Foundations for a Systematic Eclectic Psychotherapy

Current textbooks of eclectic psychotherapy consist essentially of a collection of at best loosely integrated methods and techniques from various approaches to or theories of psychotherapy. The focus is upon including the disparate rather than the common elements of the major theories. This paper proposes that any true or systematic eclecticism must start from and be built upon the basic common elements of the major theories. Three of these common elements are empathic understanding, respect or warmth, and therapeutic genuineness. They are the core or essence of client-centered therapy, but it does not, however, have a monopoly on them Two topics are currently prominent in discussions of psychotherapy: (1) eclecticism, and (2) integration. These are not synonymous terms. Goldfried (1982b), and Goldfried and Newman (1986) provide useful histories of attempts at therapeutic integration. Current formulations of eclectic psychotherapy are not really integrative. They consist of a congeries of disparate techniques from many different--and often disparate and inconsistent --theoretical approaches, with little attempt at systematic integration. They pay little, if any, attention to the common elements in the major theories. The idea of common elements in different approaches has a long history, briefly reviewed here. Two classes of common elements are distinguished: (1) nonspecific elements, i.e., those elements not specifically related to the nature of client disturbance or therapy outcomes (the placebo), and (2) specific elements, directly related to client disturbance and therapy outcomes. The second group of common elements is proposed as a basis for a systematic eclecticism. THE RISE OF ECLECTICISM Eclecticism is not a new development. Most therapists were probably eclectic in the first half of the century, before the development of the current major theories. Psychoanalysis and its derivatives were the first theories to develop and most of those therapists who were not eclectic adhered to some form of psychoanalysis or psychoanalytic (dynamic) therapy. The so-called Minnesota point of view (Patterson, 1966, 1973, 1980) was an eclectic position. Thorne (Patterson, 1966, 1973, 1980, 1986) was perhaps the first to adopt the term eclecticism to designate a detailed, systematically developed position. The number and percentage of psychologists (therapists) who considered themselves eclectic during the 40s and 50s is not known. Thorne (Personal communication, June 2, 1967) gives a figure of zero for members of the American Psychological Association who identified themselves as eclectic, but the source of this figure is not known. Kelly (1961) reported a survey in which 40% of those responding in 1960 identified themselves as eclectic. Since then numerous surveys have found the percentage of psychologists (therapists) accepting the designation ranging from 30% to 65%, and fluctuating around 50% (Garfield, & Kurtz, 1974, 1976; Swan, & MacDonald, 1978; Larson, 1980; Fee, Elkins, & Boyd, 1982; Smith, 1982; Norcross, & Prochaska, 1982; Prochaska, & Norcross, 1983; Watkins, Lopez, Campbell, & Himmell, 1966; Mahoney, Norcross, Prochaska, & Missar, unpublished manuscript, 1986). It appears that the popularity of eclecticism may be declining; it is too early to sound the death knell for schools or theories. Eclecticism, while the most frequently chosen label by therapists (clinical and counseling psychologists), still claims less than 50% of those responding to surveys. The statement by Lambert, Shapiro, and Bergin (1986, p. 2020) that "...the vast majority of therapists have become eclectic in orientation" is an overstatement. An important point not addressed adequately in surveys is just what eclecticism means WHAT IS ECLECTIC PSYCHOTHERAPY? There is an increasing literature on eclecticism in psychotherapy, including the Journal of Integrative and Eclectic Psychotherapy. Various kinds of eclecticism have been proposed: theoretical eclecticism, technical eclecticism (Lazarus, 1981), prescriptive eclecticism (Dimond, Havens, & Jones, 1978), strategic eclecticism (Held, 1984), radical eclecticism (Robertson, 1979), and perhaps others. Most discussions of eclectic therapy involve combining two theories or approaches, usually psychoanalysis and behavior therapy (e.g., Wachtel, 1977). A number of books go beyond this, however: Beutler (1983), Garfield (1980), Hart (1983), Lazarus (1981), Norcross (1986a), and Palmer (1979), Prochaska and DiClementi (1984). The general-impression from all this literature is one of confusion. It is not clear just what eclectic therapy is. Those who call themselves eclectic appear to have little in common. They do not subscribe to any common set of principles. While they may not be anti-theoretical or even atheoretical, there is nothing that could be called an eclectic theory. Garfield and Bergin (1986) note that "there is no single or precise definition of an eclectic orientation...it is exceedingly difficult to characterize an eclectic approach in terms of either theory or procedures" (p. 8). Garfield's (1982) earlier characterization still holds: "Eclecticism is perceived as the adherence to a nonsystematic and rather haphazard clinical approach" (p. 612). Strupp and Binder (1984) make a similar statement: "The term eclectic, which many therapists use to describe their orientation and practices, is so fuzzy it defies definition" (p. xii). In effect, there are as many eclectic approaches as there are eclectic therapists. Each operates out of his or her unique bag of techniques, on the basis of his or her particular training, experiences, and biases, on a case by case basis, with no general theory or set of principles as guides. Prochaska and Norcross (1983) note that: "The need for theoretical orientation has been frequently recognized, but few, if any, adequate models of systematic eclecticism have been created... Beyond its conceptual relativity and personal appeal, eclecticism in its current state may not possess adequate clinical utility or validity for increasing numbers of therapists (p. 171)... The real challenge for synthetic eclectic therapists and theorists alike is to construct models of systematic eclecticism that have both empirical validity and clinical utility" (p. 168). A true eclecticism is neither nonsystematic nor haphazard. English and English (1958) define it as follows: "Eclecticism. n. In theoretical system building, the selection and orderly combination of compatible features from diverse sources, sometimes from incompatible theories and systems; the effort to find valid elements in all doctrines or theories and to combine them into a harmonious whole... Eclecticism is to be distinguished from unsystematic and uncritical combination, for which the name is syncretism." This definition of eclecticism is accepted for the purposes of this paper. In addition, the object of the paper is not to attempt to support another kind of eclecticism, but to suggest the basis for a single, all encompassing system, which is presumably the ultimate goal of all those concerned with psychotherapy. COMMON ELEMENTS IN PSYCHOTHERAPY The confusing state of eclectic (actually syncretic) psychotherapy is due to two factors: (1) in rejecting various theories, theory has been ignored or downplayed in the eclectic stance, and (2) in the attempt to include as many diverse methods or techniques as possible, there is little concern with their compatibility or orderly integration. Most eclectic approaches have been built upon the differences among the various approaches rather than upon similarities. Yet it has been recognized for at least fifty years (Rosenzweig, 1936) that there are basic common factors or elements in the diverse approaches to psychotherapy. Following Rosenzweig, numerous writers have suggested various common factors. The common factors noted have been numerous and varied. (Our concern here is with therapist variables only, and not with client variables.) At the simplest and most concrete level, therapy consists of two persons talking to each other. At the most abstract level, therapy is an interpersonal relationship, in which the therapist's personality (undefined) is the most important element. In between are such therapist behaviors or characteristics as status or superiority, authority, expertise, rapport, and support. More current terms are therapist credibility, trustworthiness, and attractiveness. Other writers have listed more specific techniques: catharsis, suggestion, reassurance, persuasion, advice, guidance, and direction. These are not present, however, in all theories or approaches. Still other factors noted are acceptance and understanding of the client, permissiveness, non-judgementalness, respect, honesty or genuineness. Frank (1982), who has been writing about common elements for nearly 25 years, has focused on a group of components more complex than simple lists, centering on his concept of therapy as a "means of directly or indirectly combating demoralization" (p. 19). His first component is "an emotionally charged confiding relationship with a helping person," involving the therapist's status or reputation but also including the communication of caring, competence, and the absence of ulterior motives (p. 19). Second, is a healing setting that heightens the client's expectation of help from a healer and that provides safety. Third, is "a rational, conceptual scheme or myth that provides a plausible explanation for the patient's symptoms and prescribes a ritual or procedure for resolving them" (p. 20). The fourth is "a ritual that requires active participation of both patient and therapist and that is believed by both to be the means of restoring the patient's health" (p. 20). Though developed in detail over a period of time, Frank's elements are abstract and not operationalized. Yet they have apparently had wide acceptance. They bear a striking resemblance to Fish's (1973) delineation of placebo therapy. In 1967 Truax and Carkhuff, after reviewing the major theoretical approaches to psychotherapy, in a chapter titled "Central Therapeutic Ingredients: Theoretic Convergence," found three sets of characteristics: (1) "the therapist's ability to be integrated, mature, genuine or congruent," (2) "the therapist's ability to provide a non-threatening, trusting, safe or secure atmosphere by his acceptance, nonpossessive warmth, unconditional positive regard, or love," and (3) the therapist's ability to be "accurately empathic, be with the client, be understanding, or grasp the patient's meaning" (Truax & Carkhuff, 1967, p. 25). Accurate empathy, respect or non-possessive warmth, and genuineness are "aspects of the therapist's behavior that cut across virtually all theories of psychotherapy and appear to be common elements in a wide variety of approaches to psychotherapy and counseling" (p. 25). Truax and Carkhuff note that these are the therapist conditions for client therapeutic personality change posited by Rogers (1957). Recently there has been considerable attention to what has been termed the "working alliance" in psychotherapy. Gelso and Carter (1985), in their extensive review of the literature on the therapy relationship, include the working alliance as one of three components of the relationship, the other two being the transference or the "unreal" relationship, and the real relationship. In the working alliance are included the therapist's concern and compassion, empathy, genuineness and respect. The real relationship includes openness, honesty and genuineness It appears that there is general agreement that the relationship offered or provided by the therapist is a (the) basic common characteristic of all approaches to psychotherapy. There is disagreement, however, on how the elements in this relationship are viewed--as nonspecific or specific, and as necessary or as necessary and sufficient. SPECIFIC VERSUS NONSPECIFIC FACTORS The common elements have long been referred to as nonspecific factors. The term seems to derive from their wide variety, their general nature, and "the lack of a clear and consistent meaning for what these factors are. Nonspecific factors has been used as a catchall term for many variables inherent in one or more treatments...the researchers may view them as ancillary to therapeutic change but important to rule out explicitly..." (Kazdin, 1979, p. 846). The number and variety of the common or nonspecific factors suggest that it might be useful to attempt to group them into categories. Nearly 30 years ago this writer suggested that there are two kinds of so-called nonspecific or common variables (Patterson, 1959, Chap. 13). One category includes factors such as the therapist's authority, status, expertise, prestige, attractiveness, credibility. It includes techniques such as persuasion, suggestion, encouragement, reassurance, guidance. The second category includes therapist acceptance, permissiveness, warmth, respect, nonjudgmentalism, honesty, genuineness, and empathy or empathic understanding. There is little disagreement about the importance, even the necessity, of the second group of therapist variables in psychotherapy. Prioleau, Murdock, and Brody (1983) are among the many who recognize this: "The importance of such qualities have [sic]...been almost universally accepted by all psychotherapies, with varying levels of emphasis." Lambert, Shapiro, and Bergin (1986) note that "virtually all schools of psychotherapy accept the notion that these or related therapist variables are important for significant progress in psychotherapy, and in fact, fundamental in the formation of a working alliance" (p. 171). After recognizing the crucial nature of relationship factors, however, they state that this "is not to say that techniques are irrelevant but that their power for change is limited when compared to personal influence" (p. 202). The belief that techniques are necessary dies hard, as will be noted later. Lambert (1986), referring to a current review (Lambert, Shapiro, & Bergin, 1986), notes that client ratings of therapist understanding and acceptance have been found to be related to clientrated outcome "across a wide variety of therapies" and such results "are quite common in the psychotherapy literature" (p. 189). He continues that this suggests that, "at least from the patients' point of view, effective treatment is due to factors associated with relationship variables and the personal qualities and attitudes of the therapist. That these personal qualities bear a striking resemblance to each other, across studies and methodologies, is evidence that they are important in psychotherapy outcome and are prominent ingredients of change in most if not all therapies" (p. 189). It is argued here that the variables in the first category above are truly nonspecific. They constitute, in effect, the placebo (Fish, 1973; Patterson, 1985b; Pentony, 1981; Shapiro, 1971; Shapiro & Morris, 1978). Critelli and Neumann (1984) note that "the common factors of psychotherapy conform closely to traditional listings of placebo variables, including factors such as suggestion, persuasion, treatment credibility, therapist attention, expectancy of cure, and demand for improvement" (p. 35). Many writers seem to consider the entire relationship, or the therapist's entire contribution to the relationship, as nonspecific. The behavior therapists appear to be among these. This view would imply that psychotherapy is (nothing but) a placebo. Shapiro (1971) stated that his chapter would be "an examination of psychotherapy as a placebo" (p. 443). Shapiro and Morris (1978) refer to the study by Luborsky, Singer, and Luborsky (1975) that found in a comparison of the effectiveness of several types of psychotherapy that all were about equally effective, and that concluded that this improvement was related to the patient-therapist relationship shared by all types. Shapiro and Morris refer to this as a demonstration of the placebo effect. Frank, viewing the relationship as nonspecific, at least implies that it is a placebo (1982). His common elements appear to be those included in the placebo category above. And later (Frank, 1983), in a response to an article on placebos, titles his response "The placebo is psychotherapy." The variables in the second category of common elements, far from being nonspecific, are the specific elements in psychotherapy. They are the active ingredients in a healing or therapeutic relationship. Kazdin (1979, p. 850) notes that "Some of the variables grouped together as part of nonspecific factors may constitute very active ingredients in many different techniques". The three conditions enumerated by Rogers (1957) and Truax and Carkhuff (1967) have been the focus of a tremendous among of research. The significance of this research has been questioned by a number of reviewers (Bergin & Suinn, 1975; Mitchell, Bozarth, & Krauft, 1977; Orlinsky & Howard, 1978; Parloff, Waskow, & Wolfe, 1978; Lambert, DeJulio, & Stein, 1978; Watson, 1984). Any single study involves flaws and limitations. But the positive nature of the accumulative evidence is impressive (Patterson, 1984). Convincing evidence for the effectiveness of any of the variables in the first category is lacking. The Vanderbilt psychotherapy project (Strupp & Hadley, 1979), published after the major critiques, is particularly impressive since it was conducted by a long-term skeptic about the effectiveness of the therapist's relationship conditions without the addition of specific techniques. In a well-designed experiment, five experience male therapists and five untrained male college professors (selected for their ability to form an understanding, warm, empathic relationship) each treated three male college undergraduates, in twice weekly sessions for up to a maximum of 25 sessions. There was no difference in the quality of the relationship provided by the trained and experienced therapists and the college professors. While all clients improved, compared to their initial status and compared to two control groups, "patients undergoing psychotherapy with college professors showed, on the average, quantitatively as much improvement as patients treated by experienced professional therapists" (p. 1134)... "The study, on the whole, lent no support to the major hypothesis that, given a benign human relationship, the technical skills of professional psychotherapists produce measurably greater therapeutic changes" (p. 1135). Imagine what the results might have been had the college professors had some training in providing a therapeutic relationship! COMMON SPECIFIC ELEMENTS AS THE CORE OF A SYSTEMATIC ECLECTICISM The thesis of this paper is simple, and should now be obvious. A systematic eclecticism must be based upon, if it does not consist of, those factors common to all the major theories, factors that are specific in their nature, and that have the support of more research than any other factors, methods, or techniques in psychotherapy. They are specific in that they provide a good or facilitative interpersonal relationship as a treatment for the lack of, or inadequate, interpersonal relationships in the past and/or the present lives of clients. Current eclectic proposals attempt to build on the differences in methods or techniques in the major theories, resulting in a syncretism rather than an integrated systematic eclecticism. Theorists emphasize their differences from other theories rather than the commonalities, and attribute the effectiveness of their theories to the unique elements, usually those not included in the relationship, rather than to the commonalities. As Frank (1982) notes: "Those features which distinguish them from each other...receive special emphasis in the pluralistic, competitive American society. Since the prestige and the financial security of the psychotherapists depend to a considerable extent on their being able to show that their particular theory and method is more successful than that of their rivals, they inevitably emphasize their differences; and each therapist attributes his or her success to those conceptual and procedural features that distinguish that theory and method from its competitor's rather than to the features that all share" (p. 10). Eclecticists, impressed by the claims for the distinctive elements of each theory, attempt to include them all. Garfield (1982) has stated that "one important step in the desired direction [toward integration in psychotherapy] is to delineate and operationalize clearly some of the common variables which seem to play a role in most psychotherapies, and, perhaps, to regard them as the basis for a clearer delineation of psychotherapeutic principles and procedures This may not be popular, but I think it is well worth the effort." (p 620). This paper is such an effort. RESISTANCES TO COMMON ELEMENTS AS SPECIFIC FACTORS There are a number of sources of resistance to the recognition of certain of the common elements as common specific factors in psychotherapy, and therefore a foundation for a systematic eclecticism. Foremost among them has been the reluctance, even the inability, to recognize that the relationship, and specifically the contribution of the therapist to the relationship, is not only the necessary but the sufficient therapist condition for effective psychotherapy. Strupp has been one of the most persistent unbelievers (e.g., Strupp, 1982, 1986). He has repeatedly emphasized that although the therapist's contribution in the relationship is important, even necessary, there are, or must be, certain techniques or technical operations necessary for effective psychotherapy. Even after the findings of the Vanderbilt study reported earlier (Strupp & Hadley, 1979), Strupp persisted in his refusal to accept the implications of the results of this study. As Cornsweet (1983) notes, "Strupp and Hadley do not interpret their results as evidence against the efficacy of technique" (p. 308). Most recently, however (Butler & Strupp, 1986), he seems to recognize the inevitability of this conclusion. The "interpersonal context", he recognizes, is primary, but still "the procedures (techniques) and interpersonal factors are thoroughly intertwined and cannot be separated. Efforts to separate these aspects of therapy for the purpose of determining causal connections are suspect regardless of statistical or measurement sophistication" (p. 33). Later it is stated that "psychotherapy is defined as the systematic use of a human relationship for therapeutic purposes" (p. 36). In a footnote it is stated that "in its strong version our hypothesis states that all psychotherapies are primarily interpersonal events and must be understood in this perspective" (p. 36). Parenthetically, it can be argued that specific techniques and therapist relationship factors can be separated for research purposes. In fact, much, or most of the research on the effectiveness of empathic understanding, warmth or respect, and genuineness, has evaluated these conditions apart from or in the absence of any specific techniques. Since these conditions have been found to lead to therapeutic changes in the absence of any other techniques, then it must be concluded that no other techniques are necessary for such change. In fact, it can be argued that the presence of such techniques may impair the effectiveness of psychotherapy. Bergin (in Bergin & Suinn, 1975) made the interesting, though puzzling, statement, referring to these therapist variables, that "in recent years, a number of studies have induced skepticism concerning the potency of these variables except in highly specific clientcentered type conditions" (emphasis added). A possible conclusion might be that since these variables constitute or are the essence of client-centered therapy, and no other variables (or techniques) have been demonstrated to be effective, then only client-centered therapy is an effective therapy. Though these conditions may be present in other therapies, they can be nullified or counteracted by other conditions or therapist techniques. For example, Mintz, Luborsky and Auerbach (1971) found that therapists who were empathic, but also directive, were not effective. And Hoyt (1980) found that "poor" sessions, in contrast to "good" sessions, as rated by experts, were characterized by therapist efforts to extract factual information and to give advice. A second source of resistance is that to view the essence of psychotherapy as the relationship is too simple: There must be more to psychotherapy! This may be behind the resistance of those who insist that additional techniques must be necessary. If there are no additional techniques, then the responsibility falls squarely upon the therapist as a person. For years many writers have been saying that the personality of the therapist is the most important factor in psychotherapy. But they have never specified just what the therapeutic personality is. Now it can be defined. The characteristics, attitudes, and behaviors of the therapeutic personality are represented in perceiving empathically, and communicating this empathy; showing warmth, respect and concern for the client; and being genuine, honest and authentic in the relationship. The matter of techniques, or skills as they are frequently referred to, is not ignored. Although the common elements are personality characteristics or attitudes, they are manifested in specific behaviors. Techniques or skills are the behaviors which implement or communicate the attitudes. They operate through basic commonly recognized modalities of learning, including modeling, minimizing threat, reinforcement, and extinction among others. No doubt some of the resistance to the acceptance of these common elements is related to their identification with client-centered therapy. While it is true that they were first enunciated clearly by Rogers (1957), that they constitute the essence of client-centered therapy, and that most of the research on them has been done by researchers identified as client-centered, client-centered therapy has no monopoly or exclusive claim, or as Shlien puts it, a "proprietary claim" (Shlien, 1984, p. 177) on them. And, as has been emphasized earlier, they are clearly implicit, if not explicit, in every major theory of psychotherapy and in the writings of many if not most therapists beginning with Freud (Truax and Carkhuff, 1967). Empathic listening and understanding, especially, is, as Strupp and Binder (1984, pp. 46-47) note "perhaps the most fundamental principle rightfully shared by all forms of psychotherapy and by clinicians as divergent in their views as Rogers, Fromm-Reichmann, and Kohut." Many will resist accepting this basis for a systematic eclecticism because it is currently a minority point of view. The predominant view involves an active, interventionist approach to psychotherapy, with the therapist being an expert in behavior change. The approach emphasizing empathic understanding, respect, and therapeutic genuineness as the core of psychotherapy does not view the therapist as an expert in methods and techniques of changing behavior, but as an expert in providing the conditions under which the client engages in changing his/her own behavior. The theory and philosophy behind this approach to psychotherapy are not generally or widely accepted. The position does not fit with the currently accepted paradigm for research in psychotherapy: to determine what treatment, by whom, for what problem in what kind of client produces what changes (Patterson, 1986, pp. 461-462). A paradigm shift will be necessary, toward the recognition of the concept of the unitary nature of psychological disturbances and a unitary concept of treatment. Goldfried (1982, p. 991) has noted that "although it has been possible to delineate commonalities across all theoretical persuasions, formidable pressures nevertheless exist that oppose such integration." Therapists resist abandoning their habitual techniques, attributing their success to these techniques rather than to the relationship in which they are embedded. OTHER ELEMENTS A basis, or a foundation, for a systematic eclectic psychotherapy has been suggested. What other elements--if any-might be added? To be incorporated into a systematic integration, any other elements must be consistent with the elements proposed here. Most of the specific elements or techniques common in psychotherapy are not consistent. They include active interventions from an external frame of reference rather than from the internal frame of reference of the client that is the basis for empathic understanding. The research indicating that the three elements considered here are sufficient for therapeutic personality change with a wide variety of clients and client problems, suggests that there may be no other necessary elements. To be sure, continued research is necessary to determine the limits, if any, of the effectiveness of these conditions. But the therapeutic relationship is complex, and the three elements considered are themselves complex variables, or each a complex of variables. They need to be more carefully defined, analyzed, perhaps broken down into more specific elements, with the development of better measures, particularly of their perception by clients--a necessary condition in Rogers' (1957) proposal that has not been adequately studied (Watson, 1984). In addition to the three basic factors considered here, Carkhuff and Berenson (1967) have proposed four others: concreteness or specificity, confrontation, therapist self-disclosure, and immediacy. These differ from the three basic factors; they are more properly techniques. Specifically, for example, would appear to be a way of implementing empathic understanding. The others are sometimes ways of implementing the other conditions (Patterson, 1986, pp. 7590). Empathic understanding, respect, and therapeutic genuineness account for from 25 to 40 percent of outcome variance (Patterson, 1984). Critics have emphasized that this leaves the major amount of variance unaccounted for. For example, an anonymous reviewer of an earlier form of this paper emphasizes that "this means that other variables will account for more than half of the outcome variance." But this assumes that therapist variables must contribute 100 percent of outcome variance. Bergin and Lambert (1978, p. 180), however, wrote: "We believe...that the largest variation in therapy outcome is accounted for by preexisting client factors such as motivation for change, and the like. Therapist personal factors account for the second largest proportion of change, with technique variables coming in a distant third." Norcross (1984, p. 15) states that "experts estimate that about one-third of treatment outcome is due to the therapist and two thirds to the client." Thus the three core conditions account for most of the therapist variance. Techniques such as concreteness and confrontation as defined by Carkhuff (Patterson, 1985, pp. 76-78) may account for the remainder. In other words, these conditions and techniques are not only necessary but sufficient. The elements considered here are all included in the nature of the relationship provided by the therapist. Are there any non-relationship variables that are candidates for inclusion in a systematic eclecticism? Some might suggest information, social skills training, assertiveness training, etc., etc. These, however, properly fall under teaching or tutoring. In learning theory terms, psychotherapy may be considered a problem in performance with the response being in the repertoire) rather than a problem in acquiring responses not in the repertoire. Thus, behavior therapy, as well as cognitive therapy, may be considered as essentially teaching or tutoring, or reeducation. In teaching, the relationship is necessary but not usually sufficient; in psychotherapy it is necessary and sufficient. It is concluded that currently there are no other clear candidates for inclusion in the therapist's contribution to the therapy relationship in addition to empathic understanding, respect, therapeutic genuineness, and concreteness. CONCLUSION Most attempts at integration and eclecticism in psychotherapy are limited to combining two approaches, or bringing together techniques from various approaches. What is needed is a comprehensive, all-encompassing system including an integrating philosophy, theory, and related principles as well as techniques. A starting point is the basic common therapist elements of the major recognized theories. Three of these elements have been identified: empathic understanding, respect and genuineness. It is contended that these elements define a therapeutic relationship that provides the specific treatment variables for psychological emotional disturbances. It is further suggested that they constitute the necessary and sufficient therapist conditions for therapeutic change. There is a considerable literature on the theory and philosophy supporting these conditions, generally recognized as the client-centered approach. This philosophy and theory are not consistent with the current zeitgeist in psychotherapy. As a result, there is considerable resistance to the acceptance of this approach as the foundation for a single comprehensive eclecticism. It will require a change in the current paradigm for such acceptance, which is considered by the author as necessary for further progress in psychotherapy. A proposal such as this will not be popular, as Garfield (1982, p. 620), noted, but nevertheless will be, as he suggested, "worth the effort."