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Experiencing CBT from the Inside Out: Is Self-Practice Important for CBT Therapists?

JBL photo 2014James Bennett-Levy, Ph.D., University of Sydney, Australia

Guest Author

“Your growth as a cognitive therapist will be enhanced if you start applying the tools described in this book to yourself.”  J. Beck (1995)

 So wrote Judith Beck in the 1995 edition of Cognitive Therapy: Basics and Beyond. Seven years earlier, I had done a 6-month training in CBT at the Institute of Psychiatry, London. Soon after commencing, I was struck by the potential relevance of CBT not only to patients but to my own life. So I said to a fellow trainee: “Why don’t we try CBT out on ourselves?” The experience was eye-opening and turned out to be the genesis of the self-experiential training strategy known as self-practice/self-reflection (SP/SR). I piloted SP/SR as a training strategy for the first time in 1998, fortified by Judith Beck’s and Christine Padesky’s assertions of the importance of practicing CBT techniques on oneself. Now, after 17 years of SP/SR research, we have published the first SP/SR manual, Experiencing CBT from the Inside Out: A Self-Practice/Self-Reflection Workbook for Therapists (Bennett-Levy, Thwaites, Haarhoff & Perry, 2015).

We have learned many things along the way. Researchers in England, Australia, New Zealand, Ireland, Austria and Germany have demonstrated that SP/SR makes a unique contribution to therapist skill development, whether therapists are novices or experienced. A constant refrain from SP/SR participants is that using SP/SR to stand in the patient’s shoes has increased their empathy and understanding and led to a more nuanced approach to therapy. For instance, one experienced therapist reflected: “I feel I have taken away so many important things, but having experienced therapy has deepened my understanding of the importance of a good therapeutic alliance, collaboration, interest, trust, acceptance, compassion…

Another key finding has been that therapists report that their reflective capacity is enhanced by SP/SR. The 1980s work of Donald Schon (The Reflective Practitioner, 1983) and David Kolb (Experiential Learning, 1984) highlighted the key role that reflection plays in adult learning.  SP/SR therapists report becoming more reflective through the process. Consequently, their CBT understanding and skills improve, and they are better able to integrate conceptual, technical and interpersonal aspects of the therapy. More recently, we are also starting to see reports that SP/SR may also increase therapist resilience and decrease propensity for burnout. For a comprehensive SP/SR bibliography, click here).

So what is SP/SR?

Typically, SP/SR comes in a manualized form, with 6-12 modules. Participants work through the modules week-by-week. Each module may take about 2 hours. Participants select a particular problem they wish to work on during an SP/SR program. For novice therapists, we recommend that the problem is a ‘therapist problem’ – typically, this might be ‘to stop criticizing myself and undermining my confidence as a CBT therapist’. For more experienced therapists, we suggest they take either a therapist problem (e.g. ‘my difficulty working with assertive patients’) or a personal problem (e.g. ‘my social anxiety when it comes to public speaking’).

Underpinning the self-practice (SP) element of Experiencing CBT from the Inside Out is a strengths-based, behavioral/experiential approach, designed to reflect contemporary understandings of change processes in CBT. In the first part of the workbook, participants formulate and deepen their understanding of their Old (Unhelpful) Ways of Being. In the second half of the workbook, they create and strengthen their New Ways of Being drawing on experiential strategies such behavioural experiments, imagery and body-oriented interventions and narrative strategies. To amplify the old/new contrast, we have introduced a modified method of formulation, the Old Ways of Being/New Ways of Being Disk model, a transdiagnostic schema-based method of contrasting ‘how I am now’ with ‘how I’d like to be’ for anyone, regardless of their problem.

However, the self-practice (SP) aspect of the SP/SR experience is only half the story. The other equally potent half is the self-reflection (SR). SP/SR modules finish with a series of self-reflective questions, typically something like: What was your experience of using imagery to construct New Ways of Being? How do you understand this experience? What are the implications of your experience for your work with patients? How does your experience affect your understanding of cognitive theory? These reflective questions move the SP/SR participant from personal experience to professional implications. SP/SR is therefore designed as a targeted, focused training strategy, which – in contrast to personal therapy which usually just focuses on the personal – makes an explicit link between the personal and the professional.

We have offered SP/SR to groups of participants ranging from interns and assistant psychologists through to experienced supervisors. Invariably, the experience of those who engage with the program is one of astonishment – new insights, a different experience “from the inside out.” SP/SR works best in groups where participants share their reflections in group forums such as internet message boards. At the start of the program, the group decides how this is done, how frequently, etc. We have learnt that facilitating an SP/SR program requires a different skillset to ‘usual training skills’. So in our new book, we have devoted specific chapters to providing guidelines for both SP/SR facilitators and participants. A key element in fostering engagement with the SP/SR process is ensuring that SP/SR participants feel safe with the process that involves sharing self-reflections. While SP/SR can be done individually or in groups, our recommendation, if you can, is to get together a small group of colleagues – or students in a university program. Then take 2 weeks for each module, sharing the written reflections.

So is experiencing CBT from the inside out important for contemporary CBT therapists? Absolutely! The benefit of SP/SR is that it cuts both ways: it’s a stimulating, challenging way to help our patients by developing our CBT skills – and to make changes for ourselves.

A Group Cognitive Behavioral Intervention for People in Supported Employment Programs: CBT-SE

New Study (1)

 Abstract
INTRODUCTION:
Supported employment programs are highly effective in helping people with severe mental illness obtain competitive jobs quickly. However, job tenure is often a problem for many. Of the various obstacles to job tenure documented, dysfunctional beliefs regarding the workplace and one’s own abilities has been proposed as a therapeutic target.

OBJECTIVES:
The purpose of this article is threefold: (1) to describe the development and the content of a novel group cognitive behavioral intervention designed to increase job tenure for people receiving supported employment services; (2) to present the feasibility and acceptability of the intervention; and (3) to investigate some preliminary data regarding employment outcomes. A group CBT intervention offered during 8 sessions over the course of one month, in order to respect the rapid job search principle of IPS (individual placement and support), was developed. The content was tailored to facilitate the learning of skills specific to the workplace, such as recognizing and managing one’s stressors at work, determining and modifying dysfunctional thoughts (e.g. not jumping to conclusions, finding alternatives, seeking facts), overcoming obstacles (e.g. problem solving), improving one’s self-esteem as a worker (recognizing strengths and qualities), dealing with criticism, using positive assertiveness, finding coping strategies (for symptoms and stress) to use at work, negotiating work accommodations and overcoming stigma. A trial is currently underway, with half the participants receiving supported employment as well as CBT-SE and the other half receiving only supported employment.

METHODS:
A subsample of the first 24 participants having completed the 12-month follow-up were used for the analyses, including 12 having received at least 3 sessions out of the 8 group sessions and 12 receiving only supported employment. Feasibility and acceptability were determined by the group therapists’ feedback, the participants’ feedback as well as attendance to group sessions. The work outcomes looked at with the preliminary sample only included the 12-month follow-up and involved: obtaining a competitive job, number of hours worked per week as well as number of weeks worked at the same job (>24hours).

RESULTS:
In terms of feasibility and acceptability, therapists and participants all mentioned appreciating the group, finding it useful and helpful, some even mentioning feeling grateful to have had the opportunity to receive the intervention. The only negative feedback received pertained to the frequency of the meetings, which could be brought down to one meeting per week of two hours instead of two one-hour sessions per week. Participation was very good, with the average number of sessions attended being of 6/8. In terms of work outcomes, 50 % of all participants in both conditions found competitive work. Out of those working competitively, the number of participants working more than 24hours per week at the 12-month follow-up was higher in the CBT-SE group compared to the control condition (75 % vs. 50 %). Similarly, there was a trend towards the number of consecutive weeks worked at the same job being slightly superior at the 12-month follow-up for those who had received the CBT-SE intervention (22.5 weeks vs. 18.3 weeks).

DISCUSSION:
The preliminary results support previous studies where on average 50 % of people registered in supported employment programs obtain competitive work. We confirmed that the intervention was feasible and acceptable. Preliminary data suggest that the CBT-SE intervention might help people with severe mental illness use skills and gain the needed confidence enabling them to work longer hours and consecutive weeks. These results should be considered with caution given that only 24 participants were looked at whereas the final sample size will be of 160 participants. Nonetheless, these preliminary results are promising. Furthermore, additional information regarding the impact of the CBT-SE intervention on the capacity to overcome obstacles at work, self-esteem as a worker, as well as other work-related variables have been collected but have not been investigated here. Once the study is completed, the results should enlighten us regarding the usefulness of offering CBT-SE not only in terms of work outcomes but also in improving various psychosocial domains linked to workplace satisfaction.

Lecomte, T., Corbiere, M., & Lysaker, P.H. (2014). A group cognitive behavioral intervention for people in supported employment programs: CBT-SE. Encephale. 40, 81-90. doi: 10.106/j.encep.2014.04.005.

Therapeutic Alliance in Face-to- Face and Telephone-Administered Cognitive Behavioral Therapy

New Study (1)

Abstract
OBJECTIVE:
Telephone-administered therapies have emerged as an alternative method of delivery for the treatment of depression, yet concerns persist that the use of the telephone may have a deleterious effect on therapeutic alliance. The purpose of this study was to compare therapeutic alliance in clients receiving cognitive behavioral therapy (CBT) for depression by telephone (T-CBT) or face-to-face (FtF-CBT).

METHOD:
We randomized 325 participants to receive 18 sessions of T-CBT or FtF-CBT. The Working Alliance Inventory (WAI) was administered at Weeks 4 and 14. Depression was measured during treatment and over 1 year posttreatment follow-up using the Hamilton Rating Scale for Depression and Patient Health Questionnaire-9.

RESULTS:
There were no significant differences in client or therapist WAI between T-CBT or FtF-CBT (Cohen’s f² ranged from 0 to .013, all ps > .05). All WAI scores predicted depression end of treatment outcomes (Cohen’s f² ranged from .009 to .06, all ps < .02). The relationship between the WAI and depression outcomes did not vary by treatment group (Cohen’s f² ranged from 0 to .004, ps > .07). The WAI did not significantly predict depression during posttreatment follow-up (all ps > .12).

CONCLUSIONS:
Results from this analysis do not support the hypothesis that the use of the telephone to provide CBT reduces therapeutic alliance relative to FtF-CBT.

Stiles-Shields, C., Kwasny, M.J., Cai, X., & Mohr, D.C. (2014). Therapeutic alliance in face-to-face and telephone-administered cognitive behavioral therapy. Journal of Consulting and Clinical Psychology, 82(2), 349-354. doi: 10.1037/a0035554.

Workshop Participant Spotlight – Kimberly Grocher

Kimberly Grocher, LCSW traveled from NYC to attend 3 days of experiential training in CBT for Personality Disorders and Challenging Problems. She works at Weill Cornell Medical College in a group psychiatry practice where she treats clients of all ages,DSC_0254 specializing in treating adult women with anxiety and PTSD, couples, and professionals.

As a “movement oriented therapist”, CBT resonates with her personal beliefs that feelings and goals start with thoughts.

She decided to attend training at Beck Institute because, “they are the best; this is the home of CBT. Where else to learn than from the source?”

The opportunity to meet Dr. Aaron Beck and collaborate with people from around the world were her favorite parts of the training. “This has just been amazing”

Kimberly also would like to acknowledge Weill Cornell Psychiatric Specialty Center, the Training Institute for Mental Health, and Fordham University (where she will be starting her PhD in the fall).

2015 Annual Graduate Student Workshop

CBT for Depression and Suicidality
Student Workshop Collage

Our Student CBT Workshop, held in Philadelphia, August 3-5, 2015 for the sixth consecutive year, received 140 participants from twenty six states including the District of Columbia and Puerto Rico, and an amazing fifteen countries including Australia, Brazil, China, Hong Kong, Ireland, Japan, the Netherlands, Norway, Pakistan, the Philippines, Saudi Arabia, Thailand and the United Kingdom.

Thank you to everyone who made our Student Workshop such an overwhelming success!

“The examples of current clients, paired with the “on-the-spot” role play scenarios really gave tangible, concrete applications of techniques reflected by passionate providers.”

– Graduate Student Workshop Attendee

Tweet of the Week:

Student Recap Tweet

Cognitive Versus Exposure Therapy for Problem Gambling: Randomised Controlled Trial.

 New Study (1)Abstract

BACKGROUND:

Problem gambling-specific cognitive therapy (CT) and behavioural (exposure-based) therapy (ET) are two core cognitive-behavioural techniques to treating the disorder, but no studies have directly compared them using a randomised trial.

AIMS:

To evaluate differential efficacy of CT and ET for adult problem gamblers at a South Australian gambling therapy service.

METHODS:

Two-group randomised, parallel design. Primary outcome was rated by participants using the Victorian Gambling Screen (VGS) at baseline, treatment-end, 1, 3, and 6 month follow-up.

FINDINGS:

Of eighty-seven participants who were randomised and started intervention (CT = 44; ET = 43), 51 (59%) completed intervention (CT = 30; ET = 21). Both groups experienced comparable reductions (improvement) in VGS scores at 12 weeks (mean difference -0.18, 95% CI: -4.48-4.11) and 6 month follow-up (mean difference 1.47, 95% CI: -4.46-7.39).

CONCLUSIONS:

Cognitive and exposure therapies are both viable and effective treatments for problem gambling. Large-scale trials are needed to compare them individually and combined to enhance retention rates and reduce drop-out.

Smith, D. P., Battersby, M.W., Harvey, P.W., Pols, R.G., & Ladouceur, R. (2015). Cognitive versus exposure therapy for problem gambling: Randomised controlled trial. Behavior Research and Therapy, 69, 100-110. doi: 10.1016/j.brat.2015.04.008

Cognitive Therapy for Patients with Schizophrenia

New Study (1)Abstract

Background Antipsychotic drugs are usually the first line of treatment for schizophrenia; however, many patients refuse or discontinue their pharmacological treatment. We aimed to establish whether cognitive therapy was effective in reducing psychiatric symptoms in people with schizophrenia spectrum disorders who had chosen not to take antipsychotic drugs.

Methods We did a single-blind randomised controlled trial at two UK centres between Feb 15, 2010, and May 30, 2013. Participants aged 16–65 years with schizophrenia spectrum disorders, who had chosen not to take antipsychotic drugs for psychosis, were randomly assigned (1:1), by a computerised system with permuted block sizes of four or six, to receive cognitive therapy plus treatment as usual, or treatment as usual alone. Randomisation was stratified by study site. Outcome assessors were masked to group allocation. Our primary outcome was total score on the positive and negative syndrome scale (PANSS), which we assessed at baseline, and at months 3, 6, 9, 12, 15, and 18. Analysis was by intention to treat, with an ANCOVA model adjusted for site, age, sex, and baseline symptoms. This study is registered as an International Standard Randomised Controlled Trial, number 29607432.

Findings 74 individuals were randomly assigned to receive either cognitive therapy plus treatment as usual (n=37), or treatment as usual alone (n=37). Mean PANSS total scores were consistently lower in the cognitive therapy group than in the treatment as usual group, with an estimated between-group effect size of ?6·52 (95% CI ?10·79 to ?2·25; p=0·003). We recorded eight serious adverse events: two in patients in the cognitive therapy group (one attempted overdose and one patient presenting risk to others, both after therapy), and six in those in the treatment as usual group (two deaths, both of which were deemed unrelated to trial participation or mental health; three compulsory admissions to hospital for treatment under the mental health act; and one attempted overdose).

Interpretation Cognitive therapy significantly reduced psychiatric symptoms and seems to be a safe and acceptable alternative for people with schizophrenia spectrum disorders who have chosen not to take antipsychotic drugs. Evidence-based treatments should be available to these individuals. A larger, definitive trial is needed.

Bera, S.C., & Sarkar, Siddharth (2014). Cognitive therapy for patients with schizophrenia. The Lancet. 384 (9941), 401. DOI: http://dx.doi.org/10.1016/S0140-6736(14)61274-5

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