Toward an Integrative Psychotherapy

Over the years of being with clients in my office, I have become aware that therapy can help on 3 different levels. Usually, the level of help provided is not necessarily dictated by the patient but more by the level of training and expertise of the helping professional. I have broken these levels down as follows: First, is what I will call the Straight Line approach; second, the Underbelly approach; and third, the Overview approach. Any of these can be helpful to the patient, but most helpful would be to integrate all 3 levels of approach. Let’s look at this more closely.

The Straight Line approach is the most frequently used approach. It is the frontline approach for resolution of presenting symptomatology and is mandated by medical insurance companies. It is also what is most expected by our patients when they present in our offices. What is the chief complaint? What are the manifesting symptoms? How long have they been dealing with their problems? How are they managing their symptoms? Are they treating/masking their symptoms with substances? What are the treatment goals? How quickly can these symptoms be abated, treatment goals be achieved, and the patient be sent on their way? We all know how to work within these restrictive limits and we do it. Obviously, it is important to address the presenting symptoms and the treatment goals. We do this through various cognitive and behavioral methods depending on the needs of the patient and our preferred treatment frame.  However, working only from within that frame, we may miss opportunities to help the patient in deeper, more meaningful ways. It is like putting a band aide on a wound, which requires sutures.  A patient may leave feeling better since the wound is clean and has a bandage covering it however, it is likely to rupture again, given similar circumstances, as the underlying issues have not been identified or repaired. In other words, each time we sit with a patient, we have an opportunity to connect and understand the patient in a way in which no one has ever connected or understood that individual before. If we allow ourselves to be dictated solely by the guidelines of insurance mandates, and DSM guidelines, we may miss this opportunity.  However, if we are open to the challenges of deeply understanding our patients, a new and exciting relationship can begin with each patient.

The second approach, or what I will call the Underbelly Approach, challenges the therapist to understand each patient more deeply, in other words what propels the patient, how he perceives the world within which he lives, and how he continues to make the same mistakes repeatedly throughout his life to the point at which he seeks psychotherapy. So while paying attention to the patient’s chief complaints, understanding his symptoms and goals, the therapist is also listening for the roots of mis-learning or what Control Mastery Theory refers to as pathogenic beliefs. These roots usually develop early in life and are reinforced throughout childhood and repeated again and again in adult experiences.  Until these issues emerge, are understood and consciously worked through, the patient is likely to continue to reenact the same dysfunctional relationships and make the same mistakes over and over.  In part, this is what Freud described as the Repetition Compulsion, i.e. humans repeat what was done to them until it is brought to consciousness and worked through.  In other words, infants learn brain maps of their world, including how they perceive themselves and others, based on interactions learned within their family relationships. This brain-map dictates behavior until an individual recognizes it may not produce beneficial results.  

How does the therapist determine what the Pathogenic beliefs are? As we listen to the patient’s story, we inquire about his past. If we only listen to the present, we are only picking up on the current strand of his life. Each life is made up of multiple strands of experience. Most patients who walk into our office do not have a cohesive, well-woven fabric. Their lives are strands that are frayed and even knotted. We inquire about the past because we are wondering how they got to this point in which they are so distressed, anxious, or depressed that they seek help. We are looking for the telltale signs of being harshly criticized, ignored or even abused. If for example, the patient is in an abusive relationship now, the therapist might wonder if he had been criticized, ignored, overly controlled, or abused as a child. On a more unconscious level, he may feel unworthy of feeling valued, respected and appreciated. In this situation, the therapist might even speculate to the patient that perhaps he has never felt worthy of a better relationship.  If the intervention is on target, the patient may recall memories or relate the unfolding story of his past. On the other hand, if he gives you a blank stare and says he doesn’t know what you mean, this may be an indication that the interpretation is off base, or simply that the patient is not ready to explore this. The patient is always giving the therapist information. It is our job to use it as the patient can use it. The idea is to help the patient learn the patterns that have kept him drawing in and repeating unhappiness, to unlearn or stop doing the same patterns and to relearn new, healthier, and more functional ways of relating.  In the process, the patient is leaning new skill but perhaps most importantly, he is learning to become the overseer of his behaviors and relationships.

 The final approach is what I call the Overview Approach.  From the start of each therapy, and as the therapy progresses, I wonder what this patient really wants out of his life while here on this planet. Sometimes, if you ask a patient early on, what he wants to accomplish in this lifetime, he may look at you as if you are crazy. No one may have ever seriously ever asked most of our clients this question. Many have never seriously pondered this question. Often, patients don’t feel much is possible. Some have lost the passion to dream or to actualize their visions. So in this Overview Approach, the therapist is beginning to think with the patient about his life on a much grander view.  Quantum Physics tells us that for any given situation, there are an infinite number of outcomes possible. All that has to happen is an idea formulates, germinates into thoughts, develops into more thoughts, and becomes a plan. Eventually, that kernel of an idea actualizes into reality. Most of us do not know this, or believe it is possible. However, this can be extraordinarily liberating for our patients and even for us.  

These approaches do not have to happen one step at a time, although they might, depending on the individual patient. If you ask a patient on his first visit, what his lifetime plan is, he may likely think you totally missed the boat on his current suffering.  Like the fabric of each person’s life, the treatment also has a fabric. Initially, the therapist may simply be trying to help pick up the threads of a broken past in order to weave an understanding of how thoughts and behaviors create past and present and by changing thoughts and behaviors the patient can create a limitless future. The therapist always keeps in mind pathogenic beliefs, the presence of symptoms, disruptive relationships, etc. while the patient progresses. Every treatment is unique just as every individual is unique. This model of treatment requires much more than a prescriptive understanding of the DSM.  It requires the therapist to think about patients individually, and within the frame of his life, his history, his relationships and his behaviors.   The curative factor in psychotherapy is always in the relationship between the patient and the therapist. The therapist understands the patient in ways he has never understood himself, which expands not only self-knowledge but also knowledge of others as well. When the therapist is open to this level of work, everyday is a learning experience.

This article was originally published in the Spring, 2017 edition of The Clinical Page of the Georgia Society for Clinical Social Work under the title “How We Help”. All rights reserved.  Alva S. McGovern, LCSW