Training And Supervision In Cognitive Therapy

Our experience of observing skilled cognitive therapists suggests the metaphor of a swan. Above the water, it seems that the swan is composed and at one with its surroundings. However, the strength of the river's current and the nearby weirs suggest that the swan is continually taking stock of its environment and working hard beneath the water's surface. Similarly, skilled cognitive therapists are constantly formulating and reformulating clients' problems, maintaining a good working therapeutic relationship, considering the best available intervention options, modelling hope and effective problem solving and anticipating what might happen as the therapy progresses.

Developing these skills requires training and supervision. Our experience suggests several goals for cognitive therapy trainers and supervisors. A first goal is to develop therapists' formulation skills, so that interventions have a clear rationale (Bieling & Kuyken, 2003; Needleman, 1999). Novice therapists often use cognitive therapy techniques without a clear basis in a cognitive formulation of the person's presenting problems. Learning formulation skills involves learning the technical aspects of a case formulation system, the cognitive theories that underpin it and having a good understanding of how this relates to the client's personal world. A second goal is to enable trainees to develop skills in collaborative empiricism. Trainees are encouraged to learn how to work with their clients to formulate hypotheses, carry out experiments, note and analyse the outcome of experiments, and through this process facilitate client cognitive and behavioural change. When done well this is facilitative, Socratic and clearly related to client change. When done badly it can look and sound like the trainee is 'beating his or her formulation into a person' (Padesky, 1993). Third, a very common mistake in novice therapists is focussing overly on the cognitive therapy techniques and neglecting the therapeutic relationship, which can be at the cost of compromised therapeutic outcomes (Castonguay et al., 1996). Fourth, we would suggest that therapists begin training with simpler cases working towards more complex presentations as their knowledge and skills develop. Clients with complex, co-morbid and personality difficulties present therapeutic challenges for the most experienced therapists. Moreover, the change process is likely to be more sporadic and protracted (Roth & Fonagy, 1998), and requires a further layer of formulation difficulties around the change process and skills in managing therapeutic change (Leahy, 2001). Fifth, as cognitive therapy has expanded to include more and more applications across more and more service settings, the content of any cognitive therapy training programme has similarly expanded. Training in the main cognitive therapy manuals, such as Cognitive Therapy of Depression (Beck et al., 1979), should remain core to any training programme. Once this basic competency is achieved, we would suggest that the general therapy skills outlined above enable the development of transferable skills to other populations and settings. Continuing professional development, particularly supervision, will support this transfer of knowledge and skills.

Like most training in evidence-based psychological therapies, cognitive therapy training involves a combination of reading core cognitive therapy texts, didactic teaching, clinical demonstrations and supervised clinical practice. Cognitive therapy training has a long lineage dating back to small groups of training therapists working with A.T. Beck at the Centre for Cognitive Therapy at the University of Pennsylvania in the 1970s. The first cognitive therapy treatment manual, Cognitive Therapy of Depression (Beck et al., 1979) arose from this process. This seminal text set the standard for the many that have followed addressing different population and service settings. There are excellent texts that try to make fully explicit what is involved in cognitive therapy (J.S. Beck, 1995; Greenberger & Padesky, 1995; Leahy & Dowd, 2002; Needleman, 1999), and texts relating to cognitive therapy for a range of emotional problems (for example, Beck et al., 1979; Beck & Emery with Greenberg, 1985; Beck, Freeman & Davis, 2003; Chadwick, Birchwood & Trower, 1996; Heimberg & Becker, 2002; McCullough, 2000; Morrison, 2002; Segal, Williams, & Teasdale, 2002).

Basic cognitive therapy training is increasingly a part of professional training for psychologists, psychiatrists, psychiatric nurses and other mental health professionals. The extent and depth of this training will depend on the professional training programme, but would normally enable these professionals to use principles from cognitive therapy in their clinical practice on qualification. Intermediate cognitive therapy programmes tend to be aimed at qualified psychological practitioners who wish to develop their cognitive therapy practice. Advanced cognitive therapy training programmes aim for specialist cognitive therapy knowledge and skills that enable a practitioner to use cognitive therapy with clients with complex presentations and across a range of specialist settings. They also enable graduates to take on cognitive therapy teaching and supervision roles. Advanced programmes tend to be international or national training programmes (two examples are the Beck Institute for Cognitive Therapy and Research, Philadelphia and the Center for Cognitive Therapy, Newport Beach, California). There are intermediate and advanced cognitive therapy training programmes in many countries, and as more and more clinicians go through advanced training programmes the network of available teachers and supervisors widens.

Cognitive therapy supervision has a distinctive flavour, mirroring some of the distinguishing characteristics of cognitive therapy (Padesky, 1996). The aim of cognitive therapy supervision is to ensure that cognitive therapists are effective cognitive therapists. That is to say, the supervisee's practice is informed by the cognitive model, carries the distinguishing hallmarks of cognitive therapy, and enables clients to work towards their goals. The supervisor and supervisee work collaboratively in an individualised yet structured way. Supervision normally includes: attention to the supervisees' individual goals, theory-practice linking, formulation, intervention planning, education about specific techniques and interventions, generalisation of skills learned to other cases and other issues, as requested (for example, research, teaching, supervision). Cognitive therapy supervision relies on having audio or video tapes of the supervisee's therapeutic work as the basis for discussion and direct feedback. Role playing is commonly used to try alternatives to the approach adopted in the taped session or to rehearse issues that are anticipated in upcoming therapy sessions. As with cognitive therapy, effective supervision relies on a good relationship and relies on the supervisor modelling an interested, empathic, hopeful and problem-solving stance.

Cognitive therapy trainers have advocated that training, like therapy, should be evidence-based and lead to agreed and demonstrable outcomes. Therapist adherence to the core characteristics of cognitive therapy and to the treatment manuals has in some studies been linked to improved outcomes suggesting the importance of trainers ensuring that trainee therapists demonstrate these core competencies. The Cognitive Therapy Scale (Barber, Liese & Abrams, 2003) was developed for this purpose, and sets out the specific competencies that therapists must demonstrate. Cognitive therapy supervisors and trainers regularly use this scale to assess and provide feedback to trainees. There is enough evidence to suggest that it is a reliable and valid measure of therapist competence (Dobson, Shaw & Vallis, 1985). The interested reader is referred to Padesky (1996) for more detailed description of models of cognitive therapy training and supervision.

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