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Guest Editorial
Psychotherapy Education: Innovation and Evolution
Daniel H Greben, Zindel V Segal
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In Review
Implications of Psychotherapy Research for Psychotherapy Training
William E Piper
(PDF)

Advances in Psychotherapy Education
Paula Ravitz, Ivan Silver
(PDF)

Integrative Dimensions of Psychotherapy Training
Daniel H Greben
(PDF)

Original Research
Forty Years of Deinstitutionalization of Psychiatric Services in Canada: An Empirical Assessment
Patricia Sealy, Paul C Whitehead
(PDF)

Comparisons Between the South Oaks Gambling Screen and a DSM-IV-Based Interview in a Community Survey of Problem Gambling
Brian J Cox, Murray W Enns, Valerie Michaud
(PDF)

Spirituality and Psychiatry in Canada: Psychiatric Practice Compared With Patient Expectations
Marilyn Baetz, Ron Griffin, Rudy Bowen, Gene Marcoux
(PDF)

Differences Between Only Children and Children With 1 Sibling Referred to a Psychiatric Clinic: A Test of Richards and Goodman's Findings
Jacques D Marleau, Jean-Jacques Breton, Gisèle Chiniara, Jean-François Saucier
(PDF)

Book Review
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The Infant and Family in the Twenty-First CenturyReviewed by
Pratibha N Reebye

Letters to the Editor
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High Frequency of Bipolar Spectrum in Outpatients With Depression

Long-Term Lamotrigine Adjunctive to Antipsychotic Monotherapy in Schizophrenia: Further Evidence

Evidence for Early Intervention in First-Episode Psychosis

D₂ Antagonist Augmentation in Patients With a Partial Response to Atypicial Antipsychotics

In Review

Integrative Dimensions of Psychotherapy Training

Daniel H Greben, MD, FRCPC¹

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).

Review

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

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.

Attitudinal Set
Flexibility characterizes the attitudinal set of the integrative psychotherapist, setting it apart from the narrower perspective typically associated with various unimodal therapies (2,52,65,66). This openness extends to acknowledging potential compatibility and complementarity in divergent conceptual systems. Rather than being assigned hierarchical precedence over one another, affect, cognition, and behaviour are seen to interact (2,67–69). The term “rapprochement” has been used to describe the attempts to bring together previously distinct schools of thought that accompanied the integrative movement (2,5,44).

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.

Knowledge Base
The capacity to conduct integrative psychotherapy with sophistication requires a knowledge base that includes multiple theories of psychotherapy (43,45,48,52). Understanding the intellectual basis of individual treatment modalities is a prerequisite to informed efforts to integrate them. Beyond this, there is a substantial body of theory pertinent to integration specifically. This begins with comparative theory, which attends to the similarities and differences in the intellectual and philosophical foundations of alternative theories (38,65,74–80). The rationale for integration, the goals it strives for, and factors that potentially lead to increased effectiveness suggest indications for an integrated rather than unimodal therapy (66,81). Consideration of an integrative approach must take account of existing empirical data regarding the efficacy of unimodal and integrated treatment models (23,24,27,71,72). It needs to be tempered by familiarity with potential obstacles and difficulties that may be encountered, as well as awareness of potential limits and contraindications to integration (13,45,82,83).

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
Along with knowledge of multiple theories of psychotherapy, integrative psychotherapists require a multimodal skill base (24,26,28,29,38,49,106). Such prerequisite core psychotherapeutic skills as the ability to establish and maintain a positive therapeutic alliance are essential (51,64,107,108). Individualized treatment planning, potentially incorporating multiple modalities, can be rendered more sophisticated by the capacity to formulate a patient’s difficulties along multiple theoretical lines (66,109–111). Core integrative psycho- therapeutic skills include the capacity for integrative decision making in the context of increased ambiguity (30,37,45,112). Specific synthetic and technical integrative psychotherapeutic methods, such as Wachtel’s cyclical psychodynamics (68,69,88,89), Safran and Segal’s cognitive- interpersonal integration (14), assimilative integration (67), the track 1–track 2 approach based on the multidimensional model of the eating disorders (66,98–100), Lazarus’ multimodal therapy (86,87), and systematic eclectic psychotherapy (113–115) offer clearly articulated techniques that can be directly adopted and applied in suitable clinical situations. Beyond implementing fully formulated integrative methods, it has been suggested that expert therapists can exhibit emergent automatic integrative capacities derived from extensive experience (39,90).

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
Becoming a psychotherapist is by its nature a long-term developmental task (119–121). Affiliation with a given psycho- therapeutic tradition and mode of practice is often integral to this process. Becoming an integrative therapist poses special developmental challenges (39,44,45,49,122). Here, the role is less clearly defined and more open to individual evolution. Similarly, the tasks of establishing a theoretical orientation and an individual therapeutic style are less well delineated. Openness to integration affects professional role development as a psychotherapist, as a psychiatrist, and as a physician.

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
Beyond the level of individual clinician-teachers, a psychotherapy training program attending to integrative principles should foster an open, flexible attitude consistent with this approach. This goal may meet supervisory resistance to a broad perspective that is perhaps related to historical anti- pathy, prior training, theoretical allegiances, belief systems, or political factors (38,45,48,129,130). Structural and organizational aspects of the clinical setting in which training occurs, as well as the clinical referral base, can also have a major impact on the effort to reflect integrative principles (45). Textbox 3 illustrates the attempt of a postgraduate training program to establish departmental support for an integrative perspective on education in the psychotherapies (131).

Educational Issues

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.

Content
It should be emphasized that there is indeed an established body of literature describing both theory and technique within integrative psychotherapy, as demonstrated above. This material is not well known to most psychotherapy supervisors and educators; hence, the substantive foundations of this field are not broadly recognized, and the integrative approach may be dismissed as theoretically sparse (55). However, sophisticated integrative practice in fact requires particularly extensive knowledge of established psychotherapeutic theories and particular cognizance of the impact of theory on practice. Familiarity with this content is necessary to appreciate the substantial specific knowledge and skills that need be imparted if psychotherapists are to be well versed in integrative principles and treatments. There is a need to communicate that this knowledge base exists and to incorporate it within the curricula of residency training and continuing educational activities (38). The topics summarized in the preceding section cover the range of material to be addressed; taken together, they could form the basis for a comprehensive syllabus of integrative psychotherapy applicable to the needs of psychiatrists and psychiatric residents.

Format and Process
Different types of learning and professional development are required to achieve the varied capacities needed to practise integrative psychotherapy. These capacities include attitudinal qualities; theoretical, metatheoretical, and empirical knowledge; relational and technical psychotherapeutic skills; problem-solving abilities; appreciation and negotiation of unresolved theoretical and clinical issues; tolerance for and management of increased uncertainty; and aspects of professional identity and role development. How best to lead students toward accomplishing these widely varied educational and developmental goals is a central question for educators concerned with this clinical domain. It calls for multiple educational formats and the pedagogic processes they are designed to catalyze. Within a comprehensive training initiative, one needs to determine the relevant place of supervised clinical work, didactic lectures, interactive discussions, small-group seminars or courses, live or taped patient interviews, case discussions, role plays, and assigned reading (30,38,49,53). Textbox 4 describes an advanced integrative therapy course designed for senior psychiatric residents.

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.

Sequence
Unresolved questions pervade the literature, related to how to select and sequence different educational interventions appropriately for students at different levels of training and experience. Four such questions are briefly considered here.

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)?

Faculty Development
Providing an educational environment with the capacity to foster psychiatric training informed by an integrative perspective makes demands not only on individual educators and students but also on the institution itself (39,130). The need to build a cadre of supervisors who can provide skilled supervision in a wide range of psychotherapies entails a high human resource requirement (24,38). Further to this, faculty development, recruitment, and support are required to ensure that skilled integrative supervisors are available to model the necessary attitudes and teach the specific principles, theory, and skills (41,43). Expert supervision in treatments combining psychotherapy and pharmacotherapy requires broadly skilled clinical teachers in academic settings that often encourage specialization (25).

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.

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Author(s)

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

e-mail:daniel_greben@camh.net

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