How to Become a More Effective CBT Therapist E-Book
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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
How to Become a More Effective CBT Therapist explores effective ways for therapists to move beyond competence to “metacompetence”, remaining true to the core principles of CBT while adapting therapeutic techniques to address the everyday challenges of real-world clinical work. This innovative text explores how to:
- Work most effectively with fundamental therapeutic factors such as the working alliance and diversity;
- Tackle complexities such as co-morbidity, interpersonal dynamics and lack of progress in therapy;
- Adapt CBT when working with older people, individuals with long-term conditions (LTCs), intellectual disabilities, personality disorders and psychosis;
- Develop as a therapist through feedback, supervision, self-practice and training.
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Veröffentlichungsjahr: 2014
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CONTENTS
Cover
Title page
Copyright page
Dedication page
About the Editors
About the Contributors
Foreword by David M. Clark
Foreword by Tony Roth
I: The Foundations
1 Mastering Metacompetence
Introduction
The Science of CBT: Efficacy, Effectiveness and Evidence-Based Practice
The Art of CBT: Metacompetence
Three Risks to Effective Practice
Bringing the Science and Art Together: Metacompetent Adherence
Conclusion
Acknowledgements
References
2 The Central Pillars of CBT
Introduction
Core Principles of CBT
Core Framework of Therapy
Core Therapeutic Strategies
Conclusion
References
3 Developing and Maintaining a Working Alliance in CBT
What is the Nature of the Working Alliance in CBT?
Developing a Good Working Alliance
Addressing Challenges in Maintaining a Working Alliance
Where Next?
Summary
References
4 Working with Diversity in CBT
What is “Diversity”?
How is Diversity Relevant to CBT Practice?
Adapting CBT for Diversity: A Case Conceptualization Framework
Overcoming Obstacles and Building: Applying the Adaption Framework in Clinical Practice
Conclusion
References
II: Handling Complexity
5 Working with Co-Morbid Depression and Anxiety Disorders
Introduction
Co-morbid Depression and Anxiety Disorders: Epidemiology and Therapy Outcomes
A Multiple-Diagnostic Approach
Conclusion
Acknowledgements
References
6 Collaborative Case Conceptualization
Rationale for Case Conceptualization
A New Model of Case Conceptualization
Five Steps of Case Conceptualization
Conclusion
Acknowledgements
References
7 Transdiagnostic Approaches for Anxiety Disorders
The Need for a Transdiagnostic Approach to Treating Anxiety Disorders
Transdiagnostic Approaches
Transdiagnostic Approaches to Anxiety Disorders: Theory
Transdiagnostic Approaches to Anxiety
Transdiagnostic Protocol for Anxiety Disorders
Treatment Overview
Structure of Treatment
Case Example
Conclusion
References
8 When and How to Talk about the Past in CBT
Introduction
Clinical Starting Points
Meta-Cognitive Awareness
Building Up a Sense of Self
Developing an Identity
References
9 “Is it Them or is it Me?” Transference and Countertransference in CBT
Introduction
Transference in Analytic Thought
Why CBT is Wary of Transference
Cognitive Models of Transference and Countertransference
Empirical Evidence
Interpersonal Schemas
Why Transference Doesn’t Appear in CBT
Where Transference Does Appear in CBT
The Interpersonal Schema Worksheet (ISW)
A Stepped Model for Managing Transference and Countertransference
Summary
Acknowledgements
References
10 What To Do When CBT Isn’t Working?
What Do We Mean by ‘Treatment Failure’?
Resistance is Futile?
Common Forms of Resistance
References
III: Adapting for Specific Client Groups
11 CBT with People with Long-Term Medical Conditions
Introduction
Assessment, Formulation and Finding a Focus
Chronic Pain
Diabetes
Coronary Heart Disease
Chronic Obstructive Pulmonary Disease
References
12 CBT with People with Personality Disorders
Introduction
Formal Assessment of Personality Disorder
Psychological Therapy for Personality Disorders
Summary
References
13 CBT with People with Psychosis
Introduction
Practical Application
Case Example (see Box 13.1)
Delivery of CBTp
References
14 CBT with Older People
Introduction
How Common is Depression and Anxiety in Later Life?
How Effective is CBT with Older People?
How to Adapt Therapy to Address the Needs of Older People
How to Adapt Therapy for Older People with Specific Impairments
Ending Therapy
Personal note
Acknowledgements
References
15 CBT with People with Intellectual Disabilities
Introduction
Evidence of CBT Efficacy for Adults with ID
Adapting CBT for Adults with ID
Case Study: Jim
Summary and Conclusions
References
IV: Mastering Metacompetence
16 Using Self-Practice and Self-Reflection (SP/SR) to Enhance CBT Competence and Metacompetence
Introduction
What is SP/SR?
Using SP/SR to Enhance the Competencies and Meta-competencies of Inexperienced Therapists
Using SP/SR To Enhance the Artistry of Experienced Therapists
Core Conditions Recommended for SP/SR
Concluding Remarks
References
17 Using Outcome Measures and Feedback to Enhance Therapy and Empower Patients
Introduction
Types of Outcome Measures/Self-Report Questionnaires
The Art of Using Outcome Measures and Patient Feedback Throughout Treatment
Enhancing the Course of Therapy
Using Outcomes Measures in Supervision
Patients Like Them (Yes They Do!)
Acknowledgements
Useful resources
References
18 Making CBT Supervision More Effective
Background to CBT Supervision
Using CBT Supervision
Providing CBT Supervision
How to Become a More Effective Supervisor
Acknowledgements
References
19 Take Control of your Training for Competence and Metacompetence
Introduction
Theories of Learning
How to Learn Competence and Metacompetence
Training Others for Metacompetence
Conclusion
Acknowledgements
References
An Afterword about Therapist Style
What is
Your
Style?
First Impressions: An Example of How Styles Differ
Style and Competence
Developing Styles
Be Yourself
Acknowledgements
References
Index
End User License Agreement
List of Tables
Chapter 01
Table 1.1 Likely differences between trials and routine practice
Chapter 02
Table 2.1 Behavioural strategies: exposure compared to behavioural experiments
Chapter 05
Table 5.1 Conclusions based on Bauer et al.’s (2012) review of CBT outcomes for anxiety disorders with depression
Table 5.2 Recommendations from UK anxiety and depression treatment guidance regarding sequencing of treatment with co-morbid depression and anxiety (National Institute for Health and Care Excellence (NICE), 2005a, 2005b, 2009, 2011, 2013)
Chapter 11
Table 11.1 Unhelpful thoughts and possible interventions
Table 11.2 Special considerations in chronic pain, diabetes, CHD and COPD
Chapter 13
Table 13.1 CBTp books and therapy manuals
Chapter 14
Table 14.1 Strategies for adapting CBT in older people with mild cognitive impairments
Table 14.2 Strategies for adapting CBT in older people with co-morbid physical illness
Chapter 16
Table 16.1 Summary of main SP/SR research findings
Table 16.2 SP/SR Case example: Laura
Table 16.3 Example of reflective questions for a specific thought diary task
Table 16.4 Advantages and disadvantages of different methods of SP/SR delivery
Chapter 17
Table 17.1 Troubleshooting problems with measures
Table 17.2 Examples of outcome and process measures for adults with depression and anxiety disorders
List of Illustrations
Chapter 01
Figure 1.1 Competences for the effective delivery of CBT for depression and anxiety disorders (Roth & Pilling, 2007). © Crown Copyright (2007).
Figure 1.2 Different styles of CBT practice associated with loose/tight application of CBT principles, tactics and technique. © Adrian Whittington and Nick Grey (2013).
Chapter 02
Figure 2.1 Interacting systems.
Chapter 04
Figure 4.1 A framework for adapting CBT for diversity.
Figure 4.2 Pictorial graded exposure tasks, developed in session then photographed from a whiteboard to support homework. On the left, a hierarchy for exposure to trauma-related cues. On the right, repeated exposure task for panic disorder, with instructions to leave the house and buy milk daily while deploying attention externally: “Attention! Your eyes focused on your surroundings and not on your body!”
Chapter 05
Figure 5.1 Treatment choice decision tree. © Adrian Whittington (2013).
Figure 5.2 Brian’s idiosyncratic conceptualization of depression and panic disorder, showing maintaining links between the two disorders.
Chapter 06
Figure 6.1 The case conceptualization crucible. © Kuyken, Padesky and Dudley (2009). Reproduced with permission of the authors.
Figure 6.2 Descriptive conceptualization of a presenting issue.
Figure 6.3 Descriptive conceptualization of resilience.
Figure 6.4 Inter-connected descriptive conceptualization (connected at behavioural domain).
Figure 6.5 Cross-sectional inter-linked conceptualization.
Figure 6.6 Cross-sectional conceptualization linked to conditional beliefs: Mel.
Chapter 07
Figure 7.1 Transdiagnostic cognitive behavioural model of anxiety disorders. © Freda McManus and Roz Shafran 2013.
Figure 7.2 Transdiagnostic formulation of Clare’s difficulties.
Chapter 08
Figure 8.1 Initial guidelines for talking about the past.
Figure 8.2 Examples of questions about different aspects of meaning.
Chapter 09
Figure 9.1 The Interpersonal Schema Worksheet. © Moorey (2013). Reproduced with permission of the author.
Chapter 11
Figure 11.1 A biopsychosocial model.
Figure 11.2 Assessment – areas to consider.
Chapter 13
Figure 13.1 Core elements of CBTp. Data from Morrison and Barratt (2010). Jolley and Garety, 2011. Reproduced with permission from Wiley.
Figure 13.2 Maintenance formulation of Peter’s psychotic symptoms.
Chapter 14
Figure 14.1 Factors that may help to assesses suitability for CBT and may be addressed in the early stages of therapy with older people (adapted from Segal et al., 1995).
Figure 14.2 CBT conceptual framework for older people (adapted from Laidlaw et al. 2003; Laidlaw et al., 2004).
Figure 14.3 Using mini formulations to enhance older people’s psychological understanding of their emotional disorder (adapted from Charlesworth & Reichelt, 2004).
Figure 14.4 James’ four quadrant framework for applying CBT to the needs of older people (adapted from James, 2008).
Figure 14.5 Mini formulation of depression in patient with chronic emphysema.
Chapter 15
Figure 15.1 Risk factors.
Chapter 18
Figure 18.1 Competency model of supervision. © Nick Grey, Alicia Deale, Suzanne Byrne and Sheena Liness.
Figure 18.2 A structured supervision plan. © Centre for Anxiety Disorders and Trauma and Institute of Psychiatry PgDip in CBT.
Figure 18.3 Examples of questions that may be used in a supervision session, which centre on the Kolb cycle.
Chapter 19
Figure 19.1 Kolb’s Experiential Learning Cycle, applied to learning CBT.
Note
: Kolb’s model highlights different types of activities that need to be linked in order to enable learning, and shows that learners need to take up an active role in making the links and ensuring that they are progressing around the cycle.
Figure 19.2 Training target tool. © Adrian Whittington (2013).
Figure 19.3 Training target tool: completed example. © Adrian Whittington (2013).
Guide
Cover
Table of Contents
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How to Become a More Effective CBT Therapist
Mastering Metacompetence in Clinical Practice
Edited by
Adrian Whittington and Nick Grey
This edition first published 2014
© 2014 John Wiley & Sons, Ltd.
Registered OfficeJohn Wiley & Sons, Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK
Editorial Offices350 Main Street, Malden, MA 02148-5020, USA9600 Garsington Road, Oxford, OX4 2DQ, UKThe Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK
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Library of Congress Cataloging-in-Publication Data
How to become a more effective CBT therapist : mastering metacompetence in clinical practice / edited by Adrian Whittington and Nick Grey. pages cm Includes bibliographical references and index. ISBN 978-1-118-46834-0 (hardback) – ISBN 978-1-118-46835-7 (paper) 1. Cognitive therapy. 2. Clinical competence. 3. Therapist and patient. I. Whittington, Adrian, editor of compilation. II. Grey, Nick, 1970– editor of compilation. RC489.C63H69 2014 616.89′1425–dc23
2013050604
A catalogue record for this book is available from the British Library.
Cover image: © Fenykepez/iStockphoto
For David Westbrook
About the Editors
Adrian Whittington is Director of Education and Training and Consultant Clinical Psychologist at Sussex Partnership NHS Foundation Trust, where he leads on training programmes in CBT and other evidence-based psychological therapies. He works clinically with people with anxiety disorders and depression and teaches on the postgraduate CBT training programme at the University of Sussex.
Nick Grey is a Consultant Clinical Psychologist and Joint Clinical Director of the Centre for Anxiety Disorders and Trauma (CADAT), South London and Maudsley NHS Foundation Trust, King’s Health Partners. His clinical work is providing outpatient cognitive therapy to people with a variety of anxiety disorders both within randomized controlled trials and in a more general NHS service. He is actively involved in disseminating cognitive behavioural therapies, trying to ensure that the most effective treatments are applied in routine care. He is accredited as a practitioner, supervisor and trainer with the British Association of Behavioural and Cognitive Psychotherapies.
About the Contributors
James Bennett-Levy is Associate Professor at the University of Sydney's University Centre for Rural Health (North Coast). He is one of the leading researchers on the training of CBT therapists. He has co-written Experiencing CBT from the Inside Out: A Self-Practice/Self-Reflection Workbook for Therapists (2014) and the Oxford Guide to Imagery in Cognitive Therapy (2011), and co-edited the Oxford Guide to Behavioural Experiments in Cognitive Therapy (2004), and the Oxford Guide to Low Intensity CBT Interventions (2010).
Steve Boddington is a Consultant Clinical Psychologist, and Head of Psychology and Psychological Therapies, Mental Health of Older Adults and Dementia, South London and Maudsley NHS Foundation Trust. Steve is a registered Practitioner Psychologist and Chartered Psychologist with 20 years of specialist experience in working with older people. He is an associate fellow of the British Psychological Society and a past chair of the Division of Clinical Psychology's Faculty of Psychology for Older People. He has an interest in the development of accessible psychological services that meet the needs of older people, sitting on various national working groups, and has been involved in the development and delivery of training on the application of CBT for older people.
Gillian Butler is a Consultant Clinical Psychologist working with Oxford Cognitive Therapy Centre and Oxford Health NHS Foundation Trust. She now works in the forensic service and has special interests in the use of CBT during recovery from traumatic experiences in childhood, and in developing a sense of self. She is co-author of Manage Your Mind: The Mental Fitness Guide and of Psychology: A Very Short Introduction, and author of Overcoming Social Anxiety and Shyness.
Suzanne Byrne is the Deputy Course Director for CBT (IAPT Adult Programmes) at the Institute of Psychiatry, Kings College London. She is an honorary Cognitive Behavioural Psychotherapist at the Centre for Anxiety Disorders and Trauma South London and Maudsley NHS Foundation Trust.
Anna Chaddock is a Clinical Psychologist and Cognitive Behaviour Therapist. She is employed by Newcastle upon Tyne Hospitals NHS Foundation Trust in their Specialist Palliative Care and Primary Care Mental Health services. Her special interests include reflection in CBT and interpersonal processes, particularly empathy.
Simon Darnley is the Head of the Anxiety Disorders Residential Unit based at the Bethlem Royal Hospital. He was a psychiatric nurse before training as a cognitive behavioural psychotherapist. Simon has been involved in CBT treatment, training and supervision for over 20 years. He is also now Head of Mood, Anxiety and Personality Disorder Clinical Pathways for Lambeth, within the South London and Maudsley NHS Foundation Trust, managing a wide range of clinical services. He is an award-winning part-time magician, a member of the Magic Circle and President of the Kent Magicians Guild.
Kate M. Davidson is a Fellow of the British Psychological Society and Director of the Glasgow Institute of Psychosocial Interventions, NHS Greater Glasgow and Clyde and University of Glasgow. She completed her clinical training and PhD at University of Edinburgh. She is an Editor of Personality and Mental Health. She developed and evaluated the efficacy of CBT for personality disorders in both community and now in forensic settings.
Melanie Davis is a Clinical Psychologist delivering CBT in both individual and group settings as part of the Durham Pain Management Service. She supports the rest of the multidisciplinary team through consultation and training in psychological approaches to pain management. Her research interests include the interpersonal process in CBT and the use of reflection to enhance therapeutic knowledge and skill.
Nicole de Zoysa is a senior clinical psychologist working in the diabetes and cardiac rehabilitation services at King's College Hospital. She has taught on IAPT training courses for the past three years focussing on adapting step two and step three interventions for people living with long-term conditions. Nicole de Zoysa has also published in the areas of mindfulness-based cognitive therapy and motivational interviewing for primary care nurses and diabetes educators.
Alicia Deale is a Cognitive Behavioural Psychotherapist at the Centre for Anxiety Disorders and Trauma, South London and Maudsley NHS Foundation Trust. She is a part-time clinical tutor and course supervisor on the Postgraduate Diploma in CBT at the Institute of Psychiatry.
Sharif El-Leithy is a principal clinical psychologist and BABCP accredited cognitive therapist, specializing in post-traumatic stress disorder (PTSD). For the last 12 years he has worked in the Traumatic Stress Service in Tooting, South London, offering psychological treatment to diverse populations including ex-military and survivors of war and torture. He was part of the screen-and-treat program that followed the 2005 London bombings, and set up similar programs for assault victims within local hospital settings.
Myra S. Hunter is Professor of Clinical Health Psychology with King's College London. She has worked in both clinical and academic roles with people with physical health problems for over 30 years, with a particular interest in oncology, cardiology and women's health. She has developed cognitive behaviourally-based interventions for women with premenstrual and menopausal symptoms and is currently evaluating interventions for people with non-cardiac chest pain and for men with prostate cancer treatment related symptoms.
Jane Hutton was awarded her Doctorate in Clinical Psychology from the Institute of Psychiatry, where she holds an honorary contract. She is employed by South London and Maudsley NHS Foundation Trust and is Consultant Clinical Psychologist in the Department of Psychological Medicine at King's College Hospital. Her research and clinical interests are in mindfulness-based approaches and CBT for people living with physical health problems.
Stephanie Jarrett is a Consultant Clinical Psychologist with a long-standing interest in psychological approaches to physical health problems. Her doctorate was in psychosocial oncology and she now works in the chronic pain service at University Hospital Lewisham where she has set up individual and group services for patients. She has taught a wide range of medical and psychological professionals on the biopsychosocial model of chronic pain and has recently published evidence of the clinical and cost-effectiveness of using this approach.
Louise Johns is a chartered consultant clinical psychologist and coordinator of a specialist outpatient psychological therapies service for psychosis (PICuP: Psychological Interventions Clinic for outpatients with Psychosis), South London and Maudsley (SLaM) NHS Foundation Trust, London. She is also an honorary senior lecturer at the Institute of Psychiatry (IOP), King’s College London. She has worked in a clinical and research capacity in the field of psychosis for 15 years, and has published over 50 articles on psychosis, covering development and psychopathology of symptoms, and cognitive behavioural treatments.
Suzanne Jolley is a Research Clinical Psychologist at King’s College, London, Institute of Psychiatry and an Honorary Consultant Clinical Psychologist in the South London and Maudsley NHS Foundation Trust, Psychosis Recovery services. She co-developed the King’s/IOP PGDip in CBT for Psychosis. Her clinical practice, teaching and research have been primarily in psychosis over the past 20 years, with interests in training, dissemination, workforce development, cognitive models of delusions, and psychosis in children.
Nadine Keen is a Principal Clinical Psychologist at a specialist outpatient psychological therapies service for psychosis (PICuP) based at SLaM, and holds an honorary contract with the IOP where she is involved with teaching and research. She has specialized in psychosis for the past 10 years and was a trial therapist on the multicentre RCT for cognitive therapy for command hallucinations (COMMAND). Nadine was also a therapist on the London Bombings Screen and Treat Programme where she specialized in the treatment of PTSD. She has a longstanding clinical and research interest in the confluence of PTSD and psychosis as well as working with imagery in psychosis.
Helen Kennerley is a Consultant Clinical Psychologist in Oxford Health NHS Foundation Trust and a Senior Associate Tutor with the University of Oxford. She has practiced CBT for over 25 years and is a founder member of the Oxford Cognitive Therapy Centre (OCTC). She has written several popular cognitive therapy self-help books and co-authored and co-edited a number of CBT text books including a very popular introduction to CBT.
Rob Kidney attained his Doctorate in Clinical Psychology in Plymouth in 2003 and completed his Masters in Psychological Therapies (CBT) in Exeter in 2007. He has been the service lead for an adult IAPT service, academic lead for High Intensity CBT at the University of Exeter and trial therapist on the NIHR-HTA funded CoBalT trial (Cognitive Behavioural Therapy as an adjunct to pharmacotherapy for treatment resistant depression in primary care: a randomized controlled trial). He has published in the British Journal of Clinical Psychology, and provided workshops at local, national and international conferences. Currently Rob is working for Virgin on behalf of the NHS as Lead Clinical Psychologist in Southern Devon CAMHS with an emphasis upon training, supervising and delivering CBT provision.
Willem Kuyken works as a researcher, trainer and clinician at the Mood Disorders Centre in Exeter. His research and clinical work specialize in CBT and mindfulness-based approaches to recurrent depression. A particular theme of his work is exploring how therapists co-create conceptualizations with their clients that enhance the effectiveness of therapy. He has published several publications on case conceptualization, including the book, co-authored with Christine Padesky and Rob Dudley, Collaborative Case Conceptualization.
Sheena Liness is Course Director of the postgraduate adult CBT training programmes at the Institute of Psychiatry, King’s College London. Sheena organizes, teaches and supervises on a range of programmes including the High Intensity (IAPT) Programme. She is an accredited BABCP trainer, supervisor and CBT therapist and has worked in CBT clinical practice for 20 years.
Freda McManus is the (acting) Director of the Oxford Cognitive Therapy Centre and has been Director of the University of Oxford’s PG Dip in CBT for the past nine years. She has worked in both the University of Oxford’s Department of Psychiatry and at the Centre for Anxiety Disorders and Trauma (Kings College London) helping to devise and evaluate cognitive behavioural treatments for anxiety disorders. Freda McManus has published widely in the area of cognitive-behaviour therapy for anxiety disorders, and on training clinicians in CBT interventions.
Stirling Moorey is Consultant Psychiatrist in CBT and former professional Head of Psychotherapy at South London and Maudsley NHS Foundation Trust. He is a trained cognitive therapist and cognitive analytic therapist who has been teaching and supervising CBT for many years and has an interest in how the therapy relationship can be understood within the cognitive model. His other area of interest is the application of CBT to people with cancer.
Emmanuelle Peters is Reader in Clinical Psychology at the Institute of Psychiatry (IOP), King’s College London, and the director of a specialist outpatients psychological therapies service for psychosis (PICuP), based at South London and Maudsley NHS Foundation Trust. She has specialized in psychosis for the past 25 years as a clinician, researcher and trainer. Her research interests include the continuum view of psychosis, cognitive models of psychotic symptoms, and CBT for psychosis.
Roz Shafran is Professor of Clinical Psychology at the University of Reading and founder of the Charlie Waller Institute of Evidence Based Psychological Treatment. Her clinical and research interests include the development and dissemination of cognitive behavioural theories and treatments. She is an associate editor of “Behaviour Research and Therapy”. She recently received an award for Distinguished Contributions to Professional Psychology from the British Psychological Society and the Marsh Award for Mental Health work.
Biza Stenfert Kroese is a Senior Lecturer in Clinical Psychology at the University of Birmingham and a Consultant Clinical Psychologist who until recently managed an NHS psychology service for people with intellectual disabilities (ID). She has co-edited books and published papers on challenging behaviour and the application of CBT for people with ID as well as papers on mental health and ID, parents with ID and staff attitudes on working with people with ID. She is involved in a national research trial of CBT intervention for anger.
Richard Thwaites is a Consultant Clinical Psychologist and CBT therapist, employed as Clinical Lead for a large NHS IAPT service covering Cumbria, UK. In addition to delivering therapy he provides clinical leadership, supervision and training within the service and wider organization. His research interests include the role of the therapeutic relationship in CBT and the use of reflective practice in the process of skill development. He is co-author of the book Experiencing CBT from the Inside Out: A Self-Practice/Self-Reflection Workbook for Therapists (2014).
David Westbrook was a Consultant Clinical Psychologist, and was Director of Oxford Cognitive Therapy Centre (OCTC) until June 2012. He practiced CBT for over 25 years and after stepping down from the role of director he continued to work part-time in OCTC, doing training, supervision and research, and part-time as an NHS clinician, providing a service for patients with severe and complex problems. David edited a number of influential and critically acclaimed books on CBT. Tragically, David died in 2013 during the production of this book. He was known as a brilliant, humble, kind, humorous man.
Michael Worrell is Consultant Clinical Psychologist and director of postgraduate CBT training programmes at Central and North West London Foundation NHS Trust and Royal Holloway University of London. Michael directs a range of programmes including the Post Graduate Diploma and MSc in CBT, The High Intensity Training (IAPT) Programme, Post Qualification Training in CBT Supervision and the Behavioural Couples Therapy Training. His interests include “resistance”, managing endings, the therapy relationship and couple therapy.
Foreword
David M. Clark
Professor of Experimental Psychology, University of Oxford
Cognitive behaviour therapies have established their efficacy with a wide range of mental health problems, both in randomized trials and in audits of routine clinical practice. However, there has been a persistent difficulty in providing CBT treatments to everyone who could benefit, due to insufficient numbers of suitably trained therapists.
In 2008 England embarked on an exciting programme to disseminate psychological therapy on a wider scale than has been ever been attempted before, with CBT forming the core treatment to be delivered by the new services for people with depression and anxiety disorders. By 2014 the Improving Access to Psychological Therapies (IAPT) programme will have trained 6,000 new therapists in evidence-based treatments recommended by the National Institute for Health and Clinical Excellence (NICE). The training courses established follow defined curricula, which ensure that the competencies needed to provide many of the leading empirically supported CBT treatments for depression and anxiety disorders are covered, as laid out in Roth and Pilling’s (2007) competency framework.
Analysis of the outcomes delivered by the IAPT programme is confirming that CBT and the other treatments can be effective in routine services, but also that, as already observed in clinical trials, not everyone improves, or improvement may be partial (Clark, 2011). To overcome this problem we need to do two things. First, we need continue to improve our treatments. Second, we need ensure that the treatments that we currently have are delivered as competently as possible. This book focuses on the second of these imperatives, providing tools for clinicians to help them remain faithful to the treatments that are effective, while considering how and when treatments need to be tailored or adapted to specific individual circumstances and needs. Of course adaptation and flexing of CBT is not an “add-on” for some cases only, but a method of providing effective therapy in every case. However, the adaptations become more diverse and stretching in the most complex cases or when working with specific client groups that may have particular needs beyond those of the populations with which treatments were developed.
In this book Adrian Whittington, Nick Grey and colleagues explore how to tailor CBT methods while remaining true to the core principles, basing interventions on an individualized CBT formulation, guided by the best evidence and theory. The book is compiled from the distilled knowledge of some of the most skilled and experienced clinicians, who ground their insights in the foundations of CBT while suggesting ways to handle complexity and adaptations for specific adult client groups. Later chapters provide guidance to develop further as a therapist and to ensure that the learning is implemented systematically and successfully. This is a practical book to be read, but above all, to be used regularly to guide one’s work.
References
Clark, D. M. (2011). Implementing NICE guidelines for the psychological treatment of depression and anxiety disorders: The IAPT experience.
International Review of Psychiatry
,
23
(4), 318–327.
Roth, A. D., & Pilling, S. (2007).
The competences required to deliver effective cognitive and behavioural therapy for people with depression and with anxiety disorders
. London: Department of Health.
Foreword
Tony Roth
Professor of Clinical Psychology, University College London
It is a pleasure to have been invited to contribute to this book, not least because it has given me the chance to preview the contributions of a number of eminent and talented clinicians, and to use this opportunity to reflect on what metacompetences are, and how they are used.
The CBT competence framework (Roth & Pilling, 2007) was the first of what has become a suite of frameworks, now covering a range of therapeutic modalities and clinical populations. As a prototype for what followed, it acted as a test-bed for our ideas about how best to set out the knowledge and skills that underpinned the effective delivery of psychological therapies. One aim was that the framework was oriented towards competence rather than adherence, congruent with the sentiment that clinicians should not only do the right thing, but also do the right thing in the right way. Although the way we phrased competence descriptions reflected this stance, it became clear that some competences seemed to operate at a different level to others, because they focused on the way in which sets of competences were deployed, and in this sense could be seen as “meta” to others. It is fair to say that initially we lacked a well thought through conceptualization or definition that separated the “ordinary” from these “meta” competences, and even as work proceeded and we gathered examples of what they might look like, we still struggled to arrive at robust conceptualization. Without one it was all too easy for this term to become synonymous with complexity, resulting in almost everything beyond the “straightforward” application of therapy technique being flagged as a metacompetence – not a very useful development. The prefix “meta” implies that these competences are in a sense superordinate to some other set of actions, and although they are more likely to be evident when managing therapeutic challenge or complexity, it is this overarching or overseeing quality that is their appropriate focus.
One way of thinking about metacompetences is the idea of “procedural” rules that guide the assembly and sequencing of an action. These often involve balancing one decision about how to proceed in therapy against another, scoping and filtering a range of potential ways forward in order to arrive at a rational choice of action. Initially this decision making is likely to be fairly conscious, but increasingly in most, but not all cases, will become “more automatic” with experience and training, and so can be seen as a formal representation of what is often referred to as clinical acumen. Some examples from the CBT framework may help to illustrate this:
“Juggling” competing demands: An ability to maintain adherence to an agreed agenda and to “pace” the session in a manner which ensures that all agreed items can be given appropriate attention (i.e., ensuring that significant issues are not rushed)
Monitoring and responding to the way a session unfolds: An ability to be aware of, and respond to, emotional shifts occurring in each session, with the aim of maintaining an optimal level of emotional arousal (i.e., ensuring that the client is neither remote from, or overwhelmed by, their feelings).
Constructing the intervention in a way that holds in mind a holistic sense of the client’s needs: An ability to implement the CBT model in a manner that is consonant with a comprehensive formulation that takes into account all relevant aspects of the client’s presentation
Hopefully these examples make it clear that metacompetences are not abstruse; their challenge lies in the fact that they require clinicians to make particular types of judgment. The common thread is that these judgments usually involve titration: weighing the consequences of one action against the other and arriving at a decision about how best to implement the therapeutic process.
In their introduction Adrian Whittington and Nick Grey adopt an analogy for metacompetence that I also find myself using. Great cooks are distinguished not by their ability to adhere to a recipe but by their ability to use the recipe as a guide, bringing to bear knowledge of the general principles that underpin cookery and a capacity to implement specific techniques, and where necessary developing bespoke recipes that take account of missing ingredients and the utensils that they have at their disposal. This is a critical, even if obvious, observation: it means that recipes – and by analogy competence frameworks – are best seen as indicative and not prescriptive, not directives for action but guidance that should be interpreted in order to arrive at the best action to take. But identifying how this is done is quite a challenge, especially if we are to do so without resorting to portmanteau phrases such as “flair” that promise much but actually mean very little – after all, we can’t train people to show “flair” unless we know what this comprises.
What would be helpful is to define the sort of steps that amount to (or are associated with) this sort of therapeutic capacity, aiming to identify and explicate the skills that differentiate the fluent from the struggling therapist, and by incorporating these into training make it more likely that these skills will be reproduced. This, of course, is the raison d’être of this book. Students of psychological therapy often complain about the gap between what they are taught and what happens in the clinic. Few clients they see are like those described in text books, and what seems straightforward on paper is challenging in practice, sometimes overwhelmingly so. This book directly addresses this gap between theory and practice by making more explicit the thinking and judgment that is required to translate CBT theory into CBT practice, focusing on the necessary twists and turns in which therapists need to engage if the outcomes their clients seek are to be achieved.
Reference
Roth, A. D., & Pilling, S. (2007).
The competences required to deliver effective cognitive and behavioural therapy for people with depression and with anxiety disorders
. London: Department of Health.
IThe Foundations
1Mastering Metacompetence: The Science and Art of Cognitive Behavioural Therapy
Adrian Whittington and Nick Grey
In a professional kitchen, recipes are essential to creating consistent food, so that everyone takes the same path to the same place. But cooks who rely only on strictly codified formulas miss out on what is really important. Are the carrots more or less sweet, more or less tender? Is the ginger very strong, so that less should be used, or too weak for the amount specified? Or the thorniest problem: How long does it take something to cook, in a specific oven, on a specific day, with a certain set of ingredients?
Daniel Patterson, Head Chef, Coi, San Francisco1
Introduction
Cognitive Behavioural Therapy (CBT) has grown up in a scientific tradition, which has been highly productive in the development of effective therapy. Research trials have given us a firm foundation for expanding the delivery of CBT, with the approaches delivered in the trials being reproduced in routine care to help a lot of people a lot of the time.
However, these trials can seem a long way from the consulting room when as a therapist you sit down with a unique client who has a unique set of difficulties and strengths. As a therapist you face a seemingly infinite range of options in your moment to moment decision making about what to do next as you try to deliver CBT in the most helpful way with this client at this point in time. A lot of the time you probably cannot be sure of the best options and have to proceed in the hope and faith that by working collaboratively with your client you will be able to negotiate a helpful way forward. This can feel more like an art than a science. Abilities required to apply therapy artfully, in a flexible and individually tailored way, have been named “metacompetences” in Roth and Pilling’s competence framework for CBT (Roth & Pilling, 2007).
There are significant pitfalls on the path between the science of CBT and its artful delivery. These include the risk of rejecting the research base because of a sometimes imperfect fit with routine practice, the risk of drifting away from effective methods in the belief that you are being helpfully flexible, and the risk of being overly rigid in your approach in an attempt to adhere to protocol.
We believe that the science and art of CBT can and should be brought closer together to help avoid these risks, and that the concept of metacompetent adherence gives us a framework for bridging this gap. Metacompetent adherence means making your therapy decisions based on evidence that clearly supports the practice and on a sound theoretical rationale where the evidence is less clear. Mastering metacompetence is a process of making explicit and enacting the if–then procedural rules of therapy adaptation and where possible drawing on the evidence base. These rules will not take away all uncertainty, however. The experience of not knowing is inevitable and perhaps desirable for therapists – human experiences require you to respond with humility, compassion and openness to learning as you deliver the best evidence-based intervention that you can.
The Science of CBT: Efficacy, Effectiveness and Evidence-Based Practice
Thousands of research trials have been conducted to address the question of whether and for whom CBT is useful, and how it can be most effective. The research base of CBT includes efficacy studies that test treatment in carefully controlled experimental conditions and effectiveness studies that test the interventions in routine care settings, as well as a plethora of other approaches including dissemination trials, single case research, dismantling studies and experimental designs. Of these approaches randomized control trial (RCT) evidence has traditionally been viewed as the “gold standard” methodology for establishing whether an intervention works (Kaptchuck, 2001).
This scientific effort has been more intensive than for any other form of psychotherapy. Analysis of “what works for whom” clearly indicates CBT’s wide utility (Roth & Fonagy, 2005). As a consequence of this evidence, CBT has been recommended in evidence-based treatment guidance for a wide range of psychological difficulties (e.g., National Institute for Health and Clinical Excellence, 2009, 2011) and has become more widely available. In the United Kingdom, a national programme to increase access to psychological therapies for depression and anxiety disorders has seen an unprecedented expansion in the provision of CBT (Clark, 2011).
Both efficacy and effectiveness research shows that CBT works for many people with many types of difficulties and that research-based interventions can be applied in routine practice without dramatic reduction in effect. However, trial-based evidence will never resolve all of your dilemmas as a therapist about exactly what works for whom in which situations. This has led to a movement towards evidence-based practice (EBP) as an approach to guide clinical decision making, drawing on a combination of research evidence, clinical expertise and client preferences (Lillienfield, Ritschel, Lynn, Cautin, & Latzman, 2013).
Efficacy of CBT
Efficacy studies are those in which the treatment is carefully studied under “ideal” experimental conditions in a randomized controlled trial (RCT). Most reviews and meta-analyses have examined how CBT treatments have performed in efficacy studies. These have themselves been examined in a larger review of meta-analyses of CBT RCTs across a wide range of disorders (Butler, Chapman, Forman, & Beck, 2006). Overall large effect sizes for CBT were seen for unipolar depression, generalized anxiety disorder, panic disorder, social anxiety disorder and post-traumatic stress disorder; moderate effect sizes for working with pain and anger; and CBT was as effective as behaviour therapy for obsessive compulsive disorder.
The degree to which results from RCTs translate into routine practice is a contentious issue (e.g., Westen, Novotny and Thompson-Brenner, 2004). RCTs typically have a single therapeutic focus (i.e., a particular psychiatric diagnosis/disorder), have an associated treatment manual, and are usually of a relatively brief fixed duration. This all makes sense scientifically, maximizing internal validity of the study, but has led to critiques of the evidence, suggesting that RCT conditions are too divorced from the realities of routine practice.
Effectiveness of CBT
Effectiveness studies measure the outcome of interventions provided in “routine” care settings. Effectiveness research indicates that it is possible to reproduce CBT RCT interventions in routine care settings with fewer controls and without greatly reducing their effects, although this is not guaranteed. A meta-analytic review of effectiveness trials of CBT for anxiety disorders showed that mean effect sizes were comparable to those in benchmarked RCTs (Stewart & Chambless, 2009). A similar meta-analytic review of effectiveness trials of CBT for depression showed a dilution of mean effect size in routine care, although the effect remained large (Hans & Hiller, 2013). Some effectiveness trials have even shown larger effects than in comparable RCTs (Ost, 2013). At one-year follow-up CBT for anxiety disorders in routine care has produced results almost equal to those of RCTs, whereas CBT for depression has not (DiMauro, Domigues, Fernandez, & Tolin, 2013; Gibbons et al., 2010).
The differences in effect of CBT in RCTs and routine care are not uniform and are likely to differ across the variety of treatments badged as CBT. Reasons for dilution of effect are not clear where these have been observed. Possible differences between RCTs and routine care include client characteristics, therapist and therapy characteristics. All may be relevant, but there is evidence that poorer quality control of therapy in routine settings may be at least as important in reducing effects as differences in the clients seen (Stewart & Chambless, 2009; Stirman, DeRubeis, Crits-Cristoph, & Rothman, 2005).
Despite the demonstrable value of CBT in routine settings as well as in RCTs, the evidence is currently insufficient to provide a comprehensive guide to the flexible, individually adapted delivery of CBT. The areas where research cannot be the only guide include numerous areas of complexity such as how best to intervene with co-morbid conditions (Shafran et al., 2009) and how best to deliver “flexibility within fidelity” (Kendall, Gosch, Furr, & Sood, 2008).
Evidence-based practice
There will never be enough research to tell you definitively what will work best for any particular individual client, and there will always be those who seek therapy from you who are “beyond the guidelines” developed during RCT trials. This situation leaves you unable to rely solely on RCT evidence to guide your practice as a therapist. Evidence-based practice (EBP) offers the beginnings of a solution. EBP has been proposed in the United States as an approach to clinical decision-making, drawing on the “three-leg stool” of research evidence, clinical expertise, and client preferences (Spring, 2007). EBP has been distinguished from empirically supported treatments (ESTs) based on RCT evidence, which do not offer explicit specific guidance on adaptation and flexibility (Lilienfield et al., 2013). In the United Kingdom the concept of empirically grounded clinical interventions (EGCIs) also highlights the need for a broader approach to evidence-based practice than can be derived from RCT evidence alone; EGCIs are said to be derived from the sequence of clinical observation, experimental study and theory development, followed by treatment efficacy and effectiveness trials (Salkovskis, 2002). This approach values the role of experimentally derived theory as part of an evidence-based approach to intervention in the absence of specific evidence for what to do next.
As a therapist, EBP and EGCIs offer you a more comprehensive framework for making clinical decisions than trial evidence alone. However, both stop short of defining in detail the nature of the clinical expertise that you will need to draw upon and how you should put this into action.
The Art of CBT: Metacompetence
To be an evidence-based practitioner does not mean that you will always find yourself following a defined course of action or sequence of steps. In fact this is likely to feel like the exception rather than the rule in your therapy sessions. Much of the time you will base your actions on a combination of fundamental CBT therapy competences, your knowledge of specific CBT techniques and models, and an informed negotiation with your client about a way forward. The competences to enact this combination of factors into a coherent and effective therapy for anxiety disorders or depression have been defined very helpfully, drawing on an expert reference group and the manuals used in RCT trials that showed CBT to have a positive effect (Roth & Pilling, 2007).
Roth and Pilling (2007) identified five specific aspects of competence (see Figure 1.1). The first four outline competences of increasing levels of specificity to CBT and to CBT for particular problems, as follows:
Generic therapeutic competences
: Required for the delivery of any psychological therapy, which include knowledge about mental health, ability to engage and assess clients, manage a therapeutic relationship and make use of supervision.
Basic CBT competences
: The foundations of all CBT interventions, including knowledge of core CBT principles and abilities to agree goals collaboratively, jointly manage session structure and introduce a basic formulation using a cognitive-behavioural maintenance cycle.
Specific CBT techniques
: A set of core cognitive and behavioural technical interventions, delivered within the context of Socratic dialogue and including, for example, the use of thought records, behavioural experiments, exposure and activity scheduling.
Problem-specific competences
: The competences to deliver specific CBT intervention packages for particular disorders, for example the Clark intervention for panic disorder (Clark, 1986) or the Jacobson behavioural activation intervention for depression (Jacobson, Dobson, Truax, Addis, et al., 1996).
Figure 1.1 Competences for the effective delivery of CBT for depression and anxiety disorders (Roth & Pilling, 2007). © Crown Copyright (2007).
In addition, recognizing that skilled psychological therapy must be more than a combination of technical procedures, Roth and Pilling (2007) identified a fifth category:
Metacompetences
: These are defined as a set of higher order competences that “focus on the ability to implement models in a manner that is flexible and tailored to the needs of the individual client” (p. 9). Most of their list was derived from RCT therapy manuals, with some based on expert consensus and some on research evidence. Metacompetences were generated in two areas: generic metacompetences, said to be employed in all therapies, and CBT-specific metacompetences. The listed categories of metacompetences are as follows, with a number of specific metacompetences in each category:
Generic metacompetences
:
capacity to use clinical judgement when implementing treatment models
capacity to adapt interventions in response to client feedback, and
capacity to use and respond to humour.
CBT specific metacompetences
:
capacity to implement CBT in a manner consonant with its underlying philosophy,
capacity to formulate and to apply CBT models to the individual client,
capacity to select and apply skilfully the most appropriate CBT intervention method,
capacity to structure sessions and maintain appropriate pacing, and
capacity to manage obstacles to carrying out CBT.
Roth and Pilling suggested that metacompetences may be thought of as procedural rules by which therapists can apply the methods of therapy in a theoretically coherent, but appropriately adapted and individually tailored way, as a good cook may use but adapt a recipe. For example, one generic metacompetence procedural rule is listed as:
[to] maintain adherence to a therapy without inappropriate switching between modalities in response to minor difficulties (i.e., difficulties which can be readily accommodated by the model being applied).
As with the rest of the competency framework the list of metacompetences is not presented as exhaustive or permanent. Metacompetences define your art as a therapist in implementing evidence-based practice, adapting empirically grounded clinical interventions to the circumstances that are presented to you. They encompass the process of translating research findings into practice. We think there is value in building on and expanding the list provided by the Roth and Pilling (2007) framework so that procedural rules for the art of therapy can be made more explicit.
Three Risks to Effective Practice
There are risks in leaving the art of therapy as an implicit skill, assumed to be developed through experience or supervision, rather than something that is at least worth trying to define and make explicit. Without definition, lots of different forms of unhelpful practice can be labelled as appropriate flexibility or adaptation. Therapist resistance to research-based evidence can provide fertile ground in which such anomalous practice can grow. Even those committed to evidence-based practice may drift away from effective approaches or become overly rigid in their approach and not recognize that what is happening is far from artful.
The risk of rejecting research evidence
Many therapists hold research evidence as a highly valued guide in practice, and CBT therapists are likely to value it fairly highly. However, this is by no means universal. A qualitative study of US practicing psychologists found that most ranked research evidence as lower than clinical experience and intuition in guiding their practice (Stewart, Stirman, & Chambless, 2012). In the United Kingdom, therapist disquiet about applying research-based evidence is highlighted by the active debate on the subject in the UK Clinical Psychology professional literature (e.g., Smail, 2006).
Scott Lilienfield and colleagues (2013) have provided a thoughtful and constructive review and commentary on the “resistance” shown by some therapy practitioners to evidence-based practice. They highlight the risks of rejecting research evidence, citing harmful medical practices in mental health such as the prefrontal lobotomy, which gained currency through the reliance on clinical expertise in the absence of research data. Without research evidence, as a therapist you are unable to tell the difference between therapeutic effectiveness and placebo effect or spontaneous remission. This opens the way to a proliferation of spurious treatments.
There are numerous therapist beliefs that may interfere with the delivery of EBP, including a belief that what seems to be the evidence of your own eyes is more valuable than the evidence of RCTs (Lilienfield et al., 2013). Beliefs that we have found to be particularly relevant that could impede the dissemination of effective CBT treatments include beliefs that the clients who enter RCTs are not representative of the population seen in routine care and that treatments derived from RCT manuals are prescriptive and inflexible (Shafran et al., 2009). These beliefs are examined in the light of the following evidence.
Belief 1: Clients entering RCTs are not representative of those seen in routine care, where there are more severe or co-morbid presentations
Co-morbidity is very common, with axis 1 conditions co-morbid with other axis 1 or axis 2 disorders in the range of 50 to 90 per cent (e.g., Kessler, Nelso, McGonagle, & Liu, 1996). It is true that RCTs do sometimes exclude participants with co-morbidity or as a result of severity, for example, if the client is actively suicidal. However, analyses of clients that are seen in routine care suggest that only 5 per cent would have been excluded from an RCT (Stirman et al., 2005). The most common reasons for exclusion in this routine care population would not have been more severe or complex presentations, but the clients in routine care not meeting minimum severity or duration criteria. More recent trials allow extensive co-morbidity without great reduction in outcome (DeRubies et al., 2005; Duffy, Gillespie, & Clark, 2007). Furthermore, a recent study of CBT for PTSD in routine care suggests that the majority of client characteristics that would have led to exclusion from an RCT made no difference to outcome of therapy. Large effect sizes were demonstrated even for clients that would have been excluded from an RCT (Ehlers et al., 2013).
Belief 2: Interventions delivered in RCT manuals are prescriptive and inflexible
Clinical guidelines used in RCTs have been developed for diagnostic categories, which can be limiting in complex cases. However, interventions within RCTs are usually based on an individualized formulation, based tightly on a specific model for the problem that is the focus of the trial. Flexibility is in fact inherent in RCT treatments using manuals and the use of manuals must always involve “flexibility within fidelity” (Kendall and Beidas, 2007). Even in trials participants will “strain the paradigm” (Markowitz et al., 2012).
In reality there are likely to be significant differences between trial conditions and routine care, and also some differences on dimensions of resourcing, therapist expertise and quality control (Roth, Pilling, & Turner, 2010; Stewart and Chambless, 2009) (see Table 1.1).
Table 1.1 Likely differences between trials and routine practice
RCTs
Routine practice
Resources
Usually better resourced
Resources restricted
Assessment
More structured, detailed and regular
Procedures to identify focal problems and diagnoses less common
Therapists
More likely to be expert in administration of a particular treatment
Covering a wider range of main problems
Caseloads
Usually smaller
Usually larger
Therapy
Protocol controls duration and number of sessions
Often service provider controls duration and number of sessions
Engagement
Sometimes greater efforts made to maintain engagement
Sometimes less emphasis on reducing attrition rates given the often large numbers waiting for treatments
Quality control
Adherence monitoring and high quality supervision
Adherence monitoring may be limited and supervision of less consistent quality
These differences in context, therapy and therapist factors suggest that rather than RCTs needing to be more like routine practice in order to provide realistic outcomes, we should endeavour to make routine practice become more like the conditions established in RCTs in order to achieve the best outcomes.
The risk of therapist drift
In a similar vein, there is evidence that therapist “drift” from adherence to evidence-based protocols can lead to poorer responses to treatment. Glenn Waller has observed that therapists commonly “drift” away from pushing for behavioural change (a core element in component analyses of successful treatment) to a more discursive approach (Waller, 2009). This drift may be driven by a number of factors including therapists’ own beliefs, emotional reactions and safety behaviours. Waller proposed that the same factors may lead clinicians to rush to implement newer “third wave” therapies even when the best evidence-based therapy has never been tried.
A detailed analysis of video recordings of CBT for anxiety, confirmed that therapists frequently switched away from core methods such as exposure (Schulte and Eifert, 2002). Therapists explained that they perceived a need to do something different when they faced relational difficulties in the session. More frequent switches in this direction were associated with more negative outcomes of therapy, whereas more frequent switches of direction towards implementing core methods were associated with more positive outcomes. Changes in treatment direction were not triggered by a lack of progress, but by therapists feeling less positive about their relationship with their client. In light of these findings it will be important for you to distinguish metacompetent flexibility and adaptation in your practice from drift or unhelpful changes of direction.
