The Second Wave of

Psychotherapy
Integration:
Consolidating and Unifying Knowledge and Practice
Diane R. Gehart, PhD
Therapy that Works Institute

Agenda

• First-Wave Integration
• Second-Wave Integration Principles
• Diversity and Research Considerations
• Second-Wave Approaches
• Finding Your Integrative Framework
• Invitation to Learn More

©2024. Diane R. Gehart, PhD. All rights reserved. www.dianegehart.com 1

 Course Goal and Learning
Goal:
Objectives
By the end of this program, participants understand the future of
psychotherapy integration

Specific Learning Objectives:

At the end of this training, participants will be able to:
1. Identify at least 3 forms of traditional integration in
psychotherapy.
2.Distinguish between first- and second-wave integration models.
3.Identify at least 3 characteristics of second-wave integration
models and their implications for practice.

Getting Your CEs

• Login to www.therapythatworksinstitute.com/login
⚬ Email is your login
⚬ Password you can set with link to “reset password”
if you didn’t set up with welcome email
• Complete Content-Based Quiz
• Complete Course Evaluation
• Check Email for your CE certificate (including
junk/spam email folders)

©2024. Diane R. Gehart, PhD. All rights reserved. www.dianegehart.com 2

 Integration:
Everyone Is Doing It

• Most frequently endorsed

orientation in over 10 major
research studies
• “Practically all contemporary
therapists would qualify as
integrative”

(Norcross & Alexander, 2019, p.

319; Anchin et al., 2024)

First-Wave Integration
• Theoretical Integration
⚬ Create new, coherent theory from 2+
pure forms
• Technical Eclectism
⚬ Use interventions from 2+ approaches
uncoupled from theory
• Common Factors
⚬ Relationship, expectancy
• Assimilative Integration
⚬ One theoretical foundation THEN
integrate techniques from other
approaches

(Anchin et al., 2024)

©2024. Diane R. Gehart, PhD. All rights reserved. www.dianegehart.com 3

 Second-Wave Integrative Principles

Second-Wave Integration:
Principles

Characterized by:
• Unification
• Transdiagnostic approaches
• Systematic treatment selection
• Evidence-based principles of
change
• Process of change

©2024. Diane R. Gehart, PhD. All rights reserved. www.dianegehart.com 4

 Unificaton
• Meta-theoretical Scaffold
⚬ Sufficiently broad to form a coherent
framework
• Viewing
⚬ Integration is in the person viewing, not
the theory or modality
• Full Spectrum
⚬ From micro- to macro-levels: biological,
psychological, relational, sociocultural,
ecological
• Intervention
⚬ On one level affects other levels

(Anchin et al., 2024)

Transdiagnostic Approaches
• Root Cause
⚬ Targets “causal mechanisms” shared by
class of disorders
• Particularly advantageous for comorbidities
• Equal Clinical Effectiveness
⚬ Compared with a single approach
• More Cost Effective
⚬ Reduces the need for multiple theories
and training
⚬ More adaptable across contexts

(Anchin et al., 2024)

©2024. Diane R. Gehart, PhD. All rights reserved. www.dianegehart.com 5

Systematic Treatment Selection
Consoli & Beutler (2019)

• All psychotherapies are beneficial for some, but none

is effective for all
• Therapists focus too much on the cause of symptoms
and not enough on improving clinical decision-making
• Match Approach to Client
⚬ Use a less directive approach the more
resistant/unready client is for change/action
• Match Approach to Problem
⚬ Externalizing symptoms benefit more from
behavioral interventions
⚬ Internalizing symptoms from insight and
interpersonal approaches

Empirically Based Principles of

Change
• APA Task Force Identify Empirically Based Principles
⚬ 61 reduced to 39 in 2019
• Overview
⚬ Client factors
￭ Less severe when start; more hopeful and motivated
⚬ Therapist factors
￭ Choose right intervention based on client motivation, reduce
resistance, increase functioning and coping
⚬ Therapist relationship
￭ Responsiveness, positive regard, congruence, empathy,
alliance quality and repair, supportive disclosure
⚬ Intervention
￭ Quality interpretation, more feedback, flexibility, promote
interpersonal changes, emotional experiencing, behavioral
change

(Anchin et al., 2024; Castonguay & Beutler, 2006; Castonguay et al., 2019; McAleavey et al., 2019)

©2024. Diane R. Gehart, PhD. All rights reserved. www.dianegehart.com 6

 Process of Change Model
(J.Scott Fraser, 2018)

• Key to Effective Therapy

⚬ It’s not a specific “thing” but a type of process
• Guiding Question
⚬ What process will create change for the client?
• Therapeutic Relationship: Social Constructionist
⚬ Clinician must adapt to client
⚬ Co-create meaning
• Systemic Approach to Change
⚬ Systemic analysis of patterns
￭ homeostasis
￭ feedback
￭ context

Second-Wave
Integration

Diversity and Research

Considerations

©2024. Diane R. Gehart, PhD. All rights reserved. www.dianegehart.com 7

Integration with Diverse Clients

• Using integrative approach generally

encouraged
• More options for adapting to clients' unique
worldviews and needs
• Consider cultural development and
identity(ies)
• Responding to social structures and values
• Integrating spirituality and Indigenous healing
traditions

(Anchin et al., 2024; Harris et al., 2019; Prochaska & Norcross, 2018)

Research on Integrative
Approaches
• Most evidence-based treatments are
integrative approaches for a specific
disorder
• General principles have been identified
⚬ Responsiveness
⚬ Adapt to client
⚬ Work from within client worldview
⚬ Align intervention with client/problem

(Anchin et al., 2024; Boswell et al., 2019; Castonguay & Beutler, 2006 )

©2024. Diane R. Gehart, PhD. All rights reserved. www.dianegehart.com 8

 Second-Wave Integrative Models

Second-Wave
Treatment Models

1.Transtheoretical Approach
2.Integrative Psychotherapy
3.Therapy that Works Unifying
Framework

©2024. Diane R. Gehart, PhD. All rights reserved. www.dianegehart.com 9

 Early Prototypes
Integrative Multitheoretical Psychotherapy
(Brooks-Harris, 2008)
• Cognitive psychotherapy
• Behavioral psychotherapy
• Experiential-humanistic psychotherapy
• Biopsychosocial psychotherapy
• Psychodynamic-interpersonal psychotherapy
• Systemic-constructivist psychotherapy
• Multicultural-feminist psychotherapy

Biopsychosocial Metatheory
(Magnavita & Anchin, 2014)
• Individual brain/mind system
• Dyadic systems
• Triadic systems
• Larger social systems

Transtheoret
ical Model

©2024. Diane R. Gehart, PhD. All rights reserved. www.dianegehart.com 10

 Transtheoretical Model (TTM):
Organizing Principle
5 Stages of Change
1.Precontemplative
2.Contemplative
3.Preparation
4.Action
5.Maintenance

(Prochaska & Norcross, 2018; Prochaska &

DiClemente, 2019)

Transtheoretical
Model (TTM):
5 Levels of Change
1.Symptom/situational problem
2.Maladaptive cognitions
3.Current interpersonal conflict
4.Family/systems conflicts
5.Intrapersonal (intrapsychic)
conflicts

(Prochaska & Norcross, 2018; Prochaska &

DiClemente, 2019)

©2024. Diane R. Gehart, PhD. All rights reserved. www.dianegehart.com 11

 Transtheoretical
Stage of Change Model
Precontemplative Contemplation & Action/
Level of Change Stage Preparation Stages Maintenance

Symptoms/Situational Motivational Interviewing Solution-Focused Behavioral; Exposure

Maladaptive Cognitions Adlerian Third-Wave CBTs REBT

Interpersonal Sullivan Therapy Cognitive Interpersonal

Transactional
Family/Systems Conflict Strategic Structural
Bowen

Intrapersonal Conflict Psychoanalytic Existential Gestalt; DBT

Table adapted from Prochaska & DiClemente

(2019)

Integrative
Psychotherapy

©2024. Diane R. Gehart, PhD. All rights reserved. www.dianegehart.com 12

 Integrative Psychotherapy:
Hawkins & Ryde (2020)

• Psychotherapy and Organizational

Consultation Model
• Integrates 3 Epistemologies

1.Intersubjective/Relational (social
constructionism)
2.Systemic
3.Ecological

Level of Epistemology
Inter-Subjective or Social
Eco-Systemic
Objective Observation Constructionist
System Being Focused on

• Medical model
• Solution-focused
• CBT
Individual • Postmodern • Nature-based therapies
• Psychodynamic
• Feminist/Cultural
• Humanistic

• Later family therapy approaches

Interpersonal &
• Solution-focused family
Family • Early family therapy approaches
approaches
Relationships
• Postmodern family approaches

Community • Community-level interventions

Species/Gaia • Psychoanalytic Anthropology

Table adapted from Hawkins & Ryde, 2020

©2024. Diane R. Gehart, PhD. All rights reserved. www.dianegehart.com 13

 Therapy that
Works Unifying
Framework

Therapy that Works

Unifying Framework
A single, evidence-informed system
for “doing” effective psychotherapy.

• Not a theory because it does not

explain why problems develop
• Simply a step-by-step approach to
becoming a highly effective
clinician (top 15% of therapists)

(Caustonguay & Hill, 2017; Gehart, 2024)

©2024. Diane R. Gehart, PhD. All rights reserved. www.dianegehart.com 14

 Synthesis
Model
• Identify common practices across
theories
• Remove jargon
• Describe “what to do” in simple,
non-theoretical terms
• System for “doing”
psychotherapy--rather than
explaining why people have
problems

Therapy that Works Unifying

Framework
1.Self-of-the-Clinician
⚬ Meaningful personal development of clinician
2.Collaborative Connecting
⚬ Entering client meaning-making system
3.Transtheoretical Conceptualization of the
Problem
⚬ Synthesize 50 theories
4.Evidence-informed Treatment Planning
⚬ What does the research say helps the
problem/client?
5.Evidence-informed Intervention
⚬ Matching approach to client
6.Transtheoretical Conceptualization of the
Solution/Wellness
(Gehart, 2024)

©2024. Diane R. Gehart, PhD. All rights reserved. www.dianegehart.com 15

Therapy that Works Unifying Framework: Theory Grid
Theories Primarily
Level Addresses
Associated

Level 1: • Observable Behaviors • Behavioral therapies

Behavioral • Complementary Patterns • Systems theories

• Primary “Attachment-based” • Humanistic: Person-Centered, Gestalt,

Level 2:
Emotions Satir, EFT
Emotional • Secondary Emotions • Psychodynamic therapies

• Cognitive therapies
Level 3: • Cognitions and Beliefs • Systems theories
Cognitive • Identity Narratives • Solution-focused therapies
• Postmodern: Narrative and collaborative

Level 4: • Social Location • Postmodern: Narrative and Collaborative

Societal • Problem discourses • Feminist and Culturally Informed

Themes Across Second-Wave

Integration Approaches

1.Multiple Approaches
⚬ Insight-oriented, behavioral, cognitive,
systemic
2.Collaborative Therapeutic Relationship
⚬ Flexible/adaptable approach, esp with diverse
and multi-problem clients
3.Systemic Approach
⚬ Attention to broader system dynamics
4.Evidence-based principles
a. Help guide treatment, but does not dictate it

©2024. Diane R. Gehart, PhD. All rights reserved. www.dianegehart.com 16

 Themes Across Second-Wave Theories

All Traditional Primarily Social Broader Evidence-Based

Diversity Built Single Approach
Schools of Constructionist Systemic Focus or Evidence-
into Theory Across Clients
Therapy Relationship for All Clients Informed

Second-Wave Process Focused

Yes Yes Yes Yes No
Prototypes Approaches

Transtheoretical Only with couple, Evidence-base;

Yes No No No
Model family problems Some research

Integrative
No, but adds No, but adds
Psychotherapy Yes Yes No No
ecosystemic ecology
Model

Therapy that
Evidence-
Works Unifying Yes Yes Yes Yes Yes
Informed
Framework

Where to Go From
Here?

©2024. Diane R. Gehart, PhD. All rights reserved. www.dianegehart.com 17

 Where Are You?
Early Career
• Required to learn 15-20 different approaches by
universities and licensing boards

Mid-Career
• Typically integrate 2-3 approaches that have trained most
in well
• No single framework to use all of what they know easily

Later Career/Supervisors
• Often expert in 3+ traditional approaches
• May not be familiar with newer approaches supervisees
learning

Find Your Integative Framework

Everyone Needs an Organizing Framework

• Organize rapidly expanding information
in the field
• Address diverse and changing client
needs

Your Options
• Comprehensive reference list for
further reading
• Professional Training

©2024. Diane R. Gehart, PhD. All rights reserved. www.dianegehart.com 18

References
• Anchin, J. C., Řiháček, T., Roubal, J., & Boswell, J. F. (2024). Psychotherapy integration: History, current status, and
future directions. In F. T. L. Leong, J. L. Callahan, J. Zimmerman, M. J. Constantino, & C. F. Eubanks (Eds.), APA handbook
of psychotherapy: Theory-driven practice and disorder-driven practice., Vol. 1. (pp. 231–255). American Psychological
Association.
• Bishop, F. M. (2024). Modern integrative counseling and psychotherapy: A step-by-step approach. Rowman &
Littlefield.
• Brooks-Harris, J. (2008). Integrative multitheoretical psychotherapy. Lahaska Press.
• Boswell, J. F., Newman, M. G., & McGinn, L. K. (2019). Outcome research on psychotherapy integration. In J. C. Norcross
& M. R. Goldfried (Eds.), Handbook of psychotherapy integration., 3rd ed. (pp. 405–431). Oxford University Press.
• Castonguay, L. G., & Beutler, L. E. (2006). Principles of Therapeutic Change: A Task Force on Participants, Relationships,
and Techniques Factors. Journal of Clinical Psychology, 62(6), 631–638. doi:10.1002/jclp.20256
• Castonguay, L. G., & Hill, C. E. (2017). How and why are some therapists better than others?: Understanding therapist
effects (L. G. Castonguay & C. E. Hill (Eds.)). American Psychological Association.
• Castonguay, L. G., Constantino, M. J., & Beutler, L. E. (2019). Principles of change: How psychotherapists implement
research in practice (L. G. Castonguay, M. J. Constantino, & L. E. Beutler (Eds.)). Oxford University Press.
• Consoli, A. J., & Beutler, L. E. (2019). Systematic treatment selection. In J. C. Norcross & M. R. Goldfried (Eds.),
Handbook of psychotherapy integration., 3rd ed. (pp. 141–157). Oxford University Press.
• Feldman, J. B. (1985). The work of Milton Erickson: A multisystem model of eclectic therapy. Psychotherapy: Theory,
Research, Practice, Training, 22(2), 154–162.
• Fraser, J. S. (2018). Unifying effective psychotherapies: Tracing the process of change. American Psychological
Association.

References, Cont.
• Gehart, D. (2024). Mastering competencies in family therapy (4th ed.). Cengage.
• Gold, J., & Stricker, G. (2020). Integrative approaches to psychotherapy. In S. B. Messer & N. J. Kaslow (Eds.), Essential
psychotherapies: Theory and practice., 4th ed. (pp. 443–480). The Guilford Press.
• Harris, J. E., Shukla, N., & Ivey, A. E. (2019). Integrative psychotherapy with culturally diverse clients. In J. C. Norcross & M.
R. Goldfried (Eds.), Handbook of psychotherapy integration., 3rd ed. (pp. 325–340). Oxford University Press.Hawkins, P. &
Ryde, J. (2020). Integrative psychotherapy in theory and practice. Jessica Kingsley Publishers.
• Howe, L. C., Leibowitz, K. A., & Crum, A. J. (2019). When your doctor “gets it” and “gets you”: The critical role of competence
and warmth in the patient–provider interaction. Frontiers in Psychiatry, 10.
• Ilardi, S. S., & Feldman, D. (2001). The cognitive neuroscience paradigm: A unifying metatheoretical framework for the
science and practice of clinical psychology. Journal of Clinical Psychology, 57(9), 1067–1088.
• Magnavita, J. J., & Anchin, J. C. (2014). Unifying psychotherapy: Principles, methods, and evidence from clinical science.
Springer.
• McAleavey, A. A., Xiao, H., Bernecker, S. L., Brunet, H., Morrison, N. R., Stein, M., Youn, S. J., Castonguay, L. G., Constantino,
M. J., & Beutler, L. E. (2019). An updated list of principles of change that work. In L. G. Castonguay, M. J. Constantino, & L. E.
Beutler (Eds.), Principles of change: How psychotherapists implement research in practice. (pp. 13–37). Oxford University
Press.
• Norcross, J. C., & Alexander, E. F. (2019). A primer on psychotherapy integration. In J. C. Norcross & M. R. Goldfried (Eds.),
Handbook of psychotherapy integration (pp. 3–27). Oxford University Press. https://doi.org/10.1093/med-
psych/9780190690465. 003.0001
• Prochaska, J. O., & DiClemente, C. C. (2019). The transtheoretical approach. In J. C. Norcross & M. R. Goldfried (Eds.),
Handbook of psychotherapy integration., 3rd ed. (pp. 161–183). Oxford University
• Prochaska, J. O., & Norcross, J. C. (2018). Systems of psychotherapy: A transtheoretical analysis, 9th ed. Thomson
Brooks/Cole Publishing.

©2024. Diane R. Gehart, PhD. All rights reserved. www.dianegehart.com 19