Assimilative Integration and Responsive Use of

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Assimilative Integration and Responsive Use of the Assimilation Model

Lara Honos-WebbSanta Clara University

William B. StilesMiami University

The assimilation model offers a framework for clinically responsive deci-

sions integrating different therapeutic approaches. The authors suggest that the assimilation model can guide assimilative integration by delineating cli-ents’ changing requirements over the course of psychotherapy and linkingthose requirements with techniques drawn from varied theoretical ap-

proaches. According to the model, an appropriate therapeutic response isone that meets client requirements at a given stage of assimilation and helpsto shift the client’s assimilation of a given problematic experience from 1

stage to the next. The authors offer guidelines and case illustrations of integration at 4 separate time frames of intervention: treatment assignment, treat-ment strategies, treatment tactics, and moment-to-moment responsivenesswithin an intervention. At each time frame, therapists monitor client require-ments and respond with interventions most appropriate for the client’s level of assimilation.

Assimilative integration refers to importing techniques from one psy-chotherapeutic approach into a treatment guided by a different theoreticalapproach in ways that are theoretically comfortable and consistent with thelatter (Lazarus & Messer, 1991; Messer, 1992; Safran & Messer, 1997). Forexample, Stricker and Gold (1996) proposed a broad outline for integratingexperiential, cognitive, and behavioral interventions into a primarily psy-

Lara Honos-Webb, Department of Counseling Psychology, Santa Clara University;William B. Stiles, Department of Psychology, Miami University.

We thank Scott Acton, Paul Diamond, Stanley Messer, Jean Oggins, Yong Song, andMichael Surko for helpful discussions and comments on drafts of this article.

Correspondence concerning this article should be addressed to Lara Honos-Webb, De-partment of Counseling Psychology, Santa Clara University, Bannan 226, 500 El Camino

Real, Santa Clara, California 95051–0201. E-mail: [email protected]

406Journal of Psychotherapy Integration Copyright 2002 by the Educational Publishing Foundation

2002, Vol. 12, No. 4, 406–420 1053-0479/02/ $5.00 DOI: 10.1037/ /1053-0479.12.4.406



chodynamic treatment and illustrated this with a case study in which apsychodynamic therapist responded to a client’s evolving requirementsusing techniques drawn from cognitive and behavioral traditions. Con-versely, Ramsay (2001) illustrated assimilative integration with a case ex-ample in which interpretive interventions were imported into a preferredcognitive–behavioral treatment.

Authors have offered varied accounts of the process of assimilativeintegration. According to Gold and Stricker’s (2001) relational psychody-namic perspective, if a technique inconsistent with psychodynamic theoryis imported into treatment and found to be effective, the theory mustchange to accommodate the finding. Lampropoulos (2001) proposed thatassimilative integration bridges technical eclecticism and theoretical inte-gration by reconciling a therapist’s preference for one specific theory of

psychotherapy with the demands of heeding the growing literature on em-pirically supported treatments. After considering the arguments pittingassimilative integration against a unified grand theory, Fisch (2001) con-cluded that assimilative integration is the preferable end point for thepsychotherapy integration movement.

In this article, we suggest that assimilative integration can be guided bythe assimilation model, an integrative, developmental description of com-mon client change processes in successful psychotherapy that is compatiblewith different theoretical approaches to treatment (Honos-Webb & Stiles,1998; Stiles et al., 1990). By delineating clients ’ changing requirements overthe course of psychotherapy and linking those requirements with tech-niques drawn from varied theoretical approaches, the assimilation modelcan show how techniques from one approach might be integrated into a

case being treated using another approach. In effect, we suggest that theassimilation model itself can be assimilated into many approaches in orderto guide assimilative integration.

In the phrases assimilative integration and assimilation model, the wordassimilation has similar meaning but in different frames. In assimilativeintegration, assimilation refers to incorporating and integrating the tech-niques of one theoretical orientation (e.g., cognitive–behavioral) into adifferent therapy (e.g., psychodynamic). In the assimilation model, whichdescribes cognitive and affective processes within psychotherapy clients,the word refers to a client’s incorporating and integrating a problematicexperience into the self. In both cases, assimilation refers to a process of bringing into a larger context an element that may at first seem incompatible.

THE ASSIMILATION MODEL

Assimilation of problematic experiences can be understood as theemergence and acceptance of problematic internal voices into a community

Assimilative Integration and the Assimilation Model 407



of internal voices that is the self (Honos-Webb & Stiles, 1998; Stiles, 1997a,1997b, 1999). In this formulation, voice is a metaphor used to describe thetraces of the person’s experiences. The metaphor of voice is used to ac-knowledge the internal multiplicity of people and to suggest that the tracesof people’s experiences have agency; that is, they can express themselves inspeech and action. Theoretically, voices of unproblematic experiences areeasily assimilated into the community, but voices representing trauma,disturbed primary relationships, and other problematic experiences may beavoided, treated as outcasts. The assimilation model proposes a develop-mental sequence in which, through psychotherapy, an initially warded-off or unwanted problematic voice finds expression and gains strength until itchallenges the dominant community. In successful cases, this process leadsto mutual accommodation; both the problematic voice and the community

change as they develop an understanding between each other. The for-merly problematic voice joins (is assimilated into) the community andbecomes an accepted aspect of one’s experience of oneself. Thus, the clientmoves from experiencing the self as a constricted unity to experiencing theself as composed of a flexible cast of characters.

A series of intensive case studies (e.g., Honos-Webb, Stiles, Green-berg, & Goldman, 1998; Honos-Webb, Surko, Stiles, & Greenberg, 1999;Shapiro, Barkham, Reynolds, Hardy, & Stiles, 1992; Stiles, Shapiro,Harper, & Morrison, 1995; Stiles et al., 1991; Varvin & Stiles, 1999) hasyielded a tentative description of a sequence of stages of assimilation,summarized in the Assimilation of Problematic Experiences Scale (APES;see Table 1). The APES can be understood as describing the changingrelationship between the voices of problematic experiences and the dom-

inant community in successful therapy. The APES stages range fromwarded off (0) to mastery (7). Each stage is associated with particularmarkers , which are relatively easy-to-recognize distinctive signs of under-lying psychological states or processes that recur across different cases(Greenberg, Rice, & Elliott, 1993; Rice & Greenberg, 1984). Markers of assimilation stages are thus patterns in psychotherapy discourse that canindicate how far along the APES continuum a problematic experience hasprogressed. Table 1 gives examples of markers for each stage, taken froma list of 25 markers developed for facilitating APES ratings (Honos-Webb,Surko, et al., 1999).

The APES can also be translated into client requirements at each stageand can point the therapist toward appropriate interventions. An appro-priate therapeutic response is one that meets client requirements at a givenstage of assimilation and helps to shift the client’s assimilation of a givenproblematic voice from one stage to the next (Stiles et al., 1995). Table 1suggests some client requirements at each stage, markers of client readi-ness, and possible interventions. These suggestions are intended as tenta-tive and provisional rather than as prescriptive or comprehensive. For

Honos-Webb and Stiles408



example, there are many interventions besides those listed in the table that

could serve to increase awareness (e.g., increasing clients’ awareness of anger by asking them to identify environmental triggers, a cognitive–behavioral intervention).

At APES Stages 0 and 1, the problematic experience is either inacces-sible or actively avoided by the dominant community. In order for pro-gression along the assimilation continuum to occur, the client needs toincrease awareness. One marker of warding off is the transformation of theunwanted material into a somatic symptom. McDougall (1989) presentedmany case studies of clients whose physical symptoms represented asymbolization of unconscious conflict. A psychodynamic approach in whichclients are instructed to “say everything and do nothing” has been recom-mended as an appropriate intervention for accessing the unwantedexperience.

The emergence of the unwanted material into awareness occurs atStage 1 (unwanted thoughts) and at Stage 2 (vague awareness or emer-gence). These stages are characterized by negative affect with little under-standing. A marker of unwanted thoughts is fear of losing control (Honos-

Table 1. Client Requirements at Each APES Stage With Predicted Markers and IndicatedTherapeutic Techniques

APES stageClient

requirement Example of markerExample of

specific technique

0. Warded off Increase awareness Somatic symptom Interpretation of symptomas symbolization of warded-off material(psychodynamic)

1. Unwantedthoughts

Increase awareness Fear of lossof control

Focusing (experiential)

2. Emergence Intensify experiencewhile gaining control

Emotional pain Systematic evocativeunfolding (experiential)

3. Problemclarification

Intensify experience;gain understandingor insight

Emergence fromembeddedness

Two-chair dialogues(experiential)

4. Insight Elaborate insight Understandingpersonal historicalroots

Interpretation(psychodynamic)

5. Application Elaborate insight;behavioralapplication

Exploring possiblesolutions

Anger management skills(cognitive–behavioral)

6. Problemsolution

Behavioral application Specific success Assertiveness training(cognitive–behavioral)

7. Mastery Behavioralmaintenance

No marker Problem-solving skills(cognitive–behavioral)

Note. APES Assimilation of Problematic Experiences Scale (Stiles et al., 1991).




Webb, Lani, & Stiles, 1999). Clients trying to avoid unwanted thoughtsoften express a fear of exploring a problematic experience because theyexpect the experience to disrupt daily life or long-held beliefs (Table 1).Focusing (Gendlin, 1981) may be an appropriate intervention at this stage.This is an experiential technique in which the therapist guides the client tofocus on an unclear experience to get a so-called felt sense or handle on theunwanted emotion.

As the problematic experiences emerges into awareness (Stage 2), arequirement is to intensify the experience by facilitating emotional expres-sion. Once the full intensity is experienced, a requirement is to gain controlof it so it is not so overwhelming or frightening. Expressing emotional painis a marker that the unwanted experience is emerging into awareness.Systematic evocative unfolding (Greenberg et al., 1993; Rice & Saperia,

1984) is one experiential technique used to facilitate intensification alongwith control. In this technique, the therapist guides the client to alternatelyexperience vividly both the affective experience (e.g., the pain) and theconcrete sensory details surrounding emerging experience. The goal is tomove the client to the next stage, which involves explicit acknowledgmentand formulation of the problem.

At Stage 3 (problem statement and clarification), the experience ismore salient in awareness, and the client is able to state the problem inwords. When the problematic experience has entered fully into awareness,the client progresses by arriving at a clear statement of the problem. Onemarker that the client is at Stage 3 is emergence from embeddedness(Honos-Webb, Surko et al., 1999; cf. Kegan, 1982); the client is able to“have” the problem, rather than “be” the problem. Theoretically, this

represents a mutual recognition of the opposing voices. To use anothermetaphor, the client can adopt either an I-position or observe the other-Iposition. By gaining some perspective on the problematic experience, theclient can formulate the problem more clearly. One intervention that maybe useful for facilitating progress at this point is two-chair work to resolveinner splits (Greenberg et al., 1993); such work imaginally separates con-flicting aspects of the self and attempts to promote resolution of the con-flict through dialog between the conflicting parts.

Movement to Stage 4 (understanding and insight) is characterized by“aha” types of experiences and a clearer understanding of the problematicexperience, with a mixture of positive and negative affect. The resolutionof a conflict often includes a significant insight event. One marker associ-ated with insight events is the recognition of connective links between thepresent conflict and historical events. Psychodynamic exploration may beappropriate to help the client elaborate such insight events.

Stage 5 (application and working through) is characterized by morepositive affect and by specific problem-solving efforts. In Stage 6, the client




achieves a successful solution to a specific problem. In the final stage of mastery, affect is more neutral and the formerly problematic experiencemoves away from the center of attention, as the client has incorporated thechange into daily living. After the client has clearly identified the prob-lematic experience and gained insight into the conflict, behavioral inter-ventions are often appropriate to help the client generalize such progressinto changes in actual behavior outside the therapy room. Cognitive–behavioral interventions, such as behavioral prescriptions to practice as-sertiveness, facilitate progress through what the assimilation model denotesas application (Stage 5), problem solution (Stage 6), and mastery (Stage 7).

LEVELS OF RESPONSIVENESS

We propose that the assimilation model can be used to guide theresponsive assimilative integration of different therapeutic approaches. Re-sponsiveness refers to behavior that is influenced by emerging context,including perceptions of another person’s experience and behavior (Stiles,Honos-Webb, & Surko, 1998). Therapeutic responsiveness can occur ontime scales that range from months to milliseconds, from treatment assign-ment to subtle mid-intervention shifts. Assimilative integration can occurover the same range. The assimilation model provides a way to understandand track emerging client requirements, which may then be used tosuggest appropriate treatments, strategies, tactics, and implementation of interventions.

To illustrate how the assimilation model might be used to guide theintegration of techniques from different approaches, we offer examplesorganized into four hierarchical categories: treatment assignment, treat-ment strategies, treatment tactics, and moment-to-moment responsiveness(see Table 2).

Assimilative Integration at the Treatment Assignment Level

One form of integration is simply the selection of different therapiesfor different clients. Thus, assimilative integration at the level of treatmentassignment describes a form of psychotherapy integration in which thetherapist may work within the frame of one therapeutic orientationthroughout the duration of treatment. Assimilative integration at the levelof treatment assignment might characterize therapists who operate pre-dominantly from one therapeutic approach but use alternative approachesin cases of particular presenting problems, diagnoses, or types of clients.




For example, a psychodynamic therapist might provide behavioral treat-ment for clients who present with panic disorders.

One basis for differential treatment assignment level is the client’sclarity regarding the nature of his or her main presenting problem. Theassimilation model suggests that clients with clearly stated problems maydo better with cognitive–behavioral approaches, whereas clients with vaguecomplaints may require more exploratory approaches (Stiles, Barkham,Shapiro, & Firth-Cozens, 1992; Stiles, Shankland, Wright, & Field, 1997a,1997b). Therapists using cognitive–behavioral approaches are likely to be-gin by seeking to clarify clients’ presenting problems (APES Stage 3),formulate them within a rational framework (APES Stage 4), and designways to apply that understanding in everyday life (APES Stage 5). Bycontrast, therapists using psychodynamic and experiential approaches are

likely to consider the possibility that clients’ presenting problems are mani-festations of underlying conflicts or problematic experiences.

This distinction was supported, in part, in a study where the presentingproblems of clients who had been randomly assigned to time-limited cog-nitive–behavioral or psychodynamic–interpersonal treatment for depres-sion were given a rating on the APES based on the first 20 min of their firstsession. Clients whose APES ratings were below 2.5—in effect, thosewhose problem was vague and unformulated—showed equivalent im-provement regardless of treatment assignment. However, clients whoseAPES ratings were above 2.5—in effect, those who began therapy withclearly stated problems—improved significantly more if they were assignedto cognitive–behavioral treatment than to psychodynamic–interpersonaltreatment (Stiles et al., 1997a).

The following case illustrates the selection of an exploratory (experi-ential) treatment on the basis of a formulation that the presenting problem(loss of appetite) reflected warded-off experiences. This treatment formu-lation was followed by the responsive use of one theoretical orientation

Table 2. Levels of Responsiveness for Assimilative Integration

Level of responsiveness Time frame Responsiveness to Responsiveness with

Treatment assignment Length of entiretreatment

Client diagnosis Selected treatment

Treatment strategies Between sessions Case formulation Integrative alternativetreatment approach

Treatment tactics Within a session Session events andclient process

Specific intervention

Moment-to-momentresponsiveness

Within anintervention

Subtle shifts inclient themesor process

Subtle shifts in therapistcommunication




across the entire developmental spectrum of assimilation. This case and thefollowing two cases were based in part on clients that Lara Honos-Webbhas seen in therapy. However, we have disguised them and fictionalizedthem to varying degrees (and in one case, we have amalgamated elementsof two clients) to better show how the assimilation model might help guideassimilative integration. We present them to illustrate our thesis, not toclaim evidence for it.

A 64-year-old woman presented for therapy following a referral from her primarycare physician. She complained of loss of appetite for which there was no discern-able organic cause. Her primary care physician believed that her loss of appetitewas psychosomatic and that her inability to eat would endanger her health if itpersisted. The therapist adopted an experiential approach and hypothesized thatthe somatic complaint indicated the presence of a warded-off problematic experi-ence. The therapist asked the client to personify the loss of hunger as an active

voice and to act out what it might be communicating. Over the course of thisexperiment, the voice shifted from a passive statement of “I’m not hungry” to “Iwon’t eat; he can’t make me eat.” Further exploration revealed that the “he” washer husband. This intervention increased the client’s awareness of difficulties withher husband that were uncomfortable for her to acknowledge because of her fi-nancial dependence on him (Stage 1, unwanted thoughts). Through empathic ex-ploration, the client’s anger toward her husband for his domineering behavioremerged into awareness (APES Stage 2). As the voice of anger gained strength, thetherapist separated two voices in a two-chair dialogue: the soft conciliatory voicethat dominated her experience and the newly acknowledged voice of anger. Thisexercise led to the voice of anger shifting into a previously unrecognized need forself-direction. She was able to connect her inability to eat with a misguided attemptat exerting her own will in relation to her husband (APES Stage 4). She realizedthat the onset of her eating disorder corresponded to the time her husband retired.As he began spending most of his time at home, his controlling behavior becameintolerable to her as she lost control over what previously had been her domain.The therapist guided the client to imaginally dialogue with her husband in an empty

chair. In these experiments, she talked explicitly with her imagined husband abouther feelings of him invading her home. Although the experiential approach did notexplicitly guide her to change her behavior toward her husband, behavioral changedid occur as she translated her imaginal work into real-life conversations with herhusband. She and her husband were able to negotiate the changing roles entailedin his retirement as she became able to assertively express her needs. By thetermination of therapy, her appetite returned.

Treatment Strategies

Case formulation represents a traditional way in which theories areapplied responsively at the level of treatment strategy. Plans for how toconduct each session are based on a conceptual understanding of the client,which may change and develop as treatment proceeds.

The assimilation model can guide the integration of interventions fromalternative approaches at a session-by-session level. Strategies integratingtechniques from different approaches may be planned in advance or intro-




duced responsively as the case develops. Within a primary theoretical ap-proach, therapists may respond to emerging indications of client require-ments by introducing techniques from alternative approaches. This level of integration was used in Stricker and Gold’s (1996) assimilative psychody-namic approach, noted earlier, in which the therapist incorporated se-quences of behavioral and experiential interventions into an orienting psy-chodynamic approach.

Consistent with the strategy suggestion that exploratory interventionsfit earlier APES stages whereas prescriptive interventions fit later APESstages, Stiles et al. (1992) reported that when a series of psychodynamic–interpersonal sessions preceded a series of cognitive–behavioral sessions,clients showed a steady decline in the intensity of their problems, as thesame issues could be first explored (in psychodynamic–interpersonal treat-

ment) and then addressed prescriptively (in cognitive–behavioral treat-ment). By contrast, when the series of cognitive–behavioral sessions pre-ceded the series of psychodynamic–interpersonal sessions, clients showeddisruptions in the experience of their problems, which may have reflecteda tendency to shift to different problems in mid-treatment (because prob-lems well-enough formulated for prescriptive treatment in the first serieswould not require exploration in the second series).

Shapiro et al. (1992) described an approach that explicitly used theassimilation stage of the client to guide an integrative treatment strategy.The treatment protocol combined elements of psychodynamic–interpersonal and cognitive–behavioral treatments from the Sheffield Psy-chotherapy Projects. The therapist and client jointly made the decision tofocus on exploratory or prescriptive interventions on the basis of a 10- to

15-min review at the beginning of each session. In their case illustration,the therapy progressed smoothly and the client reported improvements onstandard outcome measures.

In the following case illustration, the primary treatment approach wasexperiential. Assimilation-based process diagnosis led to introduction of psychodynamic interventions (transference interpretations) and behavioralinterventions as treatment evolved.

A 54-year-old African American man came to therapy to help manage impulsivebehavior. He complained of isolation and intense interpersonal conflicts with fam-ily, friends, coworkers, and employers. He rejected work on clearly defined angermanagement goals because he attributed the sources of his anger to large, imper-sonal forces, such as legal and government agencies. The therapist responsivelyadopted a primarily empathic approach to allow a more personal and internal

problematic experience to emerge. The therapist interpreted the client ’s external-ization as a marker of unwanted thoughts (Honos-Webb, Surko, et al., 1999), thatis, a sign that the client was actively avoiding some underlying problematic expe-rience. The therapist felt powerless to help the client, who located the source of hisproblems in outside systems. The therapist hypothesized that her feelings of pow-erlessness reflected a projective identification of the client’s unwanted experience




of powerlessness. That is, the powerlessness she felt was a manifestation of thefeelings of powerlessness that the client was avoiding.

When the therapist offered this interpretation to the client, he was receptive. Al-though it was difficult for him to experience his feelings of powerlessness moredirectly, he seemed to feel as if he had gained a handle on what had previously beendisturbing and unarticulated. This progression reflected movement from unwantedthoughts (Stage 1) to vague awareness (Stage 2). In response to this shift in clientprocess, the therapist moved from primarily using empathic reflections to usinginterventions to intensify emotional expression. As the therapist and client experi-mented with empty-chair work and practice of tolerating uncomfortable feeling of fear, the client arrived at a problem statement characterized by an equal weightingof two conflicting voices (Stage 3). One of his voices sought to overpower others,acting angry and aggressive. The other voice expressed feeling powerless andafraid.

At this point in treatment, the therapist introduced techniques from another ap-proach. As the nature of the problem became clear, the therapist adopted a more

directive stance, from an interpersonal orientation. The therapist disclosed that sheoften felt “run over” by the client and that others in the client ’s life might feel thesame way in interactions with him. The therapist worked toward increasing theclient’s insight into how he was perceived by others and how that led to his manyantagonistic encounters, which often erupted into impulsive behavior.

The clients’ increased understanding of how he was perceived by others led to asignificant insight (Stage 4), connecting his personal historical roots to his inter-personal style. He connected his need to intimidate others with an important wayof protecting himself as a child. He had grown up in an abusive environment in aninner city where he was surrounded by violence. He realized that he could protecthimself by making others afraid of him. He recognized that this interpersonal stylethat had served to protect him from a threatening environment was no longeradaptive and was resulting in intense conflict with most people in his life. With thisinsight in mind, the therapist introduced a behavioral technique: She suggested ahomework assignment for the client to experiment with letting down his guard inhis interpersonal interactions. This experiment proved at least moderately success-ful, and the client reported substantial improvements in his significant relationships.

It is important that the therapist’s strategic introduction of interper-sonal and behavioral techniques into an experiential approach relied on agreat deal of uncovering and exploratory work and was responsive tochanges in the client’s condition. For example, a behavioral approach un-dertaken from the beginning may have not been very effective because theclient himself was unable to identify a clear statement of his problem.

Treatment Tactics

Treatment tactics are within-session responses to emerging client char-acteristics and immediately preceding events. Facilitating assimilation of problematic experience often requires responsive tactical shifts in the in-terests of implementing a therapeutic strategy—a balance or interplay oralternation among specific interventions. For example, in systematic evoca-




tive unfolding, noted earlier, the focus must be alternated between affectand sensory recall in response to the client’s changing experience (Green-berg et al., 1993; Rice & Saperia, 1984).

One dimension along which interventions vary is intensification versusabstraction with respect to a client’s experience of emotion. A therapistmay choose either to facilitate the emotional intensity of a client’s experi-ence or, alternatively, to help the client to gain perspective and distancefrom an experience in order to contain and tolerate it. The assimilationmodel offers some principles to aid in making such tactical decisions.

To give an illustration, as a client addresses a problem, he or she maymove through both overcontrolled and undercontrolled emotional process-ing states. At early assimilation stages (Stages 0 and 1), the model suggestsclients’ relation to emotional experience would be overcontrolled (not able

to express the emotion). A responsive therapist might note markers of these stages and work to intensify emotional expression in order to facili-tate movement toward awareness of the problematic experience. In-sessionmarkers of these early stages of assimilation include psychosomatic com-plaints, metaphors of pushing away, frequent changes of topic and speechdysfluencies, the use of narrative that approaches but does not directlyexpress the specific problematic experience, fear of loss of control, and afocus external to the self (Honos-Webb, Lani, & Stiles, 1999; Honos-Webb,Surko, et al., 1999). When the client’s experience is undercontrolled(flooded with the emotion), as in Stage 2, a responsive therapist might helpthe client abstract from the emotionally disruptive problem. Clients whoare currently overwhelmed by their negative emotional experiences relatedto a particular problematic experience may benefit from more cognitive

and interpretive interventions. Abstraction can facilitate movementthrough the assimilation continuum by enabling clients to develop a usefulformulation of their problem and own it. Distancing techniques may enablethe client to arrive at a clear statement of the problem and on to an insightevent. Markers of undercontrolled emotional experiencing include intenseoverwhelming pain, puzzlement, and disequilibrium.

A 40-year-old woman was seen in therapy for treatment of depression. Her pre-sentation suggested an overcontrolled emotional processing style in that she haddifficulty expressing both needs and anger in her intimate relationships. She wastreated with an experiential approach focused primarily on facilitating expressionof her anger toward significant others who had been abusive. However, when shetalked about the death of her mother 7 years prior to her treatment, she becameoverwhelmed with her feelings of grief and would sob uncontrollably. The therapist

continued to treat the theme of loss with interventions intended to facilitate emo-tional expression of what was at first thought to be a reaction to unresolved grief.However, on further exploration, it was revealed that the woman had previouslybeen in therapy that focused on her grief regarding the death of her mother. Theclient revealed for the first time that for the past 7 years she continued to cry everyday about her sense of loss. With this new information, the therapist switched to




interventions that would enable the client to contain what now appeared to beundercontrolled emotional processing in relation to this particular theme of loss.The client was encouraged to shift her self-statements regarding her grief frombeliefs that she could not control the overwhelming grief to a belief that she wasstrong and capable of managing her grief without losing control. Guided imagerytechniques were used that allowed her to soothe herself and modulate her emo-tions. In this way, cognitive–behavioral interventions were integrated into a pri-marily experiential treatment in response to a theme where a client demonstratedundercontrolled emotional processing.

Moment-to-Moment Responsiveness

Responsiveness occurs even as a single intended intervention unfolds.Therapists may adjust their communication mid-intervention in light of

ongoing feedback from the client. Wachtel (1991) described instances of such mid-intervention switches from a behavioral approach to a psycho-dynamic approach. For example,

[One client, named Lillian,] was instructed, in the fashion of the behavioral tech-nique of flooding, to imagine herself making the call and to imagine the worstpossible things that could happen. As she began the imagery, something unex-pected happened: Instead of picturing the consequences of her own phone conver-sations, she had a spontaneous image of merging with her mother, who had alwaysbeen extraordinarily inhibited and who, among other inhibitions, had great diffi-culty making phone calls. As she and her mother inhabited the same space in theimage, Lillian felt herself cringing, in a quite physical and literal fashion, much asshe had sometimes described her mother as doing metaphorically. (p. 45)

Wachtel reported using this spontaneous image to explore the client’s un-

conscious longings to merge with her mother. According to Wachtel’s for-mulation, to treat the client solely in terms of conditioning would havemissed the component of the symptom that was related to unfinished busi-ness with regard to the client’s mother. Therapy proceeded in the directionof exploring the client’s need to separate from this identification with hermother.

The assimilation model offers a post hoc account of this mid-intervention transition from behavioral to psychodynamic interventions. Inthe process of treating the symptom of social inhibition, it was discoveredthat the client’s avoidance masked another problematic experience: herenmeshment with her mother. An assimilation account would suggest thatthe acting out of cringing represented a problematic voice within the client,presumably composed of traces of experiences with her mother. This voicewas warded off or at least unwanted (APES Stage 0 or 1), yet it was calledforth and expressed itself in action when Lillian tried to use the telephone.It also blocked progress in using the behavioral techniques. As suggested inTable 1, this problem required increased awareness to advance to the next




APES stage, and the exploratory psychodynamic interventions were in-serted to accomplish this.Moment-to-moment responsiveness requires the therapist to be closely

attuned to his or her own experience. The therapist’s internal experiencingprovides an important guide to the internal processes of the client and canbe used to guide the choice of interventions and to determine the effec-tiveness of interventions. Different theoretical approaches provide differ-ent understandings of what therapist experience means in relation to clientexperience. Variously, the therapist’s experience is understood as a con-tainer for warded-off experiences of the client (object relations ap-proaches), as reflecting the client’s present experiencing through empathicattunement (experiential approaches), or as important information abouthow the client is likely perceived by others (solution-focused approaches).

In addition, these different approaches offer different prescriptions forusing therapist experience in treatment. Psychodynamic approaches advo-cate that therapists remain objective and use their experience to constructinterpretations (cf. Gold & Stricker, 2001), feminist approaches advocatethat therapists disclose their inner experience to minimize the power dif-ferential, and experiential approaches advocate using inner experience tocreate an I–Thou relationship with the client. Honos-Webb and Leitner(2001) have proposed a model that sequences and accounts for these variedpossibilities. According to this model, these distinct strategies for handlingthe therapist’s experience are at different times prescribed or proscribed inresponse to client requirements at a given point in therapy. In short, atherapist should use his or her experience responsively—in considerationof client characteristics.

CONCLUSION

We suggest that different sorts of treatments, strategies, interventions,or implementations may be particularly appropriate for helping clientsthrough different parts of the developmental sequence outlined in theAPES. Insofar as elements of the APES sequence are recognizable withinmany therapeutic approaches (Honos-Webb & Stiles, 1998; Stiles et al.,1990), many therapeutic approaches can assimilate the assimilation model’sdescription of developmental processes in therapy and its approach tointegrating techniques that foster movement from one stage to the next.We emphasize that our characterizations of the client requirements andmarkers at each stage (e.g., Table 1) are based in theory rather than em-pirical findings. The framework, however, provides direction for designingintegration studies.




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