A holistic and integrative approach to psychotherapy: a review of four approaches

When one considers a holistic and integrative approach to psychotherapy, it is worth evaluating and reviewing four approaches: One humanistic, one transpersonal, one existential and one psychodynamic approach.

See also a recent post integrative psychotherapy is more than combining theories

Trainee psychotherapists invariably bring tremendous personal material when assessing how to adopt an approach that seems appropriate for their own style. Students on an integrative pathway are often asked at some point in their training career to critically review different approaches to psychotherapy and then to discuss how they might form a holistic integrative model. This typically takes place in the third year of training, in four year training courses. In undertaking this exercise it is important to discuss the advantages and disadvantages of working therapeutically from a holistic perspective. Students are also asked to use case examples to illustrate their understanding of each approach whilst reviewing its efficacy and this is what the markers are looking for.

By the third year students will have built up a sizable number of placement hours and will have gained extensive experience of short term counselling. They will by then be asking themselves what does it mean to be holistic in approach. The good trainees will be developing their own approach by this stage of their training, or perhaps should be, rather than trying to emulate their supervisor or tutor.

Students are often asked to select one approach from each of the following categories:

Object relations/psychodynamic/attachment theory: Freud, Klein, Winnicott or Bowlbly (attachment theory)

Humanistic: Rogers or Gestalt

Existential: Yalom, Laing, Frankl or May

Jungian symbolism

Transpersonal: Almaas, Wilber, Washburn or the CCPE model

It is important to note that transpersonal psychotherapy does not have exclusive rights when using approaches to spirituality in the treatment room. In the world of psychotherapy there are some modalities that allow for the spiritual in their therapeutic approach. The difference with transpersonal psychotherapy is that this modality actively involves the spiritual element in the therapeutic work.

I believe that a holistic and integrative approach to psychotherapy should include all states of being, that is what I understand to be holistic, as well as potentially embracing all major theoretical traditions, this is what I understand to be integrative. It is essential, therefore, that I am aware of theoretical maps of psycho-spiritual development, or what people often term transpersonal, to help guide my long-term client work. Theory can often be considered a poor relation to practicing from a felt sense stance, especially from a yogi inspired perspective that tracks somatic energies in the client. Such an approach can arrive at unconscious material by bypassing the cognitive aspects of being. However, I believe that it is still crucially important that strong and robust theoretical knowledge should underpin the experiential practitioner as otherwise none of us would need to train in extensive training programmes. Instead, we could just sit on the yoga mat and just be.

Psychotherapy integration can be defined as an approach that includes a variety of attempts to look beyond the confines of single-school approach in order to see what can be learned from other perspectives (Messer, 1992). French (1933) was perhaps the first integrative scholar when he proposed an integration between Freudian analysis and Pavlovian conditioning commonalities (Gold & Stricker, 1993). There have been many scholars since then who have proposed further ideas on integration; including Paul Wachtel (Integrating psychoanalysis and Behavior Therapy, 1977), Gerard Egan (the Skilled Helper, 1975), Kuhn (Search for Truth, 1970) and Rorty (Particular Constructions Will Depend Upon Client Variables, 1999). I am in agreement with the pluralists, such as Cooper and McCleod (2010), when they state that therapy should be based on what the client needs, rather than getting them to comply with standardised treatments.

It could be argued there is a strong transpersonal flavour to psychodynamic counselling. To say these psychodynamic therapists are not engaging in heart to heart communication with their patients might be unfair to them. What is safe to say is that classic Freudian theory had no room for spirituality and religion, when Freud could be viewed as a quasi Marxist (1848) in his pursuit of scientific objectivity and in his disdain for organised religion as empaththe opiate of the masses. Furthermore, I would argue that being neutral should not preclude an empathetic, authentic and warm attitude. This was not well articulated in Freud’s writings but shines through in his case histories and in his patients reports of his analysis with them (Crouch, 1979).

I would also argue that in the free floating attention required of the analyst in long term analysis, when the analyst engages in deep unconscious to unconscious relationship with the patient, there is a deep spiritual connection in the room. Analysts often refer to this process as akin to listening to classical music as they let go of preconceived ideas and theories about their patients (Jacobs, 2005) and enter a deep unconscious state. Indeed, neo Freudian Michael Eigen (1988) could be viewed as exploring similar ground to the transpersonal school following his writings on mysticism. Whilst I would not call Eigen a transpersonal therapist, his analytical writings, nevertheless, demonstrate a degree of symmetry with transpersonal material when working with the unconscious and in using symbols in the consulting room. He embraced Buddhist teachings with his psychoanalytical approach. The primary orientation of his approach might not be the pursuit of a client’s soul journey but there is active engagement with visualisations, altered states of consciousness and symbolism.

In practising as an integrative psychotherapist, I integrate different theoretical models using the relational map offered by Petruska Clarkson in ‘Systemic Integrative Psychotherapeutic Model‘. This model is useful in offering a framework around which to organise my work with clients based on the primacy of relationship. I may apply the most appropriate technique depending on the needs of the client. For Clarkson, there are five ways in which the therapist and client relate:

the working alliance;
the transferential and countertransferential;
the reparative or reparenting;
the person to person (Martin Buber’s ‘I/Thou’);
the transpersonal.

Clarkson’s framework can offer a useful map to help guide long term client work. Whereas Clarkson sees a multiplicity of relationships, Kahn concentrates on the therapeutic relationship as singular, though having different facets to it. Kahn invites us to draw out the integrative aspects of Freud, Rogers, Gill and Kohut. Kahn’s (1997) project is to align insights into the therapeutic relationship from Humanist, Psychodynamic (Object Relations), and Self Psychology sources.

Both Clarkson and Kahn do not, however, make reference to the kind of relationship likely to be fostered in the technique orientated cognitive behavioural approaches. This element is addressed by Gold (1996) and Power (2002) who offer a more comprehensive integrative model by incorporating cognitive and behavioural theories. I would argue that behaviour change techniques such as anti-procrastination exercises and cognitive change techniques such as verbal disputing (and using Beck’s ABC Model) also have their role to play in effective integrative psychotherapeutic practice. CBT can often be downgraded in the psychotherapeutic brand wars (and even in so called integrative psychotherapeutic training institutes) but I believe that the successful engagement of clients in the process of therapy, particularly in short term work, can be facilitated by goal setting. Indeed, Bordin (1979), usefully conceptualized the working alliance as consisting of three parts: tasks, goals, and bond. Tasks are what the therapist and client agree need to be done to reach the client’s goals. Goals are what the client hopes to gain from therapy, based on his or her presenting concerns. The bond forms from trust and confidence that the tasks will bring the client closer to his or her goals.

Mick Cooper and David Mearns (2005) on ‘Relational Depth’ further articulate the integrative approaches of existential, phenomenological, dialogical and highlight the power of encounter relationship. Decades of research (see Feltham, 1999; Lapworth et al, 2001; Horvath and Luborsky, 1993; Mearns and Cooper, 2005; Stern, 2004; Roth and Fonagy, 2006) indicate that the provision of therapy is an interpersonal process in which the main curative component is the nature of the therapeutic relationship. The research findings indicate that the therapeutic alliance may be a better predictor of outcome than technique or approach. There are, of course, common factors that are critical to successful therapy and these can include warmth and empathy and client perceptions of hope and expectation but I would argue that these should form part of every approach. John C. Norcross’s approach to integrative psychotherapy involves selecting models and methods from across orientations so that the client’s experience is best met and in context. He shows how meta-analyses demonstrates that tailoring therapy to the individual client enhances treatment effectiveness. Norcross also alludes to the primary importance of the relationship between therapist and client (the so-called alliance) as a key determinant of good therapeutic outcome. Yalom also sees the importance of the alliance by viewing psychotherapy as essentially a good conversation.

It should also be noted that the holistic and integrative practitioner needs to be mindful of the special place of supervision, continuing professional development (CPD) and research, given the absence of specialisation in any one particular approach. Being integrative means being committed to the whole project of therapy, rather than to a particular approach.For me, it also means that the practitioner continues to do their own personal therapeutic work post qualification. The risks associated with an integrative approach is that there is no real expertise in any one approach.

counsellors pick their theory model based

on the struggles they’ve had themselves in life

Ultimately I suspect that counsellors pick their theory model based on the struggles they’ve had themselves in life. If,for instance, you have had issues with father figures, you probably will gravitate to a Freudian perspective. However, if you have had abandonment issues, you might follow object relations and attachment theory. Moreover, if you find structure and tradition distasteful you might turn to existentialism. Transpersonal will appeal to the curious and the searcher. The transpersonal approach may appear wooly and lacking in focus to some but the aim of the Elements Model, unique to the CCPE, is to bring balance and harmony between the elements as a metaphorical map and encompasses many tools and techniques from many traditions. The transpersonal appeals to the one looking to let go and really embrace change, although transpersonal training institutes attract their fair share of trainees who are avoidant and resistant and remain so throughout their training journey.