As a counselor, how do you develop a theoretical orientation? Do you just wake up one morning andvoilayou have your theoretical orientation? Your theoretical orientation will not mag

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Article 29

Designing an Integrative Approach to Counseling Practice

Gerald Corey

This article addresses the advantages of developing an integrative approach to counseling practice and deals briefly with some of the potential problems. Also presented is a framework for helping readers begin to integrate concepts and techniques from various approaches. This article is based on Gerald Corey’s (2001a) book, The Art of Integrative Counseling.

Introduction

An integrative approach to counseling and psychotherapy is best characterized by attempts to look beyond and across the confines of single-school approaches in order to see what can be learned from, and how clients can benefit from, other perspectives (Arkowitz, 1997). Integrative counseling is the process of selecting concepts and methods from a variety of systems. The integrative approach can ideally be a creative synthesis of the unique contributions of diverse theoretical orientations, dynamically integrating concepts and techniques that fit the uniqueness of a practitioner’s personality and style.

Since the early 1980s, psychotherapy has been characterized by a rapidly developing movement toward integration. This movement is based on combining the best of differing orientations so that more complete theoretical models can be articulated and more efficient treatments developed (Goldfried & Castonguay, 1992). The Society

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for the Exploration of Psychotherapy Integration is an international organization formed in 1983. Its members are professionals who are working toward development of therapeutic approaches that transcend single theoretical orientations.

One reason for the trend toward psychotherapy integration is the recognition that no single theory is comprehensive enough to account for the complexities of human behavior, especially when the range of client types and their specific problems are taken into consideration. Because no one theory has a patent on the truth, and because no single set of counseling techniques is always effective in working with diverse client populations, some writers think that it is sensible to cross boundaries by developing integrative approaches as the basis for future counseling practice (Lazarus, 1996).

A large number of therapists identify themselves as “eclectic,” and this category covers a broad range of practice. Perhaps at its worst, eclectic practice consists of haphazardly picking techniques without any overall theoretical rationale. This is known as syncretism, wherein the practitioner, lacking in knowledge and skill in selecting interventions, grabs for anything that seems to work, often making no attempt to determine whether the therapeutic procedures are indeed effective. Such a hodgepodge is no better than a narrow and dogmatic orthodoxy. Pulling techniques from many sources without a sound rationale can only result in syncretistic confusion (Lazarus, 1986, 1996; Lazarus, Beutler, & Norcross, 1992).

There are multiple pathways to achieving an integrative approach to counseling practice. Three of the most common are technical eclecticism, theoretical integration, and common factors (Arkowitz, 1997). Technical eclecticism tends to focus on differences, chooses from many approaches, and is a collection of techniques. This path calls for using techniques from different schools without necessarily subscribing to the theoretical positions that spawned them. In contrast, theoretical integration refers to a conceptual or theoretical creation beyond a mere blending of techniques. This path has the goal of producing a conceptual framework that synthesizes the best of two or more theoretical approaches under the assumption that the outcome will be richer than either of the theories alone (Norcross & Newman,

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1992). The common factors approach attempts to look across different theoretical systems in search of common elements. Although there are differences among the theories, there is a recognizable core of counseling composed of nonspecific variables common to all therapies. This perspective on integration is based on the premise that these common factors are at least as important in accounting for therapeutic outcomes as the unique factors that differentiate one theory from another.

While there are advantages to incorporating a diverse range of techniques from many different theories, it is also possible to incorporate some key principles and concepts from the various theoretical orientations. There are some concepts from the experiential approaches that can blend quite well into the cognitive- behavioral approaches. For example, the experiential approaches emphasize here-and-now awareness, the therapeutic relationship, and exploration of feelings—all concepts that can be incorporated into the action-oriented therapies. Clients can be asked to decide what they want to do with present awareness, including making behavioral plans for change. All the action-oriented therapies depend on a good rapport between client and therapist (Moursund & Erskine, 2004). Techniques will not take root if there is not a good working relationship, and clients are more likely to cooperate with a therapist’s cognitive and behavioral interventions if they feel the therapist is genuinely interested in their welfare.

Arnold Lazarus (1997), the founder of multimodal therapy, espouses technical (or systematic) eclecticism. Multimodal therapists borrow techniques from many other therapy systems that have been demonstrated to be effective in dealing with specific problems. Lazarus raises concerns about theoretical eclecticism because he believes that blending bits and pieces of different theories is likely to obfuscate matters. He contends that by remaining theoretically consistent but technically eclectic, practitioners can spell out precisely what interventions they will employ with various clients, as well as the means by which they select these procedures.

Technical eclecticism seems especially necessary in working with a diverse range of cultural backgrounds. Harm can come to clients

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who are expected to fit all the specifications of a given theory, whether or not the values espoused by the theory are consistent with their own cultural values. Rather than stretching the client to fit the dimensions of a single theory, practitioners are challenged to tailor their theory and practice to fit the unique needs of the client. This requirement calls for counselors to possess knowledge of various cultures, be aware of their own cultural heritage, and have skills to assist a wide spectrum of clients in dealing with the realities of their culture.

One study summarized the importance of taking into account cultural diversity and future trends in the practice of psychotherapy: “A major challenge for the field of psychotherapy will be to discover creative ways to integrate the values and worldviews of multiple cultures within the discourse of efficiency and evidence that currently dominate health care,” (Norcross, Hedges, & Prochaska, 2002, p. 322).

Practitioners who are open to an integrative perspective will find that several theories play a crucial role in their personal counseling approach. Each theory has its unique contributions and its own domain of expertise. By accepting that each theory has strengths and weaknesses and is, by definition, “different” from the others, practitioners have some basis to begin developing a theory that fits for them. It is important to emphasize that unless counselors have an accurate, in-depth knowledge of theories, they cannot formulate a true synthesis. Simply put, practitioners cannot integrate what they do not know (Norcross & Newman, 1992). The challenge is for counselors to think and practice integratively, but critically. Developing an integrative perspective is a lifelong endeavor that is refined with experience.

The following section addresses the topic of viewing the various theoretical approaches to determine what common ground exists that allows for an integrative perspective.

Searching for Common Denominators Across Therapy Schools

The experiential approaches (such as existential therapy and

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Gestalt therapy) place a premium on exploration of feelings in the therapeutic process. However, the concepts of working with feelings can certainly be linked closely with the necessity of exploring the thoughts and behaviors connected to these feelings. A systematic eclecticism is based on looking for common denominators that cut across therapeutic orientations, which involves identifying core concepts that various theories share or concepts that can be usefully combined.

However, as Lazarus (1997) has warned, the blending of theoretical constructs is more challenging than utilizing diverse techniques from different schools. Practitioners who attempt to blend theoretical constructs from different orientations into their own integrative model need to determine that these concepts are indeed compatible. In attempting to blend different theoretical frameworks together, it is essential that these frameworks lend themselves to a fruitful merger.

The Benefits of Integration

Since humans are integrated beings, an integrative approach to counseling practice focuses on thinking, feeling, and acting. Effective counseling involves proficiency in a combination of cognitive, affective, and behavioral techniques. Such a combination is necessary to help clients think about their beliefs and assumptions, to experience on a feeling level their conflicts and struggles, and to actually translate their insights into action programs by behaving in new ways in day- to-day living.

Preston (1998) contends that no one theoretical model can adequately address the wide range of problems clients will present in therapy. He says it is essential for therapists to have a basic grasp of various therapeutic models and for them to have at their disposal a number of intervention strategies. For him, the pivotal assessment question is, “What does this particular person most need in order to suffer less, to heal, to grow, or to cope more effectively?” Preston recommends that a practitioner’s selection of interventions should be guided by their assessment of the client. This lends weight to the

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concept of integrating assessment with treatment. Once a clinician knows what the client’s target problems and goals are, it makes sense to design specific techniques tailor-made to the client.

The Limitations of an Integrative Approach

There are some drawbacks to encouraging the development of an integrative model, as opposed to sticking primarily with one theory. An undisciplined eclectic approach can be an excuse for failing to develop a sound rationale for systematically adhering to certain concepts and to the techniques that are extensions of them. If counselors merely pick and choose according to whims, it is likely that what they select will be a reflection of their biases and preconceived ideas. It is important to avoid the trap of emerging with a hodgepodge of unamalgamated theories thrown hastily together.

Drawing on Techniques from Various Theoretical Models

For beginning counselor practitioners, it makes sense to select a primary theory that is the closest to their basic beliefs. It is essential to learn that theory as thoroughly as possible, and at the same time be open to discovering ways of drawing on techniques from many different theories. By beginning to work within the parameters of a single theory, practitioners will have an anchor point from which to construct their own counseling perspective. However, simply by adhering to a primary theory does not imply that a practitioner can apply the same techniques to all clients. It is essential to be flexible in the manner in which techniques are applied to a diverse range of clients.

On the topic of therapeutic flexibility, Paul’s (1967) question is relevant: “What treatment, by whom, is the most effective for this individual with that specific problem, and under what set of circumstances?” Regardless of what model clinicians may be working with, they must decide what techniques, procedures, or intervention methods to utilize, when to use them, and with which clients. It is

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useful for clinicians to avoid becoming wedded to a favorite set of techniques that they apply in random fashion to all clients, regardless of their cultural background. For counseling to be effective it is necessary to utilize techniques and procedures in a manner that is consistent with the client’s values, life experiences, and cultural background. Although it is unwise to stereotype clients because of their cultural heritage, it is useful to assess how the cultural context has a bearing on their problems. Some techniques may be contraindicated because of a client’s socialization. Thus, the client’s responsiveness (or lack of it) to certain techniques is a critical barometer in judging the effectiveness of these methods.

The Foundation of the Author’s Integrative Approach

In the rest of this section the author presents some elements of an integrative approach to counseling by describing existential therapy as the foundation of his approach. The author illustrates how he draws both concepts and techniques from other theoretical orientations to flesh out his integrative approach. The theory that comes closest to this writer’s worldview and serves as the foundation for constructing his theoretical orientation is existential therapy. In addition to the existential approach, two related theories that the author uses extensively are Gestalt therapy and psychodrama. After briefly describing some of the key concepts and themes from the existential, Gestalt, and psychodrama orientations, this writer shows how he incorporates basic concepts and techniques from a number of the other action-oriented therapies: Adlerian therapy, reality therapy, behavior therapy, rational emotive therapy, cognitive therapy, and feminist therapy. For a discussion of how all these above-mentioned approaches are applied to a single case, see Corey’s (2001b) Case Approach to Counseling and Psychotherapy.

Existential Therapy as a Philosophical Base

The author’s own philosophical orientation is strongly influenced by the existential approach, which conceives of counseling as a life

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changing process. Counseling can be seen as a journey in which the therapist is a guide who facilitates client exploration. There are a number of key themes from the existential approach that seem to this writer to capture the essence of the therapeutic venture. According to the existentialist view, humans are capable of self-awareness, which is the distinctive capacity that allows people to reflect and to decide. With this awareness people become free beings who are responsible for choosing the way they live. The emphasis on freedom and responsibility is central for practice, for this notion allows people to redesign their lives. Making choices gives rise to existential anxiety, which is another basic human characteristic. This anxiety is heightened when individuals reflect on the reality that they will die. Facing the inevitable prospect of eventual death gives the present moment significance. The reality of death is a catalyst that can lead to creating a life that has meaning and purpose. Humans strive toward fashioning purposes and values that give meaning to life, which is developed through freedom and a commitment to make choices in the face of uncertainty.

Both existential therapy and person-centered therapy place central prominence on the person-to-person relationship. It assumes that client growth occurs through this genuine encounter. The emphasis on the human quality of the therapeutic relationship lessens the chances of making counseling a mechanical process. In thinking about therapy from an existential perspective, techniques are always of secondary importance. From the existential perspective, it is not the techniques practitioners use that make a therapeutic difference; rather, it is the quality of the relationship with the client that heals. The therapist’s interests are in being as fully present for the client as possible, establishing a trusting relationship, and moving into the client’s subjective world. If a client is able to sense a therapist’s presence and his or her desire to make a real connection, then a solid foundation is being created for the hard work that counseling entails.

Because the existential approach is basically concerned with matters such as the goals of therapy, basic conditions of human existence, and therapy as a shared journey, practitioners are not bound by a specific set of techniques. Although they can incorporate a wide

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range of techniques from other orientations, their interventions are guided by a philosophical framework about the meaning of human existence. An existential view provides practitioners with the framework for understanding universal human concerns, including facing and dealing with: the problem of personal freedom, self- alienation and estrangement from others; the fear of death and nonbeing; living with courage; exploring the meaning of life; and making critical choices.

Existential therapy is not a distinct or well-organized counseling model. In fact, the founders of existential therapy did not aim to create a separate school of therapy, but rather that its key concepts and themes would become integrated into all therapeutic schools (May & Yalom, 2000). Bugental and Bracke (1992) see the possibility of a creative integration of the conceptual propositions of existential therapy with psychodynamic or cognitive approaches. They indicate that experienced clinicians of contrasting orientations often accept some existential concepts and thus operate implicitly within an existential framework.

Gestalt Therapy: A Holistic Perspective Gestalt therapy is truly an integrative orientation in that it

focuses on whatever is in the client’s awareness. From the Gestalt perspective, feelings, thoughts, body sensations and actions are all used as a guide to understanding what is central for the client in each moment. The centrality of whatever is in the client’s awareness is an ideal way to understand the world of the client. A Gestalt therapist approaches clients without a preconceived set of biases or a set agenda. Instead, emphasis is placed on what occurs phenomenologically with the client. By paying attention to the obvious verbal and nonverbal leads provided, the therapist has a starting point for exploring the client’s world.

Functioning within a Gestalt framework, this writer views his main goal as increasing the client’s awareness of “what is.” Change occurs through a heightened awareness of what the client is experiencing moment to moment. The approach stresses present awareness and the quality of contact between the individual and

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the environment. The Gestalt approach is characterized by many key concepts

that can be fruitfully blended into other orientations. Gestalt therapy (and psychodrama) techniques afford clients with ways of bringing painful memories and feelings pertaining to both past and present events into center stage. Through the skillful and sensitive use of Gestalt therapy interventions, it is possible to assist clients in heightening their present-centered awareness of what they are thinking and feeling as well as what they are doing. The client is provided with a wide range of tools, in the form of Gestalt experiments, for making decisions about changing the course of living.

Gestalt therapy is a creative approach that utilizes the experiment to move clients from talk to action and experience. This is a perspective on growth and enhancement, not merely a system of techniques to treat disorders. With the emphasis given to the relationship between client and therapist, there is a creative spirit of suggesting, inventing, and carrying out experiments aimed at increasing awareness.

Psychodrama: An Integrative Approach Although psychodrama is primarily used in group therapy, many

psychodrama techniques can be used fruitfully in individual counseling. Psychodrama is an approach in which the client acts out or dramatizes past, present, or anticipated life situations and roles. This is done in an attempt to gain deeper understanding, explore feelings and achieve emotional release, and develop behavioral skills. Significant events are enacted to help the client get in contact with unrecognized and unexpressed feelings, to provide a channel for the full expression of these feelings and attitudes, and to broaden the role repertoire.

Integrated into other systems—such as psychodynamic, experiential, and cognitive behavioral approaches—psychodrama offers a more experiential process, adding imagery, action, and direct interpersonal encounter. In turn, psychodrama can utilize methods derived from the other experiential approaches, and the cognitive behavioral approaches as well, to ground clients in a meaningful

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process. According to Blatner (1996), a major contribution of

psychodrama is that it supports the growing trend toward technical eclecticism in psychotherapy. Practitioners are challenged to draw on whatever tools will be useful in a given situation. Yet psychodrama is best viewed as an optional set of tools, rather than a single approach for all clients (Blatner, 1996). Psychodrama uses a number of specific techniques designed to intensify feelings, clarify implicit belief, increase self-awareness, and practice new behaviors. One of the most powerful tools of psychodrama is role reversal, which involves the client taking on the part of another person. Through reversing roles with a significant person, the client is able to formulate significant emotional and cognitive insights into his or her part in a relationship. This technique also creates empathy for the position of another person. Variations of role playing and role reversal have many uses in both individual and group counseling. A few other techniques of psychodrama that practitioners can utilize include self-presentation, soliloquy, coaching, modeling, role training, behavior rehearsal, and future projection.

It is clear that many psychodramatic techniques can be adapted to fit well within the framework of other contemporary theoretical models, including psychoanalytic therapy, behavior therapies, multimodal therapy, Gestalt therapy, Adlerian therapy, play therapy, imagination therapy, Jungian therapy, family therapy, and group therapy. According to Blatner (1997), psychodrama’s value lies in the fact that its methodology can be integrated with other therapeutic approaches rather than acting in seeming competition. [See Blatner (1996) and Corey (2004, Chapter 8) for a discussion of psychodrama applied to group counseling.]

Drawing on the Action-Oriented Therapies

As much as this writer values working with the emotional realm, he finds it essential to incorporate concepts and techniques from the action-oriented approaches as a way to bring about both cognitive and behavioral changes. What follows are a few of the ways that the

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author utilizes the action-oriented therapies (behavior therapy, multimodal therapy, cognitive-behavior therapy, reality therapy, Adlerian therapy and feminist therapy) in his integrative model. For a detailed discussion of how these action-oriented approaches are applied to a single case, see Corey’s (2001b) Case Approach to Counseling and Psychotherapy.

Behavior Therapy A basic assumption of the behavioral perspective is that most

problematic cognitions, emotions, and behaviors have been learned and that new learning can modify them. Although this modification process is often called “therapy,” it is more properly an educational experience in which individuals are involved in a teaching/learning process. There are many parallels between counseling and education. Counseling is educational in that people develop a new perspective on ways of learning, and they also try out more effective ways of changing their cognitions, emotions, and behaviors. Many of the techniques employed by other action-oriented approaches, with a strong behavioral core (such as rational emotive behavior therapy, cognitive therapy, reality therapy, and feminist therapy), share this basic assumption of counseling as an educational process, and they stress the teaching/learning aspect of the counseling process. Techniques from the action-oriented approaches can be used to attain humanistic goals that characterize the experiential therapies. It is clear that bridges can connect the experiential and the behavior therapies.

Multimodal Therapy Multimodal therapy—a branch of behavior therapy—is a

comprehensive, systematic, holistic approach to behavior therapy developed by Arnold Lazarus (1989,1995, 1997). Grounding his practice on social learning theory, Lazarus endorses drawing techniques from just about all of the therapy models. In his integrative model, new techniques are constantly being introduced and existing techniques are refined, but they are never used in a shotgun manner (Lazarus, 1992; Lazarus & Beutler, 1993).

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By using the multimodal approach, practitioners can function actively and directively by providing information and instruction. This requires a constant adjustment of therapeutic techniques to achieve the client’s goals in therapy. The question of paramount importance is, “What is best for this particular person?” Practitioners need to make a careful attempt to determine precisely what relationship and what treatment strategies will work best with each client and under which particular circumstances. The underlying assumption of this approach is that because individuals are troubled by a variety of specific problems, it is appropriate that both a multitude of treatment strategies and different therapeutic styles are used in bringing about change. Therapeutic flexibility and versatility, along with breadth over depth, are valued highly in the multimodal orientation.

Cognitive-Behavior Therapy Most of the contemporary therapies can be considered

“cognitive,” in a general sense, because they have the aim of changing clients’ subjective views of themselves and the world. However, the cognitive-behavioral approaches differ from both psychodynamic and experiential therapies in that the major focus of Cognitive-Behavior Therapy (CBT) is on both undermining faulty assumptions and beliefs and teaching clients the coping skills needed to deal with their problems.

In many respects, rational emotive behavior therapy (REBT) can be considered as a comprehensive and eclectic therapeutic practice. Numerous cognitive, emotive, and behavioral techniques can be employed in changing one’s emotions and behaviors by changing the structure of one’s cognitions. REBT is open to using therapeutic procedures derived from other schools, especially from behavior therapy.

Aaron Beck’s cognitive therapy is truly an integrative approach, since it draws from so many different modalities of psychotherapy (Alford & Beck, 1997). Cognitive therapy serves as a bridge between psychoanalytic therapy and behavior therapy. Cognitive therapy provides a structured, focused, active approach. It shares the

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phenomenological perspective of dealing with the client’s inner world with the Adlerian, existential, person-centered, psychodrama, and Gestalt therapies.

A feature the author particularly values of all the cognitive- behavioral therapies (and of feminist therapy) is the demystification of the therapy process. Being based on an educational model, these approaches all emphasize a working alliance between the therapist and client. These approaches encourage self-help, provide for continuous feedback from the client on how well treatment strategies are working, and provide a structure and direction to the therapy process that allows for evaluation of outcomes. In the cognitiv

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