Introduction
Cognitive behavioural therapy (CBT) training has long held a place for self-practice as an experiential form of clinicians’ learning, maintaining that self-practice is important in helping clinicians understand the intricacies of the model’s approach (Beck, Reference Beck1995; Padesky, Reference Padesky1996). Padesky has stated that ‘to fully understand the process of therapy there is no substitute for using cognitive therapy methods on oneself’ (Padesky, Reference Padesky1996; p. 288). However, it is only in recent decades that this has received empirical interest. While there are still considerable gaps in this research, the initial findings have indicated that ‘active’ or experiential techniques are a key component of effective CBT training and supervision (Bennett-Levy et al., Reference Bennett-Levy, Thwaites, Haarhoff and Perry2015; Gale and Schröder, Reference Gale and Schröder2014; McGillivray et al., Reference McGillivray, Gurtman, Boganin and Sheen2015; Thwaites et al., Reference Thwaites, Bennett-Levy, Davis, Chaddock, Whittington and Grey2014; Thwaites et al., Reference Thwaites, Bennett-Levy, Cairns, Lowrie, Robinson, Haarhoff and Perry2017).
Building on this, Bennett-Levy and colleagues have developed a self-practice/self-reflection (SP/SR) framework to increase the role of the self in the learning process for CBT (Bennett-Levy et al., Reference Bennett-Levy, Thwaites, Haarhoff and Perry2015; Thwaites et al., Reference Thwaites, Bennett-Levy, Cairns, Lowrie, Robinson, Haarhoff and Perry2017). The framework not only incorporates experiential elements of self-practice as the therapist, but also self-practice as a client, and client–therapist pair work, where self-reflection is emphasised for both roles. Such work is described as ‘a focused training strategy that gives therapists a structured experience of using CBT on themselves and reflecting on that experience’ (Thwaites et al., Reference Thwaites, Bennett-Levy, Davis, Chaddock, Whittington and Grey2014; p. 242). The framework is suggested to provide a bridge between the acquisition of declarative knowledge provided to trainees in a didactic manner and the development of clinical skill and expertise (Bennett-Levy et al., Reference Bennett-Levy, Turner, Beaty, Smith, Paterson and Farmer2001; Bennett-Levy et al., Reference Bennett-Levy, Thwaites, Haarhoff and Perry2015). The SR component is further emphasised as a metacompetence that allows therapists to learn from experience and to refine their clinical skill (Bennett-Levy et al., Reference Bennett-Levy, Thwaites, Chaddock and Davis2009).
SP/SR has now been used in a range of training settings for those learning CBT, from novice therapists to more experienced practitioners (e.g. Bennett-Levy et al., Reference Bennett-Levy, Turner, Beaty, Smith, Paterson and Farmer2001; Chigwedere et al., Reference Chigwedere, Thwaites, Fitzmaurice and Donohoe2019; Davis et al., Reference Davis, Thwaites, Freeston and Bennett-Levy2015; Thwaites et al., Reference Thwaites, Bennett-Levy, Davis, Chaddock, Whittington and Grey2014; Thwaites et al., Reference Thwaites, Bennett-Levy, Cairns, Lowrie, Robinson, Haarhoff and Perry2017). These programmes have typically incorporated cognitive exercises, both as class and workbook exercises, as well as behavioural experiments. The research on such SP/SR training techniques has shown it to be an effective model of learning. In particular, the method has demonstrated positive impacts on interpersonal elements of psychotherapy, including a greater attunement to clients and enhanced empathy for clients and their presenting difficulties (Bennett-Levy et al., Reference Bennett-Levy, Lee, Andrews, Pohlman, Hamernik, Travers and Hamernik2003; Bennett-Levy et al., Reference Bennett-Levy, Thwaites, Haarhoff and Perry2015; Chigwedere et al., Reference Chigwedere, Thwaites, Fitzmaurice and Donohoe2019; McGillivray et al., Reference McGillivray, Gurtman, Boganin and Sheen2015; Thwaites et al., Reference Thwaites, Bennett-Levy, Davis, Chaddock, Whittington and Grey2014). SP/SR exercises also improve understanding of cognitive behavioural theory, enhance skill and nuance in the application of cognitive behavioural strategies, and increase therapist confidence (Bennett-Levy et al., Reference Bennett-Levy, Turner, Beaty, Smith, Paterson and Farmer2001; Bennett-Levy et al., Reference Bennett-Levy, Thwaites, Haarhoff and Perry2015; Chigwedere et al., Reference Chigwedere, Thwaites, Fitzmaurice and Donohoe2019; Davis et al., Reference Davis, Thwaites, Freeston and Bennett-Levy2015; McGillivray et al., Reference McGillivray, Gurtman, Boganin and Sheen2015). On a personal level it has been shown to help trainees to gain more self-awareness, to improve their own psychological functioning, and to improved self-reflection skills (Bennett-Levy, Reference Bennett-Levy2019; Gale and Schröder, Reference Gale and Schröder2014; Thwaites et al., Reference Thwaites, Bennett-Levy, Davis, Chaddock, Whittington and Grey2014).
Generally, SP/SR is regarded as an ‘interesting, exciting, and engaging form of learning’ (Bennett-Levy and Lee, Reference Bennett-Levy and Lee2014; p. 58). It can, however, be a more challenging form of training, leading to reduced engagement for some. Factors found to negatively impact on engagement have been identified as anxiety about potential loss of control while engaging in the SP/SR activities and fear of social judgement from group elements of the training strategy (Bennett-Levy and Lee, Reference Bennett-Levy and Lee2014; Spendelow and Butler, Reference Spendelow and Butler2016). Bennett-Levy and Lee (Reference Bennett-Levy and Lee2014) found that these factors can be mitigated by other aspects of training courses. These include the structure and requirements of SP/SR courses, the expectation of benefit, feeling of safety with the process, available personal resources, and group processes. The structure of courses can influence accountability to the process, with self-selection to courses and course requirements positively influencing motivation to complete SP/SR exercises. Similarly, expected benefits, group dynamics, control over the content of such exercises, control over the level of sharing about experiences, and perceived personal resources regarding time and space to cope with the demands of the process can all influence willingness to participate in this learning framework.
Interestingly, the use of SP/SR exercises in training would appear to provide an avenue for competency-based assessment. This is yet to be discussed in the SP/SR literature. It has previously been identified that psychological practice involves competencies relating to the assessment of client needs, the ability to design evidence-based interventions, the ability to implement interventions, and the ability to evaluate outcomes of these (von Treuer and Reynolds, Reference von Treuer and Reynolds2017). SP/SR includes the formulation of the trainee’s own problems, the application of interventions to these problems, and a reflection on what is learned from the exercises. Such work would appear to provide a promising mechanism for competency-based assessment prior to actual client work. This is yet to be investigated, however.
With the exception of a study by Bennett-Levy (Reference Bennett-Levy2003), a limitation of the SP/SR research is that it has primarily focused on the evaluation of overall training programmes and has not focused on outcomes for specific exercises or training models (Spendelow and Butler, Reference Spendelow and Butler2016). A specific behavioural exercise that would appear to be important to include in therapist training would be exposure interventions, due to their importance in treating a range of anxiety conditions (Foa and McLean, Reference Foa and McLean2016; Kaczkurkin and Foa, Reference Kaczkurkin and Foa2015; Mineka and Thomas, Reference Mineka and Thomas1999). Despite this, exposure interventions tend to be under-utilised in therapy due to therapist avoidance (Deacon and Farrell, Reference Deacon and Farrell2013; Richard and Lauterbach, Reference Richard and Lauterbach2007; Scherr et al., Reference Scherr, Herbert and Forman2015) and client factors (Belleau et al., Reference Belleau, Chin, Wanklyn, Zambrano-Vazquez, Schumacher and Coffey2017; Norton et al., Reference Norton, Hayes-Skelton and Klenck2011). Application of SP/SR to training in the use of exposure interventions could potentially help to reduce these problems, fostering greater belief in their efficacy by therapists, and better conceptual and implementation skills to help manage client anxiety about such strategies.
Study aims
This project aimed to review the use of the SP/SR framework in facilitating competency-based assessment. It also sought to apply the SP/SR framework to assess the usefulness of an exposure intervention for social anxiety in teaching trainees cognitive behavioural therapy. The training included a focus on the benefits of engaging in the exposure exercise to facilitate understanding of cognitive behavioural principles; their application to practice; and common difficulties with behaviour change. It also aimed to determine the personal development achieved from the exercise and to understand potential barriers that participants might experience to gaining benefit.
Method
Participants
The study involved 41 (34 female, 7 male) trainees enrolled in their first year of a postgraduate clinical psychology training programme who were undertaking a one semester course in CBT. They were recruited from two consecutive cohorts in 2018 and 2019. The students ages ranged from 23 to 35 years.
Course requirements
The CBT course had been developed with a number of experiential exercises to which the SP/SR principles had been applied. This included real plays (i.e. where training therapists ‘play’ a client using a real issue from their own life, as opposed to a constructed example or an example from someone else; Motivational Interviewing Network of Trainers, 2014), a shame attack exercise (an exposure intervention for social anxiety) and a low frustration tolerance exercise. The shame attack exercise, low frustration tolerance exercise and written reflections on these formed part of the assessment requirements for the unit. The shame attack exercise was chosen as the exposure intervention due to the commonality of social anxiety and the intervention’s historical use in some forms of CBT training (Moldovan and David, Reference Moldovan and David2013). For the shame attack participants were asked to deliberately engage in an activity that they consider to be embarrassing (e.g. going out in public in their pyjamas, bringing attention to themselves by singing in public, wearing unusual clothes, asking embarrassing questions at a shop, etc.). In line with SP/SR principles, students were able to develop their own shame attack exercises, enabling a sense of control over the exercise (Bennett-Levy and Lee, Reference Bennett-Levy and Lee2014), and fitting it within the context of their own experience of social anxiety. For the written reflection component, participants were instructed to write a summary ‘demonstrating a formulation of the issue being addressed (i.e. ABC cognitive behavioural model), your expectations about the experiences, any strategies employed to cope with the task and what you learnt from the exercises’. The learning reflection was further emphasised in the second cohort, with further verbal direction to comment on learning from both a professional and personal perspective in the written reflections. Further clarification of the task requirements was provided verbally in class and a marking rubric noted that the written component of the assignment would be assessed on the appropriateness of the behavioural task that was devised, the detail and depth of the formulation provided, and based on a clear description of the expectations, observations and learning taken from engaging in the task.
Procedure
Research was approved by the Cairnmillar Institute Human Research Ethics Committee. Once students had completed the course, and marks had been released, students enrolled in the courses were asked to participate in the study by providing consent for their written reflections of the shame attack to be included as data for the study. The retrospective collection of data was used to reduce any potential for coercion or dual relationships between the researchers and the participants.
Data analysis
The reflection exercises were analysed using mixed methods. In terms of qualitative analysis, this involved thematic analysis in line with a hybrid inductive-deductive model developed by Fereday and Muir-Cochrane (Reference Fereday and Muir-Cochrane2006), which is also consistent with recommendations made by Braun and Clarke (Reference Braun and Clarke2006). The research was theoretically phenomenological, seeking to understand participants’ experience of the shame attack exercise. It also sought to understand how they constructed their world during the experience, thereby also making it constructivist. Guiding the deductive approach to the analysis was cognitive behavioural literature and SP/SR research. For instance, the appropriateness of the exposure tasks that were designed and the formulations of the reported-reactions were analysed based on cognitive behavioural models. The quality of these formulations was then further analysed with regard to the influence of cognitions on emotions and behaviours, and in relation to levels of cognitive processing (i.e. automatic thoughts/inferences, conditional assumptions/demands, core beliefs/evaluations; Beck, Reference Beck1995; Ellis and MacLaren, Reference Ellis and MacLaren1998). In relation to observations made during the experience, models of social anxiety disorder were used (e.g. worries about negative social evaluation, avoidant behaviours and urges, attentional issues) along with literature on the use of exposure interventions (e.g. motivation for approach behaviour, cognitive change/expectation violation, acceptance of emotional discomfort) to address such anxiety (e.g. Craske et al., Reference Craske, Treanor, Conway, Zbozinek and Vervliet2014; Hofmann, Reference Hofmann2007). The SP/SR literature informed the coding of the key learning taken from the exercise, in terms of both professional development (e.g. deepened appreciation of the cognitive behavioural model, of the model of social anxiety, for the use of exposure interventions) and personal development (e.g. increase self-awareness, improved wellbeing, and enhanced interpersonal beliefs, attitudes and skills; Bennett-Levy, Reference Bennett-Levy2019). To assess the frequency with which key skills were demonstrated or discussed (e.g. ability to develop an appropriate exposure intervention, formulation skills) in the participants’ written papers, and to assist with highlighting how often key themes were noted by participants, basic quantitative analysis (i.e. frequencies) was also conducted. Examples of the qualitative data are then presented to illustrate the reported themes.
Results
Activities undertaken
The activities developed by the participants for the shame attack were analysed to assess their fit as exposure activities for social anxiety. All the exposure exercises were appropriate to the task. The behavioural challenges developed were grouped into three themes. Seventeen (41.4%) of the participants engaged in appearance-related challenges (e.g. wearing odd clothes in public, smearing make-up over their face, talking to others with food in their teeth for an extended period). Twelve participants (29.3%) engaged in more outgoing or non-typical behaviours (e.g. singing and dancing in public settings, making announcements on trains or in lifts, walking a banana on a lead). The remaining 12 (29.3%) targeted their known areas of self-consciousness (e.g. being late to appointments, taking selfies in public, or going to a movie alone).
Formulations
An example of the formulations provided by the participants in their reflection is presented in Fig. 1. From a competency-based perspective, the reflections were assessed for their congruence with models of social anxiety and in relation to the different levels of cognitive processing identified (i.e. automatic thoughts/inferences, conditional assumptions/demands, core beliefs/evaluations). From a SP/SR perspective, the reflections were assessed in terms of deepened appreciation of the cognitive model.
Figure 1. Example of participant formulation.
Thought–feeling–behaviour interactions
The formulations of the shame attack experience were analysed for their congruence with social anxiety reactions and their depth of understanding. Forty-one participants (100%) presented congruent formulations of their anxiety reactions to the task. All the reflections also included notes on actively observing the relationship between cognitions, emotions, physical symptoms and behavioural urges during the exercise. This was observed in the following quotes:
‘This experience confirmed that it is not the reactions from the public that makes me feel anxious, but rather, it is my thoughts about the situation.’
‘Managing to sit with my anxiety and not blocking it taught me that I was not really fearful of the situation itself, rather than my own reaction to this situation.’
‘I noticed that the closer I got to the crossing, the more anxious I became. Just walking toward the lights was the activating event for me; I had thoughts like I’m going to look like a crazy person and my dancing will be terrible. I felt my chest tighten and my heart rate increased considerably.’
‘I also learnt that one of my core beliefs is that I need to uphold a reputation that others see of me and that was what was holding me back.’
Depth of cognitive formulation
The formulations were also analysed to assess the depth of understanding on the cognitive elements involved in the reaction to the shame attack. That is, they were assessed in terms of the three levels of cognitive processing commonly identified in emotional reactions. These were either identified in the moment or suggested as relevant hypotheses afterwards. The possible combinations of cognition types and the number of participants that identified these is demonstrated in Fig. 2.
Figure 2. Number of participants and their identified cognitive profiles.
Observed secondary responses
Eight (19.5%) participants also included secondary emotional responses (i.e. a subsequent emotional response to the initial emotional reaction) in the summary of their formulations for the exercise.
Coping strategies
In relation to their shame attacks, 27 (65.8%) of participants reported using one or more coping strategy to assist them through their experience. The types of coping strategies and reported effects are presented in Table 1.
Table 1. Coping strategies used with shame attack
Observations on experience during the exercise
In summarising the shame attack, participants tended to highlight observations they made while actively engaging in the exposure activity. These observations related to three themes. These were a deepened appreciation for aspects of the cognitive model of social anxiety, an enhanced appreciation of the change process, and an overall negative evaluation of the experience.
Deepened appreciation for cognitive model of social anxiety
A number of observations were made by participants that contributed to a deepened appreciation for the cognitive model of social anxiety, and its maintaining factors. For instance, 19 (46.3%) of the participants commented on the challenge they experienced managing their anxiety and its related urges for avoidant and safety behaviours. For those engaging in such behaviours, the reflections also tended to demonstrate an appreciation for how the behaviour maintained their anxiety, as demonstrated in these statements:
‘I probably didn’t pick the most suitable coping strategy because I just avoided mirrors and tried to speak with my mouth closed. I found myself playing with things a lot more, constantly cleaning up the workplace and fidgeting to make myself physically preoccupied and distract myself from my thoughts.’
‘The persistent use of experiential avoidance strategies might have removed the opportunity to recognise that there was no negative evaluation.’
‘Avoiding eye contact from the strangers around me did not completely rid me of my anxiety. I believe this is because in doing so, it catastrophised my beliefs that people were in fact, looking at me, and judging me, and I wasn’t able to appreciate what actually was happening around me.’
‘It took me a while to get around to completing this task as I was anxious about putting myself in a situation whereby I would be calling attention to myself.’
There were a range of other important observations noted by some of the participants that reflected an increased appreciation of difficulties related to social anxiety. These included:
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Increased appreciation for the discomfort induced by anxiety (3 participants)
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Recognised impact of anxiety on attention (3 participants)
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Became aware of a secondary reaction (2 participants)
Appreciation of change process
Positive observations of the change process were noted in a number of comments made whilst still involved in the exercise. Seventeen participants (41.5%) made comments reflecting a positive appreciation of change that they experienced. This is reflected in the following quotes:
‘As I expected, I found this activity embarrassing however I was surprised at how quickly my embarrassment dissipated.’
‘I learnt that stepping outside of my comfort zone and confronting what I may see as shameful situations is really rewarding.’
‘My anxiety dissipated once I was sitting in the cinema and the movie started.’
‘From this experience I learnt that the exercise was not that awful.’
Other comments on the change process related to:
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Increased appreciation for the cognitive model of change (3 participants)
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Benefit of exposure for change (1 participant)
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Appreciating the effort required to make change (1 participant)
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Appreciation of emotional fluctuations during the exposure (1 participant)
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Difficulty with applying coping statements in the moment (1 participant)
Negative observations
One participant did note having a somewhat negative experience during the exercise, reporting difficulty in tolerating their anxiety. They stated, ‘This exercise was definitely a new experience, and an experience I hope to not have to do again!’.
Key learning
All (41) of the participants reported at least one positive key learning from the exercise. These were primarily related to aspects of personal development.
Positive learning/cognitive change
The most frequently reported positive learning was with regard to experiencing cognitive change/expectancy violation, the key component of exposure interventions (Craske et al., Reference Craske, Treanor, Conway, Zbozinek and Vervliet2014; Pittig et al., Reference Pittig, Treanor, LeBeau and Craske2018). This was reported by 33 (80.5%) of participants, with sample quotes including:
‘It showed me that my worst predictions significantly influenced my anxiety to complete the task. My thoughts were much worse than reality and generally a grossly negative overreaction.’
‘I learnt that your own thoughts about the situation might be wrong and there might be a positive outcome at the end, which you would’ve never experienced had you avoided that situation.’
‘Whilst there were elements that were not completely comfortable, I found that it was not as bad as I had built it up in my mind, and I quite enjoyed the experience overall.’
Improved emotional functioning
In total, 25 (61.0%) participants reported changes to emotional functioning during the exercise. Of these, 12 (29.2%) participants reported a reduction in their level of distress, while 13 (31.7%) of the participants reported that they not only experienced a reduction in anxiety, but that they also experienced a sense of pleasure, achievement and/or empowerment for having completed the task. Examples of this included:
‘I also noticed a sense of relief and accomplishment after completing the task, like I had overcome a large obstacle, and felt much happier for the rest of the day as a result.’
‘After engaging in this shame attacking exercise, I proceeded to wear these socks to do my groceries as well as I decided that I no longer cared that much.’
Increased self-awareness
Increased insight and self-awareness were directly reported by seven participants (17.1%) as a result of the exercise. For instance, these participants stated:
‘In hindsight, I definitely don’t have the best coping strategies as they all involve some level of distraction rather than addressing the situation.’
‘Surprisingly, prior to this I had not realised the secondary emotion of guilt I had around not participating to the degree that I feel my family expects.’ [for an exercise that involved joining her family in singing a song]
‘Being unauthentic and not endorsing my own behaviours and core values has a greater negative impact on my overall mental well-being than not getting approval from strangers.’
Increased self-efficacy
Enhanced belief in capacities for distress tolerance, resilience and ability for change were reported by six of the participants (14.6%). This was reflected in comments that:
‘This has reinforced my tendency to approach anxiety provoking situations with an experimenter’s mindset.’
‘Even if your thoughts about that situation turn out to be right and at first, it appears to be an unpleasant experience, it is still better to persevere with the situation.’
‘I predicted that I would be unable to calm myself down, and that I wouldn’t be able to go through with the whole exercise. I certainly did not expect to feel liberated as the task continued.’
Increased confidence
Increased confidence was described as a direct outcome of the exercise by two participants (4.9%).
Empathy
Only one participant (2.4%) directly commented that the experience had further developed their empathy for future clients attempting similar tasks.
Discussion
The aim of the current study was to assess the value of a shame attack exercise, conducted within an SP/SR framework, in helping to teach trainee therapists CBT. The use of SP for the exposure intervention allowed for a level of competency-based assessment. This provided some insight in the trainees’ abilities to assess, formulate, design interventions, conduct interventions and evaluate outcomes for social anxiety. The SP/SR framework also promoted a deeper level of learning on the cognitive behavioural theory and practice relevant to the exercise. The SR component demonstrated an increased appreciation for the self-reinforcing cycles of anxiety, difficulties for engaging in exposure interventions, challenges with using coping strategies, and ways to modify these. While only one participant directly commented on the contribution of the exercise to the further development of their empathy, the other identified learning could also potentially contribute to the development of empathy.
SP/SR as a form of competency-based assessment
The use of SP/SR to help facilitate competency-based assessment has not been previously discussed in the literature. While SP/SR research indicates that participants often perceive themselves as more competent and confident in the application of CBT techniques, this is typically self-rated with only one study to date using marker-rated assessment of technical skill development (McGillivray et al., Reference McGillivray, Gurtman, Boganin and Sheen2015; Spendelow and Butler, Reference Spendelow and Butler2016).
In this study, the application of the SP/SR framework to a shame attack allowed for appraisal of the trainees’ abilities to assess, formulate, design interventions, and to evaluate the outcomes of these. For instance, the self-reflective formulations allowed for assessment of the depth of understanding of cognitive behavioural theory, giving insight into their understanding of the three different levels of cognitive processing suggested to be involved in an emotional reaction, and for the appreciation of secondary responses in some cases as well (Beck, Reference Beck2011; Ellis, Reference Ellis1994). It also allowed for observation of the trainees’ ability to develop appropriate exposure interventions and to assess the learning outcomes from these, which is central to the effectiveness of such interventions (Craske et al., Reference Craske, Treanor, Conway, Zbozinek and Vervliet2014; Pittig et al., Reference Pittig, Treanor, LeBeau and Craske2018). The noted areas are all consistent with the four core competencies identified by von Treuer and Reynolds (Reference von Treuer and Reynolds2017) as being central to psychological practice. These include the ability to determine client needs, the ability to design evidence-based interventions, the ability to implement interventions, and the ability to evaluate outcomes. While there was no assessment in this study of whether the exercise led to an increase in self-reflective capacity, the SR component did enable observation of the trainees’ ability to self-assess for the development of their professional skills. Such self-assessment and reflection has previously been described as a meta-competency that is central to practitioners’ ongoing development (Thwaites et al., Reference Thwaites, Bennett-Levy, Davis, Chaddock, Whittington and Grey2014; Thwaites et al., Reference Thwaites, Cairns, Bennett-Levy, Johnston, Lowrie, Robinson and Perry2015; von Treuer and Reynolds, Reference von Treuer and Reynolds2017). As an assessment task, the exercise also allowed for the provision of private, individually tailored feedback on the participant’s progress in developing these skills.
Alternatively, to further develop competency-based training elements to the SP/SR framework, it could be useful to provide questions to prompt reflection on the four core competencies identified by von Treuer and Reynolds (Reference von Treuer and Reynolds2017). For instance, formulation skills are quite important for determining client needs. Therefore questions encouraging trainees to reflect on the congruence of their formulation, the level of detail on emotional experience (i.e. intensity, related physiological sensations) and behaviour (including behavioural urges) relevant to their formulation, and regarding the depth of the cognitive aspects of their formulation (i.e. automatic thoughts/inferences, conditional assumptions/demands, core evaluations) could be useful to enhance competency with such skills.
Learning from the shame attack exercise
The qualitative reports provided by the trainees demonstrated that the exposure activity provided deepened learning of CBT theory. It also showed capacity for enhancing empathy for clients and for personal development.
Declarative and procedural learning
The utility of the shame attack exercise in enhancing declarative and procedural learning of cognitive behavioural theory and practice was most evident in the reflection on the formulations. Without exception, the participants all commented on observing the cyclical interactions between their thoughts, feelings and behaviours. The exercise also provided the participants with an opportunity to implement other interventions to help them cope with the exposure. The reflections on these demonstrated that this allowed for a more nuanced understanding of how such strategies could be developed to fit a particular presenting difficulty, and some also commented on challenges and limitations with applying such coping strategies. Finally, the exercise also allowed for a deepened appreciation of the cognitive model of change, with a number of the participants directly commenting on how it helped to change their cognitions and emotional experience.
These findings are consistent with the existing SP/SR literature (Bennett-Levy, Reference Bennett-Levy2019; Bennett-Levy et al., Reference Bennett-Levy, Turner, Beaty, Smith, Paterson and Farmer2001; Chigwedere et al., Reference Chigwedere, Thwaites, Fitzmaurice and Donohoe2019; Gale and Schröder, Reference Gale and Schröder2014; McGillivray et al., Reference McGillivray, Gurtman, Boganin and Sheen2015; Spendelow and Butler, Reference Spendelow and Butler2016). For instance, Bennett-Levy et al. (Reference Bennett-Levy, Turner, Beaty, Smith, Paterson and Farmer2001) found in their initial study that SP/SR training led to a greater understanding of the cognitive model and its process of change. This has now been repeated and reported in a number of review papers (Bennett-Levy, Reference Bennett-Levy2019; Gale and Schröder, Reference Gale and Schröder2014; Haarhoff et al., Reference Haarhoff, Gibson and Flett2011; McGillivray et al., Reference McGillivray, Gurtman, Boganin and Sheen2015). Specifically to anxiety and exposure interventions, McGillivray et al. (Reference McGillivray, Gurtman, Boganin and Sheen2015) noted that the literature has demonstrated that SP/SR promotes an increased understanding of avoidant and compensatory behaviours in maintaining dysfunction. The enhanced understanding of techniques and their limitations has also been reported previously (Chigwedere et al., Reference Chigwedere, Thwaites, Fitzmaurice and Donohoe2019; Gale and Schröder, Reference Gale and Schröder2014; McGillivray et al., Reference McGillivray, Gurtman, Boganin and Sheen2015), and has been shown to enhance therapists’ ability to flexibly adapt such techniques (Gale and Schröder, Reference Gale and Schröder2014; McGillivray et al., Reference McGillivray, Gurtman, Boganin and Sheen2015). Such outcomes have further implications for the therapist’s confidence in their competence with such techniques as well (Bennett-Levy et al., Reference Bennett-Levy, Turner, Beaty, Smith, Paterson and Farmer2001; Davis et al., Reference Davis, Thwaites, Freeston and Bennett-Levy2015).
Self-awareness
Themes relating to enhanced self-awareness were directly and indirectly noted by participants in their reflections. This included increased appreciation of their anxiety, avoidant drives and coping mechanisms, insight into belief systems and complexity added by secondary emotional responses, and appreciation of their ability to experience cognitive and emotional change. This is consistent with the existing literature on SP/SR techniques, which have typically found that participants report increased insight into their own psychological processes as a result of such training techniques (Bennett-Levy, Reference Bennett-Levy2019; Gale and Schröder, Reference Gale and Schröder2014; McGillivray et al., Reference McGillivray, Gurtman, Boganin and Sheen2015; Spendelow and Butler, Reference Spendelow and Butler2016). Such increased self-awareness has been cited as important for the development of therapist skill in managing more complex client presentations (Bennett-Levy, Reference Bennett-Levy2019).
Interpersonal skills
The enhancement of empathy has commonly been cited as an outcome for SP/SR training (Chigwedere et al., Reference Chigwedere, Thwaites, Fitzmaurice and Donohoe2019; Gale and Schröder, Reference Gale and Schröder2014; McGillivray et al., Reference McGillivray, Gurtman, Boganin and Sheen2015; Spendelow and Butler, Reference Spendelow and Butler2016). It was somewhat surprising that only two participants directly reported that their experience contributed to the development of empathy for future clients. Despite this, many of the reflective comments may have implicitly demonstrated a potential for enhancing the trainee’s empathy. For instance, increased appreciation for the difficulties associated with managing emotions and applying interventions have been noted to contribute to empathy for clients and to greater respect for efforts to change (Bennett-Levy et al., Reference Bennett-Levy, Turner, Beaty, Smith, Paterson and Farmer2001; McGillivray et al., Reference McGillivray, Gurtman, Boganin and Sheen2015).
A possible reason for more participants not directly commenting on the translation of such experiences to professional issues may have been the structure of the assignment instruction. While the participants all provided comments on their own personal experience, a number did not extend this to how such learning may impact their professional practice. This may have been a result of the instruction including reference to both personal and professional learning, but not directly asking participants to state the impact of their personal learning on their professional learning. Specific directions or questions to bridge between the two areas of learning may be required to facilitate such reflection. This is in line with suggestions by Thwaites et al. (Reference Thwaites, Bennett-Levy, Cairns, Lowrie, Robinson, Haarhoff and Perry2017), who noted that the structure and clarity of the SR guidelines can influence the depth of reflection and its utility for professional development. Thus, the benefit of structured guidelines for professional development may be through their ability to assist trainees in bridging personal experiential learning to their learning as a therapist (Bennett-Levy, Reference Bennett-Levy2019).
Challenges with using shame attacks for SP/SR
Promisingly, all participants reported positive learning from their engagement in the shame attack as a form of SP/SR. While there was considerable anticipatory anxiety noted by several of the trainees prior to the commencement of their chosen exercise, only one participant made a negative comment at completion of the task. This is consistent with challenges noted in other SP/SR research, with fear of distress being noted as a safety concern by participants (Bennett-Levy and Lee, Reference Bennett-Levy and Lee2014; Spendelow and Butler, Reference Spendelow and Butler2016). The reason this may have only been noted by one participant could have been a result of the course structure, peer support and self-determination over the exact nature of the exposure activity. These factors have previously been suggested to facilitate improved engagement in SP/SR exercises (Bennett-Levy and Lee, Reference Bennett-Levy and Lee2014).
Limitations and future directions
The study was based on short-term qualitative self-report. Further research based on objective and quantitative data and over a longer term is required to provide stronger evidence regarding the use of shame attack exercises, and SP/SR more generally, as a competency-enhancing training method. There was also no baseline measure taken of the skills reportedly enhanced by the shame attack task (i.e. formulation, empathy, interpersonal) and the exercise was provided within the greater context of a SP/SR unit and a clinical psychology course. While the SR was directly focused on the participants’ experience of the shame attack exercise, the learning outcomes from the exercise could have been influenced by pre-existing knowledge and other learning from the course. Baseline measurement and use of control groups could assist in managing these issues.
The level of self-determination over the exercise, while giving a greater sense of safety, also provides the potential for more idiosyncratic learning. This could provide benefit for some but may result in others missing out on learning opportunities. To help manage this, opportunities to share learning experiences were provided in class, but these were voluntary and after the assessment was submitted. Anonymous sharing of the reflections on this exercise in the future could provide a further mechanism for shared learning. This would be in line with other SP/SR programs (Bennett-Levy and Lee, Reference Bennett-Levy and Lee2014; Bennett-Levy et al., Reference Bennett-Levy, Thwaites, Haarhoff and Perry2015). The task also incorporated both a thought journaling exercise (i.e. development of a formulation) and a behavioural strategy (i.e. the exposure exercise itself); these two elements may contribute differently to the learning from such an exercise. This has previously been suggested by research by Bennett-Levy (Reference Bennett-Levy2003), so it would be useful to assess the impact of these individual elements on trainees’ learning.
Assessment of the professional learning outcomes from the exercise was also potentially inhibited by the structure of the instruction provided to participants. It would be worthwhile to repeat the exercise with more focused instructions for the SR component. The specific nature of the shame attack exercise also limits the ability to generalise the outcomes to other exposure interventions and to other behavioural strategies, but they were consistent with previous research on behavioural experiments within a SP/SR training framework (Bennett-Levy, Reference Bennett-Levy2003). Similarly, the results are specific to novice trainees and may not generalise to more experienced trainees. It would be useful for future research to look at the utility of other behavioural strategies as a form of SP/SR training, and to assess the reported benefits for trainees with differing levels of experience. With more advanced clinicians the exercise could also be further developed to address issues relevant to maximising the effectiveness of exposure strategies, including how to enhance expectation violation to increase inhibitory learning (Craske et al., Reference Craske, Treanor, Conway, Zbozinek and Vervliet2014; Pittig et al., Reference Pittig, Treanor, LeBeau and Craske2018).
Conclusion
This study provides support for the use of shame attack exercises within a SP/SR program to facilitate training in CBT. The exercise appears to assist in helping to provide ‘deeper’ learning of CBT theory and its application to formulation and exposure interventions. Overall, the use of the exercise as a training tool was well received by the trainees when presented within a SP/SR framework. It also provided an avenue for personal development that may assist in the development of interpersonal skills important for clinical work. The use of SP/SR as a method of training could also provide an effective avenue for competency-based assessment of psychology trainees without providing risk to client wellbeing.
Acknowledgements
None.
Financial support
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Conflicts of interest
None.
Ethical statements
The authors have abided by the APS Code of Ethics as set out by the Psychology Board of Australia. Informed written consent was obtained from all participants in the study. The study was approved by the Cairnmillar Institute Human Research Ethics Committee (reference number 2019/0207CMI).
Key practice points
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(1) Use of shame attack exercises within a SP/SR framework assists trainees in developing a ‘deeper’ level of understanding of CBT theory and its application to exposure interventions for social anxiety.
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(2) Practice of a shame attack within a SP/SR framework provided trainees with a greater appreciation of the utility of exposure interventions for working with anxiety.
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(3) While initially considered challenging by trainees, the use of the technique as a form of experiential learning is typically well received.
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(4) With experiential learning exercises it appears important to provide bridging questions to assist trainees to shift from reflection on personal development to professional development.
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(5) SP/SR exercises appear to provide an avenue for competency-based assessment in relation to formulation and intervention skills.
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