My journey toward a personal theory of psychotherapy began with a recurring dream of two houses...
One house, actually, in two parts. One part was spacious, contemporary but not modern, with beautiful stone floors and many palatial rooms, but an unfinished roof composed of enormous wooden beams. The other was rustic, cozy, and felt as if it held the long memory of a loving family safely within its rough wooden walls. The two houses were joined by a long hallway lined with the faux-wood paneling common in houses of the 1970s — in fact, just the kind of paneling in the den of my childhood home. I couldn't access either house without going outside and entering one or the other, and all the doors of the hallway were locked. There were, in other words, so many places I wanted to explore but couldn't, and effectively two separate houses, even though they were both mine.
NOTE: This article is very detailed and so somewhat lengthy. Click here to skip to a summary of my approach.
I knew instinctively that this dream was about me, but couldn't figure out what it was trying to tell me. It wasn't until I was well into my clinical rotations, when my supervisor and I had a long conversation about our patients' faith and spirituality, that I realized I'd left a part of myself behind over all those years working as a scientist. Becoming so rationally-minded and evidence-based, I'd ceased to pay attention to my deep emotional self. I'd never been religious, but an ill-defined, general spirituality had been an important part of my life and identity for a long time. That spirituality had been left by the wayside some time in graduate school. And in tracing the crooked path of my life, it dawned on me that the further afield I'd gotten from that foundation, the more desperation, confusion, and existential sadness I'd felt. My relationships with myself and those I loved had become more superficial, my emotions harder to tap into and express.
I threw myself, then, into deep introspection and self-work to recover my exiled seeker. And while I couldn't return to the early days of awed mysticism — I'd served too long in the material world of science to go embrace fantastic possibility — I could open myself to the one principle that had always guided me: a connection to others, to the universe, to a sense of purpose. I realized just how much I had to offer to others: a solid foundational knowledge about the workings of the body, brain, and mind; a profound empathy born of my own experiences of ecstatic joy and utmost sadness; and a calling to help those in need, whatever that takes or costs me.
I stopped having the recurring dream. It had fulfilled its purpose.
Assimilative psychotherapy
Although all therapists are trained in particular models or "schools" of psychotherapy, and intensively train in one or more of these models, most of us eventually develop our own approach which integrates these models and adapts theory to our own preferences and personality. The psychologist George Stricker has divided psychotherapy integration into three types:
Technical integration — The therapist systematically incorporates techniques from various models because they might be helpful to the client. Prescriptive psychotherapy is one example of technical integration.
Theoretical integration — An attempt to synthesize multiple (or all) models under a “grand unified theory.” Examples include cognitive-analytic therapy, behavioral psychotherapy, unified psychotherapy, and cyclical psychodynamics (the last one has been a major influence on my personal approach).
Assimilative integration — The therapist has a “home” theory and integrates techniques under this theory. Examples include the common factors approach, cognitive-behavioral assimilative integration, and assimilative psychodynamic integration.
My own approach is assimilative: as I explain below, I take humanistic therapy (like Virginia Satir, Carl Rogers, or Carl Whittaker) as my "home" theory and incorporate other approaches as needed. I have a couple of other guiding principles to help me add a bit of nuance to this "template" and adapt it to a given patient:
Systemic-relational theory — We're all part of different systems: systems of other people, like friends, partners, and family; interactions among the conflicting voices, thoughts, and emotions within us; cause-and-effect relationships between our biology, health, personality, and thoughts and emotions; and the influences of culture, community, and civilization on our thought processes and the meanings we assign to our words and experiences. In other words, we can't understand someone by looking at them in isolation. We have to look at them in relation — how they're influenced by their personal lives and experiences, and how they influence the systems of which they're a part.
Symbology — The deep mind is preverbal: It has limited access to the part of our brain which uses and understands language. It has to speak to us through images, sensations, memories, and little mental taps on the shoulder we interpret as intuition. That's one reason dreams are so weird. Some of these symbols are our own; others are picked up from our family, society, and culture (books, songs, stories, television and movies). Regardless, deep healing requires accessing the deep symbology within us, working with it on its own terms, and coming to a final truce with even the most uncomfortable emotions we have — these are what make us human.
Social learning theory and social cognitive theory — Many of our thoughts and behaviors are learned. They're things we've picked up from people we like or admire, like parents, friends, and role models. We've adopted them and made them habit because we've found them useful ways to adapt, survive, and possibly thrive in an unpredictable world. Most of this process is unconscious, and although some of our reactions are useful (functional), others are not (dysfunctional). Becoming aware of them is a great first step toward turning them to our advantage, rather than letting them get in the way of a fulfilling life.
Transference — Because our learned patterns have helped us adapt in one way or another, they're pervasive — they're like programs that are triggered whenever certain conditions are met, and it's really hard to short-circuit them. And because they're so pervasive, our patients automatically re-enact these assumptions and behaviors with us, the therapist. In clinical terms, they experience transference and recapitulate isomorphic processes in the therapy space.
Attachment— As I often tell my own patients, the therapeutic relationship is unlike any other relationship in our lives. A therapist is someone you can confess to, like a priest; someone you can be yourself with and bounce ideas off of, like a friend; someone who can serve as a coach or teacher when needed; and someone who (ideally) extends unconditional regard and compassion toward you, like family — and yet, we're none of these things. I've often argued that the therapeutic relationship is a different kind of attachment bond compared to all other attachments we might have in life. And that novel attachment means we have a unique opportunity to stop those learned patterns, those isomorphic processes, in their tracks, reframe them, offer new ways to think about experiences and model new ways of dealing with them. For someone who has experienced a life of trauma and antipathy, this relationship is a chance to experience unconditional empathy; for someone who has always gotten their way, it's a chance to be challenged, questioned, in a compassionate, understanding way.
Objective countertransference — The therapeutic alliance, and the therapist’s way of being (Rogerian positive regard, expectation, empathy and contingent communication, all common factors) interrupt isomorphic processes and facilitate insight, reframing, new narratives, new cognitive-behavioral patterns, and repair or establishment of new, more functional attachment patterns.
Putting it all together
I believe that treating a client or patient as a psychotherapist means attending to them holistically. My training and experience as a neuroscientist taught me that we can't separate physical pain from cognition and emotion, or emotion from cognition and physical health. This isn't a new idea — current thought in interpersonal neurobiology supports it; Satir and existential-humanistic psychotherapists have taken an integrative approach to mental health; and many of my fellow clinicians in collaborative care medicine have adopted a biopsychosocial-spiritual model of treatment. The difference is in my own conceptualization of "holistic treatment," which determines how I try to help people who come to me for therapy. It's not that I disagree with others' formulations; I've simply made them my own.
My conceptualization takes the form of a five-element model — symbolically, earth, air, fire, water, and spirit. Don't take these literally: they're just metaphors.
 | Body (earth). Establishing safe space, re-establishing mind-body connection, addressing biomedical issues, centering and embodiment exercises for pain relief. Somatic interventions have been helpful for some of my patients with chronic pain, and for a subset of patients with a history of emotional or physical abuse. |
Conscious, rational mind and automatic, unconscious thoughts and reactions (wind).Identify automatic thoughts and behaviors, explore alternatives, facilitate new communication patterns. Cognitive-behavioral therapy (CBT), cognitive-behavioral family therapy (CBFT), and mindfulness-based cognitive therapy (MBCT) are helpful models for these purposes. |  |
 | Existential drive, will, and motivation (sun/fire). Address feelings of being overwhelmed by identifying achievable goals. Prioritize symptom relief. Motivational interviewing (MI) and focused acceptance and commitment therapy (fACT) interventions. |
Deep emotions and personal symbols (water). Often "pre-verbal," this aspect often needs to be accessed through imagery and other methods. Explore remote emotional and attachment injuries in personal history. Focus on relationships and communication. This is usually the most personalized set of interventions, and may include journaling, art therapy, movement, or anything else the client/patient prefers or responds to. |  |
 | The framework: existential humanism (spirit). Emphasis on authenticity, self-actualization, personal meaning in life, and interpersonal fulfillment. |
Beyond the individual
I'm often asked how I apply this model in therapy with couples and families. In other words, we're social beings, so where does the relational aspect of ourselves fit in? The answer is: it's implied. So many other theorists and practitioners have explored the mutual influence between individuals and the human systems to which they belong that I simply didn't feel it necessary to add another layer to my model.
One way to think of my approach is that, like internal family systems, it extends an ecological model like Bronfenbrenner's downward into a person's predisposing factors and experiences. My model complements these other models and allows us to explore, in finer detail, how our social experiences are influencing us. For example, the unhelpful assumptions, thought patterns, and behaviors addressed so well in cognitive-behavioral therapy are often social in nature ("If I don't keep a close eye on my teenager, they're going to get into trouble") — and would fall into the "rational mind" category. Unfaithful spouses and critical parents can inflict deep emotional damage, and obviously fall into the "emotions" category. The loss of a loved one forces us to reassess the meaning of their lives ("symbols" category) and our own ("authenticity"). And finally, I've seen how family and work stress take their toll on my patients' bodies and irritate their chronic pain or cause flare-ups of physical symptoms. The holistic-humanistic model allows us, as therapists and other practitioners, to attend to both the root causes of psychological pain and their symptoms in a way that's tailored to the specific needs of individuals and families.
Declaration of Principles
To sum all this up, my holistic-humanistic approach to psychotherapy...
Leverages the unique attachment bond of the therapeutic relationship to re-enact learned personal and relational processes, interrupt them, reframe them, and facilitate a new, empowered experience of interaction with oneself and another human being.
Uses countertransference as a key element of this process. Far from being something undesirable, countertransference allows a client/patient and therapist to interact on a deep emotional level. The therapeutic alliance and the therapist's empathy, compassion, and capacity to care are all factors which allow therapy to work.
Assimilates various theories and techniques under an existential-humanistic framework. The guiding principle of this framework is self-actualization: embracing our freedom to act and become within the constraints of our current and future limitations; reflecting on what is truly important to us in life and engaging with the challenges we face along the way; and taking responsibility for who we are and what we do, while accepting that we cannot control everything that comes to us.
Is always adapted to each individual, never the other way around. Every person, situation, and need is unique. I believe my responsibility as a psychotherapist is to attend to all aspects of the people who come to me for healing and support, but some will need more attention to one aspect than another, and everyone needs to be tended to in a different, but equally compassionate, way.
Conceptualizes the person as comprised of five domains: the body, or body-mind connection; the rational, conscious mind and automatic thought-behavior process; the deep emotional mind; the existential drive or motivation; and the need to become, achieve, and be accepted. Each of these domains is approached in a different, evidence-based way — somatic therapy, systemic cognitive-behavioral therapy, experiential therapy, motivational interviewing and collaborative goal-setting, and integrative existential-humanistic therapy.
Extends and complements other ecological models concerned with human functioning within families, social networks, communities, and society.
References & Further Reading
Badenoch, B. (2008). Being a brain wise therapist: A practical guide to interpersonal neurobiology. WW Norton & Company.
Banmen, J. (2002). The Satir model: Yesterday and today. Contemporary Family Therapy, 24(1), 7-22.
Doherty, W. J., McDaniel, S. H., & Hepworth, J. (2014). Contributions of medical family therapy to the changing health care system. Family Process, 53(3), 529-543. https://doi.org/10.1111/famp.12092
Hodgson, J. L., McCammon, S. L., & Anderson, R. J. (2011). A conceptual and empirical basis for including medical family therapy services in cancer care settings. The American Journal of Family Therapy, 39(4), 348-359.
McDaniel, S., Doherty, W. J., & Hepworth, J. (2013). Medical family therapy and integrated care (2nd ed.). American Psychological Association.
Robinson, K. J. (2019). Satir human validation process model. In L. Metcalf (Ed.), Marriage and family therapy: A practice-oriented approach (2nd ed., pp. 165-182). Springer-Verlag.
Satir, V. (1988). The new peoplemaking. Science & Behavior Books. https://archive.org/details/newpeoplemaking00satirich
Satir, V., Banmen, J., Gomori, M., & Gerber, J. (1991). The Satir model: Family therapy and beyond. Science and Behavior Books.
Schneider, K. J., & Krug, O. T. (2010). Existential-humanistic therapy. American Psychological Association Washington, DC.
Stricker, G., & Gold, J. R. (2013). Comprehensive handbook of psychotherapy integration. Springer Science & Business Media.
Wretman, C. J. (2015). Saving Satir: Contemporary perspectives on the change process model. Social Work, 61(1), 61-68.
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