BEYOND THE DOGMAS OF CONVENTIONAL PSYCHOTHERAPY:
THE INTEGRATION MOVEMENT
PETER J. HAWKINS
University of Sunderland, U.K.
JOANNIS N. NESTOROS
University of Crete, Greece
«.....perhaps one of these days we shall see an end to the partisan and passionate proclamations of the superiority of one technique over all others, and to be able to devote ourselves to the more fundamental and more promising task of developing a unified science of psychotherapy.....»
(Judd Marmor, Academic Lecture addressing the Canadian Psychiatric Association Annual meeting, Can. Psychiatr. Assoc. J., Vol 20, p.565, 1975).
Psychotherapy today is generally understood to be not just a procedure to be applied to reduce the discomforts and suffering of life, but also a way to improve the quality of life (see Wolberg, 1988). In Epicurean terminology, the goal of psychotherapy is the attainment of the enjoyment of life ("ηδέως ζην": ideos zin). In this sense the healthier one is from the psychological point of view, the more one can benefit from psychotherapy.
A modern science with a glorious past
The widespread impression that psychotherapy is only one century old and rests mainly on the corner-stone of Freudian theory should be re-examined in the light of the ancient Greek literature, even before the "Classical Age" of 5th century BC. Evidence of psychotherapy is also found in the literature of other ancient civilizations (for example see Veith, 1975, for the traditional psychological foundations of the ancient civilizations of the far east; Venkoba Rao, 1975, for the Indus valley civilizations; Leon & Rosselli, 1975 for the aboriginal psychological beliefs and practices in Latin America before the conquest; and Margetts, 1975, for the mental mechanisms of Indian and Eskimo Canadian aborigines, to mention just a few).
Notwithstanding the contributions of other civilizations, it is clear from the "World History of Psychiatry" (for example see the compilation of papers covering almost all nations edited by Howells, 1975) that the contribution of the ancient Greeks is by far the most significant. Unfortunately the vast majority of these ancient Greek writings has perished, especially after the burning down of the library of Alexandria (see Canfora, 1986) and the many other destructions suffered by Greece. It was the lost wealth of ancient Greek writings that has led to the statement that "modern psychology has reinvented the wheel many times" (Nestoros & Vallianatou, 1990, p. 38).
Ample evidence indicates that from the 6th century B.C., during the healing rites in the temples of Asclepius, nootherapy (νοοθεραπεία: nootherapia), meaning mind therapy - that is the change in one`s way of thinking - and repentance (μετάνοια: metanoia) reached the status of sciences (Chessick, 1987). Today these therapies would be most likely classified as cognitive psychotherapies. Another form of widely employed therapy for psychological disturbances was the ritualistic 'sleeping in the temple' (ενκοίμησις: enkoimisis) (Chessick, 1987; Milns, 1986), which was probably a form of clinical hypnosis (Aravantinos, 1907; Kouretas, 1960; Nestoros et al., in press,a).
The ancient Greek version of music and dance therapy employing the flute and the kettledrum can be found in the corybantic rituals celebrating the Phrygian deity of Cybele (see Dodds, 1951 and Milns, 1986, who recites Plato's Laws,). These corybantic rituals are also believed to involve a form of catharsis (Milns, 1986). An appropriate musical mode was chosen for every particular illness. Flute music of the soft Phrygian mode was considered useful for people who were depressed and that of the graver Dorian mode was considered therapeutic to those suffering from abnormal elation of mood (Milns, 1986).
Various classical tragedies and comedies are full of interactions with psychotherapeutic significance. In one scene of the Bacchae, where, towards the end of the play, Agave is still holding her son's (Pentheus) bloody head, she is brought back to sanity by her old father in a masterful psychotherapeutic way. In this scene Agave is gradually made to acknowledge her monstrous act and to realize that she must learn to live with it (Milns, 1986). According to Devereux (1970) as cited by Milns (1986) "Euripides observed and described accurately and probably understood intuitively, not only psychological illness but also the psychotherapeutic process" and "(this) psychotherapeutic scene of Bacchae is clinically flawless and persuasive; it will bear comparison with any modern summary of a psychotherapy session written by a professional clinician" (Devereux, 1970).
Moreover, in the plays of the famous comedian Aristophanes many references to material of psychotherapeutic value are to be found. Particularly, in a passage from his play "The Wasps" he gives a long list of the different beneficial approaches to the treatment of psychological disturbances (Milns, 1986). Some of these, such as persuasion with soothing words and gentleness, can be easily recognized today as some of the common fundamental elements of all contemporary psychotherapeutic schools.
Furthermore, according to Milns (1986), ancient medical writers such as Hippocrates, Caelius Aurelianus, Celsus and Galen, emphasized the importance that we "talk to the patient and try to dispel his fantasies by reasoned argument. If, however, the patient becomes excited at being contradicted " we " should agree with (him) and humour his fantastic notions". Furthermore in their writings of Plato (Politeia, VI, 497D see edition by Adam, 1902; Philebus, 36C, see edition by Bury, 1973; Legg., I, 635B, Cambell, 1973) (as well as Jowett, 1964) the ancient Greeks believed that if we managed to realise what is that we are afraid of, then the fear disappears, as it makes no sense and has no real grounds of existence.
It is well known that Socrates was the first to assist his interlocutor find the solution to the problem by employing a particular conversation method, which became to be known as the 'obstetrical method'. Probably this approach is one of the best that psychotherapy has to offer, because the very process convinces the persons that they have within themselves the ability to find the solution to their problems (Nestoros & Vallianatou, 1990, p. 37). Thus rightly Chessick (1987) in his book entitled "Great Ideas in Psychotherapy" considers Socrates to be the founder of psychotherapy.
While at the time of Socrates "psychotherapy" was a matter concerning a minority of 'free' citizens, it later became very popular involving large segments of the population (probably larger than the percentage of people in psychotherapy in the Western world today) for seven centuries between the 3rd. Century BC and the 4th AD. In this period two schools of philosophy which were clearly "psychotherapeutic" become predominant , the Epicurean school and the school of Stoicism, founded by the Cypriot Zenon of Kition (336-263 B.C.) [Zeller & Nestle: see translation into Greek by Theodorides, 1941/1994 from 13th German edition; also Chessick, 1987]. The first promised absence of anxiety or any other disturbance (Αταραξία: ataraxia) and the second cultivated indifference and detachment to external pleasant or unpleasant events (απάθεια: apatheia). In other words both promised relief from anxiety provoked by the troubles of the times (Chessick, 1987).
Epicurus was a prolific writer, but since most of his work is lost, only some fragments of his teaching are known through his Roman student Lucretius (Chessick, 1987). With respect to the Stoics, the most important philosopher of the late classical period was Epictetus (A.D. 50-138). No writings of Epictetus have survived, although the "lecture notes" of his pupil Arrian, the famous "Enchiridion", were routinely employed by a Swiss director of a psychiatric hospital as reading material for his patients to combat their neuroses (see Copleston, 1962 and Chessick, 1987). There are also available to us today the "Meditations" of Emperor and philosopher Marcus Aurellius and a few other writings of the Stoics, which provide us with a very small and meagre sample of the glory that once was Greece. For example, it is claimed that another Cypriot, Chrysippus of Soloi, often referred to as the second founder of Stoicism, wrote more than seven hundred books (Chessick, 1987).
Finally, two established facts must be emphasized :
i) in antiquity there were many different approaches towards the treatment of mental illness, extending from psychotherapy (by dialectic reasoning and magico-religious rituals) to somatic therapies, e.g. balanced diet, medications - such as black hellebore, massage, exercise, hot and cold baths and so on (Ducey & Simon, 1975 ; Milns, 1986; Mora, 1975), and
ii) in antiquity treatment was often provided at the patients home and not only at mental institutions where treatment was of relative short duration (Ducey & Simon, 1975 ; Milns, 1986; Mora, 1975). These two findings allow us to conclude that the ancient Greeks believed that mental illness was curable. That is the reason why they kept the patients in their homes and why they fought the illness using a variety of methods. Considering the concept of Hamilton (1973) that optimism is the main characteristic of "The Greek Way" of thinking, the "mark of the Greek spirit which distinguished it from all that has gone before", it follows that the rejection of the belief that mental illness is incurable becomes its greatest achievement in terms of the therapeutic process (see also Chessick, 1987, p.68).
Modern psychotherapy currents
Nowadays psychotherapy is very fashionable. In the USA alone psychotherapy is an enterprise involving billions of dollars annually and engaging more than 25000 psychiatrists, 50000 psychologists and innumerable social workers and other counsellors such as the clergy (Frank & Frank, 1991; Marmor et al., 1981). According to more recent data (Seligman, 1995), out of 7000 respondents of the Consumer Reports survey who experienced over the previous three years "stress or other emotional problems, for which" they "sought help from any of the following: friends, relatives, or a member of the clergy; a mental health professional like a psychologist or a psychiatrist; family doctor; or a support group" responded that: 3000 (approximately 43%) "had just talk to friends, relatives or clergy"; 4100 (approximately 57%) employed "some combination of mental health professionals, family doctors and support groups". According to the same study (Seligman, 1995) the most frequently employed mental health professionals were psychologists (37%), followed by psychiatrists (22%) with social workers coming third (14%) and marriage counsellors coming fourth(9%) (for more details see Seligman, 1995, who considers this survey to be "the most extensive study of psychotherapy effectiveness on record" and the group of respondents, although not representative of the entire USA, to be "roughly representative of the middle class and educated population who make the bulk of psychotherapy patients", p. 969). The aforementioned Seligman-Consumer Reports study, of course, is subject to methodological problems (see special issue of October 1996 of`American Psychologist edited by G. R. VandenBos). Nevertheless, it gives an indication of the present popularity of psychotherapy. In some western countries these specialists are visited by at least 10% of the population at some time during their life (Marmor et al., 1981; Stapp et al., 1985). With respect to psychotherapy trends in the next decade a panel of 75 experts have recently predicted that self-help groups and social workers will increase, whereas psychotherapy by psychiatrists will decrease (see Norcross, Alford, & DeMichele, 1992 for more details).
In the 20th century, there are three main currents in psychotherapy:
The psychodynamic schools which stress the significance of unconscious conflicts
Τhe behaviouristic schools, where both normal and abnormal behaviour are understood as products of learning.
Τhe humanistic/existential schools which emphasize the freedom of will.
The first psychodynamic school was established by Sigmund Freud (1856-1939). From the beginning of this century it did not take long to attain significant authority and become the predominant school in psychotherapy. In 1895 Freud published his first psychoanalytic book entitled "Studies on Hysteria" with the collaboration of Josef Breuer. In 1900 he published the "Interpretation of Dreams" followed by "Three essays on sexuality theory" in 1905. These writings gained great publicity. The Psychoanalytic Society of Vienna was established with Freud as its President and later, in 1910, the International Psychoanalytic Society was inaugurated, with Carl Jung as its first president. In 1909 Freud was an invited lecturer at Clark University in USA, where he was awarded an honorary doctor of philosophy degree. However, a number of distinguished psychoanalysts disagreed with Freud, notably Alfred Adler, who withdrew in 1911, and Carl Jung, who resigned from the Psychoanalytic Society in 1914. As a consequence, new developments in 'psychoanalysis' occurred which led to the development of new psychoanalytic schools. Table 1 shows the names of some of the great psychoanalysts who founded 'new' schools of psychotherapy, some continuing with the development of Freud's work (the neoFreudians), whilst others, the schematics, disagreed with him (Brown, 1964). However, in some cases, neoFreudians had more differences than schesmatics with regards to their adherence to Freud`s original formulations, i.e. a) in spite of their different terminology, some of the concepts elaborated by the schesmatics are actually very congenial to Freud's original hypotheses; and b) many neoFreudians developed concepts, theories and techniques differing much more than those of the schesmatics, in spite of their supposed adherence to the original formulations by Freud. Moreover, there were a number of psychotherapists, particularly during the 1950's and 1960's who rejected psychoanalysis and developed new theories and therapies. These included Eric Berne (1910-1970), who founded Transactional analysis (Berne, 1961); Frederick Perls (1983-1970), who founded Gestalt therapy (Perls et al., 1965); Aaron T. Beck who founded Cognitive psychotherapy (Beck, 1963); and Albert Ellis who founded Rational-Emotive therapy (Ellis, 1962). The theories of Berne and Perls bridged the Psychodynamic and the Humanistic/Existential approaches whereas the theories of Beck and Ellis bridged the Psychodynamic and the Behaviouristic approaches.
1. Alfred Adler (1870-1937)
2. Carl G. Jung (1875-1961)
3. Otto Rank (1884-1939)
4. Wilhelm Reich (1897-1957)
1. Anna Freud (1895-1982)
2. Erik Erikson (1902-1994)
3. Karen Horney (1885-1952)
4. Harry Stack Sullivan (1892-1949)
5. Melanie Klein (1882-1960)
6. Frieda Fromm-Reichmann (1890-1957)
7. Erich Fromm (1900-1980)
8. Franz Alexander (1891-1961)
9. Jacques Marie Lacan (1901-1981)
The school of behaviourism was established in the second decade of this century by John B. Watson (1878-1958) who was influenced by Pavlov and Thorndike. Watson conducted the well known experiment with young Allbert in 1920 (Watson and Raynor, 1920). Four years later another researcher extinguished a preestablished fear by using a counter-conditioning procedure (Jones, 1924). The method of systematic desensitisation was applied for the first time in clinical practice in the 1950's by Joseph Wolpe when he described the procedure of "reciprocal inhibition" (Wolpe, 1958). However it was during the 1960's that behaviourism developed into a school of psychotherapy powerful enough to compete with the psychodynamic school in terms of scientific validity and popularity among therapists and patients. Table 2 indicates some of the main techniques of behavioural psychotherapy which are currently popular. In cognitive behaviourism there is an increasing interest in the internal processes which take place within the subject and mediate between stimulus and response, that is with the functions of perception, memory and information processing or reasoning. Hence, a modern version of behaviourism, termed cognitive behaviourism, comes much closer to psychodynamic psychotherapy (as clearly indicated in the case study presented by Lobitz et al., 1986), in that it postulates the existence of hypothetical mental causes of behavior that are rejected by radical behaviorism, which is non-mentalistic. Similarly, modern psychoanalysts, particularly those practising short-term psychodynamic psychotherapy, namely David Malan, Peter Sifneos and Habib Davanloo, are much closer to behaviourism (see also Marmor, 1975) than psychoanalysts have been in the past.
2. Flooding Therapy
6. Token Economy
9. Assertive Training
The third current within 20th century psychotherapy is the humanistic/existential school. One of the major factors influencing this current has been the hierarchical system of demands and motives developed by Abraham Maslow (1908-1970). According to Chessick (1987), the great psychiatrist and philosopher Karl Jaspers (1883-1969) with his book "General psychopathology" (1913) contributed considerably to the development of existentialism. Chessick argues that the psychotherapist acts simultaneously both as a philosopher and a clinician. The humanistic/existential school of psychotherapy became significant at the end of the 1940's with the development of client-centered therapy (Rogers, 1942; 1951). During the 1950's and the 1960's this school was considerably enriched with the addition of Transactional Analysis introduced by Eric Berne (Berne, 1961) and Gestalt Therapy developed by Frederick Perls (Perls et al., 1965). Other significant figures in the development of existential/humanistic approaches were Victor E. Frankl who founded logotherapy (Frankl, 1967), R.D. Laing, a psychiatrist (1960), and psychologist Rollo May (1969). Table 3 presents some of the most popular humanistic/existential psychotherapies.
1. Client-centered Therapy
2. Gestalt Therapy
3. Transactional Analysis
5. Existential Psychotherapy
In the twentieth century western societies the numerous systems of psychotherapy - which were considered to be in competition with each other - have continuously increased in number. Thus, their number proliferated from thirty six during the 1950's (Harper, 1959) to two hundred and fifty at the beginning of the 1980's (Corsini, 1981 and Herink, 1980) and now number more than four hundred (Karasu, 1986).
Table 4 presents some of the psychotherapy systems presented at the aptly named "Woodstock" of psychotherapy, i.e. "The evolution of Psychotherapy Conference" organized by the Milton H. Erickson Foundation in Phoenix, Arizona in December 1985 (Zeig, 1987). Twenty six famous international personalities, representatives of different schools of psychotherapy participated in this conference. The approaches included family psychotherapy (six different approaches), individual psychotherapy (ten different approaches, of which four were Cognitive/Behavioural, three Humanistic/Existential, and three Psychoanalytic), and group psychotherapy (three different approaches). In addition to the various psychotherapeutic approaches included in the aforementioned publication (Zeig, op. cit.), there has been a proliferation of many eclectic and integrative models which have become increasingly popular in recent years (Norcross & Goldfried, 1992).
MODERN CURRENTS IN PSYCHOTHERAPY
"THE EVOLUTION OF PSYCHOTHERAPY CONFERENCE"
I. Family Therapy:
1. Structural approach (Salvador Minuchin)
2. Strategic interpersonal approach (Jay Halley)
3. Direct approach using play and humor (Cloe Madames)
4. Developmental approach (Virginia Satir)
5. Experiential school (Carl Whitacker)
6.Interactive psychotherapy using circular causality (Paul Watzlawick)
II. Individual Psychotherapy:
1. Rational-emotive psychotherapy (A.Ellis)
2. Scientific psychotherapy (Joseph Wolpe)
3. Cognitive psychotherapy (Aaron Beck)
4. Multimodal approach (Arnold Lazarus)
5. Client-centered approach (Carl Rogers)
6. Existential/phenomenological psychotherapy (R.D. Laing)
7. Humanistic psychotherapy (Rollo May).
III. Group Psychotherapy:
1. Transactional Group Analysis
(Mary McClure and Robert Goulding)
2. Gestalt Group Psychotherapy (Miriam Polster and Erving Polster)
3. Psychodrama (Zerka Moreno).
The historical origins of integration
The concept of integration has probably existed for a long time. According to Diogenes Laertius (see page 36 of Forward, Books 1-2), who probably lived between 200 and 500 AD, and author of the well known treatise entitled "Lives of Philosophers" there was an eclectic school of philosophy introduced by Potamon of Alexandria. Moreover, according to the more extensive quotations in the "History of Greek Philosophy" by Zeller and Nestle (see translation into Greek by Theodorides, 1941/1994 from 13th German edition, pp. 314-338) during the same Hellenistic period in the Greek and Roman world the "Eclectic" approach flourished (characterising the Middle Stoa; the Academic School of the last century B.C.; to a lesser degree some Peripatetic philosophers; in a striking way the contemporary Roman philosophers: Cicero, Terentius Varro,Sextius etc.; as well as contemporary Judaeo-Hellenic philosophers, such as Philon of Alexandria).
In terms of psychotherapy, Frances (1988) and Norcross and Newman (1992) reveal that Sigmund Freud consciously struggled with the selection and integration of diverse methods. In fact, attempts at rapprochement and integration in psychotherapy can be traced to the early decades of the twentieth century (Goldfried and Newman, 1992). Specifically, the first formal ideas on synthesising the psychotherapies intrigued mental health professionals as early as the 1930s (see table 5). However, integration was often nothing more than a latent theme that ran through the literature and it is only since the 1980's that it has developed into a clearly delineated area of interest (Goldfried and Newman, 1992) which has recently taken the form of a growing and respected movement within the psychotherapy literature (Castonguay and Goldfried, 1994).
A historical perspective of psychotherapy integration is carefully reviewed by Goldfried and Newman (1992). They identified issues that have repeatedly emerged over the past half century. The following synopsis of the key issues has been based mostly on this work, as well as the reviews provided by Beitman, Goldfried and Norcross (1989), Nestoros and Vallianatou (1990), and Castonguay and Goldfried (1994). Appendix 1 provides a more detailed account of the millstones of psychotherapy integration based on at least 40 other publications, most of which are recent.
At the 1932 meeting of the American Psychiatric Association, Thomas French drew certain parallels between psychoanalysis and Pavlovian conditioning which he published the following year (French, 1933). This is generally considered as one of the earliest attempts at integrating the psychotherapies (Beitman et al., 1989; Goldfried & Newman, 1992).
In 1936, Rosenzweig argued that "the effectiveness of various therapeutic approaches probably had more to do with their common elements than with the theoretical explanations on which they are based". He suggested (Rosenzweig, 1936; Goldfried & Newman, 1992) three common factors:
• the therapist's personality
• synergistic effects of varying theoretical approaches
Studies during 1950s provided supporting evidence that positive psychotherapeutic outcome is less dependent on the psychotherapists' theoretical approach than on experience and the characteristics of the therapist's personality (Feidler, 1950; Heine, 1953).
Another landmark in the history of psychotherapy integration is the work of Dollard and Miller (1950). In their book "Personality and Psychotherapy" the primary emphasis was on the integration of psychoanalytic and Hullian learning theory. Dollard and Miller described in detail how such psychoanalytic concepts as regression, anxiety, repression, and displacement may be understood within the framework of learning theory.
Moreover, Thorne (1950), who underlined the importance of empiricism in considering how people function and change, supported the concept of the integration of different theoretical orientations, according to the same principles of understanding bodily fynctions in medicine without adhering to different schools of thought. Garfield (1957) also suggested an empirically based approach to therapy noting the following factors which he considered as common among the psychotherapies:
• an understanding and supportive therapist
• the opportunity for emotional catharsis
• and the provision of self-understanding
Glad (1959) stressed the inadequacy and ineffectiveness of the value systems instilled by doctrinaire approaches and therefore recommended that therapists be exposed to the work of psychotherapists from the major theoretical approaches.
Franz Alexander and collaborators, using one-way mirrors, observed and recorded the psychotherapeutic interactions of a number of therapists and their patients. All therapists were experienced psychoanalysts from different schools. In a number of articles Marmor (1962, 1964, 1966) attempted to explain the fundamental finding that psychoanalysts of different theoretical approaches (Freudians, Adlerians, Rankians, Jungians, Sullivanians, Horneyians and others) achieved similar therapeutic outcomes. He concluded that psychotherapy is an educational procedure which is unrelated to the therapists' conviction that the reduction of symptoms is due to their "correct" interpretation of the patient's behaviour.
Beutler (1986) has emphasized the irony of devoting 80% of the psychotherapy literature available to him to specific technologies and procedures, which account for about 10% of the change. Moreover, Bergin and Lambert (1978), in agreement with every other reviewer of meta-analytic studies, concluded "that the largest variation in therapy outcome is accounted for by pre-existing patient factors, such as motivation for change, whilst therapist personal factors account for the second largest proportion of change, with technique variables coming in a distant third." (p.180)
Marmor, on the basis of findings that very small alterations in the verbal stimuli provided by the therapist can markedly influence the patient's verbal behaviour (Krasner, 1958; Mandler & Kaplan 1956; Salzinger, 1959), concluded that a psychoanalyst's neutrality does not exist. Every psychoanalyst uses questions, interpretations, a particular tone of voice and verbal communication in general in a way that influences his patients. According to learning principles, this verbal communication transmits to the patient both the therapist's value system as well as the goals of therapy (Marmor, 1975). Certainly, a great number of important stimuli are transmitted with non-verbal communication (Fast, 1970; Hall, 1959; Kurtz, 1984; Mehrabian, 1972).
According to Marmor (1975, p. 559), psychoanalysts adhering to different theoretical approaches who attempt to assist their patients by fostering "genitality" (Freudians), "creative will" (Rankians), "social interest" (Adlerians), "full-development" (Jungians), "self-realization" (Horneyians), "integrated self" (Sullivanians) and "emotional maturity" (Eclectics), all have the same therapeutic objectives. These objectives for successful psychotherapy "are essentially similar" and reflect the ideal culturally determined goal for the patient "to have meaningful and satisfying social and sexual relationships, to love and to work effectively, and to be a responsible and productive human being within the limits of his capacity" (Marmor, 1975, p. 559).