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Psychotherapy Integration Training Around the Globe: A Personal and
Empirical Perspective
Article in Journal of Psychotherapy Integration · August 2018
DOI: 10.1037/int0000135
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Journal of Psychotherapy IntegrationPsychotherapy Integration Training Around the Globe: APersonal and Empirical PerspectiveKatie Aafjes-van Doorn, Doménica Klinar Alfaro, Markéta Fialová, and Céline KamsteegOnline First Publication, August 23, 2018. http://dx.doi.org/10.1037/int0000135
CITATIONAafjes-van Doorn, K., Klinar Alfaro, D., Fialová, M., & Kamsteeg, C. (2018, August 23).Psychotherapy Integration Training Around the Globe: A Personal and Empirical Perspective.Journal of Psychotherapy Integration. Advance online publication.http://dx.doi.org/10.1037/int0000135
Psychotherapy Integration Training Around the Globe: A Personaland Empirical Perspective
Katie Aafjes-van DoornYeshiva University and Oxford University
Doménica Klinar AlfaroAiglé Foundation, Buenos Aires, Argentina
Markéta FialováSkala Institute, Prague, Czech Republic
Céline KamsteegUniversity of Cambridge
Psychotherapy integration is now common practice around the globe. Despite itspopularity, and the many clinical writings on the application of different types ofpsychotherapy integration, very little is known about exactly how psychotherapists arebeing trained in psychotherapy integration and whether these trainings are effective. Inline with the theme of integration, we aimed to answer these questions from ascientist-practitioner perspective, reporting on our subjective clinical training experi-ences as well as the current empirical evidence. First, as early career practitioners, webriefly describe how we ourselves were trained in psychotherapy integration and reflecton our training experiences in the Czech Republic, United Kingdom, United States, andArgentina. Then, as scientist-practitioners, we turn to the research literature to examinehow psychotherapy integration may be taught effectively. We conducted a systematicliterature review of the available empirical evidence on the efficacy of training inpsychotherapy integration. We report on the characteristics and findings of the identi-fied 9 empirical studies. This low quality and quantity of studies illustrates the lack ofempirically supported trainings in psychotherapy integration. However, together withour personal experiences in different countries, it provides some indication of futuredirections with regard to how and when psychotherapy integration might best be taught.Suggestions for further examinations into the effectiveness of trainings in psychother-apy integration around the globe are discussed.
Keywords: psychotherapy training, integrative psychotherapy, international
Psychotherapy integration aims to facilitatelearning from different therapeutic viewpointsto enhance the efficacy and efficiency of ourclinical work (Greben, 2004). In practice, itportrays an ongoing process of convergence and
complementarity at a conceptual, clinical, andempirical level (Fernández-Álvarez, Consoli, &Gómez, 2016), looking beyond the confines ofsingle therapeutic modalities and keeping anopen mind about the complexity of change. This
Katie Aafjes-van Doorn, Ferkauf Graduate School ofPsychology, Yeshiva University, and Department of Clin-ical Psychology, Oxford University; Doménica KlinarAlfaro, Department of Psychology, Aiglé Foundation, Bue-nos Aires, Argentina; Markéta Fialová, Skala Institute,Prague, Czech Republic; Céline Kamsteeg, Faculty of Ed-ucation, University of Cambridge.
Markéta Fialová is now at National Institute of MentalHealth, Department of Applied Neurosciences and BrainImaging, Klecany, Czech Republic.
We thank the Society for Psychotherapy Integration forbringing us, as newly qualified practitioners, together at theinternational conference in Dublin, Ireland, in 2016 and forfacilitating our thinking around training in psychotherapyintegration.
Correspondence concerning this article should be ad-dressed to Katie Aafjes-van Doorn, Ferkauf GraduateSchool of Psychology, Yeshiva University, Rousso Build-ing, Room 123, 1165 Morris Park Avenue, Bronx, NY10461. E-mail: [email protected]
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Journal of Psychotherapy Integration© 2018 American Psychological Association 2018, Vol. 1, No. 999, 0001053-0479/18/$12.00 http://dx.doi.org/10.1037/int0000135
1
spirit of psychotherapy integration reflects thezeitgeist of the new millennium (e.g., Ablon,Levy, & Katzenstein, 2006; Norcross & Rogan,2013) in countries around the globe (e.g.,Muller, 2008; Tasca et al., 2015).
The Educational Perspective Training inPsychotherapy Integration
Although for some practitioners, psychother-apy integration may be a natural and unintendedconsequence of ongoing professional develop-ment, many therapists experience psychother-apy integration as emotionally difficult and cog-nitively challenging (Gold, 2005; Rihacek &Danelova, 2015). Indeed, therapists admit to apragmatic rather than evidence-based approachto integration early in their career, when theylack in knowledge and skill in selecting inter-ventions and look for anything that seems towork (see syncretism described by Boswell,Castonguay, & Pincus, 2009; Lampropoulos,2001). Most say they only learned to effectivelyintegrate after licensure as they began to employtechniques outside of their original framework(Consoli & Jester, 2005).
Formal training in psychotherapy integrationhas been idiosyncratic and unreliable. In con-trast to the expected breakthroughs with regardto the establishment and evaluation of trainingprograms (Norcross, 1997), psychotherapy inte-gration training has received relatively little at-tention over the past two decades. A few psy-chotherapy programs that adopt an integrativestance as a core model of clinical training havebegun to emerge (see Norcross & Beutler, 2000;Wolfe, 2000; Ziv-Beiman, 2014), and a fewillustrations of what an integrative psychother-apy training model might look like have beenpublished (e.g., Beitman & Yue, 1999; Harris,Kelley, Campbell, & Hammond, 2014; Robert-son, 1995). However, the task of integration ofdifferent therapeutic orientations per se does notappear to be a central educational focus of theseinitiatives.
Type of Integration and Timing ofTraining
Heavy debate has surrounded the question ofhow and when to incorporate integration intothe overall psychotherapy training program (seethe interviews on integration training reported
in the 2017 Society for Psychotherapy Integra-tion newsletter, Volume 3, Number 4). Thequestion of timing tends to be answered in oneof the following two ways: (a) An integrativeapproach should be taught from the very outsetof psychotherapy training, or (b) integrationshould be encouraged at a later stage in thetherapists’ development, once expertise in onespecific approach has been established. Argu-ably, timing of psychotherapy integration train-ing bears at least partly upon the specific modelof psychotherapy integration to which trainersascribe (Lampropoulos, 2001). For example, fortheoretical (e.g., Wachtel, 1997) and assimila-tive integration (Messer, 1992), solid groundingin one or more theoretical orientations is desir-able. These scholars argue that without a singleconceptual framework as a guide, students1
might not value the complexities and ambigui-ties of tensions between models (O’Hara &Schofield, 2008). There is a danger of becominga jack-of-all-trades but a master of none, result-ing in syncretistic confusion when students pulltechniques from many sources without a soundrationale (Boswell et al., 2009; Lampropoulos,2001; Rønnestad & Skovholt, 2003).
On the other hand, the common factors (e.g.,Constantino, 2017; Frank & Frank, 1991;Rosenzweig, 1936), technical eclecticism (e.g.,Lazarus, 1967), and unifying approaches to in-tegration (e.g., Magnavita & Anchin, 2013) al-low students to think and work in an integratedfashion from the very beginning, crucial forfostering a flexible, open, and unbiased ap-proach toward the potential value of other mo-dalities (e.g., Gold, 2005; Ziv-Beiman, 2014).
Aim
In an attempt to answer the question of howpsychotherapy integration might be effectivelytaught, we take the scientist-practitioner per-spective, reporting on our subjective clinicaltraining experiences as well as the current em-pirical evidence. First, as early career practitio-ners, we briefly describe our personal experi-
1 We use the term student throughout this article to reflectpsychotherapists who attend a training in psychotherapyintegration, regardless of their formal status as universitystudent or licensed practitioner, and regardless of the termsusually used within their professional trainings (e.g., resi-dents, trainees).
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ences of training in psychotherapy integrationin Argentina, the United Kingdom, the UnitedStates, and the Czech Republic, and reflect onstrengths of these trainings as well as our relatedclinical struggles. Then, as scientists, we turn tothe research literature, systematically reviewingthe available empirical evidence on the efficacyof training in psychotherapy integration. Basedon this empirical evidence and our training ex-periences in different countries, future direc-tions with regard to how and when psychother-apy integration might best be taught will beindicated.
A Global Perspective on Training inPsychotherapy Integration
Argentina
The mainstream approach of Argentinianpsychotherapists is based on Freudian-Lacaniantheory grounded in traditional psychoanalyticpractice (Muller, 2008; Plotkin, 2003; Roussos,Waizmann, & Etchebarne, 2010). More re-cently, Argentina has seen a small but rapidlygrowing number of cognitive–behavioral ther-apy (CBT) psychotherapists (Keegan, 2007;Korman, Viotti, & Garay, 2015) as well as anincreasingly large number of psychotherapistswith a more integrative/eclectic stance (e.g.,Muller, 2008). Graduate students in Argentinaare not required to take any specialized coursesin integration during their psychotherapy train-ing (4 years minimum) to practice psychother-apy. However, without being regulated, there isa need to continue training, either in a specificmodel or in integrative psychotherapy. Thismeans that once students have obtained theirlicensure, it is possible for psychologists to par-take in a postgraduate training course specifi-cally focused on psychotherapy integration. InArgentina, psychotherapy integration is a fast-growing trend, and specialized integration train-ing is provided at universities, public healthcenters, and private mental health training cen-ters (Fernández-Álvarez et al., 2016; Gómez,2007). An Argentinian training program thathas gained particular popularity is the Aigléintegrative model, taught in 2-year-long gradu-ate-level programs in Argentina since 1999 aswell as more recently in Colombia, Ecuador,Guatemala, Italy, Paraguay, Spain, Uruguay,the United States, and Venezuela (Fernández-
Álvarez et al., 2016). Fernández-Álvarez’smodel of integration brings together conceptsfrom the psychodynamic, behavioral, humanis-tic-existential, and systemic models within thecognitive-social paradigm. This model aims toprovide a common basis for all treatments and,at the same time, a tailored plan for each client.It allows treatment planning addressing differ-ent goals, ranging from symptom reduction topersonality change, achieved through diversetherapy formats (e.g., individual, family, cou-ple, and/or with other treatments like pharma-cotherapy, social assistance) depending on eachparticular case (Fernández-Alvarez, Gómez, &García, 2015). During training, students obtain“integrative supervision” to discuss how to pro-vide effective integrative treatments with thedifferent kind of clients in the different trainingsettings. After training, professional develop-ment in psychotherapy integration continuesthrough supervision and personal therapy.
United States
In North America, the governmental fundingand guidelines around “evidence-based practice”resulted in the wide application of integrative in-terventions (e.g., Hayes, Strosahl, & Wilson,2011) in the form of second- and third-wave cog-nitive–behavioral-based treatments and short-term psychodynamic treatments (e.g., Vandenbos,Hogan, & Kazak, 2017; Westen, Novotny, &Thompson-Brenner, 2004). In contrast to Argen-tina, psychotherapy training in the United Statesinvolves a very minimal focus on integration(Norcross, Sayette, & Pomerantz, 2018). In theUnited States, graduate psychotherapy programsemphasize extensive training in a particular theo-retical model determined by American Psycholog-ical Association practice guidelines, developed bythe different divisions (Norcross & Rogan, 2013;Vandenbos et al., 2017). Currently psychotherapyintegration is not specifically included in theseguidelines (Norcross et al., 2018). At the start ofgraduate training, many students are required toidentify their preferred modality, by choosing be-tween a CBT or a psychodynamically orientatedgraduate program, without being given the optionof integrating these psychotherapy approaches(Norcross et al., 2018). Also during training, stu-dents in the United States applying to internshipsthrough the Association of Psychology Postdoc-toral and Internship Centers (2018) must indicate
3TRAINING IN PSYCHOTHERAPY INTEGRATION
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a theory of practice. Although some doctoral train-ing programs in the United States offer somelimited guidance on psychotherapy integration inclinical seminars or lectures on common factors(e.g., Constantino, 2017), or in dual-focused grad-uate programs that equally emphasize psychody-namic and CBT training (Feindler & Kahoud,2015), most doctoral training programs offer train-ing in particular models only (e.g., Norcross et al.,2018).
United Kingdom
Graduate psychology training in the UnitedKingdom is provided as part of the NationalHealth System and is therefore very much focusedon training in “evidence-based treatments”(Llewelyn & Aafjes-van Doorn, 2017). In termsof training in psychotherapy integration in theUnited Kingdom, education in one major ap-proach (CBT) appears to be emphasized (Healthand Care Professions Council, 2010; NHS Digital,2014), although this also includes clinical trainingin third-wave CBT (e.g., Hayes et al., 2011) andother integrative treatment approaches (e.g., Ryle& Kerr, 2003). Both the competencies laid downby the Health and Care Professions Council(2010) and the requirements for the accreditationof courses by the British Psychological Society(2012) guidelines state that courses should pro-vide advanced training in one therapeutic modeland a working knowledge of a second (i.e., assim-ilative integration). In addition, students are ex-pected to have a critical awareness of a variety ofapproaches to therapy. In clinical case assign-ments, students are often required to choose aparticular model, depending on the client/serviceand conceptualize a case (formulation, assess-ment, intervention, and evaluation) based on thisparticular therapy model. Integration of differenttheoretical orientations is not explicitly taught butis implicitly assumed. One way this lack of inte-grative focus has been addressed in the UnitedKingdom is by offering students a wide variety ofshort-term clinical internships that allow studentsto gain treatment and supervision experience in avariety of second- and third-wave CBT ap-proaches, systemic and short-term dynamic ther-apies, depending on the client group.
Czech Republic
In contrast to Argentina, the United States,and the United Kingdom, in Czech law, there is
no protected professional title for psychothera-pists enshrined in law, no connection to anyeducational degree, no state regulation of psy-chotherapy training or practice, and no legalrequirement for providing “evidence-basedpractice” (Rihacek & Roubal, 2017). Althoughthis lack of top-down requirements or regula-tions raises ethical concerns, arguably, it doesallow students to integrate different therapymodels during and after their psychotherapytraining as they see fit. It is therefore not sur-prising that many practitioners in the CzechRepublic practice psychotherapy integration.Although only one third of practitioners self-identify as integrationists, a survey of 373 psy-chotherapy and counseling practitioners in theCzech Republic showed that 98.9% of practi-tioners used psychotherapeutic techniques fromtwo or more orientations, despite only a minor-ity (20%) actually receiving training in two ormore psychotherapy approaches (Rihacek &Roubal, 2017). Another study in the Czech Re-public surveyed 26 students on why they chose5-year psychotherapy training specifically fo-cused on integration (the Skala Institute) as theirfirst psychotherapy training (Plchová, Hytych,Rihácek, Roubal, & Vybíral, 2016). They re-ported that these future students believed inscience, were open to enduring states of uncer-tainty, and were attracted by the multivalence ofdifferent psychotherapy schools (Plchová et al.,2016). The Skala Institute offers an integrativepsychotherapy training that emphasizes the self-experience of the future psychotherapist. Theiraim is for students to get to know themselvesbetter, try different psychotherapy approaches,develop common skills that work across allapproaches, and experiment with integration ina safe environment guided by expert feedbackand supervision. Students undergo group psy-chotherapy themselves before taking part in,and later leading, psychotherapy groups withpatients. These treatment groups are video re-corded and used for feedback in supervision.Supervisors change on a regular basis to providean example of different psychotherapy styles.
Personal Psychotherapy IntegrationExperiences
It has to be noted that all four of us arrived atthe road of psychotherapy integration in aroundabout way. In our respective initial under-
4 AAFJES-VAN DOORN ET AL.
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graduate clinical trainings, we were not taughtabout psychotherapy integration explicitly, andit was only in our graduate training programsthat we gained formal integrative training ormore implicitly learned about integrationthrough supervision, reading, and clinical prac-tice.
Reflecting on our experiences as beginners inpsychotherapy, we were often anxious andwanted to know the “right” approach or tech-nique to apply in a given clinical situation.Moreover, although it was great to be super-vised by experts in particular treatment modelsduring our graduate trainings, our insecuritiesrose every time we started from scratch at a newinternship, when unsure how and when to inte-grate previously learned techniques. We allidentified a hasty adoption of the first treatmentideology we were taught, providing a falsesense of security, and it was only during grad-uate training that we became more able to con-sider other viewpoints. Similar to experiencesreported by others (e.g., Gold, 2005), we ini-tially found it difficult to experiment and de-velop our own personal viewpoints, especiallybecause we perceived university faculty mem-bers as encouraging adherence to one concep-tual framework while disapproving of others(Consoli & Jester, 2005; Feindler & Kahoud,2015), and we felt free to develop a more per-sonal integrative approach later in our graduatetraining.
Given the lack of formal training during ourinitial undergraduate training, we learned to en-gage in integrative practice more implicitlythroughout internships and externships, in thatthey taught us to adjust our theoretical, techni-cal, and empirical knowledge of psychotherapyto specific clients that may present on a contin-uum of severity, chronicity, and complexity(e.g., Blott, 2008). We all felt that, at times, insessions, it felt as if there were too many pos-sible avenues to explore (see syncretism, de-scribed by Boswell et al., 2009), and consider-ing various intervention options limited ourability to be present with clients when we wereunclear where to direct the session. In thosemoments, we found ourselves hoping for a moreconcrete example of how a client is conceptu-alized in the moment, taking multiple psycho-therapeutic models into account, how interven-tions are chosen in session, and how to decideon a treatment plan.
During graduate school, we further devel-oped an interest in psychotherapy integration,mainly through gained confidence in scientificknowledge and utilization of research findings,and our clinical experiences of perceived inef-ficacy of our usual approaches. After graduateschool, we have continued to seek out furthertraining in psychotherapy integration, workwith integrative supervisors, and gain moreclinical experience in psychotherapy integra-tion. The first author, for example, facilitated aDialectical Behavioral Therapy skills groupwithin a psychoanalytic clinic (see Aafjes-vanDoorn, Kamsteeg, Portier, & Chitre, 2018) andreflected on her clinical error of integrating atechnique in an ad hoc manner when the patientwas in crisis (see Snyder & Aafjes-van Doorn,2016). Learning from our mistakes and havingthe possibility to develop our own personal styleas integrative therapists is helpful in taking careof not only our patients but also ourselves.
Training Strengths
In our view, learning a well-supported formof integrative evidence-based practice and moreexplicit training in psychotherapy integrationearlier on in training is beneficial in buildingconfidence. From our personal experiences, wecan attest the benefits of learning about psycho-therapy integration in small-scale clinical sem-inars, and larger-scale taught courses, as well asone on one in supervision and personal therapy.Although most explicitly taught in the integra-tion training in Czech Republic, we all appre-ciated the step-by-step learning process of par-ticipating in personal therapy from differentorientations, self-experiencing the position ofclient, before facilitating integrative treatmentfrom the position of the therapist. Moreover,gaining experience with supervisors from dif-ferent orientations was helpful, in that it showedthe breadth of possibilities in clinical practice.Seeing senior psychotherapists conducting “im-perfect” integrative therapy and gaining feed-back in a safe environment helped us overcomefears of making “mistakes.” Multiple supervi-sors and group supervision also helped us seethat there is no single correct way to treat aclient. Furthermore, we all benefited from theuse of videotaped treatment sessions, in gainingfeedback from fellow students and supervisorson our (non)verbal style, basic psychotherapeu-
5TRAINING IN PSYCHOTHERAPY INTEGRATION
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tic competences, concrete techniques, and strat-egies from different approaches, and how bestto tailor the treatments to the patients’ needs.
A Scientist-Practitioner’s Viewpoint onPsychotherapy Integration Training
Given our diverse training experiences inpsychotherapy integration as early career prac-titioners, and our struggles with integrating dif-ferent psychotherapy frameworks into the ther-apeutic work with our clients effectively, wethen turned to the research literature. In anattempt to answer the question “How can psy-chotherapy integration be taught effectively?”we conducted a systematic literature review ofthe available empirical evidence on the efficacyof psychotherapy training in integration.
By reviewing the available empirical find-ings, we aimed to generate tentative hypothesesand stimulate further research on training ofpsychotherapy integration. Raising awarenessof psychotherapy integration as an integral partof clinical, academic, and empirical psychother-apy training may contribute to the developmentof clinical practice guidelines around integra-tion that may be implemented in the trainingand practice of everyday practitioners and, ulti-mately, may lead to more effective and efficienttherapies for our clients.
Method
Now that we have set up a general hypothesisregarding the potential importance of training inpsychotherapy integration, we conducted a sys-tematic review to examine the role, definition,and empirical investigation of training in psy-chotherapy integration.
Literature Search
Scope of the search. Several steps weretaken to ensure the search was systematic. First,we followed published guidance for systematicreviews of evaluations of health care interven-tions (Liberati et al., 2009), including the fivePICOS components (population, intervention,comparators, outcome, and study design) iden-tified as preferred reporting items for systematicreviews and meta-analyses (PRISMA). Second,we used operational definitions to identify andclarify constructs of interest. Psychotherapy in-
tegration was conceptually defined as “the at-tempts to look beyond and across the confinesof single-school therapeutic approaches to seewhat can be learned from other perspectives”(Arkowitz, 1992, p. 262).
Seven inclusion criteria were used:
1. The study had to be reported in the Eng-lish language and published in a peer-reviewed journal before April 2018.
2. Building on previous reports on training inthe professional development of psycho-therapists, we included studies on the ef-fect of the training from the perspective ofthe student, supervisor, training director,and/or client.
3. We included the broad range of formaltraining experiences that aim to facilitatepsychotherapy integration, including un-dergraduate psychology courses, doctoralprograms, and seminars as well as singletraining events for licensed practitioners,which could include one-to-one supervi-sion or larger group formats but excludedpersonal reflections on psychotherapy in-tegration without formal training (seeBlott, 2008).
4. To represent the wide range of practitio-ners involved in providing psychotherapyin different countries, we included studieswithin the professions of (clinical) psy-chology, counseling, psychiatry, psycho-therapy, social work, and mental healthnursing.
5. The psychotherapy training had to be ex-plicitly labeled as integrative or had theexplicit aim to facilitate psychotherapy in-tegration, to the exclusion of other poten-tially related integrative trainings of third-wave CBT approaches that incorporatetechniques from other modalities, such asdialectical behavior therapy (Linehan etal., 2015) or cognitive analytic therapy(Ryle & Kerr, 2003).
6. The study had to report on the effect oftraining in psychotherapy integrationrather than the effect of integration of di-dactic practices or formats (e.g., Carkhuff& Truax, 1965, examined integrated ap-proaches to learning rather than psycho-therapy modalities).
7. The effect of the training in psychotherapyintegration had to be measured at least
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once during or after the training ratherthan (solely) as a pre- or posttraining sur-vey of theoretical orientation (e.g., Bo-swell et al., 2009) or views on psychother-apy integration (e.g., Plchová et al., 2016,who surveyed 26 future students beforecommencing a 5-year training in psycho-therapy integration).
Search strategy. The literature review wasconducted using the following databases: ERIC,Global Health, PsycARTICLES, and Psy-cINFO. Search terms included variations on theterms for (a) integration (integrat�), (b) psycho-therapy (psychotherap�, therap�, counsel�, psy-cholog�, treatment�), and (c) training (training�,education�, student�, teaching�). The searchwas conducted on abstracts of peer-reviewedjournals with “AND” entered into the databaseto link the different categories (a, b, and c) ofsearch terms. This means that 20 (1 � 5 � 4)separate searches were conducted for all varia-tions of the terms for integration, psychother-apy, and training.
In order to increase the rigor of this system-atic review further, citations of the identifiedempirical articles were tracked and referenceswere scanned in order to identify possible arti-cles that fit the inclusion criteria but had notcome up in the initial search. The literaturesearch was conducted by the fourth author andrepeated by the first author. These two system-atic searches identified the same set of nineempirical studies to be included in this review.Figure 1 shows a PRISMA diagram of the flowof sources through the literature search. A totalof 20,263 published articles were identified dur-ing the systematic search. The final review con-sists of nine empirical studies on the effect oftraining in psychotherapy integration (describedin Table 1).
Results
Study Characteristics
Table 1 provides an overview of the studycharacteristics of the nine included studies. Allnine studies were conducted relatively recently,with the oldest study published 18 years ago(Allen, Kennedy, Veeser, & Grosso, 2000). Allstudies were conducted in English-speaking
countries: the United States (n � 3), Canada(n � 4), or the United Kingdom (n � 2).
Design. Most studies reported on descrip-tive data (n � 2) or used qualitative analyses(e.g., grounded theory, consensual qualitativemethod, thematic analysis) of the data (n � 5).Except for Pascual-Leone, Andreescu, and Ye-ryomenko (2015), all studies reported on origi-nal data sets. Pascual-Leone, Rodriguez-Rubio,and Metler (2013) reported on new data as wellas previously published data (Pascual-Leone,Wolfe, & O’Connor, 2012).2 By adding thepersonal accounts of 21 graduate students, thisstudy extended Pascual-Leone et al.’s (2012)findings on 24 undergraduates’ experiences,raising the number of cases represented in thequalitative analysis to 45. In a later study, Pas-cual-Leone et al. (2015) used quantitative anal-yses to examine this same group of undergrad-uates and graduate students in order to comparethe change in standardized outcome measuresreported by students and their clients over thetime of training. Allen and colleagues (2000)also used a control group but compared theirsurvey results with a control group of studentsin psychotherapy training that did not explicitlyfocus on integration. None of the other studiesused a control group in their study design.Seven of the nine studies were one-time mea-surements during or after training, and two stud-ies used repeated measurements at severalstages during the psychotherapy training. Typesof outcome measures included self-designedsurveys, weekly journals, written self-reflec-tions of the student and/or supervisor, focus-group recordings, and interviews. Pascual-Leone and colleagues (2015) was the only studythat also reported on the client’s perspective ofthe effectiveness of training, albeit indirectly bymeasuring the therapeutic alliance and sessionoutcome (Working Alliance Inventory–ShortRevised Version and Revised Session ReactionScale). One study (Pascual-Leone et al., 2015)reported on the use of standardized therapist/student measures (Counselor Activity Self-Efficacy Scales and Self-Awareness and Man-agement Strategies Scales for Therapists).
Training. All studies reported on longer (atleast 12 weeks) group trainings that included
2 To avoid duplicate data, we did not report on the Pascal-Leone et al. (2012) study separately.
7TRAINING IN PSYCHOTHERAPY INTEGRATION
Thi
sdo
cum
ent
isco
pyri
ghte
dby
the
Am
eric
anPs
ycho
logi
cal
Ass
ocia
tion
oron
eof
itsal
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publ
ishe
rs.
Thi
sar
ticle
isin
tend
edso
lely
for
the
pers
onal
use
ofth
ein
divi
dual
user
and
isno
tto
bedi
ssem
inat
edbr
oadl
y.
experiential, didactic, and supervision elementsrather than one-off training events. Most studiesreported on specific courses in psychotherapyintegration (n � 7); however, two studies re-ported on psychotherapy training programsmore generally (Norcross & Beutler, 2000;Wolfe, 2000; Ziv-Beiman, 2014). Sample sizesranged from n � 2 (Sotskova & Dossett, 2017)to n � 158 (Lampropoulos & Dixon, 2007).With regard to the different types of integration,most studies taught assimilative integration(n � 4), with a few reporting on theoretical(n � 2) or common factors (n � 2) integration.
Most trainings taught about psychotherapy in-tegration in a theoretical and conceptual way,whereas one study reported on training studentsby means of them facilitating an integrativepsychotherapy to clients (Trub & Levy, 2017).
With regard to timing of the integration train-ing in psychotherapists’ development, six of thenine studies reported on education about psy-chotherapy integration provided before educa-tion on one major theory or practice with inte-grative treatments. Two studies reported ontraining by means of practice with an integrativetreatment approach before education on one ma-
Records identifiedthrough database
screening n = 20.263
Duplicates excludedn = 5.598
Abstracts of recordsscreened n = 14.665
Full-text article of theidentified record
assessed foreligibility n = 93
Studies included inliterature review
n = 8
Studies excluded byabstract only n = 14.572
Full-text articlesexcluded:
Nonempirical articles n = 52
No formal training n = 3
Preassessment only n = 1
Additional titles and abstractsscreened through citation tracking
n = 91
Additional titles and abstractsscreened through reference search
n = 357
Studies excluded byabstract only
n = 406 Full-text articles
excluded: Nonempirical articles
n = 41
Additional articlesincluded in literature
review n = 1 (Fitzpatrick,
2010)
Total articles includedin literature review
n = 9
Figure 1. A flowchart of the search strategy.
8 AAFJES-VAN DOORN ET AL.
Thi
sdo
cum
ent
isco
pyri
ghte
dby
the
Am
eric
anPs
ycho
logi
cal
Ass
ocia
tion
oron
eof
itsal
lied
publ
ishe
rs.
Thi
sar
ticle
isin
tend
edso
lely
for
the
pers
onal
use
ofth
ein
divi
dual
user
and
isno
tto
bedi
ssem
inat
edbr
oadl
y.
Tab
le1
Stud
yC
hara
cter
isti
csan
dR
esul
ts
Ref
eren
ceC
ount
rySt
udy
desi
gnSa
mpl
esi
ze(n
)H
owis
itm
easu
red?
Wha
tis
mea
sure
d?N
atur
ean
dtim
ing
oftr
aini
ngT
ype
ofin
tegr
atio
nta
ught
Tra
inin
gou
tcom
es
Alle
n,K
enne
dy,
Vee
ser,
and
Gro
sso
(200
0)U
nite
dSt
ates
Post
sem
inar
eval
uatio
nco
mpa
red
with
cont
rol
grou
p
16ps
ychi
atry
resi
dent
sin
inte
grat
ive
sem
inar
;26
inge
nera
lse
min
ar
Self
-des
igne
dsu
rvey
(des
crip
tive
data
onL
iker
tsc
ale)
Subj
ectiv
efe
elin
gsab
out
the
usef
ulne
ssof
the
sem
inar
inth
eir
curr
ent
prac
tice
Wee
kly
2-hr
clin
ical
grou
pse
min
aron
mul
tiple
ther
apy
pers
pect
ives
(S)
(1)
The
oret
ical
,te
chni
cal
Hel
ped
com
pare
/con
tras
tps
ycho
ther
apy
para
digm
sus
eful
incu
rren
tpr
actic
e;m
ore
posi
tive
than
cont
rol
grou
pFi
tzpa
tric
k,K
oval
ak,
and
Wea
ver
(201
0)C
anad
a12
wee
kly
jour
nal
entr
ies
duri
ngco
urse
17co
unse
ling
psyc
holo
gym
aste
r’s-
leve
lst
uden
ts
Wee
kly
jour
nals
(qua
litat
ive
grou
nded
theo
ryan
alys
is)
Refl
ectio
nson
trai
ning
expe
rien
cean
din
tegr
ativ
epr
actic
ede
velo
pmen
t
12-w
eek
cour
seon
theo
ries
ofco
unse
ling
focu
sed
onco
mm
onfa
ctor
s(S
)(1
)
Com
mon
fact
ors
Abl
eto
deve
lop
pers
onal
theo
ryth
roug
hte
ntat
ive
iden
tifica
tions
with
theo
ries
ofpr
actic
eL
ampr
opou
los
and
Dix
on(2
007)
Uni
ted
Stat
esO
ne-o
ffqu
estio
nnai
reT
rain
ing
dire
ctor
sfr
om29
coun
selin
gps
ycho
logy
doct
oral
prog
ram
s&
139
inte
rnsh
ippr
ogra
ms
Self
-des
igne
dsu
rvey
(des
crip
tive
data
onL
iker
t-sc
ale
resp
onse
s)
Nat
ure
ofdi
dact
ican
dcl
inic
altr
aini
ngin
inte
grat
ive
ther
apy,
stud
ent
inte
grat
ive
com
pete
ncy
and
eval
uatio
n
Doc
tora
lpr
ogra
min
clud
ing
cour
seon
theo
ries
ofps
ycho
ther
apy,
tran
sthe
oret
ical
text
book
sw
ithch
apte
rson
inte
grat
ion
(G)
(2)
All
type
sPo
sitiv
een
viro
nmen
tfo
rin
tegr
ativ
eid
eas,
90%
taug
htps
ycho
ther
apy
inte
grat
ion
inth
eir
cour
ses
Low
ndes
and
Han
ley
(201
0)U
nite
dK
ingd
omPo
stm
easu
rem
ent
only
7ne
wly
licen
sed
coun
selo
rsw
hoha
dco
mpl
eted
trai
ning
inin
tegr
ativ
eco
unse
ling
Focu
sgr
oup
disc
ussi
on(q
ualit
ativ
egr
ound
edth
eory
them
atic
anal
ysis
oftr
ansc
ript
s)
How
doco
unse
lors
mak
ese
nse
ofth
erap
eutic
inte
grat
ion
follo
win
gth
eco
mpl
etio
nof
thei
rpr
ofes
sion
alqu
alifi
catio
n?
Skill
edH
elpe
rFr
amew
ork
cour
seon
com
mon
fact
ors
inth
erap
y(S
)(1
)
Com
mon
fact
ors
Opt
imis
mab
out
deve
lopm
ent,
lear
ned
toto
lera
teth
eore
tical
ambi
guity
,di
scom
fort
ofno
tbe
long
ing
topu
repa
radi
gm
Pasc
ual-
Leo
ne,
Rod
rigu
ez-R
ubio
,an
dM
etle
r(2
013)
Can
ada
Post
mea
sure
men
ton
ly21
clin
ical
psyc
holo
gym
aste
r’s-
leve
lgr
adua
test
uden
ts&
24ps
ycho
logy
unde
rgra
duat
est
uden
ts
Wri
tten
self
-refl
ectio
n,ab
out
stre
ngth
san
ddi
fficu
lties
(qua
litat
ive
grou
nded
theo
ryth
emat
ican
alys
is)
New
skill
s/st
reng
ths,
rem
aini
ngdi
fficu
lties
,an
dpe
rson
alim
pact
oftr
aini
ng
13w
eekl
y3-
hrtr
aini
ngin
psyc
hoth
erap
yco
ncep
tsus
ing
inte
grat
ive
fram
ewor
kan
dem
phas
ison
expe
rien
tial
ther
apy
(S)
(1)
Ass
imila
tive
Incr
ease
dfe
elin
gsof
com
pete
ncy,
alon
gw
ithgr
eate
rcl
arity
rega
rdin
gth
eir
prof
essi
onal
iden
tity
and
thei
rro
leas
ther
apis
tsPa
scua
l-L
eone
,A
ndre
escu
,an
dY
eryo
men
ko(2
015)
Can
ada
4m
idtr
eatm
ent
mea
sure
men
ts:
Wee
ks2,
5,9,
and
1221
clin
ical
psyc
holo
gym
aste
r’s-
leve
lgr
adua
test
uden
ts&
24ps
ycho
logy
unde
rgra
duat
est
uden
ts
The
rapi
stan
dcl
ient
stan
dard
ized
scal
es(q
uant
itativ
ean
alys
es:
RM
-A
NO
VA
)
Clie
ntra
tings
ofth
eir
trea
tmen
tse
ssio
ns&
ther
apis
tra
tings
ofow
nse
nse
ofco
mpe
tenc
e
13w
eekl
y3-
hrtr
aini
ngin
expe
rien
tial
ther
apy
conc
epts
usin
gin
tegr
ativ
efr
amew
ork
(S)
(1)
Ass
imila
tive
Incr
ease
dco
nfide
nce
and
self
-effi
cacy
;la
rges
tin
crea
sein
first
9w
eeks
(of
the
13-
wee
kpr
ogra
m)
(tab
leco
ntin
ues)
9TRAINING IN PSYCHOTHERAPY INTEGRATION
Thi
sdo
cum
ent
isco
pyri
ghte
dby
the
Am
eric
anPs
ycho
logi
cal
Ass
ocia
tion
oron
eof
itsal
lied
publ
ishe
rs.
Thi
sar
ticle
isin
tend
edso
lely
for
the
pers
onal
use
ofth
ein
divi
dual
user
and
isno
tto
bedi
ssem
inat
edbr
oadl
y.
Tab
le1
(con
tinu
ed)
Ref
eren
ceC
ount
rySt
udy
desi
gnSa
mpl
esi
ze(n
)H
owis
itm
easu
red?
Wha
tis
mea
sure
d?N
atur
ean
dtim
ing
oftr
aini
ngT
ype
ofin
tegr
atio
nta
ught
Tra
inin
gou
tcom
es
Sots
kova
and
Dos
sett
(201
7)C
anad
aPo
stm
easu
rem
ent
only
(cas
est
udy)
1cl
inic
alps
ycho
logy
mas
ter’
s-le
vel
stud
ent
&1
supe
rvis
or
Pers
onal
refle
ctio
nsof
supe
rvis
oran
dof
stud
ent
ontr
aini
ngex
peri
ence
(no
anal
yses
:se
ssio
nsfa
cilit
ated
and
late
rob
serv
edby
supe
rvis
or)
Supe
rvis
or’s
refle
ctio
nson
how
itis
tote
ach
and
stud
ent
refle
ctio
nson
how
itis
tole
arn
psyc
hoth
erap
yin
tegr
atio
n
3-m
onth
prac
ticum
ofex
iste
ntia
lin
tegr
ativ
eap
proa
chto
psyc
hoth
erap
y(S
)(3
)
Ass
imila
tive
Supe
rvis
orab
leto
synt
hesi
zetr
aini
ngin
spec
ific
mod
el,
with
inte
grat
ive
min
d-se
t;st
uden
tab
leto
see
how
toin
tegr
ate
tech
niqu
esfr
omm
ultip
leor
ient
atio
nsto
suit
the
clie
ntT
rub
and
Lev
y(2
017)
Uni
ted
Stat
esPo
stm
easu
rem
ent
only
10cl
inic
alps
ycho
logy
doct
oral
-lev
elst
uden
ts
Inte
rvie
w(q
ualit
ativ
egr
ound
edth
eory
them
atic
anal
ysis
oftr
ansc
ript
s)
Prof
essi
onal
expe
rien
ceof
cond
uctin
gin
tegr
ativ
etr
eatm
ent
and
impa
cton
iden
tified
theo
retic
alor
ient
atio
nan
dus
eof
futu
rein
tegr
atio
n
Prac
ticum
for
dyna
mic
ally
orie
nted
stud
ents
in12
sess
ions
man
ualiz
edtr
eatm
ent
for
subs
tanc
eab
use
inte
grat
ing
CB
Tte
chni
ques
(aud
iota
ped
sess
ions
revi
ewed
bypr
actic
umle
ader
)(S
)(3
)
Ass
imila
tive
Posi
tive
attit
ude
abou
tth
epo
tent
ial
for
inte
grat
ion,
grow
ing
com
pete
ncy
inca
paci
tyfo
rin
tegr
atio
n
War
d,H
ogan
,an
dM
enns
(201
1)U
nite
dK
ingd
omM
easu
rem
ent
mid
trai
ning
6co
unse
ling
psyc
holo
gym
aste
r’s-
leve
lst
uden
ts,
3co
unse
ling
psyc
holo
gist
s,an
d3
cour
sedi
rect
ors
Inte
rvie
ws:
(qua
litat
ive
them
atic
anal
ysis
)
Any
thin
gth
atin
terv
iew
eesh
ared
abou
tex
peri
ence
ofre
ceiv
ing/
prov
idin
gtr
aini
ngin
theo
retic
al/p
ract
ical
inte
grat
ion
Dif
fere
ntps
ycho
ther
apy
trai
ning
prog
ram
s(G
)(1
)
The
oret
ical
Gro
wth
prom
otin
g,ch
alle
ngin
g;ne
edm
ore
expl
icit
syst
emat
icte
achi
ngof
psyc
hoth
erap
yin
tegr
atio
n
Not
e.S
�tr
aini
ngde
sign
edto
spec
ifica
llyfo
cus
onps
ycho
ther
apy
inte
grat
ion;
G�
gene
ralp
sych
othe
rapy
trai
ning
that
incl
udes
inte
grat
ion;
1�
educ
atio
nab
outp
sych
othe
rapy
inte
grat
ion
befo
reed
ucat
ion
onon
em
ajor
theo
ryor
prac
tice
with
inte
grat
ive
trea
tmen
ts;2
�fir
sted
ucat
ion
abou
tone
maj
orth
eory
befo
reed
ucat
ion
abou
tpsy
chot
hera
pyin
tegr
atio
n;3
�tr
aini
ngby
mea
nsof
prac
tice
with
inte
grat
ive
trea
tmen
tap
proa
ch;
RM
-AN
OV
A�
Rep
eate
dM
easu
res
Ana
lysi
sof
Var
ianc
e;C
BT
�C
ogni
tive
Beh
avio
ral
The
rapy
.
10 AAFJES-VAN DOORN ET AL.
Thi
sdo
cum
ent
isco
pyri
ghte
dby
the
Am
eric
anPs
ycho
logi
cal
Ass
ocia
tion
oron
eof
itsal
lied
publ
ishe
rs.
Thi
sar
ticle
isin
tend
edso
lely
for
the
pers
onal
use
ofth
ein
divi
dual
user
and
isno
tto
bedi
ssem
inat
edbr
oadl
y.
jor theory. Only the training directors in Lam-propoulos and Dixon’s (2007) study reported onthe need to first educate students about onemajor theory before providing education aboutpsychotherapy integration.
Students and trainers. Training partici-pants included psychiatry residents, master’sstudents in clinical and counseling psychology,doctoral students in clinical psychology, under-graduate students in psychology, as well asnewly licensed practitioners. One study did notreport on the participants’ experience of thetraining directly but reported on the perspectiveof the training directors (Lampropoulos &Dixon, 2007). Four studies reported that theirrespective trainers identified as an integrativepsychotherapist (i.e., Allen et al., 2000; Fitzpat-rick, Kovalak, & Weaver, 2010; Lampropoulos& Dixon, 2007; Sotskova & Dossett, 2017).Lowndes and Hanley (2010) explicitly reportedthat the trainers did not identify as integrativetherapists, whereas for the other four studies,the theoretical orientation of the trainer wasunclear.
Training effect. All studies reported on apositive outcome of the training in psychother-apy training with regard to providing a positiveenvironment for integrative ideas to grow(Lampropoulos & Dixon, 2007), helping themcompare and contrast psychotherapy paradigmsand useful in their current practice (Allen et al.,2000), development of a personal theory (Fitz-patrick et al., 2010), optimism about future ap-plication of integrative practice (Lowndes &Hanley, 2010), increased feelings of compe-tency, and greater clarity of professional iden-tity (e.g., Pascual-Leone et al., 2013; Sotskova& Dossett, 2017; Trub & Levy, 2017). How-ever, some studies also highlighted the strug-gles, hurdles, and discomfort of tolerating am-biguity during the process of learning how tobecome an integrative psychotherapist (e.g.,Lowndes & Hanley, 2010) and the need formore explicit and systematic approaches toteaching psychotherapy integration (Ward, Ho-gan, & Menns, 2011). Although 90% of trainingdirectors indicated that they taught psychother-apy integration in their program, only half of allsurveyed training directors believed that stu-dents should be minimally competent in a vari-ety of models (Lampropoulos & Dixon, 2007)and indicated that training in more than onetheory was mandatory. Also, the training direc-
tors appeared to differ from the students in howintegration might be taught. None of the train-ing directors mentioned explicit training in howto integrate psychotherapies, 21% of trainingdirectors believed that students should betrained first to be proficient in one therapeuticmodel, and 21% believed that students shouldbe trained in a specific integrative/eclecticmodel from the outset.
Discussion
Despite the popularity of psychotherapy inte-gration among practitioners around the globe,very little is known about the efficacy of train-ings in integration. As early career practitioners,we reflected on our own professional experi-ences of training in psychotherapy integrationin the Czech Republic, Argentina, the UnitedKingdom, and the United States.
Based on our personal experiences, Argen-tina currently appears to offer the most robusttraining in psychotherapy integration, despite itspsychoanalytic tradition and only recent popu-larity of integration. Psychotherapy integrationis seen as an “evidence-based treatment in it-self” and taught to students as a valid alternativeto psychoanalysis and CBT. The Czech Repub-lic also offers lots of opportunities for psycho-therapy integration for students and licensedpractitioners alike, albeit it more informally,with no governmental guidelines. In the UnitedKingdom and the United States, the trainingfocus remains on one or two theoretical orien-tations. During training, integrative practice ismainly learned implicitly and further developedafter graduate training, within the restrictions ofevidence-based practice guidelines. This lack ofexplicit focus on integration was also reflectedin the lack of clarity on trainer/supervisor ori-entation in our reviewed studies, and is surpris-ing given our positive experiences of learningfrom different integrative supervisors as valu-able role-model. In our view, explicit training inpsychotherapy integration is crucial in guidingthe process of integration in training settingsaround the world.
The challenge in locating relevant empiricalstudies for our purpose illustrates the lack ofclarity in the field on what integration is andhow and whether it should be explicitly taught.If the maturity of a scientific and professionaldomain is indeed reflected by the level of sys-
11TRAINING IN PSYCHOTHERAPY INTEGRATION
Thi
sdo
cum
ent
isco
pyri
ghte
dby
the
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eric
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tematic and formal attention it has given totraining (Castonguay, 2005), psychotherapy in-tegration has some way to go. The findings werefurther limited by the studies’ small-scale sam-ples, postmeasurement designs, qualitativeanalyses, and the lack of standardizes measures,and illustrate how very little is known empiri-cally about effective training in psychotherapyintegration. Overall, it appeared that the ex-pected breakthroughs (see Norcross, 1997) havenot yet materialized given that psychotherapyintegration does not (yet) constitute a concep-tually coherent, empirically validated, and edu-cationally sound position for practice. The ex-treme heterogeneity of the content andprocedures of the trainings examined in theempirical studies as well as the lack of statisticalanalyses preclude drawing any strong conclu-sions about the effectiveness of these specifictraining initiatives. The need for more rigorousevaluation of integrative training initiatives isrecognized. It was also noteworthy that all em-pirical studies identified in the review were con-ducted in English-speaking countries (UnitedStates, Canada, and United Kingdom) and didnot represent the training practices in Europe orSouth America.
Training and Research Implications
Based on our personal experiences and thelimited empirical findings, this review suggeststhat there might be a number of effective for-mats and approaches that could potentially bebeneficial to students’ development of skills inpsychotherapy integration. For the majority ofstudents, the outcomes following training inpsychotherapy integration are positive. Train-ings in psychotherapy integration may addressassimilative, eclectic, theoretical, or commonfactors integration and may be offered to differ-ent mental health professionals at differentstages of their professional development. Train-ing in psychotherapy integration usually in-cludes didactic and experiential elements, aswell as readings and supervision and may betaught explicitly in a specific seminar or practi-cum or more implicitly as part of the frameworkof the overall psychotherapy training program.In line with our personal recommendations,most reviewed studies argued for the educationabout integration at the start of psychotherapytraining (common factors or technical integra-
tion) in order to enable a flexible, open ap-proach to clinical work (e.g., Consoli & Jester,2005; Ziv-Beiman, 2014). However, the con-cerns related to early integration training, thatis, the risk of feeling overwhelmed by theamount of theoretical and technical options anda lack of competency and confidence by the endof training (e.g., Castonguay, 2005; Gold,2005), also appeared to be confirmed by theempirical evidence and our personal experi-ences. Many studies reported on students’ dif-ficulty with tolerating ambiguity and not be-longing to a particular theoretical community,arguably confirming the need for training in theroots of one or two therapeutic orientations be-fore training in psychotherapy integration (i.e.,theoretical or assimilative approach to integra-tion).
Clinical experience in facilitating treatmentadhering to an integrative psychotherapy man-ual might provide students with a concrete ex-ample of how a supervisor or therapist might goabout integrating different theories or tech-niques with a given client (Ward et al., 2011).Furthermore, the use of video recordings insupervision is becoming more common in psy-chotherapy training in the United States, UnitedKingdom, the Czech Republic, and Argentina(e.g., Haggerty & Hilsenroth, 2011; NHS Dig-ital, 2014) and may further aid research into theeffect of training of psychotherapy integration.In line with our experiences, small-group vid-eotaped training that encourages self-monitor-ing and the exchange of supportive peer feed-back among psychotherapists from differentorientations might aid the comparison of differ-ent methods, models, and outcomes (e.g., Ab-bass, 2004). Face-to-face case discussionsbased on these videos might illustrate common-alities and differences in detailed therapeuticinteractions (Brown, Moller, & Ramsey-Wade,2013), helping practitioners to explain their jar-gon and thus bridging the communication gapbetween models.
Furthermore, given the global differences inhow integrative therapy is taught and the limitedresearch on their respective effectiveness, it willbe important to identify and compare differenttraining methods in integrative psychotherapy(Rønnestad, Orlinsky, & Wiseman, 2016). Inline with this, a large international initiative hasbeen set up to systematically compare the train-ing experiences of psychotherapists in different
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countries—the Society for Psychotherapy Re-search’s Interest Section on Therapist Trainingand Development (also known as SPRISTAD;Orlinsky et al., 2015). It is hoped that quantita-tive and qualitative data gathered from a largenumber of psychotherapy students of variedtypes in a wide range of training programs willelucidate different ways in which integration ofpsychotherapy models can be effectively taught(Orlinsky et al., 2015). The lack of empiricalstudies on psychotherapy integration from non-English-speaking countries identified in our re-view underlines the importance of sharing ourtraining experiences from around the globe injournals, newsletters, and conferences, and indeveloping collaborative research projects toestablish “evidence-based integrative practice.”
References
�The empirical studies reviewed as part of thesystematic review are marked with an asterisk.
Aafjes-van Doorn, K., Kamsteeg, C. D., Portier,C. H., & Chitre, G. (2018). A dialectical behaviortherapy skills group in a psychoanalytic commu-nity service: A pilot study of assimilative integra-tion. Manuscript under review.
Abbass, A. (2004). Small-group videotape trainingfor psychotherapy skills development. AcademicPsychiatry, 28, 151–155. http://dx.doi.org/10.1176/appi.ap.28.2.151
Ablon, J. S., Levy, R. A., & Katzenstein, T. (2006).Beyond brand names of psychotherapy: Identify-ing empirically supported change processes. Psy-chotherapy: Theory, Research, Practice, Training,43, 216–231. http://dx.doi.org/10.1037/0033-3204.43.2.216
�Allen, D. M., Kennedy, C. L., Veeser, W. R., &Grosso, T. (2000). Teaching the integration ofpsychotherapy paradigms in a psychiatric resi-dency seminar. Academic Psychiatry, 24, 6–13.http://dx.doi.org/10.1007/BF03340066
Arkowitz, H. (1992). Integrative theories of therapy.In D. K. Freedheim (Ed.), History of psychother-apy: A century of change (pp. 261–303). Washing-ton, DC: American Psychological Association.http://dx.doi.org/10.1037/10110-007
Association of Psychology Postdoctoral and Intern-ship Centers. (2018). About the APPIC match.Retrieved from https://www.appic.org/Match/About-The-APPIC-Match
Beitman, B. D., & Yue, D. (1999). A new psycho-therapy training program: Description and prelim-inary results. Academic Psychiatry, 23, 95–102.http://dx.doi.org/10.1007/BF03354249
Blott, M. R. (2008). Encountering difference in grad-uate training: Potential for practicum experience.Journal of Psychotherapy Integration, 18, 437–452. http://dx.doi.org/10.1037/1053-0479.18.4.437
Boswell, J. F., Castonguay, L. G., & Pincus, A. L.(2009). Trainee theoretical orientation: Profilesand potential predictors. Journal of PsychotherapyIntegration, 19, 291–312. http://dx.doi.org/10.1037/a0017068
British Psychological Society. (2012). Accreditationthrough partnership handbook: Guidance for clin-ical psychology programmes. Retrieved fromhttps://www.sheffield.ac.uk/polopoly_fs/1.304874!/file/5_1_BPS_Accreditation_Guidance_2012_PrintPages1_43_2012.pdf
Brown, E., Moller, N., & Ramsey-Wade, C. (2013).Recording therapy sessions: What do clients andtherapists really think? Counselling & Psychother-apy Research, 13, 254–262. http://dx.doi.org/10.1080/14733145.2013.768286
Carkhuff, R. R., & Truax, C. B. (1965). Training incounseling and psychotherapy: An evaluation ofan integrated didactic and experiential approach.Journal of Consulting Psychology, 29, 333–336.http://dx.doi.org/10.1037/h0022187
Castonguay, L. G. (2005). Training issues in psycho-therapy integration: A commentary. Journal ofPsychotherapy Integration, 15, 384–391. http://dx.doi.org/10.1037/1053-0479.15.4.384
Consoli, S. J., & Jester, C. M. (2005). Training inpsychotherapy integration II: Further efforts. Jour-nal of Psychotherapy Integration, 15, 355–357.http://dx.doi.org/10.1037/1053-0479.15.4.355
Constantino, M. J. (2017). Structured interview ontraining. The Integrative Therapist, 3, 12–14.
Feindler, E. L., & Kahoud, D. (2015). Two sides of atheoretical coin: Multiple perspectives on theoret-ical training in clinical psychology. In J. Bresler &K. E. Starr (Eds.), Relational psychoanalysis andpsychotherapy integration: An evolving synergy(pp. 260–281). New York, NY: Routledge.
Fernández-Álvarez, H., Consoli, A. J., & Gómez, B.(2016). Integration in psychotherapy: Reasons andchallenges. American Psychologist, 71, 820–830.http://dx.doi.org/10.1037/amp0000100
Fernández-Alvarez, H., Gómez, B., & García, F.(2015). Bridging the gap between research andpractice in a clinical and training network: Aigle’sprogram. Psychotherapy Research, 25, 84–94.http://dx.doi.org/10.1080/10503307.2013.856047
�Fitzpatrick, M. R., Kovalak, A. L., & Weaver, A.(2010). How trainees develop an initial theory ofpractice: A process model of tentative identifica-tions. Counselling & Psychotherapy Research, 10,93–102. http://dx.doi.org/10.1080/14733141003773790
13TRAINING IN PSYCHOTHERAPY INTEGRATION
Thi
sdo
cum
ent
isco
pyri
ghte
dby
the
Am
eric
anPs
ycho
logi
cal
Ass
ocia
tion
oron
eof
itsal
lied
publ
ishe
rs.
Thi
sar
ticle
isin
tend
edso
lely
for
the
pers
onal
use
ofth
ein
divi
dual
user
and
isno
tto
bedi
ssem
inat
edbr
oadl
y.
Frank, J. D., & Frank, J. B. (1991). Persuasion andhealing: A comparative study of psychotherapy.Baltimore, MD: Johns Hopkins University Press.
Gold, J. (2005). Anxiety, conflict, and resistance inlearning an integrative perspective on psychother-apy. Journal of Psychotherapy Integration, 15,374–383. http://dx.doi.org/10.1037/1053-0479.15.4.374
Gómez, B. (2007). Psychotherapy in Argentina: Aclinical case from an integrative perspective. Jour-nal of Clinical Psychology, 63, 713–723. http://dx.doi.org/10.1002/jclp.20386
Greben, D. H. (2004). Integrative dimensions of psy-chotherapy training. The Canadian Journal of Psy-chiatry, 49, 238–248. http://dx.doi.org/10.1177/070674370404900404
Haggerty, G., & Hilsenroth, M. J. (2011). The use ofvideo in psychotherapy supervision. British Jour-nal of Psychotherapy, 27, 193–210. http://dx.doi.org/10.1111/j.1752-0118.2011.01232.x
Harris, J. E., Kelley, L. J., Campbell, E. L., & Ham-mond, E. S. (2014). Key strategies training forindividual psychotherapy: An introduction to mul-titheoretical practice. Journal of Psychotherapy In-tegration, 24, 138–152. http://dx.doi.org/10.1037/a0037056
Hayes, S. C., Strosahl, K. D., & Wilson, K. G.(2011). Acceptance and commitment therapy: Theprocess and practice of mindful change (2nd ed.).New York, NY: Guilford Press.
Health and Care Professions Council. (2010). Prac-titioner psychologists: Standards of proficiency.Retrieved from http://www.hpc-uk.org/assets/documents/10002963SOP_Practitioner_psychologists.pdf
Keegan, E. (2007). Ensayos de terapia cognitive [Es-says on Cognitive Therapy]. Buenos Aires, Argen-tina: Editorial Universitaria de Buenos Aires.
Korman, G. P., Viotti, N., & Garay, C. J. (2015). Theorigins and professionalization of cognitive psy-chotherapy in Argentina. History of Psychology,18, 205–214. http://dx.doi.org/10.1037/a0038968
Lampropoulos, G. K. (2001). Bridging technicaleclecticism and theoretical integration: Assimila-tive integration. Journal of Psychotherapy Integra-tion, 11, 5–19. http://dx.doi.org/10.1023/A:1026672807119
�Lampropoulos, G. K., & Dixon, D. N. (2007). Psy-chotherapy integration in internships and counsel-ing psychology doctoral programs. Journal of Psy-chotherapy Integration, 17, 185–208. http://dx.doi.org/10.1037/1053-0479.17.2.185
Lazarus, A. A. (1967). In support of technical eclec-ticism. Psychological Reports, 21, 415–416. http://dx.doi.org/10.2466/pr0.1967.21.2.415
Liberati, A., Altman, D. G., Tetzlaff, J., Mulrow, C.,Gøtzsche, P. C., Ioannidis, J. P. A., . . . Moher, D.(2009). The PRISMA statement for reporting sys-
tematic reviews and meta-analyses of studies thatevaluate health care interventions: Explanation andelaboration. PLoS Medicine, 6(7), e1000100.http://dx.doi.org/10.1371/journal.pmed.1000100
Linehan, M. M., Korslund, K. E., Harned, M. S.,Gallop, R. J., Lungu, A., Neacsiu, A. D., . . .Murray-Gregory, A. M. (2015). Dialectical behav-ior therapy for high suicide risk in individuals withborderline personality disorder: A randomizedclinical trial and component analysis. Journal ofthe American Medical Association Psychiatry, 72,475– 482. http://dx.doi.org/10.1001/jamapsychia-try.2014.3039
Llewelyn, S., & Aafjes-van Doorn, K. (2017). Clin-ical psychology: A very short introduction. Ox-ford, UK: Oxford University Press.
�Lowndes, L., & Hanley, T. (2010). The challenge ofbecoming an integrative counsellor: The trainee’sperspective. Counselling & Psychotherapy Re-search, 10, 163–172. http://dx.doi.org/10.1080/14733141003751614
Magnavita, J. J., & Anchin, J. C. (2013). Unifyingpsychotherapy: Principles, methods, and evidencefrom clinical science. New York, NY: Springer.
Messer, S. B. (1992). A critical examination of beliefstructures in integrative and eclectic psychother-apy. In J. C. Norcross, M. R. Goldfried, & J. C.Norcross (Eds.), Handbook of psychotherapy inte-gration (pp. 130–165). New York, NY: BasicBooks.
Muller, F. J. (2008). Psychotherapy in Argentina:Orientation and Clinical Practice. Journal of Psy-chotherapy Integration, 18, 410–420.
NHS Digital. (2014). Psychological therapies. An-nual report on the use of IAPT services. England,2013–14. Retrieved from https://digital.nhs.uk/data-andinformation/publications/statistical/psychological-therapies-report-on-the-use-of-iapt-services/psychological-therapies-annual-report-on-the-use-of-iapt-services-england-2013-14
Norcross, J. C. (1997). Emerging breakthroughs inpsychotherapy integration: Three predictions andone fantasy. Psychotherapy: Theory, Research,Practice, Training, 34, 86–90. http://dx.doi.org/10.1037/h0087757
Norcross, J. C., & Beutler, L. E. (2000). A prescrip-tive eclectic approach to psychotherapy training.Journal of Psychotherapy Integration, 10, 247–261. http://dx.doi.org/10.1023/A:1009444912173
Norcross, J. C., & Rogan, J. D. (2013). Psychologistsconducting Psychotherapy in 2012: Current prac-tices and historical trends among Division 29members. Psychotherapy, 50, 490–495. http://dx.doi.org/10.1037/a0033512
Norcross, J. C., Sayette, M. A., & Pomerantz, A. M.(2018). Doctoral training in clinical psychologyacross 23 years: Continuity and change. Journal of
14 AAFJES-VAN DOORN ET AL.
Thi
sdo
cum
ent
isco
pyri
ghte
dby
the
Am
eric
anPs
ycho
logi
cal
Ass
ocia
tion
oron
eof
itsal
lied
publ
ishe
rs.
Thi
sar
ticle
isin
tend
edso
lely
for
the
pers
onal
use
ofth
ein
divi
dual
user
and
isno
tto
bedi
ssem
inat
edbr
oadl
y.
Clinical Psychology, 74, 385–397. http://dx.doi.org/10.1002/jclp.22517
O’Hara, D., & Schofield, M. J. (2008). Personalapproaches to psychotherapy integration. Counsel-ling & Psychotherapy Research, 8, 53–62. http://dx.doi.org/10.1080/14733140801889113
Orlinsky, D. E., Strauss, B., Rønnestad, M. H., Hill,C. E., Castonguay, L. G., Willutzki, U., . . .Carlsson, J. (2015). A collaborative study of de-velopment in psychotherapy trainees. Psychother-apy Bulletin, 50, 21–25.
�Pascual-Leone, A., Andreescu, C. A., & Yeryo-menko, N. (2015). Training novice psychothera-pists: Comparing undergraduate and graduate stu-dents’ outcomes. Counselling & PsychotherapyResearch, 15, 137–146. http://dx.doi.org/10.1002/capr.12007
�Pascual-Leone, A., Rodriguez-Rubio, B., & Metler,S. (2013). What else are psychotherapy traineeslearning? A qualitative model of students’ personalexperiences based on two populations. Psycho-therapy Research, 23, 578–591. http://dx.doi.org/10.1080/10503307.2013.807379
Pascual-Leone, A., Wolfe, B. J., & O’Connor, D.(2012). The reported impact of psychotherapytraining: Undergraduate disclosures after a coursein experiential psychotherapy. Person-Centeredand Experiential Psychotherapies, 11, 152–168.http://dx.doi.org/10.1080/14779757.2011.648099
Plchová, R., Hytych, R., Rihácek, T., Roubal, J., &Vybíral, Z. (2016). How do trainees choose theirfirst psychotherapy training? The case of trainingin psychotherapy integration. British Journal ofGuidance & Counselling, 44, 487–503. http://dx.doi.org/10.1080/03069885.2016.1213371
Plotkin, M. B. (2003). El psicoanálisis y sus historias[Psychoanalysis and its histories]. PsicoanálisisAPdeBA, 25, 457–461.
Rihacek, T., & Danelova, E. (2015). How therapistschange: What motivates therapists towards inte-gration. European Journal for Qualitative Re-search in Psychotherapy, 8, 5–31.
Rihacek, T., & Roubal, J. (2017). The proportion ofintegrationists among Czech psychotherapists andcounselors: A comparison of multiple criteria.Journal of Psychotherapy Integration, 27, 13–22.http://dx.doi.org/10.1037/int0000069
Robertson, M. H. (1995). Psychotherapy educationand training: An integrative perspective. Madison,CT: International University Press.
Rønnestad, M. H., Orlinsky, D. E., & Wiseman, H.(2016). Professional development and personaltherapy. In J. C. Norcross, G. R. VandenBos, D. K.Freedheim, & L. F. Campbell (Eds.), APA hand-book in clinical psychology: Education and pro-fession (Vol. 5, pp. 223–235). Washington, DC:American Psychological Association.
Rønnestad, M. H., & Skovholt, T. M. (2003). Thejourney of the counselor and therapist: Researchfindings and perspectives on professional develop-ment. Journal of Career Development, 30, 5–44.http://dx.doi.org/10.1177/089484530303000102
Rosenzweig, S. (1936). Some implicit commonfactors in diverse methods of psychotherapy.American Journal of Orthopsychiatry, 6, 412–415. http://dx.doi.org/10.1111/j.1939-0025.1936.tb05248.x
Roussos, A. J., Waizmann, V., & Etchebarne, I.(2010). Common interventions in two single casesof cognitive and psychoanalytic psychotherapies.Journal of Psychotherapy Integration, 20, 327–346. http://dx.doi.org/10.1037/a0020822
Ryle, A., & Kerr, I. B. (2003). Introducing cognitiveanalytic therapy: Principles and practice. NewYork, NY: Wiley.
Snyder, J., & Aafjes-van Doorn, K. (2016). Utilizingmeasure-based feedback in control-mastery the-ory: A clinical error. Psychotherapy, 53, 291–296.http://dx.doi.org/10.1037/pst0000075
�Sotskova, A., & Dossett, K. (2017). Teaching inte-grative existential psychotherapy: Student and su-pervisor reflections on using an integrative ap-proach early in clinical training. The HumanisticPsychologist, 45, 122–133. http://dx.doi.org/10.1037/hum0000049
Tasca, G. A., Sylvestre, J., Balfour, L., Chyurlia, L.,Evans, J., Fortin-Langelier, B., . . . Wilson, B.(2015). What clinicians want: Findings from apsychotherapy practice research network survey.Psychotherapy, 52, 1–11. http://dx.doi.org/10.1037/a0038252
�Trub, L., & Levy, D. (2017). Sowing the seeds foran assimilative integrationist stance toward psy-chotherapy. Journal of Psychotherapy Integration,27, 172–185. http://dx.doi.org/10.1037/int0000056
VandenBos, G. R., Hogan, J. D., & Kazak, A. E.(2017). 125th anniversary of the American Psy-chological Association—Accomplishments andchallenges: Introduction to the special issue. Amer-ican Psychologist, 72, 719–721. http://dx.doi.org/10.1037/amp0000235
Wachtel, P. L. (1997). Psychoanalysis, behaviortherapy, and the relational world. Washington,DC: American Psychological Association. http://dx.doi.org/10.1037/10383-000
�Ward, T., Hogan, K., & Menns, R. (2011). Percep-tions of integration in counselling psychologytraining, a pilot study. Counselling Psychology Re-view, 26, 8–19.
Westen, D., Novotny, C. M., & Thompson-Brenner,H. (2004). The empirical status of empirically sup-ported psychotherapies: Assumptions, findings,and reporting in controlled clinical trials. Psycho-logical Bulletin, 130, 631–663. http://dx.doi.org/10.1037/0033-2909.130.4.631
15TRAINING IN PSYCHOTHERAPY INTEGRATION
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ein
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user
and
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tto
bedi
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oadl
y.
Wolfe, B. E. (2000). Toward an integrative theoret-ical basis for training psychotherapists. Journal ofPsychotherapy Integration, 10, 233–246. http://dx.doi.org/10.1023/A:1009492728103
Ziv-Beiman, S. (2014). Teaching psychotherapy in-tegration from the start: A proposal to teach inte-gration as a fundamental aspect. Journal of Psy-
chotherapy Integration, 24, 251–257. http://dx.doi.org/10.1037/a0037800
Received February 8, 2018Revision received May 29, 2018
Accepted July 5, 2018 �
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