European Journal of Psychotherapy and Counselling,

March 2008; 10(1): 19–38

The integrative attitude – a personal journey

JOHN NUTTALL

School of Psychotherapy and Counselling Psychology, Regent’s College, London

and Greenwich University, London

Abstract
The origins of clinical psychotherapy date from the beginning of last century and the
development of broadly four foundational schools – psychoanalytic, cognitive-
behavioural, humanistic and transpersonal psychologies. The imperative to integrate
these schools, however, is relatively recent and in the last 25 years a professional
integration movement has developed, exemplified by the formation of SEPI and the
UKAPI, and ‘integrative psychotherapist’ is now the most popular nomenclature used
in the profession. This article gives a brief history of the integration movement, reviews
some issues raised by developments so far, and discusses the personal dilemma that
integration evokes in the would-be integrative practitioner. Using my own journey I
espouse an integrative attitude that is based on the nature of integration as an evolving
personal process rather than an ideal, fixed, profession-wide position. I describe three
interweaving modalities of integration I call constructive, complicit and contiguous
integration, which form a developmental framework that aims to encourage the
individual activity of questioning, inventing, researching and interrogating the
discipline within its philosophical, professional and social context. In concluding,
this article exhorts the profession to see integration as a personal journey, as a way of
being that is constantly becoming and unfolding in relation with the therapist’s
training, experience and interaction with peers and clients. The result is indefinable
and unnameable, and perhaps represents the soul of integrative psychotherapy.

Keywords: Psychotherapy integration, integrative psychotherapy, SEPI, therapeutic

relationship, constructive, complicit, contiguous

Introduction
Psychotherapy as an empirical-scientific discipline, although foreshadowed by
Hippocrates and Gallen, has existed for little more than a hundred years

Correspondence: John Nuttall, School of Psychotherapy and Counselling Psychology, Regent’s

College, Inner Circle, Regent’s Park, London, NWI 4NS. E-mail: [email protected]

ISSN 1364–2537 print/ISSN 1469–5901 online/08/010019–20 ß 2008 Taylor & Francis

DOI: 10.1080/13642530701869326
20 J. Nuttall

(Ehrenwald, 1976; Frank, 1986). The origins of clinical psychotherapy as we

know it today arguably date from the coincidental innovative work of Freud,
Pavlov and Moreno at the start of the last century (Corsini, 1995, p. 12).
From these beginnings three major foundational schools of psychoanalysis,
cognitive-behaviourism and humanistic psychology developed (Clarkson,
1992a, p. 3; Nelson-Jones, 2001, p. 3). To these must be added the more
recently acknowledged fourth school of transpersonal psychology (Boorstein,
1996, p. 2), which, paradoxically, has a much longer history, steeped in what
Frank (1986) called the religio-magical tradition. These schools have become
the basis of one classification of the current psychotherapy profession
although other, slightly different, classifications have been presented
(Beutler, Bongar, & Shurkin, 1997; Roth & Fonagy, 1996).
‘Integration as a point of view has probably existed as long as philosophy
and psychotherapy’ (Prochaska & Norcross, 1999, p. 459) but only in the last
25 years has it developed into a recognisable movement in the psychotherapy
profession. A number of names have been given to this movement, the abiding
characteristic of which has been, ‘a dissatisfaction with single-school
approaches and a concomitant desire to look across and beyond school
boundaries to see what can be learned from other ways of thinking about
psychotherapy and behaviour change’ (Norcross & Arkowitz, 1992, p. 1).
One of these early names was the ‘eclectic movement’, but the generally
accepted term for this professional lobby is now ‘the integration movement’
(Hollanders, 2000, p. 34) and ‘integrative psychotherapist’ is now the most
popular nomenclature used in the profession (Norcross, 1997). These trends
were crystallised by the formation in the USA of the Society for the
Exploration of Psychotherapy Integration (SEPI) in 1982, by the British
Society for Integrative Psychotherapy in 1987, (now succeeded by the UK
Association of Psychotherapy Integration [UKAPI]) and by the European
Association for Integrative Psychotherapy in 1993.
In its mission statement SEPI proclaims, ‘The primary objectives of SEPI are
to encourage communication and to serve as a reference group for individuals
interested in exploring the interface between differing approaches to
psychotherapy’ (SEPI, 2003). Significantly, the Society offers no prescription
for psychotherapy integration, nor does it clearly define what constitutes such
integration, and importantly, it allows integration to be a personal quest as well
as a profession-wide activity. However, a number of its leading members have
described the ‘three most frequently employed strategies for psychotherapy
integration as, technical eclecticism, common factors and theoretical integra-
tion’ (Safran & Messer, 1997, p. 143). These were originally enumerated by
Arkowitz (1989) and are more aptly referred to as ‘routes’ by Norcross and
Newman (1992, p. 10), who pointed out ‘integration, as is now evident, comes
in many guises and manifestations’ (p. 15) and that there is now a ‘proliferation
of integrative theories’ (Fear & Woolfe, 2000, p. 337). A number of pragmatic
ways of integrating have been suggested, such as the assimilation of a range of
techniques into a core system (Messer, 1992) and complementarity (Goldfried,
1995), the combining of techniques from different systems; ways that seem
appropriate for all the routes mentioned above.
 The integrative attitude – a personal journey 21

Studying these professional developments as part of my integrative training

led me to explore how the many theories of psychological health and
disturbance might be integrated and reconciled, and whether they could be
considered, as Roth and Fonaghy (1996) suggest, ‘approximate models of the
same phenomena: the human mind in distress’ (p. 12). Such a quest might
never be fulfilled; ‘It may never be possible to achieve coherent integration, to
create the ‘‘grand theory’’, but let the dialogue continue’ (McLeod & Wheeler,
1995, p. 287). This article is part of that dialogue and represents my attempt to
espouse an integrative attitude that will, hopefully, help others on their
personal journey.

The integration movement

The integration movement has been generally concerned with finding ways
and rationale by which the theories and practices of the four foundational
schools can be brought together to improve therapeutic outcome. The first
integrationist may have been Freud himself, as Frances (1988) highlighted
at the SEPI conference in 1988 and Javel (1999) argues in his article The
Freudian Antecedents of Cognitive Behavioural Therapy. Javel contends that
‘classical psychoanalysis’ diverged from Freud’s actual techniques and
writings, which – he argues – converge more with the tenets of cognitive-
behavioural therapy. He exhorts cognitive behaviourists ‘to look at the works
of Freud for insight, inspiration and answers . . .’ (Javel, 1999, p. 406).
Probably the first recognised attempt to integrate behaviourism and
psychoanalysis was presented to the American Psychiatric Association by
Thomas French (1933) and was later elaborated by Kubie (1934), although
their ideas were not appreciated at the time. Arkowitz (1992) describes how
others developed these links further and suggests that one of the most
influential books in this vein is Wachtel’s (1977) Psychoanalysis and Behaviour
Therapy: Towards an Integration, which examines how the psychoanalytic
theories of Sullivan and Erikson allow for understanding problematic
behaviour as a conditioned response to interpersonal relations. Wachtel
developed his ideas into an integrative system he called cyclical psychody-
namics, and continued his influence by co-founding SEPI in 1982. Overall,
these integrative developments seem to be the precursors of what emerged in
the UK as cognitive analytic therapy (Ryle, 1990).
As humanistic psychology developed in the 1960s (Moss, 1999) a greater
willingness emerged amongst the psychotherapy schools to share and accept
each other’s understanding. This was vividly demonstrated by the production
of the Gloria films (Rogers, Perls, & Ellis, 1965), but was also exemplified by
the influence of two prominent authors of that decade. Firstly, Jerome Frank,
who wrote Persuasion and Healing (1961), identified a number of features
common to the psychological healing traditions of different cultures. Secondly,
Arnold Lazarus introduced the concept of technical eclecticism in 1967 and
developed the approach called multimodal therapy (1989). However, probably
the most recognised integrative system developed in this period based on
humanistic values is Egan’s skilled helper model (Egan, 1975), which
22 J. Nuttall

Jenkins (2000) argues, ‘shares some characteristics of the cognitive-behaviour

school and is firmly grounded in the core conditions of the person-centred
approach’ (p. 163). Transactional analysis, which also developed mainly in the
1960s, has been similarly described as ‘a multi-faceted system of psychother-
apy’ that ‘integrates intrapsychic dynamics with interpersonal beha-
viours . . . within a humanistic/existential framework of values’ (Clarkson,
1992a, p.1).
This brings me to the current state of psychotherapy integration, and the
influence of the postmodern Zeitgeist, which Clarkson (1995) suggests has
encouraged a growing realisation that the so-called ‘truths’ or meta-narratives
represented by the four foundational schools are ‘fundamentally flawed as
singular definitions of reality’ (p. vii). Palmer and Woolfe (2000) point out that
‘counselling and psychotherapy are not immune from this tendency’ and
suggest that it ‘has led to a growing interest in flexibility of response and
bringing together ideas from disparate schools’ (pref.). Several professional
and economic factors have also encouraged integration. Gold (1993) described
a trend to stop ‘looking for the ‘‘best’’ therapy to a more pragmatic search for
the best of many therapies in order to survive economically and professionally’
(p. 6), and Newman and Goldfried (1996) highlighted the pressure to improve
the cost effectiveness of treatments from insurance companies and government
health services. On the professional front, another factor is that ‘the
[therapeutic] relationship is consistently being shown in research investigations
as more significant than theoretical orientation’ to clinical outcomes (Asay &
Lambert, 1999; Clarkson, 2003, p. 5). Roth and Fonagy (1996) present a
similar conclusion in their review of psychotherapy outcome research in What
Works for Whom?, which adds to Asay and Lambert’s work by reviewing
outcome studies by type of illness and client group. Such research supports
Polkinghorne’s (1992) view that ‘the large number of theories claiming to have
grasped the essentials of psychological functioning provides prima facie
evidence that no one theory is correct’ (p. 158). This view, combined with
the postmodern perspective, has resulted in the emergence of what might be
considered to be higher order models of integration that eschew deference to
psychological theories in favour of emphasising the importance of the quality of
therapeutic relationship per se. Prochaska and DiClemente’s transtheoretical
model (1984), Hobson’s conversational model (1985) and Clarkson’s
five-relationship framework (1995) are pioneering developments in this vein.
During my reflections I recognised a more personal imperative seeking
resolution or acknowledgement. I agreed with the view that ‘a personal
integration is an individual construction that can be developed to reflect the
thinking and practice of the individual therapist’ (Horton, 2000, p. 326), but I
wondered if the integrative quest also had a deeper psychological meaning and
– at least for me – was part of a broader movement towards individuation.

Personal psychotherapy integration

So, what might be the personal nature of this quest for integration? One
obvious aspect of it is that of becoming a professional integrative
 The integrative attitude – a personal journey 23

psychotherapist but as well as being a ‘construction’ our choice of approach

may be symbolic of much deeper psychic processes and aspirations.
Sussman (1992), in his book A Curious Calling, presents a range of underlying
motives for choosing this profession. He argues that one of the main reasons is
the healing of our own psyches, and we might all recognise this reflexive
process operating as we progress through our training programmes and
associated personal therapy. This link was noted by Victor Frankl, the
inventor of logotherapy, when he wrote, ‘It may be that each person who
develops his own system of psychotherapy writes, in the final analysis, his own
case history’ (Frankl, 1988, taken from Nelson-Jones, 2001, p.1).
This raises the question of what constitutes a system of psychotherapy.
The integrative therapist, John Norcross (1990), writes:
Psychotherapy is the informed and intentional application of clinical methods and
interpersonal stances derived from established psychological principles for the purpose of
assisting people to modify their behaviours, cognitions, emotions, and/or other personal
characteristics in directions that the participants deem desirable (p. 218).

On the face of it, this seems a fairly useful definition. However, it does not
clearly delineate psychotherapy because the underlying methods, principles
and purpose are not fully explicated; there is no sense of the uncertain,
subjective and chaotic nature of such interpersonal systems. Nevertheless, as
Mahrer (2000) points out:
Although the field seems to lack an officially sanctioned list of its formally stated, taken-for-
granted fundamental givens and truths, the field is rife with foundational beliefs
that are generally presumed, assumed, implied, taken for granted, and occasionally spelled
out (p. 117).

This is manifested in the diversity of metaphor used to describe the therapeutic

journey and its outcome. For example, in Studies on Hysteria, Freud (1896)
wrote, ‘Much will be gained if we succeed in transforming your hysterical
misery into common unhappiness’ (p. 305). Klein (1940) talked about
‘overcoming the depressive position’ (p. 353). On a more sanguine note, Kohut
(1977) aimed at the restoration of the self. Maslow (1970), the humanistic
psychologist, called it self-actualisation. Rogers (1961) aimed for what he
called a fully functioning person. Cognitive-behaviour therapists aim to change
maladaptive beliefs and behaviours. The existential approach is about
confronting life’s givens and one’s own-most potential. Jungians call the
journey individuation and transpersonal psychologists refer to states of
consciousness that transcend the limits of personal identity. These brief
descriptions do not do justice to the theories and practices concerned but,
nevertheless, serve to illustrate the diversity of perspective currently pervading
the profession.
It is understandable, therefore, that training as an integrative psychothera-
pist has its ups and downs – periods of apparent understanding and belief,
interspersed with periods of confusion, disbelief and occasional despondency.
It has been estimated that there are over 400 systems of psychotherapy
(Corsini, 1995), although many of these represent subclasses of the smaller
number of foundational schools mentioned earlier. These schools might be
24 J. Nuttall

considered the pillars of psychotherapy, and thinking of them in this way

reminds me of an amusing story (probably untrue) about William James, the
first professor of psychology at Harvard, who, when writing his book Varieties
of Religious Experience (James, 1902), visited a Hindu sage:
He asked the master, ‘I understand you believe the world to be supported by four huge pillars.’
‘Yes that’s true’, replied the sage.
‘But I’m curious,’ said James, ‘What holds the pillars up, on what do they stand?’
‘Why Dr. James that’s quite easy to explain, the pillars stand on the backs of four great white
elephants.’
‘But on what do these stand?’ asked James, reasoning that there must be a single foundation.
‘Well, on the backs of another four great white elephant, of course,’ replied the sage.
James, feeling irritated, was about to ask on what foundation these stood, when the sage grabbed his
arm, interrupted him, and said quietly, ‘Dr. James, Dr. James, before you ask, it is great white
elephants all the way down!’

In the same way, I wondered if the four pillars of psychotherapy had at their
base some single foundation or truth. Unfortunately, nobody has yet
discovered the ultimate truth of how to conduct psychotherapy, and the
research quoted earlier suggests no one school is more efficacious than another.
As trainees, we expect our training institution to provide us with meaning and
certainty or, at least, an approximation of the truth. Instead, we are presented
with diversity, uncertainty, relativism and a range of different ways of talking
about ostensibly similar psychological phenomena we encounter in the
consulting room. No doubt this lack of cohesion evokes in us the very psychic
dilemmas we entered the profession to resolve. For many trainees it leads to
periods akin to St. John of the Cross’ Dark Night of the Soul (Starr, 2002):
feelings of being totally abandoned by certainty. In my experience of training
others it normally hits about half way through a typical masters degree
programme in which five or six different approaches to therapy are studied.
Reconciling this complexity and tolerating the uncertainty, especially for the
trainee integrative therapist, is – in my view – the central concern of the
integrative quest. It is something of a lifetime’s task, and may never be resolved,
as Jung’s retrospective of his journey suggests. In his autobiography he wrote:
The older I have become, the less I have understood or had insight into or know about myself.
I am astonished, disappointed, pleased with myself. I am distressed, depressed, rapturous.
I am all these things at once, and cannot add up the sum. I am incapable of determining
ultimate worth or worthlessness; I have no judgement about myself and my life. There is
nothing I am quite sure about. I have no definite convictions – not about anything really.
I know only that I was born and exist, and it seems to me that I have been carried along. I exist
on the foundations of something I do not know. In spite of all uncertainties I feel a solidarity
underlying all existence and a continuity in my mode of being (Jung, 1963, p. 392).

It would be reasonable to conclude from all this, that models of psychotherapy

are just, ‘views or constructions of reality’ (Horton, 2000, p. 326). We do not
know them to be true in any objective sense. They are merely stories,
narratives of the way the pioneers constituted their experiences. Professor
Petruska Clarkson, with whom I trained for four years, used to say after every
theoretical seminar, ‘And remember, it’s only one of the stories, the thing we
are more certain about is that two people sit together and there is
relationship’. However, for a trainee therapist, this chipping away at the
 The integrative attitude – a personal journey 25

foundations of psychotherapy raises the awareness of the absence of ‘knowing’

and the lack of firm foundation and brings some anxiety about how to practice
and how to be with others. But, such awareness does not bring solace. On the
contrary, it disturbs and awakens us. I count myself fortunate to have trained
with Clarkson and Regent’s College, which, combined, encouraged a
particular integrative attitude that helped me confront and tolerate both the
psychodynamic and existential incertitude that my quest for personal
psychotherapy integration involved.
Training schools and professional affiliations may be places from which we
seek a sense of certainty but, as I have indicated, they may not always be the
places we need to look, as a story about the legendary Mulla Nasrudin (Shah,
1999, p. 62) points out. On one occasion his neighbour found him down on
his knees looking for something:
‘What have you lost Mulla?’ he asked.
‘My key,’ replied Nasrudin.
After a few minutes of helping him search, the neighbour asked, ‘Where did you drop it?’
‘At home,’ said the Mulla.‘Then why, for heaven’s sake are we looking here?’
‘Well, there’s more light here’ replied Nasrudin.

Shah points out that this is one of the most famous Nasrudin stories about
novices not knowing where to seek enlightenment (1999). As a client and
student myself, and later as a practitioner and teacher, I realised that the
certainty, knowledge, enlightenment, or whatever I was seeking was ‘at home’,
that is, within me. Heraclitus tells us, ‘It belongs to all men to know themselves
and to think well’ and that, ‘much learning does not teach understanding’
(Kahn, 1981). Teachers and schools can show us the way, but they cannot
direct our inner quest. I considered it my responsibility as an individual to
question, experiment, search and re-search for meaning and understanding in
this subject I had chosen, and psychotherapy integration raised a number of
personal and professional issues for me that needed reflection, if not resolution.
O’Brien and Houston (2007), who ‘see integration as a corrective tendency in
an over-fragmented field’ (p. 4) discuss a number of ‘obstacles to integration’
(p. 5), but the most thorough review of such issues that helped me was by
Hollanders (2000) who enumerated nine issues central to the integration
debate. I should like to discuss these briefly, adding one of my own, to pave the
way for a deeper discussion of my journey and the development of my view of
the integration process.

Issues for psychotherapy integration

Issue one concerns the definitions of eclecticism and integration. ‘Eclecticism’ is
a process of selecting out, with the implication of taking something apart;
‘Integration’ is the process of bringing things together, with the implication of
making something whole and new and Hollanders sees eclecticism as a
particular range on a continuum incorporating the three routes to integration
discussed earlier (1997). Norcross and Arkowitz (1992, p. 19) also view
eclecticism as the middle stage of a move from the segregation of schoolism,
26 J. Nuttall

to the stage of full integration, the characteristics of which are not yet
determined. These conceptualisations identify a tension active in most
integrationists, as Paul Wachtel (1991) describes, ‘eclecticism in practice and
integration in aspiration is an accurate description of what most of us in the
integration movement do much of the time’ (p. 44).
Issue two raises the incommensurability of paradigms, that the mainstream
schools of psychotherapy cannot be reconciled because of their different
philosophical or epistemological bases (Kuhn, 1970) and this raises ‘the issue
of whether integration is a viable project at all’ (Hollanders, 2000, p. 34).
Such an objection only really applies to theoretical integration, and suggests
that this particular route is idealistic or unattainable; although to accept this
would be to undervalue the work of integrationists such as Alexander (1963),
Wachtel (1977) and Ryle (1990).
Issue three is about the relationship between integration and pluralism, and
questions whether the concept of integration is out of step with the
postmodern Zeitgeist. This is only an issue if integration is viewed as the
search for a single grand theory. If, however, it is viewed as a position or
process that individual therapists determine for themselves, then it may – as
Norcross and Newman (1992) hoped – constitute ‘an open system of
informed pluralism, deepening rapprochement and empirically grounded
practice’ (p. 32). The question of whether integration is a position or a process is
the fourth issue raised by Hollanders. If the grand theory is neither possible
nor desirable then new integrative positions are only likely to add to the
proliferation of systems and bring further confusion to the marketplace. This
may be an acceptable transitory consequence, a desegregation stage, of getting
to the integrative position envisaged by Norcross and Newman above. On the
other hand, others prefer to emphasise the unending process and dynamic
nature of integration, ‘one of the most underlying values is that integration is
an ongoing process in a continual state of development and evolution’
(Clarkson, 1992b, p. 290).
The above issues interact with what I think is the most significant of the
nine Hollanders (2000) raised. This is the question of where the locus of
integration lies. He posits three possibilities: ‘Externally’ (i.e. primarily outside
the practitioner) in the profession or group; ‘Internally’ (i.e. primarily within
the individual practitioner) by therapists developing their own integrative
systems; and ‘Within the relationship’, that is between the therapist and client
as the client’s needs emerge (p. 37, original italics). Hollanders (2000) locates
the three routes described earlier as external integration. He identifies no
similar example for internal integration, but suggests it refers ‘to the whole
process involved in being a reflective practitioner’ (p. 38) and emphasises ‘this
reflection should be as widely informed as possible, by the experience of
others, the literature, varied ongoing training, etc.’ (p. 39). Similarly, the
principle behind integration within the relationship is that ‘it is the client who
indicates what is needed, and that she does so by the way in which she relates
to the therapist’ (p. 39). This concept is embraced by the integrationists
Duncan and Miller (2000) in their client-directed, outcome-informed
approach to therapy, and is perhaps echoed in the psychoanalytic school by
 The integrative attitude – a personal journey 27

Orange, Atwood and Stolorow (1997) on intersubjectivity, and Ogden (1999)

with the concept of the analytic third. There seem to be few integrative
approaches that represent this locus of integration, although Hollanders
suggests that Clarkson’s five-relationship framework (Clarkson, 1995a) is
a prominent example. He concludes that integration should take place in all
three loci, and should not just constitute a profession-level search for a grand
system.
The sixth issue concerns the question of commitment and whether the
integrative therapist can develop a sense of identity and loyalty whilst not
belonging to a recognised therapeutic school. This might be achieved by a
personal attitude of commitment, ‘not to a narrow school but to the whole
project of therapy’ (Hollanders, 2000, p. 42). This leads to issue seven about
the sociology of integration and the lack of a sense of community amongst
integrationists. The major traditions have their own professional bodies and,
although SEPI has emerged with its own journal and international network, a
more robust esprit de corps is needed amongst integrationists generally. This
may be discouraged by issue eight, the lack of a single language of integration.
On the other hand, Messer (1987) suggests that integration and the exchange
of ideas between schools would be facilitated more by therapists learning
several therapeutic languages.
The ninth issue, which I found particularly interesting, asks whether the
integrationist is a charlatan or statesperson. On this issue Hollanders (2000) is
quite emphatic and provides some resolution of all the issues when he writes
that the integrationist’s task is ‘to serve as a kind of ‘‘statesperson’’ within the
field’ (p. 44). This view of the integrationist touches on what I consider to be
a particularly important tenth issue for the integration movement. It concerns
the insular nature of psychotherapy integration so far outlined, which is
deemed to occur within the profession, the therapist or the therapeutic
relationship. Expanding Hollander’s analogy, we have a statesperson without
a policy for the environment or foreign affairs, without a view of the world
outside. This insular view ignores the kind of internal-external correspon-
dence that takes place along the boundaries of psychotherapy as it comes into
contact with the world at large. In other words, to what extent are the systems
of psychotherapy we build within appropriate for, consistent with, and
expressive of the phenomena of the world we experience around us? One of
the earliest studies of the link between human nature and that of human
institutions is probably Plato’s Republic, but in psychotherapy it is exemplified
by Freud’s Group Psychology and the Analysis of the Ego (1922), and
Civilisation and Its Discontents (1930) and in the humanistic school by
Rogers (1990) in A More Human World. This process is similar in principle to
an unnamed fourth route, referred to by Norcross and Arkowitz (1992), by
which integration is sought with allied disciplines such as psychiatry, sociology
and, lately, neuroscience. At the individual level, resolution of this internal-
external correspondence gives meaning and credence to the models of
psychotherapy we build, whether they are based on a single or a combination
of schools. So far this aspect of integration and the imperative it resolves,
although immanent, has been overlooked by the integration movement.
28 J. Nuttall

A personal journey of integration

My journey of psychotherapy integration probably began during my first
experience of psychoanalytic psychotherapy, which I found a stark contrast to
the transactional analysis I had learnt and practiced as a management
consultant. Some years later, before I started formal training as a
psychotherapist, I entered therapy again with a transactional analyst and
Gestaltist. As I gained knowledge of many different systems, I began to look
beyond the constraints of single schools to forge links that would help me
build an ideal integrative approach for application across a range of clients and
psychological conditions. For me this was quite a purposive and constructive
process and, although I did not realise it, involved my using Goldfried’s
principle of complementarity mentioned earlier, as I worked at reconciling
different theoretical concepts that had particular meaning for me. This
included Fairbairnian object relations with the ego state psychology of
transactional analysis (Nuttall, 1998), games (in transactional analysis) with
projective identification (Nuttall, 1999), Kleinian psychotherapy with
Clarkson’s relational framework (Nuttall, 2000a) and Jung with object
relations (Nuttall, 2000b). As I reflected on this work I recognised my struggle
to find the complementarity of my therapeutic experiences and, as a corollary,
reconciliation of the different objects and aspects of me these represented.
And this exploration continues as I attempt to reconcile different aspects of
myself as psychotherapist (Nuttall, 2003, 2006b).
In one form or another, this relatively simple reconciling or combining of
parts, which I have called constructive integration (Nuttall, 2002a), has
dominated the development of the integration movement in the last two
decades. It is generally made up of the three routes to integration identified by
Arkowitz (1989) and constitutes what Hollanders (2000) described as
integration with an external locus. At the professional level, the end result
represents more of a position than a process, where the new system, having
been initiated by an individual or a group, is developed in collaboration with
other professionals, academics or clinicians. Such systems may then be
adopted by other therapists as received clinical approaches that are supported
by empirical research or case history. This mode of integration is arguably
driven by the professional and economic imperatives discussed earlier. And,
as Fear and Woolfe (2000) point out, ‘the increase in debate, courses and
societies to promote the interests of integrative approaches has been
accompanied by a proliferation of integrative theories’ (p. 337) and I review
below three well-known integrative approaches that exemplify this construc-
tive modality.
The first, Gerard Egan’s skilled helper model (1975), represents the
common factors route and is primarily skills based and concerned with the
process of psychotherapy. This is broken down into the three phases of
exploration, understanding and action; with each of these engaging specific
relational skills relative to the client’s needs. Thus, ‘far from being rigid and
prescriptive, the model is intended to set out how to be with the client,
according to the varying needs of the therapeutic process’
 The integrative attitude – a personal journey 29

(Jenkins, 2000, p. 168). There is a strong resemblance between the common

factors associated with positive outcomes listed by Asay and Lambert (1999)
and the skills and techniques enumerated in the skilled helper model.
The second system, cognitive analytic therapy (CAT) developed by
Anthony Ryle (1990), represents, in my view, the quintessential example of
theoretical integration and, according to Evans and Gilbert (2005),
exemplifies the principle of complementarity (p. 31). It has a heritage that
dates back to French and Alexander and ‘CAT aims to combine within a
single framework what is most useful in psychoanalytical and cognitive
therapy theories’ (Crossley & Stowell-Smith, 2000, p. 203). The unifying
principle developed by Ryle is that of the procedural sequence model which
represents a unit of associated feelings, thoughts and behaviours of the
individual in relation to others. Pathology is conceptualised as the develop-
ment and habitual enactment of ineffective or problematic procedural
sequences. Cognitive analytic therapy is aimed at identifying such procedures
and their attendant techniques for perpetuation called traps, dilemmas and
snags, and reformulating them in a way the client will recognise and be
prepared to modify for the future.
Technical eclecticism ‘seeks to improve our ability to select the best
treatment for the person and the problem’ (Norcross & Newman, 1992,
p. 11). It was pioneered by Arnold Lazarus (1967, 1989) in his system of
multimodal therapy, which is based on thinking about and assessing the
client’s psychological problems across a range of modes of functioning. These
modes are: behaviour, affect, sensation, imagery, cognition, interpersonal and
drug/biology, for which he coined the mnemonic BASICID. Therapeutic
interventions addressing these modes are designed and introduced in order of
clinical priority and are often determined by using a variety of client profile
questionnaires. Lazarus (1992) believes that different techniques can be used
or combined, without the integration of the theories underpinning those
techniques, and argues that empirical evidence (clinical or research observa-
tion) should be the only criterion for judging which therapeutic interventions
are effective and for whom.
As my clinical experience increased, it felt more appropriate to consider
integration a personal endeavour that would allow flexibility and adaptability
for me and my relationship with my clients. I began, therefore, to examine if
Clarkson’s relational framework (1995) provided such attributes (Nuttall,
2000a, 2002b). In doing this, I recognised Clarkson’s work represented a
different perspective on integration, one that identified an emergent or higher-
order paradigm of practice that both simplified and embraced the plurality
and complexity in the profession. From this perspective integration is viewed
as an inevitable product of the ubiquitous process of synthesis that comes
from relationship and interaction. As Heraclitus said, ‘conflict (polemos) is the
father and king of all things’ and integration seems part of the natural process
of evolution and change he associated with the force of Nature he called
Physis (Kahn, 1981). This view emerged again in what the medieval
alchemist’s called the mysterium coniunctionis, a process in which, as the
Rosarium Philosophorum describes, ‘they that were two are made one as though
30 J. Nuttall

of one body’ (cited in Jung, 1946, p. 85). The theories of chaos and
complexity offer a contemporary narrative for understanding relationship in
terms of non-linear dynamic systems (Stewart, 1997). Isham (1995) also
points out that the concept of quantum entanglement suggests at a
fundamental level objects are ‘inextricably linked or entangled . . . in a sense,
they simply cease to be independent things, and one can only describe them
in relation to each other’ (p. 27).
Complicit integration takes this perspective of relationship and views some
integrative approaches as something that the contemporary sciences might
call strange attractors or emergent phenomena. In this sense, Stewart and
Cohen (1997) define emergence as ‘the appearance of recognisable large-scale
features in a system whose chain of small scale causality are far too intricate to
describe let alone follow in detail’ (p. 149). In nature such simplicity emerges
from complexity by an iterative process they call complicity. In Figments of
Reality Stewart and Cohen argue that the human condition represents such a
system, a ‘complicit interaction between culture and individual mind, each
shaping the other’ (p. x). The book presents a somewhat Heraclitian view of
the world as a place of constant interaction and flux, the underlying physical
reality of which we can only infer and never truly know through personal
experience. In deference to the above process I adopted the word complicit to
describe those integrative approaches that seem to represent such emergent
and higher-order systems of psychotherapy (Nuttall, 2002a) and I consider
Clarkson’s relationship framework (1995) and the transtheoretical model
developed by Prochaska and DiClemente (1984) to constitute such systems.
Others too have identified emergent relational modalities (Gelso & Carter,
1994; Greenson, 1967; Kahn, 1997), although these have not led to the
development of distinct models of integration.
Prochaska and DiClemente’s (1984) system ‘is predicated on the belief that
the current relativism can be transcended by discovering or constructing
concepts that cut across the traditional boundaries of the psychotherapies’
(Prochaska & Norcross, 1999, p. 491). They define it as a ‘higher-order
theory of psychotherapy’, which sets ‘out to construct a model of
psychotherapy and behaviour change that can draw from the entire spectrum
of the major theories’ (p. 491). I would argue in line with the principle of
complicity, that rather than construct, they have recognised – or identified –
a simple therapeutic process that has emerged out of the complexity of the
many disparate psychotherapy systems. Confirming this they write, ‘in
colloquial terms, we have identified the basics of how (process), when (stages),
and what (levels) to change’ (p. 505, my underlining).
The quest to find a basis for rapprochement prompted Clarkson’s research
(2003), from which she distinguished five primary modes of therapeutic
relationship, which she proposed as ‘a possible integrative framework for the
different traditions’ (p. xiii). In support, Hollanders (2000) describes it as an
‘integrative approach based essentially on the nature of the therapeutic
relationship’ (p. 23). The five modes are the working alliance; the
transferential-countertransferential; the reparative or developmentally
needed; the person-to-person or real; and the transpersonal relationships.
 The integrative attitude – a personal journey 31

Clarkson (1995) writes, ‘it is important to remember these are not stages but
states in psychotherapy, often ‘overlapping’, in and between which a patient
construes his or her unique experience’ (p. xii). Hinshelwood (1990)
supportively described Clarkson’s framework as ‘an attempt to find a
perspective from which an overview might become possible . . . instead of
having incompatibilities we have different priorities and emphasis’ (p. 129).
These approaches bring a new perspective to psychotherapy integration that is
about understanding the simplicity, the essence, or the core of what we do as
psychotherapists. They encourage the view that the four foundational schools
can be seen as complementary and enriching, rather than incompatible and
contradictory.
My interest then moved from one of finding integrative links to one of
understanding the integration process as a whole. In this I recognised a third
modality of integration, which reflects how psychotherapy relates to, and
explains, the world we experience and in which we live. It characterises
psychotherapy not only as a meta-psychology of the individual, but also of the
group, organisation and society, and represents engagement with the world
and other disciplines, such as neuroscience, sociology and anthropology. In
formulating an integrative approach I consider such contiguity or internal-
external correspondence useful in testing the approach’s robustness and
efficacy and, accordingly, I called this modality contiguous integration
(2002a). This seems to have been important historically for philosophers
and psychologists as it validated and added meaning to their conceptualisa-
tions. According to Samuels (1995), modern psychotherapy has had ‘an
ambition to give therapy to the world’. The principle of interrelatedness
underlying this dimension of integration can probably be traced back as far as
Heraclitus who wrote, ‘from all things one and from one thing all’. The
principle is apparent in later philosophies exemplified by the Hermetic adage,
‘as above, so below’ (Marshall, 2001, p. 251) or the Kabbalistic aphorism ‘so
too does the lower sphere affect the upper’ (Hoffman, 1996. p. 167). Leaving
philosophers aside, in modern psychology, Freud probably first demonstrated
this integrating process with Totem and Taboo (1913) and more concretely in
Group Psychology and the Analysis of the Ego (1922). Similarly, Freud’s Project
for a Scientific Psychology (1895) was an early attempt at integration of
psychoanalysis with the more recognised biological sciences; this particular
synthesis is also apparent in the work of Bowlby (Mitchell & Black, 1995) and,
more recently, Schore (2001).
Menzies Lyth (1986) writes, ‘psychoanalysts have been interested in society
and its institutions since ever there were psychoanalysts’ (p. 284) and,
following Freud and Klein, it was Bion (1962) who probably developed the
first comprehensive psychoanalytic theory of group and organisational
behaviour (de Board, 1995). These theories are now well-accepted
explanatory paradigms for group and organisational behaviour (Jacques,
1955; Menzies Lyth, 1986; Kets de Vries & Associates, 1991). At the political
level, Moses (1987) and Elliot (2005) show how psychodynamic processes
affect, and often hinder, the political process of conflict reconciliation, such as
those affecting the Middle East and Northern Ireland. In the humanistic
32 J. Nuttall

school, Gordon (1951) explored the applicability of Rogerian principles to

leadership and administration, and Berne’s concept of ego states and
transactional analysis have been used to understand organisational dynamics
(1963), group treatment (1966) and interpersonal games (1968). Jung also
offers one of the most extensive elaborations of internal-external correspon-
dence in the recent history of psychotherapy. Hawke (2000) refers to Jung as a
cultural theorist (p. 1) whose concept of the psyche addresses the gap between
collective norms and values on the one hand and individual beliefs and desires
on the other. Jung postulated a collective unconscious of archetypes, images,
which according to Stern (1998) ‘constitute the ultimate source of psychic
symbols, which attract energy, structure it, and lead ultimately to the creation
of civilizations and culture’ (p. 85).
The above are examples of how psychotherapy has been used to understand
and effect change in group, organisational and social behaviours and attitudes.
My exploration into this aspect has covered a range of different social
phenomena, such as the structure of social minorities (Nuttall, 2000d),
management behaviour (Nuttall, 2000c, 2004) and urban development
(Nuttall, 2002c). On a personal level this probably symbolised my struggle to
reconcile my interests in psychotherapy with other important aspects of my
life, such as my social being, professional career and personal aspirations.
These three modalities or dimensions of integration emerged from deep
reflection on my internal process as I progressed along my journey.
Eventually, I conceptualised this as a heuristic research programme made
up of four interweaving methods – phenomenological engagement with texts,
case studies, reflexive action and writing (Nuttall, 2006a). Through this
journey, I moved from a conceptually naı̈ve position of seeking an ideal
system, to one of accepting psychotherapy integration as something
necessarily personal and contextual and, therefore, at the profession level,
pluralistic. It represented a developmental process. Firstly of adding parts
together, then of seeing wholes or higher order patterns, whilst throughout
there was a dialogue with the outside world, with other disciplines and social
artefact. This process reminded me of the course of infant development
described by Stern (1985) of how the infant first integrates a range of
experiences to form the basis of the core self, which is then tested by
interaction with others before a sense of a subjective self develops. A Kleinian
metaphor also seemed applicable, as there was movement from part-object
relationship to depressive position wholeness mediated by projective-
introjective processes. The Jungian alchemical metaphor also seemed
appropriate as the prima materia of four schools, representing the ancient
elements, come together in the process called the mysterium coniunctionis in
search of the elusive philosopher’s stone, a metonym in this case for the grand
theory of psychotherapy integration. The similarity of my integration process
with these developmental models suggested I had conceptualised the
integration quest in a way meaningful for the profession.
The search for integration and reconciliation of schools is expressed
beautifully in the story of the Indian Tree, by the Sufi mystic Rumi (1991,
 The integrative attitude – a personal journey 33

pp. 55–56) (my thanks to the late Petruska Clarkson, who first used this
story in the context of psychotherapy integration [1995, p. 325])
A learned man once said, just for the sake of saying something,
‘There is a tree in India. If you eat the fruit of that tree you’ll never grow old and never die.’
Stories about ‘the tree’ were passed around and finally a king sent his envoy to India to look
for it.
People laughed at the man.
They slapped him on the back and called out, ‘Sir, I know where your tree is, but it’s far in the
jungle, and you’ll need a ladder.’
He kept on travelling, following such directions and feeling foolish for years.
He was about to return to the king, when he met a wise man.
‘Great teacher, show me some kindness in this search for the tree.’
‘My son, this is not an actual tree, though sometimes it has been called that.
Sometimes it’s called a ‘sun’, and sometimes an ocean or cloud.
All these words point to the wisdom which comes through a true human being,
Which may have many effects, the least of which is eternal life.
In the same way that one person can be a father to you and a son to someone else, an uncle to
another, and a nephew to yet another, so what you are looking for has many names, but only
one existence.
Don’t search for one of the names. Move beyond any attachment to names.
Every conflict between human beings has happened because of this disagreement about
names. It’s such a foolishness, because just beyond the arguing there’s a long table of
companionship, set and waiting for us to sit down.

Conclusion
So how might we view the integrationist? Hollanders (2000) suggests their
job is:
. . . to develop connectedness with the different parts of the field, to stand between the various
schools, to encourage dialogue and debate, and to find ways of helping each to discover and
respect the contributions of the other. In short, her role is to serve as a kind of ‘statesperson’
within the field (p. 44).

This is a commendable view and I support the need for communication and
dialogue at a profession-wide level. However, this must encourage the
continuous and personal process of integration that needs to take place
primarily within the individual therapist as well as – or alternatively – within
the therapeutic relationship. The individual may take his or her lead from
other more experienced or learned practitioners whose approaches may be
already well-recognised external systems of integrative psychotherapy. But it
is still, as Norcross and Arkowitz (1992) wrote, ‘premature to advance any
one integrative system . . . I urge students, in the integrative spirit, to take the
‘best’ from each model and to discern converging themes for themselves’
(p. 23). The process is necessarily a personal one, as Bion (1962) affirmed in
respect of the various emerging schools of psychoanalysis, ‘as a method of
making clear to himself the analyst needs his own book of psychoanalytic
theories that he personally frequently uses’ (p. 39).
The developmental journey I have described and the integrative attitude
I now espouse, will, I hope, encourage the activity of questioning,
of experimenting, of discovery, of inventing, of researching and of interrogat-
ing the discipline of psychotherapy in relationship with the experienced world
34 J. Nuttall

we seek to understand and in which we have our being. I have come to a

particularly existential view of integration that sees it more as a way of being,
constantly becoming and unfolding, rather than something that is fixed and
sedimented. The corollary of this is that integration is something that takes
place at the level of the therapist and not necessarily at the level of the
profession, school or clinical group. It becomes a personal journey, that must
be seen in the context of the individual’s skills, knowledge and philosophical
outlook and which must, therefore, in its professional expression, inevitably
embrace diversity.
The exposition of this view is not an invitation for anarchic relativism or
poor eclectic practice. As Evans and Gilbert (2005) assert, ‘any model of
integration [integrative model of psychotherapy] needs to offer a coherent
conceptual framework that reflects a consistency between philosophy, theory
and practice’ (p. 149). However, it is an exhortation to abandon rivalry, the
allegiance to names and the certitude of ideologies and not to lose sight of
the one thing that research and our experience tells us matters above all –
something that cannot be fully explained or named – and yet something that
may be eternal: the quality of relationship. As Lao Tzu said, ‘the Tao that
can be told is not the eternal Tao: The unnameable is the eternally real’
(Mitchell, 1999, p. 1). And yet we maintain our allegiance to names – the
therapeutic alliance, the frame, transference, I-Thou, intersubjectivity,
reverie, attunement, kinship libido, the reparative relationship and so on.
Perhaps the Hindu sage was right when he said it was great white elephants
all the way down.
Jung (1946) believed the alchemists viewed the soul as the domain of unity
and integration, and so I should like to finish with a Celtic blessing from John
O’Donohue’s book, Anam Cara, or ‘soul’s friend’ (1999, p. 200), for those in
the profession on the quest for personal psychotherapy integration:
May the light of your soul guide you.
May the light of your soul bless the work you do with the secret love and warmth of your heart.
May you see in what you do the beauty of your own soul.
May the sacredness of your work bring healing, light and renewal to those who work with you, and to
those who see and receive your work.
May your work never weary you, and release within you wellsprings of refreshment, inspiration and
excitement.
May you be present in what you do, and never become lost in the bland absences.
May the day never burden, and the dawn find you awake and alert, approaching your day with
dreams, possibilities and promises.
May evening find you gracious and fulfilled.
May you go into the night blessed, sheltered and protected.
May your soul calm, console and renew you.

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