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The history of psychotherapy is told in waves: first psychoanalytic, then cognitive-behavioral, now CBT plus mindfulness, and so on. But the truth is that the majority of mental healthcare providers today are “eclectic” — a word typically used to signify that they employ a variety of strategies, from a variety of different therapeutic schools of thought, depending on the needs of the patient.1
To a client, eclecticism probably makes perfect sense. Everyone has different needs, so it’s no wonder that a bespoke approach works best! But in certain professional spaces, “eclecticism” is a dirty word. While some therapists proudly identify as eclectic, others express concern. There’s a worry that those who identify as eclectic don’t account for the theoretical and evidentiary foundations of the tools in their toolkit – making them unreliable technicians at best.
Such reckless eclectics certainly exist. I encountered one or two of them as a therapy client. But I’ve also brushed shoulders with humorless dogmatists who are convinced theirs is the One True Method, whatever method that may be. In my estimation, neither of these extremes is really serving clients. I suspect that most successful therapists have bushwhacked their way to some more tenable middle ground, balancing an overarching theory of change with the flexibility that real life demands.
But how do you find this equilibrium for yourself, let alone maintain it?
Common threads
Last year, I read Borderline: The Biography of a Personality Disorder by Alexander Kriss, a therapist treating borderline personality disorder (BPD). He describes integrating mentalization-based therapy, dialectical behavior therapy (DBT), relational psychoanalysis, “and other points of view [Kriss] encountered, without identifying as a purist from any one group.” He continues:
“Humane and effective treatment often requires its own synthesis. Rather than randomly throwing things at the wall, I strive to thoughtfully draw together threads that have long been cut or separated from one another, but can be traced back to common origins.”
This vision — of building new futures out of common origins — is one of the best articulations of principled eclecticism that I have encountered. It acknowledges that, different as they may be today, all psychotherapies come from a short but dense family tree, with many of its roots in the lived experiences of 19th century Viennese Jewish intellectuals. Kriss’ vision also speaks to something that I truly believe: that it is terribly wasteful to leave ~135 years of accumulated wisdom in the midden of history, just because it exists alongside plenty of trash.
Of course, reweaving therapeutic threads is easier said than done. I’m extensively trained in DBT, considered a gold standard treatment for BPD. Out of curiosity, I recently read the manual for another BPD intervention: mentalization-based therapy (MBT). MBT is focused on increasing a client’s capacity for mentalization, well-summarized by co-authors Anthony Bateman and Peter Fonagy as the ability to “see oneself from the outside and others from the inside.”
At times, I found the overlap between the DBT and MBT to be nearly comical: both are skeptical of things like insight and schema, instead focusing on the present moment; both underscore a client-therapist dialectic, or what MBT calls “contrary moves”; both emphasize the importance of validation; both value the ability to observe the mind, whether that practice is called mentalization or mindfulness; and so on. I was also gratified to find in the MBT manual descriptions of behaviors I’ve encountered, but not quite found the words to describe within the DBT lingo. For example, MBT articulates a state of “pseudo-mentalizing,” in which a person cooks up explanations of their behavior or the behavior of others, which sounds a lot like mentalizing, but has no real basis in evidence.2
I also experienced the differences in the two modalities, both big and small, to be quite startling. For example, DBT describes six levels of validation, one of which is “mind reading.” The idea here is that you can validate your client by accurately naming their unarticulated thoughts or emotions. Most of the time, this level of validation is optional; there are plenty of other levels to choose from! In some cases, however, like when you need to speed up a behavior chain analysis, mind-reading is more essential. In MBT, by contrast, mind reading is explicitly and repeatedly discouraged, on the logic that it takes away an opportunity for the client to mentalize their own experience — the whole goal of MBT.
A second example: The MBT manual repeatedly says that the focus of therapy is not on the behaviors a client engages in, but rather the affect around those behaviors. DBT, by contrast, is focused on behaviors (it’s in the name). But DBT conceptualizes emotions and cognitions (in essence, affects) as covert behavior, to be considered alongside more overt actions like self-harm — so maybe, on this front, they’re not so different? However, in MBT, the emphasis is placed on the affect in the moment of recounting the story of past behaviors, whereas DBT is laser focused on recounting emotions when the problem behavior occurred. So maybe they’re actually radically different?3
How does Kriss (or another other eclectic therapist) navigate these theoretical tensions in practice? Does he endorse validation — but only five levels? Does he prioritize past affects, current affects, or somehow do all of the above? I don’t presume to know. And given that I, at present, do not integrate MBT into DBT, I can’t offer my own insight. But I’ve been theorizing that one means of reweaving therapeutic threads is by turning “common factors” on its head.
Common factors 2.0
Common factors is the name given to a well-developed and evidence-based observation that all effective therapeutic modalities include a strong therapeutic alliance, high therapist empathy, a therapist’s positive regard for the client, genuineness on the part of the therapist, and positive expectations from the client.
This is all well and good. But when it comes to reweaving therapeutic threads, we need to go a step further. I suspect that there are probably also a set of common factors for all BPD therapies, or all OCD therapies, all depression therapies, and so on. And we could spend a lot more time and money on identifying what these condition-specific common factors are.
The mentalization-based therapy manual actually includes some preliminary hypothesizing on this topic. Bateman and Fogarty believe that BPD can be understood, at least in part, in terms of “chronic epistemic mistrust,” in which an individuals’ relational history has trained them to be hyper-vigilant about the assumed (negative) intentions of others. As a result, the authors suspect that DBT, MBT, and other successful interventions for BPD all involve:
Clear and transparent communication of the therapeutic model to the client
Interventions to increase the client’s ability to see themselves from the outside and others from the inside
Intentional efforts to help the patient apply this learning to real-world environments in ways that are reinforcing
This may or may not be the right list, but I think the list-making endeavor is itself valuable. I can see similar possible connections in OCD treatment: Exposure and response prevention (ERP), the gold-standard treatment, and acceptance and commitment therapy (ACT), which is also applied to OCD, both emphasize that the mind is not something one must react to, and intervene to increase a sense of agency in relationship to thoughts. And there’s some evidence to suggest such pattern recognition is possible among interventions in social-emotional interventions for youth, too.
The emphasis I’m placing on condition-specific common factors is not to say that specific factors — the things that are unique to each therapeutic modality — don’t matter. They plainly do. It’s also not to say that every modality I’ve mentioned here stands on equal evidentiary ground. (At this moment in time, I think it’s fair to say that DBT has a stronger evidence base than MBT and, in particular, a stronger mechanistic theory of change.) It’s simply to say: working to understand why effective therapies work benefits everyone — and searching for condition-specific common factors is one relatively simple strategy.
Obviously, even more research on this topic would be awesome! I don’t exactly know how best to go about that, but one approach in the existing literature — “distillation and matching” — seems useful. Efforts to study the combined effect of related therapies (like DBT + MBT vs. standard DBT) are often illuminating. And my own brief lit review suggests there are many other ways to operationalize these questions.
But I also think the beauty of this emphasis on condition-specific common factors is that it doesn’t require empirical research to reap some rewards. Clinicians are already comparing and contrasting modalities by themselves and in consultation with peers. They’re finding the overlaps organically, and doubling down on their successes.
“Eclecticism” in practice
This leads me to a final consideration: how do we enhance our individual efforts at rigorous eclecticism?
I’ve found it helpful to identify my own clinical archetype — in other words, the kind of “eclecticism” one naturally leans toward, and wants to systematically cultivate (as well as the unique blindspots one will have to watch out for). There are surely many ways to think about this, but from my observations of my peers and teachers, I’ve organized the possibilities for myself like this:
The Collage Artist: These folks want to treat a specific thing, and they’ll do whatever works. → Clinician A wants to treat people who engage in impulsive behaviors. So they learn DBT, MBT, and anything else that is indicated, and learn to blend it. They are classic eclectics.
The Stalwart: These folks like a specific style of therapy, so they take on clients that the evidence says will benefit from their approach. → Clinician B loves behavioral interventions. So they deliver DBT and its adaptations to those with BPD, ADHD, and binge-eating disorder. Their eclecticism comes from A) learning those adaptations of their base model and B) knowing when their clients are ready for something new and artfully referring out.
The Sequencer: These folks want to be able to see the same client through multiple stages of treatment, so they select clients who the research suggests will benefit from one or more of the modalities they offer, each to fidelity. → Clinician C wants to treat people with complex PTSD. So they offer DBT for stabilization, EMDR for trauma, and ERP for OCD, a common co-morbid condition. Such eclecticism is consecutive, rather than concurrent.
I appear to be gravitating toward the role of a sequencer (a compelling problem I wrote about at length a few weeks back). I take comfort in knowing I’m delivering treatments in a way that closely corresponds to the techniques validated in clinical trials. I also crave variety and enjoy delivering more than one type of therapy in the course of a day or week. And, in my own way, I really believe in the work of reweaving. While I am not a technical eclectic, there are conceptual questions I want to resolve for myself by any means necessary. So I search far and wide for satisfactory explanations, even as I stick to a specific set of tools in my practice.
This all said, I’m also still very early in my clinical career! My eclectic archetype may change over time, I may end up blending more than one of these categories together, or I may forge a path I don’t even know exists yet. In this moment, though, my self-identification as a sequencer is helping me think about how to sustainably build mastery — and what to do when I inevitably bump up against my own limitations.
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Credits: Original art by Seattle-based illustrator Mara Parks Potter. Follow her on Instagram @maraparkspotter.
FWIW, there are even MORE ways to think about the concept of eclecticism — or what is also known as “integrative” psychotherapy. The Journal of Psychotherapy Integration, for example, defines five different integrative lenses in their scope statement:
common factors (core elements to effective psychotherapy that transcend a specific orientation)
technical eclecticism (application of the best treatment for a specific population and problem)
theoretical integration (combining two or more theories and their associated techniques)
assimilative integration (theoretical grounding in a single orientation with value added techniques drawn from other orientations)
unification (meta-theoretical approaches that place theories, techniques, and principles into holistic frameworks)
To be clear: I don’t think any of this is exclusive to any one diagnosis — or even to a diagnosis at all. We all experience peaks and valleys in our mentalization capacities :)
If this doesn’t sound like a big difference (past affect vs. present affect), trust me: it’s significant!
You said, "I’m extensively trained in DBT, considered a gold standard treatment for BPD."
This is a lie. DBT is not a "gold standard." The literature states that is is no better than literally *anything else.*
DBT is abuse. If you practice DBT, then you are an abuser.