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2006 VOLUME 41 NO. 2 B U L L E T I N Psychotherapy OFFICIAL PUBLICATION OF DIVISION 29 OF THE AMERICAN PSYCHOLOGICAL ASSOCIATION www.divisionofpsychotherapy.org O C A E In This Issue Psychotherapy Around the World: A Sampler Good Enough Science The Nature of Unified Clinical Science Informed Consent and the Psychotherapy Process

Spring 2006

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Page 1: Spring 2006

2006 VOLUME 41 NO. 2

BULLETIN

PsychotherapyOFFIC IAL PUBL ICAT ION OF D IV IS ION 29 OF THE

AMERICAN PSYCHOLOGICAL ASSOCIAT ION

www.divisionofpsychotherapy.org

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In This Issue

Psychotherapy Around the World:A Sampler

Good Enough Science

The Nature of Unified Clinical Science

Informed Consent and thePsychotherapy Process

Page 2: Spring 2006

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

President-electJean Carter, Ph.D.5225 Wisconsin Ave., N.W. #513Washington, DC 20015Ofc: 202-244-3505 E-Mail: [email protected]

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

TreasurerJan L. Culbertson, Ph.D., 2004-2006Child Study CenterUniversity of Oklahoma HealthSciences Center1100 NE 13th St Oklahoma City, OK 73117 Ofc: 405-271-6824, ext 45129 Fax: 405-271-8835 E-Mail: [email protected]

Past PresidentLeon VandeCreek, Ph.D.117 Health Sciences Bldg.School of Professional PsychologyWright State UniversityDayton, OH 45435Ofc: 937-775-4334 Fax: 937-775-4323E-Mail: [email protected]

Board of Directors Members-at-LargeJ. G. Benedict, Ph.D., 2006-20086444 East Hampden Ave., Ste DDenver, CO 80401Ofc: 303-753-9258,or 303-526-1101 Fax:303-753-6498E-Mail: [email protected]

James Bray, Ph.D., 2005-2007Dept of Family & Community Med Baylor College of Med 3701 Kirby Dr, 6th Fl Houston, TX 77098 Ofc: 713-798-7751 Fax: 713-798-7789 E-Mail: [email protected]

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

Charles Gelso, Ph.D., 2005-2006University of MarylandDept of PsychologyBiology-Psychology BuildingCollege Park, MD 20742-4411Ofc: 301-405-5909 Fax: 301-314-9566 E-Mail: [email protected]

Alice Rubenstein, Ed.D., 2004-2006The Park at Allens Creek160 Allens Creek RoadRochester, NY 14618Ofc: 585-271-5940 Fax: 585-271-3045E-Mail: [email protected]

Libby Nutt Williams, Ph.D., 2005-2007St. Mary’s College of Maryland18952 E. Fisher Rd.St. Mary’s City, MD 20686Ofc: 240-895-4467 Fax: 240-895-4436E-Mail: [email protected]

APA Council RepresentativesNorine G. Johnson, Ph.D., 2005-200713 Ashfield St.Roslindale, MA 02131 Ofc: 617-471-2268 Fax: 617-325-0225E-Mail: [email protected]

John C. Norcross, Ph.D., 2005-2007Department of PsychologyUniversity of ScrantonScranton, PA 18510-4596Ofc: 570-941-7638 Fax: 570-941-7899E-Mail: [email protected]

COMMITTEESFellowsChair: Lisa Porche-Burke, Ph.D.Phillips Graduate Institute 5445 Balboa Blvd. Encino, CA 91316-1509 Ofc: 818-86-5600 Fax: 818-386-5695 E-Mail: [email protected]

MembershipChair: Rhonda S. Karg, Ph.D. Research Triangle Institute 3040 Cornwallis Road Research Triangle Park, NC 27709 Ofc: 919-316-3516 Fax: 919-485-5589 E-Mail: [email protected]

Student Development ChairAdam Leventhal, 2006Department of PsychologyUniversity of HoustonHouston, TX 77204-5022Voice: 713-743-8600 Fax: 713-743-8588E-Mail: [email protected]

Nominations and ElectionsChair: Jean Carter, Ph.D.

Professional AwardsChair: Leon VandeCreek, Ph.D.

FinanceChair: Jan Culbertson, Ph.D.

Education & TrainingChair: Jeffrey L. Binder, Ph.D., ABPPGeorgia School of ProfessionalPsychology at ArgosyUniversity/Atlanta980 Hammond Drive, Ste. 100Atlanta, GA 30328Ofc: 770-407-1018 Fax 770-671-0476E-Mail: [email protected]

Continuing EducationChair: Steve Sobelman, Ph.D.Department of PsychologyLoyola College in MarylandBaltimore, MD 21210Ofc: 410-617-2461E-Mail: [email protected]

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

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

Psychotherapy ResearchChair: William B. Stiles, Ph.D.Department of Psychology Miami University Oxford, OH 45056 Voice: 513-529-2405 Fax: 513-529-2420 E-Mail: [email protected]

The Ad Hoc Committee onPsychotherapyLinda Campbell, Ph.D. and

Leon VandeCreek, Ph.D., Co-ChairsJeffrey Hayes, Ph.D. and Craig Shealy,

Ph.D., Education and TrainingJean Carter, Ph.D. and Alice

Rubenstein, Ed.D., PracticeBill Stiles, Ph.D., ResearchJohn Norcross, Ph.D., Chair

Publications BoardNorine Johnson, Ph.D., Representative

Division of Psychotherapy nn 2006 Governance StructureELECTED BOARD MEMBERS

COMMITTEES AND TASK FORCES

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John C. Norcross, Ph.D., 2002-2007Department of PsychologyUniversity of ScrantonScranton, PA 18510-4596Ofc: 570-941-7638 Fax: 570-941-7899E-mail: [email protected]

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

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

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

Alice Rubenstein, Ed.D., 2000-2006Monroe Psychotherapy Center20 Office Park WayPittsford, NY 14534Ofc: 585-586-0410 Fax [email protected]

George Stricker, Ph.D., 2003-2008Institute for Advanced Psychol Studies Adelphi University Garden City, NY 11530 Ofc: 516-877-4803 Fax: 516-877-4805 [email protected]

Psychotherapy Journal EditorCharles Gelso, Ph.D., 2005-209University of MarylandDept of PsychologyBiology-Psychology BuildingCollege Park, MD 20742-4411Ofc: 301-405-5909 Fax: 301-314-9566 [email protected]

Psychotherapy Bulletin EditorCraig N. Shealy, Ph.D., 2004-2006Department of Graduate PsychologyJames Madison UniversityHarrisonburg, VA 22807-7401Ofc: 540-568-6835 Fax: [email protected]

Internet EditorBryan S. K. Kim, Ph.D., 2005-2007Counseling, Clinical, and School Psychology ProgramDepartment of EducationUniversity of CaliforniaSanta Barbara, CA 93106-9490Ofc & Fax: [email protected]

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

PUBLICATIONS BOARD

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

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

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

Contributors are invited to send articles (up to 4,000 words), interviews, commentaries, letters to the editor,and announcements to Craig N. Shealy, Ph.D., Editor, Psychotherapy Bulletin. Please note that PsychotherapyBulletin does not publish book reviews (these are published in Psychotherapy, the official journal of Division29). All submissions for Psychotherapy Bulletin should be sent electronically to [email protected]; pleaseensure that articles conform to APA style. Deadlines for submission are as follows: February 1 (spring); May 1 (summer); July 1 (fall); November 1 (winter). Past 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 ([email protected] or 602-363-9211).

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6557 E. RiverdaleMesa, AZ 85215

www.divisionofpsychotherapy.org

Non-ProfitOrganizationU.S. Postage

PaidUtica, NY

Permit No. 83

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PSYCHOTHERAPY BULLETIN

Published by theDIVISION OF

PSYCHOTHERAPYAmerican Psychological Association

6557 E. RiverdaleMesa, AZ 85215

602-363-9211e-mail: [email protected]

EDITORCraig N. Shealy, Ph.D.

CONTRIBUTING EDITORS

Washington ScenePatrick DeLeon, Ph.D.

Practitioner ReportRonald F. Levant, Ed.D.

Education and TrainingJeff Binder, Ph.D.

Psychotherapy ResearchWilliam Stiles, Ph.D.

Student FeatureAdam Leventhal

STAFFCentral Office Administrator

Tracey Martin

Websitewww.divisionofpsychotherapy.org

PSYCHOTHERAPY BULLETINOfficial Publication of Division 29 of the

American Psychological Association

2006 Volume 41, Number 2

CONTENTS

ColumnsPresident’s Column ................................................2A World of Psychotherapy ....................................4

Psychotherapy Around the World: A SamplerPsychotherapy Research ......................................11

Good Enough Science: The CORE-OM as a Bridge Between Research and Practice inPsychological Therapies

Washington Scene ..................................................21An Exciting Future for the Flexible and Creative

Perspectives on Psychotherapy Integration ......26The Nature of Unified Clinical Science:Implications for Psychotherapeutic Theory,Practice, Training, and Research

FeaturesThe Position Paper for Funding for

Psychotherapy Research..........................................9Interview with Dr. Nadine Kaslow, Ph.D. ..............17Informed Consent and the

Psychotherapy Process ..........................................37Cultural Considerations of Informed Consent

When Conducting Mental Health Research ........43Expanding Your Psychotherapy Practice

into Primary Care ................................................47License Mobility for Credentialed

Psychologists in the US and Canada....................49

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Working in the Depart-ment of Psychiatry ofa large county hospitalfor over 25 years hasbroadened my per-spective on howresearch affects prac-tice. The questionsp s y c h o t h e r a p i s t sstruggle with do not

differ that much from those of our col-leagues in primary care. How do we trans-late research into practice? What is the roleand value of the treatment relationshipversus specific interventions? How muchcan we rely on our own clinical experiencein making treatment decisions versus evi-dence-based guidelines? How do we trainstudents as competent and knowledgeableprofessionals and caring healers?

The distinction used in medicine betweenbasic versus clinical science is very useful.Basic science pursues knowledge aboutdiagnosis and treatment by studying fun-damental biomedical processes, primarilythrough laboratory work. Clinical scienceseeks to understand diagnosis and treat-ment through studies of people in clinicalsettings. Clinical science assumes thatthere is a hierarchy of evidence rangingfrom systematic literature reviews to ran-domized clinical trials to case studies. TheNew England Journal of Medicine routinelyuses case studies as teaching tools. Lettersto the editor of medical journals are full ofclinicians challenging studies by citingtheir own clinical experience. While thereis a serious lag in translating clinicalresearch into medical practice, there is usu-ally no active resistance to research inform-ing practice.

The relationship between psychotherapyresearchers and practitioners has beenmore adversarial. While the Boulder modeladvocates the ideal of the scientist-practi-

tioner, the tension between science andpractice is just too difficult for most psy-chotherapists to contain. Many psy-chotherapy researchers are deeplyentrenched in a methodology that relies ona model of randomized clinical trials as theonly standard to prove that psychotherapyworks. In contrast, practitioners with manyyears of practice doing both short -andlong-term psychotherapy rely on the hardwon knowledge gained from personaltherapy, careful listening to patients, andworking through their own countertrans-ference issues. They are indignant andalarmed that research findings are summa-rized in systematic reviews that glibly pre-scribed practice guidelines.

There are those that see psychotherapy as aclinical science. Recent books edited byDivision 29 members advocate for a widerange of clinical evidence in evaluating theeffectiveness of psychotherapy and for theuse of evidence-based principles ratherthan evidence-based techniques. Thesebooks are:John Norcross, Larry Beutler, and RonLevant—Evidence-based practices in mentalhealth: Debate and dialogue on the fundamen-tal questionsLouis Castonguay and Larry Beutler—Principles of Therapeutic Change that WorkCarol D. Goodheart, Alan Kazdin, andRobert Sternberg—Evidence-BasedPsychotherapy: Where Practice And ResearchMeet

At a time when psychotherapy researchersand practitioners live on a fault line withperiodic shake-ups and rumblings, theseworks by our members seek to foster a sta-bile environment for constructive work.

A major function of the Division ofPsychotherapy is to contain the conflictingand contradictory views in psychotherapy.

PRESIDENT’S COLUMN Abe Wolf, Ph.D.

Psychotherapy as Clinical Science

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The program organized by Jeff Magnavita,our Program Chair for the 2006 annualAPA convention, strives for this “holdingenvironment.” The following list gives yousome idea of the range of topics that will beaddressed this summer in New Orleans: • Current Developments in the Cognitive

Neuroscience of Psychotherapy• Empirically Supported Treatment for

Personality Disorders• Research on Anger Treatments• Insight in Psychotherapy• What do you do when you hate your

patient?

We hope that you will add your voice to theongoing conversation on the theory,research, and practice of psychotherapy thatdefines and distinguishes Division 29 byattending these programs.

The field of psychotherapy faces challengesfrom without and within. The leaders ofDivision 29 are working hard to create anorganization that contains the wide range ofvoices of all psychotherapists and that canmove into effective action to meet the chal-lenges of a health-care economy in disrepair.We look forward to your continued supportand active participation in our division.

DELAY IN JOURNAL DISTRIBUTION

The Publication and Communications Office of the AmericanPsychological Association regrets any inconvenience to the members ofthe Division of Psychotherapy due to the delay in the distribution ofthe Winter 2005 and Spring 2006 issues of Psychotherapy: Theory,Research, Practice, Training. Although the journal editor sent the contentsof the issues to the APA office in a timely manner, the implementationof a new production process caused unacceptably long delays withinour office. These problems have been corrected, and the overdue issueshave been distributed. Thank you for your patience and continued support of Division 29.

Gary R. VandenBos, Ph.D.Executive Director of Publications and CommunicationsAmerican Psychological Association

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Editor’s Note: This article is the second of tworegarding psychotherapy practices around theworld (for the first article, see PsychotherapyBulletin, 2006, Vol. 41, No. 1). In the currentarticle, Dr. Abeles highlights psychotherapypractices, policies, research, and conferences ina sample of countries around the world, andprovides context and references for furtherinformation and reading.

PSYCHOTHERAPY IN AFRICAStatistics from South Africa indicate thatabout 25% of patients going to a generalmedical practitioner suffer from mentalhealth problems; 20% of high school stu-dents think about harming themselves;between 1-3% of the population in SouthAfrica has emotional problems that aresevere enough to require hospitalization(Mental health in South Africa, 2005).Partly in response to data like these, theWorld Health Organization (WHO) isworking on a “Global Mental Health PolicyProject,” which is designed to strengthenmental health and substance abuse policieswithin a number of African countries. TheWHO cites mental health in Uganda as achallenge for research, and suggests thatthis country could be a test case since con-ditions in Uganda could easily generalizeto other countries in Africa. The aim of thispilot project will include three phases. Thefirst phase will include data collection con-cerning mental health (psychiatric) needs,with particular focus on services to therural poor, including women, children, andorphans. The second phase will includeself-guided training and classroom train-ing with technology assisted “e-learning”.There will be focus on training primarycare providers that will diagnose and treatmental disorders in primary care settings.The third phase will include an evaluationof the data related to Ugandan mental

health needs and there will be an effort tosee if the Ugandan findings will be gener-alizable to other sub-Saharan countries.With regard to institutions and personnelfor this project, there are plans for a con-sortium that will work with the AfricaTelehealth group to study mental healthneeds. Personnel will include professionalstaff that have been trained in all aspects ofhealth services research (African MentalHealth project, 2005).

There is a strong presence of psychoanaly-sis in Africa, which is described in an arti-cle in the Journal of Psychology in Africa(Peltzer & Reichmayr, 1999). While psycho-analysis in Africa may sound counterintu-itive, the authors of this journal articlepoint out that psychoanalysis is alive inSouth Africa, Senegal and some NorthAfrican countries. The presence of psycho-analysis in South Africa is frequentlyattributed to an influx of German speakingimmigrants who moved there to escapefascism in Europe. There have been plansto form a psychoanalytic group in SouthAfrica, which was the residence of Frenchpsychoanalyst, Marie Bonaparte. FritzPerls, the founder of Gestalt therapy, wastrained in psychoanalysis and also lived inSouth Africa from 1933 to 1946. The time ofapartheid in South Africa deterred furtherdevelopment of psychoanalysis until apsychoanalytic study group was foundedin 1979 (Peltzer & Reichmayer, 1999). Itshould also be noted that Mary Ainsworthwrote on attachment theories while inUganda; some professionals were alsotrained in Kenya in the 1980’s. In the 1990’sthere were a number of clinical psycholo-gists and psychiatrists who practiced psy-chotherapy in Africa and some of them uti-lized psychoanalysis. There are psy-chotherapy societies in Nigeria and there is

A WORLD OF PSYCHOTHERAPY

Part II—Psychotherapy Around the World: A SamplerNorman Abeles, Ph.D., Michigan State University

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an African Chapter of the World Councilfor Psychotherapy.

PSYCHOTHERAPY IN LATIN AMERICAThere is a strong presence of psychothera-py in Latin America. The World Congressfor Psychotherapy which met in BuenosAires in August 2005 is one of many LatinAmerican psychotherapy organizations.Osvaldo Filidoro warned about convertingpsychotherapy into psychology or psychia-try at the meeting of the Latin AmericanFederation of Psychotherapy in Quito,Ecuador in 2001. He views psychotherapyas an art or ability formulated as a sciencedetermined by an empirical field of obser-vation (p 3). Filidoro regards language asan obstacle and wonders how we can evenattempt to obtain uniform criteria for a def-inition of psychotherapy when there arecountries that have more than twenty-threelanguages which “cohabitate under theroof of the Spanish language” (p 6). Henotes that the instability of politicalregimes causes a source of existential inse-curity for Latin American societies andindividuals. He insists that psychotherapyin Latin America is not tied to any domi-nant school of therapy. The Pan AmericanHealth Organization (PAHO) estimatesthat by the year 2010, 35 million LatinAmericans will suffer from depression and5.5 million will suffer from schizophrenia.PAHO recognizes that there is a need to doaway with large mental hospitals and shifttreatment to the communities but there isrecognition of the gap between what isknown and what is being done(International Development Bank, 2005).

Psychotherapy is alive and well in Brazil. A recent article (DeMello, Myczcowisk, &Menezes, 2001) reports on a random con-trolled trial concerning the efficacy of inter-personal therapy plus medication com-pared to routine clinical management plusmedication (moclobemide) for 35 dys-thymic patients. The 7th InternationalCongress on body psychotherapy tookplace in Sao Paolo, Brazil in October 2005.Body Psychotherapy goes back to the workof William Reich and involves a range of

techniques including touch, movementand breathing. Gestalt therapy, transaction-al therapy, psychoanalytic therapy, psycho-dynamic therapy, and cognitive therapiesare also frequently used by practitioners inBrazil. In an article on psychotherapy inBrazil written by Stubbe (1980), he notesthat there are a variety of Brazilian psychotherapy methods that range fromIndian medicine to spiritualism to scientif-ic founded psychotherapy. I suspect if wesearch thoroughly enough we can also findcomparable non-empirically supportedtherapies in the United States.

PSYCHOTHERAPY IN AUSTRALIA ANDNEW ZEALAND1987 saw the founding of the Australia andNew Zealand Association of Psycho-therapy (ANZAP). This association was anoutgrowth of the psychotherapy programat the University of Sydney’s psychothera-py unit at Westmead Hospital in Sydney,Australia. The ANZAP publishes a bul-letin, provides a course in adult psy-chotherapy, and provides post-graduatesupervisor-training programs (ANZAP,2005). In 1998, the Psychotherapy andCounseling Federation of Australia wasestablished. This organization serves as anumbrella association for a number of professional groups in Australia. There isalso an active Australian CounselingAssociation (ACA) that deals with stan-dards and helps to provide recognition forcounselors. Currently there are about 2500members in the ACA. This organizationhas worked to develop a register of coun-selors, therapists, and psychologists whoare willing to provide therapy for victimsof the recent tsunami. Volunteers will needto carry their own liability insurance, andare sought to provide both crisis and long-term counseling to victims.

There are numerous other associations thatrepresent various disciplines in Australia.The Association of Cognitive and BehaviorTherapy held its 28th Annual conference in2005. The Victoria Association of Psycho-analytic Psychotherapists recently present-ed an introduction to analytically oriented

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group therapy. Another seminar by thisgroup dealt with forensic psychotherapyand an understanding of the criminal mind.In addition to these groups are theAustralian and New Zealand PsychodramaAssociation, Australian and New ZealandSociety of Jungian Analysts, and GestaltAustralia and New Zealand organization.

The association that regulates therapy inNew Zealand is the New ZealandAssociation of Psychotherapists. Australiahas psychologist registration boards in thevarious states and territories that setrequirements concerning issues like the useof the term “psychologist.” In general, fouryears of academic study in psychology andtwo years of additional postgraduate train-ing or two years of supervised experienceare the prerequisites for becoming a psy-chologist. The New Zealand Association ofPsychotherapists sets standards and pro-vides expectations for the practice of psy-chotherapy in New Zealand. Admission tomembership requires a structured trainingprogram in therapy or counseling plus theequivalent of two years full-time practice.

Previously psychotherapy health care cov-erage (including psychoanalysis) providedby psychiatrists was unlimited in Australiawhile limits existed in New Zealand(Gabbard & Lazar, 1997). This was cited todemonstrate that unlimited psychotherapycare in Australia actually cost 44% less thanit did in New Zealand because of theirreliance on inpatient psychiatric hospital-ization. I do not have current statistics onthis topic, and I doubt if unlimited outpa-tient mental health care is available any-where in the world. However, please con-tact me if our readers know of a placewhere unlimited psychotherapy costs arereimbursed.

With regard to scope of practice, clinicalpsychologists in New Zealand require amaster’s degree or its equivalent plus anapproved practicum or internship whichlasts 1500 hours or more. In Australia thereis a six year training program leading to anaccredited professional psychology degree;

additional internship activities are alsoincluded. Much of the professional trainingin Australia and in New Zealand occursdoing the first four years of college. This iscontrasted by the United States, where pro-fessional training does not occur until aftera bachelor’s degree has been earned.

PSYCHOTHERAPY IN ASIA—JAPAN AND SINGAPOREThe third International Conference of theAsian Federation for Psychotherapy takesplace from August 28 to September 2006 inTokyo, Japan. This conference will be heldin conjunction with the InternationalCongress of Psychotherapy. The conferencewill be under the auspices of the JapanesePsychological Association, JapaneseSociety of Psychiatry, Association ofJapanese Clinical Psychology, andKomazawa University. Twenty-four acade-mic societies will have international sym-posia and/or workshops. Concurrentmeetings of six psychotherapy societieswill include the Japanese Society ofTransactional Analysis, and the societies ofhypnosis, autogenic therapy, transpersonalpsychology/psychiatry, rational therapy,and existential therapy.

A less familiar practice called MoritaTherapy, which was developed by theJapanese psychiatrist Shoma Morita in theearly 1900’s is also practiced in Japan.Originally designed for anxiety problemsin Japan, it is now practiced in the UnitedStates and workshops have been given inGermany and France. The aims of MoritaTherapy include the following: being ableto accept less desirable feelings and traitsas part of one self, being able to interacteffectively with the world outside and pur-suing ones goals even with symptoms(Morita Therapy, 2005). Advocates ofMorita Therapy believe that the total elim-ination of symptoms may be undesirableand probably not realistic because to do sowould eliminate our humanity and indi-viduality. Proponents of this believe thatpeople need to live with painful symp-toms. Morita Therapy focuses on the hereand now, openness to sensory experience,

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the ability to cope with reality, and theneed to accept ourselves. Dr Moritaexpressed the viewpoint that living lifefully requires the development of a balancebetween concern for self-preservation andself-development.

Methods of Morita Therapy can includeperiods of bed rest and isolation beforecounseling begins. This is possible in Japanbecause patients can obtain inpatient treat-ment. In the United States, many viewMorita Therapy as occurring on an outpa-tient basis where the focus is on providingeducational means for overcoming self-imposed limitations. Morita Therapy advo-cates have claimed that this approach hassuccessfully treated individuals who suf-fered from depression, severe illnesses, eat-ing disorders, obsessive-compulsive disor-ders, and psychosomatic problems.

The British Psychiatric Bulletin (Kang, 2001)discussed the history of psychotherapytraining in Singapore and noted that a smallnumber of psychiatrists provided psy-chotherapy training in the 1980’s in 1990’s.These psychiatrists were trained in behav-ioral or psychodynamic methods. In 1997, psychologists and psychiatristsformed the Association of Group andIndividual Psychotherapy. This coincidedwith the development of the PsychotherapyTraining Program by the Department ofPsychological Medicine at the NationalUniversity Hospital. In 1998, external visi-tors from the United Kingdom providedtraining for mental health personnel. Thesedevelopments resulted in a move to providea graduate diploma in psychotherapy thatincluded both medical and non-medicalprofessionals as trainees and supervisors.Not surprisingly there were more appli-cants for this program than had beenaccepted. The article points out that manyAsian societies still view psychotherapy as a“Western invention” (p 3) and it is notedthat in Korea there were attempts to relatepsychoanalysis to Confucian philosophy.

Singapore has an active psychological soci-ety and the recent meeting of the

International Association of AppliedPsychology (IAAP) testifies to this. Thesociety recognizes international criteria forthe use of titles like clinical psychologist,counseling psychologist, educational psy-chologist, occupational psychologist, andindustrial/ organizational psychologist.The Singapore Psychological Societyregards licensed members or our APA asmeeting their title requirements.Additionally, qualified members of theAustralian, British, and Hong KongPsychological Societies are also recognizedand can practice in Singapore. Full mem-bers of the Singapore Psychological Societywho do not meet the international criteriacan be assumed to have sufficient profes-sional skills if they have relevant academicand supervised experience.

FINAL COMMENTSIn this article, I have tried to provide thereaders of our bulletin with an introduc-tion to psychotherapy in an internationalcontext by discussing various groups andorganizations relevant to psychotherapeu-tic practice. I also provided a sampling ofsomewhat less known (as far as psy-chotherapy is concerned) places in theworld and briefly discussed issues relevantto the practice of psychotherapy. Note thatI provided a subtitle, “a Sampler,” to indi-cate the selective nature of this discussion.I chose material that particularly interestedme and acknowledge that it might not bereadily familiar to some of my colleagues.Should there be sufficient interest, I willfollow up with discussions of psychothera-py relevant to other areas of the world. Feelfree to contact me at [email protected].

REFERENCESAfrican Telehealth Project. African Mental

Health Project (2004). Retrieved April 12,2005 From http://209.250.143.167/atp.index.htm

Ang, A. (2001). Psychotherapy training inSingapore. Psychiatric Bulletin, 25,112-113.

ANZAP (2005). Australian and NewZealand Association of PsychotherapyLtd. Retrieved April 5, 2005 from http://www.anzapweb.com/training.php

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Beutler, L. & Crago, M. PsychotherapyResearch: An international review ofprogrammatic studies. Washington, D.C.APA Books.

DeMello, Myczowisk & Menezes (2001). A randomized control trial comparingmoclobemide plus interpersonal psychotherapy in the treatment ofDysthymic Disorder.

Journal of Psychotherapy PracticeResearch, 10, 117-123. Washington, D.C.American Psychiatric Association.

Filidoro, O. (2001). Reflections aboutPsychotherapy in Latin America.Psicologia y Psicopedagogia 3, March2002.

Gabbard, G & Lazar, S. (1997). Efficacyand cost effectiveness of Psychotherapy.Retrieved. April 28, 2005 fromhttp://www/apsa.org/puninfo/efficacy.html

Interamerican Development Bank (2005).Mental Health: A challenge for LatinAmerica. Retrieved April 25, 2005 fromhttp://www/fic.nih.gov/regional/america.html

International Integrative PsychotherapyAssociation (2005). Retrieved April 25

from http://www/integrativeassocia-tion.com

Klerman, C. & Weissman, M. (1993). Newapplications in interpersonal psycho-therapy. New York, AmericanPsychiatric Press.

Mental Health in South Africa (2005).Retrieved April 20, 2005 fromhttp://www.hst.org.za/udapte/50

Morita Therapy (2005). Retrieved March19 2005 from http://www/todoinstitute.org/morita.html

NZAP. What is it? What does it do?Retrieved May 4, 2005 fromhttp://www.nzap.org.nz/info.htm

PAHO. Pan American HealthOrganization. Retrieved April 25 2005from http://www/paho.org/default.htm.

Peltzer, K & Reichmayer, J. (1999). Africaand Psychoanalysis. Journal ofPsychology in Africa, 9, 101-108.

Stubbe, H. (1980). Psychotherapy in Brazil.Zeitschrift Psychosomatic MedicalPsychoanalysis, 26, 79-93.

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

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POSITION PAPERFunding for Psychotherapy ResearchApproved March 7, 2006

The Ad Hoc Committee on Psychotherapy isa set of focus groups established during theDivision 29 presidencies of Pat Bricklin,Linda Campbell, and Leon VandeCreek toset an agenda of priorities for the field ofpsychotherapy. One of the priorities estab-lished by the research focus group was toaddress the lack of government funding forpsychotherapy research. Under the leader-ship of William Stiles, chair of the Division29 Research Committee, a task force ofprominent psychotherapy researchers asso-ciated with the Society for PsychotherapyResearch wrote a white paper addressingthis lack of funding. John Norcross, Chair ofthe Publication Board, collaborated withLinda and Leon in revising that document tothe following position paper. The Division29 Board of Directors voted to endorse thisdocument.

The APA Division of Psychotherapy is com-mitted to advancing psychotherapy train-ing, research, and practice within the profes-sion of psychology. At this time, program-matic psychotherapy research is confrontedwith obstacles that endanger its continuedcontribution to the health and welfare of thepopulace. Psychotherapy researchers areincreasingly alarmed by sociopolitical poli-cies and funding priorities.

BACKGROUNDOver 5,000 empirical studies and 300 meta-analyses have established the clinicaland cost effectiveness of psychotherapy inreducing symptoms, restoring work perfor-mance, and improving quality of life for thevast majority of those who seek treatment.The research demonstrates that 75% of peo-ple who enter psychotherapy evidencemeaningful improvement. Moreover, re-search consistently indicates that psycho-therapy produces favorable results whencompared to psychoactive medications andwhen assessed for cost effectiveness.

THREE PROBLEMS AND RECOMMENDEDSOLUTIONSProblem 1: The limited funds available forpsychotherapy research are largely devot-ed to randomized clinical trials (RCTs).While RCTs are valuable designs for estab-lishing the causal effectiveness of treat-ments, they are incomplete in explicatingthe reasons for such effectiveness and intranslating science into service.

Recommended Solutions: Fund an arrayof methodological designs for psychother-apy research. These include: a. Process research is a primary method of

conducting basic research and under-standing the mechanisms of change.

b. Qualitative and single-case designs are nec-essary to study important aspects ofprocess research, such as participantmoment-by moment responsivenessand the therapist-patient relationship.

c. Effectiveness research examines psycho-therapy as it is commonly practiced andsuch critical parameters as patients atrisk for negative outcomes, and the gen-eralization of treatments validated in thelaboratory to routine clinical practice.

d. Practice-based research networks enhancecollaboration between researchers andclinicians and facilitate technologytransfer.

Problem 2: The limited funds available forpsychotherapy research are largely allocat-ed to investigating the efficacy of manual-ized treatments. These are valuable studiesbut incomplete as the research repeatedlydemonstrates that the therapeutic relation-ship, patient contributions, and therapisteffects account for as much, if not more, ofpatient success than particular treatments.

Recommended Solutions: Fund psycho-therapy research that investigates morethan manualized treatments. These include:

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a. Adaptation of treatments to patient charac-teristics (e.g., stages of change, prefer-ences for treatments, ethnic diversity) isnecessary for predicting outcome andcustomizing the most effective treat-ment for individual patients.

b. Sub-threshold disorders and comorbid disor-ders are more common than in medicineand are frequently excluded from fund-ing consideration because they fail tomeet diagnostic criteria for randomizedclinical trials.

c. Long-term treatment studies can deter-mine which treatments are most clinical-ly and cost effective.

d. Research on psychotherapy with marginal-ized clients, such as members ofethnic/racial minorities and the physi-cally disabled.

e. Couples and family therapy are treatmentsof choice for many relationship prob-lems with public health implications.Yet, psychotherapy research on couplesand family processes is rarely identifiedor funded.

f. Therapist-focused research investigates theimpact of therapists’ personal character-istics, relational style, and training ontheir effectiveness and are critical tounderstanding why some therapists aremore effective than others.

g. Application of psychological research tophysician-patient relationships contributesto health-care outcomes given theincreasing attention in the medical liter-ature to the treatment relationship.

Problem 3: The criteria for evaluatinggrant proposals in psychotherapy researchare frequently inadequate and the review-ers are expert in only efficacy designs.

RECOMMENDED SOLUTIONS:a. The criteria for evaluating research propos-

als should be appropriate for the area ofinvestigation, stage of inquiry, and stateof knowledge. When recommending criteria revision, psychotherapyresearchers are often referred to theNIMH R34 program, a standing pro-gram for many of the types of studiesrequested. These are “early” studiesproposing new models or developingnew treatment approaches.

b. Reviewers should be peers of the appli-cants and knowledgeable about the rele-vant areas of psychotherapy research.Panels should be composed of estab-lished psychotherapy researchers withexperience in the kinds of research ques-tions being reviewed and the method-ologies being employed.

c. Federal grant office staff should includedindividuals with experience in psy-chotherapy research in order to provideadequate consultation to grant appli-cants and to initiate conferencesaddressing relevant research issues.

d. Membership on special task forces is essen-tial for psychotherapy researchers inthat these working groups produce doc-uments that set priorities for futurefunding.

Bulletin ADVERTISING RATES

Full Page (8.5” x 5.75”) $300 per issueHalf Page (4.25” x 5.75”) $200 per issueQuarter Page (4.25” x 3”) $100 per issue

Send your camera ready advertisement, along with a check made payable to Division 29, to:Division of Psychotherapy (29)6557 E. RiverdaleMesa, AZ 85215

Deadlines for SubmissionJuly 1 for Fall Issue

November 1 for Winter IssueFebruary 1 for Spring Issue

May 1 for Summer IssueAll APA Divisions and Subsidiaries (TaskForces, Standing and Ad Hoc Committees,Liaison and Representative Roles) materialswill be published at no charge as space allows.

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I recall a story told to me many years agoabout a colleague who was discussing dif-ferent forms of science with a very eminenthead of a major scientific funding body.After several moments, having been pre-sented with an array of differing scientificapproaches, the latter turned and said“There are only two types of science: goodscience and bad science.” Today, termssuch as precision and specificity are oftenused as hallmarks of good science. So rais-ing the spectre of a good enough sciencemight seem strange and open to misunder-standing. However, it could provide a win-dow through which to consider slightlydiffering ways of engaging practitionersand researchers in the common task ofimproving the quality of client care. To thisend, I will set out how the phenomenon ofgood enough science has become a threadof our current research program in bridg-ing the scientist-practitioner gap. The pro-gram is based in the PsychologicalTherapies Research Centre (PTRC) at theUniversity of Leeds, England, which wasset up by David Shapiro following ourmove there from the University ofSheffield on completion of the SheffieldPsychotherapy Projects.

A CORE APPROACH TOPRACTICE-BASED EVIDENCE

Developing a family of CORE measuresIrene Waskow’s (1975) call for a core out-come battery has been the pivotal compo-nent in our program of work. The appeal ofimplementing a common outcome mea-sure or group of measures seemed so obvi-ous that it was difficult to understand whythis notion had not progressed as far as itmight. So starting in the mid 1990s, ourfocus was on devising just such a core out-come measure, the Clinical Outcomes in

Routine Evaluation-Outcome Measure(CORE-OM), which is now widely adoptedin the United Kingdom (Barkham et al.,1998, 2001, 2005; Evans et al., 2002). Twodriving principles in the development ofCORE-OM were (a) that it was informedby practitioners’ views as to what they feltwas important to measure, and (b) that thepsychometric properties of the measurewere good enough in the view of bothresearchers and practitioners. Hence, theprimary drivers were not theory or fidelity,but rather practitioner ownership and util-ity. It was also free.

Since then, we have built up a family ofderivative measures drawing on the pool of34 CORE-OM items, each being designedfor a specific purpose (e.g., initial screening,session-by-session monitoring) or popula-tion (e.g., young people). The premise is thatone version cannot fulfill all requirementsand our approach has been to be responsiveto the needs of practitioners and the require-ments of policy calls. Importantly, outcomesoccur in a broader context and the develop-ment of the fuller CORE System has beencrucial in providing contextual data withinwhich to interpret the outcome data(Mellor-Clark & Barkham, 2006). Again, thiswas devised by collaboration between prac-titioners and researchers. Having estab-lished a good enough psychometric statusfor the CORE-OM, we have recently beenidentifying and implementing ways of mak-ing the scoring of the CORE-OM, and themeaning the scores, easier for practitionersto handle and use (Barkham, Mellor-Clarket al., in press).

REWIRING EFFICACY STUDIES FORPRACTICAL RELEVANCEA key component in our program has beenestablishing the empirical relationship

RESEARCHGood Enough Science: The CORE-OM as a Bridge BetweenResearch and Practice in the Psychological TherapiesMichael Barkham, Psychological Therapies Research Centre, University of Leeds

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between the CORE-OM and other com-monly used outcome measures. Wherepractitioners have a preference for anotheroutcome measure, we want to enable themto make comparisons with the CORE-OM.Hence, we have addressed how the CORE-OM compares with other measures (Cahillet al., in press)—for example, the BeckDepression Inventory (BDI; Beck et al.,1961) and the Hamilton Rating Scale forDepression (Hamilton, 1967). More specifi-cally, we have developed transformationrules for converting individual BDI scoresinto CORE-OM scores and vice versa (Leachet al., in press). The yield of this work isthat we can now transform BDI scores (andlogically also BDI-II scores) from archivedefficacy trials into CORE-OM scores usingsimple transformation rules. Hence, resultsfrom older studies using the BDI can bemade more relevant to practitioners whouse the CORE-OM in routine practice(Barkham, Rees et al., 2005).

Towards chiasmusThe development of the CORE-OM andCORE System provided us with the toolsfor investigating the psychological thera-pies as delivered within routine service set-tings and it has become the central compo-nent in our espousing a paradigm of prac-tice-based evidence (Barkham & Mellor-Clark, 2000; Margison et al., 2000). This isthe chiastic counterpart to evidence basedpractice which itself has, over the past 20years, established randomized controlledtrials and meta-analytic studies as the goldstandards upon which governments basedecisions about health care policy.However, it leaves open issues of trans-portability to everyday practice. Ratherthan simply carrying out effectivenessstudies as a logical extension to RCTs, thereis a need for a research paradigm that notonly fulfills this function but also that issufficiently robust to initiate research frompractice settings that might then lead tomore specific investigation via RCTs. Inthis way, evidence-based practice andpractice-based evidence are complemen-tary to each other (Barkham & Mellor-Clark, 2003). Moreover, both paradigms are

necessary to build a robust knowledgebase for the psychological therapies.Hence, rather than focusing solely oneither approach alone, we need to adoptthe position of chiasmus, namely evidence-based practice and practice-based evidence. Thecombination of a good enough tool (i.e.,CORE-OM) and a research approach root-ed in practice have enabled us to build justsuch a complementary evidence-base (seeBarkham, Mellor-Clark et al., in press).

UTILISING LARGE (AND LARGER)PRACTICE-BASED DATA SETS

Building large practice-based datasetsSince our developmental work on CORE,we have accrued datasets that compriseincreasingly larger numbers of clients,practitioners, and services. These datasetswill yield results that are robust and willpermit statistical analyses on subgroupsthat would previously not have been feasi-ble (e.g., ethnic minorities, reliable treat-ment deteriorations). A CORE NationalResearch Database has now been estab-lished (see Mellor-Clark et al., in press) anda first stage of analyses has been carriedout on a sample of >30,000 clients drawnfrom within the United Kingdom’sNational Health Service.

Practice-based evidence: InformingresearchTo date, our large data sets have enabled usto develop new methods of predictingtreatment response (see Lutz et al., 2005),and to investigate the phenomenon of sud-den gains in routine mental health settings(Stiles et al., 2003). We have established thebroad equivalence of outcomes between,for example, cognitive-behavioural, psy-chodynamic-interpersonal, and client-cen-tred therapies (Stiles et al., in press).Interestingly, when each of these orienta-tions was delivered with an additionalapproach, each was, if anything, slightlymore effective. In other words, greaterpurity of these therapies did not yieldgreater effectiveness in routine settings.

We also found that the mean level of out-

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come tended to be broadly similar regard-less of the number of sessions clientsreceived. We interpreted this seeminglyparadoxical finding as being that clients exit-ed therapy when they had reached a pointthey deemed was good enough. This empir-ical observation was wholly consistent withresponsiveness theory. Hence, we arguedthat treatment duration is largely responsiveto client need – that is, it is self-regulated(Barkham, Connell, et al., in press). In a cli-mate where fixed duration is the currency,then such a finding has practical implica-tions for service planning and delivery.

Practice-based evidence: Informing servicesData from such large scale naturalistic set-tings has enabled us to focus on more ser-vice-oriented questions raised by practition-ers, service managers, and commissionersof services. We have previously establishedbenchmarks for a range of service variableson a smaller data set (Evans et al., 2003) andhave now provided a range of benchmarksusing the CORE National ResearchDatabase for service parameters in primarycare settings comprising, for example, wait-ing times, perceptions of risk, and impor-tantly the key area of outcomes (see Mullinet al., in press). However, establishingbenchmarks at a service level is not an exactscience. For example, confidence intervalscan be large at the service level and, whenconsidering benchmarks for practitionerperformance, the crucial issue of case-mixadjustment needs to be addressed. The com-plexity of some procedures for takingaccount of case-mix reduces the feasibilityof their being used – and owned – by prac-titioners in routine services and makes this akey area for developing a science that isgood enough.

TOWARDS A GOOD ENOUGH SCIENCEThe golden thread in our research programhas been the CORE-OM—a simple out-come measure which has provided thefoundation for research rooted in routinepractice. Work using the CORE-OM isplanned in many areas ranging from meth-ods of providing patient feedback to deriv-

ing indicators from the CORE-OM thatcould be used in health economics. Farfrom being just another outcome measure,our program has tried to redress the bal-ance in which trials methodology has tra-ditionally been valued by policy makers.But in order for this to succeed, there is aneed to readjust our view of science andshift to what might be called a good enoughlevel of science – a practice-based science –that can be owned by practitioners, drivenby clinical and service utility, and yetaccepted by academics and policy makersalike as a legitimate complement to trialsmethodology.

In balancing these complementaryapproaches, there might be mileage in con-sidering the notion of the expected value ofperfect (or near perfect) information. This con-cept attempts to gauge what we are pre-pared to pay for acquiring perfect, or nearperfect, information about a certain phe-nomenon. It is a process that is often usedin decision making and health economicsand is crucial in terms of allocatingresearch funding. But, even if informationcould be (near) perfect, there is then theparallel issue of perfect, or near perfect,implementation of such information with-in routine practice. In this context, ourlarge data sets – and those of others – havegreat appeal in that they enable us not onlyto profile routine practice (i.e., realisticimplementation) but also to mimic trialsmethodology by designing studies thatselect sub sets of data which meet specificcriteria in order to answer specific ques-tions (i.e., valuable but certainly not perfectinformation).

In sum, considerable effort has been direct-ed towards reshaping practice via trialsmethodology in order to fit our own con-structions of what might be seen by manyas a somewhat rigid model of science.Mindful of the concepts of the value ofinformation and implementation, we needto build a more rugged but good enoughscience that is designed to deal with thenaturally occurring and unpredictable ter-rain of routine clinical practice.

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FOOTNOTEThe work reported in this article reflects anongoing research program variously fund-ed by the Mental Health Foundation, NHSPriorities and Needs Research &Development Levy via Leeds MentalHealth & Teaching NHS Trust, theCounselling in Primary Care Trust, and theArtemis Trust. Collaborations involve theCORE System Group, PsychologicalTherapies Research Network (North), andinternational collaborators from the USand continental Europe.

REFERENCES

Barkham, M. & Mellor-Clark, J. (2000).Rigour and relevance: Practice-basedevidence in the psychological thera-pies. In N. Rowland & S. Goss (ed.).Evidence-based counselling and psycholog-ical therapies: Research and applications(pp.127-144). London: Routledge.

Barkham, M., & Mellor-Clark J. (2003).Bridging evidence-based practice andpractice-based evidence: Developing arigorous and relevant knowledge forthe psychological therapies. ClinicalPsychology & Psychotherapy, 10, 319-327.

Barkham, M., Connell, J., Stiles, W. B.,Miles, J.N.V., Margison, J., Evans, C., &Mellor-Clark, J. (in press). Dose-effectrelations and responsive regulation oftreatment duration: The good enoughlevel. Journal of Consulting and ClinicalPsychology.

Barkham, M., Evans, C., Margison, F.,McGrath, G., Mellor-Clark, J., Milne, D.& Connell, J. (1998). The rationale fordeveloping and implementing corebatteries in service settings and psy-chotherapy outcome research. Journalof Mental Health, 7, 35-47.

Barkham, M., Gilbert, N., Connell, J.,Marshall, C. & Twigg, E. (2005).Suitability and utility of the CORE-OMand CORE-A for assessing severity ofpresenting problems in psychologicaltherapy services based in primary andsecondary care settings. British Journalof Psychiatry, 186, 239-246.

Barkham, M., Margison, F., Leach, C.,Lucock, M., Mellor-Clark, J., Evans, C.,Benson, L., Connell, J., Audin, K. &McGrath, G. (2001). Service profilingand outcomes benchmarking using theCORE-OM: Towards practice-basedevidence in the psychological thera-pies. Journal of Consulting and ClinicalPsychology, 69, 184-196.

Barkham, M., Mellor-Clark, J., Connell, J.,& Cahill J. (in press). A COREapproach to practice-based evidence: Abrief history of the origins and applica-tions of the CORE-OM and CORESystem. Counselling & PsychotherapyResearch.

Barkham, M., Rees, A., Leach, C., Shapiro,D.A., Hardy, G.E., & Lucock M. (2005)Rewiring efficacy studies of depres-sion: An empirical test in transformingBDI-I to CORE-OM scores. MentalHealth and Learning Disabilities Researchand Practice, 2, 11-18.

Beck, A.T., Ward, C.H., Mendelson, M.,Mock, J., & Erbaugh, J. (1961). Aninventory for measuring depression.Archives of General Psychiatry, 4, 561-571.

Cahill, J., Barkham, M., Stiles, W.B.,Twigg, W., Rees, A., Hardy, G.E., &Evans, C. (in press). Convergent validi-ty of the CORE measures with mea-sures of depression for clients in briefcognitive therapy for depression.Journal of Counseling Psychology.

Evans, C., Connell, J., Barkham, M.,Margison, F., Mellor-Clark, J., McGrath,G. & Audin, K. (2002). Towards a stan-dardised brief outcome measure:Psychometric properties and utility ofthe CORE-OM. British Journal ofPsychiatry, 180, 51-60.

Evans, C., Connell, J., Barkham, M.,Marshall, C. & Mellor-Clark, J. (2003).Practice-based evidence:Benchmarking NHS primary carecounselling services at national andlocal levels. Clinical Psychology &Psychotherapy, 10, 374-388.

Hamilton, M. (1967). Development of a

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rating scale for primary depressiveillness. British Journal of Social andClinical Psychology, 6, 278-296.

Leach, C., Lucock, M., Barkham, M., Stiles,W.B., Noble, R., & Iveson, S. (in press).Transforming between BeckDepression Inventory and CORE-OMscores in routine clinical practice.British Journal of Clinical Psychology.

Lutz, W., Leach, C., Barkham, M., Lucock,M., Stiles, W.B., Evans, C., Noble, R., &Iveson, S. (2005). Predicting rate andshape of change for individual clientsreceiving psychological therapy: Usinggrowth curve modeling and nearestneighbor technologies. Journal ofConsulting and Clinical Psychology, 73,904-913.

Margison, F., Barkham, M., Evans, C.,McGrath, G., Mellor-Clark, J., Audin,K., & Connell, J. (2000). Measurementand psychotherapy: Evidence basedpractice and practice-based evidence.British Journal of Psychiatry, 177, 123-130.

Mellor-Clark, J. & Barkham, M. (2006).The CORE System: Developing anddelivering practice-based evidencethrough quality evaluation. In C.Feltham & I. Horton (eds.), Handbook ofcounselling and psychotherapy. (pp. 207-224). 2nd Edition. London: SagePublications.

Mellor-Clark, J., Curtis Jenkins, A., Evans,R., Mothersole, G., & McInnes. (inpress). Resourcing a CORE Network todevelop a National Research Databaseto help enhance psychological therapyand counselling service provision.Counselling & Psychotherapy Research.

Mullin, T., Barkham, M., Mothersole G.,Bewick, B.M., & Kinder, A. (in press).Recovery and improvement bench-marks in routine primary care mentalhealth settings. Counselling &Psychotherapy Research.

Stiles, W.B., Barkham, M., Twigg, E.,Mellor-Clark, J., & Cooper, M. (inpress). Effectiveness of cognitive-behavioural, person-centred, and psy-chodynamic therapies as practiced inUnited Kingdom National HealthService settings. Psychological Medicine.

Stiles, W.B., Leach, C., Barkham, M.,Lucock, M., Iveson, S., Shapiro, D.A.,Iveson, M. & Hardy, G.E. (2003). Earlysudden gains in psychotherapy underroutine clinic conditions: Practice-based evidence. Journal of Consultingand Clinical Psychology, 71, 14-21.

Waskow, I.E. (1975). Selection of a corebattery. In I.E. Waskow & M.B. Parloff(Eds.), Psychotherapy change measures(DHEW Pub. No (ADM) 74-120).(pp.245-269). Washington, DC: U.S.Government Printing Office.

Michael Barkham is Professor of Clinical &Counselling Psychology and Director ofthe Psychological Therapies ResearchCentre at the University of Leeds, UK. Hehas an abiding interest in bridging the sci-entist-practitioner gap.

ADDRESS FOR CORRESPONDENCE:Psychological Therapies Research Centre17 Blenheim TerraceUniversity of LeedsLeeds LS2 9JT UKEmail: [email protected]: +44(0)113-343-5699

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Nnaji: Dr Kaslowcan you give a briefprofessional biogra-phy starting withwhere you went toschool and endingwith what you aredoing today?

Dr. Kaslow: I a t t e n d e d t h eU n i v e r s i t y o fPennsylvania for

my undergraduate degree, where I wasmentored by Martin Seligman, Ph.D. andLyn Abramson, Ph.D. I got my Ph.D in clin-ical psychology from the University ofHuston with Lynn Rehm, Ph.D. as my pri-mary mentor. My internship and post-doc-toral training were at the University ofWisconsin—Madison in the Department ofPsychiatry. I was on the faculty of YaleUniversity School of Medicine from 1984-1990 and in 1990 moved to EmoryUniversity School of medicine, where I amcurrently a professor and the chief psychol-ogist. At Emory I am deeply involved in thetraining the next generation of psycholo-gists. Due to my passion of training futurepsychology, I became the Chair of theAssociation of Psychology Postdoctoral andInternship Centers (APPIC) from 1998-2002.Within the local community I am activelyinvolved both in clinical practice with ado-lescents, and adults as well as beinginvolved in research especially in the assess-ment and treatment of abused, suicidal andlow income African American women.Another focus is the impact of intimate part-ner violence on low- income AfricanAmerican children and treatment of suicidalbehavior in African American women.

Nnaji: You have spent much of your careerworking in the university setting, medical

schools, as a researcher and in direct ser-vice to individuals and communities. Whatwere those experiences like for you?

Dr. Kaslow: Working in medical schoolhas been a wonderful experience as I lovethe interdisciplinary approach, as well asthe clinical work, education and researchinvolved in the setting. I really cherish theopportunity to train future psychologists,particularly during their internships andpostdoctoral fellowships. This passion ledto involvement with APPIC where I was thechair for four years, an experience that hasbeen fruitful and rewarding to me. I enjoydoing clinically relevant research. I alsoenjoy taking care of patients and I am basedin part at Grady hospital, a university affili-ated inner-city hospital that predominantlyserves low-income children and adults ofcolor. At Grady, I really value the chance toprovide services to people with serious andpersistent mental and medical illness. I alsohave a private practice through the EmoryClinic where I work with adolescents,adults, couples, and families. I do a lot ofadministration as a chief psychologist and Iam very active in the medical school,Atlanta community, and committees in theuniversity. I feel it is important and person-ally meaningful to be active in one’s univer-sity, local, and larger professional communi-ty. Participation in these activities has pro-vided me with countless enriching experi-ences and has afforded me the opportunityto interact with a diverse group of fascinat-ing individuals.

Nnaji: Having worked in the medicalschools, what advice would you give topsychologists, social workers, and othermental health professionals who plan to, orare presently working in medial school set-ting where they may encounter marginal-ization from the medical staff?

INTERVIEW

Interview with Dr. Nadine KaslowBy Theodore Nnaji, M.A.

Nadine Kaslow, Ph.D., ABPP

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Dr. Kaslow: It is really important to hold toand be proud of your own professionalidentity and I also think you need to learnhow to fit into another culture. One needs tobe bi-culturally competent; that is, oneneeds to be competent as a psychologist andalso have the skill to function effectively inanother cultural environment, such as themedical culture. Also you need to berespectful of that culture. The ability to besuccessful in any environment depends inlarge part to the nature of the relationshipsthat we form with our interdisciplinarycadre of colleagues and peers, students,patients/clients, and superiors. If relation-ships are respectful and positive, we canminimize most of the historical tensions thatexist between disciplines or professionals.

Nnaji: Can you tell me about some of yourleadership roles?

Kaslow: As I mentioned earlier, I am theChief Psychologist and the Director ofPostdoctoral Fellowship Training. We haveapproximately 14 fellows each year, and itis so much fun to help them as they makethe transition to their first job. We have awonderful job mentorship program,designed to assist fellows with securingemployment. Within the medical school, Iam the chair of the board that disbursesresearch funds and the past chair of theCommittee on the Status of Women inMedicine. At the University, I am thePresident-Elect of the President’sCommission on the Status of Women. I amalso on the University Senate and will bePresident of the Senate from 2007-2008. Atthe state level, I am on both Mrs. RosalynnCarter’s mental health advisory board, andthe Mayor of Atlanta’s advisory board onwomen. At the national level I am thePresident of the American Board of ClinicalPsychology and also the secretary forAmerican Board of ProfessionalPsychology Board of Trustees. I am PastChair and Board Member Emeritus ofAPPIC and currently a board memberwhere I handle informal complaints of preand post- doctoral interns. Through thisrole, I assisted displaced interns and post-

doctoral fellows in the gulf coast states fol-lowing the tragedy of Hurricane Katrina,and for these outreach efforts, I was recent-ly honored with a Presidential Citationfrom the American PsychologicalAssociation (APA). I am also the President-Elect of the Family Process Institute Boardand currently the associate editor of threejournals: Journals of Family Psychology,Journal of Clinical Psychology in MedicalSettings, and Professional Psychology:Research and Practice. I am on the Councilof Representative for Division 12 (Societyof Clinical Psychology) within the APA andI am a Past President of Divisions 12(Society of Clinical Psychology) and 43(Division of Family Psychology).

Nnaji: You have been involved in numer-ous leadership positions not only at theUniversity but also at local, state andnational levels. What were you most proudof during your tenure in these leadershiproles.

Dr. Kaslow: One thing I am most proud ofis reaching out to multiple constituencieswhen I was APPIC Chair and now as theperson who handles informal problem res-olution processes, including graduate stu-dents, interns, and postdoctoral fellows, aswell as faculty and staff in graduate school,internship, and postdoctoral settings. I amdelighted that I have been able to commu-nicate and respond to people’s needs andmake them feel that they belong, that theyhave a voice. Through these efforts, I striveto be particularly sensitive to individualand cultural diversity and am enormouslycommitted to making people’s lives better.A second accomplishment in which I takeparticular pride was my role as Chair of the Steering Committee for the very successful, mutli-national CompetenciesConference: Future Directions in Educationand Credentialing in ProfessionalPsychology. It was quite an honor toreceive the 2004 APA DistinguishedContributions to Education and Trainingfor my investment in advancing our pro-fession with regards to the competency-movement. One of the most special aspects

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of receiving the award was having theopportunity to express my sincere andheartfelt gratitude to my family, friends,colleagues, faculty, mentees, and patientswho have so influenced my life.

Nnaji: You are associate editor to thesejournals: Journals of Family Psychology,Journal of Clinical Psychology in MedicalSetting and Professional Psychology: Researchand Practice. What type of issues should beaddressed in these publications?

Dr. Kaslow: It is important to address top-ics that are relevant to practitioners, scien-tists, educators, and policy-makers alike.There is a need to reduce the separation inour profession between quality researchand practice. Researchers need to be betterinformed by practitioners, while practition-ers need to be informed by researchers; theflow of information need to go in both direc-tions. We also need to think about the pub-lic policy implications of what we are pub-lishing. How we need to train students andourselves are also important issues to beconsidered, especially how to integrateinformation in the journals. It is also imper-ative that our publications be timely andattend to current challenges facing our soci-ety. From my vantage point, all of our schol-arly endeavors should highlight all aspectsof individual and cultural diversity, includ-ing but not limited to, race and ethnicity,age, gender, and disability/ability status.

Nnaji: What advice will you give to studentsand young professionals like myself?

Dr. Kaslow: Figure out what you want todo and go for it. You need to figure outwho you are and your strengths. Capitalizeon your personal strengths. Find your pas-sion in our profession and pursue it, and ifyou do that in a thoughtful way and allowother people to mentor and support you,you can be successful in your chosen path.It is essential to recognize that your careerpath isn’t going to be a straight line; thereare always twists and turns that you don’texpect, which invariably will enrich yourcareer and life. Find a mentor to guide you,as I firmly believe that people can really

help you to be successful. Networking iscrucial. Spend time networking. It is alsoimportant to take your learning and grow-ing seriously because the more competentyou are in a broad range of domains, thebetter you will be. And finally, don’t forgetto maintain your integrity. Self-respect isinvaluable.

Nnaji: It is evident that you have had asuccessful career, including your manycontributions to the field of psychology.What are you planning to do next?

Dr. Kaslow: I don’t know. Just like a newprofessional, I am trying to figure out thenext stage in my life and career. However, Ireally like what I am doing now, which is awonderful, albeit very busy blend, of clini-cal practice, clinically-relevant research,teaching and supervising, mentoring,administration, and policy work and advo-cacy. Therefore I plan to continue most ofthese activities. Yet, part of me is alsothinking of pursing different kinds ofopportunities, so stay tuned. I am confi-dent that the knowledge, skills, and atti-tudes that I have embraced as a psycholo-gist will serve me well in whatever direc-tion that I go. In the meantime, I love whatI do. In addition, I am really enjoying hav-ing ballet be a vital part of my life again.Ever since dancing seriously as a child andadolescent, ballet has had a special place inmy heart. Dancing actively again gets mybody in shape and alive, just as psychologykeeps my mind agile and enlivened.

Nnaji: Thank you Dr. Kaslow

Dr. Kaslow: My pleasure.

Theodore Nnaji is originally from Nigeria. Hegraduated with a B.A. (Hons.) in Philosophyfrom St. Joseph Major Seminary in Ikot Ekpene,Nigeria. He also received his M.A. in Psychologyfrom City College of New York. Currently, he isa second year graduate student in the Psy.D.program at School of Professional Psychologyat Wright State University in Dayton, Ohio.His research interests focus on health psycholo-gy, cross cultural psychology, mental health,and psychotherapy.

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When I was growing up, we used to spendthe summers at the beach. Almost everyday the challenge was to see how long thatsmall pile of nickels my parents providedwould last. Could I win enough pinballmachine games to justify having a hot dogfor lunch? If not, it was time to swim, sail,or build forts in the sand. Saturday eveningthere might be a trip to the amusementpark with its rides and skee-ball alleys.Games were special those days; never to beforgotten. Today, there is no question inmy mind that the 21st century will be anera of educated consumers utilizing themost up-to-date technology to ensure thatthey and their loved ones will have timelyaccess to the highest possible quality ofhealthcare. Yet, one must wonder: Wherewill the unprecedented advances occurringwithin the communications and computerfields actually take us? Will society come toappreciate what psychology’s expertisecan bring to their overall quality of life?Will professional psychology help shapethe future or merely react?

This spring I attended an interestingCongressional reception sponsored by theRobert Wood Johnson Foundation (RWJ),entitled Games for Health. According toRWJ, games are the world’s fastest grow-ing media form. In North America, 54 per-cent of all households purchased at leastone video game in 2004. Internationally,150 million computer-based game consoleshave been sold. Computer games are nowportable, with sales of over 170 millionhandheld systems like Game Boy or multi-player games such as Dark Ages ofCamelot generating millions of dollars insubscriptions monthly. The audience shareof some games is arguably larger thansome major cable television programs. Iwas back on the beach.

Games for Health, funded by RWJ, wasproduced by The Serious Game Initiative,an effort led by the Woodrow WilsonInternational Center for Scholars andDigitalmill which seek to apply games andgame technologies to a range of public andprivate policy, leadership, and manage-ment issues. By promoting research andthe dissemination of “best practices,” theirobjective is to build a community ofexperts who will explore how innovativecomputer and video game design anddevelopment methodologies can improvehealth and health care services.Specifically, Games for Health seeks tobuild on the enthusiasm for this technolo-gy and to capitalize on its potential to:reduce patients’ pain and the burden of ill-ness; strengthen health care providers’ andleaders’ knowledge and skills; and informthe general public about maintaining andimproving their health, while supportingtheir efforts to engage in healthy behaviors.Interestingly, psychotherapy and address-ing post traumatic stress disorder are twoof their identified interests.

At the reception we were invited to take aturn at a variety of simulation, virtual real-ity, and other innovative interactive videogames that were specifically designed toimprove health and health care. Examples:Pulse!!—a lifelike virtual environment forcivilian and military health care profes-sionals to practice clinical skills in responseto catastrophes. Yourself! Fitness—the firstmass-market PC and console-based video-game workout system. Sweat it out withyour own virtual personal trainer, Maya.Ben’s Game – designed by a nine-year-oldin remission from Leukemia and aLucasArts game professional; childrenwith cancer fight back to relieve the painand stress of treatment. And, Dance DanceRevolution—this best-selling videogame

WASHINGTON SCENE

An Exciting Future for the Flexible and CreativePat DeLeon, Ph.D., former APA President

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features dynamic dance workouts provento burn calories and hit cardio target levels.Watching the considerable enthusiasmdemonstrated by those Senate staff partici-pating, it was evident that many of us havenever really grown up. It was also evidentthat basic psychological research and atten-tion to the psychosocial-cultural-economicgradient of health care was activelyemployed in the design of the variousexhibit modules.

Highlights: Brain Age: Train Your Brain inMinutes a Day, developed for NintendoDS, is designed to push people to exercisetheir mental muscles. Inspired by a promi-nent Japanese neuroscientist, it drawsupon studies that evaluate the impact ofcertain reading and mathematical exerciseson brain stimulation. Project activitiesinclude quickly solving simple math prob-lems, counting people going in and out ofa house simultaneously, drawing pictureson the Touch Screen, and reading classic lit-erature out loud. DanceDanceRevolution(DDR): This videogame challenges playersto follow dance steps and music cues usinga special, interactive dance mat. Hugelypopular among kids, adolescents, andSenate staff, school officials in WestVirginia—a state with one of the highestobesity rates in the nation—recently part-nered with Konami to add DDR to thephysical activity curriculum in all publicschools throughout the state. “Teachersfound that kids who didn’t like sports gotinto the game and were more likely to getmoving.” Immune Attack combines 3Ddepiction of biological structure and func-tion with advanced educational technolo-gies to provide an introduction to basicconcepts in immunology for high schooland college students. It is intended to be asfun and compelling as the computer gamescurrently played by many adolescents and young adults. Students are motivated witha series of progressively more difficultchallenges in a compelling gaming envi-ronment in which success depends onincreasingly sophisticated grasp of con-cepts in immunology. The goal is to helpyoung adults to choose better lifestyle

behaviors to protect themselves from infec-tion by experiencing first-hand how diffi-cult it is for the immune system to defendagainst many viruses and bacteria. SecondLife is a Web-based multiplayer worldwhich allows its users, or citizens, to con-struct their own virtual worlds within it.This has spawned a number of amazinghealth-related efforts. For instance,Dartmouth University researchers are look-ing at using it to create virtual scenarios thathelp train first responders to react to bio-hazard attacks. Other researchers have“built” a house that approximates the visu-al experiences described by patients suffer-ing from schizophrenia, in an effort to betterunderstand and treat that condition.Scientists devoted to studying and helpingpeople with various neurological disordersalso see significant potential for this modal-ity to help individuals struggling withAsperger’s syndrome. Their game has beenused to create “Brigadoon Island,” a spacewhere people with Asperger’s and theircaregivers can interact and help patientsdevelop the socialization and coping skillsneeded to minimize the effect of their dis-ease. And, without question, my personalfavorite: FreeDive, an immersive experiencethat transports the user to a virtual sea floor.This engaging virtual reality environmentfor critically ill children seeks to reduce anx-iety and pain associated with certain med-ical procedures and to foster a more positiveoutlook for children and their families. Oncethere, visitors can explore a coral reef sys-tem, check out diverse sea life and search forsunken treasure. Researchers are looking athow exposure to this serene and interestingenvironment might help children to bettertolerate pain associated with chemotherapytreatment. The results of Phase I, which test-ed how long subjects could endure immers-ing their hand in ice water while interactingwith the game, found that the group of 60children dramatically increased their paintolerance from a baseline average of 28 sec-onds of immersion to 78 seconds. This sug-gests that procedures lasting approximatelya minute, like IV and port insertions, may beadministered with much less pain and anx-iety for the child.

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As one contemplates the changes withinhealthcare that will undoubtedly occurduring the 21st century, it is of particularinterest that the RWJ presenters noted: “Astelemedicine expands, health careproviders will need to work more andmore with their colleagues and theirpatients over vast distances and in virtualenvironments. Collaboration and network-ing are also critical aspects of modern-dayonline multiplayer games; informationsharing tools (e.g., blogs and wikis), onlineinstant communications (e.g., instant mes-saging), and virtual space manipulation(allowing players to construct or interactwithin an online world) are skills and toolsbeing pioneered in computer gaming thatare likely to become commonplace inhealth and health care.” How, we wonder,will our profession respond to thesechanges in their daily practices?

It should be quite evident that the gamingindustry is developing the technology –using physics systems, facial animationtechnologies, and artificial intelligencealgorithms—to create “virtual humans,”software-based visuals combined with arti-ficial intelligence and modeling that createbelievable and lifelike human characters.This technology, when combined with thevirtual patient technologies being devel-oped for medical uses, will result in lifelikeand accessible simulations of patients’ con-ditions. Research agendas that quicklycome to mind: Will games truly help gethealth information to hard-to-reach audi-ences, or will they primarily be used bythose already motivated to seek ways toimprove their health? Will the impact ofgames be short-term, or will the use ofhealth promotion games affect behavior ina sustained way? Are games as effective, orin some cases even more effective, at pro-moting and improving health and healthcare than other methods of training andcommunication? This is what health psy-chology is really all about. RWJ expects tomake a difference in our lifetime. Will psy-chology rise to the challenge?

Former Pennsylvania Psychological

Association President Steve Ragusea and Ifrequently discuss when private practition-ers will personally experience society’sgrowing interest in data-driven, “goldstandard” treatment protocols in theirdaily lives. The Institute of Medicine (IOM) reports that the time lag between the dis-covery of more efficacious forms of treat-ment and their incorporation into routinepatient care is unnecessarily long, in therange of about 15 to 20 years and eventhen, many medical technologies are beingused inappropriately. Further, 46 percent ofAmerican adults (60 million people) arefunctionally illiterate in dealing withhealth. Health literacy reflects having thecapacity to obtain, process, and under-stand basic health information and services needed to make appropriate health deci-sions. This is a very important aspect ofpublic health, and although as profound asany new infectious or chronic disease, it israrely discussed by patients, policy mak-ers, and the public. Nevertheless, 100+ mil-lion Americans utilize the Internet toretrieve health-related information.Psychology must be proactive in insuringthat psychological expertise becomes a“Household Expectation,“ as proposed byPast President Ron Levant and further,that as one of our nation’s bona fide health-care professions, we accept our societalresponsibility to help educate consumersin developing their expectations.

Hawaii’s Prescriptive Authority Quest – AProactive Agenda for the Future: Duringlast year’s session of the Hawaii legisla-ture, the Hawaii Psychological Association(HPA), under the leadership of JillOliveira-Berry and Robin Miyamoto, wassuccessful in having the legislature estab-lish an Interim Task Force to explore thefeasibility of psychologists prescribing.HPA’s two legislative champions co-chaired the group. This year, the HawaiiHouse of Representatives passed HR 2589,which would allow appropriately trainedpsychologists practicing within federallyqualified community health centers and inmedically underserved areas to prescribe.The legislation was supported by each of

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the 13 community health center medicaldirectors; HMSA, the Blue Cross/BlueShield plan of Hawaii; and the Hawai’iNurses’ Association. HPA’s quest becamethe topic of radio debates and newspaperarticles (including on the editorial page),where it received the enthusiastic endorse-ment of the Hawai’i Primary CareAssociation. The Senate Health Committeerecommended the adoption of the Houseproposal and ultimately both legislativebodies agreed upon a compromise underwhich the State’s Legislative ReferenceBureau was directed to study the issue andreport back their findings to the legislaturefor consideration in the 2007 legislative ses-sion. Included in this report is to be areview of the Department of Defense RxPexperiences. In my judgment, HPA madeconsiderable progress, particularly in edu-cating the broader community regardingthe clinical expertise of our profession, aswell as truly engaging their membership indetermining their own destiny. An insid-er’s view of the process – Ray Folen:

“Having previously passed through theHouse Health Committee, this prescriptiveauthority bill was recognized as havingsome ‘legs’ on it. It is an access to care billfor the underserved and uninsured peopleof our State seeking care in communityhealth centers (CHCs). Psychologists, well represented in these areas, are in mostcases unable to get the psychiatric supportneeded. Working collaboratively with pri-mary care physicians has proven to be asuccessful alternative. They trust the med-ical psychologist’s psychopharmacologyskills and want them to operate more inde-pendently.

“Psychology was well represented at thehearing. Robin and Jill, co-chairs of theHPA RxP Task Force, delivered exception-ally persuasive testimony, as did otherHPA board members, doctoral-level psy-chology trainees, CHC staff, CHC medicaldirectors, the APA Practice Directorate, theLouisiana Academy of MedicalPsychologists, DoD prescribing psycholo-gists, social workers, and community-

based organizations such as the Hawai’iPrimary Care Association. A number ofpsychologists working in CHCs testifiedand made compelling statements, butclearly the most powerful message theycommunicated to the legislature was theirvery presence in the rural and underservedcommunities.

“Organized psychiatry, also realizing that theRxP bill had ‘legs,’ was particularly unkindat the hearing. It’s amazing that some of ourlegislators still find their self-serving argu-ments persuasive. Does it matter that so fewof them provide care to the underserved?Does it matter that they have not initiatedany meaningful efforts to address the mentalhealth problems of this population?Thankfully, some of our legislators continueto champion our efforts to increase access tocare, despite the opposition.

“Psychiatry fervently brought out the sametired arguments. They reported that thenumber of Hawaii psychiatrists per capitais greater than in most other states, butfailed to mention that very few psychia-trists will treat Medicaid, welfare or unin-sured patients. Indeed, even in ruralHonolulu, it is near impossible for a wel-fare patient to get an appointment with apsychiatrist. Psychiatry did their best toscare the legislature by conjuring upvisions of psychologists killing patientsand, of course, failed to mention evidencefrom the DoD reports, the GAO reportsand the Louisiana psychologists that sug-gested a far more positive reality.Thankfully, several psychologists who tes-tified late in the session had the opportuni-ty to correct these distortions.

“More egregious were the outright lies andmisrepresentations. A state psychiatrist,attempting to minimize the severe lack ofpsychiatric services, testified that ‘everysquare mile of the State is covered by psy-chiatrists in the Adult Mental HealthDivision,’ but forgot to mention that theDivision provides services only to the SMIpopulation. After Robin spoke eloquentlyand in detail about the additional training

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prescribing psychologists receive, a psychi-atrist told the legislators it was an ‘11 weektraining program.’ After Robin provided amap showing where psychologists wereproviding services in Medically Under-served Areas, a psychiatrist testified thatpsychologists don’t work in underservedareas. We were also amused by the creativ-ity of the testimony: one psychiatrist saidwe don’t read medical journals and there-fore shouldn’t prescribe; another psychia-trist showed a graph with two years of RxPtraining presented as two hours. Whenpressed by the legislators to define the min-imum training necessary to prescribe, thepsychiatrists reluctantly suggested thetraining required for licensure as an APRN.When asked what that training entailed,they didn’t have a clue! A Professor ofPsychiatry called both psychology and thelegislature ‘immoral’ for promoting the bill.

“One of the more disturbing moments atthe hearing was when a noticeably med-icated patient read testimony that had beenprepared for her in opposition to RxP. Thepatient stumbled over words she could not pronounce and obviously had not seen

before, parroting arguments that she didn’tappear to understand.

“Over the past two decades we haveplaced many psychologists in underservedareas of the State; psychologists are in 80%of all CHCs and the goal is to have 100% bythe end of 2006. We have articulated afinancial model that will allow CHCs toeasily recoup the costs of hiring medicalpsychologists. We have a school (ArgosyUniversity/Honolulu) with a primary mis-sion of training psychologists to work withdiverse and marginalized populations. Wehave a post-doctoral psychopharmacology training program in place. On the otherhand, psychiatry is placing only 3% of itsgraduates in underserved areas. It can’t fillpsychiatry residency positions withoutrecruiting 40% from foreign countries.Psychiatry’s goal at the hearing was toinstall fear and confusion in the legislature.In the past, this strategy was effective. Itappears, however, that the reasoned wordis gaining ascendancy.” And, we wouldadd, that HPA’s membership is fullyengaged. Aloha

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PERSPECTIVES ON PSYCHOTHERAPY INTEGRATION

The Nature of Unified Clinical Science:Implications for Psychotherapeutic Theory, Practice,Training, and ResearchJack C. Anchin, Ph.D., University at Buffalo, The State University of New YorkJeffrey J. Magnavita, Ph.D., ABPP, University of Hartford and The Connecticut Center forShort-Term Dynamic Psychotherapy

THE NATURE OF UNIFIED CLINICALSCIENCEA convergence of findings from a variety ofdisciplines is dramatically advancing ourinsight into the multilevel complexities ofsuch fundamental realms of human experi-ence as the nature of consciousness and therelational-interpersonal origins of the self(Damasio, 1999; Kandel, 2005; Shore, 2003;Siegel, 1999; Wilber, 2000) and in theprocess significantly reshaping the way inwhich we conceptualize personality theo-ry, psychopathology, and psychotherapy.These latter three interrelated fields of psy-chology and their increasingly multidi-mensional frameworks offer valuable lens-es into the nature and complexities ofhuman function and dysfunction, process-es of development, and mechanisms ofchange. More broadly, these three fieldsform the foundations of unified clinical sci-ence, defined as follows:

Unified clinical science is a theoretical, clin-ical, and research movement, whichattempts to identify the structures, process-es and mechanisms that interconnect themajor domains of human functioning.Included within the domain of unified clin-ical science are personality theory, devel-opmental psychopathology, and psycho-therapy, which include the processes andmechanisms of change that are initiated inrelationship with a professsional therapist.(Magnavita, in press, ms. p. 3)

In our view, the field of psychotherapy is asubdiscipline of unified clinical science,and it provides a distinctly important and

valuable point of convergence for many ofthe multidisciplinary findings emergingfrom contemporary clinical science.

UNIFIED PSYCHOTHERAPYOur field’s quest for the “holy grail”— themost potent therapeutic approach withapplicability to the widest array of psycho-logical disorders and forms of human suf-fering—has fueled incredible discoveriesover the past century of modern psy-chotherapy. Whereas a century ago therewere few treatments for mental disorders,contemporary psychologists have a pletho-ra of methodologies from which to selectand to offer those experiencing emotionaland psychological pain. Numerousapproaches to psychotherapy have beendeveloped, some have evolved, and somehave dropped by the wayside. Unified psy-chotherapy emerges from the scientificadvances and treasure trove of clinical evi-dence accruing from these multiparadig-matic developments over the past century,and from intimately related interest indeveloping a holistic model that canaccount for the main domains of humanfunctioning while offering ever morepotent guidelines and principles for insti-gating healthy change processes.

Placed in this dynamic historical context,we perceive unified psychotherapy to bethe next emerging wave in the evolution ofpsychotherapy, preceded by three previousdevelopmental stages over the past centu-ry. The first wave was characterized by theappearance of single school models, begin-ning with Freud’s psychoanalysis and fol-

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lowed, during overlapping periods, bybehavior therapy, humanistic psychology,family systems, cognitive, and biomedicalapproaches. Each such approach tended toemphasize a particular domain or dimen-sion of human personality and function-ing, and by virtue of the parochial attitudesof developers and followers of these mod-els, contentiousness among adherents ofdifferent models was not unusual. The sec-ond wave was one of rapprochement as clin-ical theorists and practitioners, amid devel-opment of branches within each of thedominant models, undertook forays intoother schools of thought in an effort tounderstand these alternative approaches.At times these cross-theoretical under-standings were achieved through inter-preting and retranslating them into thefamiliar terms of one’s favored theoreticalsystem, well exemplified by Dollard andMiller’s (1950) significant book Personalityand Psychotherapy. The third developmen-tal wave has been psychotherapy integration.Given major impetus by Wachtel’s (1977)seminal volume Psychoanalysis and BehaviorTherapy and propelled by still additionalfactors (see Gold and Stricker, 2006), thehighly productive integrative movementhas moved psychotherapy significantlybeyond rapprochement, placing emphasison identifying and harnessing key com-mon therapeutic factors and on systemati-cally integrating theoretical concepts andtechnical procedures associated withdiverse approaches to create new thera-peutic amalgams more encompassing, ver-satile, and effective than any singleapproach taken alone.

Even as the integrative movement continuesto make highly valuable contributions to thefield’s advancement, several noteworthydevelopments convergently point to unifica-tion as a building dynamism in psychother-apy’s evolution. One such development hasbeen increasing theoretical and empiricalwork seeking to understand complex inter-relationships among clusters of domainsconstituting human structure, process, andfunctioning (e.g., neurobiology, humanattachment, self-other schemas, motives,

affect, interpersonal processes, culture),their interconnective dynamics in psy-chopathological and healthy states, andimplications for therapeutic intervention(e.g., Andersen & Saribay, 2005; Fosha, 2000;Reis, Collins, & Berscheid, 2000; Siegel,1999). This development is concordant withKendler’s (2005) call for psychiatry “tomove from a prescientific ‘battle of para-digms’ toward a more mature approach thatembraces complexity along with empiricallyrigorous and pluralistic explanatory mod-els” (p. 433). The unificationist trend is alsoevident in the growing appearance of differ-ent systems of psychotherapy founded ondistinctly unified conceptions of personality,psychopathology, and psychotherapy (e.g.,Allen, 2006; Mahoney, 2003; Marquis &Wilber, in press; Millon, 1999; Pinsoff, 1995;Singer, 2005). Each of these therapeutic sys-tems offers a cartography of the majordomains of human structure and functionand their interconnectedness, and uses itsall-encompassing metamodel as a basis forcomprehensive clinical assessment and for-mulation of specific therapeutic strategiesand interventions. A third and broaderdevelopment, incorporating but goingbeyond psychotherapy, is the highly sub-stantive body of proposals calling for thetheoretical and methodological unificationof the discipline of psychology as a whole(e.g., Henriques, 2003, 2004; Staats, 1983,1991; Sternberg and Grigorenko, 2001). Andas perhaps the most ambitious contempo-rary expressions of the unificationistZeitgeist, Wilson (1998) and Henriques (inpress) have offered provocative metatheo-ries designed to bring about nothing lessthan the transdisciplinary integration of allknowledge residing in the natural sciences,social sciences, and humanities.

Set against the backdrop of this variegatedunificationist wave, we define unified psy-chotherapy as a metatheoretical frame-work—a metaframe—on human adapta-tion, disorder, and psychotherapy thatencompasses all the major, presently iden-tifiable component domain systems ofhuman personality and functioning andtheir complex interconnections.

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Accordingly, unified psychotherapy takesinto account the entire ecosystem contextu-alizing and determinatively relevant toadaptive and maladaptive human function-ing and experience, ranging the spectrumfrom macrolevel to microlevel structures,processes and their interrelational dynam-ics. Dynamic system processes are as vitalas structures and functions, and part-wholerelationships are central, standing in dialec-tical contradistinction to reductionistic lev-els of analysis. Unified therapy is by defin-ition applicable to the entire spectrum ofpsychopathological adaptations seen inhuman systems, from microsystemic tomacrosystemic forms of dysfunction. Thisunifying framework is also capable of orga-nizing the vast assortment of empiricallysupported and clinically useful strategiesand methods now utilized in fostering ther-apeutic change. Unification does not rejectthe usefulness or validity of differentapproaches, such as cognitive-behavioral,psychodynamic, interpersonal, experien-tial, and neurobiological, but rather viewsthe respective modes of action posited byeach of these paradigms to be integralaspects of the domains and subsystems of acoherent unity.

As a context for further delineation ofimplications embedded in this unification-ist perspective, we next offer one concep-tion of a metatheoretical framework thatcan serve as a guide for unified approach-es to psychotherapy. Fundamentally, thisframework entails a biopsychosocial sys-tems model grounded in the relationalworld.

A MULTICOMPONENT, BIOPSYCHOSOCIAL SYSTEMSMODEL OF PERSONALITY AND PSYCHOPATHOLOGYA component systems model of unified psy-chotherapy, presented in detail inMagnavita (2005; cf. Magnavita, 2004b),was developed and in its evolution isbased on classic theoretical and empiricalfindings, as well as on new and pertinentfindings from clinical science. Any system

guided by principles of unification is nec-essarily an evolving one, and by its verymetatheoretical nature is equipped withboth the scope and continuing capacity toincorporate new findings from clinical sci-ence. The component system model isbased on the melding of a number ofimportant advances in clinical science,including the primacy of the biopsychoso-cial model of health and illness, its capaci-ty to incorporate the major subsystemdomains identified by clinical scientists asintegral to lifelong development and func-tioning of human systems, the particularcentrality of relational matrices in thedevelopment and evolution of personalityfunctioning and dysfunction, and theexplanatory power of systemic conceptsand principles for understanding how thisenormous complexity functions as a singu-lar, unified being.

We underscore that this is by no means apurely mechanistic conception, a doctrine offundamental determinism disguised insophisticated conceptual clothing. Processesof motivation and agency, complex issues ofhuman purpose and meaning, and theextensive impact of these animatingprocesses and issues on the vital realm ofsubjective experience are integral to thismodel. Magnusson (1995) emphasizes simi-lar points in his “integrated, holistic modelfor individual functioning and develop-ment” (p. 24). From his perspective, modelsfor understanding the “dynamic, complexprocesses” (p. 25) focused on by the naturalsciences are also applicable for theory andresearch on the functioning and develop-ment of the human being. Importantly,however, alongside similarities in structuresand processes studied in the natural sci-ences and psychological research, “there arealso essential differences, particularly whenthe interest is in the functioning of the totalorganism. At that level, fundamental char-acteristics and guiding elements in thedynamic, complex process of individualfunctioning are intentionality, linked toemotions and values, and lessons learnedfrom experience” (p. 26).

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Organizing the Various ComponentDomains and SubsystemsThere are various ways to parse and orga-nize the vast sea of structures and processesthat interactively constitute, influence, andcolor human functioning and experienceover time, but by definition any unifiedmodel must take account of structures andprocesses at every level of the humanecosystem. No vital domain can be ignored,or we risk failing to consider the nature andweighting of its contribution to maintaininga system in a state of dysfunction and pain.The component systems model presents aframework for coherently organizing andholographically representing this complexhuman ecosystem—the total ecology of thehuman personality system at its various lev-els. A holograph can be pictured as a threedimensional map of a complex system thatvisually organizes an array of data culledthrough different lenses.

The development of this model has beenstrongly influenced by the work ofBronfennbrenner (1979), who describes theinterconnected domains of human ecologyas “a set of nested structures, each insidethe next, like a set of Russian dolls” (p. 3).Building on his and others’ work, the com-ponent system model divides the totalecology of the human personality systeminto four nested levels that move from themost microscopic to increasingly macro-scopic levels. Each of the four levels is rep-resented as a triangular configuration, andeach triangle encompasses the interplayamong critical subsystems and associatedfactors identified over the course of a cen-tury of empirical and clinical investigation.

At the most microscopic level—themicrosystem—is the intrapsychic-biologicaltriangle, which concentrates on dynamicinterrelationships among affective/emo-tional, cognitive, and defensive systemsand processes, a matrix reciprocally linkedto the neurobiological system. The nextlevel is the interpersonal-dyadic triangle, onecomponent of the macrosystem andfocused on interpersonal processes in pre-

sent-day dyadic relationships. It empha-sizes the interplay among the humanattachment system, issues of closeness andintimacy, internalized relational schemas,interpersonal expectancies, verbal andnonverbal communication processes, andthe still-influential role of earlier attach-ment experiences in shaping these key rela-tional arenas. The third level, another com-ponent of the macrosystem, is representedby the relational-triadic triangle and includesamong its emphases the structure, func-tions, and processes that transpire when anunstable dyad—one experiencing moreconflict and anxiety than it can manage—seeks to stabilize itself through engaging athird individual. The fourth and widestperspective on the human personality sys-tem—the mesosystem—is offered by thesocicultural-familial triangle, encompassingcomplex interactions among the individualpersonality system, the family system, andthe sociocultural matrix; the later includesthe significant yet often underattended toimpact of cultural, economic, and politicalsystems on the functioning and dysfunc-tion of individuals, couples, and families.

Principal Dimensions of theBiopsychosocial SystemBecause of their assumptive importance,here we briefly highlight several principaldimensions that radiate throughout thisunified multicomponent biopsychosocialframework. An overarching postulate isthat the human biopsychosocial systemfunctions as a nonlinear dynamic system(Anchin, 2003, 2005, in press; Magnavita,2005a, 2005b, in press), which encompassesseveral key implications:

1. The interconnective, dialectical dimension. Aliving system functions holistically as aconsequence of the complex networks ofinterdependence that in self-organizingfashion bind together its componentdomains and subsystems into “an authen-tic substantive unity” (Millon, 2000, p. 41).Thus, we can beneficially dissect a livingsystem into the plurality of domains andsubsystems of which it is composed, as in

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the multicomponent system model pre-sented above, but there is the tacit under-standing that this diverse array of subsys-tems is united into a singular whole formthrough complex interconnective process-es. It follows that a significant epistemo-logical dimension of systems thinking is itsdialectical nature, in that “thorough under-standing of any particular constituent part[of a system] is achievable only insofar asthat understanding grasps the nature ofthat part’s reciprocal, dynamic interrela-tionships with other parts that constitutethe whole” (Anchin, 2002, p. 303).

2. The dynamic dimension. This dimensioncaptures the centrality of process, of contin-uous movement, change, and activity overtime. The vast networks of interrelation-ships that permeate the biopsychosocialmatrix unfold, in real time, as fluid, chang-ing processes of multivariate interactions.Fay (1996) offers a valuable recommenda-tion that captures this essential dimensionof systemic thinking: “Think processurally,not substantively (that is, think in terms ofverbs, not nouns). Include time as a fundamen-tal element in all social entities. See move-ment—transformation, evolution, change—everywhere” (p. 242, emphasis in original).

3. The nonlinear dimension. Nonlinearityprovides a more fine-grained picture of theinterwovenness of biological, psychologi-cal, and sociocultural processes. In contrastto the unidirectional, linear metapsycholo-gy that dominated 20th century psycholo-gy, nonlinearity highlights the multidirec-tional and circuitous pathways of influencethat radiate throughout the human biopsy-chosocial system by directing attention toreciprocal interactions, mutual effects,feedback loops, circles, networks, andcycles (Anchin, in press; Goerner, 1995;Lasser & Bathroy, 1997). Nonlinearity alsoholds that there can be a disproportionaterelationship between the magnitude of aninput and the size of its effect; a smallincrease in parental praise can dramatical-ly improve a child’s self-worth.

The Potency of Chaos Theory forExplaining Biopsychosocial ProcessesA major branch of contemporary systemsthinking exploding across the scientificlandscape over the past two decades (e.g.,Gleick, 1987; Capra, 1996; Chamberlain &Butz, 1998), chaos theory offers a powerfulexplanatory foundation for acceleratingour understanding of the complex dynam-ics of nonlinear systems and so the vastintricacies of the human biopsychosocialsystem (Anchin, in press; Magnavita,2005). Chaos theory concentrates especiallyon how nonlinear dynamic systems self-organize, develop and evolve over timeand space (Miller, 1999). Taking as its start-ing point “the delicate balance between theforces of stability and the forces of instabil-ity” (Gleick, 1987, p. 309) that pervade liv-ing systems, it articulates multivariate sys-temic processes that unfold when endoge-nous and/or exogenous factors disruptthese “dynamic tensions” (Mahoney, 1991,p. 419) between order and disorder—a bal-ance embodied in the continuous organis-mic dance between structural stability andcontinuous process in biological, psycho-logical, and social systems (Fredricksonand Losada, 2005; Mahoney, 2003). Undercertain conditions, disruption of thesedynamic tensions may trigger the system’stransition into the highly disequilibrialphase denoted by the concept of chaos. Anonlinear system in a chaotic phase under-goes turbulence, confusion, and disorder,yet this upheaval also opens the door forsignificant structural change (Perna andMasterpasqua, 1997). Nonlinear systemstransition out of chaos through self-orga-nizing processes, but the trajectory of thatmovement can be in any number of direc-tions. For the human biopsychosocial sys-tem, this can range from personal growthand development spawned by self-restruc-turing processes that create a more differ-entiated, complex, and resilient biopsy-chosocial structure, to sustaining structuralimpairments that result in compromisedlevels of functioning, negatively-tonedexperiential concomitants, and morechronic sequelea (Mahoney, 1991). In this

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light, psychotherapy entails the timely andplanful introduction into a high level ofindividual biopsychosocial “disorder anddisequilibrium” (Mahoney and Moes,1997, p. 186) salutary processes that pro-mote, enhance, and accelerate in healthydirections the individual’s intrinsic self-organizing and reconfiguring capacities.

PSYCHOTHERAPEUTIC IMPLICATIONSIt is important to delineate what differenti-ates the unification of psychotherapy frompsychotherapy integration and to specifythe numerous implications for the psy-chotherapist and clinical theorist, a taskundertaken in detail in Anchin andMagnavita (in press). The most essential dif-ferentiating factor is that psychotherapyintegration characteristically starts at thelevel of theory and then expands to theblending of therapeutic techniques, whilethe foundational starting point for unifiedpsychotherapy is the view that “integrationinheres in the person, not in our theories orthe modalities we prefer” (Millon, 2000, p.49). As such, from the outset unified psy-chotherapy emphasizes organismic holismand is multiparadigmatic within a unifyingsystemic framework. The focus of our inter-ventions is thus based on an understandingof the multilayered system. Here we brieflydistill core clinical implications derivingfrom this general perspective.

Assessment Implications of UnifiedPsychotherapyThe provision of effective psychotherapydepends significantly on the vitality andcapacity of clinical assessments and theirimplications for treatment. Most experi-enced clinicians would agree that anassessment geared towards establishing aDSM diagnosis offers only limited guid-ance about an optimal treatment package,which encompasses therapeutic approach,modalities, time frame, format and setting.From the perspective of a unified model,the progressively microscopic to macro-scopic levels that constitute the human per-sonality system necessitate a holonic, mul-tidimensional assessment, which seeks to

understand the patient’s dysfunctionalityand distress in terms of not only essentialprocesses at play within each componentdomain, but crucially, how all of thesedomains are interwoven, including howthe system has encoded at multiple levelsof analysis the core disturbance, and thefunction of symptom constellationsthroughout the total ecological system.Thus attuned to manifestations and process-es of functionality—dysfunctionality andadaptation—maladaptation across all levelsof the patient’s personality system, the ther-apist is better positioned to locate fulcrumpoints of change— that is, particular sub-system processes where well targeted inter-vention yields maximum therapeutic bene-fit. Such focal intervention can create a “tip-ping point” (Gladwell, 2000) at which theentire system reconfigures and attains ahigher level of functioning.

Unified Psychotherapy: Central Elementsof Therapeutic Strategy and InterventionIt is our strongly held belief that a unifiedmodel of psychotherapy should be able toincorporate and organize the vast body oftherapeutic methods and techniques thathave been clinically and empiricallydemonstrated to be effective across theentire spectrum of psychological disordersand relational dysfunctions. The presentunified approach does so by dividing ther-apeutic procedures into four categories ofrestructuring based on the systemicdomain level it is designed to target and inwhich its primary mutative action occurs.Specifically, coordinate with the fourdomain levels of the biopsychosocial sys-tem, these entail techniques and methodsfor achieving (a) intrapsychic restructur-ing, (b) dyadic restructuring (c) triadicrestructuring, and (d) mesosystemicrestructuring. By the same token, a unifiedmodel maintains that, by virtue of nonlin-ear interconnections throughout thebiopsychosocial system, effective restruc-turing at a given level is likely to havereverberating, constructive effects onprocesses at other systemic levels. In select-ing from the wealth of therapeutic inter-

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ventions falling within these four cate-gories, decisions must be made on the basisof the multisystem assessment and caseformulation about such matters as whethermultiple levels of the biopsychosocialmatrix need to be targeted, which systemiclevel to intervene in at any given time,whether multiple therapeutic modalitiesare needed and if so concurrently orsequentially, and the optimal fulcrumpoint(s) within a given systemic level. It isalso desirable that the therapist be able toflexibly navigate the microsystem to themesosystem in her or his interventionstrategies and, as continuous data are gath-ered and clinical understanding increases,that she or he tailor to the patient the spe-cific restructuring methods to be used.

The treatment process is also informed bythe view that for a system to evolve andgrow it must be able to increasingly differ-entiate and integrate its functions andprocesses. A system unable to differentiateas the need for more complex adaptation isdemanded is increasingly likely to falterand malfunction. To illustrate at the rela-tional-triadic level, a family low in self-dif-ferentiation may not be able to tolerate theheightened oscillations in self-identify andits relational expressions as children pro-ceed through adolescence, causing thefamily system to become pathogenicallystuck in this developmental transition.Virtually all modalities and techniques ofpsychotherapy advance differentiation andintegration within and among the variouscomponent domains of the biopsychosocialsystem, thereby enhancing growth andadaptive capacity.

TRAINING IMPLICATIONSImplications of the field’s movementtoward unification for the training of psy-chotherapists are complex and can onlybriefly be highlighted here. A unifiedmodel places an enormous burden ongraduate programs and students to masteror at least be conversant with findingsfrom all of the domain levels and subsys-tems composing the biopsychosocial sys-

tem. We believe that it is vital for traininginstitutions to provide a solid grounding inpersonality systemics (Magnavita, 2004a),which “emphasizes the study of personali-ty systems in their various forms and asso-ciated processes” (p. 19), so that thetremendous complexity of human systemscan be appreciated and understood. It isessential, as well, that psychotherapists intraining develop knowledge of the broadspectrum of therapeutic processes andtechniques associated with multiple para-digms, and that they begin to developskills in implementing selected interven-tions associated with each of the four cate-gories of restructuring. It is also highlydesirable that training programs cultivateskills in dialectical thinking vis-a-vis themultifaceted data of clinical science andpractice, for example learning to moveback and forth between thinking analytical-ly and reductionistically (e.g., keying intoand assessing different subsystems consti-tuting the patient) and thinking synthetical-ly and holistically (e.g., examining howthese different subsystems mutually influ-ence one another and discerning resultant,potent implications for intervention).

RESEARCH IMPLICATIONSThe research implications of unified clinicalscience are crucial to creating a unified psy-chotherapy that is vital and multiplyinformed. Essential to such research arenonlinear research methodologies, whichempirically study and in some cases presentin illuminatingly visual fashion processesand patterns transpiring within andbetween different domain levels of thebiopsychosocial matrix in both healthy andunhealthy states. These methods are wellillustrated by the sequential analysis tech-niques and nonlinear dynamic modelingused by Gottman (Gottman and Roy, 1990;Gottman et al., 2002), Reidbord andRedington (1995), and Fredrickson andLosada (2005). However, in a unified clinicalscience nonlinear systemic methodologiesdo not obviate the value of more traditionalreductionistic linear approaches to scientificinvestigation; rather, “the various method-

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ologies, both linear and nonlinear, are mutu-ally compatible, not contradictory. They canbe used to study different aspects of a sys-tem, depending on which is most appropri-ate for addressing the specific question athand” (Barton, 1994, pp. 12-13). Baseddirectly on the critical work of Norcross(2002) and colleagues, deciphering the com-plex webs of interconnection that existbetween the psychotherapy relationshipand therapeutic outcomes provides a com-pelling illustrative arena for integrating lin-ear and nonlinear methodologies.Qualitative-hermeneutic modes of inquiryalso have distinct value in a unified arma-mentarium of methods for studying thehuman ecological system, capturing thephenomenological emergence—that is, sub-jective experiences and meanings—thatcharacterize complex biopsychosocial inter-relationships as unified, lived phenomena.

We thus view methodological pluralism(e.g., Polkinghorne, 1983; Yancher & Slife,1997; Sternberg & Grigorenko, 2001) to bevital to unified clinical science. We suggest,as well, that methodological pluralism islikely to be embraced to the extent thatresearchers and practitioners are willing toadopt the underlying philosophical posi-tion of epistemological pluralism, whichendorses as meaningful and legitimatemultiple kinds of knowledge and multipleways of knowing (e.g., Downing, 2004).Grounded in this epistemic position, thediverse kinds of knowledge yielded byquantitative-empirical linear and nonlinearmethods and qualitative-hermeneuticapproaches can thereby be fully accommo-dated and integrated, fundamental todeveloping “truly comprehensive and uni-fied explanations and understandings ofthe complex biopsychosocial composition,dynamics, and experience of psychologicalhealth, disorder, and the transitionalprocesses that connect them” (Anchin, inpress).

CONCLUSIONThe fourth wave in the evolution of psycho-therapy is swelling, carrying compelling

implications for enriching conceptualiza-tions of personality and psychopathology,heightening therapeutic potency and effi-cacy, broadening the scope of clinical train-ing, and substantively expanding and inte-grating the foci and methodologies of con-temporary clinical science. Like any com-plex dynamic system in motion, the trajec-tory of the multiply constituted unifica-tionist wave is by no means entirely pre-dictable, but if the present article has suc-ceeded in piquing the reader’s interest inexploring and experimenting with any ofits numerous heuristic elements, its pur-poses have been effectively served.

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FEATURE: INFORMED CONSENT IN PRACTICEInformed Consent and the Psychotherapy ProcessTiffany A. Snyder, B.S. Loyola College of Maryland Jeffrey E. Barnett, Psy.D., ABPP, independent practice, Arnold, Maryland

Informed consent is an essential aspect of the psychotherapy process just as it is forresearch, teaching, consultation, and allother services psychologists provide. As ageneral concept, it seems well ingrained inthe minds of psychotherapists but itsspecifics may be less clear. Just whatinformed consent is, why it is so importantfor the psychotherapy relationship, what ele-ments it must include, what form it shouldtake, when it should occur, and the factorsthat impact its relevance are addressed inthis article. Recommendations for the appro-priate and ethical use of the informed con-sent process are also provided.

What is Informed Consent?Informed consent has been defined as “theprocess of sharing information with patientsthat is essential to their ability to make rationalchoices among multiple options” (Beahrs &Gutheil, 2001, p. 4). It is intended to protect thewelfare of clients by offering them the opportu-nity to make free and informed choices(Corrigan, 2003). Therefore, consent necessi-tates that clients and potential clients are pro-vided with the information needed for them tomake an informed decision about whether ornot to participate in a professional relationshipwith a psychotherapist. In providing this infor-mation, informed consent serves as a means ofsharing decision-making power in the thera-pist-client relationship (Meisel, Roth & Lidz,1977). Additional functions of informed con-sent include promoting client autonomy andself-determination, minimizing the risk ofexploitation and harm, fostering rational deci-sion making, and enhancing the therapeuticalliance. These factors clearly impact the thera-peutic process and the quality of the psy-chotherapy relationship.

The APA Ethics CodeThe APA Ethics Code has developedthrough its various revisions over time to

address the issue of informed consent withincreasing specificity. The EthicalPrinciples of Psychologists and Code ofConduct (APA, 2002) clearly states that allpsychologists intending to “conductresearch or provide assessment, therapy,counseling or consulting services” mustobtain the informed consent of that indi-vidual (p. 1065).

With regard to psychotherapy, the APAEthics Code states that when obtaininginformed consent, psychologists must“inform clients/patients as early as is feasi-ble in the therapeutic relationship about thenature and anticipated course of therapy,fees, involvement of third parties, and limitsof confidentiality and provide sufficientopportunity for the client/patient to askquestions and receive answers” (p. 1072).When utilizing treatments for which gener-ally recognized techniques have not beenestablished, psychologists must inform theirclients of the potential risks, uncertaintiesand alternatives to such treatments. Clientsmust also be made aware of the fact thattheir participation is voluntary in nature.Further, when a trainee offers treatment theclient must be informed that the psychother-apist is a trainee under supervision and begiven the name of the supervisor as part ofthe informed consent process (Standard10.01, Informed Consent to Therapy).

While informed consent strives to upholdmultiple ethical virtues as stated in theGeneral Principles of the APA EthicsCode—including beneficence, helping oth-ers, nonmaleficence, not doing harm, andfidelity, our obligation to clients—autono-my, or respect for a client’s independence,is said to be the foundation (Kitchener,1984; Bremer & VandeCreek, 1991).According to the APA Ethics Code, psy-chologists offering psychotherapeutic

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services are explicitly required to structurethe professional relationship to ensure thatthe client has the right to make informed,autonomous decisions regarding treatment(Fisher & Younggren, 1997).

Autonomy upholds the notion that indi-viduals have the right to live independent-ly, meaning one can think and act in anyway they choose, so long as they are notharming others (Bremer & VandeCreek,1991). When applied to informed consent,the principle asserts that a person has theright to act as a free agent and make deci-sions freely. Thus, the assumption underly-ing the implementation of informed con-sent is that doing so will protect the rightsand welfare of individuals by offeringthem the opportunity to make free andinformed choices (Corrigan, 2003). In orderto make an informed choice, a client needsinformation that is relevant to his or herdecision (Somberg, Stone, & Clairborn,1993). Once a client has such information,he or she can then weigh the positives andnegatives of treatment and decide whetheror not to enter into psychotherapy(Gustafson, McNamara, & Jensen, 1994). Itis then and only then that a client has theability to make a free and informed choice.Therefore, informed consent maintains aclient’s autonomy by providing the clientwith adequate information to make ratio-nal decisions, allowing the client to be theultimate authority regarding their health.

Consent can also be said to increases aclient’s autonomy by making him or herless dependent on the therapist for infor-mation (Handelsman, Kemper, Kesson-Craig, McLain, & Johnsrud, 1986). This inturn increases client responsibility anddecreases the likelihood of the client beingexploited (Handelsman et al). In additionto promoting autonomy, the act of obtain-ing informed consent by means of a collab-orative process should also help lay thegroundwork for and promote the thera-peutic process and relationship.

What Constitutes a Valid Decision?Informed consent must uphold three basic

elements in order to be valid. The personconsenting to treatment must be competentto do so, the consent must be voluntary,and the person must understand that towhich he or she is agreeing. With respect tocompetence, clients are presumed to havethe capacity to comprehend informationunless it has been shown otherwise (Lyden& Peters, 2004). Voluntariness asserts thatthe client’s decision is made in an environ-ment free from coercion (Meisel et al.,1977), while understanding ensures that aclient is provided with adequate informa-tion and comprehends his or her currentsituation and the proposed intervention(Lynn, 1983). For informed consent to takeplace, these three forces are expected towork together to manifest a trulyinformed, educated decision. It is assumedthat information given to a competent, freeindividual will result in understandingand that this understanding will yieldwhat is considered to be a valid decision(Meisel et al). But, ensuring a client’sunderstanding of the information present-ed is no simple matter. We must do morethan just have a client sign an informedconsent agreement or just ask if the clienthas any questions. We must actively ensureeach client’s understanding by reviewingwritten materials verbally and askingquestions to assess their understanding.

Verbal and Written ConsentIt is generally agreed that informed consentinformation should be provided to clientsboth verbally and in writing. Having infor-mation regarding the therapeutic processwritten down and at a client’s disposal mayallow clients to learn better, remember infor-mation longer, and avoid misunderstand-ings (Handelsman & Galvin, 1988). Suchforms may also increase clients’ autonomyby helping them to be less dependent on thepsychotherapist for information(Handelsman et al., 1986). In addition, byanticipating potential pitfalls, consent formsbegin a dialogue between client and psy-chotherapist. This exchange of informationmay help the dyad avoid surprises, disap-pointments and false expectations thatwould distract from the therapeutic work

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(Hare-Mustin, Maracek, Kaplan, & Liss-Levinson, 1979).

Yet, the use of written informed consentagreements presents special challenges forpsychotherapists. While a written record ofan agreement is important for client andpsychotherapist alike, just how this is doneis a matter of great importance. The typicalinformed consent agreement is written in amanner not easily comprehended by theaverage consumer. An interesting recentstudy on the readability of Notice ofPrivacy forms highlights this issue:

0 Percentage of patient privacy forms thatwere shown to be as easy to read ascomics.1 Percentage as easy to read as J.K.Rowling’s “Harry Potter and theSorcerer’s Stone.”8 Percentage as easy to read as H.G. Wells’“The War of the Worlds.”91 Percentage as easy to read as profes-sional medical literature or legal contracts.(The Numbers Game, 2005, p. F3)

It is recommended that informed consentdocuments be written at the fifth to eighthgrade reading level to ensure readabilityby our clients, although this may be modi-fied up or down depending on the popula-tion with which one works. The readinglevel of all documents may be assessed inMicrosoft Word using the Flesch-KincaidScale, which rates a document’s readingdifficulty from grade 0 to 12. It is interest-ing to note that in one recent study of 114informed consent documents used for par-ticipation in research studies in medicalschools, the average readability level was10.6, 2.8 grade levels above that which wasrequired by those institutions’ InstitutionalReview Boards (Paasche-Orlow, Taylor, &Brancati, 2003).

Several sample informed consent agree-ments are available for psychotherapists’ useand many individuals also choose to createtheir own documents. One document avail-able for our use and modification is provid-

ed on the website of the APA Insurance Trustat www.apait.org. Handelsman and Galvin(1988) have also created an outline of ques-tions regarding the nature of treatment,financial arrangements, confidentiality andtherapist credentials. By providing a clientwith a list of questions, the outline proposesall the potentially necessary content areas,while allowing the psychotherapist to elabo-rate upon the information that is relevant tothat particular client and omit unnecessaryinformation. More recently, Pomerantz andHandelsman (2004) updated this outline toinclude questions on insurance and man-aged care, use of therapy manuals or guide-lines, psychopharmacology, other approach-es to therapy, HIPPA requirements, and cre-dentials. It is intended to be used to improvethe effectiveness of whatever written infor-mation therapists give their clients or askthem to read and sign. The use of such ques-tions for discussion will also assist in ensur-ing clients’ understanding of that to whichthey are agreeing (one of the requirementsfor a valid consent process).

Informed Consent and thePsychotherapy ProcessIt has already been reviewed that informedconsent is a collaborative process thathelps to establish and enhance the psy-chotherapy relationship. The use of anactive informed consent process helps theclient to be more invested in treatment andto participate more actively in treatmentdecisions. It also works to minimize mis-understandings that could jeopardize thepsychotherapy relationship and process.

Most would agree that informed consentshould be provided prior to providing ser-vices. But, informed consent should beviewed as a process, not a singular event. Itshould be an ongoing dialogue betweenpsychotherapist and client in which bothparties exchange information, ask ques-tions, and together, reach agreementsabout the course of treatment over time(Packman, Cabot, & Bongar, 1994). Thus,the consent process should be initiated as early as is feasible in the treatment relationship and then updated on an ongo-

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ing basis as additional treatment decisionsneed to be made. Rather than being seensolely as a legal and ethics requirement,informed consent should be viewed as anintegral aspect of the psychotherapy processthat is essential for its success. In fact, theopen and honest discussion that occurs facil-itates the growth and development of thetherapeutic alliance and lays the ground-work for a relationship based on empower-ment through information sharing(Pomerantz & Handelsman, 2004). This dis-cussion also helps the psychotherapist tomore fully understand the client’s goals andconcerns regarding psychotherapy (Fisher &Younggren, 1997). Engaging in the processof informed consent, as has been described,also implies a certain level of respect forclients and their ability to utilize the infor-mation shared, make good decisions basedon it, and to participate as partners in theirtreatment. This hopefully helps set the tonefor the psychotherapy process and relation-ship to come.

What Clients Want to KnowWhile the APA Ethics Code and relevantstate laws will dictate much of what mustbe included in the informed consentprocess, knowledge of clients’ preferencesmay impact how we implement the consentprocess and which issues we emphasize. Inone study, Braaten and Handelsman (1997)found that current and former clients ratedinformation about inappropriate therapeu-tic techniques, confidentiality, and the risksof alternative treatments as most important.Yet, clients wanted to be informed firstabout how much therapy would cost,whether the psychotherapist had theappropriate credentials, and how sessionswere scheduled despite rating other factorsas most important.

Further, Pomerantz and Grice (2001) foundthat many potential clients and mentalhealth professionals were not in agreementon the ethicality of a range of behaviors bymental health professionals. The psy-chotherapy relationship will be well servedif psychotherapists ensure that clientsunderstand the psychotherapy process and

have realistic expectations regarding it. Thisis further highlighted in a study of clientsand potential clients in which 69%expressed the view that everything sharedin treatment is confidential, 74% believedthat there should be no exception to thisrule, and 96% stated that they wish to beinformed about confidentiality and any lim-its that exist prior to entering the psy-chotherapy relationship (Miller & Thelen,1986). These data are of special significancein that unanticipated breaches of confiden-tiality are likely to result in significantbreaches in the psychotherapy relationship.

Additional Issues and RecommendationsWhile a detailed discussion of the follow-ing issues is beyond the scope of this briefarticle, psychotherapists should considerthe informed consent process with variouspopulations and settings and when utiliz-ing a wide range of therapeutic media andformats. For example, we must be aware ofadditional clinical, legal and ethics require-ments regarding informed consent withminors, the elderly, when providing treat-ment to couples, families, and groups, insituations involving various custodyarrangements, in the managed care envi-ronment, and when engaging in telehealthand using various electronic media to pro-vide services. Care and attention shouldalso be given in other situations whereinformed consent may not be truly possiblesuch as with prison inmates, inpatients,and with court ordered treatment.

Current studies suggest that not all mentalhealth professionals share the same view ofthe informed consent process. It appears tobe applied in a wide range of ways andmany may not follow professional stan-dards regarding informed consent. In onerecent study (Croarkin, 2003), only 51% ofthe mental health professionals surveyedreported conducting and documenting aninformed consent process for psychothera-py in their practices. Further, only 25% ofthose surveyed acknowledged utilizing awritten informed consent agreement withtheir clients.

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Additional study is needed to betterunderstand the role, value, and benefit ofthe informed consent process and how itshould best be implemented. Any possiblelimitations or drawbacks to the informedconsent process should be understood andtheir implications addressed. It is alsoimportant to better understand just howpsychotherapists implement informed con-sent and how the decisions they makeimpact this. It will also be of value to betterunderstand the actual impact of theinformed consent process on the course ofpsychotherapy, including just whichaspects of informed consent promote a pro-ductive psychotherapy relationship andenhance psychotherapy outcomes.

REFERENCESAmerican Psychological Association

(2002). Ethical principles of psycholo-gists and code of conduct. AmericanPsychologist, 57, 1060-1073.

Braaten, E. B., Otto, S. & Handelsmann,M. M. (1993). What do people want toknow about psychotherapy?Psychotherapy, 30. 565-570.

Beahrs, J. O., Gutheil, T. G. (2001).Informed consent in psychotherapy.American Journal of Psychiatry, 158, 4- 10.

Bremer, D. A. & VandeCreek, L. (1991).Informed consent in mental health care. Psychotherapy Bulletin, 26, 13-16.

Corrigan, O. (2003). Empty ethics: Theproblem with informed consent.Sociology of Health & Illness, 23, 768-792.

Croarkin, D. O., Berg, J., Spira, J. (2003).Informed consent for psychotherapy: Alook at therapists understanding, opin-ions and practices. American Journal of

Psychotherapy, 57 (3), 384-400.Fisher, C. B., Younggren, J. N. (1997). The

value and utility of the 1992 ethics code.Professional Psychology: Research andPractice, 28, 582-592.

Gustafson, K. E., McNamara, J. R., Jensen,J. A. (1994). Parents’ informed consent decisions regarding psychotherapy fortheir children: Considerations of therapeutic risks and benefits.Professional Psychology: Research andPractice, 25, 16-22.

Handelsman, M. M., Galvin, M. D. (1988).Facilitating informed consent for outpa-tient psychotherapy: A suggested writ-ten format. Professional Psychology:Research and Practice, 19, 223-225.

Handelsman, M. M, Kemper, M. B.,Kesson-Craig, P., McLain, J., Johnsrud,C. (1986). Use, content, readability ofwritten informed consent for treatment.Professional Psychology: Research andPractice, 17, 514-518.

Hare-Mustin, R. T., Maracek, J., Kaplan, A.G., & Liss-Levinson, M. (1979). Rights ofclients, responsibilities of therapists.American Psychologist, 34, 3-16.

Kitchener, K. S. (1984). Intuition, criticalevaluation and ethical principles: The foundation for ethical decisions in coun-seling psychology. Counseling Psychologist, 12, 43-55.

Lyden, M., Peters, M. (2004). Assessingcapacity for informed consent: A ratio-nale and protocol. Mental Health Aspectsof Developmental Disabilities, 7, 97-105.Lynne, J (1983). Informed consent: Anoverview. Behavioral Science and the Law, 1, 29-45.

Meisel, A., Roth, L. H. & Lidz, C. W.(1977). Toward a model of the legal doc-trine of informed consent. AmericanJournal of Psychiatry, 134, 285-289.

Miller, D. J., Thelen, M. H. (1986).Knowledge and beliefs about confiden-tiality in psychotherapy. ProfessionalPsychology: Research and Practice, 17, 15-19.

Paasche-Orlow, M.K., Taylor, H.A.,Brancati, F.L. (2003). Readability stan-dards for informed-consent forms ascompared with actual readability. TheNew England Journal of Medicine, 348,721-726.

Packman, W. L., Cabot, M. G., Bongar, B.(1994). Malpractice arising from negli-gent psychotherapy: Ethical, legal andclinical implications of Osheroff v.Chestnut Lodge. Ethics & Behavior, 4,175-197.

Pomerantz, A. M., Grice, J. W. (2001).Ethical beliefs of mental health profes-sionals and undergraduates regardingtherapist practices. Journal of ClinicalPsychology, 57, 737-748.

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Pomerantz, A. M., Handelsman, M. M.(2004). Informed Consent Revisited: AnUpdated Written Question Format.Professional Psychology: Research andPractice, 35, 102-205.

Somberg, D. R., Stone, G. L., Clairborn, C.

D. (1993). Informed Consent: Therapists’Beliefs and Practices. ProfessionalPsychology: Research and Practice, 24, 153-159.

The Numbers Game. (April 12, 2005). TheWashington Post, F3.

Introducing the Division 29 Suite Program at APA in New Orleans—2006

Division 29 is pleased to announce our Suite Program which will be launched atAPA this summer in New Orleans. We are planning to offer a number of excit-ing opportunities to interact informally and explore your interests with some ofthe leading figures in psychotherapy. We will host hour long conversations ona variety of topics such as how to get started publishing, advice for incorporat-ing research in your clinical practice, innovations in psychotherapy practice,and others. You will have the opportunity to meet some of the leading pioneersin the field, and we will also be raffling books for students who join our division.We are encouraging our members to bring in others who might be interested injoining our division and partaking of the advantages of membership. We willbe offering a limited number of Division 29 hats for those who sign up duringthe convention. We will update you in the next issue of the Bulletin and on thewebsite at www.divisionofpsychotherapy.org as to our schedule of events. We look forward to seeing old friends, students, and new faces at our suite program in New Orleans.

Jeffrey J. Magnavita, Ph.D.Program Chair

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Informed consent is the process by whichresearch participants are informed of thepotential risks and benefits of taking partin a research study (National Institute ofMental Health [NIMH], 2005). Other basicelements of informed consent involveaddressing the purpose and goals of theresearch, assuring participants that datawill be kept confidential, and informingparticipants that they may stop participa-tion at any time without penalty (UnitedStates Department of Health and HumanServices, 2005, section 46.116). These stepsare usually completed in part by havingparticipants sign consent forms, indicatingtheir voluntary participation in the study(United States Department of Health andHuman Services, 2005, section 46.117). Thebasis for such systematic procedures lies inpreserving the autonomy of participants(Koocher & Keith-Spiegel, 1998), but theinformed consent process may be hinderedif researchers overlook cultural factors ofpotential participants, especially thosewith language and reading limitations,high regard for collectivism, great respectfor or mistrust of authority, and severe lim-itations of financial means. We discussthese potential challenges to obtaininginformed consent and offer suggestions.

LINGUISTIC/READABILITY ISSUESMany researchers agree that facility withlanguage influences the informed consentprocess because it relates to participants’comprehension of the research process asdescribed in the informed consent materi-als (Brugge, Kole, Lu, & Must, 2005;Cooper et al., 2004; Marshall, Koenig,Grifhorst, & Van Ewijk, 1998; Quill, 2002).Cooper et al. (2004) have described lan-guage barriers that arose when workingwith migrant farmworkers, most of whom

were Latinos and had limited proficiencyin English. In addition, these migrant farm-workers were often functionally illiteratein their native language, so providing justa written consent form in their native lan-guage would not have been sufficient. Inorder to accommodate the needs of thispopulation, the researchers invited bilin-gual community members to participate indeveloping questions for the research sur-vey, translated all instruments and formsinto Spanish, and provided bilingual inter-viewers. While these researchers providedinstruments in the preferred language ofthe participants, others (e.g., Fisher et al.,2002) have pointed out that some instru-ments, especially standardized instru-ments, may not be appropriate for use withsome groups if they have not been repre-sented in the test development process.

Using the MMPI-2, Lucio and Reyes-Lagunes (1994) pointed out a related issueof using translations. The researchers uti-lized transliteration, which proposes thatthe psychological meaning of the conceptin relation to the category is more impor-tant than a strict translation. They suggestthat it is important for researchers to con-sider that an exact translation is not alwayspreferable because it may not enhance par-ticipants’ comprehension of the conceptbeing assessed.

Brugge, Kole, Lu, and Must (2005) workedprimarily with an Asian population and inorder to resolve language obstacles, theyprovided participants with surveys trans-lated into Cantonese. While most of theparticipants completed the surveys them-selves, translators were available to readthe surveys and transcribe responses forparticipants who were unable to read.

FEATURE: INFORMED CONSENT IN RESEARCHCultural Considerations of Informed Consent When Conducting Mental Health ResearchTina Kaljevic and Leon VandeCreek, Wright State University, School of Professional Psychology

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While Marshall, Koenig, Grifhorst, andVan Ewijk (1998) acknowledged that trans-lators decrease some of the barriers createdby language limitations, they alsodescribed some of the potential problemsassociated with the use of translators. Onepotential drawback is that because jargondoes not readily lend itself to precise trans-lations, participants may not comprehendtranslated terminology or the nuances ofthe research task. Yet another potentialproblem is that translators may not alwaysbe objective about the content of what theyare translating, especially when the trans-lator is a member of the community or cul-ture itself. Translators’ values and beliefsmay influence how communicationsamong the translator, participant, andresearcher take place. In this case, thetranslator retains the power of decidingwhich information to relay and how torelay it to the others involved, which inturn influences the level of comprehensionthat takes place.

Another language issue influencinginformed consent is that of the readability ofthe consent forms provided to participants.Hochhauser (1999) reviewed several studiesthat have examined this issue and foundthat many consent forms were written atreading levels far higher (e.g., at a 12th gradereading level or higher) than was appropri-ate for participants and concluded thatinformed consent was not likely obtained.

As a way to remedy these issues,researchers can make concerted efforts tocreate readable consent forms by havingindividuals with similar reading/educa-tional levels as participants ensure read-ability of forms, explain information pro-vided in the consent forms, ask partici-pants to explain the content of the forms intheir own words, and provide participantswith ample time to read the consent forms.

INFLUENCE OF AUTHORITY FIGURESAnother factor that may influence theinformed consent process is that of howparticipants perceive the researchers, espe-cially as this relates to the power dynamics

within the relationship (Alvidrez & Arean,2002; Brugge, Kole, Lu, & Must, 2005;Chan, Haynes, O’Donnell, Bachino, &Vernon, 2003). Cultural characteristics suchas respect for authority may influence indi-viduals’ decision to participate in research.For example, Brugge, Kole, Lu, and Must(2005) examined how respect for authorityinfluenced elderly Asian immigrants’ deci-sion to be involved in a research study. Theresearchers presented the participants withwritten scenarios that assessed their will-ingness to participate in research if theirfamily members, their landlord, and theirphysician asked them to participate.Participants were more likely to participateif authority figures such as landlords andphysicians asked them to participate, thanif they were recruited through advertise-ments or monetary enticements.Implications of the findings includewhether or not Asian populations may bemore susceptible to taking part in researchstudies due to their respect for authorityand not necessarily due to their own will-ingness to be a part of the study. This inturn may affect participants’ willingness toask questions or refuse to participate dueto their high level of respect for theresearchers. Some racial and culturalgroups mistrust researchers (Alvidrez &Arean, 2002; Darou, Hum, & Kurtness,1993; Twenty Years After, 1992). For exam-ple, because of the Tuskegee Syphilis Study(Twenty Years After, 1992), there is an his-torical context for the mistrust ofresearchers by African Americans. Thatstudy examined the effects of syphilis ongroups of African American males whowere not told of the risks/effects and weredenied treatment for the disease. This is anextreme example of how participants’rights were grossly violated, withimmensely negative consequences. Chan,Haynes, O’Donnell, Bachino, and Vernon(2003) illustrated how the Tuskegee studycan have long-standing effects on how par-ticipants view research. They conductedfocus groups to determine the type ofinformation that couples of various racialgroups desired with regard to prostratecancer screenings. The researchers discov-

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ered that African Americans wanted infor-mation regarding the risks of the proce-dures specific to them as a racial group,which the researchers hypothesized is like-ly due to past research abuses. So,researchers must be aware of how historyplays an important role in how some cul-tural groups view research.

American Indian and Alaska Nativegroups also have unique reasons to be sus-picious of participating in health relatedresearch. Norton and Manson (1996) dis-cussed how research results were reported-ly manipulated by the media, leading toheadlines linking the groups to alcoholismand likely negative perceptions by society.It should not come as a surprise, therefore,that Native groups have shown a mistrustand dislike of researchers wanting to studytheir culture, with researchers sometimesbeing denied permission to conduct suchresearch. In the event that these groupsconsent to being part of a research study,however, historical factors may have animpact on how participants viewresearchers and how engaged they are dur-ing the informed consent process. Alvidrezand Arean (2002) have suggested provid-ing educational materials and referrals as away for researchers to maintain a presenceand develop trust in the community forpotential recruitment in future studies.

COLLECTIVISMCollectivism refers to the degree to whichmembers of a community or culture identi-fy as a single unit, with decisions beingmade by the community as a whole ratherthan individually (Brugge, Kole, Lu, &Must, 2005; Cooper et al., 2004; Darou,Hum, & Kurtness, 1993; Marshall, Koenig,Grifhorst, & Van Ewijk, 1998; Norton &Manson, 1996; Quill, 2002). This can havevast implications for researchers whoapproach participants as individuals, with-out viewing them as members of theircommunity and family.

Darou, Hum, and Kurtness (1993)explained how the idea of collectivism

influenced how Native groups in Canadaresponded to researchers studying theirculture. Researchers were expected toaddress the Crees as a community, asopposed to asking specific individuals forpermission to conduct the study.Researchers were viewed by communitymembers as creating conflict if they deviat-ed from this request. In addition,researchers had to make clear the potentialbenefits of the study for the group as awhole in order for the group to give con-sent. Finally, Norton and Manson (1996)explained that some American Indian andAlaskan communities prefer to have anymonetary compensation given to the com-munity as a whole rather than to specificindividuals.

FINANCIAL/ECONOMIC CONCERNSWhen monetary compensation is provid-ed to participants involved in researchstudies, researchers need to be cognizantof how this may influence the informedconsent process for culturally diverse par-ticipants. Norton and Manson (1996)briefly explored this idea with respect tothe American Indian and Alaska Nativegroups, as these communities sometimeshad high rates of poverty. The authorsquestioned whether compensation couldbe perceived as coercive in light of theeconomic situations of the groups. Itmight be argued that high levels of com-pensation obstruct the informed consentprocess, with participants experiencingeconomic hardships because of the per-ception that the financial benefits out-weigh any potential risks, even if this isnot necessarily true. In addition, membersof groups that are struggling economicallymay find it burdensome to miss work orpay for child care in order to be involvedin a research study (Fisher et al., 2002).

SUMMARYLinguistic and readability issues, highregard for collectivism, mistrust of author-ity, and financial issues are among a few ofthe factors that influence informed consentwhen conducting mental health research

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with culturally diverse groups. These fac-tors influence various aspects of researchincluding recruitment of participants, theparticipant-researcher relationship, andperceptions of psychological research. Anawareness of these factors may assistresearchers in creating an atmospherewhereby an open dialogue regardinginformed consent can take place. This opendialogue creates a sense of trust betweenresearchers and participants and mayallow the opportunity for participants toask more questions and gain a betterunderstanding of the risks and benefits.This in turn may increase the likelihoodthat the decisions that participants makewith regard to research participation willtruly be theirs.

REFERENCESAlvidrez, J., & Arean, P. A. (2002).

Psychosocial treatment research withethnic minority populations: Ethical con-siderations in conducting clinical trials.Ethics & Behavior, 12(1), 103-116.

Brugge, D., Kole, A., Lu, W., & Must, A.(2005). Susceptibility of elderly Asianimmigrants to persuasion with respect toparticipation in research. Journal ofImmigrant Health, 7(2), 93-101.

Chan, E. C., Haynes, M. C., O’Donnell, F.T., Bachino, C., & Vernon, S. W. (2003).Cultural sensitivity and informed deci-sion making about prostrate cancerscreening. Journal of Community Health,28(6), 393-405.

Cooper, S. P., Heitman, E., Fox, E. E., Quill,B., Knudson, P., Zahm, S. H., et al. (2004).Ethical issues in conducting migrantfarmworker studies. Journal of ImmigrantHealth, 6(1), 29-39.

Darou, W. G., Hum, A., & Kurtness, J.(1993). An investigation of the impact ofpsychosocial research on a native popu-lation. Professional Psychology: Researchand Practice, 24(3), 325-329.

Fisher, C. B., Hoagwood, K., Boyce, C.,Duster, T., Frank, D. A., Grisso, T., et al.

(2002). Research ethics for mental healthscience involving ethnic minority chil-dren and youths. American Psychologist,57(12), 1024-1040.

Hochhauser, M. (1999). Informed consentand patient’s rights documents? A right,a rite, or a rewrite? Ethics & Behavior, 9(1),1-20.

Koocher, G. P., & Keith-Spiegel, P. (1998).Ethics in psychology: Professional standardsand cases (second edition). New York:Oxford University Press.

Lucio, E., & Reyes-Lagunes, I. (1994).MMPI-2 for Mexico: Translation andadaptation. Journal of PersonalityAssessment, 63(1), 105-116.

Marshall, P. A., Koenig, B. A., Grifhorst, P.,& Van Ewijk, M. (1998). Ethical issues inimmigrant health care and clinicalresearch. In S. Loue (Ed.), Handbook ofimmigrant health (pp. 203-226). New York:Plenum Press.

National Institute of Mental Health, (2005).A participant’s guide to mental healthclinical research. (Retrieved October 30,2005, from http://www.nimh.nih.gov/publicat/clinres.cfm#clinres11).

Norton, I. M., & Manson, S. M. (1996).Research in American Indian and AlaskaNative communities: Navigating the cul-tural universe of values and process.Journal of Consulting and ClinicalPsychology, 64(5), 856-860.

Quill, T. E. (2002). Autonomy in a relation-al context: Balancing individual, family,cultural, and medical interests. Families,Systems & Health, 20(3), 229-232.

Twenty years after: The legacy of thetuskegee syphilis study. (1992,November/December). Hastings CenterReport, 22(6), 29-30.

United States Department of Health andHuman Services. (2005). Protection ofhuman subjects. (Retrieved October 30,2005, from http://www.hhs.gov/ohrp/humansubjects/guidance/45cfr46.htm#46.116).

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FEATUREExpanding Your Psychotherapy Practice into Primary CareJames H. Bray, Ph.D.

Changes in medical practice due to man-aged care have put tremendous pressureon primary care physicians (PCPs) to diag-nosis and treat a broad spectrum of bio-medical and psychosocial problems. PCPstreat over 60% of all mental health prob-lems in the United States, without assis-tance from psychologists or other mentalhealth providers. While psychologists aretrained to provide the needed services,they are often NOT trained in working inprimary care or collaborating with PCPs.Working in primary care provides greatopportunities and challenges for psycholo-gists. This paper will provide a brief intro-duction to working in primary care andhow to develop referrals from PCPs. Formore extensive information please see thereferences at the end of this article.

Psychologists can provide important diag-nostic services and information about psychological treatments. PCPs are oftenunfamiliar with various mental disordersand psychological treatments. Successfulcollaboration with PCPs needs to be a win-win business relationship for bothproviders. PCPs want psychologists’ helpin solving patient care problems, beinggiven feedback and information abouttheir patients’ status and progress, andreceiving referrals back from psycholo-gists. This type of help reduces the PCP’shassle with patient care. Psychologists canprovide important diagnostic informationabout the patient, recommend additionalpsychological treatment options, provideinformation about the progress of psy-chotropic medications and help increasepatient compliance with medical treat-ments. All of these often improve patientsatisfaction (Bray & Rogers, 1995).

PCPs are “over marketed” by pharmaceuti-cal companies, medical supply companies,

and other specialists. Thus, a variety ofcontacts will need to be made to establishand maintain an ongoing relationship withthe PCP. As we found in our research, “onceis not enough,” and the psychologist needsto arrange for regular contact with the PCP(Bray & Rogers, 1995). Many PCPs welcomepsychologists to practice in their officeseither part-time or full-time. Patients usual-ly prefer this arrangement, since they can goto one place for their health care, they mayfeel less stigma about obtaining treatmentfor their psychological problem, and appre-ciate the collaboration between PCP andpsychologist.

Physicians usually have a different practicestyle than psychologists. It is important tomake arrangements to get through the doc-tor’s staff to the physician or for the PCP tobe able to rapidly contact the psychologist.Most PCPs take phone calls during sessions,while most psychologists do not. Establishways to have regular meetings with the PCPto discuss patients (regularly scheduledbreakfast, lunch, consultation time). Thereare a variety of other opportunities for see-ing PCPs. These include joining the hospi-tal staff at medical/surgical hospitals, join-ing hospital staff committees, providingcontinuing medical education seminars tolocal medical societies and provide patienteducation and prevention services. Be sureto market your services to the entire medicalcommunity, which includes physician assis-tants, nurse practitioners, nurses, and med-ical staff and clerks.

PCPs develop long-term relationships withtheir patients and provide continuity ofcare that includes comprehensive, continu-ous services in sickness and in health(Rakel, 2002). Feedback on patient progress is essential to the PCP. Most PCPs onlywant a brief note (1 to 3 paragraphs, no

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longer than one page) about your work withthe patient. They want a diagnosis, a briefexplanation of your treatment plan, and anyrecommendations you may have toimprove patient care. It is also important tohelp the patient return to his/her PCP forfollow-up visits. Arranging for follow-upvisits is a way of continuing to market yourservices to the PCP. Working with PCPs isa great way to expand your practice.

Further information about working withPCPs can be found in:

Bray, J. H., & Rogers, J. C. (1995). Linkingpsychologists and family physicians forcollaborative practice. ProfessionalPsychology: Research and Practice, 26,132-138.

Bray, J. H. & Rogers, J. C. (1997). Thelinkages project: Training behavioralhealth professionals for collaborativepractice with primary care physicians.Families, Systems, & Health, 15, 55-63.

Frank, R. McDaniel, S. H., Bray, J. H., &

Heldring, M. (Eds.) (2004). Primarycare psychology. Washington, DC:American Psychological Association.

Haley, W. E., McDaniel, S. H., Bray, J. H.,Frank, R. G., Heldring, M., Johnson, S.B., Lu, E. G., Reed, G. M., & Wiggins, J.G. (1998). Psychological practice in pri-mary care settings: Practical tips for clinicians. Professional Psychology:Research and Practice, 29, 237-244.

Rakel, R. E. (Ed.) (2002). Textbook of fami-ly practice 6th Edition, Philadelphia, PA:W. B. Saunders.

James H. Bray, Ph.D. is a candidate forPresident of the American PsychologicalAssociation. He is Director, FamilyCounseling Clinic and Associate Professorin the Department of Family andCommunity Medicine, Baylor College ofMedicine, 3701 Kirby Drive, Houston, TX77098, (713) 798-7752, [email protected]. Hemaintains an active clinical practice focus-ing on children and families and behav-ioral health.

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ABSTRACTPsychology is rapidly becoming a mobileprofession. Credentialed psychologistshave unprecedented access to expeditedlicensure mobility as a growing number ofregulatory boards in the United States andCanada are incorporating provisions toexpedite licensure applications. Psych-ologists who hold nationally recognizedcredentials can now apply for licensure byendorsement of credentials and bypass thetime consuming and often frustrating doc-ument collection process that is traditional-ly associated with licensure applications.Expedited access to licensure acceleratespublic access to psychologists, brings psy-chology in step with other health care pro-fessions solution to mobility, and providesregulatory boards with more time to con-sider other agenda items such as emergingpractice areas that require adoption ofrules and regulations, such as psychophar-macology and telehealth. This article pre-sents a summary of mobility progress todate, data on psychologists’ movement,and addresses some of the concerns aboutlicensure mobility.

The more the workforces feels mobile...the moreit will be willing and able to jump into the newindustries and new job niches spawned by theflat world and to move from dying companies tothriving companies (Friedman, 2005, p 285).

As adapted from Hall & Lunt (2005), thereare four key components to achievingmobility for psychologists: • Consensus by the profession on

recognition standards• Demand by psychologists for mobility• Advocacy efforts by psychology organi-

zations to promote multiple pathways• Cooperation among states/provincial

regulatory boards

COMPONENT 1: CONSENSUS ONRECOGNITION STANDARDSIn the US and Canada, the definition of apsychologist is at the doctoral level.Regulations and statutes typically mandatethat the doctoral program either qualify asAmerican Psychological Association (APA)/Canadian Psychological Association (CPA)accredited or as meeting the Association ofState and Provincial Psychology Boards(ASPPB)/National Register of HealthService Providers in Psychology (NationalRegister) “Criteria for ‘Defining a DoctoralProgram in Psychology’” (http://www.na-t ionalreg i s te r.org/des ignate .h tm) .Although there is slight deviation to enterpractice in five states (AR, AZ, KY, WV, VT)and six provinces (AB, NB, NL, PEI, SK,QC) at the master’s level, there is consen-sus that the doctoral level should be theadmission standard for practice. The doc-toral internship and the year of postdoctor-al experience have been adopted by most ofthe jurisdictions in the US and Canada as arequirement for licensure. The same appliesto the national examination for psycholo-gists, the Examination for ProfessionalPractice in Psychology (EPPP). So it appearsthat at least at the present time in the US andCanada, the profession agrees on recogni-tion standards. That is critical to facilitatingthe concept of mobility, since jurisdictionsmust have assurances that their neighbor-ing states or provinces are applying essen-tially the same requirements for licensure asthey are.

COMPONENT 2: DEMAND BYPSYCHOLOGISTS FOR MOBILITYIn the 1990’s psychologists and psycholog-ical organizations began advocating for ameans to expedite re-licensure for current-ly licensed professionals who meet the

FEATURELicensure Mobility for Credentialed Psychologists in the US and CanadaJudy E. Hall, Ph.D. and Andrew P. BoucherNational Register of Health Service Providers in Psychology

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national standard for education, super-vised experience, and examination perfor-mance. There were two primary reasonsfor this movement.

Expanding Practice Opportunities:Psychologists who seek opportunitiesacross state/provincial lines can benefitfrom expedited access to licensure whetherthey provide services face-to-face or virtu-ally via telehealth. For example, a Virginialicensed psychologist treats an adolescentfor a year. The family moves to Coloradodue to a divorce, but both parents want thepsychologist to continue treating the ado-lescent. The psychologist could do thisfrom a distance, but only if the psycholo-gist is licensed in Colorado. Expeditedaccess to a Colorado license could ensuretreatment continuity. In contrast, a tradi-tional licensure process could take months,primarily because psychology licensingboards require primary source documenta-tion of education and training. In mostcases, this means tracking down andobtaining signed verification forms frominternship and postdoctoral supervisorsfrom years past who may be difficult orimpossible to locate. To compete in thehealthcare marketplace and make theseopportunities logistically and economical-ly feasible, psychology needed an expedit-ing mechanism to ease re-licensure.

Frustration and Redundancy: The evolu-tion of the information age, spurred by theInternet, rapid data exchange, increasedconsumer access to information, and glob-alization, further added to the exasperationover traditional application processes. Aspsychologists sought re-licensure to pur-sue emerging opportunities, many asked afundamental question: If I have met thelicensure requirements for licensure in atleast one state, and I have met the creden-tialing requirements for a post-licensurenationally recognized organizationthrough primary source documentation,and I have not had any disciplinary actiontaken against any license, why must I gothrough the entire process anew in anotherjurisdiction?

SURVEY DATA ON DEMONSTRATESDEMAND FOR LICENSURE MOBILITYIn a survey of National Register creden-tialed psychologists in 2004 as reported inThe Register Report (Fall, 2004), 57% of the3665 respondents indicated that licensuremobility was “very important” to them.This survey was sent to the ~8,000 NationalRegister credentialed psychologists withemail addresses on file. There was a 46%response rate to the survey. This outcomewas no surprise to the National Register asa concerted effort to address the mobilityproblem had been initiated by the NationalRegister in the late nineties based uponrepeated requests by Registrants. Separatesurveys of graduate students and earlycareer psychologists in 2005 produced sim-ilar results. Of the 3835 responses to the2005 National Register Graduate StudentSurvey, 62% described licensure mobilityas a “very important” credentialing bene-fit. Of the 1819 responses (as of 5/1/2006)to the 2005 National Register Early CareerPsychologist Survey, 57% described licen-sure mobility as a “very important” cre-dentialing benefit. Therefore, the conclu-sion can be drawn that mobility is animportant issue to doctoral students, earlycareer psychologists, and more establishedpractitioners.

COMPONENT 3: ADVOCACY EFFORTSBY PSYCHOLOGY ORGANIZATIONS TOPROMOTE MULTIPLE PATHWAYSThe National Register, established in 1974, isthe largest and most successful credential-ing organization in psychology in terms ofnumbers credentialed (Wise, Hall, Ritchie &Turner, in press). For thirty years theNational Register has promoted licensedpsychologists who are qualified by educa-tion, training and experience in health ser-vice provision to be included in health careplans. However, psychologists want morethan simply the distinction of being creden-tialed by the National Register.

Taking the initiative, Missouri was the firststate to include a mechanism for mobilitywhen it endorsed the National Register

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credential for that purpose. According toCarl Willis, (Boucher, 2001), this 1989 legis-lation, “grew out of a state-wide planningconference that addressed the future ofpsychology and what laws were neededfor the public as well as the profession” (p.16). Unfortunately, many years passedbefore other states followed Missouri’slead. In 1999, Virginia adopted theNational Register, followed by the Districtof Columbia and Maryland in 2000. Basedupon the leadership shown by these statesand a very positive Registrant response tothe value of this benefit, National Registerrepresentatives began meeting with repre-sentatives of licensing boards and psycho-logical associations across the US andCanada to discuss licensure mobility.ASPPB representatives engaged in a simi-lar and successful effort.

Licensing boards first needed to under-stand the concept of endorsement of indi-vidual credentials as a mechanism to facil-itate licensure. Slowly, the boards began torealize that by allowing a non-profitnational credentialing organization actingas a credentials repository to verify prima-ry source documentation directly to alicensing body, both the psychologist andthe board benefited, saved time andmoney, and the consumer gained by theexpedited access to services.

DEEMED EQUIVALENCEThe concept of using established mecha-nisms to facilitate licensure for alreadylicensed psychologists is based upon thelicensing board reviewing the credential-ing organization’s requirements for cre-dentialing and at the same time that theorganizations relies on primary source doc-umentation, and determining that the cri-teria are deemed to be equivalent to thoserequired for licensure. Deemed equiva-lence means that a jurisdiction mightrequire 1600 hours on internship for an ini-tial applicant but still be able to accepteither the National Register or the CPQ,both of which require a minimum of 1500hours. The difference is that these creden-

tialed psychologists are already licensed inone jurisdiction, have met national stan-dards for education and training, and haveno disciplinary actions on their record.

Current Success These efforts over the past seven years toreason with licensure boards have resultedin dynamic growth in the number of juris-dictions in which psychologists can expe-dite licensure and health service provider(HSP) recognition. As of this writing, 41jurisdictions in the United States andCanada have voted to approve theNational Register Health Service Providerin Psychology credential to expedite licen-sure. More are considering endorsement ofthe National Register for this purpose.

HOW DOES THE NATIONAL REGISTERMOBILITY PROGRAM HELP?Licensure by endorsement does not consti-tute a right to practice in other jurisdic-tions, or the right to become automaticallylicensed. The endorsement candidate mustcomplete a general information form, passany required oral or jurisprudence exams,and be approved by the regulatory board.This process simply assists licensureboards in their function to review candi-dates for licensure.

In most cases, the National Register verifi-cation exempts the psychologist fromordering transcripts, locating past supervi-sors to document the internship and post-doctoral experience, and submitting EPPPscores to the licensing board. (A few boardsrequire the EPPP scores to be sent directlyto the board office.) There is no fee chargedto the Registrant or paid by the licensingboard for the credentials verification.

The features of the expedited licensureprocess vary by jurisdiction. For ease ofunderstanding exactly what is waivedbased upon credentials verification by theNational Register, see table 1 on page 52.

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OTHER ORGANIZATIONS PROMOTEMOBILITYOther credentialing organizations promotemobility. The ASPPB Certificate ofProfessional Qualification (CPQ) and theAmerican Board of Professional Psych-ology (ABPP) specialty certification facili-tate mobility and function in much thesame way that the National Register cre-dential does, as individual endorsementmechanisms. Currently, approximately3700 psychologists hold the CPQ (ASPPB,n.d.), and 2600 hold the ABPP certification(Finch, 2006). Both of these organizationshave sought recognition by state licensing

boards and been successful. In fact, in theU.S. with its 50 different jurisdictionsenacting slightly differing laws and regula-tions, endorsement of an individual cre-dential is the most successful mechanismfor expediting licensure. The other threemechanisms (reciprocity agreements,senior psychologist provisions andendorsement of other jurisdictions’ license)have not been adopted by many jurisdic-tions and apply to fewer psychologists.

PSYCHOLOGISTS MOVEMENTIn 2004, the National Register began track-ing credentials verification letters sent on

Table 1: Jurisdictions that currently recognize or are currently in process (IP) of modifying regu-lations to accept the National Register Health Service in Provider in Psychology credential toexpedite licensure mobility

Waive Documentation of Doctoral Degree, Internship and Postdoctoral Year, and EPPP ScoreAlberta North Dakota (IP)Arkansas Northwest Territories*British Columbia Nova Scotia*California Ontario*Colorado OregonDistrict of Columbia QuebecDelaware (IP) PennsylvaniaHawaii Prince Edward IslandIndiana (IP) Rhode IslandManitoba SaskatchewanMassachusetts (IP) TennesseeMissouri TexasMontana Utah (IP)New Brunswick* VirginiaNebraska WashingtonNevada West VirginiaNewfoundland/Labrador Wyoming (IP)North Carolina (IP)

Waive Documentation of Doctoral Degree, Internship and Postdoctoral Year, and EPPP ScoreArizona Minnesota (IP)Iowa New MexicoMaryland

Board Accepts Primary Source Documentation from the National Register as part of the ApplicationProcess

South Carolina* May only apply to Canadian Licensees

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behalf of Registrants to licensure boards toexpedite mobility. As of April 2006, therewere 421 known verifications, with eachyear’s total increasing over the previousyear. However, this number is an underes-timate. It does not include the verificationsthat occur by state boards using theNational Register Find PsychologistDatabase. (For example, the Missourilicensing board verifies the NationalRegister credential holder online.) In addi-tion, while the number taking advantage oflicensure mobility may not be large in com-parison to the total number of NationalRegister credentialed psychologists(~13,000), we know from survey data andRegistrants that the availability of this ben-efit is very important to them. It is therewhen they need it.

MOBILITY WITHIN CANADAIn Canada the demand for mobility camefrom outside the profession. The federalgovernment, as a result of the Agreementon Internal Trade, mandated a multi-yearprocess of psychology organizations coop-erating together to develop a mutual recog-nition agreement (MRA). The three psy-chology organizations, (CPA, CanadianRegister of Health Service Providers inPsychology [Canadian Register], and theCouncil of Provincial Associations ofPsychologists [CPAP]), developed theMRA and 11 provinces and one territorysigned it thereby agreeing to fast trackmechanisms for expediting licensure andcompetency based assessment for initiallicensure. See Hall and Lunt (2005) orwww.cpa.ca for more information.

The fast track mechanisms included in theMRA were credentialing by the NationalRegister or the Canadian Register, gradua-tion from an APA/CPA approved programin psychology, attainment of the CPQ orfive years of licensed practice without dis-cipline. These five fast track mechanismsexpedite licensure for licensed/registeredpsychologists in Canada as long as theirdegree matches the admission require-ments in the province/territory. However,

for psychologists moving from the US toCanada, a separate approval of the creden-tial had to be secured. Today, a majority ofthe Canadian provinces have approved theNational Register and the CPQ for south tonorth mobility.

An additional mechanism for expeditedlicensure exists in Canada, the CanadianRegister, which has around 3000 creden-tialed psychologists. However it exists as amobility mechanism only in Canada, justas ABPP is written into only US laws.

BARRIERS TO MOBILITYPROTECTING THE PUBLICLicensing boards are tasked with protect-ing the public from the practice of psychol-ogy by unqualified persons. In the past andeven now with several jurisdictions thatare currently considering endorsing mobil-ity mechanisms, board members havequestioned if outsourcing the primarysource credentialing, which was tradition-ally within the purview of the board,serves the public interest. It does. In thefirst place, all National Register creden-tialed psychologists have successfullyapplied for at least one license prior to cre-dentialing, and then have met the NationalRegister credentialing requirements (seehttp://www. nationalregister.org/criteri-aforhspp.htm). In addition, almost allboards that accept the National Registercredential to expedite licensure administeran oral or written jurisprudence examina-tion to each candidate. This final stepallows the board to assess the applicant’scurrent knowledge for practicing in thatjurisdiction. Although licensure applicantsrarely fail that exam, this step gives discre-tionary authority and autonomy to thelicensing board, with the board the finalauthority on granting the license.

YEARS OF PRACTICE ANDDISCIPLINARY ACTIONSThere is no minimum number of years thata licensed psychologist must practicebefore being eligible for the National

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Register credential. This is in contrast tothe requirements for the CPQ, which statethat a psychologist must be licensed for atleast 5 years prior to qualifying for theCPQ. Some of the ABPP specialty boardsalso require a minimum number of years ofexperience. During the early years of theNational Register mobility effort, this pre-sented a problem in that a few boards wereconcerned about new psychologists apply-ing for the National Register and thenusing the credential to immediately expe-dite licensure in additional jurisdictions.Individual board members specificallynoted that the National Register creden-tialed psychologists could have little postlicensure experience and therefore no trackrecord, and could be a disciplinary risk.

The National Register disagrees with thisposition for several reasons. First, the basisof licensure by endorsement is static creden-tialing information that will not change overtime (doctoral degree, supervised experi-ence, examinations scores). Second, newpsychologists deserve mobility options, andto deny this privilege based on years ofpractice following initial licensure could beconsidered age discrimination and unfairrestriction of trade. Perhaps more com-pelling for licensing boards is that we deter-mined that new psychologists are not a highrisk population for disciplinary action.

The National Register analyzed its nationaldisciplinary data on psychologists to inves-tigate if the more newly licensed psycholo-gists had been disciplined more frequentlythan psychologists with five years oflicensed practice (Hall & Boucher, 2003).The National Register calculated the aver-age number of years lapsed betweendegree date or date of first license and dateof disciplinary action.

The disciplinary database consisted of 2748psychologists with actions taking placebetween 1971 and 2002. The NationalRegister was able to locate either thedegree date or date of first license and dateof action on 1487 of the individuals.Information regarding the individuals’

degree date / date of first license wasfound in data provided by state licensingboards; the National Register database/Registrant files (for Registrants) and APAMembership Directories between 1981 and2001.

The results showed that the average timelapsed between degree date/date of firstlicense and date of disciplinary action was20.8 years. More than 70% of disciplinaryactions analyzed occur in practitioners whoare between 11 and 35 years past degreedate/date of first license. Moreover, 94.5%of the cases involve disciplinary actionsoccurring more than 5 years after the degreedate/date of first license. The data indicatethat a doctoral psychologist in the first fiveyears after degree date/date of first licenseis less likely to commit an act resulting in adisciplinary action than a more seasonedpsychologist (Hall & Boucher, 2003).

These results support the NationalRegister’s earlier decision in 1974 to allowlicensed psychologists to apply immediate-ly if they had completed a year of postdoc-toral experience in health service provision.(At that time a majority of the states did notrequire a year of postdoctoral experience foradmission to licensure.) These data alsosupport the National Register’s more recentdecision to promote mobility for all licensedpsychologists that qualify, regardless ofamount of practice experience.

PROMOTING MULTIPLE PATHWAYSAnother question typically posed bylicensing boards is which mechanism toadopt: the National Register, the CPQ, orABPP? The National Register encouragesadoption of all three. There are several rea-sons for this. First and most importantly,adopting all three significantly increasesthe number of psychologists affected. TheNational Register currently credentials~13,000 psychologists, ~3700 psychologistshold a CPQ, and ~2600 psychologists arecertified by ABPP. Although there is con-siderable overlap, adopting all three mech-anisms affects more than 16,000 creden-tialed psychologists. When boards adopt

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fewer than all three mechanisms, the per-centage of licensed psychologists eligiblefor mobility significantly decreases. Theother primary reason to adopt all threemechanisms correlates to the overall pur-pose of mobility – eliminate repetitive cre-dentialing. For example, if a jurisdictionadopts ABPP but does not adopt theNational Register or CPQ, any NationalRegister or CPQ psychologist must applyfor the ABPP to get expedited access tolicensure, or they must apply through tra-ditional means.

LICENSURE MOBILITY IS A BENEFITPsychologists often describe licensuremobility in terms of a practitioner benefitthat saves time and money. Consumerswill come to see mobility in terms of fasteraccess to psychological services. By relyingon the National Register or another creden-tialing organization to thoroughly vet thecredentials of each applicant and to verifythe same, the board is relieved of the timeconsuming task of obtaining and review-ing primary source documentation. Thusexpedited licensure mobility is a benefit tolicensed psychologists, to the public and tothe licensing boards. There is really no jus-tifiable reason for all state, provincial andterritorial boards not to endorse the avail-able mechanisms. In time, hopefully thiswill be a national standard: expedite thelicensure process for those licensed andcredentialed psychologists with no disci-plinary actions. There are many other areasin psychology where improvement isneeded and opportunities are present.

Hopefully we can focus on progress in thefuture, not re-documenting the past.

REFERENCESAssociation of State and Provincial

Psychology Boards. (n.d.). Search andVerify CPQ Holders. Retrieved April 26,2006, from: http://www.asppb.org/mobility/cpq/results.aspx

Boucher, A. (Spring, 2001). MobilityMarker: Time & Again. The RegisterReport, 27, 16-17.

Finch, A. (2006, Winter). A Message fromthe President: Making ABPP as impor-tant as we think it is. The ABPPSpecialist, p 3.

Hall, J. E. & Boucher, A. P. (2003).Professional mobility for psychologists:Multiple choices, multiple opportunities.Professional Psychology: Research andPractice, 34, 463-467.

Hall, J. E. & Lunt, I. (2005). Global mobili-ty for psychologists: The role of psychol-ogy organizations in the United States,Canada, Europe, and other regions.American Psychologist, 60, 712-726.

Friedman, Thomas L. (2005). The World isFlat. New York, NY: Farrer, Straus andGiroux

Wise, E. H., Hall, J.E., Ritchie, P. L. J. &Turner, L.C. (in press). The NationalRegister of Health Service Providers inPsychology and the Canadian Register ofHealth Service Providers in Psychology.In T. J. Vaughn (Ed.), Everything studentsneed to know about licensure and certifica-tion. Washington, DC: AmericanPsychological Association.

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