International Journal of Integrative Psychotherapy, Vol. 8, 2017 
 

40 

 

Nested Hierarchy for Therapy Integration:  

Integrating the Integrative 

 

Valery Krupnik 

 

 

 

 

Abstract: 

 

Several well-established psychotherapies have seen a proliferation of their 

derivatives. Among notable examples are truncated forms of psychoanalysis, 

such as psychoanalytic psychotherapy and brief psychodynamic therapy; a 

variety of cognitive behavioral therapies (CBT) including CBT-I (CBT for 

insomnia), CBT-D (CBT for depression), and CPT (a trauma-focused CBT). 

Despite its relatively young age EMDR has also produced multiple modifications 

like ego states EMDR, EMDR for addiction, and EMDR for somatic conditions. 

The majority of modifications are developed by integrating new interventions with 

the original protocols. However, there is no commonly accepted ad hoc 

methodology or standard for such integration. This article suggests a “nested 

hierarchy” as a methodology for psychotherapy integration, exploring its 

ramifications for practice and research. 

 

Keywords: nested hierarchy, psychotherapy integration, EMDR, TDD, evolution. 

                             _____________________ 

 

Integrative therapies have become a mainstay in contemporary practice 

(Norcross, Karpiak, & Lister, 2005),  indicating the presence of significant factors 

driving psychotherapy integration. Some of them are extrinsic, such as market 

forces of competition between different therapies, whereby integration is another 

way of creating a new marketable product. Other factors are intrinsic and follow 

the natural trends in psychotherapy evolution (Norcross, 2005). The latter include 

the search to increase the efficacy of existing therapies, as well as their 

applicability to wider and more diverse client populations and therapeutic 

settings. Whether therapy integration often or ever results in increased efficacy is 

an open question that, to our knowledge, no study has conclusively answered.  



  
 

International Journal of Integrative Psychotherapy, Vol. 8, 2017 
 

41 

However, doubts have been raised (Schottenbauer, Glass, & Arnkoff, 2005). That 

may not be surprising considering that therapy integration comes with both 

presumed advantages and real challenges. Integrative treatment combines more 

therapeutic tools, potentially leading to a greater versatility, but that comes with 

the challenge of modifying the original therapies that have been refined in 

practice and may have developed to their maximal potential. Therefore, in 

designing an integrative therapy it is imperative to understand the reason for 

such undertaking and to choose the right strategy for the integration.  To date, 

however, there is no commonly accepted methodology for psychotherapy 

integration, leaving it mostly to personal preference and experimentation. 

 

There are four commonly identified strategies for psychotherapy 

integration: technical eclecticism, common factors integration, principle-based 

assimilative integration, and theoretical integration (Norcross, 2005). In short, 

technical eclecticism refers to a systematic combining of techniques from 

different therapies without concern for the therapies’ theoretical compatibility. 

Common factors integration builds a treatment based on a theory of universal 

principles of change common to different brands of therapy. For example, an 

empathic disposition and collaborative approach are common to most therapies 

and have significant effects on outcomes (Laska, Gurman, & Wampold, 2014). A 

system of interventions built around such common factors is then expected to 

result in an effective therapy beyond the list of original existing brands. Principle-

based assimilative integration proceeds from a certain theoretical orientation, 

assimilating techniques from other therapies in line with that theoretical frame. 

Theoretical integration refers to integration of different theoretical traditions into a 

unified theory of psychotherapy. There have also been proposals for trans-

theoretical integration meant to transcend individual integrative models. For 

example, systematic treatment selection approach (Beutler & Clarkin, 2014) 

proposes to construct a treatment by matching interventions to the contextual 

parameters of a therapeutic encounter based on empirical evidence for the 

effectiveness of such match. Those parameters include characteristics of the 

patient, the therapeutic relationship, and the process of change. In 

multitheoretical therapy, Brooks-Harris (2008) suggests approaching therapy 

integration from multiple theoretical levels including psychobiological, 

experiential, behavioral, cognitive, psychodynamic, systemic, and multicultural. 

Integration of these levels in application to a particular therapeutic encounter 

helps identify the most salient targets for intervention and instructs the therapist’s 

choice of interventions. In yet another multi-theoretical integrative model, the 

primary focus is on integrating the client’s self through a therapeutic process that 

also relies on a multi-level theoretical understanding of the client. Such 



  
 

International Journal of Integrative Psychotherapy, Vol. 8, 2017 
 

42 

understanding instructs the development of a therapeutic relationship to facilitate 

that integration (Erskine & Moursund, 2011; Erskine & Trautmann, 1996). 

 

Regardless of the strategy, therapy integration is rife with contradictions. A 

new integrative treatment combines interventions from already internally 

consistent therapeutic systems. These interventions are bound to impose mutual 

constraints that may differ from the ones placed on them in their original 

therapies. For example, in eye movement desensitization and reprocessing 

therapy (EMDR),  elements of mindfulness are embedded within reprocessing of 

target memories in Phases 3-6 (Shapiro, 2001), which represents a truncated 

form of the traditional practice of mindfulness (Kabat-Zinn, 1990). Likewise, the 

use of in vitro exposure to traumatic experience in cognitive processing therapy 

(Resick & Schnicke, 1993) is used in a more limited way compared to prolonged 

exposure therapy (Foa & Rothbaum, 2001). This suggests an approach to 

therapy integration, namely nested hierarchy (NH), designed to resolve such 

contradictions, referred to herein to as ‘dialectics,’ and thus capture their potential 

for resolution. The NH strategy encompasses all theoretical approaches, from 

theories of psychopathology to intervention techniques. This approach also 

considers that all therapies are integrative to a certain degree, which explains the 

subheading “integrating the integrative.” NH seeks to bind the interventions used 

in a therapy in a hierarchical nest, guided and constrained by the theories 

supporting those interventions. The most general theory sits at the top of the 

hierarchy, with subordinate theories becoming more specific as one moves down 

the hierarchy (Figure 1). 

 

 



  
 

International Journal of Integrative Psychotherapy, Vol. 8, 2017 
 

43 

 

 

 

Level 1 – Goal 

 

 

Level 2 – Objective/Theory 

of psychopathology (T)  

 

 

Level 3 – Mechanism (M)  

 

 

Level 4 – Intervention (I) 

 

 

Figure 1:  Nested hierarchy of psychotherapy interventions 

Key =  T – theory of psychopathology  

M – mechanism of change 

I – intervention 

 

Downward arrows indicate the hierarchy of causation; upward arrows indicate feedback validation. 

Dark triangles indicate the inverse relationships of universality vs specificity and flexibility vs. treatment 

fidelity relative to the place in the hierarchy. 

CHANGE or MAINTENANCE UNIVERSALITY 

  SPECIFICITY 

 FIDELITY 

FLEXIBILITY 

T2 

 

T1 

 

M1

11 

 

M2

11 

 

M3

11 

 

 I1 

 

 I2 

 

 I3 

 

 I4 

 

 I5 

 



  
 

International Journal of Integrative Psychotherapy, Vol. 8, 2017 
 

44 

This approach postulates that NH (a) accommodates and reconciles other 

approaches to therapy integration, (b) provides a framework for creating new 

integrative treatments, and (c) allows for an integration process specific to a 

given therapeutic encounter. In addition, an approach to psychotherapy research 

will be described that follows from NH principles, and present a clinical case that 

illustrates NH integration in practice. EMDR has been chosen to illustrate the 

application of nested hierarchy. While acknowledging the arbitrariness of such 

choice, since many other therapies might serve just as well, EMDR provides an 

excellent example of the NH approach for the purposes of this article.  

 

 From its inception, EMDR was created as an integrative treatment initially 

developed for trauma-related disorders (Shapiro, 1989).  Within a relatively short 

time EMDR has seen an explosion of modifications and derivative therapies. To 

name a few, ego state EMDR integrates ego states therapy rooted in 

psychodynamic and attachment theories into EMDR (Forgash & Knipe, 2008; 

Paulsen, 2008). Spiritual/mindful resonance EMDR integrates traditional spiritual 

healing with EMDR (Siegel, 2013). DeTUR is an eclectic model combining EMDR 

interventions with cognitive-behavioral, solution-focused, emotion freedom, and 

hypnosis techniques, among others (Popky, 2005). TDD (treating depression 

downhill)-EMDR integrates EMDR interventions into an evolutionary-based 

therapy for depression (Krupnik, 2015a, b). 

 

 

‘Horizontal’ Dialectics 

The notion of ‘horizontal’ dialectics refers to conflicting constraints that 

arise at the level of methodology and concern the question of how interventions 

are chosen and applied. We distinguish them from ‘vertical’ dialectics, which refer 

to conflicting constraints arising between theoretical levels (Figure 1) and concern 

the question of what interventions are chosen. 

 

Fidelity vs. Flexibility 

Treatment fidelity has been emphasized as a necessity for clinical 

research and as an important contributor to therapy’s effectiveness, as reviewed 

by Prowse & Nagel ( 2015). For treatment fidelity in EMDR in particular, see 

Maxfield, & Hyer (2002). Fidelity is commonly understood as implementation of 

an intervention according to the established protocol. However, once an 

intervention is adopted into a different context, the rules are, by necessity, bent to 

accommodate the new context.  In EMDR, for example, cognitive restructuring is 

practiced very differently from cognitive behavioral therapy (CBT). While the 



  
 

International Journal of Integrative Psychotherapy, Vol. 8, 2017 
 

45 

general impetus for changing beliefs about self toward more adaptive and reality-

based ones is shared with CBT, the way cognitive restructuring is understood 

and implemented in EMDR is different (Shapiro, 2001). Cognitive intervention in 

EMDR then becomes a standard to follow within EMDR. A derivative therapy, 

TDD-EMDR (Krupnik, 2015a), in turn, uses an acceptance-focused cognitive 

intervention, which is different from EMDR proper. 

 

It has been shown that therapists routinely deviate from the established 

prototype of their brand of therapy, ‘borrowing’ elements from cognate 

treatments, and that the shared elements can be most predictive of therapeutic 

outcome, as reviewed by Ablon & Jones, (2002). It is possible that finding the 

right balance between following the prototype and therapeutic flexibility may help 

maximize the therapy’s effectiveness. However, how to strike such balance 

remains a matter of further research. In addition, the therapeutic relationship and, 

by extension, the therapist’s personality may also interact with the brand of 

therapy practiced. Such interactions may also determine the optimal degree of 

following/deviating from the prototype. Consequently, studying a sample of 

psychoanalyses, Ablon and Jones (2005) demonstrated that they are better 

described as dyad-unique processes of change than a standard procedure of 

psychoanalysis. 

 

Specificity vs. Universality 

In psychotherapy, this dialectic has historically been skewed toward 

universality. Initially, psycho-social interventions were not designed for specific 

disorders but rather targeted symptoms or psychological problems. For example, 

psychoanalysis was originally designed to treat neuroses (Freud, 1966), while 

behavioral therapies targeted maladaptive information processing and resulting 

behaviors (Franks & Wilson, 1974). Mental disorders, however, are commonly 

classified as symptom constellations (Diagnostic and Statistical Manual of Mental 

Disorder, 5th ed.; DSM-5; American Psychiatric Association, 2013). Hence, by 

design psychotherapies were not specific to mental disorders. Moreover, the 

general trend among contemporary therapies has been toward universality rather 

than specificity. CBT, for example, was initially developed for depressive 

disorders but has since been used for a number of mental and psycho-somatic 

conditions. Its low specificity (and high universality) has been highlighted in 

several reviews (Butler, Chapman, Forman, & Beck, 2006; Haby, Donnelly, 

Corry, & Vos, 2006; Hollon, Thase, & Markowitz, 2002; Parker & Fletcher, 2007; 

Shedler, 2010). Likewise, EMDR was initially developed for trauma-related 

disorders (Shapiro, 1989, 2001), but has been extended to a variety of afflictions 

including affective, personality, addiction, eating disorders, and migraines 



  
 

International Journal of Integrative Psychotherapy, Vol. 8, 2017 
 

46 

(Marcus, 2008; Miller, 2010; Mosquera, Leeds, & Gonzalez, 2014; Shapiro, 

2009). More recently, a trans-diagnostic integrative therapy has been developed 

to target all categories of affective and mood disorders, which they approach not 

from the categorical but dimensional point of view as a “unified negative affect 

syndrome” (Barlow, Allen, & Choate, 2004). 

 

Universality of a tool may become a liability against its effectiveness. Lack 

of disorder-treatment specificity has been suggested as one of the factors limiting 

the success in treating depression, and a new “choose horses for courses” 

paradigm has been advocated (Parker & Fletcher, 2007; Parker, Roy, & Eyers, 

2003; Parker, Malhi, Crawford, & Thase, 2005). The authors suggest choosing an 

approach specific to the nature of a depressive disorder, differentiating between 

psychotic, melancholic, secondary depression, and dysthymia. In an attempt to 

increase treatment-condition specificity, a new self-system therapy for depression 

varies its approaches depending on the patient’s level of anxiety symptoms 

(Strauman et al., 2013). Similarly, EMDR has been deemed a trauma-focused, 

evidence-based therapy (Bisson, Roberts, Andrew, Cooper, & Lewis, 2013). 

However, its status regarding other than trauma conditions, depression in 

particular, is yet to be established. 

  
Process-oriented exploration of specificity in therapy comes mostly from 

the psychoanalytic tradition, where it is believed that specificity of the dyadic 

relationship, that is, the right match between closely timed subjective experiences 

of analyst and the patient, may serve as a mechanism of therapeutic change. 

This notion is reflected in the theory of intersubjectivity (Stern, 2005; Stolorow & 

Atwood, 1992), in the integration of infant development research into 

psychotherapy (Beebe & Lachmann, 2002), and in the theory of implicit relational 

process (Group, 2010; Tronick, 1998). Relational specificity of the therapeutic 

process has been recognized as the most essential determinant of its 

effectiveness (Bacal & Carlton, 2011). Still, the science of specificity in 

psychotherapy is considered to be in its infancy (Beutler, 2011; Norcross & 

Wampold, 2011). 

 

 

Vertical Dialectics 

The emergence of the four main models of therapy integration: technical 

eclecticism, common factors, principle-based assimilative integration, and 

theoretical integration suggest different theoretical levels of integration. The 

highest level concerns the theory of psychopathology that usually suggests a 

direction for corrective intervention; one level down is the theory of change that 



  
 

International Journal of Integrative Psychotherapy, Vol. 8, 2017 
 

47 

stipulates mechanisms, through which the corrective intervention effects change; 

the next theoretical level explicates how a particular intervention carries those 

mechanisms out. Any given therapy includes (explicitly or implicitly) all the 

mentioned levels, because any intervention has to be justified and guided by a 

theory of psychopathology as well as a theory of therapeutic action. That 

necessitates integration of the mentioned theoretical levels within a given therapy 

in order to execute an internally consistent therapeutic process. Such integration 

has to negotiate the constraints that higher theoretical levels direct down the 

theoretical hierarchy. For example, EMDR is guided by Adaptive Information 

Processing theory (AIP), whereby the source of psychopathology is believed to 

be maladaptively processed and stored traumatic memories (Shapiro, 2001). 

Accordingly, the theory stipulates that transmutation and reintegration of the 

traumatic memory into a broader memory network is the mechanism of 

therapeutic change (Solomon & Shapiro, 2008). The theory further stipulates that 

the EMDR system of interventions triggers the proposed mechanism of change 

and facilitates its action by engaging and guiding the reprocessing of cognitive, 

emotional, and sensory aspects of the traumatic memory. 

 

One way of negotiating inter-level theoretical constraints was suggested in 

Godfried’s common factors approach (Goldfried, 1980).He proposed constructing 

integrative treatments based on principles of change common to different schools 

of therapy and identified those principles as: 1) expectation of positive 

therapeutic change, 2) optimal therapeutic alliance, 3) increasing awareness 

through an external perspective, 4) improving reality testing, and 5) providing 

corrective experiences. In a related approach, stages of change are considered 

such common principles (Prochaska & DiClemente, 1986). 

 

The principles of change approach to therapy integration has its critics, 

who have identified points of contention. One is that it underestimates the utility 

of distinct theoretical orientations and the ready-to-use toolboxes associated with 

them. Another related contention is that techniques are more suitable objects for 

research than principles of change (Hill, 2009). As an alternative, Hill suggests a 

therapist-client centered integrative approach, where therapy integration is 

conceptualized as a dynamic process driven by the therapist’s techniques that 

are continually adapting and being updated depending on the client’s 

involvement, therapeutic relationship, and the interplay thereof during the 

therapeutic encounter (Hill, 2005). Such process-oriented integration seems to 

allow for greater flexibility, while still adhering to theory-based techniques, thus 

negotiating the flexibility vs. fidelity dialectic. 



  
 

International Journal of Integrative Psychotherapy, Vol. 8, 2017 
 

48 

Hoffart & Hoffart (2014) have criticized the principles of change approach 

as being incompatible with the principle of causation in therapy. They maintain 

that in psychotherapy, principles of causality should determine its interventions, 

whereas the abstract and trans-theoretical nature of principles of change may 

violate that causality. They suggest either theoretical or assimilative integration 

as strategies accommodating causality. In other words, the authors’ objections to 

the principles of change approach underscore the need for ‘vertical’ (inter-level) 

integration to construct an internally consistent therapy. The nested hierarchy 

model of therapy integration suggested here allows for integration of multiple 

theoretical levels comprising the therapeutic process, thus upholding the 

causality principle. It also integrates ‘horizontal’ dialectics, as mentioned above. 

Below, we describe the principles and structure of nested hierarchy of integrative 

treatments. 

 

 

Nested Hierarchy of Theoretical Principles for Psychotherapy Integration 

In order to integrate theoretical principles of different levels into an 

internally consistent treatment, we suggest organizing those principles in a 

hierarchy from the most general to the most specific. Such structure imposes 

causal constraints from the higher to lower levels, with those constraints serving 

as the main organizing principle of therapy integration. There are also feedback 

loops that impose constraints on the higher levels, thus refining and organizing 

the hierarchical trees of possibilities into the nests of reified treatments (see 

Figure 1). The feedback feature is essential for guiding and organizing 

therapeutic process as it evolves. We have identified four levels in the hierarchy 

of therapy integration which parallel the logic of case conceptualization. 

 

Level 1 – The Goal of Therapy 

The goal of therapy can either be effecting change or maintenance. 

Although change is the usual goal of therapy, sometimes therapy aims at 

maintaining the current level of stability, as in the recovery phase of addiction, 

preventing decompensation, or sustaining the achieved gains of therapy. This 

does not mean that change cannot occur during maintenance, only that it is not 

the intended goal.  

 

The goal of change vs. maintenance determines the set of theoretical 

principles at the next level. Since therapy is a dynamic process its goals may 

change depending on the phase of therapy. Since our primary interest is in the 

change nest, no further discussion of maintenance follows. 



  
 

International Journal of Integrative Psychotherapy, Vol. 8, 2017 
 

49 

 

 
Level 2 – Objective of Change/Theory of Pathology 

At this level, the objective of change is determined based on a theory of 

psychopathology. At least implicitly, any theory of pathology suggests a path out 

of it. Although a comprehensive discussion of different theoretical approaches to 

psychopathology is outside the scope of this paper, we suggest such theory be 

meta-diagnostic. DSM-5, as well as its previous versions, defines diagnoses as 

symptom constellations. Therefore, a diagnosis-based theory would guide the 

objective toward elimination of those symptoms. We, on the other hand, consider 

change a systemic process, whereby a systemic change drives symptom 

reduction rather than the other way around. Therefore, we favor the 

system/meta-diagnostic level of theory of psychopathology, where symptoms are 

viewed as a manifestation of the system’s dynamics. 

 

AIP, the theoretical basis of EMDR (Shapiro, 2001), is an example of such 

theory. Although EMDR was first developed for trauma-related disorders, AIP is 

not centered on traumatic symptoms but approaches them from the standpoint of 

information processing and memory formation. That breadth of scope has been 

conducive to expanding EMDR application beyond trauma-related disorders. 

Conceptualizing pathology as maladaptive processing and storage of experience 

suggests an objective for therapeutic change such as adaptive reprocessing of 

that experience (Shapiro, 2001). 

 

Evolutionary theory is the highest meta-theoretical level in life sciences, 

because it seeks to explain how the living systems have come to be the way they 

are including their development and behavior. A number of evolutionary theories 

of depression consider it a manifestation of the depressive response that evolved 

as an adaptation to insurmountable adversity (Keller & Nesse, 2006; Nettle, 

2004; Watt & Panksepp, 2009). Two therapies have recently been developed 

based on evolutionary theory of depression. Evolutionary-driven cognitive 

therapy for depression maintains that a mismatch between the modern human 

environment and innate adaptive depressive reactions that developed early in 

hominid evolution leads to depressive pathology (Giosan et al., 2014). 

Accordingly, it suggests correction of that mismatch as a therapeutic objective. 

On the contrary, another integrative therapy, treating depression downhill (TDD), 

considers depressive response adaptive for modern humans as well and 

prescribes expedited completion of such response as its objective in the initial 

phase of therapy (Krupnik, 2014). A chosen objective for change determines the 



  
 

International Journal of Integrative Psychotherapy, Vol. 8, 2017 
 

50 

mechanisms of change, which, in turn, inform the corresponding therapeutic 

interventions. 

 

Level 3 – Mechanisms of Change 

Literature concerning mechanisms of therapeutic change is vast and 

beyond the scope of this paper. In trying to find the common denominator, we 

suggest that the mechanism of therapeutic change is experience of change. 

Although it may sound like circular reasoning, it is not. Instead, we offer that 

change in therapy comes from experiential learning, which can only come from a 

new experience.  Common examples of this idea are catharsis in psychoanalysis 

(Freud, 1966), developing new core beliefs in cognitive therapy (Beck, 1967), 

habituation in prolonged exposure (Foa & Kozak, 1986), and memory 

transmutation in EMDR (Solomon & Shapiro, 2008). 

 

At Level 2, the objective (see Figure 1) directs and constrains the pathway 

to experiential learning, which can only be carried out through appropriate 

mechanisms. Not every mechanism of change may support a given pathway. For 

example, EMDR theorists posit that fear extinction, which is the proposed 

mechanism of change in PE (Foa & Kozak, 1986), would not mediate the 

restructuring of traumatic memory sought in EMDR (Shapiro, 2014). Therefore in 

EMDR, exposure is de-emphasized and its amount is limited. Although the late 

development of emotional processing theory, specifically the notion of inhibitory 

learning (Craske et al., 2008), may suggest a greater overlap between the 

mechanisms of change operating in PE and EMDR than has been 

acknowledged. 

 

Level 4 – Intervention (the delivery of change) 

Once the direction of change and its supporting mechanism/s are 

determined, they require a set of interventions to carry them out. Again, not all 

interventions may support a certain mechanism of change, though some may 

prove universal enough to fit many or most. For example, it is difficult to see how 

free association could help achieve habituation to a single trauma experience of 

a car accident, or how neurofeedback could accomplish cognitive reappraisal. On 

the other hand, a quality therapeutic alliance and active empathic listening 

appear to facilitate treatment across highly diverse therapies (for examples see 

Erskine, 2015; Goldfried, 1980). There has been considerable research on the 

importance of such non-specific interventions for therapy outcome (for review see 

Messer & Wampold, 2002). The intervention level is where psychotherapy 

integration meets the client. 



  
 

International Journal of Integrative Psychotherapy, Vol. 8, 2017 
 

51 

Intra-level Nesting 

The identified levels of therapy integration may contain sub-levels within 

them (nest inside a nest). For example, AIP theory contains several levels of 

abstraction (Shapiro, 2001), starting with conceptualizing the therapeutic action 

of EMDR as transmutation of dysfunctional traumatic memory, proceeding to 

suggesting a memory structure consisting of cognitive, emotional, and sensory 

neural networks, and further onto hypothesizing putative neural mechanisms of 

EMDR’s effects (for a recent review see Shapiro, 2014). Likewise, the 

evolutionary theory of depression suggests the depressive response to be an 

evolved adaptation, which includes sub-theories of such adaption on social, 

cognitive, physiological, genetic, cellular, and neural levels (Andrews & 

Thompson, 2009; Nettle, 2004; Watt & Panksepp, 2009). These sub-levels bear 

on both the putative mechanisms of change and the corresponding interventions 

of different levels, where the different levels of intervention may need 

reconciliation. For example, it is believed that in the desensitization phase of 

EMDR, it is important to maintain an optimal level of emotional arousal (Shapiro, 

2001), whereas cognitive interweave, an intervention of a different level, has a 

potential to resolve and thusly decrease that arousal and, if ill-timed, may prove 

premature and counterproductive. 

 

  The nested hierarchy tree features a one-to-many relationship down, as 

well as many-to-one, up the hierarchy.  Thus, more than one theoretical construct 

may correspond (be nested) to a single construct at the higher hierarchical level 

(see Figure 1). Such arrangement creates a gradient of freedom of choice from 

more stringent at the top to more relaxed at the bottom. Hence, there can be no 

flexibility at Level 1, since it is a dichotomous choice between change and 

maintenance. At Level 2, it is conceivable that more than one objective of change 

is pursued. For example, in EMDR, desensitization to traumatic experience is 

sought along with its cognitive reappraisal (Shapiro, 2001). Accordingly, multiple 

mechanisms may be at play at Level 3 to carry those objectives out, including 

affect modification, accommodation and assimilation of beliefs, and behavioral 

reinforcement.  Finally, at Level 4, all interventions with a potential to facilitate the 

involved mechanisms of change may be recruited in various combinations. Such 

integrative processes may appear to foster a chaotic multiplicity of therapies. 

However, the bottom-up feedback loops (see Figure 1) are meant to safeguard 

against that possibility by selecting and binding the nest’s components through 

an iteration of feed-forward and feedback cycles, as the nest evolves into a 

stable and reproducible therapy. In choosing an intervention the therapist will 

track back whether it is optimal (in theory and observation) for the intended 

mechanism of change, and whether that mechanism is optimal for the pursued 



  
 

International Journal of Integrative Psychotherapy, Vol. 8, 2017 
 

52 

objective of change prescribed by the theory of psychopathology that s/he bases 

interventions on. 

 

NH offers, in this way, several advantages. It reconciles the above 

mentioned horizontal and vertical dialectics, integrates the existing approaches to 

psychotherapy integration, and suggests a unified system for classification of 

therapies. NH also offers testable predictions and suggests directions for 

psychotherapy research. Finally, NH advocates for a more creative role for 

therapist in the process of integration. 

 
 
From Dichotomies to Integration 

 

 Fidelity and Flexibility 

In Nested Hierarchy, the constraints on integration relax as one moves 

down the hierarchy, thus increasing flexibility while decreasing fidelity (see Figure 

1). In a study of therapeutic process, Ablon and Jones (1999) compared how 

closely the protocols of CBT and interpersonal therapy for depression were 

followed. They observed a significant overlap between interventions used in 

those therapies. Interestingly, a drift by interpersonal therapists toward cognitive 

therapy correlated with better outcome. The NH model of integration suggests 

theoretical hierarchy as a guiding principle for a flexible adoption of interventions, 

while constraining this flexibility empirically through feedback loops (see Figure 

1). 

 

Specificity and Universality 

NH both accommodates and constrains universality, thereby providing for 

specificity of integrative therapies. Specificity increases and universality 

decreases down the hierarchy (see Figure 1).  At Level 1, universality is highest, 

since the choice between change and maintenance applies to all imaginable 

treatments, clients, and settings. At the Level of Theory (Level 2), the choice 

becomes specific to the client’s pathology and diagnostic category. The more 

universal a theory of pathology, the more conditions and diagnoses its nested 

therapy could be applied to. AIP theory of psychopathology is universal for all 

traumatic experiences, hence EMDR has been applied to a wide spectrum of 

conditions believed to be trauma-related (Shapiro, 2009). In contrast, the 

evolutionary theory of depression is specific to depressive disorders, and 

therapies that are based on it have only been applied to them and shown to be 

specific to those disorders (Giosan et al., 2014; Krupnik, 2014). 



  
 

International Journal of Integrative Psychotherapy, Vol. 8, 2017 
 

53 

 

Putative mechanisms of therapeutic actions (Level 3) further constrain 

universality, making the treatment more specific, as illustrated by modification of 

the standard EMDR protocol for current trauma (Shapiro & Laub, 2008). At the 

lowest level (Level 4), therapy grows even more specific, as the choice of 

interventions is specific not only for the theory of pathology and the putative 

mechanism of change but also for a particular client and therapeutic dyad. 

 

 

Vertical Integration 

The commonly identified pathways to psychotherapy integration - technical 

eclecticism, common factors, assimilative integration, and theoretical integration - 

are already arranged in a hierarchical order.  Theoretical integration appears at 

the top, followed by assimilative integration, then common factors, and 

eclecticism at the bottom. These integration strategies, however, are traditionally 

thought of as alternative. Moreover, according to Hoffart and Hoffart (2014) only 

theoretical and assimilative integration uphold the principle of causation and are 

thus seen as being the only valid integrative models.  NH accommodates the 

mentioned pathways by organizing them at different levels of the hierarchy (see 

Figure 1), so that theoretical integration happens at Level 2, technical – at Level 

4, common factors – at Level 3, and assimilative integration organizes 

interventions across Levels 3 and 4 under the theoretical principle of choice from 

Level 2. Hence, theoretical and assimilative integration together would comprise 

the whole nest under the Level 1 goal. 

 

Ego states EMDR therapy can illustrate such integration. At Level 1, the 

goal of this therapy is to effect change in a traumatized client, specifically a client 

with a fragile and disrupted ego. Accordingly, at Level 2, AIP theory is integrated 

with ego psychology, where they are treated as complementary (Knipe, 2015; 

Paulsen & Lanius, 2009). In short, ego states are viewed as functional units 

organizing and biasing the processing of information, particularly information 

relevant to the traumatic experience. Adaptive information processing, therefore, 

requires well-integrated stable ego states. This theoretical principle can 

assimilate a number of mechanisms of change at Level 3, as long as they do not 

contradict it. Examples of such mechanisms include inactivation of psychological 

defenses, modification of the attachment style, improved reality testing and affect 

control, and reconfiguration of traumatic memory networks in the service of 

integrating different ego states. Of note, Level 2 and 3 (Figure 1) integration in 

ego states EMDR appears seamless and organic, because adaptive information 

processing can be considered the main (if not only) ego function, which both 



  
 

International Journal of Integrative Psychotherapy, Vol. 8, 2017 
 

54 

serves and depends on well-integrated ego states. It should also be noted that 

common factors and principles of change are, by definition, trans-theoretical and 

therefore are amenable to integration into most theoretical nests. 

 

Interventions (Level 4) in ego states EMDR include an array of techniques 

supporting the above mentioned mechanisms of change. Their examples include 

developing insight into different ego states in order to better integrate them, 

establishing a trusting therapeutic relationship to facilitate change in the 

attachment style, practicing affect tolerance in order to facilitate reprocessing of 

traumatic memories, and reprocessing and desensitization of those memories. In 

addition to meeting the requirement of not violating the nest’s causal hierarchy 

(see the feedback dashed arrows in Figure 1), integration of these interventions 

also meets the criterion of necessity. A disrupted ego may not be conducive to 

reprocessing of traumatic experience, thus requiring interventions to stabilize and 

integrate it. 

 

 

Nested Hierarchy and Integrative Therapy 

Nested Hierarchy does not describe any particular model of integrative 

therapy but suggests a set of principles that can assist in developing one by 

providing both generative and constraining rules. Metaphorically speaking, NH is 

a methodological scaffold for construction (or rather co-construction) of a 

coherent, causation-driven treatment. For this reason, it is more concerned with 

the content of therapy than its process, although in psychotherapy the two are 

inextricably intertwined. Potentially, this methodology can assist development of 

as many integrative therapies as there are therapeutic encounters. The yet 

unproven rationale for using it is that the resulting coherence may entail 

consistent effectiveness. 

 

How NH relates to particular models of integrative therapy is too broad a 

question to address in a context of introducing NH principles and is, therefore, 

beyond the scope of this article except for the purpose of illustrating certain 

aspects of NH. Above, I used ego states EMDR as an example of how NH 

achieves vertical integration of theoretical principles and therapeutic 

interventions. Relational or process-oriented therapeutic models, including 

Erskine’s model of Integrative Psychotherapy (Erskine & Moursund, 2011; 

Erskine & Trautmann, 1996), correspond to NH in a more comprehensive way, 

since relational principles are embedded in NH. Psychotherapy is a process of 

social transaction, therefore therapeutic relationship is implicitly or explicitly 

present throughout NH. The relational nature of the nest is evident starting from 



  
 

International Journal of Integrative Psychotherapy, Vol. 8, 2017 
 

55 

Level 1 (see Figure 1), since the choice of therapeutic goal is arrived at through 

establishment of a therapeutic alliance. At Level 2, most theories of 

psychopathology are rooted in the developmental and, therefore, relational 

perspective, whereas all interventions at Level 4 happen through social 

transactions. Mechanisms of change (Level 3), on the other hand, may be viewed 

as intra-psychic, not necessarily relational. However, from the 

psychodynamic/developmental perspective, one would claim that many if not 

most intra-psychic processes happen in relation to other people, for whom the 

therapist may serve as a transferential object. This view aligns with Erskine’s 

understanding of human suffering as coming from disrupted relational needs and 

the corresponding goal of therapy to repair those disruptions through contactful 

therapeutic presence (Erskine, Moursund, & Trautmann, 2013). 

 

On a formal level too, Erskine’s Integrative Psychotherapy can be aligned 

with NH. The stated primary goal of his Integrative Psychotherapy is integration 

of the client’s self, which falls under the goal of change in NH (Figure 1). 

Following that goal at Level 2, Erskine’s model integrates multi-level theories of 

the client’s functioning from physiological reactions through systemic social 

constraints and influences. Malfunctioning or deficiencies of the client’s self are 

understood as stemming from disruptions of relational needs, which points to a 

possible mechanism of change at Level 3, i.e. repair of those disruptions. Such 

repair is believed to facilitate the sought integration of the client’s self. This 

mechanism of change then requires a suitable set of interventions. Whereas in 

Erskine’s Integrative Psychotherapy this set is comprised of certain techniques 

such as inquiry, attunement, and involvement, the set is conceptualized as a 

process of contactful therapeutic presence, which is both the premise and the 

goal of therapy (Erskine, Moursund, & Trautmann, 2013). 

 

Where process-based Integrative Psychotherapy meets the structure-

based nest of integration, is NH’s iterative nature. In NH, the top-down theoretical 

principles are tested and validated (or invalidated) by feedback from the lower 

levels (dashed arrows in Figure 1), thus leading to optimization of the nest. This 

iterative process is bound to therapeutic relationship, which is the ultimate source 

of the feedback as well as the endpoint of the top-down corrections. 

 

Expanding on the above metaphor, we would say that whereas NH is a 

scaffold on which an integrative therapy is built, it is built in intersubjective space 

with the material of therapeutic relationship. This metaphor may sound 

overwrought, but its challenge is to match the complexity of therapeutic 

encounter. 



  
 

International Journal of Integrative Psychotherapy, Vol. 8, 2017 
 

56 

Classification of Therapies 

Besides providing a structure and a guiding principle for therapy 

integration, Nested Hierarchy offers a taxonomy of therapies that is also 

organized as a hierarchical tree with large taxa at the top, comprising families of 

smaller taxa down the hierarchy. There are two taxa at Level 1, change and 

maintenance. Each includes a family of theories of pathology at Level 2, which in 

turn include a family of mechanisms of change at Level 3, and finally a family of 

interventions at Level 4 (Figure 1). In such a classification a therapy is identified 

by its nest. For example, EMDR would be classified as Change (Level 1), AIP 

theory (Level 2), transmutation of traumatic memory/ desensitization to traumatic 

memory (Level 3), bilateral stimulation, cognitive interweave, emotional 

awareness, and guided imagery (Level 4). Ego states EMDR would include the 

integrated AIP/ego psychology theory at Level 2, additional ego states 

mechanisms of change, and interventions such as ego states stabilization and 

integration, reality testing assistance at Level 4. 

 

Notably, elements of such taxonomy have long been in use, although not 

in a formalized way. Cognitive therapy (CT), similar to EMDR, has evolved into a 

family of therapies that includes CBT (Rachman, 1997), trauma-focused CBT 

(Cohen, Deblinger, Mannarino, & Steer, 2004), cognitive processing therapy 

(Resick & Schnicke, 1993), evolutionary-based CT (Giosan et al., 2014), 

mindfulness-based CT (Williams, Teasdale, Segal, & Kabat-Zinn, 2007), and 

exposure-based CBT for depression (Hayes & Harris, 2000).  This confirms that 

hierarchical taxonomy may be a natural evolution of psychotherapy classification 

away from a catalogue of treatment brands. 

 

NH-based taxonomy may appear cumbersome with ‘fuzzy’ boundaries, 

which is expected given the complexity of the specimen, but it offers advantages 

over an unstructured list of brands. One is that NH organizes therapies into a 

family of related and interconnected procedures, thus doing away with their 

redundant multiplicity. Two, it provides an alternative frame for psychotherapy 

research, which will be discussed below. Three, NH-based taxonomy may help 

construct integrative treatments by establishing relationships between the 

elements of cognate therapies, thus instructing practitioners on available options 

for combining theories and techniques in a systematic fashion.  

 

Research Considerations 

The nested hierarchy view of psychotherapy multiplicity and interrelationships 

forges a corresponding approach to psychotherapy research. In the predominant 



  
 

International Journal of Integrative Psychotherapy, Vol. 8, 2017 
 

57 

paradigm, therapies are treated as distinct treatment packages to be compared in 

efficacy and effectiveness. Even when common factors such as therapeutic 

alliance, empathy, and motivation for change are studied, the assumption is that 

they are common to independent therapies, and mechanisms of change are 

mostly studied within their respective theoretical orientations. 

 

Necessary and useful as it is, this paradigm has its limitations. It leaves 

certain important questions outside its scope. For example, an important question 

is how efficacious a hypothesized mechanism of change could be in different 

therapy contexts. As long as a therapy is considered a fixed set of techniques, 

the context is presumed constant, although, as mentioned before, in real 

practice, drift from the fixed sets is common. The same question remains 

unaddressed in regard to common factors of change, as they too are ‘trapped’ in 

the context of fixed treatment packages. Yet, common factors have been shown 

as the main contributors to the outcome (Laska, Gurman, & Wampold, 2014), 

leading to a hypothesis that any therapy that contains all the common factors of 

change will be efficacious. Nested Hierarchy offers a hybrid research model that 

by design would accommodate specific factors, common factors, and context. 

 

At Level 4 of NH, therapies are represented as sets of interventions (see 

Figure 1 and 3). For the sake of analysis, all interventions can be organized 

along two dimensions, verbal and non-verbal, thus forming a grid, examples of 

which (far from comprehensive) are given in Figure 2 and 4, the latter 

representing a case example. Each intervention is then given a value according 

to the length of time it takes up in therapy. That value represents the 

intervention’s dose, relative to which its contribution will be estimated. On the grid 

every therapeutic encounter appears as a unique profile of qualitatively and 

quantitatively represented interventions. Accordingly, outcomes are compared 

not between therapy brands but between sets of interventions, delivered by sets 

of therapists, to sets of clients, in sets of social encounters.  

 

 Sets of therapists are defined by their theoretical orientation (if any), 

experience, education, and demographics such as age, gender, socioeconomic 

status, family and cultural background.  Sets of clients are defined by their 

symptoms, diagnosis, demographics (same as for therapists), life experiences, 

such as traumatic, disruptive, and formative life-events, and the level of 

motivation. Motivation for change is considered essential for therapy outcome 

(reviewed in Ryan et al., 2011). Sets of social encounters are defined by the 

quality of alliance, level of trust, and emotional attunement. Whereas some of the 

above parameters are a matter of factual report, others (e.g. motivation, trust, 



  
 

International Journal of Integrative Psychotherapy, Vol. 8, 2017 
 

58 

attunement) need to be measured with the existing psychometric tools. 

Obviously, such study cannot be designed as rigorously as randomized clinical 

trials. Instead, a naturalistic design is suggested, where individual cases with the 

above parameters and outcome measures will be uploaded into a shared 

database, like a “wikitherapy” of sorts.  

 

As the database grows through crowdsourcing, it will be analyzed with 

multiple regression and factor analysis to estimate the interventions’ contribution 

to the outcome and to identify clusters of interventions that may belong in the 

same nest and facilitate the same mechanism of change.  Gradients of 

effectiveness can be expected to emerge on the grid, where certain combinations 

of interventions are more effective than others. The expected large size of the 

database may minimize the confounding variables unavoidable in such 

uncontrolled data collection process. 

 

The “highly effective intervention” sets will be organized in hierarchical 

nests with best-fitting theoretical constructs of higher (1-3) levels, thus producing 

internally consistent integrative therapies. Such empirically informed therapies 

will then be compared to well-established evidence-based brands in randomized 

controlled trials. The ineffective intervention sets may prove useful as points of 

comparison for further study of putative mechanisms of change. 

 

The proposed two-dimensional grid can be refined with additional 

dimensions to capture non-verbal communication (including silence), affective 

expression, or affective synchronization (Marci, Moran, & Orr, 2004). Such fine a 

grid, however, would have its challenges. It will require a detailed analysis of 

each video recorded session, and the number of potentially relevant variables will 

result in a statistical power tradeoff.  It is important to emphasize that the project 

outlined here is not meant as a research proposal, but as a description of a 

possible research paradigm. Therefore a detailed description of the proposed 

database is preliminary at this point and outside of the scope of this article. 

 

Another potential contribution of the NH approach is that it is designed to 

capture failed cases. Bradley and colleagues (2005) estimate the non-response 

rate for PTSD treated with evidence-based therapies, including EMDR,  is 30% at 

best. These 30% are deemed treatment-resistant and usually fall outside of 

research focus. The tradition of successful single case reports at the exclusion of 

failed ones has prevailed since Freud’s times. Yet, in order to understand how 

therapy works, it is important to figure out how and why it fails.  It is the belief of 



  
 

International Journal of Integrative Psychotherapy, Vol. 8, 2017 
 

59 

this writer that failed cases carry valuable information that the NH approach is 

capable of expounding. 

 

 

 

 

Figure 2:  An Example of the Intervention Grid 

 

Key =  BLS – bilateral sensory stimulation as used in EMDR  

TFT – finger tapping as used in Thought Field Therapy  

NFB – neurofeedback  

HT – Healing Touch Therapy 

TMS – transcranial magnetic stimulation 

ECT – electro-convulsive therapy 

 

Certain interventions can be applied in the same session or even 

simultaneously. Each intervention can be measured in the most 

appropriate units, e.g. number sessions, procedures, dose. 

 

 

Predictions 

Suggesting a strategy for therapy integration implies an expectation of 

increased effectiveness of integrative treatments relative to their prototypes. 

Accordingly, the overarching prediction for the Nested Hierarchy approach is that 

it will lead to more effective therapies. The notion of a greater effectiveness has 

several dimensions when testable hypotheses are offered. 

Verbal           Non-verbal 
BL

S 

TF

T 

NF

B 
HT 

TM

S 

EC

T 
Medications 

Behavioral 

activation 

Behavioral 

modification 

Exposure 

in vivo 

Developing insight 

          Analysis of 

transference 

          Cognitive challenge 

          Exposure in vitro 

          Self-monitoring 

          Resources 

development 

          Narrative building 

          Mourning 

          Hypnosis 

          Meditation 

          



  
 

International Journal of Integrative Psychotherapy, Vol. 8, 2017 
 

60 

 

The first of these is the general effectiveness (efficacy) dimension.  The 

prediction is that violating the nest’s hierarchy would decrease the efficacy of an 

integrative therapy. If an intervention and its putative mechanism of action do not 

conform to the nest’s Level 2 theory, that will constitute such violation and 

compromise the treatment’s efficacy. For example, it is predicted that integrating 

the unique prolonged exposure interventions (PE) into EMDR will not be 

beneficial, while integrating the unique interventions of cognitive processing 

therapy (CPT) may. The hypothesized mechanism of change in PE is habituation 

(or extinction) of fear response (Foa & Kozak, 1986). This mechanism is believed 

to differ from EMDR’s theoretical premise and presumed mechanism of action 

(Shapiro, 2014). On the other hand, the putative mechanism of change in CPT is 

cognitive restructuring (Resick & Schnicke, 1993), which is compatible with 

EMDR theory, inasmuch as it seeks a positive shift in trauma-associated 

cognitions (Shapiro, 2001). 

 

The second dimension is effectiveness for a particular client population. It 

is conceivable that an integrative therapy may not be more efficacious than its 

prototype but may produce a better outcome for a certain set of clients. Such 

therapy would need to integrate a theory of psychopathology for that particular 

subset. For example, the prediction is that evolutionary-based therapies for 

depression will be effective for clients whose pathology is based in depressive 

response, while relatively ineffective for conditions where depressive symptoms 

are secondary to anxiety or trauma-related disorders. 

 

The third dimension (less popular in current research) is effectiveness of 

delivery. That is, how effective a therapist can be in delivering a therapy. A set of 

interventions may not be neutral to a therapist’s ability to carry them out. 

Inclusion of an incongruent technique may not only be a threat to therapy’s 

efficacy but may also hamper a therapist’s delivery of it. One of the tenets of 

Adaptive Information Processing theory of EMDR is that the mind has an inherent 

ability to transform traumatic memory into a more adaptive configuration, which 

process is facilitated by EMDR (Solomon & Shapiro, 2008). Therefore, it is 

believed that the processing phase of EMDR should proceed with least possible 

interruption. Accordingly, EMDR therapists use cognitive interventions sparingly 

during processing (Shapiro, 2001). Inclusion of systematic cognitive challenges in 

this phase, as done in CBT, may not only interrupt the flow of processing, but 

disturb the therapist’s attunement to it. We predict that interventions that do not 

violate the nest’s hierarchy have less chance to undermine therapist’s 

effectiveness. 



  
 

International Journal of Integrative Psychotherapy, Vol. 8, 2017 
 

61 

 

 

Case Vignette 

The following case vignette provides an example of the co-creation and 

implementation of integrative therapy.  A complicated case was deliberately 

chosen in order to showcase the flexibility and accommodating capacity of the 

Nested Hierarchy approach. 

 
 
The Client 

Justin is a 28-year-old married man. He presented at a local mental health 

clinic after having been hospitalized for five days in a psychiatric unit following an 

interrupted suicide attempt by ingesting his pain medications. In the clinic, he was 

assigned a nurse practitioner for medication management and a therapist. 

 

During a semi-structured intake interview, Justin disclosed a chronic 

pattern of depressed mood and anxiety with an onset in early childhood, when he 

was taken from his mother’s custody and placed in his maternal aunt’s 

household. There, he grew up as the only child with the aunt and her husband 

until he graduated from high school and enlisted in the military to “get away from 

the aunt.” As a child, he had visitations with his mother and always dreaded 

coming back to the aunt. Justin did not remember having been happy for more 

than a week at a time. He remembered himself as a shy, reserved, and socially 

awkward child that spent much time playing alone. He described his aunt as a 

strict, domineering and cold woman, whom he tried to avoid as much as he 

could. 

 

Justin’s suicide attempt was precipitated by a combination of stressors 

including having a newborn child, a high workload and a back injury, for which he 

was awaiting medical retirement. He reported a tendency to be easily 

overwhelmed by stress, where he would grow anxious and would subsequently 

“freeze” with a feeling of impending doom. That tendency had remained strong 

despite his supportive wife and in-laws. Justin was diagnosed with persistent 

depressive disorder (DSM-5) by both his prescriber and therapist. The therapist 

conceptualized the case as a chronic depression precipitated by the early 

separation from mother, and sustained by learned and reinforced depressive 

response. The link between early loss and depression has long been noticed and 

described (Bowlby, 1988), and more recently, depressive response was 

hypothesized to evolve as a protective mechanism against early separation from 



  
 

International Journal of Integrative Psychotherapy, Vol. 8, 2017 
 

62 

mother (Watt & Panksepp, 2007). Accordingly, the therapist chose treating 

depression downhill (TDD)-EMDR for therapy, to which Justin consented. 

 

 

The Process of Integration 
 

TDD-EMDR is a recently developed psychotherapy integrating an 

evolutionary-based therapy designed specifically for depressive disorders, TDD, 

and a set of EMDR interventions. The main reason for this integration is to 

facilitate the second phase of TDD, which is based on mindfulness (Krupnik, 

2014). 

 

At Level 1 (see Figure 1 and 3), TDD and EMDR are obviously 

compatible, since both seek to change the client’s mental condition. Noteworthy, 

EMDR uses ‘future template installation’ to ensure that the adaptive change 

gained in therapy is activated in response to future challenges (Shapiro, 2001). 

TDD, however, does not have a future-oriented intervention, and that distinction 

became important late in Justin’s treatment. 

 

At Level 2, the therapist followed the evolutionary theory of depression, on 

which TDD is based, consistent with the case conceptualization that depressive 

response was driving Justin’s psychopathology. EMDR has been used for 

depression before from the perspective of trauma, where depressogenic life 

events were treated as traumatic, and the standard EMDR protocol was used 

(Bae, Kim, & Park, 2008; Broad & Wheeler, 2006; Grey, 2011; Gauhar, 2016; 

Uribe, Ramírez, & Mena, 2010; Hofmann et al., 2014). TDD, on the other hand, 

considers depressogenic events normative life adversity. This is an important 

theoretical difference, since it suggests different sources of psychopathology. 

Whereas EMDR (and its theoretical basis, AIP) sees the source of 

psychopathology in trauma, TDD finds it in unmet needs and frustrated drives, 

more in line with Freudian (Freud, 1966) and Maslowian (Maslow, 1943) 

traditions. Speaking of unmet relational needs, Erskine’s integrative 

psychotherapy views them as an impediment to personality integration, causing 

disruption in personal development and interpersonal functioning (Erskine, 

Moursund, & Trautmann, 2013). Although one could make an argument that a 

failure to meet a person’s needs may be traumatic, equating unmet needs with 

trauma would strip either concept of its meaning. Accordingly, the therapist used 

the TDD therapeutic frame and integrated it with select EMDR interventions that 

would not violate the TDD nest (Figure 3). 

 



  
 

International Journal of Integrative Psychotherapy, Vol. 8, 2017 
 

63 

At Level 3, the presumed mechanisms of change in TDD differ from 

EMDR. In TDD, the main mechanisms are believed to be (a) inhibition of protest 

by acceptance of defeat, and (b) behavioral activation of the reward/motivation 

circuitry, where ‘a’ and ‘b’ are activated sequentially (Krupnik, 2014). In EMDR, 

the presumed mechanism of change is reintegration of traumatic memory into a 

larger neural circuitry, which facilitates the memory’s regulation and increases 

adaptation. Traumatic memory is conceptualized as a multi-domain circuitry that 

includes physiological, emotional, and cognitive components (Solomon, & 

Shapiro, 2008). In order to maintain consistency with Level 2, the therapist 

aligned his interventions with TDD-based mechanisms of change. It is unclear 

how much overlap there is between the mechanisms hypothesized in TDD and 

EMDR due to their highly speculative and metaphorical nature. Still, formulation 

of such mechanisms is important to guide the choice of interventions. 

 

Level 4 is where the integration occurred.  Modified EMDR interventions 

(phases 3 – 7 of the standard protocol) were integrated into the acceptance 

phase of TDD, as previously described (Krupnik, 2015a, b). Since EMDR 

interventions are believed to facilitate the transformation of traumatic memories, 

the therapist hoped they could also facilitate the dispositional transformation from 

protest to acceptance, sought in acceptance phase of TDD. In evolutionary 

theory of depression, the transition from protesting disposition (against adversity) 

to acceptance (or acquiescence) has been seen as the core mechanism of 

depressive response (Watt & Panksepp, 2007). 

 

The unique procedure of EMDR is bilateral sensory stimulation (BLS), and 

although multiple hypotheses have been offered to explain the effect of BLS (for 

review see Jeffries, & Davis, 2013), its mechanism is poorly understood. 

However, a plausible hypothesis about the role of BLS in the context of TDD-

EMDR could be helpful to its practitioner. From a practitioner’s standpoint, we 

need a level of explanation consistent with the level of practice. That is, a 

systemic explanation, since a practitioner works with the whole mind, not just its 

modules or circuitries. In the acceptance phase of TDD-EMDR, a transition from 

protest to acceptance is sought in the same way that the standard EMDR 

protocol seeks transition from the negative self-appraisal to a positive one.  

 

In the dynamic systems theory such process can be described as state 

transition from one attractant state to another. To achieve such transition the 

system needs to be challenged internally or externally (Thelen & Smith, 1994). It 

is speculated that exposure to disturbing thoughts and feelings in conjunction 

with BLS facilitates such state transition by delivering a challenge that is (a) 



  
 

International Journal of Integrative Psychotherapy, Vol. 8, 2017 
 

64 

sufficient to destabilize the initial attractant state and (b) mild enough to trap the 

mind in a desirable new attractant state, i.e. acceptance or/and positive self-

appraisal. Relevant to this hypothesis, data has been found in the recent 

discovery that auditory BLS increases the amygdala activation in response to a 

noxious image by presumably inhibiting its prefrontal control (Herkt et al., 2014). 

This data can be interpreted as a synergistic destabilizing action of exposure and 

BLS.  However, experimental demonstration of BLS’ role in the presumed 

stabilization of the mind in a new attractant state is still to be determined.  

 

The use of exposure has recently been expanded from its traditional 

applications for anxiety and trauma-related disorders to treating depression as 

well (Hayes, Beevers, Feldman, Laurenceau, & Perlman, 2005). The idea that 

BLS may render dysfunctional cognitive and emotional circuits labile enough to 

make them amenable to manipulation and re-integration has been suggested 

before (Coubard, 2014). It is unclear whether the mechanisms of BLS and 

mindful meditation have anything in common, but it is noteworthy that the 

desensitization phase of EMDR utilizes mindfulness of the client’s feelings and 

bodily sensations in conjunction with BLS (Shapiro, 2001). 

 

It is important to emphasize that although the therapist approached the 

described case with an agreed upon blueprint of an integrative therapy (TDD-

EMDR), the integration evolved through a dynamic interaction of that blueprint 

with the flow and contingencies of the therapeutic process. The following is an 

account of these dynamics. 

 

 

The Course of Therapy 
 

At intake, Justin had a BDI-II (Beck, Steer, & Brown, 1996) score of 28 

(moderate severity). The exploration phase was psychodynamically informed, 

aiming at uncovering the developmental and unconscious dynamics driving 

Justin’s depression. He revealed that he had never felt depression-free for a 

significant length of time since the age of eight, when he was separated from his 

mother. He did not know and could not reconstruct the exact reason for being 

removed from her beyond a general notion that she was struggling with her 

“personal problems.” Two major themes emerged over the first three sessions. 

One was Justin’s pervasive disappointment in himself as a worker, husband, and 

head of the household. The precipitating event for his suicide attempt was an 

argument with his wife, where she threatened divorce. He felt he was 

incompetent to handle the stress of his life, stating “I’m not as good as I should 

have been.” The second theme was his feeling of entrapment in his life situation. 



  
 

International Journal of Integrative Psychotherapy, Vol. 8, 2017 
 

65 

He injured his back and was facing medical retirement, feeling anxious and 

uncertain about his ability to provide for the family, especially given that his wife 

had recently become pregnant with their second child. 

 

In exploring the underlying dynamics of Justin’s reactions to stress and life 

challenges, both themes were traced to his early childhood experiences. Justin 

recognized that abandonment by his mother had left him with a sense of low 

personal value, “not as good as I should have been,” and high vulnerability to 

slight and criticism both at work and in the family.  He also recognized that he 

had felt trapped and helpless ever since he had been placed in his aunt’s 

custody. He never felt loved in that house, and though never attempted, always 

wanted to escape. At this point, the therapist felt the projected helplessness and 

the implicit expectation of becoming a caretaker for Justin, which even prompted 

him to conduct a structured interview to rule out Dependent Personality Disorder. 

Justin endorsed traits 1, 3, and 7 of Dependent Personality Disorder (DSM-5, 

code 301.6), falling short of meeting the diagnostic criteria. His neediness, fear of 

abandonment, low self-esteem, and tendency to feel overwhelmed and helpless 

under stress were interpreted as vestiges of his childhood loss and entrapment. 

The sense of loss and low self-esteem were then chosen as the initial targets in 

the next (acceptance) phase. 

 

In the fourth session, the therapist used EMDR interventions while cuing 

Justin to the transition from protest to acceptance, according to TDD-EMDR 

protocol (Krupnik, 2015a). In short, while evoking the patient’s negative thoughts 

and feelings related to his experience of loss and his perception of self as 

unworthy, the therapist applied sets of BLS (eye movements), interspersing them 

with verbal cues. The cues were suggestive of disengagement from the protest, 

for example, “Is there anything you can do about it now? What could you do? 

Can you change that? Do you have any control over it?” Justin would 

acknowledge the limits of his control over the situation and of his ability to change 

it, which would initially perturb him, triggering sadness with the associated 

visceral bodily sensations such as tightness in the chest and emptiness in the 

stomach. As the session progressed, the sadness and visceral sensations 

decreased in intensity, and he felt “calmer.”  

 

In session five, Justin reported improved mood and a higher confidence, 

as well as more stable sleep. By that time he had come up with some positive 

statements about himself during EMDR interventions, “I’m as good as I am, I 

guess,” and expressed a more future-oriented attitude, “I need to move on.” He 

expressed confidence in his future career path, as well as his ability to provide for 



  
 

International Journal of Integrative Psychotherapy, Vol. 8, 2017 
 

66 

the family, given his retirement income and benefits. In the sixth session, his BDI-

II score dropped 50% to 14 (mild severity), at which point the therapist started the 

behavioral activation phase. Behavioral activation continued through the end of 

therapy along with other interventions. 

 

Although engaged in his behavioral plan, Justin continued presenting with 

mild and episodic depressive symptoms, including irritability, frustration when 

dealing with stress, and occasional insomnia. In general, the therapist still 

perceived in Justin a subdued hedonic tone and continuing neediness. When he 

shared that impression, Justin accounted for his residual symptoms by lingering 

anxiety about his future, as well as his frustration with chronic back pain and 

accompanying physical limitations. The therapist interpreted Justin’s negative 

reactions to stress as a still unresolved negative self-appraisal. Therefore, 

together they decided to further target his sense of defeat with EMDR 

interventions. In the following EMDR session Justin’s self-referential statements 

appeared well-balanced and without sadness. His hedonic tone, however, still 

appeared mildly depressed, so the therapist decided to return to exploration. In 

the next four exploratory sessions, again mostly psychodynamically informed, 

Justin focused on the fluctuations of his emotions related to the upcoming 

separation from his pregnant wife and his toddler daughter. They were moving to 

their home state ahead of him to set up a household there, while he was waiting 

for his medical retirement. He also reported a strong reaction to the death of his 

wife’s grandmother. The reaction surprised him, since his wife dealt with the 

death with far less distress than he. Another set of self-report measures returned 

a BDI-II score of 25, and Justin admitted that he had again slid into depression, 

losing his therapeutic gains. 

 

In the next session, the theme of his dependency on others, including the 

therapist, resurfaced. That lack of agency was interpreted as Justin’s passive 

aggression, developed in childhood as a defense against the domination of his 

aunt. At that point, Justin and the therapist decided to target his sense of being 

overpowered and defeated by life circumstances. Again, the therapist used 

EMDR interventions. Applying BLS, the therapist cued Justin into acceptance of 

the power of life circumstances as well as his personal limitations. In two EMDR 

sessions, Justin developed a seemingly more balanced perspective on his 

personal powers. He recalled instances in his childhood, where he would 

exercise the power of his agency, escaping the chokehold of his life 

circumstances. The therapist followed those revelations by ‘resource installation,’ 

a standard EMDR procedure. The therapist guided Justin to focus on his 



  
 

International Journal of Integrative Psychotherapy, Vol. 8, 2017 
 

67 

experiences of agency and the evoked feelings (“freedom,” “power,” “kind of 

cool”) while performing BLS.  

 

 Although not part of TDD-EMDR, ‘resource installation’ is especially 

central to ego states EMDR (Forgash, & Knipe, 2008). The ego strengths 

perspective does not fall under the Nested Hierarchy of evolutionary theory of 

depression, but it does not violate the nest either. Recovery from any 

psychopathology relies on a functional ego. Moreover, it can be speculated that a 

relatively intact ego is necessary for an adaptive depressive response lest such 

response degenerates into psychosis. Another set of self-report measures was 

taken in three sessions, and Justin’s BDI-II score dropped again to the mild range 

of 11. He reported feeling emotionally stable and realistically confident in his near 

future. After two follow up sessions, Justin stopped coming to therapy, since he 

felt he was getting too busy with the logistics of his retirement, which was coming 

in a month. The total length of his therapy was 20 sessions. 

 

 

 

 

Figure 3: The Nested Hierarchy of TDD-EMDR.  

(Horizontal arrows indicate overlapping interventions) 

 

 

The Case Highlights 
 

Justin’s case is one that did not go according to a clear cut template but 

instead was convoluted as a majority of psychotherapy practice can be.  This 

case attempts to illustrate how the integration evolved in the process of therapy, 

co-constructed through patient-therapist collaboration. In that we follow the notion 

that integrative therapy is not a ready-to-use product but evolves in the process 

(Hill, 2005) and is, in essence, relational (Erskine, 2015). This case also 



  
 

International Journal of Integrative Psychotherapy, Vol. 8, 2017 
 

68 

illustrates the dialectic between the process-driven intuitive “art of therapy” and a 

scientifically-based structure, where the structure provides a scaffold that is filled 

with a social encounter, while the scaffold is being built. This way, the structure 

and the therapeutic flow not only exert mutual constraints, but also build upon 

each other, not unlike the skeleton and soft tissues of a growing organism.  

 

The “integrate-as-you-go” approach has its limitations as well, as Justin’s 

case illustrates. A hierarchical nest is not a ready-to-use treatment package but 

provides a blueprint for therapy without the power to predict what exact set of 

interventions may be the most effective reification of the blueprint. For example, 

the therapist did not explore the likely possibility of Justin’s insecure attachment 

style, and no interventions were used to correct it. Nor did he address Justin’s 

lack of assertiveness and his inability to appropriately express his emotions. 

There are also different theoretical frames that could have been applied to the 

case, such as grief work over the separation and loss of Justin’s mother, or 

trauma work, had that loss been conceptualized as traumatic. It was not possible 

to determine before-hand which approach would have worked best, because 

each of them is backed by an evidence-supported therapy, such as CBT, 

interpersonal therapy, emotion-focused therapy, and EMDR. Moreover, each 

approach’s effectiveness would likely depend on how well it would match a 

particular therapeutic dyad, and a particular therapist’s style and preferences. At 

the same time, the freedom of choice plays into the therapist’s strength of using 

clinical judgment and intuition to assess the effect of chosen interventions, and, if 

need be, to adjust the nest. The Nested Hierarchy principle can always guide the 

therapist in constructing a nest, lest s/he feels ‘lost’ in the multitude of available 

interventions. It allows the therapist to make a theory-informed choice of 

interventions without being restricted to a particular treatment package or brand. 

 

“Integrate-as-you-go” also means that there are as many therapies as 

there are cases.  

This clearly presents a challenge to therapy outcome research. The proposed 

case-based research program described above may serve as complementary to 

the randomized controlled trial research paradigm. In that approach, Justin’s 

case would be represented in the database as shown in Figure 4 along with its 

hierarchical nest (see Figure 3), required psychometric measures, diagnoses, 

and demographics. 

 

 



  
 

International Journal of Integrative Psychotherapy, Vol. 8, 2017 
 

69 

Verbal             Non-verbal 

 

BLS* 

Behavioral 

practice, days 

(outside 

session) 

Medications, 

days  

(outside 

session) 

Total sessions 

Developing insight 3 5 30 240 20 

Analysis of 

transference 1 

    Challenging 

cognitions/offering 

interpretation 7 5 
   Confronting 

disturbing thoughts 

and feelings 11 5 
   Self-monitoring 

 
5 

   Resources 

development and 

'installation.' 2 2 
   Unstructured 

interventions 3 

     

Figure 4:  Justin’s Intervention Grid  

*BLS =  sets of saccadic eye movements, 25-30 movements each. 

Intervention doses are measured in number of sessions, where they were used, unless 

indicated otherwise. The sum of all sessions by intervention is greater than the total 

number of sessions, because more than one intervention was used per session. 

 

 

Conclusion 

This paper demonstrates how the Nested Hierarchy principle 

accommodates four main strategies of psychotherapy integration - theoretical, 

principle-based assimilative, common factors, and eclectic - by organizing them 

into a hierarchical nest  (Figure 1 & 3). Such hierarchy can guide and constrain 

integration of interventions and their supporting theories. NH taxonomy may 

inform practitioners about the relationship between therapy nests. One of the 

features of NH is its high flexibility at the lower levels (Figure 1), which allows for 

adjustment of the treatment to a given therapeutic encounter, thus increasing the 

treatment’s specificity. 

 



  
 

International Journal of Integrative Psychotherapy, Vol. 8, 2017 
 

70 

One overarching debate in psychotherapy research, although not always 

framed this way, is that of the art of therapy vs. the science of therapy. The 

medical model is incompatible with the art model, yet therapy is commonly 

referred to as an art. NH principles of psychotherapy integration offer a unifying 

model, whereby integration is organized by scientific rules and its effectiveness is 

studied with scientific means, and where therapeutic process is artfully 

constructed by the therapist in an encounter with the client. We see it as 

analogous to staging a play. The same script can inspire an infinite number of 

renditions, each powerful in its unique way, although some of them are bound to 

be a flop. 

 

The fact that even most effective therapies have a non-response rate of 

30% and that randomized controlled trials demonstrate similar effect sizes for 

different therapies demonstrates that there may be a significant need for such 

unique renditions to target clients unresponsive to the standard protocols. How 

do we define an effective therapist?  Is it the one who consistently produces 70% 

success rate, or the one who is able to succeed with the remaining 30%? There 

is no evidence that the same set of skills is required for the former and the latter. 

If indeed, as suspected, the skills differ at least in part, the Nested Hierarchy 

approach accommodates the therapist in pursuit of either more prototypical or 

more integrative therapies according to his or her strengths and weaknesses. 
 

 

Author: 

Dr. Valery Krupnik earned his Ph.D. in molecular biology from the Institute of 

Microbiology and Epidemiology in Moscow, Russia, and did research in 

immunology and neurodevelopment. He then made a career change to become a 

practicing psychotherapist. He initially trained in psychodynamic therapy at 

Salem State University in Salem, Massachusetts, and became a fellow with the 

American Psychoanalytic Association. His later interests include development of 

integrative therapy for depression and applying EMDR to its treatment. He is a 

certified EMDR therapist and a member of the EMDR International Asssociation.  

He is currently practicing at the department of mental health of the Naval Hospital 

at Camp Pendleton, California.  

 

 

 

 

 

 



  
 

International Journal of Integrative Psychotherapy, Vol. 8, 2017 
 

71 

References 

 

Ablon, J. S., & Jones, E. E. (1999). Psychotherapy process in the national 

institute of mental health treatment of depression collaborative research 

program. Journal of Consulting and Clinical Psychology, 67, 64-75. doi: 

10.1037/0022-006X.67.1.64 

Ablon, J. S., & Jones, E. E. (2002). Validity of controlled clinical trials of 

psychotherapy: findings from the NIMH Treatment of Depression 

Collaborative Research Program. Am J Psychiatry, 159, 775-783.  

Ablon, J. S., & Jones, E. E. (2005). On analytic process. Journal of the American 

Psychoanalytic Association, 53, 541-568.                                               

doi: 10.1177/00030651050530020101 

American Psychiatric Association. (2013). Diagnostic andstatistical manual of 

mental disorders (5th ed.). Arlington,VA: Author. 

Andrews, P. W., & Thompson, J. A. (2009). The bright side of being blue: 

Depression as an adaptation for analyzing complex problems. Psychol 

Review, 116, 620-654.  

Bacal, H. A., & Carlton, L. (2011). The power of specificity in psychotherapy: 

When therapy works—and when it doesn't. Plymouth, UK: Jason Aronson. 

Bae, H., Kim, D., & Park, Y. C. (2008). Eye movement desensitization and 

reprocessing for adolescent depression. Psychiatry investigation, 5, 60-65. 

Barlow, D. H., Allen, L. B., & Choate, M. L. (2004). Toward a unified treatment for 

emotional disorders. Behavior Therapy, 35, 205-230.  

Beck, A. T. (1967). Depression: clinical, experimental, and theoretical aspects. 

New York: Hoeber Medical Division, Harper & Row. 

Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for the Beck Depression 

Inventory-II. San Antonio, TX: The Psychological Corporation. 

Beebe, B., & Lachmann, F. M. (2002). Infant research and adult treatment: Co-

constructing interactions.: Analytic Press, Inc. 

Beutler, L. E. (2011). Prescriptive matching and systematic treatment selection. 

In J. C. Norcross, VandenBos, G. R., Freedheim, D. K. (Ed.), History of 

psychotherapy: Continuity and change (2nd ed., pp. 402-417). 

Washington, DC: American Psychological Association. 

Beutler, L. E., & Clarkin, J. F. (2014). Systematic treatment selection: Toward 

targeted therapeutic interventions. New York: Routledge. 

Bisson, J., Roberts, N., Andrew, M., Cooper, R., & Lewis, C. (2013). 

Psychological therapies for chronic post-traumatic stress disorder (PTSD) 

in adults (Review). Cochrane Database of Systematic Reviews, (12), Art. 

No.: CD003388.  doi:10.1002/14651858.CD003388.pub4 



  
 

International Journal of Integrative Psychotherapy, Vol. 8, 2017 
 

72 

Bowlby, J. (1988). A secure base: Parent-child attachment and healthy human 

development.: Basic Books Inc. 

Bradley, R., Greene, J., Russ, E., Dutra, L., & Westen, D. (2005). A 

multidimensional meta-analysis of psychotherapy for PTSD. American 

Journal of Psychiatry, 162, 214-227. doi: 10.1176/appi.ajp.162.2.214 

Broad, R. D., & Wheeler, K. (2006). An adult with childhood medical trauma 

treated with psychoanalytic psychotherapy and EMDR: A case study. 

Perspectives in Psychiatric Care, 42, 95-105. 

Brooks-Harris, J. E. (2008). Integrative Multitheoretical Psychotherapy. Boston: 

Houghton-Mifflin. 

Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T. (2006). The empirical 

status of cognitive-behavioral therapy: a review of meta-analyses. Clinical 

Psychology Review, 26, 17-31.  

Cohen, J. A., Deblinger, E., Mannarino, A. P., & Steer, R. A. (2004). A multisite, 

randomized controlled trial for children with sexual abuse–related PTSD 

symptoms. Journal of the American Academy of Child & Adolescent 

Psychiatry, 43, 393-402. doi: 10.1097/00004583-200404000-00005 

Coubard, O. A. (2014). Eye Movement Desensitization and Reprocessing 

(EMDR) re-examined as cognitive and emotional neuroentrainment. 

Frontiers in human neuroscience, 8, 1035.doi: 10.3389/fnhum.2014.01035 

Craske, M. G., Kircanski, K., Zelikowsky, M., Mystkowski, J., Chowdhury, N., & 

Baker, A. (2008). Optimizing inhibitory learning during exposure therapy. 

Behaviour Research and Therapy, 46, 5-27.                                            

doi: 10.1016/j.brat.2007.10.003 

Erskine, R. G., & Trautmann, R. L. (1996). Methods of an integrative 

psychotherapy. Transactional Analysis Journal, 26, 316-328. 

Erskine, R. G., & Moursund, J. P. (2011). Integrative psychotherapy in action. 

London, UK: Karnac Books. 

Erskine, R., Moursund, J., & Trautmann, R. (2013). Beyond Empathy: A Therapy 

of Contact-in Relationships. Routledge. 

Erskine, R. G. (2015). Relational patterns, therapeutic presence: Concepts and 

practice of integrative psychotherapy. Karnac Books. 

Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: exposure to 

corrective information. Psychological Bulletin, 99, 20-35.                        

doi: 10.1037/0033-2909.99.1.20 

Foa, E. B., & Rothbaum, B. O. (2001). Treating the trauma of rape: Cognitive-

behavioral therapy for PTSD. New York: Guilford Press. 

Forgash, C., & Knipe, J. (2008). Integrating EMDR and ego state treatment for 

clients with trauma disorders. In C. Forgash & M. Copely (Eds.), Healing 



  
 

International Journal of Integrative Psychotherapy, Vol. 8, 2017 
 

73 

the heart of trauma and dissociation with EMDR and ego state therapy 

(pp. 1-59). New York: Springer. 

Franks, C. M., & Wilson, G. T. (Eds.). (1974). Annual review of behavior therapy: 

Theory and practice. New York: Brunner/Mazel. 

Freud, S. (1966). The complete introductory lectures on psychoanalysis (J. 

Strachey, Trans.). New York: W. W. Norton & Company, Inc. 

Gauhar, Y. W. M. (2016). The efficacy of EMDR in the treatment of depression. 

Journal of EMDR Practice and Research, 10, 59-69. doi: 10.1891/1933-

3196.10.2.59 

Giosan, C., Cobeanu, O., Mogoase, C., Muresan, V., Malta, L. S., Wyka, K., & 

Szentagotai, A. (2014). Evolutionary cognitive therapy versus standard 

cognitive therapy for depression: a protocol for a blinded, randomized, 

superiority clinical trial. Trials, 15, 83. doi: doi:10.1186/1745-6215-15-83 

Goldfried, M. R. (1980). Toward the delineation of therapeutic change principles. 

American Psychologist, 35, 991-999. doi: 10.1037/0003-066X.35.11.991  

Grey, E. (2011). A pilot study of concentrated EMDR: A brief report. Journal of 

EMDR Practice and Research, 5, 14-24. doi: 10.1891/1933-3196.5.1.14 

Group, B. C. P. S. (2010). Change in psychotherapy: A unifying paradigm. New 

York: WW Norton & Company. 

Haby, M. M., Donnelly, M., Corry, J., & Vos, T. (2006). Cognitive behavioural 

therapy for depression, panic disorder and generalized anxiety disorder: a 

meta-regression of factors that may predict outcome. Australian and New 

Zealand Journal of Psychiatry, 40, 9-19.  

Hayes, A. M., Beevers, C. G., Feldman, G. C., Laurenceau, J.-P., & Perlman, C. 

(2005). Avoidance and processing as predictors of symptom change and 

positive growth in an integrative therapy for depression. International 

Journal of Behavioral Medicine, 12, 111-122.              

doi: 10.1207/s15327558ijbm1202_9 

Hayes, A. M., & Harris, M. S. (2000). The development of an integrative 

treatment for depression. In S. Johnson, A. M. Hayes, T. Field, N. 

Schneiderman & P. McCabe (Eds.), Stress, coping, and depression (pp. 

291-306). Mahwah, NJ: Lawrence Erlbaum. 

Herkt, D., Tumani, V., Grön, G., Kammer, T., Hofmann, A., & Abler, B. (2014). 

Facilitating access to emotions: neural signature of EMDR stimulation. 

PloS one, 9(8).  doi:10.1371/journal.pone.0106350 

Hill, C. E. (2005). Therapist techniques, client involvement, and the therapeutic 

relationship: Inextricably intertwined in the therapy process. 

Psychotherapy: Theory, Research, Practice, Training, 42, 431-442.       

doi: 10.1037/0033-3204.42.4.431 



  
 

International Journal of Integrative Psychotherapy, Vol. 8, 2017 
 

74 

Hill, C. E. (2009). Reaction to Goldfried (1980): What about therapist techniques? 

Applied and Preventive Psychology, 13, 16-18.                                       

doi: 10.1016/j.appsy.2009.10.006 

Hoffart, A., & Hoffart, A. R. (2014). Psychotherapy integration through general 

therapy change principles: Missing the core of psychotherapy? Journal of 

psychotherapy integration, 24, 263-274. doi: 10.1037/a0038135 

Hofmann, A., Hilgers, A., Lehnung, M., Liebermann, P., Ostacoli, L., Schneider, 

W., & Hase, M. (2014). Eye Movement Desensitization and Reprocessing 

as an Adjunctive Treatment of Unipolar Depression: A Controlled Study. 

Journal of EMDR Practice and Research, 8, 103-112.                             

doi: http://dx.doi.org/10.1891/1933-3196.8.3.103 

Hollon, S. D., Thase, M. E., & Markowitz, J. C. (2002). Treatment and Prevention 

of Depression. Psychological Science in the Public Interest, 3, 39-77.  

Jeffries, F. W., & Davis, P. (2013). What is the role of eye movements in eye 

movement desensitization and reprocessing (EMDR) for post-traumatic 

stress disorder (PTSD)? A review. Behavioural and cognitive 

psychotherapy, 41, 290-300.                                                                    

doi: 10.1017/S1352465812000793 

Jorm, A., Allen, N., Morgan, A., & Purcell, R. (2009). A Guide to What Works for 

Depression. Melbourne: beyondblue. 

Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom of your body and 

mind to face stress, pain, and illness. New York: Bantam Dell. 

Keller, M. C., & Nesse, R. M. (2006). The evolutionary significance of depressive 

symptoms: different adverse situations lead to different depressive 

symptom patterns. Journal of Personality and Social Psychology, 91, 316-

330.  

Knipe, J. (2015). EMDR Toolbox: Theory and Treatment of Complex PTSD and 

Dissociation. New York: Springer. 

Krupnik, V. (2014). A Novel Therapeutic Frame for Treating Depression in Group 

Treating Depression Downhill. SAGE Open, 4, 1-12. doi: 

10.1177/2158244014523793 

Krupnik, V. (2015a). Integrating EMDR Into a Novel Evolutionary-Based Therapy 

for Depression: A Case Study of Postpartum Depression. Journal of 

EMDR Practice and Research, 9, 137-149.  

Krupnik, V. (2015b). Integrating EMDR into an evolutionary‐based therapy for 

depression: a case study. Clinical case reports, 3, 301-307. doi: 

10.1002/ccr3.228 

Laska, K. M., Gurman, A. S., & Wampold, B. E. (2014). Expanding the lens of 

evidence-based practice in psychotherapy: A common factors perspective. 

Psychotherapy, 51, 467-481. doi: 10.1037/a0034332  

http://dx.doi.org/10.1891/1933-3196.8.3.103


  
 

International Journal of Integrative Psychotherapy, Vol. 8, 2017 
 

75 

Luborsky, L., Rosenthal, R., Diguer, L., Andrusyna, T. P., Berman, J. S., Levitt, J. 

T., . . . Krause, E. D. (2002). The dodo bird verdict is alive and well—

mostly. Clinical Psychology: Science and Practice, 9, 2-12.  

Marci, C. D., Moran, E. K., & Orr, S. P. (2004). Physiologic evidence for the 

interpersonal role of laughter during psychotherapy. The Journal of 

nervous and mental disease, 192, 689-695. doi: 

10.1097/01.nmd.0000142032.04196.63 

Marcus, S. V. (2008). Phase 1 of Integrated EMDR An Abortive Treatment for 

Migraine Headaches. Journal of EMDR Practice and Research, 2, 15-25. 

doi: DOI: 10.1891/1933-3196.2.1.15 

Maslow, A. H. (1943). A theory of human motivation. Psychological Review, 50, 

370-396. doi: 10.1037/h0054346 

Maxfield, L., & Hyer, L. (2002). The relationship between efficacy and 

methodology in studies investigating EMDR treatment of PTSD. Journal of 

Clinical Psychology, 58, 23-41. doi: 10.1002/jclp.1127 

Messer, S. B., & Wampold, B. E. (2002). Let's face facts: Common factors are 

more potent than specific therapy ingredients. Clinical Psychology: 

Science and Practice, 9, 21-25. doi: 10.1093/clipsy.9.1.21 

Miller, R. (2010). The feeling-state theory of impulse-control disorders and the 

Impulse-Control Disorder Protocol. Traumatology, 16, 2-10. doi: DOI: 

10.1177/1534765610365912 

Mosquera, D., Leeds, A. M., & Gonzalez, A. (2014). Application of EMDR 

Therapy for Borderline Personality Disorder. Journal of EMDR Practice 

and Research, 8, 74-89.  

Nettle, D. (2004). Evolutionary origins of depression: a review and reformulation. 

Journal of Affective Disorders, 81, 91-102.  

Norcross, J. C. (2005). A primer on psychotherapy integration. In J. C. Norcross 

& M. R. Goldfried (Eds.), Handbook of psychotherapy integration (2nd ed., 

pp. 3-23). New York: Oxford University Press. 

Norcross, J. C., Karpiak, C. P., & Lister, K. M. (2005). What's an integrationist? A 

study of self‐identified integrative and (occasionally) eclectic 

psychologists. Journal of Clinical Psychology, 61, 1587-1594. doi: 1 0 .1 0 

0 2 / jclp.2 0 2 0 3 

Norcross, J. C., & Wampold, B. E. (2011). What works for whom: Tailoring 

psychotherapy to the person. Journal of Clinical Psychology, 67, 127-132. 

doi: 10.1002/jclp.20764 

Parker, G., & Fletcher, K. (2007). Treating depression with the evidence-based 

psychotherapies: a critique of the evidence. Acta Psychiatrica 

Scandinavica, 115, 352-359.  



  
 

International Journal of Integrative Psychotherapy, Vol. 8, 2017 
 

76 

Parker, G., Roy, K., & Eyers, K. (2003). Cognitive behavior therapy for 

depression? Choose horses for courses. Am J Psychiatry, 160, 825-834.  

Parker, G. B., Malhi, G. S., Crawford, J. G., & Thase, M. E. (2005). Identifying 

"paradigm failures" contributing to treatment-resistant depression. Journal 

of Affective Disorders, 87, 185-191.  

Paulsen, S., & Lanius, U. (2009). Toward an embodied self: Integrating EMDR 

with somatic and ego state interventions. In R. Shapiro (Ed.), EMDR 

solutions II (pp. 337-388). New York: Norton. 

Paulsen, S. L. (2008). Treating dissociative identity disorder with EMDR, ego 

state therapy and adjunct approaches. In C. Forgash & M. Copely (Eds.), 

Healing the heart of trauma and dissociation with EMDR and ego state 

therapy (pp. 141-179). New York: Springer. 

Popky, A. J. (2005). DeTUR, an urge reduction protocol for addictions and 

dysfunctional behaviors. In R. Shapiro (Ed.), EMDR solutions: pathways to 

healing (pp. 167-188). New York: Norton. 

Prochaska, J. O., & DiClemente, C. C. (1986). Toward a comprehensive model 

of change. In W. R. Miller & N. Heather (Eds.), Treating Addictive 

Behaviors: Processes of Change (Vol. 13, pp. 3-27). New York: Springer. 

Prowse, P., & Nagel, T. (2015). A Meta-Evaluation: The Role of Treatment 

Fidelity within Psychosocial Interventions during the Last Decade. J 

Psychiatry, 18, 1-7. doi: 10.4172/psychiatry.1000251 

Rachman, S. (1997). The evolution of cognitive behaviour therapy. In D. M. Clark 

& C. G. Fairburn (Eds.), Science and practice of cognitive behaviour 

therapy (pp. 3-26). New York: Oxford University Press. 

Resick, P. A., & Schnicke, M. (1993). Cognitive processing therapy for rape 

victims: A treatment manual. Newbury Park, CA: Sage. 

Ryan, R. M., Lynch, M. F., Vansteenkiste, M., & Deci, E. L. (2011). Motivation 

and autonomy in counseling, psychotherapy, and behavior change: A look 

at theory and practice. The Counseling Psychologist, 39, 193-260. doi: 

10.1177/0011000009359313 

Schottenbauer, M. A., Glass, C. R., & Arnkoff, D. B. (2005). Outcome research 

on psychotherapy integration. In J. C. Norcross & M. R. Goldfried (Eds.), 

Handbook of psychotherapy integration (2nd ed., pp. 459-493). New York: 

Oxford University Press. 

Shapiro, E., & Laub, B. (2008). Early EMDR intervention (EEI): A summary, a 

theoretical model, and the recent traumatic episode protocol (R-TEP). 

Journal of EMDR Practice and Research, 2, 79-96. doi: 10.1891/1933-

3196.2.2.79 



  
 

International Journal of Integrative Psychotherapy, Vol. 8, 2017 
 

77 

Shapiro, F. (1989). Eye movement desensitization: A new treatment for post-

traumatic stress disorder. Journal of behavior therapy and experimental 

psychiatry, 20, 211-217.  

Shapiro, F. (2001). Eye movement desensitization and reprocessing: Basic 

principles, protocols and procedures (2nd ed.). New York: Guilford Press. 

Shapiro, F. (2014). The Role of Eye Movement Desensitization and 

Reprocessing (EMDR) Therapy in Medicine: Addressing the Psychological 

and Physical Symptoms Stemming from Adverse Life Experiences. The 

Permanente Journal, 18, 71-77. doi: http://dx.doi.org/10.7812/TPP/13-098 

Shapiro, R. E. (2009). EMDR solutions II: For depression, eating disorders, 

performance, and more. New York, NY: WW Norton & Company. 

Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American 

Psychologist, 65, 98-109.  

Siegel, I. R. (2013). Therapist as a Container for Spiritual Resonance and Client 

Transformation in Transpersonal Psychotherapy: an exploratory heuristic 

study. Association for Transpersonal Psychology, 45, 49-74.  

Solomon, R. M., & Shapiro, F. (2008). EMDR and the Adaptive Information 

Processing Model: Potential mechanisms of change. Journal of EMDR 

Practice and Research, 2, 315-325. doi: http://dx.doi.org/10.1891/1933-

3196.2.4.315 

Stern, D. (2005). Intersubjectivity. In E. S. Person, A. M. Cooper & G. O. 

Gabbard (Eds.), The American psychiatric publishing textbook of 

psychoanalysis. (pp. 77-92): American Psychiatric Publishing, Inc. 

Stolorow, R. D., & Atwood, G. E. (1992). Contexts of being: The intersubjective 

foundations of psychological life.: Analytic Press, Inc. 

Strauman, T. J., Goetz, E. L., Detloff, A. M., MacDuffie, K. E., Zaunmüller, L., & 

Lutz, W. (2013). Self‐Regulation and Mechanisms of Action in 

Psychotherapy: A Theory‐Based Translational Perspective. Journal of 

Personality, 81, 542-553. doi: DOI: 10.1111/jopy.12012 

Thelen, E., & Smith, L. B. (1994). A dynamic systems approach to the 

development of cognition and action.: The MIT Press. 

Tronick, E. Z. (1998). Dyadically expanded states of consciousness and the 

process of therapeutic change. Infant Mental Health Journal, 19, 290-299.  

Uribe, M. E. R., Ramírez, E. O. L., & Mena, I. J. (2010). Effect of the EMDR 

psychotherapeutic approach on emotional cognitive processing in patients 

with depression. The Spanish journal of Psychology, 13, 396-405. 

Watt, D. F., & Panksepp, J. (2009). Depression: An Evolutionarily Conserved 

Mechanism to Terminate Separation Distress? A Review of Aminergic, 

Peptidergic, and Neural Network Perspectives. Neuropsychoanalysis, 11, 

7-109.  

http://dx.doi.org/10.7812/TPP/13-098
http://dx.doi.org/10.1891/1933-3196.2.4.315
http://dx.doi.org/10.1891/1933-3196.2.4.315


  
 

International Journal of Integrative Psychotherapy, Vol. 8, 2017 
 

78 

Williams, J. M. G., Teasdale, J. D., Segal, Z. V., & Kabat-Zinn, J. (2007). The 

mindful way through depression: Freeing yourself from chronic 

unhappiness. New York: Guilford Press.