Integrative Therapy

Understanding and Choosing a Theoretical Orientation in Therapy

Understanding and choosing a theoretical orientation is one of the more confusing and important aspects of becoming a therapist. If you decide too early, you may miss valuable opportunities for learning. If you wait too long, you risk losing practical experience and deepening your knowledge. I chose to dive deep into this subject on my own time, as it is not a primary focus of mental health education (it is typically learned in practicum). My goal was to achieve both breadth and depth in areas of particular interest. I read extensively about psychodynamic therapy while also exploring seminal works from various orientations. This included all relevant contemporary approaches while receiving training in methods such as CBT, DBT, and IPT/IPSRT.

The Importance of Evidence-Based Practice

Before we begin, let's discuss evidence-based practice. This term is currently popular, and it may represent a long-term best practice rather than a fleeting trend. I support evidence-based or informed practice, but I also recognize its pitfalls.

1. Everything is Evidence-Based: This statement is somewhat hyperbolic, but it highlights a truth. It is rare to find well-intended practices that cause harm. Almost any intervention that undergoes rigorous research is found to be effective. Ironically, only the researcher dedicated to a specific intervention tends to report the most positive outcomes. For instance, Dr. CBT may find that his intervention outperforms IPT, while Dr. IPT argues the opposite. Both approaches, however, are better than a "wait and see" strategy. This phenomenon is known as researcher bias.

   
   

2. Fallacies of Our Scientific Method: Some theories align better with our scientific method, leading to more evidence than more abstract or individualized approaches. This does not inherently mean that more tangible or manualized approaches are superior.

   
   

3. Regression Toward the Mean: During my time at UPMC's Western Psychiatric Hospital (WPH), I learned from a president who was a businessman. He presented an intriguing perspective on evidence-based practice during Grand Rounds. He suggested that evidence-based best practices tend to regress toward a high and predictable average performance. While this limits poor performance, it may also restrict unusually high performers. If someone has a unique approach but adheres strictly to existing evidence, we might miss out on their valuable insights. It is essential for these high performers to validate their ideas, subject them to research, and educate others. This process raises the bar for evidence-based practice. Many high performers are not in labs writing grants; they are in small practices directly impacting clients and mentoring other therapists.

   
   

4. Trusting Our Intuition: I do not advocate for reckless experimentation, but I believe we should trust our instincts based on our training. We should verify those intuitions through literature reviews and conduct our analyses of various approaches. For example, using tools like the weekly PHQ-9 can help track progress. As a colleague at UPMC once said, a type 1 error (overlooking an effective intervention) is problematic, but a type 2 error (mistakenly believing an ineffective intervention works) is far more concerning. The latter wastes our time, clients' time, and healthcare resources.

   
   

Approaches to Psychotherapy

Manualized Therapy

Manualized therapy is rare in outpatient private practice settings. Some therapists adhere strictly to manuals, which may yield consistent results if the manual aligns with the patient's needs. However, this approach often lacks flexibility and may fail to address the multitude of needs that clients present. Research tends to focus on unusual clients fitting neatly into one diagnostic category, neglecting the typical, complex individuals in the community.

Eclectic Therapy

Eclectic therapy encompasses a wide range of approaches, but it can sometimes appear disorganized. The term may evoke a "shotgun" approach, where therapists throw everything at the client and hope something works. However, an eclectic therapist is likely to put considerable thought into their methods, adjusting their approach based on the client's situation. The main pitfall is the risk of being "a jack of all trades, a master of none." It is rare for an eclectic therapist to be proficient in multiple therapies, which can lead to low-average therapy experiences or confusion due to frequent changes in modality.

In terms of eclecticism, there are various ways to organize your approach. For instance, Beck, in his book on depression, recommends starting with behaviorism, such as behavioral activation, before moving to cognitive therapy. This is often the simplest and fastest solution if it works. However, if it doesn’t, you may waste time, confuse the therapy process, or diminish motivation and engagement. Beck suggests that when behavioral interventions fail, therapists should explore the cognitions that may have influenced the outcome. For example, if a client reports not following through with the behavioral activation intervention, the therapist can engage in a cognitive walkthrough to identify distorted cognitions that created barriers.

Integrative Therapy

Integrative therapy combines the proficiency of manualized treatment with the flexibility of eclecticism while remaining organized. Unlike eclecticism, which involves separate tools, integrative therapy integrates these tools into a cohesive approach. However, the key distinction is how these tools are integrated. An integrative therapist maintains a theoretical orientation, which serves as a foundation for understanding the client and organizing other information and tools. Once a conceptualization is made—how we understand the client and their symptoms in the context of our theoretical orientation—we can incorporate other approaches into therapy.

Numerous blind scientists describing their subject (an elephant) from their perspective. A theoretical orientation is a perspective - the angle and orientation from which you stand looking at the subject, psychology.

Theoretical Orientation

The discussion of integrative therapy highlights a crucial distinction from eclecticism: the starting point from which you view the client and integrate other approaches. These approaches are known as theoretical orientations. Each has its benefits and drawbacks and is often more similar than different. They all examine human psychology from distinct angles, perspectives, or orientations. If we consider thought fundamental to human psychological experience, it makes sense to approach therapy from a cognitive perspective. Conversely, if you view humans as inherently social beings, a relational dynamic perspective may be more appropriate.

I identify as an integrative relational dynamic therapist. This means that relational dynamic therapy is my primary orientation, guiding how I conceptualize clients. From this perspective, I incorporate other tools and approaches. Relational dynamic therapy itself is an integrative approach, merging Interpersonal Theory with earlier psychodynamic and psychoanalytic theories.

Once I develop an understanding of a client's relational style—including how they relate to themselves, others, and me in therapy—I can determine how to integrate other approaches that complement this perspective. Sometimes, I receive referrals or clients seeking specific treatment, and I may agree to provide therapy from another approach in which I have specialized skills. This may fall into the manualized category or a somewhat eclectic but organized set of interventions targeting the presenting concern. For example, I might provide IPSRT for bipolar disorder, DBT for emotion regulation, or CBT-E for anorexia. Some clients know they want brief therapy to acquire specific skills, while others prefer an open-ended approach. After gaining those skills, they may choose to continue with long-term therapy, at which point I would likely adopt an integrated relational dynamic approach, focusing on the skill set we developed at the beginning of therapy, assuming it remains clinically useful.

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Conclusion

Thanks for reading! We would love to hear your thoughts and your approach to therapy. Understanding and choosing a theoretical orientation is crucial for both therapists and clients. It shapes the therapeutic process and influences outcomes. By exploring various approaches and integrating them thoughtfully, therapists can provide more effective and personalized care.