Bulletin 44 3 Revised

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PSYCHOTHERAPY BULLETIN

Published by theDIVISION OF PSYCHOTHERAPY

American Psychological Association

6557 E. RiverdaleMesa, AZ 85215

602-363-9211e-mail: [email protected]

EDITORJennifer A. Erickson Cornish,

Ph.D., [email protected]

ASSOCIATE EDITORLavita Nadkarni, Ph.D.

CONTRIBUTING EDITORS

DiversityErica Lee, Ph.D. and

Caryn Rodgers, Ph.D.

Education and TrainingMichael Murphy, Ph.D., and

Eugene Farber, Ph.D.

Ethics in PsychotherapyJeffrey E. Barnett, Psy.D., ABPP

Practitioner Report

Jennifer F. Kelly, Ph.D.

Psychotherapy Research,Science, and Scholarship

Norman Abeles, Ph.D. and SusanS. Woodhouse, Ph.D.

Perspectives onPsychotherapy Integration

George Stricker, Ph.D.

Public Policy and Social JusticeRosemary Adam-Terem, Ph.D.

Washington Scene

Patrick DeLeon, Ph.D.Early Career

Michael J. Constantino, Ph.D. andRachel Gaillard Smook, Psy.D.

Student FeaturesSheena Demery, M.A.

Editorial AssistantCrystal A. Kannankeril, M.S.

STAFF

Central Office Administrator

Tracey Martin

Websitewww.divisionofpsychotherapy.org

PSYCHOTHERAPY BULLETINOfficial Publication of Division 29 of the

American Psychological Association

2009 Volume 44, Number 3

CONTENTS

Editors Column ............................................................2

Presidents Column ......................................................2

Interview ........................................................................7Abraham Wolf, Ph.D.

Psychotherapy research, scienceand Scholarship ..........................................................10

Engaging Underrepresented, UnderservedCommunities in Psychotherapy-RelatedResearch: Notes from a Multicultural Journey

Ethics in Psychotherapy..............................................15Psychotherapy, Online Social Networking,and Ethics

Education & Training ..................................................21Prioritizing Case Formulation inPsychotherapy Training

Perspectives on Psychotherapy Integration ............25Making Evidence-Based Practice Work:The Future of Psychotherapy Integration

DIVISION 29 ~ 2009 APA PROGRAM ....................29

Early Career..................................................................33Building a Private Practice by Being Public:From Social Networking Circles toPsychotherapy Groups

Feature ..........................................................................37

2009 Presidential Summit on the Future ofPsychology Practice: Collaborating for Change

Feature ..........................................................................41Ethics and the Interrogation of Prisoners

Student Feature ............................................................47Journey to Adulthood in the 21st Century

Feature ..........................................................................50Psychotherapeutic Treatment Implications

for Obese Adolescents

Call for Fellowship Applications

Division 29Psychotherapy......................................54

Membership Application............................................56

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EDITORS COLUMN

Jenny Cornish, Ph.D., ABPP, EditorLavita Nadkarni, Ph.D., Associate Editor

University of Denver Graduate School of Professional Psychology

Nadine J. Kaslow, Ph.D., ABPPEmory University Department of Psychiatry andBehavorial Sciences, Grady Health Systems

PRESIDENTS COLUMN

We are excited thatthis issue is too full tofit in more than a shortparagraph from theeditors. There issomething for every-one: two timely pa-pers on ethics (onerelated to online social

networking and theother to interroga-tions), an importantarticle on research andmulticultural issues, ahelpful piece on caseformulation in train-

ing, a thoughtful submission on evi-

dence-based practice and integrativemodels of psychotherapy, an interestingearly career paper on social networkingand private practice, and three studentpapers on a variety of topics, includingan interview with Abraham Wolf,former D29 President and outgoing In-ternet Editor. In addition, be sure toread the Presidents Column, and an im-

portant report on the PsychotherapySummit. Finally, information about ourmany award winners and the upcomingAPA convention is included. We hope tosee you soon in Toronto!

Jenny Cornish and Lavita Nadkarni(303-871-4737, [email protected])

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Culture of CompetenceThe current zeitgeistin professional psy-chology is competency-

based. Competencerefers to knowledge,

skills, and attitudes,and their integration.

Competencies are complex and dynam-ically interactive clusters of integratedknowledge of concepts and procedures,skills and abilities, behaviors and strate-gies, attitudes/beliefs/values, disposi-tions and personal characteristics, self-perceptions, and motivations that enablea person to fully perform a task with awide range of outcomes.

Educational programs are expected toproduce competence. Programs are ac-credited based in part on program out-

comes and training in key competencydomains. Professional credentialing

bodies are expected to certify individu-als as competent. Policy makers laudcompetence and consumers increasinglydemand it. Thus, the time has come to

embrace a culture of competence. Theremust be a shift within professional psy-chology toward the acquisition andmaintenance of competence as a pri-mary goal.

Many recent efforts have led to this shiftto a culture of competence and its assess-ment, including the identification of thekey foundational and functional compe-tencies and their essential components.

Foundational competencies are thoseknowledge, skills, and attitudes that

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serve as the foundation for the functionsa psychologist is expected to carry out.The foundational competencies include:professionalism, reflective practice/self-assessment/self-care, scientific knowl-edge and methods, relationships,individual and cultural diversity, ethicaland legal standards and policies, andinterdisciplinary systems. Functionalcompetencies refer to the major func-tions that a psychologist is expected tocarry out. The functional competenciesthat have emerged by consensus withinprofessional psychology include:assessment, intervention, consultation,research/ evaluation, supervision,teaching, management-administration,and advocacy.

In an upcoming article, a CompetencyBenchmarks Document (Fouad et al., inpress) will appear that delineates the es-sential components that comprise eachof these core foundational and func-tional competencies. The Competency

Benchmarks Document also articulatesbenchmarks, behavioral indicators thatreflect the expected level of perform-ance at each stage of professional devel-opment for the essential components ofeach competency domain. As a compan-ion to the Competency BenchmarksDocument, another soon to be pub-lished paper will describe a Compe-tency Assessment Toolkit forProfessional Psychology (Kaslow et al.,

in press). This toolkit builds on a grow-ing and long history of competency ini-tiatives, both within the profession andin other healthcare disciplines. Themethods include: 360-degree evalua-tion, annual/ rotation performance re-views, case presentation reviews,client/patient process and outcomedata, competency evaluation ratingforms, consumer surveys, live orrecorded performance ratings, objec-

tive structured clinical examinations,portfolios, record reviews, self-assessment, simulations/role plays,standardized client/patient interviews,

structured oral examinations, and writ-ten examinations. Given the tremen-dous strides that have been made withregard to evaluating competence, it isalso time to embrace a culture of the as-sessment of competence. The assess-ment of competence fosters learning,evaluations progress, assists in deter-mining curriculum and training pro-gram effectiveness, advances the field,and protects the public.

Psychotherapy CompetenceIntervention, which includes psy-chotherapy at its core, is one of the func-tional competencies. This competencyhas been defined as interventions thatare designed to alleviate suffering andto promote health and well-being of in-dividuals, groups, and/or organiza-tions. The essential components thathave been delineated for this compe-tency include: knowledge of interven-tions, intervention planning, skills,intervention implementation, and pro-gress evaluation. Benchmarks for eachof these essential components have beendetermined with regard to readiness forpracticum, readiness for internship, andreadiness for entry to practice.

I believe that members of the Divisionof Psychotherapy, those psychologistswith a passionate commitment anddedication to the conduct of effectivepsychotherapeutic interventions, shouldtake a leadership role in fleshing outthe intervention/psychotherapy compe-tence, including its essential compo-nents and benchmarks indicatingcompetent performance at each stage oftraining and credentialing and in termsof life-long learning. I am excited to readthe papers that will soon be publishedin Psychotherapy: Training, Research, Prac-tice, Training in which leading authorsdiscuss the essential components of thepsychotherapy competency and thefoundational and functional competen-cies informing the psychotherapy com-

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petency from various theoretical per-spectives: cognitive behavior, psycho-dynamic, family systems, andexistential/humanistic perspectives. I

believe that these papers will representan important effort toward advancing ashared articulation of the essential com-ponents of the psychotherapy compe-tency unique to each theoreticalorientation, as well as ways in whichvarious foundational and functionalcompetencies are linked to this compe-tency and how these linkages may beunique depending on the theoreticalframe and associated modality(ies).

Hopefully, other scholars, practitioners,and educators from different orienta-tions can build on these contributions tofurther hone our understanding of thepsychotherapy competency across theo-retical perspectives. It also behooves usto consider how this competency wouldappear from other theoretical frame-works, including an integrative model.Further, we need to consider bench-marks that move beyond licensure, as

this will support the significant role thatlifelong learning must play in our pro-fession. Of course, most of us do not juststrive to be competent, but rather we arededicated to being capable. Capabilityrefers to the extent to which competentindividuals adapt their skills, generatenew knowledge, and continue to im-prove their performance. The confluenceof competence and lifelong learning iscapability. I hope that you will join the

Division and the field as we continue toadvance the competencies movement,and help us bring to bear our expertisein the psychotherapy competency.

Whats New In Division 29?We are in the midst of a changing of theguard in terms of our internet editor. On

behalf of Division 29, I want to publicallythank Abe Wolf, PhD for doing a fantas-tic job for many years as our internet ed-itor. He is the founding editor of ourdivisions website and Online Psy-chotherapy Editor. Dr. Wolf has been

wonderfully responsive to the membersof the governance in terms of their web-site and listserv needs, and with regardto Psychotherapy ENews. He has been

very thoughtful in his approach to re-sponding to the various challenges anddecisions associated with the websiteand listservs. As most of you know, Dr.Wolf is a Past-President of the Division,as well as a fellow of the division, recip-ient of the divisions Jack Krasner Awardfor distinguished early career, and amember of the divisions journals edito-rial board (Psychotherapy Theory, Research,Practice, Training). Dr. Wolf is on the staff

of the Department of Psychiatry atMetroHealth Medical Center, the coun-try hospital for Cleveland, and AssociateDirector of Adult Outpatient Services.He is Professor of Psychology in Psychi-atry at the School of Medicine, CaseWestern Reserve University. Dr. Wolf hasa very active psychotherapy practice andhe lectures and supervises psychiatryresidents in individual psychotherapy.He has published in the areas of devel-

opmental behavioral pediatrics, the useof technology in psychotherapy, and theapplication of psychometric theory to in-struments used to measure psychother-apy outcome. He is interested in the roleof therapist factors in psychotherapyprocess and outcome, especially thera-pist self-awareness of countertransfer-ence reactions. He loves doing psycho-therapy. We are extremely grateful toDr. Wolf for his wonderful contributions

to our division and we will miss him ashe transitions out of his role as interneteditor. However, he will remain anextended member of the Division 29governance family.

I am delighted to introduce our new in-ternet editor, Chris Overtree, PhD. Dr.Overtree received his doctorate in clini-cal psychology from the University ofMassachusetts-Amherst. At the present

time, he is the Director of the Psycholog-ical Services Center (PSC) and the Asso-

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ciate Director of Clinical Training forthe Clinical Psychology Program at theUniversity of Massachusetts-Amherst.His scholarship is focused on psy-

chotherapy effectiveness in a naturalisticsetting, as well as more effective meth-ods of service provision in the commu-nity mental health system. He is achild/adolescent/adult and family ther-apist with specialties in anxiety disor-ders, depression, cognitive-behaviortherapy, and family conflict. He alsoserves as a consultant to schools regard-ing bullying/harassment, climate re-form, and improving academic

outcomes. Dr. Overtree has hit theground running. He is already liveningup our website, so check it out. In addi-tion, he will work with our Task Forceon Strategic Initiatives to significantlyenhance our website, so that it truly be-comes a creative and engaging informa-tion portal. We are so pleased to have Dr.Overtree on board. Do not hesitate tocontact me or Dr. Overtree if you havesuggestions about ways to make the Di-

vision 29 internet presence more mem-ber-friendly, accessible, and valuable.

APA ConventionYou will be receiving the PsychotherapyBulletinjust a few days before the annualconvention. In the Bulletin, we have pro-

vided you details of our wonderful di-visional programming. I am eager tointeract with each of you at the meetingin Toronto. I particularly hope to seeeveryone at our Business Meeting/Awards Ceremony and Social Hour,which will be held on Friday. Theseevents afford us the opportunity tohonor our awardees; meet, talk, and so-cialize with one another; and enjoy somespecial entertainment put on by mem-

bers of the Division 29 Board.

Feel Free to Get in TouchI have really appreciated the chance tointeract with so many members of ourdivision since assuming the presidency.I really value everyones input andideas. Feel free to email me [email protected] with questions,concerns, and suggestions. Please enjoythe rest of your summer!

(References available on-line.)

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JOIN THE DIVISION OF PSYCHOTHERAPY

ON-LINE!

Please visit our website to become a member,

view back issues of the bulletin, join our listserv,

or connect to the Division:

www.divisionofpsychotherapy.org

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INTERVIEW

Abraham Wolf, Ph.D.

Crystal A. Kannankeril, M.S.Doctoral Student at Loyola College in Maryland

For many psychologists, joining a professionalorganization is anothertime-intensive respon-sibility added to theseveral demands in-volved in our profes-sion and our already

busy lives. For Dr. Abraham Abe Wolf,a job requirement for his faculty positionat Case Western Reserve Universityturned into a 15 year partnership with theDivision of Psychotherapy (29). Whenlooking for a professional organization to

join, Dr. Wolf was invited to join the Divi-sion by Dr. Gerry Koocher, the incomingpresident. Dr. Wolf related that Division29 was a natural Division for me to be-come involved with given his interestsin psychotherapy and research.

Since 1993, Dr. Wolf has been an activemember and leader in Division 29, oftenusing his interests and innovation as away to propel Division 29 into the fore-front of APA. Dr. Wolf began his serviceto Division 29 as the Co-Chair of theStudent Development Committee, aposition he held for five years. Duringthis time, he aimed to increase studentmembership which he successfully

accomplished with several hundrednew student members. His committeeselected the winner of the student paperawards, which has seen several success-ful recipients including Dr. LouisCastonguay of Pennsylvania State Uni-versity. Pursuing even more leadershiproles, Dr. Wolf became coordinator ofAPAs Mid-Winter Convention Commit-tee, a joint Convention with Division 42(Independent Practice) and Division 43

(Family Psychology) in 1998. From 1996to 1998, he served as a Member-at-Largefor Division 29 and was a member of theDivisions Publication Board from 1996

to 2002. Moreover, Dr. Wolf served twoterms as the Secretary for Division 29,which led up to his terms as President-Elect in 2005 and President of Division29 in 2006.

Among these achievements and leader-ship roles, one of the hallmarks of Dr.Wolfs service to Division 29 occurred in

1997 when he became Division 29s firstInternet Editor and World Wide WebCoordinator. Dr. Wolfs interest in com-puters and statistics began early in highschool when he was offered to take partin a special computers program in 1967.During graduate school, these interestsonce again came to the forefront as he

became more involved with statisticalanalysis and computers. Once theInternet hit in 1994, Dr. Wolf jumped

on that right away as it was the mostamazing thing Ive ever seen. Whatmade Dr. Wolf a true asset and pioneerwas his determination to bring his earlyinterest and involvement with theInternet to Division 29. No doubt, theDivision needed to jump on this band-wagonthe sooner the Division had anInternet presence, the better, Dr. Wolfremarked during our interview.

His foresight and hard work over thenext eight years as webmaster madeDivision 29 a front-runner among theAPA Divisions with many Internet-

based activities. His initial goal as Inter-net Editor was for Division 29 to havea web-based presence; this includedcreating a website and listserv for mem-

bers. Dr. Wolf described these early tasksas a Mom and Pop operation. The firstwebsite was originally attached to CaseWestern Reserve University where hehas been a professor of psychology inthe schools Department of Psychiatry

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for the past 30 years, hired right out ofinternship. After many versions of thewebsite, Dr. Wolf was able to create aseparate URL for Division 29 in 2004

(www.divisionofpsychotherapy.org),allowing for easier access to users.

Dr. Wolfs other achievements in hiseight-year term as Internet Editorincluded creating and editing APAs On-line Academy (www.apa.org/ce), mak-ing Division 29 one of the few Divisionsto post online CE credits. This websiteallows members to watch archivedconferences through web-streaming,

making them easily accessible to mem-bers. Such CEs include Evidence-basedPsychotherapyRelationships:WhatWorksin General (2006), Treating the Hatedand Hateful Patient (2006), The ProperFocus of Evidence-Based Practice (2006),and Evidence-based Psychotherapy Re-lationships: Customizing the TreatmentRelationship to the Individual Patient(2007). This movement towards utilizingand pairing technology with psychology

also became part of Dr. Wolfs presiden-tial initiative in 2006 and serves as oneof his favorite memories as InternetEditor. He recognized the importance ofthe Internet in psychologys future andworkedhard towards keepingpsychologycurrent and relevant in this new age andgrowing field of technology. In addition,Dr. Wolf was named a Guest Editor for aspecial edition of Division 29s JournalPsychotherapy: Theory/Practice/Research/

Supervision which focused on the tech-nology of psychotherapy.

Dr. Wolfs achievements, however, didnot come without their fair share of hur-dles. He explained that what makes theposition of Internet Editor unique andoften challenging is facilitating commu-nication and making this new mediummeaningful to all the members of Divi-sion 29. Specifically, Dr. Wolf noted that

having a website, listserv, and onlinenewsletter may not be as simple or rele-vant for older, more well-establishedmembers who may have not have as

much experience with these technologi-cal advancements as compared to theiryounger counterparts. He indicated thatyounger psychologists or students may

take the Internet for granted, just asolder members may take radio and tele-vision for granted. So, for members whodid not grow up with the Internet, hav-ing these new online features may bemore complicated; getting them to uti-lize this medium thus becomes more ofa challenge. One of Dr. Wolfs goals wasto help the older membership move intothe 21st century. He remarked that it isstill a challenge to get people to join the

listserv and effectively use the medium,which will be a continuing challenge toleadership and members [in the fu-ture]. He did note that members are ex-cited and interested in this movement,though it is hard to make those ideasinto realistic applications.

When asked about his reflections on in-volvement with the Division, Dr. Wolfindicated that he has no regrets. He

noted that it has been truly one of themost rewarding activities I have everdone [it has allowed me] to exchangeideas, collaborate on research projects,and be involved with great peoplewhose articles you have been readingfor years - and then get to have dinnerwith them. Dr. Wolf also joked, for allthe meetings, it is really worth it. Healso wanted to acknowledge that hecould not have accomplished all that he

has without the support of his family.

Division 29 formally created the positionof Internet Editor in 2005. With Dr. Wolfserving as Chair-Elect that year, Dr.Bryan Kim from the University ofHawaii became the next Internet Editorfrom 2005 to 2008. After Dr. Kims threeyears of service, Dr. Wolf returned asInterim Internet Editor in 2008. The In-coming Internet Editor is Dr. Christo-

pher Overtree from the University ofMassachusetts Amhearst. In looking to-wards the future, Dr. Wolf is confident

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in the direction of this position. Heexplained that the website is due for amore professional makeover as it isnow five years old. His words of wis-

dom for Dr. Overtree were to have avision of where he sees the websitegrowing and continually work towardsthose goals. As Dr. Wolfs leadershiprole in Division 29 come to a close, healso wanted to express the importance

of members to get involved and showup for our meetingsit will be a deci-sion they will never regret! On behalfof the members of Division 29, I would

like to thank you, Dr. Wolf, for all thatyou have given to uswe will miss youas Internet Editor but look forward toyour continued involvement with theDivision of Psychotherapy.

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APF ROSALEE G. WEISS LECTURE

FOROUTSTANDING LEADERS IN PSYCHOLOGY

Give an Hour: Shifting Our Nations View ofMental Health and Psychology Care

Saturday, August 8, 20095:00 PM - 5:50 PM

Metro Toronto Convention Centre, Meeting Room 706

BARBARA VAN DAHLEN ROMBERG

Barbara Van Dahlen Romberg, founder and president of Give an Hour, isa licensed clinical psychologist who has been practicing in the Washing-ton, D.C., area for 16 years. She specializes in the diagnosis and treatmentof children. Dr. Romberg has spent her career interacting with and coor-dinating services within large systems, including school districts and men-tal health clinics. In addition, for many years, she served as an adjunctfaculty member at George Washington University, where she trained andsupervised developing clinicians. She received her Ph.D. in clinical psy-

chology from the University of Maryland in 1991.Concerned about the mental health implications of the Iraq War, Dr.Romberg founded a nonprofit organization called Give an Hour in 2005.The organization is creating a national network of mental health profes-sionals who are providing free services to U.S. troops, veterans, and theirloved ones. As of February 2009, the network currently has over 3,600providers.

As part of her work with Give an Hour, Dr. Romberg has participated innumerous panels, conferences, and hearings on issues facing veterans.She also writes a monthly column for Veterans Advantage and is con-

tributing to a book on post-traumatic stress and traumatic brain injuries.She is quickly becoming a notable source and expert on the psychologicalimpact of war on troops and families.


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Dr. Janet Helms, well-known for her re-search on racialidentity development(e.g., Helms, 1990),

once said, If you staywith any questionlong enough, it will

become a multicultural question. Shesaid this when I was still a graduate stu-dent in Counseling Psychology at theUniversity of Maryland. I had an intel-lectual appreciation for what she wassaying, but only later developed adeeper understanding as my researchprogressed. Much of my current re-search focuses on how to improve briefpsychotherapy with parents and infants,including basic research on importantaspects of the parent-infant relationshipthat should be targeted in such psy-chotherapy. I would like to share thestory about how my psychotherapy-related research questions became mul-ticultural questions, and how the jour-ney has led to my current efforts toengage underrepresented, underservedminority group members in my psy-chotherapy-related research.

The story begins with a randomizedcontrolled trial (RCT) of a brief, three-session, home visiting, preventive, psy-chotherapy intervention for first-time,economically stressed mothers of irrita-

ble infants and their babies (Cassidy,Woodhouse, Sherman, Stupica, Ziv, &Lejuez, 2009). The goal of the brief psy-chotherapy was to reduce the risk of in-

secure attachment. Attachment wastargeted at an outcome because of theempirical evidence that insecure infantattachment is associated with behavioral

problems and psychopathology (seeGreenberg, 1999, and Kobak, Cassidy,Lyons-Ruth, & Ziv, 2006, for reviews).While we were collecting data for thelarger RCT, a group of investigators de-

cided to conduct a smaller, qualitativestudy focused on better understandingthe precursors to infant attachment(Cassidy, Woodhouse, Cooper, Hoffman,Powell, & Rodenberg, 2005). Our think-ing was that outcomes of mother-infantpsychotherapy could be greatly improvedif we could better understand the mostimportant precursors of attachment thatshould be targeted in treatment.

After three decades of research, there is

still some degree of controversy aboutexactly how parental behavior serves asa precursor to attachment. Research hasfound via meta-analysis that there is arobust link between mothers attach-ment representations and their infantsattachment security: mothers who aresecure tend to have babies who are se-cure (van IJzendoorn, 1995). Attachmenttheory would suggest that the mecha-nism through which this link should

occur is maternal sensitive responsive-ness to the infant (Bowlby, 1969/1982).In fact, there is meta-analytic evidencethat maternal sensitivity serves as a me-diator of this link between mothers andinfants attachment (van IJzendoorn,1995). The problem, however, is that theeffect sizes for the mediation modelare much lower than theory would pre-

dict; van IJzendoorn termed this issuethe transmission gap. In fact, the connec-

tions between maternal behavior andinfant attachment are generally weakerin low-SES families (De Wolff & van

PSYCHOTHERAPY RESEARCH, SCIENCEAND SCHOLARSHIP

Engaging Underrepresented, UnderservedCommunities in Psychotherapy-Related Research:Notes from a Multicultural Journey

Susan S. Woodhouse, Ph.D., The Pennsylvania State University

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IJzendoorn, 1997). The transmission gapraised many questions for us that wethought were important to resolve, par-ticularly if our goal was to make psy-

chotherapy for low-income, at-riskmothers and their infants as efficaciousand efficient as possible. If it is impor-tant for infant-parent psychotherapy towork with parents on changing behav-iors, we need to make sure that weknow which behaviors really make adifference in later attachment outcomes.

The Cassidy et al. (2009) RCT was con-ducted in a large, metropolitan area that

had a very diverse population; that di-versity was reflected in the sample of thestudy. Participants were 169 infants andtheir economically-stressed mothers, in-cluding 42.6% African American/Black,27.2% White, 19.5% Hispanic, and 10.7%mixed race or other. For the smaller,qualitative study we examined 18mother-infant dyads (78% racial or eth-nic minority group members) who werea part of the control group in the larger

RCT. As mentioned earlier, our goal inthe qualitative study was to try to figureout which maternal behaviors most mat-tered in predicting later attachment, soas to close the transmission gap. Wehoped to be able to make suggestionsabout which maternal behaviors weremost important to support and whichwere most important to target forchange in psychotherapy.

Each research team member watched all

of the available videotape (approxi-mately 90 minutes of tape) from a labvisit (at 4.5 months) and three 30-minutevideotapes of naturalistic home observa-tions (7 to 9 months). We assessed ma-ternal behaviors by focusing on themother, but attended to the dyad forcontext using the Ainsworth, Blehar,Waters, and Wall (1978) conceptualiza-tion of sensitivity. Mothers were classi-fied as either insensitive or sensitive

according to the Ainsworth et al concep-tualization of sensitivity. In order to bein the sensitive group mothers had tomeet only a minimum, moderate level of

sensitivity. We made extensive writtenqualitative notes on interactions. Basedon our observations we attempted topredict the infant 12-month Strange Sit-

uation (Ainsworth et al., 1978) attach-ment classification and the maternalAdult Attachment Interview (AAI;George, Kaplan, & Main, 1996) classifi-cation. After independently making ourpredictions, we individually read theAAI and looked at the attachment classi-fication score, watched the 12 and 18months Strange Situation videos andlooked at the scores, and made notesabout what we had learned from the

dyad. The team then met for a two-hourdiscussion of each dyad.

We were surprised at how few motherswere rated as sensitive according to theAinsworth et al. (1978) conceptualiza-tion of sensitivity, especially given therather moderate level of sensitivity re-quired to be assigned to the sensitivegroup. Of the 18 mothers, only 3 wereclassified as sensitive and 15 were classi-

fied as insensitive. All of the motherswho were deemed sensitive had babieswho were later classified as secure in theStrange Situation. Of the 15 motherswho were classified as insensitive, how-ever, 6 had babies who were later classi-fied as secure and 9 had babies whowere later classified as insecure in theStrange Situation. The proportion of in-fants that were categorized as secure(50%) via the Strange Situation was con-sistent with the proportion secure incomparable samples (Spieker & Booth,1988). Also, the 67% match of sensi-tive/secure and insensitive/insecure in-dicates that even in a small sample thereis evidence for a connection betweenmaternal sensitivity and infant attach-ment. Of greatest interest to us, how-ever, were the 6 infants with motherswho would be deemed insensitive ac-cording to traditional measures of sensi-tivity but who later turned out to be

secure. What we learned from this qual-itative study was that what seemed to

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for their infants, as well as to under-stand how maternal caregiving waslinked to infant emotion regulation andlater attachment. My hope was that such

basic research could help us better un-derstand potential targets for interven-tion, so as to design better a bettermother-infant psychotherapy protocolthat could later be tested. The demo-graphics of Harrisburg (e.g., 50%African American) struck me as ideal forcontinuing to explore parenting acrosscultures in order to help design mother-infant psychotherapy interventions thatwere culturally appropriate. Very

quickly, though, I began to realize thatdoing research in underrepresented, un-derserved communities outside of themajor metropolitan areas was going to

be unexpectedly challenging.

When we tried to recruit mothers to par-ticipate in the pilot study we found thatthe minority group mothers simply didnot trust us or research in general. I real-ized that we needed to build bridgeswith the community and find a way to

build trust.

I partnered with two other Penn Stateresearchers (Kristin Buss and LaureenTeti) who were also interested in AfricanAmerican families. Together we metwith three African American Harrisburgcommunity leaders that we knewthrough our Penn State connections.These community leaders served as cul-tural informants for us, telling us about

the history of racism in Pennsylvaniaand a community memory for the his-tory of misuse of research findings. Theyadvised us to get to know a variety ofcommunity leaders who could help in-troduce us to the community. Theytalked about the importance of incorpo-rating tangible ways of giving back tothe community into our efforts, includ-ing community workshops and findingways to bring the results of the research

back to community members. They gaveus a great deal of advice on how to talkabout what we were doing and how itcould be relevant to the community.

Using seed money from our universityChildren, Youth, and Family Consor-tium we established Parents and Chil-dren Together (PACT): A Place for

Learning about Children and Families.We met individually with a variety ofcommunity leaders including pastors,nurses, physicians, youth arts educators,agency administrators, social workersand others and invited them to join aTask Force to help guide our efforts toengage the community in research andfind meaningful ways to give back to thecommunity. The Task Force gave usmany helpful ideas including hiring

from the community and finding waysto partner with community groups to dothe research itself. We started to attendcommunity events to talk about our re-search in the community and we hired aresearch coordinator/recruiter from thecommunity. We began providing work-shops for community members and

building a database of families inter-ested in research participation.

All of our efforts in the community havehelped us to engage the community inour individual research projects. How-ever, the most recent step we (KristinBuss, Laureen Teti, Chalandra Bryant,and Susan Woodhouse) have taken is todevelop a research partnership with achurch-affiliated, non-profit communitydevelopment corporation, HolisticHands Community Development Corpo-ration (led by Brenda Alton and RobinPerry-Smith). We are using community

based participatory research methodol-ogy to develop a specific research ques-tion related to childrens anxiety.Eventually, we expect to work with thecommunity to develop a culturally ap-propriate intervention that can help to re-duce the risk of anxiety disorders. Thework is in process, but very interestingthemes have already begun to emerge. Itis very exciting to watch communitymembers become engaged in thinking

about research at a grassroots level.


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With each passing daytechnology plays anincreasingly importantrole in the lives of bothpsychotherapists andthose we serve. The In-ternet, E-mail, socialnetworking sites, chatrooms, professional

E-mail lists, and thelike each impact howwe live, work, com-municate, and relate toeach other. While itmay seem that howpsychotherapists uti-

lize various technologic advances in ourpersonal lives is not an ethical issue, inthe digital world in which we now livethere is no clear boundary or line of

separation between our personal andprofessional lives. As will be presented,the use of social networking sites bypsychotherapists (professionally and/orpersonally) and by their clients presentsa unique set of ethical challenges anddilemmas.

Ethics and the InternetThe Ethical Principles of Psychologists andCode of Conduct (Ethics Code; APA, 2002)

states clearly that: The Ethics Code ap-plies to (professional) activities across avariety of contexts, such as in person,postal, telephone, Internet, and otherelectronic transmissions (p. 1061). Ad-ditionally, the APA Ethics Committeehas promulgated the Statement by theEthics Committee on Services by Telephone,Teleconferencing, and the Internet (APA,1997) in recognition of the growing roletechnology plays in clinical practice. The

Canadian Psychological Association(2008) developed the Ethical Guidelinesfor Psychologists Providing PsychologicalServices Via Electronic Media to address

the ethical challenges and dilemmasoften associated with utilizing the Inter-net. Further, the International Society forMental Health Online has promulgatedthe Suggested Principles for the Online Pro-vision of Mental Health Services (2000).Thus, it is clear that psychotherapistsshould give thought to the role and im-pact of the use of electronic media in

their professional roles and use thesedocuments to inform these decisions.Familiarity with relevant ethical stan-dards and practice guidelines and care-ful consideration of the impact of the useof various online media are importantfor each practicing psychotherapist.

Even with thoughtful utilization ofavailable resources, psychotherapistsmay face a myriad of ethical challenges

and dilemmas regarding the role of so-cial networking sites in our professionaland personal lives that will require ourcareful consideration. Examples include:

A seasoned psychotherapist receivesan E-mail invitation to join a socialnetworking site. The site obtained hisname and E-mail address from one ofhis clients, who hoped to learn moreabout the clinician by friendinghim on the site.

A supervisor performs a Googlesearch on one of her graduate studentsupervisees and finds a link to a pro-file he keeps on a social networkingsite. She views his profile and findsmany pictures of him in bars holdingand drinking alcoholic beverages.

An early career psychologist who uti-lizes a social networking site to keepin touch with family and friends re-ceives a friend request from a for-mer client she treated for six monthsduring her graduate training.

ETHICS IN PSYCHOTHERAPY

Psychotherapy, Online Social Networking, and Ethics

Jeffrey E. Barnett, Psy.D., ABPP and Allison Russo, M.S.



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Social Networking SitesSocial networking sites (SNSs) are de-scribed as interactive websites de-signed to build online communities for

individuals who have something incommon - an interest in a hobby, a topic,or an organization - and a simple desireto communicate across physical bound-aries with other interested people(Carter, Foulger, & Ewbank, 2008, p.682). The most popular of these are Face-

book and MySpace, although others,such as LinkedIn and Friendster, alsohave followings, albeit to a lesser extent(Salaway & Caruso, 2008).

As part of their online networking prac-tice, users typically post personal infor-mation about themselves that mayinclude educational, occupational, andcontact information, as well as descrip-tions of their interests and activities.Many users also post photographs ofthemselves alone and/or in groups.Users may communicate with eachother by leaving messages on one an-

others pages or merely learn moreabout other users via viewing their per-sonal profiles. While these sites are typ-ically used for general networkingpurposes, some appeal to particular in-terests (e.g., LinkedIns primary aim iscareer networking) or populations (e.g.,Facebook initially limited its member-ship to undergraduates, who continue tocomprise the bulk of its members; Sal-away & Caruso, 2008).

The sharing of personal informationacross as public a medium as the Inter-net brings with it a number of risks, andusers are wise to recognize that abuse orsimply negligent use of these sites mayhave deleterious effects. For example, re-vealing excessive personal informationwithout implementing sufficient privacycontrols has led to fear of identity theftand Internet stalking. Additionally, the

prominent case of Megan Meier, the 13-year-old girl who committed suicide in2006 after receiving harassing messageson MySpace from a user who had cre-

ated a fraudulent profile, has made thepotential impact of SNSs in users livesand social functioning devastatingly ap-parent. Conversely, it appears as though

SNS usage may also have positive socialeffects. Ellison, Steinfeld, and Lampe(2007) found that Facebook utilizationwas positively related to the amount ofsocial resources (social capital) en-

joyed by undergraduate students. Thiseffect was exaggerated in students whoreported lower levels of life satisfactionand self-esteem, suggesting the particu-lar usefulness of SNS usage for individ-uals with social struggles offline.

Patterns of Social Networking Site UseAn extensive survey conducted by theEducause Center for Applied Research(Salaway & Caruso, 2008) yields statis-tics on SNS usage that make the phe-nomenon impossible for psychologiststo ignore. The findings indicate that thevast majority (85.2%) of all undergradu-ate students frequent at least one SNS,with membership comprised of a

greater proportion of younger studentsthan older students (i.e., fully 95.1% of18-19 year old students report SNSusage, compared with only 37% of un-dergraduates aged 30 years or more).Furthermore, 56.8% of respondentsmake SNS usage a part of their everydayactivities, up from 32.8% in 2006, whichdemonstrates the recent and consider-able rise in the integration of SNSs inusers daily functioning. The most fre-

quently reported purpose of SNSs is tomaintain connections with existingfriends and acquaintances (96.8%); just16.8% make use of these sites to fosterentirely novel friendships. In addition,more than half of respondents use thesesites to gather more information aboutpeople they may or may not have met(51.6%) and to share photographs,videos, and other media (67.7%).

Yet, SNS use is not limited to undergrad-uate students. Facebook presently hasmore than 175 million registered users



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worldwide. More than 3 billion minutesare spent on Facebook each day andmore than 18 million users update theirpage each day (Facebook, 2009). My-

Space presently has more than 185 mil-lion registered users worldwide.Approximately 25% of allAmericans areactive MySpace users. Almost 350,000individuals sign up as new users of My-Space each day and it has achieved morethan 4.5 billion page views in a singleday. Over 1.5 billion images are sharedvia MySpace each day. Fifty millionmails are sent each day through My-Space and there are over 10 billion active

friend relationships at present (SocialNetwork Stats, 2008). The ubiquitousnature of SNSs in the lives of so many isquite evident from the above data.

Ethical Challenges and DilemmasThe use of SNSs by psychotherapists andtheir clients raises a number ofethical challenges in areas that includeinformed consent, boundaries, self- dis-closure, and multiple relationships.

Boundary violations and multiple rela-tionships are inherent concerns whenconsidering SNSs for psychotherapists.Practitioners who utilize these sites mayreceive online requests from their clientsto become friends on these sites, andaccepting these requests necessarily

blurs the lines of the therapeutic relation-ship. Although it is generally acceptedthat friends on SNSs are often mere ac-quaintances, the title may still complicate

expectations of the relationship and therole of the psychotherapist in the clientslife. Although befriending a client onlinedoes not necessarily constitute an ex-

ploitative multiple relationship (See Stan-dard 3.05 of the APA Ethics Code), it may

be the first step in a series of increasinglyinappropriate communications or disclo-sures that are not consistent with antici-pated professional roles.

Declining the clients friend request may be a clinical challenge and may havesome impact on the psychotherapy rela-tionship and process if not addressed ap-

propriately. While it seems as though thesimple solution to this dilemma is to ei-ther limit search options or refrain fromusing SNSs altogether, even these precau-

tions may not eradicate the issue: currentor former psychotherapy clients maysend electronic membership invitationsto clinicians who do not already have aSNS listing (as illustrated in Scenario 1above). For those who have a SNS the useof different levels of security settings mayprevent clients from having free access tothe psychotherapists online materials,

but the existence of the online profile isusually not hidden and clients may still

request being accepted as a friend. Fur-ther, some clients who are very computersavvy may be able to circumvent securitysettings and obtain access to informationintended only for personal use.

In some ways, friend requests and membership invitations may be viewed asauspicious, as they may indicate that theclient considers the therapeutic relation-ship to be a strong one. They may also in-

dicate a clients desire to share personalinformation with the clinician that is rel-evant to the psychotherapy and this may

be a valuable contribution to the psy-chotherapy process (Lehavot, 2009). Insuch cases, it may be possible to view theclients online materials together andprocess them as part of the ongoing ther-apeutic process. Alternatively, friend re-quests may indicate a clients suspicionof the clinician or simply a boundary

crossing to obtain more informationabout the psychotherapists personal lifeto quell curiosity. Regardless, such anevent should be addressed in psy-chotherapy in order to determine the im-petus for the request and the clientsreaction if the psychotherapist chooses todecline the invitation. As Lehavot (2009)states: By paying thoughtful attention tothe function of the client obtaining infor-mation about the clinician online, thepsychotherapist can examine this behav-ior as an opportunity to enhance theclients treatment (p. 28).



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It should be pointed out that sharing in-formation with a client in itself is notnecessarily unethical. Psychotherapistshave the right to decide how much per-

sonal information they are comfortablesharing with clients. But, psychothera-pists should also consider the impact ofsuch online relationships on the psy-chotherapy relationship and process.Considering these issues and their po-tential consequences before they becomean issue with a particular client is rec-ommended.

Issues of informed consent arise when

clinicians decide to conduct onlinesearches for their clients without theirknowledge or prior approval. While onemay argue that viewing a clients profilecan be useful clinically insofar as it mayprovide clinicians with additional orcorroborating data to enhance under-standing of various aspects of theclients life, doing so clandestinely mayhave substantial negative implicationsfor rapport. For example, if a psy-

chotherapist learns of a clients experi-mentation with illicit substances onlineand the client has not disclosed this intreatment, what does the psychothera-pist do with this information? Shouldone disclose their search and what theyhave learned, accepting any negativeimpact on the therapeutic relationship,or should one withhold the informationand not address in treatment a poten-tially significant clinical issue? Similar

issues are relevant for supervisors whosearch for information about their su-pervisees online (as depicted in Scenario2 above). Psychotherapists and supervi-sors should consider issues of trust aswell as professional role modeling whenconsidering these decisions.

It should be noted that psychotherapistsvary in their perceptions of the clinicalimpact of self-disclosure, multiple rela-

tionships, and boundary crossings andwill vary in their comfort level with theintersection of SNSs and their clinicalpractice. Williams (1997) has pointed out

that the clinicians theoretical orienta-tion may impact views of the appropri-ateness and use of psychotherapistself-disclosure. Humanistic psychother-

apists may be more open to the use ofself-disclosure to make themselves ap-pear more genuine and to narrow thepower differential between clinician andclient. In contrast, psychoanalysts andpsychodynamic psychotherapists mayprefer less transparency with theirclients to promote the transference rela-tionship and thus may utilize self-disclo-sure much more sparingly. Williamsimportantly portends the possibility of

ethically incorporating SNS usage intoclinical practice in his suggestions for athoughtful and flexible approach to

boundaries and self-disclosure. Still, ifclinicians decide to use SNSs profession-ally, they are encouraged to do so onlyafter carefully weighing costs and bene-fits and proceeding with appropriatecaution so that the standards of the APAEthics Code may be upheld and clients

best interests are addressed.

It is, however, important to keep inmind that in the Internet age, manyclients are likely to search for informa-tion about their psychotherapist. Thiswill likely be true regardless of ones de-cision to participate in SNSs given thatindividuals have been encouraged in re-cent years to become more informedconsumers of services and to be more ac-tively involved in their care, and that

use of the Internet for such purposes isprevalent. Psychotherapists should an-ticipate this occurring. In fact, one recentsurvey of consumers found that 80% ofall Internet users have searched forhealth care information online to includeinformation about specific health careprofessionals (Fox, 2005).

Cohort EffectsSeasoned ProfessionalsWhile some senior psychotherapistsmay be active online, many may feel un-affected by the SNS trend in terms of its

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influence on their ethical practice byvirtue of the fact that relatively few ofthem participate in online social net-working. Many, although clearly not all,

may also be unaware of the pervasive ef-fects of the SNS trend, given that theycame of age in a different time. How-ever, the issue remains an important oneto consider, especially when treatingclients who are active on the Internet.For seasoned professionals, limited fa-miliarity with SNSs may restrict theirability to comprehend the social sub-strate in which many of their clientsfunction, particularly those in the net

generation. These clients are so-calleddigital natives (Prensky, 2001) in thatthey have been raised in an electronicculture, speaking a digital language thatis foreign to many digital immigrantseasoned professionals. Given the wide-spread use of SNSs, it is prudent to ob-tain at least a general awareness of thepurpose, features, and potential risksand benefits of these sites so that we areable to converse with clients and under-

stand the world in which they function.

Students and TraineesThe psychology graduate student co-hort is arguably the one within our pro-fession most associated with the SNStrend. They are in a unique position as

budding professionals in the field inthat SNSs are already largely a part oftheir social lives; that is, many traineeswere undergraduates when the social

networking craze began and initiallythrived on college campuses (e.g., Face-book was launched in 2004). As such,the next generation of psychologists has

been largely immersed in the culture ofonline social networking and likelyhadnt considered issues of profession-alism in social networking prior to en-tering graduate school. The recentconcern about psychology graduate stu-dents lives on the Internet has been

mirrored by similar concerns in themedical (Thompson et al., 2008) andteaching (Carter, Foulger, & Ewbank,2008) professions.

Trainees should very carefully monitorand consider the information they in-clude in their online profiles. While it isnecessary for all practitioners to be cog-

nizant of the information they share on-line, many trainees will have developeda profile prior to their involvement inthe field of psychology. For that reason,it is recommended that trainees reviewall material on their profiles in order todetermine its appropriateness and makealterations as needed. For example, on-line videos, photos, and writings thatseemed very appropriate for an audi-ence of peers when a college sophomore

may not be viewed in the same mannerby graduate school admissions commit-tee members or even by undergraduatefaculty who are asked to write letters ofrecommendation. Then, when in gradu-ate school, ones online presence mayimpact externship and internship deci-sions. Graduate student psychothera-pists-in-training must also consider thepotential impact of their online presenceon their clients.

RecommendationsPsychotherapists should consider all on-line posts they make and profiles theykeep to be self-disclosures, even if pre-cautions are taken by setting privacycontrols on SNSs. Clinicians are encour-aged to remain cognizant of the fact thateven if a given disclosure is not unethi-cal per se, it still may have an impactclinically; that is, anything that is put on

the Internet may influence our profes-sional roles and relationships. Further-more, although the Ethics Code onlytechnically pertains to professional en-deavors, materials placed on the Inter-net for personal relationships cannot bekept completely separate from our pro-fessional roles. Additionally, informa-tion accessed about psychotherapists inour personal lives may impact the pub-lics view of us professionally as well.

It is recommended that psychotherapistsmaintain professional websites so that

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clients who search for us via the Internetwill access the information shared therethat is of relevance to our professionalroles and activities. Information shared

may include credentials, trainingexperiences, areas of specialization andpopulations worked with, and relatedprofessional information (Barnett &Hillard, 1999).Always consider the mean-ing of friend requests from clients in thecontext of their psychotherapy. When ap-propriate, use joint review of the SNSs asa therapeutic activity. That is, if a clienthas invited a psychotherapist to be theirfriend online in order to share personal

information, photos, or other media, sug-gest the option of having the client log onto their profile during session so that theprofile viewing may be done together.This may help ensure a minimal likeli-hood of boundary violations or threatsto trust and guarantees that the onlinecontent may be jointly explored andprocessed in session.

Consider the option of prescribing

SNS use to clients to address certainchallenges they may have, either as aprimary intervention or as a supplementto other, more traditional strategies.

For example, a client who is strugglingto find a worthwhile career path mayengage in standard career counselingas well as become involved inLinkedIn.com, which is largely devotedto professional development.

Teaching professionals should includetheir policy statement on online searchesof applicants and students in their pro-gram materials. Additionally, expecta-

tions for student professionalism withregard to their online presence and ac-tivities should be included in studenthandbooks and be reviewed beginningat orientation and reviewed throughouttheir training. Assisting trainees to makethe digital transition from the purelypersonal to the professional is an impor-tant role for supervisors and faculty.


20

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EDUCATION & TRAINING

Prioritizing Case Formulation in Psychotherapy Training

Eugene W. Farber, Ph.D., Emory University, Atlanta

Increasing emphasisrecently has been placed on identifyingfoundational and func-tional competenciesfor professional psy-chology practice (forreview, see Rodolfa et

al., 2005). A key purpose for elaborating

these competencies is to inform the develop-ment of competency-based models for pro-fessional training in psychology (Kaslow,2004). In contributing to the professional di-alogue on this issue, Spruill et al. (2004)identified case formulation among a set ofimportant clinical competencies in interven-tion planning. They characterized compe-tency in case formulation as requiring skillsin integrating information gleaned from theclinical assessment into a conceptual model

of both the clinical problem and pathwaysfor addressing the problem. In their discus-sion of this issue, Spruill et al. also cited therole of clinical supervision in helping psy-chotherapists in training to develop compe-tency in case formulation. Concerns recentlyhave been raised, however, about a relativelack of explicit concentration on the devel-opment of case formulation competencies in psychotherapy training (Ivey, 2006). Anelectronic search of the psychology literature

using the keywords case formulation andpsychotherapy training yields only 6 arti-cles on this topic. This points to the paucityof professional dialogue on case formulationtraining. As such, there appears to be a needto raise the level of professional discussionon the issue of training in psychotherapycase formulation as part of the overallprocess of psychotherapy training in general.This includes the articulation of trainingstrategies that support development of key

case formulation competencies in psy-chotherapy trainees.

Case Formulation: Definition and Rele-

vance to Psychotherapy Training

Psychotherapy case formulation may be de-fined as a hypothesis about the causes,precipitants, and maintaining influences of apersons psychological, interpersonal, and be-havioral problems (Kendjelic & Eells,2007, p. 66). Teaching systematic case formu-lation strategies affords trainees the opportu-

nity to organize their thinking about clinicalmaterial into a coherent plan for psychother-apy intervention. The formulation provides aconceptual framework for understanding theclient, including clinical symptoms, prob-lems, and psychological themes expressed inpsychotherapy. It also informs psychotherapy planning, including the identification ofthemes that comprise the focus of treatment,the setting of treatment goals, the selection of psychotherapy techniques and intervention

strategies, and the management of the psy-chotherapy relationship. Finally, case formu-lation can be invaluable in making sense ofunanticipated and/or clinically complexevents, crises, or problems that arise in thecourse of psychotherapy. The psychotherapisttypically must improvise in responding tothese unpredictable clinical situations (e.g.,Binder, 2004), and having a clearly definedconceptual roadmap can provide a helpful ref-erence point that anchors the psychotherapist

in this process. This is particularly valuablefor trainees, where continual and systematicuse of the case formulation as a basis for psy-chotherapeutic decision-making provides theclarity needed to organize a well thought-outresponse to challenging and ambiguous situ-ations arising in the psychotherapy process.Although research on this topic is limited,there are empirical findings supporting theusefulness of formulation-based psychother-apy practice, including the benefits of using

case formulation in psychotherapy withclinically complex cases (for review, seeKendjelic & Eells, 2007).

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Competencies and Case

Formulation Training

A competencies-based approach can help toinform thinking about the issue of training in

psychotherapy case formulation. In reportinga study showing that expert psychotherapistsdemonstrated superior case formulationswhen compared with novice and experiencedpsychotherapists (Eells, Lombart, Kendjelic,Turner, & Lucas, 2005), the study authors of-fered interpretations in explaining their find-ings that may point to some clues regardingcompetencies in case formulation. For exam-ple, they suggested that experts in their studymight have a particularly well developed ca-

pacity to glean a range of patterns from clin-ical data and use this capacity to developcomplex and nuanced formulations. Addi-tionally, the experts appeared to utilize a con-sistent and systematic formulation approachthat may facilitate a deep level of understand-ing of clinical material. The study authorsalso surmised that well developed self-mon-itoring skills also may be of benefit in thecase formulation process.

In describing a specific method for psycho-dynamically focused case formulationtraining, Ivey (2006) identified several com-petencies required for developing good for-mulations. These include skills in observingand describing both verbal and nonverbalbehavior, the ability to elicit a detailed de-scription of the patients experience that canbe elaborated into an experiential account ofthe patients problems, the capacity to trackthe patients perceptions of and relationships

to self and others, awareness of the patientsreactions to the psychotherapist, and a suffi-cient grasp of theory, including the capacityto apply it to the case formulation process.

Although not focusing on psychotherapy caseformulation competencies per se, Binder(2004), in a discussion of psychotherapy com-petency as applied to the clinical practice ofbrief dynamic psychotherapy, has describedseveral broad psychotherapy competencies

that are instructive in thinking about psy-chotherapy case formulation training. Onesuch competency pertains to having a theo-retical framework for understanding personal-

ity functioning and psychotherapy process(Binder, 2004). When training psychothera-pists in case formulation, it is critical that thetrainee learn how to work within a conceptual

model of psychological functioning and psy-chotherapy process to develop a theoreticallyinformed case formulation of a given clinicalcase. Often trainees experience a discrepancybetween their theoretical knowledge and theircapacity to apply this knowledge in develop-ing a clinically useful case formulation, andgood case formulation training should pro-vide opportunities for trainees to practice in-tegrating their theoretical knowledge withtheir clinical knowledge and skills (Ivey,

2006). A second competency outlined byBinder (2004) involves skill in developing thecase formulation itself. To develop this com-petency, the trainee must learn to make effec-tive use of the assessment process and toorganize clinical material obtained throughthe assessment process into a theoretically in-formed and coherent formulation of the prob-lem. This formulation comprises a story ofthe problem and the factors sustaining the problem and suggests a clinical focus that

guides treatment, including pathways to ad-dressing the problem (Binder, 2004). A thirdcompetency articulated by Binder (2004) in-volves the capacity of the psychotherapist toutilize the case formulation in the moment-to-moment unfolding of the psychotherapyprocess. As such, training also needs to focuson developing skills in tracking the treatmentfocus specified by the case formulation overthe course of treatment and to adjust the for-mulation where needed to accommodate new

clinical findings over time.

Examples of Case Formulation

Training Approaches

Despite the paucity of written accounts ofsystematic approaches to psychotherapycase formulation training, Ivey (2006) offersa structured model for case formulationtraining for psychology trainees. Although psychodynamic in focus, the general struc-ture of this approach could be applied to the process of case formulation training acrossthe spectrum of theoretical perspectives. Thetraining is conducted in a module that in-

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cludes weekly sessions held over a 3 month period concurrent with modules on psy-chopathology, psychotherapy, and psycho-logical assessment. Case formulation

training occurs using an 8-step process. Thefirst step focuses on definitions of case for-mulation and the clinical information do-mains that are relevant to conducting caseformulation. In the second step, trainees areprovided with written case material for prac-tice in constructing a case formulationguided by specific instructions for doing so.Trainees use their practice case formulationin step 3 as a starting point for learning thespecific criteria for what a good case formu-

lation looks like. Trainees then are asked toevaluate their practice formulations in accor-dance with these criteria. In step 4, havingalready covered general concepts of case for-mulation, the characteristics that make a for-mulation narrative explicitly psychodynamicare outlined. In step 5, the structure of thecase formulation is explained, including theconceptual elements of the formulation andhow they are synthesized to provide a coher-ent clinical narrative for understanding the

problems and concerns of the client. Thesixth step involves practice in small traininggroups, utilizing the structure outlined in theprevious step to develop case formulationsdrawn from written case material. These for-mulations are discussed and critiqued by thetrainee group. Videotaped clinical materialis provided in step 7 as the basis for furthercase formulation practice. This allowstrainees to expand their repertoire of caseformulation skills by learning to incorporate

observations of the clients nonverbal behav-ior and patterns of response to the clinician.In the final step, trainees are asked to inte-grate their subjective emotional reactions tothe client observed in videotaped samplesinto their case formulations.

Levenson (1995, 2003) has described an approach to psychotherapy case formulationtraining integrated within a 6-month programof training in time-limited dynamic psy-

chotherapy (TLDP; Strupp & Binder, 1984).Levensons (1995, 2003) approach includes aweekly didactic seminar and a psychotherapysupervision group. Trainees receive instruction

in the theoretical underpinnings of TLDP andits theoretically grounded template for devel-oping a psychotherapy case formulation. Thistemplate is comprised of model-specific cate-

gories of clinical data that can be organizedand synthesized into a narrative conceptual-ization of the case. Trainees also are explicitlyinvited to explore their own feelings and reac-tions to their clients and to incorporate theseexperiences into their case formulations.Trainees develop written case formulations oftheir psychotherapy patients using the TLDPtemplate and utilize these formulations to in-form the development of treatment goals. Thecase formulation and goals are routinely dis-

cussed in group supervision as part of eachtrainees presentation of videotaped psy-chotherapy sessions, providing opportunitiesfor input from both the supervisor and traineepeers. Trainees are specifically encouraged toreflect on how the case formulation informspsychotherapeutic decision- making and howthe case formulation may evolve or change asnew clinical information emerges.

Kendjelic & Eells (2007) conducted a study

examining the effects of clinician training inuse of a so-called generic components ap-proach to case formulation. The 4 compo-nents of their case formulation approachincluded symptoms and problems, precipi-tating stressors, predisposing events andconditions, and an inferred mechanism forconveying the psychotherapists explanationof patients problems. In this study, theTLDP case formulation approach was usedas an example of an inferred mechanism.Clinicians in the training group received a 2hour group presentation on case formulation.The training included discussion of why caseformulation is important, and introduced the4 generic components comprising the caseformulation approach. Factors contributingto the quality of a case formulation also werediscussed, and participants had an opportu-nity to practice the case formulation methodusing a sample vignette. Study resultsshowed that even with as little as 2 hours oftraining, clinicians in the training group pro-duced higher quality case formulations thanclinicians in the control group.

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Conclusions: Toward Increasing Dialogueon Case Formulation TrainingThe value of case formulation for psycho-therapy planning and intervention is widely

acknowledged across a spectrum of psychotherapy orientations (Eells, 2007).Recent empirical research underlines theusefulness of systematic training in methodsof psychotherapy case formulation (Kend-jelic & Eells, 2007). Given the importanceof good case formulation skills to psycho-therapy practice, the issue of how best to ap-

proach training in psychotherapy case for-mulation warrants further discussion. Thisdiscussion should include consideration of thekey competencies to be included in case for-

mulation training and elaboration of methodsto systematically develop these competencies.Approaches to evaluating the effectivenessof training methods in psychotherapy case for-mulation also should be considered.


CONGRATULATIONS TO OUR AWARD WINNERS!

Distinguished Psychologist Award for Contri-butions to Psychology and Psychotherapy: TheDistinguished Psychologist Award is based onsignificance of contributions to the practice,research, and/or training in psychotherapy.The 2009 award is presented jointly to Norine

Johnson, Ph.D and Jon Carlson Ed.D., in recog-nition of their outstanding accomplishmentsand significant lifetime contributions to the fieldof psychotherapy

American Psychological Foundation Division of PsychotherapyEarly Career Award is presented to Katherine Muller, Psy.D.for distinguished early career contributions to the field ofpsychotherapy and the Division of Psychotherapy.

The Division of Psychotherapy Award for Best EmpiricalResearch Article in 2008 is presented to: Michelle Newman,Louis Castonguay, Thomas D. Borkovec, Aaron J. Fisher, &Samuel S. Nordberg. (2008). An open trial of integrative therapy

for generalized anxiety disorder. Psychotherapy: Theory, Research,Practice, Training, 45, 135-147

The Division of Psychotherapy Award for DistinguishedContributions to Teaching and Mentoring, which is presentedin its inaugural year to Marvin Goldfried, Ph.D. in recognitionof his significant contributions to the field of psychotherapythrough his impact on the lives of developing psychologists intheir careers as psychotherapists

The Division is also pleased to announce the following

student paper ward winner:Mathilda B. Canter Education and Training Student Award

presented to Sarah M. Gates


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Within the past severaldecades, there has beenan increasing interest inpsychotherapy integra-tion, with several arti-cles on this topichaving recently ap-

peared in this newsletter. In writing stillanother article on psychotherapy inte-gration, my goal here is to provide a pre-diction about where it may be headingin the future. Although it is very risky topredict the future, I am taking that risk

because of a number of convergingforces within the field that point to alikely direction.

A Bit of History

When the Society for the Exploration ofPsychotherapy Integration (SEPI) wasfounded in 1983, the goals were twofold:(1) the integration of the different ap-proaches to therapy, analyzing thepoints of similarity and differencesamong them, and (2) the integration ofresearch and practice. Since that time,the vast majority of work has dealt withthe first goal, which no doubt resulted increating a zeitgeist that is now more fa-

vorable to the concept of psychotherapyintegration than it was over two decadesago. However, relatively little attentionhas been devoted to the second goal: theintegration of practice and research. Iwould suggest that the future of psy-chotherapy integration lies with the suc-cessful pursuit of this goal.

Although most of the work on integra-tion has involved a focus on considering

the similarities and differences amongvarious theoretical orientations and theirprocedures, there nonetheless have beena number of workers in the field who

suggested that, in the final analysis, itwas the empirical approach to integra-tion that was most important (see Nor-cross & Goldfried, 2005). As early as the1950s, Frederich Thorne, a psychiatrist,commented that the practice of psy-chotherapy was very different fromwhat he learned in medical school,which emphasized empirically basedprinciples of bodily functioning as theguide to clinical practice, not theoreticalorientation. Several other therapists andresearchers over the years similarly ar-gued that psychotherapy integrationshould be based on empiricism, such asthe contributions of Beutler, Garfieldand Lazarus. Most recently, Castonguayand Beutler (2006) edited an important

volume that specified empirically basedprinciples of change that were relevantfor dealing with various clinical prob-lemsregardless of ones theoretical ori-entation.

The Strained Alliance betweenClinician and ResearcherAs is well known to readers of thisnewsletter, there has been a long-stand-ing strain in the alliance between clini-

cians and researchers. Living in twodifferent professional worlds, membersof each group have tended to favor theirown approach to understanding human

behavior and the therapeutic changeprocessoften going so far as to deni-grate the contribution of the other. Re-searchers have complained thatclinicians do not read the literature,while clinicians have argued that the lit-erature has little to say about their clini-

cal practice. As recently noted by Kazdin(2008):

PERSPECTIVES ON PSYCHOTHERAPY INTEGRATION

Making Evidence-Based Practice Work:The Future of Psychotherapy Integration

Marvin R. Goldfried, Ph.D., Stony Brook University



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A frequently voiced and enduringconcern is that key conditions andcharacteristics of treatment research(e.g., therapists, patients, treatments,

and contexts) depart markedly fromthose in clinical practice and bring intoquestion how and whether to generalizethe results to practice (p. 147).

Together with Barry Wolfewho spent22 years of his career funding psy-chotherapy and research as a staff mem-

ber of the NIMHI have argued thatalthough randomized clinical trials canprovide us with important evidence

about the efficacy of different therapyprocedures, many of the methodologicalconstraints associated with the researchoften undermine the clinical validity ofthe findings (Goldfried & Wolfe, 1996).Thus, unlike what occurs in controlledclinical trials, the practice of therapyoften involves more complex clinicalcases, and is not constrained by a treat-ment manual.

As a result of the lively controversy overempirically support treatments in the lit-erature, we happily seem to have movedin the direction of recognizing that bothresearchers and clinicians have some-thing to offer. Acknowledging the limi-tations of simply identifying empiricallysupported treatments, the APA Presi-dential Task Force on Evidence-BasedPractice (American Psychological Asso-ciation, 2006) made it clear that random-ized clinical trials represent only oneapproach for providing empirical evi-dence that can inform clinical practice.Findings from other forms of research,such as basic research on the variablesassociated with various clinical disor-ders, as well as the findings on theprocess of change, are all most relevant.Moreover, the task force has under-scored the very important role of the cli-

nician, defining evidence-based practicemuch more broadly than simply thepresence of research findings. What theyhave emphasized is the central role that

clinical expertise plays in implementingspecific intervention procedures or prin-ciples of change. Thus what has beenopenly acknowledged is what we all

have known to be true, namely thatwhen it comes to doing effective ther-apy, a competent clinician is alsoneeded. Indeed, whether we are re-searchers or clinicians, when we need toselect a physician to perform a compli-cated medical procedure, we are carefulto select someone who not only is awareof the state of the art, but also who is ex-perienced and competent.

To stay with the medical analogy a bitlonger, consider the interplay betweenresearch and practice in medicine. Cer-tainly in the area of pharmacology, evenwhen a drug has been approved by theFDA after a careful analysis of researchfindings, it nonetheless is subjected toclinical scrutiny. Physicians routinely fileincident reports, indicating some of theadverse effects of the drug that were not

detected during the research trials. Thisalso occurs in other aspects of medicine,such as recent clinical findings by ortho-pedic surgeons that certain approvedhip replacement parts have resulted inproblematic clinical findings. Thus, de-spite the tension that also exists betweenmedical researchers and practitioners,there nonetheless exists a two-way

bridge, whereby each may inform theother.

Building a Two-Way Bridge BetweenPsychotherapy Practice and ResearchIn considering the relationship betweenpsychotherapy practice and research, itis possible to view clinical work as pro-viding us with the context of discovery.Working with clients directly and dis-cussing clinical cases with superviseesand colleagues presents the practitionerwith the challenge of translating general

research findings and clinical experienceso that they can be applied to the indi-



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vidual case at hand. It also affords theclinician with the opportunity of wit-nessing firsthand the ever-varying pa-rameters of human behavior and the

psychotherapy change process. In ourroles as clinicians, we can generate clini-cal hypotheses that may be studiedunder better-controlled research condi-tions, designed to verify what had beenobserved clinically. The findings fromsuch researchthe context of verifica-tioncan then, in turn, readily be fed

back to the clinical community.

As of January 2010, I will assume the

role of President of Division 12theSociety of Clinical Psychology. The pres-idential initiative that I will be undertak-ing consists of a life-long desire to builda two-way bridge between practice andresearch. Taking the lead from medicine,which has such a bridge, my goal is toestablish a mechanism whereby thera-pists can provide feedback to re-searchers about the successes andfailures in their attempts to apply empir-

ically supported treatments in clinicalpractice. Exactly how this will be done,and what the mechanism will look like,is still in the developmental stage. For-tunately, I have a group of experienced,motivated and enthusiastic researchersand practitioners who similarly havehad an ongoing dedication to closing thegap between practice and research. Thisis a standing committee of Division 12,and includes Louis G. Castonguay (Pres-ident-Elect of the Society for Psychother-apy Research); Marvin R. Goldfried(Past-President of the Society for Psy-chotherapy Research and President-Elect of Division 12 as of 2009); Jeffrey J.Magnavita (President-Elect of Division29 as of 2009); Michelle G. Newman(psychotherapy researcher with expert-ise in anxiety disorders); Linda Sobell(Past-President of Division 12); andAbraham W. Wolf (Past-President of Di-vision 29). In addition to their motiva-tion and interest, members of this grouphave had ongoing experience in work-

ing to close the gap between practition-ers and researchers, such as Cas-tonguays role as Co-Chair of theNational Research Practice Network;

Goldfrieds founding of the journal InSession, which includes research reviewswritten for the practicing clinician; Mag-navita and Newman serving as GuestEditors for this journal; Sobells collabo-ration with therapists in designing atherapy manual and research protocolfor the treatment of substance abuse (So-

bell, 1996); and Wolfs professional ded-ication to fulfilling the model of thescientist-practitioner.

Our objective is to set up a mechanismfor providing feedback to researchers,piloting this mechanism with one clini-cal problem for which an empiricallysupported treatment has been identi-fied. We decided that a clinical problemthat has received favorable research ev-idence, and one that occurs frequently inclinical practice, would be panic disorder.Despite the fact that there has been ex-

tensive research on the treatment ofpanic, we believe that there is still muchthat can be learned from the clinicianstreating such patients. Although all ther-apists who have experience with thisclinical problem would have much tooffer, we decided to focus on the use ofan intervention that has received empiri-cal supportcognitive-behavior therapy.There is a promising psychodynamictreatment for panic currently under in-

vestigation, but it has yet to haveachieved empirically supported status(Milrod, et al., 2007). Starting with infor-mal interviews with practicing cliniciansthat make use of such cognitive-behav-ioral interventions with this population,we hope to be able to identify those pa-tient, therapist, treatment, and contex-tual variables that are likely to influencethe clinical effectiveness of the empiri-cally supported treatment in actual prac-

tice. With this information on hand, wewill then move on to apply this feedback



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procedure on a broader scale.

We believe that this initiative can pro-vide an approach where everyone bene-

fitsthe clinician, the researcher, andcertainly the client. It is our hope thatthis will afford the clinician with an op-portunity to provide invaluable infor-mation for future research. For theresearcher, it provides them with re-searchableand hopefully fundablehypotheses for research that is born outof clinical practice.

How does this all tie in to psychother-apy integration? A friend who is a physi-cian once characterized psychotherapyas an infant science, where what wedo is based more on theory than evi-dence. In order for our field to mature,we need to move beyond theoreticalschools of thought and base what we doclinically on available and research find-ings that also have been shown to workin clinical practice. As I have suggested

in the past:Although varying theoretical orienta-tions have clearly been useful in helpingus to develop a wide variety of thera-peutic procedures, we see a need tomake greater use of what actually goeson clinically as a way of generating fruit-ful research hypotheses. Without such

close links between clinician and re-searcher, we face the danger of our the-ory and research becoming too farremoved from the clinical foundations

of our generalizations (Goldfried &Padawer, 1982, p. 41).

With psychotherapy in general respond-ing to pressures for accountability, evi-dence-based practice is likely to be thedriving force for how therapy is con-ducted in the future. For it to be imple-mented in an empirically and clinicallysophisticated way, the collaborative ef-forts of researcher and practitioner areessential. More than ever before, this col-laboration needs to become the organiz-ing theme for integration. It is for thisreason that I would suggest that empir-ical pragmatismbased on the converg-ing evidence obtained from research andpracticenot theory, will be the integra-tive theme of the 21st century.

Author Note

Correspondence regarding this articlecan be addressed to Marvin R. Gold-fried, Department of Psychology, StonyBrook University, Stony Brook, NY,11794-2500. Electronic mail can be sentto: [email protected]


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NOTICE TO READERS

Please find the references for the articlesin this Bulletinposted on our website:

divisionofpsychotherapy.org


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THURSDAY, AUGUST 6th

Existential Humanistic Therapy Comes of Age (Symposium)8:00 AM 9:50 AM Metro Toronto Convention Centre Meeting Room 202CChair: Kirk J. Schneider, PhDParticipant/1st AuthorAlexander Bacher, MA Pernilla Nathan, MAStacie L. Cooper, MA Orah T. Krug, PhDDave Fischer, MA Kirk J. Schneider, PhD

Two Viewpoints on Future Directions for Alliance Theory (Symposium)10:00 AM 10:50 AM Metro Toronto Convention Centre Meeting Room 203AChair: Robert L. Hatcher, PhD

Participant/1stAuthorRobert L. Hatcher, PhD Adam O. Horvath, EdD

Process and Outcome in CBT: The Importance ofCognitive Errors and Coping (Symposium)10:00 AM 11:50 AM Metro Toronto Convention Centre Meeting Room 206AChair: Martin Drapeau, PhD, MAParticipant/1stAuthorDeborah Schwartzman,

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