On the received wisdom about complexity and the problems of understanding

personalities and psychological problems

By Ian Rory Owen PhD,
Principal integrative psychotherapist,
Psychology and Psychotherapy Service,
Leeds and York Partnerships NHS Trust.
Abstract
This paper starts by making some brief comments on personality before focusing on
complexity. In the received wisdom about complexity, there are two major variables, a
persons personality style and their set of contextually-occurring psychological problems.
Psychological problems are defined in texts like DSM 5 and ICD 10 which express the
mainstream view of personality and distress offered by European and American psychiatry
and psychology. These definitions are not challenged but accepted for the purpose of
questioning the assumption of a clear difference between continual personality and on-off
contextually-defined problems. The model of integrative therapy commented on below
includes formulation which is a way of naming the interrelations between key aspects of what
developmentally has led to current problems and hypotheses about what maintains them
currently. It remains an open question as to whether therapy can alter personality but it is
more likely possible to improve the mood, self-esteem and functioning through understanding
themselves better and learning to tolerate distress.
Introduction
Phrases that point to the core of a persons personality are sayings like that is just him, this
is typically me and Ive always been like this as recognitions of a persons genuine or
authentic nature. The core of a person is their long-lasting habits, beliefs and skills including
their sensitivities to potentially problematic scenarios and the learned associations to
negativity that they defend themselves against, prior to their actual occurrence. Personality is
an attempt to define the style of an ego, of an individual, in a way that is not about their many
roles in contexts across the years but more about their style of authentic capabilities.
American psychiatry aimed to capture the distinctions that are recognised in clinical practice
by the idea that short-term problems were disorders or syndromes, axis I, whilst
personalities were axis II, not about contexts but entirely about the style that individuals
take to all contexts (American Psychiatric Association, 1994). I am using the word

syndrome to indicate that a number of presentations or variations could qualify for the
decontextualised definitions of these diagnoses. The co-occurrence of axis I and axis II
problems is referred to as co-morbidity, the most complex form of distress.
However, following Erving Goffman (1959), who was the first to argue that human
interactions are like the enactment of theatrical roles on a stage in a play, the performative
and contextual aspects of the self in culture and society are variable due to the roles taken
(worker, partner, brother, mother) and the contexts in which they are enacted (East End
working class, West Yorkshire Hindu). What is not-personality is what varies over context
and time; and what is truly personality entirely belongs to the individual and only changes
slowly over time in the absence of severe trauma. Since Plato the personality has been judged
to be a complex of habits, beliefs, associations plus the more socially-influenced aspects of
attachment style and the way that the self has learned to treat itself, often built on the model
of how it has been treated by others. Because of the necessity of understanding relational
styles and how they indicate the type of emotional functioning and relating that can be
recognised and expected (Owen, 2009a, 2009b, 2012), then it would seem that integrative
therapy, or indeed any other form, would be well-served by being able to identify the types of
thoughts, feelings and behaviours that coincide: For there are repeating patterns that comprise
the connection between personality style and how it exists socially, in a persons life as well
as in therapy relationships. This is where the received wisdom that focuses on specific
syndromes is useful but limited. For what complexity means is how to understand concurrent
multiple contextual syndromes that interact with long-standing idiosyncratic personalities.
The value of the DSM way of thinking of axis I and II is being able to record and
communicate between professionals. Thus, the terminology of paranoid, obsessive
compulsive personality and depression and phobias are useful ways of communication
and explanation to the public. Yet, the human being is complex. Someone with antisocial
personality syndrome can be full of pride, vanity, deceit, paranoia and low self-esteem, all
within the one person. In order to open these concerns for closer inspection, the following
three sections define the received wisdom view of increasing levels of complexity before
discussing them and commenting on how to work with them.
The received wisdom on complexity
The syndromes defined in the textbooks are decontextualised in that standard definitions are
given. The relation to the psychodynamics of what motivates people to act in meaningful
ways shows that the specific types of rationality and emotionality form compromise

formations with each other. But a personal limitation is that even across the course of a
working life and seeing people at a steady rate, year in year out, unique client presentations
are met that will never be repeated. There are many significant combinations of personality
syndrome, contextual syndrome, lifestyle choices, sub-syndromal vulnerabilities, personal
abilities and valued preferences. Contrary to the cognitive behavioural way of working, the
hope of applying standardised formulations and treatments to the public is impossible
because there is too much variation. Yet what is required is theory that is sufficiently
complex to capture the idiosyncrasy of individuals presentations, for it be accepted between
professionals, and for these terms to be discussible with clients.
Formulation is a way of mapping the problems of specific clients in individual
therapy through interpreting repeating psychological processes that constitute problems in
written diagrams or verbal formulations. When formulating, therapists agree with their clients
concerning the nature of the meaning-making process in which they are stuck in their lives. I
propose that a definitive aspect of integrative therapy is tailoring interventions precisely to
the needs of clients, so they understand and can find new ways to provide themselves with
understanding and change, because clarity about the rationale for a proposed treatment
provides value to the meetings. The next section makes an integrative response to the
orthodox thinking within DSM and NICE guidelines in a stepwise manner. It discusses six
increasing levels of complexity found across the full range of psychological distress, from the
lowest subsyndromal vulnerability to the highest, the comorbidity of contextual and
personality syndromes. The following six levels of treatment difficulty start with assuming
that persons who have no risk are motivated to attend and believe that they can be helped.
Complexity in attempting treatment
When people have more than one contextually-bound syndrome, it becomes a wonder as to
know where to intervene first of all. A syndrome is judged to be extent when, for any
frequency of occurrence, there is a consequent inability to do something necessary for the
minimum performance of a role at work, home or in free time. The meaning of dysfunction is
the inability to work, for instance, or being too distressed to do child care because the distress
is so strong to impair the ability to concentrate and remember, or its presence is too
embarrassing in that other aspects of social contact are avoided or impaired. Also, because of
inaccurate belief and understanding of how to respond to the distress, the person remains too
distressed to carry out one or more of its roles. This in itself has consequences that may
maintain distress. Because it is impossible to function in the factual sense of being able to do

things that self would normally be able to achieve, such an omission may act as evidence for
beliefs of low self-esteem and contribute to lowering the mood. In the received wisdom the
lowest level of complexity starts with one standard contextual syndrome where there are
well-known standard formulations and interventions, and the number of sessions required to
treat the problem and its level of severity can be estimated in advance. If a standard treatment
is provided, it should be successful for most clients to receive a permanent benefit. Good
mental health is where there is an ability to achieve across all areas of life. When there is
distress, it is responded to quickly by individuals and the adjustments they apply to
themselves work (through speaking with their partner, friends and family or getting
professional help). In a functioning lifestyle there are distressing and problematic events of a
reactive sort with respect to real problems in contexts. These cause distress and temporary
dips in functioning but can be overcome. If there are stronger, longer-lasting yet transient
forms of distress of a reactive sort, with respect to real problems in contexts, these cause
longer periods of impairment of functioning yet the distress can be soothed.
Subsyndromal vulnerability
However before complexity begins, there is a first level of psychological problems called
sub-clinical or sub-syndromal vulnerability in personality-functioning or in relation to
specific contexts. The lowest level of impairment features sub-syndromal occasional episodes
of mild negative experiences at the rate of, say, one a month, to one a week. This indicates
that there is a persistence of effect due to an initial episode and the felt-consequences for how
the ego manages itself. Having vulnerability means that a person has some of the features of
agoraphobia, for instance, but that the strength of the problem is insufficient for it to qualify
as a syndrome.
Once in a lifetime occurrence
The simplest psychological problems are not recurrent across the lifespan but are merely one
episode, a single occurrence for less than a year, of mild to moderate severity. For instance,
simple psychological problems include the following: only depression by itself, similarly
only panic, phobia, social phobia, social anxiety, agoraphobia, performance anxiety, post
traumatic stress disorder, generalised anxiety disorder and mild to medium severity obsessive
compulsive disorder. Simple psychological problems also include relationship-distress, mood
and role-change problems, pervasive anger, role-change and adjustment reactions to stressors.
Currently in the UK this level of distress is treated by primary care with cognitive
behavioural therapy by IAPT practitioners in 6 to 12 sessions.
Recurrence of one syndrome

When such distress may be prolonged, the next step up in complexity is when psychological
distress persists even though the initial stressor might have been absent for some time when
seeking help. What constitutes recurrent psychological problems is not just the contextual
causes of a single occurrence of a contextual syndrome but something belonging to the
individual that means that a part of the personality itself is vulnerable on an ongoing basis.
This next higher step in complexity is when one syndrome is established, but the amount of
impairment in the performance of roles increases due to the same motivation of inaccurate
understanding of how the self defends itself and copes with distress. The attempts at
defending currently used have not worked but are still persisted with. These can include the
frequent occurrence of unbidden thoughts, urges, images or memories that are disturbing or
distressing in what they are taken to mean. The key to understanding why the distress is
maintained is to find out how people look after themselves and attempt solutions that
maintain the problem, for example using self-harm, avoiding issues and specific emotions,
drinking or worrying perhaps.
Recurrence or persistence of two or more syndromes
The next higher level of complexity is when there are two syndromes that require tailor-made
interventions and a sufficient length of treatment with relapse prevention to make sure that
the gains received during therapy remain after the meetings have ended. The final phase of
ensuring that positive changes made remain in-place is called relapse prevention and requires
foresight about what could go wrong after the therapy is over and how clients can be
supported in rectifying it themselves. This level of complexity is a middle ground, a grey
area. One middle case is people who have had psychiatric admissions in the past for
psychosis or who have been suicidally depressed but now they want to work in therapy on
something, after they have recovered from these more serious problems. The middle area of
difficulty also includes cases where there have been two or more episodes of the same
syndromes, suggesting there is some vulnerability in the personality because the recurrence
suggests there might be maintenance factors in how the person responds to their needs.
People with relationship-oriented problems such as on-going difficulties with their partner,
work colleagues, children or parents also comprise this middle ground. This is an area of
moderate psychological difficulties which may benefit from couples or family therapy as
opposed to individual work.
Difficulty in providing treatment for two or more syndromes
The next higher level of complexity is when there are difficult to treat syndromes that require
multiple, tailor-made interventions. There is a struggle to find the central focus of where to

intervene, which reflects an actual lack of clarity that exists (and does not reflect the level of
expertise of the therapist). Not only are there two or more syndromes, the difficulties lie in
knowing how to find the most causative problem and how to work on it to establish change
and help people become self-caring. Real complexity arises when people do not respond to
standardised interventions or refuse to do obvious things that would be good for them to
minimise or remedy their problems. When I say obvious the remedies the person could
give themselves would be obvious to non-therapists who are psychologically minded. It is
helpful again to find out how problems are maintained for each individual, through basic
interviewing around what their self-harm does for them, for instance, or to find out why
suicide seems to be an option.
Comorbidity
Finally, the highest level of complexity is the co-morbidity of contextual on-off syndromes
and personality syndromes which, research shows, can also vary in strength. Contextual
syndromes might be lifelong or persistently recurrent if they are anxiety-related, low selfesteem or shame about personal identity. Research shows that contrary to the clarity of the
assumption of a strict difference between personality and contextual problems, contextual
anxiety problems may also be lifelong, contrary to the received wisdom. Therefore, anxiety
problems might be better understood as parts of the personality because their lifelong
occurrence indicates an on-going vulnerability across the lifespan (discussed below). Low
self-esteem in itself is not a formal syndrome possibly because large sections of society
would be seen as having a mental health problem. However, features of the ten personalities
is DSM also co-occur, so that it becomes confusing when specifying what is the central
personality style of a person when they are both paranoid and obsessive compulsive in
their personality in being controlling, demanding and pedantic, for instance.
Complexity of contextual syndromes
A fully complex case is where there are multiple context-related syndromes (but not of the
personality variety). A complex case is where it becomes extremely difficult to formulate, get
an agreed focus with clients themselves and sustain work on that focus. For in long-standing
complexity, there may be numerous on-going crises in the persons life. And because their
level of functioning is low, their personality factors forever prevent steady progress, and their
lives are chaotic and prevent weekly attendance, this will likely prevent the sense of on-going
progression across the meetings. When there are recurrent, severe and enduring syndromes
with decreasing functioning across the lifespan, where there have been multiple interventions

of ineffective therapy, hospitalisation and medication, all of which have not brought sustained
improvement, this may indicate that there might be biological causes at work in the
personality. But it might also be the case that the ego has not been able to understand and
manage its triggers, its contexts and its reactions to them. Complex problems are treatment
resistant because clients who have never responded to therapy or medication indicate a
riddle as to why the distress is maintained and why the help offered has been ineffective. The
problems of full complexity include the presence of resistance to change, of therapyinterfering behaviours, poor relational style, difficulties in naming their thoughts and feelings,
and low motivation to engage in therapy. Or they may believe they are beyond help and
incapable of change. Complexity includes those who have previously had psychiatric
admissions or long-term experiences of post traumatic stress, trauma-induced psychosis,
depression, schizophrenia or difficulties in the management of bipolar mood problems.
The list of what constitutes complexity can include the following: multiple lifelong
problems, lifelong suicidal thoughts and feelings without intent but perhaps with a recent
potentially fatal attempt at suicide during the last year. There are a group of people who ask
for help but reject it once it is offered: Treatment resistance may often be an expression of
an anxious ambivalent attachment style where the problem is that therapists are getting too
close to the person or to topics that are distressing and overwhelming. But the difficulty in
helping them might be for a number of reasons that need to be asked about, where the first
task is to help them engage and understand themselves in a way that becomes agreed, before
going any further. Perhaps it is because of their inaccurate empathising of other people or
what they feel and tell themselves that makes relating with them difficult. The consequent
problems entailed in working with the hard to help is that frequently at assessment, on the
client-side, there is uncertainty and an estimation taking place about the therapists ability to
help. If therapists are over-cautious, then someone who could be helped is turned away with
the implied message that they are beyond help. On the other hand, if therapists are overambitious in accepting clients who then have crises and current stressors that make them feel
overwhelmed and unable to continue with what was agreed as a focus of the treatment at
assessment. If a person is easily distressed by discussing their problems then what follows are
impasses, setbacks and difficulties that should have been found out at assessment and preemptively planned for instead. (Sometimes it is not possible to foresee problems in providing
treatment so these need to be dealt with as they occur).
To use an old fashioned term, a nervous breakdown is really a state of exhaustion
brought on for a sufficiently long period of time, where individuals are exhausted, often

depressed and overwhelmed. Many experiences of depression actually occur after a prior
period of anxiety so depression can be understood as emotional exhaustion. Although it may
also be an expression of loss, where what is lost is some valued aspiration, what could have
been or what might have been. Either way, after an extended period of distress persons can
become unable to function in their roles. This is a crisis in functioning that can be capable of
being rectified to promote a return to a more relaxed state of coping. If there are repeated
instances of crisis across the lifespan, then these effects accumulate in personalityfunctioning because the problems of relating to others and dealing with the inevitabilities of
stress and change belong solely to the individual. The remainder of the paper turns to think
through how to work with complexity once it is recognised.
Discussion: Clinical reasoning concerning complexity and unknown causation
Clinical reasoning is comprised of heuristics, rules of thumb that might be generally true and
could be formulated as if a person has syndrome 1 then it is most efficacious to start
treating ... first and ... second. Formulation is the meeting point between the bodies of
research evidence about what might work, how to maintain the relationship that holds
practice together, getting informed consent for an agreed treatment, and offering clients
choice and explicit control over what they might like to work on. These things are achieved
only once the pressing matters of suicidal intent, self-harm, harm to others and chronic
depression have been tackled.
Practice involves balancing opposing forces where even highly experienced therapists
might be working with someone who is outside of their personal clinical experience in the
mixture of factors that they bring for help. There are limitations to the guidance from
nationally approved research findings on what works and what does not, because novel
combinations of syndromes and circumstances are the norm. There are very many opinions
gained from formal research on how to treat any single syndrome (nice.org.uk). But single
occurrences of psychological syndromes are rare. Those evidence-based therapy models that
are guided by the randomised control trial evidence base are in doubt as to their applicability
because there is no evidence base concerning the huge array of the co-occurrences of
syndromes. The empirical research on what works with single syndromes is limited in its
applicability to actual individuals with complex problems. The therapeutic reality of how the
public understand themselves is not related to the professional discourse of the co-occurrence
of a number of contextual problems with lifelong personality syndromes. The psychosocial
consequences of distress entail under-achievement and what may frequently co-occur with

anxiety is low mood that impairs functioning, aimlessness, poor memory and concentration,
distress and poor habits of functioning due to feeling overwhelmed.
The usefulness of research on what is effective, according to randomised control trial
format or common factors analysis of the therapeutic process of relating, is useful as
background information. However, the individual presentation of what constitutes syndromes
demands a tailor-made approach to help unique individuals. Rather than go into further
details of how to work with specific examples of different levels of complexity, the type of
conclusions below is a re-statement of the basics of how to make therapy feel secure and the
worth of caring. The work of integrative therapy is precisely helping people change their
ways of reacting even in relation to what might be biologically-inherited temperament and
longstanding habits of believing, feeling and relating. Often people over-use specific mental
processes in relation to specific meaningful objects. This partly explains how easy it is to
jump to false conclusions without the evidence to support them. On the contrary, people can
be aware of their own tendencies and rein them in, but only by becoming fully aware of the
mental processes and repeating senses through formulation, and working out how they want
to try something new. This often means tolerating distress and trusting themselves in being
able to make changes. At a time in the future, when the human genome is fully understood, it
might be possible to know individuals biological inheritance. Until then therapists are left to
understand persons in front of them, whom they have told they can help. The pragmatic
answer is to get the understandings that clients have of themselves and formulate them
according to psychological theory: that is represent their repeating processes and experiences
to clients whilst being mindful of the findings about what works from what empirical
psychology and therapy theory provide.
However, the distinction of axis I and II has been abolished in the latest version of
American psychiatrys definitive text, DSM 5, and replaced by a standard set of diagnostic
criteria and a second more general set of criteria that is not so fixed on the classic ten types of
personality disorder (American Psychiatric Association, 2013, 645-684, 761-781). The
main justification for the creation of the two axes was that syndromes of contextually-related
problems have the tendency to be triggered and go into remission across the life-course, with
or without intervention. The bodies of information on what works in therapy as provided by
NICE in the UK, and the national bodies of other countries, all adopt the mainstream
definitions of major depression or agoraphobia and these are recognisable to practitioners.
Yet personality problems, as core aspects of how a person sees themselves and others in their
lives, regardless of role and context, are less precise in that a person who is distressed in the

personality way has long-standing difficulties that are frequently recognisable as mixtures of
the personality disorders defined in DSM 5. The first point to note about the connection
between personality and social context is that the inside learning that persons receive due to
their upbringing is active both on the inside and the outside as it were. The private and
public aspects of self are intermingled in that personality-psychology and social psychology
are really one continuum where the private is what remains unexpressed and the social is
what gets enacted between self and others. However, there are plenty of areas that are not
agreed in the broad view. McCrae and Costa, two leading personality theorists believe that
childhood has no effect on personality and they do not include it in their formulation of
personality (2003, 192-8). Of course, personality is to a degree biological as well as
psychosocial, but when it comes to specifying the causes of distress in individuals then it is
not possible to be precise just yet.
On the contrary to the received wisdom, axis I contextual problems, are always comorbid with axis II, personalities. They could not be otherwise. There is an empirical body of
knowledge that supports the view that personality and contextual syndromes can be
understood together in the work of the following authors. Bruce Pfohl (1999) argues for
recognising that the on-set of psychological disorders can be intermittent. Some personality
syndromes are on-off because they are only triggered when there is a sense of enduring
overwhelm that does not stop when the stressors are off, but can persist for a few months or
more in their external absence. The persistence may be due to triggering worry, mood
problems, rumination or negative associations (negative automatic thoughts) or other mental
and relational processes that maintain the distress and do not reduce it. When both contextual
and personality syndromes are present, they can co-occur with a flare up of problems in
personality functioning, which means that both contextual and relationship-oriented events
and personality functioning problems are reactive and not constant. And the converse occurs,
the cessation of psychological syndromes co-occurs with the cessation of syndromes of
personality functioning. The same phenomenon of the variability in personality and
standalone syndromes is noted by Tracie Shea and Shirley Yen (2003) who add that subsyndromal levels of distress can occur such that the syndromes are officially absent
diagnostically, but they remain as latent vulnerability or continue functioning at a residual,
low strength of influence. Shea and Yen (2003, 378) have found empirically that anxiety
syndromes tend to be more persistent than personality syndromes. What this means is that
contextual syndromes of anxiety are better understood as the neuroticism personality factor
because they have a tendency to be lifelong.

The range of problematic meanings is wide. Some of which need including and
accounting for are those concerned with the general mood or particular emotional spikes of
anxiety, anger, panic, contextually-specific fear or low mood in relation to specific events in
specific contexts. Emotions and mood-influence can predominate from passive consciousness
and take their place in the way that consciousness becomes aware of something that is
distressing and gets felt as being against the self, when the emotional part is felt not to be
under personal control. The ego begins to feel taken over by meanings which have little or no
control and seem to spell a mood of foreboding and doom, as though there arent many days
left to live. So that feeling detached or distant from ones previous dreams and aspirations are
given the meaning failure, that is the non-attainment of a cherished aim for self. The sense
of disconnection or alienation from the shared world is one where it is possible to feel an
absence (where there could be safety and security).
If we presume that clients have inaccurate understanding of how to rectify their
problems that produce the ineffective functioning in everyday life, then complexity is part of
the personality as it changes across the lifespan. In my own practice it seems to me that
complexity to treat is only ever the result of attempting treatment in a specific therapist-client
combination. Difficulties and impasses in treatment could be conflated by ineffective practice
which is often due to not getting an adequate understanding of what is happening for clients
at assessment and thereafter. The remainder of the essay discusses how to treat complexity.
How to treat complexity integratively
Integrative practice can be defined as structured and responsive. In the current state of
uncertainty, about what is the right treatment at the right time in the context of unknown
causes, there is a need to decide on opposing and unclear information about what is effective
and offer a range of interventions according to what might be helpful for clients with
different preferences and abilities. All therapies share some basic necessities to enable
practice though. The guiding belief about human nature is that personality theories describe
aspects of a multifactorial whole. In the main, human development occurs according to social
learning theory. Overall, therapists cannot, and should not, place all attention on any one
model of human nature and its development because there is no consensus in large parts of
developmental psychopathology. There is not sufficient reliable evidence to support these
theories. All therapies are between models and should choose accordingly. What is argued for
is social learning theory as the major influence on the origin, cause and development of
psychological problems and the on-going maintenance of these problems. Because human

nature is biopsychosocial and multifactorial, all psychological problems arise as the result of
inherited personality characteristics in complex connections with childhood and adult life
experience, personal choice and the influence of others and culture on the self. There is a
range of influences. The development, perpetuation and solution of problems is most
accurately understood as forms of social learning about how to respond to distress that need
to be understood and managed.
An integrative understanding of the process of therapeutic change accepts directives
to work towards evidence-based practice as part of clinical reasoning. However, there is no
evidence to believe in the superiority of any one explanatory model (Stiles et al, 2008a,
2008b). To claim otherwise is bad science or unprofessional. Therapists should not to impose
unproven psychological theory onto the public, but work within a social learning perspective
that assumes that what therapists do to help is part of a learning process entailing changes of
meaning in the presenting problem and associated aspects of clients lives. The range of
permissable interventions are those indicated by the evidence base and other sources.
Therapists need to get informed consent and be flexible about such recommendations.
Therapists choose interventions through discussions with informed clients and attention to
their wishes, capacities and their learning, concerning how clients might be empowered.
Therapists should be responsive and meet clients in emotional attunement in sessions. It is
this sensitivity to their needs and perspectives which guides intuition about how to help in
relation to empirical findings.
An integrative stance relates therapeutic stages to choices of interventions by the
consideration of stages in treatment. The stages of therapy are assessment, formulation,
treatment, review (including re-assessment and re-formulation) and ending with relapse
prevention. The first two stages are important. After assessment, the first is formulation to
agree the understanding of what is bothering clients. This should be done in such a way that
they understand what is being discussed and they feel free to discuss and question the
comments made about them. Only then is it possible to agree a plan of action with them
where the risks of self harm, suicide and harm to others are included. This is the proper use of
boundaries in terms of making therapy a safe place, a secure base. Integrative therapy serves
the purpose of synthesising larger areas of knowledge and practice yet delivering a treatment
plan for individuals that then includes wider perspectives and research findings. Therapists
should always try to offer choices to clients but realise that NHS services and medication can
also contribute. Theoretical considerations and actual clinical reasoning are concordant with
an attempt to provide evidence-based practice. Therapists should be present in the room with

clients and active in terms of making a therapeutic relationship with them. It is a professional
responsibility and an ethical requirement to set people at ease and enable them to participate
to the best of their ability. As we know, an integrative model is inclusive of other therapeutic
approaches and aims to be culture-appropriate because of the embedded nature of human
being. The model of working is tailored to the needs of individuals mental states and the
specifics of how they live as part of their family and culture. During practice, it is necessary
to review sessions at the end of each one, and particularly at the beginning, to monitor
clients responses and adjust the approach made. In the light of feedback from clients,
therapists should change their approach according to discussions and gain informed consent
throughout. Therapists may also suggest that certain issues may need to be looked at, so
clients may also approach those issues which are difficult for them, yet when they are
tackled, might be helpful to them.
The priority in understanding how to treat complexity is to acknowledge that for some
people, they may have an interest in having therapy but that does not mean that they are
suited to having it. Therapy is not a panacea and therapists can never do the work that clients
need to do when they apply their new understandings of their repeating problematic patterns
and change their lifestyle and manner of relating. The trajectory of some peoples lives is that
their distress and defences increase across the lifespan whilst their functioning decreases. It is
a therapeutic responsibility to assess by taking a history that can begin to understand what
influences have been working on them since they were a child. However, there are a number
of factors that mean that persons are unsuited to having therapy at all. Some of these are
clients who have complex needs:
But no desire to work and make changes on their lifestyle or tolerate distress.
Dislike being assessed and refuse to speak about certain topics because of how it makes
them feel, especially when they wish to withdraw from therapy because of distress gained
from discussing their problems.
Finally, a trauma-induced psychosis or dissociative identity disorder are not immediate
contraindications but are two examples where clarity about causes and treatment offered will
help.
However, given that assessment has been carried out, and those who are both suited to
it and interested in it have been given the necessary information about what they will need to
do in it, then work with all levels of complexity can progress. There are a number of general
pointers that can be gathered from directly asking clients who have had a positive therapeutic
outcome with oneself and through consulting the research literature on what works in

managing the therapeutic relationship. The most basic sense to be communicated from
therapists, I argue, is one of genuine interest and caring. These qualities are what we should
have experienced in our training therapies and when we have had therapy at other times.
Being cared for and having the therapist be positive towards us as clients, cannot be faked.
Nor do I think it requires specific techniques. The basics of creating a positive working
relationship with the public come from the heart, even when helping people with
backgrounds full of trauma that lead them to have complex mental health needs. However, it
is the employment of the intellect that goes further in being able to specify the pieces that
make the whole.
When attending to risk for clients and those around them, the need to maintain
confidentiality is equally important as the need to share information. If there is a need for
contact with psychiatric services, social care or psychiatric nursing, then these should be
pursued as a matter of priority before therapy begins particularly when there is strong suicidal
intent with no protective factors, or the risk of violence or death through anorexia or domestic
violence. A general heuristic is the utility of decreasing depression before beginning a more
specific focus on any other topics (Moore and Garland, 2003). Therapy-interfering
behaviours are those where an anxious ambivalent attachment appears as resistance of the
sorts of asking for help and then preventing it being delivered. Avoidant attachment occurs
when asking for help but not being willing to talk and feeling over-exposed in the process of
talking about feelings. Both indicate that either preparatory help is required, or potentially,
the person is not yet ready and needs to do some sort of personal preparation before
commencing some serious work which may well make them feel exposed and open to being
let down by their therapist. Once these items are tackled, further work on agreed focuses
according to the problem list of clients can be pursued.
Conclusion
The provision of integrative therapy requires a broad view of the field. The work of the
integrative therapist includes integrating different types of information with the desire to
create tailor-made approaches. Thinking about complexity is a way of drawing the best from
the mainstream orthodoxy as exemplified in psychology and psychiatry in texts like DSM 5
and ICD 10. What these documents collate is expert opinion of colleagues about the
meanings and experiences of the public. A good deal about how to rise to the challenge of
complexity can be gained from understanding the orthodox approach to personality and
contextually-occurring problems. Whatever the shortcomings of the classificatory systems in

mainstream psychiatry and psychology, I argue that it would be a case of throwing the baby
out with the bathwater water if they were to be abandoned. Indeed, their major function is to
act as a common language for all mental health professionals and orient research, theory,
supervision and practice around clear and shared definitions of distress. They entail thinking
psychologically about the co-occurrence of styles of the personality and the social learning
that individuals take with them, about how they understand themselves and others, and how
they work to defend themselves in ways that maintain their distress.
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