The Clinical Angle: Interpersonal Significance in a Unifying Biopsychosocial Systems Approach to Psychotherapy - Jack C. Anchin
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Interpersonal
Significances in a Unifying Biopsychosocial Systems Approach to Psychotherapy[1]
Some 30 years ago, in my summary and conclusions chapter for the Handbook of Interpersonal Psychotherapy (Anchin & Kiesler, 1982), I extracted four convergent themes characterizing that era’s emerging interpersonal theory, research, and practice: development and expansion of Sullivanian theory; adoption of an ecological/reciprocal deterministic emphasis; circumplex models of interpersonal behavior; and procedural variability among interpersonal theorists (cf. Pincus & Cain, 2008, pp. 222-223). Against the backdrop of explicating these themes, I concluded “These and other developments examined throughout this volume clearly demonstrate that the interpersonal paradigm is steadily maturing, and that more concerted attention to its evolving constructs, methodologies, and treatment procedures can considerably enrich the science and practice of psychotherapy” (Anchin, 1982a, p. 324). If, as Gordon Allport proclaimed, differentiation and integration are hallmarks of the maturational process (cited by Palkovitz, 2002), then the luminous ripening of the interpersonal paradigm is a beautiful sight to behold! Over the years that have elapsed since the words cited above were written, we see in Horowitz and Strack’s (2011) scholarly Handbook of Interpersonal Psychology the paradigm’s flowering in the form of expanded yet more fine-grained conceptualizations of interpersonal constructs, processes, and mechanisms pertaining to personality and psychopathology; growth in the paradigm’s assessment and measurement network associated with, but far from limited to, circumplex methods (cf. Pincus, 2010); heightened sophistication of research and statistical methodologies for investigating covert and overt interpersonal phenomena; steady empirical solidification of the evidence base supporting interpersonal constructs and interventions; and applications of interpersonal understandings and interventions to a broadening array of human problems in living of both a psychological and medical nature. Moreover, through the dialectical interplay between differentiation and integration, these various domains of interpersonal knowledge feed one another, and they are further enriched through syntheses with such fields as personality psychology (e.g., Kiesler, 1996; Pincus & Ansell, 2003), social psychology (e.g., Murray& Holmes, 2011; Reis, 2007), and neuroscience (e.g., Lieberman, 2007; Luyten & Blatt, 2013). Indeed, the remarkable breadth and depth of integration with constructs and findings from both basic and clinical psychological science and from disciplines outside of psychology (Magnavita & Anchin, 2014) afforded by an interpersonal perspective remains one of this paradigm’s most robust and compelling strengths (Anchin, 1982b; Pincus, 2010).
In my personal evolution as a clinical psychologist, the fertile integrative potentialities inherent in the interpersonal approach to psychotherapy catalyzed a passion for psychotherapy integration, which over time has extended into deepening interest in exploring the unification of therapeutic approaches (Anchin, 2008b; Anchin & Magnavita, 2008; Magnavita & Anchin, 2014). In this article, I sketch out in necessarily broad strokes one such unifying framework for therapeutic theory and practice that I characterize as a unifying nonlinear dynamical biopsychosocial systems (NDBPSS) approach (Anchin, 2005, in press). This approach emphasizes a holistic perspective on understanding human functioning and experience by encompassing the major domain systems that interdependently constitute and influence life-span development, personality, psychological health, and psychopathology. As elaborated momentarily, the approach merges multiple influences to promote highly individualized treatment of a wide spectrum of disordered biopsychosocial states—but as I believe will also become apparent, this approach belies the fundamental interpersonalism ineffably imprinted in my DNA.
Confluent Streams of Influence
NDBPSS is rooted in several theoretical models, each with their own historical context. The overarching foundational model is systems theory, which first achieved prominence in the mid-20th century when von Bertalanffy (1968) articulated his general systems theory, applied chiefly to biology, in an effort to explain universal principles by which complex systems operate. Often characterized as metatheory by virtue of its application across theories and disciplines, systems theory has since fostered development of various approaches to systemic thinking that includes cybernetics, chaos theory, nonlinear dynamical theory, and complex adaptive systems. These various approaches have been effectively applied throughout the physical, life, and social sciences. The assumption of holism is fundamental to systemic thinking, and holds that a complex system is composed of a variety of heterogeneous elements or parts (e.g., subsystems) that, through self-organizing interdependencies, are bound together and function as a totality or unified whole in the pursuit of the totality’s aims. The concept of teleology is integrally related, maintaining that all complex living systems actively strive toward achieving goals, attaining desired states, and realizing valued ends, reflecting purposefulness and intentionality on the part of the living system of interest (see Anchin, 2003). The dynamical dimension of systems thinking refers to the concept that complex living organisms change over time due to interactions among the organism’s multiple subsystems, while the concept of nonlinearity permits a detailed picture of these interactions by emphasizing subsystems’ reciprocal effects, feedback loops, networks, and cycles.
Engel (1977; 1980; 1997) drew explicitly on systems theory in developing the biopsychosocial model in the 1970s as a comprehensive alternative to the standard medical model for treating individuals with mental and physical health problems. Through this model, Engel provided a holistic, unified conception of the human being’s complexity through defining the multiple, hierarchically organized domains and subsystems that interdependently comprise an individual. These domains include the biological domain (genetic, anatomical, physiological, and biochemical subsystems); the psychological domain (cognitive, affective, motivational, and defense subsystems); and the sociocultural domain (speech, the behavioral subsystem, and an individual’s sociocultural environment comprising interpenetrating layers such as dyadic, family, community, religious, cultural, and political subsystems). The biopsychosocial model also incorporates the phenomenological domain (cf. Engel, 1998; Krippner, Ruttenber, Engelman, & Granger, 1985), underscoring that human biopsychosociality is a lived experience infused with purpose, values, and meaning.
While biopsychosocial systems metatheory serves as the metaphorical chassis for the NDBPSS approach, the interpersonal paradigm drives and gives direction to the treatment. As well known to the reader, the latter is rooted in Harry Stack Sullivan’s interpersonal theory of psychiatry and stresses the importance of covert and overt processes within and between two realms of human being and becoming—agency and communion—that are ineluctably fused with human development, personality, mental health, psychopathology, and psychotherapy. I use the metaconcept (Pincus, Lukowitsky, & Wright, 2010) of agency to denote one’s striving to develop a positively experienced individual self that is coherent, differentiated and integrated, and effective, and the metaconcept of communion to represent strivings to develop and maintain satisfying relationships with others, including experiences of connectedness, intimacy, and solidarity (cf. Anchin & Pincus, 2010; Magnavita & Anchin, 2014, chpt.3; Luyten & Blatt, 2013; Pincus et al., 2010). Arguably, agency and communion are the yin and yang of human existence across the entire life span. While many factors render the lived experience of these metaconcepts unique for each individual, agency and communion are the two aspects of human life that provide purpose for all humans.
The NDBPSS approach has also been strongly influenced by psychotherapy integration, which, evolving from its nascent beginnings in the 1930s, emerged in the 1980s as a fully developed movement, exerting profound impact on the field. Psychotherapy integration identifies and incorporates into the treatment process key common therapeutic factors operating across approaches and integrates the principles, concepts, and techniques from various single-school theories to create effective, comprehensive, and versatile approaches to psychotherapy. The integration movement has provided key ontological and epistemological foundations for NDBPSS by promoting plurality in psychotherapeutic theory, research methodology, and practice (Anchin, 2008a, 2008b).
NDBPSS psychotherapy is also built upon psychological approaches that incorporate a holistic understanding of the interrelationships of human structures, processes, and functioning, rather than on the reductive views of health prevalent in the traditional medical model. An exemplar of this holistic sensibility may be found in clinical science in Schore’s (2012; 2014) interdisciplinary work linking findings from neuroscience, human development, interpersonal attachment, affect regulation, and the self, while Cacioppo and colleagues’ (see, e.g., Cacioppo & Decety, 2011) approach to understanding complex behavior and the mind through investigating interconnections among the biological, cognitive, and social domains provides a basic science illustration. Additionally, NDBPSS incorporates the importance placed by the evidence-based practice of psychology (American Psychological Association, 2006) on flexibly tailoring treatment to the specific client at hand, and integrates from the rich perspectives of solution focused-strength-based psychotherapy (see, e.g., Bertolino, Kiener, & Patterson, 2009) and its kinsman positive psychology (Lopez & Snyder, 2009) explicit inclusion of the client’s biological, psychological, and/or sociocultural strengths and resources (assets, skills, and zones of health) as integral components of this tailoring process.
Theoretical Propositions
Although human beings are motivated to strive for a broad range of goals and desired states, my approach to treatment is rooted in the proposition that throughout the human life cycle, a person’s most essential motivations are those focused on the goals of agency and communion. Successfully attaining agentic and communal goals necessitates capacities for self-regulation and regulation of one’s social environment. Regulatory processes include gauging one’s current status relative to a desired agentic or communal state, communicating to the self information about discrepancies that may exist between the current and desired state, and instituting corrective actions to the extent that deviations are occurring. In the human biopsychosocial system, feedback operates as one of these principal regulatory mechanisms, with affective states serving as a primary source of feedback—barometers, as it were—about the extent of success in attaining one’s aims. Positive affective states (e.g., pleasure; happiness; relaxation; well-being) indicate effective navigation toward or attainment of a desired agentic and/or communal state, and connote that one is engaging in effective regulatory processes.
Over the life course, however, strong internal or external disruptions in biological, psychological, and/or social processes invariably lead to disturbances in a person’s biopsychosocial stability. If an individual does not adequately regulate such disturbances and their related destabilizing effects on his or her life, then the individual may become derailed from or stop effective pursuit of his or her agentic and communal goals and develop negative affective states, such as sadness, shame, anger, or anxiety. A continuation of or increase in regulatory difficulties can maintain or amplify the disturbances in a person’s biopsychosocial system, further diminish his or her capacity to effectively pursue life goals, and in turn lead to increased distress and other problematic symptoms. In accord with this conceptualization, my aim is often to help the client initiate or resume effective movement toward agentic and communal goals, which infuse her or her life with greater meaning, purpose, and positive affectivity. Improvement is achieved when the client becomes “unstuck” from maladaptive processes for regulating the self and/or the social environment, ameliorates negative affective states and symptoms, develops healthier covert and overt regulatory processes, and is solidly back on track in pursuing self-related and interpersonal aims, goals, and desired states.
Strategies and Techniques
The conceptualization described above gives rise to a high degree of technical eclecticism in facilitating initiation or resumption of movement towards personally meaningful agentic and communal goals. Depicted in the broadest of terms, techniques include blending insight- and action-oriented approaches tailored to overcome biopsychosocial disruptions in and obstacles to clients’ goal pursuits and to facilitate proactive forward movement. Integrally related, I attempt to foster effective interplay between negative and positive regulatory feedback loops, and I look for opportunities to “work the loop.”
Technical Eclecticism
In implementing the NDBPSS approach, I draw upon strategies and techniques from many major paradigms of therapy (e.g., interpersonal, psychoanalytic-psychodynamic, cognitive-behavioral, humanistic-experiential, biomedical, systemic, multicultural, hermeneutic-constructivist, and solution focused-strength based; cf. Marquis, 2009). This multiparadigmatic treatment methodology reflects the view that, when all is said and done, techniques are potentially potent, systematic ways of bringing about therapeutic effects. To promote growth and change, uncoupling techniques from their specific theoretical models (see Grawe, 2007) facilitates my clinical judgments and choices (see Anchin & Singer, in press) with regard to techniques that may be most effective for clinically intervening in a particular biopsychosocial domain and subsystem of the client within the flow of a given session.
Insight and Action
Insight-oriented techniques (e.g., interpretation, metacommunication, use of metaphor, two-chair technique, affective focusing) help clients to sharpen their self-awareness and facilitate their understanding of desired, elusive, or disrupted agentic or communal goals. Techniques designed to foster clients’ insight also assist them to identify and understand specific biopsychosocial obstacles (such as faulty core beliefs about self, health problems, psychological defenses, or maladapative interpersonal patterns) impeding attainment of desired goals. In addition, techniques that advance insight help clients to recognize healthy self-regulatory processes (e.g., sleep hygiene, constructive self-talk, managing affective states, anticipating consequences of actions, proactive coping) that facilitate their effective pursuit of agentic and communal goals. Action-oriented techniques explicitly promote enactment of healthier self-regulatory processes. Covert action-oriented techniques are exemplified by cognitive restructuring of distorted thinking and maladaptive beliefs, teaching mindfulness and distress tolerance skills, facilitating use of beneficial imagery, and fostering healthy self-relational processes (e.g., cognitive-affective self-reactions). Illustrations of overt action-oriented techniques include following medication regimens, clients taking action to change their environments, putting their values and strengths into action, or engaging in spiritual or religious practices they find to be beneficial. Insight- and action-oriented techniques are used in complementary ways to advance clients’ therapeutic progress.
Developing Negative and Positive Regulatory Feedback Loops
Effective self-regulatory processes involve the interplay between negative and positive feedback loops; the former dampen (i.e., reduce or diminish) interconnected biopsychosocial subsystem processes that inhibit or otherwise derail movement toward a desired agentic or communal goal, while the latter amplify (i.e., augment or intensify) interrelated multisubsystem processes that foster effective goal-directed movement. Techniques are differentiable in terms of whether their principal aim is to dampen particular maladaptive processes (e.g., in vivo exposure to reduce social anxiety) or to amplify healthy processes (e.g., an experiential technique to help the client contact and more deeply experience the personal strength of courage). In fostering effective pursuit of agentic and communal goals, I shuttle between techniques for facilitating development of negative feedback loops that reduce unhealthy processes, and techniques for promoting positive feedback loops in order to increase healthy processes.
Working the Loop
Working the loop refers to tapping into constructive change occurring in one subsystem for the purpose of actively promoting change in other subsystems in the same domain and/or in other domain subsystems. For example, the therapist and client examine how he or she can actively harness a given change (e.g., feeling empowered by undertaking effective metacommunication with a work colleague with whom he or she has experienced conflict) in ways that can positively impact other biopsychosocial processes (e.g., improving beliefs about one’s self-efficacy; undertaking an avoided task necessary to achieving a specific agentic goal; or attempting more self-disclosing communication in appropriate contexts). The client is also encouraged to examine within sessions and to observe between sessions how a particular change (e.g., diminishing anxiousness and increasing calmness) may be affecting processes in one or more other subsystems (e.g., physiological state; capacity to make decisions; motivation level; effectiveness of actions; interpersonal behavior). In turn, these specific constructive changes identified as occurring in other biological, psychological, and/or social subsystems are highlighted and, depending on treatment goals and progress, may themselves become targets of amplifying techniques.
Treatment Process
I utilize the approach described above both in a brief therapy format, for example when a client is encountering difficulties in a particular transitional stage in his or her life, and as a framework for long-term treatment when clients experience chronic failure in achieving agentic or communal goals, persistently experience connected psychological and emotional pain, and/or their lives are marked by persistent self-perpetuating maladaptive processes. Building and maintaining a strong therapeutic alliance is essential to the therapy process, providing a secure base for a collaborative treatment process that from the outset highlights how the client’s pain indicates a blockage or failure to achieve agentic or communal goals; when indicated, I also tailor the therapeutic relationship (e.g., through ways in which I respond and interact) with the intent of providing the client with a corrective interpersonal-emotional experience in the midst of the therapeutic work in which we are engaged. The client and I solidify his or her desired agentic and/or communal goals, and we identify and develop insight regarding maladaptive regulatory processes vis-à-vis self and/or others the client is using to cope with life disturbances and connected negative symptoms. We also distinguish and pursue insight into strengths and healthier processes the client may at times enact, however infrequently, relative to the problem situation(s) and/or in non-problematic circumstances but which can be brought to bear in the contexts of difficulty. As insight is gained into these maladaptive and adaptive behaviors, we work to help the client become “unstuck” through specific insight- and action-oriented techniques tailored to decrease maladaptive behaviors and increase healthy regulatory processes, all of this ultimately in the service of helping the client to proactively develop effective achievement of agentic and/or communal goals so that he or she can experience purpose, meaning, and more frequent positive affective states in his or her life.
Concluding Remarks
This brief, formal theoretical encapsulation cannot adequately represent the “look,” nor can it capture the intersubjective experience, of the real-time process of implementing concepts, propositions, strategies, and techniques presented above. As stated elsewhere, “like a well-played piece of music of virtually any genre, effective psychotherapy is also very much a creative process in its praxis (e.g., Zinker, 1977), invariably infused with improvisational adjustments called forth by moment-to-moment developments. The written notes are vital, but so, too, is a ‘feel’ for the music” (Anchin, 2003, pp. 350-351). With these idiographic caveats in mind, the conceptual framework, formulations, and treatment strategies outlined above may potentially serve as a useful map in helping clients initiate or reengage significant agentic and communal motivations and desires that, in their effective pursuit and achievement, can help their lives to be a truly more satisfying and meaningful place to be—a difference that makes all the difference in the world.
REFERENCES
American Psychological Association Presidential Task Force on Evidence-Based Practice (2006). Evidence-based practice in psychology. American Psychologist, 61, 271-285.
Anchin, J.C. (1982a). Interpersonal approaches to psychotherapy: Summary and conclusions. In J.C. Anchin & D.J. Kiesler (Eds.), Handbook of interpersonal psychotherapy (pp. 313-329). New York: Pergamon Press.
Anchin, J.C. (1982b). Sequence, pattern, and style: Integration and treatment implications of some interpersonal concepts. In J.C. Anchin & D.J. Kiesler (Eds.), Handbook of interpersonal psychotherapy (pp. 95-131). New York: Pergamon Press.
Anchin, J. C. (2003). Cybernetic systems, existential phenomenology, and solution-focused narrative: Therapeutic transformation of negative affective states through integratively oriented brief psychotherapy. Journal of Psychotherapy Integration, 13, 334 – 442.
Anchin, J.C. (2005, May). Using a nonlinear dynamical biopsychosocial systems paradigm to individually tailor the process of psychotherapy. Paper presented in J.J. Magnavita and J.C. Anchin (Co-chairs), Unified psychotherapy: Implications for differential treatment strategies and interventions. Symposium presented at the 21st Annual Conference of the Society for the Exploration of Psychotherapy Integration, Toronto, Ontario, Canada.
Anchin, J.C. (2008a). Contextualizing discourse on a philosophy of science for psychotherapy integration. Journal of Psychotherapy Integration, 18, 1-24.
Anchin, J. C. (2008b). Pursuing a unifying paradigm for psychotherapy: Tasks, dialectical considerations, and biopsychosocial systems metatheory. Journal of Psychotherapy Integration, 18, 310 – 349.
Anchin, J.C. (in press). Unifying nonlinear dynamical biopsychosocial systems approach. In E. Neukrug (Ed.), Encyclopedia of theory in counseling and psychotherapy. Thousand Oaks, CA: Sage.
Anchin, J.C., & Kiesler, D.J. (Eds.). (1982). Handbook of interpersonal psychotherapy. New York: Pergamon Press.
Anchin, J.C., & Magnavita, J.J. (Eds.). (2008). Special issue: Toward the unification of psychotherapy: A journal symposium. Journal of Psychotherapy Integration, 18, 259-376.
Anchin, J.C., & Pincus, A.L. (2010). Evidence-based interpersonal psychotherapy with personality disorders: Theory, components, and strategies. In J. J. Magnavita (Ed.), Evidence-based treatment of personality dysfunction: Principles, methods, and processes (pp. 113-166). Washington, DC: American Psychological Association.
Anchin, J.C., & Singer, J.A. (in press). A dual process perspective on the value of theory in psychotherapeutic decision-making. In J.J. Magnavita (Ed.), Clinical decision making in behavioral and mental health practice. Washington, DC: American Psychological Association.
Bertolino, B., Kiener, M., & Patteson, R. (2009). The therapist’s notebook on strengths and solution-based therapies. New York: Routledge.
Cacioppo, J.T., & Decety, J. (2011). Social neuroscience: Challenges and opportunities in the study of complex behavior. Annals of the New York Academy of Sciences, 1224, 162-173.
Engel, G. ( 1977 ). The need of a new model: A challenge for biomedicine. Science, 196, 129-136.
Engel, G. ( 1980 ). The clinical application of the biopsychosocial model. American Journal of Psychiatry, 137, 535-544.
Engel, G.L. (1987). Introduction: How much longer must medicine’s science be bound by a seventeenth century world view? In G.A. Fava & H. Freyberger (Eds.), Handbook of psychosomatic medicine (pp. 1-21). Madison, CT: International Universities Press.
Engel, G. L. ( 1997 ). From biomedical to biopsychosocial: Being scientific in the human domain. Psychosomatics , 38 , 521-528.
Grawe, K. (2007). Neuropsychotherapy: How the neurosciences inform effective psychotherapy. New York: Psychology Press
Krippner, S., Ruttenber, A. J., Engelman, S. R., & Granger, D. L. (1985). Toward the application of general systems theory in humanistic psychology. Systems Research, 2, 105–115.
Lopez, S.R., & Snyder, C.R. (Eds.). (2009). The Oxford handbook of positive psychology (2nd ed.). New York: Oxford University Press.
Luyten, P., & Blatt, S. J. (2013). Interpersonal relatedness and self-definition in normal and disrupted personality development: Retrospect and prospect. American Psychologist, 68, 172-183.
Kiesler, D. J. (1996). Contemporary interpersonal theory and research: Personality, psychopathology, and psychotherapy. New York: John Wiley & Sons.
Kiesler, D. J. (1999). Beyond the disease model of mental disorders. Westport, CT : Praeger .
Lieberman, M. D. (2007). Social cognitive neuroscience: A review of core processes. Annual Review of Psychology, 58, 259–289.
Magnavita, J.J., & Anchin, J.C. (2014). Unifying psychotherapy: Principles, methods, and evidence from clinical science. New York, NY: Springer Publishing.
Marquis, A. (2009). An integral taxonomy of therapeutic interventions. Journal of Integral Theory and Practice, 4, 13-42.
Murray, S.L, & Holmes, J.G. (2008). Interdependent minds: The dynamics of close relationships. New York: Guilford.
Palkovitz, R. (2002). Involved fathering and men’s adult development: Provisional balances. New York: Psychology Press.
Pincus, A.L. (2010). Introduction to the special series on integrating personality, psychopathology, and psychotherapy using interpersonal assessment. Journal of Personality Assessment, 92, 467-470
Pincus, A. L., & Ansell, E. B. (2003). Interpersonal theory of personality. In T. Millon & M. J. Lerner (Eds.), Handbook of psychology: Personality and social psychology (Vol. 5, pp. 209–229). New York: John Wiley & Sons.
Pincus, A. L., & Cain, N. M. (2008). Interpersonal psychotherapy. In D. C. S. Richard & S. K. Huprich (Eds.), Clinical psychology: Assessment, treatment, and research (pp. 213–245). San Diego, CA: Academic.
Pincus, A. L., Lukowitsky,M. R., & Wright, A. G. C. (2010). The interpersonal nexus of personality and psychopathology. In T. Millon, R. F. Krueger, & E. Simonsen (Eds.), Contemporary directions in psychopathology: Scientific foundations for the DSM-V and ICD-11 (pp. 523–552). New York: Guilford.
Reis, H. T. ( 2007 ). Steps toward the ripening of relationship science . Personal Relationships, 14, 1-23.
Schore, A. N. (2012). The science of the art of psychotherapy. New York, NY: W.W. Norton.
Schore, A.N. (2014). Introduction. In J.J. Magnavita & J.C. Anchin, Unifying psychotherapy: Principles, methods, and evidence from clinical science (pp. xxi-xlix). New York: Springer Publishing.
von Bertalanffy, L. ( 1968 ). General system theory: Foundations, development, applications. New York : Brazziler.
[1] Portions of this material are adapted from Anchin (in press).
Some 30 years ago, in my summary and conclusions chapter for the Handbook of Interpersonal Psychotherapy (Anchin & Kiesler, 1982), I extracted four convergent themes characterizing that era’s emerging interpersonal theory, research, and practice: development and expansion of Sullivanian theory; adoption of an ecological/reciprocal deterministic emphasis; circumplex models of interpersonal behavior; and procedural variability among interpersonal theorists (cf. Pincus & Cain, 2008, pp. 222-223). Against the backdrop of explicating these themes, I concluded “These and other developments examined throughout this volume clearly demonstrate that the interpersonal paradigm is steadily maturing, and that more concerted attention to its evolving constructs, methodologies, and treatment procedures can considerably enrich the science and practice of psychotherapy” (Anchin, 1982a, p. 324). If, as Gordon Allport proclaimed, differentiation and integration are hallmarks of the maturational process (cited by Palkovitz, 2002), then the luminous ripening of the interpersonal paradigm is a beautiful sight to behold! Over the years that have elapsed since the words cited above were written, we see in Horowitz and Strack’s (2011) scholarly Handbook of Interpersonal Psychology the paradigm’s flowering in the form of expanded yet more fine-grained conceptualizations of interpersonal constructs, processes, and mechanisms pertaining to personality and psychopathology; growth in the paradigm’s assessment and measurement network associated with, but far from limited to, circumplex methods (cf. Pincus, 2010); heightened sophistication of research and statistical methodologies for investigating covert and overt interpersonal phenomena; steady empirical solidification of the evidence base supporting interpersonal constructs and interventions; and applications of interpersonal understandings and interventions to a broadening array of human problems in living of both a psychological and medical nature. Moreover, through the dialectical interplay between differentiation and integration, these various domains of interpersonal knowledge feed one another, and they are further enriched through syntheses with such fields as personality psychology (e.g., Kiesler, 1996; Pincus & Ansell, 2003), social psychology (e.g., Murray& Holmes, 2011; Reis, 2007), and neuroscience (e.g., Lieberman, 2007; Luyten & Blatt, 2013). Indeed, the remarkable breadth and depth of integration with constructs and findings from both basic and clinical psychological science and from disciplines outside of psychology (Magnavita & Anchin, 2014) afforded by an interpersonal perspective remains one of this paradigm’s most robust and compelling strengths (Anchin, 1982b; Pincus, 2010).
In my personal evolution as a clinical psychologist, the fertile integrative potentialities inherent in the interpersonal approach to psychotherapy catalyzed a passion for psychotherapy integration, which over time has extended into deepening interest in exploring the unification of therapeutic approaches (Anchin, 2008b; Anchin & Magnavita, 2008; Magnavita & Anchin, 2014). In this article, I sketch out in necessarily broad strokes one such unifying framework for therapeutic theory and practice that I characterize as a unifying nonlinear dynamical biopsychosocial systems (NDBPSS) approach (Anchin, 2005, in press). This approach emphasizes a holistic perspective on understanding human functioning and experience by encompassing the major domain systems that interdependently constitute and influence life-span development, personality, psychological health, and psychopathology. As elaborated momentarily, the approach merges multiple influences to promote highly individualized treatment of a wide spectrum of disordered biopsychosocial states—but as I believe will also become apparent, this approach belies the fundamental interpersonalism ineffably imprinted in my DNA.
Confluent Streams of Influence
NDBPSS is rooted in several theoretical models, each with their own historical context. The overarching foundational model is systems theory, which first achieved prominence in the mid-20th century when von Bertalanffy (1968) articulated his general systems theory, applied chiefly to biology, in an effort to explain universal principles by which complex systems operate. Often characterized as metatheory by virtue of its application across theories and disciplines, systems theory has since fostered development of various approaches to systemic thinking that includes cybernetics, chaos theory, nonlinear dynamical theory, and complex adaptive systems. These various approaches have been effectively applied throughout the physical, life, and social sciences. The assumption of holism is fundamental to systemic thinking, and holds that a complex system is composed of a variety of heterogeneous elements or parts (e.g., subsystems) that, through self-organizing interdependencies, are bound together and function as a totality or unified whole in the pursuit of the totality’s aims. The concept of teleology is integrally related, maintaining that all complex living systems actively strive toward achieving goals, attaining desired states, and realizing valued ends, reflecting purposefulness and intentionality on the part of the living system of interest (see Anchin, 2003). The dynamical dimension of systems thinking refers to the concept that complex living organisms change over time due to interactions among the organism’s multiple subsystems, while the concept of nonlinearity permits a detailed picture of these interactions by emphasizing subsystems’ reciprocal effects, feedback loops, networks, and cycles.
Engel (1977; 1980; 1997) drew explicitly on systems theory in developing the biopsychosocial model in the 1970s as a comprehensive alternative to the standard medical model for treating individuals with mental and physical health problems. Through this model, Engel provided a holistic, unified conception of the human being’s complexity through defining the multiple, hierarchically organized domains and subsystems that interdependently comprise an individual. These domains include the biological domain (genetic, anatomical, physiological, and biochemical subsystems); the psychological domain (cognitive, affective, motivational, and defense subsystems); and the sociocultural domain (speech, the behavioral subsystem, and an individual’s sociocultural environment comprising interpenetrating layers such as dyadic, family, community, religious, cultural, and political subsystems). The biopsychosocial model also incorporates the phenomenological domain (cf. Engel, 1998; Krippner, Ruttenber, Engelman, & Granger, 1985), underscoring that human biopsychosociality is a lived experience infused with purpose, values, and meaning.
While biopsychosocial systems metatheory serves as the metaphorical chassis for the NDBPSS approach, the interpersonal paradigm drives and gives direction to the treatment. As well known to the reader, the latter is rooted in Harry Stack Sullivan’s interpersonal theory of psychiatry and stresses the importance of covert and overt processes within and between two realms of human being and becoming—agency and communion—that are ineluctably fused with human development, personality, mental health, psychopathology, and psychotherapy. I use the metaconcept (Pincus, Lukowitsky, & Wright, 2010) of agency to denote one’s striving to develop a positively experienced individual self that is coherent, differentiated and integrated, and effective, and the metaconcept of communion to represent strivings to develop and maintain satisfying relationships with others, including experiences of connectedness, intimacy, and solidarity (cf. Anchin & Pincus, 2010; Magnavita & Anchin, 2014, chpt.3; Luyten & Blatt, 2013; Pincus et al., 2010). Arguably, agency and communion are the yin and yang of human existence across the entire life span. While many factors render the lived experience of these metaconcepts unique for each individual, agency and communion are the two aspects of human life that provide purpose for all humans.
The NDBPSS approach has also been strongly influenced by psychotherapy integration, which, evolving from its nascent beginnings in the 1930s, emerged in the 1980s as a fully developed movement, exerting profound impact on the field. Psychotherapy integration identifies and incorporates into the treatment process key common therapeutic factors operating across approaches and integrates the principles, concepts, and techniques from various single-school theories to create effective, comprehensive, and versatile approaches to psychotherapy. The integration movement has provided key ontological and epistemological foundations for NDBPSS by promoting plurality in psychotherapeutic theory, research methodology, and practice (Anchin, 2008a, 2008b).
NDBPSS psychotherapy is also built upon psychological approaches that incorporate a holistic understanding of the interrelationships of human structures, processes, and functioning, rather than on the reductive views of health prevalent in the traditional medical model. An exemplar of this holistic sensibility may be found in clinical science in Schore’s (2012; 2014) interdisciplinary work linking findings from neuroscience, human development, interpersonal attachment, affect regulation, and the self, while Cacioppo and colleagues’ (see, e.g., Cacioppo & Decety, 2011) approach to understanding complex behavior and the mind through investigating interconnections among the biological, cognitive, and social domains provides a basic science illustration. Additionally, NDBPSS incorporates the importance placed by the evidence-based practice of psychology (American Psychological Association, 2006) on flexibly tailoring treatment to the specific client at hand, and integrates from the rich perspectives of solution focused-strength-based psychotherapy (see, e.g., Bertolino, Kiener, & Patterson, 2009) and its kinsman positive psychology (Lopez & Snyder, 2009) explicit inclusion of the client’s biological, psychological, and/or sociocultural strengths and resources (assets, skills, and zones of health) as integral components of this tailoring process.
Theoretical Propositions
Although human beings are motivated to strive for a broad range of goals and desired states, my approach to treatment is rooted in the proposition that throughout the human life cycle, a person’s most essential motivations are those focused on the goals of agency and communion. Successfully attaining agentic and communal goals necessitates capacities for self-regulation and regulation of one’s social environment. Regulatory processes include gauging one’s current status relative to a desired agentic or communal state, communicating to the self information about discrepancies that may exist between the current and desired state, and instituting corrective actions to the extent that deviations are occurring. In the human biopsychosocial system, feedback operates as one of these principal regulatory mechanisms, with affective states serving as a primary source of feedback—barometers, as it were—about the extent of success in attaining one’s aims. Positive affective states (e.g., pleasure; happiness; relaxation; well-being) indicate effective navigation toward or attainment of a desired agentic and/or communal state, and connote that one is engaging in effective regulatory processes.
Over the life course, however, strong internal or external disruptions in biological, psychological, and/or social processes invariably lead to disturbances in a person’s biopsychosocial stability. If an individual does not adequately regulate such disturbances and their related destabilizing effects on his or her life, then the individual may become derailed from or stop effective pursuit of his or her agentic and communal goals and develop negative affective states, such as sadness, shame, anger, or anxiety. A continuation of or increase in regulatory difficulties can maintain or amplify the disturbances in a person’s biopsychosocial system, further diminish his or her capacity to effectively pursue life goals, and in turn lead to increased distress and other problematic symptoms. In accord with this conceptualization, my aim is often to help the client initiate or resume effective movement toward agentic and communal goals, which infuse her or her life with greater meaning, purpose, and positive affectivity. Improvement is achieved when the client becomes “unstuck” from maladaptive processes for regulating the self and/or the social environment, ameliorates negative affective states and symptoms, develops healthier covert and overt regulatory processes, and is solidly back on track in pursuing self-related and interpersonal aims, goals, and desired states.
Strategies and Techniques
The conceptualization described above gives rise to a high degree of technical eclecticism in facilitating initiation or resumption of movement towards personally meaningful agentic and communal goals. Depicted in the broadest of terms, techniques include blending insight- and action-oriented approaches tailored to overcome biopsychosocial disruptions in and obstacles to clients’ goal pursuits and to facilitate proactive forward movement. Integrally related, I attempt to foster effective interplay between negative and positive regulatory feedback loops, and I look for opportunities to “work the loop.”
Technical Eclecticism
In implementing the NDBPSS approach, I draw upon strategies and techniques from many major paradigms of therapy (e.g., interpersonal, psychoanalytic-psychodynamic, cognitive-behavioral, humanistic-experiential, biomedical, systemic, multicultural, hermeneutic-constructivist, and solution focused-strength based; cf. Marquis, 2009). This multiparadigmatic treatment methodology reflects the view that, when all is said and done, techniques are potentially potent, systematic ways of bringing about therapeutic effects. To promote growth and change, uncoupling techniques from their specific theoretical models (see Grawe, 2007) facilitates my clinical judgments and choices (see Anchin & Singer, in press) with regard to techniques that may be most effective for clinically intervening in a particular biopsychosocial domain and subsystem of the client within the flow of a given session.
Insight and Action
Insight-oriented techniques (e.g., interpretation, metacommunication, use of metaphor, two-chair technique, affective focusing) help clients to sharpen their self-awareness and facilitate their understanding of desired, elusive, or disrupted agentic or communal goals. Techniques designed to foster clients’ insight also assist them to identify and understand specific biopsychosocial obstacles (such as faulty core beliefs about self, health problems, psychological defenses, or maladapative interpersonal patterns) impeding attainment of desired goals. In addition, techniques that advance insight help clients to recognize healthy self-regulatory processes (e.g., sleep hygiene, constructive self-talk, managing affective states, anticipating consequences of actions, proactive coping) that facilitate their effective pursuit of agentic and communal goals. Action-oriented techniques explicitly promote enactment of healthier self-regulatory processes. Covert action-oriented techniques are exemplified by cognitive restructuring of distorted thinking and maladaptive beliefs, teaching mindfulness and distress tolerance skills, facilitating use of beneficial imagery, and fostering healthy self-relational processes (e.g., cognitive-affective self-reactions). Illustrations of overt action-oriented techniques include following medication regimens, clients taking action to change their environments, putting their values and strengths into action, or engaging in spiritual or religious practices they find to be beneficial. Insight- and action-oriented techniques are used in complementary ways to advance clients’ therapeutic progress.
Developing Negative and Positive Regulatory Feedback Loops
Effective self-regulatory processes involve the interplay between negative and positive feedback loops; the former dampen (i.e., reduce or diminish) interconnected biopsychosocial subsystem processes that inhibit or otherwise derail movement toward a desired agentic or communal goal, while the latter amplify (i.e., augment or intensify) interrelated multisubsystem processes that foster effective goal-directed movement. Techniques are differentiable in terms of whether their principal aim is to dampen particular maladaptive processes (e.g., in vivo exposure to reduce social anxiety) or to amplify healthy processes (e.g., an experiential technique to help the client contact and more deeply experience the personal strength of courage). In fostering effective pursuit of agentic and communal goals, I shuttle between techniques for facilitating development of negative feedback loops that reduce unhealthy processes, and techniques for promoting positive feedback loops in order to increase healthy processes.
Working the Loop
Working the loop refers to tapping into constructive change occurring in one subsystem for the purpose of actively promoting change in other subsystems in the same domain and/or in other domain subsystems. For example, the therapist and client examine how he or she can actively harness a given change (e.g., feeling empowered by undertaking effective metacommunication with a work colleague with whom he or she has experienced conflict) in ways that can positively impact other biopsychosocial processes (e.g., improving beliefs about one’s self-efficacy; undertaking an avoided task necessary to achieving a specific agentic goal; or attempting more self-disclosing communication in appropriate contexts). The client is also encouraged to examine within sessions and to observe between sessions how a particular change (e.g., diminishing anxiousness and increasing calmness) may be affecting processes in one or more other subsystems (e.g., physiological state; capacity to make decisions; motivation level; effectiveness of actions; interpersonal behavior). In turn, these specific constructive changes identified as occurring in other biological, psychological, and/or social subsystems are highlighted and, depending on treatment goals and progress, may themselves become targets of amplifying techniques.
Treatment Process
I utilize the approach described above both in a brief therapy format, for example when a client is encountering difficulties in a particular transitional stage in his or her life, and as a framework for long-term treatment when clients experience chronic failure in achieving agentic or communal goals, persistently experience connected psychological and emotional pain, and/or their lives are marked by persistent self-perpetuating maladaptive processes. Building and maintaining a strong therapeutic alliance is essential to the therapy process, providing a secure base for a collaborative treatment process that from the outset highlights how the client’s pain indicates a blockage or failure to achieve agentic or communal goals; when indicated, I also tailor the therapeutic relationship (e.g., through ways in which I respond and interact) with the intent of providing the client with a corrective interpersonal-emotional experience in the midst of the therapeutic work in which we are engaged. The client and I solidify his or her desired agentic and/or communal goals, and we identify and develop insight regarding maladaptive regulatory processes vis-à-vis self and/or others the client is using to cope with life disturbances and connected negative symptoms. We also distinguish and pursue insight into strengths and healthier processes the client may at times enact, however infrequently, relative to the problem situation(s) and/or in non-problematic circumstances but which can be brought to bear in the contexts of difficulty. As insight is gained into these maladaptive and adaptive behaviors, we work to help the client become “unstuck” through specific insight- and action-oriented techniques tailored to decrease maladaptive behaviors and increase healthy regulatory processes, all of this ultimately in the service of helping the client to proactively develop effective achievement of agentic and/or communal goals so that he or she can experience purpose, meaning, and more frequent positive affective states in his or her life.
Concluding Remarks
This brief, formal theoretical encapsulation cannot adequately represent the “look,” nor can it capture the intersubjective experience, of the real-time process of implementing concepts, propositions, strategies, and techniques presented above. As stated elsewhere, “like a well-played piece of music of virtually any genre, effective psychotherapy is also very much a creative process in its praxis (e.g., Zinker, 1977), invariably infused with improvisational adjustments called forth by moment-to-moment developments. The written notes are vital, but so, too, is a ‘feel’ for the music” (Anchin, 2003, pp. 350-351). With these idiographic caveats in mind, the conceptual framework, formulations, and treatment strategies outlined above may potentially serve as a useful map in helping clients initiate or reengage significant agentic and communal motivations and desires that, in their effective pursuit and achievement, can help their lives to be a truly more satisfying and meaningful place to be—a difference that makes all the difference in the world.
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[1] Portions of this material are adapted from Anchin (in press).