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,
michaeljscott1@virginmedia.com, 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
•
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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?