Literature ReviewPrior to beginning work on this assignment, read the Ryder, Ban, & Chentsova-Dutton (2011) “Towards a Cultural-Clinical Psychology,” American Psychological Association (2014) “G

BRIEF REPORT What’s an Integrationist?

A Study of Self-Identified Integrative and (Occasionally) Eclectic Psychologists John C. Norcross, Christie P. Karpiak, and Kelly M. Lister University of Scranton We examined the views and practices of self-identified eclectic and inte- grative psychologists, particularly in the context of historical changes since 1977 and 1988. Results from 187 eclectic clinical psychologists indi- cated that 50% previously adhered to another theoretical orientation, the majority preferred the termintegrativetoeclectic, and 85% conceptual- ized eclecticism /integration as the endorsement of a broader orientation.

The most common paths toward integration were theoretical integration, common factors, and assimilative integration, as opposed to technical eclecticism. The most frequent theoretical contributor to integrative prac- tice was cognitive therapy. © 2005 Wiley Periodicals, Inc. J Clin Psychol 61: 1587–1594, 2005.

Keywords: psychotherapy integration; eclecticism; psychologists; psychotherapists; theoretical orientation Between one-quarter and one-third of contemporary American psychologists identify themselves as eclectic or integrative, making eclecticism the modal theoretical orienta- tion ( Norcross, 2005). Dozens of specific systems of eclectic/integrative psychotherapy have appeared (Lebow, 2003; Norcross & Goldfried, 2005), and literally hundreds of books proclaim themselves as integrative in their subtitles or dust jackets. Yet, our empir- ical knowledge of eclectic and integrative psychotherapists is meager indeed (Jensen, Bergin, & Greaves, 1990). The research on eclectic and integrative psychotherapists has lagged far behind clinical practice (Schottenbauer, Glass, & Arnkoff, 2005).

An earlier version of this article was presented at the 75th annual meeting of the Eastern Psychological Asso- ciation, Washington, DC.

The authors gratefully acknowledge the participation of the 187 psychologists, the technical assistance of Ms. Shannon O. Santoro, and the editorial contributions of Stanley B. Messer.

Correspondence concerning this article should be addressed to: John C. Norcross, Department of Psychology, University of Scranton, Scranton, PA 18510-4596; e-mail [email protected].

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 61(12), 1587–1594 (2005) © 2005 Wiley Periodicals, Inc.

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.20203 In 1977, Garfield and Kurtz published the first study on the views of 154 self- identified eclectic psychologists (achieving a 66% response rate to their survey). The eclectics were bound together by dissatisfaction with one orientation and concurrent selection from two or more theories, believing that no single theory could be used to treat all clients effectively. There was considerable variability among the theoretical orientations, with the synthesis of psychoanalytic theory and learning theory the most frequent at that time.

In 1988, Norcross and Prochaska revisited Garfield and Kurtz’s study on eclectic views. Of the 113 self-designated eclectic clinical psychologists (77% response rate), 58% previously adhered to a specific theoretical orientation, typically psychodynamic (44%) or behavioral (27%). The results demonstrated that the majority preferred the label integrativein describing their theoretical orientation. Although the integrative/eclectic orientation continued to be the modal orientation among American psychotherapists, the frequency of theoretical contributions was changing. Whereas the most frequent combi- nation in the 1970s was psychoanalytic and behavioral, in the 1980s the most common combinations were cognitive and behavioral and then humanistic and cognitive. The authors observed that “integration by design is steadily replacing eclecticism by default” ( p. 173).

The present study was designed to update the earlier studies in order to investigate the views and practices of self-identified eclectic and integrative psychologists in the United States.

Method Participants were recruited and eclectic/integrative psychologists were identified by the same procedures used in the previous studies. The initial subject pool consisted of 1,500 randomly selected members of Division 12 (Clinical Psychology) of the American Psy- chological Association (APA), the same organization employed in the previous two stud- ies. In August 2003, we mailed the questionnaire, a cover letter, and a prepaid return envelope to 1,500 randomly selected members and fellows of APA Division 12 living in the United States. Six weeks later, we sent a follow-up letter and another questionnaire to 500 randomly selected nonrespondents. The U.S. postal service returned 7 questionnaires as undeliverable; of the remaining 1,493 questionnaires, 694 were returned for a total response rate of 46.5%. However, 40 of the questionnaires were not usable for various reasons, primarily because of retirement (n 36). The final sample, therefore, consisted of 654 clinical psychologists affiliated with Division 12, a usable response rate of 43.8%.

( Results pertaining to the demographic characteristics, educational experiences, theoret- ical orientations, and professional activities of all 654 clinical psychologists are reported in Norcross, Karpiak, & Santoro, 2005).

Embedded in the questionnaire was a section for those psychologists selecting eclectic/ integrative as their primary theoretical orientation. Fully 29% of the respondents did so; those 187 psychologists composed the sample for the present study.

The section contained six items: three items from Garfield and Kurtz’s (1977) orig- inal study, two items from Norcross and Prochaska’s (1988) study, and one new item. The first item asked respondents whether they had previously adhered to a specific theoretical orientation and, if so, asked them to indicate that orientation. The second item asked which term,eclecticorintegrative, was preferred. The third item asked whether respon- dents considered eclecticism/integration the absence of a theoretical orientation or the endorsement of a broader one. The new item asked psychologists to choose the one type of integration/eclecticism that best represented their practice: theoretical integration 1588 Journal of Clinical Psychology, December 2005 (synthesis of multiple theories), technical eclecticism (use of various techniques without regard to the theory that spawned them), common factors (synthesis of robust common- alities across the psychotherapies), or assimilative integration (selective incorporation of techniques and concepts from different orientations into a single, preferred theory). Next, we asked for a frequency rating of theoretical orientations (behavioral, cognitive, human- istic, interpersonal, psychoanalytic, systems, and other) in their eclectic/integrative prac- tices (on a 5-point, Likert-type scale in which 1 nouse,3 occasionaluse, and 5 repeateduse). The final question asked respondents to define or explain their eclectic view and provided blank space in which to respond.

Results Previous Allegiances One-half of the 187 self-identified eclectic/integrative psychologists adhered to a spe- cific theoretical orientation before they became eclectics or integrationists. This 50% is similar to the findings of the two earlier studies, in which 58% ( Norcross & Prochaska, 1988) and 49% (Garfield & Kurtz, 1977) had previously adhered to a single orientation.

The previous theoretical orientations were varied but principally psychodynamic/ psychoanalytic (46% of respondents), cognitive (20%), and behavioral (11%). Other pre- vious orientations were systems/family systems (8%), person-centered (6%), humanistic/ existential (4%), and others (5%). Thus, as with the earlier findings, the largest shift continues to occur from the psychodynamic and psychoanalytic persuasions and the next largest from the cognitive and behavioral traditions.

Integrative Preferences The majority of psychologists preferred the termintegrativetoeclectic. Specifically, 23% strongly preferredintegrative, 36% preferredintegrative, 21% expressed no preference, 15% preferredeclectic, and the remaining 5% strongly preferredeclectic. This semantic preference is generally consistent with the findings in Norcross and Prochaska’s (1988) investigation except that the preference forintegrativehas grown from 40% to 59%.

Indeed, in the present study, only 20% preferred the labeleclectic.

When asked whether they considered eclecticism/integration the absence of a theo- retical orientation or the endorsement of a broader one in its own right (or both), the vast majority of psychologists (85%) conceptualized it as the endorsement of a broader ori- entation. Only 3% indicated it represented an absence of an orientation and 12% responded that it represented both. The 85% constitutes a rise from the 66% found in the 1988 study; the discrepancy seems to be in the reduced percentage of psychologists answering both— from 27% in 1988 to 12% in 2003. For better or for worse, integration/eclecticism is now largely seen as a distinct system of psychotherapy, as opposed to the absence of a tradi- tional pure-form system.

Integrative Paths In a new item, psychologists selected one of the four paths toward eclecticism/ integration they preferred. Theoretical integration, common factors, and assimilative integration were preferred by 27.5%, 27.5%, and 26% of the sample, respectively. These three were embraced more frequently than technical eclecticism, at 19%. The low preference for technical eclecticism corresponds with the low preference for the label ofeclectic. What’s an Integrationist? 1589 Theory Combinations Psychologists rated the frequency of their use of six major theories in eclectic/integrative practice. As a first step, to permit historical comparisons with the earlier studies, we examined the individual ratings to determine the most widely used combinations of two theories. We were able to do so for 115 of the 178 psychologists who completed these ratings. We could not reliably decipher the remaining psychologists’ intent regarding their two most prominent theories.

The most frequent combinations of theoretical orientations constituting eclectic/ integrative practice are summarized in Table 1. All 15 possible combinations of the six theories presented were endorsed by at least one self-identified eclectic/integrationist.

Cognitive therapy predominated; in combination with another therapy system, it occu- pies the first 5 of the 15 combinations and accounts for 42% of the combinations. Put differently, cognitive therapy was the most frequently and most heavily used contributor to an eclectic or integrative practice.

Over time, the behavioral and psychoanalytic combination as well as the behavioral and humanistic combination have slipped considerably. They have gradually dropped from the 1st and 3rd most frequently combined theories in 1977 to the 9th and 4th in 1988 to 13th and 14th in 2003. The behavioral and psychoanalytic hybrid—accounting for 25% of the combinations in the 1970s and only 1% in the 2000s—has been firmly replaced by a cognitive hybrid.

As a second step, we entered the ratings of the 178 psychologists into a K-means cluster analysis. Inspection of solutions ranging from 6 to 12 clusters led us to select the nine-cluster solution, on the basis of the clinical relevance of the resulting clusters and adequate distances between cluster centers. In this nine-cluster solution (and in all the Table 1 Most Frequent Combinations of Theoretical Orientations Garfield & Kurtz (1977) (N 145) a Norcross & Prochaska (1988) (N 113)Present Study (2003) (N 115) Combination Percentage Rank Percentage Rank Percentage Rank Behavioral and cognitive 5 4 ( Tie) 12 1 16 1 Cognitive and humanistic NR 11 2 7 2 ( Tie) Cognitive and psychoanalytic NR 10 3 7 2 ( Tie) Cognitive and interpersonal NR 4 12 6 4 ( Tie) Cognitive and systems NR 4 14 6 4 ( Tie) Humanistic and interpersonal 3 6 8 4 ( Tie) 5 6 Interpersonal and systems NR 5 7 ( Tie) 4 7 Psychoanalytic and systems NR 4 9 ( Tie) 3 8 ( Tie) Interpersonal and psychoanalytic NR 4 15 3 8 ( Tie) Behavioral and interpersonal NR 413 210 Behavioral and systems NR 5 7 ( Tie) 2 11 ( Tie) Humanistic and psychoanalytic NR 4 12 2 11 ( Tie) Behavioral and humanistic 11 3 8 4 ( Tie) 1 13 ( Tie) Behavioral and psychoanalytic 25 1 4 9 ( Tie) 1 14 ( Tie) Humanistic and systems NR 6 6 1 14 ( Tie) aPercentages and ranks were not reported for all combinations in Garfield & Kurtz, 1977. NR not reported.

1590 Journal of Clinical Psychology, December 2005 solutions we inspected), cognitive therapy was the defining theory for the vast majority of clusters.

Table 2 shows the final cluster centers for the nine-cluster solution. The first cluster representedbroad cognitive-behavioral therapy, as the 19 psychologists endorsed pri- marily cognitive and behavioral orientations (ratings of 4) and moderate to small use of interpersonal, humanistic, psychodynamic, and systems orientations (ratings of 3 and 2).

Cluster 2,interpersonal-humanistic, was marked by full endorsement of humanistic and interpersonal orientations (ratings of 5 on each), as well as strong endorsement of psy- chodynamic and cognitive orientations (ratings of 4). We labeled cluster 3 theubercog- nitivegroup because these 21 eclectics/integrationists rated the use of cognitive therapy (5) over and above all other therapies. This cluster stands in small contrast to thetradi- tional cognitive-behavioralcluster 4 because both cognitive and behavioral therapies were rated equally and strongly in that cluster.

Psychologists in the next two clusters indicated that they used all of the listed ther- apies frequently and, in addition, distinctively indicated routine use of an “other” therapy.

Cluster 5 might be termedmoderate eclecticism(all ratings of 3 and 4) and cluster 6 extreme eclecticism(all ratings of 4 and 5).

Cluster 7, consisting of only six psychologists, contained theuncommitted or nay- sayersin the sample. They accorded all of the listed therapies as no to low use in practice.

Themultimodalgroup in cluster 8 privileged cognitive and behavioral therapies (ratings of 5) above the others but gave the other brand-name therapies a robust rating of 4. This pattern reminded of us Lazarus’s (1997) multimodal therapy, a form of tech- nical eclecticism that draws from all therapies but most heavily from the cognitive- behavioral traditions. Finally, the 35 psychologists in cluster 9 were characterized by a cognitive-analyticorientation, as indicated by the two highest ratings in cognitive and psychodynamic. It is clear from these results that psychotherapists who describe them- selves as integrative/eclectic are a very heterogeneous group.

Definition and Explanation In the original 1977 study by Garfield and Kurtz, clinical psychologists were asked to define and explain their eclectic view. The question was repeated in the 1988 study and Table 2 Eclectic/Integrationists’ Ratings of Theoretical Orientations by Clusters Cluster Orientation1 N 192 233 214 145 126 167 68 329 35 Behavioral 434534253 Cognitive 445545354 Humanistic 254134143 Interpersonal 354444243 Psychodynamic 242334244 Systems/Family 233434143 Other 111144111 Note.Data are mean cluster loadings from participant frequency-of-use ratings for six orientations plus “other.” Each orienta- tion was rated on a 5-point, Likert-type scale (1 No Use, 3 Occasional Use, and 5 Repeated Use). What’s an Integrationist? 1591 again in this one. Two trained undergraduates independently coded all of the responses according to Garfield and Kurtz’s original five-part scheme (including an “other” cat- egory). They agreed on their ratings in 153 of the 187 responses, a reliability coefficient of .82, and subsequently reviewed and agreed on the responses in initial disagreement.

Table 3 summarizes the major categories into which the ratings fell. As seen there, the explanation of using whatever theory or methods seems best for the client continues as the predominant rationale, with 34% of responses. One psychologist wrote, “ People are different and have different diagnoses and needs as well as viewing therapy differ- ently. Therefore, I suit the therapy to the patient.” Another indicated, “I will use tech- niques from various orientations to match patient problems. Some patients only need brief cognitive interventions, whereas some seem more appropriate for insight-oriented treatment (dynamic).” Integration as the amalgamation of theories or aspects of theories was next, with 25% of responses. This explanation appears to be steadily rising over the years: from 14% of responses in 1977 to 21% in 1988 and now to 25%. Two illustrative responses were “ Prob- lem oriented/cognitive techniques to increase logical thinking style with some supportive techniques at first” and “I tend to view behavior dynamically in terms of underlying emo- tions and motivations, but work primarily with cognitions and behaviors using cognitive- behavioral therapy (CBT ) techniques.” A small number of responses essentially communicated that no single theory or ther- apy is adequate, frequently adding the corollary that some therapies are better for some purposes. For example, “No single approach seems to work with all patients; [it is] nec- essary to have training and experiences with a wider variety of useful techniques.” Discussion The integrative/eclectic orientation consistently remains the most popular orientation among clinical and counseling psychologists in the United States (Bechtoldt, Norcross, Wyckoff, Pokrywa, & Campbell, 2001), but its constituent parts and even its label con- tinue to evolve. Since the earlier studies conducted on the APA Division 12 membership, three principal changes are evident: a clear preference for the term and process ofinte- grationas opposed toeclecticism, the definite emergence of assimilative integration as another path to integration, and the encroaching dominance of cognitive therapy in inte- grative practice.

Table 3 Response Classification of “Define and Explain Your Eclectic View” CategoryGarfield & Kurtz (1977) (N 154) PercentageNorcross & Prochaska (1988) (N 94) PercentagePresent Study (2003) (N 187) Percentage Use whatever theory or method seems best for client.

Select procedures according to client and/or problem. 47 34 34 Basically use and combine two or three theories in therapy. 13 18 18 Amalgamation of theories or aspects of theories. 14 21 25 No theory is adequate—some are better for some purposes. 6 13 4 Other 20 14 18 1592 Journal of Clinical Psychology, December 2005 In both word and (self-reported) deed, practitioners are routinely favoring integra- tion over eclecticism. Fully 59% preferred the termintegrative(compared to 20% who favoredeclecticism), and 54% embraced theoretical integration or assimilative integra- tion (compared to the 19% who embraced technical eclecticism).

Our results numerically confirm the prominence of assimilation as one path toward integration. Assimilative integration entails a firm grounding in one system of psycho- therapy, but with a willingness to incorporate (assimilate) practices and views from other systems selectively ( Messer, 1992). In doing so, assimilative integration combines the advantages of a single, coherent theoretical system with the flexibility of a broader range of technical interventions from multiple systems. A behavior therapist, for example, might use the Gestalt two-chair dialogue in an otherwise behavioral course of treatment (for fuller explication and case examples, see Messer, 2001).

To its proponents, assimilative integration is a realistic way station to a sophisticated integration; to its detractors, it is more of a waste station of people unwilling to commit themselves to an evidence-based eclecticism. Both camps agree that assimilation is a tentative step toward full integration: Most therapists have been and continue to be trained in a single approach, and most therapists gradually incorporate parts and methods of other approaches once they discover the limitations of their original approach (Goldfried, 2001; Wachtel, 1997).

Our results also underscore the dominance of cognitive and cognitive-behavioral therapies in the integrative marketplace. Cognitive therapy rivaled integration/eclecticism as the modal theoretical orientation, dominated the frequent theoretical combinations, and defined most of the practice clusters. This finding is not surprising because cognitive- behavioral therapy has dominated the training orientations of clinical psychology for the past 15 years ( Nevid, Lavi, & Primavera, 1986; Robins, Gosling, & Craik, 1999). In fact, a 2004 study of APA-accredited clinical psychology programs found that the cognitive- behavioral orientation accounted for one-half of the theoretical orientations of the faculty members (33% of faculty in Psy.D. programs, 49% in practice-oriented Ph.D. programs, and 64% in research-oriented Ph.D. programs; Norcross, Castle, Sayette, & Mayne, 2004).

Of course, the current results are based entirely on American psychologists and even further on Division 12 psychologists. The ascendance of cognitive therapies and the decline of psychodynamic and humanistic approaches may be specific to Division 12 psychologists. Studies conducted on other APA divisions and other mental health disci- plines may well produce different results. Although our methods of recruiting and iden- tifying eclectic/integrative psychologists were identical to those used in the previous studies, it is important to note that the Division 12 membership has obviously evolved over the years and now includes, for example, a larger proportion of women and cogni- tive therapists than in previous years ( Norcross, Karpiak, & Santoro, 2005).

References Bechtoldt, H., Norcross, J.C., Wyckoff, L.A., Pokrywa, M.L., & Campbell, L.F. (2001). Theoretical orientations and employment settings of clinical and counseling psychologists: A comparative study. Clinical Psychologist, 54 (1), 3– 6.

Garfield, S.L., & Kurtz, R. (1977). A study of eclectic views. Journal of Consulting and Clinical Psychology, 45, 78–83.

Goldfried, M.R. ( Ed.). (2001). How therapists change: Personal and professional reflections. Wash- ington, DC: American Psychological Association.

Jensen, J.P., Bergin, A.E., & Greaves, D.W. (1990). The meaning of eclecticism: New survey and analysis of components. Professional Psychology: Research and Practice, 21, 124 –130. What’s an Integrationist? 1593 Lazarus, A.A. (1997). Brief but comprehensive psychotherapy: The multimodal way. New York:

Springer.

Lebow, J. ( Ed.). (2003). Comprehensive handbook of psychotherapy: Vol. 4. Integrative/eclectic.

New York: Wiley.

Messer, S.B. (1992). A critical examination of belief structures in integrative and eclectic psycho- therapy. In J.C. Norcross & M.R. Goldfried ( Eds.), Handbook of psychotherapy integration ( pp. 130 –168). New York: Basic Books.

Messer, S.B. (2001). Introduction to the special issue on assimilative integration. Journal of Psy- chotherapy Integration, 11, 1– 4.

Nevid, J.S., Lavi, B., & Primavera, L.H. (1986). Cluster analysis of training orientations in clinical psychology. Professional Psychology: Research and Practice, 17, 367–370.

Norcross, J.C. (2005). A primer on psychotherapy integration. In J.C. Norcross & M.R. Goldfried ( Eds.), Handbook of psychotherapy integration (2nd ed.). New York: Oxford University Press.

Norcross, J.C., Castle, P.H., Sayette, M.A., & Mayne, T.J. (2004). The PsyD: Heterogeneity in practitioner training. Professional Psychology: Research and Practice, 35 (4), 412– 419.

Norcross, J.C., & Goldfried, M.R. ( Eds.). (2005). Handbook of psychotherapy integration (2nd ed.). New York: Oxford University Press.

Norcross, J.C., Karpiak, C.P., & Santoro, S.O. (2005). Clinical psychologists across the years: The Division of Clinical Psychology from 1960 to 2003. Journal of Clinical Psychology, 61(9).

Norcross, J.C., & Prochaska, J.O. (1988). A study of eclectic (and integrative) views revisited.

Professional Psychology: Research and Practice, 19, 170 –174.

Robins, R.W., Gosling, S.D., & Craik, K.H. (1999). An empirical analysis of trends in psychology.

American Psychologist, 54, 117–128.

Schottenbauer, M.A., Glass, C.R., & Arnkoff, D.B. (2005). Outcome research on psychotherapy integration. In J.C. Norcross & M.R. Goldfried ( Eds.), Handbook of psychotherapy integration (2nd ed.). New York: Oxford University Press.

Wachtel, P.L. (1997). Psychoanalysis, behavior therapy and the relational world. Washington, DC:

American Psychological Association. 1594 Journal of Clinical Psychology, December 2005