An evaluation of the effectiveness of Diploma-level training in cognitive behaviour therapy

Background

As part of the UK government’s initiative to Increase Access to Psychological Therapies (see http://www.iapt.nhs.uk/for full details of the IAPT programme) there has been an expansion in the provision of post-graduate Diploma training in cognitive behaviour therapy (CBT). Previous evaluations of such training programmes have yielded mixed results but have been limited by small sample sizes and/or limited assessment measures.

Aims

To evaluate the impact of a long-standing Diploma in CBT training programme on a variety of measures of CBT competence.

Method

Trainees’ levels of CBT skill are compared at the beginning and end of CBT training. The effect of therapist factors such as age, professional background and gender on the development of CBT competence is also examined.

Results

Results show that trainees demonstrate higher levels of CBT skills after completing the training than they did before, with the majority achieving pre-determined criteria for competence. Trainees’ gender was not related to their performance but trainees’ age showed a negative association with CBT skill (older trainees performed worse). Trainees’ professional background also had an impact on their level of CBT competence, with trainees who were clinical psychologists demonstrating the highest levels of competence across a range of measures.

Conclusions

CBT Diploma training leads to increases in the level of trainees’ CBT competence, with the majority achieving the levels demonstrated in research trials by the end of training. Thus, this training is likely to lead to improved outcomes for patients. Further research is needed to determine the most efficient ways of enhancing CBT skills.     

Clinical Expertise: A Preliminary Attempt to Clarify Its Core Elements

The recent emphasis on evidence-based practice revolves around an integration of three domains: client characteristics, relevant research, and clinical expertise. Unfortunately, most reports focus on the examination of current research, while few guidelines exist for clarifying or developing expertise in clinical psychology. Although expertise is more advanced than competence, basic clinical competence can set the foundation for the development of more sophisticated skills. It is best to strive for narrow domains of expertise instead of global ratings of a professional as an “expert”. Five criteria are proposed for evaluating, developing, and maintaining clinical expertise: (1) the professional must possess a terminal degree in the field, (2) the professional has accumulated multiple years of clinical experience in the direct provision of clinical assessment, psychological testing, or psychological treatment, (3) the professional has attained advanced credentials in a specific area of psychology, (4) the professional is visible in the professional community at a national level, and (5) the professional has demonstrated evidence of superior clinical skills in a specific application of psychology. Together, these five criteria help to objectify the evaluation and cultivation of clinical expertise in psychology. Because each criterion is weak and flawed if used alone, it is recommended that multiple criteria are used in combination to define clinical expertise.     

Clinical Experiences in Using Cognitive-Behavior Therapy to Treat Panic Disorder

Although there is a growing body of research to support the use of psychological treatments for specific disorders, there has been no way for practitioners to provide feedback to researchers on the barriers they encounter in implementing these treatments in their day-to-day clinical work. In order to provide practitioners a means to give researchers information about their clinical experience, the Society of Clinical Psychology and the Division of Psychotherapy of the American Psychological Association collaborated on an initiative to build a two-way bridge between practice and research. A questionnaire was developed on the therapist, patient, and contextual variables that undermine the effective use of CBT in reducing the symptoms of panic disorder, a clinical problem that occurs frequently in clinical practice and has an extensive research base. An Internet-based survey was advertised internationally in listservs and professional newsletters, asking clinicians to indicate all aspects of CBT that they used in treating panic disorder, and to respond to a series of questions with variables that presumably limited successful symptom reduction in clinical work using CBT to treat panic disorder. The final database included responses from 338 participants who varied in experience in applying CBT to the treatment of panic disorders. Participants identified a wide range of patient factors that were barriers to symptom reduction, including symptoms related to panic, motivation, social system, and the psychotherapy relationship, in addition to specific problems with implementing CBT for the treatment of panic disorder.     

A Model of Therapist Competencies for the Empirically Supported Interpersonal Psychotherapy for Adolescent Depression

In order to treat adolescent depression, a number of empirically supported treatments (ESTs) have been developed from both the cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT-A) frameworks. Research has shown that in order for these treatments to be implemented in routine clinical practice (RCP), effective therapist training must be generated and provided. However, before such training can be developed, a good understanding of the therapist competencies needed to implement these ESTs is required. Sburlati et al. (Clin Child Fam Psychol Rev 14:89–109, 2011) developed a model of therapist competencies for implementing CBT using the well-established Delphi technique. Given that IPT-A differs considerably to CBT, the current study aims to develop a model of therapist competencies for the implementation of IPT-A using a similar procedure as that applied in Sburlati et al. (Clin Child Fam Psychol Rev 14:89–109, 2011). This method involved: (1) identifying and reviewing an empirically supported IPT-A approach, (2) extracting therapist competencies required for the implementation of IPT-A, (3) consulting with a panel of IPT-A experts to generate an overall model of therapist competencies, and (4) validating the overall model with the IPT-A manual author. The resultant model offers an empirically derived set of competencies necessary for effectively treating adolescent depression using IPT-A and has wide implications for the development of therapist training, competence assessment measures, and evidence-based practice guidelines. This model, therefore, provides an empirical framework for the development of dissemination and implementation programs aimed at ensuring that adolescents with depression receive effective care in RCP settings. Key similarities and differences between CBT and IPT-A, and the therapist competencies required for implementing these treatments, are also highlighted throughout this article.     

Provoked vestibulodynia: Psychological predictors of topical and cognitive-behavioral treatment outcome

Psychological factors have been found to impact the pain experience and associated sexual impairment of women suffering from provoked vestibulodynia (PV). Despite a lack of randomized treatment outcome studies, particularly concerning psychological predictors of outcome, recent studies have shown that topical applications and cognitive-behavioral therapy (CBT) are among the most popular first-line interventions for PV. The present study aimed to determine the extent to which baseline fear-avoidance variables and pain self-efficacy were differentially associated with topical application and CBT outcomes at six-month follow-up. Data were obtained from 97 women who completed a randomized trial comparing these two treatments. Regression analyses revealed that for topical treatment, higher levels of baseline avoidance predicted worse pain and sexual functioning outcomes, whereas higher levels of pain self-efficacy predicted better outcomes. For CBT, higher levels of baseline fear of pain and catastrophizing contributed to higher pain intensity at follow-up, whereas higher levels of pain self-efficacy were associated with less pain. Psychological factors did not predict sexual functioning outcomes for CBT. Consistent with biopsychosocial models of pain and sexual dysfunction, results indicate that psychological factors contribute to pain and sexual impairment following treatment for PV. Specifically, findings suggest that fear-avoidance variables and pain self-efficacy are significant predictors of topical and CBT treatment outcomes in women with PV.     

Treatment of Deaf Clients: Ethical Considerations for Professionals in Psychology

Providing therapy to deaf clients raises important ethical considerations for psychologists related to competence; multiple relationships and boundary issues; confidentiality; assessment, diagnosis, and evaluation; and communication and using interpreters. In evaluating and addressing these, psychologists must consider the American Psychological Association’s Ethics Code and other relevant issues (e.g., Americans with Disabilities Act) necessary to provide ethical treatment. The current article provides background, ethical considerations, principles and standards relevant to the treatment of deaf clients, and recommendations to support psychologists, training programs, and the field. Psychologists have the responsibility to guarantee that the benefits of mental health treatment are fairly and justly provided to this traditionally underserved population.     

Mediators of Change in Cognitive Behavior Therapy for Clinical Burnout

Evidence supporting the effectiveness of cognitive behavior therapy (CBT) for stress-related illness is growing, but little is known about its mechanisms of change. The aim of this study was to investigate potential mediators of CBT for severe stress in form of clinical burnout, using an active psychological treatment as comparator. We used linear mixed models to analyze data from patients (N = 82) with clinical burnout who received either CBT or another psychological treatment in a randomized controlled trial. Potential mediators (i.e., sleep quality, behavioral activation, perceived competence, and therapeutic alliance) and outcome (i.e., symptoms of burnout) were assessed weekly during treatment. The results showed that the positive treatment effects on symptoms of burnout favoring CBT (estimated between-group d = 0.93) were mediated by improvements in sleep quality, ab = -0.017, 95% CI_asymmetric [-0.037, -0.002], and increase in perceived competence, ab = -0.037, 95% CI_asymmetric [-0.070, -0.010]. Behavioral activation, ab = -0.004 [-0.016, 0.007], and therapeutic alliance, ab = 0.002 [-0.006, 0.011], did not significantly mediate the difference in effects between the treatments. Improving sleep quality and increasing perceived competence may thus constitute important process goals in order to attain symptom reduction in CBT for clinical burnout.     

Debating ethical expertise

This paper explores the relevance of the debate about ethical expertise for the practice of clinical ethics. We present definitions, explain three theories of ethical expertise, and identify arguments that have been brought up to either support the concept of ethical expertise or call it into question. Finally, we discuss four theses: the debate is relevant for the practice of clinical ethics in that it (1) improves and specifies clinical ethicists' perception of their expertise; (2) contributes to improving the perception of moral competence of non-ethicists; (3) gives insight into complementary styles of argumentation of ethicists and non-ethicists; and (4) contributes to the awareness of the problem of profession-building of (clinical) ethicists.     

Community Mental Health Service Providers' Codes of Ethics and the Standards for Educational and Psychological Testing

This study compared the codes of ethics of 13 professional organizations for community mental health service providers that have been represented at the meetings of the Fair Access Coalition for Testing with the Standards for Educational and Psychological Testing (American Educational Research Association [AERA], American Psychological Association [APA], & National Council on Measurement in Education [NCME], 1985) and all those standards cited in the revised Standards (AERA, APA, & NCME, 1999) that the investigators identified as pertaining to clinical assessment, as these standards apply to test users. The results suggest that only 2 of the codes of ethics address many of the Standards. Implications and recommendations for professional organizations are provided.     

Cognitive Behavior Therapy for Older Adults: Practical Guidelines for Adapting Therapy Structure

Cognitive behavioral therapy (CBT) has been shown to be an effective approach for a wide range of problems affecting older adults. While a variety of empirical and clinical papers have examined modifications to the content and delivery of CBT to enhance its efficacy with older adults, changes to the structure of therapy with this population have not been as widely discussed. Issues around optimizing the structure of CBT with older adults are presented, along with suggestions for realizing these changes within a clinical context.     

Examining Hope as a Transdiagnostic Mechanism of Change Across Anxiety Disorders and CBT Treatment Protocols

Hope is a trait that represents the capacity to identify strategies or pathways to achieve goals and the motivation or agency to effectively pursue those pathways. Hope has been demonstrated to be a robust source of resilience to anxiety and stress and there is limited evidence that, as has been suggested for decades, hope may function as a core process or transdiagnostic mechanism of change in psychotherapy. The current study examined the role of hope in predicting recovery in a clinical trial in which 223 individuals with 1 of 4 anxiety disorders were randomized to transdiagnostic cognitive behavior therapy (CBT), disorder-specific CBT, or a waitlist controlled condition. Effect size results indicated moderate to large intraindividual increases in hope, that changes in hope were consistent across the five CBT treatment protocols, that changes in hope were significantly greater in CBT relative to waitlist, and that changes in hope began early in treatment. Results of growth curve analyses indicated that CBT was a robust predictor of trajectories of change in hope compared to waitlist, and that changes in hope predicted changes in both self-reported and clinician-rated anxiety. Finally, a statistically significant indirect effect was found indicating that the effects of treatment on changes in anxiety were mediated by treatment effects on hope. Together, these results suggest that hope may be a promising transdiagnostic mechanism of change that is relevant across anxiety disorders and treatment protocols.     

The Emphasis on Cognitive‐Behavioural Therapy within Clinical Psychology Training at Australian and New Zealand Universities: A Survey of Program Directors

Surveys of clinical psychologists' self‐reports of professional practice exist in Australia and New Zealand, but comparatively little data exist on the training available in universities. The present study was designed to gather data on the training and assessment of cognitive–behavioural therapy (CBT). A semi‐structured phone interview was designed for use with clinical psychology training directors, or equivalent, in Australia and New Zealand. Out of a total of 48 universities in the region, 40 clinical directors were successfully contacted: One declined involvement, and 39 agreed to participate, yielding a response rate of 81% (six in New Zealand and 33 in Australia). The data showed that it is common for clinical training programmes in our region to provide clinical trainees with foundational knowledge in CBT (i.e., 29 of the 39 surveyed). However, CBT is mainly incorporated into the auspices of clinical training programmes, there is a wide range of assessment methods to evaluate competence in providing therapy, and relatively few academic units exist that focus exclusively on CBT.     

Comparing Alliance in Two Cognitive-Behavioural Therapies for Adolescents With ADHD Using a Randomized Controlled Trial

Alliance is defined as the client-therapist bond and their ability to collaborate on therapeutic activities. Treatment for adolescents with ADHD is rarely studied in terms of alliance. In this study, two cognitive-behavioral treatments (CBT; one structured treatment aimed at planning skills and one less-structured solution-focused treatment, both delivered in the style of Motivational Interviewing) were compared with regard to alliance and alliance-outcome association. The influence of therapist competence on this alliance-outcome association was also evaluated. The alliance between 69 adolescents diagnosed with ADHD and their therapists was measured early in treatment, using the Therapy Process Observational Coding System for Child Psychotherapy–Alliance scale. Observer-rated therapist competence was measured using the Motivational Interviewing Treatment Integrity scale (version 3.1.1.). Outcome variables were the adolescents’ reduction in planning problems and ADHD symptoms. The alliance, and, more specifically, collaboration on therapeutic activities, was significantly higher for the more structured CBT (p = .04; moderate effect size). Alliance was not related to outcome in the more structured CBT, while the alliance was positively related to the reduction in planning problems in the less structured CBT. Finally, alliance was a significant mediator between therapist competence and treatment outcome for the less-structured CBT. The clarity and structure of CBT may help facilitate alliance formation for adolescents with ADHD who often have difficulty implementing structure themselves. Therapists may need to invest more in alliance formation in less structured CBT as the alliance affects outcome. Moreover, enhancing therapist competence in less structured CBT may help improve outcomes in less structured CBT, as therapist competence may impact outcome through alliance.     

Development and Evolution of Cognitive Behavior Therapy for Depressed Adolescents

Since the 1980’s cognitive behavior therapy (CBT) has been developed and tested with adolescents experiencing depression. Early studies demonstrated that CBT was more effective than no intervention for young people with depressive symptoms. Beginning in the 1990’s CBT has been proven to be efficacious for adolescents with diagnosed depressive disorders, specifically Major Depressive Disorder (MDD). A series of increasingly challenging and methodologically rigorous trials showed that CBT was an effective intervention for mild to moderate MDD, and enhanced the benefits of anti-depressant medication, even for those adolescents who had already failed to respond to an initial medication. Simultaneously, some limitations of CBT were suggested by these studies. Results of CBT alone were not encouraging with severely depressed adolescents, and the combination of CBT plus medication was not uniformly supported. As CBT investigators worked with more challenging, complex clinical cases, such as depressed adolescents who were abusing substances or engaging in suicidal or self-harm behaviors, standard components of CBT were augmented by increased emphasis placed on emotion regulation, safety planning, and by more intensive outpatient treatment models. Newer developments include “third wave” models, which have shown initial promise.     

Treatment of obsessive-compulsive disorder: cognitive behavior therapy vs. exposure and response prevention

The efficacy of contemporary cognitive therapy for obsessive–compulsive disorder (OCD) has only recently been investigated. The current study compares exposure and response prevention (ERP) and cognitive behavior therapy (CBT) delivered in an individual format. Participants were randomly assigned to the 12 consecutive-week CBT or ERP treatment. Based on 59 treatment completers, there was no significant difference in YBOCS scores between CBT and ERP at post-treatment or at 3-month follow-up. A higher percentage of CBT participants obtained recovered status at post-treatment (67%) and at follow-up (76%), compared to ERP participants (59% and 58%, respectively), but the difference was not significant. Effect sizes (ESs) were used to compare the results of the current study with a previous study conducted at our center that utilized group CBT and ERP treatments, as well as other controlled trials that have compared CBT and ERP. The significance of these results is discussed and a comparison is made with the existing literature.     

Investigating trajectories of change in psychological distress amongst patients with depression and generalised anxiety disorder treated with internet cognitive behavioural therapy

Internet based cognitive behavioural therapy (CBT) is efficacious for the treatment of anxiety and depression. The current study aimed to examine the effectiveness of internet based CBT prescribed by primary care clinicians for the treatment of depression and generalised anxiety disorder. Psychological distress data from 302 patients who completed an online CBT course for depression and 361 patients who completed an online CBT course for generalised anxiety disorder were subjected to growth mixture analysis. For both disorders psychological distress decreased across each lesson in a quadratic trend. Two classes of individuals were identified with different trajectories of change: a large group of individuals who responded well to the courses and a smaller group of individuals with a lower response. Both groups were similar with respect to socio-demographic characteristics however the Low Responders tended to have higher levels of symptom severity and psychological distress at baseline in comparison to the responders. For the majority of patients (75-80%) the internet CBT courses for depression and generalised anxiety disorder were effective. Further research is required to identify and effectively treat the smaller proportion of patients who did not improve during internet CBT.     

Spontaneous Self‐Practice of Cognitive Behavioural Therapy (CBT) by Aboriginal Counsellors During and Following CBT Training: A Retrospective Analysis of Facilitating Conditions and Impact

Previous cognitive behavioural therapy (CBT) training studies have suggested that therapists who practice CBT strategies on themselves during training may experience professional and personal benefits. However, it has also been reported that some CBT trainees are reluctant to engage in self‐practice. The present study reports an incidental finding from a CBT training study with Aboriginal counsellors: all five counsellors reported that they practiced CBT techniques on themselves without specific encouragement by the trainers to do so. This paper therefore posed three questions: (a) Why—in contrast to some other trainees—did this group choose to apply CBT to themselves? (b) How did they apply it—with what purpose, in what contexts, and which skills? (c) What was the impact of CBT self‐practice? Data from the group's reflections were qualitatively analysed by two of the researchers, and “member checked” by the remainder. Results indicated that the counsellors were motivated to practice CBT on themselves for two principal reasons: the value they placed on CBT, and their personal need resulting from the high number of crises experienced while living and working in their communities. The counsellors reported practicing CBT in a wide variety of contexts as part of their learning. As in previous studies, the impact of CBT self‐practice was that it increased their confidence and competence as therapists. It also appeared to be a valuable burnout prevention strategy. If the results are generalisable, they suggest that self‐experiential training in CBT may be a culturally responsive and adaptive way for Aboriginal counsellors to enhance their learning of CBT skills.     

Cognitive-behavioural treatment of pathological gambling in individuals with chronic schizophrenia: a pilot study

The current study aimed to test the clinical effectiveness of a cognitive-behavioural program (CBT) specifically adapted for pathological gamblers with chronic schizophrenia, carried out in a naturalistic setting of community Mental Health Centres. Forty-four pathological gamblers with chronic schizophrenia were assigned either to a standard drug therapy for schizophrenia (control group) or to cognitive-behavioural therapy for pathological gambling plus a standard drug therapy for schizophrenia (experimental group). Psychological treatment comprised a 20-session program including psychoeducation, stimulus control, gradual exposure and relapse prevention. Therapeutic success was defined as abstinence or the occurrence of only 1 or 2 episodes of gambling during the follow-up period. While the patients treated in the experimental group showed a rate of success of 73.9%, only 19% of the participants belonging to the control group gave up gambling at the 3-month follow-up. The CBT group also did better than the control group in the number of gambling episodes and in the amount of money spent on gambling. However, the improvement of the experimental group was weaker at the 6- and 12-month follow-up. These findings support the beneficial effects of CBT as adjunctive therapy for patients with dual diagnoses (schizophrenia and pathological gambling).     

When Psychotherapy Is Not Working: Ethical Considerations

Evidence-based practice (EBP) models have been developed, in part, to enhance the likelihood that the outcome of health care treatment, including psychotherapy, leads to positive improvement. However, two additional outcomes can occur: no change and poor outcome (e.g., harm, worsening of symptoms). What does the clinician do when psychotherapy is not working? When faced with various treatment decisions, such as this, the EBP model posits that therapists should apply their clinical expertise in considering the “best available research” within the context of various patient characteristics. In part because of various limitations of this approach, I suggest that another important set of principles are important to consider in tandem when faced with this clinical dilemma—that is, ethical concerns. Borrowing from the American Psychological Association’s (2017a) Ethics Code, I discuss how the following issues exist when clinicians wrestle with this question: avoidance of harm, competence, conflicts of interest, and informed consent. I conclude this paper with a list of suggestions that can potentially foster the application of ethical principles when making treatment decisions.