An Outsider's Perspective on Psychotherapy Integration

This article offers those who are identified with progress in psychotherapy integration an outsider's perspective on progress in the field. The author argues for a contextual study of psychotherapy and psychotherapy integration, noting that the social psychology of psychotherapy may be an overlooked dimension in the study of psychotherapy integration. He suggests that perceptions of progress in psychotherapy integration may be exaggerated due to the lack of such a perspective.     

Complexity science: A framework for psychotherapy integration

The paradigm of complexity science provides a new way to address the problem of psychotherapy integration and allows us to bypass the various shortcomings of the linear-interventionist perspective. Nine criteria are outlined, which should be satisfied by any integrative approach to psychotherapy: (a) the use of complexity science to provide a meta-theoretical and generic understanding of change processes (from neuronal to social system levels); (b) a comprehensive and formalised modelling of change processes and personality development; (c) an integrative method of case formulation; (d) the ability to understand a variety of techniques in terms of basic change principles; (e) criteria to guide microdecisions; (f) the application of data-driven feedback and real-time monitoring of change dynamics; (g) standardised assessment of outcomes in naturalistic settings; (h) guidelines for training; and (i) strategies that are well-suited to science–practice integration. Using these criteria as a framework for evaluation, one may grasp the potential of complexity science to drive innovation in the pursuit of psychotherapy integration.     

Therapist orientation,supervisor match,and therapeutic interventions: Implications for session quality in a psychotherapy training PRN

Background: Theoretical orientation is a multifaceted construct that is integral to the process of psychotherapy and psychotherapy training. While some research has been conducted on personal identification with particular schools of psychotherapy, techniques used in psychotherapy sessions, and match between trainees and supervisors in training, there is insufficient information regarding how these may interact with one another. Aim: This study, conducted in a practice research network of trainee therapists, was designed to test whether these variables may be related to one another in predicting session quality. Method: The sample comprised 328 sessions from 26 clients and 11 therapists, with the clients completing session quality measures and therapists completing measures of technique immediately post‐session. Results: Using multilevel linear modelling, the data showed varied results. For behavioural therapy and person‐centred therapy, techniques and orientation were unrelated to session quality in the sample. However, process‐experiential, psychodynamic, and cognitive therapy techniques were all involved in interactions with therapist and/or supervisor orientations. Conclusions: These results suggest that the impact of specific psychotherapy techniques sometimes depends on the orientation of the therapist and/or supervisor. For instance, sessions high in cognitive therapy techniques were only associated with positive outcome when both the therapist and supervisor were highly cognitively oriented. Though preliminary, these results suggest that orientation may be an important variable to consider in training and supervision, especially in the context of other variables.     

Is three a crowd? A perspective on countertransference challenges in psychoanalytic couple psychotherapy

Two seemingly unrelated characteristics of psychoanalytic couple psychotherapy may be better understood when juxtaposed. First, countertransference in psychoanalytic couple psychotherapy holds particularly strong intensity. Second, format decisions are central to couple psychotherapy. The use of conjoint and concurrent formats, or variations thereof, has been key in the historical development of couple psychotherapy and remains an area of much debate. Some couple psychotherapists use the format of couple psychotherapy flexibly, using variations of conjoint or concurrent couple psychotherapy, while others adhere strictly to working conjointly. Decisions regarding whether to undertake concurrent or conjoint therapy are not generally linked to countertransference; this article demonstrates that reading decisions regarding format through consideration of countertransference offers a needed perspective for the therapist. Case studies published by psychoanalytic couple therapists are analysed through this prism to demonstrate that changing the format may serve to dilute countertransference. One particular manifestation of countertransference, linked to oedipal dynamics, is explored: countertransferential intensity for couple psychotherapists potentially relates to being faced with their internal parental couple and their unresolved Oedipal strivings. Possible unconscious motivations to change the format of couple psychotherapy need to be carefully considered, as format changes may mask an avoidance of bearing the countertransference.     

The development of therapeutic attitudes during and after psychotherapy training

The aim of this study was to explore changes in psychotherapeutic attitudes of students during training in psychodynamic psychotherapy and the first few years after it. Forty-six students were asked to answer a therapeutic identity questionnaire at three times during training and at one time after it. Twenty-one students completed the questionnaire on all four occasions. The questionnaire assessed attitudes on nine scales relating to beliefs about curative elements in psychotherapy, therapeutic style, and basic assumptions about psychotherapy and human nature. At the beginning of training, students had a clear psychoanalytical orientation, similar to that of their supervisors. From the last year of training, after supervision had ended, and continuing during the post-training period, students distanced themselves from the psychoanalytical orientation and their supervisors toward a more eclectic position. This development may reflect the formation of an autonomous therapeutic identity.     

The Ethics of Mandatory Personal Psychotherapy for Trainee Psychotherapists

Although the psychotherapist's personal psychotherapy has received considerable research attention in recent years, little systematic investigation of the ethical issues involved has been published. This article provides a rigorous interrogation of mandatory personal psychotherapy (MPP) as a training requirement for mental health professionals, a topic that remains ethically contentious. The article begins with a discussion of why MPP is an explicitly ethical issue, before debating the ethics of MPP under six questions, each worded to capture a salient ethical issue relevant to the appropriateness of making personal treatment a mandatory training requirement. Using principle, virtue, and care ethics perspectives, the arguments for and against MPP are critically investigated. The article concludes with an ethical position statement.     

Therapy at the Cultural Interface: Implications of African Cosmology for Traumatic Stress Intervention

The topic of intercultural or multicultural therapy continues to stimulate much debate in the field of psychotherapy. Intercultural counseling training emphasizes respect for cultural beliefs as a core dimension of appropriate intervention. This paper addresses the limitations of this perspective in guiding therapists when faced with a clinical situation in which the non-challenging of cultural belief systems seems counter-therapeutic. The discussion is focused around critical observations of circumstances in which conventional African wisdom, as understood by clients presenting for trauma counseling, appeared to be counterproductive for their recovery in terms of western intervention principles. In psychotherapy for traumatic stress and traumatic bereavement, such tensions appear to arise particularly strongly because of the inevitable search for meaning in the face of extraordinary life events. Focusing on meaning making, cognitive intervention, schema realignment and reframing within trauma therapy, the paper explores ethical considerations and areas of potential conflict with reference to theory and clinical case material. Some strategies for therapeutic engagement are proposed.     

A training outline for conducting psychotherapy process ratings: An example using therapist technique

Aims: This study addresses the effects of structured training on the development of coding skills used in psychotherapy process research. Method: Participants included graduate trainees enrolled in an APA approved Clinical PhD programme. A course outline for training is reviewed and examined in relation to ratings of therapist techniques used during psychotherapy sessions. Results: The effects of this structured training protocol for raters resulted in good to excellent levels of interrater reliability. Different groups of raters were compared along multiple factors such as level of graduate training, training received on a particular measure, and psychotherapy experience. Discussion: The implications of these findings for rater training in psychotherapy process research are discussed.     

Renunciation of the self in psychotherapy

Self-renunciation or self-denial, although often misunderstood, is a foundational concept in several major religions and is frequently associated with spiritual maturity. In spite of this, the action of self-renunciation has been viewed with suspicion by the psychological community and criticized as repressive. This article argues that the concept of self-denial found in the Sufi tradition of rebirth and the salvation paradox found in the synoptic Gospels can bring a valuable perspective to psychotherapy. First, a brief summary of the history of psychotherapy and its contributions to the understanding of the self are provided. Next, a cursory overview of the Sufi tradition of rebirth is given. Third, the salvation paradox found in the synoptic Gospels is reviewed. It is argued that these two traditions offer valuable insight into ideas surrounding the self. Finally, the clinical implications of self-denial are discussed, and conclusions are drawn related to how psychotherapy can benefit self-renunciation.     

Making a case for case studies in psychotherapy training: A small step towards establishing an empirical basis for psychotherapy training

The evidence debate in psychotherapy pays little attention to developing an evidence base for training practices. Understanding effective training requires an examination of what makes training work. This article examines the role of case studies in psychotherapy training. This has not been articulated explicitly or researched systematically in spite of its cardinal importance. An analysis of the role of case studies in psychotherapy training is presented. Reading, watching, or hearing about cases can offer novice psychotherapists access to a closed world; access to psychological theory in action; access to whole courses of therapy; access to different approaches; access to significant moments; access to the therapeutic relationship; access to a wide range of client types; access to working in different contexts; and the opportunity of identifying with therapists and clients. Writing or presenting cases offer students the opportunity of: learning to integrate information into a relevant whole; being in the ‘hot seat’; learning to give appropriate feedback; assessing the validity of interpretations, inferences, and interventions; adapting methods to suit the client; and learning to collaborate with other professionals. The paper presents directions for future research into psychotherapy training, specifically proposing an international survey of training practices at psychotherapy training institutions.     

The Future of Training and Credentialing in Group Psychotherapy

High-quality group psychotherapy training is seen as more important than ever in the current health care environment. The training opportunities available at present are assessed. It is argued that there is a body of knowledge about generic group psychotherapy that can and should be taught, and that there are appropriate people to teach it. Credentialing is discussed, and it is suggested that the assessment of actual work in clinical situations must be emphasized if such efforts are to be meaningful.     

From Interpretation to Commentary: Truth and Meaning in Psychotherapy

Some of the epistemological consequences of adopting the narrative point of view in psychotherapy are explored. Attempts to apply principles and norms from the philosophy of science to psychotherapy are criticized, since psychotherapy is not a science, but a technique. In addition, those models, related to the acquisition of knowledge, that consider that knowledge could increase by apposition without transforming the subject who is knowing are discussed. Natural science and hermeneutic metaphors are not suitable for understanding the practice of psychotherapy. Traditionally, the interpretation of symptoms or problems to solve has been the main instrument in therapy. In other words, the therapist tries to look for the truth hidden under the symptom, which then becomes a sign. Our proposition is to substitute these metaphors for the paradigm of text commentary. Text commentary, instead of providing a unique truth, provides a set of meanings suggested by a commentary. Characteristics that allow one to distinguish a good and a bad commentary, and implications of the paradigm described for the training of psychotherapists, are discussed.     

Three modes of psychotherapy and their requisite core skills

The field of psychotherapy suffers from the lack of an integrative meta‐perspective on the large variety of existing psychotherapies and on the therapeutic skills involved. In the present paper, it is suggested that the development of a more comprehensive view of this field may be facilitated if we differentiate between three modes of psychotherapy, which require different therapeutic core skills: (a) an educational mode, which requires teaching skills; (b) a reparative mode, which requires analytic‐conceptualising skills to identify some kind of disordered functioning, in combination with specific relational‐technical skills to repair this dysfunction; and (c) a developmental mode, which involves engaging in a therapeutic relationship with patients to facilitate their personal growth, and which requires non‐directivity skills. In addition, some therapeutic skills (e.g., awareness and communication skills) may be more or less important in all modes of treatment. Concrete manifestations of the three different modes of psychotherapy are discussed in terms of five different theoretical perspectives on psychotherapy: the common factors, the humanistic‐experiential mindfulness cognitive‐behavioural (CBT) and psychodynamic perspective. The common factors model is criticised as being insufficient in several respects. Finally, it is argued that if personal therapeutic skills are essential to the effects of psychotherapy, then empirical research on psychotherapy needs to be re‐oriented towards a person‐oriented study of therapist skills in action, in the context of a study of the interaction between therapist and patient.     

Evaluation of a Combined Cognitive Behavioural Therapy and Interpersonal Process Group in the Psychotherapy Training of Clinical Psychologists

It is now widely acknowledged that both content and process elements of psychotherapy play a part in client treatment outcomes. Despite this, there are pressures on Australian clinical psychology training programs to teach evidence‐based approaches in a relatively short time frame. Producing clinical psychology graduates who have an adequate level of competence in evidence‐based practice and meeting the demands of professional accreditation requirements can mean that less time is available to teach the process elements of psychotherapy. The aim of this study was to conduct a preliminary evaluation of a clinical psychology psychotherapy training program that combines an interpersonal process group with a cognitive behavioural therapy training model that incorporates self‐reflection and self‐practice. Eleven participants who participated in the training in 2008 completed the Counseling Self‐Estimate Inventory at pre‐ and post‐training. Significant improvements on the majority of the subscales of this inventory were found. A separate sample of nine trainees and clinical psychology registrars who also previously completed the program attended individual interviews in 2010 aimed at gaining their perspective regarding various aspects of the program. Self‐practice of cognitive behavioural therapy techniques was found to be important in the identification and management of trainees’ own core beliefs, and to their appreciation of how challenging this process may be for clients. The interpersonal process group was described by participants as enhancing their competency as psychotherapists. Common themes included the experience of anxiety and a high level of emotion, and understanding how this experience might be similar for clients; increased self‐awareness; and increased competence in process issues. Many participants believed the process and content components of training were equally important to their development as psychotherapists.     

Review article

A training need to help core trainees prepare for the psychotherapy long case was identified. We prepared and showed a training DVD to all core psychiatric trainees at South West London and St Georges Mental Health NHS trust. A questionnaire was designed to receive feedback from trainees. A total of 26 trainees participated. All trainees found the DVD informative. Most trainees found the DVD helpful in reducing their anxieties prior to taking on a long case. All trainees found the DVD accurately reflected their experience of psychotherapy and supervision. Using simulated and technology-aided learning material is a useful and economical way of introducing psychotherapy skills to core psychiatry trainees before the clinical supervised experience of a long case.     

Dynamic interpersonal therapy in an NHS tertiary level specialist psychotherapy service

We describe the introduction of dynamic interpersonal psychotherapy (DIT) into an National Health Service (NHS) tertiary psychoanalytic specialist psychotherapy service. Training in DIT began as our contribution to Improving Access to Psychological Therapies and primary care services, supporting the training and supervision of their DIT practitioners. We then discovered DIT could be a valuable treatment within our own tertiary NHS service for patients with complex presentations. Currently fighting for survival, like many NHS psychoanalytic psychotherapy services nationally, we have adopted a manual-guided, psychoanalytically based therapy to broaden our tertiary clinical psychoanalytic service and accommodate trends in mental health service provision, whilst protecting the quality and integrity of our psychotherapy. DIT helped us continue providing relevant and beneficial psychoanalytic and psychodynamic services to individual patients despite limitations of the financially challenged NHS, NICE guidelines and Payment by Results. We outline the progress and outcomes for patients with complex mental health presentations, include individual case discussion and our experience of using the DIT approach within a traditionally longer term psychoanalytic psychotherapy service.     

A call for dialogue: psychotherapists and psychologists specialising in psychotherapy

The development of psychotherapy as an independent discipline in many countries in Europe has stimulated debate within the field of psychology as to what constitutes psychotherapy as a specialism of psychology. The authors, both clinical psychologists who pursued further training in psychotherapy, offer a reflection in this paper on the historical battle between psychiatry and psychology for ‘ownership’ of psychotherapy, describe recent developments in Europe to clarify this specialism within psychology and discuss the distinctive contributions that psychologists offer in developing psychotherapy as a specialism within the discipline. The aim of the paper is to begin a dialogue both within the profession of psychology and outside the profession, with our psychotherapy colleagues, that can develop into an interdisciplinary discourse and a more mutually respectful professional environment.     

Integrating clients' moment‐to‐moment ratings into psychotherapy research: A novel approach

Counselling and psychotherapy researchers have considerably advanced the field's understanding of psychotherapy processes and how they relate to treatment outcomes. Despite these advances, little is known about the client's perspective of changes in psychotherapy processes that occur throughout a given session (i.e. micro‐processes). To address this gap, this article describes the novel application of methods that assess participants' moment‐to‐moment ratings to psychotherapy research. This method entails recording psychotherapy session content that clients and other potential raters (e.g. therapists, researchers) later review while simultaneously providing continuous ratings of psychotherapy processes (e.g. helpfulness, alliance). In addition, moment‐to‐moment ratings can facilitate significant events research by prompting researchers to elicit client feedback about the moments that are rated the most and least positively. However, few studies have used these methods in the context of psychotherapy research. Studies incorporating these methods may yield findings that advance psychotherapy research, training efforts and clinical practice. For example, studies may examine how the magnitude and timing of clients' moment‐to‐moment ratings of psychotherapy processes are associated with treatment outcomes, therapist ratings and physiological processes (e.g. heart rate variability). Trainee therapists and their supervisors may also use clients' moment‐to‐moment ratings to facilitate attunement to verbal and non‐verbal indicators of moments perceived more positively and negatively. Last, these methods can produce findings that are highly relevant to clinical practice, where therapists routinely navigate fluctuations in psychotherapy processes (e.g. alliance ruptures) that can be assessed using moment‐to‐moment ratings.