Psychotherapy Integration: Five Things Therapists Need to Do

Even today, the field of psychotherapy has been stunted and weakened by the lack of a common understanding of how it actually works. Each school has its own explanation in terms that belong only to that school or orientation and are not recognized by others. Since psychotherapy integration was recognized in the 1980s, among several types, theoretical integration, an explanatory framework uniting diverse therapies, has been the gold standard. Since then, it has all but been abandoned as unachievable.

In the meantime, science in a number of related domains has quietly come to the point where a common understanding is within reach, based on principles that are not particularly controversial. Perhaps the field is so accustomed to a nihilistic view that this progress has yet to be fully recognized. But times are changing. Marvin Goldfried, one of the founders of the Society for the Exploration of Psychotherapy Integration (SEPI), proposed in 2019 that it might be time to revisit the possibility of consensus.

Two years ago, a group of SEPI members—Richard Lane, M.D., Ph.D., Ben Johnson, Gregg Henriques, Ph.D., Andre Marquis, Ph.D., and me—set out to form a Special Interest Group on Convergence to look at that question: Is consensus possible? What follows is a brief outline of what we found.

Entrenched Maladaptive Patterns, Primary Targets of Psychotherapy

From the beginning, we recognized that every school has a different idea of what therapy does, so we needed to try to formulate a universal definition of pathologies treatable in therapy. Psychotherapy has always been aimed primarily at helping people change the ways they respond to circumstances, internal and external. Furthermore, the responses we can help change are those that originate from the calculations of the mind, as opposed to problems of genetics or biology. Even though there are mechanisms such as epigenetics, by which psychotherapy can influence biology, these are not our direct targets.

Why did we end up with the term entrenched maladaptive patterns (EMPs) to describe the problems that all forms of therapy are intended to address? They are patterns because they may repeat; otherwise, they would not require treatment. They are maladaptive because, in the present context, they are unsatisfactory or unhealthy, at least in comparison with some other possible response. And they are entrenched because if they were easy to change, then professional psychotherapy would not be needed.

Why Do Humans Have EMPs?

It has taken a long time for our field to absorb the theory of evolution. As we have done so, it has led to a more limited view of consciousness as a modest and variable window on the overall range of mental information processing. The unconscious mind, once seen as a source of chaos and unruliness, can now be viewed as the operation of an extraordinarily flexible information processing function evolved for the survival and reproduction of the species. With a bias toward defense against threats, the mind does much of its work automatically by producing direct actions, automatic thoughts, feelings, impulses, and visceral responses, all of which influence our conscious choices.

When these products repeatedly lead us in unhealthy directions, they can be termed EMPs. Some are inherently maladaptive, having evolved long ago, when conditions were far different from now. Others may have been the most effective adaptations possible at an earlier time in life, and yet others are maladaptive because more effective coping strategies have not been modeled or learned.

How Can EMPs Change?

As we defined the targets of psychotherapy, we found that, despite the extreme range of problems people bring to therapy, all have features in common. Foremost, the work of Kandel and others has clarified that information, including patterns of appraisal and response, are stored in memory, embodied as neural networks. This means that changing EMPs will require, as a final common pathway, changes in memory. So far, based on the learned fear paradigm as well as other experimental models in mammals and humans, modern neuroscience has elucidated just three mechanisms for modifying EMPs:

• New learning: EMPs depend either on lack of knowledge of healthy responses or old learning that leads to unhealthy responses. So one essential function of psychotherapy is to support patients’ internalizing new and more adaptive information.

• Extinction: This change mechanism, first identified by Pavlov, has now been shown to require concurrent cortical learning (for example, that wartime dangers are no longer relevant), at the same time that emotion-related memories are activated. This juxtaposition leads to inhibitory signals being sent to limbic areas where the outward expression of maladaptive patterns is blocked. Unfortunately, because the old recognition and triggering of the EMP remains unchanged, this mechanism is not permanent and must be reinforced over time.

• Memory reconsolidation: This mechanism allows stored maladaptive patterns to be updated with new, healthier information. This requires a similar juxtaposition of activation of emotion-related memories along with experiencing new, “corrective” information.

A Working Hypothesis

Based on the likelihood that these three pathways represent the common change mechanisms of psychotherapy, the work of the therapist boils down to a very few universal and fundamental activities:

• New learning of healthy responses and updated ways of appraising situations is necessary for all three change mechanisms.

• Activation of emotion-related memories is required for both extinction and memory reconsolidation. It must occur simultaneously with provision of new information. This is embodied in multiple psychotherapeutic concepts such as Alexander and French’s corrective emotional experience, exposure therapy, experiential techniques such as two-chair exercises, and cognitive-behavioral therapy in which activation of emotion-related memory may be essential but implicit.

• Arousal regulation within an optimal window has been shown to be necessary for learning. This can be promoted through a positive therapeutic relationship, as well as specific techniques such as mindfulness.

• Motivation: All therapies embody means, overt or implicit, for supporting the motivation required to take emotional risks and work at change.

• Maintenance of a positive therapeutic relationship supports each of the above aims.

In our view, pursuing these five foundational aims is universally necessary and sufficient to promote the fundamental change processes of psychotherapy. While we cannot exclude the possibility of some unknown mechanism being discovered, these five aims appear sufficiently well supported to form a working hypothesis and a kind of Rosetta Stone for psychotherapy. We hope this framework can simplify learning and give therapists and researchers of diverse backgrounds a common language by which to understand and refine the many routes by which therapist actions can lead to therapeutic change. ■