POSTGRADUATE TRAINING OBJECTIVES IN INTEGRATIVE PSYCHOTHERAPY

University of Toronto, Department of Psychiatry Psychotherapy Program, Integrative Therapy Subcommittee

I. PREAMBLE

Ideally, the integrative approach should be the overriding stance of the Department of Psychiatry and the Psychotherapy Program. Theoretically broad understanding of patients and an integrative approach to treatment should be taught and practised in all clinical teaching settings. This would not preclude training in the individual treatment modalities, rather it requires it as a prerequisite to competent integrated practice. Integration is best considered not so much a specific modality of treatment, but rather an overall stance towards the psychotherapies, their relationship to each other, and their relationship to other modalities of treatment. Putting this into practice requires appropriate attitudes, knowledge of and competence with various therapeutic modalities, as well as theoretical knowledge and clinical skills specific to the task of integration.

II. TRAINING OBJECTIVES IN INTEGRATIVE THERAPY

A. Knowledge

(1) Implications of the theory of conceptual models for psychiatric practice (2) Potential limitations of and contraindications to integrative therapy (3) Comparative theory: metatheoretical relationships between different theoretical systems of psychotherapy (basic level) (4) Differential efficacy of major therapeutic modalities (5) Systematic classification of frameworks for psychotherapy integration, with emphasis on technical eclecticism, the common factors approach, and theoretical synthesis (6) Familiarity with the details of two specific integrative methods, one technical and one theoretical; for each method this should include an understanding of that approach with respect to: classification; theoretical basis; potential advantages, disadvantages, and clinical utility; and recommendations regarding therapist goals, stance, and interventions (7) Familiarity with the comprehensive integrative management of at least one common psychiatric disorder (8) Issues arising in the integration of psychopharmacology with psychotherapy (9) Issues arising related to the involvement of multiple therapists in the treatment of a single patient (10) Familiarity with the range of therapies denoted by the term supportive-expressive continuum, including the use of supportive techniques as an important component of some therapies

B. Skills

(1) Conceptually broad assessment and management planning, tailored to the specific needs of individual patients, (with patient-treatment matching, giving consideration to factors such as symptomatology, diagnosis, stage of treatment, cognitive style, ego strengths and deficits, and psychological defensive style) (2) Formulation from multiple perspectives (3) Ongoing integrative management of patients with a wide variety of diagnoses, in a range of clinical settings (4) Analyzing and managing therapeutic blocks and decision points from an integrative perspective (5) Recognizing and managing issues arising in the integration of psychopharmacology with psychotherapy, including the dynamic meanings of the use of psychotropic medication to individual patients (6) Capacity for skilled participation in multi-therapist treatments (7) Strategies for managing ambiguity and uncertainty

C. Attitudes

(1) Flexibility (2) Emphasis on empirical efficacy (as opposed to personal preference) in the selection of therapeutic modalities (3) Openness to multiple explanations of psychopathology and human suffering (4) Openness to the potential compatibility and complementarity of different theoretical systems (5) Emphasis on tailoring management to address the specific needs and capacities of the individual patient (6) Tolerance for the increased ambiguity and complexity associated with an integrative approach

D. Enabling Objectives

(1) Core curriculum seminars: the PGY-1 & 2 years introductory seminars currently in place have been designed to encourage the appropriate attitude; (2) One small group seminar format educational experience, preferably at the PGY-4 level that are part of the centralized Advanced Psychotherapy Seminars, to work on the conceptual, clinical and personal challenges inherent in conducting integrated, comprehensive psychiatric care (3) A primary clinical training experience in an outpatient general psychiatric setting, with intensive supervision by an appropriately skilled supervisor, providing opportunities for assessment and ongoing management of patients from an integrative approach [6 months minimum] (4) A secondary clinical training experience in an inpatient setting in which severely ill psychiatric patients are treated, so as to demonstrate the value and challenges of integrating appropriate psychosocial understanding and techniques into the treatment of the acutely ill; the integrative supervisory function could be the responsibility of the primary clinical supervisor, or alternatively, it might be achieved through adjunctive means, e.g. regular involvement of an appropriately skilled consultant, or participation in weekly rounds by such a consultant [6 months]

III. FOR RESIDENTS SEEKING ADVANCED TRAINING IN INTEGRATIVE PSYCHOTHERAPY, MINIMUM OBJECTIVES INCLUDE A. Preceding Requirements Plus

B. Knowledge

(1) History and themes of the eclectic/integrative psychotherapy movement (2) Factors resulting in potential for increased effectiveness in integrated treatments (3) Obstacles to and clinical challenges of integrative practice (4) Comparative theory: metatheoretical relationships between different theoretical systems of psychotherapy (advanced level) (5) Familiarity with details of a greater number of specific integrative methods (6) Familiarity with the comprehensive integrative management of several common psychiatric disorders

C. Skills

(1) Integrative formulation (2) Consultation to assess the ongoing treatment of patients of other psychiatrists from an integrative perspective, making recommendations accordingly

D. Attitudes

As in section II.

E. Enabling Objectives

(1) A second, more intensive clinical training experience under the supervision of an integrative practitioner; this might take place in a general outpatient setting, but alternative clinical settings would be most acceptable [1 year] (2) A consultative or advisory role (under supervision) should comprise a component of this experience (3) A second opportunity for detailed examination of integrative issues and challenges should comprise a component of this experience; it may occur one-on-one with the primary supervisor, or as a small group experience with other senior trainees, led by an appropriate supervisor (4) Work to develop a focus of interest and special capacity in a specific area of integrative therapy

IV. EXPERIENTIAL TRAINING

(1) The seminar format educational experiences make use of a small supervised group of peers to foster the attitudes described above. They serve as a forum for open dialogue, exploration of alternative understandings and approaches, and consideration of clinical and training challenges. These seminars encourage the exploration of the individual's developing identity as a psychotherapist. (2) The clinical rotations represent significant opportunities for experiential training, through clinical work, supervision, and practice in a consultative role.

V. EVALUATION Evaluation within clinical rotations should be done verbally by both supervisor and resident every three months. It should be done in writing every six months, in keeping with standard departmental procedures. Specific integrative therapy evaluation forms could be developed to complement the departmental evaluation forms, if necessary.

Informal evaluation of the small group seminars should be viewed as an ongoing, collaborative process, in keeping with the attitudes such seminars are intended to foster. Formal written evaluation at the completion of the seminar series would primarily be by the residents, to provide for monitoring of seminar quality and ongoing improvement.

Notes

 Training to achieve competence in individual therapeutic modalities is not addressed herein, as it is addressed in detail by the reports of other subcommittees.

 We have initiated a process of identifying supervisors possessing appropriate skills, who would be willing to bring psychotherapeutic (including psychodynamic) expertise and training to inpatient general psychiatric settings.

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