Beyond Combining Therapy Models: How Integrative Psychological Practice Actually Works
A psychologist's perspective on how we move from knowing different therapy models to thinking integratively in clinical practice.
There are times in psychological work when an understanding makes sense, but something still does not quite fit.
We may have a thoughtful formulation, a therapeutic model that explains an important part of what is happening, or a familiar way of understanding a particular difficulty. Then something emerges that asks us to look again.
For me, this is where an integrative approach to therapy becomes particularly meaningful.
There is already a substantial literature on psychotherapy integration, including different ways of bringing therapeutic theories, methods and common therapeutic processes together (Norcross & Goldfried, 2019). Other bodies of psychological thinking help us understand formulation, the therapeutic relationship, practitioner reflexivity, culture and power, or how clinicians develop through supervision. Each contributes something important.
The question I am interested in here is how these different forms of psychological thinking relate in practice.
When we are sitting with a particular person, how do we decide what deserves attention? How does one perspective affect another? What helps us recognise when an existing understanding needs to be reconsidered? And how do our own assumptions, relationships and ways of seeing enter that process?
Integration is therefore more than drawing from different therapeutic approaches. Knowing more models does not necessarily tell us how those models should relate to one another, which perspective deserves greater weight, or what to do when a person's experience does not fit comfortably within the understanding we already hold.
This article explores how we think with different forms of psychological knowledge while remaining responsive to the person in front of us.
That involves theory and formulation, but also relationship, context, clinical judgement and reflexivity. It requires us to recognise what a perspective can illuminate without expecting it to explain everything.
When One Psychological Explanation Is Not Enough
We may have developed a thoughtful formulation of why someone finds closeness difficult and see their earlier attachment experiences as an important part of that picture. As the work develops, something else may become visible. Perhaps closeness carries a different meaning within their family or cultural context. Perhaps their responses differ depending on who they are with, the language they are speaking, or how safe they feel in the relationship.
The earlier understanding has not necessarily become wrong. Something else has become visible.
What seemed clear at one stage may look different as trust develops, circumstances shift, or we encounter something that our existing explanation does not quite hold.
People bring histories, relationships, bodies, cultures and social worlds into therapy. These do not sit neatly beside one another. They interact, and their significance can differ across situations and over time. Any psychological model inevitably brings some aspects of that experience into clearer focus than others.
The question, then, is what we do when something does not fit.
A client's response may surprise us. A familiar intervention lands differently. Something we understood as avoidance begins to look more like protection. We might notice that an explanation which had made good psychological sense leaves an important part of the experience untouched.
These moments can be clinically useful. They show us the edges of what our current understanding can explain.
Integrative practice begins, in part, with being able to notice those edges without assuming that we must either defend the existing explanation or discard it. Another way of understanding may illuminate something that was previously difficult to see.
The challenge is how we bring that knowledge into the work.
Integrative Practice Is More Than Knowing More Models
As therapists and psychologists develop, our repertoire usually grows.
We encounter different therapeutic traditions, psychological theories, formulation frameworks and ways of thinking about clinical work. Some become central to how we practise. Others help us think about particular experiences or answer particular questions.
Breadth can be valuable. Yet knowing more models does not tell us how to think with them. Psychotherapy integration includes established approaches such as theoretical integration, assimilative integration, technical eclecticism and common-factors approaches (Norcross & Goldfried, 2019). The distinction I am making here concerns a slightly different question: what happens in our thinking when more than one perspective becomes relevant to understanding a person.
A distinction I find useful in practice is between accumulation, inclusion and integration.
From Knowing More to Thinking Integratively
Accumulation expands what we know. Inclusion broadens what we remember to consider. Integration allows what we learn to shape how we understand what is happening.
A formulation can contain many perspectives without those perspectives ever really meeting. We may acknowledge culture, trauma, neurodivergence, relationships or wider systems, for example, while continuing to understand the person's difficulty in essentially the same way as before.
Integration asks whether this additional knowledge affects the thinking. It may alter the questions we ask, challenge an assumption, give different meaning to something we had already observed, or strengthen an understanding that was beginning to emerge.
Different forms of psychological knowledge do not all need to do the same work.
A theory may help us recognise a pattern. Context may alter the meaning we give to it. Something happening within the therapeutic relationship may reveal information that was not available through history alone.
Their usefulness lies partly in knowing what we are asking each to help us understand.
The reference point remains the person whose experience we are trying to understand, within the relationships and contexts through which that experience has developed.
Once different understandings become relevant, the question is how to bring them together without simply collecting them.
Formulation: How Different Understandings Are Organised
This is one of the places where psychological formulation becomes particularly useful.
Contemporary British Psychological Society guidance describes formulation as ongoing collaborative sense-making based on the person's account alongside psychological evidence, theory and principles. It explicitly includes social, systemic, environmental, biological, embodied, cultural and relational factors, and emphasises that formulation remains open to revision as new information becomes available (British Psychological Society, 2025).
Formulation gives us a process for asking how different pieces of information and different psychological hypotheses relate. Its value within integrative practice lies less in how much we can include and more in what happens between the understandings we are considering.
One hypothesis may become more convincing as the work develops. Another may explain one aspect of someone's experience but carry relatively little weight elsewhere. Two perspectives that initially appear to compete may turn out to illuminate different parts of the same pattern. New information can also alter the meaning of something that previously seemed well understood.
There will be pieces that remain unresolved.
That matters too. A formulation does not become stronger simply because every ambiguity has been explained. At times, recognising that we do not yet understand something protects us from creating coherence too quickly.
The person's own understanding also belongs within this process.
Psychological knowledge may help us notice patterns or ask questions that would otherwise remain unexplored, while the formulation still needs to remain responsive to how someone experiences their own life. Their account can support an emerging hypothesis, complicate it, or show us that the meaning we had given to something does not fit.
What matters is that the person's account remains capable of affecting the formulation rather than being absorbed into one that has already been decided.
Formulation is therefore useful here because it provides an organising and revisable psychological understanding. It allows different forms of knowledge to interact without requiring every perspective to receive equal importance.
A richer formulation does not necessarily need to become a more complicated one. Sometimes considering several possibilities helps us see more clearly what appears central. At other times, the most accurate formulation needs to retain uncertainty.
I explore psychological formulation in clinical practice in greater depth elsewhere. For integrative practice, the important point is narrower:
Formulation gives different understandings somewhere to meet, test one another and develop.
The different parts of integrative psychological thinking can therefore be understood as related processes rather than separate models. The following map shows how I conceptualise these relationships in practice.
How I Conceptualise Integrative Psychological Practice
Reconsideration does not necessarily mean changing the formulation. An additional perspective may strengthen an existing understanding, differentiate it, revise it, or leave us appropriately uncertain.
We can make this more concrete by looking at what happens when several ways of understanding the same clinical moment become available.
What Integration Looks Like in Practice
The following composite example is used to illustrate the clinical thinking process rather than describe a particular client.
Consider a client who becomes noticeably quieter whenever therapy moves towards emotionally difficult material.
The difference is observable. Its meaning is less certain.
Perhaps we initially wonder whether the client is withdrawing from something difficult. There may be good clinical reasons for that hypothesis, particularly if silence appears when the conversation approaches experiences they have previously found difficult to think or talk about.
A trauma-informed perspective might draw our attention towards safety. What happens for this person as difficult material becomes more immediate? Does silence help create distance from something overwhelming, or offer a way of remaining in the conversation when speaking feels harder?
Knowing that the client is neurodivergent may bring different questions into view. Emotional intensity can interact with processing demands, and immediate verbal expression may become harder when several things need to be processed at once. A longer pause might therefore tell us something different from disengagement.
Culture and language can alter the picture again. Silence does not carry the same relational meaning in every context, and speaking openly is not universally experienced as the clearest sign of engagement. What feels possible to say may also differ according to language, family expectations, previous experiences of authority, or the meanings attached to emotional disclosure.
None of this tells us what the client's silence means.
It changes what we are prepared to consider.
Then, during one session, the therapist notices something happening between them. As the silence lengthens, they become increasingly concerned that the client is struggling and begin asking more questions. The client answers briefly, and the therapist tries another question. The client becomes quieter still.
The clinical picture now looks different.
Something initially understood as a response occurring within the client can also be considered relationally. The therapist's understandable attempt to help may be increasing the very pressure the client is trying to manage. Perhaps the silence creates space the client needs. Perhaps the questions are experienced as an expectation to respond before they are ready. There may be another meaning altogether that neither therapist nor client has yet understood.
The silence may be significant, but its psychological meaning is not contained within the behaviour itself.
The therapist might respond differently now. Rather than filling the silence immediately, they could allow more space and later become curious with the client about what those moments are like.
Their account may support one of the possibilities already considered, challenge it, or take the enquiry somewhere different.
This is where integration becomes more than having several explanations available.
The trauma-informed perspective has not simply been added beside the neurodivergent, cultural and relational perspectives. Each has altered the questions being asked of the same clinical material. What first appeared to be avoidance may come to be understood as protection, processing, communication, a response to interpersonal pressure, or some interaction between these experiences.
And if the meaning is different, the therapeutic response may need to be different too.
A useful question for integrative practice is therefore:
Has another perspective simply been added to what we already know, or has it genuinely affected how we understand what is happening?
One Observation, Several Possible Lines of Enquiry
The purpose is not to choose between these possibilities as though one must provide the explanation. These perspectives broaden enquiry. Their integrative value lies in what happens when they interact with the developing understanding.
Several interpretations may now be plausible, but possibility alone cannot tell us which deserves clinical weight.
That requires something more from the practitioner.
Discernment, Reflexivity and the Capacity to Revise
What Deserves Weight?
Once several ways of understanding a clinical moment become possible, we have to decide what deserves weight.
A perspective may be relevant without being central.
Integrative thinking does not require us to consider every possible perspective at every moment. Part of clinical judgement is recognising what appears most relevant now, while remaining able to widen or reconsider our understanding when the work asks us to.
One hypothesis may become better supported as the work develops, while another becomes less convincing. Sometimes widening our thinking adds necessary complexity; sometimes it helps us see more clearly what appears to matter most.
The client's own understanding belongs within this process. Psychological knowledge can help us notice patterns and make connections, but those connections remain open to what the person knows about their own experience. Do they recognise what we are describing? Is there something our psychological language has made harder to see?
Agreement is not the only measure of a useful formulation. Differences in understanding can themselves become clinically meaningful, and there will also be times when neither person can yet determine what something means.
I think this could be important, but I do not yet understand enough to know what it means.
Discernment is one part of clinical judgement: weighing what appears relevant, what seems central, what remains uncertain, and what may need further enquiry.
And that raises another question:
Who is doing the judging?
Who Is Doing the Understanding?
Psychological understanding is always developed from somewhere.
As practitioners, we bring training, clinical experience and theoretical preferences into the room. We also bring personal histories, cultural worlds, social positions and assumptions about relationships, communication, distress and what change might look like.
Reflexivity brings our own position into the enquiry. Contemporary professional supervision guidance explicitly recognises reflective practice and reflexivity, alongside attention to equity, diversity and inclusion within psychological practice (British Psychological Society, 2024).
Reflection can help us consider what happened in a session, what we noticed and how we responded. Reflexivity asks something further:
How might I be participating in the understanding I am developing?
A therapist may feel unusually protective towards a client. One way of communicating may feel immediately familiar, while another is harder to read. Independence may intuitively appear to represent progress. These responses may tell us something about the client or relationship, while also giving us reason to examine the expectations through which we are interpreting what we see.
Our theoretical knowledge shapes attention too. Extensive trauma experience may make protective responses particularly visible. Relational training may sensitise us to what is happening between people. Systemic thinking may bring relationships, institutions and social conditions more readily into view.
These are valuable clinical capacities. Reflexivity keeps us interested in both what our knowledge makes visible and what it may make easier to overlook.
Culture and power make this especially important. Therapist and client meet within social worlds and within a relationship that carries professional authority. Some assumptions become apparent when they are challenged; others feel so ordinary within our own experience that we may not initially recognise them as assumptions.
In practice, cultural humility becomes particularly meaningful at these edges of our knowledge. Cultural humility has been conceptualised as an other-oriented stance involving respect and a lack of superiority towards another person's cultural background and experience (Hook et al., 2013).
Can another person's meaning genuinely affect ours? Can we recognise when something that appeared psychologically obvious was partly shaped by our own position?
Power also affects what can become known. Inviting someone to contribute does not necessarily make disagreement easy. Differences in language, culture, age, social position or previous experiences of authority may shape whether a client feels able to say, that isn't how I understand it.
What remains unsaid may therefore matter too. Recognising this requires more than psychological knowledge alone; it also depends on how the practitioner carries that knowledge within the relationship.
From Discernment to Reflexive Practice
Remaining Open to Revision
Humility allows an understanding to be revised. Curiosity helps us stay with something that does not fit. Respect gives another person's meaning room to affect our own. Tolerance of uncertainty reduces the pressure to explain something before we understand enough. Vulnerability can involve recognising that we have misunderstood and allowing that recognition to influence how we proceed.
Different therapeutic traditions give us language for parts of this process. Psychodynamic thinking helps us attend to transference, countertransference and relational communication; person-centred traditions foreground congruence, empathy and unconditional positive regard (Rogers, 1957). Each illuminates something important about the human practitioner without providing the whole account.
These human qualities influence more than how psychological knowledge is communicated.
They influence what we become capable of knowing.
If uncertainty is difficult to tolerate, we may settle on an explanation too quickly. If our assumptions are difficult to question, additional knowledge will only take us so far. If disagreement feels difficult within the relationship, information capable of challenging our understanding may never become available.
Reflexivity does not remove the practitioner from psychological understanding. It allows our own way of seeing to remain available for examination.
Revision does not mean repeatedly replacing one formulation with another. Often it is smaller: giving something different weight, reconsidering an assumption, recognising a relational process, asking a different question, or acknowledging that something remains uncertain.
What matters is that our understanding remains responsive to what we encounter.
That capacity is central to integrative practice. It is also part of how an integrative practitioner develops.
Developing an Integrative Way of Thinking
Clinical experience repeatedly tests what we think we understand.
A familiar presentation unfolds differently from what we expected. An intervention that has helped elsewhere does not reach this person in the same way. A client's account gives different meaning to something we had interpreted one way, or supervision helps us recognise an assumption that had been difficult to see from inside the work.
What follows can become part of professional development.
We may return to theory, seek supervision, learn about an experience outside our existing knowledge, or reconsider a formulation we had previously found convincing.
The development lies in what we take from the encounter: perhaps a different question becomes available, or we become more sensitive to something we had previously overlooked.
Practitioner Development Is Not Model Accumulation
Encounter Something does not quite fit.
↓
Discrepancy My current understanding reaches an edge.
↓
Enquiry What else might help me understand this?
↓
Integration What does this knowledge do to my existing understanding?
↓
Development
My capacity to recognise, weigh and work across perspectives grows.
Over time, these encounters can create greater breadth.
A practitioner may become able to draw from different therapeutic traditions, bodies of psychological knowledge and clinical frameworks because their work has repeatedly required different kinds of understanding.
Breadth can therefore be an outcome of development without being its goal.
This affects our relationship with models.
Early in training, frameworks can provide important structure. They help us recognise patterns and organise clinical material while we are learning what to attend to. With experience, the models do not need to become less important.
Our relationship with them can become more discerning.
The question gradually shifts from knowing what a model says towards recognising what work we are asking it to do.
The Integrated Developmental Model can help us think about a supervisee's changing needs across professional development (Stoltenberg & McNeill, 2010), while the Seven-Eyed Model helps move attention across different parts of the therapeutic and supervisory process (Hawkins & Shohet, 2012; McMahon et al., 2022).
The Seven-Eyed Model already brings wider context into supervisory attention. Contemporary supervision practice and guidance make questions of culture, identity, equity, power and social position increasingly explicit (British Psychological Society, 2024).
The important question is not simply whether another perspective has been added, but whether attending to it affects how we understand what is happening across the work.
Expertise increasingly involves recognising what kind of question we are asking, what form of psychological knowledge might help us think about it, and when the question itself needs to change.
Professional development may give us access to more perspectives and frameworks. The deeper development lies in becoming increasingly able to recognise what each can illuminate, where its explanatory reach ends, and when what we encounter asks us to think differently.
That is the development of an integrative way of thinking.
Integration as an Ongoing Way of Thinking
Psychological understanding does not need to be complete in order to be useful.
A formulation may guide the work while remaining open to what another perspective, something emerging within the relationship, or the person's own account may allow us to see differently.
Integrative practice asks us to remain responsive to this. We need enough psychological coherence to guide the work, alongside enough openness for what we encounter to affect that understanding.
Perhaps this is part of what develops with experience. We can know more while becoming more aware of what we do not yet know, and more able to reconsider our thinking when the work asks something different of us.
Our theories matter. Our frameworks matter. The experience we develop over years of practice matters.
And the person in front of us may still show us something that none of them had prepared us to see.
Remaining able to notice that is part of the work.
Clinical Supervision with Dr Tiffany Leung
I offer clinical supervision for psychologists, therapists and other psychological practitioners who want space to think more deeply about their clinical work, including formulation, therapeutic relationships, culture and context, practitioner development, and working integratively across different psychological perspectives.
My supervision is collaborative and formulation-led, with attention to both the clinical work and the practitioner developing within it.
This article draws on established literature in psychotherapy integration, psychological formulation, relational and reflexive practice, cultural humility and clinical supervision. The conceptual distinctions and maps used here reflect my practice-based synthesis of how these forms of psychological knowledge can interact within integrative clinical thinking; they are not presented as a separately validated model of psychotherapy.
References of Article How Integrative Psychological Therapy Practice Actually Works
British Psychological Society. (2024). Supervision guidance for psychologists. British Psychological Society. https://doi.org/10.53841/bpsrep.2024.rep178
British Psychological Society. (2025). Assessment, formulation, and diagnosis guidelines (adults). British Psychological Society. https://doi.org/10.53841/bpsrep.2025.rep188
Hawkins, P., & Shohet, R. (2012). Supervision in the helping professions (4th ed.). Open University Press.
Hook, J. N., Davis, D. E., Owen, J., Worthington, E. L., Jr., & Utsey, S. O. (2013). Cultural humility: Measuring openness to culturally diverse clients. Journal of Counseling Psychology, 60(3), 353–366. https://doi.org/10.1037/a0032595
McMahon, A., Jennings, C., & O'Brien, G. (2022). A naturalistic, observational study of the Seven-Eyed Model of supervision. The Clinical Supervisor, 41(1), 47–69. https://doi.org/10.1080/07325223.2021.2022060
Norcross, J. C., & Goldfried, M. R. (Eds.). (2019). Handbook of psychotherapy integration (3rd ed.). Oxford University Press. https://doi.org/10.1093/med-psych/9780190690465.001.0001
Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21(2), 95–103. https://doi.org/10.1037/h0045357
Stoltenberg, C. D., & McNeill, B. W. (2010). IDM supervision: An integrative developmental model for supervising counselors and therapists (3rd ed.). Routledge.
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