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Training for organizations

By Robert Hindman, PhD

A popular myth about CBT is that it’s comprised of a set of strategies used in the same manner across organizations and the individuals for whom they provide treatment. Fellow therapists often ask me which treatment manual I follow for a specific disorder. They do not realize that treatment manuals are usually inappropriate to use outside of research studies. They were designed to improve reliability and validity. In practice, good CBT should be based on the client’s individualized cognitive conceptualization instead of a one-size-fits-all approach.

Effective CBT requires practitioners to adapt the model based on the setting in which it is conducted. For example, in 2013, Beck Institute contracted with an adolescent residential behavioral health organization in Michigan, Wolverine Human Services (Wolverine), to create CBT trainings for staff at residential facilities. The audience for our trainings consisted of all types of staff who interacted with residents in a variety of settings. They needed to learn strategies to better interact with residents, treat their underlying mental health issues and deescalate tension in the residential facilities in which they worked.

To meet the unique needs of Wolverine’s team, we partnered with a psychologist specializing in implementation and dissemination, Cara Lewis, PhD (currently of Kaiser Permanente), to develop a custom training program.

We first conducted a needs assessment of the organization to determine what factors might pose an obstacle to successful training, as well as what specific content we should include. This step involved learning about the organization through stakeholder interviews, staff evaluations on factors important in successful implementation and dissemination of CBT, and focus groups with all levels of clinical and non-clinical staff, as well as current clients. We were able to use the information we gathered to identify and collaboratively develop solutions to potential barriers.

Once we addressed the barriers, we worked with Wolverine to develop a CBT training program that would best serve their organization. We developed a multi-level approach to train supervising therapists, therapists, and support staff. We supervised the Wolverine supervising therapists in how to conduct CBT based on each client’s individualized cognitive conceptualization. In turn, these supervising therapists were then able to conduct CBT in this manner and use the same approach to inform their supervision of other therapists in the organization.

While this approach might be sufficient for an outpatient mental health organization, it is a different story for many residential programs. Wolverine staff informed us that their clients have the greatest amount of interaction with staff who act primarily as safety monitors without mental health backgrounds. A standard CBT approach would not work with these staff. They were responsible for overseeing many clients at once and would not be able to step aside to help a client who needed an extended period of time with them.

Training for organizations

Due to these limitations, we adjusted their training from using CBT as a conceptualization-driven approach conducted in individual sessions to a skills-based approach conducted spontaneously with clients when the need arose. Together with Wolverine staff, we identified key issues requiring intervention so we could narrow down the most relevant CBT skills. In collaboration with Wolverine and consulting the research literature, we settled on six core skills: Active listening (effective/empathic communication), CAPES (behavioral activation through connection, accomplishment, physical activity, enjoyment, and sleep hygiene), ITCH (problem solving), TIP Skills (emotion regulation), CBT Chat Forms (cognitive restructuring) and SPEED Maps (emotional awareness and choosing different skills at different emotional intensities).

Since we were able to train both therapists and the residential staff who had the most contact with the clients, the clients experienced a comprehensive CBT treatment program. This included both the individualized cognitive conceptualization-based approach during individual therapy, as well as reinforcement and assistance in using the six core CBT skills with the safety staff.   

The results of tailoring a CBT program to the organization helped in a variety of ways. Joseph Partaka, LMSW, CADC, CCS, Wolverine Human Services Clinical and Quality Manager noted, “The partnership with Beck Institute and the University of Indiana to implement CBT practices across our residential programs has significantly impacted our work with teens. Not only has the need for physical management by staff been reduced since implementation, but the quality of therapeutic services delivered by clinicians has improved, based on recent CTRS (Cognitive Therapy Rating Scale) scores. The work we’ve done with Beck Institute and UI teams has truly helped us better meet our agency’s mission of ‘Helping Children to be Victors!’”