OFFICIAL PUBLICATION OF THE SOCIETY FOR...

BULLETIN

PsychotherapyO F F I C I A L P U B L I C A T I O N O F T H E S O C I E T YFOR THE ADVANCEMENT OF PSYCHOTHERAPYOF THE AMERICAN PSYCHOLOGICAL ASSOCIATION

www.societyforpsychotherapy.org

2016 VOLUME 51, NUMBER 3

In This Issue

Special FeatureGuidelines for Clinical Supervision in Health Service Psychology: Evidence and Implementation Strategies

Psychotherapy ResearchReplication and Open Science:

Tools for Progress in Psychotherapy Research

Education and TrainingDeliberate Practice for Early Career Psychotherapists

Psychotherapy PracticeWhat Do Psychotherapists Want?

EthicsToward Mandatory Reporting of Animal Abuse

Clinical Notes With Dr. J#BlackLivesMatter in Psychotherapy

Diversity and Social JusticePsychotherapy and Homelessness

Student FeatureExpanding Horizons: A Look at the Therapeutic Alliance

Through a Social Psychological Lens

PresidentArmand Cerbone, PhD 3625 N Paulina St Chicago, IL 60613Ofc: 773-755-0833 | Fax: 773-755-0834E-mail: [email protected]

President-electJeffrey Zimmerman, PhD 391 Highland Ave.Cheshire, CT 06410Phone: 203-271-1990333 Westchester Ave., Suite E-102White Plains, NY 10604Ofc: 914-595-4040E-mail: [email protected]

Secretary Barry Farber, PhD, 2015-2017Dept of Counslg & Clinical Psychology Columbia University Teachers College525 W 120th St New York, NY 10027Ofc: 212-678-3125 | Fax: 212-678-8235E-mail: [email protected]

TreasurerJesse J. Owen, PhD, 2016-2018University of Denver, Morgridge College of EducationCounseling Psychology Department1999 E Evans Ave Denver CO 80208Ofc: 303-871-2482E-mail: [email protected]

Past PresidentRodney K. Goodyear, PhDSchool of EducationUniversity of RedlandsRedlands, CA 92373-0999Ofc: 909-748-8800E-mail: [email protected]

Domain RepresentativesPublic Interest and Social Justice Rosemary Adam-Terem, PhD, 2015-20171833 Kalakaua Avenue, Suite 800Honolulu, HI 96815Ofc: 808-955-7372 | Fax: 808-981-9282E-mail: [email protected] PracticeBarbara Thompson, PhD, 2016-20183355 St. Johns Lane, Suite F.Ellicott City, MD 21042Ofc: 443-629-3761E-mail: [email protected] and TrainingJennifer Callahan, PhD, 2016-2018UNT Department of PsychologyTerrill Hall, Room 3761155 Union Circle #311280Denton, TX 76203-5017Ofc: 940-369-8229E-mail: [email protected] Birbilis, PhD, 2016-2018University of St. Thomas1000 LaSalle Ave., MOH 217Minneapolis, Minnesota 55403Ofc: 651-962-4654 | Fax: 651-962-4651E-mail: [email protected] CareerRayna D. Markin, PhD, 2014-2016 Department of Education and Counseling302 Saint Augustine Center800 Lancaster AveVillanova, PA 19075E-mail: [email protected]: 610-519-3078Science and ScholarshipSusan S. Woodhouse, PhD, 2014-2016Department of Education and Human ServicesLehigh University111 Research DriveBethlehem, PA 18015Ofc: 610-758-3269 | Fax: 610-758-3227E-mail: [email protected]

DiversityJairo Fuertes, PhD, 2014-2016Derner Inst. of Advanced Psychological StudiesAdelphi University Hy Weinberg Ctr Rm 319158 Cambridge Ave.Garden City, NY 11530Ofc: 516-877-4829E-mail: [email protected] Greene, PhD, 2016-2018Psychology, St. Johns University8000 Utopia Pkwy.Jamaica, NY 11439Ofc:718-638-6451E-mail: [email protected] AffairsFrederick Leong, Ph.D. (2016-2017)Michigan State UniversityDepartment of PsychologyEast Lansing, MI 48824Phone: 517-353-9925; Fax: 517-353-1652E-mail: [email protected] Council RepresentativesJohn C. Norcross, PhD, 2014-2016Dept of Psychology University of Scranton Scranton, PA 18510-4596 Ofc: 570-941-7638 | Fax: 570-941-2463E-mail: [email protected] Jean Carter, PhD, 2014-2016Washington Psychological Ctr PC 5225 Wisconsin Ave NW #513 Washington, DC 20015 Phone: 202-244-3505 x3 | Fax: 202-364-0561E-mail: [email protected]

Student Development ChairMaria Lauer, 2015-2016101 Race St. Apt 111Catasauqua, PA 18032Phone: 302-743-2578E-mail: [email protected]

Continuing EducationTony Rousmaniere, PsyDStudent Health and Counseling CenterUniversity of Alaska, Fairbanks612 N. Chandalar Drive, PO Box 755580Fairbanks, AK 99775-5580Phone: (907) 474-7043E-mail: [email protected]: Astrea Greig, PsyDBoston Healthcare for the Homeless Program780 Albany St, Rm 3107Boston MA 02118 Ofc: 857-654-1324E-mail: [email protected] Career PsychologistsChair: Kevin McCarthy, PhDDept. of Psychology / Chestnut Hill CollegeSt. Joseph’s Hall 4529601 Germantown AvenuePhiladelphia, PA 19118Ofc: 215 248-7115E-mail: [email protected] & TrainingStewart Cooper, PhDCounseling Services / Valparaiso University1602 LaPorte AvenueValparaiso, IN 46383Ofc: 219-464-5002 | Fax: 219-464-6865E-mail: [email protected]

FellowsChair: Robert L. Hatcher, PhDWellness Center / Graduate CenterCity University of New York365 Fifth AvenueNew York, NY 10016Ofc: 212-817-7029E-mail: [email protected]: Arnold Holzman, PhDBehavioral Health Consultants3018 Dixwell AvenueHamden, CT 06518Ofc: 203-288-3554 x12 | Fax: 203-281-0235E-mail: [email protected] Judge, PhD49 Old Solomon’s Island Road, Suite 200 Annapolis, MD 21401 (410) 266-8555 (answering service) E-mail: [email protected] and ElectionsChair: Jeffrey Zimmerman, PhDE-mail: [email protected]

Professional AwardsChair: Rodney K. Goodyear, PhDE-mail: [email protected]

ProgramChair: Changming Duan, PhDDept. of Psychology & Research in EducationUniversity of KansasLawrence, KS 66054Ofc:785 864-2426 | Fax 785 864-3820E-mail: [email protected] Psychotherapy PracticeChair: Barbara Vivino, PhD921 The Alameda #109Berkeley, CA 94707Ofc: 510-303-6650E-mail: [email protected] ResearchChair: Joshua Swift, PhDDepartment of PsychologyUniversity of Alaska Anchorage3211 Providence Drive, SSB214Anchorage, Alaska 99508 Phone: 907-786-1726E-mail: [email protected] JusticeChair: Hiroshi M. Sasaki, PhDPsychology Dept. / University of the West1409 N. Walnut Grove Ave.Rosemead, CA 91770Phone: 562-756-6211E-mail: [email protected]

Society for the Advancement of Psychotherapy n 2016 Governance StructureELECTED BOARD MEMBERS

STANDING COMMITTEES

PSYCHOTHERAPY BULLETIN

Published by theSOCIETY FOR

THE ADVANCEmENT OF PSYCHOTHERAPY

American Psychological Association

6557 E. RiverdaleMesa, AZ 85215

602-363-9211e-mail: [email protected]

EDITORLynett Henderson Metzger, [email protected]

ASSOCIATE EDITORIan Goncher, Ph.D.

[email protected]

CONTRIBUTING EDITORS

DiversityBeverly Greene, Ph.D., and

Jairo Fuertes, Ph.D.

Education and TrainingJesse J. Owen, Ph.D., and Jennifer Callahan, Ph.D.

Ethics in PsychotherapyJennifer A.E. Cornish, Ph.D.

Psychotherapy PracticeBarbara Thompson, Ph.D., and

Barbara Vivino, Ph.D.

Psychotherapy Research, Science and Scholarship

Susan Woodhouse, Ph.D., andJoshua Swift, Ph.D.

Public Policy and Social JusticeArmand Cerbone, Ph.D., and

Rosemary Adam-Terem, Ph.D.

Washington ScenePatrick DeLeon, Ph.D.

Early Career Rayna Markin, Ph.D., and

Kevin McCarthy, Ph.D.

Student FeaturesMaria Lauer

Editorial AssistantsKrystine Jackson, M.A.

Elizabeth Coyle, MA, LPC

STAFF

Central Office AdministratorTracey Martin

Websitewww.societyforpsychotherapy.org

PSYCHOTHERAPY BULLETINOfficial Publication of the Society for the Advancement ofPsychotherapy of the American Psychological Association

2016 Volume 51, Number 3

CONTENTS

President’s Column ......................................................2A New International Partnership

Editors’ Column ............................................................5

Special Feature ..............................................................6Guidelines for Clinical Supervision in Health Service Psychology: Evidence and Implementation Strategies

Psychotherapy Research ............................................19Replication and Open Science: Tools for Progress in Psychotherapy Research

Education and Training ..............................................25Deliberate Practice for Early Career Psychotherapists

Psychotherapy PracticeWhat Do Psychotherapists Want? ............................30

Meditation and the Mindfulness Trend in ................34 Psychotherapy: Reflections Through the Prism of a 50-Year Meditator

International Affairs ....................................................44International Affairs Update

Ethics ............................................................................46Toward Mandatory Reporting of Animal Abuse

Clinical Notes With Dr. J ............................................49#BlackLivesMatter in Psychotherapy

Diversity and Social Justice ........................................53Psychotherapy and Homelessness

Student Feature ............................................................55Expanding Horizons: A Look at the Therapeutic Alliance Through a Social Psychological Lens

Washington Scene........................................................58Fly Down the Highway

References ....................................................................68

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PRESIDENT’S COLUmN

A New International Partnership

Armand R. Cerbone, PhD, ABPPChicago, IL

By far the most significantand far-reaching achieve-ment since I wrote threemonths ago has been thepact made between Ori-ental Insight (OI) and ourSociety for the Advance-

ment of Psychotherapy (SAP). OI is an or-ganization of Chinese psychologists whowish to partner with us for mutual bene-fit. The partnership aims:

• To increase exchange between SAPand OI as organizations that pro-mote psychotherapy in the UnitedStates and in China;

• To facilitate dissemination and en-richment of psychotherapy researchacross language and national bound-aries in the United States and China;

• To promote collaborations in re-search and training among SAPmembers and Chinese researchersand practitioners in the field ofcounseling and psychotherapy inChina;

• To facilitate the recruitment in Chinaof SAP non-APA affiliate membersand APA affiliates who might wantto join SAP, and to enable SAP toprovide them some of the memberresources afforded by having trans-lated materials.

The agreement was formally signedduring the APA annual convention inDenver in August (see photo, p. 3). Dr.Guangrong Jiang, founder of OI, whowas accompanied by a colleague, Dr.Chin, signed for OI and I signed as Pres-ident for SAP. Perhaps the significancefor SAP and APA’s international agendacan best be conveyed by the list of dis-

tinguished APA dignitaries who spokeat the signing: APA Past-President Dr.Barry Anton; Dr. Jean Lau Chin, Presi-dent of Division 52 (International Psy-chology); and Dr. Merry Bullock, Directorof the APA Office for International Af-fairs. Former APA President Dr. Phil Zim-bardo also attended. SAP Past-PresidentDr. Rod Goodyear moderated the cere-mony. Before the signing, both Drs. Jiangand Chin addressed the attendees aboutthe mission and work of OI and theirhopes for our collaborations.

Dr. Changming Duan, Chair of our newInternational Committee and Past-Pres-ident Goodyear spearheaded the initia-tive over several years, establishingrelationships with our Chinese col-leagues and educating our Board of Di-rectors to the importance of thispartnership to SAP. Dr. Fred Leong, ournew Representative of the Domain forInternational Affairs, also provided crit-ical leadership in developing the rela-tionships (and has written in this issue’sInternational Affairs Column regardingthe partnership agreement and upcom-ing plans for the Domain). We are grate-ful to them for bringing this to fruition.

ConventionI am pleased to tell you that our con-vention program was a solid success.The Society’s theme, the intersections ofscience, sexuality, and psychotherapy,afforded many opportunities for the sci-entists and practitioners among us tooffer evidence-based and skill-buildingsymposia. Other presentations spanneda range of topics including publishing,supervision, diversity, theory, and even

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a session on comedy as a basis for diffi-cult dialogues. Ten of the programs car-ried a total of 13 CE credits. Feedbackfrom presenters indicates our programswere well attended and positively re-ceived.

Anyone who has ever volunteered to beProgram Chair understands the monthsof untold hours spent collaborating, re-viewing, and negotiating with other di-visions, the Convention Office, and withthe current division president from thefirst call for programs to final approvalof a convention program. The task is ar-duous and complicated in the extreme.We owe our Program Chair, Dr. Duan,and her Associate Chair, Dr. Gary How-ell, our respectful and appreciativethanks. Gary will continue as the 2017and 2108 Program Chair. President-electJeff Zimmerman is already busy plan-ning the theme for next year’s programin Washington, DC.

more on the International FrontIn June several of our Board membersattended the 32nd annual conference of the Society for the Exploration ofPsychotherapy Integration (SEPI) inDublin, Ireland. Dr. John Norcross, oneof our representatives to the APA Coun-cil of Representatives, presented oncommon factors in psychotherapy. Forthose of you unfamiliar with it, SEPI isan organization that brings psychother-apists and researchers together “to pro-

mote the development of psycho -therapies that integrate theoreticalorientations, clinical practices, anddiverse methods of inquiry.” SAPhas a longstanding relationshipwith SEPI; former SAP PresidentDr. Marvin Goldfried is one itsfounders. At this conference SAPsponsored the Continuing Educa-tion credit program. [Editor’sNote: Next year’s SEPI conferencewill be in Denver, Colorado. Pleaseconsider joining us.]

In July 2017, leading SAP researchersand Board members will attend andpresent at the 8th World Congress onPsychotherapy in Paris. The theme isLife and Love in the 21st Century.

In development is a conference on psy-chotherapy training and supervisionwith Oriental Insight in Wuhan, China,in or around April 2017.

Getting to Know Your Board membersI thought you might be interested inknowing the Editor of our lead journal,Psychotherapy, mark Hilsenroth, PhD,ABPP, and the Editor of our quarterlynewsletter, Psychotherapy Bulletin, LynettHenderson metzger, PsyD, JD.

As Editor, Mark is a key member of ourPublications Board, chaired by formerDivision 29 President Jeff Barnett. Priorto assuming the editorship of Psy-chotherapy, Mark served on the editorialboards of Psychotherapy Research, Journalof Personality Assessment, and the Journalof the American Psychoanalytic Association.

Mark graduated from the University ofTennessee’s Clinical Psychology PhDprogram in 1996 and completed hisClinical Internship at The CambridgeHospital/Harvard Medical School.When not editing the journal, Mark is a

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Photo courtesy of Chun-Chung (Chung)

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Professor of Psychology at the DernerInstitute of Advanced PsychologicalStudies at Adelphi University. There heserves as Primary Investigator of theAdelphi University Psychotherapy Proj-ect. His research interests are primarilyfocused on applied clinical issues, withover 150 peer-reviewed journal publica-tions in the areas of psychological as-sessment & psychotherapy.

Lynett Henderson metzger, JD, PsyD,earned her Juris Doctor from the University of Denver’s Sturm College of Law in 1997 and her Doctorate inClinical Psychology from DU’s Gradu-ate School of Professional Psychology in2003, where she is currently a ClinicalAssociate Professor and Assistant Direc-tor of Forensic Studies. She draws on herbackground in law and mental health toteach a variety of courses in the Foren-sic Psychology, International DisasterPsychology, and Clinical Psychologyprograms. Her areas of interest includeprofessional education and training, diversity and social justice, and victimadvocacy.

Together Lynett and Mark are keepingour premier publications relevant andthe scholarship in them outstanding andmake them a major benefit of member-ship in the Society. They deserve ourcontinuing support and thanks.

A Final AnnouncementDr. Jean Carter, one of our two CouncilRepresentatives has been elected APA

treasurer. She will assume the office inJanuary 2017.

Jean has provided strong and significantleadership in SAP. As President of ourDivision, she led the drive to add seatsto the Board to create more opportuni-ties for members to participate in gover-nance. During her presidency wechanged the structure of the Board frommember-at-large seats to domains thatexpand opportunities to promote themission of the Division. It goes withoutsaying that we will miss her presence,though we know she will take to theAPA Board of Directors the same com-mitment to advancing psychotherapythat so informed her years with us.

We will be welcoming back to the Boardformer President Libby Nutt Williamswho will step into Jean’s position asCouncil Representative for the remain-der of Dr. Carter’s term.

Finally, Dr. Stewart Cooper, currentChair of the Education & Training Com-mittee, has been elected to the APABoard of Directors. He, too, will be leav-ing us to assume his new responsibilitiesin January.

We are fortunate to have working for uscapable and dedicated professionalswho give so much and so competentlyto SAP over the years. And we remaincommitted to fostering new leadershipequally capable of leading us into thenext decades.

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As summer winds to aclose, we look back onthe past few months asexciting and busy onesfor the Society for theAdvancement of Psy-chotherapy (SAP) aswhole, as well as per-sonally for many ofour members. It waswonderful to see somany of you at theAPA Convention inDenver, and we hope

that those of you who were able to at-tend have fond memories of the eventand one another (and please take a lookat the photos in the back of this issue).

Also in this issue of Psychotherapy Bul-letin, Dr. Armand Cerbone reflects on theConvention in his President’s Column,as do Drs. Fred Leong and ChangmingDuan in their International Affairs Up-date. Our Special Feature, “Guidelinesfor Clinical Supervision in Health Serv-ice Psychology: Evidence and Imple-mentation Strategies,” is sure to be ofinterest, as will articles on replication inpsychotherapy research, “mindfulness”in psychotherapy, a student piece onlooking at the therapeutic alliancethrough a social psychology framework,and many others. Our Early Careerreaders will definitely want to read the Education and Training selection,

“Deliberate Practice for Early CareerPsychotherapists,” and members willfind the 2017 Nominations Ballot in thisissue, along with other information re-lated to important SAP business mat-ters. As always, we invite everyone tovisit the Society’s website(http://societyforpsychotherapy.org/)for this issue’s web-exclusive content.

Finally, along with the changing of theseason come changes to the Bulletin. TheEditors would like to thank Lisa WallnerSamstag, PhD, for her extraordinarywork assisting with book reviews for theBulletin, and welcome our new BookReview Editor, Tiffany Garner, PsyD.Our next deadline is November 1, 2016,and we would love to hear from youwith feedback or ideas for articles orwebsite content. You can find the Bul-letin submission guidelines in the backof this volume or online.

Have a terrific autumn!

Lynett Henderson Metzger, JD, PsyDPsychotherapy Bulletin Editoremail:[email protected]: (303) 871-4684

Ian Goncher, PsyDPsychotherapy Bulletin Associate Editor email: [email protected]: (814) 244-4486

Lynett Henderson Metzger, PsyD, JDUniversity of Denver-Graduate School of Professional Psychology

Ian Goncher, PsyDPediatric Care Specialists Division of Behavioral Health ServicesJohnstown, PA

EDITORS’ COLUmN

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Counseling psychology has demon-strated a long-standing interest and re-spect for clinical supervision as a uniquedomain that warrants its own prepara-tion for practice. Counseling psycholo-gists have distinguished themselves inthe supervision literature (e.g., Borderset al., 1991; Goodyear et al., 2000), andcounseling psychology programs havebeen much more likely than clinical andschool psychology programs to offer su-pervision coursework (Crook-Lyon,Presnell, Silva, Suyama, & Stickney,2011; Romans, Boswell, Carlozzi & Fer-guson, 1995). But other health servicepsychology specialties now have begun

to embrace the notion that supervisionrequires specific preparation. This hasbeen reflected in—and further encour-aged by—several important develop-ments in the field. Among these havebeen (a) the 1996 adoption of the ac-creditation Guidelines and Principles(American Psychological Association[APA], 1996) that required training pro-grams to provide students and internswith at least some training in supervi-sion, (b) the identification of supervisionas one of the eight core competency do-mains (Kaslow et al., 2004) and then (c)an expert panel’s articulation of super-

SPECIAL FEATURE

Guidelines for Clinical Supervision in Health Service Psychology: Evidence and Implementation Strategies

Carol A. Falender, PhDPepperdine University, Los Angeles

Catherine Grus, PhDAmerican Psychological Association

Stephen McCutcheon, PhDVeterans Affairs Puget Sound Healthcare System, Seattle

Rodney K. Goodyear, PhDUniversity of Redlands

Michael V. Ellis, PhDDepartment of Educational and Counseling Psychology,University at Albany

Beth Doll, PhDUniversity of Nebraska, Lincoln

Marie Miville, PhDTeachers College, Columbia University

Celiane Rey-Casserly, PhD, ABPPBoston Children’s Hospital

Nadine J. Kaslow, PhD, ABPPEmory University School of Medicine

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vision competencies (Falender et al.,2004). Perhaps as a result of this growing attention to the quality of su-pervision, we now have increasing doc-umentation of the alarming extent towhich supervisees in training programsand practice settings report supervisionis either inadequate or harmful (e.g.,Ellis et al., 2014).

Supervision guidelines spelling out bestpractices and expected competencies arean important means by which the fieldcan increase the quality of supervisionpractice. As a result, counseling psy-chology developed best practices (Bor-ders et al., 2014) and other disciplines(e.g., National Association of SocialWorkers and Association of Social WorkBoards, 2013; National Association ofSchool Psychologists, 2011) have devel-oped guidelines, as have psychologistsin other countries (e.g., New ZealandPsychology Board, 2010; PsychologyBoard of Australia, 2013). APA’s Boardof Educational Affairs, in recognizingthat need, convened a task group to de-velop supervision guidelines that APAthen adopted in 2014 (see APA, 2014,2015). This paper provides an importantsupplement to those guidelines. It ad-dresses the conceptual and empiricalgrounding for those guidelines, then re-views the guidelines and makes sugges-tions based on the empirical literaturefor ways psychologists can use them toimprove supervisory practice. In sup-port of that latter purpose, we present achecklist for psychologists to use to self-assess their supervision competencies.

Conceptual and Empirical Basis for the GuidelinesPerhaps understandably, psychologists’attitudes about the value of supervisiontraining have been influenced by theirown experiences. For example, those whohave received clinical supervision train-ing are more likely to affirm the impor-tance of that training (Genuchi, Rings,

Germek, & Cornish, 2015; Rings,Genuchi, Hall, Angelo, & Cornish, 2009).This finding suggests that policies requir-ing formal training of psychologists whosupervise result not only in better-pre-pared supervisors, but also may increasethe value attached to training and en-dorsement of the importance of that training.

Unfortunately, although APA accrediteddoctoral and internship programs havebeen required to provide supervisiontraining, the extent and quality of thattraining has remained variable. Lyon,Heppler, Leavitt and Fisher (2008), for ex-ample, found that only 39% of interns(26% of clinical and 73% of counselingpsychology interns) reported havingcompleted a graduate course in supervi-sion. Forty-four percent of these respon-dents reported having supervised atrainee during their internship, generallyat counseling centers, but only half ofthose had completed a graduate coursein supervision. In a related study (Crook-Lyon et al., 2011), counseling psychologytrainees also reported having receivedmore supervision training than clinicalpsychology trainees. Even so, traineesjudged the major influence on supervi-sion practice to have been the personalexperience of having been supervised.

Evidence to support the importance ofdeliberately preparing competent su-pervisors has been mounting. Ellis andcolleagues (2014) identified supervisionthat was either inadequate (e.g., failureto meet minimum standards for adequate supervision), or, worse, emo-tionally or physically harmful to the su-pervisee (e.g., pathologizing trainees,physically threatening trainees, or mak-ing sexual overtures to trainees). Acrosstwo studies with large samples, Ellis andcolleagues (2014; Ellis, Creaner, Hut-man, & Timulak, 2015) found that 35%and 25% of supervisees, respectively,

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were currently receiving emotionally orphysically harmful supervision. Re-markably, 93% of the participants in onestudy and 75% of the participants in theother reported currently receiving inad-equate supervision, including supervi-sors’ failure to monitor the supervisee’sclinical work (potentially affecting clientwelfare) or to use a supervision contract.

Other evidence for inadequate or harm-ful supervision can be found in studiesdescribing supervision that was multi-culturally insensitive (e.g., Burkard,Knox, Hess, & Schultz, 2009; Singh &Chun, 2010), lacked systematic assess-ment (Swift et al., 2014), discounted thesupervisory relationship (Ladany, 2014),or modeled unethical behavior (January,Meyerson, Reddy, Docherty, & Klonoff,2014). The risk of harm is magnified bythe supervisor’s power to evaluate andserve as a gatekeeper for the profession.In fact, supervisor difficulties perform-ing evaluations and gatekeeping func-tions (Ladany, 2014; Forrest et al., 2013)lent urgency within the field to defineguidelines for supervisors in healthservice psychology.

In 2002, the Competency Conferenceidentified supervision as a distinct pro-fessional competency for counseling,clinical, and school psychologists(Kaslow et al., 2004). Subsequently, aworkgroup of supervision experts fromcounseling and clinical psychology pro-vided a preliminary structure of compe-tencies that supervisors should achieve,prior to commencement of supervision(Falender et al., 2004). In 2012, the Amer-ican Psychological Association’s Boardof Educational Affairs authorized theformation of a task force, with membersfrom clinical, counseling, and schoolpsychology, charged with writing guide-lines for clinical supervision. The workwas informed by counseling psychologyand international guidelines (APA,2015). In 2014, the Guidelines for Clinical

Supervision of Health Service Psychologistswere approved by the APA as policy(APA, 2014) and were published in theAmerican Psychologist (APA, 2015). Theseguidelines are distinctive in their use ofa competency-based approach, ratherthan a particular (psychotherapy) theo-retical approach, and in their applicabil-ity to a wide range of training andsupervision of health service psycholo-gists (e.g., psychotherapy, assessment,and consultation services).

The guidelines defined competency-based supervision as “a meta-theoreticalapproach that explicitly identifies theknowledge, skills and attitudes thatcomprise clinical competencies, informslearning strategies and evaluation pro-cedures, and meets criterion-referencedcompetence standards consistent withevidence-based practices (regulations),and the local/cultural clinical setting(adapted from Falender & Shafranske,2007)” (APA, 2014, p. 5). The guidelinesare predicated on a number of assump-tions about supervision, listed in Table 1below. The stated objective was that theguidelines would enhance the quality ofsupervision provided by psychologists,promote the development of superviseecompetence, and assure regulators thathigh quality supervision is valued andprovided.

The guidelines address seven domains:supervisor competence; diversity; thesupervisory relationship; professional-ism; assessment/evaluation/feedback;problems of professional competence;and ethical, legal, and regulatory con-siderations. This paper provides thebridge to implementation: empiricalsupport and implementation strategiesthat will assist trainers and practitionersto apply the APA guidelines in clinicalsettings. Organized by domain (APA,2015), the paper provides a brief sum-

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mary of empirical support for each, andrecommendations for implementation. Italso introduces a supervisor self-assess-ment (Appendix, below) that was de-veloped from the guidelines, focused onsupervisors’ knowledge, skills, and atti-tudes. The self-assessment was designedto provide a structure for individualsand programs to assess and design ap-propriate training strategies, identifyareas of supervision strength that couldbe built upon, and provide a window onmetacompetence (referring here toadopting a reflective approach to whatone knows and what one does notknow—a difficult task and one that is es-sential to model to supervisees) (Falen-der & Shafranske, 2007).

The Supervision Guidelines

Domain A. Supervisor Competence• Supervisors seek to attain and main-

tain competence in the practice ofsupervision through formal educa-tion and training.

• Supervisors endeavor to coordinatewith other professionals responsiblefor the supervisee’s education andtraining to ensure communicationand coordination of goals and expectations.

• Supervisors strive for diversity com-petence across populations and set-tings (as defined in APA, 2003).

• Supervisors using technology in su-pervision (including distance super-vision), or when supervising carethat incorporates technology, striveto be competent regarding its use.

Empirical support. Empirical studies(Callahan, Almstrong, Swift, Borja, &Heath, 2009; Wrape, Callahan, Ruggero,& Watkins, 2015) have supported theimpact of supervisor competence on su-pervisees and client outcomes. How-ever, absent an agreed upon definition(Gonsalvez & Calvert, 2014), supervisorcompetence has not been addressed as

an integrated competency, but rather asvarious separate fragmented competen-cies, such as psychotherapy theory (i.e.,Watkins, 2014), ethics (Barnett & Mol-zon, 2014), and multicultural compe-tence (Falender & Shafranske, 2007)with primary focus on knowledge andskills. Supervisor competence is an arearequiring additional empirical study.

Implementation strategies. Supervisor self-assessment using the Supervisor Com-petency Self-Assessment (Appendix,below) and attention to metacompetence,or actively thinking about what one doesnot know, are proposed as ways to ad-dress supervisor competence (Falender &Shafranske, 2007). Modeling, practice, andongoing feedback have been shown to beassociated with supervisor change (Carl-son, Rapp, & Eichler, 2012). Other strate-gies include ongoing supervision trainingfocused on upgrading skill sets (Cum-mings, Ballantyne, & Scallion, 2015), train-ing on providing feedback after liveobservation of supervisees (Reddy,Kogan, Iobst, & Holmboe, 2012), and par-ticipating in peer consultation groups(Hoge, Migdole, Cannata, & Powell,2014). Supervisor self-assessment could besupported by authentic and accurate feed-back among staff (Johnson et al., 2014).

To create an environment conducive todevelopment of competence, supervisorscan model learning from supervisees toincrease collaboration and empowerment(e.g., Kassan, Fellner, Jones, Palandra, &Wilson, 2015) and model fluid expertise,moving from expert to learner (Johnsonet al., 2014). Enhanced supervision train-ing for evidence-based treatments shouldbe treatment or practice-element-centeredand target relationship, monitoring, andoutcome assessment (e.g., for child diag-noses; Accurso, Taylor, & Garland, 2011).Techniques to enhance supervisor com-petence with technology include intro-

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duction to research on innovative tech-niques (e.g., “bug in the eye”; Carmel, Vil-late, Rosenthal, Chalker, & Comtois, 2016)and on distance supervision (Rousman-iere, Abbass, & Frederickson, 2014). If system-wide change is indicated, trans-formation leadership, a powerful inter-vention, can foster a new vision andmomentum for change to a competency-based model of life-long learning(Kaslow, Falender, & Grus, 2012).

Domain B. Diversity• Supervisors strive to develop and

maintain self-awareness regardingtheir diversity competence, whichincludes attitudes, knowledge, andskills.

• Supervisors planfully strive to en-hance their diversity competence toestablish a respectful supervisory re-lationship and to facilitate the diver-sity competence of their supervisees.

• Supervisors recognize the value of,and pursue ongoing training in, di-versity competence as part of theirprofessional development and life-long learning.

• Supervisors aim to be knowledge-able about the effects of bias, preju-dice, and stereotyping. Whenpossible, supervisors modelclient/patient advocacy and modelpromoting change in organizationsand communities in the best interestof their clients/patients.

• Supervisors aspire to be familiarwith the scholarly literature concern-ing diversity competence in supervi-sion and training. Supervisors striveto be familiar with promising prac-tices for navigating conflicts amongpersonal and professional values inthe interest of protecting the public.

Empirical support. Multicultural compe-tence is an ethical imperative in super-vision, as judgments are influenced bypersonal and diversity-guided values

(Barnett & Molzon, 2014). Factoring intosupervision the constellation of diver-sity and multicultural identities amongsupervisees/therapists, clients, and thesupervisor (e.g., APA, 2003), whilegrounded in competency benchmarks(Fouad et al., 2009), has less empiricalthan conceptual support (Falicov, 2014;Miville et al., 2009). Additional empiri-cal exploration is essential.

Implementation strategies. Strategies forenhancing diversity competence includeintroducing models and studies high-lighting how supervisor diversity com-petence and attitudes directly affect thesupervisee and client care (Bertsch et al.,2014; Jernigan, Green, Helms, Perez-Gualdron, & Henze, 2010; Singh &Chun, 2010). Supervisors may use ex-emplars of training models for diversepopulations within a frame of social jus-tice (e.g., refugees, Kuo & Arcuri, 2014;geropsychology, Zucchero, Iwasaki,Lewis, Lee, & Robbins, 2014; commu-nity, Carr, Bhagwat, Miller, & Ponce,2014).

It is essential to proactively assess theemotional climate of the training envi-ronment (e.g., graduate program climatescale; Veilleux, January, VanderVeen,Reddy, & Klonofff, 2012) as well as mul-ticultural supervision outcomes (Tsong& Goodyear, 2014). Attentiveness to po-tential value conflicts between super-visees and clients requires supportingthe supervisors’ responsibility to respectand honor multiple diversity world-views, while upholding the ethical andlegal standards of the profession (Wiseet al., 2015). Other strategies could focuson providing specialized training (e.g.,affirmative therapy for LGBT popula-tions, Alessi, Dillon, & Kim, 2015; reli-gion, Shafranske, 2014). In the spirit ofmoving toward a communitarian cul-ture of competence in training (Johnson


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et al., 2014), emphasis can be placed onsupporting leadership and collegial par-ticipation in organizational diversity ini-tiatives (Renninger, et al., 2015).

Domain C. Supervisory Relationship• Supervisors value, and seek to cre-

ate, and maintain a collaborative re-lationship that promotes thesupervisees’ competence.

• Supervisors seek to specify the re-sponsibilities and expectations ofboth parties in the supervisory rela-tionship. Supervisors identify ex-pected program competencies andperformance standards, and assistthe supervisee to formulate individ-ual learning goals.

• Supervisors aspire to review regu-larly the progress of the superviseeand the effectiveness of the supervi-sory relationship and address issuesthat arise.

Empirical support. The supervisory rela-tionship is essential to supervision(Bernard & Goodyear, 2014; Falender &Shafranske, 2004; Ladany, Friedlander,& Nelson, 2005; Watkins, 2014). A strongrelationship exists between the supervi-sory alliance/relationship and super-visee self-disclosure. This is critical, asdisclosure provides the data for super-vision unless video review or live obser-vation is used (Mehr, Ladany, & Caskie,2010).

Implementation strategies. A key way tofoster the supervisory relationship is toensure that supervisors value and havethe knowledge, skills, and attitudes forestablishing the supervisory relation-ship, identifying and repairing strainsand ruptures, which are an inevitablepart of the supervision process (Asp-land, Lleweylen, Hardy, Barkham, &Stiles, 2008; Safran, Muran, Stevens, &Rothman, 2008), and managing super-visee emotional reactivity (Falender &Shafranske, 2004; Ladany et al., 2005).

Attending to and addressing the super-visory alliance provides a model for su-pervisee work with client alliancestrains (Eubanks-Carter, Muran, &Safran, 2015). A supervisory contract isa valuable tool for codifying the super-visory relationship, as it elaborates theexpectations, roles, responsibilities andprocesses (see Domain G).

Domain D. Professionalism• Supervisors strive to model profes-

sionalism in their own comportmentand interactions with others, andteach knowledge, skills, and attitudesassociated with professionalism.

• Supervisors are encouraged to provideongoing formative and summativeevaluation of supervisees’ progresstoward meeting expectations forprofessionalism, appropriate foreach level of education and training.

Empirical support. Professionalism, a corecompetency for psychologists (Fouad etal., 2009), can be defined by observablebehaviors (Grus & Kaslow, 2014). Pro-fessionalism is reflected in traits fromwhich professional behaviors and ac-tions should emanate: (1) accountabil-ity—responsibility, commitment, andappropriate deportment; (2) ethical en-gagement—knowledge of ethical stan-dards, moral reasoning, honesty,integrity, trustworthiness, and courage;(3) self-reflection—openness, self-aware-ness, and self-care; (4) professional iden-tity—view of self as a psychologist and ahealer and sense of responsibility to theprofession; (5) pursuit of excellence—commitment and self-motivation withrespect to professional development andlifelong learning; (6) humanism—care,compassion, respect for others’ dignityand choices, and cultural competence;(7) civility—polite, respectful and con-siderate behavior and communicationfor the good of the community, seeking


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common ground in the face of differ-ences; (8) collaborative orientation—work with others, teamwork, andcommunication; (9) collegial connec-tions—incorporate and use relationalmentors and competence constellationcolleagues; and (10) social responsibil-ity—altruism, advocacy on behalf ofothers, fair and ethical stewardship ofresources, and service to the community.(Kaslow, personal communication, April30, 2016)

Supervisees are impacted by bothdemonstrations of, and lapses in, pro-fessional behavior (Van Mook et. al.,2009). The impact of these on trainee de-velopment has been codified in the term“hidden curriculum,” referring to learn-ing that occurs by trainees’ observationsof actions and communications (Gab-bard et. al., 2012). Positive role modelingsupports the development of profes-sionalism, whereas problematic model-ing does the opposite (Larkin, 2003).Research, specific to psychology super-visees, is needed in this area.

Implementation strategies. Professional-ism and ethics are acquired through su-pervisor modeling. For example, in arelated field, medical residents ratedclinical supervision as the best way toassess knowledge, attitudes, and valuesof professionalism and ethics. Facultydirect observation of supervisee workwith patients and team members wasthe best way to assess skills. Generally,role modeling was the most effectiveway to teach professionalism (Marrero,Bell, Dunn, & Roberts, 2013).

Domain E.Assessment/Evaluation/Feedback• Ideally, assessment, evaluation, and

feedback occur within a collabora-tive supervisory relationship. Super-visors promote openness andtransparency in feedback and assess-

ment, by anchoring these in the com-petency development of the super-visee.

• A major supervisory responsibility ismonitoring and providing feedbackon supervisee performance. Live ob-servation or review of recorded ses-sions is the preferred procedure.

• Supervisors aspire to provide feed-back that is direct, clear, and timely,behaviorally anchored, responsive tosupervisees’ reactions, and mindfulof the impact on the supervisory re-lationship.

• Supervisors recognize the value ofand support supervisee skill in self-assessment of competence and incor-porate supervisee self-assessmentinto the evaluation process.

• Supervisors seek feedback from theirsupervisees and others about thequality of the supervision they offer,and incorporate that feedback to im-prove their supervisory competence.

Empirical support. The creation of com-petence standards has outpaced compe-tence assessment (Larkin & Morris,2015). For example, training in correc-tive feedback by physician supervisorswas associated with behavior changeand high satisfaction (Perron et al.,2013). In a psychology study, supervi-sors who did not give corrective feed-back wished they had (Hoffman, Hill,Holmes, & Freitas, 2005). Providingfeedback represents a high priority forempirical research.

Implementation strategies. Implementa-tion strategies related to assessment,evaluation, and feedback include super-visors incorporating idiopathic assess-ment of individuals’ acquisition ofcompetencies (Larkin & Morris, 2015),tracking developing competencies (San-


tos et al., 2015), using an assessment pro-tocol to track and provide feedback (Pi-azza-Waggoner, Karazsia, Hommel, &Modi, 2015) or providing collaborativefeedback empowering supervisees andclients (Minieri, Reese, Miserocchi, &Pascale-Hague. 2015). Training in form-ative (Cummings et al., 2015) and sum-mative feedback are central supervisorcompetencies. Another relevant strategyinvolves using client outcome data in su-pervision (Swift et al., 2014), as this prac-tice is associated with enhanced clientoutcomes.

Domain F. Problems of Professional Competence• Supervisors understand and adhere

both to the supervisory contract, andto program, institutional, and legalpolicies and procedures related toperformance evaluations.

• Supervisors strive to address performance problems directly.

• Supervisors strive to identify poten-tial performance problems promptly,communicate these to the super-visee, and take steps to address thesein a timely manner allowing for op-portunities to effect change.

• Supervisors are competent in devel-oping and implementing plans to remediate performance problems.

• Supervisors are mindful of their roleas gatekeeper and take appropriateand ethical action in response to su-pervisee’s performance problems.

Empirical support. An estimated 4% to10% of supervisees manifest competenceproblems, and peers often recognizethem first (Veilleux et al., 2012). There-fore, use of competency monitoring bysupervisors for early identification ofcompetence problems is essential, but(to date) has been addressed onlythrough the lens of supervisees (Kamen,Veilleux, Bangen, Vanderveen, &Klonoff, 2010). Supervisors typically are

reluctant to address supervisee compe-tence issues (Johnson et al., 2008), givennegative consequences that may result.Additional research is essential.

Implementation strategies. It is importantto address aspects of the training envi-ronment that inhibit, rather than foster,collaborative learning experiences(Shen-Miller et al., 2015) and provideskills for effective conversations (Jacobset al., 2011). It is important to identifycompetence problems early and giveformative feedback that is behaviorallyanchored. Transforming professionalcompetence problems into competenceand broader ethical frameworks can fa-cilitate faculty and supervisors in ap-proaching these as a team. This providesincreased opportunity for early notice ofcompetence problems and increased op-portunities to address these (Johnson etal., 2008). If such input and associatedguidance does not result in sufficientprogress, it is essential to progress to aremediation plan (Johnson et al., 2008)that is guided by the APA template forremediation (APA, n.d.) and the setting’spersonnel practices.

Domain G. Ethical, Legal, and Regulatory Considerations• Supervisors model ethical practice

and decision-making and conductthemselves in accord with the APAethical guidelines, guidelines of anyother applicable professional organi-zations, and relevant federal, state,provincial, and other jurisdictionallaws and regulations.

• Supervisors uphold their primaryethical and legal obligation to protectthe welfare of the client/patient.

• Supervisors serve as gatekeepers tothe profession. Gatekeeping entailsassessing supervisees’ suitability toenter and remain in the field.


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• Supervisors provide clear informa-tion about the expectations for, andparameters of, supervision to super-visees preferably in the form of awritten supervisory contract.

• Supervisors maintain accurate andtimely documentation of superviseeperformance related to expectationsfor competency and professional de-velopment

Empirical support. Modeling ethical prac-tice is a powerful part of the supervi-sor’s role (Marrero et al., 2013). Manysupervisees perceive that supervisorscommit ethical infractions (Ladany,Lehrman-Waterman, Molinaro, & Wol-gast, 1999) and lack knowledge of su-pervision ethics (January et al., 2014). Inthe group supervision context, this hasbeen found to be a central concern. Cen-tral topics, such as informed consentabout evaluation and confidentiality,were generally reported as not dis-cussed in the sample studied; groupmembers were often not recused fromsupervision if they personally knewclients under discussion (Smith, Riva, &Cornish, 2012). Survey data revealedthat supervisees may take a single ethicscourse early in their training, even priorto clinical experience, so they may notalways understand the complexity ofidentification and implementation ofwhat they learned in that course(Domenech Rodriguez et al., 2014) or itsextrapolation to the clinical and super-vision contexts.

Implementation strategies. Supervisionthat intentionally addresses ethicalevents in clinical work fosters ethicalsensitivity (e.g., Moffett, Becker, & Pat-ton, 2014). Addressing ethics early inpracticum supervision (Wise & Celluci,2014) and throughout the course of su-pervision ensures that ethics are not sim-ply viewed as relevant for riskavoidance, but rather that addressingthe topic serves as a proactive, positive

factor. The use of supervision contractsis essential (e.g., Association of State andProvincial Psychology Boards [ASPPB],2015), as they structure the ethical andlegal parameters of supervision and cri-teria for successful completion. Al-though an essential part of supervision,they are often given too little attention.Integrating attention to personal valuesystems, multiculturalism, and profes-sionalism with ethics is a central compe-tence (Wise et al., 2015).

DiscussionThe APA Supervision Guidelines heralda major shift away from learning to su-pervise through the personal experi-ences of having been supervised to amore systematic, competency-basedframework. They provide a frameworkand design criteria for supervisors toself-assess and purposefully enhancetheir supervision practices. A compe-tency-based approach requires consid-eration of practice domains, strategies,and the knowledge, skills, and attitudesof supervision. Sequential supervisiontraining should begin during graduatework and include coursework regardingessential components, models, and re-search opportunities to supervise, withsupervision-of-supervision, followed byobservation and assessment to gaugesupervision competence (Falender, Ellis, & Burnes, 2013). Following thisconsensus on the definition of compe-tency-based supervision, research onimplementation and outcomes forclients and supervisees with empiricallysupported measures are essential. Dis-semination of implementation strategiesfor the guidelines is only a preliminarystep. Transformation to competency-based supervision (Kaslow et al., 2012)requires planful execution, training, andimplementation of the various aspects ofsupervision practice. In concert with theASPPB Supervision Guidelines (2015),


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the transformation subsumes training,supervision, and regulation.

Implications for TrainingThere are a number of barriers to imple-menting the guidelines in the field ofpsychology generally, and more specifi-cally in counseling psychology. A pre-vailing attitude has been thatsupervision is not a distinct professionalcompetency. A lack of systematic gradu-ate-level training in supervision, outsidecounseling psychology, is concerning.Evidence for the provision of supervi-sion within counseling psychology is farmore positive, but still illustrates thatsome graduates never receive any for-mal training until internship, if at all.The cost of supervision training and op-timal practice reflect the lack of value at-tached to the supervision process withinthe profession. Finally, there is a generallack of empirical studies regarding theeffects of quality clinical supervision onsupervisee and client outcomes.

The development of the supervisionguidelines illustrates the change processthat is occurring in health service psy-chology, building upon counseling psy-chology literature and momentum tomore fully embrace a competency-basedapproach to education, training, and cre-dentialing. As part of the changeprocess, the guidelines are intended tofoster a process of educating supervi-sors, supervisees, administrators, andthe profession that competence in clini-cal supervision is acquired through sys-

tematic acquisition of knowledge, skills,and attitudes. Accountability for train-ing outcomes is a national focus, and thedevelopment of supervisor competen-cies will aid in the support of programattention to learning outcomes of theirstudents and supervisees. Specific stepsfor implementation of the guidelinesprovided here include: acknowledgingthat supervisor competence is an essen-tial part of the training trajectory, dedi-cating time and a commitment totraining for both supervisees and super-visors, including supervisor competencein performance review; allowing timefor supervisor consultation to sharechallenges, difficulties, and successeswith supervisees; and normatively pro-viding supervision-of-supervision to be-ginning supervisors and supervisees.These changes should lead to improve-ments in training of all health servicepsychologists, even the terrain of super-vision training in the graduate schoolpipeline, and provide a format for moresystematic investigation of the impact ofexcellent quality supervision on super-visee development and client outcomes.

See Appendix on page 17 and 18

References for this article can be foundin the online version of the Bulletinpublished on the Society for the Ad-vancement of Psychotherapy websitewww.societyforpsychotherapy.org

NOTICE TO READERS

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on the Society’s website under “Publications,” the “Bulletin.”Please click on the Bulletin issue for which you would like

references. Go to the Table of Contents, and find “References.”

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Replication has been arecent hot topic in Psychology research.With all of the con-cerns that have beenraised, many of us maywonder how replication

problems will impact practitioners andpsychotherapy researchers. The purposeof this article is to review some recent re-search on publication and replication. Iwill make suggestions and argue thatopen science principles and replicationwill lead to a healthier and more pro-gressive psychotherapy literature.

In August 2015, Science published “Esti-mating the Reproducibility of Psycho-logical Science,” the first fruit of theReplication Project: Psychology or RP:P(Open Science Collaboration, 2015). Sur-prisingly, fewer than half of the 100 at-tempted studies obtained the sameresults as the original. Though the RP:Pmet its own criticisms (Gilbert, King,Pettigrew, & Wilson, 2016), the findingshave led to questions about the reliabil-ity of research. In this, psychology is notalone. Similar conversations about relia-bility of research are happening in med-icine, biology, and economics, amongothers, and the causes of low repro-ducibility seem to be endemic to manyfields of scientific research (Ioannidis,2005).

Problems in Psychotherapy ResearchThe fundamental problem is challeng-ing to address, but easy to identify: In-centives for researchers may have

undermined the reliability of research.Specifically, a premium has been put onpublishing first and publishing in quan-tity. This gives rise to at least three sub-problems: publication bias, p-hacking,and hypothesizing after results areknown (or HARKing). I will briefly ex-plain these and apply them to psy-chotherapy research below, after whichI will describe four solutions.

Problem 1: Publication bias. Non-signifi-cant findings are common but unlikelyto be published. Therefore, the pub-lished literature becomes biased in favorof studies with significant results. At-tempts to synthesize the literature (forexample, with meta-analysis) are only asvalid as the literature being summa-rized. Imagine we want to knowwhether diaphragmatic breathing re-duces symptoms of schizophrenia. Fivestudies show a positive effect and 15studies have failed to show such an ef-fect, so we would have little hope forthis intervention. However, the five pos-itive studies are more likely to be pub-lished than the 15 negative studies.Imagine all five positive studies werepublished and just one of the negativestudies. After responsibly reviewing thepeer-reviewed literature, we might con-clude the use of diaphragmatic breath-ing as a clinical intervention will reducesymptoms of schizophrenia. This prob-lem has important implications for psy-chotherapy practice. At that point, basedon the published research, one might con-

PSYCHOTHERAPY RESEARCH

Replication and Open Science: Tools for Progress in Psychotherapy Research

Cody D. Christopherson, PhDDepartment of PsychologySouthern Oregon University


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clude it would be unethical NOT to usethis proven approach; however, basedon the entire body of research, the treat-ment is questionable at best. This illus-tration is fanciful, but there is evidenceof publication bias in real psychother-apy research; to take one example, ourbest estimates for the effects of psy-chotherapy on depression appear sub-stantially influenced by publication bias(Flint, Cuijpers, Horder, Koole, & Mu-nafò, 2015).

Problem 2: P-hacking. P-hacking is themanipulation of data or analyses untilreaching a p-value of less than .05. Themotivation: p generally must be lessthan .05 to publish. P-hacking can be ac-complished through many differentmethods, including collecting data untilp < .05, eliminating outliers to decreasep, selectively choosing outcomes todemonstrate significance, and so on.

P-hacking is facilitated by a researcherhaving many options in post-hoc analy-sis. These options, or researcher degrees offreedom, can lead to outright incorrect re-sults (Simmons, Nelson, & Simonsohn,2011). Consider a real measure of ag-gression called the “Competitive Reac-tion Time Task,” in which participants“blast” one another with sound in mul-tiple trials. According to a researchertracking this instrument, it has beenused in 122 publications but, amazingly,has been quantified in 150 differentways. Quantifications of the sound blastinclude volume in the first trial, dura-tion in the first trial, volume times dura-tion in the first trial, the mean of volumetimes duration in the first 25 trials, theaverage volume in trials 14 to 19, and soon (Elson, 2016). For a single study ofthis sort, there are at least 150 differentways to try to achieve p < .05. There issome evidence this is a concern for psy-chotherapy research. For example, psy-chotherapy outcome studies publishedover a three-year period averaged

nearly four different outcomes measureseach, with some using up to 14 (Ogles,2013). The use of multiple outcomesmeasures is not itself wrong, but with-out preregistration (see below), it doesgreatly increase researcher degrees offreedom and risk of p-hacking.

Problem 3: Hypothesizing after results areknown (HARK). HARKing distorts bothstatistical methods and creates a prob-lem of infinite theoretical support (Kerr,1998). A hypothetical example: A re-searcher studies whether mindfulnesstraining influences daily stress. Withoutmaking a prediction before data collec-tion, the data become difficult to prof-itably interpret. If mindfulness trainingdecreases stress, then we might say it isa useful therapeutic tool. If it increasesstress instead, then we can show howmindfulness training helps people be-come more sensitive to their daily stress,which could also be considered to betherapeutic. But what if the real effect ofmindfulness training, overall, is nothingat all? For some people it reduces stress,for others it increases it in equal meas-ure. Many studies may be published onboth sides and it may be years before wecan collectively know the real averageeffect of mindfulness training. If re-searchers are HARKing, it is difficult toknow for sure because any finding canbe supported by some theory post-hoc.If the true effect is zero, many studiesmay be published on both sides. HARK-ing and the other two problems abovecan lead to debates that may never besettled. Practitioners and clients are notwell-served by this needless confusion.

Potential SolutionsThe above are examples of possibleproblems with our psychotherapy liter-ature. They are blind spots caused byour own traditions and common prac-tices. As intractable as these problems


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may seem, there are proposed solutionswhich would be effective if adoptedbroadly. In this, individual labs as wellas journals, granting agencies, and uni-versities have an obligation to act to im-prove our field.

Solution 1: Pre-register. Pre-registrationcan involve creating a time-stampedrecord of your variables, target N for ad-equate power, and planned analyses. Itsolves at least two problems. First, it cre-ates a record of all studies so unpub-lished studies can be incorporated intoa meta-analysis. It also eliminates p-hacking. A pre-registration analysis planincludes a dated document with a targetN for adequate power, stopping rules,and planned analyses. Exploratoryanalyses can be identified as such.

This is a powerful tool. In one survey ofpublished antidepressant trials, 94% ofstudies showed the drug effective. Be-cause drug trials require registry withthe U.S. Food and Drug Administration(FDA), it was possible to discover thatonly 51% of studies had a positive result(Turner, Matthews, Linardatos, Tell, &Rosenthal, 2008). However, even withthe required registry, drug trials com-monly switch outcomes between pro-posal and publication (Goldacre et al.,2016.) To create a strong literature, weneed a way to ensure outcomes are iden-tified in advance. When they arechanged, the rationale should be in thereport. We do not yet know what ele-ments of our literature might be subjectto a bias similar to those in drug trials.

Though powerful, pre-registration israrely used. Of all randomized controlledtrials (RCTs) in the top 25 journals in clin-ical psychology published in 2013, only15% were pre-registered and 44% regis-tered overall (Cybulski, Mayo-Wilson, &Grant, 2016). Unlike treatments regulatedby the FDA, there is not a regulatorybody to enforce the registration of psy-

chological treatments, though the organ-izations and guidelines exist. Consoli-dated Standards of Reporting Trials(CONSORT) is one such set of voluntaryguidelines (Schulz, Altman, & Moher,2010). Over 600 journals have agreed tothese guidelines, including about 12 psy-chology journals. However, CONSORTremains ideal, not enforceable. For ex-ample, in one study, fewer than 50% ofarticles in journals endorsing CONSORTdefined their primary outcome in ad-vance (Turner, Shamseer, Altman, Schulz,& Moher, 2012). To be effective field-wide, journals and granting agenciesmust eventually adopt and enforce a pol-icy of pre-registration.

Badges are a related tool. Journals mayopt to display badge symbols next tostudies with pre-registration, open data,and open materials. This simple policydoes meaningfully influence researcherbehavior (Kidwell et al., 2016).

Solution 2: Share. Science is consideredprogressive and collaborative (“verify”),rather than reliant on authority or tradi-tion (“trust”). The American Psycholog-ical Associated (APA) Ethics Coderequires sharing of data with other pro-fessionals to verify claims (APA, 2002);however, in a recent study, only 38% ofauthors responded to a request and re-minder to send their data for re-analy-sis, including only 25% of authors in theJournal of Abnormal Psychology (Van-paemel, Vermorgen, Deriemaecker, &Storms, 2015). More than half the time,researchers were implicitly asked totrust rather than verify. Collaborativescience does not exist without inde-pendent verification.

I recently asked a colleague whether hehad considered incorporating any ele-ments of open science in a new project.Alarmed, he asked, “You mean give


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away all our data before we publish it?”Open data may seem scary or unneces-sary. Why do it? In economics, re-searchers attempted to replicate 60studies using identical data and analy-sis code. Even with help from the origi-nal authors, the researchers got the sameresults only half the time (Chang & Li,2015). Without open data, we do notknow the extent of this problem in ourliterature.

There was a time when data archiveswere unwieldy punch cards and expen-sive paper journal space could not beused to detail explicit procedures ade-quate for replication. Today, the Internetmakes data sharing and storage ex-tremely convenient. Online articles andsupplements make space issues disap-pear. It is simple to share data, protocol,and registration with tools such as theOpen Science Framework (which maybe accessed online at: www.osf.io).

Sharing can also extend to articles them-selves. The public cannot access most re-search without paying high prices forarticles. A problem specific to clinical re-searchers is that the divide betweenpractitioner and researcher grows everwider if we cannot freely communicate.Though it is difficult to estimate, onecommon claim is that takes 17 years forresearch to influence practice (Morris,Wooding, & Grant, 2011). Thousands ofstudies have been designed, funded,and executed in order to shape clinicalpractice. What if clinicians could easilyaccess them? Open access research mayfinally help close the perennial gap.

Solution 3: Determine the extent and the lo-cation of the problem. In RP:P, not all sub-fields were equally replicable. Cognitivepsychology results matched the originalapproximately half the time, but for so-cial psychology it was about 25% (OSC,2015). We do not know which areas of

psychotherapy research are prone to theproblems described above, but there areways to probe certain areas without con-ducting replications. Statistical examplesof this probing include p-curve analysis(Simonsohn, Nelson, & Simmons, 2014)and looking at the relationship of effectsize and sample size in a meta-analysisvia funnel plot and sensitivity analysis(Copas & Shi, 2000). Other ways of prob-ing might include a multi-method,meta-science approach. For example, we can survey or interview researchersregarding research practices. This cangenerate self-awareness with thick un-derstandings of research practices. As anaside, we might also consider takingqualitative and mixed methods researchmore seriously in general. Qualitativeresearch is not subject to the problemsassociated with significance testing.

Solution 4: Replicate directly. Direct repli-cation means recreating the original ex-periment as precisely as possible. Thisdiffers from a conceptual replicationwhich shares a theory with the originalstudy but changes a variable. For exam-ple, it may use novel means of inducingthe experimental condition. These twotypes of replications answer important,but different, questions. Direct replica-tion answers, “Is this finding reliable?”Conceptual replication answers, “Is thisfinding generalizable?” Conceptualreplication is common in psychology, in-dependent pre-registered direct replica-tion is rare.

Direct replication avoids endless theoryprotection. If a conceptual replicationfails, the theory is not hurt. There maybe some other reason for failure. If an ex-periment is powerfully and directlyreplicated and it fails, then that repre-sents a true threat to the theory. From apositivist point of view, the only way forscience to advance is to put our theoriesat grave danger (Meehl, 1978). Without


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direct replication, we risk building im-penetrable belts around our theories.

Barriers to ReplicationOne reason for focusing on original re-search rather than replication is that psy-chotherapy research is difficult andexpensive. Specific challenges includerecruiting a clinical sample; assuring ad-equate treatment training and fidelityfor clinicians; spending the time neces-sary to administer the treatment andmeasure follow-up; addressing highdrop-out rates; dealing with the inher-ent risk in using a vulnerable popula-tion; and identifying a true placebo.

As an alternative to many early psy-chotherapy direct replications, one re-searcher proposes adopting the methodsof the FDA in drug trials (Coyne & Kok,2014). This approach contains threephases of research. The first two phasesfilter out treatments that are unsafe, un-feasible, unreliable, or unacceptable topatients. Following Phase 3, an ade-quately powered RCT, independent pre-registered replications can be conducted.

Another way to progress without con-ducting a full-scale clinical trial replica-tion is to use specific ingredients of atherapeutic approach, particularly thosethat should show an effect in a nonclini-cal population as well as a clinical popu-lation. Then, run the study, includingmulti-site independent direct replica-tions, using a nonclinical population.Once a replicable effect has been identi-fied, build up to the full therapy in a clin-ical population. Whether any of theseideas are eventually adopted, a directreplication should be considered a goldstandard that is merited after researchhas passed hurdles such as successfulpre-registration, demonstrating adequatepower, and providing open data (for ver-ification purposes at a minimum.)

Impact and the FutureThe delivery of psychotherapy has beenbroadly impacted by the empiricallybased treatment movement. Research onempirically based relationships andtherapeutic processes has also been in-fluential on the field of clinical training,and continues to grow. How supportedis our empirical support itself? We donot know the degree to which each as-pect of clinical research, from commonfactors and therapeutic alliance to as-sessment and diagnosis to outcome, hasbeen influenced by the above considera-tions. But we also cannot dismiss theseas potential concerns. The practices thathave given rise to low replicability arepresent in clinical research. We havetools to help establish the veracity of ourmore important claims. The onus is onus to police ourselves. To improve, weneed collaboration with journals andgranting agencies willing to commit topublishing and funding replications toaccompany new studies.

This is a crossroads and a wonderfultime to be a psychological scientist. Theinternet has not yet changed everythingabout research methods, but it will.Memory will continue to get cheaperand it will be trivial to store and sharemountains of data. I predict that withinone generation, some version of openscience practices will be the standard inpsychology. This will certainly benefitour discipline because it will certainly,ultimately, benefit clients.


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In the previous issue ofthe Psychotherapy Bul-letin, Love, Davis, andCallahan (2016) ex-plored how the princi-ples of deliberatepractice can improvethe effectiveness of

clinical training in graduate school. Thisarticle aims to explore the next step:How deliberate practice can aid early ca-reer psychotherapists who want to con-tinue improving their clinical skills afterthey have completed graduate trainingand obtained their license for independ-ent practice.

First, a brief introduction to how I founddeliberate practice myself. In 2008, Igraduated from my clinical psychologyprogram and started a private practiceunder the supervision of a senior psy-chologist. Anyone who has started a pri-vate practice knows that the first year ortwo is stressful. The practice grewslowly, with only one or two new clientseach month. The thinness of my referralpipeline focused my attention on a spe-cific clinical problem: dropouts.

Clinical dropouts (also called non-com-pleters in the research literature, Swift &Greenberg, 2014) are the invisible plagueof psychotherapy. Most of us have them,but few of us like to talk about it. I hadrecognized my dropout problem early intraining at my practicum and internshipat a community health center. At leastone-third of my clients dropped outwithin a few sessions of therapy. I hadhoped that the problem was due to theclinical population I was serving (whichis a fancy way of saying that it was myclients’ fault, not mine). To my dismay,however, my clinical dropout problemfollowed me to my new private practicewhere I was serving a very differentclient population.

I looked for clinical training to help meprevent dropouts. In graduate school wehave little choice about how to train; wesimply do what our supervisors andprofessors tell us to do. After you grad-uate and get your license, things are dif-ferent: Your training regime is entirelyup to you. I quickly discovered thatthere is a bounty of clinical training op-

EDUCATION AND TRAINING

Domain Note: The Role of Deliberate Practice across the Professional Lifes-pan. The Society for the Advancement of Psychotherapy Education and TrainingCommittee is excited to be providing a series of articles on the role of deliberatepractice (DP) in the development of highly effective psychotherapists. The initialarticle (Love, Davis, & Callahan, 2016) focused on DP in training contexts. Thearticle below, by Dr. Tony Rousmaniere (who has two forthcoming books on therole of deliberate practice), continues with the next stage of professional devel-opment and with a focus on DP for ECPs.

Stewart Cooper, PhD, ABPPChair, Education and Training Committee

Deliberate Practice for Early Career Psychotherapists

Tony Rousmaniere, PsyDClinical Faculty, University of WashingtonPrivate Practice, Seattle, WA


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tions available, commonly called con-tinuing education units (CEU), includ-ing weekend workshops, lectures, andwebinars.

Unfortunately, most CEUs are taught ina passive learning format, where the au-dience sits and listens to a lecture orwatches a video, with possibly some dis-cussion. This format can be effective forlearning cognitively (e.g., new laws, reg-ulations, or clinical theory), but researchhas shown that it does not result in im-proved clinical skills or client outcomes(Taylor & Neimeyer, 2015). Most CEUsdo not include key components of skillacquisition such as repetitive practice ofspecific skills, personalized performancefeedback, and follow-up skill assess-ment and refinement (Tracey, Wampold,Lichtenberg, & Goodyear, 2014). Sum-marizing their review of the research inthis area, Neimeyer and Taylor (2010)stated, “A central concern follows fromthe field’s failure to produce reliable ev-idence that CE translates into dis-cernibly superior psychotherapy oroutcomes, which serves as the corner-stone of the warrant underlying CE andits related commitment to the welfare ofthe consumer” (p. 668).

My experience echoed the research. I attended weekend workshops, confer-ences, and webinars. I got certificationsin variety of evidence-based psycho ther-apy models. However, my clinical skillsdid not significantly improve and mydropout rate actually worsened (per-haps because I was jumping aroundfrom model to model.)

What was I missing? Deliberate practice.

Deliberate Practice: A PrimerDeliberate practice is a term introducedby K. Anders Ericsson and colleagues in the science of expertise (Ericsson,Krampe, & Tesch-Romer, 1993). Definedas “the individualized training activities

specially designed by a coach or teacherto improve specific aspects of an indi-vidual’s performance through repetitionand successive refinement” (Ericsson &Lehmann, 1996, pp. 278‒279), deliberatepractice involves an intensive trainingprocess with repetitive skill-building ex-ercises informed by expert feedback andperformed throughout a professional ca-reer. Professionals from a wide range offields, from music to sports to chess tomedicine, rely on deliberate practice toachieve expert performance (Ericsson &Pool, 2016).

Scott Miller was the first psychologist toconsider the potential benefit of deliber-ate practice for mental health training(Miller, Hubble, Chow, & Seidel, 2013;Miller, Hubble, & Duncan, 2007). Morerecently, other researchers have examinedhow deliberate practice can improve theeffectiveness of psychotherapy supervi-sion and training (e.g., Chow et al., 2015;Rousmaniere, Goodyear, Miller, &Wampold, in press; Tracey, Wampold,Lichtenberg, & Goodyear, 2014).

Of particular importance for psycho -therapists, deliberate practice requiresfive processes that are not present in tra-ditional CEU formats: observing yourown work, getting expert feedback, settingincremental learning goals just beyondyour ability, repetitive behavioral re-hearsal of specific skills, and continu-ously assessing performance (Ericsson,2006).

How can early career psychotherapistsuse this research to improve their clini-cal skills? Following is a list of nine prac-tical take-away lessons from theexpertise literature that can help thera-pists maximize their training time anddollars (Rousmaniere, in press).

#1: Focus on stalled or deteriorating cases.Choose clinical training formats that


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help you focus on your clinical weak-nesses, skill deficits, and blind spots.“Only when people face failures of theirentrenched procedures do they activelyengage in learning and modification oftheir skills” (Johnson, Tenenbaum, &Edmonds, 2006, p. 118). Research sug-gests that psychotherapists commonlyhave a particularly strong blind spot re-garding their own cases that are at riskof deterioration (Hannan et al., 2005;Hatfield, McCullough, Frantz, &Krieger, 2010). Focusing on our weak-nesses has an added benefit of guardingagainst over-confidence, termed “defen-sive pessimism” (Norem & Cantor, 1986)and “professional self-doubt” (Nissen-Lie, Monsen, & Rønnestad, 2010).

#2: Use active learning methods. Look fortraining opportunities that emphasizeactive learning methods such as repeti-tively practicing skills through role-playor simulations (in contrast to passivelylistening to a lecture or watching avideo). Simulation-based behavioral re-hearsal facilitates state-dependent learn-ing and helps move skills intoprocedural memory (McGaghie &Kristopaitis, 2015). The best learning for-mats are simulations (role-plays) that tryto closely match the conditions in whichyou will be actually using the skills (i.e.,psychotherapy). According to Ericssonand Pool (2016), “The most effectiveforms of practice are doing more thanhelping you learn to play a musical in-strument; they are actually increasingyour ability to play” (p. 43).

#3: Work at a threshold of strain. Deliber-ate practice works through intentionallyseeking disequilibrium. This is a chal-lenging process of strain and repairthrough which old habits are broken sothey can be replaced with new skills.“Lengthy engagement in some trainingactivity has minimal effect unless itoverloads the physiological system suf-ficiently to lead to associated gene ex-

pression and subsequent changes (im-provements) of mediating systems” (Er-icsson, 2003, p. 73). Learning about askill can feel comfortable or easy, but ac-tual skill acquisition is difficult.

#4: Train in long-term relationships. Clini-cal trainers can help you best when theyknow your personal weaknesses, blindspots, and growth edges. This often re-quires a long-term relationship, and can-not be accomplished through occasionalweekend workshops. A long-term rela-tionship also lets your trainer customizeyour growth specifically for your styleof learning and give you performancefeedback over time.

#5: Emphasize homework. To get the mostfrom your training dollars, pick trainerswho assign homework for you to prac-tice on your own. In most other fields themajority of learning occurs in solitary de-liberate practice (Ericsson, 2006). For ex-ample, it would be inconceivable to trainto be a professional musician, athlete,chess player, dancer, singer, or pilot with-out dedicating many hours to solitarypractice. In their first study in this area,Ericsson and colleagues (1993) foundthat solitary deliberate practice was theonly variable that predicted the skill ofviolinists: “There is complete correspon-dence between the skill level of thegroups and their average accumulationof practice time alone with the violin” (p.379). Solitary deliberate practice also hasthe important benefit of being free.

#6: Use video recordings. Asking for con-sultation on a clinical case via notes ormemory is like getting an art review byverbally describing your art instead ofletting someone see it. If you want helpidentifying your blind spots, which weall have, then you have you show yourwork. Video recording is now widely ac-knowledged as invaluable for enhanc-ing the effectiveness of clinical training


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(e.g., Bernard & Goodyear, 2014; Ellis,2010; Friedlander et al., 2012). Notably,this includes psychodynamic practition-ers, who previously were among themost cautious regarding video (e.g., Ab-bass, 2004; Briggie, Hilsenroth, Conway,Muran, & Jackson, 2016; Eubanks-Carter, Muran, & Safran, 2015; Haggerty& Hilsenroth, 2011; McCullough, Bhatia,Ulvenes, Berggraf, & Osborn, 2011).

#7: Use performance feedback loops. Skillacquisition works through performancefeedback loops: You learn a skill, prac-tice in simulation (role-play), use it withreal clients, and then review the resultsvia video with a trainer who providesfeedback, which in turn informs the nextskill to learn. This stands in contrast tomost CEU programs that are single-shotevents, or perhaps a short series ofworkshops, without opportunity for fol-low-up performance feedback. Ericsson(2015) noted that “workshops or even afour-day training will be insufficient forattaining substantial improvement ineveryday performance” (pp. 12‒13).

#8: Assess effectiveness through client out-come. In deliberate practice, client out-come is the bottom-line criteria forassessing therapist effectiveness. Thiscan be disorienting for therapists whowere trained with a focus on adherenceand fidelity. However, research hasshown little connection between adher-ence to a model and client outcome(Branson, Shafran, & Myles, 2015; Webb,DeRubeis, & Barber, 2010), and inflexi-ble adherence to a model can harmclients (Hatcher, 2015). Describing thisproblem for the broader psychotherapycommunity, the psychodynamic super-visor Jon Frederickson says, “We’vecome to prize ritualism over results”(personal communication, January 3,2016). Learning psychotherapy modelsand techniques requires a balance be-tween following the model and retain-ing sufficient freedom and flexibility to

attune with each unique client (termedappropriate responsiveness; Hatcher, 2015).

Assessing client outcome can be tricky.Research shows that therapists’ judg-ment in this area is not reliable (Walfish,McAlister, O’Donnell, & Lambert, 2012).Furthermore, clients are reluctant to ac-knowledge when therapy is not helpful;in a recent anonymous survey of 547clients, 93% reported having lied to theirtherapist, with common subjects being“pretending to find therapy effective”and “not admitting to wanting to endtherapy” (Blanchard & Farber, 2016).

To aim for a more reliable assessment,therapists should use multiple datasources for evaluating client outcome.The most common are (1) client report,(2) therapist judgment, (3) routine out-come monitoring (ROM) data, (4) quali-tative data from the client, and (5)collateral information from other peoplewho know the client (e.g., partner, em-ployer, teacher).

#9: Don’t rely on clinical experience alone toimprove your effectiveness. Ericsson (2008)described the limits of work experienceas, “Once a professional reaches an ac-ceptable skill level, more experience doesnot, by itself, lead to improvements” (p.992). Research in psychotherapy hasshown the same: Accumulating thou-sands of hours of face-to-face time withclients does not reliably lead to improvedclinical effectiveness beyond competency(for a review, see Tracey, Wampold,Goodyear, & Lichtenberg, 2015). In a no-table example, a recent study examiningthe outcomes of 170 therapists at a largeuniversity counseling center found thatthe average therapist actually had a smallbut statistically significant decrease in ef-fectiveness over time (Goldberg et al.,2016). Improving effectiveness requiresobserving your own work, getting expertfeedback, and continuously assessing


29

performance (Ericsson, 2006).

Challenges to Deliberate PracticeThe greatest challenges to deliberatepractice are that it is hard and resource-intensive, requiring time from a busyschedule and money for expert feed-back. Unfortunately, our field does notcurrently recognize, reward, or incen-tivize meaningful and sustained effortstowards skill development. Thus, en-gaging in deliberate practice requiressubstantial inherent motivation to getbetter. Most therapists enter the field outof a desire “to help others” (Hill et al.,2013); keeping this goal in mind canhelp provide motivation for sustaineddeliberate practice.

My personal motivation for deliberatepractice was to halt my alarmingdropout problem. I accomplished thisthrough two methods. First, I attended amonthly consultation group with VictorYalom, PhD, a senior psychologist in SanFrancisco. In the group I showed videosof my cases that were stalled or at risk ofdeterioration. Victor taught me specificskills to aid each case and used role-playsimulations to help me practice the skills.Second, I had biweekly individual con-sultation with two psychodynamic su-pervisors, Jon Frederickson, MSW, andAllan Abbass, MD. Those consultationsincluded videotape case review, role-plays to aid skill development, and alsolive one-way-mirror supervision (Rous-maniere & Frederickson, 2015). I moni-tored my cases with routine outcomemanagement (ROM) data, and got regu-lar client feedback with the Session Rat-ing Scale (Miller et al., 2007).

The consultants helped me preventdropouts by identifying a range of clin-ical errors I was making (Rousmaniere,in press). For example, Victor Yalom no-ticed that I used an inauthentic “thera-pist” voice with clients when I becameanxious, and helped me practice speak-

ing more authentically. Allan Abbasspointed out that I was confrontingclients too quickly, and helped me finda better balance of challenge versus en-couragement. Jon Frederickson ob-served that I was talking over some ofmy clients, and taught me how to bettercontrol my pacing and energy to fosterstronger attunement. Notably, most ofthe problems the consultants noticed inmy work were revealed only because Ishowed videos of my sessions; thesemistakes would have been invisible tous in my session notes and memory.

Over time, my dropout rate gradually im-proved. I knew that I was advancing whenone of my clients remarked to me, “You fi-nally understand what I’ve been trying totell you for months!” Two years later myfull-time private practice was full.

When a therapist transitions from grad-uate training to independent practicethere is a sudden and dramatic increasein autonomy. This can be exciting, butalso confusing or disorienting. Thera-pists can use the principles of deliberatepractice (Ericsson, 2006) as a rudder toguide their clinical developmentthrough the sometimes turbulent seas ofearly career and beyond.

Note: This article is based on the au-thor’s forthcoming edited volume, Su-pervision from Competence to Expertise:Using Deliberate Practice for Career-LongProfessional Development (co-edited byTony Rousmaniere, Rodney Goodyear,Scott Miller, and Bruce Wampold; WileyPress) and the forthcoming book, Delib-erate Practice for Psychotherapists: A Guideto Improving Clinical Effectiveness (Rout-ledge Press).


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As Sigmund Freud asked, “The greatquestion that has never been answered,and which I have not yet been able toanswer, despite my thirty years of re-search into the feminine soul, is ‘Whatdoes a woman want?’” (Jones, 1955, p.421). Psychotherapy researchers maywonder the same thing about psy-chotherapists. More than 50 years ofpsychotherapy research has broughtsome enlightenment. For example, weknow that some therapists seem to bemore effective than others and even ef-fective therapists are differentially effec-tive (Kraus, Castonguay, Boswell,Nordberg, & Hayes, 2011). However, westill have not fully grasped what thera-pists need in order to be effective.

Because the essence of psychotherapy isembodied in the therapist (Wampold &Imel, 2015), understanding the needs oftherapists seems a critical component inunderstanding their effectiveness. It issafe to assume that, if therapists’ needswere more adequately met, then theywould be more effective clinicians. Yetwe have only rudimentary understand-ing of what factors may influence thera-pist effectiveness and well-being.Understanding therapists’ needs is animportant step in assisting therapists in

being effective. Thera-pist access to informa-tion and support maybe an important com-ponent to their effec-tiveness. As membersof the Society of theAdvancement of Psy-chotherapy’s (SAP; Di-vision 29) ProfessionalPractice Domain, ourmission is to promote and advance thepractice of psychotherapy in part by ad-dressing the needs of practicing psy-chotherapists. In order to determinehow to be of value to them, we want toassess what the needs of private practi-tioners are and how practitioners accessresources. As a preliminary step, wespoke informally with therapist col-leagues in our various communities toget a basic understanding of what ques-tions need to be addressed.

When we began to discuss therapistneeds, we were struck at the vast num-ber of resources available to therapists.Resources for therapists are availablethrough national organizations (Ameri-can Psychological Association, APA


PSYCHOTHERAPY PRACTICE

What Do Psychotherapists Want?

Barbara L. Vivino, PhD Berkeley, CA

Barbara J. Thompson, PhD Ellicott City, MD

Patricia T. Spangler, PhDBethesda, MD

Soo Jeong Youn, MSPennsylvania State University

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Practice Organization, American Asso-ciation of Marriage and Family Therapy,National Association Social Work), stateand local organizations, and a multiplic-ity of Continuing Education providers.Yet, the therapists we spoke to wereoften not aware of these resources orwere not comfortable utilizing them.This was surprising, yet after discussingit among ourselves and with severaltherapists in the community, we realizedthis could be due to multiple factors.

The therapists we spoke with said therewas readily available information andsupport to them on the Internet or in re-search articles, but they were muchmore likely to seek information fromother therapists in an interpersonal ex-change, if possible, because the infor-mation gained in this context seemedmore relevant and in-depth. The typicaldelivery of information via the Internetor written literature may not match ther-apist needs, personality, or learningstyle. Psychotherapists’ personality vari-ables may influence their preference formore engagement with their informa-tion. Many therapists value interper-sonal relationships and may want morepersonal interaction, yet resources areoften available mainly via computer ordigitally.

The sheer volume of material availableto therapists also may actually be a bar-rier to accessing needed information.Therapists may be overwhelmed anduncertain of which resources to select,especially because there is no central-ized way to access the material. Re-sources for therapists are scatteredamong a variety of different disci-plines—MFT, LPC, LCSW, PhD, PsyD,and MD. Therapists are busy and oftendo not have time to locate resources be-tween sessions. Simply trying a Googlesearch may be ineffective if therapists donot know how to access more specific

websites, including those not immedi-ately available on common search en-gines. This may also contribute to thedesire to receive information relation-ally; it is much easier to have a five-minute conversation with a trustedcolleague than spend 30 minutes surfingunfamiliar Internet sites. In addition,some of the therapists we spoke withhad some animosity toward their pro-fessional organization (the APA), whichprevented them from utilizing the re-sources available to them through thoseorganizations.

It is clear from our conversations withpsychotherapists that they have needsnot currently being met. In our attemptto understand what the needs are andwhy they are not being fulfilled, we re-viewed the current literature availableon the subject. There have been previoussurveys of psychotherapists’ needs.Tasca and colleagues (2015) surveyedCanadian clinicians in a practice re-search network with a broad range ofsettings on what they wanted from psy-chotherapy research. They found that re-search on therapeutic interventions,processes, outcomes, and professionaland practice issues, particularly those re-lated to the therapy relationship, weremost important. McAleavey and col-leagues (2014) surveyed 596 therapistsin college counseling centers in a prac-tice research network on what types ofresearch are most clinically valuable; thetherapists rated research on the counsel-ing process, high-risk behaviors and dis-orders, the effectiveness of counseling,minority populations, and therapist andclient factors to be the most relevant.

There are no survey data, however, onthe broader range of needs private prac-titioners have and sometimes struggle tomeet. We therefore thought it might beinformative to talk directly with psy-


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chotherapists in private practice. Al-though we plan a more in-depth inves-tigation, our preliminary conversationswith therapists revealed several specificunmet needs, including information re-lated to business logistics such as billing,insurance, training in new Current Pro-cedural Terminology or ICD-10 codes,and marketing. Other needs includethose related to increasing or managingincome, clinical consultation, maintain-ing good self-care, and resources relatedto legal and ethical support.

A common need expressed by our col-leagues was for peer consultation andsupport. It seems many of us ask ourfriends and colleagues when we needinformation about new codes or ethicaldilemmas. Conversations may takeplace in the context of association anddivision listservs, formal peer supportgroups, or by just asking the profes-sional colleague next door. One area ofinquiry we hope to include in our for-mal survey relates to this apparentlycommon use of colleagues for informa-tion. Our ethics code supports going tocolleagues for help with ethical and clin-ical issues. For example, one questionwe have heard asked frequently of col-leagues has to do with reporting of childsexual abuse. If a colleague has alreadygone through the various legal and eth-ical channels and discovered a particu-lar process is applicable in a given state,it makes sense another colleague canbenefit from that. While this meets theneeds for accessible information as wellas streamlining the process, there maybe some reasons for caution, especiallywhen there is little research on the effec-tiveness of peer consultation/support(Carney & Jefferson, 2014).

In addition, the existing research tendsto focus on consultation about cases oron therapy process or outcome, notaround providing practical information

such as resources on business practices,technical matters, or self-care. Whilethere may be some evidence the supportprovided in peer consultation groupshelps with burnout or stress manage-ment (Truneckova, Viney, Maitland, &Seaborn, 2010), for example, there is lit-tle research on how these groups relateto improving other important aspects ofself-care.

Our preliminary conversations yieldedseveral general questions that led us todevelop a semi-structured interviewprotocol, which we will use in a qualita-tive investigation of the needs of privatepractitioners to be conducted this fall.Our questions center on what resourcesand information therapists need, whatresources have been useful, what re-sources are lacking, how therapists ac-cess resources, and what the barriers areto accessing resources. Our purpose is togain a more in-depth understanding ofthe needs of those whose primary pro-fessional endeavor is conducting psy-chotherapy in a private practice setting.Based on our qualitative results, we planto develop and distribute a survey oftherapist needs to a large sample of pri-vate practitioners. Our goal is to dis-cover what private practitioner needsare in order to tailor the Division 29Practice Domain’s approach moreclosely to the current needs of those weserve.

As psychotherapists, we spend most ofour time trying to understand and helpclients with their needs. Asking thequestion, “What do psychotherapistswant and need?” has raised our ownawareness and self-reflection. Am I get-ting all I need to be an effective thera-pist? If not, what stops me? Is it time,money, energy, or lack of knowledgeabout where or how to get those needsmet? We hope that asking the question


33

is the first step in finding an answer andthat resolving the question of what ther-apists want and need is not as perpetuala mystery as Freud’s confusion aboutwomen!


Find the Society for the Advancement of Psychotherapy at


NOTICE TO READERS

References for articles appearing in this issue can be found on the Society’s website under “Publications,” the “Bulletin.”

Please click on the Bulletin issue for which you wouldlike references. Go to the Table of Contents, and find“References.” References for all articles in the issue

will begin on that page.

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Adding to the neuro-logical research find-ings on the benefitsof meditation, a re-cent study found thatlong-term meditatorswho are age 50 andolder have a youngerbrain age than non-

meditators (Luders, Cherbuin, & Gaser,2016). Using a validated approach basedon high-dimensional pattern recogni-tion, brains of meditators were found tobe 7.5 years younger than those of con-trols. Moreover, for every additionalyear over 50, meditators’ brains were es-timated to be an additional one monthand 22 days younger than their chrono-logical age.

The findings suggest that meditation isbeneficial for brain preservation, effec-tively protecting against age-related at-rophy, with a consistently slower rate ofbrain aging throughout life. As a life-long meditator, this is indeed goodnews. If these findings are valid, theysuggest my brain may be growingyounger with each passing year, al-though my memory for some propernouns may not yet have heard the news.

The purpose of this article is to offer aperspective on issues related to the ex-plosion of research and psychothera-peutic application of meditation and,specifically, mindfulness, over the last 15years. My view is through a prism withlight refracted through studying thephilosophies and practices of varioustypes of meditation from the time I wasin high school and continuing over 50

years. In addition, I have published andpresented on the philosophy, practice,and application of meditation to psy-chotherapy (e.g., Hendlin, 1978a, 1980,1982a, 1983a, 1984a, 1984b, 1985, 1987,1989a, 1991, 1993).

History and ExperienceIn the scientist-practitioner model, thenorm is “evidence-based.” To further es-tablish “evidence” for the following per-spective, allow me to summarize someof my training and experience. At 16, Iwas introduced to Soka Gakkai, a Japan-ese Buddhist religious movement of theNichiren lineage, two years after its firstAmerican headquarters opened in LosAngeles in 1963 (Prebish, 1999). I wasinitiated into the ritual of chanting amantra, with the understanding itwould help manifest material desires ineveryday life. During the same period, Ibegan reading about Chinese Taoism,which led to further diversified study incollege and graduate school in Easternphilosophy and comparative world reli-gions, along with the practice of variousforms of meditation.

One of the forms I learned was the Chi-nese slow movement-meditation of TaiChi Chuan. During my pre-doctoral in-ternship, I experimented with the clini-cal application of Tai Chi as an adjunctto the process of psychotherapy. Thiswas done with day-treatment patients ina community mental health setting,leading to articles and workshops onhow Tai Chi could be integrated intopsychotherapy in general and Gestalttherapy in particular (Hendlin, 1977,

PSYCHOTHERAPY PRACTICE

meditation and the mindfulness Trend in Psychotherapy: Reflections Through the Prism of a 50-Year meditator

Steven J. Hendlin, PhDNewport Beach, CA


Dear SAP (Division 29) Colleague:

The Society for the Advancement of Psychotherapy (APA Division of Psychotherapy, 29) seeks nom-inations of creative individuals and great leaders! We would like both new and experienced voicesto advance our increasingly important work on behalf of psychotherapy. The SAP Board encouragescandidates from diverse backgrounds to seek nomination.

NOmINATE YOURSELF OR SOmEONE YOU KNOW TO RUN FOR OFFICE IN SOCIETY FOR THE ADVANCEmENT OF PSYCHOTHERAPY (APA DIVISION 29)

The offices open for election in 2017 are:• President-elect

• Secretary• Domain Representative for Public Interest and Social Justice

• Domain Representative for International AffairsAll persons elected will begin their terms on January 2, 2018

A Domain Representative is a voting member of the Board of Directors. The open positions will beresponsible for initiatives and oversight of the Society’s portfolio in the respective Domains. Can-didates should have demonstrated interest, expertise, and investment in the area of their Domain.

The Division’s eligibility criteria for all positions are:1. Candidates must be Members or Fellows of the Society.2. No member may be an incumbent of more than one elective office.3. A member may only hold the same elective office for two successive terms.4. Incumbent members of the Board of Directors are eligible to run for a position on the Board

only during their last year of service or upon resignation from their existing office prior to accepting the nomination. A letter of resignation must be sent to the President, with a copyto the Nominations and Elections Chair.

5. All terms are for three years, except President-elect, which is one year (and then proceeds toPresident for one year and Past President for one year).

The deadline for receipt of all nominations ballots is November 1, 2016.

As per the Society’s Bylaws, you may email your nominations to: [email protected]. Pleaseput SAP/DIVISION 29 NOMINATIONS in the subject line the email. You may also fax yournominations to: 480-854-8966, or mail to Society for the Advancement of Psychotherapy, 6557 E.Riverdale St., Mesa, AZ 85215

If you would like to discuss your own interest or any recommendations for nominations, pleasecontact the Society’s Chair of Nominations and Elections, Dr. Michael Constantino, [email protected]

Sincerely yours,

Armand Cerbone, Ph.D. Jeff Zimmerman, Ph.D. Michael Constantino, Ph.D.President President-elect Chair, Nominations & Elections

NOmINATIONS

2017 NOmINATIONS BALLOT

President-elect Secretary

____________________________________ ____________________________________

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Domain Representative for Public Domain Representative for Interest and Social Justice International Affairs

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1978a, 1978b, 1979a, 1979b).

With the Human Potential Movement infull swing during the late 1960s, 1970s,and into the early 1980s, California wasa hotbed of fervent activity. Growth centers offered workshops related tovarious methods under the rubric ofHumanistic-Existential and Transper-sonal Psychology, including Easternmeditative practices. The cross-fertiliza-tion between these disciplines meantthat I could sample the best teachers andpractices from the worlds of both psy-chology and spirituality without having togo very far from home. Before beginninggraduate school, I did some part-timeadministrative work at a well-knownLos Angeles growth center. This allowedme to participate without cost in the pot-pourri of workshops being offered byvarious teachers who were interested inmarketing themselves and their methods.

In a humanistically oriented graduateschool in San Diego from 1972 to 1975, Iwas exposed to such distinguished teach-ers as Rollo May, Sidney Jourard, AlbertEllis, Viktor Frankl, Harold Greenwald,Ev Shostrom, Ted Blau, and GeorgeAlbee. At the same time, I sought outextra-curricular growth and training ex-periences with such people as Gestalttherapy co-founder Laura Perls and mas-ter therapist James Simkin; Bioenergeticsfounder Alexander Lowen; Gestalt thera-pists Erving and Miriam Polster; Neu-rolinguistic Programming founder JohnGrinder; transpersonal theorist “spiritualemergency” treatment founder and psy-chiatrist Stanislav Grof; psychoanalystsOtto Kernberg and James Masterson; andthe psychiatrist, dolphin researcher, andconsciousness explorer John C. Lilly, whointroduced me to the altered states thatoccurred through floating for long peri-ods in a dark and soundproof sensoryisolation tank filled with warm salt water.

During graduate school, I drove up thefreeway weekly for one year to betrained at the Gestalt Therapy Instituteof Los Angeles, where some of the mostcreative Gestalt trainers in the countryhad congregated, most of whom hadbeen trained by Fritz Perls and JamesSimkin.

For burgeoning spiritual groups want-ing the reputation of their guru, teacher,or philosophy to grow more widely, itwas considered de rigueur to conductworkshops and retreats in California, ifnot to establish local centers.

Because of this confluence, I was fortu-nate to participate in numerous work-shops over a period of more than twodecades with meditation and devotionalyoga teacher Ram Dass (ex-Harvardpsychologist Richard Alpert), and had alesser amount of workshop/retreat con-tact with such teachers as Bhagavan Das(Hindu devotional chanting), SwamiMuktananda (Siddha Yoga meditation),Sueng Sahn (Korean Zen meditation),Anagarika Munindra (Vipassana InsightMeditation), and Tarthang Tulku (Ti-betan practices). I also experienced amemorable week-long intensive retreat(sesshin) in the mountains, along withother weekend retreats, with the vener-able Rinzai Zen master Joshu SasakiRoshi, who lived to be 107 (for an in-depth account of this experience, seeHendlin, 1979c, 1981). In 1993, I partici-pated in a four-day silent meditation re-treat with the Vietnamese teacher ThichNhat Hanh.

I attended the weekend public lecturesof J. Krishnamurti (held each Spring inhis hometown of Ojai) from the late1970s until his death in 1986. Duringthat time period, he was in his 80s andconsidered one of the most influentialliving philosophers in the world. Other


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prominent personalities I encounteredalong the way included Timothy Leary,Allen Ginsberg, and LSD discoverer Al-bert Hofmann.

The core of my formal immersion intoTheravada Buddhist Vipassana (Insight)meditation practice was comprised of10-day intensive silent retreats in 1981and 1982 in the Southern Californiadesert with teachers Jack Kornfield andJoseph Goldstein. I continued these for-mal retreats every year from 1983through 1987, varying from four toseven days, depending on the amount oftime I could afford to get away from myprivate psychotherapy practice. Theseretreats supported and deepened mydaily sitting practice.

Finally, in 1989, I went on a month-longBuddhist and Hindu Temple Pilgrimageto Kathmandu, Nepal, practicing forshort periods with indigenous medita-tion teachers who met with our smallgroup (Hendlin, 1989b). This pilgrimagewas capped off by a two-day car tripfrom New Delhi though Northern Indiato Dharamsala, to enjoy an audiencewith H.H. Dalai Lama and meditatewith his community of monks. Ironi-cally, a few months after my trip, HisHoliness came to my city to lead atranspersonal psychology conference inwhich I was a presenter, and I was ableto have further contact with him. Auspi-ciously, this conference took place justafter he had been awarded the NobelPeace Prize. Close to three decades later,he is one of the few teachers I will go outof my way to see when he is presentinganywhere in my area. Just last year, Iwas fortunate to be part of the local cel-ebration of his 80th birthday.

The mindfulness TrendEven the most optimistic of us in the earlyyears of transpersonal psychology wouldhave been hard-pressed to imagine thatmindfulness, as a state or practice, would

have caught on in the explosive way it hasin medicine (neurological research) andpsychology (through academic studiesand mindfulness-based therapy practice).Of course, we would have been equallysurprised by the present day ubiquitousmainstreaming of yoga.

But, with mindfulness, it is not alto-gether clear exactly what has caught on.Is it the simple awareness of bringingoneself into the present without judg-ment or evaluation? Gestalt therapytechniques offered this present-centered,non-judgmental awareness long ago,but did not call it “mindfulness.” Perls(1969) talked about allowing present-centered awareness to hover at the “zeropoint,” where attention was evenly sus-pended without evaluation. Whetherdue to sloppy historical research orbeing inconveniently discarded, the con-tributions from humanistic-existential-phenomenological and transpersonalpsychology have been lost in the currentnarrative of the history of mindfulnessin psychotherapy, much as they were inthe development of “positive” psychol-ogy (Brito, 2014; Felder, Aten, Neudeck,Shiomi-Chen, & Robbins, 2014; Harring-ton & Dunne, 2015).

Does the contemporary notion of mind-fulness have the same meaning as itdoes in the Buddhist Vipassana medita-tion I learned so long ago? It seems ap-parent from an examination of themindfulness based approaches it doesnot. What I formally practiced inten-sively in sheltered settings for up to 12hours a day bears little resemblance tothe research studies and therapeutic ap-plications presently in vogue, whichoften feature exercises ranging fromthree to 20 minutes (e.g., Semple, 2010).There appears to be little guidance re-garding the optimal amount of practicetime, as this issue has not been ad-dressed systematically (Moore, Gruber,


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Derose, & Malinowski, 2012; Slagter,Davidson, & Lutz, 2011). The Buddhistapproach to mindfulness is foundedupon personal practice of meditation—not intellectual knowledge. When re-searchers and clinicians attempt to usethe concepts without the foundation ofpersonal practice, there are bound to beproblems with their work (Grossman,2010; Walsh, 1980).

For example, the spate of recent surveyinstruments created by researchers tomeasure the impact of mindfulness relyon self-report by subjects, who are beinggiven short periods of guided exercises.Although 10 minutes of an exercise eas-ing clients into the present may help torefocus attention briefly, I am quite skep-tical that it is going to be sufficient tochange the orientation of daily experi-ence. Given today’s speedy, digital,multi-tasking world, in which peoplespend more time on their cell phonesand preoccupied with social media thanthey do in face-to-face social contact, 10minutes of mindfulness is simply notgoing to make much of a dent in theirhabitually scattered attention span.

Anyone who has practiced Vipassanameditation in a formal and intensivemanner understands that it may takehours of concentrated sitting simply toallow the musculature of the body tofully de-stress, permitting the tensionaccumulated in the shoulders, face,neck, chest, thighs, and legs to dissolve.Dealing with waves of various bodysensations, including pain, that occurwhile sitting cannot take place in a fewminutes. Likewise, the slowing of thebreath to a steady rhythm does notoccur in a few minutes, nor does beingable to sit completely still in a traditionalcross-legged posture.

So, I don’t think equating mindfulnesswith relaxing into the present with non-judgmental awareness is the same as

mindfulness as it is practiced in tradi-tional Vipassana meditation. Almostanyone may learn to bring attention intothe present for a few moments or min-utes without cognitive evaluation. Butattempting to sustain the practice continu-ously in all of one’s waking activitiesthroughout the day is a different en-deavor. From my perspective, it is the in-tention, depth, and duration of formalVipassana insight practice that distin-guishes it from the more surface orien-tation of the current concept ofmindfulness as it is being applied inpsychotherapy.

All Aboard the Thought Train During sitting meditation, when thebody has been de-stressed and settledinto a completely movement-free state,attention may be focused exclusively onmore subtle cognitive processes.Thoughts normally in the background ofawareness suddenly spring forward,clamoring for attention. It is as if one’sthoughts have a screaming voice, de-manding to be heard. This is a commonoccurrence when one has been sitting forhours, and is usually experienced aftertwo or three days of intensive practice,if not before. The meditator may getcaught in early childhood dramas, unre-solved issues in relationships, themes ofpower, control, sex, or other ego needs.For others, the content will include moreexistential issues, around meaning in lifeor important choices in life direction.There may also be vivid inner visual im-agery. This material may be of interestand significance psychologically, as itbrings to consciousness what had beenrepressed or suppressed. This, of course,is not the aim of meditation. But it is acommon occurrence and may add a di-mension of insight that otherwise wouldnot be easily accessed.

Part of the rationale for sitting in a cross-


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legged position on a cushion is to estab-lish a solid physical base so that atten-tion need not be unnecessarilydistracted by having to deal with thebody. One may then more fully and dis-passionately witness the chain of men-tal associations as they arise, linger, andthen fall away, only to be followed byanother in an ongoing stream.

In fact, one of the more powerful toolsVipassana meditation has to offer themindful psychotherapist is this ability tometiculously witness these associationsand notice how they may lead to subtlefeeling states and stronger emotions.This exquisite awareness includes whatI have called the “intending space”(Hendlin, 1984b), or thoughts related todeciding to move into action, such asspeaking or moving the body. Thesethoughts of intention are normally tak-ing place so quickly and unconsciouslythat we do not notice them as we mayduring meditation. This can be facili-tated through very slow walking medi-tation, as well. During intense retreatpractice, walking meditation typicallyalternates with periods of sitting. Itserves the purpose of not only giving themeditator a chance to relieve some of thepain of long periods of sitting, but alsoto practice mindfulness continuouslythrough all of one’s actions. The medita-tor is taught to use one word in notingan action as it is occurring. So, for ex-ample, during walking meditation, thenoting may be: “Lifting, moving, andplacing,” as one lifts the foot, moves it,and places it on the ground. This tech-nique of noting is used to help stabilizemindfulness and avoid distraction. It isbasically viewed as a scaffolding thatcan be removed when desired.

Meditators begin to more intimately un-derstand how thoughts become reified,or “hardened” and taken as substantialand real, rather than as just passing

thoughts. The pithy way to say this is,“The thought of your mother is not yourmother.” At its worst, reification ofthought may progress to obsessive ru-mination and then premature behaviorbased on the rumination. For the mind-fulness-based therapist, it is this power-ful method for enhancing the ability toclearly identify associative thought pat-terns and their relation to subtle feelingsand emerging emotion, which, I suggest,is most useful—not learning to bring themind back from reverie into the present.

This practice of thought-watching doesnot confine the meditator with instruc-tions to cut off thought by returning themind back to the present as soon as itwanders. Rather, much like a horsegiven free rein to graze in an open pas-ture, it allows the mind to roam, withthe simple instruction to witness thechain of associations without interrupt-ing or judging them.

One result of this kind of practice is theability at any moment to answer thequestion, “Where is your attentionnow?” This is a common question askedof patients in Gestalt therapy. Frombeing typically unable to answer thisquestion at the beginning of treatment,through paying more attention tothought streams and inner dialogue, thepatient learns increased ability to accessand, “hear,” thoughts more clearly.What I am suggesting is that true mind-fulness meditation—for both therapistand patient—promotes this greaterawareness of one’s inner landscape.

Another result is one experiences fewerepisodes of momentary or extended“spacing out,” in which one mentallyspirals down into an inner space tunnelof thought, but is then unable to re-member and verbalize the content ofthought when coming out of the spiral.


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Vipassana meditation helps knowingwhere one has been when one hasspaced out. One may spend time onmental detours, but, by knowing (re-membering) where one has been, onewill not have lost pockets of time in acognitive amnesiac vortex.

Contemporary portrayals of mindful-ness as present-centered and non-evalu-ative awareness do not include thetraditional Buddhist meanings of theterm, such as remembering the goals ofpractice based on previous learning(Bodhi, 2011; Dreyfus, 2011; Kirmayer,2015). This means remembering one’spurpose in meditating, including elimi-nating greed, hatred, and delusion whilecultivating wisdom, compassion, andloving-kindness (Gethin, 2011).

The Consumption Black HoleWhile we would not have predicted thecurrent surge of interest in mindfulness,it should not be surprising that thetransmission of a Western-friendly, psy-chologized, and decontextualized rendi-tion of it would be packaged forindividual mass consumption or for de-livery in health care settings. In fact,over 30 years ago, I was already warn-ing both professional and lay audiencesof what I termed “pernicious oneness”in the marketplace (Hendlin, 1983a,1983b). I put it like this:

Perhaps Marcuse (1966) was correctin his analysis of our economic sys-tem. He believed that anything thatcould potentially bring about a rad-ical transformation of the capitalistsystem (which wide-scale transper-sonal consciousness could indeeddo), would be swallowed whole bythe system before it could have adisruptive effect and then would beoffered back to the consumer in away that would further strengthenthe system itself.

Simply put, we are now confrontingthe consequences of “New Age”commercialism in the market place,not the least of which is the blend-ing of Eastern and Western philoso-phies to the point of blurring andover-simplifying their beliefs andpractices so they will be more palat-able to the Western appetite forsomething that ‘goes down easily,’where no chewing (discrimination)is required. Westerners, for the mostpart, want their spirituality thesame way they want their drive-through hamburgers: without sub-stance and without waiting.(Hendlin, 1983a, p. 63.)

In varying renditions, this point hasbeen made more recently by a numberof others (e.g., Cushman, 1995; Hunt-ington, 2015; McMahan, 2008; Purser,2014; Schedneck, 2013; Stanley, 2013;Wilson, 2014).

I will leave to Buddhist scholars andpundits to debate on the adaptation ofcontemporary notions of mindfulnessand their relation to traditional Buddhisttheory, ethics, and practice. If therapists,teachers, and consultants wish to apply“mindfulness-based” interventions toclinical and nonclinical problems suchas overeating, anxiety, obsessive-com-pulsive behavior, wasteful consumption,parenting issues, sexual pleasuring,workplace stress, achieving greater corporate profits through increased em-ployee productivity, sports perform-ance, or staying focused in policeconfrontations and military combat, Ihave no objection.

My position is simple: Any concept,method, or tool—decontextualized ornot— that helps people feel more alivethrough the immediacy of experienceand, at the same time, helps alleviate


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suffering on all levels (ego, existential,and spiritual) has a place in the thera-peutic armamentarium, as well as withthe population at large. Over 30 yearslater, it is even more apparent that thesupermassive black hole of consumerconsumption is, for good and bad, likelyto devour and homogenize everythingin its path.

Considerations for the mindful TherapistAs counterintuitive as it may seem,many of those studying or teaching con-temporary mindfulness have little or noactual experience themselves with prac-tice (Brito, 2014; Grossman, 2010; Kabat-Zinn, 2003; Khong, 2009; Mikulus, 2007,2010). Because many of the cognitive-be-havioral psychotherapies do not em-phasize that therapists in training haveexperiential engagement with the tech-niques they are learning (Brito, 2014), wehave the rather perplexing predicamentthat therapists may learn about mind-fulness only from a book or instructionmanual.

Thus, one important consideration forthe mindful therapist would be to valuethe deeper transformative possibilitiesof mindfulness meditation, as it hasbeen practiced for 2,600 years. In theBuddhist contemplative context, thismeans cultivating wisdom and compas-sion. But the search for a “higher self”need not be couched within a theistic re-ligious context, as the Dalai Lama hasbeen declaring for decades (Gyatso,1980). Healthy spirituality is not limitedto any one set of beliefs, doctrines, orpractices. As Vaughn (1991) has put it,“Spirituality can be found everywhere,not only in temples, churches and syna-gogues, not only in the stars, not only inmusic and song and dance, not only inthe beauty of nature or the intimacy of alove relationship, but in every momentof every day of ordinary life” (p. 116).

A second consideration for the mindfultherapist is the realization of the imper-manence of all phenomena. The deeperthis realization, the more one is able toallow all things to naturally “fall apart.”The body is continually changing, themind is continually offering up morethoughts, time is passing, and the outerworld in which we are living our every-day lives is in ceaseless flux. While weall know this to be true as a generality, itdoes not stop the part of us that clings tokeeping our lives as stable and secure aspossible. And, at least unconsciously, weapprehend that we are always just onebanana peel away from the end of ourlives and having to confront the GreatImpermanence.

When we not only accept but embraceimpermanence, we more easily surf thewaves of change without getting caughtin the pervasive undertow of fear anddread. This acceptance of imperma-nence is important as a coping and sur-vival skill because it allows us to becomemore resilient, to move on from surprise,trauma, disappointment, regret, and re-sentment and let go of the everyday up-sets that result when we cling too tightlyto any given fixed outcome.

A third consideration for the effectivemindful therapist is valuing the need forgoing beyond ego strengthening and in-cluding in one’s work, when appropri-ate, the process of dis-identification withthe ego to what may lie beyond the in-dividual self. Psychotherapy typicallyfocuses on developing a functional egostructure to help cope adequately withthe demands of the existing culture. Ac-cording to Kornfield (1996), traditionalpsychological techniques “do not de-velop the penetrating insight that helpsone cut through the deeper layers of il-lusion and hallucinations about individ-ual separateness” (p. 100).


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Wilber (2016) views the next step as abridging together what have been thecontrasting processes of what he calls“growing up” and “waking up.” Hemaintains that, up to the present, thesetwo distinct tasks have been addressedseparately. Growing up was the realm ofdevelopmental psychology and psy-chotherapy, while waking up was therealm of the Eastern contemplative tra-ditions. He believes it is now time for afocus on methods that address both di-mensions, claiming one without theother is only part of the picture.

Finally, the mindfulness based therapistwould be well advised to learn how toeffectively work in the present. I havewitnessed no better approach for under-standing how to do psychotherapy inthe present than Gestalt therapy. Thepower of learning how to comment on apatient’s present behavior, withoutreservation, can be quite lively and in-structive. As therapists, we are in an ex-perimental crucible that permits andencourages honesty and directness. Ifthe interest of the mindful based thera-pist is to help patients experience whatthe present is all about and to work withbehavior in the here and now, this inter-est aligns well with Gestalt philosophyand practice. While it is obviously not

currently in vogue, there are plenty ofgood Gestalt therapists still practicingthroughout the world. To expand yourcognitive-mindful practice skills, findthem and learn what they have to offer.

My perspective here has been framedthrough the lens of a life-long seeker ofwisdom in whatever belief system orpractice it may be discovered. On theone hand, I have been delighted to wit-ness the enthusiasm for contemplativewisdom beliefs and practices, such asmindfulness, expand in psychologicalresearch and practice, and into the cul-ture at large. On the other hand, I wantto see these practices be taken to adeeper level, so that they may be expe-rienced in all of their intrinsic brilliance.

Editor’s Note: For additional informa-tion, please see Dr. Hendlin’s compan-ion piece, “7 Ways to Be More Mindful”(Hendlin, 2016), available at: http://so-cietyforpsychotherapy.org/7-ways-to-be-more-mindful/


NOTICE TO READERS





With the leadership ofDrs. Changming Duanand Rod Goodyear, theInternational Domainhas initiated a partner-ship with Oriental In-sight to promotecollaboration in re-search and training.This partnership willalso help recruit moreChinese psychothera-pists to become mem-bers of SAP. With thegenerous donation ofhis Presidential Ad-

dress time, Dr. Armand Cerbone over-saw the official signing of thepartnership agreement at the APA con-vention in Denver in August (please seethis issue’s President’s Column for moreabout this historic event). SAP alsohosted a dinner for our Oriental Insightsguests at the convention.

As part of its collaboration with OrientalInsight, the Society co-sponsored a clin-ical supervision training program inChina. This co-sponsoring role was ini-tiated by then President-elect, Dr.Goodyear, and approved by SAP in its2014 Fall meeting. Since then, we havecompleted the traini one class and are inmiddle of the second class training. Thetraining is designed for a duration ofone year. In the first class we had 35trainees, and in the second, 44. Manywell-known clinical and counsellingpsychologists, including the leaders of

the Clinical and Counselling PsychologyRegistration System (CCPRS), aretrainees in the classes. The third classwill start April 2017. This program hasbeen very successful so far. It has gainedsignificant visibility in China and, mostimportantly, it has helped reinforce themessage about the critical importance ofprofessional ethics and clinical supervi-sion in the professional development ofpractitioners as well as the healthy de-velopment of the profession in China.As well, SAP has been prominentlyidentified with it.

As a follow-up to the agreement signedin Denver, the International Domain willbe proposing that the Society co-sponsorthe Wuhan conference in 2017. With themomentum built by the supervisiontraining program, CCPRS is seeking co-sponsorship from SAP to host the firstsupervision conference in April 2017 inWuhan, China, which will be organizedby Oriental Insight. Dr. Duan, a SAPmember, is a member of the three-mem-ber organizational committee, which hasmet once. The other two members areProfessor Guangrong Jiang, a leadingfigure in counseling psychology inChina, a professor in China Central Nor-mal University, a major leader inCCPRS, and the founder of Oriental In-sight, and Professor Xioming Jia, a lead-ing figure in clinical supervision (both inpractice and research), a professor inBeijing Institute of Technology, and a

INTERNATIONAL AFFAIRS

International Affairs Update

Frederick T. L. Leong, PhDDomain Representative

Changming Duan, PhDChair, International Committee


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major leader in CCPRS.

Drs. Goodyear and Falender will be in-vited to be on the seven-member Bureauof the Assembly, as well as the Scholar-ship Committee for the conference. Thetentative name of the conference is “Su-pervision and Ethics: Professionalizationof Clinical and Counseling psychologyin China.” The conference will focus onmainly an audience of practitioners, andwe intend to invite all trainees from the

three supervision training classes to at-tend. SAP’s anticipated involvement canbe providing guidance and expertise.Most likely (pending further discussion)there will be pre-conference workshopswhere SAP members’ expertise will behelpful. The benefit of SAP will includeincreasing its visibility and influence inChina, collaborating with CCPRS andOI, and having some members interactwith Chinese psychotherapy practition-ers and trainers.



Mental health professionals in most ju-risdictions are obligated to report inci-dents of abuse or neglect of children(Child Welfare Information Gateway,2016) or “at risk” adults (see, e.g., Stiegel& Klem, 2007), but are not required to re-port disclosures of animal abuse. Basedon research supporting the link betweenpathological behavior and animal abuse,however, some argue that the disclosureof animal abuse in a clinical setting iscomparable to expressing intent to harmand should be treated as such (Long &Kulkarni, 2013; Pagani, Robustelli, & As-cione, 2010; Patterson-Kane & Piper,2009; Walters, 2014). By acknowledgingthis correlation, mental health profes-sionals can better identify individualswho are at greatest risk for engaging inviolent acts and provide early interven-tion to deter such behavior, while alsoprotecting the welfare of mistreated an-imals. For these reasons, we believethere is a critical ethical need for psy-chologists and other mental health clini-cians to seriously consider thedetrimental ramifications of animalabuse. This proposed ethical mandateseeks to uphold the American Psycho-logical Association (APA) Ethics Code(2010) principles of beneficence andnonmaleficence, justice, and respect forpeople’s rights and dignity.

Animal Abuse: Concerns and CorrelatesThe strong link between animal abuseand the abuse of persons (Long &Kulkarni, 2013; Pagani, Robustelli, & As-cione, 2010; Patterson-Kane & Piper,2009; Walters, 2014) supports the ideathat animal abuse represents a real pre-cursor for human harm. The currentDiagnostic and Statistical Manual of

Mental Disorders includes animal abuseas a criterion for the diagnoses of bothAntisocial Personality Disorder (ASPD) andConduct Disorder (American PsychiatricAssociation, 2013). Conduct disorder iswidely associated with rule-breaking be-haviors, including harm to others, theft,deceitfulness, and property loss or dam-age (Haden & Scarpa, 2005). Further-more, animal abuse is viewedas a reliable diagnostic criterion of Con-duct Disorder, and indicates a likely es-calation of harm by the afflictedindividual (Haden & Scarpa, 2005). Dataanalyzing personal histories of serialmurderers, child abusers, and violent of-fenders demonstrated that, in mostcases, animal abuse was present inchildhood or early adulthood (Patter-son-Kane & Piper, 2009). Therefore, atherapist who learns a client has com-mitted animal abuse should view theabuse not as an isolated or harmless in-cident, but rather as potentially sympto-

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ETHICS

Toward mandatory Reporting of Animal Abuse

Elizabeth Shum, Nicole Pond, M.Ed, Karlyne Morawe,Leigh KunkleUniversity of DenverGraduate School of Professional Psychology

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matic of a larger constellation of psy-chological problems, which may lead tothe harming of a human. A therapistwho does not seriously consider the effects of animal abuse may miss an im-portant opportunity to prevent a possi-ble risk to society.

Of course, not all clients who harm animals will go on to harm people. Re-gardless of whether animal abuse defin-itively leads to the harming of anindividual, therapists should regard an-imal abuse as an indicator of a seriousneed for specialized treatment. Animalabuse in childhood is associated with in-creased criminality, aggressive tenden-cies, and otherwise deviant behavior inadulthood (Walters, 2014). One mayargue that using preventative strategiesin therapy is more beneficial than treat-ing an already developed mental ail-ment. If animal abuse can be viewed asa prevalent precursor to later problems,it is crucial for therapists to take extracare treating clients who are abusing an-imals, in an effort to fully assess themeaning of the client’s harmful behav-ior, and to intervene therapeutically toprevent further escalation.

Animal Rights: Benefits and ChallengesAnimal sentience is a concept both wellresearched and supported, which leadsto our final point that animals shouldhave the same rights as people. Cur-rently, in the United States, animals areprotected by the Animal Welfare Act(United States Department of Agricul-ture, 1970), but this does not addresstheir right to not be exploited by hu-mans. This Act primarily addresses theprotocol for humane use of animals inresearch studies. In both Germany andSwitzerland, animals are afforded basicrights on the same level as humans, andthis protection is embedded within theconstitutions of both countries (Evans,2010). Additionally, there is research

suggesting animal sentience is notmerely anecdotal. Several studies havefound evidence for animals possessingmoral behavior, empathic behavior, andjustice behaviors (Pierce & Bekoff, 2012).In addition, researchers now agree thatanimals feel pain in much the same waythat humans experience pain (Pierce& Bekoff, 2012). If we can accept animalsas conscious, sentient, and empathic be-ings, we can begin to conceptualizethem as belonging to the same moralcommunity as human beings—and de-serving of many of the same legal andethical protections.

Some may argue that requiring therapiststo treat the disclosure of animal abuse asan indication of increased risk may haveadverse effects on the therapeutic rela-tionship, especially if the therapist offi-cially reports these behaviors. Sucheffects may potentially include restricteddisclosure by the client or a compromiseof confidentiality. Upon initial imple-mentation of mandatory reporting forchild abuse, many psychotherapists ex-pressed similar concerns with the effectsmandatory reporting would have ontheir practice. Doueck, Levine, and Stein-berg (1997) conducted a survey of 907psychotherapists in which they outlinedmany of these concerns, including theimpact of “placing higher value on theprotection of children than therapeuticconfidentiality” (p. 112), losing theclient’s trust, and limiting the level of dis-closure by the client. However, this studyconcluded that the concerns were not asdetrimental as initially believed. In fact,25% of clients discontinued treatmentafter a mandatory report occurred. Thisnumber is not insignificant, but demon-strates that reporting child abuse did nothave as great an impact on the relation-ship as feared. Doueck and colleagues(1997) suggested strong relationshipswith clients would minimize the out-


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come of mandatory reporting, therebymaking the rupture in the relationship re-pairable. It is likely that similar dynam-ics would play out in the arena ofmandatory reporting of animal abuse.

Another common counterargument formandatory reporting of animal abuse isthat judging the extent of the abuse canbe largely subjective. Therapists may notknow where to draw the line or what isconsidered serious enough to warrant areport. Clinicians may base their opin-ions solely on personal beliefs, whichcould lead to over-reporting and misuseof resources (Webster, O’Toole, O’Toole,& Lucal, 2005). In addition, cliniciansmay not know what is meant by “ani-mal”; that is, many would not considerit necessary to treat the abuse of an in-sect seriously. For instance, if a clientmentions stepping on ants for fun, theclinician may feel conflicted as towhether or not this is animal abuse.There is not a clear answer to thisdilemma, and it would be necessary forthe therapist to gain more informationto understand the context in which theclient’s behavior occurred. One solutionwould be to attend carefully to the re-ported mistreatment of any animal (e.g.,insects, reptiles, mammals) to learnmore about why the behavior is occur-ring, and then use clinical judgment todetermine if it is serious enough to war-rant extra care.

Conclusion and Future StepsGiven the correlation between patho-

logical behavior and animal abuse, wepropose an ethical mandate for mentalhealth professionals to grant necessaryand sufficient clinical consideration tothe act of animal abuse. In so doing,mental health professionals may be ableto better identify individuals at greaterrisk for committing abuse of humans;they may gain insight on best practicesfor treatment with clients involved inthese behaviors; and they will gain re-spect for the rights and dignity of non-humans. By conscientiously exploringthe concerns raised by animal abuse, cli-nicians may better intervene to proac-tively address these correlates of violentbehavior, while simultaneously protect-ing the welfare of mistreated animals.

Although it is outside the scope of thispaper, we hope that the argumentsmade here may inspire future proposalsworking toward a revision of the APAEthics Code (2010). In particular, the au-thors invite a thorough reconsiderationof the ethical principles of beneficence,nonmaleficence, and justice in light ofthe growing body of research support-ing the conceptualization of animals assentient beings whose rights and dignitymay be inseparable from our own.


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Psychotherapy and thetherapeutic space areintended to be sanctu-aries overseen by anever-present, always-supportive clinician,but they not immune tosocietal pressures and

challenges, such as racism and prejudice.Given my previous experience in psy-chotherapy as a young child and my re-cent experiences as a clinician, I trulyvalue the ways in which clients allow meto co-create safe spaces with them so thatwe can conduct our therapeutic business.Although the space in therapy is deliber-ately intended to be “safe,” the real worldis far from a consistent or purposefullyprotective environment, and therapistand client alike can encounter significantsocietal dangers in between sessions. Is-sues related to identity are often ignoredor discouraged in the greater community,and clinicians need to work diligently toavoid reacting similarly to their clients.One frame that has been featured promi-nently in my recent therapeutic work hasbeen the Black Lives Matter movement(Cullors, Tometi, & Garza, n.d.) and is-sues related to addressing the discordand tension between police and the Blackcommunity.

When the Black Lives Matter movementstarted on the heels of the Trayvon Mar-tin-George Zimmerman case in Floridain 2012, the organization was founded inorder to both celebrate Black culture andto address areas of inequality thatplague the lives of African Americans in

the United States (Garza, n.d.). Today,that mission continues, although manyhave criticized the label “Black LivesMatter” and argue that the term is divi-sive and separatist. For those like myselfwho are members of the Black diasporahere in the United States, Black LivesMatter follows in the tradition of otherstatements of Black pride and affirma-tion such as “No Justice, No Peace,” “ByAny Means Necessary,” and “Say itLoud (I’m Black and I’m Proud).” Thestories of minority communities hereand abroad often contain references tosimilar rallying cries, as methods usedto assist the group in its march towardsequality, while also affirming pride inone’s identities. Both on social mediaand in the public conversation, there arethose who object to this slogan and in-stead would like to substitute it with theseemingly more inclusive terms “AllLives Matter” or “Black Lives Matter,Too” (see, e.g, Shapiro, 2016). To many,these revised rallying cries speak to howsociety needs to focus on affirming thelives of all its people, but what it fails toacknowledge is that there has been along and substantial history of subjuga-tion of Black people in the United States.The phrase “Black Lives Matter” is nec-essary because that has not always beenthe case, with the most perfect exampleof the lack of acknowledgement of Blacklives being how the United States Con-stitution, which was signed in 1787 andoutlined the rights of the growing na-tion, failed to acknowledge African


CLINICAL NOTES WITH DR. J

#BlackLivesmatter in Psychotherapy

Jonathan Jenkins, PsyDMassachusetts General HospitalAssistant in Child and Adolescent PsychiatryHarvard Medical School Instructor in Psychology (Psychiatry)

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Americans when espousing the equalityof all men (Fredrickson, 2003). “BlackLives Matter” is not an exclusionarystatement, but instead an opportunity tohighlight the needs of a particular com-munity that might get lost in “All LivesMatter” or similar slogans (see “11 MajorMisconceptions,” n.d.). Similar to howcollege campuses often orient sexual as-sault education and prevention towardfemale students, due to the vast and sta-tistically significant gender differences insexual assaults (RAINN, 2016), those in-stitutions are not ignorant of the needs oftheir male students, but instead want tofocus most (not all) of their energy on themost victimized population while stillsupporting males on campus to the bestof the school’s ability.

As a minority psychologist who self-identifies as an African American orBlack male, the recent clash between theBlack community and police officers hashad a unique impact on both my thera-peutic relationships and on my ownview of self. Black psychologists havehad to conduct psychotherapy in themidst of various levels of acceptanceand racism by the greater society andthis has had significant impacts on thetherapeutic delivery and job satisfactionfor clinicians of color. My modern expe-rience is no different: My therapeutic de-livery is permeable to not only theprivate circumstances occurring in myown life, but also to the current eventsof my community. Since the start of theNew Year, at least 123 members of theBlack community have been killed at thehands of police officers (Pazzanese,2016). Additionally, according to theAmerican Civil Liberties Union (ACLU),88 individuals out of the 598 citizenswho had fatal encounters with policewere unarmed (ACLU, 2016), with two-thirds of Black males killed by police re-portedly being both unarmed andinitially accosted by police for possible

nonviolent offenses (Sinyangwe, 2016).In my current city of Boston, Massachu-setts, the police homicide rate overall is1.6 per million, while it skyrockets sig-nificantly for Black people to 7.6 per mil-lion (Sinyangwe, 2016). For my clientsand for myself, these statistics illuminatea reality for many African Americanpeople in this country: members of thiscommunity do not feel safe during en-counters with police. In addition, the nu-ance of how many of these fatalencounters have been recorded to thenbe viewed on social media or the newshas added a new dimension to thisissue. Besides being reminded of thesesituations through anecdotes passeddown by family members or discussedin community hubs, these incidents cannow be viewed by the masses in graphicand explicit detail. For the clients I serve,being exposed to these videos and bear-ing witness to the violence caught ontape can increase stress and further thepsychological agitation that the client al-ready experiences. Additionally, de-pending on how peers react to thevideos or their views of the societal is-sues, clients might also feel further iso-lated from their support systems. Iremember having a conversation withone specific client about racism and hisemotions. During that conversation, andmany others like it, we spoke about theimpact of racism on his presenting issueand the client wondered out loudwhether he would be “cured” if he wereWhite and not the victim of consistentprejudice and discrimination. These con-versations continue to haunt me, as theconversations highlight the uniquestressors that clients of color face interms of not only navigating life withtypical mental health challenges, butalso having to do so often on top of cop-ing with racism and other societal ills.

As a clinician, I have felt racial stress be-


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fore and I have yet to find a solution toovercome this painful distraction. Whathas worked best for me is to listen andacknowledge. Although the listeningpart of this equation seems easy, it canoften be difficult to hear about some ofthe painful and disgusting experiencesthat some in our community have facedat the hands of others. Listening requiresthe clinician to allow the client’s story tohave an impact and to help the clientprocess the event in the context of theclient’s own social-emotional challenges.During these specific encounters, I oftendebate whether I should self-discloseand consider the potential impact ofself-disclosure on the therapeutic al-liance. My nonscientific observations onracial self-disclosure in therapy havebeen that Black children are curiousabout my experiences as an older, orslightly older, Black male. Whereas I wasonly one standard deviation away fromthe Civil Rights Movement and canwatch footage from the marches orprotest and envision my parents or otherloved ones in those situations, 10 to 14year olds today are even further re-moved from that revolutionary history.Also, the influence of President BarackObama cannot be ignored (Anderson,2016). Although we, as adults, have onlyspent a small portion of our lives withBlack people occupying significant andpivotal leadership roles in both the pri-vate and public sectors, Black childrentoday have had the luxury of spendingthe majority of their lives during a timewhen a person of color occupied themost powerful position in the Westernworld. My experience as a child was sig-nificantly different than that of childrentoday, as the most prominent Black peo-ple I saw were either family friends orfictional characters on television. I canalso distinctly remember experiences asa young child in which the invisiblehand of systemic racism squashed mydreams, including being chastised by

peers for writing a short essay in secondgrade about wanting to become Presi-dent. Clinicians like myself can seeksupport in a variety of ways to help mol-lify the ill effects of racism, includingconsultation and supervision; by reach-ing out to other clinicians, especiallythose who share similar socioculturalidentities, therapists can distill their ownfeelings, ultimately improving collabo-ration with the client. Taking this spaceas a clinician is critical, because collabo-rating around these issues in ways thatare simultaneously authentic, bound-aried, and therapeutically effective canbe challenging.

Through curating particular stories frommy Black experience, I can provide rea-sonable expectations for clients, whilealso fostering more conversation re-garding preparation for increased expo-sure to racism throughout the lifespan.But with this self-disclosure comes atremendous responsibility. Self-disclo-sure does not mean indoctrination or therandom or careless sharing of experi-ences, but it entails the thoughtful, age-appropriate disclosure of certainexperiences that can serve to further thetherapy and inform the client with athoughtful intention.

When I reflect upon my own archetyperelated to policing within the GreaterBoston community, I am compelled tothink about both historic events involv-ing police and the Black community inBoston, and my own personal historywith police officers. As a Black 11 yearold boy growing up in the GreaterBoston area, I, like many other Blackmales, was given “the talk”—whereboth of my parents educated me abouthow to interact with police, even duringtimes when I was in the right. This“talk” has become more widely knownby the greater community as several


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media commentators have spoken aboutthe term and its recent appearance in anepisode of ABC’s acclaimed show, Black-ish (Patel & Barris, 2014). Although I amsure that most people’s hearts skip abeat or two when accosted by police, myheart beats faster because I am con-sciously aware of my fear. I often hatethis fear as I have had plenty of interac-tions with pleasant, rational, and dedi-cated police officers, but my mind stillholds onto those less than stellar inter-actions. In my own life, I have sufferedunwarranted harassment by the policeand have taken no recourse because, forme, these instances were just a part ofwhat it meant to be Black in America.But it is not just my own experiencesthat inform my concerns about police;significant historical events also rever-berate in my mind, including the em-barrassing guns-drawn stop of BostonCeltics Rookie of the Year, Dee Brown, inWellesley, Massachusetts in 1990 due tothe generic description of a bank robberfrom earlier that morning (Butterfield,1990). Stories like these and my ownmemories mix to create a complicatedunderstanding of my relationship withpolice officers. I strive to be as holistic asI can in my thinking and acknowledgethat there are poorly trained and racistpolice officers, without painting mywords with too broad of a brush and la-beling all police as corrupt or danger-ous. I also recognize the power that Ihave as a clinician, in that my words

carry significant weight in the minds ofmy clients. I do not want them to acceptany biases that are going to be in con-tradiction to their stated goals of therapyor cause them physical or emotionalharm in the real world.

As a therapist, the best way I can sup-port the Black Lives Matter movementis to continue to provide a safe space forall people to speak about issues relatedto power, privilege, and prejudice, whilecelebrating the identity and accomplish-ments of my fellow Black communitymembers and other minority groups.Outside of direct clinical service deliv-ery, I can also support the Black LivesMatter movement by illuminating theunique experiences of clinicians of color,so as to make us more visible within ourown professional community. I am for-tunate to have a platform to advocate forthe unique needs of the Black commu-nity both in and out of the therapeuticspace, and, with these platforms, I hopeto foster continued dialogue on this sub-ject so that positive growth may occurfor all communities.

#BlackLivesMatter.


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An area of diversityoften overlooked is so-cioeconomic status.Homeless clients are atan extreme end of thesocioeconomic statuscontinuum and presentwith concerns and

stressors related to poverty. People oftenstart psychotherapy due to a major stres-sor in their lives. Finally, after some ap-prehension, they make the initial leap toget help and enter your clinic or office,scared, yet a bit relieved as they embarkon the journey of healing through psy-chotherapy. But, what if the client’s orig-inal stressor prevents them from beingable to access the very care from whichthey could likely benefit? Homelessnessposes such a dilemma. Homelessnessprevents many from obtaining the helpthey need to overcome or manage psy-chosocial stressors and/or mental healthdiagnoses.

The classic and stereotypical image of ahomeless individual is the unkempt,weathered man walking through citystreets, shouting and yelling to himself.Meanwhile, a common stereotype ofsomeone receiving psychotherapy is theupper middle class woman going to aprivate practice in the Upper West Side,sitting in a large office with attractivedecor. These are outdated ideas. Organ-izations and clinics providing servicesfor people with low-income and/or whoare homeless are incorporating behav-ioral health into their services. VeteransAffairs medical centers are increasinglyfocused on homeless veterans and en-

suring there are programs available tohouse and treat them. However, do notbe fooled: Access to care is still a signif-icant problem for most (Krausz et al.,2013) and studies examining access topsychotherapy often overlook thehomeless population.

Psychotherapy with the homeless popu-lation is not “treatment as usual.” Clinicsproviding services to the homeless mayneed to accept Medicare, Medicaid, or noinsurance at all. There may not even be aphysical clinic or office, and instead psy-chotherapy is provided outside on a parkbench or in a homeless shelter. Psy-chotherapists may find themselves work-ing on assertive community treatmentteams or visiting clients in transitionalhousing sites. Outreach work is oftenused with this population and is neces-sary (Krausz et al., 2013).

Currently, about half a million peopleare experiencing homelessness in theUnited States (U.S. Department of Hous-ing and Urban Development, 2015). Be-tween 79% and 92% of the homelesspopulation have a mental health and/orsubstance use disorder (Bharel et al.,2013; Krausz et al., 2013). Substance usedisorders are common in my work and,in Boston, my clients are frequently en-trenched in the opioid epidemic. Addi-tionally, opioid use disorders are acommon means by which my clientshave become homeless. In addition todrug use, the use of alcohol is alsoprevalent with this population (Bharel et

DIVERSITY AND SOCIAL JUSTICE

Psychotherapy and Homelessness

Astrea Greig, PsyDBoston Health Care for the HomelessBoston, MA


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al., 2013; Krausz et al., 2013). Anothercommon presenting concern is trauma.A recent study reveals that up to 60% ofhomeless women have experienced atrauma, whether emotional, physical, orsexual, while homeless (Riley et al.,2014); and, of course, homelessness itselfcan be traumatizing.

When first working with this popula-tion, I found myself regretting my wordchoices in giving homework and dis-cussing the nature of an assignment.Clients would say: “Well, I can do thisbut I don’t have a home for homework…”Often, clients would present with diffi-culties that seemed, from my perspec-tive, simple and easy to fix. Yet to them,these tasks seemed insurmountable. Forexample, a client with a college degreeand decades of experience working inaccounting presented with difficulty fill-ing out paperwork to request personalrecords. This population has helped meto never forget the impact that stress,anxiety, and depression can have on ourability to concentrate, plan, and focus.Psychologists working with behavioraleconomists have produced powerfulwork looking at how having no moneyaffects our cognitive processes (Shah,Mullainathan, & Shafir, 2012).

Similar to my work with clients with se-rious mental illness and psychosis, partof my work with homeless clients mustinitially focus on lengthy and high qual-ity rapport building. Engagement withprimary care and behavioral health serv-ices is difficult for this population(Krausz et al., 2013) and there is a majorlack of trust in organized systems andauthority among my clients. As a result,being engaged in the therapeuticprocess is not a given. I spend muchtime on building relationships and I feelhonored when I am let in. The physi-

cians, nurses, and case managers I workwith often have a supply of socks andtoiletries to give to clients, not just tohelp clients with their foot complica-tions or hygiene, but as a means ofbuilding rapport.

Homelessness is a social issue, largelydue to the lack of affordable housing(American Psychological Association,2010). In Massachusetts, the primaryreason for families becoming homelesscan be attributed to unstable housing.The second most reason is rooted in in-timate partner violence (MassachusettsDepartment of Housing and Commu-nity Development, 2016). Yes, once in agreat while I will come across a malin-gerer whom is trying to use various sup-ports and social services intended forpersons experiencing financial hard-ship—but someone’s willingness to dothat is also meaningful. Sometimes I be-come jaded, but then I remind myself ofthese statistics regarding the causes ofhomelessness.

While working with the homeless pop-ulation, I’ve met tremendously braveand strong people. People who have en-dured significant traumas and repeatedloss in destitute conditions, and yet whostill have a will to keep going. I haveclients who have not had the luxury of ashower and clean clothing in weeks, orthe comfort of a peaceful night’s sleep indays. I constantly find myself feelinggrateful for “the little things” in mywork, as it is a reminder these things arenot always so little.


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The therapeutic alliancehad been found to beone of the most robustpredictors of treatmentretention and therapeu-tic outcome (Horvath,Del Re, Flückiger, &

Symonds, 2011). In his seminal transthe-oretical formulation, Bordin (1979) em-phasized purposeful collaboration andthe affective bond between patient andtherapist as essential. This laid the foun-dation for its consideration as an inte-grative variable (Wolfe & Goldfried,1988) and as a change mechanism(Safran & Muran, 2000). Despite thelongstanding and widespread interest inthe alliance, there are still many who callfor a return to theorizing the construct.Questions abound regarding the overlapbetween the alliance construct and theoverall therapeutic relationship, how al-liance and therapeutic technique are re-lated, and whether the alliance measurescurrently employed by psychotherapyresearchers are valid (Hatcher &Barends, 2006; Horvath, 2006). A novelperspective on this complex relationshipmay serve to illuminate some of thesegaps in current understanding. Since itsinception, social psychology has de-voted itself to understanding interper-sonal relationships. Perhaps we maydiscern a clearer picture of the complexconstruct of the therapeutic alliance byapplying social psychological theories ofinterpersonal interaction. In doing so,we may begin to understand why itworks, how it works, and why some-times, it might not be enough.

Interdependence TheoryInterdependence theory (Kelley &Thibaut, 1959) began as a theoreticalconceptualization of social interaction.The theory aims to explain how the costsand rewards of an interpersonal rela-tionship interact with the expectationsof that relationship in order to explainthe ways in which people can affect eachother over the course of an interaction.To do so, interdependence theory takesinto account the method in which goalsare structured and how this in turn ef-fects the outcome of interpersonal inter-actions. The theory posits that, in orderto be able to predict what will occur in adyadic interaction, two features must beconsidered: the situation being con-fronted and each individual’s needs,thoughts, and motives with respect tothe current interaction (Van Lange &Rusbult, 2012). Whether each individualin a dyad is satisfied by an interaction,then, depends on whether the interac-tion gratified the needs of the individ-ual, such as the need for security orexploration (Baumeister & Leary, 1995).In the shift from self-interest to the goalsand wellbeing of the partner, interde-pendence theory explains how an inter-action is shaped in the broader contextof goals and partner welfare (Rusbult,Drigotas, & Verette, 1994).

The investment model of commitmentprocesses. Rooted in interdependencetheory, the investment model of com-mitment processes seeks to understandhow and why some relationships en-

STUDENT FEATURE

Expanding Horizons: A Look at the Therapeutic Alliance Through a Social Psychological Lens

Lauren M. LipnerAdelphi University


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dure while others crumble. This theorydeveloped out of research that revealedthat commitment was actually morepositively correlated with relationshipendurance than relationship satisfaction,as was originally implied by interde-pendence theory (Rusbult, Agnew, &Arriaga, 2012). Within the framework ofthe investment model, Rusbult andBuunk (1993) suggest that commitmentto another increases as a consequence ofsatisfaction, in addition to available out-side resources being perceived as lesssatisfying than those available in the re-lationship. A meta-analysis conductedby Le and Agnew (2003) found relation-ship satisfaction, the perceived qualityof alternatives, and investment in the re-lationship to account for nearly two-thirds of the variance in relationshipcommitment. Investment size, or the im-portance of the resources a relationshipprovides to an individual, interacts withrelationship satisfaction and perceivedpoor alternatives to result in high com-mitment to a relationship (Rusbult et al.,2012). Strong commitment to an inter-personal relationship fostered by theseprocesses results in partners being morelikely to remain in the relationship, aswell as exhibit various relationshipmaintenance behaviors (Rusbult &Buunk, 1993).

Based on our understanding of the in-vestment model, it would seem that, ifthe therapist is able to foster in the patienta satisfaction with and investment intreatment—in addition to a feeling thatthe existing alternatives, such as discon-tinuing treatment or seeing another ther-apist, are less desirable than sticking withthe current treatment—the patient’s com-mitment to the therapy will increase. Inturn, there will be a reduction in the riskof premature attrition, and a working al-liance with a foundation in a strong bondwill be cultivated, thus maximizing theimpact of treatment.

The Michelangelo phenomenon. An off-shoot of interdependence theory, theMichelangelo phenomenon describesthe mechanisms behind how close inter-personal partners can act to promote orinhibit an individuals’ movements to-ward their ideal selves (Rusbult, Finkel,& Kumashiro, 2009). The Michelangelophenomenon model proposes that peo-ple adapt to one another through theprocess of interaction, and change theirbehaviors to coordinate with another,while responding to the other’s needsand expectations (Rusbult, Finkel, & Ku-mashiro, 2009). The adaptation of one’sbehavior to another seems to be themost powerful and enduring when it oc-curs in the context of a highly interde-pendent relationship, as the mutualdependence between interdependentparties provides the opportunity for astronger influence on behavior (Rusbult,Finkel, & Kumashiro, 2009).

Partner affirmation, or the classificationof the other as ally, neutral, or enemy,has two components: partner perceptualaffirmation and partner behavioral affir-mation. Partner perceptual affirmationdescribes how partners perceive theother with regard to how compatiblethey are to their ideal selves. Partner be-havioral affirmation refers to the extentto which individuals behave in waysthat evoke behaviors from the other con-gruent with their own ideal (Rusbult etal., 2009). Individuals are most likely tomove toward their ideal selves whentheir partners exhibit both goal-affirm-ing perception and behavior, in additionto confidence in the individual’s capac-ity and behaviors that evoke features ofthe ideal self. Subsequent movement to-ward the ideal self results in both in-creased personal and interpersonalwellbeing. Thus, the Michelangelo phe-nomenon acts to “bridge the gap be-tween intrapersonal psychology and


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interpersonal psychology” (Rusbult etal., 2005, p. 375). According to Rusbult,Kumashiro, Kubacka, and Finkel’s(2009) findings, the similarity betweenpartners on the ideal self also plays alarge role in the individual’s own move-ment toward the ideal self. When eachpartner possesses components of theother’s ideal self, each serves to affirmthe other’s movement by evoking majoraspects of the other’s ideal. As each in-dividual moves closer to the ideal self inthe context of the relationship, the over-all wellbeing of the couple is augmented(Rusbult et al., 2009).

When patients present to psychotherapy,it is often because they feel far from theirideal selves. Based on our understandingof goal achievement in an interpersonalcontext provided by the Michelangelophenomenon model, the therapeutic al-liance and its propensity to result in pa-tient change may be functioning in muchthe same way. Where a strong therapeu-tic alliance has developed, members ofthe therapeutic dyad, while incongruousin many ways, tend to be similar in theirindividual perceptions of patient ideals.Further, patients would perceive thera-pists to be allies in their healing and thuscompatible to their ideal selves. In turn,the therapist would behave in ways topromote the patient’s movement towardthe ideal self by taking a supportive andtherapeutic stance in the interaction.Based on these ideas, an open discussionregarding patient goals for psychother-apy is an important component of build-ing a strong therapeutic relationship, andaddressing the expectations patientsmay have when they initiate psy-chotherapeutic treatment can be benefi-cial to having a successful workingrelationship.

Interdependence theory and its numer-ous derivatives have provided a deeperunderstanding of interpersonal interac-tion, interpersonal commitment, andchange processes. Perhaps the underly-ing mechanism of change provided by astrong therapeutic alliance in part re-sides in whether the outcomes of the in-teraction are equally satisfying for bothpatient and therapist, how both the ther-apist and patient serve to influence eachother, and how both patient and thera-pist independently perceive their rela-tionship and the available alternatives.

ConclusionThe social psychological theories of in-terpersonal interaction have providedpsychologists with a better understand-ing of the mechanisms at play in closefriendships, intimate relationships, andfamilial relationships. This perspectiveof interpersonal interaction could shedlight on one of the most promising con-cepts in the psychotherapy literature:the therapeutic alliance. Clinical psy-chologists accept that the therapeutic al-liance is important in the successfultreatment of a patient. However, gapscontinue to exist in our understandingof how the therapeutic alliance works tofacilitate change in patients and whatthe most efficient ways to build an al-liance are. The application of the inter-personal interaction theories of socialpsychology may serve to fill in thesegaps in our understanding and ulti-mately allow us to treat clients bothmore effectively and efficiently.


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The Department ofVeterans Affairs (VA)The VA is the largestemployer of psycholo-gists and nurses, andover the years hasdone an outstandingjob of providing high

quality health care while simultaneouslyfurthering the utilization of non-physi-cian providers of all disciplines. Thanksto the vision of Toni and Bob Zeiss andthe support of Ken Jones, the VA, whichhas long supported psychology intern-ships, is expected to provide approxi-mately 440 postdoctoral positions in thecoming academic year. This spring theVA proposed to amend its regulations topermit full practice authority for ad-vanced practice registered nurses(APRNs) when they are acting withinthe scope of their VA employment. “Thiswould permit VA to use its health careresources more effectively and in a man-ner that is consistent with the role ofAPRNs in the non-VA health care sector,while maintaining the patient-centered,safe, high-quality health care that veter-ans receive from VA.” At the closing ofthe public comment period on July 25,2016, over 214,000 comments had beenreceived. The American Medical Associ-ation (AMA) urged the VA “to maintainthe physician-led model within the VAhealth system to ensure greater integra-tion and coordination of care for veter-ans and improve health outcomes.” Onepolitical pundit opined that the AMAhad as much credibility on this issue asthe NRA did on gun control.

Under the leadership of APA immediatePast-President Barry Anton and Presi-dent-elect Tony Puente, 16 former APAPresidents submitted a letter in supportof the VA’s proposal:

Dear Mr. Secretary: As former Pres-idents of the American Psychologi-cal Association (APA), the nation’slargest organization of psycholo-gists with over 117,000 members,we urge you to ensure that the De-partment of Veterans Affairs (VA)allows its professional staff to workto the full scope of their practice toimprove access to timely, effective,high-quality care for Veterans. We,and the current leadership of APA,believe that expanding prescriptiveauthority within the VA for quali-fied nurses and doctoral-level psy-chologists is a fundamental andurgent component of a redesigned,improved ‘MyVA’ integrated plan.

One of the key recommendationsfrom the landmark Institute ofMedicine (IOM) report ‘The Futureof Nursing’ stated that “nursesshould practice to the full extent oftheir education and training.” Ascolleagues equally committed toproviding care for Veterans both in-side and outside the VA system, weconcur with the IOM that “nursescan and should play a fundamentalrole” in transforming care in thiscountry, and that “the power to im-prove the current regulatory, busi-ness, and organizational conditionsdoes not rest solely with nurses;


WASHINGTON SCENE

Fly Down the Highway

Pat DeLeon, PhDFormer APA President

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government, businesses, health careorganizations, professional associa-tions, and the insurance industrymust all play a role. Working to-gether, these many diverse partiescan help ensure that the health caresystem provides seamless, afford-able, quality care that is accessibleto all and leads to improved healthoutcomes.” Mr. Secretary, you havebeen instrumental in keeping theVA focused on what is best for theVeteran, and we believe that to doso requires the VA to ensure that itsclinical staff is operating at its high-est capacity.

In a similar vein, we expect that theVA also will soon make the internalpolicy changes necessary to recog-nize prescriptive authority for ap-propriately trained and certifiedpsychologists within the VA sys-tem. The Department of Defense(DoD) has granted this authority toits specialized psychologists forover 18 years, with zero adverse ef-fects or complaints during this en-tire period. The U.S. Public HealthService Commissioned Corps simi-larly allows psychologists with spe-cific training beyond their doctoraldegrees to prescribe a set of med-ications and meet the urgent needsof their populations, which includecitizens in Indian Country. Illinoisbecame the latest state to grant thisauthority to psychologists with ad-ditional degrees in psychopharma-cology and certification. It is clearthat the VA, in the face of increasingdemand for mental health care andrecognized access difficulties inrural areas specifically, must remaina pioneer in the health care arena byallowing nurse practitioners andpsychologists to serve Veteranswith the expertise and dedicationthey employ in the DoD, USPHS,and private sectors.

We would be happy to meet withyou and your Undersecretary ofHealth, Dr. David Shulkin, to dis-cuss the implementation of pre-scriptive authority within the VA...

Two additional Presidential colleaguesrequested being added to the letter;however, the submission date had al-ready passed. Our sincerest appreciationto APA’s Heather O’Beirne Kelly for heroutstanding assistance in making ourcollective voice heard on behalf of ournation’s Veterans.

A similarly supportive endorsementwas submitted by Dr. Lucinda Maine,Executive VP and CEO of the AmericanAssociation of Colleges of Pharmacy.

The American Association of Col-leges of Pharmacy (AACP) appreci-ates the opportunity to comment onthe proposed regulation… and issupportive of the proposal to “per-mit full practice authority for allVeterans Administration advancedpractice registered nurses (APRNs)when they are acting within thescope of their VA employment.” Wedraw upon significant experiencewith advanced practice authorityfor pharmacists and other healthcare providers in preparing thesecomments.

AACP recognizes that APRNs areincreasingly important providers ofprimary care services in the non-VAhealth care sector and applauds theVA for integrating these skilledhealth professionals into the VHA.We view this as an excellent oppor-tunity to “wisely manage its re-sources and fully utilize the skills ofits health care providers to the fullextent of their education, trainingand certification.” We support the


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VA taking the initiative to “estab-lish additional professional qualifi-cations an individual must possessto be appointed as an APRN withVA.” The VA’s proposal to stan-dardize the APRN full practice au-thority by reducing theconfounding factor of state regula-tion is an important step that allowsfor more consistent management ofpatient, provider and administratorexpectations within the VHA. Thisaction is an important step in in-creasing patient access to primarycare services, especially, as you rec-ognize, in medically underservedareas.

AACP is a strong proponent of pa-tient-centered team-based care. Asa founding member of the Inter-professional Education Collabora-tive (IPEC) we have worked closelywith our colleagues across aca-demic medicine, nursing, dentistryand public health to teach futurehealth professionals how to mosteffectively work together. Quite re-cently the IPEC organization ex-panded to include 9 additionalhealth professions education asso-ciations. As this includes the Asso-ciation of Schools of Allied HealthProfessions, IPEC now includes vir-tually all the health disciplines. Op-timizing the deployment of everyclinician is the only pathway to in-suring access to care for all, espe-cially special populations likeveterans who so often are in ruralor otherwise underserved commu-nities. Translating this work intothe care delivery systems our grad-uates will serve is also a high prior-ity for IPEC.

AACP shares the VA’s concernabout the timely provision of high-quality care, particularly primary

care, by qualified healthcare pro-fessionals in locations readily ac-cessible to the larger percentage ofveterans. Towards that end, AACPalso encourages the VA to considerproposing a similar set of rules forpharmacists. Like APRNs, pharma-cists in the VHA are subject to thecongressionally mandated qualifi-cations. The VA… is authorized toregulate the professional activitiesand establish qualifications andconditions of employment of phar-macists as it does APRNs. Your pro-posal reflects a model that is wellestablished in the Indian HealthService where guidance was issuedin 1996 regarding designating phar-macists as primary care providerswith prescriptive authority (SpecialGeneral Memorandum 96-2).

The VHA has been a valued partnerwith academic pharmacy fordecades and VA leadership recog-nizes the value pharmacists add tothe health care team through theircollaborative approach to patientcare. The Patient Aligned CareTeam (PACT) provides ample evi-dence that pharmacists providegreat, and could provide evengreater, value to veterans and othermembers of the primary care teamif they were consistently supportedand privileged in a manner similarto that proposed in this rule forAPRNs.

With an academy of researchersand practitioners focused on careimprovement and team-based care,AACP offers the VA the opportu-nity to initiate a discussion that cancreate even greater support for andvalue in the proposed rules relatedto APRNs through collaborationwith pharmacists and other


61

non-physician providers that areauthorized with “full practice authority.”

A particularly significant supportivecommunication also came from the Fed-eral Trade Commission (FTC).

Interesting ReflectionsFrom Floyd Jennings:

The year was 1988—now 28 yearsago—and I had been appointed asChief, Behavioral Health Services atthe PHS/IHS Santa Fe Service Unit,in Santa Fe, New Mexico. Limited,dependent prescriptive privileges(RxP) were granted to me by theMedical Director; i.e., a limited for-mulary excluding scheduled drugs,and dependent upon his supervi-sion. I had the support of the IHSAlbuquerque area psychiatrist withwhom I spoke regarding every case;review and support was granted bythe New Mexico Psychological As-sociation ethics committee. Slightlyless than two years later I was toleave that post—by which time,after being invited to speak beforethe U.S. Senate Committee on In-dian Affairs, thousands of letters ofcomplaint had been sent to theMedical Director of IHS by psychia-trists across the nation, though overthree hundred patients had beenseen, with no adverse effects (andwith enormous support from thephysicians working in IHS). Notethat in the years subsequent, therehas been no nimiety of psychiatricphysicians seeking to work or evenvolunteer in those pueblos of theAlbuquerque area!

From those turbulent beginnings,and due both to vision and persist-ence, psychologists have been givenauthority to exercise prescriptive

privileges in Iowa, Illinois, NewMexico, and Louisiana, as well as inthe Public Health Service, the U.S.military, and Guam. A cursory lookat the New Mexico Board of Psy-chologist Examiners website reveals40 names of persons with active cer-tification as prescribing psycholo-gists. Though by no meansthorough, an internet search turnsup approximately 11 who are inPHS/IHS, state or federal agencies,or mental health facilities. Manypsychologists having nationalprominence in this area have nowcompleted careers in federal serv-ices in the almost 30 years sincethose days in PHS/IHS. We haveindeed “come a long way!”

Yet there is much to be done. For ex-ample, in Texas alone, 185 of the 254counties have no psychiatrist.Nurse Practitioners have been quitesuccessful in extending their scopeof practice to include prescriptiveprivileges—in many venues. In fact,the future of primary care may welltransfer to nurse practitioners, withthe increasing specialization ofmedicine and the decreased num-ber of young persons seeking ca-reers in primary medicine, wherereimbursement rates are far lessthan in high technology. Yet, inTexas, and in many other states, thelikelihood of expanding the scopeof practice for psychology is notgreat. I argue that is far more likelyto occur when the basis is need(rather than greed). Wouldn’t it beinteresting if there were many pro-grams to train psychologists to pre-scribe—at no cost to the person—inreturn for a two-year commitmentto work in an underserved area?Wouldn’t it be exciting if there werea national recognition of the ab-


62

solute necessity to increase thearray of health resources in now un-derserved areas—of which psychol-ogy could be a part? At 75, I expectthat I shall not live to see it, but I candream, can’t I?

And, from Ray Folen, Executive Direc-tor of the Hawaii Psychological Associa-tion: “Over the last 10 years while atTripler Army Medical Center I had writ-ten 3,178 prescriptions and my colleagueMike Kellar had written 5,780. No ad-verse events.” Psychology prides itselfon being one of the learned professions.

Yet, whenever Beth Rom-Rymer pro-vides an update on the exciting imple-mentation of her Illinois success, one ofour largest Divisions declines to publishher comments on their e-mail list serve;notwithstanding that RxP is APA policy.She notes, “Our progeny have stars intheir eyes. Let’s help them realize theirdreams.” Perhaps this Division hopes toprotect their membership from the fu-ture? I am reminded of the line, “Youdon’t know what I’ve done”—but let uswork together to change that sad reality.

Aloha.



NOTICE TO READERS





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The Council addressed the followingitems that are of particular significanceto Division 29 members:

1. “Friends of Psychology”: Councilvoted to approve a bylaws amend-ment to be sent to the full member-ship to create a new membershipcategory titled Friends of Psychol-ogy. These members would be indi-vidual who are interested in themission of APA as a science andprofession but who are not other-wise eligible for any other APAmembership categories. The bene-fits for these members would be ap-proved by Council.

2. Ethics Standard 3.04: This Ethicscode revision was recommended bythe Ethics Committee to the Councilfor approval, following lengthy de-liberation and review of a largenumber of responses and feedbackfrom both individuals and gover-nance groups. Council approvedthe following underlined addition:

Standard 3.04 Avoiding Harm(a) Psychologists take reasonable

steps to avoid harming theirclients/patients, students, su-pervisees, research participants,organizational clients and otherswith whom they work, and tominimize harm where it is fore-seeable and unavoidable.

(b) Psychologists do not participatein, facilitate, assist or otherwiseengage in torture, defined as any

act by which severe pain or suf-fering, whether physical or men-tal, is intentionally inflicted on aperson, or in any other cruel, in-human or degrading behaviorthat violates 3.04 (a).

3. Committee of Teachers of Psychol-ogy in Secondary Schools: Councildiscussed and approved an amend-ment to the composition of TOPSS.

4. Resolution on Psychologists in In-tegrated Primary Care and Spe-cialty Health Settings: Councilapproved this resolution as APApolicy.

5. Resolution on Data about SexualOrientation and Gender Identity:Council approved amending theupdated resolution.

6. Resolution on the maltreatment ofChildren with Disabilities: Coun-cil approved archiving the policythat was passed by Council in 2003and approving a new version of theresolution.

7. Resolution on the Free and Re-sponsible Practice of Science, Free-dom of movement of Scientists,and APA International Engage-ment: Council voted to adopt thispolicy.

Council participated in both large andsmall group discussion of the Item “Res-

REPORT ON THE COUNCIL OF REPRESENTATIVES mEETING


August 3 & 5, 2016 • Denver Colorado

Provided byJean A. Carter, Ph.D. and John Norcross, Ph.D.Division 29 Council Reps

64

olution in Favor of Providing Supportand Assistance to Military and NationalSecurity Psychologists Striving to Abideby the APA Ethics Code and APA Pol-icy.” The item is complex and has anumber of implications for provision ofservices by military psychologists.Council voted to postpone the item tothe February 2017 Council meeting inorder to further develop the item andensure clarity around implications andmeanings of various aspects of the item.

Council’s other business included:

1. Election of 71 Fellows.

2. Approve “Unconscious Bias andMicro aggressions” as the diversitytraining topic for Council in Febru-ary 2017.

3. Postpone “Amendments to Associa-tion Rules: Council Leadership

Team and Needs Assessment, Slat-ing and Campaigns Committee” toFebruary 2017.

4. Refer “Transparency of Decisions”to the Work Group on Organiza-tional Policies and Procedures.

5. Refer “Removal of Barriers to Ad-mission to Doctoral Programs inPsychology Created by the Use ofthe Graduate Records Examination(GRE) Scores” to a work group.

The following election results were announced:

APA Treasurer: Jean A. Carter

Board of Directors Members at Large:Stewart CooperBob McGrath



65

SOCIETY FOR THE ADVANCEmENT OF PSYCHOTHERAPY

Awards Ceremony – 2016 APA ConventionDenver, Colorado

Photo credits: by FSP Media / FIL Sibley

Dr. Armand Cerbone, SocietyPresident, at the podium.

Dr. Rod Goodyear,Awards Chair, at the

podium.

Dr. Charles Gelso receives theAward for Distinguished Con-tributions to Teaching andMentoring from Drs. Cerboneand Goodyear.

Dr. Joshua Swift receives the SAP/APF Early CareerAward from Dr. Goodyear.

This year, he was a jointwinner along with

Dr. Webb.


66

Dr. Christian Webb receives theSAP/APF Early Career Award fromDr. Goodyear. This year, he was ajoint winner along with Dr. Swift.

Amanda Zold (center) receives the Donald K.

Freedheim Student Development Paper

Award from Dr. Cerboneand Maria Lauer, SAP

Student Representative.

Graham Danzer (left)receives the Diversity Student Paper Award fromDr. Cerbone and MariaLauer, SAP Student Representative.


67

Dr. Ken Critchfieldreceives the Charles

Gelso Psychotherapy Research Grant of $5000

from Dr. Cerbone.

Dr. Rayna Markin receives theCharles Gelso PsychotherapyResearch Grant of $5000 fromDr. Cerbone.

Dr. Jesse Owen (center) receives the “Most Valuable Paper” Award,for his paper published in Psychotherapy in 2015, from Dr. Mark

Hilsenroth, Psychotherapy editor, and Dr. Cerbone.

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Guidelines for Clinical Supervisionin Health Service Psychology: Evi-dence and Implementation Strategies

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Alessi, E. J., Dillon, F. R., & Kim, H. M.(2015). Determinants of lesbian andgay affirm.313(2015). Alliance-fo-cused training. Psychotherapy, 52(2),169-173. doi: 10.1037/a0037596

Falender, C. A., Cornish, J. A. E.,Goodyear, R., Hatcher, R., Kaslow,N. J., Leventhal, G., . . . Sigmon, S. T.(2004). Defining competencies inpsychology supervision: A consen-sus statement. Journal of Clinical Psy-chology, 60(7), 771-785. doi:10.1002/jclp.20013

Falender, C. A., Ellis, M. V., & Burnes,T. (2013). Response to reactions tomajor contribution: Multiculturalclinical supervision and benchmarks.The Counseling Psychologist, 41(1),140-151. doi:10.1177/0011000012464061

Falender, C. A., & Shafranske, E. P.(2004). Clinical supervision: A compe-tency-based approach. Washington,DC: American Psychological Associ-ation.

Falender, C. A., & Shafranske, E. P.(2007). Competence in competency-based supervision practice: Con-struct and application. ProfessionalPsychology: Research and Practice,38(3), 232-240. doi: 10.1037/0735-7028.38.3.232

Falicov, C. J. (2014). Psychotherapy andsupervision as cultural encounters:The multidimensional ecologicalcomparative approach framework.In C. A. Falender, E. P. Shafranske, &

C. J. Falicov (Eds.) Multiculturalismand diversity in clinical supervision: Acompetency-based approach (pp. 29-58).Washington, DC: American Psycho-logical Association. doi:10.1037/14370-002\

Forrest, L., Elman, N. S., Huprich, S. K.,Veilleux, J. C., Jacobs, S. C., &Kaslow, N. J. (2013). Training direc-tors’ perceptions of faculty behaviorswhen dealing with trainee compe-tence problems: A mixed methodpilot study. Training and Education inProfessional Psychology, 7(1), 23-32.doi: 10.1037/a0032068

Fouad, N. A., Grus, C. L., Hatcher, R.L., Kaslow, N. J., Hutchings, P. S.,Madson, M. B., . . .Crossman, R. E.(2009). Competency benchmarks: Amodel for understanding and meas-uring competence in professionalpsychology across training levels.Training and Education in ProfessionalPsychology, 3(4 Suppl), S5-S26. doi:10.1037/a0015832

Gabbard, G. O., Roberts, L. W., Crisp-Han, H., Ball, V., Hobday, G., &Rachal, F. (2012). Professionalism inPsychiatry. Arlington, VA: AmericanPsychiatric Publishing.

Genuchi, M. C., Rings, J. A., Germek,M. D., & Cornish, J. A. E. (2015).Clinical supervisors’ perceptions ofthe clarity and comprehensiveness ofthe supervision competencies frame-work. Training and Education in Pro-fessional Psychology, 9(1), 68-76. doi:10.1037/tep0000064.

Gonsalvez, C. J., & Calvert, F. L. (2014).Competency-based models of super-vision: Principles and applications,promises and challenges. AustralianPsychologist, 49(4), 200-208. doi:10.1111/ap.12055

Goodyear, R. K., Cortese, J. R., Guz-zardo, C. R., Allison, R. D., Claiborn,C. D., & Packard, T. (2000). Factors,trends, and topics in the evolution of

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PSYCHOTHERAPY BULLETINPsychotherapy Bulletin is the official newsletter of the Society for the Advancement of Psychotherapy of the American Psychological Association. Published four times each year(spring, summer, fall, winter), Psychotherapy Bulletin is designed to: 1) inform the member-ship of Division 29 about relevant events, awards, and professional opportunities; 2) providearticles and commentary regarding the range of issues that are of interest to psychotherapytheorists, researchers, practitioners, and trainers; 3) establish a forum for students and new members to offer their contributions; and, 4) facilitate opportunities for dialogue and collaboration among the diverse members of our association.

Contributors are invited to send articles (up to 2,250 words), interviews, commentaries, letters to the editor, book reviews, and announcements to Lynett Henderson Metzger, JD, PsyD,Editor, Psychotherapy Bulletin. All submissions for Psychotherapy Bulletin should be sent elec-tronically to [email protected] with the subject header line PsychotherapyBulletin; please ensure that articles conform to APA style. If graphics, tables or photos aresubmitted with articles, they must be of print quality and in high resolution. Deadlines forsubmission are as follows: February 1 (#1); May 1 (#2); August 1 (#3); November 1 (#4). Pastissues of Psychotherapy Bulletin may be viewed at our website: www.societyforpsycho -therapy.org. Other inquiries regarding Psychotherapy Bulletin (e.g., advertising) or the Societyshould be directed to Tracey Martin at the the Society’s Central Office ([email protected] or602-363-9211).

PUBLICATIONS BOARDChair: Jeffrey E. Barnett, PsyD Loyola University Maryland4501 N. Charles StreetBaltimore, MD 21210Ofc: 410-617-5382 | Fax: 410-617-2595E-mail: [email protected] Heatherington, PhD, 2016-2018Dept of Psychology Williams College Williamstown, MA 01267 Ofc: 413-597-2442 | Fax: 413-597-2085E-mail: [email protected] Lillian Comas-Diaz, PhD, 2014-2019908 New Hampshire Ave., NW Suite 700Washington, D.C. 20037Ofc: 202-775-1938E-mail: [email protected] Gold, PhD, 2013-2018Center for Psychological StudiesNova Southeastern University3301 College AveFort Lauderdale , FL 33314Ofc: 954-262-5714 | Fax: 954-262-3857E-mail: [email protected] Hatcher, PhD, 2015-2020Wellness Center /Graduate CenterCity University of New York365 Fifth AvenueNew York, NY 10016Ofc: 212-817-7029E-mail: [email protected]

Publications Board, continuedHeather Lyons, PhD, 2014-2019Department of Psychology – Loyola University Maryland4501 N. Charles St.Baltimore, MD 21210Ofc: 410-617-2309E-mail: [email protected]

Soo Jeong Youn, 2013-2014 (student mbr)311 Toftrees Ave. #37State College, PA 16803E-mail: [email protected]

\EDITORSPsychotherapy Journal EditorMark J. Hilsenroth, PhD, 2011-2020Derner Institute of Advanced Psych Studies220 Weinberg Bldg.158 Cambridge Ave.Adelphi UniversityGarden City, NY 11530E-mail: [email protected]: 516-877-4748 | Fax 516-877-4805Psychotherapy Bulletin Editor, 2014-2019Lynett Henderson Metzger, JD, PsyDUniversity of Denver-GSPP2460 South Vine StreetDenver, CO 80208Ofc: 303-871-4684E-mail: [email protected] EditorBradley Brenner, PhDDistrict Psychotherapy Associates1633 Q St., NW, Suite 200Washington, D.C. 20009Ofc: 202-986-5941E-mail: [email protected]

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