The Integrative Attitude - A Personal Journey

European Journal of Psychotherapy and Counselling,March 2008; 10(1): 19–38

The integrative attitude – a personal journey

JOHN NUTTALL

School of Psychotherapy and Counselling Psychology, Regent’s College, Londonand Greenwich University, London

AbstractThe origins of clinical psychotherapy date from the beginning of last century and thedevelopment of broadly four foundational schools – psychoanalytic, cognitive-behavioural, humanistic and transpersonal psychologies. The imperative to integratethese schools, however, is relatively recent and in the last 25 years a professionalintegration movement has developed, exemplified by the formation of SEPI and theUKAPI, and ‘integrative psychotherapist’ is now the most popular nomenclature usedin the profession. This article gives a brief history of the integration movement, reviewssome issues raised by developments so far, and discusses the personal dilemma thatintegration evokes in the would-be integrative practitioner. Using my own journey Iespouse an integrative attitude that is based on the nature of integration as an evolvingpersonal process rather than an ideal, fixed, profession-wide position. I describe threeinterweaving modalities of integration I call constructive, complicit and contiguousintegration, which form a developmental framework that aims to encourage theindividual activity of questioning, inventing, researching and interrogating thediscipline within its philosophical, professional and social context. In concluding,this article exhorts the profession to see integration as a personal journey, as a way ofbeing that is constantly becoming and unfolding in relation with the therapist’straining, experience and interaction with peers and clients. The result is indefinableand unnameable, and perhaps represents the soul of integrative psychotherapy.

Keywords: Psychotherapy integration, integrative psychotherapy, SEPI, therapeuticrelationship, constructive, complicit, contiguous

Introduction

Psychotherapy as an empirical-scientific discipline, although foreshadowed byHippocrates and Gallen, has existed for little more than a hundred years

Correspondence: John Nuttall, School of Psychotherapy and Counselling Psychology, Regent’sCollege, Inner Circle, Regent’s Park, London, NWI 4NS. E-mail: [email protected]

ISSN 1364–2537 print/ISSN 1469–5901 online/08/010019–20 � 2008 Taylor & FrancisDOI: 10.1080/13642530701869326

(Ehrenwald, 1976; Frank, 1986). The origins of clinical psychotherapy as weknow it today arguably date from the coincidental innovative work of Freud,Pavlov and Moreno at the start of the last century (Corsini, 1995, p. 12).From these beginnings three major foundational schools of psychoanalysis,cognitive-behaviourism and humanistic psychology developed (Clarkson,1992a, p. 3; Nelson-Jones, 2001, p. 3). To these must be added the morerecently acknowledged fourth school of transpersonal psychology (Boorstein,1996, p. 2), which, paradoxically, has a much longer history, steeped in whatFrank (1986) called the religio-magical tradition. These schools have becomethe basis of one classification of the current psychotherapy professionalthough other, slightly different, classifications have been presented(Beutler, Bongar, & Shurkin, 1997; Roth & Fonagy, 1996).

‘Integration as a point of view has probably existed as long as philosophyand psychotherapy’ (Prochaska & Norcross, 1999, p. 459) but only in the last25 years has it developed into a recognisable movement in the psychotherapyprofession. A number of names have been given to this movement, the abidingcharacteristic of which has been, ‘a dissatisfaction with single-schoolapproaches and a concomitant desire to look across and beyond schoolboundaries to see what can be learned from other ways of thinking aboutpsychotherapy and behaviour change’ (Norcross & Arkowitz, 1992, p. 1).One of these early names was the ‘eclectic movement’, but the generallyaccepted term for this professional lobby is now ‘the integration movement’(Hollanders, 2000, p. 34) and ‘integrative psychotherapist’ is now the mostpopular nomenclature used in the profession (Norcross, 1997). These trendswere crystallised by the formation in the USA of the Society for theExploration of Psychotherapy Integration (SEPI) in 1982, by the BritishSociety for Integrative Psychotherapy in 1987, (now succeeded by the UKAssociation of Psychotherapy Integration [UKAPI]) and by the EuropeanAssociation for Integrative Psychotherapy in 1993.

In its mission statement SEPI proclaims, ‘The primary objectives of SEPI areto encourage communication and to serve as a reference group for individualsinterested in exploring the interface between differing approaches topsychotherapy’ (SEPI, 2003). Significantly, the Society offers no prescriptionfor psychotherapy integration, nor does it clearly define what constitutes suchintegration, and importantly, it allows integration to be a personal quest as wellas a profession-wide activity. However, a number of its leading members havedescribed the ‘three most frequently employed strategies for psychotherapyintegration as, technical eclecticism, common factors and theoretical integra-tion’ (Safran & Messer, 1997, p. 143). These were originally enumerated byArkowitz (1989) and are more aptly referred to as ‘routes’ by Norcross andNewman (1992, p. 10), who pointed out ‘integration, as is now evident, comesin many guises and manifestations’ (p. 15) and that there is now a ‘proliferationof integrative theories’ (Fear & Woolfe, 2000, p. 337). A number of pragmaticways of integrating have been suggested, such as the assimilation of a range oftechniques into a core system (Messer, 1992) and complementarity (Goldfried,1995), the combining of techniques from different systems; ways that seemappropriate for all the routes mentioned above.

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Studying these professional developments as part of my integrative trainingled me to explore how the many theories of psychological health anddisturbance might be integrated and reconciled, and whether they could beconsidered, as Roth and Fonaghy (1996) suggest, ‘approximate models of thesame phenomena: the human mind in distress’ (p. 12). Such a quest mightnever be fulfilled; ‘It may never be possible to achieve coherent integration, tocreate the ‘‘grand theory’’, but let the dialogue continue’ (McLeod & Wheeler,1995, p. 287). This article is part of that dialogue and represents my attempt toespouse an integrative attitude that will, hopefully, help others on theirpersonal journey.

The integration movement

The integration movement has been generally concerned with finding waysand rationale by which the theories and practices of the four foundationalschools can be brought together to improve therapeutic outcome. The firstintegrationist may have been Freud himself, as Frances (1988) highlightedat the SEPI conference in 1988 and Javel (1999) argues in his article TheFreudian Antecedents of Cognitive Behavioural Therapy. Javel contends that‘classical psychoanalysis’ diverged from Freud’s actual techniques andwritings, which – he argues – converge more with the tenets of cognitive-behavioural therapy. He exhorts cognitive behaviourists ‘to look at the worksof Freud for insight, inspiration and answers . . .’ (Javel, 1999, p. 406).

Probably the first recognised attempt to integrate behaviourism andpsychoanalysis was presented to the American Psychiatric Association byThomas French (1933) and was later elaborated by Kubie (1934), althoughtheir ideas were not appreciated at the time. Arkowitz (1992) describes howothers developed these links further and suggests that one of the mostinfluential books in this vein is Wachtel’s (1977) Psychoanalysis and BehaviourTherapy: Towards an Integration, which examines how the psychoanalytictheories of Sullivan and Erikson allow for understanding problematicbehaviour as a conditioned response to interpersonal relations. Wachteldeveloped his ideas into an integrative system he called cyclical psychody-namics, and continued his influence by co-founding SEPI in 1982. Overall,these integrative developments seem to be the precursors of what emerged inthe UK as cognitive analytic therapy (Ryle, 1990).

As humanistic psychology developed in the 1960s (Moss, 1999) a greaterwillingness emerged amongst the psychotherapy schools to share and accepteach other’s understanding. This was vividly demonstrated by the productionof the Gloria films (Rogers, Perls, & Ellis, 1965), but was also exemplified bythe influence of two prominent authors of that decade. Firstly, Jerome Frank,who wrote Persuasion and Healing (1961), identified a number of featurescommon to the psychological healing traditions of different cultures. Secondly,Arnold Lazarus introduced the concept of technical eclecticism in 1967 anddeveloped the approach called multimodal therapy (1989). However, probablythe most recognised integrative system developed in this period based onhumanistic values is Egan’s skilled helper model (Egan, 1975), which

The integrative attitude – a personal journey 21

Jenkins (2000) argues, ‘shares some characteristics of the cognitive-behaviourschool and is firmly grounded in the core conditions of the person-centredapproach’ (p. 163). Transactional analysis, which also developed mainly in the1960s, has been similarly described as ‘a multi-faceted system of psychother-apy’ that ‘integrates intrapsychic dynamics with interpersonal beha-viours . . . within a humanistic/existential framework of values’ (Clarkson,1992a, p.1).

This brings me to the current state of psychotherapy integration, and theinfluence of the postmodern Zeitgeist, which Clarkson (1995) suggests hasencouraged a growing realisation that the so-called ‘truths’ or meta-narrativesrepresented by the four foundational schools are ‘fundamentally flawed assingular definitions of reality’ (p. vii). Palmer and Woolfe (2000) point out that‘counselling and psychotherapy are not immune from this tendency’ andsuggest that it ‘has led to a growing interest in flexibility of response andbringing together ideas from disparate schools’ (pref.). Several professionaland economic factors have also encouraged integration. Gold (1993) describeda trend to stop ‘looking for the ‘‘best’’ therapy to a more pragmatic search forthe best of many therapies in order to survive economically and professionally’(p. 6), and Newman and Goldfried (1996) highlighted the pressure to improvethe cost effectiveness of treatments from insurance companies and governmenthealth services. On the professional front, another factor is that ‘the[therapeutic] relationship is consistently being shown in research investigationsas more significant than theoretical orientation’ to clinical outcomes (Asay &Lambert, 1999; Clarkson, 2003, p. 5). Roth and Fonagy (1996) present asimilar conclusion in their review of psychotherapy outcome research in WhatWorks for Whom?, which adds to Asay and Lambert’s work by reviewingoutcome studies by type of illness and client group. Such research supportsPolkinghorne’s (1992) view that ‘the large number of theories claiming to havegrasped the essentials of psychological functioning provides prima facieevidence that no one theory is correct’ (p. 158). This view, combined withthe postmodern perspective, has resulted in the emergence of what might beconsidered to be higher order models of integration that eschew deference topsychological theories in favour of emphasising the importance of the quality oftherapeutic relationship per se. Prochaska and DiClemente’s transtheoreticalmodel (1984), Hobson’s conversational model (1985) and Clarkson’sfive-relationship framework (1995) are pioneering developments in this vein.

During my reflections I recognised a more personal imperative seekingresolution or acknowledgement. I agreed with the view that ‘a personalintegration is an individual construction that can be developed to reflect thethinking and practice of the individual therapist’ (Horton, 2000, p. 326), but Iwondered if the integrative quest also had a deeper psychological meaning and– at least for me – was part of a broader movement towards individuation.

Personal psychotherapy integration

So, what might be the personal nature of this quest for integration? Oneobvious aspect of it is that of becoming a professional integrative

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psychotherapist but as well as being a ‘construction’ our choice of approachmay be symbolic of much deeper psychic processes and aspirations.Sussman (1992), in his book A Curious Calling, presents a range of underlyingmotives for choosing this profession. He argues that one of the main reasons isthe healing of our own psyches, and we might all recognise this reflexiveprocess operating as we progress through our training programmes andassociated personal therapy. This link was noted by Victor Frankl, theinventor of logotherapy, when he wrote, ‘It may be that each person whodevelops his own system of psychotherapy writes, in the final analysis, his owncase history’ (Frankl, 1988, taken from Nelson-Jones, 2001, p.1).

This raises the question of what constitutes a system of psychotherapy.The integrative therapist, John Norcross (1990), writes:

Psychotherapy is the informed and intentional application of clinical methods andinterpersonal stances derived from established psychological principles for the purpose ofassisting people to modify their behaviours, cognitions, emotions, and/or other personalcharacteristics in directions that the participants deem desirable (p. 218).

On the face of it, this seems a fairly useful definition. However, it does notclearly delineate psychotherapy because the underlying methods, principlesand purpose are not fully explicated; there is no sense of the uncertain,subjective and chaotic nature of such interpersonal systems. Nevertheless, asMahrer (2000) points out:

Although the field seems to lack an officially sanctioned list of its formally stated, taken-for-granted fundamental givens and truths, the field is rife with foundational beliefsthat are generally presumed, assumed, implied, taken for granted, and occasionally spelledout (p. 117).

This is manifested in the diversity of metaphor used to describe the therapeuticjourney and its outcome. For example, in Studies on Hysteria, Freud (1896)wrote, ‘Much will be gained if we succeed in transforming your hystericalmisery into common unhappiness’ (p. 305). Klein (1940) talked about‘overcoming the depressive position’ (p. 353). On a more sanguine note, Kohut(1977) aimed at the restoration of the self. Maslow (1970), the humanisticpsychologist, called it self-actualisation. Rogers (1961) aimed for what hecalled a fully functioning person. Cognitive-behaviour therapists aim to changemaladaptive beliefs and behaviours. The existential approach is aboutconfronting life’s givens and one’s own-most potential. Jungians call thejourney individuation and transpersonal psychologists refer to states ofconsciousness that transcend the limits of personal identity. These briefdescriptions do not do justice to the theories and practices concerned but,nevertheless, serve to illustrate the diversity of perspective currently pervadingthe profession.

It is understandable, therefore, that training as an integrative psychothera-pist has its ups and downs – periods of apparent understanding and belief,interspersed with periods of confusion, disbelief and occasional despondency.It has been estimated that there are over 400 systems of psychotherapy(Corsini, 1995), although many of these represent subclasses of the smallernumber of foundational schools mentioned earlier. These schools might be


considered the pillars of psychotherapy, and thinking of them in this wayreminds me of an amusing story (probably untrue) about William James, thefirst professor of psychology at Harvard, who, when writing his book Varietiesof Religious Experience (James, 1902), visited a Hindu sage:

He asked the master, ‘I understand you believe the world to be supported by four huge pillars.’‘Yes that’s true’, replied the sage.‘But I’m curious,’ said James, ‘What holds the pillars up, on what do they stand?’‘Why Dr. James that’s quite easy to explain, the pillars stand on the backs of four great whiteelephants.’‘But on what do these stand?’ asked James, reasoning that there must be a single foundation.‘Well, on the backs of another four great white elephant, of course,’ replied the sage.James, feeling irritated, was about to ask on what foundation these stood, when the sage grabbed hisarm, interrupted him, and said quietly, ‘Dr. James, Dr. James, before you ask, it is great whiteelephants all the way down!’

In the same way, I wondered if the four pillars of psychotherapy had at theirbase some single foundation or truth. Unfortunately, nobody has yetdiscovered the ultimate truth of how to conduct psychotherapy, and theresearch quoted earlier suggests no one school is more efficacious than another.As trainees, we expect our training institution to provide us with meaning andcertainty or, at least, an approximation of the truth. Instead, we are presentedwith diversity, uncertainty, relativism and a range of different ways of talkingabout ostensibly similar psychological phenomena we encounter in theconsulting room. No doubt this lack of cohesion evokes in us the very psychicdilemmas we entered the profession to resolve. For many trainees it leads toperiods akin to St. John of the Cross’ Dark Night of the Soul (Starr, 2002):feelings of being totally abandoned by certainty. In my experience of trainingothers it normally hits about half way through a typical masters degreeprogramme in which five or six different approaches to therapy are studied.Reconciling this complexity and tolerating the uncertainty, especially for thetrainee integrative therapist, is – in my view – the central concern of theintegrative quest. It is something of a lifetime’s task, and may never be resolved,as Jung’s retrospective of his journey suggests. In his autobiography he wrote:

The older I have become, the less I have understood or had insight into or know about myself.I am astonished, disappointed, pleased with myself. I am distressed, depressed, rapturous.I am all these things at once, and cannot add up the sum. I am incapable of determiningultimate worth or worthlessness; I have no judgement about myself and my life. There isnothing I am quite sure about. I have no definite convictions – not about anything really.I know only that I was born and exist, and it seems to me that I have been carried along. I existon the foundations of something I do not know. In spite of all uncertainties I feel a solidarityunderlying all existence and a continuity in my mode of being (Jung, 1963, p. 392).

It would be reasonable to conclude from all this, that models of psychotherapyare just, ‘views or constructions of reality’ (Horton, 2000, p. 326). We do notknow them to be true in any objective sense. They are merely stories,narratives of the way the pioneers constituted their experiences. ProfessorPetruska Clarkson, with whom I trained for four years, used to say after everytheoretical seminar, ‘And remember, it’s only one of the stories, the thing weare more certain about is that two people sit together and there isrelationship’. However, for a trainee therapist, this chipping away at the

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foundations of psychotherapy raises the awareness of the absence of ‘knowing’and the lack of firm foundation and brings some anxiety about how to practiceand how to be with others. But, such awareness does not bring solace. On thecontrary, it disturbs and awakens us. I count myself fortunate to have trainedwith Clarkson and Regent’s College, which, combined, encouraged aparticular integrative attitude that helped me confront and tolerate both thepsychodynamic and existential incertitude that my quest for personalpsychotherapy integration involved.

Training schools and professional affiliations may be places from which weseek a sense of certainty but, as I have indicated, they may not always be theplaces we need to look, as a story about the legendary Mulla Nasrudin (Shah,1999, p. 62) points out. On one occasion his neighbour found him down onhis knees looking for something:

‘What have you lost Mulla?’ he asked.‘My key,’ replied Nasrudin.After a few minutes of helping him search, the neighbour asked, ‘Where did you drop it?’‘At home,’ said the Mulla.‘Then why, for heaven’s sake are we looking here?’‘Well, there’s more light here’ replied Nasrudin.

Shah points out that this is one of the most famous Nasrudin stories aboutnovices not knowing where to seek enlightenment (1999). As a client andstudent myself, and later as a practitioner and teacher, I realised that thecertainty, knowledge, enlightenment, or whatever I was seeking was ‘at home’,that is, within me. Heraclitus tells us, ‘It belongs to all men to know themselvesand to think well’ and that, ‘much learning does not teach understanding’(Kahn, 1981). Teachers and schools can show us the way, but they cannotdirect our inner quest. I considered it my responsibility as an individual toquestion, experiment, search and re-search for meaning and understanding inthis subject I had chosen, and psychotherapy integration raised a number ofpersonal and professional issues for me that needed reflection, if not resolution.O’Brien and Houston (2007), who ‘see integration as a corrective tendency inan over-fragmented field’ (p. 4) discuss a number of ‘obstacles to integration’(p. 5), but the most thorough review of such issues that helped me was byHollanders (2000) who enumerated nine issues central to the integrationdebate. I should like to discuss these briefly, adding one of my own, to pave theway for a deeper discussion of my journey and the development of my view ofthe integration process.

Issues for psychotherapy integration

Issue one concerns the definitions of eclecticism and integration. ‘Eclecticism’ isa process of selecting out, with the implication of taking something apart;‘Integration’ is the process of bringing things together, with the implication ofmaking something whole and new and Hollanders sees eclecticism as aparticular range on a continuum incorporating the three routes to integrationdiscussed earlier (1997). Norcross and Arkowitz (1992, p. 19) also vieweclecticism as the middle stage of a move from the segregation of schoolism,


to the stage of full integration, the characteristics of which are not yetdetermined. These conceptualisations identify a tension active in mostintegrationists, as Paul Wachtel (1991) describes, ‘eclecticism in practice andintegration in aspiration is an accurate description of what most of us in theintegration movement do much of the time’ (p. 44).

Issue two raises the incommensurability of paradigms, that the mainstreamschools of psychotherapy cannot be reconciled because of their differentphilosophical or epistemological bases (Kuhn, 1970) and this raises ‘the issueof whether integration is a viable project at all’ (Hollanders, 2000, p. 34).Such an objection only really applies to theoretical integration, and suggeststhat this particular route is idealistic or unattainable; although to accept thiswould be to undervalue the work of integrationists such as Alexander (1963),Wachtel (1977) and Ryle (1990).

Issue three is about the relationship between integration and pluralism, andquestions whether the concept of integration is out of step with thepostmodern Zeitgeist. This is only an issue if integration is viewed as thesearch for a single grand theory. If, however, it is viewed as a position orprocess that individual therapists determine for themselves, then it may – asNorcross and Newman (1992) hoped – constitute ‘an open system ofinformed pluralism, deepening rapprochement and empirically groundedpractice’ (p. 32). The question of whether integration is a position or a process isthe fourth issue raised by Hollanders. If the grand theory is neither possiblenor desirable then new integrative positions are only likely to add to theproliferation of systems and bring further confusion to the marketplace. Thismay be an acceptable transitory consequence, a desegregation stage, of gettingto the integrative position envisaged by Norcross and Newman above. On theother hand, others prefer to emphasise the unending process and dynamicnature of integration, ‘one of the most underlying values is that integration isan ongoing process in a continual state of development and evolution’(Clarkson, 1992b, p. 290).

The above issues interact with what I think is the most significant of thenine Hollanders (2000) raised. This is the question of where the locus ofintegration lies. He posits three possibilities: ‘Externally’ (i.e. primarily outsidethe practitioner) in the profession or group; ‘Internally’ (i.e. primarily withinthe individual practitioner) by therapists developing their own integrativesystems; and ‘Within the relationship’, that is between the therapist and clientas the client’s needs emerge (p. 37, original italics). Hollanders (2000) locatesthe three routes described earlier as external integration. He identifies nosimilar example for internal integration, but suggests it refers ‘to the wholeprocess involved in being a reflective practitioner’ (p. 38) and emphasises ‘thisreflection should be as widely informed as possible, by the experience ofothers, the literature, varied ongoing training, etc.’ (p. 39). Similarly, theprinciple behind integration within the relationship is that ‘it is the client whoindicates what is needed, and that she does so by the way in which she relatesto the therapist’ (p. 39). This concept is embraced by the integrationistsDuncan and Miller (2000) in their client-directed, outcome-informedapproach to therapy, and is perhaps echoed in the psychoanalytic school by

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Orange, Atwood and Stolorow (1997) on intersubjectivity, and Ogden (1999)with the concept of the analytic third. There seem to be few integrativeapproaches that represent this locus of integration, although Hollanderssuggests that Clarkson’s five-relationship framework (Clarkson, 1995a) isa prominent example. He concludes that integration should take place in allthree loci, and should not just constitute a profession-level search for a grandsystem.

The sixth issue concerns the question of commitment and whether theintegrative therapist can develop a sense of identity and loyalty whilst notbelonging to a recognised therapeutic school. This might be achieved by apersonal attitude of commitment, ‘not to a narrow school but to the wholeproject of therapy’ (Hollanders, 2000, p. 42). This leads to issue seven aboutthe sociology of integration and the lack of a sense of community amongstintegrationists. The major traditions have their own professional bodies and,although SEPI has emerged with its own journal and international network, amore robust esprit de corps is needed amongst integrationists generally. Thismay be discouraged by issue eight, the lack of a single language of integration.On the other hand, Messer (1987) suggests that integration and the exchangeof ideas between schools would be facilitated more by therapists learningseveral therapeutic languages.

The ninth issue, which I found particularly interesting, asks whether theintegrationist is a charlatan or statesperson. On this issue Hollanders (2000) isquite emphatic and provides some resolution of all the issues when he writesthat the integrationist’s task is ‘to serve as a kind of ‘‘statesperson’’ within thefield’ (p. 44). This view of the integrationist touches on what I consider to bea particularly important tenth issue for the integration movement. It concernsthe insular nature of psychotherapy integration so far outlined, which isdeemed to occur within the profession, the therapist or the therapeuticrelationship. Expanding Hollander’s analogy, we have a statesperson withouta policy for the environment or foreign affairs, without a view of the worldoutside. This insular view ignores the kind of internal-external correspon-dence that takes place along the boundaries of psychotherapy as it comes intocontact with the world at large. In other words, to what extent are the systemsof psychotherapy we build within appropriate for, consistent with, andexpressive of the phenomena of the world we experience around us? One ofthe earliest studies of the link between human nature and that of humaninstitutions is probably Plato’s Republic, but in psychotherapy it is exemplifiedby Freud’s Group Psychology and the Analysis of the Ego (1922), andCivilisation and Its Discontents (1930) and in the humanistic school byRogers (1990) in A More Human World. This process is similar in principle toan unnamed fourth route, referred to by Norcross and Arkowitz (1992), bywhich integration is sought with allied disciplines such as psychiatry, sociologyand, lately, neuroscience. At the individual level, resolution of this internal-external correspondence gives meaning and credence to the models ofpsychotherapy we build, whether they are based on a single or a combinationof schools. So far this aspect of integration and the imperative it resolves,although immanent, has been overlooked by the integration movement.


A personal journey of integration

My journey of psychotherapy integration probably began during my firstexperience of psychoanalytic psychotherapy, which I found a stark contrast tothe transactional analysis I had learnt and practiced as a managementconsultant. Some years later, before I started formal training as apsychotherapist, I entered therapy again with a transactional analyst andGestaltist. As I gained knowledge of many different systems, I began to lookbeyond the constraints of single schools to forge links that would help mebuild an ideal integrative approach for application across a range of clients andpsychological conditions. For me this was quite a purposive and constructiveprocess and, although I did not realise it, involved my using Goldfried’sprinciple of complementarity mentioned earlier, as I worked at reconcilingdifferent theoretical concepts that had particular meaning for me. Thisincluded Fairbairnian object relations with the ego state psychology oftransactional analysis (Nuttall, 1998), games (in transactional analysis) withprojective identification (Nuttall, 1999), Kleinian psychotherapy withClarkson’s relational framework (Nuttall, 2000a) and Jung with objectrelations (Nuttall, 2000b). As I reflected on this work I recognised my struggleto find the complementarity of my therapeutic experiences and, as a corollary,reconciliation of the different objects and aspects of me these represented.And this exploration continues as I attempt to reconcile different aspects ofmyself as psychotherapist (Nuttall, 2003, 2006b).

In one form or another, this relatively simple reconciling or combining ofparts, which I have called constructive integration (Nuttall, 2002a), hasdominated the development of the integration movement in the last twodecades. It is generally made up of the three routes to integration identified byArkowitz (1989) and constitutes what Hollanders (2000) described asintegration with an external locus. At the professional level, the end resultrepresents more of a position than a process, where the new system, havingbeen initiated by an individual or a group, is developed in collaboration withother professionals, academics or clinicians. Such systems may then beadopted by other therapists as received clinical approaches that are supportedby empirical research or case history. This mode of integration is arguablydriven by the professional and economic imperatives discussed earlier. And,as Fear and Woolfe (2000) point out, ‘the increase in debate, courses andsocieties to promote the interests of integrative approaches has beenaccompanied by a proliferation of integrative theories’ (p. 337) and I reviewbelow three well-known integrative approaches that exemplify this construc-tive modality.

The first, Gerard Egan’s skilled helper model (1975), represents thecommon factors route and is primarily skills based and concerned with theprocess of psychotherapy. This is broken down into the three phases ofexploration, understanding and action; with each of these engaging specificrelational skills relative to the client’s needs. Thus, ‘far from being rigid andprescriptive, the model is intended to set out how to be with the client,according to the varying needs of the therapeutic process’

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(Jenkins, 2000, p. 168). There is a strong resemblance between the commonfactors associated with positive outcomes listed by Asay and Lambert (1999)and the skills and techniques enumerated in the skilled helper model.

The second system, cognitive analytic therapy (CAT) developed byAnthony Ryle (1990), represents, in my view, the quintessential example oftheoretical integration and, according to Evans and Gilbert (2005),exemplifies the principle of complementarity (p. 31). It has a heritage thatdates back to French and Alexander and ‘CAT aims to combine within asingle framework what is most useful in psychoanalytical and cognitivetherapy theories’ (Crossley & Stowell-Smith, 2000, p. 203). The unifyingprinciple developed by Ryle is that of the procedural sequence model whichrepresents a unit of associated feelings, thoughts and behaviours of theindividual in relation to others. Pathology is conceptualised as the develop-ment and habitual enactment of ineffective or problematic proceduralsequences. Cognitive analytic therapy is aimed at identifying such proceduresand their attendant techniques for perpetuation called traps, dilemmas andsnags, and reformulating them in a way the client will recognise and beprepared to modify for the future.

Technical eclecticism ‘seeks to improve our ability to select the besttreatment for the person and the problem’ (Norcross & Newman, 1992,p. 11). It was pioneered by Arnold Lazarus (1967, 1989) in his system ofmultimodal therapy, which is based on thinking about and assessing theclient’s psychological problems across a range of modes of functioning. Thesemodes are: behaviour, affect, sensation, imagery, cognition, interpersonal anddrug/biology, for which he coined the mnemonic BASICID. Therapeuticinterventions addressing these modes are designed and introduced in order ofclinical priority and are often determined by using a variety of client profilequestionnaires. Lazarus (1992) believes that different techniques can be usedor combined, without the integration of the theories underpinning thosetechniques, and argues that empirical evidence (clinical or research observa-tion) should be the only criterion for judging which therapeutic interventionsare effective and for whom.

As my clinical experience increased, it felt more appropriate to considerintegration a personal endeavour that would allow flexibility and adaptabilityfor me and my relationship with my clients. I began, therefore, to examine ifClarkson’s relational framework (1995) provided such attributes (Nuttall,2000a, 2002b). In doing this, I recognised Clarkson’s work represented adifferent perspective on integration, one that identified an emergent or higher-order paradigm of practice that both simplified and embraced the pluralityand complexity in the profession. From this perspective integration is viewedas an inevitable product of the ubiquitous process of synthesis that comesfrom relationship and interaction. As Heraclitus said, ‘conflict (polemos) is thefather and king of all things’ and integration seems part of the natural processof evolution and change he associated with the force of Nature he calledPhysis (Kahn, 1981). This view emerged again in what the medievalalchemist’s called the mysterium coniunctionis, a process in which, as theRosarium Philosophorum describes, ‘they that were two are made one as though


of one body’ (cited in Jung, 1946, p. 85). The theories of chaos andcomplexity offer a contemporary narrative for understanding relationship interms of non-linear dynamic systems (Stewart, 1997). Isham (1995) alsopoints out that the concept of quantum entanglement suggests at afundamental level objects are ‘inextricably linked or entangled . . . in a sense,they simply cease to be independent things, and one can only describe themin relation to each other’ (p. 27).

Complicit integration takes this perspective of relationship and views someintegrative approaches as something that the contemporary sciences mightcall strange attractors or emergent phenomena. In this sense, Stewart andCohen (1997) define emergence as ‘the appearance of recognisable large-scalefeatures in a system whose chain of small scale causality are far too intricate todescribe let alone follow in detail’ (p. 149). In nature such simplicity emergesfrom complexity by an iterative process they call complicity. In Figments ofReality Stewart and Cohen argue that the human condition represents such asystem, a ‘complicit interaction between culture and individual mind, eachshaping the other’ (p. x). The book presents a somewhat Heraclitian view ofthe world as a place of constant interaction and flux, the underlying physicalreality of which we can only infer and never truly know through personalexperience. In deference to the above process I adopted the word complicit todescribe those integrative approaches that seem to represent such emergentand higher-order systems of psychotherapy (Nuttall, 2002a) and I considerClarkson’s relationship framework (1995) and the transtheoretical modeldeveloped by Prochaska and DiClemente (1984) to constitute such systems.Others too have identified emergent relational modalities (Gelso & Carter,1994; Greenson, 1967; Kahn, 1997), although these have not led to thedevelopment of distinct models of integration.

Prochaska and DiClemente’s (1984) system ‘is predicated on the belief thatthe current relativism can be transcended by discovering or constructingconcepts that cut across the traditional boundaries of the psychotherapies’(Prochaska & Norcross, 1999, p. 491). They define it as a ‘higher-ordertheory of psychotherapy’, which sets ‘out to construct a model ofpsychotherapy and behaviour change that can draw from the entire spectrumof the major theories’ (p. 491). I would argue in line with the principle ofcomplicity, that rather than construct, they have recognised – or identified –a simple therapeutic process that has emerged out of the complexity of themany disparate psychotherapy systems. Confirming this they write, ‘incolloquial terms, we have identified the basics of how (process), when (stages),and what (levels) to change’ (p. 505, my underlining).

The quest to find a basis for rapprochement prompted Clarkson’s research(2003), from which she distinguished five primary modes of therapeuticrelationship, which she proposed as ‘a possible integrative framework for thedifferent traditions’ (p. xiii). In support, Hollanders (2000) describes it as an‘integrative approach based essentially on the nature of the therapeuticrelationship’ (p. 23). The five modes are the working alliance; thetransferential-countertransferential; the reparative or developmentallyneeded; the person-to-person or real; and the transpersonal relationships.

30 J. Nuttall

Clarkson (1995) writes, ‘it is important to remember these are not stages butstates in psychotherapy, often ‘overlapping’, in and between which a patientconstrues his or her unique experience’ (p. xii). Hinshelwood (1990)supportively described Clarkson’s framework as ‘an attempt to find aperspective from which an overview might become possible . . . instead ofhaving incompatibilities we have different priorities and emphasis’ (p. 129).These approaches bring a new perspective to psychotherapy integration that isabout understanding the simplicity, the essence, or the core of what we do aspsychotherapists. They encourage the view that the four foundational schoolscan be seen as complementary and enriching, rather than incompatible andcontradictory.

My interest then moved from one of finding integrative links to one ofunderstanding the integration process as a whole. In this I recognised a thirdmodality of integration, which reflects how psychotherapy relates to, andexplains, the world we experience and in which we live. It characterisespsychotherapy not only as a meta-psychology of the individual, but also of thegroup, organisation and society, and represents engagement with the worldand other disciplines, such as neuroscience, sociology and anthropology. Informulating an integrative approach I consider such contiguity or internal-external correspondence useful in testing the approach’s robustness andefficacy and, accordingly, I called this modality contiguous integration(2002a). This seems to have been important historically for philosophersand psychologists as it validated and added meaning to their conceptualisa-tions. According to Samuels (1995), modern psychotherapy has had ‘anambition to give therapy to the world’. The principle of interrelatednessunderlying this dimension of integration can probably be traced back as far asHeraclitus who wrote, ‘from all things one and from one thing all’. Theprinciple is apparent in later philosophies exemplified by the Hermetic adage,‘as above, so below’ (Marshall, 2001, p. 251) or the Kabbalistic aphorism ‘sotoo does the lower sphere affect the upper’ (Hoffman, 1996. p. 167). Leavingphilosophers aside, in modern psychology, Freud probably first demonstratedthis integrating process with Totem and Taboo (1913) and more concretely inGroup Psychology and the Analysis of the Ego (1922). Similarly, Freud’s Projectfor a Scientific Psychology (1895) was an early attempt at integration ofpsychoanalysis with the more recognised biological sciences; this particularsynthesis is also apparent in the work of Bowlby (Mitchell & Black, 1995) and,more recently, Schore (2001).

Menzies Lyth (1986) writes, ‘psychoanalysts have been interested in societyand its institutions since ever there were psychoanalysts’ (p. 284) and,following Freud and Klein, it was Bion (1962) who probably developed thefirst comprehensive psychoanalytic theory of group and organisationalbehaviour (de Board, 1995). These theories are now well-acceptedexplanatory paradigms for group and organisational behaviour (Jacques,1955; Menzies Lyth, 1986; Kets de Vries & Associates, 1991). At the politicallevel, Moses (1987) and Elliot (2005) show how psychodynamic processesaffect, and often hinder, the political process of conflict reconciliation, such asthose affecting the Middle East and Northern Ireland. In the humanistic


school, Gordon (1951) explored the applicability of Rogerian principles toleadership and administration, and Berne’s concept of ego states andtransactional analysis have been used to understand organisational dynamics(1963), group treatment (1966) and interpersonal games (1968). Jung alsooffers one of the most extensive elaborations of internal-external correspon-dence in the recent history of psychotherapy. Hawke (2000) refers to Jung as acultural theorist (p. 1) whose concept of the psyche addresses the gap betweencollective norms and values on the one hand and individual beliefs and desireson the other. Jung postulated a collective unconscious of archetypes, images,which according to Stern (1998) ‘constitute the ultimate source of psychicsymbols, which attract energy, structure it, and lead ultimately to the creationof civilizations and culture’ (p. 85).

The above are examples of how psychotherapy has been used to understandand effect change in group, organisational and social behaviours and attitudes.My exploration into this aspect has covered a range of different socialphenomena, such as the structure of social minorities (Nuttall, 2000d),management behaviour (Nuttall, 2000c, 2004) and urban development(Nuttall, 2002c). On a personal level this probably symbolised my struggle toreconcile my interests in psychotherapy with other important aspects of mylife, such as my social being, professional career and personal aspirations.

These three modalities or dimensions of integration emerged from deepreflection on my internal process as I progressed along my journey.Eventually, I conceptualised this as a heuristic research programme madeup of four interweaving methods – phenomenological engagement with texts,case studies, reflexive action and writing (Nuttall, 2006a). Through thisjourney, I moved from a conceptually naı̈ve position of seeking an idealsystem, to one of accepting psychotherapy integration as somethingnecessarily personal and contextual and, therefore, at the profession level,pluralistic. It represented a developmental process. Firstly of adding partstogether, then of seeing wholes or higher order patterns, whilst throughoutthere was a dialogue with the outside world, with other disciplines and socialartefact. This process reminded me of the course of infant developmentdescribed by Stern (1985) of how the infant first integrates a range ofexperiences to form the basis of the core self, which is then tested byinteraction with others before a sense of a subjective self develops. A Kleinianmetaphor also seemed applicable, as there was movement from part-objectrelationship to depressive position wholeness mediated by projective-introjective processes. The Jungian alchemical metaphor also seemedappropriate as the prima materia of four schools, representing the ancientelements, come together in the process called the mysterium coniunctionis insearch of the elusive philosopher’s stone, a metonym in this case for the grandtheory of psychotherapy integration. The similarity of my integration processwith these developmental models suggested I had conceptualised theintegration quest in a way meaningful for the profession.

The search for integration and reconciliation of schools is expressedbeautifully in the story of the Indian Tree, by the Sufi mystic Rumi (1991,

32 J. Nuttall

pp. 55–56) (my thanks to the late Petruska Clarkson, who first used thisstory in the context of psychotherapy integration [1995, p. 325])

A learned man once said, just for the sake of saying something,‘There is a tree in India. If you eat the fruit of that tree you’ll never grow old and never die.’Stories about ‘the tree’ were passed around and finally a king sent his envoy to India to lookfor it.People laughed at the man.They slapped him on the back and called out, ‘Sir, I know where your tree is, but it’s far in thejungle, and you’ll need a ladder.’He kept on travelling, following such directions and feeling foolish for years.He was about to return to the king, when he met a wise man.‘Great teacher, show me some kindness in this search for the tree.’‘My son, this is not an actual tree, though sometimes it has been called that.Sometimes it’s called a ‘sun’, and sometimes an ocean or cloud.All these words point to the wisdom which comes through a true human being,Which may have many effects, the least of which is eternal life.In the same way that one person can be a father to you and a son to someone else, an uncle toanother, and a nephew to yet another, so what you are looking for has many names, but onlyone existence.Don’t search for one of the names. Move beyond any attachment to names.Every conflict between human beings has happened because of this disagreement aboutnames. It’s such a foolishness, because just beyond the arguing there’s a long table ofcompanionship, set and waiting for us to sit down.

Conclusion

So how might we view the integrationist? Hollanders (2000) suggests theirjob is:

. . . to develop connectedness with the different parts of the field, to stand between the variousschools, to encourage dialogue and debate, and to find ways of helping each to discover andrespect the contributions of the other. In short, her role is to serve as a kind of ‘statesperson’within the field (p. 44).

This is a commendable view and I support the need for communication anddialogue at a profession-wide level. However, this must encourage thecontinuous and personal process of integration that needs to take placeprimarily within the individual therapist as well as – or alternatively – withinthe therapeutic relationship. The individual may take his or her lead fromother more experienced or learned practitioners whose approaches may bealready well-recognised external systems of integrative psychotherapy. But itis still, as Norcross and Arkowitz (1992) wrote, ‘premature to advance anyone integrative system . . . I urge students, in the integrative spirit, to take the‘best’ from each model and to discern converging themes for themselves’(p. 23). The process is necessarily a personal one, as Bion (1962) affirmed inrespect of the various emerging schools of psychoanalysis, ‘as a method ofmaking clear to himself the analyst needs his own book of psychoanalytictheories that he personally frequently uses’ (p. 39).

The developmental journey I have described and the integrative attitudeI now espouse, will, I hope, encourage the activity of questioning,of experimenting, of discovery, of inventing, of researching and of interrogat-ing the discipline of psychotherapy in relationship with the experienced world


we seek to understand and in which we have our being. I have come to aparticularly existential view of integration that sees it more as a way of being,constantly becoming and unfolding, rather than something that is fixed andsedimented. The corollary of this is that integration is something that takesplace at the level of the therapist and not necessarily at the level of theprofession, school or clinical group. It becomes a personal journey, that mustbe seen in the context of the individual’s skills, knowledge and philosophicaloutlook and which must, therefore, in its professional expression, inevitablyembrace diversity.

The exposition of this view is not an invitation for anarchic relativism orpoor eclectic practice. As Evans and Gilbert (2005) assert, ‘any model ofintegration [integrative model of psychotherapy] needs to offer a coherentconceptual framework that reflects a consistency between philosophy, theoryand practice’ (p. 149). However, it is an exhortation to abandon rivalry, theallegiance to names and the certitude of ideologies and not to lose sight ofthe one thing that research and our experience tells us matters above all –something that cannot be fully explained or named – and yet something thatmay be eternal: the quality of relationship. As Lao Tzu said, ‘the Tao thatcan be told is not the eternal Tao: The unnameable is the eternally real’(Mitchell, 1999, p. 1). And yet we maintain our allegiance to names – thetherapeutic alliance, the frame, transference, I-Thou, intersubjectivity,reverie, attunement, kinship libido, the reparative relationship and so on.Perhaps the Hindu sage was right when he said it was great white elephantsall the way down.

Jung (1946) believed the alchemists viewed the soul as the domain of unityand integration, and so I should like to finish with a Celtic blessing from JohnO’Donohue’s book, Anam Cara, or ‘soul’s friend’ (1999, p. 200), for those inthe profession on the quest for personal psychotherapy integration:

May the light of your soul guide you.May the light of your soul bless the work you do with the secret love and warmth of your heart.May you see in what you do the beauty of your own soul.May the sacredness of your work bring healing, light and renewal to those who work with you, and tothose who see and receive your work.May your work never weary you, and release within you wellsprings of refreshment, inspiration andexcitement.May you be present in what you do, and never become lost in the bland absences.May the day never burden, and the dawn find you awake and alert, approaching your day withdreams, possibilities and promises.May evening find you gracious and fulfilled.May you go into the night blessed, sheltered and protected.May your soul calm, console and renew you.

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The Integrative Attitude - A Personal Journey