Psychotherapy Integration: Why Not?

Randy Fath, Unsplash

This article was first posted here 11 years ago. I’ve edited lightly to update it.

In the 21st Century, it is time to ask why not rather than why. At least half of practicing therapists are already mixing techniques from different traditions and theories. The four main objections have their roots in 19th century science and it’s time for a change in thinking. Here they are:

First, psychoanalytically oriented therapists learn early in their careers that they should hold back their feelings and reactions. This often makes them feel ashamed of engaging with patients and reluctant to use more active techniques. In the nineteenth century, scientists thought that if the therapist was a “blank screen,” that would prevent influence on the patient and what they observed would be purely “objective.” Physicists were the first to see that the observer can’t help but influence the observed. Now psychodynamic therapists understand that a disengaged therapist has just as much effect on a patient as an engaged one, but the old ideas have a lot of power, especially backed by shame.

Cognitive-behavioral therapists are no less immune to nineteenth century science. In the hope of being completely objective, John Watson, the founder of behaviorism, proclaimed that information gathered from  introspection was subjective, therefore invalid. Similarly, speculation about the past was too subjective to be taken into account. Decades ago, the cognitive revolution showed that humans don’t just react to stimuli, but react to the meanings they give to the stimuli. Today there is recognition that formulation, an explanation of why, is relevant to CBT, but old shame casts a long shadow. Therapists from the behavioral tradition might do well to notice that the “other side” has been thinking about why for a very long time.

Not to be outdone, psychodynamic training still teaches that you shouldn’t tell people what to do because it will “infantilize” them.  We all know that there sometimes you should let your child tie his or her own shoes, but there are also times when it is right to help out. Therapists are quite able to make the same judgment call. Helping people when it undercuts their own efforts does send the wrong message, but there are even more times when people need all the guidance they can get. I sometimes use the “fighting chance rule.” If the patient can figure it out, then it is good for them to do so. On another note, the psychodynamic tradition sometimes neglects the importance of behavior. When a behavior pattern is blocking the crucial emotion, a passive therapist isn’t very effective.

Finally, behaviorally oriented therapists are taught to measure everything. Once I took a tour of the Mississippi Bayou with a swamp guide. He didn’t measure much of anything, but he knew a great deal. Research is useful but experience is, too. Therapy is not research and doesn’t have to be cluttered with protocols and questionnaires. We are there to support change.

So, if it makes sense to you that pure objectivity is a myth of the past, then it might be OK for a therapist to be helpful, human and use good judgment to avoid the pitfalls. Therapists and patients can pool observations, experience, knowledge and intuition from all sources. I have come to think of therapy as a set of emotional tasks for which there are different tools. In the 21st Century, we can focus on finding the best tool for the job whatever tradition it comes from.  Why not?

What do you think? Comments are welcome.

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  • Nice summary! I think there are also other ways to slice this – for example – pathologization, linked to the separate identity of the patient relative to the therapist; and normalization/resonance, linked to an understanding of common humanity and the nature of suffering. The tools of self-compassion (for therapist and in the therapeutic relationship (as tools, source of insight, and catalysts for building relationship and identity) seem essential.

    • Thanks, Ravi for your thoughtfulness. The reason for slicing this way is that it corresponds to known change mechanisms of Extinction and Memory Reconsolidtion, which treat all information including relational as data which can be updated. Also, by going to such a foundational level, it becomes possible to describe phenomena in a way that is compatible with cognitive therapies as well.

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