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Psychotherapy’s Fifth Wave

The future of psychotherapy is unification

Written with David Allen, PT Blogger; A Matter of Personality

A little while ago a NY Times article wondered where the field of psychotherapy was headed. After profiling some of the field’s most prominent thinkers in cognitive behavioral, psychodynamic, and humanistic approaches, the author sensed that the field was on the cusp of, well, something. But it was not at all clear what that ‘something’ would be. He wrote, “As psychotherapy struggles to define itself for an age of podcasts and terror alerts, it will need ideas, thinkers, leaders. Yet the luminaries here, many of whom rose to prominence three decades ago, were making their way off the stage. And it was not clear who, or what, would take their place.”

So what will be psychotherapy’s next great thing? Will there be a so-called fifth wave? Individual psychotherapy (i.e., not counting systems views, which operate at another level of analysis) has seen four great waves. First, there was psychoanalysis, with its emphasis on the unconscious conflicts, early experience and transference. Then came behavior modification, stemming from learning theories organized into procedures for desensitization and changing contingences. Humanistic/experiential psychotherapy, which rejected the mechanistic determinism of both psychoanalysis and behaviorism and instead emphasized emotions, conscious motives, and human potential can be considered the third great wave. Finally, cognitive psychotherapy, with its emphasis on thoughts and interpretations, can be considered the fourth great wave.

So, will there be another great wave in psychotherapy? Perhaps forms of Zen-based mindfulness? Brainwise therapies? Maybe something connected to the technological explosion? While these are exciting developments, we believe the next wave will be a different kind of wave; one that will bring consolidation and clarification to the field. Instead of yet another movement defined against those that have come before, what is desperately needed now is a systematic approach that provides a common language and conceptual framework that allows practitioners to see how the key insights from the major perspectives can go together to form a coherent whole. Moreover, such an approach will more directly connect psychotherapy to the science of psychology. Philosophers of science talk about fields moving from a pre-paradigmatic state where competing schools advocate fundamentally different visions of reality to a paradigmatic state where a shared frame emerges that aligns the key insights into a coherent whole. We believe psychotherapy is on the cusp of such a transition, and the next several decades will bring a much more unified vision of the field.

Knowledgeable practitioners of the specific schools of thought will probably balk the suggestion of conceptual unification. They will rightfully point out that the different perspectives are deeply anchored into fundamentally different visions of what it means to be human. To eclectically put them all together, they argue, yields a form of mush, something far less—not more—than the sum of its parts. The unsystematic blending of ideas is a weak intellectual solution. This is why the eclecticism of the 1980s gave rise to psychotherapy integration movement of the 1990s. Integrationists realized that a taking a bit from this perspective and a bit of that technique quickly leads to chaos, and over the past several decades integrationists have tried to carve out pathways to pull together different strands of thought with integrity. Yet the integration movement itself may be stalling, perhaps as a function of its own success. For as the integration movement has gained traction, various pathways and forms of integration have proliferated (e.g., common factors, technical eclecticism, assimilative integration, and theoretical integration and so forth). There is so much variety and so little form that it is becoming increasingly meaningless to identify as a psychotherapy integrationist.

As co-chairs of the Unified Psychotherapy Project, we are part of a small but growing group of academics and practitioners who argue that the conceptual unification of psychotherapy is possible (for a book outlining how, see here). If this is so, the field of psychotherapy will shift from being pre-paradigmatic to fully paradigmatic. The Project’s founder, Jeffrey Magnavita, put the issue this way…

"[P]sychotherapists behave like members of competing tribes, with different esoteric languages and rituals. Unification assumes that we all work in the same realm with the same processes regardless of the subsystem or specific domain we emphasize and specialize in. A unified model encourages us all to be aware of the larger picture and even if domain-specific treatment is undertaken, an understanding of the system and interconnections of domains and processes keep us alert to other possibilities for further developments."

The point of this rather lengthy post is to share an outline of a unified model of personality and psychotherapy that is gaining traction and is providing practitioners a convenient way to think about individuals in a manner that is consistent with the major perspectives and modern personality theory. A more detailed articulation of the model was just published in a new journal, The Journal of Unified Psychotherapy and Clinical Science. (It is important to reiterate that what we are sharing here is a model of the individual, and thus it exists at a different level of analysis the family, group, or societal level).

Let’s start with mapping the larger picture that Magnavita referred to. Here is a map that identifies the key variables that a professional psychologist would need to consider.

The three circles in the middle identify the intersection of the three domains of knowledge most immediately relevant for a psychotherapist, namely personality theory (i.e., how are people built and what makes them unique), psychopathology (i.e., what are the kinds and causes of suffering and psychological dysfunction), and psychotherapy (i.e., what are the kinds of interventions and therapeutic processes associated improving psychological functioning and well-being). These three domains are imbedded three broad contexts. The red circle represents the Neuro-Biological context, with refers to a) the broad evolutionary history of our species; b) the unique genetic makeup of the individual; and c) the individual’s current neuro-physiological constitution. The green arrow represents the life history and developmental context, namely the distal and proximal variables that played a key causal role in the current situation. Finally, the blue circle represents the relational and sociocultural contexts in which the person (and therapist and therapy!) is embedded (think here of Bronfrenbrenner’s ecological systems model).

Although in Freud’s psychoanalysis the trifocal points of psychopathology, personality and treatment were all closely connected, with the emergence of behavioral and cognitive therapies (i.e., ESTs) and the Diagnostic and Statistical Manual the field of psychotherapy has largely drifted away from personality theory and instead focused primarily on psychopathology. Current academic research generally matches specific interventions to psychopathology categorized by the DSM, with virtually no systematic attention paid to the individual’s personality make up. We believe that interventions should be guided by holistic conceptualizations, not just lists of symptom presentations. That means we need to systematically consider personality dynamics, as well as the biological, developmental, and social contexts. In this blog we share the outline of a view of personality can align us directly with interventions and conceptualizations that cut across the major domains of individual psychotherapy.

A conference presentation at the 2010 meeting of the Society for the Exploration of Psychotherapy Integration in Florence, Italy vividly affirmed the need for a more unified approach toward conceptualizing people in psychotherapy. The presentation consisted of Drs. Leslie Greenberg and Paul Wachtel analyzing a videotape series of cognitive behavioral therapy for perfectionism conducted by Dr. Martin Antony. The patient was a motivated, attractive young woman completing a graduate degree in psychology who strove for perfection in many areas of her life. She was extremely focused on organizing, planning, and succeeding at everything she did. She also had occasional panic attacks and issues concerning her body image.

What was striking about the presentation was how Dr. Antony focused almost exclusively on daily activities, habits and actions, and the thoughts associated with them. In contrast, her emotions, relational processes and internal working models, and the way she defended against uncomfortable images, feelings, or impulses were essentially ignored. For example, at one point in the first session, Dr. Antony inquired about the woman’s eating patterns and, with tears welling up in her eyes, she hesitantly reported that she purged about once a day. Dr. Antony made little acknowledgement of her feelings or of her pained experience sharing this information. Not surprisingly, Drs. Wachtel and Greenberg criticized the way these elements were glossed over. Indeed, at one point, Dr. Greenberg commented that he did not believe that cognitive behavioral therapies treated the whole person. It is likely, however, that a cognitive behavioral therapist might retort that Greenberg’s Emotion Focused Therapy similarly does not focus on the whole person but only the emotional part. Or perhaps the individual would question the assertion by arguing that no system focused on the whole person in the manner that Greenberg implied.

We believe there are holistic maps of individuals that can guide practitioners and connect psychotherapy to both modern personality theory and psychopathology, and we share the outline of our approach here. This blog complements a prior recent post, Another Big Five for Personality, which articulated that one of the major distinctions in personality theory has been between temperament and character. Temperament (i.e., traits) refers to the broad and general dispositions of an individual; in contrast character refers much more to one’s unique identity and what is learned in particular situations. Personality research and theory has varied in terms of its focus. Although Freud’s theories and other early formulations were initially concerned with character, in the 1950s research on traits exploded, and the ‘Big Five’ (i.e., traits of extraversion, neuroticism, agreeableness, conscientiousness, and openness) probably represent the most prominent work in personality over the past several decades.

Although traits are crucial to consider for a good conceptualization (see, e.g., Singer’s excellent book Personality and Psychotherapy), it nevertheless is the case that traits are broad, general dispositions that are quite stable in adulthood and unlikely to be largely modified. Thus, they are not really the central focus of psychotherapy interventions. Thankfully, personality researchers have begun to recently turn their attention back to character. Dan McAdams’ has, for example, argued that character can be further divided into characteristic adaptations (the ways an individual specifically learns to adapt to specific situations) and identity (one’s self-concept, self-esteem, philosophy of life), and he argues for a tri-level view of personality (traits, characteristic adaptations, and identity).McAdams has focused much of his attention on identity, and noted that there is “no general Big Five theory of characteristic adaptations”.

What is remarkable is that work on a unified approach to conceptualizing individuals in psychotherapy has been developed that delineates precisely what McAdams said was missing—it offered a ‘Big Five’ map of the systems of characteristic adaptation! Delineated in the prior Big Five blog, the five systems are, in order of development: 1) the Habit System; 2) the Experiential-Affective System; 3) the Relationship System; 4) the Defensive System; and 5) the Justification System. Here is the map (for a more detailed discussion, see here).

On the left side, the three broad contextual domains (biological, developmental and sociocultural) are represented. The circle in the middle represents the personality of the individual, specifically the systems of adaptation that are often the focus of interventions. These systems are described in a previous blog. From the vantage point of developing a conceptualization useful for psychotherapists, here is a brief description of each domain of adaptation, with questions about each that might be asked.

A. Habits and Daily Activities. This domain refers to the daily activities and patterns of behavior that the individual engages in. Common domains to assess include

  1. Patterns of sleep and wakefulness (# hours sleep per night, naps, ease falling or staying asleep, nightmares)
  2. Eating (regularity of meals, restrictive or overeating, unusual or unhealthy diet)
  3. Substance use (frequency, intensity and duration of nicotine, alcohol, and illicit/prescription substance use)
  4. Exercise (frequency of exercise, degree of physical fitness)
  5. Regularity of routine
  6. Daily stressors (e.g., noise, traffic, heat)
  7. Hobbies, interests, leisure time

B. The Experiential System. This domain refers to the embodied phenomenological state (i.e., the felt experience of being). It is organized by affect, although includes perceptions, drives, and images. Common domains to assess include:

  1. Are there dominant emotional states that are chronically active/accessible, emotions that are expansive or under regulated? What about emotions that are over controlled?
  2. Does the individual know how he feels? Can he “get in touch” with his feelings? Is there harmony or alienation between the explicit justification system and the experiential system?
  3. What is the general degree of emotionality? Levels of trait extraversion? What about levels of trait neuroticism?
  4. Is the individual able to stay centered and mindful of what is happening at the experiential level?
  5. Can the individual express his feelings effectively? Does the individual have trouble with experiencing all or some emotions? Are there secondary emotions that are covering up primary emotions?
  6. Has there been a trauma that overloaded the experiential system? Does the individual experience strong images or flashbacks?
  7. Does the individual have gut feelings or a sense of things being either good or off? Is there a lot of fantasy or day-dreaming?
  8. Are there any unusual/bizarre sensations or experiences (i.e., hallucinations)?

C. The Relational System. This domain refers to the internal working models or self-other schema the individual has developed to navigate the social environment. Common domains to assess include:

  1. What is the person’s sense of relational value…to what extent do they feel generally respected, admired, loved and appreciated as opposed to neglected, rejected and criticized? Has that changed recently?
  2. Does the individual generally feel secure in her relationships? Do they have issues with trusting others and do they ever get paranoid? Do they have intimate connections with others? Have they had a lot of relationship failures?
  3. What was the attachment history? What were their early relationships (parents, siblings, early friends) like?
  4. Have they experienced a traumatic loss or betrayal from another?
  5. Is the individual more agentic (self-focused, concerned with power and autonomy) or more communal (other focused, concerned with affiliation and connection)?
  6. Is the person more or less agreeable? How does the individual handle conflict? Are they aggressive, assertive or submissive? Do they adopt a fairly agreeable or hostile stance in relationship to others?
  7. Are they particularly sensitive to criticism or rejection? Do they fear abandonment? Do they have trouble being alone?
  8. Do they experience conflict between relationship motives of power and love or autonomy and dependency? When down, do they experience splits between feeling shameful (feel they are to blame) or hostility (feel others are to blame)?

D. The Defensive System. This refers to the general harmony between the systems, the filtering between self-conscious and subconscious processes, and processes like cognitive dissonance and psychodynamic defense mechanisms. Signal anxiety activates the defensive system. Common domains to consider include:

  1. Does the individual seem guarded, hesitant to disclose, resistant to elaborating on all or certain elements of their story?
  2. Do they get words or body language in response to certain questions?
  3. How do they cope when they feel stressed?
  4. Do they engage in rationalizations or suppression/repression or other similar processes?
  5. What do they try to avoid feeling or experiencing? Do they have any affect phobias? Core fears?
  6. Do they demonstrate good insight and are they able to reflect on what drives them? Can they laugh at their foibles or defense? Or does such conscious self-reflection activate anxiety and a closed off response?
  7. When does their attention shift? Do they systematically shift away from certain topics? When do they seem less clear, less focused? Are there times in which it is hard to follow their logic?

E. The Justification System. This refers to the self-conscious, language-based belief-value networks that individual uses to make meaning out of his world, and to consciously understand himself and others. In regards to assessing the justifying self, cognitive and narrative/existential therapies allow a lens to view aspects of this portion of the psyche. Thus, thinking about the individual’s justification narrative (the story they have about themselves in relationship to the world) and automatic thoughts/inferences/core beliefs are useful concepts to bring to bear in understanding this domain. More specific elements include:

  1. What is the general functioning of their verbal system (i.e., their verbal IQ)? Vocabulary usage, complexity of sentences, etc.
  2. To what extent is their identity coherent and complex? It is rigid, certain, simplistic, hard and foreclosed? Or is it multifaceted, open to criticism, textured? What is the level of ego development? Do they reflect on who they are and why? Are they able to give complex, textured answers to reflective questions or are they brief and underdeveloped?
  3. What is their driving purpose in life? Do they connect to a higher power or follow particular religious teachings? Do they care about politics or have active views/philosophies regarding how the world works? Are they concerned with their own local reality or do they reflect on where values come from, where the country (or world) should be headed?
  4. What is the degree of self-regulation and self-control? What is their level of conscientiousness? What about their need for control? Do they exhibit a lot of self-discipline or are there problems with impulsivity?
  5. What is their self-esteem? Do they engage in a lot of self-criticism and negative self-talk? Is there an internalized parental voice constantly judging them? Do they have core beliefs about self that are negative? Or do they see themselves as a positive protagonist in the story of their lives?
  6. What is their general level of self-efficacy? Do they perceive themselves as resilient and capable of handling things or weak, an emotional wreck? Do they have high levels of agency? Adaptive levels of an internal locus of control?
  7. Are they known to others or do they frequently filter their private thoughts from their public thoughts?
  8. What is the individual’s overall evaluation of their life? Their reflective degree of life satisfaction?

Now where did this map come from? It came from applying the lens of a unified model of psychology to the key insights of the major perspectives in psychotherapy! And that is the point we want to make here. The major perspectives align with each of the domains of characteristic adaptation! Here is the alignment.

When approached from this angle, modern personality theory meshes well with the various approaches to psychotherapy. And it is clear that the various approaches in psychotherapy have emphasized different domains of character adaptation.

Our perspective is that the time has passed for the single schools with their specific interventions targeting only a part of the system. Instead, what will be revolutionary about the fifth wave is that it will lay out a truly comprehensive vision of psychotherapy that connects to the science of human psychology in a manner that allows us to appreciate our humanity grounded in the knowledge of science.