Providing suggestions for training future psychotherapists is a difficult venture, especially when data are lacking. There currently exists a plurality of program types and methods already slated with this task and, given the limited knowledge of how best to cultivate competence (if there is an objectively “best way”), this is probably a reasonable state of affairs. However, there may be pedagogical deductions from the reviews above that are applicable to future therapists. From a developmental perspective, Dreyfus and Dreyfus’s (1986)
stages from novice to expert imply changes in the levels of rule usage and immersion in the therapy process. As for the former, trainees systematically learn rules and then learn when to follow, break, and modify rules. How can this best be accomplished? First, we as educators should ensure that students are presented with a wealth of source materials on theory and practice and should be encouraged to read widely and deeply. Presumably, this is already occurring in graduate programs. Through emphasizing the underlying principles
of therapy and therapeutic change rather than just techniques alone (Flannery-Schroeder, 2005
), novice trainees may be in better position for moving towards competence. In a similar vein, Rosen and Davidson (2003) argue convincingly that graduate training programs should devote less time to the promulgation of empirically-supported (and proprietary) treatments for specific disorders (a practice that may be more reflective of and conducive to the development of techne), and should instead focus on empirically-supported principles of change and the range of their potential applications (which we feel may better allow for the development and expression of phronesis).
Further, students should be taught those aspects of competence that have been demonstrated to be teachable. For instance, evidence indicates that the ability to form a good therapeutic alliance, while not an algorithmic process, is a learnable skill enhanced with training (Crits-Christoph et al., 2006
). No training sites that we are aware of utilize alliance assessments in their student evaluations, but this could easily be remedied.
It also seems to us that competence could be augmented by increasing what could be termed the transparency of our discipline. Clinical psychology has the unusual distinction of being perhaps the only helping profession in which a member could be licensed without ever having witnessed a successful treatment from beginning to end. Though this would hopefully be a rare occurrence, it is possible nonetheless (note: psychoanalysts may be exempt from this charge if their training analysis was considered successful, and though we have not seen it explicitly stated in the analytic literature, this may be one implicit reason for the training analysis requirement). This is at least partly due to the secretive nature of therapy. In surgery, for instance, a surgeon’s craft can be demonstrated from start to finish within a large amphitheatre. The anaesthetized patient will not respond differently if 2 or 200 people were privy to the process. This is not the case in psychotherapy, and a veil of secrecy surrounds so much of our work and the presentation of our work. These needs for privacy and confidentiality conflict with the didactic methods traditionally used in other, related disciplines. In psychotherapy, process notes continue to be used in many programs, but are retrospective and vulnerable to witting and unwitting distortions. Audio and video-recorders, if widely utilized, could make didactics significantly more transparent and allow us to catalogue numerous exemplars of “good” (and bad) psychotherapy from start to finish. Thus, tape libraries of competent therapists (as advocated by Yager & Bienenfeld, 2003
) could be compiled. A reason why this is not widely done is perhaps because no one thought it would be important to have a trainee observe an entire treatment. We suggest that this could be a great learning experience. Having such readily available “models” of psychotherapy would allow students to “learn the rules” and also learn when it is ok (and that it is ok) to deviate when context warrants it. However, care should obviously be taken to ensure that the lessons learned from videotapes are not converted into technical dogmas. Discussions of important therapeutic decision points (and alternate routes that could have been taken) in the course of these recorded sessions may also facilitate transitions between Dreyfus and Dreyfus’s (1986)
first three stages. Finally, showing trainees real-world examples of extreme situations in therapy, and how competent therapists handled them, would emphasize the importance of flexibility and nuance (viz., phronesis
) that might otherwise be missed by other pedagogical techniques (e.g., reading manuals). Role playing these situations may be helpful, but having trainees respond to actual clinical impasses may be more beneficial.
Further, videotaping trainee’s own sessions (preferably with both therapist and patient views) would allow for better and more accurate supervision. In RCTs, an actual recording of session content is the prerequisite for competence assessment (and in our experience, both patients and therapists quickly adapt to this arrangement). Independent raters could even be used in order to circumvent the potential biases engendered by the supervisory relationship (Sakinofsky, 1979
). In addition, watching trainee’s sessions would allow for an early recognition of disturbing or non-therapeutic interpersonal attributes or psychopathological “blind spots.” However, it must be noted that video will not capture all of the many subtleties that are occurring in the therapy room and that absolute transparency of the therapeutic process is an unreachable goal. But these factors do not detract from their potential educational significance.
Technology could also be used to make immediate
observation and feedback possible during a trainee’s therapy sessions. Use of dual microphones and earphone receivers would allow for supervisors to closely monitor the moment-to-moment therapy process as it unfolds from another room. When the trainee becomes “stuck” or confounded or begins to travel down non-therapeutic paths, the supervisor could provide direct in vivo
feedback and suggestions to the trainee (family therapists have been using similar procedures for a long time (Gallant, Thyer, & Bailey, 1991
). Thus, when therapy is progressing appropriately and patient behavior is able to be comfortably handled, supervision would be unnecessary. However, when events surpass what could be called the trainee’s ”therapeutic zone of proximal development,” he or she could benefit from the thoughts and techniques of an expert (Leiman & Stiles, 2001
, for a discussion of importance of recognizing patients’
zones of proximal development when conducting psychotherapy).
In summary, there do not appear to be many shortcuts for developing competence. It is hopefully a lifelong project that is fervently and earnestly undertaken, as training and experience are obviously the primary vehicles for gaining clinical judgment and progressing through the outlined stages. The sections above, however, do seem to indicate certain competence benchmarks. For instance, the style of a trainee’s description of session detail implies the stage where he or she may be placed. The use of a hierarchical and parsimonious organization would be indicative of a higher stage than would a “shotgun” approach in which a multitude of facts are presented in a haphazard and disorganized fashion. In addition, the ability and skill with which one develops a therapeutic alliance appears to be an easily assessed benchmark.
Many questions related to the training of competent psychologists remain incompletely answered. One having sizable importance, though no consensus, is whether it is better to initially train psychologists in one paradigm or to simultaneously immerse them in several? This does not appear to have a straightforward answer, and it seems to us that persuasive arguments could be made for either position. For instance, it could be argued that it is important for beginning therapists to be introduced to the in-depth workings of one particular paradigm (especially in the beginning stages). Kuhn (1996)
would warn us that this would necessarily place limits on what a person could “see,” but these same lenses also allow trainees to see the deep inner workings of theory. By immersing students in one theory, they will be able to “take it to the extremes” or “run it into the ground,” revealing both strengths and limitations of the paradigm itself. On the other hand, it could be argued that a sophisticated familiarity with multiple paradigms, and an ability to switch between them, could be associated with greater flexibility (both cognitively and technically) and an ability to view patients from several different (and possibly mutually exclusive) ways. Theorists who advocate either psychotherapy integration or eclecticism would likely view the latter option as more attractive (Norcross & Goldfried, 2005
; Lebow, 2002
, for reviews).