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“A much needed and timely book, written and edited by a splendid array of top-quality CBT therapists and researchers, and aptly dedicated to David Westbrook whose own work exemplified the sophisticated integration of theory and real-world practice we find here. Practical, scientifically sound, and broad in scope – an invaluable route map for continuing therapist growth and development.”

Melanie Fennell, Ph.D., Founder, Oxford Cognitive Therapy Centre and Clinical Research Associate, Oxford University Department of Psychiatry

CBT has been shown to be effective in helping many people with a wide range of difficulties. A key strength is its empirical basis, and much effort has gone into training therapists to adhere closely to the specific treatment protocols used in research trials. However, real-world therapists need to make moment-to-moment decisions about the direction therapy should take with individual clients.

How to Become a More Effective CBT Therapist explores effective ways for therapists to move beyond competence to “metacompetence”, remaining true to the core principles of CBT while adapting therapeutic techniques to address the everyday challenges of real-world clinical work. This innovative text explores how to:

• Work most effectively with fundamental therapeutic factors such as the working alliance and diversity;

• Tackle complexities such as co-morbidity, interpersonal dynamics and lack of progress in therapy;

• Adapt CBT when working with older people, individuals with long-term conditions (LTCs), intellectual disabilities, personality disorders and psychosis;

• Develop as a therapist through feedback, supervision, self-practice and training.

Based firmly on foundations of the current evidence and richly illustrated with case studies and therapy transcripts, this practical guide will help therapists navigate complexities of clinical practice and develop as skilled practitioners of CBT.

Adrian Whittington is Director of Education and Training at Sussex Partnership NHS Foundation Trust. A Consultant Clinical Psychologist, Adrian is passionate about enabling wider access to evidence-based psychological therapies. Adrian was a director of postgraduate training programmes in CBT before taking up his current role. He works clinically with people with anxiety disorders and depression, particularly following trauma, and teaches on the postgraduate CBT training programme at the University of Sussex, UK.

Nick Grey is Joint Clinical Director and Consultant Clinical Psychologist at the Centre for Anxiety Disorders and Trauma (CADAT), South London and Maudsley NHS Foundation Trust, King’s Health Partners. He is actively involved in disseminating cognitive behavioural therapies, trying to ensure that the most effective treatments are applied in routine care. A BABCP-accredited practitioner, supervisor and trainer, Nick is also Honorary Lecturer at the Institute of Psychiatry and editor of A Casebook of Cognitive Therapy for Traumatic Stress Reactions (2009).

How to Become a More

Effective CBT Therapist

Edited by Adrian Whittington and Nick Grey

Mastering Metacompetence in Clinical PracticeISBN 978-1-118-46834-0

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How to Become a More Effective CBT Therapist

How to Become a More Effective CBT Therapist

Mastering Metacompetence in Clinical Practice

Edited by

Adrian Whittington and Nick Grey

This edition first published 2014© 2014 John Wiley & Sons, Ltd.

Registered OfficeJohn Wiley & Sons, Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK

Editorial Offices350 Main Street, Malden, MA 02148-5020, USA9600 Garsington Road, Oxford, OX4 2DQ, UKThe Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK

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All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher.

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Library of Congress Cataloging-in-Publication Data

How to become a more effective CBT therapist : mastering metacompetence in clinical practice / edited by Adrian Whittington and Nick Grey. pages cm Includes bibliographical references and index. ISBN 978-1-118-46834-0 (hardback) – ISBN 978-1-118-46835-7 (paper) 1. Cognitive therapy. 2. Clinical competence. 3. Therapist and patient. I. Whittington, Adrian, editor of compilation. II. Grey, Nick, 1970– editor of compilation. RC489.C63H69 2014 616.89ʹ1425–dc23

2013050604

A catalogue record for this book is available from the British Library.

Cover image: © Fenykepez/iStockphoto

Set in 10/12pt Galliard by SPi Publisher Services, Pondicherry, India

1 2014

For David Westbrook

Contents

About the Editors ixAbout the Contributors xForeword by David M. Clark xvForeword by Tony Roth xvii

I The Foundations 11 Mastering Metacompetence: The Science and Art of Cognitive

Behavioural Therapy 3Adrian Whittington and Nick Grey

2 The Central Pillars of CBT 17David Westbrook

3 Developing and Maintaining a Working Alliance in CBT 31Helen Kennerley

4 Working with Diversity in CBT 44Sharif El-Leithy

II Handling Complexity 635 Working with Co-Morbid Depression and Anxiety Disorders:

A Multiple Diagnostic Approach 65Adrian Whittington

6 Collaborative Case Conceptualization: Three Principles and Five Steps for Working with Complex Cases 83Robert Kidney and Willem Kuyken

7 Transdiagnostic Approaches for Anxiety Disorders 104Freda McManus and Roz Shafran

8 When and How to Talk about the Past in CBT 120Gillian Butler

9 “Is it Them or is it Me?” Transference and Countertransference in CBT 132Stirling Moorey

viii Contents

10 What To Do When CBT Isn’t Working? 146 Michael Worrell

III Adapting for Specific Client Groups 16111 CBT with People with Long-Term Medical Conditions 163 Jane Hutton, Myra S. Hunter, Stephanie Jarrett and Nicole de Zoysa

12 CBT with People with Personality Disorders 178 Kate M. Davidson

13 CBT with People with Psychosis 191 Louise Johns, Suzanne Jolley, Nadine Keen and Emmanuelle Peters

14 CBT with Older People 208 Steve Boddington

15 CBT with People with Intellectual Disabilities 225 Biza Stenfert Kroese

IV Mastering Metacompetence 23916 Using Self-Practice and Self-Reflection (SP/SR) to Enhance CBT

Competence and Metacompetence 241 Richard Thwaites, James Bennett-Levy, Melanie Davis

and Anna Chaddock

17 Using Outcome Measures and Feedback to Enhance Therapy and Empower Patients 255

Sheena Liness

18 Making CBT Supervision More Effective 269 Nick Grey, Alicia Deale, Suzanne Byrne and Sheena Liness

19 Take Control of your Training for Competence and Metacompetence 284 Adrian Whittington

An Afterword about Therapist Style 300Simon Darnley and Nick Grey

Index 306

Adrian Whittington is Director of Education and Training and Consultant Clinical Psychologist at Sussex Partnership NHS Foundation Trust, where he leads on training programmes in CBT and other evidence-based psychological therapies. He works clinically with people with anxiety disorders and depression and teaches on the postgraduate CBT training programme at the University of Sussex.

Nick Grey is a Consultant Clinical Psychologist and Joint Clinical Director of the Centre for Anxiety Disorders and Trauma (CADAT), South London and Maudsley NHS Foundation Trust, King’s Health Partners. His clinical work is providing out-patient cognitive therapy to people with a variety of anxiety disorders both within randomized controlled trials and in a more general NHS service. He is actively involved in disseminating cognitive behavioural therapies, trying to ensure that the most effective treatments are applied in routine care. He is accredited as a practitioner, supervisor and trainer with the British Association of Behavioural and Cognitive Psychotherapies.

About the Editors

About the Contributors

James Bennett-Levy is Associate Professor at the University of Sydney’s University Centre for Rural Health (North Coast). He is one of the leading researchers on the training of CBT therapists. He has co-written Experiencing CBT from the Inside Out: A Self-Practice/Self-Reflection Workbook for Therapists (2014) and the Oxford Guide to Imagery in Cognitive Therapy (2011), and co-edited the Oxford Guide to Behavioural Experiments in Cognitive Therapy (2004), and the Oxford Guide to Low Intensity CBT Interventions (2010).

Steve Boddington is a Consultant Clinical Psychologist, and Head of Psychology and Psychological Therapies, Mental Health of Older Adults and Dementia, South London and Maudsley NHS Foundation Trust. Steve is a registered Practitioner Psychologist and Chartered Psychologist with 20 years of specialist experience in working with older people. He is an associate fellow of the British Psychological Society and a past chair of the Division of Clinical Psychology’s Faculty of Psychology for Older People. He has an interest in the development of accessible psychological services that meet the needs of older people, sitting on various national working groups, and has been involved in the development and delivery of training on the application of CBT for older people.

Gillian Butler is a Consultant Clinical Psychologist working with Oxford Cognitive Therapy Centre and Oxford Health NHS Foundation Trust. She now works in the forensic service and has special interests in the use of CBT during recovery from trau-matic experiences in childhood, and in developing a sense of self. She is co-author of Manage Your Mind: The Mental Fitness Guide and of Psychology: A Very Short Introduction, and author of Overcoming Social Anxiety and Shyness.

Suzanne Byrne is the Deputy Course Director for CBT (IAPT Adult Programmes) at the Institute of Psychiatry, Kings College London. She is an honorary Cognitive Behavioural Psychotherapist at the Centre for Anxiety Disorders and Trauma South London and Maudsley NHS Foundation Trust.

Anna Chaddock is a Clinical Psychologist and Cognitive Behaviour Therapist. She  is employed by Newcastle upon Tyne Hospitals NHS Foundation Trust in their  Specialist Palliative Care and Primary Care Mental Health services. Her spe-cial interests include reflection in CBT and interpersonal processes, particularly empathy.

About the Contributors xi

Simon Darnley is the Head of the Anxiety Disorders Residential Unit based at the Bethlem Royal Hospital. He was a psychiatric nurse before training as a Cognitive Behavioural Psychotherapist. Simon has been involved in CBT treatment, training and supervision for over 20 years. He is also now Head of Mood, Anxiety and Personality Disorder Clinical Pathways for Lambeth, within the South London and Maudsley NHS Foundation Trust, managing a wide range of clinical services. He is an award-winning part-time magician, a member of the Magic Circle and President of the Kent Magicians Guild.

Kate M. Davidson is a Fellow of the British Psychological Society and Director of the Glasgow Institute of Psychosocial Interventions, NHS Greater Glasgow and Clyde and University of Glasgow. She completed her clinical training and PhD at University of Edinburgh. She is an Editor of Personality and Mental Health. She developed and evaluated the efficacy of CBT for personality disorders in both community and now in forensic settings.

Melanie Davis is a Clinical Psychologist delivering CBT in both individual and group settings as part of the Durham Pain Management Service. She supports the rest of the multidisciplinary team through consultation and training in psychological approaches to pain management. Her research interests include the interpersonal process in CBT and the use of reflection to enhance therapeutic knowledge and skill.

Nicole de Zoysa is a Senior Clinical Psychologist working in the diabetes and cardiac rehabilitation services at King’s College Hospital. She has taught on IAPT training courses for the past three years focussing on adapting step two and step three interven-tions for people living with long-term conditions. Nicole de Zoysa has also published in the areas of mindfulness-based cognitive therapy and motivational interviewing for primary care nurses and diabetes educators.

Alicia Deale is a Cognitive Behavioural Psychotherapist at the Centre for Anxiety Disorders and Trauma, South London and Maudsley NHS Foundation Trust. She is a part-time clinical tutor and course supervisor on the Postgraduate Diploma in CBT at the Institute of Psychiatry.

Sharif El-Leithy is a Principal Clinical Psychologist and BABCP accredited Cognitive Therapist, specializing in post-traumatic stress disorder (PTSD). For the last 12 years he has worked in the Traumatic Stress Service in Tooting, South London, offering psychological treatment to diverse populations including ex-military and survivors of war and torture. He was part of the screen-and-treat program that followed the 2005 London bombings, and set up similar programs for assault victims within local hospital settings.

Myra S. Hunter is Professor of Clinical Health Psychology with King’s College London. She has worked in both clinical and academic roles with people with physical health problems for over 30 years, with a particular interest in oncology, cardiology and women’s health. She has developed cognitive behaviourally-based interventions for women with premenstrual and menopausal symptoms and is currently evaluating inter-ventions for people with non-cardiac chest pain and for men with prostate cancer treatment related symptoms.

Jane Hutton was awarded her Doctorate in Clinical Psychology from the Institute of Psychiatry, where she holds an honorary contract. She is employed by South London

xii About the Contributors

and Maudsley NHS Foundation Trust and is Consultant Clinical Psychologist in the Department of Psychological Medicine at King’s College Hospital. Her research and clinical interests are in mindfulness-based approaches and CBT for people living with physical health problems.

Stephanie Jarrett is a Consultant Clinical Psychologist with a long-standing interest in psychological approaches to physical health problems. Her doctorate was in psychoso-cial oncology and she now works in the chronic pain service at University Hospital Lewisham where she has set up individual and group services for patients. She has taught a wide range of medical and psychological professionals on the biopsychosocial model of chronic pain and has recently published evidence of the clinical and cost- effectiveness of using this approach.

Louise Johns is a chartered Consultant Clinical Psychologist and coordinator of a specialist outpatient psychological therapies service for psychosis (PICuP: Psycho-logical Interventions Clinic for outpatients with Psychosis), South London and Maudsley (SLaM) NHS Foundation Trust, London. She is also an Honorary Senior Lecturer at the Institute of Psychiatry (IOP), King’s College London. She has worked in a clinical and research capacity in the field of psychosis for 15 years, and has published over 50 articles on psychosis, covering development and psychopathology of symp-toms, and cognitive behavioural treatments.

Suzanne Jolley is a Research Clinical Psychologist at King’s College, London, Institute of Psychiatry and an Honorary Consultant Clinical Psychologist in the South London and Maudsley NHS Foundation Trust, Psychosis Recovery services. She co-developed the King’s/IOP PGDip in CBT for Psychosis. Her clinical practice, teaching and research have been primarily in psychosis over the past 20 years, with interests in training, dissemination, workforce development, cognitive models of delusions, and psychosis in children.

Nadine Keen is a Principal Clinical Psychologist at a specialist outpatient psycho-logical therapies service for psychosis (PICuP) based at SLaM, and holds an honor-ary contract with the IOP where she is involved with teaching and research. She has specialized in psychosis for the past 10 years and was a trial therapist on the multi-centre RCT for cognitive therapy for command hallucinations (COMMAND). Nadine was also a therapist on the London Bombings Screen and Treat Programme where she specialized in the treatment of PTSD. She has a longstanding clinical and research interest in the confluence of PTSD and psychosis as well as working with imagery in psychosis.

Helen Kennerley is a Consultant Clinical Psychologist in Oxford Health NHS Foundation Trust and a Senior Associate Tutor with the University of Oxford. She has practiced CBT for over 25 years and is a founder member of the Oxford Cognitive Therapy Centre (OCTC). She has written several popular cognitive therapy self-help books and co-authored and co-edited a number of CBT text books including a very popular introduction to CBT.

Rob Kidney attained his Doctorate in Clinical Psychology in Plymouth in 2003 and completed his Masters in Psychological Therapies (CBT) in Exeter in 2007. He has been the service lead for an adult IAPT service, academic lead for High Intensity CBT at the University of Exeter and trial therapist on the NIHR-HTA funded CoBalT trial (Cognitive Behavioural Therapy as an adjunct to pharmacotherapy for treatment

About the Contributors xiii

resistant depression in primary care: a randomized controlled trial). He has published in the British Journal of Clinical Psychology, and provided workshops at local, national and international conferences. Currently Rob is working for Virgin on behalf of the NHS as Lead Clinical Psychologist in Southern Devon CAMHS with an emphasis upon training, supervising and delivering CBT provision.

Willem Kuyken works as a researcher, trainer and clinician at the Mood Disorders Centre in Exeter. His research and clinical work specialize in CBT and mindfulness-based approaches to recurrent depression. A particular theme of his work is exploring how therapists co-create conceptualizations with their clients that enhance the effec-tiveness of therapy. He has published several publications on case conceptualization, including the book, co-authored with Christine Padesky and Rob Dudley, Collaborative Case Conceptualization.

Sheena Liness is Course Director of the postgraduate adult CBT training programmes at the Institute of Psychiatry, King’s College London. Sheena organizes, teaches and supervises on a range of programmes including the High Intensity (IAPT) Programme. She is an accredited BABCP trainer, supervisor and CBT therapist and has worked in CBT clinical practice for 20 years.

Freda McManus is the (acting) Director of the Oxford Cognitive Therapy Centre and has been Director of the University of Oxford’s PG Dip in CBT for the past nine years. She has worked in both the University of Oxford’s Department of Psychiatry and at the Centre for Anxiety Disorders and Trauma (Kings College London) helping to devise and evaluate cognitive behavioural treatments for anxiety disorders. Freda McManus has published widely in the area of cognitive-behaviour therapy for anxiety disorders, and on training clinicians in CBT interventions.

Stirling Moorey is Consultant Psychiatrist in CBT and former professional Head of Psychotherapy at South London and Maudsley NHS Foundation Trust. He is a trained Cognitive Therapist and Cognitive Analytic Therapist who has been teaching and supervising CBT for many years and has an interest in how the therapy relation-ship can be understood within the cognitive model. His other area of interest is the application of CBT to people with cancer.

Emmanuelle Peters is Reader in Clinical Psychology at the Institute of Psychiatry (IOP), King’s College London, and the director of a specialist outpatients psycho-logical therapies service for psychosis (PICuP), based at South London and Maudsley NHS Foundation Trust. She has specialized in psychosis for the past 25 years as a clini-cian, researcher and trainer. Her research interests include the continuum view of psy-chosis, cognitive models of psychotic symptoms, and CBT for psychosis.

Roz Shafran is Professor of Clinical Psychology at the University of Reading and founder of the Charlie Waller Institute of Evidence Based Psychological Treatment. Her clinical and research interests include the development and dissemination of cognitive behavioural theories and treatments. She is an associate editor of “Behaviour Research and Therapy”. She recently received an award for Distinguished Contributions to Professional Psychology from the British Psychological Society and the Marsh Award for Mental Health work.

Biza Stenfert Kroese is a Senior Lecturer in Clinical Psychology at the University of Birmingham and a Consultant Clinical Psychologist who until recently managed an NHS psychology service for people with intellectual disabilities (ID). She has co-edited books and published papers on challenging behaviour and the application of CBT for

xiv About the Contributors

people with ID as well as papers on mental health and ID, parents with ID and staff attitudes on working with people with ID. She is involved in a national research trial of CBT intervention for anger.

Richard Thwaites is a Consultant Clinical Psychologist and CBT therapist, employed as Clinical Lead for a large NHS IAPT service covering Cumbria, UK. In addition to delivering therapy he provides clinical leadership, supervision and training within the service and wider organization. His research interests include the role of the therapeutic relationship in CBT and the use of reflective practice in the process of skill development. He is co-author of the book Experiencing CBT from the Inside Out: A Self-Practice/ Self-Reflection Workbook for Therapists (2014).

David Westbrook was a Consultant Clinical Psychologist, and was Director of Oxford Cognitive Therapy Centre (OCTC) until June 2012. He practiced CBT for over 25 years and after stepping down from the role of director he continued to work part-time in OCTC, doing training, supervision and research, and part-time as an NHS clinician, providing a service for patients with severe and complex problems. David edited a number of influential and critically acclaimed books on CBT. Tragically, David died in 2013 during the production of this book. He was known as a brilliant, humble, kind, humorous man.

Michael Worrell is Consultant Clinical Psychologist and director of postgraduate CBT training programmes at Central and North West London Foundation NHS Trust and Royal Holloway University of London. Michael directs a range of programmes including the Post Graduate Diploma and MSc in CBT, The High Intensity Training (IAPT) Programme, Post Qualification Training in CBT Supervision and the Behavioural Couples Therapy Training. His interests include “resistance”, managing endings, the therapy relationship and couple therapy.

Cognitive behaviour therapies have established their efficacy with a wide range of mental health problems, both in randomized trials and in audits of routine clinical practice. However, there has been a persistent difficulty in providing CBT treatments to everyone who could benefit, due to insufficient numbers of suitably trained therapists.

In 2008 England embarked on an exciting programme to disseminate psycho-logical therapy on a wider scale than has been ever been attempted before, with CBT  forming the core treatment to be delivered by the new services for people with depression and anxiety disorders. By 2014 the Improving Access to Psychological Therapies (IAPT) programme will have trained 6,000 new therapists in evidence-based treatments recommended by the National Institute for Health and Clinical Excellence (NICE). The training courses established follow defined curricula, which ensure that the competencies needed to provide many of the leading empirically supported CBT treatments for depression and anxiety disorders are covered, as laid out in Roth and Pilling’s (2007) competency framework.

Analysis of the outcomes delivered by the IAPT programme is confirming that CBT and the other treatments can be effective in routine services, but also that, as already observed in clinical trials, not everyone improves, or improvement may be partial (Clark, 2011). To overcome this problem we need to do two things. First, we need continue to improve our treatments. Second, we need ensure that the treatments that we currently have are delivered as competently as possible. This book focuses on the second of these imperatives, providing tools for clinicians to help them remain faithful to the treatments that are effective, while considering how and when treatments need to be tailored or adapted to specific individual circumstances and needs. Of course adaptation and flexing of CBT is not an “add-on” for some cases only, but a method of providing effective therapy in every case. However, the adaptations become more diverse and stretching in the most complex cases or when working with specific client groups that may have particular needs beyond those of the populations with which treatments were developed.

In this book Adrian Whittington, Nick Grey and colleagues explore how to tailor CBT methods while remaining true to the core principles, basing interventions on an individualized CBT formulation, guided by the best evidence and theory. The book is compiled from the distilled knowledge of some of the most skilled and experienced clinicians, who ground their insights in the foundations of CBT while suggesting ways to handle complexity and adaptations for specific adult client groups. Later chapters

ForewordDavid M. Clark

Professor of Experimental Psychology, University of Oxford

xvi Foreword

provide guidance to develop further as a therapist and to ensure that the learning is implemented systematically and successfully. This is a practical book to be read, but above all, to be used regularly to guide one’s work.

References

Clark, D. M. (2011). Implementing NICE guidelines for the psychological treatment of depression and anxiety disorders: The IAPT experience. International Review of Psychiatry, 23(4), 318–327.

Roth, A. D., & Pilling, S. (2007). The competences required to deliver effective cognitive and behavioural therapy for people with depression and with anxiety disorders. London: Department of Health.

It is a pleasure to have been invited to contribute to this book, not least because it has given me the chance to preview the contributions of a number of eminent and talented clinicians, and to use this opportunity to reflect on what metacompetences are, and how they are used.

The CBT competence framework (Roth & Pilling, 2007) was the first of what has become a suite of frameworks, now covering a range of therapeutic modalities and clinical populations. As a prototype for what followed, it acted as a test-bed for our ideas about how best to set out the knowledge and skills that underpinned the effective delivery of psychological therapies. One aim was that the framework was oriented towards competence rather than adherence, congruent with the sentiment that clinicians should not only do the right thing, but also do the right thing in the  right way. Although the way we phrased competence descriptions reflected this stance, it became clear that some competences seemed to operate at a different level to others, because they focused on the way in which sets of competences were deployed, and in this sense could be seen as “meta” to others. It is fair to say that initially we lacked a well thought through conceptualization or definition that separated the “ordinary” from these “meta” competences, and even as work proceeded and we gathered examples of what they might look like, we still struggled to arrive at robust conceptualization. Without one it was all too easy for this term to become synonymous with complexity, resulting in almost everything beyond the “straightforward” application of therapy technique being flagged as a metacompetence – not a very useful development. The prefix “meta” implies that these competences are in a sense superordinate to some other set of actions, and although they are more likely to be evident when managing therapeutic challenge or complexity, it is this overarching or overseeing quality that is their appropriate focus.

One way of thinking about metacompetences is the idea of “procedural” rules that guide the assembly and sequencing of an action. These often involve balancing one decision about how to proceed in therapy against another, scoping and filtering a range of potential ways forward in order to arrive at a rational choice of action. Initially this decision making is likely to be fairly conscious, but increasingly in most, but not all cases, will become “more automatic” with experience and training, and so can be seen as a formal representation of what is often referred to as clinical acumen. Some examples from the CBT framework may help to illustrate this:

ForewordTony Roth

Professor of Clinical Psychology, University College London

xviii Foreword

•  “Juggling” competing demands: An ability to maintain adherence to an agreed agenda and to “pace” the session in a manner which ensures that all agreed items can be given appropriate attention (i.e., ensuring that significant issues are not rushed)

•  Monitoring and responding to the way a session unfolds: An ability to be aware of, and respond to, emotional shifts occurring in each session, with the aim of maintaining an optimal level of emotional arousal (i.e., ensuring that the client is neither remote from, or overwhelmed by, their feelings).

•  Constructing the intervention in a way that holds in mind a holistic sense of the client’s needs: An ability to implement the CBT model in a manner that is conso-nant with a comprehensive formulation that takes into account all relevant aspects of the client’s presentation

Hopefully these examples make it clear that metacompetences are not abstruse; their  challenge lies in the fact that they require clinicians to make particular types of  judgment. The common thread is that these judgments usually involve titration: weighing the consequences of one action against the other and arriving at a decision about how best to implement the therapeutic process.

In their introduction Adrian Whittington and Nick Grey adopt an analogy for metacompetence that I also find myself using. Great cooks are distinguished not by their ability to adhere to a recipe but by their ability to use the recipe as a guide, bring-ing to bear knowledge of the general principles that underpin cookery and a capacity to implement specific techniques, and where necessary developing bespoke recipes that take account of missing ingredients and the utensils that they have at their disposal. This is a critical, even if obvious, observation: it means that recipes – and by analogy competence frameworks – are best seen as indicative and not prescriptive, not directives for action but guidance that should be interpreted in order to arrive at the best action to take. But identifying how this is done is quite a challenge, especially if we are to do so without resorting to portmanteau phrases such as “flair” that promise much but actually mean very little – after all, we can’t train people to show “flair” unless we know what this comprises.

What would be helpful is to define the sort of steps that amount to (or are associated with) this sort of therapeutic capacity, aiming to identify and explicate the skills that differentiate the fluent from the struggling therapist, and by incorporating these into training make it more likely that these skills will be reproduced. This, of course, is the raison d’être of this book. Students of psychological therapy often complain about the gap between what they are taught and what happens in the clinic. Few clients they see are like those described in text books, and what seems straightforward on paper is challenging in practice, sometimes overwhelmingly so. This book directly addresses this gap between theory and practice by making more explicit the thinking and judgment that is required to translate CBT theory into CBT practice, focusing on the necessary twists and turns in which therapists need to engage if the outcomes their clients seek are to be achieved.

Reference

Roth, A. D., & Pilling, S. (2007). The competences required to deliver effective cognitive and behavioural therapy for people with depression and with anxiety disorders. London: Department of Health.

I

The Foundations

How to Become a More Effective CBT Therapist: Mastering Metacompetence in Clinical Practice, First Edition. Edited by Adrian Whittington and Nick Grey. © 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

1

Mastering MetacompetenceThe Science and Art of

Cognitive Behavioural Therapy

Adrian Whittington and Nick Grey

In a professional kitchen, recipes are essential to creating consistent food, so that everyone takes the same path to the same place. But cooks who rely only on strictly codi-fied formulas miss out on what is really important. Are the carrots more or less sweet, more or less tender? Is the ginger very strong, so that less should be used, or too weak for the amount specified? Or the thorniest problem: How long does it take something to cook, in a specific oven, on a specific day, with a certain set of ingredients?

Daniel Patterson, Head Chef, Coi, San Francisco1

Introduction

Cognitive Behavioural Therapy (CBT) has grown up in a scientific tradition, which has been highly productive in the development of effective therapy. Research trials have given us a firm foundation for expanding the delivery of CBT, with the approaches delivered in the trials being reproduced in routine care to help a lot of people a lot of the time.

However, these trials can seem a long way from the consulting room when as a therapist you sit down with a unique client who has a unique set of difficulties and strengths. As a therapist you face a seemingly infinite range of options in your moment to moment decision making about what to do next as you try to deliver CBT in the most helpful way with this client at this point in time. A lot of the time you probably cannot be sure of the best options and have to proceed in the hope and faith that by working collaboratively with your client you will be able to negotiate a helpful way forward. This can feel more like an art than a science. Abilities required to apply therapy artfully, in a flexible and individually tailored way, have been named “metacompetences” in Roth and Pilling’s competence framework for CBT (Roth & Pilling, 2007).

4 Adrian Whittington and Nick Grey

There are significant pitfalls on the path between the science of CBT and its artful delivery. These include the risk of rejecting the research base because of a sometimes imperfect fit with routine practice, the risk of drifting away from effective methods in the belief that you are being helpfully flexible, and the risk of being overly rigid in your approach in an attempt to adhere to protocol.

We believe that the science and art of CBT can and should be brought closer together to help avoid these risks, and that the concept of metacompetent adherence gives us a framework for bridging this gap. Metacompetent adherence means making your ther-apy decisions based on evidence that clearly supports the practice and on a sound theo-retical rationale where the evidence is less clear. Mastering metacompetence is a process of making explicit and enacting the if–then procedural rules of therapy adaptation and where possible drawing on the evidence base. These rules will not take away all uncer-tainty, however. The experience of not knowing is inevitable and perhaps desirable for therapists – human experiences require you to respond with humility, compassion and openness to learning as you deliver the best evidence-based intervention that you can.

The Science of CBT: Efficacy, Effectiveness and Evidence-Based Practice

Thousands of research trials have been conducted to address the question of whether and for whom CBT is useful, and how it can be most effective. The research base of CBT includes efficacy studies that test treatment in carefully controlled experimental conditions and effectiveness studies that test the interventions in routine care settings, as well as a plethora of other approaches including dissemination trials, single case research, dismantling studies and experimental designs. Of these approaches rand-omized control trial (RCT) evidence has traditionally been viewed as the “gold stand-ard” methodology for establishing whether an intervention works (Kaptchuck, 2001).

This scientific effort has been more intensive than for any other form of psycho-therapy. Analysis of “what works for whom” clearly indicates CBT’s wide utility (Roth & Fonagy, 2005). As a consequence of this evidence, CBT has been recommended in evidence-based treatment guidance for a wide range of psychological difficulties (e.g., National Institute for Health and Clinical Excellence, 2009, 2011) and has become more widely available. In the United Kingdom, a national programme to increase access to psychological therapies for depression and anxiety disorders has seen an unprecedented expansion in the provision of CBT (Clark, 2011).

Both efficacy and effectiveness research shows that CBT works for many people with many types of difficulties and that research-based interventions can be applied in routine practice without dramatic reduction in effect. However, trial-based evidence will never resolve all of your dilemmas as a therapist about exactly what works for whom in which situ-ations. This has led to a movement towards evidence-based practice (EBP) as an approach to guide clinical decision making, drawing on a combination of research evidence, clinical expertise and client preferences (Lillienfield, Ritschel, Lynn, Cautin, & Latzman, 2013).

Efficacy of CBT

Efficacy studies are those in which the treatment is carefully studied under “ideal” experimental conditions in a randomized controlled trial (RCT). Most reviews and meta-analyses have examined how CBT treatments have performed in efficacy studies.

Mastering Metacompetence: The Science and Art of CBT 5

These have themselves been examined in a larger review of meta-analyses of CBT RCTs across a wide range of disorders (Butler, Chapman, Forman, & Beck, 2006). Overall large effect sizes for CBT were seen for unipolar depression, generalized anxiety disor-der, panic disorder, social anxiety disorder and post-traumatic stress disorder; moderate effect sizes for working with pain and anger; and CBT was as effective as behaviour therapy for obsessive compulsive disorder.

The degree to which results from RCTs translate into routine practice is a conten-tious issue (e.g., Westen, Novotny and Thompson-Brenner, 2004). RCTs typically have a single therapeutic focus (i.e., a particular psychiatric diagnosis/disorder), have an associated treatment manual, and are usually of a relatively brief fixed duration. This all makes sense scientifically, maximizing internal validity of the study, but has led to critiques of the evidence, suggesting that RCT conditions are too divorced from the realities of routine practice.

Effectiveness of CBT

Effectiveness studies measure the outcome of interventions provided in “routine” care settings. Effectiveness research indicates that it is possible to reproduce CBT RCT interventions in routine care settings with fewer controls and without greatly reducing their effects, although this is not guaranteed. A meta-analytic review of effectiveness trials of CBT for anxiety disorders showed that mean effect sizes were comparable to those in benchmarked RCTs (Stewart & Chambless, 2009). A similar meta-analytic review of effectiveness trials of CBT for depression showed a dilution of mean effect size in routine care, although the effect remained large (Hans & Hiller, 2013). Some effectiveness trials have even shown larger effects than in comparable RCTs (Ost, 2013). At one-year follow-up CBT for anxiety disorders in routine care has produced results almost equal to those of RCTs, whereas CBT for depression has not (DiMauro, Domigues, Fernandez, & Tolin, 2013; Gibbons et al., 2010).

The differences in effect of CBT in RCTs and routine care are not uniform and are likely to differ across the variety of treatments badged as CBT. Reasons for dilution of effect are not clear where these have been observed. Possible differences between RCTs and routine care include client characteristics, therapist and therapy character-istics. All may be relevant, but there is evidence that poorer quality control of therapy in routine settings may be at least as important in reducing effects as differences in the clients seen (Stewart & Chambless, 2009; Stirman, DeRubeis, Crits-Cristoph, & Rothman, 2005).

Despite the demonstrable value of CBT in routine settings as well as in RCTs, the evidence is currently insufficient to provide a comprehensive guide to the flexible, indi-vidually adapted delivery of CBT. The areas where research cannot be the only guide include numerous areas of complexity such as how best to intervene with co-morbid conditions (Shafran et al., 2009) and how best to deliver “flexibility within fidelity” (Kendall, Gosch, Furr, & Sood, 2008).

Evidence-based practice

There will never be enough research to tell you definitively what will work best for any particular individual client, and there will always be those who seek therapy from you who are “beyond the guidelines” developed during RCT trials. This situation leaves you unable to rely solely on RCT evidence to guide your practice as a therapist.

6 Adrian Whittington and Nick Grey

Evidence-based practice (EBP) offers the beginnings of a solution. EBP has been proposed in the United States as an approach to clinical decision-making, drawing on the “three-leg stool” of research evidence, clinical expertise, and client preferences (Spring, 2007). EBP has been distinguished from empirically supported treatments (ESTs) based on RCT evidence, which do not offer explicit specific guidance on adap-tation and flexibility (Lilienfield et al., 2013). In the United Kingdom the concept of empirically grounded clinical interventions (EGCIs) also highlights the need for a broader approach to evidence-based practice than can be derived from RCT evidence alone; EGCIs are said to be derived from the sequence of clinical observation, experi-mental study and theory development, followed by treatment efficacy and effectiveness trials (Salkovskis, 2002). This approach values the role of experimentally derived theory as part of an evidence-based approach to intervention in the absence of specific evi-dence for what to do next.

As a therapist, EBP and EGCIs offer you a more comprehensive framework for mak-ing clinical decisions than trial evidence alone. However, both stop short of defining in detail the nature of the clinical expertise that you will need to draw upon and how you should put this into action.

The Art of CBT: Metacompetence

To be an evidence-based practitioner does not mean that you will always find your-self following a defined course of action or sequence of steps. In fact this is likely to feel like the exception rather than the rule in your therapy sessions. Much of the time you will base your actions on a combination of fundamental CBT therapy com-petences, your knowledge of specific CBT techniques and models, and an informed negotiation with your client about a way forward. The competences to enact this combination of factors into a coherent and effective therapy for anxiety disorders or depression have been defined very helpfully, drawing on an expert reference group and the manuals used in RCT trials that showed CBT to have a positive effect (Roth & Pilling, 2007).

Roth and Pilling (2007) identified five specific aspects of competence (see Figure 1.1). The first four outline competences of increasing levels of specificity to CBT and to CBT for particular problems, as follows:

Generic therapeutic competences: Required for the delivery of any psychological therapy, which include knowledge about mental health, ability to engage and assess clients, manage a therapeutic relationship and make use of supervision.

Basic CBT competences: The foundations of all CBT interventions, including knowl-edge of core CBT principles and abilities to agree goals collaboratively, jointly man-age session structure and introduce a basic formulation using a cognitive-behavioural maintenance cycle.

Specific CBT techniques: A set of core cognitive and behavioural technical interventions, delivered within the context of Socratic dialogue and including, for example, the use of thought records, behavioural experiments, exposure and activity scheduling.

Problem-specific competences: The competences to deliver specific CBT intervention packages for particular disorders, for example the Clark intervention for panic disor-der (Clark, 1986) or the Jacobson behavioural activation intervention for depression (Jacobson, Dobson, Truax, Addis, et al., 1996).

Figure 1.1 Competences for the effective delivery of CBT for depression and anxiety disorders (Roth & Pilling, 2007). © Crown Copyright (2007).

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In addition, recognizing that skilled psychological therapy must be more than a combination of technical procedures, Roth and Pilling (2007) identified a fifth category:

Metacompetences: These are defined as a set of higher order competences that “focus on the ability to implement models in a manner that is flexible and tailored to the needs of the individual client” (p. 9). Most of their list was derived from RCT therapy manuals, with some based on expert consensus and some on research evidence. Metacompetences were generated in two areas: generic metacompetences, said to be employed in all therapies, and CBT-specific metacompetences. The listed categories of metacompetences are as follows, with a number of specific metacompetences in each category:Generic metacompetences:

1. capacity to use clinical judgement when implementing treatment models2. capacity to adapt interventions in response to client feedback, and3. capacity to use and respond to humour.

CBT specific metacompetences:1. capacity to implement CBT in a manner consonant with its underlying

philosophy,2. capacity to formulate and to apply CBT models to the individual client,3. capacity to select and apply skilfully the most appropriate CBT intervention

method,4. capacity to structure sessions and maintain appropriate pacing, and5. capacity to manage obstacles to carrying out CBT.

Roth and Pilling suggested that metacompetences may be thought of as procedural rules by which therapists can apply the methods of therapy in a theoretically coher-ent, but appropriately adapted and individually tailored way, as a good cook may use but adapt a recipe. For example, one generic metacompetence procedural rule is listed as:

[to] maintain adherence to a therapy without inappropriate switching between modalities in response to minor difficulties (i.e., difficulties which can be readily accommodated by the model being applied).

As with the rest of the competency framework the list of metacompetences is not pre-sented as exhaustive or permanent. Metacompetences define your art as a therapist in implementing evidence-based practice, adapting empirically grounded clinical inter-ventions to the circumstances that are presented to you. They encompass the process of translating research findings into practice. We think there is value in building on and expanding the list provided by the Roth and Pilling (2007) framework so that proce-dural rules for the art of therapy can be made more explicit.

Three Risks to Effective Practice

There are risks in leaving the art of therapy as an implicit skill, assumed to be developed through experience or supervision, rather than something that is at least worth trying to define and make explicit. Without definition, lots of different forms of unhelpful

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practice can be labelled as appropriate flexibility or adaptation. Therapist resistance to research-based evidence can provide fertile ground in which such anomalous practice can grow. Even those committed to evidence-based practice may drift away from effec-tive approaches or become overly rigid in their approach and not recognize that what is happening is far from artful.

The risk of rejecting research evidence

Many therapists hold research evidence as a highly valued guide in practice, and CBT therapists are likely to value it fairly highly. However, this is by no means uni-versal. A qualitative study of US practicing psychologists found that most ranked research evidence as lower than clinical experience and intuition in guiding their practice (Stewart, Stirman, & Chambless, 2012). In the United Kingdom, therapist disquiet about applying research-based evidence is highlighted by the active debate on the subject in the UK Clinical Psychology professional literature (e.g., Smail, 2006).

Scott Lilienfield and colleagues (2013) have provided a thoughtful and constructive review and commentary on the “resistance” shown by some therapy practitioners to evidence-based practice. They highlight the risks of rejecting research evidence, citing harmful medical practices in mental health such as the prefrontal lobotomy, which gained currency through the reliance on clinical expertise in the absence of research data. Without research evidence, as a therapist you are unable to tell the difference between therapeutic effectiveness and placebo effect or spontaneous remission. This opens the way to a proliferation of spurious treatments.

There are numerous therapist beliefs that may interfere with the delivery of EBP, including a belief that what seems to be the evidence of your own eyes is more valuable than the evidence of RCTs (Lilienfield et al., 2013). Beliefs that we have found to be particularly relevant that could impede the dissemination of effective CBT treatments include beliefs that the clients who enter RCTs are not representative of the population seen in routine care and that treatments derived from RCT manuals are prescriptive and inflexible (Shafran et al., 2009). These beliefs are examined in the light of the following evidence.

Belief 1: Clients entering RCTs are not representative of those seen in routine care, where there are more severe or co-morbid presentationsCo-morbidity is very common, with axis 1 conditions co-morbid with other axis 1 or axis 2 disorders in the range of 50 to 90 per cent (e.g., Kessler, Nelso, McGonagle, & Liu, 1996). It is true that RCTs do sometimes exclude participants with co-morbidity or as a result of severity, for example, if the client is actively suicidal. However, analyses of clients that are seen in routine care suggest that only 5 per cent would have been excluded from an RCT (Stirman et al., 2005). The most common reasons for exclusion in this routine care population would not have been more severe or complex presenta-tions, but the clients in routine care not meeting minimum severity or duration criteria. More recent trials allow extensive co-morbidity without great reduction in outcome (DeRubies et al., 2005; Duffy, Gillespie, & Clark, 2007). Furthermore, a recent study of CBT for PTSD in routine care suggests that the majority of client characteristics that would have led to exclusion from an RCT made no difference to outcome of therapy. Large effect sizes were demonstrated even for clients that would have been excluded from an RCT (Ehlers et al., 2013).

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Belief 2: Interventions delivered in RCT manuals are prescriptive and inflexibleClinical guidelines used in RCTs have been developed for diagnostic categories, which can be limiting in complex cases. However, interventions within RCTs are usually based on an individualized formulation, based tightly on a specific model for the problem that is the focus of the trial. Flexibility is in fact inherent in RCT treatments using manuals and the use of manuals must always involve “flexibility within fidelity” (Kendall and Beidas, 2007). Even in trials participants will “strain the paradigm” (Markowitz et al., 2012).

In reality there are likely to be significant differences between trial conditions and routine care, and also some differences on dimensions of resourcing, therapist expertise and quality control (Roth, Pilling, & Turner, 2010; Stewart and Chambless, 2009) (see Table 1.1).

These differences in context, therapy and therapist factors suggest that rather than RCTs needing to be more like routine practice in order to provide realistic outcomes, we should endeavour to make routine practice become more like the conditions estab-lished in RCTs in order to achieve the best outcomes.

The risk of therapist drift

In a similar vein, there is evidence that therapist “drift” from adherence to evidence-based protocols can lead to poorer responses to treatment. Glenn Waller has observed that therapists commonly “drift” away from pushing for behavioural change (a core element in component analyses of successful treatment) to a more discursive approach (Waller, 2009). This drift may be driven by a number of factors including therapists’ own beliefs, emotional reactions and safety behaviours. Waller proposed that the same factors may lead clinicians to rush to implement newer “third wave” therapies even when the best evidence-based therapy has never been tried.

A detailed analysis of video recordings of CBT for anxiety, confirmed that therapists frequently switched away from core methods such as exposure (Schulte and Eifert,

Table 1.1 Likely differences between trials and routine practice

RCTs Routine practice

Resources Usually better resourced Resources restricted

Assessment More structured, detailed and regular

Procedures to identify focal problems and diagnoses less common

Therapists More likely to be expert in administration of a particular treatment

Covering a wider range of main problems

Caseloads Usually smaller Usually larger

Therapy Protocol controls duration and number of sessions

Often service provider controls duration and number of sessions

Engagement Sometimes greater efforts made to maintain engagement

Sometimes less emphasis on reducing attrition rates given the often large numbers waiting for treatments

Quality control Adherence monitoring and high quality supervision

Adherence monitoring may be limited and supervision of less consistent quality