Simply Effective CBT Supervision For Low and High Intensity IAPT

Dr Michael J Scott

Wednesday, September 10th 2014

For this presentation and notes e-mail me, michaeljscott1@virginmedia.com, if I have not replied in

48hrs send an appropriate reminder!

Resources

1. Simply Effective Cognitive Behaviour Therapy Supervision (2014) London: Routledge Michael J Scott

2. Collaborative Case Conceptualization (2009) New York: Guilford Press Willem Kuyken, Christine A. Padesky and Robert Dudley

Learning Objectives• To distil a viable model of supervision in which supervision is

seen as a crucible for reflective thinking which reciprocally interacts with knowledge and skills

• To appreciate the similarities and differences between traditional supervision and supervision for evidence based practise

• Understand a framework for ensuring the EBP of Supervisees• Ensure Supervisees practice flexibility within fidelity• Appreciate that competence without adherence is

meaningless – fidelity = adherence + competence• Distinguish competences: stage specific, diagnosis specific

and generic• Appreciate that a failure in one competence sabotages the

others

‘I’m stuck with……….’• This is a reflection on a difficulty with a client that the

supervisee feels they are unable to resolve

• The supervisor determines whether there is a gap in the supervisees knowledge and/or skill in the matter

• Collaboratively supervisor and supervisee determine how these gaps may be closed

Thinking Back to Your Last Session as a Supervisor or

as a Supervisee (if you haven’t yet Supervised):• Was a gap in knowledge identified?

• Was a gap in skills identified?

• How were the gaps closed?

• If gaps in knowledge or skills were not identified and steps

taken, what therapist/supervisor learning has taken place?

• Overall in your supervision sessions is there a balance of didactic and experiential learning?

Important Dimensions of The Supervisory Relationship – in the last session did my supervisor (or me) provide

• Safe base e.g the supervisor was respectful of my views• Structure – sessions were structured• Commitment – did my supervisor pay attention to my

anxieties feelings• Reflective education – did my supervisor encourage me to

reflect on my practice• Role model – did I respect my supervisors skills• Formative feedback – was my supervisors feedback on

my performance constructive

Role Play Supervision re: Mark

Commonalities In Supervision Across Treatment Modalities

• Identifying gaps in knowledge

• Identifying gaps in skills

• Bridging the gaps

• Maintaining a good supervisory relationship

• Balancing didactic and experiential learning

What Is Specific About Supervision In IAPT?

Defining The Primary Function of Supervision

The Supervisor As A Conduit for EBT’s

Evidence-based treatment (EBT)

Supervisee Supervisee Supervisee

Supervisor

A Top Down Account of Evidence-Based Provision

Clinician Providers of CBT

Clients

CBT Training CoursesManagers Supervisors

Academic CliniciansRandomised Controlled Trials Scientist Practitioner Model

Question Time• How many studies show the superiority of behavioural

activation to cognitive therapy or vice versa?

• In what area/condition was a difference demonstrated?

• What, if any, are the implications for routine practice?

• How do you assess therapeutic competence in these modalities?

The Consequences of Not Appreciating The Strength of Evidence

• Manager pressurising CBT therapist to provide a group for all comers

• Inappropriate limiting of the number of sessions

• Adoption of strategies based on eminence/convenience rather than evidence

• Promotion of interventions that are new but have no demonstrated added value over a traditional CBT intervention

The Supervisor As Foreman• How do you ensure that the treatment your supervisee is

providing is evidence-based?

• If treatment is only as good as a reliable assessment, how do you ensure the latter?

• How do you ensure that you don’t stop at the first disorder/major problem identified?

• Multiple disorders are the norm, how do you help supervisees address this?

The GAP Between Supervision in RCT’s and In Routine Practise

Frequency

Focus on fidelity (adherence plus competence)

Diagnosis specific protocols

Use of a manual

Supervision takes place in the context of ‘Gold standard assessments’, standardised semi-structured interviews such as the SCID

To The Extent That Supervision In Routine Practise Departs From That

In RCTs It Is Less Likely To Be Evidence Based

‘This Is Complex’

Complexity Is Largely A ‘Fuzzy’

There is no evidence that it is not possible to interweave protocols for different disorders e.g Falsetti (2005) the treatment of panic attacks and PTSD

Scott (2009) has given detailed examples of the interweaving of protocols

There is no evidence that you have to treat one disorder e.g alcohol abuse before treating a co-existing disorder e.g PTSD, Gulliver (2010)

The Competence Engine

Generic competence

Diagnosis Specific

Competence

Stage Specific Competence

Diagnosis Specific Competences

E.g Treatment fidelity in depression

Adherence: How thoroughly were specific treatment targets and techniques addressed in the session?

Competence:How skillfully was the target addressed using the particular techniques? Rate 1-7 where no competence 1 and 7 total competence

1 2 3 4 5 6 7Not done Extensively discussed

Treatment target Technique Score

Inactivity Developing wide-ranging modest investments

Generic Competence

Can use one questionCompetence is globally rated for each session with a single rating on a 7-point scale

1 2 3 4 5 6 7Clearly Fair Good ExcellentInadequate

A therapist is rated as excellent if she or he has warm, supportive, collaborative, Socratic Style and was able to articulate the concepts clearly, making them personally relevant to the client in the setting and review of homework.

Adapted from Huppert et al (2001)

Generic Competence and the CTRS-R

• It has only been found to relate to outcome in CBT for depression (Shaw et al 1999) and the effect was modest, accounting for 19% of variance in outcome on a clinician administered measure and no relation with self-report outcome measures

• Aspects most associated with outcome were setting of agenda, assigning relevant homework and pacing the session. Guided discovery did not predict outcome

• The CTRS-R is arguably a ‘silver standard’ and not a ‘gold-standard’

First Video Clip of Supervision Session re: Mark

References On Reduction of SUDS• Bluett et al (2014) Does change in distress matter?

Mechanisms of change in prolonged exposure for PTSD. Behavior Therapy and Experimental Psychiatry,

• Meuret at al (2012) Does fear reactivity during exposure predict panic symptom reduction? Journal of Consulting and Clinical Psychology,

Second Video Clip of Supervision Session Re: Mark

Reliable Initial Evaluation – a stage specific competence

• Screen for a wide range of disorders

• Enquire about each symptom of a DSM criteria, endorse a symptom as present only if it produces significant impairment e.g a person may report nightmares of a trauma but if currently it does not cause them to wake up, then wouldn’t endorse symptom as present now. See Scott (2008) Simply Effective Cognitive Behaviour Therapy Routledge: London

• Expect that there will usually be more than one disorder present and to be targetted

Depression Group Life Role Play• Use Depression Fidelity Scale to assess Therapist

Competence

• Also Use One Item Measure of Generic competence

• Could also have used CTRS-R

• There is a Group CBT Cognitive Therapy Rating Scale in Simply Effective Group Cognitive Behaviour Therapy (2009) Scott, as well as self-help manuals for depression and each of the anxiety disorders (these are available as free download from www.michaljscottptsd.com)

Guided Self Help - Fidelity Checklist for Depression

Did the therapist focus on this and were applicable its’ implementation?

Yes (3), Yes, but insufficiently (2), No (1)

1. Assess - using CBT Pocketbook, (beginning and end of contact)  

2. Psychoeducation – Section 1 How depression develops and keeps going  

3. Section 2 No investments, no return  

4. Section 3 On second thoughts  

5. Section 4 Just make a start  

6. Section 5 Expectation versus experience and recalling the positive  

7. Section 6 Negative spin or how to make yourself depressed without really trying  

GSH Fidelity Scale for Depression contd.8. Section 7 An attitude problem  

9. Section 8 My attitude to self, others and the future  

10. Section 9 Be critical of your reflex first thoughts not how you feel  

11. Section 10 Preventing Relapse  

12. Collaboratively plan homework  

13. Seek feedback on session  

14. Clarify if there are further questions  

15. Agree next appointment  

16. Review homework  

The Supervisory Context and Organisational Mandates – some examples

• Low intensity IAPT

• Pain Management

• Eating Disorders Unit

The CBT Therapist As Engineer May Challenge Received Wisdom

• For example prolonged exposure for PTSD is an advocated EBT but few CBT therapists use it – Scott and Stradling (1997) found that only 57% of clients in routine practise complied with listening to a trauma tape. Therapists will not swallow wholesale the findings of EBT’s.

• The Engineer is concerned at the sabotage of EBT by a) the use of surrogate outcome measures e.g self report measures used in IAPT studies and b) poorly specified populations e.g no semi-structured standardised interview to determine what the client is suffering from in IAPT studies

• The Engineer is alarmed when a study of low intensity IAPT is described as ‘haemorrhaging clients’ Richards and Borglin (2011)

Scientist Practitioner Model Defunct?

CBT therapists are not an homogenous group, they consist of academic clinicians, involved in rct’s and Engineers delivering a service in routine practice. For effective dissemination and implementation communication must be bottom up as well as top down

Engineers also likely to use a ’friends and family test’ would you recommend this treatment delivered by these practitioners to a friend or family member

Engineers operate in a scientific paradigm, testing out the viability of interventions in different contexts

Supervision Is Mandatory

Does Supervision in IAPT, or indeed in CBT generally, make any difference to client outcome?

The Facts Of The Matter

1. Bambling et al (2006) compared supervision v’s no supervision in problem solving therapy for depression:

• The clients of therapists undergoing supervision did significantly better.

• Dropout rates were 35% in those not supervised and 4.5% in those supervised.

The Facts Of The Matter contd.

2. Bradshaw et al (2007) compared the effects of a 2 day course for supervisors, to enable supervisee nurses delivering a family and CBT intervention to the care givers of patients with schizophrenia, with the same intervention delivered by nurses without any supervision.

Those patients indirectly linked to supervision showed greater reduction in total psychotic symptoms.

The Facts Of The Matter contd. yet further

3. White and Winstanley (2010) trained supervisors via a 4 day course, and supervised nurses over the course of a year; the results were compared with patient outcomes where there was no supervision provided.

The result was no difference in outcome.

Opinion• Not a lot to go on

• Just 2 studies involving CBT- questionable whether representative of normal supervision with supervisees with diverse clients

• No study of the effectiveness of supervision for guided-self-help (GSH)

Is supervision evidence-based?

An evidence based intervention presumes the attainment of some target, what is the target in supervision?

Code Quality of Evidence Definition

A High

Further research is very unlikely to change our confidence in the estimate of effect.

•Several high-quality studies with consistent results•In special cases: one large, high-quality multi-centre trial

B Moderate

Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.•One high-quality study•Several studies with some limitations

C Low

Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.•One or more studies with severe limitations

D Very Low

Any estimate of effect is very uncertain.

•Expert opinion•No direct research evidence•One or more studies with very severe limitations

Grading of Recommendations Assessment, Development and Evaluation (GRADE)

‘Individually tailored ICBT is an effective and cost-effective treatment for primary-care patients with anxiety disorders with or without comorbidities’ Nordgren et al (2014), 59, 1-11.

• ‘we did not administer the SCID – interview at post-treatment or at follow up, giving us no possibility to answer questions regarding remission or recovery from the initial diagnoses’

• ‘we rely on self-report measures’

• The SCID was used initially to diagnose patients and to determine which protocol was used

‘All you need is a hot cross bun, a PHQ9 and a GAD7’

‘ Evaluating Research Is Too

Complex/Time Consuming Just Help

Supervisee Make A Good

Formulation’

Cognitive Model

Cognitions Emotion

BehaviourPhysiology

‘How Reliable Is This Way of Proceeding?’ As a Supervisor Would

You Be Happy With This?