In-Session Stuck Points and Pitfalls of Community Clinicians Learning CBT: Qualitative Investigation

Maladaptive therapist schemas in CBT practice, training and supervision: A scoping review

BACKGROUND

Maladaptive therapist schemas are hypothesized to generate difficulties within cognitive behavioural therapy (CBT) practice, training and supervision. Without adequate identification and management, they negatively affect the cognitions and emotions of the therapist, leading them to behave in ways that risk ruptures or therapy and supervision being delivered in a suboptimal fashion. Consequently, there is a need to synthesize the research that has been undertaken to date on the content, prevalence, identification and management of maladaptive therapist schemas.

METHOD

A scoping review was undertaken of studies that have been published since 2001 on the impact of maladaptive therapist schemas (also referred to interchangeably as beliefs or cognitions) in CBT practice, training and supervision. Thirteen studies were identified in a literature search from four electronic databases, a reference list search of identified articles and hand searches.

RESULTS

Three overall themes were identified in the research: (1) prevalence of therapist schemas, (2) specific therapist beliefs and (3) therapist characteristics associated with the delivery of suboptimal CBT or supervision. While there is little empirical support for therapist schemas, therapist resistance and beliefs relating to the fear of using exposure therapy were identified. Therapist intolerance of uncertainty and self-esteem were recurrent factors.

CONCLUSION

There is no consensus on how to define, identify, formulate or respond to maladaptive therapist beliefs or schemas in clinical practice, training or supervision. Further research is needed to better understand their origins, maintaining factors and appropriate management of their impact.

A Comparison Between Clinical Guidelines and Real-World Treatment Data in Examining the Use of Session Summaries: Retrospective Study

Background

Although behavioral interventions have been found to be efficacious and effective in randomized clinical trials for most mental illnesses, the quality and efficacy of mental health care delivery remains inadequate in real-world settings, partly owing to suboptimal treatment fidelity. This “therapist drift” is an ongoing issue that ultimately reduces the effectiveness of treatments; however, until recently, there have been limited opportunities to assess adherence beyond large randomized controlled trials.

Objective

This study explored therapists’ use of a standard component that is pertinent across most behavioral treatments—prompting clients to summarize their treatment session as a means for consolidating and augmenting their understanding of the session and the treatment plan.

Methods

The data set for this study comprised 17,607 behavioral treatment sessions administered by 322 therapists to 3519 patients in 37 behavioral health care programs across the United States. Sessions were captured by a therapy-specific artificial intelligence (AI) platform, and an automatic speech recognition system transcribed the treatment meeting and separated the data to the therapist and client utterances. A search for possible session summary prompts was then conducted, with 2 psychologists validating the text that emerged.

Results

We found that despite clinical recommendations, only 54 (0.30%) sessions included a summary. Exploratory analyses indicated that session summaries mostly addressed relationships (n=27), work (n=20), change (n=6), and alcohol (n=5). Sessions with meeting summaries were also characterized by greater therapist interventions and included greater use of validation, complex reflections, and proactive problem-solving techniques.

Conclusions

To the best of our knowledge, this is the first study to assess a large, diverse data set of real-world treatment practices. Our findings provide evidence that fidelity with the core components of empirically designed psychological interventions is a challenge in real-world settings. The results of this study can inform the development of machine learning and AI algorithms and offer nuanced, timely feedback to providers, thereby improving the delivery of evidence-based practices and quality of mental health care services and facilitating better clinical outcomes in real-world settings.

‘It was like the unicorn of the therapeutic world’: CBT trainee experiences of acquiring skills in guided discovery

Training as a cognitive behavioural therapist involves a considerable role transition for mental health professionals where they are expected to demonstrate competence in a range of new skills that emphasise collaboration and Socratic dialogue. This can be in stark contrast to the more didactic style that trainees are familiar with prior to embarking on their training. Guided discovery (GD) is an integral part of formulation and treatment, yet little is known at present about the experiences of cognitive behavioural therapy (CBT) trainees when learning this new skill; specifically, how they assimilate this with existing ways of working and the challenges this might involve. This research is a preliminary attempt to understand factors that help and hinder GD skill acquisition. Eighteen trainee CBT practitioners completed an online questionnaire with the subsequent data analysed using a grounded theory methodology. Three themes were identified: ‘Competing Selves’, ‘Style’ and ‘Active Engagement and Learning’. These themes were used to develop a preliminary model of factors that enable or inhibit skills in GD. The impact of previous professional roles appears to influence the acquisition of confidence and skill in GD. This paper discusses the implications of the findings for CBT trainers, supervisors and trainees.

Key learning aims

As a result of reading this paper, readers should: (1)

Cognitive-Behavioral Therapy in Intensive Case Management: A Multimethod Quantitative-Qualitative Study

Cognitive-behavioral therapy (CBT) has been shown to improve clinical outcomes in schizophrenia and severe and persistent mental illness, but access to it remains limited. One potential way to improve access to CBT is to provide it through intensive case management (ICM) teams. A 90-week quality improvement study was designed to assess if CBT could be implemented in ICM teams. Self-selected ICM clinicians (N=8) implemented CBT with their patients (N=40). These clinicians attended weekly seminars (36 h total) and group supervision (1.5 h/wk). Patient outcomes for this group were compared with those of other clinicians who did not attend the seminars [treatment as usual (TAU) clinicians (N=4)] and their patient population (N=49). Prescore and postscore on the Clinical Global Impressions scale and a quality-of-life scale (Montreal Life Skill Survey) were analyzed for completers in both groups (Clinical Global Impressions scores were analyzed for 25 patients in the CBT group and 29 patients in the TAU group). Weekly session reports by clinicians in the CBT group measured CBT interventions, session focus, and satisfaction with CBT. Qualitative data were obtained from clinicians in the CBT group. After 90 weeks, patients in the CBT group had fewer negative symptoms compared with patients in the TAU group. Our qualitative data describe 2 trajectories of patients: those who improved with CBT and those who did not, and they suggest factors that may impact patient trajectories in CBT. This study suggests that CBT can be used effectively in ICM teams working with patients suffering from severe and persistent mental illness.

Interdisciplinary Use of Argumentation among Religious Education and Philosophy Teachers-in-Training

Using document analysis, religion and philosophy pre-service teachers’ reflections on argumentation and in-class argumentation practices, which were received online, during the Special Teaching Methods course were examined. These documents included reflections of pre-service teachers on argumentation and in-class argumentation practices. Findings emerged in three dimensions: (a) the benefits of the use of argumentation (awareness and motivation skills, teaching via argumentation-based instruction), (b) difficulties in using argumentation (learning environment and motivational factors), and (c) suggestions, in which themes and codes were created in light of such dimensions. The acquired dimension of the use of argumentation consists of the themes of awareness, motivation, skills, and teaching. With regards to suggestions that can be drawn from this document analysis, both religious education and philosophy pre-service teachers stated that preliminary preparations should be made to apply the argumentation technique to the teaching process. The results offer insight on the integration of this technique into teaching as an instructional tool. As an important epistemological exercise, argumentation can be attained as a skill set during formal school education which may facilitate the integration of knowledge.

The efficacy of real-time functional magnetic resonance imaging neurofeedback for psychiatric illness: A meta-analysis of brain and behavioral outcomes

Real-time functional magnetic resonance imaging neurofeedback (rtfMRI-NF) has gained popularity as an experimental treatment for a variety of psychiatric illnesses. However, there has yet to be a quantitative review regarding its efficacy. Here, we present the first meta-analysis of rtfMRI-NF for psychiatric disorders, evaluating its impact on brain and behavioral outcomes. Our literature review identified 17 studies and 105 effect sizes across brain and behavioral outcomes. We find that rtfMRI-NF produces a medium-sized effect on neural activity during training (g = .59, 95 % CI [.44, .75], p < .0001), a large-sized effect after training when no neurofeedback is provided (g = .84, 95 % CI [.37, 1.31], p = .005), and small-sized effects for behavioral outcomes (symptoms g = .37, 95 % CI [.16, .58], p = .002; cognition g = .23, 95 % CI [-.33, .78], p = .288). Mixed-effects analyses revealed few moderators. Together, these data suggest a positive impact of rtfMRI-NF on brain and behavioral outcomes, although more research is needed to determine how rtfMRI-NF works, for whom, and under what circumstances.

Modernizing Training in Psychotherapy Competencies With Adaptive Learning Systems: Proof of Concept

PURPOSE

This proof-of-concept study assessed the feasibility, acceptability, and effectiveness of an intelligent tutoring system (ITS) as a classroom adjunct to improve training bachelor of social work (BSW) students in client engagement strategies.

METHODS

We codeveloped the ITS with 11 undergraduate students and pilot tested it with six BSW students enrolled in a class on telephone-based cognitive behavioral therapy (tCBT). Student competencies in tCBT were assessed by expert review of role-plays. We also examined time spent using ITS and relation with competency.

RESULTS

The majority of students (81.8%) in Wave 1 and all of the students who submitted role-plays in Wave 2 passed the clinical skills role-play. Students advancing through the ITS more quickly had better tCBT competency ratings than those progressing more slowly.

DISCUSSION

One of the most challenging aspects of training is how to competently deliver evidence-based practices. ITS has the potential to streamline and scale such training.

Common paraverbal errors during hypnosis intervention training

There is growing literature to support the use of hypnosis as an evidence-based behavioral medicine intervention to manage a wide variety of symptoms and side effects associated with cancer and its treatment (e.g., pain, nausea, fatigue). However, formal training in hypnosis is often lacking among cancer care providers. The purpose of this study is to identify common paraverbal errors among hypnosis trainees in order to inform future training efforts. In a sample of 196 hypnosis trainees, paraverbal errors (i.e., tone, pacing, and phrasing) were tracked across hypnotic intervention components. Results revealed that trainees had most difficulty with hypnotic tone, particularly during the Induction, Deepening, and Alerting components. Individual trainee characteristics were unrelated to paraverbal errors.

Stepped Care as an Implementation and Service Delivery Model for Cognitive Behavioral Therapy for Psychosis

Cognitive behavioral therapy for schizophrenia spectrum disorders is an evidence-based treatment that is recommended by United States schizophrenia treatment guidelines. Based on recent estimates, only 0.3% of individuals with a primary psychotic disorder are able to access this treatment in the United States. Stepped care interventions have shown promise as an applied treatment delivery model in other settings and for other psychotherapeutic interventions. The current paper describes how the stepped care model can be applied to CBT for psychosis in the US to increase access to the intervention in community mental health settings by leveraging the multidisciplinary team.

Review and Analysis of thought Records: Creating a Coding System

Background:

Thought records are a core component of Cognitive Behavior Therapy. Over time, thought records have been modified to suit various needs or preferences. A diversity of thought records have been developed, which include differing components and cognitive change strategies. Yet, due to a lack of specificity in the literature and field, different thought records are often treated as though they are interchangeable. Limited extant literature suggests that differing thought records may have unique clinical effects. However, meta-analyzing the comparable or differing effects of the distinct extant thought records is impeded by the lack of a coding system for thought records.

Objective:

The current study sought to prepare a way for further understanding the differential utility and effectiveness of different iterations of thought records by creating a coding system, which is described in detail. This coding system will be used to guide future research into which thought records work best for which problems.

Method:

Thought records were gathered from seminal texts and solicited from the certified members of the Academy of Cognitive Therapy and the American Board of Behavioral and Cognitive Psychology.

Results:

In total, 110 non-identical thought records were gathered and coded into 55 unique combinations. These results demonstrate that the variability of thought records used by qualified therapists extends well beyond those found in seminal CBT texts.

Conclusion:

This broad diversity justifies the need for a coding system to inform future lines of research.

Homework Completion, Patient Characteristics, and Symptom Change in Cognitive Processing Therapy for PTSD

We evaluated the impact of homework completion on change in PTSD symptoms in the context of two randomized controlled trials of Cognitive Processing Therapy for PTSD (CPT). Female participants (n = 140) diagnosed with PTSD attended at least one CPT session and were assigned homework at each session. The frequency of homework completion was assessed at the beginning of each session and PTSD symptoms were assessed every other session. Piecewise growth models were used to examine the relationship between homework completion and symptom change. CPT version (with vs without the written trauma account) did not moderate associations between homework engagement and outcomes. Greater pretreatment PTSD symptoms predicted more Session 1 homework completion, but PTSD symptoms did not predict homework completion at other timepoints. More homework completion after Sessions 2 and 3 was associated with less change in PTSD from Session 2 to Session 4, but larger pre-to-post treatment changes in PTSD. Homework completion after Sessions 2 and 3 was associated with greater symptom change among patients who had fewer years of education. More homework completion after Sessions 8 and 9 was associated with larger subsequent decreases in PTSD. Average homework completion was not associated with client characteristics. In the second half of treatment, homework engagement was associated with less dropout. The results suggest that efforts to increase engagement in homework may facilitate symptom change.

Attempting to reconcile large differences in Improving Access to Psychological Therapies recovery rates

The Improving Access to Psychological Therapies initiative has a reported 50 percent recovery rate. Recently, Scott published a scathing report asserting that 9.2 percent is the correct rate. This alarming assertion requires a closer look and further scrutiny of the Improving Access to Psychological Therapies. Scott's study is fundamentally flawed in many ways; chiefly, the small ( n = 87), forensically involved, convenience sample is not representative of the Improving Access to Psychological Therapies population. Scott's study is more a limited-scope non-representative-sampled audit (or pilot study audit) of the Improving Access to Psychological Therapies. Given the large amount of public funds involved in the project, further research and a high degree of transparency is warranted.

Clinical Case Consultation and Experiential Learning in Cognitive Behavioral Therapy Implementation: Brief Qualitative Investigation

There has been an increased emphasis on the implementation of cognitive behavioral therapy (CBT) to community mental health (CMH) systems due to its broad efficacy. Previous research has highlighted the importance of ongoing consultation in this process. The current study clarifies the role and process of clinical case consultation in the implementation of CBT to CMH from the consultants' perspective. Trainers from two large-scale implementation initiatives (n = 27) were surveyed regarding their strategies used in the consultation process. Historically, researchers have focused on trainees who view relational variables as the most effective elements of consultation; however, in the current study, trainers perceived experiential learning as being the most effective consultation strategy for helping CMH clinicians learn CBT. Other aspects of consultation such as case conceptualization and practice sample review are discussed in terms of their relative perceived utility in raising CMH clinician's competency to treat comorbid patients.

Best practices in supervising cognitive behavioral therapy with youth

Clinical supervision of cognitive behavioral therapy (CBT) with youth ensures better patient care and fosters trainees' professional development. However, often insufficient attention is directed toward disseminating best practices in supervision of CBT with youth. This Therapeutic Advances contribution aims to communicate the core content of supervision. Additionally, the key supervisory practices associated with CBT with youth are described. Supervisory outcomes are summarized and recommendations for supervisory practices are made.