Journal of Psychotherapy Integration

Dialectical therapy is a common factors approach to psychotherapy integration, in which four general therapeutic strategies are taken as the cardinal points of a map of the field. It is said to be “beyond psychotherapy” because what is commonly referred to as psychotherapy is more than psychological treatment. It is a dialectic between two basic levels or axes: the psychological remaking, which deals with defect-driven disorders, and the philosophical uncovering, which deals with conflict-driven problems. The first level can be graphically represented as the horizontal axis of the field, connecting a “maternal” and a “paternal” pole, in which the therapist responds to the basic psychological needs of secure attachment and responsible cooperation. The second level can be represented as the vertical axis of the field, connecting a K (knowledge) vertex and an O (unknown) vertex, in which the therapist responds to the basic philosophical needs of knowledge (“know thyself)” and of unknown as unknowable (the noumenon of all phaenomena, the source of generative and healing powers). A map is necessary to organize the basic therapeutic needs and the range of responses to them in a coherent pattern. As a good map can help in orienting empirical research, this in turn can help in constructing better maps.

This commentary on six papers about assimilative integration considers the place assimilative integration, as defined by Messer, ought to have in the discussion on psychotherapy integration. After briefly summarizing the contribution of each paper, with particular attention to whether the paper takes a position on the end point of psychotherapy integration, the author compares the relative benefits of assimilative integration to those of a unified grand theory. He argues that assimilative integration, as an end point, is preferable to a unified grand theory because it has a more generative influence on both theory evolution and clinical practice.

Two basic styles in psychotherapy integration can be described, in which respectively the assimilative or the accommodative mode of proceeding preponderate. The first is chosen by those who wish to keep a firm grounding in any one theoretical system, into which they incorporate perspectives or practices from other schools, reinterpreted and reformulated in their own terms. The second is favored by those who prefer to practice eclectically, without worrying too much about the contradictions and incompatibilities among the different approaches. The latter therapists can remain at this purely eclectic level, or move on towards a proper integration. In this case the integration does not usually happen on the base of a preferred system, as in theoretical integration, but rather follows the line of the common factors approach. This integration mode has a prevalent accommodative character. It points to a basic structure that is common to the different methods, and becomes clearer the more the relation is freed of the constriction of theoretical models. An attempt is made to show the substantial complementarity and the dialectical relation that links the two fundamental modes of psychotherapy integration.

We present an approach to the problem of structuring a therapeutic alliance with patients presenting paranoid symptoms, using both psychoanalytical and cognitive techniques. Initially, we focused on one of the main aspects of the paranoid worldview: the fear of being betrayed and the tendency to betray. This is a defense maneuver, through which patients deny their passivity, and the impotence in the relationship with their own internal needs and with the significant people in the external world, including the therapist. In our experience to build up a working relationship, both a psychoanalytical interpretation of unconscious conflicts and the cognitive analysis of dysfunctional beliefs are needed. Often, in more serious cases, the role of “nonqualified object” must be accepted at the beginning, due to the patient's need to be in control of the situation. Only then can a therapeutic phase begin, in most cases, through an integrated approach that includes pharmacological, psychodynamic, and cognitive modalities.