Simply Effective CBT Supervision For Low and High - PowerPoint Presentation

Slide1

Simply Effective CBT Supervision For Low and High Intensity IAPT

Dr

Michael J Scott

Wednesday, September 10

th

2014

For this presentation and notes e-mail me,

michaeljscott1@virginmedia.com

, if I have not replied in 48hrs send an appropriate reminder!Slide2

Resources1. Simply Effective Cognitive Behaviour Therapy Supervision (2014) London: Routledge Michael J Scott

2. Collaborative Case Conceptualization (2009) New York: Guilford Press Willem

K

uyken

, Christine A.

Padesky

and Robert DudleySlide3

Learning ObjectivesTo distil a viable model of supervision in which supervision is seen as a crucible for reflective thinking which reciprocally interacts with knowledge and skillsTo 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 Slide4

‘I’m stuck with……….’This is a reflection on a difficulty with a client that the supervisee feels they are unable to resolveThe supervisor determines whether there is a gap in the supervisees knowledge and/or skill in the matterCollaboratively supervisor and supervisee determine how these gaps may be closed Slide5

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?Slide6

Important Dimensions of The Supervisory Relationship – in the last session did my supervisor (or me) provideSafe 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 constructiveSlide7

Role Play Supervision re: Mark Slide8

Commonalities In Supervision Across Treatment ModalitiesIdentifying gaps in knowledgeIdentifying gaps in skillsBridging the gaps

Maintaining a good supervisory relationship

Balancing didactic and experiential learningSlide9

What Is Specific About Supervision In IAPT?Slide10

Defining The Primary Function of SupervisionSlide11

The Supervisor As A Conduit for EBT’sSlide12

A Top Down Account of Evidence-Based ProvisionSlide13

Question TimeHow 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?Slide14

The Consequences of Not Appreciating The Strength of EvidenceManager pressurising CBT therapist to provide a group for all comersInappropriate 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 interventionSlide15

The Supervisor As ForemanHow 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?Slide16

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 Slide17

To The Extent That Supervision In Routine Practise Departs From That In RCTs It Is Less Likely To Be Evidence BasedSlide18

‘This Is Complex’Slide19

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)Slide20
Slide21
Slide22
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The Competence EngineSlide24
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Diagnosis Specific CompetencesE.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

2 3 4 5 6 7

Not

done Extensively

discussed

Treatment target

Technique

Score

Inactivity

Developing

wide-ranging modest investmentsSlide26

Generic CompetenceCan use one question

Competence is globally rated for each session with a single rating on a 7-point scale

1 2 3 4 5 6 7

Clearly Fair Good Excellent

Inadequate

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)Slide27

Generic Competence and the CTRS-RIt 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 measuresAspects 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’Slide28

First Video Clip of Supervision Session re: Mark Slide29

References On Reduction of SUDSBluett 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,Slide30

Second Video Clip of Supervision Session Re: Mark Slide31

Reliable Initial Evaluation – a stage specific competenceScreen for a wide range of disordersEnquire 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

targettedSlide32

Depression Group Life Role PlayUse Depression Fidelity Scale to assess Therapist CompetenceAlso Use One Item Measure of Generic competenceCould 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)Slide33

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

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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

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The Supervisory Context and Organisational Mandates – some examples

Low intensity IAPT

Pain Management

Eating

D

isorders UnitSlide36

The CBT Therapist As Engineer May Challenge Received WisdomFor 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

)Slide37

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 contextsSlide38
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Supervision Is MandatorySlide40

Does Supervision in IAPT, or indeed in CBT generally, make any difference to client outcome?Slide41

The Facts Of The MatterBambling 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.Slide42

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.Slide43

The Facts Of The Matter contd. yet further3. 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.Slide44

OpinionNot a lot to go onJust 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?Slide45

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)Slide46

‘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 usedSlide47

‘All you need is a hot cross bun, a PHQ9 and a GAD7’Slide48

‘ Evaluating Research Is Too Complex/Time Consuming Just Help Supervisee Make A Good Formulation’Slide49

Cognitive ModelSlide50

‘How Reliable Is This Way of Proceeding?’ As a Supervisor Would You Be Happy With This?