Developing Metacompetence in Low Intensity Cognitive‐Behavioural Therapy (CBT) Interventions: Evaluating a Self‐Practice/Self‐Reflection Programme for Experienced Low Intensity CBT Practitioners

Self‐practice/self‐reflection (SP/SR) is a targeted training and professional development strategy in which clinicians practice cognitive‐behavioural therapy (CBT) techniques and processes on themselves and then working through a structured process of self‐reflection. Previous studies with CBT trainees and experienced mental health practitioners have found that SP/SR or experiencing CBT “from the inside out” has been perceived by participants as increasing competency in a number of important areas and increasing therapist flexibility and artistry. Low intensity (LI) practitioners are identified as a relatively new addition to mental health service delivery in the UK. These workers are differentiated from traditional mental health practitioners by a shorter training period, the delivery of a circumscribed number of CBT interventions, and a very high weekly patient load. This study, the first of its kind, reports outcomes from an SP/SR programme undertaken by seven experienced LI CBT practitioners. Participants used the following measures to track their experience of the programme: time spent on programme, personal‐ and therapy‐related belief rating, goals attained, and perceived skill rated for average and most difficult patients. Results showed a positive change in work‐related skill and behaviour change, particularly when working with the more difficult patients. The findings are consistent with those found in other groups of therapists (e.g., trainee CBT therapists and highly experienced CBT therapists), suggesting that SP/SR may be a valuable addition to LI intensity training and professional development. These findings are discussed in the context of the particular needs of LI practitioners.     

Engagement With Self‐Practice/Self‐Reflection as a Professional Development Activity: The Role of Therapist Beliefs

A number of research studies support self‐practice/self‐reflection (SP/SR) as an experiential learning process that facilitates the acquisition of therapeutic skill in a number of cognitive‐behavioural therapy (CBT) competencies and as showing potential as a valuable professional development activity. Engaging therapists to participate in SP/SR programmes is sometimes difficult, and when they are offered the option to participate in SP/SR programmes as part of professional development, relatively few volunteer. This study investigates the role of therapist beliefs about SP/SR as a potential obstacle to engagement. An online survey was developed to assess the strength of 14 commonly held therapist beliefs concerning the consequences of participating voluntarily in a SP/SR programme. Participants were a combined sample of 44 Psychological Wellbeing Practitioners and high‐intensity CBT therapists employed by an Improving Access to Psychological Therapies service in the United Kingdom. Few negative beliefs about SP/SR emerged. The majority of respondents believed SP/SR programmes were relevant to their work situation, but perceived “lack of time” as a significant barrier to participation. Three factors are considered in relation to introducing SP/SR as a workforce professional development activity: (a) The importance of managing therapist perceptions regarding time; (b) SP/SR as a mechanism to increase self‐care and reduce burnout; and (c) The need to focus mental health services' attention on the potential of SP/SR programmes to increase staff morale and improve service delivery.     

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.     

Enhancing Cognitive‐Behavioural Therapy (CBT) Skill Acquisition Through Experiential and Reflective Learning: A Commentary on Studies Examining the Impact of Self‐Practice and Self‐Reflection in CBT

Self‐practice and self‐reflection (SP/SR) is a targeted training tool that is intended to increase CBT competency in therapists. The four articles reviewed in this commentary examine the benefits of SP/SR with various types of therapists, and survey the significant obstacles faced in implementing this tool with clinicians. Collectively, these articles conclude that SP/SR is a valuable tool in improving CBT skill acquisition and preventing burnout, particularly with difficult patients, but that most therapists elect not to use it largely because of the time involved in engaging in it. In this commentary, I suggest that empirical studies with larger samples and controlled designs are needed to build on the wealth of qualitative data collected to date in order to assess the value added by SP/SR compared with other training methods, and in order to determine its impact on a range of therapeutic outcomes. I also suggest that future studies should examine the efficacy of required SP/SR engagement, isolate its critical ingredients, and assess if there are clients and therapists for whom SP/SR is comparably more effective.     

Invited Response to Commentaries: Self‐Practice/Self‐Reflection (SP/SR): Contexts,Challenges and Ways Forward

McGinn (2015) and Fernández‐Álvarez, Castañeiras, and Wyss (2015) make valuable suggestions in their commentaries on the three self‐practice/self‐reflection (SP/SR) articles in this issue of the Australian Psychologist. In our response, we use their commentaries as a springboard to highlight contextual influences and challenges for future SP/SR research, and suggest potential ways forward.     

Comment on “The Self‐Care of Psychologists and Mental Health Professionals” (Dattilio, 2015)

Professor Frank Dattilio's article “The Self‐care of Psychologists and Mental Health Professionals” provides an overview of stress and related mental health problems among psychologists, and a proposition that psychologists are not vigilant in regard to self‐care. Dattilio offers a range of self‐care strategies and recommendations, and highlights self‐care practices within various psychology frameworks, and concludes with some “healthy tips” for managing stress. In my commentary I underscore Dattilio's message that self‐care is of critical importance in psychology practice, given the responsibility of caring for others inherent in the work psychologists undertake. However, I raise additional points of consideration and suggest an alternative approach to addressing the self‐care needs of the profession. My commentary makes the following points: (a) the need to distinguish between psychology trainees and practising qualified psychologists when addressing stress and self‐care requirements in the profession; (b) the importance of developing a culture of self‐care among psychologists by providing self‐care instruction during training; (c) the need to temper research findings on stress and mental health among psychologists by the methodological weakness of the studies in this area; (d) adhering to the recent call from colleagues to shift from a focus on pathology and punishment to a positive acceptance, mindfulness, and values‐based approach for encouraging self‐care among psychologists; (e) the use of a systematic framework for organising the presentation of self‐care strategies that makes them more accessible; and (f) an appeal to professional bodies to take their responsibility in promoting self‐care in the profession.     

Exploring Decision Making Around Therapist Self‐Disclosure in Cognitive Behavioural Therapy

Background

Therapist self‐disclosure (TSD) usage varies greatly among different psychotherapy orientations. Anecdotal evidence seems to suggest that there are reasons for its judicious use, and a small number of researchers have proposed guidelines for how TSD should be used to help therapists across psychotherapy models make decisions around disclosure. However, there is almost no literature specifically exploring how cognitive behaviour therapy (CBT) practitioners make decisions around employing TSD within the CBT framework.

Objective

This study aimed to explore how experienced CBT practitioners make decisions around TSD.

Method

In‐depth qualitative interviews were conducted with six clinical psychologists who were trained and experienced in CBT, and the interviews were analysed thematically.

Results

There were two overarching themes in terms of how they made decisions to self‐disclose: (A) the rules for TSD use, which included sub‐themes (a) it must have a clear purpose, (b) it must fit, (c) the therapist must maintain boundaries, and (d) the therapist must always reflect on his/her use of TSD; and (B) how they use TSD, which included subthemes of (a) using it as a tool for change and (b) using it to manage the therapeutic relationship.

Conclusion

Participants’ decisions on whether or not to self‐disclose were strongly influenced by the CBT model, and this process went beyond what is suggested in the transtheoretical literature. Understanding this process may lead to the development of CBT‐specific guidelines for making TSD‐related decisions.     

Reflective Self‐Control in Self‐Control Scholarship: A Peircean Analysis

Vosgerau, Scopelliti, and Huh (this issue) present an important critique of much self‐control research, highlighting some of the ways that our customary operationalizations and methods may have created more confusion than clarity. Their insights, rooted in past literature and new data, offer recommendations that will undoubtedly help us improve our research in consumption self‐control. In this commentary, I frame their work using the thought of Charles Sanders Peirce, a philosopher, mathematician, and logician whose frustration with the management of the self‐control construct and subsequent revision parallels Vosgerau et al's in many ways. Further, his thought proposes that their thought traces the boundary of another type of self‐control problem, which I'll refer to as “reflective self‐control.” Taking together consumption self‐control and reflective self‐control, we're able to address a wide range of human experiences and connect self‐control to ethics, consistent with a long tradition bridging the two. Perhaps most importantly, though, a Peircean analysis suggests that Vosgerau et al's paper—whether we agree or disagree with its conclusions—exemplifies the kind of scholarly self‐control we need to display to make scientific progress, regardless of our specific domain of study.     

Self‐reported inner speech use in university students

Remarkably little is known regarding what people talk to themselves about (inner speech use) in their everyday lives. Existing self‐directed speech measures (e.g., thought sampling and questionnaires) either uniquely capture inner speech frequency and neglect its content or classify self‐reported thoughts instances in overly simplistic categories determined by the researchers. In the current study, we describe an open‐format thought listing procedure as well as a refined coding scheme and present detailed inner speech content self‐generated by 76 university students. The most frequently self‐reported inner speech activities were self‐regulation (e.g., planning and problem solving), self‐reflection (e.g., emotions, self‐motivation, appearance, behavior/performance, and autobiography), critical thinking (e.g., evaluating, judging, and criticizing), people in general, education, and current events. Inner speech occurred most commonly while studying and driving. These results are consistent with the self‐regulatory and self‐referential functions of inner speech often emphasized in the literature. Future research avenues using the open‐format inner speech listing procedure and coding scheme are proposed.     

A Path of Counselor Self‐Awareness

This article explores self‐reflection and self‐awareness from an ethical standpoint, proposing that counselors have a responsibility to themselves, their clients, and the profession to engage in these practices. The authors propose a path to counselor self‐awareness and a 2nd process that assumes counselor mastery.     

Can CBT Be Effective for Aboriginal Australians? Perspectives of Aboriginal Practitioners Trained in CBT

The objective of the study was to investigate whether high and low intensity versions of cognitive behaviour therapy (CBT) might be an effective therapeutic approach for enhancing the mental health of Aboriginal Australians. Five university‐educated Aboriginal counsellors received in‐depth training in CBT. Over the following year, they used CBT strategies with their clients, and met 10 times as a participatory action research group. The group addressed three key questions: (a) Does CBT appear to be useful for Aboriginal Australians? (b) If so, what elements of CBT are perceived to be effective? (c) What adaptations might be made to CBT to enhance its effectiveness with Aboriginal Australians? The resulting qualitative data were transcribed and analysed. Counsellors perceived CBT to be very useful for their Aboriginal clients and for themselves. They reported that it enhanced their clients' well‐being, their own clinical skills, and their own well‐being, and it reduced burnout. The qualities of CBT that were perceived to be effective were its adaptability, pragmatic here‐and‐now approach, capacity for low‐intensity interventions, safe containing structure, promotion of self‐agency, and valuable techniques. It was suggested that the prime requirement for adaptations to CBT were that they would need to fit different social and cultural contexts.     

Evaluation of a Combined Cognitive Behavioural Therapy and Interpersonal Process Group in the Psychotherapy Training of Clinical Psychologists

It is now widely acknowledged that both content and process elements of psychotherapy play a part in client treatment outcomes. Despite this, there are pressures on Australian clinical psychology training programs to teach evidence‐based approaches in a relatively short time frame. Producing clinical psychology graduates who have an adequate level of competence in evidence‐based practice and meeting the demands of professional accreditation requirements can mean that less time is available to teach the process elements of psychotherapy. The aim of this study was to conduct a preliminary evaluation of a clinical psychology psychotherapy training program that combines an interpersonal process group with a cognitive behavioural therapy training model that incorporates self‐reflection and self‐practice. Eleven participants who participated in the training in 2008 completed the Counseling Self‐Estimate Inventory at pre‐ and post‐training. Significant improvements on the majority of the subscales of this inventory were found. A separate sample of nine trainees and clinical psychology registrars who also previously completed the program attended individual interviews in 2010 aimed at gaining their perspective regarding various aspects of the program. Self‐practice of cognitive behavioural therapy techniques was found to be important in the identification and management of trainees’ own core beliefs, and to their appreciation of how challenging this process may be for clients. The interpersonal process group was described by participants as enhancing their competency as psychotherapists. Common themes included the experience of anxiety and a high level of emotion, and understanding how this experience might be similar for clients; increased self‐awareness; and increased competence in process issues. Many participants believed the process and content components of training were equally important to their development as psychotherapists.     

Aboriginal Practitioners Offer Culturally Safe and Responsive CBT: Response to Commentaries

We appreciate the valuable commentaries that have been provided for our paper “Can CBT be effective for Aboriginal Australians? Perspectives of Aboriginal practitioners trained in CBT.” The international authors identify how CBT, with adaptations by culturally responsive practitioners can be of value for non‐Western and Indigenous peoples. The commentary by Australian psychologists Dudgeon and Kelly questions the value of CBT for Indigenous Australians, terming it a “Western therapy” that is “culturally unresponsive” and “culturally blind.” They also critique the methodology of the study. We argue that CBT can be adapted by culturally competent practitioners to be culturally safe in Australia, as elsewhere. Cultural safety is mostly a function of the therapist, not the therapy. In the Bennett‐Levy et al. (2014) study, CBT was delivered in a culturally responsive way by Aboriginal counsellors within their own communities. CBT is a particularly adaptable and versatile therapy, and embodies principles of empowerment and self‐determination that are central to Indigenous social and emotional well‐being. We are concerned that CBT, which has strong empirical support and has been adapted elsewhere for a range of cultures, including Indigenous cultures, may be being denied to Indigenous Australian clients. There is considerable opportunity to evaluate the effectiveness and versatility of CBT, and variations of its mode of delivery, for all Australians.     

Positive Self‐regard and Claim to Leadership: Two Fundamental Forms of Self‐evaluation

The present article examines the common factor structure of various self‐evaluative personality constructs. Consistent with previous research, we found considerable redundancy between constructs. Two basic forms of self‐evaluation could be distinguished: Positive Self‐regard (PSR) reflects people's contentedness with themselves in comparison with their own standards. Constructs such as depression, self‐esteem and neuroticism have very high loadings on this factor. In contrast, Claim to Leadership (CTL) reflects the subjective conviction that one is called to take charge and lead others. This conviction is often called ‘narcissism’. PSR mainly reflects an intra‐personal kind of self‐evaluation, whereas CTL reflects an inter‐personal kind. Both forms of self‐evaluation independently predict intellectual self‐enhancement, but only one of them (PSR) also predicts self‐reported mental health. Moreover, the two forms of self‐evaluation are differentially associated with self‐reported and peer‐reported inter‐personal traits (Dominance and Affiliation). Finally, the concepts of ‘Grandiosity’ and ‘Vulnerability’ from narcissism research may easily be reframed in terms of CTL and PSR. The two‐dimensional framework may help overcome the conceptual confusion that exists around different forms of self‐evaluation and streamline the field for future research. Copyright © 2013 European Association of Personality Psychology     

Self‐Images and “Perspicuous Representations”: Reflection,Philosophy, and the Glass Mirror

Reflection names the central activity of Western philosophical practice; the mirror and its attendant metaphors of reflection are omnipresent in the self‐image(s) of Western philosophy and in metaphilosophical reflection on reflection. But the physical experiences of being reflected by glass mirrors have been inadequately theorized contributors to those metaphors, and this has implications not only for the self‐image and the self (or selves) of philosophy but also for metaphilosophical practice. This article begins to rethink the metaphor of reflection anew. Paying attention to the history of the glass mirror in Europe reveals and challenges the modern emergence of clear ontological distinctions between disembodied subjects and the objects of their knowledge, and suggests a compelling terrain of metaphilosophical analysis. On the reading offered by the article, the inherent complexity of the relationship between selves and their mirror images, a complexity mediated by social location, historical situation, and particular projects, points to significant spaces of unknowing, of indeterminacy, and of ontological ambiguity.     

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.     

The Evolution of Mindfulness‐based Cognitive Therapy

Metcalf and Dimidjian (this issue) present a timely review of the evolving evidence base and mechanisms of mindfulness‐based cognitive therapy (MBCT). The present commentary extends the discussion on the current evidence base for MBCT based on findings from recent meta‐analytic reviews in this field which attest to the promising outcome for mindfulness‐based therapies, particularly for depressed populations. However, the specific effects of MBCT as applied to anxiety, health and developmental populations is still very much in its infancy. The second objective of this commentary extends discussion on the transdiagnostic applications of MBCT versus traditional cognitive behavioural therapy (CBT). It is recommended that with the continuing expansion of MBCT, the effects of this therapeutic approach needs to be evaluated against other empirically supported therapies, including traditional CBT.     

Deciphering Subjective Trajectories for Life Satisfaction Using Self‐versus‐Normative Other Discrepancies,Self‐esteem and Hope

Drawing on temporal and social comparison perspectives, we examined sources of the widespread belief that life gets better and better over time by determining how young adults evaluate their past, present and anticipated future life satisfaction (LS) relative to beliefs about normative others. We assessed whether patterns of subjective LS trajectories based on self‐versus‐normative other discrepancies varied as a function of self‐esteem and whether such patterns were accounted for by hope, encompassing goal‐related cognitions and motivations. University participants (n = 394) completed measures of their own and normative others' past, present and anticipated future LS, as well as self‐esteem and hope scales. Results from latent growth curve analyses demonstrated that high‐self‐esteem and low‐self‐esteem individuals perceived normative others' LS as progressing on a similar upward subjective temporal trajectory; however, high‐self‐esteem individuals perceived self‐improvement from past to present LS and self‐consistency from present to future LS relative to others. Low‐self‐esteem individuals perceived self‐consistency from past to present LS and self‐improvement from present to future LS relative to others. These associations were accounted for by hope. This research highlights the utility of combining temporal and social comparison perspectives for understanding how people envision their LS unfolding over time. Copyright © 2012 John Wiley & Sons, Ltd.     

Need for Cognition Promotes Adaptive Style of Self‐Focusing with the Mediation of Effortful Control

Previous studies have indicated that “need for cognition” (NfC), which is the tendency to enjoy effortful cognitive activity, affects various cognitive processes and behaviors. However, the effects of NfC on mental adaptation have not been investigated. According to previous studies, it can be hypothesized that NfC decreases maladaptive self‐focusing, which is called self‐rumination, through increasing effortful control (EC); therefore, we hypothesized that NfC would indirectly inhibit self‐rumination through the mediation of EC. As we expected, the results of a cross‐sectional questionnaire study with 152 undergraduate participants indicated a negative indirect association between NfC and self‐rumination through the mediation of EC. Secondarily, the present results revealed a direct positive association between NfC and adaptive type of self‐focusing, which is called self‐reflection. The present study is the first to propose the possible contribution of NfC to mental health through decreasing self‐rumination and increasing self‐reflection.     

Working With Clients Who Self‐Injure: A Grounded Theory Approach

This article presents the findings of a qualitative study examining the experiences of counselors in their work with clients who self‐injure. Using grounded theory methodology, the authors established 6 categories to explain the counselors’ conceptualization of self‐injury and their process of working with these clients: (a) external factors to self‐injury, (b) defining self‐injury, (c) potential for harm, (d) conditions for treatment, (e) counselors’ reactions to working with clients who self‐injure, and (f) clients’ response to treatment.