Training Opportunities in Personality Disorders 1

The availability of training opportunities in personality disorders in American

Psychological Association- and Psychological Clinical Science Accreditation System-

accredited clinical and counseling psychology doctoral programs

Kenneth N. Levy

The Pennsylvania State University

William D. Ellison

Trinity University

Author Note: Kenneth N. Levy, Department of Psychology, Pennsylvania State University;

William D. Ellison, Department of Psychology, Trinity University. Correspondence concerning

this article should be addressed to Kenneth N. Levy, Department of Psychology, Pennsylvania

State University, 362 Bruce V. Moore Building, University Park, PA 16803. E-mail:

[email protected]. Phone: 814-865-5848. Fax # 814-863-7002.

© 2021, American Psychological Association. This paper is not the copy of record

and may not exactly replicate the final, authoritative version of the article. Please

do not copy or cite without authors' permission. The final article will be available,

upon publication, via its DOI: 10.1037/tep0000376

Kenneth N. Levy, PhD, is an associate professor of psychology at The Pennsylvania State

University, where he teaches Clinical Methods focused on contemporary treatments for

Training Opportunities in Personality Disorders 2

personality disorders, and directs the Laboratory for Personality, Psychopathology, and

Psychotherapy Research. He received his doctorate from The Graduate School and University

Center at the City University of New York and completed a clinical internship and postdoctoral

training at the New York Presbyterian Hospital at the Joan and Sanford I. Weill Medical College

of Cornell University. His research and professional interests include attachment theory,

personality and personality disorders, psychotherapy processes and outcome, and professional

ethical issues related to evidence based training and mental health literacy.

William D. Ellison, PhD, is an assistant professor of psychology at Trinity University. He

received his doctorate from The Pennsylvania State University and completed a clinical

internship at the Massachusetts Mental Health Center/Beth Israel Deaconess Medical Center,

Harvard Medical School. He completed postdoctoral training at Rhode Island Hospital, Warren

Alpert Medical School of Brown University. His research and professional interests include

personality and personality disorders, the use of ecological momentary assessment in research

and psychotherapy, and psychotherapy outcome for borderline personality disorder.

Training Opportunities in Personality Disorders 3

Abstract
Personality disorders are relatively common, especially in clinical settings. A number of

evidence-based treatments are now available, especially for borderline personality disorder.

However, little is known about the relevant training available to doctoral students in clinical and

counseling psychology. in the current study, data were extracted from 336 clinical and

counseling Ph.D. and Psy.D. programs from the Insider’s Guide to Graduate Programs in

Clinical and Counseling Psychology (Norcross & Sayette, 2020), including the number of

programs with faculty with specific interests in personality disorders and the number of

programs with clinical opportunities related to personality disorders. We found that formal

training in personality disorders is not widely available to most trainees in APA-accredited

doctoral training programs. Only 16% of programs have faculty with interests in personality

disorders, all of them clinical psychology programs. Ph.D. programs were more likely to have

PD-interested faculty than Psy.D. programs, and, within clinical Ph.D. programs, PCSAS-

accredited programs were more likely to have PD-interested faculty than programs without

PCSAS accreditation. Similarly, only 15% of programs (all clinical psychology programs) offer

practicum opportunities in psychotherapy for personality disorders. Our findings indicate that

doctoral level psychology programs are not sufficiently preparing their students with personality

disorder training, which serves as a substantial disservice to both trainees and the public.

Keywords: Clinical Psychology, Counseling Psychology, Ph.D., Psy.D., Personality disorders,

Training.

Public Significance Statement

This study found that training in personality disorders at APA-accredited clinical and counseling

doctoral programs is not available to a level commensurate with the prevalence and severity of

the problem. This was particularly true among Psy.D. programs and even more so counseling
Training Opportunities in Personality Disorders 4

programs. Although training in personality disorders was statistically more likely to be available

at APA-accredited programs that were also PCSAS-accredited, most of these programs,

regardless of accreditation, also lacked faculty with declared expertise and/or specified clinical

training opportunities in personality disorders. As a profession, we are at risk of not providing

needed research and clinical training.  

Training Opportunities in Personality Disorders 5

The availability of training opportunities in personality disorders in APA- and PCSAS-

accredited clinical and counseling psychology doctoral programs

Personality disorders (PDs) represent a major public health concern and as such merit

priority in the training of psychologists (Levy, in Magnavita et al., 2010). Most definitions of

personality disorders stress that they are a group of related disorders characterized by

longstanding patterns of intra- and interpersonal difficulties (Levy & Johnson, 2016). Research

shows that personality disorders are highly prevalent, commonly comorbid, and quite disruptive,

painful, and even deadly. For example, results from general population epidemiological surveys

across more than 20 countries and six continents have found prevalence rates for DSM defined

personality disorders ranging between 4.4% and 21.5% (with most studies ranging between 9-

11%; see Winsper et al., 2019). Prevalence rates are generally much higher in clinical

populations, with studies using structured diagnostic assessments finding that between 20–45%

of psychiatric outpatients and 45-50% of inpatients meet criteria for a personality disorder

(Korzekwa, Dell, Links, Thabane, & Webb, 2008; Kovanicova, Kubasovska, & Pallayova, 2020;

Marinangeli et al., 2000; Zanarini et al., 2004; Zimmerman, Rothschild, & Chelminski, 2005).

Not only are personality disorders prevalent on their own, but they are also commonly

comorbid with a range of disorders, such as bipolar disorder, depression, anxiety disorders,

eating disorders, post-traumatic stress disorder and substance abuse disorders (Zanarini et al.,

1998) and health conditions (El-Gabalawy, Katz,& Sareen, 2010; Sansone, Pole, Dakroub et al.,

2006). This comorbidity is especially meaningful in that the presence of a personality disorder

negatively affects the course and outcome of these disorders, leading to lower rates of remission

and increased rates and shorter times to relapse, prolongs the length of treatment, and reduces

treatment efficacy of otherwise effective treatments for these disorders (Bieling, Green, &
Training Opportunities in Personality Disorders 6

MacQueen, 2007; Cloitre & Koenen, 2001; Levenson, Wallace, Fournier, Rucci, & Frank, 2012;

Mennin & Heimberg, 2000; see Newton-Howes, Tyrer, & Johnson, 2006).

Personality disorders are also associated with high rates of both non-suicidal self-injury

and suicidality, especially among those with borderline and narcissistic personality disorders

(Temes et al., 2019). Recent meta-analyses suggest that completed suicide rates for those with

borderline personality disorder (BPD) are about 8%, which is higher than the individual rates for

schizophrenia (4.0%), depression (3.6%), eating disorders (2.3%), bipolar disorder (1.3%), and

post-traumatic stress disorder (PTSD) (0.4%) (Chesney et al., 2014; Palmer et al., 2005; Pompili,

Girardi, Ruberto, & Tatarelli, 2005; Pompili et al., 2004). Personality disorders are also striking

sources of social cost, family burden, morbidity and all-cause mortality (Hastrup et al., 2019;

Temes et al., 2019; Tyrer, Tyrer, & Yang, 2019; Quirk et al., 2016) and place considerable

pressure on the mental health care system (Bender et al., 2001).

Historically, personality disorders have been thought to be difficult to diagnose.

However, many studies have now found good reliability for the assessment of personality

pathology — equivalent or superior to most DSM defined disorders (Chmielewski, Clark, Bagby,

& Watson, 2016; Zanarini et al., 2000). Moreover, emerging prototypal and dimensional

diagnostic systems for personality disorders may aid in reliable diagnosis (Garcia et al., 2018), as

does increased knowledge about differential diagnosis (Pilkonis, Heape, Ruddy, & Serrao, 1991).

Still, despite several reliable and well validated evidence-based assessment measures, including

screening measures and semi-structured interviews that display good psychometric properties

(Widiger & Samuel, 2005), personality disorders are under recognized. Findings from several

studies suggest that clinicians do not diagnose personality disorders in ordinary clinical practice

(Barbato & Hafner, 1998; Zimmerman & Mattia, 1999).

Training Opportunities in Personality Disorders 7

Over the last few decades, there has also been an increasingly robust empirical literature

suggesting that personality disorders, especially BPD, are treatable with a range of specialty

therapies deriving from the cognitive-behavioral and psychodynamic traditions (Budge et al.,

2013; Cristea et al., 2017). In addition, there are a number of adjunctive interventions and

modules and generalist approaches that have been developed and show good results (Ellison,

2020). Thus, there are a wide variety of evidence-based psychosocial interventions for

personality disorders that can be taught in clinical psychology training programs.

Thus, the imperative to train future psychologists in evidence-based practice entails the

inclusion of personality disorders in the graduate curriculum. We see this curriculum as

consisting of two parts: first, the inclusion of evidence-based assessment and intervention

approaches for personality disorders in the didactic and practical coursework required of doctoral

psychology students; and second, where possible, the inclusion among program faculty of

individuals with research programs focusing on personality pathology. As to the first component,

as we have indicated above, there is solid evidence that specialized treatments for PDs,

especially BPD, outperform treatment-as-usual (Ellison, 2020). This makes the availability of

specialty therapy training for PDs especially important (Crits-Cristoph, Chambless, & Markell,

2014). The second component, that of faculty research interest in PDs, may seem like a

secondary concern. Nevertheless, we believe that having faculty with research interests in PDs

serves the immediate function of bolstering student knowledge of the clinical features of PDs,

their epidemiology, course and prognosis, and their treatment outcomes, thus contributing to the

integration of science and practice and enhancing the entrainment of evidence-based practice for

PDs (Beck et al., 2014; Castonguay, 2011). Moreover, the representation of PD experts on a
Training Opportunities in Personality Disorders 8

program’s faculty sends a signal to students that personality pathology is important and worthy

of appropriate clinical consideration.

Despite the psychological and financial toll of personality disorders on the individual and

society, the availability of several evidence-based treatments, and an identified public health

need (Beatson, 2019; Iliakis et al., 2019; Lazzari et al., 2018), specialized training in researching,

identifying, and treating personality disorders in mental health training programs has lagged

behind training in other forms of psychopathology. For example, Levy (in Magnavita, 2010)

reviewed doctoral psychology programs accredited by the American Psychological Association

(APA) using data from Norcross, Sayette, and Mayne’s (2008) Insider’s Guide to Graduate

Programs in Clinical and Counseling Psychology, which surveyed 319 programs about faculty

interest and expertise and opportunities for specialized training in specific clinical areas. Only 24

(7.5%) of these programs reported having a faculty member with expertise in personality

disorders and only seven programs (2%) indicated that they had specialized clinical training in

personality disorders. By contrast, 80 programs (25%) had a faculty member with stated

expertise in anxiety disorder (a 176 total faculty members) and 23 programs (7%) had a specialty

clinic for treating anxiety disorder. The disparity between the number of programs with faculty

and training that specialize in personality disorders versus anxiety disorders is notable

considering the prevalence in outpatients is similar for the two disorder categories (Remes,

Brayne, van der Linde, & Lafortune, 2016).

Since this study, there has been little follow-up. Although there are a few reports on

implementing training in personality disorders in psychology department clinics (Noll, Lewis,

Zalewski, Martin, Roos, Musser, & Reinhardt, 2019; Rizvi, Hughes, Hittman, & Vieira Oliveira,

2017) and several more within residency programs (for example Bernstein, Zimmerman &
Training Opportunities in Personality Disorders 9

Auchincloss, 2015; Unruh & Gunderson, 2016; Zerbo, Cohen, Bielska, & Caligor, 2013), we did

not find empirical reports of the scope of training in personality disorders in clinical psychology

programs beyond those in Magnavita et al. (2010).

The present study sought an updated estimate of the extent to which APA-accredited

clinical and counseling psychology doctoral programs offered training in personality disorders.

In addition, we examined programs accredited by an alternative accreditation body, the

Psychological Clinical Science Accreditation System (PCSAS), which since 2010 has emerged

as an alternative to the APA-accrediting system.1 Lastly, we examined differences in training

offered as a function of type of degree (Ph.D. vs. Psy.D.), type of program (Clinical vs.

Counseling), and accrediting body (APA vs. PCSAS).

We hypothesized that:

(1) the majority of doctoral programs in clinical and counseling psychology would not

offer any explicit training in personality disorders. This hypothesis follows from the

findings from Magnavita et al. (2010)

(2) to the extent training is offered, faculty interested in personality disorders and training

opportunities in personality disorders would be more likely to occur in PhD programs

as compared to PsyD programs. This was also based on findings from Magnavita et

al.

1
For ease of writing and conceptual reasons we refer to the distinction between programs accredited by the APA
and PCSAS as APA-accredited and PCSAS-accredited. Although it is important to note that currently all PCSAS-
accredited programs are also accredited by the APA. Referring to PCSAS-accredited programs as APA/PCSAS
programs, although technically correct, would be cumbersome. Similarly, referring to APA-accredited programs as
APA/non-PCSAS-accredited programs would also be cumbersome. More relevant is that fact that many PCSAS-
accredited programs (e.g., University of Arizona, UC Berkeley, UCLA, Indiana University, University of Illinois
Urbana-Champaign, University of Delaware, University of Wisconsin-Madison, University of South Florida, and
Stony Brook University) have publicly announced that their training mission is consistent with the standards of
PCSAS and that they will not renew their APA-accreditation once it expires. Some programs (e.g., UC Berkeley)
have gone as far to inform their current applicants that although APA-accredited, newly admitted students enter into
a PCSAS-accredited clinical science program and that entry into the APA-accredited program is no longer available.
Training Opportunities in Personality Disorders 10

(3) clinical programs would be more likely than counseling programs to have faculty who

study personality disorders and offer training opportunities in personality disorders,

because clinical programs focus more on psychopathology and counseling programs

more on issues of wellbeing (Morgan & Cohen, 2008; Sayette & Norcoss, 2020).

(4) a higher percentage of programs with PCSAS accreditation would have faculty with

research interests in PDs than programs with only APA accreditation, because of the

focus of the former on clinical science; and a higher percentage of programs with

only APA accreditation would offer clinical training in PDs than PCSAS- accredited

programs, given the stronger focus of the former on clinical training.

(5) and finally, that faculty representation and training opportunities in personality

disorder would lag behind that of other disorders with similar prevalence rates and

even disorders with lower prevalence rates, based on the findings from Magnavita et

al..

Method

Sampling and Procedures

The authors extracted data from the current edition of the Insider’s Guide to Graduate

Programs in Clinical and Counseling Psychology (Norcross & Sayette, 2020), which included

data from 336 APA-accredited clinical and counseling PhD and PsyD programs. The data on a

range of program, faculty, and student characteristics are provided by the directors of clinical

training programs and are collected during the spring and summer every 2 years beginning in

1991 and through 2019. The data are then published the next year. Thus, the data in the current

study were collected in 2019 and published in the 2020-2021 edition. In the current edition, the

response rate was 99% (Norcross & Sayette, 2020). For the purposes of the current study,
Training Opportunities in Personality Disorders 11

specific program information extracted included data on the number of faculty with specific

interests in personality disorders and the number of programs with specialty clinics and

practicum experiences for working with personality disorders. Programs were counted as having

faculty with an interest in personality disorders if they appeared in either the “personality

disorders” or “antisocial personality disorder” categories, which were separate in the latest

edition of the Insider’s Guide. Other faculty interest categories tallied for comparison’s sake

were mood disorders (represented by the “affective disorders/depression/mood disorders”

category in the Insider’s Guide), substance use disorder (“alcohol” and “substance

abuse/addictive behaviors”), anxiety disorders/panic (“anxiety disorders/panic disorders” and

“obsessive-compulsive disorder”), PTSD (“posttraumatic stress disorder/trauma”), eating

disorders (“eating disorders/body image”), autism spectrum disorder (“autism/Asperger’s

syndrome/developmental disorders”), and psychotic disorders (“schizophrenia” and “severe

mental illness”).

Data Analytic Plan

Hypothesis 1 was examined by frequency counts. For hypotheses 2, 3, and 4, chi-square

analyses and Fisher’s exact tests were performed on categorical variables to examine differences

between programs. Hypothesis 5 was evaluated using z-tests for proportions.

Results

Descriptive Findings

Of the 336 APA-accredited programs in Norcross and colleagues (2020) Insider’s Guide,

248 were Ph.D. programs (174 clinical PhD programs, 67 Counseling PhD programs, 1

combined clinical-school PhD program, 3 combined Counseling-school PhD programs, and 3

combined clinical-counseling PhD programs, the last of which were deemed clinical for the
Training Opportunities in Personality Disorders 12

purposes of this manuscript) and 87 were Psy.D. programs (73 clinical PsyD programs, 9

counseling Psy.D. programs, 4 clinical-school combined Psy.D. programs, one counseling-

school combined Psy.D. program, and one clinical-health combined Psy.D. program). At the

time of data extraction there were 43 doctoral programs that also had PCSAS accreditation, of

which all were clinical Ph.D. programs.

Of the 336 APA-accredited programs, only 55 (16.4%) programs indicated that they had

a faculty member interested in personality disorders. This represents a 129% increase in the

number of programs with such faculty interest over the twelve-year period from the publication

of Magnavita et al. (2010). Nevertheless, despite this increase, fewer than one in six programs

reported having any faculty with interest in personality disorders. Fifty programs (14.9%) also

reported the availability of a PD-related specialty clinic or practicum opportunity, with 22 other

programs reporting a practicum opportunity in dialectical behavior therapy (DBT), which is a

specialty treatment originally designed for BPD but has also been applied to several other

diagnoses.2

Characteristics of Programs Offering Training in Personality Disorders

Table 1 shows the characteristics of doctoral psychology programs offering research and

clinical training in PDs. All 55 APA-accredited programs that report having at least one faculty

member with interest in personality disorders were clinical programs. None of the counseling or

combined programs reported having a faculty member with interest in personality disorders.

Similarly, only two of the specialty clinic/practicum training opportunities were associated with

counseling programs, with an additional four combined programs reporting a specialty

2
Although DBT was originally developed for borderline personality disorder, it has also been used to treat other
disorders, such as eating disorders, substance use disorders, PTSD, and impulsive-spectrum disorders, and thus it
was not clear from the Insider’s Guide which disorders a program’s clinic was using DBT to treat. Thus, it was not
counted here as a specialty treatment for PDs. Nonetheless, sensitivity analyses in which programs offering DBT
specialty clinics were counted among those with specialty clinics for PDs only suggested one substantive change to
our conclusions (see below).
Training Opportunities in Personality Disorders 13

clinic/practicum. There were no differences between Ph.D. and Psy.D. programs in the

availability of faculty with interest in personality disorders or specialty clinics/practicum

opportunities. However, because none of the counseling psychology programs had faculty

members with interest in personality disorders and because most Psy.D. programs (91%) are

clinical psychology programs we wondered if an association between faculty with interest in

personality disorders and Ph.D status as hypothesized was being washed out by the inclusion of

counseling programs. Thus, a post-hoc chi-square analysis was conducted comparing Ph.D. and

Psy.D. programs with a focus on only clinical psychology programs. For this comparison, the

difference in percent of programs with a faculty member with interest in personality disorders

was significant (ꭓ2 [df = 1, N = 247] = 4.99, p = 0.03). Thus, this hypothesis was not supported

when counseling programs are included, but is supported when examined within clinical

psychology programs. Regarding PCSAS-accredited programs, they were more likely to have

both faculty interested in PDs and clinical training opportunities in personality disorders.

Personality Disorders vs. Other Disorders

Although the majority of doctoral programs in clinical and counseling psychology do not

report faculty representation in the study of personality disorders or report any explicit training in

personality disorders, it is possible that the situation is not different for other disorders. Thus,

programs’ reports of the number of faculty with interest in mood disorders, anxiety disorders,

eating disorders, posttraumatic disorders, and substance use disorders were also examined.

Figure 1 shows the percentage of faculty with interests in other disorder categories, as well as the

number of specialty clinics and practicum opportunities for other disorder categories in training

programs. For comparison, this figure also presents the established 12-month prevalence of each

disorder category in the community (Hudson, Hiripi, Pope, & Kessler, 2007; Kessler, Birnbaum,
Training Opportunities in Personality Disorders 14

et al., 2005; Kessler, Chiu, Demler, Merikangas, & Walters, 2005; Maenner et al., 2020; Trull,

Jahng, Tomko, Wood, & Sher, 2010). The proportions of programs with faculty members with

interests in anxiety disorders, substance use disorders, mood disorders, and PTSD were all

significantly greater than the proportion of programs with faculty with PD interests, (p-values

< .001). In contrast, psychotic disorders (p = .81), eating disorders (p = .31), and autism

spectrum disorder (p = .95) had representation of faculty within programs that did not

significantly differ from that of personality disorders. There were also fewer specialty training

clinics or practicum opportunities for PDs than for substance use disorders, PTSD, anxiety

disorders, and mood disorders (p-values < .02), but not for eating disorders (p = .39), autism

spectrum disorder (p = .48), or psychotic disorders (p = .81).3

Discussion

The current study sought to examine the availability of training opportunities in PDs at

APA-accredited clinical and counseling Ph.D. and Psy.D. doctoral programs and PCSAS-

accredited programs. The overall rates of faculty with interest in PDs and specialty practicum

and externship training in personality disorders was low for both Ph.D and Psy.D. degrees and

within clinical and counseling programs. The meager availability extent of training in personality

disorders in counseling programs is particularly striking and would suggest that trainees

graduating from such programs leave training for internship with a significant gap in their

knowledge. The situation is only slightly better for those graduating from clinical psychology

Psy.D. programs and non-PCSAS accredited clinical Ph.D. programs, although the situation is

significantly better for PCSAS-accredited clinical psychology Ph.D. programs. For the most part,

APA-accredited programs are not providing adequate pre-internship training regarding a

3
If DBT is counted as a specialty treatment for PDs but not for other diagnoses, all conclusions are substantively
identical except that the difference between the availability of specialty treatment for PDs is no longer significantly
different from that for PTSD (p = .55).
Training Opportunities in Personality Disorders 15

frequently occurring clinical problem. Little is known about the likelihood of psychology

trainees receiving such training while on internship. Future research should examine this

question.

Research indicates that in routine practice clinicians fail to diagnose many personality

disorder cases. The current study suggests that one reason that personality disorders go

undiagnosed is that our trainees may not be not adequately prepared to recognize them. Related,

Thompson, Mashhood, Nesci, and Rao (2015) found that early career psychiatrists reported that

their training was not very useful when dealing with personality disordered patients across a

broad array of areas, including case formulation, risk management, prescribing medication, team

dynamics, informing clients/families about diagnosis, providing psychotherapy, and managing

emergency room visits. It is likely that psychology trainees graduating from APA-accredited

clinical and counseling psychology programs would report similar difficulties.

One might hypothesize that the lack of training available in personality disorders is a

general problem – perhaps training programs also lack faculty with expertise in other forms of

psychopathology and psychotherapy. However, the number of training opportunities in

personality disorders was between a third and a half of what was available compared to

substance/alcohol/tobacco use disorders, PTSD, mood disorders, and anxiety disorders. The

number of faculty with interest in personality disorders was about the same as was available for

psychotic disorders, autism, and eating disorders, despite the much lower prevalence rates for

those disorders. Thus, faculty with interest in personality disorders and clinical training

opportunities in personality disorders were among the least common, despite the relatively high

prevalence of PD’s. In sum, although we found that the availability of training in personality

disorders has increased substantially over the past decade, we also found considerable evidence
Training Opportunities in Personality Disorders 16

that the importance of training in personality disorders is underappreciated, especially when

bearing in mind the prevalence of personality disorders and their lethality.

Although much of the focus in this article thus far has been on clinical consequences, the

neglect in training on personality disorders also has implications for conducting valid research on

other psychological disorders and difficulties. Psychopathology research itself may be hampered

if comorbid personality disorders go unrecognized. For example, initial studies suggested that

individuals with panic disorder and anxiety symptoms are at increased risk for suicidality

(Weissman et al., 1989; Lepine et al. 1993), but later studies that included measures of

personality pathology found that PD’s, aggression, and impulsivity accounted for this association

(Placidi et al., 2000; Warshaw et al., 2000). It is also possible that the lack of faculty research

expertise in personality disorders will exacerbate the scarcity of quality clinical training in PDs

by stifling the growth of the evidence base for interventions.

Although the findings from this study have a number of important implications for

doctoral training in clinical and counseling psychology, there are several limitations that should

be addressed in future work. Because we relied on data from a published survey, we were unable

to explore specific personality disorders or whether personality disorders were a primary interest

to faculty. Additionally, we were unable to determine whether other training opportunities were

provided in coursework or to document available clinical training opportunities that are not part

of a specialty clinic or a practicum experience. Additionally, there may be tenure-line and/or

non-tenure-line faculty with clinical expertise that is not represented by research interests. Thus,

there may be some underestimation of available training opportunities. Nonetheless, it is unlikely

that a large amount of training went undetected, especially without the requisite faculty

expertise, and programs would probably have little incentive to underreport the expertise of their
Training Opportunities in Personality Disorders 17

faculty on a survey that will be published as a guide to prospective program applicants.

Moreover, PD expertise was relatively underrepresented in psychology training faculty

compared to other disorder categories with equivalent or lower prevalence and burden of disease,

suggesting that underreporting is unlikely to account entirely for current findings. Nonetheless, it

would be useful for future research in this area to examine program content more directly to

better determine the extent of training offered.

Additionally, it will be important to examine which specific personality disorders are the

focus of faculty research interest, as well as which specific treatments are represented in the

available clinical training. Findings from several studies (e.g., Boschen & Warner, 2009; Sibai &

Huprich, 2019) examining the content of publications on personality disorders suggest that those

who study borderline and antisocial personality disorder may be best represented, but these

overall publication rates may not accurately reflect the full extent of faculty expertise in

psychology doctoral programs. With regard to training in specific evidence-based treatments,

there are several treatments available to clinicians, especially for borderline personality disorder,

such as DBT, Transference-Focused Psychotherapy (TFP), Mentalization-Based Treatment

(MBT), Schema Therapy (ST), and others. Among these, only DBT is given its own training

category in the Insider’s Guide. Over two decades ago, Crits-Christoph et al. (1995) found that

17 of 138 programs (12%) provided training in DBT. In the current study, only a slightly higher

percentage of surveyed programs had a specialty clinic or practicum experience focused on

personality disorders or DBT combined, and the availability of training in other specific

treatments is unclear. Given the negligible differences in outcome among various approaches in

treating personality disorders (see Cristea et al., 2017), it would be useful to know specific

details about the training opportunities available to students beyond DBT.

Training Opportunities in Personality Disorders 18

Implications of Findings

The results of the current study found that formal training in personality disorders

through mentorship opportunities with faculty or through specialty clinics or practicum

experiences are not widely available to most trainees in APA-accredited doctoral training

programs. This level of neglect regarding PDs among accredited doctoral training programs in

doctoral training programs, particularly in counseling psychology, is inconsistent with evidence-

based practice. Given the prevalence of personality disorders, their comorbidity, the negative

consequences of said comorbidity for course and outcome, and their lethality, and given the

availability of evidence-based psychological treatments and assessment tools for personality

disorders, it is incumbent upon our discipline to provide instruction and training in the

identification and treatment of personality disorders to our trainees. It is difficult to imagine how

we are to adequately train students for contemporary practice without such training. We

recommend that programs strongly consider addressing this gap between the needs of students

and patients and the training provided. A review of curriculum, relevant colloquia, and

supplemental training might be considered initial steps, as well as greater efforts to identify PD

cases in clinical training (e.g., through screening, structured assessments, and attending to

comorbidity). We would further argue that properly addressing the gap requires greater efforts to

hire relevant faculty. At a systemic level, APA and PCSAS might consider addressing this need

through their processes of accreditation.

Training Opportunities in Personality Disorders 19

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Training Opportunities in Personality Disorders 28

Table 1

Characteristics of Doctoral Training Programs Offering Faculty Research and Specialized

Clinical Training in Personality Disorders

Characteristic PD Faculty No PD Faculty Tests of independence

Clinical 55 192 χ2 = 20.4, p < 0.001*
Counseling 0 76 φ = 0.25

Ph.D. 45 203 χ2 = 2.08, p = 0.15

Psy.D. 10 77 φ = 0.08

PCSAS-accredited 17 26 χ2 = 6.10, p = .01**

non-PCSAS 28 107 φ = 0.19
PD specialty clinic No PD specialty clinic
Clinical 47 199 χ2 = 12.21, p < .001*
Counseling 2 74 φ = 0.19

Ph.D. 37 213 χ2 = 0.00, p = 1.00

Psy.D. 13 76 φ = 0.00

PCSAS-accredited 18 25 χ2 = 15.29, p < .001**

non-PCSAS 19 116 φ = 0.29
*Based on Fisher’s Exact Test

**Comparison based on clinical psychology Ph.D. programs only

Training Opportunities in Personality Disorders 29

Figure 1

Availability of Faculty with Research Interests in Different Disorder Categories and Specialty

Clinics for Disorders in APA-Approved Psychology Training Programs (N = 336) and

Prevalence of Disorders in the Community

45
40
Prevalence
35
Faculty
30
Clinics
25
20
Percentage

15
10
5
0
s r . s s s
er OH te r.. er er m er
ord / ET sa
s si o ord ord ctru ord
is UD Di D
D
Di
s
Di
s
Sp
e is
yD S SD
/
OC d ng cD
l it T c/ oo ti tis
m oti
na /P ni M Ea ch
so a a Au y
r P Ps
Pe au
m y/
Tr xi et
An

Note. Blue (dark solid) bars indicate the 12-month community prevalence of the disorder
category. Orange (striped) bars indicate the percentage of APA-accredited doctoral training
programs in psychology with faculty with research interests in the disorder category. Gray (light
solid) bars indicate the percentage of doctoral training programs in psychology with specialty
clinics or practicum sites for the disorder category.
References for prevalence rates:
a Trull TJ, Jahng S, Tomko RL, Wood PK, Sher KJ. (2010). Revised NESARC personality
disorder diagnoses: gender, prevalence, and comorbidity with substance
dependence disorders. Journal of Personality Disorders, 24, 412–426.
b Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. (2005). Prevalence, severity,
and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey
Replication. Archives of General Psychiatry,62(6), 617-627. PMID: 15939839
c Hudson, J. I., Hiripi, E., Pope, H. G., & Kessler, R.C. (2007). The Prevalence and Correlates of
Eating Disorders in the National Comorbidity Survey Replication. Biological Psychaitry, 6, 348-
358
Training Opportunities in Personality Disorders 30

d Maenner MJ, Shaw KA, Baio J, et al. (2020). Prevalence of Autism Spectrum Disorder Among
Children Aged 8 Years - Autism and Developmental Disabilities Monitoring Network, 11 Sites,
United States, 2016. MMWR Surveill Summary, 69(No. SS-4):1–12.
DOI: http://dx.doi.org/10.15585/mmwr.ss6904a1external icon.

e Kessler RC, Birnbaum H, Demler O, Falloon IR, Gagnon E, Guyer M, Howes MJ, Kendler KS,
Shi L, Walters E, Wu EQ. (2005). The prevalence and correlates of nonaffective psychosis in the
National Comorbidity Survey Replication (NCS-R). Biological Psychiatry, . 15;58(8), 668-
676. PMID: 16023620