An Introduction to the Art and Science of Cognitive Behavioural Psychotherapy
6.12 Competent CBT
The practice of all psychological therapies calls for both art and science. The prac- tice of CBT is no different. The practice of CBT has its roots in the scientific tradi- tion, and the ‘success’ and popularity of CBT owe much to the fact that the therapy has been subjected to thousands of research trials which have demonstrated patient acceptability, good levels of effectiveness and efficacy. Thanks to this scientific endeavour, the CBT community of practitioners feels it has a handle on ‘what works for whom’ (Roth and Fonaghy 1996), and there is a fair degree of confidence that CBT has a wide utility. However, it is important to inject a note of caution to balance the all-encompassing positive reputation that CBT has accrued. The note of caution is this: there are limits to the effectiveness of all psychotherapies, and in our training programme, we share with our students the secret of being a good therapist or men- tal health worker (MHW).
The secret of being a good therapist is having the ‘right’ patient working with you. The Safran and Segal suitability criteria attempt to go some way towards ensur- ing client engagement. Another ‘secret’ we share is that when you put the unique individual human dimension into the theory around psychopathology and the
Table 6.5 Cognitive methods
Identifying, evaluating and modifying negative automatic thoughts
Identifying, evaluating and modifying underlying assumptions or rules for living Identifying, evaluating and modifying core beliefs
Evaluating worries
Information and logical errors Putting things in perspective Schema-focused therapy
Examining and challenging cognitive distortions Challenging self-critical thoughts
Table 6.6 Lists various behavioural methods Exposure-based treatment strategies Reinforcement
Modelling and role play Activity scheduling Behavioural experiments Relaxation
competent practice of CBT, you come hard up against the limitations of an empiri- cal or scientific approach to therapy (Table 6.7).
Individuals rarely come to mental health services or psychological therapy ser- vices with one clinical disorder or one discrete problem of living as a consequence of being unwell. Individuals rarely present in the manner that the textbooks say they might. Most commonly people present with complex mixes of clinical disorder;
most people who are depressed also present with features of anxiety disorders and vice versa. A significant proportion of people who present to mental health services have experienced the presenting problems of living over reasonably long to very long periods of time. This element of chronicity is predictive of reduced benefits from psychological input. Other factors which influence outcome and vary from patient to patient no matter which disorder they present with are motivation and readiness for change, the nature of their interpersonal networks and the socio-eco- nomic circumstances they find themselves in.
In the face of these (and other) challenges to working effectively with people, it is hard to maintain adherence to evidence-based practice, and all MHWs can fall victim to ‘creative eclecticism’ (trying any old thing in desperation) or what has been termed more kindly as ‘therapist drift’ (Waller 2009; Waller et al.
2012).
One route to reconciling the tension between the need for science and the need for ‘artful’ approaches to helping people change is to be found in the development of CBT training programmes using an evidence-based approach to defining a framework of which elements of CBT practice and theory are most effective in given clinical presentations. This framework places significant importance on the art of applying these treatment approaches to individuals but defines, as far as possible, these nebulous artful skills into a set of operation- alised and measurable competences. Those dimensions which are the science and art of being a competent and effective MH practitioner are put on the same footing, and it is clear that it is the blending of core competences (the science bit) and metacompetences (the art bit) which needs to be addressed in training, development and supervision.
Table 6.7 Safran and Segal suitability criteria 1. Accessibility of automatic thoughts 2. Awareness and differentiation of emotions 3. Acceptance of personal responsibility for change 4. Compatibility with cognitive rationale
5. Alliance potential in-session 6. Alliance potential out-of-session 7. Chronicity of problems 8. Security operations 9. Focality
10. General optimism about therapy
As trainers, clinicians and supervisors in CBT, we welcome the recent introduc- tion of a competence framework for CBT (Roth and Pilling 2007, 2008). Roth and Pilling, with expert input from the CBT community, set out a framework which identified five specific aspects of competence which trainers, practitioners and supervisors should seek to blend to enhance outcomes for patients:
1. Generic therapeutic competences: These are competences foundational to the delivery of any psychological therapy or package of care and include the ability to engage and assess patients, knowledge of mental health theory and practice, developing and maintaining working alliances and clinical supervision.
2. Foundational or basic CBT competences: A set of knowledge and skill which includes awareness and skill of core CBT principles, working collaboratively, forming and sharing formulations which use the cognitive behavioural model of the maintenance cycle of problems of living.
3. Specific CBT techniques: A range of core behavioural and cognitive inter- ventions which have been demonstrated to have clinical utility. These include the use of thought records, the use of behavioural experiments, behavioural activation of pleasant event scheduling and the use of exposure therapies
4. Problem-specific competences and techniques: CBT practitioners have an advantage when it comes to treating specific disorders such as panic disorder or acute depression. There is a lot of guidance in the literature and specific treatment plans for these and other disorders. See Clark et al. for panic disor- der and/or Lewinsohn et al. or Jacobson et al. for depression for examples (Lewinsohn 1974; Lewinsohn et al. 1984, 1985; Clark 1986; Martell et al.
2001).
5. Metacompetences: Defined as ‘…focus on the ability to implement models in a manner that is flexible and tailored to the need of the individual…’
(Roth and Pilling 2007, p. 9). There are generic and CBT-specific metacompetences.
Generic competences will be familiar to all. Practitioners should aim to build the capacity to use clinical judgement when implementing treatment interven- tions and develop the capacity to adapt or amend the treatment in response to patient feedback. CBT-specific competences include a capacity to implement CBT treatment in a manner consistent with the theoretical and philosophical tenets of CBT, the capacity to develop and apply case formulations and to select and skilfully apply the most appropriate interventions to match the needs of the patient and, finally, the ability to pace and structure sessions while overcoming obstacles to the application of CBT in individual cases. See Fig. 6.2 for an overview.