Eclecticism in Psychotherapy: Is Integration Possible?

Despite efforts toward integrating differing approaches, little progress has been made in developing a single, comprehensive system of psychotherapy. A major problem to such integration arises with the existence of two basically incompatible or irreconcilable views of human nature and of related philosophies, theories, and practices of psychotherapy. The currently popular paradigm is questioned; a paradigm change is suggested, although the author is pessimistic about its occurrence. Interest in eclectic psychotherapy, and in the integration of various systems of psychotherapy, have been increasing in recent years. Goldfried and Safran (1986, p.463) note that "the indications are very clear that the field of psychotherapy in the 1980s is highlighted by a rapid developing movement toward integration and eclecticism". The extent of this interest is indicated by Norcross's (1986) edited book. Included are chapters by authors of the major eclectic positions including Beutler (1983, 1986), Garfield (1980, 1986), Hart (1983, 1986), Lazarus (1981, 1986), and Prochaska and DiClementi (1984, 1986). Goldfried and Newman (1986) provide a historical background, and Dryden (1986) Goldfried and Safran (1986), Messer (1986) and Murray (1986) provide critical comments. Perusal of these presentations and other writings, in the process of preparing a paper on "Foundations for a Systematic Eclectic Psychotherapy" (Patterson, 1989) suggested a number of issues that have not been adequately recognized or considered. 1. The objective of any movement toward eclecticism or integration in psychotherapy must be the development of a single comprehensive system of psychotherapy including philosophical and theoretical foundations, the derivative principles guiding practice, and the implementation of these principles. Norcross (1986b, p.11) notes that "the promise of eclecticism is the development of a comprehensive psychotherapy based on a unified and empirical body of work". At the present time, nothing of this sort has been proposed (with the exception of my paper). The existing proposals for an eclectic psychotherapy are independent of each other. Each incorporates limited combinations of methods, strategies and techniques from existing theories or approaches, with little attention to any philosophy or theory. What appears to be happening is the development of a number of new approaches on the way to becoming schools. Dryden (1986, p. 374), evaluating the contributions in the Norcross volume, writes: "There is little evidence at present that the contributors...are drawing upon one another's work to a significant degree. This surprises and troubles me." Goldfried and Safran (1986, p. 646) make the same point: "Although there is an increasing acknowledgement of the need to develop a more integrative approach to psychotherapy, we are far from having any consensus as to exactly what that approach should be...there exists a real danger that...we may ultimately end up with as many eclectic models as we currently have schools of psychotherapy..." It seems that the present situation does not provide any basis for optimism about achieving the goal of a comprehensive unified system. Norcross (1986, p. 6) writes: "The ideal of integrating all available psychotherapy systems is not likely to be met." London (1988, p. 10) recognizes that integration may not be possible but does not suggest any reasons: "Integration involving conceptual continuity across all techniques is still missing, and it is missing for a good reason, I think. It may not be possible." 2. Current eclectic attempts neglect theory. Murray (1986, p. 405) writes: "in the contributions of the eclectic therapists in this volume, theoretical orientations play a relatively small role." He continues: "However, true integration requires a coherent theoretical structure, which does not yet exist. We are still waiting for our theoretical integration." (p. 413). 3. Not only is theory neglected, but there is little concern with research support. Eclectic writers emphasize the empirical bases of their proposals, but this is essentially nothing more than their own individual clinical experience, or at most one or a few limited studies whose results agree with their system. Also, as Dryden (1986, p. 373) notes, the research literature is interpreted differently by different authorities. Clearly, we are at a very early stage in the development of a truly systematic eclectic psychotherapy. Many writers have noted obstacles in the way. The nature and seriousness of these obstacles do not seem to be adequately acknowledged or recognized. The result is that optimism about progress is perhaps greater than is warranted. Two major problems are considered. INCOMPATIBLE THEORETICAL ORIENTATIONS The neglect of theory appears in part to represent the apparent perception of many writers that (a) theory is not important in the practice of psychotherapy, or (b) there are no irreconcilable elements in the various theories, or (c) theories are too abstract and complex to attempt to integrate. Goldfried's proposal that integration should be attempted at the level of strategies rather than at the level of techniques or theory (Goldfried, 1980; Goldfried & Padawer, 1982; Goldfried and Safran, 1986), however, is based on the belief that "In the search for commonalities, it is unlikely that we can ever hope to reach common ground at either the theoretical or the philosophical level (Goldfried, 1980, p. 984). Further, Goldfried and Safran (1986, p. 468) suggest that "There is always the danger that comparative analysis [of the psychotherapy process] at the higher levels of abstraction [philosophical and theoretical] will obscure important similarities in [the] psychotherapy process, both because of differences in theoretical language and because of abstract philosophical differences that never really translate into clinical reality." But focusing on strategies rather than theories does not avoid the theoretical incompatibilities. Strategies involve goals, and goals involve theory. Casting the therapist as a strategist puts him/her in the role of expert, the planner and director of therapy. (Strategies also imply conflict-generals plan strategies in war; and chess players plan strategies in the game of chess). While this concept of the therapist is widely, if not generally, accepted, it is not the only concept of the therapist. Thirty years ago the writer suggested that there are two conflicting approaches to psychotherapy (and to human relations in general) (Patterson, 1958, 1959). One approach, the manipulative approach, casts the therapist as an expert, controlling and directing the therapy process. The second, or understanding, approach places the locus of control with the client, with the therapist facilitating the therapy process through empathic understanding. London (1964) has also noted these two major approaches to psychotherapy. These two approaches represent two different views of human beings, described by Allport (1962) as on the one hand reactive beings, controlled from without (behaviorism) or within (psychoanalysis), and on the other hand as a being in the process of becoming. That these two opposed, and irreconcilable, approaches still exist was apparent at the 1985 Phoenix Conference at which 26 of the world's leading therapists lectured and demonstrated before an audience of some 7000 (Zweig, 1987). The conference was a veritable Tower of Babel. Yet Margo Adler, reporting on the conference for PBS radio, said that there were two different kinds of therapists present: the manipulators and the enablers, or, as more commonly termed, the facilitators. Until we can reach agreement on the nature of human beings, no agreement on a philosophy or theory of psychotherapy is possible. And until some agreement on philosophy and theory is achieved, no agreement on the practice of psychotherapy is possible. THE PARADIGM FOR ECLECTIC PSYCHOTHERAPY The basis for eclectic practice is the contention that different clients and different problems require different treatments. This paradigm was stated clearly by Paul (1967, p. 111): "In all its complexity, the question toward which all outcome research should ultimately be directed is the following: What treatment, by whom, is most effective for this individual with that specific problem, and under which set of circumstances." Krumboltz (1966) had phrased it: "What we need to know is which procedures and techniques, when used to accomplish what kinds of behavior change, are most effective with what kind of client when applied by what kind of counselor." Blocher (1968, p. 16) writes: "The old question of 'Is counseling effective?' or 'Which counseling theory is correct?' are (sic) largely seen as rhetorical. They give way to questions of 'What treatment in the hands of which counselors can offer what benefit to particular clients?'" Strupp and Bergin (1969, pp. 19-20), in an extensive review of research in psychotherapy, wrote: "We have become convinced that the therapy of the future will consist of a set of specific techniques that can be applied under specifiable conditions to specific problems, symptoms or cases...the problem of psychotherapy research in its most general terms, should be reformulated as a standard scientific question: What specific therapeutic interventions produce what specific changes in specific patients under specific conditions?" This has been the model for much of the research by behaviorists in psychotherapy. Some 20 years later, no progress seems to have been made in specifying different treatment for different clients with different problems. A consideration of the requirements for adequate research following this paradigm should reveal the basis for lack of success. The model requires (a) a taxonomy of client problems (a reliable, relevant diagnostic system), (b) a taxonomy of therapist qualities, (c) a taxonomy of therapeutic interventions (strategies and techniques), (d) a taxonomy of relevant circumstances, conditions, situations, or environments in which therapy is provided, and (e) principles or empirical rules for matching all these variables. Given, for simplicity, that there are 5 classes of variables, each with 10 levels, the resulting research design would have so many cells as to be unrealistic; this is probably what led Kisch and Kroll (1980, p. 406) to note that "the compelling question of what aspects of therapy work for what kinds of problems when practiced by what kinds of therapists for what kinds of patients is probably empirically unanswerable because it is methodologically unsolvable." Yet the paradigm is still held to. Goldfried (1986) embraces this model, as do Omer & London (1988). Norcross (1986b) emphasizes that "eclecticism addresses a central concern of mental health professionals", and "the optimal match between the intervention, the patient, the problem, and the setting." Murray (1986, p. 414) still hopes that "the use of techniques that fit the particular client, problem, and situation may result in an improved product." This is, however, not the only paradigm. There is an alternative. As Ford and Urban (1987, p. 340) noted, most theories "have characterized all behavior disorder as resulting from a common nucleus...it follows that one psychotherapeutic approach will suffice for all." It is the concept of the unitary nature of emotional disturbance (Angyal, 1941; Menninger et al, 1958; Menninger et al, 1963; Patterson, 1948, 1949, 1958, 1974, 1985). Functional emotional disturbance is a problem in interpersonal relationships, resulting from the lack or inadequacy of an understanding, caring, respecting, warm (unconditional positive regard), in an honest, genuine personal environment. The providing, by the therapist, of empathic understanding, respect and genuineness is the specific treatment for this condition. It is a manifestation of the philosophy and theory of the understanding approach to human relations. Such an approach enables the client to take responsibility for himself/herself and make the choices, decisions and behavior changes that lead to becoming a more self-actualizing person--the goal of this approach to human behavior and of its system of psychotherapy. The application of this approach is spelled out in this writer's work cited above, and, of course in the work of Carl Rogers. It is not currently a popular or widely practiced approach. The therapist conditions are, of course widely recognized and accepted, but are seldom practiced consistently and without added strategies or techniques--they are accepted as important, even necessary for effective psychotherapy, but not as sufficient. The relationship that they constitute is considered as either preliminary to the beginning of "real" therapy or as providing a basis from which the therapist operates to actively intervene with other strategies and techniques. Empathic understanding, for example, is a technique, to be used to provide a basis for diagnosis and interpretation. SUMMARYCurrent eclectic approaches and attempts at integration in psychotherapy have not beensuccessful. Obstacles to integration have been noted (e.g., Dryden, 1986; Goldfried & Safran,1986; Messer, 1986; Murray, 1986). But there exist at least two sources of irreconcilabledifferences: (a) in philosophies and theories of human nature; and (b) in views of the nature offunctional emotional disturbances and its treatment. The currently accepted paradigms in each ofthese areas appear to preclude the achievement of an integrative, comprehensive system ofpsychotherapy. It is suggested that a paradigm shift is necessary before this can be achieved.Prospects for this are not good. Mook (1988, p. 5) quotes Max Planck, the physicist: "a newscientific truth does not triumph by convincing its opponents...but rather because its opponentseventually die, and a new generation grows up that is familiar with it. Mook continues:"Paradigms change by attrition as well as, or instead of, by persuasion. 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