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. [...]... 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