Book Review: The Integrity Model of Existential Psychotherapy in Working with the 'Difficult Patient'

Introduction

The authors Lander and Nahon are practising clinical psychologists in Canada who use their 'Integrity model of Existential Psychotherapy' with a range of clients. In this instance its use is being promoted for overcoming therapeutic impasses with individuals labelled as chronic or difficult. Treatment times vary, 'difficult' clients appear to be long term but this is not made clear. With 'higher functioning' populations they say it can be successful in five to six sessions. Their aim is that readers take the model and flesh it out in their own way. They use the word 'Integrity' with a capital 'I' in a special sense and this review will follow this usage to distinguish it fromthe more usual everyday usage.

There are twelve chapters covering the background and development of the Integrity model and its use in practice with case stories organised under DSMIV labels - specifically borderline personality disorder, antisocial personality, addiction, post-traumatic stress and schizophrenic/psychotic-core - which does not sit easily with the UK/European existential tradition. Later chapters on cultural diversity, burnout and organisational stress seemed inappropriate and proselytizing. For example Lander and Nahon suggest Integrity could solve world conflict, never mind difficult patients. These chapters occupy space that might have been more appropriately used for other frequently encountered 'difficult' cases such as eating disorders, mood disorders and other anxiety disorders.

The inspiration for the Integrity model comes from the work of American psychologist O. Hobart Mowrer (1907-1982) whose original insight was that personal integrity is an essential ingredient in mental health and well-being. Originally a Freudian [see note below] he came to believe we get into difficulties because of our interpersonal attitudes and behaviours, and because we try to avoid responsibility and guilt. No surprises here for an existential therapist other than the claim that it was Mowrer who first spotted this.

Mowrer was training mentor to Lander in the 1970s. She and Nahon subsequently developed his Integrity model from its focus on group functioning (both in the small formal sense and the large informal societal sense) into 'I2I' therapy. Their other main acknowledged influence is Buber. It is significant that although some other writers including Binswanger, van Deurzen, Spinelli, Cohn, May and Yalom are invoked this is only in passing. The authors awareness and understanding of existential psychotherapy as practised in the UK and Europe is patchy at best.

A key impulse for promoting the Integrity model lies in their dissatisfaction with the present [north american] zeitgeist [that] still values scientific objectivity and detachment and its tendency to assume a therapeutic impasse with a 'difficult' client is the fault of the client and his/her psychopathology. They believe an impasse can be as much the responsibility of the therapist as the client, and ask us to check out our own levels of Integrity in the relationship. This is of course important but hardly new. Psychoanalysis has been talking about this since the mid 1950s.

The Integrity Model

The overall idea is that mental health and wellness come from living with Integrity according to our values, and from the belief that confession of guilt to oneself (for living without Integrity) is not enough, it must be accompanied by penance, restitution and a change in lifestyle. There are three legs to the Integrity model:

1. Honesty - refers to honesty with oneself and others especially with regard to values. Honesty alone is insufficient for Integrity – honesty must be used responsibly and with the intent to close the space with others.
2. Responsibility - is for your own behaviour, life and well-being. They stress the importance of owning 100% of your 50% in any conflictual interaction, making amends for it and resisting the temptation to blame others. Over-owning and under-owning responsibility results in feeling burdened and resentful on one side and power stolen or given away on the other.
3. Closure of psychological space with self and others - is defined as the critical variable of the intent or spirit underlying any behaviour or intervention. Lander and Nahon say this is the most unique component of Integrity as it is lacking in most human interactions. Thus, if we confront someone about their behaviour we may be honest and responsible but if our intent is to put that person in their place the interaction is devoid of Integrity.

Well, yes - but isn't this stating the obvious?

Returning to practice, In the first session Lander and Nahon explain the Integrity model to the client, to enable them to question and monitor their levels of Integrity for themselves, and encourage a continual process of self-analysis. They say clients engage readily with this approach and become empowered to effect their own cure.

They begin work with an exploration of the client's values and where they give rise to conflict. They highlight the importance of clarifying values, ranking them and accepting they all have a price tag.

Lander and Nahon view mental illness as a social and moral illness and 'difficult' behaviour as a survival solution with a cost. In the case of 'borderline individuals' the cost is a 'deep personal Integrity violation with ensuing alienation from self and others' for which they recommend resolving boundary issues, helping the client to recognise the destructive use of their personal power and giving up their 'victim stance. Schizophrenic and psychotic individuals are challenged to 'own their ability to choose between reality and madness'. There are many ideas that echo principles that existential therapists can go along with. The difference lies in practice – giving the Integrity model to clients and applying it rigorously while explaining 'a new set of behaviours' is required to achieve Integrity and thereby healing. An important aspect of Integrity is buried in the text - Mowrer was a Behaviourist and Lander and Nahon frequently repeat his mantra 'the fastest way to change a feeling or thought is to change the behaviour'.

If only it was this easy.

Lander and Nahon claim the Integrity model 'diverges from all other therapeutic modalities, including other existential therapies...' in these ways:

• Its focus on Integrity as an organizing umbrella to understand the self as a being-in-the-world and a framework to guide and provide meaning to one's life
• Its belief that mental health arises from living with Integrity, and mental illness from a crisis of Integrity
• Its focus on value clashes and conflicts as the source of intra- and interpersonal stress.

Lander and Nahon have clearly either not read or not understood existential philosophy. For example, they claim 'Mowrer's early influence is seldom acknowledged' and that other schools of psychotherapy have incorporated his ideas such as 'the importance of values and value clashes in therapy, therapist authenticity...and spirituality'. I had never heard of Mowrer before reading this book (which may prove their point) but such claims are preposterous nonetheless. Another example is where they challenge bracketing because it may 'prevent therapists from being-in-the-encounter'. This is a very fundamental misunderstanding since it is only by bracketing our assumptions that we can become closer to the other. It is only by suspending judgement and analysis of the client's phenomena that we may become attuned to their current world view.

Conclusions

In assessing this book and trying to do justice to the authors I find myself caught between thinking that much of what they say is consistent with an existential perspective yet it doesn't feel like existential therapy.

It is written in a practical, chatty, meandering style, which at times I found grating - with weasel words like 'we respectfully disagree' and excessive qualification of 'I Nedra [think this] and I Danielle [think that]'.

It contains nothing new in existential thinking other than their formulation of some existential ideas into a model. Nonetheless their experience and apparent success in treating 'difficult' cases, drawing on 35 years work, are worth consideration. If you like models you may find this useful. The Integrity model is plausible in suggesting lines of enquiry that are consistent with an existential perspective but I do not think it is, as they claim, a map for being in the world. Indeed their 'one size fits all' approach rather than a phenomenological exploration of the client's experience is problematic for an approach which they label existential because working phenomenologically rather than prescriptively is a defining feature of Existential Psychotherapy - the British/European school anyway.

You may find it possible to adapt their model to work within your setting and it may well prove to have some value. If so, their aim in writing the book would be fulfilled. The danger is that you may also find that some principles of existential practice have been abandoned along the way. this will be, as I am sure the authors would agree, a matter you for you and your integrity.

Diana Pringle