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O F F I C I A L P U B L I C AT I O N O F D I V I S I O N 2 9 O F T H E A M E R I C A N P S Y C H O L O G I C A L A S S O C I AT I O N www.divisionofpsychotherapy.org

In This Issue

A Q-sort Model for the Empirical Investigation of Psychotherapy Integration Discourse and Healing

The Fundamental Nature of the Political Process Student Paper Award: The Relationship Between Patients’ Representations of Therapists and Parents Division 29 2007 APA Conference Program E

2007

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Division of Psychotherapy 䡲 2007 Governance Structure President Jean Carter, Ph.D 5225 Wisconsin Ave., N.W. #513 Washington DC 20015 Ofc: 202–244-3505 E-Mail: [email protected]

President-elect Jeffrey Barnett, Psy.D. 747 Buckeye Ct. Millersville, MD 21108 E-Mail: [email protected]

Secretary Armand Cerbone, Ph.D., 2006-2008 3625 North Paulina Chicago IL 60613 Ofc: 773-755-0833 Fax: 773-755-0834 E-Mail: [email protected]

Treasurer Steve Sobelman, Ph.D., 2007-2009 Department of Psychology Loyola College in Maryland Baltimore, MD 21210 Ofc: 410-617-2461 E-Mail: [email protected]

Past President Abraham W. Wolf, Ph.D. MetroHealth Medical Center 2500 Metro Health Drive Cleveland, OH 44109-1998 Ofc: 216-778-4637 Fax: 216-778-8412 E-Mail: [email protected] COMMITTEES

Fellows Vacant

Membership Chair: Annie Judge, Ph.D. 2440 M St., NW, Suite 411 Washington, DC 20037 Ofc: 202-905-7721 E-Mail: [email protected]

Student Development Chair Michael Garfinkle, 2007 Derner Institute for Advanced Psychological Studies Adelphi University 1 South Avenue Garden City, NY 11530 Nominations and Elections Chair: Jeffrey Barnett, Psy.D,

Professional Awards Chair: Abe Wolf, Ph.D.

ELECTED BOARD MEMBERS Board of Directors Members-at-Large J. G. Benedict, Ph.D., 2006-2008 6444 East Hampden Ave., Ste D Denver, CO 80401 Ofc: 303-753-9258,or 303-526-1101 Fax: 753-6498 E-Mail: [email protected]

James Bray, Ph.D., 2005-2007 Dept of Family & Community Med Baylor College of Med 3701 Kirby Dr, 6th Fl Houston , TX 77098 Ofc: 713-798-7751 Fax: 713-798-7789 E-Mail: [email protected] Irene Deitch, Ph.D., 2006-2008 Ocean View-14B 31 Hylan Blvd Staten Island, NY 10305-2079 Ofc: 718-273-1441 E-Mail: [email protected]

Jennifer Kelly, Ph.D., 2007-2009 Atlanta Center for Behavioral Medicine 3280 Howell Mill Rd. #100 Atlanta, GA 30327 Ofc: 404-351-6789 E-Mail: [email protected]

Michael Murphy, Ph.D., 2007-2009 Professor and Director of Clinical Training Department of Psychology Indiana State University Terre Haute, IN 47809 Ofc: : 812-237-2465 Fax: 812-237-4378 E-Mail: [email protected].

Libby Nutt Williams, Ph.D., 2005-2007 Chair, Dept of Psychology St. Mary’s College of Maryland 18952 E. Fisher Rd. St. Mary’s City, MD 20686 Ofc: 240- 895-4467 Fax: 240-895-4436 E-Mail: [email protected]

APA Council Representatives Norine G. Johnson, Ph.D., 2005-2007 13 Ashfield St., Roslindale, MA 02131 Ofc: 617-471-2268 Fax: 617-325-0225 E-Mail: [email protected]

John C. Norcross, Ph.D., 2005-2007 Department of Psychology University of Scranton Scranton, PA 18510-4596 Ofc: 570-941-7638 Fax: 570-941-7899 E-Mail: [email protected]

COMMITTEES AND TASK FORCES Finance Chair: Bonnie Markham, Ph.D., Psy.D. 52 Pearl Street Metuchen NJ 08840 Ofc: 732-494-5471 Fax 206-338-6212 E-Mail: [email protected] Education & Training Chair: Jean M. Birbilis, Ph.D., L.P. University of St. Thomas 1000 LaSalle Ave., TMH 455E Minneapolis, Minnesota 55403 Ofc: 651-962-4654 E-Mail: [email protected]

Continuing Education Michael J. Constantino, Ph.D. Department of Psychology 612 Tobin Hall - 135 Hicks Way University of Massachusetts Amherst, MA 01003-9271 Ofc: 413-545-1388 Fax: 413-545-0996 Diversity Chair: Jennifer F. Kelly, Ph.D.

Program Chair: Jeffrey J. Magnavita, Ph.D. Glastonbury Psychological Associates PC 300 Hebron Ave., Ste. 215 Glastonbury , CT 06033 Ofc: 860-659-1202 Fax: 860-657-1535 E-Mail: [email protected]

Psychotherapy Research Chair: William B. Stiles, Ph.D. Department of Psychology Miami University Oxford, OH 45056 Voice: 513-529-2405 Fax: 513-529-2420 Email: [email protected]

PSYCHOTHERAPY BULLETIN

Published by the DIVISION OF PSYCHOTHERAPY American Psychological Association 6557 E. Riverdale Mesa, AZ 85215 602-363-9211 e-mail: [email protected] EDITOR Craig N. Shealy, Ph.D.

ASSOCIATE EDITOR Harriet C. Cobb, Ed.D.

CONTRIBUTING EDITORS Washington Scene Patrick DeLeon, Ph.D.

Practitioner Report Ronald F. Levant, Ed.D.

Education and Training Jean M. Birbilis, Ph.D.

Psychotherapy Research William Stiles, Ph.D.

Perspectives on Psychotherapy Integration George Stricker, Ph.D. Student Features Michael Garfinkle, M.A.

PSYCHOTHERAPY BULLETIN Official Publication of Division 29 of the American Psychological Association

2007 Volume 42, Number 2

CONTENTS

President’s Column ................................................2 Perspectives on Psychotherapy Integration ........4 A Q-sort Model for the Empirical Investigation of Psychotherapy Integration

Interview with Dr. Leon VandeCreek ......................12

Student Feature ......................................................15 Psychotherapists as Witnesses Psychotherapy Research ......................................17 Discourse and Healing

Washington Scene ..................................................21 The Fundamental Nature of the Political Process Division 29 2007 APA Conference Program ......23

Student Award Paper ............................................32 The Relationship Between Patients’ Representations of Therapists and Parents

Membership Application......................................47

STAFF

Central Office Administrator Tracey Martin

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PRESIDENT’S COLUMN Opportunities Galore!

As I write this column, the year is half over. We have many things that are well begun, and those good beginnings create even more opportunities, as well as reflecting the good work that has happened so far.

Congratulations to our newly elected officers We extend a warm welcome to presidentelect designate Nadine Kaslow and Members at Large Norman Abeles and Michael Constantino (Early Career Psychologist position). Congratulations!

Reorganization and Bylaws Revision You, the members, have recently approved a revision of our Bylaws that result in a reorganization of our Board of Directors. The goal is to provide greater opportunity on the Board, to increase the effectiveness of our initiatives vis-à-vis the APA, and to enhance our ability to attend to the needs of our members. With the Bylaws revision, we have increased the number of members-atlarge to 8 and transformed them into Domain Representatives. The Domain Representatives will work collaboratively with committee chairs as they share responsibility for our Division’s areas of interest and expertise. The Domains are as follows:

Science and Scholarship Education and Training Psychotherapy Practice Public Interest Early Career Psychologists Membership Two Seats for Diversity

And we will continue to have the chair of our Student Development Committee with

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Jean Carter, Ph.D. a voting seat on the Board.

By the time of convention we will have the current members at large moved into the Domain Representative positions and be ready to roll at the September Board meeting!

Convention Fun! We have an exciting convention program, thanks to Jeffrey Magnavita, our VERY hard working Program Chair. See the special insert to find your favorite programs! I want to highlight a few special programs. This year we will present our awards and recognize our hard working volunteers at a special event that will come right before our social hour. Please plan to attend them both!

Conversation Hour (N): Awards and Recognition 8/17 Fri: 5:00 PM – 5:50 PM San Francisco Marriott Hotel Golden Gate Salons B1 and B2

Social Hour 8/17 Fri: 6:00 PM – 6:50 PM San Francisco Marriott Hotel Golden Gate Salons B1 and B2

Board member Libby Nutt Williams, ably assisted by Membership Chair Annie Judge and Student Development Committee member Erin Howard, has developed a special event for our Students and Early Career Psychologists. Leaders in our field will host lunch tables for informal discussion. Watch for the door prize drawing! Lunch with the Masters: Luncheon for Graduate Students and Early Career 8/18 Sat: 12:00 PM – 1:50 PM San Francisco Marriott Hotel Nob Hill Rooms A and B

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Looking Ahead As we move toward the fall, the Board will continue the transition to Domain Representatives. Incoming Program Chair Nancy Murdock will continue to develop plans that are already underway for the 2008 Convention. President-elect Jeff

Barnett will complete plans for the special, exciting MidWinter Meeting and CE Program to be held in St Petersburg Beach, Florida, January 12, 2008, with a day long CE offering from our own Don Meichenbaum—put it on your calendar today!

Find Division 29 on the Internet. Visit our site at www.divisionofpsychotherapy.org

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PERSPECTIVES ON PSYCHOTHERAPY INTEGRATION A Q-sort Model for the Empirical Investigation of Psychotherapy Integration Deborah A. Gillman and Paul L. Wachtel City College and the Graduate Center, City University of New York One obstacle to the pursuit of integration in the field of psychotherapy is the prevalence—in teaching, research, and theoretical discussions—of depictions of the field that privilege certain labels which refer more to political divisions within our discipline than they do to fundamental conceptual differences. Theoretical allegiances, whether in the self-identifications of therapists or in research that compares one approach to another, tend to be depicted in terms such as psychoanalytic, cognitivebehavioral, experiential, systemic, and so forth. These accounts implicitly assume that these labels each point to a unified and internally coherent set of axioms and conceptual and therapeutic tools, when in fact they represent a melange of many elements, packaged together less by virtue of logic and coherence than by allegiance to one of the professional groupings that vie for influence (and economic advantage) or by identification with certain elements of the package that lead therapists to say or think, “I am A; I am not B.”

The identifications can also frequently be traced to what labels were highly valued in the particular place where one went to graduate school or to the consequences of assortative socialization and social networks. On a small scale, one of us was part of an institute that split at one point along “theoretical” lines, but where perhaps the best predictor of who would choose to be associated with which theoretical grouping was who played tennis with whom. Of course, one might account for these tennispartner preferences on the basis of alreadyheld theoretical assonances. We are suggesting, especially based on the evidence

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presented below, that this is too simple and linear an explanation, and that the very perception of holding the “same” theoretical view as another reflects a more complex process in which certain similarities are foregrounded and other, perhaps equally weighty, differences are dissolved in the application of one of the politicized labels to any particular individual therapist’s point of view.

Therapists who identify with a particular orientation are unlikely to in fact identify with every single feature of that approach, or even every single important feature. Rather, what usually occurs, whether acknowledged or not, is that each therapist chooses the best crude approximation to his or her views from among the most prominent labels available in the professional community. Actual differences and similarities among therapists do not necessarily conform very closely to the current labels that have come to stand for those similarities and differences. The prominence of those labels, however, makes it difficult to disentangle perceptually the threads of similarity and difference, and hence other configurations and boundaries, other ways of representing therapists’ similarities and differences go largely unrecognized. This is especially the case today, when powerful economic interests have shaped the very nature of therapy outcome research, leading to funding being directed to certain forms of “horse race” studies between horses whose “owners” are usually the standard labels in the field (cf. Arkowitz, in press; Goldfried & Wolfe, 1998; Wachtel, 2006).

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We wish to describe here a study, originally undertaken with beginning therapists who identify themselves as psychodynamically oriented, that we believe has larger significance as a methodological template for studying the entire spectrum of therapeutic approaches and for seeing afresh the convergences and divergences that actually exist in the field of psychotherapy. The methodology employed in this study, centering on the use of Q-sorts and follow-up interviews, can, with appropriate modifications in the content of the Q-sort cards, readily be applied to the views of therapists of all persuasions. Importantly, the methodology described here approaches the mapping of the field of psychotherapy in a much more empirical manner that is represented by the use of such standard labels as psychoanalytic, cognitive-behavioral, experiential, systemic, or (to move to the realm that was the particular focus of the study to be described next) classical or relational.

Similarities and Differences among Psychodynamic Therapists: An Empirical Study Just as in the larger realm of psychotherapy, highly politicized labels figure prominently within the sub-realm of psychodynamic therapy. In the world of psychoanalysis and psychodynamic therapy, the two most prominent labels today are “relational” and “classical” (the latter sometimes designated by other labels such as contemporary Freudian or structural, but referring to the same tradition and large configuration as ideas as the label classical refers to). In the world of psychoanalytic discourse, the assumed antinomy between these two broad schools figures prominently, and many psychoanalytic and psychodynamic therapists see the psychoanalytic world very largely in terms of two broad competing forces. Debates between proponents of these two competing positions have at times been quite heated (e.g., Bachant, Lynch, & Richards, 1995; Benjamin, 1995; Christiansen, 1995; Gill, 1995 Marshall, 1995; Mitchell, 1995); analysts are familiar

with the term “the narcissism of small differences.” In contrast, the study described below illustrates how what look like opposing schools are actually an amalgam of ideas and preferences that therapists employ in their own particular fashion, picking and choosing specific features from different approaches rather than dividing along “official” orientation lines. After presenting the findings and their implications for understanding competing schools within psychoanalysis, we will discuss how such a conceptualization and research methodology might be extended to the larger realms of psychotherapy and psychotherapy integration.

The study aimed to investigate whether beginning psychodynamic therapists in fact can be categorized in their views according to the classical-relational dichotomy or whether a more complex configuration is necessary to capture the structure of their similarities and differences. The methodology consisted of a Q-sort and qualitative interview administered to thirty doctoral students in clinical psychology. The Q-sort offered a particularly appropriate means of investigating this question because it yielded, for each subject, a personalized profile of his or her beliefs regarding the subject domain. Rather than globally endorsing an entire “orientation,” subjects were asked to rank the importance and relevance to them of specific Q-sort statements that reflect aspects of psychodynamic psychotherapy practice.

A key feature of Q-methodological research is that it permits a form of factor analytic procedure that, in contrast with standard factor analysis, yields findings that reflect groupings of subjects rather than test items. Not all studies using Qsorts employ this method of analysis. For a discussion of Q-methodology and the options for data analysis, see Gillman, 2006, as well as Kitzinger, 1999, and McKeown & Thomas, 1988. For examples of other studies

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using the methodology employed here, see Stainton Rogers & Kitzinger, 1995, and Snelling, 1999.

The final factors of such analyses reflect clusters of like-minded people based upon how they complete the Q-sort. This methodology is particularly well suited to the question of whether psychodynamic therapists group themselves into just two groups (classical and relational) or whether other configurations better capture the variations among therapists in their views about the work. Importantly, this methodology has the potential to discern and discover groupings that are not defined a priori by the researcher (Kitzinger, 1999). Participants are not required to identify with a particular preexisting viewpoint; instead, it is they who determine the range and configuration of views that exists among them.

Q-methodology was also deemed particularly well suited for this exploration of new clinicians’ views since beginners are often not well informed about the labels for different paradigms or theories. It is thus difficult for them to accurately and validly identify themselves as belonging to a particular pre-designated orientation, but they are capable of conveying their orientation empirically through their ratings of the various specific Q-sort items. The Q-sort thus enabled trainees to indicate their implicit identification with either paradigm—or with some other organizing configuration—by stating their relative agreement or disagreement not with an orientation as a whole, but with very specific ideas or practices. Whether these choices cohered into “relational” and “classical” configurations or took on some other configuration altogether could be approached as an empirical question.

The Q-sort consisted of 54 original statements deriving from a sampling of the entire literature of psychodynamic therapy (for a more detailed account of the way in

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which the items were developed and modified, as well as of the rest of the methodology, see Gillman, 2006). The Q-sort statements were reviewed by a panel of senior clinicians who were strongly identified with either the classical or relational tradition in order to ensure the content validity of the items. This review process generated item ratings that categorized items as clearly reflecting a relational perspective (8 out of 54 or 15%); as clearly reflecting a classical analytic perspective (14 out of 54 or 26%); as “bridging” the two orientations rather than being particularly identifiable as belonging to one or the other (23 out of 54 or 43%); and as reflecting a lack of consensus, with some (of each orientation) viewing the item as more relational and some as more classical (9 out of 54 or 17%).

An example of a Q-sort item judged by the experts to represent a “relational” approach to theory or clinical practice was, Therapist self-disclosure is an inevitable part of the process. The question is not whether to disclose, but how and when to do so.

A representative item judged as clearly representing a “classical” view was, Therapeutic progress is most enhanced by the resolution of the patient’s difficulties as much as possible via interpretations rather than through support, advice, or other kinds of interventions.

Among the items for which the experts were split as to whether it belonged to the classical or relational perspective was, The therapist is involved in the construction, not merely the discovery, of the patient’s psychic reality.

And a representative “bridging” item, for which the experts tended to assign a rating

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midway between classical and relational rather than as characteristic of either, was, The dynamics of transference and countertransference are critical in any treatment, but it is important not to focus on them too exclusively. Attention to the real transactions that constitute the therapeutic alliance is also important. The full list of Q-sort items and their designation as classical, relational, split consensus, or bridging, can be found in Gillman (2006).

The Factor Analysis Analysis of the 30 Q-sort distributions across the 54 items yielded six factors and (given the bi-polar nature of one factor) seven groupings of trainees whose views were elaborated through interviews. A brief characterization of the essential common features for each of the seven groupings is as follows: (1) those whose highest priority was their commitment to an egalitarian, collaborative approach to treatment, (n =13); (2) those who considered their approach to be eclectic and who valued most highly flexibility in practice and orientation (n = 4); (3) those most influenced by object relations theory, who emphasized their patients’ and their own intrapsychic processes (n = 2); (4) those who were grouped for their preoccupation with the issue of therapist disclosure (n = 4); (5) those whose endorsements very closely approximated a classically-oriented approach, primarily in terms of how they construe the participation of the therapist in the treatment dyad (n = 2); (6) those most clearly allied with a relational approach, whose identification was expressed by their prioritizing the importance of therapist subjectivity (n = 2); and (7) a final mixed group of trainees whose commonality is difficult to categorize (n = 3). (See Gillman, 2006 for more details.) Relevance for Psychotherapy Integration Research In practice, many clinicians utilize tech-

niques associated with different “official” approaches. Within the psychoanalytic domain, clinicians of all levels of experience often identify with some elements of relational or classical models but not others (Frank, 1999). While some psychodynamic clinicians come to identify as purely relational or classical, others, in practice, choose to emphasize or prioritize only certain features associated with a given model. In the present study, the results of the Q-sort analysis implicitly challenged the relational vs. classical polarity that is so broadly assumed by contemporary psychodynamic thinkers. Far from aligning themselves with one of two dichotomized orientations, the therapists in this study implicitly grouped themselves into a much more variegated set of commonalities and differences based on their actual views about theory and practice. A minority of participants primarily prioritized statements that were anchored specifically in relational or classical approaches, but the large majority did not. Their Q-sorts proved to be largely ‘orientation-blind’ as they ranked the items according to implicit schemes that had little to do with the statements’ classification by the experts as “relational” or “classical.” What emerged, essentially, was a trend among beginning clinicians to sort through a range of views that they had been exposed to through their training and develop their own practice orientation.

The potential for this methodology to be of use in studying therapists’ views across the full therapeutic spectrum (and across a considerably greater range of experience than represented in the specific focus of the study discussed here) should be apparent. Inclusion of Q-sort statements that derive from a range of therapeutic approaches (that is, items not restricted, as in the present study, to variations within the psychodynamic—or any other—orientation) would offer an opportunity to examine the larger integrative themes that characterize thera-

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pists’ actual views and practices and to see how these views and practices do or do not fit within the boundaries of the present “standard labels” in our field (e.g., psychodynamic, cognitive-behavioral, family systems, experiential). We suspect that even the participants in this study, who were specifically chosen for their identification with the broad area of psychodynamic therapy, would, if presented with a variety of “officially” non-psychodynamic items as part of a larger and more comprehensive Q-sort, turn out to prioritize at least some of the non-psychodynamic items over some others that are more conventionally psychodynamic. This might especially be the case if care was taken (as it was in the present study) to present items in a way that did not explicitly label them as belonging to one orientation or another and that attempted to present the items in plain English rather than in the jargon of one orientation or another.

The therapists who were the subjects of this study demonstrated that one can identify with aspects of a particular orientation but not necessarily identify with that orientation label. Therapists representing Factor 1, for example, identified with many relationally-oriented ideas, but not with the label “relational.” In interviews, they stated that a relational approach was “too intense, too confrontational” or that “it can get overused.” It may be anticipated (but of course needs to be investigated) that in similar fashion there will be some subjects in a more broadly pitched study who endorse certain important features of cognitive-behavioral, experiential, or family therapy, but who are uncomfortable identifying with the particular labels. “Bridging” Ideas and the Trend toward Integration The most highly endorsed Q-sort statements in this study were those that bridged the classical-relational divide. Among this sample of trainees, many of whom proved to be disaffected from traditional psychoanalytic models

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yet not entirely enamored of newer ones, these “bridging” or consensual items carried the day. Twenty-four percent of the study participants, for example, (those loading on Factor I) particularly prioritized the importance of the “working alliance,” the “real relationship,” and the “humanness” of the therapist (cf. Norcross, 2002). At the same time, although this was the largest grouping in the study, many participants did not prioritize these items. Thus, what we found was not simply an endorsement of motherhood and apple pie, but a rather specific prime concern that characterized only a subset of the study sample. Recall here that the nature of the Q-sort task does not require participants to state that these items are not important, only that they are less important to them relative to others.

It may further be noted that these Factor I trainees, when asked subsequent to the Qsort to state their orientation using up to three descriptors, did not necessarily use the same labels, even though empirically they loaded on the same factor. The descriptors they used totaled nine different orientation labels, including “interpersonal,” “relational,” “eclectic,” and “integrative.” In part, this diversity of labels, even though the participants in this group showed a strong consensus on what most mattered to them in their practice, reflected the fact that the key items for them were bridging items, items that were not exclusively associated with either the classical or relational school, but were viewed by the experts as being equally characteristic of both.

In thinking about the importance to the participants of ways of working or thinking that are common to both of the competing paradigms examined in this study, one is reminded of the importance of common factors (e.g., Frank, 1973; Goldfried, 1980) and of the relationship as a crucial

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therapeutic factor that in most studies done thus far affects outcome even more than the “approaches” or “techniques” that are the intended target of most research in this area (Norcross, 2002). We speculate that, in developing a broader set of Q-sort items to investigate (in parallel fashion to the study described here) the ways that therapists representing the full range of currently prominent orientations actually sort themselves in terms of their specific preferences and ways of interacting with patients, we would find that the “bridging” items in that context are particularly those related to the establishment of a good therapeutic alliance (which seems to cut across approaches) and those that contribute to the broader concept of common factors.

The View from the Trenches If one views the study by Gillman (2006) as establishing a potential beachhead for the broader exploration of commonalities and differences among therapists of a wider range of “official” orientations, one may view the data from this sample of beginning psychodynamic therapists as a foreshadowing of what might be anticipated from the latter, broader grouping. We can, of course, offer here only a small sample of the interview comments made by the therapists in the study discussed here. What follows are “bridging statements” in a different sense, ideas expressed by the upcoming generation of therapists reflecting their attempts to make sense of and utilize the range of approaches to which they have been exposed in the course of their training. The names have, of course, been changed to protect the identities of the participants.

Sandor, one year out of graduate school, describes his own approach as a mix of drive structural, object relations, self, family systems, and cognitive-behavioral techniques. While in training, he experienced resistance to his own attempts to integrate: So it’s in supervision where I’ve faced a certain degree of conflict when it comes to integrating models. Not so much in figuring out how to do it in my own work, but in

working with someone who’s a little more of a purist and doesn’t draw from so many sources....So when I think about tension in the field I think about the various infighting within the department, in my program or even within the analytic community.

Sandra, a 3rd year student is “still trying to figure out” what orientation “makes the most sense” to her. She speculates: I always assume that I will be a very eclectic therapist, which I think is kind of the popular way to go now.

Margo, a 5th year student, describes her graduate training and supervision as “eclectic” and how this has impacted her thinking and practice: I don’t think anyone works clean. You know, just one theory in mind. And I don’t think it exists much anymore…I’m very much into [flexibility]. Flexibility with different techniques, so I can get a taste out of all of them…Hopefully I’ll be an integrated therapist one day.

Trainees also reflected upon being trained in a culture of distrust among proponents of different schools of thought. Lori, a 5th year student, has felt a pull from professors of different orientations to “pick a camp:” I’ve asked numerous people over the years, like what’s the difference really? And the only consistent answer I get is politics.

Ellen, a 6th year student, has also experienced the divide among orientations as unnecessarily polarized and suspect: The polarity in the literature is unnecessary. The consequence is that people think the schools are so different. Some things are…[But there is an] unnecessarily divisive effect on the way folks talk about things.

Now in her final year of doctoral training, Ellen feels increasingly free of the tension among different theoretical approaches—as well as free from dictates of her supervisors: I feel I have reached a point where I have

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my own sense of what kind of therapist I am…There is no wholesale rejection of one school or the other. I’m picking and choosing what is best from each school!

These and other comments speak to some of the challenges faced by these psychodynamic therapists-in-training in response to their own integrative impulses. Strikingly, however, they also offer a view of the field at large as increasingly accepting—perhaps even taking for granted the presence of— therapists with an “integrative,” “flexible,” or “eclectic” mindset. With this view of the field from the perspective of its newest practitioners, we feel optimistic that some of the constraints that have arisen from “the war between the orientations” may be diminishing. We hope as well that we have shown the potential for the application of the methodology described here to a broader inquiry into the thinking and practice of clinicians from across the therapeutic spectrum. Empirical demonstrations of the differences between how therapists actually think, and how they actually are similar or different from each other, may help further to decrease the stereotypy of thought that arises from excessive focus on labels that are, in the final analysis, at least as much political as conceptual and substantive. References Arkowitz, H. (in press). The therapist as theorist. Applied and Preventive Psychology. Bachant, J.L., Lynch, A.A., & Richards, A.D. (1995). Relational models in psychoanalytic theory.Psychoanalytic Psychology, 12, 1, 71-87. Benjamin, J. (1995). Comment. Psychoanalytic Psychology, 12, 4, 595-598. Christiansen, A. (1995). Commentary: Primitive splitting in the field of psychoanalysis. Psychoanalytic Psychology, 12, 4, 599-602. Frank, J. D. (1973). Persuasion and healing. Baltimore: Johns Hopkins University Press. Gill, M.M. (1995). Classical and relational

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psychoanalysis. Psychoanalytic Psychology, 12, 1, 89-107. Gillman, D.A. (2006). An exploration of the influence of relational and contemporary Freudian paradigms on the thinking and practice of beginning clinicians: A Q-methodological study. Unpublished doctoral dissertation, City University of New York Frank, K.A. (1999). Psychoanalytic participation: Action, interaction & integration. Hillsdale, NJ: Analytic Press. Goldfried, M. R. (1980). Toward the delineation of therapeutic change principles. American Psychologist, 35, 991-999. Goldfried, M. R. & Wolfe, B. E. (1998). Toward a more clinically valid approach to therapy research. Journal of Consulting and Clinical Psychology, 66 143-150. Kitzinger, C. (1999). Researching subjectivity and diversity: Q methodology in feminist psychology. Psychology of Women Quarterly, 23, 2, 267-276. Kitzinger, C., & Stainton Rogers, R. (1985). A Q-methodological study of lesbian identities. European Journal of Social Psychology, 15, 167-187. McKeown, B., & Thomas, D. (1988). Q Methodology. (Series: Quantitative applications in the social sciences, No.66). Thousand Oaks, CA: Sage Publications, Inc. Marshall, K. (1995). Toward constructive dialogue: “The ploughshare of evil” comes again–commentary on the special section on structural and relational psychoanalysis. Psychoanalytic Psychology, 12, 4, 585-592. Mitchell, S.A. (1995). Commentary on “contemporary structural psychoanalysis and relationalpsychoanalysis.” Psychoanalytic Psychology, 12, 4, 575-582. Norcross, J. C. (Ed.) (2002). Psychotherapy relationships that work. New York: Oxford University Press. Snelling, S.J. (1999). Women’s perspectives on Feminism: A Q-Methodological Study Psychology of Women Quarterly, 23, 2, 247-266.

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Stainton Rogers, R. (1995). Q Methodology. In J.A. Smith, R. Harré, & L.V. Langenhove (Eds.), Rethinking methods in psychology. London: Sage.

Wachtel, P. L. (2006). Psychoanalysis, science, and hermeneutics: The vicious circles of adversarial discourse. Journal of European Psychoanalysis, 22, 25-46.

SAVE THE DATE! Enjoy the warm Florida sunshine in January and plan to attend this outstanding workshop. Presenter:

Donald Meichenbaum, Ph.D.

Program Title:

Core Tasks of Psychotherapy: What “Expert Psychotherapists Do”

When:

Saturday, January 12, 2008 from 9:00 – 4:00 (6 CEs)

Where:

Tradewinds Island Resorts St. Petersburg Beach, Florida

Look for registration information in the next issue of the Psychotherapy Bulletin, or, when it becomes available, on-line at divisionofpsychotherapy.org

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INTERVIEW

Interview with Dr. Leon VandeCreek Michael S. Garfinkle, MA, Adelphi University

Leon D. VandeCreek, Ph.D. is a fellow and former President of the Division of Psychotherapy (2005-2006), a fellow of Divisions 12, 31, and 42, and a fellow of the American Psychological Association. Professor and former Dean in Wright State University’s School of Professional Psychology, Dr. VandeCreek has authored more than 20 books and over 150 articles and presentations on issues including professional ethics and risk management.

Michael S. Garfinkle, MA is the Chair of Student Development of the Division of Psychotherapy (2006-2008) and is a Ph.D. candidate in clinical psychology at Adelphi University. He is also a research fellow at the New York Psychoanalytic Institute.

MSG: Can you tell us about the path that initially brought you to clinical psychology?

LV: As a college student in the 1960s at Calvin College in Grand Rapids, MI, I didn’t really have any professional direction in mind. I grappled with several different college majors including sociology, theology, and eventually settled on psychology in large part because my advisor said, “you have to pick something.” So, I picked psychology because I had taken courses in the subject that I had enjoyed. I finished my degree in psychology and applied for a Masters in Clinical Psychology at Bowling Green State University and once I got into the clinical side of things, I really got excited in that area. I finished my Masters degree and got a job that was half time at a counseling center and half time teaching at Tri-State College in Indiana. I stayed there

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for three years and found that I really liked teaching as much as I liked my job in the counseling center. It was also at that time that I co-authored my first book. I then went back to graduate school for my Ph.D. at the University of South Dakota in 1969 and then did an internship in 1971-1972 at Carter Memorial Hospital in Indianapolis.

MSG: And was that your first experience working with children?

LV: It was my first major experience. It was outpatient and inpatient with kids. One of the interesting things is that this particular hospital had one of the first autism research projects, which was my first experience with major developmental disorders. MSG: Did that stay with you as an interest?

LV: Only peripherally, as I primarily work with adults and adolescents, but still perform assessments with children. From the internship in 1972, I moved to a job at the Indiana University of Pennsylvania and they were just developing Masters programs, including in clinical psychology. Eventually, I became the director of the Masters Program, and then in the 1980s was one of the co-authors for a proposal for a Psy.D. in Clinical Psychology and became the director of that program. In 1994, I moved to Wright State to become the dean of the School of Professional Psychology. MSG: And what attracted you to Wright State?

LV: It was an opportunity to be involved at an administrative level. The School of Professional Psychology only houses the doctoral program, so there isn’t the regular

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competition between undergraduates and graduates, research and practice.

MSG: Among the expansive range of topics you have written on, you recently published a book with Samuel Knapp on “Practical Ethics for Psychologists” (APA, 2006). How did you get interested in professional ethics?

LV: I’m not sure of the origins…When I moved for my first postdoctoral job at the Indiana University of Pennsylvania, one of the courses I taught was on ethics and I think I was one of the only people in the department at the time who wanted to teach that course. And I’ve taught a course on ethics every year since 1975. MSG: And your interest in a positive approach to practical ethics?

LV: I think the thrust of the past decade has been to make ethics much more hands-on and applied and less theoretical and hypothetical. And over the years, I’ve been considering how to get this message across to students and make it stick? Ethics for me, and for students, can be hard to read about and dull; finding ways to make ethics appealing and interesting is important. Also, with the development of positive psychology, the focus has shifted from how to avoid getting into trouble, to “how can I be the best psychologist I can be.”

MSG: What ethical challenges do new clinicians face that are different from previous generations?

LV: All of society is more focused on individual rights and the risks that go along with it. It has become a lot easier to sue each other and make complaints to licensure boards and there is greater awareness out there that you can make a complaint to a board by just writing a brief letter. What we have is an increased public awareness of what one’s expectations for service should be and what to do if those expectations aren’t met. The threats are much greater than in the 1970’s and the 1980’s

when there was minimal attention paid to risk-management, though there was an awareness of broad ethics. My experience of students today is that they are fairly alert and concerned about staying out of trouble. The concern about teaching ethics today is not only about teaching students how to stay out of trouble, but rather also teaching that ethics can help psychologists be the best practitioners that they can be. MSG: You have written on risk management in working with patients with memories of abuse. What inspired this work?

LV: That was a hot topic for awhile in the 1990s. That was an area of risk management where health professionals, including psychologists, didn’t pay attention to the science, to evidence-based practice. And the general public just caught up to pretty lousy practice and health professionals were sued as a result. That topic faded, and what’s left is really good research in memory. That’s kind of characteristic of the ethics/risk management business: that some of these topics wax and wane, that some of these topics come in a frenzy and then fade, like recovered memories and sex with patients. I think just about everyone agrees on those topics today.

MSG: In your scholarship, you have written a fair number of articles on issues of student training and clinical supervision. Can you comment on the state of student training in clinical psychology at present?

LV: I think there has been good research and literature on supervision in the last decade, gearing supervision to address where the student is in training (i.e., the beginning phase, middle phase, etc.). A couple of real concerns I have for psychotherapy and assessment training is that I think that we still have a lot of basic training and supervision being provided by folks who are not masters in it. Students still get supervision in psychotherapy from

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faculty who practice very little or who are not observed themselves to see how good they are. I think that the supervisors could be credentialed as Master Psychotherapists or Master Assessors. In Boulder Model schools, we hope that the supervisors in research are scholars themselves. We don’t want faculty on dissertation committees who don’t engage in scholarship themselves, so why should it be different on the practice side? Here’s another example. In some communities, graduates of the doctoral programs become the supervisors of the next generation of doctoral students. Now, while there may be good ones in the mix, we’re really running the risk of a very inbred system without outside critical review. Sometimes it’s a geographical problem, but we don’t have any external validation measures in place for doctoral supervision in most instances.

Ethics and positive psychology value credentialing supervisors instead of the current practice, which goes something like: “you’re a good supervisor unless you’ve been sued, but short of that I’m sure you’re fine.” No, we need to be able to have ways

to say with confidence: that’s a really good psychologist or a really good supervisor.

MSG: Two presidents later, how do you think the Division of Psychotherapy is doing? Where would you like to see the Division focus its efforts?

LV: I made a decision after completing my past-President year to shift out of a leadership role in the division. I’d been involved in a leadership role in the Division for about 15 years. From my vantage point now, the Division has very good leadership. Division 29, along with other divisions, suffers from declining membership, likely because of the demographics of new psychologists and the income of new psychologists. Personally, I’d like the division to continue working in areas of psychotherapy training and research, how to assure that good psychotherapy training is occurring. It’s an important topic and one that would be well served if the Division took a leadership role. MSG: Well, thank you for this interview. LV: You’re welcome.

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STUDENT FEATURE

Psychotherapists as Witnesses Erin Howard, Lehigh University

As the two-year anniversary of Hurricane Katrina approaches, it becomes increasingly relevant for psychotherapists to consider its relevance in our work and lives. Has Katrina, and its continuing aftermath, affected how we think about our clients? Has it affected how we think about psychotherapy? About trauma? Has it affected our attention to, or interest in political issues? In issues of socioeconomic standing and social class identity? In advocacy?

Hurricane Katrina demanded the attention of the entire nation – even of other parts of the world – and raised a magnifying glass to our nation’s ability to support its members. Lower social class individuals comprise not only a significant population in Gulf Coast areas in general, but also in those areas most devastated by the hurricane (The Center for Social Inclusion, 2006). Low income individuals are also among those most vulnerable to the psychological consequences of disaster (Ahern & Galea, 2006). Despite progress in rebuilding and community repair efforts in the Gulf Coast, studies (e.g., Centers for Disease Control and Prevention, 2006; Eisler, 2007) indicate that the mental health needs of Gulf Coast survivors and residents are still great. Many psychotherapists have responded to this need by volunteering with various crisis response organizations to support ongoing aid efforts, though overall, volunteer efforts are dwindling (The Greater New Orleans Community Data Center, 2007). The unusually prolonged exposure to stressors resulting from Hurricane Katrina and its aftermath, such as property and job loss and increased violence, suggests that survivors may continue to experience a significant need for mental health care for years

to come (APA Policy and Planning Board, 2006). Certainly, as applied psychology training programs continue to build on multicultural and social advocacy emphases (e.g., Goodman et al., 2004), the issue of adequately preparing therapists to manage this clinical demand warrants consideration.

Though nearly two years have passed, our responses to Hurricane Katrina are also relevant to our future clients and clinical work. By profession, psychotherapists serve most fundamentally as witnesses of humans’ experiences. At its best, the psychotherapy experience invites clients’ deepest truths, those rich in pain, sorrow, fear, and anger. We request transparency so that growth is possible. So that clients can learn to experience joy, peace, and contentedness in spite of, or perhaps because of, their darkest moments. Our ability to recognize and understand the influence of social class on patients’ problems and life experiences can be critical in providing sensitive, helpful treatment – particularly for those patients who are socioeconomically disadvantaged or experiencing problems in which social class status plays a significant role. The years to come will bring continued repair efforts to the Gulf Coast, and eventually, the physical destruction left in the wake of the hurricane may no longer be visible. People may feel, as some do currently, that it is time to move on and give attention and resources to other issues. How will Katrina have affected us then? What can we do to remain affected? To remain witnesses?

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References Ahern, J. & Galea, S. (2006). Social context and depression after a disaster: The role of income inequality. Journal of Epidemiology & Community Health, 60, 766-770. American Psychological Association Policy and Planning Board. (2006). APA’s response to international and national disasters and crises: Addressing diverse needs: 2005 annual report of the APA Policy and Planning Board. American Psychologist, 61, 513-521. Centers for Disease Control and Prevention (2006, January). Assessment of health-related needs after hurricanes Katrina and Rita – Orleans and Jefferson parishes, New Orleans area, Louisiana, October 17-22, 2005. Morbidity and Mortality Weekly Report, 55, 38-41. Eisler, P. (2007, January). New Orleans feels pain of mental health crisis: Those in need find very few doctors or facilities. USA Today. Retrieved on January 23,

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2007 from http://usatoday.com/news/ nation/2007-01-15-katrina-mentalhealth_x.html. Goodman, L., Liang, B., Helms, J., Latta, R., Sparks, E., & Weintraub, S. (2004). Training counseling psychologists as social justice agents: Feminist and multicultural principles in action. The Counseling Psychologist, 32, 793-837. The Center for Social Inclusion. (2006, August). The race to rebuild: The color of opportunity and the future of New Orleans. New York: Author. Available from http://www .centerforsocialinclusion.org/projects_katrina.html. The Greater New Orleans Community Data Center. (2007, March). The Katrina Index: Tracking recovery of New Orleans and the metro area. New Orleans, LA: Greater New Orleans Nonprofit Knowledge Works. Retrieved on March 17, 2007 from http://www.gnocdc .org/index.html.

PSYCHOTHERAPY RESEARCH Discourse and Healing

Robert L. Russell, Ph.D., Medical College of Wisconsin

Our field has made much progress in identifying core discourse components of therapy but less progress in explaining how such components heal those suffering from various forms of psychopathology. In this brief paper, I describe one very prominent component of therapeutic discourse, compare it to previously identified common factors, and offer some thoughts about how it may function therapeutically.

Over four and half decades ago, Jerome Frank published his groundbreaking work, “Persuasion and Healing: A Comparative Study of Psychotherapy” (1961). As most students of psychotherapy know, Frank identified four common factors appearing in all forms of healing and therapy: the therapeutic relationship, rationale, task, and setting. These were said to interact and influence patients in five ways: through learning, hope of relief, provision of success experiences, emotional arousal, and alleviation of a demoralizing sense of alienation. The continuing focus of theory, research and training on these and other common and specific factors attests to Frank’s prescience and widespread influence (Kazdin, 2005; Kiesler, 2004).

What is seldom appreciated, however, were Frank’s concluding views that 1.) The state or condition common to all patients that can be treated by therapy is demoralization, 2.) “Insofar as psychopathological processes are amendable to psychotherapy, they are conceptualized as expressive disorders of communication…“ and 3.) “The major psychotherapeutic tools are communicative symbols—that is, words.“ (p. 323). It is sobering to remind ourselves that Frank’s theorizing was undertaken from the point of view of a psychopathologist as much as from the point of view of a therapist.

Having embraced aspects of Frank’s views in the late 1970’s, it was natural for me to build a research program focused on therapeutic and narrative discourse (e.g., Czogalik & Russell, 1995; Russell, 1999, 2004; Russell, Bryant, & Estrada, 1995). I situated this work within a developmental and pragmatic language framework (Russell, 2007). Augmenting Frank’s insights with empirical findings obtained through time-series based micro-analytic and other studies of therapeutic discourse promised to reveal clinically relevant details. I understood that these would need consideration from theoretical and practical perspectives. Such consideration might then refine and deepen our understanding of common and specific factors and other important features of treatment. In addition, a developmental and pragmatic language framework appeared compatible with Frank’s views about psychopathology, the central role of verbal processes in treatment, and the type of findings that emerge from linguistic, discourse, narrative and time series based microanalyses of therapy process.

Empirical findings based on time-series based studies of therapeutic processes were recently summarized in a meta-analytic review (Russell, Jones, & Miller, 2007). Consideration of these studies revealed four client and five therapist processes that comprise the core foci around which therapeutic interaction is structured. The four client foci were organized around the communication of affect, the sometimes painful therapeutic work of self-formulation and insight seeking, relationship hopes, worries, and difficulties, and information exchange, including communications

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about needing help. The five therapist foci were organized around the use of specific verbal interventions, the communication of supportive understanding and empathy, an interest in obtaining further information, information pertaining primarily to the parameters of the treatment, and personal, self-disclosing information. Based on analyses of the therapeutic interaction of nearly 500 clients and 100 therapists, with ratings obtained on 25,000 units of discourse on approximately 1000 variables, these nine core areas of client and therapist discourse provide an empirically supported, process-sensitive anatomy of psychotherapy. In effect, these nine discourse foci revealed by analyses conducted at the micro-analytic level appeared to comprise core or common factors that cut across therapies. The question naturally arises as to whether these new empirical findings require modification of, or merely exemplify in empirical detail, Frank’s original common factors. As with most complex questions, the answer is not a simple yes or no. As an example, I here consider one of the four common client factors, the client’s provision of objective information, which had also emerged in our own studies of therapeutic discourse.

In a time series based study of adult therapy (Czogalik & Russell, 1994), based on over 350,000 ratings of client utterances, the factor Continuing Information Exchange accounted for the most process variance. This factor has been prominent across our studies, disorders, therapists, and cultures (i.e., therapies conducted in Germany in German versus therapies conducted in the US in English). This was a bipolar factor. The process variables with salient positive loadings on this factor included neutral description, informing, continuing, present orientation, and objective events. Variables with negative loadings included minimal display, minimal technical activity, back channel regulators (e.g., hmm, ah, oh), lacking indication of

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temporal orientation, contentless verbalizations, and affirming. The interactional meaning of this factor was glossed as “I am continuing my exchange of objective information about the events currently happening in my life and showing you I am attentively listening.” (p. 172).

The interactional meaning of this factor did not figure centrally in Frank’s depiction of common therapeutic factors. It is focused on what the client is doing rather than on the therapist. It would be easy to dismiss Continuing Information Exchange as merely a prologue to, or a consequence of, therapists’ therapeutic maneuvers. However, from a developmental and pragmatic language point of view, this dismissal would be unfortunate. Information exchange may be as important as the more glamorous technical interventions by the therapist (e.g., interpretation, reflection, confrontation). I suggest that the alternation between speaking and listening roles in discourse creates a pattern of perspective-taking out of which emerges the basic building blocks of the self and the interpersonal world. The alternation provides grounds for the possibility of linguistic communication per se. This may be why the socializing agents of society seek its achievement in children with an intensity afforded few other functions. How else can one explain the countless hours spent by caregivers with their infants, playing seemingly meaningless games structured in a turn-taking or alternating pattern? Out of the alternation of speaking and listening, a space is created in and through which a selfin-relation is born. I suggest that the alternating roles captured by Continuing Information Exchange enable the client to re-create this basic perspectival space for the (re)discovery of their voice and interpersonal ear. This alternation occurs while clients are speaking about objective events and listening to someone who is responding to them. This factor seems to be about locating the

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client within the objective coordinates defining their current situation. The client is trying to give voice to the contexts, situations, and events that she currently finds herself in. These are communicated to the therapist as best as the client can, in fits and starts, a broken branch here, an overturned stone there, with the growing hope that the therapist has heard her communications well enough to identify her current “landscape of action“ (Bruner, 1986, p.14). Thus, by joining in, the therapist can start to specify the client’s landscape, its contours and contents, by a useful set of descriptors (i.e., words). Far from being only the transfer of information from a speaker to a hearer, this first factor functions as a discourse compass for the client: “I am trying to communicate the objective events in my current life that continue to be topics of my conversational concern. These comprise the conversational topography of my objective existence now. Can anyone, can you, hear where I am. I am listening to and for you.”

The existentialists might say that all clients are alienated from their own existence and are thus estranged from others as well. The voice of the therapist, then, contains hope of both reunion and communion. The client strains to listen to the therapist. There is work being done, perhaps even remoralization, in the acknowledgement of the therapists voice, in the anticipation of being known by, and knowing, an affirming other. Every head nod, every back channel indicator, every affirmation and display of attention to the therapist’s voice, pulls the client back into the crucible of communication, where her socialization and character were once forged and where it can now be forged again. If Continuing Information Exchange, along with the alternation of speaking and listening roles it implies, is a common client factor in all types of therapies, does its absence from Frank’s list suggest that its influence on progress or outcome affects change via mechanisms that he did not identify? Again the answer may not be a

simple yes or no. The demoralizing sense of alienation could be lessened as the client learns, sometimes emotionally, that she can share her world in the relationship with the therapist. She could experience success in relating interpersonally in both speaking and listening roles. As the client gains a voice and tunes her ear, her landscape may become less demoralizing, perhaps providing a glimmer of hope, if for no other reason than that it now houses a self in relational dialogue. Consequently, the client’s alternation of the provision of information with their communication of active listening may function in some of the same ways as the more paradigmatic therapist or treatment related factors featured in Frank’s treatise so many years ago.

On the other hand, the underlying mechanism, the common curative factor, may simply be exposure to and participation in affirming discourse exchanges, including but not restricted to Continuing Information Exchange (Russell, Greenwald, Shirk, 1991; Shirk & Russell, 1996). This, after all, is how expressive and adaptive communication is learned in the first place. Ideally, future research on discourse processes in therapy will proceed with methods capable of capturing both constituent processes and holistic forms of communicative interaction.

References Bruner, J. (1986). Actual Minds, Possible Worlds. Cambridge, MA: Harvard University Press. Czogalik, D., & Russell, R. L. (1994). Key processes of client participation in psychotherapy: Chronography and narration. Psychotherapy, 31, 170-182. Czogalik, D., & Russell, R. L. (1995). Interactional structures of therapist and client participation in adult psychotherapy: P-technique and chronography. Journal of Consulting and Clinical Psychology, 63, 28-36. Frank, J. D. (1961). Persuasion and healing: A comparative study of psychotherapy.

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Baltimore: The Johns Hopkins University Press. (Quotes are from the 1974 revised edition, New York: Schocken Books). Kazdin, A.E. (2005). Treatment outcomes, common factors, and continued neglect of mechanisms of change. Clinical Psychology: Science and Practice, 11, 184-188. Kiesler, D. J. (2004). Intrepid pursuit of the essential ingredients of psychotherapy. Clinical Psychology: Science and Practice, 11, 391-395. Russell, R. L. (1999). Child psychotherapy process research: Suggestions for the new millennium. In S. W. Russ and T. H. Ollendick (Eds.), Handbook of psychotherapies with children and families (p. 541552). New York: Klower Academic/Plenum Publishers. Russell, R.L. (2004). Minding our therapeutic tales: Treatments in perspectivism. In L.E. Angus& J. McLeod (Eds.) The Handbook of Narrative and Psychotherapy (pp. 211-226). Thousand Oaks, CA: Sage Publications, Inc. Russell, R. L. (2007). Social Communication Impairments: Pragmatics. In R.L. Russell & M.D. Simms (Eds.) Language, Communication, and Literacy: Pathologies and Treatments. Pediatric Clinics of North American, 54, 483-506. Russell, R., Bryant, F., & Estrada, A. U. (1995). Confirmatory p-technique analyses of therapist discourse: High versus low quality child therapy sessions. Journal of Consulting and Clinical Psychology, 64, 1366-1376. Russell, R. L., Greenwald, S. & Shirk, S. R. (1991). A meta-analytic review of language changein child psychotherapy. Journal of Consulting and Clinical Psychology, 59, 916-919. Russell, R. L., Jones, M.E. & Miller, S.A. (2007). Core process components in

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psychotherapy: A synthetic review of P-technique studies. Psychotherapy Research, 17, 271-288. Shirk, S. & Russell, R. L.(1996). Change processes in child psychotherapy: Revitalizing treatment and research. New York: Guilford Press. Robert L. Russell, Ph.D. is currently Professor of Pediatrics at the Medical College of Wisconsin/Children’s Hospital of Wisconsin. He is Director of Research at the Child Development Center and a member of the School Performance Program in which he provides assessment and treatment for school aged children with learning, language, and psychiatric disorders. Dr. Russell received his Ph.D. from Clark University in 1984 and an MA in Linguistics in 1986 from the University of North Carolina, Chapel Hill. He has taught at the University of Kentucky, New School for Social Research, and at Loyola University prior to his current appointment. He is currently conducting research on the pragmatic language competence of children with language disorders and ADHD in addition to his research on processes of treatment in child and adolescent therapy. The current piece shares the title of a book-in-progress.

Address for editorial correspondence: Robert L. Russell, Ph.D. Professor, Pediatrics Director of Research Child Development Center Medical College/Children’s Hospital of Wisconsin Department of Pediatrics 8701 Watertown Plank Rd. PO Box 26509 Milwaukee, Wisconsin 53226 0509 Phone: 414-456-4430 Email: [email protected]

WASHINGTON SCENE

The Fundamental Nature of the Political Process Pat DeLeon, former APA President

A State-Based Dialogue: On July 10, 2007 the Governor of the State of Hawaii vetoed SB 1004 which would have allowed appropriately trained psychologists, working within our state’s community health centers, to prescribe. As Mike Sullivan observed: “A veto was inevitable somewhere sooner or later. Hawaii came closer than anytime in over two decades – major progress. Hats off to Jill and Robin and Ray!” The Governor’s veto message: “The stated purpose of this bill ‘is to authorize appropriately trained and supervised licensed medical psychologists practicing in federally qualified health centers, to prescribe psychotropic medications for the treatment of mental illness.’ This bill is objectionable because its actual effect goes beyond its stated purpose by allowing psychologists who obtain the second of two tiers of prescriptive authority established by the bill—a prescription certificate – to practice outside of federally qualified health centers (FQHCs) and to prescribe medications to individuals who are not patients at FQHCs. Furthermore, this bill does not require medical supervision of psychologists holding a prescription certificate. This bill is also objectionable because psychologists do not have the training necessary to prescribe drugs and this bill does not require sufficient didactic and clinical training for prescriptive authority....

“In addition, this bill gives psychologists with prescriptive authority a scope of practice broader than that afforded to the PDP [DoD] psychologists. PDP psychologists were limited to prescribing psychotropic medications to patients between the ages of 18 and 65 with mental conditions but without medical complications as evaluat-

ed by the supervising psychiatrist. This bill allows psychologists to prescribe psychotropic medications to patients of all ages, including children, elderly, and those with medical illnesses in addition to medical conditions. Psychologists with limited didactic and clinical training are not prepared to handle the side effects of psychotropic medications on patients with medical complications. In recognition of this concern, both the Board of Medical Examiners and the Board of Psychology, the professional licensing bodies for these two professions, have asked that this bill not become law. For the foregoing reasons, I am returning Senate Bill No. 1004 without my approval.”

The ApA President: “We welcome (the) veto of this legislation and the legislature’s decision not to attempt to override her veto. These actions placed the health and welfare of patients above politics. Psychiatric disorders—and medications— have an impact on the patient’s whole body, not just his or her brain.... (I)t is dangerous and unwise to allow prescribing of pharmacologic treatments by those... who have no medical training. Properly prescribed, psychiatric medications are safe and effective, but they are not without risks.... Moreover, over half of all patients with mental illnesses have other medical complications that must be taken into consideration when prescribing psychiatric medications. This also clearly requires medical education and training and expertise. The APA applauds the leadership and continued efforts by patients, their families and physicians in Hawaii to ensure that Hawaiians are not subjected to substandard and potentially dangerous care. The

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APA strongly supports its state associations in their ongoing efforts to vigorously resist efforts to allow psychologists to practice medicine without the benefit of medical school and supervised medical residency.”

It is important in the public policy arena to periodically reflect upon the “bigger picture.” This year a chiropractor-access bill passed the Hawaii legislature to be vetoed by the Governor at the recommendation of the Hawaii Medical Association. The HMA President: “The governor has stated her intent to veto HB 436, which would mandate that Medicaid and QUEST cover chiropractic services. I support the veto of this bill. Medicaid and QUEST are intended to be basic medical assistance programs. Chiropractic services are not basic medical services that should be included in this ‘safety net’ state program. The stated purpose of this bill is to ‘improve healthcare access in Hawai’i by requiring medical assistance programs such as QUEST and Medicaid to include chiropractic coverage.’ However, enactment of this law will harm access to quality healthcare. Current physician reimbursement rates under Medicaid and QUEST have remained low. As a consequence of low reimbursement rates, a substantial number of Hawai’i physicians have had to stop accepting Medicaid or QUEST. Other physicians have left the state. Accordingly, any additional money that is available for these two programs should be spent on increasing physician reimbursement rates. It would be a bad precedent if this bill became law. If more people use chiropractic services than were anticipated, then even more money will have to be appropriated to cover these services. In addition, in tough financial times, other services may have to be cut to ensure that these services remain fully funded.” We would ask: Is organized medicine really interested in fostering the health policy changes necessary such that the healthcare environment of the 21st century will affirmatively embrace patient-centered, indi-

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vidualized care in which educated consumers will actively utilize the most up-todate technology to ensure that they have access to the type (and quality) of healthcare that they desire? Does organized medicine have any appreciation for the critical importance of the psychosocial-economiccultural gradient of care or the benefit to patients inherent in non-silo oriented, interdisciplinary care? Given the halftruths and misrepresentations in the Governor’s veto message, does organized medicine really believe in data-based, objective determinations of quality care – including decades of evidence demonstrating that a wide range of non-physician healthcare providers provide outstanding (if not superior) care? Jim Quillin’s testimony: “With respect to safety, medical psychologists certified in Louisiana saw a total of 7,260 patients in 2005, after receiving the authority to prescribe. Of those patients, 3,863 (53%) were provided prescriptions.... There were no adverse events associated with this expanded practice.” Does organized medicine appreciate that patients are ultimately responsible for their own health care—for determining what services, and from which providers, they will receive?

Perhaps one should consider politics a full contact sport. We recommend the insightful book Food Fight by two of our profession’s visionaries, Kelly Brownell and Katherine Horgen. The focus of their concern is America’s growing obesity crisis, especially among our nation’s children.

This year, the Robert Wood Johnson Foundation announced a $500 million initiative, over five years, to Reverse Childhood Obesity, noting that about 25 million kids and teens in the nation are overweight or obese: “Childhood obesity is one of the most urgent and serious health threats confronting our nation. It deserves a serious response.” Called by critics the “Mullah of the Twinkie tax,” Kelly truly appreciates that to make a lasting differ-

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DIVISION 29 2007 APA CONVENTION PROGRAM San Francisco, California

FRIDAY, AUGUST 17, 2007

Symposium: Forgiveness Reconsidered— Exploring Underlying Constructs and Their Application to Psychotherapy 8/17 Fri: 8:00 AM - 9:50 AM Moscone Center, Room 310

Chair: Donna S. Davenport, PhD Participant/1st Author: Andrew Reichert, BA Participant/1st Author: Rod Hetzel, PhD Participant/1st Author: Donna S. Davenport, PhD Participant/1stAuthor: Randolph Pipes, PhD Discussant: Michael Duffy, PhD Symposium: Emotion-Focused Therapy of Depression—An Evidence-Based Psychotherapy 8/17 Fri: 10:00 AM - 11:50 AM Moscone Center, Room 3007

Chair: Leslie S. Greenberg, PhD Participant/1st Author: Leslie S. Greenberg, PhD Participant/1st Author: Jeanne C. Watson, PhD Participant/1st Author: Robert K. Elliott, PhD Symposium: Can We Identify MVPs (Most Valued Psychotherapists)— Therapists Effects in Psychotherapy

8/17 Fri: 12:00 PM - 1:50 PM Moscone Center, Room 2006

Chair: Raymond A. DiGiuseppe, PhD Participant/1st Author: Jeb Brown, PhD Participant/1st Author: Stevan L. Nielsen, PhD Participant/1st Author: William B. Stiles, PhD Discussant: Raymond A. DiGiuseppe, PhD

Symposium: Lying in Psychotherapy— Clients’ Views, Therapists’ Views, Theoretical and Practical Considerations 8/17 Fri: 2:00 PM - 2:50 PM Moscone Center, Room 3012 Chair: Randolph Pipes, PhD Participant/1st Author: Randolph Pipes, PhD Participant/1st Author: Leslie Martin, PhD Participant/1st Author: Caroline Burke, PhD Discussant: Annette S. Kluck, PhD

Poster Session One 8/17 Fri: 3:00 PM - 3:50 PM Moscone Center, Halls ABC

Participant/1st Author: Megan M. MacNamara, MA Participant/1st Author: Priscilla R. Fleischer, PhD, MSW Participant/1st Author: Satoko Kimpara, MS Participant/1st Author: Matteo Bertoni, MS, MA Participant/1stAuthor: Anne C. Erlebach, MA Participant/1st Author: Sarah Knox, PhD Participant/1st Author: Barbara M. Kaplan, PhD Participant/1st Author: Georgiana S. Tryon, PhD Participant/1st Author: Rafael S. Harris, Jr, PsyD Participant/1st Author: Mona Bapat, MS Participant/1st Author: Chris Brown, PhD Participant/1st Author: Michele B. Hill, PhD Participant/1st Author: Courtney A. Swatta, PsyD Participant/1st Author: George J. Kallas, PsyD, PhD Participant/1st Author: Shelah D. Adams, MA Participant/1st Author: Pedja Stevanovic, BA Participant/1st Author: Sara J. Lederer, MA Participant/1st Author: Hung-Bin Sheu, MA, MEd Participant/1st Author: Gregory S. Chasson, MA Participant/1st Author: Clara E. Hill, PhD Participant/1st Author: Shelley N. Osborn, BS Participant/1st Author: Satoko Shiraishi, MA Participant/1st Author: Lee A. Thrash, PhD Participant/1st Author: Zac E. Imel, MA Participant/1st Author: Kristin M. Perrone, PhD

Conversation Hour: Awards and Recognition 8/17 Fri: 5:00 PM - 5:50 PM San Francisco Marriott Hotel, Golden Gate Salons B1 and B2 Social Hour 8/17 Fri: 6:00 PM - 6:50 PM San Francisco Marriott Hotel, Golden Gate Salons B1 and B2

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SATURDAY, AUGUST 18, 2007

Symposium: Unifying Principles of Psychotherapy—What Have We Learned From 100 Years of Clinical and Empirical Investigation? 8/18 Sat: 8:00 AM - 9:50 AM Moscone Center, Room 3009 Chair: Jeffrey J. Magnavita, PhD Participant/1st Author: Jacques P. Barber, PhD Participant/1st Author: Jay L. Lebow, PhD Participant/1st Author: Lorna Smith Benjamin, PhD Participant/1stAuthor: Arthur Freeman, EdD Discussant: Theodore Millon, PhD, DSc

Luncheon for Graduate Students and Early Career 8/18 Sat: 12:00 PM - 1:50 PM San Francisco Marriott Hotel, Nob Hill Rooms A and B

Symposium: Evidence-Based Psychodynamic and Cognitive Therapies—Recent Findings and Future Challenges 8/18 Sat: 2:00 PM - 3:50 PM Moscone Center, Room 307 Cochair: Jacques P. Barber, PhD Cochair: Robert J. DeRubeis, PhD Discussant: William B. Stiles, PhD

Poster Session Two 8/18 Sat: 4:00 PM - 4:50 PM Moscone Center, Halls ABC Participant/1st Author: Tamara S. Shafer, BA Participant/1st Author: Timothy P. Melchert, PhD Participant/1st Author: Jennifer L. Wilson, BA Participant/1st Author: J. Alison Bess, PhD Participant/1st Author: Zohar Itzhar-Nabarro, PhD Participant/1st Author: Matthew J. Taylor, PhD Participant/1st Author: Nancy A. Fry, MBA Participant/1st Author: Christy D. Hofsess, MEd Participant/1st Author: Robinder P. Bedi, PhD Participant/1st Author: Rebecca Oakes, PhD Participant/1st Author: Rachel E. Crook Lyon, PhD Participant/1st Author: Lana O. Beasley, MA Participant/1stAuthor: Frank Fedde, MA Participant/1stAuthor: Scott A. Baldwin, PhD

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Participant/1st Author: Jill C. Slavin, MA Participant/1st Author: Brian H. Stagner, PhD Participant/1st Author: Jeffrey A. Rings, MA Participant/1st Author: Melissa S. Roffman, MA Participant/1st Author: John L. Powell, MA Participant/1st Author: Arne Kristian Henriksen, PhD Participant/1st Author: Robert J. Reese, PhD Participant/1st Author: Steven G. Benish, MSE Participant/1st Author: Melissa K. Smothers, MA Participant/1st Author: Frances A. Kelley, PhD Participant/1st Author: William K. Lamb, PhD Participant/1st Author: J.R. Fuller, PhD Participant/1st Author: Diana L. Sanchez, MA Participant/1st Author: Yun-Jy Yeh, MEd Participant/1st Author: Valerie R. Wilson, MA Participant/1st Author: D. Brian Smothers, MA Participant/1st Author: Erlanger A. Turner, MS Symposium: Psychotherapist Self-Care— Leaving It at the Office 8/18 Sat: 4:00 PM - 5:50 PM Moscone Center, Room 307 Chair: John C. Norcross, PhD Participant/1st Author: Judith S. Beck, PhD Participant/1st Author: Laura S. Brown, PhD Participant/1st Author: Lillian Comas-Diaz, PhD Participant/1st Author: Florence W. Kaslow, PhD Participant/1st Author: Michael P. Leiter, PhD Participant/1st Author: Alvin R. Mahrer, PhD Discussant: James D. Guy, PhD

SUNDAY, AUGUST 19, 2007

Symposium: Psychotherapists Around the World—-Meeting Needs of the Global Village 8/19 Sun: 9:00 AM - 10:50 AM Moscone Center, Room 309 Chair: Craig N. Shealy, PhD Participant/1st Author: Gregg R. Henriques, PhD Participant/1st Author: Shagufa Kapadia, PhD Participant/1st Author: Noelle Robertson, PhD Participant/1st Author: Eleanor H. Wertheim, PhD Discussant: Jeffrey J. Magnavita, PhD

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Symposium: Guiding Evidence-Based Practice With Outcome Data

8/19 Sun: 11:00 AM - 12:50 PM Moscone Center, Room 309 Chair: David W. Smart, PhD Participant/1st Author: David D. Dayton, BA Participant/1st Author: Takuya Minami, PhD Participant/1st Author: Russell J. Bailey, BS Participant/1st Author: Richard L. Isakson, PhD Discussant: Brent S. Mallinckrodt, PhD

MONDAY, AUGUST 20, 2007

Symposium: Culturally Competent Intervention for Abused, Suicidal African American Women 8/20 Mon: 8:00 AM - 9:50 AM Moscone Center, Room 3003 Cochair: Nadine J. Kaslow, PhD Cochair: Natalie C. Arnette, PhD Participant/1st Author: Natalie C. Arnette, PhD Discussant: Nadine J. Kaslow, PhD

Workshop: Two Become One and Then There Are None! Relationships and Couples Therapy Revisited 8/20 Mon: 11:00 AM - 11:50 AM Moscone Center, Room 2006 Cochair: Robert W. Resnick, PhD Cochair: Rita F. Resnick, PhD Symposium: International Perspectives on Feminist Multicultural Psychotherapy—Content and Connection 8/20 Mon: 12:00 PM - 1:50 PM Moscone Center, Room 262 Chair: Elizabeth Nutt Williams, PhD Participant/1st Author: Laura S. Brown, PhD Participant/1st Author: Norine G. Johnson, PhD Participant/1st Author: Ellyn Kaschak, PhD Participant/1st Author: Kathryn L. Norsworthy, PhD Discussant: Oksana Yakushko, PhD

Symposium: Cognition and Suicide—Theory, Research, and Therapy 8/20 Mon: 10:00 AM - 10:50 AM Moscone Center, Rooms 202/204/206 Chair: Lisa A. Firestone, PhD Participant/1st Author: David Jobes, PhD Participant/1st Author: M. David Rudd, PhD Participant/1st Author: Gregory K. Brown, PhD

D I V I SI

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ence, one must have vision, persistence, and presence. “Proposals to change the food environment present the food industry and the nation with serious challenges. The industry must fight off unwanted legislative, regulatory, and legal action that could damage business while at the same time it engages in practices such as marketing to children that are increasingly unpopular. The nation must decide how to deal with the food industry. Food companies confront the paradox of claiming public health as their priority while knowing that profits increase when people eat more. If the nation moves to a healthier diet, some segments of the industry will benefit and others will suffer.... Without active discussion, the nation will default to current practices.... Tight connections between the food industry and key governmental officials are legendary.... Striking parallels exist between the beginning of the war on tobacco and where the nation stands now with food. First let us address a key issue – that food and tobacco are not the same. We agree that they are not the same. People do not have to smoke, but they must eat.”

Kelly and his colleague highlight food industry tactics that are highly relevant for all who seek to modify the status quo of healthcare (including obtaining prescriptive authority): • Claim commitment to public health; • Influence public policy directly; • Seek influence through campaign contributions; • Silence critics by suing or intimidation; and, • Shift the focus of discussion. “First they ignore you. Then they laugh at you. Then they fight you. Then you win” [M.K. Gandhi]. Being personally involved is critical. Mike is absolutely correct. Our sincerest congratulations and appreciation to Robin Miyamoto, Jill Oliveira, Ray Folen, and HPA Executive Director Carol Parker. Hawaii’s psychologists have made a major contribution to society and our profession. Louisiana’s Jim Quillin: “I thought of a cold day in a duck blind many years ago when my father told me that there would come times in my life when I’d remember

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what he was to tell me—‘Son, if you don’t quit, you win.’ He was right.”

A Federal Dialogue: This Summer, Senator Enzi, ranking member of the Health, Education, Labor and Pensions (HELP) Committee, introduced legislation (S. 1783) laying out a healthcare vision for the 21st century. “Health care reform is one of the biggest needs in this country. It is the fastest escalating price in this country. It is the biggest cost to companies and individuals in this country. We need to have a solution. I have been working with Senator Kennedy (who)... has a very full plate with the Higher Education Act, the higher education reconciliation, information technology, and I could go on to mention about 53 bills we are working on in that committee. So I have had some latitude as ranking member to try to pull together some information—some legislation that would deal with health care for this Nation. This is a work in progress. This is not a finished document....

“Without the work of everyone on this, it can’t be done. If it gets polarized, it can’t be done. This is something which has to be done in a very bipartisan way. I hope we have a framework from which we can all operate, making changes, finding third ways. I work on an 80-percent rule. I anticipate and from experience have found that usually everybody can agree on 80 percent of the issues, and among the 80 percent of the issues on which they agree, they can agree on 80 percent of any one of those issues. You never get a perfect bill around here. If you can get 80 percent, you can get a lot done. That is what we are trying to do on health care.... Eighty percent would be a huge difference and will help out a lot of people. “So I rise today to talk about an issue that is literally a heartbeat away from devastating the lives of every American; that is, our current health care crisis. Undeniably, we

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have a problem. There are 46.1 million Americans, according to the last tabulation, who are uninsured. Now, we always talk about that figure and change it slightly differently because there are 7 million of those people who make over $80,000 a year and don’t have insurance, so they must chose not to have insurance, but they are uninsured.... Health care costs are outstripping inflation. They are increasing annually at three times the rate of the Consumer Price Index. It is little surprise that three out of every four Americans are concerned about health care—three out of four.... Thankfully, I am not here today to talk about these problems; I am here to provide real solutions. Americans need and deserve real solutions to this crisis now, and they are counting on this body to work together to get that. The time has come to move beyond the rhetoric and principles to true comprehensive health care reform. Congress could enact 10 major steps for health care reform. These 10 steps are the basis of the legislation I am introducing today, the Ten Steps to Transform Health Care in America, or simply ‘Ten Steps’....

“First, we eliminate unfair tax treatment of health insurance, which expands choices and coverage and gives all Americans more control over their health care.... The second step would increase affordable options for working families to purchase health insurance through a standard tax deduction.... The third step is what makes this a hybrid approach. I couple the standard deduction with a refundable, advanceable, assignable tax-based subsidy. That is a mouthful, but it ensures that Americans receive this credit in a meaningful way that allows them to purchase real insurance coverage.... The fourth key step is to provide market-based pooling to reduce growing health care costs and increase access not only for small businesses, unions and other kinds of organizations and their workers, members, and families.... Of course, a big elephant in the room was dealing with those who were misled to

fear how the initial proposal dealt with insurance mandates.... While the next step is probably one of the most obvious ones, it is also one many have not yet discussed. Currently, HIPPA portability protections are provided to group health plans.... However, those consumer protections are not provided nearly as well to individuals who are purchasing in the individual market. Ten Steps blends the individual and group market to extend important HIPPA portability protections... so the insurance security can better move with you from job to job.... The sixth step emphasizes preventive benefits and helps individuals with chronic diseases better manage their health. America should have health care, not sick care. Prevention, prevention, prevention. That makes a big difference in the cost.... (A)nother key step is to give individuals the choice to convert the value of their Medicaid and SCHIP program benefits into private health insurance, putting them in control of their health care, not the Federal Government.... The eighth step is a bipartisan proposal... the ‘Wired for Health Care Quality Act,’ which encouraged the adoption of cuttingedge information technologies in health care to improve patient care, reduce medical errors, and cut health care costs.... (T)he ninth step helps future providers and nurses pay for their education while encouraging them to serve in areas with great need.... The final step decreases the skyrocketing cost of health care by restoring reliability in our medical justice system through State-based solutions.... The Institute of Medicine... estimated that preventable medical errors kill between 44,000 and 98,000 Americans each year.... We have an opportunity, we have an obligation to take care of the people of this country, and they are demanding it. Let’s work from a basis of some information and see where we can take it so that we get a solution and we get action now.”

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Ray: “Organized medicine poorly represents the public sector physician working in underserved areas. Facing limited resources and strapped with huge patient care loads, these colleagues greatly appreciate and support the other helping professionals who are willing to share the load. It is dismaying that, in contrast, organized medicine is most interested in protecting turf. They use

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unfounded scare tactics and fill their testimony with outright lies and distortions. When it comes to scope of practice, objective data and disconfirming evidence be damned, resulting in countless thousands being denied necessary health care.” Aloha, Pat DeLeon

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THE AMERICAN PSYCHOLOGICAL FOUNDATION and APA Division 29 The Division of Psychotherapy present the 14th Annual Rosalee G. Weiss Lecture for Outstanding Leaders in Psychology “Racial Microaggressions in Everyday Life: Impact on Mental Health & Clinical Practice” Delivered by Derald Wing Sue, Ph.D. Chair: Anthony Jackson, Ph.D. Sunday, August 19, 2007 3:00 p.m. to 3:50 p.m. Moscone Center • Room 200

Dr. Weiss established the Rosalee G. Weiss Lecture Series in 1994 to honor his wife, and he ensured its perpetuity with a gift to the Foundation in 1999. Divisions 29 and 42, upon approval by the APF Board of Trustees, select an annual lecturer to speak at the APA convention. The individual must be an outstanding leader in the arts or sciences whose work has had significant impact on the discipline of psychology or an outstanding leader in any of the specialty areas within the sphere of psychology. About Derald Wing Sue, Ph.D.

Derald Wing Sue, Ph.D., is a pioneer in the field of multicultural psychology. While some scholars were doubtful of the practicality of multicultural psychology, Wing Sue had already written and researched in the field extensively, being one of the frontrunners to uncover the flourishing discipline. Wing Sue received his doctorate from the University of Oregon, and is a professor of psychology and education in the Department of Counseling and Clinical Psychology at Columbia University. His research challenges monocultural foundation of psychology. In 1972, he co-founded and served as the first president of the Asian American Psychological Association. He has also served as president of the Society for the Psychological Study of Ethnic Minority Issues and the Society of Counseling Psychology (Division 17 of American Psychological Association). Wing Sue has worked to set up cultural diversity training programs for many companies and organizations. Today, two of Wing Sue’s books have been identified as the most frequently cited works in multicultural psychology, indeed a testament of his contribution to the field.

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DIVISION 29 STUDENT PAPER AWARDS Each year, the Student Development Committee of the Division of Psychotherapy calls for papers for three awards, which are then juried by the members of the committee. In 2007, the committee received nearly 30 submissions of high caliber from students across North America. Each winning submission receives a commemorative plaque and a cash prize, presented at the annual meeting of the APA in San Francisco. Psychotherapy Bulletin is pleased to publish the winning paper from each award category.

Ms. Jesse Metzger, of Columbia University, is the recipient of this year’s Donald K. Freedheim Student Development Award. The Freedheim Award is conferred on the author of the best paper written on psychotherapy theory, practice, or research. This year’s winner, written by Ms. Metzger is titled: Between Patients’ Representations of Therapists and Patients.

Mr. Peter Panthauer, of Adelphi University, is the recipient of this year’s Diversity Award. The Diversity Award is conferred on the author of the best paper that address issues of race, gender, and cultural issues in psychotherapy. Mr. Panthauer’s award-winning paper is titled: Therapy with Lesbian Couples.

Ms. Deleene Menefee, of the University of Houston, is the recipient of this year’s Mathilda B. Canter Education and Training Award. The Canter award is conferred on the author of the best paper on education, supervision, or training of psychotherapists. Ms. Menefee’s paper on Perceptions of Trainee Attachment in the Supervisory Relationship, was this year’s award winning paper. Michael S. Garfinkle Chair, Student Development Committee

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STUDENT PAPER

The Relationship Between Patients’ Representations of Therapists and Parents Jesse A. Metzger, Teachers College, Columbia University Abstract The purpose of this exploratory research was to examine and compare the formal properties of psychotherapy patients’ internalized representations of their parents and those of their therapists. A further comparison was made between representations of parents following recall of a pleasant memory of the parent (“good parent” representations), and representations of parents following recall on an unpleasant memory of the parent (“bad parent” representations). Results indicate that patients represent their therapists significantly less in the form of images and “felt” sensations than either the “good” or the “bad parent,” and that their therapist representations are significantly less vivid overall than either parent representation. Results further indicated that the more patients tend to represent their “bad parent” in the form of images and “felt” sensations, the more they tend to represent their therapist in the form of real or imagined dialogues; by contrast, the more patients tend to represent their “good parent” imagistically, the less they tend to represent their therapist in lexical form. The findings and their implications are discussed. The Relationship Between Patients’ Representations of Therapists and Parents

Patients beginning therapy carry with them the influence of previously internalized relationships, most saliently, those of their primary caregivers or parents. From this object relational perspective, therapy can be looked at as a process of understanding and reworking representations. Success of therapy depends on both the beginning contents and organization of the patient’s representational world, and the therapist’s recognition of and sensitivity to that world. The organization—or form (vs.

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content)—of patients’ representations is the focus of the present research.

In psychology as well as the arts, the study of representation has addressed the distinction between the form of a representation and its content. The content is the what, the form is the how—the manner, shape, or defining characteristic by which a representation is known. With respect to mental representations of internalized objects, Geller, Cooley, and Hartley (198182) have observed that forms of representations do not merely act “on behalf” of content, they in fact play a role in shaping content: “formal processes are implicated in perceiving an object, in re-representing the object in its physical absence, and in communicating the experience from one person to another” (p. 130).

Understanding how patients represent significant others in the mind has much clinical utility in terms of assessing and facilitating the flexibility with which patients represent these significant others. Theoretical (Bruner, 1964; Horowitz, 1983) and empirical work (Geller et al., 1981-82; Geller & Farber, 1993; Orlinsky, Geller, Tarragona, & Farber, 1993; Rosenzweig, Farber, & Geller, 1996) has demonstrated the existence of three categories of representational form used by individuals when calling forth representations of significant others or events: imagistic, enactive, and lexical (Horowitz). The imagistic mode involves the calling forth of visual, auditory, olfactory, and other perceptual images, and is distinct among the three modes in its ‘proximity’ to perception and affect. The enactive mode is characterized by the experience of “felt” bodily sensations, or

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the sense of diffuse, emotionally-laden atmospheres. The lexical mode—the clearest, most logical, and most communicable of the modes—is characterized by languagebased or conceptual thought.

In Horowitz’s (1983) view, the flexible interrelatedness of the three modes of representational thought is a sign of psychological health, giving an individual’s experiences depth and breadth of meaning. However, individuals can sometimes become one-sided, have only one mode available, or vacillate in an unintegrated way among the modes: “Characterological styles result, in part, from a restrictive selection of and preferences for certain modes of representing experience and the use of various strategies to negotiate the relationships among them” (Geller et al., 1981-82, pp. 130-131). What is happening in such cases, proposes Horowitz, is that repression is occurring at the boundaries between these representational systems. A goal of psychotherapy is thus to reestablish continuity between ideas and attitudes in various modes of representation.

Patients’ representations of their therapists The first known systematic study of the forms of therapist representation was undertaken by Geller et al. (1981-82). Using as a conceptual starting point Bruner’s (1964) and Horowitz’s (1972) categories of representational form, the authors developed the Therapist Embodiment Scale (TES) as a system for characterizing the forms in which “evocative memories” of significant others enter awareness. A factor analysis of the TES in the Geller et al. confirmed the presence of the three distinct representational modalities in patients’ representations of their therapists: imagistic, haptic (later renamed “enactive”), and conversational-conceptual (used interchangeably with “lexical”). Each of these modalities makes possible a different form of imaginatively reliving the experience of being in the physical presence of the therapist. Patients with high scores on the imagistic factor are especially able to schemati-

cally represent the nonverbal, perceptually-based aspects of therapy sessions. Patients with high scores on the enactive factor experience tend to evoke their therapist via “certain characteristic bodily sensations” and are aware of “a particular emotional atmosphere” that gives them a sense that their therapist is “with them”; this mode of representation can be distinguished from that comprised of particular images or notional thought. Finally, patients with high scores on the lexical factor tend to represent the therapeutic interaction in terms of real or imagined dialogues with the therapist.

Research using the TES has shown that patients typically use all three modalities to evoke representations of their therapists and the therapeutic relationship, but that auditory and visual imagery tend to be the most characteristic forms of therapist representation (Geller & Farber, 1993; Orlinsky et al., 1993; Wzontek, Geller, & Farber, 1995). Other variables, such as the length of time in therapy and whether the subject is a current or former patient, have been studied in connection with the modalities of therapist representations. Research on whether length of time in therapy affects patients’ tendency to represent their therapist via particular modalities has yielded mixed results. Two studies investigating the hypothesis that patients’ internalized representation of their therapists vary with time in treatment—with patients in early phases of treatment having less articulated and differentiated representations than those in latter phases—did not confirm this hypothesis (Barchat, 1989; Wzontek et al., 1995). However, in an examination of possible non-linear trends, Rosenzweig et al. (1996) found that patients within three phases of therapy differed significantly in the extent to which they employed the imagistic mode of therapist representation. Specifically, patients who had been in therapy between one and three years tended to use visual imagery in evoking a represen-

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tation of their therapist more often than patients who had been in therapy either less than one year or more than three years.

In an examination of whether therapist representations depend on termination status, Geller and Farber (1993) demonstrated that current and former patients did not differ significantly in the extent to which they employed each of the three factorgenerated modalities to represent their therapists. Furthermore, among patients currently in therapy, the frequency of use of discrete forms to represent the therapist was unrelated to the number of sessions attended. These findings are consistent with those of Barchat (1989) and Wzontek et al. (1995), described above. Among those who have terminated therapy, however, the number of sessions attended was found to be significantly related to preferred mode of representation: the greater the number of sessions, the less frequent the use of the imagistic mode of representing one’s therapist and the more frequent the use of the lexical mode. These findings were interpreted to mean that current patients’ modes of constructing representations of the information contained in their unfolding therapy experiences do not become progressively more conceptual and less sensory in nature during the course of therapy. Once terminated, however, patients appear to more frequently invoke the therapist’s voice as a preferred modality of representation. In terms of outcome, in Geller et al.’s (198182) original study, self-reported improvement was significantly correlated with the use of the imagistic and enactive modes of representation: the tendency to experience the therapist imagistically or in terms of “felt” sensations was associated with positive self-perceived outcomes. Subsequent research using the same instrument (the Therapist Embodiment Scale, or TES) has yielded similar results. For example, Honig, Farber, and Geller (1997) found that, in a community-based sample of current patients, patients’ perceptions of how

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helpful treatment had been thus far was positively correlated with the tendency to use the imagistic and enactive modes of representing the therapist. In an examination of both current and former psychotherapy patients, Geller and Farber (1993) found that whereas among patients currently in therapy, self-reported improvement was significantly correlated with the tendency to represent the therapist in the imagistic mode, among former patients, use of the enactive mode was positively correlated with outcome. Because patients who possess this latter representational capacity are able to remain “in touch” with their therapist’s presence, and to “sense” the emotional atmosphere that accompanies feelings of relatedness, the authors concluded that “in more successful therapies, the therapist apparently becomes ‘a felt part of’ the patient” (p. 177). These findings taken together suggest that the tendency to embody the therapist imagistically and/or in terms of “felt” sensations is associated with better outcomes.

Parental representations Parental representations, in contrast to therapist representations, have not been subject to research via different modalities as defined in the present study. However, research has both compared parental and therapist representations in terms of developmental level, and examined the relationship of parent and therapist representational level to outcome. This research can serve as a broader context in which to embed the more specific definitions of representational “multimodality” utilized in the present study.

The developmental or conceptual level of object representations has been a focus of study in recent years (see Blatt & Auerbach, 2001). Based in developmental object relations theory, in this line of research representations are seen as existing on a continuum, with low-level representations being concrete, literal, fixed, and

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global, and high-level representations being more differentiated, complex, integrated, and abstract (Blatt, Wiseman, Prince-Gibson, & Gatt, 1991). Research examining the conceptual levels of parent and therapist representations has shown that there is a significant correlation between the two, particularly when the parent represented is the mother (Bender, Farber, & Geller, 1997; Honig et al., 1997). Honig et al. (1997), for example, found that patients who formed more highly integrated and differentiated representations of their mothers were more likely to form highly integrated and differentiated representations of their therapists, whereas patients whose maternal representations were more primitive and less differentiated tended to create therapist representations that reflected these same qualities. The finding is consistent with theory and research that suggest that an individual’s level of object representation is relatively stable and generalizable (e.g., Bowlby, 1988). However, Honig et al. also found that the overall level of the maternal object representation, as well as its level of complexity, was significantly higher than overall level of therapist representation. Thus, although patients’ levels of object representation were found to be positively correlated, the overall mean scores for conceptual level of therapist and maternal representations differed significantly. The authors attribute this finding to the fact that patients had only known their therapists for a limited time and could not develop realistically complex, differentiated representations of them.

Other research, however, has shown that therapist representations, as well as parent representations, become more complex and differentiated over treatment and that this higher developmental level is associated with better clinical outcomes (Blatt & Auerbach, 2001; Diamond, Kaslow, Coonerty, & Blatt, 1990; Stayner, 1994). These findings support the notion that representational structures that organize experience and patterns of interpersonal relat-

ing can become more differentiated, integrated and more intersubjectively related during clinical treatment. The implications of these findings include the potential usefulness of evaluating the differentiationrelatedness of patients’ descriptions of self and significant others in clinical practice. As Blatt and Auerbach note, “comparison of the changes in patients’ representations of parents and therapist suggests the crucial role of the therapist in facilitating clinical change (2001, p. 147).

As mentioned, although the research reviewed in this section did not examine the formal properties of parental and therapist representations as defined in the present study (i.e., imagistic, enactive, and lexical), the findings taken together suggest that helping patients to develop more differentiated and complex representations of objects leads to better outcomes. Whether the flexible interplay among the three modes of representational thought (Horowitz, 1983) represents more “differentiated” or “complex” representational thinking is a question that cannot be answered by the present study. However, if representational form is considered to play a critical role in the shaping of content, it is reasonable to assume that the greater the multimodal flexibility, the greater the complexity and richness of representational thought.

“Good parent” vs. “bad parent” representations There appear to be at least two potentially clinically relevant reasons for distinguishing between “good parent” and “bad parent” representations. First, it may be useful to discover whether “good parent” and “bad parent” representations differ from each other in form. Are “bad parents” more vividly experienced in the form of images, whereas “good parents” are more vividly experienced as “felt” parts of oneself? Although the degree to which one experiences the “good” or “bad parent” in a particular modality is likely to depend on that

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individual’s characteristic style (Geller et al., 1981-82; Horowitz, 1983), a goal of the present research is to determine whether there are general patterns to the ways in which patients represent these differing mental constructs.

In addition, to separate the “good parent” and the “bad parent” is to gain a fuller understanding of the nature of the “bad parent” representation. Writers working from clinical, case study perspectives (e.g., Loewenstein, 2004), as well as those working from transtheoretical positions (e.g., Westen, 1991) have likewise observed that representations of the so-called “bad parent” may become dissociated from patients’ awareness, particularly when there are severe disturbances in early object relationships. Thus, by focusing attention explicitly on representations of the “bad parent,” information about the representation of this particular construct may be more fully understood. Furthermore, partitioning out the ‘purely’ “bad parent”— clarifying the ways in which he or she is represented—may be beneficial in understanding particular biases or restrictions the patient may have in terms of moving flexibly among modes of thought. For example, when it comes to imagining the “bad parent,” do patients typically revert to the enactive mode of representation? (That is, do “bad parents” evoke more unformulated, “felt” sensations than do “good parents”? ) If so, this may be a signal that unformulated experiences of “badness” need to be translated into the more accessible imagistic or lexical forms. A second reason for teasing apart the “good parent” from the “bad parent” is that comparing each of these separately to the therapist representation offers an opportunity to see which of the parental representations the therapist representation more closely resembles. Are therapists coming to resemble the “good parent” or the “bad parent” in how they are represented in the mind of the patient? This kind of discovery could enable the thera-

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pist to make inferences about the transference relationship and to guide the treatment accordingly. As McWilliams (2004) has observed, the therapist simultaneously serves both as a new object (who differs from previous, disappointing objects of attachment) and as a figure to whom old, maladaptive patterns of relating inevitably get transferred. Understanding whether patients tend to transfer their “good parent” or their “bad parent” onto the therapist can provide information about which of these functions the therapist primarily serves. Although the present study does not seek to elucidate under what particular circumstances patients differentially transfer the “good” or “bad parent” onto the therapist (and it is assumed that patients do both at different times, or perhaps even simultaneously), it can elucidate whether there are general patterns to these types of transference among patients in therapy.

An important methodological question relates to how or under what circumstances we can expect patients to call forth representations of their “good” and “bad parents.” In therapy with adults, discussions of parents typically revolve around significant memories, often those occurring early in life. There is some evidence to suggest that certain kinds of memories reflect core object relational themes, thus achieving some degree of isomorphism with representations as defined throughout this paper.

Broadly speaking, autobiographical memories are the most likely to evoke object representations. Pillemer’s (1998) distinction between the imagistic (sensory, perceptual, affective, and automatic) level and the verbal (language-based and purposeful) level of autobiographical memories— in its striking resemblance to Horowitz’s (1983) distinction between imagistic (and/or enactive) and lexical modes of representation—lends support to the use of autobiographical memories as a stimulus for parental representations. Within the

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class of autobiographical memories, further subtypes can be delineated that bear directly on the evocation of object representations. Singer and colleagues, for example, have demonstrated that “selfdefining” memories (vivid memories that reflect enduring concerns or unresolved conflicts of the personality) are linked to critical relationship themes that are expressed in both patients’ intimate relationships and the transference dynamics of the therapy (Singer & Blagov, 2004; Singer & Singer, 1994). Finally, early memories may be particularly evocative of representations. In a discussion of Martin Mayman’s early memories technique, by which patients produce memories about their early experiences and relationships with caregivers, Fowler, Hilsenroth, and Handler (2000) note that one of the benefits of early memories is their ability to “summarize the patient’s subjectively experienced history, allowing the therapist to comprehend the patient’s view of self, other, and their world view” (p. 30).

In summary, given the evidence that selfdefining, autobiographical, and early memories are vivid, personally meaningful, and isomorphic with the representations they are intended to evoke, it can be reasonably assumed that guiding patients to produce these types of memory—either pleasant or unpleasant—about their relationship with a parent will produce meaningful representations of the “good” and “bad parent.” Research Questions To date, no study has examined the formal (i.e., imagistic, enactive, and lexical) properties of parent representations, nor has there been any explicit comparison of the formal properties of parent and therapist representations. Given the lack of data to support any specific hypotheses, the questions posed in the present study are considered exploratory in nature. Specifically, these questions are: 1) Are there differences in form and/or overall vividness between “good parent”/“bad parent” representa-

tions and therapist representations? Put differently, are there ‘preferred’ modes of representational thought and/or degrees of vividness depending on whether the patient calls to mind their therapist, their “good parent,” or their “bad parent”? 2) What are the relationships among the different forms of representation used for the different target figures? 3) Are there differences in form between representations of the “good parent” and representations of the “bad parent”?

Method Participants The sample consisted of a total of 20 psychotherapy patients, drawn from two different sources. One group of subjects was drawn from a subject pool utilized by Farber, Geller, and Rohde (1995). Specifically, this group consisted of 12 individuals who were currently in therapy at the time of that study. These subjects were recruited by Farber et al. from a universitybased training clinic in a large urban community. The sample consisted of 9 women and 3 men who volunteered to participate in a research project on the process of psychotherapy. The age range of these subjects was between 24 and 45.

For the purposes of the current study, a second group of subjects was recruited from the same university-based clinic (in the academic year of 2005-2006) in order to increase the sample size. This group consisted of eight individuals (seven women, one man), all currently in therapy at the clinic, who volunteered to participate in a research project on “patient views of psychotherapy.” Their ages ranged from 23 to 58.

The combined sample thus included a total of 16 women and 4 men with a mean age of 30. Sixteen of the subjects were White, three were Black, and one designated “other” as his or her ethnic category. In terms of education level, five of the subjects had attended some college, four had

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completed college, eight had attended some graduate school, and three had completed a masters degree. In terms of marital status, ten were single, five were in relationships, and five were married. The subjects had been in therapy an average of 14 months, with a range from 1 month to 91 months (7.5 years). Frequency of sessions ranged from once to twice weekly; the mean number of sessions was 98.7. Instruments and Procedure Subjects were given a packet of materials to complete and return to a box located in the clinic. Included in this packet were an informed consent form, a face sheet requesting demographic information, the Therapist Representation Inventory, revised version (TRI-II; Geller, Behrends, Hartley, Farber, & Rohde, 1992), and the Parent Representation Inventory (PRI; Smirnoff, 1986). Information about the theoretical underpinnings, development, and psychometric properties of the TRI can be found in Geller et al. (1981-1982). Information about the PRI can be found in Smirnoff (1986). The face sheet requested the subject’s gender, age, educational level, ethnicity, and marital status. In addition, subjects were asked to report for how long their current (and any past) psychotherapy had continued, and the number of times per week attended.

The TRI-II (Geller et al., 1992) has five parts, is self-administered, and is designed to measure the content, form, function, and other phenomenological properties of patients’ internal representations of their therapists. The PRI has two parts, is selfadministered, and is designed to measure the form and other phenomenological properties of patients’ internal representations of their parents following the recall of both a pleasant and an unpleasant early memory. Included in the present study is an analysis of one subscale of the TRI (the Therapist Embodiment Scale [TES]), and both subscales of the PRI (the Parent

38

Embodiment Scale-Pleasant [PES-p] and the Parent Embodiment Scale-Unpleasant [PES-u]).

Whereas the first group of subjects completed a number of other measures in addition to the demographic face sheet, TRI-II, and PRI, the second group completed only these measures. Only participants in the second group received a nominal compensation for their participation.

The Therapist Embodiment Scale (TES). The TES is a method for assessing the formal properties of patients’ internal representations (as distinct from their particular thematic contents). It asks patients to rate the relative contribution of words, pictures, sounds, bodily sensations, and so forth to their conscious experiences of the therapist outside therapy. The TES is a 12-item, ninepoint, Likert-type rating scale wherein patients are asked to determine the extent to which (1 = not at all typical; 3 = slightly typical; 5 = moderately typical; 7 = quite typical; 9 = highly typical) each item typifies the means by which they evoke images of their therapist. A factor analysis (principal axes with varimax rotations) performed by Geller et al. (1981-1982) generated a three-factor solution to the TES, with each factor seen as representing a distinct form of representation (cf. Horowitz, 1983). In the present study, one item from the 12item scale was removed prior to data analyses, since that item had failed to load onto any factor in Geller et al.’s original analysis. However, the one item that was shown by Geller et al. to load onto two factors was retained, given the exploratory nature of the present study and the fact that overlap between the two factors was statistically controlled in the data analyses.

The first factor (Imagistic) contains five items that assess the extent to which patients’ use perceptual (visual, auditory) imagery in imagining the therapist in his or her absence (e.g., “I picture a specific

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expression on my therapist’s face”; “I imagine a particular quality to the sound of my therapist’s voice”). Patients with high scores on this factor are especially able to schematically represent the nonverbal aspects of therapy sessions. The second factor (Enactive) contains three items and reflects experiences that are kinesthetically or proprioceptively felt rather than cognitively experienced (e.g., “I experience myself in certain bodily sensations”; “I am aware of a particular emotional atmosphere which gives me the sense that my therapist is ‘with me’”). The third factor (ConversationalConceptual) contains three items and reflects the degree to which the therapist representation takes the form of abstract ideas or concepts that comprise the language of the therapeutic interaction (e.g., “I think of specific comments my therapist has made to me”). In addition to assessing the formal properties of representations (per the factors), the TES also provides a measure of the overall vividness of the representation’s manifest configuration (per the overall score) (Geller et al., 1981-1982).

The Parent Embodiment Scale-Pleasant (PESp) and Unpleasant (PES-u). The PES-p and PES-u are companion pieces to the TES; they are identical to the TES, but differ in that they are administered following the subject’s recall of either a pleasant memory of their relationship with a parent, or an unpleasant memory of their relationship with a parent (“Please reflect on a specific pleasant/unpleasant memory of your relationship with either your mother or your father from your early childhood. Imagine and relive this incident in as much detail as possible: Try to remember thoughts, feelings, and sensations”). The items of the PES-p and PES-u are identical to those of the TES, except that the words “my therapist” are replaced with “him or her” (referring to the parent being imagined). Like the TES, the PES-p and the PES-u assess both the formal properties and overall vividness of patients’ internal representations of their parents.

Results Overall Scale and Factor Reliability Given that one of the goals of this research was to understand how the “good parent” and the “bad parent” are represented in the minds of patients (since the TES has never been used for anyone other than therapists), the factor structures of the TES, PESp, and PES-u were examined. As can be seen in Table 1, moderate reliability was obtained for the overall scales and most of the scale factors. The average reliability for the Imagistic factor across all three scales is .63; the average reliabilities for the Enactive and Conversational-Conceptual factors are .47 and .49, respectively. The moderate reliability of the both the scales overall and the factors supports their use in the data analyses that follow.

Descriptive Data and Comparisons Among Overall Scale and Factor Means As an initial step in the data analysis, the overall and factor means on the TES, PESp, and PES-u were computed. As can be seen in Table 2, based on the nine-point rating scale, the means for the Imagistic and Conversational-Conceptual scores on the TES fell between designations for “slightly typical” and “moderately typical,” and the mean for the Enactive scores on the TES fell between “not at all typical” and “slightly typical.” The means for all three factor scores on both the PES-p and the PES-u all fell around “moderately typical.” The overall mean for the TES fell around “slightly typical,” whereas the overall means for the PES-p and PES-u fell around “moderately typical” on the nine point scale. Examination of the average item factor means (adjusted means) indicates that whereas for the PES-p and PES-u, the Imagistic factor has the highest mean of the three factors, for the TES, the Conversational-Conceptual factor has the highest mean. In order to determine if there were detectable patterns of patients’ tendency to represent their therapist, their “good par-

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ent,” and their “bad parent” in particular forms, a repeated measures test was conducted. As indicated in Table 2, the extent to which patients’ representations were imagistic in nature differed significantly depending on the target figure. Specifically, patients tended to represent their therapist less imagistically than either parent, and to represent their “good parent” less imagistically than their “bad parent.” The extent to which patients’ representations were enactive in nature also differed significantly depending on the target figure, with patients tending to experience their therapists less as a “felt” part of themselves than either their “good” or “bad parent.” There were no significant differences in the extent to which patients tended to represent their therapists, “good,” and “bad parents” in conversational-conceptual form. In terms of the overall vividness of representation, patients’ representations of their therapists were significantly less vivid than their representations of either the “good” or the “bad parent.”

Relationship Among Factors In order to determine whether there were predictive relationships among the factors of the three scales, a multivariate analysis of variance was conducted. As can be seen in Table 3, the results indicate that higher PESu Imagistic scores significantly predicted higher TES Conversational-Conceptual scores (l = .372, p = .016; b = .648, p = .005), and that higher PES-u Enactive scores predicted higher TES ConversationalConceptual scores (l = .451, p = .040; b = .527, p = .016). That is, the more patients tended to represent their “bad parent” imagistically and/or enactively, the more they tended to represent their therapist in conversationalconceptual terms. A marginally significant finding was that higher PES-p Imagistic scores predicted lower TES ConversationalConceptual scores (l = .483, p = .055; b = .658, p = .011). In other words, the more patients tended to represent their “good parent” imagistically, the less they tended to represent their therapist in conversationalconceptual terms. No other significant relationships among the factors were found.

40

Overall Vividness of Representations To determine whether the overall vividness of either parental representation (“good” or “bad”) predicted the overall vividness of the therapist representation, a regression analysis was performed. As can be seen in Table 4, the results indicate that the vividness of both parental representations significantly predicted the vividness of therapist representations, but in opposite directions. The more vivid the “bad parent” representation, the more vivid the therapist representation (b = .748, p = .014), whereas the more vivid the “good parent” representation, the less vivid the therapist representation (b = -.792, p = .010).

Descriptive Data: Individual Items An examination of the mean scores on the items comprising the TES, PES-p, and PESu (see Table 5) indicates that patients typically use all three modalities (Imagistic, Enactive, and Conversational-Conceptual) to evoke representations of their therapists and their parents following recall of both a pleasant and unpleasant memory. As indicated in Table 5, the items with the highest mean scores on the TES were “I think of specific comments my therapist has made to me” (M = 5.05) and “My image of my therapist is not tied to a specific time or place (M = 4.30). The items with the highest mean scores on the PES-p were “I imagine [my parent] in a particular place” (M = 6.70) and “I picture a specific expression on [my parent’s] face” (M = 5.70). The items with the highest mean scores on the PES-u were “I imagine a particular quality to the sound of [my parent’s] voice” (M = 6.85), “I imagine [my parent] in a particular place” (M = 6.65), and “I picture a specific expression on [my parent’s] face” (M = 6.65). Discussion Returning to the first research question, which asked whether there are differences in form and/or vividness between “good parent”/“bad parent” representations and therapist representations, the findings sug-

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gest that indeed, there are such differences. One, patients tend to think of their parents significantly more in the form of images and “felt” sensations than they do their therapist, and two, patients’ representations of both the “good” and “bad parent” were significantly more vivid overall than therapist representations. Furthermore, with respect to the question of the relationships among the different forms of representation used for the different target figures, the results yielded a third finding that the more patients tend to represent their “bad parent” in the form of images or “felt” sensations, the more they tend to represent their therapist in the form of real or imagined dialogues. Finally, with respect to the question of whether there are differences in form between representations of the “good parent” and representations of the “bad parent,” it was found that patients tend to think of their “bad parent” significantly more in the form of images than they do their “good parent.”

The first finding—that therapists, as compared to parents, tend to be represented less in the form of images and “felt sensations,” but not less in the form of dialogues—seems to make intuitive sense, given that the primary activity of therapy is talking. Furthermore, Honig et al.’s (1997) reasoning—that patients, who have known their therapists for considerably less time than their parents, cannot develop as realistically complex, differentiated representations of their therapists—may also be applicable here: given that the therapist is a relatively new figure in the patient’s life, their representation in the patient’s mind is indeed likely to be less vivid in terms of images, felt sensations, and overall.

One way to understand the second finding—that the more vivid the “bad parent” representation, the more vivid the therapist representation, but the more vivid the “good parent” representation, the less vivid the therapist representation—is that the therapist representation is more isomorphic with the “bad parent” representa-

tion than the “good parent” representation. The more vividly the “bad parent” is experienced, the more the work of therapy is catalyzed. An intense negative representation of a parent translates to a more intense representation of the therapist (positive or negative, or a mixture), whereas an intense positive representation of a parent does not translate to an intense representation of the therapist; in fact, it appears to dilute it, or make it less intense. Perhaps having particularly intense images of the “bad parent” leads the patient to characteristically cope with new figures or situations by being vigilant (i.e., using all their sensory channels to obtain information). The more vivid the “badness” of the parent, then, the more vigilant the patient must be in order to cope with the expectation of more “badness” from other figures (e.g., the therapist). Their senses are operative in order to cope with expected “badness.” This phenomenon may simply not occur in the presence of vivid feelings of “goodness.”

The somewhat more subtle third finding— that the more patients tend to represent their “bad parent” in the form of images or “felt” sensations, the more they tend to represent their therapist in the form of real or imagined dialogues—seems to suggest that there is something about the (affectively-charged) images and (relatively unformulated) enactive modes that are translating to the therapeutic dialogue. Again, this supposition is fairly intuitive, given that the reason for going to therapy is to work out, through talking, the “bad” stuff from one’s relationship with one’s parent, not the “good” stuff. That a high degree of imagistically and experientiallyfelt “badness” corresponds with greater lexical involvement with the therapist may simply suggest that the patient really is using the lexical mode to work though theretofore unformulated “badness.”

However, such use of therapy may also be defensive in nature, or may not allow the patient to make full use of the therapist

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either as a transferential figure or as a facilitator of multi-modal experience (Horowitz, 1983). The question is: are the strongly-experienced images and felt sensations being too much translated into words in therapy? (i.e., is there “an avoidance of image associations to contents expressed in words,” or “an inattention to dim or fleeting image episodes” [p. 289], as Horowitz noted)? Is defensive intellectualization, in which ideas emerge without continuity with other ideas and feelings, taking place? If so, we as clinicians might want to be attentive to the ways in which vivid (affectively-charged) imagery or diffuse bodily sensations associated with the “bad parent” may be getting dissociated somehow, substituted with language in the therapeutic dialogue. If the therapist or the therapeutic situation is represented only or primarily in lexical terms (and not imagistically or as a “felt” part of the patient), we might worry that the therapist as a “healing figure” or “good object” is not being fully internalized (that is, the therapist is only being internalized in one particular form).

When we think of “working through” the patient’s problems “in the transference,” are we not assuming that the patient is fully reexperiencing the parent in the therapist? The findings of this study suggest that patients may not be experiencing their therapist as fully as they do either their “good” or their “bad parent”—they are only perhaps reexperiencing the therapist on one level, the lexical one. Their thoughts and feelings about their therapist may be more formulated and coherent (lexical), but the less formulated aspects (images, felt experiences) of the transference may not be taking hold in the therapy. If indeed one of our goals as clinicians is to help patients “work through” relational problems through the transference, we may need to think about helping patients access and navigate less formulated modes of thought (imagistic and enactive), evoking these modes in therapy such that the patient has access to them and can bring them to bear upon the therapist him- or herself.

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The final finding, that patients tend to think of their “bad parent” significantly more in the form of images than they do their “good parent,” may in fact be the most interesting aspect of this study. It is, in a sense, the ‘purest’ finding, in that a comparison is drawn between split representations of the same person. If the therapist understands how (especially negative) representations are being experienced by the patient, he or she might seek to make interventions commensurate with the representational properties that comprise them. For example, if we know that the “bad parent” is experienced most vividly in terms of the quality of his or her voice, we might ask the patient, “What did he or she sound like?” in order to evoke the representation and its attendant emotions most fully. Such data adds to our body of knowledge about the ways in which individuals represent significant others in the mind; they suggest that differently valenced representations may be encoded differently, which can enable the therapist to understand how to work differentially with them in therapy.

One limitation of the present study is the small sample size, which limits the generalizability of the findings. In addition, the splitting of parent representations into “good” and “bad,” but not splitting therapist representations in a likewise fashion, may present various conceptual problems. Still, given that the aim of this exploratory research was to begin to elucidate the relationship between therapist and parent representations, and to apply the TES to parent representations, the results suggest that further investigations in this area are not only warranted but potentially of great clinical utility. References Barchat, D. (1989). Vicissitudes of patients’ internalized representations of their psychotherapists and affective responses to temporary separations. Unpublished doctoral dissertation, Department of

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Clinical Psychology, Teachers College, Columbia University. Bender, D. S., Farber, B. A., & Geller, J. D. (1997). Patients’ representations of therapist, parents, and self in the early phase of psychotherapy. Journal of the American Academy of Psychoanalysis, 25, 571-586. Blatt, S. J., & Auerbach, J. S. (2001). Mental representation, severe psychopathology, and the therapeutic process. Journal of the American Psychoanalytic Association, 49, 113-159. Blatt, S. J., Wiseman, H., Prince-Gibson, E., & Gatt, C. (1991). Object representations and change in clinical functioning. Psychotherapy, 28, 273-283. Bowlby, J. (1988). A secure base: Parent-child attachment and healthy human development. New York: Basic Books. Bruner, J. S. (1964). The course of cognitive growth. American Psychologist, 19, 1-15. Diamond, D., Kaslow, N., Coonerty, S., & Blatt, S. J. (1990). Changes in separation individuation and intersubjectivity in long-term treatment. Psychoanalytic Psychology, 7, 363-397. Farber, B. A., Geller, J. D., & Rohde, A. (1995). Therapist and parent representations of clinic patients. Unpublished manuscript. Fowler, J. C., Hilsenroth, M. J., & Handler, L. (2000). Martin Mayman’s early memories technique: Bridging the gap between personality assessment and psychotherapy. Journal of Personality Assessment, 75, 18-32. Geller, J. D., Behrends, Hartley, D., Farber, B. A., & Rohde, A. (1992). Therapist Representation Inventory, revised version. Unpublished manuscript. Geller, J. D., Cooley, R. S., & Hartley, D. (1981-82). Images of the psychotherapist: A theoretical and methodological perspective. Imagination, Cognition, and Personality, 1, 123-146. Geller, J. D., & Farber, B. A. (1993). Factors influencing the process of internalization in psychotherapy. Psychotherapy Research, 3, 166-180.

Honig, M. S., Farber, B. A., & Geller, J. D. (1997). The relationship of patients’ pretreatment representations of mother to early treatment representations of their therapist. Journal of the American Academy of Psychoanalysis, 25, 357-372. Horowitz, M. J. (1983). Image formation and psychotherapy. New York: Jason Aronson. Horowitz, M. J. (1972). Modes of representation of thought. Journal of the American Psychoanalytic Association, 20, 793-819. Loewenstein, R. J. (2004). Dissociation of the “bad” parent, preservation of the “good” parent. Psychiatry, 67, 256-260. McWilliams, N. (2004). Psychoanalytic psychotherapy. New York: Guilford. Orlinsky, D. E., Geller, J. D., Tarragona, M., & Farber, B. (1993). Patients’ representations of psychotherapy: A new focus for psychodynamic research. Journal of Consulting and Clinical Psychology, 61, 596-610. Pillemer, D. B. (1998). Momentous events, vivid memories. Cambridge: Harvard University Press. Rosenzweig, D. L., Farber, B. A., & Geller, J. D. (1996). Clients’ representations of their therapists over the course of psychotherapy. Journal of Clinical Psychology, 52, 197-207. Smirnoff, A. (1986). The relationship among psychological androgyny, object representation, and modes of experiencing early memories in a sample of college men and women. Unpublished doctoral dissertation, Forest Institute of Professional Psychology, Des Plaines, Illinois. Singer, J. A., & Blagov, P. (2004). The integrative function of narrative processing: Autobiographical memory, self-defining memories and the life story of identity. In D. Beike, J. Lampinen, & D. Behrend (Eds.), The self and memory (pp. 117-138). New York: The Psychology Press. Singer, J. A., & Singer, J. L. (1994). Socialcognitive and narrative perspectives ontransference. In J. M. Masling and R.

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F. Bornstein (Eds.), Empirical perspectives on object relations theory. Empirical studies of psychoanalytic theories, Vol. 5 (pp. 157-193). Washington: DC: American Psychological Association. Stayner, D. A. (1994). The relationship between clinical functioning and changes in self and object representations in the treatment of severely impaired inpatients. Unpublished doctoral dissertation,

Department of Clinical Psychology, Teachers College, Columbia University. Westen, D. (1991). Social cognition and object relations. Psychological Bulletin, 109, 429-455. Wzontek, N., Geller, J. D., & Farber, B. A. (1995). Patients’ posttermination representations of their psychotherapists. Journal of the American Academy of Psychoanalysis, 23, 395-410.

Table 1 Reliability Coefficients of Scale Overall and Factor Scores; Averaged Factor Reliabilities TES PES-p PES-u Average Imagistic (F1) .54 .66 .68 .63 Enactive (F2) .10 .68 .64 .47 Conversational-Conceptual (F3) .42 .61 .44 .49 Overall .55 .65 .55 -

Table 2 Means and Standard Deviations of Factor and Overall Scores: Differences Between the TES, PES-p, and PES-u Factor and Overall Imagistic (F1) Enactive (F2) Conv-Conc (F3) Overall

M 19.10a 6.45a

16.90 38.35a

TES SD 7.9 3.5 6.7 11.8

Adj. M (3.82) (2.15) (4.23) (3.49)

PES-p M SD Adj. M 25.95b 9.1 (5.19) 14.15 6.6 (4.72) 16.45 7.7 (4.11) 51.05 14.5 (4.64)

M 28.90 13.55 18.70 54.30

PES-u SD 8.8 7.0 6.8 13.3

Adj. M (5.78) (4.52) (4.68) (4.94)

F 6.846* 13.236** .666 10.978**

Notes. The TES, PES-p, and PES-u scales were scored on a 9-point basis (1 = not at all typical; 9 = highly typical); adjusted means reflect average item means. N = 20 in all cases except PES-p Imagistic (F1) and PES-p Overall (N = 19). a Significantly different than PES-p and PES-u (p < .05). b Significantly different than PES-u (p < .05). * p < .01. ** p < .001.

Table 3 Multivariate Analysis of Variance TES Imagistic (F1)

β

TES Enactive (F2)

β

TES Conv-Conc (F3)

β

PES-p Imagistic (F1) -.208 -.071 -.658a PES-p Enactive (F2) -.046 -.197 -.029 PES-p Conv-Conc (F3) -.140 -.021 -.114 PES-u Imagistic (F1) -.050 .017 .648** PES-u Enactive (F2) .392 .304 .527* PES-u Conv-Conc (F3) .118 .045 .129 Note. Wilks’ Lambda (λ) for PES-u Imagistic (F1) = .372, p = .016; for PES-u Enactive (F2) = .451, p = .040; for PES-p Imagistic (F1) = .483, p = .055. a approaching significance * p < .05. ** p < .01. continued on page 45

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Table 4 Regression Analysis for Variables Predicting Vividness of Therapist Representations Vividness of Pleasant Parent Representation Vividness of Unpleasant Parent Representation Note. R2 = .37 (p = .02). * p = .01

Table 5 TES, PES-p, PES-u Item Endorsement Comparison

Item Factor 1: Imagistic Mode 1. I imagine my therapist (parent) in his/her office (a particular place) 2. I picture a specific expression on my therapist’s (parent’s) face 3. I see my therapist (parent) gesturing 5. I imagine my therapist (parent) dressed in a certain way 6. I imagine a particular quality to the sound of my therapist’s (parent’s) voice Factor 2: Enactive Mode 8. I experience myself in certain bodily sensations 10. I imagine myself in physical contact with my therapist (parent) 11. I am aware of a particular emotional atmosphere which gives me the sense that my therapist (parent) is “with me” Factor 3: Conversational-Conceptual Mode 4. I imagine just my therapist’s (parent’s) head and face 6. I imagine a particular quality to the sound of my therapist’s (parent’s) voice 7. I think of specific comments my therapist (parent) has made to me 9. My image of my therapist (parent) is not tied to a specific time or place a

Vividness of Therapist Representation

B -.648 .654

M

TES

4.25

SE B .223 .238

SD 3.09

M

PES-p SD

6.70 a

2.85

β

-.792* .748*

PES-u M SD 6.65 b

2.74

4.25 2.50 4.00

2.63 2.06 2.36

5.70 b 3.95 4.40

2.52 2.76 2.78

6.65 b 5.85 2.90

2.60 2.83 2.67

2.10

2.00

4.00

2.79

5.75

2.84

2.95

2.50

5.20

2.53

4.05

3.32

4.10

1.40

2.99

.99

5.20

4.95

2.93

3.05

6.85 a 3.75

2.43

3.04

3.45

2.50

3.85

2.81

3.60

3.08

5.05 a

2.39

4.05

2.76

4.95

2.78

4.10

4.30 b

2.99 3.18

5.20 3.35

Indicates highest-rated item on scale. b Indicates second-highest-rated item on scale.

2.93 2.78

6.85 a 3.30

2.43 2.77

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CONGRATULATIONS TO OUR AWARD WINNERS!

Distinguished Psychologist Award for Contributions to Psychology and Psychotherapy: The Distinguished Psychologist Award is based on significance of contributions to the practice, research, and/or training in psychotherapy. The 2007 award is made to Gary R VandenBos, Ph.D. and Carol D Goodheart, Ph.D.

American Psychological Foundation Division of Psychotherapy Early Career Award is awarded for the first time in 2007, to Michael J. Constantino, Ph.D.

Please join us in celebrating our award winners at the Division 29 Award and Recognition Hour, Friday, August 17th at 5:00 pm, San Francisco Marriott Hotel, Golden Gate Salons B1 and B2, to be followed immediately by the Division 29 Social Hour.

ATTENTION GRADUATE STUDENTS AND EARLY CAREER PROFESSIONALS You are invited to

“Lunch with the Masters: For New Professionals Interested in Psychotherapy” The APA Convention in San Francisco Saturday, August 18, 2007, 12:00 PM – 1:50 PM San Francisco Marriott Hotel, Nob Hill Rooms A and B

Come join Drs. Laura Brown, Jean Carter, Beverly Greene, Theodore Millon and others for lunch and conversation. No RSVP needed, but please feel free to contact Dr. Libby Nutt Williams ([email protected]) for additional information. Come find out more about Division 29 and invite others to come as well!

You do not need to be a member of Division 29 to attend, but we will have a special membership deal for graduate students and early career professionals who do want to join Division 29.

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THE DIVISION

The only APA division solely dedicated to advancing psychotherapy

Division 29 meets the unique needs of psychologists interested in psychotherapy. By joining the Division of Psychotherapy,you become part of a family of practitioners,scholars,and students who exchange ideas in order to advance psychotherapy. Division 29 is comprised of psychologists and students who are interested in psychotherapy. Although Division 29 is a division of the American Psychological Association (APA),APA membership is not required for membership in the Division.

JOIN DIVISION 29 AND GET THESE BENEFITS! FREE SUBSCRIPTIONS TO: Psychotherapy This quarterly journal features up-to-date articles on psychotherapy. Contributors include researchers, practitioners, and educators with diverse approaches. Psychotherapy Bulletin Quarterly newsletter contains the latest news about division activities, helpful articles on training, research, and practice. Available to members only.

DIVISION 29 INITIATIVES Profit from Division 29 initiatives such as the APA Psychotherapy Videotape Series, History of Psychotherapy book, and Psychotherapy Relationships that Work.

EARN CE CREDITS Journal Learning You can earn Continuing Education (CE) credit from the comfort of your home or office — at your own pace — when it’s convenient for you. Members earn CE credit by reading specific articles published in Psychotherapy and completing quizzes.

OPPORTUNITIES FOR LEADERSHIP Expand your influence and contributions. Join us in helping to shape the direction of our chosen field. There are many opportunities to serve on a wide range of Division committees and task forces.

DIVISION 29 PROGRAMS We offer exceptional programs at the APA convention featuring leaders in the field of psychotherapy. Learn from the experts in personal settings and earn CE credits at reduced rates.

NETWORKING & REFERRAL SOURCES Connect with other psychotherapists so that you may network, make or receive referrals, and hear the latest important information that affects the profession.

DIVISION 29 LISTSERV As a member, you have access to our Division listserv, where you can exchange information with other professionals. VISIT OUR WEBSITE www.divisionofpsychotherapy.org

MEMBERSHIP REQUIREMENTS: Doctorate in psychology • Payment of dues • Interest in advancing psychotherapy

Name _________________________________________________ Degree ______________________ Address _____________________________________________________________________________ City __________________________________________ State __________ ZIP ________________ Phone ____________________________________ FAX ____________________________________ Email _______________________________________________________ Member Type: 䡵 Regular 䡵 Fellow 䡵 Associate 䡵 Non-APA Psychologist Affiliate 䡵 Student ($29) 䡵 Check

䡵 Visa

If APA member, please provide membership #

䡵 MasterCard

Card # _______________________________________________ Exp Date _____/_____ Signature ___________________________________________ Please return the completed application along with payment of $40 by credit card or check to: Division 29 Central Office, 6557 E. Riverdale St., Mesa, AZ 85215 You can also join the Division online at: www.divisionofpsychotherapy.org

PUBLICATIONS BOARD

Raymond A. DiGiuseppe, Ph.D., 2003-2008 Psychology Department St John’s University 8000 Utopia Pkwy Jamaica , NY 11439 Ofc: 718-990-1955 [email protected]

John C. Norcross, Ph.D., 2002-2008 Department of Psychology University of Scranton Scranton, PA 18510-4596 Ofc: 570-941-7638 Fax: 570-941-7899 E-mail: [email protected]

Lillian Comas-Diaz, Ph.D., 2002-2007 Transcultural Mental Health Institute 908 New Hampshire Ave. N.W., #700 Washington, D.C. 20037 [email protected]

Nadine Kaslow, Ph.D., 2006-2011 Grady Hospital Emory Dept. of Psychiatry 80 Jesse Hill Jr. Dr. Atlanta, GA 30303 Ofc: 404-616-4757 Fax: 404-616-2898 Email: [email protected]

EDITORS

Psychotherapy Journal Editor Charles Gelso, Ph.D., 2005-2009 University of Maryland Dept of Psychology Biology-Psychology Building College Park, MD 20742-4411 Ofc: 301-405-5909 Fax: 301-314-9566 [email protected]

Psychotherapy Bulletin Editor Craig N. Shealy, Ph.D., 2007-2009 International Beliefs and Values Institute (IBAVI) James Madison University MSC 2802, 1241 Paul Street Harrisonburg, VA 22807 Phone: 540-568-6835 Fax: 540-568-4232 E-Mail: [email protected]

Psychotherapy Bulletin Associate Editor Harriet C. Cobb, Ed.D. Combined-Integrated Doctoral Program in Clinical/School Psychology MSC 7401 James Madison University Harrisonburg, VA 22807 Ofc: 540-568-6834 [email protected] Internet Editor Bryan S. K. Kim, Ph.D. 2005-2007 Department of Psychology University of Hawaii at Hilo 200 W. Kawili Street Hilo, Hawaii 96720-4091 Ofc: 808-974-7460 Fax: 808-974-7737 E-mail: [email protected]

George Stricker, Ph.D., 2003-2008 Argosy University/Washington DC 1550 Wilson Blvd., #610 Arlington, VA 22209 Ofc: 703-247-2199 Fax: 301-598-2436 E-mail: [email protected] Beverly Greene, Ph.D., 2007-2012 Psychology St John’s Univ 8000 Utopia Pkwy Jamaica , NY 11439 Ofc: 718-638-6451 E-mail: [email protected]

PSYCHOTHERAPY BULLETIN

Student Website Coordinator Nisha Nayak University of Houston Dept of Psychology (MS 5022) 126 Heyne Building Houston, TX 77204-5022 Ofc: 713-743-8600 or -8611 Fax: 713-743-8633 [email protected]

Psychotherapy Bulletin is the official newsletter of Division 29 (Psychotherapy) of the American Psychological Association. Published four times each year (spring, summer, fall, winter), Psychotherapy Bulletin is designed to: 1) inform the membership of Division 29 about relevant events, awards, and professional opportunities; 2) provide articles and commentary regarding the range of issues that are of interest to psychotherapy theorists, researchers, practitioners, and trainers; 3) establish a forum for students and new members to offer their contributions; and, 4) facilitate opportunities for dialogue and collaboration among the diverse members of our association.

Contributors are invited to send articles (up to 4,000 words), interviews, commentaries, letters to the editor, and announcements to Craig N. Shealy, Ph.D., Editor, Psychotherapy Bulletin. Please note that Psychotherapy Bulletin does not publish book reviews (these are published in Psychotherapy, the official journal of Division 29). All submissions for Psychotherapy Bulletin should be sent electronically to [email protected] with the subject header line Psychotherapy Bulletin; please ensure that articles conform to APA style. Deadlines for submission are as follows: February 1 (spring), May 1 (summer), July 1 (fall), November 1 (winter). Past issues of Psychotherapy Bulletin may be viewed at our website: www.divisionofpsychotherapy.org. Other inquiries regarding Psychotherapy Bulletin (e.g., advertising) or Division 29 should be directed to Tracey Martin at the Division 29 Central Office ([email protected] or 602-363-9211). DIVISION OF PSYCHOTHERAPY (29)

Central Office, 6557 E. Riverdale Street, Mesa, AZ 85215 Ofc: (602) 363-9211 • Fax: (480) 854-8966 • E-mail: [email protected] www.divisionofpsychotherapy.org

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