Did you learn CBT through the tradition of “See one, do one, teach one?” Were your instructors and supervisors clinicians who had never learned the principles of adult learning? Did they instead teach or supervise you in the way they themselves had been taught or supervised?
Dissemination and training of quality CBT therapists has become a recent focus for CBT programs throughout the world. There is a renewed focus in the field of CBT and on the skills needed to effectively teach and supervise. In fact, CBT supervision skills have independently been recognized as a competency in recent years.
Perhaps surprisingly, little research exists on CBT training. What constitutes sufficient training? What does “competence” in CBT actually mean? How should therapist “drift” be monitored and assessed? Sudak et al (2015) summarizes the current research in training and supervision.
Training is defined as the effective transfer of knowledge about and practice of the key skills of CBT. It represents both knowing that and knowing how. Most skills are taught both in training and supervision. Therapists or students first learn the rationale for a skill; they watch experts, and model what they have learned in practice with roleplayed “clients” of varying degrees of difficulty (with corrective and confirming feedback). Once trainees have the necessary skills, they can then be supervised with actual clients in a setting of “real world complexity.”
CBT supervision is most effective and efficient when the supervisor uses processes that parallel CBT therapy. The supervisory alliance is critical to effective work in supervision. The relationship needs to be safe enough for the supervisee to tell the truth and to be able to hear and incorporate constructive feedback. Supervisors should do a needs assessment with supervisees and then collaboratively set goals which form the “road-map” for supervision. Good supervision uses a session structure similar to that employed with clients in psychotherapy (Liese and Beck, 1997). By so doing, the model is reinforced and the supervisee can have an experience akin to self-practice.
Several other important parallels exist between effective supervision and therapy. These include using Socratic questions to stimulate learning and reflection, action plans between sessions and eliciting and giving feedback. Tapes of client sessions must be used to assess progress, rated by both the supervisee and supervisor with a validated instrument to determine fidelity and integrity, such as the Cognitive Therapy Rating Scale and client symptom rating scales provide data to determine if care is adequate and safe.
Supervision also requires conceptualization – both of the client and the supervisee. We are more effective supervisors if we develop a tailored educational plan based on the educational needs of the trainee and his or her capacities as therapist. The cultural competence and the cultural background of supervisees and clients should also be considered as a part of the conceptualization.
Supervisees should be encouraged to use thought records regarding their reactions to clients and expectations of themselves as therapists. This practice helps them to learn more effectively and inculcates the self-reflection that encourages expertise. Bennett-Levy (2003) has published extensively regarding this core process in CBT training. Active engagement and thoughtful implementation of several learning methods, as described by Milne and Dunkerley (2010), heightens curiosity and interest in supervisees.
Making our supervision and training more effective is also more engaging and fun for the teacher, so everyone benefits from this effort to improve our work.
Sudak, D.M., Codd, R.T., Ludgate, J., Reiser, R.J., Milne, D., Sokol, L., Fox, M. Teaching and Supervising Cognitive Behavioral Therapy. (2015) Hoboken: John Wiley and Sons.
Bennett-Levy, J. Lee., N., Travers, K., Pohlman, S., & Hammernick, (2003). Cognitive therapy from the inside: Enhancing therapist’s skills through practicing what we preach. Behavioural and Cognitive Psychotherapy, 31, 145–163.
Liese, B.S., & Beck, J. S. (1997). Cognitive therapy supervision. In E. Watkins (Ed.), Handbook of psychotherapy supervision. New York, NY: Wiley
Milne, D.L., & Dunkerley, C. (2010). Towards evidence-based clinical supervision: The development and evaluation of four CBT guidelines. Cognitive Behaviour Therapist, 3, 43–57.
By Judith S. Beck, PhD,
President, Beck Institute for Cognitive Behavior Therapy
Guilford Publications asked me to reflect on my reasons for writing Cognitive Behavior Therapy: Basics and Beyond and Cognitive Therapy for Challenging Problems: What to Do When the Basics Don’t Work, both of which Guilford first published in 1995 and 2005, respectively. Below is what I sent:
I remember the moment I conceived of writing CBT: Basics and Beyond. It was in the early 1990’s and I was presenting a workshop with my father, Dr. Aaron Beck, in California. Most of the workshop participants were familiar with his work but asked very basic questions. Again and again, I found myself surprised by what they didn’t know (e.g., how to conceptualize patients according to the cognitive model, structure a session, set an agenda, use Socratic questioning, handle homework challenges, ask for feedback). I realized they needed a basic book that could teach them these skills in a step-by-step format, with transcripts illustrating key therapeutic interventions. I had lots of automatic thoughts when writing the book (“People will think this is too simplistic,”), for which I used CBT techniques on myself to keep going. The book is now the basic text used by most graduate schools in all the mental health disciplines, in the United States and abroad.
I also remember when I conceived of writing Cognitive Therapy for Challenging Problems: What to do When the Basics Don’t Work and it traces back to the first book. When I was writing CBT: Basics and Beyond, I had to continually separate material that was basic from material that was advanced–which made me realize that people would probably need a sequel to the basic text. I presented dozens and dozens of workshops on Cognitive Therapy for Challenging Patients and Cognitive Therapy for Personality Disorders in the years that followed. At each workshop, I asked participants to specify problems they had with some of their patients. (“What does the patient do or not do in session or between sessions that’s a problem? What does the patient say or not say that’s a problem?”) I soon had a very long list of problems. The challenge for me was in organizing the material I collected, and I had lots of false starts. It took me five years to determine how the book should best be structured. Once I figured this out, it took just another two years to complete the book.
I started off my career, not in psychology, but in education. Early on, I learned how to break down and explain complicated ideas and tasks for my young elementary school students who had learning disabilities. Through my books and workshops and other training activities, I believe I’ve been able to do the same for therapists who are learning and practicing CBT.
Dr. Etchebarne works as a clinical psychologist treating adults with anxiety and performs psychotherapy research. He is currently developing a research program in Argentina about CBT for Personal Growth. He was so excited to (finally) come to Beck Institute after completing supervision and consultation with multiple Beck Institute staff.
He combined this training, Teaching and Supervising CBT, with his presentation next week at the Society for Psychotherapy Research conference at the University of Pennsylvania, which has a theme of “Psychotherapy: improving adaptation from the inner life to the outer world.” His presentation will focus on psychotherapy for personal growth.
This workshop came at the perfect time for him, because he plans to begin providing supervision to new therapists. “I’m eager to start doing everything I learned” “This workshop is a must if you want to learn how to provide evidence based supervision and teaching in CBT.”
“It’s been so good, I learned so much about teaching in general that took me by surprise. It was shocking in a good sense, I was unconsciously confident.”
Judith S. Beck and Daniella Cavenagh
How do you become a skilled CBT supervisor? Delivering effective CBT supervision requires a highly specialized, advanced set of competencies for which clinical acumen is essential but not sufficient. A growing body of literature indicates the importance of:
- developing the relationship with supervisees, including eliciting and responding effectively to their feedback
- setting goals with supervisees
- accurately assessing supervisees’ strengths and weaknesses
- developing effective individualized plans for supervision to implement within supervision sessions and across sessions
- structuring supervision sessions (in a similar way to therapy sessions)
- providing experiential exercises in and between supervision sessions (including having supervisees practice CBT conceptualization and treatment techniques on themselves)
- regularly reviewing and providing feedback on therapy recordings and on the progress of the supervisee
- teaching supervisees how to engage in effective self-reflection
- using self-reflection yourself
- engaging, on an ongoing basis, in activities to improve your own clinical and supervisory competence
When we train CBT supervisors, we first train them to be effective CBT therapists. Most of the competencies listed above have parallels in CBT treatment. Once therapists have developed a sufficient level of competence as a therapist, we provide training and supervision in CBT supervision, which includes reading the literature on CBT supervision, attending workshops on training and supervision, and receiving supervision on doing supervision (based on tape reviews of both client sessions and one’s own supervision sessions).
Self-reflection is also a crucial part of effective supervision. Supervisors need to objectively examine their knowledge and skill set and attitudes (about supervision, trainees, clients, and CBT in general). We first teach clinicians how to rate therapy sessions they conduct with their own clients (using the Cognitive Therapy Rating Scale), then how to rate the therapy sessions of their supervisees.
We also help them assess how they conducted the supervision session. For example, did they appropriately attend to the supervisee’s developmental stage? (In our experience, supervisees with relatively little CBT experience may benefit from a somewhat more directive approach than an experienced CBT supervisees for whom greater collaboration is effective). Did they use experiential learning strategies such as role plays? Did they competently handle any ethical issues? Were they attuned to cultural and diversity issues between the trainee and themselves, the trainee and the client, and indirectly, the client and themselves? Did they actively seek feedback and respond appropriately to it?
Finally, we teach supervisors (and supervisors-to-be) to reflect on the effectiveness of the supervision session as a whole. What did they do well? What might they need to improve upon? What can they do to increase their competency?
Providing CBT supervision is an incredibly rewarding experience when you see your supervisees becoming more competent and confident and their clients making good progress. But a strong CBT clinician will not necessarily be a strong CBT supervisor. We encourage researchers to continue conducting studies to establish evidence-based CBT training and supervision competencies and practices — and we encourage clinicians who wish to become supervisors to seek out effective training.
|When:||June 11-12, 2016|
|Where:||Beck Institute, Suburban Philadelphia|
|Time:||8:15am – 4pm|
|Faculty:||Donna Sudak, MD|
|Enrollment:||Limited to 42 participants|
Topics covered include:
- Structuring and conducting CBT supervision
- Measuring and evaluating therapist progress and competence
- Adapting CBT supervision to the trainee’s level of development
- Special issues in group supervision
- Working effectively with a problematic trainee
- Using measures to improve patient outcomes with informative feedback
- Creating a comprehensive CBT curriculum based on core competencies necessary for practice
- Teaching Socratic questioning and other specific competencies
- Distance learning and use of technology
- Advocating for CBT in training programs and competing for resources
Beck Institute for Cognitive Behavior Therapy is a leading international source for training, therapy, and resources in CBT.
Soldiers Suicide Prevention (Beck Institute) is a Combined Federal Campaign (CFC) Approved Charity: CFC # 11590
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