An Introduction to Integrative Psychotherapy

Ken Evans, Maria Gilbert

• Publisher: Bloomsbury Academic
• Year: 2005
• ISBN:
  9781350305816
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

This introductory text provides an invaluable and accessible overview of the rapidly developing field of integrative psychotherapy, and offers a relational-developmental approach to theory and practice. The book goes beyond the confines of the therapy room and explores the significance of the cultural, ecological and transpersonal dimensions of therapy by critiquing the philosophical bases underpinning the theoretical model and looking at the nature of resistance in different phases of therapy. This textbook is essential to students needing a comprehensive introduction to integrative psychotherapy and will also be of interest to the seasoned practitioner.

Part 1

Philosophy, history and research

1 Philosophy and values of integrative psychotherapy

Why a chapter on philosophy and values?

We believe that epistemology (theories of knowledge) is fundamentally important to an understanding of any approach to psychotherapy. Without at least a general knowledge of the philosophical bases of a psychotherapy model it is impossible to adequately critique the theory underpinning the model or the values conveyed in the clinical application of the model. It is absurd to assume that a psychotherapist can suspend her values, which may sometimes be explicit but always implicit in her behaviour and attitudes. Knowledge is instrumental to power and it is never politically innocent (Tanesini, 1999). So it is highly relevant to ask what power, apparent or implicit in its values, might a psychotherapy method, assuming any particular form of knowledge, convey to the client?

Fundamental to our approach to integrative psychotherapy will be the notion of the psychotherapist as a ‘reflexive practitioner’ based on the practice of ‘critical subjectivity’ (Reason, 1994). The reflective function as defined by Fonaghy et al. (2002) is ‘the capacity to envision mental states in self and others’ and enables us to conceptualize ‘others’ beliefs, feelings, attitudes, desires, hopes, knowledge, imagination, pretense, deceit, intentions, plans …’ as different from our own (p. 24). We therefore intend to set out clearly in this chapter the philosophies upon which our approach to integrative psychotherapy is based and the values we derive from them, as a necessary prerequisite to an understanding and appreciation of our approach together with an informed basis for constructive criticism. We trust that this will be experienced as an invitation to dialogue and creative innovation.

First we feel compelled to ask, are there really 480 different kinds of psychotherapy as reported by Karuso? (quoted in Dryden and Norcross, 1990, p. 184). Or could it be that a number of theorists from different models of psychotherapy share some central tenets but express them differently and in different therapeutic languages? Arguably the increasing movement towards psychotherapy integration would suggest greater commonality than is often realized or acknowledged but it is difficult to judge since therapists rarely appear to establish or question the epistemological assumptions underlying their theories, models and approaches thus making it difficult to compare and contrast (Mace, 1999). Goldfried’s plea for a common language for case formulation seems to us an attempt to find existing commonalities in conceptualization and create the bridge between different orientations (Goldfried, 1995b).

There is some evidence to suggest that what attracts therapists to a particular school of therapy are personal reasons rather than ‘neutral objectivity or logic’ (Barton, 1974). Frank and Frank (1991) go as far as to suggest that it is belief that is central to an understanding and application of any psychotherapeutic approach. While therapeutic progress requires sufficient belief in the therapeutic method, on the part of both therapist and client, we agree with Downing that it is dangerous when those beliefs are held as absolute truths rather than as temporary and open to critique (Downing, 2000). There is also a sense that when people have invested large amounts of time and money in training in a particular approach, it may be difficult to critically challenge that allegiance.

Over the past 20 years or so we have witnessed an important trend towards a more ecumenical spirit among the psychotherapies represented in the United Kingdom Council for Psychotherapy (UKCP) and the European Association for Psychotherapy (EAP) and evidenced in the range of issues explored at professional conferences and published in The Psychotherapist, the journal of the UKCP, the International Journal of Psychotherapy EAP and the Journal of Psychotherapy Integration (SEPI). All three of these organisations require high levels of cooperation among and between the different approaches represented to maintain collaboration and dialogue. However, while acknowledging the significance of these developments it is abundantly clear that the ‘many’ schools of psychotherapy exist in relative isolation from each other with regard to access to and interest in ‘rival’ theories. Indeed the proliferation of ‘different’ schools of psychotherapy can be likened to the proliferation of religious denominations following the breakdown in the monopoly of the Roman Catholic Church. It appears to us that within each psychotherapy ‘denomination’ there is a fundamentalist element that preserves the founding teachings relatively unchanged and holds them to be universally valid for all time, thereby underpinning dogma rather than supporting dialogue and critique. No wonder those brave enough to disagree can feel their views are tantamount to heresy and may go underground. Perhaps this is a contributory factor in the proliferation of ‘schools’ since a controversial idea may ultimately be forced to find a new home elsewhere?

Sophie Freud in a public lecture criticized her grandfather Sigmund Freud, together with Carl Jung as ‘false prophets’ by encouraging dependency and uncritical adherence among their ‘disciples’ (Freud, 2002). Her plea that we should relate to the leaders in the psychotherapy profession as ‘brothers and sisters’ rather than ‘fathers and mothers’ supports our view of the psychotherapist as a reflexive practitioner rather than a disciple. The education and training of psychotherapists must bear some responsibility for this process. As Downing asserts,

while some doubts are tolerated by a training programme, challenges to the core assumption of the approach are usually discouraged, dismissed or treated as ‘resistance’. The trainee learns rather quickly that there are ways of experiencing, behaving, and verbalizing which receive praise and reward from the mentors, and those that are greeted with raised eyebrows, silence, or even rebuke. (Downing, 2000, p. 39).

In our trainings it becomes incumbent upon us to foster dialogue across differences and respect individuality of developing frameworks and thinking.

In order to fully appreciate contemporary philosophical influences on psychotherapy we believe it is important to first understand the historical context out of which current philosophical ideas have emerged. Kuhn (1962) introduced us to the idea of paradigms, which are a way of looking at ourselves and the world that give meaning to our lives and shape an entire cultural age. A paradigm shift requires new theories and new assumptions that are contrary to and incompatible with prevailing theory(s) and bring about major changes in what is considered worthy of consideration for inquiry and inclusion in the field of study.

It is possible to distinguish three such paradigms or world views within western philosophy, religion and science. The Classical or pre-Modern Age culminated in Greece (429–347 BC) with the Platonic notion that all reality was based on ideals and forms which transcended human reason. Truth was universal because it was grounded in universal forms such as beauty, goodness, justice etc. Such forms were metaphysical and human knowledge was contingent on the existence of these forms. Within the Jewish and Christian traditions this was manifest in the notion of God as creator and everything, including human beings, were contingent upon God. Sin destroys our relationship with God and to restore the relationship we need to respond to revelation, repent and have faith. Faith results in a new form of knowledge – revealed knowledge. Truth is universal because it is grounded in an eternal and external creator.

In the seventeenth and eighteenth centuries the Modern Age, or Age of Enlightenment, moved knowledge beyond superstition and religious dogma and instead put its trust in the power of reason. Observation, calculation, checking results, deducing conclusions, testing ideas, developing theories were all made possible by new inventions like the telescope and the prism. In the West people began to move out of the prison of dogma and fear of divine punishment. The experimental methods moved away from blind faith to observed fact. A process of de-centring the universe began. There was a paradigm shift from a theocentric to a ratiocentric way of thinking. The universe was rational and could be understood by reason. Truth was universal because human beings were rational. Descartes (1596–1650) epitomized this shift from dogma to reason with his famous statement ‘I think therefore I am’ as opposed to ‘God is therefore I am.’

Now in the so-called postmodern Age we appear to have lost belief in emancipation and progress through knowledge and scientific research (Kvale, 1992). Personal knowledge and subjectivity are supported while objectivity is viewed with scepticism. According to Rosen ‘knowledge and meaning are constructed and reconstructed over time and within the social matrix. They do not constitute universal and immutable essences or objective truths existing for all times and cultures’ (Rosen, 1996, p. 20). The essential reality of nature is therefore not separate and complete such that it can no longer be examined objectively and from outside. From a postmodern perspective there is no single, universal, privileged, accurate, truthful and secure way of understanding anything, including people! We are sympathetic to Loewenthal who writes, ‘Postmodernism blows the whistle on scientific intellectualism as one more form of Victorian morality which inappropriately tries to establish itself in relation to people’ (Loewenthal, 1996).

The general tone of postmodernism is curious, confused, pluralist, fragmentary and open-ended and Tanesini (1999) believes that the idea of the postmodern expresses a widespread loss of faith in big ideals and theories. Lyotard (1996) describes the postmodern as ‘incredulity toward metanarratives’. In the postmodern age ‘It is no longer possible for psychotherapy to “intentionally or unintentionally” don the mantle of science through the seemingly scientific nature of their theoretical language, their therapeutic methods, or the locale of their practice’ (Downing, 2000, p. 237). Indeed according to Heath ‘psychotherapeutic theories are not theories: they are mind–mind myths and therefore cannot be empirically tested’ (Heath, 2000).

The origins of psychoanalysis, and thus of psychotherapy, are located within the modernist frame of nineteenth-century liberal humanism when it was believed its hypotheses could be corroborated (Tolman, 1994). While liberal humanism has been criticized by Schopenhaur, Kierkegard, Marx and Nietzche, and more recently feminist writers have been critical of Freud’s ideas for being culturally encapsulated in Judaic-Christianity, paternalistic assumptions steeped in an eurocentric perspectives are supportive of the ‘invidious relationship between the sexes, ratifying traditional roles and validating temperamental differences’ (Millet, 1969, p. 78). A further criticism (in a similar vein) of psychotherapy across the broad spectrum of approaches is the emphasis on individual experience to the exclusion of contextual/social factors which tends to isolate the individual from his environment, context and external influences that may contribute to the root of their distress (Smail, 1998).

Alternatively the postmodern constructivist paradigm is based on ‘a relativist ontology (multiple realities) a subjectivist epistemology (knower and respondent co-create meaning) and a naturalistic (in the natural world) set of methodologies’ (Denzin and Lincoln, 2000). What this means in our everyday experience of living is summed up by Cushman, ‘life is just a bridge, and a narrow one at that. It is shaky, and when there is a storm it swings back and forth too much. In times of trouble we will want for the bridge to be more than a bridge; we will try to pretend that it is solid aground. We might even, to assuage our fears, try to build a permanent house on it … no theory can be a permanent house’ (Cushman, 1995, p. 330).

Postmodernism challenges the foundations of what we know and how we know what we think we know through ‘demystifying the great narrative of modernism’ (Gergen, 1992, p. 28). It encourages inquiry and questioning of all phenomena and is thus supportive of the notion of the reflexive practitioner engaged in an ongoing process of enquiry and self-questioning.

We agree with Orange (1995, p. 46) that ‘today most psychologists and philosophers agree that all experience … is structured … observation is theory-laden and presuppositionless knowing is impossible’. However, while ‘… the postmodern emphasis on stories or narratives is intended as a statement of modesty, there can be an easy slippage into reification of narrative as a foundational form of knowledge. This can in turn lead to implicit assumptions about “better” and more “appropriate” narratives for clients and to a notion of therapy as a form of story assessment and repair. In such a case, the appeal of post-modern plurality has been diverted back into modern singularity’ (Lowe, 1999, p. 82). The assumption on the part of the therapist that his/her judgement is superior and will in the end govern the ‘storyline’ may become a form of oppression.

While absolute truth is neither as absolute nor as true as we may like to believe, the opposite polarity that truth is indistinguishable from opinion means that ‘nothing is real, nothing is true and nothing is important’ (Holland, 2000, p. 3). According to Holland modern scepticism as expressed, for example, in the writings of Jacques Derrida does not attempt to cultivate a new philosophy of life but rather to critique the theories and prejudices of others. But if we take everything apart then on what authority do we judge anything? ‘Postmodern philosophy at its worst, presumes no authority at all except to claim with authority that there are no authorities’ (Holland, 2000, p. 365). We have considerable sympathy with Holland when he concludes that ‘neither the simplicity of grand narratives nor scepticism deal with the complexities, inconsistencies and paradoxes of real life’ (Holland, 2000, p. 360). Perhaps in the end what is important is the ability to hold the tension between these polarities and accept that our own narratives may be culturally embedded, but at the same time not move to a position where there are no serious values or personal belief systems allowed for fear of becoming petrified in stone!

Lawson asks, ‘since we cannot stay where we are, and since a return to some form of realism is not a possible strategy, we must look elsewhere if we are to find a means to escape the contemporary predicament. But where might we look, and how?’ (Lawson, 2001, p. xxxvii).

We believe that what is needed is a position between the nihilism of deconstructionism and the naivety of structuralism. Some have sought to establish this ‘middle ground’ based on pragmatism. Black and Holford, for example, maintain that from a postmodern perspective it is not important as to whether something is right or wrong, true or false but whether it works (Black and Holford, 1999). In similar vein Polkinghorne writes, ‘one does not ask if a knowledge claim is an accurate depiction of the real – is it true? One asks, rather, does acting on this knowledge claim produce successful results’ (Polkinghorne, 1992, p. 151).

Others like Holland believe that liberal democracy has become complacent, failed to understand and nurture spiritual needs and sold out to commerce at the expense of human values. Nevertheless it may be possible to breathe new life into current structures rather than destroy it without a viable replacement. We agree and set out below to establish a ‘middle ground’ between conviction and uncertainty where, with Downing, we attempt to avoid our assumptions becoming reified in dogma and at the same time avoid the ultimate impotence of unyielding scepticism (Downing, 2000). We agree with Bernstein that there is an intrinsic relationship between absolutism and nihilism in that either polarity in the extreme obscures the other and is liable to become dogmatic (Bernstein, 1992). We suggest, therefore, that a way through this demise is to consider polarities from a paradoxical rather than an oppositional perspective.

Perls and his co-workers (Perls et al., 1951/94) believed that polarities were dialectical forming two ends of one continuum (Clarkson and Mackewn, 1993). You cannot have one without the other, for example, good – bad, right – wrong, structuralism – deconstructivism, absolutism – nihilism; the one defines the other. The so-called opposite characteristics do not contradict each other but instead form two sides of the same coin. In Perls’ paradoxical view, when one characteristic is foreground another polarity remains present in the background and it is possible to work with both polarities bringing both characteristics into awareness. In this way one can affirm the validity of both ends of the polarization. Polarization entails ‘either – or’ categories which can become stuck and impervious to change (Kelly, 1955), and into which one classifies events or perceptions (Korb et al., 1989). The polarization of attitudes, feelings and behaviours tend to rigidify a person’s view of self, others and the world. Polarization is appealing because it appears to offer certainty and thus security in an uncertain world – ‘… polarising of feelings, attitudes and values enable the individual to establish defining bases for relating to the world’ (Korb et al., 1989, p. 14). Polarization is arguably a prerequisite for fundamentalism for it can mean individuals strongly identifying with one polarity and denying the other. A dialectical approach to polarities helps to mitigate against seeing the truth as simple rather than complex.

This ‘middle way’ is a dialectical perspective and attitude to ‘truth’ which affirms the paradoxical nature of reality and, as such, is open to exploring the entire continuum between and including polarities. This requires a capacity for openness, a willingness for vulnerability, and the courage to sit with ambiguity and uncertainty (Gilbert and Evans, 2000). It involves a radical extension of Buber’s I–Thou to facts, opinions, beliefs, evidence, and the like, as well as to people (Buber, 1923/96). It is this radical extension of dialogue that we maintain which exemplifies the postmodern spirit of open enquiry, rather than the nihilism of a scepticism that in extremis takes anti-rationalism to absurdity (Holland, 2000). ‘You are therefore I am’ may well underpin this philosophy!

Outlined below the epistemological bases of our approach to integrative psychotherapy. We do so with conviction and an openness to criticism that accepts them as being ‘true for now’. With this attitude we hope to avoid the oppressive practice that can accompany belief in metanarratives and at the same time avoid the impotence to action that can accompany the more extreme expressions of constructivism and an absence of a belief in the importance of personal values.

The epistemological bases of our approach to integrative psychotherapy are interrelated and mutually supporting. Together they underpin the theory and method of our approach as well as providing the foundation for the values of our approach. In our opinion the epistemol...

Table of contents

• Cover
• Title
• Copyright
• Contents
• Preface to an integrative relational model of psychotherapy
• Part 1 Philosophy, history and research
• Part 2 Theoretical underpinnings
• Part 3 Clinical case study – the practical application of theory
• Part 4 Challenges and concerns
• Appendix
• Bibliography
• Index