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Theory and Design in Counseling and Psychotherapy
Susan X Day , Iowa State University and University of Houston
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CHAPTER 13: Integrative Innovation: The Example of
Cognitive-Interpersonal Therapy
Chapter Review
Integrative therapy approaches synthesize concepts and techniques from two or more therapeutic models. Since the 1970s counselors have individualized the counseling process to meet client needs by borrowing methods across schools of thought. Empirical studies have supported the effort to determine the most effective techniques considering client characteristics and presenting concerns. Cross-cultural adjustments to therapy approaches have also influenced eclectic practice. The counseling literature reveals several major integrative approaches that thoughtfully fashion the merger of multiple conceptual frameworks.
Research findings show similar counseling outcomes for interventions stemming from different approaches, leading some authors to suggest it is the common factors across theoretical orientations that create positive client change. One point of consensus across all theories is the necessity of an effective therapeutic alliance between the counselor and the client. Such transtheoretical thinking suggests that most counselors support the value of instilling hope, providing corrective emotional experiences or new experiences, and giving accurate feedback. Prochaska and colleagues also propose stages for client change: precontemplation, contemplation, preparation, action, maintenance, and termination. Counselors vary interventions according to the client's stage of readiness for change.
Some counselors, technical eclectics, may retain a singular theoretical orientation but borrow techniques from others. Other approaches, such as the multimodel approach and STS (Systematic Treatment approach), eliminate higher levels of abstract theory altogether but depend on research to define specific interventions at particular choice points in therapy. In these methods, counselors depend on clinical strategies, or principles, that guide the course of counseling and determine the techniques of choice.
Theoretical integration takes several approaches and blends multiple concepts to build a unified view that improves the explanations given by each theory separately. The cognitive-interpersonal approach combines concepts regarding relationship patterns with ideas regarding dysfunctional thoughts. Terms are taken from each theory. Self-system, a term taken from interpersonal theory, denotes how we see ourselves and our relation to others. Self-schemas, taken from cognitive theory, is a term for the internal structures formed in childhood that create a sense of satisfaction, security, and anxiety, and that dictate personal preferences. Another phrase, security operations, is used to describe defense mechanisms designed to protect an individual's self-system. We screen out evidence that would invalidate our self-systems and cause anxiety, and pay
attention only to factors that confirm our self-schemas and help us feel secure. Individuals also maintain an interpersonal schema to define expectations regarding relationships. In a cognitive-interpersonal cycle, we choose those people for relationships that allow us to maintain behavior and thoughts that are carried over from past experiences. Dysfunctional thoughts about ourselves and others in relationships are confirmed when we behave in such a way that others respond as we expect. For example, I might believe I have nothing worthwhile to say and say very little. When others rarely talk to me, it confirms my belief that no one talks to me because I have nothing important to say.
In counseling, cognitive-interpersonal therapists observe client interaction styles looking for clues, or interpersonal markers, that reveal behavioral and cognitive patterns. Counselors may also ask clients to describe their current relationships using a method called an interpersonal inventory. Collaboratively, the client and counselor determine how relationships meet expectations, if they are satisfying, and what changes might be beneficial. Through a transference process, the client will likely enact typical interaction patterns used with others outside counseling. The client's manner of communicating invokes a reaction from the counselor who shares these feelings with the client, thereby helping the client gain an understanding of her impact on others. Such metacommunication, talking about talking, also provides a chance to examine the client's internal cognitions that are related to her interactive style. The counselor is careful to respond in helpful ways and not according to typical interpersonal patterns, where the client's remarks would bring into play complementary responses, such as anger invoking anger. When the counselor discontinues the expected interactional patterns, the client experiences a new type of exchange, and the typical pattern the client has used in most relationships is disconfirmed. Homework assignments can provide further experiential disconfirmation to build and maintain client change. The client's interpersonal world is the focus of counseling. Examining dysfunctional beliefs, negative behavior patterns, and links between current and childhood experiences integrates concepts and techniques from cognitive and psychodynamic approaches.
Integrative therapy is criticized as inordinately complex. To avoid shallow eclecticism that does not synchronize multiple approaches, or is syncretic, counselors must think through how and why different principles might work together. Research validating combined approaches is also difficult. Therapists are ethically bound to be able to define the scope of their practice, to document their work, and to describe to clients what it is they do. The more varied and complex the therapist's orientation is, the more difficult it may be to explain clearly.
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