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When and how to combine different approaches?

 “[M]any clinicians have realized that one true path to formulating and
treating human problems does not exist—no single orientation has all
the answers.”
A. A. Lazarus, L. E. Beutler, and J. C. Norcross,
“The Future of Technical Eclecticism” (1992, p. 11)

 Practical pressure – time, financial, health care constraints

 Difficulty in acquiring skills in all the empirically recognized treatments
(over 70, Beutler, 2000)

  who-how-whom question: “What treatment, by whom, is most effective for

this individual with that specific problem, under which set of circumstances,
and how does it come about?” (Paul, 1969)

 How exactly can we be most effective for most of the clients most of the
time?
3 main sources of diversity in counselling:
counselling
 Individuality
o the psychology of individual differences. “Every perspective is
unique” (e.g. Adler’s Individual Psychology)
 Cultural specificity
o influence the view on counselling; influence the people that seek
counselling (e.g., sex, race, ethnicity, social class, sexual orientation,
religion)
 Human conflict
o critiques between counselors adhering to different approaches 
evolution of psychotherapies.
4 main options for theory-
theory-based counselling
 Ideological purity
o = studying and practicing one theoretical approach.
o Historically frequently practiced
o Advantage – being a master in one approach (“in depth”)
o Disadvantage – ideological dogmatism = “sacred and unalterably
truth” (e.g. Freud’s psychoanalysis)
 Theoretical integration
o = combination of at least two theoretical approaches for maximizing
effectiveness
o First attempts – theoretical purpose Dollard & Miller (1950),
Wachtel (1977)
o Current attempts – practical purpose --> effectiveness & efficiency
 Focus on common factors = search for central methods and principles
of human change
o Alexander and French (1946) - corrective emotional experience
o Rogers - certain type of relationship
o Jerome Frank (1961, 1973; 1991) - comprehensive common factors model of
psychotherapy:
• Common form of distress = demoralization hypothesis
• “Demoralization occurs when, because of lack of certain skills or confusion of goals,
an individual becomes persistently unable to master situations which both the
individual and others expect him or her to handle or when the individual experiences
continued distress which he or she cannot adequately explain or alleviate.
Demoralization may be summed up as a feeling of subjective incompetence, coupled
with distress.”(Frank, 1985, p. 56)  demoralization symptoms = primary targets
• 3 common factors of effective therapy–
therapy–
• An emotionally charged, confiding relationship with a helping person
• A healing setting = the therapist - healer/helper; the setting  a sense of safety
• A rationale, conceptual scheme, or myth = a plausible explanation
• A ritual = the process
 Technical eclecticism (eclectic
(eclectic orientation)=
orientation)= combination of
techniques without regard of their theoretical compatibility
o Based on one of three factors: (1) relevant empirical outcomes
research, (2) the pragmatics of the situation, or (3) clinical intuition.
o Critics: “mishmash of theories, a hugger-mugger of procedures, a
gallimaufry of therapies” (Eysenck, 1970)
o Empirical effectiveness: 64% “cure” or recovery rate of 7,293 cases
treated (review, Eysenk, 1952)
o Pro-eclective movement started by behaviorists:
• bad eclectism = “an arbitrary, subjective, if not capricious”
• good eclectism = “[s]electing what appears to be best in various doctrines,
methods, or styles” (Lazarus et al, 1992)
o between 30% and 70% of professionals label themselves as eclectic
(Bechtoldt et al., 2001; Norcross et al., 1997).
Informed consent in integrative approach
 Avoid the word eclectic or put it simple
 Justify your motives for not adhering to a certain theory
 Explain how you will choose the techniques
 Discuss your overall theory of human change and why your
services might be helpful
 Mention the theoretical origins of any techniques you might
frequently use
 Express the availability to discuss the reasons for the
choices you make during the treatment
 Introduced the term technical eclecticism in 1967 (no
interest in combining theories, just in the practical
application of useful approaches for the client)
 flexibility and versatility
 Central aspects:
o Assessment – “most psychological problems are multifaceted,
multidetermined, and multilayered”  BASIC ID Multimodal model
o technical applications – empirically based, logically/practically
based, or instinct based.
o therapist interpersonal style – flexible style adapted to each
individual client on the variables: formality, disclosure, new topics,
directiveness, suportiveness, reflectiveness (Lazarus, 1993)
 Multimodal Life History Inventory (Lazarus & Lazarus, 1991).
 = focus on a trauma-related memory & simultaneously rapidly
movement of the eyes back and forth (~ REM = facilitate information
processing)  desensitization in facing the traumatic memory in
<90min
 Steps:
Steps 1. History 2. Preparation 3. Assessment 4. Desensitization 5.
Installation 6. Body scan 7. Closure 8. Reevaluation
 Does not fit clearly to a theoretical approach
o Classified as: behavior therapy (Corey, 2001), exposure-based treatment
modality (Prochaska & Norcross, 2003), integrative approach (Shapiro, 1999),
eclective - empirically driven, pragmatic and not theoretically dependent
(Summers & Summers, 2004)
 Proven efficiency similar to other exposure techniques, and increased
efficacity in rape victims, single-trauma victims, and multiple-trauma
victims  “probably efficacious” for PTSD – alongside with cognitive
techniques as stress inoculation training and exposure treatment
(APA Division of Clinical Psychology’s Task Force on Promotion and Dissemination of Psychological
Procedures)
 Treatment protocols expanded to addictions, anxiety, grief and loss,
illness and somatic disorders, pain, performance enhancement,
phobias, general stress reduction, and others (F. Shapiro, 2001).
 = psychiatric symptoms (depression) occur in interpersonal
processes (grief, role dispute/transition, deficits)
 aims (1) understanding the rel. bw. Symptom & interpersonal
problem (“the sick role”), (2) developing other coping strategies
 Key question:
question “How have things been since we last met?”
 integrates principles of traditional psychodynamic therapy
(interpersonal psychiatry of Sullivan 1953), with pragmatic,
empirical conceptualization of depression.
 Characteristics:
Characteristics time-limited, focuses on 1-2 interpersonal
problem areas, on present relationships, interpersonal emphasis,
uses cognitive-behavioral conceptualizations, recognizes
personality variables. based on a medical model - clinical
depression
 Validated as a treatment for adolescent depression (Mufson et
al., 1993)
 For - parasuicidal behavior and suffering from Borderline Personality
Disorder (BPD)
 Integrates - cognitive-behavioral and Eastern meditation practices with
elements of psychodynamic, person-centered, Gestalt, strategic, and
paradoxical approaches (Heard & Linehan, 1994).
 Theory:
Theory the biosocial theoretical model of BPD (emotional dysregulation),
dialectical philosophy (reality includes opposing forces that are constantly
shifting and changing)
o 1st “Life has meaning and positive possibilities”
o 2nd “Life has no relevance, meaning, or positive possibilities.”
o 3rd “Life can be both inherently meaningful and completely irrelevant.”(negation of
the negation)
 Characteristics:
Characteristics long-term (12 months), individual & in group and in family
therapy; high implication from the client & the therapist
 probably efficacious treatment for borderline personality disorder
APA Division 12
 Currently, DBT is adapted for use with adolescents,
adolescents substance abusers,
domestic violence cases, violent male inmates, and elderly clients with
depression and personality disorders)
 Process-
Process-Experiential Psychotherapy - Combines the person-centered theory on the central role
of the therapeutic relationship with more directiveness & Gestalts techniques for experiencing
emotional issues (empty-chair and two-chair).

 Acceptance and Commitment Therapy (ACT) Hayes et al., 1999 – combines behaviorism and
psychodynamic. “the assumption of destructive normality”(suffering is normal)

 Cognitive-
Cognitive-Constructivist Psychotherapy (ACT), - Combines Psychoanalysis, behaviorism,
cognitivism, existentialism, and humanism –change needs an “affective charge” (corrective
emotional experience)
o “therapeutic relationship is the glue that makes the various therapeutic procedures work” (Hoyt, 2000,
pp. 53–54)

 The Transtheoretical Change Model (Prochaska,

( 1970; & Norcross, 2003)) - focusing on how
people change. A higher-order integrational theory of psychotherapy - emphasizing common
factors and theoretical integration: consciousness, self & environment re-evaluation, self-
liberation, counterconditioning, stimulus control, reinforcment management, helping
relationship
o Stages of changes: precontemplation, contemplation, preparation, action, maintenance, termination
o Levels of change: Symptom/situational
Symptom problems, Maladaptive cognitions, Current interpersonal
conflicts, Family-systems conflicts, Intrapersonal conflicts
  Selection of the therapy base on the utility for goals at
particular times during the course of the therapy.
Therapy Directive  ---------------------------------------------------------------  Nondirective
spectrum
Therapy Custodial- Part-relationship Complex- Analytic
type supportive reationship relationship
Doing therapy Doing therapy TO / WITH the Doing therapy BEING WITH the
TO the cient cient WITH the cient client while
he/she works on
the past issues
Associated Supportive Concrete reward system Negociated Verbal/Play
strategies behavioral therapy; re-
rehearsals experiencing
Suppressive Induced partial modeling Induced ful Corrective
modeling experience with
new skills’ tension
relief
Sequencial therapeutic process
 1st stage - full initial clinical diagnosis = initial contract
negotiation
o Diagnostics can be: categorial (dichotomous =/DSM), dimensiona
(symptom groups), ideographic (total life, no labeling)
o Use of more informants
 2nd stage of rehearsal of more simple to complex
interactional and effectual behaviors
  possible 3rd stage of exploration of more complex
intrapsychic, intercommunicational, and intrafamilial issues
Stage 1 – contract negotiation & different therapeutic styles
 Style A –„
„Manipualtive helper”
helper”
o = ‘What’s In It For You to be in Therapy?’
o NOT authoritative; not imposing own values
o Useful for children with disruptive behaviors/mistrusfull
o Directive approach
o Behavioral techniques: rewards, time-outs; direct modeling; role-play & role-reversal

 Style B – ‘Nonmanipulated Helper”

Helper”
o = ‘How Can I Help – or Take Good Enough Care of You?’
o Useful for suicidal children - more personalized relationship; protective setting;
asthma associated with depression

 Style C: - „Empathic Participant”

Participant”
o = ‘What’s It Like Being You?’
o Aimed at particularly understanding child’s emotion & perception

OBS: Alternation of the style is not connected with the effectiveness of the
therapy
Stage 2 – Behavioral rehearsal
 Instrumental Interactional Patterns: ‘Doing Therapy To/With the client
 Focuse on simple  complex behavioral-interactiona-affective
rehearsal systems
o The child learns new social skills; understanss emotion/thought; increase self
esteem
 Counsellor moves from: concrete reward systems & behavioral
rehearsals  more complex interactional patterns (self as the model for
the child; encouraging child’s self-introspection)
 Child’s perception of the counsellor: „somebody to be manipulated for
gain’  ambivalent linkages with the „model” understanding of
„being with” the therapists & increased enhancement
 End of stage: re-negotiation „Do you want to go on or stop?” 

Stage 3 - Exploration of more complex issues

 Doing therapy is far more than the simple
application of specific techniques
 Either theory or techniques alone are
necessary, but not sufficient in counselling.
(Sommers & Sommers, 2004)
 Counselours should be innovators and not
simply borrowers from various systems
(Prochaska & Norcross, 2003)