Psychotherapy: Theory, Research, Practice, Training Copyright 2007 by the American Psychological Association

2007, Vol. 44, No. 4, 378 –383 0033-3204/07/$12.00 DOI: 10.1037/0033-3204.44.4.378

PSYCHOTHERAPY TRAINING: SUGGESTIONS FOR CORE

INGREDIENTS AND FUTURE RESEARCH

JAMES F. BOSWELL AND LOUIS G. CASTONGUAY

The Pennsylvania State University
Despite our considerable depth and (Norcross, 2002) and for principles of change
breadth of empirical knowledge on psy- (e.g., Castonguay & Beutler, 2006). In addition,
chotherapy process and outcome, re- there has been a push for psychotherapists to
demonstrate the effectiveness of their practice,
search on psychotherapy training is predominately from external sources (e.g., man-
somewhat lacking. We would argue, how- aged care companies). At the very least, these are
ever, that the scientist–practitioner model important shifts in the way that we understand
should not only guide practice, but also and approach the practice of psychotherapy.
the way our field approaches training. In The variety and sheer number of evidence-
this paper we outline our perspective on based guidelines that are now available to thera-
the crucial elements of psychotherapy pists reflects the vitality and, in many respects,
the clinical relevance of more than 50 years of
training based on available evidence, psychotherapy process and outcome research (see
theory, and clinical experience, focusing Lambert, 2007). In contrast with this wealth of
specifically on the structure, key compo- information, there is an unfortunate paucity of
nents, and important skills to be learned empirical knowledge with regard to psychother-
in a successful training program. In addi- apy training. Although we agree that the practice
tion, we derive specific research direc- of psychotherapy should be informed, at least in
tions based on the crucial elements of part, by empirically derived interventions and
guidelines, we also believe that this should be the
our proposed training perspective, and case for psychotherapy training. The scientist–
offer general considerations for research practitioner model, in other words, should not
on training, including method and mea- only guide our practice—it should also be man-
surement issues. ifested in the way that we approach training. As
such, we need to anchor, as much as it is possible,
Keywords: psychotherapy, training, our training efforts on empirical evidence, and to
change principles conduct much needed research on the most effec-
tive ways to train therapists.
In the first section of this paper, we begin to
In recent years, a tremendous amount of atten- address these questions by outlining what we
tion has been paid to the relevance and impor- consider to be an effective perspective on psy-
tance of evidence-based practices. Although the chotherapy training. We believe that a successful
focus has largely been on providing evidence to training program should adhere to a coherent
support particular treatment approaches for spe- structure as well as emphasize specific compo-
cific disorders (Chambless & Ollendick, 2001), nents and foster certain skills. The perspective
research support has also been delineated for presented below is derived from the empirical
processes related to the therapeutic relationship literature as well as clinical and training experi-
ence. However, the actual impact of these ele-
ments on the competency of a psychotherapy
James F. Boswell and Louis G. Castonguay, Department of
trainee, and ultimately the individuals he or she
Psychology, The Pennsylvania State University.
Correspondence regarding this article should be addressed
treats, remains unclear. Consequently, our focus
to James F. Boswell, Department of Psychology, The Penn- in the second section will shift toward delineating
sylvania State University, 132 Moore Building, University what we believe to be important directions for
Park, PA 16802. E-mail: [email protected] research on psychotherapy training.

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 Special Section: Research in Psychotherapy Training

Structure of Training Programs Integration. In this final stage, trainees

would be encouraged to revise the constructs and
Phases of Training treatment methods learned during previous
We believe that optimally, psychotherapy phases by integrating contributions from other
training should be conducted within a systematic, orientations. Because evidence has shown that
organized, cohesive, and flexible program, which one treatment model cannot claim superiority
is most likely to involve a series of sequential over another across a variety of clinical problems
stages or phases. An example of such a proposed (Luborsky, Singer, & Luborsky, 1975; Wampold
developmental perspective (described in more et al., 1997), the limitations of one’s model of
detail in Castonguay, 2000), includes five phases choice should be recognized and interventions
of training: preparation, exploration, identifica- that are specific to an alternative treatment model
tion, consolidation, and integration. should be considered with particular clients to
Preparation. In this initial stage of training, better facilitate change, that is, a trainee who
students would begin to learn basic clinical and previously identified him or herself as a CBT
therapist would be encouraged to integrate within
interpersonal skills in an effort to socialize them
his or her technical repertoire humanistic tech-
to the therapeutic encounter.
niques to repair alliance ruptures.
Exploration. In this second stage, trainees
would be given the opportunity to apply treat-
ment protocols associated with each of the major A Focus on Change Principles
orientations; for example, the implementation of
We also argue that training programs are likely
short-term dynamic therapy (e.g., Strupp & to be more cohesive and lead to broader clinical
Binder, 1984) or cognitive– behavioral therapy skills if their primary focus is on general princi-
(CBT) for posttraumatic stress disorder (e.g., Foa ples or models of change (e.g., Castonguay &
& Rothbaum, 1998). Beutler, 2006; Hill, 2004), as opposed to a list of
Identification. After exploration, students variables or a series of empirically supported
would be encouraged to commit themselves, at treatment (EST) manuals alone. A focus on prin-
least temporarily, to one particular orientation. ciples of change, such as those described by
Students would begin by fully immersing them- Goldfried (1980; e.g., providing a new perspec-
selves in the theoretical assumptions of a partic- tive of self, facilitating corrective experience,
ular model (e.g., emotion-focused psychotherapy fostering continued reality testing), allows train-
or CBT), gaining intensive and systematic expe- ees to become aware, especially at an early phase
rience in the specific interventions prescribed by of their training (i.e., exploration), that various
this approach, and seeking in-depth knowledge of types of technique associated with divergent the-
the empirical literature supporting its process and oretical approaches can serve similar therapeutic
outcome. The rationale for this is to allow stu- functions. Focusing on principles of change dur-
dents to develop extensive competencies in think- ing the middle phase of their training (i.e., iden-
ing about and conducting therapy within one co- tification and consolidation) would help thera-
hesive framework. We believe that every major pists to fully master a variety of interventions that
approach to psychotherapy is conceptually and have been developed within one particular orien-
clinically complex, and although it is important tation to foster these global therapeutic functions.
that students be exposed to a number of ap- Once identified as a CBT therapist, for example,
proaches, we are convinced that the optimal way a trainee’s primary goal would be to achieve
to learn how to develop adequate case formula- competence in the use of cognitive techniques to
tion and treatment planning skills (at least early foster a new understanding of self, exposure in-
in a career) is to know one system well, rather terventions to facilitate corrective experiences,
than knowing a little bit about a variety of orien- and relapse prevention procedures to foster con-
tations. tinued reality testing.
Consolidation. In this stage, trainees would At the integration phase, the focus on change
expand the knowledge they have acquired during principles would allow one to enhance his or her
the identification stage to a variety of clinical clinical repertoire by incorporating interventions
roles and settings (e.g., couples or group ther- from other theoretical orientations that serve the
apy). same therapeutic function. For example, a CBT

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Boswell and Castonguay

therapist might find it beneficial to incorporate a to specialized training from those individuals
humanistic intervention such as empathic reflec- who have had a substantial impact on the field’s
tion to promote a new view of self when cogni- clinical practice (e.g., Lorna Benjamin, Marvin
tive restructuring appears to be less helpful or Goldfried, Leslie Greenberg, Hanna Levenson,
contraindicated for a particular client (see Marsha Linehan, and Jeremy Safran).
Castonguay, 2000; Goldfried & Castonguay,
1993). As such, these general principles would Important Components of a Training
actually guide the treatments and interventions Program
one chooses to emphasize based on the stage
and/or preference of the individual program or In addition to the general structural points out-
trainee. In other words, a focus on principles lined above, we believe that a successful psycho-
should always be contextualized within the train- therapy training program should include the fol-
ee’s needs and level of experience. lowing components: (a) exposure to classical
works in psychotherapy and behavior change
Supervision (e.g., Bandura, Freud, and Rogers), (b) exposure
to both applied (i.e., process and outcome) and
Key in one’s learning of therapeutic skills is basic (e.g., social, developmental, cognitive psy-
the supervision he or she receives. Considering chology) research, (c) experiential forms of train-
the complexity of psychotherapy, optimal train- ing such as self-exposure to feared objects or
ing requires, in our opinion, a variety of supervi- situations (Freeston, Cromarty, & Thwaites,
sors who can provide multiple areas of expertise, 2006), rather than a purely didactic focus, (d) the
a substantial level of experience, as well as a systematic encouragement of self-reflection
good dose of clinical insight and wisdom. To (Bennett-Levy, 2006), and (e) an emphasis on
maximize the probability of covering such multicultural competence throughout (including
breadth and depth of competence, we believe that both awareness and practice). The importance of
therapists’ in-training should receive supervision experiential forms of training and an emphasis on
from at least three sources: multicultural competence are further addressed in
Faculty members. In most clinical and coun- the later section on future research.
seling psychology programs, tenure-track faculty
have up-to-date empirical and theoretical exper- Therapeutic Skills to Be Fostered in Training
tise in particular aspects of etiology, assessment, Programs
and/or the treatment of psychological disorders.
Such expertise is likely to provide trainees with Along with the particular components pro-
useful knowledge for case formulation and treat- posed above, we argue that certain therapeutic
ment planning. In addition, we would argue that skills should be fostered throughout the course of
the opportunity for psychotherapists in-training one’s training. For example, in line with the epis-
to be supervised by faculty members is likely to temological assumptions underlying cognitive–
foster greater consistency across coursework, re- behavioral therapy, we believe that therapists
search and clinical training. should be trained in mastering relationship and
Full-time practice therapists. Although fac- technical skills that have received empirical sup-
ulty members teach and often write about clini- port (Castonguay & Beutler, 2006). Also conso-
cally relevant issues, they tend not to see a large nant with the same epistemological assumptions,
number of clients— even when they keep a inde- we think that therapists should be trained to ap-
pendent practice. Because full-time clinicians proach clinical reality as a scientist where one is
tend to work with a wide variety of clients and constantly generating and testing hypotheses
clinical problems in their day-to-day practice, about the causes of client difficulties as well as
involving them in graduate training is likely to the processes likely to facilitate his or her change
provide trainees with rich information about (i.e., Mahoney, 1976).
“what to do,” as well as “when and how to do it” Further reflecting our own cognitive–
in therapy. behavioral leanings, we would argue that all ther-
Expert therapists. In addition, we suggest apists in-training, irrespective of their theoretical
that it would be important, when possible, for preferences, are likely to improve their case for-
trainees to be exposed (via videos and seminars) mulations and treatment plans by learning how to

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implement a functional analysis of client behav- many approaches to psychotherapy during the
iors (Goldfried & Davison, 1976). Furthermore, course of one’s graduate training.
we believe that therapists’ in-training should pay In addition, we assume that the focus of train-
attention to two overarching goals of psychother- ing should be on general principles or models of
apy: (a) decreasing clients’ level of distress and change (Castonguay & Beutler, 2006; Hill,
impairment and, (b) helping clients to develop 2004). One way of testing the validity of this
coping skills that can be used to increase the assumption would be to assess whether a
efficiency of treatment and facilitate relapse pre- principle-based training would lead to more ef-
vention (i.e., skills that can help the client to fective and comprehensive practice than a sole
become his or her own therapist). Although the focus on EST manuals. In addition, we posit that
focus on these specific dimensions of client func- trainees would optimally benefit by receiving su-
tioning can be viewed as hallmarks of CBT (see pervision from multiple sources, or supervisors
Castonguay, 2005), the fostering of such pro- with different types of professional emphases
cesses of change is likely to require the use of (e.g., tenure track faculty, full-time practitioners,
procedures and interventions associated with di- etc.); a key element of this assumption is that
vergent theoretical orientations (see Castonguay, each source of supervision can provide a slightly
2000; Goldfried & Castonguay, 1993). different, yet complementary, perspective on
clinical phenomena (e.g., case conceptualization,
treatment planning, and psychotherapy process
Future Directions for Research on Training and outcome). An important question that
emerges from this hypothesis is whether students
In the first section, we offered a brief descrip-
actually experience these multiple sources of su-
tion of what we believe to be the structure, train-
pervision (provided by individuals with different
ing components, and skills to be emphasized in a
professional emphases) differently, and if so,
successful psychotherapy training program. Al-
does this multifaceted system relate to greater
though these suggestions are based, at least in
breadth and depth in the development of clinical
part, on evidence taken from the literature, each
knowledge and skills?
of the proposed elements remains to be formally
We also assume that it is important to include
tested. In this section, we would like to offer
an experiential component throughout the course
some specific directions for future research on
of one’s training, rather than relying mostly on a
psychotherapy training. Some of these directions
didactic modality. It is our experience, for exam-
are derived directly from the specific components
ple, that many trainees perceive cognitive inter-
of training discussed above, and others focus on
vention strategies, such as cognitive restructur-
more general considerations related to effective
ing, as relatively straightforward and simplistic
and comprehensive training.
when presented in a textbook or during a practi-
cum lecture. However, it is also our experience
Specific Directions for Future Research on that these same trainees quickly recognize the
Training difficulty and complexity of utilizing these inter-
vention strategies once in the therapy room with
Among the empirical questions that emerge a client. Although we assume that an experiential
from the training components highlighted above, component to training would be beneficial to
is whether or not a formal training structure or one’s training, regardless of the specific interven-
framework can enhance the acquisition of thera- tion or approach, it remains to be tested that
peutic skills. It would be interesting to determine, trainees would become more efficient in practic-
for example, if a training model guided by devel- ing CBT if they learned how to apply cognitive
opmental phases would produce better training restructuring techniques via self-exposure (e.g.,
outcomes than a “training as usual” model, where role plays with peers and supervisors; see
students typically choose to take a practicum Freeston et al., 2006) to their own distorted think-
course in a particular year based on personal ing styles and core beliefs.
preference and availability of supervisors. We In addition, although the topic of multicultural
would predict that the former would lead to a competence continues to receive greater attention
more comprehensive repertoire of skills, as it is in the field of psychotherapy, there is very little
more likely to provide a systematic exposure to evidence to inform us as to how training in mul-

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ticultural competence can be conducted most ef- of what is meant by multiple levels of investiga-
fectively in graduate training. Given the variabil- tion, one might study the training of specified
ity in exposure to diverse populations, one treatments and/or techniques within a single
important question that should be the focus of training site, while another study might directly
future research is whether a multicultural training compare the same training strategies across or
emphasis that is mostly didactic leads to different between training sites.
outcomes than a training program that does have The research directions that have been pro-
direct access to the treatment of diverse popula- posed so far in this paper have mostly focused on
tions? the independent variables to be manipulated and
We would also like to suggest a number of investigated, such as the type of training frame-
research ideas that are less directly related to the work, specific components of training (e.g., di-
components of training identified in the first sec- dactic vs. experiential), and the form of supervi-
tion of this paper. For example, considering that sion one receives. However, as a field, it will be
the majority of clinicians end up defining them- crucial to also direct our attention toward identi-
selves as integrative therapists (Orlinsky & fying the pertinent dependent variables in train-
Rønnestad, 2005), it seems important to deter- ing research (e.g., skill acquisition, trainee self-
mine whether it is best to train graduate student confidence, client outcomes, etc.). In other words,
therapists within an integrative model(s) from the we need to place more emphasis on what it is we
beginning of their training, or whether they want to change, and how we intend to measure
should first be trained competently in one (or change.
perhaps two) approach(es) and then be encour- In addition to the delineation of important in-
aged to master systematic ways to integrate dif- dependent and dependent variables, it will also be
ferent orientations later in their professional important, as a field, to reach some agreement on
training and development (see Castonguay, 2005; the proper methods of investigation, including
Consoli & Jester, 2005). clinically reliable and valid measurement. As
Finally, evidence has emerged that strongly noted above, multiple levels of investigation are
suggests that receiving direct and consistent feed- likely to also require multiple methods, such as
back on client progress can enhance psychother- the use of both qualitative and quantitative re-
apy outcomes, at least for experienced therapists search designs within and between training sites,
(Lambert, 2007). However, feedback during where each method can contribute to an accumu-
training is typically limited to what is provided lating body of knowledge. Although the call for
by one’s supervisor, and even when comprehen- investigations utilizing between-site randomiza-
sive, this information may not serve the same tion may at first appear daunting, particularly
function as other sources of feedback (e.g., client when the focus is on client outcomes, we believe
self-report measures of process and outcome). As that it can provide clinically relevant information.
such, we are inclined to think that it would be In addition, we would like to recommend that
important for trainees to receive feedback on research on training should be conducted in train-
client progress above and beyond what is typi- ing clinics. Although analogue studies provide a
cally provided in the context of supervision, and great source of knowledge, training research in
this additional feedback should result in im- naturalistic settings is likely to lead to more ex-
proved outcomes. ternally valid findings. Similar to studies con-
ducted with experienced therapists in their day-
General Issues for Consideration to-day practice, such “real world” studies do not
have to sacrifice internal validity (Borkovec &
A partial explanation for the paucity of exist- Castonguay, 1998). By conducting research on
ing research on training is the complexity in- training in the environment where students re-
volved in investigating the topic. Needles to say, ceive training, we will also go a long way toward
this reality is not likely to be sidestepped. Con- fostering therapists’ integration of the Boulder
sequently, we are perhaps better served if we model (Raimy, 1950) at the early, and most for-
recognize that research on training will require mative, stage of their career.
multiple levels of investigation in which each This training philosophy was cogently articu-
level of analysis can provide different, yet com- lated by Borkovec (2004) in a paper outlining his
plementary, types of information. As an example vision for psychotherapy training clinics func-

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tioning as a series of practice research networks. cally supported psychological interventions: Controver-
Using Borkovec’s proposed model, we can begin sies and evidence. Annual Review of Psychology, 52,
685–716.
to envision how this type of research might be CONSOLI, A. J., & JESTER, C. M. (2005). A model for
effectively conducted. For example, one crucial teaching psychotherapy integration through an integra-
element for consideration is the assessment of tive structure. Journal of Psychotherapy Integration, 15,
client outcomes across training sites. This would 358 –373.
be partially addressed through the establishment FOA, E. B., & ROTHBAUM, B. O. (1998). Treating the
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