Psychotherapy Bulletin

Psychotherapy Bulletin

Clinical Impact Statement: We argue that clinical flexibility increases our opportunities for responsive therapy. This paper provides three exercises for multi-theoretical (integrative) decision-making that were successful with Pre-Doctoral Psychology Interns. We suggest questions for discussion of matching treatment approach to therapist and client, breadth vs. depth of orientation, awareness of blind spots and the ability to offer clients both left and right brain interventions. Conversations with Indonesians about their perspectives on mental illness offer readers a chance to practice integrative, culturally-responsive treatment decisions.

Context

Before psychotherapy, there often comes a phone consultation. When I ask prospective clients how they felt about prior therapy, the most common account is of a therapist whom they regarded as a kind, non-judgmental listener, but not much else. They wonder if they were properly challenged, if there could have been more guidance, or if their clues were heard.

The second most common response I hear is that there was a heavy therapist focus on solutions; an assumption, they felt, that if their symptoms disappeared, they’d be “cured.” Some people say they had hoped therapy would be an exploration of their personality and unique circumstances. Instead, it felt like an opportunity for the therapist to demonstrate competence.

Thirdly, some prospective clients didn’t care for experiential exercises in prior therapy. Some were directed to access deep emotion, some to practice mindfulness, some to enact relationships. These strategies felt hackneyed, they said, especially when no rationale was made transparent. Clients said they felt cared-for but wondered about therapist expertise.

Of course, a client not enjoying therapy doesn’t necessarily mean a poor treatment choice. On occasion, it actually indicates a wise, strategic choice. But perhaps more likely, a skilled therapist applied their usual theoretical orientation rather than flexing to the individual. Multi-Theoretical (integrative) training may have enabled that therapist to depart from their usual approach.

Individualizing treatment isn’t easy. We’re introduced to a palette of theoretical orientations early in grad school. In some programs, we learn a few orientations in-depth. In others, we learn a broad spectrum. We then determine the right fit but do not always have structured help discerning when that approach would be contraindicated. Good supervision helps tremendously with developing an ear for what occurs in our sessions, but our blind spots may actually widen as our identification with one theoretical orientation deepens.

We are human: our vision is guided by what we’re good at. Therapist adaptability does not guarantee we transcend bias, establish rapport or make culturally responsive choices. Still, these become more likely when we hear clearly what happens in our sessions. Hall et al. (2016) as well as Smith and Trimble (2016) found that interventions adapted to culturally-based issues tend to be more effective than orthodox interventions are. Thus, integrative training could really bear fruit.

We encourage graduate and internship training that’s quite specific to clinical choice points; “perceiving forks in the road.” Knowing when and how to reach beyond one’s usual therapeutic approach is an advanced skill. Supervisors are especially valuable with assistance expanding therapist repertoire when they’ve heard or observed sessions.

Both authors spoke with people in Indonesia about their attitudes towards mental health. Interviewees kindly provided an international example of how small insights might inspire therapist adaptability.

Indonesian Perspectives

Our conversations with people in Indonesia were anecdotal but were meaningful to our understanding of their experience. Though Indonesia is majority Muslim, over 6,000 of its 17,000+ islands are inhabited, so diverse religious and ethnic groups exist. We exercise caution about generalizations. That said, some themes emerged from our interviews.

Whether Javanese or Indo-Chinese, Christian or Muslim, affluent or underprivileged, native to Jakarta, Yogyakarta, or Bali, the people we spoke with agreed that mental illness is often attributed to the action of an external force like the will of a spirit. There is stigma for families with mental illness. Explanations for unusual behavior beyond individual control help families save face.

Worries about mental illness as stigma are well-founded in Indonesia. In a practice called pasung, people exhibiting bizarre behavior are vilified, imprisoned, and in some cases shackled. Though pasung is more common in less developed regions, interviewees reported that the shame underlying this practice is felt across socioeconomics.

One interview was with a Christian, Indo-Chinese woman in her twenties who was educated and affluent. This woman had Bipolar I disorder. She explained that her family knew she saw a psychiatrist, but they insisted her symptoms were a conflict between her spirit and her dead aunt’s ghost. The family asked her to frame symptoms this way, too. This woman explained that she believes bipolar disorder to be a medical condition but finds it easier to preserve her parents’ honor by agreeing that it’s a ghost.

Preventing shame or “saving face” is so vital, she said, that her parents know she abuses benzodiazepines to cope with her symptoms, but they prefer that she continue substance use to her publicly acknowledging illness.

We also learned that it’s fairly common for Indonesians to view emotional concerns of any severity as quite stigmatizing. Even moderate anxiety and depression go untreated if these normal, neurotic conditions are conflated with something like schizophrenia, which could mean shameful pasung (imprisonment).

One interviewee in semi-rural Indonesia had lost her son in a volcanic eruption. Her auntie made contact with the university Public Health faculty, requesting outreach. The woman’s panic, self-harm, and flashbacks felt unnatural to her, and she was unfamiliar with post-traumatic stress. Faculty suggesting a possible way of looking at her symptoms — that anxiety is the body’s logical response to a disaster in the natural world, outside of her mind — reduced her panic.

Given the risk of minor emotional health issues signaling major mental illness to the community, therapy utilization in Indonesia is very low. In fact, even Indonesia’s less economically developed neighbor, the Philippines, has twice its mental health professionals per capita (Sebayang et al., 2018). Such a discrepancy suggests that more culturally relevant services might increase utilization.

Of course, learning a bit about a group norm cannot describe any one individual’s beliefs.  Nagayama Hall and colleagues (2021) add that the cultural relevance of interventions doesn’t necessarily mean personal relevance for a particular client. Nevertheless, insight increases the likelihood of thoughtful choices.

Adaptation Brainstorm

Practice multi-theoretical treatment planning. What interventions might you consider for this client:

Female, mid-30s, married to a man, identified with traditional Indonesian culture. Grieving the loss of her only son, age 7, in an earthquake, she presents with panic attacks, self-harm, nightmares, and flashbacks.

What orientations(s) do your ideas represent? Are these your usual intervention choices, or are some adapted to this client?

Below is one brainstorm; your own may look drastically different.

Acceptance and Commitment — Describe the values you aspire to. Behavioral activation to help with impulsivity.

Contextual — Discuss parenting identity. Is losing a son diminished status? How to be responsive to family and they to you.

Cognitive Behavioral — Skills for managing anxiety, to build alliance. Explore self-talk re: fear of future (Indonesia suffers many natural disasters.)

Dialectical Behavior — Mindfulness to tolerate flashbacks, diffuse self-harm impulses. Discuss flashbacks as emotional re-experiencing.

Dreamwork — Skills for changing the ending scenes of dreams, practice lucid dreaming.

Existential/Logotherapy — What do you believe happens after someone dies? Do you believe this loss occurred for a reason? Does love provide meaning in life?

Humanistic/Person-Centered — Invitation to describe son and her relationship with him. Tell the full story: what happened in the earthquake? Explore client beliefs about the meaning of her symptoms. Remain present for a gradual alliance.

Interpersonal/Relational — Express appreciation that coming for therapy is not the norm and requires courage. Model openness about any therapist/client differences. Ask if she would like the therapist to direct our focus.

Motivational Interviewing — Assess client interest in the various ways we might produce change. For example, does she have the most energy for telling her story, symptom reduction, interpersonal problem-solving, spiritual meaning, psycho-education, grieving? Follow client motivations; roll with resistance.

Problem Solving — Invite the client to describe the problem(s) from her worldview. If she’d like, collaborate on what to say to the community that will save face for the family.

Psychodynamic — Would feeling better over time make you feel worse? Inquire about survivor guilt. Discuss new relationships with her living children.

Systems — Inquire about family strengths and expectations of her. Explore family’s beliefs about the root of her symptoms; differ from own beliefs? Explore generational issues.

Gestalt — Wouldn’t utilize?

Rational Emotive — Wouldn’t utilize?

Object Relations — Wouldn’t utilize?

Emotion-Focused Therapy (EFT) — Wouldn’t utilize?

Feminist Therapy — Wouldn’t utilize?

EMDR — Am not qualified. Refer?

Exposure Therapy — Am not qualified.

Psychoanalytic — Am not qualified.

Art Therapy — Am not qualified.

Narrative Therapy — Am not qualified.

Hypnotherapy — Am not qualified.

Some clinicians would choose entirely different therapies for this client. Some would apply the therapies above quite differently. Some clinicians would choose similar interventions but consider them examples of different therapies. Realizing that the very same intervention may reflect diverse approaches and be applied with different intent is integrative training in a nutshell. Theoretical orientations are not categorical, not even close.

Cultural differences are not categorical, either. Side-stepping embarrassment is the human condition. For example, we heard about parents externalizing mental illness (just like in Indonesia) from a Euro-American, mid-twenties, coping with Bipolar I Disorder. She is transitioning male to female, and her parents have declared her symptoms to be the result of the hormone therapy (despite her diagnosis long pre-dating her gender transition). Empathy will always be a valuable guide to our treatment choices. Indeed, therapist education is not sufficient for culturally relevant choices (Nagayama et al., 2021). Clearly, multi-theoretical training would be an improvement but not a fix.

Practice Grid

One way to begin integrative training is to pose two important questions, applying these to as many theoretical orientations as possible until you have created a long grid. While serving as a Training Director, one of the authors facilitated this exercise with Pre-Doctoral Interns and Psychology Staff.

The two questions:

  1. A ______ therapy approach might be a good match for a therapist whose strengths include ______. It might be more of a challenge for a therapist who ______.

A few therapist characteristics to consider: comfort with strong emotion, ability to analyze patterns, sense of humor, understanding dynamics, knowledge of stress reduction techniques, diagnostic skills, interpersonal warmth, bravery, understanding of inequity issues, ability to provide structure, comfort with silence, tabooed topics, spirituality, etc.

  1. A ______ therapy approach might be a good choice for a client who ______. It might be a riskier choice for a client who ______.

A few client characteristics to consider: trauma history, substance use, sense of humor, verbal vs. cognitive strengths, coping style, attachment style, maturity of defenses, understanding of irony and metaphor, level of daily functioning, need for medication, need for support vs. challenge, psychological-mindedness, etc.

The response to this training exercise was unusually energetic, even appreciative. Having “no right answer” makes the process frustrating for some, but therapist self-awareness of a need for concreteness (or abstraction) is itself useful for multi-theoretical training.

Core Skill

The point of being adaptable clinically, from our perspective, is not the specific therapies chosen or identifying as “integrative,” but rather just having our bases covered. Think of this core skill as having some left brain and some right brain strategies to offer our clients.

Ideally, mental health professionals have enough range to:

  • Help clients understand relationship dynamics and learn to catch irrational thoughts.
  • Help clients feel respected, heard, and whole and teach them to regulate how much they feel when challenged.
  • Help clients understand their needs and know how to initiate behavior change.
  • Help clients articulate emotion and appreciate the impact of injustice.
  • Help clients develop coping strategies and grieve disappointments.

We aspire to help clients who are compartmentalized and those who are dysregulated. To assist those who love structure and those who rebel against it. To be effective with clients who think the way we do and those who see things differently. This ability to stretch is the core skill.

We don’t propose that graduate training cover a vast number of theoretical orientations. Rather, we can cover our bases loosely, fostering therapist development of some emotion-focused, some solution-focused, and some insight-oriented strategies. If you prefer, that’s some left brain and some right-brain ways of helping.

Recommendations

  1. Consider introducing clinical flexibility graduate year two and returning to it for internship. None of us can be expected to flex our treatment style until (1) we have a treatment style and (2) are able to perceive decision points in the session.
  2. Invite discussion in courses and supervision. What’s a bigger risk? Breadth (being multi-theoretical) at the expense of depth, or depth (single orientation) at the expense of breadth? These both confer strength; any reason we can’t have both?
  3. Create some version of the Practice Grid exercise above. Seminar participants articulate the therapist skills they believe work well with each theoretical orientation and those they may need to develop. Repeat the process, matching approaches to client needs. This exercise requires an instinctive feel for diverse therapies, pattern recognition, and some vision. It’s difficult but fun; allow generous time for discussion.
  4. Create some version of the Adaptation Brainstorm exercise above. Briefly describe a fictitious client, perhaps different from the therapist on some dimension, then imagine treatment planning utilizing elements of multiple therapies.
  5. Generate hypotheticals for discussion to illuminate the blind spots associated with any single theoretical orientation. How might a psychoanalytic approach miss opportunities for skill-building? How might a problem-solving approach neglect gender issues? How might a cognitive behavioral approach discourage deep emotion? How might a person-centered approach fall short when a client is in crisis?
  6. Play with interesting therapy combinations. How might Humanistic and DBT strategies team up to increase client self-esteem? How might Existential and Rational Emotive approaches combine to help clients bear disappointment? How might Gestalt and Systems therapies together produce amazing family insights?
  7. In supervision, help advanced students develop a secondary or tertiary approach that complements their primary theoretical orientation. Ideally, any experienced therapist has some comfort with accessing emotions, analyzing cognitions, facilitating insight, recognizing patterns, teaching behavioral strategies, and building a meaningful relationship. It's about covering our bases, not about theoretical orientation, per se.
  8. Avail yourself of fabulous training resources. Brooks-Harris & Gavetti (2001) offer a handbook for practicum teaching of micro-skills. Norcross & Popple (2016) wrote a guide to integrative supervision. Comprehensive texts include: Brooks-Harris (2007), Prochaska & Norcross (2018), Hawkins & Ryde (2019), Beutler & Clarkin (2014), Norcross & Cooper (2021), and Ingram (2011).
  9. Join the Society for the Exploration of Psychotherapy Integration. SEPI’s membership is international, their discussions inter-disciplinary, and their tone welcoming; this may be your new favorite conference. The SEPI website also provides training resources, including integrative course syllabi.

Dynamic Benefits

We hope that multi-theoretical planning earns a place in the graduate training curriculum. Learning clinical flexibility is a dynamic, unfolding process — like therapy itself — that improves our chances of helping a variety of people. Integrative thought is a rigorous and creative undertaking, but we find it engrossing to teach and to learn.

Cite This Article

Falk, D., & Gronowski, A. (2021). Multi-Theoretical training as responsive treatment: An international example. Psychotherapy Bulletin, 56(2), 11-17.

References

Beutler, L.E. & Clarkin, J.F. (2014). Systematic treatment selection: Toward targeted therapeutic interventions. Routledge. https://doi.org/10.4324/9781315803746

Brooks-Harris, J.E. (2007). Integrative multitheoretical psychotherapy. Cengage Learning.

Brooks-Harris, J.E. & Gavetti, M.F. (2001). Skill-based psychotherapy integration: A practicum handbook of intermediate microskills. Counseling Center Village: www.ccvillage.buffalo.edu/training-resources

Castro, F.G., Barrera, M., Jr., & Holleran Steiker, L.K. (2010). Issues and challenges in the design of culturally adapted evidence-based interventions. Annual Review of Clinical Psychology, 6, 213-219. https://doi.org/10.1146/annurev-clinpsy-033109-132032

Hall, G.C.N., Ibaraki, A.Y., Huang, E.R., Marti, C.N. & Stice, E. (2016). A meta-analysis of cultural adaptations of psychological interventions. Behavior Therapy, 47, 993-1014. https://doi.org/10.1016/j.beth.2016.09.005

Hawkins, P. & Ryde, J. (2019). Integrative psychotherapy in theory and practice. Jessica Kingsley Publishers.

Ingram, B.L. (2011). Clinical case formulations: Matching the integrative treatment plan to the client. Wiley Publishing.

Jenkins, N. (2016, March 21). Thousands of mentally ill Indonesians are imprisoned in shackles, report says. Time. https://time.com/4265623/indonesia-mental-illness-chains-pasung-hrw/

Nagayama Hall, G.C., Berkman, E.T., Zane, N.W., Leong, F.T.L., Hwang, W., Nezu, A.M.,

Maguth Nezu, C., Hong, J.J., Chu, J.P. & Huang, E.R. (2021). Reducing mental health disparities by increasing the personal relevance of interventions. American Psychologist 76 (1), 91-101. https://doi.org/10.1037/amp0000616

Norcross, J. C. & Cooper, M. (2021). Personalizing psychotherapy: Assessing and accommodating patient preferences. American Psychological Association. https://doi.org/10.1037/0000221-000

Norcross, J.C. & Goldfried, M.R. (Eds.). (2019). Handbook of Psychotherapy Integration, 3rd edition. Oxford University Press. https://doi.org/10.1093/med-psych/9780190690465.003.0001

Norcross, J.C. & Popple, L.M. (2016). Supervision essentials for integrative psychotherapy. American Psychological Association. https://doi.org/10.1037/15967-000

Prochaska, J.O. & Norcross, J.C. (2018). Systems of psychotherapy: A transtheoretical analysis. Oxford University Press. https://doi.org/10.1093/med-psych/9780190690465.003.0008

Sebayang, S.K,. Mawarpury, M., & Rosemary, R. (2018, November 6). Less than 1,000 psychiatrists for 260 million Indonesians. The Jakarta Post.

Smith, T. B., & Trimble, J. E. (2016). Foundations of multicultural psychology: Research to inform effective practice. American Psychological Association. https://doi.org/10.1037/14733-000

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