Training and Supervision in Cognitive TherapyDocument Transcript
Training and Supervision inCognitive TherapyTHE ACQUISITION OF COMPETENCEIN COGNITIVE THERAPYWhen, some years ago, the author took part in a national project to definecompetencies for the different models of psychological therapy, it was apparentthat cognitive therapy practitioners had a very particular take on the acquisitionof competence.1 A large group of therapists of different orientations gathered inLondon, first together and then separately in different orientation groups, tocome back together at the end of the day. By the end of the day, the cognitivetherapy group had pretty well completed a first draft describing the differentskills and competencies associated with the different stages of their model. Whenall the groups had reassembled, however, it quickly became clear that hardly anyof the other groups had got so far – one group was still discussing who was theclient and who was the therapist! This story signals both the strengths and dangers of cognitive therapy. It isobviously good to have a set of skills and competencies that can be clearlydescribed, discussed and learnt. It may, however, be problematic if the parsimo-nious ‘simplicity’ of the cognitive model is learnt in a way that lacks therapeuticartistry and subtlety. This piece will suggest that, just as the cognitive model hasdeveloped a more rounded and subtle model of therapeutic intervention, so mustits methods of training and supervision. The challenge for trainers and supervi-sors is to help trainees and practitioners to develop sophistication in both scien-tific and artistic competence in cognitive therapy, without losing the benefit ofthe simple clarity of the model. The common core content of training and keypoints about the training process will be described, including new trainingmodels incorporating an opportunity for a personal experience of therapy,in the form of self-practice and self-reflection. Descriptions of the differentelements of and approaches to supervision will follow. The subjects of training and supervision in cognitive therapy would eachwarrant coverage as a separate volume. This piece will therefore focus on twoparticularly common issues of contemporary training and supervision. The firstissue is reflected in a common experience of cognitive therapy training, such aswhat occurs when trainees may have to let go of at least some previous ideas andskills – let go of one trapeze – before they have got a reliable set of new, cogni-tive skills and concepts – to catch the other trapeze. Clutching at fresh air is anexperience that invariably leads to trepidation. As cognitive therapists becomemore aware of the interpersonal processes in therapy, so cognitive therapytrainers can use the same skills to reflect the interpersonal processes of training.The second issue is the debate that concerns the degree of systemisation thatshould be used in implementing cognitive therapy. One side of the coin is the
clarity and help that a therapist can gain from following a relatively prescribedformat of therapy, such as that described in a ‘manual’ or ‘protocol’. The otherside of this coin could be that over-adherence could easily lead to a mechanisticformat of therapy that is imposed upon the client.TRAINING IN COGNITIVE THERAPYFrom its inception, cognitive therapy has always been well received in Britain(Beck, 2004). Various well-known British trainers, such as Melanie Fennell andAdrian Wells, trained with Beck in Philadelphia and incorporated much of histraining structure and many of his methods into the training course at Oxford.The Oxford course has also subsequently influenced other courses in Britain andabroad. As the demand has grown for accredited therapists and accredited train-ing, the Oxford and other training traditions, including that of behaviourtherapy courses, have informed the course content which has come to berecommended for cognitive therapy by the British Association for Behaviouraland Cognitive Psychotherapies (BABCP; see www.babcp.org.uk)CONTENT OF TRAININGAaron Beck notes that, by the mid-1970s, cognitive therapy had ‘warrantedadmission to the arena of controversy’ (1976: 7) alongside other approaches topsychological therapy.Beck has frequently argued that this admission was war-ranted by the fact that cognitive therapy could claim to be: a system of psychotherapy which provides (1) a comprehensive theory of psycho- pathology that drives the structure of psychotherapy, (2) a body of knowledge and empirical findings which supports the theory, and (3) research findings that demonstrate its effectiveness. (Weishaar, 1993: 47)These three factors may be regarded as the bedrock features of cognitive therapyand the bedrock for training. The strength of the model derives further from thefact that there is a well-established set of principles that operationalise the abovepoints in a down-to-earth and often parsimonious way. The principles are set outin Table 1. These principles help to ensure that the therapeutic model is focused on bothshort-term interventions and pragmatic problem-solving and that, at the sametime, through informed and collaborative therapeutic relationships, it is able toswitch into other modes and to take on other types of issues. Principle 10, sug-gesting as it does that a map of the client’s problems be drawn up, also ensuresthat research-based conceptual models can be shared with the client and used toguide therapy, and thereby underpin the whole enterprise. The teaching content of cognitive therapy is generally divided into theory andpractice elements (see Table 2) and application elements (Table 3) Most trainingcourses are likely to include these elements but, as we have noted many timesthroughout Cognitive therapy, second edition (Sanders and Wills, 2005), theapplications of cognitive therapy have now expanded to the point where partic-ular courses may seek to include some and exclude others, perhaps dependingon the needs of the trainees and/or training establishment.
Table 1 Principles of Cognitive Therapy (based on Beck & Emery,1985; Beck, 1995) 1. Cognitive therapy is short term, at least initially. 2. Cognitive therapy uses problem-solving. 3. Cognitive therapy is structured. 4. Cognitive therapy is collaborative. 5. Cognitive therapy is active and directional. 6. Cognitive therapy is based on a sound therapeutic relationship. 7. Cognitive therapy uses regular homework assignments. 8. Cognitive therapy uses guided discovery and Socratic dialogue. 9. Cognitive therapy is educational.10. Cognitive therapy is based on cognitive conceptualisation.Table 2 Theory and practice content of cognitive therapy trainingPrinciples of cognitive therapy.Cognitive model of psychological problems.Conceptualisation behavioural therapy.Behavioural interventions.Problem-solving.Cognitive interventions.Schema-focused therapy.Interpersonal and therapeutic processes. Many courses in cognitive therapy use measures of therapist competence, suchas The Cognitive Therapy Scale (CTS) to assess whether therapists are doingwhat they are supposed to do. The CTS (Young and Beck, 1988) was revised in2000 (James et al., 2000) with 12 items measuring: 1. Agenda setting and adherence to the agenda; 2. Providing and eliciting feedback; 3. Collaboration; 4. Pacing and efficient use of time; 5. Interpersonal effectiveness: genuineness, warmth, empathy, trust; 6. Eliciting appropriate emotional expression; 7. Eliciting key cognitions; 8. Eliciting and planning behaviours; 9. Guided discovery;10. Conceptual integration;11. Application of methods of change: use of cognitive and behavioural methods;12. Homework.Each category is given a six-point rating, from 0 (absence of feature or highlyinappropriate performance) to 6 (excellent performance, even in the face ofpatient difficulties). The rating scale specifies exactly what the therapist shouldbe doing within each category, thereby giving highly specific instruction and
Table 3 Application elements of cognitive therapyDepression.Anxiety.Types of anxiety – panic, social and simple phobias, agoraphobia, OCD, etc.Post-traumatic stress disorder.Stress and low self-esteem.Family and couple problems.feedback. It is very valuable in this way, giving detailed guidance about the formof therapy. We also know that therapist competence, along with therapeuticalliance, is related to outcome and may well be one of the key common factorsacross the psychotherapies (Trepka et al., 2004).LEARNING PROCESSES IN TRAININGAlthough the content of training may look straightforward, learning cognitivetherapy, either as a beginning trainee, or in ongoing professional development,is a more complex process. Because cognitive therapy is often understood asincorporating ‘psycho-education’ – teaching clients about the nature of psycho-logical problems and about the way out of them – as part of its working meth-ods, there are inevitable parallels between the educational process in therapy andthe education process in training. Although there is a distinct content that needsto be imparted, attention also needs to be paid to the processes that traineesfollow when learning cognitive therapy. Such processes are described in adulteducation theory, such as the Lewin-Kolb cycle and Schon’s concept of reflectivepractice (see Bennett-Levy, 2002; Bennett-Levy et al., 2004). In brief, the Lewin-Kolb cycle suggests that there are different stages in the cycle of learning and thatthere is a characteristic sequence of stages, as shown in Figure 1. Learning theo-rists such as Honey and Mumford (1992) have suggested that, although this is acommon sequence, people vary in how they move through it: some people –‘reflectors’ – need lots of reflection time, whereas others – ‘pragmatists’ – needmore action-based experiences. In educational terms, this means that trainers and tutors probably need to spendtime thinking about the balance between different types of learning activities andthe links between them, such as following a slab of theory with some kind of prac-tical exercise. For example, in a session looking at some of the principles inTable 1, it can be useful to ‘operationalise’ one of the principles in a practice appli-cation. Trainees could be asked to take one of the principles, such as agenda settingor homework, and practise a possible line of rationale-giving that one mightuse to introduce it to a client. An additional dimension might be added to thisby suggesting that trainees select principles with which they have some difficulty.Using Uncertainty and theSocratic MethodGiven the cognitive model of understanding belief and attitude change, weshould not expect that all trainees will immediately and fully accept all of the
Experience Planning Observation ReflectionFigure 1 The Experiential learning cycle (Bennett-Levy et al., 2004; adaptedfrom Lewin, 1952; Kolb, 1984).training content, particularly the principles (Table 1) Indeed we should be sur-prised if they did. One way of conceptualising the principles is to view them notas blind facts, but as beliefs about therapy (Wills, 2005), with ‘belief’ in this con-text following the definition of Alford and Beck as ‘ideas that are worthy ofbeing tested’ (1997: 85). Thus, by introducing principles as testable hypotheses,such as ‘therapy works better when it is structured’, we are introducing traineesto the ideas of questioning, finding out, and hypothesis testing, which resonatethroughout cognitive therapy. What Padesky (1996) calls ‘therapist beliefs’ – the beliefs of individual ther-apists about what they are doing in therapy – may also come into play. Forexample, the therapist may believe that ‘clients will not like it when I ask themto do homework’. Therapist beliefs may be in the form of ‘learning heuristics’or rules governing the way in which the trainee will implement the therapyprinciples. In a longitudinal study of cognitive therapy trainees, Wills (2005).found that many trainees had an initial learning heuristic that told them that‘I must follow the steps of cognitive therapy very exactly, otherwise it will notwork.’ This heuristic often led to rigid and ineffective practice. A more effec-tive and personal style only developed when trainees were able to change thisheuristic to something more like, ‘I can try to do this my way and see if itworks’, thus introducing an experimental and discovery mode into the learn-ing process. Counsellors learning cognitive therapy experienced the most dif-ficulty when they were trying to implement the structure of therapy, especiallyin setting an agenda (Wills, 2005). This seemed to relate to a conjunctionbetween a previous immersion in person-centred counselling and sets of ‘ther-apist beliefs’ that defined structuring sessions as being ‘directive’ and disre-spectful of the client. Sometimes these beliefs would be accompanied bycatastrophic predictions about the client’s likely reaction to such ‘disrespect’.Again, such beliefs are open to be tested, by trying out the difference betweenbringing little structure or more structure to the sessions. Other cognitive therapy skills seem, in their own right, to be particularly hardto learn to do really well. Trainees often report difficulties in learning withSocratic dialogue, finding it difficult not to ‘lead’ clients towards certain answersthat seem obvious.
Sometimes the client is saying something like, ‘I’m such a failure, so useless’, or whatever, and you just feel like saying to them, ‘oh, for God’s sake, what about the two wonderful kids you have brought up?’ Not very Socratic, eh? (Wills, research interviews, 2005)This may be because at this moment, the therapist has moved from a ‘guided dis-covery’ perspective to a ‘changing minds’ perspective (Padesky, 1993) Padeskymakes the point that one of the characteristics of good guided discovery may bethat the therapist does not always know where the dialogue is heading and isgenuinely open to wherever it may lead. If we translate that thought into thetraining situation, it may be that there are times when the trainer has to find thatsame interest in the ‘wanderings’ of the trainee as he or she lurches towards the‘aha’ moment of learning. In order to learn cognitive therapy, particularly for those who have several yearsor decades of experience in other therapeutic models, trainees might have to gothrough a considerable period of confusion and discomfort while their therapy‘beliefs’ and learning heuristics adapt to their new situation. The period of confu-sion has a striking similarity to the phenomenon of aporia, described in Chapter 5of Cognitive therapy, second edition (Sanders and Wills, 2005) as a necessary partof cognitive change, facilitated through Socratic dialogue and guided discovery.Such confusion is a defining experience of training, as described in the seminalpaper by Worthless et al. (2002). There may be trainees who have moved effort-lessly towards competence but we would struggle to recall them. However, thecognitive dissonance generated by such confusion may be a necessary motivatorfor movement towards insight. If they wish to help trainees through this period ofconfusion, trainers in cognitive therapy may wish to ensure that their teachingmethods are as Socratic as they would want their trainees to be with their clients, asstrongly suggested by Christine Padesky and others (Padesky, 1996). Training in cog-nitive therapy cannot therefore just be about ‘imparting knowledge’ in a context-freeway but should, as far as possible, mirror the principles of cognitive therapy itself. The concept of ‘training heuristic’ used in Cognitive therapy, second editioncan be applied to trainees’ search for meaning and competence, clearly heard inthis reflective account of a trainee after finishing training: I am normally a confident person and I back myself but for a short while there, in the middle of training, I lost that trust. I thought that I had to apply this model as a 1, 2, 3, 4, 5 … And it really wasn’t working … but it became like a safety blanket … 1, 2, 3 … And then I thought, well, this is no good … and at that same time, I talked to the tutor and he said, ‘A., you could just try doing it’ and I thought, yes, come on A., just do it … And I realized that I could do it 1, 2, 3, 4 and it would still be wrong … So I just did it, I did it in my own way, I suppose, and it worked, and, to my amazement, the tutors thought it worked too! (Wills, 2005).This ‘silent’ dialogue going on inside the trainee’s head is very reminiscent of theway Beck (1976) describes finding out about the two streams of thinking goingon within some of his patients. This discovery led on to the concept of ‘negativeautomatic thoughts’ and to the basis of the theory of cognitive therapy. Just asthese silent ways of negative thinking could be related to feelings of dysphoria
and anxiety in patients, it is easy to see how negative training heuristics can beassociated with such feelings in trainees. A finding that surprised me in myresearch (Wills, 2005) was the pervasive anxiety that seems to surround allaspects of training, captured in Worthless et al.’s paper (2002) Sometimes it ishelpful to link what one might call ‘negative thoughts about training’ and anxi-ety with trainees, although, in our experience, they may be guarded in discussingthem until after being awarded their certificates of competence! The trainingarena in which these thoughts are most likely to come up is within case discus-sions or supervision groups. Being aware of negative training thoughts and feel-ings can help a supervisor to respond more sensitively and helpfully to the needsof trainees. Such thoughts and feelings do not of course entirely disappear afterthe completion of training and so can also be helpfully addressed in ongoingsupervision.Personal Therapy and CognitiveTherapy TrainingIn many counselling and psychotherapy traditions, personal therapy is seen asan essential requirement for training and practising as a therapist (Wilkins,2006) and therapists rate this as an important aspect of training (Macran andShapiro, 1998; Orlinsky et al., 2001). Although it is accepted wisdom that per-sonal therapy is useful, there has not been a great deal of research on its effecton subsequent therapeutic practice, nor on what learning mechanisms canexplain its effectiveness (Bennett-Levy, 2002). In a review, Macran and Shapiro(1998) found that personal therapy improved empathy, warmth and genuinenessand, given the importance of these factors in therapy, such improvements inthemselves are likely to have a good impact on outcome. By contrast, in the world of cognitive and behavioural therapies, personaltherapy is not currently seen as an essential, or widely accepted, aspect of train-ing (EABCT, 2001). The British Association for Behavioural and CognitivePsychotherapies (BABCP, 2000), while not insisting on personal therapy foraccreditation, does stipulate: ‘therapists must ensure that they can identify andmanage appropriately their personal involvement in the process of cognitiveand/or behaviour therapy’ and ‘therapists must have developed an ability torecognise when they should seek other professional advice’. Counsellors and therapists from other traditions have reported being some-what mystified by such lack of interest in individual therapy. What they havegained from their own therapy – an awareness and understanding of their ownissues and how these might impact on the therapeutic relationship, the experi-ence of being a client, a place to take difficulties that might arise during trainingor as a result of client work, material with which to conceptualize difficulties intherapy – are all seen as equally valid within cognitive therapy but have not,until recently, been explicitly focused on. In addition, we know that reflection isan important aspect of learning, and personal therapy provides the opportunityto reflect on both professional and personal issues. Part of the reason for the lackof focus on personal therapy may be historical: many of the ‘old school’ practi-tioners of cognitive therapy came from behavioural traditions and clinical
psychology, where personal therapy has not always been seen as essential or evenrelevant. Those seeing cognitive therapy as an educational model, involving theapplication of appropriate techniques, again might see therapy for therapists asunimportant. Given the strong belief in the benefits of personal therapy for therapists, itmay be rather baffling that there is little evidence of its overall effectiveness(Roth and Fonagy, 1996). This may be because of the way it has sometimes beenimplemented as a compulsory element in some training courses. We think thatthis may not be a good enough reason to undertake therapy, partly because it isimportant for the ‘client’ to be able to decide when the time is exactly right forthis commitment. We are also aware that undertaking therapy in this way hasled to some quite adverse and even abusively exploitative outcomes for some ofthe trainees and therapists involved. We are glad to report the need for personal experience of therapy is increas-ingly recognised within cognitive therapy and that our colleague, James Bennett-Levy, has devised a method for facilitating such an experience in a way thatovercomes some of the difficulties described earlier by formatting it as a saferand more educational experience. Working in Australia and more recently inOxford, he has developed a training method called Self Practice/Self Reflection,where trainees undergo cognitive therapy with a training partner, and reflect inwriting on the process of each session, thinking through the implications of thetherapy experience for themselves, for their clients and for cognitive therapy.Bennett-Levy found that SP/SR impacted on therapy in a number of ways. Thetrainees reported a ‘deeper sense of knowing’ of cognitive practices. They gaineda deeper understanding of therapy, understood themselves better and demon-strated improvement in cognitive therapy skills (Bennett-Levy, 2001; Bennett-Levy et al., 2003). They also noted a re-emphasis on therapeutic relationshipskills: ‘the experience of being “in the client’s shoes” demonstrated starkly someof the anxiety and difficulties in making changes, even as high functioning indi-viduals; and served to emphasize how valuable empathy, understanding, respect,tolerance and guidance of the therapist is’ (Bennett-Levy et al., 2003: 150) Thestudy found that SP/SR helped trainees to develop self-reflection, enabling themto reflect both during and after sessions. We know that client perception of empa-thy is correlated with positive outcome; and if SP/SR leads therapists to be moreempathic, as judged by our clients, then it is likely to lead to better outcomes. Areview of SP/SR in CBT training (Laireiter and Willutzki, 2003) confirmsBennett-Levy’s findings, showing that trainees report substantial personal andprofessional gains from using SP/SR. They report improved self-insight and self-awareness, and a better understanding of the role of the therapist and the processof therapeutic change, as well as a better understanding of and skills in CBTmethods. As summarised by Laireiter and Willutzki: ‘Although empirical evi-dence is not extensive at present, it supports the notion that most of these goalsmay be attained by a combination of person- and practice-related self-reflectiontogether with self-practice of CBT methods’ (2003: 28) Personal therapy or SP/SR may take a while to filter through to become incor-porated within cognitive therapy training, but is certainly becoming recognisedas a means of improving understanding of ourselves and of personal aspects ofour clinical practice.
LEARNING THE STRUCTURE: THERAPEUTICARTISTRY VERSUS STANDARD THERAPYFOR STANDARD PROBLEMS … nor should standard, protocol-based practice stifle innovation, but should serve as a springboard to it, since there are many situations in the psychothera- pies where there is no research evidence or even clinical consensus to indicate the best approach. (Parry, 1996) Once the basics are learned, a competent cognitive therapist develops an artful ability to conceptualize interlocking problems, make intervention choices, and solve problems in an efficient and effective manner to facilitate client learning and change. These ideals are challenging to achieve. (Padesky, 1996: 269)Many therapy procedures are now well written up into ‘manual’ and ‘protocol’formats, and one approach to training can include introducing trainees to theuse of these materials. On the one hand, cognitive therapy does promote theimportance of protocols, since research has suggested that therapists who do notfollow the structure are not as effective as those that do (Schulte et al., 1992;Wilson, 1997) On the other hand, however, developing an individual conceptuali-sation for each client we see, and following therapy accordingly, is recommended(Butler, 1998; Jacobson et al., 1999) Jacqueline Persons (1989) argues that a fail-ure to use individual conceptualisation means that our treatment would beoverly dictated by symptom identification. She uses the analogy of treating fever.If we were to only treat fever according to the symptoms, we would not be ableto distinguish between fever caused by malaria and that caused by pneumonia,and this would mean that we would be likely to make treatment mistakes. Learning to balance a structured, standard approach in therapy with workingwith individual clients can be an extremely challenging part of training, particu-larly for those therapists used to a looser, client-centred and client-directed wayof working, who fear that structure will lose the essence of working with theperson rather than with symptoms. However, to reject standard therapy on thisbasis may risk losing the therapy’s effectiveness or at least diluting its value. Thetherapeutic procedures of cognitive therapy have gained a lot from being clearlydelineated and structured, and there are strong arguments for therapists tofollow them closely. For many trainees, using a standard protocol may come asa relief, offering clear guidelines as to what to do in therapy. But even this is notwithout its problems. Henry et al. (1993) report, admittedly in the context of training in psycho-dynamic therapy, that training using protocols and/or manuals is likely toresult in therapist hostility towards clients – presumably when the clients donot conform to the client behaviour required by the protocol – and thus toadverse results. The problem raised by Henry and colleagues is one that is fre-quently reported in training. Trainees, coping with the aporia crisis of leavingone form of practice behind without having fully developed a new form ofpractice, see the process of mastering the protocol as a way out of this anxi-ety. They therefore frequently report going through a stage where they over-apply the protocol or the model:
I seemed to spend more time thinking about applying the model than thinking about the person in front of me. This felt very uncomfortable to me. In retrospect, I think that I got into a way of thinking about how to do cognitive therapy that was almost neurotically structured … (cognitive therapy trainee, quoted in Wills, 2005)More optimistically, however, trainees in the Wills (2005) research reported thatas time went on they were able to reconceptualise the situation with a learningheuristic that was more helpful to them. The solution for these trainees seemedto lie in developing the paradoxical ability to follow the protocol in their ownway and in a way that was responsive to the needs of their individual clients. In some ways the protocol versus individual therapy argument has become morepolarised than it needs to be, and successful therapy involves a balance between‘science’, or following the structure, or ‘art’, working with the individual. Artistryand science are clearly evident in Aaron Beck’s therapeutic abilities and his ideas. Itis perhaps significant that, for cognitive therapy, he has been an advocate for bothmodes of operation. This fact in itself may give us hope that the two approaches arenot necessarily mutually exclusive. Faced with a bewildering mass of issues andsymptoms, a therapist can find help in both the individual conceptualisation and inthe treatment methods and rationales of the manuals. There are, also, different understandings of what structure means in practice.One notion would hold that inside the therapist’s head there is a very clear andstructured scheme of rules on how to proceed and this is matched by anotherconsisting of clear and structured therapeutic behaviours. Another notion is thatthere is a clear and precise structure of rules inside the therapist’s head but thatthe ‘art’ of therapy depends on using the rules to steer between different poten-tial actions. Alford and Beck use the term in both these different ways: ‘The ther-apist needs a clear structure … a clear rationale on which to base a way ofproceeding … without that it will be difficult to maintain a scientific stance inpractice’ (1997: 72); ‘Structure is a defining characteristic of cognitive therapyand a reliable way to discriminate between it and other therapeutic modes … [itincludes] … the presence of an agenda, setting homework and asking the clientfor feedback at the end of the session’ (1997: 76) The first usage may be deemed as a kind of structured way of thinking aboutand understanding a situation, a way of conceptualising or formulating a client’shistory, for example. The latter we might better call ‘steps that structure action’.While a scheme of such steps can act as a facilitator of clear work with clients, itmay also be open to the danger of resulting in mechanical work. This is whytrainees also need to be ‘wired to the cognitive way’ (i.e. having a thorough wayof using cognitive conceptualisations), as Young (in Weishaar, 1993: 38.) puts it.He goes on to say: ‘Technical cognitive therapists … [are] … not really attuned tothe interpersonal component of the therapy, just with delivering a technique’(1993: 39) What we are talking about here may be the art of learning to sail ayacht by catching the wind rather than by resorting to the outboard motor. In some ways, cognitive therapy may itself have to accept at least part of theblame for the state of things regarding its implementation. As a discipline, it hasbeen over-reliant on highly quantitative outcome research and has not encour-aged much qualitative process research, with the notable exception of thein-depth, qualitative work of Bennett-Levy (2002) A strongly quantitative bias
may have been necessary in the opening phase of the history of cognitivetherapy but development of qualitative research of cognitive therapy is now longoverdue (Grant et al., 2004) As we will argue again later, we may need to developdifferent research modes – probably those of the more qualitative, process-orientedstyle – to get at more subtle questions such as, ‘when is it good to departfrom the structure/protocol and when is it necessary to stay with it?’ These arequestions that crop up time after time when an open learning approach is usedin cognitive therapy training. The question can also become a major focus ofsupervision.SUPERVISION IN COGNITIVE THERAPYSupervision in cognitive therapy probably occupies less of a ‘hinterland’ than itdoes in some of the other major models of psychotherapy and counselling.Although it has always been a part of the actual practice of the model, it hasnot been much written of or theorised about, perhaps once again showing thepractical and pragmatic nature of the model. That it has always been there,however, can be seen in the fact that Beck strongly argued for the presence ofcognitive therapy supervisors in the major research trial conducted by the USNational Institute for Mental Health in the 1980s (Weishaar, 1993) There are signs now that cognitive and cognitive-behavioural therapists arebeginning to think much more about the nature of supervision (Bennett-Levy,2002; O’Carroll, 1999; Padesky, 1996; Townend et al., 2002) There are twomain forums in which cognitive therapy supervision takes place: supervision aspart of a training course (more likely to be group supervision) and supervisionas part of ongoing development after training (more likely to be individualsupervision) Both authors have practised and experienced individual and groupsupervision in both of these contexts. Supervision after training may be particu-larly important in helping to prevent practice ‘reverting to the mean’ after train-ing. It is easy to understand how, when the frequently intensive atmosphere ofthe training situation is left behind, therapeutic practice can, first, stop develop-ing and, then, revert back to previously established models of practice (MacKayet al., 2000) Post-training environments, despite what quality assurance and mis-sion statements may say, may not nurture innovative practice, even when it isempirically supported (Wills, 2005) There is also a significant problem wherebyhighly trained therapists may be quite quickly promoted into posts where theydo less, or sometimes no, direct therapy work (Ashworth et al., 1999) In addi-tion, supervision can be informal peer supervision, as in a discussion betweencolleagues, or self-supervision, where we allow time to reflect on our work(Padesky, 1996) Christine Padesky’s (1996) excellent chapter on supervision incognitive therapy gives clear guidelines about how to bring cognitive therapyprinciples into supervision. For example, she recommends that supervisionreflect the structure of cognitive therapy by using pre-planned questions as afocus for each supervision session, with themes such as:• Is there a cognitive model for understanding and treating this client problem and is this being followed?
• Does the therapist have the knowledge and skills to implement therapy properly?• Is the therapy following expected patterns?• What might be interfering?CONTENT AND PROCESS IN COGNITIVETHERAPY SUPERVISIONCognitive therapy is a vast and growing area of application, and in comparison tothe early models, where depression was the only area to learn about, now there ismuch extra that one could learn about. Thankfully, this does not necessarily meanthat we have to know in detail the content of every intervention for every prob-lem. Many of the different applications operate to the same sort of principles andoffer similar types of interventions using similar skills. The main variation, as indi-cated earlier, would be on the development of a conceptualisation for particularproblems, mindful that our clients are individual people, whom we understandand aim to help in individual ways. From a training and supervision point of view,the variety in cognitive therapy is really more about ‘being able to find out about’rather than ‘knowing about’. Curiosity is a quality that is good for trainees andsupervisees to foster, backed up by the ability to think in a clear and scientific way. Therefore, knowledge about the content of therapy for particular client diffi-culties will probably always play quite a significant role in cognitive therapysupervision. Being able to use diagnostic system criteria to get in the right ‘ball-park’ with clients is often something that more senior practitioners can helptrainees with. However, we would stress the use of such criteria as ‘ballpark esti-mates’ rather than rock-solid facts. Help with understanding symptoms may beless relevant to more ‘seasoned’ supervisees – a good example of how super-visory needs vary over the development of a career. Townend et al. (2002) foundin their survey of cognitive behavioural practitioners that ‘conceptualisation’was the issue most raised in CBT supervision. Conceptualisation can contributeto the review of either the content or process of the therapy. It is also inevitable that issues concerning therapeutic process will often beraised in supervision. Interestingly, I kept a supervision case book of issues raisedin supervision over a period of two years and this record shows that over two-thirds of all supervision discussions were more focused on therapeutic processthan on therapeutic content. This was made all the more remarkable by the factthat the greatest proportion of the supervision discussions had taken placewithin the context of a training course. Perhaps the reason for this is that manycognitive therapy techniques are relatively simple to execute and are oftenbacked by very clear rationales. This is not by any means saying that cognitivetherapy is easy to do but that its clarity means that most of the difficulties occurin relation to its application, rather than to its execution. Process issues in cognitive therapy supervision often seem to carry the flavourof ‘I’m doing great cognitive therapy but the client isn’t!’ Some examples oftypical discussions are presented in Figure 2. We described how such cognitive-interpersonal events can be understood andworked with in cognitive therapy in Cognitive therapy, second edition. The‘seven-eyed’ model developed by Hawkins and Shohet (2000) can be very useful
I get the impression that this client doesn’t suffer fools gladly and I wonder if she sees me as a fool! M. is an extremely bright but depressed student client. She is very committed to doing CT therapy and indeed sees it as the answer to all her problems. The supervisee had only seen this client three times but on each occasion she had made a criticism of the way the therapy was being conducted and each time had asked for specific changes in the way it was being done. The supervisee made the above comment. I described one aspect of the client’s behaviour as ‘over the top’ and he stormed out of the room. F. was a depressed middle-aged man who was finding it difficult to sustain relationships with women. The female supervisee was exploring with the client his thoughts and behaviours as he ‘showered his girlfriend with gifts’, and tentatively wondered how the girlfriend might experience it. The client reacted badly – though he did call back and some discussion followed. The supervisee was able to reflect on how the client was affecting her and how she might use such ‘cognitive interpersonal’ information better in the future.Figure 2 Process Issues in Cognitive Therapy Supervisionfor identifying and working with such ‘interpersonal markers’ as those notedearlier (see Figure 3) The first three process modes of the Hawkins and Shohet model relate mainlyto fairly conscious material content of the therapy. The other process modesrelate mainly to less conscious processes in both the therapy and the supervision.Processes 1 and 2 of the Hawkins and Shohet model focus on the content of thetherapy sessions and the strategies being used in them respectively. In the case of client M. (see Figure 2), the client had been diagnosed as beingdysthymic and was indeed very emotionally flat and ‘hard to engage’. One of hercriticisms of the therapy, however, concerned filling out an inventory to measureher depression. The therapist uses many of these inventories and to save resourcesand the rainforest had started getting clients to fill them out in pencil and thenerasing their marks for reuse later. M. had objected to this and had asked for afresh sheet each time. This was the first time that any client had made this pointand the therapist had begun to wonder if the client might have an entitlementschema (Young and Klosko, 1994) The supervisor helped him think this throughand how this might link to the choice of which strategies to use, for example,whether he should agree to this request or not. What would be the implicationsof acceding or not acceding to the request for the therapeutic relationship, the thirdprocess mode of the Hawkins and Shohet model? The therapist spontaneouslybegan to consider, ‘I wonder if I like this client? What is she doing to me? AmI a bit attracted to her?’ This is the therapist process focus – process mode 4of the model. The supervisor was now aware of a reaction in himself:‘I have to make this therapist stand his ground here. I can’t let him be pushedaround by this client. This has been a weak side revealed in his work before.’This is process mode 5 of the model: focusing on the supervisory relationshipitself. Finally, the supervisor decided to step back from this latter reaction andask himself, ‘Am I getting drawn into this? Is this perhaps driven by my stuffabout my strong need to patrol my own boundaries? I could just go to a more
Organizational context Professional 7 Organizational codes and ethics constraints and expectins 6 Supervisor 5 6a Fantasy 4 relationship Therapist 2 3 1 Client Economic realities/pressures Family Social context Social normsFigure 3 The seven-eyed model of supervisionneutral position and help the therapist review the pros and cons of acceding ornot acceding to the request. He’d probably learn more from that.’ This is super-vision process mode 6: focusing on the supervisor’s process. Since devising the six process modes of the original model published in 1989,Hawkins and Shohet (2000) have added a seventh process mode in their second edi-tion. The seventh process mode concerns how the therapy and the supervision relateto the wider context of the therapy and supervision. The case of client F. (see Figure2) could profit by analysis from the perspective of the same six modes that havebeen applied to client M., above. In this case, however, the seventh process modemay also become relevant. Clients who storm out of sessions may choose to go into‘complaint mode’. Most organisations now have well worked-out, formalised waysof dealing with complaints and these may relate to wider quality assurance systems.Such systems and procedures may strike us as bureaucratic and/or ‘covering one’sbackside’ but do at least offer some protection to potentially vulnerable human ser-vice workers. Single-handed practitioners may not expect to get caught up in suchsituations and may have very little in the way of ‘organisational’ coping systems inplace. Good supervision would not only help the therapist reflect on the practiceissues, as per Figure 2, but also on the systems and potential personal liability issuesin such incidents. This might include severely practical aspects concerning whetherthe incident had been recorded and whether any witnesses were available. In gen-eral, supervision in therapy and counselling has been good and proactive in dealingwith psychological process issues, and passive and poor in dealing with system
process issues. Townend et al. (2002), for instance, report that, in their survey ofsupervision, therapist safety was never discussed. A further systems issue that has arisen in the nascent literature on supervisionfor cognitive therapists is that of ‘dual relationships’ (Townend et al., 2002) Inthe NHS, for example, where there are strong management systems, conflictmay arise when one person is trying to hold the roles of both ‘managerial super-vision’ and ‘developmental supervision’. Townend and colleagues report thatsupervisees did not generally report this as a problem but suggest caution in thisregard. They further suggest that a written contract – covering such matters asexpectations, methods and procedures – can act as a useful protection againstcontamination effects between the two roles. Townend et al.’s (2002) survey reports that many cognitive practitioners areinfluenced by the supervision models offered by Padesky (1996) and Beck andLiese (1997) These models are based on the desirability of congruence betweenthe way therapy is conducted and the way supervision is conducted. This pointcovers issues such as congruent structure, setting agendas, goals and using feed-back to guide the process, and congruent methods, such as conceptualisations,role-plays and use of tapes. In this way, the supervision session mirrors cognitivetherapy itself, and is a powerful means of experiencing the process while work-ing on the supervision issues themselves.CONCLUSION: HELPING THERAPISTSTO ESTABLISH THEIR OWN STYLESCognitive therapy walks a narrow line between scientific precision and thera-peutic artistry. As the cognitive model has developed, it has become abundantlyclear that the therapy itself and the training and supervision modes informed bythis model are usually accompanied by subtle interpersonal processes. Suchprocesses were not entirely expected in the early days of cognitive therapy.Interpersonal processes receive much of their subtlety from their idiosyncraticnature, a factor relatively easily integrated into a cognitive approach, based as itis on uncovering individual appraisal and meaning. One of the challenges facing trainee cognitive therapists, and indeed thoselonger in the tooth, is in balancing structured, standard therapy with workingwith our individual clients. There is no doubt that the therapeutic procedures ofcognitive therapy have gained much from being clearly delineated and structured.There are therefore strong arguments for therapists to follow them quite closely.These arguments also stand in favour of supervisors helping trainees and super-visees to follow them quite closely. The devil, however, is quite often in the detail.How closely should cognitive therapists stick to the protocol and what licence canthey give to their therapeutic artistry? We wonder if the debate between these two approaches has not become ratherpolarised into an either/or mode. It seems extremely unlikely that one therapistwould implement even highly specified treatments in exactly the same way asanother therapist or that either of them would work in exactly the same waywith different clients. Our own experience tells that even when a client seems tobe very much ‘with the programme’, there are hundreds of little decisionsspecific to that client and that therapy that still have to be made. Equally, even
when client and therapist are not following a manual, it is also extremelyunlikely that the therapy is not following some kind of sequence known to thetherapist from his or her reading of the literature and from previous experiencewith clients. It is likely then, that there is far more of a continuum between highand low structure than is sometimes implied in the current debate. Even when following an established sequence of therapy, clinicians themselvesconsider that their clinical judgement is a vital part of the equation for success(Butler, 1998; Nelmes, 2001) Huey argues that therapy would be likely to beenhanced by ‘effective clinical reasoning, i.e., teaching future practitioners howto, rather than what to, think about complex psychopathology’ (1999: 2) It would be helpful now to have more research on the kind of small decisionsthat sometimes can keep things on track but at other times allow for successfuldiversion. Such research would give guidance on what one might called the ‘nat-ural history’ of the therapy process. The forum of supervision, both during andafter training, seems to be the most likely location where such data would natu-rally accumulate. Within psychotherapy generally, supervision has been moreprevalent and prominent than it has been in the cognitive and behavioural fieldand yet has also been somewhat under-researched. A recent review of researchon supervision in counselling and psychotherapy (Wheeler, 2003) has, however,revealed a new focus on outcome and it is now time for cognitive therapists toadd its experience to this developing and important field. Further Reading Bennett-Levy, J. (2006) Therapist skills: their acquisition and refinement. Behavioural and Cognitive Psychotherapy, 34 (1): 57–78. Goldfried, M.R. (ed.) (2000) How therapists change: personal and profes- sional reflections. Washington, DC: American Psychological Association. Padesky, C.A. (1996) Developing cognitive therapist competency: teaching and supervision models. In P.M. Salkovskis (ed.), The frontiers of cognitive therapy (pp. 266–92) New York: Guilford Press.NOTE 1 The cognitive therapists also tended to dress more conventionally. Goldfried(2000) claims that, as a behaviourist travelling to the humanistic Mecca at Esalenin the 1970s, he used a two-sided case so that the two appropriate dress stylescould be kept separate. The Esalen side was smaller, clothing being, at that timein Esalen, optional!REFERENCESAlford, B.A. & Beck, A.T. (1997) The integrative power of cognitive therapy. New York: Guilford Press.
Ashworth, P., Williams, C. & Blackburn, I.-M. (1999) What becomes of cognitive therapy trainees? A survey of trainees’ opinions and current clinical practice after postgraduate cognitive therapy training. Behavioural and Cognitive Psychotherapy, 27 (3): 267–77.BABCP (2000) Minimum training standards for the practice of CBT. London: BABCP.Beck, A.T. (1976) Cognitive therapy and the emotional disorders. New York: International Universities Press.Beck, A.T. (2004) Origin, evolution and current state of cognitive therapy: The inside story. Keynote address, Congress of the European Association of Behavioural and Cognitive Therapies, Manchester, September.Beck, A.T. & Emery, G. with Greenberg, R.L. (1985) Anxiety disorders and phobias: a cognitive perspective. New York: Basic Books.Beck, A.T. & Liese, B.S. (1997) Back to basics: fundamental cognitive therapy skills for keeping drug-dependent individuals in treatment. National Institute on Drug Abuse Research Monograph Series, 165: 411–30.Beck, J. (1995) Cognitive therapy: basics and beyond. New York: Guilford Press.Bennett-Levy, J. (2001) The value of self-practice of cognitive therapy techniques and self- reflection in the training of cognitive therapists. Behavioural and Cognitive Psychotherapy, 29: 203–20.Bennett-Levy, J. (2002) Navel gazing or valuable training strategy? Self-practice of therapy techniques, self-reflection, and the development of therapist expertise. In J. Henry (ed.), First European positive psychology conference proceedings. Leicester: British Psychological Society.Bennett-Levy, J., Lee, N., Travers, K., Pohlman, S. & Hamernik, E. (2003) Cognitive ther- apy from the inside: enhancing therapist skills through practising what we preach. Behavioural and Cognitive Psychotherapy, 31: 143–58.Bennett-Levy, J., Butler, G., Fennell, M., Hackmann, A., Mueller, M. & Westbrook, D. (2004) The Oxford guide to behavioural experiments in cognitive therapy. Oxford: Oxford University Press.Butler, G. (1998) Clinical formulation. In A.S. Bellack & M. Hersen (eds), Comprehensive clinical psychology. Oxford: Pergamon, (pp. 1–24).European Association of Behavioural and Cognitive Therapies (EABCT) (2001) Minimum training standards. London: EABCT.Goldfried, M.R. (ed.) (2000) How therapists change: personal and professional reflec- tions. Washington, DC: American Psychological Association.Grant, A., Mills, J., Mulhern, R. & Short, N. (2004) Cognitive behavioural therapy in mental health care. London: SAGE.Hawkins, P. & Shohet, R. (2000) Supervision in the helping professions: an individual, group, and organisational approach. Buckingham: Open University Press.Henry W.P., Strupp, H.H., Butler S.F., et al. (1993) Effects of training in time-limited dynamic psychotherapy: Changes in therapist behavior. Journal of Consulting and Clinical Psychology, 61: 434–40.Honey, P. & Mumford, A. (1992) The manual of learning styles. Maidenhead: Peter Honey.Huey, D. (1999) The potential utility of problem-based learning in the education of clinical psychologists. British Association for Behavioural and Cognitive Psychotherapies Annual Conference, London.Jacobson, N.S., Schmaling, K.B., Holz-Munroe, A., Katt, J.L., Wood, I.F. & Follette, V.M. (1999) Research structured versus clinically flexible versions of social learning based marital therapy. Behaviour Research and Therapy, 27: 173–80.James, I.A., Blackburn, I.M. & Reichelt, F.K. (2000) Manual of the revised cognitive therapy scale. Newcastle upon Tyne: Newcastle Cognitive & Behavioural Therapies Centre.
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