Handbook of Psychotherapy Integration, Second Edition Part 9 pptx

Instead of teaching spe- Of critical importance in the decision to train integrative practitioners is the assumption thatcific resources, therefore, training programs are well advised to

Training, Research, and Future Directions

Training in Psychotherapy Integration

JOHN C NORCROSS AND RICHARD P HALGIN

Once upon a time, psychotherapists were from different treatments, formats, and

rela-tionships On the other hand, integrative trained exclusively in a single theoretical orien-

train-tation and in the individual therapy tradition ing exponentially increases the student press to

obtain clinical competence in multiple The ideological singularity of training did not

theo-always result in clinical competence but did ries, methods, and formats and, in addition,

challenges the faculty to create a coordinatedreduce clinical complexity and theoretical con-

fusion (Schultz-Ross, 1995) But over time, psy- training enterprise Not only must the

conven-tional difficulties in producing competent chotherapists began to recognize that their ori-

cli-entations were theoretically incomplete and nicians be resolved, but an integrative program

must also assist its students in acquiring clinically inadequate for the variety of patients,

mas-contexts, and problems they confronted in tery of multiple treatments and then in

adjust-ing their therapeutic approach to fit the needspractice They began receiving training in sev-

eral theoretical orientations—or at least, were of the client

In this chapter, we begin by introducing anexposed to multiple theories—and in diverse

therapy formats, such as individual, couples, ideal training model for psychotherapy

integra-tion We then consider training in light of thefamily, and group

The gradual evolution of psychotherapy four principal routes of integration—technical

eclecticism, theoretical integration, common training toward integration or eclecticism has

fac-been a mixed blessing On the one hand, the tors, and assimilative integration—as the training

objectives and sequence will differ somewhatmovement toward more integrative training ad-

dresses the daily needs of clinical practice, sat- among them Next, we address questions

re-garding the centrality of personal therapy andisfies the intellectual quest for an informed

pluralism, and responds to the growing re- the necessity of research training in the

prepa-ration of integrative therapists We review search evidence that different patients prosper

inte-439

grative supervision, specifically problems in the the process of successful organizational change,

as described later in this chapter

acquisition of integrative competence and an

improved system We conclude with a

discus-sion of organizational strategies for introducing

Differential Referralschanges, particularly those promoting psycho-

therapy integration, into training institutions Psychotherapists can function effectively in a

single theoretical system, providing they haveBefore proceeding to ideal training models,

a few words on terminology The term training the ethics and ability to discriminate which

pa-tients can benefit from their preferred systemcan denote a mechanistic and impersonal pur-

suit, such as training seals to clap their flippers and which cannot Referral of the latter group

of patients can then systematically be made to

or training rats to run a maze (Bugental, 1987)

We would prefer to retitle psychotherapy train- clinicians competent to offer the indicated

treat-ment In the words of Howard, Nance, and

ing something along the lines of cultivating

psychotherapists or developing psychotherapists. Myers (1987, p 415): “Without a therapist’s

willingness and ability to engage in a range ofBut precedent is against us; when we talk about

the development of a psychotherapist, many of behaviors and to employ a range of therapeutic

modalities, the therapist, by intent or default,our colleagues and students look at us quizzi-

cally Thus, we will concede to linguistic pref- will have to limit his or her practice to clients

who fit the specific range of behaviors he orerence and precedent in using the conven-

tional training throughout this chapter, but we she has to offer.” The primary problem is not

from narrow-gauge therapists per se, but fromimplore you to interpret the term in a broader

and more human meaning We try to prepare therapists who impose that narrowness on their

patients (Stricker, 1988)

graduates who are both competent

psychother-apists and better functioning people. The two essential tasks in differential

refer-ral are to train students to recognize the tive contraindications of their single psycho-therapy system and to educate them in makingINTEGRATIVE TRAINING MODELS

respec-informed referral decisions Many based compendia are now available by whichPsychotherapy trainers are immediately con-

evidence-fronted with a crucial decision with respect to to recognize indications and contraindications

of particular therapies and formats (e.g., their training objectives The major choice is

Beut-whether the program’s objective will be to train ler & Harwood, 2000; Frances, Clarkin, & Perry,

1984; Nathan & Gorman, 2003; Norcross,students to competence in a single psychother-

apy system and subsequent referral of some cli- 2003; Roth & Fonagy, 1996), and the failure

to make use of such information can no longerents to more indicated treatments, or whether

its avowed mission will be for students to ac- be construed primarily as lacunae in the

psy-chotherapy outcome literature On the commodate most of these patients themselves

con-by virtue of the students’ competence in multi- trary, difficulties in appreciating the limitations

of one’s treasured proficiencies are now largelymethod, multitheory psychotherapy The for-

mer choice is favored by briefer training pro- emotional and organizational, not intellectual

Helping single-system advocates to relinquishgrams and smaller faculty; the latter seems to

be preferred by longer and larger training pro- patients for whom another approach is better

suited will entail attention to both the grams with more resources

prescrip-In this section, we present consensual train- tions of the empirical research and the

limita-tions of their theoretical commitments.ing models for teaching both differential refer-

ral and psychotherapy integration The intro- In order to make differential referrals,

clini-cians will need knowledge of available duction and implementation of these models

com-into any program will require substantive con- munity and treatment resources Because many

students may ultimately practice in geographictent revisions, as well as a clinical sensitivity to

locations different from where they were trained, Integrative Psychotherapy

this information cannot readily generalize from

the training location Instead of teaching spe- Of critical importance in the decision to train

integrative practitioners is the assumption thatcific resources, therefore, training programs are

well advised to ensure that students know how students have both the time and talent to

ac-quire competence in several models Some

to locate resources in any community

(Nor-cross, Beutler, & Clarkin, 1990) training programs may be too brief, or students

too inexperienced, or faculty too divided toPrograms can provide several experiences in

order to assure students’ ability to develop treat- tackle the challenge Our own training

experi-ences during the past two decades affirm thatment and community knowledge First, specific

instruction and course work can emphasize the coordinated doctoral training can produce

com-petent integrative psychotherapists, althoughvalue of community services and self-help re-

sources Second, students routinely can be pro- additional time and effort are required in light

of the more ambitious goals

vided with names, phone numbers, and Web

addresses of national directories and referral An ideal psychotherapy education would

en-compass an interlocking sequence of trainingservices Careful distinction must be made here

between paid advertisements and credentialing experiences predicated on the crucial

therapist-mediated and therapist-provided determinantsorganizations, particularly on the Internet Third,

visits to community mental health centers, of psychotherapy outcome Our suggested model,

drawn largely from the consensus of severalfamily counseling agencies, child protective

services, and substance abuse programs, among journal sections on training integrative and

eclectic psychotherapists (Beutler et al., 1987;others, can give a sampling of the variety of

resources available Castonguay, 2000a; Norcross et al., 1986;

Nor-cross & Goldfried, in press), consists of sixPractice exercises also might be incorpo-

rated into both coursework and practica Train- steps Following is an ideal generic model of

training integrative psychotherapists

ees can be assigned, for instance, the task of

locating treatment resources and preparing an The first step entails training in

fundamen-tal relationship and communication skills,integrated treatment plan for an actual prob-

lem presented in either case conference or a such as active listening, nonverbal

communi-cation, empathy, positive regard, and respectclass vignette Examples can be organized around

the client’s disorder, treatment goals, stage of for patient problems Acquisition of these

ge-neric interpersonal skills can follow one of thechange, therapy preferences, and the like

In addition to course work, trainees should systematic modules that have demonstrated

sig-nificant training effects compared to controlshave extensive experience in evaluating a

range of patients under close supervision in dif- or less specified modules (see Baker, Daniels,

& Greeley, 1990, and Stein & Lambert, 1995,ferential referral and treatment assignment

These experiences are most easily obtained in for reviews) In general, the most efficient way

of maximizing learning of facilitative large treatment centers that offer a variety of

psycho-treatment programs and specialty clinics In therapy skills is to structure their acquisition

(Lambert & Arnold, 1987) The standard such a setting, the trainee can practice assess-

se-ing the patient and makse-ing differential recom- quence involves instruction, demonstration

(mod-eling), practice, evaluation (feedback), and moremendations concerning treatment setting, for-

mat, relationships, and techniques In such practice These interpersonal skills are crucial

to the establishment, repair, and maintenanceclinics, the trainee is free to consider a whole

range of therapies in selecting those that might of the therapeutic alliance

Students would be retained in this

founda-be optimal for the individual In such clinics,

too, the integration of research and practice tion course until a predefined level of

compe-tence is achieved in these skills can be facilitated and reinforced (Jarmon &

Criterion-Halgin, 1987) referenced situational tests, expert ratings, and

demonstration experiments can be used to con- be used specifically to outline criteria for

im-plementing interventions

firm such competence The point is that

stu-dents should not be automatically moved for- Following satisfactory completion of these

competency-based courses, the fifth step ward in the curriculum simply because they

in-have completed a course; they should be ad- volves the integration of disparate models and

methods The emerging consensus is that thevanced because they have demonstrated com-

per-spective occurs after learning specific therapyThe second interlocking step consists of an

exploration of various systems of human behav- systems and techniques The formal course on

psychotherapy integration would provide a ior At a minimum, the courses would examine

de-psychoanalytic, humanistic-existential, cognitive- cisional model for selecting the methods,

for-mats, and relationships from various behavioral, interpersonal-systems, and multi-

thera-cultural theories of human function and dys- peutic orientations to be a applied in given

circumstances and with given clients Samplefunction Students would be exposed to all

approaches with minimal judgment being made syllabi for such integrative courses/seminars are

now available for psychology, psychiatry,

coun-as to their relative contributions to truth

Theo-retical paradigms would be introduced as ten- seling, and social work programs (e.g., Allen,

Kennedy, Veeser, & Grosso, 2000; Beitman &tative and explanatory notions, varying in goals

and methodology Integrative frameworks and Yue, 1999; Norcross et al., 1986; Norcross &

Kaplan, 1995) This course bears the program’sinformed pluralism would thus be introduced

at the beginning of training (Halgin, 1985b), responsibility for providing “a system of

analy-sis or a framework by which a multiplicity ofbut a formal course on integration would occur

later in the sequence theories and methods could be organized into

an integrated understanding” (Reisman, 1975,The third step in the integrative training in-

volves a course on systems of psychotherapy p 191)

Finally and concomitantly, an intensiveThe focus in this course would be in applying

the models of human function and dysfunction practicum experience, such as an internship or

residency, with a wide variety of patients would

to methods of behavioral change At the outset,

multiple systems of psychotherapy would be allow novice therapists to practice integration

and to evaluate their clinical skills Theoreticalpresented critically, but within a paradigm of

comparison and integration In our experience, knowledge of integration is sorely incomplete

without supervised experience in applying it tocourses and textbooks that only present “one

theory a week” are inadequate for this purpose the real world of patients In fact, the principal

complaint of psychotherapists following Rather, the psychotherapy systems need to be

gradu-presented and, at the end of the course, com- ation is inadequate clinical experience

(Rob-ertson, 1995)

pared and integrated in a clinically meaningful

manner At this point, students would be en- These training experiences are but the

be-ginning steps in the development of competentcouraged to tentatively adopt a theoretical ori-

entation that is most harmonious with their integrative psychotherapists; genuine

educa-tion continues far after the internship or personal values and clinical preferences

resi-The fourth step in the training sequence en- dency Students would be encouraged—nay,

expected—to go forth to receive additionaltails a series of practica Neophyte psychothera-

pists would be expected to become competent training in specialized methods and preferred

populations

in the use of at least two psychotherapy systems

that vary in treatment objectives and change “Deep structure” integration will take

con-siderable time and probably come about onlyprocesses In each case, completion of the

practicum would depend on specific criteria to after years of clinical experience (Messer,

1992) Expert psychotherapists represent theirensure acquisition of the skills associated with

a given system Relevant psychotherapy hand- domain on a semantically and conceptually

deeper level than novices Conceptual books, treatment manuals, and videotapes would

learn-ing about psychotherapy integration is proba- ding these methods and formats to suit the

given situation

bly necessary to achieve deep structure

integra-tion, but is not sufficient For a therapist to In that they are disinclined toward grand

unifying theories and more interested in integrate at a deeper level requires that they

prag-first understand and integrate within each indi- matic blending of methods, technical eclectics

generally endorse teaching psychotherapy vidual therapy and, only then, across therapies

inte-Additional psychotherapy experience and disci- gration from the very beginning of training

Gradually building toward integration in plined reflection on that experience is needed

mid-to attain a mature and abiding synthesis career is considered too tentative and

theoreti-cal And for some therapists, learning integrationPsychotherapy integration, in other words,

may take two broad forms that are differentially after working for years in a specific orientation

may prove too difficult (Eubanks-Carter, accessible to novice versus expert therapists

Burc-(Schacht, 1991) The first form, accessible to kell, & Goldfried, this volume) Instead, the

eclectic mandate is to teach multiple therapyneophytes, emphasizes conceptual products

that enter the educational arena as content ad- methods and treatment selection heuristics

early on so that clients receive the optimalditions to the curriculum The second form of

integration, largely limited to expert therapists, match of treatment, format, and relationship

Eclectics also readily acknowledge the emphasizes a special mode of thinking This

limi-form enters the educational arena only indi- tations associated with faculty composition and

disposition, which results in a series of trainingrectly through accumulated clinical experiences

that promote fluent performance and creative possibilities Graduate programs will range from

those in which the faculty embrace disparatemetacognitive skills

theories and goals to programs in which there

is coordination of the training process and Specific Training Models

fac-ulty consensus about an integrative model(Norcross & Beutler, 2000) It will take consid-

Since the first edition of this Handbook

(Nor-cross & Goldfried, 1992), we have secured erable time for many senior faculty to unlearn

their own allegiance to a single, pure-form considerably more experience and a bit more

sys-research to inform the ingredients of integra- tem of conducting (and teaching)

psychother-apy Yet, many new clinical faculty have beentive training In particular, we and others have

learned that the training sequence and objec- trained in, or at least favorably exposed to, an

integrative perspective

tives are heavily influenced by the specific type

of, or route toward, psychotherapy integration Theoretical integrationists blend two or

more therapies in the hope that the result willProponents of technical eclecticism, theoreti-

cal integration, assimilative integration, and be better than the constituent therapies alone

As the name implies, there is an emphasis oncommon factors (see Chapter 1, this volume

for definitions) all have definite preferences in integrating the underlying theories of

psycho-therapy along with the integration of psycho-therapyhow and when the ideal training occurs

Technical eclectics seek to improve our abil- techniques from each As such, the training

fo-cus is far more on the theoretical systems andity to select the best treatment for the person

and the problem Eclecticism focuses on pre- building bridges between the chasms that

sepa-rate them Wolfe (2000, p 241), for one dicting for whom particular methods will work:

promi-the foundation is actuarial rapromi-ther than promi-theoreti- nent example, asserts that an integrative

train-ing program should “expose students to thecal As such, the eclectics rely on the accumu-

lating research evidence and the needs of indi- various treatment approaches that represent

the orientations to be integrated, in addition tovidual patients to make systematic treatment

selections The training emphasis is placed a unifying conceptual framework that

inte-grates at the conceptual level.”

squarely on acquiring competence in multiple

methods and formats, as opposed to pledging Assimilative integrationists similarly embrace

synthesis, but in a more tentative manner.allegiance to theories, and pragmatically blen-

Their approach entails a firm grounding in one they educate students, with the central

differ-ences being in the timing and level of system of psychotherapy, but with a willingness

integra-to selectively incorporate (assimilate) practices tion As yet, there is no controlled research on

integrative training We do not know, in anand views from other systems As such, the

training is primarily in a single system of psy- empirical sense, which training process works

best for which situation

chotherapy with an understanding that the

cli-nicians will gradually incorporate techniques Recent data indicate that program and

in-ternship directors are committed to from other systems during the course of a ca-

toward it Approximately 80% to 90% of The assimilative integrationists frequently

direc-argue that, in early training, students need a tors of counseling psychology programs and

in-ternship programs agreed that knowing onesingle theoretical system to follow Early on,

ideology provides structure, support, and direc- therapeutic model is not sufficient for the

treat-ment of a variety of problems and populations;tion Trainees internalize the theory and the

contributions of their supervisor To be sure, instead, training in a variety of models is

need-ed However, their views of the optimal the eventual goal of integration is introduced,

inte-but neophyte psychotherapists need to focus on grative training process differ: about one-third

believe that students should be trained first to

a manageable amount of clinical material, be

directed to a technique toolbox, and delimit be proficient in one therapeutic model; about

half believe that students should be trainedtheir range of experiences Otherwise, they risk

being overwhelmed by the morass of choices minimally competent in a variety of models;

and the remainder believe that students shouldand the hundreds of therapeutic methods

Thus, the practical benefits of adopting inte- be trained in a specific integrative or

eclec-tic model from the outset (Lampropoulos &gration early on are outweighed by the costs

Later, students are expected to move in an inte- Dixon, in press)

grative fashion, but from a position of

single-system comfort and strength

core ingredients that different therapies share

in common, with the eventual goal of creating The excitement engendered by integrative

training can give rise to grandiose plans andmore parsimonious and efficacious treatments

based on those commonalities As such, the overly optimistic predictions We ourselves

have been guilty of such unfettered optimismtraining focuses on the acquisition of transthe-

oretical skills that research has found to ac- at times, and we hasten to correct any illusion

that competency-based training in count for much of psychotherapy success, such

psychother-as creating a positive alliance, mobilizing cli- apy integration will be easily or instantly

at-tained At the risk of fostering the opposite ent’s resources, and helping patients acquire

re-new skills Castonguay (2000b), for example, action—that of pessimism or apathy—we will

consider several reasons that may moderate outlines a training model driven by a common

ex-factors strategy in which he recommends train- pectations regarding integrative prospects in

training These considerations, it should being students in “pure-form” therapies and, us-

ing general principles of change, expecting emphasized, apply with equal cogency to

con-ventional psychotherapy training and notthem to integrate contributions of the different

orientations in their clinical work uniquely to integrative training

To begin with, explicit training for

psycho-In reality, these specific training models are

all variations on the integrative theme In most therapy has a relatively brief history, and

re-search on training for psychotherapy has aintegrative courses and seminars, students are

exposed to all four routes to psychotherapy in- briefer history still In a classic review, Ford

(1979) evaluated training studies published tegration They overlap considerably in how

be-tween 1968 and 1979 and concluded that these cal tradition, but this similarity is hardly

re-deeming The competence of our graduatesstudies focused on teaching only one or two

discrete interviewing skills in the context of and, indeed, the adequacy of our clinical

train-ing are typically assumed rather than verifiedbrief and poorly described intervention Fur-

thermore, the dependent variables were not (Stevenson & Norcross, 1987)

Given questions about the feasibility of well-validated, the typical client sample was

train-composed of undergraduates, and the skills im- ing graduate students to competencies in

mul-tiple systems of psychotherapy in a few years,parted were simple and discrete In a more re-

cent review, Alberts and Edelstein (1990) re- the need for rigorous evaluation of training in

psychotherapy integration is particularly vealed that therapist training studies involving

ur-more traditional process-related skills appear to gent An indisputable disadvantage of multiple

competences is that they necessitate longer andhave progressed little in methodological so-

phistication or clinical relevance more comprehensive training than a single

competency Integrative psychotherapists,

simi-If current training programs do relatively

lit-tle to ensure competence in a single psy- lar to bilingual children and switch hitters in

baseball, may be delayed initially in the chotherapy model, how can competency be

acqui-ensured if we attempt to teach practitioners sition of skills or in the attainment of several

proficiencies (Norcross, Beutler, & Clarkin,several psychotherapy models? To contemplate

such questions is to understand why systematic 1990)

Even if an integrative training program isapproaches to psychotherapy integration are

not taught in most mental health programs carefully implemented and thoroughly

evalu-ated, the effects of the training would probablyThen there is the challenge of novelty—in-

tegrative training is unprecedented in the his- be complex and idiosyncratic The findings of

the Vanderbilt II project, one of the most tory of psychotherapy During the 1980s and

care-1990s, when the integrative movement was fully designed psychotherapy training ventures,

bear this out (Henry & Strupp, 1991) Thisemerging, educators faced the challenge of try-

ing to formulate integrative training curricula project was designed to investigate the manner

in which specialized training might improvewithout the benefit of learning such approaches

in a formal context themselves As Robertson the therapeutic process and outcome of

time-limited dynamic psychotherapy The effects of(1986, p 416) put it: “Quite frankly, many of

us who are trainers teach students pretty much training were mixed, involving potentially

posi-tive and negaposi-tive effects No linear relationshipthe way we were trained, and most of us were

not trained to be eclectic therapists.” In recent was found between technical adherence and

psychotherapy outcome, although the trainingyears, the situation has improved somewhat as

graduate and postdoctoral psychology programs was successful in imparting adherence to a

manualized form of therapy The training washave instituted more formalized integrative

coursework and practica However, most of also found to alter some specific and general

operations associated with improving the those who teach and supervise integrative psy-

qual-chotherapies did not have such experiences ity of dynamic therapy, but there was evidence

that some elements not directly related to thethemselves

As with psychotherapy itself, it is increasingly imparted techniques were also improved after

training The criteria for effective training aredifficult to speak of psychotherapy training

without reference to its demonstrated effective- multitudinous and individualized, no less so

than possible indications of effective ness Although many descriptions of integrative

psycho-training programs have appeared in the litera- therapy The introduction of an integrative

per-spective does nothing to reduce the subtle andture, empirical evaluations have not (for an ex-

ception, see Lecompte, Castonguay, Cyr, & complex effects of training and probably

en-larges the task of measuring training Sbourin, 1993) The same can be said for virtu-

out-ally all programs adhering to a single theoreti- come

PERSONAL THERAPY AND this admittedly influenced their valuing of it

for training

RESEARCH TRAINING

What might be the benefits of personaltreatment for the typical psychotherapist inContributors to the earlier edition of this

Handbook (Norcross & Goldfried, 1992) con- general and the integrative therapist in

particu-lar? In general, the literature contains at leastsidered questions concerning the centrality of

personal therapy and the necessity of research six recurring commonalities on how the

thera-pist’s therapy may improve his or her clinicaltraining in the preparation of eclectic or inte-

grative therapists In this section, we sum- work (Norcross, Strausser, & Missar, 1988): (1)

by improving the emotional and mental marize their responses on these contentious

func-matters and add our own views on the basis tioning of the psychotherapist; (2) by providing

the therapist-patient with a more complete

un-of 50-plus collective years un-of psychotherapy

training derstanding of personal dynamics, interpersonal

elicitations, and intrapsychic conflicts; (3) byWith respect to personal therapy, the con-

tributors agreed that its importance as a prereq- alleviating the emotional stresses and burdens

inherent in this “impossible profession”; (4) byuisite for clinical work depends on the student’s

level of psychological functioning and the serving as a profound socialization experience;

(5) by placing therapists in the role of the trainer’s own experience with personal therapy

cli-If a student’s personal problems interfere with ent and thus sensitizing them to the

interper-sonal reactions and needs of their own clients;the successful implementation of psychother-

apy, then all contributors concurred it is neces- and (6) by providing a firsthand, intensive

op-portunity to observe clinical methods In sary to remedy the situation, probably includ-

par-ing personal therapy We also sensed a marked ticular, clinicians with integrative leanings will

probably discern from personal treatment thathesitancy to endorse mandatory personal psy-

chotherapy for all students, arising in part from therapy is rarely “pure-form” in practice or

out-come, that good therapists routinely two cardinal integrative principles: (1) the em-

incorpo-pirical literature is inconclusive on the ability rate a variety of methods traditionally associated

with diverse systems, and that the therapeutic

of personal therapy to enhance clinical

effec-tiveness, and committed integrative clinicians relationship accounts for more treatment

out-come than specific techniques (Geller, are reluctant to oblige students to an activity

Nor-with unproven efficacy; and (2) the eclectic cross, & Orlinsky, 2005)

To Yalom (2002), personal psychotherapymaxim of matching the treatment to the unique

needs of the student/client would be violated is, by far, the most important part of

psycho-therapy training He reviews his own odyssey of

by insisting on a single modality for diverse

stu-dents Instead, a variety of individually tailored personal therapy during a 45-year career,

em-phasizing the diversity of theoretical personal development exercises (Beutler &

orienta-Consoli, 1992) and other life-enhancing activi- tions he sought He concludes (Yalom, 2002,

pp 41–42):

ties (Lazarus, 1992) are endorsed

In both this Handbook and research studies, It is important for the young therapist to avoid

the valence accorded to personal therapy varies sectarianism and to gain an appreciation of the

as a function of whether or not the psychother- strengths of all the varying therapeutic apist has undergone personal treatment himself proaches Though students may have to sacrifice

ap-the certainty that accompanies orthodoxy, ap-they

or herself In one representative study (Norcross,

obtain something quite precious—a greater

ap-Dryden, & DeMichele, 1992), only 4% of

psy-preciation of the complexity and uncertainty

un-chologists who received personal therapy thought

derlying the therapeutic enterprise

it was unimportant compared to 39% of those

psychologists who had not received it In their Yalom is hardly alone in his experience

Across studies and across countries, chapter, Prochaska and DiClemente (1992) re-

psycho-ported having undergone personal therapy, and therapists rate their personal therapy or analysis

the second most important influence on their Strauss, 1984) Whether or not clinicians ever

elect to produce original research, they mustprofessional development—behind only clini-

cal experience (Orlinsky et al., 2001) Given learn to respect the process of knowledge

ac-quisition, to acquire a way of thinking aboutthis and the overwhelmingly positive self-

reported outcomes of therapists’ personal ther- therapeutic phenomena, and to critically read

the relevant literature In short, research apy (Orlinsky & Norcross, 2005), we enthusias-

train-tically recommend (but not require) personal ing prepares us to question and evaluate the

way psychotherapy (and psychotherapy treatment for our trainees A “good-enough”

train-therapist (or multiple train-therapists) is necessary ing) is conducted (Meltzoff, 1984)

for the undertaking, of course Personal

ther-apy is viewed as one component of ongoing

development and continuing education INTEGRATIVE SUPERVISION

With respect to research training, the

con-sensus is that it is a desirable, but not neces- As beginners, most psychotherapists sought out

a single theory by which they could definesary, ingredient for an effective integrative ther-

apist None of the contributors to the earlier their approach, manage their anxiety, and

so-lidify their identity Beginners felt a naı¨ve sense

edition of this Handbook insisted upon its

in-clusion in clinical curricula, but several advo- of security in adhering to the methods of a

sin-gle, pure-form orientation; however, such cate a critical and searching perspective to the

reas-psychotherapy enterprise Beutler and Consoli surance was inevitably short-lived as they came

to realize the limitations of any singular (1992), for instance, asserted that a research

ap-orientation assists one to perceive relationships proach In recent years, the lure of empirically

supported treatments has led many beginnersbetween therapeutic strategies and subsequent

changes and to be a thinking therapist Simi- down a path of simplistic hope that

manual-ized treatments would have all the answers Inlarly, Lazarus (1992) placed paramount im-

portance on the multimodal therapist being time, of course, those who jumped on the

evi-dence-based bandwagon quickly came to trained to understand the workings of science,

real-to appreciate the value of inquiry, and thus real-to ize the limitations of manualized therapies

developed within laboratory settings using become critical consumers of research—not

re-necessarily producers of research We concur search volunteers Decades of psychotherapy

research has clearly documented that patientwholeheartedly

A scientific orientation, not to be equated factors and the therapeutic relationship, rather

than specific technical ingredients, are mostwith laboratory research, conveys a mode of

thought that transcends the particular brand of important to psychotherapy success (Norcross,

2003; Wampold, 2001) If we manualize therapy being conducted It teaches how to be

any-inquisitive and skeptical, how to gather data thing, it should be flexibility and effectiveness

(Beutler, 1999)

rather than opinion, how to analyze those data

and draw inferences from them These are As suggested earlier, advocates of integration

are certain to confront obstacles in guidingskills that help organize clinical knowledge

and help students select among the morass of their students toward an integrative approach

On a broad level, there are the problems withcompeting therapy claims Many integrative

therapists credit their research training for fos- curriculum and institutional change discussed

elsewhere in this chapter On a personal level,tering the thinking skills and methodological

pluralism that enabled them to proceed toward there are the predispositions of those who are

educating and the needs of those who are integration (Goldfried, 2001) Good practice,

be-like good research, depends on systematic deci- ing taught Committed integrationists will need

to find ways to help their supervisees feel sion making, reasoning from sufficient data,

com-tolerance for ambiguity, and avoidance of pre- fortable foregoing the pursuit of proficiency in

a single, pure-form system and instead work mature assumptions (Faust, 1986; Giller &

to-ward the development of a comprehensive, tance in their students about such prospects.

Even in the earliest stages of training, studentsmultifaceted system Although most supervisors

respect clinical approaches that have been often come with theoretical biases that limit

their openness to integrative approaches Thisdemonstrated to be effective in treating certain

conditions, experienced clinicians are wary of situation may be compounded by the

under-standable anxiety experienced by novices whooverreliance on approaches that suggest that

“one size fits all.” are overwhelmed by the complexity of

psycho-therapy, and therefore, who yearn for a simple,Many beginners cling to the notion that the

realm of psychotherapy is composed of a albeit narrow, theoretical model

It can be both surprising and disconcertingneighborhood of separate houses Beginners

tend to view themselves as house hunters seek- for a supervisor to encounter the supervisee

who professes adherence to a narrow modeling the home that will feel most comfortable

If educators teach psychotherapy in ways that and is resistant to the possibility of becoming

more broadly trained In these situations it maysuggest that these houses are indeed separate

parcels of real estate, new generations of begin- not be a matter of the trainee holding onto a

base of security, but rather a case of a refusalning therapists will continue to misunderstand

what the real world of psychotherapy is about to consider alternative methods Some trainees

apparently feel no need to become informedBelow are eight principles of supervising in-

tegrative psychotherapy, culled from both the about other models and methods; they

evi-dence complacency with their treasured nascent literature and our collective experience

eral premises, the most important of which per- dental In the typical undergraduate

curricu-lum, the pedagogical approach to clinical tain to the supervisee’s level of cognitive com-

ma-plexity and theoretical sophistication prior to terial tends to be discrete and categorical For

example, in a course on abnormal psychology,beginning clinical work Ideally, as delineated

earlier, the supervisee has acquired a rudimen- diagnostic conditions are commonly taught as

independent of other conditions; a textbooktary understanding of differential treatment se-

lection and has been exposed to the range of client has panic disorder or major depressive

disorder, but not both concomitantly theories and techniques that are the underpin-

Clini-nings of psychotherapy integration In our ex- cians working with real people, however, know

that most clinical presentations are perience, if the supervisee does not possess

multidi-such knowledge, then it should be taught im- mensional When they learn treatment

ap-proaches, undergraduates are likely to study mediately, if feasible, or the supervision should

in-probably not aspire to be integrative The inte- dependent, nonintegrated approaches such as

cognitive, psychodynamic, or systemic Theygrative journey is arduous; it is unrealistic to

expect beginners to competently plunge into may prematurely leap to the conclusion that a

given model is the most viable one for them tointegrative work early in their development

pursue in their own graduate training, not yetrealizing that clinical work tends to be techni-Understand Trainees’ Biases

cally eclectic

and Anxieties

Supervisors will find it easier to reach ning trainees when they approach their workThe word is only slowly spreading to educators

begin-who have not been involved in the integration with an understanding of the stages of therapist

development (Halgin, 1988) In one particularmovement about the wisdom and the pragmat-

ics of integrative training Experienced faculty stage theory (Loganbill, Hardy, & Delworth,

1982), which has become an accepted modelincreasingly appreciate integrative training, but

they may be surprised to encounter some resis- for understanding therapist development,

su-pervisees progress through three stages: stagna- pervisor can lose touch with how perplexing

and intimidating the psychotherapy process istion, confusion, and integration During the

stagnation stage, the beginner is deceived by for the neophyte

the illusion of simplicity in clinical work The

confusion stage follows, during which the

Clarify Expectations and Goalstrainee realizes that something is amiss and so-

lutions seem elusive It is only later in training In addition to the difficulty of mastering

inte-gration is the difficulty of becoming a that the supervisee attains a sense of integration

super-during which flexibility, security, and under- visee Trainees usually enter supervision with

little understanding of the process, and they standing emerge Thus, the supervisor who im-

of-patiently expects the trainee to have attained ten do not receive formal assistance in

assum-ing the role of supervisee It should come as nointegration early in training is likely to engen-

der dismay, frustration, and diminished self- surprise that trainee ratings and faculty/expert

ratings of the quality of the same supervisionesteem in the trainee

session have very low correlations (e.g., chelt & Skjerve, 2002; Shanfield, Hetherly, &Appreciate the Difficulty

Rei-Matthews, 2001) Many supervisor and

super-of Integration

visee dyads are literally not on the same page.Psychotherapy supervision, particularly ofSupervisors can often lose touch with the chal-

lenging nature of learning integration Stu- the integrative variety, requires formal

prepara-tion of students and structured orientaprepara-tion todents, when first introduced to multitheoretical

approaches, are frequently puzzled by the me- supervision (Bertger & Buchholz, 1993) Such

an orientation would address the participants’chanics of technique shifts and are dismayed

that their own attempts might prove to be awk- goals and expectations, the logistics of

supervi-sion (e.g., setting, format, boundaries, legal ward and disruptive (Wachtel, 1991) Begin-

re-ners are typically overwhelmed by the array of lationship), and its omnipresent evaluative

com-ponent (e.g., grading criteria, course credit,possibilities For example, a novice may be per-

plexed by whether an interpretation or a direc- letters of recommendations) In fact, we are

among those who opt for an explicit contracttive intervention is advisable at a given point

in a session; confronted with such an imposing for supervision (Sutter, McPherson, &

Geese-men, 2002)

choice, paralysis may set in When apprised of

such a moment in the therapy, an insensitive

supervisor may make a difficult situation even

Share Our Work with Superviseesworse for the trainee who is already feeling

miserably insecure A comment that reflects Although modeling has been shown to be a

particularly effective procedure for teachingimpatience or surprise about the trainee’s han-

dling of the therapy is likely to intensify the complex behaviors, this technique is used

sur-prisingly little in teaching psychotherapy Moststudent’s anxiety instead of fostering some risk-

taking, which is an indispensable part of the clinical educators use lecture and consultant

techniques to pass on knowledge about thelearning process

Experience provides clinicians with a spe- methods of psychotherapy Like many

consul-tants, they act and speak like experts who arecial sense of what should be done next in the

therapy; this reflects a complex, recursive deci- reluctant to acknowledge the problems that

they themselves encounter in their work.sion-making process that is informed by doz-

ens, perhaps hundreds, of bits of data related Rather than discuss the mistakes they have

committed, they are inclined to report the

suc-to client, therapist, and context considerations

Like the statistics instructor who may be oblivi- cesses they have achieved Rather than disclose

their anxieties, they are likely to boast in waysous to the fact that many students do not fully

appreciate the difference between analysis of that communicate an inflated sense of

compe-tence and self-assurance

variance and correlation, the experienced

su-This situation would be quite different if plore the parallels between what is happening

in the supervisory relationship and in the trainees could actually observe the work of

thera-their clinical supervisors; yet conducting peutic relationship (Rau, 2002)

Researchers have documented supervisorypsychotherapy before the critical eyes of super-

visees is an uncommon event Consequently, styles that are facilitative and those that are

problematic (see Neufeldt, Beutler, & trainees are deprived of the opportunity of

Ban-watching their teachers struggle with the chero, 1997) The ideal supervisor possesses

“high levels of empathy, respect, genuineness,dilemmas that are so common in clinical

(Carifio & Hess, 1987, p 244) Like good

ther-We and others (e.g., Lampropoulos, 2002;

Norcross & Beutler, 2000) emphasize the enor- apists, good supervisors are those who use

ap-propriate teaching, goal-setting, and feedback;mous value of demonstrating and modeling

psychotherapy to trainees Trainees should ob- they tend to be seen as supportive, noncritical

individuals who respect their supervisees andserve the work of clinical supervisors, conduct

psychotherapy with more experienced peers, help them understand their own responses to

patients (Shanfield, Hetherly, & Matthews,and watch videotapes of seasoned clinicians

conducting psychotherapy Trainees may also 2001) The remote and uncommitted

supervi-sory style, in particular, seems to be benefit by reading about how seasoned thera-

detrimen-pists themselves struggled in their early at- tal (Nelson & Friedlander, 2001) It tends to

beget trainee struggle or extensive anger and,tempts to develop an integrated approach to

therapy (Goldfried, 2001) in such relationships, supervisees commonly

lose trust, feel unsafe, pull back, and remainSharing our clinical work with our students

can open a rich dialogue in which the supervi- guarded

Although a negative supervisory experiencesor is willing to be vulnerable By being vulner-

able, the supervisor can commit to a trusting may be attributable to a general problematic

supervisory style, sometimes the negative and open relationship What a wonderful op-

expe-portunity for the trainee to observe the work of rience is due to more specific

counterproduc-tive events in supervision (Gray, Ladany, Walker,the expert! Supervision can focus on the diffi-

culties encountered by the therapist/supervisor, & Ancis, 2001) One such example is when

a supervisor dismisses a trainee’s thoughts andand in this process the student can develop a

greater appreciation of what takes place within feelings Another example involves the

supervi-sor directing the trainee “to be different withthe integrative therapy session Open discus-

sion of our own clinical work will also sensitize the client.” Research documents that

counter-productive supervisory events commonly lead

us to the complexity of this work When faced

with trainees asking us to explain—and de- to a weakening of the supervisory relationship

and a diminishment of the quality of work withfend—why a given intervention was chosen,

we will assuredly become aware of how diffi- the client (Ramos-Sanchez et al., 2002)

Integrative supervisors have an excitingcult practicing within an integrative approach

is; and with this awareness, we will be more opportunity to apply to the supervisory

rela-tionship some of the same methods that aresensitive to the challenges that our trainees

confront effective in integrative psychotherapy The

su-pervisor can blend the methods of several retical approaches; for example supportive,Make Optimal Use of the

theo-directive, exploratory, and interpersonal Supervisory Relationship

tech-niques can be blended within supervision insuch a way that the supervisee feels supported,Just as the therapeutic relationship is an essen-

tial curative factor in psychotherapy, the super- understood, and well-educated (Halgin, 1985a)

The supervisory relationship is an optimal visory relationship is comparably important in

con-fostering growth in clinical trainees The useful text within which to model these crucial

train-ing goals

concept of parallel process can be used to

ex-As should now be apparent, the relationship ture (e.g., Holloway & Wampold, 1986;

Stol-tenberg, McNeill, & Crethar, 1994) suggests

is simultaneously a context and a process for

change in supervision We as supervisors have that we can improve supervision by tailoring

it to three trainee characteristics in particular:the opportunity of providing our students with

wonderful gifts Ideally, they will finish their developmental stage, therapy approach, and

cognitive style (Norcross & Halgin, 1997).work with us knowing more about therapy,

more about clients, more about us, and most One of the most appealing features of

inte-grative psychotherapy is that an individualizedimportantly, more about themselves The su-

pervision can be viewed as a laboratory in treatment plan can be formulated for each

cli-ent A similar principle holds true for which creative experiments take place As su-

integra-pervisors, we have a great deal of responsibility tive supervision: an individualized supervision

plan can be formulated for each trainee on thefor ensuring that participants—the clients and

the trainees—in the experiment are treated basis of his or her style, stage, experience,

com-plexity, and other considerations

with sensitivity and care When we, the

super-visors, make it clear that we are also

partici-pants in this exciting experiment, we enhance Provide a Systematic Model

the probability of integrative success

Ideal supervisors provide feedback to students

in a variety of ways within a coherent Tailor Supervision to the

concep-tual framework (Allen, Szollos, & Williams,Individual Supervisee

1986; Carifio & Hess, 1987) A systematicmodel determines in large part whether inte-Just as we ask our students to be integrative and

prescriptive in their clinical work, so too should grative supervision is experienced as

intelligi-ble or bewildering Supervision within a

coher-we match our supervision to their unique

needs and clinical strategies The determinants ent framework is associated with a higher

quality experience; conversely, less valued

inte-of therapist behavior are too numerous and

su-pervisee needs too heterogeneous to provide grative supervisors fail to ground their clinical

interventions within larger conceptual the identical supervision to each and every stu-

The task of integrating the diverse systemsNot only are accidents of fate important in

determining theoretical orientation, but so also of psychotherapy should not be left entirely to

the trainee (Hollanders, 1999) Many programsare personal life experiences and personality

traits The biographies of Freud, Skinner, Rog- and supervisors advertise themselves as

integra-tive, offering a nonpartisan approach that ers, and others theorists convincingly demon-

ap-strate that their personal life experiences in- peals to students But what it frequently means

is that the students are taught by faculty of fluence their tenets and techniques (e.g.,

dif-Demorest, 2004; Monte & Sollod, 2003) Sim- ferent orientations, leaving students to try to

in-tegrate the systems on their own; or, the ilarly, the clinical approach of many beginning

stu-therapists is tremendously influenced by per- dents are supervised by faculty who respect all

systems but have no systematic way of sonal life experiences

synthe-Integrative supervision will obviously take sizing, sequencing, or selecting among them

for a given case (Hinshelwood, 1985)

into account a number of trainee variables

Su-pervisors will assess personality characteristics, In the midst of conducting psychotherapy, a

supervisee will desire immediate and concretesuch as introversion versus extroversion or need

for challenge versus need for support, and de- guidance on the “right treatment” for his or

her patients In the midst of conducting velop supervisory strategies that take these char-

super-acteristics into account (Lampropoulos, 2002) vision, a supervisor will want to address the

stu-dent’s immediate need but also provide a more

in order to help the supervisee develop

thera-peutic skills and discover his or her own voice general treatment selection heuristic for future

patients The most frequent integrative/eclectic

as a therapist (Rau, 2002) The research

litera-models used in this regard appear to be multi- grams enforce indoctrination and do not teach

optimal client–therapy matching

modal therapy, the common factors approach,

the transtheoretical model, cognitive-interper- One difficulty with this account is that it has

a judgmental flavor, as evidenced by the use ofsonal therapy, and systematic treatment selec-

tion, according to directors of doctoral programs words like rigid to characterize the opponents

of integration When translated into (Lampropoulos & Dixon, in press) The pre-

interper-ceding chapters in this Handbook detail these sonal messages, such characterizations are

likely to produce an antagonistic, win–loseand other systematic and evidence-based mod-

els for matching treatments to patients; our struggle, in which the integrative “good guys”

try to take over from the separatist “bad guys.”point is that supervisors should offer such a sys-

tematic model as well This is hardly likely to promote a welcoming

attitude toward integration on the part of the

“opposition”!

Moreover, one of the first principles of THE ORGANIZATIONAL CONTEXT

orga-nizational change is to listen to one’s opponents

respectfully and seriously; they probably have

The curricular and supervision models

por-trayed above represent a growing consensus on some truth on their side, and important

consid-erations may emerge from a dialogue amongthe outlines of effective integrative training In

our judgment, the training need at the present those with contrasting views Even if the

obsta-cles to integration consist largely of rigidity ontime is not so much for further conceptual re-

finement, but for progress in institutional move- the part of current faculty and students, we

must work with them; we are not likely, except

ment toward adopting such integrative

train-ing In other words, the more pressing need is in unusual circumstances, to be able to select

a body of faculty de novo It is, of course, less curricular than systemic

possi-This conclusion has led Andrews (1991) ble to select students or interns according to

explicitly integrative criteria (see Lane, Andrews,and us (Andrews, Norcross, & Halgin, 1992)

to contemplate the necessary systemic change Gabriel, Holt, & Schick, 1989, for an example),

but this is only likely to happen once the facultyprocesses—how innovations are adopted in or-

ganizations of higher education This approach themselves adopt integrative principles

Those who study social change in higherrepresents a different stream of thinking, one

that complements the conceptual models de- education emphasize the decentralization of

power in a variety of overlapping sites Ratherscribed above Our objective in this section is

to outline many of the educational, political, than a simple “line” authority structure, power

and decision making are localized in many and organizational changes that must occur in

set-order to implement even a modestly integrative tings: the formal administrative structures

in-volving deans and presidents; the faculty senateprogram

and its curriculum approval committees; thedepartment chair; and the individual facultyObstacles to Implementing

members who, within certain limits, decide onIntegrative Ideas

what is to be taught in their courses These tors make it even more imperative that we

fac-In much of the literature on psychotherapy

in-tegration, nonintegrative programs are por- draw on a variety of change strategies in

prom-ulgating integrative training

trayed as showing rigidity in the curriculum, in

those who administer it (faculty) and in those

who consume it (students) Programs that teach

Principles of Institutional Changeeither one orientation exclusively or a multi-

plicity of competing orientations are criticized In his thoughtful monograph entitled

Strate-gies for Change, Lindquist (1978) reports the

as forcing students into premature closure at

the risk of otherwise seeming to be a “wishy- results of case studies involving curricular and

institutional change on various college andwashy” eclectic It is argued that such pro-

university campuses He distills four models of members’ needs, diagnosed and

de-signed with their involvement, and influence processes that, he concludes, help to

im-delineate the channels through which an inno- plemented with their participation

2 Reduction of burdens Participants in an

vation becomes accepted and stabilized

Inno-vation—integrative training, in the current case— innovation should see it as reducing

their burdens, lightening their load

is best introduced through a combination of

the four change processes The effectively Adding responsibilities to already

belea-guered faculty, administrators, and stated (“rational”) idea is spread by means of

stu-informal social networks, linked to solutions by dents is no way to gain acceptance

3 Support at the top Although pushing

means of the problem-solving model, and

fi-nally ratified by the political process All four an innovation from the administration

without a sense of ownership at othermodels hold, in varying degrees depending on

the situation and people involved Therefore, levels is unwise, few innovations can

succeed without firm commitment to

an effective change agent will orchestrate all

four of the change processes in a flexible way them at the highest administrative level

4 Compatibility with organizational

struc-if he or she is to be fully effective

Often at conferences dealing with psycho- ture The innovation whose

implement-ing structure fits into the existimplement-ing therapy integration, complaints are voiced of

col-resistance at one’s home institution to the in- lege or university organization has the

best chance of success

troduction of integrative ideas; indeed, in some

settings the Society for the Exploration of Psy- 5 Desire for new experience Routine can

grow tedious The opportunity to dochotherapy Integration (SEPI) member may be

the only proponent of such ideas One reason something new and exciting can go far

toward gaining acceptance of a newfor this frustration may be that we tend to take

the rational model or one of the three other idea Unfortunately, it can also cause

anxiety

models as our sole view of change processes,

thereby missing the opportunity to exert influ- 6 Respect for the opposition Those

op-posed to an innovation usually haveence within a combination of models Integra-

tive ideas are best shared and implemented by sound reasons and legitimate concerns

Innovators need to sit down with the

a sage synthesis of rational information, social

network, problem-solving, and politics opposition and listen

7 Clear goals Foggy goals often lead to

failure in implementation Clear goalsFourteen Change Strategies

are prerequisite to innovation

8 Open, two-way communication Full

How best to develop a variety of organizational

change strategies? Watson (1972) offers 14 fac- and open two-way communication

be-fore and during the innovation is vital,tors that induce change in higher education

The integrationist wanting to introduce such not only to increase participant

owner-ship, but also to enhance accuracy ofchange would do well to incorporate these

strategies and to match his or her proposed in- interpretation Full feedback from

par-ticipants should be carefully maintained.novation against these criteria, asking at each

step how the endeavor to introduce integrative 9 Bugs inevitable No innovation works

right the first time Bugs and ideas could be modified to maximize its likeli-

disap-hood of becoming implemented pointments should be expected

10 Training for new roles Undertaking new

roles is difficult New skills must be

1 Ownership The more an innovation is

“owned” by those affected by it, the learned, and a training program may

need to be developed

greater will be full acceptance It is

im-portant, therefore, to be sure that a 11 Suitable materials New approaches to

curriculum, teaching, and evaluationproposed innovation is responsive to

usually require appropriate materials chial, more pluralistic, and more effective than

traditional, single theory products

and facilities Success is contingent

upon adequate resources of all kinds Our more fervent hope is that, as a process,

psychotherapy integration will be disseminated

12 Unexpected effects Change in one part

of an organization may have unex- in training methods and models consistent

with the openness of integration itself The pected consequences—some desirable,

in-others not—for other parts These need tention of integrative training is not necessarily

to produce card-carrying, flag-waving

“eclec-to be taken in“eclec-to account in planning

and implementation tic” or “integrative” psychotherapists This

scenario would simply replace enforced

con-13 Rewards Faculty, trainees, and

supervi-sors cannot be expected to participate version to a single orientation with enforced

conversion to an integrative orientation, a

in a new program without attractive

compensation A rule of thumb is that change that may be more pluralistic and

liber-ating in content but certainly not in process.participants should be rewarded at least

as fully as are those in traditional learn- Instead, our goal is to educate therapists to

think and, perhaps, to behave integratively—ing, teaching, and research pursuits

14 Climate of readiness Institutional mem- openly, synthetically, but critically—in their

clinical pursuits Our aim is to prepare bers who have an open approach to

stu-change, who are well-informed about dents to develop, if they possess the

motiva-tion and ability, into knowledgeable integrativeinnovations, and who have participated

previously in successful innovation are therapists

We firmly believe that it is inappropriate to

more accepting of new ideas

demand that students adopt any single theoretical perspective, integrative or other-wise We are equally convinced that eachpractitioner should develop an individualCONCLUDING COMMENTS

meta-Theoretical pluralism and psychotherapy inte- clinical style within his or her chosen

perspec-tive The goal of every training programgration are here to stay in training mental

health professionals Although the particular should be graduates who are knowledgeable,

broad as well as deep in their interests, andobjectives and sequences will invariably differ

across training programs, recent research dem- sufficiently curious to keep learning and

grow-ing professionally (Frances et al., 1984) onstrates that the vast majority of training pro-

Inte-grams profess a pro-integration position Train- gration, by its very nature, will be a

continu-ing process, rather than a final destination.ing directors indicate that they are committed

to providing their students with significant ex- The hope is that, in Halleck’s (1978, p 50)

words, our students will “approach our posure to the major psychotherapy models and

pa-to encouraging their students pa-to seek out prac- tients with open minds and a relentless

com-mitment to study and confront the tica that expose them to several different treat-

complexi-ment approaches And, in most programs, the ties of human behavior.”

attitudes of professors and students alike are

positive toward integration (Goldner-deBeer,

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Outcome Research on

Psychotherapy Integration

MICHELE A SCHOTTENBAUER, CAROL R GLASS,

AND DIANE B ARNKOFF

Studies consistently show that one-third to one- ter include integration of psychopharmacology

and psychotherapy (see Beitman, 2005) and half of American clinicians consider them-

in-selves to be either “eclectic” or “integrative” in tegration of treatment formats/modalities (see

Feldman & Feldman, 2005) We will primarilytheoretical orientation (for a review see Glass,

Victor, & Arnkoff, 1993) For instance, a re- focus on individual psychotherapy, with a brief

review on literature of family, couples, andcent study found that 36% of psychologists

claim to be eclectic/integrative (Norcross, Hedges, group modalities Additionally, most of these

individual treatments are for adults, as very

lit-& Castle, 2002) Psychotherapy integration is

widely believed by experienced clinicians to tle empirical research exists on integrative

therapy for children Although much of theimprove the effectiveness of psychotherapy

(Wolfe, 2001), and yet, despite a large theoreti- treatment for children may be eclectic for

prag-matic reasons, it is rarely identified as suchcal and clinical literature, empirical research

on psychotherapy integration has for many (Chorpita et al., 2002)

In conducting a review of empirical years lagged behind (Arkowitz, 1997; Glass,

out-Arnkoff, & Rodriguez, 1998; Norcross et al., come research on psychotherapy integration,

several problems are encountered First, it is1993) Fortunately, in recent years the empri-

cial outcome literature has begun to grow con- difficult to identify what constitutes integrative/

eclectic therapy We restricted our review tosiderably; nevertheless, much work is left to be

them-selves as eclectic or integrative Thus, therapiesOur chapter reviews the existing outcome

literature on psychotherapy integration, dis- that may acknowledge their eclectic heritage,

but primarily retain a pure-form identity, arecusses the difficulties inherent in conducting

this research, and suggests future possibilities not included (e.g., feminist therapy,

rational-emotive behavior therapy)

Types of integration not included in this

chap-459

A second problem in conducting such a re- The third type of integration we will cover

is theoretically driven integration Althoughview relates to what constitutes outcome re-

search A wide range of integrative therapies theoretical integration has been defined in a

variety of ways (cf Castonguay, Reid, Halperin,have been studied with case studies and purely

process studies; however, for the purposes of & Goldfried, 2003) we will consider it to be

integration in which a clear theory drives thethe current review, the standard for inclusion

was set much higher In order for a therapy to choice of techniques Unlike assimilative

inte-gration, the theory is not necessarily derived

be included in the chapter, there had to be

outcome research consisting of at least one primarily from one type of mainstream

psycho-therapy; it may be developed from an amalgamgroup study with or without comparison group,

preferably with randomization to treatment or of many theories of psychotherapy, developed

anew, or imported from a relevant field (e.g.,

to a control group We identify three levels of

empirical support: substantial empirical sup- social-ecological theory) The choice of

psy-chotherapeutic techniques is guided by theport (four or more randomized controlled stud-

ies), some empirical support (one to three ran- theory and may include techniques from one

or more systems of psychotherapy

domized controlled studies), and preliminary

empirical support (studies with no control group The fourth type of psychotherapy

integra-tion discussed in this chapter is technical

or a nonrandomized control group) Integrative

psychotherapies with only case studies or pro- eclecticism, which has typically been defined

as the use of psychotherapy techniques withoutcess research, or with no research, are included

in a later section on promising directions regard to their theoretical origins (Lazarus,

2005) Although a number of authors also

in-A third source of difficulty relates to the

pro-cess of identifying an acpro-cessing research con- clude common factors as a type of

psycho-therapy integration (e.g., the use of elementsducted and published in languages other than

English Although efforts were made to locate identified as common to many pure-form

therapies), it is only incorporated in the and include integrative treatments from Eu-

“prom-rope and South America, the results of our re- ising directions” section of the current chapter

due to a lack of outcome studies More view are largely restricted to studies published

infor-in the English language mation on common factors can be found in

the chapter by Miller, Duncan, and HubbleFinally, a fourth problem in reviewing the

integrative psychotherapy outcome literature is (2005)

Within each type of integration, we will the wide variety of ways in which psychothera-

dis-pists integrate Various attempts have been tinguish between therapies originally designed

for multiple disorders and those created to made to categorize what eclectic and integra-

ad-tive clinicians do (see Norcross, this volume, dress a specific disorder(s) A list of all

psycho-therapies covered in the chapter, along withfor a review) For our purposes, we will distin-

guish among four types of psychotherapy in- their degree of empirical support to date, is

presented in Table 22.1

tegration The first is assimilative integration,

defined by Messer (2001, p 1) as: “the

incorpo-ration of attitudes, perspectives, or techniques

from an auxiliary therapy into a therapist’s

primary, grounding approach.” The second ASSIMILATIVE INTEGRATION

is what we will call sequential and

parallel-concurrent integration, in which separate A variety of integrative therapies have been

de-veloped within the framework of a particularforms of therapy (e.g., cognitive-behavioral and

interpersonal) are given either in sequential or- system of psychotherapy, in which integration

consists of supplementing that therapy withder or during the same phase of treatment in

separate sessions or separate sections of the specific techniques or theories from other

sys-tems of psychotherapy

same therapy session

TABLE 22.1 Integrative Therapies with Empirical Support, Categorized by Degree of SupportName of Therapy Authors and References

Substantial Empirical Support (4 or More Randomized Controlled Studies)

Acceptance and Commitment Therapy Hayes, Strosahl, & Wilson (1999)

Cognitive Analytic Therapy Ryle (1990); Ryle & Kerr (2002)

Dialectical Behavior Therapy Linehan (1993)

Emotionally Focused Couples Therapy Greenberg & Johnson (1988)

Eye Movement Desensitization and Reprocessing Shapiro (1995)

Mindfullness-Based Cognitive Therapy Segal, Teasdale, & Williams (2002)

Multisystemic Therapy Henggeler, Schoenwald, Borduin, Rowland, &

Cunning-ham (1998) Systematic Treatment Selection Beutler & Clarkin (1990); Beutler & Harwood (2000) Transtheoretical Psychotherapy Prochaska & DiClemente (1992)

Some Empirical Support (1–4 Randomized Controlled Studies)

Behavioral Family Systems Therapy Robin et al (1994, 1999)

Brief Eclectic Psychotherapy for PTSD Gersons, Carlier, Lamberts, & van der Kolk (2000) Brief Relational Therapy Safran, Muran, Samstag, & Stevens (2002)

CBT and Interpersonal/Emotional Processing Therapy Newman, Castonguay, Borkovec, & Molnar (in press) for GAD

Cognitive Behavioral Analysis System of Psychotherapy McCullough (2000, 2001)

Sequential CBT and Psychodynamic-Interpersonal Shapiro & Firth (1987)

Therapy

Integrative Behavioral Couple Therapy Jacobson & Christensen (1996)

Integrative Cognitive Therapy for Depression Castonguay et al (2004)

Integrative Treatment for Agoraphobia Chambless, Goldstein, Gallagher, & Bright (1986) Interactive-Behavioral Training Daniels (1998)

Process-Experiential Therapy (Individual) Greenberg & Watson (1998)

Systemic Behavioral Family Therapy Alexander & Parsons (1982)

Multimodal Therapy Lazarus (1981, in press)

Preliminary Empirical Support (Studies with No Control Group or a Nonrandomized Control Group)

Bergen Project (FIAT Model) Nielsen et al (1987)

Client-Directed, Outcome-Informed Therapy Duncan & Miller (2000)

Cognitive Analytic Group Therapy Duignan & Mitzman (1994)

Developmental Counseling and Therapy Ivey (2000)

Functional Analytic Psychotherapy Kohlenberg & Tsai (1991)

Integrative Psychotherapy for Personality Disorders Caldero´n (2001)

Integrative Group Treatment Morgan, Winterowd, & Fuqua (1999)

Note PTSD, Posttraumatic Stress Disorder; CBT, Cognitive-Behavior Therapy; GAD, generalized anxiety disorder; FIAT, Flexibility,

Interpersonal orientation, Activity, and Teleologic understanding.

1998) and couple therapy (Greenberg & Therapies Originally Designed

John-son, 1988; JohnJohn-son, Hunsely, Greenberg, &for Any Disorder

Schindler, 1999) The couple therapy research

is included in a section on that modality later

in this chapter Individual process-experiential

Process-Experiential Therapy

Greenberg and colleagues have developed a therapy integrates process-directive and

experi-ential interventions for specific client markersprocess-experiential therapy that has under-

gone several empirical tests in different forms, with the facilitative conditions of client-centered

therapy Greenberg and Watson (1998) including individual (Greenberg & Watson,

com-pared this therapy to client-centered therapy Bergen Project on Brief

Dynamic Psychotherapy

with 34 randomly assigned clients with

depres-sion They found no difference in depressive

The Bergen Project on Brief Dynamic symptoms at termination or at a 6-month fol-

Psycho-therapy (Nielsen et al., 1987) was based on thelow-up, but the process-experiential treatment

FIAT model, which stands for Flexibility, showed some other benefits, including fewer

In-terpersonal orientation, Activity, and Teleologicsymptoms, better self-esteem, and fewer inter-

understanding The therapy designed from thispersonal problems A more recent randomized

model added supportive, behavioral, and comparison of these two approaches has been

cog-nitive interventions to psychodynamic completed with a sample of 72 depressed cli-

tech-niques In a small pilot study, Nielsen and ents (Goldman, Greenberg, & Angus, 2003)

asso-ciates (1988) found that clients with physicalAlthough both treatments significantly increased

disorders who received treatment with the FIATself-esteem and reduced depression, process-

model showed statistically significant symptomexperiential therapy resulted in significantly

change by the end of therapy, maintained suchmore improvement on most measures Al-

change at follow-up, and were judged muchthough there are only two outcome studies

improved by independent raters Their

im-on the process-experiential approach to indi- provement was equal to that of participantsvidual therapy, extensive process research has

who received one of two short-term dynamicfound support for the techniques incorporated

therapies Those in the FIAT treatment,

how-in this method of therapy (e.g., Goldman &

ever, may have reached their “peak of change”Greenberg, in press; Pos, Greenberg, Gold-

later in the process of therapy (Barth et al.,man, & Korman, 2003; Watson & Greenberg,

1988)

1996)

A larger sample of 44 clients with a widerange of Axis I and Axis II disorders, fromwhich the subsample for the previous study

Functional Analytic Psychotherapy

was taken, found that at the end of treatment,Functional Analytic Psychotherapy (FAP; Koh-

FIAT clients had not improved as much as lenberg & Tsai, 1991) uses behavioral analysis

cli-ents in the two short-term psychodynamic

psy-of the therapeutic relationship to improve

chotherapy groups, but that by 2-year manualized cognitive therapy (Kohlenberg, up they had “caught up” to the other groupsKanter, Bolling, Parker, & Tsai, 2002) The in-

follow-(Nielsen et al., 1992) The conclusions are terpersonal relationship between the client and

lim-ited because the clients were not randomly therapist is a major focus of the work, in that

as-signed to treatments but asas-signed due to problematic interpersonal client behaviors are

theo-retical reasons The FIAT model has also beennoted and elicited by the therapist, who then

applied to insomnia, with good preliminary contingently responds to client improvement

re-sults from two case studies (Nielsen, 1990).and helps the client understand the function

of these behaviors (Callaghan, Naugle, &

Fol-lette, 1996; Kohlenberg et al., 2002) Several Therapies Originally Designed

empirical case studies of FAP exist Addition- for a Specific Disorder

ally, in a quasi-empirical nonrandomized study

with a control group, Kohlenberg and colleagues

(2002) compared standard cognitive therapy to Mindfulness-Based Cognitive Therapy for Depression

FAP-enhanced cognitive therapy with 46

de-pressed clients They found significant benefits Mindfulness is a technique based in Buddhist

practice that has recently been applied in for FAP at posttreatment and 3-month follow-

psy-up on measures of depression and interper- chotherapy; it involves being aware of thoughts

and feelings and therefore achieving a sense ofsonal function, in comparison to standard cog-

nitive therapy separateness from them, as well as a sense of

their impermanence Baer (2003) reviewed the assigning participants to groups Although the

number of participants was small (21), the ICTliterature on mindfulness interventions and

found that they may be related to improvement group did significantly better than the controls

both statistically and clinically on two

mea-in a number of disorders and a number of mea-

inte-grative therapies, including Mindfulness-Based sures of depression and on global functioning.Cognitive Therapy (MBCT; Segal, Teasdale,

& Williams, 2002)

Consisting of cognitive therapy supplement- SEQUENTIAL AND

PARALLEL-ed with mindfulness techniques, MBCT (Segal CONCURRENT INTEGRATION

et al., 2002) was developed to help prevent

re-lapse in recurrently depressed clients Several Two types of psychotherapy integration that arerandomized studies have examined the efficacy not often explored empirically are what we

of MBCT Teasdale et al (2000) found that if term sequential and parallel-concurrent In clients had experienced three or more previous quential psychotherapy integration, two or moreepisodes of depression, MBCT was associated types of psychotherapy are given, each duringwith significant reduction in relapse or recur- a separate phase of time and in a specified or-rence of depression when compared with treat- der, with the aim of targeting specific problemsment as usual; however, this improvement was during each stage In parallel-concurrent psy-not found for clients with fewer prior depres- chotherapy integration, two or more types ofsive episodes This study used a sample of 145 psychotherapy are given during separate ses-participants sions (both in the same phase of treatment,

se-Ma and Teasdale (2004) replicated these re- such as during the same week) or during sults with a sample of 125 depressed outpa- rate parts of one session Sequential and paral-tients Additionally, Teasdale and colleagues lel-concurrent integration are different from(2002) found that metacognitive awareness, or other types of psychotherapy integration in thatthe ability to think about thinking, increased as they keep the component pure-form therapies

sepa-a result of MBCT in sepa-a tresepa-atment study with distinct while acknowledging the importance

87 participants Williams, Teasdale, Segal, and of including both types of therapy as part of aSoulsby (2000) randomly assigned 45 clients to complete treatment.

MBCT or treatment as usual and found that

MBCT significantly reduced the number of

generalized memories in depressed clients Sequential Psychotherapy Integrationwhen compared with treatment as usual; re-

calling generalized rather than specific

memo-ries has been found to be a maladaptive aspect First Sheffield Project: Combining

CBT and

Psychodynamic-of depression

Interpersonal Psychotherapy

One of the first significant examples of

re-Integrative Cognitive Therapy

search on combining existing approaches was

for Depression

the Sheffield Psychotherapy Project (Shapiro

& Firth, 1987) The primary goal of this studyCastonguay and colleagues (2004; Castonguay

& Maramba, 2005) have developed and tested was to compare a cognitive-behavioral

(prescrip-tive) treatment with a

psychodynamic-interper-an Integrative Cognitive Therapy (ICT) for

de-pression that uses techniques from humanistic sonal (exploratory) treatment in a crossover

re-search design (The exploratory therapy wasand interpersonal therapies to help repair alli-

ance ruptures in traditional cognitive therapy later found to integrate psychodynamic,

experi-ential, and interpersonal methods; Shapiro &They examined this integrative cognitive ther-

apy for depression in comparison to a waiting- Startup, 1992.) Forty clients with depression

and/or anxiety completed 16 sessions of list control; randomization was employed when