INTEGRATION OF SCIENTIFIC CRITERIA INTO THE PSYCHOTHERAPY INTEGRATION MOVEMENT BRAD
A. ALFORD
University
of Scranton
Summary Psychotherapy integration has recently rcccived considerable attention among behavior therapists. Although the wisdom of ecumenicism has been questioned. behavior therapy has often been credited with flexibility and modification of practice based on experimental and clinical research. From this perspective, the two central criteria for psychotherapy integration are inclusion of proven therapeutic elements and exclusion of unproven ones. Rationales for the importance of both criteria are discussed, and an analogy to the development of modern medicine is suggested. Formal acceptance of the proposed criteria would place psychotherapy integration in a proactive position to censor fee-for-service clinical practice not grounded in basic clinical or experimental research.
Opinion differs on the possibility for psychotherapy integration (e.g. Norcross, 1990; Patterson, 1989). Further, the wisdom of unilateral attempts at reconciliation with nonbehavioral therapies has been questioned (Giles, 1990a). While it is generally agreed that integrationism takes an open stance towards therapy components from diverse systems (Frances, 1988; Frank, 1982; Goldfried, 1980; Goldfried & Hayes, 1989; Wachtel. 1977), there appears to be no consensus regarding formal criteria for the selection and incorporation of such elements and/or therapies (Goldfried, 1982; Zeig, 1986). The criterion issue would appear to be of special importance at the present time, given the recent movement towards rapprochement or integration (considerations of its possibility or wisdom aside) within behavior therapy (Alford, 1990; Garfield, 1982; Kendall, 1982; Wachtel, 1982). Consistent with the increasing interest in this movement, the Society for the Exploration of Psychotherapy Integration (SEPI) enjoys increasing membership; and, its official journal-the Journal of Psychotherupy frztegrariorl begins its inaugural volume in
1991. In accord with the empirical foundations of behavior therapy (e.g. Wolpe, 1990), the present paper articulates a clinical scientific perspective on this growing integrative movement within psychotherapy. This paper proposes two simple criteria by which to judge or define a psychotherapy system as integrative. The proposal is consistent with the observation of McNamara (1980), who attributes to behavior therapy the tendency to change based on findings from experimental and clinical research. The identified criteria suggest basic standards by which new techniques or elements from other systems are appropriated to - or excluded from - clinical practice.
Correspondence should bc addressed to Dr. Brad A. Alford. of Scranton. Scranton. PA lXSltk4SY6. U.S.A.
Department
Inclusion
of All Proven
Techniques
The first criterion proposes that integrative therapy is open to incorporate within its therapeutic armamentarium all techniques and procedures shown through experimental and/ or clinical research methodology to be effective in meeting the goals of psychotherapy. Note
211
of Psychology,
O’ffara
Hall #217.
University
212
BRAD
A. ALFORD
that this is not to simply suggest the widest possible inclusion of treatment techniques (cf. Lazarus, 1967). Rather, the first criterion specifies inclusion of all those methods - yet on/y those methods - for which prima facie evidence of effectiveness exists. Considering the breadth of psychotherapeutic aims, such goals would include any outcomes collaboratively selected by the parties involved. “Techniques and procedures” include attention to therapist qualities and interpersonal processes (e.g. relationship factors) proven important in conducting successful therapy. These broad definitions are intended to encompass the diversity of stated goals and therapeutic components in the numerous contemporary psychotherapeutic systems (Zcig & Munion, 1990). To insure the efficacy of an intervention in a new therapy context, its components need to be evaluated within the context of the system integrating the technique. The rationale for inclusion of all proven interventions is as follows: As is true in the clinical practice of medicine. persons in need of psychological treatment often show idiosyncratic responses to standard treatments. A therapeutic technique aimed at alleviating the symptoms of a specific disorder may prove quite effective for one person, but ineffective for another with the same disorder. The necessity of matching treatment to person is widely acknowledged (see Beutler, 19X3). yet such matching in advance of treatment may prove impossible due to the multiplicity of variables operating in clinical practice. Therapist, client. and setting factors; uncertainties in diagnosis; and a host of process variables arc at play. These variables often make empirical observation of responses more useful than ;I set of rules as a means for sclccting treatment. Clinical practice is in part an art. This observation is likely to remain true regardless of future advances in clinical science. What does this mcan? Put simply, cffcctive change often requires a degree of L~~l)erinrc~rlttltiorl in the application of hchavioral techniques and
principles. This is true in the context of all scientifically validated treatment techniques (Kendall, 1982); otherwise. therapy would be limited to a narrow range of proven interventions. This is not to say that multiple techniques must be employed in the clinical treatment of a specific disorder. However. when a therapeutic response is not obtained. an integrative approach dictates that other techniques be considered as substitutes, or perhaps concurrently employed. Furthermore. when diverse etiological factors are identified within a given DSM-III-R category - for example some panic disorder cases (Wolpe & Rowan, 198X) multiple techniques would be applied (Alford, Beck. Freeman, & Wright, 1990; Beck, 1970; Wolpc, 1990). Confinement to a single intervention would be inappropriately limiting. To analogize, what would we think of a physician who persists with a single unsuccessful medical intervention when multiple effective treatments are available?
Exclusion of Unproven Therapies: Justifying Fees-For-Services The second criterion proposes that integrative therapy will reject techniques which have not been shown, through experimental or clinical methodology, to be effective in mecting the goals of psychotherapy. The goals would include those collaboratively selected by the parties involved. Adopting this standard, it would be a misnomer to apply the term “integrative” as is currently the case in applying the term “behavioral” - to a therapy system which borrows techniques in the absence of controlled clinical or experimental data. The term “experiment” is suggested as a more accurate label for the clinical application of techniques for which validating data are unavailable. What rationale has determined the use of this second criterion? Admittedly. it excludes
Psychotherapy
Integration
from integration many interesting notions and practices to which the terms “psychological” and “therapeutic” are often applied. Now and a novel untested technique will be again, excluded, and later be found to meet the clinical research validation criterion. In the meantime, some psychotherapists and their clients might have profited from having used the yet-to-be-validated experimental procedure. However, by rejecting unsubstantiated methods, psychotherapy integration would place itself firmly within the domain of psychological science rather than being directed by opinion, authority, or personal or “clinical” passing therapeutic fad. Such a stance provides practical advantages to psychotherapy integration in addition to consistency with the moral principle of reciprocity, which stipulates the necessity to provide something of proven value to those who pay for psychology services (cf. Giles, 1983, 1990a, b; Hayes, 1991; Mooney, 1991). What practical advantages would result? Those seeking to incorporate techniques from diverse therapies would benefit from explicit, formal guidelines for considering the merits of therapeutic elements. On inspection, it, is apparent that the vast majority of current therapies fall far short of meeting the proposed criteria (see Zeig & Munion, 1990). Demanding validity for psychotherapy techniques, measured by controlled clinical research outcomes studies, would enhance substantially the scientific status of psychotherapy generally, and the psychotherapy integration movement particularly. The inclusion of all such validated techniques would likewise lead to more effective clinical practice. It is obvious that these criteria are more difficult to implement than to delineate. Yet, if they are not recognized - and widely accepted - as central to the process of psychotherapy integration, the difficulties associated with their actualization will not be easily overcome. If they are accepted as necessary rigors, then eventual implementation is likely.
Criteria
213
An Analogy in the Development Modern Medicine
of
In terms of criteria for inclusion and exclusion of treatments, a case could be made that contemporary psychotherapy integration finds itself in a position somewhat analogous to that of early medicine. Thomas (1983) raises the following question: “How, indeed, has the profession of medicine survived so much of human history? . . . What did the man do, when called out at night to visit the sick for whom he had nothing to offer for palliation, much less cure”? (pp. 55-56). The answer is that doctors did then what many eclectic psychotherapists often still do today; that is, they employed a favored approach in the absence of consensus on rigorous standards for clinical practice. As is the case even today in the general application (versus availability) of psychotherapeutic treatments (Barlow, 1981), basic and applied medical research had yet to establish definitive scientific standards for medical procedures designed to accomplish specific therapeutic goals. The following description of early medicine is provided by Thomas (1983): . anything that happened to pop into the doctor’s mind was tried out for the treatment of illness. The medical literature of those years makes horrifying reading today: paper after learned paper recounts the benefits of bleeding, cupping, violent purging, the raising of blisters by vesicant ointments, the immersion of the body in either ice water or intolerably hot water, endless lists of botanical extracts cooked up and mixed together under the influence of nothing pure whim (emphasis added)
more
(p.
than
19).
Compare this early state of affairs in medicine to that found today in psychotherapy. Norcross (1986) has observed the following: Psychotherapeutic innovations appear and vanish with bewildering rapidity on
BRAD
214
A. AI.FOKD
the diffuse, heterodox American scene. In 19.59. Harper identified XI distinct systems of psychotherapy, and in 1976, Parloff discovered over 130 therapies on the marketplace, or more appropriately, the “jungle place.” By 1980, several estimates put the number well over 250 . Despite its shaky beginnings. medicine gradually evolved into a profession that applied standardized treatments for given disorders, while at the same time taking into consideration idiosyncratic patient responses. The essence of the process by which this transformation took place is roughly analogous to that prescribed above for psychotherapy integration. Medical practitioners gradually integrated within their professional domain all therapies shown through controlled clinical studies to be effective in treating the various disorders (cf. Medawar. 1983). They incorporated into standard medical practice a diversity of substances and procedures, while being guided clinically by the idiosyncratic rcsponscs of individual patients to a given treatment. It one treatment did not work, another was available, so that multiple treatments came to be employed in a given cast. As more and more truly effective treatments were discovered, unproven treatments became increasingly unacceptable. The dictum “first. do no harm” was extended to exclude treatments which were not scientifically validated. Physicians felt ethically obliged to refrain from administering unproven treatments as being inconsistent with responsible clinical practice. In other words. medicine integrated proven techniques and procedures. actively excluding all unproven ones (Medawar. lY8.3; Thomas. IY8.I). This analogy appears limited only in that, compared to early medicine, contemporary psychotherapy possesses many more properly validated treatments (Barlow. IYXS). Concluding In sum.
this paper
C’ommcnts proposes
that advocates
of psychotherapy integration formally confine themselves to techniques. therapeutic processes, and relationship variables of proven clinical validity, and exclude all those empirically unsupported. Research protocols exist to determine which elements of diverse systems are worthy of integration. Are these criteria likely to be accepted by those interested in psychotherapy integration? There will undoubtedly be opposition. as witness the fact that when these criteria were delineated in a paper that was submitted for publication in the inaugural volume of the official journal of the Society for the Exploration of Psychotherapy Integration, the Jo~rnul c!f’ Psyhotherupv Ir&yyation. the paper was rejected. The criteria were also deleted from a paper to appear in that journal (Alford & Norcross. in press). Among the editorial comments wet-c the following: “Your attempt to set down criteria which reject certain therapies based on your criteria seems to foster closedncss rather than openness. I thirlk that much progress is rnde in the rrhsctiw of‘ r~wrrrch and that research often (emphasis added). comes into play later and tests out the ideas that have been grown in the clinical farms” personal communication. (H. Arkowitz. 21 September 1990). Must patients continue to pay for ideas as they “grow in the clinical farms”? On ;I the farming personai nom. and to continue metaphor, on the farm in southern Mississippi where I grew up, quality and value were measured prior to marketing. On real farms apparently unlike the clinical farms - values arc established before products are sold. How would one react to discovering, upon arriving home from the grocery. shopping bags full of vcgctables,‘~ some perhaps “experimental harmful. and others which might in various ways be unfit for consumers? Is it not obvious that many of the untested therapy ideas grown on the clinical farms ~ and marketed by integrative and eclectic psychotherapists would be found by outcome researchers to be of a quality not suitable for marketing?
Psychotherapy
Integration
It is sometimes argued that scientific criteria would stifle creativity. However, adopting the suggested standards and appropriate empirical stance would not necessarily detract from innovative psychotherapeutic developments (e.g. Alford, 1986; Alford & Jaremko, 1990). It would simply demand that prior to “integration” of therapies - the proven and available methods of science be employed to determine the therapeutic validity of interventions (cf. Beck, 1986; Skinner, 1987; Wolpe, 1990). Finally, given the present state of psychotherapy, is there any realistic hope for routine incorporation of scientific criteria? If behavior therapy continues to play an active role in the evolution of the nascent integration movement, then the answer to this question is likely to be affirmative. By continuing to serve as an exemplar and by publicly articulating unassailable clinical standards, it leads the way. There are signs that highly effective behavior therapy techniques, developed decades ago but previously neglected (see Giles, 1983), are now gaining the attention of integrationists because of their obvious superiority to psychoanalysis (Norcross, in press). Perhaps this marks a beginning. Behavior therapy, broadly conceived. stands virtually alone among psychotherapy systems in its emphasis on scientific validation of techniques (Barlow, 1981; Zeig, 1986). This emphasis places it in a favorable position to include effective therapy elements from other systems - and to exclude unproven elements - in the interest of developing a more comprehensive approach to psychiatric disor “integrative” orders (Alford & Norcross, in press).
References Alford. B. A. (1986).Behavioral treatment of schizophrenic delusions: A single-case experimental analysis. Behuvior Thrrupy. 17. 637-644. Alford. B. A. (lY90). Developing potent behavior-change technologies: An invitation to applied behavior analysts. The Behrn~ior Thertrpisr. 1.3. 1. 23.
Criteria
215
Alford, B. A.. Beck, A. T., Freeman. A.. & Wright. F. D. (1990). Brief focused cognitive therapy of panic disorder. Psychotherapy, 27. 23&234. Alford. B. A., 6t Jaremko. M. E. (19YO). Behavioral design of a positive verbal community: A preliminary experimental analysis. Journul of‘ Behavior Therupv und Experimental Psychiutry. 21. 173-184. Alford. B. A.. & Norcross. J. C. Cognitive therapy as integrative therapy. Journul of Psychorherupy tnregruCon. I (In press). Barlow. D. H. (IYXI). On the relation of clinical research to clinical practice: Current issues. new directions. Jourr~al of Consulring amI C’linicnt P.v_vctwtog,v. 49. 147155. Barlow. D. H. (Ed.) (IYXS). C‘lin~ul txmdhook of p.syc/~o/o~i~~cr/ di.wrders. New York: The Guilford Prcsa. Beck, A. ‘I‘. (lY70). Cognitive therapy: Nature and relation to behavior therapy. Behuvior Therut~y. I. IX& ZOO. Beck. A. T. (19X6). Cognitive therapy: ._ A sign _ of retrogrcssion or progress? Behavior Ttrerupisr. Y. 2-3. Beutlcr, L. E. ( 19X3). Eckec~tic r~sl’c’hortzc,rur,v: A .sv.~~emtr~k crpprorrch. New York: Pergamon Press. Frances, A. ( IYXX, May). Sigmur~d Frewt: The /in/ infegrurivr ~hcrtrp~st. Invited address to the 4th Annual Convention of the Society for the Exploration of Psychotherapy Integration, Cambridge. MA. Frank. J. D. (10X2). Therapeutic components shared by all psychothcrapica. In J. Harvey & M. Parks (Eds.). P.sycho:hercrpy resewch und hetwLzior chuqe: I WI Musrer Lecrure Series. Washington: American Psychological Association. Garfield. S. I.. (IYX2). Eclectlclsm and integration in psychotherapy. Hehuvror Therrrpy. 1.3, hII!-623. Gilcs. ‘I’. R. (IYXD). Probable cupcrioritv of behavioral interventions-II: Some implications lor the ethical practice of psychological therapy. Jour~~rl oj’ Behrr~ior Ihercrpy cmd E.rperimet~rcll P.\Khirr1ry, 14. I x9- I Yh. Giles. T. R. ( IYYOa). Bias against behavior therapy in outcome reviews: Who speaks for the put&t? The BehuiGor Therupisl. 13. X&90. Giles, T. R. ( IYYOh). Underutdization ol effective psychotherapy: Managed mental health arc and other forces of change. The Behtwior T/lr~rrrpi.s/, f.?, lO7?1 10. Goldfried. M. R. (IYXO). Toward the delineation ol therapeutic change principles. Am~ricn~ PrwholoRw. 3s. YY I-YYY. Goldfried. M. R. (lYX2). On the history of therapeutic integration. Behtrvior Therrct,y. 13. 577-593. Goldfricd. M. R.. 6i Hayes. A. M. (IYXY). Can contrihutions from other orientations complement behavior therapy? The Behuvior Therupisl. 12. 57-60. Hayes. S. C. (1901). An interview with Dick McFall. The Scienrisr Prucliliorw, I. + I I Kendall. P. C. (10X2). Integration: Behavior therapy and other schools of thought. Behu~~~or Therupy. 1.1. SSY571. Lazarus, A. A. (1967). In support of technical eclecticism. Psychologicrrl Reports. 21. 31.5-4 16. Marks. I. M. (19X2). Toward an empirical clinical science: Behavioral psychotherapy in the IYXOs. Behuvior Ther(I,‘?‘. 13, 63-X1.
216
BRAD
A. ALFORD
McNamara, J. R. (1980). Behavior therapy in the seventies: Some changes and current issues. Psychorherapy: Theory, Research. and Practice, 17, 2-9. Medawar, P. B. (1983). O&r’s razor. In D. Pykc (Ed.), The threat and rhe glory: Reflections on science and scienfists. New York: Harper Collins. Mooney, C. J. (1991). Efforts to cut amount of “trivial” scholarship win new backing from many academics. The Chronicle of Higher Education. 37. 1. 13, 16. Norcross, J. C. (1986). Eclectic psychotherapy: An introduction and overview. In J. C. Norcross (Ed.), Handbook of eclectic psychotherapy (pp. 3-24). New York: Brunner/Mazel. Norcross. J. C. (1990). Commentary: Eclecticism misrepresented and integration misunderstood. P.yychotherapy. 27. 297-300. Norcross. J. C. Prescriptive matching in psychotherapy: Psychoanalysis for simple phobias‘? [special section]. Psychotherapy (In press). Patterson. C. H. (1989). Eclecticism in psychotherapy: Is integration possible? Psychorherap_~, 26. 1S7-IhI,
Skinner, B. F. (1987). Whatever happened to psychology as the science of behavior? American Psychologisl. 4-1. 78@786. Thomas, L. (1983). The youngest science: Notes oJ a medicine-Hjatcher. Toronto: Bantam. Wachtel, P. L. (1977). Psychoanalysis and behavior /herapy: Toward an integration. New York: Basic Books. Wachtel, P. L. (1982). What can dynamic therapies contribute to behavior therapy’? Behavior Therapy. IS. 594-609. Wolpe, J. (1990). The practice of behavior lherapy (4th ed.). New York: Pergamon Press. Wolpe, J., & Rowan, V. C. (1988). Panic disorder: A product of classical conditioning. Behaviour Research and Therapy. 26. 4411150. Zeig, J. K. (1986). The evolution of psychotherapy conference. lnrernalional Journul oJEclectic Psycho!herapy. 5, 233-247. Zeig, J. K., & Munion, W. M. (Eds.) (1990). WhoI IS psychotherapy?: Contemporary per.ypecrives. San Francisco: Jossey-Bass Publishers.
A. ALFORD
University
of Scranton
Summary Psychotherapy integration has recently rcccived considerable attention among behavior therapists. Although the wisdom of ecumenicism has been questioned. behavior therapy has often been credited with flexibility and modification of practice based on experimental and clinical research. From this perspective, the two central criteria for psychotherapy integration are inclusion of proven therapeutic elements and exclusion of unproven ones. Rationales for the importance of both criteria are discussed, and an analogy to the development of modern medicine is suggested. Formal acceptance of the proposed criteria would place psychotherapy integration in a proactive position to censor fee-for-service clinical practice not grounded in basic clinical or experimental research.
Opinion differs on the possibility for psychotherapy integration (e.g. Norcross, 1990; Patterson, 1989). Further, the wisdom of unilateral attempts at reconciliation with nonbehavioral therapies has been questioned (Giles, 1990a). While it is generally agreed that integrationism takes an open stance towards therapy components from diverse systems (Frances, 1988; Frank, 1982; Goldfried, 1980; Goldfried & Hayes, 1989; Wachtel. 1977), there appears to be no consensus regarding formal criteria for the selection and incorporation of such elements and/or therapies (Goldfried, 1982; Zeig, 1986). The criterion issue would appear to be of special importance at the present time, given the recent movement towards rapprochement or integration (considerations of its possibility or wisdom aside) within behavior therapy (Alford, 1990; Garfield, 1982; Kendall, 1982; Wachtel, 1982). Consistent with the increasing interest in this movement, the Society for the Exploration of Psychotherapy Integration (SEPI) enjoys increasing membership; and, its official journal-the Journal of Psychotherupy frztegrariorl begins its inaugural volume in
1991. In accord with the empirical foundations of behavior therapy (e.g. Wolpe, 1990), the present paper articulates a clinical scientific perspective on this growing integrative movement within psychotherapy. This paper proposes two simple criteria by which to judge or define a psychotherapy system as integrative. The proposal is consistent with the observation of McNamara (1980), who attributes to behavior therapy the tendency to change based on findings from experimental and clinical research. The identified criteria suggest basic standards by which new techniques or elements from other systems are appropriated to - or excluded from - clinical practice.
Correspondence should bc addressed to Dr. Brad A. Alford. of Scranton. Scranton. PA lXSltk4SY6. U.S.A.
Department
Inclusion
of All Proven
Techniques
The first criterion proposes that integrative therapy is open to incorporate within its therapeutic armamentarium all techniques and procedures shown through experimental and/ or clinical research methodology to be effective in meeting the goals of psychotherapy. Note
211
of Psychology,
O’ffara
Hall #217.
University
212
BRAD
A. ALFORD
that this is not to simply suggest the widest possible inclusion of treatment techniques (cf. Lazarus, 1967). Rather, the first criterion specifies inclusion of all those methods - yet on/y those methods - for which prima facie evidence of effectiveness exists. Considering the breadth of psychotherapeutic aims, such goals would include any outcomes collaboratively selected by the parties involved. “Techniques and procedures” include attention to therapist qualities and interpersonal processes (e.g. relationship factors) proven important in conducting successful therapy. These broad definitions are intended to encompass the diversity of stated goals and therapeutic components in the numerous contemporary psychotherapeutic systems (Zcig & Munion, 1990). To insure the efficacy of an intervention in a new therapy context, its components need to be evaluated within the context of the system integrating the technique. The rationale for inclusion of all proven interventions is as follows: As is true in the clinical practice of medicine. persons in need of psychological treatment often show idiosyncratic responses to standard treatments. A therapeutic technique aimed at alleviating the symptoms of a specific disorder may prove quite effective for one person, but ineffective for another with the same disorder. The necessity of matching treatment to person is widely acknowledged (see Beutler, 19X3). yet such matching in advance of treatment may prove impossible due to the multiplicity of variables operating in clinical practice. Therapist, client. and setting factors; uncertainties in diagnosis; and a host of process variables arc at play. These variables often make empirical observation of responses more useful than ;I set of rules as a means for sclccting treatment. Clinical practice is in part an art. This observation is likely to remain true regardless of future advances in clinical science. What does this mcan? Put simply, cffcctive change often requires a degree of L~~l)erinrc~rlttltiorl in the application of hchavioral techniques and
principles. This is true in the context of all scientifically validated treatment techniques (Kendall, 1982); otherwise. therapy would be limited to a narrow range of proven interventions. This is not to say that multiple techniques must be employed in the clinical treatment of a specific disorder. However. when a therapeutic response is not obtained. an integrative approach dictates that other techniques be considered as substitutes, or perhaps concurrently employed. Furthermore. when diverse etiological factors are identified within a given DSM-III-R category - for example some panic disorder cases (Wolpe & Rowan, 198X) multiple techniques would be applied (Alford, Beck. Freeman, & Wright, 1990; Beck, 1970; Wolpc, 1990). Confinement to a single intervention would be inappropriately limiting. To analogize, what would we think of a physician who persists with a single unsuccessful medical intervention when multiple effective treatments are available?
Exclusion of Unproven Therapies: Justifying Fees-For-Services The second criterion proposes that integrative therapy will reject techniques which have not been shown, through experimental or clinical methodology, to be effective in mecting the goals of psychotherapy. The goals would include those collaboratively selected by the parties involved. Adopting this standard, it would be a misnomer to apply the term “integrative” as is currently the case in applying the term “behavioral” - to a therapy system which borrows techniques in the absence of controlled clinical or experimental data. The term “experiment” is suggested as a more accurate label for the clinical application of techniques for which validating data are unavailable. What rationale has determined the use of this second criterion? Admittedly. it excludes
Psychotherapy
Integration
from integration many interesting notions and practices to which the terms “psychological” and “therapeutic” are often applied. Now and a novel untested technique will be again, excluded, and later be found to meet the clinical research validation criterion. In the meantime, some psychotherapists and their clients might have profited from having used the yet-to-be-validated experimental procedure. However, by rejecting unsubstantiated methods, psychotherapy integration would place itself firmly within the domain of psychological science rather than being directed by opinion, authority, or personal or “clinical” passing therapeutic fad. Such a stance provides practical advantages to psychotherapy integration in addition to consistency with the moral principle of reciprocity, which stipulates the necessity to provide something of proven value to those who pay for psychology services (cf. Giles, 1983, 1990a, b; Hayes, 1991; Mooney, 1991). What practical advantages would result? Those seeking to incorporate techniques from diverse therapies would benefit from explicit, formal guidelines for considering the merits of therapeutic elements. On inspection, it, is apparent that the vast majority of current therapies fall far short of meeting the proposed criteria (see Zeig & Munion, 1990). Demanding validity for psychotherapy techniques, measured by controlled clinical research outcomes studies, would enhance substantially the scientific status of psychotherapy generally, and the psychotherapy integration movement particularly. The inclusion of all such validated techniques would likewise lead to more effective clinical practice. It is obvious that these criteria are more difficult to implement than to delineate. Yet, if they are not recognized - and widely accepted - as central to the process of psychotherapy integration, the difficulties associated with their actualization will not be easily overcome. If they are accepted as necessary rigors, then eventual implementation is likely.
Criteria
213
An Analogy in the Development Modern Medicine
of
In terms of criteria for inclusion and exclusion of treatments, a case could be made that contemporary psychotherapy integration finds itself in a position somewhat analogous to that of early medicine. Thomas (1983) raises the following question: “How, indeed, has the profession of medicine survived so much of human history? . . . What did the man do, when called out at night to visit the sick for whom he had nothing to offer for palliation, much less cure”? (pp. 55-56). The answer is that doctors did then what many eclectic psychotherapists often still do today; that is, they employed a favored approach in the absence of consensus on rigorous standards for clinical practice. As is the case even today in the general application (versus availability) of psychotherapeutic treatments (Barlow, 1981), basic and applied medical research had yet to establish definitive scientific standards for medical procedures designed to accomplish specific therapeutic goals. The following description of early medicine is provided by Thomas (1983): . anything that happened to pop into the doctor’s mind was tried out for the treatment of illness. The medical literature of those years makes horrifying reading today: paper after learned paper recounts the benefits of bleeding, cupping, violent purging, the raising of blisters by vesicant ointments, the immersion of the body in either ice water or intolerably hot water, endless lists of botanical extracts cooked up and mixed together under the influence of nothing pure whim (emphasis added)
more
(p.
than
19).
Compare this early state of affairs in medicine to that found today in psychotherapy. Norcross (1986) has observed the following: Psychotherapeutic innovations appear and vanish with bewildering rapidity on
BRAD
214
A. AI.FOKD
the diffuse, heterodox American scene. In 19.59. Harper identified XI distinct systems of psychotherapy, and in 1976, Parloff discovered over 130 therapies on the marketplace, or more appropriately, the “jungle place.” By 1980, several estimates put the number well over 250 . Despite its shaky beginnings. medicine gradually evolved into a profession that applied standardized treatments for given disorders, while at the same time taking into consideration idiosyncratic patient responses. The essence of the process by which this transformation took place is roughly analogous to that prescribed above for psychotherapy integration. Medical practitioners gradually integrated within their professional domain all therapies shown through controlled clinical studies to be effective in treating the various disorders (cf. Medawar. 1983). They incorporated into standard medical practice a diversity of substances and procedures, while being guided clinically by the idiosyncratic rcsponscs of individual patients to a given treatment. It one treatment did not work, another was available, so that multiple treatments came to be employed in a given cast. As more and more truly effective treatments were discovered, unproven treatments became increasingly unacceptable. The dictum “first. do no harm” was extended to exclude treatments which were not scientifically validated. Physicians felt ethically obliged to refrain from administering unproven treatments as being inconsistent with responsible clinical practice. In other words. medicine integrated proven techniques and procedures. actively excluding all unproven ones (Medawar. lY8.3; Thomas. IY8.I). This analogy appears limited only in that, compared to early medicine, contemporary psychotherapy possesses many more properly validated treatments (Barlow. IYXS). Concluding In sum.
this paper
C’ommcnts proposes
that advocates
of psychotherapy integration formally confine themselves to techniques. therapeutic processes, and relationship variables of proven clinical validity, and exclude all those empirically unsupported. Research protocols exist to determine which elements of diverse systems are worthy of integration. Are these criteria likely to be accepted by those interested in psychotherapy integration? There will undoubtedly be opposition. as witness the fact that when these criteria were delineated in a paper that was submitted for publication in the inaugural volume of the official journal of the Society for the Exploration of Psychotherapy Integration, the Jo~rnul c!f’ Psyhotherupv Ir&yyation. the paper was rejected. The criteria were also deleted from a paper to appear in that journal (Alford & Norcross. in press). Among the editorial comments wet-c the following: “Your attempt to set down criteria which reject certain therapies based on your criteria seems to foster closedncss rather than openness. I thirlk that much progress is rnde in the rrhsctiw of‘ r~wrrrch and that research often (emphasis added). comes into play later and tests out the ideas that have been grown in the clinical farms” personal communication. (H. Arkowitz. 21 September 1990). Must patients continue to pay for ideas as they “grow in the clinical farms”? On ;I the farming personai nom. and to continue metaphor, on the farm in southern Mississippi where I grew up, quality and value were measured prior to marketing. On real farms apparently unlike the clinical farms - values arc established before products are sold. How would one react to discovering, upon arriving home from the grocery. shopping bags full of vcgctables,‘~ some perhaps “experimental harmful. and others which might in various ways be unfit for consumers? Is it not obvious that many of the untested therapy ideas grown on the clinical farms ~ and marketed by integrative and eclectic psychotherapists would be found by outcome researchers to be of a quality not suitable for marketing?
Psychotherapy
Integration
It is sometimes argued that scientific criteria would stifle creativity. However, adopting the suggested standards and appropriate empirical stance would not necessarily detract from innovative psychotherapeutic developments (e.g. Alford, 1986; Alford & Jaremko, 1990). It would simply demand that prior to “integration” of therapies - the proven and available methods of science be employed to determine the therapeutic validity of interventions (cf. Beck, 1986; Skinner, 1987; Wolpe, 1990). Finally, given the present state of psychotherapy, is there any realistic hope for routine incorporation of scientific criteria? If behavior therapy continues to play an active role in the evolution of the nascent integration movement, then the answer to this question is likely to be affirmative. By continuing to serve as an exemplar and by publicly articulating unassailable clinical standards, it leads the way. There are signs that highly effective behavior therapy techniques, developed decades ago but previously neglected (see Giles, 1983), are now gaining the attention of integrationists because of their obvious superiority to psychoanalysis (Norcross, in press). Perhaps this marks a beginning. Behavior therapy, broadly conceived. stands virtually alone among psychotherapy systems in its emphasis on scientific validation of techniques (Barlow, 1981; Zeig, 1986). This emphasis places it in a favorable position to include effective therapy elements from other systems - and to exclude unproven elements - in the interest of developing a more comprehensive approach to psychiatric disor “integrative” orders (Alford & Norcross, in press).
References Alford. B. A. (1986).Behavioral treatment of schizophrenic delusions: A single-case experimental analysis. Behuvior Thrrupy. 17. 637-644. Alford. B. A. (lY90). Developing potent behavior-change technologies: An invitation to applied behavior analysts. The Behrn~ior Thertrpisr. 1.3. 1. 23.
Criteria
215
Alford, B. A.. Beck, A. T., Freeman. A.. & Wright. F. D. (1990). Brief focused cognitive therapy of panic disorder. Psychotherapy, 27. 23&234. Alford. B. A., 6t Jaremko. M. E. (19YO). Behavioral design of a positive verbal community: A preliminary experimental analysis. Journul of‘ Behavior Therupv und Experimental Psychiutry. 21. 173-184. Alford. B. A.. & Norcross. J. C. Cognitive therapy as integrative therapy. Journul of Psychorherupy tnregruCon. I (In press). Barlow. D. H. (IYXI). On the relation of clinical research to clinical practice: Current issues. new directions. Jourr~al of Consulring amI C’linicnt P.v_vctwtog,v. 49. 147155. Barlow. D. H. (Ed.) (IYXS). C‘lin~ul txmdhook of p.syc/~o/o~i~~cr/ di.wrders. New York: The Guilford Prcsa. Beck, A. ‘I‘. (lY70). Cognitive therapy: Nature and relation to behavior therapy. Behuvior Therut~y. I. IX& ZOO. Beck. A. T. (19X6). Cognitive therapy: ._ A sign _ of retrogrcssion or progress? Behavior Ttrerupisr. Y. 2-3. Beutlcr, L. E. ( 19X3). Eckec~tic r~sl’c’hortzc,rur,v: A .sv.~~emtr~k crpprorrch. New York: Pergamon Press. Frances, A. ( IYXX, May). Sigmur~d Frewt: The /in/ infegrurivr ~hcrtrp~st. Invited address to the 4th Annual Convention of the Society for the Exploration of Psychotherapy Integration, Cambridge. MA. Frank. J. D. (10X2). Therapeutic components shared by all psychothcrapica. In J. Harvey & M. Parks (Eds.). P.sycho:hercrpy resewch und hetwLzior chuqe: I WI Musrer Lecrure Series. Washington: American Psychological Association. Garfield. S. I.. (IYX2). Eclectlclsm and integration in psychotherapy. Hehuvror Therrrpy. 1.3, hII!-623. Gilcs. ‘I’. R. (IYXD). Probable cupcrioritv of behavioral interventions-II: Some implications lor the ethical practice of psychological therapy. Jour~~rl oj’ Behrr~ior Ihercrpy cmd E.rperimet~rcll P.\Khirr1ry, 14. I x9- I Yh. Giles. T. R. ( IYYOa). Bias against behavior therapy in outcome reviews: Who speaks for the put&t? The BehuiGor Therupisl. 13. X&90. Giles, T. R. ( IYYOh). Underutdization ol effective psychotherapy: Managed mental health arc and other forces of change. The Behtwior T/lr~rrrpi.s/, f.?, lO7?1 10. Goldfried. M. R. (IYXO). Toward the delineation ol therapeutic change principles. Am~ricn~ PrwholoRw. 3s. YY I-YYY. Goldfried. M. R. (lYX2). On the history of therapeutic integration. Behtrvior Therrct,y. 13. 577-593. Goldfricd. M. R.. 6i Hayes. A. M. (IYXY). Can contrihutions from other orientations complement behavior therapy? The Behuvior Therupisl. 12. 57-60. Hayes. S. C. (1901). An interview with Dick McFall. The Scienrisr Prucliliorw, I. + I I Kendall. P. C. (10X2). Integration: Behavior therapy and other schools of thought. Behu~~~or Therupy. 1.1. SSY571. Lazarus, A. A. (1967). In support of technical eclecticism. Psychologicrrl Reports. 21. 31.5-4 16. Marks. I. M. (19X2). Toward an empirical clinical science: Behavioral psychotherapy in the IYXOs. Behuvior Ther(I,‘?‘. 13, 63-X1.
216
BRAD
A. ALFORD
McNamara, J. R. (1980). Behavior therapy in the seventies: Some changes and current issues. Psychorherapy: Theory, Research. and Practice, 17, 2-9. Medawar, P. B. (1983). O&r’s razor. In D. Pykc (Ed.), The threat and rhe glory: Reflections on science and scienfists. New York: Harper Collins. Mooney, C. J. (1991). Efforts to cut amount of “trivial” scholarship win new backing from many academics. The Chronicle of Higher Education. 37. 1. 13, 16. Norcross, J. C. (1986). Eclectic psychotherapy: An introduction and overview. In J. C. Norcross (Ed.), Handbook of eclectic psychotherapy (pp. 3-24). New York: Brunner/Mazel. Norcross. J. C. (1990). Commentary: Eclecticism misrepresented and integration misunderstood. P.yychotherapy. 27. 297-300. Norcross. J. C. Prescriptive matching in psychotherapy: Psychoanalysis for simple phobias‘? [special section]. Psychotherapy (In press). Patterson. C. H. (1989). Eclecticism in psychotherapy: Is integration possible? Psychorherap_~, 26. 1S7-IhI,
Skinner, B. F. (1987). Whatever happened to psychology as the science of behavior? American Psychologisl. 4-1. 78@786. Thomas, L. (1983). The youngest science: Notes oJ a medicine-Hjatcher. Toronto: Bantam. Wachtel, P. L. (1977). Psychoanalysis and behavior /herapy: Toward an integration. New York: Basic Books. Wachtel, P. L. (1982). What can dynamic therapies contribute to behavior therapy’? Behavior Therapy. IS. 594-609. Wolpe, J. (1990). The practice of behavior lherapy (4th ed.). New York: Pergamon Press. Wolpe, J., & Rowan, V. C. (1988). Panic disorder: A product of classical conditioning. Behaviour Research and Therapy. 26. 4411150. Zeig, J. K. (1986). The evolution of psychotherapy conference. lnrernalional Journul oJEclectic Psycho!herapy. 5, 233-247. Zeig, J. K., & Munion, W. M. (Eds.) (1990). WhoI IS psychotherapy?: Contemporary per.ypecrives. San Francisco: Jossey-Bass Publishers.
