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(p. 377) Training and Supervision in Psychotherapy Integration 

(p. 377) Training and Supervision in Psychotherapy Integration
Chapter:
(p. 377) Training and Supervision in Psychotherapy Integration
Author(s):

John C. Norcross

, and Marcella Finnerty

DOI:
10.1093/med-psych/9780190690465.003.0018
Page of

date: 22 September 2019

Once upon a time, psychotherapists were trained exclusively in a single theoretical orientation and in the individual therapy tradition. The ideological singularity of training did not always result in clinical competence but did reduce clinical complexity and theoretical confusion (Schultz-Ross, 1995). But, over time, psychotherapists began to recognize that their orientations were theoretically incomplete and clinically inadequate for the variety of patients, contexts, and problems they confronted in practice. They began receiving training in several theoretical orientations—or at least were exposed to multiple theories—and in diverse therapy formats, such as individual, couple, family, and group.

The gradual evolution of psychotherapy training toward integration has proven a mixed blessing. On the one hand, the movement addresses the daily needs of clinical practice, satisfies the intellectual quest for an informed pluralism, and responds to the growing research evidence that different patients prosper from different treatments, formats, and relationships. On the other hand, integrative training increases the student press to obtain clinical competence in multiple methods and formats and, in addition, challenges the faculty to create a coordinated training enterprise. Not only must the conventional difficulties in producing competent clinicians be resolved, but integrative training must also assist its students in acquiring mastery of multiple treatments and then in tailoring their therapeutic approach to fit individual patients.

In this chapter, we begin by introducing what is, in our view, an ideal training sequence for psychotherapy integration. We then consider (p. 378) training in light of the four principal routes of integration—technical eclecticism, theoretical integration, common factors, and assimilative integration—as their training objectives and sequence will vary somewhat. Next, we address questions regarding the centrality of personal therapy and the necessity of research training in the preparation of integrative therapists. We review integrative supervision, specifically seven of its distinctive practices. We conclude with a discussion of organizational strategies for promoting psychotherapy integration and offer future directions for integrative training.

A Few Words on Words

Before proceeding to the chapter proper, a few words on our terminology. The term “training” can denote a mechanistic and impersonal pursuit, such as training seals to clap their flippers or training rats to run a maze (Bugental, 1987; Rønnestad & Skovholt, 2012). We would prefer to retitle psychotherapy training something along the lines of “cultivating psychotherapists” or “developing psychotherapists.” But precedent is against us; when we talk about the development of a psychotherapist, many of our colleagues and students look at us quizzically. Thus, we will concede to linguistic preference and precedent in using the conventional “training” throughout this chapter, but we implore readers to interpret the term in a broader and more human meaning. We try to prepare graduates who are both competent psychotherapists and better functioning people.

A second bit of linguistic ambiguity concerns the term “integrative training” (and “integrative supervision”). Our use deliberatively denotes two meanings: training/supervision itself that integrates methods, modalities, and mechanisms associated with diverse theoretical orientations, and psychotherapy training/supervision conducted from an integrative approach. At times, this ambiguity proves confusing, but we believe it serves the higher purpose of underscoring the inherent parallel processes of integrative education. The integrative teacher remains theoretically flexible in systematically tailoring the education to the individual trainee, just as that trainee simultaneously adapts psychotherapy to the individual client and singular context. In this respect, the educational medium becomes much of the message (Norcross & Popple, 2017).

Integrative Training

Psychotherapy students and practitioners are confronted with a blizzard of theories and a fragmented training system. With so many therapy systems claiming success, which theories should be studied, taught, or integrated (Prochaska & Norcross, 2018)?

More specifically, psychotherapy trainers are immediately confronted with a crucial decision regarding their training objectives. The major choice is whether the program’s objective will be to train students to competence in a single psychotherapy system and subsequent referral of other clients to more specialized treatments, or whether its declared mission will be for their students to accommodate most of these patients themselves by virtue of the students’ competence in an integrative approach to psychotherapy. In this section, we present consensual training models for teaching both differential referral and psychotherapy integration. The introduction and implementation of these models into any program will require substantive content revisions, as well as a clinical sensitivity to the process of successful organizational change, as described later in this chapter. Along the way, we review several debates on the best practices in integrative training.

Differential Referrals

Each of the single-school orientations represents a feasible structure for practice, and essential work is being conducted under the patronage of “purist” approaches. Many practitioners find meaning and success, over their professional careers, with their chosen orientation (McLeod, 2017). A single theory offers valuable assistance in case conceptualization and treatment planning (Boswell et al., , 2009).

(p. 379) Psychotherapists can indeed function effectively within a single theoretical system, although they are rarely the best judge of their own performance (Walfish et al., 2012). Providing they have the ethics and ability to discriminate which patients can benefit from their preferred system and which cannot, referral of the latter patients can then systematically be made to clinicians competent to offer the indicated treatment.

In the words of Howard and colleagues (1987, p. 415): “Without a therapist’s willingness and ability to engage in a range of behaviors and to employ a range of therapeutic modalities, the therapist, by intent or default, will have to limit his or her practice to clients who fit the specific range of behaviors he or she has to offer.” The primary problem is not from narrow-gauge therapists per se, but from therapists who impose that narrowness on their patients (Miller et al., 2013; Stricker, 1988).

The two essential tasks in differential referral are to train students to recognize the respective contraindications of their single psychotherapy system and to educate them in making informed referral decisions. Many evidence-based studies are now available by which to recognize the indications and contraindications of particular therapies and formats (e.g., Aponte & Kissil, 2014; Beutler & Harwood, 2000; Fernandez-Alvarez et al., 2016; Halvorsen et al., 2016; Prochaska & Norcross, 2018; Roth & Fonagy, 1996), and the failure to make use of such information can no longer be construed primarily as lacunae in the psychotherapy outcome literature. On the contrary, difficulties in appreciating the limitations of one’s treasured proficiencies now prove largely emotional and organizational, not intellectual. Helping single-system advocates to relinquish patients for whom another approach is better suited will entail attention to both the prescriptions of the research evidence and the limitations of their theoretical commitments.

In order to make differential referrals, clinicians will need knowledge of available community and treatment resources. Because many students may ultimately practice in geographic locations different from where they were trained, this information cannot readily generalize from the training location. Instead of teaching specific resources, therefore, training programs are well advised to ensure that students know how to locate resources in any community (Norcross, Beutler, & Clarkin, 1990).

Programs can provide several experiences to ensure students’ ability to develop treatment and community knowledge. First, specific instruction and course work can emphasize the value of community services, self-help resources, and networks of private practitioners. Second, students routinely can be provided with names and web addresses of national directories and referral services. Third, visits to community mental health centers, family counseling agencies, child protective services, and substance abuse programs, among others, can give a sampling of the resources available. Fourth, trainees can be assigned the task of locating treatment resources and preparing an integrated treatment plan for an actual patient presented in either case conference or a class vignette. Examples can be organized around the client’s disorder, treatment goals, stage of change, therapy preferences, and the like. Finally, trainees should obtain extensive experience in evaluating a range of patients under close supervision in differential referral and treatment assignment. These experiences are most easily obtained in large health centers that offer a variety of treatment programs and specialty clinics. In such a setting, too, the integration of research and practice can be facilitated and reinforced (Castonguay et al., Chapter 20, this volume; Dyason et al., 2018; Jarmon & Halgin, 1987; Miller et al., 2013).

Many colleagues in the United States complain that training in differential referral is dated, that we have progressed well beyond referral. We agree that indeed proves the case for most doctoral programs in the United States, but it does not address the reality of smaller programs and other countries where psychotherapy integration is not yet firmly established. Some training programs may be too brief, or students too inexperienced, or faculty too divided to tackle the integrative challenge. We hope that, in the next volume of this book, the (p. 380) section on training in differential referral can be jettisoned permanently.

Integrative Psychotherapy

Once the program faculty decide to implement training in integrative psychotherapy, they confront a series of choices or debates on how best to approach such education—what theories or principles should be taught and when integration should be introduced to the student. Some educators believe that students should be trained integratively from the outset (e.g., Eubanks-Carter et al., 2005) as integrative pedagogy can promote the critical skills for effective practice: flexibility, open-mindedness, creativity, awareness of limitations, and resourcefulness to cope with future challenges. Such training would enable students to avoid the difficulties of trying to unlearn years of work and practice within one orientation (Norcross, 2011). In addition, when therapists commit early to one theory, numerous institutions and organizations reinforce maintaining a purist approach, which reaffirms a single-school mindset (Wachtel, 1977). An early commitment to a single theory can impede the consideration of other therapeutic possibilities.

Other educators (e.g., Castonguay, 2006) contend that we can only integrate what we know well, so trainees should master one approach before they begin to practice integration. Inexperienced students may become anxious and confused by the daunting integrative goal; a single system can serve as a secure base, at least initially (Norcross & Goldfried, 2005). Neophyte therapists’ needs for closure and resolution of conflict frequently mean that they cannot value the complexities and ambiguities of tensions between theories (Orlinsky & Rønnestad, 2005; Rønnestad & Skovholt, 2012).

Surveys indicate that training directors are committed to psychotherapy integration but disagree on the routes toward it. Approximately 80–90% of directors of counseling psychology programs and internship programs agree that knowing one therapeutic model is not sufficient for the treatment of a diversity of problems and populations; instead, training in a variety of models is needed. However, their views of the optimal integrative training process differ: about one-third believe that students should be trained first to be proficient in one therapeutic model, about half believe that students should be trained minimally competent in a variety of models, and the remainder believe that students should be trained in a specific integrative model from the outset (Lampropoulos & Dixon, 2007).

Still other educators—such as the authors of this chapter—combine both positions by introducing integration at the outset but postponing intense integrative training until later in the training sequence. We believe cumulative experience supports this practice, but we freely admit that there is insufficient research on integrative training to render any definitive judgment (Hill & Knox, 2013).

What content to teach in an integrative program is yet another choice point for professional debate. We will cover this matter in more detail in the next section, but for now, we note that some educators prefer to teach singular models of therapy (e.g., psychodynamic, cognitive-behavioral, experiential), some prefer to teach particular methods or techniques independent of their theoretical heritage, and still others prefer to teach overarching common factors or change principles. The theories and their associated techniques comprise the basic building blocks of integrative psychotherapy, but there is no consensus on which combination of these foundational elements should be taught. As illustrated in the contents of this Handbook, integrative therapies still retain distinctive favorites in which theories are represented and which are largely ignored.

The recognition that, at this point, there is no single best way to teach integration brings both liberation and apprehension, which is precisely the conflict that our students and colleagues face every day. It also means that educators are continually attempting to balance the tensions between different training approaches and disparate theoretical orientations. This entails dealing with a tremendous volume of literature and bringing educators to the core in the (p. 381) ongoing debates (Gilbert & Orlans, 2011). Does instruction and practice in several theoretical approaches from the beginning create greater fluency in integration? Or is it better to start with one or two approaches, which ultimately leaves the demanding task of integration to the individual student? At what point should students be exposed to change principles or processes common to all therapies?

The responsibility for integration is an ongoing test faced by all practitioners, no matter what their training. Ultimately, mental health professionals need to be competent and comfortable with a variety of methods to face the challenges and privileges that their profession bestows.

An Ideal Training Sequence

Here we advance an integrative training sequence encompassing an interlocking sequence of experiences that are predicated on the crucial therapist-mediated determinants of psychotherapy outcome. This five-step sequence draws heavily from the consensus of several journal sections on training integrative psychotherapists (Beutler et al., 1987; Castonguay, 2000a; Journal of Psychotherapy Integration, June 2017; Norcross & Goldfried, 2005; Norcross et al., 1986; The Integrative Therapist, October 2017).

The first step entails training in fundamental relationship and communication skills, such as active listening, nonverbal communication, empathy, collaboration, positive regard, feedback, and respect for patient problems. The relationship elements that are associated with and predictive of psychotherapy success are increasingly clear (Hill, 2014; Norcross & Lambert, 2019). Acquisition of these generic interpersonal skills can follow one of the systematic models that have demonstrated significant training effects compared to controls or less specific models (see Hill & Knox, 2013, for reviews). In general, the most efficient way of maximizing learning of facilitative psychotherapy skills is to structure their acquisition involving instruction, demonstration (modeling), practice, evaluation (feedback), and more practice. These interpersonal skills are crucial to the establishment, repair, and maintenance of the therapeutic alliance.

Students would be retained in this foundation course until a predefined level of competence is achieved in these skills. Criterion-referenced situational tests, expert ratings, and demonstration experiments can be used to confirm such competence. The point is that students should not be automatically moved forward in the curriculum simply because they have completed a course on the psychotherapy relationship; they should be advanced because they have demonstrated minimal competence in facilitative interpersonal skills (Anderson et al., 2016).

The second interlocking step consists of an exploration of various systems of psychotherapy. At a minimum, the courses would examine psychoanalytic, humanistic-existential, cognitive-behavioral, interpersonal-systems, constructivist, and multicultural theories. Students would be exposed to all approaches with minimal judgment being made as to their relative contributions to truth. At the outset, multiple systems of psychotherapy would be presented critically, but within a paradigm of comparison and integration. Psychotherapy systems would be introduced as tentative and explanatory notions, varying in goals and methodology. It is possible to synthesize training in a specific theoretical model while also cultivating an integrative mindset (Sotskova & Dossett, 2017). Integrative frameworks and informed pluralism would thus be introduced at the beginning of training (Halgin, 1985b), but a formal course on integration would occur later in the sequence.

In our experience, courses and textbooks that only present “one theory a week” are inadequate for this purpose. Rather, the psychotherapy systems need to be presented and, at the end of the course, compared and integrated in a clinically meaningful manner (Prochaska & Norcross, 2018). At this point, students would be encouraged to tentatively adopt a theoretical orientation or two that proves most harmonious with their personal values and clinical preferences.

(p. 382) The third step in the training sequence entails a series of practica, accompanied by clinical supervision and sometimes coursework. Neophyte psychotherapists would be expected to become competent in the use of at least two psychotherapy systems that vary in treatment objectives and change processes. In each case, completion of the practicum would depend on specific criteria to ensure acquisition of the skills associated with a given system. Relevant psychotherapy handbooks, treatment manuals, and videotapes can outline criteria for implementing interventions.

Following satisfactory completion of these competency-based experiences, the fourth step involves the integration of disparate models and methods. Many educators believe that the sophisticated adoption of an integrative perspective occurs after learning specific therapy systems and techniques. The formal course on psychotherapy integration would provide a decisional model for selecting the methods, formats, and relationships from various therapeutic orientations to be applied in given circumstances and with given clients. Several textbooks and sample syllabi for such integrative courses are now available for psychology, psychiatry, counseling, and social work programs (e.g., www.sepiweb.org/page/teach_train). This course bears the program’s responsibility for providing “a system of analysis or a framework by which a multiplicity of theories and methods could be organized into an integrated understanding” (Reisman, 1975, p. 191).

Finally, and concomitantly, an intensive practicum experience, such as an internship or residency, with a wide variety of patients would allow early-career therapists to practice integration and to evaluate their clinical skills. Theoretical knowledge of integration is sorely incomplete without supervised experience in applying it to the real world of patients. In fact, the principal complaint of psychotherapists following graduation is inadequate clinical experience (Bhola & Raguram, 2016; Robertson, 1995).

Throughout these clinical experiences, students will be trained in deliberate practice and reflective practice. The former derives from the science of expertise and involves repeatedly practicing specific skills with expert feedback (similar to methods used in other performance activities, such as a musician, surgeon, or pilot). It shows some early promise of improving client outcomes and enhancing therapist performance (Chow et al., 2015; Rousmaniere et al., 2017). The latter refers to the examination of one’s own covert and overt experiences to enhance learning and professional development (Stedmon & Dallos, 2009). A fundamental assumption to both forms of practice is that experience alone is insufficient to facilitate improvement; rather, focused contemplation and supervised practice prove necessary. That’s what ideally transpires in supervision.

These training experiences are but the beginning steps in the development of competent integrative psychotherapists; genuine education continues far after the internship or residency. Students would be encouraged—nay, expected—to go forth to receive additional training in specialized methods and preferred populations.

“Deep structure” integration will take considerable time and probably come about only after years of clinical experience (Messer, 1992). Expert psychotherapists represent their domain on a semantically and conceptually deeper level than novices. Conceptual learning about psychotherapy integration is probably necessary to achieve deep structure integration, but it is not sufficient. For therapists to integrate at a deeper level requires that they first understand and integrate within each individual therapy and, only then, across therapies. Additional psychotherapy experience and disciplined reflection on that experience is needed to attain a mature and abiding synthesis.

Psychotherapy integration, in other words, may take two broad forms that are differentially accessible to novice versus expert therapists (Schacht, 1991). The first form, accessible to neophytes, emphasizes conceptual products that enter the educational arena as content additions to the curriculum. The second form of integration, largely limited to expert therapists, emphasizes a special mode of thinking. This form enters the educational (p. 383) arena only indirectly through accumulated clinical experiences that promote fluent performance and creative metacognitive skills.

Specific Training Models

Since the second edition of this Handbook (Norcross & Goldfried, 2005), we have secured considerably more experience and a bit more research to inform the ingredients of integrative training. In particular, we and others have learned that the training sequence and objectives are heavily influenced by the specific type of, or path toward, psychotherapy integration. Proponents of technical eclecticism, theoretical integration, assimilative integration, and common factors (see Chapter 1 of this volume for more detailed definitions) all have definite preferences in how and when the ideal training occurs.

Four Paths

Technical eclectics seek to improve our ability to select the best treatment for the person and the problem through use of multiple techniques. Eclecticism focuses on predicting for whom particular methods will work: the foundation is actuarial rather than theoretical. As such, the eclectics rely on accumulating research evidence and the needs of individual patients to make systematic treatment selections. The training emphasis is placed squarely on acquiring competence in multiple methods and formats, as opposed to pledging allegiance to theories, and pragmatically blending these methods and formats to suit the given situation.

Technical eclectics are disinclined toward grand unifying theories and more interested in a pragmatic blending of methods. They generally endorse teaching psychotherapy integration from the very beginning of training. Gradually building toward integration in mid-career is considered too tentative and theoretical. And, for some therapists, learning integration after working for years in a specific orientation may prove too difficult. Instead, the eclectic mandate is to teach multiple therapy methods and treatment selection heuristics early on so that clients receive the optimal match of treatment, format, and relationship.

Eclectics readily acknowledge the limitations associated with faculty composition and disposition. Graduate programs will range from those in which the faculty embrace disparate theories and goals to programs in which there is coordination of the training process and faculty consensus about an integrative model (Norcross & Beutler, 2000). It will take considerable time for many senior faculty to unlearn their own allegiance to a single, pure-form system of conducting (and teaching) psychotherapy. Yet, many new clinical faculty have been trained in, or at least favorably exposed to, an integrative perspective.

Theoretical integrationists blend two or more therapies in the hope that the result will be better than the constituent therapies alone. As the name implies, there is an emphasis on integrating the underlying theories of psychotherapy along with the integration of techniques from each. Some proponents highlight the need for an emergent meta-theory, more than the sum of its parts, which will bring elements from many theories into a coherent and comprehensive approach to psychotherapy. As such, the training focuses on the theoretical systems and building bridges between the chasms that separate them.

Theoretical integration proves the most ambitious and probably the most controversial. No theory, integrative or otherwise, can seamlessly combine all potential approaches, so most theoretical integrations attempt to blend or bridge two or three theories, such as psychoanalytic and cognitive. Although theoretical integration brings together certain ideas, it simultaneously rejects others, arriving at different endpoints and potentially fragments the field further (McLeod, 2013). As a result, theoretical integration is arguably the most difficult of the paths to master, with technical eclecticism considered a more pragmatic and flexible route to integration. Assimilative integrationists similarly embrace synthesis, but in a more tentative manner. The approach entails a firm grounding in one system of psychotherapy (p. 384) with a willingness to selectively incorporate (assimilate) practices and views from other systems (Messer, 2012). The imported practice is influenced by the context into which it is absorbed. As such, the training is primarily in a single system of psychotherapy with an understanding that the clinicians will gradually incorporate techniques from other systems.

The assimilative integrationists frequently argue that, in early training, students need a single theoretical system for structure, support, and direction. Trainees internalize the theory and the contributions of their supervisors. To be sure, educators may introduce the eventual goal of integration, but neophyte psychotherapists focus on a manageable amount of clinical skills and delimit their range of experiences. Otherwise, they risk being overwhelmed by the morass of choices and the hundreds of therapeutic methods. Later, students are expected to move in an integrative fashion, but from a position of single-system comfort and strength.

Such assimilation is probably an inevitable part of the development of psychotherapists. New ideas and methods are picked up, tried, and occasionally incorporated into the repertoire of any clinician. But a technique cannot stand alone and separate from the therapy within which it is practised (Messer, 2012). This approach falls within a “pluralistic tradition, which holds that one theory or model can never pre-empt or preclude an alternate organisation of the evidence” (Norcross & Goldfried, 2005, p. 2).

Those who advocate common factors or processes seek to determine the core ingredients that different therapies share in common, with the eventual goal of creating more parsimonious and efficacious treatments based on those commonalities. Psychotherapies share important similarities, notably in the curative therapeutic relationship, responsible for therapeutic outcomes (Duncan et al., 2010). These potent commonalities include establishing a positive alliance, creating positive patient expectations, mobilizing client’s resources, and helping patients acquire new skills (Wampold & Imel, 2015).

As such, the training focuses on the acquisition of pan-theoretical skills that research has found to account for much of psychotherapy success. Castonguay (2000b), for example, outlines a psychotherapy training driven by a common factors strategy. He recommends training students in “pure-form” therapies and, using general principles of change, expecting them to integrate contributions of the different orientations in their clinical work.

Other educators prefer to educate students in common change processes or principles. Eubanks and Goldfried (Chapter 4, this volume), for example, teach students five change principles that are common across orientations and are supported by outcome research: fostering the patient’s hope, positive expectations and motivation, facilitating the therapeutic alliance, increasing the patient’s awareness and insight, encouraging corrective experiences, and emphasizing ongoing reality testing. Focusing on these principles, their students have the flexibility to select a variety of techniques responsive to the client’s individual needs and preferences Prochaska and DiClemente (Chapter 8, this volume), for another example, train students in 10 processes that they believe capture the essence of patient change in psychotherapy.

Hybrid Paths

Of course, psychotherapy training is not restricted to any single path or type of integration, and most programs appear to embrace several of them concurrently. Systematic treatment selection (STS; Consoli & Beutler, Chapter 7, this volume), to take one prominent example, combines training in change principles of psychotherapy (common factors) with training in a menu of particular techniques (technical eclecticism) to implement those principles. To our knowledge, STS is the only integrative training to show in a quasi-randomized trial that its training and supervision leads to better patient outcomes among its trainees than supervision as usual (Holt, Beutler, Kimpara, et al., 2015; Stein et al., 2017).

(p. 385) Following training in core relationship skills and courses in psychotherapy systems, STS training covers eight change principles over a 10-week period when a student begins supervised psychotherapy. Training in each pan-theoretical principle begins with a lecture and video demonstration, and then the student is introduced to a cloud-based assessment procedure on that principle. As an example, patients high in reactance (resistant to being told what to do) benefit more from less directive psychotherapies, and patients low in reactance benefit more from more directive methods. Again, with video demonstrations and lectures, the student is taught the difference between high- and low-directive treatments. In the eclectic tradition, students can select which particular methods to use as long as they remain consistent with the underlying evidence-based change principle. These methods and treatments are practiced with one or more patients in the student’s caseload, while the student is supervised and given feedback to let him or her know his or her proficiency with each type of treatment. The supervisor sets goals to help each student to improve. When the student is deemed proficient by the supervisor, the student performs an intake on a new case and uses the assessment and treatment procedures for implementing that change principle.

Pluralistic training, to take another prominent exception, blends the technical eclectic (use the method that works), theoretical integrative (use a combination of theories), and common factors (use powerful pan-theoretical principles) pathways. Adopting a pluralistic approach enables students and supervisors to use a variety of theories without the need to reconcile differences (O’Hara & Schofield, 2008). Training pluralistically emphasizes the collaborative clinician–client relationship and privileges the client as an expert on his or her own life. It is postmodernist insofar as truth is seen as constructed more so than discovered: “any substantial question admits of a variety of plausible but mutually conflicting responses” (Cooper & McLeod, 2011, p. 137). Much of graduate training, especially in Europe, seems to follow the pluralistic route. Integration is considered an evolving, processual activity, as well as an implementation of specific integrative models (Oddli & McLeod, 2017).

An Irish Example

IICP College in Dublin, Ireland, operates a suite of integrative psychotherapy programs spanning 6 years that incorporates threads from theoretical integration, technical eclecticism, common factors, and assimilative integrative approaches within a pluralistic framework. The programs hold both academic validation (from the Statutory Agency, Quality and Qualifications Ireland) and professional accreditation from the Irish Association for Counselling and Psychotherapy. At the end of year 4, students are awarded an honors undergraduate degree in psychotherapy. The degree, together with a further 450 hours of supervised clinical practice, is a pathway for professional accreditation in Ireland.

Trainees develop a critical awareness of a variety of therapeutic approaches within the three pillars of education: theory, skills, and personal development. Students gain considerable knowledge and competencies through teaching and assessment strategies such as essay writing, faculty modeling, and reflecting (under supervision) on their own audio- and videotaped practice as novice therapists. Students are encouraged to be critically reflective practitioners and to evaluate the theories and clinical cases presented to and by them.

Pluralism runs throughout the suite of programs with a more in-depth focus during the 2-year master’s program. At the postgraduate stage, there is a central focus on advanced research methods, which helps students appreciate the philosophical foundations for clinical and research practice. It affords students a practical hands-on introduction to psychotherapy research and an opportunity to develop the core clinical, theoretical, and research competencies.

Students learn and reflect on many psychotherapy models as opposed to one “true” model. In the research methods modules, students encounter and engage with different (p. 386) approaches to psychotherapy research. In contrast to a monist approach, the contemporary perspectives module introduces students a multiplicity of models for working with clients, such as mindfulness therapies, neuroscience, and trauma work. The inputs from psychology, sociology, neuroscience, mindfulness, philosophy, research, and psychotherapy itself speak to the overall pluralistic nature of the training.

As in many integrative programs, IICP students learn all four routes to psychotherapy integration within a pluralistic frame. In reality, the four paths all prove variations on the integrative theme. They overlap considerably in how they educate students, with the central differences being in the timing and level of integration.

Moderating Expectations

The excitement engendered by integrative training can give rise at times to grandiose plans and overly optimistic predictions. We ourselves have been guilty of such unfettered optimism at times, and we hasten to correct any illusion that competency-based training in psychotherapy integration will be easily or instantly attained. At the risk of fostering the opposite reaction—pessimism or apathy—we will consider several reasons to moderate expectations regarding integrative prospects in training. These considerations, it should be emphasized, apply with equal cogency to conventional psychotherapy training and not uniquely to integrative training.

To begin with, explicit training in psychotherapy has a relatively brief history, and research on training for psychotherapy has a briefer history still. In early critiques of training studies (e.g., Alberts & Edelstein, 1990; Ford, 1979), reviewers discovered that the interventions were poorly described, the dependent variables were not well-validated, typical client samples were composed of undergraduates, and the skills imparted were simple and discrete. Although progress is certainly afoot (Hill & Knox, 2013), most studies on psychotherapy training have progressed little in methodological sophistication or clinical relevance. The unhappy truth is that professional reputations are rarely made in clinical training and supervision; prestige and funding are accorded to developing psychotherapies, not teaching them.

If current training programs do relatively little to ensure competence in a single psychotherapy, how can competency be ensured if we attempt to teach practitioners several psychotherapies or an integrative model?

Then there is the challenge of novelty—integrative training is unprecedented in the history of psychotherapy. During the 1980s and 1990s, when the integrative movement was emerging, educators faced the challenge of trying to formulate integrative training curricula without the benefit of learning such approaches in a formal context themselves. As Robertson (1986, p. 416) put it: “Quite frankly, many of us who are trainers teach students pretty much the way we were trained, and most of us were not trained to be eclectic therapists.” In recent years, the situation has improved as graduate and postgraduate programs have instituted more formalized integrative coursework and practica. However, most of those who teach and supervise psychotherapy integration did not have such experiences themselves.

As with psychotherapy itself, it is increasingly difficult to speak of psychotherapy training without reference to its demonstrated effectiveness. Although many descriptions of integrative training programs have appeared in the literature, empirical evaluations have not (for exceptions, see Lecompte et al., 1993; Stein et al., 2017). The same can be said for virtually all programs adhering to a single theoretical tradition, but this similarity is hardly redeeming. The competence of our graduates and, indeed, the adequacy of our clinical training are typically assumed rather than verified (Stevenson & Norcross, 1987).

Given questions about the feasibility of training graduate students to competencies in multiple systems of psychotherapy in just a few years, the need for rigorous evaluation of training in psychotherapy integration is particularly urgent. An indisputable disadvantage of multiple competences is that they necessitate longer and more comprehensive (p. 387) training than a single competency. Integrative psychotherapists, similar to bilingual children and switch hitters in baseball, may be delayed initially in the acquisition of skills or in the attainment of several proficiencies.

Even if an integrative training program is carefully implemented and thoroughly evaluated, the effects of the training would probably be complex and idiosyncratic. The findings of the Vanderbilt II project, one of the most carefully designed psychotherapy training ventures, bear this out (Henry & Strupp, 1991). This project was designed to investigate the manner in which specialized training might improve the therapeutic process and outcome of time-limited dynamic psychotherapy. The effects of training were mixed, involving potentially positive and negative effects. No linear relationship was found between technical adherence and psychotherapy outcome, although the training was successful in imparting adherence to a manualized form of therapy. The training altered some specific and general operations associated with improving the quality of dynamic therapy, but there was evidence that some elements not directly related to the imparted techniques were also improved after training.

The criteria for effective training are multitudinous and individualized, no less so than possible indications of effective psychotherapy. The introduction of an integrative perspective does nothing to reduce the subtle and complex effects of training and probably enlarges the task of ensuring competence and measuring training outcome. We are aficionados of integrative training but realistic about the probable challenges.

Personal Therapy and Research Training

Contributors to earlier editions of this Handbook addressed questions concerning the centrality of personal therapy and the necessity of research training in the preparation of integrative therapists. In this section, we summarize their responses on these contentious matters and add our own views on the basis of 60-plus collective years of psychotherapy training.

With respect to personal therapy, the contributors agreed that its importance as a prerequisite for clinical work depends on the student’s level of psychological functioning and the trainer’s own experience with personal therapy. If a student’s personal problems interfere with the successful implementation of psychotherapy, then all contributors concurred that it is necessary to remedy the situation, probably including personal therapy.

In the United Kingdom, a certain number of hours of personal psychotherapy or personal development activities is required for professional certification. This is rarely the case for graduate mental health programs in the United States outside of psychoanalytic institutes.

We also sensed a marked hesitancy to endorse mandatory personal psychotherapy for all students, arising in part from two cardinal integrative principles. First, the research evidence is inconclusive on the ability of personal therapy to enhance clinical effectiveness (Geller, Norcross, & Orlinsky, 2005), and committed integrative clinicians are reluctant to oblige students to an activity with unproven efficacy. Second, the integrative maxim of matching the treatment to the unique needs of the student/client would be violated by insisting on a single modality for diverse students. Instead, a variety of individually tailored personal development and other life-enhancing activities are endorsed.

In both this Handbook and in research studies, the valence accorded to personal therapy varies as a function of whether or not the psychotherapist has undergone personal treatment him- or herself. In one representative study (Bike, Norcross, & Schatz, 2009), only 5% of mental health professionals who received personal therapy thought it was unimportant as a prerequisite for clinical practice compared to 57% of those who had not received it. Since approximately 85% have received personal treatment on at least one occasion (Geller et al., 2005), the vast majority of psychotherapists whole heartedly endorse it for both training purposes and continuing development.

(p. 388) What might be the benefits of personal treatment for the typical psychotherapist in general and the integrative therapist in particular? The literature contains at least six recurring commonalities on how the therapist’s therapy may improve his or her clinical work:

  • By improving the emotional and mental functioning of the psychotherapist: It makes the clinician’s life less neurotic and more gratifying in a profession where one’s health is an indispensable foundation.

  • By providing therapist-patients with a more complete understanding of themselves: The therapists will thereby conduct treatment with clearer perceptions and fewer contaminated reactions.

  • By alleviating the emotional stresses and burdens inherent in this “impossible profession”: It enables practitioners to deal more successfully with the special problems imposed by the craft.

  • By serving as a profound socialization experience: Personal therapy can help establish a sense of conviction about the validity of psychotherapy, demonstrating its transformational power in our own lives and facilitating the internalization of the healer role.

  • By placing therapists in the role of the client: It thus sensitizes us to the interpersonal reactions and needs of our own clients and increases respect for our patients’ struggles.

  • By providing a first-hand, intensive opportunity to observe clinical methods: The therapist’s therapist models interpersonal and technical skills.

In particular, clinicians with integrative leanings will take away several profound lessons about their future discipline. To wit: they will probably discern that psychotherapy is rarely “pure-form” in practice or outcome, that good practitioners routinely incorporate a variety of methods traditionally associated with diverse systems, and that the therapeutic relationship accounts for as much of treatment outcome as specific techniques (Geller et al., 2005).

To Yalom (2002), personal psychotherapy is, by far, the most important part of psychotherapy training. He reviews his own odyssey of personal therapy during a 45-year career, emphasizing the diversity of theoretical orientations he sought. He concludes (pp. 41–42):

It is important for the young therapist to avoid sectarianism and to gain an appreciation of the strengths of all the varying therapeutic approaches. Though students may have to sacrifice the certainty that accompanies orthodoxy, they obtain something quite precious—a greater appreciation of the complexity and uncertainty underlying the therapeutic enterprise.

Yalom is hardly alone in his experience. Across studies and across countries, psychotherapists rate their personal therapy or analysis as the second most important influence on their professional development—behind only clinical experience (Orlinsky, Botermans, & Rønnestad, 2001). Given this and the overwhelmingly positive self-reported outcomes of therapists’ personal therapy (Orlinsky & Norcross, 2005), we enthusiastically recommend (but not require) personal treatment for our trainees. A “good-enough” therapist (or multiple therapists) is necessary for the undertaking, of course. Personal therapy is one component of ongoing development and continuing education.

With respect to research training, the consensus is that it is a desirable, but not necessary, ingredient for an effective integrative therapist. None of the contributors to the earlier edition of this Handbook insisted on its inclusion in clinical curricula, but several advocated a critical and searching perspective to the psychotherapy enterprise. A respect for research assists one to perceive relations between therapeutic strategies and subsequent changes and to be a thinking therapist. Lazarus (1992) placed paramount importance on the multimodal therapist being trained to understand the workings of science, to appreciate the value of inquiry, and thus to become a critical consumer of research—not necessarily a producer of research. We concur wholeheartedly.

(p. 389) A scientific orientation, not to be equated with laboratory research, conveys a mode of thought that transcends the particular brand of therapy being conducted. It teaches how to be inquisitive and skeptical, how to gather data rather than opinion, how to analyze those data and draw inferences from them. These are skills that help organize clinical knowledge and help students select among the morass of competing therapy claims (Meltzoff, 1984).

Many integrative therapists credit their research training for fostering the thinking skills and methodological pluralism that enabled them to proceed toward integration (Goldfried, 2001). Good practice, like good research, depends on systematic decision-making, reasoning from sufficient data, tolerance for ambiguity, and avoidance of premature assumptions (Faust, 1986; Giller & Strauss, 1984). Whether or not clinicians ever elect to produce original research, they must learn to respect the process of knowledge acquisition, to acquire a way of thinking about therapeutic phenomena, and to critically read the relevant literature. In short, research training prepares us to question and evaluate the way psychotherapy (and psychotherapy training) is conducted.

Integrative Supervision

As beginners, many psychotherapists seek out a single theory by which they can define their approach, manage their anxiety, and solidify their identity. Beginners can feel a naïve security in adhering to the methods of a single, pure-form orientation; however, such reassurance is usually short-lived as they come to realize the clinical limitations of any singular approach. In recent years, the lure of evidence-based treatments has led many beginners down a path of simplistic hope that manualized treatments supported by randomized controlled trials (RCTs) would have all the answers. In time, of course, those who jumped on the evidence-based bandwagon quickly realized the limitations of manualized therapies developed within laboratory settings using research volunteers. Decades of psychotherapy research have clearly documented that patient factors and the therapeutic relationship prove most important to psychotherapy success (Norcross & Lambert, 2019; Wampold & Imel, 2015). If we manualize anything, it should be flexibility and effectiveness (Beutler, 1999).

Integrative supervisors find ways to help their supervisees feel comfortable foregoing the pursuit of proficiency in a single, pure-form system and instead working toward the development of a comprehensive, multifaceted system. The following sections cover seven principles of supervising integrative psychotherapy, culled from both the research literature and our collective experience. These principles are probably distinctive of, but certainly not unique to, integrative supervision (Norcross & Popple, 2017).

Understand Trainees’ Biases and Anxieties

The word has spread to educators who have not been involved in the integration movement about the wisdom and the pragmatics of integrative training. Experienced faculty increasingly appreciate integrative training, but they may be surprised to encounter some resistance in their students about such prospects. Even in the earliest stages of graduate training, students often come with theoretical biases that limit their openness to integration. This situation may be compounded by the understandable anxiety experienced by novices who are overwhelmed by the complexity of psychotherapy and who, therefore, yearn for a simple, albeit narrow, theoretical model.

It can be both surprising and disconcerting for a supervisor to encounter the supervisee who professes adherence to a single-system model and is resistant to becoming more broadly trained. In these situations, it may not be a matter of the trainee holding on to a base of security, but rather a case of a refusal to consider alternative methods. Some trainees apparently feel no need to become informed about other models and methods; they evidence complacency with their treasured singular psychotherapy.

In an early study, Heide and Rosenbaum (1988) surveyed 14 psychotherapists regarding (p. 390) their experiences in using single versus combined theoretical models in psychotherapy; their results nicely anticipate our trainee’s frequent concerns. When using a single orientation, psychotherapists reported being significantly more self-controlled, conventional, precise, and reserved. When using an integrative model, they said they were more imaginative, adventuresome, spontaneous, and changeable. That’s also our take on integrative supervision: more imaginative, adventuresome, and changeable—and more effective.

But if the clash of theoretical persuasions rings of adventure, it is also the sound of occasional disequilibrium. We will phrase five of these sources of disequilibrium in the way we often hear them: as anxious threats to therapeutic identity and competence (Norcross, 1990):

  • “But which of these many paths shall I take at any one point?” Should the student promote action or explore mental content, challenge or understand irrational cognitions, work on actual or projected relationships, empathize or redirect during a session?

  • “It is just too damn hard!” Students and supervisors alike complain of additional work and of increased mental effort.

  • “Oh, I don’t like doing this type of psychotherapy!” Therapists are not as personally attached or psychologically comfortable with some therapies as with other therapies, even controlling for competence in them.

  • “I am becoming a jack of all trades, master of none.” This concerns the inherent conflict between depth and breadth.

  • “I am opening myself up here to chaos! Who knows what can happen?” The ambiguity and uncertainty of integrative practice can be emotionally taxing even as it is exciting and spontaneous.

Integrative practice requires a cost-benefit analysis—the intellectual challenge versus the internal conflicts, the gratifying openness versus the anxious ambiguity. That’s also the reasoning behind our insistence that integrative supervision be reserved for trainees already exposed to a range of theories and techniques, with at least 2 years of clinical experience, and nascent competence in at least one system of therapy. The integrative journey is arduous; it is unrealistic to expect beginners to competently plunge into integrative work early in their development.

As is the case with therapists and their patients, supervisors will find it easier to reach beginning trainees when they approach their work with an understanding of the stages of therapist development (Halgin, 1988). In one widely accepted stage theory (McNeil & Stoltenberg, 2016), supervisees progress through several stages: stagnation, confusion, and integration. During the stagnation stage, the beginner is deceived by the illusion of simplicity in clinical work. The confusion stage follows, during which the trainee realizes that something is amiss and solutions seem elusive. It is only later in training that the supervisee attains a sense of integration during which flexibility, security, and understanding emerge. Thus, the supervisor who impatiently expects the trainee to have attained integration early in training is likely to engender dismay, frustration, and diminished self-esteem in the trainee.

Research suggests that supervisory styles are differentially effective for trainees at varying levels of experience. In the initial level, beginning students are highly motivated and highly dependent on their supervisors, while in the latter stage, advanced students seek more sophisticated formulations and are more attuned to individual differences among clients. One can immediately grasp that integrative supervision is oriented toward, and indicated for, more advanced graduate students, as we have previously noted.

In this regard, supervisors can often lose touch with the challenging nature of learning integration. Some students, when first introduced to multitheoretical approaches, are frequently puzzled by the mechanics of technique shifts and are dismayed that their own attempts might prove to be awkward and disruptive (Wachtel, 1991). Beginners are typically overwhelmed by the array of possibilities. For example, a novice (p. 391) may be perplexed by whether an interpretation or a directive intervention is advisable at a given point in a session; confronted with such an imposing choice, paralysis may set in. When apprised of such a moment in the therapy, an insensitive supervisor may make a difficult situation even worse for the trainee who is already feeling miserably insecure. A comment that reflects impatience or surprise about the trainee’s handling of the therapy is likely to intensify the student’s anxiety instead of fostering some risk-taking, which is an indispensable part of the learning process. Experience provides clinicians with a special sense of what should be done next in the therapy; this reflects a complex, recursive decision-making process that is informed by dozens, perhaps hundreds, of bits of data related to client, therapist, and context considerations.

Integrate Supervision Methods Aligned with Multiple Theories

Integrative supervision is necessarily eclectic in therapeutic content and pedagogical method. The supervisor’s work is determined both by the needs of the clients being discussed and the needs of the trainee, all of whom will call for different strokes. Thus, one supervision session might entail a directive/educative approach in which the trainee learns specific techniques for the treatment of a focused clinical problem, whereas another session with the same trainee might involve a predominantly exploratory approach, due either to the historical roots of the patient’s conflicts or because of the therapist’s countertransference struggles (Halgin & Murphy, 1995). We adhere to the integrative maxim: It depends.

Methodologically, integrative supervision entails a wide variety of techniques and stances associated with diverse psychotherapy systems. Structure follows function, but is not limited to it. As the situation dictates, supervision might involve didactic presentations, reading assignments, open-ended discussions, personal modeling, experiential activities, video review, case examples, and mini-case conferences. Nothing is a priori off the table (except unethical practices).

Importantly, we have moved away from reliance on supervisee’s self-reports and “reconstructed tales of therapy” (Norcross, 1988) to the use of videotape and live observation through one-way mirrors. This progression has substantially increased the accuracy and completeness of information about what has ensued in therapy and thereby has enhanced supervision. Despite its intrusive nature, videotaping provides the best compromise and has achieved a consensus as the best method for conducting supervision. The empirical research tends to support review of videotaped therapy sessions, supervision guidelines encourage it, and several jurisdictions now mandate a minimum number of observations (videotaped or live) of supervisee’s performance. Supervisees’ evaluations (Allen, Szollos, & Williams, 1986; Nelson, 1978) and empirical research (e.g., Ellis, 2010) indicate that direct observation and videotapes are the preferred supervisory methods.

Tailor Supervision to the Individual Supervisee

One of the most appealing (and effective) features of integrative psychotherapy is that an individualized treatment plan can be tailored to each client. A similar principle holds true for integrative supervision: an individualized supervision plan can be formulated for each trainee on the basis of his or her style, stage, preferences, experience, complexity, and other considerations. Just as we ask our students to behave integratively and prescriptively in their clinical work, so, too, should we match our supervision to their unique needs and clinical strategies.

Integrative supervision will obviously take into account a number of trainee variables. Supervisors will assess personality characteristics, such as introversion versus extroversion or need for challenge versus need for support, and develop supervisory strategies that take these characteristics into account (Lampropoulos, 2002) to help the supervisee develop and discover her own voice. Although we cannot specify a priori all the possible supervisee (p. 392) variables and permutations of those variables, our supervision experience and the research literature (e.g., Holloway & Wampold, 1986; McNeill & Stoltenberg, 2016; Norcross & Halgin, 1997) suggest that we can improve supervision outcomes by tailoring it to several trainee characteristics: supervisee preferences, developmental stage, therapy approach, cognitive style/reactance level, cultural identities, and clinical setting. We briefly consider three of these here.

Regarding preferences, we try to elicit supervisees’ expressed desires and genuine needs. And as with patients, we seriously consider supervisees’ expressed desires but are not bound to them. They form the initial basis for our discussions and eventual supervision contract. Tactful questioning and sensitive inquiry can shed light on favored cognitive and interpersonal styles. How do you best tolerate feedback from others? What was your worst supervision experience like? How do you learn most effectively about psychotherapy? What sort of supervisory relationship works well for you? What do you hope to accomplish from our supervision sessions?

Regarding reactance level, supervisees will vary in their tendency to respond oppositionally to external direction and perceived authority. Like the high-reactant client who is resistant to therapist directiveness, the high-reactant supervisee is likely to resist a directive supervisor. This student is likely to do best with a reflective and evocative supervisor who focuses on the student’s experience and is less direct in recommending technical procedures (Tracey, Ellickson, & Sherry, 1989). This student is contrasted to the low-reactant student who is likely to respond well to supervisor directives. How directive should a supervisor be? It depends. It depends on the supervisee’s preferences, cognitive style, reactance level, and cultural identity.

Regarding cultural identities, much in the way that research has demonstrated that psychological services are enhanced by fitting them to the client’s culture (Bernal & Rodriguez, 2012), supervision is improved by adapting it to the supervisee’s cultures. We respectfully ask supervisees which of their cultural identities—and the intersection of those multiple identities—are instrumental to their sense of self and their work in supervision (Inman & Kreider, 2013). By culture, we refer to all salient dimensions of identity, such as chronological age, disability status, race and ethnicity, sexual orientation, gender, religion, and indigenous heritage.

We agree that “all supervision is multicultural” (Chopra, 2013) and try to explicitly adapt integrative supervision to those cultural identities nominated as salient by the trainee. Supervisees who feel their supervisors are culturally responsive experience a more productive supervision (Burkard et al., 2006).

Responsively attending to these and other supervisee characteristics enables integrative supervisors to systematically and effectively personalize the supervision. The trick is to know which of these supervisee features are relevant in any given moment and which others are not of immediate import. The second consideration is not to artificially force supervisees into any of these cookie cutter molds; ongoing needs assessments and candid discussions will point to those that will fit the unique supervisee–supervisor dyad.

Fit Psychotherapy to the Individual Patient

In parallel fashion to their own supervision experience, supervisees are asked to fit psychotherapy to their individual patient and unique context. How they do so largely depends on the integrative therapy being conducted and supervised, but, for the sake of concrete illustration, here we discuss adapting or fitting to the patient’s transdiagnostic characteristics from the perspective of systematic treatment selection (Consoli & Beutler, Chapter 7, this volume) and transtheoretical model (Prochaska & DiClemente, Chapter 8, this volume).

In this tradition, integrative supervisors assist their trainees in assessing diagnostic and especially transdiagnostic patient characteristics at the onset of psychotherapy. It is, according to Sir William Osler (1906; the father of modern (p. 393) medicine), “much more important to know what sort of a patient has a disease than what sort of disease a patient has.” At least seven robust patient features suggest a particular treatment and relational tack as judged by meta-analyses (Norcross & Wampold, 2019): primary diagnosis, treatment goal, reactance level, stage of change, coping style, culture, and preferences. In our experience, a 1-year (50-session) course of individual supervision usually manages to cover three or four of these and assists supervisees’ in acquiring comfort and competence in assessing them in routine practice. The supervisor’s task, then, is to instruct, coach, and practice efficient means to accurately assess these patient dimensions most relevant to the case at hand and then adapt them in session.

All told, these responsive matches or treatment adaptations prove far more powerful than the match of Treatment Method A to Disorder Z. The typical effect sizes for customizing to these transdiagnostic features are in the .20 to .80 range (Norcross & Wampold, 2019), whereas the differential effects of a particular treatment method to a particular disorder fall between 0 (the equivalent outcomes of the Dodo bird) and at best .20 (Wampold & Imel, 2015).

That research evidence is strong and compelling, but what has not been empirically known was whether integrative psychotherapy can be learned through integrative supervision and, thereby, produce increased benefits for patients. A recent study addressed this issue question directly for one form of integrative supervision: STS.

The controlled study used a matched clinical trial design with quasi-random assignment of doctoral-level students to supervisors (Holt et al., 2015; Stein et al., 2017). The student therapists received supervision as usual (SAU) or supervision by STS-trained supervisors (SAS). The matching principles were those that had earned strong outcome effect sizes in meta-analytic reviews (Norcross & Wampold, 2019; Castonguay, Constantino, & Beutler, 2019), as reviewed earlier in these pages, such as adapting therapy to patient reactance level, coping style, preferences, and stages of change. The patients suffered from depressive, anxiety, and personality disorders, averaging within the moderate range of severity. Socioeconomic characteristics of the patients tended toward low income and marginal employment.

Student therapists who received the integrative STS supervision produced enhanced outcomes over those achieved by students receiving supervision as usual. At the end of treatment, the pretest/posttest effect size (d) of patients seeing SAU trainees was a respectable .72. However, the effect size achieved by the SAS group was a substantially larger (d) 1.37, with 81% of the patients in this group returning to “normal” functioning based on final outcome. Thus, STS supervision produced increased patient benefit over typical supervision.

These impressive results from a single setting require replication, of course. At the same time, these results parallel the increased psychotherapy benefits found for fitting therapy to the patient, as reviewed earlier. To our knowledge, this is one of the first controlled studies to show differential patient improvement for trainees receiving a particular form of supervision—integrative supervision.

Collect Formal Feedback from Supervisees and their Patients

In integrative supervision, we strongly urge—some would say “require”—trainees to monitor the progress and evaluate the outcome of the therapy they render. This process occurs formatively (during therapy) and summatively (posttherapy). In the former, we frequently use one of the dozen or so feedback monitoring systems (December 2015 issue of Psychotherapy). We typically use one of three feedback systems: The free Session Rating Scale (Miller, Duncan, et al., 2003) containing four items evaluating the quality of the relationship, goals and topics, approach/method, and overall satisfaction; Lambert’s (2015, www.oqmeasures.com/) computerized Outcome Questionnaire containing 30 or 45 items; or the InnerLife STS (Systematic Treatment Selection), a 100+ item, cloud-based assessment of patient problem areas, patient transdiagnostic characteristics, (p. 394) and treatment recommendations. There are many measures for collecting routine feedback from patients, but we favor those that assess both goal attainment and relationship satisfaction.

Sometimes supervisees elect to experiment with one of the other feedback methods. If more aligned with the therapy itself or supervisee preferences, the supervisee will hold an explicit discussion with the client about the quality of their relationship, goal attainment, the approach, what is working, and what can be improved.

The important point is to explicitly collect and process client feedback in session. Meta-analyses show that doing so leads to modest increases in outcome for all patients and large effects for patients at risk for dropout or deterioration (Lambert, Whipple, & Kleinstäuber, 2019). Therapists who specifically and respectfully inquire about their client’s perceptions of therapy and the relationship frequently enhance the alliance and prevent premature termination.

In a parallel process, we systematically collect formal feedback from our supervisees about the utility and fit of integrative supervision. Many of our colleagues express surprise that we ask formally, but the process is not so different from collecting feedback from our patients in session, from our students in class, and from our peers in scholarship and academia.

This is particularly useful when supervisees are collecting feedback from their clients and when students have experienced negative experiences with clinical supervision. Most practitioners report at least one unsatisfactory supervision—one in which the theory, the technique, or the style of supervision was discordant with their needs (Ellis, 2006; Gray et al., 2001; Nelson & Friedlander, 2001). We are convinced that such discordant supervision relationships suffer from (1) inadequate explication of supervision expectations and goals at the outset and (2) insufficient evaluation of the supervision throughout.

A variety of supervision and alliance measures are available for this purpose. To focus the process for supervisees and to reduce their anxiety, we favor structured ratings and written forms. Two of our favorites are the Supervisory Alliance Inventory (SWAI) and the Leeds Alliance in Supervision Scale (Wainwright, 2010). Having specific content and behavioral anchors helps launch as candid as possible discussions of students’ feelings about the supervision. In reality, the supervisor’s powerful position makes it difficult for supervisees to share candid feedback with the supervisor, but, with time and genuine commitment that the “data are always friendly,” frank evaluations do transpire. The numerical rankings are followed by open conversation about what’s working, what’s not, and what can be improved in supervision.

Model the Pragmatic Flexibility of Integration

Although modeling has been shown to be an effective procedure for teaching complex behaviors, it is used surprisingly little in supervising psychotherapy. When one reflects on it, this is a rather remarkable situation: Can one imagine surgeons, musicians, or teachers not observing the very skills they are expected to acquire? Most educators use consultant techniques to pass on knowledge about the methods of psychotherapy; the methods rely more on declarative knowledge than procedural knowledge.

Supervisors can reliably model the intellectual curiosity, pragmatic flexibility, informed pluralism, and their own mistakes central to psychotherapy success as well as to psychotherapy integration itself. Trainees fruitfully observe the work of clinical supervisors and watch videotaped segments of expert clinicians. Trainees frequently benefit by reading about how seasoned therapists themselves have struggled in their early attempts to develop an integrated approach to therapy (Goldfried, 2001). Supervisors can insure that therapists-in-training spend many hours behind the one-way mirror and the videotape/DVD screen, not just in passively watching, but also in interactive coding, responding, and anticipating the next move (Vaillant, 1997).

Sharing our clinical work with our students initiates a magnificent dialogue in which the (p. 395) supervisor becomes vulnerable. Such vulnerability tends to beget a more trusting, mutual, and open relationship. Supervision can focus on the difficulties encountered by the therapist/supervisor, and the student can develop a greater appreciation of what transpires within the integrative therapy session.

Rather than discuss the mistakes they have committed, most supervisors in our experience are inclined to report the successes they have achieved, thus communicating an inflated sense of competence and self-assurance. By contrast, we prefer to disclose the anxieties and mistakes with which we contend in clinical work. Sometimes we speak openly of the “dumb-ass” comment or missed reflection that characterized a recent session. We all struggle.

In integrative supervision, then, the importance of modeling informed pluralism and synthetic thinking cannot be overemphasized. Not unlike our children, our students learn to emulate what we do more closely than what we say (Beutler et al., 1987). But, too often, supervisors teach integration in the form of value statements instead of value actions. Resist the universal temptation to primarily critique others’ behavior rather than risking exposure and vulnerability oneself.

Provide a Systematic Model of Treatment Selection

A systematic model determines in large part whether integrative supervision is experienced as intelligible or bewildering. Supervision within a coherent framework is associated with a higher quality experience (Allen et al., 2000); conversely, less valued integrative supervisors fail to ground their clinical interventions within larger conceptual perspectives. These unsystematic integrative supervisors may lack the “big picture”—an encompassing integrative structure that organizes the case formulation and prioritizes clinical intervention. That is, be integrative, not syncretic.

The task of integrating the diverse systems of psychotherapy cannot be left entirely to the trainee (Hollanders, 1999). Many programs and supervisors advertise themselves as integrative, offering a nonpartisan approach that appeals to students. But what it frequently means is that the students are taught by faculty of different orientations, leaving students to try to integrate the systems on their own, or, the students are supervised by faculty who respect all systems but have no systematic way of synthesizing, sequencing, or selecting among them for a given case (Hinshelwood, 1985).

In the midst of conducting psychotherapy, many supervisees will desire immediate and concrete guidance on the “right” treatment for their patients. In the midst of conducting supervision, a supervisor will want to address the student’s immediate need but also provide a more general treatment selection heuristic for future patients. The most frequent integrative models used in this regard appear to be multimodal therapy, the common factors approach, the transtheoretical (stages of change) model, cognitive-interpersonal therapy, and STS, according to directors of graduate programs (Lampropoulos & Dixon, 2007). The inescapable take-home is that supervisors need to offer systematic and evidence-based models.

These integrative models specify the basis for treatment selection and guide the supervisor in enabling supervisees to determine the treatments and relationships of choice. Decisional models are provided for selecting the technical procedures and relationship stances from various therapeutic orientations to be applied in given circumstances and with given clients. All told, integrative models provide the coherence and guidance by which a multiplicity of theories and methods can be organized into an integrated understanding.

The integrative frame embraces both/and instead of either/or. The culture wars of psychotherapy have pitted the therapy relationship against the treatment method or the idiographic against the nomothetic. It is easy for trainees to choose sides, ignore disconfirming research, and lose sight of the superordinate commitment to patient benefit. The incontrovertible but oft-neglected truth about psychotherapy is that it is, at once, a relationship and a method. Integrative supervision fruitfully crafts the best of each for the supervisee so that the supervisee (p. 396) may craft the best relationship stance and technical methods for each client. Similarly, we aim to blend the idiographic and the nomothetic, the particular and the general. Many specious dualities, thankfully, fade away in integrative supervision. The clinical phenomena become fuller, richer, more verdant—and more consequential for those receiving our services.

Additional Considerations

Clinical supervision is generally rated the second most important contribution to one’s professional development, immediately behind direct experience working with patients (e.g., Henry, Sims, & Spray, 1971; Orlinsky & Rønnestad, 2005). Far more than courses and books and theories, hands-on supervision of actual clients constitutes the learning foundation.

Despite decades of investigating (and debating) the effectiveness of clinical supervision, there is no controlled research to identify precisely what supervisor behaviors substantially improve the treatment outcomes of the supervisee. The extant research has largely addressed the effects of supervision not on patient benefit but on satisfaction with supervision, the supervisory alliance, and supervisee self-ratings (Freitas, 2002; Milne et al., 2008). In attempting to bridge the science and practice of clinical supervision across 28 years of research, Ellis (2010, p. 110) concedes that “it is a bridge under construction.”

Instead, what we have from the large body of less than methodologically rigorous research is a finite list of best educational practices or principles on conducting supervision. The hundreds of research reports, as distilled by numerous reviewers (e.g., American Psychological Association, 2015; Bernard & Goodyear, 2014; Ellis, 2010; Milne et al., 2008), boil down to the following (Norcross & Popple, 2017):

  • cultivating a warm, trusting supervisory alliance

  • attending to alliance ruptures and managing countertransference

  • using informed consent and a written contract (goal setting)

  • observing what supervisees actually do in session

  • focusing on supervisee competencies and attaining minimal levels of those competencies

  • providing plentiful formative feedback and occasional summative feedback

  • modeling or demonstrating skills to be learned

  • teaching technical, relational, and conceptual skills to supervisees

  • monitoring the progress of supervisees’ patients

  • maintaining proper boundaries and modeling ethical conduct

  • documenting what transpires in supervision (and any deficits in supervisees)

  • attending to the cultural identities of all participants in the supervisory triad

  • individualizing supervision to the singular supervisee and particular context.

Of particular import: none of these research-supported practices or principles hails from a single theoretical tradition. All can be employed by supervisors of all theoretical models. These are robust pantheoretical or common factors (Watkins, 2017). Perhaps we are biased, but we characterize the cumulative results of the research as unequivocally supporting integrative supervision!

The Organizational Context of Integrative Training

The curricular and supervision models portrayed so far represent a growing consensus on the outlines of effective integrative training. In our judgment, the training need at the present time is not so much for further conceptual refinement as for progress in institutions adopting such integrative training. In other words, the more pressing need is less curricular than systemic.

This conclusion has led us (Andrews, Norcross, & Halgin, 1992) and others to contemplate the necessary systemic change processes—how innovations are adopted in (p. 397) organizations of higher education. How can so-called disruptive innovations (Christensen et al., 2000) advance integrative training? This approach represents a different stream of thinking, one that complements the conceptual models described herein. Our objective in this section is to outline several principles of organizational change that must occur to implement an integrative program.

In much of the literature on psychotherapy integration, nonintegrative programs are portrayed as showing rigidity in the curriculum, in those who administer it (faculty), and in those who consume it (students). Programs that teach either one orientation exclusively or a multiplicity of competing orientations are criticized as forcing students into premature closure at the risk of otherwise seeming to be a “wishy-washy” eclectic. It is argued that such programs enforce indoctrination and do not teach optimal client–therapy matching.

One difficulty with this account is that it has a judgmental flavor, as evidenced by the use of words like rigid to characterize the opponents of integration. When translated into interpersonal messages, such characterizations are likely to produce an antagonistic, win–lose struggle, in which the integrative “good guys” try to take over from the separatist “bad guys.” This is hardly likely to promote a welcoming attitude toward integration on the part of the “opposition!”

Moreover, one of the first principles of organizational change is to listen to one’s opponents respectfully and seriously; they probably have some truth on their side, and important considerations may emerge from a dialogue among those with contrasting views. Even when the obstacles to integration consist largely of rigidity on the part of current faculty and students, we must work with them; we are not likely, except in unusual circumstances, to select a body of faculty de novo. It is, of course, possible to select students or interns according to explicitly integrative criteria (see Lane et al., 1989, for an example), but this is only likely to happen once the faculty themselves adopt integrative principles.

Those who study social change in higher education emphasize the decentralization of power in a variety of overlapping sites. Rather than a simple “line” or hierarchical authority structure, power and decision-making are localized in many settings: the formal administrative structures involving deans and presidents, the faculty senate and its curriculum approval committees, the department chair, and the individual faculty members who, within certain limits, decide on what is to be taught in their courses. These factors make it even more imperative that we draw on a variety of change strategies in promulgating integrative training.

In his classic monograph entitled Strategies for Change, Lindquist (1978) reported the results of case studies involving curricular and institutional change on various college and university campuses. He distilled four models of influence processes that, he concludes, help to delineate the channels through which an innovation becomes accepted and stabilized. Innovation—integrative training, in the current case—is best introduced through a combination of the four change processes. The (1) rational idea is effectively stated, (2) spread by means of informal social networks, (3) linked to solutions by means of the problem-solving model, and (4) finally ratified by the political process. All four models hold, in varying degrees, depending on the situation and people involved. Therefore, an effective change agent will orchestrate all four of the change processes in a flexible way if he or she is to be fully effective.

Often at conferences dealing with psychotherapy integration, complaints are voiced of resistance at one’s home institution to the introduction of integrative ideas; indeed, in some settings, the member of Society for the Exploration of Psychotherapy Integration (SEPI) may be the only proponent of such ideas. One reason for this frustration may be that we tend to take the rational model or one of the three other models as our sole view of change processes, thereby missing the opportunity to exert influence within a combination of models. Integrative ideas are best shared and implemented by a sage synthesis of rational information, social network, problem-solving, and politics.

(p. 398) Future Directions

In the future, formal training of mental health professionals will assuredly continue using brand-name systems of psychotherapy but increasingly within a comparative and integrative frame. Students will still learn the major theories of psychotherapy but with knowledge of their respective limitations, with respect for the research evidence, and with appreciation for integration. We also expect increased training in integrative psychotherapies, including those featured in this Handbook, many of which prove the most popular for training purposes (Lampropoulos & Dixon, 2007).

Theoretical pluralism and psychotherapy integration are here to stay in training mental health professionals. Although the particular objectives and sequences will invariably differ across programs, the vast majority of training programs profess a pro-integration position. Training directors indicate that they are committed to providing their students with significant exposure to several different treatment approaches. And, in 80–90% of programs, the attitudes of professors and students alike are positive toward integration (Goldner-deBeer, 1999; Lampropoulos & Dixon, 2007).

In tech speak, most integrative training to date has been in the “sandbox”—untested practices, outright experimentation, and learning from our trials and errors. The bar has now been raised to mainstream development, certification, and competence. In the future, the field expects production of competent practitioners and research-supported training.

Psychotherapy integration is both a product and a process. As a product, integration will be increasingly disseminated through books, videotapes, courses, seminars, curricula, workshops, conferences, supervision, postdoctoral programs, and institutional changes. Our hope is that educators will develop and deliver integrative products that are more pluralistic and effective than traditional, single-theory treatments.

Our more fervent hope is that, as a process, psychotherapy integration will be disseminated in training methods and models consistent with the openness of integration itself (Cooper & McLeod, 2011; Norcross, 2011). Integration, by its very nature, will be a continuing process rather than a final destination. The intention of integrative training is not necessarily to produce card-carrying, flag-waving “integrative” or “eclectic” psychotherapists. This scenario would replace enforced conversion to a single orientation with enforced conversion to an integrative orientation, a change that may be more pluralistic and liberating in content but certainly not in process. Instead, our goal is to educate therapists to think and, perhaps, to behave integratively—openly, synthetically, but critically—in their clinical pursuits. Our aim is to prepare students to develop, if they possess the motivation and ability, into knowledgeable integrative therapists.

We join legions of others in predicting that psychotherapy training will broaden beyond classic mental disorders in specific disciplines to health behaviors in an interdisciplinary or interprofessonal healthcare. The more comprehensive repertoire and flexible style of integrative therapists prepare them to lead in treating behavioral components of chronic diseases, such as smoking, alcohol abuse, unhealthy eating, and inadequate exercise that account for half of all deaths (Mokdad et al., 2004). Behavioral health services are emerging as part of the overall healthcare system, not apart from it. And integrative therapists can be right in the middle of it, if training keeps apace.

Psychotherapy training, we predict, will become more specific and modular, as contrasted with grand theories. A module in education is a unit of knowledge or skill that is virtually self-contained; a modular approach builds skills and knowledge in discrete, largely independent units. Psychotherapy students will be increasingly trained in responding to specific, transdiagnostic patient challenges, such as responding therapeutically to an alliance rupture, an oppositional patient, someone in a particular stage of change, and the like. The responsive decision-making may be expressed in a series of “when . . . then” statements (Norcross & Wampold, 2019; Westra & Constatino, Chapter 13): When the client presents with this (p. 399) (feature), then consider doing this; when there is a rupture in the alliance, then consider doing these things. Balancing effectiveness with responsiveness, the modular approach to integrative training has shown promising results across theoretical boundaries, including with child clients (Chorpita et al., 2015) and for personality disorders (Livesley et al., 2015).

In all of training, competency has emerged as a central thrust. In two recent Delphi polls on the future of psychotherapy (Norcross et al., 2013; Taylor et al., 2018), attention to professional competence emerged as the single highest rated item on training. That future stands in marked contrast to a past where competence was occasionally defined, but rarely verified. The educational system has assumed for generations that bright-enough graduate students will make eager, competent practitioners. And that competent practitioners will make competent educators and supervisors. Folie à deux!

Competency benchmarks will be controversially incorporated into the trainee’s learning goals and into the criteria for the supervisor’s evaluation of the trainee’s performance. The same will probably occur for trainers’ competencies as well. Integrative training and supervision will be expected to identity, assess, and verify competencies for all parties involved. Competency can be nurtured through constant reflective and deliberate practice. When not working with clients, therapists can repeatedly devote time to improving their work, such as thinking about difficult cases, securing consultation on specific skills, preparing and reflecting on sessions, critiquing videotapes of previous sessions, and attending training workshops (Castonguay & Hill, 2017; Wampold, 2017).

That sustained practice will assuredly focus on facilitative relationship skills that account for the lion’s share of outcome variance (Norcross & Lambert, 2019)—second only to the patient’s contribution—and that serve as the quintessential common factor in psychotherapy. The therapeutic alliance, alliance rupture repairs, collaboration, empathy, support, gathering client feedback, responsiveness, and other interpersonal skills can be taught and learned (e.g., Crits-Christoph et al., 2006; Harris et al., 2016; Smith-Hansen, 2016). Technological advancements allow psychotherapists, neophyte and seasoned alike, to study their in-session relational behavior and improve on it. That’s the relentless and enthusiastic lifelong learning that we ideally inculcate in our students; that’s the adaptiveness and openness to challenges that distinguishes the passionately committed psychotherapist from the run-of-the-mill therapist (Dlugos & Friedlander, 2001).

As yet, there is little controlled research on integrative training and supervision. We do not know, in an empirical sense, which training process works best for which situation. We expect and welcome the generation of reciprocal linkages among practitioners, trainers, and researchers on the use of integrative approaches in mental health interventions (Cooper, 2008; Fernández-Álvarez et al., 2016). That will enlighten our understanding of which training process works best for which situation.

The Magna Charta Universitatum is a document signed by 388 rectors and heads of universities from all over Europe and beyond in 1988, the 900th anniversary of the University of Bologna. Its second principle reads: “Teaching and research in universities must be inseparable if their tuition is not to lag behind changing needs, the demands of society, and advances in scientific knowledge” (www.magna-charta.org/magna-charta-universitatum). That principle encapsulates our hopes for integrative training in the future—inseparable from the grand adventure of research.

Acknowledgments

The authors gratefully acknowledge Drs. Richard P. Halgin and John D. W. Andrews for co-authoring this chapter in previous editions of this Handbook.

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