Creating a Specialist WebsitePrior to beginning work on this interactive assignment, please read the Neimeyer, et al. (2011) “How Special Are the Specialties? Workplace Settings in Counseling and Cl

Creating a Specialist WebsitePrior to beginning work on this interactive assignment, please read the Neimeyer, et al. (2011) “How Special Are the Specialties? Workplace Settings in Counseling and Cl
The Narrowing of Theoretical Orientations in Clinical Psychology Doctoral Training Laurie Heatherington, Williams College Stanley B. Messer, Rutgers University Lynne Angus, York University Timothy J. Strauman, Duke University Myrna L. Friedlander, University at Albany Gregory G. Kolden, University of Wisconsin The focus of this article is the increasingly narrow range of therapeutic orientations represented in clinical psychology graduate training programs, particularly within the most research-oriented programs. Data on the self-reported therapeutic orientations of faculty at “clinical science” Ph.D. programs, Ph.D. programs at comprehensive universities in clinical and in counseling psychology, Psy.D. programs at comprehensive universi- ties, and Ph.D. or Psy.D. programs at freestanding spe- cialized institutions reveal a strong predominance of faculty with cognitive-behavioral orientations at the more science-focused programs, and a narrower range of orientations than in the more practice-focused pro- grams. We discuss the implications of this trend for the future development of clinical psychology and provide suggestions for addressing the attendant concerns. Key words: CBT hegemony, clinical training and research, theoretical orientation. [Clin Psychol Sci Prac 19: 362–374, 2013] The growth of our knowledge is the result of a process closely resembling what Darwin called ‘natural selection’; that is, the natural selection of hypotheses: our knowledge consists, at every moment, of those hypotheses which have shown their (comparative) tness by surviving so far in their struggle for existence; a competitive struggle which eliminates those hypotheses which are un t. Karl Popper (1979) The best way to have a good idea is to have a lot of ideas. Linus Pauling Doctoral training in clinical psychology is clearly in a state of evolution. The scientist –practitioner (“Boul- der”) model that characterized the training landscape since 1949 has been challenged by several strong ideo- logical and sociological forces and developments. Argu- ments for the value of more practice-focused doctoral training led to the development of Psy.D. programs, beginning in the 1970s. Subsequently, market forces have resulted in the explosive growth of large, prac- tice-focused doctoral training programs at freestanding institutions, dubbed “specialized institutions not offer- ing comprehensive education beyond psychology or counseling” by Sayette, Norcross, and Dimoff (2011, p. 4), and hereafter referred to as “specialized institu- tions,” as well as a crisis in the oversupply of applicants relative to the availability of doctoral internships (Munsey, 2011; Vasquez, 2011). Controversies about standards for doctoral training programs, especially with regard to the need to teach evidence-based treatments (Bray, 2011; Calhoun, Moras, Pilkonis, & Rehm, Address correspondence to Laurie Heatherington, Ph.D., Department of Psychology, Williams College, Williamstown, MA 01267. E-mail: [email protected] © 2013 American Psychological Association. Published by Wiley Periodicals, Inc., on behalf of the American Psychological Association. All rights reserved. For permission, please email: permissionsuk.wiley.com 364 1998; Davison, 1998; Eby, Chin, Rollock, Schwartz, & Worrell, 2011), continue. And most recently, the assertion by some that current American Psychological Association (APA) accreditation standards and practices are undermining the science of clinical psychology has resulted in the creation of alternative accreditation stan- dards that emphasize research and clinical training focusing on empirically supported treatments and assessment (Baker, McFall, & Shoham, 2009; McFall, 2007). The outcomes of this evolution in training are dif cult to predict, and the relative merits of the vari- ous training models are a matter of widely diverging opinions and beyond the scope of this article. However, a recent study of APA-accredited clinical Ph.D. programs (Sayette et al., 2011), including the Academy of Psychological Clinical Science (APCS, 2012) 1and non-APCS programs in regular (“compre- hensive”) university settings and in specialized universi- ties, but excluding Psy.D. and counseling psychology Ph.D. programs, demonstrated a number of signi cant differences in acceptance rates, numbers of applicants admitted, admissions credentials, extent of nancial aid, student demographic characteristics, and program fea- tures (e.g., research funding, internship acceptance rates). The study also found stronger faculty allegiance to a cognitive-behavioral orientation in APCS pro- grams (80%), as compared with non-APCS programs (67%) and programs in the specialized institutions (37%), as well as stronger allegiances to psychodynamic and humanistic/existential orientations in non-APCS versus APCS programs. This article expands and critically discusses the latter nding. We argue that the nding regarding theoretical orientation re ects a feature of the evolving training landscape that is central to the future of clinical psy- chology but which has received little formal attention, that is, the increasingly restricted range of therapeutic orientations that clinical graduate students are expected to draw upon in their professional work. We contend that an unfortunate effect of some otherwise positive developments in promoting clinical psychology as a sci- ence is the danger of a monoculture of ideas about the nature of psychotherapeutic change—speci cally, a hegemony of cognitive-behavioral theory and therapy. Furthermore, this effect is moderated by the nature of the doctoral training program. That is, the moreresearch-based, science-focused programs tend to offer the narrowest range of theoretical orientations, whereas the more practice-focused programs present the widest ones. In this article, we present data suggesting that this divide is evident within doctoral programs at compre- hensive universities, especially in clinical psychology (but not counseling psychology) programs. The divide is particularly evident when comparing clinical programs at comprehensive universities versus programs at freestanding professional schools of psychology. Following the presentation of data supporting this assertion, we discuss the dangers of these divides. First, however, consider the following thought exer- cise. Imagine that you are the mentor of a talented undergraduate who is beginning the clinical psychology doctoral application process. She has a strong liberal arts preparation, with a range of psychology courses in both clinical and nonclinical areas, and good research experience. She plans a career that includes psychother- apy research and theory development, and she wants solid clinical training as well. She is compiling an initial list of programs and is particularly interested infamily systems theory and therapy. As her mentor, you consider programs withcorefaculty (those who supervise theses and dissertations, that is, excluding adjuncts, off-site practicum supervisors, faculty in departments of psychi- atry that do not offer doctoral degrees) who publish research in addition to providing clinical training. Now, repeat the exercise withhumanistic, experiential or existential theory/therapy,withpsychodynamic theory/ther- apy,and withinterpersonal theory/therapy. Having done this exercise ourselves and having mentored students like this one, we are aware of the dif culty in coming up with programs to suggest; indeed, these lists are likely to be very short. The data presented below bear out these personal observations. We undertook a systematic study of theo- retical orientations represented in clinical and counsel- ing doctoral training programs of various types, using published sources. TheInsider’s Guide to Graduate Programs in Clinical and Counseling Psychology(Sayette, Mayne, & Norcross, 2010) provided information on self-reported theoretical orientations of program faculty in six categories, that is, Psychodynamic, Behavioral, Family Systems, Cognitive Behavioral, Humanistic/ Existential, and Other; the guide allows for faculty to THEORETICAL ORIENTATIONS HEATHERINGTON ET AL.365 indicate one or more orientations. The APA’s 2010 Graduate Study in Psychology(APA, 2010) education/ accreditation web site (http://apa.org/ed/accreditation/ programs/index.aspx) and the list of member programs published by the Academy of Psychological Clinical Science (http://acadpsychclinicalscience.org/members) provided designations of various program types. As needed, Internet searches of individual programs were used to con rm their statuses as (a) Ph.D. programs at comprehensive universities, (b) Ph.D. programs at comprehensive universities that are designated as clini- cal science programs, (c) Psy.D. programs at compre- hensive university programs, and (d) Psy.D. or Ph.D. programs at freestanding, “specialized” institutions. We included programs in the 50 U.S. states and Canada. Although the APA is phasing out accreditation of Canadian programs as of 2015, our concern is not with credentialing issues, but rather with training and con- tinued development in psychotherapy theory and research, which has been and no doubt will continue to be signi cantly in uenced by Canadian psychology. For this same reason, we also included counseling psy- chology, but treated it separately, as virtually all coun- seling psychology doctoral programs are at comprehensive universities and because there are some historical and current differences between counseling and clinical psychology. Moreover, we excluded the eight APA-accredited “combined” (e.g., school/clini- cal, school/counseling) programs. Table 1 presents the mean percentages of faculty in various types of clinical psychology doctoral programs who self-report particular theoretical orientations. 2Thecomparison is striking. In the clinical science programs, fully 80% of faculty claim a cognitive-behavioral orien- tation, and 89% claim either a behavioral or cognitive- behavioral orientation, whereas small percentages of faculty claim either a psychodynamic or a humanistic/ existential orientation. Fewer than half of the faculty in Psy.D. programs at comprehensive universities and in Psy.D. or Ph.D. programs in freestanding universities claim a CBT orientation, with noticeably higher per- centages of faculty (28% and 29%, respectively) claim- ing a psychodynamic orientation. Interestingly, the least variation across programs was found in the per- centages of faculty claiming a family systems orienta- tion, close to 20% of faculty in each type of program. Table 2 presents the mean percentages of faculty in counseling psychology doctoral programs who self- report particular theoretical orientations. These data reveal a wider range of orientations, with fewer than half claiming a behavioral or cognitive-behavioral ori- entation and nearly a third claiming a humanistic/exis- tential orientation. Explanations for this variation will be advanced shortly. Some elaboration and quali cations of these data are in order. First, in theInsider’s Guide,programs could also designate faculty with “other” orientations. These data were sparse and often unique to individual pro- grams or individual faculty and thus are not included in the table, but rather summarized as follows. Of the 54 clinical science programs, only two cited one or more “other” orientations. These (and the number of pro- grams that cited them) were neuropsychology (1), community (1), interpersonal (1), motivational inter- Table 1.Therapeutic orientations of faculty in clinical psychology doctoral training programs Program Type Psychodynamic (%) Behavioral (%)Family Systems (%) Humanistic/Existential (%)Cognitive a Behavioral (%) Ph.D. programs designated as “clinical science” bprograms (n=54)7 9 17 4 80 All other Ph.D. programs at comprehensive universities (n=116)19 11 20 24 67 Psy.D. programs at comprehensive universities (n=31)28 5 16 12 48 Psy.D. and Ph.D. programs at freestanding professional schools (n=37)29 6 22 15 32 Ms 21 8 19 14 57 aSource: Sayette et al. (2010).bSource: Academy of Psychological Clinical Science (http://acadpsychclinicalscience.org/index.php?page=members). CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE V19 N4, DECEMBER 2012 366 viewing (1), child (1), and eclectic (1). Of the 116 other clinical Ph.D. programs at comprehensive univer- sities, 15 listed faculty with “other” orientations: health (1), integrative (3), community (1), clinical neuropsy- chology (3), eclectic (1), interpersonal or interpersonal/ ego relations or cognitive/interpersonal (5), develop- mental psychopathology (1), feminist (2), cognitive (1), narrative/personal construct (1). Of the 31 Psy.D. pro- grams at comprehensive universities, only one listed an “other” orientation: integrative/transtheoretical. Of the 38 programs at freestanding professional schools, four listed “other” orientations: research (1), integrative (2), cultural diversity focus (1). And of the 66 doctoral counseling programs, 13 listed “other” orientations: eclectic (1), integrative (1), interpersonal (7), feminist/ multicultural or feminist or multicultural (13), con- structivist (2), relational/process (1), narrative (1), developmental systems (2). Second, the data on orientations in theInsider’s Guidewere only available as percentages. We do not know how many actualfacultyare represented in these percentages; “20%” of faculty claiming a family systems orientation could refer to one or two individuals in smaller programs, but several individuals in programs with larger faculties. Although the APAGraduate Study guide lists numbers of faculty, it was not possible (given changing faculty sizes, variability in the recency of the data in each source) to accurately compare the data in these two sources to derive the raw numbers of faculty. Nevertheless, this issue is of obvious importance, because it speaks to the actual availability of mentors and supervisors representing particular orientations, as well as the viability of training and research from the particular theoretical orientation at any given program. Adding the percentages for each program, however, provides a rough index of the extent to which faculty at a particular program claim more than one allegiance, that is, eclectic orientations. That is, in programs atwhich each faculty member claims a single orientation, the mean percentages for each orientation total to 100%. For programs in which faculty members claim more than one orientation, the percentages total to more than 100%, with higher totals representing more faculty claiming multiple allegiances. The total percent- ages averaged across the different program types are the following: Ph.D. programs at comprehensive universi- ties,M=129%, Ph.D. programs at comprehensive universities that are designated as clinical science pro- grams,M=107%, Psy.D. programs at comprehensive university programs,M=110%, Psy.D. or Ph.D. pro- grams at the freestanding, “specialized” institutions, M=105%, and counseling psychology doctoral pro- grams,M=114%. Interestingly, the modal and median percentage totals were the same (each 100%) for every program type. SO WHAT? IMPLICATIONS FOR TRAINING, RESEARCH, THEORY, AND PRACTICE The data revealed two major divisions: between the types of theoretical orientations in which current stu- dents/future clinical psychologists are being trained and between the theoretical orientations predominant in the more research-focused and more practice-focused programs. These divides are potentially dangerous for the eld and the future development of psychotherapy theory and research. It should be noted as well that the data revealed a third divide, between clinical and counseling psychol- ogy programs, which is noteworthy in that it provides some context for the current concern. The broader theoretical focus in counseling psychology can be explained by differences in its history and training phi- losophies. Although counseling psychology training programs have required curricula and training experi- ences that are similar to those of clinical psychology programs, counseling psychology has different roots in Table 2.Therapeutic orientations of faculty in counseling psychology doctoral training programs Psychodynamic (%)Behavioral (%)Family Systems (%)Humanistic/ Existential (%)Cognitive a Behavioral (%) Ph.D. programs at comprehensive universities (n=67)19 1 18 31 42 aSource: Sayette et al. (2010). THEORETICAL ORIENTATIONS HEATHERINGTON ET AL.367 group career counseling, vocational rehabilitation of WWII veterans (Gelso & Fretz, 1992), and counseling of “normal” individuals with developmental dif culties or life problems (Friedlander, Pieterse, & Lambert, 2012). This history dovetails with the fact that the pre- dominant training model in counseling psychology for the last 45 years has focused on relationship-oriented and microcounseling skills (Egan, 2007; Hill, 2004; Ivey & Ivey, 2007; Ridley, Kelly, & Mollen, 2011). In practicum training, the preferred supervision approach is to foster trainees’ experience with a range of theoret- ical approaches, always being guided by clients’ indi- vidual problems and needs. Most counseling psychology programs do not hire faculty members based on theoretical orientation; rather, the prevailing preference seems to be a faculty that represents a broad range of approaches. Further, re ecting the de-empha- sis on the medical model (matching treatment to diag- nosis) and the preferred emphasis on relationship skills and common factors, counseling psychology researchers have traditionally focused more on explicating thera- peutic change factors than on comparing client out- comes by treatment approach. Indeed, some of the historically most in uential lines of psychotherapy pro- cess research were conducted by counseling psycholo- gists, for example, Edward Bordin, Charles Gelso, Leslie Greenberg, Adam Horvath, Clara Hill, Laura Rice, and Stanley Strong. Returning to the two major divides, regarding the rst, we would argue that the increasing dominance of CBT, while derived in part from the early body of research (Chambless et al., 1996) examining and sup- porting its ef cacy, is not optimal for the continued development of psychotherapy speci cally, and clinical psychology more generally. In particular, we suggest that it is highly limiting to have the eld dominated by anysingle theory of change. If CBT were the only effective treatment, this would not be problematic. But converging evidence indicates that CBT isnotin fact the only effective treatment, as demonstrated by the Dodo verdict; the fact that, typically, only a small per- centage of outcome variance is accounted for by treat- ment approach (Wampold, 2001); the demonstration of therapist effects and especially (as discussed shortly) the currentresearch evidence that a number of treatments from other theoretical approaches are also ef cacious,especially for the treatment for depression (APA Task Force on Psychological Interventions’ 2012 list, http:// www.div12.org/PsychologicalTreatments/disor- ders.html). We suggest that an impartial reading of the psychotherapy ef cacy literature would not inevitably lead to such a narrow focus on a single theoretical ori- entation. We also suggest that such a narrow focus is very unlikely to encourage and facilitate the research that is sorely needed on other treatment orientations. The evolution of theory, research, and practice requires a diversity of ideas and perspectives, and, as Pauling noted, “lots” of them. Indeed, our current major theoretical perspectives evolved from a combina- tion of mutually enriching, sometimes competing, per- spectives. For CBT, these have included behavioral, psychodynamic, personal construct, social learning, and other perspectives. Messer (2004), in a discussion of “assimilative integration” (i.e., incorporation of tech- niques from other types of treatment into one’s “home” therapy), cited Keane and Barlow’s (2002) observation that Freud and Janet most in uenced the use of exposure and anxiety management—now con- sidered central features of CBT—in the treatment for PTSD. More recently, we have seen the experiential tradition in uencing the evolution of CBT in its new emphasis on affective experience, and the meditative tradition helping to shape Dialectical Behavior Therapy (Linehan,1993) and variations of cognitive-behavioral treatments for generalized anxiety disorder (Roemer, Erisman, & Orsillo, 2008). Additionally, integrative approaches to treating addictions and associated mental health issues, such as motivational interviewing, draw heavily on the client-centered model of therapeutic practice (Angus & Kagan, 2009). Why is the current dominance of a single theoretical perspective potentially problematic? A generation of students trained to think from only one perspective will become theorists, teachers, researchers, and practitio- ners whose creativity, intellectual exibility, and ability to create new treatments for changing times, troubles, and client populations are likely to be diminished. Further, a generation of students trained (implicitly or explicitly) totrustin only one perspective will become a generation that is less willing to be open to different ideas and most importantly, less able to meet the emerging mental health needs of the future. CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE V19 N4, DECEMBER 2012 368 John Stuart Mill, a strong advocate of empirical methods in scienti c procedure in the 19th century and a philosophical progenitor of behaviorism, argued that a plurality of views is needed in science (Cohen, 1961). Mill’s reasons are as appropriate for training in clinical and counseling psychology as they are for sci- enti c advancement, including the fact that a problem- atic view may contain some portion of the truth. Moreover, as the prevailing view is never the whole truth, it is only by collision with contrary opinions that the remainder of the truth has a chance of being recog- nized. One point of view that is wholly true, but not subjected to challenge, will be held as a prejudice rather than derived from a rational basis, and someone holding a particular point of view without considering alternative perspectives will not really understand the meaning of the view he or she holds. Citing Mill and framing this argument in a positive form, Safran and Messer (1997) argued that science and practice ourish in an atmosphere of confronting and discussing differ- ence, noting that “to the extent that confronting alter- nate therapeutic paradigms and techniques ips us into a ‘world-revising mode’…there is the possibility of its leading to a dialogue which can truly deepen our understanding of the human change process” (1997, p. 142). In the clinical realm as well, there are atten- dant implications for the ways in which we think philosophically about human nature and human change. It has been argued that exposing psychology students to different theories and visions of reality (Messer & Winokur, 1984) enriches their understand- ing of clients and ways to treat them, including the possibility of shifting from one perspective to another, thereby encompassing more of the complexity of human behavior (Messer, 2006). Paradoxically, having both understanding of and competence with two or more treatment orientations may help clinicians use particular treatment protocols with greater delity, when that is their goal. There is mounting evidence that the actual therapeutic interventions of clinicians who believe they are follow- ing manualized treatment protocols often do not accu- rately re ect the core treatment principles of that approach (Shoham, 2011). A proposed remedy, training students to understand the difference between going “off-manual” versus practicing “ exibility within delity” (Kendall, Gosch, Furr, & Sood, 2008; Sho- ham, 2011), requires a deep understanding of what is and what is not a prototypical intervention in the approach at hand. And the latter, we suggest, is facili- tated by knowing more than one therapeutic approach well because the distinguishing features between cate- gories of interventions help de ne them. For example, students who truly understand interpretation but who are following a CBT protocol and attempting to frame cognitive restructuring interventions will be more likely to do so with integrity because they understand the differences between these similar yet distinct con- structs at a core level. Finally, we are concerned that the trend shown in these data is likely to beget more of the same over time. The programs most likely to produce our future academic clinical psychologists—comprehensive Ph.D. programs, perhaps especially those designated as clinical science programs—are the ones with the narrowest range of orientations. Not only will this trend limit the vision and sources of ideas for current students, but also theirstudents will be even less likely to have professors and clinical supervisors who represent other orienta- tions, and consequently less likely to have research mentors who are engaged in serious research on psy- chotherapy from other orientations. We hasten to note that there is no implied criticism here of the core emphasis of clinical science training programs on the need for data regarding the development and validation of treatment approaches. In fact, one of our goals in this commentary is to emphasize and support the asser- tion that any treatment model worth learning must have compelling data that support its ef cacy and effec- tiveness (and in fact, as noted earlier, a range of treat- ment approaches do). Rather, the concern is that we may inadvertently be training a generation of students who equate a particular orientation with “good sci- ence” and, by implication, other orientations for which compelling data in fact exist, with “bad science” or “no science.” Finally, inasmuch as the growth and development of treatments is facilitated by ongoing exchanges between researchers and practicing clinicians, these divides are dangerous. There is currently considerable distance between the kinds of treatments that practitioners know and use, on the one hand, and the type of THEORETICAL ORIENTATIONS HEATHERINGTON ET AL.369 treatment that has come to dominate the research- based treatment development landscape, that is, CBT, on the other. A 2008 APA survey of 5,051 certi ed Psychology Health Service Providers in the United States revealed the following “primary theoretical orientations,” in descending order: cognitive behavioral (38.9%), psychodynamic/psychoanalytic (15.6%), inte- grative (14.6%), “other,” which was primarily “eclec- tic” (6.1%), cognitive (5.1%), humanistic/existential (4.1%), behavioral (2.9%), systems (2.8%), and less than 2% each of biological, developmental, and family (APA, 2008, http://www.apa.org/workforce/publications/ 08-hsp/index.aspx). Yet, feedback about the clinical realities of imple- menting treatments as well as (ideally) the input of practitioners into treatment development at early stages is critical. A laudable collaborative project between APA’s Division 12 (Clinical Psychology) and Division 29 (Psychotherapy) solicited clinicians’ feedback about their experiences using various cognitive-behavioral approaches for social phobia, generalized anxiety disor- der, and panic (Goldfried, 2010, 2011). This kind of exchange advances inte

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