The integrative psychotherapy movement emerged in part as a reaction to the historical pattern of divisiveness among proponents of competing psychotherapeutic traditions (1–5). Early attempts to reconcile psychoanalytic and behavioural views were met with responses ranging from bitter criticism to support for potential convergence between these 2 lines of investigation (6–8). Thus began a debate that continued over the ensuing decades (4,9–13). However, by the early 1990s, several key publications reflected increased acceptance of integrative ideas (2,14–17). Similarly, the growing interest in combining psychotropic medication and psychotherapy is in keeping with integrative principles (18–23).
As applied to psychotherapy, the term “integration” has been ascribed various meanings. The “integrative perspective” denotes a flexible, inclusive overall stance toward the psychotherapies viewed broadly; its defining principles appear later in this paper. Therapies that incorporate elements drawn from divergent psychotherapeutic traditions have taken many forms. At the level of technique, integration has come to refer to those methods involving “conceptual synthesis of diverse theoretical systems” (2). By contrast, technical eclectic methods are characterized by efforts to incorporate techniques independent of their theoretical underpinnings (2). The phrase “integrative approaches” can also be used; it refers more inclusively to the full range of strategies that have been employed to this end.
The relevance of the integrative perspective to modern psychotherapy education begins with the clinical realm in which trainees will practise. Multiple psychotherapeutic modalities are now seen as applicable within the repertoire of valid psychiatric interventions (24). Preparing psychiatric residents to function skilfully as consultants and expert psychotherapeutic practitioners well versed in the broadening range of available treatments necessarily entails attention to this reality (25–29). Expertise in this complex domain comprises not only familiarity with the various modalities but also understanding of their potential interactions, which may well affect the overall impact of clinical management (30). The ability to tailor a comprehensive treatment plan to the particular needs of individual patients is fundamental to clinicians’ roles as experts in the provision of mental health care, trained in both biological and psychological aspects of emotional suffering and psychiatric illness (22,31,32). The characteristic perspective of the integrative movement leaves it well placed to inform such capacities.
Further, integrated treatments can provide opportunities to enhance clinical benefit, particularly with patients who present with multiple problems or refractoriness to previous interventions (23). Many psychotherapies have demonstrated substantial efficacy, but no single form is consistently successful with all patients or with all problems (2,33–36). The integrative approach emphasizes the use of available models and tools within their particular domains of effectiveness (37), in combination where indicated. Its comparative theoretical perspective provides a broader clinical-educational context within which to situate the detailed learning required to master any specific psychotherapeutic modality.
Beyond residency, the integrative perspective can provide a foundation upon which practising psychiatrists can expand their existing skills to incorporate new strategies that develop over their careers. It systematically addresses the interrelations between what they already know and do and new techniques that emerge after they complete their initial psychiatric training. Hence, this approach is also potentially important for continuing professional development (38–40).
Complex issues face psychiatric educators, related to the place of an integrative perspective in psychotherapy education for clinicians at successive levels of experience. They include questions regarding both the importance to be accorded integrative principles in planning and conducting psychotherapy training and the methods by which such education can be most effectively delivered.
Key themes that emerge in reviewing the small body of literature specifically focused on integrative psychotherapy education are outlined herein (30,38–53). Historically, established training programs and procedures designed to educate integrative therapists have been relatively lacking (38,39,45, 49,54,55). The absence of a single unifying integrative theory is often mentioned as a major factor accounting for the dearth of such systematic training programs, notwithstanding that multiplicity of theoretical and technical approaches characterizes this clinical domain (38,45). Authors recognize the further layers of complexity that integrative goals add to the already complicated process of training psychotherapists (38,39,47,49). Some highlight the challenges of fostering an integrative stance that is not limited to allegiance to a single theoretical position (39,43,46,49). The relation between training toward competence in a specific modality and aspects of training designed to achieve competence at integration is discussed (30,39,49). Similarly, the relation between training in core psychotherapeutic skills that transcend individual modalities and in-depth training in modality-specific techniques is considered (39,53). In general, much attention is given to the optimal sequencing of components of the longitudinal training process that contribute to the development of a capacity for integration (30,39,49,51,56). Views differ regarding the relative place and value of personal therapy as a vehicle for learning psychotherapy (39,43,45,50,57,58). The organizational demands imposed by an integrative training effort are also recognized, including those related to faculty selection and development (39,49).
On the whole, this literature has several deficiencies. Only a small number of papers attempt to address the topic comprehensively. Many articles describe as-yet-unimplemented, idealized training programs about which discussion is essentially hypothetical. Some proposals are loosely defined, others better specified. Concrete examples of teaching initiatives include summaries of graduate courses offered and descriptions of what an individual integrative psychotherapist is offering in terms of educational efforts. With rare exceptions noted below, no evidence is provided to substantiate the educational impact of approaches actually implemented, and it is often unclear whether such evaluative data were collected. This makes it even more difficult for those who oversee clinical psychotherapy training programs to take meaningful guidance from such literature when attempting to decide whether a particular approach should be considered. The need for more rigorous evaluation of integrative training initiatives is recognized. Finally, much of this literature is discursive; detailed descriptions of educational approaches available for implementation or evaluation are in the minority. This likely reflects in part the early phase of development in which the field of integrative psychotherapeutic education has existed (30,38–41,43,45,48,49,52,53,59).
An added difficulty arises when this literature is applied within psychiatry, because much of what does exist focuses on the education of psychologists. Hence, it fails to address training and developmental issues particular to psychiatric residents (38,40,42–45,50). Specifically, the many inter- actions between pharmacotherapy and psychotherapy and the implications of the prescribing role for the medical psychotherapist are important training matters that warrant a carefully thought-out educational approach (20–23,60–63). Otherwise, these 2 potent treatment modalities may be coadministered ad hoc, irrespective of the substantial complexities such combinations introduce.
Four noteworthy exceptions stand out from the deficiencies characterizing this literature. Robertson (42,43,50) has reported over many years on a set of 4 courses that introduce novice psychology trainees to communication and intervention skills of individual, group, marital, and family therapies. The pedagogic mode is considered to be primarily, but not exclusively, experiential. Robertson provides some details of the brief questionnaires used to evaluate each course from the participants’ subjective point of view, along with mean data confirming students’ high level of agreement that multiple course goals were met. He concludes with explicit acknowledgement of the strengths and limitations of the approach taken. Although the courses are informed by his atheoretical, eclectic perspective, the tasks of integration per se do not appear to be a central educational focus of this initiative.
Beitman and Yue report on a program of psychotherapy training modules designed to introduce common psycho- therapeutic concepts; it is presently used in several residency training programs (51,64). The authors explicitly describe the program and present results from pre- and postmodule evaluative data obtained with a validated assessment instrument. Allen and colleagues describe a seminar developed to foster residents’ integration of divergent psychotherapeutic paradigms. They provide some retrospective evaluative data (30). These authors include a comparison with residents trained at another university that did not offer a similar intervention; however, the comparison group and the seminar participant group were not asked identical questions. Finally, Beitman and colleagues have authored a text meant to serve as a basis for systematic education in the integration of psychotherapy with pharmacotherapy (63).
In the context of the limitations to the literature identified above, this review seeks to provide a structured examination of the relevant integrative and educational issues. The paper attempts a systematic consideration of integrative aspects of education in the psychotherapies; it is intended to serve as a coherent starting point for psychiatric educators attentive to such factors. By enumerating the range of integrative issues that have educational importance, it may serve as a guide to developing a syllabus for integrative training. In addressing the educational challenges that accompany those issues, it draws attention to aspects of the educational process that require decisions or resolution to facilitate such training as part of psychiatric education. Some specific recommendations are made along those lines. Brief descriptions of actual educational interventions, drawn from the author’s experience at the University of Toronto, appear in the textboxes. These illustrate various applications of integrative principles to psychotherapy education. Apart from these goals and to focus further enquiry, the paper identifies central unresolved training questions, aiming to put this poorly delineated educational domain on a more empirically grounded footing in the future.
Integrative issues of educational significance can be organized into 5 major categories: attitudinal set, knowledge base, clinical techniques and skills, developmental tasks and challenges, and systemic institutional factors.
Authors tend to emphasize empiricism in guiding the match of patient to treatment (2,36,43,70–73). Further, there is attention to individualizing the psychotherapeutic approach to optimally meet the specific needs, vulnerabilities, and capacities of a particular patient (66). Textbox 1 describes one approach to introducing such integrative values to residents early in training.
Understanding how the conceptual models psychotherapists use shape their processing of clinical data and, hence, their therapeutic behaviour can help them anticipate many of the challenges that arise with integrated treatments (37,65,66,74). Attempts to bring together interventions whose underlying theoretical models are not fully consistent can lead to increased uncertainty for the therapist (37). Beneath these differences in theory lie fundamental differences in the philosophical bases subtending specific psychotherapeutic systems (75,77,78,84). Explicitly recognizing the underlying emphasis, and even life-view, embedded in a given psycho- therapeutic approach makes the choice of intervention a more richly informed one, attentive to implicit values connoted by the therapist’s words and actions (77).
Integrative treatment models offer strategies for combined interventions that address this problem to varying extents. Specific knowledge of such methods can guide psychotherapists to provide integrated treatments systematically, avoiding unplanned combinations of interventions that risk inconsistency and increase the possibility of negative interaction. Theoretical breadth is accompanied by varying degrees of theoretical depth in different approaches to integration (16,85). Technical eclecticism, for example, does not attempt to reconcile theoretical inconsistencies among therapies (86,87). Conversely, synthetic, theoretical, integrative approaches pay specific attention to such differences and, in combining modalities, strive to establish a coherent theoretical whole (14,67–69,88,89). A range of integrative frameworks have been described; these frameworks can help clinicians to organize the integrative approaches considered for adoption in the treatment of a given patient. Integrative approaches fall into 1 of 6 categories: selection, technical eclecticism, translation, common factors, theoretical synthesis, and metatheoretical integration. This underscores the fact that well-defined integrated treatment modalities are not the only forms integration can take (50,85,90).
Integrated treatment approaches have been articulated for use with certain patient populations, including those with depression (19,91), anxiety disorders (5,92,93), personality disorders (94–97), and eating disorders (66,98–101). Finally, literature exists on treatments involving more than a single therapist (102,103). Such conjoint therapies have potential advantages and disadvantages, compared with combined therapies in which the same practitioner provides interventions drawn from more than one modality (22,104,105).
Clinical Techniques and Skills
Clinicians conducting integrative work frequently encounter patients with multiple problem areas. They would do well to have systematic approaches to the psychotherapeutic management of such clinically challenging patients. Similarly, resolving psychotherapeutic impasses is made more complex with the introduction of more than a single understanding of the forces that enable or impede effective progress (24,116–118). Hence, an orderly approach that reflects integrative principles is called for. Finally, coadministering psychotropic agents can potentially greatly increase the therapist’s effectiveness, although it also requires greatly expanded skills. Many interactions exist between these different psychiatric interventions. Consequently, specific adjustments to psychotherapeutic and psychopharmacologic techniques are needed to realize optimal benefit and avoid potential pitfalls (20,21,23,60–63).
Developmental Tasks and Challenges
In eschewing a single conceptual framework as their guide, integrative therapists typically face increased ambiguity in their daily clinical interactions (37,44,74). Thus, developing the capacity to tolerate and effectively manage increased uncertainty is an essential task for trainees in integrative approaches to psychotherapy (30,47). Throughout their training, residents can encounter widely varied supervisory and theoretical influences, each one of which is potentially formative. Learning to reconcile divergent influences is a potentially confusing and difficult educational task (49,122).
The developmental challenges posed by integration extend beyond residency training: they are relevant to psychiatrists in practice more generally. The discipline is by no means static, with the emergence of new psychotherapeutic techniques and psychotropic medications an ongoing reality (24,123–128). The integrative perspective offers attitudes, knowledge, and skills that provide a rational basis upon which trained, experienced therapists can consider new treatment methods for possible incorporation into their established mode of practice. The integrative emphasis on open-minded use of the most effective modality available encourages psychotherapists to remain up-to-date. It focuses specifically on how the inclusion of novel interventions may influence a practitioner’s baseline approach and how that approach may in turn alter the ultimate form of assimilated techniques (67). Integrative approaches can play a part in a lifelong learning model wherein openness to new ideas or information, the adoption of novel techniques, and continued professional growth can occur within a coherent and adaptable framework. Consequently, continuing education incorporating an integrative stance may be advantageous. Textbox 2 describes a longitudinal continuing medical education (CME) course for practising psychiatrists in which these integrative factors were a design consideration.
Systemic Institutional Factors
Particular educational challenges attend efforts to foster competence in the above facets of integrative practice. The integrative psychotherapy literature has identified some of these; others become apparent as one endeavours to establish such an educational environment. These issues are described below and categorized as they relate to content, format and process, sequence, and faculty development. Key educational uncertainties and dilemmas are highlighted.
Format and Process
Supervision is fundamental to the process of learning psychotherapy (122,132,133). It can provide the direct, case-based teaching needed to translate theory into technique, to apply general principles to particular individuals, to develop core psychotherapeutic relational capacities, and to hone specific clinical skills. Modelling and mentoring can occur within the supervisory setting. Attitudes exhibited by supervisors, together with the theoretical orientations they represent, are potentially formative influences on their supervisees. It is here that examination of psychotherapeutic process, including the vicissitudes of the therapeutic relationship and variables such as frame, transference, countertransference, psychological defenses, affect management, activity level, adherence to technique, and therapeutic decision making in the face of uncertainty, can be addressed with sufficient depth and subtlety to further develop the therapist’s capacity to manage proficiently these demanding facets of therapy (39,44,49).
The literature focused on integrative psychotherapy supervision identifies several issues informing the supervisor’s educational role. Given the confusing array of theoretical influences facing the novice integrative therapist, the utility of a coherent conceptual framework for the conduct of supervision has been emphasized (47). The supervisor needs to embody the integrative attitudes outlined above (45,47, 52,134). Parallel process is a recognized occurrence in psychotherapy supervision generally, and no less so in integrative supervision (39,44,122,134). In addition, a supervisory approach that adjusts flexibly in response to the choice of treatment model and to the evolving learning needs, style, and developmental stage of the supervisee further reflects the flexible responsiveness inherent in the integrative approach itself. Some authors describe integrative models of supervision with several parameters analogous to the integrative model of therapy they are intended to teach (44,45,47, 48,59,134).
Integrative supervisors encounter a tension between promoting the supervisee’s breadth of approach and striving for depth of skill and understanding (38–40,47). Their role includes helping supervisees to manage the potentially overwhelming amount of knowledge and technique required for integrative clinical work and to address increased ambiguity and resultant anxiety (47). Experienced supervisors must remain aware of how difficult it can be for trainees to practise integratively within sessions. Andrews and colleagues have commented on the value of supervisor openness in this regard (39). Walder (49) has found Messer’s therapeutic choice points (112) to be a useful concept to inform supervision that attends to the challenges of integrative decision making in the moment. This literature mentions a wide range of individual and group pedagogic formats for supervision (47). Textbox 5 describes an optional clinical rotation for senior residents built around integrative supervision of varied therapeutic assessments and casework.
First, the preferred sequencing of training toward expertise in a specific psychotherapeutic modality and training in integration has been debated. One view is that training in at least one psychotherapeutic modality should precede attempts to teach integration (38,59). Trainees may only fully appreciate the issues and challenges arising with integration after they have reached a suitably advanced level, having acquired substantial clinical experience (39,40,43,45,49,56). Perhaps, some argue, trainee therapists can branch out meaningfully only after they have established a primary base of theory and technique (30). Taking this reasoning further, some suggest that students cannot properly appreciate the challenges of integration until they have been supervised in at least 2 contrasting psycho- therapeutic traditions. This would provide the opportunity to directly experience the differences in emphasis, frame, session process, activity level, and intervention associated with different approaches. A related concern is that prematurely introducing integration may diminish residents’ early efforts to master a given modality at a stage wherein they continue to require the clearer guidance a narrower focus affords.
Many authors, however, espouse an alternate view. They suggest that delaying exposure to integrative ideas will make it harder to instill openness and flexibility in psychotherapists who have already formed an allegiance to the theory and ideals of one particular school (44,45,47,49,56).
A second issue relates to training in common therapeutic elements whose importance transcends theoretical lines. Some authors recommend that, given the evidence for their impact on outcome, they should be taught before training in any specific modality (26,38,45,52). A third question is whether training in multiple modalities should be provided on a concurrent or sequential basis (44,49). Finally, should seminars be offered to residents from a narrow cohort with respect to their level of training, or should seminar composition be more heterogeneous (30,90)?
Conclusions and Recommendations
The following conclusions and specific recommendations are put forward as a response to the integrative and educational issues identified in this review and draw on the author’s experience in the realm of integrative psychotherapeutic education:
1. The integrative perspective has become substantially relevant to education in the psychotherapies within psychiatry; it should be duly considered in planning educational programs, with attention to the multiple integrative dimensions outlined above.
2. There is an unmet need for systematically planned educational initiatives in integrative approaches to psychotherapy at both the postgraduate and CME levels. Such educational endeavours should be documented in sufficient detail to allow for well-informed consideration by educators. The integrative goals, scope, theoretical framework, and content should be explicit, as should the educational methodology used.
3. To address the various types of learning needed to establish proficiency, multiple educational approaches and formats will likely be required. Developing and disseminating a syllabus of integrative therapeutic training may serve to enumerate essential content and articulate educational expectations within the postgraduate curriculum.
4. Such educational initiatives should be evaluated thoroughly to facilitate ongoing refinement and assessment by others, and the resultant evaluative data should be submitted for publication. These actions will be both steps toward the development of effective integrative educational inter- ventions and contributions toward a broader goal of consolidating integrative approaches within psychiatric practice more generally.
5. Within psychiatric residency, attention needs to be directed to the relative emphasis accorded training in unimodal psychotherapies, in core psychotherapeutic skills common to diverse modalities, and in integrative approaches to psychotherapy.
6. Multiple decisions are required to plan the sequencing of components of psychotherapeutic training over the course of residency. At present, neither consensus nor empirical data exist to resolve such questions definitively, but the competing rationales supporting various choices and associated trade-offs have been identified. One solution incorporating several views put forward in the literature consists of introducing integrative, transtheoretical ideas at the outset to influence the shaping of attitudes at what may be a critical phase. Psychotherapeutic skills associated with common therapeutic factors can then be taught. After that, focused training in individual modalities can proceed sequentially or in parallel. Late in postgraduate training, specific education in integrative theory and techniques can be directed toward the achievement of proficiency and consolidation of residents’ learning in the psychotherapies.
7. The integration of psychotherapy and pharmacotherapy should be considered a core topic within residency training and taught explicitly as part of the curriculum.
8. Owing to the potential benefits an integrative perspective can confer on continuing education in psychotherapy, and in psychiatry more generally, educators should consider how it can be used in framing CME events.
9. Faculty recruitment efforts should seek to redress imbalances in the representation of the full range of psycho- therapies for which there is departmental support. Similar attention should be devoted to ensuring that there are faculty who can provide specific education in integrative approaches to treatment, including clinical supervision sensitive to the associated professional developmental challenges. Psychotherapy faculty development efforts could be influenced by these goals. Fostering an attitude conducive to constructive dialogue among faculty with divergent theoretical viewpoints will advance the cause of a vital, forward-looking psychotherapy training program informed by integrative principles. Proponents of both traditional and newer unimodal psycho- therapeutic disciplines can well remain highly valued within this broader integrative clinical–academic context, with the relevance of their approaches to general psychiatric care reaffirmed rather than threatened.
10. Systematic study should be directed toward establishing an empirical basis to guide integrative teaching and program- planning decisions. Issues to be addressed could include determining effective pedagogic formats for delivering components of integrative training and the optimal timing of different educational elements, as well as assessing faculty and student attitudes, knowledge, and skill.
11. Formal assessment of integrative educational initiatives should go beyond subjective satisfaction questionnaires to methodologically more rigorous approaches; these could include validated assessment instruments, pre–post assessments, comparative designs, and evaluation of impact upon therapist attitudes and behaviour.
12. Clinical studies that continue to refine our understanding of the relative utility of combination and unimodal interventions will enhance the empirical base for integrative treatment planning. Where such studies exist, they should be included as part of the psychotherapy research data imparted to students.
This article has attempted to systematically examine integrative aspects of psychotherapy education. Limitations of the present effort include the lack of detailed descriptions of educational activities, which could only be summarized, and an absence of data derived from assessing such initiatives. The scope of this review precluded their inclusion; however, the specific recommendations above are intended as a foundation for future academic work in this important domain.
1. Havens L. Approaches to the mind: movement of the psychiatric schools from sects toward science. Cambridge (MA): Harvard University Press; 1973.
2. Beitman BD, Goldfried MR, Norcross JC. The movement toward integrating the psychotherapies: an overview. Am J Psychiatry 1989;146:138–47.
3. Sabshin M. Turning points in twentieth-century American psychiatry. Am J Psychiatry 1990;147:1267–74.
4. Goldfried MR, Newman CF. A history of psychotherapy integration. In: Norcross JC, Goldfried MR, editors. Handbook of psychotherapy integration. New York: Basic Books; 1992. p 46–93.
5. Goldfried MR, Wiser SL, Raue PJ. On the movement toward psychotherapy integration: the case of panic disorder. J Psychother Pract Res 1992;1:213–24.
6. French TM. Interrelations between psychoanalysis and the experimental work of Pavlov. Am J Psychiatry 1933;89:1165–203.
7. Kubie LS. Relation of the conditioned reflex to psychoanalytic technique. Arch Neurol Psychiatry 1934;32:1137–42.
8. Rosenzweig S. Some implicit common factors in diverse methods in psychotherapy. Am J Orthopsychiatry 1936;6:412–5.
9. Marks IM, Gelder MG. Common ground between behaviour therapy and psychodynamic methods. Br J Med Psychol 1966;39:11–23.
10. Marmor J. Dynamic psychotherapy and behavior therapy: are they irreconcilable? Arch Gen Psychiatry 1971;24:22–8.
11. Birk L, Brinkley-Birk AW. Psychoanalysis and behavior therapy. Am J Psychiatry 1974;131:499–510.
12. Goldfried MR. On the history of therapeutic integration. Behavior Therapy 1982;13:572–93.
13. Franks CM. On conceptual and technical integrity in psychoanalysis and behaviour therapy: two fundamentally incompatible systems. In: Arkowitz H, Messer S, editors. Psychoanalytic therapy and behaviour therapy: is integration possible? New York: Plenum Press; 1984. p 223–48.
14. Safran JD, Segal ZV. Interpersonal process in cognitive therapy. New York: Basic Books; 1990.
15. Pine F. Drive, ego, object, and self: a synthesis for clinical work. New York: Basic Books; 1990.
16. Norcross JC, Goldfried MR, editors. Handbook of psychotherapy integration. New York: Basic Books; 1992.
17. Stricker G, Gold JR, editors. Comprehensive handbook of psychotherapy integration. New York: Plenum Press; 1993.
18. Karasu TB. Psychotherapy and pharmacotherapy: toward an integrative model. Am J Psychiatry 1982;139:1102–13.
19. Karasu TB. Toward a clinical model of psychotherapy for depression, II: an integrative and selective treatment approach. Am J Psychiatry 1990;147:269–78.
20. Beitman BD, Klerman GL, editors. Integrating pharmacotherapy and psychotherapy. Washington (DC): American Psychiatric Press; 1991.
21. Schachter M, editor. Psychotherapy and medication: a dynamic integration. Northvale (NJ): Jason Aronson; 1993.
22. Gabbard GO, Kay J. The fate of integrated treatment: whatever happened to the biopsychosocial psychiatrist? Am J Psychiatry 2001;158:1956–63.
23. Thase ME. Conceptual and empirical basis for integrating psychotherapy and pharmacotherapy. In: Beitman BD, Blinder BJ, Thase ME, Riba M, Safer DL, editors. Integrating psychotherapy and pharmacotherapy: dissolving the mind-brain barrier. New York: WW Norton and Company; 2003. p 111–39.
24. Cameron PM, Leszcz M, Bebchuk W, Swinson RP, Antony MM, Azim HF, and others. The practice and roles of the psychotherapies: a discussion paper. Can J Psychiatry 1999;44(Suppl 1):18S–31S.
25. Rodenhauser P. Psychiatry residency programs: trends in psychotherapy supervision. Am J Psychother 1992;46:240–9.
26. Weerasekera P. Postgraduate psychotherapy training: incorporating findings from the empirical literature into curriculum development. Acad Psychiatry 1997;21:122–32.
27. Hoglend P. Psychotherapy research: new findings and implications for training and practice. J Psychother Pract Res 1999;8:257–63.
28. Beresin E, Mellman L. Competencies in psychiatry: the new outcomes-based approach to medical training and education. Harv Rev Psychiatry 2002;10:185–91.
29. Mellman LA, Beresin E. Psychotherapy competencies: development and implementation. Acad Psychiatry 2003;27:149–53.
30. Allen DM, Kennedy CL, Veeser WR, Grosso T. Teaching the integration of psychotherapy paradigms in a psychiatric residency seminar. Acad Psychiatry 2000;24:6–13.
31. Pardes H. A changing psychiatry for the future. Am J Psychiatry 1996;153:1383–6.
32. MacKenzie KR, Leszcz M, Abbass A, Hollander Y, Kleinman I, Livesley J, and others. Guidelines for the psychotherapies in comprehensive psychiatric care: a discussion paper. Can J Psychiatry 1999;44(Suppl 1):4S–17S.
33. Luborsky L, Singer B, Luborsky L. Comparative studies of psychotherapies: is it true that “everyone has won and all must have prizes”? Arch Gen Psychiatry 1975;32:995–1008.
34. Smith ML, Glass GV, Miller TI. The benefits of psychotherapy. Baltimore (MD): Johns Hopkins University Press; 1980.
35. Luborsky L, Rosenthal R, Diguer L, Andrusyna TP, Berman JS, Levitt JT, and others. The dodo bird verdict is alive and well—mostly. Clinical Psychology: Science and Practice 2002;9:2–12.
36. Lambert MJ, Ogles BM. The efficacy and effectiveness of psychotherapy. In: Lambert MJ, editor. Bergin and Garfield’s handbook of psychotherapy and behaviour change, 5th ed. New York: John Wiley and Sons; 2004.
37. Beahrs JO. Limits of scientific psychiatry: the role of uncertainty in mental health. New York: Brunner/Mazel; 1986.
38. Beutler LE, Mahoney MJ, Norcross JC, Prochaska JO, Robertson M, Sollod RN. Training integrative/eclectic therapists II. Journal of Integrative and Eclectic Psychotherapy 1987;6:296–332.
39. Andrews JDW, Norcross JC, Halgin RP. Training in psychotherapy integration. In: Norcross JC, Goldfried MR, editors. Handbook of psychotherapy integration. New York: Basic Books; 1992. p 563–92.
40. Castonguay LG. A common factors approach to psychotherapy training. Journal of Psychotherapy Integration 2000;10:263–82.
41. Frances A, Clarkin JF, Perry S. Teaching differential therapeutics. In: Differential therapeutics in psychiatry: the art and science of treatment selection. New York: Brunner/Mazel; 1984. p 353–63.
42. Robertson M. Teaching psychotherapy in an academic setting. Psychotherapy: Theory, Research, Practice, Training 1984;21:209–12.
43. Robertson M. Training eclectic psychotherapists. In: Norcross JC, editor. Handbook of eclectic psychotherapy. New York: Brunner/Mazel; 1986. p 416–35.
44. Halgin RP. Teaching integration of psychotherapy models to beginning therapists. Psychotherapy: Theory, Research, Practice, Training 1985;22:555–63.
45. Norcross JC, Beutler LE, Clarkin JF, DiClemente CC, Halgin RP, Frances A, and others. Training integrative/eclectic psychotherapists. Journal of Integrative and Eclectic Psychotherapy 1986;5:71–94.
46. Halgin RP. Issues in the supervision of integrative psychotherapy. Journal of Integrative and Eclectic Psychotherapy 1988;7:152–6.
47. Norcross JC. Supervision of integrative psychotherapy. Journal of Integrative and Eclectic Psychotherapy 1988;7:157–66.
48. Beutler LE, Clarkin JF, Norcross JC. Training in differential treatment selection. In: Systematic treatment selection: toward targeted therapeutic interventions. New York: Brunner/Mazel; 1990. p 289–307.
49. Walder EH. Supervision and instruction in postgraduate psychotherapy integration. In: Stricker G, Gold JR, editors. Comprehensive handbook of psychotherapy integration. New York: Plenum Press; 1993. p 499–512.
50. Robertson MH. Psychotherapy education and training: an integrative perspective. Madison (CT): International Universities Press; 1995.
51. Beitman BD, Yue D. A new psychotherapy training program: description and preliminary results. Acad Psychiatry 1999;23:95–102.
52. Norcross JC, Beutler LE. A prescriptive eclectic approach to psychotherapy training. Journal of Psychotherapy Integration 2000;10:247–61.
53. Wolfe BE. Toward an integrative theoretical basis for training psychotherapists. Journal of Psychotherapy Integration 2000;10:233–46.
54. Norcross JC. Emerging breakthroughs in psychotherapy integration: three predictions and one fantasy. Psychotherapy: Theory, Research, Practice, Training 1997;34:86–90.
55. Castonguay LG. Training in psychotherapy integration: introduction to current efforts and future visions. Journal of Psychotherapy Integration 2000;10:229–31.
56. Wolfe BE, Goldfried MR. Research on psychotherapy integration: recommendations and conclusions from an NIMH workshop. J Consult Clin Psychol 1988;56:448–51.
57. Mohl PC, Lomax J, Tasman A, Chan CH, Sledge WH, Summergrad P, and others. Psychotherapy training for the psychiatrist of the future. Am J Psychiatry 1990;147:7–13.
58. Norcross JC, Dryden W, DeMichele JT. British clinical psychologists and personal therapy III: what’s good for the goose? Clinical Psychology Forum 1992;44:29–33.
59. Stricker G. Supervision of integrative psychotherapy: discussion. Journal of Integrative and Eclectic Psychotherapy 1988;7:176–80.
60. Adelman SA. Pills as transitional objects. In: Schachter M, editor. Psychotherapy and medication: a dynamic integration. Northvale (NJ): Jason Aronson; 1993. p 109–19.
61. Goldhamer PM. Psychotherapy and pharmacotherapy: the challenge of integration. Can J Psychiatry 1983;28:173–7.
62. Magder DM, Segal ZV, Kennedy SH, Gilbert B. Guidelines for combining pharmacotherapy with psychotherapy. In: Cameron PM, Ennis J, Deadman J, editors. Standards and guidelines for the psychotherapies. Toronto: University of Toronto Press; 1998. p 292–319.
63. Beitman BD, Blinder BJ, Thase ME, Riba M, Safer DL. Integrating psychotherapy and pharmacotherapy: dissolving the mind-brain barrier. New York: WW Norton and Company; 2003.
64. Beitman BD, Yue D. Learning psychotherapy: a time-efficient, research-based, and outcome-measured psychotherapy training program. New York: WW Norton and Company; 1999.
65. Lazare A. Hidden conceptual models in clinical psychiatry. N Engl J Med 1973;288:345–51.
66. Greben DH, Kaplan AS. Conceptual models and integrative therapy: anorexia nervosa as a prototype. Can J Psychiatry 1995;40:584–92.
67. Stricker G, Gold JR. Psychotherapy integration: an assimilative, psychodynamic approach. Clinical Psychology: Science and Practice 1996;3:47–58.
68. Wachtel PL, McKinney MK. Cyclical psychodynamics and integrative psychodynamic therapy. In: Norcross JC, Goldfried MR, editors. Handbook of psychotherapy integration. New York: Basic Books; 1992. p 335–70.
69. Wachtel PL. Psychoanalysis, behavior therapy, and the relational world. Washington (DC): American Psychological Association; 1997.
70. Lambert MJ. Psychotherapy outcome research: implications for integrative and eclectical therapists. In: Norcross JC, Goldfried MR, editors. Handbook of psychotherapy integration. New York: Basic Books; 1992. p 94–129.
71. Glass CR, Victor BJ, Arnkoff DB. Empirical research on integrative and eclectic psychotherapies. In: Stricker G, Gold JR, editors. Comprehensive handbook of psychotherapy integration. New York: Plenum Press; 1993. p 9–25.
72. Roth A, Fonagy P, editors. What works for whom? A critical review of psychotherapy research. New York: Guilford Press; 1996.
73. Lambert MJ. What are the implications of psychotherapy research for clinical practice and training. Nord J Psychiatry 1998;52(Suppl 41):38–49.
74. Yager J. Psychiatric eclecticism: a cognitive view. Am J Psychiatry 1977;134:736–41.
75. Messer SB, Winokur M. Ways of knowing and visions of reality in psychoanalytic therapy and behavior therapy. In: Arkowitz H, Messer SB, editors. Psychoanalytic therapy and behavior therapy: is integration possible? New York: Plenum Press; 1984. p 63–100.
76. Messer SB, Winokur M. Eclecticism and the shifting visions of reality in three systems of psychotherapy. Journal of Integrative and Eclectic Psychotherapy 1986;5:115–24.
77. Strenger C. The classic and the romantic vision in psychoanalysis. Int J Psychoanal 1989;70(Part 4):593–610.
78. Messer SB. A critical examination of belief structures in integrative and eclectic psychotherapy. In: Norcross JC, Goldfried MR, editors. Handbook of psychotherapy integration. New York: Basic Books; 1992. p 130–65.
79. Gurman AS, Messer SB, editors. Essential psychotherapies: theory and practice. New York: Guilford Press; 1995.
80. Wachtel PL, Messer SB, editors. Theories of psychotherapy: origins and evolution. Washington (DC): American Psychological Association; 1997.
81. Norcross JC, Martin JR, Omer H, Pinsof WM, Rapp H. When (and how) does psychotherapy integration improve clinical effectiveness? a roundtable. Journal of Psychotherapy Integration 1996;6:295–332.
82. Messer SB, Winokur M. Some limits to the integration of psychoanalytic and behavior therapy. Am Psychol 1980;35:818–27.
83. Messer SB. Integrating psychoanalytic and behaviour therapy: limitations, possibilities and trade-offs. Br J Clin Psychol 1983;22:131–2.
84. Safran JD, Messer SB. Psychotherapy integration: a postmodern critique. Clinical Psychology: Science and Practice 1997;4:140–52.
85. Mahrer AR. The integration of psychotherapies: a guide for practicing therapists. New York: Human Sciences Press; 1989.
86. Lazarus AA. The practice of multimodal therapy. Baltimore (MD): Johns Hopkins University Press; 1989.
87. Lazarus AA. Multimodal therapy: technical eclecticism with minimal integration. In: Norcross JC, Goldfried MR, editors. Handbook of psychotherapy integration. New York: Basic Books; 1992. p 231–63.
88. Wachtel PL. Psychoanalysis and behavior therapy: toward an integration. New York: Basic Books; 1977.
89. Wachtel PL. From eclecticism to synthesis: toward a more seamless psychotherapeutic integration. Journal of Psychotherapy Integration 1991;1:43–54.
90. Schacht TE. Can psychotherapy education advance psychotherapy integration? A view from the cognitive psychology of expertise. Journal of Psychotherapy Integration 1991;1:305–19.
91. Hayes AM, Newman CF. Depression: an integrated perspective. In: Stricker G, Gold JR, editors. Comprehensive handbook of psychotherapy integration. New York: Plenum Press; 1993. p 303–21.
92. Wolfe BE. Integrative psychotherapy of the anxiety disorders. In: Norcross JC, Goldfried MR, editors. Handbook of psychotherapy integration. New York: Basic Books; 1992. p 373–401.
93. Gold JR. An integrated approach to the treatment of anxiety disorders and phobias. In: Stricker G, Gold JR, editors. Comprehensive handbook of psychotherapy integration. New York: Plenum Press; 1993. p 293–302.
94. Linehan MM. Dialectical behavior therapy for borderline personality disorder: theory and method. Bull Menninger Clin 1987;51:261–76.
95. Koerner K, Linehan MM. Integrative therapy for borderline personality disorder: dialectical behavior therapy. In: Norcross JC, Goldfried MR, editors. Handbook of psychotherapy integration. New York: Basic Books; 1992. p 433 –9.
96. Gold JR, Stricker G. Psychotherapy integration with character disorders. In: Stricker G, Gold JR, editors. Comprehensive handbook of psychotherapy integration. New York: Plenum Press; 1993. p 323–36.
97. Livesley WJ. A framework for an integrated approach to treatment. In: Livesley WJ, editor. Handbook of personality disorders: theory, research, and treatment. New York: Guilford Press; 2001. p 570–600.
98. Garfinkel PE, Garner DM. Anorexia nervosa: a multidimensional perspective. New York: Brunner/Mazel; 1982.
99. Garner DM, Garfinkel PE, Irvine MJ. Integration and sequencing of treatment approaches for eating disorders. Psychother Psychosom 1986;46(1-2):67–75.
100. Garner DM, Garfinkel PE, editors. Handbook of treatment for eating disorders, 2nd ed. New York: Guilford Press; 1997.
101. Tobin DL. Coping strategies therapy for bulimia nervosa. Washington (DC): American Psychological Association; 2000.
102. Ormont LR. Principles and practice of conjoint psychoanalytic treatment. Am J Psychiatry 1981;138:69–73.
103. Chiles JA, Carlin AS, Benjamin GAH, Beitman BD. A physician, a nonmedical psychotherapist, and a patient: the pharmacotherapy-psychotherapy triangle. In: Beitman BD, Klerman GL, editors. Integrating pharmacotherapy and psychotherapy. Washington (DC): American Psychiatric Association; 1991. p 105–18.
104. Alonso A, Rutan JS. Common dilemmas in combined individual and group treatment. Group 1990;14:5–12.
105. Lipsius SH. Combined individual and group psychotherapy: guidelines at the interface. Int J Group Psychother 1991;41:313–27.
106. Mohl PC. What is a balanced program? Acad Psychiatry 1995;9:94–100.
107. Marziali E, Alexander L. The power of the therapeutic relationship. Am J Orthopsychiatry 1991;61:383–91.
108. Horvath AO, Luborsky L. The role of the therapeutic alliance in psychotherapy. J Consult Clin Psychol 1993;61:561–73.
109. Perry S, Cooper AM, Michels R. The psychodynamic formulation: its purpose, structure, and clinical application. Am J Psychiatry 1987;144:543–50.
110. Weerasekera P. Formulation: a multiperspective model. Can J Psychiatry 1993;38:351–8.
111. Weerasekera P. Multiperspective case formulation: a step towards treatment integration. Malabar (FL): Krieger Publishing Company; 1996.
112. Messer SB. Behavioral and psychoanalytic perspectives at therapeutic choice points. Am Psychol 1986;41:1261–72.
113. Frances A, Clarkin JF, Perry S. Differential therapeutics in psychiatry: the art and science of treatment selection. New York: Brunner/Mazel; 1984.
114. Beutler LE, Clarkin JF. Systematic treatment selection: toward targeted therapeutic interventions. New York: Brunner/Mazel; 1990.
115. Beutler LE, Consoli AJ. Systematic eclectic psychotherapy. In: Norcross JC, Goldfried MR, editors. Handbook of psychotherapy integration. New York: Basic Books; 1992. p 264–99.
116. Atwood GE, Stolorow RD, Trop JL. Impasses in psychoanalytic therapy: a royal road. Contemporary Psychoanalysis 1989;25:554–73.
117. Arnkoff DB. Two examples of strains in the therapeutic alliance in an integrative cognitive therapy. J Clin Psychol 2000;56:187–200.
118. Omer H. Troubles in the therapeutic relationship: a pluralistic perspective. J Clin Psychol 2000;56:201–10.
119. Book HE. On maybe becoming a psychotherapist, perhaps. Canadian Psychiatric Association Journal 1973;18:487–93.
120. Bruch H. Teaching and learning of psychotherapy. Can J Psychiatry 1981;26:86–92.
121. Fennig S, Naisberg-Fennig S, Neumann M, Kovasznay B. The psychiatrist as a psychotherapist: the problem of identity. Am J Psychother 1993;47:33–7.
122. Loganbill C, Hardy E, Delworth U. Supervision: a conceptual model. Counseling Psychologist 1982;10(1):3–42.
123. Heimberg RG, Juster HR. Treatment of social phobia in cognitive-behavioral groups. J Clin Psychiatry 1994;55(Suppl):38–46.
124. Corsini RJ, Wedding D. Current psychotherapies, 5th ed. Itasca (IL): FE Peacock Publishers; 1995.
125. Frank E, Swartz HA, Kupfer DJ. Interpersonal and social rhythm therapy: managing the chaos of bipolar disorder. Biol Psychiatry 2000;48:593–604.
126. McCullough JP. Treatment for chronic depression: cognitive behavioral analysis system of psychotherapy (CBASP). New York: Guilford Press; 2000.
127. Heimberg RG. Current status of psychotherapeutic interventions for social phobia. J Clin Psychiatry 2001;62(Suppl 1):36–42.
128. McCullough JP. Skills training manual for diagnosing and treating chronic depression: cognitive behavioral analysis system of psychotherapy. New York: Guilford Press; 2001.
129. Norcross JC, Thomas BL. What’s stopping us now? obstacles to psychotherapy integration. Journal of Integrative and Eclectic Psychotherapy 1988;7:74–80.
130. Norcross JC, Newman CF. Psychotherapy integration: setting the context. In: Norcross JC, Goldfried MR, editors. Handbook of psychotherapy integration. New York: Basic Books; 1992. p 3–45.
131. Leszcz M, Psychotherapy Program Committee. Postgraduate training objectives in the psychotherapies, 1995. Located at Department of Psychiatry, University of Toronto, Toronto, Ontario.
132. Greben SE, Ruskin R, editors. Clinical perspectives on psychotherapy supervision. Washington (DC): American Psychiatric Press; 1994.
133. Ennis J, Cameron PM, Leszcz M, Chagoya L. Guidelines for psychotherapy supervision. In: Cameron PM, Ennis J, Deadman J, editors. Standards and guidelines for the psychotherapies. Toronto: University of Toronto Press; 1998. p 371–90.
134. Halgin RP. Pragmatic blending of clinical models in the supervisory relationship. Clinical Supervisor 1985;3:23–46.
Manuscript received and accepted December 2003.
1. Deputy Clinical Director and Head, Ambulatory Services, General Psychiatry Program, Centre for Addiction and Mental Health; Associate Head, Psychotherapy Program and Assistant Professor, Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario.
Address for correspondence: Dr DH Greben, Centre for Addiction and Mental Health, 250 College Street, Room G5, Toronto, ON M5T 1R8
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