An integrative framework for psychopathology and psychotherapy

Integrative Framework 2

Running head: INTEGRATIVE FRAMEWORK

An Integrative Framework for Psychopathology and Psychotherapy

Raymond M. Bergner

Department of Psychology Illinois State University

Normal, IL 61790-4620 E-mail: [email protected]

Fax: (309) 438-5789 Citation: Bergner R (2004). An integrative framework for psychopathology and psychotherapy. New Ideas in Psychology, 22, 127-141.

Key words: Psychopathology, psychotherapy, psychotherapy integration, Descriptive Psychology

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Abstract This article presents an integrative framework for psychopathology and psychotherapy. The framework differs in kind from previous ones in that it is entirely pre-empirical (specifically, conceptual and logical) in character and does not represent an attempt to create a new empirical theory (cf. Newton’s pre-empirical creation of a new conceptual system, which creation proved a necessary precondition for his subsequent empirical contentions). The present integration is accomplished in three parts. In the first of these, a definition of pathology as behavioral disability or functional impairment is presented and defended. In the second, this definition is used as a centerpiece to achieve a logical unification of many prominent explanations of psychopathology that are at present widely considered to be theoretically divergent and incompatible. In part three, established forms of intervention from our most influential schools of psychotherapy are shown to be both conceptually coherent and compatible in practice within the present overarching framework.

Integrative Framework 4 An Integrative Framework for Psychopathology and Psychotherapy

Many psychotherapists, whatever their professed allegiances, on different occasions do such “theoretically incompatible” things as correct maladaptive beliefs, modify deficient social skills, attempt to remove children from scapegoated familial positions, and recommend psychotropic medications. The aim of the present work is to accomplish two basic objectives. The first of these is to demonstrate that, while historically we have balkanized the business of explanation into behavioral, cognitive, systemic, psychoanalytic, biological, and other explanatory types, in reality all of these explanations may be integrated within a single coherent intellectual framework. The second objective is to show that the kinds of interventions noted above (and many more), all of which follow logically from these theoretically based explanatory forms, may be rendered coherent and compatible within this superordinate integrative framework. In accomplishing these objectives, the present effort represents a solution to psychotherapy integration that differs radically in kind from other prominent ones such as those proposed by Wachtel (1977, 1997), Goldfried (1980, 1995), Beutler (1983; Beutler & Clarkin, 1990), Lazarus (1986, 1992), and others. This difference lies in the fact that it is entirely pre-empirical (specifically, conceptual and logical) in character and does not represent an attempt to create a new empirical theory. Such conceptual and logical (vs. empirical) elements are very familiar and very central in other established sciences (Chalmers, 1982; Lakatos, 1974; Toulmin, 1956; Wittgenstein, 1922, pp. 67-71), but have received scant attention within psychology. Perhaps the most famous example of this is Isaac Newton’s pre-empirical creations of a new conceptual framework and of the calculus (not to mention his utilization of existing nonempirical systems such as Euclidean and analytic geometry) in the creation of his "system of the framework of the world" (Berlinski, 2000). The present article is divided into three parts. In part one, a definition of pathology as behavioral disability or functional impairment is presented and defended.

Integrative Framework 5 In part two, this definition is used as a centerpiece to achieve a logical unification of many prominent explanations of psychopathology that are at present widely considered to be theoretically divergent and incompatible. In part three, established forms of intervention from our most influential schools of psychotherapy are shown to be conceptually coherent and compatible in practice within the present overarching framework. All of the above is accomplished in a way that embodies a common language, thus avoiding the highly problematic “tower of Babel” proliferation of technical languages that continues to characterize the contemporary scene. This article employs conceptual resources from Descriptive Psychology, most notably that approach's articulation of the concept of "pathology" (Bergner, 1997; Ossorio, 1985/97). Pathology as Behavioral Disability

The definition of "pathology" presented here, originally formulated by Ossorio (1985/97), is not identical in its particulars to any other. However, it is a member of an increasingly prominent class of definitions in the mental health field that identify psychopathology with behavioral disability (or, synonymously, "functional impairment" or "dysfunction") (e.g., Spitzer, 1999; Wakefield, 1992, 1999; Widiger and Trull, 1991). As such, it contrasts both with behavioral definitions that maintain that the term “psychopathology” designates a kind of behavior (e.g., maladaptive or deviant behavior), and with medical model definitions that equate psychopathology with some unobservable, underlying, non-normative state of affairs knowable only through inference from overt symptoms (e.g., a conflictual relationship between id, ego, and superego). In a previous paper (Bergner, 1997), I argued at length that the present definition of pathology, relative both to other disability-based and to non-disability- based conceptions, does a better job of fulfilling the traditional intellectual requirements for a good definition. Specifically, it (a) better delineates the necessary and sufficient conditions for correct application of the term "pathology," (b) which conditions successfully discriminate widely agreed instances of pathology (e.g., those catalogued in DSM-IV) from agreed noninstances, and (c) separates the logically prior definitional question of what something is from the logically posterior one of what causes that

Integrative Framework 6 something, leaving the latter what it should be: an open empirical matter. Pathology as Disability: Explication of the Present Definition According to Ossorio (1985/97), a person is in a pathological state when there is a significant restriction in his or her ability (a) to engage in deliberate action and, equivalently, (b) to participate in the social practices of the community (see also Bergner, 1997). It may be noted that Ossorio is here providing a definition of the broader, more generic concept of “pathology” (or “pathological state”), and not the more specific concept of "psychopathology." Thus the definition covers psychopathology, but covers more as well, a feature whose clinical and scientific advantages will be discussed below. Notwithstanding this broader scope, the focus of this article will be on what traditionally have been considered mental disorders. In the following paragraphs, the meaning of Ossorio's definition will be clarified by considering each of its elements separately. "Significant restriction in ability." On the present definition, pathology implies some significant degree of disability. It implies, first, that the disability must be one of considerable importance--that it must be a serious or harmful one for the individual (cf. Wakefield, 1992, 1999). Secondly, it implies an important deficit in an individual's ability to behave, as opposed to a refusal or unwillingness to behave in some fashion. Though missing from many prominent definitions of psychopathology, this element of personal disability has traditionally been a central criterion for judgments of mental disorder. Persons in the mental health and legal fields have been in substantial accord in their judgments that persons who are largely able to behave otherwise, but choose not to do so (e.g., persons such as Ghandi who deliberately engage in politically motivated hunger strikes), do not have a mental disorder. In contrast, our collective judgment has been that persons who are significantly unable to behave other than they do in critical life domains (e.g., the self-starving anorexic individual) do have such a disorder. Thus, the criterion of personal disability or functional impairment distinguishes pathology from phenomena such as immorality, eccentricity, irresponsibility, or malingering, all of which conceptually imply a refusal or unwillingness to behave in certain ways, but not an inability to do so. This criterion of personal disability also distinguishes

Integrative Framework 7 pathology from limitations on persons that are entirely circumstantially imposed, such as those that might be brought about by maladaptive family interaction patterns, discrimination, poverty, or subjection to external constraint. When persons cannot behave in certain ways, not because they are personally dysfunctional, but because they are impoverished, discriminated against, or tyrannically controlled, this has not historically constituted grounds for regarding these persons as having a mental disorder (which is not to say that such negative circumstances may not cause persons to become disabled). What is "significant?" What constitutes a "significant" restriction in behavioral capabilities? Two things may be noted in this connection. First, to a large degree, there will be relatively little disagreement on this matter in most serious cases. Persons so depressed as to find it enormously difficult to tackle virtually anything, persons bound to their homes with phobias, and persons so psychotically decompensated that they cannot function outside of an institution will all be judged with high agreement to be significantly restricted in their ability to function. Second, there will be some disagreement, even among competent clinical judges, in less extreme cases since the notion "significantly disabled" possesses what linguistic philosophers refer to as "vagueness." That is, it lacks a precise, determinate point dividing the concept from its opposite. Such vagueness, however, is not a liability of the present definition relative to its competitors since all of them also possess vagueness (consider, for example, the concepts "maladaptive," "deviant," and "statistically infrequent"). Finally, vagueness has been noted by Wittgenstein (1953) to be an extremely common, inevitable, and generally nonproblematic feature of language--a feature that has in fact made its way onto the contemporary scientific scene in the form of "fuzzy sets" in artificial intelligence software design. "Deliberate action." To engage in deliberate action is to "behave" in the full sense of that term. It is to engage in some behavior B, knowing that one is doing B rather than other behaviors that one distinguishes, and having selected B as being the thing to do from among a set of distinguished behavioral alternatives (Ossorio, 1985/97; cf. Anscombe, 1957). Such behaviors as making a carefully considered move in a board

Integrative Framework 8 game, ordering a meal from a restaurant menu, or phrasing a verbal reply so as not to offend another represent clear, everyday examples of deliberate actions. Disability with respect to deliberate action, then, may logically take a number of forms. First, it may take the form of being significantly unable to know what one is doing. Examples of this would include anorexic persons who cannot see their own behavior as other than a case of "just dieting," and paranoid ones who cannot see theirs as other than a case of "exposing the conspiracy." Second, disability may take the form of being limited in one's ability to select and implement one's behaviors; i.e., to have control over them. Common examples here would include anorexic, schizoid, and profoundly depressed persons for whom it is enormously difficult to initiate important behaviors; and substance-dependent, compulsive, and impulsive persons who are impaired in their ability to restrain critical behaviors. "Social practice." Social practices are the "done things" in a culture. They are learnable, teachable, doable, recognizable, public patterns of behavior. Familiar examples from everyday life include various games (e.g., baseball, chess), social customs (e.g., writing letters, conversing, dining), and vocational routines (e.g., typing, doing scientific experiments, writing computer programs). Social practices are paradigmatically interpersonal, but may also be private and/or self-directed. Doing mental arithmetic, playing solitaire, or criticizing oneself would be examples of the latter. Being “significantly restricted in one's ability to engage in deliberate action” will in every case imply that one is restricted in one's ability to engage in some important social practice, or in some range of such practices, that for the individual constitutes a serious and harmful restriction. This aspect of the present definition is essentially identical to the DSM-IV criterion of "impairment in one or more important areas of functioning" (American Psychiatric Association, 1994, p. xx). The social practices at issue in pathology are as a rule critical ones such as negotiating differences in one's core relationships, making love, mourning the loss of a loved one, reading, conversing, courting a romantic partner, or disciplining one's children. They are critical because disability with respect to such social practices will often be tantamount to, or will result

Integrative Framework 9 in, an inability to carry on successful friendships, love relationships, and parental relationships, to function vocationally, and more. With respect to social practices, a person might be restricted from participating in a given practice at all, or be restricted in the way in which he or she can participate. For example, a man might be unable to make love to his wife at all, as in male erectile disorder; or he might be able to do so, but only in certain problematic ways (e.g., with great anxiety, as in rape trauma syndrome; without appreciable satisfactions, as in disorders of desire; or only with the inclusion of a fetish object, as in fetishism). Summary. To say that a person is in a pathological state is to say that he or she has a significant restriction in his or her ability to engage in deliberate action and, equivalently, to participate in social practices. Such behavioral disability or dysfunction may assume a number of different forms. A person might be significantly unable to initiate certain important behaviors (or a range of such behaviors) at all, to restrain enactment of these behaviors, to enact them in other than highly problematic ways, to know what he or she is doing, or some combination of the above. In its broadest sense, the overall conception of pathology here is not unlike what Freud might have arrived at had he considered the obverse of his famous definiton of mental health. Pathology, he might have said, is the "inability to love and/or to work." Discussion

Why "pathology" and not "psychopathology?" Current classificatory and clinical practice supports adoption of the more generic concept of "pathology," rather than the more specific one of "psychopathology," as our central concept (cf. Wakefield, 1992, 1999, on "disorder"). The primary basis for this claim is that the distinction between the two subtypes of pathology, psychopathology and physical pathology, was originally made (and continues, albeit very inconsistently, to be made) on the basis of etiology. Thus, for example, a paralysis based on psychogenic factors was (and continues to be) regarded as hysterical conversion or somatoform disorder, a mental disorder; while one based on spinal cord injury was (and continues to be) regarded as physical pathology. However, the use of etiology as a basis for distinguishing psychopathology from physical pathology has long since broken down, and no other basis has proven a

Integrative Framework 10 successful replacement. At present, there are many disorders listed in DSM-IV (American Psychiatric Association, 1994), such as the dementias, amnestic disorders, schizophrenias, and bipolar disorders that, some or all of the time, in whole or in part, involve well-established physiological causes. Thus, DSM-IV is already a catalog of pathologies or disorders--of dysfunctions with varying etiologies--and not of "psychopathologies" or "mental disorders." Furthermore, in clinical practice, we virtually always assess that a client is in a pathological state before we establish the etiology of that state. We determine that he or she suffers some disability or dysfunction--that he or she is depressed, manic, anxious, paralyzed, fatigued, blind, amnesic, etc.--before we determine the causes of the disability. Thus, it is the concept of "pathology," not that of "psychopathology" or of "physical pathology," that we in fact utilize in our assignment of a primary diagnosis. Third, and most critically, responsible clinical practice requires that we not preclassify behavioral disabilities or dysfunctions as mental or as physical illnesses, since doing so is tantamount to prejudging the nature of their etiologies. Such a practice creates the danger that some clinicians will fail to engage in appropriate, empirically-based investigatory activities when attempting to establish the causes of their clients' disabilities, and will proceed on erroneous, and thus either fruitless or dangerous, courses of therapeutic intervention. Some may object to this by maintaining that the concept of "pathology" does not designate behavioral disability or functional impairment, but rather the presence of some biological abnormality such as a lesion, chemical imbalance, or structural anomaly. While space does not permit a lengthy discussion of this issue, two things may be noted briefly. First, there are many instances of biological abnormality (e.g., hearts that are positioned on the right side of the body, or have three chambers rather than two) that, having no negative implications for functioning, are not considered illnesses and are not the subject of medical treatment (Ossorio, 1985/97; Wakefield, 1992). Second, there are many consensus instances of pathology (e.g. trigeminal neuralgia, senile pruritis, and tinnitus) that have never been associated with any physiological abnormality (Wakefield, 1992). Thus, in practice, there is widespread support for an equation of pathology with functional impairment, and not with

Integrative Framework 11 physiological abnormality. Where is emotional distress? Historically, many attempts to define psycho-pathology, including those adopted in the last three editions of DSM (American Psychiatric Association, 1980, 1987, 1994), have included the presence of emotional distress as a criterion. However, while such distress is a frequent accompaniment of mental disorder, and while its presence is a fact of the utmost clinical importance, there is a critical reason why it does not belong in the definition of pathology. This reason is that the presence of emotional distress does not discriminate well the set of pathologies from the set of non-pathologies, and thus does not qualify as one of the necessary and sufficient conditions for correctly imputing pathology. First of all, countless people (e.g., those recently bereaved, divorced, or dismissed from a job) may suffer terribly, but we do not regard them on that account as pathological. Second, many other persons (e.g., many psychopaths, paraphiles, and narcissists) may suffer little, yet by consensus are regarded as having a mental disorder. Is the definition overinclusive? An objection raised to an earlier version of the present definition was that it seemed overinclusive (Wakefield, 1997). In response to this, I have already noted how the notion of “significant” implies that the disability in question must be one of considerable magnitude and harmfulness, and how the present definition does cover what traditionally have been designated physical disorders as well as mental disorders. The claim of overinclusiveness also suggested that the definition seemed to encompass certain other cases that, by consensus, we do not regard as mental disorders. Specifically, these are cases of persons whose ability deficits would be expectable on the basis of their age or circumstances such as a 3-year-old who cannot read, a recent immigrant who cannot participate in the host culture, or a recently bereaved person who cannot function well. In response to this claim, it is important simply to clarify what we mean by the term "disability." In agreement with common usage, we do not impute disability to non-reading 3-year-olds, non-assimilated recent immigrants, or newly bereaved persons who are functioning poorly. Instead, we make such an attribution only under conditions where normative developmental, situational, and other expectations

Integrative Framework 12 regarding personal capabilities are unmet. Thus, expecting that 9-year-olds who have had normative educational opportunities and made reasonable efforts to learn will be able to read; and finding that Johnny, despite such opportunities and efforts, cannot, we impute disability. Thus, expecting that persons will resolve the loss of a loved one within one or two years, and finding that Mary remains prostrate with grief three years after the death of her child, we impute disability--a "pathological grief reaction." In agreement with DSM-IV, in making attributions of disability, we are talking about cases where the "syndrome or pattern must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one" (American Psychiatric Association, 1994, p. xx). Integrating Theoretical Explanations Thus, in answer to our first question, “what is pathology?”, the disability model holds that it is best conceived as behavioral disability or dysfunction. If we turn now from matters of definition to matters of explanation and integration, our question becomes one of why persons in pathological states are unable to participate in important social practices--of why they are limited in their ability to resolve differences with others, to make love, to mourn losses, to read, to work, to assert themselves, or to function in life in other critical ways. Straightforwardly, the most general explanation of behavioral disability is one that is both simple and logically true: If the enactment of a given behavior (or set of behaviors) requires something that a person does not have, that person will be restricted in his or her ability to engage in that behavior (Bergner, 1997; Ossorio, 1985/97). Thus, we may explain the behavioral deficits at issue in pathological states by reference to what the client is lacking. For example, to cite those five types of factors that have been the subject historically of the vast majority of theoretical and therapeutic attention, a given person might lack (a) the cognitive wherewithal (knowledges, beliefs, concepts), (b) the skills or competencies, (c) the biological states (structures, chemical balances, etc.), (d) the motivations, and/or (e) the opportunities requisite for any given behavior. Before turning our attention to each of these forms of explanation, it is worth noting that they are not explanations in terms of efficient causality or of etiology.

Integrative Framework 13 Instead, they are part-whole explanations that account for more global disabilities by reference to more specific disabilities or deficits. Their form is as follows: “B is a complex phenomenon (here, a behavior) that encompasses and requires constituent events, processes, or states of affairs X, Y, and Z if it is to occur; but X (or Y or Z) cannot occur; therefore, B cannot occur.” Thus, these forms of explanation are of a different kind than the more familiar causal-etiological explanations such as “He is subject to depressions as a result of suffering significant personal losses during his developing years.” They are, rather, explanations identical in form to ones such as “Combustion requires oxygen; but there was no oxygen present; therefore combustion could not occur.” Cognitive Deficit Explanations Logically, a person can only do (reliably and successfully) what he or she has the relevant cognitive wherewithal (knowledge, beliefs, concepts) to do. If, to use everyday, nonclinical examples, I lack knowledge of card suits, I cannot participate in the social practice of playing bridge; and if I lack knowledge of the Spanish language, I will be unable to read a book or newspaper printed in that language. More clinically, if, for whatever reason, I lack certain beliefs about myself (e.g., that I could be loved by another), about others (e.g., that members of the opposite sex are trustworthy), or about the future (e.g., that enduring love relationships are possible), I will be restricted in my ability to do anything that would call for such beliefs (e.g., to pursue love relationships). Further, standing in the way of my possession of such beliefs might be the simple fact that I hold maladaptive alternative beliefs (e.g., that I am unlovable, that they are untrustworthy, and/or that love cannot last). All of this is essentially a paraphrase of the well-established work of cognitive theorists. Thus, Beck and his associates stress the absence of adaptive core beliefs (“schemas”), as well as the presence of maladaptive alternative beliefs, in their explanation of pathological states (Beck, Rush, Shaw, & Emery, 1979; Beck & Weishaar, 2000; cf. Ellis, 1962, 2000). Bandura (1977, 1997) and Seligman (1975; Peterson, Maier, & Seligman, 1993) focus more narrowly on individuals’ lack of belief in their own power and efficacy to accomplish critical things in their lives, and their contradictory,

Integrative Framework 14 competing beliefs in their own “inefficacy” or “helplessness.” White and his associates (White, 1993; White & Epston, 1990) emphasize a lack of viable, narratively structured conceptions of themselves and their lives (“stories”) at the heart of human difficulties, and the presence of personally debilitating alternative versions of these. Aside from these explicitly cognitive theorists, the notion of cognitive deficits as an important basis for pathology may be found in the explanations of many classical and contemporary theories not ordinarily considered cognitive. For example, Freudian "transference distortion" explanations (Freud, 1905/1953) are open to a ready restatement of the following general form: “P is restricted in her ability to relate successfully to a certain class of other persons (e.g., males) because, based on previous negative experiences with members of that class, P lacks a view of them that would permit her to so relate.” Rogerian "alienation from one's organismic valuing process" explanations (Raskin & Rogers, 2000) may be restated as: “P is restricted in his ability to do X (e.g., address grievances with his spouse) because P lacks knowledge or awareness of his true feelings regarding the relevant issues.” Finally, self-concept explanations of personal deficit (Baumeister, 1995; Bergner & Holmes, 2000) may be restated as: "P is restricted in her ability to do X because P lacks a conception of herself as one who is eligible and/or able to do X." Skill Deficit Explanations Logically, persons can only do (reliably and successfully) what they know how to do--i.e., what they have the skills or competencies to do. This truism applies whether the behaviors in question are such everyday things as riding a bicycle or playing the piano, or such clinically significant things as negotiating interpersonal conflicts, making love, asserting oneself, or setting effective limits on one's children. Paralleling what was said above about cognitive deficits, many persons might not only lack a skill or competency, but also have acquired, and be committed to, some other, maladaptive way of doing things; e.g., to excessively critical, contemptuous, dismissive, or defensive behaviors in disagreements with others (Gottman, 1994). All of this is essentially a paraphrase of a seminal idea of behaviorally oriented theorists and practitioners such as Bandura (1986), Gottman (1994), Staats (1993), and Wilson (2000).

Integrative Framework 15 Biological Deficit Explanations Logically, persons can only do (reliably and successfully) what their current biological wherewithal equips them to do. If biological processes that are involved in a given behavior (from molar ones such as arm movements to molecular ones such as synaptic events) cannot occur, then those persons in whom they cannot occur will be restricted in their ability to engage in that behavior. Trivially, without functioning eyes, they cannot do anything that calls for vision; without well-functioning lungs (as in asthma or emphysema), they cannot do anything that requires optimum utilization of oxygen. On a more psychological note, if they have seriously deficient levels of the neurotransmitters norepinephrine and serotonin, evidence suggests that it becomes extremely difficult for them to do much of anything (Zaleman, 1995); or if the transport of sodium ions across their cell membranes is impaired, their ability to think coherently, to sleep, and to restrain their behavior may be impaired in ways characteristic of manic states (Kato, Takahashi, Shioiri, & Inubushi, 1993). Motivational Deficit Explanations Logically, persons can only do (reliably and successfully) what they have the motivation to do. While to some degree persons can make themselves do things that they do not want to do, in the long run serious motivational deficits will impose significant restrictions on persons' ability to function. In everyday life, for example, if a young student finds himself utterly without desire or interest in learning the contents of the high school curriculum, he will be significantly restricted in his ability to do so. If a young woman finds herself completely without interest in the young man whom her parents are urging her to marry, she will be restricted in her ability to pursue a relationship with him. While such persons may “want to want” these things, they cannot choose simply to want them, and their lack of motivation will place serious constraints on their ability to engage in sustained, committed action. In a more clinical vein, if an individual (one whom we would view as "narcissistic") has little interest or investment in the wellbeing of others, perhaps because he is preemptively preoccupied with receiving love and adulation in order to shore up his own esteem, he will be seriously impaired in his ability to carry on love, friendship, or any other relationship

Integrative Framework 16 that calls for such investment (Kernberg, 1975). Opportunity Deficit Explanations Logically, a person can only do what he or she has an opportunity to do. Trivially, if one is imprisoned and denied writing materials, one cannot write; if one is discriminated against in hiring practices, one will be unable to work. More clinically, if an adolescent woman is coercively charged with the fulfillment of overwhelming parental responsibilities in her family of origin, she may, though personally capable, be denied opportunities to date and otherwise engage with her peers (see Haley, 1987, on the "parental child"). In this article, pathology has been equated with personal behavioral disability, and contrasted, among other things, with restrictions imposed entirely by an individual's problematic circumstances. Thus, explanations in terms of such circumstances (e.g., “he can’t because his circumstances render it impossible”) are not per se explanations of pathology. The reason for including them here is that such problematic situations, by virtue of their being both currently damaging to persons and potentially generative of later pathology, represent an extremely common focus of therapeutic attention. Further, such situational explanations ("she can't, not because she is pathological, but because her embeddedness in a dysfunctional system precludes it") represent the central contribution of an important school of thought, family systems theory (Horne, 2000). For these reasons, they must be integrated into any general clinical framework. Summary Thus, viewed from the present vantage point, our historically most influential forms of explanation--those in terms of cognitive, skill, biological, motivational, and opportunity deficits--may all be united by their reference to a common state of affairs: the inability of persons to behave or to participate in life in critical ways. Each of these forms of explanation, as demonstrated above, may be seen as specifying one or another of the kinds of deficits that a given person might have, which deficits would impose significant limitations on his or her ability to behave. Further, far from being mutually exclusive and competitive one with another, all of these forms of explanation may be

Integrative Framework 17 seen as coherently integrated parts of a larger system for explaining behavioral dysfunction. Discussion Objection: Analysis seems oversimplified. A reasonable reaction to the integration just presented might be that it seems too simple to accomplish its stated objectives. Can the essence of the mental health enterprise, many elements of which (e.g., the psychoanalytic theory) are themselves far more complex than the schema presented here, really be subject to so tidy an integration? The present framework is an intellectual creation designed to represent the highest level of a top-down intellectual structure. Its purpose is to delineate the superordinate structure and relations between three domains, those of pathology, explanations of pathology, and therapy. Like other such intellectual entities (famous examples would include the principle of natural selection and Newton's laws), it is itself relatively simple and amenable to succinct statement, while at the same time articulating domains whose details and whose usages are virtually infinite. The simplicity of the present framework is further attributable to three basic measures taken in its construction. First, all of the metaphysical elements present in the various theories of psychopathology were deleted. That is, all of their empirically undecidable elements, such as the existence of psychic energy systems, of deterministic influences, or of innate actualizing tendencies, were dropped. Second, their many and various technical languages were abandoned in favor of a single language, one that corresponds closely to ordinary language, but suitably refined to eliminate ambiguities and superfluous meanings (cf. Driscoll, 1987; Norcross, 1987; Ryle, 1978, 1995). Third, attention was focussed on what might be termed primary explanations specifying what a person lacks such that he or she is behaviorally restricted (i.e., requisite beliefs, skills, motives, biological states, and/or opportunities). In so focussing, less attention was paid to secondary explanations articulating why the individual lacks what he or she does lack. The great majority of these secondary explanations, however, can be seen upon survey of the theoretical landscape to assume one of four general forms. They maintain that individuals will exhibit the specific deficits that they do (a) because their personal

Integrative Framework 18 histories (e.g., of observational or instrumental learning) were such that these beliefs, skills, etc. were never acquired; and/or (b) because their personal histories (e.g., of interpersonal relating leading to schema acquisition) were such that they did acquire some other belief, skill, etc. that is incompatible with any adaptive alternative; and/or (c) because the having of the requisite knowledge, motive, etc. would place the person in what is for him or her an impossible position (e.g., it would result in awareness of a devastating truth about oneself); and/or (d) because some deleterious biological state of affairs (e.g., a tumor or a virus) resulted in it . With the first two measures noted above, plus the incorporation of the secondary explanations just cited, the most complex of our historically prominent explanations of mental disorder can be restated clearly, concisely, and adequately within the present superordinate framework. Integrative Psychotherapy The foregoing conception of pathology as behavioral disability, coupled with the demonstration that our primary forms of theoretical explanation may be seen as specifying the kinds of deficits at issue in such disability, have straightforward implications for an integrative psychotherapy. If the ultimate goal of therapy is that of effectively treating pathology, its essential task becomes that of removing or diminishing these deficits, and thus enhancing the ability of persons to participate fully and meaningfully in social forms--to "love and work" as Freud might have it. In order to bring this about, the integrative clinician may engage in actions designed to alter (a) what an individual takes to be the case about self and world (ameliorated by cognitive interventions, whose basic aim is to enable persons to acquire beliefs, knowledge, or concepts requisite for enhanced participation); and/or (b) alter his or her competencies (ameliorated by skill-enhancement interventions, whose basic aim is to enable persons to acquire skills and competencies requisite for enhanced participation); and/or (c) alter his or her biological states (ameliorated usually, but not always, by biological interventions, whose basic aim is to enable persons to acquire biological states requisite for enhanced participation); and/or (d) alter his or her circumstantially imposed limitations (ameliorated by relationship change interventions, whose basic aim is to enable persons to acquire relational positions and opportunities requisite for enhanced

Integrative Framework 19 participation). (NB: A survey of the therapeutic landscape reveals that, while there are interventions that evoke existing motivations, and others that modify them indirectly by modifying other factors such as beliefs, there are no currently existing interventions that directly alter motivations.) Two things follow from this. First, operating within the present integrative framework, clinicians would have at their disposal all of the excellent techniques that have been demonstrated historically to alter cognitions, skills, biological states, and relationships. Second, they would be able to implement these various techniques in a way that is conceptually coherent and integrated, since all of them can be seen on the present analysis to represent different and in principle noncompetitive ways to accomplish one central goal: the removal of restrictions on the client's ability to participate fully and meaningfully in social forms. Conclusion In this paper, a conceptual framework that integrates existing theoretical approaches to pathology and therapy has been presented. The key elements in this framework have been (a) an articulation of a conception of pathology as behavioral disability; (b) a unification of existing theoretical explanations of pathology in terms of how all at their core specify one or another type of personal deficit (e.g., cognitive, motivational, or biological) at the root of behavioral dysfunction; and (c) an integration of existing psychotherapies in terms of how all constitute ways of accomplishing one central objective, that of reducing these specific personal deficits and thereby enhancing the ability of clients to participate in life more fully and meaningfully.

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