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, [email protected], 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) Supervisor Supervisee Supervisee Supervisee A Top Down Account of Evidence-Based Provision Academic Clinicians Randomised Controlled Trials Scientist Practitioner Model CBT Training Courses Managers Supervisors Clinician Providers of CBT Clients 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 Stage Specific Competence Diagnosis Specific Competence Generic competence Diagnosis Specific Competences E.g Treatment fidelity in depression Adherence: How thoroughly were specific treatment targets and techniques addressed in the session? 1 2 Not done 3 4 5 6 7 Extensively discussed Treatment target Technique Inactivity Developing wide-ranging modest investments Score Competence: How skillfully was the target addressed using the particular techniques? Rate 1-7 where no competence 1 and 7 total competence Generic Competence Can use one question Competence is globally rated for each session with a single rating on a 7-point scale 1 2 Clearly Inadequate 3 Fair 4 5 Good 6 7 Excellent 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? Grading of Recommendations Assessment, Development and Evaluation (GRADE) Code Quality of Evidence Definition Further research is very unlikely to change our confidence in the estimate of effect. A B C High Moderate Low •Several high-quality studies with consistent results •In special cases: one large, high-quality multi-centre trial 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 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 Any estimate of effect is very uncertain. D Very Low •Expert opinion •No direct research evidence •One or more studies with very severe limitations ‘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 Physiology Behaviour ‘How Reliable Is This Way of Proceeding?’ As a Supervisor Would You Be Happy With This?