Original Research
Trainee self-assessment of cognitive behaviour therapy competence during and after training
- Sarah Beale, Sheena Liness, Colette R. Hirsch
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- Published online by Cambridge University Press:
- 22 January 2020, e1
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Large-scale cognitive behavioural therapy (CBT) training and implementation programmes, such as the pioneering Improving Access to Psychological Therapies (IAPT) initiative in the UK, aim to develop a workforce of competent therapists who can deliver evidence-based interventions skilfully. Self-awareness of competence enables CBT therapists to accurately evaluate their clinical practice and determine professional development needs. The accuracy of self-assessed competence, however, remains unclear when compared with assessments conducted by markers with expertise in CBT practice and evaluation. This study investigated the relationship between self- and expert-rated competence – assessed via therapy recordings rated on the Cognitive Therapy Scale Revised (CTS-R) scale – for a large sample of IAPT CBT trainees during training and, for the first time, at post-training follow-up. CBT trainees (n = 150) submitted therapy recordings at baseline, mid-training and end-of-training. At 12+ month follow-up, a subset of former trainees (n = 30) submitted recordings from clinical practice. There were positive relationships (r = .27 to .56) between self and expert CTS-R scores at all time points. The proportion of tapes demonstrating significant agreement between self and expert ratings (CTS-R difference <5 points) increased significantly across training and remained stable at follow-up. Findings indicate that accurate self-awareness of competence can be developed during structured CBT training and retained in the workplace. These outcomes are encouraging given the importance of self-awareness to CBT practice and accreditation. Future investigation into the development and maintenance of accurate self-awareness of competence is warranted.
Key learning aims(1) What is the relationship between self-ratings and expert ratings of CBT competence during training and at post-training follow-up?
(2) Does agreement between self and expert competence ratings improve with CBT training?
(3) How does agreement between self and expert ratings change across training for more- and less-competent trainees?
(4) Can accurate self-awareness of competence be retained post-training in the workplace?
Education and Supervision
A new tool for rating cognitive behavioural supervision – preliminary findings in a clinical setting
- S.B. Moeller, N.K. Rosenberg, M. Hvenegaard, K. Straarup, S.F. Austin
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- Published online by Cambridge University Press:
- 16 March 2020, e2
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Cognitive behavioural therapy (CBT) is an evidence-based psychotherapy and one of the most widely used treatments for mental health problems. It is generally acknowledged that supervision improves the quality of treatment although systematic descriptions and empirical evaluation of supervision have been sparse. Moreover, there are relatively few valid and reliable instruments to evaluate supervision. Based on a comprehensive review of the supervision literature, six competency domains were identified to cover the scope of CBT supervision: Theory, Focus, Learning strategy, Techniques, Structure, and Interpersonal style. The Moeller, Moerch, Rosenberg Supervision Scale (MMRSS) was developed to evaluate supervisor performance within each of these domains after observation of supervision. The present study examined the psychometric properties of the MMRSS (inter-rater reliability and construct validity), the clinical utility, and satisfaction when using MMRSS to evaluate CBT supervision. CBT supervisors (n = 8) were recruited for the study and provided videos of group supervision. A total of 21 videos were rated using the MMRSS and the Supervisory Competency Scale (SCS) by two independent raters. Supervisees and supervisors completed a satisfaction questionnaire to capture their experience of using the MMRSS during supervision of supervision. The MMRSS showed acceptable internal consistency and validity. Several domains in MMRSS (Structure, Learning strategy, and Interpersonal style) correlated significantly with the corresponding domains in the SCS for cognitive supervision. Preliminary results indicate that the MMRSS may be a valid and clinically useful tool to evaluate CBT supervision, although further systematic evaluation is needed.
Key learning aims(1) To understand that empirically founded evaluation of cognitive behavioural supervision is essential for good training.
(2) To argue that a modern view of supervision places an emphasis on learning principles.
(3) To describe the Moeller, Moerch, Rosenberg Supervision Scale (MMRSS) and the scale’s preliminary psychometric properties.
(4) To describe the supervisors’ and supervisees’ reported satisfaction using the MMRSS.
Thanks to Reviewers
Thanks to Reviewers
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- Published online by Cambridge University Press:
- 08 April 2020, e3
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Service Models and Forms of Delivery
IAPT and the internet: the current and future role of therapist-guided internet interventions within routine care settings
- Graham R. Thew
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- 08 April 2020, e4
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Compared with the traditional face-to-face format, therapist-guided internet interventions offer a different approach to supporting clients in learning skills to manage and overcome mental health difficulties. Such interventions are already in use within IAPT (Improving Access to Psychological Therapies) and other routine care settings, but given their potential to deliver treatment more efficiently and therefore increase availability and access to evidence-based interventions, their use is likely to increase significantly over the coming years. This article outlines what is meant by therapist-guided internet interventions and why an online format is thought to be advantageous for clients, therapists, services, and communities more broadly. It reviews the current evidence in the context of common therapist beliefs about internet-based treatment. It aims to identify gaps where further research is required, particularly in relation to the broader implementation of these treatments in IAPT and other routine clinical services. Specifically, it emphasises the importance of choosing the right programmes, providing adequate therapist training in their use, and considering practical and organisational issues, all of which are likely to determine the success of implementation efforts.
Key learning aims(1) To understand what therapist-guided internet interventions are and their potential advantages.
(2) To understand the current evidence base for these interventions.
(3) To learn where further research is needed with regard to both the interventions themselves, and to their broader implementation in IAPT.
Case Study
Helping clients ‘restart their engine’ – use of in-session cognitive behavioural therapy behavioural experiments for engagement and treatment in persistent depression: a case study
- Lilian Skilbeck, Christopher Spanton, Ian Roylance
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- 13 April 2020, e5
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Behavioural experiments (BEs) are a major cognitive ingredient in the cognitive behavioural therapy (CBT) model which can be applied in-session or between-sessions. In-session BEs are particularly effective and widely demonstrated in anxiety disorders, yet they remain under-utilised in depression. Clients presenting with persistent depression are often difficult to engage due to the chronicity of their symptoms and their learnt self-perpetuating demoralised states. Research to date demonstrates the effectiveness of in-session BEs in engagement and treatment in depression. This case study details the treatment of a client presenting with persistent major depressive disorder (MDD) with hopelessness and how in-session BEs effected engagement and treatment. This case study is discussed with reference to strengths, limitations, clinical implications and recommendations for practice and development.
Key learning aimsIt is hoped that the reader of this case study will increase their understanding of the following:
(1) Using BEs to help engagement and treatment in persistent MDD.
(2) Instilling hope by starting in-session BEs during the assessment stage.
(3) When to plan or seize opportunities for off-the-cuffin-session BEs.
(4) Setting no-lose BEs to enable clients to widen their perceptual field.
(5) The importance of repeated BEs to consolidate experiential learning.
Review Paper
The practice and research of cognitive behavioural therapy in Egypt: a review of the current status
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- Reham Aly, Hisham Ramy, Shanaya Rathod
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- 13 April 2020, e6
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Cognitive behavioural therapy (CBT) is generally defined as a short-term, problem-oriented psychotherapy that focuses on modifying dysfunctional emotions, thoughts and actions. In clinical practice, CBT consists of a number of cognitive and behavioural techniques that aim to help patients suffering from psychological disorders. The practice of CBT is well established in Western countries. In non-Western countries, CBT is still in the process of being established as the evidence-based psychotherapy. Despite being the heart of the Arab world, the development and practice of psychotherapy in Egypt in general, and CBT specifically, is still emerging. The training and practice of CBT has received a mixed response in Egypt. In practical settings, evidence-based CBT is subject to individual and cultural variations and adaptations. Many local studies examining the efficacy of CBT in psychiatric disorders among different population groups in Egypt have been conducted. Unfortunately, many of these studies have not been published and therefore have missed the opportunity for international recognition. The current review aims to explore the practice of CBT with a specific focus on national research of efficacy and adaptability of CBT for different populations in Egypt.
Key learning aims(1) Current status of the practice and education of CBT in Egypt.
(2) Body of research conducted on CBT in Egypt.
(3) Needs and recommendations for further development of CBT provision in Egypt.
Practice Article
One pathway to cognitive behaviour therapy integration: introducing assimilative integrative rational emotive behaviour therapy
- Najwan Saaed Al-Roubaiy
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- 13 April 2020, e7
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In this paper, rational emotive behaviour therapy (REBT) is presented as the most comprehensive cognitive behavioural therapy (CBT) to date, with over-arching influence on most of the other therapies that came after it. However, despite REBT’s comprehensiveness and the limitations inherent in other CBT approaches, REBT has its limitations. Limitations in REBT theory are explored and an argument is made in favour of rectifying these limitations by incorporating other approaches into REBT (namely cognitive therapy and compassion-focused therapy) to create a more complete integrative psychotherapy model. It is then argued that psychotherapy integration is the future of CBT mainly due to the fact that it reflects how most therapists practise, and due to its utilization of the common factors theory. Finally, the integrative model – which I call Assimilative Integrative Rational Emotive Behaviour Therapy – is presented and demonstrated using a clinical case example.
Key learning aims(1) To understand the limitations of cognitive therapy and third-wave CBT approaches.
(2) To appreciate the comprehensiveness and over-arching influence of REBT.
(3) To understand the limitations of REBT despite its comprehensiveness.
(4) To consider rectifying the limitations in REBT by incorporating other models into it.
(5) To appreciate the complementary nature of CFT when integrated into other models.
(6) To understand the value and relevance of psychotherapy integration.
(7) To consider AI-REBT as one possible pathway to psychotherapy integration in CBT.
Original Research
Group CBT for mild to moderate depression and anxiety: an evaluation of patient satisfaction within a primary care mental health team
- Genevieve Young-Southward, Alison Jackson, Julie Dunan
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- 13 April 2020, e8
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In the UK there has been a drive towards facilitating swift access to psychological therapies. Groups are an efficient way to provide psychological interventions to a wide range of people and are recommended treatments for mild depression and anxiety, presentations commonly seen in primary care mental health teams. Group cognitive behavioural therapy (CBT) has been shown to be clinically effective, but less is known about the acceptability of groups to patients. This study evaluated patient satisfaction with CBT groups running within a primary care mental health team in Scotland. Data from a routinely administered patient satisfaction questionnaire were collected. Likert-scale responses were analysed via frequencies and percentages, and free text responses were analysed via thematic analysis. Among those who completed a group, overall satisfaction was high. The qualitative analysis revealed that for many a group environment was therapeutic in itself, and the intervention provided service users with a range of skills with which to tackle their difficulties. However, others indicated that a group environment was unsuitable for their needs, and perceptions around the accessibility and relevance of group content were mixed. Indeed, drop-out rates were high, and perceptions of groups among those who did not attend the final session are not included in this analysis. Group dynamics may be both a facilitator of and a barrier to therapeutic benefit, depending on individual factors. Future studies could evaluate satisfaction among service users who drop out of interventions in order to inform future service delivery.
Key learning aims(1) To understand the utility of delivering CBT in a group format for mild to moderate depression and anxiety.
(2) To understand service users’ perceptions regarding group CBT interventions via a mixed method inquiry.
(3) To reflect on how group dynamics within group CBT may be both a facilitator of and a barrier to therapeutic benefit.
Case Study
The use of transdiagnostic cognitive behavioural therapy for a patient with multi-morbidity: a case study
- Lisa Walshe, Chris Allen
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- 21 April 2020, e9
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Multi-morbidity, having more than two diagnosed health conditions, is becoming increasingly common within healthcare services. Approximately one third of these patients are likely to have a mental health condition. Those with multi-morbidity with physical and mental health conditions have poorer outcomes in terms of their health, increased mortality rates, and higher usage of healthcare services.
This paper presents a case of a patient with multi-morbidity, with associated mental health conditions of anxiety and depression. She was seen as part of an integrated service which provides psychological support at home alongside the nursing team. The intervention used was based on transdiagnostic cognitive behavioural therapy (tCBT), provided over nine initial sessions and two additional booster sessions. Self-report measures were completed at intervals throughout the intervention and at follow-up. Improvements on the depression and anxiety measures were seen over the initial nine sessions, followed by a relapse at the 3-month follow-up. This was the result of a deterioration in physical health which led to a deterioration in mental health. The booster sessions mitigated further deterioration in mental health, despite the physical health worsening during this time.
This case suggests that tCBT can be helpful in reducing anxiety and depression in people with multi-morbidity. However, additional booster sessions may be required as further physical deterioration can re-trigger core beliefs and result in further mental health problems.
Key learning aims(1) Transdiagnostic CBT can be beneficial for patients with multi-morbidity.
(2) Integrated care addressing both physical and mental health problems is beneficial for people with multi-morbidity.
(3) Monitoring deterioration in physical health is important, as this has an impact on mental health and may need addressing through psychological support.
(4) Formulation for people with multi-morbidity needs to include mental and physical health factors and their interaction.
Original Research
Therapist beliefs about exposure therapy implementation
- Johanna M. Meyer, Peter J. Kelly, Brett J. Deacon
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- Published online by Cambridge University Press:
- 28 April 2020, e10
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Exposure therapy is consistently indicated as the first-line treatment for anxiety-related disorders. Unfortunately, therapists often deliver exposure therapy in an overly cautious, less effective manner, characterized by using their own ‘therapist safety behaviours’. Cognitive behavioural models postulate that beliefs about therapist safety behaviours are related to their use; however, little is known about the beliefs therapists hold regarding therapist safety behaviour use. The present study aimed to identify the beliefs exposure therapists have regarding the necessity of therapist safety behaviours and to examine the relationship between this construct and therapist safety behaviour use. Australian psychologists (n = 98) completed an online survey that included existing measures of therapist safety behaviour use, therapist negative beliefs about exposure therapy, likelihood to exclude anxious clients from exposure therapy, and use of intensifying exposure techniques. Participants also completed the Exposure Implementation Beliefs Scale (EIBS), a measure created for the present study which assesses beliefs regarding the necessity of therapist safety behaviours. Beliefs about the necessity of therapist safety behaviours – particularly in protecting the client – significantly predicted therapist safety behaviour use. Findings suggest that exposure therapy training media should aim to decrease therapist safety behaviour use by addressing beliefs about the necessity of therapist safety behaviours, especially in protecting the client.
Key learning aims(1) To understand what therapist safety behaviours are in the context of exposure therapy.
(2) To identify common beliefs about therapist safety behaviours.
(3) To understand how beliefs about therapist safety behaviours relate to therapist safety behaviour use.
(4) To consider how exposure therapy delivery may be improved by modifying beliefs about therapist safety behaviours.
(5) To explore how beliefs about therapist safety behaviours may be modified to reduce therapist safety behaviour use.
Group therapists: combine alliance building with paying specific attention to the patient’s perception
- Beate Muschalla
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- 28 April 2020, e11
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In slow-open groups as well as therapies of less than ten sessions, each group session holds importance. Patients, therapists and co-therapists have different perspectives and may gain different experiences from a group session. This study investigates the perspectives of patients, therapists and co-therapists on alliance, new insights and therapist techniques in the same group session. Do the three actors perceive these group aspects similarly or differently? Which group aspects are related with the outcome coping? One hundred and forty-nine sessions of a cognitive behaviour therapy group have been investigated. Patients, therapists and co-therapists gave ratings on their perceived alliance, group topics and insights as well as therapists’ technique competency. Concerning new insights, there was concordance between patients and co-therapists (r = .211, p < .05). Concerning alliance, there was a concordance between patients and therapists (r = .327, p < .01). Therapists focusing on alliance building was associated with lower patient outcomes in terms of work coping (β = –.391). The quality of therapeutic techniques was the same in groups with higher and lower outcomes. Patients’ perception of whether they felt good in the group session was explanative for session outcome, while therapists’ perceptions and context conditions (supervision, number of participants) was not. Patients, therapists and co-therapists have different perspectives on the same group therapy session. Patients’ perceptions are associated with session outcomes. A lower session outcome must not be associated with a poor technique performance of the therapist. Therapists should not only be aware of alliance building and correct technical performance, but they must also be aware of patients’ perceptions of the group process and outcome.
Key learning aimsThe present research is the first evaluation of group session aspects and session outcomes in rehabilitation patients with work anxieties in slow-open groups. We will learn:
(1) Whether patients’, therapists’ and co-therapists’ perceptions of the same group session are similar or different;
(2) Whether group sessions that result in worse outcomes are different from group sessions resulting in a better outcome;
(3) Which aspects of the group session are predictive for a better outcome.
Invited Paper
Adapting IAPT services to support frontline NHS staff during the Covid-19 pandemic: the Homerton Covid Psychological Support (HCPS) pathway
- C.L. Cole, S. Waterman, J. Stott, R. Saunders, J.E.J. Buckman, S. Pilling, J. Wheatley
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- Published online by Cambridge University Press:
- 28 April 2020, e12
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The Coronavirus (Covid-19) pandemic is exerting unprecedented pressure on NHS Health and Social Care provisions, with frontline staff, such as those of critical care units, encountering vast practical and emotional challenges on a daily basis. Although staff are being supported through organisational provisions, facilitated by those in leadership roles, the emergence of mental health difficulties or the exacerbation of existing ones amongst these members of staff is a cause for concern. Acknowledging this, academics and healthcare professionals alike are calling for psychological support for frontline staff, which not only addresses distress during the initial phases of the outbreak but also over the months, if not years, that follow. Fortunately, mental health services and psychology professional bodies across the United Kingdom have issued guidance to meet these needs. An attempt has been made to translate these sets of guidance into clinical provisions via the recently established Homerton Covid Psychological Support (HCPS) pathway delivered by Talk Changes (Hackney & City IAPT). This article describes the phased, stepped-care and evidence-based approach that has been adopted by the service to support local frontline NHS staff. We wish to share our service design and pathway of care with other Improving Access to Psychological Therapies (IAPT) services who may also seek to support hospital frontline staff within their associated NHS Trusts and in doing so, lay the foundations of a coordinated response.
Key learning aims(1) To understand the ways staff can be psychologically and emotionally impacted by working on the frontline of disease outbreaks.
(2) To understand the ways in which IAPT services have previously supported populations exposed to crises.
(3) To learn ways of delivering psychological support and interventions during a pandemic context based on existing guidance and research.
Empirically Grounded Clinical Guidance Paper
Cognitive therapy for post-traumatic stress disorder following critical illness and intensive care unit admission
- Hannah Murray, Nick Grey, Jennifer Wild, Emma Warnock-Parkes, Alice Kerr, David M. Clark, Anke Ehlers
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- Published online by Cambridge University Press:
- 29 April 2020, e13
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Around a quarter of patients treated in intensive care units (ICUs) will develop symptoms of post-traumatic stress disorder (PTSD). Given the dramatic increase in ICU admissions during the COVID-19 pandemic, clinicians are likely to see a rise in post-ICU PTSD cases in the coming months. Post-ICU PTSD can present various challenges to clinicians, and no clinical guidelines have been published for delivering trauma-focused cognitive behavioural therapy with this population. In this article, we describe how to use cognitive therapy for PTSD (CT-PTSD), a first line treatment for PTSD recommended by the National Institute for Health and Care Excellence. Using clinical case examples, we outline the key techniques involved in CT-PTSD, and describe their application to treating patients with PTSD following ICU.
Key learning aims(1) To recognise PTSD following admissions to intensive care units (ICUs).
(2) To understand how the ICU experience can lead to PTSD development.
(3) To understand how Ehlers and Clark’s (2000) cognitive model of PTSD can be applied to post-ICU PTSD.
(4) To be able to apply cognitive therapy for PTSD to patients with post-ICU PTSD.
Challenges and opportunities for enhanced cognitive behaviour therapy (CBT-E) in light of COVID-19
- Rebecca Murphy, Simona Calugi, Zafra Cooper, Riccardo Dalle Grave
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- Published online by Cambridge University Press:
- 04 May 2020, e14
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In the past few weeks, coronavirus disease 2019 (COVID-19) has dramatically expanded across the world. To limit the spread of COVID-19 and its negative consequences, many countries have applied strict social distancing rules. In this dramatic situation, people with eating disorders are at risk of their disorder becoming more severe or relapsing. The risk comes from multiple sources including fears of infection and the effects of social isolation, as well as the limited availability of adequate psychological and psychiatric treatments. A potential practical solution to address some of these problems is to deliver enhanced cognitive behaviour therapy (CBT-E), an evidence-based treatment for all eating disorders, remotely. In this guidance we address three main topics. First, we suggest that CBT-E is suitable for remote delivery and we consider the challenges and advantages of delivering it in this way. Second, we discuss new problems that patients with eating disorders may face in this period. We also highlight potential opportunities for adapting some aspects of CBT-E to address them. Finally, we provide guidelines about how to adapt the various stages, strategies and procedures of CBT-E for teletherapy use in the particular circumstances of COVID-19.
Key learning aims(1) To appreciate that CBT-E is suitable for remote delivery, and to consider the main challenges and potential advantages of this way of working.
(2) To identify and discuss the additional eating disorder-related problems that may arise as a result of COVID-19, as well as potential opportunities for adapting some aspects of CBT-E to address them.
(3) To learn how to adapt CBT-E for remote delivery to address the consequences of COVID-19. Specifically, to consider adaptations to the assessment and preparation phase, the four stages of treatment and its use with underweight patients and adolescents.
Original Research
What are the recovery and attrition outcomes for group CBT and individual CBT for generalised anxiety disorder in an IAPT service? An exploratory study
- Marianne Fanous, Jo Daniels
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- Published online by Cambridge University Press:
- 09 June 2020, e15
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Group cognitive behavioural therapy (gCBT) is commonly used in Increasing Access to Psychological Therapies (IAPT) services. However, there is limited knowledge of the efficacy of gCBT as a delivery format for generalised anxiety disorder (GAD). To address gaps in literature, this study aims to explore the efficacy and attrition of individual and group CBT interventions, respectively, at Step 3 for GAD using data from a routine IAPT service over a 24-month period. Data were retrospectively derived from a routine serviceʼs IAPTus database, separating those eligible for comparison into group (n = 44) and individual (n = 55) CBT for GAD. Outcomes were differences in pre–post self-reported anxiety (GAD-7) and depression (PHQ-9) scores, clinical recovery and attrition for gCBT and individual CBT. Both gCBT and individual CBT yielded significant reductions in self-reported anxiety and depression scores over time. Results indicate that 53% of patients attending individual CBT achieved clinical recovery, with similar but less competitive rates of 41% in gCBT. Attrition rates were similar between gCBT (29.5%) and individual CBT (27.3%), respectively. Preliminary results suggest that both individual and gCBT are effective interventions for GAD patients in IAPT, offering symptom alleviation and comparable recovery and attrition rates post-intervention. This observational design offers credibility and insight into a pragmatic evaluative and explorative comparison. gCBT may offer an acceptable and potentially economical alternative.
Key learning aims(1) To explore whether gCBT and individual CBT yield significant symptom reduction in self-reported anxiety and depression in GAD patients from a routine IAPT service.
(2) To explore gCBT and individual CBT clinical recovery rates in non-optimum routine conditions.
(3) To explore whether gCBT for GAD produces unacceptable attrition rates and if this differs from attrition rates in individual CBT for GAD in a routine IAPT service.
Improvement in IAPT outcomes over time: are they driven by changes in clinical practice?
- Rob Saunders, John Cape, Judy Leibowitz, Elisa Aguirre, Renuka Jena, Mirko Cirkovic, Jon Wheatley, Nicole Main, Stephen Pilling, Joshua E.J. Buckman
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- Published online by Cambridge University Press:
- 09 June 2020, e16
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Treatment outcomes across Improving Access to Psychological Therapies (IAPT) services in England have improved year-on-year, with the national average proportion of patients in recovery at the end of treatment now exceeding the 50% target. This is despite the number of referrals and numbers of treated patients also increasing year-on-year, suggesting that services have evolved local practices and treatment delivery to meet needs whilst improving performance. This study explores whether there have been changes in clinical practice with regard to: (1) the number of sessions and length of treatments; (2) the number of cancellations and non-attendance; and (3) the recording of problem descriptor information, and the association with treatment outcomes in IAPT. Routinely collected data from seven IAPT services involved in the North and Central East London (NCEL) IAPT Service Improvement and Research Network (SIRN) were brought together to form a dataset of nearly 88,000 patients who completed a course of IAPT treatment. Results showed that there was a slight increase in the average number of sessions, and decreases in the length of time in treatment, as well as decreases in both the number of non-attended appointments and the use of inappropriate problem descriptors. These findings highlight a number of areas where potentially small changes to clinical practice may have had positive effects on patient outcomes. The value of using IAPT data to inform service improvement evaluations is discussed.
Key learning aims(1) How changes to treatment-delivery factors are associated with IAPT patient outcomes.
(2) The link between clinical practice and potential service performance.
(3) How analysing routinely collected data can be used to inform service improvement.
Practice Article
Are you sitting (un)comfortably? Action-based supervision and supervisory drift
- Matthew Pugh, Alexander Margetts
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- 10 June 2020, e17
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Action-based methods such as behavioural experiments, role-play and (by extension) ‘chairwork’ are powerful techniques recommended in core supervisory texts for cognitive behavioural therapy (CBT). Despite this, experiential methods are seldom used by supervisors, suggesting that supervision often drifts from a ‘doing process’ to a ‘talking process’. A number of factors contribute to this divergence from best practice, including limited confidence and a lack of familiarity with experiential procedures amongst supervisors. To address this, the current paper presents a variety of action-based techniques for enhancing supervisees’ technical, perceptual, interpersonal, reflective and personal competencies. Behavioural experiments, empty-chair, multi-chair and role-playing exercises for maintaining treatment fidelity, enhancing empathic attunement, repairing therapeutic ruptures, resolving impasses and working through negative countertransference are described, amongst others. Further research is needed to establish the nature and extent of supervisory drift, as well as the efficacy of action-based methods.
Key learning aimsAs a result of reading this paper, readers should:
(1) Understand why supervision sometimes drifts from being a ‘doing’ process.
(2) Appreciate the value of experiential, action-based supervisory methods.
(3) Feel competent using action-based methods to enhance supervisees’ clinical skills.
Education and Supervision
Improving CBT supervision. Four years of implementing NES Specialist Supervision Training for CBT in Scotland
- Nathan O’Neill, Mairi Albiston, Sandra Ferguson, Leeanne Nicklas
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- 10 June 2020, e18
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NHS Education for Scotland (NES) plays a lead role in training the NHS Psychological Therapies workforce across Scotland. Ferguson et al. (2016) outlined the challenges, opportunities and proposed evaluation of the NES Specialist Supervision Training in Cognitive Behavioural Therapy (NESSST-CBT). The aims of the training were to provide an evidence-based, flexible and learner-focused training in CBT specific supervision competencies. This paper will provide an update on the evaluation of the training using Kirkpatrick’s Impact Evaluation Model (1967, 1987). Results indicate that: (1) delegates rated the training experience positively in various ways; (2) delegates described increases in their confidence and competence in using structured measures of CBT and supervision; (3) a majority of delegates completing a 3-month follow-up questionnaire described continued use of a structured CBT measure in supervision and for self-reflection; and (4) 392 psychological therapists in Scotland have now been formally trained in CBT specific supervision skills. NESSST-CBT continues to adapt and improve as a resource for staff as NES moves forward in its Digital Strategy for Scotland’s NHS and partnership staff. Further implications of this are discussed, as well as limitations of the study.
Key learning aims(1) Readers will be able to further understand the multi-faceted role of NHS Education for Scotland in implementing CBT supervision training in Scotland.
(2) Readers will be able to list three key outcomes from the feedback data on 4 years of a specialist supervision blended-learning training for CBT supervision.
(3) Readers will be able to identify three key limitations of the study and recommendations for future research.
Invited Paper
Death anxiety in the time of COVID-19: theoretical explanations and clinical implications
- Rachel E. Menzies, Ross G. Menzies
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- Published online by Cambridge University Press:
- 11 June 2020, e19
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The recent COVID-19 pandemic has triggered a surge in anxiety across the globe. Much of the public’s behavioural and emotional response to the virus can be understood through the framework of terror management theory, which proposes that fear of death drives much of human behaviour. In the context of the current pandemic, death anxiety, a recently proposed transdiagnostic construct, appears especially relevant. Fear of death has recently been shown to predict not only anxiety related to COVID-19, but also to play a causal role in various mental health conditions. Given this, it is argued that treatment programmes in mental health may need to broaden their focus to directly target the dread of death. Notably, cognitive behavioural therapy (CBT) has been shown to produce significant reductions in death anxiety. As such, it is possible that complementing current treatments with specific CBT techniques addressing fears of death may ensure enhanced long-term symptom reduction. Further research is essential in order to examine whether treating death anxiety will indeed improve long-term outcomes, and prevent the emergence of future disorders in vulnerable populations.
Key learning aims(1) To understand terror management theory and its theoretical explanation of death anxiety in the context of COVID-19.
(2) To understand the transdiagnostic role of death anxiety in mental health disorders.
(3) To understand current treatment approaches for directly targeting death anxiety, and the importance of doing so to improve long-term treatment outcomes.
Case Study
The development of a parent–child activity based on the principles of perceptual control theory
- Anamaria Churchman, Warren Mansell, Sara Tai
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- Published online by Cambridge University Press:
- 01 July 2020, e20
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Problems most frequently reported by young people in school counselling relate to family difficulties. During adolescence, conflict between parents and young people increases as young people move towards independence whilst still being reliant on parents. The quality of communication during this period has implications for young people’s well-being. The current study explored how the principles of perceptual control theory (PCT) could be used to develop a structured activity aimed at helping young people to talk to their parents about their goals and goal conflicts.
PCT proposes that individuals function well when they are able to control things that are important to them. Every individual has numerous goals/wants and if two or more are incompatible, conflict arises. The current study focused on supporting young people to explore conflict that might arise due to incompatible goals held by them and their parent. Six families (child and parent/carer) were recruited to try a goal-setting and monitoring activity. The activity was facilitated by a Method of Levels researcher over a 10-week period. There were two follow-up appointments at 2 and 4 months. Two families were retained for the entire study. On completion, four families provided qualitative feedback. On the basis of participants’ feedback, the activity was modified to incorporate discussions on incompatible goals. Two families piloted the modified activity and provided feedback. Both families completed the study. Results suggest that a parent–child activity using the principles of PCT is feasible and acceptable among parents and young people.
Key learning aims(1) To understand how the principles of PCT can be used to support young people in communicating with their parents.
(2) To understand how talking about important goals/wants impacts young people and their parents.
(3) To understand how the principles of PCT can be used to resolve parent–child conflict.