In Review

Implications of Psychotherapy Research for

Psychotherapy Training
William E Piper, PhD1

This review article considers implications of psychotherapy research for psychotherapy

training. It considers 8 themes that characterize the research literature. The themes involve
outcome findings, common factors, empirically supported therapies, patient treatment
matches, therapy manuals and practice guidelines, brief therapies, combinations of
medication and psychotherapy, and group therapies. Each theme represents a controversial
issue that has implications for the content of contemporary psychotherapy curricula. To
assist trainees in becoming well-informed therapists, themes and implications such as these
should be covered as part of their introduction to learning about the psychotherapies. To
understand the themes and implications, as well as new findings that continually emerge
from the research literature, trainees also need to be familiar with basic research methods
and evaluative criteria, subjects that can also be covered as part of their introduction to the
psychotherapies. As their training proceeds, research findings can be integrated with the
development of their clinical skills in a broad range of psychotherapies.
(Can J Psychiatry 2004;49:221–229)
Information on author affiliations appears at the end of the article.

Highlights
· This review article highlights 8 themes that characterize the psychotherapy research literature.
Each represents a controversial issue.
· Implications of the 8 themes for psychotherapy training in psychiatry are presented.
· It is recommended that trainees be familiar with such themes and their implications for
training, as well as with basic research methods and evaluative criteria, as part of their
introduction to a broad range of psychotherapies.

Key Words: psychotherapy research, psychotherapy training

his article considers the implications of psychotherapy re-
T search for psychotherapy training in psychiatry. Recent
surveys conducted in Canada and the US indicate that psychi-
atrists continue to spend a substantial amount of time provid-
ing psychotherapy. In a survey of Canadian psychiatrists,
Leszcz and colleagues found that 92% spent almost one-half
of their clinical time engaged in psychotherapy (1). A survey
of the office practices of US psychiatrists conducted by
Olfson, Marcus, and Pincus indicated that 79% of their pa-
tients received psychotherapy in 1995 (2). Although the per-
centage had decreased from 89% in 1985, it remained
substantial. Weissman and Sanderson reported that the US
Medical Expenditure Panel Survey found the demand for psy-
chotherapy in the general population unchanged at approxi-
mately 3.4% between 1987 and 1997 (3). The demand among
psychotherapists with an MD actually increased. According
to current practice as reported in these surveys, the need for
training in psychotherapy remains strong.
This article is directed to 3 groups of readers. First are admin-
istrators responsible for developing and approving psycho-
therapy training programs. This group includes university or
hospital directors of resident training, directors of continuing
medical education (CME), and members of curriculum com-
mittees. Second are teachers and supervisors who directly
provide psychotherapy training. Third are the consumers; that
is, those who receive psychotherapy training and provide psy-
chotherapy to patients. This group includes residents and
licensed clinicians who participate in CME training.

Can J Psychiatry, Vol 49, No 4, April 2004 W 221

The Canadian Journal of Psychiatry—In Review
Scientific journals continually publish a large volume of
research articles on psychotherapy. Adair and Vohra have
described the difficult challenge that all researchers face in
keeping up with the current literature (4). The difficulty for
providers and consumers of psychotherapy training is even
greater: many are primarily clinicians who often do not have
the resources to monitor new publications comprehensively.
Even when research articles are available, however, they are
often not read and thus do not inform psychotherapy training.
There are several reasons for this. Researchers usually write
for other researchers, not for administrators, teachers, or train-
ees. Articles are often difficult to understand because they are
laden with jargon. Much research is regarded as artificial and
not applicable to clinical settings (for example, randomized
clinical trials [RCTs] of therapy efficacy). Much psychother-
apy research focuses on brief therapies and neglects long-term
therapies that are still provided by many private practitioners.
In addition, research reports are usually written tentatively,
with many qualifications and limitations that do not inspire
confidence in clinicians, teachers, and trainees.
Another problem is the lack of research on training and super-
vision. There is no body of research literature comparing the
effectiveness of different approaches to training and supervi-
sion. Training models are based on tradition, not research. For
example, didactic course work, supervised treatment of cases,
and personal psychotherapy is the time-worn model of most
psychodynamic therapy training (5). A more fundamental
problem is the lack of training for effective supervision.
Because most training programs devote little attention to the
topic of supervision, there is little to study. Most supervisors
must rely on their personal experiences as a guide to conduct-
ing supervision.
Either a relatively simple or a relatively complex approach
can be taken in addressing the implications of psychotherapy
research for training and in making recommendations for cur-
ricula. The simple approach would provide lists of therapies
that have the most evidence of efficacy for particular prob-
lems, provide references from the research literature, and
emphasize teaching those approaches in training programs.
The more complex approach would also attend to evidence of
efficacy. However, instead of focusing on current lists of ther-
apies, problems, and references, this approach would direct
readers to reviews of the research literature summarizing the
specific evidence of efficacy. The more complex approach
would also present limitations and controversies associated
with the evidence. This approach would require familiarity
with basic research methodology and evaluative criteria,
which would have to be covered as part of the training. It
would emphasize general themes emerging in the field rather
than simply listing specific findings. It would convey tenta-
tive rather than definitive observations about the evidence.
222
A simple approach is tempting. Learning to be a skillful psy-
chotherapist is a challenging task that takes time, effort, and
hard work, even when trainees feel confident about the useful-
ness of psychotherapy. Highlighting ambiguities, doubts, and
uncertainties can be problematic, particularly if this is done in
a way that leads to expectations of poor outcome, weak moti-
vation, or diminished morale. Most trainees desire direct reas-
surance that they are learning both effective techniques and
how to provide them skillfully.
Although tempting, a simple approach has several disadvan-
tages. The outcome of psychotherapy is multiply determined;
therapist technique is but a single factor. Choosing a promising
therapy from a list and attempting to conduct it skillfully will
not guarantee success. Patient, therapist, and relationship fac-
tors are also influential and need to be considered in treating
individual patients. To assume otherwise will lead to disap-
pointments. Similarly, therapists following a simple model of
treatment will be disillusioned when the inevitable limitations
of particular techniques become evident. As the field continues
to develop, a relatively simple approach will not help the thera-
pist evaluate evidence for new or emerging techniques; to do
so, one must be a well-informed consumer. It is the responsibil-
ity of training programs to produce such trainees.
In taking a relatively complex approach, this article highlights
8 themes that characterize the current psychotherapy research
literature. Each theme represents a controversial issue that has
implications for psychotherapy training and practice. Many of
the themes are related to each other and represent different
positions in regard to the controversial issues. Before present-
ing these themes, which are expressed as conclusions, their
historical context is briefly considered.
Just 50 years ago, there were no controlled or comparative
outcome studies of the psychotherapies. Nevertheless, in
1952, Eysenck published a review claiming that psychother-
apy was not effective (6). He compared the outcome reports of
24 studies, most of which involved psychodynamic therapies,
with the outcome reports of 2 control studies involving
patients who had not received psychotherapy. Eysenck con-
cluded that two-thirds of the patients improved substantially
within 2 years, whether or not they received psychotherapy.
Subsequently, there were many criticisms of his review. It was
argued that patient samples and outcome criteria differed
between the treatment studies and the control studies, that
control patients actually received treatment, and that his inter-
pretation of the treatment studies’ results was biased.
Although Eysenck did not appear to win the debate on aca-
demic grounds, he scored a victory on psychological grounds.
People invested in the practice of psychotherapy seemed
embarrassed, off-balance, and demoralized. In time, the
debate set the stage for a counteroffensive that included
W Can J Psychiatry, Vol 49, No 4, April 2004
 Implications of Psychotherapy Research for Psychotherapy Training
controlled studies and new reviews. Probably the most influ-
ential review was that of Smith, Glass, and Miller (7). Using a
new review method called metaanalysis, which involved cal-
culating an effect size for each outcome variable and then
averaging the effect sizes across studies, they summarized the
results of 485 controlled studies. These authors concluded
that psychotherapies in general are effective and that there is
little difference in effectiveness among the different types of
psychotherapies. These conclusions were regarded as inaccu-
rate by a number of people, many of whom were advocates of
behaviour therapy (8). They attacked the review methodology
and the conclusions. Debate about the validity of metaanalysis
and the conclusions one can draw from it has continued to the
present time. Nevertheless, many metaanalyses continue to be
published. In an extensive current review of the outcome liter-
ature, Lambert and Ogles (9) came to the same general conclu-
sions as Smith, Glass, and Miller and acknowledged that the
controversy has not subsided. Unfortunately, one of
Eysenck’s legacies is a polemical climate that has too often led
to attacks and counterattacks between vested-interest groups.
The latest example is the debate concerning the value of creat-
ing lists of “empirically supported therapies,” discussed
below as a controversial theme.
Another strong force that has influenced the type of therapies
studied and practised in North America is health care reform,
often referred to as the managed care movement. As
third-party controller of health care funds, managed care com-
panies have favoured short-term therapies. Further, decisions
about which therapies to fund have frequently been influ-
enced by practice guidelines. These are policy statements
from major organizations about the proper treatment of cer-
tain disorders. The preference for short-term therapies has
created pressure for researchers to study them and compete in
determining which therapies meet criteria for empirical sup-
port. It has added fuel to the polemical climate that has charac-
terized psychotherapy research and has resulted in what some
believe to be extreme positions and simplistic claims that cer-
tain techniques are superior. Within the context of these
developments, the major themes that characterize the current
psychotherapy literature are considered next. Each is pre-
sented as a conclusion. Following this, implications for train-
ing are considered.
Theme 1: There Are Few Differences in the
Outcomes of Most Psychotherapies
Metaanalytic reviews have strongly supported this theme,
which represents what has been referred to as “the dodo bird
effect” (10,11); that is, everybody has won, so all shall have
prizes. When differences among therapies have emerged, they
have often been attributed to “the allegiance effect.” This refers
to the strong relation between the theoretical orientation of the
Can J Psychiatry, Vol 49, No 4, April 2004 W
research investigator and the theoretical orientation of the treat-
ment that emerges as most effective in comparative outcome
studies (12). After statistical adjustments are made for the alle-
giance effect, the outcome differences among therapies usually
disappear. The strongest opponents of this theme are the advo-
cates of the empirically supported therapies (EST) movement.
They claim that the therapies on their lists have evidence of
superiority over other therapies for specific diagnoses (13).
Other opponents are the advocates of aptitude–treatment inter-
actions (ATI). This group believes that there are optimal
matches between patients scoring high on a particular charac-
teristic and specific therapies and patients scoring low on the
same characteristic and other specific therapies. They contend
that, when effect sizes are averaged across therapies in
metaanalyses, these specific matches (interactions) become
obscured. Opponents also attribute the small number of out-
come differences in comparative studies to such factors as
weak methodology; low power owing to small sample size;
treatment of mildly disturbed, single-diagnosis patients; use of
brief therapies; and overreliance on symptoms as outcome
criteria (14).
Implications
Trainees should be familiar with metaanalysis as a review
method, together with its strengths and limitations. They
should be aware of the findings of major metaanalytic reviews
that focus on the therapies for which they are being trained.
Theme 2: Common Factors of Therapies are
More Strongly Related to Outcome Than
Unique Factors
Common factors are therapeutic factors that are present across
therapies (for example, a helping relationship, a convincing
rationale, and feedback concerning progress) (15). In con-
trast, unique factors differ across therapies (for example,
interpretation of transference). Those who believe that there
are few differences in outcome among most therapies, as indi-
cated by metaanalytic reviews, often attribute this to the pres-
ence of common factors. In a series of studies of the actual
process of therapies with distinct orientations (that is,
psychodynamic, cognitive-behavioural, and interpersonal),
Jones and colleagues found that they had much in common,
particularly in regard to what appeared to be the effective
ingredients of favourable change (16). Separate research has
found it difficult to demonstrate that the unique theoretical
base of different therapies accounts for their effective-
ness—additional evidence for the greater importance of com-
mon factors. For example, a recent review of the literature
found little evidence for the unique theoretical underpinnings
of cognitive-behavioural therapy (CBT) (17). Similarly, a
review of the literature found little evidence that eye
223
The Canadian Journal of Psychiatry—In Review
movements were a necessary component of eye-movement
desensitization and reprocessing therapy (18).
Implications
Trainees should be familiar with the common factors and
learn how to facilitate them skillfully in their clinical work.
Theme 3: The Criteria for Empirically
Supported Therapies Should be Used to Select
Which Therapies Are Taught in Training
Programs
Criteria for empirically supported therapies and lists of thera-
pies that meet those criteria were originally championed by an
American Psychological Association task force (19). Subse-
quent lists have been prepared (20,21). The criteria have
emphasized RCT designs, treatment manuals, homogeneous
diagnostic groups, and independent replications. Many
advocates have been from the behavioural and cognitive-
behavioural orientations, with associated treatments dominat-
ing the lists. To their credit, they have advocated an account-
able, evidence-based approach to choosing treatment for
specific problems. However, their approach has been viewed
by many as premature and restrictive. Opponents of the EST
movement, which have included both clinicians and research-
ers, have criticized the use of RCT methodology. While
accepting the strong internal validity of RCTs (that is, having
confidence that the treatment was responsible for the outcome
differences), they have emphasized the weak external validity
(that is, generalization to clinical practice) of RCTs. They
have argued that clinicians usually do not accept patients ran-
domly, treat patients restricted for age and sex, treat patients
with minimal comorbidity, or use manualized, time-limited
therapies (22). They have described RCT studies as tests of
efficacy, not tests of effectiveness (that is, studies conducted
in natural clinical settings). In the UK, difficulties have been
reported in teaching general practitioners basic CBT skills
(23) and in bringing about superior improvement with CBT,
compared with nondirective counselling (24). These findings
highlight the difficulty of transferring the practices of
research clinics that conduct RCTs to primary care settings.
Opponents of the EST movement have also emphasized the
importance of nondiagnostic patient characteristics, therapist
characteristics, and patient–therapist relationship characteris-
tics in affecting outcomes. To counter the EST movement,
some opponents have created their own task force and com-
piled lists of empirically supported relationships (25,26).
These lists highlight such relationship characteristics as the
therapeutic alliance, goal consensus, self-disclosure, and
group cohesion in group therapies. Opponents have also
argued that RCTs suffer from dropouts, which undermines
random assignment, and that they are but one of many meth-
ods to investigate the effectiveness of the psychotherapies.
224
Alternative methods include naturalistic, correlational,
process–outcome, structural modelling, and qualitative
approaches, each of which can provide valid data about ther-
apy outcomes.
Implications
Trainees should be familiar with the criteria and lists of thera-
pies associated with the EST movement. They should also be
aware of its limitations. Important patient, therapist, and rela-
tionship factors should be covered, as well as the many differ-
ent approaches to studying the effectiveness of the
psychotherapies.
Theme 4: There Are Some Good Matches
Between Specific Patient Characteristics and
Specific Therapies
Evidence for good matches has come from the EST movement
and ATI research. The former has focused on patient diagno-
ses and the latter on patient personality dimensions. Perhaps
the strongest evidence for matches, as identified by the EST
movement (21), involves the anxiety disorders and forms of
CBT. Examples include CBT for panic disorder and general-
ized anxiety disorder, exposure for phobias, and exposure and
response prevention for obsessive–compulsive disorders.
Evidence from ATI studies has most often demonstrated a
match between a personality dimension and 2 or more distinct
therapies. Researchers have emphasized the importance of
making a priori, theoretically based predictions in ATI stud-
ies; this enhances the chances of finding a match as well as the
credibility of the findings. Two examples that are frequently
cited come from the work of Beutler and colleagues (27) con-
cerning the personality dimensions of externalization and
reactance. Externalizing patients responded better to skills-
oriented, symptom-focused therapies, whereas internalizing
patients responded better to insight-oriented therapies.
Reactance refers to resistance to directives. High-reactant
patients responded better to self-directive therapies, whereas
low-reactant patients responded better to directive therapies
(28). Another example concerns quality of interpersonal rela-
tionships. Patients with a history of relatively gratifying inter-
personal relationships do better in confrontive, insight-
oriented therapies, while patients with a history of relatively
problematic relationships do better in supportive psycho-
therapies. This match has been found in both individual and
group therapies (29,30). The ATI approach may have particu-
lar promise with group therapies. A review of the
group-therapy literature found that 83% of the ATI studies
had significant findings (31).
Implications
Trainees should be aware of the specific matches identified by
the EST movement. They should also be familiar with
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 Implications of Psychotherapy Research for Psychotherapy Training
examples of effective matching of patient characteristics and
therapies from the ATI literature.
Theme 5: Therapy Manuals and Practice
Guidelines Should Be Used for Training and
Clinical Practice
Psychotherapy researchers developed manuals to standardize
the therapist’s theoretical and technical orientation. Reducing
therapist variability can strengthen the internal validity of tri-
als. The use of manuals spawned adherence measures, which
are used to quantify the degree to which therapists follow
manuals. For advocates of empirically supported therapies,
the use of manuals is an essential criterion. Teachers and clini-
cians have had mixed reactions. Manuals vary considerably in
length (for example, from 20 pages to book length) and in the
degree to which they instruct therapists to comply or be flexi-
ble in providing the technique. There has been concern that
manuals may contribute to therapist rigidity and less satisfac-
tory outcome. This concern has spawned competence mea-
sures, which indicate how skillfully the therapist provides
treatment. Evidence from a large-scale psychotherapy train-
ing study indicates that therapists trained with manuals
became more adherent but less competent in providing ther-
apy (32). Concern about the possible negative effects of using
manuals has been greater among therapists from some orien-
tations (for example, psychodynamic) than others (for exam-
ple, cognitive-behavioural). Psychodynamic therapists
follow a more patient-driven model, where uncertainty about
how the session begins and what follows is part of the
intended unpredictable process. If the therapist greatly deter-
mines the content or provides standard responses, the process
is not considered to be psychodynamic. Thus, some manuals
for psychodynamic therapy (33) have been designed to pro-
vide general guidelines and to encourage therapists to use
their judgement regarding interventions (for example, the
number and timing of interpretations). Adherence measures
for such therapies must assess the degree to which general
guidelines are followed. They should monitor not only what
the therapist should be doing but also what the therapist
should not be doing (34). Both psychodynamic therapy teach-
ers and cognitive therapy teachers agree that training compe-
tent therapists takes considerable time and goes well beyond
teaching therapists to adhere to manuals (35,36).
Many of the same issues affect the use of practice guidelines
(37). Advocates believe that they usefully present
state-of-the-art procedures for treating patients with specific
disorders. Opponents argue that they prematurely bring about
closure in areas of treatment that need development and that
they soon become obsolete.
Can J Psychiatry, Vol 49, No 4, April 2004 W
Implications
Manuals and practice guidelines are useful tools for teaching
trainees the basic theoretical and technical orientations asso-
ciated with different therapies; therefore, they should be a part
of psychotherapy training. However, teachers should empha-
size the potential problems associated with rigid adherence to
manuals and practice guidelines and provide other important
components of training, such as didactic seminars, observa-
tion opportunities (involving trainees and faculty), and close
supervision of cases.
Theme 6: Brief Therapies Should Be Provided
to Patients Before Long-term Therapies and
Should Be Emphasized in Training Programs
The vast majority of psychotherapy research conducted in
North America over the last 50 years has focused on relatively
brief therapies; that is, of 20 sessions or less. For example, in
Smith, Glass, and Miller’s review of 485 studies (7), the
included therapies averaged 11 weeks’ duration. Surveys of
therapies provided in outpatient clinics also indicate a pre-
dominance of brief therapies. There are several reasons for the
high prevalence of brief therapies in clinics and research stud-
ies. First, there are strong economic pressures from third-
party payers to cover brief treatments. Second, many patients
expect and desire brief treatments. Third, therapists from
some orientations (for example, psychodynamic) have been
interested in applying their techniques innovatively in brief
therapies (for example, early-transference interpretation).
Fourth, considerable research evidence from dose–response
studies indicates that many patients can accomplish important
changes in brief periods of time. Studies by Howard and col-
leagues (38) and Kopta and colleagues (39) suggest that over
50% of patients experience significant improvement after 8
sessions and 75% after 26 sessions.
Others have been more skeptical about what brief therapies
can achieve. They have been more interested in evidence of
clinically significant, rather than merely statistically signifi-
cant, change. Clinical significance is based on normative
information and requires that, after treatment, the patient’s
problems are more characteristic of normal than of pathologi-
cal scores of disturbance. In a large survey using the more
stringent criterion of clinical significance, Lambert, Hansen,
and Finch found that only 50% of patients achieved improve-
ment after 21 sessions and 75% after more than 40 sessions
(40). In a follow-up to the well-known National Institute of
Mental Health (NIMH) collaborative study of depression,
Shea and colleagues found that 16 weeks of CBT or interper-
sonal therapy or antidepressant medication were insufficient
to achieve full remission and lasting recovery for most of the
patients (41). In our research team’s recent clinical trial of 20
sessions of dynamically oriented interpretive or supportive
225
The Canadian Journal of Psychiatry—In Review
therapy (29,42), less than one-half of the patients achieved
both clinically significant and reliable change by the end of
treatment. Although these levels were maintained through
1 year of follow-up, they did not increase. In regard to specific
outcome criteria, change in brief therapies more often
involves symptoms than interpersonal or personality change.
High comorbidity of disorders (for example, major depres-
sion and personality disorder), which is seen in community
clinics more often than in university-based research clinics, is
also associated with less impressive improvements (43). In
general, all these findings suggest that the effects of brief ther-
apies are both encouraging and disappointing—the glass is
both half full and half empty.
Although the modal form of long-term psychotherapy has
been psychodynamic therapy with a planned duration of
1 year or more, Crits-Christoph and Barber (44) have noted
that it may also represent recurrent brief therapies, mainte-
nance therapies, or brief therapies that required more time
than initially expected. Very few outcome studies of
long-term psychotherapies exist. Those that have been con-
ducted tend to be retrospective or prospective but lack com-
parison conditions and random assignment. Thus, the
scientific evidence for their effectiveness is less extensive and
strong, compared with the brief therapies. This indicates that
their effectiveness is unproven, not that they have been shown
to be ineffective. In fact, dose–response studies have demon-
strated that some patients do not improve unless they receive
long-term therapy. Several factors have discouraged research
on long-term therapies. Economic conditions have high-
lighted the importance of learning about brief therapies, ethi-
cal concerns have precluded the use of certain long-term
control conditions, and research studies of long-term therapy
are considerably more expensive, time-consuming, and diffi-
cult to complete. Nevertheless, conducting studies of
long-term psychotherapy is a much-needed research objective
that granting bodies and researchers will, one hopes, pursue.
Many clinicians believe that patients with long-term
characterological problems that have not responded well to
brief therapies or patients who require improvements in func-
tioning that extend beyond improvements in symptoms are
appropriate for long-term therapy. Many teachers of psycho-
therapy also believe that long-term cases are excellent learn-
ing opportunities for trainees. Nevertheless, skeptics
emphasize the unproven nature of long-term therapies and
maintain that it is unethical for therapists to provide long-term
therapy to patients with problems that respond well to brief
therapies. They argue that choice of therapy should be a prod-
uct of the patient’s informed consent regarding the cost-
effectiveness of different therapies (45).
226
Implications
In addition to learning how to provide brief therapies, trainees
should be made aware of the considerable research literature
that supports their effectiveness; they should also be made
aware of their limitations in regard to the types of change that
are possible and the number of patients who do not achieve
clinically significant change. Similarly, training in long-term
therapies should emphasize indications for this form of treat-
ment as well as the unproven nature of its effectiveness.
Theme 7: The Combination of Psychotherapy
and Medication Results in Better Outcomes for
Most Problems Than Either Treatment Alone
In a recent literature review, Thase and Jindal (46) conclude
that there is growing evidence of the superiority of combined
treatments for recurrent and severe major depression, schizo-
phrenia, obsessive–compulsive disorder, and bipolar affec-
tive disorder, as exemplified by the Keller and others study
(47). They argue persuasively that previous reviewers who
found little evidence that the combination added benefits did
not sufficiently take into account study design and statistical
limitations. Thase and Jindal do not believe that there is at
present sufficient evidence to support the routine use of com-
bined treatments for milder depressive and anxiety disorders,
particularly in light of the cost of providing both.
Implications
Trainees should be aware that combined treatment is widely
accepted and that there is evidence of benefit for several disor-
ders. They should also be aware that current evidence does not
appear to support the routine use of combined treatment for
the most prevalent, less severe disorders.
Theme 8: Group Therapies Have Outcomes
Similar to Individual Therapies
Reviews of comparisons between the effectiveness of individ-
ual and group therapies have provided consistent evidence of
virtually equivalent outcomes (48,49). Because multiple
patients can be treated in groups, a strong argument can be
made for their greater cost-effectiveness. Despite such find-
ings and conclusions, group therapies have been underused.
Resistance appears to come from both patients and therapists,
who typically experience greater loss of control, individual-
ity, understanding, privacy, and safety in the group situation.
Given the current economic strain in the health care field, it
can be expected that pressure to use group therapies will
increase.
Implications
Trainees should be aware of the similarity of outcomes for
individual and group therapies, and educators should increase
training in group therapies.
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 Implications of Psychotherapy Research for Psychotherapy Training
Other controversial themes that characterize the field of psy-
chotherapy research also have implications for training. Three
additional examples follow. First is the theme that supportive
therapy is a distinct form of psychotherapy that is effective for
many types of problems (50,51). Second is the theme that inte-
gration of different techniques has become a recommended
approach to the practice of psychotherapy; examples include
cognitive behavioral analysis system of psychotherapy
(CBASP) for chronic depression (52) and coping strategies
therapy (CST) for bulimia nervosa (53). Third is the theme
that transference and countertransference are important
events to be recognized and dealt with in all types of psycho-
therapy, not just in dynamically oriented psychotherapies
(54). Space limitations do not permit elaboration and consid-
eration of the implications of these and other themes.
Discussion
The implications of the themes that have emerged from the
research literature suggest specific content for a curriculum in
psychotherapy training. To be informed consumers, trainees
require training in basic research methodology. This includes
becoming familiar with the different methods of reviewing
research literature, such as metaanalysis; an appreciation of
different approaches to studying the effectiveness of the
psychotherapies; and knowledge of basic methodological and
statistical weaknesses that affect the conclusions one can
make about studies. The objective is not to transform trainees
into researchers but to provide trainees with a basic set of
skills for understanding research literature that can be confus-
ing. Trainees should be familiar with the EST movement,
including its lists of treatments and disorders and its limita-
tions. Similarly, trainees should be aware of good patient–
treatment matches from the aptitude-treatment literature.
They should also be familiar with the empirically supported
relationships movement, including its lists and limitations.
Rather than taking sides, trainees should be encouraged to
develop a constructively critical perspective to both
movements.
The extensive presence of brief therapies in the research liter-
ature and in clinics across North America indicates that they
should definitely be prominent in the curriculum. They
include brief dynamic therapy, CBT, and interpersonal ther-
apy. Both individual and group forms of these therapies
deserve attention. Accompanying these therapies are treat-
ment manuals that can be constructively used in training.
Limitations associated with the use of the brief therapies and
their manuals need to be considered. Evidence for the
effectiveness of long-term therapies, both individual and
group, is not of the same type or as strong as the evidence for
the brief therapies. Nevertheless, given the other types of evi-
dence of their effectiveness, their potential usefulness in
Can J Psychiatry, Vol 49, No 4, April 2004 W
treating problems that are severe and recurrent, and the fact
that many teachers find them to be a useful means of learning
about patients and psychotherapy, long-term therapies should
be included in the curriculum. A similar argument can be
made for including couple and family therapies.
The combination of psychotherapies and medications is a nat-
ural and important topic for the curriculum of psychiatrists in
psychotherapy training because they have general training in
medicine and, therefore, a unique area of expertise among
mental health professionals. Further, given their expected
leadership role in many mental health teams, it is important
that psychiatrists receive training in supervising, consulting,
and making referrals.
It is important that the curriculum not be restricted to the
acquisition of specific clinical skills. As indicated previously,
the field of psychotherapy research is continually evolving in
terms of both methodology and content. Teachers should be
encouraged to integrate research evidence of effectiveness,
reviews of the literature, and the latest studies that contribute
new information about the psychotherapies with the teaching
of clinical skills. Obviously, research does not address many
areas of training. Hopefully, considerably more areas will be
covered. In the meantime, there are some excellent resources
based on considerable teaching and clinical experience that
can help fill the gaps with reasonable suggestions. These
include publications by Cameron and colleagues (55–57).
Last but not least, trainees should be familiar with the contro-
versial themes and implications highlighted in this article.
Although they may heighten some uncertainties about the
broad range of psychotherapies being taught, they will pro-
vide a more realistic and enlightened perspective of the field,
commensurate with the goal of creating well-informed, com-
petent psychiatrists.
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Manuscript received and accepted December 2003.
1
Professor, Department of Psychiatry, University of British Columbia,
Vancouver, British Columbia.
Address for correspondence: Dr WE Piper, University of British
Columbia, 2255 Wesbrook Mall, Vancouver, BC V6T 2A1
e-mail: piper@interchange.ubc.ca
W Can J Psychiatry, Vol 49, No 4, April 2004
 Implications of Psychotherapy Research for Psychotherapy Training

Résumé : Implications de la recherche sur la psychothérapie sur la formation en

psychothérapie
Ce rapport de synthèse examine les implications de la recherche sur la psychothérapie sur la
formation en psychothérapie. Il étudie 8 thèmes qui caractérisent la documentation sur la recherche et
qui sont : les résultats, les facteurs communs, les thérapies soutenues empiriquement, la
correspondance des traitements aux patients, les manuels de thérapie et les lignes directrices sur la
pratique, les thérapies à court terme, les combinaisons de médicaments et de psychothérapie, et les
thérapies de groupe. Chaque thème représente une question controversée qui a des implications sur le
contenu des programmes d’études contemporains en psychothérapie. Pour aider les stagiaires à
devenir des thérapeutes bien informés, les thèmes et implications de la sorte devraient être abordés
dans le cadre de l’introduction à la formation en matière de psychothérapies. Pour comprendre les
thèmes et implications, de même que les nouveaux résultats qui sont constamment issus de la
documentation sur la recherche, les stagiaires doivent aussi être familiers avec les méthodes de la
recherche fondamentale et les critères d’évaluation, sujets qui peuvent aussi être abordés dans le cadre
de leur introduction aux psychothérapies. À mesure que se déroule leur formation, les résultats de la
recherche peuvent être intégrés au perfectionnement de leurs compétences cliniques dans une vaste
gamme de psychothérapies.

Can J Psychiatry, Vol 49, No 4, April 2004 W 229