Integrative Psychotherapy is unique amongst psychotherapy modalities in that it has two dimensions of identity, which correspond to two different aspects or conceptual levels of psychotherapy as a whole. Thus it offers the psychotherapy field a foretaste of the challenge presented to that field, by the task of creating a unified theory of the psychotherapies. The two dimensions are as follows:
1. Generic and Methodological form of identity: Assimilating Other Approaches
The Creative Dilemma of Integrative Psychotherapy
At the logical dimension of a meta-level analysis, firstly, it has a generic and methodological identity in virtue of its power to assimilate elements from modality based approaches across the board. The argument here is a conceptual distinction between a way of constructing a sub-modality at the level of content, to which the second option will come, and a meta-conceptual point about the logic of integration, in so far as it is defined as borrowing from other modality approaches. It does this in such a way that any meaningful combination or synthesis of modality based approaches might count as Integrative, being differentiated in this way from some (but not all) of Multi-Modal and Eclectic approaches. The sole criterion, or necessity-based requirement, is an adequate ground for that synthesis to be meaningful, a genuine integration, and to have some retrospective criteria for that.
At this meta level, Integrative Psychotherapy is a kind of experimental methodology for the process of integration, and as such might be exposed to view to illuminate the psychotherapy process, the process of the formation not only of integrative, but of any modality, by way of this. This addresses what constitutes the unity of a psychotherapy. There are elements of integration within the specifics of all modalities today.
- At the level of content Integrative Psychotherapy has a modality type identity
At the level of content, then, Integrative Psychotherapy has a modality type identity, whatever form of integration is adopted. Such content based types of integration might include: common factors overlap; personality integration; unification by attitudes about the degree of client centredness or relational dialogue; and so on. Many approaches started out in this way and became modalities in their own right. This probably entails that, on the one hand, no content based modality is totally watertight, and definitely boundaried, and therefore all approaches are in some measure integrative at the level of content. On the other hand, at the meta-level, modality, while essential to the development of the field of psychotherapy, is not as such able to solve the problem of what constitutes the identity and theory foundation of the field as a whole. This leaves the field with an unsolved problem. But our immediate business in developing these competences is to give a detailed overview of a specific type of approach to integration.
Our EAIP Integrative approach is a version of No. 2, Modality Identity, an integration based in dialogical relationship; process; and associated developmental and aspirational dynamics.
DOMAIN 1: PROFESSIONAL, AUTONOMOUS & ACCOUNTABLE PRACTICE
For the European Integrative Psychotherapist (‚Integrative Psychotherapist’ hereafter) Professional Practice is implicitly an Ethical and Volitional Dimension, in the realm of Kant’s Practical Reason. As such it behoves the Integrative Psychotherapist to take creative account of the tension between Autonomy and Professional Accountability. Autonomy implies and invokes personal agency, the mark of the maturity, self-accountability, and self-authority, of the person who has gone through the developmental processes of life-growth and, secondarily, the self-discovering and creativity enhancing process of psychotherapeutic training and personal development. Professional Accountability, existing ethically within the realm of the Social Contract (Rousseau), is both a radical obligation, and something which does not simply equate to obedience to Legal, Social, and Political rules. The Integrative Psychotherapist works inherently with conflict out of which may emerge creative solution-finding, but not always. There are personal and existential limits to what the Integrative Psychotherapist may find possible to do by way of intervention or abstention from intervention but abdication from responsibility is not one of them.
At the level of knowledge, the Integrative Psychotherapist both seeks to be aware of and able to critique and access the fullest knowledge and wisdom aavailable to them within the knowledge base and oral and written traditions of the profession, drawing from all relevant modalities, and wider relevant knowledge reservoirs, taking account of the developmental-relational nature of the work of an Integrative Psychotherapist, and engaging in the daily process of self- and other-discovery which is the core research base, evidence, and qualitative foundation, of the profession.
At the level of practicalities and socialisation the Integrative Psychotherapist will cultivate a congruent and as far as possible authentic public self presentation and creation of appropriate environments for work, and seek necessary support from colleagues or authorities where appropriate.
An Integrative Psychotherapist is competent to:
1.1. Establish a Professional Practice
This is based both on personal rapport and working alliance, and social contractual considerations relating to the professional and legal context, money, appointments, time scale and so forth.
1.1.1. Behave professionally:
This is based on relationship and also upon personal and professional-public boundaries, which have a contractual-legal aspect
1.1.2. Build an independent practice, or become a member of a professional team:
This is based upon the criteria of good collaboration – such as Nolan’s seven principles of public life: selflessness, integrity, objectivity, accountability, openness, honesty and leadership. Again, there is a contractual-legal dimension.
1.1.3. Work according to accepted professional standards:
This is based upon use of the appropriate theoretical background and material, including wider social dimensions, legal requirements, and ethical criteria; the competent Integrative Psychotherapist will use their judgement as to the relevant weight to give to various aspects of this range of relevant factors and criteria.
1.1.4. Record information appropriately:
The Integrative Psychotherapist will record necessary information; supplementing this according to individual professional judgement with further content and process material and bearing in mind that any records may be subject to subpoena in a legal dispute situation.
1.1.5. Liaise with other professionals:
The Integrative Psychotherapist, where necessary, will be competent to liaise with other professionals relevant to their duty of care, with attention to differences in professional dialect and approach, recognition of the weight of power structures in the relevant institutions, and mindful of ethics, law, and norms of good non-violent language and dialogue processes, in all they do.
1.1.6. Recognise difficulties in others in the professional environment:
The Integrative Psychotherapist will be sensitive to the demands, complexities, and constraints, of the professional work, upon others in the total professional environment, and adjust accordingly with relevant skill, restraint, authority, and ingenuity.
1.1.7. Monitor, critically evaluate and review the caseload:
Caseload review is essential to the function and role of the Integrative Psychotherapist and attention to personal professional judgement in different ways per individual practitioner is essential to this.
1.1.8. Maintain their fitness-to-practice in a variety of ways:
As with the previous entry, this will be maintained in different ways by different practitioners but there is a necessary minimum for each one.
1.2. Provide an Appropriate Environment
This is a general requirement, specified in what follows:
1.2.1. Provide a safe working situation:
This is about physical but also psychological safety, including confidentiality, protection against both accidents and potential violence, hygiene and care of the environment, a due decorum but not excessive, an appropriately relaxed and non-invasive manner, and similar kinds of consideration.
1.2.2. Provide a psychotherapeutic environment:
This overlaps with the previous but will focus on different emphases depending on what individual kinds of approach are most congruent for a given practitioner, for example play elements, or concentration on verbal elements, body focused work, and similar.
1.2.3. Make clear arrangements:
Similar criteria apply to time arrangements and the relevant professional communication process as in the above – a balance between a professional frame, individuality and some informality.
1.3. Engage in Quality Assurance
This is about the whole range of service provision in the ways already outlined. It may have more or less of a formal element depending on practitioner and context.
1.3.1. Routinely evaluate practice:
Again this will vary from practitioner to practitioner in mode and method but is essential at all times however it is done.
1.3.2. Review practice:
And can lead to various kinds of review and critique of practice at different stages of the Integrative Psychotherapist’s development and career.
1.4. Maintain Continuing Professional Development
Professional Development is encompassed in a whole variety of modes according to practitioner, context and national criteria, and has been covered in various ways in what has been said already. On-going learning is essential for all Integrative Psychotherapists, to prevent stereotyping, rigidity, and standardized non-individual responses, but this may be accomplished in different ways by different practitioners.
It may involve workshops but not for all, for instance deep study and creative work may be another way for the experienced practitioner.
1.4.1. Reflect on self and professional work:
Modes of self-reflection and processing are at the heart of the Integrative Psychotherapist’s work.
1.4.2. Incorporate research knowledge findings:
This may involve many kinds of research modes, reading and reflection on up-to-date research and publications, and including on-going practice and use of supervision.
1.5. Maintain Personal Development
This might include such experiences as alternative supervision and personal therapy, etc.
DOMAIN 2: THE PSYCHOTHERAPEUTIC RELATIONSHIP
The working alliance is a therapeutic common factor that consistently predicts psychotherapy outcome across all major approaches to psychotherapy. As such, it has been identified as the flagship integrative variable (Castonguay et al., 2006). A competent integrative psychotherapist is aware that developing a positive working relationship is an important principle of change, as it may not only facilitate the implementation of techniques but could also, in and of itself, provide opportunities for transformational and corrective experiences. Competence in this domain includes not only facilitative factors (see Ackerman & Hilsenroth, 2003), but also the continuous assessment of the alliance and the detection of alliance ruptures and interpersonal conflict, as well as knowledge of the diverse methods of repairing such ruptures, which requires the ability to consider the alliance from multiple perspectives (e.g., facilitative conditions and/or collaborative empiricism).
2.1. Establish a Psychotherapeutic Relationship
In Developing the Therapeutic Relationship and working through Issues the Competent Integrative Psychotherapist is able to:
2.1.1. Continue to formulate the client’s issues in terms of integrative psychotherapy.
2.1.2. Facilitate an attuned, responsive, and appropriately boundaried therapeutic relationship
2.1.3. Sensitively assist the client to gain awareness of their cognitive, emotional, behavioral, social and spiritual functioning, validating their past and present experience.
2.1.4. Accept and honour the client’s defenses or adaptations as their way of making sense of, and coping with, their world.
2.1.5. Facilitate the client to identify connections between early developmental deficits and current relational patterns.
2.1.6. Support the client to understand their defenses and adaptations as creative adjustments or survival strategies which may no longer be helpful.
2.1.7. Tolerate, affirm and normalize seemingly overwhelming feelings in the client and in self, regulating affect as appropriate.
2.1.8. Work at a pace appropriate for the client and provide an emotionally reparative relationship over time.
2.1.9. Anticipate the possible direction of therapy.
2.1.10. Recognize and work within the transference and the emergence of unconscious processes in the therapy, using counter-transference responses sensitively in the service of the client.
2.1.11. Recognize and repair therapeutic ruptures.
2.1.12. Pay particular attention to the therapeutic relationship.
Be able to enter into, maintain and wind down a professional relationship with the client. Regard the relationship with the client as a cooperative relationship. Invite the client to adopt a positive and participatory attitude.
2.2. When Conducting Initial Assessments the Competent Integrative Psychotherapist is able to:
2.2.1. Establish professional rapport and communicate empathetically with the client.
2.2.2. Elicit relevant background information e.g. psychological history, medical, family, sociocultural/ transcultural factors. Establish the client’s aims/goals and how appropriate these are for psychotherapy. Assess the nature and scale of difficulties, how these relate to the client’s intra-psychic process, and how they are manifested in their inter-personal relationships.
2.2.3. Assess the client’s level of personal and social resources (e.g. resilience, coping skills, familial and social support).
2.2.4. Be aware of standard mental health classification systems where appropriate and recognize personal limits of competence. Assess the client’s potential to form a therapeutic alliance – their motivation, commitment, capacity for insight, psychological mindedness.
2.2.5. Provide information about the nature and process of integrative psychotherapy.
2.2.6. Provide a degree of hope while also ensuring a realistic view.
2.2.7. Recognize contra-indications for therapy and/or personal limits of competence towards referring the client on if appropriate.
2.2.8. Facilitate the client to develop deeper levels of self-compassion and meaning.
2.2.9. Regularly reflect on the appropriateness and effectiveness of strategies of intervention and on the therapeutic relationship, making effective use of supervision for support and challenge.
2.3. In Working through Endings the Competent Integrative Psychotherapist is able to:
2.3.1. Manage premature endings.
2.3.2. Allow sufficient time for planned endings, recognizing and challenging avoidance/denial of endings.
2.3.3. Acknowledge and work with loss and/or separation anxiety.
2.3.4. Review the work including the effectiveness of the therapy in relation to original goals and the client’s ongoing hopes/expectations. Review, reminisce, regret, rejoice.
2.3.5. Model the ability to let go and move on.
2.3.6. Recognize and respect the impact of previous endings/losses on the client’s experience, where possible offering the opportunity for a different experience.
2.3.7. Recognize and accept when the therapist suggests/ imposes an ending and this is not appropriate for the client, considering renegotiation if possible or onward referral if unable to continue.
2.3.8. Seek supervision if struggling to manage the boundaries around ending appropriately.
DOMAIN 3: EXPLORATION (ASSESSMENT, DIAGNOSIS & CONCEPTUALIZATION)
An Integrative Psychotherapist is competent to:
3.1. Make an Assessment
3.1.1. Make use of assessment tools: which may involve – developing a clear policy, and/or implementing agency procedure, for assessment; ensuring these are consistent with aims, ethos and objectives of organisation and theoretical perspective; developing and/or implementing pre-assessment tools; providing clear and transparent information to the potential patient/client about the psychotherapy and forms of assessment; where appropriate, using any pre-assessment information in the initial assessment interview to inform the process and outcome of the interview; may use assessment tools flexibly based on various theories and modalities in an integrative manner. Practitioners from various approaches within integrative psychotherapy may have ways of working which are different in respect of the degree of open-ended relationality or systematic method.
3.1.2. Conduct an assessment interview: which may involve – ensuring the assessment process is transparent and clearly understood; undertaking an assessment interview in a manner consistent with aims, ethos and objectives of organisation and integrative psychotherapy; discovering – as far as possible – the patient/client’s issues, problems, insights and difficulties; discovering and recording any significant historical events, or previous history of psychological problems, or significant periods of stress; asking about previous experience of psychotherapeutic help; keeping a detailed record of the assessment; conduct as assessment that involves cognitive, emotional, psychodynamic, humanistic and systemic aspects. The practitioner will use, where appropriate, their own counter-transference as an assessment process.
3.1.3. Conduct a risk assessment: which may involve – being familiar with any agency/service risk assessment procedures and making a critical evaluated use of any tools or guidelines, including ethical ones; recognising language used by the patient/client that might imply harm to self or others; asking direct questions about any intention to harm self or others; facilitating the patient/client’s ability to talk about specific suicide plans and quantifying the likelihood of these being implemented; discussing and assessing the patient/client’s general support system; involving the patient/client in the process using a straightforward, empowering and sensitive approach; etc.
3.2. Formulate a Diagnosis * (Note: The word ‘diagnosis’ here is used more in a general sense, rather than in a precise medical or psychiatric sense.)
3.2.1. Recognise and critically evaluate any possible mental health / illness issues: which may involve – remaining alert to possible indications of mental health needs, or of mental illness, or of disorders; assessing or diagnosing whether the patient/client has any social, relational, somatic and/or emotional problems related to mental health / psychic illness and disorders; using previous awareness, training and experience in psychopathology; involving the patient/client in the mental health assessment process; ensuring that any assessment or diagnosis conforms to any organisational policies and procedures, is in accordance with aims, ethos and objectives of one’s integrative / methodological perspective, and is in accordance with any national medical/psychiatric guidelines; recognising personal limits of competence.
3.2.2. Recognise and evaluate any possible psychological difficulty, which is not categorised as a mental health /illness issue: assess the nature and scale of difficulties, how these relate to the client’s intra-psychic process, and how they are manifested in their inter-personal relationships; assess the client’s level of personal and social resources (e.g. ego strength, coping skills and social support); assess the client’s potential to form a therapeutic alliance – their motivation, commitment, capacity for insight, psychological mindedness; elicit relevant background information e.g. psychological history, medical, family, socio-cultural/ transcultural factors.
3.2.3. Recognize and evaluate the impact of various factors in the genesis and maintenance of the client’s difficulties, which involves an integrative conceptualization of the client’s difficulties: a cognitive conceptualization; identification of the impact of emotions; an understanding of the connections between the attachment system and aspects of client problems and difficulties; an understanding of systemic diagnostic factors; the understanding and management of the stages of change; a psychodynamic conceptualization; an understanding of spiritual factors.
3.2.4. Respond to client needs: which involves – establish professional rapport and communicate empathetically with the client; discussing possible outcomes or strategies with the patient/client, as far as is possible; recognising any need for advice, support, or for a second opinion, from supervisor, manager or mental health consultant; responding promptly to any indications of mental health needs in order to ensure that an appropriate intervention is made; critically assess and evaluate any immediate risk to the client, self or others that may result from worsening/declining mental health / psychic illness and disorders and taking appropriate action, if necessary; recognising indications of drug/alcohol/substance misuse (including prescribed or over-the-counter drugs) and taking appropriate action, if necessary; working in conjunction with other mental health specialists and in accordance with the aims, ethos and objectives of one’s integrative perspective and in accordance with any national medical/psychiatric guidelines; etc. Regulatory and self-regulatory aspects of the client’s experience should always part of the process of assessment. The integrative practitioner should draw where appropriate on their own (embodied and relational) counter-transference throughout the process of assessment.
3.3. Conceptualize and decide upon an approach
3.3.1. Make use of clinical experience, theoretical & methodological insights, and assessment tools: which may involve – developing a clear policy, and/or implementing agency procedure, for assessment; ensuring its relevance to the patient/client’s needs and to an ongoing professional psychotherapeutic relationship; conducting the assessment process in a manner suitable for the patient/client and consistent with the ethos of the integrative psychotherapy; integrating any pre-assessment information and identifying any relevant issues; provide information about the nature and process of integrative psychotherapy.
3.3.2. Conceptualize the patient/client’s needs: which may involve – identifying and critically evaluating potential problem areas, including (i) (positive or negative) situations clarified by, or as part of, the assessment process, (ii) the patient/client’s motivation, (iii) different individual needs, relating for example to culture, faith, ethnicity, language, sexuality, disability, age, gender related issues, etc., (iv) any areas of potential risks (suicide, self-harm, aggressive or violent behaviour to others), (v) possible negative transference, etc.; using critical appraisal skills and developing a critical understanding of the patient/client’s presenting problems; establish how appropriate the client’s aims and goals are for psychotherapy; ‘diagnosing’ if there might be any underlying or long-term issues that might require further (possibly specialist) assessment; evaluating and discussing whether integrative psychotherapy, or whether the particular service, might be suitable and beneficial for the patient/client, and if not, making constructive and informed suggestions for an appropriate referral; provide a degree of hope while also ensuring a realistic view.
3.3.3. Make decisions based on assessment: which may involve – making a concise and critical evaluated formulation of the patient/client’s presentation; critically analysing and interpreting all forms of information collected in the assessment process; using all available information (including patient/client’s presentation and responses in the assessment interview) to come to a conclusion about possible appropriate interventions; recognise contra-indications for psychotherapy and/or personal limits of competence; discussing with the patient/client the outcome of the assessment, ensuring language is appropriate and that the person understands; making an estimate of the amount, frequency and extent of psychotherapy and/or implementing any competent ‘care plan’, or contract, or referral within the service; being clear about other possibilities for the patient/client’s needs to be met; making an external referral, if appropriate, and explaining the reasons clearly; consulting with other colleagues/health professionals, especially if there are indications of potential risk; etc. As far as possible, the process of assessment needs to be conducted relationally and where appropriate with an I Thou stance.
3.3.4. Conclude the assessment: which may involve – in the event of mutually agreeing to proceed with psychotherapy, discussing and being open with the patient/client about their expectations, responsibilities, agreements, payments, etc.; where appropriate, providing an opportunity for the patient/client to review and feedback their experience of the assessment process; and recording the outcome of the assessment process; etc.
DOMAIN 4: ‘CONTRACTING’ (DEVELOPING GOALS, PLANS & STRATEGIES)
An Integrative Psychotherapist is competent to:
4.1. ‘Contract’ with a Patient/Client
4.1.1. Formulate the main issues: which will commonly involve the following criteria (see below), but, where also appropriate, on the basis of relationship and experience, between therapist and client, may be much more open-ended – critically reflecting on the assessment (and the sometimes contradictory information therein) and information from other sources; being able to integrate all these perspectives; articulating the patient/client’s core issues and the possible origins of these; and presenting (or reflecting back) these perspectives to the patient/client in a sufficiently appropriate and sensitive way that they can understand and accept; checking the accuracy of these formulations; and discussing the parameters behind these formulations; ensuring that this formulation is reasonably consistent with the integrative psychotherapy main ethos and theoretical understanding; etc.
4.1.2. Identify appropriate and achievable goals, plans & strategies: which involves – including prior history, the patient/client’s economic, social, emotional, intellectual and psychological capacities; identifying any potential contra-indications or any risk assessments or factors; discussing the length, frequency, cost, environment and external parameters (including the patient/client’s external relationships) around any planned course of interventions; discussing any confidentiality issues; and distinguishing what is reasonably achievable and what may not be so within the patient/client’s process; etc. (This is subject to the same considerations as 4.1.1.)
4.1.3. Discuss the patient/client’s motivation: which involves – understanding their desire and motivation for change and the factors that might have brought them to this point; recognising and evaluating the level of the patient/client’s awareness of themselves and others; acknowledging that there are (probably) several factors that might also hinder their capacity to engage fully in the psychotherapeutic process; recognising their ability to recognise and understand their level of psychological functioning; and their ability to take responsibility for their own individual process; etc. (This is subject to the same considerations as 4.1.1.)
4.1.4. Decide upon the amount or extent of the psychotherapy: which involves – having made a critical assessment about the nature of the patient/client’s core issue; having clearly explained any limits to the provision of sessions (by an agency or health insurance, etc., if relevant); having explained the process of regular review at various stages, if a more open-ended ‘contract’ seems appropriate; making an informed and mutually agreeable decision about whether integrative psychotherapy is appropriate, or the expected number of sessions; etc.
4.1.5. Make a ‘contract’: which involves – taking into account the patient/client’s circumstances; negotiating mutually agreeable terms and conditions with the patient/client; identifying cancellation or ‘no show’ policies, holiday & illness policies, fees and cost implications of the course of psychotherapy, the cancellation of any sessions, frequency of sessions, and possibly even strategies or referral possibilities if the ‘contract’ fails; etc. (This is subject to the same considerations as 4.1.1.)
4.1.6. Moderate the ‘contract’: which involves – critically evaluating and revising the ‘contract’ and re-assessing the goals at regular stated intervals; listening to the patient/client’s feelings and experiences; checking with supervisors (where appropriate); taking into account changing circumstances in the patient/client’s circumstances and in the psychotherapist’s practice; etc. (This is subject to the same considerations as 4.1.1.)
4.1.7. Give opportunities for referral on: which involves – checking with the patient/client that they are reasonably happy with you as their psychotherapist; being clear about the likelihood of the patient/client’s needs being successfully met; being open about offering them other choices and explaining these choices; facilitating any referral on to another psychotherapist or other mental health professional; discussing other alternatives; etc.
4.2. Plan the Psychotherapy
4.2.1. There is a spectrum of ways of working within integrative psychotherapy, some of which are at the quantitative end of the spectrum of gathering evidence, but some of which draw upon evidence based on experience, imagination, intuition, counter-transference and other such criteria. In the light of this, as far as possible make use of evidence of effective practice: which involves – critically evaluating appropriate and effective treatments for the particular issues facing one’s patient/client; providing information to the patient/client about recommended strategies; ensuring that one’s particular methodology has a sufficient evidence-base for the patient/client’s particular issue; etc.
4.2.2. Draw on psychotherapeutic theory: which involves – critically reflecting on and evaluating the theoretical perspectives of integrative psychotherapy that relate and may be helpful to the patient/client’s general situation, whilst also being aware of other theoretical perspectives; utilising theoretical perspectives that relate to the patient/client’s particular issues; explaining all these to the patient/client in easily understandable terms; outlining the implications of these as these pertain towards developing a strategy for the psychotherapy; knowledge of theory of at least two major psychotherapeutic orientations; a meta-perspective on theory, etc.
4.2.3. Depending upon the client’s perceived state of readiness, decide on the psychotherapeutic approach or strategy: which involves – discussing the various possibilities with the patient/client; explaining the pros and cons of the various strategies; using clinical experience and research to suggest possible strategies with reasonably successful outcomes; deciding mutually on what seems the most appropriate approach or strategy for the patient/client and their particular issues; building-in, or encouraging, an on-going self-reflective component, from both sides, that monitors and develops the strategy; etc.
4.2.4. Bearing in mind, that our appeal to implicit criteria in our work as integrative psychotherapists may be deeply intuitive, spontaneous and may be not fully defined, and therefore taking what follows as something which may be implicit, as well as explicit, that an integrative psychotherapist may moderate the plan or strategy: which involves – critically reflecting on and evaluating the experience of being a key component in the psychotherapeutic process itself to influence those aspects of theory and practice that become more relevant at any one moment; utilising the self-reflective aspects of clinical experience, professional practice, own therapy and supervision to guide and moderate one’s ‘affect’ and especially one’s choice of interventions as a psychotherapist; a continuous self-reflective practice; being sensitive and flexible to the patient/client’s current situation and emotional state, and allowing this to influence one’s choice in the moment, without necessarily deviating from the overall plan; etc.
DOMAIN 5: VARIOUS TECHNIQUES & INTERVENTIONS
An Integrative Psychotherapist is competent to:
5.1. Utilize Various Techniques & Interventions
5.1.1. Identify which techniques or interventions are appropriate: which involves – utilizing the previously performed assessment of the patient/client’s problems or difficulties and deciding which of the techniques or interventions may be appropriate for that person at that time; being aware of any contra-indications for those techniques or interventions.
5.1.2. Identify which modes of interaction are appropriate: which involves – being flexible in one’s approach; being able to modify or adapt one’s approach; sometimes being supporting and reassuring, sometimes being more directive or educational, and sometimes even confronting the patient/client, all as and when appropriate; finding a healthy balance between professional intervention and the patient/client’s own self-empowerment – a balance that will constantly change with time and circumstances; being aware of the differences between the traditional ‘medical model’ of a patient requiring treatment and the more ‘humanistic model’ of client choosing to utilise your professional services; etc.
5.1.3. Monitor and manage the process of change: which involves – being aware of the patient/client’s development and process, and of their different needs at different times; acknowledging changes that have already happened, and anticipating possible future changes; being flexible with strategies and interventions, as appropriate in a changing process and environment; working consistently with guidelines, standards, ethics, and sensitivities.
5.1.4. Manage any difficulties: which involves – working clearly within the framework of the psychotherapeutic alliance; identifying and analysing any difficulties, as they arise; managing any interventions that may cause confusion, embarrassment, anxiety or offense; managing situations where the patient/client feels distress or discomfort at values, beliefs or behaviours in others (including the psychotherapist); being flexible with interventions, phrasing and timing (brief, medium or long-term psychotherapy and with different frequency of sessions, where needed); being aware of other possible techniques and interventions, and exploring the possibility of utilising these.
5.1.5. Use research-based techniques and interventions: which involves – being aware of up-to-date developments in psychotherapy, new methodologies and approaches, and research studies on the effectiveness and efficacy of these; utilising only those techniques and interventions that seem appropriate to this patient/client and their situation; ensuring that these are only using in a proper and professional manner, from a sound basis of training, supervision and experience; etc.
5.1.6. Ensure proper training & supervision in these: which involves – where appropriate, engaging in additional training from proper training courses and getting supervision from appropriately qualified supervisors in these new and/or different techniques and interventions, so that they can be applied professionally and safely; etc.
5.2. Manage the Emotional Content of the Sessions
5.2.1. Facilitate the Processing of Emotions: which involves – acknowledging the patient/client’s emotions, at many different levels; assisting them to overcome inhibitions and resistances in expressing feelings; assisting the patient/client to experience and explore emotions in a way that facilitates their process.
5.2.2. Maintain a Psychotherapeutic ‘Presence’: which involves – being ‘present’ for the patient/client in whatever emotional state that they are in at any one moment; having a reasonable degree of one’s own sensory and bodily receptivity.
5.2.3. Handle Extreme Emotions: which involves – being able to make a risk assessment; having an awareness what to do if a patient/client becomes hyper-manic, panicky, violent or suicidal; getting appropriate training if working in situations where patients/clients experience extreme emotions regularly; etc.
DOMAIN 6: MANAGEMENT OF CHANGE, CRISIS & TRAUMA WORK
Integrative Psychotherapy Competencies for Managing Change, Crisis, and Trauma:
6.1. Working with Individuals in Crisis within Integrative Psychotherapy
Develop awareness of crisis intervention: As an integrative psychotherapist, it is essential to have a comprehensive understanding of the principles and role of brief psychotherapy, crisis intervention, and prevention within the context of integrative psychotherapy.
6.2. Working with Individuals Affected by Trauma
6.2.1. Develop awareness of trauma work: This involves being knowledgeable about potential causes and effects of trauma, and symptoms associated with trauma, including such issues as post-traumatic stress disorder, inter-generational and trans-generational trauma. Understanding the parameters necessary for working with individuals experiencing traumatic conditions and being aware of available referral options for patients/clients with trauma are essential components.
6.2.2. Engage with individuals affected by trauma: This entails the therapist’s awareness of their own competencies and limitations when working with individuals who have experienced trauma. If necessary, the therapist should refer patients/clients with trauma to additional specialized trauma services. Undertaking specialized training, if required, to enhance competence in working with individuals affected by trauma is also encouraged.
6.2.3. Cultivate awareness of challenging moments: This entails recognizing difficult moments during the course of the patient/client’s integrative psychotherapy, such as anniversaries or specific triggers of emotional distress, and many unexpected sources which trigger traumatic reactions.
6.3. Trauma-Informed Care and Self-Care
6.3.1. Implementing trauma-informed practices: Integrative psychotherapists have a deep understanding of trauma and its impact on individuals. They incorporate trauma-informed approaches into their therapeutic interventions, creating a safe and supportive environment that promotes healing and resilience. They recognize the importance of using trauma-sensitive language, pacing the therapy appropriately, and fostering a sense of empowerment and choice for clients affected by trauma. Where possible and appropriate, specific training in trauma-informed practice and methodologies is recommended. Integrative psychotherapists in this process also take care not to over-interpret all presentations as trauma, and to be aware of the different ways trauma may present.
6.3.2. Prioritize self-care: Integrative psychotherapists understand the importance of maintaining their own well-being to provide effective trauma-focused care. They engage in regular self-care practices, seek supervision and support, and set boundaries to prevent compassion fatigue and burnout.
DOMAIN 7: COMPLETION & EVALUATION
An Integrative Psychotherapist is competent to:
7.1. Work towards an appropriate outcome of the psychotherapy
7.1.1. Prepare for ending of the psychotherapy: which involves discussing (at appropriate times during the course of the psychotherapy) the possibility and eventual inevitability of ending; regularly reviewing the process of the psychotherapy, in relation to the client’s aims and goals at the outset and in relation to any subsequent changes in aims and goals; paying attention to the development and significance of the therapeutic relationship and helping the client identify and acknowledge achievements and/or disappointments. This also involves helping the patient/client to identify when they feel ready to end the psychotherapy and assessing their readiness to do so. An Integrative psychotherapist does this within the framework of their integrative model, paying attention to the level of integration the client has felt able to achieve, intra- psychically, interpersonally, emotionally, physically and where appropriate spiritually.
7.1.2. Explore feelings about endings: which involves – looking at feelings, anxieties and unconscious fantasies about ‘endings’, ‘loss’, ‘separation’ or ‘abandonment’; considering these in relation to the clients history and experience and how these may impact the client in the here and now of the therapeutic relationship. In doing so an Integrative psychotherapist supports the client to try and avoid any unconscious or unwanted repetition or any unhelpful premature ending. An Integrative psychotherapist supports the client to explore the processes of ‘integration’ including ‘individuation’, ‘independence’, ‘autonomy’, ‘ability to self-regulate’; etc. An Integrative Psychotherapist is also attentive to their own experiences and feelings in relation to endings including their embodied response to the ending of this particular therapeutic relationship and process, in order to best support the client’s interests and needs.
7.1.3. Identify any possible risks or difficulties: which involves – examining possible premature endings and any (unconscious or transferential) issues that may be behind these; considering the patient/client’s future post-therapy needs, their needs for any follow-up sessions, or their needs to maintain some form of non-, or less than-, therapeutic contact; discussing the implications of planned (or unplanned) endings with one’s supervisor, line manager, as appropriate; etc.
7.2. Manage the Conclusion of the Psychotherapy
7.2.1. Manage the conclusion: which involves – enabling the patient/client to experience an end to the psychotherapy that is (a) negotiated, (b) at a time when the psychotherapy is reasonably sufficient for them, (c) in a way that reasonably protects them (and others) from risk or harm, (d) that is, as far as possible, relatively free from any ‘counter-transferential’ influences about ‘loss’ or ‘endings’, (e) allows for any undisclosed material to emerge, and (f) allows ‘closure’ to unfold
in an unforced manner; working collaboratively with the patient/client to identify a reasonably clear end to the psychotherapy; etc. (see also §2.4.3)
7.2.2. Review the process: which may include – enabling the patient/client to review their psychotherapeutic process over the course of the therapy and any hopes and plans for the future; discussing any changes in their perceptions of themselves and others, of family, cultural and societal structures, of power and self-esteem issues in relationships, and of issues of attachment and independence; coming to terms with any possible unresolvable issues that will probably not be concluded in this course of therapy; etc. Enabling the client to specifically explore levels of integration in relation to their intra psychic, interpersonal, emotional, physical, spiritual, relational self.
7.2.3. Identify issues, thoughts and feelings: which involves – discussing issues, thoughts, feelings and implications about other ‘endings’, ‘conclusions’, ‘separations’, or ‘terminations’, the client has experienced and how these relate to or influence the current ending. Developing thoughts, plans and strategies for change with the patient/client, that take into account their current situation and relationships; exploring information about options for continuance of their process, possible referral, ongoing support and information, future therapeutic alternatives, should the need arise, etc.
7.3. Record and Evaluate the Course of the Psychotherapy
7.3.1. Where appropriate, record the process of the psychotherapy: which involves – concluding (summarising), maintaining and storing clinical records in accordance with clinical, local, national and/or professional criteria; noticing and recording, in an appropriate way, any reduction of symptoms, other change indicators (stopping smoking or drinking alcohol, drug use, getting back to work etc.), any changes of circumstances, or satisfactory (or unsatisfactory) outcome as a result of the psychotherapy; etc. As an Integrative psychotherapist it may be important to record the client’s perception of changes, satisfactions and regrets, their sense of how they have been impacted by the therapy and the therapeutic relationship from an integrative perspective.
7.3.2. Evaluate the psychotherapy: which may involve – utilising any relevant outcome assessments, client satisfaction questionnaires, follow-up studies, etc. to help evaluate the effectiveness (or efficacy) of the psychotherapy; writing a summary or case history, if appropriate; reflecting on the process of the psychotherapy and evaluating one’s own performance, issues and practice; and discussing with one’s supervisor, line manager or peer (intervision) group about any mistakes that might have been made, how they could have been avoided, the learning processes involved, and/or how anything could have been done differently (see also 2.4.4)
DOMAIN 8: COLLABORATION WITH OTHER PROFESSIONALS
An integrative psychotherapist is competent in collaborating with other professionals to provide comprehensive care to clients. This competency involves the following:
8.1. Collaborate with Other Professionals
An integrative psychotherapist is skilled in collaborating with other professionals to deliver holistic care to clients. This competency involves the following:
Establish effective communication: Subject to professional requirements, especially confidentiality, the therapist may communicate with other professionals involved in the client’s care. This may include sharing relevant information, actively listening to others’ perspectives, and creating a collaborative and respectful environment.
Recognize and respect professional boundaries: The therapist understands the roles, responsibilities, and expertise of other professionals engaged in the client’s treatment. They respect and adhere to professional boundaries while working together to ensure optimal client outcome.
Where relevant, engage in interdisciplinary teamwork: The therapist may actively participate in interdisciplinary team meetings and discussions, actively using their expertise and collaborating with professionals from diverse disciplines. The integrative psychotherapist values differing viewpoints and may collaborate to develop comprehensive treatment plans.
Share relevant information: Normally in collaboration with the client, the therapist may share pertinent information regarding the client’s progress, treatment goals, and interventions with other professionals involved in their care. This promotes continuity of care and enables informed decision-making.
Seek and provide consultation: The therapist is open to seeking consultation from other professionals when necessary, seeking guidance and expertise to enhance their understanding and effectiveness. They also contribute their own expertise and insights to support collaborative decision-making.
Respect confidentiality and privacy: The therapist upholds confidentiality and privacy principles when collaborating with other professionals. They adhere to ethical guidelines and legal requirements to safeguard the client’s sensitive information.
Advocate for the client: Where relevant, the therapist advocates for the client’s best interests within the interdisciplinary team, ensuring their voice is heard and their unique needs are considered. They actively participate in discussions and decision-making processes to promote the client’s well-being.
8.1.1. Become familiar with the work of other professionals
An integrative psychotherapist is encouraged to become familiar with the work of other professionals involved in the client’s care. This competency involves:
Researching and understanding the roles and responsibilities of various professionals who may be part of the client’s treatment team. This includes professionals from related fields such as psychiatry, social work, counselling, and other mental health disciplines.
Gaining knowledge about the theoretical approaches, techniques, and interventions used by other professionals. This allows the therapist to have a broader understanding of different treatment modalities and how they can complement or integrate with their own approach.
Attending interdisciplinary workshops, seminars, or conferences to learn more about the work of other professionals. This provides an opportunity to engage in knowledge sharing, networking, and building collaborative relationships.
Engaging in open and respectful dialogue with other professionals to exchange ideas, insights, and best practices. This fosters a spirit of collaboration and enhances the therapist’s ability to work effectively within a multidisciplinary team.
May seek opportunities for shadowing or observing other professionals in their work. This provides firsthand exposure to their methods and allows the therapist to gain practical insights into different approaches and techniques.
8.2. Function as a Team Member
An integrative psychotherapist is competent in functioning effectively as a team member in collaborative settings.
An integrative psychotherapist is able to act, where appropriate, as an advocat to persons who may be subjects to oppressive behaviour within institutions and care-systems.
DOMAIN 9: USE OF SUPERVISION, (PEER) INTERVISION AND CRITICAL EVALUATION
An Integrative Psychotherapist is competent to:
9.1. Undertake Routine Evaluation of Practice
9.1.1. Arrange Appropriate Supervision: which involves – finding an appropriately qualified and experienced supervisor (or peer supervision [intervision] group); forming an explicit agreement about the parameters of the supervision / intervision (including frequency, respective roles, goals, confidentiality, (where appropriate) costs and accountability); being open about one’s competence and needs from supervision; ensuring that the supervision / intervision conforms to all national, professional and agency guidelines; acknowledging that the purpose of supervision is to a) enhance the quality of psychotherapy that patient/clients receive and the professional well-being and development of the supervisee ; b) ensure that the psychotherapist is practicing within the limits of competence and with client groups for whom they are appropriately qualified; c) support the psychotherapist in remaining authentic in the client/therapist relationship; etc.
9.1.2. Engage in Supervision: A supervisee may have the following expectations of what they need from supervision: support, insight, containment, openness to their own creativity, careful monitoring and boundary management, an engagement in dialogue, shared exploration of values. A supervisee ideally undertakes to be psychologically available, curious, open to new learning, willing to dialogue and creatively disagree, committed to good ethics and boundaries, and fundamentally valuing the person of the client.
9.1.3. Creative response in supervision to challenges: which may involve – increasing (or reducing) supervision in relation to changes in work load; reflecting on the quality of the supervision and whether it is sufficient for one’s personal and professional needs; getting additional specialised supervision when dealing with particularly complicated or unfamiliar clinical work, or if there are additional risks (to patients/clients or to oneself); getting additional supervision in the event of any personal difficulties, conflicts with patients/clients, dual relationships, complaints, etc.; changing one’s supervisor / supervision arrangements if necessary or when appropriate, after suitable reflection and discussion; taking responsibility that one’s professional supervision / intervision is at the highest reasonable standard readily available; etc.
9.1.4. Engage in reflection on practice as required by proffessional / accrediting bodies: which involves – (where appropriate) identifying suitable criteria and evaluation tools; routinely (at least annually) take part in systematic monitoring, patient/client outcomes, annual reviews (of number of sessions per patient/client), percentage of satisfaction questionnaires and follow-up studies; etc.
DOMAIN 10: ETHICS AND CULTURAL SENSITIVITIES
An Integrative Psychotherapist is competent to:
10.1. Work within an ethical framework
10.1.1. Know relevant professional and ethical guidelines and codes of practice: which involves – being aware of national legislation relevant to professional mental health practice; being aware of national and European codes of practice and statements of ethical principles (see Appendix 6) that apply to professional psychotherapy and good mental health practice; having been informed about and being aware of good ethical practice relevant to integrative psychotherapy.
10.1.2. Apply professional and ethical guidelines: which involves – being able to draw on knowledge and apply relevant professional and ethical guidelines, codes of conduct and practice; adhering to appropriate ethical, professional and contractual boundaries in one’s relationships with patients/clients; obtaining informed consent for interventions; safeguarding the interests of patients/clients, especially when working with other professionals, team members and members of their family; recognising any limits to one’s own competence, skill and experience and engaging in appropriate training and professional development to enhance these; maintaining patient/client confidentiality and knowing when it can be breached; ensuring one’s own practice conforms to best practice; maintaining appropriate standards of personal conduct.
10.1.3. Work with ethical difficulties: which involves – recognising potential problems, ethical dilemmas, or contradictions between various codes of practice and conduct, or between ethical requirements and work requirements; recognising any problems in areas like dual relationships with patients/clients, colleagues, supervisees, trainees, employees or subordinates; using supervision, or appropriate consultation, to clarify issues or problems; analysing and discussing complex ethical dilemmas appropriately with supervisors, colleagues, or members of the ethics committee of one’s professional association; identifying and taking appropriate action (including consultation) in the event of malpractice by other therapists and colleagues; withdrawing from appropriate professional activities and seeking appropriate support, when one’s own limits are exceeded, or when there is any personal impairment, or when in an unethical situation; implementing appropriate changes to ensure one’s practice remains ethical.
10.2. Work with social & cultural differences
10.2.1. Have an awareness of cultural and social differences: which involves – identifying one’s own cultural and social position and the assumptions, belief systems and values associated with that; being aware of possible cultural and social differences, and the effects of these, with particular patients/clients – especially if they come from different social and cultural positions; recognising social and cultural differences with respect to class, gender, sexuality, including trans-issues, ethnicity, origin, age, religion, politics, individualism; understanding ways in which different social and cultural systems can sometimes be confused with mental health issues; recognising how different social and cultural issue can impact on psychological well- being; understanding how traumatic and / or historical events (e.g. war, migration, climatic breakdown, natural disasters, persecution, discrimination) can affect individuals differently.
10.2.2. Apply knowledge of cultural and social differences: which involves – respecting the patient/clients’ personal goals, identity, and value systems and how the integrative therapeutic framework might impact upon that; exploring with patients/clients how they view and understand their relationship to their own, and to other, social and cultural issues and value systems; understanding the patients/clients’ perspectives and value systems, even though they may be different, even detrimental in relation to your own understanding. Understanding the personal, familial, social and historical context of the client / patient and recognising one’s own possible limitations when working with social and cultural differences.
10.2.3. Work with social and cultural difficulties: which involves – getting specific awareness, additional information and input, and (where appropriate) supervision, when working with significantly different cultural and social differences. Recognise that some patient/client populations have experienced significant trauma as a result of discrimination and oppression; where appropriate, acknowledging that one’s own social and cultural identity may have an impact on the patient/client. Offer referral options to psychotherapists from their own social or cultural background, where appropriate and possible; recognising where there may be social, cultural and political barriers to access psychotherapeutic services and promoting greater accessibility. Work, where relevant, with social and cultural support groups, specialist workers, translators and other available resources to try to lessen social and cultural difficulties.
10.2.4. Adapt practices if working with ‘special’ client groups: which involves – when working with clients where additional specialist competencies may be required and/or where their capacity to give valid consent may be in some way restricted or impaired, as in the case of children, people with learning differences or neurodiversities, people with communication difficulties, people who have experienced and / or are experiencing mental & physical impairments, or those experiencing mental illness or any extreme or altered states – obtaining further training and awareness, additional information and input, and, where appropriate, experienced supervision, (especially if one’s usual supervisor is not experienced in the particular area). Where appropriate and without breaking professional confidentialities or ethics, obtain valid consent from, agree upon responsibilities with, check out the patient/client’s needs, and communicate appropriately about the process of the therapy with parents, guardians, or significant others and record this. When obtaining or issuing reports relevant to such a patient/client, where appropriate getting the relevant consent from other parties (parents, guardians), consulting and informing them, involving their views, and recording this. Where there are any possible language or communication difficulties, ensure translators, those familiar with other mediums of communication, or patient advocates are present, as and when needed; and that the therapeutic environment and conditions are appropriate to the patient/clients’ age, developmental stage and particular needs. In such contexts it is recognised that conditions may be not ideal or even extreme.
10.3. Work with the social, cultural and political context of psychotherapy
10.3.1. Have an awareness of the social, cultural and political context of psychotherapy: which involves – understanding how the field of mental health fits into social, political and cultural contexts, and how this has been seen differently in different time periods and in different cultures. Have an understanding of current debates about the framework of social and mental care.
10.3.2. Have an understanding of the mentioned contexts of the debates about mental health. Specifically recognize the political and professional agendas and different priorities which may at work in the delivery of mental health care by psychotherapists.
DOMAIN 11: MANAGEMENT & ADMINISTRATION
An Integrative Psychotherapist is competent to:
11.1. Handle a professional practice
11.1.1. Manage a full working case load: which involves – being aware of one’s own capacities; at the start of each session, being fresh, interested, centred and focused; starting and closing the session and the process in good time; making appropriate notes and recording client information; giving sufficient time between sessions and not doing too many sessions in any one time period; when engaged in other non-professional activities or when involved in other activities & events, creating sufficient time and space for these, so that one’s professional practice remains clear; etc.
11.1.2. Maintain appropriate support systems: which involves – engaging in appropriate supervision, case conferences and review of professional work with clients (see also Core Competencies: Domain 8); engaging regularly in appropriate discussion & contacts with colleagues; keeping in touch with developments in the profession and particularly in integrative psychotherapy; attending professional seminars, symposia and conferences; subscribing to professional journals, appropriately; undertaking Continuing Professional Development (CPD); maintaining one’s status with professional associations; etc.
11.1.3. Undertake regular self-management: which involves – regularly engaging in active self-care and self-management; taking sufficient breaks, time-off, holidays and engaging in other types of activity; in times of personal or professional difficulty, getting increased supervision, consulting an appropriate colleague, or getting advice from a mentor; etc.
11.2. Manage a self-employed or small business
11.2.1. Maintain good business practice, administration and accounting systems: which involves – having an awareness of good business practice, administration systems and accounting systems and keeping up-to-date with these regularly; conforming with all local and national legal, accounting, tax and administrative regulations and requirements as a professional person in business; filing tax forms and paying VAT (where appropriate); paying bills and employees’ salaries on time; etc.
11.2.2. Apply appropriate regulations: which involves – being aware of, and applying, appropriate health & safety, environmental & ecological regulations and considerations, especially with respect to office location and supplies; ensuring that appropriate insurance cover is maintained for patients/clients, employees (if appropriate) and members of the public; keeping up to date with any requirements of one’s professional associations; etc.
DOMAIN 12: RESEARCH
An Integrative Psychotherapist is competent to:
12.1. Be aware of psychotherapy research
12.1.1. Awareness of psychotherapy research: which involves – recognising the value of research in the systematic evaluation of psychotherapy practice; being aware of what psychotherapy research has been done and how it impacts on current practice; being aware of different research parameters and methodologies; being aware of appropriate research methods, especially for integrative psychotherapy.
12.1.2. Demonstrate a particular understanding and awareness of those models of research pertinent to integrative psychotherapy, and how these share important aspects of the underlying philosophies and values of integrative psychotherapy. Given the significant variation in models of integrative psychotherapy it is perhaps appropriate that there is also a huge and often bewildering parallel variation in research methodologies (Finlay and Evans, 2009) However there are useful starting points, for example the online European Journal for Qualitative Research in Psychotherapy, which contains articles on how to undertake research relevant to psychotherapy as well as many illuminating examples. The work currently going on to develop a metamodel of understanding for integrative psychotherapy is another possible starting point.
12.1.3. Make use of psychotherapy research: which involves – having the ability to access sources of information from a wide range of resources (books, journals, internet, etc.) that can inform one’s practice; being able to evaluate research and other evidence to inform one’s own practice; utilising or adapting any significant and appropriate findings to improve one’s practice; being open to changing one’s practice in the light of any newly evidenced developments; etc. Making use of research as an Integrative psychotherapist involves approaching research from a perspective consistent with an integrative model, for example paying attention to meaning and subjectivity, phenomenology and lived experience, mutual reciprocity and the co-created field, and the whole meta-modality dimension.
12.1.4. Where possible contribute to the field of psychotherapy research.
This may involve conducting, participating or disseminating psychotherapy research relevant to Integrative Psychotherapy. Integrative psychotherapists have many skills relevant to the research process for example, those linked to phenomenological inquiry and attunement. They are able to engage in embodied dialogic encounter and to reflect on their own and the client’s felt responses. These skills and the integrative psychotherapists’s capacity for reflexivity assist their ability to contribute as both researcher and co-researcher. However it is important that psychotherapists are also willing to learn from the field of academic research in order to be able to contribute in a way that validates and supports the development of Integrative Psychotherapy as a profession. Integrative psychotherapy is an especially important paradigm in the field of psychotherapy, since it is at the leading edge of the intersection between various individual modalities.
DOMAIN 13: PREVENTION & EDUCATION
Integrative psychotherapists have the capacity to cultivate a deep understanding of prevention theories and their application not only within the psychotherapy process but also outside of it, cultivating specific competencies in prevention and education, that are holistic and socially responsible.