POSTGRADUATE TRAINING OBJECTIVES
IN INTEGRATIVE PSYCHOTHERAPY
University of Toronto, Department of Psychiatry
Psychotherapy Stream, PHES Division
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)
(2)
(3)
Implications of the theory of conceptual models for psychiatric practice
Potential limitations of and contraindications to integrative therapy
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
(2)
(3)
(4)
(5)
(6)
(7)
as symptomatology, diagnosis, stage of treatment, cognitive style, ego strengths and
deficits, and psychological defensive style)
Formulation from multiple perspectives
Ongoing integrative management of patients with a wide variety of diagnoses, in a range of
clinical settings
Analyzing and managing therapeutic blocks and decision points from an integrative
perspective
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
Capacity for skilled participation in multi-therapist treatments
Strategies for managing ambiguity and uncertainty
C. Attitudes
(1)
(2)
(3)
(4)
(5)
(6)
Flexibility
Emphasis on empirical efficacy (as opposed to personal preference) in the selection of
therapeutic modalities
Openness to multiple explanations of psychopathology and human suffering
Openness to the potential compatibility and complementarity of different theoretical
systems
Emphasis on tailoring management to address the specific needs and capacities of the
individual patient
Tolerance for the increased ambiguity and complexity associated with an integrative
approach
D. Enabling Objectives
(1)
(2)
(3)
(4)
Core curriculum seminars: the PGY-1 & 2 years introductory seminars currently in place
have been designed to encourage the appropriate attitude;
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
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]
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
2
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)
(2)
(3)
(4)
History and themes of the eclectic/integrative psychotherapy movement
Factors resulting in potential for increased effectiveness in integrated treatments
Obstacles to and clinical challenges of integrative practice
Comparative theory: metatheoretical relationships between different theoretical systems of
psychotherapy (advanced level)
Familiarity with details of a greater number of specific integrative methods
Familiarity with the comprehensive integrative management of several common psychiatric
disorders
(5)
(6)
C. Skills
(1)
(2)
Integrative formulation
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)
(2)
(3)
(4)
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]
A consultative or advisory role (under supervision) should comprise a component of this
experience
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
Work to develop a focus of interest and special capacity in a specific area of integrative
therapy
3
IV. EXPERIENTIAL TRAINING
(1)
(2)
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.
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.
REFERENCES
Arkowitz H, Messer SB. Psychoanalysis and Behavior Therapy: Is Integration Possible? New York: Plenum,
1984.
Beitman BD, Goldfried MR, Norcross JC. The movement toward integrating the psychotherapies: an overview.
American Journal of Psychiatry 1989; 146(2): 138-147.
Beitman BD, Hall MJ, Woodward B. Integrating pharmacotherapy and psychotherapy. In: Norcross JC,
Goldfried MR (eds), Handbook of Psychotherapy Integration. New York: Basic Books, 1992.
Beitman BD, Klerman GL (eds). Integrating Pharmacotherapy and Psychotherapy. Washington: American
Psychiatric Press, 1991.
4
Beutler LE, Clarkin JF. Systematic Treatment Selection: Toward Targeted Therapeutic Interventions. New
York: Brunner/Mazel, 1990.
Gabbard GO. Psychodynamic Psychiatry in Clinical Practice: The DSM-IV Edition. Washington: American
Psychiatric Press, 1994.
Goldfried MR, Newman C. Psychotherapy integration: an historical perspective. In: Norcross JC (ed),
Handbook of Eclectic Psychotherapy. New York: Brunner/Mazel, 1986.
Goldfried MR, Wiser SL, Raue PJ. On the movement toward psychotherapy integration: the case of panic
disorder. Journal of Psychotherapy Practice and Research 1992; 1(3):213-224.
Gurman, Messer SB. Essential Psychotherapies: Theory and Practice. New York: Guilford, 1995.
Lazare A. Hidden conceptual models in psychiatry. New England Journal of Medicine 1973; 288(7):345-351.
Messer SB, Winokur M. Some limits to the integration of psychoanalysis and behavior therapy. American
Journal of Psychology 1988; 35: 818-827.
Norcross JC, Goldfried MR (eds). Handbook of Psychotherapy Integration. New York: Basic Books, 1992.
Ormont LR. Principles and practice of conjoint psychoanalytic treatment. American Journal of Psychiatry
1981; 138(1): 69-73.
Pine F. Drive, Ego, Object, and Self: A Synthesis for Clinical Work. New York: Basic Books, 1990.
Safran JD, Messer SB. Psychotherapy integration: a postmodern critique. In press.
Safran JD, Segal ZV. Interpersonal Process in Cognitive Therapy. New York: Basic Books, 1990.
Schachter M (ed). Psychotherapy and Medication: A Dynamic Integration. Northvale NJ: Jason Aronson,
1993.
Wachtel PL. Psychoanalysis and Behavior Therapy: Toward an Integration. New York: Basic Books, 1977.
Weerasekera P. Formulation: a multiperspective model. Canadian Journal of Psychiatry 1993; 38: 351-358.
Yager J. Psychiatric eclecticism: a cognitive view. American Journal of Psychiatry 1977; 134(7):736-741.
5