Are You Sure Your Therapy Has a Recipe?

Ingredients

Source: Photo by Ratul Ghosh on Unsplash

Over the past few weeks, I have been reflecting on a comment made by a clinical supervisor about the importance of having “belief in a model” in order to employ effective psychotherapy. My supervisor suggested that he did not very much care which model we utilized as long as the therapy we practiced ascribed to some coherent and cogent underlying framework that we both felt comfortable utilizing and that we believed in.

This definition of effective psychotherapy is not new. Sixty years ago, psychiatrist Jerome Frank articulated several common factors that he argued were the vehicle by which not only psychotherapy but also other culturally sanctioned forms of healing (such as religious practice) operate (Frank, 1961). One of these factors was, “A rationale, conceptual scheme, or myth that provides a plausible explanation for the patient’s symptoms and prescribes a ritual or procedure for resolving them” (emphasis added). Other scholars have since echoed this claim, such as Thomas Szasz in The Manufacture of Madness (1970) and E. Fuller Torrey in The Mind Game (1972). These authors argue that therapy requires a mutually acceptable framework of understanding, a conceptualization of human problems and their resolution that both therapist and patient share.

I have emphasized two key aspects of Frank’s common factor. First, the “plausible explanation” by which a therapist engages a patient in therapy (part 1) must also be directly linked in a causal manner to “procedure” (e.g., technique, intervention) that the therapist elects to utilize with the patient (part 2). Hence, neither having a unifying model without connection to specific interventions nor utilizing interventions without connection to a unifying model is sufficient.

How does this relate to psychotherapy integration? In two ways: First, adherence to a model—and specifically the effectiveness of being adherent to a model—may be a primary reason psychotherapists hesitate to pursue an integrative approach to therapy. Cognitive-behavioral therapy clearly articulates the ways cognitions, affect, and behaviors are linked and produce symptoms, and thought records, behavioral activation, and other interventions clearly derive from such a model. Object relational therapists understand the role of mental representations of self and other in how patients’ moods and behaviors shift and cause distress and interpersonal problems, and they intervene through increasing patients’ insight into such shifts and explicating these representational dyads. Given that belief in a model and its associated interventions is one of the vital ways therapy works, moving away from circumscribed and packaged models towards complicated and often fuzzy integration may rightfully concern the therapist who implicitly knows, like Jerome Frank, the importance of practicing from the “myth.” Yet, rigid adherence to a model without regard for flexibility is risked by overweening belief in a circumscribed model and may reduce therapy’s effectiveness.

On the other hand, an eclectic approach to therapy in which interventions from different schools are selected based on the apparent clinical need in the moment but without an overarching and consistent underlying framework explaining why such interventions will, in tandem, lead to desired change is also a limited venture. Interventions must be linked to the rationale shared by patient and therapist in order to be effective. Therapists may understandably become jaded with the tribalism and inflexibility that can spawn from monolithic schools of thought and be intrigued by the opportunity to break through the walls of theoretical orientations via “eclectic” practice; yet, if this pull towards flexibility, even if based on empirically supported treatment principles or techniques, is not accompanied by the perhaps more difficult task of adopting a new, integrative worldview, such eclecticism may fail to heal patients in the long-run.

Thus, in order for psychotherapy integration to work, both in terms of being efficacious and in terms of being appealing to therapists, it must have a comprehensive, coherent, and plausible underlying explanation for how the treatment works (part 1) and from which interventions and techniques reasonably derive (part 2). Psychotherapy integration must have a recipe, even if it is an implicit one. One cannot expect to select ingredients from the pantry at random and produce a satisfying meal. One can also not replace sugar for salt, or baking soda for flour and expect following a recipe to result in a delicious dessert. Rationale and interventions, like recipe and ingredients, must be used in harmonious tandem.

How would you explain the underlying framework from which you practice integrative psychotherapy? Please comment below!

—Benjamin N. Johnson, M.S.

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