Cognitive Behavioral Therapy Supervision in a University-Based Training Clinic: A Case Study in Bridging the Gap Between Rigor and Relevance

Principles and procedures for supervising cognitive behavioral therapy (CBT) were broadly defined in 2 early seminal texts almost 15 years ago (Liese & Beck, 1997; Padesky, 1996) and updated more recently (Beck, Sarnat, & Barenstein, 2008; Newman, 2010). However, the actual practice of CBT supervision often shows poor fidelity to this model (Townend, Iannetta, & Freeston, 2002) with notable deficiencies in the use of direct observation, standardized observational rating systems, and experiential methods in supervision (Milne, 2008). The advent of more specific competency statements on CBT supervision has been a significant leap forward (Falender et al., 2004; Roth & Pilling, 2008) but poses some practical challenges to clinical supervisors in terms of transferring broad competency statements into actual supervisory practice. We address the need for more rigor in CBT supervision within a university training clinic setting and outline some promising ingredients for this specification drawing on competencies, metacognition, and experiential learning theory.

The observed impact of training on competence in clinical supervision

OBJECTIVES

The present study analysed the impact and relative effectiveness of routine training (consultancy) versus routine training plus feedback on clinical supervision.

DESIGN

The behaviours of one supervisor and six supervisees were observed longitudinally, and comparisons made between a baseline condition and two subsequent experimental training conditions (with and without feedback) and a maintenance period.

METHOD

An observational instrument was used to code N = 1387 interactions between the supervisor and the supervisees. Supervisees' satisfaction with supervision was also recorded longitudinally.

RESULTS

The inter-observer reliability was very good initially (K > or = 0.81) and did not "drift". Supervision improved during the experimental phase, but most markedly during the maintenance phase. The results appear to reflect a lag effect for the interventions, which can be most readily explained in terms of a socialization period during which both supervisor and supervisee adapted their styles of interaction.

CONCLUSION

Competence in supervision appears to require training. The present methodology affords a promising approach to developing and analysing the effectiveness of supervision.

Moderators of trainee therapists' competence in cognitive therapy

OBJECTIVES

A revised version of the Cognitive Therapy Scale (CTS-R) was developed and used in an ecologically valid study designed to examine the acquisition of competence in cognitive therapy (CT). The relationship of therapist and patient variables to changes in competence was examined. Unlike most previous research, this study defines effectiveness of training in terms of therapist competence rather than patient outcome.

DESIGN

A longitudinal design was employed within a naturalistic setting. Trainees' competence (the dependent variable) was sampled on three occasions during a training course.

METHODS

Twenty screened out-patients, who had been routinely referred to the Newcastle Cognitive Therapy Centre, were assigned to 20 postgraduate trainees receiving training in CT. Expert raters assessed trainees' competence at three points over the first 12 sessions of treatment using the CTS-R. The relationship of therapist and patient variables to changes in competence was examined. The patient measures used were the Beck Depression Inventory (BDI) and the Suitability for Short-Term Cognitive Therapy (SSCT).

RESULTS

Three therapist factors were found to be related to competence: time (trainee therapists improving over the training period), previous experience with CT (those with most experience were most competent), and gender of the therapist (males improving at a greater rate than females). Therapist competence was also related to patients' suitability.

CONCLUSIONS

These findings suggest that previous CT experience is an advantage prior to attending an advanced training course, and also that careful patient selection helps trainees to demonstrate therapeutic competence.

Effectiveness of cognitive therapy training

Despite growing demands for effective training there remains a lack of convincing evaluations. Reviews of the training literature specify the need for multiple measures, homogeneous therapies, generalization assessments and longitudinal designs. The present analysis responds by evaluating the training of 20 mental health professionals in cognitive therapy (CT). The evaluation focussed on changes in the professionals' competence and its generalization to their patients' coping strategies (N = 20). Results indicated that a 40 day training programme led to significantly higher post-training competence scores and to improved patient coping. The implications for professional training and its evaluation are discussed.

A systematic comparison of feedback and staff discussion in changing the ward atmosphere

The efficacy of therapeutic programmes depends on several characteristics of the treatment environment. For this reason therapists are increasingly directing their efforts towards changing the social characteristics of treatment units. This study aimed to promote change in social climate by providing nursing staff with structured information about their unit. The 'real' and 'ideal' social climate of the unit was defined and assessed using the Ward Atmosphere Scale. All staff were asked to complete it during an assessment period. Feedback about their perception of the unit was provided to staff in two ways. One group of staff received written feedback only; a second group received in addition the opportunity to discuss the feedback and strategies for reducing the real-ideal discrepancies in four once-monthly meetings. The effect of the feedback on the social climate of the unit was ascertained by further assessment using the WAS and from interviews with all staff. The evaluation suggested that the feedback had contributed to changes in several procedures in the unit and to a reduction in the real-ideal discrepancies for the systems maintenance elements. The effect was greater for the group of staff who had the opportunity to discuss the feedback in a formal setting.