380 Integrative Treatment Modalities modalities for different types of clinical prob- Hogarty, G. E., Anderson, C. M., Reiss, D. J., Korn- blith, S. J., Greenwald, D. P., Ulrich, R. F., et lems; (b) design therapeutic structures that are maximally responsive to the specific needs of al. (1991). Family psychoeducation, social skills training, & maintenance chemotherapy particular individuals and families; and (c) pre- vent or overcome potential problems during in the aftercare treatment of schizophrenia II. Two-year effects of a controlled study on re-the process of individual–family or individual– group integration. Such research, combined lapse and adjustment. Archives of General Psy- chiatry, 48, 340–347. with practioners’ accumulating clinical experi- ence, offers the promise of increasingly effec- Huxley, N. A., Randall, M., & Sederer, L. (2000). Psychosocial treatments in schizophrenia: A re- tive integration of therapeutic modalities. view of the past 20 years. 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PINSOF Integrative problem-centered therapy, or IPCT CENTRAL TENETS (Pinsof, 1983, 1995, 2002), is a framework for integrating different psychoth erapeutic a pproaches A set of linked ontological and epistemological assumptions underlie IPCT. Interactive con-and a model for the conduct of specific psy- chotherapies. As a framework, it provides a set structivism asserts that there is an objective real- ity but that it is ultimately unknowable. Ourof parameters for interrelating family, individ- ual, and biological treatments. As a model for knowledge of that reality is a “construction” that derives from the interaction between thattherapy, it provides clinicians with guidelines for making decisions about what types of in- reality and our capacities to perceive, think, and feel. A construction (i.e., an assessment,terventions to use at which points in therapy with specific types of patients with specific prob- hypothesis, or diagnosis) needs to work well enough to accomplish the task at hand. Alllem s. IPCT locates psychotherapy within educa- constructions are not equal. Knowledge is always partial and evolving.tion and human problem-solving. With the ex- ception of involuntary patients, people come There are no “definitive diagnoses,” only “suf- ficient diagnoses.” However, though never de-for therapy when they cannot solve their psy- chosocial problems. The therapist teaches the finitive, knowledge is progressiv e. We can know more and more about something. As knowl-skills and knowledge people need to solve the problems for which they seek help. For some, edge accumulates, our constructions fit objec- tive reality better. Science is a set of rules forthis entails facilitating the use of skills and knowledge they already have; for others, it en- systematically evaluating the extent to which our constructions (hypotheses) fit that objec-tails helping them acquire the knowledge and skills they lack. tive reality. 382 Integrative Problem-Centered Therapy 383 A second assumption, systemic organization, subsequent treatments. It is predicated upon the belief that no specific treatment will be ef-draws on the constructions of General Systems Theory (Buckley, 1968; Von Bertalanffy, 1968) fective for all disorders or all patients—nothing works for everybody or every disorder. To helpand views nature as systemically organized. We are simultaneously systems composed of sub- the wide variety of patients who seek psycho- therapy, therapists need an integrative modelsystems (psychological, biological, etc.) and subsystems of larger systems (families, commu- that seeks alternatives in the face of treatment failure.nities, civilizations, etc.). Systems take on a quality of wholeness that gives them an integ- IPCT is not a type of family or individual therapy. It transcen ds conventional modality dis-rity and identity—“the whole is greater than the sum of its parts.” Additionally, everything tinction s. From the problem-centered perspec- tive, the only difference between family, cou-is more or less connected and therefore should not be considered in isolation. ple, and individual therapies is the location of the indirect/direct patient system boundary. InA third assumption, differential causality, posits that causality is at least bidirectional and, “individual therapy,” the identified patient com- prises the direct patient system.more broadly speaking, mutual. I influence my wife and she influences me. The same goes for me and my daughters and all of the other rela- tionships in which I participate. Every event, ASSESSMENT AND FORMULATION outcome, or problem has multiple causes that derive from horizontal (same level) as well as Assessment, diagnosis, or problem formulation within IPCT is organized around four con-vertical (subsystemic) systemic relations. My angry outburst at my wife derives from her be- cepts: the presenting problem, the patient sys- tem, the adaptive solution, and the problemhavior, my interpretation of it, my feelings, my hormonal levels, and the reactions (real and maintenance structure. imagined) of others to her behavior. Distinct causes contribute differentially. My depression The Presenting Problem contributes more to my angry reaction to my and the Patient System wife’s behavior than her behavior or the reac- tions of others. The primary target of intervention in IPCT, the presenting problem, and the unit of inter-These three assumptions and their related assertions form the underlying theoretical plat- vention, the patient system, are reciprocal con- cepts that mutually define each other. Theform of IPCT. They inform and influence the major components of the model. presenting problem is the problem for which the patient system is seeking treatment. The patient system consists of all of the people who are or may be involved in the maintenanceAPPLICABILITY AND STRUCTURE and/or resolution of the presenting problems. The presenting problem is not the thera-IPCT applies to the full range of problems that patients bring to psychotherapy. It is a compre- pist’s formulation but rather the patient’s. Typi- cally, there are other problems within the pa-hensive psychotherapeutic system. Although not designed to be applied to any specific mental tient system that play a central role in causing or maintaining the presenting problem, but fordisorder, it can and should be applied to spe- cific disorders. As an integrative framework, it a variety of reasons, the members of the system choose not to present them for therapy. Thus,begins the treatment of most disorders with a cognitive-behavioral treatment that has been Frank presents himself as struggling with panic attacks, despite his fears that his wife, Ellen, isempirically shown to be effective for the partic- ular disorder. IPCT has been designed to deal having an affair and considering leaving him. When he calls for therapy, he does not evenwith the treatment failures of these initial and 384 Integrative Treatment Modalities mention his marital concerns. Similarly, Rox- ous nonpresenting problem like Ellen’s poten- tial infidelity or Roxanne’s depression into theanne seeks help for her 14 -year-old son, Jason, who is failing in school, disobedient at home, presenting problem formulation, thereby mak- ing it a legitimate target of the therapy.and probably using drugs. She fails to mention her own depression and illegal drug use, both The patient system is differentiated into two major subsystems. The direct patient systemof which have escalated since her divorce from Ray, Jason’s father. consists of everyone with whom the therapist is working directly at this time. Direct work typi-Patients implicitly or explicitly give the ther- apist a mandate to address the presenting prob- cally involves face-to-face encounters or tele- phone contact. The indirect patient system con-lems and to not address the nonpresenting problems. The guiding principle for the prob- sists of all of the members of the patient system with whom the therapist is not working directlylem-centered therapist is that if you are going to focus on a nonpresenting problem, it must at this moment. The boundary between the di- rect and indirect systems may change duringeither be discernibly (to you and key members of the patient system) linked to the presenting therapy. For instance, in working with a cou- ple, the therapist may involve the parents ofproblem or it must threaten patient health or safety. If it fails to meet either of these criteria, the husband for a series of sessions. The par- ents move from the indirect system into thethe therapist should leave it alone. Thus, the therapist would need to explicitly link Frank’s direct system and back into the indirect system after the “family of origin episode.” Changespanic attacks and his marital problems, or Rox- anne’s depression and Jason’s school failure, to in the location of the indirect/direct boundary during therapy are negotiated carefully and injustify focusing on these nonpresenting prob- lems. The link between the presenting prob- advance with the key patients. The indirect/direct system distinction en-lem and the nonpresenting problem is an es- sential and defining characteristic of IPCT. sures that therapists never forget that they are intervening into a system (network of relation-Patient systems typically include key pa- tients who constitute the system’s major prob- ships and causal factors) that is larger than the people with whom they are interacting directly.lem formulators and power centers. Frank and Ellen are the “key patients” in the panic attack Historically, systemically sensitive psychothera- pists, whether shamans, cognitive behaviorists,system; their children, parents, and friends may participate in maintaining or resolving the psychoanalysts, or psychopharmacolo gists , have recognized that they were intervening into sys-panic attacks, but Frank and Ellen account for most of the variance in the attacks. Similarly, tems that were larger than the “afflicted indi- vidual.” Their “best” interventions incorporatedRoxanne and Jason are the “key patients” in the school failure presenting problem. How- an awareness of the existence and response pre- dispositions of the key patients in the indirectever, Jason’s father, Ray (recently divorced from his mother), would also be a “key patient.” system. The systemic orientation of IPCT is not justThe presenting problem is the starting point of therapy, the anchor of the process, and its applied to patient systems. Therapy is the inter- action of the patient system with the therapistresolution constitutes a crucial outcome. In terms of a process anchor, the problem-centered thera- system—all of the people engaged in providing therapy to the patient system. Therapist and pa-pist continually asks the key patients: What do you want to work on? Presenting problems typ- tient systems constitute the therapy system. The therapist system can also be subdivided into di-ically evolve: what people want to address at the beginning is not necessarily what they want rect and indirect systems. Supervisors, consul- tants, and care managers constitute key mem-to address 3 months into it. Their evolving un- derstanding of their problems and their alli- bers of the indirect therapist system. Perhaps the most important members of the therapistance with the therapist are inextricably linked. If the therapist has a good alliance with key system are therapists, including pharmacolo- gists, who work with other subsystems or mem-patients, it may be easier to integrate an obvi- Integrative Problem-Centered Therapy 385 bers of the patient system. It is as important to involving Ray, her ex-husband and Jason’s father, to support her initiatives, or educat-establish therapeutic alliances with other thera- pists who work with key patients as it is to es- ing herself about appropriate limits and bound- aries with a 14-year-old. If she cannot suc-tablish therapeutic alliances with key patients. A fragmented therapist system can be as trou- cessfully engage in these tasks, she and the therapist need to explore alternatives likeblesome as a fragmented patient system. decentralizing herself and centralizing Ray or other system members who can give Jason The Adaptive Solution what he needs. In addition to asking about the problems for which the y are seeking help, the therapist ne eds The Problem Maintenance Structure to ask the key patients what would constitute an adaptive solution to their presenting prob- The quest to match treatments to disorders is at best quixotic. The fundamental problemlem. Typically, this entails identifying the solu- tions that key patients have attempted in their with the matching quest is that it is not the surface features of a disorder that determine itsefforts to resolve the problem. This collabora- tive analysis of the attempted solutions is an treatment requirements but rather its underly- ing features. Within IPCT, these features con-essential step in the search for an adaptive solu- tion—a sequence of actions for the key patients stitute the problem maintenance structure—the set of constraints within the therapy system thatthat has a high likelihood of resolving the pres- enting problem. prevent the key patients from successfully im- plementing the adaptive solution. Our primaryThe therapist needs to establish a consensus with the key patients about the suitability and focus in describing the problem maintenance structure will be on the constraints (Breunlin,appropriateness of the adaptive solution. Typi- cally, this requires delineating the steps that 1992) within the patient system that prevent problem resolution. However, constraints with-need to be taken by key patients in preparation for or as part of the attempted solution. For in the therapist system or between therapist and patient systems can also play central rolesinstance, Frank needs to first decide whether he wants to try to save his marriage, and if he in preventing successful problem resolution. does, what confrontational and reconciliative steps he would need to engage in to bring that The Levels of the Problem about. Creating a consensus about an adaptive Maintenance Structure solution delineates major short- and long-term goals of the therapy. The possible constraints within the problem maintenance structure can be organized on sixAn ultimate goal of IPCT is to strengthen the patient system by making it more compe- levels, as reflected in Figure 18.1. The first, top level contains constraints from the Social Or-tent, at least in regard to the problems for which it is seeking help. This typically entails ganization of the patient system. These include boundaries—the rules that prescribe who canteaching or helping the key patients to solve the presenting problem rather than solving it do what. For instance, Roxanne needs to create appropriate time and space boundaries atfor them. The problem -centered therapist is like a coach rather than a player. Ultimately, it home so Jason can have a quiet time and place to do his homework. Additionally, she needs tois the key patients who need to do what needs to be done to resolve the presenting problem. communicate effectively with the school that provides her with accurate feedback about hisRoxanne needs to provide appropriate struc- ture (time and space boundaries) and nurtur- school performance on a timely basis. Finally, she needs to reintegrate her son’s father, Ray,ance (support/warmth) to help Jason do the work he needs to do to be successful in school. back into Jason’s life in support of her initia- tives with him and as an emotional and intel-Steps along the way might involve getting treat- ment for her depression and drug addiction, lectual resource for Jason. 386 Integrative Treatment Modalities Ellen because he believes that if he does she will admit that she does not love him and leave him. In this narrative he is unattractive, worth- less, and weak. He fears abandonment and hu- miliation. To confront her would be to reaf- firm his worthlessness. He would rather avoid that and hope that “the affair will just go away.” Roxanne fears that if she confronts and challenges Jason, he will hate her and run away. Transgenerational constraints compose the fourth level. They derive from the transgenera- tional legacies of the key patients as well the current maladaptive involvement of their fami- lies of origin members. Transgenerational lega- cies are cognitive, emotional, and behavioral Presenting Problem Organizational Biological Meaning Transgenerational Object Relations Self patterns that have characterized the families of the key patients for multiple generations. Mal- FIGURE 18.1 The Problem Maintenance Structure adaptive transgenerational legacies are patterns that prevent implementation of the adaptive solution. The belief that men are useless and weak has characterized Roxanne’s family forThe next level consists of Biological con- straints that prevent implementation of the generations. It now constrains her ability to turn toward Ray as an ally and resource in pro-adaptive solutions. These constraints include the biological components of major mental viding Jason with the structure and nurturance that he needs.disorders, learning disabilities, developmental delays, and those aspects of physical illnesses Family of origi n constrain ts include the mal- adaptive involvement of family of origin mem-that affect behavior, cognition, and emotion. The psychomotor retardation aspect of Rox- bers in the key patients’ efforts to solve their presenting problems. Frank has spent most ofanne’s depression may impede her ability to ac- complish the social organization tasks outlined his life enmeshed with his mother. She expects him to call her at least once a day and persis-above. Similarly, if she struggles with an orga- nizational learning disability, she may be un- tently depreciates Ellen. She tells him she knew that Ellen was “no good” from the firstable to provide the organizational structure Ja- son requires. Conversely, it may be hard for time she met her. His mother has escalated her “demands” that he call her and see her sinceJason to use the temporal and spatial structure she provides, because he too struggles with a his father’s death 4 years ago. Frank feels sorry for her and afraid of her wrath if he disappointslearning disorder. The third level inclu des Meaning const raint s her. He feels “caught” between his mother and Ellen.that prevent implementation of the adaptive so- lution. They typically involve maladaptive cog- The fifth level encompasses constraints from the Object Relations of the key patients. Objectnitive and emotional responses on the part of key patients. Aspects of the presenting problem relations refers to the internalized and trans- formed representations of self and importantand/or the adaptive solution “mean” something to the key patients that prevent them from solv- others that derive from the early family experi- ences of the key patients. “Important others”ing their problem. IPCT assumes that cogni- tion and emotion are the intertwined compo- are the people (or psychological objects) that were attachment figures for the key patients.nents of meaning. Meaning typically emerges as a feeling-infused narrative replete with cata- Object relations become deployed maladap- tively through defense mechanisms like denial,strophic expectations. Frank does not confront Integrative Problem-Centered Therapy 387 projection, transference and projective identi- look up to him due to his childlike attachment to his mother. In the face of this narcissisticfication. Roxanne’s mother was very harsh and puni- abandonment, she became enraged. However, instead of expressing that rage to him, she in-tive. Roxanne was scared of her and resented her depreciating and shaming behavior . In con- creasingly sought the mirroring she needed from other powerful men she could also ideal-trast, her father was affectionate and supportive but extraordinarily ineffective. His passivity in ize. A year and a half ago, that quest eventu- ated into an affair with a married man withthe face of his wife’s abusive behavior toward Roxanne and her sister infuriated Roxanne. whom Ellen works. Her narcissistic vulnerabil- ity made it difficult to tolerate Frank’s with-She learned that turning to him for support or protection was useless and only resulted in feel- drawal and to deal with it more adaptively. Rather than confronting his withdrawal anding more lonely and abandoned. In her efforts to provide Jason with the struc- enmeshment with his mother, she sought suc- cor outside of the relationship.ture he needs, Roxanne fears that if she denies and limits him, he will perceive her as an abu- sive mother and that he will “hate” her as she hated her mother. Roxanne bumps up against The Shape of the Structure her early decision that she would never be like and the Power of Constraints her mother. Additionally, Roxanne perceives Ray as being like her passive father—seeking Using a spatial metaphor like Figure 18.1, the problem maintenance space can be conceptu-his support will only exacerbate her feelings of loneliness and depression. Finally, her propen- alized as a rectangular shape with six different levels. Any particular problem maintenancesity to see Jason as perpetually angry is a projec- tion of her own anger at everybody who has structure can be thought of as a shape that has a certain depth and width within that rectangu-hurt her or let her down. She has denied, dis- owned, and displaced this anger much of her lar space. Each problem has its own unique problem maintenance structure. One structurelife, at times turning it on herself and becom- ing depressed. may be wide and relatively superficial, primar- ily encompassing constraints from the SocialThe sixth and last level consists of Self con- straints from the narcissistic vulnerabilities of Organization and Biological levels. Another structure might be bell shaped, encompassingthe key patients that interfere with their ability to adaptively address their problems. Typically, few constraints from the top levels and more from the lower, historical levels. Similar prob-these vulnerabilities derive from the failures of key attachment figures (referred to as self- lems can have different problem maintenance structures, and different problems can have vir-objects within Self Psychology) to meet their narcissistic needs early in their childhoods. tually identical structures. Constraints within a problem maintenanceThese include the need to be “mirrored” (to see oneself positively in the eyes of another), to structure can vary in power—how much they impede implementation of the adaptive solu-“idealize” (look up to), and to “twin” (to feel you are like me) with key self objects. Gener- tion. Roxanne’s paternal transference to Ray constrains her reaching out to him for supportally, the more vulnerable the self, the more rigid and immutable the object relations. with Jason. However, the mere presence of this constraint does not determine its power withinEarly in their relationship, Ellen perceived Frank as kind, sensitive, and caring. He was the problem maintenance structure. Roxanne may be able to overcome it and reach out tovery different from her own father, who was aloof, critical, and impossible to please. How- Ray for support with Jason if the therapist di- rectly encourages her to do so, or she may beever, as Ellen experienced Frank’s growing en- meshment with his mother after his father’s so entrenched in her belief that Ray is worth- less that such encouragement will fall on deafdeath, she felt abandoned. She lost his mirror- ing and found herself increasingly unable to ears. 388 Integrative Treatment Modalities On the Impossibility of Knowing Modalities: Assessment/ Intervention Contextsthe Structure in Advance The crucial difficulty with problem mainte- IPCT uses three primary assessment/interven- tion contexts that specify which members ofnance structures is that it is impossible to know their shape and the power of their constraints the patient system are directly involved in treat- ment at any particular time. Usually, thesewithout directly challenging them. Problem main- tenance structures reveal themselves through contexts are thought of as therapeutic modal- ities. The term “context” is used in IPCT be-action—the process of working with them. Cli- nicians need idiographic data that helps them cause it is more precise and carries less assum- ptive baggage. “Modality” typically confoundsdetermine the particular treatment require- ments of particular patient systems with par- contexts and orientations: it not only specifies who is directly involved in therapy but also as-ticular types of problems. That idiographic knowledge is best obtained by helping the pa- pects of theories of problem formation and change that are frequently linked to that mo-tient system resolve its presenting problem. dality. The “first” context, Community/Family,is the most inclusive and directly involves at least PROCESS OF CHANGE two members from different generations of the patient system—a parent and a child. Maxi- Because the treatment needs of the patient sys- mally, this context can involve multiple mem- tem are best determined through intervention, bers from different generations of the patient intervention and assessment are ongoing and system as well as members of the patient sys- inseparable processes. Within the IPCT, there tem from the community. The treatment of Ja- are not distinct assessment and intervention son’s presenting problems would employ this phases. The two co-occurring processes begin context, directly engaging Jason, his mother the moment the referring patient calls for help Roxanne, Jason’s teachers, possibly his father, and conclude with termination. The therapist’s Ray, and potentially other school personnel knowledge of the patient system and the prob- like a social worker or guidance counselor. lem maintenance structure is always partial The Couple context is usually dyadic and and ongoing. The goal is a sufficient diagnosis involves two people from the same generation that permits resolution of the constraints that within the patient system. The treatment of impede implementation of the adaptive solu- Frank’s panic attacks would primarily involve tion. That diagnosis evolves, becoming more Frank and Ellen. Similar and symmetrical role accurate and sufficient as feedback from the expectations are linked to the direct patients in therapist’s interventions accumulates. The as- the Couple context. Husbands and wives have sessment/intervention process in IPCT is orga- equal rights and responsibilities within their mar- nized around the sequential use of different riage. Obviously, these role expectations must therapeutic orientations and contexts. be “modified” in the context of different cul- tures. The third and last assessment/interven- tion context, Individual, directly involves just one member in the direct patient system.The Problem-Centered Modalities/ Contexts and Orientations The 3 × 6 matrix in Figure 18.2 identifies the The Problem-Centered Orientations three primary modalities and the six generic orientations that are used in IPCT. They are An orientation specifies theories of problem formation and problem resolution—how peo-listed in the order in which they are typically deployed, progressing from left to right and top ple get into and out of biopsychosocial trouble. The six IPCT orientations are generic—theyto bottom. Furthermore, the figure shows how the orientations cut across the modalities. broadly address particular levels and con- [...]... Family 57 74 13 48 77 9 54 86 13 76 99 16 73 88 15 17 83 2 16 81 3 4 10 13 4 10 13 19.1 20.3 21.07 50 .81 57.19 62.56 72.56 59 .83 58. 46 20.30 16.40 16.69 36 .86 30.99 31.07 68. 00 70.46 64.5 21.69 23.16 18. 33 63.25 53.60 75.07 69.75 63.1 82 .00 21.4 22.16 21. 38 55.79 65.95 66 .89 62.03 53.57 50. 38 16.90 14.31 13.44 31.73 27.75 26.6 64.47 65.55 50.50 20.13 21.32 16.33 52.25 56.00 58. 46 59.00 62 .8 75.27 Life... New York: John Wiley & Sons Pinsof, W M (1995) Integrative IPCT: A synthesis of Biological, Individual and Family Therapies New York: Basic Books Pinsof, W M (19 98) The changing face of emotion in integrative problem centered therapy Journal of Systemic Therapies, 17(2), 1 08 125 Pinsof, W M (2002) Integrative IPCT In J Lebow & F Kaslow (Eds.), Comprehensive handbook of psychotherapy Vol 4: Integrative... elaborated ways of integrating spiritual approaches with the practice of psychotherapy This trend is consistent with the growing awareness of the importance of religion, spirituality, and spiritual experiences in the lives of many people and the relevance of religion and spirituality for psychotherapy Two of the most well-known and clearly conceptualized approaches to integrating spirituality with psychotherapy. .. techniques of relaxation that were later incorporated into behavioral methods, such as desensitization were, at least in part, drawn from Hindu or Yogic practices The psychotherapist practicing in accord with one of the major systems of psychotherapy could benefit by looking at its ostensible philosophy, which is often denuded of spiritual content, to some of the origins of the therapeutic system This type of. .. psychotherapeutic methods or the importance of additional types of insights In this regard, there has been a history of techniques “crossing-over” from being part of spiritual traditions to becoming a psychotherapy method Linehan’s dialectical behavior therapy (DBT) involves the use of an array of techniques, most of them behavioral in origin, in the treatment of borderline personality disorder (Koerner... quasi-clergy role of the psychotherapist, who has become, in our society, an arbiter of morals and values The effectiveness of psychotherapy is thus potentiated by archetypes related to healing and spirituality These include some of the very bases of therapeutic effectiveness: the client’s belief in the value and effectiveness of psychotherapy, a specific psychotherapeutic approach, and the ability of the therapist... religious themes Bakan (19 58) has examined some of the vestiges of Jewish mysticism in Freudian thinking; and Vitz (1 988 ) has even speculated about some undercurrents of Christianity in Freud’s background Two specific examples include Freud’s awareness of the hidden meaning of dreams from Biblical sources, with which he had long been familiar, and his interpretive approach to the psyche of patients, which paralleled... siblings) of key patients to participate in a series of sessions (a family -of- origin episode) with their adult child to address current and historical aspects of their relationship Frequently, this work occurs in the context of couples therapy Framo recommends excluding the spouse of the adult child during these sessions In contrast, IPCT recommends including the spouse in most, if not all, of the family of. .. notions of mental health, such as that exemplified in the behavior of castes of Indian musts, or holy men, who are electively mute penniless wanderers devoted to a deity They often spend their lives in presumed transcendental states of consciousness while foraging in dumps and wilderness areas What About the Definition of Psychotherapy? In spite of the many efforts to integrate spirituality and psychotherapy, ... value system on the part of psychotherapists to work supportively with clients in 12-step programs Psychotherapy may complement treatment of a client in a 12-step program in a variety of Integrating Spirituality with Psychotherapy different ways Psychotherapy is, by its nature, less programmatic than 12-step programs, and thus can lead to greater awareness of individual patterns of experiencing and . Psychiatry, 27, 87 8 87 9.assessment of child and family. In P. D. Stein- hauer & Q. Rae-Grant (Eds.), Psychological Nichols, W. C. (2001). Integrative family therapy. Journal of Psychotherapy Integration,. treatments in schizophrenia: A re- tive integration of therapeutic modalities. view of the past 20 years. Journal of Nervous and Mental Disease, 188 , 187 –201. Klein, M., & Riviere, J. (1964). Love,. of Clinical Psy-therapy: A conflict resolution framework and ethical considerations. Journal of Psychotherapy chology: In Session -Psychotherapy in Practice, 56, 211–225 .Integration, 11, 349– 385 . Integrating