Introduction to the Special Issue on Psychotherapy Integration

The practice of psychotherapy has been characterized by division and dogmatism since the origins of talk therapy with Freud (McGoldrick, Gerson, & Petry, 2008; Norcross & Goldfried, 2005). Today there seem to be two competing trajectories—one that seeks to build bridges and move toward integration of psychotherapy paradigms and another that seeks firmer boundaries between different approaches and resists integration. The reasons for the latter are myriad, including the nature of clinical research, which relies on clearly operationalized treatments; the pressures of managed care, which limit creativity and experimentation; and a culture of competition within academia, which can lead to the idealization of one’s own perspective and the devaluing of others. There are also valid and theoretically driven reasons for maintaining boundaries between psychotherapy approaches. The muddling of conceptualization and technique may lead to suboptimal psychotherapy process, resulting in compromised quality of care. Despite these challenges, there has been increasing emphasis on psychotherapy integration over the course of the last few decades (Norcross & Goldfried, 2005). However, the research and clinical writing on this topic has largely focused on integrative treatments for adults (Berking, Ebert, Cuijpers, & Hofmann, 2013; Bresler & Starr, 2015). This special issue of JICAP aims to soften the reified boundaries that separate theoretical perspectives and offer new perspectives on psychotherapy integration and its challenges with children, adolescents, and their families.

Although my professional identity has largely been defined by my commitment to scholarship in the area of psychodynamic psychotherapy, there has always been a consistent thread of psychotherapy integration. My seminary training prepared me with treatment approaches that integrate issues of religiosity and spirituality. At Cambridge Health Alliance, I trained with Ross Greene and Stuart Ablon using their Collaborative Problem Solving approach. The goal was to eliminate restraints and seclusions on a child inpatient unit where there were frequent assaults (see Regan, 2006, for a first-person account of this transition). This model was a combination of cognitive and behavioral interventions rooted in a humanistic and self-reflective stance. Though my work has been primarily psychodynamic, I also developed a textbook for master’s students, in collaboration with a strong cognitive-behaviorial clinician and researcher, with the title Essential Interviewing and Counseling Skills: An Integrated Approach to Practice (Prout & Wadkins, 2014).

My interest in psychotherapy integration also stems from my experiences teaching doctoral candidates. Each cohort of students has unique ideas about the practice of psychotherapy with children, adolescents, and families. Yet every year students are consistent in their request for training on how to integrate the largely siloed psychotherapy paradigms they are learning. These students feel the culture of “othering” (McWilliams, 2017, p. 287) across the research-practice divide and, perhaps more keenly, across theoretical perspectives within academic departments (Morrison & Goodwin, 2017). There is a need for greater communication, openness, and curiosity about perspectives that differ from our own. Further, I firmly believe patients benefit from paradigmatic flexibility on the part of the practitioner.

I offer this history and perspective in an attempt to contextualize my enthusiasm for editing this special issue of JICAP. The number and quality of submissions we received was inspiring. The resultant issue contains several clinical and conceptual articles balanced with four articles rooted in psychotherapy research programs. The clinical articles include Kenneth Barish’s offering of an emotion-focused perspective on psychotherapy integration that transcends the traditional split between practical parent guidance and the depth approaches of psychodynamic psychotherapy. In another theoretically comprehensive article, Arthur Caspary presents an integrative approach to the treatment of a 6-year-old schoolyard bully. The therapeutic flexibility demonstrated in the article gives voice to a wide range of theoretical perspectives that are often cut off from one another. Child psychotherapy is almost always attendant to the presence of historical or present traumas in the life of the child. Obasaju and LiVecchi discuss the treatment of a 10-year-old Dominican American girl within a multilayered sociopolitical context. Their perspective adds a broader, more integrative view of the macrosystem within which children’s distress emerges. Naama Gershy’s contribution highlights a common clinical challenge encountered on many child and adolescent inpatient units, that is, the patient we often refer to as “treatment resistant.” Gershy’s article raises the question of what psychotherapy actually entails in circumstances when the patient can hardly engage in a conversation, much less a therapeutic relationship. The answers she offers are compassionate, practical, and contextualized with rich clinical material.

Two subsequent articles capture unique aspects of child development that attend to both the mind and the body. Diane Selinger offers readers a thoughtful and contemporary perspective on the developmental, individual difference, relationship model (DIR) in concert with a relational psychoanalytic approach to child therapy. She presents the case of Dylan, a twice exceptional child, who was struggling with emotional regulation issues. In a related article, Todd Germain details a unique and much-needed perspective on child psychotherapy. Germain’s expertise as both an occupational therapist and a psychotherapist allows him to conceptualize and intervene at multiple levels. This article is an important invitation to dialogue between fields that may not otherwise speak.

Four articles included in the special issue bridge the divide between clinical research and practice. Ness, Dahl, Critchfield, and Ulberg’s article offers a new perspective on integration, namely on the recognition of multiple perspectives within the therapeutic situation. The case of Susanna, who was treated within the context of a research study with a manualized psychodynamic approach, provides unique data. Readers are offered a window into a detailed and measurable psychotherapy process as well as discrepancies between therapist and patient perspectives during treatment. Readers are encouraged to explore the ample supplemental material (available online) offered by these authors. In another psychotherapy process article, Bate, Bekar, and Blom present detailed case material and research data from work with a mother-infant dyad who moved from a cognitive-behavioral treatment to a psychodynamic mentalization-focused treatment. Psychodynamic psychotherapy has a long and rich history of work with mother-infant dyads and research on this topic (see JICAP’s special issues on this topic from 2018, volume 17, issue 1, and 2014, volume 13, issue 1). Bate, Bekar, and Blom build on this literature by proposing ways in which attachment theory and research can link therapeutic approaches to help foster healing across generations.

Two articles focus on clinical material that emerges from robust psychotherapy research programs. Rudenstine, Wright, Morales, and Tuber detail their work on an integrative approach to child group psychotherapy. Blending ego psychology, play therapy, cognitive behavioral therapy, and dialectical behavior therapy, the Relationships. Individuals. Skills. Engagement. (RISE) groups emphasize aspects of self-regulation that are challenged in an interpersonal context. Finally, the composite case presented by Prout et al. emerges from a randomized controlled trial of psychodynamic psychotherapy and offers a behavioral reconceptualization of disruptive behavior problems. The integrated psychotherapy approach offered at the end of the article aims to reduce the chasm that currently exists between psychodynamic and behavioral approaches.

The reality of child work requires clinicians who are flexible and treatments that can be adapted for the individual child and the family. Psychotherapists who work with children and families consider what works for whom (Fonagy et al., 2014) and why. Treatments must be tailored to symptom categories, family structure, developmental and chronological age, treatment setting, and many other factors. The diversity of articles included in this special issue captures many of these salient issues that characterize infant, child, and adolescent psychotherapy.

I am especially grateful to all of the authors who contributed to this special issue and to Editor-in-Chief Susan Warshaw for her generous invitation to develop and edit this volume. Her guidance and sustained commitment to this special issue was significant. Recognizing that psychotherapy integration is not without its challenges and limitations, we asked each author to offer his or her perspective on what is lost and what can be gained in the process of integration. Though this special issue certainly rests on the premise that there is value and merit in psychotherapy integration, each article also offers a unique comparative perspective that recognizes the important distinctions between paradigms. The overall aims of this special issue were to present a variety of theoretical and technical approaches, identify places of convergence and divergence across theoretical paradigms, highlight aspects of integration beneficial to patients, and discuss challenges associated with integration. Taken together, the articles contained in this special issue accomplish these ambitious goals. Reading them as a guest editor has invigorated and inspired my clinical work and my research ideas. The process has also made me more optimistic about the future of psychotherapy integration with youth. It is my hope that readers will have the same response to the authors’ contributions.

Disclosure statement

No potential conflict of interest was reported by the author.