Tensions in integration: a qualitative exploration of clinical psychologists’ integration of various knowledge types in psychotherapy

Abstract The aim of this study was to gain knowledge about how peer-nominated clinical psychologists describe their use of different knowledge types in psychotherapy practice. This may miigate the knowledge gap concerning clinical expertise and how clinical experts integrate various knowledge types in practice. Clinical psychologists ( N = 16) who had been recommended by their co-workers were included. The participants were interviewed using semi-structured qualitative interviews. The transcripts of the interviews were subjected to hermeneutic phenomenological thematic analysis. Most of the therapists in the sample described tensions in how they integrated different knowledge types in psychotherapy practice. These tensions in integration were expressed through four themes: (a) Evidence is not carved in stone; (b) The individual beyond categories: (c) Embodied professional practice; and (d) Psychotherapy’s contextual dimension. This study provides empirically grounded insight into these real-world decision-making processes, contributing to a debate previously shaped primarily by theoretical and normative accounts. The participants did not reject research evidence. Tensions arose when evidence derived from group-level trials were applied to individual patients and when clinical guidelines encountered patients who did not fit the categories for which the guidelines had been developed. The results suggest a conception of knowledge that differs from the one commonly associated with evidence-based practice in psychology. Whereas evidence-based practice in psychology describes integration in terms of bringing together three forms of knowledge, the participants’ accounts portray integration as sustained engagement with tensions among them that cannot be fully resolved. Drawing on previous research and literature, we discuss how understanding integration in terms of tension may preserve a space for clinical judgment that an emphasis on unification risks constraining. We conclude that integration is not a straightforward process of combining different elements but a dynamic, dialectical practice requiring continuous reflection and adjustment.