Integrated therapy

Many experienced counsellors (if not all) don’t use any one single modality of therapy in their counselling but rather use a combination of approaches, techniques and ideas taken from numerous different disciplines. One of the key observations in ‘Effective Psychotherapists’ (Miller and Moyers, 2012) is that, alongside modality, rapport is what produces effective therapeutic outcomes and so paying attention to both what is done and how it is done are warranted. Rapport relates to what Rogers called a ‘way of being’ (Rogers, 1995) with a client and the model below illustrates some useful focus for any counselling session.  Rogers is worthy of mention here as this way of being transcends most/all modalities and feeds into the rapport part of therapy clearly, in terms of what is done rather than how it is done, we should turn our attention to the notion of integration. Integration and eclecticism have been used interchangeably (Norcross & Goldfield, 2005) and although some offer a distinction between the two terms here, by integration, we are referring to the notion of adding different approaches and techniques together for optimal outcomes.


Fig 1. (Miller and Rollnick, 2012)

In answer to what is an integrative therapist, we should first note that this is not some specific and special form of registration/qualification. Rather, an integrative therapist is very likely to be someone who has studied a variety of modalities over a number of years and has sufficient training to be able to borrow from one discipline as appropriate; for instance, someone working predominantly as a client centred counsellor who is helping someone with relationship difficulties and sees how the client thinks negatively about themselves feeds into their problem and then seeks to utilise a cognitive behavioural approach to help the client meet goals for that problem.

So, what does integration look like? It has been estimated that there are more than 400 different types or modalities of counselling/psychotherapy and although there are distinctions between approaches, they can all be effective and therapists will tend to borrow tools, ideas, phrases and approached from different therapies to meet their client’s needs. For instance, if you have you have evidence of maladaptive or overly negative thinking and negative self-talk from a client, it would be natural for CBT spring to mind. Ambivalence over reducing drinking and Motivational interviewing may appeal as a solution or dealing with earlier childhood trauma and the techniques/approaches of Eye Movement desensitization and reprocessing (EMDR) or schema therapy may seem warranted.

This is the beauty of the profession we are engaged in. There are almost as many modalities of counselling as there are differing problems that clients seek our help with, and we have the potential to keep on learning, practising, and developing skilfulness in different approaches for our entire working life. Additionally, the composite learning of all these divergent modalities allows us the opportunity to develop an integrative approach, to develop a practise based evidence (rather than evidence based practice) approach, which emerges from trying different techniques/ideas (after sufficient and competent training) in an holistic/well-rounded counsellor.

Although the recursive stairs model in Figure 1 is taken directly from Miller and Rollnick’s MI text (Miller and Rollnick, 2012), it fits for any mode of counselling. The idea is not simply that these are the four things which happen in a single session (although, of course they may well), but may occur across multiple sessions. The nature of engaging means it will need to be a continuous process for the duration of the counselling/therapy work, i.e., for as long as the client and therapist work together. When we consider that rapport develops from this engagement between client and counsellor and focusing is essential if we are to avoid a ‘nice’ conversation. A nice conversation is one which is revealed when you ask clients: ‘have you ever been for counselling before?’. If they answer yes, a natural follow up would be: ‘what happened?’, and when the client responds by saying something like: ‘well… they were very nice but…’. What follows is an explanation of what the client wanted but did not get. Clients can say things like: ‘they listened but we didn’t get anywhere…’, ‘they were nice, but I could have spoken to someone on a park bench’ and so on. In these scenarios the clients were not looking for simply offloading (and clearly some clients really are wanting this). So, in focussing (certainly in session one) we might simply be asking ‘what brings you here?’ or ‘how do you think counselling might help?’ to give an overall impression of what the client is hoping for. However, we must a) listen carefully and make sure we are aware of what they did not get previously and b) note that what they want may well change from session to session.

When we have asked the initial questions relating to client’s previous experience, wants and expectations, it is also important that we manage carefully what happens next. Just because a client has suggested they want advice does not mean you have the green light for immediate delivery of psychoeducation. It is well worth evoking from the client whether what you have in mind may be helpful or not. Let’s say the client does not know what to do to handle their anxiety and they have signified they want ‘ideas’ and we, of course have a whole panoply of mindfulness, breathing, grounding, thought techniques, etc, which we can now impart onto the client. As there is no clear understanding of what the client has already tried and dismissed, it makes perfect sense to enquire (and listen carefully to the answer) about what they have already tried (and to what extent if any was it successful) as well as what they have not tried yet but are considering.

When the client has, essentially, done this and you feel there are ideas they has not yet dismissed and approaches they has not yet tried, it would be a good idea to use Elicit-Provide-Elicit as an approach to advice giving (even psychoeducation style advice) it goes like this, Elicit:

‘Would it help if I told you some of the approaches my other clients have tried in a similar situation?’

If and when the client says ‘Yes’ to this, we might proceed to provide in the form of an explanation of how progressive muscle relaxation or some other intervention has worked for other clients. Finally, when the provide is over we intentionally, and carefully, need to check receipt– via elicit number two, i.e., ‘I know that has worked for some clients- what do you make of it?’

An interesting point here is what triggers a therapist to using one approach over another? When are they on safe ground to use a solution focussed therapeutic approach to move things forward? For example, if the client seems to have spent a lot of time unloading the difficulty of the situation they face and this has been listened to with a distinctly accepting, congruent, empathetic Rogerian approach, is this then the time to go SFT? Perhaps done too early, a client might be annoyed by being asked to come up with a way forward for a problem they first want another person to ‘see’ and acknowledge as extremely difficult. Whereas, when they have felt fully heard and understood, moving on to a way forward may be just what they need. Similarly, if we were to think of the maladaptive thinking and negative self-talk inherent in many clients one of the many cognitive behavioural approaches would make perfect sense for tackling this. 

Another issue in relation to integration is the extent to which counsellors use ‘favourite’ techniques because they feel comfortable with them. Naturally, we are more confident with that which we feel comfortable with, so in the true sense of integration we may well need to step outside of our comfort zones to try new approaches as we learn them.

If you are currently comfortable in the modality of counselling, you predominantly use it may be worth asking: What approach am I willing to learn about next?

References

Lapworth, P., Fish, S., & Sills, C. (2001). Integration in counselling & psychotherapy: Developing a personal approach. Sage.
Miller, W. R., & Moyers, T. B. (2021). Effective psychotherapists. Guilford Publications.
Miller, W. R., & Rollnick, S. (2012). Motivational interviewing: Helping people change. Guilford press.
Norcross, J. C., & Goldfried, M. R. (Eds.). (2005). Handbook of psychotherapy integration. Oxford University Press.
Rogers, C. R. (1995). A way of being. Houghton Mifflin Harcourt.