Reflections about different modalities of Therapy
In a study carried out in 2007 amongst 2,281 respondents by the ‘Psychotherapy Networker’, 95.8% confessed to combining multiple integrative approaches in their therapeutic interventions with clients, 68.7% of whom identified CBT as the preferred integration with their core therapy approach (Corey, 2009, p. 88).
Since completing an Advanced Practical Diploma in Clinical Hypnotherapy and Psychotherapy, in 1998, followed by numerous studies in other modalities, including a BSc. (Hons) Psychology degree and a Masters in Counselling and Psychotherapy, I have gradually integrated a number of Cognitive Behavioural approaches including ACT, CBT and MBCT into my psychodynamic practice. EFT, BWRT and other therapies have also been effectively integrated, based on a client’s paradigm, preference and needs.
Psychoanalytic treatment seeks to uncover the unconscious drives that affect relationships, behavioural patterns and a client’s mental health (Feltham, 2012). Freud’s meta theoretical position was personologism (Brien, 2007); which argues that it is the person who creates the behaviour (Altmaier et al, 2011). Erikson focused on the individual’s psychosocial stages of development and Adler focused on the individual’s relationship with society.
The issue with a purely psychodynamic approach is the time and cost factor involved, coupled with the need to acknowledge a client’s adaptive current behaviour instead of polarising on the primacy awarded to the unconscious (Palmer et al., 2013).
Psychodynamic therapy is supported by empirical evidence and posits that not only do clients maintain the benefits, but their improvement continues post-treatment (Shedler, 2010). However, psychoanalysis is not suitable for all clients, for example, clients suffering from mood disorders do not respond well to talk therapies and the majority of psychotherapeutic research in the form of clinical trials, compare the efficacy of specific psychotherapeutic interventions for “specific disorders” only – it is not universal (Lambert, 2011).
Norcross (2011) argues that Freud moved to psychoanalytic psychotherapy because he recognised the lack of universal application of classical analysis. The narrow focus of psychodynamic theory is described well in Maslow’s aphorism “if all you have is a hammer, then everything looks like a nail”.
Consequently, I went looking for other tools or modalities to integrate by talking to colleagues who had been trained in other therapies including Cognitive Behavioural, Humanistic or Integrative therapies.
Integrative psychotherapists are concerned with what works, and why it works (Norcross, 2005, p. 8), a fact that was recognised several decades ago when the benefits of amalgamating Freudian, neo-Freudian, Humanistic and Existential approaches, with cognitive learning methods and behaviourism was acknowledged (Rimm and Masters, 1979).
Integration is most commonly found in technical eclecticism (collection of techniques without subscribing to their theoretical parentage) and theoretical integration, which means creating a conceptual framework that synthesises the best aspects of two or more theoretical approaches to create a better one (Corey, 2009). I follow technical eclecticism and it allows me flexibility and confidence to deploy techniques that align with a client’s needs and wants.
For example, I had a client who presented with a chronic fear of needles who calibrated the intensity of their fear at 10+/10. Their impending operation a fortnight later motivated them to seek help. But having researched hypnosis, psychotherapy, CBT, MBCT and EFT, they informed me resolutely that they only wanted BWRT! By the end of the first session, they had reduced their phobia to 0/10. I followed up to confirm that it remained so during their hospitalisation and for a year afterwards when they were subjected to weekly ‘needling’. Had I tried any other intervention, there may have been success but time was against her and BWRT worked rapidly.
BrainWorking Recursive Therapy (BWRT)
BWRT was created by Terence Watts and Rafiq Lockhat and is now the Masters programme in two South African universities. It is model of psychotherapy based on neuroscience that affects rapid change by interrupting negative thought patterns in the brain, ranging from simple phobias to identity crisis. The process is simply based on asking a client to focus on the worst element of an undisclosed experience, creating a movie of their ideal self and creating new neurological pathways that affect change. I’ve used this method very effectively over the past couple of years and it is gaining ground throughout the world. It may be similar to NLP but there are significant differences. However, BWRT is not suitable for all clients; those with secondary gains for retaining their disorder, inability to focus or those who want a slower approach in order to understand what is happening. And this is where ACT, CBT and MBCT come to the fore.
ACT views psychological pain as a normal part of everyday living and decries suggestions that the absence of pain equates to psychological health (Feltham, 2012. p. 281). It argues that the more an individual resists (pain), the more it will persist and therein lies its maintenance. Language plays a vital role in energising a person’s beliefs (and pain) because it creates the reality of their words.
The key to change is altering their relationship to pain and developing the skills of acceptance, diffusion (or detachment), awareness of the present moment, self as context, values and committed action. I often integrate ACT with psychotherapy because it is person-focused and highlights the effect of language in an individual’s life.
As an extreme example, a young man I knew constantly used the expression ‘it’s gas…he’s a gas man’ – at 26 he died from carbon monoxide gas poisoning from an accident leak in a hotel. In Honduras, Central America, they have an expression ‘me duele a mi estomago’ (you sicken me to my stomach). Is it a coincidence that they have one of the highest rates of cancer in Central America?
Cognitive Behavioural Therapy (CBT)
CBT posits that we can think and process information through our five senses from which we interpret infer and evaluate that information. Dysfunctional thinking underlies all psychological disturbances which leads to errors in thinking. Errors in logic include arbitrary inference, dichotomous thinking, maximising and minimising, catastrophe rising, engaging mental filters, over generalisation and personalisation (Feltham, 2012).
Beck highlights genetic predisposition, childhood experiences and social influences to explain how these maladaptive cognitive schemas, automatic thoughts and cognitive distortions are acquired. Change occurs by alleviating emotional problems and behavioural responses by engaging current thinking patterns, precipitating factors and predisposing factors (Feltham, 2012).
While it is true that a significant number of clinical trials have demonstrated the efficacy of CBT, and indeed, CBT has been promoted above most other approaches, there is no empirical evidence to show that it is more effective than any other intervention.
By integrating CBT with psychodynamic approaches, I believe the net result is more holistic as it unearths unconscious motivations. While CBT is very beneficial for clients who are process driven, it has a limited focus on specific psychological disorders, resulting in its unsuitability in applying the model to all diagnostic categories (Lampropoulos, 2001).
Another effective integrative approach is MBCT.
Mindfulness Based Cognitive Therapy (MBCT)
MBCT is an amalgamation of Mindfulness meditation, Cognitive and Behavioural therapies. I incorporated it some time ago into my practice for a young self-employed man who had huge anger issues. His first session was dominated by his foul language, palpable anger and propensity to flare up if he perceived he was being challenged. Following an 8-week MBCT course, his language was inoffensive, his stress levels had reduced significantly, and he was able to ‘stop, look, adjust and take empowering action’.
So, in evaluating these integrated therapies that I use, clearly not one fits all. However, as I continue to broaden the tools in my therapeutic toolbox, there is usually one (or more) that matches the personality, paradigm and issue presented by the client.
Emotional Freedom Technique
Emotional Freedom Technique originated with Gary Craig, following his training with Dr Roger Callahan (Thought Field Therapy – TFT). Instead of learning the complex TFT algorithms based on the meridians to interrupt negative thought patterns in the body for specific ailments, Gary Craig developed a simple process (or recipe) of tapping on the key acupressure points on the body while the client verbalised the issue with ‘self-acceptance’, to disrupt the subjective unit of disturbance (SUD) of the presenting problem.
The process seemed to be too easy and it was number of months before I put my training into practice in the late 1990s. However, this technique has proven to be effective on more than one occasion and is now supported by empirical studies (Feinstein et al, 2010).
Arnold Lazarus argues that unless an individual is assessed holistically, significant concerns can be easily overlooked. His integrative Multimodal approach describes seven perspectives that interact with one another, described in his acronym ‘BASIC ID’ (behaviour, affect, sensations, images, commissions, interpersonal and drugs/biology). A competent therapist can recognise the varying degrees of influence exercised by those modalities and effect change to maximise a successful therapeutic outcome (Palmer, 2012).
Therapists’ competencies, humility and awareness of the client’s needs are mandatory for a good outcome. I suppose I have used the multimodal therapy on occasions without putting a label on it.
I agree that ‘common factors’ contribute to all successful therapies, such as interpretation, insight, support, and behavioural change, in the presence of a therapist who demonstrates the core skills of empathy, congruence and unconditional positive regard and maintains a good therapeutic relationship (Lampropoulos, 2001, Grencavage et al, 1990).
My meta theoretical position is Personologism; described as the first meta theoretical position because it argues that behaviour is a function of the individual (Altmaier et al, 2012).
In summary, my journey as a therapist started as a Hypno-Psychotherapist and evolved into an Integration Hypno-Psychotherapist that incorporates multiple complementary modalities such as BWRT, EFT, Creative Visualisation, NLP and in the exceptional cases, Past Life Regression.
No one therapy fits all but as an Integration Therapist, I find that I get better results by combining various approaches to suit the personality and disorders presented by clients.
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