Y Model Psychotherapy Training: A Qualitative Investigation of Students’ Experiences
Publication: American Journal of Psychotherapy
Abstract
This article reports on a research project investigating psychology graduate students’ experiences of Y model psychotherapy training at an Australian university. Focus group interviews were conducted with clinical psychology students (N=20), and thematic analysis was used to capture core aspects of their training experience. Participants felt that the dual training in cognitive-behavioral therapy and psychodynamic therapy gave them a significant advantage over students trained in only a single approach. Notwithstanding the perceived benefits of their training, participants emphasized how intellectually and emotionally demanding it was. Students struggled to shift between therapeutic orientations, both in learning about and conducting different therapies and in accommodating differing supervisory expectations. Psychodynamic therapy was viewed as the most conceptually, technically, and personally challenging component to learn, but also as the most enriching. Despite the emphasis the students placed on the psychodynamic arm of the Y model training, participants reported a variety of therapeutic identity positions, and most maintained a flexible view of how they would practice therapeutically.
Trainee clinical psychologists are required to acquire multiple competencies, perhaps the most challenging being the successful learning and implementation of psychotherapeutic interventions with actual clients. What therapeutic approaches or orientations to focus on, and how to optimally teach and develop these competencies in the limited time available, are important issues confronting every training institution.
Historically, we have seen a shift from single-orientation psychotherapy identification and practice among psychologists to an emphasis on eclectic, integrative, and multiple orientation stances (1, 2). This shift reflects both the impact of Western philosophical pluralism, the belief that there is “no single truth or definitive answer to a question” (3), and the ongoing reverberations of the equivalence paradox in psychotherapy research. The latter refers to the consistent finding that different therapeutic approaches, despite divergent theoretical assumptions and intervention techniques, produce approximately equivalent positive treatment outcomes (4). At the same time, exposure to the Internet and popular media has made clients more informed than ever about psychotherapy, requiring the need for collaborative decision making regarding clients’ treatment options and preferences (5).
These trends suggest the need to equip trainee psychologists with skills in more than one therapeutic approach to accommodate clients’ diverse treatment needs and predilections. Safran and Messer (6) used the metaphor of therapeutic multilingualism in recognition of the need for fluency in a few psychotherapy languages. Notwithstanding its intuitive appeal, this issue raises questions about which therapeutic languages should be taught and which training models are most suitable for teaching trainees to fluently engage clients in more than one tongue.
While eclectic and integrative models represent one approach to therapeutic multilingualism, some psychotherapy educators believe that deep knowledge of individual orientations is necessary before a practitioner can effectively combine them (7, 8). Consequently, from this perspective, eclectic or integrative training may not be best at addressing the challenge of equipping trainee psychologists with basic therapeutic skills.
An alternative approach is to train students in two or more therapeutic orientations, acknowledging any commonalties while emphasizing their differences and discouraging premature integration.
This was the approach we chose when deciding to restructure the long-standing single-orientation training in the postgraduate clinical psychology training program at our university. The program we targeted for revision was anomalous in Australia in that it was exclusively psychodynamic, whereas the dominant therapeutic orientation, in both the Australian public mental health system and psychology training institutions, is cognitive-behavioral therapy (CBT). We wanted to retain the psychodynamic strength of our program while giving equal weight to CBT, thereby producing therapeutically bilingual clinical psychologists.
In addition to the usual training in psychopathology, assessment, ethics, research, and counseling skills that students receive in their two-year, full-time clinical psychology program, we built in four 12-week psychotherapy units. In the first year, after being equipped with generic counseling theory and skills, students complete a basic CBT unit, followed by a basic psychodynamic therapy (PDT) unit. This sequencing was based on feedback that students found it easier to learn the more structured CBT and that basic therapeutic competence and confidence were necessary before commencing the more technically challenging psychodynamic training. In the first year, students also commence supervised CBT treatment of clients in the university’s psychology clinic. In the second year, students complete more advanced CBT and PDT training, while conducting supervised PDT in the psychology clinic.
After the introduction of this training model, we received anecdotal feedback from students about difficulties they were experiencing in learning and practicing two therapeutic orientations. We consequently decided to revisit our training model and research the best pedagogic approach to this dual-orientation training. Despite the current emphasis on therapeutic multilingualism, we were struck by the paucity of research literature and training guidelines on dual- or multi-orientation therapeutic training. The most clearly articulated and systematic approach to multi-orientation training we could find was the North American Y model, described below (9–11). We discovered that our dual-training model closely paralleled the Y model but thought that we could improve our training by systematically instructing our students in Y model theory and using the model to refine our teaching of the requisite competencies.
Because we had become particularly interested in the adaptive challenges that students reported in response to the demands of dual-orientation training, we decided to formally investigate the student experience of Y model training. This research is the focus of our article. After introducing the Y model, we discuss the research design, findings, and implications for psychotherapy training.
The Y Model
The Y model of psychotherapy training was born out of an American Psychiatric Association commission aimed at renewing interest in psychotherapy among North American psychiatrists in the mid-1990s (9–11). The minimal psychotherapy training psychiatrists received at the time prompted intensified efforts to equip trainees in U.S. residency programs with competences in five psychotherapeutic approaches. This overly ambitious goal evolved into a methodical approach to teaching residents the competencies required to practice three types of psychotherapy: supportive, cognitive-behavioral, and psychodynamic. This training model, based on the common factors and psychotherapy process research literature, was termed the Y model because of its tripartite structure. The single stem of the Y represents those therapeutic aspects and interventions common to all psychotherapies, supporting the treatment alliance and establishing the necessary conditions for a therapeutic process to occur. The arms of the Y represent the diverging CBT and PDT approaches, differing significantly in both their theoretical assumptions and technical interventions.
The Y model is unique in that it encompasses the common features approach without subscribing to either technical eclecticism or integrationism. The independent features of the two therapies comprise the two branches along which training independently occurs, requiring students to be multilingual but not integrative in their work. It is the most coherent published training model we could find in which dual approaches are compared, contrasted, and advanced in pursuit of general therapeutic competence (12).
Methods
The Researchers
The two researchers were the clinical psychology program coordinator (G.I.) and the psychology clinic director (C.D.) at Victoria University, Melbourne, Australia. The first author has a PDT orientation and is responsible for the psychodynamic component of the training. The second author has a CBT orientation and teaches a large part of the CBT component of the training.
Research Design and Aims
After approval by the university’s Human Research Ethics Committee, focus group interviews were conducted in 2015-2016 to explore the student experience of Y model training at our institution. To obtain an adequate sample of student experience, two focus group interviews were conducted two years apart with two successive student cohorts. All participants had completed training in both CBT and PDT (48 hours of instruction in each), and all had worked with at least two clients in each therapeutic orientation. Students in each cohort were informed by email about the research and invited to participate in a focus group discussion. The focus groups were timed to coincide with the end of the coursework component of the students’ training. The following four research questions were asked of the focus group participants:
1.
Please describe your personal experience of the Y model approach to clinical psychology training.
2.
Based on your experience, what do you think are the strengths and weaknesses of Y model training?
3.
How well equipped do you feel to use CBT and PDT in your psychotherapeutic work?
4.
How has Y model training influenced your emerging sense of professional identity and therapeutic preference?
To avoid conflict of interest and to permit students to express their opinions freely, without fear of course progress repercussions, we used an external facilitator to run the focus groups. The facilitator was an experienced clinical psychologist and independent researcher, trained in the delivery of both CBT and PDT. The facilitator was briefed by the authors on the research aims and background of the project, as well as the ethical requirement to preserve participant anonymity. To further ensure participant anonymity, the authors were not informed which students attended the focus group interviews.
Focus group discussions were audiotaped. A professional transcriber was employed to transcribe the data, with instructions to remove any references to participants’ names or gender in the transcription and to erase the audio recordings once the transcription process was complete. These measures ensured that none of the participants could be identified by researchers.
Participants
Twelve students participated in the first group and eight participated in the second. Because of the ethical requirement of participant anonymity, we do not know the gender or racial-ethnic characteristics of our participant sample.
Data Analysis
Data analysis commenced with the repeated reading of the transcribed focus group interview transcripts to get a sense of their content, structure, and the nature of the participant interaction. It has been argued that the interactive patterns in focus group data should be documented and reported in the analysis (13, 14). However, using the principle of methodological congruency, and given our primary interest in the thematic content of the discussions, we decided that these interaction dynamics were not essential to our study (13).
The analysis proper involved hand-coded thematic analysis conducted by the first author (G.I.) (15, 16). After we became familiar with the interview data, we highlighted and extracted words, phrases, and sentences that appeared salient to the research questions and grouped them in a separate document. In the second stage of data analysis, we used data-led initial coding, and the codes were worded to remain close to the participants’ experience or intended meaning. In the third stage, we grouped the codes to form thematic categories reflecting discernible data patterned around themes relevant to the research topic. In the fourth stage, we reviewed and revised the themes and generated subthemes. The first author (G.I.) then presented the second author (C.D.) with the draft coding, which was corrected and refined in the subsequent discussion between the two researchers. At this point we returned to the transcribed interviews to check that our analysis had adequately accommodated the range of focus group opinion and that it accurately reflected various participant voices. In the final stage, verbatim quotes illustrating themes were identified and incorporated into the thematic descriptions.
To increase the research credibility and trustworthiness of the study, we engaged the assistance of an experienced qualitative researcher who had no stake in the project (17, 18). This was considered necessary because of our dual roles as instructors and researchers and our vested interest in the success of the Y model training. We provided our colleague with the transcribed focus group interviews and our coding structure and requested that she audit our coding and check for questionable interpretations, omissions, and overemphases. We then met with our research auditor to discuss her impressions before we amended our analysis in response to her feedback.
Results
Our analysis generated seven themes, six of which contained two or more subthemes (Table 1). The theme frequencies in the table indicate how many participants expressed or agreed with sentiments expressed by other participants; the final column shows the number of participants associated with relevant subthemes. Reading through the focus group transcripts, we were struck by two features of the discussion. The first was the participants’ spontaneous focus on the psychodynamic component of their training. In both groups, the facilitator felt it necessary to redirect participants to speak about the foundational supportive counseling and CBT components, because these were relatively ignored. The second striking finding was how much time participants devoted to talking about how difficult they found the training. Below, we outline the significant themes and subthemes, illustrating with relevant participant quotes.
| Theme and subtheme | Theme frequency | Subtheme frequency |
|---|---|---|
| The hardest thing | 18 | |
| Workload pressure | 18 | |
| Switching hats is difficult | 11 | |
| Adapting to different supervisory styles | 9 | |
| Jack of two trades, master of none | 3 | |
| The training is not long enough | 8 | |
| Challenges of psychodynamic therapy | 15 | |
| Inaccurate student expectations | 6 | |
| I found the language hard | 6 | |
| Not knowing how to be in the chair | 5 | |
| The burden of having an unconscious | 7 | |
| Negotiating client expectations | 6 | |
| Positives outweigh the negatives | 17 | |
| It gives us the edge | 11 | |
| A deeper and broader perspective | 12 | |
| The ability to work with transference and countertransference | 10 | |
| Imagining self as client | 8 | |
| Preference for psychodynamic therapy if trainees were clients | 8 | |
| Y model teaching and supervision | 12 | |
| Therapeutic silos and training institute dynamics | 10 | |
| Inconsistent teaching quality | 8 | |
| Therapeutic preference and evolving identity | 17 | |
| Psychodynamic | 7 | |
| Psychodynamically informed | 4 | |
| No strong preference for either | 6 | |
| Incompetent vs. journeying toward competence | 8 | |
| Incompetent in both approaches | 3 | |
| Evolving toward competence | 5 |
“The Hardest Thing I’ve Ever Done”
Many participants used adjectives such as “hard,” “difficult,” “demanding,” “stressful,” “overwhelming,” and “challenging” to describe the training. They stressed that, although postgraduate clinical training is inherently challenging, their course was more so because of the dual-orientation training. One participant described it as “the hardest thing I’ve ever done, the most personally challenging kind of journey.”
The first challenge concerned the sheer workload pressure. Many other Australian courses emphasize a single therapeutic orientation (CBT) and only briefly expose trainees to other approaches. Our students, in contrast, are required to be theoretically and technically proficient in two. This required more psychotherapy training and clinic placement hours than are required for comparable training at other institutions. Related to this was some participants’ perception that two years of full-time training was not long enough to develop proper therapeutic competence in both approaches.
The second challenge concerned the struggle the students experienced in shifting between the CBT and PDT styles of thinking and working. One participant referred to this as “switching hats,” which other participants picked up on and echoed in the discussion: “If I worked from a CBT [orientation] for a period of eighteen months I could really advance my skills, but we are constantly asked to switch these hats, and I just find it so difficult sometimes.” Another participant noted, “In the morning I have my psychodynamic hat on, and I need to rush to my placement and have my CBT therapy hat on, and then the next day back to CBT. So I’m feeling a little bit like sometimes it can be all over the place.”
A subtheme associated with “switching hats” involved the experience of shifting between clinical supervision styles. Participants commented on difficulties adjusting to different supervisory styles associated with the CBT and PDT orientations:
I think initially it was difficult for me to go from a CBT to a psychodynamic supervisor. I had a tricky time going from a structured supervision where you were getting lots of feedback; I mean you do get feedback in psychodynamic supervision too, but it was, maybe I felt less supported initially in the psychodynamic supervision. I was just learning this therapy myself and what it means, and here I go into a room with somebody reacting very differently from what I was used to. And that threw me a bit.
Another participant observed:
You go from supervision speaking about each client, “What have you done with this one? What are you going to do next time?” With psychodynamic, “What are you feeling?” “What did you see?” It's all about emotion, whereas CBT was all about steps—“Have you done this, have you done that?” . . . so much more structured. For me it was more difficult to fit in with the CBT. I had to get used to the supervisor, who was very different from the previous supervisor.
Participants also responded to psychodynamic supervision’s emphasis on the therapist as a person and how the therapist’s psychology influences the therapeutic interaction. This was beautifully captured in one participant’s slip-of-the-tongue, “So yes, the change to a psychoanalytic therapist, um, supervisor, meant that I was free to, just be more free. It's been a relief.”
There were, however, two factors at play in this discussion of supervisory differences. One student, commenting on her negative experience of CBT supervision, observed, “In CBT there were certain emotions, feelings that weren't allowed in supervision, which was a fairly dire scenario. And that's not specifically due to the orientation, more the person of the supervisor.” Another student, speaking of her own negative experience with the same supervisor, expressed her belief that the supervisor’s CBT orientation negatively affected his ability to perceive interactional dynamics at play in both the therapeutic and supervision dyads:
I had a difficult relationship with my CBT supervisor, which followed a parallel process to the relationship I was having with one of my clients. I think there was projective identification going on, and that I was getting a lot of it and passing it on to my supervisor. Being CBT, [the supervisor] didn't understand that and was quite punitive with me, not trying to understand where my emotions might be coming from. They made me feel bad for having emotions: “You obviously can't handle what you're working with.” What was happening was I had a difficult patient who couldn't handle . . . stuff and was simply passing it onto to me and I was passing it up the line. And the supervisor didn't understand that and wasn't able to sit with that.
A fourth source of difficulty was captured in the words of one participant, “I feel like I am a Jack of two trades and a master of none.” Despite considerable and equal time devoted to training students in both approaches, and despite their supervised experience using both approaches with clinic clients, we found three participants who felt that, rather than becoming proficient in both, they were neither proficient nor confident in either:
And so, while there were all these benefits, I actually feel quite incompetent. I know a little bit about a lot, but I don't feel comfortable and competent in either modality. I've just scratched the surface of psychodynamic therapy, and we haven't had enough depth in CBT training to feel confident.
The Challenges of PDT
While students commented on the inherent burden of developing proficiency in two therapeutic approaches, PDT was frequently singled out as being the most conceptually, technically, and personally challenging approach to learn. Despite the program’s branding as a dual-orientation training, and even though this dualism is made clear in the selection process, few applicants applied because of the dual orientation and even fewer understood what the psychodynamic approach was. The first challenge of psychodynamic training was thus ignorance of what it involved:
I was just applying everywhere, because it is so competitive, and this is just one of ten places I applied. The psychodynamic stuff actually scared me at first because it was just so foreign to me, but at the same time there was something a little bit more appealing about this because it was a little bit different [from] everything else. So that’s how I ended up here. I wasn’t looking for the psychodynamic stuff, but it was a pleasant surprise.
Other participants thought they knew what the psychodynamic approach was, only to discover that their assumptions had been incorrect:
I don’t think I had realized it was so much about working in the transference. I thought it was more about your early life experiences sort of affecting your later life, and then there was the parenting aspect of it . . . where I was really interested. So, I wasn’t ready for that, the transference and countertransference, in as much as that is where the therapy takes place.
One participant even observed, “I might have been in denial to some extent, but when I applied, I didn’t even acknowledge the psychodynamic side of the course.”
The second challenge of psychodynamic training was coded, “I found the change in language hard.” In Australia, where there is considerable academic and professional antagonism toward psychoanalysis, few students are exposed to psychodynamic concepts at the undergraduate level. Consequently, when they encounter PDT, they feel like they are hearing a foreign language:
I found the change in the language quite hard. Before starting this course, I wasn't familiar with psychodynamic literature, so when I first started the psychodynamic supervision, I wasn't quite sure about what was being said. I wasn't quite following and I had to madly scramble to read books and background stuff to kind of understand the theories being talked about in supervision.
This experience was echoed by other participants: “When we were learning the psychodynamic material, especially when we first started learning it, my head was just spinning in those classes, just trying to change the way I was thinking. It was challenging, challenging.”
It was taxing enough for students to learn psychodynamic discourse and apply the relatively sophisticated conceptual framework to understand their clients. However, PDT posed a third and more practical difficulty, namely how to embody a psychodynamic presence and to be with clients in a way that reflects the analytic attitude. Students could appreciate that the analytic attitude differed significantly from the coaching or mentoring stance of CBT but struggled to grasp how to comport themselves as psychodynamic therapists and how to address their clients:
My struggle wasn’t understanding transference and all that stuff, it was more what does it look like, how am I supposed to be in the chair? You don’t get that from a book as much as you would pick that up visually, you know. So, they were often the questions I had with my supervisor, wondering how I am supposed to be that way, to engage with the client.
Part of the difficulty with students learning the psychodynamic approach was the sharp contrast it represented to the more active and directive CBT stance with which they had become familiar:
It is allowing yourself to be comfortable with silences and a bit more passive, so it is quite a contradiction from what we learn from the CBT point of view. It is the practical stuff, about knowing what you should say, what is appropriate; you kind of feel that you need to behave in a certain way, or say certain things that are very foreign, you know. It is confronting!
The fourth and most personally challenging aspect of psychodynamic training was coded, “The burden of having an unconscious.” Participants struggled not only with psychodynamic discourse and how to embody the analytic attitude, but also with the implications of the psychoanalytic worldview for how they experienced and perceived themselves. Unlike CBT, which has a metapsychology more congenial to students’ conscious self-perceptions, the psychoanalytic worldview confronts trainees with the “other” within, deconstructing their taken-for-granted assumptions about themselves and the nature of their significant relationships. One participant referred to this as the “burden of knowing that there is an unconscious,” while another noted it involved a “real stirring up of your worldview, like your whole world was tilted on its axis.” The introspective application of psychodynamic thinking to their own psychology left students feeling that they were in “an emotional pressure cooker”:
I think it's been demanding, especially the psychodynamic theory and therapy. And the added burden of knowing that there is an unconscious, which means everyone in the class has got one. And it’s sometimes a pressure cooker in here, especially in the clinic when you're being exposed on video. That's pretty challenging; it's unrelenting.
Another participant responded:
You start looking at your own family and your own history and questioning all these things. A lot of us started our own therapy as well. And we were dealing with this whole thing shaking up our lives in terms of who we think we are, which you don't get in CBT as much.
The fifth problem PDT posed to students was having to practice it in an environment where client expectations of psychotherapy have been powerfully influenced by CBT, the dominant therapeutic orientation in Australia. Consequently, rather than being open to the relatively unstructured, emotionally expressive, and insight-oriented emphasis of PDT, many clients would greet trainees with preconceived therapeutic goals involving practical strategies to address their difficulties. The mismatch between what clients requested and what trainees offered in their psychodynamic therapist role had an unsettling effect on trainees and made them unsure about how to deal with client expectations:
P1: The patients come in wanting strategies [because] CBT has changed the mental health vocabulary. People say, “I've got anxiety, I want strategies,” and that was a big transition for us coming from a CBT placement where we could help them with strategies and behavioral management plans to then go, “Well, you know . . . um . . . this isn't about strategies.” So that was difficult.
P2: Yeah . . . I'm much more okay with that now, but in the beginning, it made me feel a little bit incompetent. “Oh, they want strategies, they're not going to want to come back, this isn't going to work.” And you feel you can't offer them as much.
The Positives Outweigh the Negatives
While much of the focus group content was devoted to students’ accounts of how onerous the Y model training was, students were simultaneously appreciative and grateful for the benefits they perceived it to have. As one participant phrased it, “The positives outweigh the negatives.” Interestingly, while they struggled most with learning and implementing PDT, it was the PDT that students focused on in terms of how enriching their experience of Y model training was. Participants drew on their external placement (internship) experience when describing how their Y model training favorably positioned them relative to other students who did not have similar training:
I think it gives us an edge; I really do, and I can see it when I work with other students from different universities on placement. My supervisors comment on it in a positive way, like how you are picking up on things that often go unnoticed and things like that.
After protesting about the workload, another participant observed:
On the flip side, I agree the positives outweigh the negatives. It was apparent to me that the psychodynamic training really helped me at that placement, even though they weren’t particularly psychodynamic. It gave me a different perspective on clients that other students didn’t really pick up on, those who’d just [learned] mainly CBT. So I feel like, even though the workload is massive, I still think it has helped me out in the real world.
A second subtheme arose from the participants’ focus on how Y model training aided them in thinking more broadly and deeply about their clients. The breadth metaphor denotes the capacity to think about clients from multiple perspectives, while the depth metaphor refers to the ability to grasp the latent meaning in client symptoms and communication: “Where it's really helped me is with formulating and conceptualizing. It's allowed me to process and think about clients in a deeper way.” Another averred, “I don’t understand how people could just work in a pure CBT way. I think it [PDT] just really adds to what you do, and even when I’m on a CBT placement I can see how my formulating is taking into account psychodynamic factors.”
A third subtheme was “Learning how to work with transference and countertransference.” PDT stresses the importance of the relationship between client and therapist, how the client’s difficulties find unconscious expression in how they relate to the therapist (transference), and how the therapist’s emotional responsiveness to the client (countertransference) may be used to understand something of the client’s internal world and interpersonal style. Learning how to understand, manage, and work with the transference-countertransference relationship was what participants most appreciated about the PDT course component:
I feel that I’m forming stronger therapeutic relationships with my clients than with CBT. I guess it makes me a bit more aware of what is going on in the room, like being more conscious of feelings and the transference and countertransference. That I never really had with CBT, although I would probably pay more attention to that now doing CBT than I did originally. It just seems sort of richer on some levels.
The following segment of focus group dialogue illustrates how participants felt their understanding of transference-countertransference dynamics benefited them:
P1: I'm a lot more confident than people who haven't had exposure to psychodynamic work and supervision, much more equipped to sit with a patient and not feel like I have to do anything, to jump in so quickly. That's the psychodynamic training, to be able to sit with conflict and know that it's not necessarily about you.
P2: I feel like when I'm on placement, other students who aren't from here don't pick up on the transference. They don't know the stuff about their clients that we think about. Often, they'll leave the room and say, “I'm so annoyed at my client.” Well, why are you so annoyed at your client? Maybe you're in a bad mood, but maybe something else was going on; but they don't think about that.
P3: I had a similar discussion on placement last week. They were being very punitive toward a patient in group supervision, saying, “They're not trying, they're being prickly, they're being this, they're being that.” And I thought, “This is just projection, it's a communication, what do you think we can learn from this?” Even just saying that, even being able to think in that kind of a way is really valuable.
Imagining Self as Client
In one focus group, participants spontaneously began a discussion about the type of therapy they would want if they were in their clients’ position. Interestingly, all the participants said they would prefer PDT to CBT. The reasons proffered concerned the perception that PDT was “deeper” and more “personalized” and that it is better suited for self-exploration. The following dialogue captures students’ perspectives on this theme:
P1: I am not sure where I sit in terms of being a therapist, but I know if I was a client, I would be choosing psychodynamic rather than CBT.
P2: Yes, I think it [PDT] is my choice, if I’ve got the time to and I am not in a crisis situation, it is something that I want to do, I want to explore.
P3: I feel for me that psychodynamic is more for a different type of person who is looking for a deeper exploration. And I would go to psychodynamic work myself because I think it is fascinating, if I had the time and the money and everything else in my life was going relatively smoothly.
Perceptions of Y Model Teaching and Supervision
While much focus group discussion was devoted to their experience of learning about psychotherapy, participants often commented, both positively and critically, on how they felt psychotherapy was taught to them. The first difficulty was coded as “Therapeutic silos and training institute dynamics.” One student spoke about the problem of bridging the two orientations, referring to them as “silos.” In other words, the deliberate absence of theoretical and technical integration, a hallmark of the Y model, was viewed critically: “In terms of integration, that hasn't happened. It's like there are these two silos, the psychodynamic silo and the CBT silo. How do people in the real world bring those two things together and, like, integrate their knowledge?”
It was apparent that for some students the wish to integrate therapeutic approaches was strong, but they also struggled with lecturers’ differing views as to how the two approaches are related. Some lecturers emphasized the differences between the two therapies, while others emphasized the commonalties: “When I talk to D, she talks about CBT and psychodynamic as being closer together, like when you look at past experiences and fit that all in, but if you talk to J about it being closer together, his interpretation is that they are miles apart.”
Students perceived that it was not merely the emphasis on differences that created the silo impression, but also professional rivalry, antagonism, and mutual undermining between instructors and supervisors from the two orientations:
I constantly also struggle with what I perceive as staff tension about this dual training, and I don’t think I am imagining that. The CBT people here can’t understand why we are so entranced by psychodynamic work and just want us to stop and follow the evidence base and don’t mix in psychoanalytical work. And the psychodynamic people want the same from their point of view, so there is that constant tension for us to be one or the other. It is a battle; it’s confusing because it is like they are trying to sell you one side or the other.
One participant referred to the relationship between CBT and PDT staff members as an “unhealthy marriage” but was more accepting than the previous participant of this professional dynamic:
I think it is a taste of what it’s like in the real world; it is like an unhealthy marriage but in the workforce. Psychodynamic is viewed in a very skeptical way, so if we’re going to work this way, we will cop a bit, a taste of what we’ll encounter. I had an external supervisor who was strict CBT and that is where I found conflict, because I would go to her and she would cut me down: “Don’t talk your psychodynamic talk.”
The impact of this supervisor rivalry on trainees should not be underestimated, given its propensity to generate conflicting loyalties and allegiances which, in turn, may add to the emotional strain of Y model learning. As a reviewer suggested, trainees may feel “forced to choose between disputing parents.”
A second subtheme concerned participants’ perception of a discrepancy in the quality of teaching of the respective therapeutic orientations. This discrepancy had an impact on students’ experiences of feeling more proficient in one therapeutic approach than the other. The lecturer singled out as superior impressed participants by developing his own teaching materials based on his psychotherapy case work and because of his emphasis on guided discussion and applied skill development, rather than didactic instruction. While this perceived discrepancy in how the therapeutic approaches were presented is partly attributable to instructor teaching style, it is also true that there was little discussion or collaboration between these instructors regarding the teaching of their respective therapies.
Therapeutic Preference and Evolving Therapeutic Identity
Given the equal emphasis in Y model training on CBT and PDT, we were interested in exploring students’ evolving therapeutic identities and their preferred therapeutic orientation. Three students reported a “philosophical” predisposition to a psychodynamic orientation, which was consolidated during their training: “My sort of philosophy has quite a psychodynamic slant to it, I guess, but I didn’t really realize how much until I was studying it.” Others gravitated to a specific orientation based not on philosophical considerations but on their own perceived strengths: “Psychodynamic [therapy] suits my personal strengths as a therapist, whereas CBT doesn't. And I feel I've been able to learn that really well in this course.”
Four participants started out preferring CBT but, at some point in their training, made a shift to PDT:
I really liked CBT at the time, but it was only when a lot of us started having conversations about CBT just not being enough, when we were thinking about things, you know the kind of patient group we had coming through. For some people CBT just wouldn't be enough.
Some discussion between participants focused on the fact that, while they were drawn to PDT, they appreciated that it was not really feasible to only work as a psychodynamic therapist in the Australian environment: “I suppose I think of the practical aspects of it. You know, with the Medicare and cost of therapy and all of those things, it does restrict how we could work as a pure psychodynamic therapist in a job setting”; “But we would be at a massive disadvantage if we didn't learn any CBT, and it was all psychodynamic”; and “Yes, because CBT has so many applications and we are going to be much more able to work in lots of different settings.”
While none of the participants expressed a CBT practitioner identity, six indicated that they felt comfortable with both orientations and did not feel the need to choose between them at this stage of their professional development. Some participants said that practical considerations would dictate which therapeutic approach they would adopt: “Depending on where I get a job, I feel like I could be swayed either way in terms of which way I would work. If I was offered a job in a psychodynamic clinic I would happily do it. I would be happy working that way I think. So, I am still probably either/or.”
One participant said that her professional developmental maturity at this stage of her life made her inclined to seek out CBT work before returning to psychodynamic exploration later in her career:
After this I’ll look for CBT-based work, but I do think psychodynamics is something that I will revisit later in life. I don’t think I have the experience and perhaps even the maturity to be doing it at this point in my life. I want some richer CBT experiences before I move on to that.
Five participants referred to themselves as “psychodynamically informed”; in other words, rather than identifying with the psychodynamic orientation, they conceptualize their clients and the therapeutic relationship psychodynamically, without necessarily using psychodynamic interventions:
I wasn’t expecting to be a psychodynamic psychotherapist; that takes another four years, but to have a bit of a taste of it, I think that is really helpful. I can’t definitely say that I am going on to become a psychodynamic therapist, but whichever modality I do find myself fitting into, I think I will be psychodynamically informed.
Another participant who adopted the “psychodynamically informed” designation indicated a preference for CBT based on pragmatic factors such as the Australian publicly funded universal health care scheme (Medicare), which favors CBT, and the belief that CBT is better suited to assisting clients in crisis:
I think I will always be psychodynamically informed. I’ve been fascinated by it; it makes a lot of sense to me. But in today’s society where there is so much crisis and so many people going through such problematic stuff, I think CBT really does give them the strategies to get them out of that immediate crisis.
“Drowning” and “Incompetent” versus “Journeying Toward Competence”
Despite all the training, three participants still felt incompetent in both CBT and PDT contexts, and one spoke of feeling like he or she was “drowning.” This comment initiated a conversation about students’ expectations of their learning trajectories and the implications of these trajectories on their relative competence. These participants expressed the feeling that the dual-orientation training had failed them because it had not made them feel confident to leave the university and practice independently:
You should be able to walk straight into a job and feel confident and competent, but I am not feeling that at all. Because here, sometimes I think that the more you know, the more you realize you don’t know, and it gets really overwhelming with thinking, “I am never going to know all this stuff.”
Most participants disagreed with the assumption underlying this opinion: that being a provisional psychologist near the end of one’s training should mean knowing all that is required to practice professionally. The following quote indicates a different learning attitude, one that emphasizes professional learning as a slow, gradual journey toward competence: “But as a psychologist you evolve, and you continue to evolve, and I think that is part of how you should see it and continue to learn. And so the journey continues.”
Discussion
These results confirm how difficult it is to train psychologists to be therapeutically multilingual but also show that there is much to be gained by adopting the Y model approach. In their clinical placement settings, students compared their skills with those of students from other training institutions and concluded that the Y model training gave them significant advantages over other students at their level of training. These advantages included being able to conceptualize cases from differing perspectives, detect and understand client latent communication, manage and work with transference feelings, and tolerate and therapeutically process countertransference responses to client interaction. The detailed positive examples that participants provided, together with evidence of a balanced and nuanced appreciation of their training, suggest a trustworthy self-assessment and a persuasive recommendation for this type of training.
Notwithstanding the impressive benefits of the Y model training, what is also clear from the findings is that students experienced learning it to be onerous. It certainly makes more intellectual, emotional, and practical demands on trainees than programs that do not require therapeutic fluency in multiple approaches. This supports Rizq’s (19) claim that pluralistic training “produces considerable emotional strain in the trainee.” Above all, it cannot be underestimated how students struggle with the shift from one therapeutic arm of the Y to the other, which participants described as “switching hats.” These difficulties did not simply involve shifting conceptual frameworks and therapeutic stances with clients but extended to having to adapt to different clinical supervision styles and expectations, diagnostic assessments, and even report writing conventions.
While most of the participants believed themselves capable of shifting between CBT and PDT, despite the strain involved, a minority agreed with one participant’s negative self-appraisal: “I actually feel quite incompetent. I know a little about a lot, but I don’t feel comfortable and competent in either modality.” The question of how much this appraisal reflects on the trainee in question and how much it reflects on the Y model pedagogy cannot be answered.
Gaining competence in more than one therapy model is challenging, but participants did not experience learning CBT and PDT to be equally difficult. All participants singled out the psychodynamic component as being the hardest to master, both technically and conceptually. This finding is consistent with contemporary research on the difficulties trainees experience in developing psychodynamic competence (20). Aggravating the inherent difficulty of acquiring PDT skills is the broader educational context. In Australia, the difficulties begin with the fact that most psychology undergraduates—the feeder group for postgraduate professional psychology training—are either not exposed to psychodynamic thinking or are taught to dismiss PDT as antiquated, irrelevant, and lacking an evidence base. Consequently, students experience their first exposure to PDT as akin to encountering a “foreign language.”
While a pervasive scholarly antipathy toward psychodynamic psychology is a significant impediment to learning and practicing it in this context, our participants attested to other difficulties. After becoming familiar with the friendly advisor/coach role the therapist plays in CBT, which is an extension of familiar social roles, trainees struggle to adapt to the more ambiguous, less overtly active analytic attitude. From a training perspective, the relative ease with which students learn CBT skills, thereby preparing them for work with actual clients, militates against reversing the order of exposure by teaching PDT first. Thus, having learned the attitudinal requirements of CBT, trainees then put these aside to learn how to be “in the chair” in a very different, psychodynamic way. Aggravating the strain of acquiring the analytic attitude is dealing with the expectations of clients who are conversant with CBT discourse and whose treatment expectations involve “learning strategies” to manage and minimize psychological distress. Students thus need to counter both internal and external pressures to revert to a default CBT stance to learn to practice PDT.
We were impressed by the personal impact the psychodynamic component had on the trainee psychologists. The emotional “burden of knowing there is an unconscious” involves a process of self-discovery that undermines consciously held certainties and causes students to interrogate and reevaluate themselves and their significant relationships. This knowledge often prompts students to enter their own personal therapy, which serves as a further personal provocation, as well as a support. While the transformative learning inevitably involved in PDT is exciting, it also provokes anxiety, makes students feel vulnerable when they would rather be strong, and adds to the burden of an already demanding professional training. “Your whole world,” as one participant observed, is “tilted on its axis.”
Without minimizing the educational hardship that the psychodynamic training inflicts, participants were clear that it was this component that “gives us the edge” over clinical psychology trainees from other universities. Learning to read clients’ implicit communication, perceive deeper meanings evident in clients’ symptoms, appreciate the influence of transference wishes and expectations on client interaction, and understand and manage their own countertransference inclinations are valuable skills participants attributed to their hard-won psychodynamic learning.
The Y model literature is focused on therapeutic competencies, and no consideration is given to the impact this type of training has on therapeutic identity. Therapeutic identity refers to a component of the emerging professional self, namely the practitioner’s conceptions of the psychotherapist’s role and evolving orientation or theory of therapeutic practice (21–23). Published research suggests that both the theoretical emphasis of the training program and the therapeutic orientation of clinical supervisors have a significant impact on professional identity (22). We were thus curious to see how trainees from a Y model training program would think about their therapeutic identity, given the equal emphasis on CBT and PDT.
Considering the emphasis that participants placed on the psychodynamic arm of the Y model training, the distribution of psychotherapy identity positions that emerged from the focus groups is noteworthy. As is clear from our results, none of the participants identified with CBT, which is significant given the hegemony of CBT in Australian professional psychology. Possibly, the shared impression that the psychodynamic component of the Y model training gave participants the edge over other trainees also made them reluctant to identify as CBT practitioners. This finding admits an alternative interpretation, namely that a significant proportion of successful applicants to the program may have had a preexisting inclination toward PDT, making them disinclined to value and identify with the CBT orientation.
One participant embraced neither CBT nor PDT, and three indicated that they could not identify with either because they felt totally incompetent in both.
Seven of the participants identified as preferring PDT, and four others referred to themselves as “psychodynamically informed.” The significant prevalence of participants who identified with a psychodynamic orientation cannot be attributed simply to the training, because the program’s psychodynamic reputation often attracts applicants looking for something other than the conventional CBT-oriented training offered by most Australian universities. Nonetheless, four participants said that their original inclination had been toward CBT but that their identity allegiance had shifted toward PDT during the training.
Six participants indicated that they felt comfortable working with both CBT and PDT and did not feel the need to identify with either therapeutic orientation. They stated that which type of therapy they adopted would be largely guided by pragmatic considerations, such as specific work context, whether or not their clients were in crisis, and what the Australian public mental health protocol would permit.
The variety of therapeutic identity positions participants expressed is perhaps not surprising, given that the Y model aims to cultivate openness to different therapeutic orientations which, in turn, counters early identity fixity. Indeed, the pragmatism, flexibility, and conspicuous absence of identity conflict evident in most of the participants point toward a strength of Y model training.
Despite these multiple identity positions, it was interesting to observe that all participants in one focus group indicated that if they were clients, they would seek out PDT for themselves. Our interpretation of this finding is not that participants have little confidence in CBT, but that the profession of clinical psychology tends to attract self-reflective individuals who are curious about their internal world and psychic complexity. This interest coincides with the emphasis on complex motivation, self-reflection, and hidden meaning in PDT. Thus, participants may reasonably believe that if they were clients, they would seek a different type of psychotherapy (PDT) from that needed by their own clients.
The participants’ perceptions of Y model teaching and learning were instructive, particularly concerning the impression of therapeutic “silos” and the existence of adversarial relationships between staff proponents of CBT and PDT. These findings brought to our attention the fact that, while we had systematically exposed all our students to the Y model and the rationale for its implementation, we had not exercised equivalent diligence with all the staff members. While the core clinical psychology training team was familiarized with the model, a few part-time sessional instructors and supervisors were not. We suspected that these “outlying” part-timers, who had not benefited from seminars and workshops on the Y model, were largely responsible for the polarizing and divisive attitudes reported by our participants. Consequently, we now include all our staff in Y model training sessions and expose students only to clinical supervisors who are respectful of therapeutic approaches different from their own. However, as one participant observed, in the real world of professional practice, conflict between proponents of PDT and CBT inevitably exists, and trainees should be prepared to encounter and negotiate these professional tensions.
Y model literature, with its emphasis on the differentiation and integrity of distinctive therapeutic orientations, provides no guidelines for the interaction and relationship between the arms of the Y. This relationship may be the key to which of our findings are site specific and which relate more generically to Y model training across all settings. As our research illustrates, this is not only a pedagogic issue but also an ideological one that finds interpersonal expression in the relationships among educators, supervisors, and students. It is vital that the Y model training environment facilitates and promotes mutually respectful engagement between professionals of differing therapeutic orientations, especially when these orientations have been historically defined by mutual competitiveness and antagonism. Some of the following strategies may promote a more conducive learning environment: regular clinical case conferences where educators from differing orientations model collegial dialogue about their differences, familiarizing trainees with the research literature on the established effectiveness equivalence between different approaches, and setting assignments in which trainees are required to generate theoretically distinct but viable case formulations in response to client presentations.
The participants’ perceptions of tension between CBT and PDT staff also alerted us to an omission in the focus group discussions, namely the stem of the Y model, which focuses on core therapeutic aspects cutting across theoretical orientations (10, 11). These therapeutic commonalities, which, significantly, are given greater weight in a subsequent article on the Y model (9), include therapeutic listening, reflecting, and interviewing; formulating and planning treatments; establishing and maintaining a therapeutic frame and alliance; and implementing the generic interventions that define a supportive therapeutic stance. Obviously, how these commonalities are interpreted differs between CBT and PDT, but participants’ complete omission of this aspect in their discussion of their Y model training, together with the lament that CBT and PDT seem like unbridgeable silos, incline us to believe that insufficient attention to this Y model stem has been a weakness in our implementation of the model. Perhaps, in our zeal to equip students with differential CBT and PDT training, we have not provided sufficient grounding in the common factors needed by both approaches to initiate and sustain a therapeutic process. It is also possible that by omitting an interview question related to the stem of the Y model there was an implicit expectation that participant discussion would focus on a comparison of CBT and PDT, rather than on the foundational common factors.
Related to the above point is the participants’ discussion of the difference in teaching approaches adopted by two staff members responsible for the PDT and CBT components, respectively. While individual pedagogic emphases need to be respected, it seems clear to us that, whatever the therapeutic orientation being taught, trainees benefit the most from instructional approaches that are practical and focus on the “how to” aspect of the therapy being taught, rather them stressing theoretical knowledge, abstract discussion, and extensive reading.
Participants’ claims that they struggled with different supervisory expectations were also instructive, leading us to initiate a program of professional development seminars on supervision. These seminars focus on development of generic supervision skills and discussion of how these may need to be adapted for differing therapeutic approaches. The results of our research on the participants’ experience has given us a renewed appreciation of how important it is for supervisors to provide a thorough orientation to supervisees and to explore students’ supervision expectations and experiences of prior supervisory relationships.
A final comment on the findings concerns the minority of participants who felt that they were incompetent in both CBT and PDT and that this indicated a failure of either the model or its application. It was clear that the learning expectations of these students differed from those of students who felt more positively about the model. The latter appeared to appreciate and accept that learning implies a starting point of relative ignorance and relative incompetence and that mastery of the complex knowledge and skills involved in Y model training cannot be attained during a relatively brief training period. They were able to console themselves that their learning was just beginning, and that skill refinement and consolidation would come only with further post-training professional development. The frustrated students, in contrast, seemed demoralized and hopeless about ever becoming competent, blaming their training for their self-perceived incompetence. This phenomenon is evident in every psychotherapy training program, but we should acknowledge that it may be exacerbated by Y model training. Systematic monitoring and adequate support of students are prerequisite for this type of training and require substantial resources. Where these are inadequate, it is likely that struggling students will be more likely to experience the erosion of morale expressed by these participants.
This study was limited in that we investigated the experience of Y model training while participants were still learning and immersed in it. It would be worthwhile to conduct a follow-up study on Y model trainees some years after completing their training, to assess its enduring impact and obtain qualified psychologists’ retrospective appreciation of its relative merits.
Conclusions
Goldberg and Plakun (9) note that the Y model “is still in the early stages of development.” To the best of our knowledge, ours is the first study to use a systematic qualitative research procedure to investigate students’ experiences of Y model psychotherapy training and the difficulties specific to this type of training. While we have tried to present a balanced account of the positive and negative experiences of the Y model in our sample of clinical psychology trainees, the value of this approach to psychotherapy learning is clear. However, our research also reveals both how difficult it is for students to master dual therapies during basic clinical psychology training, even when these are encompassed by a clear structure for articulating and comparing them, and how these intrinsic difficulties can be exacerbated by insufficient staff education into the model’s theory, instruction, and supervised practice. We hope that this article will encourage other psychotherapy trainers using some form of Y model training to conduct similar qualitative research into their trainees’ experiences. Such research will contribute to the growth and refinement of the model.
Acknowledgments
The authors thank the student participants for their involvement in this research project. The authors also thank Julie Van den Einde, Ph.D., for her feedback on the data analysis and Celia Godfrey, Ph.D., for her focus group facilitation.
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Information & Authors
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Received: 6 April 2018
Revision received: 2 July 2018
Revision received: 30 July 2018
Accepted: 6 August 2018
Published online: 21 February 2019
Published in print: March 01, 2019
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The authors report no financial relationships with commercial interests.
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