Pedagogical Concerns for Psychoanalytic Training in a Clinical Scientist Program
Christopher E. Overtree, Ph.D. APA Convention, August 14th, 2008
I have recently acquired some more letters to follow my name, ones I have been pursuing for quite some time now. They are D-A-D, and while they were much easier to acquire than my Ph.D., I suspect the work that follows this degree will be considerably more demanding.
I have a host of upcoming (shall we call them) conflicts to resolve…Baby in house, baby on plane, baby meets dog, baby ousts me in my role as husband. But somehow, baby-attends-first-APA-conference could not win out against the need for my son to meet his great- grandparents, two glorious people, who due to illness, can no longer travel themselves. So now I am forced to seek your pardon for my absence, and hope you will indulge me by listening as Dr. Ellenhorn kindly reads my remarks to you. He is extremely generous for being willing to do this. Please blame me for anything that does not translate well from writing to speaking.
To introduce myself, I am the Associate Director of Clinical Training for the University of Massachusetts-Amherst, Clinical Psychology Program, where I am also the Director of our program’s in-house training clinic, the Psychological Services Center. While I engage in regular professorial duties such as teaching, research, and community outreach, my primary role is the development and management of our program’s clinical training. In this role, I am extensively involved in our students’ practica training, as well as in the development of our training mission and pedagogy. Ours is a scientist-practitioner program, one that has asserted its mission to train “graduate students for professional work as academic clinical psychologists” and one that has evolved to heavily emphasize academic scholarship.
I also attended UMass for my Ph.D., so my perspective spans a longer length of time than just my faculty years. As a graduate student, our program was firmly ensconced in the era of infighting, much of it due to philosophical and theoretical differences. The classic battles between behaviorist and psychoanalytic thinking were played out as students moved from one class to another, from one supervisor to another. Training “camps” were formed, academic cliques that excluded those who did not preach the party line.
A trueborn politician and administrator, I joined several of these camps. I was fortunate to have as a mentor one of our program’s most experienced and established psychodynamic psychologists. My experience with him as an advisor and supervisor was one of constant support and mentorship, with strong themes of empowerment as he encouraged me to seek my own direction.
But one of the directions I chose was to gain specialized training in Cognitive-Behavioral treatment for anxiety and depression, something that later became a specialty I practice to this day. But even in this work, I was no rigid dogmatist. As we examined the hallowed “Empirically Supported Treatments,” I questioned the dropout rates cited in the literature. Perhaps more important, I questioned whether the interventions described could be implemented with enough fidelity to justify the label of “controlled study.” And finally, I thought of my own clients, ones I knew would never flourish in such a paradigm, clients who spent their time with me pursuing deeper questions or whose mental health history would have excluded them from typically controlled studies. All throughout, my advisor helped me to characterize and understand my work, and supported my educational path as I moved forward with these questions in my mind.
Several years after I left the program, he called to tell me he was retiring from his role as the Director of Clinical Training, and I was surprised to be asked whether I would be interested in returning to coordinate clinical training in our program. This meant taking over as Director of our training clinic, the Psychological Services Center and becoming the Associate Director of Clinical Training. More importantly, it meant shaping the training mission of a program that was being hit with many new retirements and new hires. When I returned, it was quickly apparent that it was expected I would plant a flag in the ground and declare “psychoanalytic or behaviorist.” Instead, I remembered my mentor’s powerful support and planted a flag that said “you choose.”
Supporting Psychoanalytic Training in a Scientist Practitioner Program
In our scientist practitioner program, our students seek a balance between clinical training and academic scholarship. The breakdown in our program is roughly 75% academic scholarship and 75% clinical training (that’s a joke). My first goal was to revitalize our clinical training, make it so powerful and compelling, that students would want to make it a priority (I figured the academic faculty could fend for themselves). Second, to bridge what can sometimes be a wide gap, I wanted to incorporate more clinical practice into my students’ research lives, and similarly, bring research into our clinical setting. I hoped these efforts would eliminate or minimize the polarization that can occur between research and clinical work in a scientist practitioner program. I also wanted to avoid the kind of divisiveness that I experienced in graduate school. Left unchecked, our training would have quickly shifted into a cognitive-behavioral training program rather than the broader more inclusive model we had previously valued. To support this breadth in clinical training, we had to find a way to permit students to make their own choices about their practice.
Over the years, our faculty had shifted in two primary ways. The first was that more of them had become research focused, with very few remaining engaged in the delivery of psychotherapy. The second was that the faculty who were engaged in psychotherapy or supervision practiced predominantly cognitive, behavioral or integrative work, a trend that has continued as more faculty have retired. This shift, as I am sure many of you understand, reflected the changing demographic among faculty with more recently-trained psychologists replacing those who were retiring. Providing breadth of training in this new context, the one in which the concept of Evidence Based Psychological Practice was emerging, would require ongoing attention.
Gathering the Necessary Expertise
One of the gifts I inherited when I returned to UMass was a level of student engagement that had fostered connectivity with the psychoanalytic community. A student-initiated psychoanalytic discussion group was a popular offering, facilitated by Dr. Ellenhorn, and something that people had an interest in continuing. In fact, one student felt so strongly about the potential erosion of psychoanalytic training, he encouraged his family to make several donations that allowed us to continue this program at a time when our financial situation was quite dire. Taking this as a sign of continued strong interest in psychodynamic work, I sought to increase access to this training by tapping into an extremely valuable resource, our local cadre of practicing clinical psychologists. So I got in touch with many of the more experienced psychologists in our local community, asking them to serve as adjunct supervisors for our training clinic. It was my hope that these psychologists, who were predominantly psychoanalytic by training, would work with our advanced students as they finished their final years before internship. I also hoped they would play wider roles in the overall program by re-engaging in a dialogue with our students and participating in department colloquia and other aspects of our training.
The result of this re-invitation was invigorating for everyone and the response was phenomenal. As students completed their introductory-level clinical teams supervised by our full-time faculty, they were given the choice in their 4th and 5th years to work with an adjunct supervisor in individual supervision. Our student clinicians had access to psychodynamically minded practicing psychologists and were able to explore this aspect of their own professional identity in a safe, supportive atmosphere. More importantly, by articulating their clinical training goals, I could match students with supervisors who would foster them most effectively. In many ways, this adjunct supervision became a capstone to our clinical training, providing more breadth of training for those who needed it, or increased depth in an area of specialty for those who desired this. As a training clinic, we operated on a sliding fee without session limits. Thus, there were no external pressures, other than individual financial concerns, to conform psychotherapy within a specified time period or model.
Reinitiating the relationships with our adjunct faculty had a powerful impact and led to other opportunities for psychoanalytic training. We hosted a specialized course in the Rorschach, which had been removed from our formal assessment program. And despite being an elective, the majority of our eligible students took this course. We continued the psychoanalytic discussion group, sometimes formally with financial support and other times informally as interested students connected with generous volunteers. We connected with psychoanalytic supervisors at off-site practica, and interested students could select their supplementary training experiences to suit their training needs. Students got together to sponsor colloquia on psychodynamic themes, though these had a mixed response among the faculty and students.
Integrating Research and Clinical Work in Psychodynamic Training
One of our biggest programmatic changes, was also the most controversial. In my second year as the Director of our training clinic, Dr. Michael Constantino and I wrote an internal grant to develop the clinical infrastructure needed to collaborate with the Practice Research Network, a group of affiliated clinics that conduct psychotherapy effectiveness research (Borkovec, 2001; 2004). Our proposal was to standardize many of the clinical activities that had previously been determined separately by the clinician and supervisor. We implemented an initial evaluation process that that included the Structured Clinical Interview for DSM-IV and the International Personality Disorders Examination for diagnostics purposes, complete with an inter-rater reliability analysis. We adopted the Treatment Outcome Package by Behavioral Health Laboratories, a suite of outcome measures that had recently been required of all Medicaid providers in our state. We included some additional measures in our standard protocol around some areas of particular interest including patients’ and therapists’ expectations about treatment (see Greenberg, Constantino & Bruce, 2006), as well as patients’ and therapists’ assessment of the therapeutic alliance. Finally, we adopted a standard data-collection schedule, with baseline data collected prior to treatment, and clinical data collected after session one, and before sessions seven, fifteen and then every fifteenth session until the final collection point at termination.
As you might imagine, imposing this system on an already successful training clinic created many problems. Most of these were administrative and structural, but some of course, were political. We were accused of many things including conspiring to force everyone into a rigid empirically-based dogma, corrupting the therapeutic process, and burdening our clients with unnecessary paperwork. Of course, much of what we had changed was necessarily a top-down process, justifying many of these fears and requiring compromise. However, the faculty ultimately voted unanimously to support this plan, and there were a host of reasons behind this. We had ushered in the age of Evidence-Based Practice; we had seen our students being pulled in too many directions and appreciated the opportunity to see research and clinical work go truly hand-in-hand; we wanted to give students access to an in-house clinical population for their research as a way of facilitating this aspect of their training. Personally, I also viewed these changes as an opportunity to strengthen psychodynamic training for reasons I will describe next. Not surprisingly, it was psychodynamically oriented students who were most fearful of the changes being implemented.
Treatment As Usual Research
One of the primary purposes of the research infrastructure in our training clinic is to support Treatment-As-Usual Research. What ultimately assuaged the anxiety felt by some of our faculty and students was the realization that we were seeking to gather data about psychotherapy as delivered in the real world. For us, this meant psychotherapy as delivered in a complex training clinic with faculty and students from a variety of backgrounds and theoretical orientations. Far from being a dogmatic, single-minded research program, we were all equal participants, represented by the data, and free to use it for any project that could be envisioned and approved by our local IRB. And while we do track “objective” measures like symptoms and diagnoses, we also examine more subtle and universal variables such as expectancies, therapeutic alliance, and even patient satisfaction. Because we videotape every session for supervision purposes, we have the ability to design studies that rely on closer examination of session content. With the right software, our recording systems are sophisticated enough for audio to be transcribed digitally, and for facial expressions and body language to be categorized and coded. Our clinic can accommodate innumerable research questions, either using our standard protocol, by including additional measures, or even by selecting or recruiting a specialized sample for clinical trials.
Treatment-As-Usual Research is a key factor in our ability to offer broad clinical training opportunities and support the inclusion of psychodynamic training opportunities in our program. While our clinicians and supervisors have lost some autonomy in having to adhere to the standard data-collection protocol, they retain the independence to determine their own approach to psychotherapy, as well as the development of their clinical formulation, and eventually, treatment plan. In short, everything “fits” in under the umbrella of treatment-as-usual. Perhaps more important, it gives everyone powerful opportunities to gather data about the effectiveness of treatment, whether that treatment is behaviorally or psycho¬dynami¬cally oriented. In doing so, our program maintains its commitment to Evidence Based Psychological Practice. It is exciting to note that the first two student-initiated projects pose their research questions around psychoanalytic paradigms.
How Our Clinical Training and Services Have Changed
One of the concerns that many people expressed as we embarked on this process was how it would affect our clients. Would clients be frustrated by the amount of paperwork and stop coming to therapy? Would they be intimated by the prospect of research being conducted using data about them? Would the therapeutic process itself be impaired by the insertion of external protocols into the more personalized psychotherapy context? These are several questions among many that we hope to explore as this program continues. Pragmatically, we were pleasantly surprised to see many improvements in our service delivery since the beginning of this program. Among some of the positive pragmatic outcomes, we have seen our total client census go up, the number of incoming clients and service-inquiries has increased, and perhaps most impressive, the number of clients who fail to return to treatment after the initial evaluation and first session has gone down. While we need more time to evaluate competing hypotheses for these positive changes, we remain optimistic that our services have been improved in some tangible way, and at the very least, the diversity of training opportunities has increased.
I often discuss the notions of theoretical dogmatism with my students, and when the issue of being integrative comes up, we all have a great deal to say. We often speak of two types of integration. The first is the integrationist, a psychotherapist who combines the common elements and factors of pertinent theories while working with a single client, such as a case that begins with an evaluation of problematic family origins and moves into a more problem-focused perspective as therapy nears termination. A second style of integration might be the eclectic psychotherapist, one who carries a tool belt of various talents and skills to be chosen, as needed, according to the situation.
But we always come back to some essential points, namely that most so-called dogmatic theories (behaviorism and psychoanalysis for example), are themselves integrative and have many complex facets that usually get left out of a typical bullet-point discussion of theory. But the concept of integration carries with it a very important thematic point, namely to express the idea that we do not know and cannot know everything that makes us tick. Psychological theories provide the scaffolding around which we mold our professional and personal identities, but it is the humble appreciation of the unknowable that makes us human.