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Reflections From 50 Years of Integrative Psychotherapy Emphasizing Practiced-Based Evidence and Effectiveness

Internet Editor’s Note: Dr. Philip Friedman recently published an artitle titled, “Excerpt from reflections on 50 years of integrative psychotherapy emphasizing practiced-based evidence and effectiveness” in Psychotherapy Bulletin.

You can find a free copy of his article here.

This article, focusing on integrative practiced-based evidence and effectiveness, was inspired by three articles in the Society for the Advancement of Psychotherapy’s Psychotherapy Bulletin (Jacobsen, 2018; Lambert, 2016; and Savela, 2015), plus an online course by Daryl Chow on “Reigniting Clinical Supervision” (2018) and Paul Clement’s classic article on “Practice Based Evidence: 45 Years of Psychotherapy Effectiveness in a Private Practice” (2013).

Background and Early Turning Points

In 1968, I received my PhD from the University of Wisconsin. In September of 1968, I came to Philadelphia on a National Institute of Mental Health post-doctoral fellowship to study with the behavior therapists Drs. Joseph Wolpe and Arnold Lazarus, who were feuding intensely. Soon after my arrival, Wolpe made me choose between them. I chose Lazarus because he seemed to me more open, flexible, and warmer. He was already focused more on cognitive-behavioral therapy, multimodal therapy, and the person of the therapist. However, both Wolpe and Lazarus were interested in empirical assessment of change, which appealed to me, as I had been trained in behavioral approaches at Columbia and the University of Wisconsin and had a prior background in math and engineering.

The year 1977 was a personal turning point when I became actively involved with a meditation/yoga group and also A Course in Miracles (Foundation for Inner Peace, 1975), which focused heavily on forgiveness of self and others. Professionally, 1980 was a turning point. I wrote an early article in the field on “Integrative Psychotherapy” (1980) and created an integrative meta-model, followed closely by articles on integrative family therapy and integrative marital therapy (1981, 1982).

These turning points influenced the trajectory of my practice and research substantially. I have published several articles and books on the topics of well-being and forgiveness (1989, 2009, 2010, 2012) as well as creating the Friedman Well-Being Scale (1992). In addition, throughout my career, I have remained interested in technology, evidence-based practice, and tracking the effectiveness of what goes on in the psychotherapy room. In 1982, I wrote an article on “Assessment Tools and Procedures in Integrative Psychotherapy,” which was the beginning of my published articles using clinical measures to track change in psychotherapy, an evidence-based therapy approach. I wanted to see empirical measures of progress and change session by session. So I used, or developed, a variety of scales that were easily administered and scored every session. In sharing an outline of my process, I hope to provide a starting point for other psychotherapists who are interested in implementing tracking measures in their own practices.

Forgiveness and Well-Being

In 1984, I published my first article on forgiveness (followed years later in 2010 by my book The Forgiveness Solution) and an early article on the use of computers in marital and family therapy (1985). My first book. Creating Well-being (1989), based on 12 principles of well-being, was followed three years later by my first published scale, the Friedman Well-Being Scale (1992) which consisted of 20 bipolar adjectives and five subscales.

Psychotherapy Outcome and Tracking Change

I became interested not only in tracking change session by session, but also the outcome of psychotherapy. In 1996 Leslie Morey reviewed a study I conducted in the Personality Assessment Inventory (PAI) Interpretive Guide on 22 private practice clients using his PAI clinical scales (1996; see Table 1).

Morey (1996, p. 279)) said “that over 13 sessions Friedman summarized changes in effect sizes presented as standard deviations of change pre to post therapy” (the average effect size change over eight scales was 1.41). Morey (1996, p. 279)) said “Most of the changes demonstrated large changes during treatment with effect sizes greater than .70 being considered large effect sizes whereas those between .50 and .70 are considered moderate effects sizes.” Morey said that from my results the largest impact of psychotherapy could be observed in the reduction of negative affect, the improvement of self-esteem, and the reduction of interpersonal turmoil. (p.279)

I also tracked changes in four measures of well-being and life satisfaction over 13 sessions in that study (Foundation for Well- Being Research Bulletin 106: Change in Psychotherapy, 1996) with an average effect size of 2.12 (see Table 2).

 

Daryl Chow and Effect Sizes in Five Studies Over Time

As previously mentioned, I recently took an online course on reigniting clinical supervision by Daryl Chow. Chow, who now resides in Australia, works closely with Scott Miller at the International Center for Clinical Excellence (ICCE). He did a classic study in 2014 for his PhD dissertation called “The Study of Supershrinks: Development and Deliberate Practices of Highly Effective Psychotherapists.” Chow was strongly encouraging course participants to measure change session by session and calculate effect sizes for their own and their supervisees’ practices.

I went back to mostly published data (1995, 2006, 2014, and 2018) and calculated the effect size for my practice over four time periods. I used the formula post-session minus pre-session divided by the standard deviation of the pre-session as per Chow and Morey’s instructions. I selected session five and session 10 as post sessions because there was sufficient data in all the studies for these time periods; and they indicated the rate at which change took place. In all four time periods, clients were given the Friedman Well-Being Scale (1992) before every session.

The average age was 36.8 (data from 4 studies) with a range of 20 to 68. The average individual income was $56, 000 and family income was $89,000 (data available for 3 studies). There were 3 males for every 2 females in each of the 3 studies data was available) There was no correlation between income and change in the 2018 study (the only study this data was available).

Table 3 shows the effect size results for session 5 and 10 for 1995, 2006, 2013 and 2018; and the average effect size from 1995 to 2018. which was 1.43 at session 5 and 1.68 at session 10.

FWBC Effect Size 1.33 (Sess. 5) 1.69 (Sess. 10) 1995 (N=25)

FWBC Effect Size 1.58 (Sess. 5) 1.79 (Sess. 10) 2006 (N=25)

FWBC Effect Size 1.51 (Sess. 5) 1.51 (Sess. 10) 2013 (N=15)

FWBC Effect Size 1.32 (Sess. 5) 1.68 (Sess. 10) 2018 (N=16)

Also, Table 3 indicates the effect sizes taken from the Friedman Well-Being Scale published manual (1992).

The standard deviation (SD) in 1992 was 11.0. The SD in 2018 was 13.26. The SD for 1995, 2006 and 2013 was assumed to be a conservative 13.95 which is the average SD for 141 distressed clients in the Friedman Well-Being Scale manual. If the SD was lower in any of these years the effect sizes would be higher.

Comparing Effect Size Results With the Clement and Chow Studies

The effect size was less overall than that reported in Clement’s excellent 2013 article (1.90) of change in his private psychotherapy practice over 45 years. Clement, however, collected and reported only pre-post changes using a global measure of change over 17 sessions on average. In all five of my studies, data were collected every session from the client with a well researched measure of well-being. (Friedman Well-Being Scale). See Table 4 for small, moderate, high, very high, ‘supershrink’ (1.5) and Clement (1.9) ‘supershrink’ plus effect sizes.

The effect sizes by session 10 from 1995 on appear to be comparable to or exceeding the effect sizes published by Daryl Chow (2014) in his PhD thesis of “supershrinks.” In his study “supershrinks” were in the upper quartile of therapists (effect size about 1.5), and change was measured session by session. Also, the effect sizes on average could be considered overall in the high range for psychotherapy studies of effectiveness.

Improvement Over Time

Like Clement, I found no overall changes in my effectiveness between 1995 and 2018. However, unlike in the Clement study, there was an improvement overall in my effectiveness according to the data between the initial data collected in 1992 and the four other time periods (1995 to 2018). The effect sizes in 1992 at session five and 10 were 1.01 and 1.44 while the average effect size from 1995 to 2018 was 1.43 and 1.68 at sessions five and 10, respectively (see Table 3). Puzzled by that finding, I realized that I first learned energy psychology therapy techniques (tapping, breathing, and affirmations) in 1995 from Fred Gallo (2002). I have since incorporated them into my current model which I call the ICBEST (integrative, cognitive, behavioral, energy and spiritual therapy) model (2015). This model also strongly incorporates my integrative forgiveness model (2010; 2013; & 2015).

There is a real possibility that the energy psychology therapy techniques learned in 1995 were a significant contributing factor to the enhanced effectiveness in my practice from 1995 to 2018. Personally, I believe that is the case though others might disagree. (of course, it is an N of 1).

Other Process and Outcome Measures

Stress and relationship/alliance measure.

I regularly use the Hopkins Stress Symptom Checklist (Derogatis, 1973), an 83-item measure of anxiety, depression, anger, interpersonal sensitivity, and so forth (see Table 5).

The average effect sizes for session five using the Hopkins Stress Symptom Checklist  was 1.41 and for session 10 was 1.59 over four time periods from 1995 to 2018 (no data were available for 1992) These data show no significant improvement over time and comparable results to the Friedman Well-Being Scale data over time. Again the effect size scores of 1.41 and 1.59 appear to be in the “supershrink” range (see Chow, 2014).

Last year, I developed a 67-item adjective scale. On two occasions, clients filled this out about me. In April 2018, the top adjectives were as followed: Understanding, supportive, peaceful, calm, attentive/ focused, open-minded/hearted, trusting/trustworthy, positive attitude/outlook, dedicated, committed, accommodating, helpful, happy, respectful, bigger perspective, centered, patient, persistent, cheerful, intuitive, curious, intelligent/smart, wise, straightforward, loving, caring, devoted, loyal, accepting, non-judgmental, spiritual, enthusiastic, warm, kind, gracious, compassionate, and forgiving.

Client feedback measures.

Clients also rated the top eight positive behaviors to describe me:

  • Inspiring teacher/healer
  • Very good listener
  • Professional
  • Very good at isolating and analyzing problems
  • Very good at finding solutions or helping you find tools, exercises, processes, to find them.
  • Very good at giving advice and feedback
  • Storyteller (very good with stories that are instructive and helpful)
  • Very good writer (all clients receive a copy of my book the Forgiveness Solution to work with at session three)

Clients currently receive a relatively new 20-item Client Feedback Questionnaire before every session. The range on this scale is from 0 to 100. My current average is 97.6 across 11 private clients with a range of 92 to 100. However, the client feedback score does increase over time. The last two new clients went from 75 to 95 and 92 to 98 over four to five sessions. Although this is a new scale, the client feedback scores appear to correlate with the FWBC (1992) or the outcome rating scale (ORS, 2003). Any significant change session by session, even sometimes in one item, is worth a collaborative dialogue.; for example, if a client indicates the therapist seems less happy to see them or a client is less sure what they are doing in therapy.

I have used a variety of other measures to track change over the years. I also started using three new scales I developed and published this year called the Friedman Life Balance Scale, the Friedman Mini 5 Factor Personality Scale, the Friedman Spiritual Awakening Scale (2018), and the unpublished Friedman Benefits of Therapy Scale.

Reflections and Suggestions

Over the 50 years of my professional career (36 in private practice), I have developed an expanding integrative therapy approach. I started out (1960s and 1970s) with a strong interest in cognitive, behavioral, and systems approaches (marital and family) and fairly early on (1970s and 1980s) developed an interest in spiritual and well-being approaches (now called positive psychology), as well as the use of technology in psychotherapy. Later (1990s) I added the energy psychology approaches. (see Appendix A for a brief description of my clinical/practice approach)

At the beginning of my career I developed a strong interest in tracking change session by session and a practice-based evidence approach. I have summarized decades of practice data as follows:

  • I was able to calculate my effectiveness using effect sizes over 5 time periods from the early 1990s until 2018. This data indicated that the effect sizes for five to 10 sessions which was around the 1.4 to 1.7 range were comparable to the effect sizes in Chow’s “supershrink” study (1.5).
  • There appears to be no overall improvement over time in my effectiveness from 1995 to 2018 though there was obvious improvement from 1992 to 1995 and thereafter. I learned and applied energy psychology therapy techniques in 1995.
  • I have used quite a number of measures to track change session by session though I have consistently used the Friedman Well-Being Scale (FWBC) and the Hopkins Stress Symptom Checklist (HSCL) for a long time.
  • Change typically occurs rapidly in the first five sessions. Clients come in demoralized and the early sessions are in part a remoralization and reeducation process. (Frank, 1961).
  • I have also used relationship and alliance measures, focusing on the perceived relationship between the therapist and the client.

My personal interests and development over 50 years in many ways parallels the development of the field though often 10 or more years earlier than the consensus of the field (making me an early adopter). I have found this process invaluable, and would encourage other practitioners, at whatever stage of their careers, to consider implementing evidence-based tracking measures in their own practices.

 

 

Appendix A: Integrative Psychotherapy: the Clinical/Practice Model

In this section I will briefly describe aspects of the first few sessions of my psychotherapy approach not emphasized as often perhaps as other clinicians.

1. Psychological Assessment Scales

It is my normal practice to have clients fill out psychological assessment scales prior to sessions. This is helpful both in clarifying and addressing their clinical issues, tracking change over time and collecting data for research.

Before the first interview, clients are administered a battery of psychological scales in the waiting room that includes the Hopkins Symptom Checklist or HSCL (Derogatis et. al, 1973); the Friedman Scales of Well-Being (1992), Affect (1998), Belief (1993), Meaning, Purpose and Vision (1997); Self-Worth (1997); Mini-5 Factor (2018); Life Balance (2018) and Spiritual Awakening (2018); the Bradburn Well-Being Scale (1969); the Fordyce Well-Being/Happiness Scale (1987); the Diener et. al. Satisfaction with Life Scale (1985); the Diener et. al. Flourishing Scale (2010); the McCullough and Emmons GQ6 Gratitude Scale (2002); the Raes, Pommer, Neff et. al. (short form) Self-Compassion Scale (2011); the Snyder et. al. Hope Scale (1991); the Thompson et. al. Heartland Forgiveness Scale (2005); the Outcome Rating Scale or ORS (2003) and the Marital Positivity and Cohesion subscales (adapted from Spanier, 1976). I call this a Practice-Based Evidence Approach (PBEA) to psychotherapy.

With the exception of the Hopkins Symptom Checklist or HSCL all these questionnaires are short (mostly from 5 to 20 questions), easily administered and scored. Some are given before every session. Many are administered at various intervals of therapy, usually every five sessions. This permits the tracking of change over time.
Clients are also asked to complete the longer (240 items) personality inventory called the NEO-PIR (Costa and McCrae, 2010) and the clinical inventory (344 items), called the Personality Assessment Inventory or PAI (Morey, 1991) between the first two sessions. Both the NEO-PIR and the PAI are often re-adminstered later in psychotherapy.

Here is an example of one of my newest scales shortened from the published Friedman Life Balance Scale (2018) with 3 subscales that was created almost completely from client written feedback at the end of therapy telling me what they found most helpful during therapy.
Friedman Life Balance Scale
Name________________________Date____________Sex_________Age______

On a scale from 0 to 5 how much does each item describe you at the present time? 0 = not at all; 1 = rarely; 2 = a little bit; 3 = somewhat; 4 = a lot; 5 = a great deal

1. Reflect on what I can do differently in situations and choose to do it.

2. Clarify my options and problem solve.

3. Sort things out and see things in a larger perspective. 
 _____

4. Identify steps to take, to plan and then take actions.

5. Take control of my life.

6. Make good decisions.

7. Deal effectively with people upsetting me by staying calm and seeing things from their perspective

8. Understand myself and others well.

9. Have a deep connection with my feelings.

10. Be mindful of and accountable for my thoughts, feelings and actions.

11. Communicate well with others by expressing myself effectively, listening to others and feeding back what I hear.

12. Feel empathetic & connected with others.

13. Feel able to connect with myself and others.

14. Take time for myself, each day or on a regular basis.

15. Forgive myself: let go of judgments & “shoulds” & accept/love myself.

16. Know that I am good enough

17. Feel a deep capacity for self-compassion and self-love

18. Choose to feel positive & calm.

19. Change my upsetting feelings.

20. Feel strong and empowered.

Circle the 8 Items That You Find Most Valuable, Beneficial and Useful. Thanks

Copyright (c) Philip H. Friedman, Ph.D 2018 Foundation for Well-Being 610-828-4674.

See Table 6 for a graph of changes over time in the 20 item version of the Friedman Life Balance Scale for 5 clients.

As part of the second and third therapy sessions I give clients feedback on these scales. We then discuss which areas they need to strengthen the most. Then we co-create goals (10-15) which I write down for them and myself. This greatly facilitates joining between me and the client.

2. Early interventions

a) Psychological Uplifter

After filling out the initial battery of psychological scales in the waiting room that takes about 90 minutes, I conduct a thorough initial interview lasting 60 minutes to clarify the inner and outer triggers to a client’s problems as they perceive them and to understand how they see their problems in general. Naturally I have an empathetic and compassionate attitude as well. At the end of the initial session I teach them the Psychological Uplifter, which combines energy psychology therapy techniques with cognitive and spiritual approaches. (See Figure 1 and the description below)

The Psychological Uplifter Technique

The following is repeated three times while rubbing on the sore point, i.e., the neurolymphatic point: "Even though I have some of this problem or negative emotion (fill in the emotion/problem e.g. fear, anxiety,hurt, anger, depression, sadness, guilt, shame, low self-esteem, work, marital, relationship and family problems _______________etc.) I accept myself deeply and profoundly and I am a good, competent and magnificent person".

Followed by: "I love myself unconditionally despite my problems and limitations" three times while rubbing on the sore point.

Followed by: “I am entitled to miracles" 3 times while rubbing on the sore point. This is done 10-20 times per day or as often as the person can.

I demonstrate the Psychological Uplifter on myself while client’s follow me, doing it on themselves. I ask client’s which words apply to them and I circle the key words such as “hurt, anger, anxiety, depression, guilt, work and relationship problems” on the handout sheet I give them. This technique might also work well if they rub on or just hold their heart area instead of their “sore point”
I also ask them to think about setting ten to fifteen positive goals that we will co-create together in the second therapy session after dialoguing with me. I call these the “miracle goals” and I tell him they need to be changes that they can make over the next 3 months, 6 months and 1 year.

b) Anything is Possible Technique

At the beginning of the second session I review how often they practiced the ‘Psychological Uplifter’ and encourage them to practice it at least 5 times a day. Then I teach them the “Anything is Possible” technique and tell them to do it every day after the “Psychological Uplifter”. Here are the instructions.

“While tapping with five fingers of one hand on the fleshy part of the side of the other hand (often called the “karate chop point,” shown in Figure 1) repeat three times: “Anything is possible; I am entitled to miracles; Miracles are happening”; and “Miracles come from love”.

Then I ask them to practice both the “Psychological Uplifter” and the “Anything is Possible” statement one after the other. They are encouraged to practice it and the Psychological Uplifter both at least 5 times a day at home. They are also asked to take at least one small step (I call it a “penguin step”) in the direction of any of their10- 15 goals every week.

c) Releasing/Choosing Technique

At the beginning of the third therapy session I teach clients the “Releasing/Choosing” technique. The instructions are:

“While tapping with five fingers of one hand on the karate chop point (see Figure 1), repeat 2 times:

“I release the hurt, anger, depression, guilt (or whatever they are struggling with) and all of the roots and causes (known and unknown) and all of the effects on me and everyone else in my life”.

Then repeat two times:
“Instead I choose to feel calm, relaxed, peaceful and happy and forgiving” .
I first demonstrate this exercise and we then do it together. Then clients and I practice all three energy stress release techniques learned so far one after the other. Clients are strongly instructed to practice all three exercises in sequence 5 or more times per day.

If they follow the instructions, and most do, the scores on the weekly questionairres will be showing substantial changes at this point.

d) 2-Paths Model of Happiness/Change

In session 3, I also discuss what I refer to as the 2-Paths Model of Happiness/Change, using thirteen large poster board diagrams. This 15-20 minute dialogue/lecture is an educational roadmap for change that emphasizes the important role of forgiveness of grievances, judgments and “shoulds,” and clearing of attack thoughts toward oneself, others and circumstances in the change process. It also emphasizes that you can always choose between two paths, the path of happiness and peace or the path of unhappiness and fear.

e) The Forgiveness Solution Book

I then gave all my clients a copy of my book, the Forgiveness Solution (2010), which is mostly an integrated, comprehensive, easy to read workbook on forgiveness. It includes cognitive, behavioral, energy and spiritual, exercises for change and healing; which is why I call my model the ICBEST model of therapy. Clients are instructed to read the first two chapters of the book, do the exercises and bring the completed assignments back with them in the next session so I can review them with them.

f) Positive Pressure Point Technique

In session 4 I teach clients the first two levels of the Positive Pressure Point Technique (details below).

The Positive Pressure Point Technique is an energy therapy technique adapted from the emotional freedom techniques or EFT, thought field therapy or TFT and touch and breathe or TAT, among others, and has eight levels. It uses both a tapping protocol and a hold and breathe protocol using eight meridian pressure points, with and without affirmations. It also includes a forgiveness protocol and is used following the “Psychological Uplifter”, “Anything is Possible” and “Releasing/Choosing” exercises. Most clients find it quite powerful in facilitating change. (see the Forgiveness Solution (2010) Chapters 9 and 10 or Friedman (2015) for a description of the 8 Positive Pressure Point Levels with diagrams.

See Appendix B for a brief Case Study example.

Additional References for Scales

Bradburn N.M. (1969). The structure of psychological well-being. Chicago: Aldine.
Costa, P. and McCrae, R. (2002) NEO-Pi-R. Personality Inventory. Odessa, Fla., Personality Assessment Resources (PAR).
Diener E, Wirtz, D. ,Tov W., Kim-Prieto, C.,Choi D. Oishi S., and Biswas-Diener, R. (2010) New well- being measures: Short scales to assess flourishing and positive and negative feelings: Springer. Social Indicators Research 97:143–156 DOI 10.1007/s11205-009-9493-y
Fordyce, M. (1987) A review of research on the happiness measures: A sixty second index of happiness and mental health. Social Indicators Research, 20. 4. 355-381.
Friedman, P. (1993) Friedman Belief Scale and Research Manual. Plymouth Meeting, PA: Foundation for Well-Being.
Friedman, P. (1997) Friedman Self-Worth Scale. Plymouth Meeting, Pa., Foundation for Well-Being.
Friedman, P. (1997) Friedman Meaning, Purpose and Vision Scale. Plymouth Meeting, Pa., Foundation for Well-Being.
Friedman, P. (1998) Friedman Affect Scale. Plymouth Meeting, PA: Foundation for Well-Being
McCullough, M.E., Emmons, R.A., & Tsang, J. (2002) The grateful disposition: A conceptual and empirical topography. Journal of Personality and Social Psychology, 82, 112-127
Raes, F., Pommier, E., Neff, K. D., & Van Gucht, D. (2011) Construction and factorial validation of a short form of the Self-Compassion Scale. Clinical Psychology & Psychotherapy. 18, 250-255.
Snyder, C. R., Harris, C., Anderson, J. R., Holleran, S. A., Irving, L. M., Sigmon, S. T., et al.(1991). The will and the ways: Development and validation of an individual-differences measure of hope. Journal of Personality and Social Psychology, 60, 570-585.
Spanier, G.B. (1976) Measuring dyadic adjustment: New scales for assessing the quality of marriage and similar dyads. Journal of Marriage and the Family, 38, 15 28. Thompson, L. Y., Snyder, C. R., Hoffman, L., Michael, S. T., Rasmussen, H. N., Billings,
Thompson, L. Y., Snyder, C. R., Hoffman, L., Michael, S. T., Rasmussen, H. N., Billings, L.S.,Heinz, L., Neufeld, J. E., Shorey, H. S., Roberts, J. C., & Robert, D. E. (2005) Dispositional forgiveness of self, others, and situations: The Heartland Forgiveness Scale. Journal of Personality, 73, 313-359.

Appendix B: Case Study

Here is a Summary of One Client’s Therapy Experience (slightly edited for confidentiality and with her permission)

“I am 32 years old and married 6 years. I originally sought out therapy to work on anxiety and depression. I had worked with a few talk therapists in the past and while it was nice to be able to talk to someone about my issues and to receive validation that I was handling hard situations well, I wasn’t feeling better. I experienced frequent panic attacks, usually in public and most often in restaurants. I felt like I was always in fight or flight mode and was just barely existing exhaustedly from one adrenaline boost to the next. I had gotten through a decade of marriage to my best friend with a large number of stressors including challenges from his ex-wife and her abuse as I saw it of my step kids, as well as the normal struggles of raising children into young adults and the extra stresses of step parenting. I understood logically and scientifically what was happening with my anxiety and depression but was having trouble linking what I knew into practice and having it actually help ease my conditions.

I have also been in an online college for the past 3 years and work a challenging (rewarding, but challenging) job with frequently changing timelines and last-minute requests. I met briefly with a new psychiatrist who wanted to put me on anti-depressants and beta blockers. When I found Dr. Friedman through my insurance and saw his website, his ideologies and methods seemed like the perfect fit for me, bridging psychology with spirituality and energy work in a way that connected all of the pieces that felt broken for me.

During the course of treatment, all of the methods that we used helped me in different ways. Weekly scoring of the questionnaires helped the logical, data-driven part of my brain note and see progress. They also helped remind me of all the different facets of daily life and not only monitor how I was doing on a regular basis, but also point out all the things that were going well, even when one or two pieces may have been a bit more challenging that week. For instance, knowing that I was still kind, warm, loving, and trustful, even when I had some self-doubt or anger in a week helped remind me that it wasn’t an all-or-nothing endeavor and that I didn’t need to quit or feel terrible about my entire life because of a few challenges.

The affirmations, breathing, and tapping exercises were life-changing for me because regularly using them each day helped to change my baseline levels of stress and ground me, setting me up for fewer anxiety attacks during the day and erasing the exhaustion that led to depression. They also gave me tools to work with attacks and triggers as they happened. I have been able to enjoy meals after an attack in a restaurant after using the chest points, breathing exercises, and affirmations instead of having to push the food around on my plate and take it home as leftovers. I have been able to enjoy experiences where previously I would have been in my own head either spiraling into anxiety or trying to talk myself out of it.

The exercises in the Forgiveness Solution book also gave me specific things to focus on each week so that we built a foundation of calm, peaceful forgiveness and steadiness in my life rather than trying to break it apart piece by piece in talk therapy.

…I can now truly say that I see myself, I love myself, and I forgive myself on a regular basis for things that I would have beat myself up over in the past. Because of this, I am not looking to outside relationships to make me whole, which allows me to see the people in my life as their own beings rather than as pieces in my story and to love them unconditionally and forgive them, as well. I am a being full of love and I have been a loving, giving person for most of my life, but that giving felt like taking from me because of the restrictions I put on myself and the “shoulds” that I was placing on the people around me. I am now able to love myself and them so fully and see their true selves and the love that they are seeking to receive, and to give unconditionally rather than giving with strings attached. I have tapped into an endless supply of love and have connected incredibly strongly with energy exercises that involve sending love and positivity out into the world.

In specific relationships, I see my step kids much differently than before. I always knew that they were hurt and I wanted to protect them and shoulder the stress. I now see that I can’t outline their lives for them and I can’t remove the hurts that they have experienced. My anger at their mother and at their situation clouded my ability to see that this was going to be their story, no matter how much I tried to help make their story better for them. Now, since treatment, I am able to see them for their true selves and to truly love them. In forgiving them and their mother, I am able to step back and let their stories play out rather than trying to control everything in the hopes of preventing their hurts.

My husband and I have always had a great relationship, but I feel that since completing the Forgiveness Solution book, I am more patient and less controlling with him. I’m able to even more fully appreciate the life that we have and our beautiful connection to each other. I have also been able to let go of friendships that turned sour. In forgiving myself and these friends for the bad things that happened, I feel peace and can truly let go and move on instead of carrying the baggage, superiority, and hurts that built up over the years.

The biggest change is represented in my relationship with my mother, although it’s not strictly just our relationship. I had so many resentments and hurts built up based on the way she treated me and loved me that I was judgmental and critical of every thing that she did. Through forgiveness of myself, I am able to love myself wholly, and to release the need for others to replace the love that I felt I was missing. Through forgiving her, I am able to see and love her in the moment instead of seeing everything through the filter of resentment and pain. I now speak to her regularly when before I rarely did.

My love for myself allows me to release everyone around me from the “should” of loving me enough to make me whole because I am whole, in myself.”

Cite This Article

Friedman, P. (2018, October). Reflections from 50 years of integrative psychotherapy emphasizing practiced-based evidence and effectiveness. [Web article]. Retrieved from http://www.societyforpsychotherapy.org/reflections-from-50-years-of-integrative-psychotherapy-emphasizing-practiced-based-evidence-and-effectiveness

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Friedman, P. (1980) Integrative psychotherapy. In Herink, R. (eds) Psychotherapy Handbook. New York, NY: New American Library, 308-313.

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Friedman, P. (1982b) Assessment tools and procedures in integrative psychotherapy. In A. Gurman (ed.) Questions and answers in the practice of family therapy. New York, Brunner/ Mazel, 2, 46-49.

Friedman, P. (1985) The use of computers in marital and family therapy. In Figley, C. (1985). Computers in family therapy. New York. Haworth Press, 37-48.

Friedman, P. (1989). Creating well-being: the healing path to love, peace, self-esteem and happiness. Saratoga, CA: R&E Press.

Friedman, P. (1992) Friedman well-being scale and professional manual. Plymouth Meeting, PA: Foundation for Well-Being and Menlo Park, CA: Mind Garden.

Friedman, P. (1996) in Leslie Morey. An Interpretive guide to the Personality Assessment Inventory (PAI) p. 279-280. PAR. Psychological Assessment Resources. Lutz, Fla.

Friedman, P. (1996) Foundation for well-being research bulletin 106: Change in psychotherapy. Plymouth Meeting, PA. Unpublished.

Friedman, P. (2002) Integrative energy and spiritual therapy. In Gallo, F. (ed.) Energy psychology in psychotherapy: A comprehensive sourcebook. New York: Norton, 198-215.

Friedman, P., & Toussaint, L. (2006) Changes in forgiveness, gratitude, stress, and well-being during pyschotherapy: An Integrative, evidence-based approach. International Journal of Healing and Caring, 6(2) 11–28.

Friedman, P. (2010) The Forgiveness Solution: The whole body Rx for finding true happiness, abundant love, and inner peace. San Francisco, CA.: Conari Press.

Friedman, P. (2013) EFT, change, forgiveness and the positive pressure point techniques. In Church, D. & Marohn, S., (eds). The Clinical EFT Handbook. Fulton, CA: Energy Psychology Press. 517-538.

Friedman, P. (2015a); The ICBEST model of forgiveness, healing, energy therapy and change. International Journal of Healing & Caring, 15(1), 1-25.

Friedman, P. (2015b) Integrative forgiveness psychotherapy. In Neukrug, E. S. (ed.) Encyclopedia of theory in counseling and psychotherapy. Thousand Oaks, CA: Sage Publications. 557-562.

Friedman, P. (2018) Unpublished data on the use of the Friedman Well-Being Scale and Hopkins Symptom Checklist during psychotherapy. Plymouth Meeting, PA: Foundation for Well-Being.

Friedman, P. (2018) Life balance, emotional stability, well-being and spiritual awakening. International Journal of Healing and Caring, 1(18), 1-22.

Friedman, P. (2018) Friedman benefits of therapy scale. Foundation for Well-Being. Plymouth Meeting, PA, unpublished.

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Jacobson, C. (2018). Psychotherapy: The next 50 years? Psychotherapy Bulletin, 53(1), 8-9.

Lambert, M. (2016) The 10 things learned after 2 decades of tracking client progress. Psychotherapy Bulletin.

Morey, L. (1996) An Interpretive guide to the Personality Assessment Inventory (PAI). Lutz, FL: Psychological Assessment Resources.

Miller, S. D., Duncan, B.L., Brown, J., Sparks, J., & Claud, D. (2003). The Outcome rating scale (ORS): A preliminary study of the reliability, validity, and feasibility of a brief visual analog measure. Journal of Brief Therapy, 2, 91-100.

Piedmont, R. and Friedman, P. (2012) Spirituality, religiosity, and subjective quality of life. In K.C. Land et al. (eds.), Handbook of social indicators and quality of life research. Springer Science+Business Media B.V. Chapter 14.

Savela, A. (2015) 5 Lessons learned monitoring process and outcomes.  Psychotherapy Bulletin.

Toussaint, L & Friedman, P. (2009) Forgiveness, gratitude, and well-Being: The Mediating role of affect and beliefs  J Happiness Studies. 10:635–654

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