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My brand new "two-seven-two" model of integrative psychotherapy! (second post)

I began thinking yesterday about what I actually do as a psychotherapist.  This lead to a light-hearted first post describing a "two-seven-two" model of integrative psychotherapy.  The initial "two" acknowledges the importance of an overview of what has been going on for the client and a good working alliance.  The "seven" describes a series of overlapping therapeutic areas that I pay attention to.  The first three of these are probably used by most psychotherapists - problem solving relevant outer issues, problem solving unhelpful internal response styles, and - where appropriate - looking at "ball & chain" contributions from the past that may be holding back progress in the present.

Four further therapeutic areas I consider, that are maybe less often considered by some psychotherapists, are biological interventions, focus on physical health, development of wellbeing, and using the here-and-now therapeutic relationship. By biological interventions I mean drug therapies, light, dietary supplements, herbs, and so on. As a medical doctor, I'm clearly in a good position to keep an eye on the possible value of these kinds of methods. The focus on physical health honours the truth of "mens sana in corpore sano". Psychotherapists are rightly interested in emotions & the mind. We can miss the importance of the body - "If a pickpocket meets a saint all he sees are his pockets". Posts like "New research shows diet's importance for preventing depression", "Recent research: three depression papers that get me thinking", "Dose-response relationship between physical activity and mental health" and "Common sense isn't common" all illustrate the value of looking at physical health if we're trying to improve psychological difficulties. I quite often say to clients something like "It's marvellous. Pretty much all the lifestyle, self-care choices that you could make to benefit your physical health are also likely to help your psychological health. What a bonus!".

As for the development of wellbeing, less than 20% of us qualify as really "flourishing" in our lives - see "The spectrum of mental health". This matters because "flourishing" psychologically is clearly a much pleasanter more rewarding state to be in. Additionally it is associated with more effective functioning - in thinking, creativity, energy, relating. And thirdly "flourishing" protects well against relapse into mental disorder. I talk more about these points in the post "Psychotherapy & positive psychology: why psychotherapists should pay attention". There is a flowering of good research on how to nourish happiness & wellbeing. As papers like "Behavioral activation interventions for well-being: A meta-analysis" have shown, approaches we already use in our work with mental distress are also likely to promote mental wellbeing. And there is much helpful we can learn additionally from positive psychology - for example, I am a big fan of "Self-determination theory" with its emphasis on the importance of responding to our needs for Autonomy, Competence & Relatedness. Relevant research papers are numerous, examples include "Persistent pursuit of need-satisfying goals leads to increased happiness", "Change your actions, not your circumstances: An experimental test of the Sustainable Happiness Model" and "It's not just the amount that counts: balanced need satisfaction also affects well-being". I very regularly speak with clients about their values, about what they feel is most important, about how they relate to others & themselves, and what they can do to grow their wellbeing.

And the fourth of these maybe less regularly considered therapeutic approaches is directly using the here-and-now of my relationship with the client. The series of blog posts starting with "Meeting at relational depth: outline of a 'research' workshop" speaks to this area. The ability to "shift gears" into very honest, caring, empathic here-and-now sharing is so valuable both in therapy and in our own personal close relationships - see "Friendship: science, art & gratitude". It's not an openess of interaction that many of us "swim in" very often. It can be a source of so much learning and growth. The psychotherapist Irvin Yalom used to use the question "How do we feel about the space between us?" When it feels appropriate, it's a question that I use too. There are many other instances like this. For example, if a client makes some comment - often self-disparaging - about what they feel I must think about them, an option I often follow is to ask "Would you like to know what I really think about you?". If they say "yes", I may set it up as a behavioural experiment, but I certainly do my best to answer very honestly & caringly. It's powerful. And I'm very ready to reciprocate and be on the receiving end of honest feedback about what they feel about me. Another example, for a client who says that they have trouble being really authentic, is to agree to use a quick "thermometer check" intermittently during the psychotherapy session. So if 100% represents being totally open, genuine & honest and 0% represents being completely closed & inauthentic, I may ask them every so often during the session roughly how they would rate themselves in their current interaction with me. If they estimate, for example, 60 to 70%, an obvious question is "If you feel prepared to, what would you share with me if you moved up to being say at least 80% open?"

That's the "two-seven" section of the model. There's the initial combination of an overall problem-solving approach combined with honouring the importance of the working alliance, then the seven overlapping kinds of treatment approach I may suggest using. The final "two" of the model involves a knowledge of the evidence base underpinning the different interventions and careful routine monitoring of both client progress and the state of the alliance. So with the evidence base I may well say to the client, I tend to recommend we use treatment approaches that have been shown through good research to be first choices for the kind of difficulty you have been experiencing. If these first choice approaches don't achieve the progress you want, then let's move on to or add in second choice approaches, and so on. Of course this evidence based selection is going to be affected by a whole series of other factors - client preferences, client's experience & response to different forms of treatment in the past, the severity of their disorder, the availability of different treatments, and so on. Then what holds it all together and helps to prevent slipping into a fruit salad of disorganized interventions, is consistent monitoring of outcome and alliance. See the post "Psychotherapists & counsellors who don't monitor their outcomes are at risk of being both incompetent & potentially dangerous".

A lot to think about. Hippocrates had it about right when he wrote "Life is short, art long, opportunity fleeting, experience deceptive, judgment difficult." Although sitting right in front of me on my desk is another thought. It's a picture given to me spontanously by my son a quarter of a century ago when he was maybe five or six years old. Above the picture of a smiling man is the simple statement "A doctor's life is a happy one" ... and it can be so often for psychotherapists too.

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