by Diane McDonald
The Society for the Exploration of Psychotherapy Integration (SEPI) conference, New York city, May 31st- June 2nd 2018
The Society for the Exploration of Psychotherapy Integration (SEPI) is an international, interdisciplinary organisation whose aim is to promote the development of psychotherapies that integrate theoretical orientations, clinical practices, and diverse methods of inquiry. SEPI holds an annual conference to bring practitioners and researchers together and I was invited to attend the 34th annual gathering which took place in New York from May 31st to June 2nd. Drawing on Multiple Theories and Methods to Enhance the Integration of Psychotherapy Practice and Research was this year’s theme and what an array of research and dialogues on this theme there was.
The tragic and untimely death of one of SEPI’s stars was viscerally felt this year as Jeremy Safran (New School of Social Research) sadly passed away on May 7th. Safran was a co- founder of Emotion-Focused therapy along with Les Greenberg and also collaborated with J.C. Muran and others to develop Brief Relational Therapy. His sudden death made it all the more poignant to see his name throughout the conference programme and to hear the echoes of the information and experience he might have imparted had he not been so cruelly and brutally taken from this life. Safran will no doubt be most remembered for his seminal work on the therapeutic alliance and ruptures (Doran, Safran & Moran, 2017), as well as numerous articles on psychotherapy integration.
Throughout the three-day conference, delegates were treated to numerous events: workshops, symposia, plenary sessions, panel discussions, receptions and dinners, with up to seven rooms of the Marriott hotel in use at any one time. Given that I have not found a way to be in two places at once – yet – this article is a snapshot of what was on offer. A wide variety of presentations were available from familiar psychotherapy names such as John McLeod (Institute of Integrative Counselling & Psychotherapy, Dublin), Catherine Eubanks (Yeshiva University, New York), Dan Fishman (Rutgers University, New Brunswick), Art Bohart (California State University), Rhonda Goldman (Argosy University), Jay Lebow (Northwestern University), Timothy Anderson (Ohio University), Nancy McWilliams (Rutgers University), John C. Norcross (University of Scranton, Pennsylvania), Hanna Levenson (Wright Institute) and Stanley Messer (Rutgers University, New Brunswick); a dizzying array of practitioners and researchers.
In this article I hope to give a flavour of the conference by reviewing four of the seminars I attended. These were:
- Using case study evidence to inform the development of integrative therapy practice
- Couples in crisis: Three Assimilative Family Therapy (AFT) models
- Facilitative Interpersonal Skills (FIS): A common factor amongst highly effective therapists?
- ‘My journey through psychotherapy integration by twists and turns’ by Stanley Messer
I will conclude this article with a description of what it was like to present my own research at SEPI. Of note, my trip would not have been possible without the funding that Turning Point Institute secured on my behalf from the Congregation of the Sisters of Mercy Solidarity fund which I am grateful to have received. The primary aim of the Solidarity fund is to help promote a more just, peaceful and humane society by funding projects within particular categories such as mental health.
Using case study evidence to inform the development of integrative therapy practice
Many theories of psychotherapy that we are familiar with have stemmed from case study research (Fishman, 2010). For example, Carl Rogers routinely videotaped client sessions, and both psychotherapy students and experienced practitioners alike have taken inspiration from Irvin Yalom’s (1989) case studies within Love’s Executioner and Other Tales of Psychotherapy. Case study research has emerged as a way to integrate research with practice. It can show how our work with one client might inform our work with others, and perhaps provide guidance for our colleagues too. However, the qualitative nature of case study research has contributed to it being marginalised from mainstream psychotherapy research and overshadowed by quantitative methods which often rely on group comparisons of scores on specific variables (Dattilio, Edwards & Fishman, 2010). Historically, the view has been that it is simply unscientific (Fishman, 2010). Yet without a case based approach to research, it is difficult to derive meaningful principles that we can then apply to everyday practice (Edwards, Dattilio & Bromley, 2004). Many have argued for recognition of the important role of case based research in developing theory that can then be translated into practice (Flyvbjerg, 2006; Stake, 1995; Upshur, 2005; Yin, 2002) and John McLeod has been a driving force in this campaign.
I came across McLeod early on the Friday morning facilitating a panel of Irish-based therapists, all of whom were there to share their own case-study research: Marcella Finnerty, Frankie Emma Brown and Grainne Deirdre Ward. Sitting beside me was SEPI program chair Dan Fishman – an influential figure in bringing case study research to the wider community with the journal Pragmatic Case Studies in Psychotherapy. Finnerty highlighted the importance of teaching students how to write up case studies, integrating both the client’s voice but also that of the therapist and their own particular background. Brown subsequently demonstrated this well by disclosing enough of her own background to really bring her case study to life, noting the therapeutic use of her countertransference while working with a particular client.
Case study researchers may have previously been criticised for failing to implement sufficient quality controls (Dattilio, Edwards & Fishman, 2010), but each panel member here used an array of methods (both qualitative and quantitative) ensuring the reliability and validity of their findings. Hermeneutic enquiry has been found to provide a substantial framework to link theory with case material, and helps to ensure that findings are grounded in the data and phenomenology of the specific episodes described and not purely speculative (ibid.). This was the framework employed by these researchers, and measurement tools such as the YP-Core (Twigg et al., 2009), the Session Rating Scale (SRS, Duncan et al., 2003), and the Strengths and Difficulties Questionnaire (Goodman, 1997) concreted their findings further.
Morrow-Bradley and Elliott (1986) found that practitioners rarely use research to guide their practice, preferring instead to rely on clients, supervisors and their own clinical experience. Perhaps we feel the clients in research studies do not reflect those we work with, or maybe the ‘treatments’ used for particular presentations are simply too narrow and restrictive. Yet when clinical practice itself can become a source of research, it somehow seems more accessible and applicable to what we do every day, something that was brought to life by McLeod, Finnerty, Brown and Ward on this particular morning.
Couples in crisis: Three Assimilative Family Therapy (AFT) models
My next stop of the day was to see Jay Lebow chair a panel of two other prominent couple and family therapists: Evelyn Rappaport and Patricia Pitta. Given that my first love is working with couples, this seemed a natural fit for me and I was very excited to be in the presence of these experienced practitioners. In her presentation, Pitta explored the struggle and trauma that an experience of infertility can have on relationships. One in six couples will experience infertility (Thoma et al., 2013) and Pitta shared that the source of infertility stems equally from men and women. Nonetheless, Pitta has found that it is often the woman’s identity that is called into question rather than her partner’s. Some reported feelings associated with infertility are anxiety, mood swings and social isolation (Pitta, 2014). The five stages of grief (Kubler-Ross, 1969) can be evident as couples attempt to come to terms with their “shattered assumptions” (Janoff-Bulman, 1992). Comparing the experience to trauma, Pitta noted that infertility might damage perceptions of both self – which includes the identity of the couple – and of the world at large.
Pitta (2014) has developed an assimilative integrative approach to working with families and couples – assimilative integration being defined as having a ‘home theory’ to which other approaches can be incorporated into (Wolfe, 2001). At this conference, she used a video demonstration of her sessions highlighting the ways in which she conceptualises her cases, and the interventions she uses to identify the tasks of therapy in relation to coping with infertility. By differentiating the concepts of ‘having a child’ with ‘rearing a child’, Pitta showed us how she helped a couple move from pain to possibility. Combining her warmth and empathy with a vast knowledge on the theory of working with families and couples, I found Pitta joyful to watch.
Evelyn Rappaport was next to present and she did so in an energetic, dynamic and vivacious way. Her use of cartoon-slides, video explainers and comprehensive guidelines for securely attached couples provided us with a selection of the ‘tools’ she uses to educate and guide her couples. Her use of a YouTube video called How Romanticism Ruined Love (2016) was both entertaining and educative, and something I knew I could easily integrate into my own practice. This video highlights for couples many of the myths and unrealistic expectations associated with modern-day relationships, with Rappaport quick to point out that she is not out to ruin love but rather to save it. By showing her clients what a securely attached couple looks like, Rappaport helps them renegotiate their own dynamics accordingly.
Facilitative interpersonal skills (FIS): A common factor amongst highly effective therapists?
Upcoming SEPI program chair, Catherine Eubanks, organised the next symposium I attended, with Alexandre Vaz, Timothy Anderson and Michael J. Constantino all presenting. Each of these researchers are involved in exploring ‘Facilitative Interpersonal Skills’ (FIS), with their interests lying in assessing specific therapist characteristics and looking at how to apply these in practice. Therapist common characteristics are their primary focus rather than an allegiance to any particular theory, so they study integration through a ‘common factors’ lens.
- Research has found that therapist effects account for 5-9% of change in therapy (Crits- Christoph et al., 1991; Wampold, 2001). We also have evidence that while there are no superior theories (Luborsky et al., 1975), there may be more effective therapists (Lambert & Ogles, 2004). A quick search online will show up a number of references to ‘Supershrinks’ (Miller, Hubble & Duncan, 2008), a phrase coined by D.F Ricks (1974). Ricks (ibid.) used this term to describe exceptional therapists – practitioners whose outcomes appeared far more successful than their peers. A seminar the following day saw Patricia Coughlin outlining the factors that these supposed ‘Supershrinks’ have in common. Coughlin reported that they are:
- Masterful in interpersonal relations
- Courageous and confident
- Humble and approachable
- Responsive and collaborative
- Lifelong learners and always open to feedback
Facilitative Interpersonal Skills research attempts to identify what these therapist characteristics might look like, and how these skills could then be taught. The measurement scale for FIS is a performance-based measure looking at the correlation between levels of FIS in therapists and client results (Anderson et al., 2009). Timothy Anderson suggests that developing an effective FIS measure could be a useful tool when considering candidates for psychotherapy training programs. At present, Anderson notes that studies in this area are in their infancy and are, as yet, inconclusive. Sitting in this seminar, I wondered what the primary differences were between Rogers’ core conditions (Rogers, 1957) and these Facilitative Interpersonal Skills. Perhaps this was a re-packaging of familiar territory in many ways. Nonetheless, FIS provides researchers with a number of therapist components to examine: verbal fluency, building hope and positive expectations, persuasiveness, emotional expression, empathy, alliance-building capacity, alliance rupture-repair responsiveness and – those that we know so well – warmth, acceptance and understanding.
My journey through psychotherapy integration by twists and turns
My personal highlight of the conference was listening to SEPI president, Stanley Messer speak of his own integrative journey. Messer has not taken a straight path to integration, as might be gleaned from the title of his talk. Indeed, my own attempts to formulate a theoretically integrated model (Figure 1) was a particular challenge during my core training; certainly not a perfectly fitting jigsaw for many reasons, not least the fundamentally different perspectives on life and human development on which the different theories rest. For example, seamlessly integrating Freud’s pessimistic view of human nature with Rogers’ humanistic stance can feel like trying to mix oil with water.
However, throwing the baby out with the bathwater comes to mind; though theoretically they might jar, sometimes using both approaches feels far less contradictory in the room with clients than trying to justify it on paper. Messer made mention of this tension between research (or theory) and practice, and wondered whether an assimilative approach is how most practitioners have managed to integrate (using one theory as a ‘home base’ and incorporating other techniques as needed), which Messer views as a sort of middle ground between technical eclecticism and theoretical integration.
Messer has arrived at a literary framework within which to contain his own model of integration. It includes these four elements:
- Comic (Behavioural approaches)
- Tragic (Psychoanalysis)
- Romantic (Humanistic approach)
- Ironic (Systemic and, at times, psychoanalysis), which means holding a healthy scepticism about the client’s content.
Messer stated that it is not only possible, but desirable to hold multiple visions in order to address human complexity, both within and between our clients. So just as my own integrative model may not be a perfectly fitting jigsaw, neither are we as human beings.
My poster presentation
My primary motivation for attending the conference was, of course, to present my own research. This was originally carried out as part of the requirements for the degree of MSc in Integrative Counselling and Psychotherapy from Turning Point Institute/University College Cork in 2017. I was invited to present this study in a poster format at this year’s SEPI conference (Figure 2). The title of my study was Psychotherapists and Schizophrenia: A Quantitative Study of Experiences, Attitudes and Knowledge, which over two hundred members of IAHIP were gracious enough to take part in.
Having prepared my spiel and steeled my reserve, I arrived at the conference to scout for a good spot to put up my poster – an experience much like putting towels on a sun lounger early enough to beat the Germans. With numerous youthful and enthusiastic psychology students, this was not an easy task. Delegates poured out of the rooms surrounding the foyer where my presentation was set up, and I’m pleased to say that I met plenty of like-minded practitioners who valued the benefit of psychotherapy for people with schizophrenia. In fact, what struck me was how many therapists in the U.S. actively work with this presentation, demonstrating how integrated psychotherapy is within their mainstream mental health services: ‘Why would you not routinely work with people with schizophrenia in Ireland as a psychotherapist?’ was asked of me, as I explained the way in which psychotherapy generally lies outside the mainstream services here for people with such acute presentations.
One-on-one conversations about my poster enabled me to talk about very specific aspects of my research and I found it an effective way to disseminate my findings. I enjoyed the challenge of explaining my study in different ways and discovering which explanation was best received, continually honing my communication skills and learning to present in a visually interesting way as the evening progressed. All in all, the poster presentation lasted for 3 hours after which I was fit to drop.
Figure 2: Poster presented at SEPI 2018
Presenting at SEPI was nerve-wracking, exhilarating and worthwhile in equal measure. In many ways, it felt like ‘the icing on the cake’ after a year of hard graft which involved a worrying lack of fresh air and more than one complaint from my husband and children (who are tirelessly supportive I must add).
SEPI promotes dialogue between therapists of differing theoretical orientations, aiming to advance an understanding of the sources of therapeutic change and meet the needs of the growing ranks of integrative therapists. I returned to Ireland rejuvenated and with a sense of ‘belonging’ to the wider community of psychotherapy at large. The three days inspired me to integrate research into my practice more, and implement feedback systems into how I work with clients – though perhaps not to the same extent as our U.S. colleagues who appear fixated on measuring outcomes and change processes. Although I would have liked to have seen more time for juicy discussions at each presentation, overall the organisers managed to provide a jam-packed program of events and I’m already looking forward to Lisbon 2019.
Diane McDonald MIACP is also a pre-accredited associate member of IAHIP. She holds a Masters degree in Integrative Counselling and Psychotherapy and a Diploma in Marriage and Relationship Counselling. She currently works for the Mental Health Commission and runs a private practice for couples and individuals in Lucan, Co. Dublin. Diane also works as an apprentice skills trainer at Turning Point Institute. She can be contacted on firstname.lastname@example.org or through her website www.dianemcdonald.ie.
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