Libri di Psicoterapia Integrativa

               Given the vast array of theories informing psychotherapy practice, therapists and clients alike are faced with choosing a model that best meets their needs. Moreover, changes in the social climate and advances in technology pose a new dilemma for decision makers. The challenge of balancing managed-care rigors with a plethora of information available about the various choices of therapy may place one in a position in which aspects of different therapeutic models are embraced randomly and at times ineffectively. In other instances, therapists who hold rigidly to a given orientation may be placed in a position of practicing in a manner that is incompatible with the clientele or therapeutic setting. Thus far, research studies have extended the proverbial limb to a drowning person by reassuring interested parties that the relationship between the client and the therapist is more determinant of a successful psychotherapy outcome than the actual model. Although the client-therapist relationship is central, Beyond Empathy: A Therapy of Contact-in-Relationship, by Erskine et al., presents a timely model of psychotherapy that is empirically sound and appeals to clinicians who are in search of a theoretical orientation or a therapeutic stance capable of accommodating the demands of a modern day psychotherapy practice. Additionally, the importance of this work in the advancement of psychotherapy practice can be fully appreciated as a complement to Carl Rogers's client-centered approach that emphasizes relationship. Moreover, the authors' thorough and thoughtful presentation of their ideas makes this book both scholastically and clinically useful.

               The book achieves its goal of successfully integrating selected theories, establishing a structured approach to the therapeutic dyad. (The authors distinguish this carefully selected and empirically based integration from scant eclecticism.) The authors first present a review of the theoretical underpinnings of the proposed model, advancing a theory of contact in relationships. In so doing,  they clearly articulate a multifaceted model structured around client-centered therapy, transactional analysis, gestalt therapy, and contemporary psychoanalysis.

               A second type of integration is introduced in this model of psychotherapy; this integration is defined as the process of reuniting desperate parts of the self that have been alienated. This model appears to be particularly useful for clinical work with clients who have experienced trauma. As per the model, the goal of therapy is to achieve full awareness (internal and external) and contact in relationships through a process of integration.  The book introduces a new model of pathology, therapeutic task, and the curative process that is thought provoking. The model clearly delineates pathology (lack  of contact with internal as well as external aspects of the self), the therapeutic task (to bring the client to a point of having more “contactful” relationships), and the curative process (the therapeutic relationship).

               The second part of the book presents a gestalt of the concepts referred to by Erskine et al., as a view “through the keyhole.” This keyhole analogy expedites the readers' ability to grasp the conceptual and technical aspects of the whole model. The authors present compelling case studies, successfully illustrating the techniques and process of doing integrative psychotherapy. Attention is given to the development and exploration of each major conceptual idea proposed, and, where possible, these ideas are supported with clinical vignettes representing the application of theory to practice.

               Currently, individuals seeking and retaining psychotherapy services are very knowledgeable about the types of therapies available to them. Clients are savvy about therapy and are more likely to be drawn to a model that advocates respect for the client. Erskine et al.'s models of psychotherapy is an exemplary description of a therapeutic stance vis-à-vis clients. For example, the authors stress that the process of integration occurring within the therapist-client relationship should be approached with the greatest appreciation for the client's position. Other aspects of the therapeutic relationship, such as answering the client's questions, not keeping the client ignorant of the therapeutic goals, and obtaining the client's permission to pursue lines of inquiry, are necessary components of a respectful working alliance. The aspect of the model that values the therapeutic relationship and respect for the client has a universal appeal, as it offers a therapeutic stance easily embraced by therapists of various theoretical orientations.

               The model proposed by Erskine et al. is a daring one that makes bold yet well supported claims of being unique. Erskine et al.'s model not only embraces the concept of empathy and the importance of the relationship in the therapeutic process (Rogers, 1951, p.560) but also goes beyond Rogers's client-centered approach to emphasize the importance of the therapeutic relationship, as well as the necessity for respect in the therapeutic dyad. Erskine et al. acknowledge that “All … therapists, no matter how widely their theories may differ, share a common debt to Carl Rogers, who made the word ‘empathy' almost synonymous with the notion of therapeutic the relationship” (p.2). However, their work significantly advances Rogers' client-centered theories. There are clear points of departure as well as similarities between the two approaches.

               Erskine et al.'s work echoes Rogers (1951) in that the focus of therapy is phenomenological. The client's current experiences, the meanings attached to experiences,  and the extent to which experiences are integrated are all central to both models of psychotherapy. Concurrently,  Erskine et al. advance  Rogers's work by including and emphasizing an aspect of the client's experience rejected by Rogers: the role of developmental models and past experiences in therapeutic discussions (Rogers, 1961). Unlike Rogers, Erskine et al.'s theoretical model acknowledges the role of past experiences as a determinant of current patterns of relating. Beyond Empathy views a phenomenological approach to inquiry (Phase I of the model) as necessary, yet the authors hold that contact with disruptions in clients and patterns of fixed gestalten that interfere with contact may originate from a historical source.

               Erskine et al.'s past-to-future connections (p.167) are in stark contrast to Rogers's (1951) more forward-looking approach. Rogers acknowledged that learned self-images stem from a historical source and that childhood evaluations of parents and others, as well as challenges to this ideal self, result in conflict. Nevertheless, he focused on the bearing of these experiences on the future, that is, efforts to exclude incongruent experiences from the ideal self, or what Erskine et al. refer to as a lack in “contactful” experiences. Erskine et al. go beyond the considerations Rogers discussed to also consider the developmental level of the client (p.85). In fact, they go on to say that the client at various points in the relationship may regress to a developmentally earlier age and that if they do so, the therapist should respond in language appropriate to the client's developmental level. Erskine et al. view this notion of developmental attunement as imperative to the curative process in that it offers the client an opportunity to use fantasy to explore decisions and relationships in the past. In essence, the therapist does not merely return to the past with the client, but the client brings the past into the present.

               The models depart notably on their views of therapeutic change. Erskine et al. present a model for change that goes beyond Rogers's (1951) view of “unconditional positive regard” as necessary and sufficient in the therapeutic relationship. Erskine et al. extend the Rogerian view by including components of the relationship that are not simply unconditional but require more active involvement on the part of the therapist. They speak to the importance of the therapist's validation, normalization, and presence in the therapeutic relationship. More specificially, validation of clients' experiences has relevance for the future and connections to the past. Normalizing clients' experiences of making choices and accepting consequences allows clients to be relieved from experiencing poor decision making as intrinsic to some “bad” quality. The therapist is expected to be present in the session and actively involved in the therapeutic processes rather than “just being there” (Rogers, 1951, p.98). Erskine et al. stress that presence is not static but an active process requiring the therapist to have contact not only with the client's internal and external world but also with the therapist's internal climate as well. Under these circumstances, the emergence of the self occurs and is a marker for the therapeutic change. Certainly the proposed model of therapy goes “beyond empathy” and beyond Rogers's client-centered approach in notable ways that advance the practice of psychotherapy.

               Erskine et al. make some bold suggestions that clash with conventional views on the structure of therapy. However, the suggestions accommodate practice in an environment where clients' social factors may interfere with a more traditional model of therapy. Erskine et al. encourage those who embrace this model to express attunement to clients through scheduling. More specifically, they recommend accommodating clients' inability to work within the established time structure allotted for a session. Clients who, because of attention problems or for other reasons, need longer sessions should be accommodated. Erskine et al. have taken attunement to a new level with this admirable gesture with which they request therapists to do more than say they understand the client's dilemma.

               My only criticism of this book is that in order to appreciate how this work advances a client'centered Rogerian model, the reader must have some knowledge about Rogers's work. Still, the authors compensate by going beyond the call of duty to anticipate readers' questions and address them in detail. For example, Erskine et al. write “It is important to keep in mind that full contact, ‘being in the world as a whole person,' involves being fully aware of both internal and external events” (p.17). In so doing, the authors strive for and attain some level of attunement with the reader.  They prepare readers for what lies ahead by introducing ideas in summary and making clear connections at the end of each paragraph. Furthermore, their use of didactic and clinical case vignettes is compelling and should not be easily dismissed.

               Drawing from a vast array of clinical and teaching experiences in integrative psychotherapy, the authors clearly lay the premise for their model. Each chapter builds on the previous one, leading the reader through a very logical discussion about the key elements of the theory (inquiry, attunement, and involvement). Moreover, these carefully selected and scripted case vignettes serve to document the therapist's technique, and when necessary, the readers are reminded of the tone of the therapist. Descriptions and explanations offered are so thorough that the reader feels able to recognize or conduct inquiries in the proposed format. The work itself is a vivid multidimensional one that appeals to our intellect as well as our senses.

               Overall, the book presents a solid review of theory as well as introduces a model for practice. The model is clearly presented and appeals to therapists who are practicing at various levels. One may be swayed on reading the book to consider personal struggles and feel inclined to accept the challenge of striving for a more “contactful” experience of life. For clinicians looking for guidelines regarding a therapeutic stance vis-à-vis clients, this book is incredibly helpful and serves as a good reference. Finally, for those wishing to practice with confidence an integrative psychotherapy approach, this book is necessary.

REFERENCES:

Rogers, C. (1951). Client-centered therapy; its current practice, implications and theory. Oxford, England: Houghton Mifflin.

Rogers, C. (1961). On becoming a person. Oxford, England: Houghton Mifflin.