Tag Archives: Integrative Psychotherapy

Integrative Psychotherapy XIII: Concluding Thoughts

We come to the concluding chapter of Mark McMinn’s and Clark Campbell’s Integrative Psychotherapybook. They remind us that it was their endeavor to detail their model of integration, psychotherapy, and Christian approach. By integration they meant that they wanted to thoughtfully integrate a variety of psychological theories (as opposed to mindless or even pragmatic eclecticism) as well as their theological views of persons. Their version of integration is best defined, so they say, by the term theoretical integrationism (TI). “[TI] occurs when a person begins with a particular theoretical starting point and then extends the theoretical base by incorporating one or more additional theories” (p. 386). What is the heart of the IP model found in this book? McMinn started with CBT and CT and has incorporated relational approaches more likely found in dynamic models of therapy. Campbell is reported to have begun with interpersonal and family models and incorporated and practiced CT. I would suggest that CT is the heart of the IP model with relational and interpersonal understandings of persons included. I would suggest that there is little evidence of family models in this book.

The authors make brief mention of their theological integration in this chapter. They admit that they take a rather narrow view of Imago Dei and apply that to personhood and psychotherapy by looking at the image of God through the lens of functionality, structure, and relationship.

IP attempts to address life both at the level of symptom reduction AND transformation. The authors recognize that many things lead to transformation–not just therapy. However,

“Psychotherapy is only one means of transformation, but in today’s society it has become an important and ubiquitous one. Even within the church there appears to be a strong and growing interest in counseling and psychotherapeutic ministries, though suspicions about psychology persist in many congregations and denominations. Church-based counseling ministries are now commonplace, most pastors and church leaders have a referral network of therapists in their community, seminaries offer courses and degrees in counseling, and support groups and peer-counseling ministries are being established in many churches. This trend is encouraging insofar as it helps the church care for whole persons as Jesus ministered to the spiritual, physical, relational and emotional needs he saw in others” (p. 388).  

Notice the word, “insofar” in the previous sentence. The authors see increased chance for harm if we “conflate” psychotherapy and the church. They are concerned about two problems: (a) making the gospel about us (self-actualization) instead of Jesus work, and (b) having untrained and undertrained individuals offering therapeutic help and so causing harm to vulnerable people. They do not want to see the Church compromised by becoming therapeutic nor do they want to see the profession of counseling dumbed down by removing the professional, academic, and scientific groundings.

Finally, they end the book by listing 6 ways their IP model is comprehensive: (a) includes both psychology and christianity, (b) consider multiple domains of persons, (c) multiple dimensions of therapy, (d) includes both scientific and relational approaches, (e) christocentric, and (f) usable with both christian and nonchristian clients.

So, now that we have concluded their book, what do you think? Did it make you more interested in viewing therapy through the symptom, schema, and relationship lenses? Did their model seem usable in your context? Were their Christian foundations necessary, or said differently, how did their Christian beliefs change how they function with clients? Would a Christian therapist who loves Jesus but sees their work as being a relational cognitive therapist act any differently? I’m curious if you have a reaction.

Some of my reactions:

1. This is probably the best Christian integrative book I have read. They work harder in this book to make sure that they acknowledge the all-too-common superficial use of Christian beliefs in building a model of care. They also display much humility and do not want the church to water down the Gospel. Therapy isn’t everything for them. Christianity is trump, in their eyes.
2. There is almost no negativity directed at any other model. Most of us use other models as foils for why what we do is better. I congratulate them on being able to map out a model without attacking others. When they do point out weaknesses, it is in their perception of the limits of cognitive therapy.
3. The book is now in need of a follow-up that more deeply illustrates case material. What does IP look like in an extended case study. I would love to see that as a follow-up text. What they did provide were little snippets that had a lot of realism to them. I just want more. Here’s one little question. Does Scripture only come into play at the symptom level of change? It seems to by the way they write and don’t write about Scripture. Does Scripture have anything to do with transformation and experience? Scripture is not merely a cognitive or intellectual enterprise (though we often use it this way).
4. I might quibble with them on their Christology, though I found their positions not quite clear and so may not differ as much as I think. Christ’s death and resurrection IS the power for change (2 Cor. 5:16f). His life does inspire us but we cannot love others merely because of his life. I think they might agree with this, but I’m left with confusion as to where they stand here.
5. As expected, this is a text for therapy trainees. It sets out boundaries for the profession. Lay and church leaders can learn from this model, say the authors, but ought to be careful not to function as a professional. Even though I am a professional and I have found in teaching counselors that it takes character, the Holy Spirit, skill acquisition, and much practice to be a wise counselor, I am always a bit troubled by the boundary setting. It seems we are trying to protect our own domain. I do think there are wise counselors who never had any academic psychological training. It may not be common, but let’s remember that pastoral care has been helping people long before clinical psychology developed into a discipline. I would have liked to see a bit more work in informing the reader (a psychology trainee) about the dangers in trying to function like a spiritual shepherd.
6. I’m in concert with their model as it functions in session. We are conduit for reconciliation. Therefor our working relationships matter almost as much as our words and interventions. When we can reduce symptoms of suffering, we should. But, we also recognize the insidious nature of sin in our lives and must seek transformation of our minds and experiences in submitting them to reality as seen through God’s eyes.

For those interested in Mark McMinn’s further work, you might check out his new book on sin, Sin and Grace in Christian Counseling (IVP, 2008). It is also written for the counseling practitioner.


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Integrative Psychotherapy XII: Soul Care Via Relationships

In the last substantive chapter of Integrative Psychotherapy, McMinn and Campbell explore relationship-focused interventions. As we have seen in previous chapters, their therapy model begins by addressing problems at the level of symptoms and ends with considering transformation of the person via soul care. Before describing soul care interventions the authors want to set out a few of their beliefs:

  • “One does not have a soul but is a soul” (p. 349)
  • The soul is not another word for personality or self or even person. Rather it is bigger because it encompasses meaning and relationship 
  • Soul care is based on the life AND work of Christ. Some use Jesus as an example for healthy relationships but stopping with Jesus’ behaviors misses out on Christ’s atoning work in redeeming us. His work is based on both grace and truth–both necessary in any human to human soul care work
  • There are multiple forms of soul care but one should not confuse or integrate spiritual direction and psychotherapy. “Christ is central to all soul care” (p. 356) but each version has differing goals and methods. They suggest these as some of the differences between the two:
    Spiritual Direction                         Therapy
    spiritual functioning                          psychological functioning
    lifelong spiritual transformation        transforming a specific problem area
    spiritual advising                               guided discovery
    spirit centered                                   problem centered
    God focused                                      client/counselor collaboration
    under church authority                     accountable to professional standards

Relationship interventions, per the authors, must be founded on therapeutic alliance (a safe trusting and collaborative relationship between counselor and client), therapeutic frame (“a setting conducive to change”–predictable, with clear expectations, roles, etc.), and relational dynamics (the inevitable “dance that occurs in any close relationship” (p. 363)).

The relationship oriented therapist pays attention to the alliance, the frame, and the dance because they do not merely talk about the client’s life but client and therapist experience life in the session and this experience enlightens, informs, and recreates patterns in the client’s life. These dynamics are commonly referred to as transference and countertransference.

While discussing alliance, frame, and dynamics are indeed therapeutic interventions (my view), McMinn and Campbell go on to discuss 4 relational interventions designed to, “provide simultaneous support and confrontation (grace and truth) designed to promote psychological growth” (p. 372).

  • Empathy. Having the capacity to experience the client’s world “as if” it were one’s own–and so communicate understanding. Why is this important? M & C say it provides, “safety necessary to keep the client’s defenses down” (p. 374).
  • Confrontation. “Gently pointing out inconsistencies or discrepancies to the client” (ibid). The authors remind the reader that individuals do not do well when they feel their whole person is being confronted. One suggestion is given to focus on the impact of one’s words or behavior more than intent (folks are much more likely to emphasize their intent and defend against impact).
  • Interpretation. “…Connecting current behavior, feelings, and images to previous ones in the client’s life….Whne clients re-create their interpersonal problems in therapy through reenactment, testing or transference, they are not aware usually of the connection between their current reactions and the coping strategies learned in childhood” (p. 376).These interpretations are not merely made to correct thinking but to be used in the counseling relationship.
  • Role behavior changes. We learn to play certain roles in life. While these roles may be adaptive or understood as part of a larger family system, they may become maladaptive later. When clients experience and understand their role rigidity, they then have the opportunity to try on new roles within the safety of therapy.

My thoughts? Notice the difference in details and concrete interventions between the treatment of automatic thought problems in domain 1 and relationship interventions here in domain 3. It’s no wonder some counselors are more attracted to “doing something” with cognitive therapy and so avoiding the vagaries of interpesonal processes. And yet, McMinn and Campbell are correct that the therapeutic relationship between therapist and client allows both to move beyond talking about problems to experiencing stuckness and healing–and so to have the opportunity to experience a different response to the self and the world. Boundary setting is an intervention and provides wonderful fodder for healing conversations. Far too many students see boundary setting as something to be done to avoid trouble rather than a primary tool for change. Second, these 4 interventions for a good start but we need much more exploration of relational healing interventions than is possible in this introductory work. One such deepening would be Marsha Linehan’s work in validation and irreverence as means to allow the “here and now” to provide feedback to the oft invalidated client.

While I am very supportive of their primary goal in this chapter I do have a couple of questions:

  • Can we really separate psychological growth and spiritual growth from each other? I think not. This makes it messy when trying to define the roles of a spiritual director and professional therapist. But, I think any role differences are somewhat artificial, based on “turf” wars. Wise and careful directors and therapists use the same frame, neither gets too far with exhorting (McMinn and Campbell call this advising), and Christians in both fields ought to submit themselves to God as well as government.
  • How does Jesus transform the world? By example? By love? By the cross? While I am thankful for their strong Christological focus for their soul care, they aren’t quite consistent in their description of Jesus’ work. They do recognize that merely looking at Jesus’ loving examples is not enough. We must see him as God in the flesh. But they also suggest on p. 351 that Jesus transforms, “the world through the power of relationship.” It seems they suggest that he transforms the world because he so moved and influenced the disciples to establish the church. Why? They consider the relationship with the apostles to be the primary reason. While we are designed for relationship, we are not healed through relationships because Jesus so influences us. No, we heal through relationships because we have been reconciled through the cross of Christ. 2 Cor. 5 16f make this very clear. So also does Romans 5. There is little mention of the cross of Christ throughout this book. Funny, the one place in this chapter where the cross appears is on p. 354 when they quote Alan Tjeltveit, “We stand in need of grace. Through the cross, grace is available to us, always.” It would be interesting to hear McMinn and Campbell discuss why they place more emphasis on Christ’s relationships and so little on the cross.


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Integrative Psychotherapy XI: Relationship focused interventions

We’ve been following the development of the theory and application of McMinn and Campbell’s 3 tiered Integrative model of persons and change. Now, in chapter 10, we arrive at the deepest and least objective level of change that takes place in counseling: therapeutic relationships. While some problems can be dealt with through skills and behavior change and other problems can be dealt with by exploring core beliefs and schemas, there are some core or “soul” problems that are best handled by being in a healing relationship. We’ll get to what that means in a moment…

The authors begin to tackle the problem of personality disorders. They describe how we all have personality styles, how some of those styles turn into problems (unthoughtful engagements with others), and how some turn into full-blown disorders (“defined as consistent patterns of behavior, evident since childhood or adolescence, which impair social functioning and cause significant distress to self or others.” (320)).

Functionally, some people are unable to step back from their assumptions and schemas and consider alternative perspectives. Such a person experiences their life but has a hard time observing their life without being sucked into negative experiences (see inset on p. 322). The therapist’s job is to try to maintain a relationship, focusing on the here and now (the relating that is going on between the counselor and counselee) in order for the counselee to gain new experiences and thereby develop a greater capacity to step back and see self.  “The working assumption of relationship-focused IP is that relationships change people” (p. 324).

Then the authors give a little summary of key personality theory by reviewing Freud, Horney, Stack Sullivan, and family systems models regarding how interpersonal patterns develop. They conclude by saying that our interpersonal patterns, “are formed early in life as a means of reducing interpersonal anxiety, maintaining a consistent perception of self in relationship to others, and as a means of stabilizing family life” p. 331). 

McMinn and Campbell dig deeper to ask the question: how is it that these developing styles become rigidly used? How is that an early experience get “re-enacted” in adult life? They turn to 3 theories:

1. Interpersonal Process Approach. Unmet needs leads to anxiety which leads to internalizing negative feelings about the self which lead to treating others the same (ad nauseam). These interactions continue because they are familiar and they “work” for us by reducing anxiety (we can make sense of the world and they work to some degree).

2. Cyclical Maladaptive Patterns. A cycle develop that is played out in every relationship. These cycles are organized into 4 parts: acts of the self, expectations of others’ reactions, acts of others toward the self, and acts of the self toward the self (p. 335).

3. Reciprocal Role Procedures. As a person grows, they “develop more sophisticated ideas of where self ends and other begins. The growing child learns ways of relating with the other so as to maintain attachment between the I and the Thou….But each of these roles is reciprocal; that is, they are met with a response on the part of the other.”

Is there a Christian perspective on personality problems? The authors explain their take on the creation (that we are created to be in relationship) and fall (that because of our tendencies to use relationships for our own pleasures, self-deception, sins against us) we form patterns of how we see ourselves (usually victims). And finally, they briefly explore how redemption means experiencing safety and grace now in a manner to “reform faulty interpersonal patterns.”

My thoughts.Here the authors inject dynamic models of relating into the development of a mostly cognitive model–up to this point. They rightly recognize that we develop much of our sense of self in early stages of life and then cement those views in an on-going way–even when we hurt ourselves with those views. And true, we often see ourselves as victims. What is hard is to see that we are both victim AND victimizing at the same time. Unfortunately, they used up their space in the chapter in talking about how interpersonal processes can be broken without much theorizing about how and why present, positive interpersonal experiences change us and shape our constructs of self and why they change so slowly. It is somewhat easy to point out that our acting on and being acted on shapes us when we are vulnerable. But what happens in the now that enables us to open up and reconsider our identity without feeling like we lose ourselves?

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Integrative Psychotherapy X: Schema interventions for depression

In the last chapter the authors theorized about our propensity to live out of socially constructed schemas. Now in chapter 9 of Integrative Psychotherapy, McMinn and Campbell apply schema-focused interventions (domain 2–dipping beneath symptoms to core issues) to the problem of depression. But before they get to that task, they make these 2 points:

1. It’s “incorrect and potentially dangerous” (p. 278) to assume one does symptom focused interventions with anxiety problems and deeper level interventions for depression. Instead, the therapist ought to move seamlessly between them as needed. They remind the reader that their chapters are illustrations and not manuals.
2. There are useful symptom based interventions for the problem of depression that should not be overlooked: (a) medications (they explore fallacies that keep people of faith from using them and point out that meds are sometimes better than counseling alone), (b) behavioral techniques (keeping an activity schedule, assertiveness training), and (c) cognitive restructuring (keeping a dysfunctional thought and challenge record).

At this point the authors begin to illustrate their version of schema-based interventions. Unlike classic interventions (diagnosing the underlying schema and then correcting it), they describe recursive schema activation which is designed to “give clients many opportunities, session after session, to decenter [see life from another perspective] from the deep, persistent themes of their lives that can never be fully obliterated” (p. 288-9). The main difference between the IP model and the classic model is their humility in seeing schemas as understood and managed rather than corrected. Also, they desire to activate and experience schemas as much as talk about them.

The goal of this part of IP is to stand apart from one’s schema so as to see it and choose to deactivate it where it is not helpful. In the case of depression, it means standing back from “depressogenic thoughts” using mindfulness and spiritual disciplines. The client doesn’t challenge thoughts so much as he or she activates the schema in counseling over and over in a manner that allows distance and the possible formation of a new schema or identity.

Just how does this work in therapy? McMinn and Campbell suggest these strategies:

1. Taking a life history to identify re-occurring themes that might signify the presence of maladaptive schematics (e.g., long history of feeling rejected by others). In taking the history, the client not only tells but re-experiences the schema with the counselor
2. Schema inventories. They mention one in particular: www.schematherapy.com. These are used to get the client thinking about schemas that contribute to their problems.
3. Discussion of faith. The therapist explores how the client’s view of God fits in their view of self. The assumption is that a maladaptive schema likely contains distortions of the character of God. The goal is to understand at this point, not correct.
4. Moving from specific to general. Clients often describe recent painful events (and thoughts and feelings). The therapist encourages the client to explore how these thoughts and feelings fit their general conclusions in life (e.g., people always leave me).
5. Looking for themes. The counselor looks to articulate and activate themes and creates space for the client to do the same.
6. Evoking emotions. The counselor needs to move from an intellectual discussion to the emotions attache to the schema. Often-times, this means using the here-and-now to explore emotions. Otherwise clients only report on feelings in a disconnected manner. If so, they remain disconnected from the insights they gather.
7. Guided discovery (vs. just telling the client the interpretations). The authors present a good illustration  of the difference between telling and collaboration on p. 298.
8. Imagery and meditation. The goal here is to use these techniques to activate and deactivate schemas. Why? They suggest these techniques support safety (to limit overwhelming oneself). They do note that while prayer may help in schema alteration its primary purpose is to connect with God and shouldn’t be thought of as some technique apart from its main purpose.

Finally, in the last 13 pages the authors take up how recursive schema activation is a bridge-building exercise. It bridges cognitive processes (logic, analysis) and emotional and relational processes; unconscious and conscious processes; past and present; events and meanings that we give them; schema activation and deactivation. They conclude that not every person has the psychological resources to deactivate schemas once activated and point the reader to the next two chapters where relationship interventions will need to be used.

MY THOUGHTS: This is a good chapter that describes what I think is core to therapy: self-observation in a safe environment that happens as much through experience as it does through logical analysis. The reality is that our schemas shape our sense of self and the world as much as our 5 senses do. We think we merely ascertain what is happening to us but in fact we are prepping our critical thinking with assumptions. Here’s my question. Is the schema something that can be changed. I hear the authors saying that they aren’t all that optimistic about it but just maybe we can control it, decide not to listen to it. In part I agree. And yet I don’t want to underestimate just how much a person can change their outlook on life and self. Where I think the biggest challenge lies is helping clients feel safe enough to accept that they make these assumptions. In couples counseling I find many/most couples unwilling to consider the possibility that their assumptions about their no-good spouse were formed before the ever met their spouse. They come wanting to fix the marriage and part of my job is to help them see that before they can fix the marriage they need to understand how their responses tell a lot about themselves and maybe less about their spouse than they think. This is hard for counselees to accept because it sounds to them that they are responsible for their spouse’s bad behavior. Helping a client not live in all/nothing thinking is my challenge. Further, I must make sure not to fall into “telling” mode when helping someone come to this realization. Sometimes I want to speed up the process and thereby lose the client.


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Integrative Psychotherpay IX: Schema Focused Interventions

McMinn and Campbell go into detail regarding the 2nd domain of their 3 tiered model of persons/change in chapter 8 of Integrative Psychotherapy. While the first domain addresses symptoms, this domain (schema) looks beneath to deeper roots than habit and thought. “Schema-based interventions dig deeper than symptom-based interventions, looking to general core beliefs rather than specific automatic thoughts” (p. 243). Schema interventions address the heart of soul and deeply held beliefs (perceptions) about the self and the world that persist beyond specific situations.

So, they open their chapter with this assertion: “…it is often the currents beneath the surface of consciousness that have the most power and bring the most troubles in personal adjustment and interpersonal relationship.” (p. 240). They point to perceived parallels in Romans 7 (Sin causing me to do what I do not want to do) and Freudian theory regarding unmet needs to be both talking about underlying–yet controlling–currents in our lives. A wide view of sin (both active choice and result of living in a fallen world) incorporates both views without making one attack the other.

On page 242 they revisit a vignette of a unhappily married, 24 year old woman. She was afraid she didn’t love her husband and was afraid of being “doomed to misery if they stayed together.” In the vignette, “Denise” is told by her elder that she was facing a spiritual problem that required more prayer and bible reading. The authors fault the elder for having bad psychology (premature advice, no rapport) AND bad theology (that spiritual disciplines can always solve the problem of sin). They faulted the elder for not recommending a fuller orbed treatment of therapy or meds and for not considering a wider variety of underlying issues (her family of origin, communication issues, interpersonal anxiety, hidden secrets, biological predisposition, etc.)

So, is a better answer to Denise’s problem to trace her automatic thoughts back to her core belief? Not so fast say McMinn and Campbell. Linearity is nice but too simple. So, they turn to a discussion of schema.

Schema is not synonymous with core belief despite the fact that it is used that way (mea culpa in this post). Defined by the authors, “a schema is simply a structure that contains a representation of reality” (p. 247). They remind us that since we are actively interpreting our world, we shape our schemas and we shape our lives to fit our schemas. They further describe schemas with these statements (fleshed out in the book)
1. Schemas affect how we interpret and construct the world
2. Schemas are adaptive and maladaptive
3. Schemas can be activated and deactivated
4. Schemas are connect to modes (while schemas are cognitive they lead to a way of being, a personality, a motivational bent, an emotional and physiological bent)
5. Schemas can be categorized in how they interpret self, world, and future (p. 260 has a list of 18 schemas with accompanying core beliefs)
6. Schemas have a historical dimension (they point to literature describing 4 different early life experiences as key historical causes: toxic frustration, trauma, overindulged, and identifying with the pathology of a parent)
7. Schemas have an interpersonal dimension (they are not developed in a vacuum)
8. Schemas are influenced by original sin (faulty thinking doesn’t just come from bad environments. Those raised in great homes also struggle with faulty thinking because they are tainted from the Fall.)
9. Schemas have a cultural dimension (some schemas are culture-based and the authors warn against trying to change these)
10. Schemas have a faith dimension (schemas may shape perception of God; One’s theology shapes schemas)

To make this real, they refer back to “Denise.” Since Denise’s schema contains distrust of the world, she quickly interprets her husband’s cooking her favorite meal as an attempt to make up for his dis-trustfulness and so is defensive and irritable. Of course, this schema “predicts” distrust and then finds evidence of it when Don is hurt and doesn’t try to be nice after her attack of him.

So how does Integrative Psychotherapyaddress maladaptive schemas? They suggest “Recursive Schema Activation” (p. 270) over against class CT tactics that challenge core beliefs with logic. Merely engaging in logic battles minimizes, in their view, that core beliefs, “are embedded in a complex array of motivations, behaviors, emotions, and physiological responses” (p. 217). By “recursive” they mean to emphasize that we change through experience, dialog, repetitive activation and deactivation of the schema.

This means the client’s troubling schemas are activated and deactivated in the context of the therapeutic relationship, over and over again, all the time helping to foster the client’s ability to stand apart from the core beliefs and reconstruct a new, healthier identity–an outcome know as decentering. In decentering the clients begins to understand the nature, power and origins of the maladaptive core beliefs while simultaneously developing more conscious control over the schema deactivation process. (p. 272)

What is really different here from classic CT? McMinn and Campbell don’t want to talk only about a client’s schema, but to activate and experience the schema, and then decenter from it in order to understand and control it. They do not believe they can eliminate a damaged schema. Classic CT wants to correct maladaptive thoughts. IP wants attempts to recognize the impossibility of that and yet gain control and reduce the power of these maladaptive thoughts via therapeutic relationships.

My thoughts? Okay, lots to munch on here. I like how they recognize the limitations and arrogance of classic CT in correcting our struggle with deception and sin. Just as we don’t try to stop sexual temptation but fight to kill those things that lead us further along, we can’t stop initial fearful thoughts but work to stop our acting on them. What we do with our thoughts (take them captive) matters. And the authors here recognize that such efforts are not merely logical but experiential. I generally agree with their thoughts regarding how schemas color our world. We are active in shaping our interpretations of self and other and our world is active in shaping us. We are neither completely responsible for the content of our perceptions or completely victim of our perceptions. However, we are responsible for our actions and attitudes per the Scriptures. The Scriptures do not excuse us because we were mistreated. But there is grace.

I have two pet peeves. First, the example of bad pastoral care is not followed by bad example of stereotyped christian psychological care. Both are problems. I wish they did more to call out their own kind. Second, they continue to see sin primarily as only original sin. This, I think, does much to minimize active will, motivation and choices in everyday living. By listing the faith dimension of schemas last, they may unintentionally give it only a small slice of the pie when in fact it is a part of every other part of a schema. Each of the other 9 statements about schemas are clearly shaped by our spiritual beliefs and actions.  

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Integrative Psychotherapy VIII: Symptom reduction of anxiety

If you recall from prior chapters, McMinn and Campbell propose a 3 tiered model (IP) to address symptom, schema, and relationship issues. In chapter 7, they explore symptom focused interventions for anxiety (while not denying or addressing relational or schema matters of anxiety disorders). The authors provide a description of 5 types of anxiety problems (panic, phobias, OCD, PTSD, and GAD) and typical Cognitive Therapy interventions for each. For example, they describe panic as a “fear of fear” and explore interventions designed to interrupt the cycle of “internal physiological events” and “fearful appraisal of physiological sensations.” Such interventions include cognitive challenges or reframes, breathing and relaxation, and exposure (in vivo or imaginal) coupled with relaxation training. 

After providing this review of anxiety and common interventions, they move to a very brief discussion of fear from a spiritual perspective. The opposite of fear is love (not courage). They conclude that fear is, “a great spiritual problem” (p. 236). But, they quickly say, “we should not attribute anxiety problems to spiritual weakness.” They argue that doing that sets up an inappropriate simplistic model (you are anxious because you are immature) and ignores the complexities of fear. They fear it may also send the message that only people with anxiety cause their problems, when in fact we all live “outside of Eden.” So, our bodies, our communities, our wills are all tainted with sin. But, they say, “it is damaging and unrealistic to assume direct and immediate connections between a particular problem and spiritual maturity.” What should we do? “Our best response is to recognize our own brokenness so that we can, in humility, become people of compassion and understanding, willing to walk alongside others through the difficult passages of life.” (p. 236)

My thoughts? This is a classic CT review of anxiety. I’m not sure I saw much of their theological model of persons in this chapter. However, I have to remember this is a chapter designed only to address the symptom reduction aspects of therapy. The authors did not intend to look at relationships and schemas. In the real world, we can’t separate out schema and symptoms and deal with only one and not the other. I understand why they do highlight interventions in each domain in the book, but it comes at a cost (realism). I do wish they would have included a chapter on putting it all together by following a particular case. I also wish they would keep following anxiety problems through the other 2 domains of the model, but they didn’t.

My bigger concern is the thin discussion on spiritual aspects of fear symptoms. Now, maybe they will pick up more when we get to schemas since schemas look at worldview and beliefs. But, while I agree completely with the last quote above, I think they make an all-or-nothing proposal. They are right that judgmentalism and simplistic understandings of fear are inappropriate. However, avoidance tactics found with panic symptoms do reveal implicit demands for control beyond what God intends. Symptoms both happen and are chosen. These demands that we make may be unconscious and may be completely understandable. And yet, I believe we can explore symptom maintenance and reduction AND talk about spiritual matters without equating spiritual maturity with the elimination of all problems.   For example, OCD symptoms such as worry that one has caused harm to another (e.g., hit someone while driving to work) can be best treated by cognitive challenges, imaginal exposure and response prevention. But as one attempts these interventions it is likely that conversations arise about the desire to avoid causing anyone harm. Now that is a deeply spiritual conversation–and I suspect the authors agree. Hopefully we’ll see some discussion of this in the next two chapters as they look at schema issues.  


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Integrative Psychotherapy VII: Functional Domain Interventions

McMinn and Campbell start out chapter six (a deeper review of the 1st domain of interventions, that of addressing symptoms) with this helpful insight: “Many of our graduate students select psychology as a profession after deciding against one of two alternative career paths.” Some are tempted to pastoral ministry and so see psychology as a way to care for human souls. Others are tempted to medical practice and so see psychology as a way to, “help people find relief from their troubles” (p. 177). This distinction is helpful in explaining why some of us hang out in one type of intervention over another.

But whatever one’s interests, everyone must address presenting problems and not bypass symptoms as these are what bring people in to therapy in the first place. So, the authors use this chapter to outline, in general, symptom-focused interventions, The next chapter will apply these interventions specifically to anxiety.

Right off the bat, the authors bring up emotions. They want to dispel the myth that cognitive therapist care little for feelings. They want to define negative emotions as either a sign of cognitive distortions and/or a warning sign that something is off in one’s life. [Hopefully, they do not fully believe that negative emotions means that something is wrong in one’s life. It may be something is wrong in the world…]. To achieve successful interventions in this domain, one must have good relational skills to listen well to both explicit and implicit feelings.

It comes as no surprise that domain 1 interventions include behavioral skills. The authors summarize classical and operant conditioning in a few short paragraphs and suggest that these techniques may help clients have dominion (through reinforcement strategies?) over their own behaviors and responses to life. Their lack of attention to behavioral mod. sends a message.

The bulk of the chapter then focuses on the basic of cognitive restructuring. They divide this task into two parts: sorting an experience into its component parts AND challenging distorted thinking. The authors describe the technique of the thought record and walk through several vignettes to show how it might be used. The record separates situations, thoughts, and feelings (and rates intensity of feelings/experiences on 1 to 10 scale). As the client gains insight, then the work is to counter the automatic thoughts with a rational response. The authors want to remind the counselor to avoid a disputing mindset when countering a client’s distorted thought patterns. Instead, they suggest a more collaborative approach or “Socratic method” using questions and reflections to lead the client to insight rather than drag them to it. 

Beyond the thought record, they describe other methods of changing one’s thinking: scaling (moving away from all/nothing thinking to put stressors in proper perspective), probability estimates (used when someone is worried about an unlikely event), decatastrophizing (helping to move away from “extremist thinking”), humorous counters (identifying silly thinking without making fun of), role-playing (reversing roles and having the client become the counselor), paradox (overstating the client’s fears to see the logical outcome), and cognitive rehearsal (repeated challenge to automatic thoughts).

Finally, they attempt to provide a Christian appraisal of these interventions. First, they tackle the problem of relativism that may underly CT by the biblical concept of testing and trying every “truth.” Instead of rejecting all client automatic thoughts by some sort of Stuart Smalley self-talk mantra, test their thoughts with Scripture, tradition, experience, and reason—aka Wesleyan quadrilateral. Then they give some examples of how a Christian collaborative response to a client with a difficult marriage might look different from a relativistic (be happy) response. The client and the counselor work together to explore what Scripture, tradition, experience and reason might bring to the table (these are not considered equally weighted of course) in discerning the truth about our selves and our thoughts about ourselves.

My thoughts? This chapter is solidly within the CT frame with the recognition that truth has a capital T. Our job as counselors isn’t to tell the clients the truth but to walk with them in a collaborative manner. It is good to see lots of humility in the chapter. We can abuse Scripture, overplay tradition or reason, become disputational, etc. What is missing from this chapter (maybe in comes later) is that while it is helpful to recognize logical errors, it is also true that logic does not always (often?) lead to better thinking. We have some pretty embedded views of ourselves that continue even in the face of our logic. How will they deal with this issue?

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Integrative Psychotherapy V

Now here in chapter 4 of Integrative Psychotherapy, McMinn and Campbell are starting to map out their 3 domained model of persons and psychotherapy. As an aside, the next chapter will cover how to do assessment and case conceptualization within this model and the remaining 6 chapters (excluding the conclusion) will be spent exploring each domain and how to apply the concepts into practice (2 chapters per domain). Should be a fun ride.

If you will recall from their chapter 1, they imagine the imago dei as a good rubric of the nature of persons and as best described by its functional, structural, and relational aspects (i.e., behavior, cognitive/moral, and relational aspects). They note that most therapy models tend to address one of these 3 domains problems: cognitions and challenging distorted thinking/acting, schema or insight-oriented work, and relational/experiential work. Instead of separating these domains, McMinn and Campbell define them as necessary and interconnected. “A person engages in functional behavior because of certain structural capacities, and similarly, relationships influence a person’s [behaviors and schemas].” (p. 115)

I think the best way to understand the interconnected parts of their model is to see it. Page 136 offers a nice illustration (Thanks Mark for making this available.). Note how behaviors, thoughts and feelings are influenced by situations but also arise out of core beliefs/schema and relational experiences. Note also the dark arrows depict the common path of influence but that feed-back loops are in play as well. Though I wish they gave more detail here how the domains interrelate (that would be a very fat personality text!), they do a fine job illustrating what they mean by discussing the case of “James,” a man who suffers with anxiety and things his value comes from meeting others’ expectations.

Domain 1 (Functional/behavioral) lends itself to symptom reduction and skill-building activities (the heart of cognitive-behavioral therapy). A counselor might address how James might learn so anxiety reduction techniques. But stopping here leaves James and the counselor wanting more. Why does James view himself and the world this way? Where do these distorted views come from? McMinn and Campbell recognize that these views are very hard to disrupt because they are so well-engrained through experiences. Domain 2 (Structural) then looks deeper to settled core beliefs using insight-oriented techniques to expose unconscious schemas that might uncover how these schemas got started (we learn, among other things, that James’ father was harsh and that he made some understandable but problematic choices/interpretations that now lock him in a pattern of perceiving himself as a failure–even though this view violates his own Christian belief).

Domain 3 (Relational). IP recognizes that formative relationships shape our schemas AND that the formative relationship between client and counselor provides experiences to shape and reshape our experience of self, other, and God, mirroring the incarnation of Christ.

Throughout this chapter the authors show how the IP 3 domain model is similar and different from standard CT. Yes CT is interested in reducing distorted thinking and building life skills. But IP also values insight and experiential aspects to therapy and provide additional opportunities to expose settled core beliefs (See p. 132 for a great chart illustrating how IP stands as a bridge between CT and insight-oriented models). IP attempts to show how the interconnections of situations, past experiences, developed core beliefs, habits, etc. illustrate both determinism (stuff outside us shapes us significantly) AND human agency (our choices also shape us). They also explain that classic CT has not done a good job explaining how relationships, motivation, emotions and culture play in person development. Further IP is not merely CT with some additions because it is built on a Christian view of persons (creation, fall, redemption, imago dei, etc.)

MY THOUGHTS AND ONE QUESTION: Now, we are getting into the meat of their model. It is good to hear their theoretical foundations in previous chapters but now McMinn and Campbell show us how they see how humans develop. While acknowledging the Fall, here’s what I see about their view:

1. Humans are intrinsically motivated to move toward God and long for a proper relationship to God, others, and creation.
2. The fall brings misery, brokenness, and difficulty (our fundamental problem is broken relationships)
3. Fallen humans are ripe for cognitive distortion.
4. When good longings (see pt. 2) are not met, we make bad but understandable choices (even adaptive at the time) and interpretations which lead to formative experiences that we interpret in distorted ways which in turn lead to more cognitive, moral/schema, and relational problems.

Classic Reformed theology suggests we NOT ONLY inherit a broken world, we also inherit Adam and Eve’s desire to be on par with God. We have an intrinsic motivation to be God and our denial of God comes out of this motivation (Rom 1). So here’s my question (in 2 parts):

1. Do we begin with good longings that we attempt to meet in naive and foolish ways (a la James in chapter 4), OR do we begin at birth to read things in distorted ways because we are looking to be our own God? Or both
2. Does this distinction matter? How would it impact our therapy model or application?

Calvin seems to support both ideas. He says our heart are idol factories AND he says our problem is not so much what we want/desire, but how much we want it. Notice that if you emphasize the “bad response to a bad situation” then it might end up dismissing personal culpability. However, if you emphasize the “bad heart seeks self promotion” then it might end up missing the all important influence passed on from a broken world and thereby blaming people for being sinned against.


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Integrative Psychotherapy III

In chapter two of Integrative Psychotherapy, McMinn and Campbell attempt to set our their foundation for psychotherapy. You’ll remember that in the last chapter they articulated their theological foundation. This chapter nicely divides into two parts: (a) A defense of the science of psychotherapy, and (b) a summary of what is “known” about the what works, when, and why.

They begin the chapter by admitting that there are many competing and dispirit theories/models of psychotherapy–many which have never been tested through empirical means despite lofty claims. They also acknowledge that many Conservative Christians have cherry picked certain studies that show that psychotherapy is ineffective and ignored many others that say the opposite. In other words, anyone can find a stat to prove whatever they want.

McMinn and Campbell remind their readers that they intend to build a Christian Psychotherapy model built on a robust Christian worldview and fleshed out with scientific methods to tell us, “what works, whey, and why” (p. 56). They lament that since both scientists and theologians aren’t known for their humility, a robust Christian psychotherapy model has not really been built. Collective wisdom is needed to accomplish the goal.

Then the authors turn to some of the details about the science of psychotherapy? Is it really effective? They summarize some of the effectiveness and efficacy studies (these are different: effectiveness: client survey; efficacy: lab studies of very specific interventions on one particular problem). Back in the 1950s Hans Eysenck published a number of studies reporting, “there was no research evidence to support the effectiveness of psychotherapy compared to no-treatment control groups” (p. 57). By 1980, however, there was ample evidence to the contrary. In fact, McMinn and Campbell report, “that the average effect size for psychotherapy is .82 indicating that the average treated is less symptomatic than 80% of untreated persons” (p. 58). They then compare that number with the effect size of certain medications on psychiatric problems (stimulants for ADHD: .91, SSRIs for Depression: .50, Atypical Antipsychotics for Schizophrenia: .25).    

Does any one model work better than another? The authors report the oft-heard conclusion: no one model seems more effective than another. And yet, at the end of this chapter they state their preference for Cognitive theory models (due to the research published about cognitive techniques) joined to aspects of client-centered models and other aspects of psychotherapy research. In olden days, we called this eclectic. They do not call it that, most likely due to the negative connotations associated with the word (it has often been used to cover up the lack of theoretical awareness of the clinician using the term).

Before they end the chapter, they consider whether length of treatment matters. They do not really do much with this question other than to point out that most therapeutic courses are much shorter these days. They also consider the question whether therapy benefits last. Again, they don’t cite the literature but state the that certain factors will make it more or less likely for the benefits to last.

They speak briefly about two more important matters in the consideration of the effectiveness of psychotherapy: (a) recognizing that common threads of the change process (insight, affective experience, stages of change, behavioral change, etc.) and point to the works of Prochaska and DiClemente, and (b) common factors in all models of therapy that seem to account for success. They cite date regarding these factors (and the percentages the factor accounts for for therapy outcome) as

  1. Client and extratherapeutic factors (40%). Such as intelligence, motivation for change, persistence, social support, resiliency, etc.
  2. Relationship between client and therapist (30%). This is why program emphasize relational skills over techniques or models
  3. Hope/expectancy (15%). How much hope does the client have in the possibility of change?
  4. Model/Technique (15%). Notice that the learning of special therapeutic techniques only account for a small portion of the outcomes in psychotherapy.

My thoughts on this chapter. Nothing out of the ordinary here. The chapter follows conventional wisdom about the science of therapy. The reader who wants to go deeper can look look at their bibliography and dig pretty deep. The reality is that though we think we know a number of things, the research on psychotherapy is complex and sometimes controversial. This is not to say that we know nothing. But we do have a long way to go. I might have liked to see some more discussion on what we as yet do not know but really want to. Further, I would have also liked a short discussion of philosophy of science. Why? Just as we need to be tentative about some of our theological underpinnings, so we ought to be a bit tentative about the modernist underpinnings of psychological research. I don’t think they are overstating their case yet, but the reader may view these two disciplines (theology and psychology) as one having only theory and the other only fact.

I do hope that they will take a look at the presuppositions of cognitive theory in the next chapter. How does that model influence what they see? 

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