Handbook of Psychotherapy Integration, Second Edition Part 9 pptx

PART V
Training, Research, and Future Directions
This page intentionally left blank
21
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 train-trained exclusively in a single theoretical orien-
tation and in the individual therapy tradition. ing exponentially increases the student press to
obtain clinical competence in multiple theo-The ideological singularity of training did not
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 cli-cho thera pists began to recognize that their ori-
entations were theoretically incomplete and nicians be resolved, but an integrative program
must also assist its students in acquiring mas-clinically inadequate for the variety of patients,
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 fac-training toward integration or eclecticism has
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 inte-search evidence that different patients prosper

439
440
Training, Research, and Future Directions
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 Referrals
changes, 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 toor training rats to run a maze (Bugental, 1987).
We would prefer to retitle psychotherapy train- clinicia ns competent to offer the indi cated treat-
ment. In the words of Howard, Nance, anding 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 respec-
tive contraindications of their single psycho-

therapy system and to educate them in makingINTEGRATIVE TRAINING MODELS
informed referral decisions. Many evidence-
based compendia are now available by whichPsychotherapy trainers are immediately con-
fronted with a crucial decision with respect to to recognize indications and contraindications
of particular therapies and formats (e.g., Beut-their training objectives. The major choice is
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 con-commodate most of these patients themselves
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 prescrip-grams with more resources.
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 com-duction and implementation of these models
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
Training in Psychotherapy Integration
441
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. Someto 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 knowled ge. First, s pecific
instruction and course work can emphasize the coordinated do ctora l training can pro duce 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 psycho thera py education would en-
compass an interlocking sequence of trainingser vices . Careful distinc tion must be made here
between paid advertisements and credentialing exp erien ces predica ted on the crucial therapist-
mediated and therapist-provided determinantsorg aniza tions, part icula rly on the Internet. Thi rd,
visits to community mental health centers, of psycho thera py outcome. Our su ggested 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 clien t’s disorder, treatmen t 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 psycho-large treatment centers that offer a variety of
treatment programs and specialty clinics. In therapy skills is to structure their acquisition
(Lambert & Arnold, 1987). The standard se-such a setting, the trainee can practice assess-
ing the patient and making 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. Criterion-can be facilitated and reinforced (Jarmon &
Halgin, 1987). referenced situational tests, expert ratings, and
442
Training, Research, and Future Directions
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 in-ward in the curriculum simply because they
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-
petence. sophisticated adoption of an integrative 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 de-ior. At a minimum, the courses would examine
psychoanalytic, humanistic-existential, cognitive- cisional model for selecting the methods, for-
mats, and relationships from various thera-behavioral, interpersonal-systems, and multi-
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 mini mal 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 wouldto 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 gradu-Rather, the psychotherapy systems need to be
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 resi-personal values and clinical preferences.
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 learn-books, treatment manuals, and videotapes would
Training in Psychotherapy Integration
443
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 prag-integrate at a deeper level requires that they
first understand and integrate within each indi- matic blending of methods, technical eclectics
generally endorse teaching psychotherapy inte-vidual therapy and, only then, across therapies.
Additional psychotherapy experience and disci- gration from the very beginning of training.
Gradually building toward integration in mid-plined reflection on that experience is needed
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 f or years in a specific orientation
may prove too difficult (Eubanks-Carter, Burc-accessible to novice versus expert therapists
(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 limi-emphasizes a special mode of thinking. This
form enters the educational arena only indi- tations associated with faculty composition and
disposition, which results in a series of trainingrectly through accum ulate d clinical experi ences
that promote fluent performance and creative possibilities. Graduate progra ms wil l rang e from
those in which the faculty embrace disparatemetacognitive skills.

theories and goals to programs in which there
is coordination of the training process and fac-
Specific Training Models
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 sys-considerably more experience and a bit more
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 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 promi-dicting for whom particular methods will work:
the foundation is actuarial rather than 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 s imila rly embrace
synthesis, but in a more tentative manner.allegiance to theories, and pragmatically blen-
444

Training, Research, and Future Directions
Their approach entails a firm grounding in one they educate students, with the central differ-
ences being in the timing and level of integra-system of psychotherapy, but with a willingness
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 psycho-from other systems during the course of a ca-
reer. therapy integration but disagree on the routes
toward it. Approximately 80% to 90% of direc-The assimilative integrationists frequently
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 inte-the eventual goal of integration is introduced,
but neophyte psychotherapists need to focus on grative training process differ: about one-third
believe that students should be trained first toa 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.
Common factorists seek to determine the MODERATING EXPECTATIONS
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 psychother-count for much of psychotherapy success, such
as creating a positive alliance, mobilizing cli- apy integration will be easily or instantly at-
tained. At the risk of fostering the opposite re-ent’s resources, and helping patients acquire
new skills. Castonguay (2000b), for example, action—that of pessimism or apathy—we will
consider several reasons that may moderate ex-outlines a training model driven by a common
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 be-tegration. They overlap considerably in how
Training in Psychotherapy Integration
445
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 question s about the feasibility of train-well-validated, the typical client sample was
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 ur-vealed that therapist training studies involving
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 acqui-chotherapy model, how can competency be
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 care-tory of psychotherapy. During the 1980s and
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 appr oache s
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 negative 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 qual-those who teach and supervise integrative psy-

chotherapies did not have such experiences ity of dynamic therapy, but there was evidence
that some elements not directly related to thethemselves.
As with ps ychot herap y itself, it is inc reasi ngly 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 psycho-ness. Although many descriptions of integrative
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 out-Sbourin, 1993). The same can be said for virtu-
ally all programs adhering to a single theoreti- come.
446
Training, Research, and Future Directions
PERSONAL THERAPY AND this admittedly influenced their valuing of it
for training.RESEARCH TRAINING
What might be the benefits of personal
treatment 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 func-marize their responses on these contentious
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 of psychotherapy
training. derstanding of personal dynamics, interper sonal
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 clin ical work depends on the stude nt’s
level of psychological functioning and the serving as a profound socialization experience;

(5) by placing therapists in the role of the cli-trainer’s own experience with personal therapy.
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 par-sary to remedy the situation, probably includ-
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 incorpo-two cardinal integrative principles: (1) the em-
pirical literature is inconclusive on the ability rate a variety of methods traditionall y associated
with diverse systems, and that the therapeuticof personal therapy to enhance clinical effec-
tiveness, and committed integrative clinicians relationship accounts for more treatment out-
come than specific techniques (Geller, Nor-are reluctant to oblige students to an activity
with unproven efficacy; and (2) the eclectic cross, & Orlinsky, 2005).
To Yalom (2002), personal psychotherapymaxim of matching the treatment t o 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 ofby 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 orienta-personal development exercises (Beutler &
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 ap-
apist has undergone personal treatment himself
proaches. Though students may have to sacrifice
the certainty that accompanies orthodoxy, they

or herself. In one representative study (Nor cross ,
obtain something quite precious—a greater ap-
Dryden, & DeMichele, 1992), only 4% of psy-
preciation of the complexity and uncertainty un-
chologists who recei ved personal ther apy th ought
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, psycho-chapter, Prochaska and DiClemente (1992) re-
ported having undergone personal therapy, and therapists rate their personal therapy or analysis
Training in Psychotherapy Integration
447
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 train-apy (Orlinsky & Norcross, 2005), we enthusias-
tically recommend (but not require) personal ing prepares us to question and evaluate the
way psychotherapy (and psychotherapy train-treatment for our trainees. A “good-enough”
therapist (or multiple 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 senseedition 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 reas-cate a critical and searching perspective to the
psychotherapy enterprise. Beutler and Consoli surance was inevitably short-lived as they came
to realize the limitations of any singular ap-(1992), for instance, asserted that a research
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 real-trained to understand the workings of science,
to appreciate the value of inquiry, and thus to ize the limitations of manualized therapies
developed within laboratory settings using re-become critical consumers of research—not
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 any-therapy being conducted. It teaches how to be
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 be-integration (Goldfried, 2001). Good practice,
like good research, depends on systematic deci- ing taught. Committed integrati onist s will need

to find ways to help their supervisees feel com-sion making, reasoning from sufficient data,
tolerance for ambiguity, and avoidance of pre- fortable foregoing the pursuit of proficiency in
a single, pure-form system and instead work to-mature assumptions (Faust, 1986; Giller &
448
Training, Research, and Future Directions
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 singu-nascent literature and our colle ctive experience.
lar psychotherapy.
The choice of theoretical orientation early
Ensure Prerequisite Knowledge
in training is typically made on the basis of a
number of determinants, most of them acci-Successful integrative supervision rests on sev-

eral premises, the most important of which per- dental. In the typical undergraduate curricu-
lum, the pedagogical approach to clinical ma-tain to the supervisee’s level of cognitive com-
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. Clini-theories and techniques that are the underpin-
nings of psychotherapy integration. In our ex- cians working with real people, however, know
that most clinical presentations are multidi-perience, if the supervisee does not possess
such knowledge, then it should be taught im- mensional. When they learn treatment ap-
proaches, undergraduates are likely to study in-mediately, if feasible, or the supervision should
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 yet
realizing that clinical work tends to be techni-
Understand Trainees’ Biases
cally eclectic.
and Anxieties
Supervisors will find it easier to reach begin-
ning trainees when they approach their workThe word is only slowly spreading to educators
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-
Training in Psychotherapy Integration
449

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 Goals
trainee 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 super-that the supervisee attains a sense of integration
during which flexibility, security, and under- visee. Trainees usually enter supervision with
little understanding of the process, and they of-standing emerge. Thus, the supervisor who im-
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., Rei-
chelt & Skjerve, 2002; Shanfield, Hetherly, &
Appreciate the Difficulty
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 orientation 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 re-ward and disruptive (Wachtel, 1991). Begin-
ners are typically overwhelmed by the array of lationship), a nd its omnipresent eval uativ e 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 Supervisees
worse 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-
450
Training, Research, and Future Directions
This situation would be quite different if plore the parallels between what is happening
in the supervisory relationship and in the thera-trainees could actually observe the work of
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, & Ban-trainees are deprived of the opportunity of
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
work. flexibility, concern, investment, and openness”
(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 detrimen-benefit by reading about how seasoned thera-
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 expe-and open relationship. What a wonderful op-
portunity for the trainee to observe the work of rience is due to more specific counterproduc-
tive even ts 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 leadus 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 theo-
retical approaches; for example supportive,
Make Optimal Use of the
directive, exploratory, and interpersonal tech-
Supervisory Relationship
niques can be blended within supervision in
such 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 con-visory relationship is comparably important in
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-
Training in Psychotherapy Integration
451
As should now be apparent, the relationship ture (e.g., Holloway & Wampold, 1986; Stol-
tenberg, McNeill, & Crethar, 1994) suggestsis 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 integra-which creative experiments take place. As su-

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 concep-
Tailor Supervision to the
tual framework (Allen, Szollos, & Williams,
Individual Supervisee
1986; Carifio & Hess, 1987). A systematic
model 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 perspec-the identical supervision to each and every stu-
dent. tives.
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 ap-ers, and others theorists convincingly demon-
strate that their personal life experiences in- peals to students. But what it frequently means
is that the students are taught by faculty of dif-fluence their tenets and techniques (e.g.,
Demorest, 2004; Monte & Sollod, 2003). Sim- ferent orientations, leaving students to try to in-

tegrate the systems on their own; or, the stu-ilarly, the clinical approach of many beginning
therapists is tremendously influenced by per- dents are supervised by faculty who respect all
systems but have no systematic way of synthe-sonal life experiences.
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 super-velop supervisory strategies that take these char-
acteristics into account (Lampropoulos, 2002) vision, a supervisor will want to address the stu-
dent’s immediate need but also provide a morein 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 /eclecticas a therapist (Rau, 2002). The research litera-
452
Training, Research, and Future Directions
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, acc ordin g to directors of doctoral programs words like rigid to characterize the opponents
of integration. When translated into interper-(Lampropoulos & Dixon, in press). The pre-
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 orga-THE ORGANIZATIONAL CONTEXT
nizational change is to listen to one’s opponents

respectfully and seriously; they probably haveThe 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, exceptment 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, possi-less curricular than systemic.
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, & Schi ck, 19 89, 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 set-and organizational changes that must occur in
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; the
department chair; and the individual faculty
Obstacles to Implementing
members who, within certain limits, decide on
Integrative Ideas
what is to be taught in their courses. These fac-
tors make it even more imperative that weIn 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 (stude nts). Progr ams that teach
Principles of Institutional Change
either one orientation exclusively or a multi-
plicity of competing orientations are criticized In his thoughtful monograph entitled Strate-
gies for Change, Lindquist (1978) reports theas 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-
Training in Psychotherapy Integration
453
university campuses. He distills four models of members’ needs, diagnosed and de-
signed with their involvement, and im-influence processes that, he concludes, help to
delineate the channels through which an inno- plemented with their participation.
2. Reduction of burdens. Participants in anvation becomes accepted and stabilized. Inno-
vation—integr ative 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 stu-stated (“rational”) idea is spread by means of
informal social networks, linked to solutions by dents is no way to gain acceptance.
3. Support at the top. Although pushingmeans 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 toan 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 existing col-therapy integration, complaints are voiced of
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 thea 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 goals
Fourteen Change Strategies
are prerequisite to innovation.
8. Open, two-way communication. FullHow 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 disap-ideas could be modified to maximize its likeli-
hood of becoming implemented. pointments should be expected.
10. Training for new roles. Undertaking new
roles is difficult. New skills must be1. 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
454
Training, Research, and Future Directions
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 disseminated12. 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 in-pected consequences—some desirable,
others not—for other parts. These need tention of integrative training is not necessarily
to produce card-carrying, flag-waving “eclec-to be taken into 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, ain 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 stu-bers who have an open approach to
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 tomore accepting of new ideas.
demand that students adopt any single meta-
theoretical perspective, integrative or other-
wise. We are equally convinced that each
practitioner should develop an individual
CONCLUDING COMMENTS

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). Inte-onstrates that the vast majority of training pro-
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 pa-posure to the major psychotherapy models and
to encouraging their students to seek out prac- tients with open minds and a relentless com-
mitment to study and confront the complexi-tica that expose them to several different treat-
ment approaches. And, in most programs, the ties of human behavior.”
attitudes of professors and students alike are
positive toward integration (Goldner-deBeer,
1999; Lampropoulos & Dixon, in press).
References
Psychotherapy integration is both a product
and a process. As a product, psychotherapy in-
Alberts, G., & Edelstein, B. (1990). Therapist train-
ing: A critical review of skill training studies.
tegration will be increasingly disseminated
through books, videotapes, courses, seminars,
Clinical Psychology Review, 10, 497–511.
Allen, D. M., Kennedy, C. L., Veeser, W. R., &
curricula, workshops, conferences, supervision,
postdoctoral programs, and institutional changes.
Grosso, T. (2000). Teaching the integration of
psychotherapy paradigms in a psychiatric resi-
Our hope is that educators will develop and

deliver integrative products that are less paro-
dency seminar. Academic Psychiatry, 24, 6–13.
Training in Psychotherapy Integration
455
Allen, G. J., Szollos, S. J., & Williams, B. E. (1986). and future visions. Journal of Psychotherapy In-
tegration, 10, 229–232.Doctoral students’ comparative evaluations of
best and worst psychotherapy supervision. Pro- Castonguay, L. G. (2000b). A common factors ap-
proach to psychotherapy training. Journal offessional Psychology: Research and Practice, 17,
91–99. Psychotherapy Integration, 10, 263–282.
Castonguay, L. G. (in press). Personal pathways inAndrews, J. D. W. (1991). The active self in psycho-
therapy: An integration of therapeutic styles. psychotherapy integration. Journal of Psycho-
therapy Integration.Boston: Allyn & Bacon.
Andrews, J. D. W., Norcross, J. C., & Halgin, R. P. Demorest, A. P. (2004). Psychology’s grand theorists:
How personal experiences shaped professional(1992). Training in psychotherapy integration.
In J. C. Norcross & M. R. Goldfried (Eds.), ideas. Mahwah, NJ: Lawrence Erlbaum.
Faust, D. (1986). Research on human judgmentHandbook of psychotherapy integration (pp.
563–592). New York: Basic Books. and its application to clinical practice. Profes-
sional Psychology, 17, 420–430.Baker, S. D., Daniels, T. G., & Greeley, A. T.
(1990). Systematic training of graduate-level Ford, J. D. (1979). Research on training counselors
and clinicians. Review of Educational Research,counselors: Narrative and meta-analytic reviews
of three major programs. The Counseling Psy- 69, 87–130.
Frances, A., Clarkin, J., & Perry, S. (1984). Differen-chologist, 18, 355–371.
Beitman, B. D., & Yue, D. (1999). Learning psycho- tial therapeutics in psychiatry. New York: Brun-
ner/Mazel.therapy: A time-efficient, research-based, out-
come-measured psychotherapy training program. Geller, J. D., Norcross, J. C., & Orlinsky, D. E.
(Eds.). (2005). The psychotherapist’s personalNew York: Norton.
Bertger, S. S., & Buchholz, E. S. (1993). On be- therapy. New York: Oxford University Ptress.
Giller, E., & Strauss, J. (1984). Clinical research:coming a supervisee: Preparation for learning
in a supervisory relationship. Psychotherapy, A key to clinical training. American Journal of
Psychiatry, 141, 1075–1077.30, 86–92.

Beutler, L. E. (1999). Manualizing flexibility: The Goldfried, M. R. (Ed.). (2001). How therapists
change: Personal and professional reflections.training of eclectic therapists. Journal of Clini-
cal Psychology, 55, 399–404. Washington, DC: American Psychological As-
sociation.Beutler, L. E., & Consoli, A. J. (1992). Systematic
eclectic psychotherapy. In J. C. Norcross & Goldner-deBeer, L. (1999). Psychotherapy integra-
tion in doctoral training programs: Are studentsM. R. Goldfried (Eds.) Handbook of psycho-
therapy integration (pp. 264–299). New York: prepared for the future? Unpublished doctoral
paper, University of Denver, June 1999.Basic Books.
Beutler, L. E., & Harwood, T. M. (2000). Prescrip- Gray, L. A., Ladany, N., Walker, J. A., & Ancis,
J. R. (2001). Psychotherapy trainees’ experiencetive psychotherapy: A practical guide to system-
atic treatment selection. New York: Oxford Uni- of counterproductive events in supervision.
Journal of Counseling Psychology, 48, 371–383.versity Press.
Beutler, L. E., Mahoney, M. J., Norcross, J. C., Pro- Halgin, R. P. (1985a). Pragmatic blending of clini-
cal models in the supervisory relationship. Thechaska, J. O., Sollod, R. M., & Robertson, M.
(1987). Training integrative/eclectic psycho- Clinical Supervisor, 3, 23–46.
Halgin, R. P. (1985b). Teaching integration of psy-therapists II. Journal of Integrative and Eclectic
Psychotherapy, 6, 296–332. chotherapy models to beginning therapists. Psy-
chotherapy, 22, 555–563.Bugental, J. F. T. (1987). The art of the psychothera-
pist. New York: Norton. Halgin, R. P. (Ed.). (1988). Special section: Issues
in the supervision of integrative psychotherapy.Carifio, M. S., & Hess, A. K. (1987). Who is the
ideal supervisor? Professional Psychology: Re- Journal of Integrative and Eclectic Psychother-
apy, 7, 152–180.search and Practice, 18, 244–250.
Castonguay, L. G. (2000a). Training in psychother- Halleck, S. L. (1978). The treatment of emotional
disorders. New York: Jason Aronson.apy integration: Introduction to current efforts
456
Training, Research, and Future Directions
Henry, W. P., & Strupp, H. H. (1991). Vanderbilt handbook of psychotherapy integration (pp.
483–498). New York: Plenum.University: The Vanderbilt Center for Psycho-
therapy Research. In L. E. Beutler & M. Crago Lindquist, J. (1978). Strategies for change. Carls-
balds, CA: Pacific Soundings.(Eds.), Psychotherapy research: An international

review of programmatic studies. Washington, Loganbill, C., Hardy, E., & Delworth, U. (1982).
Supervision: A conceptual model. The Coun-DC: American Psychological Association.
Hinshelwood, R. D. (1985). Questions of training. seling Psychologist, 10, 3–42.
Meltzoff, J. (1984). Research training for clinicalFree Associations, 2, 7–18.
Hollanders, H. (1999). Eclecticism and integration psychologists: Point—counterpoint. Professional
Psychology: Research and Practice, 15, 203–209.in counseling: Implications for training. British
Journal of Guidance & Counseling, 27, 483– Messer, S. B. (1992). A critical examination of belief
structures in integrative and eclectic psycho-499.
Holloway, E. L., & Wampold, B. E. (1986). Rela- therapy. In J. C. Norcross & M. R. Goldfried
(Eds.), Handbook of psychotherapy integrationtion between conceptual level and counseling-
related tasks: A meta-analysis. Journal of Coun- (pp. 130–168). New York: Basic Books.
Monte, C. F., & Sollod, R. N. (2003). Beneath theseling Psychology, 33, 310–319.
Howard, G. S., Nance, D. W., & Myers, P. (1987). mask: An introduction to theories of personality
(7th ed.). New York: Wiley.Adaptive counseling and therapy. San Fran-
cisco: Jossey-Bass. Nathan, P. E., & Gorman, J. M. (Eds.). (2003). A
guide to treatments that work (2nd ed.). NewJarmon, H., & Halgin, R. P. (1987). The role of the
psychology department clinic in training scien- York: Oxford University Press.
Nelson, M. L., & Friedlander, M. L. (2001). A closetist-practitioners. Professional Psychology: Re-
search and Practice, 18, 509–514. look at conflictual supervisory relationships:
The trainee’s perspective. Journal of Counsel-Lambert, M. J., & Arnold, R. C. (1987). Research
and the supervisory process. Professional Psy- ing Psychology, 48, 384–395.
Neufeldt, S. A., Beutler, L. E., & Banchero, R.chology: Research and Practice, 18, 217–224.
Lampropoulos, G. K. (2002). A common factors (1997). Research on supervisor variables in psy-
chotherapy research. In C. E. Watkins (Ed.),view of counseling supervision process. The
Clinical Supervisor, 21, 77–95. Handbook of psychotherapy supervision. New
York: Wiley.Lampropoulos, G. K., & Dixon, D. N. (in press).
Psychotherapy integration in internships and Norcross, J. C. (Ed.). (2003). Psychotherapy relation-
ships that work. New York: Oxford Universitycounseling psychology doctoral programs. Jour-
nal of Psychotherapy Integration. Press.
Norcross, J. C., & Beutler, L. E. (2000). A prescrip-Lane, R., Andrews, J., Gabriel, T., Holt, P., &

Schick, M. (1989, May). Integrative internship tive eclectic approach to psychotherapy train-
ing. Journal of Psychotherapy Integration, 10,training from the perspectives of supervisors and
supervisees. Symposium presented at the an- 247–261.
Norcross, J. C., Beutler, L. E., & Clarkin, J. F.nual conference of the Society for the Explora-
tion of Psychotherapy Integration, Berkeley, (1990). Training in differential treatment selec-
tion. In Systematic treatment selection: TowardCA.
Lazarus, A. A. (1992). Multimodal therapy: Techni- targeted therapeutic interventions (pp. 289–
307). New York: Brunner/Mazel.cal eclecticism with minimal integration. In
J. C. Norcross & M. R. Goldfried (Eds.) Hand- Norcross, J. C., Beutler, L. E., Clarkin, J. F.,
DiClemente, C. C., Halgin, R. P., Frances, A.,book of psychotherapy integration (pp. 231–
263). New York: Basic Books. et al. (1986). Training integrative/eclectic psy-
chotherapists. International Journal of EclecticLecompte, C., Castonguay, L. G., Cyr, M., & Sa-
bourin, S. (1993). Supervision and instruction Psychotherapy, 5, 71–94.
Norcross, J. C., Dryden, W., & DeMichele, J. T.in doctoral psychotherapy integration. In G.
Stricker & J .R. Gold (Eds.), Comprehensive (1992). British clinical psychologists and per-
Training in Psychotherapy Integration
457
sonal therapy: What’s good for the goose? Clin- Reichelt, S., & Skjerve, J. (2002). Correspondence
between supervisors and trainees in their per-ical Psychology Forum, 44, 29–33.
Norcross, J. C., & Goldfried, M. R. (Eds.). (1992). ception of supervision events. Journal of Clini-
cal Psychology, 58, 759–772.Handbook of psychotherapy integration. New
York: Basic Books. Reisman, J. M. (1975). Trends for training in treat-
ment. Professional Psychology, 6, 187–192.Norcross, J. C., & Goldfried, M. R. (Eds.). (in
press). The future of psychotherapy integration: Robertson, M. (1986). Training eclectic psychother-
apists. In J. C. Norcross (Ed.), Handbook ofA roundtable. Journal of Psychotherapy Integra-
tion. eclectic psychotherapy (pp. 416–435). New York:
Brunner/Mazel.Norcross, J. C., & Halgin, R. P. (1997). Integrative
approaches to psychotherapy supervision. In Robertson, M. H. (1995). Psychotherapy education
and training: An integrative perspective. Madi-C. E. Watkins (Ed.), Handbook of psychother-
apy supervision. New York: Wiley. son, CT: International Universities Press.

Roth, A., & Fonagy, P. (1996). What works forNorcross, J. C., & Kaplan, K. J. (1995). Training in
psychotherapy integration. II: Workshops and whom? A critical review of psychotherapy re-
search. New York: Guilford.courses. Journal of Psychotherapy Integration,
5, 351–358. Schacht, T. E. (1991). Can psychotherapy educa-
tion advance psychotherapy integration? Jour-Norcross, J. C., Strausser, D. J., & Missar, C. D.
(1988). The processes and outcomes of psycho- nal of Psychotherapy Integration, 1, 305–320.
Schultz-Ross, R. A. (1995). Ideological singularity astherapists’ personal treatment experiences. Psy-
chotherapy, 25, 36–43. a defense against clinical complexity. American
Journal of Psychotherapy, 49, 540–547.Orlinsky, D. E., Botermans, J., Ronnestad, M. H.,
& The SPR Collaborative Research Network. Shanfield, S. B., Hetherly, V. V., & Matthews, K. L.
(2001). Excellent supervision: The residents’(2001). Towards an empirically grounded model
of psychotherapy training: Four thousand ther- perspective. Journal of Psychotherapy Practice
& Research, 10, 23–27.apists rate influences on their development.
Australian Psychologist, 36, 139–148. Stein, D. M., & Lambert, M. J. (1995). Graduate
training in psychotherapy: Are therapy out-Orlinsky, D. E., & Norcross, J. C. (2005). Outcomes
and impacts of the psychotherapists’ personal comes enhanced? Journal of Consulting and
Clinical Psychology, 63, 182–196.therapy: A research review. In J. D. Geller,
J. C. Norcross, & D. E. Orlinsky (Eds.), The Stevenson, J. F., & Norcross, J. C. (1987). Current
status of training evaluation in clinical psychol-psychotherapist’s own psychotherapy: Patient
and clinician perspectives. New York: Oxford ogy. In B. Edelstein & E. Berler (Eds.), Evalua-
tion and accountability in clinical training.University Press.
Prochaska, J. O., & DiClemente, C. C. (1992). The New York: Plenum.
Stoltenberg, C. D., McNeill, B. W., & Crethar,transtheoretical approach. In J. C. Norcross &
M. R. Goldfried (Eds.) Handbook of psycho- H. C. (1994). Changes in supervision as coun-
selors and therapists gain experience: A review.therapy integration. New York: Basic Books.
Prochaska, J. O., & Norcross, J. C. (2003). Systems Professional Psychology: Research and Practice,
25, 416–425.of psychotherapy: A transtheoretical approach,
fifth edition. Belmont, CA: Wadsworth. Stricker, G. (1988). Supervision of integrative psy-
chotherapy: Discussion. Journal of IntegrativeRamos-Sanchez, L., Esnil, E., et al. (2002). Nega-
tive supervisory events: Effects on supervision and Eclectic Psychotherapy, 7, 176–180.

Sutter, E., McPherson, R. H., & Geeseman, R.satisfaction and supervisory alliance. Profes-
sional Psychology: Research and Practice, 33, (2002). Contracting for supervision. Profes-
sional Psychology: Research and Practice, 33,197–202.
Rau, D. R. (2002). Advanced trainees supervising 495–498.
Wachtel, P. L. (1991). From eclecticism to synthe-junior trainees. The Clinical Supervisor, 21,
115–124. sis: Toward a more seamless psychotherapeutic
458
Training, Research, and Future Directions
integration. Journal of Psychotherapy Integra- Wolfe, B. E. (2000). Toward an integrative theo-
retical basis for training psychotherapists. Jour-tion, 1, 43–54.
Wampold, B. E. (2001). The great psychotherapy de- nal of Psychotherapy Integration, 10, 233–
246.bate: Models, methods, and findings. Mahwah,
NJ: Erlbaum. Yalom, I. (2002). The gift of therapy: An open letter
to a new generation of therapists and their pa-Watson, G. (1972). Overcoming resistance to change.
Journal of Applied Behavioral Science, 7, 72–89. tients. New York: HarperCollins.
22
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 in-half of American clinicians consider them-
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 b e 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 out-years lagged behind (Arkowitz, 1997; Glass,
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
done. those therapies that explicitly describe 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
460
Training, Research, and Future Directions
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 derivedbe 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 technicalor a nonrandomized control group). Integrative
psychotherapi es with only case studies or pro- eclecticism, which has typically been defined
as the use of psychotherapy techniques withoutces s 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 accessing 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 “prom-and include integrative treatments from Eu-
rope and South America, the results of our re- ising directions” section of the current chapter
due to a lack of outcome studies. More infor-view are largely restricted to studies published
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 dis-the wide variety of ways in which psychothera-
pists integrate. Various attempts have been tinguish between therapies originally designed
for multiple disorders and those created to ad-made to categorize what eclectic and integra-
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 therap ist’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.