With the increased demand for psychological services, and particularly for cognitive behavioural therapy (CBT), it is vital that teaching programs offer effective training that produce skilled and competent clinicians. This paper reviews the limitations of traditional approaches to training within the field of psychology, in terms of the promotion of a breadth of declarative knowledge at the expense of a deep and nuanced understanding of cognitive behavioural theory and clinical competence. It also reviews issues with existing strategies for competency-based assessment of trainees learning CBT. To date, many of these appear to assess a range of competencies concurrently and to test trainees within complex environments. Such methods may fail to provide an opportunity for the assessment of specific areas of competence and/or confound the assessment itself. It may also result in the public being exposed to trainees who are yet to develop competence. Based on recent research in training methods within psychology at large, and in relation to CBT specifically, a model of competency-based training and assessment is presented to address these issues. This model extends the existing research on the use of the experiential self-practice/self-reflection (SP/SR) framework for training in CBT. It proposes that the use of discrete exercises within a SP/SR training program promotes a more in-depth and nuanced appreciation of cognitive behavioural knowledge and skills and increased clinical competence. Furthermore, such exercises are proposed to provide an avenue for assessing clinical competence in specific skills prior to the commencement of direct client services.
(1) To review literature on training for the development of clinical competence.
(2) To review literature examining methods of assessing competence.
(3) To propose the use of experiential training through a SP/SR framework as a method for providing both competency-based training and assessment.
Cognitive-behavioural treatment for obsessive-compulsive disorder (OCD) is effective across the lifespan but is not widely available across the range of services. Delivering CBT as a blended treatment combining individual and group-based treatment with flexible parental involvement, adapted to the operational style of any particular service, is a promising option which we aimed to examine in OCD with adolescent samples. In a young people’s service based in a University Hospital, we evaluated the impact of a blended treatment combined with flexible parental involvement with adolescents (age 14–18 years of age). The CBT model used with OCD sufferers was a formulation driven approach, emphasising the importance of providing an alternative account linked to the way responsibility beliefs lead to compulsive behaviour. Six consecutively referred adolescents with their parents participated in a treatment group. Intervention consisted of eight individual meetings, eight group meetings and two meetings with parents. Five of six adolescents carried out the whole intervention. Of all participants, 5/5 scored in the clinical range for OCD at baseline, and 5/5 were no longer in the clinical range by the end of treatment; 5/5 were in the clinical range on general psychiatric problems at baseline, and 4/5 were rated as recovered at the end of treatment. Comparable changes were noted in measures of responsibility linked to intrusive thoughts. Use of a blended individual/group treatment based on a CBT model is feasible, with the results obtained being consistent with previous work on individual CBT treatment.
(1) Delivering CBT to adolescents with OCD as a blended treatment combining individual and group-based treatment with flexible parental involvement is a promising option which merits further evaluation.
(2) OCD symptoms and general psychiatric symptoms were reduced during and after treatment.
(3) Use of a blended treatment based on a CBT model is feasible.
Eating disorders are equally prevalent across socioeconomic status, and yet individuals facing socioeconomic adversity are far less likely to receive evidence-based treatments. A range of barriers contribute to this disparity, including limited awareness and provider training about eating disorders leading to underdiagnosis; a shortage of available services and long waitlists due to a lack of trained therapists, associated treatment costs (e.g. transportation expenses and costly treatment materials) and an insufficient understanding of the impact of an individual’s cultural context. While these barriers are experienced by many individuals with eating disorders, those with low income are particularly vulnerable. To ensure equitable access to effective eating disorder treatment, therapists should actively consider and address the barriers faced by these patients. In this paper, we share guidance based on our experience treating a socioeconomically diverse patient population, on factors to consider when extending the reach of recommended psychological treatments for eating disorders and suggest areas of future research. We emphasize the opportunities available to therapists to improve equity in eating disorders treatment by making accommodations that enhance access to existing evidence-based approaches rather than by making modifications to the treatments.
(1) To identify obstacles experienced by individuals with eating disorders and low income in accessing and engaging in treatment.
(2) To learn practical strategies to reduce or eliminate barriers preventing the uptake of evidence-based psychological eating disorder interventions for individuals with low income.
(3) To appreciate the intersectionality of low income with other factors impacting equity of eating disorder treatment access.
Cognitive behavioural therapy training courses recruit individuals from a wide range of professional backgrounds; however, little is known about the motivations of individuals to train in CBT, compared with other therapeutic modalities. Previous research has found that role transition generates multiple intrapersonal conflicts for trainees, therefore it is of interest to better understand the impact of motivational factors on the experience of learning and practising CBT. Forty-three qualified CBT practitioners completed an online questionnaire with the data analysed using a grounded theory approach. A core category of ‘Alignment with CBT’ was drawn from the data, characterised by two distinct groups of therapists – ‘CBT endorsers’ and ‘career enhancers’. A model was developed consisting of universal and group specific factors related to motivation. The findings add to the literature on the impact of therapist characteristics on CBT practice. Practical applications of the model for trainers and supervisors are discussed.
As a result of reading this paper, readers should:
(1) Understand how various motivations to train in CBT affect engagement with theories and interventions;
(2) Be able to identify some of their own intrapersonal challenges in the application of CBT formulations and interventions;
(3) Recognise training and supervision strategies that might assist with identifying and managing challenges related to epistemic style and theoretical orientation.
Meta-competencies govern the application of more basic therapeutic competencies and allow CBT therapists to know when and why particular skills are needed. Meta-competencies are particularly important when responding to the needs of complex or atypical clinical cases. We explore CBT meta-competencies through therapist reflections on complex clinical scenarios and judgements about CBT skills. Three groups of therapists were compared in their responses to four complex clinical scenarios: trainees, recently qualified and experienced therapists. Participants reflected on how they would respond in each scenario and made ratings of the importance of different skills. There was a highly significant difference between trainees and experienced therapists in the number of reflective statements made, but no differences in the number of anticipated actions. There were no group differences in judgements about CBT skills. Reflective capacity is a meta-competency and higher-order skill that CBT therapists continue to develop several years post-qualification. Further studies are needed to replicate this finding and understand its impact on clinical practice.
(1) To learn about CBT meta-competencies when considering clinical complexity.
(2) To learn how to test meta-competencies in groups of therapists with differing levels of experience.
(3) To identify which meta-competencies are prioritised in clinically complex scenarios.
(4) To support the development of the scale which measures meta-competencies in therapists.
Although anti-racist adaptations to dialectical behaviour therapy (DBT) are emerging, little qualitative research exists exploring adolescents’ perspectives on therapists’ approach, cultural competency and humility regarding ethnicity, race and culture (ERC) within DBT. This study explored diverse adolescents’ experiences of talking about ERC during all aspects of DBT treatment. Ten adolescents from diverse ERC backgrounds who attended DBT at a National and Specialist Child and Adolescent Mental Health Service (UK) completed semi-structured individual interviews that were transcribed verbatim and analysed using reflexive thematic analysis, adopting a critical realist approach. Five over-arching themes were developed from the data. Theme 1 captures the power for explicit ERC-related conversations to facilitate change, as they are frequently overlooked in therapy. Theme 2 discusses factors that facilitate or inhibit ERC-related discussions. Theme 3 captures the difficult ‘double bind’ that adolescents find themselves in: not wanting to be a spokesperson for ERC issues whilst hoping for their therapist to facilitate/model ERC-related discussions. Theme 4 explores how adolescents navigated their identity in relation to ERC, their wider systemic context, and experiences of ERC-related trauma. Theme 5 explored therapeutic alliance, and how therapists might encourage DBT skills use with greater ERC sensitivity, emphasising validation. Using a bottom-up approach, we show a clear mandate from diverse adolescents for (White) clinicians to proactively create the space and safety required for ERC-related discussions. We emphasise the importance of anti-racist praxis including cultural humility, multi-cultural competencies, and validation of ERC-related difficult experiences within a wider systemic context.
(1) A recent publication by Pierson et al. (2022) has raised the importance for White DBT therapists to adopt an anti-racist position and actively reflect on how a lack of anti-racist stance can form therapist treatment-interfering behaviours.
(2) The current study explores the views of adolescents from diverse ethnic, racial and cultural (ERC) backgrounds on how ERC issues are being brought into DBT.
(3) Adopting a bottom-up approach, we identify key themes from adolescents’ perspectives on the barriers and facilitators to talking about ERC in the therapy room, why such discussions are important in supporting adolescents to navigate their own identity in therapy, and recommendations for clinicians to consider on ways of increasing and enhancing such conversations in the clinical setting.
Augmented Depression Therapy (ADepT) is a novel wellbeing and recovery-oriented psychological treatment for depression. A recent pilot trial run in a university clinic setting suggests ADepT has potential to be superior to cognitive behavioural therapy (CBT) at treating anhedonic depression in a NHS Talking Therapies for anxiety and depression (NHS–TTad) context. Before proceeding to definitive trial in pragmatic settings, it is important to establish if therapists in routine NHS-TTad settings can be trained to deliver ADepT effectively and to assess therapist views on the feasibility and acceptability of ADepT in this context. A bespoke training and supervision pathway was developed (2-day workshop, four 2–hour skills classes, and 6 months of weekly supervision) and piloted with 11 experienced therapists working in a single NHS–TT service in Devon. Nine out of 11 therapists completed the placement, treating 24 clients with a primary presenting problem of depression; 21/24 completed a minimum adequate dose of therapy (≥8 sessions), with 17/24 (71%) showing reliable improvement and 12/24 (50%) exhibiting reliable recovery. Eight out of nine therapists submitted a session for competency assessment, all of whom were rated as competent. Nine therapists submitted feedback on their experiences of training. Eight out of nine therapists felt the ADepT model would be effective in an NHS–TTad context; that training was interesting, useful, well presented and enhanced their own wellbeing; and that they felt sufficiently skilled in core ADepT competencies at the end of the placement. This suggests that NHS–TTad therapists can be trained to deliver ADepT competently and view the treatment as feasible and acceptable.
(1) To become familiar with the Augmented Depression Therapy (ADepT) approach for enhancing wellbeing in depression.
(2) To evaluate the potential utility and feasibility of ADepT model in NHS Talking Therapies Services (NHS–TTad).
(3) To understand the pilot ADepT training and supervision pathway for CBT therapists in NHS–TTad services.
(4) To consider the opportunities and challenges of training therapists to deliver ADepT in NHS–TTad services.