Psychotherapy Volume 37/Winter 2000/Number 4 EVOLVING PSYCHOTHERAPY INTEGRATION: ECLECTIC SELECTION AND PRESCRIPTIVE APPLICATIONS OF COMMON FACTORS IN THERAPY GEORGIOS K. LAMPROPOULOS Ball State University Since its inception 65 years ago, the (SEPI) presently numbers hundreds of members psychotherapy integrationmovement has in several countries (SEPI, 1999) and has gener- undergone much development along its ated more than 150 training programs, courses, and workshops in psychotherapy integration major thrusts: technical eclecticism, worldwide (Norcross & Kaplan, 1995). A general common factors, and theoretical satisfaction with the movement has been reported integration. Based on findings from in a recent survey of its membership (Figured decades of exploration of psychotherapy & Norcross, 1996), and a proposal to replace integration, this article attempts to "Exploration" with "Evolution" in the society's advance the tide was recently considered. movement one step further What exactly has been explored so far? In sum, by (a) reviewing the pros and cons of major areas of attention have been (a) the theoreti- eclecticism and common factors, and cal integration route; (b) the technical eclecticism (b) integrating the two approaches into route; (c) the common factors approach; (d) the a new conceptual scheme. The new assimilative integration route; (e) the empirically integrative scheme aspires to improve supported (manualized) treatments (ESTs) move- ment (as a form of eclecticism); (f) the develop- treatment selection and application, as ment of integrative treatments for specific disor- well as facilitate integrative training ders and specific populations; (g) the development and research. of integrative-eclectic systems of treatment selec- tion, and the integrative exploration of psycho- therapy case formulation methods; and (h) train- Introduction: Celebrating the Evolution of the ing and supervision in eclectic and integrative Psychotherapy Integration Movement therapies (all reviewed in Gold, 1996; Hawkins The psychotherapy integration movement has & Nestoros, 1997; Lampropoulos, in press-a; an unofficial history of more than 65 years, and Norcross & Goldfried, 1992; Stricker & Gold, an official presence since 1983. The Society for 1993; see also Nestoros & Vallianatou, 1990). the Exploration of Psychotherapy Integration Initial explorations have been conducted in all these areas of integrative focus. While develop- ments in integrative theory, practice, and research are clearly evident, definitive answers are not An earlier version of this article was the recipient of the available for most integrative questions. Fourteen Psychotherapy Division of the American Psychological Asso- years after the 1986 National Institute of Mental ciation's Freedheim Student Development Award. Health (NIMH) conference issued research rec- The author is thankful to the anonymous reviewers for their ommendations for the society (Wolfe & Gold- comments, as well as to Carol Chalk for her assistance with the English language. fried, 1988), many of the designated areas of Correspondence regarding this article should be addressed research have not yet received appropriate atten- to Georgios K. Lampropoulos, Department of Counseling tion. Obviously, the end of the exploration era Psychology and Guidance Services, Teachers College 622, is more distant than integrationists might wish. Ball State University, Muncie, IN 47306. E-mail: Nevertheless, a period of evaluation, redefinition, [email protected] and empirical research in the application of integ- 285 Georgios K. Lampropoulos rative therapies and ideas is necessary for the move- decades (Grencavage & Norcross, 1990). The ment to evolve (Beitman, 1994; Norcross, 1997). major advantage of this approach is that it focuses This author, along with others in the field, be- on the "heart and soul of change," that is, the lieves that future efforts of the society should most important factors associated with positive focus on (a) theory-driven programmatic aptitude outcomes in various therapies (for detailed de- by treatment interaction (ATI)' research focusing scriptions see the edition by Hubble, Duncan, & on small intervention packages rather than whole Miller, 1999a). Lambert (1992; Asay & Lambert, therapies (Beutler, 1991; Shoham & Rohrbaugh, 1999) estimates that only 15% of change can be 1995); (b) the development and empirical testing attributed to specific techniques used by various of integrative models of psychotherapy for spe- therapies (with some exceptions); the other 85% cific populations, preferably against theoretically of clients' improvement can be attributed to fac- pure ESTs (Goldfried & Wolfe, 1998); (c) the tors such as the therapeutic relationship, placebo development, evaluation, and dissemination of effects, and other client factors. integrative-eclectic psychotherapy training; and Proponents of this thrust have offered different (d) the development of integrative-eclectic sys- lists of common factors to be followed in clinical tematic treatment-selection methods. practice. Among them are common factors mod- The improvement of integrative treatment- els proposed by Garfield (1986), Beitman (1992), selection systems is the focus of this article. The Frank and Frank (1991), Arkowitz (1992), Orlin- plethora and diversity of integrative developments sky and Howard (1987), and Weinberger (1993). and findings mentioned above raises a need for Commonly cited common factors include the ther- an organizational scheme to guide integrative cli- apeutic alliance, empathy and support, positive nicians. This organization is necessary, consider- expectations about therapy, emotional catharsis, ing that the integration movement is experiencing problem exploration and insight, exposure and a problem that it meant to address in the first confrontation of the problem, and learning of new place: the proliferation of different therapeutic behaviors (Grencavage & Norcross, 1990). This models, now in the form of various integrative- author counts at least a dozen psychotherapy re- eclectic approaches (Lazarus, in Lazarus & Mes- search programs that continue to provide data on ser, 1991). To organize the existing integrative common factors worldwide (for more on research clinical findings, integration within the integra- issues see Castonguay, 1993; Goldfried, 1991; tion movement is attempted here. Specifically, an Norcross, 1993a, 1995a). In addition, authors effort to integrate two of the major thrusts of who review common factors in therapy usually psychotherapy integration (i.e., common factors conclude that therapists should incorporate and and eclecticism) follows. The proposed integra- emphasize those common factors in their practice, tion is also fueled by the need to compensate in order to enhance clinical effectiveness (e.g., for existing weaknesses of eclecticism and the Asay & Lambert, 1999; Fischer, Jome, & Atkin- common factors approach (reviewed below). son, 1998; Hubble, Duncan, & Miller, 1999b). Examples of how common factors can be em- Common Factors and Eclecticism as Guiding ployed in therapy are also available (e.g., Hubble Systems in Therapy et al., 1999b). Other authors add that a combina- tion of The Common FactorsApproach: Pros and Cons common and specific factors might be necessary for optimal therapeutic effects (e.g., The common factors approach has been pro- Beitman, 1992; Lambert, 1992). Clearly, com- posed as a guiding model to describe clinical prac- mon factors do exist and are important contribu- tice in terms of ingredients common in all thera- tors to therapeutic outcome. They also appear to pies, despite the varying terminology that is used. be the major explanation for the Dodo birdverdict It has been identified as one of the major routes (i.e., that all therapies produce equivalent out- to psychotherapy integration and one of the most comes; Lambert & Bergin, 1994; Luborsky, important trends in psychotherapy in the last few 1995; Luborsky, Singer, & Luborsky, 1975). Despite the obvious importance of common factors in therapy, several weaknesses exist in l Aptitude by treatment interactions can be found when this approach. In sum, (a) common factors are different interventions are matched to client variables ac- obscurely defined; (b) common factors in differ- cording to a clinically meaningful hypothesis. ent theories are not as similar as they are claimed 286 Eclectic Applications of Common Factors in Therapy to be; (c) common factors provide only a minimal in all phases of therapy, such as the phase of description of change (least common denomina- client vague awareness of the problem and the tor) that may overlook valuable clinical informa- phase where clients are attempting a new solu- tion; (d) common factors proposals are insensitive tion? Should support have the same form and to client, problem, and therapist individual differ- intensity in all phases of change? When should ences; (e) the proposed common factors are too it be alternated with challenge, interpretation, general and abstract to guide clinical practice (be- confrontation, and insight-oriented, exploratory cause of the aforementioned two weaknesses, interventions? Is support equally necessary for all i.e., c and d); and (f) common factors are often types of clients (e.g., clients with strong vs. poor erroneously considered sufficient change agents; social support systems, constrictive and inter- some specific factors and effects also exist (see nalizing vs. impulsive and externalizing