Atlas›Domain VI · Brief, integrative, trauma, hypnosis & coaching›Guide 019
Guide VI-019

Assimilative integration

Stanley B. Messer1992
A 28 · L 54 · M 1820 interventions in the Trinity explorer
Client cardCompare
[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: Stanley B. Messer's concept of assimilative integration, introduced in his 1992 chapter (Norcross & Goldfried, Handbook of psychotherapy integration, pp. 130–165) and restated in his SAGE encyclopedia entries (2015, 2017) and his 2012 PCSP commentary. The step-by-step procedure comes from its best-documented clinical form, Stricker and Gold's assimilative psychodynamic psychotherapy (1996), and from the published case of "Grace" (Pass, 2012, with commentaries by Messer and by Stricker). The CBT-home form follows Castonguay's Integrative Cognitive Therapy as described by Constantino (2008). Messer (1992) introduced the term [source: Ramsay 2001, reference list; Stricker 2001]. Castonguay's ICT and Constantino's expectancy module follow Constantino (2008). Messer's 1992 chapter, his 2001 special-issue introduction, Messer and Winokur's visions-of-reality chapter and Messer's 2000 and 2006 papers applying it, Ramsay's full article and the ICT manual are known here only through other authors' summaries and abstracts, so any detail attributed to them is [uncertain].

What it is. Assimilative integration is a mode of integrating, not a single therapy with a manual. The therapist stays grounded in one "home" theory: psychodynamic, cognitive-behavioural, humanistic or systemic. Into it they bring a technique, concept or perspective from another approach. The home theory makes sense of the client and decides when and why the imported element is used [source: Messer 2015 SAGE entry; Stricker 2001; Ramsay 2001 abstract, which credits Messer (1992) with the idea of staying in one's preferred paradigm while selectively blending in elements of other models]. Messer places it between technical eclecticism (empirically supported techniques with no theoretical anchor) and full theoretical integration (a merged theory, such as Wachtel's cyclical psychodynamics). Ramsay calls it a "middle ground between technical eclecticism and a grand, unified theory of psychotherapy" [source: Messer 2017 SAGE entry; Ramsay 2001 abstract]. It is one of four main integration types, with common factors as the fourth [source: Messer 2017 SAGE entry; Messer 2012]. Typical examples are systematic desensitisation or social-skills training inside psychodynamic or person-centred therapy, or the client-centred focus on the relationship inside CBT [source: Messer 2015]. In CBT, Castonguay's Integrative Cognitive Therapy for depression is an explicitly assimilative example: cognitive therapy stays the home, and humanistic and interpersonal strategies for repairing alliance ruptures are added [source: Constantino 2008].

Core idea of how change happens.

  • Context gives a technique its meaning. Messer argues, drawing on the hermeneutic circle, that a technique cannot be separated from the therapy it is practised in. An imported intervention "takes on the coloring" of its new setting. For example, the two-chair technique means something different in CBT than in Gestalt therapy [source: Messer 2012, citing Messer 1992]. In his exchange with Lazarus, Messer added that clinical observation is never theory-free. Because an imported technique is assimilated and modified by its new clinical and theoretical context, its effects should be validated again in that context, not assumed from the school it came from [source: Lazarus & Messer, exchange on technical eclecticism and assimilative integration, abstract of the Spanish translation]. Stricker and Gold sum this up as: "all actions are defined and contained by the interpersonal, historical, and physical context" (p. 50).
  • Change is achieved by the home model, widened. Change still follows the home theory's mechanism (for example insight, a corrective relational experience and affect processing in a dynamic home). Imported techniques reach levels of the problem that the home method reaches poorly, and their effects are then worked through inside the home frame [source: Stricker & Gold 1996].
  • Change can begin at any level. In the psychodynamic version, insight can lead to change, follow new experience, or moderate it. The model is circular rather than one-way [source: Stricker & Gold 1996, p. 50].
  • Assimilation also changes the home theory. Stricker and Gold note that "accommodation is an inevitable partner of assimilation" (p. 50): the therapist's theory has to stretch to explain what the imported technique does [source: Stricker & Gold 1996].

Who it suits. Clinicians already trained in one model who want to add methods without becoming eclectic and losing a guiding formulation. Messer describes his own path: from traditional psychoanalytic therapy to assimilative integration, then the "visions of reality" lenses, then brief psychodynamic therapy [source: Messer, "How I have changed over time as a psychotherapist", J Clin Psychol, abstract only].

2. Framework

Assimilative integration has no fixed phases or session count of its own. Length and format are those of the home therapy [source: Messer 2015; Stricker 2001]. The two published examples show the range. The assimilative psychodynamic case of Mr S. ran about 32 months: weekly sessions, twice weekly after about a year, then weekly for the last 6 months [source: Stricker & Gold 1996, p. 52]. The AEDP-plus-expressive-writing case of Grace was a short-term therapy with a rough limit of 20–24 sessions [source: Messer 2012]. The sequence below follows Stricker and Gold (1996) and the Grace case. Where it is generalised to other home theories, that is marked [synthesis].

Phase A: Assessment and formulation in the home theory

  • Goal: a home-theory formulation broad enough to show where the home method will struggle.
  • Psychodynamic version: assess all three "tiers" and the links between them:
    • Tier 1: overt behaviour.
    • Tier 2: conscious thoughts, feelings, perceptions and sensations.
    • Tier 3: unconscious motives, conflicts, images, and representations of self and others.
    Stricker and Gold point to manualised formulation methods (Core Conflictual Relationship Theme, Plan Formulation, Cyclical Maladaptive Pattern) as ways to make this step reliable [source: Stricker & Gold 1996, pp. 50, 55].
  • CBT or humanistic home: formulate in that model's terms, and note which levels (relational, emotional, historical, behavioural) it covers less well [synthesis].
  • Move on when: you have a working formulation and a provisional idea of which levels need an imported method [synthesis].

Phase B: Alliance, safety and home-model work

  • Goal: establish the relationship and the home therapy's core process before importing anything.
  • In the Grace case, sessions 1–4 built safety and gave psychoeducation about post-traumatic reactions. Sessions 5–10 strengthened trust and helped her access emotion [source: Messer 2012].
  • Stricker and Gold note that psychodynamic exploration usually comes before active techniques, citing the Sheffield findings on sequencing [source: Stricker & Gold 1996, p. 54].
  • Move on when: the alliance can carry a new kind of task, and the formulation points to a block that the home method is not shifting [source: Messer 2012; Stricker & Gold 1996].

Phase C: Selecting and preparing an imported intervention

  • Goal: choose a technique that serves two compatible aims at once: change in current functioning and movement in the home theory's core processes [source: Stricker & Gold 1996, p. 51].
  • Preparation: mention the idea before proposing it. In the Grace case, writing was floated in general terms early on, so it would be more acceptable later [source: Messer 2012].
  • Move on when: the client shows readiness, for example by asking to approach the material more directly. In the Grace case this came around sessions 10–14, and the client was left to judge her own readiness [source: Messer 2012].

Phase D: Assimilated use, then processing in the home frame

  • Goal: deliver the technique, then explore what it meant to the client before, during and after [source: Stricker & Gold 1996].
  • Results feed back into the formulation. In Mr S.'s case, behavioural success made relational fears and transference themes reachable "in an immediate, emotionally vital manner" [source: Stricker & Gold 1996, p. 51].
  • Move on when: the imported work has done its job, and the therapy returns to its home process. Cycles C–D can repeat with other techniques; Mr S. had three [source: Stricker & Gold 1996].

Phase E: Consolidation and ending

  • Goal: end as the home therapy does: termination and relationship processing in dynamic work, relapse prevention in CBT.
  • After the writing phase, the Grace therapy kept working within AEDP, including processing the client–therapist relationship [source: Messer 2012].
  • Monitoring: the Grace case used the OQ-45 and the Trauma Symptom Inventory before and after treatment. Stricker recommends session-by-session client feedback (the Outcome Rating Scale and Session Rating Scale) [source: Stricker 2012].
  • Stricker adds that the treatment plan should be revised continuously as understanding grows [source: Stricker 2001].

3. Guiding principles

  • Keep one home theory. Practical meaning: always be able to say, in your home model's terms, why you are doing this technique now [source: Messer 2015; Stricker 2001].
  • Import techniques, not rival worldviews. Practical meaning: you borrow a procedure and re-theorise it; you do not switch models mid-therapy [source: Messer 2017; Stricker & Gold 1996].
  • Context changes meaning. Practical meaning: predict what the technique will mean to this client given the relationship so far (for example, being directed, rescued or tested), and explore that meaning [source: Messer 2012; Stricker & Gold 1996].
  • Seamless rather than abrupt. Practical meaning: introduce the technique so it flows from the current work. Messer prefers integration that proceeds "relatively smoothly or seamlessly" (citing Wachtel, 1991). Stricker adds that the client should experience one consistent treatment [source: Messer 2012; Stricker 2001].
  • Relationship and readiness first. Practical meaning: no imported technique until the alliance and psychoeducation make it acceptable. Messer judged that without these, the writing might have failed [source: Messer 2012].
  • Dual purpose. Practical meaning: choose techniques that relieve a current problem and move the home-model process forward [source: Stricker & Gold 1996, p. 51].
  • Match to immediate clinical need. Practical meaning: the moment chooses the method; for example, use calming techniques in a panic attack, when interpretation is impossible [source: Stricker & Gold 1996, pp. 53–54].
  • Work at every level the problem lives on. Practical meaning: do not treat behaviour and conscious experience as mere symptoms. Working only at the deepest level asks too much; never reaching it keeps therapy superficial [source: Stricker & Gold 1996, pp. 50, 52].
  • Offer tentatively, explore the meaning before, during and after. Practical meaning: every technique is an offer whose reception is itself clinical material [source: Stricker & Gold 1996].
  • Use the tool flexibly, not as a manual. Practical meaning: adapt the imported technique to the home goals, as Pass used writing "as a tool" rather than "as if from a manual" (Pass, 2012, p. 85) [source: Messer 2012].
  • Let theory stretch. Practical meaning: when an imported method works in ways your theory did not predict, revise the formulation rather than ignore the effect [source: Stricker & Gold 1996, p. 56].
  • Know your theory's limits. Practical meaning: knowing why your model struggles with a problem tells you what to import [source: Stricker 2001].
  • Honest about selection. Practical meaning: Stricker and Gold admit that technique choice by clinical judgement "rarely [is] reliable". Use research-informed matching (they cite Beutler) and outcome feedback where possible [source: Stricker & Gold 1996, p. 51; Stricker 2012].
  • Keep the home theory's own vision in mind. Practical meaning: Messer and Winokur contrast the psychodynamic "tragic" view of stable, repeating patterns with the behavioural "comic" view of ready change. Notice when an imported technique carries a different vision of change than your home model, and tell the client honestly what to expect [source: Stricker 2001, describing Messer & Winokur; synthesis for the practical use].

4. Intervention inventory

The inventory has two parts:

  • Part A (4.1–4.6): the integrating procedures that make a practice assimilative.
  • Part B (4.7–4.20): the specific imported techniques described in the sources.

Assimilative integration lets any technique be imported, so Part B is a list of documented examples, not a closed set [source: Messer 2015; Stricker & Gold 1996]. Each imported technique should be learned from its own primary manual. Only the assimilation steps are given here.

Part A: Integrating procedures

4.1 Multi-level formulation in the home theory

  • Purpose / when: at intake and whenever the therapy stalls. It shows which level of the problem the home method is reaching and which it is not.
  • Steps (psychodynamic version):
    1. Tier 1 (behaviour): map avoidance, compulsions, impulsive choices and skill deficits.
    2. Tier 2 (conscious experience): map "shoulds", shame, perfectionism, conscious beliefs, affect range and bodily sensations.
    3. Tier 3 (unconscious): map conflicts, defences, and representations of self and others. Mr S., for example, held fragmented identifications with an obsessive father and a passive mother, and swung between grandiosity and worthlessness.
    4. Note how each tier keeps the others going. For example, avoidance protects against shame and also prevents disconfirming experiences.
    5. Mark where the home method has traction and where it does not.
    [source: Stricker & Gold 1996, pp. 50–53]
  • Steps (other home theories): formulate in your own model (for example a CBT case conceptualisation). Then deliberately add a relational and emotional-meaning layer, so you can foresee how imported methods will be received [synthesis].
  • Example language (illustrative): "Let's look at this from a few angles: what you do when the anxiety comes, what goes through your mind, and the older patterns with important people that it seems to echo."
  • Watch for: a formulation that lives only at Tier 3 (therapy becomes too far from the client's current capacities) or only at Tier 1 (therapy becomes superficial) [source: Stricker & Gold 1996, p. 52]. Working: you can predict which technique would help and why.

4.2 Selecting an imported intervention (dual-purpose choice)

  • Purpose / when: at a choice point, when the formulation shows a block that home-model work is not shifting.
  • Steps:
    1. Assess the client's current dynamic state: tone of the alliance, the most pressing conflict, active defences, current self and other representations, and emotional state [source: Stricker & Gold 1996, p. 51].
    2. Name two compatible aims: change in present functioning and an effect on central home-model processes [source: Stricker & Gold 1996, p. 51].
    3. Use experience and research to choose the method. Published pairings include:
      • exposure or assertiveness work for social anxiety;
      • cognitive-style testing for a paranoid perception of the therapist;
      • Gestalt experiential work for an intellectualising client;
      • behavioural rehearsal and anxiety management in a crisis.
      [source: Stricker & Gold 1996, p. 51]
    4. Check what the technique will mean in this relationship (Principle: context changes meaning) [source: Messer 2012].
    5. Where available, use research-informed matching of treatment to client characteristics (Beutler is cited) instead of judgement alone [source: Stricker & Gold 1996, p. 51].
  • Example language: this step happens in the clinician's head and supervision. There is no client wording.
  • Watch for: importing because you are frustrated, which risks acting out a countertransference [synthesis]. Working: you can state both aims in one sentence, in home-model language.

4.3 Seeding and psychoeducation

  • Purpose / when: to make a later technique acceptable before it is formally proposed.
  • Steps:
    1. Early in therapy, give psychoeducation that fits the problem. Grace, for example, learned about post-traumatic reactions in sessions 1–4.
    2. Mention the possible technique in general terms, well before proposing it.
    3. Leave it open.
    [source: Messer 2012; Stricker 2012 lists psychoeducation as itself an assimilated element]
  • Example language (illustrative): "Some people find that writing about what happened, at their own pace, helps them find words for it. Not now; just something to keep in mind."
  • Watch for: seeding that feels like pressure. Working: the client later raises the idea themselves or accepts it readily.

4.4 Client-paced readiness check

  • Purpose / when: immediately before introducing an emotionally demanding import, especially trauma-related material.
  • Steps:
    1. Wait for signs of readiness, such as the client wanting to approach the material more directly.
    2. Invite the client to gauge their own readiness to handle the affect.
    3. Allow delay or a gentler version. Pass postponed the writing, held back assignments directly about the suicide, and moved to free writing.
    [source: Messer 2012; Stricker 2012]
  • Trauma readiness criteria (added) [synthesis]: current safety; no active suicidality, or a risk plan in place; ability to use at least one grounding or self-soothing skill; the client can notice and report rising distress; no severe dissociation, or it is being managed first.
  • Example language (illustrative): "On a scale you choose, how ready do you feel to go closer to this? We can go gradually, or wait."
  • Watch for: compliance with no real readiness, for example agreeing in a flat voice [synthesis]. Working: the client starts the task and stays within their tolerance.

4.5 Tentative offer and exploration of meaning (before, during, after)

  • Purpose / when: every time an imported technique is used. This is the core assimilative step.
  • Steps:
    1. Before: offer the technique tentatively, with a rationale that connects to the shared formulation. Ask what it is like to be offered something active.
    2. During: notice the client's reactions to the task and to you.
    3. After: explore what came up, including links to past figures, the transference, and wishes and fears about being helped.
    4. Fold the findings back into the home-model work.
    [source: Stricker & Gold 1996, pp. 52–54]
  • Example language (illustrative): "I'd like to suggest something a bit different from our usual way of talking. Before we try it, I'm curious how it feels to have me suggest an exercise." Afterwards: "What was it like to do that here, with me?"
  • Watch for: the technique being experienced as a "forced wedge" against a pattern the client holds as part of their identity. If so, explore it fully before pressing on [source: Stricker & Gold 1996, p. 53]. Working: new emotional or relational material appears, and the alliance holds or deepens.

4.6 Re-theorising (accommodation) and formulation update

  • Purpose / when: after each imported intervention, and in supervision.
  • Steps:
    1. Ask: what did this technique do, in my home theory's terms?
    2. If the theory did not predict the effect, widen it. Stricker and Gold, for example, came to treat behaviour change as a way into defences that interpretation could not reach.
    3. Update the formulation and the plan.
    [source: Stricker & Gold 1996, pp. 50, 56; Stricker 2001 on continuous revision]
  • Example language: this step is internal or done in supervision.
  • Watch for: losing the home anchor and drifting into unanchored eclecticism [synthesis]. Working: the formulation becomes simpler and more predictive, not more cluttered.

Part B: Documented imported techniques (with how they are assimilated)

4.7 Systematic desensitisation / graded in vivo exposure (into psychodynamic therapy)

  • Purpose / when: social anxiety or avoidance that interpretation alone does not shift. Behaviour change can loosen defences and make relational fears reachable [source: Stricker & Gold 1996, p. 51].
  • Steps:
    1. Raise the idea tentatively and explore what it means to the client (4.5).
    2. Build a graded hierarchy with the client. Mr S. had an in vivo hierarchy targeting interpersonal distance, introduced at his own request.
    3. Carry out the steps using the exposure method as taught in its own primary sources. The details are not given in this source [uncertain].
    4. Analyse results in session: what each step stirred up, for example fears of intimacy, and how it relates to core conflicts.
    [source: Stricker & Gold 1996, pp. 51, 54]
  • Safety and consent [synthesis]: get informed consent to planned discomfort. Screen for medical conditions that intense anxiety could worsen (consult the client's physician where relevant). Do not use exposure while the client is in acute crisis or actively suicidal. The client controls the pace and can stop.
  • Example language (illustrative): "We've understood a lot about why closeness feels dangerous. I wonder if trying some small steps toward it, and then looking together at what they stir up, might move us further."
  • Watch for: the client experiencing the hierarchy as a demand to perform for you. Working: avoidance drops, and associated fantasies or memories come into the sessions [source: Stricker & Gold 1996].

4.8 Assertiveness training, social-skills training and behavioural rehearsal

  • Purpose / when:
    • interpersonal distancing or skill deficits;
    • when the client asks for practical help;
    • in a crisis, together with anxiety management.
    [source: Stricker & Gold 1996, pp. 51, 54; Messer 2015 lists social-skills training as an example import into psychodynamic or person-centred therapy]
  • Steps:
    1. Pick a real upcoming situation.
    2. Rehearse it in session: the client tries it, you give feedback, the client tries again. This is standard rehearsal practice, not detailed in the source [synthesis].
    3. Agree a real-life try-out.
    4. Review it, including what it meant to ask for help from the therapist. For Mr S., asking for help was itself a developmental step [source: Stricker & Gold 1996, p. 54].
  • Example language (illustrative): "Let's try the conversation with your manager here first. I'll play him; you say it the way you'd like to."
  • Watch for: the therapist acting as coach in a way that repeats a controlling-parent pattern [synthesis]. Working: the skill is used outside sessions, and the client gains a sense of agency.

4.9 Active testing of perceptions (from cognitive therapy)

  • Purpose / when: a paranoid or rigid perception of the therapist, or of others, that interpretation of its roots only partly resolves [source: Stricker & Gold 1996, p. 51].
  • Steps:
    1. Name the perception without defensiveness.
    2. Invite the client to treat it as a hypothesis.
    3. Look together for evidence, or set up a small test in the relationship.
    4. Explore the meaning of the result alongside its history.
    [source: Stricker & Gold 1996, p. 51 for the use; steps synthesis]
  • Example language (illustrative): "You've been feeling I'm judging you. Could we treat that as something to check out together? What have you noticed that fits, and is there anything that doesn't?"
  • Watch for: a debating stance that feels like an attack [synthesis]. Working: the perception becomes more flexible, and the transference softens.

4.10 Two-chair / Gestalt experiential work (into psychodynamic or CBT homes)

  • Purpose / when:
    • an intellectualising client;
    • a client who disputes the therapist's formulations, where the dispute is functioning as a defence;
    • to bring cut-off feelings into the room.
    [source: Stricker & Gold 1996, pp. 51, 53]
  • Context matters: Messer's own example of context is that two-chair work "feels different" in CBT than in Gestalt therapy. In a CBT home it can serve evidence-weighing; in a dynamic home it serves affect and representations of others [source: Messer 2012].
  • Steps:
    1. Offer the exercise as an experiment, not a test of the client.
      • Stricker and Gold's therapist realised he had become "an accomplice" to the client's defence of attacking the theory.
      • He framed the exercise so that either outcome was informative: if it failed, that would confirm the client's view of the therapist; if it helped, the client might rethink.
    2. Set up the dialogues. Mr S. spoke to his supervisor, his father, his child self and his mother.
    3. Follow the emotion that emerges; in Mr S.'s case anger, longing and shame.
    4. Afterwards, connect the emotion to insight and to the transference.
    [source: Stricker & Gold 1996, p. 53; for method details use the Gestalt or emotion-focused primary sources [uncertain]]
  • Example language (illustrative): "Rather than argue about my ideas, would you be willing to try something and see what you notice? Imagine your father in that chair. What do you want to say to him?"
  • Watch for: flooding in fragile clients, and shame at "performing". Give the client permission to stop at any point [synthesis]. Working: emotional opening, followed by a lessening of hostile transference. Mr S.'s hostile transference eased after this success, and themes such as his mother's helplessness became reachable [source: Stricker & Gold 1996, p. 53].

4.11 Relaxation, cognitive self-soothing and calming imagery

  • Purpose / when: acute anxiety or panic in session, when interpretation is impossible [source: Stricker & Gold 1996, p. 53].
  • Steps:
    1. Shift from exploring to stabilising.
    2. Guide simple relaxation, self-soothing self-talk and calming imagery. Use standard procedures; this source does not give specific scripts [synthesis].
    3. Once the client is calmer, explore what being soothed by the therapist meant. In Mr S.'s case this brought up images of nurturance tied to his father and mother, and made the therapist a source of new internal representations [source: Stricker & Gold 1996, p. 53].
  • Example language (illustrative): "Let's pause the talking. Feel your feet on the floor, and let your breath slow a little… Now picture somewhere you feel steady." Later: "What was it like to let me help you calm down?"
  • Watch for: imagery that triggers rather than calms, for example in trauma survivors. Have a neutral, here-and-now alternative ready [synthesis]. Working: arousal drops in session, and the client can then reflect.

4.12 Expressive (therapeutic) writing assimilated into AEDP for trauma

  • Purpose / when: a client with a single-incident trauma or traumatic loss who wants to "put the story together". The writing serves the home model's goals: own voice, accessing core affect, and the self "at its best" [source: Messer 2012, citing Pennebaker 2004, Jacobs 2004, Fosha 2006]. Messer explicitly says this use was not graded exposure, despite looking similar in form [source: Messer 2012].
  • Readiness criteria: the case had an established alliance, completed psychoeducation, and the client's own sense of readiness. Writing began only after sessions 10–14 [source: Messer 2012]. Stricker notes that the client's relatively healthy functioning and the single-incident trauma helped [source: Stricker 2012]. Add a stabilisation check (4.4) [synthesis].
  • Steps:
    1. Seed the idea early (4.3).
    2. When the client is ready, set writing between sessions:
      • start with free writing if a focused assignment is too much (Pass shifted from suicide-focused writing to free writing);
      • let the client choose voice and person, for example first person or not.
    3. In session, use the writing "as a tool" and a springboard for affect processing. Do not mark it like homework.
    4. Give "judicious feedback" rather than answers, so the client becomes the author of their own story.
    [source: Messer 2012; Stricker 2012]
  • Pacing: no fixed writing schedule is given here. In the case, the topic and intensity were set by the client and graded over time [source: Stricker 2012].
  • Grounding and closure [synthesis]:
    • Advise the client to stop if overwhelmed, and to finish each writing session with a grounding activity.
    • In session, end with a return to the present and a check of distress level.
    • Teach self-soothing for use between sessions; Pass did this [source: Stricker 2012].
  • Example language (illustrative): "If you'd like, write for a while this week about whatever comes up around your brother, in whatever way feels right. Stop if it becomes too much. Bring it in only if you want to."
  • Memory caution [synthesis]: treat what is written as the client's experience and meaning-making. Do not use writing to search for or "recover" memories.
  • Watch for:
    • avoidance (missed assignments); handle this by exploring it, not by insisting;
    • escalating distress or dissociation after writing; if so, pause the writing and return to stabilisation [synthesis].
  • Working: more consistent affect processing, authentic emotion, and the client identifying where their feelings come from. Grace called the writing one of the most positive experiences she took away [source: Messer 2012].

4.13 Between-session homework (from CBT, in non-CBT homes)

  • Purpose / when: to extend the work beyond the session. Stricker reports using homework inside a psychodynamic frame while keeping "the constancy of psychodynamic understanding" [source: Stricker 2001].
  • Steps [synthesis]:
    1. Agree a small task linked to the current focus.
    2. Explore beforehand what being given homework means (compliance, rebellion, wish to please).
    3. Review it at the next session, giving equal weight to the outcome and to the meaning of doing or not doing it.
  • Example language (illustrative): "Would it help to notice, this week, when that feeling of being overlooked shows up, and jot down what was happening? And I'm curious how it feels to have me suggest something to do."
  • Watch for: non-completion. In a dynamic home this is material to explore, not failure [synthesis]. Working: the client brings richer, more specific observations.

4.14 Teaching between-session self-soothing

  • Purpose / when: a trauma client, or anyone whose emotional work in session spills over afterwards [source: Stricker 2012, describing Pass].
  • Steps [synthesis]:
    1. Choose one or two methods with the client, for example slow breathing, sensory grounding or soothing self-talk.
    2. Practise them in session.
    3. Agree when the client will use them.
    4. Review how it went.
  • Example language (illustrative): "If things feel too strong after our sessions, let's have something you can do. Shall we practise it now?"
  • Watch for: using soothing to avoid all difficult emotion [synthesis]. Working: fewer crises between sessions, and greater willingness to approach material.

4.15 Strengths and positive-affect emphasis

  • Purpose / when: to balance trauma or deficit work. Stricker identifies the strengths emphasis in the Grace case as an assimilated element from positive psychology and newer psychodynamic work [source: Stricker 2012].
  • Steps [synthesis]:
    1. Notice moments of competence, pride or connection, and name them.
    2. Slow down and invite the client to stay with the feeling. In an AEDP home this is processing positive affect [source: Messer 2012 on AEDP positive affects].
  • Example language (illustrative): "You just spoke up for yourself there. What's it like inside to notice that?"
  • Watch for: praise that feels false or that bypasses pain [synthesis]. Working: a more balanced self-view, and resilience.

4.16 Relationship focus imported into CBT

  • Purpose / when: a CBT-home therapist meeting alliance strain, or meeting interpersonal patterns that show up in session. Messer gives "attention to the therapeutic relationship" from client-centred therapy as a standard import into CBT [source: Messer 2015]. Castonguay's group documents two CBT-home versions. One is structured rupture repair in cognitive therapy for depression (see 4.19). The other is an interpersonal and emotional-processing module added to CBT for generalised anxiety disorder (Newman, Castonguay, Borkovec et al., 2011); the module's detailed content is not given here [uncertain].
  • Steps [synthesis]:
    1. Notice an in-session interpersonal event.
    2. Name it gently.
    3. Link it to the client's beliefs about self and others.
    4. Use the event as live evidence for or against those beliefs.
  • Example language (illustrative): "I noticed you apologised for being late three times. I wonder if you expected me to be annoyed. Can we check that against what actually happened between us?"
  • Watch for: turning the relationship into one more thought record [synthesis]. Working: the client has a corrective experience in session that generalises.

4.17 Narrative and interpretive interventions imported into CBT

  • Purpose / when: Ramsay (2001), a cognitive therapist, describes trying to assimilate narrative and interpretive interventions into his cognitive-behavioural home. He presents assimilative integration as a way to avert therapeutic failures, examines the theoretical and clinical barriers to practising it competently, and gives a case example. Ramsay's own procedure and case details are not reproduced here [source: Ramsay 2001, abstract; uncertain]; the steps below are the writer's synthesis.
  • Steps [synthesis]:
    1. When schemas are well mapped but change stalls, explore the life story that holds a belief in place.
    2. Offer a tentative interpretation of the belief's function. Present it as a hypothesis, in line with collaborative empiricism.
  • Example language (illustrative): "I'm wondering if believing 'I must never need anyone' once kept you safe in that family. Does that fit?"
  • Watch for: interpretations delivered as expert truths, which break CBT's collaborative frame [synthesis]. Working: a belief that resisted disputing loosens once its history is understood.

4.18 "Visions of reality" lens (Messer and Winokur)

  • Purpose / when:
    • a formulation and planning lens for seeing the client's predicament from several angles;
    • a check on what view of change each technique carries.
    Messer applied the four literary genres (tragic, comic, romantic, ironic) across psychoanalytic, behavioural and humanistic therapies, and illustrated them with a bipolar-disorder case [source: Messer, "How I have changed", J Clin Psychol, abstract]. In outline: the psychodynamic view is "tragic" (stable, repetitive patterns) and the behavioural view is "comic" (ready change) [source: Stricker 2001]. Messer later applied the lens to a brief-therapy case (Journal of Psychotherapy Integration, 2000, 10(1)) and wrote "Psychotherapy integration using contrasting visions of reality" (ch. 21 in Stricker & Gold's 2006 Casebook of psychotherapy integration). Messer and Winokur's original statement is "Ways of knowing and visions of reality in psychoanalytic therapy and behavior therapy" (1984) [source: Walder 1993, reference list]; the four visions themselves were first set out for psychoanalysis by Roy Schafer (1970) [source: Sacerdoti 2013, abstract]. No published step-by-step procedure for using the lens was found; the steps below are the writer's synthesis [synthesis].
  • Steps [synthesis]:
    1. Ask what is fixed and needs accepting or mourning (tragic).
    2. Ask what can change readily (comic).
    3. Ask where the client's hopes for growth lie (romantic).
    4. Ask where there are contradictions or ambiguity to hold (ironic).
    5. Choose imported techniques accordingly, and set realistic expectations with the client.
  • Example language (illustrative): "Some of this we can change fairly quickly, like how you handle meetings. Some of it, like the loss of your father, is more about finding a way to carry it."
  • Watch for: promising "comic" quick fixes for "tragic" problems [synthesis]. Working: the client feels understood in their full complexity, and goals feel realistic.

4.19 Alliance-rupture repair within cognitive therapy (Castonguay's Integrative Cognitive Therapy)

  • Purpose / when: a CBT-home therapist meets a strain or rupture in the alliance, such as the client voicing or showing a negative reaction to the therapy or the therapist. Castonguay developed Integrative Cognitive Therapy (ICT) for depression as an assimilative approach. Cognitive therapy (CT) stays the home, and ICT adds humanistic and interpersonal strategies for spotting, addressing and repairing ruptures, drawn from Burns (1989) and Safran and Segal (1990). The rationale was a process finding (Castonguay et al., 1996): rigid adherence to CT techniques during an alliance strain went with poorer outcome. The core premise is that exploring the source of the strain, including the therapist's own part in it, works better than tightening adherence [source: Constantino 2008].
  • Steps:
    1. Notice the strain. Resist the pull to apply the CT technique harder; work on the relationship issue directly, openly and non-defensively [source: Constantino 2008].
    2. Invite: ask the client to talk about their negative reaction to the therapy or to you [source: Constantino 2008].
    3. Empathise: respond to the client's feelings and invite further disclosure, so as to understand, respect and validate their experience [source: Constantino 2008].
    4. Disarm: defuse the client's anger or other negative feelings by acknowledging your own contribution to the rupture [source: Constantino 2008].
    5. Throughout, use metacommunication: gentle probing, active listening, empathising and disarming [source: Constantino 2008].
    6. Once the collaborative relationship is restored, resume standard CT techniques [source: Constantino 2008].
  • The ICT manual (Castonguay, 1996) is unpublished. Session count, the wording of each step and any further ICT techniques are therefore [uncertain].
  • Example language (illustrative): Invite: "When I suggested the thought record you went quiet. I wonder if something about how we're working isn't right for you. Could you tell me?" Disarm: "You're right. I pushed on with the worksheet before I'd really heard how hard this week was. That was my part in it."
  • Watch for: treating the client's complaint as one more distorted thought to challenge, which is the rigid-adherence pattern ICT was designed to avoid [source: Constantino 2008]. Also watch for disarming that sounds scripted or self-abasing [synthesis]. Working: the client re-engages with the CT tasks, and the alliance recovers, as felt in session or on a session alliance rating [synthesis].

4.20 Expectancy enhancement as an assimilated common-factor module (Constantino)

  • Purpose / when: a companion module to CT for depression that assimilates a common factor, the client's expectations, into the CT home. Use it when the client's expectations about outcome, length or the nature of treatment are low, vague or unrealistic [source: Constantino 2008].
  • Steps (components as listed):
    1. In the first session, an interview to strengthen outcome expectations and to clarify expectations about how long treatment will last and what it involves.
    2. Throughout treatment, standard expectancy strategies, plus reactive ones when expectations falter.
    3. General relationship strategies guided by the client's expectations.
    4. A termination component to help the client keep their gains. [source: Constantino 2008. The companion manual (Constantino, Klein & Greenberg, 2006) is unpublished, so the content of each strategy is [uncertain].]
  • Example language (illustrative): "Before we start, I'd like to hear what you expect from therapy: what might change, how long you imagine it taking, and what you think we'll actually do together."
  • Watch for: raising hope by overpromising, which the client may later read as failure [synthesis]. Working: the client's expectations become realistic and hopeful, and they can say what the work involves and why [synthesis].

5. Handling problems

The sources address resistance, ambivalence, defensive disputes, panic in session and readiness. All other guidance here is marked [synthesis].

  • Client attacks the method or the therapist's theory (resistance).
    • Do not defend the theory or collude with the attack. Stricker and Gold's therapist noticed he had become "an accomplice" to the defence.
    • Offer an experiential test in which either outcome is useful (4.10). Then explore the transference that follows [source: Stricker & Gold 1996, p. 53].
  • Ambivalence just before trauma-related work.
    • Let the client set the pace, and offer gentler versions such as free writing instead of focused writing.
    • Postpone the import rather than push it [source: Messer 2012; Stricker 2012].
    • Explore the ambivalence in home-model terms, for example the conflict between wanting to "close the book" and fearing the pain [synthesis].
  • Panic or overwhelm in session.
    • Move to stabilisation: relaxation, self-soothing, imagery (4.11). Process the meaning once the client is calm [source: Stricker & Gold 1996, p. 53].
    • For dissociation [synthesis]:
      1. Orient the client to the room, the date and your voice.
      2. Use sensory grounding (feet, objects, temperature).
      3. Slow the pace and stop the memory-related task.
      4. Close the session only once the client is present.
      5. Next session, review the readiness criteria (4.4) before going on.
  • Emotion bottled up, then explosions.
    • Encourage emotional expression in a supportive, non-threatening way.
    • Avoid acting out the client's family pattern of passivity or collusion.
    • Model reflection; teach self-soothing between sessions [source: Stricker 2012].
  • Imported technique feels like a "forced wedge".
    • Some patterns are experienced as part of who the client is.
    • Fully explore the symbolic meaning first, so the technique can later be experienced as benign [source: Stricker & Gold 1996, p. 53].
  • Homework not done (non-adherence) [synthesis].
    • In a dynamic or humanistic home, explore what not doing it means: autonomy, fear of failing, anger at being directed.
    • In a CBT home, problem-solve barriers and shrink the task.
    • Either way, ask whether the task fits the formulation at all.
  • Rupture after introducing an active technique [synthesis].
    • Notice the shift (withdrawal, compliance, irritation) and name it gently.
    • Take your share of responsibility, for example: "I may have jumped ahead of you with that exercise."
    • Explore what the technique meant in the relationship. Return to home-model work until repair is complete. In a CBT home, use the invite–empathise–disarm sequence from Castonguay's Integrative Cognitive Therapy (4.19), then resume the CT techniques once collaboration is restored [source: Constantino 2008].
  • Therapy stuck despite good home-model work.
    • Return to the multi-level formulation (4.1). Check which tier is untouched, and pick a dual-purpose import (4.2) [source: Stricker & Gold 1996].
    • Use session-by-session outcome and alliance feedback (ORS/SRS) to spot stalls early [source: Stricker 2012].
  • Drift into unanchored eclecticism (therapist problem) [synthesis].
    • Signs: you cannot state in home-model terms why you chose a technique; the client describes therapy as "lots of different exercises"; the formulation keeps changing without getting clearer.
    • Response: re-anchor in the formulation, use fewer imports, and take the case to supervision.
  • Imported technique not done competently [synthesis].
    • Assimilation does not replace training in the imported method. Learn exposure, chairwork and similar methods from their primary sources and supervised practice before using them.
    • Ramsay (2001) examines the theoretical and clinical barriers to competent assimilative practice, and frames assimilation as a way to avert therapeutic failures. The specific barriers are not listed here [uncertain].
  • Home theory and imported method assume different views of change.
    • Use the visions-of-reality lens (4.18) to set expectations. Do not promise rapid change for problems your formulation sees as long-standing [source: Stricker 2001 on Messer & Winokur; synthesis].
  • Trauma memories and suggestion [synthesis].
    • Do not use writing, imagery or chairwork to search for or confirm suspected memories.
    • Work with what the client already remembers and with its meaning.
  • Suicide risk emerges [synthesis].
    • Pause imported emotion-intensive tasks. Carry out a standard risk assessment and safety plan, including lethal-means counselling (safe storage and removal).
    • Resume only when the client is stable.
  • Cultural or religious context missed.
    • Stricker criticised the Grace case for not recording cultural or religious background, and for leaving the client's anger unexplored [source: Stricker 2012].
    • Include these in the formulation, and check how each imported technique fits the client's values [synthesis].

Sources

Sources:

Further sources:

Books and papers cited through other sources [uncertain]:

  • Messer, S. B. (1992). A critical examination of belief structures in integrative and eclectic psychotherapy. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (pp. 130–165). Basic Books. (Pages from Ramsay's 2001 reference list.)
  • Messer, S. B. (2001). Introduction to the special issue on assimilative integration. Journal of Psychotherapy Integration, 11(1).
  • Messer, S. B., & Winokur, M. (1984). Ways of knowing and visions of reality in psychoanalytic therapy and behavior therapy. (Title from Walder's 1993 reference list.)
  • Pass, E. R. (2012). The case of "Grace". Pragmatic Case Studies in Psychotherapy, 8(2), 60–112.
  • Fosha, D. (2000). The transforming power of affect. Basic Books.
  • Pennebaker, J. W. (2004). Writing to heal. New Harbinger.
  • Wachtel, P. L. (1991). From eclecticism to synthesis. Journal of Psychotherapy Integration, 1, 43–54.

Also cited (titles only) [uncertain]:

  • Messer, S. B. (2000). Applying the visions of reality to a case of brief therapy. Journal of Psychotherapy Integration, 10(1).
  • Messer, S. B. (2006). Psychotherapy integration using contrasting visions of reality. In G. Stricker & J. Gold (Eds.), A casebook of psychotherapy integration (ch. 21). APA.
  • Stricker, G. (2006). Assimilative psychodynamic psychotherapy integration. In G. Stricker & J. Gold (Eds.), A casebook of psychotherapy integration (ch. 5). APA.
  • Castonguay, L. G. (1996). Integrative cognitive therapy for depression treatment manual (unpublished; cited by Constantino 2008).
  • Constantino, M. J., Klein, R., & Greenberg, R. P. (2006). Guidelines for enhancing patient expectations: A companion manual to cognitive therapy for depression (unpublished; cited by Constantino 2008).
  • Burns, D. D. (1989). The feeling good handbook; Safran, J. D., & Segal, Z. V. (1990). Interpersonal process in cognitive therapy (sources of the ICT rupture strategies, cited by Constantino 2008).
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