What's the best way to learn CBT?
With so many opportunities available for professional development, have you ever considered the evidence based for training? Can you expect the time you spend on professional development activities to translate into improvements in your competence and improvements in your clients’ outcomes? In this week’s study, Henrich and colleagues (2023) undertake an updated systematic review of evaluations of the effectiveness of CBT training, half of which were not included in previous reviews.
The review uncovered 51 studies: k = 11 evaluated self-guided web-based training (WBT), k = 7 evaluated “live” instructor-led workshops or seminars (ILT), k = 22 evaluated additional supervision (taking place outside or after workshops) (AS), k = 4 involved just reading a manual; and for k = 7 the components could not be separated so these were treated as multi-component interventions (MCT). Studies were classified into 3 levels of quality with Type 1 involving random assignment, blinded assessments, clear inclusion and exclusion criteria, best available diagnostic measures, adequate sample size and clearly described statistics, Type 3 using low quality designs or very small samples, and Type 2 similar to Type 1 but missing at least one element of good design.
Web-Based Training: Most studies measured competence “standardised client” role plays. Most of these studies found small increases in competence from baseline to post-training. Compared to no-training control, two studies found higher competence for the WBT groups. However, a study that measured competence using ratings of real sessions with real clients found no difference between WBT and no training. WBT alone did not appear to be any more effective in increasing competence than reading a manual or taking part in a 2-day workshop. Adding a supervision phase after workshops led to significant increases in therapist competence over WBT in 2 studies. Similarly, adding “applied training” involving (4 x 60-min) role play sessions where an expert therapist provides corrective feedback, significantly increased therapist competence beyond WBT. Only 3 of the 11 WBT studies were considered high quality, with most suffering from unvalidated competence measures, unblinded assessment, missing data at follow-up and no evaluation of effect on clients.
Instructor-Led Training: ILT was characterised by increased emphasis on active learning; role-play or self-experiential exercises in workshop with feedback. All 7 ILT studies demonstrated within-condition increases in therapist competence and two demonstrated improvements in client outcomes. One comparison with a very simple WBT found ILT superior in increasing competence, whereas another involving a comprehensive DBT WBT found them similarly effective. In a study of ILT for clinicians in providing contingency management to people with opioid use disorders, there was a strong correlation between number of training hours attended and client outcomes over the following 3 months. Unfortunately, only one study was high quality and all studies suffered from small sample sizes.
Additional Supervision: AS conditions typically involved an ILT workshop and manual as well as supervision, which ranged in frequency from 3 x monthly x 30-min sessions to 6 years of weekly group supervision. 15 studies used group supervision and only 4 used individual supervision alone. All but 2 studies measured therapist competence by rating real sessions with real clients and 7 studies included measures of client outcome. All studies consistently showed increases in therapist competence and those investigating client outcomes found superior results for training incorporating supervision compared to training that didn’t. Exactly what supervision should consist of is less clear. In a study of CPT supervision, there was a correlation between discussion of CPT strategies in supervision and decreases in client PTSD symptoms. One low quality study found no difference between expert-led training and supervision and WBT plus peer supervision. Another study found that adding an individual session including feedback on a whole supervision did not increase competence beyond a weekly 2-hour group supervision including mandatory review of brief audio clips from sessions. Similarly, in another study of CPT supervision, supervision involving reviewing audio recordings of sessions was no more effective than a no-supervision control in improving client outcomes, whereas supervision not involving audio review achieved better client outcomes. Interestingly, in a high-quality study, the role of supervision in maintaining competence was supported: substance use disorder counsellors were randomly assigned to either: 1) treatment manual only; 2) in-person 3-day ILT + biweekly 90-min group supervision or 3) same as group 2 but received via web- and telephone conferencing. During the 12 weeks where supervision was actively provided, the competence of those who received in-person supervision increased, the competence of those who received remote supervision stagnated and the competence of the manual-only group declined. Three months after supervision was ended, the competence of all groups declined, to a similar extent. Although there is a greater weight of studies supporting supervision, only 3 were high quality with the main quality issue being the supervisor also rated therapist competence.
Multicomponent Studies: These were all Type 3 studies, four of which involved university students. The majority of participants reached pre-defined levels of competence. Two studies showed improved client outcome rates following training, one for residential eating programs and another in CPT for PTSD.
Predictors: The authors also reviewed a number of predictors of the degree of competence increase achieved through training. I am reluctant to reproduce most of these here as they were either based on a single study or were inconsistent among a small number of studies. Logically, those with lower competence at the start of training have the most capacity to demonstrate increases, and those with higher competence at the start of training tend to have higher competence at the end of it, which the current data supports. Experience in the area being trained (rather than amount of unrelated experience) also seems associated with competence at the end of training, which again is logical. Two studies of postgraduate training found that clinical psychologists tended to achieve higher CBT competence levels at the end of training than other professions, which would be consistent with greater exposure to related content prior to beginning training.
There is certainly room for a great deal more higher quality research in this area. Nevertheless, there is little doubt that supervision can facilitate greater improvement in therapist competence and client outcomes beyond that which can be achieved through workshops or reading manuals.
Workshops retain a vital role in introducing therapists to up-to-date information and overviewing well-developed systems of intervention. It would be a mistake to think that attending a workshop will significantly increase one’s competence. If the workshop is on a topic with which the therapist is already experienced and relatively competent, perhaps it is reasonable to expect some subtle recalibration or helpful “tips” that contribute to maintaining competence. However, therapists should approach workshops on an unfamiliar area with a view to deciding whether the approach presented is worth them investing the time and effort to learn properly. Learning an approach properly means committing at least some period of time to supervised practice in it. It’s impossible to manualise how to respond to every variation in client response to treatment delivery. Supervisors are likely to have seen most common problematic responses to treatment before and can help you not dilute the treatment too much in your efforts to adapt your delivery. More basically, I have found that many of us, myself included, often slightly (or largely) misunderstand material delivered in workshops, or miss an important instruction during a critical lapse of attention over a three-hour period, or our workshop instructor makes a slip-of-the-tongue that inadvertently confuses the audience. Supervision can help clarify and guard against these communication breakdowns negatively impacting our clients. Finally, you only have to look at the difference between the confident head-nodding that goes on in the audience and the wide-eyed fear and pale complexions that accompany the role-play segments of workshops to appreciate the difference between recognition-level understanding and performance-level competence. With your precious time and money, consider your professional development needs carefully and invest in the area you expect to provide the biggest payoff for the people you work most with.
Clinician Implications
On average, in-person workshops, reading treatment manuals and web-based self-directed learning are all about equally effective in contributing modest increases in therapist competence.
There is a far greater weight of evidence, that supervision produces more substantial improvements in therapist competence, which also lead to improvements in client outcomes
Use workshops to decide where to invest the majority of your professional development activity. Try to identify a client group and/or approach that would make the greatest improvement to the greatest number of people you typically work with and seek out a supervisor in that field.
The parameters of most effective supervision are not precisely specified yet but generally they involve active learning beyond just talking about cases. Sessions that involve reviews of recordings of real sessions with feedback, role play or active exercises in formulation or deliberate skill practice, or work on therapists’ therapy-interfering beliefs are likely to make a far bigger difference to your competence than didactic teaching or long case presentations.
For the original article, go to: https://www.sciencedirect.com/science/article/pii/S0272735823000247?via%3Dihub
REFERENCES
Henrich, D., Glombiewski, J. A., & Scholten, S. (2023). Systematic review of training in cognitive-behavioral therapy: Summarizing effects, costs and techniques. Clinical Psychology Review, 101, 102266–102266. https://doi.org/10.1016/j.cpr.2023.102266