Donna Sudak, MD - Drexel University College of Medicine
In the past twenty years there has been an enormous interest in the practice of cognitive-behavioral therapy (CBT). Substantial research has been conducted indicating that CBT is a significantly effective treatment for a variety of psychiatric illnesses. In 2001, the Residency Review Committee for Psychiatry adopted training requirements requiring competence in CBT for graduating psychiatry residents. In 2012, an inter-organizational task force produced guidelines for cognitive behavioral therapy training within doctoral Psychology programs in the United States (Klepac et al, 2012). Despite such requirements, dissemination of CBT remains poor (Shafran et al 2009) and training is lacking (Weissman et al, 2006). There is some evidence regarding specific methods of supervision and teaching that lead to effective application of CBT in clinical practice, but such evidence is even more poorly disseminated and inconsistently applied. Literature on the outcome of supervision is lacking. In spite of decades of emphasis on data-driven decision-making regarding the therapeutic process, there has been a relative lack of research to address questions of best practices in both training and supervision of CBT. Although dissemination of effective treatments for mental disorder is of paramount public health concern the field requires considerable progress to facilitate such dissemination.
There are at least two distinct points of view regarding therapist training represented in the training and supervision literature. First, a commonly articulated evidence-supported position is that more training produces more competent therapists (McManus et al 2010). A further assumption derived from this point of view is that more competent therapists have superior clinical outcomes. Several studies (Shlomskas et al 2005, Simons et al 2010, Bambling et al 2006) support this view and point specifically to the role of supervision in producing competent therapists. Another argument, advanced from the public health perspective, is that the process of training and supervision is far too resource intensive to be practical for illnesses such as depression (Fairburn and Cooper 2011), which will soon represent the largest global disease burden (WHO). This perspective argues for a larger group of therapists trained in low intensity interventions for specific disorders along with guided self-help and internet assisted interventions to produce the widest ranging impact. Both ideas have merit, and likely an amalgam of training strategies will continue to be developed and tested worldwide.
Given the aforementioned scarcity of resources, identifying the most efficient strategies for supervision and training is imperative for the field. Regarding supervision, a small number of studies exist that indicate it improves therapist competence (Strunk et al 2010, Shlomskas et al 2005, Simons et al 2010, Bambling et al 2006), but do not describe the most efficient and effective procedures to follow. Even more significantly, the elements of what constitutes “adequate” supervision are only recently described in the literature and have been determined by a combination of narrative and systematic reviews and expert consensus (Milne and Dunkerley). The importance of adequate training for supervisors has led to several professional organizations establishing criteria for supervisors/trainers (e.g., the Academy of Cognitive Therapy, the British Association of Behavioural and Cognitive Psychotherapy) and/or required continuing education credits pertaining to supervision.
Key principles that are derived from CBT itself, because it is rooted in learning theory, are equally applicable to the supervisory process and facilitate therapist development. These include:
- Make the terms of the supervisory relationship explicit and clear. Foster a relationship that promotes frank disclosure by the supervisee. Specific tools that may assist are handouts that teach the supervisee about how to use supervision, supervision contracts and a clear and open discussion of expectations and evaluation methods. Engagement in supervision is improved by a clear understanding of expectations of tape review and how to handle confidentiality and patient emergencies. Keep detailed supervision notes.
- Structure supervision in a similar way to CBT. The process should reflect clinical practice because all the tools we use in therapy are designed to enhance learning. Supervision sessions optimally begin with agenda setting, check-in about last week’s session, then proceed to work on particular supervision questions, followed by summaries, feedback and homework. Socratic questions should be a mainstay of the work that you do. Require the use of rating scales to track patient progress.
- Conceptualize the supervisee regarding particular learning needs, attitudes about psychotherapy, and culture. This will insure interventions that are tailored and precise.
- Aim to use a variety of methods to promote learning in a supervision session. Keep your eye on the balance between challenge and support. The supervisee needs to have sufficient confidence in the relationship in order to frankly discuss patients and be sufficiently challenged to take the next learning step.
- Identify what skill level is present in the supervisee either with direct observation of patient care or role-play practice in supervision. Train skills when necessary. If skill-training is not needed, be Socratic and help the supervisee think through and make decisions independently.
- Examine actual work samples (therapy tapes) with a validated instrument, like the Cognitive Therapy Rating Scale (Young and Beck, 1980) to ensure progress is being made. Teach the supervisee to use the instrument as well. Such work provides valuable review of the key features of the session for the trainee.
These practices in supervision will help you be more effective at teaching the skills of therapy and make the work interesting to you both!
Bambling, M., King, R., Raue, P., Schweitzer, R., & Lambert, W. (2006). Clinical supervision: Its influence on client-rated working alliance and client symptom reduction in the brief treatment of major depression. Psychotherapy Research,16(3), 317-331.
Fairburn, C. G., & Cooper, Z. (2011). Therapist competence, therapy quality, and therapist training. Behaviour Research and Therapy, 49(6-7), 373-378.
Klepac, R. K., Ronan, G. F., Andrasik, F., Arnold, K. D., Belar, C. D., Berry, S. L., & ... Strauman, T. J. (2012). Guidelines for cognitive behavioral training within doctoral psychology programs in the United States: Report of the Inter-organizational Task Force on Cognitive and Behavioral Psychology Doctoral Education. Behavior Therapy, 43(4), 687-697.
McManus, F., Westbrook, D., Vazquez-Montes, M., Fennell, M., & Kennerley, H. (2010). An evaluation of the effectiveness of diploma-level training in cognitive behaviour therapy. Behaviour Research and Therapy, 48(11), 1123-1132.
Rakovshik, S. G., & McManus, F. (2010). Establishing evidence-based training in cognitive behavioral therapy: A review of current empirical findings and theoretical guidance. Clinical Psychology Review, 30(5), 496-516.
Sholomskas, D. E., Syracuse-Siewert, G., Rounsaville, B. J., Ball, S. A., Nuro, K. F., & Carroll, K. M. (2005). We Don't Train in Vain: A Dissemination Trial of Three Strategies of Training Clinicians in Cognitive-Behavioral Therapy. Journal of Consulting and Clinical Psychology, 73(1), 106-115.
Simons, A. D., Padesky, C. A., Montemarano, J., Lewis, C. C., Murakami, J., Lamb, K., & ... Beck, A. T. (2010). Training and dissemination of cognitive behavior therapy for depression in adults: A preliminary examination of therapist competence and client outcomes. Journal of Consulting and Clinical Psychology, 78(5), 751-756.
Strunk, D. R., Brotman, M. A., DeRubeis, R. J., & Hollon, S. D. (2010). Therapist competence in cognitive therapy for depression: Predicting subsequent symptom change. Journal of Consulting and Clinical Psychology, 78(3), 429-437.
Weissman, M. M., Verdeli, H., Gameroff, M. J., Bledsoe, S. E., Betts, K., Mufson, L., & ... Wickramaratne, P. (2006). National survey of psychotherapy training in psychiatry, psychology, and social work. Archives of General Psychiatry, 63(8), 925-934.
Published July 3, 2016
