On Becoming an Integrative Psychotherapist

by Debbie Hegarty

Definition

Psychotherapy integration is defined as an approach to psychotherapy that includes a variety of attempts to look beyond the confines of single-school approaches in order to see what can be learned from other perspectives (Messer, 1992).

Background

My lifelong curiosity in the human condition, combined with a desire to understand human psychological pain, drew me to train as a counsellor in 2000. Terms such as ‘process’, ‘integration’, and ‘readiness’ were frequently used in that first year of training by trainers and trainees. Their meaning baffled and intrigued me. Up to that time I had made sense of my world with my head…feelings (apart from sadness) had been disallowed. I perceived them in others as messy and threatening and had taught myself a way of living that required little or no reliance on them. Consequently, the first and most exigent phase of my becoming an integrative psychotherapist lay in the integration of my personality. This entailed becoming aware of and thus assimilating those disallowed feelings and concealed characteristics of myself. This process of gaining a solid sense of myself is ongoing and I suspect a life long journey.

Today, nine years later, I have just achieved accreditation status with IACP and IAHIP. In the interim I completed a four-year diploma in Awareness Therapy (2006) under the tuition of the wonderful duo Brendan Connelly (sadly he is recently deceased) and Marie Herlihy. Concurrently, I graduated from UCC with a degree in the Social Sciences (2006). In 2008 I received an Honours Degree in Counselling and Psychotherapy from CIT. It has been a challenging but ultimately worthwhile and beneficial experience. During my studies I managed to integrate many views of human functioning and behaviour: psychodynamic, behaviourism, humanistic, cognitive, Gestalt, TA, object-relations theories, psychopathology, self-psychology, social psychology and developmental psychology. Studying sociology provided me with a more global perspective of the human condition as well as encouraging reflection on the implications of social and cultural influences, while philosophy stretched my hungry mind to contemplate the concepts of transcendentalism, utilitarianism, positivism, natural selection and the importance of evolution.

Being exposed to such diversity in terms of concepts, theories, and treatment approaches, as well as learning to integrate them, was sometimes a difficult and complex endeavour. Having initially assimilated Awareness Therapy with relative ease I found I had to return to practitioning with a certain degree of conscious incompetence in order to develop and utilize a more unified theoretical approach. I am increasingly curious at how often what appear to be diverse hypothesis seem to converge in terms of their attempt at understanding the origins of personality development. The differences emerge within the concept of stages of developmental deficits and around the application of the theory of change.

Integrative Psychotherapy: An Application

In essence, the fundamental philosophy underpinning my work is that it is easier to individuate from a loving mother/primary caregiver than from a neglectful, unpredictable, unresponsive or abusive one. This conception comes primarily out of my own journey as well as my experiences as a practitioner. With this in mind the principal task for me is to facilitate individuation and promote the process of full integration of the personality. It is my understanding that this process is only possible when the following components are present and integrated. When I am listening to my client’s experience in a lovingly curious and non-judgemental way using phenomenological enquiry I am achieving the first component of my therapy, which is to make contact (Erskine, 1993). In time the client learns to trust me and this enables truthful self-expression.

In particular I am influenced as I listen, and witness my client’s behaviour, by Mahler’s hypothesis of separation-individuation, Bowlby’s theory of attachment and Kohut’s self-psychology.  I find them invaluable in my understanding of the first three years of life. It is during these formative years that the practice of individuation can become frustrated and developmental deficits occur.

I regularly consult James Masterson’s (2004) handbook and workbook A Therapist’s Guide to Personality Disorders. I find the notion that there are three inputs into personality formation, namely nature, nurture, and fate, very helpful when formulating a case conceptualisation and attempting to understand the possible influences on the client’s unhealthy adaptations. In addition, it helps me prepare possible treatment plans of clients with particular character styles or disorders (Johnson, 1994). What is more the “three-part cycle, in which a client’s self-activation leads to abandonment depression, which leads to defence”(Masterson, 2004: 32) known as the ‘Disorders of the Self Triad’ allows me understand, predict, and know how to manage the therapy in times when the work seems to engender an increase in adaptive behaviours in the client.

Bowlby observed that mothers who respond promptly and sensitively to their infants crying and other emotional expression, and provide a secure base (Bowlby, 1988), have infants that cry less, are more compliant and ultimately develop from what Mahler (1968) describes as the symbiotic stage toward the separation-individuation stage.

With a view to constructing as secure a base as possible for my clients, I aspire to create the attitudinal core conditions of unconditional positive regard, empathy, and genuineness as outlined by Carl Rogers (1967). It is my contention that these, and the Gestalt recommendations for establishing a dialogic relationship (inclusion, confirmation and presence) ensure the bond between my client and I is built on mutual trust and equality. When appropriate I like using Gestalt experiments to unpack the client’s inevitable internal conflict between expressing and protecting their core nature, as well as other polarizations that are out of awareness. They are also useful in deconstructing introjects, completing unfinished situations and overcoming blockages to contact that were put in place when the movement toward the mothering figure became interrupted.

Increasingly I am finding Transactional Analysis, as conceptualised by Eric Berne, useful in my understanding of relational deficits. The concepts are applicable, accessible and straightforward enough for the client to recognise and understand. I keep a whiteboard in my room and will collaborate with clients as we hypothesize their favourite positions; possible injunctions and counter injunction and make sense of script beliefs. I am also struck by how efficient the following three processes are in effecting change:

Decommissioning of the Parent ego states.

Deconfusion of the Child ego states.

Facilitation of the much-needed redecision course of action.

I notice it allows the client dissolve defences, enhance self-awareness and develop a more cohesive sense of self (Erskine and Moursund, 1988).

Another intrinsic component in raising self-awareness is the use of Focussing (Gendlin, 1981) and the breathing exercises I became skilled at whilst training with ISAT (The Irish School of Awareness Therapy). I learned that awareness can only be experienced in the present tense. Awareness of the past may come in the form of a memory, awareness of the future in the form of a fantasized wish, hope or fear, but essentially awareness is experienced only in the here and now. Enhanced self-awareness and insight in time allows for appropriate action. My ability to co-create a workable plan and devise appropriate actions that will effect necessary behavioural changes has been enhanced recently. This is partially due to the vast and varied experience I am gaining practitioning at a counselling clinic. I am part of a team of counsellors that have been retained by the clinic and I regularly dialogue with other colleagues of diverse orientations.

In some measure my confidence in formulating a collaborative plan of action can also be attributed to the two-year training I embarked on last year in Reality Therapy. William Glasser (1999) developed the theory and his sophisticated yet accessible style of writing (I often give the client photocopied chapters from his book) allows the client consider choosing more direct and helpful ways of behaving and connecting with significant others. What follows is an attempt to epitomize the underlying philosophy of Glasser’s theory (I highly recommend his book ‘Choice Theory’ to anyone interested in knowing more). He contends all behaviours, no matter how destructive and deleterious, are chosen, and the individual’s best attempt at that time to meet one or more of their five basic genetic needs for survival, love and belonging, freedom, fun or power.

It has been my experience thus far that another component of the work of therapy is the ability to truthfully assess the archaic transference behaviours (Kohut, 1971) exhibited by my client as well as my own countertransferential responses. I have found that once the majority of these have been worked through, the aforementioned notion of presence can happen. Ultimately the task is to facilitate the re-experiencing of, and thus healing from, the intense pain of that early attempt at getting close to the mother/ primary caregiver. This in turn allows the client to loosen the grip of that crippling childhood fear of abandonment and begin the journey toward autonomy and creativity of the real self (Masterson, 1988). I am learning from my clients (they continue to be my best teachers in terms of what works in the room and more especially what does not work) that anger needs to be met, fear and sadness need to be soothed, and rage and anxiety need to be contained.

Finally, I firmly believe in the value of regular use of supervision. Within this supportive and collegial relationship I work through any blind spots, assumptions and agendas that may emerge. I also find it an ideal forum for bringing about change in any potentially damaging inclinations that may unduly influence my clients. In short I view it as a basic ingredient in ethical practitioning for the reasons that it safeguards the welfare of my clients by monitoring my professional practice, enhancing competence and developing my ‘internal supervisor’.

Conclusion

Integrating various approaches to psychotherapy, in addition to psychology, sociology and philosophy, allows me to be more flexible in terms of tailoring treatment to each unique client. It also enhances my ability to suggest specific therapeutic interventions for each of their identified problems. I am committed to on-going training, workshops and courses with a view to being as competent an integrative psychotherapist as I can be. Ultimately, I have an expectation that positive change will result from my ability to form a relationship of trust with my client, combined with the appropriate use of skills learned and theories and treatment approaches integrated. As a final point, I continue to have the utmost respect for the integrity of those that come to me to seek change.

Biographical note

Debbie Hegarty is an accredited integrative psychotherapist and works with individuals, couples and groups. She is part of a team of counsellors retained by Cork Counselling at The Hazelton Clinic.

References

Ainsworth, M.D.S., Blehar, M., Waters, E., and Wall, S. (1978) Patterns of Attachment: A Psychological Study of the Strange Situation, Hillsdale, NJ: Erlbaum.

Ainsworth, M. (1985) ‘Attachment: Retrospect and Prospect’, in C.M. Parkes and J. Ainsworth, M.D.S. (1991) ‘Attachments and Other Affectional Bonds across the Life Cycle’, in Parkes, C.M., Stevenson-Hinde, J. and Marris, P. (eds.), Attachment across the Life Cycle. New York: Routledge. pp. 33-51.

Bee, H. (2000) The Developing Child, London: Allyn and Bacon.

Berne, E. (1961) Transactional Analysis in Psychotherapy, New York: Grove Press.

Bond, T. (1993) Standards and Ethics for Counselling in Action, London: Sage.

Bordin, E.S. (1979) ‘The Generalizability of the Psychoanalytic Concept of the Working Alliance’, in Psychotherapy: Theory and Practice, Vol.16 (3), pp. 252- 260.

Bowlby, J. (1969) Attachment and Loss: Vol 1, Attachment. (1973); Vol. 2, Separation: Anxiety and Anger. (1980); Vol. 3, Loss: Sadness and Depression. New York: Basic Books.

Bowlby, J. (1988) Secure Base: Parent-Child Attachment and Healthy Human Development. New York: Basic Books.

Erskine, R.G. (1993) ‘Inquiry, Attunement and Involvement in the Psychotherapy of Dissociation. Transactional Analysis Journal, 21, pp 63-76.

Erskine, R.G. and Moursund, J.P. (1988) Integrative Psychotherapy in Action, Newbury Park, CA: Sage Publications.

Gendlin, E.T.(1981) Focussing, New York: Bantham Books.

Glasser, W. (1999) Choice Theory: A New Psychology of Personal Freedom, New York: Harper Perennial.

Hamilton, N.G. (1988) Self and Others: Object Relations Theory in practice, New Jersey: Jason Aronson.

Hill, C. E. and O’ Brien, K. M. (1999) Helping Skills: Facilitation Exploration, Insight and Action, Washington, DC: American Psychological Association.

Holmes, J. (1993) John Bowlby and Attachment Theory, London: Routledge.

Johnson, S.M. (1994) Character Styles, London: Norton.

Joyce, P. and Sills, C. (2001) Skills in Gestalt Counselling and Psychotherapy, London: Sage.

Kahn, M. (1997) Between Therapist and Client, (2^nd edn.) New York: Freeman.

Kohut, H. (1971) The Analysis of the Self, New York: International Universities Press.

Lapworth, P., Sills, C. and Fish, S. (2001) Integration in Counselling and Psychotherapy, London: Sage.

Loria, B.R. (1988) ‘The Parent Ego State: Theoretical Foundations and Alterations’ in Transactional Analysis Journal, 18 (3), pp. 35-41.

MacKewn, J. (1997) Developing Gestalt Counselling, London: Sage.

Mahler, M. (1968) On Human Symbiosis and the Vicissitudes of Individuation, New York: International Universities Press.

Mahler, M., Pine, F., and Bergman, A. (1975) The Psychological Birth of the Human Infant, New York: Basic Books.

Masterson, J.F. (1988) The Search for the Real Self. New York: Free Press.

Masterson, J.F. and Lieberman, A.R., (eds.) (2004) A Therapists Guide to the Personality Disorders: The Masterson Approach, Phoenix: Zeig, Tucker and Theisen, Inc.

Messer, S.B. (1992) ‘A critical examination of belief structures in integrative and eclectic psychotherapy.’ in J.C. Norcross and M.R. Goldfield (eds) Handbook of Psychotherapy Integration, pp. 130-165. New York: Basic Books.

Perls et al. (1951/1972) Gestalt Therapy: Excitement and Growth in the Human Personality, London: Souvenir Press.

Rogers, C. (1951) Client-Centred Therapy: It’s Current Practice, Implications and Theory, London: Constable.

Rogers, C. (1967) On Becoming a Person: A Therapist’s View of Psychotherapy, London: Constable.

Sroufe, L.A. (1988) ‘The Role of Infant-Caregiver in Attachment’, in J. Belsky and T. Newworski (eds.) Clinical Implications of Attachment, Hillsdale, NJ: Erlbaum. pp. 13-40.

Stewart, I. and Joines, V. (1987) TA Today: A New Introduction To Transactional Analysis, Nottingham: Lifespace.