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Integrative Confusion: An Examination of Integrative Models in Couple and Family Therapy
Robert L. Smith and Stephen Southern
The Family Journal 2005 13: 392
DOI: 10.1177/1066480705278468
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THE FAMILY
10.1177/1066480705278468
Smith,
Southern
JOURNAL:
/ INTEGRATIVE
COUNSELING
CONFUSION
AND THERAPY FOR COUPLES ANDAMILIES
F
/ October 2005
Integrative Confusion:
An Examination of Integrative
Models in Couple and Family Therapy
Robert L. Smith
Stephen Southern
Texas A & M University, Corpus Christi
This article examines integrative therapy, emphasizing couple and
family therapeutic models. Integrative models have developed at
such a rapid pace that a review of their origins is essential. The literature review indicates the varied and confused state of integrative
therapy. Yet, there are several promising couple and family therapy
integrative models. In an attempt to understand and integrate the
available models, their common factors are emphasized.
Keywords:
integrative; eclectic; theory; psychotherapy; couples
therapy
couple and family therapy is necessary to determine whether
integration combines the strengths of several theoretical
components or simply obscures their distinctive features
(Nichols & Schwartz, 2001). Integrative models of couple
and family therapy are discussed. Salient elements, common
to integrative couple and family approaches, are presented in
an attempt to define and clarify the concept of psychotherapy
integration in marriage and family counseling. Figure 1 presents an outline of the topics.
DEFINING INTEGRATION
Integrative family therapy is, despite its surface attractiveness, in the end a misguided, probably impossible, and
almost certainly unnecessary goal for our field.
—Henry Grunebaum, MD
C
linicians who work with couples and families are likely
to combine several techniques, theories, or factors in
their therapy to address the complexity of family systems.
However, the nature of what they actually do seems to be
murky at best. The descriptive term “integrative” has been
assigned to such an approach. Yet, there is little agreement
regarding what is actually meant by integrative, creating the
present state of confusion. In an attempt to offer effective
psychotherapeutic services to clients (i.e., couples and families), therapists have abandoned or modified underlying
“pure” theories and models. The result has been to describe or
categorize each new approach as integrative.
The authors, after a review of the literature related to integrative couple and family therapy, have concluded that there
is more confusion when using this modality than there is clarity. Due to this confusion, a closer examination of integrative
Lebow (1997) described the movement toward integration
in therapy as a quiet revolution taking place across the United
States. Although seemingly quiet, the literature includes
numerous articles and texts discussing integration in therapy
(Breunlin, Schwartz, & Mac Kune-Karrer, 1992; Corey,
2005; Duncan & Parks, 1988; Feldman, 1985; Goldenberg &
Goldenberg, 2004; Goldfried, 2004; Jacobson & Christensen,
1996; Kaslow, 1981; Nichols & Schwartz, 2001; Pinsof,
1995; Sperry, 2001; Stricker & Gold, 1993, 2003).
Today, only a modest number of therapists believe one
method or approach to therapy is sufficient to meet the needs
of a wide range of individual and couple issues. Clinicians
following the one-theory or method belief are likely to be followers of theorists who founded well-conceived approaches,
which have been advocated over many years. The original
schools of psychotherapy from which pure or unitary theories
arose recognized converging themes (cf. Goldfried, 1982).
Yet, little progress has been made in developing a single comprehensive system of psychotherapy (Patterson, 1989). As
new approaches combined techniques, theories, or factors of
therapy, the umbrella descriptor “integrative” was born. Integrative seems to be replacing another perplexing term—
“eclectic.”
THE FAMILY JOURNAL: COUNSELING AND THERAPY FOR COUPLES AND FAMILIES, Vol. 13 No. 4, October 2005 392-399
DOI: 10.1177/1066480705278468
© 2005 Sage Publications
392
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Smith, Southern / INTEGRATIVE CONFUSION 393
Integration Definitions
Journal of Psychotherapy Integration
Arkowitz, 1989; Grencavage & Norcross, 1990
Corey, Day
Nichols & Schwartz
Lazarus
Couple & Family Therapy Integration
Metaframeworks
Integrative Problem-Centered Therapy
Integrative Couple Therapy
Multimodal Therapy
Integrative-Contextual Therapy
Biopsychosocial Therapy
Integrative Family Therapy
Common Factors: CFTI Models
Theories & Factor
The Relationship
Flexibility
Developmental Concepts
Research
Conclusions
Trend
Necessity
Increasing Complexity
Research
FIGURE 1:
Integration Overview
Confusion still exists concerning the use of the terms
“integration” and “eclecticism.” Hollanders (1999) stated
that it has been difficult to arrive at universal definitions of
these terms. The traditional definition has been that eclecticism referred to the use of diverse techniques without regard
to their origins within a particular theoretical orientation,
whereas integration referred to the combining of diverse theoretical concepts often resulting in a new theory or approach.
In spite of attempts to differentiate eclecticism and integra-
tion, Norcross and Grencavage (1990) found evidence of
boundary blurring: “No technical eclectic can totally disregard theory and no theoretical integrationist can totally ignore
technique” (p. 11). Nuttall (2002) identified more than 400
new approaches that have evolved as a result of the
integrationist movement, referring to this as “an ubiquitous
process of conjunction that comes from relationship and
conflict” (p. 250).
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394 THE FAMILY JOURNAL: COUNSELING AND THERAPY FOR COUPLES AND FAMILIES / October 2005
et al. (2002) highlighted the importance of
Nuttall (2002) described integration
culture and diversity as part of all attempts
from at least two perspectives. First, as a
at therapeutic integration.
concept of emergence, he sees integration
Day (2004) observed that the field of
as an expression of chaos and complexity
Integrative
counseling has endorsed integrative
science. He referred to this emergence as
approaches for more than 30 years. She
complicit integration, driven by relational
approaches are here
considered Carkhuff’s Human Technoldynamics and systems theory. Next,
ogy, developed in the late 1960s as one of
Nuttall (2002) described contiguous inteto stay. They may
the first integrative models that was used in
gration with the view that individuals and
counselor training, combining nondirecfamilies have meaning only in relation to
soon consume, not
tive (Rogerian), psychodynamic, and
larger groups, organizations, or society.
behavioral practices. Recently, Brooks
This perspective is based on a metasystem
replace, all unitary
and Gavetti (2001) produced a Skill-Based
view of the integration phenomenon.
Psychotherapy Integration model for pracTherapeutic integration (Arkowitz,
models
ticum and internship training. Counselor
1992; Norcross & Newman, 1992) has
educators have tended to emphasize psybeen defined according to three major catchotherapy integration based on skills.
egories: theoretical integration, technical
Other authors (Miller, Duncan, &
eclecticism, and common factors. TheoHubble, 2002; Prochaska & DiClemente,
retical integration combines principles
2002; Wachtel, 1977) highlighted the common factors imporand practices from a number of pure or unitary therapies. Sevtant to successful therapy. Miller et al. (2002) found the relaeral theories are combined to produce a new approach. An
tionship to be by far the most important factor related to sucexample is the combination of individual theories of psycess in therapy, with other factors simply helping to enhance
chotherapy with marriage and family theories (e.g., personthe process. Prochaska and DiClemente (2002) discussed
centered, solution-focused, structural, and cognitiveintegration in terms of stages of change within the therapeutic
behavioral). Technical eclecticism, as the second category of
process (i.e., precontemplation, contemplation, preparation,
integration, draws on intervention techniques from a number
action, maintenance, and termination). Such stages are
of therapeutic approaches to meet the needs of one’s clients.
believed to be common across theoretical orientations.
Techniques are applied to individual, couple, and family
Wachtel (1977), an early contributor to the synthesis of
problems without regard to a particular theory. The common
behavior therapy and psychoanalysis, simply said that intefactors approach to psychotherapy integration identifies
gration was an evolving framework in which new elements
effective ingredients or principles in the therapeutic process
can enter and old ones exit.
that are included by several groups of therapies.
Integration was categorized by Nichols and Schwartz
The counseling literature has attempted to define integra(2001) as eclecticism, selective borrowing, or specially
tion (Corey, 2005; Day, 2004; Gladding, 2005; Ivey,
designed models. Eclecticism is viewed as simply drawing
D’Andrea, Ivey, & Simek-Morgan, 2002). Corey (2005)
from a number of theories and methods. Selective borrowing
stated that psychotherapy has been moving toward integrainvolves leaning toward one particular approach but occation since the early 1980s. Goldfried and Castonguay (1992)
sionally using techniques from other theories. Specially
characterized the integration movement as combining the
designed integrative models are attempts to create a new
best of several orientations that are evolving into more comapproach or theory by carefully combining workable
plete theoretical models and efficient treatments. Survey
approaches and significant therapeutic factors. This last cateresearch indicated that a number of therapists identify themgory is more comprehensive and complex than the first two.
selves as eclectic rather than integrative (Norcross, Hedges,
Current specifically designed integrative models in couple
& Prochaska, 2002). Corey (2005) discussed the eclectic
and family counseling/therapy are discussed in the next secapproach as a form of syncretism with the counselor grabbing
tion of this article. Goldenberg and Goldenberg (2004)
for what may work without determining whether any of the
defined integrative as more than combining different theoretitherapeutic procedures are effective with a particular client or
cal models and described such approaches as holistic in
problem. Others (Lazarus, 1986; Lazarus, Beutler, &
nature. They stress the importance of continually seeking out
Norcross, 1992) identified syncretistic confusion as referring
methods of integration and researching their efficacy with
to the end product when therapists pull techniques from many
couple and family problems.
different sources without a sound rationale. Corey (2005)
The literature indicates a myriad of approaches to psychonoted that integration must include cultural factors due to the
therapy integration. Researchers and commentators tend to
diversity of clientele and client problems. Other contributors
present their own views about integrative therapy, asserting
(Frame, 2003; Miller, 1999) emphasized the importance of
whether integration itself is a good idea. There is no consenspirituality as a major force in any integrative approach. Ivey
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Smith, Southern / INTEGRATIVE CONFUSION 395
sus regarding a definition or set of characteristics describing
integrative therapy. The lack of consensus and clarity is due to
the nature of this concept. Perhaps consensus is neither possible nor desirable when it comes to defining integration in
therapy. Existing integrative models developed over time will
only remain viable based on their clinical utility.
There are several additional barriers to psychotherapy
integration. Presently, consensually validated theoretical
structures do not exist (cf. Safran & Messer, 1997; Woolfolk
& Murphy, 2004). There are some irreconcilable differences
in theoretical constructs (e.g., views on the validity and utility
of the unconscious). Finally, many practitioners perceive theory as too abstract and irrelevant (Patterson, 1989). Because
psychotherapy can be understood only within the linguistic
and ideological frameworks in which they are embedded
(Safran & Messer, 1997), clinicians need to immerse themselves within the culture of a particular therapy model and
open the professional context to curiosity and dialogue
(Woolfolk & Murphy, 2004). Couple and family therapy has
been influenced by postmodern thought, including systemic
thinking, contextualism, and ecological perspective. Therefore, marriage and family counselors may be more receptive
than individual therapists to embracing the complexity (and
confusion) of psychotherapy integration.
COUPLE AND FAMILY
COUNSELING INTEGRATIVE MODELS
Several integrative models in couple and family counseling or therapy have evolved over the past few decades.
Metaframeworks grew out of the collaboration efforts of
Douglas Breunlin, Richard Schwartz, and Betty Mac KuneKarrer at the Institute for Juvenile Research in Chicago
(Nichols & Schwartz, 2001). William Pinsof and colleagues
at the Family Institute at Northwestern University developed
Integrative Problem-Centered Therapy (IPCT) (Pinsof,
1995). Jacobson and Christensen (1996) produced an Integrative Couple Therapy Model. Lazarus (1986) developed
the multimodal approach, which has been applied to couple
and family systems. Three recent applications of the integrative perspective represent theoretical integration at the systems level: an Integrative-Contextual Model (Smith, 2001), a
Biopsychosocial Model (Sperry, 2001), and the Integrative
Family Therapy Model (Walsh, 1975/2001).
Metaframeworks
Metaframeworks attempts to cross the boundaries of several marriage and family approaches, including structural,
strategic, and intergenerational theories. This model views
families through six domains: the intrapsychic, family organization, sequences of family interactions, development, culture, and gender. A collaborative approach is used with families to help release constraints in any of the six domains. The
metaframeworks model transcends individual schools of
family therapy. Because it focuses on a number of dimensions
and considers several theoretical models, metaframeworks is
a complex approach that demands practitioners to work in
context with several systems, subsystems, and factors affecting family functioning.
Integrative Problem-Centered Therapy
Integrative Problem-Centered Therapy attempts to integrate family, individual, and biological therapies (Norcross,
1996). Therapy is conducted according to identifying factors
that prevent problem resolution in families. Therapy, according to Pinsof (1995), is conducted according to the most costeffective approach first, which often means a short-term
behavioral method. Depending on the severity of the presenting problem, the therapist may need to implement other
approaches, thus transcending boundaries of pure theoretical
models. This may include examining potential biological
problems or implementing family of origin and intrapsychic
approaches. The problem-centered approach is seen as comprehensive and flexible. “By integrating so many different
orientations (behavioral, experiential, psychodynamic, etc.)
as well as individual and family contexts, the theory and practice domains one draws upon are almost endless” (Pinsof, as
cited in Norcross, 1996, p. 306).
Integrative Couple Therapy
Integrative Couple Therapy (Jacobson & Christensen,
1996) combined two major schools of therapy. The humanistic approach was added to a more traditional behavioral
approach to obtain better results when working with couples.
Jacobson and Christensen (1996) recognized patterns in the
behavior of couples that challenged the skill-building foundation of the classic behavioral model. Therefore, they
encouraged couples to practice acceptance and support. The
integrative couple therapy model emphasized empathy, a
characteristic of person-centered therapy. The therapist facilitates relationship change through acceptance and empathy.
Technical Eclecticism
Lazarus (1986) provided the best and most researched
example of technical eclecticism. Technical eclecticism
applies techniques from several sources in accordance with
the needs of the different clients. Earlier surveys (Jensen,
Bergin, & Greaves, 1990) found that clinical psychologists,
marriage and family therapists, psychiatrists, and social
workers endorsed eclecticism from 59% to 72% as their preferred approach. Many have endorsed Lazarus’s multimodal
approach, which focuses on specific modalities and combines
social, biological, relationship, and communication factors.
Clinical judgment is an important feature of this integrative
model. Lazarus recommended techniques from gestalt, cognitive, behavioral psychodynamic, and family systems
therapies.
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396 THE FAMILY JOURNAL: COUNSELING AND THERAPY FOR COUPLES AND FAMILIES / October 2005
Integrative-Contextual Therapy
The Integrative-Contextual Model (Smith, 2001) is defined
as a framework for conducting couple and family counseling/
therapy within the context of the therapeutic setting. Professionals working from this complex model consider the following: (a) therapist characteristics, client characteristics,
and their match with each other (gender, values, beliefs, experiences, culture, knowledge-base, etc.); (b) relationship skill
level; (c) developmental stages of the client system and the
developmental process of therapy; (d) integration of proven
theories, techniques, and change processes; and (e) megasystems that interact from a contextual perspective with the
therapist, client system, and the therapeutic process. This
model focuses on at least two levels of integration (Sperry,
2001) by first integrating theory (structural, cognitive-behavioral,
solution-focused, and psychoeducational) and then tailoring
treatment modalities based on a number of important contextual factors.
Biopsychosocial Model
The Biopsychosocial Model integrates theory and techniques according to client or couple levels of distress (Sperry,
2001). This model is particularly useful in health care settings
where clients might present medical problems. Several treatment modalities are utilized with this approach, including
individual, group, couple, family, and medical. In addition,
theories such as cognitive-behavioral, systemic, and psychoeducational are included within this integrative model. The
foundation of this model is that couple and family therapists
must consider the biological, psychological, and social functioning levels of their clients. Sperry (1999) described the
biopsychosocial model as a systematically eclectic approach.
Integrative Family Therapy Model
The Integrative Family Therapy (IFT) Model also combines theory and technique. Several approaches to therapy
are integrated within this model, including structural,
communication-based, cognitive-behavioral, solutionfocused, and narrative therapies. Walsh (1975/2001) described the IFT therapeutic process as well defined and structured,
usually consisting of about 10 sessions. In addition to integrating several pure theories, this model follows five stages:
structuring, observation/assessment, intervention, change
maintenance, and review/termination.
COMMON FACTORS
The integrative couple and family counseling models have
more similarities than differences. Figure 2 reflects common
factors in integrative couple and family counseling models.
All models evolved out of a desire to address effectively the
needs of diverse client systems possessing a variety of presenting problems. The founders moved away from traditional
single theory approaches and instead have drawn on concepts
and techniques representing a host of theoretical orientations.
Current couple and family counseling models are not easily
categorized in one of the three integrative categories; theoretical integration, technical eclecticism, or common factors
integration. Most of the models incorporated different theories and include a wide range of factors within their approach.
All of the approaches discussed the importance of the
relationship and include it as a major factor (Miller et al.,
2002).
Following the systemic base of marriage and family counseling and therapy, integrative theories presented are not considered linear in terms of their process or application. Each
integrative model has a working framework that is flexible in
the application of concepts, techniques, or theories. The
sequence of the integrative framework will be affected by client readiness, client system composition, presenting problems, problem severity, and other contextual factors. Flexibility and spontaneity are common elements of each approach.
All models continue to evolve and can be viewed in their
early stage of development. A characteristic common to all
models is the need to demonstrate effectiveness. As new
approaches to therapy are presented and proven effective,
each model will change and adapt. Research on effectiveness
will clarify the number of practices and concepts of existing
models. Some model components will be discarded and
replaced by more effective strategies. Research involving all
integrative approaches, with the exception of Lazarus’s
model, is considered to be at the infancy state.
CONCLUSIONS
The importance of integration in couple counseling and
family therapy is reflected by the attention given to this movement by the professional literature. According to a Delphi
poll on the future of psychotherapy (Norcross et al., 2002,
p. 318), technical eclecticism and theoretical integration were
ranked fifth and sixth, respectively, by clinicians. It is predicted that all forms of psychotherapy integration are likely to
experience significant growth in the next decade. However,
attempts at defining integration or integrative therapy have
generally failed, thus creating confusion. Due to the rapid
evolution of integration and the diverse nature of this concept,
a degree of confusion should be expected.
Within couple and family therapy, several integrative
models have evolved. Current models are diverse despite the
presence of several common features. There is a need to
research the efficacy of these models; yet, it is a difficult task
due to their complex and evolving nature. The promise of
psychotherapy integration returns the profession to the original challenge by Paul (1967): “What treatment, by whom, is
more effective for this individual with that specific problem
and under which set of circumstances?” (p. 111).
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Smith, Southern / INTEGRATIVE CONFUSION 397
Integrative ProblemCentered Therapy
Metaframeworks
Technical
Eclecticism
Common Factors
Theories & Factors
The Relationship
Flexibility
Developmental Concepts
Research
Integrative
Couple Therapy
Integrative Family
Therapy
Integrative – Contextual
Therapy
Biopsychosocial Therapy
FIGURE 2:
Common Factors: Integrative Models in Couple and Family Therapy
Several conclusions regarding integrative counseling and
therapy, with an emphasis on couple and family therapy, can
be made. First, the trend toward integration will continue.
New models, ideas, and thoughts about integrative therapy
are surfacing. Each counselor or therapist will continue to put
his or her mark on a personal practice approach, typically
involving some form of integration. The integrative phenomenon occurs due to necessity. As clients and problems continue to differentiate, so will the approaches used to solve
these problems. Integrative models in couple and family therapy will continue to grow, with early approaches being modified as new methods are presented and researched. With this
ongoing evolution, the complexity and sophistication of integrative approaches will increase. Current integrative models
already blur the integrative categories of theoretical integration, integrative eclecticism, and common factor integration.
Although definitions of integration or integrative therapy
seem elusive at times, there is general agreement that available models and approaches need to be understood and
defined with research demonstrating their efficacy. There is
consensus among consumers, professional societies, and practitioners to identify the best methods to solve various family
problems. The goal of demonstrating effectiveness should
proceed not to prove one integrative model’s superiority over
another but to simply share and collaborate on the efficacy of
all potential models and approaches. Integrative approaches
are here to stay. They may soon consume, not replace, all unitary models, with few if any clinicians working from one pure
approach. There remains a need for increasing the knowledge
and skills by integrative counselors and therapists working
with couples and families.
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398 THE FAMILY JOURNAL: COUNSELING AND THERAPY FOR COUPLES AND FAMILIES / October 2005
Despite significant confusion associated with psychotherapy integration, there are promising clinical innovations
occurring within couple and family therapy. Sound theory
development based on clinical experience and research is indicated. Ongoing exploration by marriage and family counselors and dialogue among professional colleagues from various
schools of thought will facilitate the transition to integrative
models.
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Robert L. Smith is professor and chair of the Department of Counseling and Educational Psychology at Texas A & M University, Corpus Christi.
Stephen Southern is an associate professor in the Department of
Counseling and Educational Psychology at Texas A & M University,
Corpus Christi.
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