Integrative Therapy: A Practitioner's Guide


Maja O'Brien & Gaie Houston

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    So dark a mind within me dwells,

    And l make myself such evil cheer,

    That if I be dear to some one else,

    Then some one else may have much to fear;

    But if I be dear to some one else,

    Then I should be to myself more dear.

    Shall I not take care of all that I think,

    Yea ev'n of wretched meat and drink,

    If I be dear,

    If I be dear to some one else?

    Alfred, Lord Tennyson, Maud, XV

    Preface to Second Edition

    We have been encouraged by the positive response to the first edition of this book. Integrative Therapy is gaining ground within the field of psychotherapy and counselling. It is a model of choice in the training of counselling psychology and the number of integrative psychotherapy and counselling training courses are increasing year on year. Although, according to Hollanders (2003: 296), it is not possible to tell precisely how integration will develop in the coming years, the evidence points to further continuation and growth as a major movement in the therapeutic world. This trend is even more prominent in the USA (Lambert, 2004).

    In his review of the first edition of this book Stricker (2005: 235) writes:

    ‘Effective psychotherapy must have a guiding theory, informed by research and colored by experience. There is no single theory that has a premium on the truth, and integrative efforts are more likely to be of general helpfulness than any single orientation (there may be some orientation-based approaches that are particularly suited to some specific presenting problems)’.

    We hope that the integrative effort of this book, written by therapists of quite different backgrounds, will encourage the increasing trend to an informed and intelligent integration of the whole field of psychotherapy. This integration is not only of methods and theories, but of fields of study often ignored between professions. In the original book, for example, we included references to developmental psychology and psychiatric research, that so often overlaps with and supports that in our own field: separate roads were built towards Rome, where co-operation might have brought a better road, faster.

    This new version of our book has two major enlargements or additions of what we see as useful areas which need to be integrated into practitioners' knowledge. These are on research and on the neurosciences.

    We had already written on research, to inform readers about therapy outcome and process, and human development respectively, and to some extent, to alert them to be wary of what axes were being ground by whom in some existing studies. In this edition some qualitative research methodology is set out, and some encouragement to readers to have the confidence to expand the research component that is there in all reflective therapy. A ‘rapprochement between the science and humanities/arts based research’ suggested by Strawbridge and Woolfe (2003: 14) is facilitating new approaches to the study of human beings. This opens up new possibilities for theory building for and by practitioners.

    The neurosciences have come to public attention in these first years of the new century. What is gratifying is that so many of their findings support what we have written and quoted in the first edition. There is illumination rather than refutation. The very exciting field of new discovery and changing understanding, brought to us by the neuroscientists, already suggests some different treatment approaches. Every day more is known, and no doubt more change in therapist behaviour will result. We hope that this edition be of practical help to readers who need to hold on to clarity and structure, as well as respond intelligently to this ever-modulating world, where change is the one constant.


    Our first, warm acknowledgement is to the clients, supervisees and generations of trainees who have educated, challenged and informed us as we worked together. Without them there would be no book. As well, we are very grateful for direct help from Jim Pye, who read the book and commented on it so helpfully from the point of view of a trainee in integrative therapy; Sheelagh Strawbridge, who read and commented on the chapters as they were written; Diana Sanders and Dheeresh Turnbull for reading the final manuscript; Toby Owen, who read as an outsider to the profession; and Janice Jarmain whose constant and warm support to both staff and trainees at Roehampton Institute was invaluable.

    For the help with the additions to the second edition we would like to thank Jim Pye, Sheelagh Strawbridge, Anne Marie Salm, Michael Soth, and Terry O'Brien.

  • Appendix 1: Outline of an Assessment Procedure in Cognitive Analytic Therapy (CAT)

    The aim of assessment is to identify issues, select out inappropriate cases, ensure correct assignment within the therapy services and give the patient a taste of the process of therapy. In this model the first four sessions are seen as the assessment phase, leading to a Reformulation which the therapist gives the client in a written form at the end of the fourth session.

    The areas to be covered include those listed in the CHRAP sequence:

    C H R A P

    C Complaint

    H History

    R Reformulation

    A Aim

    P Plan

    Interview Process

    Before seeing the patient, read the referral letter and have any material such as questionnaires ready. Throughout the interview note both the content and form or style; give patients scope to lead the interview but prompt for personal meaning or feelings and try to cover all the headings. Leave the Aim (A) and the Plan (P) for the end. Watch for themes manifest during the interview.

    Start by indicating what you know from the referral, say how long you've got and what the point of the meeting is. The rest of the material need not be collected in any particular order nor is it expected that all of the material will be dealt with in an initial session. The headings that have been identified as playing a part are described below.

    (C) Complaint (Presenting Problem: Why they Come to See us)

    Is the problem offered a passport or ticket (such as a physical symptoms if seen in a medical setting) or a genuine difficulty? How did it evolve? Any previous episodes? Note implicit problems not volunteered, such as low self-esteem or pervasive guilt and try these out on the patient. Identify why the patient has come at this time and possible triggers for previous episodes. Questions to ask:

    • When did it all start?
    • What else was happening at the time?
    • Has it occurred before, when?
    • What triggers it off?
    • How does it feel like?
    • Who else knows about it? (testing for available support system)
    • Previous experience of counselling. How many times has the story been told?
    (H) History

    History-taking: gathering information as well as noting how the story is told (jokey, matter-of-fact, despairing, cynical, angry – ‘why me?’; detached, too fast – not wanting to be heard; or too slow – you are on tenterhooks).

    What is person's stance in life: also visible in posture? Listen for what is missing (no mention of parents, or one parent, or a particular period in life).

    What is the main theme: ‘I am too weak’; ‘I have to go it alone’; ‘The world owes me a living’.

    The Life-Story

    Start with the most immediate:

    Adult life: occupation; living circumstances; current and past relationships; intimate, social and work contexts. Any physical disability or illness.

    Childhood: family structure, disruptions; role models; rivalries; cruelties; abuses; major separations; family rules, beliefs. What did it feel like to be this person as a child? What sense did she/he make of the situation? What were the survival procedures: ways of coping or survival strategies? (One or two words about father, mother, grandparents.)

    Adolescence: how transition into adult life (separation from family) was negotiated (any support?); school-peer-relationships and achievement; sexual experience, orientation and problems. Enquire about use of drugs; alcohol; crime; eating disorders; any other important things.

    Important events or experiences: separation and losses, death in the family, adoption, physical and sexual abuse, religion and other beliefs.

    Ask if anything important has been left out.

    What makes your heart sing?

    History of Psychiatric Illness
    • Major depression (deliberate self-harm, parasuicide, overdosing) or other possibly psychotic episodes, previous treatments and their effects (medication, in-patient admissions, therapy – what sort, what effect?); how does the patient understand his/her problems?
    • Where there is evidence of past or present psychiatric illness therapist should either ask for a psychiatric assessment or consult with a psychiatrist with a view to getting access to psychiatric help if necessary.
    • Other: medical history, problems with drugs, crime.
    (R) Reformulation

    The essence of the assessment in this model is to enter into the subjective world of the client and to give them back their story as heard by the therapist. This has a curtain-up effect and a strong emotional impact on the client. It contains an account of client's life history around the core pain as experienced by the client and as understood by the therapist (from the heart to the head).

    Reformulation needs to include what is old as well as what is new. It is an integration of the life-story, with a logical sequence which includes the past, the present and the future. It needs to link feelings, understanding and behaviour. It stems from mutual negotiation and it is created as a living thing arising through the interactive process and a joint recognition of the core pain.

    • This is what you bring.
    • This is how you understand it.
    • This is how we understand it together.
    • This is what you and I do about it together.
    (A) Aim

    Clarify what the patient hopes to achieve from therapy and what you think you can offer.

    (P) Plan

    Work out contract details, patient availability, when to start, and where. Remind patients with suicidal ideas of Samaritans and emergency clinics.

    Ask about preference for sex or race of therapist if appropriate.

    If not suitable for you to take up, explain why and arrange to refer appropriately.

    ∗From lectures by Dr Shakir Shyam Ansari and Val Coumont during CAT training attended by one of the authors.

    Appendix 2: Participative Learning: Theory

    Here are two exercises designed to enliven the learning of theory. They might be used in conjunction with Chapter 5 in this book, or to pursue the theory that underpins several others.

    Appendix 3: Ethical Codes and Dilemmas (Chapter 4)
    Appendix 4: Why are we Here and what do we Hope to Achieve? (Chapter 5)
    Appendix 5: Questions of Time and Space (Chapter 6)

    Appendix 6: Tools of the Trade – Therapeutic Relationship (Chapters 7 and 8)

    Psychodynamic Perspective
    Humanistic Perspective


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