Teaching and Supervising CBT

donna_sudak-001by Donna Sudak, MD

 

Did you learn CBT through the tradition of “See one, do one, teach one?” Were your instructors and supervisors clinicians who had never learned the principles of adult learning? Did they instead teach or supervise you in the way they themselves had been taught or supervised?

Dissemination and training of quality CBT therapists has become a recent focus for CBT programs throughout the world. There is a renewed focus in the field of CBT and on the skills needed to effectively teach and supervise. In fact, CBT supervision skills have independently been recognized as a competency in recent years.

Perhaps surprisingly, little research exists on CBT training. What constitutes sufficient training? What does “competence” in CBT actually mean? How should therapist “drift” be monitored and assessed? Sudak et al (2015) summarizes the current research in training and supervision.

Training is defined as the effective transfer of knowledge about and practice of the key skills of CBT. It represents both knowing that and knowing how. Most skills are taught both in training and supervision.  Therapists or students first learn the rationale for a skill; they watch experts, and model what they have learned in practice with roleplayed “clients” of varying degrees of difficulty (with corrective and confirming feedback). Once trainees have the necessary skills, they can then be supervised with actual clients in a setting of “real world complexity.”

CBT supervision is most effective and efficient when the supervisor uses processes that parallel CBT therapy. The supervisory alliance is critical to effective work in supervision. The relationship needs to be safe enough for the supervisee to tell the truth and to be able to hear and incorporate constructive feedback. Supervisors should do a needs assessment with supervisees and then collaboratively set goals which form the “road-map” for supervision. Good supervision uses a session structure similar to that employed with clients in psychotherapy (Liese and Beck, 1997). By so doing, the model is reinforced and the supervisee can have an experience akin to self-practice.

Several other important parallels exist between effective supervision and therapy. These include using Socratic questions to stimulate learning and reflection, action plans between sessions and eliciting and giving feedback. Tapes of client sessions must be used to assess progress, rated by both the supervisee and supervisor with a validated instrument to determine fidelity and integrity, such as the Cognitive Therapy Rating Scale and client symptom rating scales provide data to determine if care is adequate and safe.

Supervision also requires conceptualization – both of the client and the supervisee. We are more effective supervisors if we develop a tailored educational plan based on the educational needs of the trainee and his or her capacities as therapist. The cultural competence and the cultural background of supervisees and clients should also be considered as a part of the conceptualization.

Supervisees should be encouraged to use thought records regarding their reactions to clients and expectations of themselves as therapists. This practice helps them to learn more effectively and inculcates the self-reflection that encourages expertise. Bennett-Levy (2003) has published extensively regarding this core process in CBT training. Active engagement and thoughtful implementation of several learning methods, as described by Milne and Dunkerley (2010), heightens curiosity and interest in supervisees.

Making our supervision and training more effective is also more engaging and fun for the teacher, so everyone benefits from this effort to improve our work.

 

Learn from Dr. Sudak at the Teaching and Supervising CBT Workshop.

 

References

Sudak, D.M., Codd, R.T., Ludgate, J., Reiser, R.J., Milne, D., Sokol, L., Fox, M. Teaching and Supervising Cognitive Behavioral Therapy. (2015) Hoboken: John Wiley and Sons.

Bennett-Levy, J. Lee., N., Travers, K., Pohlman, S., & Hammernick, (2003). Cognitive therapy from the inside: Enhancing therapist’s skills through practicing what we preach. Behavioural and Cognitive Psychotherapy, 31, 145–163.

Liese, B.S., & Beck, J. S. (1997). Cognitive therapy supervision. In E. Watkins (Ed.), Handbook of psychotherapy supervision. New York, NY: Wiley

Milne, D.L., & Dunkerley, C. (2010). Towards evidence-based clinical supervision: The development and evaluation of four CBT guidelines. Cognitive Behaviour Therapist, 3, 43–57.

The Future of Community Mental Health for Persons with Severe Mental Illness

dr-aaron-beck-2015by Aaron T. Beck, MD

 

Part 3 of 3

Read part 1, A Biography of Cognitive Behavior Therapy

Read part 2, The Evolution of CBT in Community Mental Health

 

I think that it is going to take a number of years for us to really get our Recovery Oriented Cognitive Therapy approach fully implanted. The reason is that the approach is novel, and compared to the standard approach for the severely mentally ill, it is revolutionary.  For example, one important principle is that if that you treat these individuals as though they are normal, they are going to react normally.  They are going to show normal affect, normal behavior, and normal thinking.  Our idea is that not only can we bring out the normal personality, but we can maintain the normal personality throughout the individual’s stay in an inpatient facility and then back out into the community.

One of the problems is that this model runs counter to everything that has been taught before this.  For example, when I took psychiatry in medical school, I was taught that there were two types of psychiatric patients.  There was dementia praecox, which had to do with people who had delusions and hallucinations, who would gradually just get worse and worse until they were completely insane.  Then, there were psychopathic personalities who were individuals with very distorted personalities.  In either case, the question was, were these individuals treatable?

And so I was imbued with this story that severely mentally ill people, since they seemed so removed and so strange, were really untreatable.  Working with Paul Grant and the others on our schizophrenia team, we were able to discover that if we changed our philosophy to the ideas of Recovery and went on the assumption that underneath the abnormal symptoms, there was a normal personality, that we could maintain the personality.

But the problem was, how do you maintain the person?  Well, that becomes the problem.  So the plan became to train all the individuals that have contact with the patients–actually we call them “individuals.” This includes the art therapists, the occupational therapists, the social workers, the line staff, nurses and psychiatrists. We needed all of them to come aboard, using this new approach.  To do this, they needed a change in attitude, because many of them had the same erroneous belief that I had had—namely that the people who were insane by definition, were not capable of being sane at any time.  And we would have to create an atmosphere in which all of the personnel would work toward establishing a cognitive milieu.

Now, to accomplish that would be difficult, because there are numerous problems that the staff has to deal with, that get in the way of this full recovery.  For example, the most common problems are the negative symptoms.  Some of the severely ill individuals also act out in various ways or become aggressive toward the staff.  So numerous problems have come up, and the staff has had to learn how to deal with them.  But once they do, the individual can move along and get back into their lives.  Also, there is certainly turn-over at the various facilities, as staff comes in and out.

So, I expect that at the end of 5 years, we’re going to have a model program here at the Philadelphia Department of Behavioral Health and Intellectual Disability Services(DBHIDS), and people will come from all over the world to learn about the program.  Right now, we have national and international clinicians who are trying to learn our method and export it to their own home towns, and eventually we’ll have a training program that will involve not only people at DBHIDS but people from around the world.