Academic Psychiatry 24:6-13, March 2000
© 2000 Academic Psychiatry
Teaching the Integration of Psychotherapy Paradigms in a Psychiatric Residency Seminar
David Mark Allen, M.D.,
Charlotte L. Kennedy, Ph.D.,
William R. Veeser, Ph.D. and
Trusa Grosso, M.S.W.
Received July 8, 1997; revised September 26, 1999; accepted October 28, 1999. From the Department of Psychiatry, University of Tennessee, Memphis, 6th floor, 135 N. Pauline, Memphis, TN. Address correspondence to Dr. Allen. e-mail: DMAllen{at}utmem1.utmem.edu
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ABSTRACT
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The authors describe methods used to approach the integration of competing psychotherapy paradigms within a resident psychotherapy seminar. They distributed a questionnaire developed to assess residents' subjective feelings about the usefulness of the seminar and also surveyed a second program that teaches multiple perspectives without formal attempts at integration. Results indicate that a large majority of residents in both programs felt positively about their training experience from several perspectives. However, residents from the comparison program may have had a less uniformly positive experience in learning to compare and contrast psychotherapy paradigms.
Key Words: Psychotherapy • Integration of Paradigms
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INTRODUCTION
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New psychotherapy trainees are faced with a bewildering variety of schools of thought about the functioning of the human mind, each school with its own unique opinions about vital treatment issues and techniques. Corsini (1) estimates that as of 1994, about 400 different systems of psychotherapy existed; these were often based on contradictory assumptions. Despite limited empirical validation, rival schools make strong claims of treatment success.
Because psychology is a young science with much that is not known, competing theories are to be expected (2). Psychotherapy's subject matter is an epiphenomenon, difficult to scrutinize objectively. Double-blind, placebo-controlled studies of treatment techniques are not possible. Many observers, such as Beitman (3), believe that "none of the schools of psychotherapy has sufficient explanatory, technical, or conceptual power to help all patients despite implicit claims to the contrary" (p 203). Research findings thus far show that, although most major therapy treatments lead to patient improvement, none clearly demonstrates its superiority to the others in head-to-head competition (4).
For the last 15 years, researchers and clinicians, attempting to integrate the various theories and techniques, have created an interdisciplinary organization (Society for the Exploration of Psychotherapy Integration [SEPI]), a journal (Journal of Psychotherapy Integration), and textbooks such as the Comprehensive Textbook of Psychotherapy Integration (5). SEPI views psychotherapy integration as a process rather than an orientation or yet another therapy school.
We believe spending the time and energy required to teach an approach to integrating the various psychotherapy schools is important for general-psychiatric residencies. There are four main reasons for doing this:
First, trainees may be confused by conflicting ideas from the multiple perspectives (psychodynamic, cognitive, behavioral, couples, family, and group therapies) that are curriculum requirements of the Accreditation Council for Graduate Medical Education (6). Residents need to understand the many seeming contradictions inherent in these multiple perspectives in order to provide optimal, rational treatment to their patients.
Second, we believe that psychotherapy remains an indispensable treatment tool for psychiatrists. As we all know, it is the primary treatment for the behavioral aspects of personality disorders, which are themselves major risk factors for poor response to many pharmacological interventions, as well as for the psychosocial triggers to many Axis I conditions. Psychiatrists, as specialists, should be familiar with the latest thinking and practice in this field. Also, Harold Eist (7) believes that a perceived decline in physician psychotherapy practice is a major factor in the falling interest level in psychiatry among American medical students.
Third, the biomedical perspective of physicians is essential in helping to resolve theoretical controversies. Thus, training residents is vital for further research and development in psychotherapy. Psychiatry has been underrepresented relative to psychology in this field. Of the more than 400 members of SEPI in the United States in 1996, only 31 were psychiatrists.
Last, a focus on theoretical integration may help residents design treatment strategies for patients from diverse cultural backgrounds. An integrative approach often involves juxtaposing information about the values and belief systems of different cultural groups with the values and techniques of various therapy schools. Potential problems with a given approach because of cultural factors may become apparent. These pitfalls might then be avoided by the incorporating techniques from other schools. For example, the Rogerian ideas of empathy and respect are consistent with the cultural values of most African Americans, but the Rogerian techniques of paraphrasing, reflection, and nondirectedness are experienced by many of these patients as nonempathic (8). Directive techniques from cognitive therapy might be modified to achieve Rogerian goals. Further, the integrationist approach explores the question of how culturally important but often-ignored phenomena such as spirituality fit into existing theories.
This article describes the methods by which we foster an integrative approach in psychiatry residents within the context of a psychotherapy teaching seminar. We also present the results of a questionnaire given to current and former residents about their subjective estimation of the usefulness of the seminar in their current practices. Results from trainees surveyed in a second program are presented for comparison. To our knowledge, no integrative approaches to therapy within psychiatry residencies have been described in the literature, and no previous studies have directly compared the results of current psychotherapy teaching methods.
Our approach to psychotherapy integration is incorporated into a year-long psychotherapy seminar taught during the PGY-3 year. We describe here a process for helping trainees effectively address complex questions, so we list no specific content-based learning objectives. The topic content of the seminar is similar to that taught elsewhere. Nor do we discuss how much emphasis we give particular paradigms. In the absence of empirical data about their relative efficacy, such decisions should be made by training directors on the basis of their own evaluation. Course instructors attempting to implement these ideas should also be familiar with some of the existing literature on psychotherapy integration (5,9,10).
An intellectual understanding of theory is, of course, necessary but not sufficient to achieve competence as a therapist in practice. Some therapy educators also feel that novices should first achieve competence in a one-therapy school before they become eclectic. In our program, residents spend 1 year each with different supervisors, who train them in the practical aspects of therapy from a single perspective. The seminar provides residents with vital information about the strengths and weaknesses of each approach, the problems it is likely to create, and the problems it is not likely to solve.
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PHILOSOPHICAL FRAMEWORK FOR THE SEMINAR
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The framework we use in teaching integration in the seminar derives from our position on a debate within the psychotherapy integration movement between those advocating theoretical integration vs. those in favor of technical eclecticism.
In the former view, psychotherapy integration is often explained by use of the old parable of the blind wise men examining an elephant. One examines the trunk, another the leg, and so on, without examining the rest of the beast. Naturally, they all come to different conclusions about what an elephant is. Theoretical integration consists of putting the whole picture together.
Other observers, most notably Lazarus (11), disagree with this basic premise. He advocates technical eclecticism, in which therapists working within their own theoretical framework borrow and adapt clinically useful techniques from other schools without necessarily subscribing to the theories that spawned them. Lazarus views many theories as "ontologically and epistemologically incompatible" (p 146). He believes that apparent commonalities among the various theories are more superficial than they initially appear and that integrationists often downplay major differences. He does not believe that integration is even possible in the presence of theories based on antithetical assumptions.
We take the position that the use of dialectical thinking may solve this problem. A complete discussion of the dialectical perspective and its role in psychotherapy integration is beyond the scope of this article (see references 12–15). Basically, dialectics is a system of thinking based on the proposition that interacting entities, including people and concepts, are defined as much by what they are not as by what they are. In fact, they are what they are only by virtue of their relationship to the other entities. Of relevance here is that dialectics tells us that antithesis is no impediment to synthesis; in fact, antithesis is an absolute prerequisite for it. Consideration of an idea that is apart from, left out of, or contrary to another idea leads to a more inclusive idea that relates the one to the other.
An example familiar to most readers is the resolution of the so-called nature–nurture debate. Interestingly, although this question has effectively been settled, debates about biological vs. psychosocial psychiatry continue (16). The opposing views are commonly reconciled through an interactional perspective. External environmental contingencies and internal central nervous system processes are seen not as independent entities but as interacting parts of a larger interconnected system. These parts mutually influence and profoundly alter one another continuously. Human behavior is seen as determined by the current status of this ongoing and evolving process by which external and internal influences mold one another.
An example of the dialectical reconciliation of opposites from psychotherapy can be seen in a clinical problem noted by Linehan (15) in her discussions of therapy with patients exhibiting borderline personality disorder (BPD). She notes that much of their behavior appears contradictory. On the one hand, for example, they can appear extremely competent in some social situations, while appearing quite helpless and needy in others. Patients with BPD do not seem to be able to generalize social skills from one situation to another. Therapists confronted with this contradiction might vacillate between being too demanding in their performance expectations from patients and not demanding enough. Linehan tends to see the competent behavior as more apparent than real, which leads her to emphasize social-skills training in her therapy. If, however, the apparent lack of competence is due to the complexity of the social situation faced by the patient, then family-systems approaches might be more fruitful. In the writings of one of the authors (DMA; [Allen and Farmer,17]), these contradictory behaviors are reconciled through the dialectical idea that hiding one's competence is highly adaptive in families that exhibit certain dysfunctional characteristics common in the families of patients with BPD. Hence, appearing incompetent is paradoxically the most competent thing a patient with BPD can do.
Synthesis of the differences in psychotherapy schools can be advanced by attempting to reconcile contradictions through a Socratic process. It is this process that forms the basis for helping trainees define, explore, and better understand antithetical positions that have been advanced in debates over prominent theoretical issues. The types of questions we use are described in the next section.
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THE DIDACTIC SEMINAR
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Our weekly multidisciplinary seminar follows Schacht's (18) recommendation that integrative seminars use "heterogeneous learning groups that represent multiple forms of therapy at multiple levels of expertise" (p 316). The didactic portion of the seminar takes place in the first hour of the conference. One trainee leads a discussion of assigned readings each week, but faculty and other trainees are free to raise questions or make comments at any time. The second hour is spent reviewing a videotape of a trainee doing therapy. Integration issues are often further discussed using the videotape as clinical material.
Our reading list, available from the first author, begins with chapters from Current Psychotherapies, by Corsini and Wedding (19), and then proceeds through various therapy issues, theories, and techniques. During discussions, we interject questions and ideas conducive to the process of psychotherapy integration. This series of questions provides a basis for a Socratic dialog between faculty and trainees. They help to orient the thinking of the trainees to the relationships between different therapy paradigms, as well as their relationships to clinical problems.
Questions posed in the seminar include the following: Exactly what are the various schools of therapy really disagreeing about? Are they describing different facets of the same phenomena, disagreeing about the very nature of those phenomena, discussing completely different phenomena and ignoring others, or some combination of all of these? Why do certain schools seem to ignore processes that may be important in understanding a clinical problem? How can we incorporate these other facets for a more complete understanding? If the basic nature of certain behavior is at issue, what is the clinical evidence for one interpretation over another? Are the various explanations consistent with all known facts and logically consistent? Are the disagreements merely differences in terminology? How would an open-minded theorist from one camp explain the observations and theoretical constructs of a theorist from another?
As an example, during discussions of the psychoanalytic idea that introjection leads to the internalization of a parent's value system, a faculty member might raise the question of whether this is a learning process governed by the rules of operant conditioning. If so, could this provide a link between behavior therapy and analytic therapy? If not, why not? Furthermore, do young children incorporate new learning in the same way as adults? How might the answer to this question affect our ideas about altering dysfunctional internalizations?
Another vehicle for exploring such questions is the examination of terms used by the different schools of thought that seem superficially to have common referents. The similarities, differences, and areas of overlap between both the concepts and their theoretical implications are then explored. Some examples of such concept "sets" include 1) role-relationship schemata (from cognitive therapy), script (from transactional analysis), repetition-compulsion and transference (from psychoanalysis), and stimulus generalization (from behaviorism); 2)existential isolation (from existential therapy), and abandonment fears (from psychoanalysis); and 3)separation/individuation (from analysis), self-actualization (from experiential therapy), assertiveness (from behaviorism), and differentiation of self (from family systems therapy).
We might use the first set of terms mentioned above to continue our discussion of introjection. We could suggest that part of the internalization process might include the adoption of culturally sanctioned rules about how to behave in various social situations. This suggests a possible link between the concept of role-relationship schemata and the concept of the superego. Are these internalized rules, we might then ask, reinforced externally, or do they become permanently etched in our minds? If they are not permanent, why are they so resistant to extinction? Is repetition-compulsion a valid concept? If so, can schemata be expected to change in an analytic therapy when other environmental input does not seem to lead to change?
Another way of helping trainees integrate treatment paradigms is to raise issues on which antithetical positions are advanced by adherents of different schools of thought. Examples of issues include the following: Does self-destructive behavior serve an adaptive or defensive function or result from a psychological or physiological defect? What is the relative importance of action vs. insight in psychological change? Is self-actualization or adaptive family functioning more conducive to psychological well-being? Should therapists focus entirely on psychological symptoms or is personal growth important? How can an individual's need for psychotherapy be balanced with the needs of society for allocation and prioritization of spending on health? How should cultural problems, such as racism, be dealt with in psychotherapy? Should patients who were abused as children confront the perpetrator, and, if so, how should it be done?
One last method for helping trainees approach psychotherapy integration involves having the residents examine their own opinions about how individuals can be induced to change their behavior patterns. We believe that beginners in therapy usually come to training with their own preformed ideas about human psychology—ideas based not on previous coursework or reading, but on the trainee's own life experiences, personality, and value system. Such ideas are often only partially thought out and may contain their own unexamined contradictions. Trainees are asked to identify and articulate these ideas within the group context. The goal is to encourage them to clarify, explore, and challenge their own biases, assumptions, and values and to compare them with the points of views of the various therapy schools. In this way, integration becomes more personal and real and less of an abstract intellectual exercise.
We typically begin such an inquiry by asking trainees if they have their own theory of personality, developed out of personal experience. Their first answer is often no. We then ask them about their opinions on questions such as, "Are people basically good or evil? Do you really believe in the unconscious? Do you think people have free will?" As we explore their answers, the trainees begin to realize that they do indeed have preconceived notions of personality that may affect which therapy school appeals to them.
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SEMINAR EVALUATION
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The seminar has been given for the last 5 years and was completed by 22 residents. To evaluate the seminar, we sent out questionnaires to all residents and former residents who had completed it. We received responses from 73% (16/22). The survey results were encouraging.
In keeping with the informal feedback given by residents at the end of the seminar, most surveyed found the seminar useful on a number of dimensions. Ten out of 16 (62.5%) of our respondents rated the seminar as "very much," or "extremely good" in helping them compare and contrast psychotherapy paradigms, whereas only one answered "very little" to this question. Eleven out of 16 (68.8%) found information from the seminar "very much" or extremely useful in their current practice. As a result of taking the seminar, 14 of the 16 respondents rated themselves as having gained 1 or 2 points on a 5-point scale that rated their comfort level in treating patients who are "culturally different"; two felt that their comfort level did not change. The complete results of the questionnaire are listed in Table 1.
We surveyed a second program for comparison. According to the program director at that institution (personal communication), this program (the University of Texas Southwestern Medical Center at Dallas) teaches multiple theories but makes no formal attempts at integration. The residents are exposed to a large number of role models who are difficult to categorize in terms of their theoretical perspective and who may not speak explicitly about their own synthesis.
The survey questions were reworded to evaluate the program in its entirety rather than as a seminar. We did not ascertain whether any given respondent had individual supervisors who discussed comparison or integration of therapy paradigms. In all, 26 of 47 former residents surveyed responded, a response rate of 55.3%. The results are listed in Table 2.
Most respondents in Texas indicated that they had a favorable experience from their program on the issues being surveyed. Although the means of responses on all of the questions were similar to the Tennessee sample, one potentially important difference appeared to emerge, as shown in Table 3. On the question of comparing and contrasting therapy paradigms, the Texas sample seemed to have more responses at the higher and lower extremes. Six of the 26 Texas residents (23.1%) answered "not at all" or "very little" to the question "How would you evaluate your residency program's usefulness in helping you compare and contrast different psychotherapy paradigms?" This compared with only 1 of 16 respondents from our program (6.3%) who rated themselves similarly. We were unable to ascertain if this difference is a reliable one because the sample size was too small for meaningful statistical analysis.
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TABLE 3. Program comparison on question: How would you evaluate the seminar's/program's usefulness in helping you compare and contrast different therapy paradigms?
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DISCUSSION
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Beginners in psychotherapy are often anxious and would like to know the "right" approach or technique to apply in a given clinical situation. Unfortunately, the hasty adoption of a treatment ideology provides a false sense of security. We believe that the learning model we are proposing encourages residents to accept the ambiguity and uncertainties inherent in becoming practitioners of an inexact and young science. Faculty members model acceptance of the inherent lack of certainty within the field, thereby providing some reassurance in a time of great anxiety for the trainees. We attempt to prevent premature dogmatism, while helping residents begin to form their own ideas about how treatment might be successful.
We have outlined an approach for teaching residents and trainees from other disciplines a methodology for evaluating, comparing, and contrasting ideas from a variety of schools of thought about psychotherapy. The technique of Socratic dialog fosters discussion and debate over various conceptualizations. It helps the trainees realize that there is no single "right" answer to many clinical questions. We encourage residents to move toward forming their own theories of human behavior and behavior change, with the ultimate goal of facilitating the process of innovation and discovery.
The majority of respondents to our survey subjectively found the seminar to be useful in formulating treatment approaches, conceptualizing cases from different points of view, incorporating cultural considerations into psychotherapy, examining their own beliefs about behavior and behavior change, and comparing and contrasting different therapy paradigms. The majority of residents at the comparison program also expressed satisfaction in their training in regard to these issues, but may have had a less uniformly positive experience in learning to compare and contrast schools of thought. Training in dialectics as an approach to psychotherapy integration during a formal seminar may lead to a higher percentage of residents becoming more confident in their ability to do this with an eye towards an integrative perspective. Alternatively, the possible differences between the two programs may mean that, over the course of a 4-year program, some, but not all, of the individual supervisors of the Texas residents presented an equally effective approach to comparing treatments.
These conclusions must be made tentatively and with extreme caution for three reasons. First, we had a small sample size and a significant number of residents in both programs who did not respond. Second, subjective evaluations of course content are inherently problematic. The residents have no real reference point with which to compare their abilities and understanding. The lack of difference in most of the survey results between the two programs parallels the situation found in most studies comparing the results of competing psychotherapy schools. Last, there are at present no universally accepted measures for therapist efficacy with which to measure training outcome. The question of therapist efficacy is intricately tied up with the more general question of outcome in psychotherapy, which is notoriously difficult to measure (20).
Future research is needed to further assess whether our approach leads to a greater percentage of trainees feeling confident in their ability to evaluate competing ideas. It should include larger sample sizes and pre- and post- measurements of attitudes and perhaps skill level in spotting similarities and differences in the different therapy schools. In our program, integrative approaches are taught within the context of an ongoing course that explores key concepts within the field of psychotherapy. Such a curriculum is essential in helping residents make sense of all the competing claims and in providing coherent and effective psychotherapy.
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REFERENCES
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- Corsini RJ: Introduction, in Current Psychotherapies, 5th Edition. Edited by Corsini RJ, Wedding D. Itasca, IL, F.E. Peacock Publishers, 1995, pp 1-14
- Kuhn TS: The Structure of Scientific Revolutions. Chicago, IL, Univ. of Chicago Press, 1962
- Beitman BD: Stop exploring! Start defining the principles of psychotherapy integration: call for a consensus conference. Journal of Psychotherapy Integration 1994; 4:203-228
- Beutler LE: Have all won and must all have prizes?: revisiting Luborsky et al.'s verdict. J Consult Clin Psychol 1991; 2:226-232
- Stricker G, Gold JR (eds): Comprehensive Handbook of Psychotherapy Integration. New York, Plenum, 1993
- American Medical Association: Special Requirements for Residency Training in Psychiatry. Graduate Medical Education Directory, 1996-1997. Chicago, IL, American Medical Association, 1996
- Eist HI: On psychotherapy. Psychiatric News, 33 (Feb. 7), 1997
- Ivey A, Authier J: Microcounseling. Springfield, IL, Charles C. Thomas, 1978
- Allen D: A Family Systems Approach to Individual Psychotherapy (originally titled Unifying Individual and Family Therapies). Northvale, NJ, Jason Aronson, 1988
- Wachtel PW: Psychoanalysis, Behavior Therapy, and the Relational World. Washington, DC, American Psychological Association, 1997
- Lazarus AA, Messer SB: Does chaos prevail? an exchange on technical eclecticism and assimilative integration. Journal of Psychotherapy Integration 1991; 1:143-157
- Allen DM: Deciphering Motivation in Psychotherapy. New York, Plenum, 1991
- Allen DM: Unified therapy, in Comprehensive Handbook of Psychotherapy Integration. Edited by Stricker G, Gold JR. New York, Plenum, 1993; pp 125-137
- Basseches MB: Dialectical thinking and young adult cognitive development, in Adult Cognitive Development. Edited by Mines RA, Kitchener KS. New York, Praeger, 1986; pp 33-56
- Linehan MM: Cognitive Behavioral Treatment of Borderline Personality Disorder. New York, Guilford, 1993
- Eisenberg L: Nature, niche, and nurture: the role of social experience in transforming genotype into phenotype. Academic Psychiatry 1998; 22:213-222[Abstract/Free Full Text]
- Allen DM, Farmer RG: Family relationships of adults with borderline personality disorder. Compr Psychiatry 1996; 37:43-51[CrossRef][Medline]
- Schacht TE: Can psychotherapy education advance psychotherapy integration? a view from the cognitive psychology of expertise. Journal of Psychotherapy Integration 1991; 1:305-319
- Corsini RJ, Wedding D (eds): Current Psychotherapies, 5th Edition. Itasca, IL, F.E. Peacock Publishers, 1995
- Wampold BE: Methodological problems in identifying efficacious psychotherapies. Psychotherapy Research 1997; 7:21-43
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ABSTRACT
INTRODUCTION
