Psychotherapy

BULLETIN

PsychotherapyOFFICIAL PUBLICATION OF DIVISION 29 OF THE

AMERICAN PSYCHOLOGICAL ASSOCIATION

www.divisionofpsychotherapy.org

2009 VOLUME 44 NO. 2

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In This IssuePsychotherapy Research, Science, and Scholarship:

Adding Motivational Interviewing to Cognitive BehavioralTherapy for Anxiety

Ethics in Psychotherapy:An Examination of Integrated Deception in Psychological

Research: Ethical Issues and Challenges

Early Career:Mommy is a Psychologist, Too

Therapy Preferences Interview:Empowering Clients by Offering Choices

Diversity/Public Policy and Social Justice:A Place at the Table: Opening Up Leadership and

Governance: A Need for TransparencyThrough the Black Box

PPrreessiiddeennttNadine Kaslow, Ph.D., ABPPEmory University Department of Psychiatry and Behavioral SciencesGrady Health System 80 Jesse Hill Jr Drive Atlanta, GA 30303Phone: 404-616-4757 Fax: 404-616-2898E-mail: [email protected] J. Magnavita, Ph.D. Glastonbury Psychological Associates PC 300 Hebron Ave., Ste. 215 Glastonbury, CT 06033 Ofc: 860-659-1202 Fax: 860-657-1535E-mail: [email protected] Jeffrey Younggren, Ph.D., 2009-2011827 Deep Valley Dr Ste 309 Rolling Hills Estates, CA 90274-3655Ofc: 310-377-4264 Fax: 310-541-6370E-mail: [email protected] Sobelman, Ph.D., 2007-20092901 Boston Street, #410Baltimore, MD 21224-4889Ofc: 410-583-1221 Fax: 410-675-3451Cell: 410-591-5215 E-mail: [email protected] PPrreessiiddeennttJeffrey E. Barnett, Psy.D., ABPP1511 Ritchie Highway, Suite 201Arnold, MD 21012Phone: 410-757-1511 Fax: 410-757-4888E-mail: [email protected] RReepprreesseennttaattiivveessPublic Policy and Social JusticeRosemary Adam-Terem, Ph.D.1833 Kalakaua Avenue, Suite 800Honolulu, HI 96815Tel: 808-955-7372 Fax: 808-981-9282E-mail: [email protected]

Professional PracticeJennifer Kelly, Ph.D., 2007-2009Atlanta Center for Behavioral Medicine3280 Howell Mill Rd. #100Atlanta, GA 30327Ofc: 404-351-6789 Fax: 404-351-2932E-mail: [email protected]

Education and TrainingMichael Murphy, Ph.D., 2007-2009Department of PsychologyIndiana State UniversityTerre Haute, IN 47809Ofc: 812-237-2465 Fax: 812-237-4378E-mail: [email protected]

MembershipLibby Nutt Williams, Ph.D, 2008-2009St. Mary’s College of Maryland18952 E. Fisher Rd.St. Mary’s City, MD 20686Ofc: 240- 895-4467 Fax: 240-895-4436E-mail: [email protected]

Early CareerMichael J. Constantino, Ph.D., 2007, 2008-2010Department of Psychology612 Tobin Hall - 135 Hicks WayUniversity of MassachusettsAmherst, MA 01003-9271Ofc: 413-545-1388 Fax: 413-545-0996E-mail: [email protected]

Science and ScholarshipNorm Abeles, Ph.D., 2008-2010Dept of Psychology Michigan State University 110C Psych Bldg East Lansing , MI 48824Ofc: 517-353-7274 Fax: 517-432-2476E-mail: [email protected]

DiversityCaryn Rodgers, Ph.D., 2008-2010Prevention Intervention Research CenterAlbert Einstein College of Medicine1300 Morris Park Ave., VE 6B19Bronx, NY 10461Ofc: 718-862-1727 Fax: 718-862-1753E-mail: [email protected]

DiversityErica Lee, Ph.D., 2008-200955 Coca Cola PlaceAtlanta, Georgia 30303Ofc: 404-616-1876 E-mail: [email protected]

AAPPAA CCoouunncciill RReepprreesseennttaattiivveessNorine G. Johnson, Ph.D., 2008-201013 Ashfield St.Roslindale, MA 02131 Ofc: 617-471-2268 Fax: 617-325-0225E-mail: [email protected]

Linda Campbell, Ph.D., 2008-2010Dept of Counseling & Human Development – University of Georgia 402 Aderhold Hall Athens , GA 30602Ofc: 706-542-8508 Fax: 770-594-9441E-mail: [email protected]

SSttuuddeenntt DDeevveellooppmmeenntt CChhaaiirrSheena Demery, 2009-2010728 N. Tazewell St.Arlington, VA 22203703-598-0382E-mail: [email protected]

FFeelllloowwssChair: Jeffrey Hayes, Ph.D.Pennsylvania State University 312 Cedar Bldg University Park , PA 16802 Ofc: 814-863-3799 Fax: 814-863-7750 E-mail: [email protected]

MMeemmbbeerrsshhiippChair: Chaundrissa Smith, Ph.D.Emory University SOM/Grady Health System49 Jesse Hill Drive, SE FOB 231Atlanta, GA 30303Ofc: 404-778-1535 Fax: 404-616-3241 E-mail: [email protected]

Past Chair: Sonja Linn, Ph.D.E-Mail: [email protected]

NNoommiinnaattiioonnss aanndd EElleeccttiioonnssChair: Jeffrey Magnavita, Ph.D.

PPrrooffeessssiioonnaall AAwwaarrddssChair: Jeff Barnett, Psy.D.

FFiinnaanncceeChair: Bonnie Markham, Ph.D., Psy.D.52 Pearl StreetMetuchen NJ 08840Ofc: 732-494-5471 Fax 206-338-6212E-mail: [email protected]

EEdduuccaattiioonn && TTrraaiinniinnggChair: Eugene W. Farber, PhDEmory University School of MedicineGrady Infectious Disease Program341 Ponce de Leon AvenueAtlanta, Georgia 30308Ofc: 404-616-6862 Fax: 404-616-1010E-mail: [email protected] Chair: Jean M. Birbilis, Ph.D., L.P.E-mail: [email protected]

CCoonnttiinnuuiinngg EEdduuccaattiioonnChair: Annie Judge, Ph.D.2440 M St., NW, Suite 411Washington, DC 20037Ofc: 202-905-7721 Fax: 202-887-8999E-mail: [email protected] Chair: Rodney Goodyear, Ph.D.E-mail: [email protected]

PPrrooggrraammChair: Nancy Murdock, Ph.D.Counseling and Educational PsychologyUniversity of Missouri-Kansas CityED 215 5100 Rockhill RoadKansas City, MO 64110Ofc: 816 235-2495 Fax: 816 235-5270E-mail: [email protected] Chair: Chrisanthia Brown, Ph.D.E-mail: [email protected]

PPssyycchhootthheerraappyy PPrraaccttiicceeChair: Bonita G. Cade, ,Ph.D., J.D.Department of PsychologyRoger Williams UniversityOne Old Ferry RoadBristol, Rhode Island 02809Ofc: 401-254-5347E-mail: [email protected] Chair: Patricia Coughlin, Ph.D.E-mail: [email protected]

PPssyycchhootthheerraappyy RReesseeaarrcchhChair: Susan S. Woodhouse, Ph.D. Department of Counselor EducationPennsylvania State University313 CEDAR BuildingUniversity Park, PA 16802-3110Ofc: 814-863-5726 Fax: 814-863-7750E-mail: [email protected] Chair: Sarah Knox, Ph.D.E-mail: [email protected]

LLiiaaiissoonnssCommittee on Women in PsychologyRosemary Adam-Terem, Ph.D.1833 Kalakaua Avenue, Suite 800Honolulu, HI 96815Tel: 808-955-7372 Fax: 808-981-9282E-mail: [email protected]

Division of Psychotherapy !! 2009 Governance StructureELECTED BOARD MEMBERS

STANDING COMMITTEES

DIVISION OF PSYCHOTHERAPY (29)Central Office, 6557 E. Riverdale Street, Mesa, AZ 85215

Ofc: (602) 363-9211 • Fax: (480) 854-8966 • E-mail: [email protected]

PSYCHOTHERAPY BULLETINPsychotherapy Bulletin is the official newsletter of Division 29 (Psychotherapy) of the American PsychologicalAssociation. Published four times each year (spring, summer, fall, winter), Psychotherapy Bulletin is designedto: 1) inform the membership of Division 29 about relevant events, awards, and professional opportunities;2) provide articles and commentary regarding the range of issues that are of interest to psychotherapy the-orists, researchers, practitioners, and trainers; 3) establish a forum for students and new members to offertheir contributions; and, 4) facilitate opportunities for dialogue and collaboration among the diverse mem-bers of our association.Contributors are invited to send articles (up to 2,250 words), interviews, commentaries, letters to theeditor, and announcements to Jenny Cornish, PhD, Editor, Psychotherapy Bulletin. Please note that Psy-chotherapy Bulletin does not publish book reviews (these are published in Psychotherapy, the official journalof Division 29). All submissions for Psychotherapy Bulletin should be sent electronically to [email protected] the subject header line Psychotherapy Bulletin; please ensure that articles conform to APA style. Dead-lines for submission are as follows: February 1 (#1); May 1 (#2); July 1 (#3); November 1 (#4). Past issuesof Psychotherapy Bulletin may be viewed at our website: www.divisionofpsychotherapy.org. Other inquiriesregarding Psychotherapy Bulletin (e.g., advertising) or Division 29 should be directed to Tracey Martin atthe Division 29 Central Office ([email protected] or 602-363-9211).

PUBLICATIONS BOARDChair : Jean Carter, Ph.D. 2009-20145225 Wisconsin Ave., N.W. #513Washington DC 20015Ofc: 202–244-3505 E-mail: [email protected]

Raymond A. DiGiuseppe, Ph.D., 2009-2014Psychology DepartmentSt John’s University 8000 Utopia Pkwy Jamaica , NY 11439 Ofc: 718-990-1955 Email: [email protected]

Laura Brown, Ph.D., 2008-2013Independent Practice3429 Fremont Place N #319 Seattle , WA 98103 Ofc: (206) 633-2405 Fax: (206) 632-1793Email: [email protected]

Jonathan Mohr, Ph.D., 2008-2012Clinical Psychology ProgramDepartment of PsychologyMSN 3F5George Mason UniversityFairfax, VA 22030Ofc: 703-993-1279 Fax: 703-993-1359 Email: [email protected]

Beverly Greene, Ph.D., 2007-2012Psychology St John’s Univ 8000 Utopia Pkwy Jamaica , NY 11439 Ofc: 718-638-6451Email: [email protected]

William Stiles, Ph.D., 2008-2011Department of Psychology Miami University Oxford, OH 45056 Ofc: 513-529-2405 Fax: 513-529-2420 Email: [email protected]

EDITORSPPssyycchhootthheerraappyy JJoouurrnnaall EEddiittoorrCharles Gelso, Ph.D., 2005-2009University of MarylandDept of PsychologyBiology-Psychology BuildingCollege Park, MD 20742-4411Ofc: 301-405-5909 Fax: 301-314-9566 E-mail: [email protected]

Mark J. HilsenrothDerner Institute of Advanced Psychological Studies220 Weinberg Bldg.158 Cambridge Ave.Adelphi UniversityGarden City, NY 11530E-mail: [email protected]: (516) 877-4748 Fax (516) 877-4805

PPssyycchhootthheerraappyy BBuulllleettiinn EEddiittoorrJenny Cornish, PhD, ABPP, 2008-2010University of Denver GSPP2460 S. Vine StreetDenver, CO 80208Ofc: 303-871-4737 E-mail: [email protected]

Associate EditorLavita Nadkarni, Ph.D.Director of Forensic StudiesUniversity of Denver-GSPP2450 South Vine StreetDenver, CO 80208Ofc: 303-871-3877E-mail: [email protected]

IInntteerrnneett EEddiittoorrAbraham W. Wolf, Ph.D.MetroHealth Medical Center2500 Metro Health DriveCleveland, OH 44109-1998Ofc: 216-778-4637 Fax: 216-778-8412E-mail: [email protected]

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PSYCHOTHERAPY BULLETINPublished by the

DIVISIONOF PSYCHOTHERAPYAmerican Psychological Association

6557 E. RiverdaleMesa, AZ 85215602-363-9211

e-mail: [email protected]

EDITORJennifer A. EricksonCornish, Ph.D., [email protected]

ASSOCIATE EDITORLavita Nadkarni, Ph.D.

CONTRIBUTING EDITORSDiversity

Erica Lee, Ph.D. andCaryn Rodgers, Ph.D.

Psychotherapy Education & TrainingMichael Murphy, Ph.D., and

Eugene Farber, Ph.D.Ethics in Psychotherapy

Jeffrey E. Barnett, Psy.D., ABPPPractitioner ReportJennifer F. Kelly, Ph.D.Psychotherapy Research,Science, and ScholarshipNorman Abeles, Ph.D. andSusan S. Woodhouse, Ph.D.

Perspectives onPsychotherapy IntegrationGeorge Stricker, Ph.D.

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

Washington ScenePatrick DeLeon, Ph.D.

Early CareerMichael J. Constantino, Ph.D.

Rachel Smook, Ph.D.Student Features

Sheena Demery, M.A.Editorial Assistant

Crystal A. Kannankeril, M.S.

STAFFCentral Office Administrator

Tracey Martin

Websitewww.divisionofpsychotherapy.org

PSYCHOTHERAPY BULLETINOfficial Publication of Division 29 of theAmerican Psychological Association

2009 Volume 44, Number 2

CONTENTSEditors’ Column ............................................................2President’s Column ......................................................3Council of Representatives Report..............................7Psychotherapy research, science and scholarhsip ....9Adding Motivational Interviewing toCognitive Behavioral Therapy for Anxiety

Perspectives on Psychotherapy Integration ............13An Examination of Integrated Treatmentsfor Trauma and Co-Occurring Disorders

Ethics in Psychotherapy..............................................17An Examination of Integrated Deception inPsychological Research: Ethical Issues andChallenges

Early Career ..................................................................23Mommy is a Psychologist, Too

Education & Training ..................................................25Changes in the Sequence of TrainingLeading to Licensure

What Does a Scientist Look Like? ............................29A Therapy Preferences Interview:Empowering Clients by Offering Choices ..............33Diversity/Public Policy and Social Justice ..............38A Place at the Table: Opening Up Leadershipand Governance: A Need for TransparencyThrough the Black Box

Practitioner Report ......................................................42State Leadership Conference 2009: ExcitingTimes on Capitol Hill and Off

Washington Scene........................................................44Evidence-Based Medicine — The DevilRemains in the Details

Book review ..................................................................48Blévis, Marcianne. (2009). Jealousy:True stories of love’s favorite decoy.

Membership Application ..............................................52

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I t i s w i t h g r e a tpleasure that we offeryou this second issueof the PsychotherapyBulletin in 2009. Weare again impressedby the outstandingideas and excellentwriting provided byour wonderful con-tributing editors andguest authors.

In this issue you willfind informative and

helpful reports from our president andAPACouncil representatives, giving in-sight into and providing transparency ofthe governance processes in our Divi-sion and APA. The Practice submissionfor this issue is written by Bonita Cade,Division 29 FederalAdvocacy Coordina-tor, who reports on the recent StateLeadership Conference. Once again, PatDeLeon has written a compellingWash-ington Scene article for us. In addition,theDiversity and Public Policy and SocialJustice Contributing Editors have con-tributed an excellent article focused onconcrete ways to increase diversity inDivision 29 governance.

Several Research articles are included ona variety of topics including motiva-tional interviewing, a treatment prefer-ences interview, andwhat science “lookslike.” In addition, the Ethics contribu-tion this issue is on the use of deceptionin research.

Be sure to also read the paper on inte-grated treatments for trauma and co-oc-curring disorders. Continuing the trend

in recent issues, we also have anotherbook review for you. You will also enjoythe thoughtful Education article byMichael Murphy related to changes inthe sequence of training, and conse-quent recommendations for practicumtraining. While we applaud the attemptto better regulate practica, we agree thatthe current recommendations go too far.The Early Career Professional submis-sion this issue is on a topic close to ourhearts: combining the roles of parentand psychologist. Jenny has three sons(ages 21, 23, and 25) and Lavita has anadorable daughter (age 5); we continueto be amazed at how much we learnfrom our children, and how they enrichour professional careers.You will also note that this issue is in aslightly different size. We are experi-menting with this smaller version tohelp reduce costs while making theBulletin distinct from other divisionnewsletters. We are also now printingthe reference sections of papers online.Please let us know what you think ofthese changes.Finally, please know that we retain ourstrong commitment to the Bulletin as acreative outlet for all Division 29 mem-bers. The next issue of the Bulletin willinclude information related to the sum-merAPAconvention in Toronto (includ-ing the Division 29 program and thesuper fun social hour). We warmlywelcome your ideas, suggestions, andsubmissions!

[email protected]

EDITORS’ COLUMNJenny Cornish, Ph.D., ABPP, EditorLavita Nadkarni, Ph.D., Associate Editor

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Psychotherapy andthe EconomyI am writing this col-umn as we find our-selves in the midst ofan economic recession.There is no question

that this recession has deeply impactedour work as psychotherapists. More andmore, our patients are talking with usabout their economic woes, anxieties,and fears. Some patients are having todiscontinue therapy or reduce the fre-quency of their sessions or are request-ing reduced fees. Some psychotherapistsare fearful that their practice revenuesand caseload will significantly decline.And yet, there is some indication that adown economy is associated with aboom in therapy practices. There is evi-dence that requests for therapists haveincreased 15-20% recently in response topeople’s concerns about their financialsituation, with many people reportingthat their financial worries are their pri-mary reasons for initiating psychother-apy. It is understandable that theeconomic downturn and higher rates ofunemployment result in people feelingmore stressed, helpless and hopeless,angry, anxious and afraid, depressed,and often times suicidal because theyfeel they feel trapped by this economicdisaster. Indeed, in recent months, wehave witnessed the tragic suicides andmurder-suicides of people whose liveshave been dramatically altered by thiseconomy. Not only are people sufferingpersonally, but there appears to be morerelationship discord and arguments re-lated to increased financial strife.In order to best help our patients duringthese challenging economic times, our

therapeutic encounters need to assistpeople in both concretely and emotion-ally coping adaptively with the ways inwhich the economy is negatively affect-ing their lives. We need to aid peoplewith problem-solving creatively, work-ing collaboratively, taking action, coun-teracting the lethargy and apathy thatoften sets in when people feel economi-cally overwhelmed, and recognizing thepositives in their lives.As more people seek our services in re-sponse to their economic struggles, theremay be a decline in the stigma associ-ated with mental health care and weneed to capitalize on this greater open-ness within the country about engagingin psychotherapy. Interestingly, themedia increasingly is recommendingtherapy for helping couples effectivelyaddress the relationship stresses that aremagnified by the economy, as well as as-sisting individuals in managing theiranxiety regarding how the economy isimpacting their quality of life, sense ofisolation, self-esteem, and relationshipswith family members (partners, parents,and children). Psychologists can partnermore effectively with the media to con-vey to the public the ways in which psy-chotherapy can be invaluable whenconfronting economic hardship. It is mysincere hope that as psychologists andpsychotherapists, we will commit tofinding ways to make psychotherapymore affordable to people from all walksof life, so that everyone who wants ourservices can access them during thisdown economy (and in the years tocome). Of course, these times also high-light for us more than ever the necessityof ensuring that parity for mental healthcare truly becomes a reality.

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

PRESIDENT’S COLUMN

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Presidential PrioritiesOne of the most gratifying aspects ofserving as the President of the Divisionis that I have the opportunity to focus onaspects of the broad field of psychother-apy that are particularly meaningful tome. In this column, I want to address twoof these priorities: Diversity and Psy-chotherapy Supervision.DiversityTheDivision 29 leadership has prioritizeddiversity as a key area of focus for 2009.This emphasis is consistent with my ownclinical-research focused on culturallycompetent, gender sensitive, and devel-opmentally informed interventions. Weheld a one day diversity training for thegovernance of our division in January2009 in conjunction with our boardmeet-ing. We are hopeful that through honestdiscourse, dialogues about cross culturalcommunication, attention to subtle biases,and personal self-reflection and sharingthat we can strengthen our commitmentto mutual respect for and understandingof one another; increase our culturalawareness, knowledge, and skills; im-prove the overall climate of our work-group; and encourage greater creativityand flexibility among themembers of theboard. Greater sensitivity to diversitywillafford us better opportunities to optimizeour performance and bemore innovativeand responsive. I also firmly believe thatthis process will enrich us each individu-ally in our own work settings and in thepsychotherapies inwhichwe engage. Fur-ther, it ismyhope that the discussions thatwe had will lead us on a path to creatinga valuable product or set of products forour membership that relate to ways inwhich psychotherapists can bemindful ofthe ways in which their own diversitycharacteristics influence their therapeuticendeavors with their patients. I am grate-ful to members of the division’s diversitycommittee (Drs. Armand Cerbone, Jen-nifer Kelly, Erica Lee, Caryn Rodgers) forspearheading this effort. In addition, as afollow-up to this event, Drs. Erica Lee and

Caryn Rodgers, the Diversity DomainRepresentatives on the Division 29 boardare co-chairing a diversity strategic plan-ning initiative for the division. We willshare the details of this plan with you asthey become available.Over the past decade, there has beengrowing attention paid to the individualand cultural characteristics of our patientsand ways to ensure that our psychother-apeutic endeavors are mindful of thesefactors. However, much less focus hasbeen given to the cultural being of thepsychotherapist. Therefore, I am verypleased that Dr. Jennifer Kelly and I willbe co-editing a special issue ofPsychother-apy: Theory, Research, Practice, Training ondiversity characteristics of the psy-chotherapist and how these influence thepsychotherapeutic relationship andprocess. It is so essential that each of us inour role as psychotherapist bemindful ofthe impact that our own gender, age, gen-der, race/ethnicity, sexual orientation,ability status, religious beliefs, social class,etc., have on the psychotherapy that wepractice and theways inwhichwe are ex-perienced by our patients, both thosewhoare similar to us and those who are quitedifferent from us.Psychotherapy SupervisionI have a longstanding passion for psy-chotherapy supervision. As one of myPresidential Initiatives, I want to furtheradvance the art and science of psychother-apy supervision. I am grateful to Dr.Charles Gelso, our fabulous and very col-laborative editor of Psychotherapy: Theory,Research, Practice, Training who has gra-ciously agreed to commit a special sectionof the journal to ways in which differenttheoretical approaches to psychotherapysupervision inform the development ofpsychotherapy competencies in trainees. Iam indebted to Dr. Eugene Farber, Chairof Division 29’s Education and TrainingCommittee, who has agreed to spearheadthis special section,whichwill include pa-

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pers related to cognitive behavior, psycho-dynamic, family systems, and existen-tial/humanistic perspectives. From theirrespective theoretical vantage point, thesearticles will address the essential compo-nents of the psychotherapy competency,foundational and functional competenciesinforming thepsychotherapy competency,and psychotherapy competencies in thesupervision process. Illustrative vignetteswill be used to highlight key points anddialogues between supervisors and super-visees. I amvery excited about this specialsection.APAConventionI would like to take this opportunity toshare with you the Division’s plans forthe upcoming APAAnnual Conventionthat will be held in Toronto, Canadafrom August 6, 2009 – August 9, 2009. Iam delighted that we have a diverserange of symposia, posters, and conver-sation hours. These presentations ad-dress the breadth of the field ofpsychotherapy, with attention paid topractice, science, education and training,and policy. Here is a brief overview ofthe formal and informal activities of theDivision of Psychotherapy. Our pro-gramming promises to be engaging, in-teresting, and thought-provoking. I wantto express my gratitude to our ProgramCommittee Chair and Associate Chair,respectively, Drs. Nancy Murdock andChrisanthia Brown. They have put to-gether more than 15 sessions of highquality programming. More details onthese events can be found in the APAProgram Book.

This year, APA is organizing a Conven-tion within a Convention, with divisionscollaborating and offering more thematicprogramming.Division 29 is participatingin the Convention within the Conventionfor a two- hour symposium on Evidence-based Practice— Using Evidence-BasedPrinciples toOptimizeClinical Process andOutcomewith PersonalityDisorders. Thepresenters are Jeffrey Magnavita and

Kenneth Critchfield. This event is sched-uled for Saturday, August 8 from3–4:50pm in the Metro Toronto Conven-tion Center, Meeting Room 714A.

We will sponsor symposia on Thursdaythrough Sunday. The Thursday sym-posia include: Existential – HumanisticTherapy Come to Life; Two Viewpointson Future Directions for AllianceTheory; Process and Outcome in CBT—The Importance of Cognitive Errorsand Coping; Getting Real in Psycho-therapy—Explorations of the RealRelationship; What We Wish We HadKnown—Tips for Future Psychothera-pists; and Using a Training Center Data-base to Promote Science and Practice.The Friday symposia include: TheArt and Science of Impact: What Psy-chotherapists Can Learn From Filmmak-ers and Social Psychologists; andEminent Psychotherapists Revealed—Audiovisual Presentation of Principlesof Psychotherapy. On Saturday, sym-posia continue with: PsychotherapistsExpertise—Developing Wisdom toGuide Theory, Research, and Practice;Mistakes in Psychotherapy—YieldingPower, Constraining Dialogue, and Nur-turing Envy; and Schema Therapy forBPD— Breakthrough Treatment for Im-proving Life Functioning. Sunday’s sym-posia programming includes: AffectPhobia, Treatment Approach—TwoNew Pathways to Change; and Cultur-ally Informed Interventions with Ethni-cally Diverse Populations.

In addition to the aforementioned sym-posia, Division 29 is hosting a PosterSession on Friday. The focus of thisPoster Session is on Research in Psy-chotherapy.

There will also be a conversation houron Saturday that will consist of lunchwithMasters for Graduate Students andEarly Career Psychologists.

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The Division 29 Business Meeting is onFriday from 5:00 pm to 5:50 pm. Atthis meeting, we will honor our awardrecipients. In addition, we will providean update on divisional activities andinvite our members to engage withthe board in a dialogue about the futureof the division and of psychotherapy.We also plan to have some fun entertain-ment.

Finally, on behalf of theDivision 29 Board,I want to cordially invite all members of

the division and those interested in join-ing the division to our Social Hour,whichwill be held on Friday from 6:00 pm to6:50 pm immediately following the Busi-ness Meeting. The Social Hour offers anopportunity to meet, talk, and socializewithmembers of theDivision. Wewill beshowing pictures that reflect the historyof Division 29.

I look forward to seeing and interactingwith each of you at our various divi-sional activities.

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NOTICE TO READERS

Please find the references for the articlesin this Bulletin posted on our website:

divisionofpsychotherapy.org

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The most importantinformation to tell youabout Council is howproudNorine Johnsonand Linda Campbellare to be representingyou, our Division 29members and the cen-tral role of psychother-apy in psychology.

Getting the LemonsOut of the Way FirstEven though APA hasbeen in strong finan-cial position for recent

years, the 2008 budge realized a shortfallof $3,422,700. The national economic cri-sis, lower dues revenue than expected,and losses in investments are the majorreasons for the shortfall. Much time wasspent on this item in Council and wewant our members to know that theBoard of Directors, Paul Craig the APATreasurer, Archie Turner the APA CFOand the Executive Director, NormanAn-derson. were very forthcoming withspecific information, explanations aboutthe APA assets, dues impact, real estateholdings, publishing operations, andother factors that affect the budget. Afull and open discussion was conductedin which Council received recommenda-tions from the Board for response to thedeficit and how these would be reflectedin the 2009 budget.

After thorough discussion, the Counciladopted a budget with approximately$12 million dollars in spending cuts.These include (1) cancelling the fallboards and committee meetings, (2) cutsin spending on public education pro-grams, (3) a staff hiring freeze, and (4)elimination of the Board and Councildiscretionary funds. The final approved

budget is projected to yield a fiscalbudget surplus of $309,400 for 2009.Making LemonadeThe rest of the news from the Councilmeeting does, in fact, bode very well forthe resilience, commitment, and dedica-tion of ourmembers in governance.Muchhas been accomplished and much willcontinue to be done even in these times ofgreat restraint, ergo the lemonade.Strategic PlanIt may be hard to believe, but APA is be-ginning to conduct the very first strate-gic plan in the history of theorganization. CEO Dr. Norman Ander-son commented, “The strategic planningprocess is going to help APA be astronger andmore focused organizationin the future.” A significant step in facil-itating the strategic plan is the develop-ment and Council approval of a visionstatement that accurately represents thespirit, hopes, and direction of the organ-ization. If a vision statement can be ener-gized, exciting, and hopeful, this one isit. We hope that you are as satisfied withthe meaning and values represented aswe and the Council are:APA Vision StatementTheAmerican PsychologicalAssociationaspires to excel as a valuable, effectiveand influential organization advancingpsychology as a science, serving as:• A uniting force for the discipline;• The major catalyst for the stimula-tion, growth and dissemination ofpsychological science and practice;

• The primary resource for allpsychologists;

• The premier innovator in the edu-cation, development, and training of

APA COUNCIL OF REPRESENTATIVES REPORTFrom Lemons to LemonadeLinda Campbell, Ph.D. and Norine Johnson, Ph.D.Division of Psychotherapy Council Representatives

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psychological scientists, practition-ers and educators;

• The leading advocate for psycho-logical knowledge and practice in-forming policy makers and thepublic to improve public policy anddaily living;

• A principal leader and global part-ner promoting psychological knowl-edge and methods to facilitate theresolution of personal, societal andglobal challenges in diverse, multi-cultural and international contexts;and

• An effective champion of the appli-cation of psychology to promotehuman rights, health, well beingand dignity.

Council RepresentationThe following proposal was approvedand forwarded to the Policy and Plan-ning Committee to be drafted by thenext Council meeting:That the APA Bylaws should beamended to ensure all Divisions andSPTA’s have a seat on Council. Usingthe proportional allocation system, inthe unlikely event that the number ofvotes allocated to either is insufficient toyield enough seats to seat all Divisionsand SPTAsPublications and CommunicationsThe P&C Board of APA is the highestrevenue producing area ofAPAand cer-tainly is one of the most active and im-pactful within the profession. In 2008,the P&C Board reported that sales of theAPA Publication Manual reached 6.6million dollars. APA Journals and Divi-sion 56 began a new journal, Psychologi-cal Trauma: Theory, Research, Practice, andPolicy. APA Journals and Division 36also began a new journal entitled, Psy-chology of Religion and Spirituality. Dur-ing 2008, PsychINFO added 152,001

new records to the database and ex-panded coverage by adding 113 journalsbringing the number of journals coveredto 2,452. APA Books released 53 newscholarly titles and nine new Magina-tion Press titles. Total revenue for APA’score scholarly and professionalpublishing program exceeded $72 mil-lion in 2008.

In Other Actions, the Council:• Postponed action on proposals toreduce the costs of dues for somemembers including state, provincialand territorial association members,due to the restraints on the 2009 and2010 budgets.

• Adopted updated Guidelines forChild Custody Evaluations inFamily Law Proceedings.

• Received the report of the TaskForce for Increasing the Number ofQuantitative Psychologists.

• Established a continuing Committeeon Human Research.

• Received the final report of the Div.19 (Military) and Div. 44 (Society forthe Psychological Study of Lesbian,Gay, and Bisexual Issues) Joint TaskForce on Sexual Orientation andMilitary Experience.

• Announced the roll out of the newwebsite due later this year.

Your Council Representatives are advo-cates for the voice of Division 29 mem-bers. We do report back to you on thedecisions and the topics of discussion atthe immediate past Council meeting,but just as importantly, we want toknow in advance of meetings what yourthoughts and perspectives are so that wecan advance the mission of psychother-apy and our members. Please contact ei-ther Norine Johnson ([email protected])or Linda Campbell ([email protected]).

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Motivational Inter-viewing (MI) is “aclient-centered direc-tive method forenhancing intrinsicmotivation to changeby exploring and re-solving ambivalence”

(Miller & Rollnick, 2002, p. 25). Its’ useis well supported in the addictions do-main (Hettema, Steele, & Miller, 2005)and has been extended to the promotionof health behaviors (Rollnick, Miller, &Butler, 2008). There is strong evidencethat anMI pretreatment followed by an-other type of psychotherapy leads tobetter attendance and enhanced out-comes compared to the same psy-chotherapy without anMI pretreatment(Hettema et al., 2005). Recently, investi-gators have begun to explore the use ofMI either integrated with Cognitive Be-havioral Therapy (CBT; i.e., a shift to MIwithin CBT when ambivalence/resis-tance arises) or in combination with CBT(e.g., as a pretreatment) in the treatmentof other major mental health problemssuch as anxiety, depression, eating dis-orders, medical adherence in psychosis,and problematic gambling (Arkowitz,Westra, Miller, & Rollnick, 2008). Ourown work has centered on examiningMI as a pretreatment to CBT for anxietyand more specifically generalized anxi-ety disorder (GAD). Below I will outlinethe clinical application of MI to anxietyand summarize this research, as well asoutline current and future directions inour research program.MI for AnxietyAlthough CBT is an effective treatmentfor anxiety, numerous individuals fail toshow substantive benefit (Westen &

Morrison, 2001; Hunot, Churchill, Teix-eira, & Silva de Lima, 2007). This is par-ticularly true for GAD, the anxietydisorder least responsive to CBT (Camp-bell & Brown, 2002). Client resistance tochange and nonadherence to recom-mended treatment procedures are com-mon clinical realities in CBT. Forexample, in a survey of practicing CBTtherapists, problems in assigning home-workwere noted for 74.5% of clients andonly 38.9% of cases were identified as to-tally compliant (Helbig & Fehm, 2004).Because treatment engagement is a criti-cal contributor to outcome (Orlinsky,Grawe, & Parks, 1994), reducing resist-ance and increasing motivation throughthe use ofMImay hold significant prom-ise for improving the efficacy of CBT.MI has strong roots in the client-cen-tered approach of Carl Rogers (1956).BothMI and client-centered psychother-apies share an emphasis on understand-ing the client’s internal frame ofreference and working with discrepan-cies between behaviors and values. Bothemphasize the importance of the psy-chotherapist providing the conditionsfor growth and change by communicat-ing attitudes of accurate empathy andunconditional positive regard. However,unlike client-centered psychotherapy,MI is directive, with specific goals of re-ducing ambivalence and increasing in-trinsic motivation for change. To achievethese goals, the MI therapist tries to cre-ate an atmosphere in which the client,rather than the psychotherapist, is themain advocate for and primary agentof change. The “MI spirit” of the psy-chotherapist is central and consists of

PSYCHOTHERAPY RESEARCH, SCIENCEAND SCHOLARHSIPAdding Motivational Interviewing toCognitive Behavioral Therapy for AnxietyHenny A. Westra, Ph.D., Department of Psychology, York University

continued on page 10

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attitudes of collaboration, evocation,and respect for the client’s autonomy.This approach also consists of specificprinciples including: express empathy,develop discrepancy between valuesand problem behaviors, roll with resist-ance, and support self-efficacy.MI is well-suited for application to theanxiety disorders since ambivalenceabout change and engagement withtreatment procedures is common inthese populations. For example, individ-uals with GAD have been found to holdconflicting beliefs about worry, includ-ing both negative and positive percep-tions of the value of worry (Borkovec &Roemer, 1995). Although clients withGAD do see worry as a problem (e.g.,that it interferes with concentration andmemory), they also hold positive beliefsabout it (e.g., that worry is motivating,ensures one is prepared for negativeevents) and are therefore ambivalentabout reducing or relinquishing their ex-cessive worry. There are a number ofcase reports supporting the utility of MIwith various anxiety disorders includ-ing obsessive compulsive disorder(Simpson, Zuckoff, Page, Franklin, &Foa, 2008), social anxiety (Buckner, RothLedley, Heimberg, & Schmidt, in press),mixed anxiety disorders (Westra, 2004;Westra & Dozois, 2008) and GAD (Wes-tra & Arkowitz, in press). Readers areencouraged to examine these reports toobtain more specific information aboutthe clinical application of MI to anxiety.

Preliminary Studies Investigatingthe Efficacy of MI for AnxietyTo date, our research group has con-ducted two preliminary randomizedcontrolled trials (RCTs) examiningMI asa pretreatment for anxiety in a heteroge-neous sample of anxiety disorders andfor GAD specifically. These studies aresummarized below, as well as a qualita-tive research study on client accounts ofexperiences in CBTwith andwithout anMI pretreatment. Amanual detailing the

application of MI to anxiety used in ourresearch studies is also available uponrequest (send an email request to [email protected]).MI for a mixed anxiety disorders group(Westra & Dozois, 2006)Prior to either sessions of manualizedgroup CBT, individuals with a principalanxiety diagnosis (45% panic disorder,31% social phobia, and 24% GAD) wererandomly assigned to receive either 3sessions of an individually deliveredMIpretreatment adapted for anxiety (n =25) or no pretreatment (NPT, n = 30). TheMI group, compared to NPT, showedsignificantly higher positive expectancyfor anxiety control and greater home-work compliance in CBT.Although bothgroups demonstrated clinically signifi-cant anxiety symptom improvements,the MI group had a significantly highernumber of CBT responders compared toNPT. At six-month follow-up, bothgroups evidencedmaintenance of gains.Overall, the results of this investigationprovide support for the viability and po-tential contribution of MI as an adjunctto CBT for anxiety.MI for GAD (Westra, Arkowitz, &Dozois, 2008)To evaluate whether MI would enhanceresponse to CBT for GAD specifically, 76individuals with a principal diagnosis ofGADwere randomly assigned to receiveeither anMI pretreatment or no pretreat-ment (NPT), prior to receiving individu-ally delivered CBT. Significant groupdifferences favouring MI-CBT were ob-served for the hallmark GAD symptomof worry, percentage of treatment re-sponders, and therapist-rated home-work compliance. Onmultiple measures(worry, worry beliefs, early prognosticexpectations, intrinsic motivation), re-ceivingMIwas substantively and specif-ically beneficial for those of high worryseverity at baseline, compared to thoseof high severity not receiving MI. Those


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of moderate worry severity showed nosignificant benefit from the MI pretreat-ment on most indices. Moreover, largeeffect sizes were observed when com-paring high severity individuals acrossMI-CBT and NPT-CBT groups. Thesefindings suggest that MImay be a prom-ising adjunct to CBT for GAD, anduniquely beneficial for those of highworry severity (49% of this sample),who have historically been less respon-sive to CBT (Durham et al., 2004). At oneyear follow-up, the high severity MI-CBT group did show evidence of somerelapse; reducing the magnitudeof post-treatment group differences. Im-portantly, the data do not suggest thatthe addition of MI increased relapse butrather that those of high severity aremore vulnerable to relapse and thusmay require additional treatment orbooster sessions in order to maintaintreatment gains.Client Accounts of Experiences inCBT for GAD with and without MIpretreatmentUsing a grounded theory approach tostudy client post-treatment accounts oftheir experiences in CBT among ten highseverity clients in theWestra et al. (2008)RCT, Kertes, Westra, Angus, & Marcus(in press) found that MI-CBT and NPT-CBT groups sharply diverged in theirexperiences of the interpersonal style ofthe therapist and their experience of ac-tive engagement in CBT. MI-CBT clientsreported experiencing the CBT therapistas an “evocative guide” in the pursuit oftheir goals and, accordingly, reportedthemselves as active participants in thetreatment process. For example, MI-CBTclients reported “It’s not like the thera-pist was sitting there fixing my prob-lems. I had to do a lot of digging.” and“She (the therapist) made suggestionsbut a lot of times she would askmewhatI think.” In contrast, NPT-CBT clientsdescribed the CBT therapist as directiveand described their own role as prima-rily one of compliance with therapist di-

rection. For example, NPT-CBT clientsnoted that “The therapist was there to beaccountable to and to give me home-work,“,”My role was to show up and lis-ten,“,and “My role was to do thehomework and make sure I had some-thing to report back.” Considering thatKertes matched treatment groups onCBT therapist (n = 3 therapists), thesefindings suggest that the experience ofCBT was perceived differently depend-ing on whether the client received MIprior to CBT. These findings are consis-tent with the theoretical rationale foraddingMI to CBT and quantitative find-ings indicating that a major outcome ofadjunctive MI is increased engagementwith subsequent, more action-orientedtherapies (Burke et al., 2003; Hettema etal., 2005). The Kertes et al. (in press)study supports and strengthens thesefindings by demonstrating that in-creased engagement in subsequent treat-ment as a function of receiving MI isobserved in client accounts of their treat-ment experiences as well.Current & Future DirectionsWhile the above studies suggest that MIholds promise as an adjunct to CBT foranxiety, neither of the RCTs discussedabove ensured equivalent therapist con-tact time across treatment groups, nordid they rule out expectancy effects cre-ated by client knowledge of having re-ceived additional treatment. At present,we are intending to replicate the RCT ofMI+CBT for GAD using a control groupof extended CBT to control for theseconfounds. Moreover, we intend to adda relapse prevention procedure in orderto facilitate maintenance of treatmentgains.In addition, we are taking a process fo-cused approach to our research to exam-ine key questions of moderation andmediation, such as (1) Whymight MI beparticularly indicated for those of highworry severity? (2) What is the interper-


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sonal impact within CBT of having re-ceived an MI pretreatment compared toreceiving CBT alone? and (3) Are goodoutcome CBT therapists more “MI-ish”(e.g., collaborative, evocative, empathic)in their therapeutic style compared withpoor outcome CBT therapists?With respect to the first question, wespeculate that high severity worriersmay be more ambivalent or skepticalabout change than the moderate sever-ity worriers, and as a consequence pref-erentially benefit from the addition ofMI to CBT.At present, we are examiningthis question through the use of processmeasures of resistance and ambivalence(change-talk, counter-change talk) inCBT to examine whether those of highseverity are more resistant/ambivalentthan those of lesser worry severitywithin CBT alone. And if so, does hav-ing received MI prior to CBT decreasethis resistance/ambivalence within CBTamong those of high worry severity?With respect to the interpersonal impactof having received MI on subsequentCBT (question 2 above), findings fromthe Kertes et al. (in press) study con-verge with quantitative findings in theWestra et al. (2008) study demonstratingthat therapists of those in the MI-CBTgroup were rated by independent ob-servers, blind to client pre-treatment sta-tus, as having delivered higher qualityCBT, compared to the same therapists ofthose receiving no pretreatment prior toCBT (NPT-CBT). Thus, receivingMI pre-treatment appears to be associated withmore positive interpersonal processwithin subsequent CBT. We are cur-rently using the Structural Analysis ofSocial Behavior (SASB; Benjamin, 1974),which involves analyzing moment-to-moment client-therapist exchangesaround the interpersonal dimensions ofaffiliation and interdependence, to morespecifically examine the interpersonalimpact on CBT of receiving MI pretreat-ment compared to not having receiveda pretreatment. Given findings of high

levels of interpersonal problems in GAD(Newman, Castonguay, Borkovec,Fisher, & Nordberg, 2008), the emphasisin MI on the relationship between clientand therapist may provide clients witha corrective interpersonal experience,thereby improving interpersonalprocess in subsequent treatment.Finally, we are also examining therapisteffects (question 3 above) that emergedwithin the CBT alone group in the Wes-tra et al. (2008) study. Namely, CBT ther-apists differed in their outcomes withclient recovery rates at one year follow-up ranging from 17% to 90% across thefour CBT therapists. These differences inoutcome across therapists were medi-ated by differences in client prognosticexpectations following the first sessionof CBT, with clients of poor outcomestherapists having significantly lowerearly expectations for recovery thanthose of good outcome CBT therapists.Using the SASB, we are currently inves-tigating the hypothesis that CBT thera-pists may diverge in their managementof client counter-change talk, with goodoutcome therapists expressing more af-firming and understanding under theseconditions, while poor outcome thera-pists may engage in less understandingand more interpersonal control in re-sponse to client expressed reservationsabout change and treatment.

As with any research program, our workto date has suggested more questionsthan answers. While adding MI to CBTfor anxiety may hold promise, morerigorous, well controlled tests of this pos-sibility are required. Examiningmodera-tors andmediators within such studies isespecially important in identifying thosefor whom MI is indicated and not indi-cated, aswell as themechanisms throughwhich addingMI to CBTmay achieve its‘effects. Such researchwill have importantclinical implications for engaging indi-viduals with CBT for anxiety in anattempt to improve outcomes.

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A growing body of re-search supports the use ofseveral manual izedgroup treatment mod-e l s des igned specifi-cally for individuals withco-occurring disorders(e.g., those who have bothmental disorders and substance use dis-orders) who also have histories oftrauma. These treatment models, includ-ing the Trauma Recovery and Empow-erment Model (TREM; Harris & TheCommunity Connections Trauma WorkGroup, 1998), Seeking Safety (Najavits,2002), and others, are often referred to asintegrated treatment models, and this de-scription is applicable in more waysthan one.

First, the treatment models describedhere are integrated in the sense that theyaim to address trauma sequelae, sub-stance abuse, and general mental healthproblems as interconnected parts of awhole problem, rather than as separatesyndromes. This integrated approachrepresents a shift away from paralleltreatment models, in which addiction,trauma, andmental illness are treated indifferent facilities with different sets ofproviders. It also differs from so-calledsequential treatment approaches inwhich treatment providers maintainthat substance abuse be addressed be-fore other presenting issues (Finkelsteinet al., 2004).

These treatments are also theoreticallyintegrative. TREM, for example, focuseson the development of trauma recoveryskills through cognitive restructuring,skills training, peer support, and psy-

choeducation (Harris &The Community Connec-tions Trauma WorkGroup, 1998), while Seek-ing Safety emphasizes in-terpersonal domains aswell as cognitive, behav-ioral, and case manage-

ment elements (Najavits, 2002). Thepresent paper will provide a briefoverview of recent research evidencesupporting integrated trauma treatmentmodels, while also offering a more clin-ically-oriented description of TREM, in-cluding the core themes and skillsemphasized in TREM sessions.

Research Findings on IntegratedTrauma TreatmentsThe Women, Co-occurring Disordersand Violence Study (WCDVS) was alarge-scale quasi-experimental studyevaluating the effectiveness of inte-grated treatment programs designedspecifically for women with co-occur-ring disorders and histories of interper-sonal violence (Morrissey, Ellis et al.,2005). Funded by the Substance AbuseandMental Health ServicesAdministra-tion, the study includedmore than 2,700women across nine participating treat-ment sites. In each case, clinical out-comes at the sites using integratedtrauma treatments were compared withsites providing usual care to a compara-ble population. It is the largest study todate examining integrated treatment ap-proaches for this population.

The WCDVS findings strengthened thecase for integrative trauma-focusedtreatments. At the 12-month assessment

PERSPECTIVES ON PSYCHOTHERAPY INTEGRATIONAn Examination of Integrated Treatments forTrauma and Co-Occurring DisordersJessica Sandham Swope, M.A., Carol R. Glass, Ph.D., & Diane B. Arnkoff, Ph.D.The Catholic University of America


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point, a meta-analysis of data across alltreatment sites revealed that while therewas symptom reduction for women inboth conditions, sites using integratedtrauma treatments yielded significantlygreater improvements on measures ofgeneral mental health functioning andtrauma symptoms relative to the womenin usual care (Morrissey, Jackson et al.,2005). Looking at substance use out-comes, intervention site participantsdemonstrated statistically greater im-provement on a measure of drug useseverity at the 6-month assessment point(Cocozza et al., 2005), but differences be-tween the groups were not statisticallysignificant at 12 months.The results of studies of individual inte-grative trauma treatments in theWCDVS also suggest that these ap-proaches are beneficial for individualswith trauma histories and co-occurringdisorders. Of the interventions includedin the WCDVS, the Seeking Safety treat-ment program was the first and mostfrequently studied. In early and small-scale studies of Seeking Safety, the ther-apy was found to be effective inreducing PTSD symptoms and sub-stance abuse (Cook, Walser, Kane,Ruzek, & Woody, 2006; Najavits,Schmitz, Gotthardt, &Weiss, 2005; Zlot-nick, Najavits, Rohsenow, & Johnson,2003). Other studies have shown it to behelpful in reducing depression and gen-eral psychopathology (Najavits, Gallop,& Weiss, 2006; Najavits, Weiss, Shaw, &Muenz, 1998).

More recently, Gatz et al. (2007) reportedpromising findingswith respect to reduc-tion of trauma symptoms in their studycomparing Seeking Safety to usual careamong women in residential substanceabuse treatment programs in Los Ange-les. This studywas one component of thelarger WCDVS described above. The re-searchers found that participants in theSeeking Safety condition had significantlygreater reductions in trauma symptoms

and significantly greater gains on ameas-ure of coping skills from baseline to 12months. The two conditions did not differwith respect to participants’ improve-ments on measures of substance use andgeneral psychopathology.Findings from recent studies of TREMalso generally point to its effectivenessfor women with co-occurring disordersand histories of trauma. For example, asa part of the WCDVS, Amaro et al.(2007) examined treatment outcomesamong 342 women receiving substanceabuse treatment in the Boston area. Inthis study, intervention group partici-pants received a modified version ofTREM in addition to substance abusetreatment, while comparison group par-ticipants received usual care in compa-rable substance abuse treatmentprograms. Relative to the comparisongroup, intervention group participantsdemonstrated significantly greater im-provements on measures of PTSD, gen-eral mental health symptoms, and druguse by the 12-month interview period.Preliminary data from the District of Co-lumbia Trauma Collaboration Study(DCTCS), a study that was a part ofthe WCDVS involving 251 participants,indicate that TREM group participantsexperienced significantly greater reduc-tions in PTSD and substance use symp-toms at the 12-month assessment pointrelative to those receiving services asusual at a comparable agency. Therewere no significant differences betweenthe groups on a measure of general psy-chiatric symptoms (Fallot, McHugo, &Harris, 2009).ACloser Look at TREMOne way that some clinicians conducttrauma treatment with individuals withsevere mental illness is by modifyingsome of the more well-established cog-nitive- behavioral treatments for PTSD.For example, some treatments have been


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changed to reduce or eliminate treat-ment elements that could be particularlystressful for these individuals—such asexposure—while providing a greateremphasis on cognitive restructuring. Inthis way, the treatments focus on theavoidance, arousal and intrusive symp-toms that characterize PTSD (Rosenberget al., 2001).TREM, on the other hand, takes abroader view of the issues that need tobe addressed among individuals withhistories of trauma and co-occurring dis-orders. This treatment model was devel-oped in the 1990s by clinicians workingwith women at Community Connec-tions, a community mental healthagency in Washington, DC. The clini-cians recognized that many of theirclients struggledwith trauma-related se-quelae that extended beyond PTSDsymptoms, including a disrupted abilityto trust others and sustain relationships,a sense of powerlessness and lack ofself-agency, and difficulties with emo-tional modulation and self-soothing.The treatment was developed aroundfour core assumptions: 1) Some currentmaladaptive behaviors may have ini-tially developed as a means of copingwith trauma; 2) Women with repeatedexperiences of childhood trauma weredeprived of the chance to develop thetypes of coping skills they need asadults; 3) The experience of trauma cutsoff one’s connections to family, commu-nity, and self; and 4)Womenwith exten-sive histories of trauma feel powerlessand unable to advocate for themselves(Fallot & Harris, 2002).

Based on these principles, TREM wasdeveloped as a manualized therapy thattargets issues in trauma recovery overthe course of 33 weekly 75-minute ses-sions designed for groups of 8-10women. There are three main sections ofthe treatment model. The first focuses onempowerment, the second section aimsto help participants better understand

the experience and impact of trauma,and the third section emphasizes the de-velopment of trauma recovery skills(Fallot & Harris, 2002). Though TREMwas originally developed for use withwomen, variations of the treatmentmodel have been developed for bothmen (Fallot, 2001) and adolescent girls(Berley, Guillory, Harris, Quezada, &Seagroves, 2005).In some instances, the empowermentsection of TREM includes session topicsthat one might not immediately associ-ate with trauma recovery, such as ses-sions focused on the exploration ofself-esteem and female sexuality. For ex-ample, during the fourth week of treat-ment members explore their physicalboundaries. The rationale for this is thatthe experience of physical and sexualabuse is the ultimate violation of—andintrusion into—personal space. Abusesurvivors often find themselves con-fused about what is safe and appropri-ate contact, and may be either overlysensitive about personal space or notsufficiently aware of others’ need forpersonal space (Harris & The Commu-nity Connections Trauma Work Group,1998).Through discussion and activities, thissession allows members to explore thetopic and receive feedback from one an-other. One of the goals for the session isto have members begin to develop anidea of how much or how little controlthey have over what happens to theirbodies. Facilitators ask members to dis-cuss how much physical space theyneed and how they might typically re-spond to unwanted physical contact. Inone exercise, leaders block off boxes andcircles on the floor with masking tape atvarying distances from one another andgroup members discuss why they se-lected the boxes they did (Harris & TheCommunity Connections Trauma WorkGroup, 1998).


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In later sessions, topics are geared morespecifically toward trauma recovery andskill building. For example, in session20, groupmembers explore the links be-tween problematic addictive or compul-sive behaviors and their histories oftrauma. They discuss when they first en-gaged in these behaviors, and how thesebehaviors may be a form of self-abuse.By session 28, entitled “Feeling Out ofControl,” one of the goals is to help themembers think about effective and pos-itive ways to modulate intense emo-tions. As an exercise, membersbrainstorm a list of coping strategies—including engaging in positive self-talk,taking a walk or exercising, or listeningto soothing music (Harris & The Com-munity Connections Trauma WorkGroup, 1998).

A recent study using data from theaforementioned DCTCS, examined theextent to which participants perceivedthat the counseling services they re-ceived were integrative, based on re-sponses to several questions, including:“The services I receive treat me as awhole person rather than pulling me

apart into separate problems.” Resultsindicated that TREM participants weresignificantly more likely to perceive thattheir treatment was integrative relativeto those receiving services as usual. Inaddition, among TREM participants,perceived integration was significantlycorrelated with symptom reduction onmeasures of PTSD symptoms, generalmental health symptoms, and drug useseverity (Swope, 2009).

While the empirical findings outlinedabove make the case for continued andexpanded use of integrated traumatreatments, they also suggest that clini-cians would be well-s erved to examineand address possible connectionsamong disorders for those clients whocome into treatment with a variety ofpresenting issues. Current research find-ings support this approach for cliniciansworking with individuals who have his-tories of trauma and other mental healthproblems, but additional research isneeded to determine whether the devel-opment of integrated treatment proto-cols would be useful for other disorderswith high rates of comorbidity.

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The use of deceptionin research by psychol-ogists raises a numberof ethical issues andconcerns. Its signifi-cance is illustrated byits inclusion as a stan-dard in the AmericanPsychologicalAssocia-tion’s Ethics Code(APA, 2002, Standard8.07: Deception in Re-search). While the useof deception may offerresearchers greater

flexibility in conducting their studiesand obtaining important findings, it alsocreates potential risks for participants ofthese studies that must be addressed.The purpose of this article is to betterunderstand what deception is, highlightthe benefits and consequences of its use,examine ethical dilemmas and concernsregarding deception, and discuss theethical use of deception and possiblealternatives.

Deception has been described byHertwig and Ortmann (2008) as the“intentional and explicit provision oferroneous information—in other words,lying” (p. 222). It is one of the most con-troversial topics in research ethics due tothe potential for harm to research partic-ipants and the possible violation of theirrights. Yet, one cannot deny the signifi-cant contributions that a study utilizingdeception can add to our understandingof human behavior. On the one hand,deception can give a study greater inter-nal validity by increasing the controlthat a researcher has over the experi-ment and eliminating certain participant

biases; however, it is taking away theparticipants’ autonomy and their abilityto provide voluntary informed consent.Deception in Research:An Historical PerspectiveThe first set of ethical guidelines regard-ing human researchwas put forth in 1947in response to the inhumane humanexperiments that were carried out inGermany during World War II. Theseguidelines became known as the Nurem-berg Code, named after the trials atNuremberg where the physicians con-ducting these experiments were placedon trial and found guilty of war crimesand crimes against humanity. TheNuremberg Code (1947) specifies that re-searchmust be conducted for the good ofsociety, not impose any unnecessaryharm, and research participantsmust vol-untarily consent and be able to withdrawfrom the research study. These guidelineswere very general, not enforceable, anddid not make specific recommendationsregarding deception, but were an impor-tant first step toward the protection ofhuman research participants.In the 1960s and 70s deception was ahallmark of psychological research, andits use was the norm and not a choice oflast resort. During this period, specificethical standards were not in place tolimit the use of deception. Milgram’sobedience study (1963) and Darley andLatane’s (1968) bystander interventionstudy are examples of classic studiesthat utilized deception during this timeperiod and yielded valuable advance-ments to our knowledge of social behav-ior. However, these studies, specifically

ETHICS IN PSYCHOTHERAPYAn Examination of Integrated Deception inPsychological Research: Ethical Issues and ChallengesJeffrey E. Barnett, Psy.D., ABPP and Monica Nanda, B.A.


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Milgram’s obedience study, raisedmajorethical concerns regarding participantsafety, highlighting the need for morespecific standards to be put into place.In 1964 the World Medical Associationput forth the Declaration of Helsinki,which is a set of ethical principles forphysicians conducting human research.It highlights the rights of human partic-ipants and important factors to considerwhen conducting research with humanparticipants (World Medical Organiza-tion, 1996). Ethical principles in this doc-ument include respect for the individualduring the research process, allowingthe participant to make informed deci-sions, and ensuring that the partici-pant’s welfare always takes precedenceover science and society. In 1974 TheNational Research Act was passed inCongress and created the NationalCommission for the Protection ofHuman Subjects of Biomedical and Be-havioral Research (NCPHS) to study theethical principles underlying researchon human subjects (NCPHS, 1979). In1978 the Commission summarized itsfinding in the Belmont Report and iden-tified respect for persons, beneficence,and justice as the three fundamental eth-ical principles for research using humanparticipants (NCPHS, 1979).

Ethical Issues and Standardsfor PsychologistsThe APA Ethics Code (2002) providesthe most specific standards for psychol-ogists to follow when conducting re-search. Standard 8.07, Deception inResearch, specifies that deception is notto be used if alternative methods notusing deception are possible, if the de-ception will “reasonably be expected tocause physical pain or severe emotionaldistress”, and if the deception is not“justified by the study’s significantprospective scientific, educational, orapplied value” (p. 1070). Furthermore, ifdeception is used, study participantsmust be notified about and be provided

with an explanation of the use of the de-ception “as soon as is feasible, prefer-ably at the conclusion of theirparticipation, but no later than at theconclusion of the data collection, andpermit participants to withdraw theirdata” (p. 1070). This is usually done dur-ing a required debriefing at the comple-tion of the study where the researcherprovides the participant with informa-tion about the nature of the study aswell as any deception that may havetaken place. Additionally, when re-quired, all research protocols, whetherusing deception or not, must be re-viewed and approved by an Institu-tional Review Board (IRB) prior toconducting the research.As one can see, these standards are anattempt to place a balance between notharming research participants and ad-vancing psychological knowledgethrough controlled experimentation. It isobvious to not use deception when it islikely to result in extreme harm to par-ticipants. But, when the relative risksand benefits are less pronounced reach-ing a decision on how best to proceedmay be challenging for researchers. Thistension can be seen in the APA EthicsCode’s aspirational Principle A: Benefi-cence and Nonmaleficence which rec-ommends that psychologists endeavorto take actions that maximize benefit tothose we serve while simultaneouslyminimizing the potential for exploita-tion or harm to them. While we can eas-ily see how to apply these principleswhen the potential for harm is great andthe likely value of a study is small (andthe inverse as well) it is in those situa-tions where these distinctions are lessapparent that psychologists will strug-gle. Thus, a study such as Milgram’sobedience study, while yielding valu-able information that advances our un-derstanding about human behavior,would not likely be approved by anyIRB today. The decision to approve


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other studies in which the likelihood ofharm to participants is not so clear, yetthe potential benefits from the study aregreat, might prove more problematic forthose making these decisions.Additionally, if alternative methods thatenable the researcher to study the issuesin question are feasible, the researchermust refrain from the use of deceptionand use the alternative method. How-ever, several studies (e.g., Cooper, 1976;Forward, Canter & Kirsch, 1976; Geller,1982; Weber & Cook, 1972; Willis &Willis, 1970) have looked at the use of al-ternative methods such as role plays,naturalistic observation, and self-reportmethods in comparison to using decep-tive methods and have reported mixedresults. To eschew deception when alter-native methods are available helps elim-inate potential harm to the study’sparticipants, even if only minimal. Yet,the study could be losing valuable ex-perimental and statistical power thatwould make it more internally valid. Inorder to better understand this dilemmaand the APA’s stance on this issue, wemust examine the consequences of theuse of deception.

Risks and Benefits of UsingDeception in ResearchThe use of deception can contributegreatly to our knowledge about humanthoughts, attitudes, motivations, deci-sion making, behavior, and the like.Some of the most fascinating experi-ments in the history of psychology uti-lized deception. For example, inSolomonAsch’s conformity study (1951)participants believed they were takingpart in a study on visual perception.Rather, they were participating in astudy to see how often they would re-spond incorrectly to visual cue cards be-cause the confederates did so as well.This study gave us considerable insightinto understanding conformity. Thus,deception in research can allow us to tapinto constructs, such as conformity, that

would be difficult or nearly impossibleto measure using other methods. Addi-tionally, it helps eliminate participant bi-ases such as social desirability and otherdemand characteristics. When partici-pants do not know the true nature of thestudy that they are participating in, theycannot consciously change their behav-ior to make themselves look better. Also,they cannot easily discern the study hy-potheses and deliberately behave in away that confirms or denies them. Con-sequently, the use of deception leads tothe research having more experimentalcontrol by eliminating these extraneousvariables, giving the research studymore internal validity, increased power,and a lesser likelihood of making a TypeII error.The use of deception also allows us toexamine rare behaviors that would bedifficult to study otherwise. Through theuse of deception, Darley and Latane’sbystander intervention study (1968) wasable to help us better understand whensomeone is more likely to help an indi-vidual in an emergency without therebeing an actual emergency. Clearly, cre-ating actual emergency situations tostudy bystanders’ responses would raiseother more serious ethical issues and beimpractical. Even though studies utiliz-ing deception can provide us significantinformation concerning human thoughtand behavior, the potential contributionof a study is an essential but not suffi-cient requirement to substantiate its use.This is due to the potential of harm andother consequences brought about bythe use of deception.Milgram’s obedience study demon-strates many of the consequences thatcan come about from using deception. Inthis study, participants were led to be-lieve that they were teaching anotherparticipant word pairs and shockingthem with increasing voltage for eachresponse they answered incorrectly.


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Sixty-five percent of the participantscontinued to shock the “learner” despitethe learner’s complaints because the ex-perimenter said that they must continue(Milgram, 1963). Throughout the exper-iment, participants were apparentlynervous, anxious, scared, and dis-tressed, but the experimenter insistedthat they continue. Not only did thisstudy cause significant emotional dis-tress to the participants, but it took ad-vantage of their position as a studyparticipant by breaking their trust andnot giving the participants a chance towithdraw from participation. Addition-ally, in Milgram’s study and in otherstudies that use deception, the re-searcher is not able to obtain informedconsent since participants are not in-formed of the true nature of the study.This alone violates the participants’ au-tonomy because of their inability tomake informed, independent decisions.Furthermore, the use of deception couldcause an invasion of privacy when par-ticipants are revealing informationabout themselves that they would nothave revealed or wanted to reveal if itwere not for the deceptive methods thatwere used. Not only do participants ex-perience the consequences of deception,the field of psychology does so as well.The greater the use of deception in psy-chological experiments, the more suspi-cious participants may become whenparticipating in any psychological study.This could cause participants to behavein unnatural ways because of their sus-picions, thus eliminating the experimen-tal and statistical benefits of usingdeception.Conclusions and RecommendationsWhen ethically used, deception can con-tribute greatly to the field of psychology,but it is essential that researchers exam-ine the risks and harm that the decep-tion could potentially cause to theparticipants and make sure there are noalternatives possible that do not utilizedeception. Additionally, Benham (2008)

suggests examining the professional re-lationship between the researcher andparticipant as well as different forms ofdeception when considering its use. Wefurther recommend that psychologist re-searchers utilize a structured decisionmaking model to consider the relativerisks and benefits of the use of deceptionin research that weighs the potentialvalue of the anticipated results of thestudywith the potential for harm to par-ticipants. No easily applied formula ex-ists to replace such a deliberativedecision making process at present, buta decision making model is presentedbelow. TheAPAEthics Codemakes clearwhen the use of deception is ethical, andalthough these standards may appearstringent, the potential of harm to par-ticipants and the violation of many oftheir fundamental rights warrant thesestandards by promoting integrity, au-tonomy, safety, and privacy.Decision Making Model andSteps to Take1) Determine the potential benefits ofthe study and the value of the find-ings and data likely to be obtained.

2) Determine the potential risks to in-dividuals who may participate inthe study.

3) Consider if the typical participantwould agree to participate in thestudy if they knew of these risks inadvance.

4) Delineate all possible alternativesfor studying the research issue inquestion.

5) Consult with colleagues with ex-pertise in ethics, research, and ex-perimental design.

6) With the assistance of expert col-leagues consider the relative risksand benefits of each alternativeavailable.

7) Once a decision is reached, developa research protocol that minimizesrisks to the participants and thatmaximizes protecting their rights


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and welfare (e.g., monitoring theirfunctioning throughout the study,determining when to terminate aparticipant’s involvement in thestudy if signs of duress are noted,voluntary nature of participationand right to withdraw at any time,the debriefing process, etc.).

8) Present this research protocol to theappropriate Institutional ReviewBoard.

9) If a study utilizing deception isapproved by the IRB, implementthe study with careful monitoringof each participant’s functioningthroughout each phase of the study.Do not allow a participant to con-tinue in the study if the likelihoodof harm is evident. Obtain neededassistance for any participant whorequests it or appears to be harmed

by their participation.10) Conduct the debriefing of each par-

ticipant with careful attention totheir rights and welfare. Shouldduress or harm be evident, take ap-propriate remediative steps such asobtaining treatment for the partici-pant.

11) Ensure that participants under-stand their right to withdraw fromthe study at any time and their rightto withdraw their data as well.

12) If patterns of duress or harm arenoted in multiple participants or ifsignificant harm is noted in even asingle participant, discontinue thestudy, confer with expert colleaguesand the IRB, and determine whatmodifications need to be made tothe design of the study before pro-ceeding.

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It’s true; I am. It’s anew development. Al-though I have beentelling my childrensince they were bornthat I am a talkingdoctor, the real story is

that for the past six years, I have been afull-time parent. The psychologist partof me was an important component ofmy internal identity and my sense ofself, but I wasn’t practicing. This was ameasured choice on my part; my chil-dren were very new to the world and Iwas new to the world of mothering, andI was clear that I wanted to carve outsome time in my life for just those expe-riences. Frankly, I was also a little over-whelmed and just didn’t have theemotional energy to be attending to anyextra people. I’m glad I have spent thesesix years the way I have. Hindsight onthis issue melds comfortably with theforesight that led me to choose stayinghome in the first place.

Staying home: what a misnomer. I havebeen busier in these six years than I everwas as a full-time student or a workingnon-parent. It hasn’t gotten less busy, ei-ther, and there is a part of me that thinksmaybe it’s a little bit crazy to take onsuch a project as starting a business.About the time that my second childstarted to experiment with getting up onhis feet, though, I started to dream aboutgetting back up on mine. The therapistin me started to tug on the sleeve of myheart, gently at first, and then quite re-lentlessly. I took stock, took notes, andsought counsel. The message fromeverywhere was the same: Get back towork.

And so I’m doing it. I am building apractice, building a reputation, market-ing, reading, and feeling that quickeningof the pulse that comes whenever I lockin on my own right path and step for-ward. It is very motivating. I’m excited,energized, and brimming with ideasand possibilities. It’s a sea change,though, and my family has motion sick-ness. “What do you mean, office?” myfirst-grader demanded. “You’re ourmom.” And then, just to really rub it in,she added, wistfully, “Don’t you love usmore than you love your job?”From my seat right now, parenting andworking in combination feels refreshing.From the seat my kids and my husbandare sharing, mainly everybody is justfeeling the need to buckle up, becausethe ride has gotten a little wild. For sixyears, I have been available all of thetime, organizing everything about mytime around what the kids need andwhat we all want as a family. Sometimesit has been exhausting, but it has alsobeen a lot of fun. My parenting full-timehas been a pretty good arrangement forall of us for a long time, and now I havegone and shaken it up by becoming dis-satisfied with it as a sole way of life.While I am busy breathing a sigh of re-lief and coasting on new-project energy,my husband and children are adjustingto the fact that now I disappear a lotmore often.My husband, truth be told, is not en-tirely crushed to hear of the prospect ofme making some actual money. I havebeen either a full-time student or scant-ily paid postdoctoral fellow or a stay at

EARLY CAREERMommy is a Psychologist, TooRachel Gaillard Smook, Psy.D.Independent Practice, Northborough, MA


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home parent since wemet, worthy occu-pations all, but all rendering me rather afinancial deadbeat. But although he isrelieved to be able to share the financialresponsibility for this life we’ve con-structed together, he is also strugglingthrough the logistics and consequencesthat come from reconfiguring our divi-sion of labor on the parenting front.

Everyone except for me finds this newcareer move of mine a tricky alteration.I feel it too, actually, if impatience withtheir adjustment process counts. (I knowthis is neither fair nor admirable, but it’san accurate reporting of events.) Everyso often I do have flashes of sadness andpanic, with occasional doses of what-am-I-DOING-ness. But this is unques-tionably easier for me than it is for thefamily with whom I share my life.

When my daughter asked if I love hermore than I love my job, I answered inthe affirmative. I am, first and foremostand forever, my children’s mother. Noneof my life’s roles are as vital or as un-shakeable as that. The kind of mom Iam, though, is the kind who also reallybelieves that I have to be a happywomanin order to be a good enough parent, andI have started needing more than par-enting to makeme happy.Also, the kindof woman I am believes that children

need a model for following their heart’sdesires. My heart desires to be back inpractice. By honoring that, I bring moreof a sense of fulfillment intomy own life,enabling myself to become more of theparent I want to be for my kids, and Ishow them how to listen to their own in-stincts and dreams. Ultimately, every-body wins.

I really love being a psychologist, andit’s time to do it. Thus, I will do what allgood moms do when the little people intheir lives are seasick. I will comfortthem. I will try as much as is possible attheir stages of development to get theirsights fixed on the horizon in hopes thatit will soothe their tummies. My hus-band and I will figure out these white-waters, too, the way we have at othertimes when things have gotten choppy.We have a long enough history togetherto trust in the calm that follows storms.We will forge ahead, this family of ours,and I will hold them all close and re-mind them that I love them more thanthey can possibly fathom.

And I will keep steady on my owncourse, knowing that the ride will soonsmooth out for all of us if I do that.

To contact the author:[email protected]

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Arizona, Indiana, Ohio,Maryland,NorthDakota,Utah, and Washingtonhave passed legislationchanging their licens-ing requirements forsupervised practice

leading to licensure. These states requiretwo years of supervised experience, oneof which must be in a predoctoral in-ternship training program. The addi-tional equivalent of a year of supervisedexperience can be gained before or afterthe doctorate is conferred. At this time,most of the above states are in theprocess of developing rules for imple-menting the legislation. Students andearly career psychologists (ECPs) havebeen very enthusiastic in their supportof these changes. However, the imple-mentation will take a bit longer and it islikely that challenges are ahead as stateswork to set standards and establish re-quired documentation of supervised ex-perience for licensure.This article will briefly review the back-ground and the central issues associatedwith implementing anticipated rulesand regulations. It will also addressanticipated standards for supervisedprofessional experience and documen-tation. These issues raise importantimplications for Division 29 memberswho direct and teach in trainingprograms and those who supervisedoctoral students. Finally, the practicalimplications for students and ECPs willbe addressed.Revisions of the Model Licensing ActIt is generally acknowledged that overthe years, training programs in profes-sional psychology have increased the

amount of practicum and fieldwork re-quired for graduation. To some extent,this arises from an increase in profes-sionally focused programs. It has alsobeen driven by a perception that intern-ship programs tend to select studentswho have more clinical experience,which has led to an increase in theamount of clinical experience in thetraining programs. The result has beenthat compared to students graduating 22years ago, when the current model li-censing act was adopted, many gradu-ates have a considerable foundation inprofessional practice at the time of grad-uation.

In response to this and other changes inthe profession, Norine Johnson, thenAPA President, appointed a Commis-sion on Education and Training Leadingto Licensure that presented its final re-port to the APA Council of Representa-tives (Council) in 2001. Council deferredaction while APA Boards and Commit-tees reviewed the recommendations.

In 2005, Council adopted the policystatement that:• Affirmed the doctorate is the mini-mum educational requirement forentry into practice.

• Affirmed that licensure applicantsdemonstrate they have completed asequential, organized, supervisedprofessional experience equivalentto two years of full-time training.

• Affirmed that postdoctoral educa-tion and training remains an impor-tant part of continuing professionaldevelopment and the credentialingprocess.

EDUCATION & TRAININGChanges in the Sequence of Training Leading to LicensureMichael J. Murphy, Ph.D., ABPPProfessor of Psychology and Director of Clinical Training, Indiana State University


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The APA policy was to be incorporatedin a revision of the Model Licensing Actand a Task Force to revise the Act wasappointed in 2006. The Task Force hasdeveloped a revision of the Model Actand is currently in a second round ofpublic comment on the draft. Thechange in the sequence of training wasincorporated into both drafts of therevised Model Act and will be in theversion to be forwarded to Council foraction at its next meeting. The modellanguage addressing professionalexperience needed for licensure can beseen on page 10 of the online version ofthe draft at http://forms.apa.org/prac-tice/modelactlicensure/mla-review-2009.pdf .It can be anticipated that states will dif-fer in their responses to the provisionsin the Model Act, particularly to thoseprovisions that accept both pre- andpost-doctoral supervised experience.The states listed above are in the van-guard and more will follow. However,others are likely to maintain the require-ment for postdoctoral experience. It maytake some time before the issues getsorted out. However, the process isunderway.Implementing Change in theSequence of TrainingThe actual language that changes thesequence of training can be fairly sim-ple. All that is necessary is for the statuteto include language that asserts theapplicants for licensure must havethe equivalent of two full-time years ofsequential and organized supervisedprofessional experience and one ofthem shall be a predoctoral internship.The real issues arise in writing the rulesthat define the above words in boldtype.

The Association of State and ProvincialPsychology Boards (ASPPB) has devel-oped and is promulgating Guidelines forPracticum Experience that Is Counted for

Licensure in order to assist state psychol-ogy boards develop rules. A copy of theGuidelines is on the ASPPB website:http://www.asppb.net/files/public/Final_Prac_Guidelines_1_31_09.pdf .The Guidelines state “ASPPB is commit-ted to developing model regulationsthat provide guidance to jurisdictionsthat choose to modify requirements inthe sequence of training leading to licen-sure, resulting in consistency betweenjurisdictions.” However, the Guidelinesalso indicate that the authors have seri-ous reservations about the supervisedexperience provisions in the draft revi-sion of the Model Act and adopted thepoint of view that states: “because thepostdoctoral experience is no longer re-quired; the standards for supervised ex-perience must to be more carefullydelineated to ensure that they are organ-ized and sequential.” TheGuidelines alsoemphasize that the experiences must bedocumented carefully and in detail.ASPPB efforts reflect a careful analysisand adherence to very high standardsfor training that arises from deep con-cern about the potential for a diminutionin the preparation for licensure. There-fore, they offer standards that are basedon the highest ideals for preparation.However, they do not take into accountother factors that arise from the changesthat will be discussed below.A goal of the Guidelines is to offer speci-ficity and they aim to achieve it by settingstringent expectations. Examination ofthe resulting recommendations revealsthat they overlook the complexity oftraining, the variety of experiences, andrange of settings inwhich it occurs. Thus,the same expectations for supervision arestated regardless of the stage of the indi-vidual’s training or the nature and com-plexity of the services they are providing.For example, the ASPPB Guidelines thataddress supervision state that for four-hours of direct “patient/client contacts


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hours, for the sake of public protectionand effective learning, the studentwouldbe required to receive two hours ofsupervision.” This “one size fits all”method does not allow training pro-grams to adjust the needed supervisionto what is most appropriate for develop-ment of the trainees.While theGuidelinesraise important issues, they are not likelyto be seen as offering specific language toguide development of the rules. There-fore, the states currently developing rulesmay do better by consulting with eachother in order to provide for consistencyof standards across jurisdictions.Implications for Training ProgramsAs noted above, the issues raised in theGuidelines are informative, but the re-quirements stated in the commentary re-visits issues that the training communityhas addressed some time ago and re-solved through developing standardsfor program accreditation. The best wayto illustrate the potential impact of theGuidelines for training programs is toallow the commentary to speak for itself.The provision in Guideline 2. Breadth andDepth of Training calls for a detailedtraining plan for each practicum experi-ence. The Commentary states:There should be an explicit plan de-veloped for each student who willuse the practicum experience to meetrequirements for licensure that spec-ifies the experiences necessary, withinthe context of the graduate trainingprogram and the student’s previousexperiences, to ensure competenceappropriate to the level of training ofthe student. It is the responsibility ofthe graduate program to provide arationale for the practicum trainingfor each student, in light of previousacademic preparation and previouspracticum training.

The Commentary forGuideline 2 ends bystating:In order for the licensing board to

evaluate the quality of the practicumexperiences of the applicant for licen-sure, it is necessary that the trainingprogram provide to the licensingboard the overall training plan for thevarious practicum experiences, sothat the organized, sequential natureof that training can be assessed by theboard.It is clear that that these provisions in theGuidelines would create barriers to theuse of predoctoral supervised experi-ence to meet requirements for licen-sure.The stridency of these standards isparticularly surprising given the rela-tively limited specification of the train-ing experiences, minimal standards fordocumentation, and absence of over-sight that characterizes current provi-sions for postdoctoral supervision.Furthermore, the Guidelines do not takeinto consideration that a change in thesequence will increase the quality ofpostdoctoral experience by removingbarriers that affect ECPs’ access to third-party reimbursement for their services.It is likely that ECPs will seek and obtainpostdoctoral supervision in order to en-sure mobility and reciprocity with statesthat do not modify the change thatwould allow predoctoral experience tosatisfy the experience requires for licen-sure. Furthermore, quality of the set-tings and experiences will likely bebetter because better reimbursementbenefits sites and ECPs. In addition,training sites will be better able to de-velop and offer formal postdoctoraltraining programs that will be sup-ported by the reimbursement of servicesprovided by licensed trainees that is lim-ited by the current standards.

Implications for Students and ECPsStudents and ECPs should understandthat passing legislation is only the firststep and that careful attention and activemonitoring and participation in the rule


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making process is necessary. Studentsshould maintain careful documentationof the supervised training they receive.None-the-less, ECPs must be aware thatthey may not be able to document theirpredoctoral training retrospectively tomeet the standards adopted for super-vised expereince.As noted above, those ECPs who doachieve licensure on the basis of predoc-toral supervised experience must con-sider the issues of mobility andreciprocity. Therefore, those who are li-censedwithout completing postdoctoralsupervised experience should nonethe-less obtain and document postdoctoralsupervised experience. This will ensurethat they can meet requirements for li-censure in other jurisdictions that mayhave different requirements.

The ASPPB Guidelines express concernabout a diminution of the quality of serv-ices to patients that might be broughtabout by licensing psychologists at thetime of the doctorate is conferred on thebasis of predoctoral supervised experi-ence. However, it seems equally likelythat an increase in quality may be noted.This arises because accountability formonitoring clinical experiences will beassumed by the doctoral training pro-grams that can more effectively overseeand provide quality control over the re-quired hours of supervised experience.Furthermore, it is anticipated there willbe an increase the opportunities for post-doctoral training because services ofpostdoctoral fellows will be reim-bursable and contribute to the develop-ment and funding of postdoctoraltraining programs.

Change in the sequence of training can

be expected to have other benefits thatinclude:• Reducing the burden on employerswho will be able to obtain more ap-propriate reimbursement for theservices provided by ECPs who cur-rently earn rates of master’s levelproviders.

• Students who work under supervi-sion while completing their disserta-tions would be able to countsupervised hours toward licensure.

• ECPs, who are already burdenedwith debt from education loans,will have higher earnings.

For the above reasons the proposedchanges in the sequence of training isviewed very positively by students andECPs and those who employ them.However, even if a state passes legisla-tion that removes the requirement forpostdoctoral supervised experience,there are a number of issues that mustbe worked through in order to imple-ment the change in licensure. Further-more, the change will place greaterresponsibility on training programs andpracticum and fieldwork settings for or-ganizing and documenting supervisedexperience. As noted above, the situa-tion is further complicated by issues ofreciprocity and mobility. Professionalpsychology is at the beginning stages ofa transition that will require close mon-itoring and management by Division 29members who work in training pro-grams and in practicum and fieldworksettings. Student members must also ac-tively contribute to the effort. Each hasa role in fostering standards for qualitytraining as the means of driving change.

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What does a scientistlook like? As a child,my image of a scientistconsisted of an olderWhite man, dressed ina white lab coat, tin-kering with his exper-

iments in an austere looking laboratory.Since then, I have been educated as aCounseling Psychologist, in the scien-tist-practitioner model, by talentedwomen and men of diverse back-grounds, and still, my image of a scien-tist at 28 is not that different from myimage of a scientist at 8. Do I like thatthis is the image of a scientist that firstcomes to mind for me? No. However, Ido not believe I am alone in this un-wanted aspect of my imagination.I consider myself to be a scientist. Thisrole is part of my identity, what I value,how I define myself, and what I haveworked toward becoming. If you wereto ask me to write down 10 things aboutmyself, “scientist” or “researcher”would make the top of the list. Still,when I look in the mirror, I do not auto-matically see a scientist in the reflectionstaring back at me. As a woman, and ayoung woman at that, I am also notblind to the fact that many others do notautomatically see a scientist when theylook at me, and that, such a vision oftenrequires a period of convincing on mypart. After I completed my doctorate, Imade what was a difficult choice for me,to pursue a career in academia ratherthan clinical work, and many who didnot know me in this capacity seemedconfused, if not shocked. Are you reallygoing to do this, they would ask? Itseemed to be the general conclusion atthe time that I chose academia because I

liked teaching, since it could not havebeen because I liked research, could it?Most of us have heard the following rid-dle (or some variation of it). A father andhis son are in a terrible car accident.They are brought to the EmergencyRoom and as they are both rolled intosurgery, a doctor appears and screams,“That’s my son!” Who is the doctor? Ittakes many of us a fewmoments to real-ize that the doctor was the mother. Apersonal story may illustrate a similarpoint. I once submitted a manuscriptthat employed some advanced and com-plicated statistical procedures for blindreview. One of the reviewers kept refer-ring to the author as a “he” in his writ-ten feedback. I asked myself, why doeshe keep calling me a he? Can’t girls domath too, I thought? But then I had tostop and question myself. Why did I as-sume that this reviewer was a “he”?

While these assumptions can feel as an-cient as the scientist in my image, howcan I expect others to see me as a scien-tist, when I am still waiting for an oldman, in a white lab coat, to appear in mymirror? At the same time, we can nothelp but see ourselves (in least in part)in terms of what others reflect back tous. The faces and backgrounds of psy-chologists have changed over recentyears. Although we have a long way togo, our profession is relatively more di-verse in terms of gender, ethnicity, race,and sexual orientation. Many of the re-searchers I look up to and admire arewomen of different ages, ethnicities, andraces. So why can I not automaticallypicture any woman when you ask me,what does a scientist look like?

FEATUREWhat Does a Scientist Look Like?Rayna D. Markin, Ph.D.Villanova University, Department of Education and Human Services


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Where are all the Female Scientists?Women are clearly underrepresented inscience and university life; for example,data have shown that the proportion offemale faculty members in universitiesaround the world is almost always lessthan 25% (Lie, Malik, & Harris, 1994).Furthermore, women become increas-ingly difficult to find as one climbs upthe academic ladder. In the UnitedStates, the percentage of female full timeprofessors has been reported as only13%, slightly higher than many Euro-pean countries (Osborn, 1998). In psy-chology, only one-third of full professorsare women, and those numbers dropeven lower for department chairs,provosts, and university presidents(DeAngelis, 2008). At the same time,since 1984, the number of females ingraduate schools has exceeded the num-ber of males. Between 1995 and 2005, thenumber of male full-time graduate stu-dents increased by 27 percent, comparedto a 65 percent increase for female grad-uate students (National Center for Edu-cational Statistics, 2007). In psychology,nearly three-quarters of the field‘s doc-torates are held by women; yet, theyhold fewer than half of all tenure-trackpsychology positions, according to the(National Science Foundation, 2006).Given these statistics on the increasingnumbers of female doctoral studentsand the relatively smaller number ofwomen in science and university life,where are all the female psychologistspost-graduation?Counseling and clinical psychology doc-toral programs in particular are areas ofpsychology that typically attract a highnumber of female students. Most of thestudents in these programs begin theirstudies with little interest in researchand most pursue a career in practiceupon graduation, despite an emphasison the scientist-practitioner model intraining programs (Brems, Johnson, &Gallucci, 1996). For some students,women and men alike, research is sim-

ply not their thing. Whether or not onechooses to pursue research or practice(or neither, or both) upon graduation isa personal choice. At the same time, Iwonder what we can do in our trainingprograms to help women feel that theydo indeed have the choice.MentorshipSuppose we accept that increasing re-search productivity among male and fe-male counseling and clinical psychologygraduates is a worthy aspiration. Then,the problem becomes that despite anemphasis on research in graduate schooltraining, the typically female dominateddoctoral programs in counseling andclinical psychology, are not typicallyproducing researchers. An importantpart of the solution is likely to lie in fac-ulty mentorship of student research.Contrary to this notion, one could arguethat students who are attracted to thesetypes of programs often have personal-ity traits that do not lend themselves toresearch, and faculty cannot be asked tochange a student’s personality after all.In fact, research has shown that individ-ual differences, such as personality andinterests, play amajor role in research at-titudes and productivity (e.g., Kahn &Scott, 1997; Mallinckrodt, Gelso, & Roy-alty, 1990). Individual differences surelyplay a role in the career path that bothwomen and men choose. However,when women represent the majority ofpsychology doctoral students but theminority of psychology full time faculty,it does not seem plausible that personal-ity alone is responsible for or determin-istic of a woman’s interest in researchand science. I entered my doctoral pro-gram not exactly opposed to researchbut more fearful of it. I find that my ownstudents, especially female students, are“opposed” to research because they areafraid that they will fail at these under-takings. On top of this, they often havenot had adequate exposure to researchto really knowwhat it is. Research men-


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tors can be crucial in addressing theseobstacles (low research self-efficacy, highresearch anxiety) that often stand in theway of these students pursuing researchactivities.Much has been written about the role ofmentorship in graduate school educa-tion and it is clear that mentorship mat-ters, especially when it comes tostudents’ attitudes toward research andresearch productivity. For example, Roy-alty and Reising’s (1986) study foundthat students’ interest in research waspositively influenced by interacting withrole models or an advisor in research ac-tivities. Similarly, O’Brien (1995) andGelso (1997) both found that studentsoften focused on their relationship withfaculty members when reporting criticalincidents. Several studies suggest thatfaculty modeling or mentoring in re-search relates to the research productiv-ity and involvement of psychologystudents and recent graduates (Cronan-Hillix, Gensheimer, Cronan-Hillix, &Davidson, 1986; Galassi, Brooks, Stoltz,& Trexler, 1986; Krebs, Smither, & Hur-ley, 1991). Graduate students typicallyreport that having a mentor is a criticalcomponent of graduate school training(Atkinson, Neville, & Casas, 1991; Lark& Croteau, 1998; Luna & Cullen, 1998)and ethnic minority psychologists re-port that faculty encouragement in re-search was important and useful(Atkinson et al., 1991).

Compared to the literature onmentoringoverall, there is little research specificallyon gender and researchmentoring. Someprevious research in this area suggeststhat gender moderates the relationshipbetween the research training environ-ment, self efficacy, and research produc-tivity. The research training environmentis an empirically tested model that out-lines nine themes central to a researchtraining environment that predicts stu-dent research productivity (see Gelso,1997). Brown, Lent, Ryan, and McPart-

land (1996) found that for men, researchself efficacy had a stronger effect on re-search productivity. For women, how-ever, the research training environmenthad a stronger effect on their researchproductivity. Hollingsworth & Fassinger(2002) found that students’ researchmentoring experiences and research selfefficacy mediated the effect of the re-search training environment on researchproductivity. Unlike Brown et al. (1996),these researchers did not find differentresults for women and men. More re-search is needed to better understandwhat female psychology doctoral stu-dents need from a research mentor andhow their research involvement and pro-ductivity relates to mentorship, the re-search training environment, and theirresearch self efficacy.

Some female doctoral students in psy-chology may not enter graduate schoolwith a self-concept that allows them tothink of themselves as researchers.Whenthe cultural symbol of a scientist is aman, as a woman, it may be more diffi-cult to picture yourself as a scientist. Fu-ture research can examine femaledoctoral students’ prototypes of a scien-tist, and if these prototypes relate to thedegree towhich students identify as a re-searcher. Furthermore, future researchmay study how a student’s prototype ofa scientist and identity as a researcher re-late to their attitudes toward research,and research involvement and produc-tivity. Another potential area for futureresearch is to identify what types ofmen-toring relationships are needed for fe-male doctoral students to ultimatelypredict positive research attitudes, in-volvement, and productivity. Drawingfrom the psychotherapy research on thetherapeutic relationship and techniques,perhaps a student’s involvement in re-search is predicted by both a strongmen-toring relationship and the techniquesthat thementor uses to actually teach the


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student how to conduct research. Femaledoctoral students may need multiple re-search mentors to provide relationshipsin which they can develop their researchself-efficacy and skills.

ConclusionI am one of those lucky early career pro-fessionals to have received mentorshipin research by both men and women.These mentors have supported my sci-entific aspirations and sense of self as aresearcher. Despite all this, when I closemy eyes and picture a scientist, I still donot picture someone that looks like me,and instead, that same older man comesto mind. The scientist that lives in myimagination may always be there, nomatter the amount of education, men-

torship, or professional success in mylife. He is an amalgamation of movies,books, cultural convention, andmy ownpersonal history that I have internalized.Perhaps this will one day change, and Iwill begin to envision scientists that lookmore like me. Yet, would envisioningmyself to look more like a scientist actu-ally make me any more of a scientist?Other female psychologists and doctoralstudents may have a similar image ofwhat a scientist really looks like. How-ever, in reality, a scientist does not looklike anything or anyone. Rather than fo-cusing on what a scientist looks like, itmay be more helpful to focus on what ascientist actually does, and if you use thescientific method to get a little closer tosome truth, then you are a scientist.

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Find Division 29 on the Internet. Visit our site atwww.divisionofpsychotherapy.org

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As the field of psychotherapy moves to-ward a more collaborative approach totherapy interventions, clients’ expecta-tions of treatment and therapist-clientvariables have become a central focus ofresearch (Wampold, 2001). Ongoing re-search is being conducted at the Univer-sity of Denver’s Counseling PsychologyTraining Clinic to examine the effects ofcollaborative treatment planning andtherapeutic choice on theworking allianceand outcome. This articlewill describe therationale anddevelopment of the TherapyPreferences Interview (TPI) in which thetherapist asks clients about and discussespreferences for the therapist’s approachand type of therapy to receive. This articlepresents preliminary research onwhethertaking additional steps to actively inquireabout clients’ preferences and presentingthem with choices help strengthen theworking alliance.Importance of Client ChoiceEthical guidelines emphasize the impor-tance of informed consent and disclo-sure of the therapist’s approach andopportunity for questions and answersin the therapeutic process (AmericanPsychological Association, 2002). Atten-tion has been given to ways to developtreatment plans by varying approachesaccording to client characteristics (Beut-ler & Clarkin, 1990); however, Norcross(2003) proposed that clients directly beasked about their preferences for thetherapist’s characteristics and approachto allow the therapist to customize thetherapy provided. Wampold (2001) con-ducted a meta-analysis of the effect ofvarious factors on therapy outcome andconcluded with several recommenda-tions, one of which was “clients should

have the freedom to select the theoreticalapproach of their choice” (p. 226).According to the APA Presidential TaskForce on Evidence-Based Practice (2006),“psychotherapy is a collaborative enter-prise in which patients and cliniciansnegotiate ways of working together thatare mutually agreeable and likely to leadto positive outcomes” (p. 280). Based onNorcross (2003) and Wampold’s (2001)meta-analyses, providing clients with achoice in treatment may be an importantaspect of treatment planning in psy-chotherapy.

Working AllianceSome therapist-client variables, such asempathy, warmth, and client expectancyfor change have been identified acrossvarious treatment approaches and havebeen termed “common factors” (Lam-bert & Ogles, 2004). Of the common fac-tors, the client-therapist relationship haslong been considered a key common fac-tor in facilitating a positive therapeuticoutcome (Norcross & Lambert, 2006).Bordin (1994) broadened the concept ofthe therapeutic relationship by definingthe “working alliance” as not only thetherapeutic bond, but also collaboration

FEATUREA Therapy Preferences Interview:Empowering Clients by Offering ChoicesBarbara Vollmer, Ph.D., Jen Grote, M.Ed., Robin Lange, M.A., Charity Walker, M.A.University of Denver


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and mutual agreement between thetherapist and client on the goals andtasks of therapy. The working alliancesuggests collaboration between the ther-apist and client as the key factor throughwhich change is achieved in psychother-apy (Horvath & Symonds, 1991).

Researchers have argued that a strongtherapeutic alliance is a necessary com-ponent for therapy to be effective (Nor-cross, 2003). Horvath (2001) suggestedthat a little over half of psychotherapy’spositive effects can be attributed to thequality of the alliance. The alliance pre-dicts therapy outcome equally for alltheoretical orientations, and client’s rat-ings of alliance are more predictive ofoutcome than either therapists’ or ob-servers’ ratings. Horvath (2001) foundthat alliance is established within thefirst three sessions and remains largelystable throughout treatment, lendingfurther support to the importance ofstrong alliance in positive clinical out-comes. These findings emphasize theneed for the therapist to establish a pos-itive working alliance with the clientearly in treatment. Horvath andLuborsky (1993) suggested that researchbe focused on determining specific ther-apeutic actions that could help tostrengthen the therapeutic alliance.

Attending to clients’ preferences fortherapeutic approach may be a factorthat helps to increase therapeutic al-liance and promote other therapeuticmeasures of success. In recent years at-tention has significantly increased inpractice and research on the relation be-tween similarity of clients’ preferencesfor treatment and important processvariables, particularly the client-thera-pist relationship (Iacoviello et al., 2007).The effects of allowing clients choicesabout their treatment should be consid-ered in terms of the treatment processand clients’ outcome in therapy.

Effects of Client Choice onOutcome and ProcessArnoff, Glass, and Shapiro (2002) re-ported that studies on client preferencesand outcome are limited, though inter-est is increasing. Some research hasshown that providing clients with achoice of treatment produces positive re-sults on the treatment process, such asincreasing the likelihood of reachingtreatment goals, increasing contact withthe treatment program, and decreasinglikelihood of terminating treatmentearly (Calsyn et al., 2003; Calsyn,Winter,&Morse, 2000; Rokke, Tomhave, & Jocic,1999; de Shazer & Isebart, 2003; Swift &Callahan, 2009). Additionally, Iacovielloet al. (2007) found that a match betweenclients’ preferred treatment and treat-ment received assisted the developmentof a positive working alliance. However,research on the direct effect of clientchoice on client outcomes has producedmixed results (Adamson, Sellman, &Dore, 2005; Glass, Arnkoff, & Shapiro,2001; Atkinson, Worthington, Dana, &Good, 1991; Devine & Fernald, 1973;Rokke, et al., 1999).

Some studies have investigated the po-tential impact of matching clients totheir stated treatment preference on bothoutcome and process variables (Atkin-son et al., 1991; Goates-Jones & Hill,2008). Goates-Jones & Hill (2008) foundno difference in outcome for clients whoreceived or did not receive their prefer-ence for an insight-oriented or action-oriented single session. Atkinson, et al.(1991) identified comparability ofclient’s etiology beliefs about the prob-lemwith the explanations offered by thetherapeutic approach as a critical ingre-dient. Though clients who attended atleast three counseling sessions rated theprocess and outcome equally positiveregardless of whether their preferredtherapy approach matched that of theircounselor, clients’ perceived similarity


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of etiology beliefs was predictive ofcounselor credibility and satisfactionwith therapy. Additionally, a recentmeta-analysis of 26 studies on the im-pact of client treatment preferences onoutcome suggests that there is a smallsignificant effect (Swift & Callahan,2009). However, none of these studiesincluded in the meta-analysis specifi-cally asked clients about their prefer-ences for the client-therapist relationshipor their choice for their type of therapy.

The Treatment Preferences InterviewThe Treatment Preferences Interview(TPI) was developed to operationalizerecommendations by Norcross (2003) tocustomize the therapist-patient relation-ship. In a pilot study, twenty-four clientswith gambling problems were askedfor their preferences related to fivetypes of psychotherapy that had beendemonstrated to be effective in previousresearch studies: Cognitive-Behavioral,Psychodynamic, Solution-Focused,Moti-vational Enhancement and Twelve Step(de Shazer & Isebart, 2003; Ladouceur, etal., 2002; McCown & Chamberlain, 2000;Petry 2005; Van Wormer & Davis, 2003).Based on results from the pilot study, So-lution-Focused, Cognitive-Behavioral,and Psychodynamic therapies were in-corporated into the final TPI, which wasalso reviewed by expert consultants whohelped refine the therapy descriptions(see Tables 1 and 2 formore information).Current ResearchA larger ongoing research study is cur-rently being conducted. Adult clientswho volunteer to participate in the clinicresearch are randomly assigned to oneof three conditions: Treatment as usualin which the therapist selects the thera-peutic approach, Treatment Preference(TPI), or Assigned Treatment, in whichthe therapist is assigned the therapy ap-proach. Outcome is measured by theOutcome Questionnaire, OQ 45.2, (Lam-bert et. al., 1996), the Working Alliance-short form (WAI-S; Hatcher & Gillaspy,

2006), therapy retention, and client satis-faction. Counselors attend weekly su-pervisory sessions for assistance inadhering to the selected or assignedtherapy. Research is also being con-ducted on student-counselors’ experi-ence in collaborating with their clientsand on the effects of students’ allegianceto a type of therapy on outcome.Preliminary findings on client percep-tion of the use of the TPI with 48 clientssuggest that clients who were given theopportunity to choose the therapy ap-proach felt that it was important to beincluded in this decision. When askedabout their preferences for therapist’s re-lational approach, 84.2% of clients re-ported a positive experience and 15.9%indicated they did not like expressing apreference or were neutral.Client therapy preferences were as fol-lows: 37.5% Dynamic, 35.4% Solution-Focused, and 27% CBT. 25.6% indicatedthat they preferred to make the choiceabout therapy type, 33.3% were neutraland 41% indicated they preferred thetherapist make the choice. While moreclients tended to prefer that the therapistmake the choice about therapy typeused, when asked about how importantit was to be included in the decisionmaking process about type of approachemployed, the majority of clients indi-cated they liked being offered a choice.Data about the sample’s preference for atherapist who is directive and takescharge of a session may help to explainthe findings regarding the clients’ ten-dency to prefer that the therapist makethe decision about type of therapy. 85%preferred that the therapist take chargewhile only 15% expressed a preferencefor more control of the session. Clientsalso tended to prefer a warm, expressivetherapist (82%) as opposed to a more re-served therapist (5.1%). When studentcounselors were asked about their expe-rience of administering the TPI, prelim-


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inary results indicate that almost all in-dicated they appreciated the more col-laborative nature of the sessions.

Based on the review of previous litera-ture, Wampold (2001) and Norcross(2003) emphasized the importance of al-lowing clients their choice of treatment.Developing the TPI was an attempt toaddress the limitations of previous stud-ies and introduce a concrete tool to inte-grate clients’ preferences intopsychotherapy. While small samplesizes require that the results be inter-preted with caution, the preliminaryfindings suggest that important infor-mation can be gained by engaging

clients in collaborative treatment plan-ning and the mere act of offering clientsa say in their treatment may have a pos-itive effect on the working alliance. Theclients sampled thus far appear to preferthat the therapist make the majority ofthe decisions about treatment, howeverclients appreciated being asked to be in-volved in the process. Spending time en-gaging the client in dialogue about theirpreferences for treatment during the in-take may pay dividends throughout thetreatment, possibly by reducing thepower differential and making knownthe value of the client’s contribution tothe therapy process.

Table 1: Description of the Treatment Preferences Interview

Working Alliance Factor Question content and examples

Relational Bond Prior therapy or experience being helpedWhat was most helpful? What was the worsta therapist could do?Preferences for counselor’s characteristicsStrong preferences for counselor’s: gender, ethnicity,language, sexual orientation, religionPreferences for the counselor’s approachPreferences for a therapist who takes charge, is active/talkative and expressive/warm, or client takingcharge, and the therapist is more quiet and reserved

Consensus on Tasks Preferences for treatment modalityIndividual, couple, group and/or family sessionsPreferences for counseling tasksTry new things between counseling sessions; readingself-help books; watching self-help movies; goingon-line for information

Agreement on Therapy Beliefs about the causes of the problemGoals and Approaches Will of God, unlucky experiences, biological make-up,

unmet emotional needs, unrealistic expectations,relationship conflicts, lack of self knowledge, lifestyle, lack of willpowerPreferences for type of therapySolution-focused therapy, Cognitive Behavioraland Dynamic continued on page 37

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Table 2: Description of the therapy choices offered to clients

Solution-Focused Therapy is a goal-oriented therapy that focuses on helping youto clarify what is important to you, changes you would like to have in your life,and steps you might take to achieve your goals. This is an active therapy whereyour counselor and you will be working to identify your strengths and successesand will search with you for solutions to your present dilemma. There often is dis-cussion on what small changes and steps will improve your life, and what to payattention to and what to think about doing differently between sessions. You willbe asked to notice any progress.

Cognitive Behavioral Therapy (CBT) is a goal oriented therapy that is active anddirective in nature. The purpose of this therapy is to explore thoughts and behav-iors that may cause you to engage in problematic behaviors. You and your coun-selor work together to develop newways of thinking about problems, and youwilllearn new skills to deal with them. To help identify patterns thought logs are usedfrequently in your session and between sessions. Your counselor will ask you tocomplete assignments and try change techniques that may be practiced throughoutyour week.

Dynamic Therapy’s goals include improved relationships, attunement to feelingsand/or a resolution of a conflict. Your therapist focuses on the expression of emo-tions, and explores wishes, attitudes, and behaviors. Your therapist will help youto talk about yourself and your relationships to identify your expectations andrepetitive patterns in your life and your relationships. The focus is often on resolv-ing past experiences and prior traumas, and identifying expectations you have foryourself and others. You will be asked to think about yourself and relationshipsbetween sessions.

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The Black BoxThere was once a Lar-son cartoon showing achalk board full ofcomplex mathemati-cal equations andcomputations and anE=MC2-type conclu-sion linked by a blackbox marked “and thena miracle happens.”For many, enteringleadership and gover-nance of APA Divi-sions may feel as

mysterious as that. We need to elucidatethe black box.It may be daunting just to look at the listof officers and members of the board ofDivision 29: luminaries of the profes-sion, publishing superstars, past-presi-dents of State Provincial and TerritorialPsychological Associations (SPTA’s) orother psychological associations, APAdivisions and societies, and even past-presidents of APA—an extraordinarygroup of psychologists.There is of course great practical advan-tage to having senior and seasoned psy-chologists in governance—they know theropes, they know the people to know,they provide continuity and “institu-tionalmemory,” they carry prestige, theyunderstand the organization, and theyknow how to get things done. However,there is also a risk that this may becomewhat has been termed “a club that runsthe club,” an in-group harboring thepower of the organization that seems im-penetrable and perhaps unapproachable,or as we have heard them humorouslydescribed “APA Junkies.”

Division 29 is committed to increasingdiversity in our membership, focus ofresearch, and leadership/governance.Here we will consider the issue of lead-ership and governance. How are we toattract, retain, inspire and learn fromnew faces at the table?A couple of problems or barriersOne real issue in bringingmore diversityto governance is the verymodel of gover-nance itself. The rules and structures ofAPA and many other organizations be-long to a kind of culture of their own, atype of formal, parliamentary process inwhich participants have to know the per-haps arcane rules and regulations, be atease with speaking up in public forums,be willing to put their personal and pro-fessional stances up for scrutiny, and inthe case of elected office, to be willing toface rejection and failure. There aremanypossible ethnic and cultural barriers tofeeling comfortable in such a system.Take, for example, an Early Career Pro-fessional (ECP) of Asian or Pacific Is-lander origin and consider the values ofharmony, humility, respect for elders orperceived superiors, and honor or face.All may be in apparent contradictionwith the requirements for success in ob-taining a leadership position.Another major issue is the time vs.money problem—it seems that we reallycan have one or the other, but not both.Students come out of lengthy programsburdened with debt; ECP’s are either atthe lower end of the pay scale or are try-ing to build up their private practices,often struggling financially; mid-careerpsychologists may be so busy that they

DIVERSITY/PUBLIC POLICY AND SOCIAL JUSTICEA Place at the TableOpening Up Leadership and Governance: ANeed for TransparencyThrough the Black BoxRosemary Adam-Terem, Ph.D. and Jeffrey E. Barnett, Psy.D., ABPP


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feel they cannot afford to take the timeaway; psychologists who live far fromurban centers or in far-flung areas of theStates, Territories and Provinces have toface long, time-consuming, and verycostly journeys. There is a risk that lead-ership and governance will be popu-lated only by those who can afford it.

Why increase diversity?There are reasons of justice referenced inPrinciple D, Justice, of the APA EthicsCode (APA, 2002) that state:…fairness and justice entitle all per-sons to access to and benefit from thecontributions of psychology and toequal quality in the processes, proce-dures, and services being conductedby psychologists. (p. 1063)

This is an aspirational goal, but one thatshould apply to the way APA runs itsown business. Diversity is everyone’sbusiness. In addition, we hope that thework of the Division will be relevant totoday’s psychologists who are them-selves increasingly diverse. By diversity,wemean to include more than the racialand ethnic, linguistic and cultural spec-trum. Psychologists come from differentage and stage of professional develop-ment groups (not always correlated), ge-ographical and geosocial (urban orrural) areas, vary in gender and sexualorientation and identity, ability status,theoretical orientation, and professionalspecialty (research, training, practice)and work arena (private office, univer-sity, organization), and so on. We arecommitted to promoting and celebratingdiversity as defined in Principle E, Re-spect for People’s Rights and Dignity, ofthe APAEthics Code, which states:Psychologists are aware of and re-spect cultural, individual, and roledifferences, including those based onage, gender, gender identity, race,ethnicity, culture, national origin, re-ligion, sexual orientation, disability,

language, and socioeconomic statusand consider these factors whenworking with members of suchgroups. (p. 1064)

How then can psychologists in all theirdiversity feel included and have an ac-tive part in the life of the Division? Howdid others do it? And how did psychol-ogists from minority and underrepre-sented groups achieve what they have?In another article, we will feature somemembers’ experiences.

Let us enter the Black Box—What do you have to do to be part ofleadership or governance?There are many ways to be involved,and many paths to participation at theboard and committee level. The broad-est overview would be that a psycholo-gist or a student would decide on whatissues are most compelling or in whichthey have expertise to offer, and wouldthen communicate with other Divisionand Board members in related roles.This could be done by e-mail, by listservcommentary, by the exchange of ideas inarticles, through person to person con-tact (old fashioned idea here), by phone,at meetings, or at conferences, or evenover a cup of tea.

It is important to remember that noteveryone feels comfortable puttingthemselves forward, so it is the respon-sibility of board members and others inleadership roles to reach out and invite,encourage, and inspire others to join in.Every member of the Division’s leader-shipmust take personal responsibility tomake the Division an open andwelcom-ing place. We must each also activelyreach out to colleagues and when at-tending events andmeetings of the Divi-sion, actively seek out those we don’tknow, make them feel welcome, and en-courage their involvement and partici-pation. It’s very easy to be friendly andwelcoming to those we already know.


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What’s really needed is creating a wel-coming environment for everyone.Probably the simplest path is for those inacademia, where there is access to psy-chologists on site, where meetings, dis-cussions, and seminars provide forumsfor interaction. It is more complicated forthe private practitioner, especially in arural or remote area, where other psy-chologists may be scarce indeed.

Fortunately, new developments in tech-nology for those who can keep up (an-other possible barrier) offer betteroptions for access than ever beforethrough remote linkage. Division 29 cancontinue to develop new ways of con-necting people.

The developmental pathwayWe often speak of the “pipeline,” ametaphor for the developmental se-quence required to bring people into ourprofession. It is not enough to train stu-dents to the postdoctoral level and thendeclare them professional psychologists.Remember the Larson cartoon. We needto be able to see into the black box. Stu-dents need to be able to see the stepsahead—to first job, early career, mid-ca-reer, and mature career status.

Students can be encouraged and empow-ered to become involved in their futureprofession from the very start, for exam-ple by joining their SPTA, taking on com-mittee roles and volunteer work atconferences, presenting their work atconventions and poster sessions, joiningAPA Graduate Students (APAGS), andattending APA conventions where theycan follow APAGS programming. Thisfosters comfort and confidence and cre-ates relationships, which are often thebasis for involvement in professional or-ganizations. Of course, there are financialconstraints on live participation, espe-cially at the national level. There is a needfor creative solutions to help level theground and provide more equal access.

As they begin their professional lives,ECP’s need to stay involved. This can bea challenge: financial and practical pres-sures of the work environment can limitthe ability to travel or attend meetings.This is where mentoring comes in. It isessential to stay in touch with one ormore mentors, and many SPTA’s havespecific programs to connect ECP’s withmentors. Remaining active in at leastSPTA events is usually feasible, and itmay be possible to have live or virtualpeer support groups.These may be some foundational stepsfor gaining a level of comfort with theculture of large organizations and fromthere it may be easier to seek office orleadership roles.Back to the black box: so how do youactually go about being nominatedand elected?Any Division member in good standingcan be nominated or self-nominate for aposition. The “slates” are put togetherby the nomination committee, whichhas the responsibility of offering goodcandidates for every position open, tak-ing into consideration the diversity ofthe Division’s membership and theunique contributions that potentialnominees may make to the governanceof the Division. Separate slates may bedeveloped to create opportunities formore and less experiencedmembers, formembers of underrepresented groups,or other membership groups that willbenefit the Division. Each candidatewrites a personal statement of interestand goals. The ballots go out to mem-bers of the Division in April and thevotes are tallied centrally at APA. Re-sults come out in the summer.Assuming you get elected, then what?What does the position entail?As a board member, you would expectto travel twice a year to weekend meet-ings in Washington D.C. (for whichtravel and accommodation expenses are


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covered by the Division), and to be partof e-mail and possibly ‘phone discus-sions between times. The Division alsomeets at APA Convention and holds aterrific social hour where members getto mingle andmeet others. There are nu-merous committees to be involved withalso, and sometimes task forces.

Other leadership opportunitiesDivision members can be involved withcommittees even if they do not holdelected office. This is an excellent oppor-tunity for student members and ECP’sto have an active role, see how thingswork, and perhaps decide from there torun for office.

Division 29, like most other APA divi-sions and SPTAs, is always looking fornew members for its various commit-tees. See the list of Division 29 commit-tees on the Division 29 website. Find onethat is of possible interest to you andthen contact the Committee Chair. Ex-press your interest, learn more about thecommittee, and if it seems like a good fit,volunteer to join the committee. Ifyou’re not sure which committee mightbe best for you, contact the president ofthe Division, express your interest ingetting involved, learn what the Divi-

sion’s needs are, and then volunteer toparticipate. Another great way to startoff in the Division is to submit somebrief articles on areas of interest or ex-pertise for you to the Division’s publica-tion, the Psychotherapy Bulletin. That’s agreat way to make a contribution, to getnoticed, and to begin your involvement.

No one is expected to know everythingabout the Division right away (if ever!),who the key players are, how to getthings done, and the like.When you firstvolunteer to participate in the division,ask for a mentor. Having a senior col-league assigned to support and assistyou can make all the difference. Feelingon your own, not knowing who to askfor guidance, or what to do will likelylead to dropping out of the activity. Di-vision 29 must actively work to preventthis. Having a helpful, supportive, andcaring mentor in the division is impor-tant to all newly involved members.

For more information, visit the websiteat http://www.divisionofpsychother-apy.org or contact any of the Division of-ficers listed there. They will be glad tospeak with you or answer questions bye-mail.

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As the new FederalAdvocacy Coordina-tor (FAC) for Division29 it was my pleasureto attendmy first StateLeadership Confer-ence on your behalf inWashington D. C. this

past March 1-4. Nothing could have pre-pared me for the excitement and the en-ergy that was in the air during thesessions prior to the Capitol Hill visits.Katherine C. Nordal, Executive Directorfor Professional Practice, Practice Direc-torate, APA gave the keynote address.Dr. Nordal reminded us of the pivotaland unique role psychologists play inhealth care in this country. She informedus that in light of our training as criticalthinkers and researchers and our expe-rience as practitioners, we have a re-sponsibility to assert ourselves in thecoordination of integrated health care.Because of our knowledge of preventivemeasures and our development of pro-tocols, we can facilitate measures thatwill ultimately lead to savings in healthcare cost. She reminded us that psychol-ogists understand the relationship be-tweenmental health and physical healthand should therefore become more in-strumental and visible in the issues thatare being addressed in the potential re-structuring and delivery of the healthcare system.

Dr. Nordal’s remarks set the tone of thisyear’s conference and were consistentwith the information that followed.The theme of the conference With Chal-lenge Comes Opportunity was under-

scored by Dr. Nordal and we were off toa rousing start! Sessions entitled: The2008 Elections and the Future of HealthCare in America, The Primary Care Associ-ation Initiative: Integrated Care and RuralHealth, Health Care Delivery Systems: Pro-moting Psychology in Hospitals and OtherFacilities Through Legislation and Practi-tioner Advocacy, Understanding the NewFederal Parity Law, Medicare: How FederalPolicy Impacts Psychological Services andThe Presidential Task Force and Summit onthe Future of Psychology Practicewere justa few of the areas addressed over thenext few days.

As I was beginning to feel that our re-sponsibilities as psychologists wereoverwhelming, though critical, the cere-mony surrounding the presentation ofthe awards for the 2009 PsychologicallyHealthy Workplace Awards and BestPractices Honors occurred. We were allreminded of the potential that can be re-alized as the result of commitment andknowledge dedicated to the service ofour fellow human beings, which is ahallmark of our profession.

Thus, informed and invigorated weheaded to Capitol Hill to speak with leg-islative staffers regarding the health careissues that impact psychologists andthose they serve. This year we focusedon four primary issues in our “hill brief-ings.” Here is a brief summary of thetopics we addressed.1. The Centers for Medicare and Medi-caid Services (CMS) reduced reim-bursements for many services in 2007.

PRACTITIONER REPORTState Leadership Conference 2009: Exciting Timeson Capitol Hill and OffReport of Federal Advocacy Coordinator (FAC) for Division 29Bonita G. Cade, Ph.D., J.D., Roger Williams University, Rhode Island andPrivate Practice


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Mental health services and psycho-logical testing services experiencedthe greatest cuts. Although the Con-gress did cause a partial restorationfor some of the cuts made in 2008through TheMedicare Improvementsfor Patients and ProvidersAct of 2008( MIPPA), that “restoration” is slatedto expire on December 31, 2009. Dur-ing the visits to Capitol Hill we askedfor new legislation to continue therestoration through December 2011,at which time there will be a 5-year re-view.

2. Psychologist perform many servicessuch as establishing diagnosis andtreatment options, analyzing psycho-logical tests, counseling, the coordina-tion of care and consultation on cases.These services are all within thepurview of our licensure.

These services are considered to beevaluation and management services(E/M) for which psychologists are notreimbursed because CMS prohibitsbilling by psychologists because theseare labeled as “medical services.”Thus we requested that psychologistsbe made eligible for Evaluation andManagement code reimbursement.

3. The Medicare “physician” definitionof the Social Security Act has beenamended to include non-physicianproviders such as chiropractors, op-tometrists, dentists and podiatrists,who like psychologists, provide serv-ices to their patients and clientswithin the scope of their training andlicensure. Like many other non physi-cian practitioners, psychologists arelicensed to practice independently ofphysician supervision. The access ofolder adults, who, will increase innumber and often fail to obtain men-

tal health services, would benefitfrom the inclusion of psychologists inthe definition of “physician.” In ourdiscussions with legislative stafferswe recommended that Congressamend the Medicare “physician”definition to include psychologist.

4. Health Care Reform is a necessaryand dynamic process. It is also thecase that we as psychologists have ex-pertise to facilitate beneficial changes.Thus it is important that our profes-sional research, training and expertisebe a significant part of decisions re-lated to health care. We have studiedthe psychological and behavioral fac-tors that are related to the preventionof disease and the promotion ofhealth and wellness. We frequentlywork in an interdisciplinary mannerto implement and design programsthat encourage healthy behaviors andlifestyles. Thus we urged our law-makers to pass health care reformthat integrates psychological serv-ices in primary care, preventive serv-ices and benefit packages.

We delivered these four requests toCapitol Hill and I am grateful for the op-portunity to participate as the FederalAdvocacy Coordinator for Division 29.

In the future I will be contacting mem-bers of the division about relevant issues.On occasion I will elicit your help in con-tacting your government officials. Manyof youmay have already developed rela-tionships with particular lawmakers andare therefore strategically positioned to“make our case” to the benefit of thosewe serve. Please feel free to contact me [email protected] or [email protected] hope that this update on the 2009 SLChas been informative and I look forwardto this time of challenge!

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In the Fall of 2007, theInstitute of Medicine’s(IOM) Annual Meet-ing focused upon theimportance of integrat-ing individual clinicalexpertise with the bestavailable external evi-

dence—i.e., Evidence-Based Medicine(EBM). “Technological and scientific in-novations continue to expand the uni-verse ofmedical interventions, treatment,and approaches to care, ushering in anera rich with potential for improving thequality of health care but also rifewith in-creased uncertainty about what worksbest for whm… Reforms will be neces-sary to remedy existing shortfalls in ac-cess to care as well as to take betteradvantage of the opportunities providedby innovation, information technology,and broader stakeholder engagement.”The American Recovery and Reinvest-ment Act of 2009 (The Economic Stimu-lus legislation, P.L. 111-5) included twomajor, highly relevant federal invest-ments. The first was the inclusion of theHealth Information Technology for Eco-nomic and Clinical Health (HITECH)Act, which is intended to promote thewidespread adoption of health informa-tion technology (HIT) for the electronicsharing of clinical data among hospitals,health care providers, and other-healthcare stakeholders. Today, relatively fewproviders actually utilize HIT, the mostrecent estimate suggests that only about5% of physicians have a fully functionalelectronic health records (EHR) system.We wonder what the comparable figureis for psychology’s practitioners? Thelegislation’s goal is to bring utilizationup to 70% for hospitals and approxi-mately 90% for physicians by 2019.

HIT has been enthusiastically endorsedat the highest policy level. InApril 2004,President Bush created by ExecutiveOrder the Office of the National Coordi-nator for Health Information Technol-ogy in order to develop, maintain, anddirect a strategic plan to guide the na-tionwide implementation of HIT in thepublic and private health care sectors.During his January, 2009 Inaugural Ad-dress, President Obama: “Our healthcare is too costly…. We will restore sci-ence to its rightful place and wield tech-nology’s wonders to raise health care’squality and lower its costs….” Thebudget of the National Coordinator’sOffice was raised by the Stimulus legis-lation from approximately $66million inFY’09 to $2 billion, while numeroushealth policy experts suggest that thefederal government’s overall investmentfor HIT will reach $19+ billion under thestimulus legislation.The second significant investment wasproviding theAgency for Healthcare Re-search and Quality with $1.1 billion forcomparative effectiveness research, a de-velopment which turned out to behighly controversial. “The conferees donot intend for the comparative effective-ness research funding included … to beused to mandate coverage, reimburse-ment, or other policies for any public orprivate payer. The funding … shall beused to conduct or support research toevaluate and compare the clinical out-comes, effectiveness, risk, and benefitsof two or more medical treatments andservices that address a particular med-ical condition. Further, the conferees rec-ognize that a ‘one-size-fits-all’ approachto patient treatment is not themost med-

WASHINGTON SCENEEvidence-Based Medicine — The Devil Remainsin the DetailsPat DeLeon, Ph.D., former APA President


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ically appropriate solution to treatingvarious conditions and include lan-guage to ensure that subpopulations areconsidered when research is conductedor supported with the funds provided inthe conference agreement.” TheAct alsoestablishes an interagency advisorypanel [the Council] to help coordinateand support the research, composed ofup to 15 senior officials (includingphysicians and others with clinical ex-pertise) from federal agencies withhealth-related programs. The Council isto submit an annual report to the Presi-dent and Congress. Within this broaderpublic policy context, the 2007 IOM de-liberations are timely and prophetic.Highlights:The IOM’s vision is for a learninghealthcare system that “draws upon thebest evidence to provide the care mostappropriate to each patient…” In effect,the learning healthcare system is onewhich enlists organizations, providers,and patients in driving the process ofdiscovery as a natural outgrowth of pa-tient care, and ensures innovation, qual-ity, safety, and value in health care. Thegoal is that by 2020, 90% of clinical deci-sions will be supported by accurate,timely, and up-to-date clinical informa-tion, and will reflect the best availableevidence. The rapid pace of scientificdiscovery and technological innovationover the last several decades is unprece-dented and raises the prospect of achiev-ing dramatic improvements in thenation’s health and well-being. Yetstakeholders from across the healthcaresystem, from patients to practitioners topayers, are demanding fundamental im-provements to a system that is seen ascostly, fragmented, and ineffective.

The IOM discussions focused upon fourfundamental themes: * the forces driv-ing the need for better medical evidence;* the challenges with which patients andproviders must contend; * the need totransform the speed and reliability of

newmedical evidence; and * the legisla-tive and policy changes that would en-able an evidence-based health caresystem. Common observations whichsurfaced were: * Increasing complexityof health care; * Unjustified discrepan-cies in care patterns; * Importance of bet-ter value from health care; * Uncertaintyexposed by the information environ-ment; * Pressing need for evidence de-velopment; * Promise of healthinformation technology; * Need formore practice-based research [a direc-tion espoused for years by Steve Ra-gusea]; * Shift to a culture of care thatlearns; * Newmodel of patient-providerpartnership; and, * Leadership thatstems from every quarter.Those interested in expanding theirpractice into health psychology shouldbe particularly intrigued with the evolv-ing notion that: “With the increasingcomplexity of care, and the need and de-mand for more patient involvement, thetraditional ‘physician-as-sole-authority’model will need to adapt to support pa-tients as integral partners in medical de-cisions.”And further, the prediction thatour healthcare systemwill shift from ex-pert-based practice, which is built uponthe extensive knowledge and experienceof the physician, to a systems-supportedpractice centered on teams supported bywell-defined processes and informationtechnology tools. The demise of expert-based practice is inevitable. Thecomplexity of biomedical informationand technology will increasingly over-whelm an individual expert’s cognitivecapacity. Specialization is not the answerbecause of the accompanying fragmen-tation, which is incompatible with thepersonalization of care that is becomingpossible with progress in genomics andsystems biology. Even if its demise werenot inevitable, one would want to movebeyond expert-based practice, as otherindustries have already done through-out our history.


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Equally significant is that a consistentpattern has been found in which thequality of care, as reflected in processmeasures of care, is actually worse whenspending—and the intensity of care de-livery—is greater. In fact, if all geo-graphical regions adopted the practicepatterns of the most conservativelyspending regions of the country, healthoutcomes could be significantly im-proved and U.S. healthcare spendingcould decline by as much as 30%. Thereis a demonstrable need to focus re-sources where needed; for example, onthe care and treatment of chronic condi-tions such as heart disease, diabetes, andasthma, which affect almost half of ourpopulation andwhich represent approx-imately 78% of our nation’s healthcareexpenditures. Clearly, more is not neces-sarily better.Stressing the importance of personalizedand individualized care, it was notedthat: “For a variety of common diseases,only about 50 percent of patients will re-spond favorably to a given biopharma-ceutical agent. Moreover, such responserates in individual patients are oftenhighly variable in both their magnitudeand their duration.” Presently therapeu-tic interventions are frequently appliedin a “one-size-fits-all” approach, and themeans by which individual patients arematched to therapeutic interventionsoften occurs by “trial and error.” Gath-ering long-term, longitudinal data onoutcomes is challenging, but the cost ofdoing so is unnecessarily high becauseof the current organizational structuresand practice patterns. Massive data setscould be built that could be used to sup-port structured clinical trials and trackthe longitudinal consequences of med-ical interventions. Outcomes are the corevalue in healthcare delivery. However,we should appreciate that there is neveronly one outcome measure in any fieldor endeavor, and health care is no excep-tion. Without true patient engagementand clear and honest communication

about EBM, it is likely that many pa-tients will perceive that “the system” isout to limit their access to the care theyneed. And, it is likely to be much morecomplicated and expensive to imple-ment than is necessary. The key is to pro-tect and preserve the patient-providerrelationship, so that it is on equal footingwith public health and epidemiologicalevidence.During her confirmation hearing beforethe Senate Health, Education, Laborand Pensions (HELP) Committee toserve as Secretary of HHS, GovernorKathleen Sebelius echoed severalreoccurring policy themes of the ObamaAdministration:I have also been a health care pur-chaser, directing the state employeehealth benefits program as well asoverseeing the operation of healthservices in our correctional institu-tions and Medicaid and CHIP pro-grams, and coordinating with localpartners on health agencies acrossKansas. I took these jobs seriously….In these roles, I know first-hand thechallenge of standing up to the spe-cial interests to protect consumer in-terests…. Health care costs arecrushing families, businesses, andgovernment budgets. Since 2000,health insurance premiums have al-most doubled and an additional 9million Americans have becomeuninsured. Since 2004, the number of‘under-insured’ families – those whopay for coverage but are unprotectedagainst high costs—rose by 60 per-cent. Just last month, a survey foundover half of all Americans (53 per-cent), insured and uninsured, cutback on health care in the last yeardue to cost. The statistics are com-pelling, as are the stories…. We haveby far the most expensive health sys-tem in the world. We spend 50 per-cent more per person than the nextmost costly nation. Americans spendmore on health care than housing or


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food. General Motors spendsmore onhealth care than steel. The cost crisisin health care is worsening. TheUnited States spent about $2.2 trillionon health care in 2007; $1 trillionmorethan what was spent in 1997, and halfas much as is projected for 2018. Highand rising health care costs have cer-tainly contributed to the current eco-nomic crisis….The RecoveryAct alsomakes positiveinvestments now that will yieldhealth and economic dividends later.Through health information technol-ogy, it lays the foundation for a 21st-century system to reduce medicalerrors, lower health care costs, andempower health consumers. In thenext five years, HHSwill set the stan-dards for privacy and interoperabil-ity, test models and certify thetechnology, and offer incentives forhospitals and doctors to adopt it. Thegoal is to provide every Americanwith a safe, secure electronic healthrecord by 2014. The Recovery Act …invests $1.1 billion in comparative ef-fectiveness research to provide infor-mation on the relative strengths andweaknesses of alternative medical in-terventions to health providers andconsumers…. The President’s budgetsubmitted in February … dedicates$634 billion over 10 years to reform-ing the health care system.Psychology’s Timely Response: InMarch, 2009, APA President James Braytestified before the IOMwhich has beenasked by HHS to make recommenda-tions for prioritizing its Comparative Ef-fectiveness Research portfolio. James isa long time health psychologist who hasconsistently urged psychology to be-come increasingly involved in inte-grated healthcare.Comparative effectiveness research is acritically important tool for advancing anevidence-based approach to health caredecision-making. However, the full pub-lic health benefits of such research willonly be realized if behavioral, psychoso-

cial, and medical interventions for theprevention and treatment of mental andphysical health conditions are evaluatedindividually and in combination. Evenwhen strictly medical treatments arecompared, it is important to expand therange of outcome measures to includebehavioral and psychological outcomes,such as quality of life and adherence totreatment protocols. It is also essential toevaluate promising new models of care,such as the use of integrated, interdisci-plinary behavioral andmedical teams inprimary care settings.And finally, the ef-fectiveness of health interventions acrossthe lifespan and for different minorityand gender groups must be considered.Therefore, APA is recommending thatcomparative effectiveness research focuson these five areas:We encourage research that comparesdifferent behavioral and psychosocialinterventions for the prevention andtreatment of specific health condi-tions…. Next, we strongly encourageresearch that compares behavioraland psychosocial interventions withmedical interventions, and combina-tions thereof…. Next, we should pursueresearch that compares integrated sys-tems of care comprised of interdiscipli-nary teams of medical and behavioralhealth providers versus routine medicalcare….We also believe that all health re-search studies should include measuresof behavioral and psychosocial out-comes, such as life quality, adherence totreatment protocols, behavioral func-tioning, depression, and anxiety….Andfinally, research that examines health in-tervention outcomes across the lifespanand for different minority and gendergroups is needed to understand the ef-fectiveness of interventions within andbetween population groups….”Interestingly, current OMB DirectorPeter Orszag was one of the 2007 IOMparticipants.Aloha, Pat DeLeon

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Of all the concerns apatient could sharewith a psychothera-pist in hopes of find-ing a dialogue partnerwho might acceptsome responsibilityfor its presence and

whomight participate actively in its res-olution, you would think jealousywould be near the top of the list. Whena patient struggles with feelings of de-spair or outrage, in contrast, it is not im-mediately obvious that these states ofmind are situated interpersonally. Butjealousy can only exist interpersonally.You would think its presence in the psy-chotherapy space would tilt even a clas-sical Freudian analyst away fromthoughts about the patient’s childhoodand lead her to consider how the prob-lem relates to the relationship in whichit’s unfolding. You would be wrong.French psychoanalyst Marcianne Blévishas written a compendium of case stud-ies of jealous patients in which she doesnot, even once as far as I could tell, con-sider whether she might have donesomething wrong that made the patientjealous. Even more startling, she doesnot once consider whether the patient’slover might have done somethingwrong to make the patient jealous. In-stead, it is always the patient’s mother,and sometimes the father too, who haserred. At times, her focus on the pa-tient’s childhood becomes ludicrous. Forexample, a patient eventually says toher, openly and blatantly, “Are youthere?—it’s suddenly cold.” (Keep inmind that Blévis is sitting behind the pa-tient, who is lying on the couch.) Rather

than wonder what she might have doneto make the patient think she had snuckout of the room, Blévis decides that thepatient “lacked a mother who wouldhave caressed her and looked upon herin a happy and loving manner” (p. 114).Similarly, when a patient dreams aboutwhat Blévis interprets as “unseen ca-resses,” Blévis wonders not what it’s liketo receive care from someone the patientcannot see, but instead, “What did shenot see when she was a child?” (p. 111).This refusal to acknowledge fault oreven the co-creation of meaning is spe-cially ironic when the problem is jeal-ousy. Surely we are not alone in hopingthat our bouts with jealousy will be dealtwith first and foremost by discussing thebehavior of the other person that madeus jealous (why are you wearing yourbest outfit to a business meeting?), andsecondly by conversing with our loversabout what might make us feel more se-cure (how would you feel about wear-ing something else?). If the behavior ofthe lover is clearly not threatening, andif attempts to make the jealous personmore secure keep failing, only then doesit make sense to ask what the jealousperson is getting out of the jealousy andto see if there is some other way to getit. Since jealous people may not have theskills to examine the behavior of their in-timates objectively, and since they maynot have the skills to metacommunicateabout their relationships, psychotherapywould seem like a good place to acquirethese skills. Blévis seems not even toconsider this use of treatment, however.For example, her final case study is of aman who tortures himself about the

BOOK REVIEWBlévis, Marcianne. (2009).Jealousy: True stories of love’s favorite decoy.Olivia Heal trans. New York: Other Press.Michael Karson, University of Denver


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fresh bouquet of flowers that Blévis hasin her office every week, and not oncedoes she consider whether it might notbe a good idea to have a bouquet offlowers in one’s office.

I don’t distinguish between psycho-analysis and psychotherapy. I knowthat’s a sort of heresy, but the putativedistinction is one that patients—whoselives are on the line, whose courage is re-quired, andwhose vulnerabilities are ac-centuated regardless of the modality—should not take lying down. We maymake a big deal of the differences, but topatients it’s all the same—they’re look-ing for help with a life problem fromsomeone with power over them (thegreatest aspect of which is the powerto define the situation in the therapy re-lationship). What matters about the dif-ferences between psychotherapy andanalysis is what the patient experiences.Psychotherapists should be open, for ex-ample, to metaphorical communicationfrom patients that the sessions are tooinfrequent, or too conversational, or toohurried. (Indeed, the earliest structuresof psychotherapy were dictated by a pa-tient—Anna O.—not by an analyst;Freud’s genius was that he listened toher.) Analysts should be open, for exam-ple, tometaphorical communication frompatients that the sessions are too frequent,that the pace is too leisurely, or that it isnot productive to do things behind theirbacks. Expressions of jealousy in all itsforms could be examples of the last.In virtually every human system, in-cluding families, couples, and psycho-analyses, a hegemony of special interestsdictates acceptable behavior—a partyline, in Erving Goffman’s terms. Thehegemony then defines behavior thatchallenges the system—behavior that isout of line—in a way that preserves andprotects the hegemony. The terms of thederogatory definitions of out-of-line be-havior change according to the type ofsystem and its local culture, but in psy-

chotherapy, the hegemony—that is,therapists’ definition of themselves ashelpful and harmless—is usually pro-tected by defining patients’ protests aspathological. You can’t possibly beangry at innocent me; you must beangry at your mother. All psychothera-pists, being human, are susceptible tousing their power to define the situationto protect themselves at their patients’expense—call it therapeutic privilege—but they’re supposed to understand thisand provide a way for their patients’marginalized protests to get full voice inthe treatment.The hegemony in Blévis’s psychothera-pies is suggested by her sonorous pro-nouncements about psychology. “Thechild becomes jealously aware of herparents’ sexual prowess and feels terri-bly depressed...” (p. 110). It’s a posturethat patients will have a hard time refut-ing, since any disagreement is chalkedup to unconsciousness about their truefeelings. She also writes, categorically,“Maternal love, far from being angelic,is an impassioned love unconsciouslylaced with violence” (p. 100). What’s in-teresting, of course, is not whether ma-ternal love is laced with ugliness, butwhen—under what circumstances—andwhat to do about it when it happens.Ironically—again—this latter proposi-tion should alert the caregiving, author-itative therapist to her own violentfeelings toward the client, but wheneverBlévis experiences an undesirablethought or feeling about a patient in thisbook, she blames the patient’s motherfor producing someone so annoyingrather than look inward.This book takes us back in time—not inthe psychoanalytic sense of revisitingchildhood conflicts, but in the historicalsense of a time before the developmentsof intersubjectivity, self psychology, andobject relations theory, and before re-search on common factors foregrounded


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the therapeutic relationship. And on thesubject of time, haven’t classical analystslearned in a postmodern world to besuspicious of the accuracy of reports ofchildhood? Shouldn’t they instead betreated as communications in the pres-ent? When Blévis cleverly interprets adream as being organized around thepatient’s difficulty managing reactionsto ambiguity, Blévis doesn’t considerthat her own ambiguity is occasioningprojections from the patient. (It’s useful,of course, to use ambiguity to occasionthe patient’s projections, but the idea isto understand those projections in rela-tion to the environment in which theyoccurred.) Instead, she assumes that atsome point in childhood, the patient“may have caught an indecipherable ex-pression on her father’s face” (p. 27).Similarly, when a patient tells her directlythat he would like Blévis to precede himinto the office so as to be “sheltered from[her] gaze” (p. 81), Blévis does not askherself if she has been looking at himhurtfully, but instead she consoles herselfby attributing his self-consciousness tosomething hismother supposedly did onthe day of his birth (calling him ugly).Blévis does not consider the possibilitythat she and the patient co-created thestory of being called ugly—that of themillions of things he might have saidabout his mother, he chose one thatsuited the moment.The irony of ironies is that the analyst,eschewing responsibility for any jeal-ousy constellated in her office, blamesmothers for eschewing responsibility forjealousy! “Certain parents tolerate suchdemonstrations of intense jealousy with-out perceiving that these demonstra-tions are addressed to them; however,their refusal or inability to intervene, be-cause they think that jealousy amongsiblings is normal, is worrisome for boththe child who violently expresses hisjealousy and for the one who endures it.In both cases, the space of the child’sinner world is invaded by his parents’

own conflicts” (pp. 67-8). So whensomeone is jealous, the person in chargeneeds to realize that it is about her, andshe needs to intervene—unless the per-son in charge is me.Jealousy can be framed as a backstageproblem. We search for true, constant,and abiding love from the day we’reborn to the day we die, but all love—re-ligion aside—is at best inconsistent andvariable. With those we love, we learn totactfully ignore their variable experienceof us and we learn to disguise our vari-able view of them, largely because wecan see that our own backstage fickle-ness does not invalidate the authenticityof our front stage devotion. Jealous peo-ple have trouble reconciling their ownbackstage fickleness with the authentic-ity of their love for the other, or else theyhave some reason to think their lovercannot reconcile the two. What theyneed, generally, are assessment skillsand conflict resolution skills, and a goodway to obtain these in a relevant manneris to get involved in an ambiguous,intimate relationship where the otherperson—a psychotherapist—has someexpertise in backstage management,conflict resolution, and helping peoplefeel secure. This all-too-human psy-chotherapist can use her expertise byexpressing curiosity, warmth, and ac-ceptance about the patient’s confusionregarding the relationship between abackstage and a front stage. When apsychotherapist acts as if she has nobackstage, the situations with the disap-pointing parent, the threatening sibling,and the mysterious lover are merelyreplicated in the treatment rather thanresolved. These patients learn to blametheir parents—a sort of splitting thatprotects the lover and the analyst ratherthan the parent—rather than how to re-solve interpersonal conflicts. Blévis’sorientation is even more distressing inlight of her assertion that her book is not


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for therapists. For a lay audience, it canonly be read as encouragement forblaming one’s parents rather than re-solving conflicts with one’s lover.

Blévis has some nice things to say aboutjealousy. She calls it a “thrilling malady”(p. 1) and she tries to help one patient be-come jealous ( a patient who remindedme of Freud’s warning that people whoare not jealous at all have repressed thisnatural state of mind and accordinglyare dominated by it). But still, like manyclassical analysts, her vision of psycho-logical health seems to be one of cautionrather than one of relatedness. At least,she comes across as awfully cautiousand defended in this volume, which isalso ironic in light of Freud’s daring vul-nerability throughout his writings.

One patient gives up his jealousy andthen considers returning to it only to bethreatened with abandonment by Blévisif he reverts. He decides to stick with herand to forgo his jealousy. His choice is

represented by a dream. “I am on ahighway and I arrive at a fork in theroad. On one road, there is a toll, oneoften has to stop, and there is a risk ofaccidents. On the other road, a vehicleawaits me, a sort of rocket in which I rec-ognize all my fears represented by dif-ferent objects—it wants to take me upthe skies” (p. 43). The exciting path isone of “false hopes” according to Blévis,while the route of “real life (and of hisanalysis!)” is the one she approvinglydescribes as consisting of “obstacles ...tolls and forced stops.”What a choice. Adestructive rocket or a workaday rut.Blévis’s preference for the latter over theformer is understandable, but are thesethe only paths? She seems to validateOtto Rank’s claim that psychoanalysis“breeds patient, docile Philistines.”More importantly, both paths have thepatient travelling by himself. This bookdoes little to help jealous people withthe desperate loneliness of their condi-tion, except to tell them that they are alot like other desperately lonely people.

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MMEEMMBBEERRSSHHIIPP RREEQQUUIIRREEMMEENNTTSS:: Doctorate in psychology • Payment of dues • Interest in advancing psychotherapy

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DDIIVVIISSIIOONN OOFF PPSSYYCCHHOOTTHHEERRAAPPYY American Psychological Association

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Psychotherapy

Documents

Transcript of Psychotherapy