initial symptomatology and in-treatment symptomatology change. Another approach to understanding the contribution of the therapist to effective outcome has involved the use of behavioral and adjective checklists filled out by clients following their therapeutic contacts. Lorr (1965), for example, had 523 psychotherapy patients describe their thera-

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pists on 65 different statements. A subsequent factor analysis identified five factors: understanding, accepting, authoritarian (directive), independenceencouraging, and critical-hostile. Scores on these descriptive factors were correlated with improvement ratings, with the result that client ratings of understanding and accepting correlated most highly with client- and therapist-rated improvement. In a more recent study, Cooley and Lajoy (1980) attempted to replicate the Lorr study. In addition, they studied the relationship between therapist ratings of themselves and of outcome, as well as the relationship of discrepancies between patient and therapist ratings and outcome ratings. The patients were 56 adult community mental health outpatients who had been treated by one of eight therapists at the clinic. As with the Lorr study, patient ratings of therapist understanding and acceptance correlated most highly with client-rated outcome. On the other hand, when self-ratings of therapists attributes were compared to therapist-rated patient outcome, the correlations were insignificant, suggesting that therapists did not perceive their personal attributes as a factor influencing therapeutic outcome. Similar findings have been reported in group treatment. Glass and Arnkoff (1988) examined common and specific factors in client descriptions and explanations of change. The clients were shy and consequently treated in one of three structured group therapies for shyness or in an unstructured therapy group. Each group was based upon a different theory of change and differed in its content and focus. Nevertheless, content analysis revealed that in addition to specific treatment factors, all groups contained considerable emphasis on group process and common factors such as support. They suggest that "the role of common group process factors appeared to be at least as important to subjects as the specific therapy program content" (p. 437). Murphy, Cramer, and Lillie (1984) studied common factors by having outpatients generate a list of curative factors that they believed to be associated with their cognitive behavioral therapy. Those factors suggested by a significant portion of patients were advice (79 percent), talking to someone interested in my problems (75 percent), encouragement and reassurance (67 percent), talking to someone who understands (58 percent), and installation of hope (58 percent). The two factors that correlated most highly with outcome, as assessed by both therapist and patient, were talking to someone who understands, and receiving advice. It is interesting to note that the patients in this study were predominantly from the lower socioeconomic class, and past research has shown that these patients expect advice (Goin, Yamamoto, & Silverman, 1965). Patients frequently attribute their success in treatment to personal qualities of the therapist. That these personal qualities bear a striking resemblance to each other across studies and methodologies is evidence

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that they are highly important in psychotherapy outcome. This notion was also emphasized by Lazarus (1971) in an uncontrolled follow-up study of 112 patients whom he had seen in therapy. These patients were asked to provide information about the effects of their treatment and the durability of improvement, and their perceptions of the therapeutic process and characteristics of the therapist. With regard to therapist characteristics, those adjectives most often used to describe Lazarus were sensitive, gentle, and honest. Patients clearly felt the personal qualities of the therapist were more important than specific technical factors, about which there was little agreement. In their study comparing behavioral and more traditional insightoriented therapy, Sloane, Staples, Cristol, Yorkston, and Whipple (1975) reported a similar finding and elaborated upon the place of therapist variables in positive outcome. Although they failed to find a relationship between judges' ratings of therapists' behavior during the third therapy session (on empathy) and later outcome, they did find that patients tended to emphasize the personal qualities of their therapists as causing personality change. The notion that common factors are important in producing positive outcomes is also supported by the failure to find differential outcomes in studies comparing therapies that use highly divergent techniques. This finding has been documented in several reviews (Bergin & Lambert, 1978; Luborsky, Singer, & Luborsky, 1975), and has been dramatically illustrated in the NIMH multisite collaborative study of depression (Elkin et al, 1989), which compared a standard reference treatment (imipramine plus clinical management) with two psychotherapies (cognitive-behavior therapy and interpersonal psychotherapy, a kind of dynamic therapy). These three treatments were contrasted with a drug placebo plus clinical management control group. The study was the first head-to-head comparison of these two psychotherapies that had been shown in previous research to be specifically effective with depression. Both these therapies had been extensively tested by their developers, but less was known about the degree to which their effectiveness could be replicated by therapists outside of the groups that developed these treatments. The 250 patients seen in this study were randomly assigned to the four treatments that were offered in Pittsburgh, Oklahoma City, and Washington, D.C. They met research diagnostic criteria for a major depressive episode and a score of 14 or more on the 17-item Hamilton Rating Scale for Depression. A host of exclusion criteria were also applied so as to leave the sample who were treated as free from other disorders as possible. The therapists were 28 psychiatrists and psychologists who were carefully selected, trained, and monitored in the specific treatment they offered. Each therapist saw between one and eleven patients. The treat-

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ments were carefully defined and intended to reflect a manual that spelled out theoretical issues, general strategies, major techniques, and methods of managing typical problems. Those who completed therapy averaged 16.2 sessions. The battery of outcome measures included symptomatic and adjustment ratings from multiple perspectives. Numerous comparisons were made and the results of this study are very complex. Among the more interesting findings were comparisons of the two psychotherapies with the medication placebo plus clinical management (PLA-CM). This latter condition was intended to control for the effects of regular contact with an experienced and supportive therapist, the general support of the research setting, and the effects of receiving a drug that was thought to be helpful. Did the psychotherapies have any effects beyond what could be achieved through this rather extensive placebo? There was limited evidence of the specific effectiveness of the interpersonal psychotherapy (IPT) and no evidence for the specific effectiveness of cognitive-behavioral therapy (CBT). In general there was little evidence for superiority of the therapies in contrast to the placebo. The therapies were effective, but the patients who received the placebo also improved. Interpersonal psychotherapy, however, was more impressive with the more severely disturbed patients. In head-to-head comparisons of IPT and CBT, no significant differences were found in any of the major analyses or in comparisons with more and less severely disturbed patients. This similarity held up even on measures that were thought to be differentially sensitive to the two therapies. The authors conclude: "The general lack of differences between the two psychotherapies, together with the good results for the PLA-CM condition, suggests once again the importance of common factors in different types of psychologically mediated treatment" (Elkin et al., 1989, p. 979). Similar conclusions were reached by Zeiss, Lewinsohn, and Munoz (1979). These authors compared (a) interpersonal-skills training, (b) a reinforcement-theory program to increase pleasant activities (and the enjoyment of potentially pleasant activities), and (c) a cognitive approach to the modification of depressive thoughts. They found that all treatments were associated with reduction in depression, without any differential changes specific to aspects of the patient's problems targeted by the three treatments. Zeiss et al. (1979) note the improvements also recorded by the waiting list group and cite Frank's (1974) demoralization hypothesis as the most parsimonious explanation for the results. These researchers suggest that the impact of treatment was due to the enhancement of self-efficacy via training self-help skills, thus increasing expectations of mastery and perception of greater positive reinforcement as a function of the patient's greater skillfulness. Therefore, the common components of therapy for depression emerge as important. On the other hand, it should be noted that

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the experience level of the therapists was not high (counseling psychology graduate students and M.A.'s), and there was no monitoring of the therapists' contributions to therapy; thus treatment delivery according to the design is not assured. In addition, patients' and therapists' perceptions of curative factors were not studied, so that the attribution of causality to them is purely hypothetical. Implication 3: In general, eclectic therapies should stress commonalities, including the therapist's contribution to outcome, by emphasizing those factors common across therapies highlighted in empirical research. To the extent that they are present in therapy positive personality change is likely.

What Techniques Can Be Chosen on the Basis of Demonstrated Superiority? Given the improvement that results from homeostatic mechanisms, fortuitous events, social supports, expectations, and common factors, there has not been any general, clear demonstration of the power and differential impact of specific techniques on patient functioning. Nevertheless, technique effects sometimes show themselves in particular studies; unfortunately, replication of technique effects has proved difficult.

COMPARATIVE OUTCOME STUDIES

Traditional reviewing procedures of the earliest comparative studies have not resulted in conclusions that favor the superiority of a particular therapy across the broad categories of anxiety, depression, and interpersonal problems to which they have been applied (Meltzoff & Kornreich, 1970; Luborsky, Singer, & Luborsky, 1975; Bergin & Lambert, 1978). The newer quantitative reviews (see table 3.1) based on meta-analysis have been more likely to reflect small differential outcomes, albeit with little consistency. Data from several meta-analytical reviews (Dush et al., 1983; Nicholson & Berman, 1983; Shapiro & Shapiro, 1982; Smith, Glass, & Miller, 1980; Quality Assurance Project, 1983) tend to yield a small but consistent advantage for cognitive and behavioral methods over traditional verbal and relationship-oriented therapies. The most reliable data coming from within-study comparisons suggest some advantage for cognitive and behavioral therapies over dynamic-humanistic ones. To examine this issue more carefully, let us consider Shapiro and Shapiro's (1982) extensive meta-analysis, which focused exclusively on

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studies comparing two or more active treatments with control conditions. In consequence, their data contained more replicated comparisons between treatment methods than found in the Smith et al. (1980) review, and permitted more definitive statements concerning the comparative efficacy of treatments. Based on an examination of 143 studies, Shapiro and Shapiro (1982) found that cognitive and various behavioral treatments yielded more favorable outcomes (1.00 and 1.06 effect sizes, respectively) than other treatments with which they were compared, whereas dynamic and humanistic therapies tended to yield inferior outcomes (effect size 0.40). Like Smith, Glass, and Miller (1980), however, Shapiro and Shapiro (1982), also attributed the larger effect sizes to strong biases in the behavioral and cognitive literature toward analog studies, mild cases, and highly reactive criteria. They stated that the treatments and cases studied were unrepresentative of clinical practice but very representative of the simple experiments on those techniques that are frequently conducted in university settings. An interesting sidelight of the Shapiro and Shapiro report was the finding of a significantly larger effect size for cognitive-behavior therapy over systematic desensitization. This conclusion has, however, been challenged by another meta-analysis. Berman, Miller, and Massman (1984), using a larger, but overlapping, sample of studies, showed no difference between cognitive-behavior and desensitization therapies (effective size difference 0.06). It also revealed that the larger effect sizes for cognitivebehavior therapy occurred in studies conducted by investigators having an allegiance to that method. Also of interest was the finding that the combination of desensitization with a cognitive-behavior method did not increase effects beyond that obtainable by either treatment alone. Dobson (1989) reported a meta-analysis of 28 studies that compared Beck's cognitive therapy with no treatment, other behavior therapy, drug treatment, or other psychotherapy with depressed patients. In each study the Beck Depression Inventory was used as the outcome measure. Cognitive therapy was two standard deviations better than no treatment, and half a standard deviation was better than drug treatment, behavior therapy, or other psychotherapy. Robinson, Berman, and Neimeyer (1990) in a broader and more diverse sampling of the literature found cognitive, cognitive-behavioral, and behavioral psychotherapies to be a half standard deviation superior to general verbal therapies (which appeared to be no more effective than placebo controls). However, when allegiance of the experimenter was taken into account, the differential effects of treatments washed out. The foregoing meta-analyses reveal a mixed picture. There is a strong trend toward no differences between techniques in amount of change produced, with occasional superiority for a particular method.

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EFFECTS OF BEHAVIORAL THERAPY WITH SPECIFIC SYMPTOMS

A variety of psychotherapy research strategies have confirmed the powerful and superior effects of some behavior therapies with certain specific problems. The most clear superiority for a particular treatment is with phobic disorders. Research has suggested the necessary steps to facilitate rapid reduction of anxiety to phobic situations. These procedures involved selecting patients with clearly identified fears that are evoked by specific stimuli. In addition to identifying the evoking stimuli, the patient must be motivated to seek and complete treatment. Early reports indicated that as many as 25 percent of patients may refuse or drop out of treatment (Marks, 1978), although this is not a high figure for a research protocol. In order for the treatment to work, clients must be willing to "make contact" with the evoking stimuli until their discomfort subsides. Numerous behavioral approaches are based on this "exposure" paradigm. Desensitization involves repeated brief exposure in fantasy or in vivo with a counteracting response, such as relaxation, during and between exposure. Flooding involves rapid, prolonged approach into the phobic situation in fantasy or in vivo. Operant approaches have been used via systematic rewards for moving toward or staying in the feared situation. Modeling follows a similar paradigm in which the therapist models approach behaviors and then encourages the patient to do the same. Even in cognitive rehearsal and self-regulation approaches, the patient is encouraged to face feared situations and attain mastery of those situations through the use of effective coping strategies. Therapies for some other anxiety-based disorders such as sexual dysfunctions and compulsive rituals are dealt with through the use of similar exposure techniques. These include gradual practice in sexual situations, and response prevention following exposure to the anxiety that precedes and accompanies rituals. Although the exposure principle does not explain the reasons for improvement, it does suggest the necessary conditions for improvement and the therapeutic strategy that is to be used: identify the provoking stimuli, encourage exposure, help the patient remain exposed until the anxiety subsides, and assist in mastering thoughts and feelings linked with the disordered responses. Given enough contact with the feared situation, patients cease to respond with avoidance, anxiety, or rituals. Contrary to the expectations of some professionals and the patients themselves, increased sensitization to the anxiety-provoking situation is rare. Marks (1978) suggests such sensitization occurred in only 3 percent of the cases that were expected to be successful (i.e., had adequate motivation, absence of serious depression, no attempts to escape exposure in fantasy or reality, and completed a reasonable amount of treatment).

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Numerous studies have tried to sort out the specific procedures necessary for successful treatment. Is deep muscle relaxation necessary? Is gradual exposure through a hierarchy required? Is high arousal necessary (as in implosion)? Should exposure be in vivo or through mental images? Does modeling enhance other exposure methods? Should exposure be prolonged or brief? Will the addition of cognitive coping strategies enhance the effects of exposure treatments? The bulk of evidence on these and similar questions suggests that achieving lasting reductions in fears and rituals is a function of exposure. Time spent with deep muscle relaxation, the use of tranquilizers, and high levels of arousal, add little or nothing to treatments that focus on any effective means of encouraging exposure until anxiety reduction occurs (Marks, 1978; Emmelkamp, 1986). Likewise, interactional exposure without modeling produces fear reduction, but modeling without interactional exposure does not (Marks, 1978, p. 505). Exposure-based therapies play a major role in the treatment of panic disorder with agoraphobia (Barlow, 1988; Michelson & Marchione, 1991). Clearly they are superior to alternative techniques, with conservative estimates of clinically significant improvement approximating 50 percent and full recovery occurring in less than a third of patients (Jacobson, Wilson, & Tupper, 1988). Cognitive-behavioral treatments for panic with agoraphobia have also received considerable research attention in recent years. It is a bit early to draw definitive conclusions, but evidence is accumulating that combining cognitive therapy (aimed at cognitive restructuring and changing core beliefs, misperceptions, and misattributions related to the disorder) with gradual, therapist-guided exposure produces results superior to gradual exposure alone or in combination with other treatments (Michelson, Marchione, & Greenwald, 1989). This seemingly synergistic combination is especially interesting for eclectic practice because it strongly supports the basic premise of eclectic practice. Conclusion 4: Although the earliest studies on anxiety reduction were undertaken with simple phobias and nonclinical populations such as speech phobics, there is now an abundance of studies on clinical populations that substantiate the specific effects of exposure treatments when contrasted with other therapeutic modalities and specific techniques that don't include an exposure component. Still, research has identified boundaries to these effects; exposure treatments, although effective with agoraphobia, simple phobias, and compulsions, are not as effective nor as uniquely effective with social phobias, generalized anxiety disorders, or combinations of the above. The exposure principle seems to have more limited specific applicability with sexual dysfunctions, where the short-term effects are not followed with the same long-term effects as exposure for agoraphobics (Emmelkamp, 1986).

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The specific importance of cognitive therapy for panic and agoraphobia with panic appears promising but is in need of further investigation (Michelson & Marchione, 1991). Implication 4: Eclectic therapies that capitalize on the contributions of specific techniques are likely to be especially effective and should be recommended for practice. Since there is some evidence for the usefulness of particular techniques, eclectic therapies may be effective either because clinicians with this orientation are flexible enough to use techniques that directly address a problem or because eclectics are more open to the value of referral to clinicians skilled in the use of a particular technique. In either case, because of its flexibility in use of technique, eclectic therapy may be less likely to produce negative outcomes in patients.

Overall Conclusions and Future Research Although most eclectic therapies are based on empirically tested therapies, their foundation has been borrowed from research work on specific therapy schools. Very little research has been produced by the emerging systematic eclectic approaches. Garfield (1986), in reference to his own theory, states: "Unfortunately, no systematic research has been conducted on the approach. . . . The only evidence that exists to support the efficacy of this approach are clinical observations and anecdotes, and this is not really adequate" (pp. 157—158). Mahalik (1990) has reviewed the status of four distinct (systematic) eclectic approaches on five dimensions ranging from theoretical adequacy to empirical support. By evaluating the approaches of Beutler, Howard, Lazarus, and Prochaska, Mahalik has focused on four of the most fully developed and described representatives of eclecticism. His review clearly reflects the status of research in this area: None of the models have been well evaluated and none have received more than the beginnings of empirical support. Additionally, the great majority of research on the models has been conducted by the authors. If the systematic eclectic field is going to attain greater credibility, research outside the labs of the model's advocates must replicate and extend these findings, (p. 675)

In my view the picture is, if anything, more bleak than Mahalik points out. With the exception of the Beutler and Prochaska models, Mahalik's review showed that only two outcome studies had been conducted on the other models, and no comparative or control group studies were among these.

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For example, Lazarus (1992) has suggested that his approach is not intended to be added to the hundreds in existence but rather is an attempt to be at the cutting edge of clinical effectiveness by incorporating the findings of current research and practice. Despite his commendable efforts to be empirical, it is disappointing to see so little systematic effort directed toward a controlled investigation of the effects of a multimodal therapy that purports to be at the "cutting-edge" of therapy. What kind of improvement rate can one expect as a result of this application of technical eclecticism? Are there patients for whom this approach is more appropriate? Would this eclectic approach offer clients anything more than the cognitive-behavioral therapy to which it is most indebted? These and a host of similar questions remain unanswered at this time. But it would be surprising if the unsubstantiated reports of superiority held up in a comparative outcome study! The Beutler model (Beutler & Consoli, 1992) has generated considerably more outcome research as he has initiated several studies of his matching hypothesis and has begun to study interventions according to his theory of systematic eclecticism. Despite this, he has encountered significant difficulty in applying his matching scheme successfully, leaving important aspects of his theory without confirmation (e.g., Calvert, Beutler, & Crago, 1988). Matching patients, therapists, and therapies is no small achievement, and it continues to elude those who have the confidence to attempt it. Prochaska and DiClemente's (1992) model, the transtheoretical approach, has also generated considerable research. As compared with other eclectic systems, it rests on a more substantial base of empirical research, a good deal of which is based on a narrow sample of clients who were attempting to give up smoking. Nevertheless, empirical support for some of the most important postulates of this model (e.g., how the needs of clients change over time as they improve, how this interacts with interventions) is slowly being accumulated. The outcome research has used manuals aimed at facilitating self-change, finding that with and without a therapist present, it proved more effective at helping people quit smoking than a traditional self-change approach not based on the principles and assumptions of the transtheoretical approach. These initial steps toward evaluation of the transtheoretical approach must be followed by systematic research aimed at sorting out the advantages, if any, of this approach over singleschool or other eclectic procedures. Recent research conducted in England by Stiles et al. (1990) may be of special interest to eclectic practitioners and theoreticians. This research also has implications for eclectic, stage-model of change (e.g., Beitman, 1992; Prochaska & DiClemente, 1992). Stiles and his associates have proposed an assimilation model of change, which proposes that an important

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common change mechanism across therapies is the assimilation of problematic experiences. Eight stages of problem solution are proposed. These include (I) warded off, (2) unwanted thoughts, (3) vague awareness, (4) problem recognition, (5) insight/understanding, (6) application of understanding, (7) problem solution, and (8) mastery. As with the Beitman and with the Prochaska and DiClemente's models, the assimilation model suggests that dynamic-humanistic therapies are most suitable at the early stages of therapy, while cognitive-behavioral therapies are best suited for the issues that arise in the latter stages of problem solution and assimilation, such as mastery. Results of other research conducted in the Sheffield University project (Shapiro & Firth, 1987), similarly, have several implications for eclectic practice. These researchers, who undertook a comparative outcome study, employed an unusual research design to maximize sensitivity to technique effects. They used a crossover design in which 40 outpatients received eight sessions of cognitive-behavioral therapy and eight sessions of humanistic-dynamically oriented psychotherapy. These therapies were offered by the same therapists, but the order ot exposure was varied. This procedure allowed for a comparison of the effectiveness of both therapies while reducing the variance in outcome as a result of different therapies offered by different therapists. It also allowed for the examination of order effects; does combining therapy in a set order enhance the effects of therapy? This design thus tests the assimilation model and has implications for the transtheoretical model as well. Results of the analysis showed few differences between the two treatments, although a slight superiority for the cognitive-behavioral treatment was noted. Of greater importance in the present analysis was their study of sequencing of treatments. In view of the models just presented, and the widespread belief in establishing a relationship prior to requiring activities outside of therapy (as required in many behavior therapies), it is surprising to see no differences in outcome due to the order of receiving treatment. Although Stiles et al. (1990) have proposed the importance of sequencing interventions, it would not appear that starting therapy with a method that emphasizes reducing defenses, increasing awareness of feelings, and facilitating insight, was any more helpful than beginning therapy with cognitive-behavioral procedures that focus more on active problem solving and mastery of problems. In many ways the Sheffield Psychotherapy Research Project reflects the conclusions of meta-analytic reviews and summaries of comparative studies: slight superiority for cognitive-behavioral psychotherapies in contrast to dynamic-humanistic ones. The methodological issues noted in past reviews tended to balance out in this study. On the one hand, the dynamic therapy was offered in only eight sessions, a decision that could be seen

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as favoring the cognitive-behavioral therapy. At the same time, the allegiance of the researchers, if any, favored the dynamic-humanistic intervention. On balance, one would have to conclude that if therapists were choosing a therapy on the basis of efficacy, they have grounds, from this study, to consider adapting the cognitive-behavioral techniques, but in so doing they cannot expect to show much superiority over dynamic-humanistic practitioners. Also of considerable interest to eclectic therapists is a report on "therapist effects" arising out of this same research. Could therapists offer both therapies equally well? Shapiro, Firth-Cozens, and Stiles (1989) examined the effects of specific therapists on the outcome of therapy in the Sheffield project. The 40 patients were seen by four therapists who offered both a cognitive-behavioral and dynamic therapy to patients. Although the project used manuals and supervision to minimize the effect of individual therapists on treatment outcome, the authors discovered that the two therapists who saw the majority of patients had different outcomes. One of the therapists was more effective than the other in cognitive-behavioral therapy and less effective in the dynamic. The results of this study suggest that even with intensive supervision and training, therapists can still show differential effectiveness under the most controlled of circumstances. This appears to be true even when the therapists have an interest and a commitment to both modalities. There may well be limits to the variety of techniques that some clinicians can employ. One implication of this research is the serious demands that can be put on eclectic practitioners. The effective use of any given therapy, of course, requires considerable skill. But the effective use of many methods, the timing of their use, and the continued updating on techniques is especially challenging for the eclectic. This book responds in part to the need to organize and systemize the demanding task of the eclectic therapist. Despite the openness of eclectic theorists to knowledge derived from clinical practice and basic research, the eclectic approach has not yet produced a distinguishable body of research that supports its claims of superior efficacy. In the short run, therefore, projects aimed at demonstrating the effectiveness of eclectic approaches are sorely needed. Since eclectic theorists' most persuasive argument for effectiveness lies in their claim for flexibility in dealing with a variety of patient problems, an initial study would call for the random assignment of patients to practitioners who advocate treatment within the confines of a single-school approach and to practitioners of an eclectic approach (cf. Wolfe & Goldfried, 1988). Such a study would need to make recordings of the therapies offered in order to clarify the nature of therapeutic interventions. The patients in such a study should not be homogeneous with regard to their disorder. Instead, they

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should represent a cross section of patients typical of outpatient clinical practice. The central disadvantage of such research is that it repeats the competitive polarizing pattern that has characterized past comparative research. Unfortunately, this research may lead to the solidification of yet another therapy school rather than to agreement about the most effective intervention practices. Thus, the consequences of such research may go against the basic values of an eclectic approach, but at least it could illustrate the advantages of systematically combining treatments. One attempt to focus future research on psychotherapy integration was forged by the participants of a National Institute of Mental Health workshop reported by Wolfe and Goldfried (1988). The workshop participants developed a list of 23 recommendations, which fell into four domains: (1) conceptual clarification, (2) psychotherapy process research, (3) efficacy studies on integrative and systematic eclecticism, and (4) the training and supervision of integrative therapists. The two issues of greatest relevance to this chapter are efficacy research and process research. The need for more studies of efficacy have already been addressed. There is also an urgent need for process studies that link therapist and patient actions to positive change. Two studies will be highlighted to provide the reader with intriguing strategies that illuminate the process-outcome connection. Jones, Gumming, and Horowitz (1988) attempted to demonstrate that there are, indeed, specific factors (not common across therapies) that lead to therapeutic change. They studied the effects of therapist actions and techniques, as well as patient attitudes and behaviors, on psychotherapy outcome. They examined Psychotherapy Process Q-Sort ratings of brief (12-session) psychodynamic psychotherapy with patients suffering stress response syndromes following traumatic events or bereavement. The authors found that different factors predicted success with more and less disturbed patients. Those patients who were initially more seriously disturbed seemed to respond better to supportive interventions such as direct reassurance, avoidance of threatening interpretations, directing the dialogue, and support of defenses (rather than analysis of defenses). Those patients who were less disturbed tended to do better with the aggressive approaches. These patients were more aware of conflicts surrounding their dependency needs, were more clear in their ability to express problems, and were more organized. The therapists more often drew connections between the patients' current relationships and their past relationships and experiences. The here and now was also more emphasized within therapy sessions. Although Jones and colleagues emphasize the importance of their results for highlighting specific techniques in contrast to common factors, the implications for eclectic therapy are limited. First, the divergence of

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effective techniques is easily handled within a pure-school approach. Thus, this process research does not suggest the need for techniques outside of a dynamic theory of change. Second, the nature of the report makes it impossible to assess the accuracy of their interpretation of results, since the items that did not correlate with outcome in either group were not reported and their analysis was post hoc. It remains to be seen if more or less disturbed clients can be systematically identified before treatment and then assigned to ideal and unideal matches. Nevertheless, this research strategy allows for a complex analysis of therapy process and it can be recommended for further use in studies that investigate the active ingredients of psychotherapy. A second illustrative study was reported by Richards, Burlingame, Barlow, and Lambert (1990). These authors examined the interpersonal style of a select set of six patients who manifested clinically significant improvement or deterioration following 16 weeks of group psychotherapy. All group interactions that involved the patient, the therapist, and group members were selected from three sessions: early, middle, and late in the therapy. In all, nearly 4,000 interaction units were analyzed using the Structured Analysis of Social Behavior (SASB) developed by Benjamin (1982). A stable pattern emerged for patients regardless of who in the group they were speaking to, and who was speaking to them. Those who improved were self-reflective and self-accepting, and their therapists related to them in an accepting manner. Those who deteriorated tended to avoid self-reflection, were warded off and closed up, had many more hostile interactions, and often had interactions in which they were hostilely compliant. In addition, therapists related to them in more parental ways. The patients tried to befriend their therapist, and therapists were friendly in return. Thus, it was not therapist hostility that was related to deterioration but rather that therapists failed to draw patients out of their defensive and placating style. These results are similar to those of Henry, Schacht, and Strupp (1986), who found that nonimprovers in individual therapy had approximately the same high levels of hostile behaviors. Both process studies identify patient styles that suggest the need for interventions that were not offered, and both suggest ways of increasing the effectiveness of psychotherapy quite apart from a single-school approach. In this sense they illustrate the natural affinity between process research and psychotherapy integration (Goldfried, Castonguay, & Safran, 1992). Despite the seeming compatibility of psychotherapy research and eclectic psychotherapy, there is little evidence that eclectic therapies are being carefully researched. Before claims of superiority based on integration of the best from single-school approaches can be supported, empirical investigations will need to be conducted. Until such investigations have

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been conducted, eclectic practitioners would do well to be more modest in their claims for superiority. It may be that eclectics are far too eager to integrate the least important aspects of treatment (techniques) while neglecting the central facilitating forces within treatments (common factors). In so doing they may even produce therapies that are less efficacious than the single-school approaches from which they are often derived.

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GARFIELD, S. L, & KURTZ, R. (1977). A study of eclectic views. Journal of Consulting and Clinical Psychology, 45, 78—83. GASTON, L. (1990). The concept of the alliance and its role in psychotherapy: Theoretical and empirical considerations. Psychotherapy, 27, 143-153. GASTON, L., MARMAR, L. R., THOMPSON, L., & GALLAGHER, D. (in press). The importance of the alliance in psychotherapy of elderly depressed patients. Journal of Gerontology: Psychological Sciences. GLASS, C, & ARNKOFF, D. B. (1988). Common and specific factors in clientdescriptions of and explanations for change. Journal of Integratwe and Eclectic Psychotherapy, 7, 427-440. GOIN, M. K., YAMAMOTO, ]., & SILVERMAN, J. (1965). Therapy congruent with class-linked expectations. Archives of General Psychiatry, 38, 335—339. GOLDFRIED, M. R., CASTONGUAY, L. G., & SAFRAN, J. D. (1992). Core issues and future directions in psychotherapy integration. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. GOLDFRIED, M. R., & WACHTEL, P. L. (1987). Clinical and conceptual issues in psychotherapy integration: A dialogue. Journal of Integrative and Eclectic Psychotherapy, 6, 131—144. GOMES-SCHWARTZ, B. (1978). Effective ingredients in psychotherapy: Prediction of outcome from process variables. Journal of Consulting and Clinical Psychology. 46, 1023-1035. GRENCAVAGE, L. M., & NORCROSS, J. C. (1990). Where are the commonalities among the therapeutic common factors? Professional Psychotherapy: Research and Practice, 21 372-378. GURMAN, A. S. (1977). The patient's perception of the therapeutic relationship. In A. S. Gunman & A. M. Razin (Eds.). Effective psychotherapy: A handbook of research, (pp. 503-543). Elmsford, NY: Pergamon. HAHLWEG, K., & MARKMAN, H. J. (1988). Effectiveness of behavioral marital therapy: Empirical status of behavioral techniques in preventing and alleviating marital distress. Journal of Consulting and Clinical Psychology, 56, 440-447. HAZELRIGG, M. D., COOPER, H. M., & BORDUIN, C. M. (1987). Evaluating the effectiveness of family therapies: An integrative review and analysis. Psychological Bulletin, 101, 428-442. HELD, B. S. (1984). Toward a strategic eclecticism: A proposal. Psychotherapy, 21, 232-241. HENRY, W. P., SCHACHT, T. E., & STRUPP, H. H. (1986). Interpersonal process in differential psychotherapeutic outcome. Journal of Consulting and Clinical Psychology, 54, 27-31. HERINK, R. (Eo.). (1980). The psychotherapy handbook: The A to Z guide to more than 250 different therapies in use today. New York: Meridian. HORVATH, A. O., & GREENBERG, L. (1989). Development and validation of the Working Alliance Inventory. Journal of Counseling Psychology, 36, 223—233.

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JACOBSON, N. S., FOLLETTE, W. C., & REVENSTORF, D. (1984). Psychotherapy outcome research: Methods for reporting variability and evaluation clinical significance. Behavior Therapy, 15, 336—352. JACOBSON, N. S., WILSON, L, & TUPPER, C. (1988). The clinical significance of treatment gains resulting from exposure-based intervention for agoraphobia: A reanalysis of outcomes data. Behavior Therapy, 19, 539—552. JENSEN, J. P., BERGIN, A. E., & GREAVES, D. W. (1990). The meaning of eclecticism: New survey and analysis of components. Professional Psychology: Research and Practice, 21, 124—130. JOHNSON, M. E. (1988, June). Construct validation of the therapeutic alliance. Paper presented at the annual meeting of the Society of Psychotherapy Research, Santa Fe, NM. JONES, E. E., GUMMING, J. D., & HOROWITZ, M. J. (1988). Another look at the nonspecific hypothesis of therapeutic effectiveness, journal of Consulting and Clinical Psychology, 56, 48-55. JORM, A. F., (1989). Modifiability of trait anxiety and neuroticism: A metaanalysis of the literature. Australian and New Zealand Journal of Psychiatry, 23, 21-29. KAZDIN, A. E., & BASS, D. (1989). Power to detect differences between alternative treatments in comparative psychotherapy outcome research. Journal of Consulting and Clinical Psychology, 57, 138-147. LAMBERT, M. J. (1976). Spontaneous remission in adult neurotic disorders: A revision and summary. Psychological Bulletin, 83, 107-119. LAMBERT, M. J. (1982). The effects of psychotherapy (Vol. 2). New York: Human Sciences Press. LAMBERT, M. J. (1983). Introduction to assessment of psychotherapy outcome: Historical perspective and current issues. In M. J. Lambert, E. R. Christensen, & S. S. Dejulio (Eds.). The assessment of psychotherapy outcome (pp. 3—32). New York: Wiley. LAMBERT, M. J., BERGIN, A. E., & COLLINS, J. L. (1977). Therapist-induced deterioration in psychotherapy. In A. S. Gurman & A. M. Razin (Eds.), Effective psychotherapy: A handbook of research (pp. 552-581.) Elmsford, NY: Pergamon. LAMBERT, M. J., CHRISTENSEN, E. R., & DEJULIO, S. S. (Eos.). (1983). The Assessment of Psychotherapy Outcome. New York: Wiley. LAMBERT, M. J., DEJULIO, S. S., & STEIN, D. M. (1978). Therapist interpersonal skills: Process, outcome, methodological considerations and recommendations for future research. Psychological Bulletin, 85, 467—489. LAMBERT, M. J., SHAPIRO, D. A., & BERGIN, A. E. (1986). The effectiveness of psychotherapy. In S. L. Garfield & A. E. Bergin (Eds.), Handbook of psychotherapy and behavior change (3rd ed., pp. 157-212). New York: Wiley. LANDMAN, J. T., & DAWES, R. M. (1982). Psychotherapy outcome: Smith and Glass conclusions stand up under scrutiny. American Psychologist, 37, 504— 516.

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LARSON, D. (1980). Schools, styles, and schoolism: A national survey. Journal of Humanistic Psychology, 20, 3-20. LAZARUS, A. A. (1971). Behavior therapy and beyond. New York: McGrawHill. LAZARUS, A. A. (1992). Multimodal therapy: Technical ecelecticism with minimal integration. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. LEVANT, R. F., & SHLIEN, ]. M. (Eos.). (1984). Client-centered therapy and the person-centered approach: New directions in theory, research and practice. New York: Praeger. LEWINSOHN, P. M., ANTONUCCIO, D. O., BRECKENRIDGE, J. S., & TERI, L. (1984). The coping with depression course. Eugene, OR: Castalia. LORR, M. (1965). Client perceptions of therapists. Journal of Consulting Psychology, 29, 146-149. LUBORSKY, L., McLELLAN, T., WoODY, G., O'BRIAN, C., & AuERBACH, A. (1985).

Therapist success and its determinants. Archives of General Psychiatry, 42, 602-611. LUBORSKY, L., SINGER, B., & LUBORSKY, L. (1975). Comparative studies of psychotherapies: Is it true that "everybody has won and all must have prizes?" Archives of General Psychiatry, 32, 995-1008. MAHALIK, ]. R. (1990). Systematic eclectic models. The Counseling Psychologist, 18, 655-679. MANN, A. H., JENKINS, R., & BELSEY, E. (1981). The twelve-month outcome of patients with neurotic illness in general practice. Psychological Medicine, 11, 535-550. MARKS, I. (1978). Behavioral psychotherapy of adult neurosis. In S. L. Garfield & A. E. Bergin (Eds.), Handbook of Psychotherapy and Behavior Change (2nd ed., pp. 493-547). New York: Wiley. MARMAR, C. R., GASTON, L., GALLAGHER, D., & THOMPSON, L. W. (1989). Alliance and outcome in late-life depression. Journal of Nervous and Mental Disease, 177, 464-472. MARZIALI, E. (1984). Three viewpoints on the therapeutic alliance: Similarities, differences, and associations with psychotherapy outcome. Journal of Nervous and Mental Diseases, 172, 417-423. MELTZOFF, ]., & KORNREICH, M. (1970). Research in psychotherapy. New York: Atherton. MICHELSON, L. K., & MARCHIONE, K. (1991). Behavioral, cognitive, and pharmacological treatments of panic disorders with agoraphobia: Critique and synthesis. Journal of Consulting and Clinical Psychology, 59, 100—114. MICHELSON, L., MARCHIONE, K., & GREENWALD, M. (1989, November). Cognitive-behavioral treatments of agoraphobia. Paper presented at the annual meeting of the Association for the Advancement of Behavior Therapy, Washington, DC.

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MILLER, R. C, & BERMAN, J. S. (1983). The efficacy of cognitive behavior therapies: A qualitative review of the research evidence. Psychological Bulletin, 94, 39-53. MILLER, W. R., TAYLOR, C. A., & WEST, J. C. (1980). Focused versus broadspectrum behavior therapy for problem drinkers. Journal of Consulting and Clinical Psychology, 48, 590-601. MITCHELL, K. M., BOZARTH, J. D., & KRAUFT, C. C. (1977). A reappraisal of the therapeutic effectiveness of accurate empathy, nonpossessive warmth, and genuineness. In A. S. Gurman & A. M. Razin (Eds.), Effective psychotherapy: A handbook of research (pp. 482—502). Elmsford, NY: Pergamon. MORGAN, R., LUBORSKY, L, CRITS-CHRISTOPH, P., CURTIS, H., & SALOMON, J. (1982). Predicting the outcome of psychotherapy by the Penn helping alliance rating method. Archives of General Psychiatry, 39, 397—402. MURPHY, P. M., CRAMER, D., & LILLIE, F. J. (1984). The relationship between curative factors perceived by patients in their psychotherapy and treatment outcome: An exploratory study. British journal of Medical Psychology, 57, 187-192. NICHOLSON, R. A., & BERMAN, J. S. (1983). Is follow-up necessary in evaluating psychotherapy? Psychological Bulletin, 93, 261—278. NORCROSS, J. C. (Ed.). (1986). Handbook of eclectic psychotherapy. New York: Brunner/Mazel. NORCROSS, ]. C., & GRENCAVAGE, L. M. (1989). Eclecticism and integration in counselling and psychotherapy: Major themes and obstacles. British Journal of Guidance and Counselling, 17, 227—247. NORCROSS, J. C., & NEWMAN, C. F. (1992). Psychotherapy integration: Setting the context. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. NORCROSS, J. C., & PROCHASKA, J. O. (1982). A national survey of clinical psychologists: Affiliations and orientations. The Clinical Psychologist, 39, 1-6. OGLES, B. M., LAMBERT, M. J., & CRAIG, D. (1991). A comparison of self-help books for coping with loss: Expectations and attributions. Journal of Counseling Psychology, 38, 387-393. O'MALLEY, S. S., SUH, L. S., & STRUPP, H. H. (1983). The Vanderbilt Psychotherapy Process Scale: A report on the scale development and a processoutcome study. Journal of Consulting and Clinical Psychology, 51, 581—586. PATTERSON, C. H. (1984). Empathy, warmth, and genuineness in psychotherapy: A review of reviews. Psychotherapy, 21, 431-438. PRIOLEAU, L., MURDOCK, M., & BRODY, N. (1983). An analysis of psychotherapy versus placebo studies. The Behavioral and Brain Sciences, 6, 275—310. PROCHASKA, J. O., & DICLEMENTE, C. C. (1986). The transtheoretical approach. In J. C. Norcross (Ed.), Handbook of eclectic psychotherapy (pp. 163—200). New York: Brunner/Mazel.

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PROCHASKA, J. O., & DICLEMENTE, C. C. (1992). The transtheoretical approach. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. QUALITY ASSURANCE PROJECT. (1982). A treatment outline for agoraphobia. Australian and New Zealand Journal of Psychiatry, 16, 25—33. QUALITY ASSURANCE PROJECT. (1983). A treatment outline for depressive disorders. Australian and New Zealand Journal of Psychiatry, 17, 129—146. QUALITY ASSURANCE PROJECT. (1985). Treatment of outlines for the management of anxiety states. Australian and New Zealand Journal of Psychiatry, 19, 138-151. RACHMAN, S. J., & WILSON, G. T. (1980). The effects of psychological therapy (2nd ed.). Elmsford, NY: Pergamon. RICHARDS, L, BURLINGAME, G. M., BARLOW, S., & LAMBERT, M. J. (1990, June). Comparison of group interactions of improvers and deteriorators on the 5A5B. Paper presented at the Society for Psychotherapy Research, Wintergreen, VA. ROBINSON, L. A., BERMAN, J. S., & NEIMEYER, R. A. (1990). Psychotherapy for the treatment of depression. A comprehensive review of controlled outcome resources. Psychological Bulletin, 108, 30—49. ROSENTHAL, R. (1983). Assessing the statistical and social importance of the effects of psychotherapy. Journal of Consulting and Clinical Psychology, 51, 4-13. SCHAPIRA, K., ROTH, M., KERR, T. A., & GURNEY, C. (1972). The prognosis of affective disorders: The differentiation of anxiety states from depressive illnesses. British Journal of Psychiatry, 12, 175—201. SCOGIN, F., BYNUM, J., STEPHENS, G., & CALHOUN, S. (1990). Efficacy of selfadministered treatment programs: Meta-analytic review. Professional Psychology: Research and Practice, 21. 42—47. SHAPIRO, D. A., & FIRTH, ]. (1987). Prescriptive v. exploratory psychotherapy: Outcomes of the Sheffield psychotherapy project. British Journal of Psychiatry, 151, 790-799. SHAPIRO, D. A., FIRTH-COZENS, J., & STILES, W. B. (1989). The question of therapists differential effectiveness: A Sheffield psychotherapy project addendum. British Journal of Psychiatry, 154, 383-385. SHAPIRO, D. A., & SHAPIRO, D. (1982). Meta-analysis of comparative therapy outcome studies: A republication and refinement. Psychological Bulletin, 92, 581-604. SLOANE, R. B., STAPLES, F. R., CRISTOL, A. H., YORKSTON, N. J., & WHIFFLE, K. (1975). Short-term analytically oriented psychotherapy vs. behavior therapy. Cambridge, MA: Harvard University Press. SMITH, M. L., & GLASS, G. V. (1977). Meta-analysis of psychotherapy outcome studies. American Psychologist, 32, 752-760. SMITH, M. L., GLASS, G. V., & MILLER, T. 1. (1980). The benefits of psychotherapy. Baltimore: Johns Hopkins University Press.

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STEIN, D. M., & LAMBERT, M. J. (1984). On the relationship between therapist experience and psychotherapy outcome. Clinical Psychology Review, 4, 1—16. STEINBRUECK, S. M., MAXWELL, S. E., & HOWARD, G. S. (1983). A meta-analysis of psychotherapy and drug therapy in the treatment of unipolar depression with adults. Journal of Consulting and Clinical Psychology, 51, 856—863. STILES, W. B., ELLIOT, R., LLEWELYN, S. P., FIRTH-COZENS, S. A. MARGISON, F. R., SHAPIRO, D. A., & HARDY, G. E. (1990). Assimilation of problematic experiences by clients in psychotherapy. Psychotherapy, 27, 411—420. TICHENOR, V., & HILL, C. E. (1989). A comparison of six measures of working alliance. Psychotherapy, 26, 195-199. TINGEY, R., BURLINGAME, G. M., LAMBERT, M. S., & BARLOW, S. (1990, June). Extensions of a method for assessing clinically significant change. Paper presented at the Society for Psychotherapy Research, Wintergreen, VA. WAMPLER, K. S. (1982). Bringing the review of literature into the age of quantification: Meta-analysis as a strategy for integrating research findings in family studies. Journal of Marriage and the Family, 11, 1009—1023. WINDHOLZ, M. J., & SILBERSCHATZ, G. (1988). Vanderbilt psychotherapy process scale: A replication with adult outpatients. Journal of Consulting and Clinical Psychology, 56, 56-60. WOLFE, B. E., & GOLDFRIED, M. R. (1988). Research on psychotherapy integration: Recommendations and conclusions from an NIMIH workshop. Journal of Consulting and Clinical Psychology, 56, 488—451. ZEISS, A. M., LEWINSOHN, P. M., & MUNOZ, R. F. (1979). Nonspecific improvement effects in depression using interpersonal skills training, pleasant activity schedules, and cognitive training. Journal of Consulting and Clinical Psychology, 47, 427-439.

CHAPTER 4

A Critical Examination of Belief Structures in Integrative and Eclectic Psychotherapy STANLEY B. MESSER

SURVEYS OF CLINICAL AND COUNSELING psychologists conducted over the past three decades have revealed that a substantial proportion of the respondents (from 19 percent to 65 percent) regard themselves as integrative or eclectic in their practice of psychotherapy (Jensen, Bergin, & Greaves, 1990). In their own recent poll, which included clinical psychologists, marriage and family therapists, social workers, and psychiatrists, Jensen et al. (1990) found that an even higher percentage of these professional groups (from 59 percent to 72 percent, with an average of 68 percent) endorsed eclecticism as their preferred orientation. Interpreting similar survey results in the strongest terms, Smith (1982) declared that "the days of individual schools in counselling and therapy are drawing to a close" (p. 805). Along with such empirical surveys affirming the popularity of eclectic practice have come books, articles, conferences, and journals furthering the cause of eclecticism (see Norcross & Newman, 1992). Psychotherapy integration and eclecticism, it would seem, are on the march. Nevertheless, not all is tranquil on this psychotherapy frontier. To begin with, the figures quoted above do not show a neat, linear rise in the incidence of eclecticism. To take the most current and dramatic example, whereas Jensen et al. (1990) reported that 68 percent of practitioners are eclectic, the corresponding figure determined by Norcross, Prochaska, and Gallagher (1989) was only 29 percent. This large discrepancy could not be explained on the basis of either the year of the study or the group polled. Jensen and colleagues quite rightly concluded that until empirical studies examine exactly what self-declared eclectics do in practice, such results will remain ambiguous.

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A further problem with what to make of these figures lies in the definition of eclecticism. The College Dictionary (1972) defines eclectic as "not following any one system, as of philosophy, medicine, etc., but selecting and using what are considered the best elements of all systems" (p. 418). The surveys, however, typically include under the rubric of eclecticism a substantial proportion of therapists who selectively employ a single (not combined) theory or method that they regard as best suited for the client and/or problem at hand. In the survey by Garfield and Kurtz (1975), for example, 55 percent could be so described, as could 47 percent in a survey by Norcross and Prochaska (1988). Since it appears that such practitioners employ individual theories or methods for particular clients one at a time, they are not being integrative or eclectic at any one time, in the definition's sense of selecting and using the best elements of several approaches (Slife, 1987). Thus, statements such as, "The basis for eclectic practice is the contention that different clients and different problems require different treatments" (Patterson, 1989, p. 158) are mistaken. More accurate terms for this mode of practice are prescriptive selection (Beutler & Clarkin, 1990), differential therapeutics (Frances, Clarkin, & Perry, 1984; Clarkin, Frances, & Perry, 1992), or "diagnose-the-problem and prescribethe-treatment" (Mahrer, 1989), but not eclecticism. In addition, as Slife (1987) points out, one must have (or, at least should have) a system for making such prescriptive judgments, which itself is a theory, but it is not one that includes several theories at once. The net effect of this argument is a marked reduction in the incidence of eclecticism, at least as that term has been traditionally defined and understood. Another implication is that we should discriminate as much as possible among different kinds of "eclecticism," as the rationale for and practices within each type are likely to differ substantially. Since it has become common practice in discussions of integration and eclecticism to include prescriptive matching, I will do so as well by referring to prescriptive matchers as "selective" eclectics. As I will try to show, the belief system that underlies this approach is quite different from that of integrative eclectics. In this chapter, I present several different, largely independent perspectives on eclecticism, each of which can be evaluated on its own particular merits. Although I have discussed some of these issues elsewhere (e.g., Messer, 1986a, 1987; Messer & Winokur, 1984, 1986) I expand upon and update them below. First, I take up three philosophical notions that aid our understanding of the beliefs that fuel eclecticism. The first, the unitydiscovery model, argues that underlying the appearance of diversity and contradiction in the world is a basic unity. When we organize data at a superordinate level, the integrative eclectics claim apparent contradictions disappear and the integrated fabric of knowledge emerges. A second belief,

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which drives what I have referred to above as selective (vs. integrative) eclecticism, is that we do not merely discover what is already present in nature but, rather, we create our categories and impose them on the world. That is, there are different ways of construing our observations of human behavior, each having a certain legitimacy. As a result, the selective eclectic advocates the use of different approaches for different clients (selective or prescriptive matching), compared with the integrative eclectic who proposes a single, comprehensive, adequate, and unified therapy for all clients. A third belief underlying eclecticism is that we can share a common, neutral language in psychology, replacing the diversity of theoretical and ideological terms we currently employ. I question whether this is possible. The second topic is a consideration of how each psychotherapy embodies a vision of life of mythopoetic proportions. The literary forms described include the tragic, romantic, ironic, and comic, and the systems of therapy to which they are applied include psychoanalysis, behavior therapy, and experiential-humanistic therapy. This forms a backdrop to consider both the prospects and problems of eclecticism as a function of the change in visions of reality that eclecticism necessarily brings about. The third section takes up the issue of what constitutes evidence or knowing in different therapeutic frameworks. The empirical-experimental method is contrasted with the hermeneutic attitude toward truth-seeking. The ways in which this split create certain potential obstacles to eclecticism are discussed. In the fourth section, I briefly consider how the value framework of therapists affect their attitude toward eclecticism and integration, since, in the final analysis, it is they who must implement the therapy. Finally, the fifth section presents an alternative to present forms of integration, which 1 call "assimilative integration." It consists of incorporating perspectives or practices from other approaches within one's primary theoretical or therapeutic outlook, while taking their new context into account.

Philosophical Considerations Different forms of eclecticism are related to certain philosophical attitudes that psychotherapists rarely recognize or acknowledge. In this section I try to show that integrative eclecticism is closest to the philosophical belief called "organicism"; that selective eclecticism views the process of knowledge acquisition as discovery rather than invention; and that integrationists conceive of the (questionable) possibility of a language of description that is neutral and therefore acceptable to proponents of different therapies.

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ORGANICISM AND THE UNITY-DISCOVERY MODEL

In a far-reaching philosophical treatise, Pepper (1942) spelled out four "world hypotheses" into which all explanations are said to fall: mechanism, contextualism, formism, and organicism. Each has a root metaphor that provides the basic analogy by which we can get a grip on that world hypothesis. Thus, for mechanism, the root metaphor is the machine. In psychology we embrace mechanism when we conceive of psychological data as consisting of individual, independent parts or pieces existing in a spatiotemporal configuration, and which are governed by a set of universally valid laws. The British empiricists Locke, Berkeley, and Hume are most closely connected with this tradition insofar as they emphasized the existence of separate ideas that get linked up by association. Behaviorism falls within the mechanistic world hypothesis. Contextualism, unlike mechanism, is synthetic rather than analytic. The root metaphor is the historical event as seen within a setting or context. An act or event is explained by revealing the specific relationship it bears to other events occurring in its psychosocial sphere. The point is not to integrate all events in the field, nor to presume that there are timeless laws governing the data, but to limit the explanation to the specific domain and time period studied (White, 1973). As stated by Pepper (1942), "The quality of an event is the fused qualities of its strands, and the qualities of its strands come partly out of its context" (p. 249). That is, unlike the case in mechanism, there is no separation of detail from context. Psychobiography is contextualist in that it stresses the uniqueness and individuality of its subject matter. The phenomenological approach is contextualist, too, in its emphasis on a description of the world of experience with full allowance for detail embedded in context. This world hypothesis takes us in an interpretive or hermeneutic direction as opposed to a causal-exploratory (mechanistic) one (Smith, 1988). A third world hypothesis is formism, the root metaphor of which is similarity. It seeks classes of things or events whose similarity to or difference from others can be described. "The formist considers an explanation to be complete when a given set of objects has been properly identified, its class, generic and specific attributes assigned, and labels attesting to its particularity attached to it" (White, 1973, p. 14). In psychology, when we set about to construct a personality typology, such as Jungian archetypes, or a stage theory that presupposes ideal forms, such as Piaget's, we are encountering formism. Finally, organicism is the most integrative world hypothesis within which a philosophical (vs. pragmatic) eclecticism can find a home. The organicist believes that in the world, we encounter fragments of experience, such as observations of a school of therapy; these appear with certain

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connections that inevitably encounter contradictions, gaps, or opposition from other fragments of experience, such as the observations of other theories of therapy. The various fragments have a tendency to be resolved by incorporation into an organic whole that, all the while, was implicit in the fragments and that transcends the previous contradictions by means of a coherent totality (Pepper, 1942, p. 283)—or, we might say, by an integrative eclecticism. By organizing the data at a higher level, the appearance of conflict is dissolved into the reality of the organic whole. Progress is achieved by including more and more of the fragments into a better integrated whole. In terms of integrating parts of one therapy with parts of another, the integrative eclectic, like the organicist, would argue that the apparent contradictions were never really contradictions at all because they vanish when the integrated system is constructed (see Beitman; Garfield; Prochaska & DiClemente; Wachtel & McKinney; all 1992). Nothing is lost in such a system because it takes in the pieces of one therapy and joins them to another. Individual pieces get aggregated into wholes that are greater than the sum of their parts. Organicism is linked to belief in unity of knowledge. Some scholars proceed from the premise that unity of knowledge is possible because "the connections were really there all the time, working in nature. . . . There was nothing to do but let them come together. . . . These are immediately discoverable in observation" (Pepper, 1942, p. 292). Now, if this is the case, we have a powerful argument at hand in favor of integrative eclecticism: In joining parts of different theories or therapies, we are contributing to that unity which is, in fact, the natural order of the psychological (and physical) universe. Within psychology, the most fervent spokesperson for this viewpoint is Arthur Staats (1983, 1988), who argues that our field is in a crisis of disunity and that a unified science of psychology is now possible and desirable. He has suggested "that psychology marshall itself toward establishing an interest in such unification which will demand development of the need for unified theory" (Staats, 1981, p. 253). In the therapeutic realm, those integrationists (e.g., Beitman, 1992; Garfield, 1992; Goldfried, 1980; Omer & Alon, 1989; Omer & London, 1989; Orlinsky & Howard, 1987) who view the power of the different psychotherapies as lying within their shared elements (such as a good therapeutic relationship, emotional release, exposure to conflicts, explanations of some sort), implicitly are making the same claim—that the different schools of psychotherapy, in fact, share a commonality of viewpoint beneath the surface diversity. So have those theoretical integrationists who construct a superstructure encompassing various systems of psychotherapy (e.g., Prochaska & DiClemente, 1992; Wachtel & McKinney, 1992; Safran & Segal, 1990). Norcross (1986, 1992)

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applauds such eclectic therapists for recognizing how differentiated parts of psychotherapy can be organized and integrated into the whole at a higher level, and for appreciating the unity and complexity achieved thereby. By referring to such theorists as having "successfully reached the summit," he is, in effect, strongly endorsing the value of unity. If the reader is persuaded that there is an affinity between integrative eclecticism and organicism, he or she should note that, in Pepper's scheme, organicism is but one of four world hypotheses. In fact, behaviorism, psychoanalysis, and existential-phenomenology are not basically organicist in outlook: philosophical eclectics share one particular philosophical outlook on the best way to view psychological data, whereas adherents of specific schools of therapy prefer others. Consciously or otherwise, we operate within a particular world view but tend to lose sight of the existence of other, equally viable alternatives. In the field of psychotherapy, at the current time, we are in no position to judge, in a once-and-for-all fashion, which world hypothesis or theory is best. It can be argued that what is best at present is the continued existence of a dynamic tension among these models, rather than a unimodel, organicist view. Royce (1982) calls this "constructive dialectics, where dialectic has to do with maintaining the tension between viable conceptual alternatives" (p. 259). Of course, one of the possible outcomes of such a dialectic is some form of rapprochement or integration of the models. Although Pepper insists that we should not compromise or combine these root metaphors or world hypotheses, Smith (1988) challenges this view, arguing that in psychology we "cannot avoid dealing with our topic in both the causal [mechanistic] and the interpretative [contextualist] mode . . . we seem indeed to be creatures intrinsically linked to mixed metaphors" (p. 11). PERSPECTIVISM AND PLURALISM

The counterpart of the unity-discovery model and, hence, of an integrative eclecticism, is that psychology, by its very nature, is pluralistic, and "is not a single or coherent discipline but rather a collectivity of studies of varied cast. . . . Paradigms, theories, models (or whatever one's label for conceptual ordering devices) can never prove pre-emptive or preclusive of alternate organizations" (Koch, 1981, p. 268). There is no single truth out there to discover. Similarly, Royce (1982) argues that psychology is conceptually pluralistic, multiworld view and multitheoretic. Note that this is not the older way of viewing systems of therapy, in which only one system—"the true one"—was expected to emerge victorious. In fact, to quote Omer and London's (1988) pithy phrase: "Pluralism waives exclusivism in favor of relativism" (p. 178).

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In discussing these issues in the context of the integratability of the therapies, Schacht (1984) viewed the pluralistic outlook on psychology as related to the idea that we do not merely discover what is inherent in nature, but invent our categories and theories and view nature through them. For Gergen (1982) this dichotomy is captured by a comparison of exogenic with endogenic thinking. In the latter, "recordings of reality are not so much correct or incorrect as they are creations of the observer. . . . Multiple interpretations of experience are usually held to be both legitimate and desirable" (pp. 176-177; italics added). Schacht (1984) points out that "the pluralistic position cherishes contradictions as spurs to the creation of knowledge and as antidotes to the suffocating intellectual effects of an a priori assumption of unity" (p. 125). He contends that insofar as efforts at eclecticism lead to a truly new and creative theory of therapy, such efforts are to be valued. But insofar as they attempt merely to summarize and unify current therapies, they may tend to stultify, not enrich our discipline. In this connection, Walsh and Peterson (1985) concluded, after considering the merits of a synthesis among major theoretical viewpoints, that "the most cognitively responsible yet comprehensive view available at this time is the position of pluralism" (p. 152), insofar as it encourages a crossfertilization of ideas and healthy cross-school competition. Rychlak (1987) believes that unification of theoretical outlook is deadly and reminds us that it is certainly not the norm in the physical sciences. Similarly, William James (1909/1977) embraced a pluralistic philosophy in which "nothing includes everything, or dominates everything. . . . The pluralistic world is thus more like a federal republic than like an empire or kingdom" (p. 145). However, James would not have discouraged efforts at integration, as long as alternative viewpoints could receive a fair hearing (Viney, 1989). Even within a single theoretical domain, psychoanalysis, Mitchell (1991) has written, "We need to learn to regard differences in theoretical perspectives not as unfortunate deviations from one accurate understanding, but as fortunate expressions of the countless ways in which human experience can be organized" (p. 6). Although it might be more satisfying and elegant if the world were not a multiverse, but a universe (Wertheimer, 1988), the pluralists assure us that, alas, this quest will never be realized. Given that different ways of conceptualizing reality are always possible and even desirable from perspectivist and pluralist standpoints, there will continue to be several extant theories of therapy. Some therapists will choose to practice within a single-school approach. Others will attempt to unite two or more therapies, as integrative eclectics do. Selective eclectics seem to take a bird's-eye view of the therapies and are prepared, in pragmatic fashion, to use any that seem suited to the purpose at hand, even if they presume different theories of human nature or change. Of course,

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one can also be a hybrid eclectic, that is, selective in practice but singleminded in theory (see Lazarus, 1992). PROSPECTS FOR A COMMON, NEUTRAL LANGUAGE

There is a recognition among those attracted to integration and eclecticism that therapists holding different theoretical outlooks employ different psychological languages. If a truly integrative therapy is to be proposed and developed, how are the different languages to be joined? If the phenomenologist uses terms like "the phenomenal sense of self," the psychoanalyst, "the self-system" or "selfobject," and the social learning theorist, "self-efficacy," how are we to understand each other, and develop a common framework? The suggestion made by some is that we abandon our familiar language communities and develop a "genuinely neutral metalanguage" (Murgatroyd & Apter, 1986, p. 280), or "a superordinate language system in order to separate real differences among approaches from label differences" (Beutler, 1986, p. 94). Others suggest that we agree to speak in the vernacular or, in order to preserve a link to the broader discipline of experimental psychology, adopt the language of cognitive psychology (Goldfried, 1979, 1983; Goldfried & Newman, 1986; Ryle, 1978, 1987; Sarason, 1979; Wolfe & Goldfried, 1988). Goldfried (1983) has suggested that such a language offers us "a set of relatively neutral concepts, having a minimal theoretical superstructure, (one that is) closely related to the kinds of phenomena that we see in our clinical work" (p. 103). This position presumes the possibility of a psychological Esperanto that would draw the world of psychotherapy closer together. But is such a proposal possible or desirable? Even within established sciences such as physics, there are specialized subfields employing different languages suited to their own purposes. "Language is at best a feeble instrument, even among members of a highly trained language community having quite limited problematic interests. None of the currently institutionalized sciences form single homogeneous language communities" (Koch, 1964, p. 27; see also Keller, 1985). Are cognitive concepts and language with their own unique set of suppositions and presuppositions, their own theoretical superstructures and substructures, any more neutral than those of phenomenology, behaviorism, or psychoanalysis (Messer, 1984)? I believe not. While terms like script or schema may not carry the same negative connotations for behavior therapists as unconscious fantasy, or the same negatively conditioned association for psychoanalysts as behavioral chain, they are not in any absolute sense neutral terms, nor can they be. "No natural language and no scientific one of any richness can be regarded as organized into logical levels such that all terms are reducible, or definable upon, a common definition base" (Koch, 1964, p. 26). Whether

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we recognize it or not, as psychologists we are always viewing phenomena from one angle or another, none of which is ever free from theoretical bias. As the literary critic, Richard Rorty (1979) stated it, "We have not yet a language which will serve as a permanent neutral matrix for formulating all good explanatory hypotheses, and we have not the foggiest notion of how to get one" (p. 348). Rorty's statement is not surprising since "language is itself the vehicle of thought" (Wittgenstein, 1953, p. 107). Therefore, in order to have a common language, we would also need to have an agreed-upon mode of thinking about things. However, as we know, there are always multiple ways of viewing and conceptualizing any cultural or social phenomenon, including psychotherapy. Such diversity of theory and language is bound to continue, as long as people continue to think freely and creatively. In fact, such divergent thinking is an advantage in that it promotes the generation and clash of new ideas, each of which is expressed in terms of its own linguistic form (Messer, 1987). Andrews (1989a) has pointed to a disadvantage of the use of a common language in a setting where eclecticism and congeniality of staff relationships was prized: "the common language solution may sometimes be a protection from confronting the rough edges of conceptual differences that would be revealed more sharply by the use of theory-based technical language" (p. 299). What is gained in ease of communication among staff with different theoretical and language preferences by seeking common or neutral ground is lost by sacrificing the complexity and utility of theorybased and theory-bonded languages. Would that we could have it both ways. In his more recent writings on this topic, Goldfried (1987) has acknowledged that there are limits to the use of the terms of experimental cognitive psychology as a common language. Because the latter may be insufficiently comprehensive, he advocates only selected translations that will allow incorporation of advances from related fields of psychology. He suggests the use of different common languages for different purposes, such as discourse within one theoretical school, across different schools of therapy, with other psychologists and social scientists, and for research purposes (Goldfried, 1987; Wolfe & Goldfried, 1988). Mahrer (1989) also expressed agreement with my stance, stating that terms cannot be translated without doing harm to their real meaning. "Watch out," he says, "for terms that appear to be neutral, for they either are so generalized that they have little or no meaning or they mask a particular theoretical approach" (p. 104). His solution is to restrict efforts at a common, neutral language to the increased clarification of special terms that refer to observable events in psychotherapy, such as the client slapping the arm of the chair.

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Would this work? While we might agree on a language for describing the latter event, the trouble would begin as soon as we imputed meaning to the act. Is slapping the arm of the chair the client's way of releasing tension, expressing anger, or being exuberant? How long would it take before we brought our broader theoretical framework and specialized languages to bear on its meaning? Could we really set aside our theoretical and linguistic presuppositions that guide us in doing so? I think not. And even if we could, the result would be rather bland, a lowest common denominator not satisfying to anyone. To illustrate the difficulty of extracting theory from observations, I will draw upon a recent exchange between Lazarus and Messer (1991). To support his claim that "observations simply reflect empirical data without offering explanations," Lazarus offered the statement, "Adolescents tend to imitate the behavior of their peers whom they respect" (p. 147). Let us examine whether this fulfills the requirement of a neutral language of observation, the kind also sought for some terms by Mahrer. Imitation, I suggest, is a theoretical term used by social learning theorists to imply a social influence process. It is not neutral. After all, one could have said that adolescents identify with their peers, implying a belief that they feel that they are like their peers, which is a more cognitively laden phrase. It is the language that provides the clue to the underlying theoretical premise. In a like vein, I have examined (Messer, 1987, 1988) the definition of "resistance" that Driscoll (1987, 1988) offered as an exemplar of common or ordinary language. "Resistance indicates opposition to something with clear intent or purpose to oppose" (Driscoll, 1987, p. 190). This definition is couched in the language of intention, which is a mental or cognitive construct that classical behaviorists would oppose (resist?). It also implies a conscious attitude, thereby not readily encompassing a theory of unconscious motivation. As such, it allows for one kind of discrimination and sensitivity but not for others. To avoid theory-laden constructs in our definitions is appealing from the viewpoint of parsimony and ease of communication, but is constraining and unsatisfying from the standpoint of richness, complexity, and the particular sensitivities of many language and theoretical communities. Within a hermeneutic perspective (Messer, Sass, & Woolfolk, 1988), language, definition, and theory are inextricably intertwined, and the effort to disentangle them typically leads to impoverished definitions and concepts. It follows that In psychology we must have many language communities: Many subgroups of individuals equipped with diverse stocks of discriminations and differently specialized sensitivities. By definition, we must have a greater number of language communities in psychology than perhaps in any other field of inquiry currently institutionalized. (Koch, 1964, p. 28)

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In addition, we should note that psychological meanings only make sense by virtue of their interrelations to other terms within a broad context. Even a staunch behavior therapy advocate like Franks (1984) pointed out that a term like symptom substitution has meaning within a psychoanalytic context but not for a behaviorist, who may use the term response substitution. Are they the same? According to Franks, "the difference between symptom substitution and response substitution is far more than semantic. Each has a specific contextual meaning and intimately interwoven series of conceptual linkages that make the two notions incompatible. Each becomes logically meaningful only within its own context" (p. 238). It would seem that the logical positivist's dream of a neutral data language has been largely abandoned. The emergent viewpoint is a version of the Whorfian hypothesis that what we perceive around us and how we experience it are a function of the language we employ. There is no bedrock language of definitions to which we can point and nod in agreement. The particular sensitivities of the observers will determine the extent to which high interobserver agreement is possible. There is no immaculate perception! In the phraseology of the modernist writers, we do not speak language; language speaks us. Beutler, Goldfried, and others are right in one sense: we are prisoners of language. But they are wrong if they think that escape from that prison is possible. How then can we breach the barriers among the different language communities in order to learn from one another? My suggestions are as follows: 1. Multilingualism. In order to appreciate the insights of orientations other than our own, we should become fluent in more than one psychotherapy language. Just as knowing a foreign language allows us to connect more intimately with a culture not our own, so does learning a "foreign" psychotherapy tongue allow for an appreciation of its concepts and ideology. We often return from a lengthy visit abroad with a new way of looking at things, and a recognition that our homebred habits are not the only ones possible. Regarding psychotherapy integration, this can lead to the assimilation of concepts or attitudes into our preferred theoretical system, to its potential benefit. Multilingualism, however, requires that professional training provide the opportunity for exposure to more than one language of psychotherapy. 2. Clarity in language and thought. We must strive to avoid unnecessary jargon, especially when communicating with proponents of other schools of psychotherapy. Use of ordinary language, as Driscoll proposed, or the vernacular, may be the most expedient, although we should remain aware of the tradeoffs involved. Another way to promote a readier integration and assimilation of foreign concepts is through empirical research. The advantage of engaging in research is that it requires us to operationalize

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our terms, making them clearer and thus more accessible to everyone (Wolfe & Goldfried, 1988).

Visions of Reality: Mythic Forms in Psychotherapy Every system of psychotherapy contains an underlying thematic structure emboding its way of viewing life's possibilities, which are as integral to it as its theory or technical procedures. Although there are different ways of classifying such broad outlooks, I have found one scheme to be particularly useful. It was developed by the literary critic Northrop Frye (1957, 1965) to categorize different genres or mythic forms in literature, and was subsequently applied by Schafer (1976) to psychoanalysis. The four visions are called the romantic, the ironic, the tragic, and the comic. To these, Andrews (1989b) has added the Darwinian and combative visions and the visions of order and faith, showing how they reflect characteristic styles and patterns of psychopathology. Winokur and I (Messer & Winokur, 1980, 1984, 1986) have employed Frye's taxonomy to spell out the contrasting visions of reality in psychoanalytic, behavioral, and humanistic forms of treatment. After illustrating the intersection of each of these therapeutic modes with the four visions, I will discuss the difficulties and the possibilities of psychotherapeutic integration that such a framework reveals.

THE ROMANTIC VISION

From the romantic viewpoint, life is an adventure or quest in which the person as hero transcends the world of experience, achieves victory over it, and is liberated from it. "It is a drama of the triumph of good over evil, of virtue over vice, of light over darkness, and of the ultimate transcendence of man over the world in which he was imprisoned by the Fall" (White, 1973, p. 9). The romantic vision emphasizes exploration and conquest of the unknown, the mysterious, the irrational. It is more the world as we would like it to be, than the world as we find it. Humanistic therapists, such as Maslow (1971) and Rogers (1961), view life primarily as an adventuresome quest. In emphasizing peoples' potential for continued psychological growth, their willingness to take risks, and the ability to self-actualize, humanistic therapies are operating with a romantic outlook. Rogers, in fact, claims that we are born with an "organismic valuing" process that allows us to appreciate and strive for that which is life-enhancing. The romantic vision idealizes individuality and what is "natural"

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since, by its lights, human nature is intrinsically good. To express oneself freely and impulsively is prized. "The fully developed individual is characterized by true spontaneity, by the richness of his subjective experience" (Strenger, 1989, p. 595). In a strongly romantic spirit, those therapies considered part of the human potential movement, stress "doing one's own thing," acting naturally, and being authentic. Similarly, they advocate the pursuit of a unique lifestyle and the continuous search for self-realization. Psychoanalytic therapy also partakes of the romantic vision, but with a different emphasis. In stressing an exploration of the unconscious, of the irrational and the unknown, psychoanalysts are influenced by the romantic attitude. Psychoanalysis is also viewed as a journey, a quest for redemption. The therapeutic process encourages a regression away from everyday reality and into the world of dreams, free associations, and fantasies. Unlike humanistic therapy, however, it envisions more obstacles enroute and is much less optimistic about the possibilities for ultimate self-actualization and liberation. Nor does it value as strongly as some humanistic therapies, acting "naturally" and, what it might term, narcissistically. In contrast to both the psychoanalytic and humanistic therapies, the behavior therapies are much more reality-oriented and practical than they are romantic. While behavior therapists may hold an attitude of curiosity and openness to the unexpected and the unknown, exploration of irrational fantasies is not encouraged in behavior therapy. Rather, problems are operationally defined, carefully measured on objective scales, and pragmatically treated. In some forms of cognitive behavior therapy, for example, irrational thoughts are disputed rather than explored and understood (e.g., Ellis, 1984; Ellis & Grieger, 1977). Since there is no objective, rational reason for clients needing to be perfectionistic or to be liked by everyone, the therapist wants to disabuse them of these irrational ideas. The romantic notion of the quest—so prominent in psychoanalytic and humanistic therapy—is almost entirely absent in behavior therapy. THE IRONIC VISION

The ironic attitude is the enemy of romance. It is an attitude of detachment, of keeping things in perspective, of recognizing that there is another side of the coin. It challenges our beliefs, traditions, and (romantic) illusions. Like the tragic vision, it emphasizes the inherent difficulties of human existence, the impossibility of mastering the world, and even of truly knowing its mysteries. "The ironic perspective in analytic work results in the analysand's coming to see himself or herself as being less in certain emotional respects than was initially thought—less, that is, than the unconscious ideas of omnipotence and omniscience imply" (Schafer, 1976, p. 52). Interestingly,

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humanistic therapy is linked in a dialectical fashion to psychoanalysis in that it results in clients seeing themselves and life's possibilities as more than they initially thought. Psychoanalytic therapists adopt the ironic attitude in therapy when they take a position of relative detachment (Stein, 1985). They do so in order to detect the flip-side of the client's utterances and behavior—the hidden meaning, contradictions, and paradoxes—how cheerfulness may cover sadness, and well-wishing, murderous thoughts. By contrast, in their therapeutic demeanor, behavior therapists and humanistic therapists are more apt to be friendly, self-disclosing, transparent, and affectively expressive, which may lessen the possibility of discerning irony. Behavior therapists are also more likely to accept client complaints at face value, including their stared therapeutic objectives (Wilson & O'Leary, 1980), and humanistic therapists tend to accept most client feelings as authentic expression. It is the essence of the ironic posture to take nothing for granted and, in this sense, such accepting attitudes are a breach of the ironic position. THE TRAGIC VISION

The tragic and ironic visions are linked insofar as they both include a distrust of romantic illusions and happy endings in life. Furthermore, they are reflective in attitude, whereas the romantic and comic views are more action oriented. Tragedy, however, unlike irony, involves commitment. In a tragic drama, the hero has acted with purpose and in so doing, has committed, at least in his or her mind, an act causing shame or guilt. He or she suffers by virtue of the conflict between passion and duty and, after considerable inner struggle, arrives at a state of greater self-knowledge. What interests us in the work of the tragic poet "is the glimpse we get of certain profound moods or inner struggles. Now, this glimpse cannot be obtained from without" (Bergson, 1937/1956, p. 167). Such a mode of knowing may be contrasted with "the kind of observation from which comedy springs. It is directed outwards" (Bergson, 1937/1956, p. 169). In the tragic vision the limitations in life are accepted—not all is possible, not all is redeemable, not all potentialities are realizable. The clock cannot be turned back, death cannot be undone, human nature cannot be radically perfected. Tragedy "requires one to recognize the elements of defeat in victory and of victory in defeat; the pain in pleasure and the pleasure in pain; the guilt in apparently justified action; the loss of opportunities entailed by every choice and by growth in any direction . . ." (Schafer, 1976, p. 35). Among the three major therapeutic orientations, the humanistic therapies are most dyssynchronous with the spirit of tragedy. In viewing people as fundamentally good, innocent, and unfallen (e.g., Rogers, 1961), the

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beliefs of humanistic therapy fly in the face of the tragic vision. To espouse the view that all the potentialities of human beings are in the service of maintaining and enhancing life falls squarely within the romantic and not the tragic mode. To encourage risk taking without taking cognizance of the potentially dire consequences is to operate within the comic, not tragic, perspective. To posit an inborn "striving toward superiority or perfection" (Adler, 1927) or to emphasize the possibility of "unselfish love" and "unbiased understanding" (Maslow, 1962) is to accentuate the romantic and to downplay the tragic. For both Rogers and Maslow, if the environment provides love, respect, and acceptance, along with satisfaction of basic physiological needs, that is enough for the natural unfolding process of self-actualization to take place (Maddi, I960). Transposing this principle to psychotherapy, the therapist's warmth, genuineness, and unconditional positive regard are considered sufficient for therapy to progress. Psychoanalysis, more than humanistic or behavior therapy, falls within the tragic vision. People are viewed as caught within early fixations, which themselves are subject to repression and thus lie beyond their ken. The fixations result from our sexual and aggressive nature and the conflicts such a nature gives rise to, conflicts from which we never can be entirely free. The psychoanalytic therapist recognizes "that suffering while learning and changing cannot usually be avoided, nor can the analysand realize himself or herself most fully and resume growth in the absence of adversity and deprivation" (Schafer, 1976, p. 42). Even then, the kind of reconciliation that occurs at the end of a psychoanalytic therapy is not unmixed joy and happiness. It is a fuller recognition of what one's struggles are about, the conditions of life one must work within. These conditions "set the limits on what may be aspired to and what may be legitimately aimed at in the quest for security and sanity in the world" (White, 1973, p. 9). "Freud's vision resides in his emphasis that humankind cannot achieve fulfillment at a low price" (Strenger, 1989, p. 598). Only through suffering can our consciousness be illuminated (Mujeeb-ur-Rahman, 1990). Behavior therapy has a far less somber outlook than psychoanalysis, and the kind of hope for cure it holds out is greater. Its emphasis on learning through modeling and reinforcement, direct and vicarious, allows for greater optimism regarding people's ability to change. For example, in a study assessing therapists' beliefs about practice, behavioral therapists were much less likely to view psychological change as difficult than psychoanalytic therapists (Mahoney & Craine, 1991). In research comparing the process of psychotherapy as it was conducted by therapists of different theoretical orientations, Goldfried (1991) found that cognitive-behavioral therapists conveyed the message that things were not as bad as they appeared, whereas psychodynamic therapists communicated that things were not as good as clients thought.

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Similarly, cognitive therapists, in focusing on the correction of irrational cognitive constructions and attributions, imply a malleable and improvable subject. In Ellis's rational-emotive therapy, however, there is a recognition of people's necessity to accept imperfections and limitations, which is compatible with the tragic vision. That it differs from the full tragic vision is apparent from Hyman's (1957) comment on the tragic hero's situation: A person is locked in struggle with "inner forces of evil and must win through to some private redemption and true-seeing by means of his own suffering" (p. 169). In behavior or cognitive therapy, by contrast, clients are helped to feel better or to change their behavior or thoughts rather than to reach an inner reconciliation based on self-knowledge. THE COMIC VISION

Whereas in tragedy things go from bad to worse, in comedy the direction of events is from bad to better, or even best. True, there are obstacles and struggles in a comedy, but these are ultimately overcome and there is a reconciliation between hero and antagonist, between the person and his or her social world. Harmony and unity, progress and happiness prevail. For this reason, dramatic comedies often end with festive celebrations. Note that the conflicts portrayed in a comedy are ones between people and the unfortunate situation in which they find themselves, and not the kind of inner struggles or implacable oppositions encountered in dramatic tragedy. In behavior therapy, too, conflict is often ascribed to external situations or forces that can be mastered through application of behavioral principles. Behavior therapists are not as interested as psychoanalysts in their clients' internal struggles but more in the direct alleviation of suffering and a rapidly achieved positive outcome. A phobia of crossing bridges, or a complaint of lack of assertiveness, is approached head-on with a spirit of optimism and laboratory-tested techniques from the behaviorist's repertoire. By contrast, struggles over separation issues symbolically expressed in difficulty crossing a bridge, or over fear of aggressive impulses in the unassertive client, are explored by the psychoanalyst not only with the goal of their remediation (psychoanalysis does have some comic thrust), but with the view that increased consciousness of one's condition is itself worthwhile. Humanistic therapies do not strive for happy endings in quite the way behavior therapies do, nor are they as basically contemplative about inevitable warring and discordant factions of the mind as is psychoanalysis. But they do emphasize the substantial possibilities for gratifying impulses that Kris (1937/1952) has described as an essential aspect of the comic view. For them, a freer, more joyful, laughter-filled existence is attainable. Our

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fondest hopes and daydreams can be achieved. The true self one comes to know in a humanistic therapy is not one fraught with struggle, nor is it one seeking reduction of tension, but rather it is an authentic self, free of conditions of worth, in touch with its natural, organismic valuing, and satisfied with life's enormous possibilities for self-enhancement. Insofar as the humanistic therapist's job is to penetrate the false self, and reveal the good, innocent, unfallen, romantic beneath, it partakes of the comic vision. ECLECTICISM AND THE VISIONS OF REALITY

Certain changes that have occurred in each of the three psychotherapeutic modes have brought about a certain degree of therapeutic eclecticism. Such modifications, however, involve alterations in the therapies' visions of reality. For example, in a sphere of psychoanalytic therapy known as "short-term," "brief," or "time-limited," a focus is established at the outset and goals are set, thus delimiting the purview of the therapy (see Rasmussen & Messer, 1986; Winokur, Messer, & Schacht, 1981). In so doing, the romantic vision—with its emphasis on a time-unbounded journey into the unknown—is curtailed in favor of a pragmatic, problemsolving attitude (psychoanalytic style), more comic in outlook than romantic. Within both the theory and practice of behavior therapy, a major change has been the development of cognitive approaches with an emphasis on concepts such as expectancies, plans, schemas, and scripts (Mahoney & Freeman, 1985; Persons, 1989). This has led to a relatively greater interest in cognitive conflict that lies within the tragic mode. Humanisticexperiential therapy, on the other hand, continues to view people in process-oriented terms such as exchanging, emerging, unfolding, flowing, and experiencing (Greenberg & Safran, 1987; Levant & Shlien, 1984; Rice & Greenberg, 1992). There is an even greater emphasis in humanistic theory now than in the past on human beings' actively seeking stimulation and novelty, and on their vast resources for self-understanding and growth (Raskin, 1985). In this way, it persists in upholding the romantic vision. TRADE-OFFS IN THE SERVICE OF ECLECTICISM

Variants of psychoanalysis, such as ego psychology, neo-Freudianism, and brief psychodynamic therapy, bring psychoanalytic therapy closer in its outlook and practice to behavior therapy, whereas self-psychology brings it closer to humanistic therapy. All thereby become more integrative. Whether or not this is viewed as desirable depends on the relative value one places on the particular blend of the four visions. In emphasizing sociocultural influences (as does neo-Freudianism) and the power of the ego

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(as does ego psychology) versus the immutable drives, and the curative power of the client-therapist relationship (as does self-psychology) versus self-knowledge through interpretation, the full force of the tragic viewpoint is muted (Fox, 1984; Waldron, 1983). In recommending action along with psychic exploration (e.g., Wachtel & McKinney, 1992), the ironic vision is tempered by closing off avenues to further and deeper meaning and intention. And in setting goals and a focus in advance (as in brief dynamic psychotherapy), the romantic vision is curtailed. In short, there is no free lunch, which anyone with a tragic view of life would be quick to discern. Behavior therapy has become more comprehensive or integrative by bringing cognitive, affective, and even unconscious factors into its purview. By so doing, it reduces its appeal of clearly measurable goals and specifiable environmental triggers. The attractiveness of eliminating problems like phobias, compulsions, or headaches in a rather straightforward way is traded-off for a more complicated and subjective view of client problems. It should be noted, however, that not all behaviorists or behavior therapists agree that such an integrative shift is necessarily for the better (e.g., Ledwidge, 1978; Skinner, 1987; Wolpe, 1976). In viewing the three modes of therapy together, it would seem that both behavior therapy and psychoanalytic therapy have become more humanistic in outlook, whereas humanistic therapy has deepened and refined its concepts even while remaining basically romantic in both its theory and therapeutic process. It is probably true to say that humanistic therapy has had more impact on behavior therapy (e.g., Curtiss, 1976), on cognitive therapy (e.g., Safran & Segal, 1990), and on psychoanalytic therapy (e.g., Appelbaum, 1979; Kahn, 1985; Stolorow, 1976) than it has been influenced in any fundamental way by them. It appears that humanistic therapists generally have been willing to forego the potential advantages of an integrative vision. They have not compromised on their strong allegiance to the romantic vision but instead have concentrated on developing even further within it.

The Debate over Evidence In most of the chapters of this volume, there is a strong value placed on empirical research in determining what shall be included in an integrated or eclectic therapy. The alternative in the minds of several authors seems to be reliance on unsupported speculation and conjecture. This empiricalexperimental method of truth seeking, which psychologists have adopted from the natural sciences, relies heavily on observation, laboratory studies, elementism, and objectivism (Kimble, 1984; Krasner & Houts, 1984). It

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stems from the philosophy of scientific modernism, which includes the belief that nature has an existence independent of the observer and is accessible to the operations of the human mind (Schrodinger, 1967). Findings are typically context-free and presumably lead to universal, nomothetic laws. For some time, however, there has been a call for methodological pluralism in psychology (Messer, 1985; Polkinghorne, 1984). Cook (1985), for example, recommends a "postpositivist critical multiplism," in which agreement from independent epistemological perspectives is our best grounding for approximating truth (cited in Howard, 1991). Similarly, Bevan (1991) warns us to be wary of rule-bound methodology. "Use any method with a full understanding of what it does for you but also what constraints it may place on you. ... Be mindful of the potential value of methodological pluralism" (p. 479). And Woolfolk, Sass, and Messer (1988) have stated, regarding the different sources of knowledge: Most contemporary psychology researchers write as if they believe themselves to be accumulating neutral, objective facts in a value free, transhistorical, epistemological arena. From a hermeneutic perspective, such an approach ignores the extent to which such facts are inextricably interwoven with theory, with the researchers' biases, with the choice of language used to describe the terms employed, and with sociocultural and historical influences—all of which preclude the notion of facts existing apart from the interpretative process. This is not to say that traditional psychological data-gathering approaches are without value in the study of personality, psychopathology, and psychotherapy. It does say, however, that such methods have no epistemic pedigree that renders them superior to other methods, including clinical case analysis, phenomenological description, anthropological field studies, metaphorical comparisons, narrative forms, and literary studies, (pp. 24-25)

Whereas the experimental approach is referred to as paradigmatic and logicoscientific (Bruner, 1984), and as leading to historical truth or empirical truth, the alternative typically leads to what is variously called narrative truth (Bruner, 1984, 1986; Spence, 1982; Howard, 1991), hermeneuticdialectical truth (Barratt, 1976, 1984; Chessick, 1990; Gadamer, 1975), or, in Bruner's (1984) words, "truth-likeness" or "verisimilitude." It comes in the form of good stories (Sarbin, 1986; Vitz, 1990), believable historical accounts, and a good narrative fit. It stresses meaning of experiences and their interpretation. Rather than seeking generality, it opts for an account of uniqueness, of "personal events in their full comprehensible richness" (Bruner, 1984, p. 8). How are we to judge the adequacy of a narrative? Sherwood (1969) offers three criteria. To satisfy the first, self-consistency, the general

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statements made must be logically consistent with each other. The second, coherence, requires a fit between parts of the narrative and the whole, in which the narrative hangs together by virtue of its resolving the apparent incongruities in the material to be understood. The third, comprehensiveness, is the extent to which the narrative account covers the ground; for example, the various portions of a case history are all included (see also Ricoeur, 1981). As should be apparent, this method is akin to textual interpretation employed in history, literature, and biblical exegesis. It is hermeneutic in that it involves meaning, interpretation, and disciplined subjectivity more so than fact, causal explanation, and strict objectivity. While the above account of the distinction between these two ways of knowing is necessarily brief, it is sufficient to make the following point: Insofar as eclectic or integrative therapy systems place sole value on behavioral science criteria for truth, it will be very difficult for them to incorporate psychoanalytic and phenomenological-existential approaches. As Franks (1984) has stated in regard to behavior therapy, "For data to be acceptable, they must conform to the hypothetico-deductive or some related methodology of the behavioral scientist. ... it is conformity to a generally accepted set of rules that constitutes one essential unity of contemporary behavior therapy" (pp. 233-234). Is it possible to accept both modes of knowing and, therefore, to include both sets of criteria? Franks's response is a categorical "no": It needs to be reaffirmed, that the fact that such alternative intellectual styles cannot be ruled out is no reason for behavior therapists to abandon their conviction that, for behavior therapy to progress, it is an objectivist methodology that is more likely to yield fruitful results rather than an alternative system or some form of integration of the behavioral and psychoanalytic approaches,

(p. 237)

Nevertheless, others do see a complementarity of these two modes of truth-seeking: Psychology needs to incorporate both modes of discourse, and hermeneutics can make a substantive and essential contribution to the understanding of human systems. I can readily accept Apel's (1967) argument that the human sciences should involve an interplay between hermeneutic-dialectical and naturalistic discourse, that is, in another sense between hermeneutics and empirics. These approaches should be complementary. (Barratt, 1976, p. 473)

Similarly, Blight (1981) argues, "We must give up the view that science seeks verified, ultimate explanations while the humanities settle for mere conjecture. On the contrary, all knowledge is conjectural and

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permanently so" (p. 191). The implementation of this complementarity remains to be accomplished, but if and when it is achieved, the prospects for integration, at least among certain therapies, will brighten.

The Epistemological Values of the Therapist The distinction between a hermeneutic and natural science approach to the psychotherapeutic enterprise may also constitute a therapist's epistemological preferences, which in turn have an impact on their attitude toward psychotherapeutic eclecticism. That is, by virtue of their strong allegiance to a particular way of truth-seeking, many therapists will reject eclecticism. For example, Schacht and Black (1985) compared the epistemological commitment of behavioral and psychoanalytic therapists using the PsychoEpistemological Profile developed by Royce and Mos (1980). It yields the relative standing of subjects on the variables Metaphorism, Empiricism, and Rationalism. Metaphorism resembles the hermeneutic approach insofar as it involves testing of one's beliefs in terms of the way in which they fit into meaning structures. It emphasizes analogical reasoning and the construction of meaning rather than observation per se. Eighty-six percent of the psychoanalytic therapists showed a profile with Metaphorism as the highest score, which was significantly higher than the 33 percent attained by the behavior therapists. Behavior therapists had somewhat higher mean Rationalism scores and were much more likely than psychoanalysts to rate Empiricism as their preferred way of knowing (36 percent vs. 6 percent). Similarly, in comparing the values of behavioral scientists with nonbehavioral scientists in psychology, Krasner and Houts (1984) found the former to endorse quantitative, empirical, and objectivist approaches to the study of human behavior, whereas the latter endorsed humanistic and subjectivist approaches. As Norcross (1981) has pointed out, "clinical investigators have repeatedly encountered numerous and predictable differences in both the activities and beliefs of therapists of differing theoretical orientations" (p. 1544; e.g., see McGovern, Newman, & Kopta, 1986; Plutchik, Conte, & Karasu. 1988). These studies cited are meant merely to illustrate that many therapists will likely remain strongly attracted to a specific way of knowing their clients, to specific visions of reality, and to specific values. For them, eclecticism and integration will hold little attraction. Others—perhaps those whose value system, personality structure, or epistemological stance are more fluid—will be more comfortable integrating features of more than one therapy without feeling that they are violating deeply held philosophical outlooks. It is interesting to note that in the study by Schacht and Black (1985), behavior therapists were more evenly distributed among the three

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epistemological styles than the psychoanalytic therapists, suggesting, perhaps, their greater openness to eclecticism in therapy.

Assimilative Integration My own approach to integration can be described along the dimensions discussed above. It encompasses a language based in any one theory versus common or ordinary language; a pluralistic attitude regarding the validity of different systems of psychotherapy; the recognition of a constellation of visions of reality specific to each school; a way of knowing that acknowledges metaphoric, interpretive, and narrative modes of truth-seeking as legitimate, along with traditional empiricism; and, in Pepper's terms, a contextualist world hypothesis. It is pluralistic insofar as it acknowledges the relative adequacy and comprehensiveness of each school of psychotherapy, even in comparison to a full eclecticism (see Messer, 1986a, pp. 380—382, for a discussion of this point). It is contextualist in that it emphasizes, when incorporating elements of other therapies into one's own, that a procedure takes its meaning not only from its point of origin, but even more so from the structure of the therapy into which it is imported. In plain terms, this mode of integration favors a firm grounding in any one system of psychotherapy, but with a willingness to incorporate or assimilate, in a considered fashion, perspectives or practices from other schools. The concept of contextualism requires further elaboration. It is closely wedded to the notion of the hermeneutic circle that speaks to the relationship between the whole and its parts. Consider the meaning of a sentence, for example: The sentence derives its meaning from the individual words it comprises, but our interpretation of word meanings within a sentence is also governed by their relations within the sentence and the meaning of a sentence as a whole. Thus, interpretation occurs within a circle in which parts are always interpreted within some understanding of the whole, which in turn is understood by coming to understand constituent parts. The hermeneutic circle describes the contextual nature of knowledge. A "fact" does not stand on its own independent from its context or its interpreter, but rather is partially constituted by them. A fact can be evaluated only in relation to the larger structure of theory or argument of which it is a part. At the same time, this larger structure is dependent on its individual parts, as well as on other related information. In explicating the circle of understanding, we move back and forth between the part and whole. (Woolfolk, Sass, & Messer, 1988, p. 7)

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To understand people or events, from the contextualist's standpoint, we must take account of the network or context in which they are embedded (Gergen, 1982). As applied to the clinical situation, it follows that one cannot import a technique from one therapy to another without recognizing that it has become something else within its new setting or context. The technique gets "recontextualized" and thereby its meaning gets revised (Schafer, 1980).

ADAPTING A GESTALT TECHNIQUE TO A BEHAVIORAL THERAPY

A good example of how the meaning of a therapeutic practice changes in a different setting is the use of the empty- or two-chair technique. Within experiential-Gestalt therapy, the therapist encourages the client to experience two parts of a conflict in two different chairs and then helps to create contact between the sides (Greenberg, 1979). The process of conflict resolution involves expressing a felt desire from one side of the conflict in the first chair, and criticizing the self from the opposite side of the conflict in the second chair, which lead, according to research studies (Greenberg, 1984), to a softening attitude of the internal "critic." When Lazarus adopted the technique in the spirit of technical eclecticism, however, he used it, at least in this particular instance, to help a client develop a more assertive position with her employer by having her engage in behavioral rehearsal—role-playing her boss in one chair and herself in the other (Lazarus & Messer, 1991). In this way, it fit within the social learning stance that he adopts as a theoretical underpinning for multimodal therapy. But note that the technique takes on a very different coloring in the two therapies. Whereas Greenberg, as a Gestalt therapist, was most concerned with the client's felt experience, Lazarus, in the behavioral tradition, focused on the client's external behavior. Clearly, the technique was used differently by the two therapists and, undoubtedly, was experienced differently by the clients according to the context in which it was employed—a context that included the theoretical outlook of the therapist. In assimilative integration, one makes the borrowed technique one's own by fitting it into a preferred theoretical approach. Assimilative integration avoids dogmatism by recognizing the value of the practices of others while permitting relative consistency in one's own theory and practice.

ASSIMILATING COGNITIVE OR BEHAVIORAL PRACTICES INTO PSYCHOANALYTIC THERAPY

In the foregoing example, a Gestalt technique was adopted within a broad, multimodal therapy. Following is an example of incorporating a

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cognitive approach within the framework of psychoanalytic therapy. I am treating a young, professional man who experiences severe anxiety bordering on panic in his new work setting, the first since his recent graduation from professional school. He feels that he will not succeed at his work, thinks of himself as less able and less prepared than his colleagues, and worries that he will be fired. We had been exploring the roots of the problem both in his relationship to a demanding and critical father, who had very high expectations of him, and in a life-threatening illness contracted when he was 11 years old, leaving him with the feeling that doom and catastrophe always lay around the corner. The illness also markedly increased his dependency on his parents. In line with the goals of psychoanalytic therapy, my work was aimed at freeing him from the no-longer present dangers to which he was psychically held hostage, and that he generalized to the work situation. Nevertheless, he was having trouble getting through the day at work without becoming overtly anxious and inhibited in pursuing his work. Therefore, I decided to adopt some procedures from cognitive therapy. We discussed his "selective negative focus" on the worst aspects of the work setting, his "magnification" of them, and "catastrophizing" about them (Beck, Emery, & Greenberg, 1985; Persons, 1989). I asked what he could say to himself at such times to counter his dysfunctional thinking, and together we came up with strategies that turned out to be helpful to him. These included reminding himself that he had succeeded in similar situations in the past; that he was only a beginning professional and need not expect so much of himself; and that he could focus on just getting started on the task without "predicting the future" (Persons, 1989), namely, a failed conclusion. Within a psychodynamically oriented therapy, my effort was to be helpful to him without becoming overly directive and thereby setting myself up as an authority like his father (Berman, 1985). While a nondirective, neutral stance is generally considered important in psychoanalytic therapy, it was of specific relevance in the case of this client who, in work situations, became overly dependent on the guidance and advice of older men. The danger was that he would enact the role of the helpless child, and I, the powerful, rescuing parent. The way in which I finessed this problem was to try to have him come up with the solutions as much as possible, and to follow up on the psychological meaning of my more active, less neutral, exploratory stance. Following the session with the cognitive interventions, he acknowledged his wish for more of this kind of direct guidance, a wish that I proceeded to explore in terms of his felt dependency and inadequacy. This raises a second important principle of assimilative integration, namely, the subsequent processing of the imported procedure. Insofar as the integrative effort changes the nature of the relationship of client to therapist,

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or is jarring in some other respect, it is necessary to discern its meaning to the client in its new context. In a clarifying example of assimilative integration, Frank (1990) introduced a relaxation technique in the context of psychoanalytic therapy, to which the client responded angrily, saying that it felt like submitting or losing herself. Further exploration revealed that her mother had encouraged the client's dependence, only to let her down by not protecting her from her assaultive father. For her, then, the relaxation technique posed specific dangers, leading the therapist to explain that, in taking a more directive role, he seemed to have threatened her feelings of autonomy. Frank pointed out how her "reactions of anxiety, anger, hopelessness, and pulling back, might all have been dictated by a view of the potential for hurt, not for gain" (p. 747). Feeling understood and gaining this insight, she was then able to use the relaxation technique to good effect. For other useful examples of seamlessly incorporating behavioral techniques into psychodynamic therapy, see Wachtel (1991). In discussing importations, or "parameters," within psychoanalytic practice, Eissler (1953) offered the following recommendations: (1) a parameter should not be used unless there is a very strong reason for doing so; (2) it should be introduced in a conservative way; (3) it should be allowed to operate only as long as necessary to achieve a particular goal; and (4) it should be introduced only if it can be analyzed later. Although this is a rather restricted view of the uses of integration, its thrust is in accordance with the cautious attitude 1 am proposing regarding a contextually sound integration.

INTEGRATIVE PRACTICE AS EVOLUTIONARY

Assimilative integration also can be viewed as an evolutionary process in which therapy systems incorporate not only specific clinical practices, but also certain perspectives from one another (Messer, 1986b). For example, an emphasis on the importance of external reality has long been a cardinal concept of behavior therapy that is now taken much more seriously by psychoanalytic therapists. In this connection, Langs (1973) has written: We already know that human beings function basically by reacting and adapting to stimuli; only if we correctly ascertain the stimulus can we correctly understand their response on any level. . . . Context defines the problem with which the patient is dealing, the reality event (or internal upheaval) which has prompted the patient's adaptive responses, (p. 31 H Note how the external context is emphasized by Langs. Self-psychologists such as Kohut (1977), and object relations theorists like

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Winnicott (1965), have also emphasized the critical role of environment (vs. primarily drive-related fantasy) in personality development, and have applied this emphasis in advocating that therapists provide an "empathically attuned" or "holding" environment. In a parallel fashion, behavioral and cognitive therapists are now more willing to accept and incorporate the notion of unconscious processing into their purview (Mahoney, 1991; Meichenbaum & Gilmore, 1984). However, it is not quite the concept of a dynamic unconscious that is assimilated, since the latter does not readily fit within the context of a social learning or cognitive therapy. In this way, each school is influenced by developments in the broader field, thus maintaining its status as adequate and comprehensive. TEACHING AND LEARNING ASSIMILATIVE INTEGRATION

In a paper describing the ways in which psychotherapy integration may be learned and fostered, Schacht (1991) observed that the thinking processes of expert (vs. novice) psychotherapists tend to "support disciplined improvisation ('integrative process')." Experts represent their domain on a semantically deeper level than novices and operate according to principles, learned through practice, that may not be readily verbalized. Several therapies are deconstructed within the therapist (Kramer, 1989), who adapts them to the client at hand. Thus, an assimilative integration may take place only partly through the novices' conceptual learning that allows them to represent problems in terms of surface features only. For therapists to integrate on a deeper level, they must first understand and integrate within each individual therapy and, only then, across therapies. This leads to the recommendation that, in training, we "agree to teach multiple techniques and many theories to everyone who studies psychotherapy" (London, 1988, p. 10). This is similar to the recommendation I came to previously regarding language use in psychotherapy integration, namely, multilingualism. In the present case, it refers to the advantages of training students in a plurality of theories and methods that will lead, ultimately, to deep structure integration. This is not to say that teaching psychotherapy integration directly is not useful, but only that we recognize that the most meaningful integration will take some time and probably come about only after some years of experience. (Also see Andrews, Norcross, & Halgin, 1992, for a discussion of training issues).

Concluding Comments None of the analyses of the basic assumptions, beliefs, world hypotheses, or visions of reality of eclecticism presented in this chapter are meant to

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imply that some degree of integration in practice is not desirable. It is. For purposes of validating theories of therapy, however, the intrusion of foreign elements breaks up the structure of corroboration. Kuhn (1977) makes a similar point in distinguishing between the basic scientist and applied scientist, whose "decision to seek a cure ... must be made with little reference to the state of the relevant science" (p. 236). Pepper (1942) contends that in the interest of intellectual clarity we want our theories pure and not eclectic. In matters of practice, however, we want to be able to draw upon any theoretical ideas or techniques that are backed by evidence, are potentially useful, and can be assimilated in a contextually meaningful way. We want to be rational and reasonable, not dogmatic. This is exemplified in the work of various authors in this volume who borrow from a diversity of sources in the service of an efficacious therapy. Nevertheless, we may ask, what should be the proper degree of integration to introduce into practice? For some of the very reasons already set forth, this will remain a subject of debate. Some will see the resulting integrative therapy as more comprehensive and adequate, but others will protest that it is no more so than a present, existing therapy. Where some will see virtue in the expansion of the visions of reality in an integrative therapy, others will see an abrogration of the purer vision of its progenitors. There are those who will find intellectual satisfaction in the steps taken toward a unified theory of therapy, and others who will protest that such a view is neither possible nor desirable. Whereas some will embrace a diversity of social science methods to obtain corroborating evidence, others will remain wedded to a particular philosophy of science. And, finally, whereas some therapists by virtue of their personal dispositions, beliefs, ways of knowing, and visions of reality will embrace full integration or eclecticism, others will stick closer to a favored outlook even while slowly assimilating some diverse elements from the panoply of existing therapeutic approaches.

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429. PROCHASKA, J. O., & DICLEMENTE, C. C. (1992). The transtheoretical approach. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. RASKIN, N. J. (1985). Client-centered therapy. In S. J. Lynn & J. P. Garske (Eds.), Contemporary psychotherapies: Models and methods (pp. 155—190). Columbus, OH: Charles E. Merrill. RASMUSSEN, A., & MESSER, S. B. (1986). A comparison and critique of Mann's time-limited psychotherapy and Davanloo's short-term dynamic psychotherapy. Bulletin of the Menninger Clinic, 50, 163—184. RICE, L. N., & GREENBERG, L. S. (1992). Humanistic theories. In D. Freedheim, H. J. Freudenberg, J. W. Kessler, S. B. Messer, D. R. Peterson, H. H. Strupp, and P. L. Wachtel (Eds.), History of psychotherapy: A century of change. Washington, DC: American Psychological Association Press. RICOEUR, P. (1981). Hermeneutics and the human sciences (J. B. Thompson, Trans.). New York: Cambridge University Press. ROGERS, C. (1961). On becoming a person. Boston: Houghton Mifflin. RORTY, R. (1979). Philosophy and the mirror of nature. Princeton, NJ: Princeton University Press. ROUSSEAU, J. J. (1970). The social contract. London: Penguin. (Original work published 1762)

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ROYCE, ]. R. (1982). Philosophy issues, Division 24, and the future. American Psychologist, 37, 258-266. ROYCE, J. R., 4 Mos, L. P. (1980). Manual: Psycho-Epistemological Profile. University of Alberta, Edmonton, Center for Advanced Study in Theoretical Psychology. RYCHLAK, J. F. (1987, August). Unification through understanding and tolerance of opposition. Paper presented at the meeting of the American Psychological Association, New York. RYLE, A. A. (1978). A common language for the psychotherapies? British Journal of Psychiatry, 132, 585-594. RYLE, A. A. (1987). Cognitive psychology as a common language for psychotherapy. Journal of Integratioe and Eclectic Psychotherapy, 6, 168—172. SAFRAN, J. D., & SEGAL, Z. V. (1990). Interpersonal process in cognitive therapy. New York: Basic Books. SARASON, J. G. (1979). Three lacunae of cognitive therapy. Cognitive Therapy and Research, 3, 223—235. SARBIN, T. R. (Ed.). (1986). Narrative psychology: The storied nature of human conduct. New York: Praeger. SCHACHT, T. E. (1984). The varieties of integrative experience. In H. Arkowitz & S. B. Messer (Eds.), Psychoanalytic therapy and behavior therapy: Is integration possible? (pp. 107-131). New York: Plenum. SCHACHT, T. E. (1991). Can psychotherapy education advance psychotherapy integration? Journal of Psychotherapy Integration, 1, 305-319. SCHACHT, T. E., & BLACK, D. A. (1985). Epistemological commitments of behavioral and psychoanalytic therapists. Professional Psychology, 16, 316—323. SCHAFER, R. (1976). A new language for psychoanalysis. New Haven, CT: Yale University Press. SCHAFER, R. (1980). Narrative actions in psychotherapy. Worcester, MA: Clark University Press. SCHRODINGER, E. (1967). Mind and matter. New York: Cambridge University Press. SHERWOOD, M. (1969). The logic of explanation in psychoanalysis. New York: Academic Press. SKINNER, B. F. (1987). Whatever happened to psychology as the science of behavior? American Psychologist, 42, 780-786. SLIFE, B. (1987). The perils of eclecticism as therapeutic orientation. Theoretical and Philosophical Psychology, 7 (2), 94-103. SMITH, D. (1982). Trends in counseling and psychotherapy. American Psychologist, 37, 802-809. SMITH, M. B. (1988). Beyond Aristotle and Galileo: Toward a contextualized psychology of persons. Theoretical and Philosophical Psychology, 8(2), 2-15. SPENCE, D. P. (1982). Narrative truth and historical truth. New York: Norton. STAATS, A. W. (1981). Paradigmatic behaviorism, unified theory, unified the-

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cism, cognitive eclecticism, and "exposure" empiricism. Journal of Behavior Therapy and Experimental Psychiatry, 7, 109—116. WOOLFOLK, R. L, SASS, L. A., fc MESSER, S. B. (1988). An introduction to hermeneutics. In S. B. Messer, R. L. Woolfolk, & L. A. Sass (Eds.), Hermeneutics and psychological theory: Integrative perspectives on personality, psychotherapy, and psychopathology (pp. 2—26). New Brunswick, NJ: Rutgers University Press.

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PART II

INTEGRATIVE AND ECLECTIC PSYCHOTHERAPY MODELS

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CHAPTER 5

Eclectic Psychotherapy: A Common Factors Approach SOL L. GARFIELD

A

NUMBER OF FACTORS have influenced my views of the psychotherapeutic process over the years and have led me to assume an eclectic stance. During the time that I was a graduate student at Northwestern University, 1938-1942, the only truly influential therapeutic orientation, apart from a somewhat directive form of counseling, was that of psychoanalysis. I was introduced to Adlerian, Jungian, and Lewinian theories of personality, but Freud was the significant figure when it came to psychotherapy—a rather awesome and psychiatrically dominated area of clinical practice in the early 1940s. Like most other beginning psychotherapists, probably, I attempted to use psychoanalytic theory and techniques at the outset of my career as a therapist during World War II. However, I was not particularly impressed with the results of my attempts at applying analytic procedures. Another early important influence, and one that has persisted, was my expectation that empirical evidence should be provided in support of a given clinical or therapeutic procedure. Although Freudian theories were interesting and provocative, they were also speculative. They provided a great many interesting hypotheses for both clinical practice and research but little in the way of empirical evidence in support of the theories. This was certainly true as far as the efficacy of psychoanalytically oriented therapy was concerned. Although I did find several published reports by well-known psychoanalysts on failures in psychoanalysis and some critical

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discussions of the need for evaluations of psychotherapy (Obendorf, 1943; Obendorf, Greenacre, & Kubie, 1948), actual research studies were limited. Another important influence was the publication of Counseling and Psychotherapy by Carl Rogers in 1942. I did not get a copy of this work until two or three years later, but it did have an impact. As far as I know, Rogers was the first psychologist to author a text on psychotherapy. Furthermore, his whole approach, criticizing the "expert" role of the psychotherapist, was diametrically opposed to that of the psychoanalysts. Also, Rogers was more likely to refer to research studies and to formulate statements as hypotheses requiring study and verification. For example, in his 1942 book, Rogers made reference to "a research program in which counseling and therapeutic interviews have been phonographically recorded. . . . This procedure holds much promise for the future" (pp. viii—ix). Frederick Allen's Psychotherapy with Children, also published in 1942, was yet another early influence. The active and responsible role of the therapist, with the emphasis on the current behaviors of the child in the therapy situation, made a definite impression on my thinking. Gordon Allport, in quite a different way, also influenced my thinking. Allport was not a psychotherapist or clinician, but an academic psychologist who published one of the first scholarly books on personality (1937). His emphasis on the idiographic view of personality as compared to the nomothetic view made a profound impression. Whether it was related to my own view of the limited value of psychiatric diagnosis (Garfield, 1957, 1983, 1986), I do not know; however, my clinical experience appeared to support the idiographic emphasis and also made me critical of the generalizations applied to patients with specific diagnoses. Although there has been an increased emphasis on psychiatric diagnosis and specific treatments for specific disorders in recent years, I still perceive too much variability among patients to follow the current emphasis uncritically. Without question, my scientific research training has influenced my views of clinical practice throughout my life. I have always wanted to see sound empirical data in support of any clinical procedure, and I have never been able to accept authorities who do not provide such supporting data. As a result, I generally tried to keep an open mind about the process and outcome of psychotherapy and to see what research data were available to support a given view. The lack of such data for psychotherapeutic approaches was somewhat surprising since, in the area of psychological testing, psychologists usually required information on the reliability, standardization, and validity of such instruments. However, it became clear to me that at least a number of dynamically oriented psychologists took the view that psychotherapy was an art and therefore could not be subject to empirical research—a view that is still held by some (Lehrer, 1981). Consequently, the fact that even in the 1940s there were a number

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of different theoretical orientations and approaches to psychotherapy suggested that there were different and opposing explanations concerning what were the therapeutic variables in psychotherapy. There were also some publications that suggested the possibility of some common factors operating in the various approaches to psychotherapy. Rosenzweig (1936) had actually discussed the possibility of a few common factors in psychotherapy. Levine (1948) also discussed a number of so-called supportive therapeutic techniques that to me appeared as potential variables common to most of the different forms of psychotherapy. Finally, an important supporting influence on my thinking was the study conducted by my long-time friend, Ralph Heine (1953). Heine studied the evaluations provided by patients treated by three different groups of therapists: client-centered, psychoanalytic, and Adlerian. These patients tended to account for comparable changes in very similar ways and led Heine to conclude that a common factor (or factors) was operating in the different forms of therapy investigated. The net impact of these influences, as well as my own clinical experience in an army hospital, a V.A. hospital, two V.A. outpatient clinics, several university clinics, and a medical school, led me to reach certain conclusions. One was that it was not wise to adhere rigidly to one psychotherapeutic system. The second was to consider seriously the possibility that there were common factors operative in most forms of psychotherapy that actually might be among the most important variables in psychotherapy. And third, that the research available for evaluating psychotherapy was too limited for drawing any really solid conclusions. Only research in the future would allow us to be more definitive in our appraisals of what was of consequence in psychotherapy. These thus constituted the bases for my views of the psychotherapeutic process and led me early to an eclectic orientation. My first published reference to possible common factors, however, did not appear until 1957, when I devoted 10 pages to this topic in my first book, Introductory Clinical Psychology. My earlier views of potential common factors among the different forms of psychotherapy were reinforced over time by the accumulating body of research data resulting from comparative studies of psychotherapy (Bergin, 1971; Bergin & Lambert, 1978; Luborsky, Singer, & Luborsky, 1975; Smith, Glass, & Miller, 1980). The fact that such studies for the most part did not show marked differences in outcome between such supposedly different schools of psychotherapy as psychoanalytically oriented therapy and behavior therapy (Sloane, Staples, Criston, Yorkston, & Whipple, 1975) provided some empirical support for my views and strengthened my conviction that it was not wise to adhere strictly to one therapeutic approach. Consequently, I chose an eclectic approach as my means of going

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beyond adherence to one theoretical system. This allowed me the freedom to use techniques and procedures from practically any orientation and to use them as I saw fit in the individual case. Although this type of approach allows the therapist the greatest flexibility and range of procedures, there are fewer specific guidelines to follow as compared with adherence to some of the well-known schools of psychotherapy. Also, since an eclectic approach can be used with a variety of patients, there is not the specificity to be found in a manual for a specific disorder. Before proceeding to a discussion of some of the emphases in my eclectic approach, I want to make a brief reference to a study of a sample of clinical psychologists who had identified themselves previously as eclectics (Garfield & Kurtz, 1977). In this study, 154 therapists completed and returned the study questionnaires. Apart from a considerable variability among the sample in the various theoretical orientations they usually combined in their clinical work, one theme appeared to be most prominent. These eclectic clinicians tended to emphasize that they used the theory or methods they thought were best for the individual client. In essence, procedures were selected for a given patient in terms of that client's problems, instead of trying to make the client adhere to a particular form of therapy. An eclectic therapy thus allows the therapist potentially to use a wide range of therapeutic techniques, a view similar to my own in most respects. Thus there is a large degree of freedom in an eclectic approach. One does not have to adhere to one theoretical orientation or keep from using procedures that are inconsistent or frowned upon from that particular orientation. This approach is clearly opposite to the emphasis on using psychotherapy manuals to train psychotherapists to adhere strictly to a specific form of therapy in order to ensure the integrity of the type of psychotherapy being evaluated. In the past, psychotherapies were simply named or labeled without specifying what was involved in the therapy and without any monitoring of the therapy being conducted. The new emphasis, therefore, is an attempt to operationalize the forms of psychotherapy being studied and appraised. To the extent that this practice will tend to particularize the forms of therapy being investigated, it would appear to be going in a direction opposite to both the spread of eclecticism and the more recent move toward integration in psychotherapy (Garfield, 1982; Goldfried, 1980, 1982; Marmor & Woods, 1980; Norcross, 1986). It will be interesting to see what develops in the future in terms of these different emphases. SOME GUIDING PRINCIPLES

As mentioned earlier, one of my guiding principles is that most of the accepted and apparently successful forms of psychotherapy rely on com-

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mon therapeutic factors for much of the positive outcomes attained. Each of the psychotherapies may have some individual components that have been emphasized by them and that are of some potential utility. However, these unique aspects have been overemphasized at the expense of the potentially important common factors. It is understandable that therapists who have been trained in a given form of therapy and have been identified with it are reluctant to acknowledge the importance of common factors— factors they essentially share with other forms of psychotherapy. Because the different forms of psychotherapy are derived from different theoretical orientations and use different terms and concepts, the various forms of psychotherapy appear more different than may actually be the case. Consequently, some common variables or processes are viewed as different even when they are essentially similar. Even potentially more significant is the fact that some basic and important processes are overlooked because they are not stressed in the formal descriptions of the individual forms of therapy. Investigators tend to investigate the processes and procedures hypothesized to be of significance in the particular orientations. Others tend to be disregarded, or are considered to be "nonspecific" and of lesser importance. In most of the presentations on psychotherapy, the emphasis also has tended to be on particular forms of psychotherapy. These have been descriptions of a specific form of psychotherapy such as psychoanalysis or client-centered therapy, or they have been catalogues of a number of different approaches to psychotherapy (Binder, Binder, & Rimland, 1976; Corey, 1991; Corsini & Wedding, 1989; Morse & Watson, 1977. Although each of the therapies may be characterized as having some unique features that distinguish them from the others, for the most part they are viewed as alternative approaches to psychotherapy. One is expected to select that form of therapy that appears best or most appealing to the individual, and that one form of therapy is supposed to be adequate to handle all or most types of psychological disorders. The possibility of common factors among the psychotherapies, or the possibility of combining aspects of several of the therapies generally has received little emphasis until fairly recent times (see Goldfried & Newman, 1992). However, if one shifts one's focus from the differences among the psychotherapies to possible commonalities among them, some intriguing possibilities become apparent. Certainly, without trying too hard, one can note at least some superficial commonalities. Practically all forms of psychotherapy consist of at least one therapist and one patient who meet together for a stipulated amount of time for one or more scheduled therapy sessions. Furthermore, most use an interview type of format in which talk or verbal interchange takes place. The therapist generally is a socially designated and sanctioned healer with all the powers, status, and privileges

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accorded to such individuals. The patient, on the other hand, is a person with some psychological discomfort or affliction, generally anxiety, depression, or both, who is seeking to be helped and relieved of discomfort by the therapist. In addition to the above, there are some other potentially common aspects of many therapies that can be suggested. Patients seek out therapy because of feelings of demoralization and the hope of being helped (Frank, 1971, 1973, 1979). In meeting with a therapist, they will also have an opportunity to talk about their problems, hopes, and fears, regardless of the therapist's theoretical orientation. Most therapists will have some ideas or formulations about how to conduct therapy. Although these may differ, they will tend to provide the therapist with a way of proceeding and generally give the patient the feeling that the therapist knows what he or she is doing. This may heighten the patient's confidence and acceptance of the therapy and the therapist. The therapist also can be expected to say something about the patient's disturbance and the treatment to be received. The explanations offered, even though they may differ from one orientation to another, may be comforting to the patient. In essence, such communication indicates the therapist's knowledge and skill as well as a familiarity with the patient's problems, all of which may have a positive influence on the patient. More will be said about other possible common factors in psychotherapy in subsequent sections.

Patient Assessment Compared to many psychotherapists, I probably devote relatively little emphasis to patient assessment in any formal sense. I am opposed to routine diagnostic testing and assessment except for research purposes. A number of factors have contributed to my views in this area and I will mention them briefly. Early in my career, patient assessment meant an intensive battery of psychological tests that required at least two visits by the patient. After the testing was completed, several weeks were required for the scoring, interpretation, and write-up of the results. This generally was followed by a staff conference. This whole process usually took a month and, in my view, mainly delayed the beginning of therapy. Whether the emphasis was on psychiatric diagnosis or on intrapsychic dynamics, I saw the assessment process as primarily a ritual that delayed therapy, increased the costs of professional services, and generally contributed little to the efficacy or efficiency of treatment. The preceding critical statements are based in great part on empirical research in the areas of psychological assessment (Garfield, 1957, 1974,

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1983), and psychotherapy (Garfield, 1978, 1986). The reliability of clinical diagnosis in the past left much to be desired, and the validity of psychological tests for both clinical diagnosis and psychodynamic predictions was distinctly unimpressive. Furthermore, prediction of therapeutic outcome on the basis of pretherapy appraisals is disappointingly low. I should make clear that the above statements refer to the routine assessment of every patient, not to the intensive assessment required for very difficult diagnostic cases where such problems as possible brain pathology or incipient psychotic disorders need to be clarified. In most instances, the initial interview generally suffices as both the assessment interview and the first therapeutic interview. Instead of postponing treatment, this procedure allows therapy to begin immediately. Actually, assessment and treatment are intertwined and continue throughout therapy. In the first interview, however, there are a number of areas that need to be assessed and discussed. These include such items as the patient's reasons for seeking help now, the patient's personal and social problems, the duration of the difficulties, previous therapy, and the patient's expectations about psychotherapy. The extent to which each of these areas are pursued and clarified will depend on the particular patient. I, personally, do not attempt to make a formal psychiatric diagnosis, since this is not critical in my judgment; however, it is generally required where third-party payments are involved. Of greater concern are variables that are potentially related more closely to psychotherapy process and outcome. One aspect concerns the estimate of positive outcome—in other words, is psychotherapy a viable therapy for the patient and can I be of help. It is not easy to be precise in amplifying the preceding paragraph, particularly the prediction of positive outcome. In fact, if approximately two-thirds of the patients improve by means of psychotherapy, then our predictive measures would have to do considerably better if the base rates are to be exceeded. One, therefore, may state his or her opinions or beliefs but should not be too strongly attached to them. In many respects, my views are probably not very different from most that have appeared in the research literature. I prefer patients who have "reasonably" clear problems, are not psychotically impaired, exhibit some degree of anxiety or depression, appear to want to work on their problems, and show no serious occupational or social disorganization. Such individuals are usually referred to in psychotherapeutic lore as "good patients." I also pay close attention to how the patient interacts with me in the initial session, as characteristic patterns of behavior typically play an important role in the therapeutic process. I recognize that predictions of outcome based on evaluations at intake or the first therapy interview may not add much to the base rates, but the therapist must strive to make as good an appraisal as possible. At the same time, I also

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recognize that psychotherapy is not a panacea for extremely severe psychological disorders. During the first interview, I also attempt to clarify the person's expectations about therapy, including such matters as what may take place, the possible length of therapy, the problem or problems considered most important, and the probabilities for, and extent of, positive change. I allow the person to ask any questions he or she may have, and 1 may indicate that we can take stock of how therapy is progressing after a few sessions. There does seem to be some empirical research on both behavioral and psychodynamic psychotherapy that indicates that, beginning with the third interview, signs of progress are positively correlated with some criteria of outcome (Bandura, Jeffrey, & Wright, 1974; Mathews, Johnston, Shaw, & Gelder, 1974; O'Malley, Suh, & Strupp, 1983; Sachs, 1983). Consequently, one can reappraise some of the issues that were not particularly clear at the initial session. It is also possible that at a later session the patient may present what seems to be the "real" problem, the one that appears to be the cause of the person's current discomfort. Some individuals need to have more than one session before they feel free to trust the therapist with their innermost problems. I do not have any set scheme for prioritizing treatment goals. In general, it is my view that we attempt to deal with the problems that the patient presents to us, not some goals set by the therapist. If, in terms of the general criteria mentioned earlier, it appears that the patient's difficulties can be ameliorated by means of psychotherapy, I would be guided by the patient's ranking of the problems and by which one might be handled most quickly. Where the patient mentions several problems, making some tangible progress quickly on one problem may have an overall positive effect. It demonstrates that change is possible, it increases hope and possibly self-efficacy, and may also increase the patient's active cooperation in working on other problems.

Applicability and Structure As far as I can tell, an eclectic approach of this type can be used in most typical clinical settings, particularly outpatient settings. I have only used it for individual and couples therapy, but I see no reason why it couldn't be adapted for work with families. Obviously, in the latter instance the family would be the unit to consider, and particular attention would have to be paid to the family system and its interactions. However, I have not worked much with families and thus my statements should be viewed as speculative. The therapy is essentially brief and sometimes time-limited. As indi-

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cated earlier, I believe the client should be given some reasonably clear idea of how long therapy will last. After all, the client's time and money are considerations here as well as the client's desire for improvement as quickly as possible. Most of my cases have taken between 15 and 20 sessions, and I usually indicate this amount of time in the first session. In a few cases, sometimes determined by the reality needs of the patient (e.g., having to make a decision quickly, moving away, not sure about therapy), 1 have set or agreed to a specific time limit. I tend to see my therapy clients on a once-per-week basis for the usual 50-minute period. However, when it appears warranted, or as the termination of therapy approaches, I usually modify this to once every two weeks. This change in the arrangement hopefully signifies to the client that progress is being made, there is less need for dependence on the therapist, and the end of therapy is close at hand. I view this as a desirable practice for most forms of psychotherapy, since it prepares the client for the termination of therapy and makes this process a gradual and natural one. It also tends to reduce the more-or-less abrupt ending of therapy. In most instances I do not see patients on a more frequent basis than once a week, for several reasons. I believe that increasing the frequency of therapy increases the dependency of the client on the therapist and thus is undesirable. I also feel that spaced learning is more effective than massed learning. Related to this is my clinical belief or bias that significant change in the client occurs or is achieved in the client's actual social environment and not in the consulting room. To the extent also that "time heals all wounds," it seems best to space appointments in a moderate or reasonable fashion. A final reason for my own preference in this instance is the matter of the cost of therapy to the client. Meeting with a client two or three times a week leads to a greatly increased cost for therapy, since usually there does not appear to be a corresponding decrease in the length of therapy.

Interventions and Relationships It is difficult to specify precisely the amount of structure I provide in the therapy sessions; it depends on the particular patient and the specific circumstances. Even though this sounds too general and evasive, I must admit, there is no consistent plan that I follow strictly. The first session is probably the most highly structured, in that there are several specific topics or areas that I try to cover. At the beginning I ask patients to tell me about the problem or problems that have been troubling them and that have led them to seek therapy. I then proceed to discuss some of the other topics mentioned earlier in the section on patient assessment. From that point on, the type and extent of therapeutic inter-

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vention is determined by the presenting problem, the individual patient, and not infrequently, by the amount of time available for therapeutic work. However, after the initial interview, which is structured to a great extent by the therapist, clients are given considerable opportunity to discuss their problems and to express or ventilate feelings. For the most part, I allow them to determine the content of the sessions in these interviews. There are several considerations that 1 view as important during these early sessions. First, I do not want to indicate or reinforce a passive role for the client, so I try to create the expectancy that the client will be participating actively in the therapy. Second, I believe that empathic listening on the part of the therapist helps to convey the therapist's sincere interest in the client and a genuine desire to help. This, in turn, is of some importance in facilitating a positive relationship in therapy and in motivating the client to collaborate in the therapeutic enterprise. Third, at least some patients need to develop trust in the therapist before they really reveal the problem that is most disturbing to them. The pattern of therapy described here thus may facilitate this process and allow a greater potentiality for positive change. In addition to the considerations already mentioned, there are at least two features or processes that may occur when the client is encouraged to discuss personal problems or feelings in a favorable therapeutic climate. One is the opportunity for emotional release or catharsis. This may take place with only a small percentage of clients, but when it does, it is a most impressive phenomenon. I have hypothesized that this may occur and be most therapeutic for individuals experiencing acute guilt. Another process that may occur as the client discusses difficulties is that of desensitization. The client has the opportunity to discuss problems at some length and as a result, they may not appear to be as troublesome as the client originally viewed them. Consequently, the emphasis in the early sessions is on encouraging the patient to discuss personal problems and to express feelings openly in therapy. New material and concerns may be brought up in these sessions, which may influence the plan and direction of therapy. Although therapists should have a flexible stance, it is best if they have some general plan in mind as a guide for intervention. As new material and observations are secured, plans can be modified. It is also conceivable, and even possible, that some patients will not make use of the opportunity to express themselves and to explore possible difficulties. In such instances, the therapist has to try to overcome this problem and to engage the patient in therapy if at all possible. The kind of patient behavior referred to above has been called "resistance" by psychodynamic therapists. Regardless of what it is called, it may have different causes and be a hindrance to progress in therapy. I do not

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believe there is any simple solution to the problem. The therapist can offer explanations to the patients and encourage them to try to express their thoughts and feelings. However, I do not attempt to "wait out" the patient's lack of participation or resistance, which some therapists may do. Such a procedure tends to drag out therapy, increasing its length and cost, but not necessarily its efficacy. Psychotherapy does require the cooperation of the client. Although it is possible to force-feed individuals and to administer medical injections against a person's will, the situation in psychotherapy is quite different. Consequently, the patient's attitudes and behaviors during the early sessions are important indicators of later progress in therapy and of developing problems. If the patient appears unresponsive, this should be discussed without undue delay. Such talks may also reveal more clearly the patient's expectations about therapy, feelings toward the therapist, and early dissatisfactions with therapy. Hopefully, these matters can be resolved by such open discussion, and therapy should resume on a more positive basis. On the other hand, if this is not possible, perhaps a mutual decision to terminate therapy at this point can be reached with the understanding that therapy can be reinstituted when the patient feels inclined to do so. My own bias is to try to handle such matters early in therapy, at least by the fifth interview or so, in order that long impasses do not develop and the patient does not drop out of therapy. Thus far, our discussion has focused on the early sessions. Although the emphasis has been on the patient discussing problems and expressing thoughts and feelings—with the therapist as an empathic listener—other therapist behaviors can begin to be brought into play as deemed appropriate for the given case. The therapist may ask the client for clarification of certain points, may ask direct questions, may offer suggestions, and may assign specific tasks to be performed by the client in the interval between therapy sessions. Unfortunately, I cannot spell out concretely and in specific detail the precise and orderly behaviors the therapist will use for each specific kind of patient. My approach to therapy is simply not that refined or methodical. I have no detailed therapy manual that spells out precise procedures for each session. I can only offer some general guidelines that I believe have some utility (Garfield, 1980, 1989). Apart from showing sincere interest in the client and in evaluating the client and his or her problems as adequately as possible, the therapist does not, and should not, respond in exactly the same way to each and every client. Clients vary in a number of ways that may influence the process of therapy and the therapist's behavior. They vary in age, sex, family situation, socioeconomic status, education, motivation, personality, and type of psychopathology. What might be indicated as important or useful for one client may not be of much value for a different client. Thus, the therapist

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usually cannot follow one specific set of procedures for all patients, even if they appear to have similar diagnoses. Rather, the therapist continually has to evaluate and reevaluate the client and the process of therapy, selecting procedures that appear useful, and discarding ones that do not appear to be aiding the progress of therapy. In this process, the therapist should make use of any procedures or techniques that appear applicable to the problem at hand and that have received research support. For example, if a client has a specific phobia as one feature of the reasons for seeking help, exposure or desensitization can be used as one part of the therapeutic plan. If this works out satisfactorily, it will have potentially positive effects not only on the phobic behavior, but also on other aspects of the client's total functioning. First, it demonstrates to the client that positive change is possible, thus increasing the client's hope and confidence in the therapeutic process and in further progress. Second, it tends to increase the client's self-esteem and self-efficacy. As a result of these changes, the client is both better equipped and more highly motivated to work on the other problems that present difficulties. In a similar fashion, other cognitive or behavioral techniques that have been shown on the basis of empirical research to produce positive outcomes can also be employed as deemed appropriate. Attempts to modify distorted cognitions, providing information, practicing social skills, modeling, homework assignments, daily logs, and similar techniques may be of use in individual cases. A primary difference in my use of such techniques and what appears to be their use by more cognitively and behaviorally oriented therapists is the emphasis placed on these procedures and how they are viewed theoretically. In my view, the application of these procedures may produce positive results even though the theoretical explanation advanced by the originators may not explain adequately the actual process of change. For example, Wolpe's (1958) theory of reciprocal inhibition has not been widely accepted by his fellow behaviorists, although they accept generally the finding that systematic desensitization produced positive results. Part of the success of the procedure could be due to the expectancies brought by the patient, the confidence of the therapist, the rationale given to the patient, and the fact that the patient does confront his or her problem to some extent by means of the procedure. I would also tend to see such procedures as one part of the therapeutic process, in which the therapeutic relationship and potential common factors provide the essential frame of reference. As a consequence, I would not emphasize them as much as their originators and would not use them in quite as rigid a manner. For example, in an instance where mild obesity was mentioned as one problem, I had the client keep a detailed log of all she ate and the time and place of eating. After several sessions in which she failed to bring the log to the therapy session, 1 did not force the issue with

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the client nor offer any dynamic interpretations. I pointed out this rather unusual pattern and asked her what she made of it. It became clear that the weight problem was not a major concern and by not stressing it, I was accepting this fact. These sessions, however, gave her the necessary time to develop trust in me and to finally bring forth her main concerns—the ones that led her to seek therapy. Later, on her own, she told me that she had lost 10 pounds and was seemingly proud of the fact that it was of her own doing. A final aspect of the therapist's work that I want to mention here is the importance of observing patients' behavior in the therapy hour. Although they may have one or more specific symptoms or problems, the patients' style of interpersonal behavior is of some importance in their overall adjustment—whether it be a cause or a result of the current difficulties. In either case, an attempt to modify the behavior may be worthwhile. As the therapist observes the client's behavior in the clinical situation, he or she should be able to note certain characteristic patterns that may account, at least in part, for the client's difficulties. Focusing on these patterns and discussing them with the client becomes more than a mere verbal interaction, since the focus is on actual behavior that can be pointed out by the therapist. Obviously, this has to be done in a sensitive and understanding manner. However, since the intent is to help the client function in a more satisfying manner, and as such discussion can be followed by attempts to modify the behaviors in question, the client can respond positively. In such instances, use can be made of role play and of exercises and tasks carried out in the client's social environment. In this approach, therefore, the therapist is considered to play an active role, even by ostensibly just listening to the verbalizations of the client. The therapist has the responsibility to evaluate the client, to plan the therapy, to guide the process, and to evaluate it and institute changes where possible. I emphasize this point even though the type of client clearly has an important influence on the process of therapy and its outcome. Still, we have too frequently blamed the client when therapy has not progressed in the manner we would have liked. Some clients may be difficult or recalcitrant, and the possibility of helping them by means of psychotherapy may be extremely limited. Nevertheless, the therapist, as the professional, is responsible for what takes place. If the prognosis for positive outcome is poor, this should be made explicit at the start and an appraisal made at that point regarding the value of initiating therapy. A responsible therapist should not continue to see a client over a long period of time with no significant change, and then place the responsibility for lack of progress on the client. This leads rather naturally into the topic of termination. The client, the goals of therapy, and the particular kind of therapy all may influence

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the actual process of termination. In dynamically oriented long-term psychotherapy, the dependency of the client on the therapist appears to be increased, and consequently termination has been viewed as a problem. In relatively short-term therapy of the type described here, this does not appear to be the case. References to termination are made in a natural manner at various stages of therapy. In the initial session some reference is made to the possible length of treatment, which gives the client some potential termination dates. As therapy proceeds and as some of the goals of therapy are being reached, mention of the impending termination of therapy can also be made. Termination can then be discussed with the client and an agreedupon date set. I generally discuss termination about two or three sessions before the end of therapy. In addition, I usually stagger the final couple of sessions so that we meet every two weeks instead of weekly. What I have just described, of course, applies to the "normal" or modal cases of psychotherapy, those cases in which there are no unusual problems. Although the problems of termination in short-term eclectic therapy do not appear to be as frequent or serious as they seemingly have been in therapy that lasts for several years, a few potential problems may be mentioned here. Probably the most serious issue is presented where there is an obvious lack of progress in therapy. The reasons may be diverse or obscure, but the fact remains that satisfactory progress has not been made. This is clearly a disappointment to most therapists and frequently is difficult to face. Nevertheless, as emphasized earlier, the therapist has a responsibility to evaluate the progress of therapy and to face the facts, unpleasant though they may be. In some cases, there may be good reasons for shifting to a different therapeutic strategy and trying some other potentially helpful procedures. In other instances, however, this does not seem reasonable, and steps should be taken to terminate the therapy. In this process I would be open and frank with such patients, indicating that our goals have not been reached and that it is probably not worth continuing. Unless you feel confident that someone else has a high probability of helping them, it does not seem wise to refer them elsewhere, for they may again experience failure and incur added expenses. I would express my disappointment and suggest that they see how they get along for a few months and then contact me for other recommendations if needed. Sometimes a problem in terminating therapy may occur with an unusually dependent patient. The therapist, of course, should be alerted early to such a problem by the behavior of the patient in therapy. Reference to future termination, therefore, should be made at the first appropriate opportunity, and earlier than would otherwise be the case. Furthermore, in such cases, it is particularly important to begin spacing out the last few

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visits. Usually, the staggered visits send a message to the patients that they are fully capable of getting along without the therapist. In one instance, I agreed to see a patient an additional time one month after what was to have been the last therapy session. However, before the time of the appointment the patient called to say that he no longer felt the need for the extra session. Termination, in general, should be determined by the progress (or lack of progress) of the patient. When the goals of therapy have been reasonably met and the patient's comments in therapy are generally of a positive nature, it is time to think of terminating therapy. Sometimes, this situation may occur in a relatively brief period of time. Although some therapists, particularly in training, are reluctant to face up to this positive trend and to release the patient from therapy, I believe this is clearly counterproductive. When a patient reports consistent progress, has little to discuss pertaining to the initial reasons for seeking therapy, or asks the therapist when therapy will end, it is time to discuss termination! I see no reason to continue therapy when there are no real problems that are bothering the patient, even when therapy has only lasted for a few sessions.

Mechanisms of Change Earlier in this chapter, reference was made to the potential importance of common therapeutic factors in facilitating client change. Such factors have been referred to by some as "nonspecific" because an understanding of their role was unclear and because factors other than those hypothesized by a particular orientation apparently had some therapeutic impact. I prefer to refer to such potential therapeutic variables or factors as common factors, since they appear to be present in most forms of psychotherapy. It is difficult to spell out precisely the relative contribution of the various hypothesized therapeutic variables. What exist at present are, for the most part, opinions or formulations and not clearly demonstrated empirical facts. Thus, many statements should be viewed as hypotheses, although some postulated variables have received empirical support (Orlinsky & Howard, 1986). Within this context, I believe some aspects, such as a "good" therapeutic relationship, are a prerequisite for potential progress in psychotherapy. However, a good relationship alone does not ensure positive change; it is only a prerequisite. The skill of the therapist is of potential importance in my view, although we have not clearly defined skill in psychotherapy, nor have we conducted much in the way of systematic research. We have compared therapists in terms of theoretical orientation, gender, years of experience,

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professional discipline, adherence to training manuals, and personal therapy, but not on skill. This is an interesting commentary on psychotherapy. In a related fashion, I am inclined to hypothesize that the personality and psychological health of the therapist also play a role in effective therapy, although data to support my hypotheses are hard to come by. The personality of the therapist, however, has to be evaluated in terms of interactions with different clients. It is a commonly accepted belief in the field of psychotherapy that each therapist works more successfully with some clients than with others. Thus, one cannot speak only of the therapist's personality, but must consider it in relation to client variables (Strupp, 1980). With respect to the mental health or integration of the therapist, we unfortunately lack sound empirical data. On a clinical level, I believe a disturbed therapist is capable of producing negative results. Some years ago, Allen Bergin and I conducted a small study of student therapists and did find a positive relationship between the adjustment level of the therapists as measured by the MMPI and the outcomes of the clients treated (Garfield & Bergin, 1971). While this is encouraging, the finding cannot be viewed as truly robust without more systematic replication. On the other hand, there has been little disagreement that patient variables are extremely important as far as outcome in psychotherapy is concerned. Although prediction of outcome on this basis is usually only slightly better than chance, many well-known psychotherapists have stated that the client is the most important variable as far as outcome is concerned (Frank, 1979; Strupp, 1973). I have been somewhat critical of this view because it allows us to place the blame for therapeutic failure too easily on the client (Garfield, 1973), but the latter does influence the outcome. The cooperation of the client is a necessary prerequisite for practically all psychological work. However, once such cooperation is secured, other variables or mechanisms of change are necessarily involved. The therapist, who is perceived favorably by the client, first of all provides a source of hope for the client. If a positive relationship develops, the initial hope is reinforced and increases the client's confidence in the therapist and in himself. This, in turn, helps to foster the possibility or release of a number of other potentially therapeutic variables. Which ones come into play in a particular instance depend to some extent on the particular client and her problems. In some instances, some of these changeinducing variables have appeared to play a critical role in fostering change. In other instances, it has sometimes been difficult to specify clearly the change mechanisms. In what follows, only a brief presentation of some of the potential therapeutic variables will be made. A more detailed exposition is available elsewhere (Garfield, 1980, 1989).

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THE RELATIONSHIP IN PSYCHOTHERAPY

The relationship in psychotherapy has been accorded a place of importance in practically all forms of psychotherapy, including behavioral approaches (Goldfried & Davison, 1976; Emmelkamp, 1986; O'Leary & Wilson, 1987). First, a positive relationship is necessary if therapy is to continue beyond the first few interviews. The relationship affects both participants. The patient in a positive relationship is more highly motivated to participate constructively in therapy, and the same holds to some degree for the therapist. If the latter perceives the client as motivated and willing to collaborate in the therapeutic endeavor, there is a higher probability of a desirable therapeutic relationship developing. Some research has provided at least some support for the importance of the therapeutic relationship and of the patient's involvement in therapy (Luborsky, Crits-Christoph, Alexander, Margolis, & Cohen, 1983; O'Malley, Suh, & Strupp, 1983). If the patient is involved in therapy and feels that something positive is under way, there is a greater likelihood of positive outcome. If the evaluations of therapy offered by patients are viewed as one means of appraising the relationship, certain perceived qualities of the therapist are of great importance. In one study, the patients stressed the personal qualities of the therapist and the opportunity to discuss the personal problems that were bothering them as the important factors in their psychotherapy (Feifel & Eels, 1963). In a study of behavior therapy, "The patients felt . . . that the most universally helpful elements of their experience were the therapists' calm, sympathetic listening, support and approval, advice and 'faith' " (Ryan & Gizynski, 1971, p. 8). The factors emphasized by the successful patients in the study conducted by Sloane and his colleagues (1975, p. 206) are also pertinent. The five items considered "extremely important" or "very important" by at least 70 percent of the successful patients who received either analytically oriented psychotherapy or behavior therapy were the following: 1. 2. 3. 4. 5.

The personality of your doctor His helping you to understand your problem Encouraging you gradually to practice facing the things that bother you Being able to talk to an understanding person Helping you to understand yourself

Thus, the patient's perception of the therapist is exceedingly important. If the therapist is perceived as interested in the client's welfare, as competent, and as trustworthy, a positive relationship between therapist and client is more likely to develop, and there is a greater likelihood of progress, regardless of the form of therapy used.

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EMOTIONAL RELEASE, OR CATHARSIS

Besides the central role of the therapeutic relationship, there are other potential variables that appear important in psychotherapy. One of these, long recognized in psychotherapy, has been designated as emotional release, catharsis, or abreaction. Some forms of therapy have deliberately sought to induce or foster such strong emotional reactions in patients (Nichols, 1974), whereas such reactions have occurred more or less spontaneously in more conventional forms of psychotherapy. Where a patient is in a state of tension or turmoil, the opportunity to fully confide and express one's feelings and emotions to a trusted and accepting therapist may lead to a strong emotional discharge, with positive consequences. This has only happened a few times in my own clinical experience, but when it does, it is noticeable and sometimes dramatic. One brief example can be given here. A young man wanted to discuss a problem that involved his relationship with his girlfriend. When he came into the office he was acutely upset, and as he described his relationship with her, he began to talk very quickly and quite emotionally. My interactions were limited primarily to listening, nodding, and trying to be empathic. The few times I tried to offer some therapeutic wisdom to the client, he ignored me and continued with his emotional outpouring. As he described his difficulties, the solution to his problem, which he was unable to face earlier, became clear to him. He now saw clearly that his planned marriage was not a good decision. Although he had strong feelings of guilt about this, these seemed to be fully expressed in the session, and he ended with a great sigh of relief. Before I could offer another bit of therapeutic wisdom, he thanked me profusely, and quickly departed. Of course, not all cases will respond as the preceding case did. However, I have noted significant improvement in several cases where the emotional release or catharsis was not anywhere near as vivid or evident. Nevertheless, in two cases that come to mind, the bringing out and discussing something that was decidedly guilt producing in the individual gave evidence of some relief and marked the beginning of positive change.

EXPLANATION, RATIONALE, AND INTERPRETATION

Another aspect of psychotherapy that appears to contribute to positive change is the therapist's providing the patient with some explanation of the latter's difficulties and how psychotherapy may improve the situation. Again, this is a common factor in practically all forms of psychotherapy, although it has been viewed and labeled differently within the differ-

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ent therapeutic systems. Whether one emphasizes interpretation of unconscious conflicts, distorted perceptions, or irrational beliefs, the patient is being given an explanation for his or her behavior. Even behavior therapists, who pay no attention to such dynamic concepts as interpretation and insight, do provide their patients with some explanation of how their behavioral difficulties have arisen, as well as a rationale for the procedures they will employ in therapy. The emergence of cognitive-behavior therapy is also an indication of how explanatory concepts are being incorporated into behavioral approaches. One of the fascinating aspects of interpretation and explanation in psychotherapy is that they appear to vary tremendously among the diverse approaches to psychotherapy. This need not be spelled out here in any detail. It is apparent that the explanations offered by Freudians, Adlerians, Jungians, Sullivanians, Skinnerians, cognitive therapists, and rationalemotive therapists differ greatly, but, supposedly, they all are therapeutic. Frank (1971, 1973) has also described this as a process of providing the patient with a rationale or myth, but a process of some importance in psychotherapy. It is also interesting that in the study of encounter groups by Lieberman, Yalom, and Miles (1973), the groups that secured better outcomes tended to emphasize explanations and cognitions. It thus appears that the explanations offered by therapists during psychotherapy have a potentially positive impact on the patient. Consequently, whether the explanation or interpretation given is "true" in the theoretical or scientific sense is really of little significance in the therapeutic situation. This is a strong pronouncement on my part, and it tends to be rather cooly received by therapists— and understandably so. It challenges their own professional-scientific belief system and would appear to denigrate their professional work. Nevertheless, the implications of comparable outcomes among the major forms of psychotherapy, and the emphasis placed on the importance of cognitions in psychotherapy (particularly recently), should make us face this issue in a forthright manner. It is suggested, therefore, that providing the patient with a rationale or belief system is of some therapeutic value. I have explained this in the following way: The fact that the therapist appears to understand the patient's problems and is able to provide this understanding to the patient appears to reduce the letter's anxiety about his problems and to engender hope for alleviating them. When an individual is experiencing discomfort and does not understand what his symptoms signify, what has caused this unhappy state of affairs, or how serious his condition may be, it is reassuring to contact a professional therapist who

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seems to know what the problem is, what factors are responsible for it, and who also offers a treatment which supposedly can alleviate the patient's situation. (Garfield, 1980, p. 101)

Thus, the particular explanations or interpretations offered by the therapist do not seem to be of primary importance. Rather, the critical factor appears to be whether the patient finds them to be credible and acceptable. If the explanation is unconvincing or incomprehensible, it is likely that the patient will not accept it. In such instances, the proffered rationale will have little positive effect. On the other hand, if the patient fully accepts the explanation, several positive effects may take place: uncertainties and doubts may be lessened, the patient may be reassured, and hopes and expectations about therapy may be increased. In addition, the patient may be motivated to collaborate more intensively with the therapist and to try out new behaviors. All of this includes a lot of "maybe's," but it appears to be a reasonable hypothesis. Some support for the preceding supposition is apparent in the way some prospective clients shop around for specific kinds of therapy. Because of the increasing popularity of psychotherapy, people have become more sophisticated about it than they were in the past. It is possible that certain clients are more receptive to certain rationales than others, and that therapy would be more effective if the proper matching of rationale and client occurred. However, it seems reasonable to believe that the quality of the therapeutic relationship may also influence the client's receptivity to the therapist's explanations and rationale. Although it is not fully understood how the process actually works, I believe we should try to give the clients some explanation of their difficulties, together with some rationale for the approach to be undertaken in therapy. REINFORCEMENT IN PSYCHOTHERAPY

Although many nonbehavioral approaches make no specific theoretical reference to reinforcement in psychotherapy, it would appear that reinforcement is a commonly used therapeutic technique. All therapists respond positively to verbal reports or behaviors that appear positive to them and thus reinforce both in-therapy and out-of-therapy behaviors. Such therapist behaviors as nodding, smiling, frowning, and verbal responses of selected kinds can influence the behavior of the client. Even client-centered therapists such as Carl Rogers tend to reinforce certain client responses (Murray, 1956; Truax, 1966). To say that the therapist is capable of influencing the behavior of the patient should not be a surprising statement. Certainly, most therapeutic approaches would assume this to be possible, but how the influence process

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works or how it can be used most effectively gets into more controversial areas. Behaviorally oriented therapists do make more conscious use of reinforcement principles than do humanistic or dynamically oriented therapists, and in a sense the comparison is between structured learning and incidental learning. Theoretically, however, all therapists are desirous of promoting positive change in the client, thereby reinforcing certain behaviors and "modifying" or "extinguishing" others. Therapists should therefore be aware of their role in influencing patients by means of reinforcement, and should also use such knowledge to secure changes in patients. The strongest reinforcement effects, however, are achieved when clients under the guidance of the therapist attempt behaviors that are personally and socially rewarding for them. DESENSITIZATION

Desensitization has become a well-known behavioral technique, usually referred to as systematic desensitization. However, even before the latter procedure was described by Wolpe (1958), a more general description of desensitization had been presented by others (Dollard & Miller, 1950; Garfield, 1957; Levine, 1948; Rosenzweig, 1936). It was noted that as patients discuss their problems in the understanding and accepting climate of therapy, over time these problems appear less threatening. It is as if the process of bringing out concerns into the open and examining them or sharing them with the therapist lessen their impact. Problems may be perceived differently as the client discusses them. By having to communicate items that are disturbing, the individuals have to organize their experience and to be somewhat more objective and realistic in appraising their life situation. In terms of a learning orientation, clients' anxieties about their difficulties are gradually extinguished as they discuss them in the security of the therapeutic setting, with no negative consequences following. Whether this process is actually one of gradual extinction or whether other processes are also involved is not clear. However, it does seem as if a process of desensitization occurs with at least some patients. As is the case with the other therapeutic mechanisms hypothesized to operate in successful psychotherapy, it may be just one of many operating in any given case. Nevertheless, its potential importance should not be overlooked by the therapist. Wolpe's (1961) approach, systematic desensitization, is a more structured and focused emphasis on desensitization. Although his theoretical formulations have been criticized, the practical results of systematic desensitization have, for the most part, been positive (Davison & Wilson, 1973). Thus, although, in vivo exposure treatment has been more heavily favored

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for phobias in recent years (Emmelkamp, 1986; Marks, 1978; Mathews, Gelder, & Johnston, 1981), systematic desensitization can be used with positive effect in the outpatient setting as one aspect or component of the overall treatment.

FACING OR CONFRONTING A PROBLEM

This particular aspect of the psychotherapeutic process has something in common with exposure treatment but is not synonymous with it. It does not have to be limited to the treatment of phobic behaviors, and it can begin on the basis of verbal discussions in therapy. In fact, the term confrontation has been used for some time in strictly verbal psychodynamic psychotherapy, where the therapist confronts the patient with matters that the patient has avoided facing or about which he or she needs to be informed. These include such matters as interpretation of content, behaviors in therapy, problems of resistance, and the like. It is certainly true that many people tend to avoid certain situations that make them feel uncomfortable or inadequate, even if the behaviors are not pronounced enough to be labeled as clinical phobias, such as shyness. However, if the avoidance behaviors can be pointed out to the patient in a sympathetic manner as the source of much of the discomfort, the patient may gradually acknowledge this. More important, the patient may then be willing to enter situations that have been avoided. If these experiences are successful, both anticipations of negative consequences and actual discomfort should decrease, and more socially adaptable behaviors should result. The last sentence does indicate the similarity between "facing one's problem" and in vivo exposure, but I would point out that several other therapeutic techniques such as systematic desensitization, flooding, implosion, and modeling have also reported positive results when applied to different fears and avoidance behaviors. Thus, there appears to be some common factor operating in all of these approaches, namely that the client in some way is confronted with the negative situation and learns that it can be faced without any catastrophic consequences.* I have made use of this procedure after at least a few sessions of therapy, when I felt that I had an understanding of the client's problem and that some confidence and trust in me had developed. Suggestions can then be made that the client is willing to accept. I favor beginning with activities that are less threatening and that the client is more likely to attempt. One can then go on to activities that are more important for the client's overall *I am indebted to Marvin Goldfried for pointing out the relevance of an old Chinese proverb: "Go to the heart of danger, for there you will find safety."

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adjustment. Nothing succeeds like success, and positive feedback is the strongest form of reinforcement. As the client succeeds in situations that previously were avoided or caused discomfort, increases in self-confidence and self-esteem are likely to occur. Furthermore, "visible evidence of improvement also facilitates an increased expectancy of positive outcome in psychotherapy on the part of the client, which is also of some benefit" (Gar-field, 1980, p. 122). INFORMATION AND SKILLS TRAINING IN PSYCHOTHERAPY

At least a certain number of individuals who seek out psychotherapy are poorly informed about topics of importance or are deficient in desired social skills. In such instances, providing information or attempting to improve social skills can be beneficial. In fact, some recent approaches to psychotherapy have emphasized developing certain personal skills by focusing on social skills training and assertiveness training (Becker, Heimberg, & Bellack, 1987; Liberman, DeRisi, & Mueser, 1989; Matson & Ollendick, 1988). The main difference between these approaches and my eclectic approach is that the former tend to focus on a specific type of problem and to emphasize skills training as the form of therapy, whereas I might use such procedures as one aspect of therapy at a particular time. Traditional, dynamically oriented therapists have been reluctant to provide information or to answer questions asked by the patient for fear this would foster excessive dependence. Although there is some validity to this view, I believe that it has been too rigidly adhered to in the past. If the patient asks a question about something of real concern, a direct answer may be very therapeutic. This would appear to be particularly the case if the patient had false fears about his condition, which correct information might dispel. I can recall two patients with excessive anxiety and guilt about masturbation, who improved noticeably when relevant information was provided in an empathic manner. Similar comments can be made for the training of certain social skills. Again, this would be just one component of psychotherapy and would be used to help the person become more adept and self-confident in her social adjustment. If certain social inadequacies or skills are not fully acknowledged by the patient initially, then the process would be one of confronting her with this problem, as described in the earlier section. However, if it were clearly seen by the patient as a personal deficiency, no confrontation is necessary and the focus would be on improving the patient's skills. Some role playing can be used along with suggestions for activities to be attempted in the social environment.

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TIME AS A VARIABLE IN PSYCHOTHERAPY

A final variable that I want to mention is time. Although we all recognize that a certain amount of time is required for therapy to be conducted, experts disagree about the optimum time for treating different kinds of problems. However, time per se is not given much emphasis, despite the old folk saying that "time heals all wounds." The concept of spontaneous remission in medicine also involves time. It is, of course, difficult to appraise the role of time in psychotherapy because it appears as a "given" and as a background variable for the introduction and interaction of other variables. In some cases, maturational or recuperative processes may occur within the individual and account largely for the positive changes evident. Anyone who has worked with children is aware of the changes that take place as a result of growth and maturation. It is also possible that very positive (or negative) events may occur in the patient's life that affect the process and outcome of psychotherapy. Some people have more favorable social support systems and recover more quickly from crises and stress situations.

Case Example I accepted a woman as a patient whose major complaint centered around marital difficulties. She had been seen twice before at the outpatient clinic by different therapists for periods ranging from 18 to 24 sessions, and although she had been a cooperative patient, she had made relatively little progress. She complained mainly of depression and fears centering around her marital difficulties. Apparently, her husband was abusive at times and because there were two young children in the family, leaving her husband or attempting to dissolve the marriage were not seen as adequate solutions. Despite the fact that the marital situation appeared to be central in terms of this woman's difficulties, apparently little attempt had been made to involve the husband in therapy. Consequently, I insisted that her husband had to participate as well. It was apparent to me that the wife was highly motivated to try to improve her situation and was a reasonably good case for psychotherapy. It was also apparent that the husband was essentially the opposite. The wife indicated that she had wanted her husband to participate in therapy previously, but he had refused; she had thus undertaken therapy herself. The husband did appear at our first session because I had insisted on it as a condition for accepting the wife as a patient, and the wife in turn had threatened to leave him if he did not comply. Both patients were in their early thirties, ran a small business, and had

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been married for about eight years. The difficulties between them were largely related to the husband's drinking, sometimes stimulated by economic pressures. His drinking bouts were episodic, and his abusive treatment of his wife was related to them. They were high school graduates, appeared to be of average intelligence, and both wanted to avert a marital breakup. Although the husband clearly displayed little interest in participating in therapy and stated that his wife was the one who had this interest, I emphasized that two people were involved in the current difficulties, so treatment had to be conducted with both of them. We started on a weekly basis. Although the wife participated actively and the husband only defensively or in response to questions or reflections from me, I felt it was important to have the therapy oriented to the two of them. There were several reasons for this. The husband had avoided therapy previously, and I felt it was important to have him see that he was involved in this problem and had a responsibility in this regard. I also took the view that marital problems are best resolved when both partners participate in therapy. Moreover, the different perceptions or appraisals of husband and wife can be most directly handled when both are in therapy. And last, the previous therapy of the wife alone had not resulted in real or sustained progress. The patients were seen on a weekly basis for eight sessions. During this period therapy progressed satisfactorily, but I felt this was mainly because the husband "behaved himself" in therapy. During these sessions the same behavior was noted in therapy as mentioned earlier. The wife seemed to welcome the opportunity to express her concerns and feelings, demonstrated a strong interest in therapy, and was responsive to my comments and suggestions. Her husband said relatively little, appeared to be uncomfortable, and showed little interest in the therapy sessions. Consequently, I instituted a change at this point. I noted their different attitudes and said that I thought the wife would like to continue in therapy and to talk about her situation and her feelings. On the other hand, it was clear that the husband now realized his role in the marital problems but was somewhat uncomfortable in talking about himself and his feelings. I tried to present this in an understanding and empathic manner, and both agreed with my appraisal. From that point on I said I would see the wife individually for two weekly sessions and then the husband for one weekly session. This was agreed to and became the plan we followed for a couple of months. Using the same rationale, after some progress was made, I saw the wife every two weeks and the husband once a month. My goals were to clarify the patients' patterns of interactions, to increase the wife's self-esteem, confidence, and assertiveness, to confront the husband with the implications of his behavior, to help him accept his positive features, and to make their life a more harmonious one if possible.

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In line with what has been described earlier, I attempted to develop a good relationship with both patients, but succeeded mainly with the wife. I avoided partiality to either patient, communicated interest and sincerity in helping them, allowed each of them an opportunity to express their thoughts and feelings, reinforced positive statements and behaviors, provided some explanations about the causes of their difficulties, made suggestions, and where appropriate, offered encouragement and reassurance. I also had the patients attend particularly to events that appeared to precipitate conflict and abusive behavior, and to work out behaviors to avoid this kind of buildup. I saw the wife for a total of 30 individual sessions and the husband for 13 sessions. The wife clearly appeared to profit from our sessions. She expressed her concerns, discussed different ways of responding to her husband, and tried to be consistent and confident in her reactions. Therapy seemed to have a very reassuring effect on her. Although the degree of change in the husband was not as pronounced, he did appear less defensive and was somewhat better able to accept his share of responsibility in the problems discussed. There were fewer abusive incidents, the mood of both parties seemed much more positive, and the marriage appeared more stable. The wife made what I regarded as significant progress—which is one reason I remember this case. She was much more self-confident, was no longer depressed, and said that she had profited a great deal from therapy. She also stated that she felt she could cope better with future problems. In our final session, she mentioned that I was the first man that she felt she could trust, and that this was an important aspect of therapy for her. I agree that trust is a feature of a desirable therapeutic relationship and is particularly important with patients whose lives have been deficient in adequate interpersonal relationships.

Research As I see it, eclecticism is a stage in the development of more efficient and effective psychotherapeutic treatment. It has become the most popular approach to the practice of psychotherapy (Garfield & Kurtz, 1976; Jensen, Bergin, & Greaves, 1990; Prochaska & Norcross, 1983; Smith, 1982) because many therapists have discovered that adherence to just one system or approach is not the most effective way to best meet the needs of individual clients (Garfield, 1980, 1982, 1990b; Garfield & Kurtz, 1977). As a result, individual psychotherapists have tended to develop their own eclectic approach on the basis of their clinical experience and, to some extent, also on the available research literature on psychotherapy outcome

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(e.g., Beitman, 1992; Beutler & Consoli, 1992; Lazarus, 1992). This, of course, means that there is no one universal form of eclectic psychotherapy and that considerable variability undoubtedly exists. In fact, several different types or categories of eclecticism have been delineated in the Casebook of Eclectic Psychotherapy (Norcross, 1987): "Systematic Technical Eclecticism," "Structural-Phenomological Eclectic Psychotherapy," "Functional Eclectic Psychotherapy," "Radical Eclecticism," "Multi-Modal Therapy," and my own form of just plain unadulterated "Eclectic Psychotherapy." Consequently, it is difficult to provide systematic research data on "an eclectic approach," since there is considerable uniqueness and variation among eclectic practitioners. Perhaps more than is true of such other approaches to psychotherapy as psychoanalysis, behavior therapy, or client-centered therapy, there is more individuality among eclectic practitioners in how they conduct their psychotherapy. Because of this, although some of the early research studies did report evaluations of eclectic psychotherapy and Eysenck, in his famous 1952 review reported a much higher rate of improvement for eclectic therapy than for psychoanalysis, no really strong conclusions should be drawn. These were very early studies. There was no precise operational definition of eclectic therapy, no training manuals were used, and there were no detailed observations or recordings of what individual therapists actually did in the studies reviewed. These limitations, of course, apply to most of the research conducted on psychotherapy until very recent times. Furthermore, if one attempts to evaluate any given eclectic approach to psychotherapy, the potential problems are even greater, for the specific therapy not only is confounded with the skill and personality of the therapist, but problems of objectivity, subject samples, clinical problems, and related issues illustrate the additional difficulties involved. Thus far psychotherapy researchers have focused almost exclusively on type of psychotherapy, as if psychotherapy consisted solely of a set of standard technical skills and the individual application of the therapist was of little consequence. Research on the reliability of psychiatric diagnosis (Garfield, 1986) and on the accuracy of psychological test interpretation (Garfield, 1983), let alone the vast research literature on the psychology of individual differences, clearly should raise strong doubts about such an assumption. Whether or not the variability within samples of psychotherapists has influenced the results obtained, the comparative studies of psychotherapy outcome have reported few differences among the different forms of psychotherapy (Lambert, Shapiro, & Bergin, 1986; Stiles, Shapiro, & Elliot, 1986). It is this research that lends support to the views expressed here concerning the importance of common factors in psychotherapy. It is interesting to point out, also, that there appears to be an increasing

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acknowledgment of common factors in psychotherapy (Kazdin, 1986; Lambert, Shapiro, & Bergin, 1986), and my own eclectic approach is characterized in this fashion in the present volume and in the one recently edited by Zeig and Munion (Garfield, 1990b).

Clinical Training At present, it appears that the training of psychotherapists generally tends to emphasize one form of psychotherapy exclusively (e.g., psychoanalysis or behavior therapy) or consists of a cursory review of a dozen different orientations. I personally regard the former as a form of indoctrination that limits critical evaluation and flexibility. I also tend to be critical of the second approach, since it presents a menu of therapies without a true critical appraisal of them or of the possible reasons for this state of affairs. In some cases the view is presented that students simply need to select the form of therapy that appeals to them and "run with it." Although it is important that the therapist get some feelings of satisfaction when engaged in psychotherapy, the satisfaction should result from helping the patient improve and not from other considerations. My own approach is to focus on the potentially important therapeutic variables in psychotherapy—a less clear-cut or dogmatic approach to follow, perhaps, but it can be done. After discussing patient and therapist variables, I proceed to a discussion of possible therapeutic variables. Following a brief presentation of the therapeutic variables emphasized by psychoanalysts, Rogerians, and behavior therapists, I go on to discuss the therapeutic variables, or mechanisms of change, more broadly, as illustrated earlier in this chapter. I have been teaching graduate students and conducting postdoctoral workshops on this approach for many years, and more recently have published some books that I hope facilitate such teaching (Garfield, 1980, 1989). Former students have also told me that they have incorporated many of my views into their practice and teaching.

Future Directions At the present time, I am inclined to view eclecticism as an intermediate development between the reliance on one therapeutic approach and a more advanced stage, where a synthesis or integration of psychotherapeutic methods and theories is developed. One aspect of this development will be a greater consideration of the role that common, as well as specific, factors play in securing positive outcome. Such research will be difficult,

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but as studies of the therapeutic relationship have indicated, it can be accomplished. Recently, Glass and Arnkoff (1988) conducted a study of four different types of group therapy and attempted to appraise common and specific factors. Although the specific emphases of the three structured group therapies were reflected in the clients' explanations of why changes occurred, evidence for the existence of common factors also was evident. "It is important to note that approximately half of the subjects in each of the structured conditions emphasized common group process factors as accounting for their improvement, citing these factors as often or more often than factors specific to the methods used in their treatment program" (Glass & Arnkoff, 1988, p. 435). Another interesting finding that is relevant here comes from the NIMH Collaborative Study of the Treatment of Depression in which a cognitive therapy was compared with a form of interpersonal therapy (Elkin et al., 1989). In line with most other comparative studies, no differences were found between the two forms of therapy on the general measures of outcome. However, of particular interest is the lack of difference found between specialized measures of cognitive functioning and social adjustment hypothesized to differentiate the two forms of psychotherapy. Although we can point to clear differences in the manuals used and in the behaviors of the two groups of therapists, the comparable findings obtained suggests both the likely possibility of underlying common factors and the need to describe and verify these factors. The latter task will not be an easy one (Garfield, 1990a; Stiles, Shapiro, & Elliot, 1986). Although an effective, systematic, and integrated formulation of psychotherapy awaits the future, I am confident it will be secured and will include a proper emphasis on common therapeutic factors. This, of course, does not preclude appropriate attention to specific factors or variables that are particularly effective with specific problems.

References ALLEN, F. H. (1942). Psychotherapy with children. New York: Norton. ALLPORT, G. W. (1937). Personality: A psychological interpretation. New York:

Henry Holt. BANDURA, A., JEFFREY, R. W., & WRIGHT, C. L. (1974). Efficacy of participant modeling as a function of response induction aids. Journal of Abnormal

Psychology, 83, 56-64. BEEKER, R. E., HEIMBERG, R. G., & BELLACK, A. S. (1987). Social skills training treatment for depression. Elmsford, NY: Pergamon. BEITMAN, B. D. (1992). Integration through fundamental similarities and useful differences among the schools. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books.

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BERGIN, A. E. (1971). The evaluation of therapeutic outcomes. In A. E. Bergin & S. L. Garh'eld (Eds.), Handbook of psychotherapy and behavior change (pp. 217-270). New York: Wiley. BERGIN, A. E., & LAMBERT, M. ]. (1978). The evaluation of therapeutic outcomes. In S. L. Garh'eld & A. E. Bergin (Eds.), Handbook of psychotherapy and behavior change (2nd ed., pp. 139-189). New York: Wiley. BEUTLER, L. E., & CONSOLI, A. J. (1992). Systematic eclectic psychotherapy. In ]. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. BINDER, V., BINDER, A., & RIMLAND, B. (1976). Modern therapies. Englewood Cliffs, NJ: Prentice-Hall. COREY, G. (1991). Theory and practice of counseling and psychotherapy (4th ed.). Pacific Grove, CA: Brooks-Cole. CORSINI, R. J., & WEDDING, D. (1989). Current psychotherapies (4th ed.). Itasca, IE: F. E. Peacock. DAVISON, G. C., & WILSON, G. T. (1973). Processes of fear reduction in systematic desensitization: Cognitive and social reinforcement factors in humans. Behavior Therapy, 4, 1-21. DOLLARD, ]., & MILLER, N. E. (1950). Personality and psychotherapy. New York: McGraw-Hill. ELKIN, L, SHEA, T., WATKINS, J. T., IMBER, S. D., STOTSKY, S. M., COLLINS, J. F., GLASS, D. R., PILKONIS, P. A., LEBER, W. R., DOCHERTY, J. P., FIESTER, S. ]., & PARLOFF, M. B. (1989). National Institute of Mental Health Treatment of Depression Collaborative Research Program. General effectiveness of treatment. Archives of General Psychiatry, 46, 974-982. EMMELKAMP, P. M. G. (1986). Behavior therapy with adults. In S. L. Garfield & A. E. Bergin (Eds.), Handbook of psychotherapy and behavior change (3rd ed., pp. 385-442). New York: Wiley. EYSENCK, H. J. (1952) The effects of psychotherapy: An evaluation. Journal of Consulting Psychology, 16, 319-324. FEIFEL, H., & EELS, J. (1963). Patients and therapists assess the same psychotherapy. Journal of Consulting Psychology, 27, 310-318. FRANK, J. D. (1971). Therapeutic factors in psychotherapy. American journal of Psychotherapy, 25, 350-361. FRANK, J. D. (1973). Persuasion and healing (2nd ed.). Baltimore: Johns Hopkins University Press. FRANK, ]. D. (1979). The present status of outcome studies. Journal of Consulting and Clinical Psychology, 47, 310-316. GARFIELD, S. L. (1957). Introductory clinical psychology. New York: Macmillan. GARFIELD, S. L. (1973). Basic ingredients or common factors in psychotherapy? Journal of Consulting and Clinical Psychology, 41, 9—12. GARFIELD, S. L. (1974). Clinical psychology. The study of personality and behavior. Chicago: Aldine. GARFIELD, S. L. (1978). Research on client variables in psychotherapy. In S. L.

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Garfield & A. E. Bergin (Eds.), Handbook of psychotherapy and behavior change (2nd ed., pp. 191-232). New York: Wiley. GARFIELD, S. L. (1980). Psychotherapy: An eclectic approach. New York: Wiley. GARFIELD, S. L. (1982). Eclecticism and integration in psychotherapy. Behavior Therapy, 13, 610-623. GARFIELD, S. L. (1983). Clinical psychology. The study of personality and behavior (rev. ed.). Hawthorne, NY: Aldine. GARFIELD, S. L. (1986). Problems in diagnostic classification. In T. Millon & G. L. Klerman (Eds.), Contemporary directions in psychopathology. Toward the DSM-IV (pp. 99-114). New York: Guilford. GARFIELD, S. L. (1989). The practice of brief psychotherapy. Elmsford, NY: Pergamon. GARFIELD, S. L. (1990a). Issues and methods in psychotherapy process research. Journal of Consulting and Clinical Psychology, 58, 273—280. GARFIELD, S. L. (1990b). Multivariant eclectic psychotherapy. In J. K. Zeig & W. M. Munion (Eds.), What is psychotherapy? Contemporary perspectives (pp. 239—243). San Francisco: Jossey-Bass. GARFIELD, S. L., & BERGIN, A. E. (1971). Personal therapy, outcome and some therapist variables. Psychotherapy: Theory, Research and Practice, 8, 251—253. GARFIELD, S. L., & KURTZ, R. (1976). Clinical psychologists in the 1970s. American Psychologist, 31, 1-9. GARFIELD, S. L., & KURTZ, R. (1977). A study of eclectic views. Journal of Consulting and Clinical Psychology, 45, 78-83. GLASS, C. R., & ARNKOFF, D. B. (1988). Common and specific factors in client descriptions of and explanations for change. Journal of Integrative and Eclectic Psychotherapy, 7, 427-440. GOLDFRIED, M. R. (1980). Toward the delineation of therapeutic change principles. American Psychologist, 35, 991-999. GOLDFRIED, M. R. (Eo.). (1982). Converging themes in psychotherapy. New York: Springer. GOLDFRIED, M. R., & DAVISON, G. C. (1976). Clinical behavior therapy. New York: Holt, Rinehart & Winston. GOLDFRIED, M. R., & NEWMAN, C. F. (1992). A history of psychotherapy integration. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. HEINE, R. W. (1953). A comparison of patients' reports on psychotherapeutic experience with psychoanalytic, nondirective and Adlerian therapists. American Journal of Psychotherapy, 7, 16—23. JENSEN, J. P., BERGIN, A. E., & GREAVES, D. W. (1990). The meaning of eclecticism: New survey and analysis of components. Professional Psychology: Research and Practice, 21, 124—130. KAZDIN, A. E. (1986). Research designs and methodology. In S. L. Garfield & A. E. Bergin (Eds.), Handbook of psychotherapy and behavior change (3rd ed.,

pp. 23-68). New York: Wiley.

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LAMBERT, M. }., SHAPIRO, D. A., & BERGIN, A. E. (1986). The effectiveness of psychotherapy. In S. L. Garfield & A. E. Bergin (Eds.), Handbook of psychotherapy and behavior change (3rd ed., pp. 157—211). New York: Wiley. LAZARUS, A. A. (1992). Multimodal therapy: Technical eclecticism with minimal integration. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. LEHRER, A. (1981, February). [Letter to the editor]. APA Monitor, p. 42. LEVINE, M. (1948). Psychotherapy in medical practice. New York: Macmillan. LIBERMAN, R. P., DERISI, W. J., & MUESER, K. T. (1989). Social skills training for psychiatric patients. Elmsford, NY: Pergamon. LIEBERMAN, M. A., YALOM, I. D., & MILES, M. B. (1973). Encounter groups: First facts. New York: Basic Books. LUBORSKY, L., CRITS-CHRISTOPH, R., ALEXANDER, L., MARGOLIS, M., & COHEN, M. (1983). Two helping alliance methods of predicting outcomes of psychotherapy. Journal of Nervous and Mental Disease, 171, 480—491. LUBORSKY, L., SINGER, B., & LUBORSKY, L. (1975). Comparative studies of psychotherapies: Is it true that "everybody has won and all must have prizes?" Archives of General Psychiatry, 32, 995-1008. MARKS, I. (1978). Behavioral psychotherapy of adult neurosis. In S. L. Garfield & A. E. Bergin (Eds.), Handbook of psychotherapy and behavior change (2nd ed., pp. 493-547). New York: Wiley. MARMOR, J., & WOODS, S. M. (Eos.). (1980). The interface between the psychodynamic and behavioral therapies. New York: Plenum. MATHEWS, A. M., GELDER, M. G., & JOHNSTON, D. W. (1981). Agoraphobia: Nature and treatment. London: Tavistock. MATHEWS, A. M., JOHNSTON, D. W., SHAW, P. M., & GELDER, M. G. (1974). Process variables and the prediction of outcome in behaviour therapy. British Journal of Psychiatry, 125, 256-264. MATSON, J. L., & OLLENDICK, T. H. (1988). Enhancing children's social skills. Assessment and training. Elmsford, NY: Pergamon. MORSE, S. J., & WATSON, R. L, JR. (1977). Psychotherapies. A comparative casebook. New York: Holt, Rinehart & Winston. MURRAY, E. J. (1956). A content-analysis method for studying psychotherapy. Psychological Monographs, 70 (13, Whole No. 420). NICHOLS, M. P. (1974). Outcome of brief cathartic therapy. Journal of Consulting and Clinical Psychology, 42, 403-410. NORCROSS, J. C. (Eo.). (1986). Handbook of eclectic psychotherapy. New York: Brunner/Mazel. NORCROSS, J. C. (Eo.). (1987). Casebook of eclectic psychotherapy. New York: Brunner/Mazel. OBENDORF, C. P. (1943). Results of psychoanalytic therapy. International Journal of Psychoanalysis, 24, 107-114. OBENDORF, C. P., GREENACRE, P., & KUBIE, L. (1948). Symposium on the evaluation of therapeutic results. International Journal of Psychoanalysis, 29, 7-33.

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O'LEARY, K. D., & WILSON, G. T. (1987). Behavior therapy. Application and outcome (2nd ed.). Englewood Cliffs, NJ: Prentice-Hall. O'MALLEY, S. S., SUH, C. S., & STRUPP, H. H. (1983). The Vanderbilt Psychotherapy Process Scale: A report on the scale development and a processoutcome study. Journal of Consulting and Clinical Psychology, 51, 581—586. ORLINSKY, D. E., & HOWARD, K. I. (1986). Process and outcome in psychotherapy. In S. L. Garfield & A. E. Bergin (Eds.), Handbook of psychotherapy and behavior change (3rd ed., pp. 311—381). New York: Wiley. PROCHASKA, J. O., & NORCROSS, J. C. (1983). Contemporary psychotherapists: A national survey of characteristics, orientations, and attitudes. Psychotherapy: Theory, Research and Practice, 20, 161—173. ROGERS, C. R. (1942). Counseling and psychotherapy. Boston: Houghton Mifflin. ROSENZWEIG, S. (1936). Some implicit common factors in diverse methods of psychotherapy. American Journal of Orthopsychiatry, 6, 412—415. RYAN, V. L., & GIZYNSKI, M. N. (1971). Behavior therapy in retrospect: Patients' feelings about their behavior therapies. Journal of Consulting and Clinical Psychology, 37, 1-9. SACHS, J. S. (1983). Negative factors in brief psychotherapy: An empirical assessment. Journal of Consulting and Clinical Psychology, 51, 557—564. SLOANE, R. B., STAPLES, F. R., CRISTON, A. H., YORKSTON, N. ]., & WHIFFLE, K. (1975). Psychotherapy versus behavior therapy, Cambridge, MA: Harvard University Press. SMITH, D. (1982). Trends in counseling and psychotherapy. American Psychologist, 37, 802-809. SMITH, M. L., GLASS, G. V., & MILLER, T. I. (1980). The benefits of psychotherapy. Baltimore: Johns Hopkins University Press. STILES, W. B., SHAPIRO, D. A., & ELLIOTT, R. (1986). Are all psychotherapies equivalent? American Psychologist, 41, 165—180. STRUPP, H. H. (1973). On the basic ingredients of psychotherapy. Journal of Consulting and Clinical Psychology, 41, 1—8. STRUPP, H. H. (1980). Success and failure in time-limited psychotherapy. Further evidence (Comparison 4). Archives of General Psychiatry, 37, 947—954. TRUAX, C. B. (1966). Reinforcement and nonreinforcement in Rogerian psychotherapy. Journal of Abnormal Psychology, 71, 1—9. WOLFE, J. (1958). Psychotherapy by reciprocal inhibition. Stanford, CA: Stanford University Press. WOLFE, J. (1961). The systematic desensitization treatment of neuroses. Journal of Nervous and Mental Disease, 132, 189-203.

CHAPTER 6

Integration Through Fundamental Similarities and Useful Differences Among the Schools BERNARD D. BEITMAN

Fo

L OUNDERS AND FOLLOWERS OF SCHOOLS of psychotherapy have constructed ideals toward which others are asked to aspire. Despite having lost much popularity, both rigid psychoanalysts and rigid behavior therapists continue to deny the value of each others' findings and to insist that their pieces of truth are the entire truth. Some therapists have developed manuals for their approaches (e.g., Beck, Rush, Shaw, & Emery, 1979; Luborsky, 1984; Klerman, Weissman, Rounsaville, & Chevron, 1984; Kernberg, Selzer, Koenigsberg, Carr, & Applebaum, 1989), which are believed to be useful for research purposes. Each requires its practitioners to follow strict formats. However, most psychotherapy practitioners are not interested in manuals or in following psychotherapy ideologies. Instead, they are interested in discovering what works for the patient in front of them. In response to the obvious value of a variety of approaches to psychotherapy, several psychotherapists have created integrative approaches. Unfortunately, the forms of many of these integrative approaches bear strong resemblance to those created by rigid psychoanalysts, rigid behavior therapists, and manual-driven psychotherapists (e.g., Hart, 1983; Lazarus, 1986). Like their predecessors, these integrative psychotherapists have created ideals to which practitioners are asked to aspire. An alternative approach to psychotherapy integration is to create a model with sufficient flexibility so that (3) it will continue to assimilate new ideas generated from patients, other psychotherapies, other psychotherapists, colleagues, personal life experiences, and research; (2) it can be accommodated to the psychotherapy schemas of each individual therapist;

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and (3) it can ultimately be adapted to the schemas of each patient. Rather than being a solid form, the ideas of this approach would be like the molecules of a liquid in that they would fit the cognitive containers of their users.

The Approach In 1970 I was an angry first-year psychiatric resident. I wanted to become a psychotherapist but was frustrated with the claims for correctness from each of the many existing schools of psychotherapy. They were too much like fundamentalist religions, each complaining about the other's blasphemy while claiming to possess the truth. I was disturbed by the Vietnam conflict and the terrible effect it was having on our culture and society. I wanted to find a way to bring an end to these conflicts. I had a "saviorlike" self-image at the time. The Beatles had a song with the phrase "Come Together Right Now Over Me," which summarized my aspirations. I also had been reading in a variety of different areas. General systems theory, for example, had described the possibility of constructing a model that was applicable to a variety of systems (von Bertalanffy, 1964). These confusing but intriguing and hopeful writings had influenced me to look for the underlying common structures in a variety of different settings. Similarly, my reading in mysticism stirred me to search for unity in complexity, and encouraged me to believe that modern science had missed some crucial aspects of knowledge (e.g., Crowley, 1944). When I was in college, I began reading George Kelly's The Psychology of Personal Constructs (1955). I kept trying to understand his primary axiom: A person's processes are psychologically channelized by the way he anticipates events. Although he denied he was a cognitive therapist, he was obviously interested in how the mind influenced experience and behavior. In medical school and during my internship, psychoanalysis and Sigmund Freud were raised as ideals toward which to aspire. During that time I came to know personally a well-respected psychoanalyst who married one of his patients and subsequently committed suicide. This personal experience helped me see the limits of these idealizations. (See Beitman, 1990, for further biohistorical details.)

Guiding Principles Consistent with the above, I would like to offer the following eight guiding principles for implementing this approach to integration.

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Triflexibility of Integration The term integration has several applications to psychotherapeutic practice: (I) integrate the multiple schools of psychotherapy; (2) integrate this integration with the personal and psychotherapeutic concepts of each individual therapist; (3) integrate this integration with the concepts, selfdefinitions, and world views of the patients currently in front of the therapist. This three-dimensional notion of integration is based upon the suggestion from psychotherapy research that the patient is the most crucial variable in outcome, that the relationship-establishing ability of the therapist is the second most crucial influence on therapeutic outcome, and that technique is the least important of the three (Lambert, 1986). Therefore, any effective, pragmatic integration must be conceptualized in ways that permit its concepts to be adapted readily to the world view of each individual patient, couple, or family. Similarities and Differences Among the Schools One of the more difficult challenges to the human mind while viewing multiple entities is to perceive simultaneously their similarities and differences. The world tends to be divided into "lumpers" or "splitters," but psychotherapy integration requires therapists simultaneously to see differences and similarities. Integration should define fundamental similarities and incorporate useful differences among the schools. Cause and the Personal Future Theories developed by schools of psychotherapy are designed to offer causal explanations for psychological difficulty. However, cause is a philosophically problematic issue (see the section on mechanisms of change). In keeping with the need to focus on the patient's world view, therapists should frame causal statements in terms that imply or suggest change alternatives. This goal is best fulfilled by adopting a teleological perspective; that is, human beings can be considered to be drawn by their future conceptions rather than created by their past (although future conceptions are formed by past experiences). When the future view is reconstructed by new alternatives, change can be attributed to these reconstructions. Since the future is moldable and the past is "passed," the future offers the clearest avenue for causal explanations that lead to change. Symptom Relief Versus Core Schematic Change While patients and most therapists seek symptomatic relief at first, many therapists and fewer patients want to get to the "cause" of the difficulties

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so that they do not recur. Change in core schemas is usually required for enduring results, a point that will be developed in the section that follows. Although there are often clear relationships between symptoms and underlying core schemas, the treatment distinctions between them is crucial for both therapist and patients. Techniques useful for symptom relief (e.g., placebo response, relaxation training, hypnosis, medication, behavioral suggestions) are less likely to bring about enduring change in basic schemas than are direct approaches to them. But isn't symptom remission often enough? Each patient-therapist pair must answer this question. The 70-percent Rule of Technical

Efficacy

No concept or technique is always useful or correct. In psychopharmacology, it has been concluded that antidepressants, for example, are effective in approximately 70 percent of cases with major depression, according to many research studies (Manning & Frances, 1990). Furthermore, many of the study patients judged to be improved continue to have difficulties. To expect any psychotherapy technique to be more frequently effective is to expect too much. Keep It Simple One of the attractions to some therapists of psychoanalytic, behavioral, and more recent cognitive theories is their complexity. For the practicing psychotherapist, however, simple models of psychopathology and change are more easily remembered and used. Simple flexible models are more easily communicated and adapted to the mind sets of patients as well. In this context, "simple" refers to the difficult explication of basic psychotherapeutic principles that may be applied in various combinations to individual patients, couples, or families. Self-observation Is Crucial to Change To self-observe is to record one's own thoughts, emotions, and behaviors. Therapists have differed primarily about what is to be observed. To selfobserve is to be able to report very personal experiences as targets for pattern analysis and change. Through reports of their intrapsychic and behavioral lives, therapists can direct patients to optimal fulcrums for change. Exposure Is the Key to Most Change Although first emphasized in behavior therapy, exposure in its many forms is central to both intrapersonal and interpersonal change. In psychody-

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namic thinking, anxiety and avoidance are central to repression, the treatment of which involves "uncovering" (exposing patients to) feared images, emotions, and/or thoughts often in a stepwise fashion (Greenson, 1967), as suggested by Wolpe's (1973) systematic desensitization. Marital therapy usually involves conflict resolution, a central aspect of which is exposing each partner to the thoughts and feelings of the other (Heitler, 1990). Often this exposure is feared because it leads to increased vulnerability to hurt by the other. Exposure seems to mean "controlled exposure to reality" so that new information helps to correct old distorted schemas. More will be said about this in the next section. Stages in Psychotherapy Since psychotherapy is a series of events through time, it may be called a process. This process may be divided into four stages: engagement, pattern search, change, and termination. The change stage has three substages, including giving up the old pattern, beginning a new pattern, and maintaining the new pattern (Beitman, 1987).

Central Tenets Enduring psychotherapeutic change may be achieved by directing the therapeutic focus to unresolved traumatic experiences and to the core interpersonal schema. The core interpersonal schema is the chief architect of interpersonal loops, and exposure in its many forms is usually necessary for change. These concepts are further described below. UNRESOLVED TRAUMA

Often patients have failed to resolve the effects of traumatic events and processes, including sexual abuse, physical abuse, emotional abuse, rape, and early caregiver loss through death or separation. The painful emotions are walled off from consciousness but enter consciousness indirectly when some environmental event bears sufficient similarity to the old hurtful situations to trigger its associated feelings. Patients usually have no idea about the origin of these feelings, which usually present as symptoms. Patients may build their self-identities on their abilities to deny the terrible influence of these past events. "I'm so strong because it wasn't a problem and does not bother my life." In fact these events did affect their lives and helped to create problematic self-other representations—core schemas.

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CORE INTERPERSONAL SCHEMA

Schemas are maps by which people interpret and construct reality. Inherent in Korzybski's (1958) pithy phrase, "The map is not the territory,"* is a crucial objective of psychotherapeutic change. While schemas organize a wide spectrum of interactions between self and environment, the focus for major psychotherapeutic change may be called "the core interpersonal schema." This schema is based upon early experiences with caregivers and modified by subsequent intimate relationships. It represents the self in relationship to others and carries with it both self-identity and the manner in which interpersonal relationships are to be formed. Partial descriptions of this idea are scattered throughout the writings of a wide variety of psychotherapy schools (Stiles et al., 1991). A crucial implication of the core interpersonal schema is that intrapersonal and interpersonal events are derived from the same source. Therefore, both intrapersonal and interpersonal data provide information about this core psychic structure. The core schema provides self-definition and the manner by which close interpersonal relationships are to be formed. Structurally, the schema may be thought to have "buttons" and "scripts." When "buttons are pushed," emotion and/or cognition (automatic thoughts) and/or behavior may be evoked. These products, often appearing as symptoms, may be used to flesh out the specific details of the schema. For example, excessive, inappropriate anxiety may be accompanied by the automatic thought, "I might fail and might lose my job." This pairing suggests a core schema in which the person is continually vulnerable to rejection. These two responses (the automatic thought and the anxiety) may help to flesh out the details of the schema. While the core schema may be construed as a still photograph, the script is the movie based upon the theme of the core schema. The script of the previously mentioned "self as imminent failure" schema may be one in which the person is rejected because of failure, is abandoned, and lives forever alone. The basic elements of the core interpersonal schema are two figures in relationship to each other. Usually one of the two figures is dominant and the other is submissive. Although one pole may appear dominant, therapists may assume that its opposite is present but submerged, suggesting support for the ancient idea that "everything contains its opposite." This duality appears under multiple labels throughout the psychotherapy schools: superego-id and grandiose-depreciated self (psychoanalysis), parent-child (transactional analysis), topdog-underdog (Gestalt), ultimate rescuer-supplicant (existential) as well as angel-devil from various religions 'Quote appears in Handler & Grinder (1975, p. 7).

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(see Zalaquett, 1989, for a review). The poles are in a dynamic equilibrium creating a dialectic tension seeking resolution, and the degree of psychopathology appears to be dependent upon the degree of this power differential. In addition, more severely disturbed people fluctuate more rapidly between the two poles (Gabbard, 1990). Borderline personalities, for example, fluctuate between the two states, whereas narcissistic patients are more stable in either one or the other. The more extreme the difference, the greater the psychopathology. Both intrapersonal and interpersonal conflict are usually based on these two aspects of the self, and information about the schema may therefore be derived from both intrapersonal and interpersonal information. INTERPERSONAL LOOPS

The core schema is played onto the environment through expectations and behavior. Human beings are remarkably skilled in inducing others to fit their role expectations through a variety of subtle clues that fall under the term "metacommunication" (Watzlawick, Beavin, & Jackson, 1967; Strong, 1987). These metacommunications from one person interact with the metacommunications from another person, thereby developing loops that may be called vicious cycles, virtuous cycles, or cyclical psychodynamics (Wachtel & McKinney, 1992; Wachtel & Wachtel, 1986). These loops possess multiple intervention points, some of which the various schools of psychotherapy have selected for their interventions. Behavior therapists emphasize changing environmental responses or initiating new behaviors; psychoanalysts look for past influences on core intrapersonal schemas; interpersonal therapists try to change behavior with others; and cognitive therapists try to alter automatic thoughts. Each of these intervention points has the potential for altering the loops and thereby influencing core interpersonal schemas. PATTERNS ARE STILL LOGICAL BUT NO LONGER REALISTIC

The more the patient accepts the intentions and the aims of the therapist, the more quickly therapeutic change is likely to proceed. Changing a core interpersonal schema requires the patient to self-observe the core interpersonal schema in enough detail so that change points can be clarified. A therapist may offer a broad description of the schema, but details provide the patient with the focus for change. For example, the "self as imminent failure" person mentioned earlier required delving into his own history to find out how he learned to be so afraid of rejection. He could identify early caregivers who trained him to be fearful of making an error. In such cases it is often useful to explain to patients that their core

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interpersonal schemas are still logical but are no longer realistic. In other words, they have a logic of their own derived from early relationships, but this logic is carried forward into a present where that logic no longer applies. A key aspect of changing a core schema is for the patient to selfobserve while new information is available in the environment. A kind of dual vision is required with one eye on new information and the other eye on the core schema, so that the new light exposes the darkness of old thinking. This "psychotherapeutic periscope" is formed through the working alliance with the therapist, whose other-observer aligns with the selfobserver of the patient. Insight is in this way coupled with "outsight." When presenting the details of the core interpersonal schema to the patient, the pattern should be described in terms of the future. It is insufficient to say, "You got this way because your mother acted a certain way and this made you think a certain way"; rather, that "certain way" must be defined in terms that imply an alternative, another way of thinking or another way of behaving. For example: "You are afraid of failure because your mother threatened you with rejection and abandonment each time you did something slightly wrong. Therefore, you must examine each present and future situation to see if that same threat exists. If it does not, you have other alternatives." The examination of the script associated with the schema is a crucial aspect of change. The expectation of certain events, however unconsciously construed, may be addressed and then changed. For those patients who develop strong transference responses to their therapists, the playing out of the transference in imagination becomes a here-and-now method by which the script may be analyzed. For instance, a patient wishing to have sex with her therapist discovered that she was simply trying to prove that all men are like her father, who had a history of affairs. She concluded at an early age that all men want sex only and are untrustworthy and unreliable, creating multiple sexual contacts with men to continue to prove this hypothesis. By playing out this script in imagination to discover that it doesn't end as expected—she could be in a relationship without sex and still be cared for—she allowed the script to be altered. EXPOSURE IS A CENTRAL CHANGE MECHANISM

There are a variety of methods by which a psychotherapist can bring about change in core schemas and unresolved trauma. Fundamental to all of them is letting new, more realistic information alter them. New information to dysfunctional schemas is like oxygen to a wound. Once the oxygen reaches the malfunctioning area, healing can begin. Acceptance of the devastation of traumatic events leads to their resolution.

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Exposure comes in a variety of forms, each of which is intended to get new information to the core schemas. Both Wolpe (1973) and Freud (1963) exposed patients to irrationally feared entities. Wolpe's tended to be external (phobias, self-assertion), whereas Freud's tended to be internal (negative emotion, fantasies). This process is ubiquitous among the other schools. Following is a list of some forms of exposure: 1. Education by others. Patients can see their own patterns in others, whether it be in a group therapy context or in the form of bibliotherapy. This experience of "not being the only one" helps them to elucidate and face their cognitive and behavioral limitations. 2. Education by the therapist. Therapists have the opportunity to present much new information. For instance, descriptions of general patterns may invite patients to fill them in with details from their own minds. Here the idea of exposure is expanded beyond desensitization to fears. In effect, exposure is desensitization ignorance, on which excessive fear is often based. 3. Insight. This term has been often abused. Insight refers to looking in, but more than just looking in is required. Insight coupled with "outsight" can provide change. The intimacy phobic must be able to look at the dysfunctional schema and at the partner simultaneously in order to discover that intimacy need not be so frightening. 4. Instructions to act differently. Behavior therapists, strategic therapists, and others strongly encourage people to act differently. If the patient is consciously looking for different responses in self and others while behaving differently, then change is likely (see, Fixed Role Therapy of George Kelly, 1955). For example, a young woman firmly believed she needed eye makeup in order for people to talk with her. She was asked to not wear it to see if people talked to her, which indeed they did. She was then able to change her notion of why people interacted with her. 5. Grief work. Since "the only constant is change," much therapy has to do with loss and therefore grief work. Grief is the pain of a lost future. Grief work requires that the present be confronted while the lost future is held in mind. Often people do not want to grieve because it is so painful, just as phobics do not like to expose themselves to feared objects or ideas. 6. Look for the positive. With much psychotherapeutic focus on psychopathology, few therapists have been trained to look for the positive. Patients and therapists both seem phobic of the strong and the capable in the patient. This bias appears to be changing. Islands of power, adaptability, and cleverness within schemas provide foundations for constructing better lives. Looking for and finding these strengths may require overcoming unexpected fears in both patient and therapist.

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The Major Schools of Psychotherapy: Useful Differences The following is a summary of the useful contributions of the schools of psychotherapy, in which the emphasis is on differences among them. Many of these ideas will be used in the ensuing case presentation. HUMANISTIC

1. Basic goodness. Each human being is basically good. 2. Acceptance. If a person is received by another with warm, positive regard and nonjudgmental, accurate empathy and genuineness, that person will individuate (come closer to the true self) through which the inherent goodness will appear (Rogers, 1951). 3. Imagine the other. Therapists may be accurately empathic by actively imagining the ongoing experience of the patient (Havens, 1974). 4. Paraphrase with patient's emotion. To express accurate empathy, the therapist may paraphrase, while speaking with a similar emotion, what the patient has just said (Rogers, 1942). EXISTENTIAL

1. Death anxiety. Death anxiety is a central problem of Western culture. The failure to accept death by facing it creates multiple problems including psychiatric disturbance. Acceptance of death allows one to live (Becker, 1973). 2. Isolation. Social isolation is terrifying and represents a death in society. Many people will make many compromises to avoid it, including attachment to "saviors" or to "supplicants" (Yalom, 1980). 3. Authenticity. Life in society requires the development of "personae" (false fronts), which achieve desired social goals but can inhibit self-development. The courage to be oneself, to express one's own true essence, is beyond the potential of many. Yet the distortion of this selfexpression leads to much discontent. The most satisfying relationships are ones in which participants are able to express and be accepted for who they are in the here-and-now. 4. Free will. Does free will exist? Each person has zones of responsibility, areas of interpersonal and intrapersonal life, that are potentially under that person's influence. Human influence is limited by biology and culture and the accidents of birth. Within these constraints the therapist helps patients unbridle or constrain their wants and needs within their zones of responsibility. 5. Boundary experiences. Each person confronts loss with great regularity, which can trigger intimations of personal mortality. Death of a loved

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one, major injury to a friend, or a promotion at work can trigger a sense of loss. These boundary experiences assault us with the irrepressible force of time, the limits of human power, and the inevitability of death. Anniversary reactions represent one common form of this experience (Yalom, 1980). 6. The here-and-now. Perhaps the past forms us and the future pulls us, but we live only in the eternal present. The "now" extends forever and may be beautiful to enter (Perls, 1973; Yalom, 1980). 7. Existence precedes essence. Humans may recreate themselves because there is no absolute meaning or purpose to life. Positive or negative is every person's choice. BEHAVIORAL

1. Operant conditioning. Behavior is conditioned by its consequences. The possibility that a desired behavior will be repeated is increased if it is followed by positive consequences or the redirection of negative consequences. The possibility of its not being repeated is increased if a behavior is followed by negative consequences or no consequence. 2. Associative learning. If a new stimulus is paired with an effective stimulus, the new stimulus can trigger, on its own, the response associated with the effective stimulus (classical conditioning). The pairing of the stimuli transfers the value of the consequences to the new stimulus. 3. Modeling. Observation of an effective model performing feared or unlearned tasks in a graded fashion can accelerate behavior change. 4. Exposure. Anxiety, which leads to avoidance and is central to neurosis, can be extinguished through exposure to feared stimuli. A key objective of treatment is defining these stimuli, since some may be external and some may be intrapsychic. 5. Homework. Patients should work outside the therapy session. Homework assignments include careful recording of target behavior and their associated stimuli. 6. Suggestions. Behavior change is the focus of therapy. Direct behavioral suggestions may be useful in promoting behavior change. COGNITIVE

1. Maps for the territory. Human beings create in their own minds "maps for the territory" of external reality. The distortions of and deletions from these maps are associated with psychological difficulties (Bandler & Grinder, 1975). 2. Schemas. Schemas, representations of specific aspects of reality, are the focus of change. Key schemas are those representing the self in close interpersonal relationships (Horowitz, 1988).

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3. Automatic thoughts. Automatic thoughts, internal statements to the self and often out of awareness, are triggered by external stimuli that activate specific schemas (Beck et al, 1979). 4. A—B—C. Patient and therapist identify the stimuli that are associated with symptoms (anxiety, depression, anger, suicidal thinking, etc.) and look for the automatic thoughts connecting them. (Antecedent > Belief > Consequence.) 5. Symptoms as clues. Symptoms are viewed "positively" since they can lead to identification of automatic thoughts that are associated with dysfunctional schemas (Beck et al., 1979). 6. Schema change. Patients can change their schemas in several interrelated ways: (a) by examining their own thinking for evidence of distortion or missing knowledge; (b) by accepting evidence or information from the therapist and others; (c) by entering situations that are likely to provide contradictory evidence (e.g., exposure to feared situations); and (d) by observing another person doing that which the patient feels unable to do—modeling (Raimy, 1975). 7. New self-talk. Self-statements may be modified by logic and experience (e.g., black-white thinking becomes gray), or self-statements may be replaced by soothing, positive, encouraging words such as "I can do it; I am loved" (Meichenbaum, 1977). PSYCHODYNAMIC

1. The past influences the present. Past experiences with childhood caregivers form schemas by which current intimate relationships are understood and by which the self is judged. Knowing the general outline by which previous experience influences responses in the present has two practical effects: (a) patients believe that they have discovered a "cause" for their problems; and (b) they tell themselves, "The past is not the present," thereby learning to alter current responses based on past experiences. 2. Transference. Symptoms and other unwarranted responses may be activated in close interpersonal relationships including the psychotherapeutic relationship (transference). These signals can help to elucidate the schemas. 3. Grandiose-depreciated self. The degree of individual psychopathology is based upon extremes of the grandiose and depreciated selves. As suggested earlier, the greater the grandiosity (or the greater the depreciation), the greater the psychopathology. More disturbed people also tend to shift between these states (e.g., borderline patients). A corollary is: the greater the psychopathology, the poorer the self-other boundaries (Kohut, 1968; Kernberg, 1975). 4. Boundary violations. The poorer the patient's self-other boundaries,

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the more carefully must the therapist monitor and set limits to patient "boundary violations" such as coming late, repeated telephone calls, unwarranted requests for medications or extra visits or contact outside the office (Langs, 1973, 1974). 5. Countertransference. Therapists also have interpersonal schemas that may result in distorted thinking or behavior and can interfere with their carrying out effective treatment. 6. Resistance. The manner in which patients thwart therapeutic expectations may reflect basic neurotic styles. Attention to these avoidances can therefore provide signal behavior needing change. INTERPERSONAL

1. Interpersonal needs. People seek to satisfy their interpersonal needs by developing relationships with others. The failure to secure certain interpersonal needs can lead to psychological distress (Strong, 1987). 2. Metacommunication. When talking with each other, people are unconsciously communicating rules and directives about how they would like the receiver to respond (Watzlawick et al., 1967). 3. Gender roles. Gender role stereotypes in most cultures socialize and teach males to be dominant and females to be submissive. In Western society, marriage seems to promote the health and happiness of males while reducing the health and happiness of women. Being unmarried has the opposite effect for each gender (Klerman et al., 1984). 4. Dominant-submissive roles. Dysfunctional relationships are often characterized by rigid asymmetrical power relationships: someone is always in power and someone is always helpless. The person in each role may shift but the rigid imbalance remains. 5. Reducing vulnerability to hurt. Personality disorders and many other ineffective interpersonal strategies are established, in part, by their effectiveness in successful adaptation to early caregivers. Their function is to hold others in relationships to the self while reducing vulnerability to hurt (Cashdan, 1973). 6. Grief and interpersonal loss. Most relationships do not endure for a lifetime, and if they do, their character changes; therefore, people must be able to adapt to interpersonal loss and transition. Interpersonal psychotherapy may focus on grief generated from interpersonal change. MARITAL SYSTEMS (COUPLES)

1. Not a school. No school dominates marital therapy, since concepts from each school may sometimes be successfully applied to marital therapy. 2. Danger to marriages. Individual psychotherapy may be dangerous

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for marriages, since change in the patient is likely to create demand for change in the spouse. If the spouse does not change, the patient may become symptomatic again or the marriage may become strained. 3. Marital developmental stages. Like individuals and families, marriages have predictable developmental stages that foretell the problems facing them: (a) courtship, (b) the first year, (c) parenting and young children, (d) adolescence and middle marriage, (e) letting children go, and (f) alone again (Haley, 1973; Jacobson & Gurman, 1986). 4. Level of commitment. Therapists must quickly evaluate the level of commitment to continuing the marriage. Problem categories in order of increasing disintegration are (a) major problems but no question of divorce, (b) ambivalence in one partner about continuing the marriage, and (c) definite decision by one partner to divorce but wants therapy to smooth the exit from marriage. 5. Countertransference. Therapists must be careful to avoid the temptation to "save" marriages. Divorce may sometimes be the best solution. 6. 50-50 rule. Therapists must assume that each partner is contributing equally to the current problem until proven otherwise. 7. Better communication. Marital problems usually involve inability to communicate accurately to, and be understood by, each other. This failure leads each one to act negatively to the other, which spirals on itself and leads to painful withdrawal and stalemates (Heitler, 1990). 8. Multiple intervention points. Interventions may take place in several places along the vicious spiral created by the couple. The intervention points are determined by the mutual predispositions of therapist and couple; highlight past-present distortions; incorporate homework to behave more positively with each other; and involve strategic interventions that involve reframing, such as, "She yells at you so much because she loves you" (Jacobson & Gurman, 1986). FAMILY SYSTEMS

1. Transgenerational patterns. Across the generations families form cultures that contain rules by which the current family unconsciously operates. Genograms can elucidate them by identifying repeated patterns of behavior over the generations (Bowen, 1978). Patients often have great difficulty accepting the impossibility of changing their dysfunctional parents. 2. Enmeshed or disengaged. Families may be too enmeshed or too disengaged. These states create poor role definitions for the family members, leading to symptomatic expression by one of them. One approach to change is to establish clear subsystems with the parents in charge (Minuchin, 1974).

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3. Triangulation. Triangulation involves the use of a third person to reduce anxiety between two others. Commonly a child becomes the stabilizer for marital conflict by forming a cross-generational alliance with one parent. The child may become symptomatic, but the focus of therapy is often on the marriage. 4. Sexual abuse. Sexual abuse of girls is so common among psychologically disturbed patients that therapists must ask every female patient about it (Russell, 1986). It is not as uncommon in males as was once believed and therefore must be asked of them as well. 5. Motivated parents. A child's opinion about, or direct negative reaction to, specific dysfunctional marital patterns is likely to add impetus to change because parents want the best for their children. Including children in the interview not only offers new information but also can accelerate change. 6. Culture, gender roles, and values. Families contain the rules of the greater culture as well as of the genetic family. One great problem in our culture is that girls are considered inferior to boys, and women are considered inferior to men. The movement toward equality by women (and concerned men) creates a conflict in families that predisposes them to dysfunction. Therapists who encourage the independent equality of women are agents of cultural change. In this and other areas, therapists must clarify their own values (Goldfried & Davison, 1976; Leupnitz, 1988).

Patient Assessment Before seeing the therapist, each patient fills out several self-report questionnaires, including the Zung Anxiety Scale (Zung, 1971), the Beck Depression Inventory (Beck, Ward, & Mendelson, 1961), the Brief Symptom Inventory (Derogatis & Melisaratos, 1983), the Michigan Alcohol Screening Test (Selzer, 1971), and the Marks Mathews Fear Inventory (Marks & Mathews, 1979). With this information, the therapist overviews the symptoms experienced by the patient, particularly those that the patient does not describe as the most important. If the patient presents with anxiety, the Beck Depression Inventory picks up depression that might otherwise be missed because of the patient's concern about anxiety. Therapists are notoriously unwilling to ask about alcohol or drug abuse; the Michigan Alcohol Screening Test forces the therapist to confront this information. The Brief Symptom Inventory provides a long list of symptoms that might otherwise be overlooked. In addition, our clinic is beginning to ask each patient before coming to the first interview to complete a computerized diagnostic interview schedule, the C-DIS (Blouin, 1990). This procedure,

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which takes from one to one and a half hours, provides the therapist with an extensive inclusive list of diagnostic possibilities, which can be refined by direct interviewing. While some may see these instruments as intrusions on the therapeutic relationship, it is my view that when these mechanical questions are put aside, the relationship can begin more quickly. DSM-III-R diagnostic categories for which research has shown treatment responsiveness and other prognostic indicators must be defined first. For example, when seeing a patient diagnosed as having panic disorder, the therapist may then assume that there is a 50 percent chance that one first-degree relative also has panic disorder (Crowe, 1990). This information encourages therapists to consider the patient's children at greater risk for shyness, school phobia, and perhaps panic disorder and agoraphobia (Biederman et al, 1990). In addition, since panic disorder has been shown to be responsive to medications (Ballenger, 1986) as well as cognitive behavior therapy (Barlow, 1988), the therapist can then offer predictions about treatment outcomes. Diagnosis can often help educate the patient about the disorder and instill hope and confidence in the therapist. The MMPI and other personality inventories are useful in diagnostic assessment when there are questions about personality disorders. The presenting symptoms provide clues to the problems in the patient's intrapersonal and interpersonal life. Symptoms can be followed intrapersonally into distorted schemas and interpersonally into difficulties with others. The nature of the marital relationship is a crucial aspect of assessment, since this relationship often influences the beginning symptomatic behavior as well as maintains it (Hafner, 1986). Assessments are made at the individual, dyadic, and family levels as well as the work system, under the assumption that core problems are likely to be played out in any interpersonal sphere. Multiple environments provide different contexts to highlight the basic consistencies of maladaptive patterns. A symptom is a dramatic example of the generic "discrepancy" between normal responses and the patient's response. Investigations into such discrepancies are not done in a linear or categorical way. Instead, symptoms and discrepancies are assessed throughout the patient's interpersonal and intrapersonal life as signals for the underlying pattern in need of change. Assessment and treatment are integrated in two ways related to the sequential goals of therapy. Some patients simply want symptomatic relief. Whether to aim for symptom relief alone is a question for the assessment. Symptoms may be relieved in a variety of ways, including the placebo response, medications, systemic interventions, relaxation techniques, and education. As symptoms are being relieved, they become reframed as signals for information about distorted schemas.

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Applicability and Structures The approach I am advocating has been developed through work with patients having both panic disorder and major depression, who also have relatively disabling personality disorders. This approach appears useful for those with neurotic conditions and moderately severe personality disorders, as well as those with lesser conditions, who seem to be responsive to most types of interventions (Elkin et al., 1989). Although it has been developed in outpatient psychiatric settings, this form of treatment is likely to be applicable to similar patients in any outpatient setting. The typical frequency of sessions is once per week, and the typical length of session is 50 minutes. Therapy is not time limited but usually runs between 10 to 30 sessions. Combined modalities are an integral part of this treatment, especially if the patient is married. Medications are also a vital treatment option (Beitman, Hall, & Woodward, 1992; Beitman & Klerman, 1991). Although psychotherapy has been tried for a broad range of psychological dysfunctions, more recent work has made it clear that some patients are better served by educational and rehabilitation programs. Schizophrenics, chronic bipolar patients, and drug abusers have often missed crucial developmental challenges. They have not learned basic social and work skills. Psychotherapy can unleash already existing potentials in less disabled people through anxiety reduction and the incorporation of new information, while the chronic populations require structured learning and experience. It is very important, therefore, that psychotherapists recognize the limits of our scientific craft.

Interventions and Relationships It is the therapist's task to engage patients in therapy and to help them define patterns for change after symptoms are relieved. As the patterns to be changed are defined and the alternatives for change are understood by the patient, the therapist's responsibility becomes reduced somewhat (cf. Goldfried & Davison, 1976). Some methods for engagement work synergistically are (1) empathic reception, (2) suggestions that usually work (including medications and relaxation training), (3) clear explication and education about the problem, and (4) finding strengths and other positives in the patient (Beitman, 1987). Resistances and blocks to treatment usually exist when therapists have specific notions of what the patient is supposed to do. Resistances

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function like symptoms in that they signal dysfunctional schemas. For example, when assigning patients homework, failure to comply could be a possible outcome. The reasons for such failure provide information about parallel struggles within the patient and between the patient and people in the environment. Perhaps the most common errors of therapists operating within this approach are related to countertransference difficulties. If this were a highly systematic approach, there would be little chance for the personality of the therapist to interfere with the operation of therapy. But because it is intended to be integrated with each therapist's personal schemas, idiosyncratic distortions are more likely to affect decision making adversely. In regard to therapist activity, much is dependent on the activity of the patient. Although the therapist must actively engage the patient and help to define patterns to be changed, once the patient understands what is to be changed, activity level shifts to the patient. The therapeutic relationship is a precondition of change, as the therapist uses the leverage gained by engagement to help the patient consider changing maladaptive schemas. The therapeutic relationship can provide information about schemas to be changed and can provide a context in which schemas can be altered. Although psychoanalysts have overemphasized transference, it is not to be discarded, since dramatic here-and-now behavioral changes may take place through discussions of the relationship between patient and therapist, which generalize to other settings. There are a wide range of intimacy levels possible. Clinicians need to be very careful about maintaining boundaries while still being therapeutically close. Beginners may have the most difficulty, but as one becomes more mature and understands therapeutic role definitions, intimacy, closeness, laughter, joking, and making fun with each other can become part of therapy. As the patient takes more and more control over change, the relationship can become quite friendly. The dysfunctional schemas become problems more and more external to them personally as they keep challenging their sometimes resistant and resilient nature. The lack of problems to discuss often provides a signal for termination. Patients may rattle on about a variety of inconsequential ideas, or may describe problems they have already solved. At such times, termination is obviously something to be discussed. Another time to bring up termination is when the patient initiates changes—when it is obvious that major change in thinking and behavior are beginning to take place. This early mention of termination can elicit transference reactions for discussion, as change is practiced and maintained.

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Mechanisms of Change In 19th-century philosophy of science, cause was unidirectional (e.g., X caused Y). Since those simple early days, causal statements have become more complex. Although Einstein objected to the idea that God plays dice with the universe, probabilities seem more related to the association between discrete events than does any linear cause. The term variance so common in statistical analyses reflects our limited ability to explain temporal links in any but probabilistic means. Further complication in causal understanding has been added by notions of interactive causation (e.g., vicious or virtuous spirals). These principles are beginning to inform psychotherapy thinking about mechanisms of change (e.g., Pentony, 1981). Attempts to describe the mechanisms of change in psychotherapy must take into consideration the limits of other scientific causal explanations. In psychopharmacology current knowledge cannot explain how our antidepressants work despite several decades of intense work. Partial contributing factors are being uncovered for the mechanism of action of neuroleptics on dopamine receptors in schizophrenics (Seeman, 1991), but much more remains to be understood. The placebo response further confounds the change mechanisms of psychopharmacology. How is this crucial, yet usually overlooked, response to be understood? Horvath (1988) has suggested that patients learn to alter their self-talk in more encouraging directions. Understanding of the placebo response will increase our knowledge of the relationship between the "active ingredients" of psychotherapy and outcome. Psychotherapists need targets for change, as do their patients. When the "magic" of pills and placebo is insufficient, when intriguing paradoxical suggestions do not seem to work, then the hard labor of direct psychological change is necessary. The target of enduring change is the hypothetical core interpersonal schema, a simple idea whose complexity may only be realized as its crevices and textures are elucidated through the hard work of homework and self-observation. Change is "caused" by somehow providing both insight and outsight through paying attention to the inner schema and the outer matched aspects of reality. Somehow, with the patient's necessary acquiescence, the new information alters the old and change takes place. Several repetitions or repeated exposures are necessary. Rarely is the dramatic "aha" experiences sufficient. But to answer the question about how exposure of a distorted schema to new relevant information changes the schema is to go beyond current knowledge.

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Case Example In order to illustrate the preceding descriptions of this approach, I present a detailed case report.* SUMMARY Laura is a 30-year-old woman with a 15-year history of intermittent panic disorder and major depression. Treatment was focused first on symptoms using medications (imipramine and alprazolam), cognitive-behavioral diaries, diagnostic education, and looking for the positive. The core interpersonal schema centered around the need to be perfect for (1) her father, who was always threatening to leave the family and finally did get a divorce, and (2) her mother, who was a heavy smoker and emotionally dependent on Laura. The patient feared independence and self-assertion. Change was stymied through unconscious efforts by her husband to maintain the familiar equilibrium. Couples therapy, which focused on his difficulties as well as theirs, accelerated each of them to change. Session frequency was once weekly for approximately one year, with two early months of twice weekly individual psychotherapy. Follow-up frequency was biweekly or monthly. INITIAL ASSESSMENT

Laura, a mother of two girls ages 5 and 2, was accompanied by her husband, Keith, at her first session in January 1990. She was referred by a psychologist who knew of my interest in treating patients with panic disorder and depression. She had seen another psychiatrist, who had started her on 4 mg. of alprazolam. Self-report questionnaires revealed the following information: (1) no drugs of abuse, no caffeine use; (2) Beck Depression Inventory was 22, suggesting moderate depression; (3) Zung Anxiety Scale was 38, suggesting moderate anxiety; (4) Marks-Mathews Fear Inventory yielded scores of over 30 on both social phobia and agoraphobia, which suggested not only agoraphobia but great sensitivity to criticism by authority figures (including possibly the therapist); and (5) Brief Symptom Inventory yielded many symptoms scored 3 or 4, suggesting anxiety, depression, agoraphobia, and fears of mental illness. The patient noted that her anxiety would have been higher if she had not been taking alprazolam. The patient did not want to continue with alprazolam for very long, 'Both "Laura" and "Keith" read this report and provided consent for its publication.

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but was frightened to stop it. I suggested that she try imipramine.* As she increased the imipramine, the alprazolam would be reduced; she accepted this suggestion. I spent much of the first session describing panic disorder, depression, and their treatments. I suggested to her that panic disorder has several different overlapping psychological causes, which include (1) illness fears, (2) unresolved grief reactions, (3) fears of one's own anger, and (4) unresolved reactions to traumatic events, including sexual and physical abuse. I suggested to her that depression has multiple causes and one of them has to do with excessive perfectionism and negative self-talk. Since there are biological causes of depressivelike symptoms, I suggested that we get a thyroid screen, especially since her mother had had thyroid difficulties. It was normal.

ENGAGEMENT AND SYMPTOMATIC TREATMENT

The patient readily accepted the possible explanations for panic disorder and depression and willingly proceeded with a diary for panic attacks and depression. She also willingly developed a hierarchy for adventures out of the home. She was able to reach 150 mg of imipramine, the target dose, and in parallel spent increasingly more time away from the house by herself, with decreasing anxiety. In confronting these fears, she noticed and reported additional data about her intrapersonal life. The MMPI summary suggested that "she forms deep emotional attachments and tends to be quite vulnerable to hurt. She avoids confrontation and seeks nurturances from others, often at the price of her own independence." This suggestion was confirmed by details from her diary. Indeed, she was very dependent upon her husband's attention to her. She began to wonder how she used her agoraphobia to control him. She soon was able to taper off her alprazolam by April 10, 1990.

CORE SCHEMA

During Christmas, about a month before she came to see me, she had several severe panic attacks. Her father was visiting at her house, accompanied by a woman only two years older than the patient. Some persistent, gentle digging helped the patient admit to herself that she was angry about 'Alprazolam (Xanax), like diazepam (Valium), a benzodiazepine, had received much negative media attention because of its supposed "addiction" potential. It is safe and effective in early treatment, but for people with drug or alcohol abuse histories, it is likely to be misused. As with many panic patients, Laura feared losing control, so she wanted a medication easier to taper. Imipramine, an inexpensive antidepressant with several potentially uncomfortable side effects, could reduce her depression while also blocking her panic attacks.

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her father's being there, especially with "that other woman." This information suggested to both of us that perhaps anger avoidance had something to do with triggering her panic attacks. Further investigation over four to five months revealed many details around her relationship to her parents, which seemed central to her panic attacks and passive character. Her father was continually threatening to leave and actually separated from the family when the patient was 7, only to return. He finally obtained a divorce when the patient was age 15. She found herself trying to keep him happy at all costs. Her mother, who was a constant smoker, used the patient as her sole source of emotional support. Her mother eventually contracted lung cancer, despite the patient's protestations against smoking, and died when Laura was 28. Laura had not fully grieved her mother's death. This unresolved grief was another contributor to her panic attacks, since abnormal physical sensations reminded her of her mother's death and tended to trigger panics. Therapy involved attempts to have her visualize, despite her great resistances, her mother on her death bed. The patient's repeated phobic responses to her own bodily sensations, which sometimes became panic attacks, were based on her identification with her mother's suffering. She viewed herself as a "balancer" who was responsible for the emotional well-being of her parents. It was she who kept the marriage together by keeping her father happy. It was she who supplied emotional support for her mother. On the other hand, her needs remained unaddressed for, in fact, she was the emotional servant to both. She had been trained to stay home and became afraid to leave both because she did not want to abandon her mother by acting like her father and because she had so little experience in the world. In her marriage, Laura assumed the helpless needy role her mother had modeled for her, while feeling responsible for everything bad that happened or could happen. She gave Keith great power over her while also demeaning him through his lack of "perfect caring." Her self-opinion moved between great power and great helplessness (usually the latter), as did her relationship with Keith. TRANSFERENCE AND COUNTERTRANSFERENCE

During the first month of therapy, the patient called me three weeks in a row at my office on late Friday afternoons. She described many symptoms and many fears, and only later was able to admit that she was afraid she would never get me during the weekend when she "most needed" me. She was becoming deeply dependent upon me and terrified that I might abandon her. This was a reflection of her reality-based fear that her father and mother would leave her. I found these calls irritating, but she

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responded to firm limit setting. When she became confident that I wouldn't abandon her, these calls ceased. When, after a few months, she asked for twice-weekly psychotherapy, I felt she might be asking for unlimited time with me. But she was able to clearly state her strong desire to get through this difficulty, be a better mother for her children so they would not have to suffer from her unnecessary anxieties. This argument seemed genuine, although 1 suspected some other, more distorted reasons, including a need to feel closer and more dependent. The only other times these desires for additional attachment appeared were during termination discussions. Slow tapering of termination sessions seemed to desensitize her to these fears of loss. A major countertransference response was triggered in me when I was told that she had become pregnant, as will be described later. I had great hopes that she would follow her wish not only to be a mother but also to continue her schooling. By becoming pregnant again I felt "that she and her husband had ruined my great work." I could laugh at myself later, but 1 was also responding empathically to her. There was much in Laura and Keith that attracted me to them, that made me want to help them. She came from the East Coast and spoke with an accent reminiscent of my high school friends. She was intelligent and motivated and wanted to do the right thing. I shared many of her values. Her husband was a hardworking, sincere young man engaged in graduate studies in psychology. He reminded me of some of my classmates in college and medical school. CHANGE TARGETS AND CHANGE TECHNIQUES

The target for change was her core interpersonal schema, the details of which we tried to elucidate. As noted above, she described herself as "a balancer"; she tried to reduce her father's unhappiness with the family and her mother's own personal unhappiness. Some of the anxiety-generating self-statements associated with this core schema included: "I'd better not do anything because something bad might happen;" "Anything that goes wrong is my fault." The latter self-statement held her responsible for her mother's death and any other awful occurrences. In her relationship with her husband, Laura had adopted many of the earlier characteristics of those relationships. She was afraid he would leave her, and needed to control him with her symptoms as her mother had controlled her. She feared her own anger because it could upset the mental equilibrium. In addition to continuing education about her panic disorder and depression, I used several other techniques: 1. Simple instruction to do something different. This included an attack on her belief that things always turned out badly whatever she did.

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I suggested that she begin a garden. She gained some satisfaction from seeing this belief in her own incompetence challenged as her garden grew. 2. Exposure in its various forms became a critical part of therapy. Exposure to images of her mother's death was most crucial. 3. Addressing her grandiose-depreciated self, particularly the notion that "I am responsible for everything." I approached this by suggesting in various ways that there were many events in the world about which she had nothing to do, including the choice of her own mother. I formulated her interpersonal sensitivity as a "phobia of slights" to which she needed to be exposed. 4. I helped her modify her internal dialogue both by permitting herself to be more flexible about her thinking and by adding soothing self-talk in situations where she needed to be able to encourage herself, instead of inducing her husband to encourage her. THE BEGINNING OF RELAPSE

By May 18 she had reduced her imipramine and was directly confronting her self-talk about perfectionism. On May 22 she found herself pregnant. She quickly withdrew from the imipramine and became immediately afraid of the delivery. As she discussed this, it became clear that lying on the delivery table reminded her of her mother's pain during her last days of life in the hospital bed. She did not want to break this connection to her mother but saw that it was disrupting her ability to live now. She could begin to see the positive in her mother's death: freeing her of the caretaking. Yet she feared (1) the empathic reexperiencing of her mother's pain, (2) the guilt for having not stopped her from dying, and (3) the associated grief of her mother's death. Within a month of her becoming pregnant, Keith almost forced her into a situation in which she was very likely to have a panic attack. He wanted her to return to a park in which she had already had several panic attacks. Furthermore, he began to discuss with her the need for him to sell the car she used to get around town. By July she was becoming more anxious and afraid of seeing people or going out by herself. She did not want to talk about Keith's contribution to any problems; she was afraid he might leave. During our July sessions she became overly obsessional, asking such questions as "Why?" "What should I do?" "What does this mean?" I became irritated. I insisted that Keith come into treatment. She had difficulty telling him why we had asked him to return. She was starting to slip back into her old self. I listed the suspicious events by which Keith had kept her at home— pregnancy, encouraging her into a situation likely to trigger a panic attack, and wanting to sell her car. Intellectually he understood that these events

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indicated his resistance to her changing, but emotionally he could not take responsibility. He was quite happy with the way she was now. It seemed that after many years, she now was again the same person he had married. Gradually the focus shifted to Keith and his problems. His mother had had panic attacks. As a teenager he had seen her through a very difficult divorce. He could almost admit that he was afraid that if Laura changed, she might leave him. He was struggling with school while trying to support his family on a limited income. He wanted to keep things the way they were. We tried to help him stop monitoring her symptoms and encouraged Laura to monitor his difficulties. As she focused more on his problems, she became less symptomatic and more able to go out on her own. She became more confident that she could get angry at him, and it became clear that he could accept it. In the office, we practiced her listening to him and asking him questions. It was difficult for her at first, but with some instruction and guidance, she was able to move her attention to him and away from herself. Keith also could monitor himself more as he paid less attention to her. A year after we started, their third child, Mike, was born. The birth went very smoothly. She felt in control of the whole process by gathering around her friends upon whom she felt she could lean, including her husband. Her mother hardly entered into her consciousness. She had told herself when she knew she was pregnant that nine months later she would be psychologically liberated. Indeed, this self-programming seemed to have taken place. Her husband still had problems with his own mother, especially with the manner in which she interfered with their marriage. We would address these issues in once-monthly meetings. They had a child to bring through the first few months of his life. In March 1991, Laura stated that she was better. An "invisible hand" was moving her to do what she would not have done before. She felt anxious and went shopping instead of staying home. She casually told people about her anxiety problems and made fun of her illness fears. I predicted for them that her anxiety would return, but with decreasing frequency and intensity. She could use alprazolam to abort incipient panic attacks. Keith remained defensively skeptical, fearing that her intense neediness would return. By her steady improvement, he could allow himself to be convinced and no longer needed to be her ultimate rescuer. He too could become more himself as a result. Laura developed the "Chicken Little theory" of her problems. When she felt a strong sensation in her body, it became a catastrophe, just like Chicken Little in the children's tale, who, when hit by an acorn, feared the sky was falling. "What should I do now?" she asked me. "I feel good; I have more to learn. I know if I do things, I'll do more things." "Keep doing," I said. "You

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need to learn to find, test, and trust your intuition. That 'still small voice' is often hard to find but is your best source of advice."

Research and Future Directions No formal research is being undertaken to test these ideas. The informal research on this approach resembles the search for effective ideas, which characterize any psychotherapist willing to challenge personal beliefs when confronted with apparent anomalies or surprises. The need to integrate the psychotherapies through the discovery of similarities and the respect for differences harbingers the even greater necessity to break down other ideological boundaries in the same way. Religious, ethnic, racial, gender, and nationalistic belief systems provide the justification for terrible cruelty. I hope that the psychotherapy integration movement can provide a model by which the human beings of earth can embrace their similarities while also respecting their differences.

References BALLENGER, ]. C. (1986). Pharmacotherapy of panic disorders. Journal of Clinical Psychiatry, 47, 27-32. BANDLER, R., & GRINDER, J. (1975). The structure of magic (Vol. I). Palo Alto, CA: Science & Behavior Books. BARLOW, D. (1988). Anxiety and Us disorders. New York: Guilford. BECK, A. T., RUSH, A. J., SHAW, B. F., & EMERY, G. (1979). Cognitive therapy with depression. New York: Guilford. BECK, A. T., WARD, C., & MENDELSON, N. J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 53—63. BECKER, E. (1973). The denial of death. New York: Free Press. BEITMAN, B. D. (1987). The structure of individual psychotherapy. New York: Guilford. BEITMAN, B. D. (1990). Why I am an integrationist. British Journal of Guidance and Counseling, 17, 259-273. BEITMAN, B. D., HALL, M. ]., & WOODWARD, B. (1992). Integrating pharmacotherapy and psychotherapy. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. BEITMAN, B. D., & KLERMAN, G. L. (Eos.). (1991). Integrating pharmacotherapy and psychotherapy. Washington, DC: American Psychiatric Press. BlEDERMAN, J., RoSENBAUM, ]. F., HlRSHFELD, D. R., FARAONE, S. V., BoLDUC, E.

A., GERSTEN, M., MEMINGER, S. R., KAGAN, ]., SNIDMAN, N., & REZNICK, ]. S. (1990). Psychiatric correlates of behavioral inhibition in young children of

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parents with and without psychiatric disorders. Archives of General Psychiatry, 47, 21-26. BLOUIN, A. (1990). C-D/S. Ottawa: Ottawa Civic Hospital. BOWEN, M. (1978). Family therapy in clinical practice. New York: Jason Aronson. CASHDAN, S. (1973). Interactional psychotherapy. New York: Grune & Stratton. CROWE, R. (1990). Molecular genetics and panic disorder: New approaches to an old problem. In Ballenger, J. (Ed.), Neurobiology of panic disorder (pp. 59-70). New York: Allan R. Liss. CROWLEY, A. (1944). Tarot of the Egyptians. New York: Samuel Weiser. DEROGATIS, L. R., & MELISARATOS, N. (1983). The Brief Symptom Inventory: An introductory court. Psychological Medicine, 13, 595-605. ELKIN, I., SHEA, M. T., WATKINS, J. T., IMBER, S. D., SOTSKY, S. M., COLLINS, J. F., GLASS, D. R., PILKONIS, P. A., LEBER, W. R., DOCHERTY, J. P., FIESTER, S. ]., & PARLOFF, M. B. (1989). National Institute of Mental Health treatment of depression collaborative research program: General effectiveness of treatments. Archives of General Psychiatry, 46, 971—982. FREUD, S. (1963). Therapy and technique (P. Rieff, Ed.). New York: Collier. GABBARD, G. (1990). Psychodynamic psychotherapy in clinical practice. Washington, DC: American Psychiatric Press. GOLDFRIED, M. R., & DAVISON, G. C. (1976). Clinical behavior therapy. New York: Holt, Rinehart & Winston. GREENSON, R. (1967). The technique and practice in psychoanalysis (Vol. 1). New York: International Universities Press. HAFNER, R. J. (1986). Marriage and mental illness: A sex roles perspective. New York: Guilford. HALEY, J. (1973). Uncommon therapy. New York: Norton. HART, J. (1983). Modern eclectic therapy. New York: Plenum. HAVENS, L. (1974). Existential uses of self. American Journal of Psychiatry, 131, 1-10. HEITLER, S. M. (1990). From conflict to resolution. New York: Norton. HOROWITZ, M. J. (1988). Introduction to psychodynamics. New York: Basic Books. HORVATH, P. (1988). Placebos and common factors in two decades of psychotherapy research. Psychological Bulletin, 104, 214-225. JACOBSON, N. S., & GURMAN, A. S. (Eos.). (1986). Clinical handbook of marital therapy. New York: Guilford. KELLEY, G. (1955). The psychology of personal constructs. New York: Norton. KERNBERG, O. (1975). Borderline conditions in pathological narcissism. New York: Jason Aronson. KERNBERG, O. F., SELZER, M. A., KOENIGSBERG, H. W., CARR, A. C., & APPELBAUM, A. H. (1989). Psychodynamic psychotherapy of borderline patients. New York: Basic Books. KLERMAN, G. L., WEISSMAN, M. M., ROUNSAVILLE, B. J., & CHEVRON, E. S. (1984). Interpersonal psychotherapy of depression. New York: Basic Books.

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KOHUT, H. (1968). The psychoanalytic treatment of narcissistic personality disorders. Psychoanalytic Study of the Child, 23, 86-113. KORZYBSKI, A. (1958). Science and sanity (4th ed.). Lakeville, CT: International Non-Aristotelian Library. LAMBERT, M. J. (1986). Some implications of psychotherapy outcome research for eclectic psychotherapy. International Journal of Eclectic Psychotherapy, 5, 16-46. LANGS, R. (1973, 1974). The technique of psychoanalytic psychotherapy (Vols. 1 & 2). New York: Jason Aronson. LAZARUS, A. (1986). Multi-modal behavior therapy. New York: Springer. LEUPNITZ, D. A. (1988). The family interpreted: Feminist theory in clinical practice. New York: Basic Books. LUBORSKY, L. (1984). Principles of psychoanalytic psychotherapy: A manual for expressive treatment. New York: Basic Books. MANNING, D. W., & FRANCES, A. J. (1990). Combined therapy for depression-. A critical review of the literature. In D. W. Manning & A. J. Frances (Eds.) (pp. 1—34), Combined pharmacotherapy and psychotherapy for depression. Washington, DC: American Psychiatric Press. MARKS, I. M., & MATHEWS, A. M. (1979). Brief standards self-rating for phobic patients. Behavior Research and Therapy, 17, 263-267. MEICHENBAUM, D. (1977). Cognitive-behavior modification. New York: Plenum. MINUCHIN, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press. PENTONY, P. (1981). Models of influence in psychotherapy. New York: Free Press. PERLS, F. (1973). Gestalt approach: An eyewitness to therapy. Ben Lomand, CA: Science & Behavior Books. RAIMY, V. (1975). Misunderstandings of the self. San Francisco: Jossey-Bass. ROGERS, C. R. (1951). Client-centered psychotherapy. Boston: Houghton Mifflin. ROGERS, C. R. (1942). Counseling and psychotherapy. Boston: Houghton Mifflin. RUSSELL, D. E. H. (1986). The secret trauma: Incest in the lives of girls and women. New York: Basic Books. SEEMAN, P. (1991, February). Dopamine receptors in schizophrenia. Paper presented at the meeting of the American College of Psychiatrists, Ft. Lauderdale, FL. SELZER, M. L. (1971). Michigan Alcohol Screening Test: The quest for a new diagnostic instrument. American Journal of Psychiatry, 727, 89-94. STILES, W. B., ELLIOTT, R., LLEWELYN, S. P., FIRTH-COZENS, J. A., MARGISON, F. R., SHAPIRO, D. A., & HARDY, G. (1991). Assimilation of problematic experiences by clients in psychotherapy. Psychotherapy, 27, 411—420. STRONG, S. R. (1987). Interpersonal theory as a common language for psychotherapy. Journal of Integrative and Eclectic Psychotherapy, 6, 173—183. VON BERTALANFFY, L. (1964). General systems theory. New York: George Braziller. , WACHTEL, P. L., & McKiNNEY, M. K. (1992). Cyclical psychodynamics and

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integrative psychodynamic therapy. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. WACHTEL, E. F., & WACHTEL, P. L. (1986). Family dynamics in individual psychotherapy. New York: Guilford. WATZLAWICK, P., BEAVIN, ]. H., i JACKSON, D. D. (1967). Pragmatics of human communication. New York: Norton. WOLFE, J. (1973). The practice of behavior therapy (2nd ed.). Elmsford, NY: Pergamon. YALOM, I. D. (1980). Existential psychotherapy. New York: Basic Books. ZALAQUETT, C. P. (1989). The internal parts model: Parts, polarities, and dichotomies, journal of Integrative and Eclectic Psychotherapy, 8, 329-342. ZUNG, W. K. (1971). A rating instrument for anxiety disorders. Psychosomatics, 12, 271-379.

CHAPTER 7

Multi-modal Therapy. Technical Eclecticism with Minimal Integration ARNOLD A. LAZARUS

A,

A LTHOUGH RIGID SCHOOL ADHERENCE in psychotherapy is by no means passe, it has become increasingly clear to most theorists and practitioners that no single orientation can shed light on the vast range of problems and issues for which people consult psychotherapists. When I called for a technically eclectic approach over 25 years ago (Lazarus, 1967) the response was anything but favorable or supportive. For example, immediate expulsion from the editorial board of Behaviour Research and Therapy was followed by a vitriolic attack by the recondite Eysenck (1970), who railed that eclecticism "would lead us to nothing but a mishmash of theories, a huggermugger of procedures, a gallimaufry of therapies, and a charivaria of activities having no proper rationale, and incapable of being tested or evaluated" (p. 145). This is not the place to offer an extensive rebuttal of Eysenck's position (for a comprehensive critique of Eysenck's controversial contributions to behavior therapy, see Lazarus, 1986), but it is worth emphasizing how far the field has progressed during the past 20 to 25 years. Today, 59 to 72 percent of counselors and clinicians endorse an eclectic stance (Jensen, Bergin, & Greaves, 1990). Many would now agree that a systematic, prescriptive, eclectic approach offers the greatest opportunities for clinical practice and psychotherapy research (Norcross, Alford, & DeMichele, 1992). I wish to thank, in addition to the editors, Drs. Allen Fay, Clifford Lazarus, and Stanley Messer for their helpful suggestions.

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Systematic (Technical) Eclecticism There are vast differences between a haphazard, subjective, smorgasbord conception of eclecticism (known as syncretism), and one that rests on the practical application of psychological science (Norcross, 1986). Systematic (technical) eclecticism borrows or imports techniques from diverse sources without subscribing to the theories that spawned them. Nevertheless, technical eclecticism is neither antitheoretical nor atheoretical. As a technical eclectic, I subscribe mainly to a social and cognitive learning theory (Bandura, 1986) because its tenets are open to verification or disproof. The efficacy of any technique from free association to behavioral shaping will be accounted for in social learning theory terms. The active ingredients of techniques as diverse as the empty-chair, projected imagery, cognitive restructuring, relaxation, assertiveness training, abreaction, biofeedback, flooding, structured daydreams, and so forth, are readily explained by social and cognitive learning principles (Lazarus, 1989). Thus, a rhythmic breathing technique to offset certain anxiety-inducing cues may be adopted from yoga practice, but its efficacy does not require one to subscribe to yoga principles. I have yet to administer an effective technique that was not readily explicable in terms of conditioning, vicarious learning, modeling, identification, self-talk, and other parameters of social and cognitive learning processes. Technical eclectics may draw ideas, strategies, and observations from Adlerian, Rogerian, and Ericksonian schools, or from any other approach— for example, psychodrama, Gestalt, reality, transactional—without embracing any of the diverse theoretical positions. Blending bits and pieces of different theories is likely to obfuscate matters. Remaining theoretically consistent but technically eclectic (see Dryden, 1987) enables therapists to spell out precisely what procedures they use with various clients, and the means by which they select those particular methods.

Integration: Proceed with Caution Those who favor an integrative over an eclectic viewpoint are apt to employ techniques from various sources, while also seeking to harness greater power by combining different theories or aspects of particular schools of thought. Some theoretical positions can readily be amalgamated with others. For example, general systems theory (von Bertalanffy, 1974) seems to be compatible with social learning theory. Indeed, Franks (1982), a vociferous opponent of the eclectic or integrative movement, concedes that to combine systems theory with the precepts of behavior therapy

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"offers considerable promise" (p. 5). Kwee and Lazarus (1986) addressed some clinical avenues that may be enriched by a systems/social learning theory merger. But for the most part, one cannot be too cautious about the dangers of combining elements from two or more theories. Close scrutiny will show that many theoretical positions that appear to be interchangeable are actually irreconcilable, intrinsically incompatible, if not antithetical (Messer & Winokur, 1981). Let us address one of the most prevalent errors in this connection. Many clinicians have contended that when treating phobias, they employ desensitization to get rid of the symptoms, while drawing on psychodynamic concepts to achieve insight (e.g., Fensterheim & Glazer, 1983; Wachtel, 1987). On the face of it, this psychobehavioral hybrid combines the best of two worlds, but if one understands that phobias, from a psychodynamic perspective, entail conflicting urges, symbolic processes, and often serve hidden (unconscious) purposes, desensitization would violate the very essence of the "real" problem and its attendant functions. So-called symptomatic treatment is at odds with psychoanalytic drive theory, ego psychology, object relations theory, and self-psychology. Conversely, from a social learning perspective, most psychodynamic insights draw on putative processes that are not verifiable or capable of disproof and are therefore outside the realm of science. A cognitivebehavioral conception of phobias rests on entirely different assumptions from those embraced by psychodynamic thinkers, both from the viewpoint of the origin of the disturbance and from the point of view of their appropriate method of treatment (Bandura, 1986; Lazarus & Messer, 1988; O'Leary & Wilson, 1987). Nevertheless, a thorough assessment may reveal that a given phobia patient is riddled with conflict, is struggling with triangulated and enmeshed familial relationships, and is deriving secondary gains from his or her avoidant behaviors. A salubrious treatment outcome calls for attention to, and remediation of, each of these aspects of the problem. Similarly, as emphasized elsewhere (Lazarus, 1991), if a person is claustrophobic and he or she feels trapped in an untenable marriage, it is unlikely that treatments addressed only to the external stimuli will be adequate. But when enabling patients to resolve their conflicts, or undo unfortunate familial collusions, it is wise to avoid the quagmire of psychodynamic theorizing, and it is equally expedient to keep away from theoretical assumptions offered by Bowen, Haley, Minuchin, Watzlawick, or other members of a family systems perspective (since the views of these personages are often untestable and are often directly opposed to one another). Instead of drawing on potentially incompatible theories, many of which, over time, may be proved inaccurate, a technical eclectic may draw quite freely on observations from many and diverse sources. For example,

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psychodynamic thinking, when stripped of its excess theoretical baggage, enables one to appreciate the observation that people are capable of denying, projecting, disowning, displacing, splitting, and repressing their emotions, and that unconscious motivation is often important for the full understanding of behavior—which should not be confused with reified versions of "the unconscious mind" and "defense mechanisms" (see Lazarus, 1989).

Can Observations Be Separated from Theories? How do theories differ from observations? Theories are essentially speculations that attempt to account for or explain various phenomena. A theory endeavors to answer how and why certain processes arise, are maintained, can be modified, or can be eliminated. Observations simply reflect empirical data without offering explanations. Given the fact that observations do not occur in a vacuum but are influenced by our viewpoints (we bring our theoretical ideas to what we observe), is it, in fact, possible to separate observations from theories? According to extreme views of social constructionism (Gergen, 1982), we create what we observe to the extent that we cannot discover what is inherent in nature; rather, we invent our theories and categories, and view the world through them. From this perspective, it is impossible to separate observation from theory. A less extreme view would concede that therapists probably have no "hard" facts, "brute" data, or "pure" observations, but that the distinction between observations and theories is nevertheless worth upholding—even though observations cannot be entirely separated from theory (Lazarus & Messer, 1991). "Observations" refer to notions that call for minimal speculation. Compare the following two statements: "People overheard him arguing with his boss, and when he came home he kicked the dog." "He did so because of displaced conflictual impulses toward his boss, a father figure who exacerbated his castration anxiety based on ego-dystonic homosexual fantasies." The first statement (the observation) contains some low-level inferences and is not 100 percent theory-neutral, but the range of assumptions conveyed in the second statement makes it quantitatively and qualitatively different from the first. The point at issue is that observations do not have to constitute pure facts in order to be separable from theories. If it were deemed impossible ever to separate the two, how would we ever test our theories? It is futile to garner bits of information and blend theoretical elements from the hundreds of different psychotherapeutic schools in the hopes of

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constructing a superordinate umbrella under which disparate ideas can be reconciled. This type of theoretical integration only breeds confusion. But the effective practice of psychotherapy requires a basis from which we can draw to account for the vagaries and idiosyncrasies of human temperament, personality, and behavior. What concepts and observations (not theories) from any source are necessary to provide a basis for understanding human psychology and creating a comprehensive and scientific approach to psychotherapy? Wielding Occam's razor, we would want only those concepts that are absolutely necessary. The following list of basic concepts is one that I consider necessary and sufficient to account for the factors that shape and maintain human personality: (1) associations and relations among events (i.e., operant and Pavlovian conditioning—see Rescorla, 1988); (2) modeling and imitation (see Bandura, 1986); (3) nonconscious processes (not to be confused with "the unconscious," but drawing solely on the observation that people have different levels and degrees of awareness, and that unrecognized—subliminal—stimuli can influence one's thoughts, feelings, and behaviors); (4) defensive reactions (not to be equated with the Freudian theory of "defense mechanisms"); (5) private events or idiosyncratic perceptions (addressing the fact that people do not respond to some real environment, but rather to their perceived environment, thus factoring in the personalistic use of language, semantics, expectancies, encoding, and selective attention); (6) metacommunications (we communicate about our communications); and (7) thresholds (people have different frustration-tolerance thresholds, different stress-tolerance thresholds, different pain-tolerance thresholds, and so forth, all of which are largely innate and account for a good deal of interpersonal variance). The foregoing all rest on a biochemical-neurophysiological substrate. (For a detailed account of the role these concepts play in multimodal assessment and therapy, see Lazarus, 1989). To recapitulate, whereas rigid adherence to competitive schools of psychotherapeutic thought is rapidly being replaced by a systematic, eclectic, and integrative climate, one must guard against the temptation to merge notions that are intrinsically incompatible. By operating from a consistent, testable, theoretical base, it is possible to draw on techniques and observations from diverse sources, thereby enriching one's clinical armamentarium without violating the integrity and testability of one's underlying assumptions. But while this technically eclectic and cautiously integrative stance will enable therapists to bypass the many prohibitions and limitations that individual systems may impose, it does not provide practitioners with any guidelines for clinical decision making. Eclecticism per se, offers no modus operand! for selecting treatments of choice, matching therapy styles to particular client variables, or choosing the type of relationship stance that is most likely to facilitate growth and change.

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Multimodal assessment is presented as a method within a systematic, technically eclectic position that offers a "blueprint" for attaining these objectives.

The Multimodal Approach In keeping with the foregoing technically eclectic framework, resting mainly on social and cognitive learning theory, the goal of multimodal therapy (MMT) is to reduce psychological suffering and promote personal growth as rapidly and as durably as possible. Its practice is based on the view that an effective way to think about people and to assess their psychological strengths and weaknesses is in terms of their various actions and interactions across seven discrete but interactive modalities of functioning: Behavior, Affect, Sensation, Imagery, Cognition, Interpersonal relationships, and Biological processes. By referring to the biological modality as "Drugs/Biology," the convenient acronym BASIC I.D., derived from the first letters of each dimension, creates a useful mnemonic. As a model for clinical practice, the BASIC I.D. embodies the following principles: 1. Human beings act and interact across the seven modalities. 2. These modalities exist in a state of reciprocal transaction and flux, connected by complex chains of behavior and other psychophysiological processes. 3. Accurate and thorough assessment often requires systematic assessment of each modality and its interaction with every other. 4. Durable treatment outcomes are more likely if significant problems throughout the BASIC I.D. are specifically corrected. 5. Psychological disturbance is a product of one or more of the following: conflicting or ambivalent feelings and reactions, misinformation, missing information, maladaptive habits, biological dysfunctions, interpersonal inquietude, issues pertaining to negative self-acceptance, external stressors, and existential concerns (see Lazarus, 1989, for a full exposition of these factors). The multimodal approach evolved mainly from follow-up inquiries showing that durable outcomes seemed to be a function of how much patients had learned during therapy, moving from a somewhat rigid behavioral perspective into a broad-spectrum approach, before finally emerging as distinctly multimodal per se (Dryden, 1991a). It seems straightforward to assume that the more useful and relevant information a person leams in

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therapy, the greater will be the range of his or her coping responses, and that it is thus less likely that relapse will occur. The advantages of breadth over depth became clear when people who consulted me after receiving psychotherapy elsewhere (sometimes for several years) still displayed significant excesses and deficits in many areas of their BASIC I.D. For example, patients who had received "cognitive therapy" often remained at the mercy of intrusive images and untoward sensations that had not been adequately addressed and that overwhelmed their best attempts at cognitive restructuring. Those who had been in psychodynamic therapy were often armed with insight but remained devoid of social and interpersonal skills and other adaptive behavioral responses that called for explicit training, coaching, and modeling. Patients who had been in existential analyses, or had received affectively charged treatments (e.g., bioenergetic, primal, or various forms of psychodrama) had never learned how to challenge specific cognitive errors and dysfunctional beliefs, or overcome a variety of maladaptive behavioral and interpersonal difficulties. Many had been seen by biologically oriented psychiatrists who seemed to think that adequate treatment of the "D" modality would ipso facto take care of problems throughout the BASIC I. Nevertheless, it should not be concluded that MMT advocates the complete assessment and treatment of the BASIC I.D. in virtually every case. Indeed, there are those for whom the correct antidepressant will solve 90 percent of their difficulties; others need no more than a shoulder to cry on, a confidant to lean on, or a nonjudgmental and empathic listener whom they can respect. Perhaps the most important skill in any therapeutic endeavor is the ability to determine who and what each individual is most likely to find particularly helpful. In MMT the emphasis throughout is on (1) treatments of choice (i.e., knowing what the research literature has to say about specific remedies for particular problems); (2) tailored interventions (i.e., selecting psychotherapeutic strategies to fit patients' goals, coping behaviors, situational contexts, affective reactions, "resistances," and basic beliefs); and (3) therapists' styles (i.e., going beyond formal diagnoses to match treatment styles to specific client characteristics). Beutler and Clarkin (1990) discuss prescriptive decisions that enable therapists to match technical interventions as well as interpersonal styles according to several parameters. Many writers pay lip service to individual uniqueness and aver that therapy must be tailored to the personalistic needs of each patient. Having stated this, the practitioners proceed to fit all-comers into the confines of their (usually narrow) system of therapy. The polar opposite of the prescriptive emphasis of MMT is exemplified by the work of the late Carl Rogers and his person-centered followers (Lazarus & Lazarus, 1991a). Strict Rogerians never ask: "What type of relationship will be best-suited to this client's personality and problems?"

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"How much direction and support will best meet the demands of this person's needs at various times throughout therapy?" "What specific techniques will facilitate change; when and how should these methods be introduced and implemented?" Instead, the entire counseling process rests on the therapeutic alliance, wherein the therapist endeavors to communicate genuine empathy and unconditional positive regard, which is deemed both necessary and sufficient for constructive personality change (Bozarth, 1991). Multimodal clinicians regard the patient-therapist relationship as the soil that enables the techniques to take root—it is not the complete means to the end (Lazarus & Fay, 1984). The multimodal view is that within the context of a warm, caring therapeutic relationship, it is necessary to remedy maladaptive behaviors, faulty cognitions, and other problems throughout the BASIC I.D., and that effective therapy often calls for coping skills training (communication skills, relationship skills, health maintenance skills, problem-solving skills, sexual skills, and career development skills—to name a few). Some of the main hypothesized mechanisms of change, from a multimodal perspective, may be listed as follows: • Behavior: Positive reinforcement; negative reinforcement; punishment; counterconditioning; extinction • Affect: Acknowledging, clarifying, and recognizing feelings; abreaction • Sensation: Tension release; sensory pleasuring • Imagery: Coping images; change in self-image • Cognition: Cognitive restructuring; heightening awareness • Interpersonal Relationships: Modeling (developing assertive and other social skills); dispersing unhealthy collusions • Drugs/Biology: Identifying medical illness; substance abuse cessation; better nutrition and exercise; psychotropic medication when indicated A point worth emphasizing is that one cannot elicit or change affects or emotions directly; this modality can be worked with only indirectly (Lazarus & Lazarus, 1990). One can deal directly with behavior ("Do this; say that; act like this; don't stand there; don't say that"). The sensory modality is open to direct stimulation ("Hear that; see this; touch that; smell this; taste that"). In the interpersonal modality, direct interventions such as imitation, modeling, and role playing are among the most common. The biological modality lends itself to numerous direct interventions, drugs and surgery being the most obvious. Even inferred constructs such as cognitions and images are amenable to direct intervention: "Dispute that false belief," "Think about it this way," "Imagine yourself sitting under a palm tree," "Picture an elephant running across a field." But affect can only be accessed or reached through behavior, sensation, imagery, cognition, inter-

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personal relationships, and biological processes. While many people seek therapy because they feel bad (i.e., they are experiencing negative affective states such as anxiety, depression, and guilt), the multimodal position is that the most elegant and thorough way of reducing anxiety, lifting depression, and assuaging guilt is to eliminate the specific and interrelated dysfunctional patterns of behavior, sensation, imagery, cognition, interpersonal relationships, and possible biological processes.

Initial Interviews In multimodal assessment there is no slavish attention to order. A person in crisis needs a good listener and someone who can offer immediate support, reassurance, and perhaps guidance and technical intervention. There are those who enter therapy with many misgivings, such as low levels of basic trust, so that a sensitive period of rapport building is essential before any specific measures can be applied. Some patients are "window shoppers," whose uncommited attitude can be very trying but who need a nonthreatening environment, because these potential consumers are easily scared away. And then there are those who come mainly to complain. Most rewarding, of course, are those "customers" who are willing to work and are ready for change. Irrespective of the patient's readiness for change, two basic questions need to be thought through in every case: (a) What has led to the current situation? (b) Who or what is maintaining it? Any good clinician will be on the alert for signs of psychosis, intellectual impairment, homicidal or suicidal tendencies, and other indications of serious psychopathology. And any astute therapist will note what patients say, and how they say it—being on the lookout for hesitations, blocks, changes in affect, significant gestures and movements, rapid breathing, frequent swallowing, and other minutiae (without reading too much into them). A major emphasis throughout MMT is on flexibility and versatility. Initial interviews provide a neutral, accepting, and open atmosphere. It is then necessary to gauge how best to augment the level of rapport with each individual. For some, gentle clarification of their affective reactions is a necessary precursor to any specific training or assignments, and a reflective ambience is made to order. Others grow impatient with purely supportive tactics and respond best to immediate cognitive disputation. How can a therapist determine when it is advisable to remain silent, pensive, and quietly reflective, versus being active, directive, and distinctly didactic? By using his or her clinical judgment and studiously observing the impact of each intervention (Lazarus, 1989). Howard, Nance, and Myers (1987) have

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discussed the need for therapists to vary the extent of directiveness and supportiveness throughout therapy, and they provide interesting choice points for reaching these decisions. Whenever there is a definite discrepancy between the client's apparent presymptomatic stress and the severity of the ongoing disorder, particular attention should be paid to biological considerations. A typical mentalstatus examination is performed. If this examination suggests neurological impairment, a thorough testing of the client's comprehension, attention, grasp, reasoning, judgment, and other neuropsychological factors is called for. When in doubt, a neurological consultation is strongly recommended. The patient's interests are best served when the therapist has a network of competent physicians for consultation (psychiatrists, neurologists, endocrinologists, internists). In essence, initial interviews are used to arrive at 12 determinations: 1. Are there signs of psychosis (e.g., delusions, thought disorder, bizarre or inappropriate behavior, incongruity of affect)? 2. Are there signs of organicity (e.g., disorientation, memory lapses, rigid posture, untoward mannerisms)? 3. Is there evidence of depression, or suicidal or homicidal tendencies? 4. What are the presenting complaints and their main precipitating events? 5. Why is the patient seeking therapy at this time—why not last week, last month, or last year? 6. What appear to be some important antecedent factors? 7. Who or what seems to be maintaining the patient's overt and covert problems? 8. What does the patient wish to derive from therapy? 9. Are there clear indications or contraindications for the adoption of a particular therapeutic style? (Does a basic directive or nondirective initial stance seem preferable?) 10. Are there any indications that it would be in the patient's best interests to be seen individually, as part of a dyad, triad, family unit, and/or in a group? 11. Is it likely that a facilitative therapeutic relationship will be established, or should the patient be referred elsewhere? 12. What are some of the patient's positive attributes and strengths? While the foregoing typifies the multimodal approach during the early stages of therapy, it is not distinctly different from most broad-based, eclectic practices. Yet MMT has several unique assessment procedures that set it apart from other approaches.

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How Multimodal Therapy (MMT) Differs from Other Eclectic Approaches MMT has been used with inpatients (Brunell & Young, 1982; Kwee, Duivenvoorden, Trijsburg, & Thiel, 1986; Roberts, Jackson, & Phelps, 1980), children (Keat, 1979, 1990), adolescents (Edwards & Kleine, 1986), and with specific populations in various settings (Brickner, 1984; Greenburg, 1982; Kertesz, 1988; O'Keefe & Castaldo, 1985; Ponterotto, 1987; Ridley, 1984; Rudolph, 1985; Sank, 1979; Slowinski, 1985; Smith & Southern, 1980). The present account will deal with the treatment of adult outpatients.

MODALITY PROFILES

Information derived from initial interviews and the 15-page Multimodal Life History Inventory (Lazarus & Lazarus, 199lb) usually provide the therapist with information sufficient to design a comprehensive treatment program. The inventory, in addition to obtaining routine background information, contains a "Modality Analysis of Current Problems" via behavior, affect, sensation, imagery, cognition, interpersonal relationships, and biological factors. In tandem with observations obtained during the first couple of interviews, after the patient completes the Multimodal Life History Inventory, the therapist is in a position to construct a BASIC I.D. chart, or Modality Profile—a distinctive feature of multimodal assessment. The Modality Profile lists salient problems in each dimension of the BASIC I.D. with recommended treatments. Table 7.1 is the Modality Profile of a 37-year-old man in treatment for generalized anxiety. Some MMT practitioners use these problem checklists routinely, but I construct them only when therapy is not proceeding apace and when unforeseen problems arise. The discipline and time (seldom more than 15 or 20 minutes) required to construct these profiles is usually well worth the effort, and they often enable the therapist to pinpoint specific issues and interactions that may have eluded other avenues of inquiry. C. N. Lazarus (1991) has provided clear-cut and vivid examples of the ways in which Modality Profiles are far superior to traditional psychiatric diagnoses for facilitating treatment selection. Given a Modality Profile, how does one proceed to select and prioritize treatment goals? A basic rule is to start with items that are likely to respond to one's ministrations, thereby augmenting one's credibility. In many instances, certain problems call for immediate attention. For example, an individual who is unduly tense may require some form of relaxation training before other measures can be introduced. Another person with a

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Modality Profile Modality Behavior

Problem

Intervention

Procrastination

Contingency contracting Modeling and role playing of assertiveness skills

Tends to pout or withdraw when frustrated Volatile and explosive Affect

Anxiety Depression

Sensation

Imagery Cognition

Interpersonal relationships Drugs/ biology

Jealousy Tension (esp. in jaws and neck) Lower-back pain Lonely images Images of failure Perfectionism Negative scanning Dichotomous thinking Self-downing Passive-agressive Unassertive Has few friends Insufficient exercise Overweight

Relaxation and communication training Breathing and deep muscle relaxation; stress inoculation training Coping imagery; increase rewarding activities Flooding and cognitive disputation Relaxation training Orthopedic exercises Picturing various coping responses Cognitive restructuring

Social skills and assertiveness training Healthy lifestyle program

clearly dysfunctional belief that undermines several areas of discourse may require "cognitive disputation" as an initial intervention. Generally, the choice of problem areas to be addressed, and the techniques to be administered are discussed with the patient, and decisions are made in concert with his or her input. When deciding upon the interactive cadence that is most likely to yield respect, compliance, or treatment adherence by the patient, multimodal therapists pay close attention to three items on the Multimodal Life History Inventory (p. 4). "In a few words, what do you think therapy is all about?" "How long do you think your therapy should last?" "What

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personal qualities do you think the ideal therapist should possess?" Someone who thinks that therapy is all about the past and its current implications is likely to be displeased with an exclusively here-and-now inquiry. A person who anticipates a three-to-six-month course of treatment may be nonplused in the hands of a long-term psychotherapist. A patient who considers a good therapist "someone who is an active listener, who says very little but takes in a whole lot," will probably take unkindly to an active-directive, task-oriented clinician. It would be naive to assume that patients necessarily know what is best for them or that the therapist must comply with each of their expectations. Nevertheless, I have found that it is wise, initially, to follow the patient's script fairly closely so that adequate rapport is established. Thereafter, it is more acceptable and less threatening when the therapist rewrites parts of the scenario and develops a modus operandi that seems better suited to overcome the patient's fundamental problems. Most patients elect to terminate therapy before all the entries on their problem profile have been addressed and successfully resolved. When the more debilitating or disturbing features have been overcome, some patients may decide to "go it alone." They usually feel capable of living with the remaining problems, or have acquired sufficient coping skills to apply them in a self-help capacity and thereby further attenuate residual difficulties. Others may elect to undergo several different courses of therapy, preferring to deal with different problems at different times (and perhaps with different therapists). The task-oriented nature of MMT seems to avert the development of undue dependency, wherein treatment termination becomes a problem in and of itself. The goal of MMT is to deal with as many specific problem areas as seem feasible, cost-effective, and worthy of attention. Thus, the Modality Profile provides an overall "blueprint" of major and minor problem areas, so that specific treatment goals can be selected from the total list. It is important to avoid suggesting treatment goals that patients are unlikely to attain.

STRUCTURAL PROFILES

In addition to the Multimodal Life History Inventory and the use of Modality Profiles, another assessment procedure that is unique to MMT is the use of Structural Profiles—quantitative ratings across the BASIC I.D. The following instructions (p. 14 on the Multimodal Life History Inventory) are sufficient for drawing up these Structural Profiles: Directions: Rate yourself on the following dimensions on a 7-point scale, with 1 being the lowest and 7 being the highest.

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BEHAVIORS

Some people may be described as "doers"—they are action oriented, they like to busy themselves, get things done, take on various projects. How much of a doer are you?

1 234567

FEELINGS

Some people are very emotional and may or may not express it. How emotional are you? How deeply do you feel things? How passionate are you?

1 23 45 67

PHYSICAL SENSATIONS

Some people attach a lot of value to sensory experiences, such as sex, food, music, art, and other "sensory delights." Others are very much aware of minor aches, pains, and discomforts. How "tuned in to" your sensations are you?

1 23 4567

MENTAL IMAGES

How much fantasy or daydreaming do you engage in? This is separate from thinking or planning. This is "thinking in pictures," visualizing real or imagined experiences, letting your mind roam. How much are you into imagery?

1 23 4 567

THOUGHTS

Some people are very analytical and like to plan things. They like to reason things through. How much of a "thinker" and "planner" are you?

1 23 4 567

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INTERPERSONAL RELATIONSHIPS

How important are other people to you? This is your self-rating as a social being. How important are close friendships to you, the tendency to gravitate toward people, the desire for intimacy? The opposite of this is being a "loner."

1234567

BIOLOGICAL FACTORS

Are you healthy and health-conscious? Do you avoid bad habits like smoking, too much alcohol, drinking a lot of coffee, overeating, etc.? Do you exercise regularly, get enough sleep, avoid junk foods, and generally take care of your body?

123 4 5 67

These ratings are easily depicted on a graph. Despite their subjective nature, they often enable one to obtain useful clinical information. Important insights may be gained when the therapist explores the meaning and relevance of each rating. With couples, when husband and wife each fill out a Structural Profile, important differences and areas of potential incompatibility are readily discerned. When seeing couples, it is also helpful to obtain "metacommunicative" scores; they are asked to rate how they think their spouse will depict them. These scores often provide additional inputs that can be put to good effect. Thus, in couples therapy, it is useful to determine the way a person rates himself or herself and to compare this with the way he or she rates his or her spouse. There is also a 35-item Structural Profile Inventory (SPI); see appendix 4 in Lazarus (1989). The merits of a standardized instrument are selfevident. The development of the SPI was achieved by generating a variety of questions that, on the basis of face validity, appeared to reflect essential components of the BASIC I.D. Factor analytic studies gave rise to several versions of the questionnaire until one with good factorial stability was obtained. Additional research (Herman, 1991; Landes, 1988) has borne out the reliability and the validity of this instrument. Again, the SPI has been particularly useful with couples because the scores frequently generate meaningful discussions and promote better mutual understanding while pinpointing areas of misunderstanding. When necessary, MMT practitioners may call for other standardized

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tests and additional diagnostic and assessment procedures (in the same technically eclectic spirit as a therapeutic method may be employed), but the mainstay of multimodal assessment centers on Modality Profiles and Structural Profiles. TRACKING THE FIRING ORDER

Another specific feature of the multimodal approach is the observation that a fairly reliable pattern may be discerned behind the way in which people generate negative affect. Different people tend to arouse feeling states through individualistic perceptions of the BASIC I.D. For example, some dwell first on aversive images (I) (pictures of dire and catastrophic events), followed by unpleasant sensations (S) (shortness of breath, palpitations, sweating, tremors), to which they attach negative cognitions (C) (ideas about their impending death), leading to maladaptive behavior (B) (avoidance, withdrawal, and isolation). This I-S-C-B firing order (ImagerySensory-Cognitive-Behavioral) may require a different treatment strategy from that employed with say a C-I-S-B sequence (Cognitive-ImagerySensory-Behavioral), or from yet a different firing order. Our clinical findings suggest that it is usually better to select techniques in accordance with the patient's chain reaction. A man who could not account for his frequent "anxiety attacks" was encouraged through self-observation to track his modality firing order during the course of a week. He stated: "My anxieties usually begin to develop when I tune into the fact that my body is feeling a little 'off,' such as a queasy feeling in my stomach, or a little tension in my neck. This sets off the chain. These feelings grow stronger as I attend to them, and then new ones develop, and pretty soon I start thinking that something dreadful is going to happen to me. These thoughts stir up a whole series of memories and pictures of the time I came down with pneumonia—which went undiagnosed for six weeks." In this case we have a Sensory-Cognitive-Imagery sequence. Since the patient's anxieties were triggered first by sensations, the therapist selected several sensory techniques (rhythmic breathing exercises, deep muscle relaxation, biofeedback) as the initial antianxiety regimen. Next, the cognitive modality was addressed (e.g., providing instructions in positive self-talk), followed by imagery methods (e.g., specific pictures wherein the patient saw himself being healthy, warding off disease). Alternatively, if a patient's anxiety commences with cognitive inputs ("I'm doing fine, when suddenly I start thinking of all the things that could possibly go wrong in my life"), followed by unpleasant images ("Then I picture myself, quite vividly, passing out and making a complete fool of myself"), leading to negative sensations ("My hands get clammy,

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my chest tightens up, and I get butterflies in my stomach"), the use of biofeedback and relaxation as a first line of attack may not be effective, since the sensory mode is the third sequence in the chain. As already stated, clinical impressions suggest that the end result is enhanced by matching patients' specific firing orders to the treatments selected, although the active ingredient may well be the power of suggestion—the aura of a therapist who appears to be implementing a "scientific" and "custom made" trajectory. A multimodal maxim, however, is that if something proves helpful, use it, don't analyze it!

BRIDGING

A strategy that is probably employed by most good intuitive therapists can readily be taught to novices via the format of the BASIC I.D. Typically, a therapist is interested in a patient's emotional responses—his or her fundamental feelings about various events—but may be receiving only defensive and perhaps irrelevant intellectualizations. In response to the question, "How did you feel about your father's decision to leave home?" the therapist receives a cognitive appraisal of the situation: "My father tended to place his needs first, and neither my mother nor I were factored into the equation." "Yes, but how did you feel about that?" "Well, you have to understand his own family background in order to appraise the significance of his actions." Clearly, for reasons known or unknown, the patient is reluctant to address his feelings, and it may be counterproductive to point this out. Even the tactful comment, "You seem to be avoiding my questions regarding how you feel about these matters," may prove too confrontational for some. Unfortunately, it is not uncommon for some therapists to strongly upbraid (if not attack) patients for providing intellectualizations rather than discussing their feelings. In the foregoing instances, the multimodal practitioner uses "bridging" to ensure that relevant information is obtained, thereby allowing therapy to remain on target. Bridging refers to a procedure in which the therapist deliberately tunes into the patient's preferred modality before branching off into other dimensions that seem likely to prove more productive. Thus, when confronted with intellectual barriers rather than emotional reactions, the therapist will join the patient in his or her cognitive modality. For example: THERAPIST: So your father's family background predisposed him to put his needs first. PATIENT: He seemed to identify with his very selfish mother, and ended up being the opposite of his own father.

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T: I wonder if he saw his mother as strong and his father as weak? P: I think it had more to do with the fact that he did not respect his father. Comment: Instead of challenging the patient's intellectualizations or interpreting his "resistance," the therapist joins him in the cognitive modality. Thus, the patient does not feel hurt, misunderstood, criticized, or attacked. The therapist may go along with the patient's cognitive content for about five minutes and then bridge into a modality that is less threatening than the affective domain, for example, the sensory area: T: By the way, can you tune into some sensations anywhere in your body? I'm wondering if this conversation has made you feel tense or if you are in touch with any other sensations? Comment: If the patient is unaware of any tension or discomfort, the therapist may then ask him to dwell for a few minutes on various parts of his body. Thus, one has bridged out of the cognitive modality into the sensory modality. From a discussion of sensations (or the absence of sensations), it is usually possible to bridge into the affective modality. At this juncture, a question such as "I really wonder how you feel about the things your father has done" is less likely to evoke the same cognitive defenses. If the patient does not avoid or disavow his sensory reactions, the interchange may continue as follows: P: I have quite a nasty headache. Also, my shoulders and my jaws feel tight. T: Let's pay attention to your headache and those tense sensations. Would you mind closing your eyes and studying those sensations for a few moments? P: (Sits with eyes closed for about 40 seconds) The tension is mainly in my neck. T: Try rubbing your neck, massage it gently and see if that helps at all. P: (Rubbing his neck) When I press here, it is quite painful. T: Is this pain connected to any feelings? P: How do you mean? T: Well, the things we were discussing about your dad sounded rather painful. P: (Emotionally) Although I try to understand the reasons behind his actions, I still feel he is a selfish bastard. T: What else do you feel? Comment: It should be reemphasized that a therapist's failure to tune into the patient's presenting modality can lead to feelings of alienation—

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the patient may feel misunderstood, or may conclude that the therapist does not speak his or her language. Thus, it is recommended that therapists start where the patient is and then bridge into more productive areas of discourse. SECOND-ORDER BASIC I.D. ASSESSMENTS

Yet another advantage of working from a multimodal perspective is the degree of precision that becomes possible. The initial BASIC I.D. chart (Modality Profile) translates vague, general, or diffuse problems (e.g., depression, anxiety, unhappiness) into specific, discrete, and interactive difficulties. Thereafter, while avoiding push-button panaceas, the initial selection of techniques is usually straightforward. When undue physical tension is evident, relaxation training is applied; dysfunctional beliefs will call for the correction of misconceptions; timid and unassertive behaviors usually require the application of assertiveness training. Nevertheless, treatment impasses arise—for example, when a patient's unassertive reactions are not being changed despite the diligent application of role playing, behavior rehearsal, modeling, and other relevant training. When this occurs, a more detailed inquiry into associated behaviors, affective responses, sensory reactions, images, cognitions, interpersonal factors, and possible biological considerations may shed light on the situation. This recursive application of the BASIC I.D. to itself adds depth and detail to the macroscopic overview afforded by the initial Modality Profile. Thus, a patient who was not responding to assertiveness training, when asked to examine in detail the repercussions of assertiveness responses across the BASIC I.D., revealed a significant "cognition" that seemed to account for his "resistance." In essence, it seemed that he did not feel entitled to certain rights and privileges. Consequently, "cognitive restructuring" was required before role playing and other behavioral measures proved effective. Another case in which a Second-Order BASIC I.D. shed light on issues that had not emerged previously concerned a young man who felt a strong but puzzling fear at the prospect of being promoted at work. Cliches regarding his presumed "fear of success" had been offered by others, but this made no sense to him. "I see myself as very ambitious . . . I'm a go-getter." Analysis of his reactions through a Second-Order BASIC I.D. revealed nothing significant in Behavior, Affect, or Sensation when picturing himself having attained a significant advancement (apart from minor and understandable concerns about having to put in longer hours, and some trepidation about working under the scrutiny of senior executives). But when traversing the Imagery Modality, he first stated, "I picture myself impressing the Board Members," and after a long pause

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came up with an image that called a halt to the inquiry: "I picture my father dying and my brothers blaming me." This peculiar image called for closer attention. It was shown to fit into a convoluted pattern of reasoning that proceeded more or less as follows: The youngest son, with three older brothers, the patient had already exceeded his own expectations regarding his station in life. He was the only college graduate in a blue-collar family, and he sensed real or imagined envy from his siblings, especially his oldest brother. A rebellious child, he had a turbulent relationship with his father, who disapproved of his academic aspirations and often accused him of wanting to look down on the entire family. Nevertheless, he had "written his own script" and had obtained a liberal arts education instead of following the family tradition of becoming a tradesman. In part, he had missed the camaraderie that his brothers had with one another and with their father, but he also felt superior to them—a feeling that was tainted with guilt. All of this information had been obtained from the Multimodal Life History Inventory, but only while focusing on the Second-Order BASIC I.D. did he realize to what extent additional achievements on his job symbolized the demise of his father and signaled total alienation from his siblings. This opened up a productive discussion of his family attachments and obligations and eventuated in a decision to "go full steam ahead." Later he said: "I knew I wasn't afraid of the added responsibility and new demands that would be placed on me, but i couldn't figure out what was holding me back." The therapist pointed out that he may have adopted a standoffish attitude toward his family, and recommended that he make deliberate overtures to participate with them in mutually enjoyable activities—family dinners, picnics, bowling, and other sporting events. The outcome was decidedly positive. The Second-Order BASIC I.D. rapidly brought to the fore some important issues that had been elusive and enabled the therapist to intervene effectively.

SUMMARY There are six distinctive features that set MMT apart from all other approaches: 1. 2. 3. 4. 5. 6.

The specific and comprehensive attention given to the entire BASIC I.D. The use of Second-Order BASIC I.D. assessments The use of Modality Profiles The use of Structural Profiles Tracking the modality firing order Deliberate bridging procedures

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MMT places primary emphasis on the uniqueness of each and every person. Hence, there is no typical treatment format. When tuning into the expectancies and demand characteristics of one patient, the therapist may adopt a passive-reflective stance. At other times, or with a different patient, the therapist may be extremely active and directive. Bearing in mind the fundamental question of who or what is best for this individual, the first issue is whether the therapist should work with the patient or refer him or her to someone else. Although the therapist will endeavor to function as an "authentic chameleon," in assessing and respecting the needs of each individual, there are obvious limits to everyone's versatility. Hence, a judicious referral to a more compatible resource may be necessary (see Dryden, 199lb). Obviously, patients who display grossly bizarre behaviors, active delusions, thought disorder, and other signs of psychosis, are probably best seen in a psychiatric facility, and those who are clearly homicidal or suicidal often require medical and custodial intervention. MMT practitioners are drawn from the full range of health service providers. Psychiatrists, psychologists, social workers, psychiatric nurses, pastoral counselors, and other mental health workers each have members within their disciplines who employ multimodal methods. Some multimodal therapists have a strong background in health psychology and behavioral medicine; many are clinically adept with substance abusers, sexual offenders, or with specific problem populations (e.g., bulimia nervosa, obsessive-compulsive disorders, posttraumatic stress disorders).

Case Example Ken, aged 23, complained that for the past year he had been suffering from anxiety and depression, and he expressed frustration over his inability to sustain erections during sexual intercourse, a difficulty he had experienced for approximately five years. He was good looking and neatly groomed, but conveyed an aura of defeat and agitation. Ken had recently dropped out of law school, a fact that produced additional tensions with his "reticent" father, a 47-year-old attorney who specialized in tax law and real estate closings, and his "overprotective" 43-year-old mother, an elementary school teacher. His 28-year-old sister, a certified public accountant, was married to an architect and had a 2-year-old daughter upon whom the entire family doted. Ken stated with some passion: "I'd like to get married and have kids myself some day." Regarding his sister, Ken emphasized that his parents seemed to prefer her to him, usually sided with her against him, and that her outstanding academic record contrasted sharply with his own rather average scholastic performance. Two additional factors were mentioned during the initial interview:

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(1) at age 16 he was extremely upset over the death of his maternal grandmother of whom he was especially fond; (2) at age 18, the tragic demise of his girlfriend as the result of a cerebral aneurysm (his first sexual relationship) had a profoundly negative impact. After the initial interview, Ken took home the Multiniodal Life History Inventory (Lazarus & Lazarus, 199lb) and mailed it to the therapist before his second session. It provided the following list of salient interactive problems: Behavior

"Can't get going." Procrastination Avoidance, tends to withdraw

Affect

Anxiety, depression, guilt feelings

Sensation

Tension in head and shoulders Headaches and bouts of dizziness Dryness in mouth

Imagery

Vivid pictures of grandmother's funeral Events of his girlfriend's demise Images of failure Vivid pictures of parental censure

Cognition

Self-downing and self-blaming tendencies Demands (shoulds, oughts, musts) Catastrophic thinking Thoughts about personal failure

Interpersonal relationships

Familial tensions Has withdrawn from most friends Avoids sexual encounters "My mother tries to control and restrain me."

Drugs /biology

Drinks up to a six-pack of beer some nights Has stopped playing tennis and jogging

The questionnaire also indicated that Ken expected therapy to last no more than six months, and that he favored a cognitive-behavioral approach that would be didactic rather than purely exploratory. Describing Ken as a young man suffering from anxiety, depression, and sexual problems provides a succinct description of his major difficulties, but does not point the way to the selection and implementation of specific treatment strate-

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gies. The Modality Profile outlined above provides a "blueprint" for personalized and immediate remedies (see C. N. Lazarus, 1991). Given his pervasive tension, Ken was taught basic relaxation skills and given cassette recordings for home use. He also responded favorably to a simple meditation technique wherein, while sitting in a quiet room, he would repeat a "mantra" and focus on rhythmic breathing. He was encouraged to practice relaxation and meditation daily. At the same time, his "cognitive modality" was addressed, and in addition to the initial entries on his Modality Profile, it soon became clear that he had a penchant to disqualify the positive (only negative events "counted," while positive happenings were dismissed or forgotten). He was also prone to all-ornothing thinking, interspersed with a negative filter (i.e., dwelling on particular negative events to the extent that his vision of life became bleak and dark). Thus, broadly speaking, the first five sessions focused on relaxation, meditation, and cognitive restructuring. His dysfunctional thinking was disputed (Ellis, 1989), and he was urged to monitor self-destructive thinking and to challenge his own faulty inferences and false conclusions. His anhedonic philosophy and eschewal of pleasure prompted the application of a Second-Order BASIC I.D. assessment, which brought two additional factors to light: (1) he irrationally blamed himself for his grandmother's death ("I should have persuaded my parents to take her to better doctors"); (2) given the tragic ending of his first love-sex relationship, he had acquired a superstition that future romantic liaisons would follow the same trajectory. This called for an active-directive-persuasive-cognitive realignment and occupied the bulk of the next five sessions. In essence, his irrational ideas were parsed and challenged, and paradoxical interventions were added to the regimen. "If you try really hard, I'm sure you'll manage to invent some other things apart from your late grandmother and girlfriend for which you can castigate yourself!" Ken chuckled appreciatively at these kinds of remarks and soon began to see how ridiculous his self-blaming really was. Behavior rehearsal and role-playing methods were used to offset his inept dealings with his parents, especially his "controlling mother," and a highly significant focus became the fact that in his overzealous desire to please them, he was not leading his own life. He drew up a list of parental put-downs and pejorative remarks and embarked on a successful course of self-desensitization. At the same time, positive and coping images (wherein he pictured himself succeeding, be it sexually, in dealings with his parents and other significant individuals) were added to his "homework package" (Lazarus, 1984; Zilbergeld & Lazarus, 1987). By the 10th session, Ken was eager to share various insights he had acquired into many facets of his life, and he was excited over "forgotten memories" he had retrieved. For example, he reported with great astonish-

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ment and some consternation how he had remembered that, when 10 or 11 years old, he had wished to be a girl. It soon became evident that this was related to the favoritism that his parents had shown toward his sister. This brought our attention back to the salient realization that Ken continued to march to his parents' drum, instead of asking himself, What do / want out of life? For example, he had downplayed the fact that he was extraordinarily dexterous and could perform wonders with his hands. He demeaned these talents in favor of aspiring to develop a brilliant legal mind. He declined the suggestion that some family therapy sessions with his parents, and perhaps even his sister, might readily resolve some lingering familial tensions. "I'd feel like a kid, like a schoolboy at a parent-teacher conference," he said, and added that he felt fully confident at this juncture that he could deal with them himself. It took over four months for Ken to emerge significantly less anxious, euthymic, and sexually potent. He no longer appeared to have any regrets about dropping out of law school and had decided to apply to dental school instead. He had undergone 14 sessions in all. Approximately a year later, he consulted me again, in the company of a young woman whom he described as a "potential fiancee." He complained of intermittent erectile inadequacy, a problem that was overcome in one session by emphasizing that performance anxiety was behind his difficulty, and stressing that instead of dwelling on his own erections (or lack thereof), he would be better advised to focus on the pleasures he could bestow on his partner via manual, digital, and oral stimulation. He was attending dental school, a fact that had earned him "unexpected respect" from his family. Ken was not a difficult patient. He was intelligent, cooperative, competent, and willing to change. This particular case was selected in order to illustrate how the multimodal framework, with its emphasis on breadth, permits one to address significant interactive elements in a person's life in an immediate, comprehensive, and systematic fashion.

Research Findings Several dissertations have explored the clinical utility of MMT suppositions and findings (e.g., Aigen, 1980; Ferrise, 1978; Olson, 1979; Schaut, 1991). Lawler (1985) found a significant degree of interrater reliability in terms of problem identification, and the extent of agreement regarding the relevant modalities for treatment. Mann (1985) showed that therapists' personal BASIC I.D. profiles did not appear to influence their assessment of others. Rosenblad (1985) studied Structural Profiles given to distressed

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and nondistressed couples. Among the dysfunctional couples, spouses tended to estimate incorrectly the way that the other person would rate them (i.e., their metacommunications were faulty). As noted earlier, Herman (1991) and Landes (1988, 1991) have obtained data on the reliability and validity of the Structural Profile Inventory. Several studies are presently under way, exploring the relevance of multimodal approaches in industrial and organizational contexts. Kwee (1984) conducted a controlled outcome study using multimodal therapy with 44 severe obsessive-compulsive patients and 40 extremely phobic individuals in a general psychiatric hospital. Of these patients, 90 percent had previously undergone psychiatric treatment without success, and 70 percent had suffered from their disorders for more than four years. Various measures were administered at intake, on admission, after 12 weeks, at discharge, and at follow-up nine months later. The follow-up showed that 64 percent of the obsessive-compulsive people remained significantly improved. Among the phobic patients, 55 percent had maintained or had proceeded beyond their treatment gains. Williams (1988), in a carefully controlled outcome study, compared multimodal assessment and therapy with other treatments in helping children with learning disabilities. The study took several years to complete and emerged with clear data pointing to the efficacy of the multimodal approach in comparison to other treatments. Perhaps it should be emphasized again that MMT is an approach that tries to incorporate state-of-the-art research findings into its framework. It is not intended as yet another "system" to be added to the hundreds in existence. Rather, it is an approach that attempts to be at the cutting edge of clinical effectiveness by continually scanning the field for better assessment and treatment methods. Whether this augments clinicians' overall effectiveness remains an empirical question. Clinically, the writer has conducted several outcome and follow-up inquiries. A three-year follow-up of 20 "complex cases" who had responded favorably to the writer's ministrations (e.g., people who had overcome extreme agoraphobia, pervasive anxiety, panic disorder, obsessive-compulsive rituals, or enmeshed marital or family problems) showed that 14 maintained their gains or had made additional progress without further therapy. In another survey, 100 patients who had not responded to at least three therapists before seeking multimodal therapy, revealed that 61 achieved objective and unequivocal benefits. Many of these patients were considered intractable by their former therapists. The patients who fared poorly in this series suffered either from anorexia nervosa or chronic alcoholism. Although this is not meant to imply that these are the results of comparative outcome studies, it seems reasonable to suggest that there are clinical findings supporting the notion that MMT

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usually succeeds where less comprehensive approaches have previously failed.

Clinical Training One of the major aims of effective clinical training should be to prevent formal coursework from undermining the talents and skills with which most trainees are endowed naturally. It is most unfortunate that many therapists, during their courses of training, seem to acquire a stylized professionalism replete with pejorative labels and questionable proscriptions (Lazarus, 1990). It is debatable whether therapists, before becoming technically eclectic or multimodal, should be steeped in several systems (e.g., Gestalt, behavioral, psychoanalytic) so that they attain competence in many different approaches. My opinion is that it is counterproductive to study the theoretical underpinnings of different systems, but, as already discussed, it can be fruitful to cull observations, methods, and techniques from many sources. My experiences at the Graduate School of Applied and Professional Psychology at Rutgers University, where, since 1974, I have trained selected Psy.D. and Ph.D. students in the multimodal orientation, suggest that certain theories undermine effective therapy. In short, students who have learned to approach clinical phenomena from a psychoanalytic viewpoint are inclined (from my perspective) to spend too much time exploring mental conflicts rather than promoting action; they often fail to direct therapeutic tasks or initiate topics of discussion; and instead of challenging irrational ideas, they are apt to explore them (see Messer, 1992). The well-trained MMT practitioner asks when, with whom, and under what circumstances it seems better to delve into nonconscious fantasies than to modify irrational beliefs (and vice versa). In keeping with social learning theory, performance-based methods will usually be preferred to purely verbal or cognitive inputs. Students who are especially enamored of family systems approaches are prone to see the woods but miss the individual trees. In MMT, the focus swings back and forth from the individuals and their parts, to the people in their social milieu. Students enamored of a particular unimodal, bimodal, or trimodal approach are apt to pursue a favorite line of inquiry, or to continue employing a particular procedure despite the absence of change. For example, those who are particularly devoted to cognitive therapy are inclined to dispute, challenge, explain, argue, interpret, and reframe, even when it seems obvious that their words are falling on deaf ears. Because they often regard a change in cognition as the be-all and

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end-all, they are reluctant, if not unwilling, to switch to a different modality. It would seem that some of the better students are those who have majored in psychology, with extensive course work in sociology, anthropology, and biology. Their graduate training seems best devoted to courses in behavioral medicine, psychopathology, tests and measurements, interviewing skills, research design, and various electives that afford the opportunity to undergo several apprenticeships. In other words, a most valuable learning experience is derived from working closely with expert therapists—observing them in action, sitting in on sessions, serving as cotherapists, and receiving formal supervision. This affords students the opportunity of appreciating the nuances of interpersonal style and seeing what works, regardless of the ways in which different therapists rationalize their results. MMT calls for as much breadth as the individual clinician can muster. It is not difficult for most students to learn and apply MMT methods— drawing up Modality Profiles, constructing Structural Profiles, formulating assessments and strategies in BASIC I.D. terms, using bridging and tracking maneuvers when necessary. Nevertheless, considerable attention has to be paid to more subtle aspects of therapy. Thus, a useful and frequently employed training tactic is the analysis of response couplets. Whenever a patient makes a response, the therapist is obliged to react. For example, if a patient asks, "Do you think I should tell my mother how I feel about my brother's divorce?" the therapist has to respond. He or she may respond simply by saying nothing, by repeating the patient's question (e.g., "You want to know if you should discuss your feelings about your brother's divorce with your mother"), by deflecting the issue back to the patient (e.g., "Do you think it would be beneficial to discuss it with your mother?"), by making an interpretation (e.g., "Perhaps you are more concerned about the way your mother feels about the divorce"), or by offering advice (e.g., "I think it would be better if you first discussed the way your father reacted"). The range of possible responses is great, but the goal is to rate and seek group consensus of the therapist's response in terms of its negative, neutral, or positive potential. Thus, during group supervision, trainees play tape recordings of ongoing sessions, and at judicious points, the recorder is switched off and various response couplets are examined. It is particularly helpful to stop the recording at the point where the therapist is required to make a response, and before hearing what was actually said and done, to discuss a variety of facilitative reactions. The analysis of response couplets enables supervisors to discern instances wherein the trainee fails to appreciate the patient's feelings, is inappropriate in timing his or her remarks, is angry or defensive, or even worse, shows disdain, impatience, disrespect, intolerance, or induces guilt.

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This process primes the supervisor to zero in on irrelevant questions, confusing remarks, and false reassurance. On the positive side, it enhances the trainer's capacity to model concise and accurate phrasing, display sensitivity to relevant and highly charged emotional issues, underscore the virtues of profound respect and significant understanding, and discuss the appropriate use of humor. How important is personal therapy? If personal problems are likely to interfere with trainees' successful implementation of accurate assessment and effective treatment, it is necessary to remedy the situation. I disagree with those who contend that personal therapy should be mandatory, and that all trainees should be encouraged to undergo psychotherapy. Of course, in keeping with the multimodal philosophy, if it is considered necessary or advisable for some students to receive personal therapy, it is important to help them find the type of therapy and therapist who would most likely be the best for them.

Future Directions The multimodal framework is eclectic without being fragmented; it provides integration of salient observations without a futile rapprochement of conflicting theories; and it calls for broad-based clinical training without sacrificing "depth." It is essentially an approach (not a system) that seeks to incorporate into its purview helpful diagnostic and treatment procedures garnered from many disciplines. It is the polar opposite of cultism. Thus, despite requests to do so, I have refused to launch a journal of multimodal therapy, because this would foster the very thing to which I am opposed— an in-group mentality. But the field of psychotherapy is still replete with cult members, devoted followers of a particular school of thought. Various gurus and their disciples only reiterate findings that fit their own needs and tie into the perceptions of their flock. As mentioned at the start of this chapter, these tendencies have receded but have not extinguished. High priests of psychological health are still engaged in competitive strife and internecine battles. Many have such desperate needs for a leader and a sense of belonging that virtually anyone with a tinge of charisma and an appealing party line can attract overzealous adherents. There are those who believe that the foregoing state of affairs is on the verge of its demise, and to bolster their position, they point to books such as this one, to the existence of journals devoted to psychotherapy integration, and especially to the Society for the Exploration of Psychotherapy Integration (SEPI). Yet if one looks closely at the SEPI conference contents, it becomes clear that those who search for "common ingredients"

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are at loggerheads with members who espouse specific points of emphasis. Many resort to an arbitrary fusion of two or more systems (e.g., behavioral-Gestalt, systems-psychodynamic), and others are strongly committed to one school of thought while paying lip service to being open to input from others. Norcross and Prochaska (1988) conducted a survey of selfidentified eclectics and found considerable divergence and little convergence. Thus it would appear that the integration movement has done little (if anything) to diminish the chaos that surrounds the hundreds of different schools of psychotherapeutic thought, and that differences among various integrationists may even surpass those of the most rigid school adherents. This state of affairs seems unlikely to change in the near future. Yet few would disagree that we require greater rigor; that we need to operationalize and concretize therapist decision-making processes; that we would do well to broaden our theoretical bases; and that systematic, differential, and prescriptive therapeutic strategies are called for. The question is how best to achieve these worthy ends, and herein lies the problem: people cannot agree on an acceptable modus operandi. Perhaps mounting socioeconomic pressures for rapid and effective short-term therapies, the availability of pharmacotherapeutic remedies, and the impact of managed health care may induce otherwise recalcitrant theorists to seek compelling solutions for psychological disturbances. One can but hope that more professionals will appreciate the limitations of theoretical integration, that treatments of choice and different therapies will be accurately matched to patients' needs, and that clinical and programmatic research will yield answers that are desperately needed (see Lazarus, Beutler, & Norcross, 1992). The establishment of training institutes that offer courses on technical eclecticism, articulate the value and limitations of integration, provide technically eclectic supervision, and address many of the issues and concerns noted throughout this chapter would move the enterprise of psychotherapy into the 21st century.

References AIGEN, B. P. (1980). The BASIC ID obsessive-compulsive personality profile. Unpublished doctoral dissertation, Graduate School of Applied and Professional Psychology, Rutgers University, New Brunswick, NJ. BANDURA, A. (1986). Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice-Hall. BEUTLER, L. E., & CLARKIN, J. F. (1990). Systematic treatment selection: Toward targeted therapeutic interventions. New York: Brunner/Mazel. BOZARTH, J. D. (1991). Rejoinder: Perplexing perceptual ploys. Journal of Counseling and Development, 69, 466—468.

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BRICKNER, D. (1984). Multimodal therapy as a framework for the EAP counselor. EAP Digest, March/April, 18-21. BRUNELL, L. F., & YOUNG, W. T. (1982). Multimodal handbook for a mental hospital. New York: Springer. DRYDEN, W. (1987). Theoretically consistent eclecticism: Humanizing a computer "addict." In J. C. Norcross (Ed.), Casebook of eclectic psychotherapy (pp. 221-237). New York: Brunner/Mazel. DRYDEN, W. (Eo.). (1991a). The essential Arnold Lazarus. London: Whurr. DRYDEN, W. (Eo.). (I99lb). A dialogue with Arnold Lazarus: It depends. Buckingham: Open University Press. EDWARDS, S. S., & KLEINE, P. A. (1986). Multimodal consultation: A model for working with gifted adolescents. Journal of Counseling and Development, 64, 598-601. ELLIS, A. (1989). Rational-emotive therapy. In R. J. Corsmi & D. Wedding (Eds.), Current psychotherapies (pp. 197-238). Itaska, IL: Peacock. EYSENCK, H. ]. (1970). A mish-mash of theories. International Journal of Psychiatry, 9, 140-146. FENSTERHEIM, H., & GLAZER, H. I. (Eos.). (1983). Behavioral psychotherapy: Basic principles and case studies. New York: Brunner/Mazel. FERRISE, F. R. (1978). The BASIC ID in clinical assessment. Unpublished doctoral dissertation, Graduate School of Applied and Professional Psychology, Rutgers University, New Brunswick, NJ. FRANKS, C. M. (1982). Behavior therapy. An overview. In C. M. Franks, G. T. Wilson, P. C. Kendall, & K. D. Brownell (Eds.), Annual review of behavior therapy: Theory and practice (Vol. 8, pp. 1—38). New York: Guilford. GERGEN, K. J. (1982). Toward transformation in social knowledge. New York: Springer-Verlag. GREENBURG, L. S. (1982). Using the multimodal approach as a framework for eclectic counselor education. Counselor Education and Supervision, 22, 132— 137. HERMAN, S. M. (1991). A demonstration of the validity of the multimodal structural profile inventory through a correlation with the Vocational Preference Inventory. Unpublished manuscript, Department of Psychology, Rutgers University, New Brunswick, NJ. HOWARD, G. S., NANCE, D. W., & MYERS, P. (1987). Adaptive counseling and therapy: A systematic approach to selecting effective treatments. San Francisco: Jossey-Bass. JENSEN, J. P., BERGIN, A. E., & GREAVES, D. W. (1990). The meaning of eclecticism: New survey and analysis of components. Professional Psychology, 21, 124-130. KEAT, D. B. (1979). Multimodal therapy with children. Elmsford, NY: Pergamon. KEAT, D. B. (1990). Child multimodal therapy. Norwood, NJ: Ablex. KERTESZ, R. (1988). The multimodal approach to group therapy. Official Journal of the Japan Association of Group Psychotherapy, 4, 83-86.

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KWEE, M. G. T. (1984). Klinische multimodale gedragtstherapie. Lisse, Holland: Swets & Zeitlinger. KWEE, M. G. T., DUIVENVOORDEN, H.}., TRIJSBURG, R. W., & THIEL, J. H. (1986). Multimodal therapy in an inpatient setting. Current Psychological Research and Reviews, 5, 344-357. KWEE, M. G. T., & LAZARUS, A. A. (1986). Multimodal therapy: The cognitivebehavioural tradition and beyond. In W. Dryden & W. Golden (Eds.), Cognitive-behavioural approaches to psychotherapy (pp. 320—355). London: Harper & Row. LANDES, A. A. (1988). Assessment of the reliability and validity of the multimodal structural profile inventory. Unpublished doctoral dissertation, Graduate School of Applied and Professional Psychology, Rutgers University, New Brunswick, NJ. LANDES, A. A. (1991). Development of the Structural Profile Inventory. Psychotherapy in Private Practice, 9, 123—141. LAWLER, B. B. (1985). An interrater reliability study of the BASIC ID. (multimodal assessment). Unpublished doctoral dissertation, Graduate School of Applied and Professional Psychology, Rutgers University, New Brunswick, NJ. LAZARUS, A. A. (1967). In support of technical eclecticism. Psychological Reports, 27, 415-416. LAZARUS, A. A. (1984). In the mind's eye. New York: Guilford. LAZARUS, A. A. (1986). On sterile paradigms and the realities of clinical practice: Critical comments on Eysenck's contribution to behaviour therapy. In S. Modgil & C. Modgil (Eds.), Hans Eysenck: Consensus and controversy (pp. 247-257). London: Palmer Press. LAZARUS, A. A. (1989). The practice of multimodal therapy. Baltimore: Johns Hopkins University Press. LAZARUS, A. A. (1990). Can psychotherapists transcend the shackles of their training and superstitions? Journal of Clinical Psychology, 46, 351—358. LAZARUS, A. A. (1991). A plague on Little Hans and Little Albert. Psychotherapy, 28, 444-447. LAZARUS, A. A., BEUTLER, L. E., & NORCROSS, J. C. (1992). The future of technical eclecticism. Psychotherapy, 29, 11-20. LAZARUS, A. A., & FAY, A. (1984). Behavior therapy. In T. B. Karasu (Ed.), The psychiatric therapies (pp. 485—538). Washington, DC: American Psychiatric Association. LAZARUS, A. A., & LAZARUS, C. N. (1990). Emotions: A multimodal therapy perspective. In R. Plutchik & H. Kellerman (Eds.), Emotion: Theory, research and experience (Vol. 5, pp. 195—208). San Diego: Academic Press. LAZARUS, A. A., & LAZARUS, C. N. (1991a). Let us not forsake the individual nor ignore the data: A response to Bozarth. Journal of Counseling and Development, 69, 463-465. LAZARUS, A. A., & LAZARUS, C. N. (1991b). Multimodal Life History Inventory. Champaign, IL: Research Press.

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LAZARUS, A. A., & MESSER, S. B. (1988). Clinical choice points: Behavioral versus psychoanalytic interventions. Psychotherapy, 25, 59—70. LAZARUS, A. A., & MESSER, S. B. (1991). Does chaos prevail? An exchange on technical eclecticism and assimilative integration. Journal of Psychotherapy Integration, 1, 143-158. LAZARUS, C. N. (1991). Conventional diagnostic nomenclature versus multimodal assessment. Psychological Reports, 68, 1363—1367. MANN, J. P. (1985). A study of the interrater agreement of therapists using the BASIC ID profile as an assessment tool. Unpublished doctoral dissertation, Department of Psychology, Western Kentucky University, Bowling Green. MESSER, S. B. (1992). A critical examination of belief structures in integrative and eclectic psychotherapy. In J. C. Norcross and M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. MESSER, S. B., & WINOKUR, M. (1981). Therapeutic change principles: Are commonalities more apparent than real? American Psychologist, 36, 15471548. NORCROSS, ]. C. (Ed.). (1986). Handbook of eclectic psychotherapy. New York: Brunner/Mazel. NORCROSS, ]. C., ALFORD, B. A., & DEMICHELE, J. T. (1992). The future of psychotherapy: Delphi data and concluding observations. Psychotherapy, 29, 150-158. NORCROSS, ]. C., & PROCHASKA, J. O. (1988). A study of eclectic (and integrative) views revisited. Professional Psychology, 19, 170—174. O'KEEFE, E. J., & CASTALDO, C. (1985). Multimodal therapy for anorexia nervosa: An holistic approach to treatment. Psychotherapy in Private Practice, 3, 19-29. O'LEARY, K. D., & WILSON, G. T. (1987). Behavior therapy: Application and outcome (2nd ed.). Englewood Cliffs, NJ: Prentice-Hall. OLSON, S. C. (1979). A multimodal treatment of obesity using Lazarus' BASIC ID. Unpublished doctoral dissertation, Department of Psychology, University of South Dakota, Vermillion. PONTEROTTO, J. G. (1987). Counseling Mexican Americans: A multimodal approach. Journal of Counseling and Development, 65, 308—312. RESCORLA, R. A. (1988). Pavlovian conditioning: It's not what you think it is. American Psychologist, 43, 151-160. RIDLEY, C. R. (1984). Clinical treatment of the nondisclosing black client: A therapeutic paradox. American Psychologist, 39, 1234—1244. ROBERTS, T. K., JACKSON, L. ]., & PHELPS, R. (1980). Lazarus' multimodal model applied in an institutional setting. Professional Psychology, 11, 150—156 ROSENBLAD, L. V. (1985). A multimodal assessment of perception and communication in distressed and nondistressed married couples. Unpublished master's thesis, Department of Psychology, Rutgers University, New Brunswick, NJ. RUDOLPH, J. A. (1985). Multimodal treatment of agoraphobia: A problem-

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focused approach. In A. A. Lazarus (Ed.), Casebook of multimodal therapy (pp. 35-49). New York: Guilford. SANK, L. I. (1979). Community disasters: Primary prevention and treatment in a health maintenance organization. American Psychologist, 34, 334—338. SCHAUT, J. ]. (1991). A multimodal assessment model of dual-diagnosis. Unpublished doctoral dissertation, Graduate School of Applied and Professional Psychology, Rutgers University, New Brunswick, NJ. SLOWINSKI, ]. W. (1985). Three multimodal case studies: Two recalcitrant "ghetto clients" and a case of post-traumatic stress. In A. A. Lazarus (Ed.), Casebook of multimodal therapy (pp. 81—107). New York: Guilford. SMITH, R. L., & SOUTHERN, S. (1980). Multimodal career counseling: An application of the BASIC ID. Vocational Guidance Quarterly, 29, 56-64. VON BERTALANFFY, L. (1974). General systems theory and psychiatry. In S. Arieti (Ed.), American handbook of psychiatry (Vol. 1, pp. 1095—1117). New York: Basic Books. WACHTEL, P. L. (1987). Action and insight. New York: Guilford. WILLIAMS, T. (1988). A multimodal approach to assessment and intervention with children with learning disabilities. Unpublished doctoral dissertation, Department of Psychology, University of Glasgow. ZILBERGELD, B., & LAZARUS, A. A. (1987). Mind power. Boston: Little, Brown. (Paperback 1988. New York: Ivy Books)

CHAPTER 8

Systematic Eclectic Psychotherapy" LARRY E. BEUTLER AND ANDRES ]. CONSOLI

.HERE ARE THREE OBSERVATIONS that have underwritten the deTH velopment of systematic eclectic psychotherapy (s.e.p.t Beutler, 1983). First, the past three decades have seen an exponential growth in the number of psychotherapies being offered and the variety of theories underlying them. The proliferation of theories suggests that all of these constructions have failed to respond adequately to the spectrum of human behavior that characterizes both therapists and patients. This failure, in turn, suggests the need for integrative approaches, wherein specific interventions can be designed for specific populations. Second, although a preponderance of the literature on psychotherapy theory is devoted to justifying the use of theory-specific methods and procedures, most of the effectiveness of psychotherapy can be attributed to factors that are common to most effective therapists (Lambert, 1992; Shapiro & Shapiro, 1982). Most of contemporary literature is devoted to understanding the factors that account for a very small percentage of therapeutic change. Third, there has been a persistent lack of communication between practitioners and psychotherapy researchers (Barlow, 1981; Strupp, 1981a). While the advent of treatment manuals (Luborsky & DeRubeis, 1984) in research, and their translation to clinical practice, promises to reduce the •Research for this chapter was supported by NIAAA grant No. I ROl AA08970. tWe have elected to use the abbreviation s.e.p. for systematic eclectic psychotherapy, both for the sake of simplicity and space. It is our intention neither to introduce a new acronym nor a new therapy. For this reason, our abbreviation appears in lowercase letters.

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significance of this point, it remains true that most psychotherapy theories have little or no foundation in research. With the appearance of this volume, undertaking to describe different integrative and eclectic psychotherapies, there is a danger that we "eclectics," like the theoreticians before us, may become so concerned with our pet viewpoints that we will fail to provide a truly eclectic approach. Integration and advancement can come only with continued discussion. It is often as important to be wrong as to be right, as long as theories are constructed in such a way as to allow one to tell the difference through empirical research.

Background S.e.p., as it has evolved and expanded during the past decade (see Beutler, 1979a; Beutler, 1983; Beutler & Clarkin, 1990), has its roots both in clinical practice and in empirical research. From practitioners have come an appreciation for the need for a pragmatic form of eclecticism and the accompanying belief that different interventions are effective for different types of patients (Garfield & Kurtz, 1977; Norcross & Prochaska, 1983). It is also from practitioners that we have adopted a degree of skepticism regarding the value of diagnosis for planning psychosocial interventions. Nearly three decades ago, Cole and Magnussen (1966) observed the low relationship that existed between diagnosis and treatment assignment, and argued for a diagnostic system that was predictive of treatment outcome. The magnitude of the relationship between diagnosis and treatment assignment has not improved much in the ensuing years (Beutler, 1989; Gillis, Lipkin, & Moran, 1981). From empirical research has come an appreciation of the power of the therapeutic bond. Numerous investigators have asserted that the relative inability to distinguish the outcomes of different psychotherapies suggest that they all work through the same basic mechanisms—the therapeutic bond, or alliance (Luborsky, Singer, & Luborsky, 1975; Sloane, Staples, Cristol, Yorkston, & Whipple, 1975; Smith, Glass, & Miller, 1980). In turn, work on therapist-patient matching has convinced us that good therapeutic relationships arise from a complex of initial similarities and dissimilarities between patients and therapists (Beutler, 1981; Beutler & Bergan, 1991; Kelly, 1990). At the same time, we are aware that some of these research-based observations conflict with the assumptions of clinical practitioners. For example, on one hand, respected scientists who have reviewed large bodies of research have frequently reiterated the conclusion that training in specific therapies and their associated procedures does not enhance the likeli-

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hood or magnitude of outcomes (cf. Luborsky et al, 1975). On the other hand, the sociopolitical emphasis placed upon technical proficiency by training institutions and licensing boards, as well as the parochial arguments lodged by different practitioners, implies that special skills and techniques do matter. Responding to these disparate conclusions, we have turned to a search for conditions under which certain procedures do and do not work, the conditions largely being defined both by patient transient reactions and enduring characteristics (e.g., Beutler, 1991; Beutler & Clarkin, 1990). S.e.p. represents an attempt to bridge the gap between these polar views, and to do so by translating contemporary research into a model of treatment selection that accepts both the value of common therapeutic qualities and the reality of indicators and contraindicators for the use of certain procedures. Bolstered by the work of Frank (1973), Goldstein (Goldstein & Simonson, 1971; Goldstein, Heller, & Sechrest, 1966), and, to a lesser extent, by that of Strong (1968) and Brehm (Brehm, 1976; Brehm & Brehm, 1981), we have adopted a philosophy that psychotherapy is a social-influence or persuasion process in which the therapist's operational theory forms the content of what is persuaded, and the therapist's technology functions as the means of influence. The quality of the therapeutic relationship is thought to define the limiting influence of the procedures used. S.e.p. represents an effort to define relevant variables from which differential effects may be predicted. This effort has proceeded, first, from a retrospective review of empirical work (Beutler, 1979a), progressed to a construction of a theoretical model of treatment decision making (Beutler, 1983; Beutler & Clarkin, 1990), and has finally been manifested in prospective empirical tests of that model (Beutler, Engle, Shoham-Salomon et al., 1991; Beutler & Mitchell, 1981; Beutler, Mohr, Grawe, Engle, & MacDonald, 1991; Calvert, Beutler, & Crago, 1988). From the outset, it has been a commitment of s.e.p. to seek knowledge upon which changes in the system can be made. Accordingly, a number of changes have occurred in s.e.p. that correspond with the extensions and modifications of the first (Beutler, 1983) and of the most recent (Beutler & Clarkin, 1990) renditions.

Concepts of Systematic Eclectic Psychotherapy To be practical, an eclectic psychotherapy must emphasize three working principles. First, it must consider all or most psychotherapy approaches as potentially beneficial to some individuals. Second, it must act on the assumption that therapeutic procedures are capable of being implemented

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independently of their originating theories. Third, eclecticism must operate from a theory of change that gives credence to a variety of technical procedures. This is a tall order and may seem impossible to those who maintain that certain procedures are, per force, incorrect and inappropriate. However, most psychotherapists identify themselves as eclectic (Garfield & Kurtz, 1977; Norcross & Prochaska, 1983; Norcross, 1986; Norcross & Newman, 1992) and thereby advocate the use of those procedures that fit the patient best, regardless of the theoretical origins of those procedures. It is the operationalization of this point of view that we pursue. To this end, three questions are faced by s.e.p.: (1) On what dimensions should patients and therapists be matched to be maximally effective? (2) Within compatible patient-therapist matches, what is the best combination of patient and procedure? (3) What considerations can best dictate the alteration of therapeutic procedures in treatment across time? The promise of eclectic psychotherapy rests in the faith that one can extract, from research and theory, dimensions, characteristics, and patterns that will allow one to make maximally effective and reliable decisions. In response to this challenge, s.e.p. addresses theories at two levels. The first of these levels is as an attribute of the given therapist. From this view, the therapist's formal theory provides both the foundation for communicating with other professionals and constitutes the philosophy of life that is taught to the patient or client. In this context, one theory is considered as "true" as another, the value resting more on its usefulness and believability than upon its truth. At the second level, theory represents a pragmatic description of the dimensions and criteria for making treatment decisions. At this level, theory is not explanatory but descriptive and closely follows clinical and empirical data that defines relationships between patients and environments, on one hand, and treatment contexts (settings, modalities, formats, frequencies, duration) and methods (i.e., procedures), on the other. At the first level of theory, s.e.p. suggests that therapists develop and use their own life experiences to inform their explanatory philosophies. At the second level of theory, s.e.p. proposes that identifiable patient and environmental qualities can be used as indicators and contraindicators for assigning treatment components (Beutler & Clarkin, 1990). The social-persuasion theoretical formulation on which s.e.p. is loosely based, unlike most that are applied to psychotherapy, does not address the nature of psychological disturbance (psychopathology) but the nature of the interpersonal forces and mechanisms that instigate or inhibit change. At this level of abstraction, each therapist's personal theory of symptom development provides (1) an explanation of change that may be understood by the patient and (2) a formulation of treatment objectives that provides a focus for the interventions employed.

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In comparing various psychotherapy approaches, Luborsky, CritsChristoph, Alexander, Margolis, and Cohen (1983) and Shaw (1983) have observed that treatment effectiveness is more a function of whether therapists consistently follow their particular theories of intervention than of what techniques or philosophies they employ. Theoretically, at least, a therapist's view of human behavior and psychopathology provides such a focus and directs the therapeutic interventions to "relevant" patterns of behavior (Strupp, I98lb). Because it is more a collection of empirical observations than of explanatory constructs, models of social influence are sufficiently flexible to encompass a broad array of explanatory theories (i.e., psychodynamic, behavioral, and systems orientations), thus (potentially) circumventing some of the problems of intertheory communication. Moreover, exploring psychotherapy from the larger perspective of persuasion or social-influence theory leads to certain predictions about matching patients with therapy procedures. To wit: 1. The collection of procedures that induce desired persuasion is partially dependent upon how these procedures "fit" with the recipient's characteristics. Persuasion methods that affect people who use one style of coping with stressors may work poorly tor those who use others. Persuasion is effective to the degree to which it manages arousal levels and focuses efforts. 2. Other things being equal, discrepancies between the point of view taken by a valued persuader (the therapist) and the point of view held by a willing recipient (the patient) of a persuasive message will be predictive of the amount of attitude change or persuasion initiated. The strength of this relationship, however, will be limited by the degree to which the therapist is perceived as a safe, knowledgeable, trustworthy, and credible individual. Discrepancy of viewpoints induces motivation (i.e., arousal), and the content of the message provides a direction for intended change. 3. Recipients of persuasive communications vary in their receptivity to direct persuasive efforts. Hence, an important aspect of persuasive strategies is the degree to which they alter or adapt to these variations in receptivity.

Patient-Therapist

Compatibility

Most authors (Guidano, 1987; Bowlby, 1979; Larson, 1987; Mahoney, 1991) concur in asserting the imperious necessity of developing a therapeutic alliance, a bond that will ultimately be the vehicle tor the therapeutic achievements, yet few authors elaborate on what the components of such an alliance or bond are (Atkinson & Schein, 1986; Beutler 1979c; Beutler & Bergan, 1991; Bordin, 1976; Talley, Strupp, & Morey, 1990). As qualities

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of a process of persuasion and influence, the therapeutic alliance is understood as representing unavoidable imprints of its participants. Two types of variables—demographic characteristics (age, ethnicity, gender, socioeconomic status) and interpersonal response patterns (attributions, beliefs/values, strivings) of the participants—will partially give form and determine the quality of their relationship. The question then is, what similarities and dissimilarities along these dimensions are most conducive to developing a successful treatment relationship and outcome? Among the demographic dimension, ethnic similarity has been amply researched and reviewed by Atkinson and collaborators, among others (Atkinson, 1983; Atkinson & Schein, 1986; Wampold, Casas, & Atkinson, 1981), with some mixed results. Black patients appear to prefer black therapists, but such preference has not been connected to therapeutic effectiveness, nor has it been replicated consistently among other ethnic groups. The clinical practice of assigning ethnically similar therapists to minority clients may fail to account for more important sources of diversity (i.e., age, gender, socioeconomic status). Findings regarding demographic similarity, although not solid, allow some preliminary statements (cf. Beutler & Clarkin, 1990). Demographic similarities tend to facilitate positive perceptions of the treatment relationship, retention in therapy, and treatment adherence, especially among minority and disenfranchised patients. These process findings are not directly seen in outcome gains, however. Beutler and collaborators (Beutler, Crago, & Arizmendi, 1986) have concluded that attitudinal flexibility and perceived similarity, rather than actual similarity, account for the modest effects observed on outcome. Patterns of interpersonal response may be more directly involved in outcome than demographic ones. S.e.p. identifies two domains in which patient-therapist matching is important for facilitating the therapeutic relationship. The first of these reflects interpersonal strivings or needs for interpersonal attachment and affiliation, qualities that have been found to represent stable characteristics that transcend diagnostic groupings (e.g., Widiger, Trull, Hurt, Clarkin, & Frances, 1987). At one end of this dimension may be individuals who desire affiliation, dependency, relatedness, recognition, and twinship (Kohut, 1977), while at the other are individuals whose lives are committed to the pursuit of individuality, distinction and autonomy from others. Berzins (1977) suggests that therapists who are unlike their patients on dimensions that reflect dependency and autonomy needs are most likely to produce positive therapeutic change, regardless of whether the patient or the therapist places the highest value on these dimensions. The second domain of interpersonal-response pattern matching consists of attitudes, beliefs, and values. Several lines of investigation have

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suggested that patients who acquire their therapists' belief systems over the course of treatment tend to have a higher likelihood of improvement than those who do not change or who diverge from the belief systems of their therapists (Beutler, 1981; Beutler & Bergan, 1991; Beutler et al, 1986; Hamblin, Beutler, Scogin, & Corbishley, 1988; Kelly, 1990; Tjelveit, 1986). In turn, a number of clinically relevant studies (e.g., Beutler, Johnson, Neville, Elkins, & Jobe, 1975; Mendelsohn & Geller, 1963) have suggested that the patient-therapist convergence process is facilitated by the presence of initial dissimilarity between the two. To summarize, demographic and background similarities between patients and therapists may serve to facilitate the patients' adherence to treatment regimens early in the treatment process (Beutler el al., 1986). As treatment progresses, however, the attitudinal and conceptual changes that we frequently call "improvement" are based on the patients' efforts to assimilate the discrepant views of a valued therapist. From the standpoint of therapeutic process, it seems prudent to attempt case assignments that have the lowest number of patient-therapist background mismatches. Mismatches are minimized by demographic and background similarities and dissimilarities in relevant attitudes. Likewise, the therapist may do well to introduce attitudes about which the members of the dyad may have different views, somewhat later in treatment.

Matching Therapy Technique to Patient Characteristics The field of patient-therapy interaction research is not a new one, and its contributions are being reassessed. Shoham-Salomon's (1991) adaptation of an old familiar saying, "different folks benefit from different strokes," has been an appealing call to renew the search for preferable patient-therapy matching. To address the task of discovering "what kind of therapy, or elements thereof, benefits what kind of client" (Shoham-Salomon & Hannah, 1991, p. 219), one must assume a framework designed to make effective interventions specific to certain patient characteristics and qualities. Hence, both procedures and patient qualities must be addressed in more treatment-relevant ways than that captured either by therapy brand names or by diagnostic labels. For example, while formal diagnoses have a role in the derivation of medical treatments (Frances, Clarkin, & Perry, 1984), psychological interventions must be tailored to more specific qualities of patients' personalities, styles of coping, and knowledge repertoires than these clinical diagnoses allow. Faced with the endless and unattainable task (cf. Beutler, 1991) of exploring every possible interaction between

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psychotherapy variables (therapy, patient, therapist), we propose the study of selective patient variables and associated classes of interventions with which they interact, and the study of patient-therapist compatibility. IDENTIFYING AND MEASURING PATIENT VARIABLES

Assessment of treatment-relevant patient dimensions relies on a combination of both formal and informal procedures. In most cases, the evaluation process is not clearly distinct from the therapeutic one. Hence, it makes little sense to separate the definition of these variables from the means used for assessing them. There are numerous patient dimensions that may enhance the predictive efficacy of psychotherapy. Beutler's (1979a) initial efforts extracted from comparative psychotherapy studies those dimensions that were present when one theoretical approach emerged as more effective than another. While the list has expanded since that time, here we will restrict our discussion to four dimensions: problem severity, problem complexity, reactance level, and coping style. Problem Severity Problem severity is a concept constructed to express how successful the patient's coping styles are. This concept is used to refer to the ways in which coping methods have or have not being able to maintain anxiety and distress within manageable limits. Severity can be conceptualized as a continuum, ranging in extremes from reflecting minimal symptoms to the presence of symptoms that are incapacitating. The severity of the problem is indicated by impairments in the patient's capacity to relate in the social, occupational, and interpersonal demands of daily life. A final evaluation of each of these subvariables considers their dynamic interaction and their response to stress. Stressful events or situations challenge the individual's coping mechanisms. The result is a multidetermined response that is sensitive to the complexity of the situation and the patient's diverse strengths. These strengths include intellectual capacity, levels of ego integrity, and quality of family and social network and support systems (Beutler & Clarkin, 1990). Special consideration is given to problem seventy when formulating a treatment plan, since the acuteness and intensity of the problem will affect motivation and investment in treatment. It will also determine the format, duration, and immediate goals of the treatment planned. The suitable assessment methods to evaluate problem severity include, but are not limited to, detailed clinical interview, drawing of the patient's human resources and social network map, a life-history question-

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naire, mental status exam, review of current assets, and use of objective tests (Beutler & Clarkin, 1990). Problem Complexity We believe that it is both necessary and consistent with current research to distinguish between problem severity and problem complexity. While problem severity is easily conceptualized as a continuum of impairment, we find it useful to think of problem complexity as a simple dichotomy, expressing on one hand, "generalized habits or transient responses" and, on the other, "complex problems" that are symbolized in recurrent themes or patterns of behavior (Beutler & Clarkin, 1990). Complex problems, therefore, represent a clinical judgment of the degree to which the presenting problem(s) are both repeated as themes of underlying dynamics across situations and are represented symbolically in the patient's manifest complaints. The two concepts, problem complexity and problem severity, are among the most significant patient dimensions for predicting effectiveness of treatment. The concept of problem severity captures the acute, intense, situation-specific aspects of the patient's difficulties that require immediate attention, while problem complexity addresses the more enduring, less situation-specific characteristics of the patient's complaints—those that require long-term attention. The designation of a problem along a dimension of complexity and the definition of those themes that are manifest when the complexity of problems is high are necessary in order to select the focus of treatment. Complex problems, or thematic issues, merit a broad-band treatment—one that is aimed at conflict resolution—while situation-specific problems and habits warrant a treatment that is symptom oriented. The degree to which a presenting problem represents a linear generalization from the conditions under which it was initiated allows us to determine if it is a simple habit or a symbolic expression of an associated conflict. If given symptoms bear only an indirect, obscure, or symbolic relationship to the events that initiated them, one must elect in favor of identifying the problem as "complex" rather than the symptoms as "habitual." In this case the feared punishment that gave rise to the reaction pattern is frequently no longer in evidence, and the behavioral symptoms themselves are discomforting and result in pain or anguish. Indeed, one of the major indices of a complex problem is that the associated behaviors are not conducive to pleasure or satisfaction but to a prolonged suffering and continuing interpersonal impairment (Bond, Hansell, & Shevrin, 1987). The clinician has to evaluate different sources of information when assessing the dimension of problem complexity. First, he or she must

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explore the way in which relevant, recurrent patterns develop in the patient's life history. Second, the therapist should assess unconscious needs and wishes that might be represented symbolically in these patterns. Finally, a close look and assessment of the relative roles that social reinforcements and conflictual needs play in the maintenance of the symptom pattern is warranted (Beutler & Clarkin, 1990). The SCL-90R (Derogatis, Rickels, & Rock, 1976) is particularly useful for assessing symptom severity and complexity, because it presents estimates of both intensity of distress and symptom generality or spread. Monosymptomatic symptoms and habits often can be separated from multisymptomatic and complex ones by this means. When one determines that a complex pattern is being presented, the next major task is to define the focal theme in terms of a dynamic interaction. The exact framework by which one formulates a dynamic focus, however, though not irrelevant, is not specifically dictated by s.e.p. The eclectic approach simply emphasizes the importance of explicitly defining a theme or conflict, using whatever terminology one finds compatible with one's own theory, and then using this theme to maintain treatment consistency. The theory from which this conflict is defined reflects one's beliefs both about mental health and the life philosophy that is taught to the patient in the course of therapy. We find the empirically based methods of defining interpersonal themes elucidated by dynamic theorists (e.g., Strupp, 198lb; Strupp & Binder, 1984; Luborsky, 1984) to be helpful. The Core Conflictual Relationship Theme (CCRT) (Luborsky, McLellan, Woody, O'Brien, & Auerbach, 1985) encourages the therapist to make a global judgment about the principal needs or wishes that guide the patient's interpersonal behavior. Once defined, the most frequently observed motive or behaviorally expressed "want" is then considered along with other patient qualities such as coping style, reactance against loss of autonomy, and expectations, to complete a thematic formulation. This formulation then is used to alert the therapist to important issues in the patient's life, as a model against which to test patient responses in therapy, as the basis of interventions designed to facilitate self-understanding, and as a framework from which the intermediate and immediate goals of specific interventions are selected. Reactance Level

The concept of interpersonal reactance derives directly from persuasion theory, models of interpersonal influence, and concepts of behavior change (Brehm, 1976; Brehm & Brehm, 1981; Goldfried & Davison, 1976). Reactance is the tendency to respond oppositionally to external demands, and the potential for such reaction is thought to represent a trait that varies in

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strength from person to person. This trait is related to an individual's acquired sensitivity to perceived interpersonal threats to one's autonomy and is indexed by one's ability to comply with externally imposed demands. Tolerance of external demands varies along a continuum, reflecting the level of therapeutic directiveness that will be tolerated without rebellion. Those who are easily threatened by a perceived loss of autonomy respond more positively both to low levels of therapeutic directiveness and to the use of paradoxical interventions (e.g., prescribing the symptom or symptom exaggeration) than those who have high tolerance for such threats (Ollendick & Murphy, 1977; Shoham-Salomon, Avner, & Neeman, 1989). Mismatching the use of highly directive procedures with reactanceprone patients may result in worsening of one's symptoms (e.g., Forsyth & Forsyth, 1982). Recently, we have used a combination of MMPI scales reflecting defensive anxiety (Edwards Social Desirability Scale + Taylor Manifest Anxiety Scale) to predict therapeutic response to directive and nondirective procedures (Beutler, Engle, Mohr et al., 1991). Coping Style One's efforts to cope include an array of specific defense mechanisms (e.g., American Psychiatric Association, 1987; Hinshelwood, 1989; Laplanche & Pontalis, 1973), and characteristic preferences come to be expressed in patterns of interrelated defenses, called coping styles. Although there have been numerous attempts to classify coping styles, four categories are sufficient to capture treatment-related distinctions (Beutler & Clarkin, 1990). An internalizing coping style is characterized by self-blame and selfdevaluation, accompanied by compartmentalization of affect and idealization of others. Jnternalizers attribute faults and mishaps to their lack of skills or abilities, and then try to compensate by engaging in ritualistic behavior with the intention of undoing the faulty behavior. Those with a low reactance potential are prone to be intrapunitive and to constrict their emotional responses to the point of impoverishment. On the other hand, those with a high reactance level are prone to overcontrol impulses and feelings, masking high levels of underlying anger and periodically expressing this anger through explosive outbursts. These outbursts may be followed by profuse apologies and guilt. These variations may parallel the diagnostic groupings of avoidant and obsessive personality disorders. Externalizers, in sharp contrast to internalizers, attribute responsibility for their lack of well-being and discomfort to external objects or to others. Among those who have low reactance proneness, symptoms rather than people may be blamed for the externalizers' problems, and

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one may expect those patients to express feelings of being unable to control what happens to them. Specific defense mechanisms that might be expected to characterize these low reactant, externalizing persons include diversion, distraction, displacement, and passive-aggressiveness. On the other hand, externalizers with high reactance potential tend toward more direct and person-centered blame and acting out, including overt oppositionalism and extrapunitiveness. Diagnoses frequently associated with high reactant externalizers include paranoid and antisocial personality, whereas narcissistic and passive-aggressive personalities often are associated with lower reactant levels. We believe that two other patterns also have implications for treatment planning: repressive and cyclic coping styles. Repressive individuals invest their resources in maintaining a generalized level of ignorance, a process through which the harmful components of a situation are not recognized, even at the expense of ignoring the situation altogether. Repressive style persons who have high reactance potentials tend to respond to threatening situations by relying on the defense mechanisms of repression and reaction formation, whereas those with low reactance tendencies may be more reliant on denial and negation. Cyclic coping styles are characterized by instability and mutability, fluctuating between internalization to externalization or from passive to active defenses. People with low reactant, cyclic coping styles present rationalization as their common defense mechanism, and those whose reactance levels are more dominant tend to become hypersensitized to indications of threat. The first group tends to receive diagnoses such as impulse and dysthymic disorders, as well as passive-aggressive personality. The second group frequently presents diagnoses that include borderline, cyclothymic, and sometimes unstable paranoid personalities. The MMPI (Dahlstrom, Welsh, & Dahlstrom, 1972)—and we believe the MMPI-2—is especially helpful in obtaining an estimate of the patient's coping style. Moreover, when the MMPI-2 is combined with clinical history a determination of reactance level is also possible. We have found that the relative constellation of scores described by Welsh (1952) distinguishes among patients with externalizing and internalizing coping styles (Beutler, Engle, Mohr et al, 1991). INTERVENTIONS

The avenue to effective change in s.e.p. lies in the potential of employing procedures from any and all available schools on the basis of their fit to the patient rather than on the basis of their fit with the theoretical model of change that is unique to any single theory. In order to match specific procedures with corresponding patient qualities, Beutler and

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Clarkin (1990) identified the functional goals and demand characteristics around which different therapeutic procedures clustered. This analysis indicated that while they had many qualities in common, each school of psychotherapy had developed identifiable and specific procedures that seemed to fit its peculiar objectives. Beutler and Clarkin (1990) concluded that specific procedures, from whatever school, varied in breadth of objectives, the level of experience addressed, the amount of therapist directiveness required, and preference for intratherapy versus extratherapy material. For example, psychoanalytic therapy espouses broad-band (conflictual) goals, relies on evocative procedures (e.g., engaging transference reactions), focuses on unconscious experiences (e.g., defenses), and addresses extratherapy material (e.g., early experiences). On the other hand, experiential therapy, while also addressing conflictual goals, uses a preponderance of directive interventions, focuses on emotional and sensory experiences, and addresses intratherapy material; cognitive therapy addresses more narrow-band (symptomatic) goals, while utilizing directive interventions, focusing dominantly on manifest cognitive experiences, and addressing extratherapy material; and behavior therapy has symptomatic goals, uses directive interventions, focuses on behavioral experiences, and addresses extratherapy material. By assessing the functional use of procedures that differ in these qualities, the procedures can be matched to the needs of different patients

MATCHING

Beutler and Clarkin (1990) cross-matched therapy procedures with the relevant patient qualities. They suggest the following guidelines for matching these treatment dimensions to the patient characteristics discussed in the foregoing paragraphs: 1. Problem complexity directs us to differentiate between conflictual and symptomatic treatment goals. 2. Problem severity helps us define some of the intermediate objectives of our intervention and to plan on the order to which symptoms and themes will be addressed. 3. Patient coping style specifies the level of functioning most affected, and effective interventions are selected to correspond with this level. Four subgroupings of procedures roughly correspond to the four-fold categorization of coping styles: (a) procedures that facilitate emotional arousal and awareness with internalizing coping styles; (b) procedures that facilitate uncovering and insight with repressive coping styles; (c) procedures that facilitate cognitive self-control with cyclic coping

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styles; (d) procedures that facilitate behavioral change with externalizing coping styles. 4. Defining patient reactance proneness pinpoints the amount of therapist directiveness that may be tolerated in implementing interventions. Imagine, for example, that Jack is a patient whose ubiquitous symptoms of depression and anxiety are judged to arise from symbolized and persistent fears of losing dependency attachments (i.e., complex problem associated with dependency/attachment needs). Moreover, he has a history of avoiding or resisting interpersonal demands (i.e., high reactance potential) by social withdrawal, emotional inhibition, overcontrolled expression of affect, and extensive self-criticism (i.e., he copes by internalizing). Under these circumstances, the therapist may elect to focus on interpersonal themes and conflicts because of the level of problem complexity presented; to use emotional focusing and imagery exercises that enhance emotional awareness on the basis of the internalizing coping style presented; to employ nondirective or evocative questions and reflections because of the level of reactance expected; and to draw out these fears by exploring feelings that arise in situations that are imbued with the threat of loss and separation. The degree of Jack's impairment may be used to determine how quickly one may begin focusing upon thematic patterns rather than symptomatic behaviors to restore immediate functioning. Severity may also help us assess the level of motivational arousal present to support the targeted changes and lead us to use either procedures for increasing or reducing arousal levels.

Modifying Treatment Strategy as Patients Change Two separate factors underlie the need to modify the therapeutic procedures that are used at different points in therapy. First, many patients do not maintain a consistent level of either reactance or coping style and may vary on these dimensions when stressed. Hence, one must modify the therapeutic procedure from moment to moment as the patient vacillates on these dimensions. Second, with effective treatment, patients may be expected to move on all four major character dimensions. Patterning of interventions across time is a function of matching the phases of problem resolution to the mediating goals of treatment. Beitman (1992) has observed that psychotherapy ordinarily proceeds along four stages: relationship enhancement, pattern identification, change efforts, and termination planning. These stages define the mediating goals of therapy toward which the patient and therapist work.

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However, the mediating goals of treatment must also reflect the patients' progress in solving their problems. Prochaska and DiClemente (1992) have described four stages people ordinarily go through when resolving difficult problems: precontemplation, contemplation, action, and maintenance. The principal goals of the therapist in working with patients who have achieved the precontemplative phase is relationship enhancement. If successful, the relationship propels them to the phase of contemplation and invokes the therapist's goals of assessing patterns of problematic behavior. In turn, as the patient moves to the action phase, the therapeutic goal becomes facilitating intrapersonal and interpersonal change, thus setting the stage for the patient to move to the phase of maintenance. In this latter phase of problem resolution, the mediating goals of therapy become planning for termination and relapse prevention. Moreover, as one moves toward the phase of maintenance, the value of group and family interventions is thought to increase as a way of providing needed social support.

Patient Assessment Among most patients who are referred specifically for psychotherapy from trusted professional sources, intake assessment dimensions overlap almost completely with those used for selecting specific psychotherapy procedures. Based on this observation, we have considered the specific methods for assessing relevant patient dimensions in the previous sections. However, if not determined in advance by the referral process, one must become satisfied that the patient does not represent a current risk, is suitable for psychotherapy, and that other aspects of treatment assignment (e.g., setting, modality, and patient-therapist match) are appropriate. Three fundamental questions must be asked when a patient enters the consultation relationship with a prospective therapist: "Why are you here?" "Why are you here?" and "Why are you here now?" In the context of answering questions about safety and suitability for psychotherapy, one must explore relevant history. The latter can also be used to determine if the patient's difficulty represents a habit pattern or a thematic problem. In making an initial assessment of the patient's ability to respond to psychotherapy, one must address history, previous treatment, and the nature of the disturbance. In certain disorders, psychotherapy must be supported through other forms of intervention (e.g., group therapy, psychoactive medication, hospitalization). There may even be conditions in which psychotherapy is directly contramdicated. It is at this stage of the decisional process that formal diagnoses may have a place. Assessment of the patient's mental status, family history, medication history, and health

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status, as well as of the nature of the problem and the events that have brought the patient to treatment are all critical Once suicide risk, bipolar disorder, psychoses, organicity, and major medical problems have been ruled out as primary problems, one can make a better decision about the patient's potential for effecting a helpful psychotherapy relationship. We prefer to have patients send or bring with them to the first appointment pertinent medical records, including recent physical examination findings that may be relevant to their specific complaints. If patients initially present with suicidal ideation, the first decisional alternative must address the control of this behavior and the protection of the patient, rather than the resolution of the distressing conflict. If a patient is sufficiently intact and the intensity of the problem is such that he or she is willing to make a nonsuicide contract, the potential for a helpful therapeutic relationship is more certain. In a similar way, patients presenting with psychotic ideation, dementia, or major physical complaints must be considered for alternative forms of treatment first. Frances et al. (1984) have described some of the indicators and contraindicators for such protective interventions and externally controlled treatments. Initial assessment is facilitated by the use of formal psychological devices that can be integrated with background material and clinical impressions. The differentiation among organic versus functional, psychotic versus nonpsychotic, or complex versus noncomplex disturbances may entail either relatively little or a great deal of intensive psychological investigation for ultimate clarification. Among most patients, however, the initial decisions about working diagnosis and treatment appropriateness can be made within the first one or two treatment sessions, especially if the therapist has pertinent medical history at hand, and the patient is supplied with self-administered psychological assessment devices at the time of the first appointment. We find instruments such as the Shipley Institute of Living Scale (Paulson & Lin, 1970), the SCL-90R (Derogatis et al., 1976), the Locus of Control Scale (Rotter, 1966), and the MMPI-2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) particularly useful in defining various aspects of functioning that are significant in global treatment planning. History and direct observations both supplement these decisions and define primary conflictual themes.

Treatment Applicability The avowed purpose of eclectic psychotherapy is to affect a broad range of patients by differentially altering the therapeutic procedure applied. However, the value of psychotherapy itself is subject to some question for

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some populations. Psychotherapy seems least relevant for individuals with active thought disorders, those with bipolar affective disorders, and those whose psychiatric and psychological symptoms are the result of some biological impairment. Although the concepts of s.e.p. were originally applied primarily to individual treatment, Beutler and Clarkin (1990) extended the concepts to the selection of medical modalities and formats, settings of various levels of restrictiveness, and to short- and long-term interventions. Indicators and contraindicators for various forms of group and family therapy and for short- and long-term therapy include (1) problem severity, (2) availability of external support systems, (3) phase achieved in problem-solving efforts, (4) coping style, and (5) reactance proneness (for treatment prescription, see Feldman & Powell, 1992; Clarkin, Frances, & Perry, 1992). One must ordinarily expect that psychotherapy will be relatively short term, being limited either by external requirements or by the patient's decision to terminate. While the therapist must work with this assumption, recommendations for long-term treatment are often appropriate and are made upon observing the degree of problem severity and complexity, and the nature of the setting. The more focal the problem to be addressed, the less severe its manifestation, and the more oriented the treatment setting to brief therapy, the more appropriate it is to set predetermined time limits. We find it useful to establish an initial contract for 20 sessions, with an understanding that a new contract can be negotiated at the end of that time. A few patients do not accept a contract of this length, and adjustments to as few as five sessions are occasionally made. By the end of 10 sessions the therapist should have an idea of how rapidly the patient is moving through the phases of therapy, initially resolving symptoms and progressing on to explorations of interpersonal, behavioral, cognitive, and affective environments. This awareness can help in the assessment of treatment goals and, eventually, in the establishment of another contract, if the patient is willing. Psychotherapy should not be considered as a process with a given beginning and a final end. Patients are best prepared to face the world when they understand their difficulties within the context of an ongoing life struggle. This is true as much of symptomatic behaviors as it is of complex patterns. The door to therapy is advisably left open, even though planned vacations and terminations may occur. Termination may thus best be seen as a phase of treatment, rather than the end of treatment.

Treatment Structure The limitations placed on the duration, setting, frequency, or structure of eclectic psychotherapy are those that are also placed on psychotherapy

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generally. The duration and structure of the intervention as well as the setting depend largely on the contract of mutual expectation that is entered into with the patient. The critical features, rather than setting, frequency, or duration, are the patient's compliance, the therapist's flexibility, the indications of common expectations, and a compatible patient-therapist match. Beyond this, the therapist's ability to assess adequately the patient's needs and to apply a suitable treatment menu that maintains the patient's investment in the treatment process are limiting factors. Research on the power of interpersonal influences that characterize different learning environments (e.g., Corrigan, Dell, Lewis, & Schmidt, 1980) suggests that one does well to vary interpersonal distance, posture, emotional expressions, self-disclosure, and even office decor as a function of various patient characteristics. For example, highly reactive, externalizing patients respond poorly to therapists' self-disclosures of emotional experience and even to therapists' expressions of liking (Tennen, Rohrbaugh, Press, & White, 1981; Kolb, Beutler, Davis, Crago, & Shanfield, 1985). As a result, such patients' treatment may require a formal and nondisclosing verbal pattern by the therapist. Highly reactant patients tend to respond best if their therapist is seen as distant, occasionally unsure, and without a great deal of emotional or charismatic appeal. In contrast, patients with relatively low levels of reactance are tolerant of a broad range of therapist behaviors and therapeutic interventions. They tend to respond best to individuals who emphasize personal contact, who disclose positive feelings, and who may even engage in supportive physical contact. A forward-balanced posture and relatively informal attire and environment might satisfy their need for relationships with benign, egalitarian, and friendly authorities. The therapist's assigned power, which is derived from the title, the office, and the expectancy inherent in the term psychotherapist, carries a great deal of weight if it is not severely discordant with the patient's desires and expectancies (e.g., Corrigan et al, 1980). As treatment proceeds, however, the therapist's individual style emerges and begins exerting increasing influence on the treatment process and outcome (Martin, Moore, & Sterne, 1977). To maximize therapeutic impact, therapists should be comfortable with a wide range of interpersonal relationship styles. Persuasion theory argues that patients will more easily be persuaded to adopt a new viewpoint or set of behaviors if the technical procedures used in the persuasion effort are consistent both with preexisting expectations and needs for control, ascendance, and power. This match between patient styles and technical interventions must be accomplished with great care so that the strategies that are used enable patients to attain greater attitudinal consonance without impeding their ability to adapt to a changing environment.

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Mechanisms of Change S.e.p. is an integration of therapy procedures, not of personality theories. Although one needs a superordinate theory of human functioning to direct and guide one's interventions, the nature of this theory is directed by one's personal preferences, not by any specific aspects of eclecticism. Theories of interpersonal influence offer some understanding of the process of change that is convenient and still compatible with the particular explanations that characterize most theories that are constructed for psychotherapy. Within this framework, a fundamental concept in understanding change is cognitive dissonance. Therapeutic dissonance may occur when patients become aware that their attitudinal system is discrepant from that of a valued therapist. When confronted with this situation, they have a choice of either changing their own attitudinal construct in order to become similar to that of the valued other, devaluing the significant other, or exiting the system. The therapist's task in this process is to maintain sufficient value and influence in the patients' eyes so as to seriously question their own attitudinal systems when such dissonances arise, rather than prematurely exiting the system or disregarding the therapist's viewpoint. This process is analogous to "working through" a problem and relies on the therapist's ability to keep the patient in cognitive contact with the conflict. It is noteworthy that patients tend to use their therapists as attitudinal models, not only for defining the internal constructs that will supplant old, unworkable ones, but also for modeling the methods of resolution. That is, values tend to change over the course of psychotherapy and to become increasingly similar to those of the therapist (Arizmendi, Beutler, Shanfield, Crago, & Hagaman, 1985; Beutler, Arizmendi, Crago, Shanfield, & Hagaman, 1983). A relationship that balances the ability to maintain interpersonal attachment with the ability to confront and model attitudes provides the basis for a corrective emotional experience (Frank, 1973). For most volunteer patients, termination is at the patient's initiation, and our own preference is to gradually experiment with reducing the frequency of sessions rather than engage in abrupt termination. This tends to facilitate generalization and allows the patient to reenter treatment without a sense of failure.

Case Example Jorge, a 34-year-old male from a civil-war-ridden Central American country, requested help with his two older children's school performance and

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social skills. He had been married to Silvia, a compatriot woman his age, for 12 years and they had four children; two girls, aged eight and six, and two boys, aged ten and seven. Jorge was born into a family of three brothers and two parents, and lived in a large city. His youngest brother, aged 26, had been diagnosed with schizophrenia five years before. Jorge left his country 14 years ago, searching for a better economic situation in San Diego, where he met Silvia, who had also recently immigrated to the United States. Over the phone, Jorge mentioned being unemployed for the last six months and "not feeling good about it." He complained about "health problems" and "feeling in no condition to look for a job." He had seen a number of physicians, who found "nothing wrong" with him. We scheduled an intake interview for Jorge and his family and requested that Jorge bring in school records of his children (all four), the children's teachers' names, his medical records, along with the names, addresses, and telephone numbers of the physicians he had visited (the compliance or noncompliance of patients to such a request gives important clinical information about their reactance level as well as their motivational state). When Jorge and his family came in for the intake interview, they impressed us as a traditional, conservative family. They were all wellgroomed, looking ready for "Sunday mass." Jorge, although attentive, appeared exhausted. The student records of the children did not reveal any out-of-the-ordinary situation, and their teachers expressed satisfaction in their comments. Jorge's medical records showed no pathological conditions. We excused the children and asked Jorge and Silvia to tell us in what way we could be of help. Silvia complained about the economic hardships that the family was facing. They were currently living on Silvia's income as a part-time housecleaner, were behind in their rent payments, and were facing imminent eviction by the landlord. Silvia expressed concern about Jorge's health, about his "problems." We asked Jorge about his "problems" and got the following description. He enjoyed driving buses and trucks, and was at one time employed in a parcel service company, but the job was too hard on his body. He started to worry about his job performance and to question his ability to support his family financially. In a couple of weeks he began to feel restless, irritable, tense, dizzy, short of breath, and to have difficulties falling asleep, symptoms that were still present at intake. He learned about openings in a local bus company and decided to apply. After an intensive screening process to become a bus driver, he made it to the final ten candidates. All that was left was a month of training, and for that Jorge quit his other job. Throughout the selection process Jorge's symptoms intensified. On the first training day, Jorge went into the classroom, sat down, and within a few minutes started to feel "uncomfortable," with most of his symptoms

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reactivated, and had what he named "un ataque" (an attack). He excused himself from the meeting, went home, and since the feeling didn't subside, went to the hospital. A thorough check-up revealed nothing abnormal, but Jorge felt in no condition to go back to the training. He asked for consecutive medical leaves, but after a week of absence he was discharged from the program. After this incident, Jorge saw a number of physicians without receiving a diagnosis for his condition. He had attempted to regain employment but had felt tired, depressed, and had feared that another "ataque" would "take over." He expressed being desperate for a job, not wanting to be at home all the time, feeling isolated, and worrying about his behavior with his children. He said he was being harsher with the children, compulsively checking their homework, although no physical abuse was involved. During the intake interview it was noted that the marital relationship was tense and strained. Jorge and Silvia weren't making eye contact, sat apart, and did not seem to pay much attention to each other. The therapist attempted to explore these dynamics, but the couple expressed no interest. Following are the therapist's initial impressions on the four salient dimensions of the patient's conflict. With respect to problem severity, Jorge's condition was judged to be moderately severe since his coping mechanisms had been unsuccessful in keeping his anxiety level within manageable limits for the past several months. His present symptoms were interfering with his ability to secure a job and were affecting his family life (potential eviction from a housing complex) and social network. Jorge had abandoned contact with many of his friends and felt little desire to keep in touch with his closest friends, saying, "Nobody wants to be friends with a bum." With respect to problem complexity, Jorge's maladaptive responses were deemed as transient, reactive behaviors. They appeared to have a direct relationship with situational and environmental stressors that allowed a linear generalization. A symptomatic therapeutic intervention that addressed his presenting complaints (generalized anxiety, panic attack, depressed mood) seemed warranted (for the systematic eclectic treatment of a case presenting nonlinear symptomatology, see Beutler, 1986). These procedures needed to be tailored to Jorge's needs, taking into account his personal and interpersonal patterns of self-doubt, self-defeating statements, and psychosomatization tendencies. With respect to reactance level, Jorge seemed very compliant and submissive to authority. Based on his personal history, psychological assessments, and the therapist's clinical impressions, Jorge's reactance level was estimated low, facilitating the implementation of relatively directive therapeutic procedures. It was anticipated that Jorge would follow the therapist's suggestions and directions, but a delicate balance through accu-

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rate clinical judgment needed to be found between Jorge's anticipated high levels of compliance and his depleted energies. With respect to coping style, Jorge's predominant style could be defined as internalizing. Such a pattern, accompanied by Jorge's low reactance, set the stage for his defense system: constriction of affect, intropunitive cognitions, withdrawing, and isolation. Jorge also presented externalizing coping characteristics that were expressed in passive-aggressive interpersonal interactions with his wife, and overcontrol of their children. The basic characteristics of understanding, caring, and respect in the therapeutic relationship were assured by the therapist's previous training and current supervision. Also, the therapist-patient cultural, ethnic, gender, and age similarities were all demographic affinities that are associated with moderately positive perceptions by the patient of the treatment relationship. Differences between therapist and patient on the dimensions of personal autonomy and attachment were present, favoring the development of a successful working alliance. The therapist's etiological framework, based on a rational-cognitive understanding of the patient symptomatology, contrasted with Jorge's animistic and self-depreciating perspective. FORMULATION AND TREATMENT PLAN

Jorge's somatic complaints, minority status, and low income are all factors associated with high dropout and premature termination. These characteristics and Jorge's linear symptomatology made him a candidate for time-limited therapy. The focus of the treatment could be narrow, mainly aimed at symptom alleviation. Given his level of distress and type of coping style, the procedures also needed to consist of those that reduced arousal while increasing awareness of internal cues of stress. Many cognitive interventions reflect these interests. We proposed the following plan to the family. First, we would work with Jorge on his symptoms, and for that we needed to contact his physicians to determine his current and past medical history. We would see him once a week at the beginning and every other week as he progressed, for a total of 20 sessions. Second, we would contact the children's teachers to evaluate their school performance, and based on their impressions, we would be making arrangements as needed. Third, we needed to enlist Silvia's cooperation to create a resource network for the family, given their critical economic situation. Because of their immigration status (temporary residency), the family did not want to claim any "official aid." We offered a number of private resources, and although reluctant at the beginning (an expected culturally syntonic reaction), Silvia accepted them. She had already filed an application with the district housing office to receive a

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subsidy for which the family qualified. We committed ourselves to do our best to speed up that process, which was successful within a month. We contacted Jorge's physicians and learned that it was the last one, a psychiatrist, who had suggested to Jorge to see a psychotherapist after Jorge's tests indicated no signs of physical abnormality. The systematic eclectic treatment combined a cognitive/behavioral model of symptom relief, social skills training, and family-social networking. The first few sessions were devoted to the development of rapport and to the understanding of the precise nature of Jorge's symptoms and how he interpreted them. From Jorge's description it could be concluded that he had experienced generalized anxiety for at least two months prior to a single panic attack. Subsequent to this, the anxiety symptoms continued and a depressive mood secondary to his unemployment set in. In the exploration of the panic attack, automatic thoughts and prodromic symptoms were explained as follows: While he was in the office of the bus company on the first morning of the final training, he felt a reactivation of his month-long anxiety symptoms including some perspiration on his forehead and palms. His hands felt cold, and he didn't want to shake his "sweaty and cold" hand with the trainer. A few moments later, he found himself breathing shallowly, feeling dizzy and disoriented. All of a sudden he felt a brief, sharp pain under his left rib, and said to himself, "My heart is about to stop; I am about to have a heart attack." He stood up and left, feeling very scared and confused. He went back home but later to a hospital. The situations in which panic was likely to be feared were explored in therapy, and some commonalities among the situations allowed the therapist to consider Jorge's problems in the realm of social anxiety. This phenomenon was expressed by Jorge's perception and expectation of disapprobation and critical regard by others and low self-esteem; he had rigid ideas of appropriate social behavior, and reported having uncomfortable bodily sensations in social situations (Beck, Emery, & Greenberg, 1985). In subsequent sessions, a process of reattribution was started, offering Jorge a different interpretation of anxiety and the symptoms leading to the panic attack. In spite of the medical reports, Jorge maintained that his problem was a physical one that the physicians had not "been able to figure out yet." The therapist persisted on the nonpathological nature of the symptoms, addressing them one by one, and offering a reinterpretation, a strategy in which Jorge was willing to engage. For example, the morning of the panic attack was explored in detail. Jorge recalled thinking, "I don't want to be late," and decided to run the last few blocks. Once he sat down, he was agitated and out of breath. The sharp pain below his left rib was interpreted as "gas," something that Jorge had complained about. Since his

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symptoms involved breathing anomalies, he was taught corrective breathing techniques. The therapist proposed to Jorge role plays that would simulate job interviews, which were used as in vitro exercises, gradually increasing exposure. These activities allowed the production of "minipanic attacks" within the context of treatment, which afforded the opportunity to teach Jorge coping practices such as breathing into a brown bag. It was also at this time that Jorge's social image, both as perceived by him and as he thought he was being perceived by others, was addressed. Jorge was taught distraction techniques, his favorite one being "talking with people," something he found extremely comforting, since he enjoyed it as a regular activity but he had not done much of since he had started feeling depressed. Jorge started to regain confidence as anxiety seemed more under his control. Jorge was instructed on different methods to cope with anxiety (Beck, 1988; Beck et al, 1985) and a process of systematic exposure was started. Jorge complied when the therapist asked him to go to a county facility that offered vocational orientation and training, but came out disappointed. As Jorge came in for his next appointment, he noticed an advertisement in Spanish and pointed out that it was misspelled. The therapist pulled out a copy of a Spanish newspaper and asked Jorge to identify misspellings and grammatical errors, which Jorge did with noticeable ease and enjoyment. Jorge said that he had never thought highly of those skills, although he enjoyed reading very much. We brainstormed with him about job placements where his abilities could be put to use. By this time, Jorge's systematic exposure process needed in vivo exposures, so job interviews were assigned to him. He stated feeling eager and ready. Jorge was quite successful in his job interviews, finding a job with the local Spanish newspaper. He was able to identify the prodromic symptoms during the interviews, and managed to keep the anxiety at bay. Future sessions were spread over a period of two months, one session every other week. As treatment was ending, Jorge raised a number of different issues, the first one having to do with painful memories that depicted his father in a mental hospital, the place where his father eventually died. Jorge's father seemed to have suffered a form of schizophrenia that presented similar symptoms to those that Jorge's brother was experiencing. At this point, Jorge remembered that while having the panic attack he had feared going crazy "like my brother and my father." A second issue was related to the relationship with his wife, whom he "had not kissed for at least 8 years." The therapist asked Jorge whether he would be interested in working on the relationship, to which he replied, "Right now." After

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contacting Silvia, who stated her interest, arrangements were made with them for marital therapy.

Research Research in s.e.p. has been in two fundamental areas. The first area has addressed the matching of patients and therapists; the second area has emphasized matching of patients to therapeutic procedures. This second area is only now achieving a level of sophistication that is sufficient to draw conclusions. Research on patient-therapist matching has emphasized the roles of similarities and dissimilarities in belief and value systems. Two related programs of investigation have been undertaken in this regard. The first applies to similarities and dissimilarities between the belief systems of patients and therapists. The second applies to the acceptability of belief systems, a concept that is only indirectly associated with similarity. Both of these lines of research rely in part on the demonstration that effective psychotherapy is accompanied by attitudinal convergence between the two participants. This latter point of view is supported by a large number of research studies that have used a wide variety of personality, attitudinal, and value concepts (cf. reviews by Beutler, 1981; Kelly, 1990; Tjelveit, 1986). Our investigations have confirmed the observation that initial (pretreatment) patient-therapist dissimilarity on global attitudinal value dimensions is positively associated with the development of productive therapeutic processes (Beutler, 1971a; Beutler, 197 lb; Beutler, Jobe, & Elkins, 1974; Beutler et al, 1975; Beutler et al., 1983). Its relationship to therapy outcome is more complex and difficult to assess. Attitudinal acceptability must be considered along with the dimension of attitude similarity in order to understand therapeutic improvement. In our investigations of this issue, for example, we (Beutler, 1971a; Beutler et al., 1974; Beutler, 1979b) determined that if the therapist's attitudes were acceptable to the patient, the patient was more likely to adopt the therapist's belief systems about sex, authority, and discipline. Not surprisingly, we have also discovered that if the therapist's latitudes of acceptance are broad enough to encompass the preferred viewpoints of the patient, both therapeutic process and outcome are facilitated even if the patient finds the therapist's preferred viewpoint unacceptable. A fewer number of studies have been devoted to the matching of specific therapeutic technologies with patient dimensions, but research in this area is growing in visibility (Shoham-Salomon, 1991). The derivation of the treatment-matching dimensions was based on an intensive reanalysis

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of psychotherapy outcome studies (Beutler, 1979a; Beutler, 1983; Beutler & Clarkin, 1990), and subsequent research has been directed at exploring and expanding these relationships (Beutler & Mitchell, 1981; Beutler, 1989; Beutler, Engle, Mohr et al., 1991; Beutler, Mohr et al., 1991; Calvert et al., 1988). Four foundation studies have provided support for the predictive utility of patient coping style and resistance potential as predictors of differential response to various qualities of psychotherapy procedures. These studies have demonstrated significant patient characteristic by treatment interaction effects, one of which comprised a cross-validation on an international sample. Two of these studies (Beutler & Mitchell, 1981; Calvert et al., 1988) used naturalistic designs and heterogeneous outpatient samples. These studies provided the foundation for a larger and more tightly controlled randomized clinical trial on patients with major depressive disorder, to which most of our attention here will be devoted. Two studies have provided by far the strongest foundation for the current investigation, since they both provided criteria-controlled treatments, random assignment, refined measurements of coping style and resistance potential, and demonstrated that both patient dimensions yielded differential responses to different therapies. The central study (Beutler, Engle, Mohr et al., 1991) employed three manualized treatments designed to vary along two dimensions: insight focused (focused-expressive psychotherapy, or FEP, and supportive, selfdirected procedures, or S/SD) to symptom focused (cognitive therapy, or CT), and directive (FEP and CT) to nondirective (S/SD). The three treatments revealed a very clear interaction effect between coping style and outcome. Among patients assigned to cognitive therapy, treatment outcomes (reduction of depression) were greater among patients whose initial MMPI configurations consisted of high scores on indices of sociopathic and impulsive qualities (externalization) as compared to those whose scores indicated fewer of these latter qualities. Conversely, among patients seen in the two insight-oriented treatments (FEP, S/SD), the reverse was true. While mean outcomes for this latter group were nearly identical to those in CT, it was those whose MMPI indicators of externalizing patterns were relatively low who experienced the greatest amounts of symptom reduction. The results also indicated that patients who were initially assessed to have high levels of anxious defensiveness (high reactance potential) did better when assigned to the nondirective treatment (S/SD) than when assigned to either of the other, directive treatments. Conversely, those with low levels of initial defensiveness, as assessed at intake, performed comparably well when assigned to either of the two treatments that employed therapist directives (Beutler, Engle, Mohr et al., 1991).

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The pattern of results for both patient variables and both types of treatment were subsequently cross-validated in the fourth study, using several different measures of coping style and resistance potential. In this study, a sample of anxious and depressed patients from the Bern (Switzerland) Psychotherapy Research Program (Beutler, Mohr et al., 1991) was studied using a randomized clinical trial design. Coping style significantly predicted the differential value of symptom-focused (behavior therapy) and insight-focused (client-centered therapy) interventions. Likewise, resistance potential was differentially predictive of the use of directive and nondirective procedures. The zero order correlations indicated differences both in the magnitude and direction of the relationships between improvement and patient characteristic in the two treatments.

Implications for Clinical Training Eclectic psychotherapy maintains that therapists should be simultaneously trained to competency levels in a variety of highly specific models. Whether therapists can, in fact, become equally or even minimally proficient in such a broad range of procedures is uncertain. We are currently exploring this issue, but it is too early to provide definitive results. The eclectic model proposes, however, that at least some therapy procedures should be learned from different categories of objectives (such as insight enhancement, emotional awareness, emotional escalation, emotion reducing, behavioral control, perceptual change). Moreover, these procedures should be learned in a way that allows their implementation through both high and low therapist directiveness. Training programs for eclectic psychotherapy would ideally be based on competency criteria for procedures representing all of the six categories of objectives. The alternative is to consider psychotherapists specialists and to determine those skill areas in which they are able to achieve competence or with which they are most comfortable. In this model, eclectic approaches would encourage therapists to define and limit their practices to those patient groups for whom their particular strategies and orientations will be most productive. It is rather naive to assume that therapists will thereafter only treat the patients for whom they and their skills are most fitted. It is somewhat reassuring to observe, however, that there may be an automatic selection process that directs patients to therapists by whom they are likely to be most helped (cf. King & Blaney, 1977). If nothing else is certain, literature to date suggests that training programs that emphasize accreditation and credentialing on the basis of time spent and classes taken, rather than competence, are outmoded. Even highly trained and experienced therapists from such programs do not

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achieve the ability to define appropriate therapeutic foci or to adjust treatment strategies appropriately (Strupp, 198lb). The importance of competency-based programs is seen in recent observations that therapists' ability to comply with the procedures they say they implement are stronger contributors to treatment outcome than the procedures themselves (Shaw, 1983; Luborsky et al., 1985). Competency-based programs with criteria levels of performance will be necessary in order to implement any eclectic psychotherapeutic treatment. To be an effective eclectic psychotherapist, one must be familiar with a wide range of therapeutic procedures. One must have demonstrated competence in implementing those procedures, and one must be trained to observe and assess conflictual themes in a way that allows these themes to be the focus of concentrated treatment. Additionally, and even more important, the therapist should be able to facilitate and use relationshipenhancement procedures, which are generally characteristics of effective therapists, independent of any particular therapeutic school. These tasks are probably best accomplished in a training program that first and foremost emphasizes the development of skills for establishing and maintaining therapeutic relationships. Active listening skills, methods of exploring interpersonal relationships, and a solid foundation in relationship-oriented procedures should be established. Only subsequently should specific technologies be emphasized. A well-rounded eclectic psychotherapist will receive ample supervision in the development of behavioral methodologies, cognitive change interventions, and the many techniques for exaggerating or escalating affective states that are borrowed from Gestalt therapies. The therapist will also receive supervised experience with interventions that highlight interpersonal processes and psychoanalytically oriented procedures for enhancing and interpreting transference relationships. In each of these areas the therapist should be exposed to the foundations of theory as well as to a sampling of the technologies employed. Thereafter, and as a final step in the training process, the therapist should concentrate on exploring integrative models such as the one proposed here. Although research experience and training may be important to the training endeavor, it is probably not a necessary ingredient for becoming an effective, integrative therapist. Nonetheless, a research orientation assists one to perceive relationships between therapeutic strategies and subsequent changes, and to be a thinking therapist. Research training may also give one an appreciation for methods of questioning, measuring, and assessing one's impact. Hence, such a research perspective should be acquired during training. A guiding model such as that proposed here is useful in developing therapeutic menus for directing research and clinical efforts. Finally, in addition to the formal training requirements previously

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outlined, we consider it important to emphasize the significance of a healthy lifestyle and personal development exercises as part of the training of future therapists and the continuing education of experienced practitioners.

Future Directions The most pressing needs in s.e.p., as in psychotherapy generally, are (1) the validation of therapeutic efficacy and (2) the delineation of the processes that portend therapeutic changes. The past seven years has seen a substantial (not yet dramatic) increase in the number of empirical studies on therapy-patient-therapist matching. Yet much needs to be done in extracting, from the hundreds of variables that have been touted by various authors as matching dimensions, those that do serve as indicators and contraindicators. Our own research has successfully moved from correlational demonstrations of the efficacy of various matching dimensions to prospective studies. These studies are beginning to demonstrate the differential predictive power of three patient dimensions: motivational distress, coping style, and reactance. The evidence is strongest for the value of coping style and reactance level (resistance) as differential indicators for insight versus behaviorally oriented procedures, and directive versus nondirective procedures, respectively. But there are numerous other variables in our model of treatment decision making whose hypothesized role in treatment selection is still unknown. Work is needed to make operational the concepts of problem complexity and severity, as well as to develop measures for assessing reactance, coping style, and motivational distress. S.e.p. suggests that the concepts of treatment matching should generalize across diagnostic groups, but no research is currently available to support this contention. Hence, research is sorely needed to see how well the relationships that have been observed between coping style and level of focus, and between reactance level and directiveness translate from major depression and general anxiety symptoms to other diagnostic groups. At this point, it is still not certain whether all patients or disorders can be efficaciously matched with specific therapy procedures. Systematic research is needed in order to determine if the procedures presently available are sufficiently broad and flexible to encompass most patient patterns. Work with the seriously mentally ill, alcohol and drug populations, and anxiety disorders is needed to complement existing research findings. Our current research, under sponsorship of the National Institute on Alcohol Abuse and Alcoholism, is now testing the relationship between patient coping style and behavioral versus insight-oriented procedures among

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alcoholics. This work concentrates on invoking family interventions as well. There is also the question of what to do to enhance outcome when therapist and patient are incompatible and referral is not possible. Are there behaviors and methods that will help the therapist to enhance the quality of therapeutic contacts in those cases where patients and therapists cannot be suitably matched? Finally, a great deal of research is still needed on training effective therapists. The questions of whether one can become equally or minimally proficient in employing the variety of therapeutic strategies proposed as necessary by the s.e.p. model is yet to be answered. Of equal concern to the issue of training is the question of the degree to which proficiencybased training enhances therapeutic outcome. Chiefly, what are the methods that will best teach therapists to apply definite therapeutic procedures in ways that include both common and specific variables that enhance outcome? Beyond these research questions, it is expected that the future will see a continuation of interest among therapists in the clinical application of eclectic methods. As research questions are addressed, the methods for assisting clinicians directly in developing effective treatment plans are likely to become available. Ultimately, if any eclectic approaches to psychotherapy prove to be more beneficial than the theories they attempt to integrate, they must stand the empirical as well as the clinical test. The concepts derived must be useful to the clinician, verifiable to the scientist, and acceptable to a diversity of practitioners and theoreticians.

References AMERICAN PSYCHIATRIC ASSOCIATION. (1987). Diagnostic and statistical manual of mental disorders (3rd rev. ed.). Washington, DC: Author. ARIZMENDI, T. G., BEUTLER, L. E., SHANFIELD, S., CRAGO, M., & HAGAMAN, R. (1985). Client-therapist value similarity and psychotherapy outcome: A microscopic approach. Psychotherapy: Theory, Research and Practice, 22, 16— 21. ATKINSON, D. R. (1983). Ethnic similarity in counseling psychology: A review

of research. The Counseling Psychologist, 77(3), 79—92. ATKINSON, D. R., & SCHEIN, S. (1986). Similarity in counseling. The Counseling Psychologist, 74(2), 319-354. BARLOW, D. H. (1981). On the relation of clinical research to clinical practice: Current issues, new directions. Journal of Consulting and Clinical Psychology,

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BECK, A. T. (1988). Cognitive approaches to panic disorder: Theory and therapy. In S. Rachman & J. D. Maser (Eds.), Panic: Psychological perspectives (pp. 91-109). Hillsdale, NJ: Lawrence Erlbaum. BECK, A. T., EMERY, G., & GREENBERG, R. L. (1985). Anxiety disorders and phobias: A cognitive perspective. New York: Basic Books. BEITMAN, B. D. (1992). Integration through fundamental similarities and useful differences among the schools. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. BERZINS, J. I. (1977). Therapist-patient matching. In A. S. Gurman & A. M. Razin (Eds.), Effective psychotherapy: A handbook of research (pp. 222—251). Elmsford, NY: Pergamon. BEUTLER, L. E. (1971a). Attitude similarity in marital therapy. Journal of Consulting and Clinical Psychology, 37, 298-301. BEUTLER, L. E. (197lb). Predicting outcomes of psychotherapy: A comparison of predictions from two attitude theories. Journal of Consulting and Clinical Psychology, 37, 411-416. BEUTLER, L. E. (1979a). Toward specific, psychological therapies for specific conditions. Journal of Consulting and Clinical Psychology, 47, 882-897. BEUTLER, L. E. (1979b). Individual, group, and family therapy modes: Patienttherapist value compatibility and treatment effectiveness. Journal of Counseling and Psychotherapy, 47, 43-59. BEUTLER, L. E. (1979c). Values, beliefs, religion and the persuasive influence of psychotherapy. Psychotherapy: Theory, Research and Practice, 16, 432-440. BEUTLER, L. E. (1981). Convergence in counseling and psychotherapy: A current look. Clinical Psychology Review, 7, 79—101. BEUTLER, L. E. (1983). Eclectic psychotherapy. A systematic approach. Elmsford, NY: Pergamon. BEUTLER, L. E. (1986). Systematic eclectic psychotherapy. In J. C. Norcross (Ed.), Handbook of eclectic psychotherapy (pp. 94-131). New York: Brunner/ Mazel. BEUTLER, L. E. (1989). Differential treatment selection: The role of diagnosis in psychotherapy. Psychotherapy, 26, 271-281. BEUTLER, L. E. (1991). Have all won and must all have prizes? Revisiting Luborsky et al.'s verdict. Journal of Consulting, and Clinical Psychology, 59, 226-232. BEUTLER, L. E., ARIZMENDI, T. G., CRAGO, M., SHANFIELD, S., & HAGAMAN, R. (1983). The effects of value similarity and clients' persuadability on value convergence and psychotherapy improvement. Journal of Social and Clinical Psychology, 7, 231-245. BEUTLER, L. E., & BERGAN, 1. (1991). Value change in counseling and psychotherapy: A search for scientific credibility. Journal of Counseling Psychology, 38, 16-24. BEUTLER, L. E., & CLARKIN, J. F. (1990). Systematic treatment selection: Toward targeted therapeutic interventions. New York: Brunner/Mazel.

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BEUTLER, L. E., CRAGO, M., & ARIZMENDI, T. G. (1986). Therapist variables in psychotherapy process and outcome. In S. L. Garfield & A. E. Bergin (Eds.), Handbook of psychotherapy and behavior change (3rd ed., pp. 257—310). New York: Wiley. BEUTLER, L. E., ENGLE, D., MOHR, D., DALDRUP, R. J., BERGAN, J., MEREDITH, K., & MERRY, W. (1991). Predictors of differential and self-directed psychotherapeutic procedures. Journal of Consulting and Clinical Psychology, 59, 333-340. BEUTLER, L. E., ENGLE, D., SHOHAM-SALOMON, V., MOHR, D. C, DEAN, J. C, & BERNAT, E. M. (1991). University of Arizona: Searching for differential treatments. In L. E. Beutler & M. Crago (Eds.), Psychotherapy research: An international review of programmatic studies (pp. 90—97). Washington, DC: American Psychological Association. BEUTLER, L. E., JOBE, A. M., & ELKINS, D. (1974). Outcomes in group psychotherapy: Using persuasion theory to increase treatment efficiency. Journal of Consulting and Clinical Psychology, 42, 547-553. BEUTLER, L. E., JOHNSON, D. T., NEVILLE, C. W., JR., ELKINS, D., & JOBE, A. M. (1975). Attitude similarity and therapist credibility as predictors of attitude change and improvement in psychotherapy. Journal of Consulting and Clinical Psychology, 43, 90-91. BEUTLER, L. E., & MITCHELL, R. (1981). Differential psychotherapy outcome among depressed and impulsive patients as a function of analytic and experiential treatment procedures. Psychiatry, 44, 297—306. BEUTLER, L. E., MOHR, D. C., GRAWE, K., ENGLE, D., & MACDONALD, R. (1991). Looking for differential treatment effects: Cross-cultural predictors of differential psychotherapy efficacy. Journal of Psychotherapy Integration, 1, 121— 141. BOND, J. A., HANSELL, J., & SHEVRIN, H. (1987). Locating transference paradigms in psychotherapy transcripts: Reliability of relationship episode location in the Core Conflictual Relationship Theme (CCRT) method. Psychotherapy, 24, 736-749. BORDIN, E. S. (1976). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research and Practice, 16, 252-260. BOWLBY, J. (1979). The making and breaking of affedional bonds. London: Tavistock. BREHM, S. S. (1976). The application of social psychology to clinical practice. Washington, DC: Hemisphere. BREHM, S. S., & BREHM, J. W. (1981). Psychological reactance: A theory of freedom and control. New York: Academic Press. BUTCHER, J. N., DAHLSTROM, W. G., GRAHAM, J. R., TELLEGEN, A., & KAEMMER, B. (1989). Manual for the restandardized Minnesota Multiphasic Personality Inventory: MMPI-2. An administrative and interpretive guide. Minneapolis: University of Minnesota Press. CALVERT, S. J., BEUTLER, L. E., & CRAGO, M. (1988). Psychotherapy outcome as

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a function of therapist-patient matching on selected variables. Journal of Social and Clinical Psychology, 6, 104-117. CLARKIN, }., FRANCES, A., & PERRY, S. (1992). Differential therapeutics. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. COLE, J. K., & MAGNUSSEN, M. (1966). Where the action is. Journal of Consulting Psychology, 30, 539-543. CORRIGAN, J. D., DELL, D. M., LEWIS, K. N., & SCHMIDT, L. D. (1980). Counseling as a social influence process: A review. Journal of Counseling Psychology, 27, 395-441. DAHLSTROM, W. G., WELSH, G. S., & DAHLSTROM, L. E. (1972). An MMPI handbook: Vol. 1. Clinical interpretation. Minneapolis: University of Minnesota Press. DEROGATIS, L. R., RICKELS, K., & ROCK, A. F. (1976). The SCL-90 and the MMPI: A step in the validation of a new self-report scale. British Journal of Psychiatry, 128, 280-289. FELDMAN, L. B., & POWELL, S. (1992). Integrating therapy formats. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. FORSYTH, N. L., & FORSYTH, D. R. (1982). Internality, controllability, and the effectiveness of attributional interpretations in counseling. Journal of Counseling Psychology, 29, 140-150. FRANCES, A., CLARKIN, J., & PERRY, S. (1984). Differential therapeutics in psychiatry. New York: Brunner/Mazel. FRANK, J. D. (1973). Persuasion and healing: A comparative study of psychotherapy (rev. ed.). Baltimore: Johns Hopkins University Press. GARFIELD, S. L., & KURTZ, R. (1977). A study of eclectic views. Journal of Consulting and Clinical Psychology, 45, 78-83. GILLIS, J. S., LIPKIN, M. D., & MORAN, T. J. (1981). Drug therapy decisions: A social judgement analysis. Journal of Nervous and Mental Disease, 169, 439447. GOLDFRIED, M. R., & DAVISON, G. C. (1976). Clinical behavior therapy. New York: Holt, Rinehart & Winston. GOLDSTEIN, A. P., HELLER, K., & SECHREST, L. B. (1966). Psychotherapy and the psychology of behavior change. New York: Wiley. GOLDSTEIN, A. P., & SIMONSON, N. R. (1971). Social psychological approaches to psychotherapy research. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of psychotherapy and behavior change (pp. 154-195). New York: Wiley. GUIDANO, V. F. (1987). Complexity of the self: A developmental approach to psychopathology and therapy. New York: Guilford. HAMBLIN, D. L., BEUTLER, L. E., SCOGIN, F. R., & CORBISHLEY, A. (1988, June). Patient responsiveness to therapist values and outcome in group cognitive therapy. Paper presented at the annual meeting of the Society for Psychotherapy Research, Santa Fe, NM.

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HINSHELWOOD, R. D. (1989). A dictionary of Kleinian thought. London: Free Association of Books. KELLY, T. A. (1990). The role of values in psychotherapy: Review and methodological critique. Clinical Psychology Review, 10, 171—186. KING, D. G., & BLANEY, P. H. (1977). Effectiveness of A and B therapists with schizophrenics and neurotics: A referral study. Journal of Consulting and Clinical Psychology, 45, 407-411. KOHUT, H. (1977). The restoration of the self. New York: International Universities Press. KOLB, D. L, BEUTLER, L. E., DAVIS, C. S., CRAGO, M., & SHANFIELD, S. (1985). Patient personality, locus of control, involvement, therapy relationship, drop-out and change in psychotherapy. Psychotherapy: Theory, Research and Practice, 22, 702-710. LAMBERT, M. J. (1992). Psychotherapy outcome research: Implications for integrative and eclectic therapists. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. LAPLANCHE, J., & PONTALIS, J. B. (1973). The language of psycho-analysis (D. Nicholson-Smith, Trans.). New York: Norton. (Original work published 1967) LARSON, V. A. (1987). An exploration of psychotherapeutic resonance. Psychotherapy, 24, 321-324. LUBORSKY, L. (1984). Principles of psychoanalytic psychotherapy: A manual for supportive-expressive treatment. New York: Basic Books. LUBORSKY, L., CRITS-CHRISTOPH, P., ALEXANDER, L., MARGOLIS, M., & COHEN, M. (1983). Two helping alliance methods for predicting outcomes of psychotherapy: A counting-signs vs. a global rating method. Journal of Nervous and Mental Disease, 171, 480-491. LUBORSKY, L., & DERUBEIS, R. J. (1984). The use of psychotherapy treatment manuals: A small revolution in psychotherapy research style. Clinical Psychology Review, 4, 5—14. LUBORSKY, L., MCLELLAN, A. T., WOODY, G. E., O'BRIEN, C. P., & AUERBACH, A. (1985). Therapist success and its determinants. Archives of General Psychiatry, 42, 602-611. LUBORSKY, L., SINGER, B., & LUBORSKY, L. (1975). Comparative studies of psychotherapies: Is it true that "everybody has won and all must have prizes?" Archives of General Psychiatry, 32, 995-1008. MAHONEY, M. J. (1991). Human change processes: The scientific foundations of psychotherapy. New York: Basic Books. MARTIN, P. J., MOORE, J. E., & STERNE, A. L. (1977). Therapists as prophets: Their expectancies and treatment outcome. Psychotherapy: Theory, Research and Practice, 14, 188-195. MENDELSOHN, G. A., & GELLER. M. H. (1963). Effects of counselor-client similarity on the outcome of counseling. Journal of Counseling Psychology, 10, 71-77.

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NORCROSS, J. C. (1986). Eclectic psychotherapy: An introduction and overview. In J. C. Norcross (Ed.), Handbook of eclectic psychotherapy (pp. 3—24). New York: Brunner/Mazel. NORCROSS, J. C., & NEWMAN, C. F. (1992). Psychotherapy integration: setting the context. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. NORCROSS, ). C., & PROCHASKA, J. O. (1983). Clinicians' theoretical orientations: Selection, utilization, and efficacy. Professional Psychology: Research and Practice, 74, 197-208. OLLENDICK, T. H., & MURPHY, M. J. (1977). Differential effectiveness of muscular and cognitive relaxation as a function of locus of control. Journal of Behavioral Therapy and Experimental Psychiatry, 8, 223-228. PAULSON, J. J., & LIN, T. T. (1970). Predicting WA1S IQ from Shipley-Hartford scores. Journal of Clinical Psychology, 26, 453-461. PROCHASKA, J. O., & DICLEMENTE, C. C. (1992). The transtheoretical approach. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration). New York: Basic Books. ROTTER, J. B. (1966). Generalized expectancies for internal versus external control of reinforcement. Psychological Monographs: General and Applied, 80 (1, Whole No. 609). SHAPIRO, D. A., & SHAPIRO, D. (1982). Meta-analysis of comparative therapy outcome studies: A replication and refinement. Psychological Bulletin, 92, 581-604. SHAW, B. F. (1983, July). Training therapists for the treatment of depression: Collaborative study. Paper presented at the meeting of the Society for Psychotherapy Research, Sheffield, England. SHOHAM-SALOMON, V. (1991). Introduction to special section on client-therapy interaction research. Journal of Consulting and Clinical Psychology, 59, 203204. SHOHAM-SALOMON, V., AVNER, R., & NEEMAN, R. (1989). You're changed if you do and changed if you don't: Mechanisms underlying paradoxical interventions. Journal of Consulting and Clinical Psychology, 57, 590—598. SHOHAM-SALOMON, V., & HANNAH, M. T. (1991). Client-treatment interaction in the study of differential change processes. Journal of Consulting and Clinical Psychology, 59, 217-225. SLOANE, R. B., STAPLES, F. R., CRISTOL, A. H., YORKSTON, N. J., & WHIPPLE, K. (1975). Psychotherapy versus behavior therapy. Cambridge, MA: Harvard University Press. SMITH, M. L, GLASS, G. V., & MILLER, T. I. (1980). The benefits of psychotherapy. Baltimore: Johns Hopkins University Press. STRONG, S. R. (1968). Counseling: An interpersonal influence process. Journal of Counseling Psychology, 15, 215-224. STRUPP, H. H. (198 la). Clinical research, practice and the crisis of confidence. Journal of Consulting and Clinical Psychology, 49, 216—219.

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STRUPP, H. H. (198 Ib). Toward the refinement of time-limited dynamic psychotherapy. In S. H. Budman (Ed.), Forms of brief therapy (pp. 219-242). New York: Guilford. STRUPP, H. H., & BINDER, J. L. (1984). Psychotherapy in a new key. A guide to time-limited dynamic psychotherapy. New York: Basic Books. TALLEY, F. P., STRUPP, H. H., & MOREY, L. C. (1990). Matching in psychotherapy: Patient-therapist dimensions and their impact on outcome. Journal of Consulting and Clinical Psychology, 58, 182—188. TENNEN, H., ROHRBAUGH, M., PRESS, S., & WHITE, L. (1981). Reactance theory and therapeutic paradox: A compliance-defiance model. Psychotherapy: Theory, Research and Practice, 18, 14—22. TJELVEIT, A. C. (1986). The ethics of value conversion in psychotherapy: Appropriate and inappropriate therapist influence on client values. Clinical Psychology Review, 6, 515—537. WAMPOLD, B. E., CASAS, J. M., & ATKINSON, D. R. (1981). Ethnic bias in counseling: An information processing approach. Journal of Counseling Psychology, 28, 498-503. WELSH, G. S. (1952). An anxiety index and an internalization ratio for the MMPI. Journal of Consulting Psychology, 16, 65-72. WIDIGER, T. A., TRULL, T. J., HURT, S. W., CLARKIN, J. F., & FRANCES, A. (1987). A multidimensional scaling of the DSM-III personality disorders. Archives of General Psychiatry, 44, 557—563.

CHAPTER 9

The Transtheoretical Approach JAMES O. PROCHASKA AND CARLO C. DICLEMENTE

I

MPETUS FOR THE TRANSTHEORETICAL APPROACH came from several different sources. First and foremost was a discontent with the state of affairs in psychotherapy theory, research, and practice. The narrowness and frequent dogmatism of the proponents of many therapies, the consistent research findings of a few, and the differences in outcome among therapy systems encouraged a search for alternatives. Each therapy system focused more on theories of psychopathology and single mechanisms of change than an exploration of the process of change. Unconditional positive regard, authenticity, living in the here and now, confrontation of beliefs, social interest, conditioning, and contingencies are valuable rules for human functioning but are not sufficient to explain therapy change. In 1977 Prochaska, with the help of his students, embarked on a journey through the various systems of therapy, seeking the commonalities across the rigid boundaries of the most popular theories of psychotherapy. Systems of Psychotherapy: A Transtheoretical Analysis (Prochaska, 1984) represents the culmination of this journey. The map used for the journey indicated that theories of psychotherapy can be summarized by 10 separate processes of change. Although the framework used in this analysis appeared to have face validity, it remained a theoretical construct with no empirical basis. Since that initial work, we and a number of collaborators applied the model, expanded its scope, and explored its limitations in studies of intentional change, surveys of practitioners and patients, and the creation of assessment instruments. This research supported and expanded our theorizing and encouraged us to continue the development of what we

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have called The Transtheoretical Approach: Crossing the Traditional Boundaries of Therapy (Prochaska & DiClemente, 1984). A final impetus for our work was found in the general Zeitgeist among practitioners and theorists of psychotherapy. We heard clearly the pleas of the participants of a 1981 APA symposium (e.g., Marvin Goldfried and Hans Strupp) who called for a more integrated and comprehensive approach to psychotherapy. What seemed to be needed was an approach that would take into account the differences in the experiences of therapists and clients (Sloane, Staples, Cristol, Yorkston, & Whipple, 1975). Moreover, in our thinking, an integrative approach should be able to account for how individuals change on their own (unaided by psychotherapy) as well as how they change as the result of psychotherapy.

The Transtheoretical Approach The proliferation of psychotherapy systems reflects the complex, interactive nature of psychotherapy. The daily dilemma facing the clinician is what to do, when to do it, with whom, in what way, and with which problem. Both in the research literature and in clinical experience, it has become clear that no one system of therapy addresses adequately all these questions. From our perspective, an integrative perspective will accomplish the following goals: 1. Preserve the valuable insights of major systems of psychotherapy. Trying to reduce all therapy systems to their least common denominator removes the richness of the major therapy systems. 2. Provide some practical answers to the questions faced by clinicians. However theoretically elegant it might be, an impractical, oversimplistic, or irrelevant integration would never be adopted. 3. Bring some order to the chaotic diversity in the field of psychotherapy. However, if we act like children ordered to clean up their rooms, throwing an assorted collection of techniques into the toy box may offer some relief, but will only hide the chaos. 4. Offer a researchable alternative to single-system and comparative types of research. Explanation without experimentation will not silence the critics of both eclecticism and psychotherapy. 5. Generate a systematic approach, a structure or set of principles and constructs that are comprehensive enough to include the critical dimensions of psychotherapy and, at the same time, that are adequately flexible to promote collaboration, creativity, and choice.

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PROCESSES OF CHANGE

An analysis of the 24 most popular theories of psychotherapy (Prochaska, 1984) yielded the first of the three basic elements of the transtheoretical approach—the processes of change. Transtheoretical therapy began with the assumption that integration across a diversity of therapy systems most likely would occur at an intermediate level of analysis between theory and technique, the level of processes of change. Coincidentally, Goldfried (1980, 1982) in his well-known call for a rapproachment, independently suggested that the principles of change were the appropriate starting point at which rapprochement could begin. The processes of change, then, may be best understood as a middle level of abstraction between the basic theoretical assumptions of a system of psychotherapy and the techniques proposed by the theory. A process of change represents types of activity initiated or experienced by an individual in modifying thinking, behavior, or affect related to a particular problem. Although there are a large number of coping activities, there appear to be a finite set of processes that represent the basic change principles underlying coping activities. In a similar manner, techniques of therapy can be analyzed to see which type of process they would draw upon or promote. Thus, confrontation by the therapist would provide new information, challenge current thinking about the problem, and offer feedback. All these therapist activities would enable the individual to engage in more accurate information processing. From a transtheoretical perspective, these activities represent the process of change called consciousness raising. Subsequent modifications of our original formulation through research yielded 10 separate and distinct processes of change: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Consciousness raising Self-liberation Social liberation Counterconditioning Stimulus control Self-reevaluation Environmental reevaluation Contingency management Dramatic relief Helping relationships

Our studies indicate that people in the natural environment generally use these 10 different processes of change to modify problem behaviors. Most major systems of therapy, however, theoretically employ only two or three

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processes (Prochaska, 1984). One of the assumptions of the transtheoretical approach is that therapists should be at least as cognitively complex as their clients. They should be able to think in terms of a more comprehensive set of processes and be able to apply techniques to engage each process when appropriate. STAGES OF CHANGE

A second basic element of the transtheoretical approach is the stages of change, which reflect the temporal and motivational aspects of change. Intentional change is not an all-or-none phenomenon, but a gradual movement through specific stages (cf. Beitman, 1987; Egan, 1986). Lack of awareness of this staging phenomenon has led some theories of therapy to assume that all clients presenting for therapy are in the same stage of change and are ready for the same change processes. Studies of various outpatient populations (McConnaughy, Prochaska, & Velicer, 1983; McConnaughy, DiClemente, Prochaska, & Velicer, 1989; DiClemente & Hughes, 1990) have found a variety of profiles on the Stages of Change Scale. Clearly, all individuals who come to therapy are not at the same stage of change. We have been able to identify five basic stages of change: precontemplation, contemplation, preparation, action, and maintenance. In our approach, a stage of change represents both a period of time and a set of tasks needed for movement to the next stage. While the time spent in each stage may vary, the tasks to be accomplished in order to achieve successful movement to the next stage are assumed to be invariant. In the move from precontemplation to contemplation, an individual must become aware of the problem, make some admission or take ownership of the problem, confront defenses and habit aspects of the problem that make it difficult to control, and begin to see some of the negative aspects of the problem in order to move to the next stage of seriously contemplating change. One of the most helpful findings to emerge from our research is that particular processes of change are emphasized during particular stages of change (Prochaska & DiClemente, 1983). The integration of stages and processes of change can serve as an important guide for therapists. Once a client's stage of change is clear, the therapist knows which processes to apply in order to help the client progress to the next stage of change. Rather than apply change processes in a haphazard or trial-and-error approach, integrative therapists can begin to use change processes much more systematically. Table 9.1 presents a diagram showing the integration that was revealed from our exploration of the stages and processes of change (Pro-

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Processes of Change Emphasized at Particular Stages of Change Precontemplation

Contemplation

Preparation

Action Maintenance

Consciousness raising Dramatic relief Environmental reevaluation Self-reevaluation Self-liberation Contingency management Helping relationship Counterconditioning Stimulus control

chaska & DiClemente, 1983; in press). During precontemplation, individuals use change processes significantly less than people in any other stage. It was found that precontemplators process less information about their problems; spend less time and energy reevaluating themselves, experience fewer emotional reactions to the negative aspects of their problems, are less open with significant others about their problems, and do little to shift their attention or their environment in the direction of overcoming their problems. In therapy these are clients who are labeled resistant. What can help assist people from precontemplation to contemplation? Table 9.1 suggests several change processes that are most helpful. First, consciousness-raising interventions, such as observations, confrontations, and interpretations, can help clients become more aware of the causes, consequences, and cures of their problems. To move to the contemplation stage, clients have to become more aware of the negative consequences of their behavior. Often we have to first help clients become more aware of their-defenses before they can become more conscious of what they are defending against. Second, the process of dramatic relief provides clients with helpful affective experiences (e.g., psychodrama or the Gestalt intervention using the empty chair), which can raise emotions related to problem behaviors. Life events such as the disease or death of a friend or lover can also move precontemplators emotionally, especially if such events are problem related.

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Clients in the contemplation stage are most open to consciousnessraising interventions such as observations, confrontations, and interpretations. Contemplators are much more likely to use bibliotherapy and other educational interventions. As clients become increasingly more aware of themselves and the nature of their problems, they are freer to reevaluate themselves both affectively and cognitively. The self-reevaluation process includes an assessment of which values clients will try to actualize, act upon, and make real, and which they will let die. The more central problem behaviors are to the core values, the more will their reevaluation involve changes in their sense of self. Contemplators also reevaluate the effects their behaviors have on their environments, especially the people they care most about. Addicts, for example, may ask, "How do I think and feel about living in a deteriorating environment that places me and my family at increasing risk of disease, death, poverty, or imprisonment?" For some addictive behaviors, like heroin addiction, the immediate effects on the environment are much more real. For other addictions, like smoking, the emphasis may need to be on longer-term effects. Movement from precontemplation to contemplation, and movement through the contemplation stage, involves increased use of cognitive, affective, and evaluative processes of change. To better prepare individuals for action, changes are required in how they think and feel about their problem behaviors and how they value their problematic lifestyles. Preparation indicates a readiness to change in the near future and acquisition of valuable lessons from past change attempts and failures. They are on the verge of taking action and need to set goals and priorities accordingly. They often develop an action plan for how they are going to proceed. In addition, they need to make firm commitments to follow through on the action option they choose. In fact, they are often already engaged in processes that would increase self-regulation and initiate behavior change (DiClemente et al., 1991). People typically begin by taking some small steps toward action. They may use counterconditioning and stimulus-control processes to begin reducing their problem behaviors. Addicted individuals, for instance, may delay their use of substances each day or may control the number of situations in which they rely on the addictive substances. During the action stage it is important that clients act from a sense of self-liberation. They need to believe that they have the autonomy to change their lives in key ways. Yet they also need to accept that coercive forces are as much a part of life as is autonomy. Self-liberation is based, in part, on a sense of self-efficacy (Bandura, 1977, 1982), the belief that one's own efforts play a critical role in succeeding in the face of difficult situations. Self-liberation, however, requires more than just an affective and

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cognitive foundation. Clients must also be effective enough with behavioral processes, such as countercondiHoning and stimulus control, to cope with those external circumstances that can coerce them into relapsing. Therapists can provide training, if necessary, in behavioral processes to increase the probability that clients will be successful when they do take action. As action proceeds, therapists provide a helping relationship in which they serve as consultants to the clients-as-self-changers, assisting them to identify any errors they may be making in their attempts to change their behavior and environment in healthier directions. Since action is a particularly stressful stage of change that involves considerable opportunities for experiencing coercion, guilt, failure, rejection, and the limits of personal freedom, clients are also particularly in need of support and understanding. Knowing that there is at least one person who cares and is committed to helping serves to ease some of the distress and dread of taking life-changing risks. Just as preparation for action is essential for success, so too is preparation for maintenance. Successful maintenance builds on each of the processes that has come before, and also involves an open assessment of the conditions under which a person is likely to be coerced into relapsing. Clients need to assess the alternatives they have for coping with such coercive conditions without resorting to self-defeating defenses and pathological responses. Perhaps most important is the sense that one is becoming more of the kind of person one wants to be. Continuing to apply counterconditioning and stimulus control is most effective when it is based on the conviction that maintaining change maintains a sense of self that is highly valued by oneself and at least one significant other (cf. Wolfe, 1992). LEVELS OF CHANGE

At this point in our analysis, it appears that we are discussing only how to approach a single, well-defined problem. However, as all of us realize, reality is not so accommodating, and human behavior change is not so simple a process. Although we can isolate certain symptoms and syndromes, these occur in the context of complex, interrelated levels of human functioning. The third basic element of the transtheoretical approach addresses this issue. The levels of change represent a hierarchical organization of five distinct but interrelated levels of psychological problems that can be addressed in psychotherapy: 1. 2. 3. 4. 5.

Symptom/situational problems Maladaptive cognitions Current interpersonal conflicts Family systems conflicts Intrapersonal conflicts

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Historically, systems of psychotherapy have attributed psychological problems primarily to one or two levels and focused their interventions on these. Behavior therapists have focused on the symptom and situational determinants; cognitive therapists on maladaptive cognitions; family therapists on the family systems level; and analytic therapists on intrapersonal conflicts. It appears to us to be critical in the process of change that both therapist and client agree as to which level they attribute the problem and at which level or levels they are willing to engage in together as they work to change the problem behavior. In the transtheoretical approach, we prefer to intervene initially at the symptom/situational level because change tends to occur more quickly as this level and often represents the primary reason for which the individual entered therapy. The further down the hierarchy we focus, the further removed from awareness are the determinants of the problem, and the more historically remote and more interrelated the problem is with the sense of self. Thus, we predict that the "deeper" the level that needs to be changed, the longer and more complex therapy is likely to be and the greater the resistance of the client (Prochaska & DiCIemente, 1984). These levels, it should be emphasized, are not completely isolated from one another; change at any one level is likely to produce change at other levels. Symptoms often involve intrapersonal conflicts, and maladaptive cognitions often reflect family systems beliefs or rules. In the transtheoretical approach, the complete therapist is prepared to intervene at any of the five levels of change, though the preference is to begin at the highest most contemporary level that clinical assessment and judgment can justify. INTEGRATING LEVELS, STAGES, AND PROCESSES

In summary, the transtheoretical approach sees therapeutic integration as the differential application of the processes of change at specific stages of change, according to identified problem level. Integrating the levels with the stages and processes of change provides a model for intervening hierarchically and systematically across a broad range of therapeutic content. Table 9.2 presents an overview of the integration of levels, stages, and processes of change. Three basic strategies can be employed for intervening across multiple levels of change. The first is a shifting-levels strategy. Therapy would typically focus first on the client's symptoms and the situations supporting the symptoms. If the processes could be applied effectively at the first level, and if the client could progress through each stage of change, therapy could be completed without shifting to a more complex level of analysis. If this approach were not effective, therapy would necessarily shift to other

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Interaction of Levels, Stages, and Processes of Change Stages Levels

Precontemplation Contemplation Preparation Action Maintenance

Symptom/ situational

Consciousness raising Dramatic relief Environmental reevaluation Self-reevaluation Self-liberation Contingency management Helping relationship Counterconditioning Stimulus control

Maladaptive cognitions Interpersonal conflicts Family systems conflicts Intrapersonal conflicts

levels in sequence in order to achieve the desired change. The strategy of shifting from a higher level to a deeper one is illustrated in table 9.2 by the arrows moving first across one level and then down to the next level. The second option is the key-level strategy. If the available evidence points to one key level of causality of a problem, and the client can be effectively engaged at that level, the therapist would work almost exclusively at this key level. The third alternative is the maximum-impact strategy. With many complex cases, it is evident that multiple levels are involved as a cause, an effect, or a maintainer of the client's problems. Interventions can be created to affect clients at multiple levels of change in order to establish a maximum impact for change in a synergistic rather than a sequential manner.

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Theoretical complimentarity and integration are the keys to synthesizing the major systems of psychotherapy. Table 9.3 illustrates where leading systems of therapy fit best within the integrative framework of the transtheoretical approach. The therapy systems included in table 9.3 have been the most prominent contributors to the transtheoretical approach. Depending on which level and at which stage we are working, different therapy systems will play a more or less prominent role. Behavior therapy, for example, has developed specific interventions at the symptom/situational level for clients who are ready for action. At the maladaptive cognition level, however, Ellis's rational-emotive therapy and Beck's cognitive therapy are most prominent for clients in the contemplation and action stages. By definition we have not excluded any therapy systems from the transtheoretical approach. Our approach is an open framework that allows for integration of new and innovative interventions, as well as the inclusion of existing therapy systems that either research or clinical experience suggest are most helpful for clients in particular stages at particular levels of change. A major therapy system that is not included in table 9.3 is Rogers's (1951, 1959) client-centered therapy, a system that has been most prominent in articulating and demonstrating the importance of the therapeutic

TABLE 9.3

Integration of Major Tlierapy Systems Within the Transtheoretical Framework Stages Levels

Precontemplation Contemplation Preparation

Symptom/ situational

Action Maintenance Behavior therapy

Maladaptive cognitions

Adlerian therapy

Rational-emotive therapy Cognitive therapy

Interpersonal conflicts

Sullivanian therapy

Couples communication Transactional analysis

Family systems conflicts

Strategic therapy

Bowenian therapy

Intrapersonal conflicts

Gestalt therapy Psychoanalytic Existential therapy therapies

Structural therapy

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relationship as a critical process of change. Our own thinking and research on the helping relationship as a major process of change has been most influenced by client-centered therapy, even though we do not rely just on client-centered techniques for developing a helping relationship. Thus, Rogers's influence on the transtheoretical approach cuts across the levels of change.

Patient Assessment Accurate assessments of the client's stage, level, and processes of change are critical to the transtheoretical approach. Therapy would be most effective if patient and therapist were matched and working at the same stage and level of change. The joining of the patient and the therapist is centered around the structure and process of intentional change. The therapist's role is one of maximizing self-change efforts by facilitating neglected processes, deemphasizing overused processes, correcting inappropriately applied processes, teaching new or unknown processes, and redirecting change efforts to the appropriate stages and levels of change. Clinical assessment of the stages, levels, and processes requires some modification of the traditional interview. Knowledge of both the attitude toward a problem, as well as the actions taken with regard to it, is needed for assessment of the stages of change. It is important to know that a man stopped drinking one week ago, when his wife left him. Equally important, however, is knowing whether this is the first step in taking significant action toward intentional change of his problem drinking, or an attempt to change his wife's behavior. Another method of assessing the current stage of change is to evaluate both time and energy used in accomplishing the tasks of any prior stage of change. If someone has contemplated changing only casually for a couple of weeks, for example, then that person would not be prepared to take action. Assessment of the levels of change requires a clinical interview that addresses each of the levels. In a case of vaginismus, we must know the symptomatic expression and situational determinants of the sexual dysfunction, but we should also explore self-statements, the couple's interpersonal functioning, family-system involvement, and any possible intrapersonal conflicts regarding identity, self-esteem, and so on. In this assessment it would be important to establish at which level or levels the patient perceives the problem, as well as the levels that the clinician assesses are integrally involved in the problem.

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Evaluating the processes of change being employed by the patient can be an extensive task. Therapists should explore what the patient is currently doing with regard to the problem, how often these activities are occurring, and what has been done in the past in attempts to overcome the problem. An obsessive patient may be relying heavily on consciousness raising as the most important process, while neglecting self-liberation and more action-oriented processes. In our research, we have begun to develop assessment instruments to aid in the evaluation of the stages, levels, and processes of change. The University of Rhode Island Change Assessment Scale (URICA) is a 32-item questionnaire with four subcomponents; profiles are based on scores on the four subcomponents. Research on these profiles continues, with some of the profiles needing more empirical interpretation. However, the existing profiles can be used clinically to direct therapy interventions based on patient scores on the precontemplation, contemplation, action, and maintenance subscales. Several forms of a questionnaire to assess the processes of change have also been developed. The questionnaires typically contain four to five questions about activities that would represent each of the processes, and clients are asked to indicate how frequently each activity occurs on a 5-point Likert Scale (1 = not at all; 5 = very frequently). Since changeprocess activity is somewhat different for diverse problems, we have attempted to adapt this basic format to problems of alcoholism, overeating, distress, and smoking; a more general form for psychotherapy has also been developed. These questionnaires have shown remarkable consistency across problem areas (Prochaska & DiClemente, 1986), and principal component analyses have yielded 10 or more consistent components in their use with both clients and therapists. This type of questionnaire can be used to assess change processes used before and during therapy to examine how therapy interventions affect the use of the processes. Change-process activity has been found to relate to therapist theoretical orientation (Prochaska & Norcross, 1983) and client activity in the various stages of change, and to be predictive of successful movement through the stages of change. Questionnaires have also been developed to assess the levels of change. The questionnaires typically contain four questions representing each of the five levels of change used in the transtheoretical model. In addition, five other levels are assessed, since people do not attribute their problems only to psychosocial sources. The other levels include bad luck, spiritual determinism, biological determinants, insufficient effort, and preferred lifestyle. The levels have been developed for use with psychotherapy clients and with health-related behaviors like smoking (Norcross, Prochaska, & Hambrecht, 1985).

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Treatment Applicability We are attempting to develop a transtheoretical framework applicable to all clinical problems of psychological origin. The levels of change represent a means of categorizing patient problems, which is compatible with current DSM-III-R diagnosis but is somewhat more comprehensive, since it includes systems and interpersonal problems. Thus, we envision the framework as appropriate for all types of psychopathology and health-related problems. In addition, the framework can be used to categorize treatment delivery systems according to the kind of clients and problems they primarily address. Since we often intervene first at the symptom/situational level, the transtheoretical approach can be used in both a short-term and long-term format. Length of therapy, setting, and modality are determined more by the stage of change, level of problem involvement, and type of processes employed rather than a predetermined set on the part of the therapist. Thus, a family intervention that brings family members together to make an effective confrontation of the patient can be used for a precontemplative alcoholic. Individual and couples therapy can be used to work through contemplation issues to achieve effective action when working with sexual dysfunctions. Duration and timing of therapy would also depend on the problem levels and the stage of change. Individuals who have rather circumscribed problems and are in the action stage often modify the problem in a relatively brief period of time. Someone with multiple problems, who may be at the precontemplation stage with several of them, would necessarily require significantly longer treatment. In this context, several important considerations should be kept in mind. Action and maintenance are separate and important stages of change. Discontinuation of therapy when the client has taken action could do a disservice to the client, especially one who is at high risk for relapse. Since our approach concentrates on intentional change, contraindications for the use of the transtheoretical approach would indicate any setting or problem where intentional change was not the primary goal. In a correctional setting or in managing the self-destructive behavior of a child, control, not intentional change, may be the primary goal. In this context, being aware of the stages and levels of change may nonetheless be desirable. However, external behavioral control appears to be the treatment of choice, using the processes of contingency control and stimulus control. Once the immediate threat to self or others has been managed, therapists can work to bring the problem behaviors under intentional self-control rather than external control. In fact, this should be an important

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secondary goal if treatment or incarceration goals are to be maintained after the person is released into the community. In working with intentional change, the transtheoretical approach is quite compatible with the traditional treatment structure of psychotherapy. Weekly, hour-long sessions can be used to implement the treatment process. Since we envision psychotherapy as an adjunct to self-change, what occurs between therapy sessions is as important as what happens within therapy sessions. However, modifications of the traditional treatment structure may be negotiated with a client, depending on the stage and level being addressed. A longer, more intense therapy session that includes significant others may be needed for an individual in precontemplation to overcome defenses. Less frequent sessions may be more appropriate for those in contemplation and maintenance. For the former, more time between sessions can allow clients time to use the processes of consciousness raising and self-reevaluation in the service of decision making. For the latter, time between sessions can be used to monitor temptation levels and encounter any obstacles to continued action or maintenance, which occur less frequently. Thus, in effect, therapy sessions become booster sessions.

Treatment Specificity The goal of our clinical and research work on intentional change is to identify the variables that are most effective in helping clients move through the stages of change with regard to a particular problem. In this context, treatment: selection is too generic a term. The more specific issue is to identify which process would be most effective in helping to move a person from one particular stage of change to the next with regard to a certain level or levels of change. The decision to use a particular process is multiply determined. Rather than stating a priori that counterconditioning is the treatment of choice for phobic problems, we prefer to analyze first the stages and levels of change, then the processes currently being used, before making prescription. We realize that this approach places a sizable burden on the therapist. However, in the case of psychotherapy, we believe that simplicity can be a source of mediocrity and confusion. We have found, for example, that insufficient use of consciousness raising in the contemplation stage forces individuals to rely excessively on self-liberation or willpower in their efforts to change, and opens the way to what Janis and Mann (1977) have called "post-decisional regret." The overuse of self-reevaluation during maintenance, on the other hand, is predictive of relapse (DiClemente & Prochaska, 1985). Thus, matching patients with processes requires a general knowledge of the stages, processes, and levels of change and how they

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interact, as well as specific knowledge about individual clients and what they have been doing to effect changes in their lives. While matching is a complex process that has not yet been adequately researched, mismatches (from our perspective) are more readily apparent. A therapist committed to consciousness raising and exploration of all the levels of change prior to taking action will frustrate a client ready to take action at the symptomatic level. An action-oriented behavior therapist will be constantly disappointed by precontemplative clients who fail to implement the suggested behavioral techniques. The family therapist, who insists that change take place at the family systems level with the whole family present, may be unable to engage a system that has a critical member who is in precontemplation. Therapists must become aware of their preferences for particular stages, processes, and levels of change. Certain therapists, by constitution or training, do not have the temperament or skills to address adequately certain stages, processes, or levels. Awareness of these limitations is essential in approaching the question of patient-therapist matching. If a therapist does not have the patience to handle what may be experienced as endless contemplation on the part of the client, it is unlikely that a therapeutic relationship will be developed. Respecting a client's position on the stages of change is an important first step in the joining of therapist and client. Treatment matching should not simply focus on disorders, which amounts to a continuation of the medical model. From our perspective, the problem with using this model as the framework for psychotherapy is that it is not applicable to intentional change. Even with physical problems that require some health-behavior modification, the medical model has been problematic. Compliance, diet control, and exercise all require intentional change and are extremely difficult problems for a medical model that relies on processes of change, such as surgery, which are invasive, externally applied procedures. Disorder is an important concept for developing a taxonomy that enables us to bring together certain symptoms and syndromes for classification. While this information is important in understanding a problem, knowledge of a disorder by itself has limited value in prescribing therapy interventions (Beutler, 1983; Beutler & Consoli, 1992).

Therapeutic Relationship Although therapists have not struggled with all the particular problems faced by different clients, all therapists have had some experience with the

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processes of change. This is the common experiential ground that forms the basis of the relationship between therapist and client. In general, the therapist is seen as the expert on change—not in having all the answers, but in being aware of the critical dimensions of change and being able to offer some assistance in this regard. Clients have potential resources as self-changers, which must be used in order to effect a change. In fact, clients need to shoulder much of the burden of change and look to the therapist for consultation on how to conceptualize the problem and ways to free themselves to move from one stage to another. As with any interactive endeavor, rapport must be built to accomplish the work. However, the type of relationship needed for the work of psychotherapy can vary somewhat with the stage and level of change being addressed. Thus, the consultant-client relationship needs to be modulated according to the client's particular issues. Initiation of therapy with a precontemplation client, for example, takes on a different flavor. A client's unwillingness to see or own a problem is not viewed as resisting the therapist or being uncooperative, but rather as resisting change. Therapists must become aware of how frightening and anxiety provoking the prospect of change can be. With this shift in perspective, the therapist can take on the role of a concerned adviser who can help the client explore the problem (DiClemente, 1991). The therapist becomes an ally rather than another person attempting to coerce change. For a person contemplating change, the therapist should take care not to be too impatient. Contemplation can be a lengthy, frustrating stage of change. While therapists should not support chronic contemplation, they must also avoid blame, guilt, and premature change. In order to make a decision to change a problem behavior, individuals must see that change is possible and in their own best interests. The therapist can challenge clients by making explicit the pros and cons of both the problem behavior and the change. Support, understanding, and a relationship that would enable the therapist to make explicit the fears and concerns of the client is needed during this time. During the action and maintenance stages, the therapist can assume a more formal teaching relationship, since at these stages, the client is likely to idealize the therapist. When initiating action, the client needs the support of a helping relationship and may need to rely on the confidence of the therapist rather than a self-generated sense of efficacy. Initial efforts are likely to be tentative, and seeing the therapist as the expert on change can be comforting. However, as soon as is feasible, it is important to have the client develop more self-confidence and independence from the therapist. For therapists who need to be needed, this can pose a problem. Letting go and allowing the client to take ownership of the change are the final stages of the therapist-client relationship.

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Mechanisms of Change As already noted, a central principal of the transtheoretical approach is that different processes are most important in producing change at different stages. The mechanisms that move someone from precontemplation to contemplation are different from the processes that move someone from preparation to action. What moves people from precontemplation into the contemplation stage of change? What facilitates or forces people to become aware that previously acceptable patterns of behavior are now problematical or pathological? To respond to these questions, we have had to go beyond research data and rely more on clinical experience and clinical theory (Prochaska & DiClemente, 1984). The important theoretical issue here is that intentional change, such as occurs in therapy, is only one type of change that can move people. Developmental and environmental changes are other events that can cause people to alter their lives. The transtheoretical approach focuses primarily on facilitating intentional change, but it recognizes and, at times, relies on other types of change when working with clients. It is assumed, however, that unless developmental or environmental changes produce intentional change as well, clients can feel coerced by forces not of their choosing, and will be likely to revert to previous patterns once the coercion is removed. Therapists can help clients progress more freely into the contemplation stage of change if they can help their clients accept the developmental or environmental forces that are pressuring them to change. Clients may, for example, have difficulty identifying with the developmental process of aging, even though it comes from within their skin. Whether entering a new age becomes a life crisis or an opportunity for growth may be determined by whether we experience aging as imposed on us or as part of us. Most of us, for example, identify with aging when we become 21. Our sense of self includes becoming more independent, mature, and adult. Becoming 40 or 50, on the other hand, is more often experienced as an imposition in a society that identifies with youth. As clients and therapists begin to develop a shared identity that is the essence of a therapeutic relationship, clients become much more open to influence from therapists, much freer to respond to feedback and education about the alienated aspects of their lives. Once clients begin to move into the contemplation stage, their insight and understanding are critical for further progress. Whether the insight is historical-genetic, interactive, cognitive, or situational depends on the level of change that is needed. For clients working at the symptom/ situational level, a functional analysis of the immediate antecedents and

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consequences of troubled behavior may be all the understanding that is needed. Clients attempting to change troubled relationships, however, will need insight into the interactive nature of their problems. Clients who are not free enough from their family of origin or who are plagued by internalized interpersonal conflicts are more likely to need insight into the historical-genetic causes of their conflicts. Moving from contemplation to action involves both consciousnessraising (e.g., confrontation) and self-reevaluation (e.g., value clarification) processes. Helping clients to work through a decisional balance, for example, can clarify which course of action is most likely to reflect the kind of person the client wants to become. Balancing the pros and cons of a particular course of action also prepares clients to pay the price that comes with any major change in life and moves them to develop the solid commitment and plans needed in the preparation. When it comes to action, skill acquisition and/or utilization are most important for therapeutic progress. Applying such behavioral skills as desensitization, assertion, communication, or negotiation are important aspects of the action stage. Which skills are employed depends on the clients level of change. Desensitization, for example, is used most often at the symptom/situational level, whereas communication training is much more important for the interpersonal level. Renegotiating dysfunctional family rules can be particularly liberating at the family systems level. An existentially based assertiveness can be one of the most liberating means for expressing the enhanced sense of self that emerges when interpersonal conflicts are being resolved.

Case Example By its very nature, an integrative therapy cannot be illustrated by a single case. Rather, it would take a long series of cases to reflect the full range of stages, levels, and processes of change used with a diversity of clients. One of the essential values of integration is that it encourages therapists to be rich, diverse, and creative in their choice of interventions with each person. Thus, if the reader were looking over the shoulder of a transtheoretical therapist, the therapist's interventions would be seen to vary tremendously, depending on the needs of particular clients. Nevertheless, we will try to illustrate some of the richness of our approach through the treatment of a psychologically distressed client, partially within the context of marital therapy. Tom, a 50-year-old schoolteacher, was referred for marital therapy by a colleague who had been working with Torn's wife, Barbara, in individual therapy for about a year. Barbara's therapist did not believe that Tom

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would stay in treatment for more than three sessions, even though he was quite distressed. Barbara's therapist actually thought her husband needed individual therapy, but Tom agreed to go to therapy only if they went as a couple. Tom and Barbara were seen together in the first session to assess their problems and their ability to work together at the interpersonal level. Usually we begin by talking about the problems that bring people to therapy, but the first problem at hand in this case was Tom's resistance to therapy. Confronting the problem directly communicates to the client that we are going to try to deal with problems in a straightforward and direct manner. It communicates that the therapist cares about the client's resistance and that the client need not be defensive about it. It also communicates the therapist's hope that maybe there is something the client and/or the therapist can do to make it easier for the client to be a more willing participant. Many spouses have said that their partners would never come to therapy, and if they did, they would not stay. But we have found that almost all reluctant partners would come in for at least one session if the therapist asked, and most would continue in therapy. Tom said, "I don't believe therapy is worthwhile. My wife has been going to therapy for a year, and she's still always lying and spending money like it's going out of style." "Sounds like you might be angry at her therapist," the therapist responded. "You're damn right! He just feeds into her wasting money," said Tom. "Have you let him know you're angry?" the therapist asked. "No, he doesn't want to talk to me," Tom said. "Would you like me to let him know you're angry?" the therapist asked. "Yeah, I would appreciate that," said Tom. So we're off and running. Tom's resistance to therapy is being addressed, if only at the situational level. But at least he does not have to be defensive about his defensiveness. He may be able to experience the therapist as someone who cares about his defensiveness and is trying to understand it. He may, to his surprise, experience the therapist as being helpful, both in dealing with his resistance and with his anger. At the same time, the therapist has to be concerned with Barbara experiencing the therapist as Tom's ally. The therapist could have addressed Tom's anger toward his wife for what he labels "lying and wasting money." But this would have risked putting Barbara on the defensive, and if she counterattacked, the couple could slip into the blame game that involves partners quickly shifting from the offensive to the defensive position. "It must be hard to have your husband accusing you of lying and

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wasting money." I said this to Barbara, knowing I was still risking the blame game but feeling that I wanted to empathize with her as well as with Tom. I also wanted to communicate that I appreciated that there are two sides to every marital conflict, and that her perspective was as important as Tom's. These opening segments of therapy indicate that treatment usually begins immediately, with no formal assessment period, although assessment occurs right from the start. In the course of the first two therapy sessions, the following information was shared: Tom's mood was usually depressed; he couldn't relax; he was having trouble sleeping; he was irritable and often verbally abusive; he felt lousy about himself; and he was having trouble relating to his students, his colleagues, and the customers who sought his services in his after-school job. Tom's distress increased whenever he approached Barbara sexually and she refused, which happened at least once a day. Barbara was really angry at Tom. She was angry about his constant accusations about her lying, spending money behind his back, and having affairs when she went out on Friday night with her women friends. He would check the phone bill to see whom she had been calling; he would open mail addressed to her to see what money she owed; and he would sometimes follow her out with her friends to see if she was seeing other men. How could she want to make love, when they were so embroiled in a game of cops and robbers? Tom had coerced her into having sexual intercourse a couple of times and she resented it. Barbara also resented Tom's preoccupation with money. If he wasn't preoccupied about her spending money, he was preoccupied with his compulsive gambling. Tom denied that his gambling was a problem. If they lost everything on his gambling, it would come to $1,000 a year, and between the two of them, they were making over $80,000. What is a therapist to believe? At worst, we have a compulsive gambler and an obsessive and possessive lover married to a compulsive liar and an impulsive spender. We may have classic character disorders who have trouble managing their own lives let alone managing marriage effectively. Character disorders either do not stay in therapy or they stay forever. From the transtheoretical perspective, it appeared that Tom was in the precontemplation stage in regard to most of his problems. The exception was his gambling, which Tom had changed on his own to relatively controlled gambling. Barbara, on the other hand, was prepared to take action. She had been contemplating changes in her marriage for the past year while in therapy. The problem was that the action she most likely was going to take—although she did not say so directly—was divorce. Unfortunately, few couples present asking for divorce therapy. Most couples

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present asking for marital therapy. Assessing whether a couple is likely to be a divorce case rather than a marital case can make a considerable difference in therapeutic outcomes. Elsewhere, we present in detail the subtle, and not so subtle, signs of impending divorce, which we use to assess a couples case (Prochaska & DiClemente, 1984). In the present case, among the obvious signs was the fact that Barbara had been contemplating divorce for some time. More important, she had told some of her family and friends that she was contemplating a divorce. When people go public with their contemplations, they are moving much closer to action. She had also lost her excess weight and engaged in some other self-improvement activities. Making oneself more marketable is often preparatory action for people heading for divorce. Furthermore, Barbara had been in individual therapy for a year, with the theme being increased independence and autonomy. Tom, on the other hand, was psychologically distressed. He had not been contemplating divorce, although he knew that Barbara was. On the contrary, he was obsessed with trying to control Barbara's actions to prevent losing her. Tom was resistant to change, as if he knew the ultimate change in their marriage was going to be divorce. He was also distressed by the prospect of having the drastic change of divorce imposed upon him. The imposition of change is one of the most common causes of psychological distress. Psychological distress caused by imposed change is likely to lead to people resisting change (cf. Beutler & Consoli, 1992). Change can be experienced as a threat, not an opportunity, and they defend against any awareness of needs to change as they dig more deeply into the precontemplation stage. Moreover, they have trouble contemplating change as they become cognitively impaired by distress (Mellinger et al, 1983), trouble making decisions, and trouble taking action, even action that could lead to self-enhancement. What do we do when we have spouses in two different stages of change, which is common in marital therapy? What do we do when we have spouses in two different stages of divorce, which is even more common in divorce therapy? The most common pattern is to have one spouse in precontemplation and one who is ready for action, like Tom and Barbara. When we are treating psychological distress precipitated by an impending and imposed divorce, we need to slow down the spouse who is ready for action and speed up the spouse who is resisting change. Barbara was willing to spend some time trying to resolve some of their interpersonal problems. The therapist made it clear that they were going to work at the interpersonal level to improve their relationship whether they stayed together or got divorced. Either way, they were going to have a long-term relationship, in part because they shared two lovely daughters.

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The couple needed to become more conscious of the interactive nature of their conflicts. Tom and Barbara agreed that their struggles over control produced the most conflict. The therapist presented feedback based on the therapist's assessment of what was going on at the interpersonal level. Tom's actions appeared to be based on his intention to keep the marriage going, and his actions were based on values of closeness and togetherness. Barbara, on the other hand, had developed an increased need for independence; her actions were based on values of individualness and separateness. The problem was that the more Tom tried to control their being together, the more Barbara felt a need to be apart. Barbara agreed. Conversely, the more Barbara pulled apart, the more Tom felt the need to control her to keep them together. Tom agreed. The needs and values that Tom was expressing set off opposite needs and values in Barbara. The blame game is based on our preference for linear causality—she acts and I react. Circular causality, on the other hand, can help couples appreciate that they both act and react—that their behavior is both a cause and an effect of their ongoing relationship (cf. Wachtel & McKinney, 1992). Tom and Barbara were becoming more conscious of what they personally contributed to their control struggles. They were going beyond the blame game. They were also able to reevaluate their partner's behavior to some extent. Togetherness is somewhat more positive than dependence. Separateness is something different from selfishness. With the help of the therapist's minilectures based on his experience with family life education (Prochaska & Prochaska, 1982), Tom and Barbara became aware that a more mature relationship includes both togetherness and separateness. They were taught that individuals mature in their relationships from dependence to independence to interdependence, with interdependence being the caring and sharing of two independent individuals with separate identities. The problem was that Tom was entirely in charge of togetherness and Barbara was standing just for separateness. They were, however, willing to risk acting differently. The therapist recommended that Tom be in charge of separate activities and Barbara be in control of shared activities. Tom was going to liberate himself from a vicious circle by acting more like Barbara, and vice versa. The longer they could continue such reversal of roles, the more they would condition themselves to respond with new alternatives. This action worked for a while. Tom took charge of recording on the calendar Barbara's nights out with her friends and his golfing dates. Barbara recorded their dates together on the calendar and was in charge of initiating shared activities. They were communicating better and feeling better. Tom's chief complaint was that Barbara was not initiating any sex. Because they were doing better, the therapist recommended that

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gradual involvement in sexual relating could help them overcome anxieties they may have about sexual performance. They had been avoiding sex for quite a while, and the first steps of sensate focusing (Masters & Johnson, 1970) might give Barbara, in particular, a chance to deal with her feelings about gradually getting close again. They agreed with the idea and agreed that they would start with light massage. Tom came alone to the next session. "Barbara is not coming back again. She said she knows she just wants out of the relationship." The therapist probably had made a mistake in too quickly encouraging the couple to move to action in their sexual relationship. After the session, the therapist called Barbara and expressed his concern that he might have made a mistake and inquired if she would be willing to come in to talk about how she was feeling. Barbara actually came in for a couple of sessions. She said that the only thing the therapist's recommendation had done was force her to realize that she just didn't want to be close to Tom anymore. The fact that their relationship had improved somewhat made her even more aware that she just didn't feel the same about Tom. She was still concerned that Tom would not be able to handle a divorce, but she wanted out. Tom was distressed but not devastated. Fortunately, therapy had become a place where he could be open about his feelings. He wasn't all alone as he had feared. He allowed himself to relive the memories of losing his first love. He had felt more rejected then than he felt now. He had so many regrets about not having tried harder in that relationship. But this time he had been trying. Back then, he withdrew from everyone. He stayed in his room, unable to eat or work. His parents were concerned, but they left him alone. No wonder he avoided contemplating divorce. He never, ever wanted to go through such emotional hell again. He did not think he would make it—that he could handle another rejection—but he realized he did not have to go through it alone this time. Not only was therapy available, but he had other helping relationships. Now, Tom could talk more openly and rely more on the social supports in his natural environment. The therapist encouraged Tom to explore fully why that rejection as a young man had been so distressing. Eventually, he focused on the rejection he had experienced from his parents. When Tom was about 7 or 8, his parents had lost their business and did not have the financial resources to take care of him. Tom had gone to live with an aunt and uncle who had no children. They weren't particularly loving, but they did give him a lot of money. After a couple of years, Tom's parents were on their feet again and were able to have him back. Tom recalled not wanting to go back, and not wanting to give up all that money. He had forgotten how rejected he had felt as a child. The therapist suggested that perhaps he had

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substituted all that money for the love he had lost. Yes, maybe that was why money had come to mean so much to him. Gambling was fun but he also felt more lovable when he won. And when he lost? Well, maybe he was getting used to losing love. After that early separation, Tom had closed off his relationship with his parents, or maybe it had always been too closed. The therapist took a lead from Bowen (1978) and encouraged Tom to act on his emerging feelings. He encouraged Tom to talk to each of his parents individually about how they had experienced that time in their lives. Tom's mother was especially pleased with the opportunity to talk. She had never told Tom how much it had hurt her to give him up and how much it hurt when he didn't want to return home. She felt that he was always angry at her after that. Tom began to realize that his hurt and his anger had caused him to close off close contact with others. But now Tom was risking new ways of relating—with his parents, his daughters, and his friends. He was communicating more spontaneously and openly, and felt more sensitive to the needs of others. He was asserting himself more at work without having to get angry. Tom was making many self-changes after a total of 22 therapy sessions, but was puzzled by his reluctance to take action and move out and get a place of his own. He told himself that it was because he wanted to be close to his daughters, but he knew he was really afraid that Barbara might turn them against him. He also realized that he was still concerned about money and didn't want to spend the money on an apartment if he could help it. Furthermore, staying in the house was a safe way of expressing his resentment at Barbara for rejecting him. At a deeper level, Tom became aware that leaving his home stirred up painful feelings about when he had had to leave his family's home. And at an intrapersonal level, Tom became aware that he really did have some unresolved dependency problems. He had, for example, never lived alone. The therapist helped Tom to appreciate that moving out and living on his own was a maximum impact action that could facilitate further progress at each level of his life. At a situational level, Tom would be moving into an entirely new environment that would reflect the new era of his life, free from all the reminders that elicited so many painful thoughts and feelings. At a cognitive level, Tom would be challenging his "awfulizing" tendencies that added to his distress, such as his belief that it was awful that he was the one to have to move when he didn't want the divorce in the first place (cf. Ellis, 1973). At the interpersonal level, Tom could further let go of his desire to remain in control of his relationship with Barbara. As long as Barbara wanted him out and he refused to leave, Tom felt in control. But he could let go of this need to control and accept that Barbara was getting the house.

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At the family level, Tom was very tempted to move back with his parents. Moving on his own, however, would enable him to further separate from his parents without rejection or resentment. And at the intrapersonal level, Tom could experience himself as becoming more fully adult. He would be moving beyond dependence to independence and would be better preparing himself for an interdependent relationship. After a couple of months of encouragement in therapy and additional harassment at home, Tom was ready to leave his nest. This was a major move in his life. It evoked a variety of countertransference feelings in his therapist, who felt like a parent watching his 50-year-old son going off to college. Would he be distressed by loneliness and homesickness, or would he spread his wings and fly, enjoying his new-found freedom. Needless to say, Tom soared. He felt more fully connected to life than he had ever known. For the first time in his life he began to appreciate activities like concerts and plays. He asserted himself and found women responding rather than rejecting. Certainly he felt lonely at times, but never alone. He even felt a spiritual awakening, for which his atheist therapist takes no credit whatsoever. Therapy was already terminating when Tom met a special woman. Ironically, she too had just come out into the world in the past few years. She had hidden in a nunnery while Tom had hidden within himself and his home. She had had several years of therapy, struggling with intrapersonal issues both before and after leaving the nunnery; Tom was terminating after nine months of therapy. Tom had made a remarkable transformation from a distressed and defensive man preoccupied with a small portion of his existence to a growth-oriented person able to function more freely and fully at each level of life. What process or processes account for such rewarding changes? First, Tom had been facing turning 50, and he probably had the benefit of developmental changes urging him on to a new stage of life. He also faced dramatic but distressing environmental changes being imposed upon him. Therapy had helped Tom shift from a resentful and resistant position in the precontemplation stage to becoming more conscious of and committed to the self-liberating qualities of intentional change. Tom, the gambler, would also attribute some of his good fortune to lady luck. The last time the therapist talked to Tom, not only was he doing well with his woman friend, his family, his daughters, his friends, and himself, he also had just won $750 in the lottery two weeks in a row. Tom was on a roll!

Research on the Approach Considerable care has been taken to operationalize and validate each of the core constructs of the transtheoretical approach. The stages of

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change, for example, have been identified and validated with a questionnaire applied to a range of patients entering psychotherapy (McConnaughy et al, 1983, 1989; Medeiros & Prochaska, 1991), alcoholics entering treatment (DiClemente & Hughes, 1990), and obese patients entering behavior therapy (Prochaska, Norcross, Fowler, Follick, & Abrams, in press). Brief algorithms have been used to validate stages of change for a broad range of problems (see Prochaska & DiClemente, in press). The processes of change also have been replicated and validated across a broad range of problems. These include smoking (DiClemente & Prochaska, 1982; Prochaska & DiClemente, 1983; Prochaska, Velicer, DiClimente, & Fava, 1988), psychological distress (Norcross & Prochaska, 1986; Prochaska & DiClemente, 1985; Prochaska et al., in press), weight control (Prochaska & DiClemente, 1985; Prochaska et al., in press), alcoholism (Snow, 1990), cocaine abuse (Rosenbloom, 1990), heroin abuse (Tejero, Trujols, & Hernandez, 1991), exercise acquisition (Marcus, Rossi, Selby, & Niaura, in press), and a mixture of mental health disorders (Medieros & Prochaska, 1991). The levels of change have received less empirical attention but have been replicated and validated with such problems as alcohol abuse (Begin, 1988), cocaine abuse (Rosenbloom, 1991), smoking (Norcross, Prochaska, Guadagnoli, & DiClemente, 1984), and a mixture of DSM-III-R disorders (Penny, 1987; Medeiros & Prochaska, 1991). The systematic relationship between the stages and processes of change have been well supported in cross-sectional studies (Prochaska & DiClemente, 1983; DiClemente et al., 1991; Marcus et al., in press). In a longitudinal analysis of subjects who progressed, regressed, and remained the same over a six-month period, discriminant functions predicted movement for the groups representing the precontemplation, contemplation, action, and relapse stages. Predictors included the ten processes, two decision-making variables and measures of self-efficacy and temptation, all variables that are open to change (Prochaska, DiClemente, Velicer, Ginpil, & Norcross, 1985). When more static variables such as age, education, smoking history, withdrawal symptoms, reasons for smoking, and health problems were used as predictors, the results were much less significant (Wilcox, Prochaska, Velicer, & DiClemente, 1985). The point is that dynamic measures are much better predictors of change than are the more commonly used static measures, like client characteristics. At least five longitudinal studies have found that the amount of progress individuals make following intervention is directly related to the stage they are in prior to intervention. Over an 18-month follow-up, smokers who were in the precontemplation stage initially were least likely to progress to the action or maintenance stages following intervention. Those in the contemplation stage were more likely to make such progress,

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and those in the preparation stage made the most progress (DiClemente et al., 1991; Prochaska & DiClemente, in press). In an intervention study with smokers with heart disease, Ockene and her colleagues (in press) found that 22 percent of the smokers who were in the precontemplation stage prior to treatment were not smoking at a six-month follow-up. Of those who were in the contemplation stage, 44 percent were not smoking at six months, and approximately 80 percent of those in preparation or in action were not smoking at six months. With a household sample of MexicanAmericans in small towns in Texas who smoked, Gottlieb, Galavotti, McCuan, & McAlister (1990) replicated most of the cross-sectional relationships between stages and processes and other dynamic variables such as decisional balance and self-efficacy. Furthermore, over a 12-to-18-month follow-up, they found that smokers who were originally in the contemplation stage progressed to the action and/or maintenance stages four times as frequently as smokers who were originally in the precontemplation stage. The amount of progress head injury adults made in rehabilitation was directly related to their stage of change prior to treatment (Lam, McMahon, Priddy, & Gehred-Schultz, 1988). Dropout is a major problem for psychotherapy patients in general, and for addictive patients in particular. In some studies for addictive problems, as many as 80 percent of participants drop out (Abrams et al., 1988). In a study of therapy dropouts using variables such as SES, age, and gender, we were unable to predict the 40 percent of patients who terminated prematurely. Using stage-related variables such as the stages-ofchange questionnaire, however, we were able to predict these drop-outs with 93 percent accuracy (Medeiros & Prochaska, 1991). In a cognitivebehavior therapy intervention for weight control, the stages and processes of clients early in therapy were the best predictors of both premature termination and progress at follow-up (Prochaska et al., in press). The only comparative outcome research to date on the transtheoretical approach involves efforts to facilitate change with smokers. A transtheoretical (TTT) action manual was tested in pilot studies with smokers, many of whom had not been able to quit on their own during the past two years. These pilot studies included a comparison of the TTT materials with the sophisticated American Lung Association (ALA) action manual, which have been accepted as the "gold-standard" manuals for smoking cessation (Glasgow & Rosen, 1978) under both self-administered (manual) and fourweek therapist-administered (clinic) conditions. Results of these pilot studies were encouraging. In the clinic, at the four-week posttest, the percentage of subjects who had taken action in the TTT clinic groups was much higher than in the ALA clinic groups (58 percent vs. 23 percent). At the six-month follow-up for these subjects, 17 percent of the TTT clinic subjects (n = 4) reported they were not smoking,

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compared to only 3 percent (n = 1) of the ALA subjects. Similar six-month results were found in a second site. Five of 12 subjects (42 percent) in the TTT clinic group were not smoking at six months, compared to one of 16 subjects (6 percent) for the ALA group. In the self-administered manual studies, 42 subjects received the TTT manual and 42 subjects the ALA manual. At the four-week follow-up, only three TTT subjects and two ALA subjects reported quitting in the past month. However, the delayed quitting effect was striking. At the six-month follow-up, 38 percent of the TTT manual subjects reported taking action in the past month, compared to only 17 percent of the ALA manual subjects. In a recent study we randomly assigned 770 smokers in Rhode Island by stage to one of four treatment conditions: standardized, individualized, interactive, and personalized (Prochaska, DiClemente, Velicer, & Rossi, 1992). The standardized treatment involved the best self-help program currently available, namely, the American Lung Association's action and maintenance manuals. The individualized self-help manuals were individualized to the stage of change of each participant. The interactive (ITT) condition involved computer-generated progress reports that included feedback about the participant's stage of change, decisional balance measures regarding the pros and cons of quitting smoking (Velicer, DiClemente, Prochaska, & Brandenburg, 1985); up to six processes of change that were being underutilized, overutilized, or utilized appropriately (Prochaska et al, 1988); temptations and self-efficacy across the most important smoking situations (Velicer, DiClemente, Rossi, & Prochaska, 1990); and techniques for coping with specific situations. The personalized (PITT) condition included the stage-based manuals, computer reports, and four counselor calls. The calls were proactive, initiated by the counselors rather than reacting to calls from the participants. Except for one call, counselors had the computer reports to help counsel clients about changes they were making on key process variables. The results were revealing. The two manual conditions basically replicated each other through the 12-month follow-up. At the 18-month follow-up, however, the individualized transtheoretical (TTT) manuals (18.5 percent abstained) appeared to be performing better than the standardized (ALA + ) manuals (11 percent). The interactive (ITT) computer reports outperformed both manual conditions at each of the four followups. The computer reports produced more than twice as much quitting at each follow-up than did the gold standard ALA manuals (e.g., 25.2 percent vs. 11 percent at 18 months). The personalized counselor-call condition nearly doubled the quit rates of the two manual conditions up to the 12-month follow-up. By the 18-month follow-up, effects from the PITT condition appeared to have plateaued (18 percent for PITT). At 18 months, the PITT condition only outperformed the ALA+ manuals, while the

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transtheoretical manual condition seemed to have caught up with the counselor-call condition. These results suggest that interactive computer feedback on stagerelated variables has the potential to outperform the best self-help program currently available. These results also suggest that the field may now have self-help programs that are appropriate and effective for the vast majority of smokers who are not prepared to take action. Providing smokers interactive feedback about their stages of change, decisional balance, processes of change, self-efficacy, and temptation levels in critical smoking situations can produce greater success than just providing the best self-help manuals currently available. Preliminary data from 4,200 smokers indicate that only about 17 percent of smokers are in the preparation stage. This highlights the importance of offering interventions for all smokers, not just those ready to take action. Unfortunately, in the health psychology area, the vast majority of interventions are action oriented. If only a minority of individuals are ready to take action, it helps to account for why participation rates are so low for behavior problems related to health and mental health. In the health area, less than 10 percent of people with risk behaviors participate in professionally developed programs. In the mental health area, only about 25 percent of people with DSMTII-R disorders seek psychotherapy. In the smoking cessation area, for example, only 1 to 5 percent of eligible smokers typically participate in home-based or self-help programs (Schmid, Jeffrey, & Hellerstedt, 1989). In our randomdigit dialing study using stage-matched interventions and proactive recruitment, we have been able to produce 75 to 80 percent participation rates. Research to date has been highly supportive of the core constructs of the transtheoretical approach and the hypothesized integration of constructs such as stages and processes. Longitudinal studies have supported the relevance of these constructs for predicting premature termination and short-term and long-term outcomes. Comparative outcome studies support the potential of stage-matched interventions to outperform the best alternative treatments available. Population-based studies support the importance of developing interventions that match the needs of individuals at all stages of change. These same studies suggest the relevance of this approach for generating participation rates that are dramatically higher than traditionally reported.

Future Directions Psychotherapy is probably 10 to 20 years away from its heyday. This prediction is based on what has happened in biology and medicine for the

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past 30 years. As biology made breakthroughs in understanding different levels of organisms, from basic genetic processes to cellular processes to organ functioning, medicine has benefited immensely. The dramatic increases in basic knowledge of biological processes lead to equally dramatic increases in medicine's ability to apply this knowledge. Medicine has been experiencing its heyday in recent years, with the development of creative interventions ranging from genetic engineering to biochemical controls for diseased cells to transplants of entire organs. Fortunately, as society begins to turn more and more to behavior changes and lifestyle changes as the best preventions and interventions for many health problems, psychology is likely to replace biology as the hottest science, just as biology once surpassed chemistry. Psychology has already been making major strides toward understanding different levels of human behavior. The most important issue that integrative therapists will need to address is how we can best apply the knowledge that will emerge from research on each of the basic levels of human functioning. Psychotherapy practitioners and researchers are in a position to contribute to our knowledge of how change can best be facilitated in troubled situations, cognitions, interactions, systems, and intrapersonal dynamics. Integrative psychotherapists can contribute to our understanding of how changes at one level can lead to changes at other levels, even though no direct intervention was made at the other levels. Eclectic psychotherapists are in a unique position to discover the best ways to integrate change processes derived from diverse therapy systems that are seen as inherently incompatible. To improve integrative approaches, we need comparative studies to assess what advantages, if any, there are to adopting a technical eclectic, as opposed to a theoretical, integration. Alternatively, should therapists be encouraged to take the easier alternative of becoming specialists in just one therapy system? We need to demonstrate empirically what those advantages are and how different forms of integration vary in the degree to which they contribute to these advantages. To improve integrative theory, we need to know much more about the processes and patterns of change. What techniques, for example, are best for applying each of the basic processes of change? Have interpretations been overused in the past, at the expense of confrontations and observations that may facilitate greater reliance on self-change and less reliance on therapy? Or perhaps feedback from computers may get processed with less resistance than similar feedback from therapists. What are the patterns of change that we can expect with different problems at different levels of change? Is it true, for example, that little change can be expected at the intrapersonal level when we are working with character disorders?

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The transtheoretical approach seeks to facilitate a movement toward integrating self-change and therapy-change processes. We are working to create a more complete spectrum of change alternatives for specific problems, ranging from people choosing to change entirely on their own to choosing to rely on longer-term therapy. Between these alternatives, individuals could choose to use self-help materials based on the transtheoretical approach; correspondence courses that are individualized and interactive according to the person's stage and level of change; and short-term therapy that is more personalized and individualized, allowing them to progress in therapy while learning a model of change they can use on their own once therapy is over. Future directions include more work on developing the key-level and maximum-impact strategies for intervening at different levels of change. This work will involve further development of the levels of change test for assessing the clients' problem levels. The more therapists are able to identify a key level that is involved in maintaining a client's problem, the more therapists will be able to use the limited time they have with clients effectively and efficiently. One of our most creative challenges will be to develop the maximum impact strategy for work with clients with multilevel problems. If clients know that therapeutic interventions or homework assignments have the potential for facilitating changes at the symptom/situational, cognitive, interpersonal, family systems, and intrapersonal levels, we would expect them to be willing to spend more time and energy on such therapeutic activities. The purpose here is to use our integrative model to produce a synergistic effect that can help clients progress more fully and efficiently at each level of change.

References ABRAMS, D. B., FOLLICK, M. }., & BIENER, L. (1988, November). Individual versus group self-help smoking cessation at the workplace: Initial impact and twelve month outcomes. In T. Glynn (Chair), Four National Cancer Institute—funded self-help smoking cessation trials: Interim results and emerging patterns. Symposium presented at the annual meeting of the Association for the Advancement of Behavior Therapy Convention, New York. BANDURA, A. (1977). Self-efficacy: Toward a unifying theory of behavior change. Psychological Review, 84, 191-215. BANDURA, A. (1982). Self-efficacy mechanism in human agency. American Psychologist, 37, 122-147. BEGIN, A. (1988). Levels of attribution of alcoholics, their spouses and therapists at pre and post in-patient treatment. Unpublished dissertation, University of Rhode Island.

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BEITMAN, B. D. (1987). The structure of individual psychotherapy. New York: Guilford. BEUTLER, L. E. (1983). Eclectic psychotherapy: A systematic approach. New York: Pergamon. BEUTLER, L. E., & CONSOLI, A. J. (1992). Systematic eclectic psychotherapy. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. BOWEN, M. (1978). Family therapy in clinical practice. New York: Jason Aronson. DiCLEMENTE, C. C. (1991). Motivational interviewing at the stages of change. In W. R. Miller & S. Rollnick (Eds.), Motivational Interviewing: Preparing people to change addictive behaviors. New York: Guilford. DICLEMENTE, C. C., & GORDON, J. R. (1984, February). Stages of change in alcoholism treatment. Paper presented at the eighth annual Alcoholism Conference on Current Issues in the Treatment of Alcoholism, El Paso, TX. DICLEMENTE, C. C., & HUGHES, S. O. (1990). Stages of change profiles in alcoholism treatment. Journal of Substance Abuse, 2, 219—235. DICLEMENTE, C. C., & PROCHASKA, J. O. (1982). Self-change and therapy change of smoking behavior: A comparison of processes of change of cessation and maintenance. Addictive Behaviors, 7, 133—142. DICLEMENTE, C. C., & PROCHASKA, J. O. (1985). Processes and stages of change: Coping and competence in smoking behavior change. In S. Shiftman & T. A. Wills (Eds.), Coping and substance abuse. New York: Academic Press. DiCLEMENTE, C. C., PROCHASKA, J. O., FAIRHURST, S., VELICER, W. F., VELASQUEZ,

M., & Rossi, J. S. (1991). The process of smoking cessation: An analysis of precontemplation, contemplation and preparation stages of change. Journal of Consulting and Clinical Psychology, 59, 295—304. EGAN, G. (1986). The skilled helper (3rd ed.). Montery, CA: Brooks/Cole. ELLIS, A. (1973). Humanistic psychotherapy: The rational-emotive approach. New York: McGraw-Hill. GLASGOW, R. E., & ROSEN, G. (1978). Behavioral bibliotherapy: A review of self-help behavior therapy manuals. Psychological Bulletin, 85, 1—23. GOLDFRIED, M. (1980). Toward the delineation of therapeutic change principles. American Psychologist, 35, 931—950. GOLDFRIED, M. (Eo.). (1982). Converging themes in psychotherapy. New York: Springer. GOTTLIEB, N. H., GALAVOTTI, C., McCuAN, R. S., & McALiSTER, A. L. (1990). Specification of a social cognitive model predicting smoking cessation in a Mexican-American population: A prospective study. Cognitive Therapy and Research, 74, 529-542. JANIS, I. L, & MANN, L. (1977). Decision making: A psychological analysis of conflict, choice, and commitment. New York: Free Press. LAM, C. S., McMAHON, B. T., PRIDDY, D. A., & GEHRED-SCHULTZ, A. (1988). Deficit awareness and treatment performance among traumatic head injury adults. Brain Injury, 2(3), 235-242.

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MARCUS, B., Rossi, J. S., SELBY, V. C., & NIAURA, R. S. (in press). The stages and processes of exercise adoption and maintenance. Health Psychology. MASTERS, W., & JOHNSON, V. (1970). Human sexual inadequacy, Boston: Little, Brown. McCoNNAUGHY, E. A., DlCtEMENTE, C. C., PROCHASKA, J. O., & VELICER, W. F.

(1989). Stages of change in psychotherapy: A follow-up report. Psychotherapy: Theory, Research, and Practice, 26, 494—503. MCCONNAUGHY, E. A., PROCHASKA, J. O., & VELICER, W. F. (1983). Stages of change in psychotherapy: Measurement and sample profiles. Psychotherapy: Theory, Research and Practice, 20, 368—375. MEDIEROS, M., & PROCHASKA, J. O. (1991). Predicting premature termination from psychotherapy. Manuscript submitted for publication. MELLINGER, G. D., BAITER, M. B., UHLENHUTH, E. H., CISIN, 1. H., MANHEIMER, D. I., & RICKELS, K. (1983). Evaluating a household survey measure of psychic distress. Psychological Medicine, 13, 607-621. NORCROSS, J. C., & PROCHASKA, J. O. (1986). Psychotherapist heal thyself: The self-initiated and therapy facilitated change experiences of mental health professionals. Psychotherapy, 23, 345—356. NORCROSS, J. C., PROCHASKA, J. O., GUADAGNOLI, E., & DICLEMENTE, C. (1984). Factor structure of the Levels of Attribution and Change (LAC) Scale in samples of psychotherapists and smokers. Journal of Clinical Psychology, 40, 519-528. NORCROSS, J. C., PROCHASKA, J. O., & HAMBRECHT, M. (1985). The Levels of Attribution and Change (LAC) Scale: Development and measurement. Cognitive Therapy and Research, 9, 631-649. OCKENE, J., KRISTELLAR, J., GOLDBERG, R., OCKENE, I., MERRIAM, P., BARETT, S., PELSOW, P., HASMER, D., & GIONELLY, R. (in press). Smoking cessation and severity of disease. The Coronary Artery Smoking Intervention Study. PENNY, D. (1987). Levels of change attribution in alcoholic and general psychiatric inpatients. Unpublished dissertation, University of Rhode Island. PROCHASKA, J. M., & PROCHASKA, J. O. (1982). Dual career families: Challenges for spouses and agencies. Social Casework, 63, 118—120. PROCHASKA, J. O. (1984). Systems of psychotherapy: A transtheoretical analysis (2nd ed.). Homewood, IL: Dorsey. PROCHASKA, J. O., & DI&EMENTE, C. C. (1983). Stages and processes of selfchange of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51, 390—395. PROCHASKA, J. O., & DICLEMENTE, C. (1984). The transtheoretical approach: Crossing the traditional boundaries of therapy. Homewood, IL: Dow Jones-Irwin. PROCHASKA, J. O., & DICLEMENTE, C. (1985). Common processes of change in smoking, weight control and psychological distress. In S. Shiftman & T. Wills (Eds.), Coping and substance use: A conceptual framework. New York: Academic Press. PROCHASKA, J. O., & DICLEMENTE, C. C. (1986). Toward a comprehensive model

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of change. In W. R. Miller & N. Heather (Eds.), Treating addictive behaviors: Processes of change. New York: Plenum. PROCHASKA, J. O., & DICLEMENTE, C. C. (in press). Stages of change in the modification of problem behaviors. In M. Hersen, R. M. Eisler, & P. M. Miller (Eds.), Progress in behavior modification. Newberry, CA: Sage. PROCHASKA, J. O., DICLEMENTE, C. C., VELICER, W. F., GINPIL, S. E., & NORCROSS, J. C. (1985). Predicting change in smoking status for self-changers. Addictive Behaviors, W, 395-406. PROCHASKA, J. O., DICLEMENTE, C. C., VELICER, W. F., & Rossi, J. S. (1992). Standardized, individualized, interactive and personalized self-help programs for stages of smoking cessation. Manuscript submitted for publication. PROCHASKA, J. O., & NORCROSS, J. C. (1982). The future of psychotherapy: A Delphi Poll. Professional Psychology, 12, 620-627. PROCHASKA, J. O., & NORCROSS, J. C. (1983). Psychotherapists' perspectives on treating themselves and their clients for psychic distress. Professional Psychology: Research and Practice, 14, 642—655. PROCHASKA, J. O., NORCROSS, J. C., FOWLER, J., FOLLICK, M., & ABRAMS, D. B. (in press). Attendance and outcome in a work-site weight control program: Processes and stages of change as process and predictor variables. Addictive Behavior. PROCHASKA, J. O., VELICER, W., DICLEMENTE, C., & FAVA, J. (1988). Measuring processes of change: Applications to the cessation of smoking. Journal of Consulting and Clinical Psychology, 56, 520—528. ROGERS, C. (1951). Client-centered therapy. Boston: Houghton Mifflin. ROGERS, C. (1959). A theory of therapy, personality, and interpersonal relationships as developed in the client-centered framework. In S. Koch (Ed.), Psychology: A study of a science. Vol. 3: Formulations of the person and the social context. New York: McGraw-Hill. ROSENBLOOM, D. (1991). A transtheoretical analysis of change among cocaine users. Unpublished doctoral dissertation, University of Rhode Island. SCHMID, T. L, JEFFREY, R. W., & HELLERSTEDT, W. L. (1989). Direct mail recruitment to house-based smoking and weight control programs: A comparison of strengths. Preventive Medicine, 18, 503—517. SLOANE, R., STAPLES, F., CRISTOL, A., YORKSTON, N., & WHIFFLE, K. (1975). Psychotherapy versus behavior therapy. Cambridge, MA: Harvard University Press. SNOW, M. G. (1990). A transtheoretical analysis of strategies in the recovery process from alcohol problems. Unpublished doctoral dissertation, University of Rhode Island. TEJERO, A., TRUJOLS, J., & HERNANDEZ, E. (1991). Processes of change in heroin addicts: A preliminary report. Manuscript submitted for publication. VELICER, W., DICLEMENTE, C., PROCHASKA, J., & BRANDENBURG, N. (1985). A decisional balance measure for predicting smoking cessation. Journal of Personality and Social Psychology, 48, 1279-1289.

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VELICER, W. F., DICLEMENTE, C. C, Rossi, J. S., & PROCHASKA, J. O. (1990). Relapse situations and self-efficacy: An integrative model. Addictive Behavior, 75, 271-283. WACHTEL, P. L, & MCKINNEY, M. K. (1992). Cyclical psychodynamics and integrative psychodynamic therapy. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. WILCOX, N. S., PROCHASKA, J. O., VELICER, W. F., & DICLEMENTE, C. C. (1985). Client characteristics as predictors of self-change in smoking cessation. Addictive Behaviors, 10, 407-412. WOLFE, B. E. (1992). Integrative psychotherapy of the anxiety disorders. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books.

CHAPTER 10

Cyclical Psychodynamics and Integraiive Psychodynamic Therapy PAUL L. WACHTEL AND MARY K. MCKINNEY

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-YCLICAL PSYCHODYNAMICS is the theoretical basis for an integrative therapy that seeks to synthesize key facets of psychodynamic, behavioral, and family systems theories. The therapy that derives from this theoretical perspective is known as integrative psychodynamic therapy. The first statements of this theoretical point of view appeared in 1977 (Wachtel, 1977a, 1977b), and significant revisions and additions were incorporated in two later books (Wachtel & Wachtel, 1986; Wachtel, 1987). A major restatement of the clinical applications of the theory is currently in progress (Wachtel, in press). Cyclical psychodynamics seeks to provide an internally consistent theoretical approach to personality functioning, as well as a way of preceding clinically within the therapy hour. In contrast to a technically eclectic approach, which might consist of a hodgepodge of techniques selected probabilistically because they have seemed to work with patients possessing similar characteristics, cyclical psychodynamics seeks to develop a coherent theoretical structure that can guide both clinical decision making and general principles. As an integrative theory, cyclical psychodynamics rejects the assumption of fundamental incompatibility among the theoretical viewpoints it attempts to integrate. This does not deny differences among perspectives with different labels; the theoretical differences are real. Cyclical psychodynamic theory, however, selects from among these various competing perspectives, choosing those aspects of each that can be put together in a new synthesis. Each of the theoretical perspectives that cyclical psychodynamics draws upon is attuned to a different, and only partially overlapping, set

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of observations and clinical interventions. Cyclical psychodynamics attempts to forge a new, more inclusive synthesis—a synthesis that can encompass the full range of observations addressed by its contributory sources and also provide a context for as wide a range of clinical interventions as can be coherently employed. As the name implies, cyclical psychodynamics, although drawing upon multiple contributions and perspectives, has been most influenced by the psychodynamic point of view. Many of Freud's basic concepts, such as the emphasis on unconscious processes and inner conflict, and the importance of understanding the patient's relationship with the therapist, are maintained, though with modifications. The neo-Freudian and interpersonal traditions that followed Freud have also shaped cyclical psychodynamic theory considerably, especially the ideas of Horney, Sullivan, Alexander, and Erikson. In applying its psychodynamic perspective, cyclical psychodynamics places its primary emphasis not on the notion of fixation upon traumatic past events and relationships, but on the vicious cycles set in motion by those events and relationships and on the ways those cyclical patterns persist into the present. Its analyses show how problematic patterns are sustained and strengthened not in spite of, but precisely because of, our current reality. Behavioral and family systems traditions have also enriched and expanded the theoretical premises of cyclical psychodynamics by contributing to the focus on a detailed account of how and when neurotic patterns are evoked, and on the patient's current social and cultural context. Both external and internal realities are critical. Indeed, from the perspective of cyclical psychodynamic theory, the distinction between them breaks down; they continually define and redefine each other (Wachtel, 1987). On a concrete level, both behavioral and systemic models provide therapeutic change techniques to complement the psychoanalytic emphasis on insight and examination of the transference. Rather than assuming that change will follow insight automatically, the cyclical psychodynamic therapist views change as a synergistic process in which new behaviors and feedback promote new insights, and such insights in turn generate increased motivation to try new behaviors.

Cyclical Psychodynamics: Origins and Key Concepts In order to avoid awkward locutions and referring to oneself in the third person, this section of the chapter, written by the first author, will be in the

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first person singular. It describes the origins of the cyclical psychodynamic approach and, in the process, addresses a number of key theoretical and clinical issues. I was originally trained in the psychodynamic tradition, first at Yale in psychoanalytic ego psychology, later complemented in my postdoctoral training by an interest in the interpersonal point of view. These influences have remained considerable in my own thinking, indeed so much so that I still tend to think of my approach to psychotherapy as best described as "integrative psychodynamic therapy" (Wachtel, 1985). As will be evident both from the present chapter and from my other writings, there remain many ways in which I remain committed to psychoanalytic ideas. Nonetheless, as my psychoanalytic training proceeded, a number of dissatisfactions slowly developed, which eventually shaped a central concern with developing a psychodynamic model that was not limited by the problems I will shortly note. It might well be said that the development of such a psychodynamic model and the development of a model for therapy integration are two perspectives on the same task. The psychodynamic model described here is one that by its very nature points to a wider range of therapeutic interventions and incorporates observations whose origins lie outside the psychodynamic tradition.

OVEREMPHASIS ON EARLY EXPERIENCE

One of the most significant sources of dissatisfaction with standard psychodynamic accounts was what I experienced as an excessive emphasis on very early experiences, and in particular an emphasis on early experience formulated in a way that made it seem as if those early experiences remained lodged in the psyche as a foreign body, unchanged by later experience. Such an emphasis leads a therapist to pay relatively little attention to the influence of ongoing events in the person's life, and indeed places theoretical obstacles to full consideration of such influences. Both daily personal observation and my reading of the results of empirical research persuaded me of the importance of ongoing life events. Both our behavior and our experience vary greatly in different contexts, and a theory that did not fully and readily accommodate this obvious fact was unnecessarily limited. I sought an alternative that could retain the important insights and surprising observations deriving from the psychoanalytic tradition, yet could integrate into its account of personality development and psychological distress the important role of environmental context (cf. Mischel, 1968, 1973; Wachtel, 1973a, 1973b).

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OVEREMPHASIS ON INSIGHT

Around the same time, I began to be skeptical that knowing something about oneself was the major source of change. The idea of insight seemed an inexorably cognitive notion, and although the distinction between intellectual and emotional insight was clearly rooted in sound and important clinical observation, it was conceptually extremely problematic. It seemed to me that judgments about whether an insight was intellectual rather than emotional were very frequently post hoc decisions that reflected rather circular reasoning. With hindsight, insights were accorded the status of merely intellectual insights if not followed by clinical change, and of emotional insights if the results were more favorable. This made the theory relating insight to change invulnerable, but not very useful. The basically negative attitude of the psychoanalytic community toward Alexander's notion of the corrective emotional experience (e.g., Alexander & French, 1946) seemed to me unfortunate. In my own clinical experience, it seemed that the experiential component was a critical one, and that not only new experiences in the relationship with the therapist but also new experiences more generally, which disconfirmed neurotic expectations, were of greater import than insights that were of a more cognitive sort. As I began to become more familiar with the methods of behavior therapists, it became clear to me that, however they were formulating what they were doing, providing opportunities for such corrective experiences was very much at the center of what good behavior therapists were doing. Even now, I find that in my own practice I am more likely to use traditional behavioral methods than to borrow from more cognitive-behavioral approaches, even though the formulations of more cognitively oriented therapists are closer in many ways to my own than are S-R formulations. I believe this is due both to my own preference for the mediating variables from the psychodynamic tradition and to the fact that my move in an integrative direction was to a substantial degree sparked by what I perceived to be an overly cognitive (if less explicitly and avowedly cognitive) emphasis in traditional psychoanalytic approaches.

UNCLARITY ABOUT THE PROCESS OF CHANGE AND INSUFFICIENT EXPLOITATION OF FREUD'S REVISED ANXIETY THEORY

Having been trained at Yale during the days when John Dollard and Neal Miller were there (Dollard & Miller, 1950), I was alerted early to see alternative ways of understanding the process of change that seemed to me more clearly formulated. In particular, 1 began to feel that the concept of extinction of anxiety as a major source of change, while it probably would

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not have met with a warm reception from Freud, actually captured better the implications of Freud's (1926/1959) later insights into the role of anxiety in neurosis than anything in the psychoanalytic literature. The extinction concept was closely linked to an important procedural variable—exposure to the cues that were previously fearfully avoided. Avoidance as a consequence of fear prevents new encounters that might demonstrate that the fear is no longer warranted. Dollard and Miller's analysis suggested that the cues being avoided were not limited to external cues of the sort typically emphasized by behavior therapists. They could include as well what Dollard and Miller called "response-produced cues"— cues associated with the person's own thoughts and affective reactions. Thus they forged a potential link between psychoanalytic concepts of repression and the avoidances addressed by more behaviorally oriented therapists. As implied in a different but related way in Freud's notion of signal anxiety, when the individual begins to perceive cues that are even marginally associated with a thought that has become a source of anxiety, there is a strong inclination to avoid those cues. Whether described in terms of "repression" or "defense" in traditional psychoanalytic terminology, in terms of "selective inattention" in Sullivan's terminology (e.g., Sullivan, 1953), or in terms of the response of "not-thinking," in Dollard and Miller's conceptualization, what is being addressed is a tendency to not notice, to reinterpret, to change the subject, or in other ways to avoid or attenuate the experience of the forbidden. Everything we know about extinction of anxiety associated with more overtly observable cues suggests that what is crucial is repeated exposure to the frightening stimulus, in circumstances where the expected harmful consequences does not occur. Almost always this exposure must occur on many occasions, and the reduction of anxiety occurs only gradually. If the reader is following the logic of the argument being developed here, it will be apparent that what is being described is another perspective on what in psychoanalytic terms is referred to as "working through." Psychoanalytic accounts of working through are often rather vague. Freud sensed early that singular flashes of insight are unlikely to lead to permanent change, that something more arduous and less dramatic was usually required. This observation has been confirmed so readily in clinical practice by others that therapists reading or talking about working through feel they know precisely what is being referred to. But while the experience of working through is a familiar one, the process that is represented is not nearly as clear. Psychoanalytic accounts tend to discuss it in terms of examining the newly discovered thoughts, feelings, and experiences from a variety of different perspectives until it is fully understood. The emphasis, in other words, is again often cognitive. The extinction concept, together with Freud's revised theory of anxi-

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ety, suggests another explanation. Working through is needed because what is most essential in therapeutic change is the overcoming of anxieties learned early in life, which are no longer appropriate (if they ever were). Fears and inhibitions resulting from the cognitive and motor limitations of children, their misunderstanding and overgeneralization of parental prohibitions, and the restrictions placed on children that are not applied to adults (for example, about sexuality) must be unlearned. The unlearning of these fears, however, is impeded by the avoidance they engender, which makes impossible the needed experience of encountering the source of fear and discovering it is no longer a danger. And once the therapist does manage to bring about exposure to the previously avoided cues, repeated exposure to them is necessary. In the case of formulations guided by psychoanalytic thought, this implies bringing the patient back into contact with the thoughts and affects that have been repressed—that is, avoided. Thus, it is not enough merely to "see" what you have blinded yourself to; it is essential to see it again and again, to undergo repeated extinction trials for the anxiety to these cues or, in psychodynamic terminology, to participate in working through. From this perspective, one of the key functions of "interpretations" is that they are comments that either interrupt the person's way of avoiding cues associated with the feared thought (defense interpretations) or, by stimulating associations and/or saying out loud the thought that can't be spoken, increase the likelihood that the patient will begin to be exposed to the therapeutically relevant cues. When psychoanalytic treatment is successful, it is likely that a good deal of its success is due to its effectiveness in bringing the patient into contact with thoughts and images that have theretofore been fearfully avoided. The process of working through, however, may be approached inefficiently if it is conceived of as a quasicognitive process of exploration and understanding rather than as a reflection of the repetition necessary for extinction of the maladaptive anxiety. Rather than looking for "new material" or new perspectives or new understanding, the therapist might more deftly accomplish the therapeutic task by helping the patient to be exposed to the same cues over and over until an efficient, focused extinction process is effected. INSUFFICIENT ATTENTION TO THE ROLE OF SOCIAL SKILLS

A further important consequence of the anxiety and avoidance so regularly associated with psychological disorders is that it generally leads, in the course of development, to the bypassing or truncating of important developmental experiences. The complex social skills required of every adult in an advanced society take many years to learn, and their effective learning requires both careful observation of others and much practice and

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honing of one's interactional style. That much of this observation and practice goes on automatically, without self-consciousness or even awareness that one is doing such things, does not in any way diminish its ubiquity or importance. If anxieties and conflicts make it more comfortable to avoid certain kinds of experiences early in life, and the countless practice sessions that life offers are not encountered, there will be an impact on one's ability to negotiate the shoals of social interaction. This does not necessarily mean that the individual will be grossly inappropriate or a social outcast. To begin with, the deficits are often quite focused, showing up only in very specific contexts. Thus the patient might in many ways be a highly skilled participant in social interactions, showing just a few odd lacunae in an otherwise general picture of competence. The lacunae in each case would be related to specific areas of anxiety and avoidance, but the relationship is not necessarily a simple one-to-one. Many dimensions of life experience, including just where one is forced to sink or swim despite one's anxiety, and where, in contrast, well-rationalized avoidance is possible, will influence where reasonable skillfulness develops and where avoidance takes its toll. THE IMPORTANCE OF ACTIVE INTERVENTION

These and other considerations led me to believe that much more active intervention into people's difficulties was both possible and desirable than I was taught by my psychodynamic teachers. I began to be struck by the possibilities inherent in the interventions developed by behavior therapists, whose conceptions did not prevent them from intervening actively. And as I will discuss shortly, I began to see that their overall approach did not need to be viewed as thoroughly incompatible with a psychodynamic view, as was commonly believed. THE CONTINUED IMPORTANCE OF THE PSYCHODYNAMIC PERSPECTIVE

Despite the aforementioned dissatisfactions, my basic outlook continues to be best characterized as a version of psychodynamic thought, and various features of the psychodynamic approach have seemed to me crucial to retain. Perhaps most important, I continue to be struck by the pervasiveness of conflict and by how readily people can deceive themselves about their own motives and feelings. Self-deception is really the very heart of the psychodynamic point of view, and instances of self-deception seem to me prevalent enough that I regard it as one more instance of the phenomenon to develop a view of human psychology that is not centrally rooted in this reality. The psychodynamic perspective not only alerts us to conflict and to

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the ubiquity of self-deception, it also provides guidelines about where and how to look for inclinations and experiences that are being disavowed. Although the rules of inference that countenance analytically oriented therapists' claims have still not been sufficiently spelled out, the situation is not as arbitrary as the most implacable critics of psychoanalysis would have it. Close examination of the logic of inference among responsible psychoanalytic clinicians reveals a variety of useful rules that can be followed with reasonable consistency. It is certainly true that eschewing the kinds of inferences that analysts make can protect the clinician from numerous errors of overinterpretation, but a state of affairs exists that is akin to the unavoidable tradeoff in statistical inference between Type I and Type II errors: Avoidance of the danger of erroneous inferences that the psychoanalytic interpretive method does indeed present can only be achieved by increasing the danger of missing crucial areas of conflict and self-deception, a danger whose clinical consequences may be even more serious. Relying too preponderantly on what the patient can consciously report increases the danger of misformulations of the patient's aims and difficulties. It is very easy to assume that what people want and feel are the things that society teaches us they should want and feel. When one looks and listens closely, however, in the way that the psychodynamic tradition teaches us to look and listen, one may be struck by how often people's effective motives and assumptions do not correspond to what is socially expected or normative. Naturally, it is just such nonnormative motives and experiences that are most likely to be inaccessible to the person's conscious awareness. It is interesting to note—and this bears quite relevantly on the issue of the potential compatibility of psychodynamic and behavioral perspectives—that the inferences on which psychoanalytic formulations are based are often most essentially rooted in paying attention to people's behavior, to how what they do differs from what they say. It is in noticing contradictions between patients' avowed intentions and the consistent consequences of their actions that dynamic inferences are frequently born. BEHAVIORAL CONTRIBUTIONS

As I began to be more familiar with the work being done by behavior therapists—I had earlier been taught to be rather dismissive toward this approach and had paid little attention to it—I was struck by several things. First, behavior therapy was particularly strong in some key areas where the psychodynamic tradition was particularly weak. For example, behavior therapists had available to them active intervention methods frankly designed to produce change. The psychoanalytic tradition, in contrast, had

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few specific interventions. The process of exploration, which might well be thought to be primarily a diagnostic rather than a therapeutic process, was forced to serve double duty, as it were. It seemed to me entirely consistent with the substantive empirical discoveries deriving from the psychoanalytic method to develop intervention procedures based on the understanding of motivation and conflict achieved in the early exploratory and diagnostic work with the patient. The work of Alexander and his colleagues, as I read them, was based on a similar estimate (e.g., Alexander et al, 1946; Alexander, 1956, 1961). The impetus behind Alexander's efforts was a view that Freud's work was too valuable to be embalmed in a method that was essentially a preliminary, early 20th-century stab at how to apply the new insights, and that explicit efforts to take Freud's ideas and develop new therapeutic methods based on them would likely prove more fruitful. Despite the largely rejecting attitude that greeted Alexander's work, I think he was basically correct, and I regard my own efforts as, in a sense, carrying on in this tradition. Part of the resistance to explicit intervention methods on the part of psychoanalysts seems to reflect an ideological commitment to a highly individualistic worldview in which autonomy is the supreme value and in which healthy interdependency and problematic dependency are confused (cf. Wachtel, 1989). Part also is due to an affirmation of the emphasis Freud placed on psychoanalysis as a research method. Freud's research interests shaped the psychoanalytic method in ways that were useful for the research enterprise but placed significant and unacknowledged constraints on the clinical side (Wachtel, 1987, chap. 12). Variability and Context A second area of strength for behavior therapy that filled (and highlighted) a gap in the psychoanalytic approach was its considerably greater attention to the role of context in human behavior and, as a consequence, to the variability of our behavior and experience in different contexts. This seemed to me consistent with my own experience, both in observing others and in observing myself, of quite significant range in both level and mode of functioning, depending on the situation and the other people involved. Such a recognition of variability with context need not lend itself to what Bowers (1973) has called "situationism"—an overemphasis on the determining influence of situations that excludes or underestimates the concurrent role of the perceptions, motives, and prior experiences of the people who find themselves in the situation. Rather, in its more sophisticated versions, it points to an appreciation of how characteristics of the individual and the situation interact to jointly codetermine what occurs (see also Magnusson & Endler, 1977; Wachtel, 1973a).

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This emphasis on the contextual nature of human behavior provided an important corrective to formulations that emphasized the person's fixation or arrest at a particular developmental level and that, in effect, treated the enormous variability in the actual level of functioning of almost every individual as "noise." Moreover, it provided a much better handle on appreciating and building on the patient's strengths rather than focusing the therapist's attention almost exclusively on pathology. In addition, it pointed much more readily to the way changes in patients' ongoing behavior and changes in the situations they encountered could codetermine each other, introducing the possibility of synergistic circles of therapeutic change (Wachtel, 1985, 1987). Validation and Research Commitment Another feature of the behavioral tradition that drew my attention was its emphasis on the need to validate concepts and procedures. From its inception, psychoanalysis has been weak in this area. The emphasis on privacy, the corollary resistance to tape recording as it developed as a potentially powerful research tool, and the indifference to—or even antipathy toward—the experimental method shown by many analysts all contributed to an atmosphere in which clinical lore and private convictions predominated. The vulnerability of uncontrolled clinical observations to bias and selective perception and memory seemed to me greatly underestimated by the psychoanalytic community; the possibility of adding techniques that were being seriously evaluated by strenuous methods was very appealing. COMPATIBILITY OF DYNAMIC AND BEHAVIORAL APPROACHES: THE DEVELOPMENT OF CYCLICAL PSYCHODYNAMICS

As I began to examine closely and seriously the work of leading behavior therapists, I found to my surprise that there were ways of understanding what they were doing that suggested considerably greater compatibility with a psychodynamic view than I had thought possible. The possibilities for a fruitful merger seemed particularly enticing with regard to the interpersonal version of psychodynamic thought which was increasingly coming to characterize my views. The key to reconciling the two views was appreciation of the largely circular nature of causality in human affairs: The events that have a causal impact on our behavior are very frequently themselves a function of our behavior as well. If situations have a greater impact on our functioning than most psychodynamic formulations tend to acknowledge, it is also the case that the situations we encounter are not simply independent variables, as they might seem from the perspective of the experimental studies to which

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early behavior therapists largely attended (cf. Wachtel, 1973a). Rather, they can themselves be understood as a function of the extant personality organization. By choosing to be in certain situations and not others, by selectively perceiving the nature of those situations and thereby altering their psychological impact, and by influencing the behavior of others as a result of our own way of interacting, we are likely to create for ourselves the same situation again and again. The situations we find ourselves in are not just what the world throws us into, but are very largely consequences or expressions of our personalities. Both the reality of the impact of the situation on our behavior and experience, and the reality of our capacity to choose and alter the situations we encounter, must be taken into account by a fully satisfactory theory. Neither is more basic or correct. By and large, psychodynamic theorists have given greater weight to what might be called the "inside-out" direction of causality, and behavioral theorists to the "outside-in." Interpersonal versions of the former and social learning and cognitive versions of the latter tend to treat the causal sequences less unidirectionally (e.g., Sullivan, 1953; Horney, 1939, 1945; Bandura, 1978), providing further footholds and handholds for the theorist seeking an integrative model. In attempting to sketch out the outlines of a more fully integrative picture of personality development, I have increasingly relied upon the analysis of vicious circles that maintain consistency in personality functioning over time despite the considerable forces potentially pushing for change. The term cyclical psychodynamics reflects the dual emphasis of this point of view on elucidating the cyclical nature of causal processes in human affairs and elucidating the unconscious motives, fantasies, and conflicts that are so crucial in almost everything we do (cf. Strupp & Binder, 1984, who also present a perspective that they describe as cyclical psychodynamics). From a cyclical psychodynamic perspective, it became clear that (1) the active intervention methods of behavior therapists (and later of therapists from other perspectives; see, for example, Wachtel & Wachtel, 1986) could be of significant value in promoting the changes dynamic therapists were working toward, and (2) those methods could be employed logically and consistently within a modified psychodynamic context. The key to the latter point was the recognition that the transference phenomena that were at the heart of much of the psychoanalytic therapist's concerns were being conceptualized in most psychoanalytic accounts in a needlessly constricting way. From a cyclical psychodynamic perspective, transference reactions are understood as the individual's idiosyncratic way of construing and reacting to experiences, rooted in past experiences, but always influenced as well by what is really going on. The therapist's interventions do not "muddy" or

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"distort" the transference because all transference reactions are reactions to something. Moreover, it is as important to understand what occurrences the patient is reacting to as to understand why, based on past history, he reacts to the situation in the particular way he does. From this vantage point there is no neutral point from which, if the therapist just gets out of the way and doesn't interfere or distort, the real transference will "emerge" or "unfold" (cf. Wachtel, 1987. chap. 3). Rather, transference is a complex set of responses, varying with context, but highly informative about the patient's key interpersonal experiences and maneuvers. Whatever therapists do (whether they remain silent and restrict themselves to interpreting, actively direct the treatment, or assist the patient in devising a regimen of therapeutic experiences) their behavior with the patient will have an impact. And whatever they do, the meaning of that impact is essential to understand (cf. Sullivan's [1953] conception of participant observation and also Gill's and Hoffman's formulations [Gill, 1982; Gill & Hoffman, 1982; Hoffman, 19831). As this point of view emerged clearly for me, I began to get training in behavior therapy and to study closely the work of leading behavior therapists. I also began experimenting with ways to incorporate behavioral methods into my clinical work. At first my use of behavioral methods was fairly orthodox—even if the setting in which 1 employed them was not. That is, when I used these methods I looked pretty much the way a traditional behavior therapist looked when he or she used them (though it was not long before at least some variations began to become evident—the consequence of my having had psychoanalytic training and retaining a strongly psychodynamic point of view in many respects). Before long, however, I began to notice that the dividing line between which aspects of my clinical work represented the behavioral side of my work and which represented the psychodynamic side began to blur. Not only did 1 begin to give a psychodynamic flavoring to my use of behavioral methods, but my style of carrying through the psychodynamic side of the work—of interpreting, of communicating my understanding, and even of listening— began to be influenced by my increasing immersion in the behavioral point of view. Much of this is communicated and illustrated in Psychoanalysis and Behavior Therapy (Wachtel, 1977b) and Action and Insight (Wachtel, 1987). In those books are illustrations both of the use of standard behavioral procedures and of some of the ways they have been modified in the effort to incorporate them into a dynamically oriented therapy. In the present chapter, we will illustrate the further evolution of the cyclical psychodynamic approach to integration. Originally, the emphasis was on combining methods derived from different theoretical perspectives, or incorporating methods from one viewpoint into work essentially informed by another.

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More recently, cyclical psychodynamic efforts have moved toward a fuller synthesis or integration. In much of the work presently approached from a cyclical psychodynamic viewpoint, it is hard to say which is the psychodynamic part and which is the behavioral. The work, one might say, is becoming more seamless. At this point we would like to elaborate with a clinical vignette that illustrates the fruitful merging of frames of reference.

Case Example John N. was a quite prominent member of his profession, who had never, to his great consternation, passed the licensing examination. He had taken the exam five times before and had failed each time, despite the fact that his professional stature was such that his own work was occasionally addressed on the exam. Although he presented himself as a case of "test anxiety," and informed me of that self-diagnosis in the first session, it quickly became clear that more was involved. John had grown up in a prominent Boston family and had been taught by his parents, who were quite demanding and status-conscious, that he must not only excel but also appear to do so effortlessly. This was not something that John was able at the outset to say directly. At first I was merely struck by his various efforts to let me know, indirectly but most assuredly, who it was I was dealing with. He worked very hard at conveying both his stature in the profession and his social status, and seemed very uncomfortable with being in the role of patient. In looking for a way to inquire into this tendency that did not leave John feeling criticized or put down (cf. Wachtel, in press), I wondered out loud if his parents had been very concerned about status and what the impact on him might have been. At this he seemed to experience a good deal of relief and immediately relaxed some. He said yes, they were like that and it was very oppressive. John's conscious views were much more liberal than his parents', and this added still further to his dilemma: He could not readily acknowledge his concerns about status, or appreciate the role those concerns played in his life, because he had struggled hard to disavow them and, as far as he knew, he had done so. By raising them as his parents' concerns, I made it possible for him to begin addressing them while still maintaining his view that he himself did not endorse them, indeed while expressing his distaste for them. Attempting to open further a path for John's exploration of attitudes I sensed were an important part of his difficulties, I then added that it must have been difficult growing up in such an environment not to adopt some

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of their views simply in self-defense; with their relentless emphasis on status and success it would have been extremely painful not to attend to this himself. This comment seemed to make it a bit easier for John to take a look at his own concerns about status, most likely because it implicitly conveyed that it was not his fault that he felt this way. Through this process of gentle and gradual confrontation with his disavowed status concerns, John began to recognize that he had felt defensive and humiliated by having to take the exam, and had as a consequence not prepared seriously enough. This was somewhat the case even the first time he took it: He felt he had to be very cool and casual about his preparation despite considerable anxiety—anxiety largely prompted by the internal necessity not just to pass but to do spectacularly well and to do so without "sweating it." Needless to say, the pressure became even greater as he took and failed the exam over and over. This initial bit of "insight-oriented" work modified the program of behavioral interventions that was to be employed. Although, as I will describe shortly, I did indeed use systematic desensitization to help John overcome his test anxiety, I also concentrated more than I otherwise would have on his preparing more thoroughly for the challenge the exam represented. By helping him to see the unacknowledged feelings and ideas that had led him to treat the exam dismissively, the initial work enabled John to address the situation more seriously this time around. As he came to see, it was not just a matter of anxiety that had to be overcome. The anxiety, while in certain respects excessive, and certainly interfering with his performance, was not entirely unrealistic: It was based in part on his unacknowledged perception that he had not taken the exam seriously enough to be properly prepared. After working a good deal on the internal pressures that had led John to be dismissive toward the exam, and on how he could study for it more seriously this time, we did turn to desensitization. Initially, the major dimension for the development of a hierarchy was a temporal one. The images moved from a period considerably before the test, through increasingly close approaches to his actually appearing at the door, to his sitting down at his desk, to his confronting various experiences he would encounter when actually taking the examination. As we went through these images, the nature of his discomfort became clarified in a number of specific situations. Thus, when he pictured walking into the room, he became aware of the crowd of exam takers pressing in together, and he experienced a strong sense of indignity at being pushed and at having his identity checked. This, more than any concern about failure, was his primary source of distress with these images. We discussed this in relation to the legacy of his upbringing, and it led to an important discussion of his strategy lor studying for the test. He was

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struggling with dual inclinations to study much harder than anyone else and to study much less. We worked on images of his being just one of the crowd until he could imagine this with little discomfort, and he found that this enabled him, as well, to have a much clearer sense of what would be an appropriate amount of preparation: He could do it "just like everyone else." Similarly revealing was his reaction to the image of approaching the door of the building. It became clear as he immersed himself in the image that another source of discomfort was seeing the guard at the door. He recalled that the same man had been on duty on several occasions and felt very uncomfortable at the idea that this man would see that he was taking the test still one more time. He worked on this image for much of a session, finally overcoming the anxiety when he pictured himself taking the bull by the horns and saying "good morning" instead of trying to slink in unnoticed (as he realized at some point he was doing in the image). The most interesting developments occurred when John imagined himself visiting the room the day before the exam. The aim in this set of imagery exercises was initially for him to acclimate himself to the setting in which the test would take place. He was asked to look carefully around the room, to touch the various surfaces such as the desk and walls, to experience the lighting, and so forth. It was hoped that thereby some portion of the anxiety he tended to experience in the exam situation could be eliminated. When he began the imaging, however, a fascinating series of associations and new images came forth. At first he spontaneously had the association that the room seemed like a morgue, and then that the rows of desks seemed like countless graves covering the site of a battlefield. Then he felt overcome with a feeling of impotence. I asked him if he could picture himself as firm and hard, ready to do battle. He did so (I left it ambiguous whether he should take this specifically to mean having an erection or as an image of general body toughness and readiness). He said he felt much better, stronger, and then spontaneously had an image of holding a huge sword and being prepared to take on a dragon. He associated this image to our various discussions of his treating the exam as a worthy opponent, taking it seriously yet being able to master it. He was exhilarated by this image and I suggested he engage in such imagery at home between sessions, a suggestion he endorsed with great enthusiasm. In the next session we began with his again picturing himself visiting the exam room the day before the test. For a while, as he checked out the various features of the room, he felt quite calm and confident. But suddenly he felt a wave of anxiety, as if something was behind him. I asked him to turn around and see what was there. He reported seeing a large cat, a panther. Here I made a kind of interpretation. I offered that the panther

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represented his own power and aggression and that it was a threat to him only so long as he kept it outside of him or out of sight. I asked him if he could reappropriate the panther part of him, adding that what he was feeling threatened by was his own power, his own coiled intensity. He pictured the panther being absorbed into himself, and the anxiety receded. I then elaborated—quite speculatively, to be sure, but in a way rooted in the understanding we had achieved together about the dynamics of his difficulty with the exam—on why it might be that he had chosen a panther in particular to represent the part of himself that needed to be reappropriated. I noted that panthers were not only strong and purposeful but were also meticulous and supremely respectful of their prey. Despite being awesome creatures, 1 suggested, panthers did not take their prey lightly. They did not just casually leap out whenever they saw a potential source of nourishment. They did not act as if it were beneath their dignity to stalk for hours, crawling on their bellies. Panthers, 1 said, were diligent students who became experts on the habits of the creatures they tracked— experts whose expertise was the result not just of instinct or superb natural equipment but of attention to detail and a respect for the difficulty of the task of conquest nature required of them. Their grace might look effortless, but it was far from casual; panthers were supremely serious. Now in all this it is impossible for me to distinguish how much reflected an empathic grasp of the actual layers of meaning that led to John's experiencing that particular image, and how much was simply suggestion on my part. The "interpretation" seems plausible, but at the very least I was gilding the lily, using the panther image to point toward attitudes I felt it would be useful for him to incorporate, whether they were the actual sources of the image or not. What is important is that my comments were meaningful to the patient. Whether or not they accurately depicted the origins of the image, they did resonate with the ripples of meaning that the image engendered, and they helped to amplify and consolidate the utility of the image itself, which was, after all, John's creation. In further work on the test anxiety and—significantly—later on his own in dealing with a range of other concerns, John, for whom imagery turned out to be a very salient modality, made great use of the panther image and its variants (cf. Lazarus, 1992). He aided his efforts at relaxation, for example, by imagining himself as a big cat, relaxing and licking himself. When faced with a difficult challenge, he again imagined himself and the panther as one, and felt that he didn't have to be overtly aggressive, since he knew deep inside he was capable of whatever was necessary. Sometimes he would even imagine himself emitting low murmuring sounds deep in his throat, which, as he put it, "remind the panther that it's a panther." One of my favorites of his spontaneous creative uses of the panther

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image came later in the desensitization work. We were at the point of his imagining actually sitting and taking the test, when a wonderful smile appeared on his face. He told me he had just had an image that the point of the pencil with which he was writing the exam was actually the claw of the panther; that the panther was firmly within him, incorporated and channeled, and as the claws came through the tips of his fingers they were pencils that were writing out the answers with very sharp points. This time around, his points were indeed sharp. After having failed the exam five times previously, he not only passed but did very well. I cannot, of course, determine whether he would have passed even without therapy of any kind, or whether a more orthodox course of either behavior therapy or psychoanalytic therapy alone (or of any other approach for that matter) would have done just as well. Only systematic research can enable us to sort out with confidence the many questions that cases like this raise. Conceptualizing and implementing such research, and ensuring that it addresses the complexities that cases such as this present, will be a considerable challenge that will tax our powers of persistence and methodological innovation. COMMENT ON THE CASE

In one sense, the case just described is atypical. The patient, to begin with, turned out to be unusually adept and creative with imagery. Moreover, the degree of synthesis of differing methods, the extent of the "seamlessness" of the therapeutic effort, was greater than it is often possible to achieve. In this sense, the experiences with John described here are noteworthy less for their representativeness than for their providing a model of the kind of full synthesis toward which the cyclical psychodynamic perspective aims. In daily practice, therapy conducted from this perspective often is limited to a less complete form of integration, in which procedures deriving from one tradition or another are used at different times. Although they fit together into a coherent framework, they are nonetheless clearly identifiable as separate parts. The integration in this case is more seamless in that what emerged were procedures that were not quite what most behavior therapists would do and not quite what analysts would do, but rather emergent procedures reflecting the integrative intent of the therapy. The case differs, as well, from most cases seen from a cyclical psychodynamic perspective in that it had a narrowly defined goal. Rather than being directed primarily at a set of characterological features that were manifested in various aspects of the patient's life (as is more common in this approach to therapy), the work here focused rather sharply and pointedly on John's difficulty with the test.

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Nonetheless, the case nicely illustrates a number of features of the cyclical psychodynamic point of view. To begin with, we may see a number of vicious circles evident in John's difficulties, which interweave influences from his past, from his motivational conflicts and internal necessities, and from his daily transactions with the world of actual events. John's conflicting needs to be outstanding and to appear to do everything effortlessly made it difficult for him to study sufficiently to do well on the test, and made the first failure especially painful. These influences then fed on themselves. Feeling so humiliated and embarrassed, John's anxiety increased, making still further failure more likely. Moreover, his need defensively to deride the exam, and also not to appear shaken and therefore not to study too hard, both repeated the state of affairs associated with the first failure and set the stage for the next. An additional circular process, reinforcing the interlocking set of influences just described, involved the excessively high standards that John had absorbed from his parents in his youth. Those standards were maintained as a continuing psychological irritant, not just by his attachments to the objects and images of his earlier days, but by the new relationships he continually established with others. By presenting himself as special, John evoked expectations of being special and created a life structure that replicated the circumstances of his childhood in this way. That he was in fact a very talented individual enabled this potentially fragile structure to be maintained, but at a very high psychic cost. As they became enmeshed with his difficulties with the exam, and with the other circles described above, these influences further exacerbated John's difficulties. It was not really enough for him to pass the exam; he had to do extraordinarily well. This pressure increased as the number of his failures mounted and, of course, it interacted toxically with his anxiety. Thus we may see that even in a therapy focused on a relatively simple and narrowly defined problem, the cyclical psychodynamic perspective points us to seeing how interacting circular processes tie together past and present and internal and external influences. We also see in this case a number of characteristic features of the approach to therapeutic intervention that is associated with the cyclical psychodynamic point of view. We see, for example, the emphasis on exposure to what one has been afraid of and on structuring that exposure in such a way that it will be both vivid and able to provide the patient with an experience of mastery. In addition, the therapist's efforts were directed toward helping John change his overt behavior with regard to the exam and his preparation. At various points, John's strategies for studying were examined quite explicitly and suggestions made, both implicitly and explicitly, for ways to achieve a better synthesis of his competing aims. Illustrated, too, is the concern with skills that have been impaired by anxiety

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and avoidance, and with helping the patient explicitly to improve those skills. The primary focus here was on study skills (in keeping with the more limited aims of this particular case), but even here, other dimensions were brought to bear. In working with John on his attitudes about other people who might notice that he was taking the exam again, at least some work was done on his more general assumptions about what others would think of him and on how he dealt with those attitudes. It should also be apparent from this case illustration how a therapy rooted in the cyclical psychodynamic perspective integrates the exploration of warded-off experiences and inclinations with direct and active efforts at promoting change. Although various active intervention methods were employed, the direction toward which the therapeutic efforts were addressed depended considerably on the initial exploratory work done with John. Enabling John to acknowledge and understand how he had kept himself from appreciating the extent of his status concerns, and why he had needed to do so, was important in developing the focus of the overall approach. Appreciation of his conflict over working hard to prepare for the exam, as well as the unrecognized need he had to make it all appear effortless (not only to others but to himself), led to further active intervention efforts directed toward helping John study more effectively and take the exam more seriously. Moreover, understanding the importance of the indignity John experienced in the process and his embarrassment at taking the exam still again provided another focus for desensitizing efforts, as well as for further explorations of the impact of these feelings on his life more generally. The case also illustrates some of the concerns about the therapist's use of language that have increasingly been at the center of the therapeutic effort from a cyclical psychodynamic point of view. The inquiry into John's status concerns—concerns that at first were vigorously disavowed by him—began by addressing his parents' concerns, and proceeded only gradually to inviting him to explore his own. Moreover, the latter exploration was undertaken in a way carefully designed to enable John to examine these concerns in a manner that permitted him to maintain his self-respect. Ultimately, the aim was for John to be able to acknowledge and take responsibility for his attitudes, and the general evolution of the case indicates that he indeed was able to do so. The path toward doing so, however, led initially through a preliminary disavowing of responsibility: It was his parents' attitudes that were really at issue, and he could not help absorbing some of them. Such a strategy for enabling people to recognize and take responsibility for their experiences by initially placing the responsibility outside themselves has been described in recent cyclical psychodynamic explorations of therapeutic language as "externalization in the service of the therapy." It is one of a number of strategies we have recently

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developed to ensure that the fostering of insight enhances, rather than diminishes, the patient's self-esteem. The exploration of the language used by the therapist in communicating his understanding to the patient has become increasingly central in the evolution of the cyclical psychodynamic approach. The modes of communication we have been developing aim at synthesizing cognitive, behavioral, and psychodynamic considerations to enable patients to hear the therapist's message with less defensiveness and to use the therapist's comments to take the steps necessary for change (see Wachtel, in press).

Relevant Research The research evidence supporting cyclical psychodynamic theory is still only indirect. Studies have not yet been done comparing the outcome of therapy conducted from this point of view with that of other approaches. Nor has explicit testing of cyclical psychodynamic propositions been undertaken thus far. There is, however, a significant body of research, especially in social and developmental psychology, that supports the basic tenets of the theory described here. Studies about self-fulfilling prophecies, also called expectancy effects or behavioral confirmations, are perhaps more strikingly relevant to the concepts underlying cyclical psychodynamics. Social psychologist E. E. Jones (1986) summed up the findings of this line of investigation as follows: "We are not passive observers of our respective social worlds, but active forces in the shaping of those worlds. To an important extent, we create our own social reality by influencing the behavior we observe in others" (p. 41). Numerous studies of expectancy effects have shown results consistent with the major thrust of cyclical psychodynamics—that the patterns of our lives are sustained and strengthened not in spite of, but precisely because of, our current reality. To use the terminology of cyclical psychodynamic theory (e.g., Wachtel, 1977a, 1977b, 1987), in subtle and unconscious ways we induce others to act as unwitting "accomplices" in maintaining the beliefs that support our life structure, including those that maintain neurotic or maladaptive patterns. The research cited below demonstrates both the range of situations in which accomplices may be found and the subtlety of our recruitment methods. Much of the research cited is about first impressions and the interactions of strangers. But as Jones (1986) points out, there is reason to think that such patterns are found in long-term relationships as well. He argues that the increasing contact can "generate patterns of behavioral escalation" (p. 46), a conclusion quite congruent with the conception of vicious cycles at the heart of cyclical psychodynamic theory.

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THE SELF-FULFILLING PROPHECY

First defined by sociologist Robert Merton (1948, 1957), a selffulfilling prophecy is an understanding of a situation, originally incorrect, which leads to behavior that causes the false assumption to come true. We respond not to an objective reality but to the meaning we ascribe to our perceptions. Thus, "the specious validity of the self-fulfilling prophecy perpetuates a reign of error. For the prophet will cite the actual course of events as proof that he was right from the very beginning" (Merton, 1957, p. 477). Sociologists and psychologists have followed Merton's lead to show how self-fulfilling prophecies may explain a host of social problems, especially ethnic and sexual prejudices (e.g., Snyder, 1981, 1982). Expectancies perpetuate negative stereotypes about race (Word, Zanna, & Cooper, 1974), social class (Darley & Gross, 1983), mental health problems (Farina, Gliha, Boudreau, Allen, & Sherman, 1971), and homosexuality (Snyder & Uranowitz, 1978). As early as 1978, Rosenthal and Rubin conducted a meta-analysis of 345 studies of expectancy effects and concluded that the phenomenon exists "beyond doubt" and is substantial in its impact. One of the most controversial and frequently replicated studies of a self-fulfilling prophecy, called "Pygmalion in the Classroom," was reported by Rosenthal and Jacobson in 1968. In this study, elementary school teachers were led to believe that IQ tests indicated that a few of their students would "bloom" academically during the course of the year. Although the targeted children had been randomly selected, at the end of the school year they performed significantly better on the same intelligence tests. Fulfilling the prophecy, chosen children bloomed in comparison with their peers, presumably because the teachers' expectations somehow led to subtle changes in teaching behavior that benefited those target students. In another influential study, Snyder, Tanke, and Berscheid (1977) wanted to see whether stereotypes about physical attractiveness would affect dyadic interactions, since it has been found that attractive people are assumed to possess more desirable social skills (Berscheid & Walster, 1974). Before making a getting-acquainted phone call, male undergraduates were shown a Polaroid snapshot of either a very pretty or a rather plain woman. The photo was presented as the person he was about to call, although in fact, each photo was of a woman not in the study. As expected, male subjects who had seen a photo of a pretty woman were judged more sociable and friendly than those talking to presumably plain women. Perhaps more important, raters listening only to the women's end of the conversation found that when women were talking to men who assumed they were attractive, they were judged to be more confident, animated, friendly, and likable than the women who were imagined to be plain.

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Although the women were told nothing about their conversation partner's false preconceptions, they behaved in a manner consistent with being physically "attractive" or "unattractive." In addition to school performance and social traits linked with attractiveness, cycles of self-perpetuating bias have been generated and examined for a wide variety of personality traits. Experiments have shown that when target subjects are expected to act more hostile (Snyder & Swann, 1978), competent (Feldman & Prochaska, 1979), or competitive (Kelley & Stahelski, 1970a, 1970b), their behavior tends to confirm the perceiver's expectation. That people enter an interaction with certain preconceptions, act in manner geared to elicit behaviors congruent with their conceptions, and then perceive the behavior as confirming their assumption, was nicely demonstrated in a study by Curtis and Miller (1986). They found that by falsely leading subjects to think that another person liked or disliked them, a subsequent interaction between the partners led the subjects to actually be liked or disliked correspondingly. Moreover, when expecting to be liked, subjects disclosed more, used a more pleasant tone of voice, and engaged in fewer distancing behaviors, such as disagreeing with their partner. As Curtis and Miller point out, their research demonstrates how those who believe they will be disliked contribute to their own unpopularity. Self-fulfilling prophecies appear to be especially powerful when they involve the maintenance of an individual's self-image. Swann and Read (1981) report research that strongly suggests people seek out and attend to information that will preserve their vision of themselves, whether that vision be as likable or dislikable. Subjects also behaved in ways that reinforced their self-concept, and they selectively remembered social feedback that confirmed their view of themselves. Thus, confirmation bias occurred before, during, and after interactions. This was true even with the subjects who had negative self-images. Subjects who thought of themselves as dislikable, and were interacting with a partner whom they had been led to believe had a favorable impression of them, tended to act especially unpleasantly and were actually more disliked by their partners than subjects in other conditions. Swan and Read concluded that self-verification can be an even more powerful motivation than self-enhancement. Keisner (1985) points out how this kind of negative self-fulfilling prophecy can be played out during the course of psychotherapy. He describes treating a patient who, from the beginning of their work together, accused Keisner of being selfish, without compassion, and abusive "just like anyone else." With more candor than shown in many case histories, Keisner admits that he indeed came to dislike the patient and at

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times wished that the patient would follow through on repeated threats to end treatment. "In other words," concludes Keisner, "he was successfully inducing me to feel toward him the way he expected me to feel" (p. 443). Considerable research supports the view that the expectations of both patients and therapists inevitably influence the therapeutic relationship and its success. In Jerome Frank's classic work Persuasion and Healing (1973) and in the latest revised edition coauthored with his daughter (Frank & Frank, 1991), the role of expectations is linked with placebo effects, symptom relief, and treatment duration. The authors review studies that show that inert medications or placebo-attention therapy can be as effective as psychotherapy because the placebos arouse hope in demoralized patients (e.g., Arkowitz, 1992; Bootzin & Lick, 1979; Elkin et al, 1989). Symptom relief after six weeks of therapy has been correlated with patients' optimism about therapy results measured before treatment begins (Uhlenhuth & Duncan, 1968). According to Frank, self-fulfilling prophecies play a greater than average role for people with limited or inflexible social repertoires, such as the paranoid patient who antagonizes others with a surly, suspicious manner. "Breaking these vicious circles by confronting patients with the discrepancies between their preconceptions and the world around them is [an] important goal of psychotherapy" (Frank & Frank, 1991, p. 33). DEVELOPMENTAL STUDIES OF CYCLICAL PROCESSES

Recent studies in infant development have raised questions about the conception of infants as passively reacting to environmental forces or inner drives, and have suggested, instead, that the infant is an active participant in the creation of its interpersonal world. The new infant research also describes the infant as shaped and guided particularly by interpersonal expectancies. Studies have shown that even neonates have the capacity to detect contingencies between actions and environmental events and to develop causal expectations (Finkelstein & Ramey, 1977; Millar & Watson, 1979; Watson, 1985). By 3 months of age, an infant needs only two encounters with a novel event to form expectancies about whether that event will recur (Fagen, Morrongiello, Rovee-Collier, & Gekoski, 1984). The cognitive capacity to form expectations develops early, and the expectancies that the child forms about social interactions with the mother and other caretakers are thought to form the basis of early inner representations of self and other, even before verbal representation becomes possible (Beebe & Lachman, 1988; Lamb, 1981). Stern (1985) speaks of the child's formation of expectations about social interactions as important from the second or third month in forming a core sense, and he calls such interpersonal expectancies "Representations of Interactions that have been Generalized (RIGs)" (p. 97).

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The terms used by these researchers all highlight the cyclical nature of the interactions of focal interest. For example, Brazelton and colleagues refer to "reciprocity" (Brazelton, Kozlowski, & Main, 1974), Beebe and Lachman (1988) write about the implications of "mutual influence," and "bidirectional" impact is the focus of work by Cohn and Tronick (1988). The findings of contemporary infant research suggest that in normal mother-child dyads, there is a continual exchange of cues in which each member has an impact on the expressive state of the other (e.g., Cohn & Tronick, 1987; Jaffe, Stern, & Peery, 1973; Jasnow & Feldstein, 1986; Stern, 1977; Tronick, Als, & Brazelton, 1977). The study by Cohn and Tronick (1988) of face to face interactions between mothers and infants used time-series statistical analyses to focus specifically on whether mothers were generally responding to their infants or vice versa. These researchers found that mother and child influence was bidirectional; the mother's positive affective state often induced the child to join her in a smile, and the child's expressions, in turn, led to shifts in the mother's state. At ages 3 months and 9 months, mothers and infants were equally likely to influence the directions of the interaction. However, when the baby was 6 months old, the mother was more likely to follow the child's lead, a finding that the authors suggest may be due to developmental changes resulting in increased interest in objects at this age. Cohn and Tronick also found that at all ages, babies were more likely to respond to changes in their mother's behavior if the mother was responsive to changes in their behavior. Within a matrix of sensitive caretaking, babies quickly learn to attend to and read social cues that lead to positive cycles of interpersonal exchange. On the other hand, infants with unresponsive parents may learn that their social cues are ineffective, as appears to be the case when parental psychopathology interferes with caretaking skills. Studies of depressed mothers and their infants have shown that such mothers are less able to respond appropriately to their babies' signals, and thus the infants experience themselves as having little impact on their social environments (Cohn, Matias, Tronick, Cornell, & Lyons-Ruth, 1986; Field, 1984, 1986). This may be one reason why infants and young children of depressed mothers are at increased risk for developmental problems (Tronick & Gianino, 1986). From the first month, the child develops expectations with regard to the effectiveness of its interpersonal signals and whether social interactions will be satisfying and enjoyable. The dyadic reciprocity found by developmental researchers, and the cyclic impact of expectations, is having growing impact within the psychoanalytic community on therapeutic work with adults. In a paper on the implications of infant development research for psychodynamic theory and therapy, Zeanah, Anders, Seifer, and Stern (1989) come to con-

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elusions remarkably similar to those on which cyclical psychodynamics is founded. [A] major paradigmatic shift away from the fixation-regression model of psychopathology and development is indicated. A new model that better fits available data is proposed instead. In this continuous construction model, there is no need for regression, and ontogenetic origins of psychopathology are no longer necessarily tied to specific critical or sensitive periods in development. ... In the continuous construction model, patterns of internal subjective experience and patterns of relating to others are derived from past relationship experiences but are continuously operating in the present, (p. 657)

The "continuous construction model" proposed by these authors prompts them to call for multimodal treatment that focuses more explicitly on the here and now, especially through the transference relationship. The view of child development as a continual, interactive, and mutual influencing process between the child and its environment also makes it possible to reconcile theorists who insist on the importance of early life events—the view of the vast majority—with the vociferous minority (e.g., Clarke & Clarke, 1976) who argue that negative events that occur during the first few years of life do not inevitably and irrevocably mar later development. For example, Kagan (1976, 1979a, 1979b) has argued that children have an enormous capacity for change throughout life, and that there is little evidence that events during the first year of life produce irreversible consequences—what he calls the "tape recorder theory of development" (1979, p. 886). To support a theory of discontinuity in development, Kagan presents a comparative study of the cognitive capabilities of Guatemalan children and American children of the same ages, who show very different rates of cognitive development in early childhood, but who end up at similar levels of cognitive functioning by adolescence (Kagan & Klein, 1973; Kagan, 1976). Kagan attributes this apparent absence of a predictive relationship between cognitive functioning during infancy and pubescence to the specific cultural expectations of the Guatemalan parents. In these isolated villages, infants were not generally held or played with and were kept indoors for the first year of life because the outside sun, air, and dust were considered unhealthy. Kagan's point is that childrearing practices that in our country would be considered extreme deprivation, and that would indeed lead to severe and permanent retardation, have very different outcomes where a lack of stimulation during the first year of life is the norm. Since the expectations for these children in later years differ from the dire expectations that would prevail—and be fulfilled—here, the consequence of the early experience is very different.

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Kagan's view of potential discontinuity in development and the traditional psychoanalytic views of the vital importance of early experience can be reconciled within the cyclical psychodynamic framework. In our framework, early interactions are important not because they permanently "fix" or "arrest" development, but because they start an individual on a life course in which further such interactions are made more likely. They "skew" development and perpetuate themselves by recreating over and over again the circumstances for their repetition. This is not a matter of a "repetition compulsion," an inner force driving one to repeat, but a dynamic in which people are at once author and victim, in which what happens to them leads them to act in ways that make it likely the same thing will happen again. American children reared in as "deprived" a way as Kagan's Guatemalan children are an exception, a specially deprived subclass, and they are likely to continue in a deprived environment for many years. Moreover, they are likely to be perceived by those outside their family or social group as damaged, and to be treated as damaged even by those who treat other children in a facilitative way. In contrast, the Guatemalan children who are "understimulated" in the first few years of life, and who are perceived by American observers as "apathetic," "passive," or "timid," are not a special subgroup of their own society. They are "normal" children of "normal" parents and are perceived that way. They are thus in a position to respond adaptively and effectively to the stimulating experiences that their culture—with a different agenda and timetable—provides in later childhood. DISCONFIRMATION OF PATHOGENIC EXPECTATIONS: BREAKING VICIOUS CIRCLES

In contrast to the large body of research about self-fulfilling prophecies, there are relatively few studies that have explored the conditions necessary for expectations to be broken (Darley & Fazio, 1980; Miller & Turnbull, 1986). A self-disconfirming prophecy occurs when the original belief leads to behavior that prevents that expectation from coming true. For example, falsely expecting someone to be shy and withdrawn might lead one to act especially solicitous and comforting, thus inducing that person to open up and behave more gregariously than usual. Snyder (1984) and Swann and Snyder (1980) suggest that the key to whether a prophecy is confirmed or disconfirmed lies in the link between the expectation and the individual's hypothesis about how best to behave, given that expectancy. For instance, teachers may have different theories about how best to instruct a gifted student. One teacher may believe that students with naturally high abilities will achieve their potential only with effective instruction, thus generating a self-fulfilling

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prophecy by lavishing attention on the presumably gifted students. Another teacher may believe that gifted students are most likely to bloom if left alone to develop their natural abilities. In this scenario, the students may perform more poorly than those believed to be less gifted because they are never taught the academic skills they need. The teacher's "hands off" policy may thus lead to a disconfirming prophecy. Empirical investigation (Swann & Snyder, 1980) supports this analysis of teacher hypothesis and student performance. Motivation also appears to be a key factor in whether prophecies are confirmed or disconfirmed. Darley, Fleming, Hilton, and Swann (1988) found that the motivational set with which individuals approached an interaction influenced whether or not negative expectations were confirmed. These researchers asked college students to interview someone who they had been led to believe performed poorly under pressure and became highly emotional during stressful situations. Half the subjects were told that the goal of the interchange was to choose a partner for a cooperative, high-stress game, while the other half were told that the goal was to have casual conversation. The subjects who were motivated to find a game partner chose to ask questions that would help them find out whether the targets were calm or frantic, while the subjects choosing questions for casual conversation did not ask questions that would allow their expectations to be disconfirmed, and thus continued to view the other person as frantic, whether or not this was true. Negative stereotypes may be especially prone to perseverance in the face of contradictory evidence. For example, Farina and Ring (1965) led perceivers to believe falsely that a coworker was mentally ill, and found that the perceivers then behaved in a manner that led the targets to work more competently than when they were believed to be "normal"—an example of behavioral di'sconfirmation. However, despite objective measures of competence, the targets were still perceived by their coworkers as performing poorly. We sometimes see what we expect to see rather than reality. Swann and Ely (1984) looked at what happens when two people in an interaction have conflicting expectancies with regard to the self-image of one of them. Prior to a social interaction between female undergraduates, Swann and Ely manipulated the perceivers' expectancies so that some women were certain that their target partner would be introverted, some were certain of extroversion, and others were relatively uncertain whether their partner would be introverted or extroverted. Firmly held or not, the perceivers' expectancies were always the opposite of their partners' true self-image. The researchers found that target women who started with a strong view of themselves as extroverted tended to be outgoing and gregarious during the conversations, continued to view themselves as

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extroverted at the end of the experiment, and managed to change the mind of those perceivers who had expected an introverted partner. However, when the perceiver was certain of a particular level of extroversion, and the target was uncertain of her own self-image, behavioral confirmation of the perceiver's expectations occurred. If the perceiver, for example, expected the target woman to be introverted, and the target entered the experiment with a view of herself as extroverted, but with no great certainty about this view, she tended to act more and more introverted over the course of the conversations and to modify her own self-image by the end. When we are unsure of ourselves, we are much more easily swayed by the expectations of others. These findings are congruent with the cyclical psychodynamic emphasis on interaction cycles as dependent on the characteristics and actions of both partners. They provide further understanding of why it is that patients may sometimes learn to interact in new and adaptive ways within the therapy hour, yet may revert back to old patterns in interacting with friends and family, whose expectations and ways of interacting differ from those of the therapist. The cyclical psychodynamic approach to therapy is keenly attentive to these phenomena. It is one of the key reasons that work on the transference is usually complemented by explicit attention to the patient's interactions in his or her daily life. Generally, it is necessary to rework over and over again the processes of skewed perception and behavioral induction that maintain the patient's vicious circles. Both the patient and significant others in the patient's life have long-held expectations that are not likely to yield instantly to changes in the actual events and behaviors encountered. The schemas that are most central in our psychological difficulties tend to be characterized by an overemphasis on assimilation and a slowness to accommodate to new perceptual input (Wachtel, 1987, chap. 2). We continue to see what we expect to see long after the circumstances that led to that expectation have changed. Because all of the schemas by which we grasp reality and interact with the world—no matter how skewed or rigid—inevitably have elements of accommodation as well as of assimilation (cf. Piaget, 1952; 1954), eventually our perceptions will accommodate to real changes in our experiences with others. But because the behavior of others is itself responsive to our expectations of them, it can often happen that before the patient has sufficiently recognized the changes that have begun, those changes have been undermined by the effects of the still persisting old perceptions. That is, if the other person were to continue acting in new ways toward the patient, the patient would eventually notice it. But because the patient's slowness to notice it has consequences, the new circumstances have dis-

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solved before they have been effectively perceived. Thus once again the expectation is confirmed despite its initial "objective" disconfirmation. And before they are subjectively and adequately registered, the data of experience themselves accommodate; by the end of the process the "objective" reality once again matches the reality expected. The tenacity with which beliefs are held (see Jelalian & Miller, 1984, for a review) also points to the conclusion that insight may not be enough to lead to change in most cases. A number of lines of research point to limits in the capacity of understanding, however emotionally charged, to shift opinions. Many studies have shown, for example, that when research subjects are misled, their erroneous beliefs persist even after debriefing (Nisbett & Ross, 1980; Ross, Lepper, & Hubbard, 1975). If these newly formed self-concepts are so difficult to modify, how much more impervious are long-standing beliefs about the self? It is interesting to note in this context that even most "cognitive" therapies include considerable effort to bring about changes in behavior and to induce patients actively to test out the assumptions by which they have been living.

DIRECTIONS FOR FUTURE RESEARCH

While the self-fulfilling prophecy paradigm has influenced research in the classroom, the workplace, the laboratory, and in casual social situations, it has not tended to be incorporated into studies of psychotherapy. It is appropriate at this time to test directly how cycles of behavioral confirmation and self-verification are played out within the therapy hour. It is also time to test the techniques and interventions deriving from cyclical psychodynamics. As such research is conducted, we suggest that it should be guided by an awareness of how interactive patterns and expectations may shape research methodology, and we find the guiding principles of family therapy process research helpful in this regard (e.g., Gunman, 1983; Gurman, Kniskern, & Pinsof, 1986; Wynne, 1984). Specifically, the conceptual framework and methodological guidelines suggested by Pinsof (1989) include an emphasis on the interaction between therapist and patient systems, "which is nonlinear and implies bidirectional mutual causality or influence" (p. 55). According to this point of view, therapy process research must be aware not only of how the therapist influences the patient(s), but how the patient subtly sways the therapist, how a supervisor makes an impact, and how the patient's system—not only family of origin but friends and coworkers—maintain the status quo or push for change.

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Future Directions The cyclical psychodynamic approach to theory and to clinical practice developed as an integrative effort to incorporate the observations and concepts of diverse perspectives into a coherent conceptual framework. Over the years, this point of view has evolved so that in certain respects it now resembles a "theory of personality" in its own right. This is both a sign of progress and a signal of danger. The increasing coherence and comprehensiveness of this point of view are encouraging, as is its fertility in generating new ideas for how to proceed clinically (e.g., Wachtel, in press). But it is essential that theorists who are integrative in their intent not lose track of the spirit of the integration movement. Nothing could be more alien to this spirit than the development of separate "schools" of integration, replicating the very parochialism they were designed to transcend (also see Norcross & Newman, 1992). Further progress in developing the cyclical psychodynamic approach, therefore, may be expected to derive not only from efforts to incorporate perspectives from still other established orientations (much as the approach moved from the integration of psychodynamic and behavioral approaches to the further incorporation of ideas and methods from family systems approaches); they will derive, as well, from efforts to synthesize the ideas and methods of cyclical psychodynamics with those of other integrative efforts, such as those described in this volume. An integrative theory such as cyclical psychodynamics is continually evolving and seeking new sources of nourishment from other viewpoints, at the same time that it seeks to bring order and coordination into these assimilative efforts. Cyclical psychodynamics is by its very nature an open-ended approach. It can be expected to change not only as a result of examining and attempting to integrate other theoretical perspectives, but also from efforts to come to grips with new empirical observations—those deriving from controlled research in clinical, developmental, social, and other branches of psychology, and those based on clinical observation. One of the most likely sources of new ideas and of changes in the theory is the inevitable failures and difficulties that will arise in new clinical cases. Failures in clinical work are humbling, but are also perhaps the most potent potential source of theoretical development. Nothing is quite as effective in combating complacency and premature closure as the daily challenges of clinical work. Finally, one further direction in which the cyclical psychodynamic point of view is likely to evolve is in the examination of the broader social context within which people's difficulties develop. This framework has already been applied in a number of works of social criticism (e.g., Wachtel, 1989), and further explorations of the interface between social and psycho-

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logical processes from a cyclical psychodynamic point of view are in progress. Because this perspective probes deeply into unconscious fantasies and unarticulated wishes and expectations without positing a separate "inner world" cut off from the world of everyday experience, and because it emphasizes context in all psychological processes, cyclical psychodynamics lends itself readily to psychologically oriented examination of social processes. Questions of race, class, poverty, quality of life, environmental deterioration, and social values are extremely pressing ones in our society. It is one of the aims of the cyclical psychodynamic point of view to address these questions in a way that brings together our understanding of their psychological foundations and of the social context in which they are manifested. Such an agenda may be the most demanding of all the challenges an integrative effort can assume. In today's world, it may also be the most essential.

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PART III

INTEGRATIVE PSYCHOTHERAPIES FOR SPECIFIC DISORDERS

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CHAPTER 11

Integmtive Psychotherapy of the Anxiety Disorders BARRY E. WOLFE

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IROUNDLESS EXPECTATIONS have been the chief formative influence in the development of my integrative perspective on the anxiety disorders. Like so many of my friends in the Society for the Exploration of Psychotherapy Integration (SEPI), I had the experience of being trained in a particular orientation, only to be rudely confronted with its limitations when applied to particular patients or problems. Patients often refuse to accept the parts assigned to them by the dictates of a given therapy orientation. Instead, they respond in very individual ways and, in the process, decimate any grand theory that may be imposed upon them.

Background of the Approach My training as a therapist served to generate a number of expectations regarding how patients develop and maintain their emotional problems. Perhaps the best way to describe the therapeutic approach in which I was trained is that I learned to talk "psychodynamic" but to practice an eclectic blend of Rogerian and Gestalt therapy. A patient's problem might be formulated in psychodynamic terms, but the actual awareness-heightening therapeutic operations might include "evocative reflection" (Rice & Greenberg, 1984) or the "two-chair technique" (Greenberg, 1979). As useful as this combined approach has been in the treatment of some patients, its benefits for many others were limited. I found with phobic patients, for example, that it provided little resolution of the avoidance behavior, since it lacked a performance-based, confrontative approach

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to the treatment of phobias, which was being touted in the research literature (Barlow & Wolfe, 1981). Particularly in the area of phobias, I believed that behavior therapists had a lock on effective treatment. I then made the popular logical error in thinking that effective treatment necessarily implies an accurate conceptualization of the problem being treated; therefore, I eagerly received some training in a variety of behavioral techniques, including a number of exposure-based procedures. When I attempted to employ traditional exposure therapy, however, my expectations were unsubstantiated once again. The application of imaginal exposure to the phobic patient's feared object or situation led to a series of recurring clinical observations that profoundly altered my conceptualization of the formation, maintenance, and treatment of phobic disorders. The following observations serve as the empirical foundation for my etiological model of anxiety disorders. Exposure-Induced Catastrophic Imagery I had assumed that anxiety somehow becomes conditioned to the phobic object and that imaginal exposure would allow the patient to experience the habituation of that anxiety by means of continual exposure. What I serendipitously discovered, however, was that imaginal exposure uniformly elicited images of catastrophe associated with the experience of extremely painful emotions. The imaginal scenes that spontaneously arose would find the patient in a powerless position, about to be humiliated or badly harmed by the phobic object. As my patients and I would explore their catastrophic imagery, we would find that they were either recapturing long-forgotten traumatic events in their own history or that these images were constructed prototypes that symbolized their sense of helplessness, powerlessness, and doom originally experienced much earlier in their lives (cf. Weitzman, 1967). As the serendipitous discovery of catastrophic imagery became a routine occurrence in my treatment of phobias, I was increasingly struck by the irony that unconscious conflicts were being elicited by a therapeutic approach that denied their existence. Of course, this was not new. Feather and Rhoads (1972a, 1972b) had demonstrated something like this phenomenon 20 years ago when they attempted to employ systematic desensitization to previously elicited unconscious fears. Even before that, Stampfl and Levis (1967) and Weitzman (1967) originally highlighted the importance of psychodynamic issues in the development and maintenance of phobias. Anxiety as Signal of Surfacing Painful Emotions With phobic patients, for example, images of confrontation with the phobic object would result initially in very high anxiety. If the patient was able to

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experience the anxiety associated with the catastrophic imagery, rather than trying to avoid or interrupt it, the anxiety eventually would give way to a variety of feared emotions, including rage, humiliation, shame, hopelessness, and despair. A similar phenomenon occurred with panic patients for whom there may not be an external phobic object. These patients typically fear their body sensations, particularly the sensations of anxiety (Reiss, 1987). Such patients would be asked to focus on the most prominent body site of anxiety. Once a patient was able to maintain a continual focus on the experience of his or her anxiety, one or more of the aforementioned frightening and painful emotions would be experienced. It was through such experiences that a patient would come to realize that the anxiety appeared to function as a signal or an alarm of very threatening emotions. For example, one patient who suffered from a severe fear of flying experienced his anxiety predominantly in his throat. He would feel a severe constriction whenever he imagined himself on a plane. When we were able to induce this constriction through imaginal exposure, I would instruct him to maintain a strict attentional focus on his throat. After doing this for a few minutes, he suddenly burst into sobs as he reexperienced his long-dormant rage at his mother, which would eventually segue into an intense feeling of extreme sadness over her apparent neglect. As he experienced and explored the meaning of these feelings, his anxiety disappeared. This particular patient, however, found depressive sorrow to be as painful as the anxiety and panic, and the anxiety reappeared upon the next trial of imaginal exposure. Repeated episodes of imaginal exposure demonstrated to the patient, beyond doubt, that his anxiety signaled the surfacing of depressive sorrow, a feeling for which he possessed virtually no tolerance.

Painful Meanings, Painful Sensations The fear of pain, particularly emotional pain, can be observed in virtually all anxiety patients. As patients begin to allow themselves to experience some emotions connected to their phobogenic catastrophes, they discover that they fear both the sensations associated with the emotion as well as the meanings embedded in the feeling. The patient mentioned above, for example, had so little tolerance for negative affect that he terminated therapy for a brief period so that he would not have to encounter the painful affect. Anxiety patients fear both the medium and the message.

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Symbolic Connection of the Phobia When phobic patients explore their catastrophic imagery elicited by imaginal exposure to their feared object, they are able quite frequently to discover the connection between the phobic object and the catastrophe. One driving phobic patient whose central fear was of being lost, recaptured the memory of being kidnapped by her father when she was 4 years old and placed in a house full of strangers. Feelings of isolation, abandonment, terror, and rage were reexperienced during her imaginal exposure work, the same feelings that she experiences whenever she gets lost while driving. "Being lost" while driving appears to symbolize her childhood trauma. But for other patients, the phobic object may be an adventitious element of the catastrophic scene. For example, another driving phobic had felt his world coming apart when his wife, while driving him from Sacramento to San Francisco, told him she was ending their marriage. In such instances, the phobic object appears to function more as a sign than a symbol. Experiencing the Dreaded Emotions Another frequently observed phenomenon involves the diminution of anxiety that results when phobic and panic patients are able to experience the emotions they fear. When such patients can maintain a strict attentional focus on what they fear, whether it be a specific external object or an internal sensation, they will contact the rage, humiliation, and despair that appear to be obscured by the anxiety. Often, but not always, patients will notice that experiencing these feelings is actually less painful than the anxiety. All of these observations, I hasten to mention, are predicated on the patient's being able to experience the anxiety long enough for the catastrophic imagery and the painful emotional processing to occur. But what if the patient is unable to experience the anxiety? Another set of recurring clinical observations were made in conjunction with some patients' inability to experience their anxiety. Metappraising Perhaps the most frequently observed phenomenon with patients suffering from an anxiety disorder is their tendency to experience an emotional reaction to their anxiety. Most frequently emphasized in the published literature is what Goldstein and Chambless (1978) have called "fear of fear." Reiss (1987) has investigated the similar phenomenon of anxiety sensitivity. Both constructs describe a two-step emotional reaction that anxiety patients, in particular, experience: First, they become anxious either for some unknown reason or because of the situation in which they currently

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find themselves; second, they become anxious about being anxious. As most clinical investigators have noticed, the fear of fear rapidly escalates the intensity of the original fear and may well be a specific catalytic process by which anxiety spikes into panic (Goldstein, 1982). While my observation of patients becoming fearful of their fear was ubiquitous, I also began to notice that these patients experience a variety of emotions in reaction to their first-order fear. They would become angry, depressed, ashamed, and humiliated by their fear. This form of emotional processing seemed to be a general phenomenon that uniformly resulted in the experience of intensely negative affect. In an earlier article, I called this form of emotional processing "metappraising," an emotional appraisal of a first-order emotional appraisal (Wolfe, 1989). It was further apparent that while patients metappraised their fear, they could not experience it directly. Reflexive Focus of Attention on Self As I began to ponder the phenomenon of metappraising, it occurred to me that patients were using their attention in a particular way. Instead of remaining in contact with their direct experience of the world, they were focusing on themselves as a person in the ad of being fearful—almost as if they were watching another person in the throes of fear. As a form of self-awareness, this way of focusing attention had some properties that distinguished it from a more immediate perception of one's reactions to what is happening outside one's skin. Duval and Wicklund (1972) had described two forms of self-awareness in their social psychological theory that were distinguished only by the way in which the individual focused his or her attention. According to their theory, there were two options: subjective self-awareness, which described a focus on the environment, and objective self-awareness, which described an attentional focus on self as object. In short, they were describing a distinction between a nonreflexive and a reflexive focus of attention. Their description of objective selfawareness comported well with my clinical experience with anxiety patients. Their notion of subjective self-awareness, however, obscures two different attentional foci. Reflexive, Sentient, and Exterior Awareness Reflexive self-awareness is perhaps the easiest attentional focus to define. Attention is focused on self as object. To achieve this focus, however, we must remove ourselves from our immediate, direct experience of the world. Instead of experiencing the world, we are replaying thoughts, beliefs, images, and fantasies that we have internalized about ourselves. But our attention apparently can be focused in two other directions, either

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(a) wholly on the environment, with virtually no self-awareness, or (b) on our in-the-moment experiences of our interactions with the physical and social world. I have called the former attentional focus exterior awareness, and the latter focus, sentient awareness. Duval and Wicklund's subjective self-awareness seems to encompass these two attentional foci (Wolfe, 1992). An example may clarify. A young man is on a date listening to the animated conversation of the young woman sitting next to him. His attention might be wholly absorbed by what she is saying and how she is saying it, that is, in exterior awareness. Or it might be on his current emotional reactions arising spontaneously as he listens to her; this is sentient self-awareness. Finally, he may be wondering what she thinks about him or whether he is giving the impression that he is listening closely enough to her; this would be reflexive self-awareness. One's attention, in reality, shifts back and forth among the three foci. The point is that our experience of self varies significantly with the focus of attention. Reflexive thinking, for example, is a self-contained cognitive-affective process that involves only internal stimuli and our reactions to those stimuli. If we become fixated in reflexive awareness, we literally lose contact with the outside world. Sentient awareness is the direct experience of our felt meanings (Gendlin, 1962), which can include our in-the-moment "senses of self" or our own personal, emotional reactions to what we perceive outside our skins. Exterior awareness is akin to direct perception without self-awareness. Reflexive Self-awareness and Self-endangerment Experiences Another set of clinical observations ties together the experience of anxiety and the focus of attention. I have observed that when patients feel themselves significantly endangered, their attention automatically shifts to reflexive self-awareness. At such times, they cannot seem to focus their awareness on either the task at hand or on their direct experience of the environment. A case in point is the person suffering from test anxiety who cannot focus on the examination because he or she seems literally stuck in catastrophic thoughts about failure and its implications. In the published literature, an almost identical phenomenon has been labeled "self-focused attention" (Barlow, 1988; Ingram, 1990). In my model, however, reflexive awareness represents only one way of focusing attention on the self. The Nature of Self-endangenneut Finally, I would like to sketch the nature of this experienced sense of danger to the self. Quite clearly, it is rarely, if ever, associated with actual physical

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harm posed to the individual. Self-endangerment experiences appear to be confined to the psychological realm; to fears associated with interpersonal rejection and loss; to experiences of "self loss"; and to the processing of extremely painful emotions, particularly shame, humiliation, or despair. Interestingly, panic patients, for whom many of these fears operate at a tacit level, and who are habitually hypervigilant for the experience of unusual body sensations, will convert a nebulous psychological danger into an imagined physical one with catastrophic thoughts relating to these sensations. Upon reflection, I was struck with how closely these self-endangerment experiences mirrored those mentioned by Freud (1926) and several psychoanalysts who followed him. In his paper on anxiety, Freud proposed that anxiety is the experience of helplessness, or a signal of impending helplessness, with further content specification varying according to developmental phase. He referred to this phenomenon as the "epigenetic unfolding of danger situations," which included, in developmental progression, • Fear from • Fear • Fear • Fear • Fear • Fear

of being overwhelmed by traumatic excitation, from without or within of loss of the object of primary care and attachment of the loss of the object's love of castration or other bodily punishment or hurt of superego, conscience, or social condemnation of abandonment by the powers of fate

Anna Freud (1946) spoke of several types of "narcissistic catastrophes," such as fear of fusion, fear of ego disintegration (self loss?) in the face of excessively strong drives, fear of humiliation, fear of loss of self-esteem. All of these fears have been observed clinically in anxiety patients when they have been confronted with the objects and situations that they consciously fear. It should be noted that the perception of a danger situation is always relative to the person's ability to cope with that particular situation. The danger may be specific to the situation or may be a more general problem relating to a deflated sense of coping ability. ETIOLOGICAL ODYSSEY

These observations of what happens when anxiety patients can and cannot experience their anxiety for any length of time progressively altered my sense of the etiology of these disorders. While there was no denying the potency of exposure-based therapy, the behavioral conception of the acquisition and treatment of phobias left much to be desired. In fact, considering the kind of material that continually turned up in imaginal

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exposure, I began to wonder what was so wrong with the original psychoanalytic conception of the development of a phobia. The information obtained from the imaginal exposure work appeared to confirm several aspects of the psychoanalytic model of phobia acquisition: (1) that catastrophic, unconscious conflicts were at the root of the phobia; (2) that an internal danger had been displaced onto a concrete, external reality (i.e., the phobic object or situation); (3) that the phobic object or situation bore some relationship to the conflict, usually a symbolic one; and (4) that an unmanageable internal danger was made manageable by displacement and projection onto an external object or situation. But the Freudian model of phobia deemphasizes the emotional processing of personal meaning in favor of drive or instinctual dynamics. The Freudian drive metapsychology is, by common consensus, the least compelling aspect of this theoretical orientation. The corrections in emphasis offered by the recent theoretical developments in the self psychology and object relations versions of psychoanalysis move it closer to a psychology of meaning that, in my view, offers a more accurate picture of the phenomena of anxiety disorders. What was also surprising was the frequency of childhood traumas that phobic patients apparently experienced at the hands of their caretakers. Although, these traumas were occasionally sexual in nature, more often they concerned disillusioning experiences of abandonment by—or the unreliability of—the patient's caretakers. The question of whether psychopathogenic traumas are real or imagined is one that has been debated since Freud's time. As is well known, the course of psychoanalytic history and theory experienced a sea-change when Freud abandoned his own sexual trauma hypothesis in 1897. I would suggest—as Bowlby (1988) frequently has—a second look at the possibility that there are many more real traumas happening to our patients than is typically believed. Whether or not these catastrophes were "real" in any veridical sense, they had a profound effect upon the anxiety patient's self-experiencing, in terms of both the patient's immediate self-experience and self-beliefs. The price of such childhood trauma is the recurring, jolting experience of self-endangerment or loss of safety. Although such self-experiences are most prominently felt when confronted with the phobic object, they reflect more enduring self-beliefs and unresolved conflicts about one's self. Exposure therapy has been found to be most helpful in dealing with the phobic avoidance behavior in the short run. But for long-term, durable change, it appears that these underlying issues of self-experience have to be addressed. Exploration of patient self-experiencing began to show the importance of tacit emotional processing, or, put more simply, the difficulties that phobic patients generally have with the experience and expression of

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particular painful feelings. Such issues, however, seemed to be tailor-made for an experiential therapeutic approach, which brought me full circle back to the virtues of my original orientation. In summary, I started from an experiential-dynamic frame of reference, flirted with behavioral conceptions, returned to a more psychodynamic view of the phenomena, and most recently see much potential in a cognitive-experiential perspective. This is to say, of course, that all of these perspectives contribute insights into the phenomena of anxiety disorders. But their limitations also highlight the need for an integrative framework.

Treatment Approach Groundless expectations have been as instrumental in the development of my treatment approach as they were in shaping my current thinking regarding the etiology of anxiety disorders. As mentioned earlier, I had been led to believe that the application of exposure therapy for simple phobias, for example, would lead to a fairly rapid reduction or elimination of phobic symptoms in at least 60 to 70 percent of the cases (Barlow & Wolfe, 1981). In fact, for the phobic patients that I see in private practice, simple phobias are not so simple. Sometimes, exposure therapy would lead to a rapid reduction in symptomatology. Often, however, patients experienced at least three other outcomes: (1) they found the exposure therapy too frightening, however gradual it might be, and were not able to complete the treatment; (2) they would experience symptomatic relief, which would not last; and (3) they were able to reduce their avoidance behavior, but would continue to experience substantial anxiety whenever they confronted their feared object or situation. Thus it became apparent that it was necessary to treat more than just the phobic symptomatology and thus to do more than just exposure therapy. And to do that one had to discover whether the phobia existed as an independent, circumscribed disorder or whether it was connected to other issues and problems in the patient's life. In the small and biased sample of patients that I see in my practice, it is the rare individual who presents with a circumscribed simple phobia. In the majority—but not all—of cases that I have treated, simple phobias turn out to be quite complex disorders involving dysfunctions in a variety of areas in the patient's life, and these dysfunctions turn out to be integrally connected to the patient's phobia. The limits of exposure therapy and the serendipitous discovery of tacit catastrophic emotional processing suggested that an integrative therapy was necessary for the resolution of a phobic disorder and the various issues associated with it. The two major therapeutic approaches to the

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treatment of phobias have dealt with only a subset of the issues involved in these disorders. The psychoanalytic error was to focus only on the underlying issues, ignoring the phobic symptoms. The error of behavior therapists has been to focus only on the phobic symptoms, ignoring the underlying issues. It was apparent that both symptoms and associated issues need to be addressed. The two foci appear to be united by a concern with the endangered self, that is, the patient's anticipation of a state of helplessness. THE GOALS OF TREATMENT

In the case of a complex phobia, the overall goal of treatment is self-repair, which involves both alterations in the individual's self-concept and in the process of self-experiencing. The subsidiary goals of self-repair include • Enhancing the individual's sense of agency, or self-efficacy • Increasing the individual's tolerance for emotional experience, but particularly negative affects • Reducing the various defensive interruptions to sentient selfexperiencing • Restoring a better balance between reflexive and sentient self-awareness • Increasing the patient's ability to engage in authentic relationships (i.e., relationships in which one allows oneself to be known and to know the other) • Restructuring toxic self-representations In an earlier article (Wolfe, 1989), I outlined a treatment approach involving a sequence of four basic steps: 1. 2. 3. 4.

Establish the working alliance. Elicit phobogenic and panicogenic conflicts. Teach anxiety-management techniques. Resolve conflicts.

These four treatment stages simultaneously targeted phobic and panic symptoms as well as the phobogenic and panicogenic traumas and conflicts. With an increasing focus on issues of self-experiencing, I began to see how each of these treatment stages contributed to the repair of specific aspects of self-experiencing, both the contents of self-experiencing (e.g., immediate senses of self and self-representations) and the processes of self-experiencing (attentional focus, emotional processing, and defensive interruptions).

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ESTABLISHING THE THERAPEUTIC ALLIANCE AND REPAIRING TRUST

Phobic and panic patients often begin therapy quite distrustful of both the therapist and themselves. The personal and interpersonal dynamics of trusting have their source in the close relationship between how one is treated by others and how one sees oneself (Guidano, 1991). If the actions and communications of others toward us suggest that we are not trustworthy, or if our general experience with others is that they are not trustworthy, then the task of coming to trust ourselves is made all the more difficult. So repairing the patients' ability to trust another contributes to their ability to trust themselves. The source of distrust in both cases is often childhood interpersonal traumas inflicted by caretakers. The evolution of trust, therefore, is a difficult process for phobic and panic patients. Consequently, trust is usually the first issue that is negotiated in therapy, either as an explicit or a tacit issue. A frequently occurring phobogenic conflict in agoraphobic patients, for example, involves the bipolar dimension of freedom versus security. Each pole possesses both a positive and a negative valence. Freedom connotes autonomy and isolation; security connotes being cared for and being controlled. With such patients, therapists will be called upon to pass very specific tests of trustworthiness (Friedman, 1985; Weiss & Sampson, 1986). Can therapists care for without controlling agoraphobic patients? By the same token, can therapists allow patients to function autonomously without abandoning them? Unless the therapists pass such tests, agoraphobic patients cannot make use of any of the specific therapeutic techniques, including imaginal or in vivo exposure. The first therapeutic task then is for therapists to establish their trustworthiness, and for patients to acknowledge to themselves this trustworthiness. To the extent that the therapist is being trustworthy, he or she is providing the patient with important information to be assimilated. But because of past disillusionments and resultant fears of disappointment, the patient may find it difficult to acknowledge the therapist's care and concern. Part of the alliance-building phase of therapy will include identifying the various ways the patient defensively interrupts his or her sentient experiencing of the therapist's trustworthiness. As these defenses are identified and found to be inapplicable in the present context, the patient may begin to experience sentiently the therapist's trustworthiness. The resurrection of sentient experiencing will begin to lead to a corrective emotional experience regarding the dependability of a significant other. The sentient experiencing of the therapist's trustworthiness indirectly contributes to the rebuilding of the patient's sense of self-efficacy. With the therapist as ally, the patient feels more confident of his or her ability to face

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the phobic object or situation, and to endure the automatically occurring anxiety.

ELICITING THE TACIT CATASTROPHIC IMAGERY

When some modicum of trust has been established by the therapist and acknowledged by the patient, we are ready to move to the next stage of treatment. In the case of phobics, this entails imaginal exposure to the feared object. In the case of panic patients, it involves a strict attentional focus (i.e., interoceptive exposure) on the bodily sites of fearful sensations. In both instances, the procedure begins the same way, with a breathinginduction exercise. This induction procedure helps the patient tune out competing stimuli from the external environment, allowing him or her to focus attention inwardly. The patient is then invited to be receptive to his or her internal productions, that is, to any thoughts, feelings, images, or ideas that arise automatically. In the case of phobias, the patient is asked to imagine the feared object or situation, and while intensively focusing attention on the phobic scene, to notice any automatically arising feeling or thought. In the case of panic disorders, the patient is asked to identify the most prominent bodily sites of anxiety or fearful body sensations and to maintain a strict attentional focus on these sites. Typically, within one or two sessions,* this procedure results in the appearance of several thematically related and emotionally laden images. The imagery is imbued with themes of conflict and catastrophe that the patient is helpless to prevent or terminate. One interesting feature of applying this procedure with panic-disorder patients is that whereas, consciously, their fears are about physical destruction, the tacit catastrophic imagery is most often about psychological destruction. The goals of this version of imaginal exposure depart somewhat from those of the more behavioral version. The experience of anxiety is not only for the purpose of learning that the feared disaster will not take place or that the anxiety will habituate, but also for the patient to uncover the felt catastrophe and to experience the associated feelings. Imaginal and interoceptive exposure have the potential to benefit all of the various senses of self; redress the imbalance between reflexive and sentient self-experiencing; enhance the processing of painful emotions; identify the tacit, negative self-representations; and elicit the various ways in which patients defensively interrupt their immediate experiencing. By staying focused on the body site of anxiety until the conscious emotional *H usually takes longer with panic-disorder patients because they have great difficulty contacting emotionally laden imagery. Despite this, however, the procedure is almost uniformly successful in eliciting the panicogenic, catastrophic imagery.

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processing begins, panic-disorder patients experience several positive senses of self: they learn that they do not fall apart (coherence), are not destroyed (continuity), can tolerate negative affects (coherence and agency), and can master their fear and expand their behavioral horizons (agency). Once they begin to experience the various dysphoric emotions, we can identify the toxic self-representations that need to be modified as well as the conflicts that need to be resolved. A content analysis of the modal conflicts of phobic and panic patients tempts me to offer the following generalization: in the broadest sense, the issues of conflict are existential. By that I mean that the conflicts involve confrontations with difficult, unavoidable human realities. While the conflicts were probably developed in the context of historical interpersonal traumas, then and now they relate to several realities that we all must face: the inevitability of loss; the experience of a separate consciousness; the yoke of personal responsibility; the ubiquity of anxiety; the struggle for self-esteem; the unavoidability during that struggle of experiencing selfdenigrating emotions such as humiliation, guilt, and shame; the awareness and acceptance of our mortality; the need to equilibrate our actions and our expressiveness in the face of sociocultural demands; and, finally, the need to engage in painful negotiations between the quest for freedom, autonomy, and novelty, on the one hand, and comfort, security, and safety, on the other (cf. Koerner & Linehan, 1992). TEACHING ANXIETY-MANAGEMENT TECHNIQUES

In addition to exploring the feelings that underlie anxiety, patients need a sense of increasing control over the anxiety when it begins to escalate. In other words, patients need to be taught ways to turn off the alarm switch, and to cope with their anxiety when they encounter the phobic object, or, in the case of panic patients, when they experience frightening body sensations. One effective technique now generally used for modulating the levels of anxiety is diaphragmatic breathing. Patients are taught this slow, deep-breathing procedure for use during in vivo exposure. Generally, it has been successful in bringing an immediate decrease in the level of anxiety. A second procedure attempts to deal with the catastrophic thinking that usually accompanies the experience of frightening body sensations. Didactic prompts are used to reassure patients that the anxiety they are experiencing, while unpleasant, will not lead to any life-threatening cardiovascular dysfunction, will not make them go crazy, and will eventually dissipate. Patients are told to reflect on recent experiences of anxiety or panic attacks to verify that these catastrophes do not usually take place.

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RESOLVING CONFLICTS

Once the tacit, catastrophic conflicts have been identified, a major focus in therapy concerns their resolution. Conflict resolution essentially involves the creation of a synthesis between incompatible aims. The steps in resolving conflict include (J) identifying the poles of the conflict, (2) employing the two-chair technique in order to heighten the experience of each pole, (3) beginning a dialogue between the two poles in an effort to create a synthesis, and (4) making a provisional decision to take specified steps toward change. Once a decision has been made regarding specific behavioral changes, the next step is to take action and allow sentient experience to inform the patients of the results of the change steps taken. Successful outcomes that result from these self-fashioned choices increase the likelihood of a change in dysfunctional self-representations. As the patients try to change, they will encounter the specific ways in which sentient experience is defensively interrupted, and additional work will be necessary to limit the impact of these defenses and thereby enhance sentient self-experiencing.

Other Treatment Modalities Since the generative context of phobic and panic disorders is frequently, if not always, interpersonal, it is often the case that interpersonally formatted therapies are quite helpful in the resolution of these disorders. Marital and family therapies often play a significant role in changing interpersonal patterns that have influenced the anxiety-disorder patients' war against their own sentient self-experiencing. Marital therapy, for example, is often the context in which new patterns of self-experience are forged. While the patterns of self-experiencing may have developed independent of their marriage, the marital relationship of panic patients often reinforces these patterns. Even in relatively untroubled marriages in which the panic/agoraphobic patient's spouse is quite supportive, the patient will often employ the spouse in the service of protecting him or her from painful feelings. Thus, for example, one patient would call her husband and ask him to leave work and come home whenever she began to feel bad. His arrival often did have the effect of reducing her anxiety or other dysphoric feelings, but it also allowed her to avoid confronting whatever issues were keeping her agoraphobic. In this instance, marital therapy was instrumental in helping the patient assume responsibility for "soothing" herself whenever she felt bad, and in helping the spouse to understand how his wellmeant supportiveness actually contributed to the maintenance of her problems, as well as the problems between them. Such a change was brought

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about by a gradual and systematic delineation of proper spheres of responsibility in the relationship, particularly in the area of feelings. Although I have never employed family therapy as a modality with panic patients, I believe it can also be useful in bringing about changes in patterns of self-experiencing.

Patient Assessment The assessment of phobias and panic disorder focuses on six key elements: (1) the nature of phobic and panic symptoms, (2) the intensity of the fear, (3) the extent of interference in the patient's life, (4) the underlying catastrophic events and conflicts (if any), (5) other physical and psychological problems, and (6) the degree of connection between the auxiliary problems and phobic or panic symptomatology. Assessment is carried out by means of an extensive clinical interview and an intensive imaginal exposure procedure. The clinical interview includes a close analysis of phobic and panic symptoms, fear intensity, and the degree of interference that the symptoms produce in the patient's life. The imaginal exposure procedure identifies any previous catastrophic situations or conflicts that relate to the source and meaning of the phobias, as well as the initial unexpected panic attacks. The clinical interview usually identifies issues of comorbidity or other auxiliary problems, while the imaginal exposure procedure often reveals the nature and degree of connection between the phobic symptoms and the auxiliary problems. It is important to obtain as detailed a description as possible of the precise nature of the phobic symptoms because of the frequent co-occurrence of such combinations of specific phobias (e.g., social phobia with agoraphobia, driving phobia with other travel phobias), and because a particular simple phobia may embed one or more other simple phobias. For example, Howard, Murphy, and Clark (1983) found that a fear of flying may represent a fear of heights, a fear of being trapped, or a fear of having a panic attack, among others. Even when one has determined the specific conscious fears associated with a particular phobia, imaginal exposure will shed light on the source and meaning of tacit fears that may discriminate between people who putatively suffer from the same phobia. For example, I recently treated three driving phobics who turned out to have quite different tacit fears. One fit a straight trauma-induced conditioning model, in that she had been in a serious accident and began avoiding driving. A second patient initially had a panic attack while driving and subsequently avoided driving in an effort to control against the possibility of having another panic attack. The tacit fear, however, turned out to be the patient's dread of assuming

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responsibility for his own life. A third patient was terrified of driving because she tacitly feared she would never return to a husband she did not love but was not ready to leave. I will be describing these three cases in more detail shortly. The imaginal and interoceptive exposure procedures have been particularly useful in eliciting the content of the catastrophic material associated with the phobic object, or the bodily sensations associated with panic attacks. Typically, these exposure procedures result in the appearance of catastrophic imagery and the experience of intense, painful emotions. For example, a bridge phobic imagined that he threw himself over the bridge. As we explored this image, he began to experience intense despair about his life and his future prospects.

Applicability and Structure As the title of the chapter suggests, this developing integrative treatment is most relevant for patients suffering from anxiety disorders. My clinical experience, however, suggests that many aspects of this approach are relevant for patients suffering from mood disorders, somatoform disorders, and milder forms of certain personality disorders (e.g., dependent, avoidant, and obsessive). It is much less relevant for—or at least much less successful with—borderline and narcissistic personality disorders, which might best benefit from other integrative approaches (e.g., Koerner & Linehan, 1992). In general, this approach seems most relevant with those disorders for which the inhibition of emotional processing and sentient experiencing play a central role in their acquisition and maintenance. In certain mood disorders, for instance, patients have become fixated in self-denigrating, reflexive self-experiencing that leaves them feeling futile and hopeless regarding their abilities to change their lives for the better. The difficulties they encounter with regaining access to their sentient experiencing leaves a number of painful emotions unprocessed, such as sadness, anger, and disappointment.

Mechanisms of Change Psychotherapy researchers by and large have concluded that the debate about whether insight or behavior change is the fundamental mechanism of therapeutic change is a sterile one. Insight without behavior change often results in a new way of talking about one's problems, but behavior

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change without a change in the individual's "central processing unit" (i.e., cognitions, emotional processing, attitude, or perspective) is not likely to endure. Each mechanism, however, seems to point to a particular truth about change. Behavior change implies a proactive engagement with the world in which one makes a decision to act, implements that decision, and experiences the consequences of that decision. Whatever else is included in a concept of therapeutic change, the element of behavior change as proactive engagement seems to be a necessary one (also see Wachtel & McKinney, 1992). The concept of insight, however, points to the necessity of change in the way we perceive, think, and feel about the world and ourselves; thus, insight implies some kind of cognitive-emotional change in the way we construe self and world. What has been sundered by the polemics between psychoanalysts and behavior therapists needs to be (re)integrated. An integrative concept of change, therefore, must encompass both behavior change and "deep structure" change (cf. Wachtel & McKinney, 1992). Change in this model is construed as an oscillative process between engagement with the world and the articulation of emotional experience resulting from that engagement. Change results from the emotional processing of experiential contact with the world. This is the cardinal element in sentient self-experiencing, which involves both contact with the world and the emotional processing of information received from such contact. The phobic patients who can remain anxious when confronting the feared situation will thus eventually begin to experience disavowed emotions connected to past catastrophic situations. When patients can do this, they come to see that they are actually not being threatened in the present. Once the discrimination can be made between past catastrophe and present situation, phobic patients eventually come to experience a sense of safety in the feared situation. Change in the short run is brought about by the restoration of sentient self-experiencing during which the individual begins to have inthe-moment change experiences (i.e., doing, thinking, or feeling things differently). The key question is how short-term changes become longterm, deep structural changes. To this question I can only offer some speculations. It seems to me that one critical element is to identify and modify the defenses that interrupt the pathway of sentient experience to self-concept. Once the pathway is cleared, new experiences can begin to build new "self-structures" on top of the old; that is, new conceptualizations of the self begin to take shape. These new structures supersede, but never replace, the old. This explains why in times of stress and selfendangerment, we switch from the new ways of functioning and selfperception back to the old ways. This view, of course, is nothing more than a cognitive-experiential conception of regression.

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CHANGE IN THE ANXIETY DISORDERS

These general considerations of therapeutic change can be applied to the anxiety disorders. Early childhood traumas (Bowlby, 1988) seem to be particularly implicated in the development of anxiety disorders. Typically, the type of trauma and the ways in which the child attempts to cope with them are major influences in the kind of anxiety disorder that develops. These traumas mark particular situations, objects, or even bodily sensations as "contexts of fear." Whenever anxiety patients encounter one of these fear contexts, they will automatically feed-forward the early trauma onto present reality. Usually, only somatic traces of the original fear reactions are fed forward whenever the fear context is encountered. These fear reactions now have become contemporaneous indications of a pending catastrophe. In other words, the patient acts as if the early trauma is happening—or is about to happen—again. A self-protective defensive sequence emerges that includes shutting down sentient experiencing, shifting attention to reflexive self-experiencing (i.e., emotional avoidance), which in turn leads to behavioral avoidance of the fear contexts. To effect change in an anxiety disorder, then, sentient experiencing must be restored. The restoration of sentient self-experiencing involves experiencing the anxiety while still in the fear context long enough for the stalled emotional processing system to restart. Emotion-laden imagery relating to earlier trauma situations will typically emerge, which informs patients that their fear or panic does not in fact relate to the present encounter with the phobic object or situation. Patients can then begin to discriminate present reality from past trauma. This discrimination will allow the patients to identify and work through the dangers encompassed in these self-endangerment experiences. In turn, the patients eventually are able to enter the feared situations they previously avoided.

CHANGE IN THE TREATMENT OF SPECIFIC PHOBIAS

The restoration of sentient experiencing in the treatment of specific phobias is brought about by means of in vivo exposure. By having patients enter the phobic situation directly, the above-mentioned discrimination takes place between present reality and past trauma, and the phobic object comes to be seen for what it really is, a signal of extreme emotional pain. In addition, by staying in the present sentient experience of the phobic object or situation, patients provide themselves with new information about their ability to cope with frightening situations and sensations. This, in turn, begins to influence their sense of self-agency or self-efficacy (Bandura, 1977).

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It is possible to achieve substantial, short-term improvements in a phobia by means of exposure therapy alone, but it is sufficient only for the least complicated of phobias. If, however, the phobia is connected to core issues of self-experiencing, involving tacit catastrophic conflicts, then exposure therapy usually does not suffice. Supplementing in vivo exposure is imaginal exposure. In the treatment of phobias, imaginal exposure tends to have a slightly different purpose than in vivo exposure, namely, to stimulate the further articulation of felt meaning with respect to the phobic object. The sentient selfexperiencing process has been interrupted by an actual trauma or a feared catastrophe. The articulation of felt meanings associated with the phobic object provides additional experiential information about the personal meaning of the fear context. It is not so much that old information is replaced by new, but something more is learned about the experience associated with the phobic object. CHANGE IN THE TREATMENT OF PANIC DISORDER

In panic disorder, where the fear context is frightening body sensations rather than an external object or situation, sentient experiencing is restored by means of interoceptive exposure. The rigid attentional focus on these frightening sensations and an openness to the spontaneous imagery that emerges in my version of this behavioral treatment, typically result in the patient beginning to experience painful emotions associated with earlier traumas. By staying focused on the body site of anxiety until the conscious emotional processing begins, panic-disorder patients begin to learn a variety of things about themselves. These patients thus come to understand the self-protective significance of anxiety, as well as what the anxiety is protecting them from. The recovered painful emotions that are eventually experienced through interoceptive exposure point to the areas of sentient and reflexive selfexperience that require repair. Often there are toxic self-representations that have been internalized as a result of an accumulation of painful-totraumatic encounters with primary caretakers or other significant people in the patient's earlier life. At the same time, the patient requires work on coping with the panicky sensations themselves. Here the mechanism of change involves the way in which the individual construes the meaning of these sensations. Panic challenges (Barlow, 1988) are used to simulate panicking sensations, and a variety of cognitive and breathing retraining methods are employed to help the patient reduce the anxiety and recognize that these sensations do not mean that a catastrophe is imminent.

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THERAPEUTIC RESISTANCE

The process of therapeutic change rarely runs as smoothly as may be implied by the above description. The dynamics of change appear to be characterized by oscillations between old and new patterns of functioning, between expansions and contractions in self-experiencing (Mahoney, 1991). From the point of view of the subjective experience of the patient, any change will be experienced initially as dissonance relative to the individual's current level of self-organization. Accordingly, change tends to be resisted, not because of pathology, but rather because of, as Mahoney (1991) puts it, "individuals' healthy caution about embarking upon or embracing experiences that challenge their integrity, coherence, or (felt) viability as a living system" (p. 329). Resistance to change, therefore, is viewed as a precondition to change. The therapist attempts to work toward identifying the sources of resistance and endeavors to help patients understand its necessary functions. The patients need to accept that they will resist change as much as they need to accept other aspects of their current functioning (i.e., feelings and appraisals). The acceptance of "who they are" at the moment is an enabling condition of change. In-the-moment self-acceptance allows people to focus attention on their sentient self-experience. And it is sentient self-experiencing that provides the necessary information for human change. For panic and phobic patients, resistance to change is manifested by avoidance of situations and feelings that appear to threaten the viability of self-experience. Whenever patients try to enter a particular context of fear, they experience the growing presentiment of self-annihilation. Therapist empathy and patient acceptance of this experience are necessary prerequisites of change.

Case Examples In order to illustrate the variety and complexity of phobic and panic disorders that may be dealt with using this integrative approach, I will present three brief case vignettes of patients, all of whom suffer from a "driving phobia." Although all three patients exhibit great fear when confronted with the prospect of driving an automobile, they came by their phobia in somewhat different ways, construe the meaning of driving differently, and fear different catastrophes associated with driving. The first vignette concerns a circumscribed driving phobia that developed as a result of an automobile crash. The second patient's phobia was driven by a tacit catastrophic conflict of which she was initially unaware. The third devel-

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oped as a result of a panic attack in conjunction with an emerging panic disorder.

A SIMPLE DRIVING PHOBIA

An 18-year-old young woman was driving on a narrow two-lane road on a rainy fall day when she was broad-sided by a man who, thinking the way was clear, made an inappropriate left turn into my patient's car. Right after the crash, the man who hit her got out of the car and began screaming at her at the top of his lungs that the accident was her fault. As a result, she avoided driving from that point onward. She stated that she had lost confidence in her driving and was afraid that she might involve herself in another accident. A detailed clinical interview yielded no other phobias nor any clue that this phobia was connected to any broader areas of psychopathology. We began treatment with imaginal exposure to probe for any tacit catastrophic conflicts. Finding none, we then planned a very gradual in vivo exposure treatment that began with her driving one block. Once she became comfortable with a drive of that distance, she was to increase her driving by a block each time. The therapy was carried out mostly as homework, since she was able to enlist the aid of her mother and her boyfriend. In the course of two months, she was able to drive up to five miles. Within six months, her driving was unrestricted. In this case of an uncomplicated, specific phobia, in vivo exposure was sufficient for its resolution. It is important to note, however, that treatment began about a month after, rather than years after, the phobia's inception, which, in part, may explain why the phobia so easily yielded to exposure therapy. The next case of driving phobia will show that because it was more complicated, exposure therapy needed to be supplemented.

A COMPLICATED DRIVING PHOBIA

A 30-year-old married woman presented with a driving phobia of several years duration. Although she was able to drive to my office, she could only come by a certain route, and her driving was always accompanied by severe anxiety. A clinical interview indicated that she had been suffering from symptoms of anxiety and depression for many years. She appeared to be quite unhappy in her marriage. She was withdrawn emotionally and appeared to be putting severe controls on her emotional experience and expression. Since her husband had similar difficulties with his emotions, they always found it difficult to establish any kind of intimate connection with one another. By the same token, she yearned for that

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emotional connection and would get frustrated when he could not meet her emotional needs. During the first two sessions of treatment, I was able to establish rapport with her, which allowed her to be more open with me. During the third session we began imaginal exposure. I had her imagine leaving her house, getting into her car, and driving to my office. As she imagined herself beginning to drive away from her house, she became extremely anxious and had to stop the imagery. !t was a session or two later before we discovered what was making her so anxious. During the guided imagery, she was able to pursue the scene, although it made her extremely anxious. She saw herself driving to another city and never returning to her husband and child. She felt a great sense of liberation and relief during this image, which segued into terror, because she would be all alone. The thought of having to carry on in her life alone was terrifying. The thought of remaining in what was for her a loveless marriage plummeted her into despair. After this tacit, catastrophic conflict clearly emerged, treatment began to focus simultaneously on the driving phobia and on resolving the conflict. For the driving phobia, we implemented a gradual in vivo exposure program in which she drove increasingly longer distances from home. In addition, she continued in individual, exploratory psychotherapy in order to confront and resolve her conflict between remaining in the marriage and carrying on her life alone. Once the conflict was out in the open, she had to grapple with the options available to her, as well as the painful emotions associated with those options. After a number of sessions of individual psychotherapy, we also began marital therapy in the hopes of solving some basic problems in the marriage, which would allow her to recommit to it or, if she could not, to plan to move her life in another direction. After 15 sessions of marital therapy, it became clear to her that she wanted to leave the marriage. During the individual therapy, we explored her feelings about being alone, and worked on preparing her to pursue a new life. In the meantime, the gradual exposure therapy had helped her to increase the distance that she could comfortably drive. She even began to experiment with different routes, so that by the time therapy terminated, her driving anxiety was minimal. All was not light, however; an alliance rupture developed when she discovered that I could not respond to all of her emotional needs. Therapy terminated prematurely. I spoke with her a year later. She had left the marriage. She was finding living alone difficult but preferable to remaining in her marriage. The driving anxiety was reduced, but not completely eradicated.

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A DRIVING PHOBIA RESULTING FROM PANIC ATTACKS

A 35-year-old graduate student presented with a severe driving phobia that left him entirely dependent on others for transportation. Unlike the above two cases, this patient's driving phobia began after a major panic attack. The panic attack occurred while he was driving with his wife and she informed him that their marriage was over. Since that time, he had been unable to drive at all. This situation was in ironic contrast to an earlier period in his life when, as a young man, he would drive 25 miles every day to visit a girlfriend who lived in a neighboring town. A clinical history revealed that this was not his first panic attack. The first attack was traceable to his childhood, when he was left alone by his parents at the age of 8, completely responsible for two younger siblings (ages 6 and 2). His mother had accompanied his alcoholic father during one of his drinking binges at a local bar. The attack came when my patient called his parents at the bar and his urgent pleas for their return were ignored. This was one of many traumatic family events that impeded the development of his sense of self-agency. Thus my patient had experienced a life-long difficulty in assuming responsibility for his life, always searching for someone to take care of him. His relationships with women had been characterized by this pattern. When the burden would become too heavy for the woman, she would leave and another crisis would loom for my patient over issues of self-agency. Treatment began with imaginal exposure involving his driving alone as far from home as possible. This scene quickly revealed tacit, catastrophic imagery involving the conflict that so many agoraphobic patients experience—between freedom and isolation, on the one hand, and security and being controlled, on the other. Interestingly, while he experienced great fear as he drove miles away from home, he also became aware of great anger, particularly at his mother for her previous neglect. At one point, he had an insight that his phobia might be related to an effort to make her responsible for his well-being in his adulthood, since she neglected that responsibility in his childhood. In terms of this patient's self-experiencing, his panic attacks would result in two separate but interrelated outcomes: (a) the manifestation of a specific phobia, usually connected to some aspect of the situation in which the panic attack occurred; and (b) a collapse in self-confidence regarding issues of self-agency. An in vivo exposure program was planned to deal with the specific phobic symptoms, and an exploratory, experientially oriented therapy was begun to resolve the conflicts surrounding issues of self-agency. We began with his driving only a block at a time. We quickly

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progressed up to a half a mile, at which point the anxiety began to increase dramatically. Probably the most troubling manifestation of his anxiety was that his breathing was affected. He felt as if he could not catch his breath. He would become light-headed, shift his attention to reflexively noticing that he was having these symptoms, and become extremely fearful that he would lose control of the car. There were four coping procedures that I tried to teach him to implement while driving: (1) diaphragmatic breathing, (2) avoiding catastrophic thinking, (3) training his attention to remain in sentient awareness rather than reflexive awareness, and (4) separating the source of anxiety from the experience of driving the car. By these means, he was able to travel up to eight miles away from home before he would become extremely anxious. At one point during the in vivo exposure therapy, he had driven for five miles, reflexively noticed that he was free of anxiety, and subsequently became very anxious. This experience, which occurred more than once, suggested the idea that his anxiety protected him from assuming too much responsibility for his life too quickly, an issue that we addressed at length in the exploratory phase of his therapy. In sum, the in vivo exposure produced significant progress in his ability to drive short distances by himself, without, however, completely resolving his phobia. Interestingly, the distance that he could drive at any one time was almost perfectly correlated with what was going on in the rest of his life. Any reverses that he experienced with respect to getting a job, or finding his own living space, or reentering graduate school, led to a corresponding reduction of the distance that he could drive. By the same token, any positive increase in self-agency that he experienced in his life led to an increase in the distance that he could drive. The exploratory therapy actually had two different foci: (a) exploring his feelings and (b) making and implementing plans to move his life in self-chosen directions. During the exploration phase, we focused on his fear of processing a variety of felt meanings, including his family's treatment of him, his conflicts about assuming responsibility for his life, his fear of being isolated, rootless, alone, or confined. It was also difficult for him to experience and express his anger toward the significant people in his life, which inevitably changed into unexpressed (and often unacknowledged) resentment. As he began to experience some of these feelings, he could no longer avoid facing his basic life conflict, which involved his making other people responsible for his life while, at the same time, resisting all efforts by others to take control of his life. It was an astonishing and painful revelation to him when he finally faced the fact that his life was up to him, and that while he was free to make his choices, he had to live by the consequences of those choices. It also became increasingly clear to him that besides the reality of his driving phobia, this problem carried much symbolic freight about his

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feeling rootless and unsure of the directions in which he should "drive to" in his life. As he gradually began to accept responsibility for his life (which occurred only after great resistance), he began to focus on five areas of his life in which he experienced deficiencies: (1) obtaining his own living space, (2) finding a suitable job, (3) making and implementing a decision about returning to graduate school for his Ph.D., (4) enhancing his moribund social life, and (5) communicating his feelings to the people in his life. To achieve each of these aims, I employed a combination of behavioral and cognitive-experiential procedures. During the early phases of therapy, he was living with his mother and step-father in an exurb of Washington, D.C. While this arrangement provided the security that he sought, it also increased his sense of isolation and dependency on his parents for transportation. An explicit strategy was devised for him to seek an apartment in the city where he also contemplated attending graduate school and where he was more likely to find employment in his chosen area of interest. He was successful in achieving each aim, and with each success, his driving anxiety eased. And with each success, I had him focus his attention on the sentient experiencing of his feelings that arose as he succeeded, as a way of "anchoring" the experience of each discrete success. But there were setbacks. For example, the first job did not work out. This setback was accompanied by increased difficulty in driving. It was actually quite remarkable how the vicissitudes of the driving phobia paralleled the vicissitudes in his life. As he pursued his self-chosen aims in life, I encouraged him to experience whatever in-the-moment feelings arose and to use these experiential data as part of the information he needed to make future decisions. In this way, my patient was able to restore the balance between sentient and reflexive self-experiencing. Currently, he is finishing his Ph.D. at an out-of-town university. He is happy with his new life, and his driving is much less restricted. I cannot say, however, that he is completely "cured" of his driving phobia, but the progress he made both in alleviating the restrictions of his phobia and in resolving the conflicts in his life was substantial.

Current Research and Future Directions Since this model of psychotherapy integration has not yet been subjected to empirical research, the key future direction for this approach is to find ways to subject it to empirical investigation. It must be said at the outset, however, that there are certain features of the model that present great

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difficulties for the researcher. As I have tried to show, self-experiencing, both in its sentient and reflexive modes, is the critical process that is altered by the formative events leading to the development of panic and phobic disorders, and is, therefore, the critical focus of therapeutic change. The existing research literature (from various subdisciplines in psychology) on self-schemas and self-representations has contributed—and will continue to contribute—much to the development of this model (e.g., Markus & Wurf, 1987; Segal & Kendall, 1990). But research on sentient experiencing is a bit more challenging. Sentient experiencing revives a very old dilemma for psychotherapy research, the dilemma of trying to be objective and systematic about subjective experience. For the therapist/researcher, the experience of one's own subjectivity is a reality as palpable to us as persons as it is invisible to us as scientists. As researchers, we are painfully aware of the measurement difficulties presented by any conception of the subjective self. As therapists, however, we are also keenly aware that a patient's subjective experience, and his or her struggle with it, is integrally involved in the formation, maintenance, and alleviation of mental, emotional, and behavioral disorders. The evolving cognitive perspectives attempt, to some degree, to capture certain aspects of the experiencing self, but their efforts have focused mainly on what is available to us in reflexive awareness, namely our self-representations (Segal & Kendall, 1990). The literature on the Experiencing Scale (Klein, Mathieu, Gendlin, & Kiesler, 1970) is quite germane and is based on a conception of the process of experiencing that bears many similarities to the conception presented here. The Experiencing Scale, however, rarely, if ever, has been applied to research on the anxiety disorders (see Borkovec et al., 1991, for a rare exception). A significant future direction, therefore, is to develop measures for assessing various aspects of sentient experiencing. A major impediment to therapeutic change involves the various ways in which an individual interrupts sentient experiencing in an effort to defend against the acknowledgment of painful or self-threatening information. There appear to be three primary sites where sentient awareness can be interrupted: (1) awareness of emerging thoughts, feelings, and motives that are painful to the self; (2) expressive action, either its implementation or its implications; and (3) processing the self-relevant meanings of information coming from external sources, such as the communications and actions of others. Thus, in addition to measures of sentient self-experiencing, measures need to be developed for assessing various types of defensive interruption of sentient self-experiencing. A third research need is to develop a reliable measure of the tacit catastrophic imagery elicited by imaginal and interoceptive exposure. Im-

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agery as a focus of scientific investigation has continued its return from ostracism documented by Holt (1964) over a quarter of a century ago. It is now imperative to investigate imaginal processes and their relationship to felt meanings in the context of treatment intervention studies. A final research need is to systematically evaluate the efficacy of the integrative treatment package with specific phobic and panic-disorder patient groups. The standardization of this treatment package presents some formidable difficulties, however, because substantial flexibility is required in the choice and timing of the operations employed in the individual case. Similar concerns have been expressed by Lazarus; Beitman; and Prochaska and DiClemente; all 1992); individually tailoring treatments to unique clients compounds uniform standardization of "the treatment." I have tried to present the guiding principles of this approach, as well as the modal sequence of operations that typically evolves in treatment. But much work is needed in terms of further specification of appropriate sequences of treatment operations. Clinically, I hope to extend the scope of this integrative model to other disorders (e.g., mood disorders) in order to determine (1) if similar cognitive-affective processes operate in the acquisition and maintenance of these disorders (see Arkowitz, this volume), and (2) whether this integrative treatment will be effective in changing more than just the manifest symptoms of these disorders. A second priority is to attempt to develop effective procedures for the more intractable cases of anxiety disorders. Some people are so frightened of their feelings, or so convinced of the veracity of their catastrophic ideas, that it is difficult for them to experience any anxiety or engage in any conscious processing of sentient experience. Exposure therapy has been too frightening for them to continue. Third, I would like to gain a better understanding of the reciprocal dynamics between the two forms of self-awareness. Finally, I hope to continue to develop procedures to help patients revive their stalled emotional processing and integrate this source of information with others obtained from a more reflexive consciousness.

References BANDURA, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84, 191—215. BARLOW, D. H. (1988). Anxiety and its disorders. New York: Guilford. BARLOW, D. H., & WOLFE, B. E. (1981). Behavioral approaches to anxiety disorders: Report on NIMH-SUNY, Albany, Research Conference. Journal of Consulting and Clinical Psychology, 49, 448—454. BEITMAN, B. D. (1992). Integration through fundamental similarities and useful

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differences among schools. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. BORKOVEC, T.D., HOPKINS, M., LYONFIELDS, J., LYTEL, R., POSA, S., ROEMER, L, & SHADICK, R. (1991), Efficacy of non-directive therapy, applied relaxation, and combined cognitive-behavior therapy for generalized anxiety disorder. Paper presented at the annual meeting of the Association for the Advancement of Behavior Therapy, New York. BOWLBY, J. (1988). Developmental psychiatry comes of age. American Journal of Psychiatry, U5, 1-10. DUVAL, S., & WICKLUND, R. A. (1972). A theory of objective self-awareness. New York: Academic Press. FEATHER, B. W., & RHOADS, J. M. (1972a). Psychodynamic behavior therapy: 1. Theory and rationale. In J. Marmor & S. M. Woods (Eds.), The interface between the psychodynamic and behavioral therapies (pp. 293—309). New York: Plenum. FEATHER, B. W., & RHOADS, J. M. (1972b). Psychodynamic behavior therapy: 2. Clinical aspects. In J. Marmor & S. M. Woods (Eds.), The interface between the psychodynamic and behavioral therapies (pp. 313-330). New York: Plenum. FREUD, A. (1946). The ego and the mechanisms of defence. New York: International Universities Press. FREUD, S. (1926). Inhibitions, symptoms, and anxiety. In Standard edition (Vol. 20, pp. 87-172). London: Hogarth. FRIEDMAN, S. (1985). Implications of object-relations theory for the behavioral treatment of agoraphobia. American Journal of Psychotherapy, 34, 525—540. GENDLIN, E. T. (1962). Experiencing and the creation of meaning. New York: Free Press. GOLDSTEIN, A. J. (1982). Agoraphobia: Treatment successes, treatment failures, and theoretical implications. In D. L. Chambless, & A. J. Goldstein (Eds.), Agoraphobia: Multiple perspectives on theory and treatment (pp. 183-213). New York: Wiley. GOLDSTEIN, A. J., & CHAMBLESS, D. L. (1978). A reanalysis of agoraphobia. Behavior Therapy, 9, 47-59. GREENBERG, L. S. (1979). Resolving splits: Use of the two-chair technique. Psychotherapy: Theory, Research and Practice, Id, 310—318. GUIDANO, V. F. (1991). The self in process. Toward a post-rationalist cognitive therapy. New York: Guilford. HOLT, R. R. (1964). Imagery: The return of the ostracized. American Psychologist, 12, 254-264. HOWARD, W. A., MURPHY, S. M., & CLARKE, J. C. (1983). The nature and treatment of fear of flying: A controlled investigation. Behavior Therapy, 14, 557-567. INGRAM, R. E. (1990). Self-focused attention in clinical disorders: Review and a conceptual model. Psychological Bulletin, 707, 156—176. KLEIN, M. H., MATHIEU, P. L., GENDLIN, E. T.. & KIESLER, D. J. (1970). The

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Experiencing Scale-. A research and training manual. Madison: Wisconsin Psychiatric Institute, Bureau of Audio Visual Instruction. KOERNER, K., & LINEMAN, M. (1992). Integrative therapy for borderline personality disorder: Dialectical behavior therapy. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. LAZARUS, A. A. (1992). Multimodal therapy: Technical eclecticism with minimal integration. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. MAHONEY, M. J. (1991). Human change processes: The scientific foundations of psychotherapy. New York: Basic Books. MARKUS, H., & WURF, E. (1987). The dynamic self concept: A social psychological perspective. Annual Review of Psychology, 38, 299—337. PROCHASKA, J. O., & DIC.LEMENTE, C. C. (1992). The transtheoretical approach. In J. C. Norcross and M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. REISS, S. (1987). Theoretical perspectives on the fear of anxiety. Clinical Psychology Review, 7, 585—596. RICE, L. N., & GREENBERG, L. S. (1984). Patterns of change: Intensive analysis of psychotherapeutic process. New York: Guilford. SEGAL, Z. V., & KENDALL, P. C. (1990). Self-processes and emotional disorders. Cognitive Therapy and Research, 14, 111—112. STAMPFL, T. G., & LEVIS, D. J. (1967). Essentials of implosive therapy. Journal of Abnormal Psychology, 72, 496-503. WACHTEL, P. L., & McKiNNEY, M. K. (1992). Cyclical psychodynamics and integrative psychodynamic therapy. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. WEISS, J., & SAMPSON, H. (1986). The psycho-analytic process. New York: Guilford. WEITZMAN, B. (1967). Behavior therapy and psychotherapy. Psychological Review, 74, 300-317. WOLFE, B. E. (1989). Phobias, panic and psychotherapy integration. Journal of Integrative and Eclectic Psychotherapy, 8, 264—276. WOLFE, B. E. (in press). Self-experiencing and the integrative treatment of the anxiety disorders. Journal of Psychotherapy Integration.

CHAPTER 12

A Common Factors Therapy for Depression HAL ARKOWITZ

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'EVERAL LINES OF EVIDENCE suggest that the comparable effectiveness of different psychotherapies for depression may be due to the factors that they share in common, rather than to those that distinguish them. In this chapter, I review this evidence and propose that these common factors can be fruitfully conceptualized as the provision of social support to people whose problems are related to inadequate social support. Finally, I describe a common factors therapy for depression based on providing social support to depressed individuals through the therapistclient relationship. One goal of this chapter is to raise questions for both the psychotherapist who treats depressed clients and the researcher who studies psychotherapy for depression. My question to the psychotherapist is: To what degree is your therapy with depressed clients effective because of your specific therapy techniques, or because you provide social and emotional support to people who are lacking such support in their daily lives? Perhaps the complex therapy techniques and strategies that we work so hard to implement in therapy and to teach our students may not be what primarily help depressed clients. Perhaps we just think these are the most effective elements of our therapy. The evidence that I review suggests the possibility that our specific techniques may contribute surprisingly little to the outcome of psychotherapy for depression. Instead, it appears that the The author thanks James McClelland for his assistance with the library research for this chapter, and Carol Capelli, Marvin Goldfried, and John Norcross for their helpful comments on an earlier draft.

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therapy relationship may provide depressed persons with social and emotional support, and that the improvement we see in our depressed clients may be largely due to this rather than to our specific techniques and strategies. My related question to the psychotherapy researcher is: Do we have any convincing evidence that specific therapy techniques add anything to the outcome of psychotherapy with depressed persons over and above control conditions that primarily provide social and emotional support? The evidence that I present suggests that such control conditions are as effective as specific therapies. Based on these studies, I suggest that in future depression outcome research, any specific therapy must prove itself against a common factors therapy based on social support, such as the one I propose in this chapter. If claims are made that a particular therapy is uniquely effective for depression, the implication is that it contains elements over and above those that all therapies share in common. The burden of proof is on the particular therapy to demonstrate that it can improve upon the outcomes that can be achieved by a common factors therapy. Only when we have such demonstrations can we seriously entertain the possibility that the specific therapy has some "active" ingredients beyond those contained by all or most other therapies for depression. In addition, I outline a therapy for depressed clients based primarily on providing them with social and emotional support, with minimal use of establishing therapy techniques. I offer this therapy to both the psychotherapist and the researcher and challenge them both with the question: Can you top this?

Rationale for a Common Factors Therapy for Depression There are several lines of evidence that point to the possibility of common factors as the effective elements in the treatment of depression. These include the lack of differential effectiveness of different therapies for depression; the surprising effectiveness of so-called attention-placebo control conditions in the treatment of depression; research demonstrating that depressed people are low in social support, which predicts the onset of a depressive episode; and the importance of the relationship in psychotherapy in general, and for depression in particular, as a potentially important source of social support. It is to these areas that I now turn. LACK OF DIFFERENTIAL EFFECTIVENESS OF VARIOUS THERAPIES

In the last decade, psychotherapy researchers have made tremendous progress in demonstrating the effectiveness of different psychotherapies

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for a variety of disorders in well-designed outcome studies (e.g., Elkin et al., 1989; Lambert, Shapiro, & Bergin, 1986; Sloane, Staples, Cristol, Yorkston, & Whipple, 1975: Smith, Glass, & Miller, 1980). We can now say with some confidence that many of the therapies that have been empirically studied produce changes that are significantly greater than those due only to the passage of time or the reactive effects of assessment. But when specific therapies are compared to one another, the conclusions are less clear. While psychotherapy is indeed more effective than no treatment, we do not yet have any strong evidence that any one therapy is consistently more effective than any other. In 1986 Lambert, Shapiro, and Bergin published their comprehensive review of outcome research in psychotherapy with adults experiencing a wide range of disorders. They concluded that "research carried out with the intent of contrasting two or more bona fide treatments shows surprisingly small differences between the outcomes for clients who undergo a treatment that is fully intended to be therapeutic" (p. 167). The question of whether all therapies are equally effective for all disorders continues to be debated in the field of psychotherapy (Beutler, 1991; Beutler, Mohr, Grawe, Engle, & MacDonald, 1991; Stiles, Shapiro, & Elliott, 1986). When we examine the evidence relating to this issue specifically for the treatment of depression, the data are even clearer. A number of well-controlled studies and meta-analyses point to the conclusion that the different therapies for depression are not differentially effective. Although a comprehensive review of outcome studies for depression is beyond the scope of this chapter, such a review was published in 1990 by Robinson, Berman, and Neimeyer, who used meta-analysis to answer a number of questions about the outcome of psychotherapy for depression. They identified 58 studies that met the following criteria: clients were outpatients suffering primarily from depression; the study included comparisons between treatment and no treatment, or between different types of therapy; only therapies with a prominent verbal component were included. The few studies involving marital or family therapy were excluded because of their different focus. Robinson et al. (1990) classified the therapies into one of the following four categories: cognitive, behavioral, cognitive-behavioral, and general verbal. The last category included psychodynamic therapies, clientcentered therapies, and various forms of interpersonal therapy as described by Klerman, Weissman, Rounsaville, and Chevron (1984). In their initial analyses, they found what appeared to be support for differential effectiveness. The effect size for cognitive-behavioral therapies was significantly greater than for behavior therapy only. In addition, cognitive, behavioral, and cognitive-behavioral therapies yielded effect sizes that were significantly greater than tor general verbal therapy. Had the investigators

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stopped their analyses at that point, it would indeed seem as if they had found support for at least some degree of differential effectiveness. However, since previous research had demonstrated that the preference or allegiance of the researcher can have a substantial effect on the outcome of the therapy (Berman, Miller, & Massman, 1985; Smith et al., 1980), the authors conducted further analyses taking this factor into account. These analyses yielded no significant differences in effect size among the four categories of treatment. Based on these analyses, they concluded: "In fact, once the influence of investigator allegiance was removed, there remained no evidence for the relative superiority of any one type of therapy" (p. 36). Robinson et al. (1990) suggested that one reason for the inconsistencies in earlier meta-analyses (e.g., Dobson, 1989; Nietzel, Russell, Hemmings, & Gretter, 1987) may have been because these studies did not evaluate the effects of researcher preference, thereby leaving this potentially influential factor uncontrolled. It is possible that this factor may account for the results of a more recent meta-analysis by Svartberg and Stiles (1991), whose results suggest that short-term psychodynamic therapy is significantly less effective than other therapies for depression, especially cognitive therapy. The Robinson et al. (1990) review included studies that were published through 1986. Since that time, several other well-controlled comparative outcome studies of depression have appeared, which have similarly failed to find consistent or significant differences among various therapies (e.g., Beutler, Engle et al., 1991; Elkin et al., 1989). A review by Beckham (1990) included some of these more recent studies and similarly concluded that the research has failed to uncover any significant differences in effectiveness among different psychotherapies for depression. Of the studies that have appeared since 1986, the NIMH Collaborative Research Program (Elkin et al., 1989) is clearly the largest and most carefully controlled. Elkin and associates (1989) assigned 250 clients diagnosed with major depression to one of four conditions, all involving individual contact: cognitive-behavior therapy; interpersonal therapy; imipramine plus clinical management; and placebo pill plus clinical management. The results showed that on almost all measures, the two psychotherapies were equally effective in reducing depression. The authors concluded that "there is no evidence in this study of the greater effectiveness of one of the psychotherapies on measures of depressive symptoms and overall functioning" (p. 979). From this brief review, we can conclude that a considerable body of evidence from well-controlled studies has largely failed to find significant differences in effectiveness among different therapies for depression. These provocative findings may be interpreted in a number of different ways (Beutler, 1991; Butler & Strupp, 1986; Stiles et al., 1986). First, there is an

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explanation based on individual differences in response to treatments. According to this view, the apparent equivalence of outcome is reflected in group averages that obscure important individual differences in responses to different treatments; outcome studies have focused on main effects at the expense of interaction effects. A second explanation raises the possibility of differential change that may be achieved by the different therapies. In this view, the apparent equivalence of outcomes could reflect a failure of the research to measure the unique changes achieved by different treatments. Greater specificity in the measurement of outcome might reveal that certain therapies are better than others for achieving certain types of changes. A third possibility, raised by Kazdin and Bass (1989), is that most psychotherapy outcome studies do not have adequate statistical power to detect differences that may actually be present. While this is true for the majority of published outcome studies, it should be noted that although the NIMH Collaborative study was designed to have adequate statistical power, it nonetheless largely failed to find differential effects. A fourth possibility concerns the problems in accepting the null hypothesis based on equivalence of outcome on the measures employed. The logic of statistics does not allow us to accept the null hypothesis. It is always possible that different measures, procedures, or research designs will demonstrate differential effectiveness in future research. Finally, there is that possibility that common factors present in all of the therapies are primarily responsible for the effectiveness of those therapies, leading to the equivalent outcomes that have been obtained. These five explanations are not mutually exclusive. In particular, the discovery of individual differences in response to treatments, or of different therapies achieving different types of change, or even of the demonstration of some degree of differential effectiveness in future research do not invalidate the possible contribution of common factors to outcome. Similarly, support for common factors does not invalidate the other possibilities. Rather than polarizing the area into common versus specific factors, it might be more productive to ask what percentage of the variance of outcome may be accounted for by each of these explanations. It is the argument presented here that a common factors explanation can account for a significant amount of this variance. EFFECTIVENESS OF PLACEBO TREATMENTS

The failure to find consistent and reliable differences in efficacy among different therapies for depression is one source of data consistent with a common factors point of view. Another source of data relates to the effectiveness of placebo treatments for depression. Such treatments are usually designed to have at least some of the factors that the different

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therapies have in common. If the various psychotherapies are effective because they contain specific active change factors over and above common factors, then the psychotherapies should be significantly more effective than these placebo control groups. In the psychotherapy outcome literature for depression, the most common design consists of one or more psychotherapies compared to a waiting list control group. Several studies have also included some type of "attention-placebo" control group against which the psychotherapies are evaluated. While the exact nature of these procedures has varied considerably across studies, they are usually designed to be credible to the client, to induce expectations of help and improvement, and to provide the client with some degree of access to a professional person who is open to listening to their complaints and problems. In some respects, these attention-placebo conditions have been included in order to rule out a common factors explanation. The attention-placebo treatments are designed to contain some of the basic and common elements of active therapies (e.g., attention, support, catharsis, positive expectations for change), but without including any of the specific interventions associated with each of the active therapies. If it can be demonstrated that the psychotherapies are significantly more effective than the attention-placebo conditions, then we can conclude more strongly that the psychotherapies contain some unique change agents over and above those contained in the attention-placebo interventions. The meta-analysis of psychotherapy for depression by Robinson et al. (1990) discussed earlier also sheds light on this issue. These researchers compared the effect size for the psychotherapies with effect sizes obtained from attention-placebo and waiting list control groups. They identified nine studies that included an attention-placebo condition and found no significant differences in the effect size obtained for psychotherapy versus attention placebos, with both doing significantly better than waiting list control conditions. Thus, in a number of studies with a variety of placebo conditions, psychotherapy has not yet proven more effective than placebo. The NIMH Collaborative study also included an evaluation of a carefully constructed placebo-clinical management condition (PLA-CM) that included general supportive professional contact along with a pill placebo. Consistent with the findings of Robinson et al. (1990), there were no significant differences in effectiveness between the psychotherapies and the placebo control group. When the groups were subdivided into more and less severely depressed clients at pretest, some interesting findings emerged. For the less severe depressives, there were no significant differences in comparisons among interpersonal therapy, cognitive therapy, and placebo. For the more severe depressives, however, there was evidence that interpersonal therapy was significantly more effective than placebo,

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but not cognitive therapy. It is important to note that the placebo condition did not do well for the more severely depressed clients. For them, analyses revealed that drug therapy and both psychotherapies were significantly more effective than the placebo-clinical management condition. This finding suggests that a common factors explanation may account for more variance in outcome for milder as opposed to the more severe depressives. In general, however, the results for placebo comparisons from the NIMH Collaborative study provides some evidence that is consistent with the results from the Robinson meta-analysis in suggesting that psychotherapy is not significantly more effective than placebo, with these results most consistent for mild depressives, and more mixed for the more severe depressives. It should also be noted that this lack of difference was not due to the relative ineffectiveness of the psychotherapies to which the placebo condition was compared. To the contrary, both therapies led to great improvements and very high rates of complete remission in the subjects who received them. To quote once again from the NIMH report: "The general lack of differences between the two psychotherapies, together with the good results for the PLA-CM condition, suggests once again the importance of common factors in different types of psychologically mediated treatment" (Elkin et al., 1989, p. 979). Despite the converging evidence that placebo or common factors might constitute powerful interventions for depression, there is no real consensus regarding the precise nature of what these factors may be, even after more than 50 years of speculation about them in the psychotherapy literature (Arkowitz, 1992; Goldfried & Newman, 1992; Grencavage & Norcross, 1990). I believe that the literature on social support and depression can provide us with some important leads about the common factors that might be important, and I turn to this next. SOCIAL SUPPORT AND DEPRESSION

The study of social support has been one of the most active research areas in psychology in recent years (cf. Garfield, 1987; Sarason, Sarason, & Pierce, 1990). Although definitions of social support vary across studies, Lin, Dean, and Ensel (1986) attempted to synthesize the different views and provide an integrative definition of social support that will serve as a general framework for the present discussion. They defined social support as "the perceived or actual instrumental and/or expressive provisions supplied by the community, social networks, and confiding partners" (p. 18). Social support involves the person's perceived or real access to confiding relationships in which various types of help and opportunities for emotional expression are potentially available. People may lack social support because they are socially isolated or because their close relation-

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ships are distressed, resulting in alienation from others who could potentially provide social support. There now exists a large body of evidence linking social support with depression. Evidence for this relationship comes from two main sources. One consists of studies demonstrating that depressed persons are lower in social support than appropriate comparison groups. The other source consists of studies demonstrating that individuals who are low in social support are more likely to develop a subsequent depressive episode. The studies I will briefly review suggest that lack of social support may be both a consequence and cause of depression. Depressed Persons Lack Social Support Data from a number of studies have demonstrated that depressed persons are lower in social support than comparison groups (Bell, LeRoy, & Stephenson, 1982; Billings, Cronkite, & Moos, 1983; Billings & Moos, 1984; Blazer, 1983; Dean & Ensel, 1982; Gore, 1978; Leaf, Weissman, Myers, Tischler, & Holzer, 1984; Lewinsohn, Hoberman, & Rosenbaum, 1988; Schaefer, Coyne, & Lazarus, 1981; also see reviews by Barnett & Gotlib, 1988; Coyne, Burchill, & Stiles, 1990; Coyne & Downey, 1991). Typically, these studies have found correlations between various indices of social support and depression, demonstrating that depressed persons have smaller social networks, fewer close relationships, and less supportive relationships than control groups. For example, Leaf et al. (1984) found that, compared to controls, persons with diagnoses of depression reported less contact with friends, fewer friends nearby who can help, less satisfaction with friends and relatives, less confiding in their spouses, and less satisfactory marital relationships. These researchers also found that the quality of close relationships, most notably with the spouse, correlated more with diagnosis of depression than did the quality of more distant relationships. A number of other studies have also examined the relationship between marital adjustment and depression, similarly finding that the marriages of depressed persons are more distressed and characterized by more friction, negative communications, and hostility than the marriages of others (Arkowitz, Holliday, & Mutter, 1982; Coleman & Miller, 1975; Hinchliffe, Hooper, & Roberts, 1978; Kahn, Coyne, & Margolin, 1985; Weissman & Paykel, 1974). Weissman (1987), in her extensive epidemiclogical study of depression, reports some provocative findings in this regard. Being married and being able to talk to one's spouse was associated with far less risk for depression than being married but unable to talk to the spouse. This suggests that it may be access to the confiding relationship with the spouse that is more important than simply the physical presence of the spouse in the home.

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Coyne (1976) has suggested that depressed people may alienate others and, by their interpersonal behavior, reduce the social support available to them. Results from a number of studies of depressed persons in interaction with others have provided results consistent with the hypothesis that depressed behavior has an aversive impact on others, and that depressed people are more likely to be met by interpersonal rejection than people who are not depressed (see review by Coyne, Kahn, & Gotlib, 1987). Thus, depressed people may be alienating those people who are potential sources of social support. A number of studies thus demonstrate strong and consistent associations between depression and lack of social support on a wide variety of indices. Given the correlational nature of these studies, it is not possible to determine whether social support causes depression or depression causes a lack of social support, or whether a third factor may mediate this association. The prospective studies in the next section address this issue to some extent. Lack of Social Support Predicts the Onset of Depressive Episodes If lack of social support is a contributing causal factor to the onset of depression, it should precede the depressive episode and predict who develops a depressive episode. Several sources of evidence suggest that some aspects of social support are antecedents to depression onset, especially for women. To begin with, it has been found that the stressful lite events that precede depression very frequently involve loss of significant relationships (Finlay-Jones & Brown, 1981; Dohrenwend, Shrout, Link, Skodol, & Martin, 1986; Oatley & Bolton, 1985). Moreover, people who recover from a depressed episode have often been found to have residual deficits in social adjustment that may relate to their ability to obtain social support from their environment. For example, Billings and Moos (1984) found that remitted depressives had fewer friends and close relationships, and perceived their family support as poorer than did controls. Weissman and Paykel (1974) similarly reported that remitted depressives had more inhibited communication and interpersonal friction in their marriages than did normal controls. Finally, and most important, measures that relate to lack of social support and marital conflict have been found to predict subsequent occurrence or relapse, especially for women (Brown & Harris, 1978; Cutrona, 1984; Lewinsohn et al., 1988; Lin & Ensel, 1984; Paykel & Weissman, 1973; Phifer & Murrell, 1986). For example, Lewinsohn et al. (1988) found that women, but not men, who had fewer social contacts were at greater risk of developing depression than were those with more social contacts. Research has also demonstrated that critical comments made by spouses

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when they brought a depressed person for admission to the hospital predicted posthospital relapse, independent of the patient's level of symptomatology (Hooley, Orley, & Teasdale, 1986; Vaughn & Leff, 1976). Although much work needs to be done to clarify the meaning and measurement of social support, it is clear that some important aspects of basic human contact are significant in depression. Our review, as well as that of Barnett and Gotlib (1988) point to the possibility that any intervention that can potentially increase the quantity and/or quality of social support available to the depressed person may be potentially helpful in reducing depression. In this regard, it is important to acknowledge the therapeutic relationship as a source of social support, perhaps constituting the most powerful common factor in psychotherapy for depression. THE RELATIONSHIP IN PSYCHOTHERAPY

There has been a renewed interest in measuring and studying the relationship in psychotherapy (cf. Greenberg & Pinsof, 1986). Indeed, many common factors theorists have speculated that the relationship may itself be the main source of effective common factors in psychotherapy, quite apart from the techniques employed by therapists (cf. Beitman, 1992; Frank, 1961, 1973, 1982; Garfield, 1992; Lambert, 1992; Schofeld, 1964). Strupp and Hadley (1979) conducted a study that sought to examine the role of the relationship versus specific factors in psychotherapy. Subjects were college students who suffered from a variety of problems, not solely from depression (i.e., depression, anxiety, and social withdrawal). The clients were randomly assigned to individual contact with either one of five well-trained and highly experienced professional psychotherapists, or one of five college professors selected because of their reputation for warmth, trustworthiness, and interest in students. The most striking finding from this study was that both groups of therapists did equally well in helping these clients. While later publications from this project illustrated possible individual differences in responses to the different conditions (Strupp, 1980a, 1980b, 1980c, 1980d), the main results are consistent with a common factors explanation. One plausible interpretation of these results is that the relationship, apart from specific therapy techniques, might have had positive and therapeutic effects. Berman and Norton (1985) conducted a meta-analysis to examine the relative effectiveness of professional versus paraprofessional therapists with various disorders, including, but not limited to, depression. They found 32 studies that met their inclusion criteria. The overall findings were quite clear: The experienced and professionally trained therapists were not significantly more effective than relatively untrained paraprofessionals. A further analysis did reveal the possibility that professional therapists were

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somewhat more effective in shorter-term therapies, while paraprofessionals were somewhat more effective in longer-term therapies. The lack of difference in effectiveness between professional and paraprofessional therapists in these studies is consistent with those common factors models that emphasize the importance of relationship factors in all helping relationships, as opposed to specific technique factors associated with different therapies. SUMMARY I have reviewed four lines of evidence that are consistent with an explanation of the effectiveness of different psychotherapies for depression as at least partially due to common factors. These include (I) the failure of outcome studies to clearly demonstrate differential effectiveness of different therapies for depression; (2) the relative effectiveness of placebo conditions in the treatment of depression; (3) findings that suggest lack of social support may be both a cause and a consequence of depression; and (4) the equivalent effectiveness of trained and untrained therapists for people with depression or related disorders. To the extent that the therapy relationship provides an important source of social support to people whose depression may, in part, be due to a lack of supportive contact, then it should be quite helpful in reducing depression, apart from the application of any specific therapy techniques. Until we can rule out the other plausible explanations of the outcome research, or determine the proportion of variance accounted for by each explanation, we must retain the common factors account as a reasonable and strong contender to explain a wide range of strong and consistent findings. For these reasons, I believe it is important that clinicians and researchers examine more closely the processes and outcomes of a common factors therapy for depression in which the essential ingredient is the provision of social support. To help accomplish this, I will consider certain therapeutic guidelines based on common factors and the use of supportive social contact for the treatment of depression.

Development of a Common Factors Therapy Manual The development of therapy manuals for use in psychotherapy research (cf. Beck, Rush, Shaw, & Emery, 1979; Luborsky, 1984; Strupp & Binder, 1984; Klerman et al., 1984) has been one of the main reasons for the tremendous advances in psychotherapy research over the past decade. These manuals offer detailed descriptions of therapist attitudes and behaviors associated with each approach, thus providing a standard that can be used in different

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studies, as well as greater comparability and replicability across studies. Unfortunately, the study of common factors in psychotherapy has not been associated with the development of any widely agreed-upon manual. As a result, the attention-placebo procedures and nonspecific therapy control conditions employed in different studies have varied considerably, despite being assigned similar names. This situation has resulted in considerable confusion in trying to make sense of the results of these different studies. A standard manual for such therapy would reduce this confusion and allow us to draw clearer conclusions across studies about the relative efficacy of common and specific factors in therapy, as well as permit us to study the change processes that might be involved in common factors therapy. The only group that has attempted to address this concern is the NIMH Treatment of Depression Collaborative Research Program. In addition to using established manuals for the cognitive therapy (Beck, et al., 1979) and interpersonal therapy (Klerman et al., 1984), these researchers also developed and published a manual for clinical management and administration of imipramine and placebo (Fawcett, Epstein, Fiester, Elkin, and Autry, 1987). In addition to providing detailed information regarding drug dosage, scheduling, and delivery, it also discusses the therapists' attitudes, behaviors, and roles, as well as the interpersonal processes that were permitted as part of "clinical management." The manual encourages therapists to induce positive expectancies about change, and to create a supportive and encouraging relationship that includes instruction, education, and information related to drug therapy and the biology of depression. The authors of this manual also outlined those therapist behaviors that were not permitted as part of this treatment (i.e., clear delivery of specific techniques associated with major schools of psychotherapy). The NIMH investigators used the placebo-clinical management condition as a control group for both the psychotherapy and drug-therapy conditions. For psychotherapy research, it would be desirable to have a common factors therapy that was more directly comparable to the procedures used in the various psychotherapies (also see Beitman, Hall, & Woodward, 1992). Hence, a common factors therapy that does not include a drug or placebo, and one that is based on common factors theory and research, appears to be in order. It is just such a therapy that will be proposed in this chapter. I prefer to name the proposed therapy "common factors therapy" rather than "attention-placebo," "control group for nonspecific factors," or "clinical management." I believe that this name better captures the flavor of the proposal as a potentially effective therapeutic approach, defined by the implementation of particular conditions and techniques in therapy believed to be common elements in all psychotherapies. Perhaps this title will place this "CFT" on a more equal footing with CBT and IPT.

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At: first glance, it may seem that all we need to do to create a common factors therapy is instruct therapists not to engage in any of the techniques specified by any of the major therapies. This is unrealistic. What we can do is instruct therapists to minimize the use of techniques formally associated with major schools of psychotherapy for depression. In addition to instructing therapists what not to do, however, we also need to instruct therapists more affirmatively what to do in conducting a common factors therapy for depression. What are the common factors and how can they best be conceptualized and implemented? Unfortunately, there is no consensus in the field, nor is there clear data to guide our decision. There have been a number of proposals for common factors in psychotherapy (cf. reviews by Arkowitz, 1992; Goldfried & Padawer, 1982; Grencavage & Norcross, 1990), with no data that allow us to choose one over the other. Grencavage and Norcross (1990) developed a coding system to describe and categorize the various proposals, and their findings suggest that there is considerable overlap among them. In order to develop a common factors therapy, I will first examine the nature of social support more closely for leads regarding what such a therapy should contain. I will then consider one of the most comprehensive and influential proposals for common factors in psychotherapy—that of Jerome Frank (1982). I believe that both the social support literature and the work of Frank are very useful starting points for the development of a common factors therapy for depression. The social support literature calls our attention to several factors that are potentially important commonalities among different psychotherapies. The integrative definition of social support offered by Lin et al. (1986), discussed earlier, pointed to the instrumental and/or expressive benefits supplied by the community, social networks, and confiding partners. Lin and associates consider the confiding partner to be the most important source of social support, and presented evidence consistent with this view. My focus will be on the therapist as a confiding partner who can provide real or perceived instrumental or expressive support to the client in psychotherapy. The instrumental dimension of social support involves the use of the relationship as a means to achieve a goal. The therapy relationship clearly fits this criterion, serving as it does to help achieve the goal of reducing or eliminating depression and increasing a sense of well-being. Lin and colleagues (1986, p. 20) further discuss the expressive functions of social support as involving the activity of "sharing sentiments, ventilating frustrations, reaching understanding on issues and problems, and confirming one's own as well as other's worth and dignity." Almost every therapy relationship strives to provide opportunities for these expressive functions. Thus, the social support literature points to the importance of the client perceiving the therapy relationship as providing help toward achieving

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important goals, especially of symptom reduction and greater well-being, and to its providing opportunities to express and experience emotions in a positive and accepting context. The most widely cited and accepted formulation of common factors can be found in the work of Frank (1961, 1973, 1982), who identified four components that he believes are shared by all forms of psychotherapy: 1. An emotionally charged relationship with a helping person 2. A healing setting 3. A rationale, conceptual scheme, or myth that provides a plausible explanation for the client's symptoms and prescribes a ritual or procedure for resolving them 4. A ritual that requires active participation of both client and therapist and that is believed by both to be the means of restoring the client s health Frank (1982) suggested that myth and ritual serve a number of important purposes in psychotherapy. They combat demoralization by strengthening the therapeutic relationship through the bond of a common belief system; they inspire expectations of being helped; they provide new learning experiences; they arouse the client emotionally; they enhance the sense of mastery or self-efficacy; and they provide opportunities for rehearsal and practice. In an attempt to synthesize the main elements of the social support literature with Frank's discussion of common factors, I propose the following as basic elements that must be included in any common factors therapy: 1. A warm and positive relationship with the therapist along with instructions about how to implement and maintain this type of relationship. Most of this component focuses on the therapist's attitudes toward the client and the communication of these attitudes. 2. A set of procedures engaged in by the therapist, which are believed to lead to change. In the context of a positive relationship, these procedures should provide support, encouragement, and acceptance, as well as ample opportunity for emotional expression. 3. A rationale underlying those procedures, which provides a plausible explanation for the client's symptoms and is logically connected to the procedures used in the therapy. 4. Positive expectancies on the part of both the therapist and the client that the treatment will lead to beneficial changes. Without the therapist and client having a reasonable set of positive expectancies about change from this therapy, it is unlikely that the therapy will be effective. There remains the possibility that the expectations generated by the common factors therapy may be less positive than those generated by specific therapies. We will return to this point later in the chapter.

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In developing the outline of a manual, I have drawn from a number of sources, including the placebo-clinical management manual for the NIMH project (Fawcett et al, 1987), the work of Carl Rogers (1951, 1957) and others who have followed in his tradition (Guerney, 1977), as well as other manuals that contain components related to providing interpersonal support (Ridley, Phillips, & Muszynski, 1988). Anyone attempting to develop a common factors therapy manual faces one immediate dilemma. It is easier to describe to therapists conducting this therapy what not to do (i.e., any systematic application of techniques associated with specific therapies) than what to do to feel as if they are engaging in potentially helping behaviors in therapy. On the one hand, if we tell them not to do all the things they have been trained to do in order to be helpful, we will likely have ineffective therapists, groping for what they can do. On the other hand, if we describe a clear set of attitudes and behaviors for them to communicate during therapy, we run the risk that these may resemble an existing approach to psychotherapy. We chose to describe a set of attitudes and behaviors in detail so that the procedure could be operationalized and taught, and so that therapists and clients would have a clear structure and framework for this therapy. In many respects, the therapeutic orientation of Rogers most clearly fits the criteria for the kind of approach we seek. It is appealing, for our purposes, because it strongly deemphasizes the use of specific techniques, and largely advocates the communication by the therapist of therapeutic attitudes and conditions as the main vehicle for effecting change. I believe that most therapists, regardless of their specific orientation, try to create these or similar conditions in their relationships with clients. Therapists doing client-centered therapy (or person-centered therapy, as it later was called by Meador and Rogers, 1979) are credible, have positive expectations about change, and seem to create positive expectations in their clients (Truax & Mitchell, 1971). In what follows, I will identify and describe a set of therapist attitudes, roles, and behaviors that seem to capture the essence of the most important common factors in therapy, and recommend these as the basis for a treatment for depression in both clinical practice and outcome research. What is presented below is an outline rather than a completed manual.

Guidelines for a Common Factors Therapy for Depression I assume that responsible therapy researchers will conduct a careful assessment to determine diagnosis, the nature of the problem, important contributing factors, the presence of any organic conditions that may affect the

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depression, and the need for medication, and will continuously assess suicide risk. The focus here is on the essence of the common factors therapy, and not on these important clinical considerations. The therapy I am proposing consists of encouraging the client to speak about his or her feelings, concerns, hopes, and fears to a therapist who holds attitudes of genuineness, empathy, and positive regard, and who encourages emotional arousal in the client and provides reflections and realistic support and encouragement. THE INITIAL SESSION

During this session, the main task of the psychotherapist is to encourage clients to talk openly about their symptoms and concerns. The therapist should mainly ask open-ended questions to encourage the client to talk about symptoms, concerns, fears, and problems. Appropriate questions early in the first interview may deal with the symptoms the person is experiencing, for how long, any past history of depression or other problems, how disturbing are the symptoms, what the client believes may have contributed to the onset of the depression, suicide potential, and an inquiry into the current status of their work and important personal relationships. As the client talks, the therapist should listen carefully and encourage further talk with questions such as, "Can you say some more about that?" or "How did that make you feel?" Some clients may begin the interview with a great deal that they wish to discuss. Such clients mainly need the opportunity to talk while the therapist listens closely. Others may not know what to talk about, or may be inhibited in expressing themselves. These clients will need more structure to the interview, with the therapist taking a more active role in asking questions. The therapist should maintain a calm, accepting, and nonjudgmental attitude toward the information that the client supplies in the interviews, avoiding questions that imply a judgment about what the client is doing or feeling. The therapist should be particularly sensitive to the possibility that such judgments can be communicated by the content of a question as well as by the nonverbal cues accompanying the question (facial expression, vocal intonation, etc.). For example, a therapist might inquire about why a client has stopped exercising. Some ways of asking about this may convey the message that this was clearly not a wise thing to do and that the client should begin exercising again. The question "Why did you stop exercising?" can be asked in an accepting, inquiring way, or in a judgmental way that suggests that it was a foolish thing for the client to do. It is particularly important that therapists communicate to the client that they are competent, familiar with the problem of depression, know

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how to work with depressed people, and are optimistic about the possibility of the client recovering from depression with psychotherapy. Some of these themes can be communicated by the nature of the questions asked, which will likely convey not only their interest, but also their expertise, as they inquire into relevant aspects of depression that the client is experiencing. Thus, by inquiring about energy level or suicidal ideation, therapists communicate their awareness that these symptoms are often experienced by depressed persons, increasing the likelihood that they will be perceived by the client as knowledgeable and potentially able to help. Well before the end of the first session, the therapist should provide a summary of what he or she has heard so far (but not a formulation of what the therapist thinks is going on), reflecting the most important aspects of content and feeling in what the client has discussed. At that point, the therapist should also describe the rationale for therapy described below. RATIONALE FOR THERAPY PRESENTED TO THE CLIENT

The rationale should be presented in a clear and confident manner, and should be tailored to fit the particular client. The therapist might make an initial statement that contained the following information: It does sound like the kind of problems and depression that you've been experiencing fits well with the type of therapy that I offer. Let me tell you some more about this therapy. Most depressed people have a lot of feelings that they keep bottled up inside of them. They need an opportunity to express and examine those feelings. Part of this therapy is to provide you with opportunities to express your thoughts and feelings. The more you are able to do this in therapy, and the clearer you can become about what your thoughts and feelings really are, the better you will feel. Depressed people often speak with friends and family members about their problems, and this may sometimes help for a short while, and sometimes not. The kinds of discussions we are talking about having in therapy are more likely to help because therapists are trained to listen for certain things and bring these things to the attention of the person. As I listen to you, I will try to put myself in your shoes, to the extent that I am able, and I will share with you some of the perceptions I have from that perspective. These reflections should help you to clarify what you are thinking and feeling in ways that I hope will be helpful. One of the reasons that depressed people often do not benefit from speaking to friends and family members is that they seem to keep going over the same ground about how bad they feel and how pessimistic they are about things getting better. Often, this may make the depressed person feel worse and will leave friends and family members somewhat helpless about how to respond. As therapists, we have learned ways to help depressed people get a somewhat

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different perspective on what they are feeling and experiencing. We don't do this by giving you advice or by telling you what to do. Instead, we do it by looking to your own strengths and trying to put you in touch with these strengths. We believe that people have the ability to change in themselves and that what therapists can do is to help people find these inner resources. In order to do this, I will listen carefully and try to reflect back to you what I think I hear you saying or feeling. By serving as a kind of mirror for your thoughts and feelings, but a mirror that sharpens the reflection and helps you see yourself more clearly, I believe that you will become able to find inner strengths and resources that will help you move out of your depression. That has been my experience in working with other depressed people, and there is also a considerable amount of research that has demonstrated that this type of therapy can be helpful with depression as well as other problems.

If the therapist or client wishes, the therapy might be referred to as "expressive-reflective psychotherapy." This might be preferable to calling it "common factors therapy," since the former sounds like a more active therapy approach than the latter, and will more likely engender positive expectations, similar to other "name brand" therapies. THERAPIST ATTITUDES

It is important that the therapist hold to certain attitudes and styles in interacting with the client. These have been described and discussed in detail by Rogers (1951) in his book Client-Centered Therapy. Therapists would be well-advised to read this work as part of their preparation for conducting this therapy. The attitudes recommended are genuineness, unconditional positive regard, and empathy. Genuineness The therapist should not present a facade to the client, but rather should respond genuinely and honestly. The goal is not necessarily for the therapist to self-disclose, but when an expression of feeling, concern, or support is conveyed, it should come from a genuine experience of the therapist. Thus, a comment that "It sounds like you really suffered after that argument with your son" should only be made if the therapist truly felt and believed that the client was indeed suffering after the argument. Unconditional Positive Regard The therapist should accept the client's experience for what it is and not what the therapist thinks it should be (cf. Koerner & Linehan, 1992). The

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therapist communicates a sense of liking, or what Rogers (1957) has called "prizing," to the client, without any evaluation of the client or of his or her experiences. Unconditional, positive regard implies a liking and caring for the client in a nonpossessive way, without passing judgment either in thought or action. Empathy Rogers (1957) described empathy as sensing "the client's private world as if it were your own, but without ever losing the 'as if quality" Thus, if the client is angry or disappointed, the therapist may have a sense of how the client feels. The therapist may enter the client's world and experience, at least to some extent, and share some of the feelings and reactions that the therapist has as a visitor to the client's experiential world. In this way, therapists can communicate understandings that clients may have had, but of which they were only vaguely aware. Thus, empathy allows the therapist to communicate with clients in ways that enhance their understanding of themselves and their experiences. Therapists should be aware of how helpful the communication of these attitudes are to clients in therapy (e.g., Traax & Mitchell, 1978). They should also strive to hold this positive, nonjudgmental, and sharing attitude toward the client, rather than acting this way when they don't really feel it. Acting nonjudgmental while one is feeling or thinking judgmentally about the client would be nongenuine, and would be an obstacle rather than a facilitator of therapeutic change. Although Rogers emphasized these attitudes as the foundation of his therapeutic approach, it is unlikely that every therapist can fully hold these attitudes with every client to the degree that Rogers would recommend. What is important, however, is that therapists strive toward these attitudes in their thinking about and working with each client without being too self-conscious about trying to adhere to them. Statements that provide advice, opinions, or information are permitted, but they should be only a small part of the therapist's communications to the client. THERAPIST BEHAVIORS

The main therapist behaviors can be described as encouraging affective expression, providing empathic reflections of thoughts and feelings, and providing realistic support and encouragement. Encouraging Affective Expression As clients discuss their symptoms or life situations, the therapist should be particularly attuned to the emotions they are experiencing. While the

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therapist can certainly ask questions of clients about what they thought about something, particular attention should be focused on what they are feeling during the events that they are describing, and also on what they are feeling in the present moment. Questions such as, "How did that make you feel?" "What were you feeling when that happened?" and "How are you feeling now as you talk about it?" are appropriate. If the client responds to these questions in a general way ("I just felt awful"), the therapist might inquire what it was like to feel awful. The therapist perhaps has a sense of that awful feeling as well, and might use that experience for further inquiries: "Maybe when you feel that awful you also feel hopeless, like it's not worth trying so hard any more." The therapist should try to "tune in" to the client and experience what the client might be going through in the "as if" way that Rogers described. This tuning in can serve as a guide for further questions and observations by the therapist. As clients focus more on emotional experiences, they will likely experience increased emotional arousal. With depressed people, this may initially be a sense of increased depression. In some cases, the therapist may sense that part of the client's experience is anger or resentment, or a sense of helplessness. By sharing these observations as questions ("Could it be that you feel resentful toward him?"), the therapist can help clients clarify the nature of their emotional experience. If emotional arousal does increase with this approach, as is likely, the therapist should also communicate a sense of calm in the face of the client's emotions, and a sense that the client's experience of these emotions is likely to be helpful in both the short and long term. With more intense emotional experiences, like sobbing or yelling, the therapist might convey reassurance that feeling these strong emotions is alright and likely to help, although they may be difficult for the client at the moment. If the client's emotional experience remains intense as the end of the session is drawing near, the therapist might help the client to calm down and move the discussion away from the direct experience of the emotions and more toward talking about what it was like to feel so emotional. It is preferable not to end a session on a strong and unresolved note of emotional expression. It is also important to spend some time helping the client consolidate this experience before the session ends. Providing Empathic Reflections Reflecting is most often done around emotions, but it can also be done with attitudes and thoughts. In reflection, the therapist tries to stay within the client's frame of reference, but rephrases what the client is saying or discussing or feeling. The goal of this reflection or rephrasing is to help the client think or feel somewhat differently, most often in the direction of "crystallizing" some trend that was already there and of which the client

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was somewhat aware. The reflection should be only "one step" away from the client's current experience, and should extend that experience rather than putting a completely new frame of reference on it. Consider the following example of a woman discussing her reactions upon finding out that her husband had been having an affair with another woman: CLIENT: I just couldn't believe it. I was shocked when I found out. I never thought he would do that to me, and I felt worthless and ugly. How could he do that to me? If the therapist senses a feeling of anger or resentment in the client as she makes these statements, the therapist might say: THERAPIST: What did you feel toward your husband when you found out? This question moves more toward an interpersonal exchange, which would likely involve resentment or anger. By contrast, if the therapist sensed that the main feeling might be self-depreciation and hostility directed inward, the therapist might ask: THERAPIST-. What was it like for you to feel worthless and ugly? In both cases, the therapist does not jump right to the emotion that may be there, but through questioning helps point the client in particular directions, so that she can determine what feelings were or are actually there. As the interchange continues, the client might begin to make comments that suggest she was angry at her husband or at herself. Note that the main goal of empathic listening is to help the client crystallize what she is feeling or thinking but of which she may not be fully aware. As the interaction continues, the goal would be to have the client move toward a greater awareness of some aspects of her experience that were not fully in her consciousness prior to the interaction. The therapist need do no more than point her in these directions and see where she goes, being careful to avoid adding interpretations of the client's experience or advice about how to handle situations (cf. Koerner & Linehan, 1992). Providing Realistic Support and Encouragement Throughout treatment, the therapist should provide realistic support and encouragement. This involves the communication of a sense of realistic optimism relating to what is being discussed. In the first session, the therapist should communicate his or her optimism that the therapy will be

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helpful. Over the course of the therapy, positive changes in thinking, feeling, or behaving should be generally supported and encouraged by the therapist, while avoiding specific suggestions for specific changes. For example, a client might report having more social contact during the past week and feeling less depressed as a result. Rather than specifically endorsing or assigning increased social activity, the therapist might show encouragement by saying, "I'm glad you're feeling somewhat better this week. It seems as if the more you're with people, the better you feel." It is important that therapists be realistic in what they choose to support or encourage, and that the sense of optimism that therapists convey should also reflect a reasonable appraisal of the client's current situation. These communications should be genuinely held beliefs on the part of the therapist that reflect his or her appraisal of the client and problem, and not a blanket optimistic response to the depressed client. It would be inappropriate for the therapist to say "I'm quite sure that this therapy will help you and that you will improve with this treatment." While such a statement might be meant to be reassuring, it is too strong. The truth is that the therapist and client both know that the therapist can only guess at the prognosis and cannot provide any guarantee. Statements that convey a positive and optimistic attitude, without implying a guaranteed positive outcome, are more appropriate. These would include such comments as "I think we can work on that," "Many other people that I've seen with depression as bad as yours have been helped by this kind of therapy," "My guess is that this therapy is going to be helpful for you," "Let's try to work some more on that one," and "I think with some more work, you might be able to feel differently about things." In a similar vein, when the client has made some small changes, the therapist should generally encourage them in the belief that such changes are potentially helpful, without making unrealistic generalized promises of positive outcomes. Realistic optimism is also conveyed by the therapist's competent and confident manner, communicating that he or she knows what to do in therapy, has a plan for approaching the client's problems, and is acting on that plan during the therapy with the client. Support and encouragement may also be given for those thoughts and behaviors that the therapist believes may help reduce depression. Thus, if a lonely and isolated depressed man starts to wonder about possibly doing volunteer work in order to have some contact with people, the therapist might say, "That sounds like it might be a good idea for you." If the client discovers that he has been thinking too negatively about some issue, the therapist might underline that things may not be as bad as the client thought they were. Note that in these cases, the therapist is supporting and encouraging an action or way of thinking that the client has noted and brought up spontaneously. This approach differs from cognitive or

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behavior therapy in which the therapist might initiate and suggest new ways of thinking and acting.

GENERAL CONSIDERATIONS

It is important that therapists have a clear sense of what this therapy is about, what their roles and attitudes should be, and what the therapeutic behaviors are in which they are expected to engage. Without such a cohesive sense of the therapy, the client will not perceive a structure and plan to the contact, will feel more hopeless, and may even drop out of therapy. I have tried to specify clear attitudes and behaviors for therapists that are likely to be helpful with depressed persons. At times, clients may need to be reminded of the rationale of the therapy, and asked whether they think the therapy is going according to this plan and whether it is helping. Discussion of this sort may lead to a change of focus (e.g., talking more about family and less about work), but it should not lead to any significant change in the overall strategy or approach.

WHAT NOT TO DO IN COMMON FACTORS THERAPY

Now that I have discussed what the therapist can do, I should also caution the therapist what not to do as part of this therapy. The general rule is that the therapist should not engage in specific interventions that are associated with specific organized systems of psychotherapy. These are to be avoided as much as possible, even though it may sometimes be difficult to do. At these times, the therapist may engage in a particular intervention (e.g., an interpretation or a suggestion). While some degree of this may be unavoidable, the therapist should try to keep such interventions to a minimum and should most certainly not become a consistent part of the treatment, either within or across sessions. In particular, the following should be avoided: 1. Interpretations of the client's behavior or feeling, including both present-based interpretations and interpretations that link the present to the past. Examples of such interpretations: "Perhaps one reason you may avoid conflict with your wife is that such conflict brings up old memories and feelings about the awful fights that your parents used to have," or "Could it be that your anger toward your wife is related to some of the conflicts you've been having with your boss at work?" 2. Active attempts to correct negative and distorted thinking. Direct corrections (e.g., "Things just can't be that bad") and indirect corrections through questions should also be avoided. Beck's cognitive therapy employs a Socratic questioning method to help clients discover for themselves

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that their thinking is distorted. This usually involves a sustained focus on a particular theme, and the questions are designed to help clients see the errors in their thinking. Questions of this nature and with this purpose are to be avoided. 3. A persistent focus on interpersonal conflict, interpretations of that conflict, and pointing to ways to resolve the conflict. Consider the example of a depressed woman who is experiencing a very distressing conflict with her adolescent daughter. The therapist should certainly attend to that topic when the client brings it up, but should not try to steer the conversation back to the topic in future sessions. It should be entirely up to the client to return to the subject. The therapist should avoid presenting interpretations of that conflict and also avoid comments that point the client toward feelings of which she may be unaware. If the client suggests some reasonable strategies for resolving the conflict, the therapist can respond with support and encouragement as discussed above, but should avoid presenting to the client any new ways of dealing with the situation. The main responses to the topic should be listening, encouraging emotional expression, reflecting thoughts and feelings, and being generally supportive and encouraging of positive attempts at conflict resolution without being specific. 4. Specific behavioral instructions, suggestions, assignments, or "experiments." 5. Psychodynamic explanations of underlying conflicts. 6. A persistent focus on specific psychological themes. The therapist should focus on following and reflecting the client's experience rather than on directing attention to specific themes. Although this may sound like a long list of don'ts, the list of do's that were discussed earlier should be more than enough to provide a satisfying therapy for the therapist to conduct and a helpful therapy for the client to undertake.

Conclusion My goal in this chapter has been to argue for a common factors approach to the treatment of depression, and to present an outline for a common factors therapy manual that might be incorporated into comparative outcome studies for depression. In order to show that a specific approach to therapy is uniquely effective, one must demonstrate that it has a greater effect than a common factors therapy such as the one proposed in this chapter. If specific therapies cannot be shown to be more effective than a common factors approach, there remains the distinct possibility that they are effective, not because of the theoretical reasons underlying their devel-

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opment, but because they simply constitute a vehicle for providing social support to depressed persons. It would be important to evaluate a common factors therapy for credibility (cf. Rokke, Carter, Rehm, & Veltum, 1990) and for expectancies of both therapists and clients that the treatment will be helpful. Therapist and client expectancies of change from a common factors therapy should ideally be equivalent to those associated with other types of therapy. If they are not, the effects of expectancies should be controlled by statistical means in order to permit meaningful comparisons between common factors and other therapies. In addition, the work of Robinson et al. (1990), reviewed earlier, points to the importance of assessing the clinical researcher's allegiance to the different approaches under study. In addition to encouraging outcome studies that include social support conditions, the literature reviewed in this chapter suggests that we may need to look to process research on social support as well. If social support is an important element in therapy, then we need to study how it operates over the course of therapy to reduce depression. At a simple level, there is the question of whether depressed clients in psychotherapy experience an increase in perceived social support with psychotherapy. If so, are such increases over the course of therapy associated with decreases in depressive symptoms? If both of these hypotheses are supported, we can begin to ask questions about what particular aspects of social support might be the most important in reducing depression. For example, we may look more closely at emotional support and the benefits of the expression and disclosure of upsetting events (cf. Pennebaker, 1989). Further, we may look at instrumental support or at characteristics of the social networks of depressed people. If we can show that social support is indeed an important element in the treatment of depressed persons, then we need to understand and study more precisely its role in therapy. The proposed common factors therapy can also serve a purpose for practicing therapists working with depressed clients. It may encourage psychotherapists to ask to what degree their therapy may be effective because it provides social support, as opposed to the specific theoretical reasons they believe underlies their choice of techniques and therapy strategies. This chapter may also lead practitioners to take their support functions more seriously. Rather than doing "nothing" or "only" being supportive, the literature reviewed here suggests that therapists—as well as paraprofessionals and groups—may be doing a great deal in providing social support to depressed individuals. The arguments presented in this chapter are specific to the disorder of depression. Whether the same conclusions and suggestions will apply to other disorders is an open question. The literature documenting the role of social support is strongest for depression. If future research finds that social

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support is as important in other disorders as it is in depression, then my points would apply to those disorders as well. Until we have such evidence, I restrict my suggestions to depression. Further, given the findings of the NIMH project that the placebo-clinical management condition was quite effective for milder depressives, but relatively ineffective for more severe depressives, it may be that the arguments presented here are most applicable to milder depressions. All too often, debates about common factors and the outcome of psychotherapy have posed the issues in an adversarial way—common versus specific factors. Although the evidence reviewed in this chapter provides considerable support for the importance of common factors in psychotherapy for depression, I believe the issue is better stated as the amount of variance in outcome that is accounted for by common and specific factors, and what those factors may be. It is my hope that this discussion will stimulate both the psychotherapist and the researcher to attend more seriously to this issue.

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CUTRONA, C. E. (1984). Social support and stress in the transition to parenthood. Journal of Abnormal Psychology, 93, 378-390. DEAN, A., & ENSEL, W. M., (1982). Modelling social support, life events, competence and depression in the context of age and sex. Journal of Community Psychology, W, 392-408. DOBSON, K. S. (1989). A meta-analysis of the efficacy of cognitive therapy for depression. Journal of Consulting and Clinical Psychology, 57, 414—419. DOHRENWEND, B. P., SHROUT, P. E., LlNK, B. G., SfcODOL, A. E., & MARTIN, J. L.

(1986). Overview and initial results from a risk factor study of depression and schizophrenia. In J. E. Barnett (Ed.), Mental disorders in the community: Progress and challenge (pp. 184-215). New York: Guilford. ELKIN, I., SHEA, T., WATKINS, J. T., IMBER, S. D., SOTSKY, S. M., COLLINS, J. F., GLASS, D. R., PILKONIS, P. A., LEBER, W. R., DOCHERTY, J. P., FIESTER, S. J., & PARLOFF, M. B. (1989). National Institute of Mental Health Treatment of Depression Collaborative Research Program: General effectiveness of treatments. Archives of General Psychiatry, 46, 971—982. FAWCETT, J., EPSTEIN, P., FIBSTER, S. J., ELKIN L, & AUTRY, J. H. (1987). Clinical management-imipramine/placebo administration manual: NIMH Treatment of Depression Collaborative Research Program. Psychopharmacology Bulletin, 23, 309-324. FiNLAY-JoNES, A. R., & BROWN, G. W. (1981). Types of stressful life events and the onset of anxiety and depressive disorders. Psychological Medicine, 11, 803-815. FRANK, J. D. (1961). Persuasion and healing. Baltimore: Johns Hopkins University Press. FRANK, J. D. (1973). Persuasion and healing (2nd ed.). Baltimore: Johns Hopkins University Press. FRANK, J. D. (1982). Therapeutic components shared by all psychotherapies. In J. H. Harvey & M. M. Parks (Eds.), The master lecture series: Vol. 1. Psychotherapy research and behavior (pp. 73—122). Washington, DC: American Psychological Association. GARFIELD, E. (1987). The 1983 articles most cited in the SSCI 1983-1985. Current Contents, 4-3, 3—9. GARFIELD, S. L. (1992). Eclectic psychotherapy: A common factors approach. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. GOLDFRIED, M. R., & NEWMAN, C. F. (1992). A history of psychotherapy integration. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. GOLDFRIED, M. R., & PADAWER, W. (1982). Current status and future directions in psychotherapy. In M. R. Goldfried (Ed.), Converging themes in psychotherapy: Trends in psychodynamic, humanistic, and behavioral practice (pp. 3—49). New York: Springer. GORE, S. (1978). The effects of social support in moderating the health conse-

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quences of unemployment. Journal of Health and Social Behavior, 19, 157— 165. GREENBERG, L. S., & PINSOF, W. M. (Eos.). (1986). The psychotherapeutic process: A research handbook. New York: Guilford. GRENCAVAGE, L. M., & NORCROSS, J. C. (1990). Where are the commonalities among the therapeutic common factors? Professional Psychology: Research and Practice, 21, 372-378. GUERNEY, B. G., JR. (1977). Relationship enhancement. San Francisco: Jossey-Bass. HINCHLIFFE, M., HOOPER, D., & ROBERTS, F. J. (1978). The melancholy marriage. New York: Wiley. HOOLEY, J. M., ORLEY, J., & TEASDALE, J. D. (1986). Levels of expressed emotion and relapse in depressed patients. British Journal of Psychology, 148, 642-647. KAHN, J., COYNE, J. C., & MARGOLIN, G. (1985). Depression and marital conflict: The social construction of despair. Journal of Social and Personal Relationships, 2, 447-462. KAZDIN, A. E., & BASS, D. (1989). Power to detect differences between alternative treatments in comparative psychotherapy outcome research. Journal of Consulting and Clinical Psychology, 57, 138-147. KLERMAN, G. L., WEISSMAN, M. M., ROUNSAVILLE, B. f., & CHEVRON, E. S. (1984). Interpersonal psychotherapy of depression. New York: Basic Books. KOERNER, K., & LINEHAN, M. (1992). Integrative therapy for borderline personality disorder: Dialectical behavior therapy. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. LAMBERT, M. J. (1992). Psychotherapy outcome research: Implications for integrative and eclectic therapists. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. LAMBERT, M. J., SHAPIRO, D. A., & BERGIN, A. E. (1986). The effectiveness of psychotherapy. In S. L. Garfield & A. E. Bergin (Eds.), Handbook of psychotherapy and behavior change (3rd ed., pp. 157—211). New York: Wiley. LEAF, P. J., WEISSMAN, M. M., MYERS, J. K., TISCHLER, G. L., & HOLZER, C. E. (1984). Social factors related to psychiatric disorder: The Yale Epidemiologic Catchment Area Study. Social Psychology, 19, 53-61. LEWINSOHN, P. M., HOBERMAN, H. M., & ROSENBAUM, M. (1988). A prospective study of risk factors for unipolar depression. Journal of Abnormal Psychology 97, 251-264. LIN, N., DEAN, A., & ENSEL, W. (1986). Social support, life events, and depression. New York: Academic Press. LIN, N., & ENSEL, W. (1984). Depression mobility and its social etiology: The role of life events and social support. Journal of Health and Social Behaviour, 25, 176-188. LUBORSKY, L. (1984). Principles of psychoanalytic psychotherapy: A manual for supportive-expressive treatment. New York: Basic Books. MEADOR, B. C., & ROGERS, C. R. (1979). Person-centered therapy. In R. J.

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Corsini (Ed.), Current psychotherapies (2nd ed., pp. 131—184). Itasca, IL: Peacock. NIETZEL, M. T., RUSSELL, R. L, HEMMINGS, K. A., & GRETTER, M. L. (1987). Clinical significance of psychotherapy for unipolar depression: A metaanalytic approach to social comparison. Journal of Consulting and Clinical Psychology, 55, 156-161. OATLEY, K., & BOLTON, P. (1985). A social-cognitive theory of depression in reaction to life events. Psychological Review, 92, 372—388. PAYKEL, E. S., & WEISSMAN, M. E. (1973). Social adjustment and depression. Archives of General Psychiatry, 28, 659—663. PENNEBAKER, ]. W. (1989). Confession, inhibition, and disease. In L. Berkowitz (Ed.), Advances in experimental social psychology (Vol. 22, pp. 211-244). New York: Academic Press. PHIFER, J. F., & MURRELL, S. A. (1986). Etiologic factors in the onset of depressive symptoms in older adults, journal of Consulting and Clinical Psychology, 95, 282-291. RIDLEY, C, PHILLIPS, J. A., & MUSZYNSKI, R. (1988). Mutual problem solving program: Couples manual. Unpublished manuscript, University of Arizona, Tucson. ROBINSON, L. A., BERMAN, J. S., & NEIMEYER, R. A. (1990). Psychotherapy for the treatment of depression: A comprehensive review of controlled outcome research. Psychological Bulletin, 108, 30-49. ROGERS, C. R. (1951). Client-centered therapy. Boston: Houghton Mifflin. ROGERS, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21, 95—103. ROKKE, P. D., CARTER, A. S., REHM, L. P., & VELTUM, L. G. (1990). Comparative credibility of current treatments for depression. Psychotherapy, 27, 235—242. SARASON, B. R., SARASON, I. G., & PIERCE, G. R. (1990). Social .support: An interactional view. New York: Wiley. SCHAEFER, C., COYNE, J. C., & LAZARUS, R. S. (1981). The health-related functions of social support. Journal of Behavioral Medicine, 4, 381—406. SCHOFELD, W. (1964). Psychotherapy. The purchase of friendship. Englewood Cliffs, NJ: Prentice-Hall. SLOANE, R. B., STAPLES, F. R., CRISTOL, A. H., YORKSTON, N. ]., & WHIPPLE, K. (1975). Psychotherapy vs. behavior therapy. Cambridge, MA: Harvard University Press. SMITH, M. L., GLASS, G. T., & MILLER, T. I. (1980). The benefits of psychotherapy. Baltimore: Johns Hopkins University Press. STILES, W. G., SHAPIRO, D. A., & ELLIOTT, R. (1986). "Are all psychotherapies equivalent?" American Psychologist, 41, 1—8. STRUPP, H. H. (1980a). Success and failure in time-limited psychotherapy: A systematic comparison of two cases (Comparison 1). Archives of General Psychiatry, 37, 595-603. STRUPP, H. H. (1980b). Success and failure in time-limited psychotherapy: A

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systematic comparison of two cases (Comparison 2). Archives of General Psychiatry, 37, 708-716. STRUPP, H. H. (1980c). Success and failure in time-limited psychotherapy: With special reference to the performance of a lay counselor (Comparison 3). Archives of General Psychiatry, 37, 831-841. STRUPP, H. H. (1980d). Success and failure in time-limited psychotherapy: Further evidence (Comparison 4). Archives of General Psychiatry, 37, 947— 954. STRUPP, H. H., & BINDER, J. L. (1984). Psychotherapy in a new key: A guide to time-limited dynamic therapy. New York: Basic Books. STRUPP, H. H., & HADLEY, S. W. (1979). Specific vs. nonspecific factors in psychotherapy: A controlled study of outcome. Archives of General Psychiatry, 36, 1125-1136. SVARTBERG, M., & STILES, T. C. (1991). Comparative effects of short-term psychodynamic psychotherapy: A meta-analysis. Journal of Consulting and Clinical Psychology, 59, 704-714. TRUAX, C. B., & MITCHELL, K. M. (1971). Research on certain therapist interpersonal skills in relation to process and outcome. In S. L. Garfield & A. E. Bergin (Eds.), Handbook of psychotherapy and behavior change (2nd ed., pp. 299-344). New York: Wiley. VAUGHN, C. E., & LEFF, J. P. (1976). The influence of family and social factors on the course of psychiatric illness. British Journal of Psychiatry, 129, 125— 137. WEISSMAN, M. E., & PAYKEL, E. S. (1974). The depressed woman. Chicago: University of Chicago Press. WEISSMAN, M. M. (1987). Advances in psychiatric epidemiology: Rates and risks for depression. American Journal of Public Health, 77, 445-451.

CHAPTER 13

Integrative Therapy for Borderline Personality Disorder: Dialectical Behavior Therapy KELLY KOERNER AND MARSHA M. LINEHAN

L/IALECTICAL BEHAVIOR THERAPY is an integrative outpatient treatment for patients who meet the criteria for borderline personality disorder (BPD). Developed by Linehan and her colleagues at the University of Washington, this approach blends cognitive-behavior therapy with Linehan's biosocial theory of borderline personality (Linehan, 1987b, in press a; Linehan & Koerner, in press) and with dialectical philosophy. The biosocial theory organizes case conceptualization and treatment planning; dialectical philosophy provides a metaperspective that influences all levels of the therapy from the theory of change to specific interventions. This chapter begins with an overview of the principles that guide the approach, moves to a description of the therapy and a case example, and ends with a summary of the research to date on the approach.

Background of the Approach Dialectical behavior therapy (DBT) began as Linehan modified traditional cognitive and behavior therapy techniques in response to difficulties she encountered working with parasuicidal clients. Parasuicide is any intentional, acute, self-injurious act, including, but not limited to, suicide attempts. In the late 1970s, Linehan and her research team began to observe Linehan's sessions with parasuicidal clients to systematically identify and distill the most useful aspects of her interventions and style. They were surprised to discover that seemingly paradoxical interventions were interspersed with the intended behavior therapy techniques. These "paradoxi-

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cal" techniques included matter-of-fact exaggerations of the implications of events (similar to Whitaker, 1975, pp. 12—13), encouragement to accept feelings and situations in the tradition of Zen Buddhism (e.g., Hanh, 1975), and double-bind statements directed at pathological behavior (e.g., Watzlawick, 1978). Serendipitously, the term dialectical was adopted to describe the integration of behavior therapy with these interventions traditionally associated with other theoretical orientations. In hindsight, the term was chosen for two reasons. First, the therapy was called dialectical rather than paradoxical behavior therapy because of the fear that inexperienced therapists would misinterpret and misuse paradoxical interventions (e.g., prescribe suicide—DBT does not prescribe suicide under any circumstances). Second, the term highlighted important polar opposites experienced by both client and therapist in their work together. For example, the dialectical perspective takes seriously the BPD patient's phenomenological ambivalence of wanting both to live and to die. It is not that one desire is true and the other false, or even that these positions rapidly alternate: both positions are simultaneously true. To hold up only one side is to imply that if one really wanted to die or really wanted to live, one would act differently, so that one's actions would be consistent with one's "true" desires. However, the dialectical resolution here is to accept suicidal behavior as an understandable response to the chaos and misery of these clients' lives. Suicide is one way out of a chaotic and miserable life. An equally valid alternative—to change one's life—is proposed by DBT.

Influential Concepts This integrative approach continues to evolve, drawing concepts from three areas: behavior therapy, a biosocial theory of BPD, and dialectical philosophy. Because most readers have some knowledge of behavior therapy and because numerous textbooks on behavior therapy are available (e.g., Barlow, 1985; Goldfried & Davison, 1976; Jacobson, 1987), only brief mention will be given to the assumptions of behavior therapy. Rather, the majority of the following section will be devoted to introducing ideas from Linehan's theory of BPD and from dialectical philosophy that influence the practice of DBT.

BEHAVIOR THERAPY PRINCIPLES

DBT's roots are in behavior therapy. The essential characteristics of behavior therapy, according to Kazdin (1978), include the following:

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1) focus upon current rather than historical determinants of behavior; 2) emphasis on overt behavior change as the main criterion by which treatment should be evaluated; 3) specification of treatment in objective terms so as to make replication possible; 4) reliance upon basic research in psychology as a source of hypotheses about treatment and specific therapy techniques; and 5) specificity in defining, treating and measuring the target problems in therapy, (p. 375)

DBT shares these characteristics. As in traditional behavior therapy, deviant or problematic behavior is thought of in terms of deficiencies in adaptive behavior, or excesses in maladaptive behavior, rather than as "illness." This leads to a focus on capability enhancement to increase skilled performance, rather than personality reorganization or understanding of original causes or psychodynamic concomitants. Suicidal behavior and other maladaptive behaviors often seen in BPD clients are conceptualized as extreme attempts at problem solving that have been reinforced over more socially sanctioned solutions. Often, skills deficits partially contribute to extreme problem-solving styles. For example, in a family where direct communication of distress is ignored or punished, the resultant discrepancies between emotional experience and emotional expression may interfere with an ability to communicate distress. A client with such a history may verbally express great despair while smiling or exhibiting no affect. The lack of corresponding affect expression may persuade the therapist to discount the client's seriousness, thus making it necessary for the client to communicate her or his despair in a more convincing way. This is an example of a skills deficit (inability to effectively communicate distress) and would be addressed by teaching the client to gain help with less extreme methods. BIOSOCIAL THEORY OF BORDERLINE PERSONALITY DISORDER

Much of DBT, especially the selection and priority of treatment targets, is guided by Linehan's biosocial theory of the etiology and maintenance of borderline personality (Linehan, 1987b, in press; Linehan & Koerner, in press). Briefly, the core pathology in BPD is seen as emotion dysregulation. Affective instability, particularly the control and expression of anger, is an important defining characteristic of BPD in most diagnostic schemes (American Psychiatric Association, 1987; Gunderson, Kolb, & Austin, 1981; Kernberg, 1984) and has been discussed with respect to the depression-mania continuum (e.g., Gunderson & Elliott, 1985). Linehan's theory, however, conceptualizes the relationship of emotion dysregulation to BPD as the primary dysfunction in the disorder rather than simply symptomatic or definitional. Borderline individuals have emotion dysregulation across several, perhaps all, emotions, and this systemic dysregulation

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is produced by emotion vulnerability and inadequate attempts at emotion regulation. Emotion vulnerability is conceptualized as a physiological predisposition to be highly sensitive to emotional stimuli, to respond intensely to emotional stimuli, and to return slowly to baseline. Emotion regulation is the ability to (a) inhibit inappropriate behavior related to strong negative or positive affect, (b) self-sooth physiological arousal that the strong affect has induced, (c) refocus attention, and (d) organize (oneself) for coordinated action in the service of an external goal (Gottman & Katz, 1990, p. 373). Linehan hypothesizes that emotion dysregulation in BPD individuals, then, is a combination of emotion vulnerability and the inability to adequately regulate affect. This emotion dysregulation at the core of BPD is a joint outcome of temperamental vulnerability and certain developmental circumstances, which, in combination, set the stage for later adult psychopathology. The crucial developmental circumstance believed to be important here is the invalidating environment, by which Linehan (1987a, 1987b, 1989, in press) means aspects of the social and physical environment that are particularly likely to generate and exacerbate emotion vulnerability and difficulties regulating emotions. A defining characteristic of the invalidating environment is the tendency to respond erratically and inappropriately to private experience and, in particular, to be nonresponsive to private experience, which does not have easily interpreted public accompaniments (e.g., broad smiling when happy). These families also tend to respond extremely (overor underresponding) to the public accompaniments of private experience. In a more optimal environment, the parent pays attention to cues and helps the child accurately label feelings. In invalidating environments, a parent may not anticipate or attend to the effects that events are likely to have on the child; for example, if the child's dog dies, no one notices or says anything about it. These parents also actively tell children not to feel what they are feeling; for instance, telling the child who cries after a fall and scraped knee, "Stop crying—that didn't hurt," or "Stop crying or I'll give you something to cry about." Furthermore, in an invalidating environment, children are not taught to label accurately or modulate arousal or to trust their own experiences as valid responses to events. Instead they are actively taught to invalidate their own private experiences and to search the social environment for cues about how to think and feel. By oversimplifying the ease of solving problems, the invalidating environment does not teach the child to tolerate distress or to form realistic goals or expectations. By punishing communication of negative emotions or responding only to escalated emotional expressions, the child learns to oscillate between extremes of emotional inhibition and expression. One of the most traumatic and prototypic invalidating experiences is

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childhood sexual abuse. There is good reason to believe that childhood sexual abuse is related to a diagnosis of BPD (Briere & Zaida, 1989; Bryer, Nelson, Miller, & Kroll, 1987; Herman, Perry, & van der Kolk, 1989; Wagner & Linehan, 1989) and may be the most influential predisposing factor to later diagnosis of BPD. The trauma of the actual molestation may be only one among many concomitant factors that determine the extent to which sexual abuse affects the person. Other factors, such as the broad effects of parenting practices that fail to protect or actually promote abuse, impairment of the child's developing sense of self in relation to others, and the responses of the family and others to disclosure or secrecy regarding the abuse, may potentially influence the extent to which sexual abuse affects the person. However, given that all children who are sexually abused do not later receive a diagnosis of BPD, it remains unclear as to which aspects of sexual abuse (e.g., age when abuse began, duration, identity and number of perpetrators) lead to later BPD or whether other factors (e.g., biologically based differences in emotion regulation) are crucial in moderating the effects of abuse. This biosocial theory of BPD guides conceptualization and treatment planning. From-this perspective, much of the problematic behavior of BPD individuals, including suicidal behavior, is a consequence of current and past attempts to cope with emotion dysregulation. Therefore, given the theory of BPD proposed here, the first year of DBT is designed to teach skills that foster emotion regulation. Emotion dysregulation (e.g., inappropriate mood-dependent behavior, mood-escalating cognitive rumination) is blocked and emotion regulation (e.g., self-soothing, organizing for longterm adaptive goals) is reinforced. In addition, clients learn (1) skills that increase interpersonal effectiveness in conflict situations, and thus have the promise of decreasing environmental stimuli associated with negative emotions; (2) strategies culled from the behavioral treatment literature on affective disorders (depression, anxiety, fear, anger) that increase selfregulation of unwanted emotions in the face of actual or perceived negative emotional stimuli; (3) skills for tolerating emotional distress until changes are forthcoming; and (4) self-management skills, which are a prerequisite for actively learning any other skills. DIALECTICAL PHILOSOPHY

Dialectics provides a metaperspective that permeates all aspects of the therapy, informing the most abstract understanding of change processes to the more concrete selection of specific interventions. Dialectics is used here to mean both the world view on the nature of reality and how we know it, and the process of therapeutic change (persuasion through the experiential resolution of opposites).

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Dialectical perspectives on the nature of reality and human behavior share three characteristics (cf. Wells, 1972, for discussion of shift to dialectical philosophy across the sciences). First, dialectical perspectives stress the fundamental interrelatedness or wholeness of reality. This means that, similar to systemic approaches, dialectics views any analysis of individual parts of a system as of limited value per se, unless the analysis clearly relates the part to the whole. Second, reality is not seen as static but as comprised of opposing forces (thesis-antithesis), out of whose synthesis evolves a new set of opposing forces. Third, dialectical approaches see the nature of reality as change rather than as stable structure or content. This perspective of reality differs from usual habits of thought that somewhat arbitrarily separate causes from effects, subjects from objects, parts from wholes, and most important, the individual from the environment. One of the most articulate proponents of dialectical models, Robert Kegan (1982), describes the evolution of self as a process of transformations over the life span, generated by tensions between self-preservation and self-transformation within the person and within the person-environment system, punctuated by temporary truces or developmental balances. In order to appreciate this evolutionary process of self-development, Kegan (1982) writes that, As important as it is to understand the way the person creates the world, we must also understand the way the world creates the person. In considering where a person is in his or her evolutionary balancing we are looking not only at how meaning is made; we are looking, too, at the possibility of the person losing this balance. We are looking, in each balance, at a new sense of what is ultimate and what is ultimately at stake. We are looking, in each new balance, at a new vulnerability. Each balance suggests how the person is composed, but each suggests, too, a new way for the person to lose her composure, (p. 114) These general ideas permeate DBT. At the broadest level, the process of change is seen as dialectical, as a naturally evolving, continuous movement between acceptance and change, in which the therapist supports the client's attempts at self-preservation and self-transformation. The therapist trusts that the client has within herself all of the potential that is necessary for change. Metaphorically, the acorn is the tree, that is, the essentials of growth are already present in the current situation. The person and environment both reciprocally limit and challenge each other. At every moment, there is a temporary balance between the client's attempts to maintain herself as she is without changing, and her attempts to change herself regardless of the constraints of her history and current situation. The transition to a new temporary stability is often experienced as a painful crisis. "Any real resolution of the crisis must ultimately involve a new way

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of being in the world. Yet the resistance to doing so is great, and will not occur in the absence of repeated and varied encounters in natural experience" (Kegan, 1982, p. 41). The therapist helps the client negotiate crises by balancing acceptance and change strategies. That is, the therapist simultaneously accepts and nurtures the patient while benevolently demanding that the patient change and leam to better help herself, and simultaneously exerts control and guidance while recognizing and fostering the patient's autonomy. At the case conceptualization level, a dialectical approach to BPD differs from cognitive and biological approaches because it does not assume a priori that explanations emphasizing one mode of behavior are intrinsically more important or compelling than others. Rather, the crucial question is under what conditions covariations among emotions, cognitions, overt behaviors, and physiological responding hold, and under what conditions these relationships obtain in the current situation. This makes ongoing assessment crucial. More specifically, the therapeutic dialogue itself is seen as dialectical, as change via persuasion that comes through experiential knowledge. In discussions, the therapist communicates to the patient that truth is neither relative nor absolute, but rather evolves, develops, and is constructed over time. Because it is not possible to grasp the totality of the truth at any one particular time, the DBT therapist looks for what has been left out of her or his own and the patient's point of view, encouraging the patient to collaborate in the search for the wisdom inherent in each position. The DBT therapist recognizes that each statement contains its opposite. As Goldberg (1980) writes, "I assume that truth is paradoxical, that each article of wisdom contains within its own contradictions, that truths stand side by side. . . . Contradictory truths do not necessarily cancel each other out or dominate each other, but stand side by side, inviting participation and experimentation" (pp. 295—296). In other words, the therapist does not become dialectical only in order to get the client to move (as seems sometimes the case with paradoxical interventions), but rather is constantly searching for aspects that have been overlooked, so that the therapist and client develop increasingly whole explanations and accounts of the client's life problems. At the most specific level, dialectical perspectives alter the implementation of many standard cognitive behavioral techniques in DBT. For example, cognitive modification is not approached in the typical rational way of standard cognitive therapy (e.g., Beck, Rush, Shaw, & Emery, 1979). Dialectics makes DBT cognitive interventions incompatible with the current cognitive therapy emphasis on rationality as the sole criterion of healthy thought. Rather, intuition and nonrational thought are also considered valid and valuable and are explicitly taught in DBT. Cognitive and

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behavioral therapists also emphasize changing painful emotional states, whereas the DBT therapist is as likely to encourage the acceptance of painful emotional experiences (cf. Messer, 1992).

Model of Integration The overlap between DBT and other psychotherapy approaches is one of its most salient characteristics. DBT incorporates strategies that other approaches take as central to their own treatment approach. For example, DBT validation strategies emphasize acceptance and are very similar in form and intent to aspects of client-centered treatment (cf. Arkowitz, 1992). The emphasis on balancing polarities, the inherent wisdom of each client, and the attention to and acceptance of emotions is similar to elements of Gestalt therapy. The priority given to the interpersonal relationship between client and therapist and to the work on therapy-interfering behaviors is very similar to the emphasis in psychodynamic therapy on transference and countertransference issues and analyzing resistance (cf. Wachtel & McKinney, 1992). The reciprocal communication strategy overlaps nicely with nursing strategies of "using self," whereas the irreverent communication strategy is similar in many respects to strategic interventions of Carl Whitaker (e.g., Whitaker, 1975). An important aspect of DBT, however, is that the adoption of these strategies is guided both by empirical support and by theory (dialectical and biosocial). DBT does not advocate combining techniques without theoretical integration. The primary reason DBT does not advocate atheoretical eclecticism is that, especially with clients who have multiple problems and multiple crises, there is a strong temptation to prematurely and arbitrarily change treatment plans and interventions based on the therapist's distress. Theory and empirically driven decisions help the clinician develop and persist with the treatment plan in the face of weekly crises without being overwhelmed and losing track of the overall direction of therapy; on the other hand, theory also determines when change in the treatment plan is indicated. The primary value of technical eclecticism, with this population in particular, is that we know so little about the components of effective treatment for serious chronic mental disorders. Despite the promising initial results in the treatment outcome research on DBT (see research section for further discussion), much work remains to be done to improve what we have to offer these clients. Data about the course of the disorder suggest that a large portion of BPD patients do not receive treatment that significantly improves the quality of their lives (McGlashan, 1983; Pope, Jonas, Hudson, Cohen, & Gunderson, 1983; Stone, 1989). The relative lack

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of progress with these patients is often attributed to their "manipulativeness," "resistance," and "undermining" of treatment—in other words, to their refusal to comply with treatment efforts that should be enough to effect significant relief. An alternative, however, is to consider the possibility that these patients are much like cancer patients. We have some idea of what might contribute to their disorder, but the available treatments are insufficient. We do not express anger toward cancer patients because the therapy doesn't "cure" them; we don't blame them if the chemotherapy doesn't result in remission; we don't insist that they are deliberately trying to keep themselves from getting better when, despite our best efforts, they continue to deteriorate. If the nature of BPD makes this an apt analogy, efforts should be directed at improving treatment rather than blaming the patient for the inadequacy of the treatments we now have available.

Patient Assessment and Treatment Goals Treatment planning in DBT is assessment driven, and it is hard to emphasize this point strongly enough. Assessment and case conceptualization are organized in behavioral terms. That is, the therapist and client identify problematic behaviors and the factors associated with the initiation and maintenance of problematic patterns; next they identify excesses and deficits that interfere with the client engaging in goal behaviors; and then they identify what the client must learn, experience, and do in order to engage in the goal behavior. Goals need not be simplistic; for example, a goal behavior may be to experience intimacy in close relationships without distancing oneself from the experience. By behavioral we mean behavioral in the broadest sense, including emotions and cognitions, and both private and publicly observable behavior. In other words, assessment information is obtained for multiple-response systems (overt motor, cognitive, verbal, and physiological responses). Pretreatment assessment begins with a thorough diagnostic workup, including diagnosis of BPD with the DSM-III-R (American Psychiatric Association, 1987) and the Gunderson Diagnostic Interview for Borderlines (Gunderson, Kolb, & Austin, 1981). Pretreatment, or early in treatment, a thorough history of all prior suicidal behaviors, including detailed information on the environmental and social contingencies associated with them, is obtained to allow the estimation of current and long-term risks for parasuicide and suicide. This information is crucial for treatment planning, because a high proportion (10 to 20 percent) of borderlines who engage in self-injurious behavior eventually suicide (Frances, Fyer, & Clarkin, 1986), because the clinician needs to have a good assessment of the risks

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involved in suicidal crisis management, and because the clinician begins to identify problems that precipitate suicidal crises. In addition to needing good information about the risk of the client's suicidal behavior, another reason for the strong emphasis on assessment is that, because of stereotypes associated with the diagnosis of BPD, the clinician is often tempted to infer negative motivational causes for client behavior (Reiser & Levenson, 1984). In DBT, however, rather than taking the therapist's feeling of being manipulated as a de facto indicator of the client's intent, an assessment is made, in which trying to control the therapist is only one of many possible client intents. Assessment may identify that, although the therapist feels manipulated, the client had no intent to manipulate the therapist but does, however, have skills deficits that result in an inability to communicate distress in ways that make others feel like helping rather than feeling manipulated. DBT has a set of nonnegotiable treatment goals, prioritized according to theoretical importance, to which the client must agree (even if halfheartedly) as part of the acceptance into treatment. To be accepted into treatment the client must make a commitment to (1) decrease suicidal and other life-threatening behavior. During treatment, client and therapist develop the commitment to (2) decrease interpersonal behaviors that interfere with therapy, and to decrease behaviors that seriously interfere with the client's quality of life, such as substance abuse, losing housing, financial problems, and medical problems; and (3) increase behavioral skills. Once progress has been made on these goals, the focus shifts to treatment to alleviate lasting effects of childhood physical and sexual abuse, then to development of broad-based self-respect, and finally to work toward any other client goals. Practical considerations have led to this hierarchy. Parasuicidal behavior is the first priority because it is associated with accidental death, permanent physical injury, and therapist stress and burnout (Roswell, 1988). Behaviors that threaten life, threaten treatment efficacy. Changing behaviors associated with intent to harm oneself goes to the heart of the treatment enterprise: the goal is to help, rather than harm, oneself. The reduction of therapy-interfering behavior on the part of both client and therapist is the second goal. Client therapy-interfering behaviors include frequently missing sessions, an inability or refusal to work in therapy, continuous disruptive crises, excessive psychiatric hospitalizalions, psychotic episodes, dissatisfaction with therapy, lying, excessive demands on the therapist and other behaviors that have a negative effect on the therapeutic relationship. In group therapy, these behaviors are nonattendance, highly disruptive behavior in group, and overt hostility to other group members. Negative therapist behaviors include not returning client calls, being late to appointments, engaging in hostile or negative comments, and wanting to terminate therapy or reject the client. All these

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issues are treated nonjudgmentally as problems to be solved in the therapy. Quality-of-life-interfering behaviors (e.g., inability to maintain stable housing, failure to attend to medical problems) are important because the overarching goal of the therapy is to create lives worth living and thereby to reduce suicidal behavior in the long term. The practical reason for this nonnegotiable hierarchy is that it helps the therapist structure the therapy and cope with the temptation to switch from one field of intervention to the next in response to the unrelenting series of crises. Individual session time is allocated so that those targets at the top of the hierarchy take precedence. Assessment occurs in each session throughout treatment to determine appropriate interventions. Clients fill out daily behavioral diaries, covering targeted problem areas, and bring these to session. In the session, the therapist's assessment is guided by two questions: Does the client have the skill to solve the problem? If the client does have the capability, what prevents the client from taking the necessary steps to solve the problem? The therapist continually assesses whether the client has the capability to engage in more adaptive responses; if not, then skill training is indicated. Interpersonal problems may be due in part to deficient assertiveness or anger-management skills. Assessment may identify conditions that support problematic behavior and interfere with the development of less problematic behavior. For example, a client's low-level overdose may precipitate a hostile roommate to show caring by taking the patient to the emergency room, where they have a heart-to-heart conversation resolving some differences. The client may or may not have intended to have this effect; nevertheless, such consequences increase the probability of future suicidal behavior. If assessment identifies such conditions supporting problematic behavior, then the therapist works with the client to change these conditions. Assessment also identifies what inhibits or interferes with the client's attempts at adaptive problem solving. To the extent that anxiety, shame, or other emotional responses interfere with engaging in better behavior, exposure-based treatment is indicated. To the extent that the application of existing problem-solving capabilities are interfered with by faulty beliefs and assumptions, cognitive modification is indicated.

Applicability and Structure DBT was developed as a treatment for people who met criteria for BPD and who engaged in parasuicidal behavior. Thus, this is the patient population for which DBT is clearly indicated. Very few borderline males have been treated with DBT, and all outcome data have been based on female

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clients. There are some client characteristics that, although not contraindications, do potentially complicate treatment. Clients who are court ordered and will not commit to a year of therapy otherwise are more likely to drop out. Benefits from DBT group skill training are more likely for those clients who are at least somewhat able to control the overt expression of hostility toward other group members. One note here is that the typical DBT protocol may need modifications with adolescent borderlines or borderlines who are still living with their families. DBT makes much use of the therapeutic relationship to foster change in the client. When the individual's suicidal behavior is serving a fundamentally communicative function within her family, DBT may need to include family and/or peer therapy. The therapist's influence is often mitigated by the influence of family and friends. Or to put it another way, the DBT therapist must be an important person to the patient in order to be able to exert influence. With adolescents whose primary relationships are with family and peers, the therapist may need to do more than is usual in adult therapy to establish a relationship likely to promote change. DBT has been adapted to a variety of settings. One unique aspect of the program at the University of Washington is that it is a "program" designed specifically for the treatment of BPD. The program consists of an assessment team, individual outpatient therapy, skills training, an optional supportive process group for advanced clients, individual and group consultation for therapists, a research team, and ancillary treatments such as hospitals and pharmacotherapy. For clients, there is a credibility, and even a bit of mystique, associated with the Suicidal Behaviors Research Clinic. The health-promoting influence of increasing hopeful expectations among a group of clients who typically have had numerous prior therapies should not be underestimated. Individual therapy is provided by the "lead" therapist, who is responsible for the majority of the treatment and crisis management. Session length varies according to the current therapy task, but sessions are usually between 50 to 90 minutes. Skills training is conducted in weekly sessions by either a behavioral technician or in a group psychoeducational format. Both individual therapy and skills training are required during the first year of the program. Telephone consultations are available between sessions with the individual therapist to facilitate in vivo practice of the skills that clients learn in group and for crisis intervention. Supportive interpersonal process groups are available and optional after the client completes one year of skills training. Therapist participation in a uniquely structured consultation group may be crucial to the successful implementation of DBT. Our consultation group meets weekly for one to two hours. There are six agreements that guide the consultation group. First, all agree to adopt a dialectical philoso-

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phy so that when polarities arise, all will search for the synthesis rather than battle to establish an absolute truth. Second, everyone agrees to consult with the patient about how the patient can better interact with other staff rather than tell other staff how to interact with the patient. Third, all the therapists can make their own rules about the conditions of therapy, which need not be consistent with those of other members of the treatment team. The goal of treatment is not to create a stress-free environment for the client but to help her better negotiate the real world, in which people have different limits. Fourth, therapists agree to observe their own limits and agree not to conclude that other members' limits are wrong if different from their own. Thus, members of the consultation group do not infer that narrow limits are due to fears of intimacy, self-centeredness, or a generally withholding nature, nor are broad limits assumed to be caused by problems with boundaries, projective identification, and naivete. Fifth, all agree to search for phenomenologically empathic, nonpejorative explanations of patient behavior. Finally, all agree that therapists are fallible. Mistakes in difficult and complex cases are inevitable, and a willingness to admit and repair mistakes is important. The consultation group helps the therapist both by validating the inherent wisdom in the position that created the problem and by generating solutions to the problem. DBT has been adapted to inpatient units and day-treatment programs as well. The challenge in these settings is to modify the format of the treatment while maintaining the essential content and spirit. There are many possibilities. Changes in the format of skills training have included offering weekly large-group lectures to teach fundamentals of new behavioral skills, with frequent, small, homework groups and drop-in consultation hours for help in applying skills. All inpatient staff can share the responsibility of coaching the client in the application of specific skills to specific situations, decreasing the necessity of phone calls to the lead therapist. Whereas in our outpatient setting the behavioral and solution analyses of parasuicidal and therapy-interfering behaviors are conducted by the lead therapist, in an inpatient setting the analyses can be conducted by any combination of unit staff, nurses, the entire milieu, during unit meetings, or by the individual therapist. In one inpatient setting, a behavioral and solution analysis of each self-harm incident is applied in every setting: one-on-one interactions with nursing staff, individual psychotherapy, and the weekly unit meeting. Another inpatient setting prohibits discussion of anything other than a behavioral/solution analysis with the patient for the 24 hours following each incident of parasuicide (a substitute for the previous practice of having the patient sit on a couch in front of the nurses' station for the next 24 hours). The variations are seemingly endless, each keeping a focus on the essential balance of acceptance/ validation versus change/problem solving.

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Clinical Interventions The general idea of DBT is to create a validating environment that allows the therapist to simultaneously extinguish maladaptive behavior, teach more adaptive behavior, and soothe and cajole the patient through the experience. This section describes client and therapist roles, basic strategies in individual therapy and skills training, communication styles used, and the role of the therapeutic relationship in DBT. CLIENT AND THERAPIST ROLES

As mentioned previously, DBT requires the patient to commit to several treatment goals that are nonnegotiabie, that is, they must be accepted or the patient will not receive treatment at our program. The client's role is to work as hard as she can to accomplish the goals of the therapy. The client commits to stay in therapy for one year (or other specified period), to attend scheduled sessions, to abide by any agreedupon research requirements, and to pay negotiated fees. The therapist's role is to be an educator, coach, cheerleader, and consultant to the patient. The therapist agrees to make every reasonable effort to conduct competent and effective therapy, to be available for weekly sessions and phone consultations, to provide needed therapy backup, to respect the integrity and rights of the patient, to be sensitive to the power differential inherent in the therapeutic relationship, and to maintain confidentiality. BASIC STRATEGIES IN INDIVIDUAL AND GROUP THERAPY

The majority of interventions in both individual and group DBT are drawn from the validation, problem solving, and dialectical strategies. Both group and individual therapists adopt irreverent and reciprocal communication styles; however, individual therapists are more likely to use the therapeutic relationship to create conditions for change, whereas the group therapist's prime objective is to teach skills. The following section briefly describes these interventions. Validation Strategies There are two types of validation strategies in DBT. In the first, the therapist finds the wisdom, correctness, or value in the client's emotions, thoughts, or actions. To do this the therapist identifies the response pattern, communicates hearing or accurately observing the client's response, and communicates that the client's reactions make perfect sense given her

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life history and current circumstances. The emphasis is on finding those events that support or validate the patient's response rather than finding the distortion or error of the response. In the second type of validation, the therapist observes and believes in the inherent capability of the patient to improve her life. The therapist does this both by verbally stating confidence in the client's basic worth and competence and by engaging in actions that show respect for the client's strengths rather than an overconcern about the client's fragility. Problem Solving Parasuicide and other maladaptive behaviors are seen as attempts at problem solving, and so a major focus of the treatment is to help the client find alternative ways to solve problems. The first stage is to define the problem and identify precipitants and ways in which the client's actions, emotions, and thoughts influence and are influenced by the environment. This is repeated until the client sees the situation-response patterns involved (i.e., has insight). The next stage is the generation, evaluation, and implementation of alternative solutions. Depending on assessment information, one or more of four change strategies may be indicated: (1) if the client does not have the capability to engage in more adaptive responses, skills training is indicated; (2) if reinforcement contingencies support problematic behavior and interfere with the adoption of less problematic behavior, contingency management strategies are used; (3) if the client's attempts at adaptive problem solving are inhibited by anxiety, shame, or other emotional responses, exposurebased treatment is indicated; and (4) if the application of existing problemsolving capabilities are interfered with by faulty beliefs and assumptions, cognitive restructuring is indicated. Dialectical Strategies The crucial dialectic is balancing change and acceptance. The idea with these strategies is to avoid being drawn into one side of a polarity to the exclusion of the other, and to emphasize the validity of both positions. This translates into the therapist answering both yes and no, true and not true. The therapist does not do much to resolve the client's resulting confusion, but rather expects that it will clear over time. Dialectical strategies can be used to promote change or acceptance. The therapist may tell stories, use metaphor, or philosophize, but the objective is to encourage the client to attempt or adopt better behavior by setting up a contrast. For example, if a client said that she could not do some new behavior (such as finding a place to live while in the midst of a crisis) because it was too hard and too

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painful, the DBT therapist would combine validation and insistence on the necessity of change, with active support and help. The therapist might say, "Of course you can't do it, and this is the worst possible time to be trying to get these new skills to work, but the fact of the matter is, you have to do it anyway. I'll help, but I can't do it for you. Let's go through it together. What is the first thing you need to do?" ASPECTS OF SKILLS TRAINING IN DBT

DBT is primarily a skills-training approach (Linehan, in press b). In addition to interpersonal effectiveness skills and self-management skills, clients are taught skills to regulate and tolerate emotional arousal. This emphasis on tolerating and allowing emotional arousal is crucial. One of the most interesting integrative aspects of DBT has been its adaptation of techniques drawn from contemplative and Eastern meditation practices. The "core skills" taught in the first year of therapy help the client develop control over her attention as she learns to observe, describe, and participate. Observing is paying attention to the flow of events, emotions, and other responses without trying to change them. Describing is when one labels events, emotions, or other responses, identifying thoughts as thoughts, feelings as feelings, and noting that one's observations and labels are different from that which is observed and labeled. Participating is being fully involved in the flow of events, emotions, or other responses without self-consciousness, not mindlessly but with full attention and alertness. Clients learn to observe, describe, and participate cultivating a nonjudgmental, mindful focus on doing what works. Distress-Tolerance Skills As mentioned earlier, the DBT therapist is as likely to encourage the acceptance of painful emotions as she or he is to suggest the client use strategies to alter her emotions. Distress-tolerance skills encourage the client to work on accepting reality as it is. This is not the same as approving of reality. Rather, the client is taught strategies to help her tolerate distress when the sources of her distress are unlikely to change or until she is able to effect some change. These strategies include distraction, self-soothing, imagery, and mentally rehearsing pros and cons of tolerating distress versus taking impulsive action to end distress in the short term. Emotion-Regulation Skills Emotion-regulation training directly teaches clients to identify and label emotions, to identify obstacles to changing emotions, to increase positive

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emotional events, and to change emotions by acting independently of one's mood. Clients are encouraged to reduce vulnerability to emotional liability by getting sufficient sleep, staying off mood-altering drugs, eating and exercising properly, and participating in activities that create a sense of mastery and meaning. COMMUNICATION STYLES IN DBT

Two communication styles—irreverent and reciprocal—are prevalent in DBT. Irreverent communication is talking about past dysfunctional behavior (suicidal, therapy-interfering, and escape behavior) in a matter-offact or "off-the-wall" way—accepting such past behaviors as a normal consequence given their history and current life circumstances. The style is direct, confrontational, and more responsive to indirect rather than overt aspects of client communication. The suffering that accompanies these extreme behaviors, however, is never treated with indifference. Reciprocal communication is warm, flexible, and responsive to the overt message or question the client communicates. Therapists use their own personal experiences in a nonjudgmental way to point out the effects of the client's behavior on the therapist. For example, rather than engage in a power struggle with the patient, the therapist accepts the situation and, in a matter-of-fact way, makes his or her own feelings of frustration or impotence part of the agenda to be discussed. Or less frequently, therapists might share some relevant aspect of their own struggle with the same issue. Self-disclosure and modeling are important aspects of this style.

The Therapeutic Relationship In traditional behavior therapy the therapeutic relationship is seen as a means to an end, as a way for the therapist to have sufficient contact and leverage to implement the therapy and thus create change. In DBT, however, the experience of an intense caring therapeutic relationship itself is thought to bring about change. The relationship must not only create conditions that facilitate the implementation of techniques, the therapist must also create a caring therapeutic relationship that allows the client to heal developmental deficiencies, stimulates innate potential for growth, and fosters client autonomy. Clients who meet criteria for BPD often have numerous interpersonal problems, and the therapeutic relationship is the primary ground for developing better interpersonal skills. The DBT therapist explicitly accepts the relationship as it is, including acceptance of lack of progress. This means that the therapist has a high tolerance for criticism and hostile affect while

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maintaining a nonjudgmental attitude. The therapist works on developing a strong relationship by clarifying what the client can realistically expect from the therapist and the treatment. The therapist uses the contingencies inherent in the client's attachment to the therapist to motivate change for which there is little reinforcement or even punishment in the patient's environment. Skillful decisions about using interpersonal contingencies to foster change are based on the benefits likely to accrue for the client and an accurate assessment of the client's actual ability to make the changes. For example, DBT therapists observe their limits rather than setting limits arbitrarily. This is a difficult process for the therapist. In order for the client to learn about and modify the effects her behavior has on others, it is crucial to use natural rather than arbitrary consequences. Limits need to respect the therapist's capacities while simultaneously benefiting the client. Similar to a developmental perspective, The best limit setting (at any stage in development) is not merely about prevention, control or the application of authority; it is about the exercise of just those preventions, controls, or authorities which we can reasonably assume the developing person to next take over on her own. (Kegan, 1982, p. 145)

In DBT both the therapist and the client can contribute to problems in the therapy. When either therapist or client has unhappiness, dissatisfaction, or frustration with the relationship, this is treated as a matter-of-fact problem to be solved and, when relevant, generalized to similar problems encountered outside of the therapy. The DBT therapist is typically more sensitive to what analytic therapists would call transference and countertransference than behavior therapists. However, DBT therapists do maintain the traditional behavioral position that client resistance is often used by the therapist to rationalize unsuccessful therapy. In other words, compliance with treatment is multiply determined, and the DBT therapist would be slow to infer motivational explanations of client resistance. For example, client resistance could result from skill deficits that create an inability to comply with the therapy. Resistance should occasion assessment to identify the variables that contribute to it. In DBT the belief is that careful case management and accurate assessment of the problem will lead to successful resolution of most resistance.

Mechanisms of Change As previously mentioned, dialectical perspectives strongly influence all aspects of therapy, including the theory of psychotherapeutic change. For sake of space, three areas in which this perspective holds will be described.

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First is the tension between change as a gradual, cumulative process and as a sudden qualitative shift. Dialectics would suggest that change is both continuous and discontinuous. For example, there are gradual continuous changes that may occur over many years in the structural features of a bridge before the sudden qualitative shift that occurs when a bridge collapses. The theory of client change in DBT is similar. Clients slowly change, sometimes moving forward sometimes back, acquiring competence with new skills, slowly coming to believe that the therapist's caring and support are genuine. Clinically, we have also observed a sudden seemingly qualitative shift that takes place, somewhat similar to a conversion experience, in which the client gains a sudden clarity that she will live and stop hurting herself. For example, a young woman in group decided she would never cut herself again after seeing the scarred arms of older group members, and from that point on parasuicide was not a problem in her therapy. In other words, insight is not assumed to generate behavior change directly. These clients have often had prior therapy and are able to be insightful, yet this does not necessarily generate behavior change. For instance, insight into the childhood causes of current patterns is sometimes helpful. The DBT therapist might help the client understand how she came to think that she was undeserving of good things, because that was how her family acted toward her. But from a DBT perspective, insight alone may or may not be sufficient. The therapist is more likely to extend an insight into very practical how-to applications (also see Wachtel & McKinney, 1992). The second way dialectical perspectives influence thinking about mechanisms of change in DBT is that simple, main-effect models are not considered useful or likely to account for much variance; rather, models of change should always be transactional. Because reality is viewed as whole, the impact of cognitive modification, contingency management, exposure strategies, and skills training are thought to be different perspectives on the same phenomena. Behavioral and solution analyses, for example, follow each instance of suicidal behavior, and the effectiveness of this intervention may be thought of in a number of ways. Because a detailed analysis of the antecedents and consequences follows every parasuicide episode, behavioral analysis may be a correction-overcorrection procedure, reducing parasuicide by providing a consistent aversive consequence for each instance of parasuicide. Alternatively, behavioral and solution analysis may reduce parasuicide because, in the course of the analyses, the patient learns new sequences of behavior and alternate solutions, and thus, change results from skills training. A third perspective is that discussing events and reactions to events that elicit parasuicide is often enormously stressful and may evoke shame and anxiety similar to that experienced in the initial situations. Such dis-

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cussions provide a form of exposure, and to the extent that the emotions elicited by the events are functionally related to parasuicide, the procedures may desensitize the individual to the emotion-provoking situations. Yet another alternative is that in the course of behavioral/solution analyses, expectations surrounding the events leading to parasuicide are examined, tested, and changed when necessary, a clear example of cognitive modification. The dialectical position here is that rather than propose single mechanisms by which change occurs, investigators should develop models of change that accurately include all relevant perspectives on the phenomena. Finally, dialectical perspectives lead to the view that change is best considered a process of synthesizing opposites. Thus, the therapeutic relationship should simultaneously be warmly controlling and supportive of autonomy. Some preliminary pilot work suggests that the client perception of the therapist as simultaneously warm, controlling, and autonomy giving is in fact related to subsequent decrease in suicidal behavior (Shearin, 1990).

Case Example Jane S. is a white, never-married, single woman with diabetes. She has a high school education and is gifted with her hands. An accomplished mechanic who can "fix anything," she draws well and plays banjo and guitar. Jane was court referred at age 30 to the second author. She had been hospitalized at least 30 times since age 12. Jane had received numerous diagnoses (schizophrenia, latent type, minimal cerebral dysfunction, major depressive episode, passive-aggressive personality disorder with suicidal acting out, and borderline personality disorder). At the time of referral, she met DSM-III-R and Gunderson's diagnostic criteria for borderlines. Over the years Jane had been prescribed a variety of antidepressant and antipsychotic drugs, with little success. She was continuously on insulin for her diabetes. She had been in individual therapy for nine years. Her most recent therapist, with whom she had had her longest continuous therapy (two years), had terminated with her because of a recent, near-lethal overdose. Hospital records, school reports and Jane's self-report strongly suggested invalidating environments at home and at school. Hospital records report that Jane's mother had not wanted her pregnancy with Jane and had attempted to miscarry several times. In school, Jane was labeled as mentally retarded, although hospital records report her to be of "average" to "superior" intelligence. She was placed in special education classes from second grade until it was discovered at age 18 that she had dyslexia. When Jane asked for remedial education to help her get a job, she was placed in a class for mentally retarded students. She quit and a year later was refused further

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help because she did not demonstrate the ability to keep a job if trained to get one. After keeping a job for two years but being fired for problems related to her diabetes, she was refused training because she had demonstrated that she could keep a job. This sort of catch-22 characterized many of Jane's interactions with "helping" bureaucracies. Jane's parasuicidal behavior began at age 9 when during an argument with her sisters she tried to jump out a third-story window. At 12, Jane overdosed and slit her wrists. This was the year her father was fired from his third job and the family "went into seclusion," withdrawing from social activities. Jane began running away and would stay out for two or three days at a time. Over the years she continued to cut, head-bang, and overdose. When treatment began, Jane was going to sleep with a scarf tied around her neck, tight enough to seriously constrict circulation. She reported that this was the only way she could stop her painful emotions. During the previous year she had on six occasions stopped taking her insulin. Her failure to comply usually precipitated a series of crises that would lead to emergency-room treatment. In addition, there were numerous minor drug overdoses and one near-lethal one. The initial treatment goals were to reduce parasuicide and to form a strong therapeutic relationship. The therapist made an important first step i-n establishing a strong alliance by virtue of being the only person willing to accept the patient into therapy, thereby keeping the state from involuntarily committing her again. Jane's acceptance into therapy was contingent on Jane convincing the therapist that she was committed to actively work to reduce parasuicide. By accepting her into treatment, the therapist communicated acceptance of Jane as she was, and at the same time, redefined their supportive alliance as one committed to inducing change. Behavioral analysis was used in sessions to identify the sequence of events that precipitated Jane's suicidal urges and behaviors. Jane reported via diary cards a high frequency of suicidal images that would appear seemingly out of the blue. For example, while cleaning a plate-glass window, Jane would suddenly see the window smashing inward, cutting her body. Repeated behavioral analyses showed that long hours alone in her apartment correlated highly with suicidal images, which in turn was followed by parasuicide. In contrast, hours spent on manual labor such as gardening, construction work, and fixing cars correlated with low daily "misery," suicidal ideation, and urges to parasuicide. Jane's major therapy-interfering behavior was withdrawal. She let her long hair cover her face, slumped down in her chair, and responded to therapist questions or comments only after long silences, if at all. Behavioral analysis revealed that withdrawal increased in sessions following family interactions that Jane interpreted as rejecting, interactions with the therapist where Jane believed the therapist took other people's side rather

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than hers, or following unsuccessful assertive attempts directed at bureaucracies, such as welfare or her bank. Withdrawal also followed the therapist's attempts to direct therapy discussions toward prior interpersonal losses and rejections, unsuccessful assertive attempts, or current feelings in the session. The therapist hypothesized that the behavioral and verbal withdrawal was a way of avoiding and/or inhibiting intense emotional responses, especially anger. Jane agreed and reported that her silences during sessions were attempts to ward off uncontrollable emotions. She worried that she would lose control and feared that she might attack others physically. She also worried that she would be left to tolerate the effects of the emotional arousal alone after the session. These expectations appeared grounded in many prior experiences where those outcomes were the norm, not the exception. These in-session behaviors corresponded to a similar style of withdrawal from, and avoidance of, situations outside of therapy that elicited negative affect. She would withdraw by staying in her bed or lying on the floor, not opening mail, avoiding contact with her family and others, and not taking care of housework or personal hygiene. Over the first four months of therapy, a characteristic sequence of events that preceded parasuicide was identified: rejection or problem that occasioned painful emotion, followed by suicide fantasies; if emotional pain did not abate, then psychological withdrawal; if still in pain, then overdose or strangulation. The images appeared linked to current incidents that elicited anger or reminders of previous losses. A number of strategies were used to treat the parasuicide and therapy-interfering behaviors. Problem-solving strategies consisted of ongoing behavioral and solution analysis identifying patterns and generating alternative behaviors to preclude suicidal ideation or to cope with intense emotions and parasuicide urges when they arose. Suicide images and fantasies were reframed as signals of anger or grief that had not yet been attended to. The therapist encouraged Jane to experience and observe the painful emotions (i.e., inhibit impulsive escape behaviors). She agreed to a goal of spending at least six hours outside her apartment each day and kept track of the number of hours and the nature of her activities on her diary card. In addition, behaviors incompatible with parasuicide were encouraged, such as inducing other intense internal stimuli (e.g., standing under a hot shower), listening to relaxation tapes, working on projects, calling friends (or the therapist), mentally reviewing reasons against parasuicide, or leaving her apartment. These alternative behaviors were taught during group and individual sessions and during phone calls with the therapist. Eight months into therapy, Jane's strangling behavior had decreased. The focus of therapy became experiencing and expressing her feelings of

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grief over the sense of never belonging to a family. During this period Jane disclosed to the therapist an activity that she had engaged in for years but had never told anyone about. It consisted of involved fantasy in which innumerable crises always led to rescue by a family member. Diary accounts revealed an average of six to eight hours spent daily in this fantasy. The reinforcing effects of this fantasy on helpless and passive behavior was explained to jane repeatedly; reducing the hours devoted to this fantasy became a new treatment target. Jane contended that, after parasuicide, this activity was her most effective mode of affect control. Thus until other, more effective methods could be taught, the only treatment was daily self-monitoring. During the next few months Jane began to express fears of getting too close to the therapist, thereby setting herself up for another interpersonal rejection and subsequent unendurable emotional experience. Phone calls and therapy sessions were marked by long silences. At the same time, her noncompliance with her diet and insulin became more frequent. Dialectical strategies were employed involving simultaneous validation of Jane's emotional pain, with exhortations to expose herself to the painful stimuli and affects she was inhibiting. Medication noncompliance was framed as another way of avoiding difficult topics and painful emotions, since generally noncompliance resulted in several days of hospitalization, and cessation of discussion of other problems. The therapist pointed out with stories, metaphor, and with what Jane accurately referred to as "lectures," that amid this continuous quitting and avoidance, Jane's problems were never resolved. Relationship strategies, and primarily relationship contingencies, proved to be powerful approaches to reducing parasuicidal behaviors, increasing the amount of verbal discourse in sessions, and decreasing some between-session withdrawal/avoidance behavior. At first this consisted of reminding Jane of her initial commitment to work to stop parasuicide and eliciting renewed commitment, including a good-faith effort to approach experiencing at least some of the unbearably painful feelings of anger and grief she worked to escape. In addition, therapist contingencies were used; the therapist often remarked that she was getting tired of pulling Jane back up when she kept jumping off the mountain (a metaphor comparing therapy work to a two-person team scaling a mountain). Over time the therapist shaped therapy work and nonavoidance, both by threatening withdrawal of therapy if Jane did not work in therapy and by providing praise, encouragement, and warmth when Jane reported problem confrontation between sessions or reduced within-session avoidance behaviors. A gradual reduction in emotional inhibition was shaped by combining validation of emotional pain with continued teaching of emotional regulation skills.

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Jane has continued in therapy, although she no longer meets criteria for borderline personality disorder and no longer engages in self-harm. Her therapy now is focused on recovering from effects of childhood sexual abuse and developing broad-based self-respect.

Research on the Approach Even when potentially effective pharmacotherapy is instituted, it is commonly assumed that ancillary psychosocial treatment of some form is necessary for BPD patients. Randomized, controlled studies demonstrating the effectiveness of any psychosocial treatment with BPD are sparse. DBT has been evaluated in two experimental treatment studies. In the first treatment evaluation study (Linehan, Armstrong, Suarez, Allmon, & Heard, 1991), clients received the comprehensive DBT package consisting of weekly individual therapy and group skills training. Forty-seven chronically parasuicidal women meeting criteria for borderline personality disorder were randomly assigned to DBT or to a community treatment as usual (TAU) control group. Treatment lasted for approximately 12 months. Assessments were given at 4-, 8-, 12-, 18-, and 24-month intervals. Results indicated that compared to the patients assigned to treatment as usual, patients receiving DBT had fewer and less medically serious parasuicide incidents, fewer psychiatric inpatient days per hospital admission, reported less interpersonal anger, and were more likely to start and remain in psychotherapy. Superiority of DBT was maintained when it was compared to outcomes for those TAU patients who received stable individual psychotherapy. Treatment gains were maintained at follow-up, although there were no significant group differences at the 24-month follow-up. This failure to find continuing differences may have been due to the inability to assess some of the TAU subjects because of severe psychiatric impairment. In the second study (Linehan, Heard, & Armstrong, 1991), only DBT group skills training was added to ongoing community individual psychotherapy. Nineteen subjects were randomly assigned to individual TAU plus DBT skills training or to individual TAU alone. Results indicated that adding DBT skills training to ongoing therapy is of virtually no value, at least on any outcome measures that we used. Although there are many possible reasons for this apparent failure, the most likely is that without communication between individual and skills-training therapists, there was little or no integration of the behavioral skills into the client's daily life. This is despite the almost unanimous opinion of the participants and their individual therapists that it was very beneficial!

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Future Directions DBT is an integrative therapy in a number of ways. It integrates different treatment formats (individual, group, and ancillary treatments); it integrates Western psychotherapy with dialectical perspectives and Eastern practices; it integrates research, clinical practice, and treatment development; and it integrates a variety of behavioral techniques with cognitive, humanistic, and interpersonal interventions. In the future, we plan to continue developing a treatment with maximal likelihood of effectiveness and to examine which parts of the treatment are critical to its effectiveness. Currently, members of our research group are conducting preliminary studies to identify therapist and client in-session behaviors associated with decreases in subsequent client suicidal behavior. Realizing that most clinical settings have limited resources, we hope to determine ways to adapt the basic DBT concepts to a broad range of settings. For example, we hope to investigate the effectiveness of the full DBT package (individual plus skills group) with DBT group skills training alone and individual DBT alone. This type of research will allow us to determine the relative power of treatment modality and thus inform cost-benefit decisions about the allocation of treatment resources. The discrepancy between the high needs of this patient population and the limited resources of private and community mental health providers makes urgent the search for efficacious cost-effective therapy.

References AMERICAN PSYCHIATRIC ASSOCIATION. (1987). Diagnostic and statistical manual of mental disorders (3rd rev. edj. Washington, DC: Author. ARKOWITZ, H. (1992). A common factors therapy for depression. In ]. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. BARLOW, D. H. (Eo.). (1985). Clinical handbook of psychological disorders. New York: Guilford. BECK, A. T., RUSH, A. ]., SHAW, B. F., & EMERY, G. (1979). Cognitive therapy of depression. New York: Guilford. BRIERE, J., & ZAIDA, L. Y. (1989). Sexual abuse histories and sequelae in female psychiatric emergency room patients. American Journal of Psychiatry, 146, 1602-1606. BRYER, J. B., NELSON, B. A., MILLER, J. B., & KROLL, P. A. (1987). Childhood sexual and physical abuse as factors in adult psychiatric illness. American Journal of Psychiatry, 144, 1426-1430.

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FRANCES, A., FYER, M., & CLARKIN, J. F. (1986). Personality and suicide. In J. J. Mann & M. Stanley (Eds.), Psychobiology of suicidal behavior. Annals of the New York Academy of Sciences, 487, 281-293. GOLDBERG, C. (1980). The utilization and limitations of paradoxical intervention in group psychotherapy. International Journal of Group Psychotherapy, 30, 287-297. GOLDFRIED, M. R., & DAVISON, G. C. (1976). Clinical behavior therapy. New York: Holt, Rinehart & Winston. GOTTMAN, J. M., & KATZ, L. F. (1990). Effects of marital discord on young children's peer interaction and health. Developmental Psychology, 25, 373381. GUNDERSON, J. G., & ELLIOTT, G. R. (1985). The interface between borderline personality disorder and affective disorder. Journal of Personality and Social Psychology, 142, 277-288. GUNDERSON, J. G., KOLB, J. E., & AUSTIN, V. (1981). The Diagnostic Interview for Borderlines. American Journal of Psychiatry, 138, 896-903. HANH, T. N. (1975). Miracle of mindfulness. Boston: Beacon. HERMAN, ]. L., PERRY, J. G., & VAN DER KOLK, B. A. (1989). Childhood trauma in borderline personality disorder. American journal of Psychiatry, 146, 490495. JACOBSON, N. S. (1987). Psychotherapists in clinical practice: Cognitive and behavioral perspectives. New York: Guilford. KAZDIN, A. E. (1978). History oj behavior modification: Experimental foundations of contemporary research. Baltimore: University Park Press. KEGAN, R. (1982). The evolving self: Problem and process in human development. Cambridge, MA: Harvard University Press. KERNBERG, O. F. (1984). Severe personality disorders: Psychotherapeutic strategies. New Haven, CT: Yale University Press. LINEHAN, M. M. (1987a). Dialectical behavior therapy: A cognitive behavioral approach to parasuicide. Journal of Personality Disorders, 1, 328—333. LINEHAN, M. M. (1987b). Dialectical behavior therapy for borderline personality disorder: Theory and method. Bulletin of the Menninger Clinic, 51, 261— 276. LINEHAN, M. M. (1989). Cognitive and behavior therapy for borderline personality disorder. In A. Tasman, R. E. Hales, & A. J. Frances (Eds.), Review of psychiatry (pp. 84-102). Washington DC: American Psychiatric Press. LINEHAN, M. M. (in press, a). Cognitive behavioral treatment of borderline personality disorder: The dialectics of effective treatment. New York: Guilford. LINEHAN, M. M. (in press, a). Using skillful means: Psychosocial skills for borderline patients. New York: Guilford. LINEHAN, M. M., ARMSTRONG, H. E., SUAREZ, A., ALLMON, D., & HEARD, H. L. (1991). Behavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48, 1060-1064. LINEHAN, M. M., HEARD, H. L., & ARMSTRONG, H. E. (1991). Components of

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dialectical behavior therapy for borderline personality disorder: Group and individual therapy. Unpublished manuscript. LINEMAN, M. M., & KOERNER, K. (in press). Behavioral theory of borderline personality disorder. In ]. Paris (Ed.), Borderline personality disorder: Etiology and treatment. Washington, DC: American Psychiatric Association. McGLASHAN, T. H. (1983). The borderline syndrome: 2. Is it a variant of schizophrenia or affective disorder? Archives of General Psychiatry, 40, 1319— 1323. MESSER, S. B. (1992). A critical examination of belief structures in integrative and eclectic psychotherapy. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. POPE, H. G., JONAS, J. M., HUDSON, ]. I., COHEN, B., & GUNDERSON, J. F. (1983). The validity of DSM-III borderline personality disorder. Archives of General Psychiatry, 4-0, 23-30. REISER, D. E., & LEVENSON, H. (1984). Abuses of the borderline diagnosis: A clinical problem with teaching opportunities. American Journal of Psychiatry, 141, 1528-1532. ROSWELL, V. A. (1988). Professional liability: Issues for behavior therapists in the 1980s and 1990s. The Behavior Therapist, 11, 163-171. SHEARIN, E. N. (1990). Perceptions of borderline personality disorder patients and relationship to treatment progress. Unpublished doctoral dissertation, University of Washington, Seattle. STONE, M. (1989). The course of borderline personality disorder. In A. Tasman, R. E. Hales, & A. J. Frances (Eds.), Review of psychiatry (pp. 103—122). Washington, DC: American Psychiatric Press. WACHTEL, P. L, & MC.KINNEY, M. K. (1992). Cyclical psychodynamics and integrative psychodynamic therapy. In ]. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. WAGNER, A., & LINEHAN, M. M. (1989, November). Parasuicide: Characteristics and relationship to childhood sexual abuse. Paper presented at the annual convention of the Association for Advancement of Behavior Therapy, Washington, DC. WATZLAWICK, P. (1978). The language of change: Elements of therapeutic interaction. New York: Basic Books. WELLS, H. D. (1972). Alienation and dialectical logic. Kansas Journal of Sociology, 3, 1. WHITAKER, C. A. (1975). Psychotherapy of the absurd: With special emphasis on the psychotherapy of aggression. Family Process, 14, 1-16.

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PART IV

INTEGRATIVE TREATMENT MODALITIES

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CHAPTER 14

Differential Therapeutics: Macro and Micro Levels of Treatment Planning JOHN F. CLARKIN, ALLEN FRANCES, AND SAMUEL PERRY

IN THE PREFACE to our first publication on differential therapeutics in 1984 (Frances, Clarkin, & Perry, 1984), Robert Michels wrote: "The easiest way to practice psychiatry is to view all patients and problems as basically the same, and to apply one standard therapy or mix of therapies for their treatment. Although some may still employ this model, everything we have learned in recent decades tells us that it is wrong—wrong for our patients in that it deprives them of the most effective treatment, and wrong for everyone else in that it wastes scarce resources" (p. xiii). While some (e.g., Smith & Sechrest, 1991) would suggest that there are few data for matching patients with specific treatments, the clinical and research community has moved more and more for treatment specificity. The Society for the Exploration of Psychotherapy Integration (SEPI) is an example, as is the three-volume treatment planning project by the American Psychiatric Association (1989). The generation of a diagnostic system that is multiaxial and based upon reliably assessed behavioral criteria, enhances more specific treatment planning and better communication between clinicians, and fosters research on reliably defined and more homogeneous groups. In this chapter we describe differential therapeutics, that is, the application of principles derived from research and clinical experience in matching the individual patient to the most efficacious treatment. We also discuss differential therapeutics on the macro level, involving five areas of treatment planning, and on the micro level, involving the adjustment of therapeutic strategies and techniques within the treatment process itself. Finally, we apply these principles of treatment planning to a representative Axis

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I diagnosis (major depression), an Axis II syndrome (borderline personality disorder), and a problem area (marital disputes) in order to illustrate how they can be used with specific patient difficulties.

Five Dimensions of Macro Treatment Planning Although there is much interdependence among the various macro dimensions of treatment planning, we have found it pedagogically helpful to separate them in order to illustrate the decisions that are being made, either knowingly or implicitly, on each of these dimensions. The setting (I) and format (2) of treatment provide the environment and the ecology, both in terms of place (hospital, office, patient's home, site of phobias) and persons (patient, patient and family, group of patients) who will be present. The strategies and techniques (3) are the technical interventions that the therapist uses to introduce change. The decisions about strategies and techniques have been the narrow, if not the sole, concern of other attempts at treatment integration. The duration and frequency (4) are the aspects of how the treatment is imbeded in time. Insurance companies and managed care have particular interest in this consideration due to its direct relationship to cost. The appropriate use of medication (5) and other somatic treatments (ECT, light) have been the focus of much clinical research.

SETTING

The settings of treatment have remained somewhat constant in the last several decades: inpatient (chronic and acute), day hospital, outpatient clinic, private practice, treatment in the family home, and sessions at the site of disorder (e.g., systematic desensitization in vivo). From a practical point of view, the actual accessibility of these treatment settings is changing dramatically in the current era of cost containment. Inpatient care is more and more restricted in terms of who obtains it (the most severely disturbed patients in acute distress) and how much of it is available (the length of stay is becoming more restrictive). This constriction of resources is forcing clinicians to be more creative in using alternatives to hospitalization in crisis situations. The change suggests that the use of the day hospital setting will become increasingly more available for very disturbed patients.

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FORMAT

The treatment format is the interpersonal context within which the intervention is conducted. The choice of a particular treatment format is determined, in part, by the perspective from which a presenting problem is initially defined, either by the patient/family and/or the clinician. Some couples apply to a family clinic for marital treatment for what they perceive as an interpersonal problem or conflict. Another couple in the same situation may prompt the wife to call a clinic and ask for an appointment for herself. From the clinician's point of view, the treatment of the spouse with depression can vary, depending on whether it is viewed (etiology aside) as a current adaptation to a larger problem involving the family unit (suggesting a need for family intervention) or as the patient's personal adaptation to a unique biological, social, or historical situation (in which case, individual or group treatment is more likely indicated). The mediating and final goals of treatment will vary accordingly. Although therapeutic strategies and techniques are influenced, in part, by treatment format, these can vary independent of format and in accordance with the particular theoretical model from which the therapist is working.

Individual Treatment Format The individual treatment format is one in which the patient and therapist meet in the privacy of the therapist's office with the goal of treating the patient's problem. The development of the individual format of treatment served several adaptive functions within the historical context from which it evolved. The individual was seen as the locus of difficulty, with unconscious and preconscious motives and desires viewed as a driving force in that person's psychopathology. Subsequent developments, including the behavioral and interpersonal therapy concepts, continued to focus on the individual with his or her learning history and patterns of interpersonal behavior as the locus of difficulty and the focus of treatment. The final goal of individual treatment, like that of other formats, is to alleviate the symptoms and conflicts that brought the individual for help. The relationship between therapist and patient is fostered and used as the framework for the application of a multitude of therapeutic techniques to assist the individual in coping with symptoms and resolving interpersonal conflicts through their replay with the therapist. The individual treatment format is the easiest (since it requires the motivation of only one person) and most versatile format for treatment. It can be used whenever the patient does not meet criteria for both more economical treatments (such

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as group) or treatments that approach the problem in their own setting (e.g., marital and family treatment). The individual format has the following advantages, which give it special status under certain circumstances: • Problems of dyadic intimacy, which require the development of a relationship with a therapist for some resolution to occur • Patients whose character or symptoms are based on firmly structured intrapsychic conflict, which causes repetitive life patterns that, more or less, transcend the particulars of the current interpersonal situation (e.g., family, job relationships) • Adolescents or young adults who are striving for autonomy • Symptoms or problems that are of such private and/or embarrassing nature that the secrecy of individual treatments is required at least for the beginning phase The only relative contraindications include patients who meet clear indications for family/marital treatment or patients who regress in individual therapeutic relationships. Group Treatment Formats The group treatment format is one in which a small group of patients meets with one or several therapists on a regular basis for the goal of treating the disorders of the group members. The historical impetus for the development of the group treatment format was based, in part, on the functional advantages that it afforded: an economic mode of delivering treatment, an effective means of reducing or circumventing the resistance expressed in individual therapy, adjunctive support or ancillary therapists in the form of other patients, and a setting in which interactional forces could be played out and examined. Group treatments fall on a continuum of theoretical assumptions, methodologies, and mediating and final goals. Thus, in our attempt to organize indications for use of a group therapy format, we will not distinguish among the different schools (which will be accomplished in the section on strategies and techniques), but will organize our decision tree around one distinction: that between the indications for heterogeneous versus homogeneous group membership. Although this distinction is not yet supported by controlled research, it has been used extensively in clinical practice. In heterogeneous groups, individual patients differ widely in their problems, strengths, ages, socioeconomic backgrounds, and personality traits.

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Treatment in heterogeneous groups fosters self-revelation of one's inner world in an interpersonal setting where sharing and feedback are encouraged. The group provides a context in which interpersonal behavior patterns are reexperienced, discussed, and understood, and in which patients experiment with new ways of relating. The variety of interactions and misperceptions that result affords all group members an opportunity to correct their distortions about others, to discover how others regard them, and to alter their maladaptive patterns. Patients are encouraged to take interpersonal risks, first within and later outside the group. They learn to share the therapist and discover that they can be helped by their peers and be helpful to them. There are two general indications for heterogeneous group therapy. 1. The patient's most pressing and salient problems occur in current interpersonal relationships. If these interpersonal difficulties are currently exhibited mainly in family relations, referral to family/marital treatment should be considered. 2. Prior individual therapy formats have failed for various reasons; for instance: (a) the patient has a strong tendency to actualize interpersonal distortions in individual therapy formats; (b) the patient is excessively intellectualized; (c) the patient cannot tolerate the dyadic intimacy of individual therapy; (d) the patient has a treatment history of eliciting harmful reactions from individual therapists. The enabling factors for heterogeneous group therapy include a capacity to participate in the group treatment as evidenced by openness to influence from others, willingness to participate in the group process, and willingness and ability to protect group norms. The patient's motivation for group treatment must be sufficiently adequate to foster participation. There are, however, some centra-indications for heterogeneous group therapy. 1. The situation is an acute psychiatric emergency or crisis that requires more urgent, intense, and individualized attention. 2. The patient is likely to respond to brief planned therapy. 3. The patient meets criteria for another form of treatment that may be more beneficial. For example, by becoming comfortable in group treatment, the patient is avoiding the anxiety of engaging in intense individual treatment for serious problems around dyadic intimacy. 4. The patient manifests interpersonal behavior that would disorganize the group process. This would, for example, be true of patients with severe organic brain syndrome or severe impairment in reality testing; or dishonest, manipulative, suspicious, or explosive behavior. Homogeneous groups are self-help or professionally led groups in which all members share the same symptom or set of symptoms, which are the focus of the intervention and change. The goal of the homogeneous group

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is to change behaviors related to the symptom focus of the group. The group is highly structured and provides a social network for the patient, who previously may have felt alone and isolated with the target symptom. There may be a formal hierarchy within the group, a system of gradual promotion as the patient improves systematically and gains new skills, and in some cases, the possibility of members eventually rising to leadership roles. The sense of commonality—of jointly fighting a common problem— provides support and self-validation. Homogeneous groups tend to avoid techniques of psychological interpretations, since the goal is not insight but behavioral change with group inspiration, didactics, modeling, and advice. The indications for homogeneous group treatment include the following: 1. The patient's most salient problem or chief complaint involves a specific disorder for which a homogeneous group is available. These problems fall into four general categories: (a) specific impulse disorders (e.g., obesity, alcoholism, addictions, gambling, violence, and criminal behavior among prisoners): (b) problems adjusting to and coping with medical disorders such as cardiac ailments, ileostomy, terminal illness, chronic pain, and others; (c) problems of a particular developmental phase such as geriatrics, childhood and adolescence, or child-rearing; and (d) specific psychiatric disorders or symptom constellations such as agoraphobia, somatoform disorders, and schizophrenia. 2. The patient experiences his or her salient problem with a sense of embarrassment and/or isolation and may benefit from sharing these problems with others who have had similar experiences. 3. The patient does not have a sustaining and supportive social network, and/or has an existing social network that is composed of individuals with the same disorder (e.g., alcoholics whose only friends drink at the same bar). The following are relative contraindications for homogeneous group therapy: 1. The patient will be harmed by associating too exclusively with others who have the same difficulties. An example would be a physically handicapped person who needs to learn to associate with and cope with the nonhandicapped. 2. The patient resents and will not tolerate a central aspect of the homogeneous group program. For example, some people react negatively to the Alcoholics Anonymous spiritual, didactic, and mystical elements. Family Treatment Formats The family treatment format is one in which various subgroups of a family (a nuclear family, a couple, a couple with family of origin) meet on a regular

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basis with a therapist (see Feldman & Powell, 1992). The family format was derived in large part from an emphasis on the contextual origins of the presenting problems. More recently, family and marital treatments have been applied more broadly, with greater emphasis on their practical utility rather than solely or primarily on the role of family/dyad in the etiology of the problem. Hence, we see family- and marital-based treatments for various medical problems (such as hypertension) and psychiatric disorders (such as agoraphobia and schizophrenia), wherein the spouse or family member is enlisted to serve as adjunct therapist or to provide social support to the patient. A review of the early trends in the development of the family treatment format suggests that it served several adaptive treatment functions. It was recognized to be an important adjunct to individual interventions with children and adolescents whose family environments contributed to their problems. It helped to diminish family resistance to continuation of the child's treatment. It was particularly well suited to brief treatment of focal problems occurring in the context of the family or marital unit. The final goals of family and marital treatments are at times indistinguishable from those of the group and individual treatment formats. All formats work toward the ultimate goal of alleviating the symptoms and conflicts that brought the individual(s) to treatment. The mediating goals, however, begin to distinguish the formats. The mediating goals of family and marital treatments are to change the rigid and repetitive interpersonal family interchanges that are in themselves the focus of complaint or are hypothesized to be related to the symptoms of one or more individuals in the family system. The methods of family and marital treatment are the same as those of individual and group treatment formats: psychodynamic, behavioral, and experiential techniques. However, if the targets of intervention are interpersonal behaviors of family members, the use of the family format allows direct therapeutic assessment and impact on these behaviors as they operate in predictable sequences in the family setting. The relative indications for family/marital formats include the following: 1. Family/marital problems are presented as such without either spouse or any family member designated as the identified patient. 2. A marital couple committed to each other presents with symptoms that occur almost exclusively within the marriage. 3. Symptomatic behaviors are experienced almost predominantly within the family/marital system. 4. The family presents with current structured difficulties in intrafamilial relationships, with each person contributing collusively or openly to the reciprocal interaction problems.

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5. Adolescent acting-out behavior (promiscuity, drug abuse, delinquency, vandalism, violence) is disrupting the entire family. 6. The family is unable to cope adequately with the chronic mental illness of one family member. 7. Symptoms in one family member seem related to repetitive interpersonal issues in the family or marriage. For example, mild to moderate unipolar depression in a spouse seems related to marital conflict. 8. A spouse needs to be involved in the treatment program of his or her mate in order for it to succeed. For example, the spouse suffers from an eating disorder or agoraphobia, and the mate is needed to assist in behavioral treatment compliance and general support. The following are relative centra-indications for family/marital formats: 1. The presenting problem of the individual does not have a significant relationship or effect on the family system. 2. Family therapy would provide a defense through which individual responsibility for major personality or character disorders could be derived. 3. Individuation of one or more family members requires that they have their own and separate treatment. 4. Family treatment has stalemated or failed and has resolved what crises it can, but one or more individuals require additional individual treatment. 5. One or more family members is strongly motivated to be seen alone (e.g., an adolescent states emphatically that he or she has personal problems and wants private help). STRATEGIES AND TECHNIQUES

We have just experienced a period of proliferation of treatment strategies and techniques. In the early 1960s there were some 60 different treatments (Garfield, 1982). By the late 1970s there were over 250 identified approaches (Herink, 1980). A recent count would put the number at over 400 (Kazdin, 1988). Currently, however, forces are fostering consolidation in treatment strategies and techniques (Norcross & Newman, 1992). Treatment manuals are now being written to guide research and training in the techniques of the various schools (dynamic, behavior, cognitive) for diverse patient populations, such as anxiety (Beck & Emery, 1985), depression (Beck, Rush, Shaw, & Emery, 1979), schizophrenia (Falloon, Boyd, & McGill, 1984), interpersonal problems (Luborsky, 1984; Strupp & Binder, 1984), and suicidal behaviors (Linehan, 1987). Clinical research is beginning to suggest which strategies and techniques are effective with specific patient problem areas. These manuals are helpful in explicating the treatments and showing similarities (despite different theories and theoretical

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language) and differences. In addition, technical eclecticism—which advocates the use of multiple techniques, regardless of theoretical heritage—is growing (Norcross, 1986a; Norcross & Newman, 1992). This esprit fosters consolidation of techniques across schools into useful treatment packages. There have been volumes written comparing the various schools as related to strategies and techniques. There seems to be an unwritten consensus that the differences between treatments—differences seen as crucial for outcome—are captured at the level of techniques. We would question this assumption as being incomplete, and suggest rather that psychotherapy has advanced in its specificity not through investigation of techniques, but through research into the disorders that provides the key foci of the treatment (also see Wolfe, 1992). For example, the family treatment of schizophrenia flourished once the concept of expressed emotion (EE) and its influence on the course of the disorder was explicated. As the nature of EE is further refined, with recent work on attribution, for example (Hooley, 1987), the treatment will be further focused. The implication is that no treatment strategy or technique can be considered in and of itself, but its value lies in the context of achieving specific mediating goals of treatment for the specific problem. Thus, while we discuss strategies and techniques abstractly in this section, it is only when considering specific disorders in the latter part of this chapter that one matches mediating goals with specific techniques. We will review here the major treatment strategies and techniques that emerge from a survey of the existing treatment manuals. Although this is not meant to be an exhaustive review of all manuals (which increase in number each day), we have included those that cover a range of patient pathologies and schools of therapy, which enables us to make some generalizations. Common Strategies and Techniques With the proliferation of treatment manuals, one can examine them for similarities and differences. Despite their diversity in terms of philosophy, strategies, and patient populations, we are struck by the methods that are repeated in many of the manuals. Indeed, the finding that most treatments are equally effective may be related to the common ingredients as noted in an inspection of the manuals (Arkowitz, 1992; Garfield, 1992). While adherents of the various schools of psychotherapy emphasize their theoretical and strategic uniqueness, a large body of data suggests that experienced therapists of different persuasions do many things in common (e.g., Frank, 1973; Goldfried, 1982; Kazdin, 1980; Saltzman & Norcross, 1990). A recent meta-analysis (Barker, Funk & Houston, 1988) found that treatment was more effective than well-designed, nonspecific

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factors control conditions, and these in turn were more effective than no treatment. In fact, psychological treatments were approximately twice as effective as the well-designed, nonspecific factors control conditions. The schools deviate from one another most in the mediating goals chosen, and the specific techniques that are used to accomplish these mediating goals. Even here there are commonalities. All or most therapies encourage the patient to make certain basic behavioral changes, including confrontation of fears, in order to master them; reality testing; and practice and working through (see Grencavage & Norcross, 1990, for a review). Encouragement of behavioral change can be direct (e.g., specific behavioral assignments, homework) or indirect (e.g., modeling, questioning); but the basic message is the same: the patient must at some point begin to behave differently and to expand his or her behavior repertiore. In somewhat diverse ways, the therapist, of whatever persuasion, models the notion of behavioral risk and change. In the existing treatment manuals, there are strategies common to all the therapies. These commonalities include (1) establishing and fostering a therapeutic alliance (e.g., conveying support for the patient's wish to achieve treatment goals, conveying a sense of understanding and acceptance of the patient), (2) managing patient resistance (e.g., identifying resistance, inviting the patient to examine the resistance), (3) structuring the treatment, (4) focusing the treatment, and (5) termination. Although the schools of therapy utilize different techniques, they are alike in using these common strategies. The relationship between therapist and patient is the bedrock upon which the use of any technique must be based, and the development and nuturance of that relationship is crucial (Crits-Christoph et al., 1991). Specific Strategies and Techniques In addition to using the strategies and techniques common to the various schools of therapy, the clinician must consider the use of more specific strategies and techniques that might be appropriate for the particular case (Lambert, 1992). In this process, one considers most carefully the mediating goals of treatment and those strategies and techniques that might be instrumental in reaching those goals. We are conservative in our approach and emphasize those strategies and techniques that have been manualized for a specific patient diagnosis or problem area and have shown effectiveness in clinical trials. In rare instances, specific strategies and techniques have shown superiority over competing ones in comparison studies. In addition, we have tried to classify techniques with the goal of treatment planning specifically in mind. The clinician must determine specific mediating goals for each particular patient,

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given his or her unique diagnosis, social environmental situation, and personality assets and liabilities. For example, psychodynamic techniques have the mediating goal of insight and conflict resolution; behavioral techniques, the mediating goals of specific behavioral changes; cognitive techniques, the mediating goals of change in conscious thought processes; and experiential-humanistic techniques, the mediating goals of increased awareness that is more fully integrated into the patient's personality.

DURATION AND FREQUENCY

Treatment duration is multifaceted. The major reference is to the duration of the treatment episode, that is, the time from evaluation to termination of a particular treatment period. Alternatively, one could consider the duration of each aspect of the total treatment package. For example, the total treatment package for one episode of a disorder may include different treatment settings (inpatient followed by outpatient), treatment formats (individual and family therapy), medications of different classes, and diverse strategies and techniques. Finally, treatment can be lifetime, that is, involving many episodes of treatment throughout the lifetime of a patient who has a chronic mental disorder, such as schizophrenia or bipolar disorder. A number of factors make the relationship between treatment duration and outcome relatively unpredictable. The duration of the treatment episode and the frequency of sessions are related to the amount of effort and length of time needed to achieve the mediating and final goals of the intervention, which, in turn, are related to the nature of the disorder and symptoms under treatment. In general, the more extensive and intensive the therapeutic goals, the longer treatment takes. Alternatively, when the goals of treatment are circumscribed, treatment can be brief. Setting the duration for a brief treatment can assist in ensuring that the goals will be reached more quickly than leaving the duration open-ended.

Crisis Intervention Crisis intervention is an intense, timely, brief (usually less than one month), and goal-directed treatment intended to resolve a crisis of major and urgent proportions and recent onset. A period of disorganization and crisis follows the precipitating event. During this time the individual tries many forms of coping; the resolution that is achieved over a period of time may be adaptive or nonadaptive. The treatment often requires frequent (perhaps daily) and prolonged sessions, 24-hour staff availability, the potential use of psychotropic medications, the mobilization of family members and other

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community resources, environmental manipulations, and a multidisciplinary team. The intervention is focused on the presenting problem, particularly an exploration of its precipitating events. The goal is the relief of the symptoms, avoidance of further decompensation, and development of more adaptive coping skills for future crises. Indications for crisis intervention would include the following: 1. The patient's symptoms, distress, and risk factors must be severe enough to warrant urgent and intense attention—perhaps to require inpatient hospitalization if a crisis intervention is not offered. This degree of urgency may result from suicidal threats or acts, psychosis, severe depression, panic disorders, grief, or excited states. 2. Often a major precipitating stress provides a clear focus for the intervention. This may be accidental (injury, illness, death, job loss), interpersonal (an affair, a bitter argument), or developmental (a child is born, goes to school, marries)3. Onset of symptoms is an indication if they occurred relatively recently. The following are some patient-enabling factors for crisis intervention: 1. The patient is willing to participate, keep appointments, be available for home visits, take medication, and the like. 2. Social and family networks are adequate or can be mobilized. Brief Versus Longer-term Therapy We may well be in an era in which the brief psychotherapies are the predominant form of treatment ror many patients. Whether it is planned in advance or not, most patients now treated with psychotherapy engage in it for only a short period of time. Patients seeking clinic outpatient psychotherapy generally expect it to last no more than three months, and a very high percentage of patients actually remain in treatment for fewer than 12 sessions. Most therapy has always been brief; what is new is the notion of time-limited therapy by design, The first step in planning for treatment duration is to decide whether to recommend a brief or a longer-term outpatient intervention. Some clinicians offer brief therapy as the initial treatment for all patients, except those few who have already had an unsuccessful experience with it, or those who present with clear motivation and indications for long-term treatment. Since it is difficult to predict from one or two interviews which patients require and can benefit from longer interventions, a trial of brief therapy is often useful as an extended evaluation and/or role induction. The brief psychotherapies differ among themselves in goals, treatment techniques, strategies, format (group, family, or individual), setting

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(inpatient, day hospital, outpatient), and selection criteria. In fact, the different models of brief therapy are at least as diverse as those applied in longer treatments. Certain essential features, however, characterize the brief therapies: establishing a time limit, achieving a focus with clear and limited goals, and an active therapist. The indications for brief therapy, of whatever model, include the following: 1. A definite focus, precipitating event, or target for intervention must be present. 2. The patient's overall motivation and goals may be limited but must be sufficient for cooperation with the brief treatment. 3. The patient must be judged to be capable of separation from treatment. 4. The patient's usual level of functioning is adequate and does not require the level of change usually brought about only by long-term or maintenance treatment. 5. Limited financial and/or time resources on the part of the patient or the delivery system may incline toward brief treatment. 6. Brief therapy may be preferable to longer treatment to avoid secondary gain, negative therapeutic reactions, unmanageable therapeutic attachments, or other iatrogenic effects. The models of brief therapy influence the indications over and above those listed so far. For example, when the treatment is brief in psychodynamic orientation, there are more stringent enabling factors than noted above (e.g., history of positive and intimate relationships, ability to reflect on own experience). An important consideration in making the decision for brief treatment is the potential usefulness of one of the brief therapies for a specific patient problem area. Difficulties brought by patients can be broadly conceptualized as either symptomatic or conflictual in nature (Beutler & Clarkin, 1990). Brief treatments have been articulated for symptoms (e.g., depression, anxiety), unrecognized feelings or behaviors (e.g., phobias), and interpersonal conflicts—leaving aside for the moment the question of strategies and techniques—(Koss & Butcher, 1986; Hollon & Beck, 1986; Clarkin & Hull, 1991). The nature of both the patient's condition and the psychological treatment may dictate the duration of the treatment episode. For example, a patient with panic and agoraphobia may need an exposure treatment until the avoidance diminishes, and there may be no relapse as the anxiety reduction takes place. Contrariwise, we know that relapse with depression is common. Moreover, for those with a first depressive episode, brief treatment may be sufficient to resolve the episode. But for those patients who have a second episode of depression, they are likely to relapse yet

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again, and they may need more open-ended treatments rather than another brief treatment. While most psychotherapy research studies have dealt with brief therapy, these studies are impressive in the number of patients who do not respond to the brief intervention. The overuse and limitations of brief therapies have been described elsewhere (Clarkin & Hull, 1991). Long-term Psychotherapy Regardless of technique, the rationale for treatment of long-term duration is that some problems are so ingrained, complex, and extensive that an extended period of time is necessary for both their dissection and resolution, and for the patient to assimilate and apply the new solutions into daily life. Because regularly scheduled long-term psychotherapy is expensive and is weakly supported by available research, the prescription of this duration requires the most thoughtful assessment of indications, contraindications, and enabling factors. Patient factors that tend to lengthen the treatment include the diagnosis of chronic mental disorders (e.g., schizophrenia, bipolar disorder), multiple problem areas, poor patient-enabling factors for treatment, and relatively poor premorbid functioning and adjustment. A poor or insufficient response to brief treatment is an empirical demonstration of the need for further intervention. MEDICATION

Major advances have been made in the investigation of various medications to treat symptoms and symptom constellations as related to the various Axis 1 and some Axis II disorders. These medications can be used as the primary intervention, or combined with a major psychosocial intervention, but should never be given alone. Noteworthy situations that call out for a combination of medication and psychotherapy would include schizophrenia, bipolar disorder, and major depression. Clinical and research directions for integrating psychotherapy and pharmacotherapy are included in Beitman, Hall, and Woodward (1992).

No Treatment as the Prescription of Choice Most patients present with symptoms and feeling the need for treatment. The whole context lends itself to assessment and the beginning of treatment. In this situation, clinicians are not inclined to recommend no treat-

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ment, and rarely do so for patients applying to an outpatient clinic (Frances & Clarkin, 1981). By way of contrast, many patients discontinue their treatment rather quickly for a host of reasons. It is helpful for treatment-planning purposes to distinguish groups of patients who might be seriously considered by the clinician for no treatment. These would include (1) patients likely to improve without treatment ("spontaneous remission"), (2) those likely not to respond to treatment (nonresponders), (3) those at risk for a negative response to treatment, and (4) those for whom the recommendation of no treatment is an intervention in itself, aimed at resistance (Frances et al, 1984). Each of these categories deserves some description. In many ways the most felicitious situation is one in which the clinician evaluates a person suffering from acute stress, but who has a history of effective functioning and coping. These individuals are often capable of coping with the stress by using their own resources, along with reassurance from the evaluator. In contrast, there are those who are at risk for a negative response to the treatment itself. We are talking here of those individuals who actually become worse in clinical status and/or functioning during the treatment. The incidence of negative response to treatment ranges from 3 to 28 percent (Bergin & Lambert, 1978). There are many potential reasons for negative response: reasons related to the nature of the treatment itself, to further progression of the disorder, or to adverse environmental stressors. For treatment planning, it is most important to identify those people who are likely to experience a lasting deterioration because of treatment. Therapeutic factors that seem most related to negative effects include inaccurate and deficient assessment of the patient, poor therapist training and skills, therapist personality, therapistpatient relationship, misapplication of therapeutic technique, and patient qualities. Those patient qualities that put the patient at risk for a negative response to treatment include negative therapeutic reactions in masochistic and narcissistic/oppositional patients. In addition, borderline patients seem vulnerable to a negative response to treatment due to their affective liability, fragile sense of self, and need to attach because of frightening fears of abandonment. Some borderline patients become psychotic in intense therapeutic relationships. They are prone to act upon their transference fantasies rather than to investigate them, and often do this in a self-destructive and provocative manner. Finally, there are those patients at risk for showing no response to treatment. They are individuals who are not motivated for treatment, and/or do not get involved in the interpersonal process in such a way as to foster change.

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Micro Levels of Treatment Planning Our original approach (Frances et al., 1984) was to focus on the evaluation process, with the final goal of appropriate referral of the patient to a most optimal treatment, along the lines of the five macro areas of treatment planning already outlined. Since then, there has been some integration of differential therapeutics and in-treatment modifications (Beutler & Clarkin, 1990; Beutler & Consoli, 1992). Treatment planning only begins with the referral. Patient and therapist, whatever the original treatment goals, foci, and methods, must constantly make reevaluations, modifications, and adjustments. A major point here is that while the diagnosis and problem area focus the content of the intervention, the cognitive style of the patient will dictate the process and style of the intervention. Thus, two people with equal levels of depressive symptomatology may get different interventions, depending on the patient's problem complexity, coping style, and reactance. Matched with the patient's problem complexity is the breadth of treatment goals (see table 14.1). In terms of problem complexity, we have distinguished between simple or habitual symptoms and complex symptom patterns. Habitual or simple symptoms are currently supported by reinforcing environments, and bear a clearly discernible relationship to their original adaptive form and etiology. Complex symptom patterns, by contrast, are indicative of underlying conflicts, which can be inferred when the symptoms have departed from their original and adaptive form and are evoked in environments that bear little relationship to the originally evoking situation. Somatic treatments by definition are symptom focused. Likewise, behavioral and cognitive psychotherapies are directed most specifically to altering simple symptom presentations. In contrast, interpersonal-experiential and psychodynamic therapies are more broadly focused on symptomatic change and change in internal characteristics of the patient. Manuals for conflict-focused psychotherapies are illustrative by defining conflict-oriented therapeutic focus. Experiential (Daldrup, Beutler, Engle, & Greenberg, 1988), interpersonal (Klerman, Weissman, Rounseville, & Chevron, 1984), psychodynamic (Strupp & Binder, 1984), and family (Minuchin & Fishman, 1981) therapies all formulate treatment foci and mediating goals that are beyond the simple symptom focus itself. The coping style of the patient is central to treatment planning, as it sets the parameters on the depth of experience that can be addressed in the treatment. There is no single correct way to categorize patient coping styles, but we have summarized existing empirical information and reduced the coping styles to four: internalization, repressive, cyclic, and externalizing (Beutler & Clarkin, 1990). Thus, the coping styles of the patient will in

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TABLE 14.1

Matching of Patient Dimensions and Therapy Procedures Patient Dimensions

Therapy Decisions

Problem complexity

Breadth of treatment focal goals

Coping style

Depth of experience addressed

Reactance level

Degree of therapy directiveness

some ways determine the depth of experience aroused and addressed in the treatment with depth of experience ranging from overt behaviors, to dysfunctional cognitive patterns, to unidentified feelings and experiences, and, finally, to relatively unconscious motivations, wishes, and conflicts (see Prochaska & DiClemente, 1992). There is no implication here that for a therapy to be effective it must reach to the depth of unconscious motivations. It does suggest, however, that the therapist must coordinate the problem complexity (symptom or conflict) with the depth of experience addressed in the treatment as limited by the coping style of the patient. Finally, the patient's attitude toward seeking assistance from others— reactance—must be taken into consideration by any therapist in titrating the moment-to-moment interventions in therapy. As noted in table 14.1, we speculate that the reactance level of the patient relates to the degree of therapy directiveness. In general, patients high in reactance will not respond well to directive therapies and therapeutic strategies. Rather, more unintrusive interventions such as acceptance, empathy, encouragement, and restatement are most effective with patients manifesting high levels of reactance to the therapist's intervention. Conversely, patients low in reactance may accept more directive approaches (e.g., setting limits, providing guidance and advice) and use them productively. The expert therapist is constantly monitoring the reactance level of the patient, which can change in the course of a session or the course of a treatment episode, and adapting accordingly.

Diagnosis, Problem Areas, and Treatment Planning In our original publication (Frances et al., 1984), we did not base differential therapeutic principles on diagnosis, since we thought at that time there was too little information concerning diagnosis and treatment planning. We

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have since provided case books organized by patient diagnosis and have considered differential treatment planning within the context of diagnosis along with other variables (Perry, Frances, & Clarkin, 1985; Perry, Frances, & Clarkin, 1990). At the present, designs for clinical research, both in psychotherapy and medication research, depend on diagnosis for defining homogeneous patient groups. There have been accumulating data on the nature and treatment of diagnoses that are reliably assessed with the introduction of DSM-III in 1980 and its subsequent revision in 1987. It seems clear that any comprehensive treatment planning algorithim must make use of this accumulating data, so in this description of differential therapeutics, we extend the system along diagnostic lines. Although behavioral systems of differential treatment do put important weight on the specific problem area of the patient (e.g., Goldstein & Stein, 1976; Lazarus, 1992), other orientations seem to imply that the principles of treatment planning cut across the problem areas. They provide little attention to different problem areas and how these might influence treatment planning. The clinician's practice setting will influence the emphasis on diagnosis and its relative weight in treatment planning. The more symptomatically disturbed and less functional the patient, the greater the need to specify via diagnostic criteria those areas of symptomatology and dysfunction in order to begin a specific remediation process. At the other extreme, for those patients with less severe symptoms, who are functional and have clear assets, the diagnosis is less specific, and the treatment approaches can be more varied. This section is in no way meant to be exhaustive of the current information on diagnosis as relevant to treatment planning. For reviews of that information, see other references (e.g., APA, 1989; Bellack & Hersen, 1990). Rather, here we will employ three prevalent diagnosis/problem areas in which there is information as examples of the use of diagnosticrelated information in the treatment-planning process. To that end, we will focus on one prevalent Axis I disorder, major depression, one prevalent and severe Axis II disorder, borderline personality disorder, and one V code, namely, marital distress. We will use these disorders as prototypes for treatment planning.

Major Depression The prevalence and multidetermined nature of depression makes it an important focus for treatment planning. Treatment planning for unipolar depression must take into consideration four factors in its phenomenology: (1) the phase of the illness (the acute phase or thereafter), (2) the severity

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of the disorder, (3) the duration of the disorder (chronic or nonchronic), and (4) the contributory causes of the depression. The phase of the disorder, either acute or between episodes, dictates both the intensity and goals of treatment. The severity of the disorder would include in its conceptualization into subtypes, such as melancholia and psychotic depression. In terms of treatment planning, the distinction between psychotic versus nonpsychotic depression is important, dictating different medication and treatment settings. The duration of the mood disorder, chronic or nonchronic, influences medication strategies and may relate to the personality issues. Because of space limitations, we will discuss treatment considerations only for nonpsychotic, mild-to-moderate levels of unipolar depression on an ambulatory basis. MODEL OF THE DISORDER

The multisite NIMH treatment study of ambulatory depression (Elkin et al, 1989) is illustrative of how several competing models of a disorder are related to treatment options. Two individual treatments—cognitivebehavioral and interpersonal—with different underlying models of the disorder were compared to a standard symptom treatment, imiprimine. Instruments were used in the study to detect not only generalized changes in depression, but also mediating changes that were hypothesized by the two different models of depression, cognitive changes in one model and changes in interpersonal conflict/relations in the other. While differences were not detected in the hypothesized directions, the research strategy is clear: a concise model of the disorder related to focused strategies with hypothesized mediating changes. We think that in this way the field will proceed from reliable diagnostic criteria, to models of the disorders, to treatment planning specifying not only the most useful dimensions of treatment intervention but also foci and related strategies and techniques. MEDIATING GOALS OF TREATMENT

The mediating goals of the treatment of depression are related to the phase and severity of depressive symptoms, and presumed causes leading to their development and maintenance (i.e., a model of the disorder). Depending on the individual patient and his or her idiosyncratic assets, liabilities, stressors, and social supports, the mediating goals of treatment will include symptom improvement (decrease in symptoms of depression, control and management of suicidal ideation and/or behavior); cognitive changes (change in faulty or depressogenic cognitions); interpersonal changes (increase in social skills, social support, and positive and rewarding experiences, decrease in interpersonal conflict); and personality /dynamic changes

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(modification in interpersonal behavior, modification in intrapsychic conflict, including a decrease in overharsh standards and modification of excessive narcissistic concerns). TREATMENT CHOICES

Setting The severity of the depressive symptoms and/or the associated aspects of depression such as suicidal ideation or behavior may, at times, necessitate hospitalization, especially when social supports are low. Under usual circumstances, such a hospitalization would be of brief duration, but might be lengthened when the depression is accompanied by a co-morbid condition such as suicidal ideation/behavior and borderline personality disorder. Other than these unusual situations, the treatment of depression can be carried out in an outpatient setting. Strategies and Techniques The manuals for the individual treatment of depression on an outpatient basis have utilized a range of psychoeducational, behavioral, cognitive, interpersonal, and psychodynamic strategies and techniques. In general, these treatments are highly structured, with the assessment resulting in specific foci that are negotiated with the patient. The use of homework assignments between sessions is common (for an alternate treatment approach, see Arkowitz, 1992). The various individual treatment strategies and techniques are effective, but not differentially so for patients with mild to moderate depressions (Bellack, 1985; Elkin et al, 1989). Since the treatment strategies/ techniques evaluated to date are of equal effectiveness in at least the brief treatment of outpatient mild-to-moderate depressives, the clinician is faced with the dilemma of how to decide which techniques or combination of techniques to use. Although this is not clinically satisfying, the most parsimonious explanation may be that different brief therapy models draw upon common change facilitating elements (see Arkowitz, 1992). One solution is to assess each patient for the presence or absence of difficulties in the focal areas posited by the various models of depression, and target those areas where problems are noted in the evaluation. Thus, depressed patients with faulty interpersonal relations and/or poor social skills will receive treatment focused on these areas. Those patients with prominent cognitive dysfunctions may need some focus on these faulty cognitions. Those with long-standing internal conflicts will need attention

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in this area. In other words, the mediating goals of treatment will vary, depending on the specifics of the individual case. In light of this clinical reality, the clinician must draw flexibly and creatively from a range of behavioral, cognitive, interpersonal, and dynamic techniques in the treatment of depression. One important point that is emerging from research in the treatment of depression should be emphasized. It would appear that the patient must have some minimal level of competence in the area targeted for remediation for the outcome to be positive (Rude & Rehm, 1991). Without some minimal level of competence in the targeted area, the patient does not respond well to intervention, at least in brief therapies. This issue needs more investigation, and may well become a central one in differential treatment planning. Medication and Psychotherapy The combination of medication and psychotherapy for depressed patients is a common approach. There has been extensive investigation of the relative efficacy of cognitive therapy and tricyclic antidepressants (Rush & Hollon, 1991). The recent multisite NIMH study on the treatment of depression is also current and informative (Elkin et al., 1989). In this brief planned treatment for depressed outpatients, two forms of psychotherapy, interpersonal and cognitive treatments, were compared to a standard treatment, imipramine. In general, the psychotherapies were as effective as the pharmacotherapy, and all three were more effective than a placebo. When one looks at more detailed questions, there were some indications of a few differences. Interpersonal therapy, but not cognitive therapy, was somewhat more effective than the placebo for the more severely depressed. Moreover, the rate of change was faster for certain depressive symptoms in patients treated with medication as opposed to those treated in psychotherapy. With those patients who present with mild to moderate depression, it is often advisable to begin a psychotherapeutic intervention without medication. Placebo response rates in these conditions tend to be high, and instilling hope may result in marked clinical improvement which would otherwise be attributed to the medication (see Arkowitz, 1992). In general practice, it may be advisable with mild to moderate, nonurgent depressions to have at least a several-week period in which one can determine how much psychotherapy alone results in improvement, with the understanding that the patient can then be placed on an antidepressant later if needed. In fact, this procedure can be seen by patient and therapist as an empirical procedure to find the best treatment.

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A major limitation in the prescription of tricyclic medications is their lethality when ingested in even relatively small overdoses—often as little as one week's supply. In most instances, they also require two or more weeks to attain therapeutic effectiveness. For these reasons, seriously suicidal patients must receive the medication in a structured, inpatient, hospital setting. What may be of most relevance in treatment planning are the issues of prophylactic treatment and relapse prevention. For example, some studies have found that cognitive therapy either alone or in combination with tricyclic antidepressants is superior to medication treatment without subsequent maintenance in preventing relapse following the termination of treatment (Blackburn, Eunsen, & Bishop, 1986; Simons, Murphy, Levine, & Wetzel, 1986). Further data is needed on this question, and follow-up of the NIMH multisite depression study may help clarify this issue (Elkin et al., 1989). Format Behavioral, cognitive, and interpersonal treatments delivered individually has been researched, and this may reflect the predominant treatment format in clinical use for depression. The focus of treatment in the individual format is the patient's cognitions, social-skills deficits, and problematic interpersonal relations and intrapersonal conflicts. Some of the techniques used in the individual format may be used effectively and more efficiently in the group format, but this has received less research attention. The use of marital and family formats for the treatment of some aspects of depression is in its research infancy (see Clarkin, Haas, & Click, 1988). Among the questions being studied are: Under what conditions is a marital/family treatment indicated when the identified patient is suffering from an affective disorder? What are the mediating goals of treatment of an affective disorder that would call for a marital/family intervention? Behavioral marital treatment, when the depressed individual has concomitant marital conflicts, may be useful (Jacobson, Dobson, Fruzzetti, Schmaling, & Salusky, 1991; O'Leary & Beach, 1990), especially when one of the targets of intervention is marital conflict that preceeded the onset of depression in one spouse (O'Leary, Risso, & Beach, 1990). On a practical level, the clinician must assess for common family problem areas, regardless of whether they predate, coexist with, or follow from the affective symptoms in the patient. It is often impossible to sort out the time sequence and causal relations between symptoms and interpersonal stressors. Family and marital areas of prime relevance to intervention would include marital conflict, anger toward and rejection of the patient, lack of marital intimacy, poor parenting behavior, hostility and

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overinvolvement (high expressed emotion) with the patient, poor medication compliance, and lack of family support for this compliance. In addition to the focus on presence or absence of common problem areas when one family member is depressed, a sequence of possible levels of family interventions is available. There is a potential progression of family intervention from psychoeducation, to routine communication training and problem-solving skills enhancement, to more involved systems and psychodynamic intervention. It would appear to us that for any family in which a member has an episode of major depression, family psychoeducation is indicated. Indeed, in families who have excellent premorbid communication and problem solving, psychoeducation may be sufficient. In the majority of families, however, the insult and stress of a major depressive episode will call for at least a planned, relatively brief family/marital intervention, mainly cognitive and behavioral in strategy focused on assisting the family in coping with the disorder. Finally, there are a subset of families in which premorbid marital conflict, interpersonal difficulties, and poor problem solving are endemic. In these situations, often the patient has concomitant Axis II pathology, and the spouse may also have moderate to serious psychopathology. Then, a longer and more involved family intervention may be of assistance, although it is in these cases where small gains are long in coming. Duration The predominant outpatient treatment for mild to moderate depression that has been researched is a brief, 12-to-25-session psychotherapy. It is quite likely, however, that clinical practice is at variance with the brevity of the treatment in research. This is especially so with cases of more severe depressive symptomatology and where this Axis I condition is confounded with Axis II disorders, which become either an impediment to brief treatment or the focus of intervention once the depressive symptoms have been alleviated. In many cases, a brief treatment can be negotiated with the patient at initial evaluation, but at the end of this brief intervention further evaluation will determine the need for more extended intervention. Theoretically, it is possible to describe patients most likely to respond to brief treatments (little character pathology, absence of previous depressive episodes, those who form a good therapeutic alliance, areas of healthy functioning); in reality, it is often difficult to predict which patients will respond to brief treatments. An empirical approach is best. In evaluating whether brief therapy is appropriate for a particular depressed patient, the duration, severity, nature, and causes of the depression, as well as the presence or absence of a co-morbid Axis II condition

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are important considerations. Brief cognitive-behavioral and interpersonal therapies have been shown to be effective in the diminution of mild to moderate depressions in outpatients with at least some functional capacity. Successful brief therapy has been accomplished when the mediating goal is cognitive changes (Rush, Beck, Kovacs, & Hollon, 1977), social-skills training (Hersen, Bellack, Himmelhoch, & Thase, 1984), increases in pleasant events (Thompson & Gallagher, 1984), changes in interpersonal problems (Weissman et al., 1979), and psychodynamic changes (Thompson & Gallagher, 1984). It should be noted that a sizeable minority of patients do not respond to brief treatment. For example, in one carefully designed study (Hersen, et al., 1984), female unipolar depressives responded to all four treatment conditions (social skills, social skills plus amitriptyline, amitriptyline, and psychotherapy) with marked improvement. However, when a conservative cutoff score (below 10 on both the Beck Depression Inventory and the Hamilton Rating Scale for Depression) was used, only 23 to 49 percent of the patients were rated as improved. This limitation of therapeutic range may be seen in many other studies. Although behavioral treatment was effective in another study (Brown & Lewinsohn, 1984), at six-month follow-up, 25 percent of the patients still met RDC criteria for depression. Low responders to this educational treatment (those who needed more treatment and/or another treatment) reported depressions earlier in life, had significant life stresses, and had greater dissatisfaction across more areas of life, especially with friends. Although there is no guarantee that depressed patients would respond better to a longer treatment, results such as these suggest that longer and more intensive treatments should be employed for patients whose depressive symptoms do not substantially remit after brief therapy. IN-TREATMENT MODIFICATIONS

Once the depressed patient is in treatment, there will likely be needed modifications in the ongoing treatment plan. With depression, the likely modifications are focus (cognitive versus interpersonal), the level of therapist control and direction, and the length of the treatment. Once there is some alleviation of the initial depression, attention will often be more concentrated on accompanying interpersonal behavior and personality disorder traits, which, as noted earlier, are quite common in depressed patients. These difficulties may have helped cause the depression or may have been instrumental in occasioning circumstances leading to the depression, and without intervention they may very likely cause relapse. The presence of personality disorders accompanying depression will have an impact on many aspects of the treatment. The prognosis for recovery

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is not as favorable when the two are co-occurring (Sotsky et al, 1991), and the treatment duration will probably be longer, with personality traits becoming the focus of treatment.

Borderline Personality Disorder MODEL OF THE DISORDER AND TREATMENT-RELEVANT SUBTYPES

The diagnostic criteria of DSM-III and DSM-III-R provide phenomenological criteria for the diagnosis of borderline personality disorder (BPD) and, as such, can be considered a working definition of common difficulties presented by individuals with the diagnosis. The criteria, however, vary widely in their sensitivity, specificity, and predictive power with respect to the diagnosis (Clarkin, Widiger, Frances, Hurt, & Gilmore, 1983). Few individuals classified as having the disorder manifest all eight criteria. Because BPD, like most DSM-III or DSM-III-R diagnoses, is polythetic (i.e., a fixed number of criteria, fewer than the total number of possible criteria, is minimally required to make the diagnosis), it is inevitable that individuals with the disorder will be quite heterogeneous with regard to the criteria and the problem areas they represent. This heterogeneity among people with BPD makes it difficult to define generalized treatment strategies for the group. On the one hand, designing treatment strategies for the individual criteria themselves or for the many possible combinations of criteria seems overly specific. On the other hand, a treatment strategy designed to address the entire complex of criteria would fail to address the modal individual with the diagnosis who has fewer than the complete set. We have recently reported data (Hurt et al., 1990) related to one part of this problem. Combining data from four separate studies of the BPD diagnosis in patients with a primary personality disorder diagnosis, we explored the relationships among the criteria used in making the diagnosis to develop homogeneous clusters of criteria. We then identified those cluster combinations that were related to the BPD diagnosis more often than would be expected by the simple mathematical permutations of the criteria involved. The results indicated that three relatively distinct subsets of criteria could be extracted from the eight DSM-III criteria. One cluster, referred to as the Identity cluster, consisted of the criteria of chronic feelings of emptiness or boredom, identity disturbance, and intolerance of being alone. This cluster reflects commonly described borderline features such as a need for involvement with others and a reliance on external support for self-definition. A second cluster, referred to as the Affective cluster, consisted of the criteria of intense, inappropriate anger, instability of affect, and unstable interpersonal relationships. These criteria capture the frequently

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stormy, often dramatic and intense affective qualities of interpersonal relations described in the clinical literature. The third cluster, referred to as the Impulse cluster, consisted of self-damaging acts and impulsive behaviors. This cluster taps the behavioral inconsistency and proneness to engage in self-destructive behaviors, and represents the more dramatic life- and treatment-threatening qualities that are so very characteristic of BPD patients. At a descriptive level, these three clusters constitute relatively homogeneous collections of problems/behaviors presented by individuals with BPD. We also used these combinations to explore the taxonomy of the disorder. Using cluster combinations allows a more parsimonious consideration of subtypes than is possible with the eight criteria considered individually. In this mixed inpatient and outpatient population, subtypes with criteria combinations involving the Affective and Impulse clusters occurred 2.5 times more often than would be expected by chance alone, whereas subtypes involving the Identity and Impulse clusters occurred only onehalf as often as expected by chance. These three clusters of the DSM-III criteria for BPD and their observed relationships to one another form a basis for the development of treatment strategies for BPD. CO-MORBIDITY

Borderline patients often have extensive co-morbid conditions on both Axis I and Axis II. Many BPD patients have a co-morbid Axis I diagnosis of some form of depression, and they often get into treatment because of a depressive episode. There is an involved debate about the nature of BPD, some suggesting that it is simply a variant of an affective disorder. From a practical point of view, borderline patients with depression need attention for the depression at the beginning, after which the treatment can proceed to other disruptive BPD behaviors (Skodol, 1989). On Axis II it is common for borderline patients to have overlap with narcissistic and histrionic personality disorder and/or features. MEDIATING GOALS OF TREATMENT

The mediating goals of treatment, in order of priority, would be: (1) control of suicidal and other self-destructive behavior (e.g., serious alcohol abuse), (2) induction into treatment with normalization of intreatment behavior (e.g., attendance at each session, reduction in multiple contacts between sessions), (3) treatment of depressive affect and other labile and uncontrolled emotions, (4) improvement in interpersonal relations and behavior, and (5) improvement in self-esteem and identity. The mediating goals of treatment will depend on the co-morbid conditions of the particular BPD patient (e.g., existence of current depression, transient psychotic symptoms), and the particular mix of BPD criteria.

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TREATMENT CHOICES

Setting Under usual circumstances the borderline patient can be treated on an outpatient basis. However, since many of these patients have episodes of serious self-destructive behavior, acute hospitalization may be needed periodically to control such behavior. The range of functioning, both psychosocial and vocational, varies widely in the borderline group, such that some of these patients may need day hospital treatment for the development of these skills. Format While the predominant clinical format is individual treatment, the most researched treatment formats for BPD are a combination of individual and group formats, and group format alone (Clarkin, Marziali, & Munroe-Blum, 1991). The group format has the advantage of diluting the BPD patient's reliance and involvement with one individual therapist, and providing a group of people who can be models for coping and interaction (also see Koerner & Linehan, 1992). This format may provide one antidote to the danger of overinvolvement and iatrogenic effects of individual treatment in borderline patients (Strupp, Hadley, & Gomes-Schwartz, 1977). Strategies and Techniques There are two manualized treatments for BPD patients: a cognitive-behavioral approach, which combines individual and group formats supported by a clinical trial (Linehan, Armstrong, Suarez, Allmon, & Heard, 1991), and a modified psychodynamic approach (Kernberg, Selzer, Koenigsberg, Carr, & Appelbaum, 1989). Psychodynamic treatments show differences in the use or nonuse of early transference interpretation, emphasis on a holding environment versus exploring negative transference, and different conceptualizations of the therapist's role (Waldinger, 1987). Successful dynamic treatments of borderline patients suggest that early treatment goals must focus on controlling acting-out behavior around both the destruction of the treatment and self-destructive behavior, which is then followed by other treatment goals (Waldinger & Gunderson, 1984). Medication A range of pharmacologic treatments have been tried with borderline patients, including the use of neuroleptics, antidepressants, minor tranquilizers, anticonvulsants, and lithium (Beitman, Hall, & Woodward, 1992; Soloff, 1989). Consistent with our earlier discussion of the various symp-

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torn clusters in this heterogeneous group of patients, it is helpful to think of the target symptoms as related to each of the classes of medications. Neuroleptics may be useful as targeted to anger and hostility; cognitive symptoms of paranoia and referential thinking, derealization, and depersonalization; anxiety and phobias; impulsivity; and depression and suicidal ideation. The tricyclic antidepressants (TCAs) target the depression, but have the disadvantage of providing borderlines with lethal substances and have been known to precipitate an increase in suicidality, assaultiveness, and psychoticism. The monoamine oxidase inhibiters (MAOIs) target atypical depression such as labile mood, hyperphasia, hypersomnolence, and rejection sensitivity. They also target impulsivity and self-destructiveness. Carbamazepine may be useful in targeted impulsivity and behavioral dyscontrol, anger, suicidality, and anxiety. And, finally, the benzodiazepines may be useful for anxiety and panic, volatile mood, depression, and paranoia, but unfortunately they may precipitate behavioral dyscontrol and impulsiveness. Since medication effects are only modest, and since borderline personality disorder is a heterogeneous condition, medication should be a part of the overall treatment plan. Duration It is generally agreed that substantial progress with BPD patients will take a treatment of longer duration. Linehan's dialectical behavioral treatment is one year in duration (Koerner & Linehan, 1992), and Kernberg's (Kernberg, Selzer, Koenigsberg, Carr, & Appelbaum, 1989) manualized dynamic treatment presupposes a treatment period of some two years. Brief treatments, however, may be effective at times of crisis for the BPD patient, which may or may not be followed by long-term therapy. Those BPD patients who have gotten into intense and destructive treatment relationships previously may need only brief treatments in crisis. IN-TREATMENT MODIFICATIONS

What modifications in treatment approach must the therapist be aware of in the treatment of borderline patients? These patients present many situations (i.e., potential treatment dropout, threatening of suicidal behavior) that may call for the clinician to be flexible and change strategies in midstream. From a psychodynamic orientation, Kernberg et al. (1989) have suggested that the therapist may have to retreat from therapeutic neutrality at times with these patients, especially when there are suicidal threats and psychotic transferences. From any perspective, the nature and tone of the relationship between patient and therapist must be carefully monitored. BPD patients are prone to become intensely attached, both positively and negatively, to the therapist, and acting-out, self-destructive

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behavior will often occur in the context of this relationship and its viscisitudes. SUMMARY

When planning treatment for the BPD patient, these procedures should be followed: 1. Consider the action potential of the patient (suicidal behavior, other impulsive behaviors); these behaviors need to be controlled right from the start of the treatment. 2. Consider the co-morbid Axis I disorders; depression is common, and in about 10 percent of the cases, bipolar disorder is present. 3. Consider the co-morbid Axis II disorders; the continuum of antisocial, malignant narcissism, narcissism with antisocial traits, and borderline alone is relevant for treatment planning and prognosis. 4. Whether using dialectic/cognitive-behavioral or dynamic treatments, both of which have been manualized, the structure of the treatment from the start is crucial, as exemplified in the contract-setting phase of the treatment. 5. Consider the strengths of the patient.

Marital Distress The extensive prevalence of marital conflict is indicated not only by the high divorce rate but also by the presence of marital conflict in patients who have other symptoms and mental disorders. It is an important phenomenon that demands attention because many individuals present for help with such conditions, because the presence of other psychiatric disorders (e.g., depression) may be partially triggered or exacerbated by marital conflict, and because such conflict is potentially disruptive to the stability of family life and psychological stability of the children. Because of its high frequency in clinical populations and its complicated nature, we will use marital distress as a problem area not only for differential assessment but also for intervention. Marital distress raises interesting questions along many of the axes of differential treatment planning. MODEL OF MARITAL CONFLICT

Marital problems are noted in DSM-III-R as a condition not attributable to a mental disorder that may be a focus of intervention. ICD-10

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includes parental overconcern, sexual and physical abuse, and conflictual relations. There are a number of models, not mutually exclusive, that attempt to explain why marriages become conflicted, dissatisfying, and painful, sometimes to the point of dissolution. The most developed and clinically applicable theories are the exchange model of Thibaut and Kelly (1959), the object relations model of Dicks (1967), and systems concepts that apply to the marital subsystem both within and in relation to the other subsystems of the family (Minuchin, 1974). None of these theories is totally adequate, but from them come some guiding notions and hypotheses of dysfunction in marital dyads that are clinically useful. There is a growing database on the phenomenology of marital conflict, unaccompanied by other mental disorder and occurring in the context of a mental disorder in one spouse. From a phenomenological point of view, marital conflict shows the characteristics of poor communication of information; expression of negative affect, especially in escalating cycles; and absent or poor problem-solving and conflict resolution behavior (Oarkin & Miklowitz, in press). Distressed couples engage in fewer rewarding (positive reinforcement) exchanges and more punishing (negative reinforcement) exchanges than nondistressed couples. Individuals in distressed relationships arc more likely to be immediately reactive to the negative (actual or perceived) stimuli of the partner, and respond in kind. Distressed couples are likely to attempt to control the behavior of one another through negative communication and the withholding of positive communication. Unhappy couples tend to strive for behavior change in the other by aversive control tactics, that is, by strategically presenting punishment and withholding rewards. CO-MORBIDITY

There is to our knowledge hardly any literature providing comorbidity data regarding marital conflict. There is, however, some literature on the presence of marital conflict given the presence of Axis I disorders, such as depression, anxiety, and substance abuse. The most prominent literature is that which suggests a pronounced overlap between depression and marital conflict. DECISION TREE AND ASSESSMENT QUESTIONS

The clinician must ascertain the following to make treatment decisions: 1. Are both spouses committed to the marriage? If one or both are not committed to the marriage or are considering separation or divorce, this must be addressed before launching into marital treatment. Some form of

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separation, divorce assistance, and counseling (e.g., what to tell the children) may be needed. 2. Is one or both parties currently sexually unfaithful? If sexual acting out is going on and unknown to the other party, this must be addressed between therapist and patient. If the sexual acting out is known to the other party, this issue can be addressed directly in the marital treatment. 3. In marriages that are committed and sexually faithful, what is the focus of conflict? Is the conflict contained in the marriage unit, or does the conflict involve other family subsystems (e.g., children, family of origin)? 4. Does one or both spouses have an Axis I disorder? The most prevalent is depression, which may require treatment either first or in conjunction with treatment of the marital conflicts. When an Axis I disorder is present, it will modify the focus of the treatment. For example, if one spouse has a diagnosis of bipolar disorder, the difficulties in management of that condition must be part of the evaluation. Upon evaluation, it may be that the bipolar disorder has little to do with the marital distress, or it may be a central area of difficulty; treatment will be focused accordingly. A second common condition is one in which one spouse has currently or in the recent past had major depression or dysthymia. In this situation, it would appear that marital treatment is effective for both the marital distress and the depression. When there is no Axis I disorder, and the chief complaint is centered around marital distress, the marital conflicts themselves are the focus of intervention. It seems more likely in these situations that both parties are contributing to the conflict, and the use of marital treatment format has more face validity. Even here, there are situations (e.g., when one spouse uses the treatment to attack the other) when individual format is more beneficial (see Feldman & Powell, 1992). There is a growing literature on the effectiveness of cognitive and behavioral techniques to modify communication and problem-solving difficulties. MEDIATING GOALS OF TREATMENT

The mediating goals of treatment for marital distress will depend on an initial assessment regarding whether both individuals are contributing to the conflict, or whether the predominance of one person's difficulties is mostly or totally responsible. In the case of marital conflict in which two parties are contributory, the mediating goals would include specification of problems, recognition of mutual contributions to the conflicts, increase in expressive and listening skills, increased reciprocity, decrease in mutual coercion and blame, and cooperative problem solving. While the mediating goals of marital intervention may depend in part on the school or orientation of the therapist (Gurman, 1978), we maintain

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it should depend more on the particular problems of the couple. One can pursue mediating goals of treatment that relate to the identification and improvement of interactional behaviors causing the disruption; cognitive and behavioral strategies can be used quite effectively in these situations. On the other hand, situations in which one spouse has an Axis I disorder (e.g., major affective disorder), and the marital conflict seems secondary to the condition in that spouse, the individual treatment of that spouse may clear up the marital disputes. There are other situations in which the deficit model of marital disruption, and the cognitive-behavioral approach aimed at increasing communication and problem-solving skills, is inappropriate. In these situations, the couple may have the requisite skills, and they may use them effectively in all areas of their lives except with their spouses, with whom they are in serious conflict. These complex situations and their behavioral sequelae, including violence and sexual affairs, have been eloquently described by Dicks (1967). Dynamic strategies used in a couples format are indicated here. If the conflicts are too severe, and too deep-rooted in one person, treatment in an individual format may be indicated. With the high divorce rate, it is not uncommon for the clinician to be faced with impending divorce. In these situations, it often happens that one spouse wants marital therapy to improve the situation, and the other spouse seeks to use the therapy forum to reveal the intent to separate and divorce. Under such circumstances, the first mediating goal is to surface the motivations and intentions of the spouse wishing divorce. The sessions are then focused on the goals of the separating spouse, and concrete steps are taken to manage the crisis that is being created. If the situation moves toward divorce, dealing with issues concerning children and the mourning process of the spouse being left are central. The most effective sequencing of the mediating goals of treatment can be informed by crossover experimental designs that focus on various aspects of individual symptomatology. For example, patients with both marital and phobic-obsessive problems were treated in a crossover design, with exposure for phobic-obsessive targets and marital therapy (Cobb, McDonald, Marks, & Stern, 1980). The exposure treatment led to significant improvement in the phobic and obsessive symptoms, with no benefit on marital adjustment. Likewise, marital therapy led to improvement in marital difficulties only. In another study, treatment in the marital format that focused on sexual dysfunction positively affected both the dysfunction and marital conflict, whereas treatment that focused first on marital conflict had some benefit, but the sexual difficulty was not changed until this was approached specifically (Hartman & Daly, 1983). This kind of study would suggest that attention to specific symptoms and behaviors should come first, followed by attention to generalized conflict.

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TREATMENT CHOICES

Format The format that has the most validity for the treatment of marital conflict is one in which both spouses are present for all or most of the sessions. This format has many advantages, the most obvious being that it provides a forum where the conflicts can be verbally articulated and enacted for the intervention of the therapist. There may be situations where the marital treatment format is impossible (e.g., one spouse refuses to attend) or contraindicated (Bennun, 1984). The latter would include situations in which the spouses are immature and cannot tolerate the stress of a competitive conjoint interview, unresolved conflicts in one individual threaten the relationship, excessive interactional emotionality and physical aggression is present and conjoint treatment simply stimulates more of this behavior, and when one partner presents with low self-esteem and self-depreciation not related to depression. A model of marital intervention has been articulated in which one spouse is treated in the individual format with attention to the other spouse, including a conjoint evaluation (Bennun, 1984). Strategies and Techniques Cognitive-behavioral treatments have proven effective in reducing marital conflict and increasing positive marital interaction. Behavioral marital treatment packages incorporate strategies for understanding behavior, increasing couples' communications and problem-solving skills (Baucom & Epstein, 1990; Bornstein & Bornstein, 1986; Jacobson & Margolin, 1979). The research on marital disputes has been done almost exclusively on cognitive and behavioral techniques, which have been found to be effective. An exception is the recent study suggesting that dynamic treatment of marital disputes in the marital format is more durable in its results than cognitivebehavioral strategies (Snyder & Wills, 1989; Snyder, Wills, & GradyFletcher, 1991).

IN-TREATMENT MODIFICATIONS

Adapting the strategies and techniques to the coping style and problems of the individual patient is compounded when there are two individuals—in conflict with each other—in the marital treatment format. It is quite possible that the individuals in the marital dyad may have matching or nonmatching coping styles and levels of reactance. Clearly, the task of

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therapist adaptation to the defensive style and reactance level of the patient is compounded in marital treatment. To make matters even more complicated, it may be the nonmatching cognitive and coping styles of the marital partners that is the essence of the marital difficulties in themselves.

Concluding Comment With the progression of time and the inevitable comparison with other views of psychotherapy integration (Norcross & Newman, 1992), the substance of differential therapeutics in terms of its goals and content, its assets and its limitations has become more clear. Differential therapeutics was originally intended as a framework (based upon research and accumulated clinical wisdom) within which one could teach students of mental health delivery (psychiatry residents, psychology interns and fellows, nursing and social work students) a methodology for clinical decision making. This continues to be the main function of differential therapeutics: it is a framework within which one can continually make use of new research information to reformulate guidelines for treatment planning. While conceived as a teaching framework, differential therapeutics can also be used as a guide for generating hypotheses for clinical research. It has been repeatedly pointed out that the number of possible combinations of patients by type, by diagnosis, by treatment, is almost infinite, and we cannot plan for research on all combinations. Rather, one must strategically plan research on the most likely fruitful combinations. Part II of this volume is focused on systems of psychotherapy integration, and Part III pertains to integrative psychotherapies for specific disorders. In many respects, differential therapeutics includes, but is limited to, neither a system of psychotherapy integration nor to specific disorders. Integrative systems focus on what the therapist does in terms of therapy strategies and techniques at different phases of an individual treatment. Differential therapeutics originally lacked attention to such detail in the therapy session, but has been applied to these situations in a more recent exploration (Beutler & Clarkin, 1990). From a time perspective, differential therapeutics comes before systems of psychotherapy. Rather than assuming that the patient is in individual psychotherapy of whatever strategy, differential therapeutics is concerned with the evaluation and treatment planning for the individual from the first evaluation, whether that be in a hospital emergency room, in a walk-in clinic, or in a private practitioner's office. This system does not assume that the clinician will be treating the patient, but rather that the evaluation can have more degrees of freedom if evaluator and patient do not assume that the evaluator will be doing the treatment. From the

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perspective of the initial evaluation, many avenues of treatment tailored to the individual patient are real possibilities. Other kinds of systematic treatment integration place little emphasis on the use of diagnosis. We think that as data accrue on the differential treatment response of various diagnostic groups, they will continue to provide important modifiers in the treatment planning process. There are limitations to the use of diagnosis (Beutler & Clarkin, 1990), but the diagnosis is the first step in specifying the nature of the patients' difficulties, relevant to the focus and methods of intervention. At the extremes, this statement is clear. One does not treat chronic schizophrenics and adjustment disorders alike. In the mid-range (e.g., depressed outpatients) the nature of the disorder and its relation to differential treatment is less clear.

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& PARLOFF, M. B. (1989). NIMH Treatment of Depression Collaborative Research Program: 1. General effectiveness of treatments. Archives of General Psychiatry, 46, 971-982. FALLOON, I. R. H., BOYD, J. L, & MC&LL, C. W. (1984). Family care of schizophrenia. New York: Guilford. FELDMAN. L. B., &. POWELL, S. L. (1992). Integrating therapeutic modalities. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. FRANCES, A., & CLARKIN, J. F. (1981). No treatment as the prescription of choice. Archives of General Psychiatry, 53, 242—248. FRANCES, A., CLARKIN, J. F., & PERRY, S. (1984). Differential therapeutics: A guide to the art and science of treatment planning in psychiatry. New York: Brunner/ Mazel. FRANK, J. D. (1973). Persuasion and healing: A comparative study of psychotherapy. Baltimore: Johns Hopkins University Press. GARFIELD, S. L. (1982). Eclecticism and integration in psychotherapy. Behavior Therapy, 13, 610-623. GARFIELD, S. L. (1992). Eclectic psychotherapy: A common facts approach. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. GOLDFRIED, M. R. (Eo.). (1982). Converging themes in psychotherapy. New York: Springer. GOLDSTEIN, A. P., & STEIN, N. (1976). Prescriptive psychotherapies. Elmsford, NY: Pergamon. GRENCAVAGE, L. M., & NORCROSS, J. C. (1990). Where are the commonalities among the common factors? Professional Psychology: Research and Practice, 27, 372-378. GURMAN, A. S. (1978). Contemporary marital therapies: A critique and comparative analysis of psychoanalytic, behavioral and systems theory approaches. In T. J. Paolino, Jr., & B. S. McCrady (Eds.), Marriage and marital therapy (pp. 445-567). New York: Brunner/Mazel. HARTMAN, L. M., & DALY, E. M. (1983). Relationship factors in the treatment of sexual dysfunction. Behavior Research and Therapy, 21, 153—160. HERINK, R. (Eo.). (1980). The psychotherapy handbook. New York: New American Library. HERSEN, M., BELLACK, A. S., HIMMELHOCH, J. M., & THASE, M. E. (1984). Effects of social skills training, amitriptyline, and psychotherapy in unipolar depressed women. Behavior Therapy, 15, 21. HOLLON, S. D., & BECK, A. T. (1986). Research on cognitive therapies. In S. L. Garfield & A. E. Bergin (Eds.), Handbook of psychotherapy and behavior change (3rd ed., pp. 443-482.). New York: Wiley. HOOLEY, J. (1987). The nature and origins of expressed emotion. In K. Hanlew & M. Goldstein (Eds.), Understanding major mental disorder: The contribution of family interaction research (pp. 176—194). New York: Family Process Press.

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HURT, S. W., CLARKIN, J. F., MUNROE-BLUM, H., & MARZIALI, E. (in press). Borderline behavioral clusters and the treatment manuals. In J. F. Clarkin, E. Marziali, & H. Munroe-Blum (Eds.), Borderline personality disorder: Clinical and empirical perspectives. New York: Guilford. HURT, S. W., CLARKIN, J. F., WIDIGER, T., FYER, M., SULLIVAN T., STONE, M., & FRANCES, A. (1990). Evaluation of DSM-III decision rules for case detection using joint conditional probability structures. Journal of Personality Disorder, 4, 121-130. JACOBSON, N. S., DOBSON, K., FRUZZETTI, A. E., SCHMALING, K. B., & SALUSKY, S. (1991). Marital therapy as a treatment for depression. Journal of Consulting and Clinical Psychology, 59, 547-557. JACOBSON, N. S., & MARGOLIN, G. (1979). Marital therapy: Strategies based on social learning and behavior exchange principles. New York: Brunner/Mazel. KAZDIN, A. E. (1980). Research design in clinical psychology. New York: Harper & Row. KAZDIN, A. E. (1988). Child psychotherapy: Developing and identifying effective treatments. Elmsford, NY: Pergamon. KERNBERG, O. F., SELZER, M. A., KOENIGSBERG, H. W., CARR, A. C, & APPELBAUM, A. H. (1989). Psychodynamic psychotherapy of borderline patients. New York: Basic Books. KLERMAN, G. L, WEISSMAN, M. M., ROUNSAVILLE, B. J., & CHEVRON, E. S. (1984). Interpersonal psychotherapy of depression. New York: Basic Books. KOERNER, K., & LINEHAN, M. (1992). Integrative therapy for borderline personality disorder: Dialectical behavior therapy. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. Koss, M. P., & BUTCHER, J. N. (1986). Research on brief psychotherapy. In 5. L. Garfield & A. E. Bergin (Eds.), Handbook of psychotherapy and behavior change (3rd ed., pp. 627-670). New York: Wiley. LAMBERT, M. J. (1992). Psychotherapy outcome research: implications for integrative and eclectic therapists. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. LAZARUS, A. A. (1992). Multimodal therapy: technical eclecticism with minimal integration. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. LINEHAN, M. M. (1987). Dialectical behavioral therapy: A cognitive behavioral approach to parasuicide. Journal of Personality Disorders, 4, 328-333. LINEHAN, M. M., ARMSTRONG, H. E., SUAREZ, A., ALLMON, D., & HEARD, H. L. (1991). Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48, 1060—1064. LUBORSKY, L. (1984). Principles of psychoanalytic psychotherapy. A manual for supportive-expressive treatment. New York: Basic Books. MINUCHIN, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press.

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MINUCHIN, S., & FISHMAN, H. C. (1981). Family therapy techniques. Cambridge, MA: Harvard University Press. NORCROSS, J. C. (1986a). Eclectic psychotherapy: An introduction and overview. In ]. C. Norcross (Ed.), Handbook of eclectic psychotherapy (pp. 3-24). New York: Brunner/Mazel. NORCROSS, J. C. (Eo.). (1986b). Handbook of eclectic psychotherapy. New York: Brunner/Mazel. NORCROSS, J. C., & NEWMAN, C. F. (1992). Psychotherapy integration: Setting the context. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. O'LEARY, K. D., & BEACH, S. R. H. (1990). Marital therapy: A viable treatment for depression and marital discord. American Journal of Psychiatry, 147, 183-186. O'LEARY, K. D., Risso, L. P., & BEACH, S. R. H. (1990). Attributions about the marital discord/depression link and therapy outcome. Behavior Therapy, 21, 413-422. PERRY, S., FRANCES, A., & CLARKIN, ]. F. (1985). A DSM-III casebook of differential therapeutics: A clinical guide to treatment selection. New York: Brunner/Mazel. PERRY, S., FRANCES, A., & CLARKIN, ]. F. (1990). A DSM-III-R casebook of treatment selection. New York: Brunner/Mazel. PROCHASKA, ]. O., & DICLEMENTE, C. C. (1992). The transtheoretical approach. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. RUDE, S. S., & REHM, L. P. (1991). Response to treatments for depression: The role of initial status on targeted cognitive and behavioral skills. Clinical Psychology Review, 11, 493-514. RUSH, A. J., BECK, A. T., KOVACS, M., & HOLLON, S. (1977). Comparative efficacy of cognitive therapy and pharmacotherapy in the treatment of depressed outpatients. Cognitive Therapy and Research, 1, 17—37. RUSH, A. ]., & HOLLON, S. D. (1991). Depression. In B. D. Bietman & G. L. Klerman (Eds.), Integrating pharmacotherapy and psychotherapy (pp. 121—142). Washington, DC: American Psychiatric Press. SALTZMAN, N., & NORCROSS, J. C. (Eos.). (1990). Therapy wars. Contention and convergence in clinical practice. San Francisco: Jossey-Bass. SIMONS, A. D., MURPHY, G. E., LEVINE, ]. E., & WETZEL, R. D. (1986). Cognitive therapy and pharmacotherapy for depression: Sustained improvement over one year. Archives of General Psychiatry, 43, 43—49. SKODOL, A. E. (1989). Problems in differential diagnosis: From DSM-III to DSMIII-R in clinical practice. Washington, DC: American Psychiatric Press. SMITH, B., & SECHREST, L. (1991). Treatment of aptitude X treatment interactions. Journal of Consulting and Clinical Psychology, 59(2), 233-244. SMITH, M., GLASS, G., & MILLER, T. (1980). The benefits of psychotherapy. Baltimore: Johns Hopkins University Press. SNYDER, D. K., & WILLS, R. M. (1989). Behavioral versus insight-oriented

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marital therapy: Effects on individual and interspousal functioning. Journal of Consulting and Clinical Psychology, 57, 39—46. SNYDER, D. K., WILLS, R. M., & GRADY-FLETCHER, A. (1991). Long-term effectiveness of behavioral versus insight-oriented marital therapy. Journal of Consulting and Clinical Psychology, 59, 138—141. SOLOFF, P. H. (1989). Psychopharmacologic therapies in borderline personality disorder. In A. Tasman, R. E. Hales, & A. J. Frances (Eds.), American Psychiatric Press Review of Psychiatry (Vol. 8, pp. 65—83). Washington, DC: American Psychiatric Press. SOLOFF, P. H., GEORGE, A., NATHAN, R. S., SCHULZ, P. M., ULRICH, R. F., & PEREL, J. M. (1986). Progress in pharmacotherapy of borderline disorders. Archives of General Psychiatry, 43, 691-697. SOTSKY, S. M., GLASS, D. R., SHEA, M. T., PILKONIS, P. A., COLLINS, J. F., ELKIN, I., WATKINS, J. T., IMBER, S. D., LEBER, W. R., MOYER, J., & OLIVERI, M. E. (1991). Patient predictors of response to psychotherapy and pharmacotherapy: Findings in the NIMH Treatment of Depression Collaborative Research Program. American Journal of Psychiatry, 148(8), 997-1008. STRUPP, H. H., & BINDER, ]. L. (1984). Psychotherapy in a new key. New York: Basic Books. STRUPP, H. H., HADLEY, S. W., & GOMES-SCHWARTZ, B. (1977). Psychotherapy for better or worse: An analysis of the problem of negative effects. New York: Jason Aronson. THIBAUT, J. W. & KELLEY, H. H. (1959). The social psychology of groups. New York: Wiley. THOMPSON, L. W., & GALLAGHER, D. (1984). Efficacy of psychotherapy in the treatment of late-life depression. Advances in Behavioral Research and Therapy, 6, 127. WALDINGER, R. J. (1987). Intensive psychodynamic therapy with borderline patients: An overview. American Journal of Psychiatry, 744(3), 267-274. WALDINGER, R. J., & GUNDERSON, J. G. (1984). Completed psychotherapies with borderline patients. American Journal of Psychotherapy, 38, 190—202. WEISSMAN, M. M., PRUSOFF, B. A., DiMAscio, A., NEU, C, GOKLANEY, M., & KLERMAN, G. (1979). The efficacy of drugs and psychotherapy in the treatment of acute depressive episodes. American Journal of Psychiatry, 136, 555-558. WOLFE, B. E. (1992). Integrative psychotherapy of the anxiety disorders. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books.

CHAPTER 15

Integrating Therapeutic Modalities LARRY B. FELDMAN AND SANDRA L. POWELL

INDIVIDUAL, FAMILY, AND GROUP THERAPY have developed as

separate, and often antagonistic, modalities. The rigid separation between these modalities has limited therapists' ability to conduct comprehensive clinical assessments and to intervene in ways that promote both intrapsychic and interpersonal changes. The integration of individual, family, and group therapy has the potential to markedly enhance clinical assessment and psychotherapeutic treatment of a wide range of emotional and behavioral problems (Feldman, 1992; Gurman, 1981; Kramer, 1980; Lipsius, 1991; Pfeifer & Spinner, 1985; Sager, 1981; Sander, 1979; Schachter, 1988; Scheidlinger & Porter, 1980; Shapiro, 1978; Steinhauer, 1985; Swiller, 1988; Wachtel & Wachtel, 1986). In this chapter, we present a model for integrating these modalities and illustrate it with clinical examples. The chapter is divided into four sections. In the first section, the advantages and limitations of each modality are discussed. The second section focuses on general considerations regarding the process of integrating different modalities. The third section is devoted to individual and family therapy integration, while the fourth describes individual and group therapy integration.

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Advantages and Limitations of Individual, Family, and Group Therapy

ADVANTAGES OF INDIVIDUAL THERAPY

Individual psychotherapy provides a particularly valuable context for assessing intrapsychic problems and strengths and for promoting intrapsychic and behavioral changes. The privacy of the individual setting reduces defensiveness and facilitates discussion of feelings and thoughts about self and significant others. Often, individuals are able to discuss in an individual meeting important issues that they would be too fearful, ashamed, or guilty to discuss in the less private context of family or group therapy. Examples of such issues include feelings of worthlessness, suicidal ideation, thoughts about divorce, homosexual impulses or behavior, alcohol or drug abuse, marital or parental violence, extramarital affairs, and sexual abuse. When the therapist's assessment does not include a detailed understanding of such issues, that assessment will be incomplete. In some instances, such as when an individual is suicidal, potentially violent, or the victim of physical or sexual abuse, the assessment may be dangerously incomplete. Individual therapy allows the therapist to develop an in-depth assessment of one person's behavior, feelings, and thoughts. All aspects of the individual's life—family, work, interests, friends—can be explored. In family and group therapy, this is more difficult because of the need to assess more than one person at a time, as well as the dynamic interactions between the family or group members. In addition to its value as a context for the assessment of intrapsychic concerns, individual therapy is also a valuable source of hypotheses about interpersonal problems and strengths and interpersonal problem stimulation and reinforcement processes. Through the individual's self-reports and the therapist's direct experience of a one-on-one relationship with him or her, valuable hypotheses about interpersonal dynamics often emerge. Individual therapy provides a particularly valuable setting for the establishment of a therapeutic alliance. By relating with empathy, respect, concern, and genuineness (Rogers, 1980), the therapist fosters the development of a safe, collaborative relationship within which difficult feelings, thoughts, and behaviors can be explored and changed. The intimacy of the individual therapy relationship contributes to feelings of trust and hope, and a sense that the therapist "really cares about me," "has my interests at heart," and is "my ally." The privacy and focused intensity of individual therapy stimulates intrapsychic change processes. The opportunity to experience a primary relationship with a "good object" (Klein & Riviere, 1964) facilitates the

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process of therapeutic intemalization (Meissner, 1981). Individuals are able to identify with the therapist's empathic and respectful attitude toward them, thereby enhancing their own self-understanding and self-respect. The opportunity to explore conscious and unconscious experiences within the context of a secure "holding environment" (Winnicott, 1965) facilitates the processes of insight and working through (Wachtel, 1985). In this context, cognitive distortions and transference projections can be clarified and the connections between these processes and unconscious anxiety and conflict can be uncovered and worked through. The intensity of the one-on-one relationship stimulates the development of emotionally charged reactions toward the therapist. Because the therapist is the only other person physically present, cognitive and emotional responses toward him or her are particularly compelling. In family and group therapy, the presence of other individuals may dilute the intensity of the transference and distract the therapist's attention away from a focused examination of these reactions. Individual therapy affords the therapist frequent opportunities to concentrate his or her empathic understanding on the dynamics of the therapeutic relationship. Discussion of these dynamics in the privacy of the individual setting has the potential to produce substantial intrapsychic change (Luborsky, 1984). In addition to facilitating intrapsychic change, individual therapy also provides a valuable context for promoting behavioral change (Wachtel, 1977; Wachtel & Wachtel, 1986). Within the secure environment of the individual setting, new forms of behavior can be safely tried out. This takes place in two ways. In direct interactions with the therapist, the individual has opportunities to experiment with a variety of new behaviors. For example, passive, compliant people can risk being more assertive because they know that the therapist will not be judgmental or attacking. Indirect interactions with the therapist via role-played behavior rehearsal provide an opportunity to address specific problem situations in the individual's day-to-day life. For instance, people who are unassertive with their spouse can use behavior rehearsal with the therapist to reduce their anxiety about assertive behavior toward the spouse. LIMITATIONS OF INDIVIDUAL THERAPY

The limitations of individual therapy are derived from its reliance on the one-to-one relationship with the therapist as the sole context for clinical assessment and therapeutic intervention. While this relationship is important, it is also limited. In terms of assessment, an individual may withhold important information that is essential for formulating a treatment plan. For example, a person with an alcohol or drug abuse problem may be afraid to admit

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having a problem in this area; a suicidal person may be ashamed to admit feeling suicidal; a violent person may feel too guilty to discuss his or her violent behavior. In such situations, meeting with one or more significant others is often very illuminating. At times, it may be lifesaving. Another limitation of individual therapy is that it does not allow the therapist to observe directly the individual interacting with anyone other than the therapist. Often, people behave quite differently in different contexts. A person may, for example, be calm and cordial during an individual meeting with the therapist but may manifest a great deal of hostility in a family or group meeting. Conversely, a person may be quite hostile in an individual meeting but calm and cordial in a family or group meeting. When the therapist's observations are drawn from individual meetings only, a great deal of important information may be lost. In regard to therapeutic intervention, individual therapy does not provide opportunities for the therapist to influence directly the interpersonal behavior of the significant people in the person's life. Furthermore, there are no opportunities for anyone other than the therapist to interact with the individual in therapeutic ways. In family and group therapy, such opportunities are readily available. ADVANTAGES OF FAMILY THERAPY

Family therapy, with couples or multigenerational families, provides a particularly valuable context for assessing interactional problems and strengths, and for promoting positive changes in marital or family interaction patterns. By meeting with family members together, the therapist has the opportunity to join with them in a collaborative effort to understand and change their problematic interactions and to facilitate the development of more positive, intimacy-promoting experiences. In conjoint meetings, the therapist is able to observe how family members organize themselves (who sits next to whom, who speaks to whom, etc.). He or she is also able to observe their postures, gestures, and facial expressions and the quality, pitch, and volume of their voices. Sequences of nonverbal and verbal behavior are valuable sources of insight into the ways family members consciously and unconsciously stimulate and reinforce each other. For example: a husband moves back in his chair whenever his wife begins to talk about their sexual relationship; a son interrupts when his mother and father begin to argue; a mother consistently answers questions that are addressed to her daughter. Equally valuable are the therapist's observations of the similarities and differences among each family member's perceptions of the problems and strengths in the family, and of the constructive and destructive ways that family members discuss the problems that they have identified. Based on

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these observations, the therapist can directly intervene to reduce the frequency and intensity of destructive behaviors and to foster the development of constructive problem-solving interactions. Conjoint marital or family meetings also provide an opportunity for consensual clarification of self-reported behaviors and behavior sequences. Often, family members remember the same events in quite different ways. For instance, a husband may report that he drinks once or twice a week, while his wife states that he drinks every day. Similarly, a teenage boy may indicate that school is "fine," but his mother reports that she is receiving frequent complaints from his teachers about his behavior. Clarification of these differences is essential for the development of an accurate assessment. In addition to their value as contexts for assessing interpersonal problems and strengths, conjoint meetings are also valuable sources of hypotheses about individual problems and strengths and intrapsychic problem stimulation and reinforcement processes. Observing individuals in the context of their family provides a unique perspective from which to formulate hypotheses about intrapsychic dynamics. Individual resistances are often reduced in family therapy because problems are identified as family problems rather than exclusively individual ones. Each family member is viewed as partially responsible for finding solutions to the problems. This avoids individual scapegoating and facilitates the engagement of each person in a therapeutic effort to improve the quality of family interactions. Conjoint meetings also promote the development of intimacy among family members. These meetings are an opportunity for individuals to share their feelings and thoughts about themselves, each other, and their life together. The therapist helps each person to communicate constructively his or her feelings and thoughts about self and others, and to listen actively as others communicate their feelings and thoughts. This process increases empathic understanding and promotes feelings of intimacy. The time that family members spend with each other before and after family therapy meetings is often very therapeutic. For many families, this is the only time they are together during the week. During these times, they are able to share experiences and feelings that they otherwise might not have shared. Many families report that after leaving therapy meetings, they continue to work productively on issues that they had begun working on during the meeting. LIMITATIONS OF FAMILY THERAPY

Family therapy has traditionally relied on conjoint meetings as the sole context for clinical assessment and therapeutic intervention. While conjoint meetings have many benefits, they also have limitations.

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One of the limitations is that family members are often unwilling to raise or discuss important issues concerning themselves, other family members, or interactions among family members. Examples of such issues were previously noted (see advantages of individual therapy), as was the importance of the therapist having knowledge of these issues in order to formulate an accurate and complete assessment. Another limitation of family therapy is that conjoint meetings do not allow the therapist to observe and interact with individuals outside of the context of their marriage or family. As previously discussed, the differences between how people behave when seen with their families and how they behave when seen individually are often quite dramatic. When the therapist's observations are limited to conjoint meetings only, his or her assessment will be markedly incomplete. Finally, family therapy is limited in its ability to facilitate intrapsychic change processes. The presence of other family members interferes with both the focused attention and the empathic responsiveness necessary for the establishment of a secure environment for intrapsychic exploration. ADVANTAGES OF GROUP THERAPY

Group therapy provides a particularly valuable context for assessing interpersonal problems and strengths, and promoting positive changes in interpersonal behavior. In the group setting, interactions of group members with each other and with the therapist offer multiple and complementary opportunities for assessment and therapeutic intervention. Functional and dysfunctional behaviors become apparent as individuals relate to each other within the group setting. Group members may "act out," challenge, or confront in ways a therapist would not. Behavioral and emotional responses in these stressful situations provide valuable information about coping skills, vulnerability, and resiliency. Conscious and unconscious intrapsychic processes are often brought to light as group interactions stimulate cognitive distortions and transference reactions. Individuals' seli-reports and group members' feedback are both valuable means for identifying irrational or distorted thoughts and feelings. The shared feelings and experiences of the group members provide an important "normalizing" function. Commonality of life experiences or problem areas provides reassurance and facilitates openness and full disclosure. The humiliation that many people experience about coming for professional help- not being "able to solve one's own problems"—can be substantially diminished by the shared experience of group treatment. The normalizing function of the group experience not only expands assessment opportunities by counteracting inhibitions and facilitating shar-

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ing, but also makes a significant contribution to therapeutic change. Individuals often come to treatment with low self-esteem, fueled by a sense of isolation, feeling different or "defective," and set apart from others by "unique" problems, experiences, or family backgrounds. Group therapy provides a context in which individuals can experience consensual validation, hear others report familiar struggles, recognize similarities, and reframe elements of their personal dilemma as part of the human dilemma. Group members frequently report a sense of relief as this process unfolds (Yalom, 1985). Group therapy is also an empowering experience. The group members serve as change agents and facilitators; there are numerous opportunities for leadership and for experiencing oneself in benevolent ways. In the group context, individuals give to one another, and in that giving, receive a renewed sense of self-worth. By offering support, encouragement, reassurance, and insight through direct feedback and interpretations, group members influence each other in ways that facilitate growth and change for themselves and for others. At the time of termination, individuals often report the special significance of interventions by their peers. Affirmations may be less suspect because the group member is not "being paid to do the praising." Suggestions and interpretations may be considered more credible coming from "others who have been there." Confrontations may be easier to tolerate when they come from "one of us," not from the expert, the parent, or the authority figure. Acceptance can be relished when it seems hard won, rather than a professional responsibility that "comes with the territory." Learning through others in the group occurs directly and indirectly. Members influence each other directly by offering suggestions, validation, affirmation, or confrontation. They influence each other indirectly by means of observing and absorbing therapeutic changes. As a fellow group member develops insight or modifies behavior, others identify with the process. In this way, therapeutic changes become available for all. "Vicarious therapy" (Yalom, 1985) is one of the distinct advantages of group treatment. The whole in group therapy is more than the sum of its parts. An entity develops—"the group"—which generates its own information and offers learning through interpersonal process. This interpersonal process provides a corrective emotional experience. If individual therapy creates an opportunity for a primary relationship with a "good enough" parent, then group therapy offers a context in which issues involving the entire family may play themselves out. Dysfunctional sibling rivalry is often addressed in group process as individuals compete for the attention and admiration of the therapist and other members. Varying positions of inclusion and exclusion in the group often represent individuals' sense of themselves and

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their role in their family of origin. A sense of belonging, never fully experienced in childhood, may develop as the group becomes increasingly cohesive. Conflict between members, unsuccessfully resolved in the family system, may be dealt with constructively in the group setting. Empathic understanding, acceptance, validation, and affirmation that were lacking in the individual's first significant group experience, the family, can be found in the present group experience. Group therapy is particularly valuable in helping individuals with socialization problems. A heightened awareness of self and others can be developed in this interpersonal context. A person may present to a therapist in individual treatment with one set of attitudes, feelings, and behaviors, but demonstrate a very different set of reactions when in a group setting. Often it is the latter presentation, in the form of missed social cues, inappropriate boundaries, limited communication skills, or difficulty in establishing empathy or dealing with conflict, that alienates individuals from others in their work or home environments. A "self-fulfilling prophecy" often develops in which the "difficult" person behaves in "difficult" ways, the one who anticipates rejection rejects first or acts out in ways guaranteed to elicit rejection, the painfully shy young adult withdraws from interaction, thus reinforcing the view of self as socially inadequate. Therapeutic intervention in a group context can interrupt this vicious cycle (see Wachtel & McKinney, 1992), as the therapist and group members identify dysfunctional patterns and work together toward the development of social skills and a more positive sense of self. The group setting offers a safe, contained arena in which various feelings, thoughts, and behaviors can be explored and modified. Unlike other social situations, there are specific boundaries, norms, and guidelines developed by the group and designed to provide a testing ground in which people can risk exposure, experience catharsis, and enjoy support. LIMITATIONS OF GROUP THERAPY

While many individuals find the group format liberating through the sharing of common issues and life experiences, some feel inhibited by the presence of others. For these people, the shame, guilt, and anxiety about exposure is multiplied by the number of participants. Long-guarded "secrets" around issues such as incest, substance abuse, family violence, or suicidal behavior may be more difficult to reveal in a group context. In such cases, the privacy of individual therapy provides an opportunity for more complete self-disclosure, less defensiveness, and greater risk taking. Issues of trust are often more problematic in group therapy, since group members may fear judgment, lack of understanding, or untempered confrontations from their peers.

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A further limitation of group therapy concerns the limited amount of time available for each person. Group members often refer to the "battle for air time." Some people feel the need for more time, energy, and attention directed toward their specific concerns and their unique situation than can be offered in a group. The focused intensity and increased time available in individual therapy facilitate such personalized attention. For those who were deprived in early childhood of positive one-to-one involvement with a primary caregiver, the group experience may fail to provide the necessary corrective emotional experience; a singular primary relationship may be essential for healing. Time constraints also limit the opportunities for in-depth exploration of transference reactions to the therapist. Moreover, the highly valuable intensity of such reactions is often diluted in group treatment by the development of emotionally charged relationships with the other group members.

Integration: General Considerations Individual, family, and group therapy are complementary and synergistic approaches. The advantages of each modality reinforce and expand those of the others; their limitations are compensated for by the others' strengths. Integration allows the therapist to utilize the complementary benefits of each approach. In this section, we discuss some general issues that are of common concern in both individual and family and individual and group therapy integration. The first of these is confidentiality. CONFIDENTIALITY

When individual therapy is integrated with either family or group therapy, confidentiality is an important concern. There are a number of ways of dealing with this issue, each of which has advantages and disadvantages. Therapists need to decide which approach they are most comfortable with, communicate this at the outset, and then apply the approach consistently throughout the course of the therapy. The first question that needs to be addressed is whether the therapist will maintain confidentiality in regard to the other members of the family or group. One way of dealing with this question is for the therapist to state that because of the importance of information exchange between the modalities, it is essential that he or she be free to share information from individual meetings with the other family or group members. This position maximizes communication between the different modalities, but it places

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serious limits on the willingness of many people to discuss important information in their individual meetings. Also, even though the members have agreed to a free flow of information, they may still experience sharing of information by the therapist as a "betrayal of confidence." A second approach is for the therapist to take the position that integration will be most effective when the "integrity" of each process is preserved by the strict maintenance of confidentiality. This position maximizes openness in the individual meetings, but minimizes communication between the modalities. The position that we recommend incorporates elements of both of these approaches. Confidentiality in regard to anyone outside the therapy is strictly maintained, as long as doing so would not endanger anyone's safety. Within the therapeutic milieu, however, there is a dynamic interplay. Everyone is encouraged to take responsibility for introducing relevant feelings, thoughts, conflicts, or insights from individual sessions into family or group sessions. The therapist refrains from sharing such information unless he or she has obtained explicit permission to do so. When such permission is requested, it is important that the therapist be clear about what will be shared and limit the sharing to that specific information. In addition to discussing the therapist's position about his or her confidentiality, it is also important to discuss recommendations to family or group members about their own confidentiality. In regard to anyone outside the family or group, confidentiality is essential. In regard to sharing material from individual sessions with family or group members, it is generally best to leave the decision to each member, although the therapist should discuss the possibility that if such information is shared, it can lead to difficulties. This is particularly true when one person shares comments that the therapist reportedly made about others in the family or group, such as, "He said that the reason we have marital problems is because you're overly sensitive," or, "She said you really came on too strong when you attacked me in the last group meeting." It is important to request that if individuals are told about such remarks, they discuss their reactions with the therapist so that clarification, correction, and working through can take place. ONE THERAPIST OR TWO?

In most instances, one therapist can effectively integrate individual therapy with either family or group therapy. Indeed, there are specific advantages to a one-therapist structure: (a) the therapist has direct access to the information and observations derived from the individual and family or group meetings; (b) the therapist has the opportunity to form both individual and family or group therapeutic alliances; (c) there is maximal

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coordination of the different therapeutic modalities; (d) there is maximal flexibility in regard to structure change (i.e., increasing or decreasing the frequency or length of the individual, family, or group meetings); (e) there is minimal conflict between the individual and family or group therapists; and (f) one therapist is more cost-effective than two. There are times, however, when the advantages of a one-therapist structure are outweighed by the disadvantages. With individual and family therapy integration, a two-therapist structure is indicated when the number and/or severity of the presenting problems are unusually high, when a symptomatic person is extremely resistant to sharing "his or her" therapist with the other family members, or when an individual therapy relationship has been firmly established prior to the introduction of marital or family therapy. When two therapists are used with multigenerational families, one therapist meets with the symptomatic child or adolescent, the other meets with the parents, and both meet with the family. With couples, one therapist meets with each spouse and both meet conjointly with the couple. With individual and group therapy integration, a two-therapist structure is indicated for those with a particularly strong need for an exclusive relationship with an individual therapist. In some instances, this need is present from the outset; in others, it arises as a result of being in individual therapy for a considerable period of time. In either case, when the integration is divided between two therapists, communication and collaboration are essential. Conflicts and misunderstandings need to be resolved and a unified approach developed and maintained.

Integrating Individual and Family Therapy CLINICAL ASSESSMENT AND TREATMENT PLANNING

Both individual and family assessment provide essential and complementary information about individual and family interactional problems and strengths (Feldman, 1992). With families in which there is a symptomatic child or adolescent, the assessment process consists of one or more meetings with the parents, one or more meetings with the child or adolescent, and one or more conjoint family meetings. With couples, there are one or more conjoint meetings with the couple and one or more individual meetings with each partner. Families An initial meeting with the parents provides the therapist with an opportunity to gather detailed information about the presenting problems, to place

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these problems in perspective by collecting information about the family history, to discuss the parents' current and past attempts at problem solution, and to explore individual and familial strengths. It also allows the therapist to begin the process of establishing a positive working alliance with the parents. When the parents are living together, the initial meeting is conducted conjointly with both parents. When they are separated or divorced, it is generally best to meet initially with each parent individually. Later, a conjoint meeting may be indicated. It is essential that the therapist involve both parents in the assessment process. Each parent's perceptions of the problems and strengths of the symptomatic child or adolescent and of the family are of the utmost significance. It is similarly important that the therapist establish a therapeutic alliance with both parents from the outset. The second component of an integrated family assessment is an individual meeting with the symptomatic child or adolescent. This meeting is directed toward an exploration of the young person's feelings and thoughts about self, family, and the presenting problems. With adolescents, the meeting is generally entirely verbal; with children, verbal discussion is combined with diagnostic play activities, such as therapeutic board games, picture drawing, story telling, and doll or puppet play (Broder & Hood, 1983; Gardner, 1979; Wachtel, 1987). The third component is a conjoint family meeting. This meeting always includes the parents and the symptomatic child or adolescent and may also include other family members (e.g., siblings, grandparents) if the therapist believes their presence is necessary for a comprehensive assessment. When the parents are living together, they both participate in the same conjoint family meeting; when they are separated or divorced, it is usually best to conduct separate conjoint meetings with each parent, at least initially. During the meeting, family members are asked to discuss those aspects of family life that they are feeling good about and those aspects that they would like to be different. The therapist clarifies the family members' requests for change and helps them to express these requests in clear, specific language. Then, he or she helps them identify and discuss their emotional and cognitive reactions to the requested changes and to negotiate one or more behavior change agreements. The order of the three components of an integrated assessment is primarily a matter of therapist preference. Some therapists prefer to have a conjoint family meeting first; others prefer to begin by meeting with the symptomatic child or adolescent. Whichever order the therapist chooses, all three components need to be included in the assessment process.

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Couples In the initial conjoint meeting with a couple, the therapist clarifies the nature, intensity, and history of the presenting problems; discusses the couple's current and past attempts at problem solving; observes the couple's communication and problem-solving interactions; and explores current and past relationship strengths. At the same time, he or she begins the process of forming a therapeutic alliance with the couple. In individual meetings with each partner, the therapist explores feelings and thoughts about the presenting problems, the relationship, the partner, and the self. Initially, the focus is on clarifying the individual's emotional and cognitive reactions to the partner's behavior. Later, the focus is shifted to an exploration of the individual's understanding of the partner's emotional and cognitive reactions to his or her behavior. As in the conjoint meeting, the therapist inquires about each partner's perceptions of individual and relational strengths. In addition to looking at current strengths, he or she explores strengths that were present in the past but are currently not in evidence. When the problems and strengths have been clarified, family-oforigin history is explored. This exploration provides a foundation for understanding the connections between feelings, thoughts, and behaviors in relation to the partner, and conscious or unconscious feelings and thoughts in relation to members of the family of origin (i.e., transference reactions). As with families, the order of the conjoint and individual assessment interviews with couples is a matter of therapist preference. Some therapists prefer to begin with the conjoint meeting; others prefer to have individual meetings with each partner first. In either case, it is essential that the therapist include both conjoint and individual meetings in the assessment process.

Formulation and Treatment Recommendations By integrating the information and observations derived from the conjoint and individual meetings, the therapist is able to develop a comprehensive diagnostic formulation. This formulation includes an assessment of the nature and intensity of individual and familial problems, the interpersonal and intrapsychic factors that are stimulating and reinforcing those problems, and the individual and interpersonal strengths that are limiting the severity of the problems and providing a foundation for constructive problem resolution. Based on his or her diagnostic formulation, the therapist generates treatment recommendations, which are then discussed with the family

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members. The therapist explains his or her reasons for suggesting the particular treatment plan that is being recommended and asks for feedback about this recommendation. Based on this feedback, the recommended treatment plan may be accepted, or one or more modifications may be introduced. In either case, it is most helpful to implement the agreed-upon treatment plan on a time-limited basis (for example, one month) and then reassess whether to retain or modify the existing plan.

THERAPEUTIC STRUCTURE

In developing an integrative treatment plan, the therapist devises a therapeutic structure that he or she believes is most likely to promote a decrease in individual and family interactional problems and an increase in strengths. The first step in this process is clarification of each family member's explicit and implicit therapeutic goals.

Goals When individuals or families come for psychotherapy, they come for a reason; they want something to be different. The therapist needs to identify what they all want to be different about themselves, other family members, and the family as a whole. Often, different family members identify different, and sometimes conflicting, goals. For example, the parents of a depressed adolescent boy identify their major goal for the therapy as the alleviation of their son's depression, whereas the boy indicates that his major goal is a reduction in the level of conflict between him and his mother; a husband states that his goal in coming for marital therapy is to improve his marriage, while his wife states that her goal is to dissolve the marriage. When the therapist discovers that two or more family members have conflicting therapeutic goals, he or she utilizes individual and conjoint meetings to explore the possibility of developing a set of treatment goals that all family members can accept. In doing this, the notion of time-limited goals is often helpful. Suppose, for instance, a couple comes for marital therapy and the wife reveals in an individual meeting that she is uncertain about whether she wants to stay in the marriage. The therapist can explore this with the wife and determine whether she is willing to make a time-limited commitment to try to improve the marriage, and then to reevaluate her feelings. If she is willing to make such a commitment, marital therapy is possible; if she is not, divorce therapy is the only possible option.

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Structure After exploring each family member's therapeutic goals, the therapist recommends a treatment structure that he or she believes has the greatest likelihood of promoting the attainment of those goals. In most instances, this structure involves the symmetrical or asymmetrical integration of individual and family therapy meetings (Feldman, 1992). Symmetrical integration is characterized by an equal emphasis on each type of format. In symmetrical therapy with couples, conjoint meetings with the couple alternate with concurrent individual meetings with each partner. In symmetrical therapy with families, conjoint meetings with the family or a family subgroup (e.g., parents) alternate with individual meetings with the symptomatic child or adolescent. With both couples and families, conjoint and individual meetings can either take place on separate visits, or each visit can be divided into conjoint and individual components. For instance, a conjoint family meeting may be followed by an individual meeting with the symptomatic child or adolescent; individual meetings with each member of a couple may be followed by a conjoint meeting with the couple. Asymmetrical integration is characterized by an emphasis on one format more than the other. In asymmetrical therapy with couples, the structure is either (a) two or more conjoint meetings in a row, followed by one set of concurrent individual meetings (conjoint-oriented integration); or (b) two or more sets of concurrent individual meetings, followed by one conjoint meeting (individually oriented integration). In asymmetrical therapy with families, the structure is either (a) two or more conjoint meetings with the family or family subgroup, followed by one individual meeting with the symptomatic child or adolescent (conjoint-oriented integration); or (b) two or more individual meetings with the child or adolescent, followed by one conjoint meeting with the family or family subgroup (individually oriented integration). As with symmetrical integration, the conjoint and individual meetings may take place on different visits, or each visit may be divided into asymmetrical components. For example, there may be a 15-minute conjoint family meeting, followed by a 45-minute individual meeting with the child or adolescent; with a couple, there may be 15-minute individual meetings with each partner, followed by a 45-minute conjoint meeting with the couple. A symmetrical structure is indicated when the degree of individual and interactional dysfunction is equally high. When individual dysfunction is greater than interactional dysfunction, an individually oriented integration is indicated. A conjoint-oriented structure is indicated when there is a greater degree of interactional dysfunction.

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In addition to assessing the level of individual and interactional dysfunction, the therapist also assesses the level of resistance to individual and conjoint meetings. When there is a high degree of resistance to either format, it is often most helpful to begin with an asymmetrical structure, with the primary emphasis on the nonresisted format. Later in the therapy, it may be possible to make an adjustment toward a more symmetrical structure. Combining individual and conjoint components during the same visit is often indicated when family members have difficulty making good use of one of the interview formats. A highly conflictual couple, for example, may have great difficulty engaging in constructive problem solving during a conjoint meeting unless this meeting is preceded by individual meetings with each partner. In such meetings, they can ventilate some of their hostility and then prepare themselves to listen to the other's point of view. Conversely, a child may have difficulty engaging in an individual meeting unless this is preceded by a conjoint family meeting in which individual and family interactional problems and strengths are identified and discussed. The combined structure is also useful if the frequency of visits is reduced. This allows the therapist to continue using the same type of structure, even though the overall frequency of the contact is less. For example, if conjoint family meetings have been alternating with individual meetings with a symptomatic child on a once-a-week basis, and the frequency is reduced to once every two weeks, it may be helpful to combine conjoint and individual meetings during each visit. The structure of the therapy is arrived at by a process of collaboration between therapist and family. During the assessment process, the therapist elicits each family member's reactions to the conjoint and individual meetings. These reactions are then combined with the therapist's perceptions of the therapeutic needs of the family or couple and its individual members, leading to a recommendation of either a symmetrical or asymmetrical therapy structure. This recommendation is then discussed with the family members and an agreed-upon structure is arrived at. The process of matching the treatment structure to the specific therapeutic needs of particular individuals and families is an example of systematic eclecticism. Other examples of this approach are found in Lazarus, as well as Beutler and Consoli (both 1992). CHANGE PROCESSES

Therapeutic change has been conceptualized by individual therapists primarily in terms of processes for promoting intrapsychic changes (e.g., Carek, 1979; Luborsky, 1984; Meichenbaum, 1985), while family therapists have focused primarily on processes for promoting interactional changes

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(e.g., Aponte & VanDeusen, 1981; Gordon & Davidson, 1981; Jacobson, 1981). From an integrative perspective, both intrapsychic and interactional change processes are highly significant. Each type of change process facilitates and strengthens the other (Feldman, 1992; Wachtel & McKinney, 1992). When there is a block to change at one level, it can frequently be reduced or eliminated by change at the other level. In the following sections, the interactions between intrapsychic and interactional change processes will be discussed and illustrated with clinical examples. Using Intrapsychic Change Processes io Facilitate Interactional Changes Behavioral changes in family or couple systems are frequently blocked by the dysfunctional cognitions and emotions of individual family members. When these intrapsychic factors are neglected, therapy often becomes bogged down in frustratingly repetitious efforts to promote change by means of interactional change processes alone. Reduction or elimination of the intrapsychic blocks allows behavioral change to proceed. The following are two representative examples. A conflictual couple were unable to learn effective problem-solving skills because each spouse blamed the other for their marital problems, did not listen to the other person's complaints, and refused to initiate any behavioral changes. Each person magnified the dysfunctional aspects of the other person's behavior and minimized his or her own dysfunctional behaviors. Underlying these perceptual distortions were preconscious anxieties. Both spouses were afraid that if they acknowledged their own role in creating and maintaining the marital problems, the other would not reciprocate and they would be labeled as "the cause" of their problems. They were both afraid to make any changes for fear that they would be humiliated if the other did not also change. In individual meetings with each spouse, intrapsychic change processes (insight, working through, and cognitive restructuring) were utilized to decrease their resistance to accepting responsibility for their role in maintaining the marital problems and to increase their ability to tolerate the anxiety associated with making behavioral changes. As their defensiveness was reduced, they were increasingly able to make use of conjoint meetings and interactional change processes (suggestion, modeling, and behavior rehearsal) to develop constructive problem-solving interactions. A 16-year-old girl and her parents came for therapy because of frequent dysfunctional conflicts between the girl and her mother. These conflicts generally took the form of the mother becoming enraged with her daughter when she "broke the rules"—for example, talking too long on the

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telephone, staying out past curfew, not doing her chores at home. During these conflicts, mother and daughter were each verbally abusive toward the other. The father's role was primarily that of mediator between his wife and daughter. In individual meetings, the daughter was helped to experience and understand the feelings and thoughts that were stimulating her oppositional behavior. She said that she felt smothered by her mother and desperately wanted to be independent of her. With further exploration, she began to realize that her oppositional behavior was having the opposite effect—the more oppositional she was, the more involved her mother was in her affairs. This realization helped her become aware of an intrapsychic conflict between her wish for independence and her fear of separation. As this conflict was worked through, she was able to develop more constructive ways of separating from her mother. Using Interactional Change Processes to Facilitate Intrapsychic Changes Intrapsychic changes by individual family members are often blocked by dysfunctional interactional processes in the family or couple. When these interpersonal blocks are ignored, therapeutic insights are not translated into lasting intrapsychic and behavioral changes. Reduction or elimination of the interpersonal blocks allows intrapsychic change processes to proceed. A 30-year-old woman had been hospitalized on multiple occasions for suicidal depression. Medication and individual psychotherapy led to temporary improvement but not long-term change. After repeated relapses, she and her husband were referred for marital therapy. In conjoint meetings, it soon became apparent that the wife's depressive symptoms were being stimulated and reinforced, in part, by dysfunctional interactions between her and her husband. When she was feeling less depressed and began functioning more effectively, he complained that she was neglecting him. This led to a series of intense, dysfunctional arguments and stimulated guilt feelings in the wife. Soon, she began to feel more depressed and to function less effectively. When that happened, her husband became very concerned and solicitous, thus reinforcing the depressive symptoms. In marital therapy, the spouses learned to deal with their conflicts in more constructive ways and to alter their habitual ways of responding to the other's behavior. The husband began to reinforce his wife's effective, nondepressed behavior and to be less "hovering" when she expressed feelings of depression. The wife became more sensitive to her husband's vulnerabilities and began to pay more attention to him when she was

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feeling better. Each spouse's behavioral changes reinforced those of the other. As the interaction pattern changed, the wife was able to use insight and working through to resolve the intrapsychic conflicts related to her experiences in her family of origin that had been contributing to her repeated depressions. At the same time, her husband was able to use these same change processes to resolve his own intrapsychic conflicts, which had been masked by his wife's depressions. An 11-year-old boy and his family were referred for therapy because of the boy's failing grades in school and his hostile, oppositional behavior at home. His parents were divorced and he lived primarily with his mother. During the previous year he had been in individual therapy, which had led to little behavioral or emotional improvement. During the assessment process, it became clear that this boy was extremely angry with his father for having "abandoned" him after the divorce. In conjoint meetings with him and his father, there was initially much defensiveness. Soon, however, the father began to respond to his son's expressed feelings of abandonment by increasing the time and attention he gave to his day-to-day activities. As he did so, the boy began to realize that he had been acting out his angry feelings toward his father by means of passive-aggressive behavior at school and hostile behavior at home. He also began to realize that this was self-defeating and was able to translate this realization into positive behavioral changes. INTERRUPTING MULTILEVEL PROBLEM-MAINTENANCE PROCESSES

Individual and familial problems are maintained by a combination of intrapsychic and interpersonal factors, along with the interactions between them. In order to interrupt the problem-maintenance process, both intrapsychic and interpersonal changes are needed. In some instances, change at one level will lead to change at the other. For example, anxiety reduction in one family member may lead to a reduction in his or her defensive behavior, which may stimulate changes in family interaction. Conversely, family interactional changes may lead to reduced anxiety and defensiveness in one or more family members. Often, however, change at one level is blocked by lack of change at the other. For instance, anxiety reduction in one family member may prove to be temporary because of a lack of behavioral change by other family members. Conversely, family interactional change may prove to be temporary because of the unchanged anxieties of one or more family members. By implementing an integrated combination of intrapsychic and interpersonal change processes, blocks at each level can be reduced or eliminated.

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Integrating Individual and Group Therapy

CLINICAL ASSESSMENT AND TREATMENT

PLANNING

The process of integrating individual and group therapy begins with one or more individual meetings. In these meetings, the focus is twofold: first, individuals need to be understood in terms of their intrapsychic and interpersonal worlds, and their strengths and vulnerabilities must be assessed; second, the appropriateness of group involvement must be determined in accordance with the developing conceptualization of the individual's needs. Indications and contraindications for an integrated approach must be considered in these earliest interactions. The question of how many individual sessions there should be before integrating the group experience is a controversial one. Some therapists, like Amaranto and Bender (1990), recommend limiting initial contact to two or three individual meetings for assessment and group preparation. Their experience supports Yalom's (1985) earlier position that long-term individual involvement with the therapist makes the transition into group more difficult and that the inability to share the therapist with other group members is often a contributing factor to premature termination. Other therapists maintain that lengthy individual work provides the necessary foundation for individual and group therapy integration. For instance, Scheidlinger and Porter (1980) believe that one to two years of individual psychotherapy are essential to accomplish certain therapeutic tasks that are prerequisites for group involvement. Our recommendation is to determine the number of initial individual meetings on the basis of the specific needs of the particular person. Some people can begin an integrated approach after only a few individual meetings; others need more lengthy preparation. Certain people presenting in acute distress are not initially good candidates for individual and group integration. Those who are flooded with extreme anxiety, immobilized by severe depression, or lost in psychosis are often unable to respond to others in their environment; they may need individual attention exclusively for a period of time in order to begin their recovery. Severely disturbed individuals manifesting extreme forms of paranoia or narcissism may need significant preparation in order to be able to use the group format productively. Borderline personalities are likely to respond to an integrative approach by "splitting" the modalities into the good treatment and the bad treatment, the good therapist and the bad group members, or the good group and the bad therapist. This tendency can be offset, in part, through adequate individual preparation. In all these instances, careful assessment during the initial meetings allows the

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therapist to design a treatment plan that meets the specific needs of particular individuals and is consistent with the specific needs of particular groups. In contrast to the aforementioned situations, many people struggling with various issues are able to maximize their opportunity for growth and change through participation in an integrated form of psychotherapy after only a few individual sessions. For them, the process of preparing for integration begins with an initial assessment meeting designed to explore the presenting problems and previous attempts, both successful and unsuccessful, to address these problems. Information about past and current functioning is elicited, and the therapist evaluates intrapsychic and interpersonal strengths and weaknesses. A family history and history of other group experiences provide important data. This process continues into one or more subsequent individual meetings as the therapist formulates early diagnostic impressions and begins to develop a therapeutic alliance with the person. The therapist's questions and feedback provide problem clarification, support, and empathic understanding. Even in this assessment phase, as difficulties are expressed and events described, treatment begins. When the diagnostic picture is reasonably clear and a therapeutic alliance reasonably well established, the focus shifts to goal setting and the formulation of a treatment plan. The rationale for integrating individual and group therapy and its specific value for this person are discussed. The time between individual meetings allows for the emergence of questions, anxieties, and resistances. These concerns are addressed and the therapist provides clarification, reassurance, and education. Anxieties frequently relate to the person's relationship with the therapist and to anticipated relationships with other group members. Individuals may interpret the recommendation for integration into the group in a variety of troubling ways: "The therapist is bored with me and my problems"; "The therapist is overwhelmed by my difficulties and needs to draw on additional resources"; "I have failed at individual therapy"; "I am hard to be alone with." Feelings of rejection, embarrassment, shame, or guilt often emerge. Some people feel sadness, anger, and fear in response to their interpretation of the integrative treatment plan. The therapist must be alert to these possibilities and provide opportunities for working through. Transference and countertransference reactions are often activated in this process and need to be dealt with constructively. Individuals may feel angry at the prospect of sharing the therapist and apprehensive about those group members who will be part of "their" treatment. They may be concerned about "losing control in front of other people." Fear of rejection, confrontation, and judgment are common: "I know they'll blame me for my problems, just like my family does." Fear of

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ridicule often prompts resistance: "I don't need anybody else to make fun of me; I get enough of that at the office." Skepticism is often present: "How can they help me if they're in the same boat?" . . . "if they're not professionals?" . . . "if they need therapy themselves?" Most people are able to work through these anxieties and move into discussion of the structure of group and individual integration. This structure is a function of the ratio of group to individual meetings, which is determined through careful assessment of individual therapeutic needs and resistances. For some, a balanced or symmetrical integration is indicated: individual sessions alternate with group sessions. This structure is most helpful when intrapsychic and interpersonal issues are of equal concern. For others, the need for individual attention and a primary focus on intrapsychic issues is most compelling. When this is the case, an individually oriented asymmetrical integration is indicated, consisting of two or more individual meetings for each group meeting. A group-oriented asymmetrical structure is indicated when people present primarily interpersonal problems; here, two or more group sessions are held for each individual session. When any form of asymmetrical structure is employed, it is critical that the less frequent format be offered often enough so that its unique benefits can be experienced, and that the complementary and synergistic effects of integration have an opportunity to develop. When children and adolescents are evaluated, the structure of the initial meetings is somewhat different than for adults. The first contact most frequently is a phone call from a concerned parent or parents, after which a series of beginning sessions is set up. The first of these is usually an extended meeting subdivided into child, parental, and family components. In assessing the therapeutic needs of children and adolescents, their day-today interactions with other family members must be considered. The therapist may decide that along with individual and group therapy, family therapy is also needed. This therapy may be conducted by the same therapist that provides the individual and group treatment, or there may be clinical indications suggesting that a different therapist should supply the family therapy component. THERAPEUTIC

PROCESS

The potentiating effects of combining individual and group therapy become evident even before the first group meeting. With the introduction of the concept of integration, reactions are triggered in the individual sessions that provide valuable data. As the individual considers group involvement, thoughts and feelings surface that deepen and broaden clinical understanding and provide early opportunities for therapeutic intervention.

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The initial group meeting begins with a discussion of the rules, expectations, and restrictions upon the group members and the therapist. Clear guidelines and consistent adherence are critical for successful integration. Confidentiality is discussed and decisions are made regarding member contacts outside the group. Some therapists insist upon limiting contacts to the therapy sessions; others are open to or even encourage members to socialize outside of group meetings. Whichever position the therapist takes, it is essential that this be communicated at the outset and thoroughly discussed with the group. Once the ground rules are established, group members are encouraged to share whatever information about themselves, their problems, their history, or their goals in treatment they feel ready to volunteer. Immediate reactions, thoughts, and feelings about being in this group at this time are often elicited. In this first group meeting, the therapist needs to inhibit the impulse to volunteer information from individual sessions. Group members need the opportunity to begin to know each other and to begin developing a sense of trust in the process. The therapist may stimulate group interaction by offering and inviting questions, comments, and general feedback. His or her role, however, is that of facilitator; the initial task is to provide a safe arena and elicit information so that some sense of common purpose begins to emerge. Even within the first group meeting, the cross-fertilization between individual and group therapy is evident. Group members often refer to work done in individual sessions as they identify themselves and offer their ideas for group treatment goals. For example: "I guess I'm shy . . . looks like I have a problem with self-esteem and need to learn how to assert myself. Is that a problem for any of the rest of you?" This introduction is derived, in part, from work done in early individual sessions. The flow of material from individual to group therapy continues throughout treatment and serves as a vital element in the therapeutic process. Group treatment is enriched by the input from each member's individual work. The focused intensity of the one-to-one sessions produces insights that can benefit other group members. Moreover, sharing these insights promotes group cohesiveness and enhances the self-esteem of the person sharing the insight and those who receive it. For example: A group meeting was focused on the painful feelings of humiliation and inadequacy that several group members had experienced during recent work performance evaluations. Another group member volunteered that in his individual therapy sessions, he had become aware of a link between his feelings about his critical supervisor and his feelings about his critical father. This link helped explain the depth of his sense of inadequacy and the intensity of his distress in his current job situation. The other group

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members drew from his shared experience. They felt understood and reassured by his identification with their plight. They were enlightened as his revelations triggered an awareness of their own transference reactions. The group process was enriched by the empathy and insight provided by sharing the work of individual therapy. Individual therapy also facilitates group therapy by offering personalized attention in ministering to narcissistic injuries, challenging cognitive distortions, and role-playing possible confrontations. The individual is able to bring to group sessions a heightened awareness of his or her strengths and vulnerabilities. Role play in individual sessions provides the preparation some people need for more active group participation. Under certain circumstances, the support and understanding provided by individual therapy may interrupt flight from group treatment. Another way in which individual therapy enhances group treatment is by providing the therapist with a variety of valuable opportunities for cross-referencing. Aided by an in-depth understanding of each participant, the therapist is able to facilitate productive movement in group process. The therapist may use eye contact, an encouraging nod, or a knowing glance to facilitate appropriate sharing in the group. He or she may raise questions or invite comments on issues known to be of particular concern. On occasion, the therapist may ask permission to share relevant individual material with the group. When such a request is made, it must be general enough so that confidentiality is maintained. Just as individual therapy facilitates group treatment, so too does group therapy facilitate individual treatment. The group provides a safe arena for testing some of the new attitudes and behaviors developed in individual sessions. Members are able to take their heightened self-awareness into a social context, gather data about self and others, and return to individual therapy for further in-depth exploration. Experiences in the group often trigger unexpected intrapsychic reactions, which may be carried back to individual therapy, as the following example illustrates: A young woman brought to an individual therapy session some very disturbing feelings that she had been experiencing in the group. She hesitatingly "confessed" to feeling enraged with the therapist whenever she offered empathic feedback to any other group member. This data led to fruitful, in-depth exploration of this woman's role in her family of origin. As the oldest of six children, she had been forced into the role of mother's assistant at an early age. Her dependency needs had been denied, and any efforts to be heard, supported, or understood had met with a stern rebuff. This woman's yearning for nurturance made it difficult for her to share that

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aspect of the therapist. The depth of her rage (conscious and unconscious) created anxiety, confusion, and the impulse to flee treatment. Group therapy provided the stimulus for these reactions; individual therapy provided an arena in which they could be explored. She was able to experience the therapist as reassuring, empathic, and accepting of her, even in her fear and anger. She developed important insights, received some of the nurturance she craved, and began to understand from the therapist's psychoeducational approach how she might glean support from the other group members, not only from the "good enough" mother. As attachments develop with various group members, the individual's base of support broadens. Dependency needs are met not only by the therapist but also by the other group members. As reliance upon the therapist diminishes, people become less anxious about sharing all their feelings in their individual therapy sessions. They are increasingly willing to challenge, confront, or disagree with the therapist. Supported by a sense of belonging, it becomes easier to tolerate the exploration of narcissistic injuries or a break in the therapist's empathy in individual therapy. The group experience also enhances individual therapy by providing the therapist with valuable data and opportunities for intervention. People may behave very differently in this social context, and the presentation of self, communication skills, and coping behaviors may enlighten the therapist concerning additional work needed in individual treatment. Therapists may observe expressed attitudes and behavioral reactions to cognitive distortions that need to be challenged in the privacy of the individual session. Certain problem areas may not be on the individual therapy agenda because the people may not be aware that these difficulties contribute to their dissatisfaction. In an integrated approach, the therapist can draw on material from the group to define the work of individual therapy. Cross-referencing by the therapist may be direct or indirect. Specific reference can be made to group observations, or this information can be integrated into the therapist's overall understanding and approach to the individual. The following clinical example illustrates these phenomena: A 10-year-old boy was referred for individual treatment with symptoms of depression and social isolation. In the initial family meeting, the parents expressed confusion about the reasons for their son's "lack of friends." The boy reported feeling "sad and bored." He insisted that his isolation was a choice; other children were "too babyish" and he simply wasn't interested in connecting. The therapist contracted with the boy for an "experiment" in treatment involving individual and group therapy integration. She was then able to draw from group observations critical data regarding dysfunctional behaviors, attitudes, and coping skills. The

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boy's yearning for peer acceptance and approval was obvious in his affect. The behaviors he employed—knowing all the answers, directing the activity, correcting others' mistakes—alienated, rather than impressed, his peers. His defensive posture, unconsciously designed to cover his vulnerabilities and quiet his anxieties, was experienced by peers as arrogance. Aided by these observations, the therapist was able to work more productively with this boy in individual therapy, focusing on the ways he created and reinforced his dilemma, and the intrapsychic issues that stimulated this behavior. In general, these kinds of cross-references provide valuable therapeutic opportunities. A caution must be issued, however, because the inexperienced therapist may allow individuals to act out their resistance to one format in the "safety" of the other. When transference reactions are triggered, it is important at some point that they be addressed in the modality in which they developed. When people bring complaints about group members or group process to their individual sessions, the therapist must consider the significance of the reaction, identify the work that needs to be done individually, and then direct the person to discuss his or her feelings in the group. A simple statement, such as "this sounds like something you need to take back to group," may suffice. Similarly, those who choose to air complaints about their individual therapy in the "diluted" environment of the group need to be encouraged to work through those grievances in the individual meetings. The transference work of individual therapy must be preserved, even when the person experiences the therapist in both settings. Often, themes can be extracted, generalized, and productively addressed in both the individual and group formats, as this case illustrates: A young woman was frightened by another group member's angry comment. In the group, it was important that she share these feelings and discuss her experience of the other group member directly with that person. In her individual therapy, it was important that she explore the link between her reaction in the group and her feelings about her mother's anger and impatience with her throughout childhood. Her impulse to withdraw from the angry group member and the group itself was painfully similar to her retreats to her bedroom as a young girl fleeing a threatening parent. In some instances, one format supplies support for the confrontation that needs to occur at the site of the working through. In the previous example, the young woman found it helpful to role-play in individual session her approach to the hostile group member. Focused exploration of

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her phobic reaction to anger in any context facilitated intrapsychic growth and understanding, defused some of her anxiety, and prepared her for productive work in the interpersonal realm of the group setting. Another illustration of the dynamic interplay between group and individual therapy is found in the previously described example of the man who felt criticized by his father and by his current work supervisor. In that situation, the group members' responses to this man's contribution of insight broadened his understanding of his own dilemma. His self-esteem was enhanced as other group members affirmed him for his courage in sharing, and expressed appreciation for his valuable input. He returned to individual therapy with a renewed sense of self-worth and a strong determination to tackle his remaining issues.

Conclusion Integration of individual therapy with family and group therapy has the potential to markedly enhance the accuracy and comprehensiveness of clinical assessment and the flexibility, range, and efficacy of therapeutic intervention. Support for this position is provided by a number of clinical case reports (e.g., Feldman, 1992; Friedmann & Silvers, 1977; Lindenbaum & Clark, 1983; Pfeifer & Spinner, 1985; Schachter, 1988; Stumphazer, 1976; Swiller, 1988) and exploratory clinical trials (e.g., Amaranto & Bender, 1990; Liebman, Honig, & Berger, 1976; Ney & Mills, 1976; Rosenberg & Linblad, 1978). Future development of this area of therapeutic integration will require controlled outcome studies and comparative studies of integrated versus nonintegrated therapies. Equally important are process studies of the most effective ways of (a) integrating different modalities for different types of clinical problems, (b) designing therapeutic structures that are maximally responsive to the specific therapeutic needs of particular individuals and families, and (c) preventing or overcoming potential problems during the process of individual-family or individual-group integration.

References AMARANTO, E. A., & BENDER, S. S. (1990). Individual psychotherapy as an adjunct to group psychotherapy. International Journal of Group Psychotherapy, 40, 91-101. APONTE, H. ]., & VANDEUSEN, ]. M. (1981). Structural family therapy. In A. S. Gurman & D. P. Kniskern (Eds.), Handbook of family therapy. New York: Brunner/Mazel. BEUTLER, L. E., & CONSOLI, A. J. (1992). Systematic eclectic psychotherapy. In

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J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. BRODER, E. A., & HOOD, E. (1983). A guide to the assessment of child and family. In P. D. Steinhauer & Q. Rae-Grant (Eds.), Psychological problems of the child in the family. New York: Basic Books. CAREK, D. (1979). Individual psychodynamically oriented psychotherapy. In J. D. Noshpitz (Ed.), Basic handbook of child psychiatry (Vol. 3, S. Harrison, Ed.). New York: Basic Books. FELDMAN, L. B. (1992). Integrating individual and family therapy. New York: Brunner/Mazel. FRIEDMANN, C., & SILVERS, F. (1977). A multimodality approach to inpatient treatment of obsessive-compulsive disorder. American journal of Psychotherapy, 37, 456-465. GARDNER, R. A. (1979). Helping children cooperate in therapy. In ). D. Noshpitz (Ed.), Basic handbook of child psychiatry (Vol. 3, S. Harrison, Ed.). New York: Basic Books. GORDON, S. B., & DAVIDSON, N. (1981). Behavioral parent training. In A. S. Gurman & D. P. Kniskern (Eds.), Handbook of family therapy. New York: Brunner/Mazel. GURMAN, A. S. (1981). Integrative marital therapy: Toward the development of an interpersonal approach. In S. Budman (Ed.), Forms of brief therapy. New York: Guilford. JACOBSON, N. S. (1981). Behavioral marital therapy. In A. S. Gurman & D. P. Kniskern (Eds.), Handbook of family therapy. New York: Brunner/Mazel. KLEIN, M., & RIVIERE, J. (1964). Love, hate, and reparation. New York: Norton. KRAMER, C. H. (1980). Becoming a family therapist: Developing an integrated approach to working with families. New York: Human Sciences Press. LAZARUS, A. A. (1992). Multimodal therapy: Technical eclecticism with minimal integration. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. LIEBMAN, R., HONIG, P., & BERGER, H. (1976). An integrated treatment program for psychogenic pain. Family Process, 15, 397—405. LINDENBAUM, S., & CLARK, D. (1983). Toward an integrativc approach to psychotherapy with children. American journal of Orthopsychiatry, 53, 449-459. LIPSIUS, S. H. (1991). Combined individual and group psychotherapy: Guidelines at the interface. International journal of Group Psychotherapy, 47, 313— 327. LUBORSKY, L. (1984). Principles of psychoanalytic psychotherapy. New York: Basic Books. MEICHENBAUM, D. H. (1985). Cognitive-behavioral therapies. In S. J. Lynn & ]. P. Garske (Eds.), Contemporary psychotherapies: Models and methods. Columbus, OH: Charles E. Merrill. MEISSNER, W. W. (1981). Internalization in psychoanalysis. New York: International Universities Press.

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NEY, P. G., & MILLS, W. A. (1976). A time-limited treatment program for children and their families. Hospital and Community Psychiatry, 27, 878879. NORCROSS, ]. C. & NEWMAN, C. (1992). Psychotherapy integration: Setting the content. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. PFEIFER, G., & SPINNER, D. (1985). Combined individual and group psychotherapy with children: An ego developmental perspective. International Journal of Group Psychotherapy, 35, 11—35. ROGERS, C. R. (1980). A way of being. Boston: Houghton Mifflin. ROSENBERG, J. B., & LINDBLAD, M. B. (1978). Behavior therapy in a family context: Treating elective mutism. Family Process, 17, 77—82. SAGER, C. ]. (1981). Couples therapy and marriage contracts. In A. S. Gurman & D. P. Kniskern (Eds.), Handbook of family therapy. New York: Brunner/ Mazel. SANDER, F. (1979). Individual and family therapy-. Toward an integration. New York: Jason Aronson. SCHACHTER, J. (1988). Concurrent individual and individual-in-a-group psychoanalytic psychotherapy. Journal of the American Psychoanalytic Association, 6, 455-480. SCHEIDLINGER, S., & PORTER, K. (1980). Group psychotherapy combined with individual psychotherapy. In T. B. Karasu & L. Bellak (Eds.), Specialized techniques in individual psychotherapy. New York: Brunner/Mazel. SHAPIRO, R. L. (1978). The adolescent, the therapist, and the family: The management of external resistances to psychoanalytic therapy of adolescents. Journal of Adolescence, 1, 3-10. STEINHAUER, P. D. (1985). Beyond family therapy: Toward a systemic and integrated view. Psychiatric Clinics of North America, 8, 923—945. STUMPHAZER, ]. S. (1976). Elimination of stealing by self-reinforcement of alternative behavior and family contracting. Journal of Behavior Therapy and Experimental Psychiatry, 7, 265—268. SWILLER, H. I. (1988). Alexithymia: Treatment utilizing combined individual and group psychotherapy. International Journal of Group Psychotherapy, 38, 47-61. WACHTEL, E. (1987). Family systems and the individual child, journal of Marital and Family Therapy, 13, 15—27. WACHTEL, E., & WACHTEL, P. (1986). Family dynamics in individual therapy. New York: Guilford. WACHTEL, P. L. (1977). Psychoanalysis and behavior therapy: Toward an integration. New York: Basic Books. WACHTEL, P. L. (1985). Integrative psychodynamic therapy. In S. J. Lynn & J. P. Garske (Eds.), Contemporary psychotherapies: Models and methods. Columbus, OH: Charles E. Merrill. WACHTEL, P. L. & McKiNNEY, M. K. (1992). Cyclical psychodynamics and

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integrative psychodynamic therapy. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. WINNICOTT, D. W. (1965). The maturational processes and the facilitating environment. New York: International Universities Press. YALOM, I. D. (1985). The theory and practice of group psychotherapy. New York: Basic Books.

CHAPTER 16

Integrating Pharmacotherapy and Psychotherapy BERNARD D. BEITMAN, MOLLY J. HALL, AND BURNS WOODWARD

T

J.HE "MIND-BRAIN" BARRIER is being eroded by research and clinical studies of the interaction between psychoactive medications and psychotherapy. Although the mental health professions are likely to continue their unfortunate arguments over power and money, the time has come to recognize that their patients often have disturbances of both mind and brain. The title of our federal research agency, the National Institute of Mental Health, has become an archaic misnomer. It more accurately should be called the National Institute of Mind-Brain Health. In this chapter, we address several interrelated clinical and research issues involved in the dissolution of this long-standing dichotomy. These issues include the historical background of combined treatments, the placebo response, research in combined treatments, clinical interactions between medications and psychotherapy, and the psychotherapist-pharmacotherapist collaboration. (More detailed accounts of these topics can be found in Beitman & Klerman, 1984, 1991.)

Historical Overview of Combined Treatment The creation of psychoanalysis in the late 19th century introduced a major alternative treatment modality for mental disorders. Prior to this time, clinicians' efforts to alleviate mental illness were based on the prevailing understanding that psychopathology reflected a disease state of the "organ of the mind"—the brain (Bodemer, 1984). Interventions were somatic or biological, albeit primitive and often pharmacologically inert if not

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irrational. Treatments aimed at psychosocial influences were not developed by medical practitioners. Although Freud (1964) himself forecast the development of specific and effective pharmacotherapies, psychiatry was dominated by the study of psychosocial determinants of human mental functioning through the 1950s. Mental disorders were seen as "disorders of the mind," and psychotherapy was the potent modality in the treatment of neurotic disorders. In the 1960s, the efficacy of drugs discovered a decade earlier became evident, and the concept of mental disorders as "disorders of the brain" again became more tenable. The dominant concern of the literature during this time was the treatment of schizophrenia. In the 1970s, the literature focused on the treatment of affective illness, disorders that lent themselves most easily to combinations of psychotherapy and pharmacotherapy (Karasu, 1982). Many new psychotherapies were developed (e.g., cognitive-behavioral, family, brief) and, in conjunction with discrete, efficacious medications available for anxiety, mood, and psychotic disorders, active discussion of the merits, indications, and contraindications of various treatment combinations was pursued. Discussions about the combination of psychotherapy and pharmacotherapy in mental health practice today are significantly different from such discussions 20 years ago. The separatist position is largely of historical interest; that is, the notion that psychotherapy alone offered a "true cure" on the one hand, and that medication was a palliative measure at best, or at worst an inhibitor of motivation and change, on the other (Klerman, 1991). The recognition of the efficacy of combined treatment has been facilitated by a number of changes. At the theoretical level, the doctrine of determinism or linear causality has been altered by the development of systems theory (von Bertanlaffy, 1964; Schwartz, 1982). The mind-brain dichotomy of human mental functioning has been substantially modified by an understanding of the truly multidimensional nature of mental life reflected in the biopsychosocial model. The multiaxial diagnostic system of the DSM-III and DSMTII-R (American Psychiatric Association, 1987) is a tangible record of interdependent, hierarchial clinical views or perspectives on any given patient. The recently developed capabilities in neuropsychiatric research have further blurred boundaries between the heuristic but artificial "organic" and "functional" distinctions. The Axis I symptom, or "state" disorders, are not distinct from Axis II, or "trait" disorders. For example, schizotypal personality disorder may be a phenotypic variant of a schizophrenic genotype. Finally, clinical experience and research have demonstrated the efficacy of many forms of psychotherapy—psychodynamic, behavioral, cognitive, interpersonal, marital, family, group, and brief, among others

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(Frances, Clarkin, & Perry, 1984). Clinicians are less likely to competitively guard the techniques associated with any one method from another. Similarly, the well-established indications for, and responses to, medications measurable beyond placebo responses have made either-or arguments about the various treatment modalities untenable. In fact, retrospective analyses and literature reviews (Luborsky, Singer, & Luborsky, 1975; Uhlenhuth, Lipman, & Covi, 1969; GAP, 1975), which were statistically analyzed in the meta-analysis of Smith, Glass, and Miller in 1980, have compared combination treatment, psychotherapy alone, and medication alone. The consensual interpretation of this research is that combined treatments have additive and, in some instances, synergistic effects. At the very best, combination regimens do not diminish the effect of one modality relative to another. Psychiatrists often use combined treatments (Beitman & Maxim, 1984) but struggle with the lack of clear guidelines or a rational plan for the conjoint use of medication and psychotherapy. In part, this stems from the fact that designing research to study the relevant variables in combined regimens of psychotherapy and pharmacotherapy is such a daunting task (Elkin, Pilkonis, Docherty, & Sotsky, 1988a, 1988b). The list of factors to be taken into account is lengthy and would include diagnosis, severity, chronicity, treatment setting, goals, stage, and type of psychotherapy. Furthermore, research would need to control such issues as the different "active ingredients" for each modality, different mechanisms of delivery, time course of response, outcome criteria, therapist attitude, and patient expectation. A simpler but no less important consideration is that clinicians often struggle with their conflicting modes of interaction with patients when prescribing medication versus conducting psychotherapy. This has been characterized by Docherty, Marder, Van Kammen, and Siris (1977) as the problem of "bimodal relatedness" and by Gutheil (1982) as the clinician's "mind-brain barrier." Attention to, and awareness of, one's shift in style from a more receptive, open-ended or tolerant manner to a more authoritarian or directive one tends to protect the therapeutic relationship and outcome. Ideally, clinicians may bring these two forms of relatedness together by considering that pharmacotherapy may be a psychotherapeutic intervention (Beitman, 1981). Prescription itself is a dynamic intervention with transference and countertransference implications, as is any other intervention in an ongoing treatment relationship. Consideration of these and related matters is a critical requirement for successful treatment integration. The past three to four decades has seen substantial development of psychotropic agents to treat an array of psychiatric symptoms and disorders. As understanding of these psychopharmacological mechanisms of

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action has increased, these medications have been prescribed in a more sophisticated and specific manner. Similarly, the proliferation of psychotherapeutic techniques has provided potentially selective applicability to different clinical problems. The additive advantages of combinations of these major treatment modalities are not well recognized. Rational guidelines for integrated therapy will continue to be developed for individual diagnostic groups as the treatments themselves become more finely tuned.

Controlled Research Trials A vast literature in single and combined treatments is developing. This section begins with a review of the least discussed aspect of these trials— the placebo response—a reaction that may be due in large part to factors common to psychotherapy. Following the placebo discussion is an overview of the relationship between pharmacotherapy and diagnosis that leads to the unsettling conclusion that many antidepressants are effective for disorders beyond depression, such as panic disorder and bulimia. The section concludes with a discussion of the limitations and hopes for combined treatment research trials. THE PLACEBO RESPONSE

The inert look-alike placebo capsule has been a standard part of controlled clinical medication trials for many years. Its remarkable effectiveness, however, tends to be ignored except when the data suggest that the active substance was not more effective. In studies of chronic pain, the placebo response rates tend to be approximately 50 percent of the active drug (Evans, 1985). Similar rates seem to hold for studies of panic disorder and major depression. How are these findings to be explained? To participate as a researcher in drug trials is to gain some understanding of the mechanisms by which patients apparently receiving no treatment are, in fact, being treated. The following observations are based on the experiences of one of us (BDB) who has been the principal investigator in five placebo controlled medication trials and one nonblinded medication study.* Despite the seeming scientific objectivity of research reports on drug trials, investigators develop strong emotional investments in their subjects. Each subject who "counts" (fits criteria and completes minimal treatment requirements) means one more step toward the final goal. To "count" 'The authors are grateful to Ms. Melanie Grafing, research assistant, for her contributions to this discussion.

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means not only that the subject is willing to take the medication but is also willing to do so for several weeks. Furthermore, candidates are recruited through a painstaking screening process that may require an average of 10 to 14 contacts before an eligible person is found. Unfortunately, eligibility does not necessarily result in participation, and willingness to begin participation does not necessarily mean willingness to complete the protocol. Therefore, the research team pays close attention to the needs of each person in the trial, especially at the beginning. In essence, the researchers make every effort to engage eligible subjects in the research scheme. Engagement is the first stage of psychotherapy (Beitman, 1987). The team often uses common engagement techniques such as empathic reception, demonstration of specialized knowledge (diagnosis and prognosis), and the offer of something that works (the pill). In addition, potential subjects are usually graciously received and encouraged to believe that they may not only be helping themselves but also others. Standard medication protocols prohibit the staff from doing "psychotherapy." But often providing generic psychotherapy is exactly what they do! The protocol provides subjects/patients with a rationale for understanding their difficulties (a psychiatric diagnosis) and a ritual (the treatment protocol). The research is carried out in a healing setting, generally a hospital clinic where medical studies including blood and urine analysis and electrocardiograms may be performed. Patients usually form strong relationships with one or more clinicians. Others become strongly committed to the project itself. These four qualities of drug trials—rationale, ritual, healing setting, and relationship—are the shared features of most psychotherapies (Frank, 1976). Many of the therapeutic functions common to most psychotherapies as described by Frank (1976) are also present in these research programs. In the following paragraphs these functions are italicized. The researchers instill hope through their own beliefs in the treatment itself, because most researchers are also clinicians who have seen similar medications work effectively in patients with the same presenting symptoms. Hope also encourages subjects to return. Through the instillation of hope, specialized knowledge, and warm empathic reception, the researchers can effectively strengthen the therapeutic relationship. Researchers also provide cognitive learning about the disorder, usually in terms of a diagnostic label that implies some biological causation. The label itself provides several other important pieces of information: it implies that the symptoms are understood, experienced by others, and amenable to professional intervention. Through these effects, the label may reduce symptom intensity by eliminating the need to seek further help, since symptom intensity is in part driven by the desire for an acceptable caregiver. Patients acquire additional information by keeping diaries and answering protocol questions, through

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which some are able to establish connections between their symptoms and events in their lives. Simply talking about the details of their difficulties often leads to emotional arousal which, according to Frank, supplies the motive power for attitude and behavior change. Some patients initiate behavior change because their repeated visits clarify the debilitating nature of their difficulties and the possible solutions. Other patients are not "fooled" by the placebo. They know that the pill they are taking is inactive because they are not responding, and yet they decide anyway to make key changes in their lives. The repeated pill taking and weekly visits are constant reminders that change is necessary. Patients may find new jobs, alter their marriage patterns, or in other ways decide to act in their own best interests. Although they are called "placebo responders," they have stopped waiting for someone or something to take care of their problems and have taken charge themselves. Generally, drug trials, like generic psychotherapy, heighten patients' sense of mastery through these therapeutic functions and the associated success experiences. Patients learn to name their nemesis and become less afraid of it through cognitive learning and behavioral experimentation. In these ways, then, psychopharmacological trials may inadvertently be utilizing common factors in psychotherapy to encourage change. If this conclusion is valid, then the use of active medication in drug trials represents an integration of pharmacotherapy and psychotherapy, since each patient is not only affected by the active drug but is also influenced by the contextual common factors. Of further interest are the questions raised about the reciprocal relationship between active drug and common psychotherapy factors. If the active drug has a physiological effect that is sensed by the patient, does this awareness augment the common factor effects by instilling yet more hope in a positive outcome? If a patient believes the pill contains the active drug, for example, does this belief increase the likelihood of decisions leading to positive behavior change? Is placebo psychotherapy plus active drug not simply additive but synergistic? And what accounts for the differences in placebo response rates across diagnostic categories? Generalized anxiety-disorder patients may be the most frequent responders to placebo; three placebo controlled trials suggested a 50 percent placebo response rate (Scott McDonald, personal communication, April 1991; C. Lewis, personal communication, March 1989; Chouinard, Annable, Fontaine, & Solyom, 1982). Panic disorder (Ballenger et al., 1988) and major depression (Ward, 1991) seem to have lower placebo response rates, between 35 and 45 percent. Obsessivecompulsive disorder (OCD) has a much lower placebo response rate, from 0 to 20 percent (Perse, Greist, Jefferson, Rosenfeld & Dar, 1987; Goodman

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et al., 1989; Insel et al., 1983; Jenike et al., 1990). While acute schizophrenics seem to have a surprisingly high placebo response rate of 25 percent, another 50 percent on placebo actually become much worse (Davis, 1976). Psychotherapy research suggests that psychotherapy alone is typically insufficient for schizophrenia (Marder, Johnston-Crank, Wirshing, & Eckman, 1991), while in the treatment of OCD, only behavior therapy with exposure and response prevention components appears to be effective (Jenike, 1991). In these disorders it would appear, then, that common factors alone are not sufficient to bring about desired results. However, for generalized anxiety, depression, and panic, the generic psychotherapy offered in medication trials is effective in more than one-third of patients.

PHARMACOTHERAPY AND DIAGNOSIS

Physicians strive to find the cause of disease in order to find the cure. Unfortunately, this ideal only holds for a limited number of disease categories, most notably bacterial infections, for which antibiotics are a remarkable treatment advance. Psychopharmacologists also aspire to treatmentspecific diagnoses and appeared to have achieved this ideal with the antidepressants, which as a class have shown remarkable efficacy compared to placebo in the treatment of depression. The standard against which most new antidepressants are compared is imipramine (Tofranil).* Over the years this medication has been found to be effective not only for depression but also for panic disorder (Shear, 1991), bulimia (Yager, 1991), generalized anxiety disorder (McLeod, Hoehn-Saric, Zimmerli, DeSouza, & Oliver, 1990), and attention deficit disorder (Husain & Cantwell, 1991). The closely related chemical clomipramine (Anafranil) has been shown to be effective in obsessive-compulsive disorder (Jenike, 1991). Other antidepressants whose chemical structures are unrelated to imipramine have also been shown to be useful in other diagnostic categories. Fluoxetine (Prozac), for example, may be useful for panic disorder, obsessive-compulsive conditions, and weight loss. Amitriptyline (Elavil) seems to be clinically useful both for primary insomnia and for some pain syndromes, including migraine headaches (Couch and Hassanein, 1979). It therefore appears that the term antidepressant is a misnomer for many of these medications. Some of them might more properly be called antineurotic medications. Other medications are more diagnosis specific. Neuroleptics (antipsychotic drugs) are quite remarkable in reducing psychotic thinking. No other *In identifying medications, the generic name will be followed by the most prominent trade name in parentheses.

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class of drugs currently available can alter the content of certain thoughts in the way that these medications can reduce paranoid thinking. Lithium and, more recently, carbamazepine (Tegretol) and valproic acid (Depakote) are effective in the treatment of mania. Benzodiazepines (e.g., Valium, Xanax) are rapidly effective in the treatment of certain anxiety states (panic and generalized anxiety disorder) and far superior to the barbiturates they replaced. Efforts are under way now to replace benzodiazepines because they are abused by people with drug and alcohol histories and because they must be withdrawn slowly. Quick taper of these medications increases the likelihood of untoward effects (e.g., seizures, paniclike symptoms). LIMITATIONS OF MEDICATION TREATMENT TRIALS

Treatment trials, whether pharmacological or psychotherapeutic or both, only approximate clinical reality. Clinicians must generalize cautiously from research to clinic patients. Following is a list of some of these limitations: 1. Research patients are willing to accept placebo, medication, and/or psychotherapy. Many clinic patients have biases for and against these alternatives that would preclude their participation in controlled trials. 2. Research patients must be compliant with the many tasks required by the research protocol. Clinic patients often balk at tasks that are not obviously connected to their symptoms. 3. Research patients are often recruited by newspaper and other media advertising. The differences between them and clinical populations have not been clearly ascertained. 4. Most co-morbid conditions are exclusionary in drug trials. Patients with depression or anxiety disorders, drug abuse, alcohol abuse, and major personality disorders may not be included, although such patients in clinic populations are not turned away because of comorbid disorders. Combined psychotherapy and pharmacotherapy treatment trials have additional limitations: 5. The small differences in outcome measures between each treatment alone and the combined treatment, as well as the large variance in response within each treatment group, require that a large number of subjects must be enrolled in order to show significant differences. 6. In order to achieve scientific "correctness," up to 15 cells may be needed to control for variables like "spontaneous remission," placebo in both psychotherapy and pharmacotherapy, and interactive effects of these variables. Thus a large number of recruits is necessary to accomplish this end (Hollon, Shelter,, & Loosen, 1991).

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HOPES FOR COMBINED TREATMENT

Clinicians cannot easily judge which patient is most likely to respond to pharmacotherapy and which to psychotherapy. Combining treatments at the outset offers patients two effective options simultaneously: Medications may make patients more responsive to psychotherapy by reducing symptoms; psychotherapy may help reluctant patients become more willing to take medications over time. Psychotherapy may also permit a quicker and deeper dose reduction than pharmacotherapy alone. After treatment discontinuation, psychotherapy may be more likely to prevent relapse than medication alone. In these and other ways, the two treatments may interact synergistically to augment the effects of each other.

Research in Combined Treatment for Three Disorders A rich literature describing combined pharmacotherapy and psychotherapy treatment trials is developing rapidly. In this section the clinical implications of combined treatment in the treatment of depression, schizophrenia, and agoraphobia are summarized. Much of the information in this section appears in Integrating Pharmacotherapy and Psychotherapy (edited by Beitman and Klerman, 1991). DEPRESSION

The treatment of depression has been the most studied of all the diagnostic entities (Manning & Frances, 1990). The many forms of psychotherapy used in these studies have included cognitive, interpersonal, psychodynamic, marital, and behavioral. Conclusions from these studies may presage conclusions from work with other diagnostic categories. First, in part because of the need for large sample sizes, the findings from these studies have generally suggested that combined treatment is not more effective than either treatment alone. In their critical review of the subject, Manning and Frances (1990) could only conclude that combined treatment is as good as either treatment alone. "Apparently, at least, medication and psychotherapy do not get in each other's way" (p. 21). Garvey, Hollon, and DeRubeis (1985) found, in their studies involving cognitive therapy, that more severely depressed patients responded better to combined therapy than to drugs alone. Mild to moderately depressed patients did well in all therapy conditions. A family history of depression suggested better treatment outcome for combined therapy than

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with cognitive therapy alone. Others have suggested that combined treatment may reduce symptoms more quickly than either treatment alone (Manning & Frances, 1990). There is some suggestion of differential effects; namely, medications help more with somatic symptoms, whereas psychotherapy helps in improving social adjustment and cognitions (for further discussion, see Rush & Hollon, 1991; Manning & Frances, 1990).

SCHIZOPHRENIA

Schizophrenia has also been well-studied in combined treatment trials. The forms of psychological treatment have varied widely, from regularly scheduled individual contacts to rehabilitative, social learning approaches. In their review of the combined treatment literature, Marder and associates (1991) found that patients who received a placebo instead of a neuroleptic had a worse outcome when assigned to supportive individual psychotherapy than those who had received no psychotherapy at all. The drug-treated patients responded better to combined treatment than to medication alone. When behavioral family therapy is combined with medications, patients appear to be more compliant with medications and also to require lower doses. One possible contribution to the need for less medication may be that behavioral family therapy reduces family tension. There is little question that medication is necessary in the treatment of schizophrenia. But what form of psychotherapy is to be used? If the patient has an intact family, then problem-oriented family therapy (including identifying the stressors, developing stress-prevention and coping strategies, implementing stress-control strategies, and engaging in anticipatory planning) appears to be beneficial (Goldstein, 1991). The chronically mentally ill seen in state hospital systems may require social-skills training emphasizing very carefully designed contingencies (e.g., Paul & Menditto, 1992). Ambulatory patients may respond well to group training modules for social skills (see Marder et al., 1991; Goldstein, 1991).

AGORAPHOBIA

In his review, Mavissakalian (1991) concluded in agoraphobia research that four of five studies suggested that imipramine enhances the therapeutic effects of exposure (going out into the feared situations) only at doses above 150 mg. On the other hand, two studies suggested that some instruction to exposure is necessary to maximize the antiphobic effects of imipramine. Thus the available studies suggest that imipramine and exposure are mutually potentiating. Furthermore, the combined behavioral and pharmacological treatment may both maximize the initial re-

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sponse and minimize relapse upon discontinuation (see Mavissakalian, 1991, for references and further discussion).

Research Comparing Pharmacotherapy and Psychotherapy for Five Disorders Combined treatment studies for other diagnostic entities are in their initial stages, but several disorders have been studied comparing pharmacotherapy with psychotherapy. What is most interesting is that single treatments often tend to be equally effective in short-term treatment trials. However, some differences not evident from data analysis may be observed clinically, as described below.

PANIC DISORDER

At this writing, several clinical trials for combined treatment of patients with panic disorder are under way. Most antidepressants and benzodiazepines have been shown to be useful in its treatment. Beginning evidence for the efficacy of cognitive-behavioral approaches to panic is also very encouraging (Klosko, Barlow, Tassinari, & Cerny, 1990). Clinically, there are several indications for the use of combined treatments. Some patients have poor medication tolerance and may require psychotherapeutic exploration of their reactions to pills. Panic-disorder patients are often unwilling to accept medications, perhaps because of their strong desire for control. Psychotherapy may help them to consider the medication as "their" pill and therefore within their own control. On the other hand, distress levels may be so high that psychotherapy alone will not reduce their symptoms quickly enough, making pharmacotherapy essential. As with all diagnostic indications for pharmacotherapy, some patients are minimally responsive to this treatment form; personality and interpersonal variables may interfere. Therefore, couples therapy, family therapy, and in-depth cognitive-behavioral and/or psychodynamic approaches may be necessary to augment medication responsiveness (see Shear, 1991, for further discussion). OBSESSIVE-COMPULSIVE DISORDER

In the treatment of obsessive-compulsive disorder (OCD), specific behavioral approaches and certain medications appear to be differentially effective. Although most antidepressants may be somewhat useful, fluoxetine (Prozac) and clomipramine (Anafranil) appear much more effective.

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Behavioral treatment is based upon exposure to the feared element (e.g., dirt) and response prevention (e.g., cessation of excessive hand washing). Although patients with OCD often appear ripe for psychoanalytic interpretations (e.g., sexual and aggressive impulses drive the washing behavior), there is no evidence that this approach does more than simply make patients accepting of medications and break the boredom of behavior therapy. Treatment response may depend on the predominance of obsessions versus compulsions. Patients with obsessive thoughts and without compulsions seem to respond better to medications, particularly monoamine oxidase inhibitors (MAOIs), according to Jenike (1991). Although behavior therapy has little to offer such patients, those with rituals appear to respond to either approach (see Jenike, 1991, for further discussion). SOCIAL PHOBIA

Social phobia has received less attention from researchers and clinicians than the aforementioned disorders. While most readers of this chapter are familiar with the anxiety associated with presenting talks to audiences, many are unaware of the debilitating nature of other forms of social phobia. Like panic patients, social phobics may create constricted lives, but these constrictions are not as apparent as those of agoraphobics. This fact may account for its lack of attention. Studies suggest that phenelzine (Nardil), alprazolam (Xanax), and clonazepam (Klonopin) may be useful. Other studies suggest that various forms of behavior therapy, including socialskills training and cognitive-behavior therapy, are effective. Exposure to the feared situations are central to both psychotherapeutic approaches. One study suggested that cognitive therapy and the beta-blocker propranolol are equally effective. No one has yet published research on combined treatment for social phobia. Currently, clinicians have little research to guide their practice except to note that there are strong similarities between the pharmacological and psychotherapeutic approaches to both panic disorder and social phobia. The differences will be important to elucidate (see Uhde & Tancer, 1991, for further discussion). BULIMIA NERVOSA

More than any other disorder studied, bulimia nervosa research illustrates the problems in generalizing about the efficacy of "psychotherapy." First, some evidence suggests that, in the short term, bulimia among women in their mid-20s tends toward modest "spontaneous" improvement. In a survey of 628 women with eating disorders (predominantly bulimia) followed over approximately 20 months, the subjects reported

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modest improvement in their binge eating and purging. The rates were similar regardless of whether they had sought professional help. Second, treatment studies of bulimia have employed the widest range of psychotherapies, including psychodynamic, educational, cognitive-behavioral, behavioral, family, and group, as well as various combinations such as family plus individual psychotherapy (see Feldman & Powell, 1992). Nevertheless, consistent among these studies is the persistent use and effectiveness of behavioral approaches that address the presenting behaviors of binge eating, self-induced vomiting, and laxative abuse. Generally, these methods include keeping detailed food diaries, goal setting, stimulus control (times and conditions under which they could eat), response delay (delay between desire to eat and actual eating), and response prevention (do something else besides eating). As with other disorders, severity of symptoms and accompanying personality disorders make the prognosis more guarded. Imipramine and other antidepressants appear useful in the treatment of bulimia, according to several controlled studies. Many patients are prone to side effects, increasing the difficulty with compliance. Because of vomiting, some have difficulty achieving therapeutic levels even when compliant. Blood levels may therefore be useful to ensure adequate medication levels. As in the treatment of OCD, the antidepressants appear to have an antibulimic effect in patients with no clinical depression. Fluoxetine (Prozac) has gained considerable popularity among bulimics because it too is effective in restraining binge eating and purging, and does not induce carbohydrate craving as do the other antidepressants. It may also help to reduce weight. Clinical experience suggests that several different medication trials may be necessary until an acceptable side effect profile is found. However, the one controlled study that systematically compared imipramine, intensive group treatment, and a combination of the two found that the psychosocial treatment was superior to the imipramine alone. Adding the antidepressants to group treatment did not improve the eating disorder symptoms, although it decreased symptoms of anxiety and depression more than did the group treatment alone. This finding is consistent with other studies suggesting that medications do not add to wellconducted psychosocial interventions in the treatment of bulimia. In deciding whether to use medications, psychotherapy, or both, clinicians must again take into consideration the patient's predispositions. Any choice, however, should be accompanied by educational, nutritional, and behavioral elements (see Yager, 1991, for further discussion). BORDERLINE PERSONALITY DISORDER

Of the diagnostic categories discussed in this section, borderline personality is the most conceptually diffuse. Two general approaches to

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classification have been used. The psychodynamic approach emphasizes hypothetical intrapsychic structures: "Splitting" and the "grandiose versus depreciated self" refer to the tendency of such patients to divide themselves and the world into black-and-white categories and to vacillate between these states, in their views of both others and themselves. The second conceptual approach emphasizes what can be observed, including impulsive, often self-destructive behavior; intense, shifting affective states; and intact reality testing in structured situations, with "slippage" in unstructured situations. Unstable and manipulative interpersonal relationships associated with an inability to tolerate aloneness and superficial social relationships is also seen in this disorder. Although the DSM-1II-R criteria did not include vulnerability to transient psychotic episodes, this characteristic helped to form the label "borderline," as this label was applied to patients considered to be on the "borderline" between neurotic and psychotic. Treatment of borderline patients with medication, psychotherapy, or both is problematic. Research in integrative cognitive-behavior therapy is described elsewhere in this volume by Linehan (Koerner & Linehan, 1992). Ongoing psychodynamic research is being conducted by Kernberg's group (Kernberg, Selzer, Koenigsberg, Carr, & Applebaum, 1989). A survey of experienced psychodynamic psychotherapists found that the average borderline patient was seen three times a week for four and a half years, and outcome was better the longer the patient stayed in therapy. During the first six months in psychotherapy, however, discontinuation rates between 23 and 66 percent have been reported. Conclusions from drug studies are limited for many reasons. For one, there are currently very few controlled studies, and each has a relatively small number of patients. Notably, these patients respond significantly to placebo and to structure. For another, patients also manifest a high dropout rate (from 14 to 54 percent in the various studies over a 6-to-12-week time period). For still another reason, medication effects are generally modest; that is, medications reduce symptoms from severe to moderately severe rather than to levels of marked improvement or remission. Finally, medications have little discernable impact on maladaptive character patterns; in fact, some patients, relatively free of their symptoms, become yet more exploitive. With these caveats in mind, it appears that low-dose neuroleptics, the most studied medications, reduce impulsive behavior, anger, anxiety, and some symptoms of depression. A monoamine oxidase inhibitor, tranylcypromine (Parnate), and an anticonvulsant, carbamazepine (Tegretol), were more effective than placebo in reducing impulsivity and anger in one study. The studies also suggested little effectiveness of tricyclic antidepressants and suggested that they may have a detrimental effect on some patients.

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Clinical experience, however, suggests that antidepressants may be useful in some patients on the depressive spectrum. One of the most vexing problems facing researchers is the obvious differential responsiveness of patients fitting the borderline criteria, suggesting several subcategories that will need to be elucidated. Medications, like most other major therapeutic interventions, have great meaning to borderline patients. Effective pharmacotherapy requires an alliance that fosters accurate reporting of symptoms and side effects. Unfortunately, borderline patients are likely to provide distorted reports of medication effects because of their need to induce certain feeling states in their therapists. When idealizing a therapist, for example, borderline patients may erroneously take personal responsibility for medication side effects, so as to maintain the therapist as an ideal protector who would never make the patient feel uncomfortable. By contrast, in an effort to make a therapist feel helpless, the patient may attribute a psychological or interpersonal dysphoria to the medication. These examples illustrate the manner in which borderline patients may use their tendency to "split" by exploiting the mind-brain dichotomy prevalent in Western thinking (see Koenigsberg, 1991, for further discussion).

The Reciprocal Relationship Between Pharmacotherapy and Psychotherapy That interacting entities mutually affect each other is increasingly part of psychotherapeutic and psychological wisdom (Wachtel & McKinney, 1992; Mahoney, 1990; Pentony, 1981). Like some borderline patients, many psychotherapists must also refrain from the clinical tendency to dichotomize mind and brain by noticing how medications influence psychotherapy process and how psychotherapy influences pharmacotherapy. In order for clinicians to appreciate these complex interrelationships, they must be willing to be "surprised" by allowing themselves to be open to unexpected crossings of the mind-brain barrier. Following are several cases of these relationships reported by the senior author, organized according to the stages of psychotherapy and the phenomena of transference and countertransference (Beitman, 1987).

ENGAGEMENT

Psychotherapists must establish trust with patients in order to proceed to the intimate revealing and courageous behavior often required of behavior change. Among the synergistic methods available to therapists to

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facilitate engagement are empathic reflection, demonstrating specialized knowledge, and effective suggestions. The prescription of a medication demonstrates specialized knowledge. If it works, it becomes an effective suggestion. Accurate diagnosis, upon which pharmacotherapy usually depends, may become a form of empathic understanding, since the patient is placed in a category about which much knowledge is usually available. Effectiveness of medications does not necessarily guarantee engagement. Some patients are satisfied with symptom relief and refuse psychotherapy. Conversely, failure of medications does not necessarily lead to termination of psychotherapy. Discussions of medication ineffectiveness and the therapist's willingness to try them can nonetheless provide a scaffolding for engagement. Effective or not, medication side effects can become the focus of patient anger, leading to blaming the therapist for attempts to control or harm the patient. Similarly, pills may serve as engagement transference and countertransference vehicles. For example, an effective medication may lead a patient to idealize everything the therapist does. On the other hand, a medical psychotherapist who does not want to see a certain patient may prescribe an MAOI for which the dietary restrictions are quite important, but neglect to tell the patient about them. More commonly, a therapist might frighten a patient away with undue emphasis upon dietary restrictions and potential side effects. For some patients extensive psychotherapeutic work is necessary before they will consider medication treatment. Paranoia, distrust of medications, and the desire to avoid the social stigma associated with psychiatric medications, may foster avoidance of needed pharmacotherapy. PATTERN SEARCH

Attention to patient reactions to pharmacotherapy may offer remarkably sharp illustrations of important maladaptive patterns for psychotherapeutic work. Following are some case examples. Focus on the negative. A 23-year-old woman was excessively anxious. Despite her history of alcohol abuse (to control her anxiety), I carefully initiated an eight-week course of a benzodiazepine. On her return visit, she reported that the medication was ineffective in controlling her obsessive cleaning. She was quite discouraged. Only after some prompting did she report better sleeping, better functioning in school, and much less anxiety. She was highly perfectionistic in all she did and rarely felt gratified by her positive accomplishments. Goodness always disappears in the future. A highly anxious 34-year-old woman refused to take an occasional antianxiety medication, although she was often severely disabled by her anxiety. "I'm afraid if I take it too often,

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it won't work anymore." After I suggested to her that this was an illustration of a common pattern in her thinking, she asked, "Will you be leaving this city soon?" She had grown up learning that anything good will almost certainly be followed by something awful. Self-abuse through medication. A 37-year-old with severe panic disorder failed to renew her prescription for the benzodiazepine she had been taking for several years. She had been warned not to stop it suddenly but she decided to "tough it out." She experienced severe withdrawal symptoms. As a child she had learned to "tough out" sexual abuse by a series of stepfathers and physical abuse by her mother. "Nothing and no one can help me." A 48-year-old man was referred to a psychiatrist by his psychotherapist for pharmacological evaluation and treatment. He had been in psychotherapy since age 22. His first psychotherapy relationship was most helpful for him but ended abruptly when his graduate student therapist announced after 10 sessions that they would meet no longer. He was deeply hurt by what he perceived to be rejection and betrayal. He believed that none of his eight subsequent psychotherapists were useful to him. The psychiatrist tried him on three different types of medication, each of which was dramatically effective in the first few weeks but just as dramatically lost their effectiveness subsequently. Nevertheless, the patient insisted upon continuing with the psychiatrist in psychotherapy and in dropping the other psychotherapist. After several months of treatment, the patient declared that this psychotherapeutic relationship was not helpful and in fact hurtful. He terminated. Each therapist had missed the patient's belief that nothing and no one could help him. "If she wants something of mine, I'll give it to her." A 38-year-old married man in his second psychotherapeutic relationship wanted to find a way to divorce his wife with the help of a therapist because he couldn't find a way to do it on his own. During his first psychotherapy he had asked his psychoanalytically oriented therapist to see his wife. Because this therapist did not do couples therapy, and because his agoraphobic wife needed treatment, the patient stopped seeing this therapist so that his wife might see him. After several sessions with me, he reported that his wife wanted to see me for medication evaluation because "you are an expert in anxiety disorders." To his amazement, I refused. My refusal required that he explain to her that I was not willing to allow him to give up yet another therapist to her and that he too was not willing to do so. He had, in many other ways, given in to most of her requests of him. This boundary construction provided him with a wedge by which to continue the process of separation. The separation and subsequent divorce, incidentally, was associated with great reduction in her agoraphobic behaviors.

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PATTERN SEARCH: TRANSFERENCE AND COUNTERTRANSFERENCE

Interpersonal patterns may play out in the interaction between therapist and patient about medication use. Both patient and therapist are potential contributors to medication-associated distortions. The pill is the therapist: A 47-year-old woman insisted that she receive sleep medication from me but refused to discuss the thoughts she had when trying to fall asleep. Her demands escalated and we reached a stalemate. Slowly she revealed that she was unable to go to sleep because she was preoccupied with sexual fantasies about me. She wanted the medication to overcome these thoughts. Although she later showed much evidence of developing erotic feelings toward me, she refused to discuss them. Give the patient a pill to calm down the therapist. A 24-year-old woman developed a strong sexual attraction for her 28-year-old male therapist. He was disturbed by his own sexuality and denied to himself that any woman could find him sexually appealing. To reduce what he thought was her anxiety, he prescribed an antianxiety medication. The patient was confused by this offer, was not aided by the pills, and rightly questioned the therapist's ability to treat her (Langs, 1973).

CHANGE Medications and psychotherapy may interact in surprising ways to bring about change. Medications may make patients more responsive to psychotherapy, but may also help with the initiation and maintenance of new behaviors (e.g., imipramine may help agoraphobic patients expose themselves to fearful situations). On the other hand, psychotherapy may uncover a medication-responsive diagnosis not considered during the initial evaluation (e.g., couples therapy may later reveal a social phobia). It is likely that additional change synergies wait to be recognized. Pharmacotherapy helps to separate a patient from her mother. A 23-yearold woman had been depressed since she was 16 years old but had never sought treatment. Although she lived independently, she always asked her mother's advice about major decisions. Since she clearly met criteria for depression, she was offered an antidepressant. Her mother emphatically instructed her not to take it because "I don't want any drug addict for a daughter." The patient therefore refused. As psychotherapy proceeded, the patient realized how much she was striving to please her mother while at the same time being furious with her for her emotional abuse and physical threats during childhood. After several months she was offered imipramine again. She accepted and decided not to tell her mother of this decision. Not only did she gain pharmacological benefit, but also, for the first time in her life, she made an important decision without consulting and reporting to

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her mother. This action allowed her a more objective view of their relationship, leading her to freer attachments to subsequent friends and lovers. Psychotherapy leads to an unrecognized medication-responsive diagnosis. At age 28 the patient's ex-husband entered her office at work and shot her in the head. She suffered minimal brain damage but had recurrent panic attacks with agoraphobia, continuing depression, and posttraumatic stress disorder. She had had no psychiatric problems before the shooting and was maintained on a benzodiazepine and an antidepressant. Psychotherapy focused on her dependent relationship with her mother and her agoraphobia. Over the many years of litigation surrounding this incident, she was required to undergo numerous interviews by lawyers and mental health professionals. She often had panic attacks when asked about the details of the incident or about her ex-husband. The many roadblocks thrown up by the "system" infuriated her, causing her to think that "they" were trying to subvert her legal intent. I encouraged her to gradually expose herself to these situations and these ideas. Without telling me she was going to do it, she went to another interview. She became agitated. She threw furniture around. She was furious. She thought the pictures on the wall were telling her to destroy them. I inquired more carefully into her belief about the plot against her and asked her mother about other paranoid thinking. Indeed, the patient had been paranoid for many years since the shooting. Exposure instructions had revealed psychotic thinking that was subsequently responsive to a low dose of the neuroleptic, thiothixene (Navane) 2-3 mg/day. TERMINATION

Termination may be the most predictable stage of therapy, since the range of options for both participants is relatively limited at this time. For example, the patient or therapist may independently decide to terminate, or the decision may be made together. They may terminate abruptly, set a specific date, or gradually separate by spacing out meeting intervals. Each may also have difficulty letting go of the relationship and may therefore experience various aspects of grieving (Beitman, 1987). Patient responses to pharmacotherapy may reflect general patterns of separation. Refusal to restart an effective but unnecessary medication harbingers termination. Laura, the 30-year-old panic disorder patient described at length in another chapter of this book (Beitman, 1992), had discontinued her imipramine during the later stages of therapy because of her pregnancy. As session intervals became monthly or longer, she became worried about her failure to be "cured" because she still had an occasional panic attack. These attacks tired her and her husband because she lost sleep and then spent hours analyzing them. "Could we just start the imipramine again?" She was looking for answers from me even though she had enough information

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herself to make the decision. I simply handed her a prescription and asked her to decide for herself. She did not like that. Six weeks later she returned to report that she had not started the imipramine. She had a panic attack the night before our session "because I just don't want to think about this stuff anymore. Denial is a good thing." With some prodding, she could express her anger at me for not making her completely well. She grudgingly recognized that she would need to continue to do the work of change herself, without pills and without psychotherapy. I asked her to return in one year to let her see how much she had changed. Wish to discontinue necessary medications is harbinger of abrupt termination. A 48-year-old woman with panic disorder and agoraphobia was struggling with a difficult marriage. Her husband would be kind to her only when she was physically or emotionally ill. She developed a strong emotional attachment to me. After four years of contacts at approximately one-to-three-month intervals, she was becoming more and more exasperated with her husband. During one session I too expressed some minor frustration about her situation. Her sensitivity to criticism triggered intense anger at me. She called me that night, threatening to stop her medications. She knew that without them she would likely spiral into depression and panic. She was able to accept my suggestion that her anger at me had driven her to this decision. Without this discussion she would have also quit psychotherapy. She continued the medications as well. Unfortunately, her marital difficulties contributed to a suicide attempt with medications she had stored up from another physician. She did not want to use the pills she had gotten through me. Only after divorce and the beginning of a new, successful relationship was she able to reduce her medication dosages and her treatment frequency.

Psychotherapist-Pharmacotherapist Collaboration Surveys of professional societies indicate that approximately 65 percent of psychiatrists and 80 percent of psychologists participate in arrangements in which different clinicians provide psychotherapy and pharmacotherapy to the same patient (Beitman, Chiles, & Carlin, 1984; Chiles, Carlin, Benjamin, & Beitman, 1991; Bascue & Zlotowski, 1980; Goldberg, Riba, & Tasman, 1991). While many collaborations work well, problems arise in others. These include the patient idealizing one clinician and devaluing the other, accusations of clinicians "stealing" patients from colleagues, requests for fraudulent signatures on insurance forms, and psychotherapy patients acting out by surreptitiously obtaining pharmacotherapy (Woodward, An-

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derson, & Woodward, 1991). In addition, there is widespread perception of potential for problems; in a recent report, 25 percent of collaborating psychiatrists believed collaborative treatment could alienate them from psychotherapists, and 40 percent believed it could result in lawsuits (Goldberg et al, 1991). There has been little discussion of collaborative treatment in the literature, and no research on its efficacy. Studies of combined psychotherapy and pharmacotherapy typically do not specify whether the treatments were administered by the same or different clinicians and do not describe the arrangements for different communication between clinicians (Woodward et al., 1991). We believe the relationship between the two clinicians is central to effective collaborative treatment; it can support the patient and both clinicians, or it can become the instrument for amplifying the patients' conflicts. Factors determining the clinicians' relationship include the treatment setting, the patient, the history of the relationship, and the ground rules for clinician communication. Collaborative treatment is most therapeutic when both clinicians understand the potential sources of tension in their relationship and when all three participants agree on and adhere to a three-way therapeutic contract.

THE TREATMENT SETTING

Clinicians in collaborative treatment may be peers in a hospital or clinic, employer and employee in an office, or colleagues or unknowns in private practice. In any setting, systemic and interdisciplinary issues from the larger system can intrude into therapeutic relationships, making the clinicians vulnerable to identifying with the patients' conflicts. Likewise, clinicians in independent practice exist in a professional community in which each maintains a reputation; they may also be linked by office proximity, shared professional activities, or even marriage. The treatment setting usually determines the administrative relationship between the two clinicians; they may be independent peers, or one may employ or supervise the other. In the absence of an employment or supervisory relationship, each is responsible for his or her own work and not for that of the other (Applebaum, 1991). Supervisory arrangements are more acceptable to some patients and can provide support for clinicians. They are also more comfortable for physicians who are not experienced in being a peer to nonmedical psychotherapists. Unfortunately, supervisory relationships also raise issues of autonomy and self-esteem, which, if not understood and monitored, may make the clinicians more vulnerable to splitting by the patient.

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THE PATIENT

Patients hold beliefs about the nature of their problems and about the treatments they prefer, frequently expressed by their choices of whom they initially consult for help. Some patients center their hope in physicians and can initiate psychotherapy only when it is medically prescribed, while others believe their problems are psychological in origin and can accept medication only with the endorsement of a nonmedical therapist. Referral to a second clinician may elicit feelings of failure, relief, inadequacy, loyalty, hope, or despair. Many patients experience referral to a second clinician as a rejection. Adding a second clinician mobilizes some patients' tendencies toward projective identification; this may be an advantage in holding some patients in treatment, but destructive splitting requires unusually close collaboration between the clinicians. Similarly, patients with potential for violence or suicide, or difficulties with treatment compliance, are likely to require closer collaboration. DEVELOPMENT OF THE CLINICIANS RELATIONSHIP

Tension between clinicians may originate in differences in ideology (Klerman, 1991), disagreement about treatment goals and methods, or interdisciplinary rivalry. Patients' conflicts may intensify these tensions. The working relationship between the two clinicians is central in managing problems from any of these sources. Ideally, the clinicians' relationship is built on each one's skills and self-esteem and on previous experience in working together. In the absence of sharing cases, a common theoretical orientation, institutional affiliation, or supervisory relationship may facilitate the development of trust between clinicians. The collaborative relationship may take time to develop. This can be shortened by a preliminary discussion of beliefs about treatment approaches, interpersonal styles, and common problems in collaborative treatment (Corder, Cornwall, & Whiteside, 1984). In addition, it is helpful to be meticulously complete about communication the first time two clinicians work together; the goal is to build a working relationship as well as to treat the particular patient. COMMUNICATION BETWEEN CLINICIANS

Collaborating clinicians may work separately, with no communication between them; they may communicate when either perceives the need; or they may routinely discuss all aspects of the patient's treatment. When the patient is capable of conveying the information necessary for treatment,

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and when the clinicians trust and respect each others' work, no communication may be necessary. This has the advantage of reducing the intrusion of the pharmacotherapist relationship into the process of psychotherapy (Zinberg, 1987). Communication when problems are perceived permits clinicians to share information, formulate the case together, and manage the patient's distortions of their relationship. This more flexible approach still acknowledges the boundaries of the psychotherapy relationship. Routine communication is used in many institutional settings in the form of rounds and supervision; it is advantageous in managing complex cases, with more disturbed patients who may act out violently or not comply with treatment, and for those who are likely to induce splitting in the therapeutic triad. In very difficult cases it may be helpful for the clinicians to meet together with the patient. THE THREE-WAY THERAPEUTIC CONTRACT

Whatever arrangements for treatment are selected, it is essential that all three participants comprehend, concur, and comply with the therapeutic contract. This contract is an agreement among the clinicians and patient about the purpose of each treatment, the respective roles of the clinicians, any employment or supervisory relationship between them, policies for clinician communication, whom the patient should call in case of emergency, coverage arrangements for vacations and other absences, and any fees for initial and ongoing clinician communication. These issues should be negotiated at the beginning of treatment; in some cases it may be helpful for all three participants to meet together to discuss the contract (Chiles et al., 1991) or for the patient to have a written summary of these policies (Applebaum, 1991). Collaborative treatment is widely practiced but rarely discussed; we need research on its efficacy and on the optimal arrangements for collaboration. It has both advantages and potential for problems. It is most therapeutic when the clinicians attend to tensions in their relationship and when all three participants understand and adhere to the three-way therapeutic contract.

Concluding Comment The conceptual mind-brain barrier is eroding as research and clinical experience demonstrate the synergy between pharmacotherapeutic and psychotherapeutic treatments. Further research in combined treatments for other diagnostic categories such as manic-depressive illness should be forthcom-

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ing, as well as further analysis of more frequently studied categories. In addition, if clinicians working with patients being treated with both modalities will allow themselves to be "surprised" about potential treatment interactions, useful clinical principles for integrated treatment are also likely to emerge.

References AMERICAN PSYCHIATRIC ASSOCIATION. (1987). Diagnostic and statistical manual of mental disorders (3rd rev. ed.). Washington, DC: Author. APPLEBAUM, P. S. (1991). General guidelines for psychiatrists who prescribe medication for patients treated by nonmedical psychotherapists. Hospital and Community Psychiatry, 42, 281-282. BALLENGER, J. C, BURROWS, G. D., DuPoNT, R. L, LESSER, I. M., NOYES, R., PECKNOLD, J. C., RIFKIN, A., & SWINSON, R. P. (1988). Alprazolam in panic disorder and agoraphobia: Results from a multicenter trial: 1. Efficacy in short-term treatment. Archives of General Psychiatry, 45, 413-422. BASCUE, L. O., & ZLOTOWSKI, M. (1980). Psychologists' practices related to medication. Journal of Clinical Psychology, 3d, 821-825. BEITMAN, B. D. (1981). Pharmacotherapy as an intervention during the stages of psychotherapy. American Journal of Psychotherapy, 25, 206-214. BEITMAN, B. D. (1987). The structure of individual psychotherapy. New York: Guilford. BEITMAN, B. D. (1991). Medications during psychotherapy: Case studies of the reciprocal relationship between psychotherapy process and medication use. In B. D. Beitman & G. L. Klerman (Eds.), Integrating pharmacotherapy and psychotherapy. Washington, DC: American Psychiatric Press. BEITMAN, B. D. (1992). Integration through fundamental similarities and useful differences among the schools. In J. C. Norcross and M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. BEITMAN, B. D., CHILES, ]., & CARLIN, A. (1984). The pharmacotherapy-psychotherapy triangle: Psychiatrist, nonmedical psychotherapist, and patient. Journal of Clinical Psychiatry, 45, 458-459. BEITMAN, B. D., & KLERMAN, G. L,. (Eos.). (1984). Combining psychotherapy and drug therapy in clinical practice. New York: Spectrum. BEITMAN, B. D., & KLERMAN, G. L. (Eos.). (1991). Integrating pharmacotherapy and psychotherapy. Washington. DC: American Psychiatric Press. BEITMAN, B. D., & MAXIM, P. (1984). A survey of psychiatric practice: Implications for residency training, journal of Psychiatric Education, 8. 149-153. BODEMER, C. W. (1984). Historical perspectives on combined treatment. In B. D. Beitman & G. L. Klerman (Eds.), Combining psychotherapy and drug therapy in clinical practice. New York: Spectrum. CHILES, J. A., CARLIN, A. S., BENJAMIN, G. A., & BEITMAN, B. D. (1991). A physician, a nonmedical psychotherapist, and a patient: The pharmacother-

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apy-psychotherapy triangle. In B. D. Bellman & G. L. Klerman (Eds.), Integrating pharmacotherapy and psychotherapy. Washington, DC: American Psychiatric Press. CHOUINARD, G., ANNABLE, L., FONTAINE, R., & SOLYOM, L. (1982). Alprazolam in the treatment of generalized anxiety and panic disorders: A double-blind placebo-controlled study. Psychopharmacology, 77, 229—233. CORDER, B., CORNWALL, T., & WHITESIDE, R. (1984). Techniques for increasing effectiveness of co-therapy functioning in adolescent psychotherapy groups. International Journal of Group Psychotherapy, 34, 643—654. COUCH, J. R., & HASSANEIN, R. S. (1979). Amitriptyline in migraine prophylaxis. Archives of Neurology, 36, 695-699. DAVIS, ]. M. (1976). Recent developments in the drug treatment of schizophrenia. American Journal of Psychiatry, 133, 208—214. DOCHERTY, J. P., MARDER, S. R., VAN KAMMEN, D. P., & SIRIS, S. G. (1977). Conceptual issues. American Journal of Psychiatry, 134, 529—533. ELKIN, I., PILKONIS, P. A., DOCHERTY, J. P., & SOTSKY, S. M. (1988a). Conceptual and methodological issues in comparative studies of psychotherapy and pharmacotherapy: 1. Active ingredients and mechanism of change. American Journal of Psychiatry, 145, 909-917. ELKIN, I., PILKONIS, P. A., DOCHERTY, ]. P., & SOTSKY, S. M. (1988b). Conceptual and methodological issues in comparative studies of psychotherapy and pharmacotherapy: 2. Nature and timing of treatment effects. American Journal of Psychiatry, 145, 1070-1076. EVANS, F. ]. (1985). Expectancy, therapeutic instructions, and the placebo response. In L. White, B. Tursky, & G. E. Schwartz (Eds.), Placebo: Theory, research, and mechanisms. New York: Guilford. FELDMAN, L. B., & POWELL, S. L. (1992). Integrating therapeutic modalities. In ]. C. Norcross and M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. FRANCES, A. ]., CLARKIN, J., & PERRY S. (Eos.). (1984). Differential therapeutics in psychiatry: The art and science of treatment selection. New York: Brunner/ Mazel. FRANK, J. (1976). Restoration of morale and behavior change. In A. Burton (Ed.), What makes behavior change possible? New York: Brunner/Mazel. FREUD, S. (1964). An outline of psychoanalysis. In Standard edition (Vol. 23). London: Hogarth. GAP (Group for the Advancement of Psychiatry). (1975). Pharmacotherapy and psychotherapy: Paradoxes, problems, and progress. New York: GAP Report 93. GARVEY, M. J., HOLLON, S. D., & DERUBEIS, R. ]. (1985). Prediction of response to pharmacotherapy, cognitive therapy, and combined cognitive-pharmacotherapy: 2. Predicting response in the CPT project. Unpublished manuscript, University of Minnesota and the St. Paul-Ramsey Medical Center, Minneapolis-St. Paul. GOLDBERG, R. S., RIBA, M., & TASMAN, A. (1991). Psychiatrists' attitudes toward

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prescribing medications for patients treated by nonmedical psychotherapists. Hospital and Community Psychiatry, 42, 276—380. GOLDSTEIN, M. ]. (1991). Schizophrenia and family therapy. In B. D. Beitman & G. L. Klerman (Eds.), Integrating pharmacotherapy and psychotherapy. Washington, DC: American Psychiatric Press. GOODMAN, W. K., PRICE, L. H., RASMUSSEN, S. A., DELGADO, P. L., HENINGER, G. R., & CHARNEY, D. S. (1989). Efficacy of Fluvoxamine in obsessivecompulsive disorder. Archives of General Psychiatry, 46, 36—44. GUTHEIL, T. G. (1982). The psychology of psychopharmacology. Bulletin of the Menninger Clinic, 46, 321-330. HOLLON, S. D., SHELTON, R. C, & LOOSEN, P. T. (1991). In B. D. Beitman & G. L. Klerman (Eds.), Integrating pharmacotherapy and psychotherapy. Washington, DC: American Psychiatric Press. HUSAIN, S. A. & CANTWELL, D. P. (1991). fundamentals of child and adolescent psychiatry. Washington, DC: American Psychiatric Press. INSEL, T. R., MURPHY, D. L., COHEN, R. M., ALTERMAN, A., KILTS, C., & LINNOILA, M. (1983). Obsessive-compulsive disorder. Archives of General Psychiatry, 40, 605-612. JENIKE, M. A. (1991). Obsessive-compulsive disorder. In B. D. Beitman & G. L. Klerman (Eds.), Integrating pharmacotherapy and psychotherapy. Washington, DC: American Psychiatric Press. JENIKE, M. A., HYMAN, S., BAER, L., HOLLAND, A., MINICHIELLO, W. E., BUTTOLPH, L., SUMMERGRAD, P., SEYMOUR, B. S., & RicciARDi, J. (1990). A controlled trial of Fluvoxamine in obsessive-compulsive disorder: Implications for a serotonergic theory. American Journal of Psychiatry, 147, 1209—1215. KARASU, T. B. (1982). Psychotherapy and pharmacotherapy: Toward an integrative model. American Journal of Psychiatry, 139, 1102-1113. KERNBERG, O. F., SELZER, M. A., KOENIGSBERG, H. W., CARR, A. C., & APPELBAUM, A. H. (1989). Psychodynamic psychotherapy of borderline patients. New York: Basic Books. KLERMAN, G. L. (1991). Ideological conflicts in integrating pharmacotherapy and psychotherapy. In B. D. Beitman & G. L. Klerman (Eds.), Integrating pharmacotherapy and psychotherapy. Washington, DC: American Psychiatric Press. KLOSKO, J. S., BARLOW, D. H., TASSINARI, R., & CERNY, J. A. (1990). A comparison of alprazolam and behavior therapy in treatment of panic disorder. Journal of Consulting and Clinical Psychology, 58, 77-84. KOENIGSBERG, H. W. (1991). Borderline personality disorder. In B. D. Beitman & G. L. Klerman (Eds.), Integrating pharmacotherapy and psychotherapy. Washington, DC: American Psychiatric Press. KOERNER, K., & LINEHAN, M. (1992). Integrative therapy for borderline personality disorder: Dialectical behavior therapy. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books.

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LANGS, R. (1973). Psychoanalytic psychotherapy (Vol. 1). New York: Jason Aronsan. LUBORSKY, L, SINGER, B., & LUBORSKY, L. (1975). Comparative studies of psychotherapy: Is it true that "everybody has won and all must have prizes"? Archives of Genera! Psychiatry, 132, 995-1008. MAHONEY, M. (1991). Human change processes. New York: Basic Books. MANNING, D. W., & FRANCES, A. J. (Eos.). (1990). Combined pharmacotherapy and psychotherapy for depression. Washington, DC: American Psychiatric Press. MARDER, S. R., JOHNSTON-CRONK, K., WIRSHING, W. C, & ECKMAN, T. (1991). Schizophrenia and behavioral skills training. In B. D. Beitman & G. L. Klerman (Eds.), Integrating pharmacotherapy and psychotherapy. Washington, DC: American Psychiatric Press. MAVISSAKALIAN, M. (1991). Agoraphobia. In B. D. Beitman & G. L. Klerman (Eds.), Integrating pharmacotherapy and psychotherapy, Washington, DC: American Psychiatric Press. McLEOD, D. R., HOEHN-SARIC, R., ZIMMERLI, W. D., DE SOUZA, E. B., & OLIVER, L. K. (1990). Treatment effects of Alprazolam and Imipramine: Physiological versus subjective changes in patients with generalized anxiety disorder. Biological Psychiatry, 28, 849-861. PAUL, G. L., AND MENDITTO, A. A. (1992). Effectiveness of inpatient treatment programs for mentally ill adults in public psychiatric facilities. Applied and Preventative Psychology: Current Scientific Perspective, J, 1—64. PENTONY, P. (1981). Models of influence in psychotherapy. New York: Free Press. PERSE, T. L., GREIST, J. H., JEFFERSON, J. W., ROSENFELD, R., & DAR, R. (1987). Fluvoxamine treatment of obsessive-compulsive disorder. American Journal of Psychiatry, 44, 1543-1548. RUSH, A. J., & HOLLON, S. D. (1991). Depression. In B. D. Beitman & G. L. Klerman (Eds.), Integrating pharmacotherapy and psychotherapy. Washington, DC: American Psychiatric Press. SCHWARTZ, G. E. (1982). Integrating psychobiology and behavior therapy: A systems perspective. In G. T. Wilson, & C. M. Frances (Eds.), Contemporary behavior therapy: Conceptual and empirical foundations. New York: Guilford. SHEAR, M. K. (1991). Panic disorder. In B. D. Beitman & G. L. Klerman (Eds.), Integrating pharmacotherapy and psychotherapy. Washington, DC: American Psychiatric Press. SMITH, M. L., GLASS, G. V., & MILLER, T. I. (1980). The benefits of psychotherapy. Baltimore: Johns Hopkins University Press. UHDE, T. W., & TANCER, M. E. (1991). Social phobia. In B. D. Beitman & G. L. Klerman (Eds.), Integrating pharmacotherapy and psychotherapy. Washington, DC: American Psychiatric Press. UHLENHUTH, E. H., LIPMAN, R. S., & Covi, L. (1969). Combined pharmacotherapy and psychotherapy: Controlled studies. Journal of Nervous and Mental Disease, 148, 52-64.

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VON BERTALANFFY, L. (1964). General Systems Theory. New York: George Braziller. WACHTEL, P. L, AND McKiNNEY, M. K. (1992). Cyclical psychodynamics and integrative psychodynamic therapy. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. WARD, N. G. (1991). Psychosocial approaches to pharmacotherapy. In B. D. Beitman and G. L. Klerman (Eds.), Integrating pharmacotherapy and psychotherapy. Washington, DC: American Psychiatric Press. WOODWARD, B., ANDERSON, T. I., & WOODWARD, B. (1991). The Clinicians' relationship in psychotherapist-pharmacotherapist collaborations. Unpublished manuscript. YAGER, J. (1991). Bulimia nervosa. In B. D. Beitman & G. L. Klerman (Eds.), Integrating pharmacotherapy and psychotherapy. Washington, DC: American Psychiatric Press. ZINBERG, N. E. (1987). Elements of the private therapeutic interview. American Journal of Psychiatry, 144, 1527-1533.

PARTY

TRAINING AND RESEARCH DIRECTIONS

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CHAPTER 17

Training in Psychotherapy Integration JOHN D. W. ANDREWS, JOHN C. NORCROSS, AND RICHARD P. HALGIN Psychotherapists who will be extant in the year 2000 will have to be . . . enormously more broadly trained than the subspecialized people turned out today. Gardner Murphy, Psychology in the Year 2000

T

J.HE INDICTMENT AGAINST conventional psychotherapy training is lengthy and growing. A small number of these concerns would include inadequate clinical experience, exposure rather than competence, insufficient evaluation, superficial multitheory or single theory, and a disjointed training process (Norcross, Beutler, & Clarkin, 1990). These common difficulties are raised not to shame our training system (further), but rather in an effort to outline corrective steps one would take in constructing an ideal integrative training program. The foregoing problems are compounded by the introduction of differential therapeutics and integrative principles. Not only must the conventional difficulties in producing competent clinicians be resolved, but an integrative program must also assist its students in acquiring mastery of multiple treatment combinations and then in adjusting their therapeutic approach to fit the needs of the client. This "ideal" training outcome may well necessitate "ideal" psychotherapy training (Norcross et al., 1990). In this chapter we begin by introducing an "ideal" training model for both systematic referral and psychotherapy integration. Issues are then considered concerning the importance of personal therapy and the necessity of research training in the preparation of eclectic or integrative therapists. Thereafter, we review integrative supervision—the current (flawed) system, problems in the acquisition of integrative competence, and a future (improved) system. We conclude with a discussion of organizational strate-

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gies for introducing changes, specifically those promoting psychotherapy integration, into training institutions.

Integrative Training Models Before considering ideal training models, trainers are confronted with a critical decision with respect to training objectives. The major choice is whether the program's objective will be to train students to competence in a single psychotherapy system and subsequent referral of some clients to more appropriate treatments, or whether its avowed mission will be for trainees to accommodate most of these patients themselves by virtue of the students' competence in multimethod, multimodality psychotherapy. Either alternative would probably constitute an improvement over current training paradigms. In this section, then, we present consensual training models for teaching both systematic referral and psychotherapy integration. The introduction and implementation of these models into any program will require substantive content revisions, as well as a clinical sensitivity to the process of successful organizational change, as described later in this chapter. SYSTEMATIC REFERRAL

Psychotherapists can function effectively in a single and comfortable theoretical system, providing they have the ethics and talent to discriminate which patients can benefit from their preferred system and which cannot. Referral of the latter group of patients can then systematically be made to clinicians competent to offer the indicated service. In the words of Howard, Nance, and Myers (1987): "Without a therapist's willingness and ability to engage in a range of behaviors and to employ a range of therapeutic modalities, the therapist, by intent or default, will have to limit his or her practice to clients who fit the specific range of behaviors he or she has to offer" (p. 415). The primary problem is not from narrow-gauge therapists per se, but from therapists who impose that narrowness on their patients (Strieker, 1988). The two essential tasks in this model are to train students to recognize the respective contraindications of their single psychotherapy system and to educate them in making informed referral decisions. Several empirically based compendia are now available by which to recognize indications and contraindications of particular therapies (e.g., Beutler & Clarkin, 1990; Frances, Clarkin, & Perry, 1984), and the failure to make use of such information can no longer be construed primarily as lacunae in the psycho-

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therapy outcome literature. On the contrary, difficulties in appreciating the limitations of one's treasured proficiencies are now largely emotional, not intellectual. Helping single-system advocates to relinquish patients for whom another approach is better suited will entail attention to both the prescriptions of the empirical research and the limitations of their theoretical commitments. In order to make thoughtful decisions about referral, the clinician should have knowledge of available community resources. Since many students are trained in geographically different locations than those in which they are ultimately employed, this information cannot readily translate from training programs. Instead of teaching specific resources, therefore, training programs are well advised to ensure that students know how to seek and find resources in a community (Norcross et al., 1990). Ideally, a training program will provide several specific types of experiences in order to assure the student's ability to develop community knowledge. First, specific instruction and coursework might be provided to emphasize the value of community support services. Second, students routinely can be provided with names, addresses, and phone numbers of both national resource groups and local referral services. A number of national directories are available that allow referral to specific practitioners and to service agencies. Third, visits to community mental health clinics, family counseling agencies, foster placement agencies, child protective services, and substance abuse programs can give a sampling of the variety of resources available. Practice exercises also might be incorporated into both course work and practica. Trainees can be assigned, for instance, the task of locating a list of treatment resources and preparing an integrated treatment plan based upon potential referral sources for an actual problem presented in either case conference or prepared as a vignette for class illustration. In addition to course work and knowledge of referral sources, trainees should have extensive experience in actually evaluating a range of patients and participating under close supervision in differential referral and treatment assignment. These training experiences are most easily obtained in a setting where a variety of treatment programs are available. In such a setting, the trainee can practice assessing the patient and environment characteristics, and making differential treatment recommendations concerning treatment setting, format, strategies, and techniques. In such clinics, the trainee is free to consider a whole range of therapies in selecting those that might be optimal for the individual. In such clinics, too, the integration of research and practice can be facilitated and reinforced (Jarmon & Halgin, 1987; Perry, Frances, & Clarkin, 1990).

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PSYCHOTHERAPY INTEGRATION

Of critical importance to the decision to train integrative practitioners is the assumption that students can learn to practice several models competently. While it still is uncertain whether most mental health trainees are capable of acquiring such skill, some evidence has accumulated to suggest that it is possible for a given therapist to selectively apply in an effective way methods drawn from different perspectives (e.g., Beutler & Consoli, 1992; Hardy & Shapiro, 1985; Lazarus, 1992; Prochaska & DiClemente, 1992). Our own training experiences over the last decade also affirm the possibility of producing competent integrative psychotherapists, although additional time and effort may be required in light of the more ambitious training goals. An ideal psychotherapy education would encompass an interlocking sequence of training experiences predicted on the crucial therapistmediated and therapist-provided determinants of psychotherapy outcome. Our suggested model, drawn largely from the consensus of two journal sections on training integrative and eclectic psychotherapists (Norcross et al., 1986; Beutler et al., 1987), consists of five steps. The first step entails training in fundamental relationship and communication skills, such as active listening, nonverbal communication, empathy, respect, and regard for patient problems. Acquisition of these generic interpersonal skills can follow one of the systematic modules that have empirically demonstrated significant training effects compared to controls or less specified programs (Matarazzo & Patterson, 1986). Promising candidates would include human relations training (Truax & Carkhuff, 1967), microcounseling (Ivey & Authier, 1978), and structured learning therapy (Goldstein, 1973). In general, the most efficient way of maximizing learning of facilitative psychotherapy skills and attitudes is to structure their acquisition (Lambert & Arnold, 1987). The standard sequence involves instruction, demonstration (modeling), practice, evaluation (feedback), and more practice. With such practice, students seem to acquire increasing levels of sensitivity, become more willing to confront difficult emotions, and develop greater flexibility (e.g., Tracey, Hays, Malone, & Herman, 1988). In our proposed program, students would be retained in this foundation course until a predefined level of competence was achieved in the expression of therapeutic warmth and understanding. Criterion-referenced situational tests, expert ratings, and demonstration experiments could be utilized to confirm such effectiveness. The second interlocking step in the training consists of an exploration of various models of human behavior. At a minimum, the courses would examine psychoanalytic, humanistic-existential, cognitive-behavioral, and

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interpersonal-systems theories of human function and dysfunction. Students would be exposed to all approaches with minimal judgment being made regarding their relative contributions to truth. Theoretical paradigms would be introduced as tentative and explanatory notions, varying in level of experience, goals, and methodology. Integrative frameworks and informed pluralism would thus be introduced at the beginning of training (Halgin, 1985b), but a formal course on integration would occur later in the sequence. The third step in the integrative training model involves a course on theories of psychotherapy. The focus in this course would be in applying the models of human function and dysfunction to methods of behavioral change. At the outset, multiple systems of psychotherapy would be presented critically, but within a paradigm of comparison and integration. The conceptual underpinnings of change processes would be examined in the context of understanding the human values and cultural norms that are used to explain change. At this point, students would be encouraged to adopt tentatively a perspective that is most harmonious with their own values and clinical preferences. The fourth step in the training sequence entails a series of practica. Neophyte psychotherapists would be expected to become competent in the use of at least two systems that vary in therapeutic objectives and change processes. In each case, completion of the practicum would depend on specific criteria to ensure acquisition of the skills associated with a given approach. Relevant psychotherapy handbooks and treatment manuals would be used specifically to outline criteria for implementing specific interventions (Norcross et al., 1990). Compliance with competency criteria based upon treatment manuals has been found to relate, to some extent, to treatment outcome and efficiency (e.g., Luborsky, Crits-Cristoph, Alexander, Margolis, & Cohen, 1983; Shaw, 1983; Rounsaville et al., 1987; Dobson & Shaw, 1988; Strupp, Butler, & Rosser, 1988). Following satisfactory completion of these competency-based courses, the final step involves the integration of disparate models and methods. The emerging consensus is that the sophisticated adoption of an integrative perspective occurs after the learning of specific therapy systems and techniques (see Beutler et al., 1987; Guest & Beutler, 1988; Halgin, 1988; Norcross et al., 1986; Robertson, 1986). The formal course on psychotherapeutic integration would provide a decisional model for selecting the procedures from various therapeutic orientations to be applied in given circumstances and with given clients. This course bears the program's responsibility of providing "a system of analysis or a framework by which a multiplicity of theories and methods could be organized into an integrated understanding" (Reisman, 1975, p. 191). Concomitantly, an

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intensive practicum experience, such as an internship or residency, with a wide variety of patients would allow novice therapists to practice systematic integration and to evaluate their clinical skills. These training experiences are but the beginning steps in the development of competent integrative psychotherapists; genuine education continues far after the internship or residency. Students would be encouraged— nay, expected—to go forth to receive additional training in specialized methods and preferred populations (Norcross et al., 1990). "Deep-structure" integration will take considerable time and will probably come about only after years of clinical experience (Messer, 1992). Expert psychotherapists represent their domain on a semantically and conceptually deeper level than novices. Conceptual learning about psychotherapy integration is probably necessary to achieve a deep-structure integration, but it is not sufficient. As Messer (1992) notes, for therapists to integrate at a deeper level requires that they first understand and integrate within each individual therapy and, only then, across therapies. Additional psychotherapy experience and disciplined reflection on that experience is needed to attain a mature and abiding synthesis. Psychotherapy integration, in other words, may take two broad forms that are differentially accessible to novice versus expert therapists (Schacht, 1991). The first form, accessible to neophytes, emphasizes conceptual products that enter the educational arena as content additions to the curriculum. The second form of integration, largely limited to expert therapists, emphasizes a special mode of thinking. This form enters the educational arena only indirectly through accumulated clinical experiences that promote fluent, automatic performance, and creative metacognitive skills. MODERATING EXPECTATIONS

The excitement and potential engendered by integrative training may give rise on occasion to grandiose plans and overly optimistic predictions. We have ourselves been guilty of such unfettered optimism at times, and we hasten to correct any illusion that competency-based training in psychotherapy integration will be easily or instantly attained. At the risk of fostering the opposite reaction—that of pessimism or apathy—we will consider several reasons to moderate expectations regarding integrative prospects in training. These considerations, it should be emphasized, apply with equal cogency to conventional psychotherapy training and not uniquely to integrative training. To begin with, explicit training for psychotherapy has a relatively brief history, and research on training for psychotherapy has a briefer history still (Matarazzo & Garner, 1992). In a classic review, Ford (1979) evaluated training studies published between 1968 and 1979 and con-

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eluded that these studies focused on teaching just one or more discrete interviewing skills in the context of very brief and poorly described intervention. Furthermore, the dependent variables were not well-validated, the typical client sample was composed of undergraduates, and the skills imparted were simple and discrete. A more recent review (Alberts & Edelstein, 1990) revealed that therapist training studies involving more traditional process-related skills appear to have progressed little in methodological sophistication or clinical relevance. Considering the variability in training content and processes, Hirschenberger, McGuire, and Thomas (1987) assert that "it is impossible to determine for any given graduate whether the competencies have been developed that are essential for protecting client rights while providing effective treatment" (p. 317). If current evaluation research and training programs do so little to ensure competence in a single psychotherapy model, how can competency be ensured if we attempt to teach practitioners several intervention models? To contemplate such issues is to understand why systematic approaches to psychotherapy integration are not taught in most mental health programs. In a survey of 58 prominent integrationists and eclectics (Norcross & Thomas, 1988), the second most severe impediment confronting integrative psychotherapy was inadequate commitment to training in more than one psychotherapy system. As with psychotherapy itself, it is increasingly difficult to speak of psychotherapy training without reference to its demonstrated efficacy. However, while descriptions of integrative training programs have appeared in the literature (e.g., Beutler et al., 1987; Norcross et al., 1986; Robertson, 1986), empirical evaluations have not. The same can be said for virtually all programs adhering to a single theoretical tradition, but this convergence is hardly redeeming. The competence of our graduates and, indeed, the adequacy of our clinical training are typically assumed rather than verified (Malouf, Haas, & Forah, 1983; Stevenson & Norcross, 1987). Little research has been conducted on evaluating training in either pureform or integrative systems of psychotherapy (cf. Greenberg & Goldman, 1988; Strupp et al., 1988), but recent developments in manualization, adherence measurement, and competency judgments show promise (e.g., Dienst & Armstrong, 1988; Shaw & Dobson, 1988; Tori, 1989). The need for rigorous, ongoing evaluation of training in psychotherapy integration is particularly urgent, given questions about the feasibility of training graduate students to competencies in multiple models (or techniques) of psychotherapy. An indisputable disadvantage of aiming to establish multiple competence is that it will necessitate longer and more comprehensive training than a single competency. Integrative psychotherapists, similar to bilingual children and switch hitters in baseball, may be delayed initially in the acquisition of skills or in the attainment of several

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proficiencies (Norcross et al., 1990). The future promises of increased efficacy, applicability, and efficiency seem to exercise little influence in relation to the daily needs of clients and students (Norcross, 1990). Even if an ideal integrative training model is carefully implemented and thoroughly evaluated, the effects of the training would probably be complex and idiosyncratic. The emerging findings of the Vanderbilt II project, one of the most carefully designed psychotherapy training ventures, bear this out (Henry & Strupp, 1991). This project was designed to investigate the manner in which specialized training might improve the therapeutic process and outcome of time-limited dynamic psychotherapy. The effects of training were mixed, involving potentially positive and negative effects. No linear relationship was found between technical adherence and psychotherapy outcome, although the training was successful in imparting adherence to a manualized form of therapy. The training was also found to alter some specific and general operations associated with improving the quality of dynamic therapy, but there was evidence that some elements not directly related to the techniques that were taught were also improved after training. The criteria for effective training are multitudinous and individualized, no less so than possible indications of effective psychotherapy. The introduction of an integrative perspective does nothing to reduce the subtle and complex effects of training, and probably enlarges the task of measuring training outcome in several psychotherapy systems.

Personal Therapy and Research Training Questions concerning the importance of personal therapy and the necessity of research training in the preparation of eclectic or integrative therapists were considered by several of the contributors to Parts II and III of this volume. In this section we summarize their responses on these contentious issues and add our "three cents" on the basis of 40-plus years of collective psychotherapy training. With respect to personal therapy, contributors to this volume have suggested that its importance as a prerequisite for clinical work depends on the student's level of psychological functioning and the author's own experience with personal therapy. If a trainee's personal problems interfere with the successful implementation of psychotherapy, then all contributors agree it is necessary to remedy the situation, probably including personal therapy. We also sense in the preceding chapters a marked hesitancy to endorse mandatory personal psychotherapy, arising in part from two cardinal integrative principles: (1) the empirical literature is inconclusive on the ability of personal therapy to enhance clinical effectiveness, and these

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committed eclectic and integrative clinicians are reluctant to oblige students to an activity with unproven efficacy; and (2) the eclectic maxim of matching the treatment to the unique needs of the student/client would be violated by insisting on a single modality of uniform length for diverse students. Instead, a variety of individually tailored "personal development exercises" (Beutler & Consoli, 1992) and other life-enhancing activities (Lazarus, 1992) are endorsed. In both this volume and research studies, the valence accorded to personal therapy varies as a function of whether those psychotherapists have undergone personal treatment themselves. In one recent study (Norcross, Dryden, & DeMichele, 1992), only 4 percent of psychologists who received personal therapy thought it was unimportant, compared to 39 percent of those psychologists who had not received it (also see Norcross & Prochaska, 1984). Prochaska and DiClemente (1992) report having undergone personal therapy, and this experience admittedly influenced their valuing it for training. What might be the benefits of personal treatment for the typical psychotherapist in general and the integrative therapist in particular? In general, the literature contains at least six recurring commonalities on how the therapist's therapy may improve his or her clinical work (Norcross, Strausser, & Missar, 1988): (1) by improving the emotional and mental functioning of the psychotherapist; (2) by providing the therapist-patient with a more complete understanding of personal dynamics, interpersonal elicitations, and conflictual issues; (3) by alleviating the emotional stresses and burdens inherent in this "impossible profession"; (4) by serving as a profound socialization experience; (5) by placing therapists in the role of the client and thus sensitizing them to the interpersonal reactions and needs of their own clients; and (6) by providing a firsthand, intensive opportunity to observe clinical methods. In particular, clinicians with integrative leanings will probably discern from personal treatment that therapy is rarely "pure-form" in practice or outcome, that good therapists routinely incorporate a variety of interventions traditionally associated with disparate systems, and that the therapeutic relationship accounts for more treatment outcome than specific techniques (also see Lambert, 1992). On these grounds and the overwhelmingly positive self-reported outcomes of therapists' personal therapy (Norcross, 1990), we enthusiastically recommend (but not require) personal treatment for our trainees. A "good enough" therapist (or multiple therapists) is necessary for the undertaking, of course. Personal therapy is viewed as one component of ongoing development and continuing education. With respect to research training, the consensus is that it is a desirable, but not necessary, ingredient for an effective integrative therapist. None of the contributors to this volume insist upon its inclusion in clinical curricula,

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but several advocate a critical and searching perspective to the psychotherapy enterprise. Beutler and Consoli (1992), for instance, assert that "a research orientation assists one to perceive relationships between therapeutic strategies and subsequent changes, and to be a thinking therapist." Similarly, Lazarus (1992) places paramount importance on the multimodal therapist being trained to understand the workings of science, to appreciate the value of inquiry, and thus to become critical consumers of research— not necessarily producers of research. We concur wholeheartedly. A scientific orientation, not to be equated with extensive laboratory research, conveys a mode of thought that transcends the particular brand of therapy being conducted. It teaches how to be inquisitive and skeptical, how to gather data rather than opinion, how to analyze those data and draw inferences from them. These are skills that help organize clinical knowledge and help students select among the morass of competing therapy claims. Good practice, like good research, depends on rational decision making, logical reasoning from sufficient data, and avoidance of premature assumptions (Ciller & Strauss, 1984). Whether clinicians ever elect to produce original research, they must learn to respect the process of knowledge acquisition, to acquire a way of thinking about therapeutic phenomena, and to read the relevant literature critically. In short, a research orientation prepares us to question and evaluate the way psychotherapy (and psychotherapy training) is conducted (Meltzoff, 1984).

Integrative Supervision Most of us who are committed to psychotherapy integration in its various guises have likely encountered the common but troubling challenge of introducing beginning therapists to multitheoretical approaches. As we accumulate years of clinical experience, we become increasingly forgetful of those anxiety-provoking first sessions in which we struggled with our concerns about what to say next. We may suppress the feelings of confusion and desperation with which we were confronted as we initially attempted to respond to our clients with an air of competence. As beginners, many of us sought out a singular psychotherapy model by which we could define our approach. It has been fairly well-established that neophyte therapists commonly seek out a sense of safety and security within the framework of a single model (Loganbill, Hardy, & Delworth, 1982). This phenomenon presents an interesting challenge for integrative clinicians providing supervision, many of whom are uncertain regarding the advantage of beginners first learning discrete models of therapy. However, even those educators who are open to trainees sequentially learning discrete models are certain to confront some challenges in supervision with

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these students. For example, supervisors are likely to find that a narrow approach to therapy is too restrictive in the face of the particular needs of each client. In such situations, the supervisor faces the dilemma of whether to allow the narrow therapeutic preference of the supervisee to unfold or whether to insist on a broader, more flexible approach with the client. THE CURRENT SYSTEM

As advocates of integration confront the task of guiding their students toward integration, they are certain to confront some obstacles. On a broad level, there are the problems with curriculum discussed elsewhere in this chapter. However, there are also problems of a more personal nature, pertaining to the predispositions of those who are educating, and the needs of those who are being taught. Committed integrationists may find themselves searching for ways to help their supervisees feel comfortable, foregoing the pursuit of proficiency in one or more discrete models of psychotherapy and working instead toward the development of a comprehensive multifaceted system of intervention. As we look at current training curricula in the mental health field, we often encounter a rather absurd set of psychotherapy courses and clinical practica. The absurdity lies in the fact that models of psychotherapy are so often taught in their historically pure forms. This might lead someone unfamiliar with the actual practice of psychotherapy to conclude, for example, that behavior therapists limit their interventions to narrow behavioral techniques and are unconcerned with feelings, personal history, family dynamics, and anything other than the target behavior under consideration. An interplanetary visitor might understandably but mistakenly conclude that this division of theories in the clinical curriculum reflects the real-life practice of clinicians. It would come as no surprise if this visitor were to guess that physiology is taught at the local medical school through separate, unrelated courses on "the foot," "the nose," and "the right eye." Having listened to the rationales offered by some psychotherapy educators, our extraterrestial friend would be prepared to listen to medical school professors defending their teaching methods with some intriguing arguments. The foot professor, for example, might proudly boast of expertise in foot dynamics, contending that this competency can be passed on to each group of physicians in training. Upon completing the array of diverse courses (left leg, face, scalp, etc.), the trainee could then proceed to integrate the different systems; in some (miraculous) manner, the different systems and components would fit together and the trainee would be able to understand the multifaceted relationships among all the parts. The analogy is ridiculous of course, because few, if any, interplanetary visitors are interested in psychotherapy training.

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Just in case we were called upon to explain the current state of affairs, we might discuss the obstacles within the field as a whole that stand in the way of effective integrative training and supervision. Such problems have been addressed elsewhere (e.g., Norcross et al., 1990; Norcross, 1988), and they seem to us secondary to the obstacles that exist in those training programs that profess to be integrative or eclectic, particularly within the supervision contexts of those programs. In this section, we will briefly consider problems that may impede the successful acquisition of eclectic and integrative competence among supervisees. We will then move on to consider how to improve the supervision system. TEACHING WHAT WE WERE TAUGHT

Anyone who has ever prepared a lecture can appreciate the emergent anxiety while preparing a presentation on a topic about which we lack a comfortable level of knowledge. Usually the more knowledgeable we feel about the topic, the greater the level of ease with which we can approach the presentation. Ease of presentation is sometimes further facilitated when we have a teaching model upon which to rely, with the most accessible model being the one by which we were taught. This presents an interesting dilemma for those aspiring to teach multitheoretical clinical approaches, because few integrative clinicians have a clear supervision model upon which to rely for communicating such approaches. As Robertson (1986, p. 416) put it: "Quite frankly, many of us who are trainers teach students pretty much the way we were trained, and most of us were not trained to be eclectic therapists." Contemporary integrative therapists have been self-taught individuals who lack formal training or supervised experience in systematic integrative methodologies (Norcross et al., 1986). A possible result of this situation is that supervisors may resort to those training approaches that were used in their early training days. Perhaps they lean toward a reiteration of the ideas and techniques that they initially learned, while being a bit oblivious to the confusion that any suggestion of narrowness or inflexibility may engender in the beginning trainee who is anxiously trying to learn about effective psychotherapy. Despite profession of an integrative approach, some supervisors revert to the model in which they were initially trained, because this affords them an established training system upon which to base their supervision. For example, the supervisor whose original training was in a psychodynamic framework might be inclined to rely on the interpretive and exploratory techniques that served as the foundation for his or her clinical career. To the extent that such a narrow orientation predominates in supervision,

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a considerable irony emerges in which the supervisor's teaching fails to correspond to his or her actual clinical work. TEACHING WHAT OUR STUDENTS WANT TO LEARN

Sometimes it is not the teacher who is narrow, but the student. It can be both surprising and disconcerting for a supervisor to encounter the supervisee who professes adherence to a narrow model and is resistant to the possibility of becoming more broadly trained. In these situations it may not be a matter of the trainee naively holding onto a base of security, but rather a case of an obstinate refusal to consider alternative methods. At times an arrogance is heard in the words of the trainee, who feels no need to become informed about other models, but evidences unyielding complacency with the myopic view of the espoused psychotherapy model. There are any number of reasons underlying the choice of clinical approach. One's orientation might be influenced by accidental factors, such as exposure to a given model in one's own therapy, in course work, or in training programs (Steiner, 1978). Orientation may also emerge from personal values and philosophy (Norcross & Prochaska, 1983). Of less concern are trainees who opt for a given model on the basis of good information and choice. But what about those who anxiously grasp "conceptual hooks" (Brammer, 1969) on which to hang their clinical perceptions and their professional identification? Supervisors working with rigidly narrow trainees may encounter the perplexing experience of being intimidated by a combative trainee who seems eager to engage in debates regarding the appropriateness of the espoused model. The debate may be fueled by the trainee citing outcome literature associated with the model, while devaluing the broader approach being pursued by the supervisor. When such battles ensue, the issues are probably far more complex than a matter of what clinical approach is better. Often such disagreements are symptoms of other problems, such as emotional conflicts within the trainee or an antagonistic style on the part of the supervisor.

IGNORING SUPERVISEES' DEVELOPMENTAL STAGE Much has been written about the progression through a series of stages and the need for supervisors to respond differentially to trainees at different levels of experience (Halgin, 1988; Heppner & Roehlke, 1984; Hogan, 1964; Loganbill et al, 1982; Stoltenberg, 1981; Worthington, 1987). In one stage theory (Loganbill et al., 1982), supervisees progress through three stages: stagnation, confusion, and integration. During the stagnation stage, the beginner is deceived by the illusion of simplicity in

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clinical work. The confusion stage follows, during which the trainee realizes that something is amiss and solutions seem elusive. It is only later in training that the supervisee attains a sense of integration during which flexibility, security, and understanding emerge. Thus, the trainee begins to recognize that the supervisor who impatiently expects the trainee to have attained a sense of integration early in training is likely to engender dismay, frustration, and diminished self-esteem in the trainee. FAILING TO RECOGNIZE TRAINEES UNIQUE STYLE

Even within comparable levels of training, there exist very special needs and styles associated with each trainee. It is important for supervisors to recognize each trainee's personal idiom (Hogan, 1964), the unique meshing of personality and method; this is quite different from theoretical rigidity discussed above. Supervisors who fail to recognize and appreciate each trainee's personalized approach will likely provoke considerable upset if the supervisor's own style is being imposed on the trainee. One of the most appealing aspects of an integrative approach is that an individualized treatment plan can be formulated for each client's unique needs. Some supervisors overlook the fact that a similar principle can hold true for the trainee; the student's unique style, interests, and experiences can be used to inform a general approach to treatment and specific treatment plans for each client. UNDERESTIMATING THE DIFFICULTY OF INTEGRATION

Many integrative supervisors lose touch with the challenging nature of learning integration. Wachtel (1991) points out that many students, when first introduced to multitheoretical approaches, are puzzled by the mechanics of technique shifts, and are dismayed by a concern that their own attempts might prove to be awkward and disruptive. Beginners are typically overwhelmed by the array of possibilities. For example, a novice may be perplexed by whether an interpretation or a directive intervention is advisable at a given point in the therapy; confronted with such an imposing choice, paralysis may set in. When apprised of such a moment in the therapy, an insensitive supervisor may make a difficult situation worse for the trainee, who is already feeling miserably insecure. A comment that reflects impatience or surprise about the trainee's handling of the therapy is likely to intensify the student's anxiety instead of fostering some risk taking, which is such an important part of the learning process. Experience provides clinicians with a special sense of what should be done next in the therapy; on a deep level, this special sense reflects a very complex decision-making process that is informed by dozens, perhaps

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hundreds, of bits of data related to the client, the therapist, and the context. Like the computer whiz who becomes oblivious to the fact that many people do not know the difference between "software" and "hardware," the experienced clinician can lose touch with the reality of how perplexing and intimidating the psychotherapy process can be for the neophyte. In a similar vein, the language that is used in the supervision context can play a central role in facilitating or impeding learning. Andrews (1989) has pointed out the utility of using the vernacular rather than model-bound jargon. This point would seem particularly important in a context in which technical terms may be unfamiliar to the trainee. HIDING OUR WORK FROM OUR SUPERVISEES

Although modeling has been shown to be a particularly effective procedure for teaching complex behaviors, this technique is used surprisingly little in teaching psychotherapy. Most clinical educators use lecture and consultant techniques to pass on knowledge about the methods of psychotherapy. Like many consultants, they act and speak like experts, reluctant to acknowledge the problems that they themselves encounter in their work. Rather than discuss the mistakes they have committed, they are inclined to report the successes they have achieved. Rather than disclose the anxieties with which they contend in their clinical work, they are likely to boast in ways that communicate an inflated sense of competence and self-assurance. This situation would be quite different if trainees could actually observe the work of their clinical supervisors; yet conducting psychotherapy before the possibly critical eyes of supervisees is an uncommon event. Consequently, trainees are deprived of the opportunity of watching their teachers struggle with the dilemmas that they have come to realize are very much a part of clinical work. FAILING TO USE THE SUPERVISORY RELATIONSHIP

The therapeutic relationship has long been established as a primary curative factor in psychotherapy. It does not involve a great leap of understanding to perceive the supervisory relationship as being comparably important in fostering growth in clinical trainees (Lambert & Arnold, 1987). Despite this fairly obvious fact, it is surprising to observe the manner in which some supervisors approach their relationships with supervisees. Researchers have conducted some interesting investigations of supervisory styles that are facilitative and those that are problematic. Carifio and Hess (1987) reviewed the supervision literature and concluded that the

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ideal supervisor possesses "high levels of empathy, respect, genuiness, flexibility, concern, investment, and openness" (p. 244). Like good therapists, good supervisors are those who use appropriate teaching, goal setting, and feedback; they tend to be seen as supportive, noncritical individuals who respect their supervisees. Integrative psychotherapists have an interesting opportunity when they conduct supervision: they can apply to the supervisory relationship some of the same principles that are effective in integrative psychotherapy. This does not mean that they should look for ways to convert the supervision into a therapy of sorts; in fact, such an approach is considered objectionable by many trainees (Carifio & Hess, 1987; Rosenblatt & Mayer, 1975). Yet, the supervisor can blend the methods of several theoretical approaches; for example, supportive, directive, exploratory, and interpersonal techniques can be blended within a supervision in such a way that the supervisee feels supported, understood, and well-educated (Halgin, 1985a). Fundamental skills in relationship enhancement and communication, as discussed earlier, are critical first steps in the process toward learning integration. The supervisory relationship seems an optimal context within which to model these critical training goals. THE FUTURE SYSTEM

We have discussed some of the obstacles present in the current system that stand in the way of successful integrative supervision. At this point the reader might mistakenly conclude that there is little cause for optimism about changing the status quo. Hopelessness about the matter seems extreme; at the same time, the challenges are considerable. Later in this chapter, consideration is given to some of the political and curricular obstacles that stand in the way of successful movement toward integration, as well as some ideas about what can be done. In this section, our attention will focus on improvements that could be made within the context of clinical supervision. Successful integrative supervision rests on several premises, the most important of which pertain to the level of understanding and theoretical sophistication that the trainee should have acquired prior to beginning clinical work. Ideally, the trainee has acquired at least a rudimentary understanding of differential treatment selection (Beutler, 1986; Beutler & Clarkin, 1990; Frances et al., 1984; Lazarus, 1986) and has been exposed to the range of theories and techniques that are the underpinnings of integrative approaches. Just as we ask our students to be integrative and prescriptive in their clinical work, so too should we match our supervision to their unique needs and clinical strategies. The determinants of therapist behavior are too

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numerous and supervisee needs too heterogenous to provide the identical supervision to each and every student. Integrative supervision will obviously take into account a number of trainee variables, three of which have been addressed in the literature: developmental stage, therapy approach, and cognitive style (see Norcross et al, 1990, for summary). Within the personal learning context, we can return to the foregoing obstacles and make some mention about ways that they can be overcome. When tempted to teach our students what we were taught, we may need to put aside those teaching and supervisory approaches that strike us as being tried, true, and safe; these should be replaced by supervisory content that is reflective of the therapy we conduct in the privacy of our clinical offices. Grinker (1976) commented that once the office doors are closed, much goes on within the psychoanalytic hour that clearly departs from orthodox analysis. The same probably holds true for many integrative psychotherapists who take risks and incorporate experimental interventions that they do not yet feel comfortable sharing with their supervisees. In such cases, it is both ironic and unfortunate that supervisees are deprived of knowing what really works in the therapies that their supervisors conduct. Ideal supervisors provide feedback to students in a variety of ways within a coherent conceptual framework (Allen, Szollos, & Williams, 1986; Carifio & Hess, 1987). Addressing themselves to the history of psychotherapy training, Matarazzo and Garner (1992) conclude that the refinement of feedback to the learner has been of great importance in imparting skill. We have moved away from trainees' case reporting and "reconstructed tales of therapy heroics" (Norcross, 1988) to the use of audiotape, co-counseling, observation through one-way mirrors, and videotaped self-confrontation. This progression has substantially increased the accuracy and completeness of information about what has ensued in therapy, and thereby has enhanced supervision (Nelson, 1978; Stein, Karasu, Charles, & Buckley, 1975). Whatever the feedback mechanism, the presence of a systematic schema determines in large part whether integrative supervision is experienced as intelligible or bewildering. Supervision within a coherent framework is associated with a higher quality experience; conversely, less valued integrative supervisors neglect theory and fail to ground their clinical interventions within larger conceptual perspectives. When confronted with students who seem to be rigidly adhering to narrow approaches, it would do well for supervisors to try to understand the basis for such predispositions. Sometimes such situations are reflections of underlying anxiety on the part of the trainee who has sought solace in the familiar. The supervisor faces the challenge of cultivating personal growth in the trainee without provoking alienation. As we discuss elsewhere in this chapter, it would be unfortunate if such disagreements

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deteriorate into antagonisms between "good guys" and "bad guys." Perhaps this obstacle might best be approached with attention to two other obstacles discussed earlier—those pertaining to the trainee's developmental stage and unique style. Teaching psychotherapy has some commonalities with parenting of adolescents. Arguing usually resolves little, but respect and support go a long way. The successful supervisor assesses the strengths of the trainee and maximizes growth by building upon those strengths. Sharing our own clinical work with our students can serve to open up a rich dialogue in which the supervisor is willing to be vulnerable. By agreeing to such vulnerability, the supervisor can make a strong commitment to a trusting and open relationship. What a wonderful opportunity for the trainee to observe the work of the expert! Following such observations, discussion can focus on the difficulties encountered by the therapist, and in this process the student can develop a much greater and more personal appreciation of what takes place within the integrative therapy session. Open discussion of our actual clinical work will also sensitize us to the complexity of this work. When faced with trainees asking us to explain—and defend—why a given intervention was chosen, we will assuredly become aware of how very difficult practicing within an integrative approach is; and with this awareness, we will be more sensitive to the challenges that our trainees confront. Finally, there is the issue of the supervisory relationship. As should be apparent by much of what has been said so far, the relationship is simultaneously a context and a process for change in supervision. We, as supervisors, have the opportunity of providing our students with wonderful gifts. Ideally, they will finish their work with us knowing more about therapy, more about clients, more about us, and most important, more about themselves. The supervision can be viewed as a laboratory in which creative experiments take place. As supervisors, we have a great deal of responsibility for ensuring that subjects—the clients and the trainees—in the experiment are treated with the greatest of sensitivity and care. When we, the supervisors, make it clear that we are also subjects in this exciting experiment, we enhance the probability of integrative success.

The Organizational Setting of Integrative Thinking A shift has come about in the concerns of psychotherapy integration during the past five years that reflects progress in the development of integrative models. In addition to the founding of the Society for the

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Exploration of Psychotherapy Integration (SEPI), considerable conceptual progress has been made. For example, Prochaska and DiClemente, writing in 1986 (Norcross et al, 1986), state that "the most debilitating obstacle to integrative therapeutic approaches is the lack of adequate models which are compelling and sensible" (p. 82). Today, however, many such models exist, as is indicated in part by the work cited earlier in this chapter, as well as that represented in the present Handbook. More specifically, the curricular and supervision models portrayed above represent an increasing consensus on the outlines of an effective integrative training model. Thus, in our judgment, the training need at the present time is not for further conceptual refinement, but for progress in institutional movement toward adopting such integrative models. In other words, the more pressing need is less a curricular than an organizational one. This conclusion has led us to contemplate ideas concerning organizational change processes—how innovations are adopted in organizations, and specifically in organizations of higher education. This approach represents a new stream of thinking, one that complements the conceptual models already described. Our objective in this section is to outline some of the educational, political, and organizational changes that must occur in order to implement even a modestly innovative program. OBSTACLES TO IMPLEMENTING INTEGRATIVE IDEAS

In much of the literature on psychotherapy integration, nonintegrative programs are portrayed as showing rigidity in the curriculum, in those who administer it (faculty), and in those who consume it (students). Schools that teach either one method exclusively or a multiplicity of competing methods are criticized as forcing students into premature closure at the risk of otherwise seeming to be a "wishy-washy" eclectic. It is argued that there is too much indoctrination in such approaches, and it often breaks down into a confusing situation as the trainees are confronted with the diversity of the current therapeutic scene. Also, schools that use one method for all purposes will not effectively teach optimal client-therapy matching. One difficulty with this account of obstacles is that it has a judgmental flavor, as evidenced by the use of words like rigid to characterize the opponents of integration. If translated into messages to colleagues, such characterizations are likely to produce an antagonistic, win-lose struggle, in which the integrative "good guys" try to take over from the separatistic "bad guys." This is hardly likely to promote a welcoming attitude toward integration on the part of the "opposition"! Moreover, one of the first principles of organizational change is to listen to one's opponents respectfully and seriously; they probably have some

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truth on their side, and important considerations may emerge from a dialogue among those with contrasting views. Even if the obstacles to integration consist largely of rigidity on the part of current faculty and students, we must work with them; we are not likely, except in very unusual circumstances, to be able to select a body of faculty de novo. It is, of course, possible to select students or interns according to explicitly integrative criteria (see Lane, Andrews, Gabriel, Holt, & Schick, 1989, for an example), but this is only likely to happen once the faculty themselves adopt integrative principles. Those who study social change in higher education emphasize the difficulties in this process due to the decentralization of power in a variety of overlapping sites. Rather than there being a simple "line" authority structure, power and decision making are localized in many settings: the formal administrative structures involving deans and presidents; the faculty senate and its curriculum approval committees; the department head; and the individual faculty members who, within certain limits, decide on what is to be taught in the courses they teach. These factors make it even more imperative that we draw on a variety of change strategies in promulgating integrative training approaches. PRINCIPLES OF CHANGE IN INSTITUTIONS OF HIGHER EDUCATION

In his thoughtful monograph entitled Strategies for Change, Lindquist (1978) reports the results of case studies involving curricular and institutional change on various college and university campuses. He distills four models of influence processes that, he concludes, help to delineate the channels through which an innovation becomes accepted and stabilized. We believe that awareness and utilization of these channels can help the integration-minded instructor or supervisor to become more conscious of the change process, and hence be more effective in promoting acceptance of integrative ideas. Rational Model The first change approach relies on what Lindquist (1978) calls the rational model. The rational planning approach uses theory and research to develop a logically plausible change program. The initiator relies on sound evidence and the reasonableness of the innovation to produce acceptance among members of the institution. This model is probably the most compatible with the intellectual style and self-image of the typical academician, but it seems to be no more complete an account of actual change in universities than it is in more "irrational" institutions. In sum, the rational approach concentrates on developing the most effective and persuasive message

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possible. In the case of encouraging psychotherapy integration, this might involve sharing reprints with a colleague, invoking the treasured academic principle of pluralism, holding a departmental colloquium on integration, or distributing a book such as this one. This is not by any means the only channel through which change can be introduced in an institutional setting. Lindquist discusses three other models of change processes; we describe these models here in the hope that they will help others interested in psychotherapy integration to understand better the nature of the situations they face and the opportunities they present. Social Interaction Model This second approach stresses social networks and influence processes. The change agent works through opinion leaders and reference groups, the informal influence patterns through which new ideas are communicated and spread. It links innovative practices to potential adopters, whose credibility will persuade others to make similar changes. Proponents of psychotherapy integration would do well to examine their own social networks—including their own place in that network—and to "map" areas of support and resistance in order to develop a networking change strategy. In short, the social interaction model focuses on how the persuasive message forged through the rational model can best be communicated within the organization. Problem-Solving Model Third, the human problem-solving model is focused on how individuals come to feel the need, and then the willingness, to change. The innovator tries to help link a problem recognized within the organization with one or more potential solutions. Lindquist (1978) notes that there are affective, often hidden, motives to adopt or resist change, such as anxiety or frustration, or the needs for dependence, autonomy, and power. This strategy focuses on "diagnosing" the felt problems within an organization, and then devising solutions that reduce frustration. It often involves human relations consultation to help deal with psychological barriers to change. For example, the faculty retreat—encompassing a day or two at an offsite location accompanied by an outside facilitator—is often used (Golombiewski & Blumberg, 1970; Messer, Fishman, & McCrady, 1991) to enable faculty as a group to consider the implications of a new educational direction. The problem-solving model suspends efforts to communicate a solution—in this case, the concept of psychotherapy integration—in favor of exploring various problem definitions and the corre-

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spending solutions in an open-ended manner. To pursue this approach, the integratively oriented person must temporarily set aside a focus on the integrative "answer" in favor of working with colleagues on identified problems. Some such problems might include the confusion felt by graduate students as they face contrasting models of therapeutic change, or the incompleteness of training reported by program graduates. Thus, the problem-solving approach focuses on the fit between the innovative idea and the problem experienced by the members of the organization.

Political Model Fourth, the political model is based on the view that vested interests and power bases are primary motivators. To accomplish change, we need to build powerful coalitions among interest groups and obtain authoritative decisions that will be enforced by requiring people to change their attitudes and behavior. This approach, though overlapping with the social interaction and problem-solving models, relies on a conflict strategy and formal institutional authority to achieve its ends. One would not expect to influence the "opposition" so much as to amass superior power—through committees, administrators, and formal decision channels—to accomplish one's ends. Thus, a departmental curriculum committee might be the setting of a debate and vote concerning integrative elements in training.

Combination of Models Lindquist (1978) states that innovation is best introduced through a combination of the four change processes, echoing a cardinal principle of psychotherapy integration itself. The effectively stated ("rational") idea is spread by means of informal social networks, linked to solutions by means of the problem-solving model, and finally ratified by the political process. Lindquist (1978, p. 12) adds that "all these assumptions (of the four models) hold, probably in varying degrees depending on the issue, the situation and the people involved." Therefore an effective change agent will orchestrate all four of the change processes in a flexible way if he or she is to be fully effective. Often at conferences dealing with psychotherapy integration (e.g., SEPI), complaints are voiced of resistance at one's home institution to the introduction of integrative ideas; indeed, in some settings the SEPI member may be the only proponent of such ideas. One reason for the frustration involved may be that we tend to take the rational model or one of the three other models as our sole view of change processes, thereby missing the opportunity to exert influence within a combination of models.

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Fourteen Change Strategies Within the above framework, one can develop a variety of organizational change strategies. Lindquist cites Watson (1972) regarding 14 factors that are important in inducing change. The integrationist wanting to introduce such change would do well to match his or her proposed innovation against these criteria, asking at each step how the endeavor to introduce integrative ideas could be modified to maximize its likelihood of becoming implemented. Watson offers the following list of strategies: 1. Ownership. The more an innovation is "owned" by those affected by it, the greater will be full acceptance. It is important, therefore, to be sure that a proposed innovation is (a) responsive to members' needs, (b) diagnosed and designed with their involvement, and (c) implemented with their participation. 2. Reduction of burdens. Participants in an innovation should see it as reducing their burdens, lightening their load. Adding responsibilities to already beleaguered faculty, administration, and students is no way to gain acceptance. 3. Support at the top. Although pushing an innovation from the administration without a sense of ownership at other levels is unwise, few innovations can succeed without firm commitment to them at the highest administrative level. 4. Compatibility with organizational structure. The innovation whose implementing structure fits into the existing college or university organization has the best chance of success. 5. Desire for new experience. Routine can grow tedious. The opportunity to do something new and exciting can go far toward gaining acceptance of a new idea. Unfortunately, it can also cause anxiety. 6. Respect for the opposition. Those opposed to an innovation usually have sound reasons and legitimate concerns. Innovators need to sit down with the opposition and listen. 7. Clear goals. Foggy goals among innovators often lead to failure in implementation. Clear goals are prerequisite to innovation. 8. Open, two-way communication. Full and open two-way communication before and during the innovation is vital, not only to increase participant ownership but also to enhance accuracy of interpretation. Full feedback from participants and other affected parties should be carefully maintained. 9. Bugs inevitable. No innovation works right the first time. Bugs and disappointments should be expected. 10. Training for new roles. Undertaking new roles is difficult. New skills must be learned, and a training program may need to be developed.

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11. Suitable materials. New approaches to curriculum, teaching, and evaluation usually require appropriate materials and facilities. Success is contingent upon adequate resources of all kinds. 12. Unexpected effects. Change in one part of an organization may have unexpected consequences—some desirable, others not—for other parts. These need to be taken into account in planning and implementation. 13. Rewards. Faculty, trainees, and supervisors cannot be expected to participate in a new program without attractive compensation. A rule of thumb is that participants should be rewarded at least as fully as are those in traditional learning, teaching, and research pursuits. 14. Climate of readiness. Institutional members who have an open approach to change, who are well-informed about innovations, and who have participated previously in successful innovation are more accepting of new ideas. APPLICATION OF LINDQUIST S MODEL TO SUPERVISION

The supervision process offers a setting for applying the four-facet model to educational change. To begin with, the emphasis on integration should not really be an option for students. If we genuinely believe that integrative models will predominate 10 or 20 years from now, it is a lapse in responsibility to leave the choice of integration up to the student, who is in the least favorable position to judge its value. Here, then, we must assert our authority in accord with the political model, and state quite straightforwardly that we expect our students to entertain seriously the notion of psychotherapy integration. Within this context, the other models can come into play. A good supervisor will explore the human problem-solving aspects of resistance to change. The student may evidence a number of concerns toward psychotherapy integration, and these deserve to be treated with respect. For example, anxiety over abandoning one model in favor of integration is an experience that deserves to be taken seriously. It is only by working with such anxieties that the trainee's developmental struggles can be identified and treated sensitively. The networking model provides an excellent format for collaborative supervisor-supervisee interaction. Applied to the dyadic relationship, it provides a paradigm for collegial communication that not only offers a model for professional collaboration, but also supports bidirectional sharing that moves the trainee toward an experience of mutuality with the supervisor. One of the best vehicles for accomplishing this climate is to co-lead a group or conduct a therapy session together. There is no substi-

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tute for collaboration as a means of cross-fertilizing techniques and of appreciating the nitty-gritty of clinical work. Although introduced first above, the rational model is in many ways the last change model to be incorporated into the supervision process. Trainees are least likely to learn new therapeutic techniques through the formalities of literature and lecture. Rather, rational influence will be most effective when it is introduced within the context of the political, networking, and problem-solving models. Rational messages are, despite our indoctrination as intellectual beings, dependent for their impact on the social environments in which they exist. What we recommend, then, is that the supervisor make full use of the three social models as a way of building rapport with the supervisee; it is then that the rational message of the value of psychotherapy integration will find its place as a contribution to the growth of the student's professional development.

Conclusions It is important to develop training methods and models that are consistent with the openness of psychotherapy integration itself. The intention of integrative training is not necessarily to produce card-carrying, flag-waving "eclectic" or "integrative" psychotherapists. This scenario would simply replace enforced conversion to a single system with enforced conversion to an integrative system, a change that may be more pluralistic and liberating in content but certainly not in process. Instead, our goal is to educate therapists to think and, perhaps, to behave integratively—openly and synthetically, but critically—in their clinical pursuits. Our aim is to prepare students to develop, i/they possess the motivation and ability, into knowledgeable prescriptive therapists (Norcross et al., 1990). Psychotherapy integration, then, will consist of creatively synthetic perceiving, thinking, and acting. While always involving the application of research knowledge, psychotherapy will remain what Schact (1991) calls "disciplined innovation." Teaching integration is analogous in this view to teaching jazz piano. The student must acquire factual knowledge, master technical skills, and appreciate musical principles. Then—and only then— the disciplined improviser must learn to combine these elements in unique, improvisational, and yet coherently integrated performances. We firmly believe it is inappropriate to demand that students adopt any single metatheoretical perspective, integrative or otherwise. We are equally convinced that each practitioner should develop an individual clinical style within his or her chosen perspective. The goal of every training program should be graduates who are knowledgeable, broad as

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well as deep in their interests, and sufficiently curious to keep learning and growing professionally (Frances et al., 1984). The hope is that, in Halleck's (1978, p. 50) words, our students will "approach our patients with open minds and a relentless commitment to study and confront the complexities of human behavior."

References ALBERTS, G., & EDELSTEIN, B. (1990). Therapist training: A critical review of skill training studies. Clinical Psychology Review, 10, 497-511. ALLEN, G. }., SZOLLOS, S. I., & WILLIAMS, B. E. (1986). Doctoral students' comparative evaluations of best and worst psychotherapy supervision. Professional Psychology: Research and Practice. 17, 91-99, ANDREWS, J. D. W. (1989). Integrative languages in therapeutic practice and training: Promises and pitfalls, journal of IntcgrnHve and Eclectic Psychotherapy, 8, 291-301. BEUTLER, L. E. (1986). Systematic eclectic psychotherapy. In J. C. Norcross (Ed.), Handbook of eclectic psychotherapy (pp. 94-131). New York: Brunner/ Mazel. BEUTLER, L. E., & CLARKIN, J. (1990). Systematic treatment selection: Toward targeted therapeutic interventions. New York: Brunner/Mazel. BEUTLER, L. E., CLARKIN, J. F., & NORCROSS, J. C. (1990). Training in differential treatment selection. In L. E. Beutler & J. F. Clarkin (Eds.), Systematic treatment selection: 'Toward targeted therapeutic interventions. New York: Brunner/Mazel. BEUTLER, L. E., & CONSOLI, A. J. (1992). Systematic eclectic psychotherapy. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. BEUTLER, L. E., MAHONEY, M. J., NORCROSS, j. C., PROCHASKA, J. O., SOLLOD, R. M., & ROBERTSON, M. (1987). Training integrative/eclectic psychotherapists II. Journal of Integrative and Eclectic Psychotherapy, 6, 296-332. BRAMMER, L. M. (1969). Eclecticism revisited. Personnel and Guidance Journal 48, 192-197. CARIFIO, M. S., & HESS, A. K. (1987). Who is the ideal supervisor? Professional Psychology: Research and Practice, 18, 244-250. DIENST, E. R., & ARMSTRONG, P. M. (1988). Evaluation of students' clinical competence. Professional Psychology: Research and Practice, 19, 339—341. DOBSON, K. S., & SHAW, B. F. (1988). The use of treatment manuals in cognitive therapy: Experience and issues. Journal of Consulting and Clinical Psychology, 56, 673-680. FORD, J. D. (1979). Research on training counselors and clinicians. Review of Educational Research, 69, 87-130. FRANCES, A., CLARKIN, J.. & PERRY, S. (1984). Differential therapeutics in psychiatry. New York: Brunner/Mazel.

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CILLER, E., & STRAUSS, ]. (1984). Clinical research: A key to clinical training. American Journal of Psychiatry, 141, 1075-1077. GOLDSTEIN, A. P. (1973). Structured learning therapy: Toward a psychotherapy for the poor. New York: Academic Press. GOLOMBIEWSKI, R., & BujMBERG, A. (1970). Sensitivity training and the laboratory approach. Itasca, IL: Peacock. GREENBERG, L. S., & GOLDMAN, R. L. (1988). Training in experiential therapy. Journal of Consulting and Clinical Psychology, 56, 696—702. GRINKER, R. R. (1976). Discussion of Strupp's "Some critical comments on the future of psychoanalytic therapy." Bulletin of the Menninger Clinic, 40, 247-254. GUEST, P. D., & BEUTLER, L. E. (1988). The impact of psychotherapy supervision on therapist orientation and values. Journal of Consulting and Clinical Psychology, 56, 653-658. HALGIN, R. P. (1985a). Pragmatic blending of clinical models in the supervisory relationship. The Clinical Supervisor, 3(4), 23-46. HALGIN, R. P. (1985b). Teaching integration of psychotherapy models to beginning therapists. Psychotherapy, 22, 555—563. HALGIN, R. P. (Eo.). (1988). Issues in the supervision of integrative psychotherapy [Special section]. Journal of Integrative and Eclectic Psychotherapy, 7, 152-180. HALLECK, S. L. (1978). The treatment of emotional disorders. New York: Jason Aronson. HARDY, G. E., & SHAPIRO, D. A. (1985). Therapist response modes in prescriptive vs. exploratory psychotherapy. British Journal of Clinical Psychology, 24, 235-245. HENRY, W. P., & STRUPP, H. H. (1991). Vanderbilt University: The Vanderbilt Center for Psychotherapy Research. In L. E. Beutler & M. Crago (Eds.), Psychotherapy research: An international review of programmatic studies. Washington, DC: American Psychological Association. HEPPNER, P. P., & ROEHLKE, J. J. (1984). Differences among supervisees at different levels of training: Implications for a developmental model of supervision. Journal of Counseling Psychology, 31, 76—90. HIRSCHENBERGER, R. H., McGuiRE, P. S., & THOMAS, D. R. (1987). Criterionreferenced, competency-based training in behavior modification. In B. A. Edelstein & E. S. Berler (Eds.), Evaluation and accountability in clinical training. New York: Plenum. HOGAN, R. A. (1964). Issues and approaches in supervision. Psychotherapy: Theory, Research and Practice, 1, 139—141. HOWARD, G. S., NANCE, D. W., & MYERS, P. (1987). Adaptive counseling and therapy. San Francisco: Jossey-Bass. IVEY, A. E., & AUTHIER, J. (1978). Microcounseling (2nd ed.). Springfield, IL: Charles C. Thomas. JARMON, H., & HALGIN, R. P. (1987). The role of the psychology department

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clinic in training scientist-practitioners. Professional Psychology: Research and Practice, 18, 509-514. LAMBERT, M. J. (1992). Psychotherapy outcome research: Implications for integrative and eclectic therapists. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. LAMBERT, M. ]., & ARNOLD, R. C. (1987). Research and the supervisory process. Professional Psychology: Research and Practice, 18, 217-224. LANE, R., ANDREWS, J., GABRIEL, T., HOLT, P., & SCHICK, M. (1989, May). Integrative internship training from the perspectives of supervisors and supervisees. Symposium presented at the annual conference of the Society for the Exploration of Psychotherapy Integration, Berkeley, CA. LAZARUS, A. A. (1986). Multimodal therapy. In J. C. Norcross (Ed.), Handbook of eclectic psychotherapy (pp. 65—93). New York: Brunner/Mazel. LAZARUS, A. A. (1992). Multimodal therapy: Technical eclecticism with minimal integration. In ]. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. LINDQUIST, J. (1978). Strategies for change. Carlsbalds, CA: Pacific Soundings. LOGANBILL, C., HARDY, E., & DELWORTH, U. (1982). Supervision: A conceptual model. The Counseling Psychologist, 10, 3-42. LUBORSKY, L., CRITS-CRISTOPH, P., ALEXANDER, L., MARGOLIS, M., & COHEN, M. (1983). Two helping alliance methods for predicting outcomes of psychotherapy: A counting signs vs. a global rating method. Journal of Nervous and Mental Disease, 171, 480-491. MALOUF, ]. L., HAAS, L. ]., & FORAH, ]. (1983). Issues in the preparation of interns: Views of trainers and trainees. Professional Psychology: Research and Practice, 14, 624-631. MATARAZZO, R. G., & GARNER, A. M. (1992). Research on training for psychotherapy. In D. K. Freedheim (Ed.), History of psychotherapy: A century of change. Washington DC: American Psychological Association. MATARAZZO, R. G., & PATTERSON, D. (1986). Research on the teaching and learning of therapeutic skills. In S. L. Garfield & A. E. Bergin (Eds.), Handbook of psychotherapy and behavior change (2nd ed., pp. 821-843). New York: Wiley. MELTZOFF, J. (1984). Research training for clinical psychologists: Point-counterpoint. Professional Psychology: Research and Practice, 15, 203—209. MESSER, S. B. (1992). A critical examination of belief structures in integrative and eclectic psychotherapy. In ]. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. MESSER, S. B., FISHMAN, D. B., & MC.CRADY, B. S. (1991). Conducting a selfstudy in a professional psychology program. Professional Psychology: Research and Practice, 22, 405-406. NELSON, G. (1978). Psychotherapy supervision from the trainee's point of view: A survey of preferences. Professional Psychology, 9, 539—550.

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NORCROSS, J. C. (1988). Supervision of integrative psychotherapy, journal of Integrative and Eclectic Psychotherapy, 7, 157—166. NORCROSS, ]. C. (1990). Personal therapy for psychotherapists: One solution. Psychotherapy in Private Practice, 8, 45—59. NORCROSS, J. C., BEUTLER, L. E., & CLARKIN, J. F. (1990). Training in differential treatment selection. In Systematic treatment selection: Toward targeted therapeutic intervention (pp. 289—307). New York: Brunner/Mazel. NORCROSS, J. C., BEUTLER, L. E., CLARKIN, J. F., DICLEMENTE, C. C., HALGIN, R. P., FRANCES, A., PROCHASKA, J. O., ROBERTSON, M., & SUEDFELD, P. (1986). Training integrative/eclectic psychotherapists. International Journal of Eclectic Psychotherapy, 5, 71—94. NORCROSS, J. C, DRYDEN, W., & DEMICHELE, J. T. (1992). British clinical psychologists and personal therapy: What's good for the goose? Clinical Psychology Forum, 44, 29—33. NORCROSS, ]. C., & PROCHASKA, J. O. (1983). Clinicians' theoretical orientations: Selection, utilization, and efficacy. Professional Psychology, 14, 197—208. NORCROSS, J. C., & PROCHASKA, J. O. (1984). Where do behavior (and other) therapists take their troubles? II. The Behavior Therapist, 7, 26—27. NORCROSS, J. C, STRAUSSER, D. ]., & MISSAR, C. D. (1988). The processes and outcomes of psychotherapists' personal treatment experiences. Psychotherapy, 25, 36-43. NORCROSS, ]. C., & THOMAS, B. L. (1988). What's stopping us now? Obstacles to psychotherapy integration. Journal of Integrative and Eclectic Psychotherapy, 7, 74-80. PERRY, S., FRANCES, A., & CLARKIN, J. (1990). A DSM-III-R casebook of treatment selection. New York: Brunner/Mazel. PROCHASKA, J. O., & DICLEMENTE, C. C. (1992). The transtheoretical approach. In ]. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books. REISMAN, ]. M. (1975). Trends for training in treatment. Professional Psychology, 6, 187-192. ROBERTSON, M. (1986). Training eclectic psychotherapists. In J. C. Norcross (Ed.), Handbook of eclectic psychotherapy (pp. 416—435). New York: Brunner/ Mazel. ROSENBLATT, A., & MAYER, J. E. (1975). Objectionable supervisory styles: Students' views. Social Work, 20, 184-189. ROUNSAVILLE, B. J., CHEVRON, E. S., PRUSOFF, B. A., ElKIN, I., IMBER, S., SOTSKY,

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Collaborative study. Paper presented at the meeting of the Society for Psychotherapy Research, Sheffield, England. SHAW, B. E., & DOBSON, K. S. (1988). Competency judgments in the training and evaluation of psychotherapists, journal of Consulting and Clinical Psychology, 56, 666-672. STEIN, S. P., KARASU, T. B., CHARLES, E. S., & BUCKLEY, P. J. (1975). Supervision of the initial interview. Archives of General Psychiatry, 32, 265—268. STEINER, G. L. (1978). A survey to identify factors in therapists' selection of theoretical orientation. Psychotherapy: Theory, Research and Practice, 15, 371— 374. STEVENSON, J. F., & NORCROSS, J. C. (1987). Current status of training evaluation in clinical psychology. In B. Edelstein & E. Berler (Eds.), Evaluation and accountability in clinical training. New York: Plenum. STOLTENBERG, C. (1981). Approaching supervision from a developmental perspective: The counselor complexity model. Journal of Counseling Psychology, 28, 59-65. STRICKER, G. (1988). Supervision of integrative psychotherapy: Discussion. Journal of Integrative and Eclectic Psychotherapy, 7, 176-180. STRUPP, H. H., BUTLER, S. F., & ROSSER, C. L. (1988). Training in psychodynamic therapy. Journal of Consulting and Clinical Psychology, 56, 689—695. TORI, C. D. (1989). Quality assurance standards in the education of psychologists. Professional Psychology: Research and Practice, 20, 203—208. TRACEY, T. J., HAYS, K. A., MALONE, ]., & HERMAN, B. (1988). Changes in counselor response as a function of experience. Journal of Counseling Psychology, 35, 119-126. TRUAX, C. B., & CARKHUFF, R. R. (1967). Toward effective counseling and psychotherapy: Training and practice. Chicago: Aldine. WACHTEL, P. L. (1991). From eclecticism to synthesis: Toward a more seamless psychotherapeutic integration. Journal of Psychotherapy Integration, 1, 43—54. WATSON, G. (1972). Overcoming resistance to change. Journal of Applied Behavioral Science, 7, 72—89. WORTHINGTON, E. L. (1987). Changes in supervision as counselors and supervisors gain experience: A review. Professional Psychology, 18, 189—208.

CHAPTER 18

Core Issues and Future Directions in Psychotherapy Integration MARVIN R. GOLDFRIED, LOUIS G. CASTONGUAY, AND JEREMY D. SAFRAN

T

iHE FIELD OF PSYCHOTHERAPY APPEARS to be at a crossroads. Until recently, it has been alternately described as being "in a mess" (Rogers, 1963), a "bewildering world" (Frank, 1972), a "therapeutic jungleplace" (Parloff, 1976), and a field best characterized by "sibling rivalry" (Beitman, Goldfried, & Norcross, 1989). Not only has there been growing proliferation and confusion among different schools of thought, but even within a given paradigm, clinicians have begun to acknowledge that their theoretical constructs and methods fall short of dealing with what they are likely to see clinically (Norcross & Newman, 1992). This has led an increasing number of therapists to become more willing to entertain the possibility that contributions from other orientations might serve to enhance their clinical effectiveness. With this ever-growing interest in psychotherapy integration, an important point has been reached. What for over half a decade has been a latent theme in the literature has now emerged into a very definite movement (see Goldfried & Newman, 1992). An exciting but difficult issue now becomes the direction in which this movement should head. In considering the question of future directions in psychotherapy integration, it is essential that we specify what we believe to be the ultimate goal. When Alice came across the Cheshire cat sitting in a tree and asked it which path she might take, the cat wisely replied: "That depends Partial support for writing this chapter was provided by NIMH grant number 40196 to Marvin R. Goldfried, and by the Social Sciences and Humanities Research Council of Canada in the form of a fellowship to Louis G. Castonguay.

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a good deal on where you want to get to." The ultimate objective of the psychotherapy integration movement is to improve our clinical effectiveness, and any potential future directions or needs must be evaluated with this goal in mind. Before outlining some of these future directions, it would be helpful to evaluate the major themes that have emerged, to date, from those involved in psychotherapy integration. A review of these themes and core issues will provide us with a clearer picture of the current state of the field. Following this, we discuss some of the barriers to rapprochement and integration, and then move on to the question of where we are likely to head in the future.

Major Themes and Core Issues In considering the work done on psychotherapy integration to date, a number of issues have emerged. Included among these is the distinction between integration and eclecticism, the converging trends that seem to have grown from within given orientations, the potential complementarity among different orientations, the common factors that appear to cut across different schools of thought, and the accumulation of research findings regarding the effectiveness of given schools of thought. INTEGRATION AND/OR ECLECTICISM

As noted by Wolfe (1989), there is a "tactical debate" that prevails among those involved in the integration movement concerning the best way to improve our understanding of change processes and our methods of intervention. Several authors, sometimes referred to as "integrationists" (e.g., Beitman, 1992; Wachtel & McKinney, 1992), maintain that the field should work primarily toward the theoretical integration of divergent approaches. Such efforts, it is believed, may lead to new conceptual models from which can be generated a coherent synthesis of different methods (see Wachtel, 1991). Others, who prefer to be identified as "eclectics" (e.g., Beutler & Consoli, 1992; Lazarus, 1992), have stressed a more pragmatic blending of techniques. Without being committed to an integrative theory, these therapists are interested in the empirical delineation of the most effective procedures, or combination of procedures, for specific types of disorders. Integrationists have argued that the absence of integrative conceptual models explains why eclectic therapists are still accused of practicing a "wishy-washy" kind of therapy. They also claim that a coherent and well-articulated integrative theory represents the best strategy to generate hypotheses about how different therapies work, and which combination of

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methods could be most beneficial (Arkowitz, 1989). Systematic or technical eclectics, on the other hand, assert that because they have been primarily interested in building theories of personality and psychopathology, the efforts of integrationists have failed to address the practical concerns of the eclectic clinician. For Beutler (1989), while it may lead to better understanding of etiology, this type of integrative theory will not guide therapists in their moment-to-moment decisions, specify the decisive factors in the development of a good therapeutic alliance, or urtcover patient characteristics that are most predictive of therapeutic response. Recent contributions in both sides of this dialogue, however, seem to point to growing consensus concerning the role of theory in the advancement of psychotherapy integration. Leading proponents of systematic eclecticism have already recognized the influence of several conceptual models on their approaches, and have rejected the contention that technical eclecticism is totally atheoretical (e.g., Beutler & Consoli, 1992; Lazarus, 1992). Beutler and Consoli, for example, have affirmed that although technical eclecticism has not been favorable to the development of yet another theory of personality, one of its major goals is to provide the field with a cohesive model that would predict change under specific patient, therapist, environment, and treatment conditions. Arkowitz (1989) has similarly suggested that rather than searching for a "grand" theory of psychotherapy that addresses all dimensions of the therapeutic process, integrative theorists should restrict their models to specific elements of different approaches. As we will describe in a later section, we propose that integrative efforts should not attempt to account for all aspects of human functioning and every type of clinical problems at once. More useful would be the development of several integrative approaches that focus on the mechanisms of change and treatment of choice for different clinical problems. A major source of agreement that seems to be emerging from these different perspectives is the need for specific models of the therapeutic process. Ideally, such clinical models would delineate therapeutic processes operating in both eclectic and "pure form" therapies, and shed light on the factors associated with improvement under specific circumstances. Considering such consensus, Wachtel (1991) might be right when he affirmed that "eclecticism in practice and integration in aspiration is an accurate description of what most of us in the integrative movement do much of the time" (p. 44). CONVERGING TRENDS WITHIN ORIENTATIONS

In their pure form, the three major approaches to therapeutic intervention—psychodynamic, behavioral, and experiential—originally reflected

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the assumption that focusing on a given aspect of patients' functioning, be it their misperceptions resulting from events in the past, their behavioral deficiencies or inadequacies, or their emotional experiencing, would be the key to therapeutic change. Although the theoretical premises associated with each of the three orientations may have emphasized a given component of a patient's functioning—thinking, behavior, or affect—the clinical application of these models soon led practicing therapists to recognize that more was needed in order to effect change. It is particularly noteworthy that all three orientations have come to recognize the central role of cognitive processes in human functioning and therapeutic change process, and each has independently looked toward cognitive science as a way of better understanding how this might come into play (e.g., Goldfried & Robins, 1983; Horowitz, 1988; Wexler & Rice, 1974). Another important point of convergence among disparate therapeutic orientations in recent years has been a shift toward a constructivist epistemology. In the psychoanalytic tradition, this trend is exemplified by the work of theorists such as Spence (1982) and Schafer (1976), who argue that the analyst does not necessarily uncover truths that are historically accurate, but rather works with his or her client to construct truths that have a narrative coherence or plausibility. This type of hcrmeneutic perspective has sparked vigorous debates between its proponents and critics (see Messer, 1992), and many theorists still disagree with aspects of the hermeneutic position. Nonetheless, it is clear that this constructivist perspective is having a growing influence on psychoanalytic theory. In fact, Hoffman (1991) maintains that it is part of a paradigm shift in psychoanalytic theory that he designates as social-constructivist in nature. In the cognitive therapy tradition, theorists such as Mahoney (1991) and Guidano (1987), who designate themselves as constructivists, are having a growing influence on cognitive theory. Drawing upon a wide range of different theorists such as Maturana and Varella (1987), Weimer (1979), and Hayeck (1967), they argue that therapy does not involve helping clients to construe some objective reality more or less accurately. Instead, it aids them in constructing an amorphous reality more or less adaptively. In the experiential tradition, Gendlin (1981), who has been strongly influenced by the phenomenological tradition, has done much to amplify a central trend that has been constructivist from its inception. The seeds of this perspective can be found in Rogers's early work (Kirschenbaum, 1979), which emphasized the importance of articulating the idiosyncratic nuances of the client's construal, rather than discovering or adapting to any kind of objective reality. Still another important point of convergence has been a shift toward

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an interpersonal perspective. In psychoanalytic theory, this trend has been well documented by theorists such as Eagle (1984) and Greenberg and Mitchell (1983), who argue that the growing shift away from an intrapsychic and drive model toward an interpersonal or relational perspective has been the major trend in psychoanalytic theory (see also Wachtel & McKinney, 1992). Among cognitive theorists, there has been a growing openness to drawing on developments in attachment theory and developmental psychology, which view the need for interpersonal relatedness as a fundamental motivational principle (e.g., Guidano & Liotti, 1983; Mahoney, 1991; Safran & Segal, 1990). This trend is consistent with the growing interest within cognitive-behavioral circles in using the therapeutic relationship as a vehicle for exploring and modifying dysfunctional schemas (e.g., Arnkoff, 1983; Goldfried & Davison, 1976). In the experiential tradition, Wheeler (1991) has recently documented the way in which Gestalt therapy has shifted over time, away from a philosophical stance in which an excessive emphasis was placed upon the importance of autonomy, toward one that recognizes the interdependent nature of human existence. Thus, this new emphasis places a greater focus on the contact boundary between self and other. A final point of convergence is that toward flexibility in technique. In psychoanalytic theory, this can be seen most clearly in the movement away from a classical psychoanalytic stance that viewed departures from therapeutic neutrality as a nontherapeutic "violation of the frame" (Langs, 1974). Instead, there is a growing recognition of the importance of being appropriately supportive in the right context (Gill, 1982; Kohut, 1984; Wallerstein, 1989; Winnicott, 1965). An interesting historical illustration of this kind of shift can be seen in client-centered therapy. Client-centered practice has gradually evolved away from its more traditional stance, in which therapists limited themselves to being accurately empathic, to one that has emphasized therapist genuineness (Kirschenbaum, 1979). As Rogers (1963) points out, this change was strongly influenced by their work with schizophrenics in the Wisconsin project, where being "real" seemed to be what was most important for making contact with this population. In the cognitive-behavioral tradition, there has been a dramatic interest in borrowing both theory and techniques from other traditions. This openness has ranged from the empty-chair exercise in Gestalt therapy to the developmental reconstruction of psychoanalysis (e.g., Arnkoff, 1983; Fodor, 1987; Goldfried & Hayes, 1989). Thus, although theory has clearly been essential in directing us clinically, it is also quite apparent that many of our theoretical guidelines have become changed over the years in light of clinical reality.

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COMPLEMENTARITY AMONG ORIENTATIONS

Different therapy traditions have tended to focus on different phenomena and different aspects of human functioning. In this sense, the various orientations can be seen as having become specialists in different realms. For example, the psychoanalytic emphasis on the unconscious has led to the development of a highly specialized and differentiated understanding of phenomena outside of the patient's awareness, and a range of different interventions for working with this material (e.g., free association, dream analysis, analysis of resistance). In this regard, it has developed procedures to help patients increase their awareness about the ways they misperceive themselves and others, the historical roots of these misperceptions, and the ways they are played out in maladaptive interpersonal relations. The cognitive-behavioral tradition has specialized in the use of behavioral enactments and in the promotion of treatment generalization. Consequently, it has offered the field potential ways in which a patient's behavioral risk taking may be encouraged, including the modification of distorted cognitions. Once again, there is a vast knowledge base that has been developed here, which is less developed in other treatment modalities that emphasize other aspects of treatment. The client-centered emphasis on the importance of the therapeutic relationship and phenomenological investigation has led to a finely articulated understanding of the role that variables such as empathy and experiencing play in the change process (e.g., Gendlin, 1989; Rice & Saperia, 1984). In general, experiential therapists have devised finely tuned and clinically sensitive procedures to help clients become aware of their immediate emotional experience, and how this may be integrated into their lives. If one begins with the assumption that therapeutic change is brought about by dealing with only one aspect of a patient's functioning—be it lack of insight, problematic behaviors, or muted affect—then these different orientations are clearly irreconcilable. If, on the other hand, one assumes that there is a synergy among thoughts, actions, and emotions, then the strength of any given approach may be viewed as offering a complementary contribution to the other orientations. An openness to integration thus offers the opportunity to depart from the theoretical fragmentation that has characterized our field, but still benefit from its conceptual and technical specialization. Happily, attempts at such clinically sensitive integration of methods are beginning to emerge (Beitman; Beutler & Consoli; Koerner & Linehan; Lazarus; Prochaska & DiClemente; Wachtel & McKinney; and Wolfe, all 1992).

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COMMON FACTORS

In addition to the converging trends within orientations and the potential complementarity across orientations, the psychotherapy integration movement has also received impetus from the belief that there may be common principles of change that can be found in all approaches to treatment. We might note that therapists have been somewhat slow to acknowledge the existence of such common factors. As observed by Frank (1976), "little glory derives from showing that the particular method one has mastered with so much effort may be indistinguishable from other methods in its effects" (p. 74). Nevertheless, beginning with the idea that there are "nonspecific" factors within all forms of therapy that contribute to the change process (e.g., Frank, 1973), it is now being acknowledged that there exist variables associated with therapeutic change that can be specified and that are common to different forms of therapy (e.g., Beitman, 1987, 1992; Castonguay, 1987; Castonguay & Lecomte, 1989; Egan, 1986; Garfield, 1992; Goldfried & Padawer, 1982; Grencavage & Norcross, 1990; Prochaska & DiClemente, 1992). Common therapeutic factors have been identified on the basis of how therapists from differing orientations have described the change process. For the most part, these commonalities have more of a theoretical and clinical basis than a direct empirical derivation. To summarize the points of commonality, it may be said that most forms of therapy are similar in the following ways: • Basic structure of therapy. It occurs within a relatively delineated setting, with separate stages or phases. • Function of therapy. The overriding goal is to decrease demoralization and increase a sense of self-mastery, along with the acquisition of new ways of thinking, feeling, and acting. • Nature of therapeutic interaction. There is an interpersonal influence process characterized by the therapist's concern and involvement, as well as a working alliance based on open communication, shared goals, and agreed-upon methods. • Common clinical strategies. The therapist provides feedback to enhance patients' awareness, encourages risk taking, and facilitates ongoing reality testing. The presence of common factors within different dimensions of the therapeutic interaction does not negate the existence and the impact of variables unique to specific theoretical orientations. As shown by Lambert (1992), however, the therapeutic effect of these unique variables is not as

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powerful as the proponents of each school have traditionally proclaimed. Moreover, it is more than probable that the therapeutic value of most of these variables are mediated by factors that cut across all forms of interventions. For example, most behavior therapists practicing desensitization would agree that for the clients to attain a deep level of relaxation and courageously confront some of their worst fears, a minimal level of trust and working alliance must be established. Furthermore, it is conceivable that what first appears as a unique characteristic of a particular treatment represents a specific way of implementing a common element that underlies the practice of different therapies. The psychoanalytic interpretation, the challenge of clients' beliefs in cognitive-behavior therapy, and the reframing interventions performed by systemic therapists may well correspond to the same general therapeutic principle. Despite their technical differences, all these interventions provide clients with a new perspective and allow them to acquire a more realistic view of themselves and the world. Considering our stage of knowledge about the psychotherapy process, however, more empirical efforts are crucially needed to determine the respective impact of the common and unique variables, as well as to understand how these two sets of factors interact within particular approaches. As suggested elsewhere (Castonguay & Lecomte, 1989; Goldfried, 1991; Wolfe & Goldfried, 1988), research priority should be given to the investigation of strategies of intervention (e.g., therapist's feedback) and the basic processes of therapeutic interaction (e.g., working alliance, interpersonal influence). Put another way, we encourage the study of mechanisms of change that are both more robust and generic than the particular techniques defining the therapies, and at the same time are closer to the clinical observable than some of the inferential constructs that comprise the theoretical edifice of different systems (Goldfried & Padawer, 1982). EMPIRICAL SUPPORT FOR THE PSYCHOTHERAPIES

The failure of psychotherapy outcome studies to support the efficacy of one school of therapy over the others consistently has provided yet another important impetus for interest in psychotherapy integration. The dilemma that the field currently faces is that while there are many psychosocial treatments, their clinical effectiveness—with some exceptions—tend to be comparable (see Lambert, 1992). The failure to find uniform differences in the efficacy of various treatments has led a number of researchers to suggest that the focus of investigation should be on the process of change rather than therapeutic orientation (Elliott, 1983; Gendlin, 1989; Rice & Greenberg, 1984; Stiles, Shapiro, & Elliott, 1986).

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The thinking here is that the treatment orientation is too large a unit of analysis to help us refine our understanding of what works. Any treatment—for that matter, any therapy session—consists of a large number of treatment events in which a specific intervention is administered in the context of a specific client state. For example, the therapist analyzes the client's resistance and its defensive bases in a specific way when the client intellectualizes. The therapist challenges the client's automatic thoughts in a specific way when the client is self-critical. Psychoanalysis, however, consists of much more than the analysis of resistance, and cognitivebehavior therapy consists of much more than challenging automatic thoughts. By conducting our research using too large a unit of analysis, we may not be able to understand the variety of processes that lead to change within any given orientation, be they unique or common. By investigating what specific intervention works best at a particular moment in the process, we may be able to develop a body of contextsensitive information that can be of use to the practicing clinician. This type of research strategy is extremely compatible with the move toward integration, since it can potentially provide knowledge about what specific intervention to use in what specific context, regardless of the particular theoretical intervention (cf. Beutler & Consoli, 1992).

Three Barriers to Rapprochement and Integration A consideration of future directions for psychotherapy integration cannot be fully appreciated without some discussion of the barriers that have traditionally kept the field of psychotherapy fragmented. We hesitate to add that these have obstructed not only rapprochement, but also the ultimate goal of the integration movement: the enhancement of clinical effectiveness. Some of these obstacles to psychotherapy integration are addressed by Norcross and Newman (1992). We will deal with three barriers—social, linguistic, and epistemological—each of which is closely allied with one's theoretical constructions of the therapy process.

SOCIAL BARRIERS

The days have long since past when it was possible for a lone scientist to arrive at important discoveries in complete isolation from colleagues. Some would argue that this characterization of the scientific process has indeed never existed, and that discoveries always required some kind of interchange among like-minded scholars. Sociologists of science have re-

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ferred to the existence of the "invisible college," which involves a community of scholars that is not actually located in a given physical setting, but rather is a group of professionals who interact with each other by virtue of their common interests. We all have our reference groups, and it is hard to imagine how we could function professionally without them. There are a number of important purposes that are served by the social structure of science and other professions. To begin with, such networks provide an essential source of information exchange. We rely on colleagues within our reference group to share their theoretical discoveries, methodological advances, and new findings, and also to serve as an audience for our own contributions. Our professional groups go even beyond this. Just as our careers have served to provide us with a source of identity as we move from adolescence into adulthood (Erikson, 1950), so do our specific theoretical orientations serve to shape our conceptualization of ourselves professionally. After discovering what we do for a living, others often ask us about our theoretical orientation. Alluding to the important guidelines for professional functioning that we derive from our theoretical orientations, it has been suggested that "without a specific therapeutic orientation, how would we know what journals to subscribe to or which conventions to attend?" (Goldfried, 1980, p. 996). The theoretical allegiances that form the basis of our professional communities serve as double-edged swords. Some years ago, George Kelly (1955) suggested that patients' cognitive processes were similar to those of scientists. In order to understand the world around them, patients develop a set of theoretical constructs, some of which are outmoded or wrong and in general have failed to serve them well. We may profitably turn this observation around, and suggest that we as therapists are cut from the same cloth as our patients, in that cur theoretical constructions of the therapeutic process at times can bias us in ways that serve neither our patients nor ourselves as well as we would like. Our theories of therapy can be thought of as therapeutic schemas, in that they enable us to perceive relevant events selectively, to fill in the gaps when certain information is not immediately available, and to be able to recall the essential aspects of the given case at hand. Quite often, this schema functions in a most adaptive way, especially when we are able to go beyond what is provided by patients and make inquiries into areas of their lives that may not have been discussed. At other times—and we might add, therapists rarely become aware of this unless they talk with colleagues from other orientations—our therapeutic schemas serve as a hindrance to our effective functioning; it can lead us to distort information provided, to fill in the gaps inaccurately, or to recall selectively only that which fits with our theoretical construction. Henri Bergson (1935) once

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observed that whereas our faith can lead us to think we can move mountains, our beliefs are even more dramatically reflected in our inability to see the mountain that needs to be moved. LANGUAGE BARRIERS

A related obstacle to psychotherapy integration is the different vocabulary that has been used across orientations to describe human functioning and the therapeutic change processes. Although different approaches have placed their emphasis on different phenomena, there are times when they clearly deal with similar aspects of the clinical reality. The constructs used to make sense of this reality, however, have been so embedded within a given theoretical framework that basic agreement or potential complementary contributions have been obscured. Take, for example, the notions of "transference" and "schema-driven perceptions," both of which concern historically based views of others that more accurately describe past interactions than those in the patient's current life situation. One of the consequences of having idiosyncratic and competitive languages is that it has been difficult to identify and study what appears to be robust clinical phenomena, such as distorted perceptions that occur within the therapeutic relationship. Another consequence is that, for the most part, refinements in a particular theory have not been stimulated by advancements that may have been made with other orientations. As R. R. Grinker, Sr., has lamented, "It seems that we are writing for ourselves with little effect on others" (personal communication, February 1979). As if they were emerging from incommensurable paradigms, the discoveries or developments in each particular orientation have traditionally failed to contribute to the growth of other approaches. EPISTEMOLOGICAL BARRIERS

These differences in theory-driven language have deep roots in basic and often tacit philosophical assumptions. As accurately noted by Messer and associates (Messer, 1992; Messer & Winokur, 1980), different vocabularies represent divergent visions of reality and are dictated by different ways of reasoning. It is important to recognize that our effort toward integration has been limited by the fact that major orientations are based on different epistemologies (Bouchard & Guerette, 1991; Castonguay, 1989). Psychodynamic, experiential, and behavioral therapists differ in what they consider as valid forms of knowledge, such as inference, subjective meaning, and observation. They also differ in what they accept as reasonable methods for acquiring such knowledge, such as interpretation, phenomenological exploration, and experimental method.

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The Future of Psychotherapy Integration: Where Do We Go from Here? To advance the field of psychotherapy integration, so that we may have available more effective clinical guidelines as well as a better understanding of the change process, certain efforts need to be undertaken. We would suggest that these efforts include (1) consolidation and rapprochement of existing schools of thought, (2) integration within the context of specific clinical problems, (3) consideration of how contributions derived from basic research in psychology may shed light on therapeutic change, and (4) specification of therapeutic principles that are informed by both clinical theory and research.

CONSOLIDATION AND RAPPROCHEMENT ACROSS ORIENTATIONS

Within the foreseeable future, it is highly likely that psychodynamic, behavioral, and experiential orientations will continue to prevail. The survival and development of these three theoretical orientations will be guaranteed by their own social networks, their idiosyncratic languages, and more important, by their different epistemological assumptions. We have predicted elsewhere (Goldfried & Castonguay, 1992) that therapists will receive their training more from traditional orientations than by some of the approaches that emerged in the 1960s and 1970s. We have also suggested that the development of each orientation is likely to be more open to the contributions from other orientations Instead of expecting the discovery of one universally accepted model to explain change, it is our impression that the integration movement will facilitate the development of each orientation by stimulating the acceptance of contributions from other approaches at both theoretical and clinical levels. At the theoretical level, we anticipate that some approaches will improve the validity of their constructs by including conceptual perspectives developed by other orientations. An example is Safran and Segal's (1990) integration of interpersonal and developmental dimensions to concepts central to cognitive therapy. The notion of the "interpersonal schema," for example, can allow cognitive therapists to consider the historical roots of relationship patterns that are contributing to clients' current difficulties. At the clinical level, we think it highly unlikely that clinicians will reject methods they have learned within their professional training. We predict instead that they will add to their existing repertoires procedures derived from theoretical perspectives that have given more attention to certain phenomena. An example of one such clinical development is dialec-

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tical behavior therapy (see Koerner & Linehan, 1992). Working with a patient population to which behavior therapists have not traditionally addressed themselves—the borderline personality disorder—dialectical behavior therapy underscores the importance of communicating a therapeutic acceptance of the problems that borderline patients may be experiencing and, at the same time, provides them with the opportunity to develop skills for coping with such difficulties. FOCUS ON SPECIFIC CLINICAL PROBLEMS

Most of the history of psychotherapy integration has concerned psychotherapeutic change in general (Goldfried & Newman, 1992). It is clear, however, that the field of psychotherapy over the years has become more specialized, targeting specific clinical issues and developing procedures for dealing with them. Although it would serve the field well if we could arrive at general principles of change, perhaps a more appropriate goal would be to learn more about the change mechanisms associated with the treatment of specific clinical problems. It is more than likely that different processes of change are associated with particular problems (Arkowitz, 1992; Garfield, 1992; Murray, 1986; Prochaska & DiClemente, 1992). The field of integration will gain by continuing to be mindful of what Kiesler (1966) referred to as a "uniformity myth" in psychotherapy, and not be guided by the assumption that the same mechanisms of change are involved in the treatment of everything we are likely to encounter clinically. Clinical reality also reminds us that even the most straightforward of clinical problems requires attention to a variety of factors. Conjoint efforts by therapists of divergent persuasions may increase the likelihood of our addressing the multiple dimensions pertinent to the treatment of a particular psychological difficulty. Regardless of orientation, therapists who work with certain clinical problems are likely to share a common set of observations—filtered, of course, through their therapeutic schemas—and arrive at a similar appreciation of the trials and tribulations of the change process with a given patient population. Thus, dealing with specific clinical problems may lead to unforeseen consensus, both in terms of the conceptualization of the change processes and in the choice of therapeutic interventions. In fact, one may argue that the theoretical and clinical divergences among the major approaches are due in part to the different clinical population treated by the pioneers of these schools. Thus, Freud's work with sexually abused women may have dictated an emphasis on the exploration and reexperience of hidden and conflictual feelings. By contrast, Rogers's confidence in the therapeutic value of empathy and in the intrinsic capacity of self-directive-

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ness may have resulted from his early work with college students confronted with identity problems. A focus on specific problems is likely to increase our clinical effectiveness if it is paralleled by a search for precise determinants of these problems. Indeed, specific disorders may have varied etiologies (Goldfried, Greenberg, & Marmar, 1990). Depression, for instance, may be caused by unresolved grief, marital conflict, loss of self-esteem, or biochemical imbalance. The practicing clinician who deals with patients displaying depressive symptomatology more often than not would readily acknowledge that there are different pathways to depression. Research and conceptual progress in the etiology of the kinds of problems we are likely to encounter clinically may help the therapist to delineate the most appropriate focus of intervention and to design a comprehensive treatment. Ultimately, then, integrative approaches should provide an understanding of the mechanisms of change involved in the treatment of specific problems, as well as an explanation of the causes of such problems. As noted by Arkowitz (1989), our advancement in process research can shed light on how change occurs, while our increased knowledge of psychopathology can inform us about what needs to be changed. More precisely put, what we need is "an understanding both of the determinants of any client's disorder and the mechanisms of change, and of the interventions needed to produce change for these determinants. Research must aim to demonstrate that for this determinant, this intervention produces this type of change process, resulting in this type of outcome" (Goldfried et al., 1990, p. 669). The paradox for the integration movement is that we need to be very specific in order to be comprehensive. The more we know about a given clinical problem and the difficulties in producing change, the more we can appreciate the fact that numerous issues at times need to be addressed. Acknowledging that various orientations may have tended to specialize in some issues (e.g., distorted cognitions), but not others (e.g., self-defeating behaviors), it becomes apparent that an integrative approach can provide the clinician with a broader perspective on important determinants and a wider array of clinical procedures. CONTRIBUTIONS FROM BASIC RESEARCH

Another direction that can add to the progress of psychotherapy integration is drawing on knowledge from domains other than psychotherapy itself. In particular, we believe that basic research in cognitive science and social psychology can allow for a better understanding of the change processes in divergent therapeutic approaches. In this respect, these

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basic research disciplines can provide a partial solution to the problem of different therapeutic language systems (Wolfe & Goldfried, 1988). Experimental cognitive psychology can provide psychotherapy with a key to a body of research and theory relevant to the process of change. For example, it can help us to understand better the nature of self-schemas that may stem from patients' past experiences, and how these distortions may manifest themselves during the course of therapy, and the reasons they can be so resistant to change (Goldfried & Robins, 1983). Social psychology is another domain that can offer new and insightful perspectives to therapists interested in exploring psychotherapy integration. Several authors have already highlighted the contributions that basic research in social psychology can offer to psychotherapy in general (e.g., Frank, 1973; Strong, 1986). Others, such as Egan (1986) and Beutler (1983; Beutler & Consoli, 1992), have placed a major emphasis on such constructs as interpersonal influence, cognitive dissonance, and reactance within their own particular integrative approach. Wachtel and McKinney (1992) have reviewed how basic research in social psychology relates to the notion of "cyclical psychodynamics," whereby self-fulfilling prophesies cause individuals to behave in ways that perpetuate the very problems in living they are seeking to eliminate. The growing interest in the interface between social psychology and psychotherapy (e.g., Abramson, 1988; Ingram, 1986; Turk & Salovey, 1988) also ties in with the increased attention that has been given to the relationship between individual therapy and changes in an individual's social system. Wachtel and Wachtel (1986) provide a psychodynamic perspective on how individual and family therapies may be integrated, and Feldman and Powell (1992) offer clinical guidelines for combining individual and conjoint sessions. The importance of working with families and spouses, together with the identified patient, has been underscored by therapists of other orientations as well (e.g., Beach & O'Leary, 1986; Chambless, Goldstein, Gallagher, & Bright, 1986; Jacobson, HoltzworthMonroe, & Schmaling, 1989). Consequently, we believe that social psychological constructs can be especially beneficial for an integrated approach that focuses on changing both individuals and the systems within which they must function. COMBINING THEORETICAL AND EMPIRICAL METHODS OF INVESTIGATION

In order to advance the field of psychotherapy in general, and psychotherapy integration in particular, it is important that we agree on how knowledge about the change process may be acquired. In this regard, a number of important questions need to be addressed. To what extent

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should advances in the field be made on a theoretical basis? What is the role of research findings in understanding the change process and in deciding upon the optimal way of drawing on different therapeutic approaches? Are these two strategies for the acquisition of knowledge mutually exclusive? We believe the future of psychotherapy integration should be guided by both of these approaches. The importance of these two knowledge acquisition strategies has been emphasized by Goldfried and Safran (1986) when they suggest the utility of both "top down" and "bottom up" approaches. The top-down strategy refers to the delineation of integrative constructs at various levels of theoretical abstraction. An example of a high level of abstraction would be Bowlby's (1969) attachment theory. An example at a somewhat lower level is Andrews's (1991) "self-confirmation" theory, which deals with the interrelationship between individuals' conceptions of themselves and their thinking, affect, action, and interactions with others. Another example at this lower level involves Wachtel and McKinney's (1992) notion of "cyclical psychodynamics" described earlier. Although these lower-level constructs may be applied to a higher-order theoretical framework, they are nonetheless able to stand alone, in that they remain fairly close to what most can see within the clinical interaction. In other words, they deal with robust phenomena that are derived from a theory of psychosocial functioning, but are only minimally inferential. By contrast, the bottom-up strategy entails an empirical investigation of the therapeutic interaction. This research strategy may be conducted in order to refine key therapeutic constructs, as in the attempt to study the parameters associated with the therapeutic alliance (Raue, Castonguay, & Goldfried, 1991; Safran, Crocker, McMain, & Murray, 1990), or the role of patients' experiencing within significant therapeutic sessions (Wiser, Goldfried, & Hager, 1991). Such clinical research may also serve to discover yet unspecified mechanisms of change, such as the differential impact of interpersonal and intrapersonal links made by therapists from different orientations (Kerr, Goldfried, Hayes, Castonguay, & Goldsamt, in press). More comprehensive discussions of the possible future research directions relevant to psychotherapy integration may be found elsewhere (Arnkoff, Glass, & Victor, 1991; Goldfried, 1991; Wolfe & Goldfried, 1988). Based on the examples given above, top-down and bottom-up strategies of investigation are obviously not mutually exclusive; ideally, they should be mutually enhancing. Theory, in either explicit or implicit form, typically guides our research, and empirical findings are especially valuable if they can help us in revising our theoretical constructs. It is important to point out, however, that top-down and bottom-up strategies are closely related to the epistemological differences that exist between therapeutic schools of thought (Bouchard & Guerette, 1991; Castonguay, 1989; Messer, 1992). Psychodynamic therapists have traditionally relied on infer-

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ences and theoretical constructions—based on clinical experience—for providing an exploration of the etiology and treatment of clinical problems. Behavior therapists, by contrast, have typically relied on observations and empirical investigation to select and evaluate the effect of their interventions. To a large extent, these different ways of thinking about and conducting therapy reflect therapists' allegiance to a hermeneutic versus a positivistic approach to reality. More than ever before, however, there seems to be a growing dissension within major orientations concerning what are useful and valid clinical data and what are appropriate methods to acquire such knowledge. For instance, some psychoanalysts refuse to describe psychoanalysis as a hermeneutic discipline and argue that Freud always defended the scientific (i.e., empirical) nature of his theory and treatment (e.g., Grunebaum, 1984). Similarly, not all behavior therapists are positivistic (e.g., Mahoney, 1991), nor do they oppose the potential contributions of other epistemologies, such as hermeneutics and phenomenology, in their understanding of psychotherapy (Franks, 1984). Just as different therapeutic approaches often deal with different but not mutually exclusive domains of a patient's functioning, we believe it is too soon to reject the possibility that these separate epistemological paradigms are incompatible. Indeed, considering the complexity of clinical reality, we would argue that the field may gain in an understanding of the change process if it were to be explored simultaneously by both hermeneutic and empirical methods of inquiry. What we are suggesting, in essence, is the possibility of an epistemological eclecticism (Castonguay, 1989).

Concluding Comments We have touched on what we believe to be some of the core issues in psychotherapy integration, including the distinctions between integration and eclecticism, the growing convergences and flexibility that have taken place within existing orientations, common therapeutic factors that exist across schools of thought, and the possible implications of available psychotherapy process and outcome research findings. We have also identified some of the social, linguistic, and epistemological barriers to psychotherapy integration, all of which serve to define the issues that need to be resolved if we ever hope to reach our goal of improving the effectiveness of our clinical procedures. Although the traditional theoretical orientations are very likely to continue in the future, we anticipate that they will continue to incorporate contributions from other schools of thought. Advances in psychotherapy

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integration are more likely to occur within the context of specific clinical problems, and the findings of basic psychological research can contribute invaluable information on the therapeutic change process. It is also our contention that the future of psychotherapy in general, and psychotherapy integration in particular, will be greatly enhanced if our knowledge of the change process is informed by both empirical and theoretical knowledge acquisition strategies. As we suggested at the outset of this chapter, the notion of being able to integrate diverse approaches to therapy has progressed over the past half century from a latent theme to a definite therapy movement. An important catalyst to this movement has been the Society for the Exploration of Psychotherapy Integration (SEPI), which has functioned as an international professional network that lowers the social barriers to integration and facilitates dialogue between clinicians and researchers of differing orientations. In all likelihood, SEPI will continue to be an important influence on the future of psychotherapy integration.* Although we have offered our predictions about the future of psychotherapy integration, we are mindful of the dangers in doing so. Sociologists of science have documented that disciplines make progress not only from theoretical and empirical work done within the discipline, but also by external political and economic factors, which are often difficult to predict or control (Cole & Cole, 1973). Thus, World War II served as an impetus for dramatic advances in physics, and Sputnik gave rise to the numerous scientific and technical achievements that were made within the United States. At the 1991 SEPI conference held in London, we were struck by the dramatic increase in interest in the integration movement on the part of our European colleagues. Apparently, this involvement by European psychotherapists was evoked by concerns about the forthcoming standardization of professional practice within the European Community in 1992. These concerns about the guidelines for evaluating therapeutic competence across Europe are certainly very real, since they will affect the practice of thousands of therapists. How it will influence the psychotherapy integration movement is unknown. Certainly, the interest among so many of our colleagues to label themselves as "integrative" is heartening. Still, we must confess to having some concerns about the temptation to delineate "integrative psychotherapy" as another therapeutic school, especially since there is no consensus as to what specifically should be integrated (Lambert, 1992; Norcross & Newman, 1992). It is our hope that the psychotherapy integration movement, and SEPI 'For further information about SEPI, write to Dr. George Strieker, The Derner Institute, Adelphi University, Garden City, NY 11530, U.S.A.

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in particular, will continue to remain an open forum for dialogue and a vehicle for expanding our therapeutic boundaries. The operative word in the Society for the Exploration of Psychotherapy Integration is "exploration." Moreover, integration should not be viewed as a pathway for renewed competition regarding who can develop the best form of psychotherapy integration, a point that has been strongly emphasized elsewhere (Goldfried & Safran, 1986). In commenting on this general issue, Kazdin (1984) has noted: Integrationism as a general movement represents a highly significant development in psychotherapy. However, it may be the general movement that is worth promoting rather than the specific attempt to integrate psychodynamic and behavioral views. At this point, individual positions suffer from loose concepts and weak empirical bases, problems that are not resolved and perhaps may even be exacerbated by their combination. The overall goal is establishing an empirically based and theoretically viable account of therapy. Premature integration of specific positions that are not well supported on their own may greatly impede progress, (pp. 141—142)

It has been the hallmark of those involved in SEPI to remain distant from any signs of "conceptual imperialism" and to denounce any dogmatism or defensiveness. Hoping that it can prevent us from developing an inflexible and complacent attitude, we would hope that those involved in the pursuit of psychotherapy integration adopt the following French motto: "]'admire ceux qui cherchent la verite, je fuis ceux qui la trouve," the translation of which is, "I admire those who search for the truth. I avoid those who find it."

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Name Index

Abrahamson, L. Y., 607 Abrams, D. B., 325, 326 Adler, A., 144 Aigen, B. P., 254 Alberts, C, 569 Alexander, F., 51, 338, 343 Alexander, L., 268, 567 Alford, B. A., 5, 18. 22, 231 Allen, D. M, 14, 68 Allen, G. )., 579 Allen, J. G., 355 Allmon, D., 456, 489 Allport, G. W., 5 Als, H., 358 Amaranto, E. A., 522, 529 Anchin, J. C., 63 Anders, T. F., 358 Anderson, T. I., 553 Andrews, G., 100, 101 Andrews, J., 23, 25, 582 Andrews, ]. D. W., 22, 69, 72, 138, 141, 155, 577, 608

Andrews, J. G., 98 Annable, L., 538 Antonuccio, D. O., 99 Aponte, H. J., 519 Appelbaum, A. H., 202, 489, 490, 546 Appelbaum, P. S., 553, 555 Appelbaum, S. A., 11, 29, 58, 147 Apter, M. J., 137 Arizmendi, T. G., 16, 269, 282 Arkowitz, H., 4, 7, 9, 10, 13, 14, 15, 22, 29, 32, 59, 64, 69, 70, 71, 73, 357, 408, 409, 414, 440, 471, 482, 483, 595, 605, 606 Armstrong, H. E, 456, 489 Armstrong, P. M., 569 Arnkoff, D. B., 62, 68, 75, 109, 597, 608 Arnold, R. C., 566, 577 Asay, T. P., 101 Atkinson, D. R., 268, 269 Auerbach, A. H., 16, 273

Austad, C. S,, 8 Austin, V., 435, 441 Autry, J. H., 413 Avner, R., 274 Babcock, H. H., 5, 68 Baer, D. M., 59 Ballenger, J. C., 217, 538 Handler, R., 207, 212 Bandura, A., 61, 232, 233, 235, 305, 345, 390 Barber, B., 46 Barker, S. L, 471 Barkham, M., 70 Barlow, D. H., 115, 202, 213, 216, 264, 374, 378, 381, 391, 434, 543 Barlow, S., 102, 121 Barnett, P. A., 409, 411 Barratt, B. B., 148, 149 Bascue, L. O., 552 Bass, D., 9, 103, 406 Bastine, R., 57, 61, 76, 61 Baucom, D., 495 Beach, S. R. H., 68, 484, 607 Beavin, J. H., 208 Beck, A. T., 9, 18, 64, 72, 73, 74, 75, 153, 216, 286, 287, 412, 413, 439, 470, 475, 486 Becker, E., 211 Beckham, E. E., 405 Beebe, B., 357, 358 Begin, A., 325 Beitman, B. D., 5, 13, 14, 24, 27, 64, 67, 70, 117, 134, 203, 206, 218, 277, 303, 399, 411, 413, 476, 490, 533, 535, 537, 541, 547, 551, 552, 593, 594, 598, 599 Bell, R. A., 409 Bellack, A. S., 480, 482, 486 Belsey, E., 98 Bender, S. S., 522, 529 Benjamin, G. A., 552 Benjamin, L. S., 121

618

NAME INDEX

Bennun, I., 495 Benton, M. K., 101 Bergan, }., 265, 268, 270 Berger, H., 529 Bergin, A. E., 4, 8, 9, 13, 15, 16, 18, 52, 53, 54, 55, 67, 94, 96, 98, 100, 103, 110, 112, 130, 231, 404, 477 Bergson, H. L, 143, 602 Berman, E., 153 Berman, J. S., 101, 112, 113, 404, 405, 411 Bcrscheid, E., 355 Berzins, J. I., 269 Beutler, L. E., 7, 9, 10, 11, 13, 16, 20, 24, 27, 28, 32, 64, 67, 70, 76, 1 1 7 , 131, 137, 237, 259, 264, 265, 266, 267, 268, 269, 270, 271, 272, 273, 274, 275, 276, 280, 281, 282, 288, 289, 290, 314. 320, 404, 405, 475, 478, 496, 497, 518, 563, 564, 566, 567, 569, 571, 572, 578, 594. 595, 598, 601, 607 Bevan, W., 148 Biederman, J., 217 Billings, A. G., 409, 410 Binder, J. L., 9, 273, 345, 4 1 2 , 470, 478 Birk, L., 5, 53, 55, 56, 68 Bishop, S.. 484 Black, D. A., 150 Blackburn, I. M., 484 Blanchard, E. B., 101 Blaney, P. H., 290 Blaustein, A. B., 58 Blazer, D. G., 409 Blight, J. G., 149 Blouin, A, 216 Blumberg, A., 583 Bodemer, C. W., 533 Bohart, A.. 63 Bolton, P., 410 Bond, J. A., 272 Bootzin, R. R., 357 Bordin, E. S., 268 Borduin, C. M, 101 Boring, E. G., 46, 78 Borkovcc, T. D., 398 Bornstem, M. 495 Bornstein, P., 495 Bouchard, M. A., 603, 608 Boudreau, L. A., 355 Bowen, M,, 215, 323 Bowers, K. S., 343 Bowlby, |., 268, 380, 390, 608 Boyd, J. L, 470 Bozarth, J. D., 104, 238 Brabeck, M. M., 4 Brady, J. P, 29, 52, 53, 61 Brammer, L. M, 53, 575 Brandenburg, N., 327 Brazelton, T. B., 358 Breckenridge, J. S., 99 Brehm, 1. W., 266, 273 Brehm, S. S.. 266, 273 Brickner, D., 24! Briere. ]., 437 Bright, P., 66, 607 Brinklcy-Birk, A., 56 Brodc-r, E. A., 514 Brown, C. W., 410 Brown, M. A., 60 Brown, R. A., 486 Brunell, L. F., 241 Bruner. J., 148 Brust A. M, 4, 15

Buckley, P I., 579 Burchifl, S A. L., 409 Burlingame, G. M.. 102, 121 Burton, A., 58 Butcher. |. N'.. 279, 475 Butler, S. F., 405, 567 Calvert, S. J., 117, 266, 289 Cantwell, D. P.. 539 Carek, D., 518 Carifio, M. S., 577, 578, 579 Carkhuff, R, R., 566 Carlin, A., 552 Carr, A. C., 202, 546 Carter, A. S., 426 Gasas, I M, 269 Cashdan, S, 69, 214 Castaldo. C, 241 Castonguay, L. G., 4, 14, 15, 67, 69, 121 599, 600, 603. 604, 008, 609 C o r n y , J. A., 543 Chambless. L). L., 66, 59, 376, 607 Charles, E. S, 579 Chessick, R D . 148 Chevron, E. S., 202, 404, 478 Chiles, J. A., 552, 555 Chouinard, G., 538 Chrisrensen, E. R., 103, 104 Christiansen, H , 102 Clark, D., 529 Clarke, A B D , 359 Clarke, A. M., 359 Clarke, I. C., 387 Clarkin, I F.. 10, I 1, 14, 28, 131, 237, 265, 266, 267, 2o9, 270, 2 7 1 , 272, 273, 274, 276, 280, 289, 441, 463, 473, 475, 476, 477, 478, 480, 484, 487, 489, 4"2 496, 497, 535, 563, 564, 565. 578 Cobb, I.. 494 Cohen, B., 440 Cohen, I , 100 Cohen, 1.. H o2 Cohen, \-1 , 268, 567 Cohn. |. F., 358 Cole, ]. K , 265 C'ole, |. R.. (MO Cole, S., cIO C oleman, R E , 409 Collins, ,'. L, 103 Connell, D.. 358 Consoli, A. I., 11, 27, 117, 314, 320, 478, 497, 518, 566, 5 7 1 , 572, 594, 595, 598, 601, 607 Conte, II R 150 Cook, T n, 148 Cooley, h. }., 109 Cooper, H. M., 101 Cooper, ]., 355 Crirbishley A., 270 Corder, B. 554 Cornwall, T, 554 Corngan, | D., 281 Couch, I. R., 539 Covi, L., 535 Coyne ). C 409, 410 Crago, VI. 1O 16, 117, 266, 269, 281, 282, 289 Craig. D.. 99 Craine, M H., 144 Cramer, D . 109 Cristol, A. H. 30, 57, 110, 265, 301, 404 CnKChnstoph, P, 268, 472. 567

Name Index Endler, N., 343 Engle, D., 266, 274, 275, 289, 404, 405, 478 Ensel, W., 408, 410 Ensel, W. M., 409 Epstein, N., 495 Epstein, P., 413 Erikson, E. H., 602 Eunson, K. M., 484 Evans, F. )., 536 Eysenck, H. J., 20, 98, 195, 231

Crocker, P., 597, 608 Cronkite, R. C, 409 Cross, D. G., 28 Crowe, R., 217 Crowley, A., 203 Cumming, J. D., 120 Curtis, R. C., 356 Curtiss, S., 147 Cutrona, C. E., 410 Dahlstrom, W. G., 275, 279 Daldrup, R. J., 478 Daly, E. M, 495 Dar, R., 538 Darley, J. M., 355, 360, 361 Davidson, N., 519 Davis, C. S., 281 Davis, J. D., 5, 65 Davis, J. M., 539 Davison, G. C., 58, 59, 75, 216, Dawes, R. M., 101 Dean, A., 408, 409 Dejulio, S. S., 103, 104 Dell, D. M., 281 Delworth, U., 572 DeMichele, J. T., 5, 231, 571 Derogatis, L. R., 216, 273, 279 DeRubeis, R. J., 9, 264, 541 DeSouza, E. B., 539 Diamond, R. E, 59 Dickman, S., 30 Dicks, H. V., 492, 494 DiClemente, C. C., 11, 27, 65, 301, 303, 304, 305, 307, 311, 325, 326, 327, 399, 479, 566, 605

619

218, 273, 434, 597

77, 117, 134, 278, 313, 315, 316, 320, 571, 581, 598, 599,

Dienst, E. R., 569 Dobson, K. S., 101, 113, 405, 484, 567, 569 Docherty, J. P., 535 Dohrenwend, B. P., 410 Dollard, ]., 48, 49, 50, 338, 339 Downey, G., 409 Driscoll, R., 25, 27, 29, 64, 67, 139 Dryden, W., 4, 5, 15, 16, 20, 22, 28, 61, 63, 64, 232, 236, 251, 571 Duhl, B., 68 Duhl, F., 68 Duivenvoorden, H. J., 241 Duncan, B. L., 96 Duncan, D. B., 357 Dush, D. M., 101, 112 Duval, S., 377 Eagle, M. N., 597 Eaton, T. T., 107 Eckman, T., 539 Edelstein, B., 569 Edwards, S. S., 241 Egan, G., 57, 303, 599, 607 Eissler, K. R., 154 Elkin, I., Ill, 218, 357, 404, 405, 408, 413, 481, 482, 483, 484, 535 Elkins, D., 270, 288 Elliott, G. R., 435 Elliott, R., 9, 43, 66, 404, 600 Ellis, A., 142, 253, 323 Ely, R. ]., 361 Emery, G., 9, 75, 153, 202, 286, 412, 439, 470 Emmelkamp, P. M. G., 115

Fagen, J. W., 357 Falloon, I. R. H., 470 Farina, A., 355, 361 Farkas, G. M., 71, 76 Fava, ]., 325 Fawcett, ]., 413, 416 Fay, A., 238 Fazio, R. H., 360 Feather, B. W., 55, 56, 374 Feldman, L. B., 11, 14, 68, 280, 469, 493, 503, 517, 519, 529, 545, 607 Feldman, R. S., 356 Feldstein, S., 358 Fenichel, O., 61 Fensterheim, H., 26, 28, 64, 233 Ferrise, F. R., 254 Ferster, C. B., 56 Feyerbend, P., 3 Field, T., 358 Fiester, S. J., 413 Finkelstein, N. W., 357 Finlay-Jones, A. R., 410 Firth, ]., 118 Firth-Cozens, J., 70, 119 Fischer, ]., 28, 59 Fishman, D. B., 583 Fishman, H. C., 478 Fleming, J. H., 361 Fodor, I., 597 Follette, W. C., 102 Follick, M., 325 Fontaine, R., 538 Forah, J., 569 Ford, J. D., 568 Forsyth, D. R., 274 Forsyth, N. L., 274 Fowler, ]., 325 Fox, R., 147 Frances, A., 6, 14, 22, 131, 205, 269, 270, 279, 441, 463, 477, 478, 479, 480, 487, 535, 541, 564, 565, 578, 588 Frank, ]., 537 Frank, J. D., 13, 50, 51, 54, 56, 111, 266, 282, 411, 414, 415, 471, 593, 599, 607 Frank, K. A., 154 Franks, C. M., 4, 10, 70, 140, 149, 232, 609 Freedheim, D. K., 4 Freeman, A., 70, 146 French, T. M., 6, 47, 70, 338 Freud, A., 379 Freud, S.. 50, 210, 339, 379, 534 Friedling, C., 30, 31 Friedman, P., 68 Friedman, S., 383 Friedmann, C., 529 Frieswyk, S. H., 10, 106 Fruzzetti, A. E., 484 Frye, N., 141

513,

280, 542, 357,

620

NAME INDEX

Funk, S. C, 471 Fycr, M, 441 Gabbard. G., 208 Gabriel, T., 582 Gadamer, H., 148 Galavotti, C., 326 Gallagher, D,, 108, 486 Gallagher, K M , 4, 130 Gallagher, R , 06, 007 Garcia-Marques, L, 16 Gardner, R. A., 514 Garfield, E., 408 Garfield, S. L., 5. 7, 13, 14, 17, 18, 19, 20, 27, 28, 50, 55, 58, 62, 65, 71, 95, I 16, 131, 134, 265, 267, 411, 470, 471, 569, 605 Garner, A. VI, 568, 579 Garvey, .M, I,, 541 Gaston, L., 106 107, [08 Gehred-Schult?, A., 326 Gekoski, M. J., 357 Geldcr, M C,, 52, 53 Geller, M, H., 270 Gendlin, E. T., 378, 398, 596, 598, 600 Gergen, K I., 136, 152, 234 Gevins, A., 64 Gianiana. A. F., 3.58 Gi!!. M. M., 74, 75, 346, 597 Ciller, E., 572 Gillis, ). S., 265 Cilmore, J. B., 73, 74, 155 Gilmore, M., 487 Glad, D. D,, 50 Glasgow, R E., 326 Glass, C. R., 32, 68, 109, 608 Glass, G. V., 9, 10, 100, 101, 103, 112, 113, 2o5 404, 535 Glazcr, H 1, 28, 64, 233 Click, 1. D,, 484 Gliha, D., 355 Coin, M. K., 109 Goldberg, C , 439 Goldberg, R. S., 552, 553 Goldfned, M R,, 3, 4, 5. 6, 7, 10, 12, 13, 14, 16, 22, 23, 24, 25, 28, 29, 30, 58, 60, 61, 62, 63, 65, 66, 67, 68, 69. 70, 72, 73, 74, 75. 77, 95, 119, 120, 121, 134, 137, 138, 141, 144. 216, 218, 273, 302, 408, 414, 434, 471, 593. 596, 597, 599, 600, 602, 604, 605, 606, 607, 608, 611 Goldman, R. L., 569 Goldsamt, L, 69, 608 Goldstein, A. J, 59, 66, 376, 377, 607 Goldstein, A. P., 266. 480. 566 Goldstein, M. J., 542 Golombiewski, R.. 583 Gomes-Schwartz, B., 10 107, 108, 489 Goodman, W. K , 538 Gordon S. B., 519 Gore S.. 409 Gotlib, I. H., 409, 410, 41 i Gottlieb, N H., 326 Gottman, ). M , 436 Grady-Fletcher, A , 495 Graham, J. R., 279 Grawe, K., 266, 404 Greaves, P. W,, 4, 8, 15, 16, 18, 94, 96, 130, 231 Grebstein, L. C.. 68 Greenberg. 1 R., 597

Greenberg, L, S, 5 14, 28, 64, 67, 68, 107, 146, 152, '73, 411. 478, 569, 600, 606 Creenberg, R. L., 153, 286 Greenburg, L S,, 241 Greening, T C 59 Greenson, R.. 206 C.reenwald VI., 115 Greist, I. H., 538 Grcncavage, L. .VI 5, 10, 22, 29, 30, 68, 71, 73, 95, 104, - J O B . 414, 472 599 Crettrr, M L . 405 Crieger, R,, 142 Grinder, |., 207, 212 Grinker, R R.. Sr.. 57, 579, 603 Gross, P it. 355 Grunebaum. A., 609 Guadagnoli E., 325 Cuerette L., 603, 608 Guerney, B.C.. Jr.. 416 Guest P D., 567 Cuidano, V. F., 29, 65, 67, 69, 268, 383, 596, 597 Guitar. B. 101 Gunderson, 1. G., 435. 440, 441, 489 Cuiman. A. S., II, 29, 59, 62, 68, 104, 215, 363, 494 503 Gurney C 98 Gutheil. T. G. 535 I laaga, D A., 70 Haas, G., 484 1 laas, L !.. 509 Hadlcy, S. VV, 10, 411, 489 Hafner R, J., 217 Hagaman, R., 282 Hager, M., 608 Hahlweg. K, 101 Hahn, T N.. 434 Haley, i , 215 Halgm. R. P . 22. 24, 66, 67, 155, 565, 567, 575, 578 Hall, M. J., 14, 218, 413, 476, 490 Halleck, S. L... 588 Hamblin D. L., 270 Hambrecht, M, 311 Hannah, M. T 270 Hansell, J., 272 Hardy, E 572 Hardy. C. E., 566 Harris, T, D. 410 Hart, J., 65, 202 Hartman, L. M. 495 Harvey, R, 100, 101 Hassanem, R S., 539 Hatcher C 68 Havens, L... 211 Havens, R. A.. 59 Haycvk F. A. 596 Hayes, A M, 69, 75, 597, 608 Hays, K. A. 566 Hazelrigg. M D., 101 Heard H I... 456, 489 Heffner. R., 21 Heitler, S. \I. 206, 215 Held, B. S., H, 96 Heller, K , 266 Hellerstedt, VV. L., 328 Hemmings K A., 405 1 lenle M , 5 Henry. W. P. 121, 570

Name Index Heppner, P. P., 575 Herink, R., 99, 470 Herman, B., 566 Herman, J. L, 437 Herman, S. M, 245, 255 Hernandez, E., 325 Hersen, M., 480, 486 Herzberg, A., 48, 49 Hess, A. K., 577, 578, 579 Hill, C. E., 107 Hilton, ]. L., 361 Himmelhoch, ]. M., 486 Hinchliffe, M., 409 Hinshelwood, R. D., 274 Hirschenberger, R. H., 569 Hirt, M. L., 101 Hoberman, H. M., 409 Hoehn-Saric, R., 539 Hoffman, I. Z., 346, 596 Hogan, R. A., 575, 576 Holliday, S., 409 Hollon, S. D., 475, 483, 486, 540, 541, 542 Holstein, L., 8 HoU, P., 582 Holt, R. R., 399 Holtzworth-Monroe, A., 607 Holzer, C. E., 409 Honig, P., 529 Hood, E., 514 Hooley, ]. M., 411, 471 Hooper, D., 409 Horney, K., 345 Horowitz, M. J., 14, 120, 212, 596 Horvath, A. O., 10, 107 Horvath, P., 220 Horwitz, L, 56 Houston, B. K., 471 Houts, A. C., 147, 150 Houts, P. S., 55 Howard, G. S., 101, 148, 239, 564 Howard, K. I., 67, 134 Howard, W. A., 387 Howie, P., 101 Hubbard, M., 363 Hudson, J. L., 440 Hughes, S. O., 303, 325 Hull, ]., 473, 475, 476 Hunt, H. F., 58 Hurt, S. W., 269, 487 Husain, S. A., 539 Hutter, M., 409 Hyman, S. E., 145 Ingram, R. E., 378, 607 Insel, T. R., 539 Ivey, A. E., 566 Jackson, D. D., 208 Jackson, L. J., 241 Jacobson, L., 355 Jacobson, N. S., 102, 115, 215, 434, 484, 495, 519, 607

Jaffe, ]., 358 James, W., 136 Janis, I. L., 313 Jarmon, H., 565 Jasnow, M., 358 Jayaratne, S,, 18

621

Jefferson, J. W., 538 Jeffrey, R. W., 328 Jelalian, E., 363 Jenike, M. A., 539, 544 Jenkins, R., 98 Jensen, J. P., 4, 8, 15, 16, 18, 29, 94, 96, 130, 231 Jobe, A. M., 270, 288 Johnson, D. T., 270 Johnson. M., 16 Johnson, M. E., 106, 107 Johnson, V., 322 Johnston-Cronk, K., 539 Jonas, J. M., 440 Jones, A. C., 59 Jones, E. E., 120, 354 Jorm, A. F., 102 Kaemmer, B., 279 Kagan, J., 359 Kahn, E., 147 Kahn, J., 409, 410 Kaplan, A. G., 21 Kaplan, B., 21 Kaplan, H. S., 56 Karasu, T. B., 30, 150, 534, 579 Katz, L. F., 436 Kazdin, A. E., 7, 9, 30, 63, 103, 406, 434, 470, 611 Keat, D. B., 241 Kegan, R., 438, 439, 450 Keisner, R. H., 356 Keller, E. F., 137 Kelley, G., 203, 210 Kelley, H. H., 356, 492 Kelly, G. A., 74, 602 Kelly, T. A., 265, 270, 288 Kendall, P. C., 5, 65, 398 Kernberg, O. F., 202, 213, 435, 489, 490, 491, Kerr, S., 69, 608 Kerr, T. A., 98 Kertesz, R., 241 Kiesler, D. )., 15, 398, 605 Kimble, G. A., 147 King, D. G., 290 Kirschenbaum, H., 596, 597 Klein, M., 504 Klein, M. H., 398 Klein, R. E., 359 Kleine, P. A., 241 Klerman, G. L., 64, 202, 214, 218, 404, 412, 478, 533, 534, 541, 554 Klosko, J. S., 543 Kniskern, D, P., 363 Koch, S., 135, 137, 139 Koenigsberg, H. W., 202, 489, 490, 546, 547 Koerner, K., 69, 76, 385, 388, 419, 422, 433, 489, 490, 546, 598, 605 Kohut, H., 213, 269, 597 Kohut, L., 154 Kolb, D. L., 281 Kolb, J. E., 435, 441 Kommer, D., 61 Kopta, S. M., 150 Kornreich, M., 100, 112 Korzybski, A., 207 Koss, M. P., 475 Kovacs, M., 486 Kozlowski, B., 358

471,

546

413,

435,

622

NAME INDEX

Kraft, T., 53 Kramer, C. H., 503 Kramer, P. D.. 155 Krasner, L.., 59, 147, 150 Krauft, C. C., 104 Kris, E., 145 Kroll, P. A., 437 Kubie, L. S., 47 Kuhn, T. S., 3, 156 Kurtz, R., 7, 17, 18, 19, 58, 95, 131, 265, 267 Kwee, M. G. T,, 233, 241, 255 Lachmann, F. M., 357, 358 Lajoy, R., 109 Lam, C, S., 326 Lamb, A. G., 363 Lamb, M., 357 Lambert, M, ]., 9, 10, 13, 16, 24, 28, 29, 96, 98, 99, 100, 101, 102, 103, 104, 110, 112, 121, 204, 264, 404, 411, 472, 477, 566, 571, 577, 599, 600, 610 Lambley, P., 56, 58 Landau, R. J., 30, 62 Landes, A A., 245, 255 Landman, J. T., 101 Landsman, T, 26, 56 Lane, R., 582 Langs, R,, 154, 214, 550, 597 Laplanche, ]., 274 Larson, D,, 3, 95 Larson, V. A., 268 Lawler, B. B., 254 Lazarus, A. A,, 5, 6, II, 13, 20, 25, 27, 28, 32, 52, 53. 54, 58, 59, 62, 69, 71, 72, 77, 110, 117, 137, 139, 152, 202, 231, 232, 233, 234, 235, 236, 237, 238, 239, 241, 245, 252, 253, 256, 259, 350, 399, 480, 518, 566, 571, 572, 578, 594, 595, 598 Lazarus, C. K., 237, 238, 241, 252, 253 Lazarus, R. S., 409 Leaf, P. )„ 409 Lebow, I. L., 11, 68 Lecomce, C, 67, 599, 600 Ledwidgc, B., 147 Left, ]. P., 411 Lepper, M. R., 363 LeRoy, J. B., 409 Leupnitz, D. A., 216 Levant, R. F., 104, 146 Levay, A. N., 58 Levenson, H., 442 Leventhal, A. M,, 52 Levine, J. E., 484 Levis, D. J., 374 Lewinsohn, P. M., 99, 111, 409, 410, 486 Lewis, C., 538 Lewis, K. N., 281 Lick, J. R., 357 Liebman, R., 529 Lillie, F. I., 109 Lin, N., 408, 410, 414 Lin, T, T., 279 Lindblad, M. B., 529 Lindenbaum, S., 529 Lindquist. L, 582, 583, 584, 585 Linehan, M. M., 69, 76, 385, 388, 419, 422, 433, 435, 436, 437, 456, 470, 489, 490, 546, 598, 605 Link, B. G., 410 Linsenhoff. A,, 6! Liotti, G , 65, 597 Lipkm, M. D., 265

Lipman, R. S, 535 Lipsius, S. H, 503 Llewelyn, S P , 76 Loganbill, C. 572, 575 London, P., 4 5, 7, 8, 9, 11, 13, 51, 53, 55, 68, 70, 134, 135, 155 Loosen, P T, 540 Lorr, M., 108 Luborsky, L,, 9, 103, 110, 112, 202, 264, 265, 266, 268, 273, 291, 412, 470, 505, 518, 535, 567 Lundc, D. T. 6 Lyons-Ruth, K, 358 MacDonald, R., 266 Maddi, S, R., 144 Magnussen, M., 265 Magnusson, D., 343 Mahalik, J. R,, 24, 95, 96, 116 Mahoney, M. ]., 8, 14, 27, 31, 60, 61, 63, 64, 72, 73, 74, 144, 146, 155, 268, 392, 547, 596, 597, 609 Mahrer, A, R,, 10, 15, 70, 131, 138 Mam, M., 358 Malone, ], 566 Malouf, |. L , 569 Mann, A. H , 98 Mann I. P , 254 Mann, L., 3 13 Manning, D. W., 205, 541, 542 Marchione, K., 115, 116 Marcus, B., 325 Marder, S, R., 535, 539, 542 Margolin, G,, 409, 495 Margolis. M , 268, 567 Markman, H. |., 101 Marks, I M,, 52, 53, 55, 114, 115, 216, 494 Markus, H., 398 Marmar, C. R., 5, 107, 108, 606 Marmor, I,, 30, 51, 53, 54, 61 Martin, C G., 55 Martin, I. L., 410 Martin, I'. [,, 281 Marziali, E., 107, 489 Mascitelh, S,, 63 Maslow, A. H., 141, 144 Massman, P. I, 113, 405 Masters, W , 322 Matarazzo, R. C, 566, 568, 579 Mathews, A. M., 216 Mathieu, P L,, 398 Matias, R., 358 Maturana, H. R., 596 Mavi.ssakalian. M,, 542, 543 Maxim, P., 535 Maxwell, S. E, 101 Mayer, I, E., 578 McAlister, A. L., 326 McConnaughy, E. A , 303, 325 McCrady, B. S., 583 McCuan, R. S, 326 McDonald, R,, 494 McDonald, S., 538 McGill, C W., 470 McGlashan, T. H, 440 McGovern, M. P, 150 McGuire, P S., 569 McKinney, M. K., 1 1, 32, 134, 147, 208, 321, 389, 440 4 5 1 , 510, 519, 547, 594. 597, 598, 607, 608 McLellan. A T.. 273 McLeod, D R., 539

Name Index McMahon, B. T., 326 McMain, S., 608 Meador, B. C, 416 Medieros, M, 325, 326 Meichenbaum, D., 73, 74, 155, 213, 518 Meissner, W. W., 505 Melisaratos, N., 216 Mellinger, G. D., 320 Meltzoff, }., 100, 112, 572 Mendelsohn, G. A., 270 Menditto, A. A., 542 Merton, R. K., 355 Messer, S. B., 5, 6, 22, 24, 25, 26, 29, 30, 31, 61, 64, 65, 66, 67, 68, 71, 72, 73, 76, 77, 131, 137, 138, 139, 141, 146, 148, 151, 152, 154, 233, 234, 256, 440, 568, 583, 596, 603, 608 Meyer, R., 65 Michels, R., 463 Michelson, L. K., 115, 116 Miklowitz, D., 492 Mikulas, W. L., 59 Millar, W. S., 357 Miller, A. G., 409 Miller, D. T., 360 Miller, ]. B., 437 Miller, K., 356 Miller, N. E., 48, 49, 50, 55, 338, 339 Miller, R. C., 101, 113, 405 Miller, T. I., 9, 10, 300, 103, 112, 113, 265, 404, 535 Miller, W. R., 105 Millon, T., 29 Mills, W. A., 529 Minuchin, S., 215, 478, 492 Mischel, W., 337 Missar, C. D., 571 Mitchell, K. M., 54, 104, 416, 420 Mitchell, R., 266, 281 Mitchell, S. A., 136, 597 Mohr, D., 266, 274, 275, 289, 290, 404 Moore, J. E., 281 Moos, R. R, 409, 410 Moran, T- J,, 265 Morey, L. C., 268 Morgan, R., 107 Morrongiello, B. A., 357 Mos, L. P., 150 Moultrup, D., 4 Mujeeb-ur-Rahman, M., 144 Munion, W. M., 196 Munoz, R. F., 111 Munroe-Blum, H., 489 Murgatroyd, S., 137 Murphy, G. E., 484 Murphy, M. J., 274 Murphy, P. M., 109 Murphy, S. M., 387 Murray, E. ]., 3, 5, 65, 605 Murray, N. E., 58, 76 Murray, P., 608 Murrell, S. A., 410 Muszynski, R., 416 Myers, J. K., 409 Myers, P., 239, 564 Nance, D. W., 239, 564 Napolitano, G., 12, 14, 18 Neeman, R., 274 Neimeyer, R. A., 101, 113 Nelson, B. A., 437

623

Nelson, G., 579 Neville, C. W., Jr., 270 Newman, C. F., 6, 7, 10, 69, 76, 94, 96, 130, 137, 267, 364, 408, 470, 471, 593, 601, 605, 610 Newman, F. L., 150 Ney, P. G., 529 Niaura, R. S., 325 Nicholson, R. A,, 101, 112 Nielsen, A. C., 61 Niemeyer, R. A., 404 Nietzel, M. T., 405 Nisbett, R., 363 Norcross, J. C., 3, 4, 5, 7, 9, 10, 11, 12, 14, 15, 16, 18, 19, 20, 22, 24, 25, 26, 29, 30, 31, 32, 66, 67, 68, 70, 71, 73, 94, 95, 96, 104, 130, 131, 134, 150, 155, 231, 232, 259, 265, 267, 311, 325, 364, 408, 414, 470, 471, 472, 496, 563, 565, 566, 567, 568, 569, 570, 571, 574, 575, 579, 581, 587, 593, 599, 601, 610 Norton, N. C., 411 Oatley, K, 410 O'Brien, C. P., 273 Ockene, ]., 326 Ogles, B. M., 99 O'Keefe, E. J., 241 O'Leary, K. D., 59, 68, 143, 233, 484, 607 Oleshansky, B., 21 Oliver, L. K., 539 Ollendick, T. H., 274 Olson, S, C., 254 O'Malley, S. S., 106, 108 Omer, H., 13, 68, 134, 135 Orley, J., 411 Orlinsky, D. E., 67, 134 Padawer, W., 29, 30, 63, 73, 414, 599, 600 Palmer, J, O, 65 Palmer, M., 5, 9, 68, 70 Papajohn, ]. C., 65 Parks, M. B., 96 Parloff, M. B., 593 Patterson, C. H., 20, 52, 104, 131 Patterson, D., 566 Paul, G. L., 28, 542 Paulson, J. ]., 279 Paykel, E. S., 409, 410 Peery, C., 358 Pennebaker, J. W., 426 Penny, D., 325 Pentony, P., 220, 547 Pepper, S. P., 133, 134, 156 Perloff, M. B., 8, 16 Perls, F., 212 Perry, J. C., 437 Perry, S., 14, 270, 280, 463, 480, 535, 564, 565 Perse, T. L,, 538 Persons, J. B., 146, 153 Peterson, L. E., 136 Pfeifer, G., 503, 529 Phelps, R., 241 Phifer, J. F., 410 Phillips, J. A., 416 Piegct, ]., 362 Pierce, G. R., 408 Pilkonis, P. A., 535 Pinsof, W. M., 11, 26, 68, 363, 411 Plubchik, R., 150 Polanyi, M., 74

624

NAME INDEX

Polkinghorne, D. E.. 148 Pontalis, J. B., 274 Ponterotto, J. G., 241 Pope, B., 62 Pope, H. G,, 440 Poppen, P. J., 11, 17, 58 Porter, K,, 503. 522 Powell, D. H., 5, 68 Powell, S., 14, 280, 469, 493, 545, 607 Press, S., 281 Pnddy, D, A., 326 Prioleau, L., 101 Prochaska, J M., 321 Prochaska, ). O.. 4, 5, 7, 11, 12, 16, 18, 19, 27, 29, 31, 60, 65, 68, 77, 95, 117, 130, 131, 134, 259, 267, 278, 300, 301, 302, 303, 304, 307, 311, 313, 316, 320, 321, 325, 326, 327, 356, 399. 479, 566, 571. 575, 581, 598, 599, 605 Rachman, S. J., 98 Raimy, V., 56, 213 Ramey, C. T., 357 Raskin, N". J., 146 Rasmussen, A., 146 Raue, P. J., 608 Read S. ]., 356 Rebecca, M., 21 Rehm, L. P., 426, 483 Reiser, D. E , 442 Reisman, J. M., 567 Reiss, S.. 375, 376 Rescorla, R. A., 235 Revenstorf, D., 102 Rhoads, J. M., 5, 26, 55, 56, 62, 68, 374 Riba, M., 552 Rice, L. M., 68, 146, 373, 596, 598, 600 Richards, L., 121 Rickels, K., 273 Ricks, D. F., II, 17, 58 Ricoeur, P., 149 Ridley, C., 241, 416 Ring, K., 361 Risso, L. P., 484 Riviere, )., 504 Roberts, F. )., 409 Roberts, T. K., 241 Robertson, M, 16, 20, 23, 60, 567, 569. 574 Robins, C., 596, 607 Robinson, L. A., 101, 113, 404, 405, 407, 426 Rock, A. F., 273 Roehlke. ] ]., 575 Rogers, C. R., 51, 57, 141, 143, 211, 309, 416, 419, 420, 504, 593, 597 Rohrbaugh, M., 281 Rokke, P. D., 426 Rorty, R., 138 Rosen, G.. 326 Rosenbaum, M., 409 Rosenberg, J B., 68, 529 Rosenblad, L. V., 254 Rosenblatt, A., 578 Rosenbloom, D., 325 Rosenfcld, R., 538 Rosenthal, R., 100, 355 Rosenzweig, S., 48, 54 Ross, L, 363 Rosser, C L., 567 Rossi, |. S, 325, 327 Roswell, V. A., 442

Roth, M., 98 Rotter, I. B., 20, 279 Rounsaville, B. ]., 202, 404, 478, 567 Rovee-Collier, C., 357 Royce, J R., 135, 150 Rubin, D. B., 355 Rude, S. S., 483 Rudolph, ]. A., 241 Rush, A. J., 9, 75, 202, 412, 439, 470, 483, 486, 542 Rusk, G. S., 96 Russell, D E. H., 216 Russell, R. L., 405 Rychlak, |. F., 136 Ryle, A., 25, 30, 60, 62, 63, 64, 67, 137 Safran, J. D., 4, 14, 22, 25, 28, 29, 30, 64, 66, 67, 68, 73, 121, 134, 146, 147, 597, 604, 608, 611 Sager, C. )., 503 Salovey, P., 607 Saltzman, N, 30, 471 Salusky, S., 484 Salzman, L., 26 Sampson, H., 383 Sander, F., 503 Sank, L. L, 241 Saperia, E. P., 598 Sarason, B. R., 408 Sarason, 1. G., 30, 60, 137, 408 Sarbin, T, R., 148 Sass, L. A., 68, 139, 148, 151 Schacht, T. E.. 15. 70. 71. 121, 136, 150, 155, 568, 587 Schachter, J., 503, 529 Schaefer, C.. 409 Schafer, R., 141, 142, 143, 144, 152, 596 Schapira, K., 98 Schaut, J. I., 254 Scheidlinger, S., 503, 522 Schick, M.. 582 Schmaling, K. B, 484, 607 Schmid, T. L., 328 Schmidt, L. D., 281 Schofeld, W., 411 Schrodinger, E., 148 Schroeder, H., 101 Schwartz, B. D., 62 Schwartz, G. E., 15, 27, 534 Scogin, F , 102 Scogm, F. R , 270 Sears, R. R 62 Sechrest, L B., 266, 463 Seeman, P., 220 Segal, Z V., 28, 73, 134, 147, 398, 597, 604 Scgravcs, R. T., 1 I, 28, 30, 58, 64, 68. 75 Seifer, R., 358 Selby, V. C., 325 Selzer, M. A., 202, 216, 489, 490, 546 Serber, M., 55 Shanfield S., 268, 269, 281, 282 Shapiro, D, 100, 101, 112, 113, 118, 119, 264 Shapiro. D. A., 9, 66, 70, 96, 100, 101, 103, 112, 113, 118, 119, 264, 404, 566, 600 Shapiro, D. H., Jr., 59 Shapiro, R. L, 503 Shaw, B F.. 9, 75, 202, 268, 291, 412, 439, 470, 567, 569 Shear, M. K., 539, 543 Shearin, E. N.. 452 Shectman. F. A., 57

Name Index Sheehan, P. W., 28 Shelton, R. C., 540 Sherman, M., 355 Sherman, W. O., 8 Sherwood, M., 148 Shevrin, H., 30, 272 Shlien, J. M., 104, 146 Shoham-Salomon, V., 266, 270, 274, 288 Shrout, P. E., 410 Silberschatz, G., 106, 108 Silverman, J., 109 Silverman, L. H., 56 Silvers, F., 529 Simek-Downing, L., 69 Simon, K. M., 70 Simons, A. D., 484 Simonson, N. R., 266 Singer, B., 9, 103, 110, 112, 265, 535 Singer, J. L., 75 Siris, S. G., 535 Skinner, B. F., 147 Skodol, A. E., 410, 488 Slife, B., 131 Sloane, R. B., 30, 53, 57, 71, 110, 265, 301, 404 Slowinski, J. W., 241 Smith, D., 130 Smith, D. K., 495 Smith, D. S., 8, 16 Smith, M. B., 133, 135 Smith, M. L., 9, 10, 100, 101, 103, 112, 113, 265, 404, 405, 535 Smith, R. C., 58 Smith, R. L., 241 Snow, M. G., 325 Snyder, D. K., 495 Snyder, M., 355, 356, 360, 361 Sollod, R. N., 22, 56 Soloff, P. H., 490 Solyom, L., 538 Sotsky, S. M., 487, 535 Southern, S., 241 Spence, D. P., 148, 596 Spinner, D., 503, 529 Staats, A. W., 27, 62, 134 Stahelski, A. J., 356 Stampfl, T. G., 374 Staples, F. R., 30, 57, 110, 265, 301, 404 Stein, D. J., 15 Stein, D. M., 101, 104 Stein, M. H., 143 Stein, N., 480 Stein, S. P., 579 Steinbrueck, S. M., 101 Steiner, G. L., 575 Steinfeld, G. J., 27, 68 Steinhauer, P. D., 503 Stephenson, J. B., 409 Stern, D. N., 357, 358 Stern, R., 494 Sterne, A. L, 281 Stevenson, J. F., 569 Stiles, T. C., 405 Stiles, W. B., 9, 66, 117, 118, 119, 207, 404, 405, 409, 600

Stolorow, R. D., 147 Stoltenberg, C., 575 Stolz, S. B., 59 Stone, M., 440 Strauss, L, 572 Strausser, D. ]., 571

625

Strieker, G., 25, 30, 31, 564 Strong, S. R., 25, 30, 67, 208, 214, 266, 607 Strupp, H. H., 9, 10, 55, 57, 59, 61, 77, 106, 121, 264, 268, 273, 291, 345, 405, 411, 412, 470, 478, 489, 567, 569, 570 Stumphazer, J. S., 529 Suarez, A., 456, 489 Suh, L. S., 106 Sullivan, H. S., 75, 339, 345, 346 Svartberg, M., 405 Swan, G. E., 15 Swann, W. B., 356, 360, 361 Swiller, H. I., 503, 529 Symonds, B. D., 10 Szollos, S., 579 Talley, F. P., 268 Tancer, M. E., 544 Tanke, E. D., 355 Tasman, A., 552 Tassinari, R., 543 Taylor, C. A., 105 Teasdale, J. D., 411 Tejero, A., 327 Tellegen, A., 279 Tennant, C., 98 Tennen, H., 281 Teri, L., 99 Textor, M. R., 64 Thase, M. E., 486 Thibaut, J. W., 492 Thiel, J. H., 241 Thomas, B. L, 22, 29, 68, 569 Thomas, D. R., 569 Thompson, L, 108, 486 Thoresen, C. E., 11, 56 Thorne, F. C., 50 Tichenor, V., 107 Tingey, R., 102 Tischler, G. L., 409 Tjelveit, A. C., 270, 288 Tori, C. D., 569 Torrey, E. F., 55 Tracey, T. J., 566 Trijsburg, R. W., 241 Tronick, E. Z., 358 Truax, C. B., 54, 416, 420, 566 Trujols, )., 325 Trull, T. ]., 269 Tupper, C., 115 Turk, D. C., 607 Turkewitz, H., 59 Turnbull, W., 360 Uhde, T. W., 544 Uhlenhuth, E. H., 357, 535 Uranowitz, S. W., 355 van der Kolk, B. A., 437 VanDeusen, J. M., 519 Van Kammen, D. P., 535 Varella, F. )., 596 Vasco, A. B., 16 Vaughn, C. E., 411 Velicer, W. F., 303, 325, 327 Veltum, L. G., 426 Victor, B. J., 608 Viney, W., 136

626

NAME INDEX

Vitz, P. C, 148 von Bertalanffy, L., 203, 232, 534 Wachtel, E. F., II, 14, 68, 208, 335, 345, 362, 364 503, 505, 514, 607 Wachtel, P. L., 5, II, 12, 13, 14, 25, 26, 31, 32, 57 63, 64, 65, 67, 68, 71, 72, 73, 75, 76, 77, 95, 134 147, 154, 208, 233, 321, 335, 336, 337, 343, 344 345, 346, 354, 389, 440, 451, 503, 505, 547, 571 594, 595, 597, 598, 607, 608 Wagner, A., 437 Waldinger, R. )., 489 Waldron, S., 147 Wallerstein, R. S., 597 Walsh, B. W,, 136 Walster, E., 355 Walton, D- E., 16 Wampler, K. S., 101 Wampold, B. E., 269 Wandersman, A,, II, 17, 58 Ward, D. E., 27 Ward, N. G., 538 Waskow, I. E., 16 Watson, G., 48, 585 Watson, ]., 357 Watzlawick, P., 208, 214, 434 Weimer, W. B., 596 Weiss, ). 383 Weissberg, 1. H., 58 Weissman, M. E,, 409, 410 Weissman, M. M , 202, 404. 409, 478, 486 Weitzman, B., 52, 374 Welfel, E. R., 4 Wells, H. D., 438 Welsh, G. S., 269, 275 Werner, H., 21 Wertheimer, M., 136 West, J. C., 105 Westen, D., 69, 75 Wetzel, R. D.. 484 Wexler, D. A., 596 Wheeler, G,, 597 Whipple, K., 30, 57, 110, 265, 301, 404 Whitaker, C. A,, 434, 440 White, H., 133, 141, 144 White, L., 281 Whitehouse, F. A., 52 Whiteside, R., 554 Wicklund, R. A., 377

Widiger, T., 269, 487 Wilcox, N. S., 325 Williams, B. E,, 579 Williams, T,, 255 Wills, R. M., 495 Wilson, G. T., 98, 143, 233 Wilson, L., 115 Wmdholz, M. J., 106, 108 Winnicott, D. W., 155, 505, 597 Winokur, M., 61, 71, 72, 131, 141, 146, 233, 603 Wirshing, W. C., 539 Wiser, S.. 608 Wittgenstein, L, 138 Wittman, L., 65 Wogan, M., 15, 16 Wolf, E., 52 Wolfe, B. E, 4, 12, 15, 16, 24, 28, 29, 30, 68, 69, 119, 120, 137, 138, 141, 306, 374, 377, 378, 381, 382, 471, 594, 598, 600, 607, 608 Wolpe, I., 147, 206, 210 Woods, S. M, 61 Woodward, B., 14, 218, 413, 476, 490, 552, 553 Woodworth, R. S., 48 Woody, G. E., 273 Woody, R. H., 52, 54, 56 Woolfolk, R. L,, 68, 139, 148, 151 Word, C, O., 355 Worthmgton, E. I.., 575 Wurf, E., 398 Wynne, L. C, 363 Yager, J., 539, 545 Yalom, 1. D,, 211, 212, 509, 522 Yamamoto, J., 109 Yates, A. L, 5, 25, 28, 29, 65, 70, 71, 72 Yorkston, N. ]., 30, 57, 110, 265, 301, 404 Young. W. T., 241 Zaida, I.. Y., 437 Zalaquett, C. P., 208 Zanna, M. P., 355 Zeanah, C. H., 358 Zeig, J. K.. 196 Zeiss, A. M, Ill Zilbergeld, B., 253 Zimmerli, W. D., 539 Zmberg, N. E., 555 Zlotowski, M., 552 Zung, W. K., 216

Subject Index

Abreaction, 186, 238 Addictive behavior, treatment of, 326, 468 Adlerian therapy, 171, 187, 232, 309 Adler Society for Individual Psychology, 63 Adolescents, 470, 513, 514 Agoraphobia: outcome research on, 100, 115, 116, 255; patient assessment in, 387; treatment of, 9, 383, 468, 475, 542-43 Alcohol abuse and alcoholism, 325, 468; outcome research on treatment in, 105-6; systemic eclectic psychotherapy for, 292—93 Alprazolam, 221, 544 American Family Therapy Association, 68 American Orthopsychiatric Association, 48 American Psychiatric Association, 47, 274, 435, 463 American Psychological Association (APA), 15, 56, 301, 480, 534 Amitriptyline, 539 Anafranil, 539, 543 Antidepressant medication, 539; borderline personality disorder treatment with, 490; bulimia nervosa treatment with, 545; depression treatment with, 484; outcome research on, 100-2; panic disorder treatment with, 543 Anxiety and anxiety disorders, 206, 232, 492; brief therapy for, 475; change mechanisms in treatment of, 390; cyclical psychodynamics approach to, 347—54; experiencing emotions and reduction of, 376; extinction theory and, 338-40; fear of pain in, 375; Freudian theory of, 338-40, 378; goals of treatment in, 382; integrative psychotherapy of, 373—99; management techniques for, 385; medication for, 540; metappraising as form of emotional processing in, 376—77; multimodal therapy for, 246, 252, 254; outcome research on, 98, 112, 114, 255; patient assessment in, 216, 387—88; placebo response rates in, 538; selfawareness in, 377-78; self-endangerment experiences in, 378-79; self-experiencing in, 389, 390, 395, 398; surfacing painful emotions signalled by, 374-75; treatment approach in, 381-86, 470, 522

Apprenticeship model, 66 Assertiveness training, 191 Assessment. See Patient assessment Assimilative integration, 151-56 Association for Advancement of Behavior Therapy (AABT), 15, 59, 61 Associative learning, 212 Attention deficit disorder, 539 Automatic thoughts, 213 Aversion therapy, 56 Avoidance behavior, 61, 190, 206, 339 BASIC I.D., in multimodal therapy, 236, 237, 243, 249, 254, 257 Beck Depression Inventory, 113, 216, 486 Behavior: context and, 343; dialectic perspective on, 438; early development and, 337; individual therapy and, 505; inferences and, 342; preconceptions and, 356 Behavioral confirmations, 354 Behaviorism, 48, 56, 58, 73, 135 Behavior rehearsal, 253 Behavior therapists, 140, 338; development of psychotherapy integration and, 48-49, 57; epistemological values of, 150, 603; explanations for patients provided by, 187; exposure used by, 210; reinforcing behaviors of, 189; use of integration by, 15, 18, 30, 31 Behavior therapy, 307; cognitive methods used in, 53-54, 60, 62, 68, 69, 73-74, 96; common factors approach using, 180; contributions to integration from, 212; converging trends within major approaches and, 595—97; cyclical psychodynamics and, 336, 342—47; development of psychotherapy integration and, 48, 49, 56, 58, 59; dialectical behavior therapy (DBT) and, 433, 434-35; exposure and change in, 205-6; Gestalt techniques used with, 152; integrative approaches to, 70; limitations inherent in, 51; marital therapy with, 59; metacommunications and intervention points

628

SUBJECT INDEX

Behavior therapy {continued) in, 208; mythic forms in, 141-47; need for research validation in, 344; obesity treatment with, 325; outcome research on, 113, 114-16; personality disorders treatment with, 76; phobia treatment with, 145, 147, 374, 382; psychoanalytic approaches used with, 56, 57, 59—60, 62, 66, 71, 73, 76-77, 152-54; psychodynamic therapy compared with, 51-52; psychodynamic therapy integrated with, 52-53, 55-56, 69; psychotherapy integration combinations using, 18, 19. 21; psychotherapy integration interactions with, 26, 27-28; self-help materials with, 99; therapeutic alliance in, 185; training and, 196 256: transthcoretical approach and.. 309, See also Cognitivebehavioral therapy (CBT); Learning therapy Benzodiazepmes, 490, 540, 549 Bereavement, outcome research on, 120 Belief structures, 130-56; definitional issues in, 131; epistcmological values of therapist and, 150-51, 603; hermeneutic and natural science approach in, 147-50; mythic forms in psychotherapy and, 141 -47; patient and. 187-88; philosophical considerations in, 132-41 Bibliotherapy, 210 Biofeedback, 232 Biosocial theory of borderline personality disorder, 435-37 Bipolar disorders, 218, 280, 476, 493 Black patients, and choice of therapist, 269 Borderline personality disorder (BPD.), 208, 433, 477; biosocial theory of. 435-37; combined pharmacotherapy and psychotherapy treatment for, 545-47; co-morbid conditions with, 488; diagnostic criteria for, 487—88; dialectical behavior therapy (DBT) for, 433-34, 441-56, 490; goals of treatment of, 442, 488—89; treatment planning for, 487-91, 522 Boundary experiences, 21 1- 12, 213—14 Bowenian therapy, 27, 309 Breathing techniques, 391, 396 Bridging, in multimodal therapy, 247-49 Brief psychodynamic therapy, 146, 467; depression treatment with, 485-86; duration of, 474; indications for, 475; planning for, 474-76; psychoanalytic therapy used with, 52. See also Short-term psychotherapies Brief Symptom Inventory, 216 Buddhism, 59, 434 Bulimia nervosa, 544-45

California Psychotherapy Alliance Scale tCALPAS), 107, 108 Carbamazepine, 490, 540, 546 Case examples: common factors approach, 192-94; cyclical psychodynamics, 347—54; dialectical behavior therapy (DBT) of borderline personality disorder (BPD), 452-56; individual and family therapy integration, 519—20, 520—21; individual and group therapy integration and, 526—28; integrative approach to panic disorder and major depression, 221-27; integrative psychotherapy of phobias, 392—97; multimodal therapy, 251— 54; systemic eclectic psychotherapy, 282—88; transtheoretical approach, 317-24 Catastrophic imagery, and phobias, 374, 384-85 Catharsis, and common factors approach, 178, 186 Causality, and cyclical psychodynamics, 344-45

C-D1S, 216-17 Change: anxiety disorders treatment and, 338-40; assimilation model of, 117-18; combined pharmacotherapy and psychotherapy treatment and. 550--51; common factors approach and mechanisms of, 183—92, 599; common factors approach to, 13; core schemas and, 204—5, 206, 207, 208-9, 213; cyclical psychodynamics and, 353; desensitization and, 189-90; development of integrative approach and focus on, 56, 61; dialectical behavior therapy (DBT) of borderline personality disorder (BPD) and, 450—52; dialectical perspectives on, 438—39; emotional release or catharsis related to, 186; explanation, rationale, and interpretation needed for, 186—88; exposure and, 2 0 5 - 6 209--IO: extratherapeutic (between sessions/, 49-50, 63-64; individual and family therapy integration and, 518—21; insight as source of. 338, 389 45 1; mechanisms of, 220, 388-89; multimodal therapy and, 238-39; outcome research on factors influencing, 120—21; patient variables and degree of. 184; patient's perception of therapist and, 185; problem confrontation and, 190-91; processes in, 51; reinforcement and, 188-89; relationship in psychotherapy and, 185; research on processes and patterns of, 329-30; resistance to, 392; self-observation by patient and, 205; skill of therapist and. 183-84; skills training for patient for, 191; stage:; of, 324-25; systemic eclectic psychotherapy and, 282; targets for, 220, 224—25; time as variable for, 192; transtheoretical approach and, 302--8, 316--I7; treatment strategy modifications related to degree of. 277-78; working through and, 339-40 Children: behavior therapy for conduct disorders in, 13; borderline personality disorder (BPD) development and, 43o-37; expectation formation in, 357-58; phobia and traumas in, 380: role of therapists with, 1 70 Choice ot a therapeutic approach: affective-cognitive-behavior schema in, 27; common factors approach and, 179—80; comparative outcome studies on, 112-13, 195; diagnosis and, 165; factors influencing, 16-17; multimodal therapy and, 62, 237-38; need for outcome research on techniques affecting, 28, 95-96; no treatment as choice in, 476-77, research as one factor in, 29; technical eclecticism and, 11 Client-centered therapy and Rogerian therapy, 141, 171, 196, 3 73, 597; complementarity among orientations and, 598; outcome research on, 104, 106; psychotherapy integration combinations using, 17, 19, 232, 416; reinforcing behaviors in, 188: research viewed in, 170; similarities among psychoanalytic and behavioral therapies and, 53; transtheoretical approach and, 309—13 Clomipramine, 539, 543 Clonazepam, 544 Cocaine abuse treatment, 325 Cognitive-behavioral therapy (CBT), 597; borderline personality disorder treatment with, 489; complementarity among orientations and, 598; marital distress treatment with, 494, 495; outcome research on, 110-11, 112, 113, 115-16, 118-19; phobia treatment with, 233. See also Behavior therapy Cognitive psychology, and common language issues. 30, c-3-o4, 137-38 Cognitive rehearsal, and outcome, 1 14

Subject Index Cognitive styles, and treatment planning, 478, 479 Cognitive therapists: tragic vision used by, 145; use of integration by, 15 Cognitive therapy, 60, 62, 307, 607; behavior therapy with methods from, 53-54, 60, 62, 68, 69, 73—74, 96; belief structure in, 146; common factors approach using, 180; contributions to integration from, 212-13; converging trends within major approaches and, 596—97; depression treatment with, 197, 541; dialectical behavior therapy (DBT) and, 439-40; Gestalt techniques used with, 62; integrative approaches with, 27—28, 70; metacommunications and intervention points in, 208; outcome research on, 113, 197; panic disorder treatment with, 13; personality disorders treatment with, 76; psychoanalytic therapy used with, 152—54; psychotherapy integration combinations using, 18, 19; research on, 289; self-help materials with, 99; therapeutic relationships in, 75-76. See also Cognitive-behavioral therapy (CBT) Common factors approach, 10, 13—14, 169—97; applicability of, 176-77; change mechanisms in, 183—92; comparative studies supporting, 171, 195; depression treatment with, 412—27; early research on, 171; emotional release or catharsis in, 178, 186; first session in, 177—78; frequency and length of sessions in, 177; future directions in, 196—97; guiding principles of, 172—74; interventions to be avoided in, 424—25; lack of progress during, 182; patient assessment in, 174—76; plan for intervention in, 178; research on, 194— 96; resistance in, 178—79; selection of procedures in, 179—80; social support in, 415; termination in, 177, 181-83; therapeutic relationship in, 180-81; therapist's approach in, 179—80; training and, 196 Communication styles; combined pharmacotherapy and psychotherapy treatment and, 554-55; dialectical behavior therapy (DBT) of borderline personality disorder (BPD) and, 449 Community support services, 565 Compulsive disorders: behavior therapy for, 147; outcome research on, 114, 115 Conditioning, 25, 47-48, 232 Conduct disorders, behavior therapy for, 13 Confidentiality, 511-12 Conflict resolution, 206; anxiety treatment with, 386; intervention and, 343 Confrontation, 190 Conjoint therapy, 13. See also Marital therapy Consciousness-raising process, 302, 304, 305, 308, 313, 314 Context, and behavior, 343, 364 Contextualism, 133, 151-52 Contingency management, 302, 308 Contract, therapeutic, 280, 555 Coping styles: alcohol abuse treatment and, 29293; change and, 238; cyclic types in, 275, 276, 478; internalizing types in, 274-76, 285, 478; outcome research on, 115, 289—90; patient assessment of, 274-75, 276-77, 285; problem severity and, 271; repressive, 275, 276, 478; transtheoretical approach and, 302; treatment planning and, 478-79 Core Conflictual Relationship Theme (CCRT), 273 Core schema: case example of treatment with, 222— 23; change and, 204-5, 208-9, 220; interpersonal relationships and, 207—8; metacommunications and and interpersonal loops in, 208; self-observation and, 208, 209

629

Counterconditioning, 302, 306, 308 Countertransference, 440; case example with, 22324; integrative approaches and, 214, 215, 219, 548, 550 Couples therapy. See Marital therapy Crisis intervention, 473-74 Cultural values: development of different schools of therapy and, 54; gender role stereotypes and, 214, 216 Cyclical psychodynamics, 335—65, 608; behavioral contributions to, 342—47; case example of, 347— 54; characteristic features of, 352-53; influences on development of, 336; origins and key concepts in, 336-47; research on, 354-65; synthesis forged in, 336, 347 Day hospital, 464 Deep muscle relaxation, 115 Defense mechanisms, 235, 274, 339 Depakote, 540 Depression, 481, 606; borderline personality disorder with, 488; brief therapy for, 475; case example of treatment of, 221—27, 252; combined pharmacotherapy and psychotherapy treatment for, 541—42; common factors therapy for, 402— 27; goals of treatment of, 481—82; group therapy for, 470; integrative approaches to, 218, 221-27, 470, 527-28; marital distress and, 492, 493; medication for, 413, 483, 484, 539; mother-child dyad and, 358; multimodal therapy for, 252; outcome research on, 98, 102, 110, 112, 113, 197, 405-6; patient assessment for, 240, 483; placebo treatments for, 406—8; social support and, 408-11, 414-15; treatment planning for, 480-87, 522 Desensitization: cognitive-behavioral approach to, 233; common factors approach and, 178, 189-90, 600; cyclical psychodynamics case example with, 348, 351; nature of process of, 189; outcome and, 114; phobia therapy with, 190, 233 Development: borderline personality disorder (BPD) and, 436-7; emphasis on early, 337; social skills and, 340 Diagnosis: borderline personality disorder and, 487-88; multiaxial system for, 463, 534; outcome research and, 98; patient assessment and, 217; pharmacotherapy and psychotherapy integration and, 539-40; treatment choice and, 265, 479-80 Diagnostic and Statistical Manual (DSM-III), 480, 487, 488, 492, 534; DSM-III-R, 217, 312, 441, 452, 487, 534, 546 Dialectical behavior therapy (DBT): applicability and structure of, 443-45; background of, 433-34; borderline personality disorder (BPD) treatment with, 433—34, 441—56, 490; case example of borderline personality disorder treatment with, 452— 56; client and therapist roles in, 446; concepts influencing, 434-40; dialectical philosophy in, 437-41; future directions for, 457; goals of, 442; mechanisms of change in, 450—52; model of integration in, 440—43; patient assessment in, 441 — 43; research on, 456; strategies and, 446-48; therapeutic relationship in, 449—50 Differential therapeutics, 131, 463—64 Divorce, 504; marital distress treatment and, 494; marital therapy and, 215, 320 Dramatic relief process, 302, 304, 308 Dream analysis, 598 Driving phobia: case examples of integrative psy-

630

SUBJECT INDEX

Driving phobia (continued! chotherapy of, 392—97; patient assessment in, 387-88 Drug abuse, 218 Drug therapy. See Medication and specific drugs Duration of therapy: brief therapy and, 474—76; common factors approach and, 176-77; contract for, 280; crisis intervention and, 473—74; longterm psychotherapy and, 476; outcome and, 473; systemic eclectic psychotherapy and, 280; transtheoretical approach and, 312 Eating disorders, 9, 544 Eclecticism, 62, 95; characteristics and attitudes of therapists using, 16-17; consensual distinctions between integration and, 12-13; degree of freedom in use of, 172; factors influencing choice of, 16—17; future directions for, 594-95; incidence of, 15-16, 130—31; reasons for existence of, 60; syncretism in approach to, 20-21, 232; theories used by, 18, 19; therapist orientations in, 96, 130—31; types or categories of, 195; use of term, 4, 18-19. See a/so Psychotherapy integration Education of client: anxiety management techniques in, 385; case example with, 224—25; dialectical behavior therapy (DBT) of borderline personality disorder (BPD) and, 448-49; integrative approaches with, 210, 217, 218 Edwards Social Desirability Scale, 274 Ego psychology, 146-47, 233 Elavil, 539 Emotional release, in common factors approach, 178, 186 Emotion-regulation training, 448-49 Empathy, 420, 421-22, 605 Empty-chair technique, 62, 152, 232 Encounter groups, 187 Environment: borderline personality disorder (BPD) and, 436; personality development and, 155, 337 Environmental reevaluation process, 302, 308 Ericksonian school, 232 Ethnic factors, and choice of therapist, 269 Existential therapy, 27. 135; contributions to integration from, 211-12; core interpersonal schema in, 207 Expectancy effects, 354 Expectations: cognitive capacity and, 357-58; cyclical psychodynamics and, 360—63; symptom relief and, 357; training and, 568-70 Experience Scale, 398 Experiential therapy, 146, 276, 478; converging trends within major approaches and, 595—97; psychotherapy integration and, 21, 30, 70 Explanations, therapeutic value to patient of, 186— 87, 188 Exposure, 212; case example with, 225, 393; change and, 205-6, 209-10; forms of, 210; phobia treatment with, 374, 381, 391, 393 Exposure-based therapies, outcome research on, 115 Expressed emotion (EE), 471 Externalizing coping style, 274—75, 277, 478 Extinction, 61, 238 Extratherapeutic improvement, 97, 98 Family systems theory, 256-57, 330, See also General systems theory Family therapy, 254, 307; advantages of, 506--7; anxiety treatment including, 386, 387; common

factors approach for, 176; contra-indications for, 470, contributions to integration from, 215—16; depression treatment with, 484, dialectical behavior therapy (DBT) of borderline personality disorder (BPD) and, 444; formats for, 468-70; indications for, 469—70; individual therapy integrated with, 513-21, 607; limitations of, 507-8; one-therapist structure for, 512-13; psychotherapy integration with, 14, 68; schizophrenia treatment with, 542. See also Marital therapy Fixed Role Therapy, 210 Flooding, 114, 190, 232 Fluoxetine, 539, 543, 545 Focused-expressivc psychotherapy (FEPj, 289 Formisrn, 133 Free association, 598 Free will, 211 Frequency of sessions: common factors approach and, 177, 182-83; integrative approach and, 218 Freudian theory, 169, 187, 336; anxiety theory in, 338-40, 378; phobia in, 380 Future directions, 593—611; anxiety disorders treatment and, 397—99; common factors approach and, 196—97; cyclical psychodynamics and, 364— 65; dialectical behavior therapy (DBT) of borderline personality disorder (BPD) and, 45 7; integrative approaches and, 227; multimodal therapy and, 258—59; psychotherapy integration and, 604-9; supervision in training and, 578-80; systemic eclectic psychotherapy and, 292-93: transtheoretical approach and, 328-30 Gambling, 468 Gender roles, 214, 216 Generalized anxiety states, 540 General systems theory. 203, 232. See also Family systems theory Genograms, 215 Gestalt therapy, 48, 61, 256, 304, 309, 373, 440; behavior therapy combined with, 152; cognitive therapy combined with, 62; core interpersonal schema in, 207; empty-chair technique in, 62, 152; integrative approaches using, 70, 232, 597; training and, 291; two-chair technique in, 152, 373, 386 Goals of therapy: borderline personality disorder (BPD) and, 442, 488; depression treatment and, 481-82; dialectical behavior therapy (DBT) and, 442; family and marital therapies, 469; individual and family therapy integration and, 516; individual therapy and, 465; integrative psychotherapy of anxiety disorders and, 382; marital distress treatment and, 493—95; multimodal therapy and, 236, 241-42; prioritizing, 176; psychotherapy integration and, 4, 76—77; transtheoretical approach and, 301; treatment strategy modifications and, 277-78 Grief work: case example with, 223; integrative approaches and, 210, 214 Group for the Advancement of Psychiatry (GAP), 535 Groups, self-help, 99 Group therapy: advantages of, 508—10; bulimia nervosa treatment with, 545; contra-indications for, 467, 468; dialectical behavior therapy (DBT) of borderline personality disorder (BPD) and, 446— 48; exposure in, 210; formats for, 466-68; heterogeneous groups in, 466—67; homogeneous groups in, 466, 467-68; indications for, 467, 468;

Subject Index individual therapy integrated with, 522-29; limitations of, 510-11; one-therapist structure for, 512-13; outcome research on, 109, 197; psychotherapy integration with, 14 Gunderson Diagnostic Interview for Borderlines, 441, 452 Hamilton Rating Scale for Depression, 486 Health maintenance organizations (HMOs), 8 Histrionic personality disorder, 488 Homework assignments, 49—50, 212, 218 Homosexuality, 355, 504 Humanistic therapy: contributions to integration from, 211; development of psychotherapy integration and, 56, 58; mythic forms in, 141-42, 143-44, 145-46; outcome research on, 96, 118— 19; psychotherapy integration combinations using, 17, 18, 19. See also Client-centered therapy and Rogerian therapy; Gestalt therapy Human potential movement, 8 Hypnosis, 205 Hysterical disorder, outcome research on, 98 Identification, 232 Imagery exercises, 349-51 Imipramine, 110, 221, 225, 539, 542, 545 Imitation, 235 Implosion, 190 Impulse disorders, 468 Individual psychotherapy, 5; advantages of, 466, 504—5; behavioral change in, 505; common factors approach for, 176; contra-indications for, 466; failure of, 467; family therapy integrated with, 513-21, 607; format for, 465-66; goal of, 465; group therapy integrated with, 522—29; limitations of, 505-6; marital therapy and, 21415; psychotherapy integration with, 14, 31, 68; therapeutic relationship in, 465, 504 Inference, 342, 603, 608-9 Initial interview: common factors therapy and, 17778, 417-18; multimodal therapy and, 239-40; patient assessment during, 175, 176; transtheoretical approach and, 310 Insight, 99, 348; change through exposure and, 210, 389, 451; emphasis on use of, 338; treatment techniques with, 292-93 Integration: three-dimensional notion of, 204; use of term, 4, 18—19. See also Psychotherapy integration Integrative psychodynamic therapy, 335. See also Cyclical psychodynamics Interpersonal relationships: borderline personality disorder (BPD) and, 449; change in therapy and, 238; core schema and, 207; group therapy and, 466—67; response patterns in, 269—70; roles in, 214 Interpersonal therapy, 478; common language issues and, 67; contributions to integration from, 214, 336; depression treatment with, 197; learning environments and, 281; metacommunications and intervention points in, 208; outcome research on, 110-11, 197; psychotherapy integration combinations using, 18, 19 Interpretations, therapeutic value of, 187-88 Interventions: behavior therapy and, 342; cognitive style of patient and, 478; cyclical psychodynamics and, 345; importance of active, 341; integrative approaches and, 218—19; marital therapy and multiple, 215: metacommunications and points

631

for, 208; reactance level and, 274; systemic eclectic psychotherapy and, 275-76 Interviews. See Initial interview Ironic vision, 141, 142-43, 147 lungian therapists, 187 Klonopin, 544 Language: approaches to, 140—41; belief structures and, 137-41; disadvantages to use of common, 138; limits to a common, 138—40; multilingualism as approach to, 140, 155; psychotherapy integration use and issues in, 25, 29-30, 63-64, 67, 151, 603, 607; therapist's use of, 353-54; training and, 155; use of vernacular as common, 29, 67, 137, 140-41 Learning, interpersonal influences on, 281 Learning theory, 137, 139; psychotherapy integration combinations using, 17, 19, 232; therapeutic changes in terms of, 51. See also Behavior therapy Length of sessions: common factors approach and, 177; transtheoretical approach and, 313 Listening skills, 291 Lithium, 490, 540 Locus of Control Scale, 279 Long-term psychotherapy, 476 Mania, treatment of, 540 Manuals, treatment, 9, 202, 326-27, 412-16, 470, 471, 472, 478, 482 Marital distress, 492; co-morbid conditions with, 492; decision tree and assessment questions in, 493; goals of treatment of, 493—95; spontaneous improvement in therapy and, 98; treatment planning for, 491-96 Marital therapy, 221; anxiety treatment including, 386-87; common factors approach for, 176, 19294; conflict resolution in, 206; contra-indications for, 470; contributions to integration from, 214— 15; depression treatment with, 484; format for, 465; indications for, 469—70; integrative approaches used in, 59, 70; outcome research on, 255; transference issues in, 75; transtheoretical approach to, 317—24. See also Conjoint therapy; Family therapy Marks Mathews Fear Inventory, 216 Medication, 205, 217; borderline personality disorder treatment with, 490, 546—47; depression treatment with, 413, 483, 484, 541-42, outcome research with, 100-2; panic disorder treatment with, 217, 539, 540, 549; psychotherapy integration with, 14, 68; self-abuse through, 549; treatment planning with, 476 Meditation, 448 Menninger Foundation Psychotherapy Research Project, 56 Metacommunication, 214; interpersonal loops in, 208; personality and, 235 Michigan Alcohol Screening Test, 216 Minnesota Multiphasic Personality Inventory (MMPI), 217, 274, 275, 289; MMPI-2, 275, 279 Modality Profiles, 241-43, 246, 249, 250, 252-53, 257 Modeling, 190, 235; change mechanisms with, 238; development of psychotherapy integration and, 49, 212; outcome and, 114, 115

632

SUBJECT INDEX

Monoamine oxidase inhibiters (MAOls), 490, 544, 548 Motivation: expectations and, 361; intervention and, 343 Multimodal Life History Inventory, 241, 242, 243, 250, 252 Multimodal therapy (MMT), 27, 236-59; BASIC I.D. in, 236; bridging in, 247-49; case example of, 251—54; change mechanisms in, 238—39; development of, 52; distinctive features of, 250—51, future directions in, 258-59; goal of, 236, 24142; initial interviews in, 239—40; integration in, 232-34; Modality Profiles used in, 241-43, 246, 249; outcome in, 236-37; patterns seen in, 24647; prescriptive decisions in. 62, 237—38; research findings in, 254-56; Second-Order BASIC I.D. in, 249-50; Structural Profiles used in, 243-46; training in, 256-58, 572 Mythic forms, 141-47; comic vision in, 145-46; eclecticism and, 146—47; ironic vision in, 142—43; romantic vision in, 141—42; tragic vision in, 143-45 Narcissistic personality disorder, 488 Nardil, 544 National Institute of Mental Health (NIMH), 4, 12, 69, 110, 120, 197, 405, 406, 407, 408, 413, 416, 481, 483, 533 Navane, 551 Neo-Freudian theory, 17, 22, 146-47, 336 Neuroleptic medications, 490, 539, 542 Neurotic conditions, 98, 218 Obesity treatment, 325, 468 Object relations theory, 154, 233. See also Psychoanalysis and psychoanalytic therapy Obsessive-compulsive disorder (OCD): combined approaches to, 56, 543—44; multimodal therapy for, 255; outcome research on, 98, 255; placebo response rates in, 538, 539; specialized clinics for treatment of, 9 Operant conditioning, 114, 212, 235 Organicism, 133—34; eclecticism and, 132, 135; unity-discovery model in, 134—35 Organicity, patient assessment of, 240, 279 Organizations, interdisciplinary professional, 4-5, 7, 10, 15, 65, 78, 602 Outcome; assimilation model of change and, 11718; client reporting on, 108-9; common factors approach and, 183-84; common factors across therapies and, 103—4, 105; coping styles and, 115, 289-90; deterioration during therapy as, 103; different therapies and differences in, 9, 110-12, 119, 120, 403-6; duration of therapy and, 473; factors affecting change and, 120—21; patient variables influencing, 10, 121, 184, 204, 406; placebo response and, 220; progress during sessions and, 176; qualities of therapists and, 109-10, 183-84, 204; self- fulfilling prophecy and, 356—57; spontaneous remission as, 98—99; superiority of one school or technique affecting, 103—12; technique variables influencing, 10, 204; therapeutic alliance and, 10, 104-8, 265; therapist self-ratings and, 109; training of therapists and, 265—66; treatments as generally beneficial in, 99— 103; without formal psychological intervention, 98-99 Outcome research, 94-122; choice of treatment

techniques and, 95-96; commitment to, 95; comparative studies in, 118-19, 195, 197; conclusions and implications of, 96—112; depression therapy in, 98, 102, 110, 112, 113, 197, 405-6; future directions in, 28, 96, 116-22; group therapy in, 109; improvement percent as function of therapeutic factors in, 96-98; lack of, as obstacle to use of integrative approach, 24; meta-analytic reviews of effects of therapy in, 100—2; multimodal therapy in, 255; therapist variables in, 119; surveys used in, 96 Panic disorder, anxiety reduction through experiencing emotions in, 376; case example of treatment of, 221-27, 395; catastrophic imagery in treatment of, 384, 385; change mechanisms in treatment of, 391; cognitive therapy for, 13; combined pharmacotherapy and psychotherapy treatment for, 543; integrative approach to, 218, 221-27; medication for, 217, 539, 540, 549; outcome research on, 115, 116, 255; patient assessment in, 217, 387; placebo response rates in, 538; surfacing painful emotions signalled by, 375 Parasuicidal behavior, 433; borderline personality disorder (BPD) and, 441, 442, 447; dialectical behavior therapy (DBT) and, 451-52, 453, 454 Parnatc, 546 Patient assessment, 216—17; anxiety therapy with, 387—88; case example of use of, 221—22; common factors approach with, 174—76; coping style in, 274-75; depression treatment and, 482; diagnostic categories and, 217; dialectical behavior therapy (DBT) of borderline personality disorder (BPD) and, 441-443; individual and family therapy integration and, 513-15, individual and group therapy integration and, 522—24; individual therapy and, 504, 505-6; initial interview and, 175-176; levels of, 217; marital distress treatment and, 493: multimodal therapy and, 239-40, 241-46, 254; no treatment as choice after, 477; problem complexity and, 272—73; problem severity and, 271-72: questionnaires for, 216; reactance level in, 273—74; research on, 174—75; systemic eclectic psychotherapy and, 271-77, 278-79; transtheorehcal approach and, 310—11; treatment integration with, 217 Pavlovian conditioning, 47-48, 235 Personality: basic concepts of, 235, 337; behavior therapy and, 345; environment and development of, 155; idiographic view of, 170; of therapist, and outcome, 184 Personality disorders, 214; cognitive-behavioral approach to, 76; integrative approaches to, 218; spontaneous improvement and, 98 Perspectivism, 136-37 Persuasion theory, 281 Pharmacotherapy and psychotherapy integration, 70, 533-56; change and, 550-51; contract used in, 555; controlled research trials in, 536-41; diagnosis and, 539—40; historical overview of, 533-36; research on, 543-47, termination and, 55 1-52; therapist collaboration in, 552-55; transference and countertransference in, 550 Phenelzine, 544 Phenomenology, 133, 137. See also Gestalt therapy; Humanistic therapy Phobias and phobic disorders, 655; anxiety reduction through experiencing emotions in, 376: be-

Subject Index havior therapy for, 145, 147, 374, 382; brief therapy for, 475; case examples of integrative psychotherapy of, 392-97; catastrophic imagery in, 374, 384-85; change mechanisms in treatment of, 390-91; desensitization for, 190, 233; exposure therapy for, 374, 381, 391, 393; Freudian model of, 380; multimodal therapy for, 255; outcome research on, 98, 115, 255; patient assessment in, 387-88; symbolic connection of, 376. See also specific phobias Piagetian theory, 70 Placebo response, 51, 205, 217; change as result of, 220; combined pharmacotherapy and psychotherapy treatment and, 536-39, 542; depression treatment and, 406—8, 483; outcome research on, 97, 357 Pluralism, 135-35 Positive feedback, 191 Preorgasmic disorder, 52 Prescriptive selection, 131 Problem complexity, in patient assessment, 272-73, 276, 284 Problem-focused psychotherapies, 8, 61 Problem severity, in patient assessment, 271-72, 276, 280 Prozac, 539, 543, 545 Psychoanalysis and psychoanalytic therapy, 48, 66, 171, 219, 276, 338; behavior therapy used with, 56, 57, 59-60, 62, 71, 73, 76-77, 152-54; cognitive therapy used with, 152—54; common language issues and, 135, 137, 140; complementarity among orientations and, 598; core interpersonal schema in, 207; importations or parameters used within, 154; interpersonal perspective in, 597; metacommunications and intervention points in, 208; mythic forms in, 141, 142-43, 144, 145, 146-47; Pavlovian conditioning similarities to, 47—48; phobias in, 380; psychotherapy integration combinations using, 17, 18, 19, 21, 233; psychotherapy integration interactions with, 26, 27-28, 31, 56; relaxation technique in, 154; systemic desensitization used with, 52, 53; training and, 196, 256; transtheoretical approach and, 309; working through in, 339. See also Psychodynamic therapy Psychoanalytic therapists, 31, 170 Psychobehavioral therapy, 52 Psychobiography, 133 Psychodrama, 232, 304, 473 Psychodynamic therapists, use of integration by, 18, 31, 57 Psychodynamic therapy, 478; behavior therapy compared with, 51-52; behavior therapy integrated with, 52—53, 55—56; borderline personality disorder treatment with, 489; converging trends within major approaches and, 595—97; cyclical psychodynamics and, 336, 341-42, 34447; integrative approach using, 56, 70, 213-14, 233; limitations inherent in, 51; therapeutic relationships in, 75-76. See also Psychoanalysis and psychoanalytic therapy Psycho-Epistemological Profile, 150 Psychopharmacology: effectiveness of, 205; psychotherapy integration with, 14. See also Pharmacotherapy Psychotherapists. See Therapists Psychotherapy: common factors seen in, 171, 173— 74; mythic forms in, 141—47; proliferation of schools of, 7; stages of, 206

633

Psychotherapy integration: barriers and obstacles to use of, 22-25, 581-82, 601-3; characteristics or attitudes of therapists using, 16-17; common factors approach to, 13—14, 169—97; complementarity of divergent approaches in, 26-27, 598; convergence of areas in, 30—31; current interest in use of, 6-7; differing perspective on reality in, 71—73; eclecticism differentiated from, 12—13; evolutionary process of, 154-55; factors facilitating choice of, 7, 16—17; future of, 604—9; goals of, 4, 76-77; guiding principles for, 203-6; history of, 46-78; ideological struggle and, 3-4, 5-6; inadequacy of single theories and, 7—8; interaction of cognition, behavior, and affect in, 27-28; interest in short-term psychotherapies and, 8; lack of research on, 14—15, 24—25; language issues in, 25, 29-30; models for, 202-3. 205; multiple paths toward, 6; need for more research on strategies in, 28-29; opportunities to observe and experiment with, 8—9; outcome differences among different therapies and, 9; parameters definition in, 14-15; prevalence of, 15-16, 17-19, 22-23; professional organizations and networks devoted to, 4—5, 7, 10, 65; publications and journals devoted to, 4, 5, 7, 53, 65; routes to, 10-15; stages in use of, 21; summary of contributions from schools in, 211—16; technical eclectism in, 11; themes in use of, 26-31; theoretical integration in, 11-13 Punishment, and therapeutic change, 51, 238 Racial factors, and choice of therapist, 269 Rapprochement. See Psychotherapy integration Rational-emotive therapy, 145, 309 Rationales, therapeutic value of, 187-88, 415, 418 Reactance level, 284-85; patient assessment of, 273-74, 277; treatment choice and, 280, 281, 479 Referral decisions, and training, 564-65 Reflexive thinking, 378 Reinforcement, 188-89, 191, 238 Relationship-oriented therapy, outcome research on, 112 Relaxation techniques, 115, 154, 205, 217, 218, 232, 253 Repression, 206, 339 Research: anxiety disorders treatment and, 397—99; behavior therapy validation with, 344; belief structures and importance of, 147-50; change processes and, 329—30, 606; combined pharmacotherapy and psychotherapy treatment and, 543—47; common factors approach and, 171, 194-96; comparative studies needed in, 329; cyclical psychodynamics and, 354—65; depression therapy in, 405—6; development of methodologies for, 29; dialectical behavior therapy (DBT) and, 456; integrative approaches and, 226; methodological pluralism in, 148; multimodal therapy and, 254-56; need for psychotherapies based in, 24-25, 28-29, 169-70; patient assessment in, 174-75; psychotherapy integration and, 606-7; systemic eclectic psychotherapy and, 288-90; training effectiveness and, 293; transtheoretical approach and, 324-28 Resistance, 139, 477, 598; change and, 392, common factors approach and, 178—79; integrative approaches and, 218-19; outcome research on, 289-90 Response patterns, 269—70

634

SUBJECT INDEX

Rewards, and therapeutic change, 5 I Rogerian theory. See Client-centered therapy and Rogerian therapy Role playing, 253; common factors approach using, 181; skills training using, 191 Romantic vision, 141—42, 146 Schema, 146, 212; change and, 204-5, 207-9, 213, 220; common language issues and, 30, 137; integrative models using, 62, 74; metacommunications and and interpersonal loops in, 208; resolution of unresolved trauma and, 206 Schizophrenia, 218, 468. 470, 471, 476, 597; combined pharmacotherapy and psychotherapy treatment for, 542; medications for. 534, 539 Scientific modernism, 148 SCL-90R, 273, 279 Scripts, 146; change and, 209; common language issues and, 30, 137; integrative models using, 62 Second-order BASIC I.D., 249-50, 253 Self-awareness, and anxiety disorders, 377-78, 398 Self-experience, in anxiety disorders treatment, 389.. 390, 395, 398 Self-fulfilling prophecy, 354, 355--57 Self-help, 99 Self-liberation process, 302, 305-6, 308, 313 Self-psychology, 146—47. 154, 233. See also Psychodynamic therapy Self-reevaluation process, 302, 305, 308, 313 Self-regulation approaches, and outcome, 1 14 Self-statements, 213, 232 Sexual abuse, 206, 216, 437, 605 Sexual dysfunctions, 56, 495; multimodal therapy for, 252; outcome research on, 114; specialized clinics for treatment of, 9 Sheffield Psychotherapy Research Project, I 18 Shipley Institute of Living Scale, 279 Short-term psychotherapies, 8, 56; psychoanalytic therapy used with, 52. See also Brief psychodynamic therapy Sibling rivalry, 509-10 Signal anxiety, 339 Situationism, 343 Skills training: dialectical behavior therapy (DBT) of borderline personality disorder (BPD) and, 444, 448, 456, 457; patient change and, 191, 486 Smoking, transtheoretical approach to, 325-28 Social interaction model, 583 Social issues: cyclical psychodynamics and, 364-65; development of psychotherapy integration and, 50 Socialization issues, and group therapy, 530 Social learning theory, 137, 139, 232 Social phobia, 544 Social skills: patient training for, 191, 352-53; therapy and learning of, 340-41, 486 Social support: depression incidence and, 408-11; depression treatment and, 414-15; spontaneous improvement in therapy and, 98; treatment choice and, 280 Society for the Exploration of Psychotherapy Integration (SEPI), 5, 10, 22-23, 65, 78. 258, 373, 463, 584, 610-H Somatoform disorders, 468 Spontaneous remission, 192, 477; clinical trials and, 540; outcome research on, 98-99 Stages of Change Scale, 303 Stereotypes, 214, 355, 361

Stimilus control, in transtheoretical approach, 302, 306, 308 Strategic therapy, 210, 309 Stress-response syndromes, outcome research on, 120 Structural Profile, 243-46, 250, 254-55, 257 Structural Profile Inventory (SPI), 245 Structural therapy, 309 Structured Analysis of Social Behavior (SASB), 121 Substance abuse, 492 Suicidal tendencies, 5 10; borderline personality disorder (BPD) and, 435, 437, 441, 457, 488, 490; common factors therapy for depression and, 418; individual therapy and, 504, 506; patient assessment for, 240, 279; treatment manuals for, 470 Sullivanian therapy, 28, 75, 187, 309, 339. See also Interpersonal therapy; Psychodynamic therapy Supervision: developmental stages and, 575—76; training and, 572-80; use of integrative approaches and, 24, 66—67 Supportive therapeutic techniques, i 7 I , 289 Support systems. See Social support Surveys: outcome research with, 96; use of eclecticism or integration self-reported in, 15, 77—19, 22-23, 96, 130-31, 172, 259 Symptom relief: patient expectations and, 357; techniques for, 204-5, 217 Syncretism, 20-21, 232 Systematic desensitization, 190, 206; outcome research on, T 1 3 ; psychoanalytic therapy used with, 52, 53. See «/SD Desensitization Systematic eclecticism, 232, 595. See also Eclecticism; Psychotherapy integration Systematic eclectic psychotherapy (s.e.p.), 264-93; background to, 265—66; case example of, 282— 88; change and treatment strategy modifications in, 277-78; change mechanisms in, 282; concepts of, 266-68; future directions for, 292-93; identifying patient variables in, 271-75; interpersonal response patterns in, 269—70; interventions used in, 275-76; matching technique to patient characteristics in, 276-77; patient assessment in, 278— 79; patient-therapist compatibility in, 268—70; research on, 288-90; training and, 290-92; treatment applicability of, 279-80; treatment structure in, 280-81 Systems psychotherapists, and use of integration, 23, 96 Systems theory, 18, 19, See also Family systems theory; Genera! systems theory Taylor Manifest Anxiety Scale, 274 Technical eclecticism, 8, 14, 17, 232, 471, 595; borderline personality disorder (BPD) and, 440; introduction of, 52; as route to integration, 10, 3 I. See also Eclecticism Techniques: choosing. See Choice of a therapeutic approach; matching of patients to, 64, 270—77, 313-14, 478-79; outcome research on effectiveness of, 95—96, 97; outcome variance and variables in, 10, 204; 70-percent rule of efficacy of, 205. See also Strategies Tegretol, 540, 546 Termination; combined pharmacotherapy and psychotherapy treatment and, 551-52; common factors approach and, 177. 179, 181-83; determining date of, 183; group therapy and, 509;

Subject Index integrative approaches and, 219; multimodal therapy and, 243 Theories and theoretical orientations: cultural values and differences in, 54; ideological struggle in, 3-4, 5-6; need for eclectic approach in, 59; proliferation of, 7; theoretical integration and emphasis on, 11 Theoretical integration, 10, 11-13, 14, 18. See also Psychotherapy integration Therapeutic alliance; anxiety disorders treatment and, 382, 383—84; combined pharmacotherapy and psychotherapy treatment and, 554; common factors approach and, 180—81, 185; depression treatment and, 411-12; dialectical behavior therapy (DBT) and, 440, 449-50; dissonance in, 282, 293; expectations in, 357; individual therapy and, 465, 504; integrative approaches and, 69, 75-76, 219, 383-84, 608; matching of patients to therapists and techniques in, 64, 282, 288-89; outcome and factors in, 10, 104—8, 265; placebo response and, 537; resistance in, 392; systemic eclectic psychotherapy and, 268-70; transtheoretical approach and, 314—15 Therapists; change-process activities and orientation of, 311; client relationship with. See Therapeutic alliance; combined pharmacotherapy and psychotherapy treatment and collaboration between, 552—55; common factors approach and, 173-74, 419-24; confidentiality issues and, 51112; depression treatment and, 419-24; dialectical behavior therapy (DBT) of borderline personality disorder (BPD) and role of, 445; education of client by, 210; epistemological values of, 150-51, 603; factors in choosing, 269; integrative approach and differences in styles of, 61, 237; language use by, 353-54; matching of patients to, 64, 313-14; multimodal therapy and, 251, 254; outcome and skill of, 183-84, 204; outcome related to ratings of, 109-10; patients' perceptions of, 109-10, 185; personal therapy of, 570-72; personality and psychological health of, 184; reinforcing characteristics of, 49, 188—89; role of, 170; self-reporting on orientations of, 96, 13031, 172, 259; systemic eclectic psychotherapy and, 267; trust and, 194. See also specific types of therapists Thiothixene, 551 Thought disorders, 280 Time: as variable in psychotherapy, 192. See also Duration of therapy; Frequency of sessions Tragic vision, 141, 143-45, 147 Training, 563-88, 604; analysis of response couplets in, 257—58; apprenticeship model in, 66; assimilative integration in, 155; change strategies for, 585-87; choice of eclecticism influenced by, 17; common factors approach and, 196; competency-based programs in, 291, 566-67; developmental stages and, 575—76; difficulty of integration and, 576-77; focus on important therapeutic variables in, 196; impetus for integration in, 8, 66-67; institutions of higher education and, 58284; integrative models for, 564-70; moderating expectations in, 568—70; multimodal therapy and, 256—58, 572; multiple techniques in, 155; objectives of, 564; obstacle to use of integrative therapy in lack of, 23—24; outcome related to,

635

265—66; personal therapy as part of, 570—72; psychotherapy integration and, 566—68; research training and, 571-72; skills, for patient, 191; supervision in, 572-80; systematic referral and, 564—65; systemic eclectic psychotherapy and, 290-92 Tranquilizers, outcome research on, 115 Transactional analysis, 207, 232, 309 Transference, 25, 213, 219, 440; case example with, 223—24; combined pharmacotherapy and psychotherapy treatment and, 548, 550; core schema changes and, 209; cyclical psychodynamics and, 345-46, differences in therapeutic approaches to, 61, 74—75; information processing in, 75; termination and, 219; training and, 291 Transtheoretical approach, 11, 300-30; case example of, 317—24; change levels in, 306—7; change process in, 302-3, 316-17; complementarity of divergent approaches in, 27, 309-10; contra-indications for use of, 312—13; development of, 60, 300-1; future directions for, 328-30; goals of, 301; maximum-impact strategy in, 308, 320; outcome research on, 117; patient assessment in, 310-11; research on, 324-28; stages of change in, 303—6; summary of, 301—10; therapeutic relationship in, 314-15; treatment applicability in, 312—13; treatment specificity in, 313—14 Tranylcypromine, 546 Traumatic events: core schemas and resolution of, 206, 209; outcome research on therapy in, 120; phobia and panic disorders and, 380, 391 Treatment manuals, 9, 202, 326-27, 412-16, 470, 471, 472, 478, 482 Treatment planning: borderline personality disorder and, 487-91; depression and, 480-87; format in, 465—70; individual and family therapy integration and, 515—16; macro levels of, 464—76; marital distress in, 491-96; micro levels of, 478-79; no treatment as choice in, 476—77; setting in, 464 Triangulation, 216 Tricyclic antidepressant medications, 484. 490 Two-chair technique, 152, 373, 386 Unconscious, integrative approaches to, 74 University of Rhode Island Change Assessment Scale (URICA), 311 Validation strategies, in dialectical behavior therapy (DBT) of borderline personality disorder (BPD), 446-47 Valium, 540 Valproic acid, 540 Vanderbilt Psychotherapy Process Scale (VPPS), 107, 108 Weight control, 325 Working alliance. See Therapeutic alliance Working through, 339-40 Xanax, 540, 544 Zen Buddhism, 59, 434 Zung Anxiety Scale, 216