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Psychotherapy
O F F I C I A L P U B L I C AT I O N O F D I V I S I O N 2 9 O F T H E
U
A M E R I C A N P S Y C H O L O G I C A L A S S O C I AT I O N
www.divisionofpsychotherapy.org
In This Issue
L
Interview
Abraham Wolf, Ph.D.
L
and Scholarship
Engaging Underrepresented, Underserved
Communities in Psychotherapy-Related
Research: Notes from a Multicultural Journey
E
Ethics in Psychotherapy
Psychotherapy, Online Social Networking, and Ethics
T
Prioritizing Case Formulation in
Psychotherapy Training
Feature
I
2009 Presidential Summit on the Future of
Psychology Practice: Collaborating for Change
N
E
PSYCHOTHERAPY BULLETIN
Psychotherapy Bulletin is the official newsletter of Division 29 (Psychotherapy) of the American Psychological
Association. 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) provide articles and commentary regarding the range of issues that are of interest to psychotherapy the-
orists, 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 mem-
bers of our association.
Contributors are invited to send articles (up to 2,250 words), interviews, commentaries, letters to the
editor, and announcements to Jenny Cornish, PhD, Editor, Psychotherapy Bulletin. Please note that Psy-
chotherapy Bulletin does not publish book reviews (these are published in Psychotherapy, the official journal
of Division 29). All submissions for Psychotherapy Bulletin should be sent electronically to jcornish@du.edu
with the subject header line Psychotherapy Bulletin; please ensure that articles conform to APA style. Dead-
lines for submission are as follows: February 1 (#1); May 1 (#2); July 1 (#3); November 1 (#4). Past issues
of Psychotherapy Bulletin may be viewed at our website: www.divisionofpsychotherapy.org. Other inquiries
regarding Psychotherapy Bulletin (e.g., advertising) or Division 29 should be directed to Tracey Martin at
the Division 29 Central Office (assnmgmt1@cox.net or 602-363-9211).
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PSYCHOTHERAPY BULLETIN
Published by the
PSYCHOTHERAPY BULLETIN
DIVISION OF PSYCHOTHERAPY
Official Publication of Division 29 of the
American Psychological Association American Psychological Association
1
EDITORS’ COLUMN
Jenny Cornish, Ph.D., ABPP, Editor
Lavita Nadkarni, Ph.D., Associate Editor
University of Denver Graduate School of Professional Psychology
We are excited that dence-based practice and integrative
this issue is too full to models of psychotherapy, an interesting
fit in more than a short early career paper on social networking
paragraph from the and private practice, and three student
editors. There is papers on a variety of topics, including
something for every- an interview with Abraham Wolf,
one: two timely pa- former D29 President and outgoing In-
pers on ethics (one ternet Editor. In addition, be sure to
related to online social read the President’s Column, and an im-
networking and the portant report on the Psychotherapy
other to interroga- Summit. Finally, information about our
tions), an important many award winners and the upcoming
article on research and APA convention is included. We hope to
multicultural issues, a see you soon in Toronto!
helpful piece on case
formulation in train- Jenny Cornish and Lavita Nadkarni
ing, a thoughtful submission on evi- (303-871-4737, jcornish@du.edu)
PRESIDENT’S COLUMN
Nadine J. Kaslow, Ph.D., ABPP
Emory University Department of Psychiatry and
Behavorial Sciences, Grady Health Systems
Culture of Competence comes and training in key competency
The current zeitgeist domains. Professional credentialing
in professional psy- bodies are expected to certify individu-
chology is competency- als as competent. Policy makers laud
based. Competence competence and consumers increasingly
refers to knowledge, demand it. Thus, the time has come to
skills, and attitudes, embrace a culture of competence. There
and their integration. must be a shift within professional psy-
Competencies are complex and dynam- chology toward the acquisition and
ically interactive clusters of integrated maintenance of competence as a pri-
knowledge of concepts and procedures, mary goal.
skills and abilities, behaviors and strate-
gies, attitudes/beliefs/values, disposi- Many recent efforts have led to this shift
tions and personal characteristics, self- to a culture of competence and its assess-
perceptions, and motivations that enable ment, including the identification of the
a person to fully perform a task with a key foundational and functional compe-
wide range of outcomes. tencies and their essential components.
Foundational competencies are those
Educational programs are expected to knowledge, skills, and attitudes that
produce competence. Programs are ac-
credited based in part on program out- continued on page 3
2
serve as the foundation for the functions structured oral examinations, and writ-
a psychologist is expected to carry out. ten examinations. Given the tremen-
The foundational competencies include: dous strides that have been made with
professionalism, reflective practice/self- regard to evaluating competence, it is
assessment/self-care, scientific knowl- also time to embrace a culture of the as-
edge and methods, relationships, sessment of competence. The assess-
individual and cultural diversity, ethical ment of competence fosters learning,
and legal standards and policies, and evaluations progress, assists in deter-
interdisciplinary systems. Functional mining curriculum and training pro-
competencies refer to the major func- gram effectiveness, advances the field,
tions that a psychologist is expected to and protects the public.
carry out. The functional competencies
that have emerged by consensus within Psychotherapy Competence
professional psychology include: Intervention, which includes psy-
assessment, intervention, consultation, chotherapy at its core, is one of the func-
research/ evaluation, supervision, tional competencies. This competency
teaching, management-administration, has been defined as interventions that
and advocacy. are designed to alleviate suffering and
to promote health and well-being of in-
In an upcoming article, a Competency dividuals, groups, and/or organiza-
Benchmarks Document (Fouad et al., in tions. The essential components that
press) will appear that delineates the es- have been delineated for this compe-
sential components that comprise each tency include: knowledge of interven-
of these core foundational and func- tions, intervention planning, skills,
tional competencies. The Competency intervention implementation, and pro-
Benchmarks Document also articulates gress evaluation. Benchmarks for each
benchmarks, behavioral indicators that of these essential components have been
reflect the expected level of perform- determined with regard to readiness for
ance at each stage of professional devel- practicum, readiness for internship, and
opment for the essential components of readiness for entry to practice.
each competency domain. As a compan-
ion to the Competency Benchmarks I believe that members of the Division
Document, another soon to be pub- of Psychotherapy, those psychologists
lished paper will describe a Compe- with a passionate commitment and
tency Assessment Toolkit for dedication to the conduct of effective
Professional Psychology (Kaslow et al., psychotherapeutic interventions, should
in press). This toolkit builds on a grow- take a leadership role in fleshing out
ing and long history of competency ini- the intervention/psychotherapy compe-
tiatives, both within the profession and tence, including its essential compo-
in other healthcare disciplines. The nents and benchmarks indicating
methods include: 360-degree evalua- competent performance at each stage of
tion, annual/ rotation performance re- training and credentialing and in terms
views, case presentation reviews, of life-long learning. I am excited to read
client/patient process and outcome the papers that will soon be published
data, competency evaluation rating in Psychotherapy: Training, Research, Prac-
forms, consumer surveys, live or tice, Training in which leading authors
recorded performance ratings, objec- discuss the essential components of the
tive structured clinical examinations, psychotherapy competency and the
foundational and functional competen-
portfolios, record reviews, self-
cies informing the psychotherapy com-
assessment, simulations/role plays,
standardized client/patient interviews, continued on page 4
3
petency from various theoretical per- wonderfully responsive to the members
spectives: cognitive behavior, psycho- of the governance in terms of their web-
dynamic, family systems, and site and listserv needs, and with regard
existential/humanistic perspectives. I to Psychotherapy ENews. He has been
believe that these papers will represent very thoughtful in his approach to re-
an important effort toward advancing a sponding to the various challenges and
shared articulation of the essential com- decisions associated with the website
ponents of the psychotherapy compe- and listservs. As most of you know, Dr.
tency unique to each theoretical Wolf is a Past-President of the Division,
orientation, as well as ways in which as well as a fellow of the division, recip-
various foundational and functional ient of the division’s Jack Krasner Award
competencies are linked to this compe- for distinguished early career, and a
tency and how these linkages may be member of the division’s journal’s edito-
unique depending on the theoretical rial board (Psychotherapy Theory, Research,
frame and associated modality(ies). Practice, Training). Dr. Wolf is on the staff
Hopefully, other scholars, practitioners, of the Department of Psychiatry at
and educators from different orienta- MetroHealth Medical Center, the coun-
tions can build on these contributions to try hospital for Cleveland, and Associate
further hone our understanding of the Director of Adult Outpatient Services.
psychotherapy competency across theo- He is Professor of Psychology in Psychi-
retical perspectives. It also behooves us atry at the School of Medicine, Case
to consider how this competency would Western Reserve University. Dr. Wolf has
appear from other theoretical frame- a very active psychotherapy practice and
works, including an integrative model. he lectures and supervises psychiatry
Further, we need to consider bench- residents in individual psychotherapy.
marks that move beyond licensure, as He has published in the areas of devel-
this will support the significant role that opmental behavioral pediatrics, the use
lifelong learning must play in our pro- of technology in psychotherapy, and the
fession. Of course, most of us do not just application of psychometric theory to in-
strive to be competent, but rather we are struments used to measure psychother-
dedicated to being capable. Capability apy outcome. He is interested in the role
refers to the extent to which competent of therapist factors in psychotherapy
individuals adapt their skills, generate process and outcome, especially thera-
new knowledge, and continue to im- pist self-awareness of countertransfer-
prove their performance. The confluence ence reactions. He loves doing psycho-
of competence and lifelong learning is therapy. We are extremely grateful to
capability. I hope that you will join the Dr. Wolf for his wonderful contributions
Division and the field as we continue to to our division and we will miss him as
advance the competencies movement, he transitions out of his role as internet
and help us bring to bear our expertise editor. However, he will remain an
in the psychotherapy competency. extended member of the Division 29
governance family.
What’s New In Division 29?
We are in the midst of a changing of the I am delighted to introduce our new in-
guard in terms of our internet editor. On ternet editor, Chris Overtree, PhD. Dr.
behalf of Division 29, I want to publically Overtree received his doctorate in clini-
thank Abe Wolf, PhD for doing a fantas- cal psychology from the University of
tic job for many years as our internet ed- Massachusetts-Amherst. At the present
itor. He is the founding editor of our time, he is the Director of the Psycholog-
division’s website and Online Psy- ical Services Center (PSC) and the Asso-
chotherapy Editor. Dr. Wolf has been continued on page 5
4
ciate Director of Clinical Training for APA Convention
the Clinical Psychology Program at the You will be receiving the Psychotherapy
University of Massachusetts-Amherst. Bulletin just a few days before the annual
His scholarship is focused on psy- convention. In the Bulletin, we have pro-
chotherapy effectiveness in a naturalistic vided you details of our wonderful di-
setting, as well as more effective meth- visional programming. I am eager to
ods of service provision in the commu- interact with each of you at the meeting
nity mental health system. He is a in Toronto. I particularly hope to see
child/adolescent/adult and family ther- everyone at our Business Meeting/
apist with specialties in anxiety disor- Awards Ceremony and Social Hour,
ders, depression, cognitive-behavior which will be held on Friday. These
therapy, and family conflict. He also events afford us the opportunity to
serves as a consultant to schools regard- honor our awardees; meet, talk, and so-
ing bullying/harassment, climate re- cialize with one another; and enjoy some
form, and improving academic special entertainment put on by mem-
outcomes. Dr. Overtree has hit the bers of the Division 29 Board.
ground running. He is already livening
up our website, so check it out. In addi- Feel Free to Get in Touch
tion, he will work with our Task Force I have really appreciated the chance to
on Strategic Initiatives to significantly interact with so many members of our
enhance our website, so that it truly be- division since assuming the presidency.
comes a creative and engaging informa- I really value everyone’s input and
tion portal. We are so pleased to have Dr. ideas. Feel free to email me at
Overtree on board. Do not hesitate to nkaslow@emory.edu with questions,
contact me or Dr. Overtree if you have concerns, and suggestions. Please enjoy
suggestions about ways to make the Di- the rest of your summer!
vision 29 internet presence more mem-
ber-friendly, accessible, and valuable. (References available on-line.)
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JOIN THE DIVISION OF PSYCHOTHERAPY
ON-LINE!
Please visit our website to become a member,
view back issues of the bulletin, join our listserv,
or connect to the Division:
www.divisionofpsychotherapy.org
6
INTERVIEW
Abraham Wolf, Ph.D.
Crystal A. Kannankeril, M.S.
Doctoral Student at Loyola College in Maryland
For many psychologists, to 2002. Moreover, Dr. Wolf served two
joining a professional terms as the Secretary for Division 29,
organization is another which led up to his terms as President-
time-intensive respon- Elect in 2005 and President of Division
sibility added to the 29 in 2006.
several demands in-
volved in our profes- Among these achievements and leader-
sion and our already ship roles, one of the hallmarks of Dr.
busy lives. For Dr. Abraham “Abe” Wolf, Wolf’s service to Division 29 occurred in
a job requirement for his faculty position 1997 when he became Division 29’s first
at Case Western Reserve University Internet Editor and World Wide Web
turned into a 15 year partnership with the Coordinator. Dr. Wolf’s interest in com-
Division of Psychotherapy (29). When puters and statistics began early in high
looking for a professional organization to school when he was offered to take part
join, Dr. Wolf was invited to join the Divi- in a special computers program in 1967.
sion by Dr. Gerry Koocher, the incoming During graduate school, these interests
president. Dr. Wolf related that Division once again came to the forefront as he
29 was a “natural Division for me to be- became more involved with statistical
come involved with” given his interests analysis and computers. Once the
in psychotherapy and research. Internet hit in 1994, Dr. Wolf “jumped
on that right away as it was the most
Since 1993, Dr. Wolf has been an active amazing thing I’ve ever seen.” What
member and leader in Division 29, often made Dr. Wolf a true asset and pioneer
using his interests and innovation as a was his determination to bring his early
way to propel Division 29 into the fore- interest and involvement with the
front of APA. Dr. Wolf began his service Internet to Division 29. “No doubt, the
to Division 29 as the Co-Chair of the Division needed to jump on this band-
Student Development Committee, a wagon—the sooner the Division had an
position he held for five years. During Internet presence, the better,” Dr. Wolf
this time, he aimed to increase student remarked during our interview.
membership which he successfully
accomplished with several hundred His foresight and hard work over the
new student members. His committee next eight years as webmaster made
selected the winner of the student paper Division 29 a front-runner among the
awards, which has seen several success- APA Divisions with many Internet-
ful recipients including Dr. Louis based activities. His initial goal as Inter-
Castonguay of Pennsylvania State Uni- net Editor was for Division 29 to have
versity. Pursuing even more leadership a web-based presence; this included
roles, Dr. Wolf became coordinator of creating a website and listserv for mem-
APA’s Mid-Winter Convention Commit- bers. Dr. Wolf described these early tasks
tee, a joint Convention with Division 42 as a “Mom and Pop operation.” The first
(Independent Practice) and Division 43 website was originally attached to Case
(Family Psychology) in 1998. From 1996 Western Reserve University where he
to 1998, he served as a Member-at-Large has been a professor of psychology in
for Division 29 and was a member of the the school’s Department of Psychiatry
Division’s Publication Board from 1996 continued on page 8
7
for the past 30 years, hired right out of much experience with these technologi-
internship. After many versions of the cal advancements as compared to their
website, Dr. Wolf was able to create a younger counterparts. He indicated that
separate URL for Division 29 in 2004 younger psychologists or students may
(www.divisionofpsychotherapy.org), take the Internet for granted, just as
allowing for easier access to users. older members may take radio and tele-
vision for granted. So, for members who
Dr. Wolf’s other achievements in his did not grow up with the Internet, hav-
eight-year term as Internet Editor ing these new online features may be
included creating and editing APA’s On- more complicated; getting them to uti-
line Academy (www.apa.org/ce), mak- lize this medium thus becomes more of
ing Division 29 one of the few Divisions a challenge. One of Dr. Wolf’s goals was
to post online CE credits. This website to help the older membership move into
allows members to watch archived the 21st century. He remarked that “it is
conferences through web-streaming, still a challenge to get people to join the
making them easily accessible to mem- listserv and effectively use the medium,
bers. Such CEs include Evidence-based which will be a continuing challenge to
Psychotherapy Relationships: What Works leadership and members [in the fu-
in General (2006), Treating the Hated ture].” He did note that members are ex-
and Hateful Patient (2006), The Proper cited and interested in this movement,
Focus of Evidence-Based Practice (2006), though “it is hard to make those ideas
and Evidence-based Psychotherapy Re- into realistic applications.”
lationships: Customizing the Treatment
Relationship to the Individual Patient When asked about his reflections on in-
(2007). This movement towards utilizing volvement with the Division, Dr. Wolf
and pairing technology with psychology indicated that he has no regrets. He
also became part of Dr. Wolf’s presiden- noted that it has been “truly one of the
tial initiative in 2006 and serves as one most rewarding activities I have ever
of his favorite memories as Internet done – [it has allowed me] to exchange
Editor. He recognized the importance of ideas, collaborate on research projects,
the Internet in psychology’s future and and be involved with great people
worked hard towards keeping psychology whose articles you have been reading
current and relevant in this new age and for years - and then get to have dinner
growing field of technology. In addition, with them.” Dr. Wolf also joked, “for all
Dr. Wolf was named a Guest Editor for a the meetings, it is really worth it.” He
special edition of Division 29’s Journal also wanted to acknowledge that he
Psychotherapy: Theory/Practice/Research/ could not have accomplished all that he
Supervision which focused on the tech- has without the support of his family.
nology of psychotherapy.
Division 29 formally created the position
Dr. Wolf’s achievements, however, did of Internet Editor in 2005. With Dr. Wolf
not come without their fair share of hur- serving as Chair-Elect that year, Dr.
dles. He explained that what makes the Bryan Kim from the University of
position of Internet Editor unique and Hawaii became the next Internet Editor
often challenging is facilitating commu- from 2005 to 2008. After Dr. Kim’s three
nication and making this new medium years of service, Dr. Wolf returned as
meaningful to all the members of Divi- Interim Internet Editor in 2008. The In-
sion 29. Specifically, Dr. Wolf noted that coming Internet Editor is Dr. Christo-
having a website, listserv, and online pher Overtree from the University of
newsletter may not be as simple or rele- Massachusetts Amhearst. In looking to-
vant for older, more well-established wards the future, Dr. Wolf is confident
members who may have not have as continued on page 9
8
in the direction of this position. He of members to get involved and “show
explained that the website is due for “a up for our meetings—it will be a deci-
more professional makeover” as it is sion they will never regret!” On behalf
now five years old. His words of wis- of the members of Division 29, I would
dom for Dr. Overtree were to have a like to thank you, Dr. Wolf, for all that
vision of where he sees the website you have given to us—we will miss you
growing and continually work towards as Internet Editor but look forward to
those goals. As Dr. Wolf’s leadership your continued involvement with the
role in Division 29 come to a close, he Division of Psychotherapy.
also wanted to express the importance
9
PSYCHOTHERAPY RESEARCH, SCIENCE
AND SCHOLARSHIP
Engaging Underrepresented, Underserved
Communities in Psychotherapy-Related Research:
Notes from a Multicultural Journey
Susan S. Woodhouse, Ph.D., The Pennsylvania State University
Dr. Janet Helms, well- problems and psychopathology (see
known for her re- Greenberg, 1999, and Kobak, Cassidy,
search on racial Lyons-Ruth, & Ziv, 2006, for reviews).
identity development While we were collecting data for the
(e.g., Helms, 1990), larger RCT, a group of investigators de-
once said, “If you stay cided to conduct a smaller, qualitative
with any question study focused on better understanding
long enough, it will the precursors to infant attachment
become a multicultural question.” She (Cassidy, Woodhouse, Cooper, Hoffman,
said this when I was still a graduate stu- Powell, & Rodenberg, 2005). Our think-
dent in Counseling Psychology at the ing was that outcomes of mother-infant
University of Maryland. I had an intel- psychotherapy could be greatly improved
lectual appreciation for what she was if we could better understand the most
saying, but only later developed a important precursors of attachment that
deeper understanding as my research should be targeted in treatment.
progressed. Much of my current re-
search focuses on how to improve brief After three decades of research, there is
psychotherapy with parents and infants, still some degree of controversy about
including basic research on important exactly how parental behavior serves as
aspects of the parent-infant relationship a precursor to attachment. Research has
that should be targeted in such psy- found via meta-analysis that there is a
chotherapy. I would like to share the robust link between mothers’ attach-
story about how my psychotherapy- ment representations and their infants’
related research questions became mul- attachment security: mothers who are
ticultural questions, and how the jour- secure tend to have babies who are se-
ney has led to my current efforts to cure (van IJzendoorn, 1995). Attachment
engage underrepresented, underserved theory would suggest that the mecha-
minority group members in my psy- nism through which this link should
occur is maternal sensitive responsive-
chotherapy-related research.
ness to the infant (Bowlby, 1969/1982).
The story begins with a randomized In fact, there is meta-analytic evidence
controlled trial (RCT) of a brief, three- that maternal sensitivity serves as a me-
session, home visiting, preventive, psy- diator of this link between mothers’ and
chotherapy intervention for first-time, infants’ attachment (van IJzendoorn,
economically stressed mothers of irrita- 1995). The problem, however, is that the
ble infants and their babies (Cassidy, effect sizes for the mediation model
Woodhouse, Sherman, Stupica, Ziv, & are much lower than theory would pre-
Lejuez, 2009). The goal of the brief psy- dict; van IJzendoorn termed this issue
chotherapy was to reduce the risk of in- the transmission gap. In fact, the connec-
secure attachment. Attachment was tions between maternal behavior and
targeted at an outcome because of the infant attachment are generally weaker
empirical evidence that insecure infant in low-SES families (De Wolff & van
attachment is associated with behavioral continued on page 11
10
IJzendoorn, 1997). The transmission gap sensitivity. We made extensive written
raised many questions for us that we qualitative notes on interactions. Based
thought were important to resolve, par- on our observations we attempted to
ticularly if our goal was to make psy- predict the infant 12-month Strange Sit-
chotherapy for low-income, at-risk uation (Ainsworth et al., 1978) attach-
mothers and their infants as efficacious ment classification and the maternal
and efficient as possible. If it is impor- Adult Attachment Interview (AAI;
tant for infant-parent psychotherapy to George, Kaplan, & Main, 1996) classifi-
work with parents on changing behav- cation. After independently making our
iors, we need to make sure that we predictions, we individually read the
know which behaviors really make a AAI and looked at the attachment classi-
difference in later attachment outcomes. fication score, watched the 12 and 18
months Strange Situation videos and
The Cassidy et al. (2009) RCT was con- looked at the scores, and made notes
ducted in a large, metropolitan area that about what we had learned from the
had a very diverse population; that di- dyad. The team then met for a two-hour
versity was reflected in the sample of the discussion of each dyad.
study. Participants were 169 infants and
their economically-stressed mothers, in- We were surprised at how few mothers
cluding 42.6% African American/Black, were rated as sensitive according to the
27.2% White, 19.5% Hispanic, and 10.7% Ainsworth et al. (1978) conceptualiza-
mixed race or other. For the smaller, tion of sensitivity, especially given the
qualitative study we examined 18 rather moderate level of sensitivity re-
mother-infant dyads (78% racial or eth- quired to be assigned to the sensitive
nic minority group members) who were group. Of the 18 mothers, only 3 were
a part of the control group in the larger classified as sensitive and 15 were classi-
RCT. As mentioned earlier, our goal in fied as insensitive. All of the mothers
the qualitative study was to try to figure who were deemed sensitive had babies
out which maternal behaviors most mat- who were later classified as secure in the
tered in predicting later attachment, so Strange Situation. Of the 15 mothers
as to close the transmission gap. We who were classified as insensitive, how-
hoped to be able to make suggestions ever, 6 had babies who were later classi-
about which maternal behaviors were fied as secure and 9 had babies who
most important to support and which were later classified as insecure in the
were most important to target for Strange Situation. The proportion of in-
change in psychotherapy. fants that were categorized as secure
(50%) via the Strange Situation was con-
Each research team member watched all sistent with the proportion secure in
of the available videotape (approxi- comparable samples (Spieker & Booth,
mately 90 minutes of tape) from a lab 1988). Also, the 67% match of sensi-
visit (at 4.5 months) and three 30-minute tive/secure and insensitive/insecure in-
videotapes of naturalistic home observa- dicates that even in a small sample there
tions (7 to 9 months). We assessed ma- is evidence for a connection between
ternal behaviors by focusing on the maternal sensitivity and infant attach-
mother, but attended to the dyad for ment. Of greatest interest to us, how-
context using the Ainsworth, Blehar, ever, were the 6 infants with mothers
Waters, and Wall (1978) conceptualiza- who would be deemed insensitive ac-
tion of sensitivity. Mothers were classi- cording to traditional measures of sensi-
fied as either insensitive or sensitive tivity but who later turned out to be
according to the Ainsworth et al concep- secure. What we learned from this qual-
tualization of sensitivity. In order to be itative study was that what seemed to
in the sensitive group mothers had to
meet only a minimum, moderate level of continued on page 12
11
best predict attachment outcomes was secure base provision measure avoids
not sensitivity as typically conceptual- emphasizing the importance of certain
ized, but instead whether the mother culturally-bound parenting practices
was willing to serve as a secure base for found in white, middle class samples
the infant. Insensitivity, per se, was not (e.g., sweet tone of voice, affectionate
antithetical to security. In other words, comments, moment-to-moment affective
mothers could engage in a larger num- attunement) and does not pathologize
ber of insensitive behaviors as long as in other culturally-based parenting prac-
the end, at least 50% of the time, the tices (e.g., what might be termed “no-
mother relented and allowed the baby to nonsense parenting”). Instead the coding
come in for comfort when distressed, system focuses on behaviors that appear
did not activate the attachment system to predict later infant attachment across
while the child was exploring, and re- groups. Frequently, differences between
frained from certain particularly nega- racial groups are cast as an indication that
tive behaviors (e.g., frightening the baby, minority group children deviate from
harsh/hostile responses to infant dis- typically developing children, and there
tress). It was as if one central thing the is a lack of research on adaptive strategies
infants were learning from all their ex- and pathways to success (Garcia-Coll,
periences with their mothers was 1990). Use of assessments of parenting
whether, on the whole, their mothers that are based on white, middle class
would provide a secure base for them norms frequently results in the patholo-
when they most needed it. Instead of gizing of minority group parents’ care-
taking an “average” of the mothers’ sen- giving. In order to design culturally
sitive/insensitive behaviors in terms of appropriate and relevant preventive
a moment-by-moment matching to in- psychotherapy, it is crucial to avoid
fant signals, infants seemed to be think- pathologizing culturally-based parenting
ing about how episodes of distress tended practices (e.g., “no nonsense parenting”)
to turn out in the end when they most that are not detrimental to children’s
needed something (Cassidy et al., 2005). attachment security.
As part of their online networking prac- Patterns of Social Networking Site Use
tice, users typically post personal infor- An extensive survey conducted by the
mation about themselves that may Educause Center for Applied Research
include educational, occupational, and (Salaway & Caruso, 2008) yields statis-
contact information, as well as descrip- tics on SNS usage that make the phe-
tions of their interests and activities. nomenon impossible for psychologists
Many users also post photographs of to ignore. The findings indicate that the
themselves alone and/or in groups. vast majority (85.2%) of all undergradu-
Users may communicate with each ate students frequent at least one SNS,
other by leaving messages on one an- with membership comprised of a
other’s pages or merely learn more greater proportion of younger students
about other users via viewing their per- than older students (i.e., fully 95.1% of
sonal profiles. While these sites are typ- 18-19 year old students report SNS
ically used for general networking usage, compared with only 37% of un-
purposes, some appeal to particular in- dergraduates aged 30 years or more).
terests (e.g., LinkedIn’s primary aim is Furthermore, 56.8% of respondents
career networking) or populations (e.g., make SNS usage a part of their everyday
Facebook initially limited its member- activities, up from 32.8% in 2006, which
ship to undergraduates, who continue to demonstrates the recent and consider-
comprise the bulk of its members; Sal- able rise in the integration of SNSs in
away & Caruso, 2008). users’ daily functioning. The most fre-
quently reported purpose of SNSs is to
The sharing of personal information maintain connections with existing
across as public a medium as the Inter- friends and acquaintances (96.8%); just
net brings with it a number of risks, and 16.8% make use of these sites to foster
users are wise to recognize that abuse or entirely novel friendships. In addition,
simply negligent use of these sites may more than half of respondents use these
have deleterious effects. For example, re- sites to gather more information about
vealing excessive personal information people they may or may not have met
without implementing sufficient privacy (51.6%) and to share photographs,
controls has led to fear of identity theft videos, and other media (67.7%).
and Internet stalking. Additionally, the
prominent case of Megan Meier, the 13- Yet, SNS use is not limited to undergrad-
year-old girl who committed suicide in uate students. Facebook presently has
2006 after receiving harassing messages more than 175 million registered users
on MySpace from a user who had cre- continued on page 17
16
worldwide. More than 3 billion minutes propriately. While it seems as though the
are spent on Facebook each day and simple solution to this dilemma is to ei-
more than 18 million users update their ther limit search options or refrain from
page each day (Facebook, 2009). My- using SNSs altogether, even these precau-
Space presently has more than 185 mil- tions may not eradicate the issue: current
lion registered users worldwide. or former psychotherapy clients may
Approximately 25% of all Americans are send electronic membership invitations
active MySpace users. Almost 350,000 to clinicians who do not already have a
individuals sign up as new users of My- SNS listing (as illustrated in Scenario 1
Space each day and it has achieved more above). For those who have a SNS the use
than 4.5 billion page views in a single of different levels of security settings may
day. Over 1.5 billion images are shared prevent clients from having free access to
via MySpace each day. Fifty million the psychotherapist’s online materials,
mails are sent each day through My- but the existence of the online profile is
Space and there are over 10 billion active usually not hidden and clients may still
friend relationships at present (Social request being accepted as a friend. Fur-
Network Stats, 2008). The ubiquitous ther, some clients who are very computer
nature of SNSs in the lives of so many is savvy may be able to circumvent security
quite evident from the above data. settings and obtain access to information
intended only for personal use.
Ethical Challenges and Dilemmas
The use of SNSs by psychotherapists and In some ways, friend requests and mem-
their clients raises a number of bership invitations may be viewed as
ethical challenges in areas that include auspicious, as they may indicate that the
informed consent, boundaries, self- dis- client considers the therapeutic relation-
closure, and multiple relationships. ship to be a strong one. They may also in-
Boundary violations and multiple rela- dicate a client’s desire to share personal
tionships are inherent concerns when information with the clinician that is rel-
considering SNSs for psychotherapists. evant to the psychotherapy and this may
Practitioners who utilize these sites may be a valuable contribution to the psy-
receive online requests from their clients chotherapy process (Lehavot, 2009). In
to become “friends” on these sites, and such cases, it may be possible to view the
accepting these requests necessarily client’s online materials together and
blurs the lines of the therapeutic relation-process them as part of the ongoing ther-
ship. Although it is generally accepted apeutic process. Alternatively, friend re-
that “friends” on SNSs are often mere ac- quests may indicate a client’s suspicion
quaintances, the title may still complicate of the clinician or simply a boundary
expectations of the relationship and the crossing to obtain more information
role of the psychotherapist in the client’s about the psychotherapist’s personal life
life. Although befriending a client online to quell curiosity. Regardless, such an
does not necessarily constitute an ex- event should be addressed in psy-
ploitative multiple relationship (See Stan- chotherapy in order to determine the im-
dard 3.05 of the APA Ethics Code), it may petus for the request and the client’s
reaction if the psychotherapist chooses to
be the first step in a series of increasingly
inappropriate communications or disclo- decline the invitation. As Lehavot (2009)
sures that are not consistent with antici- states: “By paying thoughtful attention to
pated professional roles. the function of the client obtaining infor-
mation about the clinician online, the
Declining the client’s ‘friend’ request may psychotherapist can examine this behav-
be a clinical challenge and may have ior as an opportunity to enhance the
some impact on the psychotherapy rela- client’s treatment” (p. 28).
tionship and process if not addressed ap- continued on page 18
17
It should be pointed out that sharing in- that the clinician’s theoretical orienta-
formation with a client in itself is not tion may impact views of the appropri-
necessarily unethical. Psychotherapists ateness and use of psychotherapist
have the right to decide how much per- self-disclosure. Humanistic psychother-
sonal information they are comfortable apists may be more open to the use of
sharing with clients. But, psychothera- self-disclosure to make themselves ap-
pists should also consider the impact of pear more genuine and to narrow the
such online relationships on the psy- power differential between clinician and
chotherapy relationship and process. client. In contrast, psychoanalysts and
Considering these issues and their po- psychodynamic psychotherapists may
tential consequences before they become prefer less transparency with their
an issue with a particular client is rec- clients to promote the transference rela-
ommended. tionship and thus may utilize self-disclo-
sure much more sparingly. Williams
Issues of informed consent arise when importantly portends the possibility of
clinicians decide to conduct online ethically incorporating SNS usage into
searches for their clients without their clinical practice in his suggestions for a
knowledge or prior approval. While one thoughtful and flexible approach to
may argue that viewing a client’s profile boundaries and self-disclosure. Still, if
can be useful clinically insofar as it may clinicians decide to use SNSs profession-
provide clinicians with additional or ally, they are encouraged to do so only
corroborating data to enhance under- after carefully weighing costs and bene-
standing of various aspects of the fits and proceeding with appropriate
client’s life, doing so clandestinely may caution so that the standards of the APA
have substantial negative implications Ethics Code may be upheld and clients’
for rapport. For example, if a psy- best interests are addressed.
chotherapist learns of a client’s experi-
mentation with illicit substances online It is, however, important to keep in
and the client has not disclosed this in mind that in the Internet age, many
treatment, what does the psychothera- clients are likely to search for informa-
pist do with this information? Should tion about their psychotherapist. This
one disclose their search and what they will likely be true regardless of one’s de-
have learned, accepting any negative cision to participate in SNSs given that
impact on the therapeutic relationship, individuals have been encouraged in re-
or should one withhold the information cent years to become more informed
and not address in treatment a poten- consumers of services and to be more ac-
tially significant clinical issue? Similar tively involved in their care, and that
issues are relevant for supervisors who use of the Internet for such purposes is
search for information about their su- prevalent. Psychotherapists should an-
pervisees online (as depicted in Scenario ticipate this occurring. In fact, one recent
2 above). Psychotherapists and supervi- survey of consumers found that 80% of
sors should consider issues of trust as all Internet users have searched for
well as professional role modeling when health care information online to include
considering these decisions. information about specific health care
professionals (Fox, 2005).
It should be noted that psychotherapists
vary in their perceptions of the clinical Cohort Effects
impact of self-disclosure, multiple rela- Seasoned Professionals
tionships, and boundary crossings and While some senior psychotherapists
will vary in their comfort level with the may be active online, many may feel un-
intersection of SNSs and their clinical affected by the SNS trend in terms of its
practice. Williams (1997) has pointed out continued on page 19
18
influence on their ethical practice by Trainees should very carefully monitor
virtue of the fact that relatively few of and consider the information they in-
them participate in online social net- clude in their online profiles. While it is
working. Many, although clearly not all, necessary for all practitioners to be cog-
may also be unaware of the pervasive ef- nizant of the information they share on-
fects of the SNS trend, given that they line, many trainees will have developed
came of age in a different time. How- a profile prior to their involvement in
ever, the issue remains an important one the field of psychology. For that reason,
to consider, especially when treating it is recommended that trainees review
clients who are active on the Internet. all material on their profiles in order to
For seasoned professionals, limited fa- determine its appropriateness and make
miliarity with SNSs may restrict their alterations as needed. For example, on-
ability to comprehend the social sub- line videos, photos, and writings that
strate in which many of their clients seemed very appropriate for an audi-
function, particularly those in the net ence of peers when a college sophomore
generation. These clients are so-called may not be viewed in the same manner
“digital natives” (Prensky, 2001) in that by graduate school admissions commit-
they have been raised in an electronic tee members or even by undergraduate
culture, speaking a digital language that faculty who are asked to write letters of
is foreign to many “digital immigrant” recommendation. Then, when in gradu-
seasoned professionals. Given the wide- ate school, one’s online presence may
spread use of SNSs, it is prudent to ob- impact externship and internship deci-
tain at least a general awareness of the sions. Graduate student psychothera-
purpose, features, and potential risks pists-in-training must also consider the
and benefits of these sites so that we are potential impact of their online presence
able to converse with clients and under- on their clients.
stand the world in which they function.
Recommendations
Students and Trainees Psychotherapists should consider all on-
The psychology graduate student co- line posts they make and profiles they
hort is arguably the one within our pro- keep to be self-disclosures, even if pre-
fession most associated with the SNS cautions are taken by setting privacy
trend. They are in a unique position as controls on SNSs. Clinicians are encour-
budding professionals in the field in aged to remain cognizant of the fact that
that SNSs are already largely a part of even if a given disclosure is not unethi-
their social lives; that is, many trainees cal per se, it still may have an impact
were undergraduates when the social clinically; that is, anything that is put on
networking craze began and initially the Internet may influence our profes-
thrived on college campuses (e.g., Face- sional roles and relationships. Further-
book was launched in 2004). As such, more, although the Ethics Code only
the next generation of psychologists has technically pertains to professional en-
been largely immersed in the culture of deavors, materials placed on the Inter-
online social networking and likely net for personal relationships cannot be
hadn’t considered issues of profession- kept completely separate from our pro-
alism in social networking prior to en- fessional roles. Additionally, informa-
tering graduate school. The recent tion accessed about psychotherapists in
concern about psychology graduate stu- our personal lives may impact the pub-
dents’ lives on the Internet has been lic’s view of us professionally as well.
mirrored by similar concerns in the
medical (Thompson et al., 2008) and It is recommended that psychotherapists
teaching (Carter, Foulger, & Ewbank, maintain professional websites so that
2008) professions. continued on page 20
19
clients who search for us via the Internet SNS use to clients to address certain
will access the information shared there challenges they may have, either as a
that is of relevance to our professional primary intervention or as a supplement
roles and activities. Information shared to other, more traditional strategies.
may include credentials, training For example, a client who is struggling
experiences, areas of specialization and to find a worthwhile career path may
populations worked with, and related engage in standard career counseling
professional information (Barnett & as well as become involved in
Hillard, 1999). Always consider the mean- LinkedIn.com, which is largely devoted
ing of “friend” requests from clients in the to professional development.
context of their psychotherapy. When ap-
propriate, use joint review of the SNSs as Teaching professionals should include
a therapeutic activity. That is, if a client their policy statement on online searches
has invited a psychotherapist to be their of applicants and students in their pro-
“friend” online in order to share personal gram materials. Additionally, expecta-
information, photos, or other media, sug- tions for student professionalism with
gest the option of having the client log on regard to their online presence and ac-
to their profile during session so that the tivities should be included in student
profile viewing may be done together. handbooks and be reviewed beginning
This may help ensure a minimal likeli- at orientation and reviewed throughout
hood of boundary violations or threats their training. Assisting trainees to make
to trust and guarantees that the online the digital transition from the purely
content may be jointly explored and personal to the professional is an impor-
processed in session. tant role for supervisors and faculty.
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EDUCATION & TRAINING
Prioritizing Case Formulation in Psychotherapy Training
Eugene W. Farber, Ph.D., Emory University, Atlanta
Increasing emphasis Case Formulation: Definition and Rele-
recently has been vance to Psychotherapy Training
placed on identifying Psychotherapy case formulation may be de-
foundational and func- fined as “…a hypothesis about the causes,
tional competencies precipitants, and maintaining influences of a
for professional psy- person’s psychological, interpersonal, and be-
chology practice (for havioral problems…” (Kendjelic & Eells,
review, see Rodolfa et 2007, p. 66). Teaching systematic case formu-
al., 2005). A key purpose for elaborating lation strategies affords trainees the opportu-
these competencies is to inform the develop- nity to organize their thinking about clinical
ment of competency-based models for pro- material into a coherent plan for psychother-
fessional training in psychology (Kaslow, apy intervention. The formulation provides a
2004). In contributing to the professional di- conceptual framework for understanding the
alogue on this issue, Spruill et al. (2004) client, including clinical symptoms, prob-
identified case formulation among a set of lems, and psychological themes expressed in
important clinical competencies in interven- psychotherapy. It also informs psychotherapy
tion planning. They characterized compe- planning, including the identification of
tency in case formulation as requiring skills themes that comprise the focus of treatment,
in integrating information gleaned from the the setting of treatment goals, the selection of
clinical assessment into a conceptual model psychotherapy techniques and intervention
of both the clinical problem and pathways strategies, and the management of the psy-
for addressing the problem. In their discus- chotherapy relationship. Finally, case formu-
sion of this issue, Spruill et al. also cited the lation can be invaluable in making sense of
role of clinical supervision in helping psy- unanticipated and/or clinically complex
chotherapists in training to develop compe- events, crises, or problems that arise in the
tency in case formulation. Concerns recently course of psychotherapy. The psychotherapist
have been raised, however, about a relative typically must improvise in responding to
lack of explicit concentration on the devel- these unpredictable clinical situations (e.g.,
opment of case formulation competencies in Binder, 2004), and having a clearly defined
psychotherapy training (Ivey, 2006). An conceptual roadmap can provide a helpful ref-
electronic search of the psychology literature erence point that anchors the psychotherapist
using the keywords “case formulation and in this process. This is particularly valuable
psychotherapy training” yields only 6 arti- for trainees, where continual and systematic
cles on this topic. This points to the paucity use of the case formulation as a basis for psy-
of professional dialogue on case formulation chotherapeutic decision-making provides the
training. As such, there appears to be a need clarity needed to organize a well thought-out
to raise the level of professional discussion response to challenging and ambiguous situ-
on the issue of training in psychotherapy ations arising in the psychotherapy process.
case formulation as part of the overall Although research on this topic is limited,
process of psychotherapy training in general. there are empirical findings supporting the
This includes the articulation of training usefulness of formulation-based psychother-
strategies that support development of key apy practice, including the benefits of using
case formulation competencies in psy- case formulation in psychotherapy with
chotherapy trainees. clinically complex cases (for review, see
Kendjelic & Eells, 2007).
continued on page 22
21
Competencies and Case ity functioning and psychotherapy process
Formulation Training (Binder, 2004). When training psychothera-
A competencies-based approach can help to pists in case formulation, it is critical that the
inform thinking about the issue of training in trainee learn how to work within a conceptual
psychotherapy case formulation. In reporting model of psychological functioning and psy-
a study showing that expert psychotherapists chotherapy process to develop a theoretically
demonstrated superior case formulations informed case formulation of a given clinical
when compared with novice and experienced case. Often trainees experience a discrepancy
psychotherapists (Eells, Lombart, Kendjelic, between their theoretical knowledge and their
Turner, & Lucas, 2005), the study authors of- capacity to apply this knowledge in develop-
fered interpretations in explaining their find- ing a clinically useful case formulation, and
ings that may point to some clues regarding good case formulation training should pro-
competencies in case formulation. For exam- vide opportunities for trainees to practice in-
ple, they suggested that experts in their study tegrating their theoretical knowledge with
might have a particularly well developed ca- their clinical knowledge and skills (Ivey,
pacity to glean a range of patterns from clin- 2006). A second competency outlined by
ical data and use this capacity to develop Binder (2004) involves skill in developing the
complex and nuanced formulations. Addi- case formulation itself. To develop this com-
tionally, the experts appeared to utilize a con- petency, the trainee must learn to make effec-
sistent and systematic formulation approach tive use of the assessment process and to
that may facilitate a deep level of understand- organize clinical material obtained through
ing of clinical material. The study authors the assessment process into a theoretically in-
also surmised that well developed self-mon- formed and coherent formulation of the prob-
itoring skills also may be of benefit in the lem. This formulation comprises a “story” of
case formulation process. the problem and the factors sustaining the
problem and suggests a clinical focus that
In describing a specific method for psycho- guides treatment, including pathways to ad-
dynamically focused case formulation dressing the problem (Binder, 2004). A third
training, Ivey (2006) identified several com- competency articulated by Binder (2004) in-
petencies required for developing good for- volves the capacity of the psychotherapist to
mulations. These include skills in observing utilize the case formulation in the moment-to-
and describing both verbal and nonverbal moment unfolding of the psychotherapy
behavior, the ability to elicit a detailed de- process. As such, training also needs to focus
scription of the patient’s experience that can on developing skills in tracking the treatment
be elaborated into an experiential account of focus specified by the case formulation over
the patient’s problems, the capacity to track the course of treatment and to adjust the for-
the patient’s perceptions of and relationships mulation where needed to accommodate new
to self and others, awareness of the patient’s clinical findings over time.
reactions to the psychotherapist, and a suffi-
cient grasp of theory, including the capacity Examples of Case Formulation
to apply it to the case formulation process. Training Approaches
Despite the paucity of written accounts of
Although not focusing on psychotherapy case systematic approaches to psychotherapy
formulation competencies per se, Binder case formulation training, Ivey (2006) offers
(2004), in a discussion of psychotherapy com- a structured model for case formulation
petency as applied to the clinical practice of training for psychology trainees. Although
brief dynamic psychotherapy, has described psychodynamic in focus, the general struc-
several broad psychotherapy competencies ture of this approach could be applied to the
that are instructive in thinking about psy- process of case formulation training across
chotherapy case formulation training. One the spectrum of theoretical perspectives. The
such competency pertains to having a theo- training is conducted in a module that in-
retical framework for understanding personal- continued on page 23
22
cludes weekly sessions held over a 3 month in the theoretical underpinnings of TLDP and
period concurrent with modules on psy- its theoretically grounded template for devel-
chopathology, psychotherapy, and psycho- oping a psychotherapy case formulation. This
logical assessment. Case formulation template is comprised of model-specific cate-
training occurs using an 8-step process. The gories of clinical data that can be organized
first step focuses on definitions of case for- and synthesized into a narrative conceptual-
mulation and the clinical information do- ization of the case. Trainees also are explicitly
mains that are relevant to conducting case invited to explore their own feelings and reac-
formulation. In the second step, trainees are tions to their clients and to incorporate these
provided with written case material for prac- experiences into their case formulations.
tice in constructing a case formulation Trainees develop written case formulations of
guided by specific instructions for doing so. their psychotherapy patients using the TLDP
Trainees use their practice case formulation template and utilize these formulations to in-
in step 3 as a starting point for learning the form the development of treatment goals. The
specific criteria for what a good case formu- case formulation and goals are routinely dis-
lation looks like. Trainees then are asked to cussed in group supervision as part of each
evaluate their practice formulations in accor- trainee’s presentation of videotaped psy-
dance with these criteria. In step 4, having chotherapy sessions, providing opportunities
already covered general concepts of case for- for input from both the supervisor and trainee
mulation, the characteristics that make a for- peers. Trainees are specifically encouraged to
mulation narrative explicitly psychodynamic reflect on how the case formulation informs
are outlined. In step 5, the structure of the psychotherapeutic decision- making and how
case formulation is explained, including the the case formulation may evolve or change as
conceptual elements of the formulation and new clinical information emerges.
how they are synthesized to provide a coher-
ent clinical narrative for understanding the Kendjelic & Eells (2007) conducted a study
problems and concerns of the client. The examining the effects of clinician training in
sixth step involves practice in small training use of a so-called generic components ap-
groups, utilizing the structure outlined in the proach to case formulation. The 4 compo-
previous step to develop case formulations nents of their case formulation approach
drawn from written case material. These for- included symptoms and problems, precipi-
mulations are discussed and critiqued by the tating stressors, predisposing events and
trainee group. Videotaped clinical material conditions, and an inferred mechanism for
is provided in step 7 as the basis for further conveying the psychotherapist’s explanation
case formulation practice. This allows of patient’s problems. In this study, the
trainees to expand their repertoire of case TLDP case formulation approach was used
formulation skills by learning to incorporate as an example of an inferred mechanism.
observations of the client’s nonverbal behav- Clinicians in the training group received a 2
ior and patterns of response to the clinician. hour group presentation on case formulation.
In the final step, trainees are asked to inte- The training included discussion of why case
grate their subjective emotional reactions to formulation is important, and introduced the
the client observed in videotaped samples 4 generic components comprising the case
into their case formulations. formulation approach. Factors contributing
to the quality of a case formulation also were
Levenson (1995, 2003) has described an ap- discussed, and participants had an opportu-
proach to psychotherapy case formulation nity to practice the case formulation method
training integrated within a 6-month program using a sample vignette. Study results
of training in time-limited dynamic psy- showed that even with as little as 2 hours of
chotherapy (TLDP; Strupp & Binder, 1984). training, clinicians in the training group pro-
Levenson’s (1995, 2003) approach includes a duced higher quality case formulations than
weekly didactic seminar and a psychotherapy clinicians in the control group.
supervision group. Trainees receive instruction continued on page 24
23
Conclusions: Toward Increasing Dialogue proach training in psychotherapy case for-
on Case Formulation Training mulation warrants further discussion. This
The value of case formulation for psycho- discussion should include consideration of the
therapy planning and intervention is widely key competencies to be included in case for-
acknowledged across a spectrum of mulation training and elaboration of methods
psychotherapy orientations (Eells, 2007). to systematically develop these competencies.
Recent empirical research underlines the Approaches to evaluating the effectiveness
usefulness of systematic training in methods of training methods in psychotherapy case for-
of psychotherapy case formulation (Kend- mulation also should be considered.
jelic & Eells, 2007). Given the importance
of good case formulation skills to psycho- (References available on-line.)
therapy practice, the issue of how best to ap-
24
PERSPECTIVES ON PSYCHOTHERAPY INTEGRATION
Making Evidence-Based Practice Work:
The Future of Psychotherapy Integration
Marvin R. Goldfried, Ph.D., Stony Brook University
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NOTICE TO READERS
28
DIVISION 29 ~ 2009 APA PROGRAM
THURSDAY, AUGUST 6th
Existential Humanistic Therapy Comes of Age (Symposium)
8:00 AM – 9:50 AM • Metro Toronto Convention Centre – Meeting Room 202C
Chair: Kirk J. Schneider, PhD
Participant/1st Author
Alexander Bacher, MA Pernilla Nathan, MA
Stacie L. Cooper, MA Orah T. Krug, PhD
Dave Fischer, MA Kirk J. Schneider, PhD
29
FRIDAY AUGUST 7th
The Art and Science of Impact: What Psychotherapists Can Learn From
Filmmakers and Social Psychologists (Symposium)
8:00 AM – 9:50 AM • Metro Toronto Convention Centre – Meeting Room 713A
Chair: Jeffrey K. Zeig, PhD
Participant/1stAuthor
Jeffrey K. Zeig, PhD
Patricia Rozema
Discussant: Lee D. Ross, PhD
Symposium (S):
Eminent Psychotherapists Revealed Audiovisual Presentation of
Principles of Psychotherapy
2:00 PM – 3:50 PM • Metro Toronto Convention Centre – Meeting Room 801A
Chair: Jeffrey J. Magnavita, PhD
Participant/1stAuthor ____
Jeffrey J. Magnavita, PhD Hanna Levenson, PhD
Jay Lebow, PhD Judith S. Beck, PhD
Discussant: Nadine J. Kaslow, PhD
Business Meeting
5:00 PM – 5:50 PM
Fairmont Royal York Hotel – Territories Room
Social Hour
6:00 PM – 6:50 PM
Fairmont Royal York Hotel – Salon B
30
SATURDAY AUGUST 8th
Psychotherapist Expertise Developing Wisdom to
Guide Theory, Research, and Practice (Symposium)
9:00 AM – 9:50 AM • Metro Toronto Convention Centre – Meeting Room 802B
Chair : Allen K. Hess, PhD
Participant/1stAuthor
Robert M. Leve, PhD
Leonard Greenberg, PhD
Barbara Schwartz, PhD
C. Alexander Simpkins, PhD
Tanya H. Hess, PhD
Discussant
Carol Falender, PhD
Edward P. Shafranske, PhD
31
SUNDAY, AUGUST 9th
Schema Therapy for BPD Breakthrough: Treatment for
Improving Life Functioning (Symposium)
9:00 AM – 10:50 AM
Metro Toronto Convention Centre
Meeting Room 712
Chair: Joan M. Farrell, PhD
Participant/1stAuthor
Arnoud Arntz, PhD
George Lockwood, PhD
Ida A. Shaw, MA
Michael Webber, MD
Discussant
Jeffrey Young, PhD
29
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EARLY CAREER
Building a Private Practice by Being Public:
From Social Networking Circles to Psychotherapy Groups
Renee Hoekstra, Psy.D., Private Practice, Boston, MA
It Starts with was in this situation? Was anyone start-
Your Strengths ing his or her own practice? Who else
What now? My post- wanted their own practice, but felt as if
doc had ended, I had they had no idea where to go? And who
no job, and I had lived else has been successful in starting a
in four different states practice and would be willing to let me
in order to complete pick their brain?
a master’s degree, a
doctorate degree, a pre-doctoral intern- Inspiration from Revolve Nation’s
ship, and a post-doctoral fellowship. To Boston Entrepreneur Group
this end I found myself living in Boston Two weeks after I passed the Examina-
with a determination to get licensed and tion for Professional Practice in Psychol-
to stop moving across the universe. I ogy (EPPP), I went to a meetup group
wasn’t looking for the 9-5 grind, I for entrepreneurs. It was the business-
wanted autonomy and creativity in my networking world that I knew nothing
clinical work, and I wanted to earn rea- about, and I went not only for the social-
sonable money. I had heard enough peo- izing, but also because I was thinking
ple complain about poor starting about selling my watercolor artwork. I
salaries in hospital positions. I was not was gently encouraged to come back. I
interested in the responsibilities in- started to think about the possibility of
volved in administration or supervision, business networking, which led to more
and I wanted the majority of my work ideas about starting my practice, which
to be direct clinical services. The one led to ideas about networking with
thing that I wanted to do for sure was to healthcare providers, which led to
lead psychotherapy groups. the current brainstorms and flurry of
activity that followed over the last year.
Shortly after obtaining my license, I took
I started joining list-serves and looking
out a calculator and figured that I could
for books and articles about starting a
make more than my post-doc salary if I
practice. I dug up my psychology of busi-
conducted two psychotherapy groups a
ness class material and started poring
week. The question was: Given that I
through it. I tentatively proposed a study
knew nothing about running my own
group on various list-serves, which led to
practice or being in business for myself,
meeting other psychologists. I selected a
how exactly was this going to happen?
book: Financial Success in Mental Health
Practice (Walfish & Barnett, 2009) and
Despite being here for one post-doctor-
proposed to the online community a
ate year, I still barely knew anyone in
study group with weekly meetings to
Boston; let alone how to get from Ja-
read, discuss, and plan assignments that
maica Plain to Somerville without a
moved people in the direction of their
GPS! I needed a job, a professional com-
own practice. I established a mission for
munity, and an opportunity to connect
the study group:
and establish myself as a professional.
Boston was a huge city with many re- • To help early career psychologists
cent transplants. I wondered: Who else continued on page 34
33
build and establish their own private I continued to attend the weekly meet-
practices up groups hosted by the entrepreneurial
• To learn together the relevant aspects law firm—the first to not bill by the
of the business of psychology hour. They served wine and cheese and
• To decrease our vulnerability to pub- were attended by a range of business
lic and private organizations inter- professionals ranging from CEO’s to in-
ested in hiring psychologists terested college students. People there
provided a sense of business-minded
• To decrease our vulnerability to poor
mentorship and had a plethora of re-
pay
sources I wouldn’t have known where
• To establish and generate goals and to find elsewhere. I met someone who
strengths, and to be able to utilize agreed to help me with a business plan.
these in a marketable way I started to think seriously about my el-
• To develop peer consultation, net- evator speech and the audience of non-
working groups, and the support and mental health professionals. I started to
resources of other early career psy- listen to advice and feedback about mar-
chologists keting and business.
• To locate available resources when
we lack answers or have further I also decided to host an EPPP forum for
questions post-docs. I rounded up recently li-
censed psychologists to talk about the li-
I posted my mission on various list-serves censure application process, studying
and started to establish a following. for the EPPP, and the jurisprudence
The authors of Financial Success in Men- exam. My state association offered office
tal Health Practice contacted me and of- space, and the rest was a matter of tap-
fered to answer questions via e-mail ping the relevant list-serves. I e-mailed
between our study groups. I began cre- all of the post-doctoral training directors
ating assignments, such as developing listed on my state association website, as
mission statements for our practices, well as the EPPP and early career list-
working on website and marketing serves. This was popular. I felt as if I had
plans, and generating and finding re- found an unmet need in the community
sources for ourselves. and had been able to reach that need. I
started to think about this as an experi-
Fits and Starts mental step in marketing, and I felt like
Despite my involvement with the it was an additional way of being con-
worthwhile early career activities above, nected to early career psychologists.
I still did not have a job. I had been inter-
viewing intermittently while studying My business of psychology class profes-
for licensure, but nothing yet had come sor had done something clever that I at-
to fruition. However, accessing re- tempted to replicate: she brought in
sources, talking to psychologists, and business-related persons to our class.
reading the list-serves provided me with This not only allowed them to market
important insight during my job search. their services, but also allowed her to
For example, I had a firm grasp on the maintain her relationships with the busi-
pros and cons of joining group practices. ness community. I started to think about
One narrative stood out to me- psychol- the various business-related persons
ogists in group practices were losing who might be interested in fulfilling a
money that they could be retaining if on need for early career psychologists, and
their own. Thus, I started calculating the I started to put together workshops for
costs of starting out on my own and the
possible means to achieve this end. continued on page 35
34
early career and private practice-inter- both formal and informal. I met people
ested psychologists. Early in my en- who were a few years down the road
deavors, I was contacted by another from me and found out what they were
early career psychologist and encour- doing and how they were doing it. Peo-
aged to apply for the early career schol- ple started asking me about taking on
arship to attend the American different leadership roles. People started
Psychological Association (APA) Lead- to e-mail me and ask about job leads and
ership Convention. My state association other resources. I reflect back on the ad-
nominated me to the Early Career Psy- vice of a psychologist I met in graduate
chologist Committee and I was granted school, who stated that she made the ef-
the scholarship. fort to meet someone connected to the
field of psychology for lunch at least
Connecting and Including once a week.
Community
I wanted to continue to give people a I was licensed in October of last year. I
chance to socialize and network, and I had a few false starts with jobs, but
continued to have an interest in connect- found office space to sublet and got my
ing recent post-doctoral transplants who website up by April of this year. I was
had similar confusion about driving offered a job in a group practice in a dif-
around the Boston-cow-paths-turned- ferent geographical area than my own
into-roads. My many transitions to get practice. The offer came from someone
through graduate school had left with who was clearly impressed with my
me several family-less holidays, and I early career endeavors and receptive to
often thought about hosting Thanksgiv- the idea of starting on my own at the
ing dinner for all the family-less post- same time.
docs and interns.
Practical Aspects
I started to host social hours, which pro- I found someone to develop my website
vided the opportunity for psychologists for a very reasonable rate. I found out
who were not interested in clinical work how easy it was to sublet office space for
or private practice to connect and join. a few hours a week. I found a business
Through my social networking I found planner who got me started with finan-
someone with a space big enough to cial bookkeeping software and devel-
host potlucks. I was also contacted by oped my own personal profit and loss
senior psychologists, people interested statement. I solicited feedback about my
in hiring psychologists, and persons in- website from various parties before
terested in mentorship. I was offered a going live, and I created my own art-
job shortly after hosting a social hour. I work to communicate my interest in
also offered to cross post job offers to dif- psychotherapy groups. I distributed var-
ferent list-serves and connect job-seekers ious mailings and found ways in which
with job-finders. people advertise services in the Boston
area. I tried to meet people for lunch
Through all my efforts, I have been im- whenever possible. I contacted people
mensely rewarded and enriched in a va- providing Dialectical Behavioral Ther-
riety of ways that I never anticipated at apy (DBT), as well as group psychother-
the outset. The more I offered to host ac- apy, and I joined the Northeast Society
tivities and spread the word, the more I Group Psychotherapy and presented at
was put into contact with persons who their conference. I signed up to teach a
could help me build my practice. People class through the Boston community
became interested in me and my pur-
suits. I found a diverse array of mentors, continued on page 36
35
college for adult education. not going to stop the social networking
anytime soon. I’m getting around
A Lot of Work Boston and I’m meeting people, and I
Like starting groups in private practice, feel more connected than I did before. I
starting the early career efforts wasn’t al- know people who work with autistic
ways easy. Some things were not always spectrum disorders, provide group ther-
well attended, but I continue to commit apy for substance abuse, work with deaf
to doing them and meet new people children, and specialize in medical hyp-
every time I host an event. I get what I nosis and sexual pain disorders. And the
can out of what I do and continue to go best part is that I could probably find a
from there. referral for a specific concern if I did a
little searching.
The client referrals are starting to trickle
in. My business planner tells me that 4-
I’m having fun being the center of all the
5 phone calls a week is good news for
attention. The good news is that there is
someone just starting out. I get impa-
always room for entrepreneurship and
tient, but people say that all my work
creativity, and if people are willing to in-
will pay off shortly. Someone recently
vest the energy they can create their own
was incredulous that I actually thought
early career networking circles. I did. I’m
I might not get referrals. I panic some-
making this up as I go along, and this is
times at the thought of getting flooded,
my story of what’s happened as a result.
and people say that private practice has
And I’m certainly receptive to a helping
its ebbs and flows. I’ve almost got
hand if a helping hand shows up.
enough people to start a DBT group, and
I’m starting to get inquiries about indi-
I believe that if nothing else, Boston
vidual clients. I’ve got a mixed bag with
early career psychologists should have
the insurance: I’m not able to take it be-
the opportunity to socialize and net-
cause most insurance companies dis-
work from time to time. I’m currently
criminate against recently licensed
working on establishing a “Welcome to
psychologists. Although there is some
Boston” social hour for incoming psy-
room for negotiation, I’ve gotten a wide
chology interns and post-docs in Sep-
range of feedback and perspectives from
tember of 2009. If you’ve never been
private practice individuals who both
here, I’ll teach you how to say things like
endorse and hate insurance companies.
“pahk” and “nor’easter” and tell you
It’s a lot to think about. But I’ve worked
about the pros and cons of buying a
very hard to get to where I am today and
GPS. If interested in this or any of my
am determined to generate revenue that
other endeavors, you can check out my
reflects that.
website at www.bostondbtgroups.com
A Ways to Go or get in touch with me at Renee_Hoek-
While I haven’t yet climbed the ladder stra@yahoo.com.
to financial freedom (although I’ve cer-
tainly met my share of financial plan- (References available on-line.)
ners!), the groundwork is being laid. I’m
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FEATURE
2009 Presidential Summit on the Future of Psychology
Practice: Collaborating for Change
James H. Bray, APA President,
Department of Family &
Community Medicine Baylor
College of Medicine
Carol Goodheart, APA President-
Elect, Independent Practice,
Princeton, New Jersey
Margaret Heldring, Independent
Practice, Seattle, Washington
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Come join Drs. Lynne Angus, Judith Beck, Beverly Greene, Leslie
Greenberg, Nadine Kaslow, Arthur Nezu, and others for lunch and
conversation. We will also host a book raffle and early career focus
group to determine the needs of our early career constituents.
No RSVP needed, but please feel free to contact Dr. Michael J. Constantino
(mconstantino@psych.umass.edu) for additional information.
Come find out more about Division 29 and invite others to join!
40
FEATURE
Ethics and the Interrogation of Prisoners
Norman Abeles, Ph.D., Michigan State University
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FEATURE
Psychotherapeutic Treatment Implications for
Obese Adolescents
Dena F. Miller, M.A., University of Denver,
Graduate School of Professional Psychology
Headlines regularly mental consequences for youths. Ado-
highlight the dramatic lescence is an often anxiety-producing
rise in the rate of developmental stage where peer pres-
childhood obesity. sure and psychosocial stressors abound.
Photographs of 300 Teens who are overweight are at addi-
pound teenagers ac- tional risk for weight-related teasing,
company headlines body dissatisfaction, low self-esteem,
like, “Into the Mouths depression, anxiety, and suicidal
of Babes: Childhood Obesity” in the New ideation (Fulkerson, Strauss, Neumark-
York Times (Zeller, 2007), “Dear Parents: Sztainer, Story, & Boutelle, 2007).
Your Child Is Fat” in Time Magazine
(Losh, 2008), and, “It’s not baby fat: There is a clear need for effective psy-
Among 4-year-olds, nearly 1 in 5 is chotherapeutic treatments for childhood
obese” on CNN (Park, 2009). These and adolescent obesity. Numerous med-
catchy headlines point to the perceived ical treatments including drug therapy
severity and prevalence of childhood and surgical interventions exist to treat
obesity in the United States. obesity, yet “successful [psychothera-
peutic] treatments for obesity have been
Obesity is diagnosed when a child’s elusive” (Stice, Shaw, & Marti, 2006, p.
Body Mass Index (BMI) is at or above the 667). This article outlines psychotherapy
85th percentile for their age. According to interventions to address the treatment of
the American Heart Association (AHA; obese adolescents. Family-based inter-
2009), 23.4 million children between the ventions, cognitive behavioral therapy,
ages two to nineteen are overweight and and motivational interviewing modali-
obese. Approximately 8-13% of ties will be discussed.
preschoolers and between 13% and 22% There are numerous obstacles to treating
of children and adolescents are now con- adolescents who are obese. Weight gain
sidered overweight, and an additional is common and difficulty can be disap-
31% are at risk for becoming obese pointing for counselors and therapists.
(AHA, 2009; Powell, Calvin, & Calvin, Mental health providers often assume
2007). The consequences for children and that obesity can only be treated med-
adolescents who are obese can be signif- ically, rather than behaviorally. Other cli-
icant and lasting, including an increased nicians too readily accept that genetic
risk for numerous health problems such blueprints for obesity preclude effective
as coronary heart disease, type II dia- nutritional and behavioral treatments
betes, cancer, and hypertension (Stice, (Panzer, 2006). Despite these challenges,
Prensell, Shaw, & Rohde, 2005). it is the responsibility of mental health
providers to learn and develop interven-
Increasingly described as a global epi- tions to help obese teenagers who are
demic (Powell et al., 2007), obesity can clearly at risk and in need of services.
result not only in severe physical health
problems, but has significant negative Because obesity tends to run in families,
psychosocial, emotional, and develop- continued on page 51
50
researchers have developed family- should focus on both behavior change
based interventions, targeting eating be- and parental and teen skill develop-
havior and activity change in the ment, as well as increasing healthy eat-
children and their parents (Epstein, ing behavior with an emphasis on
Paluch, Roemmich, & Beecher, 2007). mealtime strategies and incorporating
This model includes teaching parents be- positive family support.
havioral skills to facilitate change in their
teenagers. The therapy focus is on be- Cognitive behavior therapy (CBT) is an
havioral interventions including ad- evidence-based treatment modality de-
dressing poor parental modeling and signed to address the negative psycho-
support for overeating and under exer- logical effects of obesity. One study
cising. A primary goal of family-based outlines a CBT model that incorporates
interventions is to mobilize family re- psychoeducation, diet change, and in-
sources to support the teen’s healthy eat- creasing physical activity into therapy
ing as well as increased physical activity (Panzer, 2006). The treatment protocol
level. At least one parent is asked to take states that, “Sessions should include
an active role in the intervention. Treat- weighing the child…reviewing food and
ment typically lasts 16 weeks to 8 activity charts… providing positive re-
months and includes follow-up periods inforcement, exploring and addressing
of at least one year with “booster” ses- various forms of nonadherence or resist-
sions to help children maintain both ance, assigning cogent homework tasks,
healthy eating behavior and physical ac- summarizing the interview, and plan-
tivity (Epstein et al., 2007). The length of ning for the next visit (Panzer, 2006, p.
treatment varies based on the family, and 540).”
the level of severity of the adolescent’s
CBT uses behavior modification to help
obesity. Some studies have taken into
adolescents achieve diet and exercise
consideration different levels or severity
goals in treatment. Sessions begin with
of obesity (Panzer, 2006; White, 1986)
introducing and refining specific strate-
given that White (1986) found, “the more
gies and using psychoeducation to teach
obese the child, the greater the psycho-
adolescents about obesity. Identifying
logical consequences” (p. 263).
and recognizing cognitive patterns
In addition to behavioral interventions, within the family is important, along
other family-based treatment models with identifying negativistic and dichoto-
focus on the family environment and ac- mous thinking and overgeneralizations.
tivities, such as mealtimes. Fulkerson et Other cognitive techniques such as re-
al. (2007) found that making family framing can be useful for teaching ado-
meals a priority and having a positive lescents coping skills to manage feelings
mealtime environment were positively of hunger and body image concerns. CBT
associated with psychological well is a structured psychotherapy model de-
being and inversely associated with de- signed to help teenagers change un-
pressive symptoms and unhealthy healthy eating behavior through
weight-control behaviors in adolescents. identifying and challenging their dys-
Indicators of poor psychological health functional thoughts and behaviors. Help-
included family members teasing teens ing teens identify and then change their
about their weight and parental encour- dysfunctional thoughts about eating, and
agement to diet; such teasing was negative thoughts about themselves can
strongly correlated with negative psy- significantly increase self-esteem, as well
chosocial outcomes (Fulkerson et al., as create positive and lasting healthy
2007). These findings indicate that fam- lifestyle changes.
ily-based psychotherapy interventions continued on page 52
51
Motivational interviewing (MI) is an- associated with less body dissatisfaction
other therapeutic technique that has been for certain ethnic minority groups (Stice
used to treat obesity (Carels et al., 2007). et al., 2006). In addition to race and eth-
MI was designed to enhance motivation nicity, age and development may impact
and decrease ambivalence toward behav- psychotherapeutic outcomes for obese
ior change (Miller & Rollnick, 2002). Al- teenagers. For example, an insightful
though MI was originally developed to and mature 17-year-old may be more
treat addictions, it is increasingly being successful using a CBT perspective,
used in psychotherapy to motivate ado- while a younger child may benefit from
lescents who are resistant to treatment more parental guidance and support
and to enhance health behaviors. A recent using a family-based approach.
study integrated MI into a behavioral
weight loss intervention (Carels et al., Socioeconomic status and gender also ef-
2007). When poor progress toward fect treatment outcomes. Children who
weight loss goals was detected, MI was live in single-parent homes, for example,
used to enhance motivation. Findings may not have a parent who can commit
showed that participants lost more to an intensive family-based intervention.
weight and engaged in greater weekly Psychotherapists should be sensitive to
exercise when MI was used. Using MI these important potential barriers to chil-
alone, or in conjunction with other psy- dren’s success in therapy. Gender is an-
chotherapy techniques may help moti- other important consideration for the
vate teens to decrease sedentary behavior treatment of obesity. One study found
and increase both healthy eating and ex- that, “sex differences may exist in vulner-
ercise and physical activity. ability to weight stigma in youths” (Puhl
& Latner, 2007). For example girls tend to
In addition to outlining effective psy- engage in relational aggression more fre-
chotherapeutic treatment interventions quently than boys (Simmons, 2002), and
for obese teenagers, previous research may be at higher risk for being teased
emphasizes the importance of consider- and becoming depressed.
ing adolescents’ demographic character-
istics in treatment. Race/ethnicity, age, The medical and mental health risks for
gender, and socioeconomic status, all ef- teenagers who are obese are great. Not
fect adolescents’ presentation in therapy, only does obesity increase the probabil-
and are especially important when treat- ity that these teens will face future med-
ing obese teenagers. Latino and Black ical complications and chronic health
adolescents are more likely to be obese conditions, but the psychological, social,
(Stice, Shaw, & Marti, 2006), and over and developmental repercussions of
one third of Latino and Black children obesity cannot be ignored. Mental health
ages 2-19 are considered obese (AHA, providers can make a difference in the
2009). This suggests that interventions childhood obesity epidemic by helping
targeting these high-risk youths may be adolescents develop new behaviors and
more effective because there is a greater skills and ultimately lead healthier lives.
opportunity to show a prevention effect.
However, obesity is less stigmatized and (References available on-line.)
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CONGRATULATIONS TO DIVISION 29
IMMEDIATE PAST PRESIDENT
JEFFREY E. BARNETT, PSY.D., ABPP
APA Award for Distinguished Professional
Contributions to Independent Practice
The Complete Practitioner: Still a Work in Progress
Friday, August 7, 2009 from 11:00 am – 11:50 am,
at the Convention Center, South Building, Meeting Room 703
The APA/APF Award Ceremony Friday from 4:00 pm – 5:50 pm
in the Fairmont Royal York Hotel (room to be announced)
BRIEF BIO— Jeffrey E. Barnett, Psy.D., ABPP received his doctorate from the
Ferkauf Graduate School of Yeshiva University in 1984. He is a licensed psychol-
ogist in independent practice in Arnold, Maryland where he provides psychother-
apy and comprehensive psychological evaluations, primarily for children and
adolescents. He is Professor on the faculty of Loyola College of Maryland. He is
a Diplomate of the American Board of Professional Psychology in Clinical Psy-
chology and in Clinical Child and Adolescent Psychology and a Distinguished
Practitioner of the National Academies of Practice. He is a Fellow in seven APA
Divisions.
53
CALL FOR FELLOWSHIP APPLICATIONS
DIVISION 29—PSYCHOTHERAPY
Jeff Hayes, Chair, Fellows Committee
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O
N O F P S Y C H O THE THE DIVISION OF PSYCHOTHERAPY
RA P Y
D I V I SI
The only APA division solely dedicated to advancing psychotherapy
29
M EM BE R SH I P APPLICATION
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N PSYCHOLOGI C 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
Psychological Association (APA), APA membership is not required for membership in the Division.
JOIN DIVISION 29 AND GET THESE BENEFITS!
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articles on psychotherapy. Contributors History of Psychotherapy book, and
include researchers, practitioners, and Psychotherapy Relationships that Work.
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