Psychotherapy Integration

Synopsis: This website (which started life as course handout for resident psychiatrists) presents a way of thinking about psychotherapy integration combining psychodynamic with cognitive-behavioral theory and technique. The approach is built on the observation, derived from work with trauma patients, that lasting change takes place at moments of catharsis or of internalization or of both at once. Examining these moments helps to understand the action of therapy and makes it possible to bridge between competing schools, such as psychoanalysis and cognitive therapy. Furthermore, a focus on key moments helps to navigate towards healing and growth.

The Problem

Tension between the "art" and "science" of psychotherapy threatens to split the field. The need for one robust framework to pull different schools together is acute. The New York Times reports it thus:

It was clear at this landmark meeting that, although the participants agreed it was a time for bold action, psychotherapists were deeply divided over whether that action should be guided by the cool logic of science or a spirit of humanistic activism. The answer will determine not only what psychotherapy means, many experts said, but its place in the 21st century. (Benedict Carey, The New York times, December 27, 2005 reporting on a conference entitled "The Evolution of Psychotherapy" held in Anaheim, California)

The Lost Rosetta Stone: How People Change

The key to resolving this dilemma is simple, but not obvious. Fortunately, all therapies seek similar results, presumably through basically similar mechanisms. What is missing is a clear, detailed understanding of how people change in therapy. Such an understanding would allow translation between languages and traditions, including the cognitive-behavioral and psychodynamic ones.

It turns out that how therapy works is not an easy subject. Change happens but it is hard to pin down when it happens, how long it takes and exactly what factors promoted it. Lacking a molecular explanation, each school has explained change within its own constructs, which tend to be incompatible with those of other schools. Work with survivors of extreme trauma brings out the healing processes in dramatic relief.

In addition, a little recognized factor has worked against bringing change processes into sharp focus. Imagine that you firmly believed the celestial object in your telescope is a single body, you will be less likely to notice that it is actually two. You will describe it as having an irregular shape. Only when your mind is ready to accept that there are two bodies, will you begin to see two perfect circles superimposed on each other.

This is exactly the situation with regard to psychotherapeutic change mechanisms. Each school has remained at least partly bound by its original discovery of a single mechanism. I will argue that there are, in fact, two. The problem is that attempts to force two processes into one explanation have resulted in confused and incomplete formulations that have not been sharp enough to bridge across therapeutic traditions. The psychodynamic and the cognitive-behavioral traditions have each been subject to the same phenomenon.

Freud originally stated that "making the unconscious conscious" could bring about healing. This single explanation led to the technique of "interpreting" deeper meanings to bring unconscious thought and feeling to consciousness. The apparent unity and elegance of this explanation unravel when the details are examined. Currently most psychodynamic therapists hold a general notion that interpretation is necessary, but that there is something crucial derived from the therapeutic relationship.

Cognitive-behavioral therapists have assumed a similarly unitary notion of what is happening. Based on learning theory, this tradition has looked for a single healing mechanism involving repeated exposure to correct cognitions. Current theory suggests that repetitive identification and correction of errors of thinking and behavior will gradually realign neural networks. In line with Watson's original desire for objectivity, cognitive-behavioral psychotherapy rejects the validity of data derived from "insight" and sees the therapist more as a technician than a unique individual.

These two approaches are so different that it is hard to imagine that they are talking about the same phenomenon. Each, however, offers patients resolution of the same "entrenched dysfunctional patterns of reaction" that cause so much human suffering.

Finding the Rosetta Stone

Work with patients who have suffered major trauma brings out the fine grain of how people change and heal. The work clearly and naturally divides into two parts, resolution of painful affects (I will call it catharsis), and modification of pathological, internalized attitudes and values (Hereafter called internalization). An examination of the development of affect regulation in children will suggest that these two mechanisms originate at different developmental periods and have very distinct characteristics. Catharsis is optimized by empathy, while internalization works best in a context of slight aloofness. Understanding these two mechanisms in detail makes it clear that the many varieties of psychotherapy represent different ways of achieving conditions that promote catharsis or internalization or both.

Armed with this understanding, not only does it become natural to talk about cognitive-behavioral and psychodynamic approaches in the same breath, but the barriers to mixing different techniques begin to fade. It becomes possible to design and conduct a therapy for each patient based on the easiest and most comfortable way to foster the needed change processes.

Epistemology

Part of the difficulty with the psychodynamic and cognitive-behavioral traditions is that each rejects the other's method of gathering information. I will bypass the problem by appealing to the reader's common sense and experience at being human. The facts and observations required to form a common framework for understanding psychotherapy are within the scope of experience of most if not all of us.

I am not offering new data nor contradicting observations that others have made. Instead I propose a revised framework for making sense of what we have all seen and experienced. I have high respect for the discoveries and observations of the many schools of psychotherapy, without which the present understanding would be impossible. I will suggest the following principle of epistemology: Everyone is right except when they say the other is wrong.

Lucid Psychotherapy

The theme of this writing is to make psychotherapy lucid. By that I mean seeking a quality of openness and clarity. In today's world of informed consumers, the more lucid we are in our practice, the more effective we are and the better is our partnership with our patients. Psychotherapy does not have to be mysterious or rely only on arcane concepts and jargon. Beginning with a high resolution examination of how people change, these pages will give a detailed outline of this approach and its practical application.

Originally this website served as the handout for a class on Intermediate Psychotherapy Technique for psychiatry residents at New York Medical College. The writing is condensed, as it must be for a website. It is my expectation that this material will eventually form the basis of a book for therapists and interested lay people.

DISCLAIMER: I have attempted to make this material brief and simple, but it is NOT a beginning course in psychotherapy. Psychotherapy is a powerful tool that should be learned by direct interaction with a supervisor who has experience. Substantial training is required to do psychotherapy and to bring new ideas into practice with safety. These ideas are intended to stimulate thought, not to tell anyone what to do or to substitute for professional judgment. The ideas presented here should not be applied blindly or by inexperienced therapists without consultation or supervision