Khan et al did a 'systematic Review of Comparative Efficacy of Treatments and Controls for Depression' - linked below - their results show that there isn't very much difference between any of the various therapies - behavioural or drug and whilst all are better than doing nothing, none are markedly better than placebo. Hence selection of therapy is really a matter of taste and training rather than one therapeutic approach being better than any other

http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0041778

If all therapies are equal, is the key not the interaction between therapist and client (therapeutic alliance?) and is the question not how this interaction could be instrumental in bringing about emotional change for the client? The brain-based approach seems to be the logical one to follow - incorporating where applicable elements of the older models. After a century (or more) we now have the DSM 5 that lists symptoms but does not tell us why or how to help. Time for a change and the brain-based approach rings true for me. Or am I wrong?

The answer seems to be that it doesn't make any difference what the therapist does just so long as they do something more than leave the client on waiting list.

The brain based approach is no help here either as it has hit a brick wall that has seen most of the world's pharmaceutical companies either abandon this area completely or significantly reduce their investment http://www.academia.edu/2240421/The_failure_of_the_antidepressant_drug_discovery_process_is_systemic

With the drug companies no longer being interested in psychiatric illness and reluctant to even consider new ideas http://www.academia.edu/1145735/Depression_An_Evolutionary_Adaptation_Organised_Around_the_Third_Ventricle it is hard to see where the required progress will come from

Colin, I will read your papers. Thanks for giving me the links. Is it not then rather a matter of looking at the processing of the sensory inputs rather than looking for a drug to alleviate the symptoms. I think Bob sees "brain-based" as "re-programming" the emotions. I understand "brain-based" to include our genetic make-up and its consequences. How would you see it if viewed in this light? Perhaps Bob can shed some light on his views?

Hi John - my view is that depression is caused by the release of an unknown (probably cytokine) inflammatory agent into the Third Ventricle - the damage caused by this then mediates the behavioural syndrome associated with depression.

Since this is highly defensive in nature, the hypothesis further suggests that depression developed as a response to the social emergency of individuals needing to remain in tribal groups that had become hostile to their presence.

There is more detail about this in the second paper I linked above but the basic thesis is that depression developed because of the behavioural syndrome it produces rather than anything else and the emotional response is secondary to this - although this does not make depression any less of an unpleasant experience and, like pain, this is something we seek to avoid.

A rather humble note: my experiences are related only to a close relative of mine. Drug treatment does not solve the problem, but (as far as I can see) alleviates it. A complete abandonment of using drugs almost alwasy (at least in 3 major cases) led to serious symptoms. I read a lot form experts on mental problems, and apparently two, diametrically opposite opinions exist (without being able to convince each other): one thinks that mental illlnesses are nothing but biological problems,, the other thinks that mental illnesses are purely social/psyhical problems, and behavior treatment cures them fully. I do not see this "nothing but" approach acceptable. Drugs obvisousy influence the mental processes, sometimes for the better.

Perhaps I can add some insight into my intent behind my question. I did not intend this to be framed as a medication versus psychotherapy approach to treatment. Instead, I meant it only in the sense of psychotherapy. Additionally, it is posed as to all disorders, including depression, anxiety, OCD, schizophrenia, personality disorders, etc., where psychotherapy has been applied. Stricker (2013) has noted 4 categories of integration: common factors, technical ecleticism, theoretical integration, and assimilative integration. Common factors refers to aspects that are present in most approaches to therapy. Technical ecleticism has no unifying theory and the therapist relies on the knowledge of the literature and previous experience to choose interventions appropriate to the patient. Assimilative Integration is when the therapist adheres to one theoretical approach but is willing to use techniques from other therapeutic approaches. True theoretical integration is considered the most difficult to achieve because it requires integrating theoretical concepts from different approaches, and these approaches may differ in fundamental philosophy about human behavior. This would be a "Grand Unified Theory" which has not been done to date according to Stricker. He was pessimistic about the possibility of this ever occurring since it would have to integrate a theory about the stability of behavior with a theory about the changeability of behavior. Integration has evolved to the point that major textbooks on psyhcotherapy include discussion and organizations exist dedicated to this pursuit (Society for the Exploration of Psychotherapy Integration). I believe true integration is viable and took a first step in that direction based on a brain model. I have attached that article which was published this year. However, there may be ways I have not considered as to how the field may progress and there are certainly other views other than my own on how the brain processes and codes information. I see research gate as a unique avenue to facilitate discussion of views on this and other topics since there are is a diverse representation of young and old scientists/clinicians who can respond. I want to thank each of you who have responed, and would like to hear more from you and others. Thanks. Bob

Stricker, G. (2013). An introduction to psychotherapy integration. Independent Therpaist, 33, 81-84.

Article Psychotherapy and the Brain: The Dimensional Systems Model a...

I have just a moment this evening, but I suspect we will see more integration of mindful awareness and mindfulness practices in psychotherapy, in general, and in CBT approaches, in particular. As a researcher, I am concerned that the integrity of some mindfulness practices will be lost as they are adopted by clinicians with limited experience using them. I look forward to the Association for Behavioral and Cognitive Therapy meeting in Nashville, where mindfulness approaches will be widely discussed.

Dear Robert, I am not an expert in Psychotherapy, however I have assessed a great deal of research in relation to different types of therapies and have found some general trends.

1) Correlational evidence shows that in general all therapy types activate for instance different areas of the prefrontal lobes, which then allows for down regulation of areas of the brain, such as the HPA Axis, resulting in the alleviation of symptomology of different types across different disorders and their sub types.

2) Different forms of therapy used in a targeted way, such as meta cognitive therapy for instance have specific results and are beginning to gather a correlational evidence base, indicating that some form of therapies are more effective in certain types of disorder - subtypes in patients with specific medical/psychologica/familiall backgrounds. However this evidence is far too young to state this with great confidence as the convergence of evidence is not quite there yet.

3) As different therapeutic approaches grow in skill and refinement, and the specific impact these have on physiological processes, symptomologies and cognitive processes are known, I believe the research on different forms of therapies will result in the understanding of which types of therapies are most effective in different mental illness scenarios.

4) Currently we are limited by the methodologies used when researching the effect of therapeutic approcahes whilst using imaging technology. Findings have been made, but variables such as the type of therapy, length of therapy, use of concomitant psychopharmatherapy, skill of therapists, psychometric instruments and other factors have played a major role in dtermining the success of outcomes of different therapy types.

5) The concept of one therapy fits all will most likely fall away to be replaced with targeted and different forms of therapy for specific situations, with brain based evidence supporting the efficacy of the therapies concerned. It must be noted that in cases of neurobehavioural targeted therapy in patients with some form of organic or trauma based insult on the brain, that certain findings indicate that targeted therapy works well, when focusing on a specific function, set of functions. As always other factors play a role, such as age, gender, brain laterality, medical/psychological history and concomitant disorders, familial history, genetic disposition etc.

Hope this helps

Cheryl, you have made some interesting and insightful points. The finding of frontal lobe involvement is what I have suggested as necessary for any current psychotherapy approach to work. Based on the clinical biopsychological theory the action columns of the left lateral frontal operculum (including Broca's area) is the location of the verbal interpreter involved in any self-talk, including schemas. These become involved in all forms of talk therapy. The right frontal columns are those exerting top-down control over the right posterior cortical sensory columns which are not directly accessible by the left frontal lobe interhemishperic connections. The right hemisphere is accessed by experiential techniques and visual imagery. The medial frontal cortex interconnects with subcortical structures such as the amygdala and ventral striatum to allow the down-regulation of the HPA axis (such as by the paraventricular hypothalamus), as well as theroetically having more immediate effects by reducing perifornical hypothalamic activation route which leads to sympathetic ganglion activity and the fast onset physical symptoms associated with anxiety/stress. This is the reason I believe a brain theory provides a way to suggest why the various therapeutic approaches have impact. Schema-based therapies impact left cortical input to the subcortical areas while experiential techniques impact right cortical input. Notably, medication would theoretically have direct effects on subcortical structures or moderate some of the cortical activity to reduce its subcortical effects. However, the drug therapies, either via development of tolerance or discontinuation, would not have long-term effects via alteration of the frontal cortical columns formation and connections. This would indicate a higher expected relapse rate from just using medication alone if cortical emotional and action memories were major factors in creating the problematic symptoms. Maryanne made the point about mindfulness being an effective approach which I believe strongly impacts interhemispheric congruence (i.e., the right and left frontal cortices arrive at the same "interpetation" or conclusion about ongoing external or internal sensroy input). In that case an individual's verbal-thinking and emotional-thinking are aligned which reduces inhibitory effects of one frontal lobe on the other. Increased internal "peace" is the perceived result. The left hemisphere verbal interpreter is either disengaged or has a new rule it employs not to "judge" any thoughts or feelings. In relation to your suggestion that therapies can be more prescriptive, I agree and hope the clinical biopsychological model provides a step in that direction. In this case, it says all approaches to therapy have a basis, but primarily address right versus left vesus congruence. I think it is possible to address all three.

Another point you made is in relation to backgrounds. Influential negative emotional memories, particularly those tied to past and current relationships, appear to have two common aspects when formed. One is uncontrollability and the other involves perceptions of personal responsibility/inadequacy (my 2007 article discusses this in detail). The right posterior cortical memories are not easily addressable via schema-based approaches and are those most effectively accessed and addressed via experiential techniques and imagery. If only uncontrollability is involved, such as in many cases of non-relationship trauma (e.g., someone gets his arm trapped between the rollers of an industrial machine), then simple exposure procedures are predictably very effectve. These negative emotinal memories are those that I believe are the "moderating" factors which can largely determine treatment effectiveness. If they are not effectively addressed, then the treatment outcome will be much worse with increased risk of relapse.

One final point is related to the current methodologies used to assess brain areas involved, particulalry related to imaging techniques such as fMRI. The research I have reviewed suggests that in relation to indications of increased cortical metabolic activity, this occurs in the early learning prcess and is likely not evident once the new memories are well consolidated. If accurate, then identifying the cortical areas which house the influential long-term memories cannot be done with current imaging technologies/algorithms and can lead to misinterpretation of the strong influence of cortical memories. In this case, imaging will show the subcortical activation (e.g., amygdala) triggered by the cortical meomories without demonstrating the cortical activation. I reviewed a couple of articles in the paper I attached to this question in which i believe this occurred. This is another value of a theoretical brain model in that it can provide interpretive guidance.

Overall, I think you and I are on the same page in viewing the future of psychotherpay integration.

Excellent response Robert, I am in agreement. The only finding I have which I am currently busy in a research study about, is that though Pharmacotherapy works and various forms of Psychotherapy work, techniques such as deep brain stimulation works etc, there seems to be a trend of approximately 30% for instance in depressive sub types that do not remit (depending on one's view of terminology and remittance). In these cases various forms of psychotherapy, or pharmacotherapy in isolation have shown on a correlational basis to be less effective than a treatment combination of both, and even then there is still about 30% who do not remit. Thus for me the question becomes, would targeted psychotherapy, and more targeted pharmacotherapy work, or are we not at the point where we know the answer, do we need more sophisticated technology to establish what factors are at play, are we diagnosing disorders that may in that 30% actually be a different form of disorder, which we have not as yet established. I also agree that the use of imaging technology, in conjunction with normal clinical tools ( psychometric instruments) generally tend to be short term tests, with the estblishment of long term changes being required, as well as the finding of technology that can track and find the actual physiological components of long term memories in conjunction with schemas etc. I think we still have a long way to go.....

The title is "An introduction to psychotherapy integration" and the source is the Independent Practitioner, the APA Division 42 publication. Stricker has done a number of chapters and articles, but this was the most recent one I know.

Hi Robert,

I'm wondering if Jack Anchin, Jeffrey Magnavita and Steven Sobelman (all involved with the Journal of Unified Psychotherapy and Clinical Science) would be good contacts for this subject of integrative psychotherapeutic models?

You can find the journal here:

http://www.unifiedpsychotherapyproject.org/ejournal/ojs-2.2.2/index.php/Journal

Jean, I look forward to the posting and thanks for the suggestion Matt. I became aware of the Journal due to the editors' association with the Neurospychotherapist. The articles at the Journal are quite interesting and present a different angle than the brain-based one I have suggested. Matt, perhaps you could invite them to visit us here and contribute to our discussion. I would also ask that you add the link to the Neuropsychotherapist since I suspect those reading the responses to my question would find the website very interesting. Coming from a brain-based view I particulalry like the thrust of the new International Journal of Neuropsychotherapy since it is directed toward providing articles on applied neuropsychotherapy approaches. I have begun to submit some of my own work there since it is the only journal specifically directed toward what I obviously believe is the future of psychotherapy.

I will let Jack and Jeffrey know about this site and invite them to join the conversation. For those interested The Neuropsychotherapist platform is at http://www.neuropsychotherapist.com - As Dr. Moss says, we are keen to inform about applied neuropsychotherapy to the wider mental health community.

The next level of awareness may be the discovery of the improbability of integrating the diverse approaches to psychotherapy. Each approach is rooted, explicitly or implicitly, in a different philosophy of life, and a different conception of "cure," even though there may be a few conceptual parallels. In the ongoing process of treatment, lower level similarities like the dialog format, and the attempt to relieve emotional pain, may eventually be transcended by different developmental destinations. Unless the core models of personality and philosophies of life are examined in depth, any attempt at higher level integration may be limited to superficial comparisons of therapeutic technique.

I logged on to comment, but instead spent my moments (before my first psychotherapy client/patient of the day) reading the engaging, stimulating responses, which lead in interesting directions I wouldn't have guessed by reading the question alone: 1) The individualization of targeted treatment, 2) the integration of psychotherapy with brain processes, and 3) though tangential, thinking about processes happening at many levels at once (genetic and epigenetic to cognitive to sociocultural). All of these have been strong interests of mine, so it's exciting to see them touched upon all in one conversation. Thanks so much.

I gave a response to a similar question in a LinkedIn group to which i belong and thought this would be of interest to this questions followers. Bob

Eric, the neurophysiological common language is the correct level of interpretation in relation to what allows the brain to achieve “higher cortical functions.” Whether referring to abilities to have language, problem solve, use verbal schemas, or form emotional schemas, the common denominator in my proposed model is the cortical column. From a neuroscience standpoint this gives the level at which to look for future research. Other current levels are molecular, neurotransmitter/receptor, modular, probabilistic or frequency coding, and large structure circuits. Methods of measurement involve single cell recordings up to imaging techniques and EEG/MEG. If the correct level of the “code” is the column, then findings from all research at these other levels should be explicable by the columnar model. For example, I reviewed studies that indicate increased fMRI activity during initial learning only. This means that once a permanent long-term memory exists in relation to a stimulus, imaging is not expected to show increased cortical activity in the location of the columns involved with that memory. In relation to intense emotional memories, there would be increased activity at the subcortical level, such as the amygdala on the side where the memory is stored. In a clinically relevant study I mentioned in the 2013 paper, fMRI showed increased right frontal activity during exposure to decrease anxiety to spiders. At 6 month follow up, treatment gains were maintained but the right frontal activity was no longer observed. The study authors suggested the right frontal region was not involved in the maintained benefits. I suggested the columns in this region are still involved and are the ones that allow the decreased anxiety, but show no increased metabolic activity since the columnar circuits are consolidated and require no generalized activity that was necessary for initial memory consolidation. A radical difference in my model and the one that has been predominate since the 1980’s relates to the hippocampus. The current view is that initial storage of memory occurs in the hippocampus and is somehow later transferred to other areas, such as the cortex. The columnar theory says the memories are stored cortically from the outset in the same circuit involved in initial processing, and the hippocampus serves as the pacemaker to allow gamma frequency oscillations and dynamic column formation to strengthen the synaptic connections among the columns. I discuss this and other aspects (such as related to Alzheimer’s and schizophrenia) in a brief article in the Speculation section of the upcoming Neuropsychotherapist magazine on October 1.

More relevant to the current discussion, the common language relates to the Clinical Biopsychological Model in which there are 3 cortical aspects (right hemisphere, left hemisphere, interhemispheric congruence) being addressed as related to negative emotional memories (e.g., trauma, relationship problem memories), current factors (e.g., pain, stressful work environment, marital arguments), and loss positive stimuli (e.g., loss of relationship, loss of job). As I hope I have been able to communicate in my articles, I believe it is possible to use the model to assist in identifying all areas to be addressed in an efficient manner (typically one session) followed by a detailed explanation (conceptualization) being given to the client that explains how the presenting problems developed and how treatment will address each. The conceptualization gives a common language between the therapist and the client, with an understanding of how therapy will proceed. This also allows a way to see how issues addressed in one manner influences issues in a different area. An example of this relates to the distinction I made in the article published (in the International Journal of Neuropsychotherapy, available at Neuropsychotherapist.com) last week on Type-G (Giver) and Type-T (Taker) interpersonal behavior patterns. A description based on this model is an integral part of the emotional restructuring session used to deal with relationship negative emotional memories. In that procedure, the description allows the client’s verbal interpreter (left hemisphere) to gain an understanding (a new schema) of the exact behavior patterns of the target individual (i.e., the person who is the focus of the session, such as a parent, a boss, a spouse, etc.). In the session, this allows interhemispheric congruence since the client better verbally understands the actions of the target individual with better acceptance of the right hemisphere-based emotional reactions of the client (i.e., the client both thinks and feels his/her emotional reactions are reasonable). The same Giver/Taker conceptual framework provides the rationale for how to deal most effectively with individuals in current relationships as I have discussed in my treatment manual and included in the article as an appendix. The concept further serves to insulate the client from developing future detrimental negative emotional memories in relationships since it allows the client to comprehend an individual’s behaviors are a function of how that person has learned to interact in relationships. This externalization prevents perceptions of personal inadequacy and loss of control by the client.

Please ask further questions if you have them since I believe this type of dialogue is the best way for me to convey all aspects of the theory and applications. I have an article that is to be published in New Therapist magazine in the next 2 to 4 months since I am trying to reach out to practicing, non-academic therapists. You can also listen to me talk about the model since I am the guest on Shrink Rap Radio in the show that is scheduled to be posted this Thursday afternoon. It is a 50+ minute discussion available as a free podcast at that website.

Here is a preprint for a paper on integration that might be useful:

Research on psychotherapy integration: Building on the past, looking to the future

Psychotherapy Research. 05/2015; 25(3). DOI: 10.1080/10503307.2015.1014010