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Psychotherapy
O F F I C I A L P U B L I C AT I O N O F D I V I S I O N 2 9 O F T H E

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A M E R I C A N P S Y C H O L O G I C A L A S S O C I AT I O N

www.divisionofpsychotherapy.org

In This Issue

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Psychotherapy Research, Science, and Scholarship:
Adding Motivational Interviewing to Cognitive Behavioral
Therapy for Anxiety

L
Ethics in Psychotherapy:
An Examination of Integrated Deception in Psychological
Research: Ethical Issues and Challenges

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Early Career:
Mommy is a Psychologist, Too

Therapy Preferences Interview:

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Empowering Clients by Offering Choices

Diversity/Public Policy and Social Justice:


A Place at the Table: Opening Up Leadership and

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Governance: A Need for Transparency
Through the Black Box

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2009 VOLUME 44 NO. 2


Division of Psychotherapy ! 2009 Governance Structure
ELECTED BOARD MEMBERS
P re s i d e n t Professional Practice Diversity
Nadine Kaslow, Ph.D., ABPP Jennifer Kelly, Ph.D., 2007-2009 Caryn Rodgers, Ph.D., 2008-2010
Emory University Department of Psychiatry Atlanta Center for Behavioral Medicine Prevention Intervention
and Behavioral Sciences 3280 Howell Mill Rd. #100 Research Center
Grady Health System Atlanta, GA 30327 Albert Einstein College of Medicine
80 Jesse Hill Jr Drive Ofc: 404-351-6789 Fax: 404-351-2932 1300 Morris Park Ave., VE 6B19
Atlanta, GA 30303 E-mail: jfkphd@aol.com Bronx, NY 10461
Phone: 404-616-4757 Fax: 404-616-2898 Ofc: 718-862-1727 Fax: 718-862-1753
E-mail: nkaslow@emory.edu Education and Training E-mail: crodgers@aecom.yu.edu
P resi de nt- ele ct Michael Murphy, Ph.D., 2007-2009
Jeffrey J. Magnavita, Ph.D. Department of Psychology Diversity
Glastonbury Psychological Associates PC Indiana State University Erica Lee, Ph.D., 2008-2009
300 Hebron Ave., Ste. 215 Terre Haute, IN 47809 55 Coca Cola Place
Glastonbury, CT 06033 Ofc: 812-237-2465 Fax: 812-237-4378 Atlanta, Georgia 30303
Ofc: 860-659-1202 Fax: 860-657-1535 E-mail: mmurphy4@isugw.indstate.edu Ofc: 404-616-1876
E-mail: magnapsych@aol.com E-mail: edlee@emory.edu
Membership
S e c re t a ry Libby Nutt Williams, Ph.D, 2008-2009 APA C ou nci l Rep resen tati ves
Jeffrey Younggren, Ph.D., 2009-2011 St. Mary’s College of Maryland Norine G. Johnson, Ph.D., 2008-2010
827 Deep Valley Dr Ste 309 18952 E. Fisher Rd. 13 Ashfield St.
Rolling Hills Estates, CA 90274-3655 St. Mary’s City, MD 20686 Roslindale, MA 02131
Ofc: 310-377-4264 Fax: 310-541-6370 Ofc: 240- 895-4467 Fax: 240-895-4436 Ofc: 617-471-2268 Fax: 617-325-0225
E-mail: jeffyounggren@earthlink.net E-mail: enwilliams@smcm.edu E-mail: NorineJ@aol.com
Treasu rer
Steve Sobelman, Ph.D., 2007-2009 Early Career Linda Campbell, Ph.D., 2008-2010
2901 Boston Street, #410 Michael J. Constantino, Ph.D., Dept of Counseling & Human
Baltimore, MD 21224-4889 2007, 2008-2010 Development – University of Georgia
Ofc: 410-583-1221 Fax: 410-675-3451 Department of Psychology 402 Aderhold Hall
Cell: 410-591-5215 612 Tobin Hall - 135 Hicks Way Athens , GA 30602
E-mail: steve@cantoncove.com University of Massachusetts Ofc: 706-542-8508 Fax: 770-594-9441
P a s t P r e s i de nt Amherst, MA 01003-9271 E-mail: lcampbel@uga.edu
Jeffrey E. Barnett, Psy.D., ABPP Ofc: 413-545-1388 Fax: 413-545-0996
1511 Ritchie Highway, Suite 201 E-mail: mconstantino@psych.umass.edu Stu den t Devel o pm ent C hai r
Arnold, MD 21012 Sheena Demery, 2009-2010
Phone: 410-757-1511 Fax: 410-757-4888 Science and Scholarship 728 N. Tazewell St.
E-mail: drjbarnett1@comcast.net Norm Abeles, Ph.D., 2008-2010 Arlington, VA 22203
Dept of Psychology 703-598-0382
D om a i n R e pr e s e nt a t i v e s Michigan State University E-mail: Sheena.Demery@fedex.com
Public Policy and Social Justice 110C Psych Bldg
Rosemary Adam-Terem, Ph.D. East Lansing , MI 48824
1833 Kalakaua Avenue, Suite 800 Ofc: 517-353-7274 Fax: 517-432-2476
Honolulu, HI 96815 E-mail: abeles@msu.edu
Tel: 808-955-7372 Fax: 808-981-9282
E-mail: rozi7@hawaii.rr.com
STANDING COMMITTEES
Fel lows Educat ion & Trai ning Psychotherapy Practic e
Chair: Jeffrey Hayes, Ph.D. Chair: Eugene W. Farber, PhD Chair: Bonita G. Cade, ,Ph.D., J.D.
Pennsylvania State University Emory University School of Medicine Department of Psychology
312 Cedar Bldg Grady Infectious Disease Program Roger Williams University
University Park , PA 16802 341 Ponce de Leon Avenue One Old Ferry Road
Ofc: 814-863-3799 Fax: 814-863-7750 Atlanta, Georgia 30308 Bristol, Rhode Island 02809
E-mail: jxh34@psu.edu Ofc: 404-616-6862 Fax: 404-616-1010 Ofc: 401-254-5347
E-mail: efarber@emory.edu E-mail: bcade@rwu.edu
Membership
Chair: Chaundrissa Smith, Ph.D. Past Chair: Jean M. Birbilis, Ph.D., L.P. Associate Chair: Patricia Coughlin, Ph.D.
Emory University SOM/ E-mail: jmbirbilis@stthomas.edu E-mail: drpcoughlin@gmail.com
Grady Health System Continuing Educat ion Psychotherapy Res earch
49 Jesse Hill Drive, SE FOB 231 Chair: Annie Judge, Ph.D. Chair: Susan S. Woodhouse, Ph.D.
Atlanta, GA 30303 2440 M St., NW, Suite 411 Department of Counselor Education
Ofc: 404-778-1535 Fax: 404-616-3241 Washington, DC 20037 Pennsylvania State University
E-mail: csmit33@emory.edu Ofc: 202-905-7721 Fax: 202-887-8999 313 CEDAR Building
Past Chair: Sonja Linn, Ph.D. E-mail: Anniejudge@aol.com University Park, PA 16802-3110
E-Mail: sglinn@verizon.net Associate Chair: Rodney Goodyear, Ph.D. Ofc: 814-863-5726 Fax: 814-863-7750
E-mail: goodyea@usc.edu E-mail: ssw10@psu.edu
Nominations and Elections
Chair: Jeffrey Magnavita, Ph.D. Progra m Past Chair: Sarah Knox, Ph.D.
Chair: Nancy Murdock, Ph.D. E-mail: sarah.knox@marquette.edu
Professional Awards Counseling and Educational Psychology
Chair: Jeff Barnett, Psy.D. Li aisons
University of Missouri-Kansas City
Committee on Women in Psychology
Fi nanc e ED 215 5100 Rockhill Road
Rosemary Adam-Terem, Ph.D.
Chair: Bonnie Markham, Ph.D., Psy.D. Kansas City, MO 64110
1833 Kalakaua Avenue, Suite 800
52 Pearl Street Ofc: 816 235-2495 Fax: 816 235-5270
Honolulu, HI 96815
Metuchen NJ 08840 E-mail: murdockn@umkc.edu
Tel: 808-955-7372 Fax: 808-981-9282
Ofc: 732-494-5471 Fax 206-338-6212 Associate Chair: Chrisanthia Brown, Ph.D. E-mail: rozi7@hawaii.rr.com
E-mail: drbonniemarkham@hotmail.com E-mail: brownchr@umkc.edu
PUBLICATIONS BOARD EDITORS
Chair : Jean Carter, Ph.D. 2009-2014 Psychothe rapy Journal Editor
5225 Wisconsin Ave., N.W. #513 Charles Gelso, Ph.D., 2005-2009
Washington DC 20015 University of Maryland
Ofc: 202–244-3505 Dept of Psychology
E-mail: jcarterphd@aol.com Biology-Psychology Building
College Park, MD 20742-4411
Raymond A. DiGiuseppe, Ph.D., 2009-2014 Ofc: 301-405-5909 Fax: 301-314-9566
Psychology Department E-mail: Gelso@psyc.umd.edu
St John’s University
8000 Utopia Pkwy Mark J. Hilsenroth
Jamaica , NY 11439 Derner Institute of Advanced
Ofc: 718-990-1955 Psychological Studies
Email: DiGiuser@STJOHNS.edu 220 Weinberg Bldg.
158 Cambridge Ave.
Laura Brown, Ph.D., 2008-2013 Adelphi University
Independent Practice Garden City, NY 11530
3429 Fremont Place N #319 E-mail: hilsenro@adelphi.edu
Seattle , WA 98103 Ofc: (516) 877-4748 Fax (516) 877-4805
Ofc: (206) 633-2405 Fax: (206) 632-1793
Email: Lsbrownphd@cs.com Psychothe rapy Bulletin Editor
Jenny Cornish, PhD, ABPP, 2008-2010
Jonathan Mohr, Ph.D., 2008-2012 University of Denver GSPP
Clinical Psychology Program 2460 S. Vine Street
Department of Psychology Denver, CO 80208
MSN 3F5 Ofc: 303-871-4737
George Mason University E-mail: jcornish@du.edu
Fairfax, VA 22030
Ofc: 703-993-1279 Fax: 703-993-1359 Associate Editor
Email: jmohr@gmu.edu Lavita Nadkarni, Ph.D.
Director of Forensic Studies
Beverly Greene, Ph.D., 2007-2012 University of Denver-GSPP
Psychology 2450 South Vine Street
St John’s Univ Denver, CO 80208
8000 Utopia Pkwy Ofc: 303-871-3877
Jamaica , NY 11439 E-mail: lnadkarn@du.edu
Ofc: 718-638-6451
Email: bgreene203@aol.com Internet Editor
Abraham W. Wolf, Ph.D.
William Stiles, Ph.D., 2008-2011 MetroHealth Medical Center
Department of Psychology 2500 Metro Health Drive
Miami University Cleveland, OH 44109-1998
Oxford, OH 45056 Ofc: 216-778-4637 Fax: 216-778-8412
Ofc: 513-529-2405 Fax: 513-529-2420 E-mail: axw7@cwru.edu
Email: stileswb@muohio.edu

PSYCHOTHERAPY BULLETIN
Psychotherapy Bulletin is the official newsletter of Division 29 (Psychotherapy) of the American Psychological
Association. Published four times each year (spring, summer, fall, winter), Psychotherapy Bulletin is designed
to: 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 offer
their 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 the
editor, 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 journal
of Division 29). All submissions for Psychotherapy Bulletin should be sent electronically to jcornish@du.edu
with 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 issues
of Psychotherapy Bulletin may be viewed at our website: www.divisionofpsychotherapy.org. Other inquiries
regarding Psychotherapy Bulletin (e.g., advertising) or Division 29 should be directed to Tracey Martin at
the Division 29 Central Office (assnmgmt1@cox.net or 602-363-9211).

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Central Office, 6557 E. Riverdale Street, Mesa, AZ 85215
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PSYCHOTHERAPY BULLETIN
PSYCHOTHERAPY BULLETIN
Published by the Official Publication of Division 29 of the
DIVISION OF PSYCHOTHERAPY
American Psychological Association
American Psychological Association

6557 E. Riverdale 2009 Volume 44, Number 2


Mesa, AZ 85215
602-363-9211
e-mail: assnmgmt1@cox.net CONTENTS
Editors’ Column ............................................................2
EDITOR
Jennifer A. Erickson President’s Column ......................................................3
Cornish, Ph.D., ABPP
jcornish@du.edu Council of Representatives Report..............................7
Psychotherapy research, science and scholarhsip ....9
ASSOCIATE EDITOR Adding Motivational Interviewing to
Lavita Nadkarni, Ph.D.
Cognitive Behavioral Therapy for Anxiety
CONTRIBUTING EDITORS Perspectives on Psychotherapy Integration ............13
Diversity
An Examination of Integrated Treatments
Erica Lee, Ph.D. and for Trauma and Co-Occurring Disorders
Caryn Rodgers, Ph.D. Ethics in Psychotherapy..............................................17
An Examination of Integrated Deception in
Psychotherapy Education & Training Psychological Research: Ethical Issues and
Michael Murphy, Ph.D., and Challenges
Eugene Farber, Ph.D.
Early Career ..................................................................23
Ethics in Psychotherapy Mommy is a Psychologist, Too
Jeffrey E. Barnett, Psy.D., ABPP
Education & Training ..................................................25
Practitioner Report Changes in the Sequence of Training
Jennifer F. Kelly, Ph.D. Leading to Licensure
Psychotherapy Research, What Does a Scientist Look Like? ............................29
Science, and Scholarship
Norman Abeles, Ph.D. and A Therapy Preferences Interview:
Susan S. Woodhouse, Ph.D. Empowering Clients by Offering Choices ..............33
Perspectives on Diversity/Public Policy and Social Justice ..............38
Psychotherapy Integration A Place at the Table: Opening Up Leadership
George Stricker, Ph.D. and Governance: A Need for Transparency
Through the Black Box
Public Policy and Social Justice
Rosemary Adam-Terem, Ph.D. Practitioner Report ......................................................42
State Leadership Conference 2009: Exciting
Washington Scene Times on Capitol Hill and Off
Patrick DeLeon, Ph.D.
Washington Scene ........................................................44
Early Career Evidence-Based Medicine — The Devil
Michael J. Constantino, Ph.D. Remains in the Details
Rachel Smook, Ph.D.
Book review ..................................................................48
Student Features Blévis, Marcianne. (2009). Jealousy:
Sheena Demery, M.A. True stories of love’s favorite decoy.
Editorial Assistant Membership Application ..............................................52
Crystal A. Kannankeril, M.S.

STAFF
Central Office Administrator O
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Tracey Martin
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EDITORS’ COLUMN
Jenny Cornish, Ph.D., ABPP, Editor
Lavita Nadkarni, Ph.D., Associate Editor
It is with great in recent issues, we also have another
pleasure that we offer book review for you. You will also enjoy
you this second issue the thoughtful Education article by
of the Psychotherapy Michael Murphy related to changes in
Bulletin in 2009. We the sequence of training, and conse-
are again impressed quent recommendations for practicum
by the outstanding training. While we applaud the attempt
ideas and excellent to better regulate practica, we agree that
writing provided by the current recommendations go too far.
our wonderful con-
tributing editors and The Early Career Professional submis-
guest authors. sion this issue is on a topic close to our
hearts: combining the roles of parent
In this issue you will and psychologist. Jenny has three sons
find informative and (ages 21, 23, and 25) and Lavita has an
helpful reports from our president and adorable daughter (age 5); we continue
APA Council representatives, giving in- to be amazed at how much we learn
sight into and providing transparency of from our children, and how they enrich
the governance processes in our Divi- our professional careers.
sion and APA. The Practice submission
You will also note that this issue is in a
for this issue is written by Bonita Cade,
slightly different size. We are experi-
Division 29 Federal Advocacy Coordina-
menting with this smaller version to
tor, who reports on the recent State
help reduce costs while making the
Leadership Conference. Once again, Pat
Bulletin distinct from other division
DeLeon has written a compelling Wash-
newsletters. We are also now printing
ington Scene article for us. In addition,
the reference sections of papers online.
the Diversity and Public Policy and Social
Please let us know what you think of
Justice Contributing Editors have con-
these changes.
tributed an excellent article focused on
concrete ways to increase diversity in Finally, please know that we retain our
Division 29 governance. strong commitment to the Bulletin as a
creative outlet for all Division 29 mem-
Several Research articles are included on bers. The next issue of the Bulletin will
a variety of topics including motiva- include information related to the sum-
tional interviewing, a treatment prefer- mer APA convention in Toronto (includ-
ences interview, and what science “looks ing the Division 29 program and the
like.” In addition, the Ethics contribu- super fun social hour). We warmly
tion this issue is on the use of deception welcome your ideas, suggestions, and
in research. submissions!

Be sure to also read the paper on inte- jcornish@du.edu


grated treatments for trauma and co-oc- 303-871-4737
curring disorders. Continuing the trend

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PRESIDENT’S COLUMN
Nadine J. Kaslow, Ph.D., ABPP
Emory University Department of Psychiatry and
Behavorial Sciences, Grady Health Systems
Psychotherapy and therapeutic encounters need to assist
the Economy people in both concretely and emotion-
I am writing this col- ally coping adaptively with the ways in
umn as we find our- which the economy is negatively affect-
selves in the midst of ing their lives. We need to aid people
an economic recession. with problem-solving creatively, work-
There is no question ing collaboratively, taking action, coun-
that this recession has deeply impacted teracting the lethargy and apathy that
our work as psychotherapists. More and often sets in when people feel economi-
more, our patients are talking with us cally overwhelmed, and recognizing the
about their economic woes, anxieties, positives in their lives.
and fears. Some patients are having to As more people seek our services in re-
discontinue therapy or reduce the fre- sponse to their economic struggles, there
quency of their sessions or are request- may be a decline in the stigma associ-
ing reduced fees. Some psychotherapists ated with mental health care and we
are fearful that their practice revenues need to capitalize on this greater open-
and caseload will significantly decline. ness within the country about engaging
in psychotherapy. Interestingly, the
And yet, there is some indication that a
media increasingly is recommending
down economy is associated with a
therapy for helping couples effectively
boom in therapy practices. There is evi-
address the relationship stresses that are
dence that requests for therapists have
magnified by the economy, as well as as-
increased 15-20% recently in response to
sisting individuals in managing their
people’s concerns about their financial
anxiety regarding how the economy is
situation, with many people reporting impacting their quality of life, sense of
that their financial worries are their pri- isolation, self-esteem, and relationships
mary reasons for initiating psychother- with family members (partners, parents,
apy. It is understandable that the and children). Psychologists can partner
economic downturn and higher rates of more effectively with the media to con-
unemployment result in people feeling vey to the public the ways in which psy-
more stressed, helpless and hopeless, chotherapy can be invaluable when
angry, anxious and afraid, depressed, confronting economic hardship. It is my
and often times suicidal because they sincere hope that as psychologists and
feel they feel trapped by this economic psychotherapists, we will commit to
disaster. Indeed, in recent months, we finding ways to make psychotherapy
have witnessed the tragic suicides and more affordable to people from all walks
murder-suicides of people whose lives of life, so that everyone who wants our
have been dramatically altered by this services can access them during this
economy. Not only are people suffering down economy (and in the years to
personally, but there appears to be more come). Of course, these times also high-
relationship discord and arguments re- light for us more than ever the necessity
lated to increased financial strife. of ensuring that parity for mental health
care truly becomes a reality.
In order to best help our patients during
these challenging economic times, our continued on page 4
3
Presidential Priorities Caryn Rodgers, the Diversity Domain
One of the most gratifying aspects of Representatives on the Division 29 board
serving as the President of the Division are co-chairing a diversity strategic plan-
is that I have the opportunity to focus on ning initiative for the division. We will
aspects of the broad field of psychother- share the details of this plan with you as
apy that are particularly meaningful to they become available.
me. In this column, I want to address two
of these priorities: Diversity and Psy- Over the past decade, there has been
chotherapy Supervision. growing attention paid to the individual
and cultural characteristics of our patients
Diversity and ways to ensure that our psychother-
The Division 29 leadership has prioritized apeutic endeavors are mindful of these
diversity as a key area of focus for 2009. factors. However, much less focus has
This emphasis is consistent with my own been given to the cultural being of the
clinical-research focused on culturally psychotherapist. Therefore, I am very
competent, gender sensitive, and devel- pleased that Dr. Jennifer Kelly and I will
opmentally informed interventions. We be co-editing a special issue of Psychother-
held a one day diversity training for the apy: Theory, Research, Practice, Training on
governance of our division in January diversity characteristics of the psy-
2009 in conjunction with our board meet- chotherapist and how these influence the
ing. We are hopeful that through honest psychotherapeutic relationship and
discourse, dialogues about cross cultural process. It is so essential that each of us in
communication, attention to subtle biases, our role as psychotherapist be mindful of
and personal self-reflection and sharing the impact that our own gender, age, gen-
that we can strengthen our commitment der, race/ethnicity, sexual orientation,
to mutual respect for and understanding ability status, religious beliefs, social class,
of one another; increase our cultural etc., have on the psychotherapy that we
awareness, knowledge, and skills; im- practice and the ways in which we are ex-
prove the overall climate of our work- perienced by our patients, both those who
group; and encourage greater creativity are similar to us and those who are quite
and flexibility among the members of the different from us.
board. Greater sensitivity to diversity will Psychotherapy Supervision
afford us better opportunities to optimize I have a longstanding passion for psy-
our performance and be more innovative chotherapy supervision. As one of my
and responsive. I also firmly believe that Presidential Initiatives, I want to further
this process will enrich us each individu- advance the art and science of psychother-
ally in our own work settings and in the apy supervision. I am grateful to Dr.
psychotherapies in which we engage. Fur- Charles Gelso, our fabulous and very col-
ther, it is my hope that the discussions that laborative editor of Psychotherapy: Theory,
we had will lead us on a path to creating Research, Practice, Training who has gra-
a valuable product or set of products for ciously agreed to commit a special section
our membership that relate to ways in of the journal to ways in which different
which psychotherapists can be mindful of theoretical approaches to psychotherapy
the ways in which their own diversity supervision inform the development of
characteristics influence their therapeutic psychotherapy competencies in trainees. I
endeavors with their patients. I am grate- am indebted to Dr. Eugene Farber, Chair
ful to members of the division’s diversity of Division 29’s Education and Training
committee (Drs. Armand Cerbone, Jen- Committee, who has agreed to spearhead
nifer Kelly, Erica Lee, Caryn Rodgers) for this special section, which will include pa-
spearheading this effort. In addition, as a
follow-up to this event, Drs. Erica Lee and continued on page 5
4
pers related to cognitive behavior, psycho- Kenneth Critchfield. This event is sched-
dynamic, family systems, and existen- uled for Saturday, August 8 from
tial/humanistic perspectives. From their 3–4:50pm in the Metro Toronto Conven-
respective theoretical vantage point, these tion Center, Meeting Room 714A.
articles will address the essential compo-
nents of the psychotherapy competency, We will sponsor symposia on Thursday
foundational and functional competencies through Sunday. The Thursday sym-
informing the psychotherapy competency, posia include: Existential – Humanistic
and psychotherapy competencies in the Therapy Come to Life; Two Viewpoints
supervision process. Illustrative vignettes on Future Directions for Alliance
will be used to highlight key points and Theory; Process and Outcome in CBT—
dialogues between supervisors and super- The Importance of Cognitive Errors
visees. I am very excited about this special and Coping; Getting Real in Psycho-
section. therapy—Explorations of the Real
Relationship; What We Wish We Had
APA Convention Known—Tips for Future Psychothera-
I would like to take this opportunity to pists; and Using a Training Center Data-
share with you the Division’s plans for base to Promote Science and Practice.
the upcoming APA Annual Convention The Friday symposia include: The
that will be held in Toronto, Canada Art and Science of Impact: What Psy-
from August 6, 2009 – August 9, 2009. I chotherapists Can Learn From Filmmak-
am delighted that we have a diverse ers and Social Psychologists; and
range of symposia, posters, and conver- Eminent Psychotherapists Revealed—
sation hours. These presentations ad- Audiovisual Presentation of Principles
dress the breadth of the field of of Psychotherapy. On Saturday, sym-
psychotherapy, with attention paid to posia continue with: Psychotherapists
practice, science, education and training, Expertise—Developing Wisdom to
and policy. Here is a brief overview of Guide Theory, Research, and Practice;
the formal and informal activities of the Mistakes in Psychotherapy—Yielding
Division of Psychotherapy. Our pro- Power, Constraining Dialogue, and Nur-
gramming promises to be engaging, in- turing Envy; and Schema Therapy for
teresting, and thought-provoking. I want BPD— Breakthrough Treatment for Im-
to express my gratitude to our Program proving Life Functioning. Sunday’s sym-
Committee Chair and Associate Chair, posia programming includes: Affect
respectively, Drs. Nancy Murdock and Phobia, Treatment Approach—Two
Chrisanthia Brown. They have put to- New Pathways to Change; and Cultur-
gether more than 15 sessions of high ally Informed Interventions with Ethni-
quality programming. More details on cally Diverse Populations.
these events can be found in the APA
Program Book. In addition to the aforementioned sym-
posia, Division 29 is hosting a Poster
This year, APA is organizing a Conven- Session on Friday. The focus of this
tion within a Convention, with divisions Poster Session is on Research in Psy-
collaborating and offering more thematic chotherapy.
programming. Division 29 is participating
in the Convention within the Convention There will also be a conversation hour
for a two- hour symposium on Evidence- on Saturday that will consist of lunch
based Practice— Using Evidence-Based with Masters for Graduate Students and
Principles to Optimize Clinical Process and Early Career Psychologists.
Outcome with Personality Disorders. The
presenters are Jeffrey Magnavita and continued on page 6
5
The Division 29 Business Meeting is on the division and those interested in join-
Friday from 5:00 pm to 5:50 pm. At ing the division to our Social Hour, which
this meeting, we will honor our award will be held on Friday from 6:00 pm to
recipients. In addition, we will provide 6:50 pm immediately following the Busi-
an update on divisional activities and ness Meeting. The Social Hour offers an
invite our members to engage with opportunity to meet, talk, and socialize
the board in a dialogue about the future with members of the Division. We will be
of the division and of psychotherapy. showing pictures that reflect the history
We also plan to have some fun entertain- of Division 29.
ment.
I look forward to seeing and interacting
Finally, on behalf of the Division 29 Board, with each of you at our various divi-
I want to cordially invite all members of sional activities.

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NOTICE TO READERS

Please find the references for the articles


in this Bulletin posted on our website:
divisionofpsychotherapy.org

6
APA COUNCIL OF REPRESENTATIVES REPORT

From Lemons to Lemonade


Linda Campbell, Ph.D. and Norine Johnson, Ph.D.
Division of Psychotherapy Council Representatives

The most important budget is projected to yield a fiscal


information to tell you budget surplus of $309,400 for 2009.
about Council is how
proud Norine Johnson Making Lemonade
and Linda Campbell The rest of the news from the Council
are to be representing meeting does, in fact, bode very well for
you, our Division 29 the resilience, commitment, and dedica-
members and the cen- tion of our members in governance. Much
tral role of psychother- has been accomplished and much will
apy in psychology. continue to be done even in these times of
great restraint, ergo the lemonade.
Getting the Lemons
Strategic Plan
Out of the Way First
It may be hard to believe, but APA is be-
Even though APA has
ginning to conduct the very first strate-
been in strong finan-
gic plan in the history of the
cial position for recent
organization. CEO Dr. Norman Ander-
years, the 2008 budge realized a shortfall
son commented, “The strategic planning
of $3,422,700. The national economic cri-
process is going to help APA be a
sis, lower dues revenue than expected,
stronger and more focused organization
and losses in investments are the major
in the future.” A significant step in facil-
reasons for the shortfall. Much time was
itating the strategic plan is the develop-
spent on this item in Council and we
ment and Council approval of a vision
want our members to know that the
statement that accurately represents the
Board of Directors, Paul Craig the APA
spirit, hopes, and direction of the organ-
Treasurer, Archie Turner the APA CFO
ization. If a vision statement can be ener-
and the Executive Director, Norman An-
gized, exciting, and hopeful, this one is
derson. were very forthcoming with
it. We hope that you are as satisfied with
specific information, explanations about
the meaning and values represented as
the APA assets, dues impact, real estate
we and the Council are:
holdings, publishing operations, and
other factors that affect the budget. A APA Vision Statement
full and open discussion was conducted The American Psychological Association
in which Council received recommenda- aspires to excel as a valuable, effective
tions from the Board for response to the and influential organization advancing
deficit and how these would be reflected psychology as a science, serving as:
in the 2009 budget.
• A uniting force for the discipline;
After thorough discussion, the Council • The major catalyst for the stimula-
adopted a budget with approximately tion, growth and dissemination of
$12 million dollars in spending cuts. psychological science and practice;
These include (1) cancelling the fall • The primary resource for all
boards and committee meetings, (2) cuts psychologists;
in spending on public education pro-
grams, (3) a staff hiring freeze, and (4) • The premier innovator in the edu-
elimination of the Board and Council cation, development, and training of
discretionary funds. The final approved continued on page 8
7
psychological scientists, practition- new records to the database and ex-
ers and educators; panded coverage by adding 113 journals
• The leading advocate for psycho- bringing the number of journals covered
logical knowledge and practice in- to 2,452. APA Books released 53 new
forming policy makers and the scholarly titles and nine new Magina-
public to improve public policy and tion Press titles. Total revenue for APA’s
daily living; core scholarly and professional
• A principal leader and global part- publishing program exceeded $72 mil-
ner promoting psychological knowl- lion in 2008.
edge and methods to facilitate the
In Other Actions, the Council:
resolution of personal, societal and
• Postponed action on proposals to
global challenges in diverse, multi-
reduce the costs of dues for some
cultural and international contexts;
members including state, provincial
and
and territorial association members,
• An effective champion of the appli- due to the restraints on the 2009 and
cation of psychology to promote 2010 budgets.
human rights, health, well being
• Adopted updated Guidelines for
and dignity.
Child Custody Evaluations in
Council Representation Family Law Proceedings.
The following proposal was approved • Received the report of the Task
and forwarded to the Policy and Plan- Force for Increasing the Number of
ning Committee to be drafted by the Quantitative Psychologists.
next Council meeting: • Established a continuing Committee
on Human Research.
That the APA Bylaws should be
amended to ensure all Divisions and • Received the final report of the Div.
SPTA’s have a seat on Council. Using 19 (Military) and Div. 44 (Society for
the proportional allocation system, in the Psychological Study of Lesbian,
the unlikely event that the number of Gay, and Bisexual Issues) Joint Task
votes allocated to either is insufficient to Force on Sexual Orientation and
yield enough seats to seat all Divisions Military Experience.
and SPTAs • Announced the roll out of the new
website due later this year.
Publications and Communications
The P&C Board of APA is the highest Your Council Representatives are advo-
revenue producing area of APA and cer- cates for the voice of Division 29 mem-
tainly is one of the most active and im- bers. We do report back to you on the
pactful within the profession. In 2008, decisions and the topics of discussion at
the P&C Board reported that sales of the the immediate past Council meeting,
APA Publication Manual reached 6.6 but just as importantly, we want to
million dollars. APA Journals and Divi- know in advance of meetings what your
sion 56 began a new journal, Psychologi- thoughts and perspectives are so that we
cal Trauma: Theory, Research, Practice, and can advance the mission of psychother-
Policy. APA Journals and Division 36 apy and our members. Please contact ei-
also began a new journal entitled, Psy- ther Norine Johnson (NorineJ@aol.com)
chology of Religion and Spirituality. Dur- or Linda Campbell (lcampbel@uga.edu).
ing 2008, PsychINFO added 152,001

8
PSYCHOTHERAPY RESEARCH, SCIENCE
AND SCHOLARHSIP
Adding Motivational Interviewing to
Cognitive Behavioral Therapy for Anxiety
Henny A. Westra, Ph.D., Department of Psychology, York University

Motivational Inter- Morrison, 2001; Hunot, Churchill, Teix-


viewing (MI) is “a eira, & Silva de Lima, 2007). This is par-
client-centered direc- ticularly true for GAD, the anxiety
tive method for disorder least responsive to CBT (Camp-
enhancing intrinsic bell & Brown, 2002). Client resistance to
motivation to change change and nonadherence to recom-
by exploring and re- mended treatment procedures are com-
solving ambivalence” mon clinical realities in CBT. For
(Miller & Rollnick, 2002, p. 25). Its’ use example, in a survey of practicing CBT
is well supported in the addictions do- therapists, problems in assigning home-
main (Hettema, Steele, & Miller, 2005) work were noted for 74.5% of clients and
and has been extended to the promotion only 38.9% of cases were identified as to-
of health behaviors (Rollnick, Miller, & tally compliant (Helbig & Fehm, 2004).
Butler, 2008). There is strong evidence Because treatment engagement is a criti-
that an MI pretreatment followed by an- cal contributor to outcome (Orlinsky,
other type of psychotherapy leads to Grawe, & Parks, 1994), reducing resist-
better attendance and enhanced out- ance and increasing motivation through
comes compared to the same psy- the use of MI may hold significant prom-
chotherapy without an MI pretreatment ise for improving the efficacy of CBT.
(Hettema et al., 2005). Recently, investi-
gators have begun to explore the use of MI has strong roots in the client-cen-
MI either integrated with Cognitive Be- tered approach of Carl Rogers (1956).
havioral Therapy (CBT; i.e., a shift to MIBoth MI and client-centered psychother-
within CBT when ambivalence/resis- apies share an emphasis on understand-
tance arises) or in combination with CBT ing the client’s internal frame of
(e.g., as a pretreatment) in the treatmentreference and working with discrepan-
of other major mental health problems cies between behaviors and values. Both
such as anxiety, depression, eating dis- emphasize the importance of the psy-
orders, medical adherence in psychosis, chotherapist providing the conditions
and problematic gambling (Arkowitz, for growth and change by communicat-
Westra, Miller, & Rollnick, 2008). Our ing attitudes of accurate empathy and
own work has centered on examining unconditional positive regard. However,
MI as a pretreatment to CBT for anxiety unlike client-centered psychotherapy,
and more specifically generalized anxi- MI is directive, with specific goals of re-
ety disorder (GAD). Below I will outline ducing ambivalence and increasing in-
the clinical application of MI to anxiety trinsic motivation for change. To achieve
and summarize this research, as well as these goals, the MI therapist tries to cre-
outline current and future directions in ate an atmosphere in which the client,
our research program. rather than the psychotherapist, is the
MI for Anxiety main advocate for and primary agent
Although CBT is an effective treatment of change. The “MI spirit” of the psy-
for anxiety, numerous individuals fail to chotherapist is central and consists of
show substantive benefit (Westen & continued on page 10
9
attitudes of collaboration, evocation, application of MI to anxiety used in our
and respect for the client’s autonomy. research studies is also available upon
This approach also consists of specific request (send an email request to hwes-
principles including: express empathy, tra@yorku.ca).
develop discrepancy between values
and problem behaviors, roll with resist- MI for a mixed anxiety disorders group
ance, and support self-efficacy. (Westra & Dozois, 2006)
Prior to either sessions of manualized
MI is well-suited for application to the group CBT, individuals with a principal
anxiety disorders since ambivalence anxiety diagnosis (45% panic disorder,
about change and engagement with 31% social phobia, and 24% GAD) were
treatment procedures is common in randomly assigned to receive either 3
these populations. For example, individ- sessions of an individually delivered MI
uals with GAD have been found to hold pretreatment adapted for anxiety (n =
conflicting beliefs about worry, includ- 25) or no pretreatment (NPT, n = 30). The
ing both negative and positive percep- MI group, compared to NPT, showed
tions of the value of worry (Borkovec & significantly higher positive expectancy
Roemer, 1995). Although clients with for anxiety control and greater home-
GAD do see worry as a problem (e.g., work compliance in CBT. Although both
that it interferes with concentration and groups demonstrated clinically signifi-
memory), they also hold positive beliefs cant anxiety symptom improvements,
about it (e.g., that worry is motivating, the MI group had a significantly higher
ensures one is prepared for negative number of CBT responders compared to
events) and are therefore ambivalent NPT. At six-month follow-up, both
about reducing or relinquishing their ex- groups evidenced maintenance of gains.
cessive worry. There are a number of Overall, the results of this investigation
case reports supporting the utility of MI provide support for the viability and po-
with various anxiety disorders includ- tential contribution of MI as an adjunct
ing obsessive compulsive disorder to CBT for anxiety.
(Simpson, Zuckoff, Page, Franklin, &
MI for GAD (Westra, Arkowitz, &
Foa, 2008), social anxiety (Buckner, Roth
Dozois, 2008)
Ledley, Heimberg, & Schmidt, in press),
To evaluate whether MI would enhance
mixed anxiety disorders (Westra, 2004;
response to CBT for GAD specifically, 76
Westra & Dozois, 2008) and GAD (Wes-
individuals with a principal diagnosis of
tra & Arkowitz, in press). Readers are
GAD were randomly assigned to receive
encouraged to examine these reports to
either an MI pretreatment or no pretreat-
obtain more specific information about
ment (NPT), prior to receiving individu-
the clinical application of MI to anxiety.
ally delivered CBT. Significant group
Preliminary Studies Investigating differences favouring MI-CBT were ob-
the Efficacy of MI for Anxiety served for the hallmark GAD symptom
To date, our research group has con- of worry, percentage of treatment re-
ducted two preliminary randomized sponders, and therapist-rated home-
controlled trials (RCTs) examining MI as work compliance. On multiple measures
a pretreatment for anxiety in a heteroge- (worry, worry beliefs, early prognostic
neous sample of anxiety disorders and expectations, intrinsic motivation), re-
for GAD specifically. These studies are ceiving MI was substantively and specif-
summarized below, as well as a qualita- ically beneficial for those of high worry
tive research study on client accounts of severity at baseline, compared to those
experiences in CBT with and without an of high severity not receiving MI. Those
MI pretreatment. A manual detailing the continued on page 11
10
of moderate worry severity showed no rection. For example, NPT-CBT clients
significant benefit from the MI pretreat- noted that “The therapist was there to be
ment on most indices. Moreover, large accountable to and to give me home-
effect sizes were observed when com- work,“,”My role was to show up and lis-
paring high severity individuals across ten,“,and “My role was to do the
MI-CBT and NPT-CBT groups. These homework and make sure I had some-
findings suggest that MI may be a prom- thing to report back.” Considering that
ising adjunct to CBT for GAD, and Kertes matched treatment groups on
uniquely beneficial for those of high CBT therapist (n = 3 therapists), these
worry severity (49% of this sample), findings suggest that the experience of
who have historically been less respon- CBT was perceived differently depend-
sive to CBT (Durham et al., 2004). At one ing on whether the client received MI
year follow-up, the high severity MI- prior to CBT. These findings are consis-
CBT group did show evidence of some tent with the theoretical rationale for
relapse; reducing the magnitude adding MI to CBT and quantitative find-
of post-treatment group differences. Im- ings indicating that a major outcome of
portantly, the data do not suggest that adjunctive MI is increased engagement
the addition of MI increased relapse but with subsequent, more action-oriented
rather that those of high severity are therapies (Burke et al., 2003; Hettema et
more vulnerable to relapse and thus al., 2005). The Kertes et al. (in press)
may require additional treatment or study supports and strengthens these
booster sessions in order to maintain findings by demonstrating that in-
treatment gains. creased engagement in subsequent treat-
ment as a function of receiving MI is
Client Accounts of Experiences in observed in client accounts of their treat-
CBT for GAD with and without MI ment experiences as well.
pretreatment
Using a grounded theory approach to Current & Future Directions
study client post-treatment accounts of While the above studies suggest that MI
their experiences in CBT among ten high holds promise as an adjunct to CBT for
severity clients in the Westra et al. (2008) anxiety, neither of the RCTs discussed
RCT, Kertes, Westra, Angus, & Marcus above ensured equivalent therapist con-
(in press) found that MI-CBT and NPT- tact time across treatment groups, nor
CBT groups sharply diverged in their did they rule out expectancy effects cre-
experiences of the interpersonal style of ated by client knowledge of having re-
the therapist and their experience of ac- ceived additional treatment. At present,
tive engagement in CBT. MI-CBT clients we are intending to replicate the RCT of
reported experiencing the CBT therapist MI+CBT for GAD using a control group
as an “evocative guide” in the pursuit of of extended CBT to control for these
their goals and, accordingly, reported confounds. Moreover, we intend to add
themselves as active participants in the a relapse prevention procedure in order
treatment process. For example, MI-CBT to facilitate maintenance of treatment
clients reported “It’s not like the thera- gains.
pist was sitting there fixing my prob-
lems. I had to do a lot of digging.” and In addition, we are taking a process fo-
“She (the therapist) made suggestions cused approach to our research to exam-
but a lot of times she would ask me what ine key questions of moderation and
I think.” In contrast, NPT-CBT clients mediation, such as (1) Why might MI be
described the CBT therapist as directive particularly indicated for those of high
and described their own role as prima- worry severity? (2) What is the interper-
rily one of compliance with therapist di- continued on page 12
11
sonal impact within CBT of having re- levels of interpersonal problems in GAD
ceived an MI pretreatment compared to (Newman, Castonguay, Borkovec,
receiving CBT alone? and (3) Are good Fisher, & Nordberg, 2008), the emphasis
outcome CBT therapists more “MI-ish” in MI on the relationship between client
(e.g., collaborative, evocative, empathic) and therapist may provide clients with
in their therapeutic style compared with a corrective interpersonal experience,
poor outcome CBT therapists? thereby improving interpersonal
process in subsequent treatment.
With respect to the first question, we
speculate that high severity worriers Finally, we are also examining therapist
may be more ambivalent or skeptical effects (question 3 above) that emerged
about change than the moderate sever- within the CBT alone group in the Wes-
ity worriers, and as a consequence pref- tra et al. (2008) study. Namely, CBT ther-
erentially benefit from the addition of apists differed in their outcomes with
MI to CBT. At present, we are examining client recovery rates at one year follow-
this question through the use of process up ranging from 17% to 90% across the
measures of resistance and ambivalence four CBT therapists. These differences in
(change-talk, counter-change talk) in outcome across therapists were medi-
CBT to examine whether those of high ated by differences in client prognostic
severity are more resistant/ambivalent expectations following the first session
than those of lesser worry severity of CBT, with clients of poor outcomes
within CBT alone. And if so, does hav- therapists having significantly lower
ing received MI prior to CBT decrease early expectations for recovery than
this resistance/ambivalence within CBT those of good outcome CBT therapists.
among those of high worry severity? Using the SASB, we are currently inves-
tigating the hypothesis that CBT thera-
With respect to the interpersonal impact pists may diverge in their management
of having received MI on subsequent of client counter-change talk, with good
CBT (question 2 above), findings from outcome therapists expressing more af-
the Kertes et al. (in press) study con- firming and understanding under these
verge with quantitative findings in the conditions, while poor outcome thera-
Westra et al. (2008) study demonstrating pists may engage in less understanding
that therapists of those in the MI-CBT and more interpersonal control in re-
group were rated by independent ob- sponse to client expressed reservations
servers, blind to client pre-treatment sta- about change and treatment.
tus, as having delivered higher quality
CBT, compared to the same therapists of As with any research program, our work
those receiving no pretreatment prior to to date has suggested more questions
CBT (NPT-CBT). Thus, receiving MI pre- than answers. While adding MI to CBT
treatment appears to be associated with for anxiety may hold promise, more
more positive interpersonal process rigorous, well controlled tests of this pos-
within subsequent CBT. We are cur- sibility are required. Examining modera-
rently using the Structural Analysis of tors and mediators within such studies is
Social Behavior (SASB; Benjamin, 1974), especially important in identifying those
which involves analyzing moment-to- for whom MI is indicated and not indi-
moment client-therapist exchanges cated, as well as the mechanisms through
around the interpersonal dimensions of which adding MI to CBT may achieve its‘
affiliation and interdependence, to more effects. Such research will have important
specifically examine the interpersonal clinical implications for engaging indi-
impact on CBT of receiving MI pretreat- viduals with CBT for anxiety in an
ment compared to not having received attempt to improve outcomes.
a pretreatment. Given findings of high
12
PERSPECTIVES ON PSYCHOTHERAPY INTEGRATION
An Examination of Integrated Treatments for
Trauma and Co-Occurring Disorders
Jessica Sandham Swope, M.A., Carol R. Glass, Ph.D., & Diane B. Arnkoff, Ph.D.
The Catholic University of America

A growing body of re- choeducation (Harris &


search supports the use of The Community Connec-
several manua l i z e d tions Trauma Work
g ro u p treatment mod- Group, 1998), while Seek-
e l s d e s i g n e d specifi- ing Safety emphasizes in-
cally for individuals with terpersonal domains as
co-occurring disorders well as cognitive, behav-
(e.g., those who have both ioral, and case manage-
mental disorders and substance use dis- ment elements (Najavits, 2002). The
orders) who also have histories of present paper will provide a brief
trauma. These treatment models, includ- overview of recent research evidence
ing the Trauma Recovery and Empow- supporting integrated trauma treatment
erment Model (TREM; Harris & The models, while also offering a more clin-
Community Connections Trauma Work ically-oriented description of TREM, in-
Group, 1998), Seeking Safety (Najavits, cluding the core themes and skills
2002), and others, are often referred to as emphasized in TREM sessions.
integrated treatment models, and this de-
scription is applicable in more ways Research Findings on Integrated
than one. Trauma Treatments
The Women, Co-occurring Disorders
First, the treatment models described and Violence Study (WCDVS) was a
here are integrated in the sense that they large-scale quasi-experimental study
aim to address trauma sequelae, sub- evaluating the effectiveness of inte-
stance abuse, and general mental health grated treatment programs designed
problems as interconnected parts of a specifically for women with co-occur-
whole problem, rather than as separate ring disorders and histories of interper-
syndromes. This integrated approach sonal violence (Morrissey, Ellis et al.,
represents a shift away from parallel 2005). Funded by the Substance Abuse
treatment models, in which addiction, and Mental Health Services Administra-
trauma, and mental illness are treated in tion, the study included more than 2,700
different facilities with different sets of women across nine participating treat-
providers. It also differs from so-called ment sites. In each case, clinical out-
sequential treatment approaches in comes at the sites using integrated
which treatment providers maintain trauma treatments were compared with
that substance abuse be addressed be- sites providing usual care to a compara-
fore other presenting issues (Finkelstein ble population. It is the largest study to
et al., 2004). date examining integrated treatment ap-
proaches for this population.
These treatments are also theoretically
integrative. TREM, for example, focuses The WCDVS findings strengthened the
on the development of trauma recovery case for integrative trauma-focused
skills through cognitive restructuring, treatments. At the 12-month assessment
skills training, peer support, and psy- continued on page 14
13
point, a meta-analysis of data across all and significantly greater gains on a meas-
treatment sites revealed that while there ure of coping skills from baseline to 12
was symptom reduction for women in months. The two conditions did not differ
both conditions, sites using integrated with respect to participants’ improve-
trauma treatments yielded significantly ments on measures of substance use and
greater improvements on measures of general psychopathology.
general mental health functioning and
trauma symptoms relative to the women Findings from recent studies of TREM
in usual care (Morrissey, Jackson et al., also generally point to its effectiveness
2005). Looking at substance use out- for women with co-occurring disorders
comes, intervention site participants and histories of trauma. For example, as
demonstrated statistically greater im- a part of the WCDVS, Amaro et al.
provement on a measure of drug use (2007) examined treatment outcomes
severity at the 6-month assessment point among 342 women receiving substance
(Cocozza et al., 2005), but differences be- abuse treatment in the Boston area. In
tween the groups were not statistically this study, intervention group partici-
significant at 12 months. pants received a modified version of
TREM in addition to substance abuse
The results of studies of individual inte- treatment, while comparison group par-
grative trauma treatments in the ticipants received usual care in compa-
WCDVS also suggest that these ap- rable substance abuse treatment
proaches are beneficial for individuals programs. Relative to the comparison
with trauma histories and co-occurring group, intervention group participants
disorders. Of the interventions included demonstrated significantly greater im-
in the WCDVS, the Seeking Safety treat- provements on measures of PTSD, gen-
ment program was the first and most eral mental health symptoms, and drug
frequently studied. In early and small- use by the 12-month interview period.
scale studies of Seeking Safety, the ther-
apy was found to be effective in Preliminary data from the District of Co-
reducing PTSD symptoms and sub- lumbia Trauma Collaboration Study
stance abuse (Cook, Walser, Kane, (DCTCS), a study that was a part of
Ruzek, & Woody, 2006; Najavits, the WCDVS involving 251 participants,
Schmitz, Gotthardt, & Weiss, 2005; Zlot- indicate that TREM group participants
nick, Najavits, Rohsenow, & Johnson, experienced significantly greater reduc-
2003). Other studies have shown it to be tions in PTSD and substance use symp-
helpful in reducing depression and gen- toms at the 12-month assessment point
eral psychopathology (Najavits, Gallop, relative to those receiving services as
& Weiss, 2006; Najavits, Weiss, Shaw, & usual at a comparable agency. There
Muenz, 1998). were no significant differences between
the groups on a measure of general psy-
More recently, Gatz et al. (2007) reported chiatric symptoms (Fallot, McHugo, &
promising findings with respect to reduc- Harris, 2009).
tion of trauma symptoms in their study
comparing Seeking Safety to usual care A Closer Look at TREM
among women in residential substance One way that some clinicians conduct
abuse treatment programs in Los Ange- trauma treatment with individuals with
les. This study was one component of the severe mental illness is by modifying
larger WCDVS described above. The re- some of the more well-established cog-
searchers found that participants in the nitive- behavioral treatments for PTSD.
Seeking Safety condition had significantly For example, some treatments have been
greater reductions in trauma symptoms continued on page 15
14
changed to reduce or eliminate treat- the experience and impact of trauma,
ment elements that could be particularly and the third section emphasizes the de-
stressful for these individuals—such as velopment of trauma recovery skills
exposure—while providing a greater (Fallot & Harris, 2002). Though TREM
emphasis on cognitive restructuring. In was originally developed for use with
this way, the treatments focus on the women, variations of the treatment
avoidance, arousal and intrusive symp- model have been developed for both
toms that characterize PTSD (Rosenberg men (Fallot, 2001) and adolescent girls
et al., 2001). (Berley, Guillory, Harris, Quezada, &
Seagroves, 2005).
TREM, on the other hand, takes a
broader view of the issues that need to In some instances, the empowerment
be addressed among individuals with section of TREM includes session topics
histories of trauma and co-occurring dis- that one might not immediately associ-
orders. This treatment model was devel- ate with trauma recovery, such as ses-
oped in the 1990s by clinicians working sions focused on the exploration of
with women at Community Connec- self-esteem and female sexuality. For ex-
tions, a community mental health ample, during the fourth week of treat-
agency in Washington, DC. The clini- ment members explore their physical
cians recognized that many of their boundaries. The rationale for this is that
clients struggled with trauma-related se- the experience of physical and sexual
quelae that extended beyond PTSD abuse is the ultimate violation of—and
symptoms, including a disrupted ability intrusion into—personal space. Abuse
to trust others and sustain relationships, survivors often find themselves con-
a sense of powerlessness and lack of fused about what is safe and appropri-
self-agency, and difficulties with emo- ate contact, and may be either overly
tional modulation and self-soothing. sensitive about personal space or not
The treatment was developed around sufficiently aware of others’ need for
four core assumptions: 1) Some current personal space (Harris & The Commu-
maladaptive behaviors may have ini- nity Connections Trauma Work Group,
tially developed as a means of coping 1998).
with trauma; 2) Women with repeated
experiences of childhood trauma were Through discussion and activities, this
deprived of the chance to develop the session allows members to explore the
types of coping skills they need as topic and receive feedback from one an-
adults; 3) The experience of trauma cuts other. One of the goals for the session is
off one’s connections to family, commu- to have members begin to develop an
nity, and self; and 4) Women with exten- idea of how much or how little control
sive histories of trauma feel powerless they have over what happens to their
and unable to advocate for themselves bodies. Facilitators ask members to dis-
(Fallot & Harris, 2002). cuss how much physical space they
need and how they might typically re-
Based on these principles, TREM was spond to unwanted physical contact. In
developed as a manualized therapy that one exercise, leaders block off boxes and
targets issues in trauma recovery over circles on the floor with masking tape at
the course of 33 weekly 75-minute ses- varying distances from one another and
sions designed for groups of 8-10 group members discuss why they se-
women. There are three main sections of lected the boxes they did (Harris & The
the treatment model. The first focuses on Community Connections Trauma Work
empowerment, the second section aims Group, 1998).
to help participants better understand continued on page 16
15
In later sessions, topics are geared more apart into separate problems.” Results
specifically toward trauma recovery and indicated that TREM participants were
skill building. For example, in session significantly more likely to perceive that
20, group members explore the links be- their treatment was integrative relative
tween problematic addictive or compul- to those receiving services as usual. In
sive behaviors and their histories of addition, among TREM participants,
trauma. They discuss when they first en- perceived integration was significantly
gaged in these behaviors, and how these correlated with symptom reduction on
behaviors may be a form of self-abuse. measures of PTSD symptoms, general
By session 28, entitled “Feeling Out of mental health symptoms, and drug use
Control,” one of the goals is to help the severity (Swope, 2009).
members think about effective and pos-
itive ways to modulate intense emo- While the empirical findings outlined
tions. As an exercise, members above make the case for continued and
brainstorm a list of coping strategies— expanded use of integrated trauma
including engaging in positive self-talk, treatments, they also suggest that clini-
taking a walk or exercising, or listening cians would be well-s erved to examine
to soothing music (Harris & The Com- and address possible connections
munity Connections Trauma Work among disorders for those clients who
Group, 1998). come into treatment with a variety of
presenting issues. Current research find-
A recent study using data from the ings support this approach for clinicians
aforementioned DCTCS, examined the working with individuals who have his-
extent to which participants perceived tories of trauma and other mental health
that the counseling services they re- problems, but additional research is
ceived were integrative, based on re- needed to determine whether the devel-
sponses to several questions, including: opment of integrated treatment proto-
“The services I receive treat me as a cols would be useful for other disorders
whole person rather than pulling me with high rates of comorbidity.

N O F P S Y C H O THE
O
RA P Y
D I V I SI

29
ASSN.
AMER I

C
AL

A
N PSYCHOLOGI C

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16
ETHICS IN PSYCHOTHERAPY
An Examination of Integrated Deception in
Psychological Research: Ethical Issues and Challenges
Jeffrey E. Barnett, Psy.D., ABPP and Monica Nanda, B.A.

The use of deception biases; however, it is taking away the


in research by psychol- participants’ autonomy and their ability
ogists raises a number to provide voluntary informed consent.
of ethical issues and
concerns. Its signifi- Deception in Research:
cance is illustrated by An Historical Perspective
its inclusion as a stan- The first set of ethical guidelines regard-
dard in the American ing human research was put forth in 1947
Psychological Associa- in response to the inhumane human
tion’s Ethics Code experiments that were carried out in
(APA, 2002, Standard Germany during World War II. These
8.07: Deception in Re- guidelines became known as the Nurem-
search). While the use berg Code, named after the trials at
of deception may offer Nuremberg where the physicians con-
researchers greater ducting these experiments were placed
flexibility in conducting their studies on trial and found guilty of war crimes
and obtaining important findings, it also and crimes against humanity. The
creates potential risks for participants of Nuremberg Code (1947) specifies that re-
these studies that must be addressed. search must be conducted for the good of
The purpose of this article is to better society, not impose any unnecessary
understand what deception is, highlight harm, and research participants must vol-
the benefits and consequences of its use, untarily consent and be able to withdraw
examine ethical dilemmas and concerns from the research study. These guidelines
regarding deception, and discuss the were very general, not enforceable, and
ethical use of deception and possible did not make specific recommendations
alternatives. regarding deception, but were an impor-
tant first step toward the protection of
Deception has been described by human research participants.
Hertwig and Ortmann (2008) as the
In the 1960s and 70s deception was a
“intentional and explicit provision of
hallmark of psychological research, and
erroneous information—in other words,
its use was the norm and not a choice of
lying” (p. 222). It is one of the most con-
last resort. During this period, specific
troversial topics in research ethics due to
ethical standards were not in place to
the potential for harm to research partic-
limit the use of deception. Milgram’s
ipants and the possible violation of their
obedience study (1963) and Darley and
rights. Yet, one cannot deny the signifi-
Latane’s (1968) bystander intervention
cant contributions that a study utilizing
study are examples of classic studies
deception can add to our understanding
that utilized deception during this time
of human behavior. On the one hand,
period and yielded valuable advance-
deception can give a study greater inter-
ments to our knowledge of social behav-
nal validity by increasing the control
ior. However, these studies, specifically
that a researcher has over the experi-
ment and eliminating certain participant continued on page 18
17
Milgram’s obedience study, raised major with an explanation of the use of the de-
ethical concerns regarding participant ception “as soon as is feasible, prefer-
safety, highlighting the need for more ably at the conclusion of their
specific standards to be put into place. participation, but no later than at the
conclusion of the data collection, and
In 1964 the World Medical Association permit participants to withdraw their
put forth the Declaration of Helsinki, data” (p. 1070). This is usually done dur-
which is a set of ethical principles for ing a required debriefing at the comple-
physicians conducting human research. tion of the study where the researcher
It highlights the rights of human partic- provides the participant with informa-
ipants and important factors to consider tion about the nature of the study as
when conducting research with human well as any deception that may have
participants (World Medical Organiza- taken place. Additionally, when re-
tion, 1996). Ethical principles in this doc- quired, all research protocols, whether
ument include respect for the individual using deception or not, must be re-
during the research process, allowing viewed and approved by an Institu-
the participant to make informed deci- tional Review Board (IRB) prior to
sions, and ensuring that the partici- conducting the research.
pant’s welfare always takes precedence
over science and society. In 1974 The As one can see, these standards are an
National Research Act was passed in attempt to place a balance between not
Congress and created the National harming research participants and ad-
Commission for the Protection of vancing psychological knowledge
Human Subjects of Biomedical and Be- through controlled experimentation. It is
havioral Research (NCPHS) to study the obvious to not use deception when it is
ethical principles underlying research likely to result in extreme harm to par-
on human subjects (NCPHS, 1979). In ticipants. But, when the relative risks
1978 the Commission summarized its and benefits are less pronounced reach-
finding in the Belmont Report and iden- ing a decision on how best to proceed
tified respect for persons, beneficence, may be challenging for researchers. This
and justice as the three fundamental eth- tension can be seen in the APA Ethics
ical principles for research using human Code’s aspirational Principle A: Benefi-
participants (NCPHS, 1979). cence and Nonmaleficence which rec-
ommends that psychologists endeavor
Ethical Issues and Standards to take actions that maximize benefit to
for Psychologists those we serve while simultaneously
The APA Ethics Code (2002) provides minimizing the potential for exploita-
the most specific standards for psychol- tion or harm to them. While we can eas-
ogists to follow when conducting re- ily see how to apply these principles
search. Standard 8.07, Deception in when the potential for harm is great and
Research, specifies that deception is not the likely value of a study is small (and
to be used if alternative methods not the inverse as well) it is in those situa-
using deception are possible, if the de- tions where these distinctions are less
ception will “reasonably be expected to apparent that psychologists will strug-
cause physical pain or severe emotional gle. Thus, a study such as Milgram’s
distress”, and if the deception is not obedience study, while yielding valu-
“justified by the study’s significant able information that advances our un-
prospective scientific, educational, or derstanding about human behavior,
applied value” (p. 1070). Furthermore, if would not likely be approved by any
deception is used, study participants IRB today. The decision to approve
must be notified about and be provided continued on page 19
18
other studies in which the likelihood of would be difficult or nearly impossible
harm to participants is not so clear, yet to measure using other methods. Addi-
the potential benefits from the study are tionally, it helps eliminate participant bi-
great, might prove more problematic for ases such as social desirability and other
those making these decisions. demand characteristics. When partici-
pants do not know the true nature of the
Additionally, if alternative methods that study that they are participating in, they
enable the researcher to study the issues cannot consciously change their behav-
in question are feasible, the researcher ior to make themselves look better. Also,
must refrain from the use of deception they cannot easily discern the study hy-
and use the alternative method. How- potheses and deliberately behave in a
ever, several studies (e.g., Cooper, 1976; way that confirms or denies them. Con-
Forward, Canter & Kirsch, 1976; Geller, sequently, the use of deception leads to
1982; Weber & Cook, 1972; Willis & the research having more experimental
Willis, 1970) have looked at the use of al- control by eliminating these extraneous
ternative methods such as role plays, variables, giving the research study
naturalistic observation, and self-report more internal validity, increased power,
methods in comparison to using decep- and a lesser likelihood of making a Type
tive methods and have reported mixed II error.
results. To eschew deception when alter-
native methods are available helps elim- The use of deception also allows us to
inate potential harm to the study’s examine rare behaviors that would be
participants, even if only minimal. Yet, difficult to study otherwise. Through the
the study could be losing valuable ex- use of deception, Darley and Latane’s
perimental and statistical power that bystander intervention study (1968) was
would make it more internally valid. In able to help us better understand when
order to better understand this dilemma someone is more likely to help an indi-
and the APA’s stance on this issue, we vidual in an emergency without there
must examine the consequences of the being an actual emergency. Clearly, cre-
use of deception. ating actual emergency situations to
study bystanders’ responses would raise
Risks and Benefits of Using other more serious ethical issues and be
Deception in Research impractical. Even though studies utiliz-
The use of deception can contribute ing deception can provide us significant
greatly to our knowledge about human information concerning human thought
thoughts, attitudes, motivations, deci- and behavior, the potential contribution
sion making, behavior, and the like. of a study is an essential but not suffi-
Some of the most fascinating experi- cient requirement to substantiate its use.
ments in the history of psychology uti- This is due to the potential of harm and
lized deception. For example, in other consequences brought about by
Solomon Asch’s conformity study (1951) the use of deception.
participants believed they were taking
part in a study on visual perception. Milgram’s obedience study demon-
Rather, they were participating in a strates many of the consequences that
study to see how often they would re- can come about from using deception. In
spond incorrectly to visual cue cards be- this study, participants were led to be-
cause the confederates did so as well. lieve that they were teaching another
This study gave us considerable insight participant word pairs and shocking
into understanding conformity. Thus, them with increasing voltage for each
deception in research can allow us to tap response they answered incorrectly.
into constructs, such as conformity, that continued on page 20
19
Sixty-five percent of the participants suggests examining the professional re-
continued to shock the “learner” despite lationship between the researcher and
the learner’s complaints because the ex- participant as well as different forms of
perimenter said that they must continue deception when considering its use. We
(Milgram, 1963). Throughout the exper- further recommend that psychologist re-
iment, participants were apparently searchers utilize a structured decision
nervous, anxious, scared, and dis- making model to consider the relative
tressed, but the experimenter insisted risks and benefits of the use of deception
that they continue. Not only did this in research that weighs the potential
study cause significant emotional dis- value of the anticipated results of the
tress to the participants, but it took ad- study with the potential for harm to par-
vantage of their position as a study ticipants. No easily applied formula ex-
participant by breaking their trust and ists to replace such a deliberative
not giving the participants a chance to decision making process at present, but
withdraw from participation. Addition- a decision making model is presented
ally, in Milgram’s study and in other below. The APA Ethics Code makes clear
studies that use deception, the re- when the use of deception is ethical, and
searcher is not able to obtain informed although these standards may appear
consent since participants are not in- stringent, the potential of harm to par-
formed of the true nature of the study. ticipants and the violation of many of
This alone violates the participants’ au- their fundamental rights warrant these
tonomy because of their inability to standards by promoting integrity, au-
make informed, independent decisions. tonomy, safety, and privacy.
Furthermore, the use of deception could
cause an invasion of privacy when par- Decision Making Model and
ticipants are revealing information Steps to Take
about themselves that they would not 1) Determine the potential benefits of
have revealed or wanted to reveal if it the study and the value of the find-
were not for the deceptive methods that ings and data likely to be obtained.
were used. Not only do participants ex- 2) Determine the potential risks to in-
perience the consequences of deception, dividuals who may participate in
the field of psychology does so as well. the study.
The greater the use of deception in psy- 3) Consider if the typical participant
chological experiments, the more suspi- would agree to participate in the
cious participants may become when study if they knew of these risks in
participating in any psychological study. advance.
This could cause participants to behave 4) Delineate all possible alternatives
in unnatural ways because of their sus- for studying the research issue in
picions, thus eliminating the experimen- question.
tal and statistical benefits of using 5) Consult with colleagues with ex-
deception. pertise in ethics, research, and ex-
perimental design.
Conclusions and Recommendations 6) With the assistance of expert col-
When ethically used, deception can con- leagues consider the relative risks
tribute greatly to the field of psychology, and benefits of each alternative
but it is essential that researchers exam- available.
ine the risks and harm that the decep- 7) Once a decision is reached, develop
tion could potentially cause to the a research protocol that minimizes
participants and make sure there are no risks to the participants and that
alternatives possible that do not utilize maximizes protecting their rights
deception. Additionally, Benham (2008) continued on page 21
20
and welfare (e.g., monitoring their by their participation.
functioning throughout the study, 10) Conduct the debriefing of each par-
determining when to terminate a ticipant with careful attention to
participant’s involvement in the their rights and welfare. Should
study if signs of duress are noted, duress or harm be evident, take ap-
voluntary nature of participation propriate remediative steps such as
and right to withdraw at any time, obtaining treatment for the partici-
the debriefing process, etc.). pant.
8) Present this research protocol to the 11) Ensure that participants under-
appropriate Institutional Review stand their right to withdraw from
Board. the study at any time and their right
9) If a study utilizing deception is to withdraw their data as well.
approved by the IRB, implement 12) If patterns of duress or harm are
the study with careful monitoring noted in multiple participants or if
of each participant’s functioning significant harm is noted in even a
throughout each phase of the study. single participant, discontinue the
Do not allow a participant to con- study, confer with expert colleagues
tinue in the study if the likelihood and the IRB, and determine what
of harm is evident. Obtain needed modifications need to be made to
assistance for any participant who the design of the study before pro-
requests it or appears to be harmed ceeding.

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21
22
EARLY CAREER
Mommy is a Psychologist, Too
Rachel Gaillard Smook, Psy.D.
Independent Practice, Northborough, MA

It’s true; I am. It’s a And so I’m doing it. I am building a


new development. Al- practice, building a reputation, market-
though I have been ing, reading, and feeling that quickening
telling my children of the pulse that comes whenever I lock
since they were born in on my own right path and step for-
that I am a talking ward. It is very motivating. I’m excited,
doctor, the real story is energized, and brimming with ideas
that for the past six years, I have been a and possibilities. It’s a sea change,
full-time parent. The psychologist part though, and my family has motion sick-
of me was an important component of ness. “What do you mean, office?” my
my internal identity and my sense of first-grader demanded. “You’re our
self, but I wasn’t practicing. This was a mom.” And then, just to really rub it in,
measured choice on my part; my chil- she added, wistfully, “Don’t you love us
dren were very new to the world and I more than you love your job?”
was new to the world of mothering, and
I was clear that I wanted to carve out From my seat right now, parenting and
some time in my life for just those expe- working in combination feels refreshing.
riences. Frankly, I was also a little over- From the seat my kids and my husband
whelmed and just didn’t have the are sharing, mainly everybody is just
emotional energy to be attending to any feeling the need to buckle up, because
extra people. I’m glad I have spent these the ride has gotten a little wild. For six
six years the way I have. Hindsight on years, I have been available all of the
this issue melds comfortably with the time, organizing everything about my
foresight that led me to choose staying time around what the kids need and
home in the first place. what we all want as a family. Sometimes
it has been exhausting, but it has also
Staying home: what a misnomer. I have been a lot of fun. My parenting full-time
been busier in these six years than I ever has been a pretty good arrangement for
was as a full-time student or a working all of us for a long time, and now I have
non-parent. It hasn’t gotten less busy, ei- gone and shaken it up by becoming dis-
ther, and there is a part of me that thinks satisfied with it as a sole way of life.
maybe it’s a little bit crazy to take on While I am busy breathing a sigh of re-
such a project as starting a business. lief and coasting on new-project energy,
About the time that my second child my husband and children are adjusting
started to experiment with getting up on to the fact that now I disappear a lot
his feet, though, I started to dream about more often.
getting back up on mine. The therapist
My husband, truth be told, is not en-
in me started to tug on the sleeve of my
tirely crushed to hear of the prospect of
heart, gently at first, and then quite re-
me making some actual money. I have
lentlessly. I took stock, took notes, and
been either a full-time student or scant-
sought counsel. The message from
ily paid postdoctoral fellow or a stay at
everywhere was the same: Get back to
work. continued on page 24
23
home parent since we met, worthy occu- need a model for following their heart’s
pations all, but all rendering me rather a desires. My heart desires to be back in
financial deadbeat. But although he is practice. By honoring that, I bring more
relieved to be able to share the financial of a sense of fulfillment into my own life,
responsibility for this life we’ve con- enabling myself to become more of the
structed together, he is also struggling parent I want to be for my kids, and I
through the logistics and consequences show them how to listen to their own in-
that come from reconfiguring our divi- stincts and dreams. Ultimately, every-
sion of labor on the parenting front. body wins.

Everyone except for me finds this new I really love being a psychologist, and
career move of mine a tricky alteration. it’s time to do it. Thus, I will do what all
I feel it too, actually, if impatience with good moms do when the little people in
their adjustment process counts. (I know their lives are seasick. I will comfort
this is neither fair nor admirable, but it’s them. I will try as much as is possible at
an accurate reporting of events.) Every their stages of development to get their
so often I do have flashes of sadness and sights fixed on the horizon in hopes that
panic, with occasional doses of what- it will soothe their tummies. My hus-
am-I-DOING-ness. But this is unques- band and I will figure out these white-
tionably easier for me than it is for the waters, too, the way we have at other
family with whom I share my life. times when things have gotten choppy.
We have a long enough history together
When my daughter asked if I love her to trust in the calm that follows storms.
more than I love my job, I answered in We will forge ahead, this family of ours,
the affirmative. I am, first and foremost and I will hold them all close and re-
and forever, my children’s mother. None mind them that I love them more than
of my life’s roles are as vital or as un- they can possibly fathom.
shakeable as that. The kind of mom I
am, though, is the kind who also really And I will keep steady on my own
believes that I have to be a happy woman course, knowing that the ride will soon
in order to be a good enough parent, and smooth out for all of us if I do that.
I have started needing more than par-
enting to make me happy. Also, the kind To contact the author:
of woman I am believes that children Rachel@birchtreepsychology.com

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EDUCATION & TRAINING
Changes in the Sequence of Training Leading to Licensure
Michael J. Murphy, Ph.D., ABPP
Professor of Psychology and Director of Clinical Training, Indiana State University

Arizona, Indiana, Ohio, amount of practicum and fieldwork re-


Maryland, North Dakota, quired for graduation. To some extent,
Utah, and Washington this arises from an increase in profes-
have passed legislation sionally focused programs. It has also
changing their licens- been driven by a perception that intern-
ing requirements for ship programs tend to select students
supervised practice who have more clinical experience,
leading to licensure. These states require which has led to an increase in the
two years of supervised experience, one amount of clinical experience in the
of which must be in a predoctoral in- training programs. The result has been
ternship training program. The addi- that compared to students graduating 22
tional equivalent of a year of supervised years ago, when the current model li-
experience can be gained before or after censing act was adopted, many gradu-
the doctorate is conferred. At this time, ates have a considerable foundation in
most of the above states are in the professional practice at the time of grad-
process of developing rules for imple- uation.
menting the legislation. Students and
early career psychologists (ECPs) have In response to this and other changes in
been very enthusiastic in their support the profession, Norine Johnson, then
of these changes. However, the imple- APA President, appointed a Commis-
mentation will take a bit longer and it is sion on Education and Training Leading
likely that challenges are ahead as states to Licensure that presented its final re-
work to set standards and establish re- port to the APA Council of Representa-
quired documentation of supervised ex- tives (Council) in 2001. Council deferred
perience for licensure. action while APA Boards and Commit-
tees reviewed the recommendations.
This article will briefly review the back-
ground and the central issues associated In 2005, Council adopted the policy
with implementing anticipated rules statement that:
and regulations. It will also address • Affirmed the doctorate is the mini-
anticipated standards for supervised mum educational requirement for
professional experience and documen- entry into practice.
tation. These issues raise important • Affirmed that licensure applicants
implications for Division 29 members demonstrate they have completed a
who direct and teach in training sequential, organized, supervised
programs and those who supervise professional experience equivalent
doctoral students. Finally, the practical to two years of full-time training.
implications for students and ECPs will • Affirmed that postdoctoral educa-
be addressed. tion and training remains an impor-
tant part of continuing professional
Revisions of the Model Licensing Act
development and the credentialing
It is generally acknowledged that over
process.
the years, training programs in profes-
sional psychology have increased the continued on page 26
25
The APA policy was to be incorporated Licensure in order to assist state psychol-
in a revision of the Model Licensing Act ogy boards develop rules. A copy of the
and a Task Force to revise the Act was Guidelines is on the ASPPB website:
appointed in 2006. The Task Force has http://www.asppb.net/files/public/Fi
developed a revision of the Model Act nal_Prac_Guidelines_1_31_09.pdf .
and is currently in a second round of
public comment on the draft. The The Guidelines state “ASPPB is commit-
change in the sequence of training was ted to developing model regulations
incorporated into both drafts of the that provide guidance to jurisdictions
revised Model Act and will be in the that choose to modify requirements in
version to be forwarded to Council for the sequence of training leading to licen-
action at its next meeting. The model sure, resulting in consistency between
language addressing professional jurisdictions.” However, the Guidelines
experience needed for licensure can be also indicate that the authors have seri-
seen on page 10 of the online version of ous reservations about the supervised
the draft at http://forms.apa.org/prac- experience provisions in the draft revi-
tice/modelactlicensure/mla-review- sion of the Model Act and adopted the
2009.pdf . point of view that states: “because the
postdoctoral experience is no longer re-
It can be anticipated that states will dif- quired; the standards for supervised ex-
fer in their responses to the provisions perience must to be more carefully
in the Model Act, particularly to those delineated to ensure that they are organ-
provisions that accept both pre- and ized and sequential.” The Guidelines also
post-doctoral supervised experience. emphasize that the experiences must be
The states listed above are in the van- documented carefully and in detail.
guard and more will follow. However, ASPPB efforts reflect a careful analysis
others are likely to maintain the require- and adherence to very high standards
ment for postdoctoral experience. It may for training that arises from deep con-
take some time before the issues get cern about the potential for a diminution
sorted out. However, the process is in the preparation for licensure. There-
underway. fore, they offer standards that are based
on the highest ideals for preparation.
Implementing Change in the However, they do not take into account
Sequence of Training other factors that arise from the changes
The actual language that changes the that will be discussed below.
sequence of training can be fairly sim-
A goal of the Guidelines is to offer speci-
ple. All that is necessary is for the statute
to include language that asserts the ficity and they aim to achieve it by setting
applicants for licensure must have stringent expectations. Examination of
the equivalent of two full-time years of the resulting recommendations reveals
sequential and organized supervised that they overlook the complexity of
professional experience and one of training, the variety of experiences, and
them shall be a predoctoral internship. range of settings in which it occurs. Thus,
the same expectations for supervision are
The real issues arise in writing the rules
that define the above words in bold stated regardless of the stage of the indi-
type. vidual’s training or the nature and com-
plexity of the services they are providing.
The Association of State and Provincial For example, the ASPPB Guidelines that
Psychology Boards (ASPPB) has devel- address supervision state that for four-
oped and is promulgating Guidelines for hours of direct “patient/client contacts
Practicum Experience that Is Counted for continued on page 27
26
hours, for the sake of public protection evaluate the quality of the practicum
and effective learning, the student would experiences of the applicant for licen-
be required to receive two hours of sure, it is necessary that the training
supervision.” This “one size fits all” program provide to the licensing
method does not allow training pro- board the overall training plan for the
grams to adjust the needed supervision various practicum experiences, so
to what is most appropriate for develop- that the organized, sequential nature
ment of the trainees. While the Guidelines of that training can be assessed by the
raise important issues, they are not likely board.
to be seen as offering specific language to
guide development of the rules. There- It is clear that that these provisions in the
fore, the states currently developing rules Guidelines would create barriers to the
may do better by consulting with each use of predoctoral supervised experi-
other in order to provide for consistency ence to meet requirements for licen-
of standards across jurisdictions. sure.The stridency of these standards is
particularly surprising given the rela-
Implications for Training Programs tively limited specification of the train-
As noted above, the issues raised in the ing experiences, minimal standards for
Guidelines are informative, but the re- documentation, and absence of over-
quirements stated in the commentary re- sight that characterizes current provi-
visits issues that the training community sions for postdoctoral supervision.
has addressed some time ago and re-
solved through developing standards Furthermore, the Guidelines do not take
for program accreditation. The best way into consideration that a change in the
to illustrate the potential impact of the sequence will increase the quality of
Guidelines for training programs is to postdoctoral experience by removing
allow the commentary to speak for itself. barriers that affect ECPs’ access to third-
The provision in Guideline 2. Breadth and party reimbursement for their services.
Depth of Training calls for a detailed It is likely that ECPs will seek and obtain
training plan for each practicum experi- postdoctoral supervision in order to en-
ence. The Commentary states: sure mobility and reciprocity with states
that do not modify the change that
There should be an explicit plan de- would allow predoctoral experience to
veloped for each student who will satisfy the experience requires for licen-
use the practicum experience to meet sure. Furthermore, quality of the set-
requirements for licensure that spec- tings and experiences will likely be
ifies the experiences necessary, within better because better reimbursement
the context of the graduate training benefits sites and ECPs. In addition,
program and the student’s previous training sites will be better able to de-
experiences, to ensure competence velop and offer formal postdoctoral
appropriate to the level of training of training programs that will be sup-
the student. It is the responsibility of ported by the reimbursement of services
the graduate program to provide a provided by licensed trainees that is lim-
rationale for the practicum training ited by the current standards.
for each student, in light of previous
academic preparation and previous Implications for Students and ECPs
practicum training. Students and ECPs should understand
that passing legislation is only the first
The Commentary for Guideline 2 ends by step and that careful attention and active
stating: monitoring and participation in the rule
In order for the licensing board to continued on page 28
27
making process is necessary. Students be expected to have other benefits that
should maintain careful documentation include:
of the supervised training they receive.
None-the-less, ECPs must be aware that • Reducing the burden on employers
they may not be able to document their who will be able to obtain more ap-
predoctoral training retrospectively to propriate reimbursement for the
meet the standards adopted for super- services provided by ECPs who cur-
vised expereince. rently earn rates of master’s level
providers.
As noted above, those ECPs who do
• Students who work under supervi-
achieve licensure on the basis of predoc-
sion while completing their disserta-
toral supervised experience must con-
tions would be able to count
sider the issues of mobility and
supervised hours toward licensure.
reciprocity. Therefore, those who are li-
censed without completing postdoctoral • ECPs, who are already burdened
supervised experience should nonethe- with debt from education loans,
less obtain and document postdoctoral will have higher earnings.
supervised experience. This will ensure
that they can meet requirements for li- For the above reasons the proposed
censure in other jurisdictions that may changes in the sequence of training is
have different requirements. viewed very positively by students and
ECPs and those who employ them.
The ASPPB Guidelines express concern
However, even if a state passes legisla-
about a diminution of the quality of serv-
ices to patients that might be brought tion that removes the requirement for
about by licensing psychologists at thepostdoctoral supervised experience,
there are a number of issues that must
time of the doctorate is conferred on the
basis of predoctoral supervised experi-be worked through in order to imple-
ence. However, it seems equally likely ment the change in licensure. Further-
more, the change will place greater
that an increase in quality may be noted.
This arises because accountability for responsibility on training programs and
monitoring clinical experiences will bepracticum and fieldwork settings for or-
assumed by the doctoral training pro- ganizing and documenting supervised
grams that can more effectively overseeexperience. As noted above, the situa-
tion is further complicated by issues of
and provide quality control over the re-
quired hours of supervised experience. reciprocity and mobility. Professional
psychology is at the beginning stages of
Furthermore, it is anticipated there will
a transition that will require close mon-
be an increase the opportunities for post-
doctoral training because services of itoring and management by Division 29
postdoctoral fellows will be reim- members who work in training pro-
bursable and contribute to the develop-grams and in practicum and fieldwork
ment and funding of postdoctoral settings. Student members must also ac-
training programs. tively contribute to the effort. Each has
a role in fostering standards for quality
Change in the sequence of training can training as the means of driving change.

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

What does a scientist liked teaching, since it could not have


look like? As a child, been because I liked research, could it?
my image of a scientist Most of us have heard the following rid-
consisted of an older dle (or some variation of it). A father and
White man, dressed in his son are in a terrible car accident.
a white lab coat, tin- They are brought to the Emergency
kering with his exper- Room and as they are both rolled into
iments in an austere looking laboratory. surgery, a doctor appears and screams,
Since then, I have been educated as a “That’s my son!” Who is the doctor? It
Counseling Psychologist, in the scien- takes many of us a few moments to real-
tist-practitioner model, by talented ize that the doctor was the mother. A
women and men of diverse back- personal story may illustrate a similar
grounds, and still, my image of a scien- point. I once submitted a manuscript
tist at 28 is not that different from my that employed some advanced and com-
image of a scientist at 8. Do I like that plicated statistical procedures for blind
this is the image of a scientist that first review. One of the reviewers kept refer-
comes to mind for me? No. However, I ring to the author as a “he” in his writ-
do not believe I am alone in this un- ten feedback. I asked myself, why does
wanted aspect of my imagination. he keep calling me a he? Can’t girls do
math too, I thought? But then I had to
I consider myself to be a scientist. This stop and question myself. Why did I as-
role is part of my identity, what I value, sume that this reviewer was a “he”?
how I define myself, and what I have
worked toward becoming. If you were While these assumptions can feel as an-
to ask me to write down 10 things about cient as the scientist in my image, how
myself, “scientist” or “researcher” can I expect others to see me as a scien-
would make the top of the list. Still, tist, when I am still waiting for an old
when I look in the mirror, I do not auto- man, in a white lab coat, to appear in my
matically see a scientist in the reflection mirror? At the same time, we can not
staring back at me. As a woman, and a help but see ourselves (in least in part)
young woman at that, I am also not in terms of what others reflect back to
blind to the fact that many others do not us. The faces and backgrounds of psy-
automatically see a scientist when they chologists have changed over recent
look at me, and that, such a vision often years. Although we have a long way to
requires a period of convincing on my go, our profession is relatively more di-
part. After I completed my doctorate, I verse in terms of gender, ethnicity, race,
made what was a difficult choice for me, and sexual orientation. Many of the re-
to pursue a career in academia rather searchers I look up to and admire are
than clinical work, and many who did women of different ages, ethnicities, and
not know me in this capacity seemed races. So why can I not automatically
confused, if not shocked. Are you really picture any woman when you ask me,
going to do this, they would ask? It what does a scientist look like?
seemed to be the general conclusion at
the time that I chose academia because I continued on page 30
29
Where are all the Female Scientists? ply not their thing. Whether or not one
Women are clearly underrepresented in chooses to pursue research or practice
science and university life; for example, (or neither, or both) upon graduation is
data have shown that the proportion of a personal choice. At the same time, I
female faculty members in universities wonder what we can do in our training
around the world is almost always less programs to help women feel that they
than 25% (Lie, Malik, & Harris, 1994). do indeed have the choice.
Furthermore, women become increas-
ingly difficult to find as one climbs up Mentorship
the academic ladder. In the United Suppose we accept that increasing re-
States, the percentage of female full time search productivity among male and fe-
professors has been reported as only male counseling and clinical psychology
13%, slightly higher than many Euro- graduates is a worthy aspiration. Then,
pean countries (Osborn, 1998). In psy- the problem becomes that despite an
chology, only one-third of full professors emphasis on research in graduate school
are women, and those numbers drop training, the typically female dominated
even lower for department chairs, doctoral programs in counseling and
provosts, and university presidents clinical psychology, are not typically
(DeAngelis, 2008). At the same time, producing researchers. An important
since 1984, the number of females in part of the solution is likely to lie in fac-
graduate schools has exceeded the num- ulty mentorship of student research.
ber of males. Between 1995 and 2005, the Contrary to this notion, one could argue
number of male full-time graduate stu- that students who are attracted to these
dents increased by 27 percent, compared types of programs often have personal-
to a 65 percent increase for female grad- ity traits that do not lend themselves to
uate students (National Center for Edu- research, and faculty cannot be asked to
cational Statistics, 2007). In psychology, change a student’s personality after all.
nearly three-quarters of the field‘s doc- In fact, research has shown that individ-
torates are held by women; yet, they ual differences, such as personality and
hold fewer than half of all tenure-track interests, play a major role in research at-
psychology positions, according to the titudes and productivity (e.g., Kahn &
(National Science Foundation, 2006). Scott, 1997; Mallinckrodt, Gelso, & Roy-
Given these statistics on the increasing alty, 1990). Individual differences surely
numbers of female doctoral students play a role in the career path that both
and the relatively smaller number of women and men choose. However,
women in science and university life, when women represent the majority of
where are all the female psychologists psychology doctoral students but the
post-graduation? minority of psychology full time faculty,
it does not seem plausible that personal-
Counseling and clinical psychology doc- ity alone is responsible for or determin-
toral programs in particular are areas of istic of a woman’s interest in research
psychology that typically attract a high and science. I entered my doctoral pro-
number of female students. Most of the gram not exactly opposed to research
students in these programs begin their but more fearful of it. I find that my own
studies with little interest in research students, especially female students, are
and most pursue a career in practice “opposed” to research because they are
upon graduation, despite an emphasis afraid that they will fail at these under-
on the scientist-practitioner model in takings. On top of this, they often have
training programs (Brems, Johnson, & not had adequate exposure to research
Gallucci, 1996). For some students, to really know what it is. Research men-
women and men alike, research is sim- continued on page 31
30
tors can be crucial in addressing these land (1996) found that for men, research
obstacles (low research self-efficacy, high self efficacy had a stronger effect on re-
research anxiety) that often stand in the search productivity. For women, how-
way of these students pursuing research ever, the research training environment
activities. had a stronger effect on their research
productivity. Hollingsworth & Fassinger
Much has been written about the role of (2002) found that students’ research
mentorship in graduate school educa- mentoring experiences and research self
tion and it is clear that mentorship mat- efficacy mediated the effect of the re-
ters, especially when it comes to search training environment on research
students’ attitudes toward research and productivity. Unlike Brown et al. (1996),
research productivity. For example, Roy- these researchers did not find different
alty and Reising’s (1986) study found results for women and men. More re-
that students’ interest in research was search is needed to better understand
positively influenced by interacting with what female psychology doctoral stu-
role models or an advisor in research ac- dents need from a research mentor and
tivities. Similarly, O’Brien (1995) and how their research involvement and pro-
Gelso (1997) both found that students ductivity relates to mentorship, the re-
often focused on their relationship with search training environment, and their
faculty members when reporting critical research self efficacy.
incidents. Several studies suggest that
faculty modeling or mentoring in re- Some female doctoral students in psy-
search relates to the research productiv- chology may not enter graduate school
ity and involvement of psychology with a self-concept that allows them to
students and recent graduates (Cronan- think of themselves as researchers. When
Hillix, Gensheimer, Cronan-Hillix, & the cultural symbol of a scientist is a
Davidson, 1986; Galassi, Brooks, Stoltz, man, as a woman, it may be more diffi-
& Trexler, 1986; Krebs, Smither, & Hur- cult to picture yourself as a scientist. Fu-
ley, 1991). Graduate students typically ture research can examine female
report that having a mentor is a critical doctoral students’ prototypes of a scien-
component of graduate school training tist, and if these prototypes relate to the
(Atkinson, Neville, & Casas, 1991; Lark degree to which students identify as a re-
& Croteau, 1998; Luna & Cullen, 1998) searcher. Furthermore, future research
and ethnic minority psychologists re- may study how a student’s prototype of
port that faculty encouragement in re- a scientist and identity as a researcher re-
search was important and useful late to their attitudes toward research,
(Atkinson et al., 1991). and research involvement and produc-
tivity. Another potential area for future
Compared to the literature on mentoring research is to identify what types of men-
overall, there is little research specifically toring relationships are needed for fe-
on gender and research mentoring. Some male doctoral students to ultimately
previous research in this area suggests predict positive research attitudes, in-
that gender moderates the relationship volvement, and productivity. Drawing
between the research training environ- from the psychotherapy research on the
ment, self efficacy, and research produc- therapeutic relationship and techniques,
tivity. The research training environment perhaps a student’s involvement in re-
is an empirically tested model that out- search is predicted by both a strong men-
lines nine themes central to a research toring relationship and the techniques
training environment that predicts stu- that the mentor uses to actually teach the
dent research productivity (see Gelso,
1997). Brown, Lent, Ryan, and McPart- continued on page 32
31
student how to conduct research. Female torship, or professional success in my
doctoral students may need multiple re- life. He is an amalgamation of movies,
search mentors to provide relationships books, cultural convention, and my own
in which they can develop their research personal history that I have internalized.
self-efficacy and skills. Perhaps this will one day change, and I
will begin to envision scientists that look
Conclusion more like me. Yet, would envisioning
I am one of those lucky early career pro- myself to look more like a scientist actu-
fessionals to have received mentorship ally make me any more of a scientist?
in research by both men and women. Other female psychologists and doctoral
These mentors have supported my sci- students may have a similar image of
entific aspirations and sense of self as a what a scientist really looks like. How-
researcher. Despite all this, when I close ever, in reality, a scientist does not look
my eyes and picture a scientist, I still do like anything or anyone. Rather than fo-
not picture someone that looks like me, cusing on what a scientist looks like, it
and instead, that same older man comes may be more helpful to focus on what a
to mind. The scientist that lives in my scientist actually does, and if you use the
imagination may always be there, no scientific method to get a little closer to
matter the amount of education, men- some truth, then you are a scientist.

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Find Division 29 on the Internet. Visit our site at


www.divisionofpsychotherapy.org

32
FEATURE
A Therapy Preferences Interview:
Empowering Clients by Offering Choices
Barbara Vollmer, Ph.D., Jen Grote, M.Ed., Robin Lange, M.A., Charity Walker, M.A.
University of Denver

As the field of psychotherapy moves to-


ward a more collaborative approach to
therapy interventions, clients’ expecta-
tions of treatment and therapist-client
variables have become a central focus of
research (Wampold, 2001). Ongoing re-
search is being conducted at the Univer-
sity of Denver’s Counseling Psychology
Training Clinic to examine the effects of
collaborative treatment planning and
therapeutic choice on the working alliance
and outcome. This article will describe thehave the freedom to select the theoretical
rationale and development of the Therapy approach of their choice” (p. 226).
Preferences Interview (TPI) in which the According to the APA Presidential Task
therapist asks clients about and discusses Force on Evidence-Based Practice (2006),
preferences for the therapist’s approach “psychotherapy is a collaborative enter-
and type of therapy to receive. This article
prise in which patients and clinicians
presents preliminary research on whether negotiate ways of working together that
taking additional steps to actively inquireare mutually agreeable and likely to lead
about clients’ preferences and presenting to positive outcomes” (p. 280). Based on
them with choices help strengthen the Norcross (2003) and Wampold’s (2001)
working alliance. meta-analyses, providing clients with a
Importance of Client Choice choice in treatment may be an important
Ethical guidelines emphasize the impor- aspect of treatment planning in psy-
tance of informed consent and disclo- chotherapy.
sure of the therapist’s approach and
Working Alliance
opportunity for questions and answers
Some therapist-client variables, such as
in the therapeutic process (American
empathy, warmth, and client expectancy
Psychological Association, 2002). Atten-
for change have been identified across
tion has been given to ways to develop
various treatment approaches and have
treatment plans by varying approaches
been termed “common factors” (Lam-
according to client characteristics (Beut-
bert & Ogles, 2004). Of the common fac-
ler & Clarkin, 1990); however, Norcross
tors, the client-therapist relationship has
(2003) proposed that clients directly be
long been considered a key common fac-
asked about their preferences for the
tor in facilitating a positive therapeutic
therapist’s characteristics and approach
outcome (Norcross & Lambert, 2006).
to allow the therapist to customize the
Bordin (1994) broadened the concept of
therapy provided. Wampold (2001) con-
the therapeutic relationship by defining
ducted a meta-analysis of the effect of
the “working alliance” as not only the
various factors on therapy outcome and
concluded with several recommenda- therapeutic bond, but also collaboration
tions, one of which was “clients should continued on page 34
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and mutual agreement between the Effects of Client Choice on
therapist and client on the goals and Outcome and Process
tasks of therapy. The working alliance Arnoff, Glass, and Shapiro (2002) re-
suggests collaboration between the ther- ported that studies on client preferences
apist and client as the key factor through and outcome are limited, though inter-
which change is achieved in psychother- est is increasing. Some research has
apy (Horvath & Symonds, 1991). shown that providing clients with a
choice of treatment produces positive re-
Researchers have argued that a strong sults on the treatment process, such as
therapeutic alliance is a necessary com- increasing the likelihood of reaching
ponent for therapy to be effective (Nor- treatment goals, increasing contact with
cross, 2003). Horvath (2001) suggested the treatment program, and decreasing
that a little over half of psychotherapy’s likelihood of terminating treatment
positive effects can be attributed to the early (Calsyn et al., 2003; Calsyn, Winter,
quality of the alliance. The alliance pre- & Morse, 2000; Rokke, Tomhave, & Jocic,
dicts therapy outcome equally for all 1999; de Shazer & Isebart, 2003; Swift &
theoretical orientations, and client’s rat- Callahan, 2009). Additionally, Iacoviello
ings of alliance are more predictive of et al. (2007) found that a match between
outcome than either therapists’ or ob- clients’ preferred treatment and treat-
servers’ ratings. Horvath (2001) found ment received assisted the development
that alliance is established within the of a positive working alliance. However,
first three sessions and remains largely research on the direct effect of client
stable throughout treatment, lending choice on client outcomes has produced
further support to the importance of mixed results (Adamson, Sellman, &
strong alliance in positive clinical out- Dore, 2005; Glass, Arnkoff, & Shapiro,
comes. These findings emphasize the 2001; Atkinson, Worthington, Dana, &
need for the therapist to establish a pos- Good, 1991; Devine & Fernald, 1973;
itive working alliance with the client Rokke, et al., 1999).
early in treatment. Horvath and
Luborsky (1993) suggested that research Some studies have investigated the po-
be focused on determining specific ther- tential impact of matching clients to
apeutic actions that could help to their stated treatment preference on both
strengthen the therapeutic alliance. outcome and process variables (Atkin-
son et al., 1991; Goates-Jones & Hill,
Attending to clients’ preferences for 2008). Goates-Jones & Hill (2008) found
therapeutic approach may be a factor no difference in outcome for clients who
received or did not receive their prefer-
that helps to increase therapeutic al-
ence for an insight-oriented or action-
liance and promote other therapeutic
oriented single session. Atkinson, et al.
measures of success. In recent years at-
(1991) identified comparability of
tention has significantly increased in
client’s etiology beliefs about the prob-
practice and research on the relation be-
lem with the explanations offered by the
tween similarity of clients’ preferences
therapeutic approach as a critical ingre-
for treatment and important process
dient. Though clients who attended at
variables, particularly the client-thera-
least three counseling sessions rated the
pist relationship (Iacoviello et al., 2007).
process and outcome equally positive
The effects of allowing clients choices
regardless of whether their preferred
about their treatment should be consid-
therapy approach matched that of their
ered in terms of the treatment process counselor, clients’ perceived similarity
and clients’ outcome in therapy.
continued on page 35
34
of etiology beliefs was predictive of 2006), therapy retention, and client satis-
counselor credibility and satisfaction faction. Counselors attend weekly su-
with therapy. Additionally, a recent pervisory sessions for assistance in
meta-analysis of 26 studies on the im- adhering to the selected or assigned
pact of client treatment preferences on therapy. Research is also being con-
outcome suggests that there is a small ducted on student-counselors’ experi-
significant effect (Swift & Callahan, ence in collaborating with their clients
2009). However, none of these studies and on the effects of students’ allegiance
included in the meta-analysis specifi- to a type of therapy on outcome.
cally asked clients about their prefer-
ences for the client-therapist relationship Preliminary findings on client percep-
or their choice for their type of therapy. tion of the use of the TPI with 48 clients
suggest that clients who were given the
The Treatment Preferences Interview opportunity to choose the therapy ap-
The Treatment Preferences Interview proach felt that it was important to be
(TPI) was developed to operationalize included in this decision. When asked
recommendations by Norcross (2003) to about their preferences for therapist’s re-
customize the therapist-patient relation- lational approach, 84.2% of clients re-
ship. In a pilot study, twenty-four clients ported a positive experience and 15.9%
with gambling problems were asked indicated they did not like expressing a
for their preferences related to five preference or were neutral.
types of psychotherapy that had been
demonstrated to be effective in previous Client therapy preferences were as fol-
research studies: Cognitive-Behavioral, lows: 37.5% Dynamic, 35.4% Solution-
Psychodynamic, Solution-Focused, Moti- Focused, and 27% CBT. 25.6% indicated
vational Enhancement and Twelve Step that they preferred to make the choice
(de Shazer & Isebart, 2003; Ladouceur, et about therapy type, 33.3% were neutral
al., 2002; McCown & Chamberlain, 2000; and 41% indicated they preferred the
Petry 2005; Van Wormer & Davis, 2003). therapist make the choice. While more
Based on results from the pilot study, So- clients tended to prefer that the therapist
lution-Focused, Cognitive-Behavioral, make the choice about therapy type
and Psychodynamic therapies were in- used, when asked about how important
corporated into the final TPI, which was it was to be included in the decision
also reviewed by expert consultants who making process about type of approach
helped refine the therapy descriptions employed, the majority of clients indi-
(see Tables 1 and 2 for more information). cated they liked being offered a choice.
Data about the sample’s preference for a
Current Research therapist who is directive and takes
A larger ongoing research study is cur- charge of a session may help to explain
rently being conducted. Adult clients the findings regarding the clients’ ten-
who volunteer to participate in the clinic dency to prefer that the therapist make
research are randomly assigned to one the decision about type of therapy. 85%
of three conditions: Treatment as usual preferred that the therapist take charge
in which the therapist selects the thera- while only 15% expressed a preference
peutic approach, Treatment Preference for more control of the session. Clients
(TPI), or Assigned Treatment, in which also tended to prefer a warm, expressive
the therapist is assigned the therapy ap- therapist (82%) as opposed to a more re-
proach. Outcome is measured by the served therapist (5.1%). When student
Outcome Questionnaire, OQ 45.2, (Lam- counselors were asked about their expe-
bert et. al., 1996), the Working Alliance- rience of administering the TPI, prelim-
short form (WAI-S; Hatcher & Gillaspy, continued on page 36
35
inary results indicate that almost all in- clients in collaborative treatment plan-
dicated they appreciated the more col- ning and the mere act of offering clients
laborative nature of the sessions. a say in their treatment may have a pos-
itive effect on the working alliance. The
Based on the review of previous litera- clients sampled thus far appear to prefer
ture, Wampold (2001) and Norcross that the therapist make the majority of
(2003) emphasized the importance of al- the decisions about treatment, however
lowing clients their choice of treatment. clients appreciated being asked to be in-
Developing the TPI was an attempt to volved in the process. Spending time en-
address the limitations of previous stud- gaging the client in dialogue about their
ies and introduce a concrete tool to inte- preferences for treatment during the in-
grate clients’ preferences into take may pay dividends throughout the
psychotherapy. While small sample treatment, possibly by reducing the
sizes require that the results be inter- power differential and making known
preted with caution, the preliminary the value of the client’s contribution to
findings suggest that important infor- the therapy process.
mation can be gained by engaging

Table 1: Description of the Treatment Preferences Interview

Working Alliance Factor Question content and examples

Relational Bond Prior therapy or experience being helped


What was most helpful? What was the worst
a therapist could do?
Preferences for counselor’s characteristics
Strong preferences for counselor’s: gender, ethnicity,
language, sexual orientation, religion
Preferences for the counselor’s approach
Preferences for a therapist who takes charge, is active/
talkative and expressive/warm, or client taking
charge, and the therapist is more quiet and reserved

Consensus on Tasks Preferences for treatment modality


Individual, couple, group and/or family sessions
Preferences for counseling tasks
Try new things between counseling sessions; reading
self-help books; watching self-help movies; going
on-line for information

Agreement on Therapy Beliefs about the causes of the problem


Goals and Approaches Will of God, unlucky experiences, biological make-up,
unmet emotional needs, unrealistic expectations,
relationship conflicts, lack of self knowledge, life
style, lack of willpower
Preferences for type of therapy
Solution-focused therapy, Cognitive Behavioral
and 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 you


to 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 where
your counselor and you will be working to identify your strengths and successes
and 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 pay
attention to and what to think about doing differently between sessions. You will
be asked to notice any progress.

Cognitive Behavioral Therapy (CBT) is a goal oriented therapy that is active and
directive 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 new ways of thinking about problems, and you will
learn new skills to deal with them. To help identify patterns thought logs are used
frequently in your session and between sessions. Your counselor will ask you to
complete assignments and try change techniques that may be practiced throughout
your week.

Dynamic Therapy’s goals include improved relationships, attunement to feelings


and/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 you
to talk about yourself and your relationships to identify your expectations and
repetitive patterns in your life and your relationships. The focus is often on resolv-
ing past experiences and prior traumas, and identifying expectations you have for
yourself and others. You will be asked to think about yourself and relationships
between sessions.

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DIVERSITY/PUBLIC POLICY AND SOCIAL JUSTICE
A Place at the Table
Opening Up Leadership and Governance: A Need for Transparency
Through the Black Box
Rosemary Adam-Terem, Ph.D. and Jeffrey E. Barnett, Psy.D., ABPP

The Black Box Division 29 is committed to increasing


There was once a Lar- diversity in our membership, focus of
son cartoon showing a research, and leadership/governance.
chalk board full of Here we will consider the issue of lead-
complex mathemati- ership and governance. How are we to
cal equations and attract, retain, inspire and learn from
computations and an new faces at the table?
E=MC2-type conclu-
sion linked by a black A couple of problems or barriers
box marked “and then One real issue in bringing more diversity
a miracle happens.” to governance is the very model of gover-
For many, entering nance itself. The rules and structures of
leadership and gover- APA and many other organizations be-
nance of APA Divi- long to a kind of culture of their own, a
sions may feel as type of formal, parliamentary process in
mysterious as that. We need to elucidate which participants have to know the per-
the black box. haps arcane rules and regulations, be at
ease with speaking up in public forums,
It may be daunting just to look at the list be willing to put their personal and pro-
of officers and members of the board of fessional stances up for scrutiny, and in
Division 29: luminaries of the profes- the case of elected office, to be willing to
sion, publishing superstars, past-presi- face rejection and failure. There are many
dents of State Provincial and Territorial possible ethnic and cultural barriers to
Psychological Associations (SPTA’s) or feeling comfortable in such a system.
other psychological associations, APA Take, for example, an Early Career Pro-
divisions and societies, and even past- fessional (ECP) of Asian or Pacific Is-
presidents of APA—an extraordinary lander origin and consider the values of
group of psychologists.
harmony, humility, respect for elders or
There is of course great practical advan- perceived superiors, and honor or face.
tage to having senior and seasoned psy- All may be in apparent contradiction
chologists in governance—they know the with the requirements for success in ob-
ropes, they know the people to know, taining a leadership position.
they provide continuity and “institu-
Another major issue is the time vs.
tional memory,” they carry prestige, they
money problem—it seems that we really
understand the organization, and they
can have one or the other, but not both.
know how to get things done. However,
Students come out of lengthy programs
there is also a risk that this may become
what has been termed “a club that runs burdened with debt; ECP’s are either at
the club,” an in-group harboring the the lower end of the pay scale or are try-
power of the organization that seems im- ing to build up their private practices,
penetrable and perhaps unapproachable, often struggling financially; mid-career
or as we have heard them humorously psychologists may be so busy that they
described “APA Junkies.” continued on page 39
38
feel they cannot afford to take the time language, and socioeconomic status
away; psychologists who live far from and consider these factors when
urban centers or in far-flung areas of the working with members of such
States, Territories and Provinces have to groups. (p. 1064)
face long, time-consuming, and very
costly journeys. There is a risk that lead- How then can psychologists in all their
ership and governance will be popu- diversity feel included and have an ac-
lated only by those who can afford it. tive part in the life of the Division? How
did others do it? And how did psychol-
Why increase diversity? ogists from minority and underrepre-
There are reasons of justice referenced in sented groups achieve what they have?
Principle D, Justice, of the APA Ethics In another article, we will feature some
Code (APA, 2002) that state: members’ experiences.

…fairness and justice entitle all per- Let us enter the Black Box—
sons to access to and benefit from the What do you have to do to be part of
contributions of psychology and to leadership or governance?
equal quality in the processes, proce- There are many ways to be involved,
dures, and services being conducted and many paths to participation at the
by psychologists. (p. 1063) board and committee level. The broad-
est overview would be that a psycholo-
This is an aspirational goal, but one that gist or a student would decide on what
should apply to the way APA runs its issues are most compelling or in which
own business. Diversity is everyone’s they have expertise to offer, and would
business. In addition, we hope that the then communicate with other Division
work of the Division will be relevant to and Board members in related roles.
today’s psychologists who are them- This could be done by e-mail, by listserv
selves increasingly diverse. By diversity, commentary, by the exchange of ideas in
we mean to include more than the racial articles, through person to person con-
and ethnic, linguistic and cultural spec- tact (old fashioned idea here), by phone,
trum. Psychologists come from different at meetings, or at conferences, or even
age and stage of professional develop- over a cup of tea.
ment groups (not always correlated), ge-
ographical and geosocial (urban or It is important to remember that not
rural) areas, vary in gender and sexual everyone feels comfortable putting
orientation and identity, ability status, themselves forward, so it is the respon-
theoretical orientation, and professional sibility of board members and others in
specialty (research, training, practice) leadership roles to reach out and invite,
and work arena (private office, univer- encourage, and inspire others to join in.
sity, organization), and so on. We are Every member of the Division’s leader-
committed to promoting and celebrating ship must take personal responsibility to
diversity as defined in Principle E, Re- make the Division an open and welcom-
spect for People’s Rights and Dignity, of ing place. We must each also actively
the APA Ethics Code, which states: reach out to colleagues and when at-
tending events and meetings of the Divi-
Psychologists are aware of and re- sion, actively seek out those we don’t
spect cultural, individual, and role know, make them feel welcome, and en-
differences, including those based on courage their involvement and partici-
age, gender, gender identity, race, pation. It’s very easy to be friendly and
ethnicity, culture, national origin, re- welcoming to those we already know.
ligion, sexual orientation, disability, continued on page 40
39
What’s really needed is creating a wel- As they begin their professional lives,
coming environment for everyone. ECP’s need to stay involved. This can be
a challenge: financial and practical pres-
Probably the simplest path is for those in sures of the work environment can limit
academia, where there is access to psy- the ability to travel or attend meetings.
chologists on site, where meetings, dis- This is where mentoring comes in. It is
cussions, and seminars provide forums essential to stay in touch with one or
for interaction. It is more complicated for more mentors, and many SPTA’s have
the private practitioner, especially in a specific programs to connect ECP’s with
rural or remote area, where other psy- mentors. Remaining active in at least
chologists may be scarce indeed. SPTA events is usually feasible, and it
may be possible to have live or virtual
Fortunately, new developments in tech- peer support groups.
nology for those who can keep up (an-
other possible barrier) offer better These may be some foundational steps
options for access than ever before for gaining a level of comfort with the
through remote linkage. Division 29 can culture of large organizations and from
continue to develop new ways of con- there it may be easier to seek office or
necting people. leadership roles.

Back to the black box: so how do you


The developmental pathway
actually go about being nominated
We often speak of the “pipeline,” a
and elected?
metaphor for the developmental se-
Any Division member in good standing
quence required to bring people into our
can be nominated or self-nominate for a
profession. It is not enough to train stu-
position. The “slates” are put together
dents to the postdoctoral level and then by the nomination committee, which
declare them professional psychologists. has the responsibility of offering good
Remember the Larson cartoon. We need candidates for every position open, tak-
to be able to see into the black box. Stu- ing into consideration the diversity of
dents need to be able to see the steps the Division’s membership and the
ahead—to first job, early career, mid-ca- unique contributions that potential
reer, and mature career status. nominees may make to the governance
of the Division. Separate slates may be
Students can be encouraged and empow- developed to create opportunities for
ered to become involved in their future more and less experienced members, for
profession from the very start, for exam- members of underrepresented groups,
ple by joining their SPTA, taking on com- or other membership groups that will
mittee roles and volunteer work at benefit the Division. Each candidate
conferences, presenting their work at writes a personal statement of interest
conventions and poster sessions, joining and goals. The ballots go out to mem-
APA Graduate Students (APAGS), and bers of the Division in April and the
attending APA conventions where they votes are tallied centrally at APA. Re-
can follow APAGS programming. This sults come out in the summer.
fosters comfort and confidence and cre-
ates relationships, which are often the Assuming you get elected, then what?
basis for involvement in professional or- What does the position entail?
ganizations. Of course, there are financial As a board member, you would expect
constraints on live participation, espe- to travel twice a year to weekend meet-
cially at the national level. There is a need ings in Washington D.C. (for which
for creative solutions to help level the travel and accommodation expenses are
ground and provide more equal access. continued on page 41
40
covered by the Division), and to be part sion’s needs are, and then volunteer to
of e-mail and possibly ‘phone discus- participate. Another great way to start
sions between times. The Division also off in the Division is to submit some
meets at APA Convention and holds a brief articles on areas of interest or ex-
terrific social hour where members get pertise for you to the Division’s publica-
to mingle and meet others. There are nu- tion, the Psychotherapy Bulletin. That’s a
merous committees to be involved with great way to make a contribution, to get
also, and sometimes task forces. noticed, and to begin your involvement.

Other leadership opportunities No one is expected to know everything


Division members can be involved with about the Division right away (if ever!),
committees even if they do not hold who the key players are, how to get
elected office. This is an excellent oppor- things done, and the like. When you first
tunity for student members and ECP’s volunteer to participate in the division,
to have an active role, see how things ask for a mentor. Having a senior col-
work, and perhaps decide from there to league assigned to support and assist
run for office. you can make all the difference. Feeling
on your own, not knowing who to ask
Division 29, like most other APA divi- for guidance, or what to do will likely
sions and SPTAs, is always looking for lead to dropping out of the activity. Di-
new members for its various commit- vision 29 must actively work to prevent
tees. See the list of Division 29 commit- this. Having a helpful, supportive, and
tees on the Division 29 website. Find one caring mentor in the division is impor-
that is of possible interest to you and tant to all newly involved members.
then contact the Committee Chair. Ex-
press your interest, learn more about the
committee, and if it seems like a good fit, For more information, visit the website
volunteer to join the committee. If at http://www.divisionofpsychother-
you’re not sure which committee might apy.org or contact any of the Division of-
be best for you, contact the president of ficers listed there. They will be glad to
the Division, express your interest in speak with you or answer questions by
getting involved, learn what the Divi- e-mail.

N O F P S Y C H O THE
O
RA P Y
D I V I SI

29
ASSN.
AMER I

C
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A
N PSYCHOLOGI C

41
PRACTITIONER REPORT
State Leadership Conference 2009: Exciting Times
on Capitol Hill and Off
Report of Federal Advocacy Coordinator (FAC) for Division 29
Bonita G. Cade, Ph.D., J.D., Roger Williams University, Rhode Island and
Private Practice
As the new Federal scored by Dr. Nordal and we were off to
Advocacy Coordina- a rousing start! Sessions entitled: The
tor (FAC) for Division 2008 Elections and the Future of Health
29 it was my pleasure Care in America, The Primary Care Associ-
to attend my first State ation Initiative: Integrated Care and Rural
Leadership Confer- Health, Health Care Delivery Systems: Pro-
ence on your behalf in moting Psychology in Hospitals and Other
Washington D. C. this Facilities Through Legislation and Practi-
past March 1-4. Nothing could have pre- tioner Advocacy, Understanding the New
pared me for the excitement and the en- Federal Parity Law, Medicare: How Federal
ergy that was in the air during the Policy Impacts Psychological Services and
sessions prior to the Capitol Hill visits. The Presidential Task Force and Summit on
the Future of Psychology Practice were just
Katherine C. Nordal, Executive Director a few of the areas addressed over the
for Professional Practice, Practice Direc- next few days.
torate, APA gave the keynote address.
Dr. Nordal reminded us of the pivotal As I was beginning to feel that our re-
and unique role psychologists play in sponsibilities as psychologists were
health care in this country. She informed overwhelming, though critical, the cere-
us that in light of our training as critical mony surrounding the presentation of
thinkers and researchers and our expe- the awards for the 2009 Psychologically
rience as practitioners, we have a re- Healthy Workplace Awards and Best
sponsibility to assert ourselves in the Practices Honors occurred. We were all
coordination of integrated health care. reminded of the potential that can be re-
Because of our knowledge of preventive alized as the result of commitment and
measures and our development of pro- knowledge dedicated to the service of
tocols, we can facilitate measures that our fellow human beings, which is a
will ultimately lead to savings in health hallmark of our profession.
care cost. She reminded us that psychol-
ogists understand the relationship be- Thus, informed and invigorated we
tween mental health and physical health headed to Capitol Hill to speak with leg-
and should therefore become more in- islative staffers regarding the health care
strumental and visible in the issues that issues that impact psychologists and
are being addressed in the potential re- those they serve. This year we focused
structuring and delivery of the health on four primary issues in our “hill brief-
care system. ings.” Here is a brief summary of the
topics we addressed.
Dr. Nordal’s remarks set the tone of this
year’s conference and were consistent 1. The Centers for Medicare and Medi-
with the information that followed. caid Services (CMS) reduced reim-
bursements for many services in 2007.
The theme of the conference With Chal-
lenge Comes Opportunity was under- continued on page 43
42
Mental health services and psycho- tal health services, would benefit
logical testing services experienced from the inclusion of psychologists in
the greatest cuts. Although the Con- the definition of “physician.” In our
gress did cause a partial restoration discussions with legislative staffers
for some of the cuts made in 2008 we recommended that Congress
through The Medicare Improvements amend the Medicare “physician”
for Patients and Providers Act of 2008 definition to include psychologist.
( MIPPA), that “restoration” is slated
to expire on December 31, 2009. Dur- 4. Health Care Reform is a necessary
ing the visits to Capitol Hill we asked and dynamic process. It is also the
for new legislation to continue the case that we as psychologists have ex-
restoration through December 2011, pertise to facilitate beneficial changes.
at which time there will be a 5-year re- Thus it is important that our profes-
view. sional research, training and expertise
be a significant part of decisions re-
2. Psychologist perform many services lated to health care. We have studied
such as establishing diagnosis and the psychological and behavioral fac-
treatment options, analyzing psycho- tors that are related to the prevention
logical tests, counseling, the coordina- of disease and the promotion of
tion of care and consultation on cases. health and wellness. We frequently
These services are all within the work in an interdisciplinary manner
purview of our licensure. to implement and design programs
that encourage healthy behaviors and
These services are considered to be lifestyles. Thus we urged our law-
evaluation and management services makers to pass health care reform
(E/M) for which psychologists are not that integrates psychological serv-
reimbursed because CMS prohibits ices in primary care, preventive serv-
billing by psychologists because these ices and benefit packages.
are labeled as “medical services.”
Thus we requested that psychologists We delivered these four requests to
be made eligible for Evaluation and Capitol Hill and I am grateful for the op-
Management code reimbursement. portunity to participate as the Federal
Advocacy Coordinator for Division 29.
3. The Medicare “physician” definition
of the Social Security Act has been In the future I will be contacting mem-
amended to include non-physician bers of the division about relevant issues.
providers such as chiropractors, op- On occasion I will elicit your help in con-
tometrists, dentists and podiatrists, tacting your government officials. Many
who like psychologists, provide serv- of you may have already developed rela-
ices to their patients and clients tionships with particular lawmakers and
within the scope of their training and are therefore strategically positioned to
licensure. Like many other non physi- “make our case” to the benefit of those
cian practitioners, psychologists are we serve. Please feel free to contact me at
licensed to practice independently of drbcade@gmail.com or bcade@rwu.edu.
physician supervision. The access of I hope that this update on the 2009 SLC
older adults, who, will increase in has been informative and I look forward
number and often fail to obtain men- to this time of challenge!

43
WASHINGTON SCENE
Evidence-Based Medicine — The Devil Remains
in the Details
Pat DeLeon, Ph.D., former APA President
In the Fall of 2007, theHIT has been enthusiastically endorsed
Institute of Medicine’s at the highest policy level. In April 2004,
(IOM) Annual Meet- President Bush created by Executive
ing focused upon the Order the Office of the National Coordi-
importance of integrat- nator for Health Information Technol-
ing individual clinical ogy in order to develop, maintain, and
expertise with the best direct a strategic plan to guide the na-
available external evi- tionwide implementation of HIT in the
dence—i.e., Evidence-Based Medicine public and private health care sectors.
(EBM). “Technological and scientific in- During his January, 2009 Inaugural Ad-
novations continue to expand the uni- dress, President Obama: “Our health
verse of medical interventions, treatment, care is too costly…. We will restore sci-
and approaches to care, ushering in an ence to its rightful place and wield tech-
era rich with potential for improving the nology’s wonders to raise health care’s
quality of health care but also rife with in-
quality and lower its costs….” The
creased uncertainty about what works budget of the National Coordinator’s
best for whm… Reforms will be neces- Office was raised by the Stimulus legis-
sary to remedy existing shortfalls in ac- lation from approximately $66 million in
cess to care as well as to take better FY’09 to $2 billion, while numerous
advantage of the opportunities provided health policy experts suggest that the
by innovation, information technology, federal government’s overall investment
and broader stakeholder engagement.” for HIT will reach $19+ billion under the
The American Recovery and Reinvest- stimulus legislation.
ment Act of 2009 (The Economic Stimu- The second significant investment was
lus legislation, P.L. 111-5) included two
providing the Agency for Healthcare Re-
major, highly relevant federal invest-
search and Quality with $1.1 billion for
ments. The first was the inclusion of the
comparative effectiveness research, a de-
Health Information Technology for Eco-
velopment which turned out to be
nomic and Clinical Health (HITECH)
highly controversial. “The conferees do
Act, which is intended to promote the
not intend for the comparative effective-
widespread adoption of health informa-
ness research funding included … to be
tion technology (HIT) for the electronic
used to mandate coverage, reimburse-
sharing of clinical data among hospitals,
ment, or other policies for any public or
health care providers, and other-health
care stakeholders. Today, relatively few private payer. The funding … shall be
providers actually utilize HIT, the most used to conduct or support research to
recent estimate suggests that only about evaluate and compare the clinical out-
5% of physicians have a fully functional comes, effectiveness, risk, and benefits
electronic health records (EHR) system. of two or more medical treatments and
We wonder what the comparable figure services that address a particular med-
is for psychology’s practitioners? The ical condition. Further, the conferees rec-
legislation’s goal is to bring utilization ognize that a ‘one-size-fits-all’ approach
up to 70% for hospitals and approxi- to patient treatment is not the most med-
mately 90% for physicians by 2019. continued on page 45
44
ically appropriate solution to treating new medical evidence; and * the legisla-
various conditions and include lan- tive and policy changes that would en-
guage to ensure that subpopulations are able an evidence-based health care
considered when research is conducted system. Common observations which
or supported with the funds provided in surfaced were: * Increasing complexity
the conference agreement.” The Act also of health care; * Unjustified discrepan-
establishes an interagency advisory cies in care patterns; * Importance of bet-
panel [the Council] to help coordinate ter value from health care; * Uncertainty
and support the research, composed of exposed by the information environ-
up to 15 senior officials (including ment; * Pressing need for evidence de-
physicians and others with clinical ex- velopment; * Promise of health
pertise) from federal agencies with information technology; * Need for
health-related programs. The Council is more practice-based research [a direc-
to submit an annual report to the Presi- tion espoused for years by Steve Ra-
dent and Congress. Within this broader gusea]; * Shift to a culture of care that
public policy context, the 2007 IOM de- learns; * New model of patient-provider
liberations are timely and prophetic. partnership; and, * Leadership that
Highlights: stems from every quarter.
The IOM’s vision is for a learning Those interested in expanding their
healthcare system that “draws upon the practice into health psychology should
best evidence to provide the care most be particularly intrigued with the evolv-
appropriate to each patient…” In effect, ing notion that: “With the increasing
the learning healthcare system is one complexity of care, and the need and de-
which enlists organizations, providers, mand for more patient involvement, the
and patients in driving the process of traditional ‘physician-as-sole-authority’
discovery as a natural outgrowth of pa- model will need to adapt to support pa-
tient care, and ensures innovation, qual- tients as integral partners in medical de-
ity, safety, and value in health care. The cisions.” And further, the prediction that
goal is that by 2020, 90% of clinical deci- our healthcare system will shift from ex-
sions will be supported by accurate, pert-based practice, which is built upon
timely, and up-to-date clinical informa- the extensive knowledge and experience
tion, and will reflect the best available of the physician, to a systems-supported
evidence. The rapid pace of scientific practice centered on teams supported by
discovery and technological innovation well-defined processes and information
over the last several decades is unprece- technology tools. The demise of expert-
dented and raises the prospect of achiev- based practice is inevitable. The
ing dramatic improvements in the complexity of biomedical information
nation’s health and well-being. Yet and technology will increasingly over-
stakeholders from across the healthcare whelm an individual expert’s cognitive
system, from patients to practitioners to capacity. Specialization is not the answer
payers, are demanding fundamental im- because of the accompanying fragmen-
provements to a system that is seen as tation, which is incompatible with the
costly, fragmented, and ineffective. personalization of care that is becoming
possible with progress in genomics and
The IOM discussions focused upon four systems biology. Even if its demise were
fundamental themes: * the forces driv- not inevitable, one would want to move
ing the need for better medical evidence; beyond expert-based practice, as other
* the challenges with which patients and industries have already done through-
providers must contend; * the need to out our history.
transform the speed and reliability of continued on page 46
45
Equally significant is that a consistent about EBM, it is likely that many pa-
pattern has been found in which the tients will perceive that “the system” is
quality of care, as reflected in process out to limit their access to the care they
measures of care, is actually worse when need. And, it is likely to be much more
spending—and the intensity of care de- complicated and expensive to imple-
livery—is greater. In fact, if all geo- ment than is necessary. The key is to pro-
graphical regions adopted the practice tect and preserve the patient-provider
patterns of the most conservatively relationship, so that it is on equal footing
spending regions of the country, health with public health and epidemiological
outcomes could be significantly im- evidence.
proved and U.S. healthcare spending
could decline by as much as 30%. There During her confirmation hearing before
is a demonstrable need to focus re- the Senate Health, Education, Labor
sources where needed; for example, on and Pensions (HELP) Committee to
the care and treatment of chronic condi- serve as Secretary of HHS, Governor
tions such as heart disease, diabetes, and Kathleen Sebelius echoed several
asthma, which affect almost half of our reoccurring policy themes of the Obama
Administration:
population and which represent approx-
imately 78% of our nation’s healthcare I have also been a health care pur-
expenditures. Clearly, more is not neces- chaser, directing the state employee
sarily better. health benefits program as well as
overseeing the operation of health
Stressing the importance of personalized services in our correctional institu-
and individualized care, it was noted tions and Medicaid and CHIP pro-
that: “For a variety of common diseases, grams, and coordinating with local
only about 50 percent of patients will re- partners on health agencies across
spond favorably to a given biopharma- Kansas. I took these jobs seriously….
ceutical agent. Moreover, such response In these roles, I know first-hand the
rates in individual patients are often challenge of standing up to the spe-
highly variable in both their magnitude cial interests to protect consumer in-
and their duration.” Presently therapeu- terests…. Health care costs are
tic interventions are frequently applied crushing families, businesses, and
in a “one-size-fits-all” approach, and the government budgets. Since 2000,
means by which individual patients are health insurance premiums have al-
most doubled and an additional 9
matched to therapeutic interventions
million Americans have become
often occurs by “trial and error.” Gath-
uninsured. Since 2004, the number of
ering long-term, longitudinal data on ‘under-insured’ families – those who
outcomes is challenging, but the cost of pay for coverage but are unprotected
doing so is unnecessarily high because against high costs—rose by 60 per-
of the current organizational structures cent. Just last month, a survey found
and practice patterns. Massive data sets over half of all Americans (53 per-
could be built that could be used to sup- cent), insured and uninsured, cut
port structured clinical trials and track back on health care in the last year
the longitudinal consequences of med- due to cost. The statistics are com-
ical interventions. Outcomes are the core pelling, as are the stories…. We have
value in healthcare delivery. However, by far the most expensive health sys-
we should appreciate that there is never tem in the world. We spend 50 per-
only one outcome measure in any field cent more per person than the next
or endeavor, and health care is no excep- most costly nation. Americans spend
tion. Without true patient engagement more on health care than housing or
and clear and honest communication continued on page 47
46
food. General Motors spends more on cial, and medical interventions for the
health care than steel. The cost crisis prevention and treatment of mental and
in health care is worsening. The physical health conditions are evaluated
United States spent about $2.2 trillion individually and in combination. Even
on health care in 2007; $1 trillion more when strictly medical treatments are
than what was spent in 1997, and half compared, it is important to expand the
as much as is projected for 2018. High range of outcome measures to include
and rising health care costs have cer- behavioral and psychological outcomes,
tainly contributed to the current eco- such as quality of life and adherence to
nomic crisis…. treatment protocols. It is also essential to
The Recovery Act also makes positive evaluate promising new models of care,
investments now that will yield such as the use of integrated, interdisci-
health and economic dividends later. plinary behavioral and medical teams in
Through health information technol- primary care settings. And finally, the ef-
ogy, it lays the foundation for a 21st- fectiveness of health interventions across
century system to reduce medical the lifespan and for different minority
errors, lower health care costs, and and gender groups must be considered.
empower health consumers. In the Therefore, APA is recommending that
next five years, HHS will set the stan- comparative effectiveness research focus
dards for privacy and interoperabil- on these five areas:
ity, test models and certify the
technology, and offer incentives for We encourage research that compares
hospitals and doctors to adopt it. The different behavioral and psychosocial
goal is to provide every American interventions for the prevention and
with a safe, secure electronic health treatment of specific health condi-
record by 2014. The Recovery Act … tions…. Next, we strongly encourage
invests $1.1 billion in comparative ef- research that compares behavioral
fectiveness research to provide infor- and psychosocial interventions with
mation on the relative strengths and medical interventions, and combina-
weaknesses of alternative medical in- tions thereof…. Next, we should pursue
terventions to health providers and research that compares integrated sys-
consumers…. The President’s budget tems of care comprised of interdiscipli-
submitted in February … dedicates nary teams of medical and behavioral
$634 billion over 10 years to reform- health providers versus routine medical
ing the health care system.
care…. We also believe that all health re-
Psychology’s Timely Response: In search studies should include measures
March, 2009, APA President James Bray of behavioral and psychosocial out-
testified before the IOM which has been comes, such as life quality, adherence to
asked by HHS to make recommenda- treatment protocols, behavioral func-
tions for prioritizing its Comparative Ef- tioning, depression, and anxiety…. And
fectiveness Research portfolio. James is finally, research that examines health in-
a long time health psychologist who has tervention outcomes across the lifespan
consistently urged psychology to be- and for different minority and gender
come increasingly involved in inte- groups is needed to understand the ef-
grated healthcare. fectiveness of interventions within and
between population groups….”
Comparative effectiveness research is a
critically important tool for advancing an Interestingly, current OMB Director
evidence-based approach to health care Peter Orszag was one of the 2007 IOM
decision-making. However, the full pub- participants.
lic health benefits of such research will
only be realized if behavioral, psychoso- Aloha, Pat DeLeon
47
BOOK REVIEW
Blévis, Marcianne. (2009).
Jealousy: True stories of love’s favorite decoy.
Olivia Heal trans. New York: Other Press.
Michael Karson, University of Denver

Of all the concerns a than wonder what she might have done
patient could share to make the patient think she had snuck
with a psychothera- out of the room, Blévis decides that the
pist in hopes of find- patient “lacked a mother who would
ing a dialogue partner have caressed her and looked upon her
who might accept in a happy and loving manner” (p. 114).
some responsibility Similarly, when a patient dreams about
for its presence and what Blévis interprets as “unseen ca-
who might participate actively in its res- resses,” Blévis wonders not what it’s like
olution, you would think jealousy to receive care from someone the patient
would be near the top of the list. When cannot see, but instead, “What did she
a patient struggles with feelings of de- not see when she was a child?” (p. 111).
spair or outrage, in contrast, it is not im-
mediately obvious that these states of This refusal to acknowledge fault or
mind are situated interpersonally. But even the co-creation of meaning is spe-
jealousy can only exist interpersonally. cially ironic when the problem is jeal-
You would think its presence in the psy- ousy. Surely we are not alone in hoping
chotherapy space would tilt even a clas- that our bouts with jealousy will be dealt
sical Freudian analyst away from with first and foremost by discussing the
thoughts about the patient’s childhood behavior of the other person that made
and lead her to consider how the prob- us jealous (why are you wearing your
lem relates to the relationship in which best outfit to a business meeting?), and
it’s unfolding. You would be wrong. secondly by conversing with our lovers
about what might make us feel more se-
French psychoanalyst Marcianne Blévis cure (how would you feel about wear-
has written a compendium of case stud- ing something else?). If the behavior of
ies of jealous patients in which she does the lover is clearly not threatening, and
not, even once as far as I could tell, con- if attempts to make the jealous person
sider whether she might have done more secure keep failing, only then does
something wrong that made the patient it make sense to ask what the jealous
jealous. Even more startling, she does person is getting out of the jealousy and
not once consider whether the patient’s to see if there is some other way to get
lover might have done something it. Since jealous people may not have the
wrong to make the patient jealous. In- skills to examine the behavior of their in-
stead, it is always the patient’s mother, timates objectively, and since they may
and sometimes the father too, who has not have the skills to metacommunicate
erred. At times, her focus on the pa- about their relationships, psychotherapy
tient’s childhood becomes ludicrous. For would seem like a good place to acquire
example, a patient eventually says to these skills. Blévis seems not even to
her, openly and blatantly, “Are you consider this use of treatment, however.
there?—it’s suddenly cold.” (Keep in For example, her final case study is of a
mind that Blévis is sitting behind the pa- man who tortures himself about the
tient, who is lying on the couch.) Rather continued on page 49
48
fresh bouquet of flowers that Blévis has chotherapy, the hegemony—that is,
in her office every week, and not once therapists’ definition of themselves as
does she consider whether it might not helpful and harmless—is usually pro-
be a good idea to have a bouquet of tected by defining patients’ protests as
flowers in one’s office. pathological. You can’t possibly be
angry at innocent me; you must be
I don’t distinguish between psycho- angry at your mother. All psychothera-
analysis and psychotherapy. I know pists, being human, are susceptible to
that’s a sort of heresy, but the putative using their power to define the situation
distinction is one that patients—whose to protect themselves at their patients’
lives are on the line, whose courage is re- expense—call it therapeutic privilege—
quired, and whose vulnerabilities are ac- but they’re supposed to understand this
centuated regardless of the modality— and provide a way for their patients’
should not take lying down. We may marginalized protests to get full voice in
make a big deal of the differences, but to the treatment.
patients it’s all the same—they’re look-
ing for help with a life problem from The hegemony in Blévis’s psychothera-
someone with power over them (the pies is suggested by her sonorous pro-
greatest aspect of which is the power nouncements about psychology. “The
to define the situation in the therapy re-child becomes jealously aware of her
lationship). What matters about the dif- parents’ sexual prowess and feels terri-
ferences between psychotherapy and bly depressed...” (p. 110). It’s a posture
analysis is what the patient experiences. that patients will have a hard time refut-
Psychotherapists should be open, for ex- ing, since any disagreement is chalked
ample, to metaphorical communication up to unconsciousness about their true
from patients that the sessions are too feelings. She also writes, categorically,
infrequent, or too conversational, or too “Maternal love, far from being angelic,
hurried. (Indeed, the earliest structures is an impassioned love unconsciously
of psychotherapy were dictated by a pa- laced with violence” (p. 100). What’s in-
tient—Anna O.—not by an analyst; teresting, of course, is not whether ma-
Freud’s genius was that he listened to ternal love is laced with ugliness, but
her.) Analysts should be open, for exam- when—under what circumstances—and
ple, to metaphorical communication from what to do about it when it happens.
Ironically—again—this latter proposi-
patients that the sessions are too frequent,
tion should alert the caregiving, author-
that the pace is too leisurely, or that it is
not productive to do things behind their itative therapist to her own violent
backs. Expressions of jealousy in all its feelings toward the client, but whenever
forms could be examples of the last. Blévis experiences an undesirable
thought or feeling about a patient in this
In virtually every human system, in- book, she blames the patient’s mother
cluding families, couples, and psycho- for producing someone so annoying
analyses, a hegemony of special interests rather than look inward.
dictates acceptable behavior—a party
line, in Erving Goffman’s terms. The This book takes us back in time—not in
hegemony then defines behavior that the psychoanalytic sense of revisiting
challenges the system—behavior that is childhood conflicts, but in the historical
out of line—in a way that preserves and sense of a time before the developments
protects the hegemony. The terms of the of intersubjectivity, self psychology, and
derogatory definitions of out-of-line be- object relations theory, and before re-
havior change according to the type of search on common factors foregrounded
system and its local culture, but in psy- continued on page 50
49
the therapeutic relationship. And on the own conflicts” (pp. 67-8). So when
subject of time, haven’t classical analysts someone is jealous, the person in charge
learned in a postmodern world to be needs to realize that it is about her, and
suspicious of the accuracy of reports of she needs to intervene—unless the per-
childhood? Shouldn’t they instead be son in charge is me.
treated as communications in the pres-
ent? When Blévis cleverly interprets a Jealousy can be framed as a backstage
dream as being organized around the problem. We search for true, constant,
patient’s difficulty managing reactions and abiding love from the day we’re
to ambiguity, Blévis doesn’t consider born to the day we die, but all love—re-
that her own ambiguity is occasioning ligion aside—is at best inconsistent and
projections from the patient. (It’s useful, variable. With those we love, we learn to
of course, to use ambiguity to occasion tactfully ignore their variable experience
the patient’s projections, but the idea is of us and we learn to disguise our vari-
to understand those projections in rela- able view of them, largely because we
tion to the environment in which they can see that our own backstage fickle-
occurred.) Instead, she assumes that at ness does not invalidate the authenticity
some point in childhood, the patient of our front stage devotion. Jealous peo-
“may have caught an indecipherable ex- ple have trouble reconciling their own
pression on her father’s face” (p. 27). backstage fickleness with the authentic-
Similarly, when a patient tells her directly ity of their love for the other, or else they
that he would like Blévis to precede him have some reason to think their lover
into the office so as to be “sheltered from cannot reconcile the two. What they
[her] gaze” (p. 81), Blévis does not ask need, generally, are assessment skills
herself if she has been looking at him and conflict resolution skills, and a good
hurtfully, but instead she consoles herself way to obtain these in a relevant manner
by attributing his self-consciousness to is to get involved in an ambiguous,
something his mother supposedly did on intimate relationship where the other
the day of his birth (calling him ugly). person—a psychotherapist—has some
Blévis does not consider the possibility expertise in backstage management,
that she and the patient co-created the conflict resolution, and helping people
story of being called ugly—that of the feel secure. This all-too-human psy-
millions of things he might have said chotherapist can use her expertise by
about his mother, he chose one that expressing curiosity, warmth, and ac-
suited the moment. ceptance about the patient’s confusion
regarding the relationship between a
The irony of ironies is that the analyst, backstage and a front stage. When a
eschewing responsibility for any jeal- psychotherapist acts as if she has no
ousy constellated in her office, blames backstage, the situations with the disap-
mothers for eschewing responsibility for pointing parent, the threatening sibling,
jealousy! “Certain parents tolerate such and the mysterious lover are merely
demonstrations of intense jealousy with- replicated in the treatment rather than
out perceiving that these demonstra- resolved. These patients learn to blame
tions are addressed to them; however, their parents—a sort of splitting that
their refusal or inability to intervene, be- protects the lover and the analyst rather
cause they think that jealousy among than the parent—rather than how to re-
siblings is normal, is worrisome for both solve interpersonal conflicts. Blévis’s
the child who violently expresses his orientation is even more distressing in
jealousy and for the one who endures it. light of her assertion that her book is not
In both cases, the space of the child’s
inner world is invaded by his parents’ continued on page 51
50
for therapists. For a lay audience, it can represented by a dream. “I am on a
only be read as encouragement for highway and I arrive at a fork in the
blaming one’s parents rather than re- road. On one road, there is a toll, one
solving conflicts with one’s lover. often has to stop, and there is a risk of
accidents. On the other road, a vehicle
Blévis has some nice things to say about awaits me, a sort of rocket in which I rec-
jealousy. She calls it a “thrilling malady” ognize all my fears represented by dif-
(p. 1) and she tries to help one patient be- ferent objects—it wants to take me up
come jealous ( a patient who reminded the skies” (p. 43). The exciting path is
me of Freud’s warning that people who one of “false hopes” according to Blévis,
are not jealous at all have repressed this while the route of “real life (and of his
natural state of mind and accordingly analysis!)” is the one she approvingly
are dominated by it). But still, like many describes as consisting of “obstacles ...
classical analysts, her vision of psycho- tolls and forced stops.” What a choice. A
logical health seems to be one of caution destructive rocket or a workaday rut.
rather than one of relatedness. At least, Blévis’s preference for the latter over the
she comes across as awfully cautious former is understandable, but are these
and defended in this volume, which is the only paths? She seems to validate
also ironic in light of Freud’s daring vul- Otto Rank’s claim that psychoanalysis
nerability throughout his writings. “breeds patient, docile Philistines.”
More importantly, both paths have the
One patient gives up his jealousy and patient travelling by himself. This book
then considers returning to it only to be does little to help jealous people with
threatened with abandonment by Blévis the desperate loneliness of their condi-
if he reverts. He decides to stick with her tion, except to tell them that they are a
and to forgo his jealousy. His choice is lot like other desperately lonely people.

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