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Psychotherapy Integration Training Around the Globe: A Personal and

Empirical Perspective

Article  in  Journal of Psychotherapy Integration · August 2018

DOI: 10.1037/int0000135

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Journal of Psychotherapy IntegrationPsychotherapy Integration Training Around the Globe: APersonal and Empirical PerspectiveKatie Aafjes-van Doorn, Doménica Klinar Alfaro, Markéta Fialová, and Céline KamsteegOnline First Publication, August 23, 2018. http://dx.doi.org/10.1037/int0000135

CITATIONAafjes-van Doorn, K., Klinar Alfaro, D., Fialová, M., & Kamsteeg, C. (2018, August 23).Psychotherapy Integration Training Around the Globe: A Personal and Empirical Perspective.Journal of Psychotherapy Integration. Advance online publication.http://dx.doi.org/10.1037/int0000135

Psychotherapy Integration Training Around the Globe: A Personaland Empirical Perspective

Katie Aafjes-van DoornYeshiva University and Oxford University

Doménica Klinar AlfaroAiglé Foundation, Buenos Aires, Argentina

Markéta FialováSkala Institute, Prague, Czech Republic

Céline KamsteegUniversity of Cambridge

Psychotherapy integration is now common practice around the globe. Despite itspopularity, and the many clinical writings on the application of different types ofpsychotherapy integration, very little is known about exactly how psychotherapists arebeing trained in psychotherapy integration and whether these trainings are effective. Inline with the theme of integration, we aimed to answer these questions from ascientist-practitioner perspective, reporting on our subjective clinical training experi-ences as well as the current empirical evidence. First, as early career practitioners, webriefly describe how we ourselves were trained in psychotherapy integration and reflecton our training experiences in the Czech Republic, United Kingdom, United States, andArgentina. Then, as scientist-practitioners, we turn to the research literature to examinehow psychotherapy integration may be taught effectively. We conducted a systematicliterature review of the available empirical evidence on the efficacy of training inpsychotherapy integration. We report on the characteristics and findings of the identi-fied 9 empirical studies. This low quality and quantity of studies illustrates the lack ofempirically supported trainings in psychotherapy integration. However, together withour personal experiences in different countries, it provides some indication of futuredirections with regard to how and when psychotherapy integration might best be taught.Suggestions for further examinations into the effectiveness of trainings in psychother-apy integration around the globe are discussed.

Keywords: psychotherapy training, integrative psychotherapy, international

Psychotherapy integration aims to facilitatelearning from different therapeutic viewpointsto enhance the efficacy and efficiency of ourclinical work (Greben, 2004). In practice, itportrays an ongoing process of convergence and

complementarity at a conceptual, clinical, andempirical level (Fernández-Álvarez, Consoli, &Gómez, 2016), looking beyond the confines ofsingle therapeutic modalities and keeping anopen mind about the complexity of change. This

Katie Aafjes-van Doorn, Ferkauf Graduate School ofPsychology, Yeshiva University, and Department of Clin-ical Psychology, Oxford University; Doménica KlinarAlfaro, Department of Psychology, Aiglé Foundation, Bue-nos Aires, Argentina; Markéta Fialová, Skala Institute,Prague, Czech Republic; Céline Kamsteeg, Faculty of Ed-ucation, University of Cambridge.

Markéta Fialová is now at National Institute of MentalHealth, Department of Applied Neurosciences and BrainImaging, Klecany, Czech Republic.

We thank the Society for Psychotherapy Integration forbringing us, as newly qualified practitioners, together at theinternational conference in Dublin, Ireland, in 2016 and forfacilitating our thinking around training in psychotherapyintegration.

Correspondence concerning this article should be ad-dressed to Katie Aafjes-van Doorn, Ferkauf GraduateSchool of Psychology, Yeshiva University, Rousso Build-ing, Room 123, 1165 Morris Park Avenue, Bronx, NY10461. E-mail: katie.aafjes@yu.edu

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Journal of Psychotherapy Integration© 2018 American Psychological Association 2018, Vol. 1, No. 999, 0001053-0479/18/$12.00 http://dx.doi.org/10.1037/int0000135

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spirit of psychotherapy integration reflects thezeitgeist of the new millennium (e.g., Ablon,Levy, & Katzenstein, 2006; Norcross & Rogan,2013) in countries around the globe (e.g.,Muller, 2008; Tasca et al., 2015).

The Educational Perspective Training inPsychotherapy Integration

Although for some practitioners, psychother-apy integration may be a natural and unintendedconsequence of ongoing professional develop-ment, many therapists experience psychother-apy integration as emotionally difficult and cog-nitively challenging (Gold, 2005; Rihacek &Danelova, 2015). Indeed, therapists admit to apragmatic rather than evidence-based approachto integration early in their career, when theylack in knowledge and skill in selecting inter-ventions and look for anything that seems towork (see syncretism described by Boswell,Castonguay, & Pincus, 2009; Lampropoulos,2001). Most say they only learned to effectivelyintegrate after licensure as they began to employtechniques outside of their original framework(Consoli & Jester, 2005).

Formal training in psychotherapy integrationhas been idiosyncratic and unreliable. In con-trast to the expected breakthroughs with regardto the establishment and evaluation of trainingprograms (Norcross, 1997), psychotherapy inte-gration training has received relatively little at-tention over the past two decades. A few psy-chotherapy programs that adopt an integrativestance as a core model of clinical training havebegun to emerge (see Norcross & Beutler, 2000;Wolfe, 2000; Ziv-Beiman, 2014), and a fewillustrations of what an integrative psychother-apy training model might look like have beenpublished (e.g., Beitman & Yue, 1999; Harris,Kelley, Campbell, & Hammond, 2014; Robert-son, 1995). However, the task of integration ofdifferent therapeutic orientations per se does notappear to be a central educational focus of theseinitiatives.

Type of Integration and Timing ofTraining

Heavy debate has surrounded the question ofhow and when to incorporate integration intothe overall psychotherapy training program (seethe interviews on integration training reported

in the 2017 Society for Psychotherapy Integra-tion newsletter, Volume 3, Number 4). Thequestion of timing tends to be answered in oneof the following two ways: (a) An integrativeapproach should be taught from the very outsetof psychotherapy training, or (b) integrationshould be encouraged at a later stage in thetherapists’ development, once expertise in onespecific approach has been established. Argu-ably, timing of psychotherapy integration train-ing bears at least partly upon the specific modelof psychotherapy integration to which trainersascribe (Lampropoulos, 2001). For example, fortheoretical (e.g., Wachtel, 1997) and assimila-tive integration (Messer, 1992), solid groundingin one or more theoretical orientations is desir-able. These scholars argue that without a singleconceptual framework as a guide, students1

might not value the complexities and ambigui-ties of tensions between models (O’Hara &Schofield, 2008). There is a danger of becominga jack-of-all-trades but a master of none, result-ing in syncretistic confusion when students pulltechniques from many sources without a soundrationale (Boswell et al., 2009; Lampropoulos,2001; Rønnestad & Skovholt, 2003).

On the other hand, the common factors (e.g.,Constantino, 2017; Frank & Frank, 1991;Rosenzweig, 1936), technical eclecticism (e.g.,Lazarus, 1967), and unifying approaches to in-tegration (e.g., Magnavita & Anchin, 2013) al-low students to think and work in an integratedfashion from the very beginning, crucial forfostering a flexible, open, and unbiased ap-proach toward the potential value of other mo-dalities (e.g., Gold, 2005; Ziv-Beiman, 2014).

Aim

In an attempt to answer the question of howpsychotherapy integration might be effectivelytaught, we take the scientist-practitioner per-spective, reporting on our subjective clinicaltraining experiences as well as the current em-pirical evidence. First, as early career practitio-ners, we briefly describe our personal experi-

1 We use the term student throughout this article to reflectpsychotherapists who attend a training in psychotherapyintegration, regardless of their formal status as universitystudent or licensed practitioner, and regardless of the termsusually used within their professional trainings (e.g., resi-dents, trainees).

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ences of training in psychotherapy integrationin Argentina, the United Kingdom, the UnitedStates, and the Czech Republic, and reflect onstrengths of these trainings as well as our relatedclinical struggles. Then, as scientists, we turn tothe research literature, systematically reviewingthe available empirical evidence on the efficacyof training in psychotherapy integration. Basedon this empirical evidence and our training ex-periences in different countries, future direc-tions with regard to how and when psychother-apy integration might best be taught will beindicated.

A Global Perspective on Training inPsychotherapy Integration

Argentina

The mainstream approach of Argentinianpsychotherapists is based on Freudian-Lacaniantheory grounded in traditional psychoanalyticpractice (Muller, 2008; Plotkin, 2003; Roussos,Waizmann, & Etchebarne, 2010). More re-cently, Argentina has seen a small but rapidlygrowing number of cognitive–behavioral ther-apy (CBT) psychotherapists (Keegan, 2007;Korman, Viotti, & Garay, 2015) as well as anincreasingly large number of psychotherapistswith a more integrative/eclectic stance (e.g.,Muller, 2008). Graduate students in Argentinaare not required to take any specialized coursesin integration during their psychotherapy train-ing (4 years minimum) to practice psychother-apy. However, without being regulated, there isa need to continue training, either in a specificmodel or in integrative psychotherapy. Thismeans that once students have obtained theirlicensure, it is possible for psychologists to par-take in a postgraduate training course specifi-cally focused on psychotherapy integration. InArgentina, psychotherapy integration is a fast-growing trend, and specialized integration train-ing is provided at universities, public healthcenters, and private mental health training cen-ters (Fernández-Álvarez et al., 2016; Gómez,2007). An Argentinian training program thathas gained particular popularity is the Aigléintegrative model, taught in 2-year-long gradu-ate-level programs in Argentina since 1999 aswell as more recently in Colombia, Ecuador,Guatemala, Italy, Paraguay, Spain, Uruguay,the United States, and Venezuela (Fernández-

Álvarez et al., 2016). Fernández-Álvarez’smodel of integration brings together conceptsfrom the psychodynamic, behavioral, humanis-tic-existential, and systemic models within thecognitive-social paradigm. This model aims toprovide a common basis for all treatments and,at the same time, a tailored plan for each client.It allows treatment planning addressing differ-ent goals, ranging from symptom reduction topersonality change, achieved through diversetherapy formats (e.g., individual, family, cou-ple, and/or with other treatments like pharma-cotherapy, social assistance) depending on eachparticular case (Fernández-Alvarez, Gómez, &García, 2015). During training, students obtain“integrative supervision” to discuss how to pro-vide effective integrative treatments with thedifferent kind of clients in the different trainingsettings. After training, professional develop-ment in psychotherapy integration continuesthrough supervision and personal therapy.

United States

In North America, the governmental fundingand guidelines around “evidence-based practice”resulted in the wide application of integrative in-terventions (e.g., Hayes, Strosahl, & Wilson,2011) in the form of second- and third-wave cog-nitive–behavioral-based treatments and short-term psychodynamic treatments (e.g., Vandenbos,Hogan, & Kazak, 2017; Westen, Novotny, &Thompson-Brenner, 2004). In contrast to Argen-tina, psychotherapy training in the United Statesinvolves a very minimal focus on integration(Norcross, Sayette, & Pomerantz, 2018). In theUnited States, graduate psychotherapy programsemphasize extensive training in a particular theo-retical model determined by American Psycholog-ical Association practice guidelines, developed bythe different divisions (Norcross & Rogan, 2013;Vandenbos et al., 2017). Currently psychotherapyintegration is not specifically included in theseguidelines (Norcross et al., 2018). At the start ofgraduate training, many students are required toidentify their preferred modality, by choosing be-tween a CBT or a psychodynamically orientatedgraduate program, without being given the optionof integrating these psychotherapy approaches(Norcross et al., 2018). Also during training, stu-dents in the United States applying to internshipsthrough the Association of Psychology Postdoc-toral and Internship Centers (2018) must indicate

3TRAINING IN PSYCHOTHERAPY INTEGRATION

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a theory of practice. Although some doctoral train-ing programs in the United States offer somelimited guidance on psychotherapy integration inclinical seminars or lectures on common factors(e.g., Constantino, 2017), or in dual-focused grad-uate programs that equally emphasize psychody-namic and CBT training (Feindler & Kahoud,2015), most doctoral training programs offer train-ing in particular models only (e.g., Norcross et al.,2018).

United Kingdom

Graduate psychology training in the UnitedKingdom is provided as part of the NationalHealth System and is therefore very much focusedon training in “evidence-based treatments”(Llewelyn & Aafjes-van Doorn, 2017). In termsof training in psychotherapy integration in theUnited Kingdom, education in one major ap-proach (CBT) appears to be emphasized (Healthand Care Professions Council, 2010; NHS Digital,2014), although this also includes clinical trainingin third-wave CBT (e.g., Hayes et al., 2011) andother integrative treatment approaches (e.g., Ryle& Kerr, 2003). Both the competencies laid downby the Health and Care Professions Council(2010) and the requirements for the accreditationof courses by the British Psychological Society(2012) guidelines state that courses should pro-vide advanced training in one therapeutic modeland a working knowledge of a second (i.e., assim-ilative integration). In addition, students are ex-pected to have a critical awareness of a variety ofapproaches to therapy. In clinical case assign-ments, students are often required to choose aparticular model, depending on the client/serviceand conceptualize a case (formulation, assess-ment, intervention, and evaluation) based on thisparticular therapy model. Integration of differenttheoretical orientations is not explicitly taught butis implicitly assumed. One way this lack of inte-grative focus has been addressed in the UnitedKingdom is by offering students a wide variety ofshort-term clinical internships that allow studentsto gain treatment and supervision experience in avariety of second- and third-wave CBT ap-proaches, systemic and short-term dynamic ther-apies, depending on the client group.

Czech Republic

In contrast to Argentina, the United States,and the United Kingdom, in Czech law, there is

no protected professional title for psychothera-pists enshrined in law, no connection to anyeducational degree, no state regulation of psy-chotherapy training or practice, and no legalrequirement for providing “evidence-basedpractice” (Rihacek & Roubal, 2017). Althoughthis lack of top-down requirements or regula-tions raises ethical concerns, arguably, it doesallow students to integrate different therapymodels during and after their psychotherapytraining as they see fit. It is therefore not sur-prising that many practitioners in the CzechRepublic practice psychotherapy integration.Although only one third of practitioners self-identify as integrationists, a survey of 373 psy-chotherapy and counseling practitioners in theCzech Republic showed that 98.9% of practi-tioners used psychotherapeutic techniques fromtwo or more orientations, despite only a minor-ity (20%) actually receiving training in two ormore psychotherapy approaches (Rihacek &Roubal, 2017). Another study in the Czech Re-public surveyed 26 students on why they chose5-year psychotherapy training specifically fo-cused on integration (the Skala Institute) as theirfirst psychotherapy training (Plchová, Hytych,Rihácek, Roubal, & Vybíral, 2016). They re-ported that these future students believed inscience, were open to enduring states of uncer-tainty, and were attracted by the multivalence ofdifferent psychotherapy schools (Plchová et al.,2016). The Skala Institute offers an integrativepsychotherapy training that emphasizes the self-experience of the future psychotherapist. Theiraim is for students to get to know themselvesbetter, try different psychotherapy approaches,develop common skills that work across allapproaches, and experiment with integration ina safe environment guided by expert feedbackand supervision. Students undergo group psy-chotherapy themselves before taking part in,and later leading, psychotherapy groups withpatients. These treatment groups are video re-corded and used for feedback in supervision.Supervisors change on a regular basis to providean example of different psychotherapy styles.

Personal Psychotherapy IntegrationExperiences

It has to be noted that all four of us arrived atthe road of psychotherapy integration in aroundabout way. In our respective initial under-

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graduate clinical trainings, we were not taughtabout psychotherapy integration explicitly, andit was only in our graduate training programsthat we gained formal integrative training ormore implicitly learned about integrationthrough supervision, reading, and clinical prac-tice.

Reflecting on our experiences as beginners inpsychotherapy, we were often anxious andwanted to know the “right” approach or tech-nique to apply in a given clinical situation.Moreover, although it was great to be super-vised by experts in particular treatment modelsduring our graduate trainings, our insecuritiesrose every time we started from scratch at a newinternship, when unsure how and when to inte-grate previously learned techniques. We allidentified a hasty adoption of the first treatmentideology we were taught, providing a falsesense of security, and it was only during grad-uate training that we became more able to con-sider other viewpoints. Similar to experiencesreported by others (e.g., Gold, 2005), we ini-tially found it difficult to experiment and de-velop our own personal viewpoints, especiallybecause we perceived university faculty mem-bers as encouraging adherence to one concep-tual framework while disapproving of others(Consoli & Jester, 2005; Feindler & Kahoud,2015), and we felt free to develop a more per-sonal integrative approach later in our graduatetraining.

Given the lack of formal training during ourinitial undergraduate training, we learned to en-gage in integrative practice more implicitlythroughout internships and externships, in thatthey taught us to adjust our theoretical, techni-cal, and empirical knowledge of psychotherapyto specific clients that may present on a contin-uum of severity, chronicity, and complexity(e.g., Blott, 2008). We all felt that, at times, insessions, it felt as if there were too many pos-sible avenues to explore (see syncretism, de-scribed by Boswell et al., 2009), and consider-ing various intervention options limited ourability to be present with clients when we wereunclear where to direct the session. In thosemoments, we found ourselves hoping for a moreconcrete example of how a client is conceptu-alized in the moment, taking multiple psycho-therapeutic models into account, how interven-tions are chosen in session, and how to decideon a treatment plan.

During graduate school, we further devel-oped an interest in psychotherapy integration,mainly through gained confidence in scientificknowledge and utilization of research findings,and our clinical experiences of perceived inef-ficacy of our usual approaches. After graduateschool, we have continued to seek out furthertraining in psychotherapy integration, workwith integrative supervisors, and gain moreclinical experience in psychotherapy integra-tion. The first author, for example, facilitated aDialectical Behavioral Therapy skills groupwithin a psychoanalytic clinic (see Aafjes-vanDoorn, Kamsteeg, Portier, & Chitre, 2018) andreflected on her clinical error of integrating atechnique in an ad hoc manner when the patientwas in crisis (see Snyder & Aafjes-van Doorn,2016). Learning from our mistakes and havingthe possibility to develop our own personal styleas integrative therapists is helpful in taking careof not only our patients but also ourselves.

Training Strengths

In our view, learning a well-supported formof integrative evidence-based practice and moreexplicit training in psychotherapy integrationearlier on in training is beneficial in buildingconfidence. From our personal experiences, wecan attest the benefits of learning about psycho-therapy integration in small-scale clinical sem-inars, and larger-scale taught courses, as well asone on one in supervision and personal therapy.Although most explicitly taught in the integra-tion training in Czech Republic, we all appre-ciated the step-by-step learning process of par-ticipating in personal therapy from differentorientations, self-experiencing the position ofclient, before facilitating integrative treatmentfrom the position of the therapist. Moreover,gaining experience with supervisors from dif-ferent orientations was helpful, in that it showedthe breadth of possibilities in clinical practice.Seeing senior psychotherapists conducting “im-perfect” integrative therapy and gaining feed-back in a safe environment helped us overcomefears of making “mistakes.” Multiple supervi-sors and group supervision also helped us seethat there is no single correct way to treat aclient. Furthermore, we all benefited from theuse of videotaped treatment sessions, in gainingfeedback from fellow students and supervisorson our (non)verbal style, basic psychotherapeu-

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tic competences, concrete techniques, and strat-egies from different approaches, and how bestto tailor the treatments to the patients’ needs.

A Scientist-Practitioner’s Viewpoint onPsychotherapy Integration Training

Given our diverse training experiences inpsychotherapy integration as early career prac-titioners, and our struggles with integrating dif-ferent psychotherapy frameworks into the ther-apeutic work with our clients effectively, wethen turned to the research literature. In anattempt to answer the question “How can psy-chotherapy integration be taught effectively?”we conducted a systematic literature review ofthe available empirical evidence on the efficacyof psychotherapy training in integration.

By reviewing the available empirical find-ings, we aimed to generate tentative hypothesesand stimulate further research on training ofpsychotherapy integration. Raising awarenessof psychotherapy integration as an integral partof clinical, academic, and empirical psychother-apy training may contribute to the developmentof clinical practice guidelines around integra-tion that may be implemented in the trainingand practice of everyday practitioners and, ulti-mately, may lead to more effective and efficienttherapies for our clients.

Method

Now that we have set up a general hypothesisregarding the potential importance of training inpsychotherapy integration, we conducted a sys-tematic review to examine the role, definition,and empirical investigation of training in psy-chotherapy integration.

Literature Search

Scope of the search. Several steps weretaken to ensure the search was systematic. First,we followed published guidance for systematicreviews of evaluations of health care interven-tions (Liberati et al., 2009), including the fivePICOS components (population, intervention,comparators, outcome, and study design) iden-tified as preferred reporting items for systematicreviews and meta-analyses (PRISMA). Second,we used operational definitions to identify andclarify constructs of interest. Psychotherapy in-

tegration was conceptually defined as “the at-tempts to look beyond and across the confinesof single-school therapeutic approaches to seewhat can be learned from other perspectives”(Arkowitz, 1992, p. 262).

Seven inclusion criteria were used:

1. The study had to be reported in the Eng-lish language and published in a peer-reviewed journal before April 2018.

2. Building on previous reports on training inthe professional development of psycho-therapists, we included studies on the ef-fect of the training from the perspective ofthe student, supervisor, training director,and/or client.

3. We included the broad range of formaltraining experiences that aim to facilitatepsychotherapy integration, including un-dergraduate psychology courses, doctoralprograms, and seminars as well as singletraining events for licensed practitioners,which could include one-to-one supervi-sion or larger group formats but excludedpersonal reflections on psychotherapy in-tegration without formal training (seeBlott, 2008).

4. To represent the wide range of practitio-ners involved in providing psychotherapyin different countries, we included studieswithin the professions of (clinical) psy-chology, counseling, psychiatry, psycho-therapy, social work, and mental healthnursing.

5. The psychotherapy training had to be ex-plicitly labeled as integrative or had theexplicit aim to facilitate psychotherapy in-tegration, to the exclusion of other poten-tially related integrative trainings of third-wave CBT approaches that incorporatetechniques from other modalities, such asdialectical behavior therapy (Linehan etal., 2015) or cognitive analytic therapy(Ryle & Kerr, 2003).

6. The study had to report on the effect oftraining in psychotherapy integrationrather than the effect of integration of di-dactic practices or formats (e.g., Carkhuff& Truax, 1965, examined integrated ap-proaches to learning rather than psycho-therapy modalities).

7. The effect of the training in psychotherapyintegration had to be measured at least

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once during or after the training ratherthan (solely) as a pre- or posttraining sur-vey of theoretical orientation (e.g., Bo-swell et al., 2009) or views on psychother-apy integration (e.g., Plchová et al., 2016,who surveyed 26 future students beforecommencing a 5-year training in psycho-therapy integration).

Search strategy. The literature review wasconducted using the following databases: ERIC,Global Health, PsycARTICLES, and Psy-cINFO. Search terms included variations on theterms for (a) integration (integrat�), (b) psycho-therapy (psychotherap�, therap�, counsel�, psy-cholog�, treatment�), and (c) training (training�,education�, student�, teaching�). The searchwas conducted on abstracts of peer-reviewedjournals with “AND” entered into the databaseto link the different categories (a, b, and c) ofsearch terms. This means that 20 (1 � 5 � 4)separate searches were conducted for all varia-tions of the terms for integration, psychother-apy, and training.

In order to increase the rigor of this system-atic review further, citations of the identifiedempirical articles were tracked and referenceswere scanned in order to identify possible arti-cles that fit the inclusion criteria but had notcome up in the initial search. The literaturesearch was conducted by the fourth author andrepeated by the first author. These two system-atic searches identified the same set of nineempirical studies to be included in this review.Figure 1 shows a PRISMA diagram of the flowof sources through the literature search. A totalof 20,263 published articles were identified dur-ing the systematic search. The final review con-sists of nine empirical studies on the effect oftraining in psychotherapy integration (describedin Table 1).

Results

Study Characteristics

Table 1 provides an overview of the studycharacteristics of the nine included studies. Allnine studies were conducted relatively recently,with the oldest study published 18 years ago(Allen, Kennedy, Veeser, & Grosso, 2000). Allstudies were conducted in English-speaking

countries: the United States (n � 3), Canada(n � 4), or the United Kingdom (n � 2).

Design. Most studies reported on descrip-tive data (n � 2) or used qualitative analyses(e.g., grounded theory, consensual qualitativemethod, thematic analysis) of the data (n � 5).Except for Pascual-Leone, Andreescu, and Ye-ryomenko (2015), all studies reported on origi-nal data sets. Pascual-Leone, Rodriguez-Rubio,and Metler (2013) reported on new data as wellas previously published data (Pascual-Leone,Wolfe, & O’Connor, 2012).2 By adding thepersonal accounts of 21 graduate students, thisstudy extended Pascual-Leone et al.’s (2012)findings on 24 undergraduates’ experiences,raising the number of cases represented in thequalitative analysis to 45. In a later study, Pas-cual-Leone et al. (2015) used quantitative anal-yses to examine this same group of undergrad-uates and graduate students in order to comparethe change in standardized outcome measuresreported by students and their clients over thetime of training. Allen and colleagues (2000)also used a control group but compared theirsurvey results with a control group of studentsin psychotherapy training that did not explicitlyfocus on integration. None of the other studiesused a control group in their study design.Seven of the nine studies were one-time mea-surements during or after training, and two stud-ies used repeated measurements at severalstages during the psychotherapy training. Typesof outcome measures included self-designedsurveys, weekly journals, written self-reflec-tions of the student and/or supervisor, focus-group recordings, and interviews. Pascual-Leone and colleagues (2015) was the only studythat also reported on the client’s perspective ofthe effectiveness of training, albeit indirectly bymeasuring the therapeutic alliance and sessionoutcome (Working Alliance Inventory–ShortRevised Version and Revised Session ReactionScale). One study (Pascual-Leone et al., 2015)reported on the use of standardized therapist/student measures (Counselor Activity Self-Efficacy Scales and Self-Awareness and Man-agement Strategies Scales for Therapists).

Training. All studies reported on longer (atleast 12 weeks) group trainings that included

2 To avoid duplicate data, we did not report on the Pascal-Leone et al. (2012) study separately.

7TRAINING IN PSYCHOTHERAPY INTEGRATION

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experiential, didactic, and supervision elementsrather than one-off training events. Most studiesreported on specific courses in psychotherapyintegration (n � 7); however, two studies re-ported on psychotherapy training programsmore generally (Norcross & Beutler, 2000;Wolfe, 2000; Ziv-Beiman, 2014). Sample sizesranged from n � 2 (Sotskova & Dossett, 2017)to n � 158 (Lampropoulos & Dixon, 2007).With regard to the different types of integration,most studies taught assimilative integration(n � 4), with a few reporting on theoretical(n � 2) or common factors (n � 2) integration.

Most trainings taught about psychotherapy in-tegration in a theoretical and conceptual way,whereas one study reported on training studentsby means of them facilitating an integrativepsychotherapy to clients (Trub & Levy, 2017).

With regard to timing of the integration train-ing in psychotherapists’ development, six of thenine studies reported on education about psy-chotherapy integration provided before educa-tion on one major theory or practice with inte-grative treatments. Two studies reported ontraining by means of practice with an integrativetreatment approach before education on one ma-

Records identifiedthrough database

screening n = 20.263

Duplicates excludedn = 5.598

Abstracts of recordsscreened n = 14.665

Full-text article of theidentified record

assessed foreligibility n = 93

Studies included inliterature review

n = 8

Studies excluded byabstract only n = 14.572

Full-text articlesexcluded:

Nonempirical articles n = 52

No formal training n = 3

Preassessment only n = 1

Additional titles and abstractsscreened through citation tracking

n = 91

Additional titles and abstractsscreened through reference search

n = 357

Studies excluded byabstract only

n = 406 Full-text articles

excluded: Nonempirical articles

n = 41

Additional articlesincluded in literature

review n = 1 (Fitzpatrick,

2010)

Total articles includedin literature review

n = 9

Figure 1. A flowchart of the search strategy.

8 AAFJES-VAN DOORN ET AL.

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Tab

le1

Stud

yC

hara

cter

isti

csan

dR

esul

ts

Ref

eren

ceC

ount

rySt

udy

desi

gnSa

mpl

esi

ze(n

)H

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itm

easu

red?

Wha

tis

mea

sure

d?N

atur

ean

dtim

ing

oftr

aini

ngT

ype

ofin

tegr

atio

nta

ught

Tra

inin

gou

tcom

es

Alle

n,K

enne

dy,

Vee

ser,

and

Gro

sso

(200

0)U

nite

dSt

ates

Post

sem

inar

eval

uatio

nco

mpa

red

with

cont

rol

grou

p

16ps

ychi

atry

resi

dent

sin

inte

grat

ive

sem

inar

;26

inge

nera

lse

min

ar

Self

-des

igne

dsu

rvey

(des

crip

tive

data

onL

iker

tsc

ale)

Subj

ectiv

efe

elin

gsab

out

the

usef

ulne

ssof

the

sem

inar

inth

eir

curr

ent

prac

tice

Wee

kly

2-hr

clin

ical

grou

pse

min

aron

mul

tiple

ther

apy

pers

pect

ives

(S)

(1)

The

oret

ical

,te

chni

cal

Hel

ped

com

pare

/con

tras

tps

ycho

ther

apy

para

digm

sus

eful

incu

rren

tpr

actic

e;m

ore

posi

tive

than

cont

rol

grou

pFi

tzpa

tric

k,K

oval

ak,

and

Wea

ver

(201

0)C

anad

a12

wee

kly

jour

nal

entr

ies

duri

ngco

urse

17co

unse

ling

psyc

holo

gym

aste

r’s-

leve

lst

uden

ts

Wee

kly

jour

nals

(qua

litat

ive

grou

nded

theo

ryan

alys

is)

Refl

ectio

nson

trai

ning

expe

rien

cean

din

tegr

ativ

epr

actic

ede

velo

pmen

t

12-w

eek

cour

seon

theo

ries

ofco

unse

ling

focu

sed

onco

mm

onfa

ctor

s(S

)(1

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Com

mon

fact

ors

Abl

eto

deve

lop

pers

onal

theo

ryth

roug

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ntat

ive

iden

tifica

tions

with

theo

ries

ofpr

actic

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ampr

opou

los

and

Dix

on(2

007)

Uni

ted

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rain

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dire

ctor

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coun

selin

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ycho

logy

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oral

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139

inte

rnsh

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Self

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data

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Nat

ure

ofdi

dact

ican

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aini

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inte

grat

ive

ther

apy,

stud

ent

inte

grat

ive

com

pete

ncy

and

eval

uatio

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Doc

tora

lpr

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clud

ing

cour

seon

theo

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ofps

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ther

apy,

tran

sthe

oret

ical

text

book

sw

ithch

apte

rson

inte

grat

ion

(G)

(2)

All

type

sPo

sitiv

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viro

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rin

tegr

ativ

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eas,

90%

taug

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ycho

ther

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inte

grat

ion

inth

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cour

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and

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ley

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nite

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rem

ent

only

7ne

wly

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selo

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trai

ning

inin

tegr

ativ

eco

unse

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Focu

sgr

oup

disc

ussi

on(q

ualit

ativ

egr

ound

edth

eory

them

atic

anal

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oftr

ansc

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doco

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mak

ese

nse

ofth

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inte

grat

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follo

win

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mpl

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alqu

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cour

seon

com

mon

fact

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inth

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)(1

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Com

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9TRAINING IN PSYCHOTHERAPY INTEGRATION

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7)C

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est

udy)

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onal

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nsof

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peri

ence

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anal

yses

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ssio

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late

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serv

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refle

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how

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ach

and

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how

itis

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arn

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tegr

atio

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onth

prac

ticum

ofex

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lin

tegr

ativ

eap

proa

chto

psyc

hoth

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imila

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ualit

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atic

anal

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essi

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expe

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uctin

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tegr

ativ

etr

eatm

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and

impa

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iden

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retic

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dus

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n

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for

dyna

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stud

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sess

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attit

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tth

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tent

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for

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grow

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pete

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paci

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d,H

ogan

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nite

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rem

ent

mid

trai

ning

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unse

ling

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holo

gym

aste

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unse

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10 AAFJES-VAN DOORN ET AL.

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jor theory. Only the training directors in Lam-propoulos and Dixon’s (2007) study reported onthe need to first educate students about onemajor theory before providing education aboutpsychotherapy integration.

Students and trainers. Training partici-pants included psychiatry residents, master’sstudents in clinical and counseling psychology,doctoral students in clinical psychology, under-graduate students in psychology, as well asnewly licensed practitioners. One study did notreport on the participants’ experience of thetraining directly but reported on the perspectiveof the training directors (Lampropoulos &Dixon, 2007). Four studies reported that theirrespective trainers identified as an integrativepsychotherapist (i.e., Allen et al., 2000; Fitzpat-rick, Kovalak, & Weaver, 2010; Lampropoulos& Dixon, 2007; Sotskova & Dossett, 2017).Lowndes and Hanley (2010) explicitly reportedthat the trainers did not identify as integrativetherapists, whereas for the other four studies,the theoretical orientation of the trainer wasunclear.

Training effect. All studies reported on apositive outcome of the training in psychother-apy training with regard to providing a positiveenvironment for integrative ideas to grow(Lampropoulos & Dixon, 2007), helping themcompare and contrast psychotherapy paradigmsand useful in their current practice (Allen et al.,2000), development of a personal theory (Fitz-patrick et al., 2010), optimism about future ap-plication of integrative practice (Lowndes &Hanley, 2010), increased feelings of compe-tency, and greater clarity of professional iden-tity (e.g., Pascual-Leone et al., 2013; Sotskova& Dossett, 2017; Trub & Levy, 2017). How-ever, some studies also highlighted the strug-gles, hurdles, and discomfort of tolerating am-biguity during the process of learning how tobecome an integrative psychotherapist (e.g.,Lowndes & Hanley, 2010) and the need formore explicit and systematic approaches toteaching psychotherapy integration (Ward, Ho-gan, & Menns, 2011). Although 90% of trainingdirectors indicated that they taught psychother-apy integration in their program, only half of allsurveyed training directors believed that stu-dents should be minimally competent in a vari-ety of models (Lampropoulos & Dixon, 2007)and indicated that training in more than onetheory was mandatory. Also, the training direc-

tors appeared to differ from the students in howintegration might be taught. None of the train-ing directors mentioned explicit training in howto integrate psychotherapies, 21% of trainingdirectors believed that students should betrained first to be proficient in one therapeuticmodel, and 21% believed that students shouldbe trained in a specific integrative/eclecticmodel from the outset.

Discussion

Despite the popularity of psychotherapy inte-gration among practitioners around the globe,very little is known about the efficacy of train-ings in integration. As early career practitioners,we reflected on our own professional experi-ences of training in psychotherapy integrationin the Czech Republic, Argentina, the UnitedKingdom, and the United States.

Based on our personal experiences, Argen-tina currently appears to offer the most robusttraining in psychotherapy integration, despite itspsychoanalytic tradition and only recent popu-larity of integration. Psychotherapy integrationis seen as an “evidence-based treatment in it-self” and taught to students as a valid alternativeto psychoanalysis and CBT. The Czech Repub-lic also offers lots of opportunities for psycho-therapy integration for students and licensedpractitioners alike, albeit it more informally,with no governmental guidelines. In the UnitedKingdom and the United States, the trainingfocus remains on one or two theoretical orien-tations. During training, integrative practice ismainly learned implicitly and further developedafter graduate training, within the restrictions ofevidence-based practice guidelines. This lack ofexplicit focus on integration was also reflectedin the lack of clarity on trainer/supervisor ori-entation in our reviewed studies, and is surpris-ing given our positive experiences of learningfrom different integrative supervisors as valu-able role-model. In our view, explicit training inpsychotherapy integration is crucial in guidingthe process of integration in training settingsaround the world.

The challenge in locating relevant empiricalstudies for our purpose illustrates the lack ofclarity in the field on what integration is andhow and whether it should be explicitly taught.If the maturity of a scientific and professionaldomain is indeed reflected by the level of sys-

11TRAINING IN PSYCHOTHERAPY INTEGRATION

Thi

sdo

cum

ent

isco

pyri

ghte

dby

the

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tematic and formal attention it has given totraining (Castonguay, 2005), psychotherapy in-tegration has some way to go. The findings werefurther limited by the studies’ small-scale sam-ples, postmeasurement designs, qualitativeanalyses, and the lack of standardizes measures,and illustrate how very little is known empiri-cally about effective training in psychotherapyintegration. Overall, it appeared that the ex-pected breakthroughs (see Norcross, 1997) havenot yet materialized given that psychotherapyintegration does not (yet) constitute a concep-tually coherent, empirically validated, and edu-cationally sound position for practice. The ex-treme heterogeneity of the content andprocedures of the trainings examined in theempirical studies as well as the lack of statisticalanalyses preclude drawing any strong conclu-sions about the effectiveness of these specifictraining initiatives. The need for more rigorousevaluation of integrative training initiatives isrecognized. It was also noteworthy that all em-pirical studies identified in the review were con-ducted in English-speaking countries (UnitedStates, Canada, and United Kingdom) and didnot represent the training practices in Europe orSouth America.

Training and Research Implications

Based on our personal experiences and thelimited empirical findings, this review suggeststhat there might be a number of effective for-mats and approaches that could potentially bebeneficial to students’ development of skills inpsychotherapy integration. For the majority ofstudents, the outcomes following training inpsychotherapy integration are positive. Train-ings in psychotherapy integration may addressassimilative, eclectic, theoretical, or commonfactors integration and may be offered to differ-ent mental health professionals at differentstages of their professional development. Train-ing in psychotherapy integration usually in-cludes didactic and experiential elements, aswell as readings and supervision and may betaught explicitly in a specific seminar or practi-cum or more implicitly as part of the frameworkof the overall psychotherapy training program.In line with our personal recommendations,most reviewed studies argued for the educationabout integration at the start of psychotherapytraining (common factors or technical integra-

tion) in order to enable a flexible, open ap-proach to clinical work (e.g., Consoli & Jester,2005; Ziv-Beiman, 2014). However, the con-cerns related to early integration training, thatis, the risk of feeling overwhelmed by theamount of theoretical and technical options anda lack of competency and confidence by the endof training (e.g., Castonguay, 2005; Gold,2005), also appeared to be confirmed by theempirical evidence and our personal experi-ences. Many studies reported on students’ dif-ficulty with tolerating ambiguity and not be-longing to a particular theoretical community,arguably confirming the need for training in theroots of one or two therapeutic orientations be-fore training in psychotherapy integration (i.e.,theoretical or assimilative approach to integra-tion).

Clinical experience in facilitating treatmentadhering to an integrative psychotherapy man-ual might provide students with a concrete ex-ample of how a supervisor or therapist might goabout integrating different theories or tech-niques with a given client (Ward et al., 2011).Furthermore, the use of video recordings insupervision is becoming more common in psy-chotherapy training in the United States, UnitedKingdom, the Czech Republic, and Argentina(e.g., Haggerty & Hilsenroth, 2011; NHS Dig-ital, 2014) and may further aid research into theeffect of training of psychotherapy integration.In line with our experiences, small-group vid-eotaped training that encourages self-monitor-ing and the exchange of supportive peer feed-back among psychotherapists from differentorientations might aid the comparison of differ-ent methods, models, and outcomes (e.g., Ab-bass, 2004). Face-to-face case discussionsbased on these videos might illustrate common-alities and differences in detailed therapeuticinteractions (Brown, Moller, & Ramsey-Wade,2013), helping practitioners to explain their jar-gon and thus bridging the communication gapbetween models.

Furthermore, given the global differences inhow integrative therapy is taught and the limitedresearch on their respective effectiveness, it willbe important to identify and compare differenttraining methods in integrative psychotherapy(Rønnestad, Orlinsky, & Wiseman, 2016). Inline with this, a large international initiative hasbeen set up to systematically compare the train-ing experiences of psychotherapists in different

12 AAFJES-VAN DOORN ET AL.

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countries—the Society for Psychotherapy Re-search’s Interest Section on Therapist Trainingand Development (also known as SPRISTAD;Orlinsky et al., 2015). It is hoped that quantita-tive and qualitative data gathered from a largenumber of psychotherapy students of variedtypes in a wide range of training programs willelucidate different ways in which integration ofpsychotherapy models can be effectively taught(Orlinsky et al., 2015). The lack of empiricalstudies on psychotherapy integration from non-English-speaking countries identified in our re-view underlines the importance of sharing ourtraining experiences from around the globe injournals, newsletters, and conferences, and indeveloping collaborative research projects toestablish “evidence-based integrative practice.”

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15TRAINING IN PSYCHOTHERAPY INTEGRATION

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chotherapy Integration, 24, 251–257. http://dx.doi.org/10.1037/a0037800

Received February 8, 2018Revision received May 29, 2018

Accepted July 5, 2018 �

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