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The Narrowing of Theoretical Orientations in Clinical

Psychology Doctoral Training

Laurie Heatherington, Williams College

Stanley B. Messer, Rutgers University

Lynne Angus, York University

Timothy J. Strauman, Duke University

Myrna L. Friedlander, University at Albany

Gregory G. Kolden, University of Wisconsin

The focus of this article is the increasingly narrow range

of therapeutic orientations represented in clinical

psychology graduate training programs, particularly

within the most research-oriented programs. Data on

the self-reported therapeutic orientations of faculty at

“clinical science” Ph.D. programs, Ph.D. programs at

comprehensive universities in clinical and in counseling

psychology, Psy.D. programs at comprehensive universi-

ties, and Ph.D. or Psy.D. programs at freestanding spe-

cialized institutions reveal a strong predominance of

faculty with cognitive-behavioral orientations at the

more science-focused programs, and a narrower range

of orientations than in the more practice-focused pro-

grams. We discuss the implications of this trend for the

future development of clinical psychology and provide

suggestions for addressing the attendant concerns.

Key words: CBT hegemony, clinical training and

research, theoretical orientation. [Clin Psychol Sci Prac

19: 362–374, 2013]

The growth of our knowledge is the result of a process closely

resembling what Darwin called ‘natural selection’; that is, the

natural selection of hypotheses: our knowledge consists, at

every moment, of those hypotheses which have shown their

(comparative) fitness by surviving so far in their struggle for

existence; a competitive struggle which eliminates those

hypotheses which are unfit.

Karl Popper (1979)

The best way to have a good idea is to have a lot of

ideas.

Linus Pauling

Doctoral training in clinical psychology is clearly in a

state of evolution. The scientist–practitioner (“Boul- der”) model that characterized the training landscape

since 1949 has been challenged by several strong ideo-

logical and sociological forces and developments. Argu-

ments for the value of more practice-focused doctoral

training led to the development of Psy.D. programs,

beginning in the 1970s. Subsequently, market forces

have resulted in the explosive growth of large, prac-

tice-focused doctoral training programs at freestanding

institutions, dubbed “specialized institutions not offer-

ing comprehensive education beyond psychology or

counseling” by Sayette, Norcross, and Dimoff (2011,

p. 4), and hereafter referred to as “specialized institu-

tions,” as well as a crisis in the oversupply of applicants

relative to the availability of doctoral internships

(Munsey, 2011; Vasquez, 2011). Controversies about

standards for doctoral training programs, especially with

regard to the need to teach evidence-based treatments

(Bray, 2011; Calhoun, Moras, Pilkonis, & Rehm,

Address correspondence to Laurie Heatherington, Ph.D.,

Department of Psychology, Williams College, Williamstown,

MA 01267. E-mail: [email protected]

© 2013 American Psychological Association. Published by Wiley Periodicals, Inc., on behalf of the American Psychological Association. All rights reserved. For permission, please email: permissionsuk.wiley.com 364

1998; Davison, 1998; Eby, Chin, Rollock, Schwartz,

& Worrell, 2011), continue. And most recently, the

assertion by some that current American Psychological

Association (APA) accreditation standards and practices

are undermining the science of clinical psychology has

resulted in the creation of alternative accreditation stan-

dards that emphasize research and clinical training

focusing on empirically supported treatments and

assessment (Baker, McFall, & Shoham, 2009; McFall,

2007). The outcomes of this evolution in training are

difficult to predict, and the relative merits of the vari-

ous training models are a matter of widely diverging

opinions and beyond the scope of this article.

However, a recent study of APA-accredited clinical

Ph.D. programs (Sayette et al., 2011), including the

Academy of Psychological Clinical Science (APCS,

2012) 1 and non-APCS programs in regular (“compre-

hensive”) university settings and in specialized universi-

ties, but excluding Psy.D. and counseling psychology

Ph.D. programs, demonstrated a number of significant

differences in acceptance rates, numbers of applicants

admitted, admissions credentials, extent of financial aid,

student demographic characteristics, and program fea-

tures (e.g., research funding, internship acceptance

rates). The study also found stronger faculty allegiance

to a cognitive-behavioral orientation in APCS pro-

grams (80%), as compared with non-APCS programs

(67%) and programs in the specialized institutions

(37%), as well as stronger allegiances to psychodynamic

and humanistic/existential orientations in non-APCS

versus APCS programs.

This article expands and critically discusses the latter

finding. We argue that the finding regarding theoretical

orientation reflects a feature of the evolving training

landscape that is central to the future of clinical psy-

chology but which has received little formal attention,

that is, the increasingly restricted range of therapeutic

orientations that clinical graduate students are expected

to draw upon in their professional work. We contend

that an unfortunate effect of some otherwise positive

developments in promoting clinical psychology as a sci-

ence is the danger of a monoculture of ideas about the

nature of psychotherapeutic change—specifically, a hegemony of cognitive-behavioral theory and therapy.

Furthermore, this effect is moderated by the nature of

the doctoral training program. That is, the more

research-based, science-focused programs tend to offer

the narrowest range of theoretical orientations, whereas

the more practice-focused programs present the widest

ones. In this article, we present data suggesting that this

divide is evident within doctoral programs at compre-

hensive universities, especially in clinical psychology

(but not counseling psychology) programs. The divide

is particularly evident when comparing clinical

programs at comprehensive universities versus programs

at freestanding professional schools of psychology.

Following the presentation of data supporting this

assertion, we discuss the dangers of these divides.

First, however, consider the following thought exer-

cise. Imagine that you are the mentor of a talented

undergraduate who is beginning the clinical psychology

doctoral application process. She has a strong liberal

arts preparation, with a range of psychology courses in

both clinical and nonclinical areas, and good research

experience. She plans a career that includes psychother-

apy research and theory development, and she wants

solid clinical training as well. She is compiling an initial

list of programs and is particularly interested in family

systems theory and therapy. As her mentor, you consider

programs with core faculty (those who supervise theses

and dissertations, that is, excluding adjuncts, off-site

practicum supervisors, faculty in departments of psychi-

atry that do not offer doctoral degrees) who publish

research in addition to providing clinical training.

Now, repeat the exercise with humanistic, experiential or

existential theory/therapy, with psychodynamic theory/ther-

apy, and with interpersonal theory/therapy. Having done

this exercise ourselves and having mentored students

like this one, we are aware of the difficulty in coming

up with programs to suggest; indeed, these lists are

likely to be very short.

The data presented below bear out these personal

observations. We undertook a systematic study of theo-

retical orientations represented in clinical and counsel-

ing doctoral training programs of various types, using

published sources. The Insider’s Guide to Graduate

Programs in Clinical and Counseling Psychology (Sayette,

Mayne, & Norcross, 2010) provided information on

self-reported theoretical orientations of program faculty

in six categories, that is, Psychodynamic, Behavioral,

Family Systems, Cognitive Behavioral, Humanistic/

Existential, and Other; the guide allows for faculty to

THEORETICAL ORIENTATIONS � HEATHERINGTON ET AL. 365

indicate one or more orientations. The APA’s 2010

Graduate Study in Psychology (APA, 2010) education/

accreditation web site (http://apa.org/ed/accreditation/

programs/index.aspx) and the list of member programs

published by the Academy of Psychological Clinical

Science (http://acadpsychclinicalscience.org/members)

provided designations of various program types. As

needed, Internet searches of individual programs were

used to confirm their statuses as (a) Ph.D. programs at

comprehensive universities, (b) Ph.D. programs at

comprehensive universities that are designated as clini-

cal science programs, (c) Psy.D. programs at compre-

hensive university programs, and (d) Psy.D. or Ph.D.

programs at freestanding, “specialized” institutions. We

included programs in the 50 U.S. states and Canada.

Although the APA is phasing out accreditation of

Canadian programs as of 2015, our concern is not with

credentialing issues, but rather with training and con-

tinued development in psychotherapy theory and

research, which has been and no doubt will continue

to be significantly influenced by Canadian psychology.

For this same reason, we also included counseling psy-

chology, but treated it separately, as virtually all coun-

seling psychology doctoral programs are at

comprehensive universities and because there are some

historical and current differences between counseling

and clinical psychology. Moreover, we excluded the

eight APA-accredited “combined” (e.g., school/clini-

cal, school/counseling) programs.

Table 1 presents the mean percentages of faculty in

various types of clinical psychology doctoral programs

who self-report particular theoretical orientations. 2 The

comparison is striking. In the clinical science programs,

fully 80% of faculty claim a cognitive-behavioral orien-

tation, and 89% claim either a behavioral or cognitive-

behavioral orientation, whereas small percentages of

faculty claim either a psychodynamic or a humanistic/

existential orientation. Fewer than half of the faculty in

Psy.D. programs at comprehensive universities and in

Psy.D. or Ph.D. programs in freestanding universities

claim a CBT orientation, with noticeably higher per-

centages of faculty (28% and 29%, respectively) claim-

ing a psychodynamic orientation. Interestingly, the

least variation across programs was found in the per-

centages of faculty claiming a family systems orienta-

tion, close to 20% of faculty in each type of program.

Table 2 presents the mean percentages of faculty in

counseling psychology doctoral programs who self-

report particular theoretical orientations. These data

reveal a wider range of orientations, with fewer than

half claiming a behavioral or cognitive-behavioral ori-

entation and nearly a third claiming a humanistic/exis-

tential orientation. Explanations for this variation will

be advanced shortly.

Some elaboration and qualifications of these data are

in order. First, in the Insider’s Guide, programs could

also designate faculty with “other” orientations. These

data were sparse and often unique to individual pro-

grams or individual faculty and thus are not included in

the table, but rather summarized as follows. Of the 54

clinical science programs, only two cited one or more

“other” orientations. These (and the number of pro-

grams that cited them) were neuropsychology (1),

community (1), interpersonal (1), motivational inter-

Table 1. Therapeutic orientations of faculty in clinical psychology doctoral training programs

Program Type Psychodynamic (%) Behavioral (%) Family Systems (%) Humanistic/Existential (%)

Cognitivea

Behavioral (%)

Ph.D. programs designated as “clinical science”b programs (n = 54)

7 9 17 4 80

All other Ph.D. programs at comprehensive universities (n = 116)

19 11 20 24 67

Psy.D. programs at comprehensive universities (n = 31)

28 5 16 12 48

Psy.D. and Ph.D. programs at freestanding professional schools (n = 37)

29 6 22 15 32

Ms 21 8 19 14 57

a Source: Sayette et al. (2010). b Source: Academy of Psychological Clinical Science (http://acadpsychclinicalscience.org/index.php?page=members).

CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE � V19 N4, DECEMBER 2012 366

viewing (1), child (1), and eclectic (1). Of the 116

other clinical Ph.D. programs at comprehensive univer-

sities, 15 listed faculty with “other” orientations: health

(1), integrative (3), community (1), clinical neuropsy-

chology (3), eclectic (1), interpersonal or interpersonal/

ego relations or cognitive/interpersonal (5), develop-

mental psychopathology (1), feminist (2), cognitive (1),

narrative/personal construct (1). Of the 31 Psy.D. pro-

grams at comprehensive universities, only one listed an

“other” orientation: integrative/transtheoretical. Of the

38 programs at freestanding professional schools, four

listed “other” orientations: research (1), integrative (2),

cultural diversity focus (1). And of the 66 doctoral

counseling programs, 13 listed “other” orientations:

eclectic (1), integrative (1), interpersonal (7), feminist/

multicultural or feminist or multicultural (13), con-

structivist (2), relational/process (1), narrative (1),

developmental systems (2).

Second, the data on orientations in the Insider’s

Guide were only available as percentages. We do not

know how many actual faculty are represented in these

percentages; “20%” of faculty claiming a family systems

orientation could refer to one or two individuals in

smaller programs, but several individuals in programs

with larger faculties. Although the APA Graduate Study

guide lists numbers of faculty, it was not possible (given

changing faculty sizes, variability in the recency of the

data in each source) to accurately compare the data in

these two sources to derive the raw numbers of faculty.

Nevertheless, this issue is of obvious importance,

because it speaks to the actual availability of mentors

and supervisors representing particular orientations, as

well as the viability of training and research from the

particular theoretical orientation at any given program.

Adding the percentages for each program, however,

provides a rough index of the extent to which faculty

at a particular program claim more than one allegiance,

that is, eclectic orientations. That is, in programs at

which each faculty member claims a single orientation,

the mean percentages for each orientation total to

100%. For programs in which faculty members claim

more than one orientation, the percentages total to

more than 100%, with higher totals representing more

faculty claiming multiple allegiances. The total percent-

ages averaged across the different program types are the

following: Ph.D. programs at comprehensive universi-

ties, M = 129%, Ph.D. programs at comprehensive universities that are designated as clinical science pro-

grams, M = 107%, Psy.D. programs at comprehensive university programs, M = 110%, Psy.D. or Ph.D. pro- grams at the freestanding, “specialized” institutions,

M = 105%, and counseling psychology doctoral pro- grams, M = 114%. Interestingly, the modal and median percentage totals were the same (each 100%) for every

program type.

SO WHAT? IMPLICATIONS FOR TRAINING, RESEARCH,

THEORY, AND PRACTICE

The data revealed two major divisions: between the

types of theoretical orientations in which current stu-

dents/future clinical psychologists are being trained and

between the theoretical orientations predominant in

the more research-focused and more practice-focused

programs. These divides are potentially dangerous for

the field and the future development of psychotherapy

theory and research.

It should be noted as well that the data revealed a

third divide, between clinical and counseling psychol-

ogy programs, which is noteworthy in that it provides

some context for the current concern. The broader

theoretical focus in counseling psychology can be

explained by differences in its history and training phi-

losophies. Although counseling psychology training

programs have required curricula and training experi-

ences that are similar to those of clinical psychology

programs, counseling psychology has different roots in

Table 2. Therapeutic orientations of faculty in counseling psychology doctoral training programs

Psychodynamic (%)

Behavioral (%)

Family Systems (%)

Humanistic/ Existential (%)

Cognitivea

Behavioral (%)

Ph.D. programs at comprehensive universities (n = 67)

19 1 18 31 42

a Source: Sayette et al. (2010).

THEORETICAL ORIENTATIONS � HEATHERINGTON ET AL. 367

group career counseling, vocational rehabilitation of

WWII veterans (Gelso & Fretz, 1992), and counseling

of “normal” individuals with developmental difficulties

or life problems (Friedlander, Pieterse, & Lambert,

2012). This history dovetails with the fact that the pre-

dominant training model in counseling psychology for

the last 45 years has focused on relationship-oriented

and microcounseling skills (Egan, 2007; Hill, 2004;

Ivey & Ivey, 2007; Ridley, Kelly, & Mollen, 2011). In

practicum training, the preferred supervision approach

is to foster trainees’ experience with a range of theoret-

ical approaches, always being guided by clients’ indi-

vidual problems and needs. Most counseling

psychology programs do not hire faculty members

based on theoretical orientation; rather, the prevailing

preference seems to be a faculty that represents a broad

range of approaches. Further, reflecting the de-empha-

sis on the medical model (matching treatment to diag-

nosis) and the preferred emphasis on relationship skills

and common factors, counseling psychology researchers

have traditionally focused more on explicating thera-

peutic change factors than on comparing client out-

comes by treatment approach. Indeed, some of the

historically most influential lines of psychotherapy pro-

cess research were conducted by counseling psycholo-

gists, for example, Edward Bordin, Charles Gelso,

Leslie Greenberg, Adam Horvath, Clara Hill, Laura

Rice, and Stanley Strong.

Returning to the two major divides, regarding the

first, we would argue that the increasing dominance of

CBT, while derived in part from the early body of

research (Chambless et al., 1996) examining and sup-

porting its efficacy, is not optimal for the continued

development of psychotherapy specifically, and clinical

psychology more generally. In particular, we suggest

that it is highly limiting to have the field dominated by

any single theory of change. If CBT were the only

effective treatment, this would not be problematic. But

converging evidence indicates that CBT is not in fact

the only effective treatment, as demonstrated by the

Dodo verdict; the fact that, typically, only a small per-

centage of outcome variance is accounted for by treat-

ment approach (Wampold, 2001); the demonstration of

therapist effects and especially (as discussed shortly) the

current research evidence that a number of treatments

from other theoretical approaches are also efficacious,

especially for the treatment for depression (APA Task

Force on Psychological Interventions’ 2012 list, http://

www.div12.org/PsychologicalTreatments/disor-

ders.html). We suggest that an impartial reading of the

psychotherapy efficacy literature would not inevitably

lead to such a narrow focus on a single theoretical ori-

entation. We also suggest that such a narrow focus is

very unlikely to encourage and facilitate the research

that is sorely needed on other treatment orientations.

The evolution of theory, research, and practice

requires a diversity of ideas and perspectives, and, as

Pauling noted, “lots” of them. Indeed, our current

major theoretical perspectives evolved from a combina-

tion of mutually enriching, sometimes competing, per-

spectives. For CBT, these have included behavioral,

psychodynamic, personal construct, social learning, and

other perspectives. Messer (2004), in a discussion of

“assimilative integration” (i.e., incorporation of tech-

niques from other types of treatment into one’s

“home” therapy), cited Keane and Barlow’s (2002)

observation that Freud and Janet most influenced the

use of exposure and anxiety management—now con- sidered central features of CBT—in the treatment for PTSD. More recently, we have seen the experiential

tradition influencing the evolution of CBT in its new

emphasis on affective experience, and the meditative

tradition helping to shape Dialectical Behavior Therapy

(Linehan,1993) and variations of cognitive-behavioral

treatments for generalized anxiety disorder (Roemer,

Erisman, & Orsillo, 2008). Additionally, integrative

approaches to treating addictions and associated mental

health issues, such as motivational interviewing, draw

heavily on the client-centered model of therapeutic

practice (Angus & Kagan, 2009).

Why is the current dominance of a single theoretical

perspective potentially problematic? A generation of

students trained to think from only one perspective will

become theorists, teachers, researchers, and practitio-

ners whose creativity, intellectual flexibility, and ability

to create new treatments for changing times, troubles,

and client populations are likely to be diminished.

Further, a generation of students trained (implicitly or

explicitly) to trust in only one perspective will become

a generation that is less willing to be open to different

ideas and most importantly, less able to meet the

emerging mental health needs of the future.

CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE � V19 N4, DECEMBER 2012 368

John Stuart Mill, a strong advocate of empirical

methods in scientific procedure in the 19th century

and a philosophical progenitor of behaviorism, argued

that a plurality of views is needed in science (Cohen,

1961). Mill’s reasons are as appropriate for training in

clinical and counseling psychology as they are for sci-

entific advancement, including the fact that a problem-

atic view may contain some portion of the truth.

Moreover, as the prevailing view is never the whole

truth, it is only by collision with contrary opinions that

the remainder of the truth has a chance of being recog-

nized. One point of view that is wholly true, but not

subjected to challenge, will be held as a prejudice

rather than derived from a rational basis, and someone

holding a particular point of view without considering

alternative perspectives will not really understand the

meaning of the view he or she holds. Citing Mill and

framing this argument in a positive form, Safran and

Messer (1997) argued that science and practice flourish

in an atmosphere of confronting and discussing differ-

ence, noting that “to the extent that confronting alter-

nate therapeutic paradigms and techniques flips us into

a ‘world-revising mode’ … there is the possibility of its leading to a dialogue which can truly deepen our

understanding of the human change process” (1997,

p. 142). In the clinical realm as well, there are atten-

dant implications for the ways in which we think

philosophically about human nature and human

change. It has been argued that exposing psychology

students to different theories and visions of reality

(Messer & Winokur, 1984) enriches their understand-

ing of clients and ways to treat them, including the

possibility of shifting from one perspective to another,

thereby encompassing more of the complexity of

human behavior (Messer, 2006).

Paradoxically, having both understanding of and

competence with two or more treatment orientations

may help clinicians use particular treatment protocols

with greater fidelity, when that is their goal. There is

mounting evidence that the actual therapeutic

interventions of clinicians who believe they are follow-

ing manualized treatment protocols often do not accu-

rately reflect the core treatment principles of that

approach (Shoham, 2011). A proposed remedy, training

students to understand the difference between going

“off-manual” versus practicing “flexibility within

fidelity” (Kendall, Gosch, Furr, & Sood, 2008; Sho-

ham, 2011), requires a deep understanding of what is

and what is not a prototypical intervention in the

approach at hand. And the latter, we suggest, is facili-

tated by knowing more than one therapeutic approach

well because the distinguishing features between cate-

gories of interventions help define them. For example,

students who truly understand interpretation but who

are following a CBT protocol and attempting to frame

cognitive restructuring interventions will be more

likely to do so with integrity because they understand

the differences between these similar yet distinct con-

structs at a core level.

Finally, we are concerned that the trend shown in

these data is likely to beget more of the same over

time. The programs most likely to produce our future

academic clinical psychologists—comprehensive Ph.D. programs, perhaps especially those designated as clinical

science programs—are the ones with the narrowest range of orientations. Not only will this trend limit the

vision and sources of ideas for current students, but also

their students will be even less likely to have professors

and clinical supervisors who represent other orienta-

tions, and consequently less likely to have research

mentors who are engaged in serious research on psy-

chotherapy from other orientations. We hasten to note

that there is no implied criticism here of the core

emphasis of clinical science training programs on the

need for data regarding the development and validation

of treatment approaches. In fact, one of our goals in

this commentary is to emphasize and support the asser-

tion that any treatment model worth learning must

have compelling data that support its efficacy and effec-

tiveness (and in fact, as noted earlier, a range of treat-

ment approaches do). Rather, the concern is that we

may inadvertently be training a generation of students

who equate a particular orientation with “good sci-

ence” and, by implication, other orientations for which

compelling data in fact exist, with “bad science” or

“no science.”

Finally, inasmuch as the growth and development of

treatments is facilitated by ongoing exchanges between

researchers and practicing clinicians, these divides are

dangerous. There is currently considerable distance

between the kinds of treatments that practitioners

know and use, on the one hand, and the type of

THEORETICAL ORIENTATIONS � HEATHERINGTON ET AL. 369

treatment that has come to dominate the research-

based treatment development landscape, that is, CBT,

on the other. A 2008 APA survey of 5,051 certified

Psychology Health Service Providers in the United

States revealed the following “primary theoretical

orientations,” in descending order: cognitive behavioral

(38.9%), psychodynamic/psychoanalytic (15.6%), inte-

grative (14.6%), “other,” which was primarily “eclec-

tic” (6.1%), cognitive (5.1%), humanistic/existential

(4.1%), behavioral (2.9%), systems (2.8%), and less than

2% each of biological, developmental, and family

(APA, 2008, http://www.apa.org/workforce/publications/

08-hsp/index.aspx).

Yet, feedback about the clinical realities of imple-

menting treatments as well as (ideally) the input of

practitioners into treatment development at early stages

is critical. A laudable collaborative project between

APA’s Division 12 (Clinical Psychology) and Division

29 (Psychotherapy) solicited clinicians’ feedback about

their experiences using various cognitive-behavioral

approaches for social phobia, generalized anxiety disor-

der, and panic (Goldfried, 2010, 2011). This kind of

exchange advances intelligent development and refine-

ments of our treatments, but it will be less and less

likely to happen among, for example, family therapy,

psychodynamic, and experiential researchers and practi-

tioners, given the shrinking numbers of academics ask-

ing such questions from these perspectives.

LIMITATIONS AND POSSIBLE COUNTERARGUMENTS

There are some limitations in the data themselves.

Only allegiances to the categories of therapeutic orien-

tation included by the Insider’s Guide were assessed;

also, objections may be raised to the ways in which the

approaches are categorized in that book, for example,

separating behavioral and cognitive behavioral, and cat-

egorizing all psychodynamic approaches as one. Other

orientations (e.g., Interpersonal Therapy [IPT], group,

eclectic) are missing altogether. An “integrative” choice

would have been particularly relevant to the current

questions. As it is not included in the Insider’s Guide,

we have no way of knowing whether faculty “orienta-

tion” refers to an orientation with regard to one’s clini-

cal practice (and indeed, how many faculty are engaged

in active clinical practice), personal theoretical prefer-

ence, research domain, or some combination. Further,

the focus of these categories on treatment orientations

does not capture allegiance to training orientations that

focus on aspects of the therapeutic relationship, which

transcend treatment type, but which are also critically

important not only for treatment outcome but also for

theory development and research (Norcross, 2011). On

the other hand, we note that our sample itself is

broader and more representative of psychologists cur-

rently engaged in training than other surveys of theo-

retical orientation, for example, surveys restricted to

members of APA’s Division 12 (Clinical Psychology;

Norcross, Karpiak, & Santoro, 2005).

The data also cannot reveal how the current state of

affairs applies to the actual coursework and practicum

training offered within the various types of training pro-

grams, nor do the percentages include part-time and

adjunct faculty who are hired to teach practical and who

are sometimes involved in supervising theses and disser-

tations at Psy.D. and professional school programs, and

thus have some influence on doctoral students’ outlooks.

We would argue, however, that the impact of their

research mentorship may not be as strong as that of core

faculty, who are engaged in research and predominantly

shape the intellectual ethos of the program.

In the spirit of the Popper quote, a counterargument

to ours may be mounted, namely, that the evolution

we described is precisely what is best for the field. The

strongest stance would be that it is no longer accept-

able to use—or to train students to use—psychological treatments that have not been empirically supported as

efficacious for specific psychological disorders in rigor-

ous randomized clinical trial research. On the other

end, there are stances that allow for evidence-based

practice and training (Levant & Hasan, 2008) that in

addition to basing practice on findings from random-

ized clinical trials, more explicitly recognize the role of

clinical expertise, client values and preferences, and

other forms of research evidence (Messer, 2004). There

are a variety of opinions about the standards by which

the acceptability of evidence for a treatment should be

decided. We will not hash out the empirically sup-

ported treatments debate here as it has been thoroughly

discussed in the literature, but we acknowledge that

individuals’ and programs’ stances on what constitutes

acceptable evidence of treatment effectiveness/efficacy

are a key factor in training policies.

CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE � V19 N4, DECEMBER 2012 370

We agree that training students in a diversity of

poor or wholly untested treatments for the sake of hav-

ing a variety of options makes no sense and that dis-

credited theories and treatments (cf. Castonguay, 2010;

Lilienfeld, 2007), as well as those for which no one

seems to be willing or able to mount research programs

to evaluate, should be “eliminated as unfit.” But we are

a long way from the claim that only cognitive-behav-

ioral treatments are empirically supported. As Messer

(2004) noted, the literature also reveals a number of

what Wampold (2001) defined as “bonafide” therapies:

those with a firm theoretical base, an extensive practice

history, and a research foundation, even if the treat-

ment does not meet the “empirically supported” crite-

ria as defined by the Task Force (Wampold, Minami,

Baskin, & Tierney, 2002; Wampold et al., 1997).

Indeed, as noted earlier, the updated APA Division 12

list of research-supported treatments for depression

now goes far beyond the narrow range of treatment

approaches originally identified and includes 12 differ-

ent empirically supported treatments for depression that

are based on humanistic, psychodynamic, interpersonal,

and cognitive therapy models (http://www.div12.org/

PsychologicalTreatments/disorders.html). Yet, the increas-

ing lack of opportunity for serious graduate study and

research on the full range of evidence-based approaches

risks creating a situation in which their development

will fall increasingly behind, widening these divides.

POSSIBLE SOLUTIONS AND FUTURE DIRECTIONS

First, preparing students to think in an integrative man-

ner may help. It has been demonstrated that the funda-

mental tenets of one theory also explain client change

from other theoretical perspectives. Consider operant

conditioning, a hallmark of CBT, which Castonguay,

Reid, Halperin, and Goldfried (2003) found to occur

in psychodynamic as well as humanistic therapies.

Contrariwise, there are features of CBT that are bor-

rowed, knowingly or not, from psychodynamic therapy

and that are correlated with change in CBT (Shedler,

2010). The psychotherapy integrationist movement has

a long history, which includes Dollard and Miller’s

(1950) comparative analysis of behaviorism and

psychoanalysis, Frank’s (1961) description of curative

factors in healing across cultures, and Lazarus’s (1967)

technical eclecticism and multimodal therapy. The

growing trend toward integration came from major

theorists who recognized the complexity of the change

process and the shortcomings of many unimodal theo-

ries. In his 2010 presidential address to the Society for

Psychotherapy Research, Castonguay predicted that

psychotherapy integration will continue to grow and

that the four major systems of therapy will be

improved based on research that emphasizes common

and contextual factors with diverse client populations.

According to him, as we narrow the division between

research and clinical practice, integrative psychotherapy

is likely to become the gold standard, even if it is not

superior to a “pure form” approach. In our data set,

there were a few programs that were clearly integra-

tionist evidenced by both a variety of orientations rep-

resented and a total number of orientations listed that

was well over 100%. Furthermore, a substantial body

of efficacy research indicates that successful treatment is

accounted for by individual client differences, individ-

ual therapist effects, and common factors (expectancy,

alliance, etc.) more so than by techniques specific to

any particular theoretical orientation (Wampold, 2001).

Thus, truly integrative thinking requires training in

these research and theoretical bases as well.

Second, the training of top-notch future psychother-

apists, psychotherapy theorists, and psychotherapy

researchers needs to include an understanding of the

latest clinical science in related domains of knowledge

such as developmental psychopathology and affective

neuroscience. For example, attachment, emotion regu-

lation, autobiographical memory specificity, and per-

ceptual-cognitive biases, among many other topics, are

highly relevant to therapy; not only will this under-

standing enrich the pool of ideas that inform the study

of change process mechanisms, but also it will enhance

entry-level clinicians’ ability to think broadly and

deeply about how and when to use the tools they

have. It is erroneous to assume that one orientation is

more compatible with basic science than another, the

current data notwithstanding. The challenge, of course,

is to be true to the intent of training models—to actu- ally expose students to science, teach them how to

understand it (and in some cases, how to engage in it),

and most importantly, help them to integrate emerging

findings in behavioral and clinical science into their

practices.

THEORETICAL ORIENTATIONS � HEATHERINGTON ET AL. 371

Third, we suggest that monocultures, or near mono-

cultures, tend to reproduce themselves in both subtle

and less subtle ways without deliberate attention to

intellectual diversity. The chance to talk with col-

leagues from other theoretical orientations as well as

from related disciplines is affected by program infra-

structure, from the seemingly mundane (office and lab-

oratory placements, research group assignments, habits

of colloquia invitations and attendance) to the less

mundane (faculty hiring and graduate student admission

practices, tenure and promotion pressures that foster

not straying too far from colleagues’ beliefs or prevail-

ing department culture). Professional conferences, with

a few exceptions (Society for Psychotherapy Integra-

tion, Society for Psychotherapy Research), have

become increasingly balkanized, top-ranked doctoral

programs tend to admit students whose prior training

and attitudes about theoretical orientation are fairly set

and mirror that of their potential advisor, and grant

pressures (which currently favor the predominant treat-

ment approach) help keep students fairly narrowly

focused from the time they enter their doctoral pro-

grams. Our field needs to think collectively about the

implications of such practices. Finally, it bears repeating

that advocates of promising treatment approaches that

are not widely available for training at present and that

do still require stronger empirical evidence need to

continue their research efforts and to be better sup-

ported in doing so. It is interesting and hopeful in this

regard that those doctoral programs in comprehensive

universities not designated as clinical science programs,

and the doctoral programs in counseling psychology,

had the highest mean percentages of multiple orienta-

tions claimed, 129% and 114%, respectively.

It will be interesting to see whether or not future psy-

chotherapy training continues to be organized around

broad umbrella “orientations” or organized more

around some other features of treatments. We note, for

example, that CBT now represents a highly diverse cate-

gory of evidence-based protocols (EBPs), which are

quite different from each other in underlying theories of

change (e.g., exposure in Prolonged Exposure [PE],

cognitive restructuring in Cognitive Processing Therapy

[CPT]), structures (90-min sessions in PE, 60-min ses-

sions in CPT), and techniques/procedures (in-session,

repeated imaginal exposures in PE, use of written narra-

tives in CPT). In fact, the United States Department of

Veterans Affairs (VA) purports to provide training and

dissemination of specific EBPs for clinicians providing

mental health services to veterans (Karlin et al. 2010).

The VA’s list of these includes the following: CBT for

depression, Acceptance and Commitment Therapy

(ACT) for depression, IPT for depression, CPT for

PTSD, PE for PTSD, Social Skills Training (SST) for

severe mental illness, Integrative Behavioral Couple

Therapy (IBCT), and Family Psychoeducation.

Should graduate psychotherapy training programs

aspire to training models that de-emphasize a focus on

particular theoretical orientations and focus more than

at present on training in a broad range of evidence-

based protocols? On the one hand, it would be a way

for students to acquire knowledge earlier in a range of

efficacious treatments so that internship and postdoc-

toral psychotherapy training could be organized around

providing more advanced training and supervision.

(Currently, many internship and postdoctoral training

sites can only provide introductory exposure to evi-

dence-based protocols from approaches other than

CBT, due to students’ very limited [if any] exposure to

these approaches during graduate training.) Further, it

might be expected that with experience and supervi-

sion, trainees in EBPs naturally evolve toward integra-

tion and adaptation of EBPs according to the unique

characteristics of individual patients. On the other

hand, it could be argued that this kind of training strat-

egy, especially at the graduate (vs. internship or extern-

ship) level, would be atheoretical, too narrow and too

focused on specific protocols. Rather, students should

be trained in the broader theoretical outlooks and non-

specific relationship skills, and only then in the specific

EBPs, which will lead naturally to an integrative

approach informed by a deeper understanding.

In another vein, Follette and Beitz (2003) offer

some sensible suggestions for creating a curriculum that

teaches students to think in a broad and rigorous scien-

tific manner about empirically supported treatments.

Specifically, these suggestions call for more attention to

mechanisms of psychotherapeutic change, which is by

definition a multitheoretical or even pantheoretical

enterprise, at least. In addition, programs seeking to

build strength in training for more than one orientation

should “put their best foot forward” by highlighting

CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE � V19 N4, DECEMBER 2012 372

the available data, exposing students to the theoretical

and empirical base that justifies training in a particular

orientation.

In sum, healthy evolution in our field, as in all

fields, requires new ideas that derive from varying per-

spectives. As clinical science progresses, this kind of

flexibility, which transcends singular allegiances to one

theoretical orientation versus another, will become

increasingly important in the development of theory,

research, and practice.

ACKNOWLEDGMENTS

We gratefully acknowledge the able research assistance of

Laura Christianson and Joshua Wilson, and very helpful com-

ments from Marlene Sandstrom, Catherine B. Stroud, and an

anonymous reviewer.

NOTES

1. These are programs that have been determined to meet

the criteria outlined by the Academy of Psychological Clini-

cal Science and thus designated by that body as “clinical sci-

ence” programs. See http://acadpsychclinicalscience.org/

members.

2. The raw data, including a list of programs in each cate-

gory, are available upon request.

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