o f f i c i a l p u

2007 VOLUME 42 NO. 4

BULLETIN

PsychotherapyOFFIC IAL PUBL ICAT ION OF DIV IS ION 29 OF THE

AMERICAN PSYCHOLOGICAL ASSOCIAT ION

www.divisionofpsychotherapy.org

E

In This Issue

Empirically Validated Educationand Training?

Metacognition Disorders:Research and Therapeutic Implications

The Amazing Albert Ellis

Student Paper Award:Perceptions of Trainee Attachment in the

Supervisory Relationship

Division 29 2008 Nomination Ballot

STANDING COMMITTEES

PresidentJean Carter, Ph.D5225 Wisconsin Ave., N.W. #513Washington DC 20015Ofc: 202–244-3505E-Mail: [email protected]

President-electJeffrey Barnett, Psy.D.747 Buckeye Ct.Millersville, MD 21108E-Mail: [email protected]

SecretaryArmand Cerbone, Ph.D., 2006-20083625 North PaulinaChicago IL 60613Ofc: 773-755-0833 Fax: 773-755-0834E-Mail: [email protected]

TreasurerSteve Sobelman, Ph.D., 2007-20092901 Boston St. #410Baltimore, MD 21224Ofc: 410-617-2461E-Mail: [email protected]

Past PresidentAbraham W. Wolf, Ph.D.MetroHealth Medical Center2500 Metro Health DriveCleveland, OH 44109-1998Ofc: 216-778-4637 Fax: 216-778-8412E-Mail: [email protected]

BOARD OF DIRECTORSDOMAIN REPRESENTATIVESScience and ScholarshipJames Bray, Ph.D., 2005-2007Dept of Family & Community MedBaylor College of Med3701 Kirby Dr, 6th FlHouston , TX 77098Ofc: 713-798-7751 Fax: 713-798-7789E-Mail: [email protected]

Public Interest and Social JusticeIrene Deitch, Ph.D., 2006-2008Ocean View-14B31 Hylan BlvdStaten Island, NY 10305-2079Ofc: 718-273-1441E-Mail: [email protected]

Psychotherapy PracticeJennifer Kelly, Ph.D., 2007-2009Atlanta Center for Behavioral Medicine3280 Howell Mill Rd. #100Atlanta, GA 30327Ofc: 404-351-6789E-Mail: [email protected]

Education and TrainingMichael Murphy, Ph.D., 2007-2009Professor and Director ofClinical TrainingDepartment of PsychologyIndiana State UniversityTerre Haute, IN 47809Ofc: : 812-237-2465 Fax: 812-237-4378E-Mail: [email protected]

MembershipLibby Nutt Williams, Ph.D.,2005-2007, 2008-2010Coordinator of Women, Gender, &Sexuality StudiesSt. Mary’s College of Maryland18952 E. Fisher Rd.St. Mary’s City, MD 20686Ofc: 240- 895-4467 Fax: 240-895-4436E-Mail: [email protected] Career PsychologistsMichael J. Constantino, Ph.D., 2007,2008-2010Department of Psychology612 Tobin Hall - 135 Hicks WayUniversity of MassachusettsAmherst, MA 01003-9271Ofc: 413-545-1388 Fax: 413-545-0996E-Mail:[email protected] Council RepresentativesNorine G. Johnson, Ph.D., 2005-200713 Ashfield St.,Roslindale, MA 02131Ofc: 617-471-2268 Fax: 617-325-0225E-Mail: [email protected] C. Norcross, Ph.D., 2005-2007Department of PsychologyUniversity of ScrantonScranton, PA 18510-4596Ofc: 570-941-7638 Fax: 570-941-7899E-Mail: [email protected]

Division of Psychotherapy �� 2007 Governance StructureELECTED BOARD MEMBERS

FellowsChair: Jeffrey J. Magnavita, Ph.D. Glastonbury Psychological Associates PC 300 Hebron Ave., Ste. 215 Glastonbury , CT 06033 Ofc: 860-659-1202 Fax: 860-657-1535E-Mail: [email protected]

MembershipChair: Annie Judge, Ph.D.2440 M St., NW, Suite 411Washington, DC 20037Ofc: 202-905-7721E-Mail: [email protected]

Student Development ChairMichael Garfinkle, 2007Derner Institute for AdvancedPsychological Studies - AdelphiUniversity1 South AvenueGarden City, NY 11530Ofc: 917-733-3879E-mail: [email protected]

Nominations and ElectionsChair: Jeffrey Barnett, Psy.D,Professional AwardsChair: Abe Wolf, Ph.D.FinanceChair: Bonnie Markham, Ph.D., Psy.D.52 Pearl StreetMetuchen NJ 08840Ofc: 732-494-5471 Fax 206-338-6212E-Mail:[email protected] & TrainingChair: Jean M. Birbilis, Ph.D., L.P.University of St. Thomas1000 LaSalle Ave., TMH 455EMinneapolis, Minnesota 55403Ofc: 651-962-4654E-Mail: [email protected] EducationChair: Michael J. Constantino, Ph.D.Department of Psychology612 Tobin Hall - 135 Hicks WayUniversity of MassachusettsAmherst, MA 01003-9271Ofc: 413-545-1388 Fax: 413-545-0996E-Mail:[email protected]

Diversity Chair: Jennifer F. Kelly, Ph.D.Atlanta Center for Behavioral Medicine3280 Howell Mill Road Suite 100Atlanta, GA 30327Ofc: 404-351-6789 Fax: 404-351-2932 E-mail: [email protected]

ProgramChair: Nancy Murdock, Ph.D.Counseling and EducationalPsychologyUniversity of Missouri-Kansas CityED 215 5100 Rockhill RoadKansas City, MO 64110Ofc; 816 235-2495 Fax: 816 235-5270E-Mail: [email protected]

Psychotherapy ResearchSarah Knox, Ph.D.Department of Counseling andEducational PsychologySchool of EducationMarquette UniversityMilwaukee, WI 53201Ofc: 414/288-5942 Fax: 414/288-6100 E-mail: [email protected]

PSYCHOTHERAPY BULLETIN

Published by theDIVISION OF

PSYCHOTHERAPYAmerican Psychological Association

6557 E. RiverdaleMesa, AZ 85215602-363-9211

e-mail: [email protected]

EDITORCraig N. Shealy, Ph.D.

ASSOCIATE EDITORHarriet C. Cobb, Ed.D.

CONTRIBUTING EDITORSWashington Scene

Patrick DeLeon, Ph.D.

Psychotherapy PracticeJeffrey Magnavita, Ph.D.

PsychotherapyEducation and Training

Jean Birbilis, Ph.D.

Psychotherapy ResearchWilliam Stiles, Ph.D.

Perspectives onPsychotherapy IntegrationGeorge Stricker, Ph.D.

Student FeaturesMichael Garfinkle, M.A.

Editorial AssistantCrystal Kannankeril

STAFFCentral Office Administrator

Tracey Martin

Websitewww.divisionofpsychotherapy.org

PSYCHOTHERAPY BULLETINOfficial Publication of Division 29 of the

American Psychological Association

2007 Volume 42, Number 4

CONTENTSPresident’s Column . . . . . . . . . . . . . . . . . . . . . . . . .2President-Elect’s Column . . . . . . . . . . . . . . . . . . . .4An Interview with Dr. Jeffrey Barnett,

APA Division 29 President-Elect . . . . . . . . . . . . .6Division 29 Student Paper Awards . . . . . . . . . . . .9Student Award Paper . . . . . . . . . . . . . . . . . . . . . .10

Perceptions of Trainee Attachment in theSupervisory Relationship

Washington Scene . . . . . . . . . . . . . . . . . . . . . . . . .27Signs of Change for the 21st Century

Psychotherapy Research . . . . . . . . . . . . . . . . . . . .32Metacognition Disorders: Research andTherapeutic Implications

2008 Nominations Ballot . . . . . . . . . . . . . . . . . . . 35Psychotherapy Practice . . . . . . . . . . . . . . . . . . . . .41

Can Practitioners Love Science or is theDialectic More than We Can Bear?

Psychotherapy Education and Training . . . . . . .45Empirically Validated Education and Training?

Perspectives on Psychotherapy Integration . . . .48Balanced Psychotherapy Research

The Amazing Albert Ellis (1913–2007) . . . . . . . . . .55Report of APA Council of Representatives . . . .62Call for Award Nominations . . . . . . . . . . . . . . . .64Membership Application . . . . . . . . . . . . . . . . . . .71

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This is my last columnas President of thisgreat Division. It star-tles me to note awhole year gone by, ayear of satisfaction forwhat we have doneand disappointmentfor what is not yeta c c o m p l i s h e d .

Fortunately, the Division will be in goodhands with Jeff Barnett coming in asPresident and Nadine Kaslow to followhim. I am also deeply appreciative of thementoring, support, collegiality andfriendship of Abe Wolf, Past President.

Appreciating What WorksI am proud of our Journal under the edi-torship of Charlie Gelso. He is a masterfuland dedicated editor who has broughtPsychotherapy: Theory, Research, Practice andTraining up to new standards of excellence.Submissions are up, quality is up, and rat-ings are up. Moving the Journal to APAPublications has brought us into the elec-tronic age, with the entire history of theJournal available electronically, increasingits accessibility, and bringing the Divisionsignificant annual revenues from electroniclicensing fees. Always a significant mem-ber benefit, we can be justifiably proud ofthe Journal as a major incentive for belong-ing to the Division. Our thanks also go toRay DiGiuseppe, who provides excellentoversight of our Publications Board andour editors.

Under Abe Wolf’s leadership, the OnlineAcademy, which is developed and man-aged in partnership with APA, has severalsuccessful offerings. We hope to continueto offer new programs for the benefit of ourmembers. Abe has been creative and dar-ing in his selection of programs, as well as

attending to the organizational detail thatmakes it all work.

Our relationship with Society forPsychotherapy Research has continued todevelop as we work to enhance theresearch and scholarly aspects of theDivision. We have served as the CESponsors for recent SPR Conferences andwill continue to do so. Mike Constantinoserved as CE Chair and liaison on this part-nering, whileAbeWolf attended SPRmeet-ings to officially represent the Division,and we welcomed Jacques Barber to ourAwards and Recognition Meeting at theAPA Convention.

At the APA Convention in San Francisco,Libby Nutt Williams chaired a highly suc-cessful luncheon for early career psycholo-gists and students, with great help fromAnnie Judge (Membership Chair),Michael Garfinkle (Student DevelopmentChair) and members of various commit-tees. Books that had been donated bymembers of the Division and bright greenDivision 29 hats were handed out as doorprizes. Thanks to Norine Johnson, RayDiGiuseppe, Laura Brown, Nick Ladany,Bev Greene, and Ted Millon who joinedme in hosting tables.

Making Big ChangesWe are in the process of implementing bigchanges in the structure of the Board.Thanks to the creativity of your Board ofDirectors and Committee Chairs and withyour approval, we have transformed ourmembers-at-large into Domain Represen-tatives who will carry portfolios and helpus better address the major issues that theDivision and psychotherapy itself face inthe changing world of psychology, psycho-logical research and training and the

PRESIDENT’S COLUMN Jean Carter, Ph.D.

Reflections on a Year Gone By

continued on page 32

healthcare system. We are also in a positionto respond more actively and appropriate-ly on issues of social justice and humanwelfare. These changes are exciting, butwill require significant attention over thecoming year to be sure that they are imple-mented well. Organizational change is noteasy, but can be tremendously important inenlivening the organization and enrichingthe lives of its members.

Psychotherapy and Social JusticeI have a deep personal commitment toissues around diversity and social justice,and I have been heartened and warmed bythe extent to which this commitment isshared by other members of the Board andthe Division.

Throughout this year we have strength-ened the Division’s attention to issues ofpublic interest, social justice and diversity,recognizing that the principles of psy-chotherapy and our shared goals of psy-chological well-being should apply verybroadly to human welfare and social con-cerns. The Division has joined theDivisions for Social Justice (a group ofDivisions that devote significant attentionto issues of social concern and the applica-tion of psychology to the betterment ofsociety and its members). We have createda Domain Representative seat for PublicInterest and Social Justice; Irene Deitch hasalready made several proposals forDivision initiatives. We have created twoDomain Representative seats for Diversity,allowing us to attend properly to all aspectsof diversity among our members, ourclients, our research applications and ourteaching. These positions are intended notjust to include new faces on our Board butmuch more importantly, to strengthen ourknowledge and involvement in issues relat-ed to the increasingly diverse and globalworld in which we live. We participated ina cross-cutting convention program in SanFrancisco on the applicability of evidence-

based practice within a context of multicul-turalism; thanks to Bryan Kim for hisefforts in putting this program together tocreate a successful submission. We begandiversity training at the Board level at ourJanuary meeting and will continue in thecoming year.

Personally and on behalf of our Division, Ihave been concerned by recent increases inhate crimes that target both individualsand groups. At this time in history, fewminority groups seem exempt. Althoughwe have been motivated to action by thetargeting of a good colleague at ColumbiaUniversity Teachers College, it is essentialto see the on-going and cumulative natureand impact of hate crimes. The Divisionextends its deep regret and dismay toMadonna Constantine and our other col-leagues at Teachers College. With the assis-tance of the American PsychologicalFoundation, I have begun collection ofmoney for a special fund designated toresearch, policy and programs addressinghate crimes within the violence preventionfunding category. I have made a personalcontribution and the Division, along withother Divisions, has made an initial contri-bution. I hope you will join me in con-tributing to this as well. Please make con-tributions to APF with the designation“Violence and Hate Crimes” and your con-tribution will be credited to this specialfund.

And Thank YOUI have been honored to serve as your presi-dent this year. It has been a year of excitingchallenges and rewarding results. I lookforward to next year as I can offer JeffBarnett my assistance, as Abe Wolf offeredme his! Thank you to all of the members—my friends and my colleagues. This hasbeen a wonderful year!

Jean Carter, PhDPresident, 2007, Division 29

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It is with great please that I write this col-umn as your incoming 2008 President ofDivision 29. Rather than waiting to writemy first column as President in the nextissue of the Psychotherapy Bulletin I wantedto share a bit with you about myself, myactivities this past year as President-Elect,and my plans for the coming year.

First, I want to say how delighted I am tobe serving in this leadership position inDivision 29 and what a great experience ithas been for me so far. I can attest that yourelected Board members and appointedcommittee chairs and members are a hardworking group who are committed toadvancing psychotherapy. It has been apleasure to work with each of them thusfar and I’m excited about our work in thecoming year.

One of the major projects I’ve beeninvolved with this year has been the plan-ning of Division 29’s joint MidwinterBoard Meeting with Division 42,Psychologists in Independent Practice. Inpast years Divisions 29 and 42 collaboratedon a number of successful projects and themidwinter conferences were very wellattended and well received. One of myPresidential Initiatives has been to revital-ize this connection. Thus, we are holding ajoint meeting January 11-13, 2008 in St.Petersburg Beach, Florida. The two Boardswill meet separately to conduct their ownbusiness and will then meet jointly to dis-cuss areas of mutual concern and to devel-op ways of working together towardshared goals. Additionally, on January 12we are hosting a six-hour continuingeducation workshop that is presentedby Division 29 member, DonaldMeichenbaum, Ph.D., “Core Tasks ofPsychotherapy: What ‘Expert’ Psycho-therapists Do.” I strongly encouragemembers to register and attend. It shouldbe a great event. You may register atwww.division42.org .

Another new initiative has been the expan-sion of our online newsgram, PsychotherapyE-News, to include a new feature “NewsYou Can Use.” The goal of this feature is tohelp better bridge the gap between psy-chotherapy research and practice.Psychotherapy researchers write brief (2-3double spaced typed pages) reviews of anarea of research and explain how psy-chotherapists may utilize these findingsand integrate them into their practices nowto enhance the quality and impact of theirwork as psychotherapists. Several havealready been published and can be read athttp://www.divisionofpsychotherapy.org/.I welcome submissions for our upcomingissues. If you have an idea and would liketo discuss it please contact me right away.I’m actively seeking submissions to helpreduce the length of time between researchbeing done and it making its way into theeveryday practices of psychotherapists.Your participation will provide a valuableservice to our members and those weserve.

Please note that we are actively solicitingarticles for this publication, thePsychotherapy Bulletin. If you have an ideaplease contact our Editor, Craig Shealy. Iwould also like to welcome thePsychotherapy Bulletin’s new EditorialAssistant, Crystal Kannankeril. Crystal is asecond year Psy.D. student in ClinicalPsychology at Loyola College in Maryland.She’s doing a great job and already makinga significant contribution.

Your Board has also been working todevelop diversity training for the Board inthe coming year, we are developingprocesses and mechanisms for the effectiveuse of our newly appointed DomainRepresentatives on the Board of Directors,we are developing an exciting conventionprogram along with special plans to cele-

PRESIDENT-ELECT’S COLUMN Jeffrey E. Barnett, Psy.D., ABPP


brate the division’s 40th Anniversary thissummer at the APA Convention in Boston,and we have numerous other activitiesongoing. If you are interested in becomingmore involved in your Division ofPsychotherapy, if you would like to join acommittee, if you would like to write anarticle for Psychotherapy E-News or thePsychotherapy Bulletin, if you would like to

get involved in any other way, or even ifyou have ideas for issues we should beaddressing, please contact me directly. I dowant to hear from you and do want towork with you to advance our division andthe interests of psychotherapy. My e-mailaddress is [email protected] . I lookforward to working together over thecoming year. Best wishes to all.

Find Division 29 on the Internet. Visit our site atwww.divisionofpsychotherapy.org

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INTERVIEWAn Interview with Dr. Jeffrey Barnett,APA Division 29 President-ElectBy Paul MonsonMiami University of Ohio

I interviewed Dr.Jeffrey Barnett tooffer the readers ofPsychotherapy Bulletina portrait of thePresident-Elect ofAPA Division 29. Dr.Barnett will be assum-ing the role ofPresident of the

Division of Psychotherapy on January 1,2008. As a first-year graduate student inclinical psychology, I feel fortunate to havehad the opportunity to speak to Dr.Barnett. He has had a distinguished careeras a public servant, scholar, educator, andpsychotherapist. He has served as a presi-dent of APA’s Division 31, State andProvincial Psychological AssociationAffairs; president of the MarylandPsychological Association; president ofAPA’s Division 42, Psychologists inIndependent Practice; Chair of APA’sBoard of Convention Affairs; member ofthe APA Ethics Committee; and as a mem-ber, chair, coordinator, and trustee innumerous other state and national organi-zations. In addition to maintaining a full-time private practice (four days each week)Dr. Barnett currently holds faculty appoint-ments at Loyola College in Maryland andthe University of Maryland, BaltimoreCounty. (When I spoke with him, he was inthe process of grading papers for a gradu-ate practicum he teaches on psychotherapyskills at Loyola.) For over a decade he hasbeen an approved ethics training providerfor several licensure boards, and has exten-sively presented on and taught ethics at thestate and national level. He has both editedand authored books on ethics, and hasauthored chapters on a wide range ofissues facing practicing psychotherapists.

He has also published widely in journalson a wide range of topics facing the practi-tioner, most notably on ethics and profes-sional practice issues. As a psychothera-pist, Dr. Barnett has been in private prac-tice for nearly 20 years, was a group psy-chologist with the US Army, and a staffpsychologist at a Baltimore psychiatrichospital.

This year as President-Elect of Division 29,Dr. Barnett has been laying the groundworkfor next year when hewill be president. Twospecific Presidential Initiatives are alreadyplanned for the upcoming year. The first isfostering greater involvement in APA andcollaboration with other APA groups. Aspart of this initiative, a joint midwintermeeting and Continuing Education pro-gram will be held in St. Petersberg Beach,Florida for Divisions 29 and 42(Psychologists in Independent Practice) onJanuary 11-13, 2008. Leaders from these twodivisions, who in the past have met sepa-rately, will have an opportunity to interactthrough the Board meetings of the two divi-sions and at an all-day continuing educationworkshop presented by DonMeichenbaum,Ph.D. titled “Core Tasks of Psychotherapy:What “Expert Psychotherapists Do.” Theevent will be advertised both locally andnationally and will hopefully bring togetherboth psychologists and other health careproviders from across the nation. Dr.Barnett sees this joint event in the largercontext of stimulating greater involvementin Division 29 and APA.

The second Presidential Initiative is thecultivation of a stronger link betweenresearch and clinical practice. As part of


this initiative, Dr. Barnett has created a newsection of the Division 29 email newsletter,Psychotherapy E-News. The section, “NewsYou Can Use,” is designed as a part of hisPresidential Initiative to create linksbetween research and practice. Dr. Barnettnoted during the interview that there istypically a 7 to 14 year gap betweenresearch being conducted and its resultsbeing implemented in by practitioners.Appearing Bi-Monthly, each “News YouCan Use” will be written by psychotherapyresearchers, and will summarize findingsthat are directly relevant to practicing psy-chologists. The focus will be on importantareas of psychotherapy research that can beintegrated and put into practice right nowby practicing psychotherapists. If you arenot already subscribed to the emailnewsletter, Dr. Barnett encourages you tocontact him directly at [email protected] to be placed on the list. You canalso find Psychotherapy E-News archivedon the Division 29 website athttp://www.divisionofpsychotherapy.org/PsychotherapyENews/home.php .

During our interview, I spoke to Dr.Barnett on a number of issues. One consis-tent theme emerged in all the topics we dis-cussed: the need to be pro-active and for-ward thinking. The clearest example of thisin his own career is his work on ethics. Asa member of the Ethics Committee for theMaryland Psychological Association, mostof his time was spent adjudicating com-plaints. In response, he moved to an activerole of outreach and education on goodethical practice. Rather than focusingentirely on the punitive side of ethics, hefinds it just as important to approach ethi-cal practice as something that can be inte-grated into all professional activities. Assection editor of Focus on Ethics in the APAjournal, Professional Psychology: Researchand Practice, Dr. Barnett has brought therole of ethics in professional practice anddevelopment to the forefront through brief,relevant, and applicable articles.

During our talk, Dr. Barnett highlighted

the importance of being pro-active to otherimportant areas in psychology. In particu-lar, we spoke about the need to have thegreatest possible representation of perspec-tives at all levels of psychology. To bestserve our clients, it is imperative to active-ly bring underrepresented groups intoleadership, practice, and education rolesthrough active outreach and mentorshipinitiatives. Principle E of the APA Code ofEthics focuses on diversity in its broadestsense. Dr. Barnett spoke passionately aboutthe need to use this comprehensive defini-tion of diversity as a guide for infusing ourprofession with the broadest possible rep-resentation of individuals of diverse back-grounds. Without opening ourselves toalternative perspectives through such ini-tiatives, Dr. Barnett noted, we do not knowwhat we are missing and ultimately limitour competence and effectiveness.

The importance of a positive, aspirationalapproach extends from diversity to advo-cacy in the larger context of issues we facetogether as psychologists and humanbeings. Dr. Barnett has a deep belief thateach psychologist needs to see her/himselfas an integral part of the whole solution.The most effective way that we can posi-tively impact the whole health care systemis through self-advocacy. Psychologists, henoted, can do more to be involved in thepolitical process, advocating real solutionsto the current healthcare crisis. Essential toa solution is a movement from the currentfocus on disease management to healthpromotion. An important part of healthpromotion is psychotherapy and all psy-chotherapists have to offer clients thatenhances their mental and physical health.From the beginning, think tank stages, psy-chologists need to be involved in thechange the health care system faces. Wecan bring specific research and experienceto planning of changes, education of legis-lators, and implementation of changes. Tobe a part of this process will requireinvolvement in the political process


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beyond lobbying. Dr. Barnett encouragedpsychologists to involve themselves inAPA and state psychological associations;to form relationships with representativesin state and national organizations; toserve as consultants in policy making; andperhaps most importantly, to developongoing relationships with representativesat the local, state and national levels.Political life does not only occur on votingday, but is an ongoing process whichdeserves our involvement.

At the end of our interview, I found myselfinspired by Dr. Barnett’s vision of pro-active engagement. I have thought about

many of the topics we spoke about, andhave wondered how to participate in civicengagement. Dr. Barnett highlighted theimportance of active involvement in ourprofession and the place of the individualin the larger picture. Concordant with hisview of integrating research and practice,he emphasized the role of the relationshipin advocacy for psychologists in all areas ofpractice and policy.

Paul Monson is a graduate student in theClinical Psychology program at MiamiUniversity of Ohio. His research interestsinclude significant dreams, narrative, andidentity.

8

Each year, the Student Development Committee of the Division of Psychotherapycalls for papers for three awards, which are then juried by the members of thecommittee. In 2007, the committee received nearly 30 submissions of high caliberfrom students across North America. Each winning submission receives a com-memorative plaque and a cash prize, presented at the annual meeting of the APAin San Francisco. Psychotherapy Bulletin is pleased to publish the winning paperfrom each award category.

Ms. Jesse Metzger, of Columbia University, is the recipient of this year’s DonaldK. Freedheim Student Development Award. The Freedheim Award is conferredon the author of the best paper written on psychotherapy theory, practice, orresearch. This year’s winner, written by Ms. Metzger is titled: Between Patients’Representations of Therapists and Patients.

Mr. Peter Panthauer, of Adelphi University, is the recipient of this year’s DiversityAward. The Diversity Award is conferred on the author of the best paper thataddress issues of race, gender, and cultural issues in psychotherapy. Mr.Panthauer’s award-winning paper is titled: Therapy with Lesbian Couples.

Ms. Deleene Menefee, of the University of Houston, is the recipient of this year’sMathilda B. Canter Education and Training Award. The Canter award is con-ferred on the author of the best paper on education, supervision, or training ofpsychotherapists. Ms. Menefee’s paper on Perceptions of Trainee Attachment in theSupervisory Relationship, was this year’s award winning paper.

Michael S. GarfinkleChair, Student Development Committee

DIVISION 29 STUDENT PAPER AWARDS

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STUDENT AWARD PAPERPerceptions of Trainee Attachment in the Supervisory RelationshipDeleene S. Menefee, M.A.University of Houston

Susie X. Day, Ph.D.University of Houston

Robert H. McPherson, Ph.D.University of Houston

Frederick G. Lopez, Ph.D.University of Houston

Rodney Goodyear, Ph.D.University of Southern California

Lisa M. Penney, Ph.D.University of Houston

ABSTRACT: The strength and nature of thesupervisory relationship has been support-ed as a common factor in psychologisttraining. The influence of adult attachmentamong trainees on supervision outcomeshas merit for informing supervision prac-tice. However, traditional adult attachmentmeasures do not account for the presenceof evaluation in supervision The purposeof this research was to develop and vali-date an empirically supported measure,the Supervisee Attachment Strategies Scale(SASS) that would provide a frameworkfor exploring trainee attachment strategieswhile accounting for the evaluative natureof supervision. Participants were recruitedthrough their training directors at APPICinternship member programs in the USand Canada. Data were nationally collect-ed from 352 trainees representing pro-grams in Canada and 49 US states. In thissample, the mean age was 30, 78% identi-fied as females, 67% as Caucasian, 8%Hispanic or Latino/Latina, 13% AfricanAmerican, 5% were Asian/Pacific Islander,and 6% were bi-racial or multi-racial. Themajority of trainees were doctoral-level(78%, n = 259) and 42% of all trainees wereenrolled in counseling (n = 139), 47% inclinical (n = 158), and 11% were in schoolpsychology programs (n = 36). On aver-age, participants had completed fourpracticums prior to their current place-ment, 65% were providing psychologicalservices to adults, and were distributedamong placement types (e.g., counseling

centers, medical centers, schools, correc-tional facilities, community based centers,and private practice). Construct validitywith a panel of experts in clinical supervi-sion established the initial SASS 200 items.An alpha factor analysis with varimaxrotation of the SASS reduced the items andyielded three interpretable factors thataccounted for 53.8% of the total variance inthe scores. The SASS scale factors (avoid-ance, anxiety, and evaluation) for the final25-item SASS converged with adult attach-ment theory and explained additional vari-ance specific to the evaluative nature of thesupervisory relationship. SASS reliabilityestimates demonstrated coefficient alphafor the total scale at r = .75, avoidant scale r= .94, the anxiety scale r = .88, and evalua-tion scale r = .80.

When participants were asked, “In theoverall scheme of things, how does thetime you spend with your supervisorimpact your training?” they respondedwith either “no impact on training/ wasteof time” (51%) or “big impact/very helpfulin shaping training” (49%). A hierarchical,logistical regression revealed that SASSavoidance, anxiety, and evaluation scoresaccurately classified perceived impact ofsupervision while controlling for length oftraining time and state anxiety. SASS scoresaccurately predicted high impact (SENS =.92) and low impact group membership


(SPEC = .66) and added incremental valid-ity over variance found in workingalliance, c2 (6, n = 249) = 198.89, p < .001;Nagelkerke R2 = .75. Higher avoidant, anx-ious, and evaluative attachment strategiespredicted diminished perceptions of theimpact of training by the supervisory rela-tionship. Trainees who engage in secureattachment strategies may be more likelyto address conflict, negotiate additionalexplorative opportunities in training, andmay be more likely to seek out their super-visors in times of uncertainty.

IntroductionClinical supervision is a transtheoreticalmechanism that allows psychologists to beself-regulatory gatekeepers while traineesare developing skills that could not beobtained solely through laboratory experi-ences (Lambert & Ogles, 1997). The off-campus supervisor functions as a safetynet for trainees, thereby allowing them toexplore their range of skills, take risks withincreasingly challenging client circum-stances, and formulate professional identi-ties (Bernard & Goodyear, 2004). The clini-cal supervisor provides performance feed-back, guidance, and a secure base whentrainees experience confusion, feel uncer-tain, or need additional support for chal-lenging circumstances. The supervisoryrelationship aims to provide correctiveadjustments of inaccurate perceptions ofcompetence, or counseling self-efficacy,and illuminates emotional experiencesrelated to interpersonal processes. Giventhe demands of the training environmentfor immediate application and transfer oftheory to practice, research is needed thatexamines the dynamic processes in thesupervisory relationship in order to pro-vide optimal training and practice guide-lines for supervisors. The influence ofattachment behaviors among trainees onthe supervisory working alliance has meritfor informing clinical supervisors andtraining programs about enduring strate-gies that have been hypothesized to con-tribute to trainee supervision outcomes(Bernard & Goodyear, 2004).

Significance of the StudyThe strength and nature of the supervisoryrelationship has been confirmed as a com-mon factor in successful counselor training(Lampropolous, 2002). Researchers havehypothesized that the supervisory work-ing alliance, a term borrowed from a psy-chodynamic explanation of the client-ther-apist relationship, explains facets of thesupervisory relationship. The workingalliance between the supervisor andtrainee has been shown to be a relativelystable and predictable variable for explain-ing components of the supervisory rela-tionship (Bernard & Goodyear, 2004) andassociated with role conflict and role ambi-guity (Ladany & Friedlander, 1995).

Despite the increased empirical investiga-tion over the past 25 years on supervisionvariables, there are still few measures ofthe supervisory relationship that are bothpsychometrically robust and driven by the-ory (Ellis & Ladany, 1997). Stable andenduring attributes for forming relation-ships, such as attachment styles, havereceived only conceptual address (Bernard& Goodyear, 2004). Pistole and Watkins(1995) offered a brief attachment theoryapplication to counselor training andsupervision. Case examples of a securecounselor were provided by Neswald-McCalip (2001) that supported Pistole andWatkins’ conception of attachment behav-ior in supervision. Watkins (1995) pro-posed a conceptual framework based onearly childhood attachment theory(Bowlby, 1979; 1988) that potentiallyexplains trainee pathological styles insupervision. Only one empirical investiga-tion of attachment behaviors in supervi-sion exists in the literature (White &Queener, 2003), and no studies have inves-tigated Watkins’ pathological styles insupervision (Bernard & Goodyear, 2004).

Research is needed to understand howtrainees’ perceptions of the supervisoryrelationship might differ due to attachmentdimensions, subsequently affecting how


trainees utilize the secure base (Ainsworth& Bowlby, 1991) offered by their clinicalsupervisors. Given the advanced empiri-cal findings on adult attachment (F.G.Lopez & Brennan, 2000), this theory poten-tially offers a grounded conceptual frame-work that could predict, explain, andempirically test both healthy andunhealthy behaviors in the supervisoryrelationship. However, there are no identi-fiable measures that have been designedand validated to measure the characteris-tics of adult attachment behaviors in super-visory relationships. Existing measures ofattachment generally were not designed toassess adult attachment in the presence ofevaluative, power-laden relationships.

The purpose of this proposed study is todevelop an empirically supportedSupervisee Attachment Strategies Scale(SASS) that will 1) provide a framework forexploring attachment behaviors in thesupervisory relationship, and 2) contributeto and expand existing knowledge aboutthe nature of trainees’ perceived superviso-ry working alliance and self-reportedattachment behaviors with a supervisor.This proposed study will describe the scaledesign, development, reliability and valid-ity findings for the SASS among counsel-ing and clinical psychology trainees whoare actively engaged in supervisory rela-tionships. Researchers have suggested thatattachment variables explain resistance tosupervision and poor training outcomes(Bernard & Goodyear, 2004); yet, there is asignificant gap in the literature that fullyexplores or supports these suggestions.Findings from this study may increase ourcurrent understanding of the trainee’sinteraction within the supervisory relation-ship and provide a grounded frameworkfor explaining both positive and negativesupervision outcomes.

Conceptual models traditionally based andformulated from clinical observations(Bernard & Goodyear, 2004) have attempt-ed to explain the role of the supervisor(Bernard, 1979; Holloway, 1995) and the

developmental processes of the trainee(Loganbill, Hardy, & Delworth, 1982;Skovholt & Ronnestad, 1995; Stoltenberg,McNeil, & Delworth, 1998). The nature ofthe interaction between the supervisor andtrainee appears to have mediating or mod-erating effects (Ellis & Ladany, 1997) ontraining outcomes. However, the supervi-sory relationship remains largely under-studied, and its characteristics lack thedepth and breadth of understanding andempirical validation needed to accuratelyinform training and practice. Further, thesetherapeutically-modeled approaches tosupervisory relationships often fail to takeinto account the evaluation componentand potential power differentials absentfrom the therapeutic relationship(Lampropolous, 2002). There are limitedempirical findings that explain aspects ofthe supervisory relationship.

The Application of Adult AttachmentTheory to the Supervisory RelationshipAdult attachment has been studied as apredictor of feelings about conflict (Pistole& Arricale, 2003), self-image (Mikulincer,1995), stability in romantic relationships(Roisman, Madsen, Hennighausen, Sroufe,& Collins, 2001), attention and memory(Fraley, Garner, & Shaver, 2000), and socialsupport seeking behavior (Collins &Feeney, 2000). Adult attachment processesinvolving affective regulation have beenassociated with college student distress(Lopez, Mitchell, & Gormley, 2002) andself-other similarity (Mikulincer, Orbach, &Iavnieli, 1998). Further, adult attachmenttheory has been applied to the therapist-client relationship (Mallinckrodt, Gantt, &Coble, 1995).

Trainees’ complex and dynamic internalprocesses and skill-sets are continuouslyevolving over the trajectory of their train-ing program experiences. The supervisedtrainee transitions from observing profes-sionals, to providing basic counseling skills(e.g., establishing rapport), and, finally, toindependently engaging in increasingly


more complex interactions with clients thatinvolve multiple subskills. As this transi-tion occurs, the supervised trainee is nolonger simply demonstrating or perform-ing a basic skill, such as attending to theclient, but becomes challenged to adjustand integrate his or her thoughts andbehaviors in accord with the client, theclient circumstances, and the supervisor’sexpectations. This guided push towardsindependence is likely to signal increasedrisk and provoke at least mild distressamong trainees. Given that attachment the-orists have found that individual differ-ences in attachment are most apparentwhen people are mildly distressed (Lopez& Brennan, 2000) and that the supervisoryrelationship, which is usually somewhatworrisome but not calamitous, is likely tosignal mild distress, supervision may be anexemplary arena for the appearance ofindividual differences in attachment style.

From the perspective of attachment theory,the supervisor offers a safe haven for pro-tection and basic needs as well as a securebase from which trainees can exploreincreasingly more challenging skills(Collins & Feeney, 2000). In line withBowlby’s theory, under these assumptions,trainees’ attachment systems would beactivated and they would subsequently actupon their internalized dispositions toengage in relational processes with eitheradaptive or maladaptive strategies.Adaptive strategies would theoreticallyenlist supervisor responsiveness in a con-tingent manner to help trainees managetheir internal responses to distress. On theother hand, trainees who engage in mal-adaptive strategies could potentially needexcessive reassurance or be compulsivelyself-reliant (Pistole & Watkins, 1995;Watkins, 1995).

Watkins (1995) provided a conceptualpaper on the pathological styles of attach-ment in supervision. Relying on case exam-ples from his own experiences as a super-visor, Watkins identified three pathologicalattachment styles; compulsive self-

reliance, anxious attachment, and compul-sive caregiving. Watkins suggested thattrainees with pathological attachmentstyles are frequently resistant to supervi-sion and can create problems for graduatetraining programs. Watkins suggested thatpreventing such applicants from gainingentry into training programs might be wor-thy of additional consideration. Moreimportantly, one might argue that theemphasis should be on the potential cor-rective nature of the supervision environ-ment to recalibrate these types of relationsprocesses among trainees. This calibrationseems especially true given that it may bethe evaluative component of supervisionthat brings about the heightened and affec-tively charged environment and activatesthe attachment system. Watkins’ conceptu-alization also fails to account for the styleor responsiveness of the supervisor, whichis essential to understanding the interac-tional nature of the supervisory relationsand the perceived attachment strategies ofthe trainee. Consistent nonresponsiveness,unavailability, and rejection among super-visors have been cited causes for negativeexperiences in supervision (Nelson &Friedlander, 2001) and potentially lead totrainee doubts about self-worth, impairedself-efficacy, mistrust, chronic distress dur-ing internship and failure to adequatelydisclose important information to supervi-sors (Ladany, Hill, Corbett, & Nutt, 1996).Attachment theory informs our under-standing of trainee resistance and providessupervisors with interventions to helptheir trainees benefit from corrective feed-back, engage in increasingly more sophisti-cated self-appraisals, and successfullymanage their own internal affective states.Further, attachment theory might lendexplanations as to why many trainees areable to benefit from the supervisionprocess. Attachment theory providesexplanations for healthy adult processesand has been associated with self-reflectiveprocesses that allow for self-regulation andmetacognitive functions and making infer-


ences about mental states of others.Theorists have hypothesized that the pres-ence of these types of inner resources(Mikulincer & Florian, 1998) for cognitiveand affective self-regulation lead to higherorder and healthier interpersonal interac-tions and prevent anxiety-driven oravoidant behaviors. These types of self-reflective processes are needed in order tobenefit from the supervisory relationship.

Some researchers have asserted that theemotional bond in the working alliancesignificantly overlaps with attachmentbehaviors (Robbins, 1995). However,empirical evidence is lacking that providesconfirmation of this assertion. In a studyon client-to-therapist attachment,Mallinckrodt et al. (1995) differentiatedattachment behaviors from the emotionalbond in the working alliance. Mallinckrodtet al. noted that attachment behavior ismore likely to be measured from a soundtheoretical base and contain essential com-ponents that would not be captured bypantheoretical measures of the workingalliance (Bernard & Goodyear, 2004) as itwas originally proposed by Bordin (1979).

One study has been reported that exam-ined the supervisory alliance and attach-ment among trainees. White and Queener(2003) surveyed 67 supervisory dyads inorder to examine the influence of the abili-ty to form attachments on the workingalliance. These researchers hypothesizedthat both the ability to make attachmentsand the level of social support would pre-dict the nature of the working alliancebetween the predominantly masters’ leveltrainees and their site supervisors. Theyreported that trainees’ self-reported abili-ties to make attachments failed to predictthe working alliance with their supervi-sors. However, the supervisors’ self-reported attachment style positively pre-dicted their perceptions of the workingalliance with their supervisees.Furthermore, the supervisors’ self-view ofattachment predicted the trainee percep-

tions of the alliance. The level of

social support was not a significant predic-tor in this study. These researchersaddressed the limitations of their studyand provided some reasoning for whytheir model accounted for differences inthe supervisors’ perceptions of the work-ing alliance but not those of the trainees.

White and Queener accounted for the lackof significance by discussing the hierarchi-cal relationship in supervision and sug-gested that for the trainee, attachment hasless importance in the relationship withtheir supervisor than other issues. Moreplausible explanations for the findings ofthis study may be related to the choice ofinstruments. They utilized the superviseeand supervisor forms of the SupervisoryWorking Alliance Inventory (Efstation,Patton, & Kardash, 1990) to measure theworking alliance. Internal consistency forboth forms is below .77 on all but one of thesubscales, and the two forms are nonparal-lel (Ellis & Ladany, 1997). This instrumentis further limited by the limited evidencethat it is consistent with the workingalliance originally theorized by Bordin(1979). In addition, they measured “theability to make attachments” with the AAS(Collins & Reed, 1990) instead of a retro-spective instrument, such as the AdultAttachment Interview (George, Kaplan, &Main, 1985) which would allow a moreconclusive argument to be made aboutearly attachments. Given that this instru-ment was not designed to measure rela-tionships where there is an imbalance ofpower in a relationship with an evaluativenature, it is not surprising that it did notcapture the nature of attachment behaviorsamong trainees. The supervisors in theWhite and Queener study were not underthe same evaluative constraints as theirsupervisees and were freer to engage intraditional relationship attachment strate-gies with their trainees. The component ofevaluation is always present within thesupervisory relationship and has thepotential to impact the student and thesupervisor differently.


The White and Queener study providessupport for the development of a measurethat assesses the construct of adult attach-ment strategies when an evaluative orpower-laden characteristic is present in therelationship. The validity of such a scalewould add to the existing adult attachmenttheory without creating redundancy in theliterature with the addition of a new scale(Netemeyer, Bearden, & Sharma, 2003).Further, the validity of this scale couldincrease our understanding of the emotion-al bond in a dyadic working alliance aswell as its relation to attachment strategies.Understanding the nature of attachmentrelationships among supervisors andtrainees could also lend to understandingabout the weakenings and repairs in theserelationships (Burke, Goodyear, &Guzzardo). However, a theoretically dri-ven measure of supervisee attachmentstrategies is needed in order to determinethe nature and extent of such attachmentsand their relations to other supervisionconstructs. The development and constructvalidation of the SASS was the primarypurpose of the current study. It washypothesized that trainees’ attachment tosupervisors, as measured by the self-reportscores on the SASS, would indicate thatdimensions of anxiety and avoidance inrelationship to their supervisors are clearinterpretable factors. It was anticipatedthat items that reflect the evaluative com-ponent of supervision would be reflectedin the final factor analysis. Further, it waspredicted that trainees’ attachment tosupervisors would uniquely and incre-mentally account for variance in perceivedimpact of supervision.

MethodParticipantsData were collected online from a nationalsample of 352 trainees representing graduatetraining programs from Canada and 47 ofthe United States. Graduate student traineesin APA-accredited counseling or clinicalpsychology programs were eligible if theywere enrolled in a masters’ or doctoralpracticum or in an advanced internship for

predoctoral students. The participants whoprovide demographic information (n = 333)ranged in age from 22 to 63 (mean age =29.2) with 90% of the sample under the ageof 35. Seventy-six percent of the participantsidentified as females (n = 252). As for ethniccomposition, 67% were Caucasian (n = 224),13% were African American (n = 44), 8%were Hispanic/Latina/Latino (n = 26), fivepercent were Asian/Pacific Islander (n =18),and six percent were bi-racial or multi-racial(n =21).The majority of participants were doctoral-level trainees (78%, n = 259). Overall, 42%of trainees were enrolled in counseling psy-chology (n = 139), 47% in clinical psychology(n = 158), and 11% were in school psycholo-gy programs (n = 36). Over 98% of thetrainees in this study had completed at leastone practicum before their current supervi-sion placement (mean number of practicums= 4.8). Current training sites were identifiedas community based clinics (29.4%), hospi-tals or psychiatric facilities (21.6%), universi-ty counseling centers (19.5%), Veteran’sAdministration services (14.4%), school dis-tricts (10.5%), private practice (2.4%), or cor-rectional institutions (2.1%). Trainees report-ed providing adult therapy and assessment(54.6%), child or adolescent therapy andassessment (26.4%), or combined services(18.9%) in their current placements.Supervisor gender was reported as 52%female and 48% male. Supervisor ethnicity(n = 289) was reported as 73% Caucasian,11% African-American, nine percentAsian/Pacific Islander (n =18), four percentHispanic/Latina/Latino, and two percentbi-racial or multi-racial.Participants were notified in the informedconsent that they were under no obligationto participate in this voluntary study andthat if they chose to participate, they couldwithdraw from the study at any point. Theonline informed consent required aresponse, either “agree to participate” or“decline participation,” before entering theactual survey.


Instrument DevelopmentThe initial pool of items for the proposedSASS was developed using a multi-stepprocess that ensured adherence to the con-struct of adult attachment theory. An a pri-ori approach was used to ensure the devel-opment of the avoidance and anxietydomains in this scale as well as to exploreother potential dimensions that are relatedto the power-laden relationship (Brennan,Clark, & Shaver, 1998). A panel of expertsreviewed the sample of items in order toensure that the items accurately representedthe domain of attachment theory and wererelevant to the supervisory relationship.Intraclass correlation coefficients rangingfrom 0 to 1 were calculated for all judgessimultaneously across items (.65), bydomains (.78), and by expert type (.79; stu-dent, faculty, or community agency supervi-sor). It was hypothesized that the finalitems would represent orthogonal, bipolarcontinuums for the domains of anxious andavoidant supervisory attachment strategies.

ProceduresIn order to assess the psychometric integri-ty of the SASS’ generalizability, graduatestudents (Haynes, Nelson, & Blaine, 1999)enrolled in a psychology practicum orinternship were recruited to participate ina confidential study regarding their “per-ceptions of the supervisory relationship.”A link to the online survey was posted onthe Association of Psychology Postdoctoraland Internship Centers (APPIC) listservthrough an email that went out to all sub-scribers. Interested trainees completed anonline survey through an encrypted inter-net provider.

MeasuresSupervisee Attachment Strategies (SASS).The final draft of the SASS contained 36items that were scaled constructed using a6-point anchor response format of stronglydisagree to strongly agree. Participantsresponded to items regarding their currentsupervisors. The psychometric propertiesof the SASS are presented below in theResults section.

Working Alliance Inventory – Supervisee Form(WAI; Horvath & Greenburg, 1992). Thesupervisoryworking alliancewasmeasuredwith the supervisee form of the WAI. In thisstudy, Cronbach’s alpha for the subscale oftask agreement was r = .95, for goal agree-ment r = .93, and r =.94 for emotional bond.

ResultsSASS scores were examined for their prop-erties of central tendency, variance, covari-ance, and correlation for each of the initial36-items. Internal consistency estimateswere calculated with Cronbach’s (1951)alpha or the mean of all possible split-halfcoefficients calculated by the Rulonmethod. During the conceptual aspects ofthe scale development, it was hypothe-sized that two clearly interpretable factorswould emerge congruent with the struc-ture of adult attachment theory; one repre-senting trainees’ avoidance and the otherrepresenting their anxiety in the superviso-ry relationship. Given the anticipated find-ing that the SASS would be a multi-dimen-sional scale, an exploratory factor analysiswas conducted to determine its factorstructure. The “eigenvalue-greater-than-one” rule was used to determine the num-ber of factors that account for independentvariance in the correlation matrix that aregreater than any one item (Netemeyer etal., 2003; Nunnally & Bernstein, 1994).Before factor extraction, a Kaiser-Meyer-Okin (KMO; Kaiser, 1974) statistic was gen-erated to determine sampling adequacy forthe 352 trainee responses with the a prioriexpectation that the statistic be higher than.60 in order to proceed. In this study, theKMO statistic was .94, indicating a suffi-cient sampling adequacy and that the datawere likely to respond to factor analysis.

An initial principal components analysiswas conducted in order to estimate themaximized shared variance across theitems (Kim & Mueller, 1978). A uniformrandom variable with a range of one to six(anchor format for SASS items) was insert-ed into the data set to discriminate error


variance from other correlates. Missingdata were replaced with the item mean.Based on the initial factor analysis, six fac-tors emerged that accounted for 54% of thevariance in the scale. The six factor modelfailed to reproduce the observed correlatesin the model. There was substantial errorfound in the residual matrix with a sub-stantial number of residuals with absolutevalues greater than .05 indicating a poor fitbetween the observed and reproducedmatrices (Tabachnick & Fidell, 2001).

Given that principal component analysisdoes not take into account the communaland unique variances in the structural ele-ments, alpha factoring with varimax rota-tionwith Kaiser normalizationwas conduct-ed over multiple iterations. Alpha factoringwith the 36 items of the SASS and the ran-dom variable revealed a six factor model.Examination of the 6-factor scree test plotrevealed that the slope of the line approach-ing zero significantly deviated after factor 3.Items were removed for redundancy and tocontrol for multicollinearity.

The final exploratory factor analysis wasconducted on 25 items. Factors wereretained from the rotated solution wherethere was aminimum of three items loadingon each structural element. Retained factorswere compared to the a priori hypothesiswhere the final solutionwas restricted to theorthogonal dimensions hypothesized in thisstudy related to adult attachment and theevaluative nature of supervision on the rela-tionship. From the rotated solution of the25-item SASS scale, three interpretable fac-tors were extracted that accounted for53.84% of the total variance in the scores.The first factor was congruent with theadult attachment avoidance construct andaccounted for 53% of the model variance.The second factor was similar to the adultattachment anxiety constructed andaccounted for 34% of the model variance.The content of items in the third factor wasspecific to the evaluative nature of thesupervisory relationship and accounted for13% of the model variance in the scores. The

SASS rotated pattern matrix for the three-factor model is presented in Table 1.Reliability estimates for the 25-item SASSwere calculated and coefficient alpha for thetotal scale was r = .75, the avoidant scalewas r = .94, the anxiety scale was r = .88, andthe evaluation scale was r = .80.

In order to establish criterion validity forthe SASS, mean scores from the WAI wereexamined with the SASS subscales.Moderate to high correlations were foundfor the WAI subscales. Scores on the SASSavoidance scale were negatively correlatedwith WAI task agreement (r = -.80, p. < .01,two-tailed), goal agreement (r = -.81, p. <.01, two-tailed), and emotional bond (r = -.82, p. < .01, two-tailed). Scores on theSASS anxiety scale were negatively corre-lated with WAI task agreement (r = -.28, p.< .01, two-tailed), goal agreement (r = -.30,p. < .01, two-tailed), and emotional bond (r= -.35, p. < .01, two-tailed). Scores on theSASS evaluation scale were negatively cor-related with WAI task agreement (r = -.60,p. < .01, two-tailed), goal agreement (r = -.61, p. < .01, two-tailed), and emotionalbond (r = -.69, p. < .01, two-tailed). Higheravoidance, anxiety, and evaluation attach-ment strategies were related to reports ofless task agreement, goal agreement, andemotional bond among trainees.

A logistic regression analysis was conduct-ed in order to test the incremental validityand clinical utility of the SASS compared tothe working alliance and roleconflict/ambiguity. However, high inter-correlations between the WAI subscaleswere found in this study. Bivariate correla-tions showed multicollinearity for task andgoal agreement, r = .95, for task agreementand emotional bond, r = .89, and for goalagreement and emotional bond, r = .88.Given these psychometric concerns and inaccord with other researchers (Patton andKivlighan, 1997), it was decided to use thesummated WAI score as the measure ofworking alliance rather than the subscales.When participants were asked, “In the


overall scheme of things, how does the timeyou spend with your supervisor impactyour training?” they responded with either“no impact on training/ waste of time”(51%) or “big impact/very helpful inshaping training” (49%). T-tests were usedto examine high and low impact group dif-ferences from this item for the WAI scoresand the SASS subscales (see Table 2). Resultsshowed that the lower impact groupendorsed more role conflict and ambiguityand less strength of a working alliance thanthe high impact group. A series of t-testsrevealed that high and low impact groupssignificantly differed on the SASS subscalesby gender, type of degree sought, andlength of time with supervisor but not onitems of ethnicity or type training program.Gender, type of degree sought, and lengthof time with supervisor were used in thefirst block of the subsequent regressionmodels to test incremental validity.

Nagelkerke R2 was derived to assess incre-mental validity of the SASS over the WAI.The Nagelkerke R2 is the most frequentlyreported of the R-squared estimates(Nagelkerke, 1991). Given that NagelkerkeR2 will improve as the number of variablesincreases, diagnostic efficiency statisticswere computed for overall correct classifi-cation (OCC), sensitivity (SENS), specifici-ty (SPEC), and Cohen’s kappa (see Streiner,2003) using the decision rule of a predictedprobability of .50 or greater. In the currentstudy, OCC refers to the proportion of indi-viduals correctly identified as having per-ceived low or high impact of supervisionon training, SENS is defined as the propor-tion of people identified with high impactwho are detected as such; SPEC is the pro-portion of people who do not meet diag-nostic criteria for high impact and are cor-rectly identified as low impact, and Kapparepresents the level of agreement betweenthe predictor(s) and the diagnostic criteriabeyond that accounted for by chance alone.As illustrated in Table 3, gender, type ofdegree sought, and length of time variableswere entered in Block 1, followed by the

addition of WAI summated scores and theSASS subscales in Block 2. A stepwiseregression was employed to determine thebest predictor model among the variables.In Block 1, gender and degree did not con-tribute to the prediction of group member-ship but length of time in supervision wassignificant, c2 (3, n = 249) = 20.90, p <.001.The Nagelkerke R2 was .11. The OCC rateusing the demographic variables was64.6%. The Hosmer-Lemeshow test, a testof the model goodness of fit, produced afail to reject decision c2 (7, n = 249) = 4.34,p > .05, a result consistent with the assump-tion that the specified logistic model wascorrect. The demographic variablesexplained less than 10% of the variance inthe group differences in perceived impacton training. The length of time in supervi-sion accurately predicted high impactgroup membership, (SENS = .80) but wasless likely to accurately predict low impactgroup membership (SPEC = .35). In Block2, the SASS variables were entered in a for-ward, stepwise regression method. Table 2outlines the significant discriminabilty ofthe stepwise model with WAI scoreentered in step one, the SASS avoidancescale entered in step two and the anxietyscore entered in the final step. Entry of theSASS and WAI scores was significant inpredicting group membership, c2 (6, n =249) = 198.89, p < .001 with a good fit of thedata to the model, c2 (8, n = 249) = 1.7, p >.05. The Nagelkerke R2 was .75. The OCCrate using a combination of ECR subscalesand SASS subscales were 88% with a goodfit of the data to the model, c2 (8, n = 213) =.39, p > .05. Diagnostic efficiency statisticimproved with the addition of the SASS inBlock 2 indicating increased clinical utilityover the WAI in predicting impact ofsupervision group membership, change inc2 (1, n = 249) = 45.3, p < .001, change inNagelkerke R2 to .72. The SASS accuratelypredicted both high impact group mem-berships (SENS = .92) and low impactgroup membership (SPEC = .66).


DiscussionClinical supervision is a transtheoreticalmechanism that allows psychologists to beself-regulatory gatekeepers while traineesare developing skills that could not beobtained solely through laboratory experi-ences. The strength and nature of thesupervisory relationship has been support-ed as a common factor in successful coun-selor training and development. Stable andenduring strategies for forming relation-ships, such as those in adult attachmenttheory, had previously received only con-ceptual address in the supervision litera-ture. This study developed an empiricallysupported Supervisee AttachmentStrategies Scale (SASS) that 1) provides aframework for exploring attachmentbehaviors in the supervisory relationship,and 2) expands existing knowledge aboutthe nature of trainees’ perceived superviso-ry working alliance and self-reportedattachment behaviors with a supervisor.

Factor analysis of the participant responseson the SASS yielded a three-factor scalethat converged with adult attachment the-ory and explained additional variance spe-cific to the evaluative nature of the super-visory relationship. The initial item devel-opment for the SASS was based onassumptions that adult attachment strate-gies would be activated given the stressfulnature of training and supervision.Therefore, items were created to gauge theimportance of supervisor accessibility,desire for closeness, and security forexploring new opportunities and evaluat-ing outcomes. The final, 25-item SASSdemonstrated high internal consistencyamong the three factors.

The pantheoretical construct of the work-ing alliance has been consistently used toexamine variability in training and super-vision. However, researchers have estab-lished that theWAI has psychometric prob-lems that limit its clinical utility. In thisstudy, the high correlations between thethree subscales of the WAI resulted in thecollapse of all items into one composite

score, further limiting the interpretabilityof the findings from this measure. SASSscores were found to be positively relatedto scores on established measures of thesupervisory working alliance, role conflictand role ambiguity in supervision.

Given that the SASS was developed ingrounded-theory, it was anticipated thatthis scale would add incremental validity tothe supervisory working alliance in predict-ing satisfaction with supervision. SASSscores added incremental validity and clini-cal utility beyond theWAI in explaining sat-isfaction with supervision. Those partici-pants endorsing high avoidance strategiesand low working alliance were most likelyto report low impact of supervision ontraining. Conversely, those with low avoid-ance strategies, limited evaluation concerns,and high working alliance reported highimpact of supervision training.

Limitations of the StudyOne potential limitation of this study maybe the influence of a strictly online surveydata collection on the response to requestsfor participation in this study. It is notknown how many trainees preferred theconvenience of an online survey to a writ-ten survey that has to be returned by mail.Additional participants were recruitedbeyond the 300 desired due to early dis-continuations of the online survey. It is notknown if participants discontinued due tothe length of the survey, the ease of closinga browser versus the demand of a writtensurvey, or other circumstances related toelectronic data collection. Another poten-tial limitation of this study is that general-ly the supervisory working alliance is mea-sured by examining both the trainee andsupervisors perceptions in order to capturethe interactive feature of the workingalliance (Efstation et al. 1990). Future stud-ies should aim to collect data from bothmembers of the dyadic relationship toexplore the relationship of trainee per-ceived attachment to supervisors’ percep-tions of the relationship.


ImplicationsThe influence of adult attachment behav-iors among trainees on supervision out-comes has merit informing supervisionpractice. While the WAI has reliably pre-dicted role conflict, role ambiguity, andperceived satisfaction, both the constructand the instrument have limitations. Onthe other hand, the SASS provides a frame-work for explaining variability in thesupervisory relationship based on adultattachment theory. In line with Bowlby’stheory, trainees’ attachment in supervisioncould entail either adaptive or maladaptivestrategies. Adaptive strategies would theo-retically enlist supervisor responsivenessand help the trainee manage their internalresponses to distress. On the other hand,trainees who engage in maladaptive strate-gies could potentially need excessive reas-surance or be compulsively self-reliant.Implications for future research couldinclude an outcome studies that examinethe relationships between trainees’ per-ceived attachment and supervisors’ ratingsof trainees’ capacity for benefiting fromcorrective feedback, engaging in self-reflec-tive processes, and regulating affect, vari-ables informed by adult attachment theory.Future research could also explore media-tional variables that explain coping withdistress with negative supervisory events.

One strength of this study is the construc-tion of an instrument that could explainweakening and repairs in the supervisoryrelationship (Burke et al., 1998). Traineeswho are engaging in avoidant strategieswith their supervisors may be less likely toaddress conflict, negotiate additionalexplorative opportunities in training, andmay be less likely to proactively seek outtheir supervisors in times of mild distress.On the other hand, those trainees who areactively engaged in the relationship maybe able to capitalize on the relationship,thereby allowing them greater explorationof new learning and to seek out theirsupervisors in times of uncertainty.Further, those trainees who are avoidant

may appear to be autonomous and

independent rather than disengaged insupervision. This possibility speaks to aconcern that perhaps supervisors are notinfluencing trainees in the way that theyare. Additional research is needed thatcompares the congruency of trainees andsupervisors’ perceptions of attachmentstrategies in the supervisory relationship.ReferencesAinsworth, M. S. & Bowlby, J. (1991). Anethological approach to personalitydevelopment. American Psychologist,46, 333-341.

Bernard, J. M. (1979). Supervisor training:A discrimination model. CounselorEducation and Supervision, 19, 60-68.

Bernard, J. M. & Goodyear, R. K. (2004).Fundamentals of clinical supervision.(3rd ed.) Boston: Pearson Education.

Bordin, E. S. (1979). The generalizability ofthe psychoanalytic concept of the work-ing alliance. Psychotherapy: Theory,Research, and Practice, 16, 252-260.

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Brennan, K. A., Clark, C. L., & Shaver, P. R.(1998). Self-report measurement of adultattachment: An integrative overview. InJ.A.Simpson & W. S. Rholes (Eds.),Attachment theory and close relation-ships (pp. 46-76). New York: TheGuilford Press.

Burke, W. R., Goodyear, R. K., & Guzzardo,C. R. (1998). Weakenings and repairs insupervisory alliances: A multiple-casestudy. American Journal ofPsychotherapy, 52, 450-462.

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process, and supervision. TheCounseling Psychologist, 23, 457-478.

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Roisman, G. I., Madsen, S. D.,Hennighausen, K. H., & Collins, W. A.(2001). The coherence of dyadic behavioracross parent-child and romantic rela-tionships as mediated by the internal-ized representation of experience.Attachment & Human Development, 3,156-172.

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Tabachnick, B. G. & Fidell, L. S. (2001).Using Multivariate Statistics (4th ed.).Boston: Allyn and Bacon.

Watkins, C. E. (1995). Pathological attach-ment styles in psychotherapy supervi-sion. Psychotherapy, 32, 333-340.

White, V. E. & Queener, J. (2003).Supervisor and supervisee attachmentsand social provisions related to thesupervisory working alliance. CounselorEducation & Supervision, 42, 203-218.


Table 1.Structure Coefficients, Communality Estimates, Eigenvalues, and Variance in a Three-Factor Rotated Solution from AlphaFactoring for the Supervisee Attachment Strategies Scale Items with Varimax Rotation (N = 352)

Factor Structure CoefficientsSASS Item Factor 1 Factor 2 Factor3 h2

12. My supervisor seems attentive to my needs. 0.83 0.16 0.21 0.5927. I feel encouraged by my supervisor to continue trying new things. 0.82 0.00 0.00 0.427. I rely on my supervisor as a sounding board for problem-solving

tough issues. 0.80 0.00 0.00 0.5124. The relationship I have with my supervisor helps me manage the

stress associated with training. 0.77 0.10 0.15 0.6416. The interactions that I have had with my supervisor make me feel

good about the profession of psychology. 0.75 0.00 0.35 0.481. I look to my supervisor as an experienced person that I can depend on. 0.74 0.00 0.20 0.5732. I trust that my supervisor is nearby and ready to help. 0.73 0.21 0.12 0.6110. It is difficult for me to depend on my supervisor to help me solve

problems. 0.70 0.26 0.14 0.7634. When my training experiences are distressing, I actively seek my

supervisor for support. 0.68 0.00 0.00 0.3020. I rely on my supervisor to help me gain competence. 0.65 -0.13 0.00 0.7021. It is difficult for me to predict how my supervisor will behave. 0.56 0.28 0.50 0.5415. I look to my supervisor to provide a protective environment while I

am in training at his or her site. 0.55 0.00 0.00 0.4525. I worry about my supervisor rejecting me. 0.26 0.76 0.13 0.5811. I worry that I don’t measure up to my supervisor’s expectations. 0.19 0.74 0.15 0.6322. I wish that I could be sure about whether or not my supervisor really

likes me. 0.24 0.72 0.00 0.6626. I need a lot of reassurance that my supervisor approves of my work. -0.18 0.69 0.00 0.5133. I worry about my supervisor finding out how incompetent I feel. 0.00 0.62 0.00 0.6818. Even when my supervisor reassures me that I am doing okay,

I have a hard time believing it. 0.00 0.61 0.00 0.452. I worry about displeasing my supervisor. 0.10 0.59 0.26 0.509. I feel bad about myself when my supervisor gives me corrective

feedback. 0.11 0.58 0.37 0.5936. My supervisor has reassured me that I am performing well but I still

feel that I will be negatively evaluated. 0.10 0.56 0.27 0.395. I am worried that no matter how well I perform that my supervisor

will give me a weak evaluation. 0.37 0.33 0.57 0.6417. My supervisor only seems to notice me when I make mistakes. 0.25 0.25 0.49 0.3828. I feel defensive when my supervisor gives me feedback about my

performance. 0.11 0.44 0.49 0.4731. My supervisor sometimes sees my desire for autonomy as resistance

to supervision. 0.36 0.21 0.47 0.40Eigenvalue 7.19 4.56 1.70Variance accounted for in the three factor model 28.78 18.25 6.80

Note. Structure coefficients extracted with Alpha Factoring using the Varimax with Kaiser Normalization rota-tion method.


Table2

Descr

iptive

andT

-Test

Stati

stics

andE

ffect

Size

sfor

SASS

,WAI

,RCR

AI,a

ndST

AIsco

resfor

theT

otalS

ample

andt

heHi

ghan

dLow

Impa

ctGr

oups

SASS/W

AI/R

CRAI

Total

Sample

HighImpactGroupa

LowImpactGroupb

tdc

(n=352)

(n=165)

(n=102)

Mean

SDMin

Max

Mean

SDMin

Max

Mean

SDMin

Max

SASS

Avoidance

25.70

11.3

12.0

70.0

21.2

5.212.0

37.0

34.6

14.0

13.0

70.0

11.09

**.40

SASS

Anxie

ty23.40

8.49.0

51.0

42.0

7.79.0

51.0

24.5

8.310.0

42.0

2.98**

.12SA

SSEvalu

ation

7.78

3.74.0

21.0

6.49

2.24.0

15.0

10.2

4.84.0

21.0

8.07**

.21WAI

198.3

339.3

36.0

252.0

217.5

918.2

143.0

252.0

167.2

44.9

36.0

246.0

-12.7

9**

.60

Notes.aHighimpact

n=165.

b Low

impactgroup

n=102.

c Cohen’seffectsize

=eta

squared.SA

SS=SuperviseeA

ttachment

Strateg

iesScale

;WAI

=Working

Alliancecom

positescale;

**p<

.001


Table3

Hiera

rchica

l,St

epwi

seLo

gistic

Regr

ession

Analy

seswi

thSA

SSSu

bsca

les,W

orkin

gAl

lianc

e,an

dSt

ateAn

xiety

toPr

edict

Low

and

High

Grou

psPe

rceive

dImp

acto

fSup

ervisi

on(N

=24

9)

Variable

BSE

BNagelk

erke

R2∆Nagelk

erke

R2OC

CSENS

SPEC

PPP

NPP

Kappa

Block1

.11–

.64.80

.35.68

.55.21

Constan

t.21

.439

Gender

-.01

.008

Degreea

-.06

.007

Timeb

.33**

.008

Block2

.75.65

.88.92

.66.82

.84.76

Constan

t–

4.76

Time

18.48

**.14

3WAIc

.68**

.016

SASS

Avoid

ance

.07**

.047

Anxie

ty-1.25

*.04

6.24

**

Notes

.aDe

gree

=Master

’sor

Docto

rateDe

gree

Sought.bTime=

Lengthoftim

einsupervision.cWAI

=working

allian

ce.O

CC=

Overall

corre

ctcla

ssification;SENS=

Sensitivity;SPEC=Specificity;PPP=Positivep

redictive

power;N

PP=Negative

predictive

power.

*p<.01

.**p<.00

1.

25

26

Special CE Event for Division of Psychotherapy Members

Division 29, in conjunction with Division 42 (Independent Practice) is pleased to present the following workshop that is offered to all Division 29 members in conjunction with our mid-winter board meeting. We hope all members will attend.

Core Tasks of Psychotherapy:What ‘Expert’Psychotherapists Do

Presented by: Donald Meichenbaum, Ph.D.

Saturday, January 12th, 2008

from 9:00am – 4:00pm (6 CEs)

Tradewinds Resort, St. Pete Beach, FL

Registration fee includes breakfast and lunch

Member Fee: $120.

Nonmember Fee: $150.

Earn 6 APA-approved CEU’s. Learn from an internation-

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therapy, Donald Meichenbaum, a founder of Cognitive Behavior Modification and voted

one of the ten most influential psychotherapists of the past century. Learn how to imple-

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approach to behavior change and his case conceptualization model that informs both

assessment and treatment decision making, learn strategies to prevent relapse, to reduce

noncompliance, to increase resilience, and more. This workshop is intended for practicing

psychotherapists interested in learning to apply the latest psychotherapy research findings

to their daily practices and for researchers and teachers interested in cutting edge research

on psychotherapy effectiveness. This will be an interactive workshop with demonstrations

of the strategies and techniques to be taught.

Registration opens October 1, 2007 at www.division42.org To learn more about the Tradewinds Resort visit:

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Plan your stay now. A limited number of rooms are available at the reduced rate

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before December 20, 2007 for this great rate. Join your colleagues for an out-

standing weekend at one of Florida’s premier resorts. Don’t miss this special

opportunity to meet and learn from Donald Meichenbaum, one of the greatest

psychotherapy researchers, teachers, clinicians, and innovators.

During the Presidency of Lyndon Johnson,America enthusiastically rallied around hisvision for a “Great Society.” During thoseyears, psychologist John Gardner servedas Secretary of the Department of Health,Education, and Welfare (HEW)—“Whatwe have before us are some breathtakingopportunities disguised as insoluble prob-lems (1965).” The Administration’s laud-able (and admittedly ambitious) underly-ing objectives were to: end poverty,promote equality, improve education,rejuvenate cities, and protect the environ-ment. Medicare was launched and theCorporation for Public Broadcasting wascreated. A little noticed program, ademonstration initiative called theNeighborhood Health Centers Program,was begun through the Office ofEconomic Opportunity (OEO).

Today, this Community Health Centers(CHCs) initiative serves as the true “safetynet” for more than 15 million Americans,including many of our approximately 45.5million citizens without health insurance,at 3,745 centers across the nation.Unfortunately, few CHCs include psychol-ogy training programs and it has beenquite difficult to obtain a definitive countof the number of employed health centerpsychologists. It is our judgment, however,that CHCs are the venue for psychology’sfuture participation as integrated, primarycare professionals within our nation’sevolving national healthcare environment.The Commonwealth Fund has reportedincreasing concerns that these centers cur-rently lack the capacity to provide the fullrange of services required, especially whenit comes to providing effective off-site spe-cialty care, including referrals to medicalspecialists and mental health and sub-stance abuse treatment. Not surprisingly,the most commonly reported barriers to

care are providers’ unwillingness to takeMedicaid patients or those without insur-ance, the inability of patients to pay for ser-vices up front, and inadequate coverage forneeded services.

Participating in the public policy (i.e., polit-ical) process, one soon learns that there isnever enough money or resources. And yet,as our colleague John Gardner might havesuggested, perhaps the unprecedentedadvances occurring within the communica-tions and technology fields may ultimatelyprovide a viable solution. With exciting newdemonstrations in providing psychologicalcare via virtual realities (for returning Iraqveterans with PTSD, as but one example)and the potential for telehealth linking-uphealth centers with specialty hospitals andspecialists in private practice in “real time,”we expect that psychology will soon have agreater presence—especially as societycomes to appreciate the critical importanceof the psychosocial-cultural-economic gra-dient of quality care.As an aside, duringmyAPA Presidency, at the suggestion of RubyTakanishi, I was honored to awardSecretary Gardner with anAPAPresidentialcitation for his decades of service to ournation. Ruby reported that he always con-sidered himself to be a psychologist andthat he was very pleased to receive thisrecognition from his colleagues.

Bill Gates, Chairman of the MicrosoftCorporation, in The Wall Street Journal:“Health Care Needs an InternetRevolution—We live in an era that has seenour knowledge of medical science andtreatment expand at a speed that is withoutprecedent in human history. Today we cancure illnesses that used to be untreatableand prevent diseases that once seemed

WASHINGTON SCENESigns of Change for the 21st CenturyPat DeLeon, Ph.D.


inevitable. We expect to live longer andremain active and productive as we getolder.... But for all the progress we’vemade, our system for delivering medicalcare is clearly in crisis. According to agroundbreaking 1999 report on health-carequality published by the Institute ofMedicine (the medical arm of the NationalAcademy of Sciences) as many as 98,000Americans die every year as a result of pre-ventable medical errors. That numbermakes the health-care system itself thefifth-leading cause of death in this coun-try.... At the heart of the problem is thefragmented nature of the way health infor-mation is created and collected. Few indus-tries are as information-dependent anddata-rich as health care. Every visit to adoctor, every test, measurement, and pro-cedure generates more information....Isolated, disconnected systems make itimpossible for your doctor to assemble acomplete picture of your health and makefully informed treatment decisions.... Thereis widespread awareness that we need toaddress the information problem.... In his2006 State of the Union address, PresidentBush called on the medical system to‘make wider use of electronic records andother health information technology.’

“What we need is to place people at thevery center of the health-care system andput them in control of all their health infor-mation. Developing the solutions to helpmake this possible is an important priorityfor Microsoft. We envision a comprehen-sive, Internet-based system that enableshealth-care providers to automaticallydeliver personal health data to each patientin a form they can understand and use.... Ibelieve that an Internet-based health-carenetwork like this will have a dramaticimpact. It will undoubtedly improve thequality of medical care and lower costs byencouraging the use of evidence-basedmedicine, reducing medical errors andeliminating redundant medical tests. But itwill also pave the way toward a moreimportant transformation. Today, our

health-care system encourages medicalprofessionals to focus on treating condi-tions after they occur—on curing illnessesand managing disease. By giving us com-prehensive access to our personal medicalinformation, digital technology can makeus all agents for change, capable of push-ing for the one thing that we all really careabout: a medical system that focuses onour lifelong health and prioritizes preven-tion as much as it does treatment. Puttingpeople at the center of health-care meanswe will have the information we need tomake intelligent choices that will allow usto lead healthy lives – and to search outproviders who offer care that does as muchto help us stay well as it does to help us getbetter. The technology exists today to makethis system a reality. For the last 30 years,computers and software have helpedindustry after industry eliminate errorsand inefficiencies and achieve new levelsof productivity and success.... Technologyis not a cure-all for the issues that plaguethe health-care system. But it can be a pow-erful catalyst for change, here in the U.S.and in countries around the globe whereaccess to medical professionals is limitedand where better availability of health-careinformation could help improve the livesof millions of people.”

This fall, the Centers for Medicare andMedicaid Services (CMS) announced afive-year demonstration project that willencourage small to medium-sized physi-cian practices to adopt electronic healthrecords (EHRs). “EHRs can help reduceadverse drug events, medical errors, andredundant tests and procedures by ensur-ing doctors have access to all their patients’relevant health history at the place andtime care is delivered. During the five-yearproject, it is estimated that 3.6 million con-sumers will be directly affected as their pri-mary care physicians adopt certified EHRsin their practices. In order to amplify theeffect of this demonstration project, CMS isalso encouraging private insurers to offer


28

similar incentives for EHR adoption. ‘Thisdemonstration is designed to show thatstreamlining health care management withelectronic health records will reduce med-ical errors and improve quality of care for3.6 million Americans,’ [HHS] SecretaryLeavitt said. ‘By linking higher payment touse of EHRs to meet quality measures, wewill encourage adoption of health informa-tion technology at the community level,where 60 percent of patients receive care.We also anticipate that EHRs will producesignificant savings for Medicare over timeby improving quality of care. This is anoth-er step in our ongoing effort to become asmart purchaser of health care – paying forbetter, rather than simply paying formore.’” The CMS demonstration will beopen to participation by up to 1,200 physi-cian practices by spring. Financial incen-tives will be provided to those using certi-fied EHRs to perform specific functionsthat CMS believes will positively affectpatient care. A bonus will be provided eachyear based on a physician group’s score ona standardized survey that assesses thespecific EHR functions a group employs tosupport the delivery of care. The demon-stration supports HHS’s efforts to shifthealth care toward a system based onvalue, through its Value-Driven HealthCare initiative, with Four Cornerstones:interoperable electronic health records,public reporting of provider quality infor-mation, public reporting of cost informa-tion, and incentives for value comparison.Organized psychology should, of course,work to ensure that non-physician grouppractices qualify for the project – if for noreason than “to be at the table” and “havea voice” during the ongoing public policydeliberations.

The Past is Prologue For the Future: It isimportant to appreciate that fundamentalchange does not occur in a policy vacuumand instead, is almost always based uponpast experiences. We all owe MarilynRichmond of the APA Practice Directorateour sincerest appreciation for her efforts

over the past decade on behalf of the enact-ment of federal mental health parity legis-lation. Most mental health policy expertspredict that President Bush will sign a par-ity bill this Congress. Collectively, weshould not forget that Marilyn has beenworking on this legislative agenda since1996, when the limited law was passed.Mahalo.

June, 2004 – Senator Specter: “The Instituteof Medicine published a report identifyingup to 98,000 deaths a year due to medicalerrors. They specified a program for savingup to $150 billion over a 10-year period byreducing medical errors. The Sub-committee on Health and Human Services,which I chair, had provided funding tomove ahead in implementing the reductionin those errors. There would be savingsfrom improving health care quality, effi-ciency, and consumer education, and therewould be considerable savings in primaryand preventive care providers. There needsto be a great deal of additional education....We know that the lack of insurance ulti-mately compromises a person’s healthbecause he or she is less likely to receivepreventive care, is more likely to be hospi-talized for avoidable health problems, andis more likely to be diagnosed in the latestages of disease....

“Accordingly, today I am introducing theHealth Care Assurance Act of 2004.... Aprovision is included that would providefor demonstration programs to test bestpractices for reducing errors, testing theuse of appropriate technologies to reducemedical errors, such as hand-held electron-ic medication systems, and research in geo-graphically diverse locations to determinethe causes of medical errors. To assist in thedevelopment by the private sector of need-ed technology standards, the bill wouldprovide for ways to examine use of infor-mation technology and coordinate actionsby the Federal Government and ensurethat this investment will further the nation-al health information and infrastructure....

29

The legislation would set up demonstra-tion projects to educate the public regard-ing wise consumer choices about theirhealth care, such as appropriate health carecosts and quality control information....Language is included to encourage the useof non-physician providers such as nursepractitioners, physician assistants, andclinical nurse specialists by increasingdirect reimbursement under Medicare andMedicaid without regard to the settingwhere services are provided.... An ade-quate number of health professionals,including doctors, nurses, dentists, psy-chologists, laboratory technicians, and chi-ropractors is critical to the provision ofhealth care in the United States.”June, 2005 – Senators Frist, Clinton,Obama, and others: A bill to reduce health-care costs, improve efficiency, and improvehealthcare quality through the develop-ment of a nation-wide interoperable healthinformation technology system: “[SenatorFrist] (W)hen it comes to health informa-tion, when it comes to electronic medicalrecords, we are in the Stone Age not theinformation age.... [Senator Clinton] (W)ecertainly do need to bring our health caresystem out of the information dark ages....I introduced health quality and informa-tion technology legislation in 2003 to jump-start the conversation on health IT. I amvery pleased that I have had the opportu-nity now to work with the majority leaderfor more than a year on realizing what webelieve would work, that would enablepatients, physicians, nurses, hospitals – all– to have access electronically in a privacy-protected way to health information.” Wewould suggest, along the lines of JohnGardner’s visionary challenge, that aggres-sively addressing the unacceptable “med-ical errors” crisis also provides a vehicle forultimately ensuring that psychology’s con-tributions to quality healthcare are appro-priately recognized.Interdisciplinary Care: The Institute ofMedicine has called for the various health-care disciplines to forgo their traditional

“silo” mentalities and begin to systemati-cally and respectfully work closely withother disciplines (including training) toensure that health care is patient-centeredand data-driven (i.e., utilizing “gold stan-dards” of care). This fall, I had the opportu-nity to participate in the White CoatCeremony for the inaugural class of the col-lege of pharmacy at the University ofHawaii at Hilo. The Pharm.D. typicallytakes four years of post-baccalaureate train-ing with 15 to 20 percent of the graduates(from 100-plus pharmacy programs acrossthe nation) annually pursuing post-gradu-ate residency training, for example, in men-tal health. The 90 first year students proud-ly took the Oath of a Pharmacist: “At thistime, I vow to devote my professional life tothe service of all humankind through theprofession of pharmacy. I will consider thewelfare of humanity and relief of humansuffering my primary concerns. I will applymy knowledge, experience, and skills to thebest of my ability to assure optimal drugtherapy outcomes for the patients I serve. Iwill keep abreast of developments andmaintain professional competency in myprofession of pharmacy. I will maintain thehighest principles of moral, ethical andlegal conduct. I will embrace and advocatechange in the profession of pharmacy thatimproves patient care. I take these vowsvoluntarily with the full realization of theresponsibility with which I am entrusted bythe public.” As we indicated, very few psy-chology programs have reached out tocommunity health centers to establishtraining experiences for our next genera-tion as primary care providers for the trulyunderserved. Clinical pharmacy appreci-ates the critical importance of professionalsocialization and we fully expect that inHawaii pharmacy will become active part-ners with our 13 federally qualified com-munity health centers as they develop theirclinical practicum sites. For those col-leagues interested in psychology’s prescrip-tive authority (RxP) agenda, they shouldappreciate that over 25 years ago pharmacy

30


leaders in the State of Washington wereable to obtain their profession’s first legisla-tive recognition of “collaborative practice”authority and that today 44 states formallyrecognize pharmacy’s impressive drug

expertise. Aloha,

Pat DeLeon, former APA President –Division 29 – November, 2007

31

Correspondence concerning this articleshould be addressed to GiancarloDimaggio, c/o Terzo Centro diPsicoterapia Cognitiva, via Ravenna 9/c00161, Rome, Italy.Email: [email protected]

Clinicians find it very difficult to reducethe malaise of patients with AvoidantPersonality Disorder (AvPD), as thesepatients usually describe their emotionsonly vaguely and generically. How can oneagree on goals when it is difficult even toguess at why a patient has requested psy-chotherapy? Patients with NarcissisticPersonality Disorder (NPD) acknowledgewhat they feel and think, but when asked,for example, the causes of any gloominess,they often reply with abstract theories suchas “How can’t you be in a bad mood attimes like these?” – or with quasi-biologis-tic explanations such as “My mood tendsto always be black”. Personality Disorder(PD) patients’ problems are not restrictedto describing their inner states, a questiondiscussed recently by Ogrodniczuk (2007)in his article on alexithymia, a difficulty indistinguishing and naming one’s emotions.PD patients often describe others’ minds ina stereotyped – schema driven – and ego-centric fashion. For example, patients withParanoid Personality Disorder (PPD) arequick to see deceit in others’ eyes but havedifficulty forming alternative readings oftheir behaviors. To frame it more generally,patients with PDs, and, more seriously,patients with schizophrenia, experiencevaried difficulties with metacognition, thatis, with thinking about mental states, boththeir own and others’.Our group has concentrated on PD

patients’ metacognitive problems.

We were inspired by Fonagy’s (1991) earlywork on poor thinking about thinking inpatients suffering from BorderlinePersonality Disorder (BPD; see also howthis concept has been translated into a ther-apy model for BPD; Bateman & Fonagy,2004) and by Frith’s (1992) work on themindreading deficit in schizophrenia. Wehave studied, for example, PD patients’difficulties in understanding how relation-ships influence their emotions and deci-sions, in decoding facial expressions and inmaking multiple hypotheses about themotivations behind others’ actions(Semerari, 1999; Semerari, Carcione,Dimaggio et al., 2003).

The picture is not so simple as the patientshaving an overall impairment in a single-faceted skill. Simply saying that a patienthas a metacognitive disorder conveys littleinformation, like observing that a personhas a memory deficit. The clinicians wantto know what aspect of memory isimpaired: Working memory? Digit memo-ry? Autobiographical memory?

Metacognition does not refer to a singleability that can be intact or impaired to dif-ferent degrees. Instead, data increasinglysuggest that metacognition involves anumber of related but distinct capacities.Some can operate or be impaired indepen-dently of one another and others mayrequire a number of distinct cognitiveprocesses (Harrington, Seigert & McClure,2005; Saxe, 2005). Evidence from studiesemploying an array of methodologies havesuggested that, in both clinical and com-munity samples, the capacity for thinkingabout one’s own thoughts and the ability

PSYCHOTHERAPY RESEARCHMetacognition Disorders: Research and Therapeutic ImplicationsGiancarlo Dimaggio, Antonino Carcione and Giuseppe NicolòThird Center for Cognitive Psychotherapy – Rome


to think about or make inferences aboutothers’ thoughts are not reducible to oneanother. Individuals may have more diffi-culties with one ability than with another,and the brain regions activated by one taskmay not completely overlap with thoseactivated by the other (Mitchell, Macrae &Banaji, 2006). Nevertheless, the two skillsappear to be linked. Individuals withproblems reading their own mental states,as in alexithymia, simultaneously havedifficulty understanding others’ minds(Moriguchi, Ohnishi, Lane et al., 2006).

In our opinion the different dysfunctionalfeatures of patients’ metacognition shouldbe distinguished during therapy (Carcione,Dimaggio, Semerari & Nicolò, 2005). It isone thing to help individuals with AvPD todefine their emotions better and another tohelp BPD patients to think that the intenseemotions they feel are the product of theirimagination and not reality. Stiles’ work(1999; Stiles, Elliott, Llewelyn et al., 1990)has been fundamental for transformingsuch clinical observations into a researchprogram. Stiles noted how patients havevarious levels of awareness of their prob-lems: from a vague awareness of their dis-tress, surfacing as intrusive thoughts, tohigher levels, in which they describe thecontents and causes of their suffering.Similarly, he observed that therapeuticinterventions should foster the skill levelimmediately above the one possessed by apatient, thus working on the Zone ofProximal Development (Leiman & Stiles,2001; Vygotsky, 1930/1978; see Bateman &Fonagy, 2004 for a similar approach).Interventions outside the zone are not like-ly to be effective. For example, it is point-less explaining to patients that they getangry when others impose something onthem, when they are not even aware ofbeing angry.Metacognition Assessment Scale: Thetool and Research ResultsThe Metacognition Assessment Scale(MAS) was created in Italian (Carcione,Falcone, Magnolfi & Manaresi, 1997) and

then translated into English (Semerari etal., 2003). It sees metacognition as com-posed of sub-functions. Its purpose is topinpoint mental understanding problemsin transcripts of psychotherapy sessions orother conversations. It contains sub-scalesfor assessing whether a patient succeeds orfails in: a) understanding of his or her ownmind, b) understanding of another’s mind,and c) mastery, i.e. command of relationalproblems and subjective suffering througha knowledge of mental states.

Understanding of one’s own mind includesitems such as: relating variables, i.e. the abil-ity to grasp the relationships between dif-ferent aspects of mental processing, such asthe events provoking emotions (“I was sadbecause I was thinking about the reasonsfor failing”) or the motivations behindactions. Another example is the itemDifferentiation, which assesses whetherpatients are capable of distinguishingbetween their fantasies or hypotheses andthe real state of the world.

Understanding of other’s mind includes itemsassessing whether patients are able to definehow others react to stimuli, think and feelemotions in a variety of contexts. It also eval-uates whether patients realize that others’actions may not involve them, for examplewhen their partner has a somber expressionbecause of a sick relative and not becausehe/she is considering leaving them.

We have used the case study method (Stiles,2005), involving the accumulation of succes-sive observations to test, modify or add toour initial hypotheses about metacognitionin PD patients. We have recorded, tran-scribed and analyzed entire psychothera-pies with the MAS. The results are encour-aging. Taken together, the data show thatPD patients have an impaired metacogni-tion, which improves in good outcome ther-apies (see Semerari, Carcione, Dimaggio,Nicolò & Procacci, 2007 for a review). Thehypotheses that metacognition is not


34

TThhee AAssssoocciiaattiioonn ffoorr WWoommeenn iinn PPssyycchhoollooggyy

AA FFeemmiinniisstt VVooiiccee SSiinnccee 11996699

Announcing the First Annual

Oliva Espin Award for Social Justice Concerns in Feminist Psychology

recognizing work in the areas of

Gender and Immigration and

Ethnicity, Religion, and Sexual Orientation The award was established through a generous founding contribution from Oliva Espin, a long time AWP member and feminist scholar. It was Oliva�s desire to recognize the work of feminists who are making important contributions to practice, education and training, and/or scholarship in the areas of (a) Gender and Immigration and (b) Ethnicity, Religion, and Sexual Orientation. Oliva�s life long contributions to each of these areas of feminist practice and scholarship have been significant. AWP is pleased to partner with Oliva to recognize and support ongoing work in these important areas. Nominations and submissions may be made on the basis of noteworthy contributions to (a) practice, (b) education and training, and/or (c) scholarship (presented, published, or unpublished but in APA-style publication-ready format) in one of the following two areas: Gender and Immigration or the intersection of Ethnicity, Religion, and Sexual Orientation. For the inaugural award, which will be announced and presented at the 2008 AWP conference in San Diego, nominations and submissions in both categories - Gender and Immigration, and the intersection of Ethnicity, Religion, and Sexual Orientation, will be considered. In subsequent years, it is anticipated that the award categories will alternate. Deadline for Inaugural (2008) Award Submissions: January 15, 2008. All nominations, submissions, and supporting documentation must be received via email attachment (MS Word .rtf format only) by the date indicated. Direct materials and questions to Michele C. Boyer [email protected] Submissions will be reviewed by a committee of AWP members. Deadline for the 2009 Award will be May 1, 2008. The 2009 Award will be announced at the 2008 APA Conference and the recipient will be invited to present at the 2009 AWP Annual Conference. Award: A $250 cash prize will be awarded. The recipient will be invited to present at the Annual AWP Conference. Donations: Individuals wishing to contribute to the Oliva Espin Award fund (to help sustain cash prizes) can do so by sending a check payable to AWP (in the note area indicate �Oliva Espin Award�) to Michele C. Boyer, Department of CDCSEP, Indiana State University, Terre Haute, IN 47809. Oliva will be notified of your gift.

2008 NOMINATIONS BALLOTDear Division 29 Colleague:Division 29 seeks great leaders! Bring our best talent to the Division of Psychotherapy (29) as weput our combined talents to work for the advancement of psychotherapy.

NOMINATE YOURSELF OR SOMEONE YOU KNOW TO RUN FOR OFFICE IN THEDIVISION OF PSYCHOTHERAPY. THE OFFICES OPEN FOR ELECTION IN 2008 ARE:

President-Elect (1)Secretary (1)

Domain Representative – Public Interest and Social JusticeAll persons elected will begin their terms on January 2, 2009

This is our first election for the NEW DOMAIN REPRESENTATIVE positions! The DomainRepresentative for Public Interest and Social Justice is a member of the Board of Directors who will beresponsible for creative initiatives in the Division’s public interest portfolio. Candidates should haveinterest in the area and demonstrated investment to issues of public interest and/or social justice.

The Division’s eligibility criteria for all positions are:• Candidates for office must be Members or Fellows of the division.• No member many be an incumbent of more than one elective office.• Amember may only hold the same elective office for two successive terms.• Incumbent members of the Board of Directors are eligible to run for some position on theBoard only during their last year of service or upon resignation from their existing office priorto accepting the nomination. A letter of resignation must be sent to the President, with a copyto the Nominations and Elections Chair.

Return the attached nomination ballot in the mail. The deadline for receipt of all nominations ballotsis December 31, 2007. We cannot accept faxed copies. Original signatures must accompany ballot.

EXERCISE YOUR CHOICE NOW!If you would like to discuss your own interest or any recommendations for identifying talent inour division, please feel free to contact the division’s Chair of Nominations and Elections, Dr.Nadine Kaslow at 404-616-4757 or by Email at [email protected]

Sincerely,

Jean Carter, Ph.D. Jeffrey E. Barnett, Psy.D. Nadine Kaslow, Ph.D.President President-elect Chair, Nominations and Elections

NOMINATION BALLOTPresident-elect Secretary

_______________________________________ ______________________________________________________________________________ _______________________________________

Domain Representative – Public Interest and Social Justice______________________________________________________________________________

Indicate your nominees, and mail now! In order for your ballot to be counted, you must putyour signature in the upper left hand corner of the reverse side where indicated.

35

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Fold Here.

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37

impaired overall but only in specificaspects, and that these aspects vary fromone PD to another have received support.Four BPD patients, for example, were goodat defining their inner states but failed sig-nificantly both in distinguishing betweentheir fantasies and external reality and inintegrating multiple images of self-with-other into coherent narratives (Semerari,Dimaggio, Nicolò, Pedone, Procacci &Carcione, 2005). On the other hand, NPDand AvPD patients had problems mainly inseeing the cause-effect links in their ownpsychological processes (Dimaggio,Procacci, Nicolò et al., 2007). Preliminaryresults from analyses of a patient withObsessive-Compulsive PD and narcissistictraits currently under way show problemssimilar to pure NPD. That is, this patienthad difficulties in understanding the causesof people’s actions and emotions; in addi-tion, the patient was significantly unable totake others’ perspectives and to master herown problems effectively or feel she was incontrol of her own actions.

Research conducted by Paul Lysaker, withour involvement, confirms that metacogni-tion is seriously impaired in schizophrenia.Many patients analyzed display seriousand ongoing deficits – unlike the PDpatients, who swing between periods ofgood and deficient metacognition. In schiz-ophrenia the impairment involves basicaspects of the ability to understand thathuman beings are driven by intentions (nota problem in PDs). However, the deficit isnot homogeneous: some patients displaylarger impairments, whereas others’ func-tioning is somewhat better. Moreover, theMAS scales show a relative independencein schizophrenia; for example, they corre-late differently with symptoms, neurocog-nition tests and executive function(Lysaker, Carcione, Dimaggio et al., 2005;Lysaker, Dimaggio, Buck, Carcione &Nicolò, 2007; Lysaker, Warman, Dimaggioet al., in press).

Therapeutic ImplicationsExpanding on Ogrodniczuk’s observations

(2007) about alexithymia, poor metacogni-tion makes treatment problematic. Beingaware of a problem makes it possible toformulate treatment correctly. We havedesigned a manualized psychotherapymodel for the PDs, MetacognitiveInterpersonal Therapy (MIT) (Dimaggio,Semerari, Carcione, Nicolò & Procacci,2007). A core MIT assumption is that PDpatients should first be helped to improvetheir ability to think about mental states -before being pushed towards change, solv-ing symptoms or building new ways ofrelating. Another MIT assumption con-cerns the role of interpersonal relation-ships, which are always problematic for PDpatients. These patients often underminethe therapeutic relationship, and this gen-erally makes the therapeutic alliance frag-ile and puts it in danger. With MIT a thera-pist concentrates from the start on identify-ing the relational problems occurring dur-ing sessions and on avoiding contributingto ruptures with his/her own actions.When the therapist has repaired thealliance – often by metacommunicatingduring sessions and suggesting the patientjoin in reflecting on the causes of the prob-lems between them (Safran &Muran, 2000)– he or she can adopt strategies for improv-ing the patient’s metacognition. Theseinclude: inviting the patient to narrateautobiographical episodes with definitespace and time boundaries and in whichthe self’s and others’ actions are clear, andthen studying the affects experienced atthat moment and why.

A therapist needs to self-disclose often.This can improve an alliance and letspatients feel that their therapist is similarto them and, therefore, less dominant orcritical: “I’ve the feeling that you feel para-lyzed and see the future as a dead end. Itoo feel powerless to help you at thismoment and recall that I’ve had similarexperiences at other times in my work. Irealize that you must feel unwell, but Iknow it’s something we can tackle togeth-


er, without yielding to despair.” If thealliance improves, a therapist should passon to stimulating the patient’s metacogni-tion. A 28-year-old man suffering fromNPD and BPD maintained that his prob-lems were entirely of a biological natureand could only be cured with drugs (natu-rally, he had already tried every antide-pressant on the market and various kindsof psychotherapy, with very limited bene-fit). After months of repeating these theo-ries and of defiance and contempt andrepeated therapist suggestions that hethink that his emotions might depend onwhat had happened to him, he came to onesession with a particularly gloomy expres-sion. Towards the end of the session hesaid, with a neutral tone, that his girlfriendhad been unfaithful. The therapist’s inter-vention was more or less: “Gosh. It musthave been really horrible finding that out!In general, everyone feels bad when theyfeel betrayed and I felt awful too, when Ihad similar experiences. Do you think yourbeing gloomy today could depend onthis?” The patient opened his eyes wideand replied with surprise: “I never thoughtI too could function in such a banal way!”As illustrated in this example, even if poormetacognition is an obstacle to treatment,it can respond to interventions, andpatients with problems in this area can betreated successfully.

Future DirectionsWe are currently completing and validat-ing a standard interview for a quick assess-ment of metacognition at the start of a ther-apy and measuring it repeatedly duringtreatment. Together with this, we performtests covering the seriousness of symp-toms, interpersonal functioning, personali-ty structure, and therapeutic relationshipquality. We also measure skills theoretical-ly correlated to metacognition, like theability to successfully interpret emotionsfrom facial expressions.

The goals of this research concern: a) psy-chopathology: Does metacognition corre-

late with personality diagnoses? Does itdepend on global functioning? Are somedysfunctions linked more to symptoms orto interpersonal patterns?, b) the therapeu-tic process: In assessing wider populations,is there a confirmation of the idea thatmetacognition is poor at the start of treat-ment but improves in successful therapies?c) effectiveness: Could MIT be a choicetreatment for PDs?

The preliminary data, covering about 100patients treated with MIT and given theinterview for assessing metacognition, areencouraging. Patients with PD seem tohave worse metacognition than patientswith only an axis I diagnosis, and differentPD disorders involve different metacogni-tive impairments. Outcome data are notyet available, but the drop-out rate (asmeasured after 6 months) appears low; thisencourages us to further investigatemetacognition, impairments thereof, andour hypothesis that if a therapist inter-venes with the aim of improving the defi-cient aspects of metacognition, a therapy ismore likely to succeed.

ReferencesBateman, A. & Fonagy, P. (2004). Psy-chotherapy for Borderline PersonalityDisorder: Mentalisation based treat-ment. Oxford: Oxford University Press.

Carcione, A., Falcone, M., Magnolfi, G. &Manaresi, F (1997). La funzionemetacognitiva in psicoterapia: Scaladella Valutazione della Metacog-nizioneca (S.Va.M) [Metacognitivefunction in psychotherapy: Metacogni-tion Assessment Scale]. Psicoterapia, 3,91-107.

Carcione, A., Dimaggio, G., Semerari, A. &Nicolò, G. (2005). States of mind andmetacognitive malfunctionings are notthe same in all personality disorders: Areply to Ryle (2005). Clinical Psychologyand Psychotherapy, 12, 367-373.

Dimaggio, G., Procacci, M., Nicolò, G.,Popolo, R., Semerari, A., Carcione, A, &


Lysaker, P.H. (2007). Poor Metacognitionin Narcissistic and Avoidant PersonalityDisorders: Analysis of four psychothera-py patients. Clinical Psychology andPsychotherapy, 14, 386-401

Dimaggio, G., Semerari, A., Carcione, A.,Nicolò, G. & Procacci, M. (2007).Psychotherapy of Personality Disorders:Metacognition, States of Mind andInterpersonal Cycles. London: Routledge.

Fonagy, P. (1991). Thinking aboutThinking: Some Clinical and TheoreticalConsiderations in the Treatment ofBorderline Patient. International Journalof Psycho-analysis, 72, 639-56.

Harrington, L., Seigert, R.J. & McClure, J.(2005). Theory of mind in schizophrenia:a critical review. Cognitive Neuropsy-chiatry, 10, 249–286.

Leiman, M., & Stiles, W. B. (2001).Dialogical sequence analysis and thezone of proximal development as con-ceptual enhancements to the assimila-tion model: The case of Jan revisited.Psychotherapy Research, 11, 311-330.

Lysaker, P.H., Dimaggio, G., Buck, K.D.,Carcione, A. & Nicolò, G. (2007).Metacognition and the sense of selfwithin narratives of schizophrenia:Associations with multiple domains ofneurocognition. Schizophrenia Research,93¸ 278-287.

Lysaker, P.H., Warman, D.M., Dimaggio,G., Procacci, M., LaRocco, V., Clark, L.,Dike, C., Nicolò, G. (in press).Metacognition in schizophrenia:Associations with multiple assessmentsof executive function. Journal of Nervousand Mental Disease.

Lysaker, P. H., Carcione, A., Dimaggio, G.,Johannesen, J.K., Nicolò, G., Procacci, M.& Semerari, A. (2005). Metacognitionamidst narratives of self and illness inschizophrenia: Associations withinsight, neurocognitive, symptom andfunction. Acta psychiatrica scandinavica,112(1), 64-71.

Mitchell, J.P, Macrae, C.N. & Banaji, M.R.(2006). Dissociable Medial PrefrontalContributions to Judgments of Similar

and Dissimilar Others. Neuron, 50, 655-663.

Moriguchi, Y., Ohnishi, T., Lane, R.D.,Maeda, M., Mori, T., Nemoto, K.,Matsuda, H. & Komaki, G. (2006).Impaired self-awareness and Theory ofMind: An fMRI study of mentalizing inalexithymia. Neuroimage, 32, 1472-1482.

Ogrodniczuk, J.S. (2007). Alexithymia:Considerations for the Psychotherapist.Psychotherapy Bulletin, 42(1), 4-7.

Safran, J.D. & Muran, J.C. (2000).Negotiating the therapeutic alliance. A rela-tional treatment guide. New York:Guilford.

Saxe, R. (2005). Against simulation: Theargument from error. Trend in CognitiveSciences, 9, 174-179.

Semerari, A. (Ed.) (1999). Psicoterapiacognitiva del paziente grave [Cognitivepsychotherapy with severe patients]. Milan:Cortina.

Semerari, A., Dimaggio, G., Nicolò, G.,Pedone, R., Procacci, M., & Carcione, A.(2005). Metarepresentative functions inborderline personality disorders. Journalof Personality Disorders, 19, 690-710.

Semerari, A., Dimaggio, G., Nicolò, G.,Procacci, M. & Carcione, A. (2007)Understanding minds, different func-tions and different disorders? The con-tribution of psychotherapeutic research.Psychotherapy Research, 17, 106-119.

Stiles, W.B. (1999). Signs and voices in psy-chotherapy.Psychotherapy Research, 9, 1-21.

Stiles, W. B. (2005). Case studies. In J. C.Norcross, L. E. Beutler, & R. F. Levant(Eds.), Evidence-based practices in mentalhealth: Debate and dialogue on the funda-mental questions (pp. 57-64). Washington,DC: American PsychologicalAssociation.

Stiles, W. B., Elliott, R., Llewelyn, S. P., FirthCozens, J. A., Margison, F. R., Shapiro, D.A., & Hardy, G. (1990). Assimilation ofproblematic experiences by clients inpsychotherapy. Psychotherapy, 27, 411-420.


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Vygotsky, L. S. (1930/1978). Mind in soci-ety:The development of higher psychologicalprocesses. Cambridge, MA: HarvardUniversity Press. (Or. work published1930, 1933, and 1935).

Author’s note: This paper has been sup-ported with a grant received by FondazioneAnna Villa e Felice Rusconi

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Jeffrey J. Magnavita,Ph.D. ABPP is a Fellowof Division 29, served aspast Program Chair, andis currently the Chair ofthe Fellows Committee.He is the recipient of the2006 DistinguishedContribution to thePractice of Psychology

Award. Correspondence may be addressed tothe author at Glastonbury Medical ArtsCenter, 300 Hebron Ave. Suite 215,Glastonbury, CT 06033 or through email:[email protected]

In a recent session where I was engaged inco-joint individual psychotherapy with acolleague who was conducting EMDR on acomplex trauma patient the seed for thisarticle, my first, in this column was plant-ed. The patient decided to undertakeEMDR after having conducted her ownresearch and coming to the conclusion thatthe only way she thought EMDR would beuseful was for me to be in the room whilethe EMDR therapist worked. She previous-ly had undergone a few trials with somewell trained EMDR practitioners but feltthat the outcome would be improved if shecould use her relationship with me toground her while she went through hersignificant trauma history. During one ofthe sessions, referring to me, the patientspontaneously reported to the EMDR ther-apist how much “he loves science”. I wasstruck by the accuracy and feeling of being“located” by this comment because she iscorrect that I love science and enjoy read-ing about the clinical sciences, psychother-apy, neuroscience, anthropology, medicineand other scientific and clinical endeavors.

I suspect that part of what gave me awaywas the Scientific American journals in thewaiting room, my trying to explain her suf-fering using the latest findings from the lit-erature, as well as my invitation for her totry some new Heart Rate Variabilitybiofeedback that I have been incorporatinginto my practice and research. This experi-ence made me ponder the tension that Ihave experienced as a practitioner of psy-chotherapy for over 20 years between theart of practice and science of psychothera-py. The tension in this dialectic compels meto focus on this in my first practice column.

I often have wondered why scientists lookdown at those who primarily devote them-selves to practice and why practitionersbelieve researchers are irrelevant and“don’t have a clue about real life”. The crit-icisms are well known: “psychotherapistspractice without any evidence to base whatthey do on” and “researchers idealize sta-tistics from randomized, manualized treat-ment studies with patients who are neverseen in real clinical practice”. We all haveheard the arguments from both cornersand all suspect that there is truth to bothsides of these accusations. As pressure isexerted on practitioners to base their workon the available evidence base and empiri-cal findings the tension between these twotribes seems to be intensifying. I would liketo explore the dialectic of this tension andsuggest some possibilities.

What is the “real” difference between prac-titioners of psychotherapy andresearchers? Let me begin with trying todescribe what I have experienced andobserved about being a psychotherapist.

PSYCHOTHERAPY PRACTICECan Practitioners Love Science or is theDialectic More than We Can Bear?Jeffrey J. Magnavita


Psychotherapists spend their days sittingwith and listening to stories of pain andsuffering, and have been confirmed thesocietal role of “healer”. Thus, much of thetime is devoted to attempting to enterother people’s frames of reference byexploring the phenomenology of whatmakes the suffering of the patient uniqueand what makes it similar to others withsimilar diagnostic and symptom clusters.Coming with this role of healer are anumber of privileges, responsibilities,demands, and perks. There is the privilegeof being a member of society who has spe-cialized training and knowledge and therespect that goes along with this special-ized role. There is also the demand of try-ing to understand and alleviate the suffer-ing of those who may be in intense painand sometimes chronic states of suffering,without hope and meaning to their lives.There is the gratification of helping indi-viduals recover and relieve symptoms.Occasionally, there is the shear joy of assist-ing people in identifying and eliminatinglifelong patterns of self-defeating and self-sabotaging behavior. There is also thestress of dealing with those who get worsein treatment and even more dreadful deal-ing with the acts of severe self-harm andsuicide. Witnessing and being part of thesereenactments is often vicariously trauma-tizing the psychotherapist. Losing a patienton our watch is nothing less than a night-mare come true. There are perks to this roleand position. We are respected and privi-leged members of society and when peoplechange under our care they are enormous-ly grateful and generous in recognizing ourrole and commitment to the process.Psychotherapists are either paid by theinstitution they work for or by the patientsthey see. They are reliant on their integrityand word of mouth to stay in practice.When practicing fee for service they eithersink or swim based on their perceivedvalue in the free market economy.Scientists, whether clinical, medical or psy-chotherapy researchers operate in a

domain that emphasizes different

core values and roles than practitioners.Researchers are also in the privileged posi-tion of “scientist” in our culture and thuscommand respect and authority for theirknowledge and mastery of the principlesand language of scientific discourse.Scientists value objectivity, rationality, andevidence. The best scientists are also cre-ative and push the boundaries of knowl-edge, which often results in being scorned,until later they are given Nobel prizes. Thedemands of science are challenging andrequire a solid character that can withstanda lack of daily feedback and validation forsome longer-term sense of gratification.They must have some level of obsessivecompulsiveness to their personalities inorder to persist. Effective researchers mustbe able to predict and envision how a par-ticular study will unfold over time at itsinception and then bring it to completion.Scientists must be conversant with statisti-cal and research methods and be able towrite coherently and have their work pub-lished. They must be able to convince oth-ers that supporting their work with fund-ing is a worthwhile venture and risk. Theymust be able to decide what the impact oftheir findings will be on society and cul-ture. Even something which is clearly evi-dent in the findings may have implicationsthat are negative for some group of people.Researchers, unlike psychotherapists, existunder the intense scrutiny of grant givingoverseers and can be declared irrelevantand mocked by politicians who have apolitical axe to grind. There are perks forsuccessful researchers such as joy of dis-covery, respect of society, opportunity totravel, and high status. The most successfuloften are additionally rewarded with fameand fortune and are considered rock starsand innovators of science.

Of course there are many who woulddescribe themselves as scientist-practition-ers or who practice both psychotherapyand research. It is probably very difficult tobe a highly skilled psychotherapist and


expert researcher as each role demands somuch of their practitioners. Most of usadmire those unique individuals like CarlRogers who are able to “walk the line” andbalance practice and research activities.

There are some inherent struggles betweenthe healers and seekers. Psychotherapistsare healers who daily face the demands ofthose in suffering, in the role of patient orclient depending upon your preference,want to do everything they can to diminishsuffering and offer hope. In medicine thereare reports of physicians who never giveup hope and continue to try everythingpossible to save the lives of those entrustedin their care, sometimes resorting to radi-cal procedures. Practitioners often are inthe position of facing challenges beyondwhat clinical science and evidence has tooffer and will try different approaches thatare based on clinical experience, intuition,and knowledge. When faced with some-one in intense and chronic emotional painit is necessary to maintain hope and doone’s best to alleviate the suffering even ifthere is little in the literature to go by.Psychotherapists like theory and methodsto guide their work and view these as theirnavigational and technical systems. Theyare often vulnerable to following guruswho offer to show the way because suffer-ing and uncertainty can feel like more thanwe can bear and gurus offer hope. Theoryoften advances before empirical findingsand thus there may be psychotherapeuticsystems which are laughable to us todaybut seemed entirely reasonable to those ofyesteryear.

Researchers are also reliant on theory toguide their work. They are in the positionof trying to decide which theory is worththeir research effort and then devote theirenergy and resources to seeing if the theo-ry is tenable. This is a critical decision for apsychotherapy researcher as it will shapethe future of his or her career path. Once aline of investigation is selected it may takeyears before any fruitful results are ready

to be published. Research often lagsbehind practice and the challenge is toremain relevant as the theoretical systemsevolve and gain momentum and then maybe absorbed or forgotten.

Scientists like psychotherapists are datacollectors whose tools and techniques havemore in common than would appear to theoutside observer. Psychotherapists andresearchers view clinical phenomenathrough somewhat different lenses butboth rely on observation and testinghypotheses to determine how to predictthe outcome. A researcher must have astrong interest in understanding humannature and change and a psychotherapistmust be able to capitalize on these forcesand bring them to bear in the clinical situ-ation.

Even though it seems like psychothera-pists and researchers are from differenttribes there is no doubt we are from thesame nation of clinical science on whichthe foundation of our work rests. Science isnot only for the lab or bench. We can all beclinical scientists by taking the time to readthe current research findings in our disci-pline and related sciences and incorporat-ing the evidence base to guide clinicalpractice. The psychotherapist’s consultingroom is a lab for hypothesis testing indetermining what works and what doesn’twith each patient. The scientist in us ishungry for any knowledge that can assistus in understanding and explaining thecomplexity of phenomena that we witnessin those we work within the clinical set-ting. We can rejoice in our devotedresearcher friends and peers who sacrificeso much in search of truth.

Recently, I had the honor to participate inan interdisciplinary conference on tran-scendence and science hosted by JamesMadison University and funded by aSTARS research grant. Spending two dayswith a group of leading primatologists,


anthropologists, sociologists, biologists,linguists, developmental psychologists,and others reminded me of the shared mis-sion we are all on with our brethren fromother disciplines. The study of humannature, consciousness, mind-body connec-tion, language, personality, psychotherapy,and other topics are critical for addressingthe challenges that face us on a global level.I hope that this column will reawaken yourlove for science and compel you to taketime to read our journals and cull theresearch findings from them. Even more I

hope that you will consider reading morebroadly in other disciplines and buildingrelationships with their members. It is alsomy hope that we all will accept theinevitable tension between the perspectiveof science and practice and not fall prey todemonizing the other. We are all chargedwith the mission of understanding humannature to alleviate suffering of those whoneed our care. We must allow ourselves tohold the tension between the dual lenses ofscience and practice without succumbingto anxiety and eschewing the other.

44

In 1974 the federal government of theUnited States passed PL 94-142, whichrequired all children to receive a free edu-cation in the least restrictive environment.This law was later revised, and is nowknown as I.D.E.A. As a result of PL 94-142,Individualized Education Plans (IEPs) andoutcome-based education emerged.

In the early part of the twentieth century,corporations began providing medical ser-vices to their employees, and the seeds ofmanaged care were sown. In recent years,as managed care companies have grown insize and number and have begun to controlthe criteria for third party reimbursementof medical services, evidence based treat-ment (also known as empirically support-ed or empirically validated treatment) hasproliferated.

Whatever your beliefs about outcomebased education or empirically validatedtreatment, they have become firmlyentrenched in the education and managedcare worlds. Ironically, although psycholo-gy has contributed methodologies to both(e.g., operationalizing and measuringbehaviors), the field of psychology hasbeen slower to apply these methodologiesto its own education and training.Psychology has shifted to outcome basededucation only recently as the educationand training of psychologists has evolved.The shift has correlated with the rise inpopularity of Psy.D. programs, which trainpractitioner/scholars and most of whichare based on the National Council ofSchools and Programs in ProfessionalPsychology (NCSPP) model of training.

The NCSPP model is competency basedand originally included six competencies

(Relationship, Assessment, Intervention,Management/Supervision, Consultation/Education, and Research/Evaluation),with Diversity described as a componentof training integrated throughout the entirecurriculum in concert with the six compe-tencies to underscore its preeminence (e.g.,Bourg, Bent, Callan, Jones, McHolland, &Stricker, 1987; Peterson, Peterson, Abrams,& Stricker, 1997). In 2002, NCSPP alsoincluded Diversity as a seventh, freestand-ing competency. Most recently, inSeptember, 2007, NCSPP approved theDevelopmental Achievement Levels (DALs,which were formerly known as the“Competency Grids”) for inclusion in theNCSPP educational model. The DALsdescribe the knowledge, skills, and attitudesassociated with development of the sevencompetencies of the NCSPP model andcan be found at http://www.ncspp.info/pubs.htm.

As Kaslow (2004) has noted:The past two decades have witnessed aburgeoning interest in competency-based education, training, and creden-tialing in professional psychology(Sumerall, Lopez, & Oehlert, 2000).Education and training groups havearticulated competency-based trainingmodels, including the National Councilof Schools and Programs of ProfessionalPsychology (NCSPP; Bourg et al., 1987;Peterson, Peterson, Abrams, & Stricker,1997), scientist-practitioner clinical psy-chologists (Belar, 1992), counseling psy-chologists (Stoltenberg et al., 2000), andclinical scientists (http://psych.ari-zona.edu/apcs.html). (p. 774)

PSYCHOTHERAPY EDUCATION AND TRAININGEmpirically Validated Education and Training?Jean Birbilis, Ph.D., University of St. ThomasMary M. Brant, Ph.D., Private Practice, Kansas City, MO


The burgeoning interest by various groupsdescribed by Kaslow (2004) converged fiveyears ago, as representatives from a num-ber of professional organizations within thefield of psychology met for the 2002“Competencies Conference: FutureDirections in Education and Credentialingin Professional Psychology” and developeda description of competencies deemed nec-essary as the outcome of the education andtraining of psychologists. Those competen-cies include ethical and legal issues, indi-vidual and cultural diversity, scientificfoundations and research, psychologicalassessment, intervention, consultation andinterprofessional collaboration, supervi-sion, and professional development. Mostrecently, the October, 2007 issue ofProfessional Psychology: Research andEducation (volume 38, number 5) wasdevoted to the assessment of competence.A review and comparison of the competen-cies originating from various sources, begin-ning with NCSPP and culminating in the2002 Competencies Conference, revealrecurring themes. In all cases, the salience ofthe therapeutic relationship in psychothera-py as a healing factor (Bachelor & Horvath,1999; Norcross, 2002) is confirmed.

Managed care has often been criticized forignoring, or at least diminishing, the thera-peutic relationship, and for focusing pri-marily or even exclusively on outcomes.Indeed, managed care has shifted the verylanguage describing psychological servicesfrom mental health care to behavioralhealth care. [One definition of psychologyused in the 1970s was the study of mindand behavior. As psychology has chasedthird party reimbursement that medicinechased first, it seems that psychology drift-ed from mind and behavior to behavior. Inthe meantime, other professions have con-tinued to focus on the mind and/or soul ofhuman beings without becoming tied tothird party payers. Someday, psychologistsmight benefit from reviewing the decisionpoints that led psychology down this road,given clients’ concern about therapists’

level of caring as well as level of clinicalcompetency (Bremer, 2001).] Ironically, oneof the most promising aspects of the recentshift in psychological education and train-ing towards measurable outcomes is theconsistent inclusion of relational variables.As competencies become more and moreformally embedded in psychological edu-cation and training, educators and trainershave a responsibility to advocate for (aswell as teach students and superviseeshow to build) the therapeutic relationship.And if competencies continue to be thefocus of education and training, educatorsand trainers also have a responsibility tomake sure that they are teaching the rightcompetencies. Competencies have beenproposed by professional consensus; justas psychotherapy models were applied byconsensus to supervision in the early daysof supervision and then the research fol-lowed, it appears that competencies arebeing derived from what is already beingpracticed in the field of psychology, andtheir validation in their entirety is yet to beexamined. To be sure, some already beingapplied to education and training havealready been validated, such as the rela-tionship competency, but the research onothers has not been done. As Lichtenberg,Portnoy, Bebeau, Leigh, Nelson, Rubin,Smith, and Kaslow (2007) note:…psychology’s shift to a competencymodel would be a challenging endeav-or, but one that is required in view ofthe need to reinforce credibility in com-petence for the practice of psychology.Achieving consensus [our emphasis]within the profession and across itsdiversity of specialties, orientations,and models on the necessary competen-cies for professional practice is a criticalfirst step. Establishing the mechanismsand systems for competency assess-ments, and evaluation [our emphasis]and building the commitment acrossthe profession to carry it out, are impor-tant additional steps (p. 478).


ReferencesBachelor, A., & Horvath, A. (1999). Thetherapeutic relationship. In M. Hubble,B. Duncan & S. Miller (Eds.), The heartand soul of change: What works in Therapy(pp. 133-178). Washington, DC:American Psychological Association.

Bourg, E., Bent, R., Callan, J., Jones, N.,McHolland, J., & Stricker, G. (Eds.)(1987). Standards and evaluation in the edu-cation and training of professional psycholo-gists. Norman, OK: Transcript Press.

Bremer, B. A. (2001). Potential clients’beliefs about the relative competencyand caring of psychologists: Implicationsfor the profession. Journal of ClinicalPsychology, 57(12), 1479-1488.

Kaslow, N. (November, 2004).

Competencies in professionalpsychology. American Psychologist, 774-781.

Lichtenberg, J.,.Portnoy, S., Bebeau, M.,Leigh, I., Nelson, P., Rubin, N., Smith, I.,& Kaslow, N. (2007). Challenges to theassessment of competence and compe-tencies. Professional Psychology: Researchand Evaluation, 38, 474-478.

Norcross, J. C. (Ed.). (2002). Psychotherapyrelationships that work. New York: OxfordUniversity Press.

Peterson, R., Peterson, D., Abrams, J., &Stricker, G. (1997). The National Councilof Schools and Programs of ProfessionalPsychology education model.Professional Psychology: Research andEducation, 28, 373-386.

47

IntroductionThe fields of psychotherapy and psy-chotherapy research have fought fordecades to develop generally accepted pro-cedures for a balanced approach to psy-chotherapy research. Balanced means inthis context:• Truly informative for psychotherapypractice

• Not limited to or one-sidedly favoringspecific approaches to psychotherapy

• Not limited to one type of patient (e.g.those falling clearly into one diagnosticcategory)

• Living up to the standards of psy-chotherapy practice AND of rigorouspsychotherapy research.

There is a wealth of articles discussing oneor the other aspect of how appropriate psy-chotherapy research should be done. Mostreaders are assumed to be familiar with atleast part of the literature; we will notattempt to summarize it but rather concen-trate on one aspect: The balance betweeninternal and external/clinical/ecologicalvalidity. This is a crucial question in theadvancement of empirical underpinningsof principle-oriented, integrative psy-chotherapy, as it is explicitly or implicitlypracticed by a majority of psychotherapists(Stricker, 2005; Norcross, Hedges &Prochaska, 2002).

The Randomized Clinical Trials (RCT) andEmpirically Supported Treatment (EST)initiative (Calhoun, Moras, Pilkonis, &Rehm, 1998; Chambless & Hollon, 1998;Kendall, 1998; Nathan & Gorman, 2002), ormore generally, the experimental approachto outcome research, which has dominated

psychotherapy research for many years,has its emphasis clearly on internal validi-ty. Political arguments (“psychotherapyper se is at stake in the competition withdrugs”), as well as the intrinsic logicalstrength of the experimental paradigmwhen it comes to causal argumentation,have strengthened this approach. Theyhave also rendered colleagues with reser-vations against ESTs moderate and hesitantregarding statements questioning thisapproach, but they have obviously notsilenced them (Elliott, 1998; Borkovec &Costonguay, 1998; Goldfried & Wolf, 1998 ;Westen, Novotny & Thompson-Brenner,2004). They have also stimulated construc-tive activities to compensate for the weak-nesses of this approach.Improving the situationTwo initiatives are most noteworthy, as dis-cussed in a previous article in this journal(Arnkoff, Glass & Schottenbauer, 2006):• The initiative to balance the one-sidedemphasis on techniques and on patientsbelonging to clear diagnostic categoriesby collecting and discussing evidenceregarding the psychotherapy relation-ship and its facets, by the APA Division29 Task Force (Norcross, 2002).

• The initiative to develop empiricallysupported principles which could carrypsychotherapy beyond the application ofempirically supported techniques by theDivision 12 Task Force (Castonguay &Beutler, 2006).

Each of these initiatives has great merits aswell as severe limitations that preventthem from being the last decisive step

PERSPECTIVES ON PSYCHOTHERAPY INTEGRATIONBalanced Psychotherapy ResearchFranz Caspar, University of Bern, SwitzerlandDept. of Clinical Psychology and PsychotherapyGesellschaftsstrasse 49, CH 3000 Bern [email protected]


towards balanced psychotherapy research,although they are important stages on thestony path towards it. The main shortcom-ing in the relationship approach is the currentlack of experimental research (although wemust acknowledge the greater difficulty ofexperiments related to the relationshipcompared to technique). The main short-coming of the principle approach is thatempirical rigor in the formulation of prin-ciples bleaches out much of what would berelevant for sufficiently concrete and com-plete instructions for practice.Premises and solutions of the ESTapproachTo understand some fundamental prob-lems in practice relevant research, we mustbe aware of fundamental assumptions ofthe still dominating EST (empirically sup-ported treatments) approach. A therapeuticapproach is developed for a group ofpatients, tested in such a way that it is pos-sible to determine causal effects of that spe-cific procedure, and if it is successful, it isrecommended for the treatment of futurepatients. This follows the logic of experi-mental research, which is the moststraightforward way for causal argumenta-tion: We try to develop instruments tobring about effects, and we must makesure that observed changes with patientsare actually brought about by these instru-ments and nothing else. Unless we can dothis, we cannot really recommend a proce-dure to be used with patients. Every proce-dure costs time and money, and preventsalternative procedures from being applied,therefore we must have good reasons forfavoring what we recommend.

Much of the early psychotherapy researchis of no or limited value because it has notsufficiently specified what the therapy con-sisted of. Postulates for specifying proce-dures more concretely are obviously justi-fied. This is one of the crucial criteria ofinternal validity.The EST initiative clearly specifies the wayto do this: By manualisation. If a psy-

chotherapeutic procedure under study isprescribed in sufficient detail, it can bechecked in the study itself whether thera-pists adhere to the procedure (also:whether the extent of adherence is posi-tively correlated to outcome, which is notalways the case!). Once studies haveshown effectiveness, therapists can followthe procedure and if they do this thor-oughly, they can expect outcomes that cor-respond to those found in the studies. It iscrucial that the manual be strict enough tolimit the variations of possible procedures,so as to prevent as much as possible the useof procedures that remain in scope of themanual but are inferior in outcome. This isthe principle. Some of the best knownman-uals are nevertheless rather flexible, fromrather old (Beck, Rush, Shaw & Emery,1979 ) to newer ones (e.g. Linehan, 1993).From a clinical practice point of view, thisis desirable, as it allows adaptations to theindividual patient. What if an agoraphobicpatient has had already three cardiacbypass operations? What if a patient whoshould stick to a strict behavioral program,as far as his symptoms are concerned, isbeing reactant due to motives of autonomyon the level of the therapeutic relationship?

Some authors of manuals don’t formulaterules algorithmically (in a narrow sense,allowing to follow them step by step, sothat the procedure with patient A resem-bles very much the procedure with patientB), but rather heuristically (so that, while aresemblance remains in principle, on thesurface, procedures may vary consider-ably). They do this for reasons of gain ineffectiveness, applicability to a broaderrange of patients, or more generally, a gainin clinical or external validity of a thera-peutic approach and the empirical evalua-tion coming along with it. The sameapplies to practitioners who use algorith-mically formulated, high-internal-validityapproaches heuristically, or extend theduration (Morrison, Bradley & Westen,2003): They may not be aware of it, but


they trade external for internal validity.Trying to improve applicability, quality ofprocesses, and outcome from a clinical(external) point of view, they take the riskof jeopardizing internal validity. The rangeof possible concrete procedures is broad-ened by the flexibility allowed by the useof heuristic rules, or by using algorithmicrules in a more sloppy way than envi-sioned by the developers.

Apart from this first big issue, the compa-rability of procedures, there is a second: thecomparability of patients. Specifying thetype of patients was a part of the postulatesby Kiesler (1966) as well as Paul (1967) toabolish uniformity myths. In the ESTmovement, this is typically done by usinghomogeneous, monosymptomatic, non-comorbid groups of patients (majordepression, no other axis I or axis II diag-nosis). It seems a matter of course thateffectiveness found for one group ofpatients cannot be transferred to differentpatients. Unless my patient stronglyresembles the patients in a study in all rel-evant criteria, I cannot expect comparableeffects, even when precisely applying theprescribed procedure. Therefore one needsto specify the group to which a procedurehas been applied. Homogeneity can cer-tainly be increased by the procedure typi-cal for ESTs. It should be mentioned, how-ever, that this approach is far from perfect,because a concentration of diagnostic crite-ria (in the sense of DSM) usually meansneglecting so called “nondiagnostic”aspects, such as interpersonal properties,which have been shown to be critical inchoosing the appropriate procedure(Beutler & Harwood, 2000; Grawe, Caspar& Ambühl, 1990). One could certainly per-fect the homogenization beyond the pointthat is typical for ESTs, and there are goodclinical arguments in favor of doing so. Thecommon critique goes, however, in a dif-ferent direction: What proportion ofpatients in common practice can be cov-ered if treatments are tailored to specificdiagnostic groups? So far, only a small part

of defined diagnostic groups have beencovered by manuals (Beutler, Malik,Alimohamed, Harwood, Talebi, & Noble,2004), and given the high standards andcosts of RCTs it is completely unrealistic tothink that this approach can ever comeclose to covering most patients. This is par-ticularly true when one thinks of combina-tions of patient properties of known rele-vance. It would be unfair not to mentionthat more recently, comorbidity has beenincluded to a larger extent by the RCTapproach (Hollon, 2007), but this does notsolve inherent problems of the sheer num-ber of groups needed to be studied toavoid having to say too often to a patient“sorry, bad luck, no sufficiently compara-ble group for you”! In addition, evenamong patients who would qualify for atreatment, only a relatively small part endsup using and receiving a number of thera-py sessions sufficient to make therapyeffective, and providing all the data need-ed for evaluation. This is another threat togeneralizibility.Pragmatic solutionsPragmatic solutions for problems with thecoverage of patients in natural settings byRCTs go again in the direction of usingfindings for groups sufficiently similar to aparticular patient in a heuristic manner, ofadding rules derived from a non-diagnos-tic perspective (Beutler & Harwood, 2000).

This is not to argue against a clinically rea-sonable development and use of therapeu-tic procedures, but to remind ourselves ofthe fact that most often, a gain in exter-nal/clinical/ ecological validity means aloss of internal validity. Unfortunately, thisdilemma is often personalized: In oral andwritten discussions, some colleagues takethe role of partisans of external, others ofinternal validity and present argumentswhy one is more important than the other.By selection of examples and criteria, it isalways possible to make a convincingpoint, and it is good that, for example in


the activities of NIMH, the RCT initiative iscomplemented by a wealth of activitiesdirected towards clinical practice andbridging the gap between basic effective-ness research and practice oriented effec-tiveness research. Process and process-out-come research are, of course, also neededto enhance our understanding of how andwhy psychotherapy works. In the follow-ing lines I will argue in favor of making astep back from commonly accepted butunnecessarily limiting solutions, and makesome postulates related to the balance ofinternal and external validity.

Stepping back from some solutionsAs mentioned above, APA prescribes man-ualisation. This is a self-evident solutionfor the need to specify the therapeutic pro-cedure. When it is questioned, this hap-pens for reasons of negative side effects, inparticular from a clinical perspective.These side effects make developers as wellas users depart from a narrow procedurethus jeopardizing the very idea behind thespecification. If it is largely unrealistic thatthe procedure-related conditions of RCTsare met, the question of alternative solu-tions for the justified goal of specificationarises. An obvious alternative is to specifythe procedure retrospectively instead ofprescriptively. This means: Instead of ask-ing therapists to follow a precise manualand to check adherence, they can be givenmore heuristic rules, and by means ofquantitative and possibly qualitativeprocess research we can study what hasactually been done in therapy. To study theactual process in all included therapies indetail is clearly an additional investment infavor of gaining flexibility, because in tra-ditional RCTs adherence checks are typical-ly considered to be sufficient, but onecould argue that here too a more extensivedescription of what actually happens intherapy should take place. If this would beundertaken, the alternative proposed herewould not be more costly.As an example, in their 1990 study Grawe,Caspar and Ambühl prescribed different

ways of doing case conceptualizations andof deriving and justifying concrete proce-dures. What therapists did on the level ofconcrete interventions was up to them,very much in the sense of Lazarus’ multi-modal behavior therapy (Arnkoff et al.,2006). They were even allowed to includeinterventions and ideas from other thancognitive behavioral approaches as long asthis was plausibly justified in light of theindividual case conceptualization. As theconcrete procedure depended on the differ-ent ways of doing case conceptualizations(which was the prescribed experimentaldifference), differences in the proceduresemployed were expected; these were con-sidered not as a problem, but already as aconsequence and intervening variable, anddescribed in the analysis of the data. Oneknows what the therapists did, but not byprescription, but by description. Thisopens up possibilities postulated byArnkoff et al. (2006), which are needed foran approach to effectiveness research inpsychotherapy integration with integra-tion taking place on the level of individualpatients, and it opens up possibilities fordirect experimental research on the effectsof using principles (Castonguay & Beutler,2006) and therapeutic factors instead of fol-lowing narrowly defined procedures. Therequirement of knowing what the proce-dure is met, but in a different way than iscommon to RCTs.

As far as patients are concerned, a priorihomogenization is also not the only avenueto knowing to what type of patients’results apply. Here too, we can make a stepback and think of the goal rather than ofthe commonly accepted means. There arealso alternatives. An obvious one is toinclude a larger range of less selectedpatients (those more representative of com-mon practice), describe the sample precise-ly, followed by analyses of differentialeffects. This has also been done in thestudy by Grawe et al. (1990): Only psychot-ic, substance addicted and acutely suicidal


patients were excluded. Effects on thewhole group could equally be described asfindings specific to one group of patients. Itmust be admitted that, corresponding tothe state of the discussion at that time,diagnostic groups had not been sufficientlydifferentiated, but this could easily be donecorresponding to the emphasis given tothis criterion today. In principle, one wouldknow what results can be related to whichsubgroups, the sample being more repre-sentative to patients in a natural settingdue to the lack of a restrictive selection pro-cedure. The issue here is differential out-come research – not so much as a means forincreasing effects, which in general hasbeen a rather disappointing approach sofar, but to specify what effects can beexpected for which patients according tothe postulate of RCTs.A panacea?These two examples—methodologicalalternatives to common procedures—arenot offered as panaceas for the problemsdiscussed here. But they are illustrationsfor opening up the solution space by notconfounding goals and means, and consid-ering alternative means with fewer sideeffects. Even if discussion would revealthat one would trade one side effect foranother, the variation would be an advan-tage when thinking of combining studiesfor compensation of weaknesses. The cru-cial point is, that with such procedures theadvantage of experimental research incausal argumentation can be maintained,and the type of case conceptualisation orthe application of a therapeutic principle orheuristic rule can be introduced as experi-mental factor.What is the postulate? A huge problemwhen it comes to balancing external andinternal validity is the lack of elaborate dis-cussion of how to value criteria and advan-tages in terms of one against the other. Thislack is not only regrettable from an acade-mic point of view. It also brings aboutchoices for “the safe side” by researchers aswell as reviewers of grant proposals and

manuscripts. The safe side is internal valid-ity: Although some criteria of externalvalidity have been discussed more intense-ly in recent time (such as exclusion ofcomorbidity and its consequences for rep-resentativeness), internal validity is muchbetter specified. Researchers are thereforetempted or feel even pressured to givemore attention to it and to make compro-mises in favor of internal validity in case ofdoubt. For example. they would prescribea therapeutic procedure in a more narrowway than they might from a clinical per-spective, they are more selective withpatients. etc.

Reviewers are not gods with total freedomof choice: Usually they prefer judgmentswhich they can justify as clear applicationsof consensual standards. As far as internalvalidity is concerned, standards are muchfarther developed and –as they correspondto the experimental paradigm valued toohighly in psychology and related fields -than for external validity. This is unfortu-nate for approaches requiring flexibility,such as psychotherapy integration on thelevel of individual patients. It is also unfor-tunate for researchers dedicated to it, whothen turn away from (funded and wellpublished) mainstream research, with con-sequences for both careers and thosepatients who fall between the chairs.

A rationale for balancing external andinternal requiredThe imbalance between the clarity andimportance given to criteria of external andinternal validity is not the only and maybenot even the main problem: It is rather thelack of rational evaluation and decisionprocesses evaluating and balancing oneand the other side. Reviewers are as help-less in this respect as researchers/authors –and of course, they are often the same indi-viduals in different roles. It is obvious thata gain in internal validity if often paid forby a loss of external validity and vice versa.For some problems related to this, creative


solutions may be possible as illustrated bythe “stepping back” and considering alter-native solutions. It is for sure that this willnot solve all problems. But how much lossof internal validity and what kind of losscan be tolerated in favor of a gain in exter-nal validity, and vide versa? What arerationales for an optimal balance wheneven much creativity does not lead to atruly satisfactory extent of both while cru-cial clinical questions wait to be answered?Unfortunately, the author is, after extensivediscussions (among others in the context ofthe German Research funding agencyDFG; Caspar, 2006) not able to provideanswers. This is clearly a domain waitingfor an engagement of the most knowledge-able and bright spirits in the domain – andalthough it might seem paradoxical thatpractitioners should rank methodologicalquestions very high: They should pull for itprimarily.

ReferencesArnkoff., B.D., Glass, C.R., &Schottenbauer, M.A. (2006) OutcomeResearch on psychotherapy integration.Psychotherapy Bulletin, 41, 43-50

Beck, A. T., Rush, J. A., Shaw, B. F., &Emery, G. (1979). Cognitive therapy ofdepression. New York: Guilford Press

Beutler, L., & Harwood, M. (2000).Prescriptive psychotherapy: a practical guideto systematic treatment selection.NewYork:Oxford University Press.

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How very fortunatefor the field of psy-chology that AlbertEllis struck out in hisfirst two career goals:writing Broadwaymusicals and theGreat AmericanNovel. Instead, hewent on to a brilliant

career that spanned over 50 years andhelped change the face of psychotherapy.

Early YearsBorn in Pittsburgh, Ellis grew up in theBronx, the oldest of three children andgrandchild of Jewish émigrés from Russiaand Germany. He had what could certain-ly be viewed as a rather difficult childhood:his parents divorced when he was 12, histraveling salesman father was rarelyaround and his mother, whom he oftendescribed as a “fun-loving screwball,”spent much of her time playing mahjongwith friends and little on the care of herchildren. During his approximately sixhospitalizations between the age of 5 and 8(for nephritis or streptococcal infections)—at some distance from his home—his par-ents rarely visited him.Ellis made the most of this family situation,he claimed, by not taking his parent’sbehavior too seriously and by becoming, inhis words, “a stubborn and pronouncedproblem-solver.” His mother’s “negli-gence” provided him with the freedom topursue his reading, writing, and music,even though he also took on some of thehousehold responsibilities, including help-ing to get his younger siblings off to schoolin the morning. As a teen, he held livelydiscussions with fascinated friends aboutthe philosophers he had been reading inhis favorite hangout, the Bronx BotanicalGardens; and it was there that he conduct-

ed his first experiment in desensitization,approaching 100 girls and being rejectedby all but one (who failed to show up attheir date!).

It was in the 1930’s—the height of theGreat Depression and with his now-divorced father unable to provide muchfinancial support— that Ellis, concludingthat it seemed unlikely that he was goingto be able to support himself and his fami-ly through writing, enrolled in the CityUniversity of New York, where he earnedhis B.A. in business in 1934. He then start-ed a business with his brother, matchingpants to financially-strapped men’s stillusable jackets, and following that, becameoffice manager at a novelty firm.

Around this time, Ellis began to readeverything he could find about sex andrelationships (and also did “fieldwork,”having overcoming his shyness withwomen!). He became so knowledgeable inthis area that his friends, who began to con-sider him somewhat of an expert on thesubject, often asked him for advice. After awhile, he concluded that disturbed rela-tionships were really a product of dis-turbed persons, “and that if people weretruly to be helped to live happily with eachother, they first had better be shown howthey could live peacefully with them-selves.” Discovering that he liked counsel-ing as well as writing, but with no formaltraining available in marriage and sexcounseling, he turned to clinical psycholo-gy, and in 1947 he completed his Ph.D. atColumbia University.

From Psychoanalysis to REBTBelieving at that time that psychoanalysiswas the only truly “deep” and effectiveapproach to understanding human behav-


THE AMAZING ALBERT ELLIS (1913-2007)Janet L. Wolfe, Ph.D.

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ior, Ellis decided to undertake a traininganalysis. At a time that psychoanalytic insti-tutes would only accept MDs, but he wasfinally able to find an analyst who was will-ing to work with him: Richard Hulbeck, amember of the Karen Horney group. Aftercompleting his analysis at age 35, he begana part-time practice of psychoanalysisunder Hulbeck’s supervision, and soonthereafter, in the late 1940’s, he becameChief Psychologist of the New JerseyDepartment of Institutions and Agencies.During the six or so years that he practicedpsychoanalysis, Ellis became increasinglydissatisfied with what he considered to bethe inefficiency of psychoanalysis and by1953 had begun to take a more active role,as he had when counseling people on fam-ily or sex problems. Impressed with howthe work of philosophers such as Epictetus,Spinoza, Schopenauer and BertrandRussell had helped him work throughmany of his own problems, he began toteach some of these principles to his thera-py clients. At the heart of his emergingapproach was the idea, as Epictetus hadexpressed it, that “people are not disturbedby things, but by the views they take ofthem.” More and more he began to focuson helping people change the self-defeat-ing beliefs, learned in childhood but car-ried into the present, which kept themstuck in their own emotional morass. Helost faith in the idea that parents areresponsible for just about everything thatcomes later, and that analysis could pro-vided them with some magic-bulletinsights that could free them from theirdisturbance. “My experience when I prac-ticed psychoanalysis,” he wrote, “usuallyshowed me…the more I helped clientsfocus on and understand the past, the lessthey usually thought rationally about andallowed themselves enjoyable experiencesin the present and future.”Between his break with psychoanalysis in1953 and in his first presentation of “rationaltherapy” at the annual A.P.A. convention in1956, Ellis set forth the core principles of his

new approach (now known as rational emo-tive behavior therapy (REBT), which moreaccurately reflects its focus not only on cog-nition, but on emotions and behavior). Hisearliest papers on his approach appeared inthe Journal of Clinical Psychology in 1955 and1957, and his first book on REBT for profes-sionals, Reason and Emotion in Psychotherapy,was published in 1962.

In addition to the philosophers he had readin his teens—Epictetus, Marcus Aurelius,Spinoza, and Schopenauer—Ellis was alsoinfluenced byAlfredAdler’s concept of the“inferiority complex” and Karen Horney’s“tyranny of the shoulds.” He embracedthe flexibility and anti-dogmatism of thescientific method, contending that rigidabsolutism was the core of human distur-bance. The behavioral component of hisapproach—still a major emphasis—wasdrawn from such early pioneers in behaviortherapy as J.B. Watson and Mary CoverJones, whose techniques he had successfullyapplied to his own public speaking anxiety.

The Growth and Development of REBTEllis passionately loved his work. Adevouthumanist, he believed that he could helppeople to lead happier and healthier livesby making it his life’s mission to developand teach the approach he believed couldmost help them. He viewed REBT not onlyas a clinical approach, but a realistic phi-losophy of life. In this regard, he was influ-enced by existentialists Tillich andHeidegger, who put the responsibility forone’s feelings squarely on the shoulders ofthe individual’s beliefs and by the writingsof general semanticist Alfred Korzybski,who emphasized the powerful effect oflanguage on our emotional processes.

A cornerstone of Ellis’s philosophy wasthat by helping people to identify and chal-lenge their irrational beliefs, they coulddevelop the power to relieve their emo-tional pain. In his writings, therapy, andpresentations, he urged people to deal with


reality in a rational way and to create a bet-ter life for themselves—as long as they didnot needlessly hurt themselves or others inthe process. He defined irrationality as“that which prevents people from achiev-ing their basic goals and purposes.”Although some critics wrongly inferredthat becomingmore “rational” might resultin emotional constriction, Ellis’s goal wasto help people to change their dysfunctionalemotions (such as rage, anxiety, anddepression) to the less disturbing feelings(such as annoyance, disappointment,apprehension, or concern). Through thisprocess, they would then be able to free uptheir emotional energy for achieving high-er levels of life enjoyment and fulfillment.Ellis especially challenged people to giveup the three internalized demands that hesaw as the root of emotional disturbance: 1)“I must be perfect and successful at alltimes, or else I’m a worthless failure (anattitude that leads to depression and self-downing); 2) “Significant people in my lifemust love and approve of me at all timesand treat me well, and if not, they shouldbe made to suffer” (beliefs leading to anger,rage, or even genocide;” and 3) “the worldmust always be comfortable and provideme with exactly what I want” (leading todepression, a low tolerance for life’sinevitable frustrations, inertia, and self-pity). He felt strongly that self-evaluation(including “self-esteem”) was one of themain sources of disturbance, and wasskeptical about the existence of a “true” or“real” self that Rogers and others expound-ed. Rather than facilitating change, he sawself-evaluation as leading to depressionand anxiety, as opposed to evaluating one’sbehavior, which was more likely to makepeople do better as well as feel better.Following their disputation of their self-defeating beliefs, Ellis also stronglyencouraged people to take positive actionto achieve their goals and made individu-alized “homework” assignments a promi-nent feature of his therapy. He increasinglybelieved that there was also a strong bio-

logical component in people disturbance:that “practically all individuals havestrong innate as well as learned tendenciesto act like babies all their lives.”Notwithstanding, people could overcomethese tendencies, Ellis asserted, throughhard, persistent work on their self-defeat-ing belief systems.Although the initial reception by sometherapists, both to his therapy system andhis colorful style, was not always enthusi-astic, Ellis persevered. In the next 50 yearshis approach—considered the first expres-sion of CBT—would become the zeitgeistof psychology, with more than two-thirdsof psychologists in a 2007 NIMH-spon-sored study identifying themselves asusing some form of cognitive behaviortherapy. In a 1982 survey of American andCanadian psychologists, Albert Ellis wasrated the second most influential person inpsychology—ahead of Sigmund Freud andtopped only by Carl Rogers. Over theyears, as he persisted in “spreading thegospel according to St. Albert” around theworld, he was given numerous awards,including Humanist of the Year from theAmerican Humanist Organization andawards for outstanding professional con-tributions from APA, the AmericanCounseling Association, ABCT, the Societyfor the Scientific Study of Sex, and otherorganizations. He was even mentioned inan off-Broadway play that was based onthe writings of Dalton Trumbo, whoreferred to Ellis as “the greatest humanitar-ian since Gandhi.”

REBT’s Wide Range of ApplicationsAlbert Ellis was one of the earliest expo-nents of prevention and positive mentalhealth. Facilitated by a foundation grant tohis Institute, the Living School was found-ed in 1970 and housed in the Institutebuilding for five years. In addition to theusual academics, students ages 8-13 weretaught self- and other-acceptance and howto manage anxiety, anger, and frustration,and curricula based on this early work


have been expanded and used worldwide.His approach has also had a major impacton the field of addictions. S.M.A.R.T.Recovery—an alternative to AlcoholicsAnonymous based on REBT principles—was started in the 1980’s and groups con-tinue to proliferate. In S.M.A.R.T. meetings,substance-abusing individuals are provid-ed with techniques and support for coun-tering the kinds of thoughts that triggerurges and relapses.

One of the first to write self-help books,many of which (such as his Guide toRational Living) have remained in print fordecades, Ellis’ writings included booksboth for professionals and the public onREBT’s wide range of applications, includ-ing anxiety, depression and anger, work-place issues, overcoming procrastinationand addictions, counseling religiousclients, aging and tolerance. He also spokeabout current world problems such as ter-rorism and nuclear weapons. To Ellis,REBT was not just a clinical approach, buta realistic philosophy of life focusing onlong-range (rather than short-range) hedo-nism and an unconditional acceptance ofself and others and high frustration toler-ance for a difficult and often unfair world.

Although the theory and practice of REBTwere laid out in his 1963 work, Reason andEmotion in Psychotherapy, Ellis continued toexpand his work, writing several seminalpapers over the next 40 years. Theseincluded an expansion of his personalitytheory (in Corsini’s 1978 book Readings inCurrent Personality Theory); emphasis onregularly doing forceful and energetic dis-puting in order to create meaningful, long-last change; REBT as a constructivist ratherthan a rationalist approach; and dealingwith resistance. One of his greatest contri-butions was his focus on what he called dis-comfort anxiety,” low frustration tolerance(LFT) or I-can’t-stand-it-itis, which hebelieved was a primary factor in suchproblems as anger, addictions, procrastina-tion, self-pity and relationship difficulties.

The Albert Ellis InstituteThe not-for-profit Institute that Albert Ellisfounded in 1959 moved to its present head-quarters in New York City in 1965, and in1968 was granted a charter as the Institutefor Rational-Emotive Therapy by the N.Y.State Board of Regents to provide profes-sional training, low-cost clinical services,and public education. It was one of the firstpsychologist-run facilities, since up to thattime the N.Y. State Department of MentalHygiene had restricted the management ofmental health clinics to physicians. UnderEllis’s and my helm, and with the aid ofmany outstanding trainers, the Albert EllisInstitute (as it was renamed in the ‘90s)grew from a staff of four to a world-renowned training center with affiliatesaround the world.

Amain source of funding for the Institute’sbuilding and operations was the incomefrom all of Ellis’s books, therapy clients,lectures and workshops, all of which hedonated to the Institute. He lived simplyand for most of his years at the Institute,received a salary of $12,000—less than thatof many parish priests.

Sexual Revolutionary and FeministLong before he published Reason andEmotion in Psychotherapy in 1962, Ellis hadwritten several books on sex and relation-ships including The Folklore of Sex (1951),The American Sexual Tragedy (1954), and Sexwithout Guilt (1958)—the first widely-readbooks to challenge the longstandingemphasis on romance and sexual piety. In1957 he helped found the interdisciplinarySociety for the Scientific Study of Sex, laterreceiving its award for DistinguishedScientific Achievement. On radio and TVand in his lectures, he was almost a lonevoice for sexual liberation, making a casefor sex education in the schools, guilt-freemasturbation, and the non-pathologizingof homosexuality.

In 1953, Ellis wrote an article on “The Mythcontinued on page 59

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of the Vaginal Orgasm,” pointing out thatwhile Freud, most men (and even manywomen) believed that not having anorgasm coitally was a sign of frigidity, theclitoris was where it was at for mostwomen. He believed that this view of theprimacy of the so-called “vaginal orgasm”had prevailed for so long—even afterKinsey’s research was published—becausemen, who found intercourse to be a mar-velous and reliable route to orgasm, didnot want to face up to the “inconvenience”of having to do (at times lengthy) clitoralstimulation.

In The Intelligent Woman’s Guide toManhuntin (1963), Ellis demonstrated hiscommitment to feminism, encouragingwomen to strongly challenge their beliefthat their entire worth and happiness rest-ed on having a perfect face and body andbeing married. He encouraged women toseek fulfillment not only in sex-love rela-tionships, but in other areas, such as devel-oping their careers and other vital absorb-ing interests. He exhorted women not to beswayed by a man who, however attractivehe might appear, was a male supremacist:“Poison is his name,” he wrote, and “Mrs.Dead Duck is yours if you are crazyenough to marry him!”

My own relationship with Albert Ellisdemonstrates that he not only preached,but also practiced feminism. Not contentto have me simply take over the adminis-tration of the newly-expanding Institute in1965 (freeing him from the everyday tasksof managing an organization), he encour-aged me to get my doctorate in clinicalpsychology at New York University inorder to become his full professional part-ner, leading to a fulfilling career in whichI have written and lectured worldwideon the application of REBT to women’sand couples’ problems. When we partedas friends in 2002, he reiterated his respectand gratitude for my important contri-butions to the growth of the Instituteand REBT.

A Bundle of Energy with a Gene for EfficiencyEllis’s energy was boundless. He whizzedaround the Institute, airports, and over ahundred lecture venues a year with suchspeed that he left those in his wake dazed.In a typical day during the majority of hiscareer, he saw individual and group clientsfrom 9:30 a.m. to 10:30 pm (approximately140 clients a week). He conducted over 80lectures and workshops a year and pub-lished or edited over 70 books and hun-dreds of articles and tapes. There is,undoubtedly, no therapist in history whohas seen more clients or given more thera-py demonstrations! Not infrequently, Elliswould return from a lecture tour at mid-night, see a full day of clients the next day,then catch a flight that evening for some-place halfway around the world to conductseveral more workshops. In the 4-dayREBT certificate practica that the Institutesponsored in the U.S. and abroad, both theattendees and the trainers were pooped bythe time they finished supervision at 5:30pm: not so Ellis, who, well into his 80s,resumed from 7-10:00 p.m. to conduct alively group therapy demonstration or givea talk on addictions. Even more remark-able was the fact that despite his jam-packed schedule, he managed to answermost of his voluminous correspondencewithin two days and rarely (if ever) turnedin a manuscript after its due date!

Anecdotes abound of Ellis’s unceasingwork and disdain for leisure activities. Heclaimed he wouldn’t visit the Taj Mahalunless he was invited to do a workshopthere. In the late ‘60s, he took an actual“vacation” to Jamaica, mainly to please me.Once there, he came out once to the terrace,took one look at the sea, and went backinside to work on his latest book. Onanother occasion, when co-opted into visit-ing a casino (he had never been in one), hetook the 50 dollars his host had given hisguests to gamble with and donated it to theInstitute, retreating to a corner to catch upon his journals until he was able to escape.


Even after his hospitalization for an intesti-nal infection and pneumonia most of hislast 1 ½ years of life (and a major hearingloss that required people to speak into amicrophone connected to his earphones),Ellis continued to meet with groups of stu-dents at his bedside, refusing to canceleven when feeling under the weather. Atage 91 when, in his words, he was “forcedby the Board of Trustees and senior staff ofthe Institute to stop doing my Friday nightworkshop and any other work teaching orseeing clients for the Institute,” he rented ahall next door and continued—beforepacked groups—to conducting the enor-mously popular Friday night workshop/demonstrations that he had been doing fornearly four decades. He calmly took suc-cessful legal action two years ago againstthe Institute for what the judge referred toas his “disingenuous” removal from theBoard; another major lawsuit is still inprocess.His rift with the Institute marked thebeginning of a period of over a year and ahalf during which Ellis bounced back andforth between the hospital and rehab for allbut the last three or so weeks of his life,when he returned to his Institute apart-ment. Instrumental in maintaining theround-the-clock care that extended his lifewas Debbie Joffe, anAustralian hired as hisassistance in 2002 and whom he subse-quently married.

Will the Real Albert Ellis Please Stand Up?On the personal side, Ellis was a bundle ofseeming paradoxes. His colorful language,one-line zingers, his colorful and attention-grabbing style of presentation, and hismunching sandwiches on the platformgave many the impression of someonegoing out of his way to be outrageous. Inactuality, Ellis believed that his provocativelanguage made his presentations and ther-apy more impactful and that far more peo-ple found it helpful than were turned off byit. His hilarious sense of humor and play-fulness always left audiences howling withdelight (as well as insight), and me con-

vulsed in giggles when, over dinner, hemade faces, quipped, and sang silly songs.His wit and humor were hilarious andunparalleled. In impugning the idea of an“inner child,” for example, Ellis declaredthat “the only way to have an inner child isif you’re pregnant,”and he coined suchcatchy phrases as “Blood is sicker thanwater” and “Shouldhood leads tos__hood.” Strongly believing that emotion-al disturbance usually involved takingthings too seriously, Ellis returned to hislove of Broadway musicals and wrote over100 songs to popular old tunes, including“Whine, Whine, Whine,“ I Am Just aF__cking Baby,” and “Glory, GloryHallelujah, People Love ‘Ya Till They Screw‘Ya”. Many of the terms he originated havenow become part of the psychotherapy lex-icon, including awfulizing, shoulding, cata-strophizing, LFT, and musturbation.

As for the public sandwich-eating: Elliswas an insulin-dependent diabetic whointended to live as long and healthfully aspossible. Without ever complaining, heinjected himself twice a day, checked hisblood sugar regularly, and made six ormore sandwiches a day for 55 years so thathe could maintain proper blood levelswithout having to interrupt his work formeals. He became a powerful role modeland inspiration for hundreds of people indealing with the frustrations of illness orimpairment through conscientious healthmanagement and refusal to engage inawfulizing or self-pity.

Behind Ellis’ at times somewhat pricklypublic persona was a person of tremen-dous supportiveness and compassion—a“closet mensch,” as I referred to him at his90th birthday party. He never refused col-leagues’ requests to help them sort out acrisis in their lives, and when a friend ofmine needed care after his hospitalizationwith AIDS, Albert immediately agreed tohaving him stay in our apartment for aslong as necessary. He mentored hundreds


of students and professionals over theyears, writing detailed critiques of manu-scripts or therapy tapes and helping themin any way he could to further their careers.

At the Institute’s dozens of training practi-ca, many therapists who had cowered infear in anticipation of Ellis’ comments ontheir taped sessions reported that not onlydid he give them incredibly helpful feed-back, but was also one of the most sup-portive and encouraging supervisors theyhad ever had. Although some people erro-neously contend that REBT practitionersare supposed to be Ellis sound-alikes (com-plete with four-letter words), superviseeswere encouraged to develop their ownunique style. In his Friday night work-shops as well as in his therapy sessions,contrary to “yelling at people,” as somecritics claimed, Ellis incisively helpedmembers of the public to attack their irra-tional beliefs, but never attached the personwith whom he was working. Despite his

having been at times strongly attacked forhis ideas and presentation style (and hadhis ideas frequently used, without attribu-tion, by other self-help writers), he neverengaged in self-pity or anger.

Although the world will be a lot less color-ful now that this remarkable man has leftus, it is undoubtedly a better place as aresult of his many contributions to helpingpeople lead happier and more fulfilledlives. He used to say to me, when he cameup to our apartment, “heighty-ho,” andwhen he went to bed, “nighty-night.”So…heighty-ho, Albert, and nighty-night.

Janet L. Wolfe, Ph.D. lived with Albert Ellisfrom 1965 to 2002, and for 36 years served asthe director of the Albert Ellis Institute. She hasauthored numerous chapters, articles, andbooks and lectures worldwide on REBT. She iscurrently in private practice and an AdjunctProfessor at New York University.

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AddendumIn reference to the article, “A Q-sortModel for the Empirical Investigation ofPsychotherapy Integration” by Deborah A.Gillman and Paul L. Wachtel, published inthe summer 2007 issue of the PsychotherapyBulletin, please note that this research wasconducted with the support of a grantfrom The Fund for PsychoanalyticResearch of the American PsychoanalyticAssociation.

The APA Council of Representatives meton two days surrounding the annual APAconvention in San Francisco. Following areseveral of the more important matters ofinterest to the Division of Psychotherapymembership.

Psychologist participation at USDetention Centers was the agenda item ofmajor concern. Intense effects to find com-mon ground were conducted for threedays, culminating in a Council vote onSunday with by-standers on the side andback cheering and booing the discussion.The national press was also present asselect Council members worked extremelyhard and, for the most part, collegially on aresolution that reflected outrage over actsof torture and other cruel, inhuman, ordegrading treatment. The final resolutionpassed by a significant majority and can beviewed onAPA’s web page (www.apa.org).We strongly encourage you to read theentire resolution and not just base yourjudgment on what you might hear or readin newspapers or on listservs.

The final language is strong and unequivo-cal: psychologists do not participate, con-done, or consult in torture and other cruel,inhuman or degrading treatment or pun-ishment. The disagreement was whetheror not APA should specify sites, such asdetention centers where torture is used, asplaces of employment where psychologistsshould not work. The counter-argumentwas made that the presence of psycholo-gists saves lives and improves the health ofdetainees. The issue is extremely complexand clearly will continue to be debated.

The Council of Representatives voted tosend out to the membership for approvalan APA Bylaw change to increase the size

of the Council of Representatives to

include representation of the AsianAmerican Psychological Association, theAssociation of Black Psychologists, theNational Latina/o PsychologicalAssociation, and the Society of IndianPsychologists. All the Associations but theABP were present at Council and werepleased at the passage of this importantexpansion of governance. ABP declines theinvitation at the current time.

A new Council item was passed in reac-tion to the forced resignations of Israelischolars from the editorial boards ofBritish scholarly publications to strength-en APA’s position against anti-Semitism.The item condemns academic boycotts as aviolation of academic freedom and a dis-ruption of the exchange of scientific andscholarly ideas.

The item proposed by your Division 29Representatives and supported stronglyby the Division 29 Board passed to strong-ly encourage the use of the terms “psychol-ogy,” “psychological” and “psychologists”when referring specifically to the activitiesof psychologists.

Council passed a resolution to EnhanceEthnic Minority Recruitment, Retention,and Training in Psychology by continuingthe work of the CEMRRAT2 Task Force.Council also passed an increase in reim-bursement for ethnic minority members ofCouncil.

During his CEO report, Dr. NormanAnderson, reported his major concernabout the possibility of a large deficit bud-get. He is also developing anAPAstrategicplan to begin in 2008. A Chief DiversityOfficer for APA will be hired in 2008 to

REPORT OF APA COUNCIL OF REPRESENTATIVES:AUGUST 2007Norine G. Johnson, Ph.D. and John C. Norcross, Ph.D.


oversee the implementation ofAPA’s prior-itizing of diversity.

Significant changes in Central Office staffwere announced. Russ Newman, executivedirector of of Practice will be leavingJanuary 1, 2008, Jack McKay, executivedirector of Finance, announced his resigna-tion, and Attorney Jim Mc Hugh also isleaving after many years leading APA’sLegal Affairs.

The biggest new financial item was theapproval of $7,600,000 to fund the WebRelaunch Project to make APA’s site moreuser-friendly and relevant for our mem-bers and the public. It is believed that thisexpenditure is necessary to support ourcurrent activities, enhance the availabilityof psychological information to the publicand our members, and to do theAssociation business in a more effectiveand efficient manner.

On line voting for APA elections wasapproved.

A revision of the RecommendedPostdoctoral Education and TrainingProgram in Psychopharmacology forPrescriptive Authoritywas passed in prin-ciple to amend the 1996 document. Thedocument is posted on APA’s web pagewhere you may see the details. The docu-ment recognizes the multitude of changesthat have occurred in the education andtraining of prescribing psychologists in thepast 10 years. There was significant sup-port for the changes recommended. Theprimary differences were focused on theamount of doctoral course work that may

be credited toward the granting of a post-doctoral degree in psychopharmacology.

APA’s Attorney Natalie Gilfoyle reportedon current litigation in which APA hasbeen engaged. One APA amicus briefspoke to the lack of scientific evidence topredict future dangerousness in certain set-tings such as a secure correctional facility. Irecommend you go on line and read herreport, which includes Justice Stevens’opinion, “Expert testimony about a defen-dant’s ‘future dangerousness’ to determinehis eligibility for the death penalty, even ifwrong ‘most of the time’ is routinelyadmitted.” Another filing of our attorneyswas to the Meredith v. Jefferson CountyBoard of Education and Parents v. SeattleSchool District – U.S. Supreme Court thatsignificantly impacts desecration efforts.

Corann Okorodudu received a PresidentialCitation for her important work with theUnited Nations, and Florence Denmarkwas presented the Raymond FowlerAward for lifetime contributions to theAmerican Psychological Association.

Finally, on a personal note, this Councilmeeting marked the end of our three-yearterms representing the Division ofPsychotherapy. John Norcross completedhis second term and is rotating off Council.He will be replaced by Linda F. Campbell,who will join Norine Johnson, who waselected to a second term on Council. Thethree of us collectively thank you for thesupport and, as always, welcome yourinput on the directions of the APA Councilof Representatives.

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The American Psychological Foundation(APF) is a nonprofit, philanthropic organi-zation that advances the science andpractice of psychology as a means ofunderstanding behavior and promotinghealth, education, and human welfare.

Background: The Division of Psycho-therapy fosters collegial relations betweenpsychologists interested in psychotherapy,stimulates the exchange of informationabout psychotherapy, encourages the eval-uation and development of the practice ofpsychotherapy, and educates the publicregarding the service of psychotherapists.The APF Division 29 Early Career Award rec-ognizes promising contributions to psy-chotherapy, psychology, and the Divisionof Psychotherapy by a Division 29 memberwith 10 or fewer years of post-doctoralexperience.

Eligibility Criteria:Applicants must be:

• Members of Division 29,• Be within 10 years of receiving his orher doctorate, and

• Demonstrate promising professionalachievement related to psychotherapytheory, practice, research, or training

Application Materials:The following are the required applicationmaterials:• A nomination letter written by a col-league outlining the nominee’s careercontributions (no self-nominations areallowed)

• A current vita• Up to four (4) supporting letters ofrecommendation

Application Procedures:Application materials must be submittedonline at http://forms.apa.org/apf/grants/

Deadline: January 1, 2008

CALL FOR AWARD NOMINATIONS

The APA Division of Psychotherapy invites nominations for its 2008 DistinguishedPsychologist Award, which recognizes lifetime contributions to psychotherapy,psychology, and the Division of Psychotherapy.

Letters of nomination outlining the nominee’s credentials and contributions shouldbe forwarded to the Division 29 2008 Awards Chair:

Jean Carter, Ph.D5225 Wisconsin Ave., N.W. #513Washington DC 20015Ofc: 202–244-3505E-Mail: [email protected]

The applicant’s CV would also be helpful. Self-nominations are welcomed.Deadline is January 1, 2008

CALL FOR NOMINATIONSAPF Division 29 Early Career Award


The Publication Board of the APADivisionof Psychotherapy is seeking applicationsfor the position of Editor of thePsychotherapy Bulletin. Candidates shouldbe available to assume the title of IncomingEditor on or before March 1, 2008 for athree-year term. During the first year of theterm, the incoming editor will work withthe incumbent editor.

The Psychotherapy Bulletin is an officialpublication of the Division of Psycho-therapy. It serves as the primary communi-cation with Division 29 members and pub-lishes archival material and official noticesfrom the Division of Psychotherapy. TheBulletin also serves as an outlet for timelyinformation and discussions on theory,practice, training, and research in psycho-therapy. Now in its 42nd year of publica-tion, the Bulletin reaches more than 4,000psychologists and students with eachissue.

Prerequisites:• Be a member or fellow of the APADivision of Psychotherapy

• An earned doctoral degree in psychology• Support the mission of the APADivision of Psychotherapy

Responsibilities:The editor of the Psychotherapy Bulletin isresponsible for its content and production.The editor maintains regular communica-tion with the Division’s Central Office,Board of Directors, and contributing edi-

tors. The editor is responsible for manag-ing the page ceiling and for providingreports to the Publication Board as request-ed. The editor must be a conscientiousmanager, determine budgets, and adminis-ter funds for his or her office. As an ex offi-cio member of the Publication Board, theeditor attends the scheduled meetings andconference calls of the Division’sPublications Board. An editorial term isthree years.

Oversight:The Editor of the Psychotherapy Bulletinreports to the Division of Psychotherapy’sBoard of Directors through the PublicationBoard.

Search Committee:Raymond DiGiuseppe, PhD, (ChairPublications Board), Beverly Greene, andGeorge Stricker, PhD.

Nominations:To be considered for the position, pleasesend a letter of interest and a copy of yourcurriculum vitae no later than Dec. 1, 2007to: Ray DiGiuseppe, Ph.D. PublicationBoard, Department of Psychology, St.John’s University, 8000 Utopia, Parkway,Jamaica, NY11439, or electronically [email protected]. Inquiries about theposition should be addressed to Dr. RayDiGiuseppe (718-990-1955; [email protected].) and/or to the incumbenteditor, Dr. Craig Shealy (540-568-6835;[email protected]).

CALL FOR NOMINATIONSEditor of Psychotherapy Bulletin


The Division of Psychotherapy is nowaccepting applications from those whowould like to nominate themselves or rec-ommend a deserving colleague for Fellowstatus with the Division of Psychotherapy.Fellow status in APA is awarded to psy-chologists in recognition of outstandingcontributions to psychology. Division 29 iseager to honor those members of our divi-sion who have distinguished themselvesby exceptional contributions to psy-chotherapy in a variety of ways such asresearcher, clinician, teacher, etc.

The minimum standards for Fellowshipunder APA Bylaws are:

• The receipt of a doctoral degree basedin part upon a psychological disserta-tion, or from a program primarily psy-chological in nature;

• Prior membership as an APAMemberfor at least one year and a Member ofthe division through which the nomina-tion is made;

• Active engagement at the time of nomi-nation in the advancement of psycholo-gy in any of its aspects;

• Five years of acceptable professionalexperience subsequent to the grantingof the doctoral degree;

• Evidence of unusual and outstandingcontribution or performance in the fieldof psychology; and

• Nomination by one of the divisionswhich member status is held.

There are two paths to fellowship. Forthose who are not currently Fellow of APA,you must apply for Initial Fellowshipthrough the Division, which then sendsapplications for approval to the APAMembership Committee and the APACouncil of Representatives. The followingare the requirements for initial fellowapplicants:

• Completion of the Uniform FellowBlank;

• A detailed curriculum vitae (please sub-mit 3 copies);

• A self- nominating letter (self-nominat-ing letter should also be sent toendorsers);

• Three (or more) letters of endorsementof your work by APA Fellows, at leasttwo of whom must be Division 29Fellows who can attest to the fact thatyour “recognition” has been beyond thelocal level of psychology.

• A cover letter, together with you c.v.and self-nominating letter, to eachendorser.

Those members who have already attainedFellow status through another divisionmay pursue a direct application forDivision 29 Fellow by sending a curricu-lum vita and a letter to the Division 29Fellows Committee, indicating in your let-ter how you meet the Division 29 criteria.

Initial Fellow Applications can beattained from the central office or onlineat APA:Tracey MartinDivision of Psychotherapy6557 E. Riverdale St.Mesa, AZ 85215Phone: 602-363-9211Fax: 480 854-8966Email: [email protected]

DEADLINE FOR SUBMISSION. Thedeadline for submission to be consideredfor 2008 is December 15, 2007. The initialnominee must complete a Uniform FellowApplication, self-nominating letter, three ormore letters of endorsement, updated CV,along with a cover letter, and three copiesof all the original materials. Incompletesubmission packets after the deadline will

CALL FOR FELLOWSHIP APPLICATIONS DIVISION 29—PSYCHOTHERAPYJeffrey J. Magnavita, Ph.D., Chair, Fellows Committee


not be considered for this year. Those whoare current Fellows of APA who want tobecome a Fellow of Division 29 need tosend a letter attesting to your qualificationsand a current CV. The nomination processis ongoing but don’t delay to be consideredfor 2008.

Completed Applications should be for-warded to:

Jeffrey J. Magnavita, Division 29 Chair,Fellows CommitteeGlastonbury Medical Arts Center300 Hebron Ave. Suite 215Glastonbury, CT 06033Email: [email protected]: 860-659-1202

Please feel free to contact me or otherFellows of Division 29 if you think youmight qualify and you are interested indiscussing your qualifications or theFellow process. Also, Fellows of ourDivision who want to recommend adeserving colleague should contact mewith their name.


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The Publications Board is seeking applica-tions for the position of Internet Editor forthe APA Division of Psychotherapy. TheInternet Editor manages the electronicresources and communications of theDivision of Psychotherapy, principally itshomepage and listserv. Candidates shouldbe available to assume the title of InternetEditor on January 1, 2008.

Prerequisites:• Be a member or fellow of the APADivision of Psychotherapy

• An earned doctoral degree in psychology• Support the mission of the APADivision of Psychotherapy

Qualifications:The applicant should have experience withthe creation and management of Internetresources and electronic publications. Theapplicant should be familiar with currentdevelopments in the application of com-puter technology to the field of mentalhealth as well as a broad background inpsychotherapy and editing skills.

Responsibilities:The Internet Editor is responsible for con-tent and production of the Division’s website and management of the member list-serv. The editor regularly updates informa-tion on the website, including informationabout meetings, changes in governance,new publications, and links to relevantwebsites. The editor reviews all posts to thelistserv, adds new members as required,and responds to requests for assistance.The editor is familiar with APA policies onthe use of internet resources and ensures

division compliance. The editor maintainsregular communication with Division com-mittees, the Division’s Central Office,Board of Directors, and Publications Board.As an ex officio member of both thePublication Board, the internet editorattends the governance meetings of theDivision of Psychotherapy.

Time Commitment:Editing the website and managing the list-serv requires several hours each month.The home page should be updated on amonthly basis. An editorial term is threeyears (2008-2011).

Oversight:The Internet Editor reports to the Divisionof Psychotherapy’s Board of Directorsthrough the Publication Board.

Search Committee:Jean Carter, PhD (President), JeffreyBarnett, PhD (President Elect), RaymondDiGiuseppe, PhD (chair of the PublicationBoard), and George Stricker, PhD, BryanKim, Ph.D (current editor).

Nominations:To be considered for the position, pleasesend a letter of interest and vision for theweb and a copy of your curriculum vitaeno later than November 1, 2007 toRaymond DiGiuseppe, PhD [email protected]. Inquiries about theposition should also be addressed to theincumbent editor, Dr. Bryan Kim([email protected]).

CALL FOR NOMINATIONSInternet Editor

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Please join us for the 33rd Annual

Association for Women in Psychology Conference

Hilton San Diego - Mission Valley March 13-16, 2008

Expanding the Boundaries of Feminist Psychology:

Want to get involved? Want more information? Contact the Conference Coordinators: Cathy Thompson & Oliva Espin

[email protected]

www.awpsd.org

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THE DIVISION OF PSYCHOTHERAPYThe only APA division solely dedicated to advancing psychotherapy

MEMBERSHIP APPLICATIONDivision 29 meets the unique needs of psychologists interested in psychotherapy.

By joining the Division of Psychotherapy,you become part of a family of practitioners, scholars,and students who exchange ideas in order to advance psychotherapy.

Division 29 is comprised of psychologists and students who are interested in psychotherapy. Although Division 29 is a division of the American PsychologicalAssociation (APA),APA membership is not required for membership in the Division.

JOIN DIVISION 29 AND GET THESE BENEFITS!

Name _________________________________________________ Degree ______________________

Address _____________________________________________________________________________

City __________________________________________ State __________ ZIP ________________

Phone ____________________________________ FAX ____________________________________

Email _______________________________________________________

Member Type: �� Regular �� Fellow �� Associate �� Non-APA Psychologist Affiliate �� Student ($29)

�� Check �� Visa �� MasterCard

Card # _______________________________________________ Exp Date _____/_____

Signature ___________________________________________

Please return the completed application along with payment of $40 by credit card or check to:Division 29 Central Office, 6557 E. Riverdale St., Mesa, AZ 85215

You can also join the Division online at: www.divisionofpsychotherapy.org

FREE SUBSCRIPTIONS TO: PsychotherapyThis quarterly journal features up-to-datearticles on psychotherapy. Contributorsinclude researchers, practitioners, and educators with diverse approaches.Psychotherapy BulletinQuarterly newsletter contains the latest newsabout division activities, helpful articles ontraining, research, and practice. Available tomembers only.

EARN CE CREDITSJournal LearningYou can earn Continuing Education (CE) cred-it from the comfort of your home or office —at your own pace — when it’s convenient foryou. Members earn CE credit by reading specific articles published in Psychotherapyand completing quizzes.

DIVISION 29 PROGRAMSWe offer exceptional programs at the APA convention featuring leaders in the field ofpsychotherapy. Learn from the experts in personal settings and earn CE credits atreduced rates.

DIVISION 29 INITIATIVESProfit from Division 29 initiatives such as theAPA Psychotherapy Videotape Series, Historyof Psychotherapy book, and PsychotherapyRelationships that Work.

NETWORKING & REFERRAL SOURCESConnect with other psychotherapists so thatyou may network, make or receive referrals,and hear the latest important information thataffects the profession.

OPPORTUNITIES FOR LEADERSHIPExpand your influence and contributions.Join us in helping to shape the direction of ourchosen field. There are many opportunities toserve on a wide range of Division committeesand task forces.

DIVISION 29 LISTSERVAs a member, you have access to our Divisionlistserv, where you can exchange informationwith other professionals.

VISIT OUR WEBSITEwww.divisionofpsychotherapy.org

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If APA member, please provide membership #

PUBLICATIONS BOARDRaymond A. DiGiuseppe, Ph.D., 2003-2008Psychology DepartmentSt John’s University 8000 Utopia Pkwy Jamaica , NY 11439 Ofc: 718-990-1955 E-mail: [email protected]

John C. Norcross, Ph.D., 2002-2008Department of PsychologyUniversity of ScrantonScranton, PA 18510-4596Ofc: 570-941-7638 Fax: 570-941-7899E-mail: [email protected]

Lillian Comas-Diaz, Ph.D., 2002-2007Transcultural Mental Health Institute908 New Hampshire Ave. N.W., #700Washington, D.C. 20037E-mail: [email protected]

Nadine Kaslow, Ph.D., 2006-2011Grady HospitalEmory Dept. of Psychiatry80 Jesse Hill Jr. Dr.Atlanta, GA 30303Ofc: 404-616-4757 Fax: 404-616-2898Email: [email protected]

George Stricker, Ph.D., 2003-2008Argosy University/Washington DC1550 Wilson Blvd., #610Arlington, VA 22209Ofc: 703-247-2199 Fax: 301-598-2436E-mail: [email protected]

Beverly Greene, Ph.D., 2007-2012Psychology St John’s Univ 8000 Utopia Pkwy Jamaica , NY 11439 Ofc: 718-638-6451E-mail: [email protected]

EDITORSPsychotherapy Journal EditorCharles Gelso, Ph.D., 2005-2009University of MarylandDept of PsychologyBiology-Psychology BuildingCollege Park, MD 20742-4411Ofc: 301-405-5909 Fax: 301-314-9566 E-mail: [email protected]

Psychotherapy Bulletin EditorCraig N. Shealy, Ph.D., 2007-2009International Beliefs and ValuesInstitute (IBAVI)James Madison University MSC 2802, 1241 Paul Street Harrisonburg, VA 22807 Phone: 540-568-6835 Fax: 540-568-4232 E-Mail: [email protected]

Psychotherapy Bulletin Associate EditorHarriet C. Cobb, Ed.D.Combined-Integrated Doctoral Programin Clinical/School PsychologyMSC 7401James Madison UniversityHarrisonburg, VA 22807Ofc: 540-568-6834E-mail: [email protected]

Psychotherapy Bulletin EditorialAssistantCrystal Kannankeril, B.A.Department of PsychologyLoyola College in Maryland4501 N. Charles StreetBaltimore, MD 21210E-Mail: [email protected]: (973) 670-4255E-mail: [email protected]

Internet EditorBryan S. K. Kim, Ph.D. 2005-2007Department of PsychologyUniversity of Hawaii at Hilo200 W. Kawili StreetHilo, Hawaii 96720-4091Ofc: 808-974-7460 Fax: 808-974-7737E-mail: [email protected]

Student Website CoordinatorNisha NayakUniversity of HoustonDept of Psychology (MS 5022)126 Heyne BuildingHouston, TX 77204-5022Ofc: 713-743-8600 or -8611 Fax: 713-743-8633E-mail: [email protected]

DIVISION OF PSYCHOTHERAPY (29)Central Office, 6557 E. Riverdale Street, Mesa, AZ 85215

Ofc: (602) 363-9211 • Fax: (480) 854-8966 • E-mail: [email protected]

PSYCHOTHERAPY BULLETINPsychotherapy Bulletin is the official newsletter of Division 29 (Psychotherapy) of the American PsychologicalAssociation. Published four times each year (spring, summer, fall, winter), Psychotherapy Bulletin is designed to: 1) inform the membership of Division 29 about relevant events, awards, and professional opportunities; 2) providearticles and commentary regarding the range of issues that are of interest to psychotherapy theorists, 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 4,000 words), interviews, commentaries, letters to the editor,and announcements to Craig N. Shealy, Ph.D., Editor, Psychotherapy Bulletin. Please note that PsychotherapyBulletin does not publish book reviews (these are published in Psychotherapy, the official journal of Division29). All submissions for Psychotherapy Bulletin should be sent electronically to [email protected] with thesubject header line Psychotherapy Bulletin; please ensure that articles conform to APA style. Deadlines for submission are as follows: February 1 (spring), May 1 (summer), July 1 (fall), November 1 (winter). Past issuesof Psychotherapy Bulletin may be viewed at our website: www.divisionofpsychotherapy.org. Other inquiriesregarding Psychotherapy Bulletin (e.g., advertising) or Division 29 should be directed to Tracey Martin at theDivision 29 Central Office ([email protected] or 602-363-9211).

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