CBTF
undament
al
s
:
Pr
oc
es
s
esandT
ec
hni
quesi
n
Cog
niv
eBeha
v
i
ourT
her
a
py
De
v
el
opedby
:
Modul
e10:Rel
a
ps
ePr
e
v
en ona
nd
As
s
es
s
i
ngT
her
a
pi
s
tCa
pa
bi
l
ies
CBT Fundamentals | Module 10: Relapse Prevention and Assessing Therapist Capabilities
CONTENTS
Contents................................................................................................................................................. 2 Learning Outcomes for Module 10......................................................................................................... 3 10.1 Introduction .................................................................................................................................... 3 10.2 Tapering Sessions ......................................................................................................................... 4 10.3 Self-Therapy Sessions ................................................................................................................... 5 10.4 Relapse Prevention Techniques .................................................................................................... 6 10.4.1 Reframe “Getting Worse” ........................................................................................................ 6 10.4.2 Self Monitoring ........................................................................................................................ 6 10.4.3 Wellbeing Plan ........................................................................................................................ 7 10.5 Assessing Therapist Capabilities ................................................................................................... 8 10.5.1 Sticking to the Model ............................................................................................................... 9 10.6 Developing and Refining Capabilities .......................................................................................... 10 10.6.1 Therapist Capabilities Assessed with the CTRS ................................................................... 10 Part 1: General Therapeutic Skills ................................................................................................ 10 Part 2: Conceptualisation, Strategy, and Technique .................................................................... 11 10.7 Awareness of In-Session Therapist Reactions ............................................................................ 11 10.8 Working in an Environment with Limited Resources.................................................................... 13 Module 10 Summary ............................................................................................................................ 14 Module 10 Assessment........................................................................................................................ 15 © 2011 The Australian Psychological Society Ltd
www.elearning.psychology.org.au
Page 2 of 15
CBT Fundamentals | Module 10: Relapse Prevention and Assessing Therapist Capabilities
LEARNING OUTCOMES FOR MODULE 10
In this final module, we look at two aspects of the therapeutic process in general – how to conclude a
course of therapy with a client, and how therapists can assess and develop their own capabilities –
and how these general aspects work in CBT specifically. By the end of this module, you should be
able to:
1. Demonstrate an understanding of the role of various processes and strategies in relapse
prevention within CBT, and
2. Demonstrate an understanding of the capabilities required for CBT practice.
There are several readings and websites listed that should prove to be useful ongoing resources, as
well as the chance to discuss with your colleagues in the online forums the challenges and obstacles
you face in your own practice.
Please note: All case studies and examples in this course have been compiled using information
from multiple cases and in no way represent actual clients seen by the authors.
10.1 INTRODUCTION
This CBT Fundamentals course has been designed to provide a learning experience regarding the
fundamental processes and techniques in CBT. Starting with the general CBT model, we centered on
assessment issues and how to gather information to begin developing a collaborative CBT
formulation for the client. After discussing structural elements central to the process of the therapy, we
moved to the practical application of CBT by covering central behavioural and cognitive techniques,
which are broadly applied within CBT for a range of clinical disorders.
Throughout this course we have advocated for focusing on the client’s individual goals, rather than on
applying a “package of interventions” to treat specific disorders. This can be considered as reflective
of the central principles in CBT, but it is also practically how the approach is integrated into everyday
clinical practice.
It is beyond the scope of this course to provide a detailed process guide to the capabilities required
among therapists for the development, maintenance, and conclusion of professional relationships with
clients. In light of this, it is expected that practitioners consult more detailed resources on these
relationship issues (keeping in mind the present context of concluding therapy, also known as
“termination” processes).
© 2011 The Australian Psychological Society Ltd
www.elearning.psychology.org.au
Page 3 of 15
CBT Fundamentals | Module 10: Relapse Prevention and Assessing Therapist Capabilities
Further Readings 10.1
There are many sources for information and guidelines on how to conclude the CBT
relationship, and you are encouraged to look into additional material related to your
particular practice needs. The textbooks below are recommended as helpful starting
points. If you wish to investigate these optional readings further, you can log in to the
APS eLearning site (http://www.psychology.org.au/Members/LogIn.aspx) or visit the
sites directly for more information:
a. Norcross (ed): Psychotherapy Relationships That Work: Evidence-Based
Responsiveness [Second Edition]
http://www.oup.com.au/titles/academic/psychology/9780199737208
b. Koocher, Norcross and Hill (eds): Psychologists' Desk Reference [Second
Edition]
http://ebookee.org/Psychologists-Desk-Reference-Gerald-P-Koocher-John-CNorcross-Sam-S-Hill_330884.html
TIPS FOR DECIDING WHEN CBT COULD CONCLUDE
•
Your client has made significant progress towards their therapy goals – or actually attained
them – and symptoms are notably changed.
•
Your client no longer meets the diagnosis for their presenting Axis I disorder (in the DSM
system).
•
Your client has made progress with developing flexibility in the core beliefs and intermediate
beliefs that have been collaboratively identified as predisposing or perpetuating factors to
their initial presentation.
Note: Also see 10.8 below for comments on working within limited resources.
10.2 TAPERING SESSIONS
Both clients and therapists in CBT require an understanding that the overall goal is to facilitate
improved functioning through the client acquiring practical skills (behavioural and cognitive) that
maintain their new perspectives. In other words, the goal of the therapy is for the client to be their own
therapist.
The fact that the client is active in this process from the start of therapy begins to socialise them to the
idea that they are primarily responsible for their own progress through therapy. Similarly, the central
role of between-session therapeutic work underscores the importance of clients practicing and
refining therapeutic skills in the everyday situations where they experience their problems.
The process of tapering sessions (gradually reducing the number of sessions from weekly, to
fortnightly, to monthly for example) provides a useful opportunity for the client and therapist to
measure the sustained benefit of the therapeutic work, and also to explore the maintenance of
wellbeing without the therapist’s direct support. In the same way, it might be useful to have follow-up
(or “booster”) sessions to review the client’s progress at three month, six month, or sometimes yearly
intervals.
© 2011 The Australian Psychological Society Ltd
www.elearning.psychology.org.au
Page 4 of 15
CBT Fundamentals | Module 10: Relapse Prevention and Assessing Therapist Capabilities
Further Reading 10.2
Clinicians interested in reading more about prevention of common presenting
problems are encourage to look at the textbook linked below. It covers current
practices in prevention and presents empirical evidence for risk and vulnerability of
depression and anxiety sufferers respectively. If you wish to investigate this optional
reading further, you can log in to the APS eLearning site
(http://www.psychology.org.au/Members/LogIn.aspx) or visit the site directly for more
information:
Dozois and Dobson (eds): The Prevention of Anxiety and Depression: Theory,
Research, and Practice
http://www.apa.org/pubs/books/4316024.aspx
10.3 SELF-THERAPY SESSIONS
Because CBT is fundamentally about helping clients to be their own therapist, it makes sense that
clients be able run their own therapy sessions. Many clients report conveying principles and strategies
from CBT to significant others in their lives (especially their children) because the techniques have
been so beneficial.
In self-therapy sessions, the therapist asks the client to set aside about an hour (or the usual length of
the session) for the client to conduct his or her own therapy session. If this strategy is used along with
tapering sessions, it can make sense for clients to conduct their own sessions at the time that the
therapy normally occurred.
In this activity, the client reviews the previous week’s homework, creates a session agenda (usually
comprising of re-reading supporting materials previously given to them by the therapist, or reflection
of therapeutic skills and their application), and schedules some “new” homework to complete. The
therapeutic activities a client chooses for their self-therapy session agenda and homework speaks
volumes about what has been helpful during the course of their sessions with the therapist.
The task requires that the client accept a degree of personal responsibility for change, and is in a
relatively stable emotional state. Self-therapy is an idea that can be unfamiliar to many therapists who
identify themselves as CBT in orientation, but as an effective therapeutic tool it is worth considering
during the final stages of therapy. That being said, even though self-therapy can have distinct
benefits, it is not recommended for all clients all the time – some clients will find running their own
therapy session too challenging, or the idea will simply not hold much appeal.
If self-therapy is identified as an appropriate activity, it is useful for the therapist to spend time
collaborating with the client to discuss how their first “own therapy session” might proceed. Often it
can be helpful to incorporate imagery to enable clients to rehearse starting with the task. When used
in this way, imagery is particularly useful as an opportunity to seek client feedback about the
physiology, emotions, and thoughts (including images and memories) that are triggered by the task.
By projecting into the future about the likely experiential obstacles, the therapist can assist the client
to consider their options in the present.
There are no specific forms or worksheets recommended for constructing self-therapy sessions.
Clients are encouraged to take their own session notes for each individual session, keeping these
notes in a safe place for future reference. Clients keeping notes of important ideas and
understandings can be just as beneficial to self-therapy sessions as for sessions with the therapist.
© 2011 The Australian Psychological Society Ltd
www.elearning.psychology.org.au
Page 5 of 15
CBT Fundamentals | Module 10: Relapse Prevention and Assessing Therapist Capabilities
Further Reading 10.3
For a guide to understanding and designing self-therapy sessions, and other
therapeutic work between formal sessions, the text below is particularly illuminating.
Clinicians interested in using client self-therapy are encouraged look at this and other
similar resources. If you wish to investigate this optional reading further, you can log in
to the APS eLearning site (http://www.psychology.org.au/Members/LogIn.aspx) or visit
the site directly for more information:
Rosenthal (ed): Favorite Counseling and Therapy Homework Assignments [Second
Edition]
http://www.amazon.com/Favorite-Counseling-Homework-Assignmentsebook/dp/B004QM9W9S/ref=sr_1_3?ie=UTF8&m=A24IB90LPZJ0BS&s=books&qid=
1305290801&sr=8-3
10.4 RELAPSE PREVENTION TECHNIQUES
10.4.1 REFRAME “GETTING WORSE”
Many clients have the expectation that their conditions will improve in direct relation to the number of
CBT sessions they undertake. In fact, there is data (albeit with significant limitations) that suggests
symptom change occurs in response to the number of sessions. However, there is also data
suggesting that some clients may experience a “sudden gain” in symptoms when receiving CBT. In
both cases, the relationship is not linear. There is a recursive pattern to improvements in symptoms
and functioning, significant events, and emotional distress, because many events continue to happen
in life. It is important for clients to maintain realistic expectations about their experience, both during
and following therapy. In this light, “getting worse” can be usefully framed as part of the normal ebb
and flow of human experience. In fact, the re-emergence of symptoms can be thought of as an useful
signal that the client’s strategies for maintaining well-being, reduction of responsibility, and other selfcare strategies are needed; thereby the re-emergence of symptoms is a signal to enhance well-being.
Further Readings 10.4
Below are links to some of the studies referred to above that provide data on client
symptom change over the course of CBT. Therapists are encouraged to keep up to
date with this kind of empirical support for the CBT process. Please note there is a
charge to view these articles if you are not a member of the relevant sites. If you wish
to investigate these optional readings further, you can log in to the APS eLearning site
(http://www.psychology.org.au/Members/LogIn.aspx) or visit the sites directly:
a. Hansen and Lambert: An evaluation of the dose-response relationship in
naturalistic treatment settings using survival analysis
http://www.ncbi.nlm.nih.gov/pubmed/12602642
b. Tang, DeRubeis, Beberman et al.: Cognitive Changes, Critical Sessions, and
Sudden Gains in Cognitive-Behavioral Therapy for Depression
http://psycnet.apa.org/index.cfm?fa=buy.optionToBuy&id=2005-01321-020
10.4.2 SELF MONITORING
In progressing through CBT, clients will have gained various strategies for increased selfunderstanding. Many clients report that it is useful to revisit their therapy notes on a semi-regular
basis (for example every month) to refresh their memory of the strategies developed, and to practice
the techniques.
© 2011 The Australian Psychological Society Ltd
www.elearning.psychology.org.au
Page 6 of 15
CBT Fundamentals | Module 10: Relapse Prevention and Assessing Therapist Capabilities
Many clients respond to the general CBT model so well – particularly the VAS and thought records –
that they will continue with experiments and positive data logs long after the completion of therapy.
This self-monitoring is useful in helping clients to identify times when they may need to refocus on
therapy skills. In essence, client self-monitoring is about the client being on the look-out for early
warning signs of their presenting problems re-emerging.
CLINICAL TIPS IN PREPARING FOR THE END OF CBT
•
Begin to socialise the client to the idea of therapy concluding from the very first session,
emphasising that the therapy is about helping the client to become their own therapist, and by
referring to a particular number of sessions.
•
Discuss with the client the idea of tapering the frequency of sessions as therapy progresses.
•
Have measurable therapy goals, and regularly revisit to refine them and measure progress.
•
Build in expectations that the client will experience non-linear progress – “Things don’t just get
better in a sequence.” Prepare the client for repeating cycles in distress and wellbeing, and
for movement back and forth between confusion and clarity or insight.
•
Clearly attribute the client’s progress to their engagement and own self-therapeutic work.
•
When the client has made progress, prepare them for the possibility of setbacks (i.e.,
imagining using CBT skills when the unexpected happens, or when distress re-emerges).
•
Be aware of client thoughts about their own capabilities in therapy, the therapy itself, and
reliance on the therapist (such as, “I’m a hopeless case, nothing I do turns out right”; “I’m sick
of talking, nothing you people do actually makes a difference”; “I need your help, how will I
manage without you?”). Utilise CBT techniques to deal with these cognitions during the
therapy process.
10.4.3 WELLBEING PLAN
As with all aspects of CBT, it is useful for the client to take an active role in constructing an
individualised summary of the useful elements of therapy, in preparing for the likely re-emergence of
emotions and problems. The key principle of specificity is important here – encourage the client to
specify the symptoms and how they will re-engage with therapeutic skills. For example, rather than
schedule generic future activities for self-therapy, specify which activities have proven useful for the
client during therapy, which activities they will maintain, and which activities they will use to have the
most impact when a problem initially re-emerges.
The tips and checklist below can be useful either as a client self-reflection exercise between sessions
towards the end of therapy, or as the basis of an in-session discussion with the therapist:
© 2011 The Australian Psychological Society Ltd
www.elearning.psychology.org.au
Page 7 of 15
CBT Fundamentals | Module 10: Relapse Prevention and Assessing Therapist Capabilities
CLINICAL TIPS FOR RE-EMERGENCE OF PROBLEMS
•
Encourage the client to engage in regular self-monitoring activities (especially monitoring
thoughts, emotions, behaviours, and functioning that were prominent during their initial
presentation).
•
Identify situations or events that represent “high risk” situations for the client (for example
births, relocations, or changes in relationship status).
•
Encourage the client to maintain a “balanced” lifestyle, in a manner consistent with (rather
than in conflict with) their values, preferences, and aspirations.
•
Develop a wellbeing plan that incorporates a summary of what has been learned in therapy,
and what strategies will be helpful for the re-emergence of different emotions and problems.
Wellbeing Plan
What have I learned in therapy about my problems?
What changes have I made?
What are my areas of vulnerability?
What do I need to do to work on my vulnerabilities?
What should I do if I have a setback?
What strengths do I have?
Online Activity 10.1 – Relapse Prevention
Consolidate your understanding of various strategies to prevent client relapse by
logging in to the APS eLearning site
(http://www.psychology.org.au/Members/LogIn.aspx) and completing Online Activity
10.1 now.
10.5 ASSESSING THERAPIST CAPABILITIES
In years past, trained clinicians were considered capable (or competent) simply because they had
completed a certain number of coursework subjects and hours of supervised practice. The advent of
ongoing professional development internationally has shifted that perspective to understand therapist
capabilities as something that fluctuates from day to day, from session to session, and from client to
client. There is a growing body of literature supporting the idea of CBT competence as a fluid concept,
and efforts to define and assess this in research studies are currently undergoing significant
development.
© 2011 The Australian Psychological Society Ltd
www.elearning.psychology.org.au
Page 8 of 15
CBT Fundamentals | Module 10: Relapse Prevention and Assessing Therapist Capabilities
Further Reading 10.5
Below is one example of research suggesting therapist competence is a fluid thing.
There are many more to be found in journals and articles online, and you are
encouraged to seek out more of these studies if you have a particular interest in
emerging studies on therapist capabilities. If you wish to investigate this optional
reading further, you can log in to the APS eLearning site
(http://www.psychology.org.au/Members/LogIn.aspx) or visit the site directly for more
information:
Forehand, Dorsey, Jones et al.: Adherence and Flexibility: They Can (and Do)
Coexist!
http://onlinelibrary.wiley.com/doi/10.1111/j.1468-2850.2010.01217.x/abstract
10.5.1 STICKING TO THE MODEL
There is an important difference between sticking to the CBT model, and limiting flexibility in practice.
Two therapists can each use behavioral activation, but only one therapist might be a CBT practitioner.
Two therapists can use thought records, but neither of them might be a CBT practitioner. The point is
that the techniques do not define the therapy. It is why and how a practitioner uses techniques in
sessions with clients that actually defines their practice. Many surveys of practitioners’ theoretical
orientations exist, but these have largely only captured self-identification. These studies have missed
the important distinction between what techniques are being used within CBT, and why they are being
used by a given therapist for a particular client.
Further Reading 10.6
Linked below is a recent survey on interventions that concentrate on the therapist’s
self-identification. It is important to note when reading this article the absence of
information relating to why different techniques are used by therapists for different
clients, as discussed above.
Cook, Biyanova, Elhai et al.: What do psychotherapists really do in practice? An
Internet study of 2,000 practitioners.
http://psycnet.apa.org/index.cfm?fa=buy.optionToBuy&id=2010-13424-014
In this course, we advocate for learning and studying one therapeutic model well – developing
capabilities and refining them through specialist CBT supervision and ongoing professional
development workshops. If a therapist is proficient in the integration and application of Beckian CBT,
it need not limit their selection of techniques (unless they directly conflict with the defining principles of
CBT as outlined in Module 1).
Online Discussion 10.1 – Your Therapeutic Capabilities
Now is a good time to reflect on your own therapeutic capabilities and how these fit
with the CBT model, and compare your experience of particular CBT techniques with
your colleagues. Please log into the APS eLearning site
(http://www.psychology.org.au/Members/LogIn.aspx) and participate in the Module 10
– Online Discussion 10.1 forum by posting your response to the questions below:
•
•
•
What interventions are you using in CBT?
What form of CBT referrals are you receiving?
What form of CBT referrals would you like to receive?
© 2011 The Australian Psychological Society Ltd
www.elearning.psychology.org.au
Page 9 of 15
CBT Fundamentals | Module 10: Relapse Prevention and Assessing Therapist Capabilities
10.6 DEVELOPING AND REFINING CAPABILITIES
A different concept when assessing the practice of therapists is the idea of “capabilities” (also called
“competence” or “skill”). Sticking to the model is a necessary condition, but is not in itself sufficient for
developing therapist capabilities. Clearly the latter cannot exist without the former.
Assessing capabilities in the practice of CBT has a long history. Aaron T. Beck and colleagues
developed a supervisor (or observer) rating scale accompanied by a manual for the evaluation of
therapist capabilities. This scale – known as the Cognitive Therapy Rating Scale (CTRS) – and its
scoring manual are freely available from the Academy of Cognitive Therapy websites. The CTRS has
been subject to numerous revisions since its first writing in 1980, but none possess the same broad
application or have produced the same level of psychometric support as the original.
Further Reading 10.7
The article linked below (free to view) reviews the current empirical evidence for the
measurement and evaluation of therapist competence, lending support to the CTRS
as a proven and effective technique. If you wish to investigate this optional reading
further, you can log in to the APS eLearning site
(http://www.psychology.org.au/Members/LogIn.aspx) or visit the site directly for more
information:
Kazantzis: Therapist Competence in Cognitive-behavioural Therapies: Review of the
Contemporary Empirical Evidence
http://www.atypon-link.com/AAP/doi/pdf/10.1375/bech.20.1.1.24845?cookieSet=1
Websites 10.1
Free downloadable versions of the CTRS and the CTRS manual are linked below.
You will find these resources to be valuable in assessing your own capabilities as a
therapist, and we recommend you save a copy for future use.
a. Cognitive Therapy Rating Scale
http://www.academyofct.org/Upload/Documents/CTRS.pdf
b. Cognitive Therapy Rating Scale Manual
http://www.academyofct.org/upload/documents/CTRS_Manual.pdf
10.6.1 THERAPIST CAPABILITIES ASSESSED WITH THE CTRS
PART 1: GENERAL THERAPEUTIC SKILLS
•
•
•
•
•
•
Agenda Setting
Feedback
Understanding
Interpersonal Effectiveness
Collaboration
Pacing and Effective Use of Time
© 2011 The Australian Psychological Society Ltd
www.elearning.psychology.org.au
Page 10 of 15
CBT Fundamentals | Module 10: Relapse Prevention and Assessing Therapist Capabilities
PART 2: CONCEPTUALISATION, STRATEGY, AND TECHNIQUE
•
•
•
•
•
Guided Discovery
Focusing on Key Cognitions and Behaviours
Strategy for Change
Application of Cognitive-Behavioural Techniques
Homework
In terms of therapist training and development, the CTRS can also provide an effective structure for
specialist CBT supervision. Through listening to or watching therapy sessions, the supervisor is able
to evaluate the two key aspects of a therapist’s practice: the elements that define the therapist’s
approach, and the extent to which those elements were executed in a capable fashion.
TIPS FOR REVIEWING YOUR OWN CBT SESSIONS USING THE CTRS
•
Note what you are doing well (include at least two things).
•
Pay attention to your own processes and reactions (body language and reactions, and reflect
in terms of the CBT model).
•
Keep notes on what the client says for your CBT case formulation.
•
Make note of the capabilities the client shows (especially in considering their suitability for
short term cognitive behavior therapy).
•
Do the client’s therapy goals match what is going on in this session?
•
Based on what you observe, what would you do differently in the future when using the same
techniques or processes (try to limit to one thing to improve on per session)?
10.7 AWARENESS OF IN-SESSION THERAPIST
REACTIONS
It is useful for therapists to be aware of their own interpersonal process, including their emotions and
cognitions. Therapist self-awareness has long been established as a key element in the practice of
psychotherapy, and makes sense in all therapeutic contexts since therapy is fundamentally an
interpersonal process. In that vein, despite the ideas of “transference” and “countertransference”
being more commonly related to the psychoanalytic model, it is possible to usefully understand them
within the cognitive model.
© 2011 The Australian Psychological Society Ltd
www.elearning.psychology.org.au
Page 11 of 15
CBT Fundamentals | Module 10: Relapse Prevention and Assessing Therapist Capabilities
Further Readings 10.8
The two journal articles and textbook listed below are recommended for further
explanations of the ideas of “transference” and “countertransference” in a CBT
context. Please note that there is a fee to view or download the full journal articles if
you are not a member of the relevant website. If you wish to investigate these optional
readings further, you can log in to the APS eLearning site
(http://www.psychology.org.au/Members/LogIn.aspx) or visit the sites directly:
a. Hayes, Gelso and Hummel: Managing countertransference
http://psycnet.apa.org/journals/pst/48/1/88/
b. Rudd and Joiner: Countertransference and the Therapeutic Relationship: A
Cognitive Perspective
http://www.ingentaconnect.com/content/springer/jcogp/1997/00000011/00000
004/art00001
c. Stedmon and Dallos (eds): Reflective Practice in Psychotherapy and
Counselling
http://www.amazon.com/Reflective-Practice-Psychotherapy-CounsellingStedmon/dp/0335233619/ref=sr_1_1?s=books&ie=UTF8&qid=1305293499&s
r=1-1
TIPS FOR MONITORING YOUR OWN INTERPERSONAL PROCESS
•
Pay attention to your emotions in-session, writing them down afterwards.
•
Pay attention to your thoughts in-session, writing them down afterwards.
•
Use CBT techniques to evaluate and gain perspective on your own beliefs.
•
If your client cancels and you feel relieved, consider what is going through your mind.
•
Consider any persistent thinking about clients between sessions (outside of the routine work
of case notes, CBT formulation work, and treatment planning).
•
Consider any persistent thinking or emotions you have about processes in CBT.
•
Take any thoughts or behaviours you have about stretching the boundaries of your
professional relationship to clinical supervision (such thoughts and behaviours might be
extending sessions for some clients, making allowance to see some clients on days that are
not convenient for you, feelings of attraction to clients, or sharing personal information with
clients that does not have a direct bearing on their presenting problems or the therapy
process).
Further Reading 10.9
The free article below is a useful discussion of supervising homework tasks in CBT. If
you wish to investigate this optional reading further, you can log in to the APS
eLearning site (http://www.psychology.org.au/Members/LogIn.aspx) or visit the site
directly for more information:
Haarhoff and Kazantzis: How to Supervise the Use of Homework in Cognitive
Behavior Therapy: The Role of Trainee Therapist Beliefs
http://www.nwlcbttraining.net/documents/101213therapistbeliefsandhomework.pdf
© 2011 The Australian Psychological Society Ltd
www.elearning.psychology.org.au
Page 12 of 15
CBT Fundamentals | Module 10: Relapse Prevention and Assessing Therapist Capabilities
10.8 WORKING IN AN ENVIRONMENT WITH LIMITED
RESOURCES
CBT was a therapy first designed as a treatment for depression, and in that context, to comprise 20
sessions over a 16-week period (with the first 8 sessions offered twice a week). In contemporary
practice, CBT is rarely offered in this format for those experiencing depression. In fact, only a small
proportion of clients will attend therapy for as many as 20 sessions with government or insurance
funding. While CBT formulations for other problems vary in session numbers, the reality is we can
rarely offer clients the number of CBT sessions that were used in research to establish CBT as an
effective approach.
From 1 July 2011, clients will be able to access up to six Medicare-subsidised psychological services
per calendar year, with a further four available to clients who require additional assistance. Thus,
there is a need to utilise the time available in the most efficient way.
CLINICAL TIPS FOR MAKING THE BEST OF LIMITED RESOURCES
•
Set a limited number of sessions for preliminary evaluation of the client’s therapy goal(s), and
then also for the likely conclusion of therapy.
•
Early in the therapy process discuss tapering the frequency of sessions with the client.
•
Set therapeutic goal(s) that are likely to be attainable within the time available. If clients can
learn to apply CBT techniques in one area with your support, they can often apply them in a
second area without much of your support.
•
Consider using resources such as self-help books or web-based interventions for those
clients who are high functioning and not experiencing high levels of distress.
Online Discussion 10.2 – Working with Limited Resources
Your colleagues also undertaking this course are a useful source of knowledge and
advice on how to make the best of limited resources in CBT practice. Think about the
obstacles you have experienced because of restrictions in client access to CBT, the
limitations of access to professional training, and any other external limitations to
practice. Then log into the APS eLearning site
(http://www.psychology.org.au/Members/LogIn.aspx) and participate in the Module 10
– Online Discussion 10.2 forum, thinking about the questions below:
•
•
•
•
What are some of the issues in practicing CBT in our current funding climate?
What opportunities are there for CBT specific supervision?
What opportunities are there for CBT training and supervision for those in
regional areas?
What areas of further training are needed for professionals?
© 2011 The Australian Psychological Society Ltd
www.elearning.psychology.org.au
Page 13 of 15
CBT Fundamentals | Module 10: Relapse Prevention and Assessing Therapist Capabilities
MODULE 10 SUMMARY
That brings us to the end of this module, and of this CBT Fundamentals course. Fittingly, in this
module we covered how to conclude CBT therapy with clients, paying particular attention to preparing
clients for the end of regular sessions and equipping them with the skills and therapeutic tools to “be
their own therapist” if their presenting problems re-emerge. We also discussed how therapists can
assess their own capabilities, and develop and refine their capabilities in CBT practice.
In the cue card below, highlight important summary notes from this module and note any questions
that are remaining about either concluding a course of therapy or therapist assessment and
development. Also note any issues you would like to raise on the discussion forum relating to this
module, or to the course in general.
While this CBT Fundamentals course has covered the key concepts of CBT, and discussed primary
elements and techniques of practice, it is up to each individual practitioner to seek out further relevant
information for their particular practice, to keep up to date on emerging empirical research, and to
continually reflect on and develop their therapeutic capabilities. We encourage you to refer to as many
of the resources listed throughout this course as possible, as each of them will help your own practice
in different ways.
MODULE CUE CARD
Cue Card for Module 10
© 2011 The Australian Psychological Society Ltd
www.elearning.psychology.org.au
Page 14 of 15
CBT Fundamentals | Module 10: Relapse Prevention and Assessing Therapist Capabilities
MODULE 10 ASSESSMENT
It is now time to complete your Module 10 assessment online. The purpose of this assessment activity
is to examine your knowledge of the key topic areas presented in Module 10.
Online Quiz – Module 10 Assessment
Log in to the APS eLearning site (http://www.psychology.org.au/Members/LogIn.aspx)
and complete the Online Quiz in Module 10.
This assessment consists of 10 multiple-choice questions and you are allowed two
attempts to achieve a passing score of 80% or higher.
Once you have successfully completed the Module 10 assessment and have accessed all other
required resources from the APS eLearning site, the entire CBT Fundamentals course will be marked
as complete and you will be able to access your completion certificate online.
© 2011 The Australian Psychological Society Ltd
www.elearning.psychology.org.au
Page 15 of 15