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THERAPEUTIC ATTITUDES AND THE A CQ UISITION OF

COMPETENCE DURING
TRAINING IN COGNITIVE BEHAVIOUR THERAPY

FRANK ROBERT WILLS

A dissertation submitted to the University of Bristol in accordance with the requirements of the degree of Doctor in Philosophy in the Faculty of Law and Social Sciences and the School for Policy Studies

December 2007 80,000 words

ABSTRACT

hasdifferentiatedinto modelsof practicebasedon diverseprinciples. Psychotherapy treatments, Currentpoliciesin the UK favour expansion of empirically supported in is likely This behaviour (CBT). therapists to therapy seeking result especiallycognitive training in CBT after previouslyadheringto other models. to anothermodelwould inhibit acquisitionof This studyaimedto test whetheradherence Previous CBT skills. It also soughtto find out how suchinhibition might be overcome. but the training the measuring without adherence effect of model on researched studies 1997). learning 1996; Freiheit & Overholser, (Persons et at, effect on skill
The author devised the Cognitive Behaviour Therapy Training Questionnaire and used it to track trainee attitudes before and after training and at one year follow-up. He also interviewed trainees about their experiencesof training. A group of assessors rated trainees' competenciesin CBT skills using the Cognitive Therapy Scale - Revised. The results show that trainees with previous adherenceto psychodynamic and personcentred therapy (PCT) showed less than averageadherenceto CBT principles. CBT skill performancesby psychodynamic trainees however were not inhibited by these attitudes. The performances of PCT trainees showed some significant difficulties in CBT skill acquisition, especially during early stagesof training. Apart from for a few PCT trainees whose competencedevelopment was delayed, however, these difficulties were overcome. PCT trainees reported more `task interfering cognitions' about skill acquisition, especially those connectedwith structuring therapy. Most of them reported that they were able to overcome these difficulties by developing more relaxed attitudes towards assessment and rethinking certain specific attitudes.

In conclusion,certainspecificattitudesconnected inhibit trainees with othermodelsmay in the acquisitionof CBT skills. Traineescan,however,generallyovercome these difficulties by rethinkingspecificattitudesandby avoidingoverly rigid and fearful attitudestowardassessment.

DEDICATION

AND ACKNOWLEDGEMENTS

I would like to acknowledge and thank, my supervisors,previously Professor Geraldine Macdonald and subsequentlyDr William Turner, for their unstinting help and support during the completion of this work. I would also like to thank the trainees and staff of the University of Wales College Newport for giving me so much time and so many good ideas during the course of this

I dedicate this work to them. research.

AUTHOR'S DECLARATION I declare that the work in this dissertation was carried out in accordance with the Regulations of the University of Bristol. The work is original except where indicated by special reference in the text, and no part of the dissertation has been submittedfor any other academic award. Any views expressedin the dissertation are those of the author.

1, SIGNED: --. ...........................................................

DATE:

3.

""o'

2o07

Table of Contents 1: Chapter 1: Introduction 1.1: Background to the study: The development of psychological therapy 1.2: The evolution of CBT

1.3:Personalmotivation for the study

1.4: Organisational and policy factors that influence the process of training 1.5: Research aims and questions

1.6:Relationto theory 1.7:Methodsof datacollection and analysis 1.8: Conclusionto Chapter1

2: Chapter 2: The principles and practice of cognitive behaviour therapy 2.1: Principle 1: CBT is brief and time limited

1 2 5 10 11 13 14 17 18

20 22 22 2.1.1: Defining short-termand ling-term therapy 24 2.1.2: The rationalefor short-termtherapy 25 2.1.3: Longer term versionsof CBT 26 2.1.4: Length of therapyand efficacy 2.1.5: Length of therapy in other therapeutic models 27 2.2: Principle 2: CBT is structured and directional 29 2.2.1: The rationalefor structureand direction 29 2.2.2: Structureand direction in othertherapeuticmodels 31 2.3: Principle 3: CBT is problem and goal oriented 32 2.3.1: Rationalefor a problem and goal orientedapproach 32 2.3.2: Problem-solvingin othertherapeuticmodels 32 2.4: Principle 4: CBT uses an educational model 33 2.4.1: Rationalefor an educationalapproachto therapy 33 2.4.2: Psycho-education 34 in other therapeuticmodels 2.5: Principle 5: Homework is a central featureof CBT 37 2.5.1: Definition of `homework' in CBT 37 2.5.2: Rationalefor the homeworkprinciple in CBT 38 2.5.3: Homework in CBT: complianceand resistance 38 2.5.4: Homework and outcomein therapy 40 2.5.5: Homework in other therapeutic models 41 2.6: Principle 6: CBT uses the Socratic method 43 2.6.1: The rationale for the use of Socratic methods in CBT 43 2.6.2: Socratic methods in other therapeutic models 44 2.7: Principle 7: The therapy and techniques of CBT 45 rely on inductive method 2.7.1: The rationale for cognitive and behavioural inductive 45 methods 2.7.2: Cognitive techniques 48 2.7.3: Behavioural techniques 49 2.7.4: The use of inductive techniques in other therapy models 51 2.8: Principle 8: CBT requires a sound therapeutic relationship 52 2.8.1: The rationale for the therapeutic relationship in CBT 52 2.8.2: The therapeutic relationship in other therapeutic models 53 2.9: Principle 9: CBT is a collaborative effort by client and therapist 54 2.9.1: The rationale for collaboration in CBT 55 2.9.2: Collaborationn othertherapeuticmodels 57 2.10: Principle 10: CBT is based on the cognitive model of emotional disorders 59 2.10.1:The development and rationalefor cognitive modelsof psychopathology 59

disorder behavioural development The of panic model 2.10.2: of the cognitive

61

2.10.3: The efficacy for CBT treatment for panic disorder in formulation The 2.10.4: cognitive models schemaconcept and

63 65
70

2.10.5: The development and rational for cognitive models: an overview

2.10.6: Specific formulation models in other therapeutic models 2.11: Conclusion to Chapter 2 2.11.1: Points of difference between CBT and other models 2.11.2: Points of convergence 2.11.3: Therapy integration 2.11.4: Summary

70 73 74 75 76 76

78 Chapter 3: Skills training in CBT 79 3.1: Skills and training for psychological therapy 83 3.1.1: The impact of recording equipment on therapy skill identification 84 3.1.2: The Counselling skills movement 87 3.2: Skills and training for CBT 92 3.3: CBT training with trainees changing models 3.3.1: The reservationsabout CBT held by trainees with a psychodynamic 93 background 98 3.3.2: Trainees from multiple orientations 101 3.3.3: Trainees from a substanceabusebackground 3.3.4: Overview of studies of CBT training with trainees with non-CBT 103 orientations 106 3.4: Conclusion to Chapter 3

Chapter 4: Methodology
4.1: Design

108
108

4.2: Participants 109 4.2.1:Attrition of questionnaire 110 respondents 4.3: Materials 112 4.3.1:The CognitiveBehaviourTherapyTraining Questionnaire (CBTTQ)112 4.3.1.1:The CognitiveBehavioural PrinciplesInventory(CBPI) 113 4.3.2:The CognitiveTherapyScale-Revised 114 (CTS-R) 4.3.3:How the principlesof CBT arelinked to CBT practiceskills 118 4.4.4:The semi-structured interview schedule 119 4.4: Procedure 121 4.4.1: Surveyandinterviews 122 4.4.2: Competence 124 assessment 4.5: Ethicalaspects 125 of the study
4.6: Data analysis 126

4.6.1:Analysisof quantitativedata 4.5.2:Analysisof qualitativedata

Chapter 5: Results: Questionnaire and Skill Assessment Data 5.1: Demographics 5.2: Education and employment

126 126
129 129 130

5.3: Employers'supportof traineesundertaking training in CBT 5.4: Preferred modelof therapy

132 133

5.5: ResearchQuestion: Attitude change towards CBT principles during training and 136 at one year follow-up

5.5.1: Reliability of the Cognitive Behavioural Principles Inventory(CBPI)

136

5.5.3: Changes in attitudes towards individual CBT principles during in CBT training Changes B: Question competencies 5.6: Research

follow-up CBPI in training Changes and 5.5.2: scoresover mean 5.6.1:The form of CBT skills assessment
5.6.2: Pre-training CBT skill assessment

137
138 142

142
144

Therapy General skills 5.6.3: Mid-training assessment of

145

146 End 5.6.4: of training assessments 147 5.6.4.1: End of training reassessmentof General Therapy skills 5.6.4.2: Comparison of pre-training and end of training assessmentof

QuestionC: What influencedoesmodel preference play on the 5.7: Research 153 in CBT acquisitionof competence items CBT individual by skill 5.7.1: Traineecompetence of shown assessment
155 by orientation at pre-training 157 by items CBT Time to 5.7.2: orientation taken achieve competence on all

150 tapes 5.6.5: End of training assessmentof trainees submitting pre-training 150 for tapes Skill trainees 5.6.6: not submitting pre-training assessments 5.6.7: Time taken to achieve competence in all General Therapy and Specific 151 for CBT skills all trainees

Specific CBT skills

147

5.7.3: Rank order of model preference of performance and assessment by 5.7.4: Summaryof analysisof differencesin CBT skills performance 5.8: Summaryand conclusionto Chapter5
Chapter 6: Presentation of Data from the Semi-structured interviews 6.1: The pre-training stage model preference and ranking

159
162

163
167 168

6.1.1: Traineeswith CBT model preference at pre-training 6.1.2: Traineeswith PCT model preference at pre-training

168 170
174

6.1.3: Trainees with a psychodynamic model at pre-training

6.1.4: Traineeswith Integrated/Eclectic model preference 6.1.5: Pre-trainingsummary 6.2: The training period

175 176 183

183 185 189 190 191

6.2.1: Experience of training: trainees with a CBT preference 6.2.2: Experience of training: trainees with a PCT preference 6.2.3: Experience of training: trainees with a Psychodynamic preference 6.2.4:Experienceof training: traineeswith a Integrative/Eclecticpreference 6.2.5: Training stage summary 6.3.1: Trainees with CBT model preference at post-training

6.3: The post-trainingphase

197
197

6.3.2: Traineeswith PCT model preference at post-training 6.3.3: Traineeswith a psychodynamic model at post-training 6.3.4: Traineeswith Integrated/Eclectic model preferenceat post-training 6.3.5: Post-trainingsummary 6.4: Developinga CentralThematicChart
Chapter 7: Conclusions and implications of the study 7.1: Introduction 7.2: Context of the present study 7.3: Previous studies

199 201 202 203 210

221 221 221 224

7.4: A resumeof the main results of the study 7.5: Implications of study for further research 7.6: Suggestionsfor further research 7.7: Generalisation of findings to wider populations 7.8: Implications of CBT training policy 7.9: Implications for CBT training methods 7.10: Conclusions

227 231 236 237 238 240 243

REFERENCES: APPENDICES:
I: Cognitive Behaviour Therapy Training Questionnaire (CBTTQ)

244 267
268

II:

interview schedule. Semi-structured List of tables, charts and figures

276

between CBT principlesandCTS-R items Table2.1: The congruence interview for data Table4.1: Response and rates questionnaire between CBT principlesandCTS-Ritems Table4.2: The congruence
Table 4.3: Data collection process: September2000- September2004

79 111 119
123

Table4.4: Detailedoutline of datacollectionprocedures by cohorts Table5.1: Gender by agegroup Table 5.2:Distribution of gender background Table5.3: Educational at pre-trainingby cohorts
Table 5.4: Professional qualifications by cohorts

125 129 130 130

130

Table5.5: Employmentstatusby cohorts

Table 5.6: Presentwork role by cohorts

131
131

Table5.7: Time in currentpost by cohorts 131 Table5.8: Coursefee paid by employer 132 Table5.9: Employersgrantingleaveto attendtraining course 133 Table 5.10:Trainees estimates of employersupportiveness andpriority given to CBT 133 training
Table 5.11: Preferred model of therapy at pre-training 134 Table 5.12: Mean CBPI scoresfor different modalities 134 Table 5.13: Multiple comparisonsof mean CBPI scoresby different model preference 135 at pre-training

Table5.14:Reliability of the CBPI (10 items)

136

Table 5.15: Means of CBPI scoresat different stages 137 Table 5.16: One factor repeatedmeasuresANOVA analysis of CBPI mean scores 138 Table 5.17: ANOVA post-hoc analysis of CBPI scoresusing the Bonferonni

138 correction for individual CBPI principlesover time, with repeated Table 5.18:Meanscores
ANOVA measures 140 Table 5.19: Pair-wise comparisonsof mean differences principle ratings at pre, post 141 and follow-up using the Bonferonni correction Table 5.20: CBT skills assessment: trainee rates of achieving competenceat all stages

143 Table5.21:General 145 therapycompetence at pre-trainingandmid-training Table5.22:End of training assessment of Generaltherapyskills not achievedat midtraining 147

Table 5.23: Comparison of trainees submitting and not submitting re-training tapes: General Therapy skills with of assessment mean competence rates at mid-training 151 independent t-test analysis Table 5.24: Comparison of trainees submitting and not submitting pre-training tapes: CBT training specific skills with of assessment end of mean competence rates at 151 independent t-test analysis Table 5.25: Time taken to achieve CBT competence using CTS-R assessment 152 methods 153 Table 5.26: Pre-training model preference and rank order of CBT Table 5.27: Mean CBPI scores over the period of training by initial model preference 153 ANOVA analysis with one way Table 5.28: Rank assignedto CBT in ranking of models (pre, post and follow-up) 154 Table 5.29: Performance in individual CBT skills items by pre-training model 155 preference at pre-training assessment 156 by initial model preference Table 5.30: Mid-training assessment 156 Table 5.31: End of training assessmentby initial model preference Table 5.32: Tie taken to meet CBT assessmentcriteria by stated orientations at pre158 training Table 5.33: Cross-tabulation of rank order of CBT at pre-training and mean skill 160 Spearman's rho analysis with competencerates at pre-training, Table 5.34: Cross-tabulation of rank order of CBT at pre-training and mean skill 160 competence rates at mid-training 161 Table 5.35: End of training results by rank order of CBT at pre-training Thematic Chart 1: CBT trainees at pre-training 178

ThematicChart 2a: PCT traineesat pre-training

Thematic Chart 2b: PCT trainees at pre-training

179
180

ThematicChart 3: Psychodynamic traineesat pre-training ThematicChart 4: Integrative/Eclectic traineesat pre-training ThematicChart 5: CBT traineeson-training experiences ThematicChart 6a: PCT traineeson training experiences ThematicChart 6b: PCT traineeson training experiences ThematicChart 7: Psychodynamic traineeson training experiences
Thematic Chart 8: Integrative/Eclectic on training experiences

182 186 192 193 194 195

196

ThematicChart 9: CBT traineesat post-training

205
206 207 208 209

Thematic Chart 10a: PCT trainees at post-training Thematic Chart 10b: PCT trainees at post-training Thematic Chart 11: Psychodynamic trainees at pre-training Thematic Chart 12: Integrative/Eclectic trainees at post-training

Figure 2.1: Typical CBT session structure (Beck, J., 1995) 57 Figure 2.2: The suggestedsequenceof events in a panic attack (Clark, D. M., 1986) 61 Figure 3.1: Skill use in different therapy models (adapted from Ivey et al, 1997) 81 Figure 3.2: CBT skill and personal quality areasas defined by various CBT writers 82 Figure 4.1: The Development of the Cognitive Therapy Scale 115 Figure 5.1: Specific CBT skill results at pre-training and end of training 149 Figure 5.2: Trainees with outstanding skill assessmentitems at the end of training 157 Figure 6.1: Central Thematic Chart: Experiences and Process in Training 211 Figure 6.2: Pathways through training 220

Chapter 1: Introduction
An increasing number of graduatestudentsand professionals from a variety of other backgrounds may desire training in cognitive-behavioural approaches.A central issue not yet addressedby the current cognitive behavioural training literature is how to teach cognitive behavioural techniquesto individuals from other therapeutic orientations effectively (Freiheit & Overholser, 1997, p.79). Like patients, trainees arrive in the classroom with value-laden models of psychopathology and psychotherapythat are not fully conscious or articulated and that they are not eager or able to summarily relinquish. The teacher's job is to help trainees become aware of their pre-existing penchantsand predispositions, examine them, and information that allows them to make whatever adjustmentsthey might wish new acquire to make to their own working models. Thus, we argue that an important strategy for ... overcoming obstaclesto teaching and learning is to make the obstaclesexplicit and to promote flexible, thoughtful examination of them... Our experience is that willingness to try a new idea or new intervention is a key step in learning a new model (Personset al, 1996 p. 212).

The above quotations describe the practice of training therapists in cognitive-behavioural therapy (CBT) within arenaswhere many of the trainees held prior preferencesfor other therapy models, usually the psychodynamic and/or humanistic models. Personset at (1996) found that a previous training in psychodynamic therapy led trainees to have considerablereservationsabout the CBT model. These reservations are described in Chapter 3. This present study, like those above, is also concernedwith the training of therapists in CBT and with the effect that any such reservations held on entering training might have on the processand outcomes of that training, especially with acquisition of competentpractice skills.

The trainees in this study came from a variety of practice and training backgrounds. Some showed reservationsabout CBT similar to those described by Persons (1996). al et Person-centredand humanistic models of practice are, however, more common in the backgroundsof counsellor participants in this study partly becauseof the strong influence of the person-centredmodel in the development of counselling (McLeod, 2003) than in the studies of Personset al (1996) and Freiheit & Overholser (1997). This study is therefore particularly interested in the way that any principles and methods of practice that have been developed within previous training in humanistic therapy might influence learning CBT. The study, however, also has a wider focus of concern in that holding

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that is trainee held may characteristic possible one only model principles of a previously influence the learning of CBT. distinguish for CBT. It to in training the aimed process The study was set the context of how these two the training the trainees, and of process nature the therapeuticattitudes of factors interact. In order to understandhow the researchquestionswere formulated, this Introduction will describehow CBT developedwithin the context of a field with multiple basesof knowledge.It will then briefly introduce the aims and proposedmethods of the CBT training. on study 1.1: Background to the Study: The Development of Psychological Therapy: Although the origins of psychological therapy have beentraced as far back as Ancient Greece(Xenakis, 1969), it appearsin its modem form with the work of Freud and his into 19th Century. Freud's developed the the a of work end eventually at colleagues 'school' of psychotherapy,which was termed psychoanalyticand, later and more broadly, Century, 20th During the psychotherapyexpandedrapidly, especially psychodynamic. influenced II, helping War World the also many and of other professions,such as after The is based work. psychodynamic and social perspective on certain specific counselling conceptsand values regardingthe natureof the person,the developmentof of psychologicalchange. psychopathologyand the processes

Many psychodynamicconceptsand valuesproved to be controversial and the Freudian perspectivesoon found many critics. Someof thesecritics went on to establish schools basedon quite oppositeprinciples. Behaviourism, for example,developedin reaction againstthe so-called'mentalism' involved in the conceptof the 'unconscious'and wanted to focus more on observableand concretebehaviour. Behaviourism has had several cycles of development.The early breakthroughcame in the 1920swith the work of Watson.A big expansionin US psychology in the 1920sfollowed on from the work of Watson,and anothersurge in behavioural psychology came in the 1950sonwards from the work of Skinner. More recently, behaviourism hastendedto join forces with the

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forming field in in both the therapeutic a and psychology general perspective cognitive broad school of therapy now termed 'cognitive-behavioural' (Rachman, 1997b). Humanistic in the the thinking of Another reaction against psychoanalytic shape came Here from 1940s Rogers the Carl the reaction the onward. of work with school, starting its 'pessimism' the focussed theory the Freudian and of alleged on was concepts against been have Humanistic & Russell, 2002). therapists its (Rogers `directiveness' of practice human idea based that the that growth to on was concerned evolve a model of practice 1967). Existential 1951; (Rogers, therapy, 'self-actualising' and natural are processes however, is usually bracketed within the humanistic school, yet dissentsfrom this view 2002). (van Deurzen-Smith, human nature of The expansion of schools of therapy has appearedto be exponential. In a review of the field, Norcross & Arnkoff (1992) reported that they had been able to identify over 400 decreasing in detect the number of They sign of no growth could models of practice. fatigue' 'narcissistic that would stop the expansion. Many of only models and suggested these schools are very small and operateas splinters or sub-groups of others.

The three main schools introduced above: Psychodynamic, Humanistic and CognitiveBehavioural - remain the three of the four most dominant paradigms in the field - the fourth being Eclectic or Integrative. A survey of counsellors in 1993 revealed that 75% of counsellors describedthemselvesas practising within one of these 3 broad schools, whilst most of the rest described themselvesas 'eclectic or integrative' in their practice (BACP, 2002). The trend of practitioners divided between theoretical and practical `schools' has been evident in other helping professions, such as clinical psychology and social work. In effect, this meansthat psychological therapies are practised in fields that are theoretically fragmented and where no one approach holds a dominant position. It also meansthat the professions involved do not always share assumptionsamongst themselvesand may have difficulty in finding a common language to talk about issues within the professions involved in psychological therapy and in representing the profession to outside bodies. In discussing relations between the schools, however, it is

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1966) (Kiesler, `uniformity he that will the myth' to a possibility aware of also wise exaggerate the uniformity of attitudes within each school.

This thesis is concerned primarily, however, with training in the skills of CBT. It is important to locate the context of such training in a field where knowledge is fragmented, CBT fragmentation described This training that trainees may approach means above. as hinder learning help This different this that or may model. attitudes with a variety of interaction between beliefs is the the and attitudes about study centrally concerned with how therapy is practiced that trainees hold as they come into training and the way training itself modifies - or fails to modify - attitudes. This aim has a certain congruence during helps therapy the therapist the of cognitive which clients many of activities with to develop ways of modifying their thinking in order to evolve a form of functioning that is closer to their life goals (Beck, 1995).

The study is also interested in how trainees achieve behavioural competence in practising the therapy and how this is influenced by attitudes of trainees at the start of training. This focus on behavioural competence has congruence with the aims of behavioural therapy. Persons (1989,1995; Persons et al, 1996) have argued that CBT reaches maximal individual assessmentsof clients result in formulation of carefully effectiveness when how their individual cognitive and behavioural patterns have evolved and are maintained.

CBT is a form of psychological therapy based on the assumption that certain psychological problems have their origins in, and are maintained, by patterns of maladaptive schemas1,cognitions, emotion and behaviour. The `cognitive specificity hypothesis' maintains that specific psychological problems have specific types of thinking patterns (Salkovskis, 1996). The therapist works to build a formulation specifying the pattern elements and the relationship between them for each individual client. Therapist and client then collaboratively plan a series of interventions to produce ameliorative change in maladaptive patterns. The modern form of CBT first arose in the 1960s, as the more cognitive approaches of Ellis and Beck developed and then combined
CB T practitioners have preferred the use of the plural term `schemas' to the more correct 'schemata'.

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history behavioural is fully in This described the approaches. more evolving with already following section. This study is particularly concerned with the fusion of the cognitive tradition oi' 13eckwith the principles of' behaviour therapy. Stressing a "formulation in CB T Britain influential is (RARCP, training mode of within education an model" 1999) and is the training model used on the course programme within which this study is located (UWCN, 2004). The term `cognitive behavioural therapy', CB'I', will be used as the wider parent school within which various models of'practice can he securely defined. Both Hawton et al (1989) and Rachman (1997b) describe CUT as the integration of behaviour therapy and cognitive therapy. This integration is possible because key principles are so similar. The term 'cognitive therapy' refers to the particular 2 Beck CBT Aaron to the wider parental approach. contributions of

The evolution of CBT 1.2: The evolution of CB'[' took place in three stages: the development of behavioural therapy, the development of cognitive therapy and the Fusion of these therapies into an overall model: CBT (Rachman, 1997b). Each stage of development will be described along with brief consideration of whether there is an imminent `fourth wave' of CBT developing. It is difficult to give precise dates for these stages but it is possible to mark out periods when each stage began to emerge. Significant developments of CB"l' have occurred in the United States, the United Kingdom and in other countries. Sometimes these developments have been relatively independent of each other whilst at other times there has been marked synchronicity and cooperation. Behaviour therapy emerged during the period 1950 to 1970. In the UK, behavioural therapy was more influenced by the theories of Pavlov, Watson and Hull. Wolpe (1958) and Eysenck (1960) played significantly roles in developing therapeutic interventions based on these ideas. In contrast, behaviour therapy in the US was more influenced by the operant conditioning theories of B. F. Skinner and this especially showed itself in the development of `token economy' regimes for especially disturbed psychiatric patients (Ayllon & Azrin, 1968). Wolpe's (1958) work was centred on fear-reduction techniques
21 am aware that there are different conventions in the use of terminology therapeutic models.

regarding these various

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w .

for anxiety disorders.The theoretical issuesconnectedto neurotic disorders were of particular interestto him and to Eysenckand they were both keen to attack The Maudsley Hospital and the Institute of Psychiatry, both psychoanalyticapproaches. in London, were centresfor the developmentof behaviour therapy. Neither centre was involved with long stay patientsso that there was less interest in the `token economy' that had beendeveloping in the US. British behavioural therapiststherefore approaches tendedto follow the focus of Wolpe (1958) and Eysenek(1960) on the anxiety disorders, especiallyto agoraphobia.Anxiety problemswere defined in strictly behavioural terms and this led to treatmentsusing `systematicdesensitization' and `exposure' (Wolpe, 1958),which beganto achieveclinically significant results and thereby generatedwhat Rachman(1997b, p.7) refers to as `un"British levels' of enthusiasm. Unlike American behaviourtherapy, however, behavioural therapy in the UK was always less influencedby the `radical behaviourists', such as the Skinnerians.Rachman(1997b, British behaviourtherapy as, "... a qualified environmentalism in p.6) characterises which neurotic disorderswere regardedas the product of environmental events, learning experiences, and conditioning in particular... " There were certainly major conflicts betweenbehaviouralpsychologistsand `medical model' psychiatrists in the UK (Meyer & Chesser,1970)but somepsychiatristswere involved in developing behaviour therapy. This was not the casein the US. Clinical psychology was a new emerging profession at this time and usedthe new behavioural approachto demarcatean areaof expertise for itself.

between differences Despite the British andAmericancontexts, these therewasalso began to cross-fertilize muchcommongroundanddevelopments andcohereasthis
period went on. Like many other `movements',however, behaviour therapy began to hit certain more intractable problems of developmentalso. The theoretical unity of the becamemore remote from psychology approachbeganto suffer as clinical researchers The latter were beginning to show that even simple Pavlovian researchers. conditioning was more complicatedthan had beenthought (Rescorla, 1986).There was also a

belief that findingsbased pervasive on animalresearch couldnot be transferred

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behavioural in `dryness' kind traditional There human of was a contexts. automatically to than did other mechanisms, what other not allow even speculation about empiricism that Finally, in involved be existing psychopathology. those that were observable,might behavioural treatmentsbegan to reach the outer limits of their applications. The treatment had behavioural especially proved depression not approaches area where one was of for developed Therapy Cognitive Beck's fact that specifically effective and the depressionopened a door that was attractive to many existing behaviour therapists. Cognitive therapy emergedas a distinct therapeutic model from the mid-1960s onwards. for jump be therapy first thought that cognitive It might at could prove a considerable behaviour therapists, especially in certain theoretical features such as the reliance of the it had had behaviour fact, to In therapy areas expanded more as patients' self-reports. begun to consider the role of cognition anyway: thought, for example, could be defined as functioning internal forbidden Previously 1967). (Cautela, behaviour' `covert areasof a The for behaviourists. theoretical principles of cognitive out opening were now it be but in 2 Chapter this should noted that, although at point approachesare covered stressingcognitive factors in the development and treatment of psychological problems, both Ellis and Beck, its earliest proponents,also stressedthe importance of behavioural for insight Ellis (1962) that effective change, was not enough specifically argued change. had be to which securedby behavioural change.The Beckian tradition also stressedthe role of behavioural experiments in the changeprocess,though it tended to define these in experiments cognitive terms. A client who believed that he couldn't stand the embarrassment of failing in public might, for example, be induced to devise an experiment during which he did `fail' in public, in order to find out if he could stand it. Another feature of Beck's cognitive therapy that was attractive to behaviourists was the emphasison empirical outcome learnt from behaviour therapy research.The early results of the cognitive therapy of depressionwere sufficiently strong to causeintense interest in the therapeutic community (Weishaar, 1993). The successof the early trials was not completely replicated in the large scaleNIMH trial during the 1980s.Paradoxically, cognitive methods have had a stronger impact on the anxiety disorders, which were

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its 1988). In Barlow, (Clark, 1986: turn, behaviour therapy the of preserve originally have depression formulation find behavioural treatment also to of and a newer attempts These Hollon, 1996a; 1996b). & (Jacobson crossovers proved much more successful behavioural integration for the and the even, of collaboration, scope potential proved cognitive therapies. The CBT `fusion' was perhapssignalled when the British Association for Behavioural formed in itself 1972. This (BABCP) Psychotherapies Cognitive was presciently and before the term `cognitive behaviourtherapy' was in common use: the earliest usageI have beenable to find is that of Mahoney (1974) and Meichenbaum(1977), who referred to `cognitive and behaviourmodification' and 'cognitive-behavioural modification' fusion late (1997b, 18) from 1980s Rachman the the p. sees main starting respectively. onwards:
It is possibleto discern an exchange,in which cognitive conceptswere absorbedinto behaviourtherapy, and cognitive therapistsattachedincreasing importance to behavioural experimentsand exercises.

I referred earlier to the `dryness' of traditional behaviouraltheory lying in its for look to content that suppliesunderlying constructsthat might bolster unwillingness behaviouralapproaches. Beck (1976) had speculated that he would find specific cognitive for other psychological problemsas he had for depression,the `cognitive content ' Much researchhas now beencompletedby many researchgroups specificity hypothesis. and has indeedbegun to supply much valuable information about the cognitive content of not only well known areassuch as anxiety and depressionbut also areas and processes suchas eating disordersand even personalitydisorders(Salkovskis, Ed., 1996). Thus, as Rachman(1997b, p. 18) puts it, `Cognitive therapy is supplying content to behaviour therapy.' Even herethere could be danger,in that therapistsmight take up research-based formulations too readily without taking enoughaccountof idiosyncratic client factors. By the late 1980s,whilst exciting new and confirmatory evidenceabout cognitive to the anxiety disorders,especially panic disorder emerged,some of the approaches conceptualframework of the approachto depressionwas being increasingly questioned. The schemaconcept,though plausible, was proving very difficult to operationalise and

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factors. dormant depressogenic that vulnerability schemaswere test: especially the notion in recovered patients, raising the Researchfailed to show evidence of such Schemas impossible dependent' to be `mood thus as causative show they that and might suspicion factors for such moods. Teasdale(1993) added a powerful critique by suggestingthat in depression the was non-conscious and was not relevant cognitive processing much of by then current cognitive techniques. therefore not easily accessed It has, however, been a characteristic of CBT that it has been relatively open to criticism Teasdale's Part its to the has theories of response and methods. regularly revised and This 1996). 1996; Teasdale, (Beck, the and concept of schema critique was a revision of between itself that the to emotion and relationship related wide recognition revision was discern linear is difficult It to is highly one. often complex and certainly not a cognition the effect of a cognitive intervention becauselittle is really known about the time interventions Whilst intervention to some cognitive seem work effects. of sequence be Indeed, `work there through'. time to something may need quickly, others may debates few One the sharp change. of remaining unconvincing about rapid cognitive betweenbehaviour therapy and cognitive therapy has been about whether cognitive interventions really add anything to the outcome of exposuretreatment. Network theories of emotion and cognition are emerging: suggestingthat there are many different firing order relationships between emotion, cognition, physiology and behaviour (Teasdale, 1996). Cognitive content is only one part of the active processesin psychopathology. The attention processis increasingly seenas an areato target in CBT. In OCD (obsessivecompulsive disorder), one of the most intractable anxiety disorders, for example, the thought content of OCD patients does not differ significantly from non-patients. The decisive factor seemsto lie in the way patients pay obsessiveattention to those thoughts (Wells, 1997). Similarly, the content of worrying thoughts in GAD (generalised anxiety disorder) patients is the same in non-patients as in patients. Patients, however, attend to theseworries differently and this results in rumination (Leahy, 2005). Recent developmentsin CBT owe something to Buddhism in that therapists have encouraged

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defuse in `mindful the effects of to to to thoughts awareness' such order clients pay CBT be distant from This to the of methods original may seem quite negativeattention. but, nevertheless, mindfulnesshas beensubjectedto outcome scrutiny and early results have discerned (Segal 2002). Some a `fourth wave' of even seempromising et al, people CBT building up in thesedevelopments(Hayes et al, 2004). CBT has shown little tendencyto stay still for long so far so it does seemlikely that there will a fourth wave at issue it has One has been CBT the that of somestage. not addressed enduring criticism of emotionsin therapy as thoroughly as is required (Greenberg,2002). All the new developmentsin CBT seemto be pointing at the areaof new models of understanding and changingthe relationship, increasingly appreciatedas complex, between cognition, emotion and behaviour. 1.3: Personal Motivation for the Study

I have beeninterestedin Cognitive Behaviour Therapy since the early 1980swhen I first readBeck et al's book Cognitive Therapyof Depression. I was then a social work educatorwith a backgroundin behaviouralmethods.I becamemore familiar with CBT methodsafter training as an Alcohol Counsellor in 1984,a Rational Emotive Behaviour Therapist(REBT) in 1992 and a Cognitive Therapist in 1994.As I learnt and practised thesecognitive-behavioural methods,I becamemore and more personally comfortable began I found I that to achievemore concreteand satisfying results them with and also I involved in training for counsellors At time, the was getting more same with clients. full in 1988, time University post organising and teaching therapists secured a and, and on a programmeof counselling training courses.

hostile Some quite andsuspicious seemed students of the CBT modelandthis was
its incompatibility in terms to the conceptsof other models: most of usually couched usually the 'client-centred'nature of Rogers'model and somewhatless frequently by the psychodynamicobjection that CBT only dealswith the surfaceof the problem and ignored the problem's supposed deeperroots. Sheldon(1995) describesteaching the C approachto social workers as operating"in a cold climate" (p.5) due to the tendency of somesocial work studentsto avoid the CB approachon "vague philosophic grounds -

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have that Other too (p. 31). be better observed writers phrase" a aestheticgrounds might the hold quite these model about reservations may psychotherapists and counsellors behaviour therapy Rachman 1996). Persons 1998; even (Dryden, notes, frequently et al, (1996) field. Beck UK the psychiatric `lead to quite un-British excitement' within least in UK, been the has within at therapy received well that always cognitive considers has been for CBT blessing there be an antifield. This as a mixed may the psychiatric CBT to both in some seem may work, and social and counselling psychiatry movement to be `guilty by association' with psychiatry. My interest in the researchareadescribed above came from these experiences.I began to in from trainees therapy if engaging prevented some wonder certain attitudes concerning learning CBT either by preventing the development of a motivation for learning and/or by putting more specific blocks in the way of learning specific concepts and in turn decided I to the test. CBT to these learning the put notions skills. of undermining 1.4: Organisational and Policy Factors that May Influence the Process of Training Trainee responsesto any educational processare likely to be influenced by the age, Data trainees. the of concerning these achievement genderand previous educational factors were collected and analysedas part of this study. It is also important to in in takes this that therapeutic case,one social place a context activity acknowledge that relates to systemsof provision of therapeutic services, involving both the public and private sectors. The modern history of the development of psychological therapy, described earlier in this began in the field of private practice: the consulting rooms of Freud's own chapter, home. Freud, however, had links with the University in Vienna and psychoanalytic practice quickly spreadinto the hospitals via the University professors of medicine and for Jung, psychiatry. example, was a doctor within the Burgholzi Mental Hospital, attachedto the University of Zurich. The public provision of psychological therapy grew only slowly in the UK and USA even after World War II. In the last two decadesof the 20thcentury demand for therapy servicesrose but all forms of public service provision

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for In increasingly the the evidence concerning outcomes of provision. were scrutinised 1990sin the USA the systemof ManagedCare developedin both generalmedicine and mental health services(Hoyt, 2000). There was a coincidenceof interest between both the health insurancecompaniesand public health agenciesto contain costs in the provision of health care and mental health care services.This resulted in a situation in which someagenciesand companieswould only provide funding for psychological therapy where there was a clearly diagnosedcondition, in the caseof mental health, as defined in the Diagnostic and Statistical Manual (DSM.; American Psychiatric Association, 2000) that could be matchedwith an empirically supportedtreatment (EST). In 1995,the Clinical PsychologyDivision of the American Psychological Association identified a number of psychological interventionsas empirically supported.Cognitive behaviouralapproaches constitutedthe majority of theseESTs (Chambless& Ollendick, 2001; Herbert, 2003; Sanderson, 2003). The identification of specific forms of effective therapy diverged from a well-known trend in psychotherapyresearch,the so-called `Dodo Bird' trend that claims all therapiesare nearly equivalent in effect (Castclnuovo et al, 2004). The empirical claims of CBT have led to somehostile reaction from proponentsof other models. Such claims may therefore act as a double edgedsword in the processof disseminatingCBT: they may attract some potential traineesbut repel others.

In the UK, governmentreports and mental health policy documentsstartedto use the languageof evidencebasedmental health (Roth & Fonagy, 1996; Parry & Richardson, 1996;Dept of Health,1999)culminating in the provision of advice leaflets to GPs

regardingtherapiesof choice - in which CBT featuredprominently. Since 2006, these by the proposal from the Labour peer, Lord Layard, policy factors have beenaccentuated to greatly increaseaccess to psychologicaltherapy, especially to CBT (Roth & Pilling, 2007). There are currently ambitious training plans to expandCIT training. This policy plannedexpansionhas important implications for traineesand trainers and thesewill be discussedin the conclusion to the study in Chapter7. This presentstudy therefore sought to find if thesepolicy and employment influences were evident at individual employment level: for example,were employeesin NHS mental health settingsbeing encouragedto

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Were in CBT based training practice? as a prominent example of evidence undertake

by by the that they their trainees might enhance careerprospects perception motivated learningCBT skills?
CBT has been highlighted in other public services as well - including Probation (McGuire, 1995) and Social Work (Sheldon, 1995). The study was also concernedto influence CBT in how the was of experienced professional agencies widely establish linked individual be to this might perceptions of training needs. and whether generally Durkheim (1952) advised against making `psychologistic' assumptionsabout human behaviour. Such assumptionsmight prove over-individualised explanations of behaviour that discount the influence of sociological influences. Consideration of the social and by be the examination of the post-training work will processes augmented employment followed CBT Ashworth (1999) trainees in the NHS three years al up et environment. had been found training them that of already after and many promoted into management positions where they no longer saw clients in face-to-face clinical work.

1.5:

Research Aims and Questions

The studyaimedto answerthe following research questions: " What attitudesdo trainees enteringa CBT training coursehold towards CBT practiceprinciplesandhow do theseattitudesdevelopduring training andin the yearfollowing the endof training? With what level of pre-existingcompetence in performingthe skills
associatedwith CBT practice do trainees enter CBT training and how do these CBT skills develop during training? 0 What kind of association and influence do the attitudes towards CBT principles held before and during training have in the development of competencein skills associatedwith CBT practice?

What characteristics do CBT trainees of CBT training anddevelopment reportasbeingmost likely to leadto the resolutionof difficulties in
learning CBT during training?

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be CBT theory or practice might It was hypothesisedthat attitudesreflecting reservationsabout held by sometraineesenteringtraining with strong allegiancesto other models and that these mi hypothesised It during that strong resistanceto change training. was attitudesmight change inhibit certain types of skill development.The longitudinal nature of the study offered some be far how for change might retained after training and gave trainee attitude prospect exploring chanceto reflect on what aspectsof training, practice and employment might enhance change u maintenanceof change.

1.6: Relation to Theory Piaget (1950) suggested that information processingis accomplishedby the joint of assimilation and accommodation.Assimilation refers to the reception and processes by Accommodation is difference the to the material. of sensory acceptance mind made assimilation. The processes of assimilation and accommodationresult in adaptation: the way humanshave of orientating themselvesto information in the world. This is in the mind by setsof schemas. Piaget developedthe concept of schema from represented Bartlett (1932), whosework establishedthat certain perceptionsmight be assimilated into the mind in a way influenced by pre-existing schema.Piaget extendedthis idea into his development in intellectual studiesof children. For example,a young child might physically seea dog but might not yet have a schemaof `four-legged ness' and so might fully it four-legged not perceive as a creature.Accommodation, a more convinced organisationof information into more permanentforms of knowledge - dependson the developmentof more permanentknowledge structures. This study beginswith the assumptionthat traineesmay approachCBT courseswith a rangeof different schemasabout psychological therapy and theseschematamay be evident in various therapeuticprinciples and attitudes. Furthermore,theseschemasmay influence the way that traineesassimilatethe new conceptsfrom CBT theory and about therapy may also influence the processof adaptation practice. Pre-existing schemas to new schemasrelatedto CBT principles and attitudes. One hypothesisthat was tested in this regardwas that where traineescome to training with therapeuticattitudes and

in CBT, the process that arevery differentto equivalent Schemas concepts of adaptation

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CB hypothesis further distorted. A also that may delayed acquisition be skill was or may be aversely effected by these delays and skews. When a person is attempting to assimilate new ideas with older ones, that person may dissonancerefers to the Cognitive 1957). (Festinger, dissonance' `cognitive experience Festinger's ideas time. the holding same two or more contradictory at experienceof have Many 2003). (Atherton, literature studies concept has spawneda considerable to dissonance to tends seek new motivate people the that experienceof confirmed long be dissonance periods over quite maintained though may meaning, of syntheses (Atherton, 2003). Periods of dissonanceare very evident in many of the Socratic dialogues (Neighbour, 1992; Nehemas, 1998). The term aporia, of Greek origin, has been The dissonance. describe ancient meaning of aporia the state of experiencing usedto is The 1998). (Nehemas, term being used now point to crossing no with at a river relates by philosophersto indicate a gap in knowledge. Later discussion will consider whether the experienceof dissonancein training may be an unavoidable and perhaps even desirable stageof learning new ideas. Aronson & Pratkanis (2001) suggestthat people with dissonant ideas tend to move towards new synthesesthat maintain their view of themselves as rational and social beings. It was quite likely therefore that the trainees in this study, especially those with dissonance likely be in different to cognitive therapeutic report training a model, would different degrees be likely in CBT. They to and to training report will also as a reaction experiencesof moving towards new synthesesof old and new therapeutic principles. There could also have been evidence of synthesesthat reflect the maintenanceof selfconcept. Atherton (1999), reporting on professional training, suggeststhat professionals because likely for in have invested to training to the training claim value are effort who had been imply tricked or sold short. that would one admit otherwise To some extent, the ideas of assimilation and dissonanceduring training assumethat an influencing processis present in any training situation. The processesof influencing other been in have & For Petty extensively social studied psychology. example, people Capiocco (1981; 1986) have distinguished between peripheral and central change

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by Attitudes peripheral processes are quite amenableto change, often gained processes. in influencing New reached attitudes processes such as persuasion. via relatively unsubtle this way, however, may be short-lived and may not show much resilience when however, are more challenged.Attitudes resulting from effortful central processes, resistantto changevia influencing and are generally most likely to changeby a process of elaborationlikelihood. The elaborationlikelihood model (ELM) model suggeststhat a situation in which the learner is able to consider new ideasas against old ideas and is given relative freedomto `play' with new setsof ideasis more likely to result in them being able to reacha convincing personalaccommodation.The probability of elaboration likelihood is increasedwhen: 1) the personhas the capacity to elaborateattitudes, 2) the personis motivated to elaborateattitudes,3) thoughts favourable to a new attitude predominatein the person's mind, and 4) thoughts favourable to the new attitude are stored in long term memory (Heesacker& Meija-Millan, 1996). It is important to note that peripheral and central cognitive processingoccur on a continuum. A strongly held another attitude (Petty & Krosnick, attitude can serveas a peripheral cue for assessing 1995).The ELM has beenapplied to psychological therapy (Heesacker& Mejia-Millan, 1996)but not yet to training in psychological therapy. Elaboration likelihood may be by the values of adult educationtheory as advancedby writers such as Knowles enhanced (1984). Knowles suggested that successfuladult learning is characterisedby andragogy including especially self-directedness, for learning from life experience, resourcefulness for from tasks performanceof social roles, and problem-centred motivation required learning. Cassidy (2004) found that psychiatric residentsin Canadareported such an approachto wanting to learn CBT as part of continuing medical education. Merriam (1993,2001), however, suggeststhat the principles of the `andragogic' orientation are for not, example,be appropriatefor certificated learning. context specific and may Psychiatric residentsmay, for example,regard themselvesas having attained their primary professionalidentity and may seeCBT as `additive' learning (Atherton, 1999). Trainers in certificated learning usually exercisecontrol over the processes of curriculum implementationand training coursemanagement.Data from all kinds of learnerscertainly suggests the presence of a pervasive senseof anxiety about assessment and the achievementof qualification by trainees(Baxter Magolda, 1996; Clarkson, 1994)

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He learning in theory. light Knowles' of subsequentadult Tight (2002) also reviews work Knowles' transcended value own the never completely that concept andragogy suggests basebut neverthelessplayed an important role in the development of a unique the Along learning as such concepts to the with needs of adults. educational approach 1984), learning (Kolb, the 1983) (Schon, the cycle experiential and reflective practitioner learning has helped such to methods, adult contemporary shape such concept andragogy based Experiential learning. learning, problem reflective practice and as experiential learning has been widely taken up in counselling education (Johns, 1996). Problem based has 2005) & Taylor, (Burgess in influential been has learning and social work education beenused in clinical psychology (Huey, 2001) and CBT training (Myles & Milne, 2004). Adult education approachesto training in psychological therapy are further reviewed in Chapters3.and discussedin Chapters6&7.

1.7:

Methods of data collection and analysis

This section will describe the main researchmethods used in the study. Data collection followed a strategy basedon survey design. The methods used to gather data regarding trainees' experiencesduring training were:

" " "

Questionnaire Interview Assessmentof competenceusing a validated scale

The data were analysedwith regard to the researchquestions presentedin 1.5, especially concerning the characteristicsof trainees,their perceptions of CBT training and the developmentof competenceduring training. Becausethe study required data to facilitate understandingof teaching and learning processesover a considerableperiod of time: between 2 -3 years covering the pre-training period, the training period and the posttraining period - the study design is longitudinal, involving `panels' of participants and repeatedmeasures(de Vaus, 2001). A questionnaire,the Cognitive Behaviour Therapy Training Questionnaire (CBTTQ), including a Cognitive Behaviour Principles Inventory (CBPD, was developed to measure

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the trainees' beliefs systemsand their compatibility with the principles of CBT (Beck & Emery, 1985; Beck, 1995).The questionnairealso askeda number of questions about the for degree training: the of example, aspects of training support social and employment from employers.This questionnairewas administeredjust prior to the commencementof training, at the end of the training courseand at one-yearfollow up. The aim of this questionnairewas to get broad, quantitative data.At its final administration, respondents were askedif they would be willing to participate in a semi-structuredinterview.

The aim of interviews wasto gather narrower, morequalitativedatafrom what was

be likely to as a smaller sample.Having sourcesof quantitative and qualitative assumed data both bearing on the sametraining processes offered the possibility of triangulating different types of data,thereby examining the samephenomenafrom different angles (Bryman, 2004). A decision was madeto interview only those traineeswho had finished the programmeof studies- which included a period of researchafter the CB training one year after the completion of all studies.This decision was made in order to limit the effect on `social desirability' factors that may have beenlinked to traineesbeing interviewed by a person involved in the courseteaching team. Trainee acquisition CBT of CBT competencemeasure(Milne et al, 2001). skills was measuredusing a standardised The questionnairedata were analysedusing the SPSSprogramme, 14thEdition, and analysis focussedon describingthe structureand content of trainees' initial therapeutic principles and how they developedover the period of the study. Analysis was also made of employment factors to determine if different agenciesexert influence over motivation for training and for practice. The semi-structuredinterview was developmental in nature and gatheredretrospectivedata about the training experienceand prospective data on expectationsabout the future. A number of areasoverlapped in the questionnaireand interview schedule,allowing for crosscheckingof information given at different points of time and triangulation of quantitative and qualitative data bearing on the sameresearch questions.The researchdesign and methodswill be more fully describedin Chapter 4. 1.8: Conclusion to Chapter 1

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The study aimed to build a solid picture of trainee characteristics, training processesand the in they of consideration operate, allowing which the social and employment context The factors in training these outcomes. successful most effective combinations of findings are reported in Chapters 5 and 6 and their implications are discussedin Chapter 7. During the life of this research,the UK government announced a programme to expand CBT training so the policy implications of this researchfor therapy training and provision discussed. be will Other researchhas covered some of the ground covered in this study but new factors give its lie in longitudinal factors These depth this to nature, the new study. greater development development the over time, the measurementof of attitude measurementof helped development learning trainees' the views on what consideration of and and skill lack focus & Overholser (1997) in As Freiheit difficulties training. note, of on overcome in important has been gap previous research: an skill acquisition
The present study is limited by having only clinical graduate students as subjects, and relying on a self-report measureto assessfrequency of using cognitive and behavioural techniques. Without confirming evidence from observation or reports from clinical supervisors, it is difficult to determine the accuracy of self-report usageof cognitivebehavioural techniques. Moreover, the proficiency of using cognitive-behavioural Becausestudents had different supervisors, the techniques as trainees was not assessed. utility of competency-basedscoreswould have been questionable. Future research may want to address whether trainees from other orientations become as competent at using CB techniques as trainees with a CB bias (Freiheit & Overholser, 1997, p. 85, Bold italics added).

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CHAPTER 2: The Principles and Practice of Cognitive Behaviour Therapy

Take no enterprisein hand at haphazardor without regard to the principles governing its fundamentals: life brief, Make the to yet so as embrace your rules of proper execution... recurrenceto them will suffice to removeall vexation... (p.63)

by the pugilist,not the In the management takeexample principles, of your ... is his blade has down it One to the and again; other never pick up puts swordsman. only to clenchit (p.182). withouthis hand,andsoneeds MarcusAurelius,TheMeditations. (OxfordUniversityPress,1989)

This chaptercritically examinesthe principles of CBT and the model of practice derived from them. It will pay particular attention to featuresof the principles that arc likely to increaseor decrease traineesagreementwith and adherence to them. In some cases,the CBT be to the to of principles will adhere affected by adherenceto previous ability 1996). The (Persons et al, emphasison assimilation and of practice models accommodationin the processingof information whilst learning CBT reflects some of the processof the CBT model itself. aspects According to the ShorterOxford Dictionary (Onions, 1973,p. 1585),the word `principle' has three meanings: 1) `origin, source', 2) `fundamentaltruth, law or motive force', 3) `rudiment or element'. Many applied subjectsuse the expression`principles and practice' in the secondmeaning.A set of principles, derived from a parsimoniousset of axioms, is describedand linked to practical stepsinvolved in their implementation.Training in the is subject often structuredround the teachingof principles and practice of of a application their implementation.Beck (1976), Beck & Emery (1985), Beck (1995), and Alford & Beck (1997) describean evolving set of principles regardingthe nature and implementationof cognitive therapy. Beck's cognitive therapy has already been located within the evolution of the wider school of CBT. The purposeof this chapter is to describeand critically examinethe principles describedby Beck and his colleagues.This is an important step in the overall rationale of this thesis because the thesis focuseson how groupsof traineesin CBT were able to learn theseprinciples and the extent to which they were able to implement them in practice. The principles will be critically reviewed in their own right and also by comparisonwith the theoretical and practical principles of

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in 1, Chapter trainees As will therapy. to noted was psychological other approaches frequently be influenced by these other principles. field the how of The introductory chapter explained multiple approachesemerged within had therapy (1976) and of age that Beck come cognitive therapy. claimed psychological had "warranted admission to the arenaof controversy" (p. 7) alongside other approaches Cognitive frequently has that the Beck of admission argued to psychological therapy. be: it fact by to field that the claim could Therapy to this wider was warranted
(1) theory of a comprehensive provides which of psychotherapy a system ... body knowledge (2)_ drives and the of that a structure of psychotherapy, psychopathology demonstrate findings (3) that findings theory, the and research which supports empirical its effectiveness(Weishaar, 1993, p.47).

The principles of CBT were first discussedin general form by Beck (1976). These by Beck & Emery then of statements of principles series presentedas a principles were (1985) and were again discussedby Beck (1995) and Alford & Beck (1997). The clearest formulated 10 (1985), Emery is by & Beck these them as who principles statementof separatestatements: 1) Cognitive therapy is brief and time-limited. 2) Cognitive therapy is structured and directive. 3) Cognitive therapy is problem and goal-oriented. 4) Cognitive therapy is basedon an educational model. 5) Homework is a central feature of cognitive therapy.

6) Cognitivetherapyusesprimarily the Socraticmethod.

7) The theory and techniques of cognitive therapy rely on the inductive method. 8) A sound therapeutic relationship is a necessarycondition for effective cognitive therapy. 9) Therapy is a collaborative effort between therapist and patient. 10) Cognitive therapy is basedon the cognitive model of emotional disorders. Each principle will be described in turn. The rationale for each will be explained, and researchand other evidence pertaining to it will be explored. The description of each

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-w ,

it how to by equivalent be relate might of consideration concluded principle will less 9, 8 Some offer and in as such principles, therapeutic models. other principles described be from therefore for differentiation therapy models and will not other potential highly 10, 1,2 Other length are and in equivalent to others. principles, especially intrinsically They basis CBT. in to the theoretical of significant their contribution These from CBT those differentiate the beliefs associated of other schools. with length The be than therefore chapter will covered at greater others. principles will CBT in how describing CBT by skills used currently principles are reflected conclude inventories.

Beck's work beganas an approachto treating depressionand was then also applied to CBT have CBT into different theory Applications and now spread areas. of many anxiety. in however, the treatment of anxiety tested clearly still most established and are practice, final The from This depression. therefore these two use examples areas. review will and

formulation in by its' CBT illustrated importance be the of applicationto will principleof PanicDisorder,oneof the anxietydisorders asdefinedin DSM"IV TR (APA, 2000).

2.1: Principle 1: CBV is brief and time limited

Just as he (Beck) was completing his analysis,they (Beck and his wife) were attending a meeting of the American PsychoanalyticAssociation, where they spotted a sign outside a lecture hall reading 'Symposium 15: Problemsof re-Analysis.' Beck recalls Phyllis'

"re-analysis? "What!" sheexclaimed, You mean reaction. you haveto go backand get " Beck his own That's claimsthatheropinionhelpedcrystallise crazy! re-analysed? for aftertwo anda half yearsof analysis, he hadn'tnoticedany changes thoughts, ) 1993,pg.19. (Weishaar, Cognitivetherapy to treatment approach of anxietyis a time-limited,problem-focused 1997, 42). disorders based (Wells, the p. model of anxiety on cognitive 2.1.1: Defining short-term and long-term therapy Any current discussionof time limits in psychological therapy has the inherent difficulty that stemsfrom the relativity of the terms'long-term' and 'short-term'. In practice, a identify definitions has that developed would a continuum consensus around pragmatic
' The use of the terms 'cognitive therapy' and `CBT' follow the statementmade on page 12, and follow the usageof Hawton et al (1989) and Rachman,(1997b).

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fewer being 20 defined be and sessions one-hour 'short-term' or as end would the where 40 duration or more being therapy of a of one year or more - approximately 'long-term' as is to `medium The term' 1997). (Ivey used sometimes expression et al, such sessionsis, terms The the long hour 39 21 between relativity of sessions. describetherapy of and defined been has for Panic Disorder CBT however, evident at all points of the continuum. Garcia& Botella (Clark, 1996; few 5 in as sessions as being available a package of as in be therapies Some that 1999). can practised Palacios, certain other authors claim Desensitisation Movement Eye for formats: and example, session single potentially Reprocessing(EMDR) (Shapiro, 1995), solution-focussed brief therapy (O'Connell, health in UK interventions care The current primary 2001). majority of counselling is 6-8 in sessions,usually conducted over counselling settings and employee assistance limit 1996: (Parry & Richardson, being this to over needed go with special permission BACP, 1998). At the other end of the continuum, psychoanalytic therapy may be for (and for 10 4 to 3 times over years more), giving a potential up per week conducted or 2,000 sessions.The psychoanalyst, Winnicott, for example, is described as having his (Grolnick, training than this of as part analysis number of sessions attendedmore 1991). The length of traditional psychoanalytic treatment led Rogers (1967) to regard his being 'short-term' that the therapy when volume reveals same as client-centred of model Rogers frequently refers to working with clients for between 80-100 sessions. There has been a major contextual change in the last 20 years in that psychological therapieshave gradually moved into the mainstream health systemsof Britain and USA. At a time when both the central government and insurance basedwelfare funding sources that pay for these systems have been subject to constant review (Cummings & Sayama, 1995) this has meant that the therapieshave had to contend with a "socio-economic climate that values shorter treatmentsand demonstratedefficacy" (Weishaar, 1993, p. 141). Studiesof psychological therapy developed a more rigorous approach to outcome from the 1970sonward. They have tended to show that, for most clients, changebegins in therapy and is enhancedby long-term interventions only in some cases early relatively

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(Ivey et al, 1997; Cummings & Sayama,1995). Reviewing a wide variety of describes the (1995) Sheldon this interventions, and view concurswith psychological `short for `decreasing social work, advocates marginal utility' of therapy over time and is Therapy Cognitive Beck's intensive' interventions.(p. 16). The short-term nature of first describedin the seminal 1979publication on the cognitive therapy of depression (Beck et al, 1979) in a chapterdescribingthe typical courseof therapy. This typical for helpful it is is It held 15 often over weeks. noted that courseis defined as 20 sessions initial therapy the during have the two of to phase the depressed sessions per week patient but this can be droppedto one sessionper week after 3-4 weeks. 2.1.2: The rationale for short-term therapy Whilst an early pattern in therapy of 2 sessions per week is justified by the idea that detailed is initial to therapeutic needed achieve mass symptom relief, no overall critical length is for therapy the of offered in Beck et al's (1979) work. general rationale If anything, the implied rationale is an empirical one, basedon researchstudies on implementing the CBT structurein which the averagenumber of sessionsturned out to be 15 (Beck et al, 1979).Nonethelessthis pattern seemsto have set the norm for the length definitions CBT. Most subsequent of typical length have taken 20 sessionsas of standard the upper limit. There has beensomevariation accordingto the problem area being in generalthe numberof sessions for the treatmentof anxiety disorders has addressed: beenset slightly lower than other areas,especially depression. A more detailed and rationale-giving discussionof the short-term nature of cognitive therapy is given in the considerationof CBT principles in Beck and Emery (1985), who describeits application to anxiety disorders.The authorsoffer the samepattern of for the treatmentof anxiety as that for the treatmentof depression(Beck et al, sessions 1979)- twice weekly treatmentfor a short period followed by weekly sessionsup to 20. The needfor the number of sessions to match individual problems and patterns is acknowledged:so that specific anxieties may be treated in fewer sessionsand individual however, The therapy, time. this is cognitive of patientsmay require extra spirit of aspect indicated in statements that, "Long-term therapy for anxiety is unnecessary and is, in

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" brisk. is "... (p. 171), therapy " the relatively pace of and, many cases,undesirable. to the patient that problems (p. 171).This short-term emphasiscontains a meta-message are capableof solution. It is suggestedthat the therapist "rushes slowly" (p. 171) and this implies covering important areasbut being able to "move on quickly" (p. 171). Such important areasmight be background history and the exploration of original causes.Beck & Emery (1985) be kept As these to the areasare that a minimum. material such of exploration suggest in therapists therapy, are often psychodynamic psychodynamic emphasised strongly 172) & (1985, 1996). Beck Emery CBT (Persons offer a this p. at, et aspectof critical of for keeping cognitive and encouragements number of other supplementary guidelines behaviour therapy time-limited: 1) Keep it simple. 2) Make treatment specific and concrete. 3) Stresshomework.

4) Make on-goingassessments.

5) Stay task-relevant: Discussing religious, spiritual or philosophical beliefs, if not insists If therapy. the to the concern, prolongs patient on patient's main pertinent how it from distracts discussions, the main the therapist can out point such businessof therapy. 6) Use time-managementtechniques: e.g., setting an agendafor each session. 7) Develop a brief-intervention mind-set. 8) Stay focused on manageableproblems.

It may be noted that the development of `a brief intervention mind-set' amongst trainees in for business-like key The list this the study. a area of concern of spirit evident reflects points above is somewhat less emphasisedin the parallel set of principles given by Judith Beck. Judith Beck (1995, p.7) comments:
Cognitive therapy aims to be time limited (but) make enough not all patients ... ... progressin a few months. Some patients require I or 2 years of therapy (possibly longer) to modify very rigid dysfunctional beliefs and patterns of behaviour that contribute to their chronic distress.

2.1.3: Long-term versions of CBT Judith Beck shows a slight shift in emphasison the question of time limits by changing them from a given to an aim. This may have resulted from CBT refashioning itself

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1996). (Persons at, therapists et somewhatto appealto a wider range of counsellorsand If we examineCBT as a social and therapeutic `movement', it may be that in its early years it was concernedto differentiate itself from the other therapiesthat were on offer. When it cameto be regardedas a significant player - `warrantedadmission into the arena longer & Beck (1997, 7) in Alford the neededto and no p. of controversy' words of it has been it be its identity, that able to take a less rigid view of certain may establish have length The the therapy may principle concerning of principles. slight softening on (Young `schema-focused because the the therapy' et at, of emergence model of occurred 2003). Young et al (2003, pp 2-4) describehow the evolution of schemafocused therapy beganas they found that the following assumptionsunderlying the 'standardmodel' of fit did therapy a significant minority of patientswith more difficult not cognitive problems: 1) Patientshave access to feelings with brief training.

haveaccess 2) Patients brief to thoughts training. andimages with 3) Thepatienthasidentifiableconcerns on which to focus.

4) Patientsare motivated to do homework assignmentsand learn self-control strategies.

in a collaborative 5) Thepatientcanengage relationship with the therapistin a few sessions. 6) Difficulty in the therapeutic is not a majorproblemfocus. relationship

7) Cognitive and behavioural patternscan be changedthrough empirical analysis, logical discourse,experimentation,gradual stepsand practice.

When theseassumptionsare not met, therapy is likely to last longer than the 20-session limit. Somecritics have consideredthat there has beena 'psychoanalytic drift' inherent to cognitive therapy (Milton, 2001, p.44 1). The developmenttowards a more open-ended and longer version of CBT may be taken as evidencefor this 'drift' and could threaten the parsimonyof the initial model. 2.1.4: Length of therapy and efficacy There has beencomparatively little researchinto the effects of different lengths of psychologicaltherapy (Roth & Fonagy, 1996).This is perhapssurprising given the socioeconomicimperative towards briefer work. A large cost benefit analysis was conducted longitudinal studies,run over 25 years between 1960s as part of the Kaiser Permanente and 1980s(Cummings, 1977; Cummings & Sayama,1995).The results showed that, for

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benefits therapy 85% the i. were of measurable of clients, much of around most, e., 'diminishing first 10 in trend the a noticeable of returns' was sessions and achieved for brief be This therapy. taken thereafter. as straightforward a rationale might evident There were, however, also smaller groups of clients, around 10%, for whom middle range finally, i. is `dose 20 the size' and, most effective number of sessions, e., around or over, the other 5% may need much longer-term therapy. One getsthe impression that the landscapeof practice has shifted so much that almost all by brief is the therapy outcomes estimating of relatively of all conducted research recent types (Cummings et al, 1998; Cummings & Cummings, 2000). It is interesting to note that there has been a shift towards briefer psychodynamic models (Malan, 1976; Della Selva, 2004). Roth & Fonagy (1996), for example, report on brief dynamic therapy for depression:in a mode of 12 sessiontreatments (range 12-36). This type of model has beenused in clinical trials as the alternative treatment condition to CBT, against which it less (Andrews, 1999; Hollon et al, 1996), though symptom reduction recorded generally in some studies it has performed equally in this and other respects(Milton et al, 1999). Interpersonaltherapy (IPT), a brief protocol-based dynamically orientated treatment (Weissmanet al, 2000) was devised as an alternative treatment method to cognitive therapy in the large NIMH trials in the late 1980s.It performed as well as cognitive therapy in many aspectsand is now regarded as a treatment of choice, alongside CBT, for depression disorders (Roth & Fonagy, 1996). types of and eating many Cummings & Sayama,(1995) suggestanother compelling issue for therapists exploring the idea of `dose size'. They suggestthat therapists should question their assumptions be therapy should whether about continuous. The data from the Kaiser Permanente studies suggeststhat, especially for clients with longer-term needs, a `general practice' model may be more relevant than weekly sessions.Such an approach is defined as "brief intermittent psychotherapythroughout the life cycle" (Cummings & Sayama, 1995, 9). p. 2.1.5: Length of therapy in other therapeutic models CBT has a pronounced leaning towards short-term work. This characteristic was both

andonesuitedto the personal temperament pragmatic of its founders,showinga

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CBT business: The for'doing the models, the early short-term success of preference in have imperatives, the increasing shifting a part played socio-economic along with field towards working over shorter time periods. therapy whole psychological The traditional model of psychodynamictherapy has beena long-term one. This is partly because the needto `work though' problems of long duration, the theory has stressed usually developedin childhood (Jacobs,2004). The fact that many of the underlying dynamicsof theseproblems are held to be unconsciousmay make this working through a lengthier process,typically lasting yearsrather than weeksor months. Humanistic therapy has typically arguedagainstthis length of therapy and has seengiving ample time as part of the respectthat should be extendedto clients (Rogers, 1967).Person-centred have also beenresistantto the idea that therapy should be structured and approaches focusedby the therapist for fear of imposing the therapist's agendaon the client. This have in focus humanistic therapy developing more as a to resulted may reticence `medium term' therapy than a brief one. Perhapsin response to the demand for shorter term therapy, however, briefer models for both psychodynamic(Della Selva, 2004) and humanistic (O'Connell, 2001) models have emergedin more recenttimes. Paradoxically, as this shorteningof other modelshas developed,longer-term versions of Therapy (Young et al, 2003) and Dialetical CBT have emerged:Schema-Focused Behaviour Therapy (Linehan, 1993)are both concernedwith working with client personality problems. There is growing consensus on the potential efficacy of short-termwork and conversely a long-term towards sceptical attitude work: although the definition of length itself is more problematic. Additionally, most therapists,eventhose with a preferencefor shorter-term work, agreethat some clients will require longer, sometimesconsiderably longer, periods of therapy. At the end of the day, the real differencesbetweenmodels may turn on how large this group is estimatedto be (Cummings & Sayama,1995).

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In relation to this study, we might hypothesisethat a trainee open to shorter-term work (Bolter et at, 1990) would be more open to the CBT model, although the polarisation that be in been have so pronounced now. years past may not expected might The relatively short-term nature of CBT has affected other areasof practice. It has led to direction have (Principle 2). It CBT that may also meant and more emphasison structure had to focus on more sharply defined problems in order to make best use of its more limited time perspective,comparedto other approaches(Principle 3). CBT has followed the behavioural tradition in defining problems in concrete, often behavioural and/or is in development focus The based the terms. shown on problems of the symptoms list' (Fennell, 1989; Persons, 1989). The list is `problem the problem a menu of concept basis. is It the client and on a regular with reviewed used as a guide agreed of problems be finished is focus to thereby therapy and an aid maintaining may a on shorton when term therapy. 2.2: Principle 2: CBT is structured and directional.

2.2.1: The rationale for structure and direction The debateabout structure is sometimesconfused becausethe term `structure' is used in two rather different but inter-related ways. Firstly, structure may refer to a series of behavioural stepsthat therapist and/or client can follow within a sessionor series of has definite CBT a sessionstructure that should be quite closely followed, sessions. in (Beck, 1995). The session every structure consists of sequential steps generally beginning with conducting a `mood check' on how the client is feeling, followed by for items, including Agenda the agenda session. an setting checking homework tasks, are then pursuedas sessiontargets. The sessionfinishes by setting a new homework task and by taking client feedback on the session.Structure in this sensecan also be extended to the characteristic shapeof the therapeutic intervention over time; for example, that CBT usually begins by targeting symptom relief and proceedslater to preventative work on (Beck vulnerabilities underlying et al, 1979; Wells, 1997).

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One rationale for structureof this kind is that clients are often in a confusedand chaotic Therapy during life structure can their counselling. period of and are emotionally aroused be helpful boundaries this contained. can arousal confusion and within which offer Therapistsmay sometimesforget that therapy is an unfamiliar experiencefor many in for learn be it the know their to When them role the easier may clients. structure clients the collaborative therapy.Alford & Beck (1997) also arguethat structureenhances transferof learning from the therapy context to the real life context.

in directional Structured to the endof goal thattheyarestructured sessions are

therapeutic (1995) Sheldon that approaches and within social structured notes attainment. direction Both structure need, and with greatereffectiveness. work are associated however,to be negotiatedwith the client. Two aspectsof the structure are especially (collaborative agreementof issues helpful in conducting such negotiation: agenda-setting feedback (evaluating taking the client's in be therapy and the session) to tackled Clients be the to session). may resistant the of structure or usefulness of perception it is Whilst 1994). (Beutler that the cognitive both recommended direction or et al, (Leahy, 2001), it is helpful to adjust explored this are resistance often also componentsof direction. and/or structure A secondusageof the term `structure' in therapy may refer to the `deep structure' of the kind lies This in the therapist's ways of 1997). (Ivey of structure therapy et al, the about the underlying psychological understanding client's problems and assumptions is facilitate. the therapy that to Another attempting processes collaborative value change is however, try to CBT, to make this structural rationale as explicit as possible to the of client:
Structureis necessary for collaboration.Patientsmust learn how improvement is obtained in order to view themselvesas collaborative partnersin the therapeuticenterprise.To teach patientsin this manner,therapistsmust themselvespossess a theoretical rationale for specific treatmenttechniques.Otherwise,there is no structureon which to basethe processof collaboration... The American Board of ProfessionalPsychology states explicitly that to earnthe ABPP Diploma, a psychologist must treat or make `in a meaningful and consistentmanner... backed by a coherent recommendations rationale' (ABPP, 1996,p.3, cited in Alford & Beck, 1997, p. 12).

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Rogerian in be this with that case is term can easily confused, `Direction' perhapsanother directive is CBT been thus has It that `non-directive'. and `directive' argued and terms, direction' `offering By the terms and using self-determination. works againstclient `maintaining direction' `accepting that selfand directional' `being one can clarify It 1985). & Macdonald, (Hudson may determination' are not mutually exclusive concepts (Bandura, is `directionless' `directional' the which opposite of also be helpful to consider 1969,quoted in Sheldon, 1995, p. 25). 2.2.2: Structure and Direction in Other Therapeutic Models in itself `structure' hostile to the notion of Psychodynamictherapists are not usually because they usually do have structural notions of the kind of interventions that they are idea Whilst that they are 1997). the (Eells, they accept can usually trying to make following a structure, perhapsmore like a `deep structure', they tend to be less happy CBT, taking therapy they spontaneity may see as out of the which of structure overt with both keep for `free inhibit thereby This the might association' and scope may sessions. the subject matter at surface level (Personset al, 1996) and prevent more `unconscious' description fuller 2001). A (Milton, from the of psychodynamic emerging material (1996) is in by Chapter 3. Persons CBT et al offered established about reservations Humanistic therapists, especially person-centredtherapists and counsellors, are generally `directiveness'. CBT `Person-centred' to the and adherence structure of quite suspicious describe by had Rogers (1980) final to type therapy term that the a of used was 1942) been (Rogers, `client-centred' (Rogers, `non-directive' and called previously 1951). A key idea of the Rogerian approach is that therapists should not regard themselvesas `experts' in the client's problems and should therefore resist the impulse to At `direct' to and make suggestions clients. most, the therapist might advice give facilitate the client in such markedly accepting ways that the chancesof clients finding their own solutions is maximised. This is an influential notion in psychotherapy and is, to followed in CBT (Beck et al, 1979). Rogerians tend to hold a strong version some extent, focus this much therapeutic attention on avoiding direction of clients. principle and of Therapistswho strongly follow the concept of `non-directiveness' may therefore be wary

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CBT that imposed the they that the principle may see client, and on of anything appears light. in directive this the therapist to structure provide overt and encourages Principle 3: CBT is problem and goal-orientated

2.3:

2.3.1: Rationale for a problem and goal-oriented approach Hudson & Macdonald (1985) make the point that although all therapy models must have be The holds behavioural that the tradition problemgoals should such overt. goals, Beck in by & be in CBT therapy the offered guidelines seen can clearly solving emphasis important Emery (1985, p. 172).They stressworking on manageable problems as an rationale for brevity:
Becausecognitive therapy is time-limited, many of the patient'sproblems will remain By have time the treatment the treatment. enough the will ends, patient end of unsolved at his knowing that the to and solve problems tools on own, approach psychological if booster for is sessions necessary. therapist available

the client to develop the potential to becomeher own The transfer of skills encourages therapist.Brewin (1996) exploresthe evidenceregardingthe effective elementsof CBT treatment.He concludesthat the transfer of problem-solving skills is likely to be one of Evidence that a main advantageof CBT for suggests the most effective elements. depressionis that it promotesrelapsepreventionby increasingthe client's ability to solve 1996). Jacobson (Hollon therapy et al, et al (1999a: 1999b) also show that problems after depression CBT is likely to rest with relatively simple the with of efficacy of much

be by that taught skills can non-therapist staff. problemsolving

Beck & Emery (1985, p. 171) invoke a deliberately business-likeand problem-solving "... puts in a task-orientated spirit by arguing that specifying a certain number of sessions frame for getting down to business. "
2.3.2: Problem-solving in other therapeutic models

Although almost all therapiesaim to solve problems,they may not have such a clear focus on `problem-solving' asthat presentedin CBT. The focus on problem solving in CBT is closely relatedto its preferencefor a briefer time scale.As both psychodynamic

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have in form, do this traditional humanistic therapy, short-term not especially and different have they ways of solving problems, often characteristically emphasisso focusing `on underlying mechanisms' rather than overt problems. Various cognitive and to problem solving have stressedconcrete and specific steps in behavioural approaches focus invariably 1999). These & Nezu, (D'Zurilla more on concrete steps the process focus better, than the on rather more psychodynamic managingovert problems CBT `underlying the the the of or supposed origins problem. mechanisms' modifying therapists,as a first assumption,are more likely to come directly to the overt problem, likely look it. is Such to therapist underneath problem more a psychodynamic whereas it into helpful is takes the client's current problem-solving style when solving particularly have favoured Rogers Humanistic 1995). therapists (Sheldon, such as exploring account has been distrustful `rational' Gestalt Its to therapy of approaches problems. problems. founder, Fritz Perls, suggestedthat the humans should `lose their minds and come to their Some 1993). have CBT & MacKewn, (Clarkson to approaches recent conceded senses' that CBT practitioners may indeed have been over-rational in their approach to problem is it important Hayes (2004) 2004). (Hayes to consider what al suggest et al, et solving has Sometimes to the the the client may solve problem. client used previously strategies be trying to use the therapy to buttress a dysfunctional solution. Hayes et al (2004) therefore suggestthat it is important to invest more effort in ensuring that the client has `accepted'the problem and is `committed' to changing it. Problem-solving that preceded such acceptancecould prove premature and ultimately unsatisfactory. This line of however, is not advocating abandoning rational problem solving per se but is reasoning, may have non-rational elements. suggestingthat change processes 2.4: Principle 4: CBT uses an educational model

2.4.1: Rationale for an educational approach to therapy

It is helpful for the therapist to view himself as a teacher of anxiety-managementskills. (Beck & Emery, 1985, p. 185)

Learning has taken a central role in the behavioural and cognitive approachesof both generalpsychology and psychotherapy. CBT practitioners often use the term `psychoeducation' (Hawton et al, 1989) to describe this aspectof their practice. This term seems

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to be usedin two slightly different ways. In the first use of the term, the therapist seeks to help the client to `learn to learn' (Beck, 1976,p.229): that is, how to open one's thinking because important in is This behaviour therapeutic clients to work other possibilities. and learn failing by 1975) (Raimy, to in `neurotic be the and paradox' so-called may stuck from negativeexperiences, may keep repeatingthe samemistakes. The secondsensein which `psycho-education'is used is that of offering the client new information from a psychologically informed point of view. It seemslikely that more clients are now accessinginformation about their psychological problem areasand & Luce, 2003). Internet (Taylor The from Internet the treatments of quality possible information is highly variable so that clients may still not be well informed about the being for the depression, some may regard of more symptoms and as example, nature of if Furthermore, depressed, they thinking their are than they are. actually pathological influenced by be is likely to the pessimismand negative their condition own about depressive (Beck, thinking 1988: 1967: Brewin, bias of that characteristic are attention Gotlib & Hammen, 1992). information is available, it cannot be assumed Even when appropriatepsycho-educational that clients will assimilateit. There is much evidencethat patients in general medical key health information (Williams do assimilate not et al, 2000) and this may be settings field in the of psychologicaltherapy. It is becauseof this problem even more pronounced functional information the that psycho-educationis of more assimilation concerning tackled in a systematicway by CBT practitioners.

2.4.2: Psycho-education in other therapeutic models. probably because of the assumptionof `expert knowledge' that lies at its heart. Barker & Buchanan-Barker (2004) warn that psycho-educationcan be a kind of `one size fits all' and seeminglykind treatmentstrategythat is actually more interestedin fitting the `patient' into the treatmentprogrammethan in respondingto the patient as a unique individual. Somehumanisticpractitionershave expressed reservationsabout `psycho-education'

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Debatesabout `patient empowerment' in health services often focus on the nature of treatmentprogrammesand individuals' respond to them. Cahill (1999) reviewed the literature on patient participation and suggestedcriteria to assessgenuine participation: 1) 2) 3) 4) There should be a relationship between the treatment agent and the patient. The knowledge gap between the two should be narrowed. The treatment agent's power should be surrenderedto a degree. The processshould result in selective activities.

5)

The patientshouldmakea positive gain from the process.

Treatmentprotocols have played an important role in the development of CBT (Clark, 1996).Most protocols contain a psycho-educationalphase.The five criteria above are in the CBT literature - for example, the emphasison collaboration covered generally well and therapeutic relationship within the principles of CBT being now considered. The issueof power is obviously complex. CBT has been criticised for not addressingthe issueof their social power and of not adopting a `power sensitive' perspective (Spong & Hollanders, 2003). Critics, however, do not always follow Weber's useful distinction betweenpower and authority - Weber defines authority as legitimate power (Gerth & Mills, 1991). The patient or client gives the therapist at least some legitimacy by voluntarily entering into a relationship with them. Beyond that point, abuseof legitimacy or power is somewhatprotected by professional codes of ethics. If CBT therapists follow the suggestedstructure and protocols, they may minimise potential abuseby explaining the rationale for interventions, seeking feedback from clients and trying to keep therapy as parsimonious as possible.

Humanistic reservationsabout therapist `expertise' may not have considered distinguishing between `being an expert' and `having expertise'. A client may frequently expect that the therapist will lay claim to some expertise. The therapist can, however, her expertise as expertise about people in general but believe that this will be of regard little avail unless it can ally itself with the client's expertise about her life. This view is consonantwith the concept of `collaborative empiricism' described by Beck et al (1979).

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Humanistic therapy has beenespecially influenced by the `anti-psychiatry' movement of the 1960sand 1970sand this position has revived again recently within humanistic therapy (Newneset al, 2001). Newnes et al (2001) advocatean `anti-psychiatry' position within the person-centred/humanistic model and argue for the needto conduct an ongoing fight againstthe medical model of mental health in a way reminiscent of the 1960s anti-psychiatry movement.

Thereis aninteresting historicaltwist herein thatthereis a case to be madefor the early

British behaviouraltherapistsas more effective opponentsof the `medical model' in psychiatry than the `anti-psychiatry' movement.The behaviouraltherapistsset up idiographic formulation based treatments on effective alternative of the patients in (Bruch & Bond, based 1998).Paradoxically, CBT `symptom treatment' to opposition been have in times more contentto work within symptom based practitioners more recent favour combining such work with an idiographic they would also protocols, though formulation of the client (Beck, 1995)4.As someof the `expertise' claimed by CBT therapistswould involve, for example,the pragmaticuse of DSM terminology, person`anti-psychiatry' therapists an perspectivemight well find this aspectof with centred CBT hard to accept.Many CBT therapistsare locatedwithin mental health settings (BABCP, 2005: personalcommunication)and may therefore seemto some humanistic by `guilty being association'with psychiatry. practitioners as From a psychodynamicpoint of view, there could be educationalintent in trying to facilitate the client's `insight' into his condition. Psychodynamictherapists,however, may tend to seethe generationof insight as part of a more generalaim to make the `unconscious conscious' (Jacobs,2004) and this could just be seenas part of psychoeducationas defined in the first definition of 2.4.1 above.Freud's concept of the `compulsionto repeat' (Jacobs,2004) is quite close to Raimy's (1975) concept of `neurotic paradox. ' Psychodynamic therapistsare, however, less focusedon `maladaptive behaviours'than on individual experiences and so might well avoid the more explicit and

4 There is further discussion of this point under considerationof principle 10.

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`information giving' activities of psycho-education in CBT that are inevitably focused on more general experiences. 2.5: Principle 5: Homework is a central feature of CBT

2.5.1: Definition of `homework' in CBT The educational emphasisof CBT is also evident in the advocacy of `homework'. This term refers to the tasks that clients are askedto undertake between therapy sessions. Homework assignmentscan operate over different areasof behaviour and cognition, in be different both may stressed of which phasesof therapy. Early assignments either or information for depression include specific about, example, reading can or a specific Clients are askedwhat they thought and felt about the experience of anxiety problem. such reading at the start of the next sessionand whether any further questions arise in their minds. This type of activity, known as bibliotherapy, appearsacceptableto clients and may sometimesconstitute an effective intervention in its own right. Health authorities are increasingly supplying `book prescription' schemes(Frude, 2005). Later homework become for has difficulties may more experiential on, example, a client who because to relating others of social anxiety may be asked to open a low-risk conversation be the time, same aware of his negative thoughts and feelings -a `behavioural and, at experiment' (Wells, 1997; Bennett-Levy et al, 2004). Innovative aspectsof homework are becoming evident in CBT and other approaches, including the use of video recording (Wells, 1997), email (Murdoch & Connor-Greene, 2000) and the internet ( Taylor & Luce, 2003). There have been clinical trials using CDrom basedCBT materials currently running in the NHS (NICE, 2005). These developmentsare often part of a `steppedcare' approach (Williams, 2002). `Steppedcare' attempts to stimulate wider dissemination of CBT by interventions that vary the amount of therapy materials (books and other resources) and therapist time on a First interventions scale. step sliding may involve all materials and no therapist time. Later stepsinclude more therapist time if the client has not respondedto earlier steps. Such developmentsare likely to strengthenthe role of homework and `out of session' work.

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2.5.2: Rationale for the homework principle in CBT

CBT theory assumes that psychologicalchangeis generally hard to achieve and is unlikely to come about from the generationof insights alone (Beck et al, 1979; Beck, 1988;Bennett-Levy et al, 2004). Homework tasks describedabove focus on different levels of changeas defined within CBT. Listening to a sessiontape is a deliberately lowkey activity and aims to ensurethat this, usually early, task is one that the client can do, thus reinforcing therapy as a `self-efficacious' experience.Tasks such as keeping thought being in interventions recordsreinforce skills learnt in sessions well as valuable as themselves.Behavioural experimentsare seenas particularly powerful homework tasks, beliefs. (Seelater Section 2.7.2 on disconfirmation to of aiming act as experiential inductive methods). More generally,theserepresenta strategic factor: that CBT has taken an intentionally in that to gains therapy transferto the client's everyday life systematicapproach ensure (Ivey et al, 1997; Roth & Fonagy, 1996).Hollon et al (1996) have hypothesisedthat this dimensionof CBT explains why it shows greatergains in current methods for measuring do by helping than some other approaches: to minimise relapse efficacy and effectiveness at follow-up. 2.5.3: Homework in CBT: Compliance and Resistance Burns & Spangler(2000), Burns & Nolen-Hoeksema(1991) and Personset al (1988) have researched the effectivenessof setting homework in naturalistic therapy settings. Thesestudiesshowedthat clients completing homework assignments are more likely to in therapy. There may, however, be other mediating variables gains make and maintain that affect outcomes- for example,the type of clients who are preparedto do homework tasks might in any casebe more likely to make gains regardlessof any therapeutic had that they undertaken(Kazantzis,2000; Kazantzis & Ronan, 2006; Kazantzis activity & Deane, 1999;Kazantzis et al, 2000; Kazantziset al, 2005a; Kazantzis et al, 2005b; Kazantzis& L'Abate, 2007).

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finding: have been focused in homework tasks on psychotherapy Researchon the use of homework to the influencing completion of 1). Factors compliance with and resistance and, influenced homework therapy outcomes. degree to The completion 2). which high be homework levels tasks to have that can quite Severalwriters of resistance noted homework (March, 1997). The difficulties setting with and practitioners often report lose been homework 'no has in to the tasks for this therapists set as regard standardadvice homework: before in them them to setting as session 1experimentsand start
It is helpful when setting up assignmentsinitially to stressthat useful data can be homework. fail do her In does if to this way, the patient who the patient even obtained does not do the homework is less likely to brand herself a failure and thus feel more dysphoric (Beck, J, 1995, p.255).

Beck et al (1979) suggestthat client and therapist might agreethat the therapist telephone describes fulfilled. (1985) factors had been Dryden if the that tasks to the client see inhibit and enhancethe client's motivation to do homework. In a case study of a phobic fact homework invariably be that the tasks the to to the related appeared resistance client, involved facing up to previously avoided situations. Dryden recommends negotiating but "challenging Hansen (1992) tasks. to the not overwhelming" achieve et al client with importance in OCD (Obsessive their the study of negotiation of emphasise also Compulsive Disorder) clients, for whom negative experiencesof homework often led to dropout. Clients who dropped out of therapy were both less likely to complete homework less doing homework their than clients who anxiety when experienced and also doing This homework but to the treatment. the not only points efficacy of also completed highlights the fact that the homework itself must be meaningful and at times, challenging, to the client. Leahy (2001) arguesthat non-compliance with homework can be often 'self-limiting designed to to avoid further loss, humiliation or clients' strategies', related (2001) Leahy suggeststhat therapists can help by identifying such strategies, regret. implications the negative of achieving goals and by encouraging clients to examining limitations. their own accept

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2.5.4: Homework and outcome in therapy Complianceis frequently assumed to correlatewith good therapeuticoutcomes. A numberof studieshave supportedthis notion. Personset at (1988) studied 70 clients treatedfor depressionin their private practice. They judged improvement by reductions in scoreson the Beck DepressionInventory (BDI) and found that clients who had regularly completedhomework assignments reducedtheir BDI scoresby 65.5%, three times greaterthan that observedfor clients who had not regularly completed homework tasks. Bums & Nolen-Hoeksema(1991) completed a retrospectivesurvey of 185 clients who had had CBT treatmentfor depression.They were particularly interestedin whether the Experience therapist predictive of good outcome. were of clients' perceptionsof empathy therapistempathywas indeed found to be predictive of outcome.They also found, however,that homework completion had a positive effect on outcome over and above that of the client's perception of therapist empathy. The studiesso far reported are limited by the lack of random allocation to the homework leaving them opento the criticism that the correlation and no-homework conditions, intervening be to variable such as social class or attitude to could related some other treatment. Neimeyer & Feixas (1990) studiedcognitive treatmentof 63 clients with half depression, the clients to a cognitive treatment assigning randomly unipolar homework half included to a cognitive treatment condition not that and regular condition including homework. Homework completion was found to be predictive of greater treatment gain by the end of therapy, but interestingly, not at 6 months follow-up. The included degree the to which CB skills had actually been assessment of also study acquiredand this was predictive of the maintenanceof gain at 6 months. It appearsthen that homework completion in itself was not a guarantee of cognitive behavioural skill acquisition. Clients not included in the homework condition showed signs of CB skill acquisition and when they did, they showedthe sameability to maintain gain as those who had beenin the homework condition.

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in homework to (2000) a condition also used random assignment a Bums & Spangler hypothesis data for depression. Their the consistent with therapy was study of cognitive did in depression. Clients has who on changes homework effect a causal compliance that did little homework. In improved those than or no homework who more the most homework influence did depression to compliance. appear not of severity contrast, be for did to homework proxy any other variable, appear a not Furthermore, compliance

suchasmotivation.
Kazantzis et al (2000) conducted a meta-analysisof studies researchingthe effect of homework in psychotherapy.Although, there are an increasing number of studies with the large studies generatedonly many of results, showing positive sizes sample quite levels themselves that were very variable. sizes effect so small power 2.5.5: Homework in other therapeutic models Kazantzis et al (2005a) show that CBT therapists report a significantly greater use of homework tasks than practitioners of other modalities. CBT therapists do not, however, `own' homework as a therapeutic idea and other approachesare beginning to use homework tasks, some in a major way (Rosenthal, 2001; Kazantzis et al, 2005a). Kazantzis et al (2005a) surveyed all clinical psychologists in New Zealand and found that defined homework themselves as regularly of orientations, giving regardless a majority, tasks to clients and saw homework as an important part of their practice. CBT therapists but differences likely homework to the give of usagerates amongst more were somewhat different orientations were not great.

Person-centred counsellors have sometimes reported a senseof inhibition about asking homework do `person-centred' desire this to to to avoid the role and may a relate clients `teacher' (Mooney & Padesky, 1998; Persons, `expert' and appear or patronising of 1989).There could also be a language effect here becausein UK English, the `term' homework is especially related to a school setting and not really, for example, to a Informal enquiries have establishedthat in American English, in setting. university German and in Japanese, the term would be used equally in schools and universities.

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however, therapies, put more humanistic Traditional approaches to and psychodynamic have do the in insight not and change generatingpsychological emphasison the role of in Some CBT. her behaviour for imperative to as the client actively experimentwith same inaction'. impatient `bossy CBT `pushy' therapists of and other may regard or as Interestingly, Kazantzis et al (2005b) report a similar attitude to homework amongst traineeson a CBT Diploma coursein New Zealand.

Reluctanceto use homework may be related to the strong emphasisthat other therapies humanistic The therapeutic the encounter. the therapeutic place on relationship and therapiesadvocatethe developmentof an'I-Thou' (Buber, 1970)relationship between therapistand client, the honesty and integrity of which is held to be associatedwith key is held be both. The to the for therapeutic encounter positive emotional growth be between homework therapeutic could completed that time the when elementso interest. less be encounters of may Stricker (2006, p.221) reviews the use of homework in psychodynamictherapy and notes that:
The approaches to treatmentthat focus on the activity within the session,rather than least be to compatiblewith the useof homework. Foremost among outside, would appear theseapproaches are psychodynamicpsychotherapy...and many of the humanistic and Psychodynamic traditionally placesemphasison therapies. psychotherapy experiential the introspective activities of the patient and the therapist.To assignhomework would because it framework from deviate the to placesthe therapist in the role of an seem it directs directive and patients' attention away from the therapeutic authority, active, interaction and their own internal processes toward the areaoutside the treatment room... However, appearances sometimesare deceiving.The useof homework, even in traditional psychodynamicpsychotherapy,is more widespreadthan is readily seen. For few there are practitioners of psychodynamicpsychotherapywho do not ask example, their patientsto remembertheir dreams,perhapseven to write them down... This is a type ofjournaling that would be recognizableto any practitioner of cognitive behaviour therapy, although that is hardly the specific assignmentthat would be given.

Thus, he argues,although the use of homework would be incompatible with "... the strict (p. 236), it is possibleto devise a set of criteria for its of... psychoanalysis" application use in more recentpsychodynamicmodels: describing his own use of "... an assimilative,

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fact (p. 219). These that the criteria stress integrative model of psychodynamic therapy" individualised be highly in and non-prescriptive. homework this modality should in increasingly is being homework that used most other therapies, is There also evidence in the systemic therapies concernedwith 1995) (Halligan, brief and therapy especially 2000a, 1999; Jongsma families (Schultheis et al, et al, working with groups, couples and

2000b).
literature in featured has the theoretical homework of either strongly Although not humanistic or psychodynamictherapy, it has begun to appear in accounts of practice of format Accounts `brief in their versions. of the use of therapies, especially those homework in humanistic therapy include logotherapy (Henrion, 2001), client-centred focusing (Engel 1991) 2001), therapy (Corey, et al, and counselling expressive therapy (1995) have Pollack (1999) Markowitz 1998). Kinnier, & (Hay and supplied generally in brief dynamic homework therapy. the use of of accounts To summarise,setting homework has played a key role in the development of CBT, in in that the therapy are generalised to gains made chances especially attempts maximise finishes. life There is life therapy both and after evidence suggesting to outside sessions that homework does enhancetherapy outcomes: though there may be other mediating in have been have but Homework tasks therapy used active of other modes variables. by inhibited in been therapy some schools of a very strong emphasison the perhaps interpersonaland experiential encounter in the therapy sessionitself. Even in those modes is increasing however, there therapy, also evidence of an willingness to consider of homework tasks as additional options in therapy. Kazantzis & Ronan (2006) have homework for is factor' `common the that of use a candidate consideration as a suggested in modern psychotherapy.

2.6:

Principle 6: CBT usesthe Socratic Method.

2.6.1: The rationale for the use of Socratic methods in CBT

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For a shift in cognitive perspectiveto take place, a client's thinking usually needsto include a perspectivethat includesreflective and critical thinking. This type of thinking is As linked Socratic Socrates defined the the method. and with of name using appropriately Popper(1959) remarks,Socratesis known for, "... his belief that the searchfor truth through critical discussionwas a way of life - the best he knew." (p. 157). The main use is by discovery', by in `guided CBT Socratic Socratic mostly questioning: method of
The cognitive therapist strives to use the question as a lead as often as possible... Good questionsinduce the patient to: 1) becomeawareof what his thoughts are, 2) examine them for cognitive distortions, 3) substitutemore balancedthoughts, and 4) make plans to develop new thought patterns(Beck & Emery, 1985,p. 177).

Padesky(1993, p.! ) suggests that CB therapistsusethe method of `guiding discovery rather than changingminds' and offers guidelinesto shapepatternsof questions interspersed with summariesto achieveeffective Socratic questioning.Nonetheless,this key skill of CBT remainsone of the hardestto master.The technique can be experienced as subtle persuasionand this may be off-putting to those it is aimed at (Padesky& Greenberger,1995).Heesacker& Meija-Millan (1996) presentevidence from researchstudiesshowing that therapist influence psychological and psychotherapeutic may be optimal when clients perceivea small gap in expertisebetweenthemselvesand therapist may produce a counter-reactionin the their therapists.Thus an over-persuasive have Some trainees similarly negative counter-reactionsto over-persuasive may client. that the ideal trainer style for trainers. Fennell (Personalcommunication)has suggested teaching cognitive therapy comesfrom adult educationtheory - influenced by andragogy (trainee-centredlearning, Knowles, 1984),encouragingexperiential learning and facilitating questioningand problem-based learning rather than lecture-basedlearning.

2.6.2: Socratic Methods in other therapeutic models Even the seemingly simple injunction to ask questionscan be problematic for a CBT trainee who has had previous training in person-centred counselling. This problem could traineesmay come to initial counselling training with a tendencyto ask too arise because many questionswith the result that the attention that they put on asking questions

distracts themfrom listeningwell (Inskipp,1996).Whilst the aimsof initial training in

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balance by dominated to trainees to their efforts get questions with more are counselling in training the process may and reflection, result an over-emphasis on use of paraphrasing `reflective listening'. Hence CBT trainers may consider that counsellors in training for CBT reflect too much on the content of what the client says and not enough on its learning from CBT Trainees content. a person-centredperspective underlying cognitive hard in listening feel they that skill a won when they are encouraged are abandoning may to ask questionsin the way demandedby Socratic methods. Another perception of CBT that may trouble both humanistic and psychodynamic therapistsis that it has what can be seenas an over-persuasive `technology' that may All have `characteristic therapeutic the models perhaps client. sins' and the overwhelm be is Humility failsafe defence CBT over-persuasion. not a may against this sin. sin of Even Socrateswas seenby some as indulging in `mock modesty' (Nehemas, 1998) during which he would ask apparently guileless questions that increasingly tied his dialogue partner into knots - in CBT terms, he thoroughly `decentered' his interlocutors `experience in to them one's own role constructing reality' (Safran & Segal, causing 1990,p.6). Socrateswas not always thanked for his pains. As Socratesleft no written dependent idealised the on possibly are we picture of him from Plato. It is perhaps work, fortunate that few of us would be able to match the skills of dialogue portrayed in these however We Padesky (1993) that over-persuasion is may safely concur with accounts. least in ineffective, longer the term. Although neither the humanistic nor at simply psychodynamicmodels of therapy explicitly espousea `Socratic' approach to both kind they give some questioning, of role to asking questions and these may at times take on a Socratic form. Both approachesfoster more wariness of persuasion than CBT, be less likely to systemisequestion asking as recommended in CBT (Leahy, would so and 2003: Padesky& Greenberger, 1995; Wells, 1997). -

2.7:

Principle 7: The therapy and techniques of CBT rely on the inductive method

2.7.1: The rationale for cognitive and behavioural inductive methods

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The Shorter Oxford English Dictionary (SOED, 3`dEd, 1969)offers eight different definitions of `induction'. The meaningcoming closestto meaning indicated in the
be: (1985) Emery Beck would and principles of The processof inferring generallaw or principle from the observationof particular instances(SOED, 1969,p.257).

In light of the abovediscussionof the Socraticmethod it is interesting that the first definition offered in the dictionary is "The act of inducing by persuasion. " Beck and Emery (1985) intend that someof the values of inductive scientific method may be used to help clients regardtheir dysfunctional thoughtsand beliefs "hypothesesrather than facts" (p. 188). Beck and Emery (1985) arguethat inductive activities help to achieve decenteringbecause theseactivities can counteractthe influence of negative attention in psychological problems (Brewin, bias and other dysfunctional cognitive processes 1988).The conceptof negativeattention bias describesshowshow the focus of attention is frequently for distorted by the depressionand pays in depressed example, clients, disproportionateattention to negativeinformation and takesless notice of positive information. To bring clients to more balancedways of thinking - and thereby promote positive mood and behaviour - the therapisttries to help them to decenterfrom their decentering The thinking. to allow the client to of processthen progresses negativemode reflect on their thinking and modify it. Thus the decenteringprocessis usually inductive instances from follows it during which they of clients' experiences, many particular as may have, for example,thought of themselvesas `having failed' but moved to a more failure'. `being desired The therapeuticend of this process a as generalself categorisation is, however, `disconfirmation' of that over-generalised thinking (Safran & Segal, 1990).

CBT has beenseenas a therapeuticapproachthat has many methodsand techniques. Thesemethodsare often divided into two main groups: cognitive techniquesand behaviouraltechniques.What unites the use of thesetechniquesis they will be employed accordingto the therapist's overall formulations of clients and their situations, as will be discussedlater.

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in This by assessmentculminates CBT is preceded a psychological and social assessment. (Persons, 1989; Beck, formulation the main problems client's of the developmentof a formulation in impact for this the to their way on ability Techniques selected are 1995). important, hold Cognitions though likely to an not change. produce most as calculated formulation For formulations. behavioural in an example, a of cognitive role, exclusive linked fearful to that are equally strong cognitions reveal might client anxious just how The thoughts with might show a preoccupation client's behavioural avoidance. intolerably bad and dangerousthese anxious feelings are. Knowledge of the actual indicate however, that these physical sensationsare not would of anxiety, processes Furthermore, during the dangerous they client's anxiety episode. seem as usually as behavioural dispel A habituation these symptoms. anxious cognitive usually exposureand intervention might encouragethe client to change an avoidant behavioural responseso hoping disconfirm distorted feelings; to `stay the the anxious and with' that the client will danger (Foa Kozak, 1986). degree & that they the represent of appraisal of exaggerated has become behaviourally formulation the that depression, In client might reveal a is. home `failure' A time on what a she at ruminating withdrawn and spendsmuch her hypothesise be likely behavioural to that thoughts therapist and would cognitive behavioursare linked but might take a pragmatic approach about which factor was the intervene by behavioural The to influence. therapist conducting a might choose primary if increases levels, lead to the this client activity spending might whether on experiment less time in depressiverumination. Alternatively, the therapist might try to get the client to modify her negative thoughts to seeif this would increasethe likelihood that she will be by knowledge how Intervention would specific about options selected go out. interventions work with different symptom patterns, followed by collaborative discussion For the example, practitioners generally consider that the more severethe client. with depression,the stronger the indication to tackle behavioural problems first (Beck et al, 1979; Fennell, 1989). On the other hand, if the client is simply not willing to try such a be likely is hard. it to too to the unhelpful client push strategy, We can seein these examplesthat a variety of techniques might be relevant in CBT interventions. The caseformulation is used, along with client choices and preferences,to

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OF BRISTOL [LBRARJY

UNIVERSITY

in technically been has CBT eclectics interventions. regardedas relatively plan a seriesof in its key from to target borrowing therapies problems its approachto techniques other integrity however, theoretical the that CB 1992). therapistsargue, formulations (Dryden, it is technically by is eclectic, that, the although the concept maintained model of in key impact client to elements cognitive on techniquesselectedshould also aim formulations. CBT is a formulation-driven therapy, not a techniques-driventherapy (Wells, 1997).

2.7.2: Cognitive technique but is beyond the this description can review scopeof A detailed of cognitive techniques be for focus therefore this on the use A chapterwill be found in Leahy (2003). particular be & Padesky, 1995), Greenberger 2003: (Leahy, can which of the `thought record' to their for to automatic and evaluate respond tool "... patients the primary regardedas thoughts"(Beck, J. p. 125). how basic of cognitive techniquesare used will rationale Firstly, a brief overview of the be presented.Secondly,some guidelines are offered for working with different levels of cognitions. from holding job the to client is negative automatic It not the therapist's persuade but ineffective Attempts beliefs. are may also not only usually at persuasion thoughts and by for sometimes prompting clients to'defend' their be counter-productiveexample, beliefs more fiercely (Bennett-Levy et al, 2004; Leahy, 2003; Safran & Segal, 1990). The in beliefs. facilitate their is to clients and questioning examining therapist'stask rather CBT distinguishesthree main levels of cognitions - automaticthoughts, assumptionsand immediately Emery, 1985). Automatic & (Beck thoughts beliefs are not conscious core but are relatively accessibleto reflection. They representways of appraising immediate for In teacher, teaching the a presentation, events. middle of a moment-to-moment himself looking bored `I think to and might a am making observe student example,might
SA technically eclectic approachstresses the importanceof a theoretical formulation of the problem based to seek change on a coherentrationalebut is preparedto draw from a rangeof diverse practical approaches in the problem.

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be The to this This specific particular situation. very might appraisal a messof this'. in his life. his On be teaching himself to competent and generally teachermight consider deeper hand, thought cognitive set that contains appraisals this a might represent the other belief) (unconditional `Unless boring core and/or `I my person' such as am really a (conditional failure' I'm assumption). a teaching goes well, begin behavioural therapists that should cognitive cognitive It is generally suggested interventions at the level of working with negative automatic thoughts (Blackburn & Grant 2004). Many 2003; Leahy, 1995; techniques, such as Beck, 1994; et at, Davidson, help the their to and challenge client review automatic thought used are record, using a designed to maximise the chancesthat therapy will The techniques all are thoughts. it described In be fashion Socratic in many the earlier. cases, may not necessary proceed level far beyond the of negative automatic thoughts. This to take cognitive restructuring behavioural in in itself, with work, result conjunction major symptom and work can dysfunctional however, (1995), that the Beck suggests some work at assumption relief. is level belief useful as part of a relapse prevention stage of the therapy. and maladaptive The fact that clients write down negative thoughts is an important part of the rationale for the thought record. Beck (1976) makes the point that cognitive techniques often represent 6) (p. Good to `common thinking. strategy undermining negative mental sense' a functioning may be dependenton the mind being able to monitor and review the accuracy its Conscious (Epstein, 1998). be to appraisals of effort rarely needs used and adaptability during thesemental housekeepingactivities. If a client becomesdepressed,however, thesenormal everyday cognitive activities do not work as well as they normally do. The is depressed thinking subject to negative distortions, attention biases and mental client's fatigue, resulting in less adaptive functioning - often evident in a `vicious cycle' of feelings (Fennell, The is helped 1989). thoughts to take the mental and client negative in their thinking the way they would when they were not depressed.It is to steps review difficult for the depressedclient to follow the cognitive stepsinvolved in mental review (Gotlib & Hammen, 1990). solving and problem 2.7.3: Behavioural techniques:

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CB therapistsuse techniquesfrom behaviourtherapy. The main techniquesare exposure behavioural therapy, gradedtask assignments, activity scheduling,self monitoring, behavioural 1995). Other behavioural diaries Ed., (Hersen, methods experimentsand in described (1995). The Sheldon only real point of contingency are such as management departurebetweencognitive and behaviourtherapy has beenthe conceptthat these techniquesare effective both in their own right and as reinforcementof cognitive change: in that they disconfirm dysfunctional client cognitions during `behavioural experiments' (Bennett-Levy et at, 2004). For example,the client with panic disorder believes that the panic symptomswill drive her mad. Exposing herself to situations that have triggered panic reactionsin the past and refraining from `safety behaviours' might mean that she like this may eventually can find that shedoesnot go mad. Repeatedexperiences disconfirm the belief. The likelihood of such `disconfirmation' has resulted in debate betweencognitive therapistsand behaviourtherapists(Rachman,1997a).Cognitive therapistshave arguedthat adding cognitive elementsto, for example, exposure treatmentsenhanced their effectiveness whereasbehaviourtherapistsargued that they madeno difference. Each party was able to offer somesupportive evidence for its case (Rachman,1997a;Eysenck, 1997). The conceptualframework offered by Brewin (1996) hasbeenhelpful in resolving this debate,suggestingthat one must distinguish firstly, between`situationally accessible' and `verbally accessible'knowledge,and, secondly,betweenspecified and generalised disorders,to understandthe relative contributions of cognitions and behaviours in knowledge or insight allows reflective techniques different disorders.Verbally accessible to be effective. Situational knowledge may, however,require a specific type of stimulus to provoke emotionally relevant knowledge.This is often the casein anxiety disorders, where discussionof fear experiences without somefeeling of anxiety being actually helpful & Kozak, does (Foa 1986).Brewin also usesthe distinction present not seem betweenspecific cognitions linked to specific disorders:for example,the highly specific thinking that goeswith panic (Clark, 1996) - and the more generalisedcognitions that go with generalisedanxiety disorder (Wells, 1997)to suggestground rules for choosing the interventionsmost likely to shift particular types of thinking: sometimesthesemay be

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be behavioural behaviours they that will interventions and sometimes shift cognitive interventions that shift cognitions.
in therapies inductive techniques other The 2.7.4: use of

inductive but techniques that have per se much against so not Other therapies argued (Weishaar, 1993). Wilkins (2002) technique been argues has with CBT over-concerned from a humanistic perspectivethat over-concentration on techniques undermines the be thinking technique because therapist the about and may therapeuticrelationship having is Technique therefore be'genuine' the fail viewed as client. to with thereby become to therapists for using averse much conscious may so other artifice potential fact that certain counsellors the (1980) Rogers about expressedgreat alarm technique. Consequently is the through there skill of reflection. that achievable empathy advocated in idea development the little been of a portfolio of skills this model -a distinct has of between skills and techniques in persondistinguishes (2003) Tolan CBT. to contrast deepening therapeutic Skills and making connected with therapy. all are centred be in in CBT Techniques, that they the might understood sense are not relationships. described.There have, however, been advocatesof revised humanistic models that have Egan, learning (Carkhuff, 1987; 2002) is though their work now rarely skills emphasised humanistic by therapists. acknowledged The methodsof psychodynamic therapists have also been very much focused on the developmentand maintenanceof the therapeutic relationship. They too have been 2001). One CBT (Milton, for be techniques this the of reason array of may of suspicious issues `underlying' to address and corresponding suspicion of aim the psychodynamic

1996). (Persons et al, relief symptom

This brief review has shown that other therapy schools are likely to hold reservations not in CBT but indeed techniques the specific many used about the notion of only about beliefs These itself. obstruct interest in CBT and especially to learning CBT technique techniques.The 1995 versions of CBT principles (Beck, J., 1995) are broader than the 1985(Beck & Emery, 1985) version. The 1995 version drops the word 'inductive. ' This intent it is though the a more populist of author, also probably true that may represent

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(i. that the 'veridicality' accuracy of perception less view is e., there emphasison scientific Segal, & (Safran CBT in texts functioning) more recent is very closely tied to `positive' 1990;Padesky,1994).This view is now prevalent in the CBT literature and would mean in functionality terms of in be than terms rather of that cognitions might explored more their accuracy(Leahy, 2003; Brewin, 1996;Teasdale,1996).

2.8:

Principle 8: Cognitive therapy requires a sound therapeutic relationship:

The conceptof the 'therapeuticrelationship'holds a special place in psychotherapeutic discourse.On the one hand, the therapeuticrelationship is held to be the chief'common factor' to all modelsand to be a decisive, if not the decisive determinant,of therapeutic it be hand, is On 1994). (Orlinsky term that the can vague al, other also a et effectiveness in usageand its importancemay be conceptuallysusceptibleto becoming over-inflated (Feltham,Ed., 1999). 2.8.1: The rationale for the therapeutic relationship in CBT Beck et al's (1979) description of the therapeuticrelationship actually has much in common with that given in the work of Carl Rogers (1957; 1980),though unlike Rogers, Beck et al (1979) regardthe `core conditions' of empathy,warmth and genuineness,as but necessary not sufficient for change.A collaborative relationship in which the therapist has considerableskill and expertiseis regardedas a further necessaryfactor. From a CBT perspective,one would expect individual clients to react differently to the sametype of therapeuticrelationship because they hold different beliefs about relationships. Some clients, for example,may expect the therapistto expressa lot of empathy but others might suspectthe sincerity of that samedegreeof expressed empathy. In CBT, client and therapist should ideally form a'team' that unites and works together (Beck To key 1979). this `team', the therapist brings a the el al, against client's problems knowledge about psychological problems and and considerableamount of expertise processes of psychological change.This expertisemay not, however, prove useful if it cannotbe applied to this particular client's life. Clients therefore also bring expertise Neither `team'. therapeutic the to their client nor therapist can about own experiences

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from domains likely is to these two come uniting of most success alone succeed usually into a working partnership. expertise 2.8.2: The Therapeutic relationship in other therapeutic models (1957) for Rogers 'core that the humanistic example, argues From a perspective, for `therapeutic ' CBT, both sufficient personality and change. as necessary conditions' are describedby Beck et al (1979) regardsthe core conditions as necessary,or at least very helpful, but not as sufficient to promote psychological change. CBT proposes that these CBT the therapeutic takes which within work place. a relationship conditions create intrinsically that have are such relationships out rewarding also pointed theorists (Sheldon, 1995) and do influence clients (Hudson & Macdonald 1986). There is also direction, being CBT the therapists skills of that can combine giving empathic evidence if than (Sloane types therapists influencing not more, as, effectively other clients of et and be however, 2000). For CBT Keijsters to 1975; the therapist work al, effective, et al, interpersonal both have technical as to and expertise well as conceptual skills needs (Padesky& Greenberger,1995).

Like humanistic therapy, psychodynamic therapy has placed a heavy emphasis on the therapeuticrelationship as the vehicle of change - though for rather different reasons. Psychodynamictherapists regard many client problems as being causedor exacerbatedby They believe that these unconscious wishes will and motives. unconsciouswishes themselvespermeatethe therapeutic encounter as 'transferencereactions'. Transference brief, in based client responses are, on unconscious wishes and may date back reactions to primary relationships in early experience. As these experiencesmay have been language, be difficult they to accessvia consciousnessbut may be may without encoded in evident the client's transferencereactions. Transferencereactions may then elicit from the therapist. `Counter-transference' reactions 'counter-transference' are regarded as the responsethat the client's transferenceelicits from the therapist's unconscious. Thus the therapeuticrelationship becomesan arena in which these transference and countertransferenceissuescan be 'worked through' and resolved. `Working through' has been identified as the main activity of psychodynamic therapy (Holmes, 2000). As noted in

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been being has discussion, `working traditionally the through' as seen a activity earlier of long-term processand this factor has therefore identified psychodynamictherapy as being in generala longer-term processthan are other types of therapy. CBT has tendedto eschewsuchactivities, certainly as a main focus of therapy. Beck et al (1979), for example,acknowledgethat transferencereactionsdo occur but suggestthat they can be dealt with in the sameway as any other type of cognitive distortion. In recent years,however, it hasbeenacknowledgedthat such reactionscan be more pervasive in clients with enduringpersonality problems (Beck et al, 2003; Layden et al, 1993; Young et al, 2003). In thesecases,someof the activities of psychodynamictherapy, such as transferenceinterpretationsand `limited re-parenting'may becomepart of CBT, its longer-term in therapy (Young et at, 2003). It is especially version: schema-focused worth acknowledgingthat critics of CBT did predict that it would eventually show signs drift': back to psychodynamicpractice (Weishaar, 1993). reversion of'psychodynamic This brief review indicatesthat there is both difference and similarity amongst the therapeuticmodels' approaches to the therapeuticrelationship. All therapieshave stressed the importanceof the therapeuticrelationship and the differencesmay be hard to fully articulate in the sort of simple one line statements of principles used here. 2.9: Principle 9: CBT is a collaborative effort by client and therapist

Collaboration meanssimply `working together' and, as such should prove the least controversialprinciple as client and therapistmust surely have to work together in some way for effective therapy to occur. Yet, for many, `collaboration' carries some extra meaningthat is associated with a more equal and democraticway of working. This kind of therapeuticrelationship is most associated with the person-centred model of Carl Rogers(1967; 1980).Rogerstook much inspiration from Martin Buber, especially from his distinction between`I-Thou' relationshipsand 'I-It' relationships.Yet when Rogers and Buber conducteda famous dialogue, Buber would not agreewith him that the therapeuticrelationship was an equal relationship (Kirschenbaum& Henderson, 1990). Buber agreedthat therapy had to have momentsof the `I-Thou' dimension and yet did not

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disagreement Agreement in its this be it with and entirety. one equal that an should agree being to the the attributed nature of collaboration. turn meaning exact on may principle in CBT for The collaboration 2.9.1: rationale beyond the the 194) that goes core (1991b, collaborative relationship suggests Beck p. by Rogers: described conditions
I certainly consider the therapeutic alliance as a common factor shared with other focus believe I But that the shared and on changing belief systems, explicit therapies. also developing for testing, coping strategies and make a more reality reinforcing and refining robust therapy.

CBT usesfactors that are common to many other therapies, but is more specific in how (1997) & Beck is Alford that factors the argue cognitive change active used. are such ingredient of many of the `common factors' amongst psychotherapies.CBT aims to but by direct types therapy Such other the as of a outcome more route. same produce developing by is means of a collaborative relationship and collaborative work achieved Emery 1985, 175): (Beck p. and empiricism The cognitive therapist implies that there is a team approach to the solution of a is, that a therapeutic alliance where the patient supplies raw problem: patient's data (reports on thoughts and behaviour... ) while the therapist provides structure how The is to solve on problems. expertise emphasis and on working on problems defects than on correcting or changing personality. The therapist fosters the rather better heads `two than one' in approaching personal difficulties. When are attitude the patient is so entangledin symptoms that he is unable to join in problem have-to therapist the may assumea leading role. As therapy progresses, solving, the patient is encouragedto take a more active stance. Collaborative empiricism helps the therapist to `get alongside' the client. The work of `attacking' client's problems is not experiencedas an attack on clients themselves:
It is useful to conceive of the patient-therapist relationship as a joint effort. It is not the therapist's function to reform the patient: rather his role is working with the patient against `it', the patient's problem. Placing emphasison solving problems, rather than his deficits bad habits, helps the patient to examine his difficulties with or presumed more detachmentand makes him less prone to experience shame, a senseof inferiority and defensiveness. (Beck, 1976, p.221)

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Beck & Emery (1985) spell out two practical implications of this stance:firstly, the therapy relationship developson a reciprocal basis.Both therapist and client are working togetherto observeand commenton the clients' ways of being, to offer solutions to the problemsand difficulties facing them. When the client cannot seea way forward, or an alternativeto his thoughts or beliefs, the therapist may be able to offer a different view to the client. Similarly, the client can seeand offer to the therapist anotherperspective. Secondly,this approachavoids hidden agendas. CBT is an explicit therapy. The therapist doesnot form unsharedhypothesesabout or interpretationsof the client. The aim of therapy is madeexplicit. If client and therapist are working to different agendas,then it is likely that therapy will not proceedsmoothly. A collaborative spirit gives a reflective, reciprocal quality: with therapistand client taking roughly equal time to speak. The spirit of collaboration may be most clear when it is absent:when, for example, the therapiststell clients what to do or think. Therapistsmay becomeoverly directive - not always from authoritarian intent, but often from a genuinedesire for the client to get to a betterplace. In true collaboration, however, the therapist is willing to help the client without being patronising or disempowering.In developing a good therapeutic collaboration,therapistsshould be empathicand non-judgemental.The processof developingsuch a collaborative relationship involves working with the client to set goals for therapy, determinepriorities, and maintain a therapeuticfocus and structure. Collaboration is expressedin many of the activities of CBT. At the first meeting, CBT is discussed. Therapist its rationale and client work together to identify explained and simple yet meaningful goals acrosstherapy, such as `being able to go out and seefriends' or `get back to work. ' Mutual agreementon the natureof the problems is striven for. Collaboration is also built into the structureof sessions:
Figure 2.1: CBT SessionStructure (Beck, 1995) 1. 2. 3. 4. 5. 6. Brief updateand check on mood. Bridge from previous session. Setting the agenda. Review of homework. Discussionof issueson the agenda. Final summaryand feedback.

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be is that the for should over what consulted client Setting an agenda, example, ensures if therapist to 'Bridging' the any ask allows also discussedat the start of each session. beginning before the from left present one. been sessions have previous over issues homework is the client consulted about appropriate Finally, at the end of each session, has just These how feedback the gone. session to about assignmentsand asked give 1985; 1979; Beck & Emery, (Beck CBT et al, protocol a of part always are activities behaviour Cognitive & 2000). Leahy, therapists Holland 1997; Wells, aim 1995; J., Beck, kind `rolling that into therapy the a of collaborative structure so to weave collaboration feedback, The 2006). (Wills, the process of regular is client with made contract' both tone, therapist thinking and client collaborative sets a also summariesand reflection is discovery Guided in is therapy. a collaborative way of working, on going about what different find them the of seeing to ways without and answers the client enabling didactic. is becoming The be to the to aim or encourageclients expert therapist appearing having in decision the themselves in that they as a central role be therapy see so to active for become Information the to their aiming client are shared, and skills making progress. own therapist. 2.9.2: Collaboration in other therapeutic models We have already noted that collaboration in CBT does not imply `equality' in the distinct The is two the therapist as and are seen roles expected to therapeuticrelationship. have some `expertise' in areasrelevant to the client, though it is for the therapist to make in this particular situation. The notion of expertise is a count the that generalexpertise dubious one to many humanistic counsellors who are rightly concerned about the imbalance between Even in for therapist. the person-centred client and power potential has different from however, the therapist that of the client. It may clearly a role model, judgement importance be that to one or the other a value attributes only more ultimately fact, In neither role can succeedwithout the other. The main motivator here role. actual desire `medical be to the avoid models', as noted earlier. This was a key concern of may Rogers,who was an astutepolitical player in the struggle against medical hegemony of the therapy field during his years of practice (Rogers & Russell, 2002).

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Humanistic therapistswould also be likely to react againstthe hegemonyof in the therapy field. The hegemonyof psychoanalysiswas related to that psychoanalysis for many years it was difficult for non-medical people to of the medical model because becomepsychoanalysts. One of the criticisms traditionally madeof psychoanalysts was that they were `experts' who were relatively immune from feedbackfrom their clients (Crews, Ed., 1998)and, even at times, colleagues(Gabbard,2005). Gabbard, himself a psychodynamictrainer, gives the following example:
I once attendeda caseconferencewhere an anxious resident(i. e., trainee psychiatrist) was presentinga caseto a distinguishedvisiting professor.The resident commented that the patient came into the sessionand she said sheneededto have her brakes checked before shedrove home. The visiting professorinterrupted the presenterand said with " Many of the sweepingauthority, "She's afraid that she's going to kill her husband. residentsreactedwith awe at the omniscienceof the consultant and wished that they would somedaybe able to read minds as well as he could (Gabbard, 2005. p.336).

Gabbard(2005) presentsexampleasthe wrong way to teach psychodynamic therapy and is feature that they have steppedback from such approaches a of modem psychodynamic Perhaps 1987). (Lomas, a problem with the notion of the over-interpretation `unconscious'has beenthat it may negatethe client's consciouscontributions as being fully valid (Beck, 1976). So for traditional psychoanalysts, it is easyto acknowledge an `expert' role but may be more difficult to acknowledgethe extent to which a client may by collaborating with such expertise.The possibility of contribution make a significant by more recent writers within this `disempowering' clients has been,however,deprecated tradition. Lomas (1987; 1994; 1999),for example,has arguedthat this aspectof have in may resulted psychodynamictherapistsover using interpretation psychoanalysis to the detriment of their clients. Jacobs(2004) has also criticised over interpretation in psychodynamicpractice and arguedthe casefor a more open- and in effect collaborative to the approach work. Humanistic therapistsexpressingconcernover therapistsacting as `experts' may fail distinguish clearly enoughbetweenpower and authority (Gerth & Mills, 1991). The client can be seenas giving limited authority to the therapistby seekinghis help. Furthermore,client surveysshow that clients regardexpertiseas being key a element that they are seekingin a counsellor (Strong & Matross, 1973). to

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by CBTs the therapist to structuring of the given power of To summarise, element It the therapy. throughout by may balanced the elements is collaborative of use sessions these from of safeguardsand may so aware not are schools other be that therapists be `disempowering' CBT to to them that appear less become concernedabout elementsof that. these against protection to if as offering elements of clients they come see disorders the is based the CBT 10: of emotional cognitive model on 2.10: Principle for development The cognitive models of psychopathology rationale 2.10.1: of and is by fact the to shown importance of psychopathology The attributed cognitive models for that first the is it offered a system of psychotherapy earlier was criteria the of that (Alford & Beck, 1997). Such a system should have: A comprehensivetheory of psychopathology that drives the structure of (p. 7) psychotherapy ... Clark (1996) describesthe characteristic processesby which Beck's cognitive therapy has developedcomprehensiveapproachesto models of psychopathology. He locates the developmentof cognitive behavioural models - specific models particular to specific disorders- in the early stepsof Beck's work on depression.The process has been greatly in has CBT terms the of numbers of practitioners and researchers expanded as refined involved in the multifarious treatment areasin which it is now participating. Clark describesthe processas having 5 characteristic stages: 1) Moving from clinical insight to specify a simple clinical model for a particular

2)
3)

problemarea. investigation Experimental of the model.

Detailed accountsof factors that prevent cognitive change in the absenceof treatment. Carefully chosentreatment proceduresfor targeting cognitive change. Controlled trials of the effectiveness of those procedures.

4) 5)

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therapy between the cognitive be of Clear overlap can seen criteria establishing validity its (comprehensive theory with empirical support and efficacy researchsupporting interventions)defined by Beck and the above stagesdescribedby Clark.
Beck (Beck & Alford), 1997): Comprehensive theory of psychopathology that supportsstructureof therapy. Knowledge & empirical findings that support the theory. Researchfindings supporting efficacy. Clark (Salkovskis, Ed., 1996):

I&4 above Stages

Stages2&3 above Stage5 above.

for CBT development in be the of An accountof thesestageswill given the context of it has been because is Disorder Panic acknowledged as one of the Disorder. Panic chosen has 1997a). It CBT (Rachman, strong also of models application current clearest In (Eysenck, 1997). reviewing and efficacy supportingevidenceof constructvalidity (1997a, Rachman Disorder, Panic p. 110) says: CBT treatmentof
To summarise,the cognitive theory has exceptionalexplanatory value and has garnered a form has is demonstrably It therapy deal that a of generated effective. of support. good Moreover, there is no satisfactoryexplanationfor the success of this therapy other than between itself. The the theory and its clinical applications theory coherence the cognitive is an addedstrength.Moreover, we now have a reasonablygood idea why and when likely Any increases to the opportunity that occur. setting or prompt are panic episodes the opportunity for a misinterpretation of for catastrophicinterpretations,or that increases an internal or external threateningstimulus occurring, will raise the probability that the in Significant the number and an episode of panic. changes experience will person intensity of relevant bodily sensations and/or a strong tendencyto interpret these imminent danger indicators know We that of can promote as panics. also sensations bodily changing experiences sensations of the type that can provide although everybody an opportunity for catastrophicmisinterpretations,very few people make the induce that a panic. misinterpretations

It is important to note that although cognitive theory emphasises role of cognitive in development the of psychologicalproblems,this doesnot mean either that it processes arguesthat cognitions are causativeor that environmentalfactors are not influential (Weishaar,1993).Beck's model is clearly a'stress-diathesis' model and recognisesthat the aetiology of psychological problems is multi-factorial and includes social and environmentalfactors (Weishaar, 1993).The cognitive approachto panic is one that offers exceptionaldegreesof fit betweentheory, practice and efficacy.

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behavioural the development The cognitive model of panic of 2.10.2: from Beck's for ideas therapy came clinical insights during The original cognitive discovery 'negative from for thoughts' the automatic of a breakdown example, treatment: (Beck, 1976). insights Beck's formulated patient a particular with were of communication into a seriesof propositions - for example and in particular, cognitive specificity: a (Beck, 1967,1976). test The to and research was subjected validity whose concept different that types posits of psychological symptoms are concept specificity cognitive for linked to negative patterns of cognition: characteristically example, specifically fear future danger linked depressive to of whereas are symptoms are anxiety symptoms linked to thoughts about past loss and failure. Clark and Steer (1996) review evidence for from from hypothesis' 21 1978 and 1994. The cognitive `cognitive studies the specificity did disorders the theory would predict, though not emerge as clearly as anxiety of profile Panic Disorder was highly specific and could be reliably distinguished from both any kind of depressionand from GeneralisedAnxiety Disorder (Clark et al, 1994). Panic Disorder is estimatedas one of the most prevalent, disabling and costly to treat in psychological problems reported primary medical care (Roy-Byrne et al, 2005). Panic in "ubiquitous" as anxiety and are reported as the commonest attacksare regarded disorders (Clark, 1986). Panic disorder is the with other anxiety co-morbid symptom frequently a problem of suddenonset and is often experienced as coming without a clear is It generally accompaniedby strong physiological symptoms, such as precipitant. breathlessness and increasedheart beat. It may be accompaniedby agoraphobia - the fear into here being the public places precipitants are more recognisable. of Figure 2.2- The suggested sequence of events in a panic attack (Clark, 1986)
Trigger Stimulus (Internal or external) Perceivedthreat

interpretations of Sensationsas Catastrophic

Apprehension

Body Sensations

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Clark's cognitive model statesthat:

Individuals who experiencerecurrentpanic attacksdo so because they have a relatively in a catastrophicfashion. The enduring tendencyto interpret certain bodily sensations that are misinterpretedare mainly those involved in normal anxiety sensations The catastrophicmisinterpretationinvolves perceiving those sensationsas responses.... than they really are, and, in particular, interpreting the sensations much more dangerous as indicative of an immediatelyimpendingphysical or mental disaster- for example, perceiving palpitations as evidenceof an impending heart attack (Clark, 1988, p. 149).

It is sometimesarguedthat Panic Disorder has a biochemical baseor has been learnt by conditioning. The biochemical argumenthas beenbasedmainly on the successfuluse of inhibiting (SSRI) medication. This argumenthas, however, selectiveserotoninre-uptake failed to provide a convincing causaltheory, especially as it cannot account for the efficacy of purely psychological therapy (Rachman,1997a).The cognitive behavioural explanation,however, is that the Disorder is causedby the'enduring tendency to however, described It be that thesecognitions are could, earlier. misinterpret' i. 'epiphenomena' Panic but The has theory associated with e., not causally. cognitive therefore beenbuilt by testing eachcomponentpart of the underlying conceptsof the model asthoroughly as possible.

Clark (1996) suggests that there are 4 central and testablepredictions of the model presentedabove: a) Panic Disorder patientswill be more likely to have catastrophicinterpretations of bodily symptomsthan individuals who do not experiencepanic. b) Procedures that activate catastrophicmisinterpretationswill produce an increasein anxiety and panic in panic patients. c) Reducingthe patient's tendencyto make catastrophicmisinterpretations can prevent panic attacks. d) Sustainedimprovement after the end of treatmentwill depend on whether cognitive changeoccurred during the courseof therapy.

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it is be to necessaryto establish that there is a correlation confirmed, For prediction a) bodily of symptoms and the occurrence of Panic misinterpretation betweencatastrophic beyond to is It go establishing this correlation because necessary Disorder. also for in itself does the causality: establish example, misinterpretations could not correlation developed b), d) Predictions to provide this extension. c) and were be epiphenomena. limitations the b) to some of of retrospective 'self-reports' by Prediction aims remove intentionally Prediction to generated panic attacks. of c) seeks studies prospective by then misinterpretations manipulating and observing whether the causation establish Prediction d) by beyond the the occur. model extends causal chain changespredicted immediate recovery to estimatethe on-going causal power of both the presenceand longer-term in the Clark (1996) post-treatment phase. misinterpretations of absence have been to that these thoroughly show predictions tested evidence exhaustive presents be the found to of model. confirmatory and 2.10.3: The efficacy for CB treatment for Panic Disorder The studiesalready describedhave included various cognitive and behavioural in CBT. These type developed the in CBT used of manipulations were manipulations interventions and then tested as protocols in randomised clinical trials (RCTs). RCTs are for findings `gold in the (Parry & standard' research many as quarters regarded Richardson, 1996), though this view is not without critics (Roth & Fonagy, 1996; Rowlands & Goss,2002). Systematicreviews for the treatment of panic frequently take the form of meta-analyses. Meta-analysisis a procedurethat considers data from separatestudies collectively. It for by formula: the size each an effect study way of calculates Effect size= MI- M2 SD M1 is the mean improvement of the treatment group, M2 is the mean improvement of the is SD deviation the and standard group of the pooled variance. This statistic control determination Z-scores, for the of allowing the aggregation of different types of allows Although is meta-analysis a powerful researchtool, its power is dependenton measure.

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data from being decisions studieswith sound allowing about made consistentlygood 2002). (Rowlands & Goss, into the analysis validity Furukawa et al (2007) conducteda systematicreview on panic disorder for the Cochrane They reviewed the efficacy results for trials involving psychotherapy, Database. disorder, in CBT, the treatment of panic with and without antidepressants predominantly 21 identified 23 They studies, of with and without agoraphobia. randomisedcomparison which involved behaviouralor cognitive-behaviouraltherapy. In the acute phase, combinedtherapy was superior to antidepressant pharmacologyalone or psychotherapy alone.The combinedtherapy produced,however, more dropouts due to side effects than drug long After the the was continued, the superiority as as psychotherapy. acutephase, After to termination of the the persist. appeared of combination over either mono-therapy of continuation treatment,the combined therapy was acutephaseand the commencement The than as effective as psychotherapy. and was plain more effective pharmacologyalone languagesummaryconcludes(Furukawa et al, 2007, p. 2):
Either combinedtherapy or psychotherapyalone may be chosenas first line treatments for panic disorder with or without agoraphobia,dependingon client preference.

The cumulative effect of studiesof CBT treatmentof Panic Disorder has meant that it is how the researched and testedcognitive model of a of now regardedas a strong example disorder can provide an invaluable template for the practitioner. Such a template gives information that the practitioner can useto assess and understandthe client and to plan interventionsin such a way as the chancesof success are maximised. Rachman (1997a, p. 111) comments:
Leaving asidethesechallenging theoretical questions,the growing potency of CBT is extremely welcome and clinicians are well placed to provide effective help for many people and to do so with well-grounded confidence.In the studiesreported over the past of patientswho were left free of panics rangesfrom 80-90% sevenyears,the percentage powerful method. an unprecedentedly

Whilst the overall efficacy of the CBT for panic has beenwell demonstrated,there are still questionsregardingthe effective elementsof the intervention. Shearet al (1994) followed a similar logic to that of Beck et al (1992) by comparing CBT to non-prescribed

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designed for to the effects of the therapy form control of non-directive therapy, a differences but between the two no significant reported therapeuticrelationship conditions. both den (1994) Hout Van & (1994) attempted 'dismantling' studies to Basoglu et al for CBT Panic Disorder for treatment different Agoraphobia. of the effects and partial out They cameto the conclusion that Panic Disorder and Agoraphobic symptoms improve findings have led to current UK treatment This independently. and other relatively for interventions Agoraphobia different for Panic exposure and advising guidelines Disorder - cognitive therapy. Their conclusions are admirably summed up in the title of 'Exposure (1994)'s Hout den paper, reduced agoraphobia but not panic, Van et al but ' is, however, It that therapy not agoraphobia. these panic reduced notable cognitive differenceson how agoraphobiainfluenced outcome are not discussedby Furukawa et al (2007). follow-up have interviews (2005) conducted Durham et al with patients who had suffered from panic and other anxiety disorders between 2 and 14 years after CBT treatment. They is CBT in longer the that term, undoubtedly the effective term whilst short out point demonstrated. been It is have that there yet appears not a group of patients with effects frequently do for lengthy further who return ongoing problems and sometimes persistent Busch (2006) have suggestedthat although Psychodynamic critics such as treatment. CBT may tackle panic symptoms effectively, this does not rule out that other more deeply be left This untouched. may critique may point toward client issuesthat problems seated With it is to this reference schema-focused. point, worth noting that Milrod et at are more (2007) report a successfulrandomisedtrial of psychodynamic therapy for panic disorder. Milrod et at (2007) arguethat psychodynamic therapy might prove particularly useful for developmental issues long term that connect to their panic symptoms. clients with 2.10.4: The place of the schema concept and formulation in cognitive models It can be observedthat most of the theoretical and efficacy work detailed above describes the maintenancecycle of current functioning of the disorder. It does not describe how

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suchcurrent functioning may be linked with the client's developmentalhistory and childhood experience,though sometimessuspected generallinks with types of childhood experienceare describedelsewhere(Salkovskis et al, 1998).The therapeutic work equally focuseson that cycle. Underlying vulnerabilities associatedwith panic disorder are neither describednor worked upon in the Clark's (1988) treatment plan. Fundamentallythe underlying vulnerabilities of psychological disordershave been much harder for cognitively basedresearchto identify.

The guiding conceptthat has beenusedin the researchon vulnerabilities has been that of schema.This concepthas proved a controversial one. The schemaconcept has been taken into CBT caseformulation (Persons,1989;Beck, 1995).Caseformulation is a method that is increasingly used acrossthe rangeof psychotherapymodels (Eells, 1997) and Personset al (1996) have arguedthat CBT idiographic formulation that can incorporate early experiencevia the schemaconceptmakesthe CBT model less aversive to psychodynamictherapists.Two different emphases on formulation, however, are evident in CBT: firstly, general `problem based' models,such as Clark's theory of panic, that typically are not hypothecatedon schemadescriptionsand, secondly, idiographic formulation, including schemadescriptions,of the problems of individual clients. This section will therefore review the schemaconceptand then describesome current discussionsabout formulation in CBT. Commentatorssuch as Brewin (1988,1996) and Eysenck (1997) have appraisedthe schemaconcept as having face validity. They have also, however, noted that the concept has proved difficult to validate scientifically. Eysenck (1997) suggeststhat there are 3 main problems faced by schematheory: 1) The amorphousnature of the definition of a schema.It is, for example, quite difficult to define the difference betweena belief and a schema. 2) The existenceof schemais often basedon a circular argument. Cognitive biasesare sometimesclaimed as a by-product of schemas and sometimesas an influence on schemas.

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is less disorders in markedly evident 3) Schema-congruent processing anxiety than schematheory would predict. in theory to that relation the schema anxiety, supports (1997) evidence Wells reviews studies of patient populations and from self-report two retrospective sources mainly control patients. and non-anxious patients anxiety of studies experimental (Ottaviani & Beck, 1987, Beck 1987) et al, populations Retrospectivestudiesof patient however, by There biases theory. a schema are, number of predicted the cognitive show Firstly, they are over-reliant on self. these difficulties studies. with methodological data (Wells, 1997). Secondly, it is limit known the to validity of very are which reports, degree during to the schema-congruent which results occur mainly tease to out difficult disorder to the the compared when chronic and recovery phases. of phase the acute feature disorders is the marked of anxiety and may Cognitive avoidance a particularly in be fears client self-reports. unacknowledged may that mean difficulties by devising these have to tried circumvent experiments with Researchers in hyper-valent biases to in particularly relation anxiety, and, attention of covert measures The tasks. principal methods used in information processing tasks information processing dot-probe detection tasks and Strop tests (Wells & filtering tasks, tasks, are encoding illustration, filtering By typical task is the dichotic listening 1994). of a way Matthews, headphones different that in different present given Participants are word signals test. is to to tasks attention The asked pay and to perform related participant one source ears. the This neutral words whilst presents other source threatsource contains many only. if is It that participants to the assumed pay attention words. other source of words, related deteriorate. Mathews tasks & the McLeod (1985) found that will on their performances less than did. well performed Both non-anxious Wells participants participants anxious (1997) Eysenck conclude that a reliable bias effect has been shown in these (1997) and McNally (1993) have doubted that these tests as such though others, are studies, in field. to the Furthermore, they really clinical relation valid only help us to ecologically data are as they would be were schematheory valid. the that conclude

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less but in depression the been has much bias appears Memory phenomenon established "Individuals (1997) Wells As 1994). & Matthews, in (Wells with notes, stable anxiety Nevertheless, danger information. the for bias schema-congruent anxiety show attention However, for bias effects require systematicevaluation... underlying mechanisms between in the cognition and anxiety remain relationship questionsof causality unresolved"(Pg.13-14). We might summarisethe evidenceabout the role of `underlying causes'in CBT suggests that whilst there is good reasonto be confident that the therapy works, it is not well heart has led how it This therapy the the some question at of works. understood is Prominent to try to the these schema concept. amongst researchers redefine researchers Teasdalearguesthat the schemaconcept is liable to Teasdale(1996). In essence, `structure' In thing, to as a a as presentation previously quoted. place of this, reification he arguesthat it should be seenas a relationship betweendifferent elementsof functioning. He presentsa'network' conceptof interconnectingsubsystemsthat process affective, physiological, behaviouraland cognitive information. He terms this network (ICS) framework. It is informed by many research the Interacting Cognitive Subsystems findings from his earlier work on tracing the way the affective, physiological, behavioural influence (Teasdale & Barnard, 1993). The various each other cognitive systems and implicational the and propositional such as subsystems subsystems, mutually influence in however, the whole systemthat act to synthesise There core elements are, each. become These especiallypowerfully effective and act as syntheses cognitive products. information or schematicprocessing.Teasdale(1996) claims that of networks persuasive the ICS conceptis congruentwith other leading attemptsto provide a clearer definition of that schemasmight schemawithin cognitive theory. For example,Beck (1996) suggests be better thought of as 'modes'- evolutionary network connectionsbetween the functioning systemssimilar to the ICS network concept describedabove. Anxiety is a based illustration reactions on evolutionary advantagethat particularly good of network life (Beck & Emery, 1985).Teasdaleclaims become in liabilities may everyday modem

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CBT to techniques is evolve attempts recent more ICS with compatible concept that the beliefs. disconfirmation lead negative of likely to from CBT therapists ICS acceptance the wide concept will gain The extent to which factors be This causal be about underlying may problematic uncertainty to seen. remains that the psychodynamic model, place such especially therapeutic modalities, to other located the client's within early experience, causes. usually underlying, on stress great debt behavioural Bruch & Bond to the tradition. CBT in considerable a owes Formulation behaviourist, British Meyer, (Meyer & Chesser, the the early role of (1998) acknowledge Meyer 1979)). Turkat, & Meyer was particularly concerned to counter the 1970; it time that to the and wanted of replace psychiatry of with an `diagnostic' emphasis learning history. individual Such based the client's an emphasis was also on approach American behavioural therapist, Turkat (1985; 1990). Persons the in the of work reflected in bringing formulation Turkat into built the of case work (1989) also on cognitive however, (1998) her & Bond Bruch critical are, of work on a number of counts. therapy. Most notable for the discussion here is their assertionthat in using the term `underlying imply `... (rather to than) to some psychodynamic analogy, attempt seems she cause' formulate a valid clinical theory.' (p. 14) different traditions, within cognitive modelling there ambiguities, and are In summary, in CBT. Many CBT formulation questions making remained as yet unanswered about and formulation, including: Is there any validity and usefulnessfor diagnosis group formulations? . Is there and validity and usefulnessfor `underlying mechanisms' in group or individual formulation?

Cognitive therapistswould be likely to answer these questions with `Yes' and `Yes', `No' therapists `Yes. ' Behaviourists might psychodynamic and with and person-centred is, `No. ' It however, `No' and not clear to what extent even many CBT well answer, therapistsappreciatethat these subtle differences do exist within the broader church of `CBT formulation. ' Kuyken (2006) has suggestedthat more rigorous tests of formulations needto be developed.

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2.10.5: The development of and rationale for cognitive models: an overview

It hasbeennecessary to chart the rather preciseand difficult paths through various, for features development the especiallyevidential, of of cognitive models rationale and severalreasons:

"

Thepowerof the modelis derivedfrom establishing preciselinks between

problematic thinking, emotions and behaviour, The appealof the model to practitioners is often basedon its empirical standing. Even if they do not always appreciatemuch of the detail of this, detailed research findings may be consulted. Health systemsare increasingly managedon the basis of `empirically supported' treatments.Even if the managersdo not always appreciatemuch of the detail of this, again,the detailed researchis available. All therapy models are increasingly requiredto find such evidence.

"

"

It is known that professionalsin the field of psychologicaltherapy have been as disinclined to read researchevidenceregardingthe efficacy of their work as it seemsare (Persons, 1995). Now that decision-making bodies in groups most other professional health frequently arenas and other require more researchevidence, it is governmental helpful to be able to cite evidencethat supportsone's work. The CBT field has been in combining the work of researchers successful unusually and practitioners into unitary practices.It is probably the professionalgroup in psychological therapy that has come closestto achieving the `Boulder' model of the scientific practitioner (Hayes et al, Ed., 1995; Clark & Fairbum, 1997).

2.10.6: Specific formulation models in other therapeutic models: In consideringhow other therapeuticmodels might regardthis formulation principle, it is to distinguish betweenhow they might respondto the idea of having specific necessary treatmentsgearedto specific disordersand how they might respondto the idea of a specific cognitive treatmentfor a specific disorder.

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idea be to the that therapy should be specifically modalities How sympatheticmight other humanistic approaches disorders? Both different the person-centred and towards shaped formulating though the problems psychological notion of of element offer some McLeod (2003, is inimical 137) therapists. to person-centred p. writes psychopathology in humanistic therapy, process the assessment of
Humanistic practitioners seelittle value in conventional approachesto psychological fit diagnostic label is For likely to to to attempt a any a client example, assessment. intrude into the relationship between client and therapist, and interfere with the task of from his her the client's experience or point of view. understanding

Rogerian formulating therapy stressesthe value of 'unconditional of element The main judgemental' highly anon has been that attitude so and much emphasis regard' positive that others, their the especially significant parents, of requiring effect children on put in lives. For their `conditions high of worth' example, when parents expect too meet judge `failure', damage then their this the self-concept of the and may much of children developing child. The highly accepting nature of the humanistic counsellor is supposedto influence Within the this and empower negative client. person-centred counteract few if there for therapy, are any general and models example, of counselling depression.There has, however, been some recent work by Mearns & Thorne (1999) distortions in of selfconcept relation to severeproblems such as showing specific borderline personality disorder. Within person-centredtherapy, there is a great emphasis on the individual client and therapist building up an understandingof that client's unique view of the world. Johnstone& Dallos (2006, p. 11) note, "... not all therapeutic approachesuse formulation Humanistic have therapists been point. starting reluctant to engage in a processthat as a Carl Rogers(1951) saw as an unhelpful imposition of an expert point of view on the " Interestingly, one of the main early efficacy findings on personclient's experiences... in the by Smith, Glass & Miller (1980) that was meta-analysis counselling centred had therapy strong efficacy with problems with self- concept and showedperson-centred low self esteem(Ivey et al, 1997). Problems with low self esteemare obviously often linked to other psychological problems.

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for that, This emphasison the individual uniquenessin humanistic models may mean is it background, peoplewho come into training in CBT with a person-centred knowledge demand formulations that of to cognitive with work and accept problematic in functioning for individual the therapists to client review specific cognitive content and the light of such knowledge. Suchan approachmay have the double jeopardy of taking the role of'expert' and of conspiring in the 'labelling' of clients. Eells (1997) notesthat psychodynamictherapy has always had an implicit notion of formulation and with the developmentof shorterterm dynamic models, this has now becomemore explicit. Leiper (2006, p. 48) describespsychodynamicformulation as having strikingly different featuresfrom other models. Apart from having different core in knowing' is `not defence there a strong element of mechanisms, elementssuch as formulation: psychodynamic
Such a generalway of looking at clinical material leavesa lot of scope for diversity in formulation like. look `accurate' useful, might simply a even or what an

This type of `diverse' formulation contrastswith the more definite and empirically based formulations of CBT. Traineeswho enter CBT training already influenced by be likely be ideas to therefore resistantto the general and symptom_ may psychodynamic focusedmodels of CBT and are likely to be more influenced by individual explanations interesting It focused to seethe extent to which was experience. the on early of client versionsof CBT'case formulation' that adapta generalclinical model of a disorder to the individual client (Beck, 1995) can satisfy this tendencytoward individual casehistory background for in training trainees coming a psychodynamic cognitive with within behaviourtherapy. Personset at (1996) suggestthat individual cognitive formulations

are

helpful in overcoming psychodynamictherapists'reservationsabout cognitive therapy. Beck & Emery's (1985, p.87) definition of the formulation principle is "Cognitive " whilst Judith Beck's therapy is basedon the cognitive model of emotional disorders, definition is, "Cognitive therapy is basedon an ever-evolving formulation of the patient in (Beck, 5). Historically, her 1995, terms" the difference p. cognitive problems and betweenthe two statements may reflect the influence of the 'formulation' (or 'conceptualisation)concept,which was implicit in Beck's earlier works but was made

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(1989). Formulation implies a greater consideration of the by Persons explicit it build individual though the would also such client, idiosyncratic situation of described The disorder the models above. the general of use with understanding in CBT the of within current range of shift position a marks perhaps formulation concept to therapists to the appeal more who stress ambition show may and psychotherapies in to these the the formulation, though which activities are extent rooted individual solely is, by CBT taken as noted above, controversial. researchers approach more empirical depression disorders, for such as specific and anxiety, In summary, cognitive models CBT. development Whilst in these the of models offer role have played a central do not necessarily preclude adaptation to a more they therapist, the to advantages Other do have for therapeutic client. models not such a strong each individualised model disorder-based faith in individual and models put more and emphasison generalised humanistic perspective, this individual emphasis is motivated From a conceptualisations. by frame individual's for and the of reference reluctance to 'label' the client. by respect From a psychodynamic perspective,it may be motivated by a lack of faith in the client's interest CB in The therapist's generalised models may consciousself-conceptualisation. humanistic This inimical therapists. be to and psychodynamic aversion may therefore by the degreeto which they can be induced to believe that the be tempered perhaps be by individual the the may counter-balanced models use of generalised case effects of in cognitive therapy (Personset al, 1996). process conceptualisation

2.11: Conclusion to the Chapter

hasbeento describe the distinctive principlesof CBT andto The mainaim of this chapter
differences the two the and similarities with principles of other psychotherapy explore broad three This trends: reveals review models. 1). Some quite sharp points of difference: for example, the significance of symptoms,the use of therapy structure, therapist directiveness and the emphasis in CBT. techniques of

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2). Someevidenceof convergence has integrated ideas CBT especially where from the other therapies:for example,ideasregardingthe therapeutic relationship and the use of longer term work with certain clients. 3). Evidence of increasedtherapy integration of CB conceptsinto some aspects of other models: for examplein the use of homework and formulation. 2.11.1: Points of difference between CBT and other models The main points of difference concernthe foci of therapeuticinterventions: variation on the foci on symptomsand on underlying mechanisms(for example,earlier negative learning and negative childhood experiences)and then of the consequentways of working with thesedifferent foci. For CBT, symptom relief is a key objective for therapy do indeed, in that the mechanisms not becomean intrusive and, underlying event be problem, symptom relief may regardedas the only objective for therapy (Layden et al, 1993).As CBT has expanded,however, underlying mechanismshave been targeted longer-term in the version of cognitive therapy: schema-focusedtherapy more, especially (Young et al, 2003). Symptoms are taken seriously in CBT. Therapeutic interventions are seenas needingrelatively robust methodsto overcomethe effects of symptoms. This line justify CBTs been has to more structuredand directed techniques used of reasoning (Dryden, 1998). Other models of therapy, however,tend to regard symptoms as having lessersignificance than underlying mechanisms. Symptomsare therefore often ignored in relative terms and most of the therapist'seffort is put into tackling underlying problems. The emphasison the needto address underlying issuesmay be justified by an apparently one-way causalhypothesis:that the symptomsresult from the influence of such underlying mechanismsand can therefore only be amelioratedby changing the underlying mechanisms.In CBT, in contrast,a reciprocal relationship between symptoms and underling mechanismsis assumed,so that working on the symptoms can ameliorate the underlying mechanisms. It is, for example,possible to learn to act as if one has the to cope with a dangerous resources world, even if one doesnot quite believe it. Over time, it is at least possible,though obviously not certain, that continuously behaving in sucha way may lead to the inner beliefs that one doeshave the resourcesand that the world is perhapsnot quite so dangerous,or to both.

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In CBT, the therapeutic relationship tends to be defined as a vehicle in which the change forward (Feltham, 1999. ) The therapeutic the carried work are of change mechanisms involve directed interventions. in CBT In other structured and usually mechanisms is itself therapeutic the the change mechanism and the therapy, relationship models of is Because the therapeutic it is defined in emphasis put much on so relationship, vehicle. directed Structured be therapeutic terms. tends to and work subtle seenas very to the the sustain required subtlety relationship. contravening With regardto the areasresearchedby this thesis, there is a noticeable difference in the CBT. Some against arguments such arguments may be termed nature of some `criticisms', for example, that clients will feel demeanedby being set homework. These least in be at principle via resort to evidence: how do clients criticisms may explored doing homework? Other the of experience such arguments may be more accurately report termed as `reservations' - for example, that CBT does not place enough emphasis on the interpersonalrelationship betweentherapist and client. These arguments may be much harderto work through becausethey relate to more intangible questions: for example, how much emphasisis `enough'? The intangibility of the `reservation' may help to keep them more impervious to change. 2.11.2: Points of convergence the hope that CBT will gradually ceaseto exist as a Beck has expressed separateschool 1996, 538). (Salkovskis, Beck hopes therapy p. that, "... what we call cognitive therapy of (conceptualisationsand treatment plans informed by research,collaboration, and guided discovery) will be taken for granted as the basics of good therapy, just as Carl Rogers's principles of warmth, empathy, and genuine regard for patients were adopted as basics therapy " all of relationships. necessary One of the featuresof writing this review that has surprised the author has been the degreeto which this has already begun to happen. For example, a striking developing are across all the modalities. These models treatment models all tend to use formulations, structured interventions and homework. Part of the reason for this has been number of brief

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the pressurefor short-termwork and evidence-based practice in USA, UK and world in has been increase Despite there this wide, mentionedearlier. an pressure, psychologicaltherapy servicesoffered within the UK health care system.There has also, however,beenan even bigger increasein demand(Parry & Richardson, 1996). A series of large-scalerecent studiesof counselling in the NHS (Bowers et al, 2000; Chilvers et al, 2001) have shown that counselling has becomethe most popular treatment for anxiety and depression with patients in primary care. If psychological therapy is to reach down into servicesfor the generalpopulation, it is clear that this can only be achieved by future. foreseeable in the therapies relatively short-term 2.11.3: Therapy integration Beck has also expressed the hope that CBT might be a vehicle for the achievement of a (Alford & Beck, is 1997). There integration the therapeutic models all of wider a very integration interest in therapy and many therapistsreport that they practice some active kind of integratedor eclectic form of therapy (Eells, Ed., 1997).The most active area development is in brief is the therapies.As discussedabove, the there of evident where have CBT had to techniques appear of a great impact in the field of brief methodsand therapy. It is, however, also evident that when writers describetheir theories in more formal terms, very few allusions are madeto integrating conceptsfrom CBT, whereas descriptionsof CBT frequently contain allusions to integrating items from other therapies (Woolfe & Dryden, 1996).This may be becauseclinicians have dominated the developmentof the short-termtherapies.As Brewin (1996) notes, it frequently takes theoreticianssometime to catch up with and provide theoretical explanations for the developmentsof clinicians.

2.11.4: Summary: A seriesof competing ideashave evolved to explain the processes of psychopathology and its therapy. Someideashave been in sharpcontradiction of each other, other ideas appeared so closethat they have led to the hope of an overarching integrated theory emerging.This variation in debating style may explain why debatersin different eras havereferredto both `Cold War' (Norcross & Arnkoff, 1992) and `post-tribal' (Inskipp,

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1996)relations betweenthe models. It has been difficult to avoid debatesbetween the difference that either or similarity. The approach of this over-emphasise therapy models define been to to try theory has therefore principles of and practice as precisely as study how to then such principles might appear to proponents of other compare possibleand CBT Our the hypothesise of principles of suggests review that we can points of view. hand, hold to opposite principles will experience the strongly one traineeswho, on dissonance degrees learn high CBT. On trying to the other hand, of when abnormally however, they are not likely to hold equal reservation about all CBT principles. The study identifying by this the further area combinations of attitudes to particular to explore aims impact on performance of practice skills, As by the held trainees. principles principles we different hypothesise that CBT towards combinations of attitude also principles might in learning CBT These impact hypotheses skill general or specific on ways. would are tested in the remaining chaptersof this study.

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Chapter 3: Skills training for CBT in involves for therapy students using skills, theory and educating Training psychological different 1997). Given (Ivey the in al, et practice a competentand effective way in decide to train the theory trainers to whether students skills, must practice, approaches In than just them them. the more one of all paradigms, or of main of one and practice of is in that trained student a rigorously at practice, current accreditation systemsrequire least one approachbut usually also require that students are introduced to the other main Society (BPS) for example, requires that its Psychological British The approaches. be introduced to the should all main approachesand psychologists counselling chartered least Private institutions in be them. two training be tend to of at centres proficient should bastions for remain as mono-therapy models. Public for particular approachesand least introduction to different models and are offer at some institutions more regularly in different trained have It be traditions. likely members therefore, to staff can seen, more background different frequently takes the place against of paradigms and that training least introduction have different in to at some a range trainees will of and, some most from Therapists ideas. background theoretical one particular may ways, competing in Mackay (2001) for example, describe the train to another. et al therefore need from to trying change mainly person-centredto experiencesof counsellors The counsellors reported various difficulties in practice. psychodynamic-interpersonal including that they realising tried these to adhere too strictly changes sometimes making had this often negative effects on their practice. This chapter will to the new model and in training development of skill counselling and psychotherapy and will the describe have been from trainees who into changing CBT practice. of other studies models review the between elementsof skills, theory and practice has varied over the balance The history of training of psychological therapists and has also varied within and between the Early attempts at psychoanalytic training were mainly based different main approaches. theory and case study based practice teaching of teaching didactic on - with by a mentor figure. More analysis and supervision personal accompanying emphasis was the for techniques as opportunities and easily recording therapeutic sessions put on skills trainers have therapists CBT and embraced this technological development increased.

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have developedwidely used skills most enthusiastically,and, characteristically, interventions CTS-R., the therapy to and and guide such as numerous manuals measures, humanistic Psychodynamic trainers, emphasisingrelationship over technique, and skills. have expressed more reservationsabout the skills basedapproach.Skills-based training is have evolved, however, even in used and sometherapy manualsand skills measures someareasof training for both psychodynamicand humanistic therapy. Training can therefore be an areaof both cooperationand conflict betweenthe different approaches. One solution to conflict is to have completely separateinstitutions, as exist in the case of someprivate training agencies.This solution may not be available to public institutions, which can therefore be subjectto the forces of both cooperationand conflict between Traineesmay therefore be subjectto a variety of different influences that approaches. may impact on their attitudestowards practicing therapy and these attitudes may influence the learning of skills, theory and practice. 3.1: Skills and training for psychological therapy: Generaldefinitions of `skill' have stressed three main features(Concise Oxford English Dictionary: Soanes& Stevenson, Eds., 2004): Skilled activities are identified as being performed expertly or well, 0 " Skilled activities are performed with `dexterity' or smoothness, Skills are developedas a result of training or experience.

Skilled activities showing expertiseand smooth execution still, however, need to be conductedin a way that is appropriateto the objectives of the overall activity of which they are a part and to the context to which they pertain. Underpinning knowledge should When skills are so performed, the personperforming them enhanceappropriateness. may Competenceis often seenas an indication of adequate claim to have competence. qualification to perform certain tasks. Competencemay be understoodas a general or particular attribute of a person's performance(Concise Oxford English Dictionary: Soanes & Stevenson, Eds, 2004):

la. The stateor quality of being adequatelyor well qualified: ability.

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lb. A specific range of skill, knowledge or ability. have been in and psychotherapy more actively Skills and competencies counselling linked been have 1970s with certain sorts of proactive often and defined since the `intentionality'. Ivey, (1987, 1 1) in and self-efficacy as such p. psychology attitudes intentional to the practice of counselling and psychotherapy: locatesskills as central
Intentionality is acting with a senseof capability and deciding from a range of alternative has individual intentional behavior than The thought more one action, to or actions. life The intentional in individual can from to changing situations. responding choose in from different situation a given and approach a problem alternatives vantage generate different and to of skills personal qualities, adapting a variety styles using suit points, cultural groups.

involves from intentional choosing a range of theoretical ideas and Making choices Skill learning during in training. and competence counselling and concepts,usually from has the a preoccupation with progressed relatively abstract psychotherapy discussionswith a mentor figure associatedwith early attempts to establish training to the The development definition `micro-skills' skills. of subsequent teaching of precise more fed naturally into the development of therapy manuals and 1987) (Ivey, learning and in have for the these played a central role search more consistently protocols and based `evidence (Roth practice and psychotherapeutic practice' and Fonagy, effective 1996).It is helpful to distinguish between different skill areasand Ivey et al (1997) note different different therapy will models emphasis skill areas,see Figure 3.1. that Figure 3.1 below shows that the skill profile for CBT is distinctly different from that of like therapy, and psychodynamic which are more person-centred each other with a focus The CBT has been criticised for a narrow relationship skills. on model particular focus on techniques(Weishaar, 1993) but actually CBT theorists have tended to specify three broad areasof practice skills already described: technical, formulation and 2003; Bennett-Levy, (Sudak 2006). Figure 3.2 below shows some et al, relationship in broad the these skills of areas specifications

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Figure 3.1: Skill use in different therapy models (Adapted from Ivey et al, 1997)

Person centred (PCT) there

Psychodynamic therapy

CBT

ATTENDING SKILLS
open questions

Closed questions
Encouragers Paraphrase Reflection of feeling

Reflection of meaning 'i Summarising

INFLUENCING SKILLS

Feedback Advicelinformation Self-disclosure

Interpretation

Logical consequences
Directives

Influencing summary Confrontation

---FOCUS OF WORK

Client
Thera ist

EXTENT OF THERAPIST TALKING

ISSUE OF MEANING

Feelings/ relationships

Unconscious

motivation

Unhelpful cognitions

Key:

-= Little = use;

Some use: Red spa

= Much use

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Equipment Recording Impact The 3.1.1: of during to (1947) Porter method clientnon-directive studied adherence Blocksma and degree the to which they found They trainees that over-estimated vastly training. centred advances in because the the The of study was possible followed non-directive practice. Carl the therapy and willingness of sessions of easeand cost of making recordings Recording development in therapy. the technology of equipment Rogersto use such fashion: 78-rpm in be to successively on more accurate a recorded allowed sessions formats. MP3 CD, DVD Audio later, film, and videotape, and, audiotape, records, in the research intrusive least these is the and methods played a major role of recording 1967; 1980). (1942; 1951; Rogers Carl work of A main thrust of Rogers' approachto therapy was to understandclients in terms of their by listening Rogers them to `frames carefully and showing of reference' empathy. own (1980, p. 139), however, later referred to the "appalling consequences"that came from developing mechanical skills from his work. Such skills, referred to as `listening skills' in `empathic now common use amongst therapists of all types and are skills' are and They involve training techniques taught courses. may on specific such as often `paraphrasing'and `reflecting' (Carkhuff, 1969a, 1969b; Egan, 2002; Nelson-Jones, 2003.). These skills developed from analysis of audio recordings of counselling sessions. Theseresearchers were able to delineate many significant features of the counselling 138) (1980, his Rogers p. recalled a sense of excitement as researchteam process. from interviews. recorded material analysed
Then came my transition to a full time position at Ohio State University, where, with the help of students,I was able at last to scrounge equipment for recording my and my interviews. I cannot exaggeratethe excitement of our learning as we clustered students' about the machine that enabled us to listen to ourselves, playing over and over some puzzling point at which the interview clearly went wrong, or those moments in which the client moved significantly forward.

And in a later interview,he added:

It is true that, becausewe were recording, we tended to focus on the immediate verbal Therefore, we got too wound up in technique; but at the time, it was incredibly response. exciting to realize that each thing you did or said and -I would add now each attitude hold, difference in the therapy in progress. It was something that makes a real you had we before. done It was putting therapy under never a microscope, and it was a very good microscope: we learned all kinds of things... I realise, `Wow, that was a historical step

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' At the time, eachstep seemedentirely natural... But it took me that was really fantastic. a long time to realisethat those seminarswere an historical event (Rogers & Russell 2002, pp.128-129).

Seeman (1997, p. 1140),who was.involved in the project, claims that this research was " Once therapeutic skills had been "... the beginning of modem psychotherapyresearch. identified in this way and additionally once the effects on the processand outcome of therapy had beencharted,the way was open for the adoption of a skills based approach to training in counselling and psychotherapy(Egan, 2002). 3.1.2: The Counselling Skills Movement As interest in counselling skills developmentgrew apace,Rogers(1980) preferred to stressthe needfor therapist attitudesand personalqualities, rather than skills. This in been has retained more recent person-centred practice (Tolan, suspicionof skills 2003). Rogershimself moved onto other areasof interest such as encounter groups so (Truax & Carkhuff, 1967)to develop the base for the that it fell to other researchers in `counselling the late 1960sand early 1970s.These the skills movement' growth of framework by Rogerian developed the adding new, more `action-oriented' skills authors definitions of skills connectedwith, for example, empathy. They also and more specific in for training the counselling skills by showing that unskilled counsellors advanced case More definitions harm do did allow the use of skills to be to specific clients. could measuredfor both teaching and researchpurposes.Carkhuff (1969a) assertedthat competencein counselling skills could be achievedin a training course of 100 hours. This stood in stark contrastto the yearsof traditional psychotherapytraining. In the UK, there has beena large increasein the number of counselling skills courses from the 1980sonwards.Rushton & Davies (1992), for example,evaluated a 60-hour courseto train community-basedprofessionalsin the basic skills of counselling families of children with disabilities. They concludedthat the coursewas cost effective and was linked to improved performanceby the trainee professionalsand linked this to benefits for the subsequent clients of thesetrainees(Davies & Rushton, 1991).

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Egan (2002) `micro-skills' training developed and similarly model a Ivey (1987) have Bolger (1985), Some helper' `skilled as argued such writers, developedthe model. helping. For in the of styles over-mechanical resulted on skills the that concentration Russell & Dexter (1993) have that: trainers however, with agreed many most part, to saythatthe measurement of competent practiceis elusiveand It is no longerplausible it is identifiable its is if teachable, and competent use counselling unquantifiable... (p. is 268) it If the then of counselling validity courses. we must query not, observable. Trainers involved in teaching skills stressedthe action-orientated element of helping from developed integration Rogerian Egan's 2002). (Egan, an of and model models feature in that it developed some has The theory. original an model cognitive-behavioural Carkhuff (1969a) into identified by helping the process a comprehensive of the stagesof for identified in were skills particular uses at specific stagesof skill model which specific first In interventions. the edition of the Skilled Helper, these stageswere therapeutic identified as: Exploration, Understanding and Action. Egan went on to identify different for different A the the stages similar sequential use of of process. use patternsof skill for CBT. Some be CBT be tied to sequential aspects mapped of skills also can can skills the CBT sessionstructure. For example, agendasetting must be completed near to the The CBT be therapy the thought of as session. sequential of nature skills can start of by Egan. for This identification to the similar model used allows of where conceptually fit into intervention. how Approaches such as the the skills might specific overall and have and person-centred models a particular emphasis on the therapeutic psychodynamic have been deliberate the often and suspicious of use of techniques. Stewart relationship (1978, p.27) comments: Apparently a largenumberof counsellors andpsychologists of the humanisticschoolare theoretically andphilosophically to the applicationof any form of technologyto opposed humanbehaviors. Kelly (1969, p.55), however, writing from within the humanistic school, assertsthat: Humanistic psychology needs its humane a technologywith which to express interventions. In describing the use of skills in person-centredcounselling, Tolan (2003, ix) p. suggests that:

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therapy, which is so It may seemrather anomalousthat a book about person-centred foundedon relationships,should have `skills' in the title. I hope that it will quickly becomeclear to the readerthat this book is not a collection of `techniques' but one which practice. tries to illustrate the liveliness and immediacy of person-centred

Tolan's book is almost exclusively concernedwith achieving empathy, congruence and in `core Rogerian (the the relationship and conditions') regard unconditional positive doesnot include material on the intentional use of skills or techniqueswithin that CB, or other action-orientated,approach. a would as relationship, from `shallowness' that the the can arise Milton (2001) has expressed about reservations detailed A CBT. in accountof psychodynamic attitudes more technique on over-emphasis is later in (1996) this in Persons is CBT and chapter. al presented et towards given Inskipp (1996) showshow the developmentof counselling skills teaching has been influential in the developmentof counsellingtraining in Britain. The British Association for Counselling and Psychotherapy(BACP) has beenthe principal accrediting body for In in Britain. order to achievecourseaccreditation, training centres counselling courses hours 450 least training, 200 of which have to be in counselling must run coursesof at skills (BACP, 2002). The methodsof teaching skills are not prescribedbecausethe different types and orientations. During the cover courses of accreditationrequirements 1990sBACP was active in the Lead Body consortium involved in defining and assessing (Aldridge & Rigby, 2001). Defining competencybegan with defining competencies National Vocational Qualification awards(NVQ) for counselling and more recently has involved defining National OccupationalStandards (NOS) for counselling in conjunction Skills Council. In the wake of the counselling NVQs, with the government-sponsored a project to define NVQ awardsfor psychotherapywas initiated in 1996 but was never implemented.The first report of the NOS project for psychotherapy,which was focused on CBT, reportedin August 2007 (Roth & Pilling, 2007). Roth & Pilling's framework for defining thesestandardsis shown in column 7 of Figure 3.2., and will be commented on further in the following section.

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3.2: Skills and training for CBT:

(1996,p.266) notesthat: Padesky

detailed first to therapies specifications the provide Cognitive therapy was one of in Clear treatment specification for treatment stages,structure and methods... how to these therapists to adhered closely evaluate methods allowed researchers different these protocols correlated of elements whether treatment protocols and be Treatment a used as can also treatment outcome... outcome... with positive that therapists Several obtain suggest studies therapist competence... measureof better treatment outcome for depressionif they adhere closely to the structure of follow the the 1988) (Shaw, procedures of standardised therapy and cognitive therapy (Thase, 1994). large, for developed been had the that multi-site Beck et al (1979) usedthe protocol different 18 This develop contained checklist TDCRP trial to a competencychecklist. Cognitive Therapy Scale development the for basis became the of the competenciesand CTS (CTS-R: James A the 1980,1988). & Beck, of Young et al, version (CTS; revised is described in development the therefore in the scale of this 2000) was used researchand

4. in Chapter the sectionon research materials of skills-based cognitive training. Dobson& Shaw(1993)reportthe early development
develop to the them to key identify therapy tasks relate They the and need of cognitive help key to The to: therapy tasks are clients of cognitive skills. particular reappraise their unhelpful cognitions, and,

based behaviours behaviour of on thesereappraisals. or set enacta new

They add (p. 574):
In order to assistthe processesof reappraisal and enactment, cognitive therapists have three principle activities that they need to attend to. These activities, in likely descending order of importance, are: 1) relationship activities, 2) caseformulation, and 3) techniques.

This tripartitedivision fits well with the variousskill groupings in that will be described
this section, as shown earlier in Figure 3.2. Dobson & Shaw (1993) regardedthe ability to build therapeutic relationships as being as `relatively immutable' in training. They suggestthat the trainee's ability to form such be should assessed relationships as part of the selection process for CB training. The CBT in courses this study make use of interpersonal group exercises as part of the selection (UWN, Course information 2004). Various aspectsof the ability to collaborate process -

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be ideas listen `run the to to and with' of other group members- can observed and for ' for `collaborative the style preferred empiricism, consideredagainstthe requirement the therapeuticrelationship in CBT. Dobson & Shaw (1993) regarded,subjectto the motivation of trainees,techniques as the degree They to the which one can the three teachable regard of attributes. sets of most teachthe ability to producea caseformulation as being somewherebetween the `immutability' of relationship building ability and the ready ability to learn techniques. They define a number of trainee characteristicsthat are likely to enhancethe ability to learn the skill of formulating: Commitment to learning cognitive therapy. No strong attachmentto anothersystemof psychotherapy. Relative inexperienceas a therapist. The ability to tolerate clients' negativeemotions. A preferencefor active, rather than passive,therapeutic styles. `Psychologicalmindedness'.

1) 2) 3) 4) 5) 6)

It shouldbe notedthat points2 and5 above andtheir link to the natureof trainees'
by the to the study reported in this thesis. posed questions research attitudesrelate Padesky(1996, p. 270-1) describesher experienceas a CBT trainer. She notes that the be by follow CBT to the ability to form a therapeutic must structure matched ability relationship and an understandingof the empirical scientific method. Empirical method be however, operationalisedwith clients to lead them towards guided discovery. must,
Therapistswho are not willing to participate in a highly interactive therapeutic relationship are poor candidatesfor Cognitive Therapy training The ideal cognitive ... therapist is capableof being highly structured in therapy, comfortable tracking a number of taskswithin a session,and yet sensitiveto adaptingtherapy to individual clients to maximise collaboration and positive therapeuticrelationships.

Bennett-Levy (2002) notesthat role-play exercisesare effective in training. For Padesky (1996, p. 281) exercisescan take the form of either group demonstrationsand/or experiential exercises.

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Beginning therapistsoften learn best from very structured, time-limited, and goalbecome As therapists cognitive more skilled, these roleexercises. practice orientated become in be therapist open-ended, with greater very choices goals, clinical can plays In level become this client complexity. way, experiential of exercises more methods, and knowledge increase. like In therapist therapy as and experience actual advanced more and different is instructive it the the therapist choices with to compare results of workshops, the sameclient situation.

Role-play is a useful low-risk method of trying out skills during the initial phasesof the learning of any particular skill set. Skills must be tested in real clinical situations. CBT practice tapes submitted by trainees. Coursetutors use the CTS or CTS-R to assess The use of audio and video recordings was incorporated into the early development of CBT practice (Beck et al, 1979; Dryden, 2004) and CBT training and has continued to be (Dryden, 2004; Padesky, 1996). One limiting factor is that since ever practice standard This trainees to tapes to choose which allow submit. mainly should, however, courses limit the dangerthat a trainee might be assessed on the basis of work with a particularly difficult client (Markowitz, 2001). The interpretation of CTS ratings varies somewhat from courseto course. Some coursesfollow a `red line' strategy that attributes an overall is held have `passed' (Strupp trainee to the a assessment at which score et al, 1988). Dependingwhere the red line is set exactly, trainees may have some leeway to do poorly if items in they two perform or above average others. Other courses, including the one on one in the presentstudy, require trainees to reach a prescribed `pass' level in all items. There have been two previous studies that have compared pre and post training measures do CTS to that trainees scores establish make significant gains in CBT skill acquisition of during training. Williams et al (1991) used the CTS, 1980. Milne et al (1999) used draft a CTS-R the of with sameresult. There have been 2 other studies that have version examinedthe effect of therapist competencemeasuredby the CTS on the outcome of therapy (Shaw et al, 1999; Trepka et al, 2004). Shaw et al (1999) used data collected in the large scale clinical trial, the Treatment of DepressionCollaborative ResearchProject (TDCRP) that compared the treatment effects interpersonal therapy, therapy and medication. CBT therapists treated cognitive of from suffering major depressivedisorder in three different sites using a outpatients

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format of 20 sessions spreadover 16 weeks.The findings offered "... limited support for the relationship betweentherapistcompetence as measuredby the CTS (1988 version) and reduction in depressivesymptomatology" (Shaw et al, 1999,p. 844). Only one of the three outcomemeasures, the Hamilton Rating Scalefor Depression(HRSD-17, Hamilton, 1960),was relatedto therapistcompetence, and then only after statistical to the protocol and therapist control for in-take HRSD score,therapist adherence facilitative conditions. Shaw et al (1999) noted that there were difficulties in the TDCRP for that contravenedtheir own previous recommendations: especially, on-going supervision.They also note that one casewas removed from the data as an outlier. This and very poor outcome: had it remained in, a caseshowedvery low therapist competence and outcome would have been much strongerrelationship betweencompetence demonstrated. The authorsdiscussthe possibility that the CTS does not measure however, (1993), fully. Whisman notesthat therapists in researchtrials have competence for be included in had been to the trial and so are likely to competence assessed already leading to results likely to be quite conservative in of competence, range show a narrower their estimatesof the relationshipsbetweencompetenceand outcome. Trepka et al (2004) also researched the relationship betweencompetenceand outcome, but in the context of more routine practice situations.A randomly selectedCBT session from eachof 30 coursesof therapy was rated using the CTS, 1988version, and also the California PsychotherapyAlliance Scale(CALPAS: Marmar & Gaston, 1988). Both therapeuticalliance and therapist competence were relatedto outcome. In regression analysis,the alliance remainedsignificantly related to outcomewhen controlling for but competence not vice versa.Theserelationshipswith outcome were primarily attributableto therapistsrather than to clients. Associationswith outcome appeared strongerfor those clients who completedtherapy than for those who did not. These findings suggested factors both common to diverse treatment methods that measurable and specific to particular methodsshould be included in efforts to account for therapy outcome.

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is in learning helpful in different CBT domains that different skills skill areas Separating learning for different the therapists of cycle be phases and with with may associated learning (Bennett-Levy, 2006). Bennett-Levy teaching strategies and different types of between differences based declarative knowledge there that skills are on (2006) suggests depression how based learning factual based affects a client about and skills on on judgement. for Declarative knowledge knowledge example, clinical skills procedural for As trainees. training in training learnt neophyte of stages progresses, earlier are in be techniques to try and skills role play and client settings and will able traineeswill benefit from role play, simulations and casediscussions that will enable them to build up A `when, involving then' type training more rules. advanced of skills and/or procedural be for development the interpersonal needed may of reflective and supervision on-going focus therapeutic but These so not much on establishing would skills relationships skills. therapeutic by they of tested repair relationships and when the are maintenance more on difficult situations (Safran and Muran, 2000). Developing these more complex skills develop CBT trainees Bennett-Levy that would more self-reflectivity. and might require Thwaites (2006) suggestthat CBT supervisors should be more prepared to take on this dimensionthan it traditionally has. There is also a debatewithin the CBT community CBT in trainees therapy, should undertake personal as psychodynamic over whether therapy. Bennett-Levy and Thwaites (2006) have, however, suggestedthat a process both therapy trainees therapist and client can with experience each other as whereby function be therapy the as personal same and can monitored more carefully perform within the training course. Bennett-Levy and Beedie (2007) have studied how CBT trainees experience the developmentof competenceduring the period of training. The early period of training is in but technical less with gains competence much gain, and in some cases, associated lossesin interpersonaltherapy skills. The greater difficulty with learning CBT interpersonalskills may be accountedfor by the fact that trainees are having to learn to follow the manual and `go by the book'. Trainees probably suffer somewhat from divided Similar findings times. were reported in studies of psychodynamic and attention at such interpersonaltraining studies (Henry et al, 1993a, 1993b; Mackay et al, 2001). In the

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study by Bennett-Levy and Beedie (2007) trainee interpersonalskills were starting to improve towards the end of training but we do not know how far this improvement would continue into the post-training situation.

There are somestudiesthat report problems with maintaining training gain unless good is Ashworth (Dobson Shaw, 1993; CBT and available et al, quality on-going supervision 1999).All in all, thesestudiessuggestthat there is a need for more interpersonal focus in CBT training and that this should be maintainedby supervision into post-training. The developmentof therapistsafter training also draws attention to the need for appropriate There be for for CB therapists to stay tendency may a practice. environments on-going within their own professionalassociationsand pre-training areasof practice partly because the developmentof CBT practice may not be developedor prioritised in other is first developing The the to standards of national step a wider establishment areas. because for help in therapists such standards can agencies all areas to of support system have a systemof referencefor what might be neededto support the growth of CBT into their areas.Sudaket al (2003) describeCBT competencystandardsfor psychiatric in USA doctors list the and gives a preliminary of skills and knowledge areas, an resident in is Figure 3.2. Roth shown which and Pilling (2007) completed the first draft outline of for CBT in the UK, also shown earlier in Figure 3.2. At standards of national occupation the time of writing (December,2007), thesestandards are being drafted and discussed by is the which of author group, a member.Comparedto the wider field of a working psychotherapy,the developmentof identifying, defining, measuring,teaching and promoting skills in CBT has beenrapid, though there is still much work to be done. The is likely to be needfor responsivetraining systemshas beenevident. Such responsiveness in needed order to engagetraineeswho will come for CBT training having absorbeda different therapy model. 3.3: CBT training with trainees changing models: It was noted earlier that CBT training is a secondarytraining for most trainees.The British Association for Behavioural and Cognitive Psychotherapies (BABCP) is made up for 5 main professionalgroups Clinical psychologists(30%), Nurses (28%), -

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(13%) Social Workers (5%) (Personal Doctors/Psychiatrists (20%), and Counsellors 2005). All these groups have had a primary to BABCP author, office communication: likely have introductions to, and in some during to they training are which professional in, CBT. training than psychotherapeutic thorough other approaches other casesmore & Shaw's Dobson (1993) description reflections on CBT training noted The earlier of that a pre-existing strong allegiance to another therapeutic model might constitute a have been a small number of authors who have There for CBT training. contraindication looked into this question further. As this issue lies at the heart of the research questions these this in thesis, consider will now this chapter studies. pursued

from how have therapists othertraditionslearnCBT includethose Studies that examined

Overholser Freiheit (1997) (1996), Morgenstern (2001). and Persons and at et et al of Personsis a cognitive therapist and trainer, involved in training psychologists in CBT in her home stateof California. Personstrained psychologists who are more likely to be from a psychodynamicbackground. The study, written jointly with some of her trainees, describesand makessuggestionsabout how the transition to new learning is made in thesesituations. Freiheit and Overholser (1997), who are also involved in training CBT, in Their this some cover of same ground. study involves participants psychologists backgrounds. It includes knowledge therapeutic pre and post measures of of varied and but The this by Morgenstern study, of unlike skill not, competence. study use skill et al (2001) reviews a study of how well counsellors previously trained in `12 step' methods learn CBT. It does the include skill competence dealing can skills addictions of with of but measures they use a measurespecifically applied to the addiction field. 3.3.1: The Reservations about CBT held by trainees with a Psychodynamic background: Personset al (1996) describe the reaction of trainees from a psychodynamic orientation identified is Persons CBT training. as a CBT trainer and the other three authors were to trainees,originally trained in psychodynamic methods but taught CBT by her. The CBT trainees of psychodynamic about are described. It is not made entirely reservations

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or their views own however, trainee expressing three are the authors whether clear, how it they is Neither clear made whetherthey are expressingthe views of othersas well. data for describe, was any whether they example, the set of reservations arrived at is it to safest information therefore, probably to the In contrary, collected. the absenceof but to for trying themselves also concludethat the three trainee authorsare speaking trainees and orientated psychodynamically of the group a wider of views articulate described: Three therapists. main areasof questionsand reservationare 1) The therapeuticrelationship in CBT, 2) The focus of interventions in CBT, and 3) The depth of changein CBT. in For trained therapists psychodynamic Questions about the therapeutic relationship: is CBT of often nature theory and practice, the active, structuredand problem-focused is because This its interpretation. development transference hindering of and the seenas is be the therapist is to relatively neutral. when strongest the transference expected behavioural therapist as the the theorists active role of cognitive Psychodynamic regard likely to generateeven more client reactions.They may also consider the structured development inhibits the CBT necessarily of emotional responses sessions of nature involved in a corrective emotional experience.
Cognitive behavioural sessions seemto promote corrective intellectual experiences, but from Thus, the point of view of the psychodynamic ones. emotional not corrective therapist, the cognitive-behaviouraltherapist seemsto neutraliseor misuse one of the hesitates The therefore therapist psychodynamic aspects of psychotherapy. potent most to behavioural by (Persons interpretations taught the therapist. the cognitive active use et al, 1996.P. 204.)

Considerationof the therapeuticrelationship in CBT leadsPersonset al (1996, p. 205) to assertthat "... psychodynamictherapists,on the whole, still accord a greater therapeutic do behavioural " therapists. than to the cognitive role patient-therapistrelationship Questions about focus of therapeutic interventions: Psychodynamictherapy typically highly emotionally charged involves a processof bringing to consciousawareness helps The therapist from the client to understand the patient's past. unconscious material

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believes is that this deeply understanding and clearly and his or her situation more behavioural From the therapist's this cognitive healthy perspective, for change. essential have less "... to specific solving problems, and on over-focus seem may to change route individualised the developing understanding of nuances of an and a rich on emphasis fits `one to a espouse size appear all' individual's psychological situation... and highly by the cognitive the is of structured approach This exacerbated approach... P. 206). Aversion 1996. to the (Persons perceived overal, et therapist" behavioural in itself the CBT use of skills show associated with particularly may of nature structured

of sessions: the startandendphases

beginning is therapist's of way and ending sessions often The cognitive-behavioural The beginning CB therapist. to the psychodynamic of a session objectionable particularly discussion homework the includes of previous week's and agenda-setting and typically inventory, Beck the the include on a symptom responses patient's such as of review may DepressionInventory. By starting the sessionin this way, the CB therapist seems(to the forfeit valuable data about what has been percolating in the to therapist) psychodynamic the that the the clues about patient's current as well as emotional state week over patient in first 2 be At the to the the articulate clearly minutes of able session. not may patient CB homework for the therapist the the session reviews and assigns the session, of end following week. The procedure is unappealing to the psychodynamically orientated important learned has that emotion-laden material often emergesat the end who therapist, from Thus, CBT the the trained therapist, viewpoint of psychodynamically the session. of focusesprematurely on fixing things without understanding them, and it ignores emotion. (Personset al, 1996. P. 206)

be CBT difficulty in executing these principles may associated with Reservationsabout them, therapy, such structuring CBT with as agendasetting, pacing, connected skills the feedback. homework eliciting and setting

Questions about understanding in CBT: CBT has developed by demarcating a series for depression, conceptualisations example, specific anxiety and other of problems with be They theory however, These regarded as general models. may are not, areas. idiographic type of conceptualisation that will take principles more a incompatible with from general theory and apply them to individual clients. It was only in the second (Persons, 1989) that this was clarified as a principle of CBT, CBT models of generation idea been individual has that the it argued of conceptualisation was implicit in though

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Beck's earlier writings (Personset al, 1996).The apparentlack of emphasison individual clients may have led therapists from other models to regard CBT as consisting of for diagnosis that standardised who criteria protocols, so all patients meet a given receive the same set of standardised interventions. Learning how to use idiographic conceptualisationsis, however, now regarded as a standard part of cognitive therapy training (Padesky,1996). As a study of the use of protocols (Payne & Blanchard, 1995) illustrates, cognitive behavioural therapists are beginning to incorporate the individual formulation process into their standardised protocols. Persons et al (1996, p. 207) summarisethe situation as follows:
It is also accurateto say that cognitive behaviouraltherapistsplace less emphasis on understandingand more on changethan psychodynamictherapists... Cognitive behaviouraltherapistsare willing to considerchanging something even if they do not understandit very well.

Psychodynamictherapistshave identified emotional content as an area in which the is sometimesseenas promoting emotional highly structuredformat of CBT sessions avoidance.A more accuratecritique could point to the fact that cognitive behavioural therapistsmay indeed encourageclients to over-ride emotional reactions at times and that somehave postulatedthat this capacity to use such emotional managementin appropriate ways is one the essentialelementsof `emotional intelligence' (Epstein, 1998). Questions about depth of change in CBT: Previous discussionlinked the psychodynamicconceptof `working through' with working at the level of `deep change, By contrast, CBT may seemlike it could promote only shallow change:
To the psychodynamicclinician, the symptom-focused,problem-orientated nature of CBT makesit appear`Band-Aid' like, intent on removing symptoms while apparently ignoring their underlying mechanisms as if the cognitive behavioural therapist were attemptingto cool a feverish patient without addressingthe underlying pathology that the fever (Personset al, 1996,P.209). causes

In response to this criticism, Personset al (1996, p. 209) suggestthat although "Cognitive behaviouraltherapistsdo tend to focus on overt problems; the work on overt problems is guided by a hypothesisabout the underlying mechanisms. " Here they are referring to the principle of `formulation' basedon CBT concepts.

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The CB therapist may therefore seemto psychodynamic trainees to view overt symptom be but to treatment unconcerned about underlying the and the change of goal as change himself would rather hypothesise that direct work on behavioural therapist cognitive Persons (1996) the change. et underlying al summarise produce will overt problems position thus: It is certainly accurateto say that the cognitive behavioural therapist is first focusedon symptom removal and in this respect often operatesquite differently from psychodynamictherapists.(p. 210) however, they reach the conclusion that CBT is more these points, Having reviewed This is than trainees to models may suppose. that there to not say psychodynamic similar The differences differences. that be authors suggest such should are no significant for further learning. stimuli clarified and usedas
We believe that a clear awarenessof differences can facilitate learning and teaching. (Personset al, 1996. p.203).

They suggestthat psychodynamictherapists' reluctance to experiment with CBT will diminish if they are more aware of points of convergence.Some differences between the be For in the resolved empirically. principle example, questions of whether could models by behavioural the therapist or the "bottom-up" "top-down" used cognitive approach the approachusedby the psychodynamictherapist provides greater protection against relapse is but to certain appropriate groups of patients each not others are empirical or whether between the models seemto have more to do with matters differences Other of ones. fact (Bolter 1990: Messer & Warren, than 1998). of matters et al, rather values Personset al (1996, p.21 1) therefore sum up their findings and recommendations:
Like patients,trainees arrive in the classroom with value-laden models of psychopathologyand psychotherapythat are not fully conscious or articulated and that they are not eageror able to summarily relinquish. The teacher's job is to help trainees becomeawareof their pre-existing penchantsand predispositions, examine them, and information that allows them to make whatever adjustments they might new acquire wish to make to their own working models... Thus, we argue that an important strategy for

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to teaching and learning is to make the obstaclesexplicit and to overcoming obstacles promote flexible, thoughtful examinationof them.

And further (p. 203):

Our experienceis that willingness to try a new idea or new intervention is a key step in learning a new model. This step is an important one becauseit probably leads to some her his begins the therapist a process of critically values by value shifts as examining or testing them in the crucible of therapy. Our experienceis that psychodynamically trained therapistswho are awareof and can articulate their reservationsabout the cognitive behavioural approachto the therapeuticrelationship are able to experiment more fully with CBT.

This study is a helpful guide to the kind of theoretical objections and reservations that therapistswith a backgroundin anothertheoretical model might hold whilst undertaking training in CBT. Although the focus is on the way psychodynamicmodel may shape humanistic CBT, trainees view of therapy may hold similar objections. views of with a The weaknessof Personset al's (1996) study is, however, that it does not make it clear how data were obtained. Additionally, it doesnot presentany kind of follow up data concerningthe extent to which thesetraineesactually went on to practice CBT or on their by Freiheit do The & Overholser (1997), described below, to study so. competence someof thesepoints. addressed 3.3.2: Trainees from multiple orientations: Freiheit & Overholser (1997) Freiheit and Overholser (1997) undertook a study of post graduatestraining in clinical CBT American and within an university. The traineeshad varied prior psychology in different theoretical positions. This was a typical training variety a of experience situation and one that the authorsconsiderwill have to be taken into account more frequently in the future. A central issuenot yet addressed by the current cognitive behavioural training literature is how to effectively teach cognitive behavioural techniquesto individuals from other therapeuticorientations (Freiheit & Overholser, 1997, p.79). Suchtraineeswill havevaried attitudestowards CBT and thesemay affect how they learn anotherapproachto therapy. Theseattitudes may in turn affect their capacity to achieve in CBT. competence

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CBT 6 followed trainees through (1997) of six successive cohorts Overholser & Freiheit between 6 in 8 40 to trainees, The small resulting were cohorts praticums. yearlong one Caucasian 30 40 All trainees the were and in of were whole. the a as study participants had Trainees 28.28 in to training trainees years. the choose was female. The mean age of CBT If they from and approaches. chose psychodynamic the client-centred, two models in CBT Semester in 1 practice undertook general and they CBT grounded ere option, the 2. They in Semester therapy undertook also supervised in Beck's cognitive training had had They training. during all the some previous of experience period practice clinical hours in 68.2 such of practice. number mean practice -a of clinical hypothesis: following the test The study set out the It is expectedthat traineeswho enter the course with a cognitive behavioural knowledge, have more positive more attitudes, and report gain will orientation than trainees skills more often who are not cognitive using cognitive-behavioural behavioural. (Freiheit & Overholser, 1997, p.80)

Behaviour Therapy Survey devised measure and questionnaire combined a The authors Sections: 3 has BTS The (BTS). . " 20 multiple choicequestions Knowledge: aboutCBT theory andpractice. Attitudes:25 Lickert-typestatements on attitudesto generaland specific
therapy principles.

"

Behaviourrelatedto CBT: Estimates of how many hoursof CBT practice

in techniques the of use of extent everyday practice. and

The BTS was used as a pre and post-CBT training measure.Analysing how students' developed CBT intervention, the authors the the training over period of of understanding in data: following their trends the identified Negative evaluations of CDT were strongest amongst trainees with a psychodynamicorientation at pre-test but these negative evaluations of CBT decreased significantly at post-test.

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"

Traineeswho beganthe training with positive evaluations of CBT reported a non-significant increasein positive evaluation of CBT at the end of training. The pre-testpositive evaluationsof CBT from trainees with behavioural, humanistic & psychodynamicorientations stayedthe same at post-test.

After training, there appeared to be 3 groupswith significantly differently attitudes to CBT: pro-CBT, anti-CBT and undecided.These3 groups showed no significant differenceswith regardto the numberof hours of CBT practice that they were differences between 3 No in the the the course. after groups were period undertaking behavioural knowledge frequency the to cognitive or either of use regard observedwith of behavioural,cognitive techniquesat pre and post-test.The main differences echo Personset al (1996) - emphasisingthe initially greaternegative evaluation of CBT, initially less positive evaluation of CBT amongsttraineeswith a strong previous differences These the to orientation. were reduced by training psychodynamic allegiance so that Freiheit & Overholser (1997, pp. 83-4) summarisetheir results:
The results suggestthat participating in a courseabout CBT significantly decreasesinitial biases toward CBT. Moreover, regardlessof initial therapeutic orientation, the negative studentsgainedsimilar amountsof knowledge and reported using CB techniques with similar frequencyover the courseof the CB practicum... Although trainees who initially enteredthe practicum without a CB orientation had significantly more negative evaluationsand fewer positive evaluationsof CBT than trainees from a CB orientation, in generaltraineesattitudestoward CBT improved. (pp. 83-4)

However, an increasingly positive attitude towards CBT did not indicate any great reduction in belief in previous orientation:
While traineesheld their ideasabout other orientations,their attitude about CBT improved. (Freiheit & Overholser, 1997,p.85)

Thesefindings are compatible with the conceptof cognitive dissonance(Festinger, 19S7) and might suggestthat a changeof mind takesplace over severalcycles - holding two ideasmay be a way-marker of a longer-term changeprocess.Alternatively, separate We cannotrule out the possibility that traineesmay revert to previous theories and practices after the immediateimpetus of training. Additionally, theseparticular traineeswere -100-

in have lasting longer orientation might changes a much more and newcomers relative in this study. than available was period gestation following limitation lack 85) (1997, the to the Overholser related & note p. of Freiheit measures: skill use assessment
Moreover, the proficiency of using cognitive behavioural techniques as trainees was not had different the Because supervisors, utility of competency-based students assessed. Future been have to research may want addresswhether questionable. would scores become from as competent at using cognitive behavioural other orientations trainees behavioural bias. " (p. 85) trainees a cognitive with techniquesas

They finally conclude that:

Remaining open to researchand new techniques in psychotherapy may lead to replacing The less techniques techniques. effective with new, more effective practising older, has (APA, to current with remain psychotherapy a responsibility research, clinician 1992), and to incorporate new effective techniques into their practice... In essence, to clinicians may need and practising remain open to new treatment students graduate in therapeutic techniques so that their clinical their education continue modalities and improve. (p. 85) to continue skills will

it did follow that deficit this up traineesafter training. Another was was not study One of
how learnt CBT the trainees This deficit is lacked it of well assessment skills. any that following from in background trainees by the study of a substance addressed partly Morgensternet al (2001). 3.3.3: Trainees from a substance abuse background: A CBT Training Study by Morgenstern et al (2001) The authorsanalysea CBT training project in New Jersey,USA during which a group of had trainees, who a strong pre-existing therapeutic approach (the '12 step 29 counsellor 2004) with attitudes dissimilar to CBT) entered training in (Denning et al, approach' 20 in for the trained abuse. of subjects were substance manual-guided CBT therapy 9 based for training. abuse and entered substance non-CBT methods The traineeshad considerableexperiencein the field but were without any previous higher-level in CBT. The therapeutic training itself involved 35 skills and/or training

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hours of intensive didactic instruction over two weeks followed by on-going supervision groups.The authorshad three researchaims: firstly, to examine the trainees' experiences of training, secondly,to explore the relationship betweentrainees' beliefs about addiction and therapy:
Specifically we assessed whether counsellorsallegiancesto the 12 step approach posed an obstacleto learning CBT and whether training servedto modify counsellors' beliefs in 12 step and social learning theory models (Morgenstern et al, 2001, p. 84).

A third aim was, to evaluatethe counsellors' ability to deliver CDT following training. Relationship between the Counsellor/Trainees' Beliefs and adaptation to CBT training In order to establishchangesundertakenby the counsellor traineesduring and after training, the authorsusedthe following pre and post training measuresof therapeutic attitude and skills: 1) Understandingof Alcoholism Scale(UAS) 50 items arranged in 2 subscales:

b) Psychosocial Disease subscale. model modelsubscale. a)

2) Questionnaire(TPQ) with 35 items, including items TreatmentProcesses on the DiseaseModel (10 items), the Psychosocialmodel subscale(17 items) and 8 other items. 3) Match video tape rating scale(MTRS).

Repeatedmeasures were taken and ANOVA analysiswas usedto determine if counsellorsin the CBT training group reportedsignificant increasesin social learning belief and decreases in diseasemodel belief following training. The results showed that the group put into the CBT training condition reporteda decreased level of adherenceto diseasemodel beliefs, whilst thesebeliefs increasedin the non-CBT substance abuse training condition. Generally the counsellorsin the CBT training group saw CBT as not conflicting with previously held beliefs about substance abusecounselling when the training was part of a wider programme.When the CBT training was a `stand-alone', however,they saw it as a moderateto severethreat to previous beliefs.

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From the respondents'qualitative responses, the authorsconcluded that the counsellors had beenable to acceptCBT training because they held diseasemodel beliefs prior to training in a way that showed"little evidenceof dogmatism and closed-mindedness" (P. 134). Respondents also "acknowledgedthe limitations of current treatments and were

for new skills that couldimproveclient outcomes"(p.134). activelysearching

The MTRS had beendevised for a previous CBT trial with substanceabuse problems, Project MATCH in 1997.The post training MTRS scoresdid show significant gains in CB skills in the traineeswho had undertakenthe CBT for substanceabuse training have have least deemed levels 90% to to attained adequate were at of whom condition, of CBT skilfulness. The MTRS measure,although it doescontain items similar to the Cognitive Therapy Scale,also containeda number of substanceabusespecific skills. It J; F Neither do the authorspresentany analysisof different types and levels and pre-training beliefs. They seemto assumea degreeof uniformity of beliefs amongst these particular trainees. using the CTS. cannot thereforebe directly comparedto results of skill assessment

Further major limitations to the study were that only a very limited range of CBT coping 1992) (Kadden taught et al, and that no attemptswere made to assessclient skills were outcomes. 3.3.4: Overview of studies of CBT training with trainees with non"CBT orientatiogs Overall, thesestudiessuggestthat problems associatedwith training people fro ma noI_ CBT therapeuticorientation into the conceptsand skills of CBT are not insuperable. All three studiesdescribetraineeswho are at a comparatively early stagein their careers or. had not received substantialprior therapytraining. It may be rememberedthat Dobson & Shaw (1993) suggested that such traineesmay more easily changemodels. Even so there is a minority of traineesfor whom such a changeof track in problematic. The studies have given somequalitative indication of who thesetraineesare and what attitudes they held but theseindications have not beenbackedup by fuller quantitative data. The fact that none of the studiesdescribedabovehave beenable to incorporate CTS style skill

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have been describe to they that these able not whether any of means also assessment
difficulties are mirrored in the acquisition of practice skills. The study in this thesis was further light on the question of how training affects skill designed throw to specifically from beginning different for trainees a model outlook... acquisition, especially The studiesdo not describeany of the mechanismsand processesof attitude change in data from interviews The collected qualitative study current with therapy training. interviews belief during the these reflections on of contain nature change traineesand however, did differences (2001), in Morgenstern that the way new note al et training. influenced be by how taken information trainees might on are viewed the of pieces in held beliefs. information The to CBT that relation previously context of of purpose influence training trainees' the trainees' overall programme might training within for CBT the `stand-alone' training this whether example, point, was of a or perception has (1999) Atherton also expressesa similar idea in his differentiation `subset' element. knowledge is intended (when to add to existing knowledge) and `additive' new between knowledge is intended to replace existing knowledge) training (where new `supplantive' in his description of training social care workers in new interventions. He suggeststhat `supplantive' training is seenas much more threatening to current practice and is from For trainees. to resistance more adherentsof other therapy models, subject therefore be CBT in more akin to supplantive training and might require some would training in CBT in perhaps change, using a prime method the attitude change and significant dialogue. Socratic field: the educational

The fact that current traineesin CBT come for training with backgrounds in other training meansthat they are mature adults and raises the relevance professional primary This theory to their theory, which emphasisesself-directed situation. education of adult has learning, been influential in approachesto counselling education and experiential (Johns, 1998). Such student centred learning stressesthe value of trainees defining their learning in targets and enjoying strong participation course and assessment own however, been increasingly has It realised that adult education covers a wide processes. for from example, activities: a non-certificated evening class to certificated rangeof

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described in Merriam the this training, above courses and such as study. professional (1993,2001) arguestherefore that the way adult education theory is implemented varies Where different in there are centralised validating contexts. processesand considerably democratic liberal the training, and processesof andragogy professional scrutiny of Knowles, best known in the be the the way. same advocate of andragogy realised cannot fact by amending his view that andragogy and this himself acknowledged concept describing being to them phenomena exclusive as mutually on a were pedagogy 1984). (Knowles, continuum

Cassidy (2004) has reviewed the place of CBT training for psychiatric residents in Canada.He surveyed a large group of residentsand found that they held a highly CBT training towards their when viewed as part attitude of continuing andragogic CBT as not only a useful set of additional psychiatric This development. saw professional intervention techniquesbut also as of personal value to trainees. Whilst it can be seen as a for be education psychiatric residents, we of might model cautious of applying suitable in likely training contexts for CBT. Whilst resident other the sameperspective it `additive' take training, other professionals with other useful as may psychiatrists having implications for training the future their as regard may professional statuses and leading into to the as process more controlled entry see a professional status. correctly From this perspective,they might not expect, or indeed welcome, an overly democratic Such likely to be exacerbatedby the policy expectations only are training experience. imperativesthat favour the growth of CBT services (Roth & Pilling, 2007). In practice, however, CBT training doestry to mirror some of the collaborative nature of CBT itself by encouragingself-direction and reflective practice (Bennett-Levy, 2002) for example, be by tutors and other course members using guided may encouraged reflexivity the way discovery in the contexts of skill and practice development. The processof assessment, however, is usually expert-centredbecauseof the professional accreditation that is linked it. with

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3.4: Conclusion to Chapter 3 After many yearswhen training for psychological therapy did not focus on skills, the counselling and psychotherapytraining fields have now become increasingly aware of the needfor quality training in therapeuticskills. Although skills are complex and manylayered,progresshas beenmade in identifying and measuringtherapy skills and relating betweenthe principles of CBT and skill them to outcome.There is a resonance development.This resonance has also allowed CBT to advancein the context of evidence-based practice. Much has beenlearnt about CBT skills and CBT skills training, though much still remainsto be learnt. Current developmentsin the field are likely to doing. for for in in As the training so need more effective models empirically result supportedtherapiesgoesup the policy agenda,so doesthe likelihood that therapists with other types of training will wish to undertakeCBT training as either additive or supplantiveto their current practice. Studieson training therapistswith other model preferences are not only useful in themselvesbut also highlight certain principles that can strengthenmodels of training and skill acquisition.

The review of current studieshas,however, shown a gap in current knowledge in that none have focusedon skill acquisition in the situation where trainees may be changing in This therefore took the context of model change is its skill study acquisition model. main focus. It examinedthe therapeuticattitudesof succeedingcohorts and the growth of their competencein CBT. The study operationalisedtheseaims with the following four researchquestions: A: What attitudes do traineesentering a CBT training course hold towards CBT practice principles and how do theseattitudes develop during training and in the year following the end of training? B: With what level of pre-existing competencein performing skills

associated with CBT practice do traineesenter CBT training and how do these CBT skills developduring training?

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C:

Whatkind of association and influencedo the attitudestowardsCBT

during have before in development held training the and of competence principles in the skills associatedwith CBT practice? What characteristicsof CBT training and development do CBT trainees

D:

being likely lead to to the resolution of difficulties in as most most often report

learningCBT duringtraining?
The following Chapter,4, describesthe methods devised to researchthese questions. Chapters5 and 6 presentquantitative and qualitative results respectively and Chapter 7 its by discussing the overall results and reflecting on the educational and study concludes for CBT implications the training. practice of policy

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CHAPTER 4: Methodology

in design this the describing by begin used research explaining and This chapterwill it describe by followed then the the will research, described the strategy Having study. to: taken steps detailed and sequential

design questions Justifythe selection relatedto the research of research

and hypothesesof this study. 0 Identify and recruit participants, Design and develop researchmaterials,

followed to collect and analyserelevantdata. Developthe procedures

4.1. Design in be that taken this study required a wide view of various posed The researchquestions development time to three over a span and performance of up years. trainee of aspects longitudinal data from that designed three therefore as a study collected The project was University-based in behavioural training course of a cognitive cohorts annual successive in how different interest the trainee focus sub-groups was within The cohorts of therapy. Although training the the study had some similarity course. of the to stimulus responded did it not and use control naturalistic was groups and/or random study, to an outcome design. therefore Data an was not experimental and collection participants of allocation data from the same participants as they for of gathering the consisted study activities the training process:pre-training, post-training and at one year different of stages reached by techniques Data were survey questionnaire and by interview. collection follow-up. The questionnairewas administeredat pre-training, post-training and one-year follow-up. focused the questionnaire of on trainee attitudes towards the A principal element in being taught the training, degree particularly the to which on principles therapeutic these therapeutic as compelling principles principles: that is, principles traineesregarded therapeutic The of range a wide situations. over valid questions relating to these that were in form the same the exactly asked at each of the stages training were of principles They therefore constituted `repeatedmeasures' described above. and allowed for process,

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Other training the the trainees' of the process. over period questions attitudes analysis of for determined trainees: characteristics of various example, age, in the questionnaire This for therapeutic orientation. allowed pre-existing and gender,employment based trainees to these subgroups of whether explore on categories analysis subsequent to training: in particular, did trainees with different had significantly different responses differently to the training: especially with therapeutic orientations react pre-existing in for the therapeutic taught the training of to use skills competent acquiring regard behavioural therapy. cognitive The interview schedulewas semi-structuredand consisted of open questions and to designed to respondents encourage give more open and reflective responses prompts, This in in questionnaire. resulted a valuable qualitative data that often than were possible focusedon similar areasto the questionnaire responses.This allowed for a degree of data follow from Benefits that can on such triangulation include the ability to triangulation. information differently the to same give respondents phrased questions on check whether both for example, questionnaire and interview asked about first model the samesubject: found had helpful difficult, respondents what about and and conversely, preference about CBT training. Additionally, whereasquestionnaires generally facilitate a larger number interviews in are often more successful getting at more subtle aspectsof of respondents, for About data. model preference, example, respondentscould have a preference but the implement to methods feel associatedwith such a preference and therefore not able not that interacting label themselves with preference when to with clients or other able

therapists.
of trainees' competenceinvolved appraisal of CBT practice tapes by using a The assessment inventory. measurement competency standardised 4.2. Participants The survey was conductedwith all the participants in three successiveannual cohorts of a in behavioural therapy. There were 59 trainees cognitive training course recruited into

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in Table Response CBT three successive the training shown cohorts of course. rates are 4.1.

Membershipof the cohort groupsof the training coursewas regardedas the sole inclusion criterion for the study. Failure to completethe course was regarded as limiting the inclusion of data from the traineesconcerned- e.g., results could be compared up to the time when the personleft the coursebut results for the person could not be retained in comparisonsof later outcomes.

4.2.1: Attrition of questionnaire respondents In longitudinal research,decisionsinvariably have to be made about how to handle data before it finishes leave (Robson, 2002). People who drop the study on participantswho be of some classesof participant (Howitt & out of studiesmay over-representative Cramer,2000): for example,traineeswith less securepractical arrangementsfor their training: such as arrangements concerningthe payment of training fees and granting of study leave. Excluding such traineesfrom the data set has the potential to introduce bias into the study. Such exclusionscould be particularly difficult in a longitudinal study because all previous responses may have to be left out of the analysis. This can threaten the samplesize and the internal and external validity of any findings. In this study, the drop out rate during training did not turn out to be a great problem: only 2 trainees left the training programmeand theseboth occurredwithin the first few weeks of training. Thesetraineeswere not replaced.They both gave the reasonsfor leaving as `personal' and indicated that they wished to return to study in the following year - though neither did. Although they both did respondto the initial questionnaire,it was decided to exclude from the study altogetherbecauseneither trainee reachedthe theseresponses point in training when CB skills assessmentsthat were at the heart of the researchquestions on CB competencies Two further traineeschosenot to respond to any requests were made. for information and they also were eliminated from the study. Having respondedto requestsfor information once, most traineescontinued to respondto further requests, although a small number,4 of 55 available at post-training and 3 of 51 available at oneyear follow-up administration of the questionnaire,did not. Participants in the

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The data questionnaire number. survey an anonymous under gave questionnaire survey in if to they participate a semiwilling were respondents asking question contained a had 30 their trainees the all completed interview course. after completing structured interview. 24 invited to to interviews thus agreed the were by and time the of studies did to All 4.1. request any particular Table not respond who participants see participate data The further trainees concerning request. followed a with only up once for data were in in kept the the further and was used study was to requests failed to some respond who information had in the given data to the respondents which stages relevant analysis when was considered. and Interview Data Collection in the Study

Table 4.1: Response Rates for Questionnaire

Time I (Pre-course)

Time 2 (End course)

Time 3 (Follow-up questionnaire)

Time 4 (Follow-up interview)

Available sam le 59 57 Respondents (55 admitted to study).

55 51

51 48

30 24

Response rate

96.6% 93.2%

92.7%

91.9%

80%

It was not practical to use the sametime sequenceas shown in Table 4.1 for skill
because the prospect of participants submitting tapes once they had the assessment course Data on skill performance were therefore collected just immediately uncertain. were prior to the commence of training (Time A: pre-training), at the half way point in training

(Time B: mid-training) and at the end of training (Time C: end of training). At Time A data on the pre-training skill performancesof 41 of the 55 trainees admitted to the study and who submitted a pre-training tape was measuredusing a standardisedCBT Section 4.3.2. Skill performances on these 41 trainees measure see competence was Time B, at mid-training, and Time C, end of training assessment, also measured along with skill performancesof 14 trainees who had not submitted pre-training tapes but who at mid-training and end of training. were assessed
-.. 3': r; aa:: 3C'EFTItW3F_': : 5 ti, . cu.h .=_.. a . _...

. ..

.r

.,..

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4.3. Materials The researchmaterialsused for the study were: 1. The Cognitive Behaviour Therapy Training Questionnaire(CBTTQ).

2. The Cognitive Therapy Scale- Revised (CTS-R). 3. A semi-structuredinterview schedule.

4.3.1. The Cognitive Behaviour Therapy Training Questionnaire (CBTTQ) The questionnairewas developedusing the principles of questionnaire and scale by Oppenheim(2000). At the core of the questionnaire was a set developmentsuggested inventory: together the Cognitive Behavioural as an of attitude statements, grouped Principles Inventory (CBPI) - basedon the principles formulated by Beck & Emery (1985) and Beck (1995) and describedin Chapter2. Theseprinciples were transcribed keeping into attitude statements, close to the format used in Beck & Emery generally (1985) and Beck (1995). Each principle was, however, operationalisedby using up to 5 different ways of stating eachof the ten principles. These statementswere then piloted on traineesfrom previous cohorts and in other similar programmesof study.. It was possible that elicited the fewest queries from responders to selectout the 10 principle statements The final form the responses. consistent most and gave of questionnairewas achieved by adding 22 further questionsconcerningother aspectsof the students' characteristics and situationsthat were relevant to the researchquestions.A further round of piloting of the whole questionnairewas conductedduring which various amendmentsto questions were final The versions of 32 questionswere organisedinto the questionnaire as made. follows6:

Section A.

Background information. (7 questions) Gender,age, presentjob, time in post, previous job, Duration and type of education,professional qualifications.

6 Full copy of all versionsof the questionnaireare in Appendix 1.

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B Section

in CBT (5 training Employers towards questions) attitudes Practicalsupport(Fees,studyleave,studyallowances,

CBT supervision, Other.) Encouragement (CBT priority, general

support)CBT qualificationseenan advantage. Futurein present type of post. SectionC Principles(13 questions) Attitudeto Therapeutic & strengthof preference. Previous modelpreferences
(3 questions). Cognitive Behavioural Principles Inventory. (CBPI) (10 questions)

SectionD

Experiences of LearningCBT (3 questions) Difficult & beneficialaspects; expectations of how practicewill change.

Section E

ResearchProcessQuestions (4 questions)

Access to summary results;perceptions of questionnaire; (any topic suggestions); research permissionto be perceptions of interviewed.

The questionnairehad to be varied somewhat for each stage of its administration: for be difficult do `What learning the to the most you ex ct aspects question of example, CBT?' (Question D1 in the Pre-courseversion) had to become `What did you find to be the most difficult aspectsof learning CBT7' in the post-course and follow-up versions. Somequestions- for example, on the trainee's preferred therapy model at the pretraining stage- were eliminated from the later versions. The questionnaire therefore had in format for its question variations pre-training, post-training and follow-up small versions. The CBTTQ questionnaire in its two versions (pre-training, and, post-training & ;follow-up) is in Appendix 1.

43.1.1: The Cognitive Behavioural Principles Inventory (CBPI)

The CBPI constituted a major sectionof the CBTTQ andaskedtraineesto respondto 10 based on the 10principlesof CBT described in Chapter2. attitudestatements

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held level indicate Respondents to the with the statements. of agreement were asked 3= 4= Likert Responses to agreement, agreement, where scale, strong were requested a These statementsremained the same 2= disagreement, and, 1= strong disagreement. to the attitude throughout the study and actedas repeatedmeasures of responses When the Inventory was piloted somerespondents wrote comments statements. indicating that their response might dependon the situation they were dealing with. The following instruction was therefore:"It is sometimesdifficult to generalise about these principles. Try to think about how they might apply to a typical client of your practice. " 4.3.2. The Cognitive Therapy Scale - Revised (CTS-R)7 Beck et al (1979) listed a seriesof competencies associatedwith cognitive therapy. Each levels defined derivation had item The of various competence. competency of these is not discussed. They were revised into the Cognitive Therapy Scale competencies (CTS: Young & Beck, 1980)and usedextensively in subsequent trials of cognitive therapy.A rating manual (Young & Beck, 1980) accompaniedthe scale. The competency items were condensed and reducedinto 11 items. The CTS scale has been widely used and has shown good reliability and validity (Vallis et al, 1986; Beckham & Watkins, 1989). Some further adjustmentswere made in 1988 (Young & Beck, CTS, 1988). Researchers and trainers at University of Newcastle reported some difficulties in obtaining inter-rater reliability amongststaff on their training course (Jameset al, 2000; Milne et al, 2001). They undertook a project to improve inter-rater reliability by offering staff further training in using the Scale.This project resulted in a revised scale with 12 items: the Cognitive Therapy ScaleRevised(CTS-R, 2000). Reichelt et al (2003) reported improved reliability for this revision. Thesedevelopmentsrepresentactive but give some problems in reporting attemptsto improve competence measurement as all three versions are in current use. In Britain, the CTS-R is a widely usedscale on training coursesand was usedto analysethe data in this study. The different versions of the scale are shown in Figure 3.3 and all future referencesin this thesis to the use of the scale will be labelled to indicatewhich version was used.CBT competencymeasures, such as the CTS-R, are often usedalongsidetherapy manualsin both training and research trials.
7A copy the CTS-R is in Appendix 2 of

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Traineeswere required to submit examplesof CBT practice with real clients, purposes: authenticated as such by their supervisors,on audiotapefor course assessment by the so that their ability to successfullypractice CBT methodscould be assessed trainers. Traineeshave to reacha defined level of competenceto passthe course and to be awardedthe qualification, Diploma/MA in Counselling (Cognitive-behavioural). Immediately before the start of the course,they were askedto supply an audiotape of a CBT sessionwith a real client. This was usedto give a pre-training baseline measure of CB competence. The tapeswere assessed using the Cognitive Therapy Scale Revised (CTS-R; Milne et al, 2001) an instrument for measuringadherenceto and competence in following the structureand using the techniquesof cognitive behaviour therapy. The CTS-R is a revisedversion of the Cognitive Therapy Scale(Young & Beck, 1980) and the following aspectsof the therapy session: assesses General therapy items: 1) 2) 3) 4) 5) Agenda-settingand adherence. Feedback. Collaboration Pacing & efficient use of time and efficient use of time. Interpersonaleffectiveness.

Specific CBT items: 6) 7) 8) 9) 10) 11) 12) Eliciting appropriateemotional expression. Eliciting key cognitions. Eliciting behaviours. Guided Discovery. Conceptualintegration (Formulation). Application of changemethods. Setting homework.

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being CTS the for as original the revision of Milne et al (2001) describethe rationale fact the has that the Firstly, over factors. arisen some confusion basedon two main it take to 1988), to & Beck, (Young in 1988 allow partly itself CTS was revised original been however, has The in CBT. not, developments version second some account of has first this testing that the was and one reliability the and to validity same subjected (2001) Secondly, Milne in being the time. both in et al use at same versions resulted for CTS inter-rater this levels the low and was commonly reliability of reported fact from in items that there the to to was significant overlap relating result considered Milne (2001) has CTS that the et al suggest not kept pace the therapeutic relationship. developmentsin CBT. They believe that the original version practice theoretical and with focused focused techniques CTS too on acquiring and the not was enough on the of facilitate for to the client. They suggest that experiential change therapist'sability for is improvement therapeutic follow essential they change and the model experiential by Kolb (1984). They produced a learning proposed revised version of the of experiential items 10 CTS the 4 of original retained and added which new items focused on scale, items: Interpersonal to the original change effectiveness; Facilitation of experiential Facilitation expression; experiential of experiencing and General emotional and facilitation of movement round the experiential cycle to take more account of the need to learning for the client. Eventually, however, they collapsed 3 the facilitate experiential of into one, producing the 12-item scale shown above. They also suggest 4 new categories a basedon the levels suggestedby Dreyfus & Dreyfus (1986): system new scoring
Level 0: Incompetence.

Level 1:
Level 2: Level 3: Level 4: Level 5:

Novice.
Advanced beginner. COMPETENT. Proficient. Expert.

in levels for these relation to each skill are defined in the CTS-R Manual Criteria (James is 3 Level level the regarded 2000). as of competenceto be achieved by the et al, end of level therefore 3 In this study, and above were regarded as having training. achieved

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data The to having level below 2 recorded was competence. as not and and competence for rates eachskill. allow calculation of meancompetence Blackburn et al (2001) investigatedthe psychometricproperties of the CTS-R. They health by 21 in its 102 therapy mental provided analysed use assessing videotapesof the tapesusing the CTS-R. The trainee CB therapists.Four experiencedratersassessed CTS-R showedstrong internal reliability with Cronbachalphas ranging from 0.92 to

by intra-class inter-rater 0.97.Theauthors correlations reliability calculating assessed

(ICC) for all scaleitems. Theserangedfrom 0.34 to 0.86, with an averageof 0.63. These ICCs were slightly superior to those calculatedby Vallis et al (1986) for the original, CTS. Whilst acknowledgedthat further work was neededon validity, the authors is CTS-R face "The the that, good, as the expert raters all agreed of validity maintained that they found the scaleeasierand more meaningful to rate than the original CTS. All found it difficult to go back to using the CTS in their daily work, after rating 51 tapes eachon the CTS-R" (Blackburn et al, 2001, p. 440). Work has continued on developing have CTS-R assessment their the and associates regularly reported back to authors and

helpful development One hasbeenthe emergence BABCP. of annual conference of

have CBT Reichelt (2003) in tapes. training at et reported that such , specialised rating training doesresult in significantly improved inter-rater reliability amongst groups of, it. it have For these reasons, was considered appropriate to who overtaken staff members in for CTS-R tapes this study. the assessing use

4.3.3: How the Principles of CBT are linked to CBT practice skills Beck (1991b) has arguedthat there is an unusually close fit between CBT theory and in Chapter having 2, we are now in a the examined closely principles and practice fit between degree them and the main defined skills of CBT. to the of estimate position The position is laid out in Table 4.2, where the 10 principles are put alongside the CBT skills nominatedby the Cognitive Therapy Scale- Revised(CTS-R: Jameset al.

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Table 4.2: The Congruence between the Principles

Cognitive Therapy Revised Scale Items 1. Agenda Setting

of CBT and CTS-R Items.

Beck & Emery (1985) Principles CBT is structured and directional A sound therapeutic relationship is required for effective CBT

2. Facilitating emotional expression 3. Interpersonaleffectiveness

4. Collaboration 5. Pacing and efficient use of time 6. Focusing on key cognition and behaviours 7. Guided discovery 8. Formulation

A sound therapeutic relationship is required for effective CBT

CB Therapy is a collaborative therapist and client CBT is time-limited CB T uses primarily method uses the Socratic effort between

CBT is problem orientated CBT is based on the cognitive model of the emotional disorders

9. Application of cognitive techniques 10. Application of behavioural_techni ues

11. Homework 12. Eliciting Feedback

CBT relies on the inductive method CBT is based on an educational model CBT relies on the inductive method
Homework is a central feature of CBT Therapy is a collaborative effort between therapist and client

is from indeed table that there the be a good degree of fit between the It can seen described in CBT this as the chapter and of main skills and methods of CBT as principles CB instrument by type of skills the most used on CBT training courses. The defined both for principles and skills can be cross-referenced closely between the language used in table. the two columns 4.3.4. The semi-structured interview schedule 8

for 76) the makes case (1998, semi-structured interviews by suggesting that p. Flick they the expectation that the interviewed subjects' linked with "... are viewpoints are more in designed be a relatively openly interview situation than in expressed to likely the

$ The Schedule is in Appendix 2.

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interviews, interview less " Even the standardised or questionnaire. with structured however,there is a rangeof interview types. Someauthors have distinguished between in-depth qualitative and semi-standardised interviews (Fontana& Frey, 2000: May, 2001; Mason (2002) and Patton (2002). May suggests that semi-standardisedinterviews offer the opportunity to seekclarification and elaborationby using probes. Arthur & Nazroo (2003, p. 111) say that:
interviews, the interviewer asks key questions in In semi-structuredor semi- standardised the sameway eachtime and doessomeprobing for further information, but this probing is more limited than in unstructured,in-depth interviews.

interview still follows a script to a Bryman (2004) points out that the semi-standardised individual limited lead to to this responsiveness personal contexts. and may certain extent Limiting probing may also meanthat material from confident people gets disproportionaterepresentationin the researchdata.Despite this caveat, which may in any caseapply to all interview situations,the semi-structuredinterview in this study did anticipatesome likely responseoptions - partly, as Arthur and Nazroo (2003) note, because it is likely to result in a more structureddata analysis stage. The interview schedulewas developedspecifically for the purposeof the study and following the sections: contained Section A: Experiencesbefore CBT Training (8 questions); e.g., Question Al: How did your interest in CBT begin? Experiencesduring CBT Training (6 questions); e.g. Question B 10: What aspectsof CBT Training did you gain most from? Experiencesafter CBT Training (6 questions):e.g., Question CIS: Would you now describeyourself as a Cognitive Behaviour Therapist? Section D: Experienceof the actual interview experienceitself (2 questions)

Section B:

Section C:

The interview scheduleallowed for more reflective considerationof how the processesof assimilationand adaptationof training and other information were made during training.

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CBT for immediate and, example, which sense What were the struggles,what made in learning factors What this fully role process a played accepted? never were principles interaction if What, effects seemed interventions, any, tutor experienceswith clients etc.? have for learning tutor between may passeda example, a these eventsto occur

implement led to trainee the that a successful abouta client situation comment
intervention. The interview schedulewas piloted on three interviewees who were not otherwise involved in this study. One had been trained in Family Therapy; another in a behavioural form of alcohol counselling and one had been a trainee of a previous cohort of the CBT in Several the study. amendmentsof the schedule were made surveyed training course from commentsby the pilot interviewees. The main one concerned the fact that in the `training' interchangeably. `course' from Data terms the and were used version, original indicated interviewees `course' interviews that the term when was used, the pilot were When likely `training' to the term up with course specific responses. come was more likely As to to training were more the research refer generic processes. respondents used, in final interested training the generic processes, version of the schedule used was more the term `training' throughout.

for last to timed Interviewswere onehour. The full interview schedule canbe seenin
Appendix 2.

4.4. Procedure The researcherspoke to each cohort of trainees in the study when trainees came to enrol for the before began. their The month course one course study was described to the trainees and their It requested. was was also made clear that they should feel free not to participate co-operation to from able withdraw they were that the study at any time without prejudicing their training. and It was also pointed out that, becausethe data were stored by a member of staff not otherwise involved with the students,the researcherwould not know who had and who had not participated their (see the of following end studies after until paragraph). They were also asked to bring a tape CBT practice of with them to the first teaching session that the of their current so researcher

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followed by letter The a researcher'spresentationwas their current competency. could assess letter did however, The for not, the trainee's consent. again re-explaining the project and asking first by the It that questionnaire of returning to assumed the trainee consent. written give require in Appendix 1. is included letter The the join the with questionnaire study. gave consentto If the questionnairewas not returned,one further copy was sent, along with a letter that join be to the consent this giving that assumed as not study would of one non-return explained information. In for further these arrangements seem retrospect, requests on no and would result inadequateand they will be discussedagain during consideration of the limitations of the study in Chapter7. 4.4.1: Survey and interview Lists of enrolled traineesin eachof the three cohorts were obtained from course data All study number given a and concerning were participants administrators. degree thus that number, offering a of anonymity to stored under were participants in School involved in The the teaching the staff of was other member not participants. CBT trainees(referred to in the previous paragraph)and kept a list of study numbers and the matching namesof participants.The author of the study did not know the matches betweenthe study numbersand participants' namesuntil they had completed study in the University. The other memberof staff sentout all requestsfor questionnaire data with a be him. He was also askedto store to to returned envelope stampedaddressed information - for example,about which study numbershad responded- in appropriate The other member of staff was able files before passingdata on to the main researcher. therefore to support the researchproceduresby sending out further requeststo trainees who had not respondedto earlier requestswithout involving the main researcher.He was information to either researcheror participant where to also able supply contact interview for for (for purposes).He was also later able to contact example, appropriate data by to CBT the researcher. other results collected match up skills assessment The CBTTQ was sent out to all enrolled studentswithin two weeks of their enrolment of training. A covering letter, including and at leasttwo weeks before the commencement the points coveredby the researcher at enrolment was attachedto the CBTTQ

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in the training the All trainees course requisite period were asked entering questionnaire.

CBTTQ, filling by initially the training the and again at end of out and then to participate had All training training. participants completed the who at one year after completion of CBT training and had completed all other academic requirements (most usually a interviewed, interviewed, be facedissertation) to were and were willing either research to-face or, in two instances,by telephone. Interviews were conducted after the one-year follow-up stage.The interviews were mainly conducted in the participants' homes at times of their convenience.A small number, however, had to come to the University found it be interviewed for to there. convenient other and some reason training centre Table 4.3: Data collection process, September 2000-July 2004.
Pre-course
Questionnaire administration

Post-course
Questionnaire administration

Mar

Follow-up

Interviews

Questionnaire administration

Cohort 1

September2000

July 2001

July 2002

September November 2002 SeptemberNovember 2003 September 2004

Cohort 2

September2001

July 2002

July 2003

Cohort 3

September2002

July 2003

July 2004

The pre-training version of the questionnaire was sent out to the first cohort in 2000. Participants were askedto return the questionnaire by using a stampSeptember envelopeprovided within 2 weeks of its receipt. This return period was addressed maintainedthroughout the study. A small number of reminders were sent out when questionnaireswere not returned within this time. Analysis of the pre-training practice tapessubmitted by this cohort was carried out in November, 2000. Analysis of practice tapessubmitted during the training period (and part of the formally assessed element of the training) was carried out in January and June 2001. The post-training version of the questionnairewas administered in July 2001. The one-year follow up version was administeredin July 2002. The semi-structured interviews for this cohort were carried out betweenSeptemberand November 2002.

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The samesequence of procedures was carried out with the second cohort, starting with in the enrolment address CBTTQ the and administrationof pre-training questionnaire September 2001 and finishing with the semi-structuredinterviews between Septemberand November 2003.

Theprocess with the third cohort followedthe same procedures up until the one year .,
follow-up administration of the CBTTQ questionnairein July 2004. Data collection was 2004 after interviews with some available cohort members then terminatedin September 4.4.2: Competence assessment It is a common procedureon CBT training coursesto ask traineesto submit audio or video tapesfor assessment using an instrument such as the CTS-R. In this study, trainees were askedto submit tapesimmediately before the start of the course (pre-training tapes), at mid-training (mid-training tape) and at the end of training (end of training tape). The pre-training tape was a purely voluntary submissionbut the mid and end of training tapes The pre-training assessment both were usedas part of courseassessment. assessed Generaland Specific CBT skills (as defined in the CTS-R), the mid-training assessment GeneralTherapy skills only and the end of training assessment assessedSpecific assessed CBT skills and any GeneralTherapy skills in which the trainee had not shown by Each two tutors, one of which was the tape assessed was competenceat mid-training. by Grades tutors were usually in close from 3 team tutors. awarded author, a of and accorded an agreement.Tutors then discussedtheir respectivegradeassessments involved Occasionally, this consultation with the third tutor. For agreedcommon grade. the researchproject, gradeswere stored under the student number used in the survey had trainees to completed their training at the until were not subjected analysis University. and

The full data collection cycle for the survey, interviews and competenceassessment is shown in Table 4.4.

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Table 4.4: Detailed outline of data collection

DATES
September 2000

Procedures.
COHORT 3: 2002-3

COHORT 1: 2000-1
Introduce study to
participants
11n1r11', tir 1'rc 11.1 mi ljlic't

COHORT 2: 2001-2

November 2000
January 2001
June 2001

ohort I he im it uwuns ('I1 skill assessment FIMF A Pre-training

TIME B ('11 skill assessment

Mid-training ('Ft skill assessment I'IMI: C'

July 2001 September 2001

Cohort I ends training:

h. rII inc. urviunn, nrr

Introduce study to
participants
Jmnn, irr yur, I'lc tr; unin_ Urmn: rnr assessment

Cohort 2 begins training

October 2001 ('I4 skills

TIMF A PRF
January 2002 June 2002 July 2002 I ollo%%-upo(trainng
questionnaire

C'13skills assessment TIME B MID 011 skills assessment l IM! [ C IfNI) Cohort 2 ends training
I 'lrtit-trainink w, twi ire

September 2002

AJ1111I11'ier

Introduce study to participants:

Pf L'-tr; 1111InIi

questionnaire

OCtobet 2002 November 2002 January 2003 June 2003

n .;n . iu ,l nr; 'c-mi-structured inters ress

Cohort 3 begins ttainin CB skills assessment l IME A PRI: C[3 skills TIME CB skills TIME
of training questionnaire Semi-structured inters es Follow-up

assessment R MID assessment C END

July 2003 Au
October

Cohort 3 ends training: foist-tr! 1111P c nest on iatrk

2003
bei 2003
2003

Semi-structured inters riss.

Il "rrrrctrircd linen r ,

July 2004 September 2004

1-otkov. -ur ot-training

questionnaire

Semi-stntctured interviews

4.5: Ethical aspects of the study At the time the study was undertaken, there was no formal requirement to seek ethical in either the University where the study was undertaken or in the University permission in which it was supervised. It was, however, recognised that certain ethical issues were trainees the training researching amongst with with whose author was connected Efforts rights to the have safeguard of consent and confidentiality already connected. been described in the section on procedure.

125 -

With theseissuesin mind, the study proposal and methodswere presentedto the research it it in University the of School ethical aspects which took place and of the committee of The author made severalsubsequentpresentations about were examinedand discussed. The School. the study was the to the the on-going work of researchcommittee and study in for in the counselling and code of ethics research with conducted adherence Psychotherapy for Counselling by British Association the and psychotherapy,published (BACP, 1996). Further aspectsof the ethical approachtaken to this research, including discussionof its limitations is included in Section, 7.6 of the final chapter.
4.6. Data Analysis

4.6.1: Analysis of Quantitative Data Quantitative analysiswas undertakenusing the SPSSstatistical package (Fourteenth Edition). Frequencyanalyseswere usedto explore the nature and spreadof the collected data. Tests of association,such Chi-squareand Spearman's-rho,and tests of difference such as ANOVA, were usedto establishif there were significant differences between sub-groups of the trainee cohorts: for example,whether studentswith different pre-existing therapeutic orientations performed differently when assessed for competencyin the skills being taught.

4.6.2: Analysis of Qualitative Data Analysis was carried out using framework analysis (Ritchie & Lewis, 2003). The basic iterative involves between framework text and developing oscillation analysis processof categorisation(Charmaz, 1995).The first step involved scrutinising the texts and constructing a framework index of terms likely to prove useful in evolving categories for data analysis.A matrix was then constructedin which the columns representthe individual questionsof the interview scheduleand in which the rows consist of individual Entries into the matrix stuck as closely as possible to the casesor respondents. respondents'own language.The matrix was edited to bring together responseswith thematic similarity and then usedto producethematic charts.The on-going process of data analysiswas iterative, oscillating betweencategorisationand raw text. The analyst this stagewas looking for categoriesthat give a good purchaseon the data and, for example,explain, differencesbetweencategories(Ilammersley & Atkinson, 1995). The at

-126-

first iterative cycle results in the construction of thematic charts (Ritchie & Lewis, 2003) in which key issuesare isolated and the themes of the index are elaborated and refined. This was active processand it is inevitable with human researchersthat there will be Huberman, (Miles & 1994). These degree of meaning construction of constructions some for in by be however, data testable way: example some comparison with other or should, 1994). (Denzin, theory existing The semi-structuredinterviews were structured around three key themes: the decision to in CBT (the during in CBT training training pre-training phase); experiences undertake (the training phase)and the evolution of practice since training in CBT (the post-training phase).The major cross-cutting theme was the way previously held theories of influenced For these each one of phases. each of these categories, the psychotherapy author wrote respondentanswersonto cards and then sorted the cards into sub-themes. After the first card sort, the overall sub-themeswere re-examined and resorted to allow consolidation of some categoriesand amendmentsto others. A third card sort made final adjustmentsto the categoriesand sub-themes,ready for presentation to a group of described below. colleagues,

The author made a presentationof the initial categoriesthat emerged from his first 8 to a group of colleagues involved in CBT teaching, including some who had analysis trained in the course under study. Transcripts were also made available to the group memberswho were askedto read them andjoin a discussion of the themes that seemed evident in them. The group made useful suggestionsabout the categories proposed by the author, suggestingmodifications and new possible categories to consider. One consistent theme mentioned by group memberswas the difference between trainees influenced by different modalities and how these varied over time. These categories remained through the subsequent phasesof iterative analysis and were evolved into the 12 thematic charts

by frameworkanalysis(Ritchie & Lewis, 2003). andelaborated

Twelve thematic charts were therefore created for the four approachesto psychotherapy held by trainees for the responsesto each of the three phasesof the study. The charts,

-12/-

into integrated the themes one the charts thematic of all which chart, central with a along 6. in Chapter Lewis, 2003), & figure (Ritchie are presented central The processof selectingout respondentstatementsinevitably has some subjective features.The reader,however,will have the opportunity to check the selections made in the thematic charts located in Chapter6.

-128-

III

541 iq M1 )

k5 a -4 k

t4 'h

Chapter 5: Attitude and Skill Development during CBT training by data Cognitive Behaviour the describes collected This chapter and analyses Cognitive Therapy Revised Scale (CBTTQ) Questionnaire the Training and Therapy (CTS-R). The CBTTQ data show a group of mature students with varied educational CBT training backgrounds towards the with varied attitudes entering professional and development during It these CBT. the the attitudes of course of charts of principles CBT development data CTS-R the The of practice skills amongst the chart training. between Finally, the the the relationship attitudes, trainees. explores chapter same

CBT development the practice skills. of acquisition their and

The chapter will begin by describing the general features of the participants involved in the study. As each variable is introduced, it will be initially shown for the three is demonstrate in This between involved to the near equivalence study. each cohorts features description After data the the the of general of study sample, sample. cohort directly related to three of the four research questions of the study will be presented. Data analysis was conducted using SPSS for Windows, version 14. The analysis of fourth is data in Chapter 6. to the research question presented relating qualitative 5.1: Demographics:

The samplecomprisedof traineesrecruitedby a single training centrein 3

The initial 55 cohorts. size annual was of sample participants, who consecutive respondedto the pre-training questionnaire. There was a small amount of attrition over the period of the study so that the sample size was 51 for the post-training survey follow-up for 48 the survey. The distribution of participants by gender at each and cohort intake is shown in Table 5.1.

Table 5.1: Gender: by cohorts Cohort 1

Female Male TOTAL 1890% 2(10%) 20(100%)

Cohort 2
1482% 3(18%) 17(100%)

Cohort 3
13(72%) 5(28%) 18 100%

TOTAL
45(82%) 10 18% 55(100%)

The mean age of the respondents at the start of training was 45.78 years (SD = 7.59). The agesof respondentsranged from 30 to 58 years. Age-groups for trainee cohorts by age at the start of training is shown in Table 5.2.

129

Table 5.2" Distribution of tender by are groups at ach time intake

5.2:

Education and Employment

Study participants were mature students from varied educational and occupational backgrounds (Tables 5.3 and 5.4). Participants were relatively evenly divided between for Entry the training course on which the study criteria graduatesand non-graduates. is basedrequired that applicants should already have completed a course in in level. held Diploma They to qualifications all professional almost counselling counselling and almost 60% of them combined this with professional qualifications from other helping professions, including nursing, social work and youth work. A small number of trainees were admitted using Accreditation of Prior Achievement when they had been in work and training situations in which key elements of been had training achieved. counselling
Table 5.3: Educational I
GCSE only A-level only

Backfround

at Pre-training

by cohorts

Cohort I
9 (45%)-I 4 (20%

Cohort 21
(WY.) 5 29%)

Cohort 3'-5(28%) 4 (22%) 7(39%) 15(27%) 13 24% 23 (42%)

Undergraduate Postgraduate 102

7 (35%)

9(53%)

2(il%) 100%) 1 17 Is

4(8 55

Table 5.4: Professional Ouslifications Cohort I 5(25%)

4 20"/.

by cohorts: Cohort 3 5 (28"/.

2 (j I"/.

Counselling /nursing
Counselling/social work

Cohort 2 6 35%
4 24/.

16 29
10 18.0

Counselling/other
hel in profession

2(10%) 9(45%)
0

2(12%) S 29"/.
0

2 (11"/. ) _6X33"/. 3 16% 18

6 (11% 20
3 S`

Counselling only
Helping profession only

TOTAL

20000%)

17

55 (1-nno.

130

Thirty the of six data participants. the study of status 5.5 work Table about shows described full the time others and described themselves as employed sample There who person was one self-employed. or part-time employed themselvesas either was not employed.
Table 5.5: Employment status by cohorts
Cohort I 12 (60%) 3(15%) Cohort2 9 (53%) 2(12%) Cohort 3 15 (83%) 1(6%) TOTAL 36 (67%) 6(11%)

Full-time employed Part-time employed

Self-employed
Not employed TOTAL

5(20%)
0 20 100%

6(35%)
0 17(l %0

1(6%)
1(6 e/. 18

12(21%)
1 1% 55

Thirty describe & 5.7 the participants' patterns of employment. Tables 5.6 aspectsof 20 job `counsellor' defined themselves as initial their and saw as roles the sample of in jobs their such as nurses or social role work as part of practising counselling into but in jobs to Five trainees move as office work wanted such were other workers. for less in jobs 5 had been Most their than trainees years present counselling work. been in had to that non-counselling posts. and previously
Table 5.6: Present Work Role by cohorts
Counsellor Helping Cohort I 15(75%) 5(25%) 0 20(100% Cohort 2 10(59%) 5(29%) 2(12%) 17 Cohort 3 5(28%) 10 (56%) 3(17%) 18 TOTAL 30(55%) 20(36%) 5(9%) 55(100%)

LgE: A
Other Less than 1 year
1-4. years

Table 5.7: Time in Current Post by cohorts Cohort1

4(20%)
11(55%)

Cohort2
4(24%)
10(59%)

Cohort 3
6(33%) 9 (50%) 3(17%)
0

TOTAL
14(25%) 30 (55%) 8(15%) 3(5% 55 (! 00%)

5-

ears

10 & more years

TOTAL

3(15'/" 2(10 20 100'/.

2(12%) 1(6%) 17(100%)

18(100%)

In summary, the trainee sample was mainly female and of mature age. Questions Biv) Bv) trainees hoped asked what they what to do after training. Their answers and had they that gravitated towards counselling work within the last five showed years CBT training as an opportunity to refine their skills and move into saw and more specialist areasof counselling work.

131

5.3:

Employers' support of trainees undertaking training in CBT Jobs carrying the descriptor `counsellor' are relatively recent arrivals in the

employment field (Woolfe & Dryden, 1996; McLeod, 2003). Unlike professions such large had have natural and not as social work and clinical psychology, counsellors employment basessuch as in local government or the NHS.

Tables 5.8,5.9 and 5.10 describe different aspects of the degree to which employers it. Employer CBT to training trainees to gave priority and supported undertake by has Employers can support aspects. provide support practical and psychological such practical steps as helping with training fees and by giving trainees leave to attend training sessions. As can be seen in the tables 5.8 and 5.9, trainees in this study only rarely had such practical support. Only 12 out of 55, for example, had all or even part 20 leave by 55 fees to attend their training of were given employers. paid course of

the course, whilst others had to take unpaid leave or leave from their holiday in be however, Employers other ways. Trainees also encouraging may, allocation. high levels from themselves quite of support general experiencing as reported here be influenced by data The (Table 5.10). the complexity of some may employers during interviews, the the the data semi-structured revealed of employment patterns for which is presentedin the next chapter.
Table 5.8: Course fee paid by employer Cohort I 4(20%) 16 (80%) 0 20(100%) Cohort 2 3(18%) 12 (71%) 2(12%) 17(100%) Cohort 3 5(28%) 12 (67%) 1(5%) 18-cl 00% TOTAL 12 22% 40 (73%) 3 4e%o 55 (1 onQ/

Course fee paid Course fee not paid Self-employed TOTAL

Twelve respondentsdefined themselvesas `self-employed' (Table 5.5) yet in 3 the only support employer respondentsexempted themselves question on answering from answering becauseof this status. It appearsthen that 9 respondents who had previously defined themselvesas `self-employed' also regarded themselves as having legitimate expectation of practical support from employers who might employ them for sessionalor occasional work.

132

Table 5.9: Employers' granting leave to attend training course

Cohort I 7 35% 13 (65%) 0 20 100% Cohort 2 5(29%) 10 59% 2(12%) 17 100% Cohort 3 8(44%) 9 (50%) 1(6% 18 100% TOTAL 20(36%) 3258% 3(5%) 55(100%)

Granted Not granted Self-employed TOTAL

degrees of employer Table 5.10 shows trainees' estimates concerning perceived be It by CBT noted training should to employers. the accorded priority support and The in lower the the than for survey. rest of these questions was that the responserate higher their than of sense trainees as slightly towards rated was employers' support is interesting is, however, that to It CBT for employer support note training. priority degree highest had by 3, the of highest practical support of actual which cohort rated be for in 3 increased The trainees a cohort may practical support the three cohorts. desirability CBT the of exhibiting a growing recognition of small sign of employers training.

Table 5.10: Mean ratings of trainees' estimates of employers' supportiveness and CBT by defining (n=43) training to themselves trainees as employed given priority
Cohort I n=15 2.40 2.60 Cohort 2 n=11 2.43 2.57 Cohort 3 (n=16) 2.43 2.71 All cohorts (n=42) 2.42 2.63

Employer priority* Employer support*

*(Ratings: I= Weak; 2= quite weak; 3= quite strong; 4= strong) In summary, the respondents' reports of employers' attitudes towards their efforts to be trained in CBT did not show much of a senseof priority for specific training in that Whilst employers showed some levels of support and priority for the modality. training that the trainees were undertaking, it was not clear whether this was because it was training in CBT or merely any training that contributed to the trainees' career development. and/or personal

5.4:

Preferred model of therapy

The questionnaire askedthe traineesabout their preferred modelsof therapeutic 5.11 Table how shows traineesdescribedtheir preferred model therapy practice. of at the pre-trainingstage:

133

Table 5.11: Preferred therapy model at pre-train

Cognitive Behaviour Cohort I 3(15%) Cohort 2 2(12%) Cohort 3 3(17%) TOTAL 8(15%)

Therapy CB
Person-centred Therapy (PCT) Psychodynamic Therapy Integrated/Eclectic Therapy TOTAL 10(50%) 6(30%) 1 (5%) 20(100%) 9(53%) I (6%) 5(29%) 17 7 (39%) 0 8 (44%) 18

26(47%) 7 (13'/. ) 14 (25'/") 55

important to the research questions in in therapeutic are models Preferences relation to different trainees trace to with whether this thesis becausethe questions sought however, do Descriptor differently choices, to training. name preferencesresponded in At the points their various preferences. actual the of tell story all not necessarily be discontinuities been that there has it may pointed out history of psychotherapy, between the way therapists describe their practice and the actual way that they both CBT The to trainees 1997). principles, as (Ivey of response al, et practice individual principles and as an aggregatedscore of responsesto the principles, offered beliefs their into insight practice. their about another between 1, CBPI the recording strong scored were Responsesto each principle of disagreementwith the CBT principle, and 4, recording strong agreement with the to, CBT between to 10 scores could respond As vary principles there were principle'. 40, for full strong agreementwith the principles, and 10, strong disagreement how from trainees different 5.12 Table the of results them. shows agreementwith CBPI. the on preferences scored modality

Table 5.12: Mean CBPI scores for different modality

references at

re-trainin

o_5

' As shownin 4.3.1.1

134

The mean aggregated score for all 55 trainees responding to the pre-training 4.74) (SD 30.40 for CBT that which shows = was support principles questionnaire high The for mean at pre-training. scores subgroups of trainees was generally quite descriptor `CBT' 34.75 (n=8; SD 2.82); the name choices were: = various = preferring `Integrated/Eclectic' therapy (NB These trainees frequently named CBT as a key 31.79 (n=14; SD= 4.26), 'Person-centred' their = approach) and element of `Psychodynamic' therapy, traditionally most critical of CBT, 28.81 (n=26; SD=4.89)

One ANOVA SD 3.10) (n=7, 28.57 way analysisof variance = respectively. and
(F differences between (3,51) 4.80, the the scores were significant mean = showed in less 5 100 differences being had 005), that than the there chances p= significance, . Table 5.13 by Bonferonni2 the shows multiple comparisons using chance. arisen

between difference, 05, CBT & PCT between <. p a show significant and correction
CBT and Psychodynamic therapy.

Table 5.13: Multiple and integrated comparisons of mean CBPI score by different model preference at pre-training (n=55) using ANOVA with the Bonferonni correction:
Comparison of: _ CBT With: Mean difference Std Error Sig.

PCT Ps chod namic

Integrated CBT

5.94* 6.18*
2.96

1.74 2.23

PCT

Ps chod namic

Integrated

1.91 1.74 -5.94* Ps chod namic 24 1.84 . Int rated 1.43 -2.99 CBT 2.23 -6.18* PCT 24 1.84 -. In 2.00 rated -3.21 CBT 1.91 -2.96 PCT 2.99 1.43 Ps chod namic 3.21 2.00 i ne mean aitterence is signiticant at the 05 level. .

008 . 047 .

762 . 008 . 1.00 253 . 047 . 1.00 680 . 762 . 253 . 680 .

In summary, trainees beginning this course of training in CBT described their preferred model of therapy in various terms, the majority of which were not CBT. Trainees preferring the four different main models of therapy showed significantly different responsesto a measure of agreement with CBT principles - the CBPI. Trainees preferring the CBT model showed significantly more positive responsesto CBT principles than trainees preferring both the PCT and Psychodynamit models.
2 The Bonferroni test is the appropriate test for small numbers of multiple comparisons. It helps to guard against Type I errors by keeping the overall Type I error rate at 05 (Field, 2000). .

135

5.5: Research Question A: Attitude training follow up one year and at

CBT towards principles change

during

The following section presentsdata showing the way trainees reported their attitudes Cognitive in the CBT individual principles operationalised towards the various before CBTTQ (CBPI) the and after Inventory Principles Behavioural section of found degree data trainees The to follow-up. the which shows training and at one year degree how CBT this in of agreement and themselves agreementwith principles developed over time. The movement of the attitudes was generally towards a higher degreeof agreementwith CBT principles over the time of the training and follow up description Secondly, is Firstly, a of the the reliability of measure considered. periods. Thirdly, is time in the reported. measureover changes aggregatedmean scoresof described. individual in time are over principles changes

5.5.1: Reliability of the Cognitive Behavioural Principles Inventory (CBPI) Cronbach's alpha measureshow well a set of items measuresa single, unidimensional latent construct. When data has a multidimensional structure, Cronbach's alpha will for Cronbach's describe be low. Helms (2006) the of practice use good usually et al alpha coefficient for summatedscales.Cronbach alpha and other reliability scores data Behavioural Principles Inventory (CBPI) for for Cognitive the were calculated for The Cronbach's its overall. scores and alpha and, for administration each stageof the sake of comparison, Gutman half-split3 and the Spearman-Brown` are shown in Table 5.14:

Table 5.14: Reliability of the CBPI (10 items)

Cronbach alpha Pre-trainin n=55 Post-training (n=51) Follow-up n=48 All stages 0.842 0.783 0.808 0.872 I Gutman halt split' 0.845 0.783 0.753 0.855 Spearman 0.857 0.784 0.753 0.860

3 The Gutman half-split coefficient is an alternative reliability responses on one half of a scale with the other.

measure calculated by comparing

The Spearman-Browncoefficient is also a split-half measurebut also estimatesthe effects of lengthening and shortening a scale.

136

These scores are all over 0.75, and therefore high enough to suggest that the measure

has minimal reliability for the data to be aggregated for analysis (Helms et al, 2006; Hinton, et al, 2004; Streiner & Norman, 2003). Alpha scores were also calculated for 9 10 the of of combinations principles at the three different of the various possible 30 All 0.75 these scores of alpha were above and ranged from times of administration. 0.752 to 0.844. 5.5.2: Changes in mean CBPI scores over the period of training and follow-up Means were calculated for the aggregated scores of all principles and were then (ANOVA), a repeated measures analysis using of analysed variance and compared factor. Table 5.15 time participants presents the mean scores and as a within with
Table 5.16 summarises the results of the ANOVA analysis.

Table 5.15: Means of CBPI scores at different Pre-training _. _(N=48) CBPI score 3.08

stages of training Follow-up (N=48) 3.44

Post-training (N=48) 3.51

(SD=. 42)

(SD=. 38)

(SD=. 35)

The interpretation of the following repeated measuresANOVA calculations follows the SPSSprocedure suggestedby I linton et al (2004) who advise that data should be tested for sphericity, using Mauchly's test. If the Mauchly's W score produces a significant result, then sphericity cannot be assumed. In this instance, the W score is 0.858 and is significant, p<0.05. In this situation, Hinton et al recommend checking the Greenhouse-Geisserepsilon score, which if close to 1.0 can allow us to assume The epsilon score is 0.876. If we regard this as close to 1.0, then the sphericity. Sphericity Assumed F-score is 25.931 and is significant, p<0.05. Alternatively, a multivariate test, such as Wilks' Lamda, makes fewer assumptions about the data and is therefore less vulnerable to problems of sphericity. The Wilks' Lamda F-score for the above change in mean CE3PIscores over time is: F (2,46) = 25.93, p<0.0001. The ANOVA analysis is presented in Table 5.16. As both these ways of calculation highly in significant F-scores, this allows us to conclude that there are result significant differences in the mean total CBPI scores generated by administrations at different stagesof the training.

137

i.

Table 5.16: One factor repeated measures ANOVA

Sphericity tests Mauchly's W Mauchly's Sig.

Analysis of CBPI mean scores:

GreenhouseGreenhouse -

Geisser Epsilon
0.858 Sphericity Assumed 0.03 Df, sig. 0.876 Wilkes Lamda

Geisser
F-value, Si v. 0001 36.473 . Df, sig.

F-scores

25.931

2,48,

0001 .

25.931

2,48(. 0 001

Bonferroni the 5.17 Table presentspost-hoc analysis comparing mean changes using between differences It mean group scores there that are significant correction. shows
follow-up between CBPI pre-training and post-training, pre-training and on but not between post-training and follow-up. The training period is associated with significant these between that in and trainees post-training and pre-training attitude change

least training. largely themselves year after at one until maintain changes
Table 5.17: ANOVA Post-hoc Analysis of CBPI mean scores using the Bonferroni correction:
With Post-training Mean difference -4.35 Sig. <. 0001

Compare Mean CBPI score of Pre-training

Pre-training Post-training

Follow-up Follow-up

-3.65 0.71

<. 0001 05 >. .

In summary, the data show that there were significant changesin the attitudes towards agreementwith CBT principles over the period of training and that the training in for likely be itself is CBT to associated with changes positive regard process follow-up is It that these are maintained at changes also shows and that principles. there is no significant reversion to previous attitude structures between the end of training and at least one year later.

5.5.3: Changes in attitudes towards individual CBT principles

The CBP Inventory consisted of ten individual CBT principles. It is important to

examine the development of individual principles over time becausethere is variation in the level to which trainees expresslevels of agreementwith the various principles at pre-training and it is germaneto the researchquestions posed in this study to observethe amount of variation that is retained or is narrowed over time and whether thesechangesthemselves show similar or different patterns amongst the various principles.

138

Table 5.18 presents changesin mean scores for individual principles at pre-training, follow-up ANOVA repeated and accompanying measures and analysis. post-training Trainee agreement with all the individual principles showed significant increases, p< largely These during training. maintained at follow-up. Table 5.19 0.05, changeswere Bonferroni the using analysis, correction, conducted on the pair-wise shows post-hoc differences between pre and post scores, pre and follow-up scores and post and follow-up mean scores for each of the principles. This analysis shows that there were in for between differences, p<0.05 mean scores each principle presignificant between training and post-training and pre-training and follow-up but not between follow-up. There to this trend was one and exception and that was the post-training importance keeping brief. In the therapy this case, there was a of stressing principle between difference but between pre-training and post-training not presignificant implies follow-up. This that agreement with this principle showed a training and degree of reversion towards pre-training attitudes held by trainees.

139

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Table 5.19 Pair wise comparisons

of mean differences

in principles

ratings at

follow-up, Bonferonni Mean difference and the correction: using. and pre, post (significance in brackets)

Pre-Post comparison

Pre-Follow-up comparison

Post-Follow-up comparison

1. Formulation
2. Therapeutic relationship

60 (. 0001)* . 63 (. 0001)* . 33 (0.35)* .

58 (.001)* . 33 (. 036)* .

19 (. 32) . 02 (1.00) .

3. Collaboration

4. Goal-direction
5. Present time focus 6. Educational focus

54 (.002)* .
27 (. 032)* . 31 (.003)* .

35 (.003)* .
27 (. 042)* . 29 (. 014)* . 27 (. 093) . 63 (.0001)* . 46 (.0001)* . 52 (.0001)* .

31 (.003)* .

19 093 . .

02 (. 70) .

00 (1.00) . 21 (. 10) . 25 (. 04)* . 02(. 083) . 17 091 . . 08 97 . .

7. Brief therapy 8. Structure 9. cognitive focus 10. Homework

52 (. 0001)* . 65 (. 0001)* . 63 (. 0001)* . 60 (. 0001)* .

141

in individual Changes B: Question Research 5.6: training:

CBT competencies during

for CBT has developed by appraising the use of A tradition of training assessment skills via standardisedmeasuresthat rate the extent and quality of skill use as In this in by videotape. or audio trainee on recorded performances sessions evidenced 3 trainees were made at of the cohorts successive of of skills assessments such study, in 3 CBT during training training successive pre-training, mid-training and end of CB below trainees data The were skills which shows presented years. academic be to to training still needed ones and, conversely, which as possessingprior assessed in fairly The gain rapid general pattern of skill acquisition was one of achieved. competenceas training progressed.As might be expected, some skills proved more difficult to master than others. Nevertheless,most trainees had acquired most of the found however, by Some training. trainees, the particular skills end of stipulated skills hard to master and thus had to submit extra assessment tapes after the end of training. Inevitably they took longer to acquire competencein the full range of CBT skills. 5.6.1: The form of CBT skills assessment General therapy skills7 of the CTS-R were assessed at mid-training ('mid-training CTS-R CBT Specific the of were assessed skills8 at the end of assessment')and training ('end of training assessment').General therapy skills in which trainees had been deemedas not yet competent at mid-training could be re-assessed at the end of training. Any general or specific skills in which competencewas not achieved by the further be training one on occasion before the re-assessed could end of ('final the year assessment'). academic next commencementof

For the purposesof the researchproject, trainees were asked to submit an audiotape of an attempt to do what they consideredto be CBT before the commencement of This was done on a voluntary basis and could training (pre-training assessment). not for the degree to which trainees result in any training credit. The tapeswere assessed both CBT General Specific Therapy and skills. Pre-training, mid-training, exhibited for final the 41 trainees who did submit preresults post-training and assessment
7 CTS-R General therapy skills include: Agenda setting; Eliciting feedback; Collaboration; Pacing and Interpersonal effectiveness. CTS-R Specific CBT skills include: Eliciting emotions; Eliciting key cognitions; Eliciting behaviours; Guided Discovery; Formulation; Application of changemethods, and, Setting homework.

142

WON i SIT ta }
q. y

Y. . .

5.20, in Table accompanying with tapes presented are training

ANOVA

analysis. 14

but did later tapes did tapes in submit at not submit pre-training trainees the study by dividing the calculated number was A score competence trainee mean skill stages. by taking trainees the all each of number competence trainees achieving of indicate high 1.0 to rates of achieving close therefore scores mean assessment, low indicate 0.0 to of achieving competence. rates those close and competence by describing begin the skill assessmentresults in this data section will The presented be to tapes 41 appraised at the pre-training stage and trainees who submitted for the There training. through they phases of subsequent will their moved as results then did for 14 trainees follow the not submit pre-training who results analysis of then tapes but did submit tapes at subsequentstagesof assessment.

Table 5.20: CBT Skills Assessment: Trainee rates of achieving Stages (n=41):
A. CBT skills (as per CTS-R) B. Mean (& SD) competence grades per trainee: Pre-training C. Mean (& SD) competence grades per trainee: Mid-training General Thera D. Mean (&SD) competence grades per trainee: End-training skills

competence

at all

E. ANOVA F-ratio Degrees of freedom, (Significance)

1. Agenda-setting 2. Feedback 3. Collaboration 4. Pacing 5. Interpersonal

effectiveness

0.32 47 . 0.27 45 . 0.93 26 . 0.56 50 . 1.00 (. 00)

0.66(. 48) 0.90 30 . 0.8506) 0.95 22 . 0.98 (. 16)

Specific CBT skills

1.00 (. 00) 0.95 (. 44) 0.80 (. 40) 0.88 (. 33) 0.83 (. 38) 0.88 (. 33) 0.93 (. 26)

F (1,40) F (1,40) F (1,40) F(1,40) F (1,40)

= 17.43 (. 0001)* = 48.81 (. 0001)* = 1.30 (. 262) n. s = 21.25 (. 0001)* = 1.00 (.323) n. s

1. Eliciting
emotions

0.93 (. 26) 0.76 (. 44) 0.27 (. 45) 0.07 (. 26) 0.24 (. 44) 0.32 (. 47) 0.66 (. 48)
"

F (1,40) = 3.16 (. 083) n. s F (1,40) = 7.40 (. 010)* F (1,40) = 46.32 (. 0001)* F (1,40) = 165.00
(. 0001)*

2. Eliciting key
cognitions

3. Eliciting
behaviours

4. Guided
discovery

5. Formulation) 6. Application of
change methods

F (1,40) = 147.79 (. 0001)* F (1,40) = 42.66 (. 0001)* F (1,40) = 11.75 (. 001)

7. Setting
homework

Significance p <. 05

RepeatedmeasuresANOVA analysis shown in Table 5.19 indicates the significance in the mean scores between pre-training (Column B), mid-training-training changes of

143

for 41 D) trainees those (Column who submitted C), (Column and end of'training tapes at all these stages. 'f'able 5.19 shows ANOVA increases, at least p<0.05, F) (Column significant results

in the number of trainees achieving competence for 9 of'

12 skills listed in the CTS-R. The 9 skills listed in the categories of General 't'herapy Specific C'BT skills are: skills and

General Therapy skills: Agenda-setting & adherence, Feedback, and, Pacing & efficient use of time.

0 " "

Specific CBT skills: Eliciting key cognitions, Eliciting behaviours, Guided Discovery, Conceptual integration (Formulation), Application of change methods, and, Setting homework.

" " " " " "

Changes in the mean competence rates for the three other skills Collaboration, Interpersonal effectiveness and Eliciting emotions are not significant. This is due to the fact that mean competence rates at pre-training, 1 00 and 0.93 respectively, were . already very high.

5.6.2:

Pre-training

CBT Skill Assessment

41 trainees submitted tapes at the pre-training stage. The results for the assessment of the individual skill items as represented in these tapes have already been presented in "Table 5.19, column B. It can be seen that competence rates for Collaboration and

Interpersonal effectiveness were very high at pre-training, with almost all trainees half in Over trainees showed competence at Pacing, them. showing competence whilst Eliciting Feedback. did Agenda-setting third and so at under a

144

5.6.3:

Mid-training

assessment of General Therapy

skills:

in The Therapy General shown results are skills only were assessed. At mid-training, for in figures be It C. that the that table 5.19, noted presented Table should column for trainees tape those who presented prea mid-training assessmentrepresent only in had Trainees (n=41). those that skills showed marked gains training assessment lower competence rates at pre-training and showed a slight decline in competence in been high had at pre-training. very rates areaswhere competence Table 5.21 shows how trainees who had made a pre-training submission fared at their first and second attempts at demonstrating general therapy skills by cross-tabulating results at pre- and mid-training:
Table 5.21: Trainees' General Therapy Competence at Pre-training (n-41)
A. CBT general skills
(As per CTS-R)

& at Mid-training:
E. Achieved
competence

B. Achieved
competence at

C. Achieved
competence at pre

D. Did not
achieve

pre-training & mid-training 1. Agenda setting &

adherence

but not at midtraining 1 2 5 1 1

competence at pre but did at

mid-training

at neither pre nor midtraining

12 9 33 22 40

15 28 2 17 0

13 2 1 1 0

2. Feedback 3. Collaboration 4. Pacing & efficient use of time 5. Interpersonal effectiveness

Column D in Table 5.21 shows that there were big increases in the number of trainees in Agenda setting & adherence; Feedback, and, Pacing & competence achieving between time the pre-training assessmentand mid-training use of efficient Interpersonal effectiveness and Collaboration began with high mean assessments. competencerates and both showed a slight deterioration at mid-training. Column E in Table 5.21 allows us to compare the relative improvements in the number of trainees achieving competence in Agenda setting & adherence and Pacing & efficient use of time at mid-training. It is noticeable that more trainees failed to achieve competence in Agenda setting & adherence a second time than for any other general skill. The fact that 13 trainees did not achieve competence looks striking but it

145

first formal be the that this of this skill and that this assessment was must remembered difficulty The failures had that trainees three cohorts. over of accumulated number had in structuring therapy was also one of the motivating factors for the study as did in 18 in 1. Only 1 Chapter the trainees competence achieve of who not reported Pacing & efficient use of time at pre-training did not achieve competence at midtraining, comparedto 11 of the 28 traineeswho did not achieve competence in Agenda setting & adherenceat pre-training and also not at mid-training.

There were assessment sheetreports, which offered reasonsfor failures, and these were analysedby the researcher.This analysis adopted line-by-line scrutiny to establish key categoriesand themes in the assessor'scomments. This showed that whereasthe majority of trainees did not achieve competenceat pre-training because they showed no attempt to set any kind of agenda,the majority of the trainees who did not achieve competenceat mid-training were failed becausethey either did not set an appropriate agendaor failed to adhereto the agendathat had been set. Several different tasks, it is evident, are nestedwithin the overall criteria for this skill. At pretraining, trainees tended to fall at the first fence: i. e., setting any kind of agenda and for the further criteria of ensuring a relevant agenda and so could not be assessed sticking to it. Other comments made by assessors concerned the quality and relevance of agendaitems. In the CTS-R Manual, Jameset al (2000) comment that agenda items should be clear, discrete and relevant as opposedto vague and irrelevant. Assessors sometimesacceptedthat agendaitems had been set but in some casesqueried the clarity and relevance of these items in some tapes and rated them as not showing competence. 5.6.4: End-of-training skills assessments

The results at end of training for trainees who also submitted a pre-training tape have already been reported in Table 5.20, column D. These results showed big gains in competencerates for Specific CBT skills compared to pre-training results, though some traineeswere not rated as competent in them. The ANOVA analyses in Table -, 5.21 shows the gains were significant, p<0.05, in the mean competence rates of trainees for all specific CBT skills, except Eliciting emotions at the end of training, comparedto the pre-training stage.

146

be described. Firstly, CB further will Two skill assessment aspectsof end-of-training in had not achieved competence one or more the re-assessment of those trainees who described. be five General Therapy the skills assessed at mid-training will of Secondly, a comparison will be made between how trainees assessedin the various Specific CBT skills at pre-training and how they fared at end of training assessment.

5.6.4.1:

End of training reassessment of General Therapy skills:

21 of the 41 (51.2%) trainees who submitted pre-training tapes achieved competence in all 5 General Therapy skill items at mid-training assessment, 20 (48.8%) therefore

had to be re-assessed in these items. 16 trainees had to be re-assessed on just l item (most usually agenda-setting & adherence), 2 on 2 items, I on 3,1 on 4 items. Thus items being trainee total reassessed was 27. The results of reskill the number of items 21 in the Table training these at end skills of general are reported of assessment 5.22: CBT the End training 5.22: of general skills not achieved at Table assessment of 20, being items): (Trainee assessed on n=27 skill n= mid-training
GENERAL SKILLS Number of trainees Number of trainees TOTAL

1. Agenda setting & adherence 2. Feedback

3. Collaboration 4. Pacing and effective

not achieving competence 5 0

0 0

achieving competence 9 4
6 2

14 4
6 2

use of time 5. Interpersonal effectiveness TOTALS

0 5

1 22

1 27

Table 5.22 shows that at the end of training, the 20 trainees who had submitted pretraining tapes were mostly successful in achieving competence in the 27 general skill items that they had not achieved at mid-training assessment.The only exceptions did five in Agenda setting & adherence for trainees not who achieve competence were a secondtime.

5.6.4.2:Comparison of pre-training and end of training assessmentof Specific

CBT skills:

147

tapes achieved pre-training trainees submitted 5.1 who Figure that most shows decisively less than though that CBT Specific 7 stage: in 3 at skills of the competence in 41 38 the Therapy competence General achieved of in the assessment skills. of in Homework. The Setting 26 key in Eliciting 30 Eliciting emotions, cognitions and be in for these high contrasted can skills achieving competence numbers relatively in 10 in Guided Discovery, 41 3 for lower the the other skills, of number with much Conceptual Integration (Formulation), 11 in Eliciting Behaviour and 13 in the Application of Changemethods. The large majority of the trainees who did not it by had, however, in these achieved end of skills at pre-training achieve competence training: (33 in Guided Discovery and in the Application of Change Methods, 26 in Conceptual Integration, 28 in Eliciting behaviour). These figures once again underline the steady growth of competencein skills over the period of training for the large majority of trainees. They also show a small number of trainees had not yet achieved competenceby the end of training and so therefore had to make resubmissions.

148

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5.6.5: End of training assessmentof trainees submitting pre-training tapes: At the end of the training period, 17 of the 41 trainees still had 1 or more outstanding items: 9 had just 1 item, 5 had 2,1 had 3,1 had 4 and finally 1 had 7) 33 CB skills items - General Therapy and Specific CBT - in all) from the general and/or specific do The CTS-R them to training to the regulations allowed course resubmit. skills of this on one further occasion before the commencementof the next training year, i. e., in 13 (76.7%) 3 All 17 achieved competence all within months. resubmitted and (along had items. The 4 2 trainees with others who remaining not outstanding had for further Semestersof training, tapes) to re-register submitted pre-training during which they could resubmit their assessment tapes. All 4 completed this task successfully. 5.6.6: Skill assessmentfor trainees not submitting a pre-training tape: 14 other trainees enteredthe study without submitting a pre-training tape. Results far have excluded those for these trainees as the presentation of results reported so becausethey have been focused on comparing pre-training with later results. As these 14 trainees did respond to requeststo return the CBTTQ, the results of their skill assessments at mid and end of training were included in the study. The inclusion of this data helps to give the fullest possible picture of trainee skill performance during training. It also allows us to consider if thesetrainees were performing differently than traineeswho had submitted a pre-training tape.

Someof the trainees did who not submita pre-trainingtapewere unableto submit
tapesbecausethey did not have appropriate clients, adequaterecording equipment or becausetheir agencieshad not agreedto them taping clients as yet. One trainee had been unwell and another had made a very late decision to join the training and had missed the introductory pre-course meeting at which the request to submit tapes had been made. Later, several trainees, however, also reported that they had been unwilling to submit their work for scrutiny at that stage.Although tapes would be stored anonymously, the trainee's voice was likely to be recognisable. As all these 14 it seemsinstructive to brief indicate trainees did submit tapes for later assessment, how they fared in their results. Tables 5.23 & 5.24 present Independent samples t-test analysis comparing mean performance results of this group with the previous results presentedfor the group of trainees who did submit pre-training tape.

150

Table 5.23: Comparison of trainees submitting and not submitting pre-training assessment of General tapes: Mean (&SD) competence rates at mid-training Therapy skills with independent t-test analysis:
Trainees who had submitted pretraining tapes (n=41) 0.66 0.90 0.85 0.95 0.98 Trainees who had not submitted pretraining tapes n=14 0.64 0.93 0.84 0.86 0.86 T-values for df=53 (Significance)

1. Agenda setting 2. Feedback 3. Collaboration 4. Pacing 5. Interpersonal Effectiveness

T= 105 (. 92) . t=- 288 (. 77) . t= 584 (. 56) t= 1.163 (. 25) t= 1.699(.095)

Table 5.24: Comparison of trainees submitting and not submitting Pre-training tapes: Mean (&SD) competence rates at end-of-training assessment of Specific CBT skills with independent t-test analysis:
Trainees who had submitted pretraining tapes n=41 1.00 0.95 0.80 0.88 0.88 0.88 0.93 Trainees who had not submitted pretraining tapes n=14 1.00 1.00 0.79 0.71 0.93 1.00 1.00 T-values for df=53 (Significance)

1. Eliciting emotion 2. Eliciting

cognition

t= -. 832(. 41) t= 152 (. 98) . t= 1.43 (. 16) t= -. 90 (. 37) t= -1.37 (. 18) t= -1.03 31 * .

3. Eliciting behaviour 4. Guided Discovery 5. Formulation 6. Applying change methods 7. Homework

Table 5.23 and Table 5.24 show that there were no significantly different scores between the two groups in the assessmentof either General Therapy or Specific CBT skills at mid and end of training respectively.

Though there were these differences, neither group was superior in all areas: the group that submitted pre-training tapes scoring higher in 6 of the 12 skill areas and lower in the other 5.In one area both groups scored the same. 5.6.7: Time taken to achieve competence in all General and Specific CBT skills: for all trainees: In summary, most trainees were eventually able to achieve CBT competence using the skills assessment procedures of the CTS-R but the time periods needed to achieve this

151

(training 12 (up 9 training between period the to months period), of end months varied (training 18 for final period plus months and assessment) plus resubmission 5.25 Table the further to training shows modules). retake period of a resubmission and cumulative completion rate over time:
Table 5.25: Time taken to achieve CBT competence using CTS-R assessment methods:
Number of trainees achieving competence in all CTS-R items Cumulative percentage

Training period Sept- June (9 months)

period + resubmission. Sept-Sept Training

32
17

58.2%
89.1%

following

(12 months) Training period + resubmission + further module. Sept - Sept -

100.0%

Feb. 18 months TOTAL

55

100.0%

Table 5.25 shows that almost 58% of the trainees in this training programme were able to establish competencein CBT skills (as measuredusing the CTS-R) within the academicyear in which the course ran. A further 31% of the trainees had required the cushion of a brief resubmissionperiod to complete satisfactory competence in all the skills. This left a small group of six trainees who neededto retake various aspects of the training course again during an extra 6 month Semesterbefore they were finally able to successfully attain competencein all the skill areas.Thus this final small group took almost twice as long as the larger group of trainees who were able to complete CBT skill acquisition within the academic year.

152

5.7:

Research Question C: What influence in CBT? of competence

does model preference

play on the

acquisition

The CBT skill assessmentresults presented in the previous section will now be refor between began be the trainees results who made examined and comparisons will Two different therapy aspects of model preference preferences. model training with indicating is Firstly, to the be there self-description adherence general explored. will between descriptor for ideas therapeutic choosing example, or another: one set of labels such as `Cognitive-behavioural' or `Person-centred'. Secondly, there is a rank For trainee influence the a might choose the example, such choices. of of order highly CBT influence but description, `Person-centred' quite as an might rank overall CBT indicate low to lowly. A aversive responses some quite might ranking or quite CBT identified descriptor Name of were rank ordering choices and at preprinciples. factors: 5.26 Table the tabulation two of a cross training questionnaire. shows Table 5.26: Pre-training model preference and rank order of CBT
-ist CBT 8 PCT 1 Ps chod namic 0 Integrated/Eclectic 2 TOTAL 10

2 3` 4` 5`

0 0 0 0

10 6 6 3

1 2 2 2

7 3 1 1

19 11 9 6

Total

26

14

55

Table 5.27 shows how trainees of different model preferences reported the therapeutic attitudes described in Section 5.5 and how these developed over the course of training.
Table 5.27: Mean CBPI scores over the period of training by initial with one-way ANOVA analysis
Pre-training (N=55) Mean 34.75 (n=8, SD= 2.82) 28.81 n=26 SD=4.89) 28.57 (n=7, SD=3.10 31.79 (n=14, SD=4.26) 30.40
n=55 SD=4.74

model preference

Preference CBT PCT Psychodynamic Integrated/ Eclectic

ALL

Post-training (N=51) Mean 37.00 (n=7, SD=3.46) 34.65 n=23 SD=4.21) 34.71 n=7 SD=3.40) 35.21 (n=14, SD=3.09) 35.14
n=51 SD=3.70)

ANOVA F-score df , , i g.) (S

F (3 54) =4 80 (.005) * , .

F (3,50)= 0.74 (. 53)

Follow-up I N=48 Mean 35.71 (n=7, SD=1.80 34.59 n=22 SD=3.57) 31.14 (n=7, SD=4.67) 35 25 . (n=12, SD=2.42) 34 42 . n=48 SD=3 .50 F (3,47)=2.92 (.045)*

oignincance,

p<U. U5

153

for Bonferroni all three stages. correction were made Multiple comparisons using the CBT between 6.18 in difference and score of At pre-training there was a mean differences both PCT, CBT between 5.94 showed Psychodynamic, and, and At training, the 008 047 end of p<0.05. where respectively, and . significance, . differences between mean scores for the different orientations, has narrowed and no

longer shows a significant difference in the ANOVA analysis, F=. 742, df= 3,50 difference follow-up, At the 532, that relevant. multiple comparisonsare not so p=. between mean scoresof the different orientations is again significant, F=2.92, df=3, 47, p=.045, but no significant mean differences between trainees with different model in preferencesare reported the SPSSoutput.

Trainees were also askedto rank order their therapy model preferences from a range follow-up. The then at rank order and again at pre-and post-training of models is in 5.28: CBT Table to shown ascribed
Table 5.28: Rank assigned to CBT in ranking of models (Pre, Post & Follow-up)

First Second Third Fourth Fifth TOTAL

10 19 11 9 6 55

17 25 6 3 0 51

16 25 5 2 0 48

The ten trainees nominating CBT as their first ranking influence at pre-training included eight who had named CBT as their first preferred model and two who had integrated/eclectic therapy as their preferred model but nominated CBT as named
their first ranking influence. The rank ascribed to CBT shows modest progress over the period of training and follow-up: the number of trainees nominating CBT as either their first or second main influence increased from 29 of 55 trainees at pre-training to 41 of 48 at follow-up. Table 5.28 shows that for most trainees there was a general movement of preference towards assigning a higher rank towards CBT during and after training.

Table 5.27 showed that increasesin adherenceto CBT principles were evident across held that trainees prior to training. Table 5.28 all pre-training model preferences higher CBT to that ranks on the rank order of preferred models of showed moved

154

,,
F ik. .. J..

"d CBT 1St 2 85% follow-up or of respondents gave rank, compared therapy, so that at
to 53% at pre-training..

individual by the Trainee of assessment 5.7.1: competence shown by orientation preference at pre-training:

CB skill items

individual CB items 5.29 trainee on all skill Table performance at all stages by reports by indicated therapy selection of a name preference orientation pre-training descriptor. As previously, performance is described by mean competence rates where imply high 0.0 imply 1.0 to to and competence rates scores close very scores close low competence rates. very Table 5.29 to 5.31 show that there are some differences in the achievement of initially different between in CBT trainees preferring skills models at competence different stagesof training

Table 5.29: Performance

PRE-TRAINING (n=41) 1. Agenda setting & adherence 2. Feedback 3. Collaboration
4. Pacing & efficient use of time

in individual
PCT (n=18) 0.22 0.33 0.94 0.33 1.00 0.89 0.67 0.00 0.00 0.22 0.11 0.44

CB skills items by pre-training at pre-training assessment:

Psychodynamit (=_5) 0.00 0.40 1.00 0.40 1.00 1.00 0.40 0.40 0.20 0.40 0.20 0.60
= Signiticant,

model preference
One way ANOVA F-ratio 3.98 0.73 1.70 4.73 0.59 2.95 14.68 2.58 0.47 7.39 3.36 Degrees of freedom, Significance (3,37). 02* 3.37 (3,37). (3,37) (3,37). 62 (3,37) 05* . (3,37) 00011* . (3,37). 07 (3,37). 71 (3,37). 001* (3,37). 03* 52 . 19 01 .

CBT (n=8) 0.75 0.25 0.75 1.00 1.00 0.88 1.00 0.88 0.25 0.13 0.88 1.00

Integrated/ Eclectic N=10 0.30 0.10 1.00 0.70 1.00 1.00 0.90 0.20 0.00 0.30 0.30 0.80
p<U. U5

All (n=41) 0.32 0.27 0.93 0.56 1.00 0.93 0.76 0.27 0.07 0.24 0.32 0.66

5. Interpersonal effectiveness 6. Eliciting emotion 7. Eliciting key cognitions 8. Eliciting behaviours 9. Socratic Questioning 10. Formulation 11. Application of change methods 12. Setting homework

Table 5.29 shows that in the pre-training assessment,differences are big enough to attain significance, p<0.05, in the General Therapy skills of Agenda setting & adherence,and, Pacing & efficient use of time. Differences also attain significance in the Specific CBT skills of Eliciting key cognitions, Eliciting behaviours, Applying

155

that there Post-hoc homework. Setting showed analysis pair-wise changemethods and in the PCT CBT between the stage differences pre-training at and were significant Eliciting & Pacing time, & efficient use of skills of Agenda setting adherence, behaviours, and, Setting homework. It also shows that there were significant differences between CBT & Psychodynamic and CBT & Integrated/Eclectic in pretraining performance in Eliciting behaviours and Applying change methods at pretraining.

Table 5.30: Mid-training assessmentby initial model preference (n=55)

MID-TRAINING (n=55) 1. Agenda setting & adherence 2. Feedback 3. Collaboration 4. Pacing& efficient
use of time

CBT (n=8) 1.00 1.00 0.88 1.00 1.00

PCT (n=26) 0.42 0.81 0.77 0.85 0.92

Psychodynamic (=7) 0.71 1.00 1.00 1.00 1.00

Integrated/ Eclectic N=14 0.86 1.00 0.86 1.00 0.93

All (n=55) 0.65 0.91 0.84 0.93 0.95

One way ANOVA F-ratio 5.28 2.13 0.76 1.63 0.38

Degrees of freedom, Si nificance (3,51), 003* . (3,51), 11 . 3,51 52 ,. (3,51), 19 . (3,51), . 77

5. Interpersonal effectiveness

"= Signiticant, p<U. US

Table 5.30 shows that at the mid-training stage,there was still a significant difference in the performance of Agenda setting & adherence.Post-hoc pair-wise analysis between CBT & PCT Integrated/Eclectic & PCT. difference this that and was showed

Tale 5.31: End of training assessmentby initial model preference: (n=55)

END OF TRAINING n=55 1. Eliciting
emotion

CBT (n=8) 0.88 1.00 1.00 1.00 0.88 1.00 1.00

PCT (n=26) 0.96 0.92 0.69 0.81 0.81 0.88 0.88

Psychodynamic (=7) 1.00 1.00 0.86 0.86 0.86 1.00 1.00

Integrated/ Eclectic (N=14) 0.86 1.00 0.86 0.86 0.93 0.86 1.00

All (n=55) 0.93 0.85 0.80 0.84 0.85 0.91 0.95

One way ANOVA F-ratio 0.76 0.75 1.45 0.92 0.35 0.69 1.17

Degrees of freedom, Si nificance (3.51).. 52 (3,51). 53 (3,51) (3,51), 24 . 60 .

2. Eliciting cognitions 3. Eliciting

behaviours

4. Guided discovery 5. Formulation 6. Apply change methods 7. Homework

51 79 ,. (3,51). 56 3, '. 33

Table 5.31 shows that at the end of training, there were no significant differences in Specific CBT skills performancesbetween trainees from difference modality preferencegroups. In general, rates of achieving competencewere high in most areas once training is underway so that significant differences are not evident at end of

156

lesser Agenda-setting, though gains especially areas showed certain training: Eliciting behaviours and Conceptual Integration (Formulation). PCT trainees, however, tend to perform somewhat less well in most CB skill areas at all stages of in developing the trend this slower was more noticeable skills of agendatraining and formulation. behaviours and setting, eliciting After the end of training trainees were given one final chance to achieve competence in skills that they had not as yet demonstrated before the commencement of the following academic year. The numbers involved are too small to analyse by ANOVA in but As 5.7 all six trainees passedtheir outstanding skill reported analysis. in final details Some assessment. of these six trainees, who all elected to assessment take extra module teaching in the following academic year are shown in Figure 5.2:

Figure 5.2: Trainees with outstanding skill assessment items at the end of training Preference: Skill items outstanding: Trainee:
A: B: C: D: PCT PCT PCT PCT Agenda-setting; Eliciting behaviours; Guided Discovery. Agenda-setting; Guided Discovery. Eliciting behaviours. Eliciting cognitions.

E:
F:

Psychodynamic
Integrated/Eclectic

GuidedDiscovery. Agenda-setting;
Eliciting behaviours.

All these trainees did enrol for further Semestersof study and did manage to achieve in CBT further their skills all periods of study. It can be seen that some in the group of trainees who began with a PCT background generally did less well than those with other modality preferences. Most, however, did achieve competence within the academic year of the course but a small number continued to struggle with certain competenciesand this led them to pursue further periods of training, thus taking

longerto achievecompetence in all the skills measured by the CTS-R.

5.7.2: Time taken to achieve CBT competence on all assessment items by orientation:

Theprevioussectionshowedthat all the trainees who enteredthis study were eventuallyassessed ashaving achievedCBT competence in using both the General Therapy andSpecific CBT items in the CTS-R. Sometrainees,however, took nearly

157

laid 5.25 Table time the than relevant out long this others. to result twice as achieve These during CBT them. competence period and the number of trainees achieving from the be the orientation of perspective time periods will now reconsidered background of the trainees completing during them and reported in Table 5.32:

Table 5.32: Time taken to meet CBT assessment criteria training (n=55): 9 months
C BT 7

by stated orientations

at pre-

12 months
1

18 months
0

Mean completion time (SD)

9.38 1.06

PCT Ps chod namic Integrative/Eclectic Total

12 5 8 30

10 1 5 19

4 1 1 6

11.54 3.14 10.71 (3.40) 10.71 (2.56) 10.91 2.85

Table 5.32 shows that just over half the trainees achieve competence in all the CTS-R assessment items by the end of nine months of training. Trainees with a PCT first therapy model preference have a notably lower completion rate by this stage. Most trainees are able to quickly resubmit and achieve all items within a further three bringing the overall competence rate up to nearly 90%. A small group of months, trainees, within whom those with a PCT background are somewhat over-represented, need a further extension of learning but are able to achieve competence in all skill items by the end of that time. One-way ANOVA analysis of the differences between

mean completion times for trainees with different modality preferences, however, is not significant, giving an F-score of 1.25, p> 0.05.

Summary of the CBT skills performances descriptor model choice:

of different

trainee groups by name

There are consistent differences between the performance of trainees choosing different model name descriptors and these achieve significance between particular modalities, especially between CBT and PCT, at particular times, especially at pretraining assessment, and in the assessment of particular skills, especially agendasetting & adherence. Other differences between modalities are sometimes evident but these differences do not reach significance in ANOVA analysis due to the low number

of participants in the study leading to the results being under powered.

158

5.7.3: Rank order of model preference and assessmentperformance Trainees were askedto indicate model preferencesbefore they began training in CBT and CBT indicate they to would rank where amongst the plurality of they were also asked influence It likely be important them. theorised in to that this was that could were models for indicate PCT but trainees example, a preference, rank CBT as the might that some influence By their highest contrast another trainee might on practice. ranking second but influence CBT 4th 5th her PCT It only as rank or an on preference a practice. report be differently trainees hypothesised these two types that response of might reflected was in trainee skill performance.

Analysis here will presentassessment results at various stagesof assessmentby rank influence CBT Rank the the of at of model pre-training. orders were taken only ordering in the pre-training administration of the CTTQ questionnaire. Table 5.33 to 5.35 show cross tabulation of rank order of model preferencesand skill outcomes and the matching Spearman's-rho this relationship using of analysis of mean competence rates at analysis the different stagesof assessmentby rank order of Preference for CBT at pre-training:

159

Table 5.33: Cross-tabulation of rank order of CBT at pre-training and mean skill Spearman's rho analysis: with competence rates at pre-training,
First Second Third Fourth Fifth Correlation coefficient (Spearman's Agenda 0.60 0.38 0.14 0.17 0.0 rho) 43* - . 38* Sig. (2 tailed). . 01

Feedback
Collaboration

0.20
0.70

0.38
1.00

0.14
1.00

0.0
1.00

0.67
1.00

04 .

.
.

79
02 -

Pacin
Interpersonal effectiveness

0.90
1.00

0.54
1.00

0.43
1.00

0.16
1.00

0.67
1.00

36* -.
-

02 . 49 . 08 . 04 .
. 20

Elicit emotion
Elicit cognition Elicit behaviour Guided discovery Formulation Apply change methods Homework

0.90 0.90 0.60

0.20 0.30 0.60 0.80

0.92 0.85 0.77

0.00 0.15 0.31 0.85

0.86 0.57 0.00

0.14 0.57 0.14 0.43

1.00 0.67 0.00

0.00 0.00 0.17 0.17

1.00 0.60 0.40

0.00 0.20 0.20 0.20

11 . 27 -. 33* -.
20 -. 06 -. 33* -. 29 -.

70 . 03 . 06 .

Significance, p<0.05

level (two-tailed)

Table 5.33 showsthat there are associationsbetweenrank order of CBT preference at pre-training and skill competencein 5 of the 12 skills: Agenda setting, Collaboration, Pacing,Guided Discovery, Eliciting behaviour and Applying change methods. All these
direction higher in the trainees the of reporting a rank of preference for associations are

CBT at pre-training tendedto be more likely to attain competence:with the exception the
skill of Collaboration, where the reverse was the case. Table 5.34: Cross-tabulation of rank order of CBT at pre-training and mean skill competence rates at mid-training, with Spearman's rho analysis:
First Second Third Fourth Fifth Correlation coefficient Sig.

(Spearman's
Agenda 0.90 0.84 0.64 0.44 0.50 rho 29* -. . 03

Feedback Collaboration
Pacing Interpersonal effectiveness

1.00 0.90
1.00 1.00

0.84 0.95
1.00 1.00

0.82 0.73
0.91 1.00

1.00 0.78
0.89 1.00

1.00 0.67
0.67 0.67

33* 29 -.

04 . -. 24

77 . 08 .
01 . 03 .

Significance,

p<0.05

level (two-tailed)

-'

160

for CBT between at preference rank order Table 5.34 shows that there are associations Pacing Agenda in the setting, skills of mid-training at competence skill and pre-training direction in that the All the showing are associations Interpersonal effectiveness. and be for CBT to tended higher at pre-training preference ranking trainees who reported a

in those likely areas. skill to competence attain more

Table 5.35: End of training
First Second

results by rank order CBT at pre-trainin

Third Fourth Fifth Correlation coefficient Sig.

(Spearman's rho) Elicit

emotion Elicit cognition Elicit behaviour Guided discovery Formulation Apply change methods Homework

1.00
1.00 0.80 0.90 0.90 1.00

1.00
0.95 0.79 0.84 0.89 0.84

1.00
1.00 0.82 0.73 0.82 1.00

1.00
0.89 0.78 0.78 0.67 0.89

1.00
1.00 0.83 1.00 1.00 0.83

06 -. . 01 .

68 92 84

03 -. 09 -. 07 -.

52 . 60 .

1.00

0.95

0.91

0.89

1.00

- .08

55

Table 5.35 showsthat there are no significant associationsbetween rank order preference for CBT at pre-training and the attainment of competencein Specific CBT skills at the Such training. rank order effects for these skills at pre-training are no longer end of evident at the end of training.

The results reported above for associations of rank order preference for CBT and subsequent competence attainment show that there are some consistent differences in by performance rank ordering of the CBT model at pre-training and that some of skill these persist at mid-training. Generally, those ranking the model higher perform better than those ranking the model lower, especially those ranking CBT in the very lowest By the end of training, however, the positive relationship between ranks. giving CBT a high initial ranking and being more likely to achieve CBT skill competencies is no longer evident.

161

5.7.4: Summary of the analysis of differences in CBT skills performance

by model

preference and ranking: The analysisfor researchquestionC showsthat there are some differences between the by different distinguished trainees model choices and ranking of performanceof in differences These for CBT are shown pre-training at pre-training. preference items: following the skill of assessment Agenda setting & adherence: Collaboration: Model preference& rank order preference for CBT Model preference& rank order preference for CBT (reverse) Pacing& efficient use of time, Eliciting cognitions: Eliciting behaviours, Application of changemethods Setting homework. Model preference& rank order preference for CBT Model preferenceonly. Model preference& rank order preference for CBT Model preference& rank order preference for CBT Model preferenceonly.

Wherepair-wisecomparisons to showthat in the caseof model theytended weremade

CBT better tended to than others, trainees significantly perform preferring preference, especiallyPCT trainees,in someareas. As training proceeds,thesedifferencesbecomeless pronounced,and no longer show significant differences,with the exception of mid-training assessment of: Agenda setting: Pacingand efficient use of time: Interpersonaleffectiveness: Model preference& rank order preference for CBT Rank order preferencefor CBT only. Rank order preferencefor CBT only.

As at pre-training, however,though most PCT traineesare attaining competence,some them continue to do less well, especially when comparedto CBT trainees.A small numberof trainees,often of the PCT preference,continue to show difficulty with

of

162

designated & the the in Agenda at end of even adherence setting competence achieving have They to retake certain subsequently year. academic training period of one by CBT final the delays competence, as assessed their of this attainment and assessments CBT Psychodynamic PCT trainees tended to accord a As and CTS-R. was shown earlier, influence. The the skill assessment of analysis lower ranking as a pre-training lowest in CBT that they the showed ranks, trainees, ranked who performance of for it PCT Although trainees. but less this was only evident a was more well performed the PCT competence that attaining trainees after start more problems showed of minority in began CBT be the that to group this over-represented minority appears of training, but by for by holding model, also a non-CBT allocating a a preference training, not only influences in CBT therapy for their model low rank rank order of

5.8: Summary and Conclusionto Chapter 5:

The study followed three cohorts of trainees with backgrounds in employment and in CBT. The trainee cohorts in training who undertook specialist training counselling Women formed in 80% the surveyed. characteristics most of around equivalent of were the final sample of trainees.Trainees were mature studentswith an average age of around 46 years.They came from a variety of educational and employment background, were between They and non-graduates. were split graduates and evenly counsellors, mostly looking into to move more counselling orientated or more specialist were mostly Though had backing few the work. some of employers, enjoyed much counselling issues fees over such support as paying and arranging time off to attend training. practical Very few employers were reported as regarding training that was specifically in CBT as a priority. Before training, the trainees in general showed quite high levels of agreementwith most CBT principles, though they also held reservations about some of these principles, especiallythose that concernedstructuring therapy and aiming to keep therapy timelimited. Almost half the trainees declared a preference for the Person-centredmodel of therapy,with the others divided between preferencesfor the CBT, Psychodynamic and Integrated/eclectictherapy models. Even when indicating a preference for another model,

163

21 traineeswith preferencesfor anothermodel ranked CBT first or second in their rank however, influences. Twenty trainees, preferred a non-CBT therapy six model order of influence. Over in the period of 5th 3`d, 4t' CBT rank order of or model and allocated their level of agreementwith CBT principles training in CBT, most traineesincreased higher influence CBT in to CBT declared their a rank or moved main new as and either their ordersof therapy model influence. The attitude changeswere significant at the posttraining phaseand were largely maintainedat one year follow-up so that the change from follow-up to attitudeswas also statistically significant. attitudes pre-training

In pre-training CBT skills assessment, most traineesshowed some pre-existing ability to perform someof the skills of CBT, especiallythose most strongly related to general therapy skills, such as Interpersonaleffectivenessand Eliciting emotions. Competence increases for at mid-training and end-of-training significant showed skills rates most have CBT to A trainees problems continued mastering of minority small assessment. instruction. All did had these trainees to take modules of additional skills and some had items, but in long them taken twice some of all as competence to achieve eventually had in trainees this already achieved competence all skill areasat end-ofwho as achieve training assessment.

Performancein CBT skill assessments was examinedby initial identification of by CBT in Trainees with a stated CBT, of order rank model preferences. and orientation Psychodynamicand an Integrative/Eclectictherapy orientation generally performed better than traineeswith a Person-centred orientation, though thesedifferences only achievedsignificance in ANOVA analysisfor some skill areasat some stages.Personcentredtraineestendedto have specific problems with such areasas structuring the Given the initial observation that structuring therapy and Agenda setting & adherence. seemed a consistentproblem for a minority of traineesand the reported reservations held by person-centred therapistson structuring, such a skill result was hypothesised as likely. On the other hand, psychodynamicorientatedtherapistsalso report this reservation and yet traineeswith initial psychodynamicpreferencedid not show such difficulty with Theseproblemstendedto persist in a minority of PCT structuring in assessments.

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learning modules have retake to and/or to assessments them resubmit trainees, causing higher The the CBT in rank areas. skill longer to all success take achieve to and thus likely to they the CBT achieve were more to pre-training, at trainees ascribed which order the CB least in at pre-training areas assessment skill some at better rates of competence between Differences order modality and rank stages. assessment and mid-training for did training significance the not reach and less of end at pronounced preferenceswere any skill or skill area. Overall, the influence of model preferenceand model ranking was consistent: e.g., CB in less skill areas, especially at many PCT well performed orientation a trainees with but trends these failed 11 were not setting, agenda when pre- and mid-training board. Analysis the across to of significance statistical achieve enough strong consistently is trainees indicated there that with of non-CBT model group a preferences order rank influence lowly CBT that they tend to of and tendency as a model rank a preferencesand in CBT for lower skills assessments competence achieving rates to attain significantly to attain overall competence. slower are and follow-up. training in tested of and end one year the Attitudes at pre-training, study were Skills were tested at pre-training, mid-training, end of training and final assessment. differences in of performance of some Differences attitudes were associatedwith some Both training changed skills as the and progressed. attitudes stage. pre-training at skills Positive changesin attitude were significant at the end of training and at follow up. Positive changesin skill acquisition also progressedas training progressed. Some from between in different differences trainees skill performance orientations significant but by facts These imply training. that factors at end of evident mid-training not were still have been deal the training to able with attitudinal period may connectedwith in learning but facilitated the that about model a way skill results examined reservations thus far do not tell us much about how and when this was achieved. The next chapter interviews follow-up 24 in the trainees the analysis of with presents period. The interviews throw some further light on some of the issuesanalysed in this chapter. Additionally, they present more reflective data on the trainees' experiencesof training:

165

found difficult how difficulties found helpful, in they they they and what what overcame training. The chaptertherefore presentsdata that relatesto the final researchquestion, D, of the study that seeksto explore what ways traineesreport surmounting difficulties learning CBT.

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Chapter

6: Trainee Perceptions

of the CBT Training

Process

Introduction during data interviews collected semi-structured of analysis This chapter presents interview The training. the trainees end of schedule asked after year trainees one with during The to, training. and alter analysis prior their experiences to reflect on from different 4 the between trainees the of answers orientation distinguishes different 3 into 12 these and consolidates stages responses of preferences at each in to the throughout chapter close sections which they are thematic charts, presented headings followed by in Data the category of various consists charts discussed. brief quotations from the interviews. The quotations, categories and representative in Iterative further the text the of chapter. category elaborated themes are development and refinement of categories emerging from the charts culminates in the Chart & Thematic Lewis, 2003) (Ritchie Central located towards the construction of a linkages in Discussion the whole of associations and the evident chapter. end of in Chapter 7 discussion interview takes that the place mainly so analysis of of process data may run in parallel with consideration of the quantitative where they overlap. data at the many points

Presentation of data from the interviews will be in three parts. Firstly, there will he data in Section to to the A of the the relation questions responses of of analysis interview schedule, covering pre-training factors. This will be followed by analysis of

data from Sections B, on experiences of training, and then, Section C, on how trainees have developed since CBT training. Particular focus will be devoted to tracing the thinking processes of trainees as they adapt to the challenges of CBT training.

Each quotation has an identifying

tag, including an identifier

of the gender of the

full A explanation of the identifying respondent.

tag is given with the first quotation

There interviewees 5 the page. are next on who began training with a CBT preference, 2 of whom are males. There are 13 interviewees who began with a PCT preference, I is There 3 interviewees, male. are whom of all female, who began with a psychodynamic preference. Similarly, with an Integrated/Eclectic preference. there are 3 interviewees, all female, who began

167

6.1:

The pre-training stage (Section A of the interview schedule):

Categoriesin the thematic charts were developed in an iterative process throughout analysis. The iterative processinvolved consultation with a group of colleagues and former trainees who read interviews, examined categories and made suggestions resulting in refinements of categories.The main categories that arose in relation to the how trainees' thinking about undertaking CBT training concerned pre-training phase developed:

* *

What rangeof ideasdid trainees'knowledgeof CBT come from? How CBT seemed to sit within that rangeof knowledgeand with their ideas current abouttherapy
How the training would fit with their ideas about how their careers develop might

How they consideredthat their employment situation might change as a result of CBT training.

6.1.1: Trainees with CBT model preference atpre-training:

for began CBT divided between Trainees training with a model preference who finding their first impetusto takeup CBT in either a training experience:
In the Diploma year, we did cognitive therapy (and)... I immediately realised that it was the theoretical approach for me... I have always gone about life addressing my thinking and questioning myself in a rational way. (476/F/A1/CBT')

or in experienceas a therapist:
I first got interestedwhen I worked as a social worker... in a behavioural unit... There was a psychologist there who was a behaviourist... I got some training... and got introduced to Beck's work during sometraining at Goldsmith's (597/M/A1/CBT).

They often recall an immediatesense of personal appealwhen they had first heard aboutCBT:
I do think that CBT fits with my personality because I believe that I am a pretty direct ... person (342/F/A1/CBT).

1The first number refers to the respondentnumber, the following letter tag refers to gender, the second interview location number to the the question of quotation and third (letter) tag to the orientation interviewee: In this case,Respondent342, who was female of the and reported an initial CBT preference, is answering question Al of the interview schedule.

168

for CBT, than these trainees began other models preferences with Unlike trainees who fit ideas how they their with what might were about existing about had no reservations CBT the had strong estimates and made of of They views positive very to learn.

CBT how typical When CBT. was, a responsewas: effective asked of effectiveness
9. (476/F/A4/CBT) 10,1 0 to a say would On a scale of

have to tended rejectedother models: Thesetrainees

dreary and vague ... and psychodynamic theory was so seemed all Person-centredstuff difficult to grasp (342/F/A2/CBT) I did not like the Rogers stuff much... it was very much like what I don't want to be like (358/M/A2/CBT).

CBT knowledge had this that of and felt they a grasp quite good that already They be by This training. could fit understanding refined or extended well with would further training and professionalism:
I thoughtthat the training would be an extension:more of the same,refining it, understanding it betterandbecominga betterpractitioner(358/M/A5/CBT).

They tended to stresscareer motivation and sometimes reflected relatively pragmatic

choices:
but the counselling I wantedto become a proficient practitioner... I wantedto specialise looked it, I if I the that the way was very, very general at was course can get psychology ... for counsellingpsychology... not kill two CBT qualification,I canoffset a lot of requirements birds with onestoneexactlybut satisfymy needfor training in CBT and move towardsmy (471/F/A6/CBT). status. chartered aim ultimate -

in fears about failing the the study,thesetraineesexpressed trainees Like almostall but develop to also stressed strong a motivation a recognised training course competence: professional
I hoped that I'd become competent at CBT... be able to implement it more thoroughly be a ... professional ... I feared that I wouldn't complete the course ... (342/F/A7/CBT).

I hopedthat the reputationof the courseand of CBT would help me to becomea professional therapist ratherthanjust a counsellor(346/F/A6/CBT).

the CBT orientedtraineesshoweda more pragmatic attitude to the In somerespects, training than of concerns other trainees: practical

169

I was about to do a course in the Midlands and then I realised that there was a more local one (471/A5/F/CBT).

have did Unlike othertrainees, thesetrainees relevant so not and wereself-employed

have They tended to training. reached their current comments on employer support of

idiosyncratic by quite position routes:

I had a pension from the Police and I did other coursesto be able to get some more money and pay my way through (358/M/A8/CBT).

In summary, the trainees with a preference for CBT entered the training with naturally learn it fit into how their they would would and positive expectanciesabout what from in independent These transition to paid trainees were often current practice. from had to employment and perhaps most gain allying themselves to a rising for jobs like CBT. They therapy competition were aware of and seemed to paradigm bank on the CBT training and the Masters degree helping them to secure other employment. They stressedmore pragmatic and career orientated motivations for doing the training than some other trainees.

6.1.2: Trainees with PCT model preference at pre-training: PCT trainees mostly came to hear about CBT in their initial counselling training:
I only really heard about CBT as such during the Diploma course. One of the tutors was CBT and did a demo session.I could seeit in action and saw that it worked (347/F/Al/PCT)2.

Or during the experience of doing therapy:

I started working as a student counsellor... I used the person-centredapproach and I became more and more dissatisfied with what I could offer students... I wanted something that felt a little more practical, I guess(472/F/A1-4/PCT).

I was having to do more short term work in my job and then, during the Diploma course, I startedtalking to another student who was into CBT, doing shorter term work and I was impressedby what she was saying (469/F/Al/PCT).

During initial training, they reported being introduced to the different models of therapy, some of which were congenial whilst others were rejected:
I never rejected the person-centredmodel but I did reject the psychodynamic theory. Something happenedin College but I was already very, very doubtful... The (psychodynaniic) tutor has said that there is always a hidden agenda... (In one group) we were discussing a case had 11 siblings and the tutor said, `There is something you've where the client all missed.

170

How many of us are there in this group? There are eleven! '... Most of us just looked at our We all sat there feeling about 3 years old (345/F/A4/PCT). boots. ... In the Diploma course, we did little sections on psychodynamic and then cognitive... when we did psychodynamic I thought I've never heard so much rubbish... cognitive (in) comparison... felt right for me... more scientific... not airy fairy, wishy-washy (349/Al/PCT).

instant PCT trainees introduced an personal to the often reported When model, appeal:
The Certificateyear for me was falling in love with Carl Rogers(345/F/A1/PCT)

limitations PCT identify began the however, to approach. of As time went on, some
hang Rogerian to to tended trainees that limitations on These were mainly practical so

for "more look the time practice: effective" same at whilst values,
To me, person-centred was effective because it chimed in with my values... but there was also but have ' I did kind `well hit that I'd kind doubt... now what? understand we of a stop of a being for had but CBT feelings effective my clients about concern more about mixed (343/F/A4-5/PCT). I had a very strong belief in person-centred to begin with but the doubts came in... (Especially) in relation to short term work... So I stayed with PCT but hoped that I could find better (469/F/A4-5/PCT). it integrate it, to things to work with make other

When these PCT oriented trainees encountered CBT, however, some of them reported

by CBT: the trainees to that preferring reported personal of pull similar a sense
but I had a I startedusinga layman'sversionof CBT... I liked the valuesof person-centred few doubtsaboutits effectiveness. I wasunsureabouttraining in CBT but got more optimistic as it got closer(347/F/A4/PCT).
I felt that I was more directive than other people (in the PCT training group). It wasn't enough Carl Rogers3.I thought that I could integrate CBT and that they would fit quite well (468/F/A4-5/PCT).

PCT trainees showed a strong attachment to Rogerian values though a lesser PCT to practice. The non-directive principle is a strong aspect of PCT attachment values. PCT trainees, along with psychodynamic trainees, often had entertained overt or covert reservations about how learning CBT would fit with the values of their current style of practice.
There was some fear that I was moving away from the person-centred model, having to be structured and set an agenda and all that raised anxieties... you're not just sitting down and saying, `Tell me your story. ' You know, `homework', how was I going to ask my client that? That was quite a drift from person-centred work. Would I be able to hold onto my personcentred values? (477/F/A7/PCT) 'This trainee was a French-speaking Vietnamese woman with a Welsh husband. This statement means `The Rogerian approach was not enough for effective therapy! '

171

We may alsonoticethat asthey reflect on thoseattitudesnow at the research

interview, the way PCT attitudes subsequentlydeveloped sometimes becomes apparent:
I am more of a goal-orientated person... I was worried that CBT was controlling and I struggled with that. I talked it over with one of the tutors and she said, `Are you getting confusedbetween directive and controlling? ' .... I thought, `Hang on; I am confusing direction with controlling' (347/F/A3-5/PCT). I think that it was first and foremost that CBT fitted my personality... Compared to Rogers it is more directive... but it isn't saying that you have to go in there with hobnail boots on.... Not overly directive - and that is nice... (When I did PCT) I tended to explore too many things and I'd end up not getting anything done (351/F/A5-6/PCT).

Theyweresometimes awareof CBT becomingmoretalked about in the professional

or wider community:
CBT had been in the media... Anthony Clare's radio programme and it just seemed to make sense.The qualification wasn't the priority for me; I wanted to be an effective practitioner (356/F/A6/PCT).

This group of trainees often did have reservations about CBT, but training in it also seemedto offer potential gains:
I was relatively late back into education and it was a way of developing me: it was a dream, to be honest, to go to a university and have the chance for a higher degree and maybe get some work out of it too. Wow, nice one! ... The hope was always to finish the course and get the qualification (346/F/A6-7/PCT). I wanted to achieve competencein CBT... I wanted to know the underlying theory... not a 6week effort; you know. If you haven't got the tools and knowledge behind you to do that, then that makes you a bad practitioner (351/F/A7/PCT).

Gains,however,frequentlyinvolvedthe risk of failure:

The main fears were all academic.I was afraid to apply, I didn't even think that I'd get on the course, never mind pass it (347/F/A7/PCT).

I neverthoughtthat I'd actuallyfail but I fearedthat I wouldn't be ableto do it well and that would havefelt like the wasteof a coupleof yearseffort (353/F/A7/PCT).

Other fears included the loss of previously hard won competence in a more reflective style of counselling:
I never feared that I might lose the relationship in CBT as many of the other person-centred inclined people did but I worried that the relationship might change in a way that I didn't really feel comfortable with, you know, like you could become a CBT automaton! (472/F/A7/PCT) I did wonder if CBT was a bit cold and impersonal but I hoped that they could be integrated (595/M/A5/PCT).

172

In contrast to the CBT trainees, most of the PCT trainees worked in organisations and had employers. Some of organisations showed some hostility to CBT:
Quite a few people in [the agency] were person-centred and very anti-CBT... They knew that I was doing CBT but it wasn't something to discuss very much! SECTOR4) (477/FA8/PCTNOLUNTARY

interested in fact the that their employees were being rarely very only Employers were it If was mainly there CBT. personal support, in was support: trained
form, CPD interest the just no real it signing of after that... My team a case Oh well, was kind but interest, that of personalsupportmore than professionalsupport was leadertook an (353/A8/PCT/PSYCHOLOGIST).

limited: kind werevery Support of a morematerial andrecognition

I'd by the time the done completed I'd training My employers that thought enough Counselling Diploma. They weren't particularly interestedin CBT and certainly not into giving me any money(345/A8/PCT/YOUTH WORK).
My employers did give me money to do the course - after a fight! - But there wasn't much interest in what exactly I was doing or in CBT as such. (472/A8/PCT/STUDENT COUNSELLOR)

In summary, PCT trainees entered CBT training with a mixture of hopes that training both fears CBT their that could prove practice make could more effective, and, inimical to their person-centred values and difficult to learn. Some began to recognise, however, that as well as a respect for person-centred values, they also leaned towards a more goal-oriented approach, as is stressed in CBT. Perhaps trainees attracted to had held PCT in they the that goal-direction position a slightly more pragmatic way so already begun to incorporate some CBT methods, such as thought records, even before CBT training (349/A3). Others, perhaps adhering to the more ideological version of PCT, feared that learning a structured therapy might lead them to lose their non-directive values and thus leave them in a kind of no-man's land - neither one thing nor the other. They could, however, see the possibility that some kind of integration of past and future practice might be possible "A way of working with losing on change without people a person-centred senseof warmth, " as Respondent 343 put it in answer to question Al. In spite of their fears, they expressed a strong desire to learn CBT yet reported comparatively little interest in how having CBT a benefit their careers. might qualification

For quotations on employment, a job/profession tag is added.

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6.13:

Trainees with a psychodynamic model preference atpre-training:

for initial Like mostothertrainees, trainees with an preference the psychodynamic

into having CBT therapy: came experience of model via either
I did a Diploma and it had a requirement for personal therapy... The counsellor that I went to used the cognitive approach and used imagery. Within the cognitive approach ... I worked on some health issuesthat I had and it seemeduseful (361/F/AI/PSYDYN).

doingtherapy: or from experiences

It began as a natural outcome to what I was already doing - working at Relate... In my (psychodynamic) training the messagewas very much `This is the only way to do things' I ... thought it was the only way... I was a sort of true believer, I suppose... I expected CBT to fit in with psychodynamic becausethey both look at the client's learning history. (355/F/A1-4/ PSYDYN)

CBT impressed by These the trainees efficacy evidence supporting yet weregenerally in their practice: to strand psychodynamic a significant alsowanted retain
I think that about 80% of clients benefit from psychodynamic therapy, 20% are left cold by it. (Later)... I began to get the sensethat some clients could really benefit from shorter-term work; things like panic and PTSD could be helped quite well in a format of 6 sessions.... My (psychodynamic) supervisor told me to change my language and suspendbelief (during CBT training). I was worried I might lose the stuff I'd learnt. (361/F/A4-5/PSYDYN) I felt that psychodynamic therapy did work but the sessionscould wander a bit. I was unsure how CBT might fit my practice (480/F/A4-5/PSYDYN).

Like manyPCT trainees, thesetrainees recalledhaving reservations about CBT by Persons similar to thosedescribed et al (1996):
I had a tendency to react very negatively to prescribed treatment and the treatment manual. It seemedtoo cut and dried and perhaps ignored the relational aspect of the work. It made me very resistant and I still think it is very important to find your own way of doing it (3611FB1IIPSYDYN). I feared that it might be cold and over-structured... I feared it (i. e., CUT) would seem cold and but don't it's I taking to that clipboard and pen that I couldn't mind notes my clients... remote get past... I might lose all my previous stuff and become regimented; they wouldn't be able to seeme! (480/F/A7/PSYDYN)

The psychodynamic trainees had similar employment backgrounds to some other trainees: mixing independentpractice with sessionalemployment (e.g., offering block `sessions' in units of 3 hours of therapy to employers like EAPs (Employee assistance programmes) and the NHS on several days per week. Some of these employers did show some interest in developing CBT but were not in a position to offer practical
support:
I was mostly self-employed at the start of the course but was doing some work for EAP companiesas well. I had no real practical support, you know with fees towards doing the courseand that sort of thing. One EAP company was interested in the CBT bit. I now work in

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the NHS part-time too: they are quite interested in CBT - that may have helped me get that work (361/F/A8/PSYDYN).

described interviewees had their initial orientation three In summary, there were who different One, to the they Psychodynamic responses rather showed questions. and as Respondent 355, had become `frustrated' (response to question A2) with the for impetus. She did theoretical a new very ready was and psychodynamic approach have many fears about the ideas or practice of CBT. Like respondent, 343, she felt followed in She how focus therapy. CBT understanding action on that could add more therapy, that she still valued about psychodynamic thought what could retain she also She training therefore the its the entered as a relationship. emphasis on namely desirous 361 Respondent `convert'. CBT more of maintaining much seemed potential her psychodynamic stance and saw the chance of undertaking CBT training in a more had developed Her towards strongly quite providing sessional way. work pragmatic in based interest for NHS. She the the evidence growing was aware of services `additive'. NHS CBT She in training therefore the as expected saw and she practice field. in Respondent 480 her CBT this training appeal that market would strengthen indeed 361 they shared the same type that to that took a stance of and was quite close did in They NHS express some of the reservations sessional work. of practice setting Persons (1996) but described by CBT PCT took trainees the and et al a many of about finding difficulties to these and of way a use view on overcoming pragmatic more CBT to their own and their clients' advantage.

6.1.4: Trainees with an Eclectic/Integrated model preference at pre-training: Eclectic/Integrative trainees also described being exposed to a variety of `schools' of therapy and being attracted to some and repelled by others:
I was doing a psychodynamic training and (after an incident on the course) I began to look at in terms of boundaries, supervision, experiential groups, I the whole thing... It spilled out ... just didn't feel it was held... personal therapy was part of the course but they told you which (and it turned out that these therapists)... were part of the organisation! therapist to go to ... On top of that, you were never told that you had to go to extra workshops, which, funnily enough, were organised by members of the organisation too. It just seemed so self-financing, self-perpetuating. You couldn't possibly think of doing counselling practice until you had been with them for 5 years. It just made me question the whole thing (357/F/AIIECINTEG).

175

For Integrative/Eclectic trainees,part of the attractivenessof CBT was its increasing practice. A case for Integrated/eclectic therapy reputation as a form of evidence-based is that one may `cherry pick' what seem like the most effective ideas and methods from different models. Though eclectic/integrative work was attractive, one of its downsidesmay be that it could defuse expertise and limit the scope of therapy:
I wouldn't say that I had a strong belief in its' (i. e., eclectic/integrated therapy's) effectiveness... I was a bit worried aboutjust dipping in and out and not doing anything as professionally as I might have... I had great hopes of CBT. It fitted me. I am a bit directive as a person so I neededto managemy CBT practice so I didn't come over as too directive (357/F/A4-5/ECINTEG). I thought eclectic work was good in some areasbut uneven and not very good for things like anxiety and depression... I thought CBT could add a lot to it... CBT gives you angles that can take you into peoples' worlds (473/F/A5/ECINTEG).

Thesetrainees expressedother more pragmatic career factors as motivations for doing this particular CBT training course:
The possibility of getting a Masters was an important part of it. It is a thing that is a big advantagein nursing right now, to be honest (360/F/A6/ECINTEC).

from employersasothertraineesbut did include Theyhadthe samemixed response leastonepositivestory of support:

My support was excellent. I got 50% fees and 50% study leave and they were often quite generousin increasing that. My senior nurse was very, very encouraging... they seemed far keener on CBT than all that touchy-feely stuff in counselling! (360/F/A8/PSYCHIATRIC NURSE)

at

In summary, the trainees who preferred an Integrated/Eclectic model at pre-training showed, as other trainees did, quite pragmatic attitudes towards learning CBT. They had rather mixed experiencesof trying non-CBT models including experiencing a lack of integrity of approach in working with multiple models. They also stressed the advantagesof the clinical reputation of CBT in obtaining what they considered personal professional advantage,for example in the NHS, as expressedby Respondent360. In her case,employers seemedto back her perception by offering greater support than had been offered to other trainees. 6.1.5: Pre-training: Data summary: In summary, trainees described embarking on CBT training as a result of either hearing about CBT during other training or from experiencesin therapy practice, mainly as counsellors but sometimesas clients. They were often considering other

176

humanistic therapy and making positive and or psychodynamic as such options initial Trainees for the with on offer. preferences options negative appraisals of doubt CBT the those than about effectiveness expressed of often other models CBT In this the evidence on seemed attractive. efficacy study, which against models, have CBT described in likely to the the reservations about trainees most PCT were including images McLeod, 2001), 1996; CBT being (Persons of as literature et al, in literature, however, CBT The the of efficacy cold. status over-structured and being it lead learning idea trainees towards that inspired the could more effective and in in For Psychodynamic the their strongly some, more represented work. professional linked to more pragmatic CBT training Integrative/Eclectic trainees, was and for it the trainees, whereas person-centred advancement, motivations such as career being linked For to the more effective practitioners. of satisfaction more seemed for began CBT training training motivations with a preference, trainees who both desire improve to of considerations and elements pragmatic career a contained practice.

Someof the traineesconsidered that their currentmodelscontainedareasof ineffective practice.Trainees'hopescentredon making positive changes to their by desire be to often accompanied a strong seenas more professional.Fears practice, by failing dominated as students were and/orpractitioners.For PCT trainees,there fear an additional of not making the transition in style from PCT, wasoften `non-directive', to CBT, characterised as characterised as `directive', an aspectof CBT practicethat seemed threateningto their previously held values. The degree of employersupportfor CBT training was generallyweak, althoughsome trainees weremostly self-employedandwere not thereforein a position evento claim Some traineesgot psychologicalsupportfrom immediatecolleagues support. but such few got much significant practical supportwith fees,other expenses or even leave time to attendtraining. The employerof only onetrainee,an NHS psychiatric nurse, of the 24 interviewedoffered anything like a commitmentto encouragingCBT training,backedby financial supportof the trainee.

177

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6.2:

The training period:

trainees the training morale anxieties the and of asked period about The questionson including the training classroom, practice and times different process, of at how They trainee's the ascertained perceptions of also experience. employment developed. CBT of weaknesses and strengths
CBT trainees training: Experience with a preference: of 6.2.1:

for CBT began training gavemostly affirmative with a preference Traineeswho

their at mid-training: experience of accounts
I was feeling pretty good because I felt that I was putting the trimmings on it. My tape The I I that. theory was no think, was pleased with so average above was, assessment favourable (342/F/B9/CBT) feeling I the So training. about generally was problem. I was chuffed becauseI did well in the assessment... and I was finding that CBT worked well with clients. (476/F/B9/CBT)

Only one of these5 traineesfailed to report this kind of experience.The in this was with assessment at mid-training evident particular account: preoccupation
I feared assessment... and then there was a hiccup with my assessmentwhen two tutors took different views on one aspect of my tape... I was relieved when it was resolved by the more experienced tutor who had come down on my side. (471/F/B9/CBT)

When asked what they thought had been the most valuable gains from training, as divided these between trainee trainees' the group, whole answers roughly equally with CBT CBT to The theory to connected and practice. references to CBT references theory were dominated by references to the conceptualisation (formulation) model in CBT. This was widely seen as being relatively clear and easy to apply. It was also seenas giving a clear theoretical spine to CBT work:
I gained a lot from the CB conceptualisation process. I saw that it was fuller and richer than I had realised: not just `here and now' but deeper elements from the client's history as well... the most psychodynamic aspect of CBT, I reckon (476/FIB10/CBT).

Conceptualisation also featuredprominently in points that proved most difficult in the training:
I sometimes wondered what exactly was meant by `conceptualisation'. Trainees seemed to have different versions of it, and so did tutors at times! (476/FB101CBT)

183

Anothermain areaof both gain anddifficulty was CBT practice.Various aspectsof the practicemodelwerehighlighted,including applicationsof CBT and using CBT
structure:
CB applications to problems like depressionwere most helpful. I thought to myself, `You are in Big School now' (342/]F/B10/CBT). The structure of CBT was interesting. I tried to use it all the time, as best I could. My previous style had been quite unstructured so that was a challenge but a rewarding one (597/MB9/CBT).

Other trainees mentioned appreciating CBT skill learning:

I liked skills learning via video and audio and getting honest feedback on how I had done (358/MBIOICBT).

A variety of otherissuesconcerning the actualtraining courseitself were mentioned difficulties: as

The sheeramount of material to be learnt was challenging, not to mention certain complex bits on researchmethods (342/FB1l/CBT).

Other difficulties concerned implementing practice. Implementation problems included remembering what one was supposedto do with clients and why one was in implementation it. do The theme to of over-deliberation was often supposed referred to:
I wasn't alwayssurehow andwhy I was supposed to targetcertainareas...Youknow, how lead for the client?(358/MB11/CBT) interventions to to change these supposed were
I found it difficult to move from very consciously applying the skills to a more natural forth of CBT practice (597/M/B11/CBT).

The crux of actually learning of CBT came when trainees tried to apply it with clients in their everyday practice setting. Some anxiety was attached to the assessment this of practice becausetrainees were continually looking for a taped session good and for There was also a more general to assessment. comprehensiveenough submit CBT in to make work practice. One question in the interview everyday struggle

asked

how well trainees found that CBT worked with their clients during training. Two themesthat arosein responseswere degree of success(how well CBT could work) (with CBT suitable of clients range whom would work). The trainees who had and begun with a CBT-orientation tended to report more uniformly successful practice

andsuccess with a wider rangeof suitableclientsthan othertrainees:

I didn't really come acrossmany clients who couldn't run with it (CBT), though I had to vary the pace and form of it with some clients (358/M/B12/CBT).

184

it it When worked, worked really, really well... but not with clients. most It worked well with (471/FB12/CBT). all clients obviously didn't time... the clients of some most respond to it but that was my CBT worked pretty well inexperience probably (597/M/B12/CBT).

by degree the the model are reflected greater applying of Reportsof successfully having theory the by training grasp of and practice a good at end of of feeling a sense for CBT: initial preference with trainees
lot... had lot. I learned I certainly read a as good a grasp of CBT as one year's felt a that I learning allowed (597/M/B13/CBT).

had CBT the largely trainees preferred the who model at pre-training In summary, from CBT having training they experienced that emerged a successful reported in felt They their confidence acquisition of skills and that they learning experience. in they the which areas of were able to use CBT. They had number had widened but training the Respondent 471 of were also critical areas many of some: appreciated have been `stronger' Respondent 476 found teaching could and skill some of thought Their formulation contradictory. employment on situations were teaching the having felt the training that had aided their they and/or qualification and changing 358 Respondents 597 had CBT-related posts for and obtained employment. quests for interview. finishing Respondent the 476 reported and coming course between interesting hunt told the job her qualification may of and to experience where starting in disadvantage that the been manager of the agency was less well qualified. a have The reports on employment seeking were perhaps signs that whilst CBT has made during the in period of the research, knowledge of and agencies many inroads

for CBT was still limited to certain agenciesand areas. preference

training: trainees PCT Experience of with a 6.2.2: preference: CBT, trainees the the person-centred trainees to preferring Compared

were more

likely to report some specific unfavourable experiences. These included the anxieties in Chapter 5, they were more likely and, assessment as reported with connected to fail items at all stages: CB skills assessment
Around that point (half way through) I felt pretty depressed and worried... I had been not failed on any piece of work for 15 years (595/M/B9 (/PC's. or referred

185

They also reported difficulty implementing CBT practice in their everyday client be both CBT Implementing that the was a challenge could structure rewarding work. and perplexing.
For me, it (i. e., the main difficulty) was the structuring of the sessions... One student said CBT is tidy and tidy is a good word for it; sessionswith a start, middle and end gave me an be done. (346/FB9/PCT) things that could experience I had problems remembering the structure we were supposedto follow... especially trying to fit conceptualisation into it. (472/FB11/PCT)

One frequently reported reaction was to try too hard and to over-structure the therapy, in has been (McKay training that tendency other studies reported et al, 200%, work, a

Henry et al, 1993):

lose for I dreadful... The assessment to trust in myself and I became seemed a while, was over-structured for a time... I had to do it 1,2,3,4,5... I couldn't play with it... The overall approach of CBT was neat and coherent. The clarity of Beck's thought and the way he used the underlying principles was striking to me (343/F/B9-10/PCT). This for me was the `confusion period'... I realised that I had been working quite willy-nilly with clients... Perhapsit was not so much `confused' and then I was probably trying too hard to be structured... (351/FB9/PCT)

Realising that one had become trapped by one's own stereotypical picture of CBT from detaching `trying too hard': oneself sometimessparkeda way of
I was a victim of my own stereotypeof CBT at time... I saw CBT as very rigid and this got in the way of me learning it for a while. I was trying too hard to be CBT (349/FB11/PCT).

decision had how handle SomePCT trainees to to this issue: make a on now
I realised... that I was not going to just swan through this one... I had to cut a deal with my aversion to the manualised approach and learn how to do the good stuff (595/MB9APC

As with other trainees, learning CBT formulation (conceptualisation) both challenged and rewarded PCT trainees:
I couldn't get conceptualisation at first and it drove me bananasfor a while. I think it was the jargon terms that put me off (347/FBI1/PCT). Before the course, I'd thought that CBT was just about fixing things, so seeing how conceptualisationcould drive the therapy was enlightening (477/F/B9/PCT).

Conceptualisation sometimesreferred to an idiosyncratic formulation of an individual client but the sameconcept was capable of use in understanding wider areas of psychological problems, such as anxiety disorders and depression:
I really liked going into the separateareassuch as depression and OCD the applications CBT. My former nursing self could connect with that... I really feel it of would have great to focus even more on that (472/FBIO/PCT).

186

have been included in CBT groups not always Skill learning and self-development however, been have, They 2001). the strongly associated with (Bennett-Levy, training for 1999) (Mearns, PCT training this and may account of nature experiential more it for PCT trainees: `confusion' surrounding the some of
Previous courses I had done had self-awareness work and I wasn't sure if that was supposed to be part of CBT... That question seemed to divide the trainees (346/F/B I1/PCT).

learning CBT focused more general of aspects of views about positive on Other points Trainees including sometimes mentioned specific skills: skills. practice, and theory
I liked the tools that CBT made available to me... I liked being able to identify cognitive distortions and use Socratic Dialogue (595/MIB10/PCT).

idea The `collaboration' in liked the the of skills were used. way was style They also in PCT in that they important trainees were practising not reassuring an especially directive manner: overly
The fact that I was helping my clients with CBT was really helpful to me, especially when it for done be example, writing conceptualisations with the client collaboratively, could (351IFB1OIPCT).

is individuality in the Rogerianmodel, because the of clients emphasised Perhaps

by fact had CBT idiographic that the trainees also reassured PCT were

conceptualisation:
I especially liked the way it takes you to what the client is thinking and feeling... about their situation... it was almost like putting a tap on, you know... And you think `I have got your internal dialogue here' and have accessto some ideas that might help with that

(353/FB10/PCT).

linked to a structuredtherapy They were,however,more wary of conceptualisation

protocol:
At first I was very resistantto the idea of following a CBT protocol... later I movedto seeing themas a sourceof things that I could try (595/MIB 11/PCT).

Other reported difficulties were more idiosyncratic:

I felt anxietyaboutall therewas to learn... for example,if you were dealing with a client with anxiety,then you hadto know aboutthe CBT approachto anxiety... In person-centred, the approach was alwaysthe same,no matterwhat the problem was. (356/FB11/PCT)

Trainees who beganwith a PCT preference reportedmore difficulties in implementingCBT, comparedto thosewho beganwith a CBT preference.Whilst distinct success: somereported
It fitted like a glove really... It worked very well with most of my clients (347IF/BI2/PCT).

Others reportedmixed success, sometimesin directions different from thosethey'd expected:

187

I guessmixed results really: funnily enough, [Agency - previously reported as having many, had it because lots fit into they of anxiety more clients would anti-CBT] workers who were and depression.(477/FB12/PCT)

Perhapsbecauseof these mixed results, PCT trainees described slower resolution of

training difficulties asthey movedto the endof the training process:

There were still some difficulties that I hadn't completely resolved - for example, but have I then there was still some anxiety about these since solved skills. conceptualisation them. (477/FB13/PCT)

Others,however,sawthemselves ashaving comethroughtheir sense of dissonance:

I was over my little crisis by then. I had found my own way of doing CBT instead of having to `follow' it. My work started to have a good solid feel to it (343/F/B13/PCT).

Suchgrowingconfidence waseasierto sustainwhen concreteresultsaffirmed

progress:
I was definitely working in a different, more streamlined way... I was losing fewer clients and got more measurablechange (346/FB13/PCT).

Though for some confidence remained high even when reverses occurred:
I was so angry with myself for not passing the final tape first time... just silly things that I had forgotten to cover... but I knew it was just a bad tape, it didn't stop me thinking that I could do it (468/FB13/PCT).

PCT trainees were more likely to report on-going anxiety even after passing their assessments:
I felt quitereasonably confidentat the endbut I knew that I still hadthings to work on. I have in myself: eventhoughI had passed the final tape and I this funny thing aboutconfidence could seeothershadn't (356/FB13/PCT).

In summary, the PCT trainees mostly negotiated the CBT training programme did, fluctuations As trainees they reported other successfully. and anxieties during the & Beedie, 2007), (Bennett-Levy especially those connected with process implementing CBT in a way that was congruent with their values. Some saw benefit in adopting more structure for therapy and were able to loosen their value constructs do to this relatively easily. For others, there was more of to them enough allow a senseof crisis, often coinciding with the actual periods of skill assessment.Various strategieswere employed to surmount these crises, including moving away from `trying too hard to be CBT' (351) to allowing oneself leeway to `play with, implementing CBT. These problems, however, probably did delay the acquisition of competencefor some of the trainees. In some casestrainees retained a distinct awareness of distinct weak spots even when they had passedassessments (343,477).

188

6.2.3: Experience of training: trainees with a Psychodynamic preference: Trainees who began training with a psychodynamic preference shared many of the

including learning trainees the at mid-training, anxiety other of of and experiences

being assessed.
I did think that I had got the actual basic idea of Apart from being terrified of the assessment, it andthat I could useit... I was startingto feel quite excited. (480/F/B9/PSYDYN)

fewer however, PCT they trainees, Unlike the reservationsand were now reported beginningto find favourableaspects of CBT, oncetraining was underway:
The (CBT) structurewas very helpful. It was goodto be clear with the client and write things down.I found it helpful to think aboutwhat homeworkmight be helpful and addedthat on (3611F/B10/PSYDYN). I foundthe CBT conceptualisation and use: for example,for panic, I model easyto understand be helpful. It The to that... clear and write things down. I was good structure was very use still found it helpful to think aboutwhat homeworkmight be helpful. (361/F/B9/PSYDYN)

They reportedgainsand difficulties in both the theory and practice of CBT similarly to other students:
There is a lot of material to learn and because of my enthusiasm I always want to learn it all... which of course is impossible (355/FBI1/PSYDYN). I had a tendency to react very negatively to the idea of `prescribed treatment'. It made me very resistant and, I still think it is important to find my own way of doing it (3611FB11/PSYDYN).

implementing CBT with clients They did, however,report more mixed experiences of than someothers:
It worked sometimes and sometimes it didn't... I had a tendency to want to try it on everyone I met (3551FB12/PSYDYN). Well, I knew it wasn't seamlessbut it was `good enough'... My style had certainly become more distinctive... I was able to be more upfront with clients and explain the rationale of what I was trying to do. It seemedto work pretty well... I was always keen to assessfor suitability and that is something that I have stuck with as good practice (361/FB12-13/PSYDYN).

The threeintervieweesfrom a Psychodynamic backgrounddid well in overall

at mid and end of training - failing to demonstrate competence on only assessment item between the three of them. This item was retrieved at the first one opportunity. They generally reported successful learning experience, which has resulted in one, 355, `converting' to CBT, whilst the other two, 361 and 480, report using CBT more pragmatically and retaining psychodynamic elements to their practice. 480, however, was one of the only 3 trainees who had gained CB therapist accreditation by the time

189

done have These interviews, trainees also though the so subsequently. more of reported some difficulties in implementing CBT that are similar to those reported by PCT traineesbut they did not describe them in terms of protracted crisis, as some of

had. the PCT trainees

6.2.4: Experience of training: trainees with an Integrative/Eclectic preference: Trainees with this preference appraisedprogress at mid-training in a similar way to CBT and Psychodynamic-orientedtrainees but were more favourable than PCT trainees:
items and was naturally a bit gutted... but... I thought I would get there in I failed assessment the end with the practice skills. It was the academic work that had me more worried. It is something that I have always struggled with (360/FB9/ECINTEG).

They were attracted by both the theory and practice of CBT:

I liked the structure of CBT andbeingableto write notesand draw diagramsand work in a way (473/F/B10/ECINTEG). very focused

Whenreportingdifficulties aboutlearningCBT, they quite often referredto their

in CBT to training than training general. Interestingly, this was course rather specific the only point in the interview where respondentsdid this. Several referred to skill

learn development trainees to were encouraged where skills via experiential groups, difficulties. CBT trying other's skills on each work: essentially
I felt exposed I foundthe small groupwork on skills difficult because at time. I'd have liked to chosen whom I workedwith. (473/FBI I/ECINTEG)

Attempts to implement CBT practice with clients were generally successful but, as with other trainees, the question of client suitability arose:
I worked in a hospice and not all clients were suitable... but some did work well with it... my supervisor was a bit anti and that didn't help. Retrospectively, I think she was a bit threatened by my training (357/F/B12/ECINTEG).

These trainees reported having a reasonablegrasp of the model by the end of training but reported still needing to work on some aspects:
I reckon that my practice knowledge was good but I wasn't so sure about theoretic knowledge ` but then I have a personal issue there doubting my own thinking power and all that ... (473/F/A13/ECINTEG).

Employer responses to trainees at the end of training evoked disappointment in this group of trainees,as in others, but there was at least one more positive story:
My employers have become quite interested... (And eventually) paid some of my fees. There a psychiatrist who is researchingtreatments for PTSD, including CBT. They gave me him... Some is interesting It sessionalwork with really I work... and will probably look to go even in (360/FB14/Psychiatric more specialist time nurse).

190

traineesreporteda positive learning experienceand although The Integrative/Eclectic in did in learning delayed difficulties that result acquisition of they reported difficulties. been is had It to these they that overcome able noticeable competence, difficulties knowledge based the with academic and they particularly reported by They but the training. expressed more confidence about posed skills challenges for importance CBT. the client suitability of assessing also noted 6.2.5: Training stagesummary: Therewere striking similarities in the way traineesfrom all modalities reportedtheir having Most tended to trainees training. types report of similar of experience overall CBT. Quite items difficulties theory the the practice of often and such with gainsand both therapy formulation were specified using structure as a gain and a and as difficulty in training, indicating a challengingbut eventually rewarding learning however, did difficulties PCT trainees, report more and anxieties about experience. learningCBT than did traineesfrom other modalities. They also reportedless feeling Although than trainees. confidence and other most traineesstarting with a of success have did CBT, PCT did the trainees about preference reservations seemto non-CBT that relatedto a sense havereservations of threat to strongpersonalvalues,relating issue is in in `who ' (5951M). the therapy? to of charge often
Most PCT trainees, however, report that a process of working through these difficulties was emerging as they approached the end of the training period so that the be in final to the able successful were course assessments.A relatively small majority however, have to continued minority, problems and therefore faced having to make further skills submissions and thus were delayed in the acquisition of competence. CBT-oriented trainees reported these difficulties much less often than PCT trainees. The results for the other two modalities, Psychodynamic and Integrative/eclectic, be and may mixed seen as falling between the CBT and PCT groups, though were thesesub groups also involved a lesser number of trainees.

191

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The post-training phase:

The categories in the thematic charts relating to the post-training period were indicated degree had that themes the to trainees transferred which around organised into from training the their current practice situations. This learning course their involved distinguishing how they now referred to themselves and their practice. This defining for involved terms the their act of current practice and examining question One described `converting' into trainee CBT terms those were used. a sense of so why (Atherton, 1999). `supplantive' Others training the was referred to a degree of that increasing CBT practice effectively that had supplanted aspects of their practice, CBT `additive' dimensions training as to their saw adding others extra whereas but leaving intact. The development types areas of other of work practice current of involved in to the they themselves extent related was professional activities practice involvement CBT Active here implied strong the professional community. within development but lack CBT involvement did not necessarily of of active post-training imply that post-training development in CBT was weak. Exploration of perceptions of the impact of training were categorised around the width and depth of such linked these to perceptions of how CBT and evaluations were often engagement develop in future. the might practice

6.3.1: Traineeswith a cognitive behavioural preference at post-training:

When asked whether they now called themselves CB therapists, these trainees largely in answered the affirmative and also often referred to a dynamic between selfdescription and description by others:
Yes, most definitely... In my job, I'm called a `counsellor' but I think of myself as being a cognitive behavioural therapist (358/M/C15/CBT). I am actually employed as a `counsellor' but I think of myself as a cognitive behavioural therapist... it's a slightly tricky one... with titles you get into a status thing (597/M/C15/CBT).

The statusissuereferredto aboveimplies advantage in the use of one term over This meantthat sometraineeshad carefully another. consideredhow best to `advertise'themselves:
Oneof the first things I did wasto get the words `CBT' on my businesscard... It is also the way I advertisemyself in Yellow Pages (3421F/C15/CBT).

Furtherquestionsaskedtraineesaboutthe extentto which they use CBT in their currentpracticeand how they saw their practice developing in the future. Most of

197

these trainees reported using CBT with many of their clients. Some gave percentage between 100% Most 50 their that current client workloads. of and estimates ranged increasing CBT the as time went on and some took the chance to record saw role of be directions like happen to to taken: they might or speculateon which what might
I use CBT in about 80-85% of my work. The only situations that I wouldn't use it in would be in casesof bereavementand things like that... I haven't been able to get the sort of post that I would really like yet but I hope that when I do, CBT will be a predominant factor in my work (476/F/C16-18/CBT).

It is known that the effects of training may be lost through inertia and atrophy if the trainee does not keep up links with the subject area in the post-training period (Ashcroft et al, 1999). A key aspectof maintaining links with the CBT community was the relationship that trainees developed with BABCP, the UK national professional association for CBT. BABCP has an accreditation process, which is body for by UKCP, the chief national automatically endorsed psychotherapy. Completion of the course helped trainees to satisfy some of the criteria for by by both BABCP and the British Association for Counselling and accreditation Psychotherapy(BACP). BABCP has a journal and runs conferences and workshops on a local and national basis. The main themes in the answer to this question concernedwhether trainees were current members, the reasonsfor and against either joining or being an active member, the extent of membership activities and the claims interviewees 24 16 `rival' the of reported being current BABCP of organisations.

initial CBT 5 bar trainees an with preference members one were members- all to non-membersas for the group as a whole: actuallythe sameratio of members
I am a BABCP member and do go to conferencesand meetings. I like BABCP more than BACP (British Association for Counselling and Psychotherapy) it's full of `earth mothers'! When I deal with the NHS, I stressmy CBT credentials (342/F/C19/CBT). I'm not in BABCP right now. I plan to put more energy into BPS (British Psychological Society) at this time. That could changelater (471/F/C19/CBT).

The final question of the interview askedtrainees to describe whether they thought that their view of CBT had changedas a result of training and also to assessthe impact of the training on them. Changing views of CBT dependedon what their original view of it had been. The biggest changeswere reported by those who began with reservations about the model, most of which had greatly reduced after training. Most trainees reported that training had a big impact on them, their practice and their careers.For trainees with an initial CBT preference,though, there was less of a conversion effect and the impact of learning CBT was secondaryto getting higher a

198

degreeor to move towardsprofessionalaccreditation,though both factors helped traineesto feel more competentand professional:
I see CBT as more comprehensive... It had had a big impact on me and my confidence. I- feel like I have the authority of the University behind me... I feel more professional and that (342/F/C17/20/CBT). in work my shows I saw it pretty much as I saw it before I actually admired some of he practitioners I have seen. I went in wanting to be more like them... (The training) had an absolutely huge impact impact had feel but like I I even of an on more me personally... perhaps professionally... (3581M/C17/20/CBT). better lot now a understand

for began CBT were the the training trainees the with a preference In summary, who for CB Even however, therapists. them, likely themselves there to were call now most They legitimacy title. the that the recognised using significant of about questions in for define that, their these ways and certain other work purposes might people other be They definitions, than their officially would sanctioned. own, rather also other describe a desire to expand their use of CBT and generally move towards more CBT They has that the training make engagement. clear and professional practice oriented had a big impact of their careers and lives but also suggest that that process began before the training

6.3.2: Trainees with a person-centred preference at post-training:

For the PCT trainees,the questionaboutusing the term `cognitive behavioural therapist' to describethemselves than amongstthe evokedmore ambiguousresponses distinction They between the groups. modality showed same other self and other
definitions but were often less sure than the CBT trainees about what self-description they favoured now:
It is hard to say about that. I would but my agency wouldn't... acceptable term to them (351/F/C15/PCT). `Counsellor' is a more

I usethe term `counsellor'but if I were doing private work, as I hope and plan to, then I would usethe term `CBT' (356/F/CI5/PCT).

The issueof gaining advantage by using one term rather than anotherhas meant that PCT traineeshavealso considered how best to `advertise' themselves: some
I call myself Integrativenow. I'm in the processof designing little business a card ... and I'm thinking of putting CBT on it (477/F/C15/PCT).

Somefound the issueof using the CBT title embarrassing:

I can't sayyes or no. I find it embarrassing... I may be underplayingmyself, I think (468/F/C15/PCT).

199

A significant minority of the PCT trainees were genuinely undecided and, perhaps how they their to and time situations themselves new consider sensibly, were giving handle them: to wanted
No, not really. I find it hard to get used to the idea of being CBT... I still use the term `counsellor.' (346/C15/PCT)5

Yes,I do usetheterm but it doesn'tmeanthat muchto me. It is what I do, not what I am (347/F/C15/PCT)6
I think the honest answer is I don't know. BecauseI have thought of developing a private integrative I Or CB therapist now? truly I therapist. am more an practice... could call myself a (595/M/C15/PCT)

Oneway roundthis dilemmawasto try a doublebarrel solution:

I do, well I'd sayI'm a counsellorwho doesCBT. I am That's a tricky one.Sometimes thing that goeswith it (472/C15/PCT). thinking aboutall that now - there'sa status

Interestingly, in the period since the interviews, two of the above interviewees, 346 CB Perhaps, UKCP become therapists. have BABCP 347, registered and even at and this stage,the PCT trainees were allowing their practice to run ahead of their claims about their practice status, certainly many reported that they were stepping up their CBT work by extending the range of clients with which they might apply CBT:
I work with a majority of patients (as a counsellor attachedto a health centre) using CBT, though not necessarily in a pure form... it has to fit in 6 to 8 sessionsfor a start... it could grow but I'm not in any hurry... there are other things I'd like to expand as well (345/F/C16/18/PCT).

I havebeenusingCBT with mostclients(in a studentcounsellingcentre)for a while now. The students really like CBT but it may not be suitablefor all... (Mentionsclient with cancer)...I amhopingit will grow... I am still readinground it (472/F/C16/18/PCT).

From employers, PCT trainees, like others, mainly got only small glimmers of disappointment is distinct in there the way this is reported: sense a of and recognition
(I felt) a bit deflated really. I got my certificate... and took it over to give it to them (Human Resources).And someonein the Office said thanks. And that was it. I felt there should have been more... They still... don't value counselling... they still think it is tea and sympathy... (4721FB14/University counsellor)

Someinterpreted thesesignsof a lack of recognitionas an indication that it was time to moveon. Othersachievedimprovedjob statusa little later:
They announcedmy successin the staff meeting... but otherwise no immediate change... then they wanted CBT people and a graduateand I got the job of actually writing the programme (351/FB14/Drug agency counsellor).

6 This trainee CBT therapist abouttwo yearsafterthe interview. alsobecame a registered

This trainee becamea registered CBT therapist one year after this interview.

200

label but CBT jobs that had carried a even so were starting to Some actually obtained
develop, they to of practice might styles perhaps other showing a what return consider therapies: the of range whole amongst search
Oh yes a lot. I am working at [a private hospital] and do individual and group CBT all the time... I do so much I can hardly imagine doing more... Actually I do see the value of doing doing I thinking things... of group analysis as my next `thing' (347/F/C16/18/PCT). am other

began training with a PCT preference report a more the trainees who In summary, developments. This be due fact to the may that partly of post-training varied set first 347 346 in like the the the study and so more were of and cohort cohort trainees is known about their longer period of post training development. The PCT trainees developing CBT but less be this to about practice confidence some of appears a show diffidence CB There is the therapist. about claiming status of a comparatively genuine little discussion of any on-going reservations about CBT but rather some reflection on how they overcame their reservations. It is clear that the outcomes of practice will be in degree is CBT for terms the to of this group of trainees. which varied used more This group seemslikely to consist of some who will go into CBT practice in a major way whilst others, perhaps the majority, will continue to `play with' their degree of it. with engagement 6.3.3: Trainees with a psychodynamic preference at post-training:

Traineeswith an initial psychodynamicpreferencegavemore decisive answersto the how describe to themselves of as CB therapists: question
Yes, I put `CBT' on my business card and `counsellor' too (355/F/C15/PSYDYN).
Yes, I put CBT on my business card as soon as I had passed the course. Some people did it before! I also call myself a `therapeutic counsellor' (480/F/CI51PSYDYN). ...

One of these trainees, had, moved some way toward CBT practice but wanted to make pragmatic use of such practice:
If anything I now see myself as an integrated therapist... though I might stress my CBT credentials if I were talking to a doctor (361/F/C15/PSYDYN).

Estimates of how far they usedCBT currently varied widely from 10% to 80% of clients. They also estimatedthat their views of CBT had shifted considerablybut 2 of the 3 respondents, continuedto describereservationsabout the `structured' aspect of CBT:
My preconception that it (i. e., CBT) was very mechanicalhas because I have found that I gone canapply it in my own way. I am still a bit worried aboutthe `manual' approach (361/F/C17/PSYDYN).

201

The above trainee demonstratedthat she regarded CBT as `additive' to her practice so that it would remain to be basedin the Psychodynamic approach as a first influence. Shetherefore aimed to keep the degreeto which they practiced CBT steady at the CBT in limited level the community engagementwith and planned only current future:
The NHS would like to have more of my CBT and me but, to be honest, I don't find that an attractive option... I am a member of BABCP but my allegiance is more with BACP to be honest... CBT has turned out to be a useful tool in my tool-bag. It has made me acceptable to employers like the NHS and EAPs (361/F/C17, C19 & C201PSYDYN).

Another trainee with an initial psychodynamic preference described her original

believer', for it `true that as of a shenow refersto herself as a `convert' preference to her currentinvolvementwith CBT aslikely to increase: anddescribes
It (i. e., CBT) will play a big role in the future.... I am a convert really... I am a member of BABCP and... I would say that the training has transformed my career and my practice. It has altered the way I think about all sorts of things, including my own life (355/F/C17, C19 & C20/PSYDYN).

In summary, in these 3 trainees we seemto seethe full range of positive responses to training in a new form of practice. Using Atherton's (1999) terms, one trainee (355) had adopted a `supplantive' approachto CBT training and was effectively converted into another model. Respondent361 has adopted a clearly more `additive' approach: she has retained her adherenceto Psychodynamic theory and practice but has also'* made a pragmatic adaptation to CBT with a weather eye on current shifts in the perceptions of service providers and potential employers. The third trainee, 480, has between these other two points on the continuum. She an probably made adaptation has maintained a leaning towards Psychodynamic practice but has also developed an enthusiasmfor CBT and, additionally has become a registered and accredited CBT , practitioner. One might seethis as either a stageof dissonance- holding two different ideas at the sametime - or as a stageof maturity. She terms herself at the interview as `Integrative' -a position sometimesheld as one that transcendsnarrow school

loyalty.

6.3.4: Trainees with an Integrative/Eclectic preference at post-training: Traineeswith an initial preference for the Integrative/Eclectic orientation

showed a

more pragmatic approachto the matter of how they now labelled themselves as

202

in lay that Some could appreciation of advantages an show answers practitioners. lead to they though different conflict: could sometimes self-descriptions: claiming
Yes, I got told off about that (i. e., calling herself a CB therapist)... I think cognitive behavioural psychotherapy sounds posh! Some people in the NHS don't like that! (360/F/C15/INTEGEC)

how decided if descriptions in to they of and use when evident also Pragmatism was CBT as part of their Integrative/Eclectic practice:
About 50/50 I'd say. It depends which environment I'm working in. I work in a hospice and I don't do much CBT there... I believe that CBT will always be there and I'd like it to develop. I'm interested in specific areas like social phobia... I'd like to do a workshop on that (357/F/C 16/18/ECINT E G).

highly been having CBT training a significant part of their was seenas Although development it the development, of a varied and as part of wide seen range was career into organised a personalportfolio: of practice,professionaland educationalelements,
I am not a member of BABCP. It is the money that stops me. I am a member of BASRT (British Association for Sexual & Relationship Counselling) that to also offers a route ... UKCP (United Kingdom Council for Psychotherapy) accreditation (473/C19/ECINTEG). I see CBT about the same as before I guess... The course had an enormous impact but I think that it more having the Masters that really does it for me... it is the MA that will have most effect on my career (360/C17/20/ECINTEG).

In summary, trainees who began the training with a preference for Integrative/Eclectic therapy show most similarity with the psychodynamic trainees in their descriptions of has had CBT training a clear impact on them and CBT their post-training experiences. has taken on an important role in their post-training practice. Once again, a degree of is CBT is into evident and seen as gateway certain favourable positions in pragmatism the current arena for therapy. These trainees most clearly articulated interests in other (357), as such rehabilitation work research (360) and sexual and couple matters, therapy (473). They seem to be developing a well-rounded portfolio of different helping the skills within profession and CBT has been an important professional set of skills alongside their other skills.

new

6.3.5: Post-training summary:

In summary, the traineesall reportedthat CBT theory and practice still had a impact on them at the time of the interviews, around one year after considerable training.A rangeof different responses was evident in the answersto the questionof how they termedthemselves astherapists.The number of traineespreparedto declare

203

themselvesas CBT practitioners showed an increase over the level of declared CBT preferenceat pre-training. It was also clear that there were some quite complex micro and macro political nuancesto choosing a name and that these might run alongside or in deciding how inclinations. Some trainees the were still process of counter personal. to handle these issuesand it was clear that it is a processthat may take several years to finally resolve. Others had clearly decided to limit any claims to being a CB therapist and to seeany CBT that they might offer as mainly `additive' to other therapeutic or professional skills.

The extent of the impact of CBT training on trainees varied between, on the one hand, full-on being doing CBT themselves therapists seeing as mostly CBT therapy with their clients and, on the other, seeing CBT as a useful arm of integrative practice and/or of wider professional skills. Most of the trainees kept up or planned to keep up contact with professional bodies promoting CBT in some way, though quite often at the sametime as keeping up loyalties with other therapy organisations. Whilst a CBT dimension had been incorporated into the post-training profile of all the interviewees, there was also plenty of evidence of a healthy pragmatism: stressing the CBT `credentials' when it was advantageous to do so, and stressing other aspects of theory and/or practice when it wasn't.

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Developing a central thematic chart During data analysis, the author was struck by parallels between the research is itself. Central CBT therapy to the theory the a process and practice of questions and is associatedwith a consequencevia a mediating state antecedent whereby an influence. Curiously, both the behavioural and cognitive arms of CBT have CBT. Behavioural `ABC' ABC different to type analysis analysis of contributed a behaviour works on establishing a pattern of antecedentevent - consequencesof behaviour (Sheldon, 1995). Cognitive ABC analysis works on establishing a pattern belief & Dryden, (Ellis 1991). The in consequences parallels of antecedentevent fact in began be findings the the trainees that training with the seen may my behaviours, therapeutic of attitudes and antecedentsof one set usually set within an happens in during (mediating the training something or occupational context, event) of new therapeutic attitudes and behaviours. and often leads to the consequences

The author therefore used an ABC format to construct the central thematic chart for

Figure 6.1 with which to concludethis chapter. in the preparationfor CBT training, The CentralThematicChartshowstypical stages follow, it by the intervieweesin that the the experience asdescribed of and outcomes this study.A variety of responses areevidentat eachstage.Obviously, not all trainees showeveryresponse at eachstage.
This final section of the chapter will begin by presenting the chart and then discussing its nature and showing how the movement of trainees through its various stages can be followed.

210

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The Central Thematic Chart representsvarious routes from pre-training deliberation how to engagewith training, to the experiences of the process of on whether and training itself and then finally to the way the trainees and their practice develop after training. Discussion of the chart will follow the sequenceof the boxes in the chart from left. discussion The to will conclude with consideration of running right movements between the various boxes.

Engaging with the training experience: The interviews show that the trainees approachedtraining with various expectations, motivations and reservations.Expectations, motivations and reservations in the chart but banded in their combinations are also shown having are shown as most usual degreesof overlap: some trainees may have combined many reservations with a strong motivation to overcome them.

The motivation to undertake CBT training was strongest in the CBT-oriented trainees - Interviewees 342,358,476 and 597. Interviewees 342,358 and 476 had from CBT in been tutors their previous more generic teaching to oriented all exposed training in counselling. They all noted feeling a personal responseto the teaching becauseit seemedto appeal to their personality style - in being `direct' or 'businesslike'. Interviewee 597 had learnt some CBT during in-service training whilst working in psychiatric social work. The other CBT-oriented trainee, Interviewee 471, differed interested in in that was she pursuing general counselling psychology somewhat training with the British Psychological Society (BPS) and saw this training as a prerequisite to that aim.

Motivation was almost as strong amongst a group of trainees with other preference models but also close to `conversion' to CBT. The PCT orientated trainees, Interviewees 346,349,351 and 356, showed awarenessof shortcomings in the person-centredpractice and saw CBT as having the potential to, for example, focus directionless. Interviewee 351 worked in an agency linked that seemed work to the Probation service, where the CBT approachedhas been adapted as a priority (McGuire, 1995).

212

CBT the model were evident More mixed motivations and more reservations about 343,345,353, Interviewees, PCT trainees, interviewees. orientated the other amongst `directiveness' the the 595, of abut reservation all mentioned 468,469,472,477 and issue `values' being the same of and an as These qualified were CBT. reservations issues. them as practice of had view pragmatic more a trainees had in love `fallen Carl Rogers' initial her during training with 345, who Interviewee did for that therapy, she mentioned example, had psychodynamic rejected and for her in CBT training counselling post-Diploma than options other consider in had her the she CBT which completed college option was available at training. The included in Other lived. training options, other Diploma and was close to where she located but her been have to values were current closer types of therapy that might fact had local the that The she and distance course a of convenience away. some CBT her through about meant that she adopted reservations begun to work some of Her the training. be to train with motivation engagement pragmatic called might what her having by her regarded CBT as undertaken in employers who was not enhanced her current role. By the time of the interview, she had moved into for training enough health CBT in care, where primary was regarded as another work setting, counselling definite asset. a Mixed motivation and reservations were also held by the Psychodynamic orientated trainees, Interviewees 361 and 480. These reservations also concerned structure but, unlike the person-centred reservations that typically centred on structuring sessions, focused interventions, on structuring psychodynamic reservations were more in form The the treatment resistance to protocols was of protocols. especially ignored based interventions when protocols on uncovering childhood exacerbated history. Interviewee 355 however entertained few reservations. She had been `true believer' in Psychodynamic therapy. She was a therapist trained as a previously having just moved from another part of the country to the years standing and of many in based, the which course was area, well motivated for a change of therapy style. She showed strong engagement right from the start of training. She enjoyed the training thoroughly and `got hooked on CBT fairly quickly'.

213

The Integrated/Eclectic-orientated,

Interviewees 357,360 and 473, had good

integrating fears few CBT learning about specific reported and about expectations CBT into their practice.

Experiences of training: by described training their experiencesof was characterised The way interviewees by followed learning attitude three main themes: experiences;periods of confusion elaboration; experiencesof academic and, particularly, skill assessment. By and large these were characterisedby responsesthat were mostly positive or interviewee feelings. No showed a mostly negative responsesshowing mixed response.

The CBT oriented trainees tended to report the most positive responsesto training did holding began they taught, they because the were they paradigm as same not and They doing in also reported experiences. mainly well elaboration attitude many report for fillip 342, Interview to the example, referred of confidence that came assessment. from realising that she had performed "above average" in the mid-course skill in failing interviewee 358, item Only this group, reported a skill one and assessment. do he he in that the therapy and was therefore that the then could realised context even item. One CBT-oriented this of about re-assessment respondent, confident but this arose in Interviewee 471, did report feeling some anxiety about assessment, the unusual context of two tutors apparently disagreeing about an aspect of her work.

In contrast, the PCT-orientated trainees reported many more mixed experiences of, both training and assessment. The fears about not being able to square CBT with person centred values were particularly stressed,especially during the early phases of training. Interviewee 349, for example, described a series of doubts that she had to work through, as did Interviewees 343,345,353 and 477. On the other hand, these, doubts were often coupled with a senseof growing confidence in the second half of training, as mentioned by Interviewees 347,351,468,469 and 472. The theme of a lack of confidence about both the self and in relation to learning CBT was strongly Interviewees 356 trainees these and and 472 both mentioned representedamongst

lingering senseof self doubt even after successfully completing skill assessments. Given that lack of confidence was a strong issue with this group of trainees, it is not

214

is frequent for that anxiety of about assessment mention also made surprising 343,346,356 477. Even by Interviewees and a very confident trainee such example, he failed items 595 Interviewee the reported anxiety when some of mid-course as he had failed first for He time that the anything years. many wisely assessment be he `swan to through' this training. that not able would concluded Of the Psychodynamic and Integrated/Eclectic

oriented trainees, only

Interviewee 480 reported being anxious, indeed `terrified' of assessment.These trainees were more likely to report difficulties with academic work, as did Interviewees 355 and 360. Interviewee 361 reported a phase of thinking, `I can't do this' and considered leaving CBT training. As she passed all her skills assessments first time, this anxiety was more likely connected to reservations about CBT her her discussing She these to take supervisor, with who advised reported principles. the pragmatic position of putting her reservations to one side and see what she could find of help in CBT. This she resolved to do.

Attitude elaboration processes Attitude elaboration processeswere not evident amongst CBT-oriented trainees but

by The PCT-oriented trainees. detailed the particularly reported most were descriptions came from Interviewee 343 and have already been described in Section 6.2.2. Such processeswere also evident in the accounts of Interviewees 347,477, Many 595. PCT trainees had strong reservations about whether CBT contravened and the principles and values of `non-directive' therapy advocated by the Rogerian model.

Interviewee 347, a trainee who began with and stuck to PCT values, describes an interaction with a tutor in which she re-examined and then reframed the meaning of `non-direction'. Interviewee 351 describes coming to a similar realisation herself by coming to see that CBT was `not over-directive' and that, after all, it did not advocate `going in there with hob-nail boots on. '

Amongst the Psychodynamic-oriented

trainees, the concepts of CBT made senseto

Interviewee 355 and she began to quickly make use of the basic CB model on the between thoughts, emotions and behaviour. She was then relation able to use that model to explain to clients what underlying factors might be driving the panic attacks 215

her that As training these with congruent were experiences they experienced. well as did fit to had dissonant the not seem model experienceswhen expectations,she also for some clients. She began to realise that she was over-applying the model and that this was partly becauseshe still had much to learn about using it. She was able to step back from this type of over-application through a process of elaborating, discussing discussion, through her to case original attitudes practice and reformulating that through the methods and she was concepts sifting generally supervision and learning. In contrast Interviewee 361 held reservations about CBT and made a more it. learning to pragmatic adaptation A more pragmatic approachto learning was also evident in the Integrated/Eclectic both had 473 360 Interviewees trainees, of whom and strong career oriented former directions in the as an experienced psychiatric nurse and the agendas other latter as a sex therapist. The other trainee from this group, Interviewee 357 had come into training from a businesscareer and saw that learning CBT was helping to convert into more of helping professional. Attitudes reflecting reservations about CBT do seemto have some ability to delay biggest The training other outcomes. perhaps and specific competenceacquisition

in detected between trainees the this that that was amongst study was clash an the skills of `settingan agenda'. aversionof being `directive' andmastering
Interviewee 477, a trainee with an initial PCT preference, describes evolving a I mantra -'I must set an agenda, must set an agenda!' - to say to herself as she went into sessionsto help her overcome this tendency.

It is interesting that very few trainees reportedany problemsaboutsettinghomework, thoughthis may be regarded asanotherform of agenda setting- but one that comes at both traineeandclient are in more attuned the endof a session, whenperhaps
interpersonal contact and are therefore more relaxed. The main fears of PCT-oriented traineesin CBT are, firstly, that being overly directive may make the therapist seem like an over-bearing `expert', and, secondly, it could disrupt a trusting and

between therapeutic therapistandclient. collaborative relationship

216

Experience in the post-training stage: by interviews the themes was from of characterised the phase Data post-training identity CBT their how trainees and professional practice after adapted relating to themselves their they key A call would what and concerned question training. degree feel inclined they to the to the turning which should use on practice, obviously `CBT' in Most their trainees this themselves of `CB and/or practice. therapist' of term `counsellors' themselves this had as and offered a regarded previously sample does CBT'. is Duality in label the also who evident way counsellor -'a compromise for balance CBT but their describe the most saw practice, plenty of space of trainees for `other It be have things'. thought that to might space even anxious also many were CBT, be there the would also advantage of market advantages though many stressed duality in There the way trainees thought things. being to was also in able offer other how thought them thought they about others themselves and about - some retained CB but label `counsellors' themselves clearly regarded as now as the external interviews, Five 342,346,477,353 the of therapists. and 480 described redesigning label. The business to of extent of an emerging cards accommodate changes their CBT professional identity was also evident in the degree to which trainees connected CBT BABCP, the the community, via association, professional conferences or with supervisory activities.

The CBT-oriented trainees, such as 342 and 476 were the most firm in claiming the title of CB therapist. Interviewees 358 and 597 had jobs title as `counsellors' but CB Interview 471 themselves therapists. saw as was once again the maverick clearly in this group. She did not call herself a CB therapist and continued to aspire to the status of counselling psychologist via BPS accreditation. She was not a member of BABCP, whereas Interviewee 342,358 and 597 were and 476 intended to join as finances as allowed. soon

For PCT-oriented trainees, post-training practice and,professional stance were influenced by the extent to which initial reservations about CBT training have been worked through and also by the relative smoothness with which CB competence is Good experiences tended to lead to practicing CBT and becoming engaged attained. with various professional group activities such as association membership, pursuit of accreditation and conference going.

217

interview but the PCT time the of at began stance she training with a Interviewee 346 `conversion This CBT therapist. a brink was partly of accreditation as a was on the by been had it that but substantial rewarded was a conversion experience experience' Wow, degree higher `... get some work... and maybe a pragmatic and career gains: looking for Indeed it trainees ' were who new nice one! as she put so succinctly. CBT find did it find their than to to status of recognition easier employment seemed fact. the their to trying of same employers current trainees who were appraise Similar patterns were evident amongstPsychodynamic-oriented trainees. The `conversion' experienceof Interviewee 355 has already been referred to. By way of follow interview, herself `Integrative' 361, had Interviewee at up as reported contrast, difficulty and saw some advantagesof wearing a without undue attained competence CBT badge as far as certain employers might see it, but maintained only a pragmatic like how describes her CBT to vary she and, others, might work commitment is `I CBT if I were talking to: to might stress my credentials she whom according talking to a doctor.'

The CentralThematicChartis a usefuldevicefor conceptualising the various

in described interviewees how this the their engagement with CBT study of elements in different training at stages the process.There are recognisable patterns through these stages,ranging from passing from expected strong commitment to realised

throughto expectation of pragmaticcommitmentto realised strongcommitment,

between. is It likely that different types of and, points commitment, also pragmatic trainees make different types of journeys. Some trainees particularly may want to key issues in therapeutic the CBT how such as relationship addresssome and they do this may influence how they proceed.

Some possible pathways between the stageswere not evident in the interviews

- no

trainees described following pathways from weak engagementto non-practice. This is following because trainees such a route were a small minority and were less probably likely to participate or be interviewed in the study. A psychodynamic-oriented trainee, Interviewee 361, did however mention that the dissonanceproblem had been so great for her that at one stage she contemplated leaving the course and was only dissuaded

218

interviewed because Another trainee her by who was not external clinical supervisor. did dissertation had her during doing tell that the me she a major crisis still was she felt her CBT. dealt She that she could not resolve reservations about course when she from by `off for the sick' course this going about a month and seriously situation with did, however, She in her though succeed returning. working contemplated not to the made a successful return eventually complete and course. reservations The processesdescribed by the Central Thematic Chart are probably generic ones that learning described types them to those of situations: some many of match may apply by McKay et al (2001) in their qualitative study of counsellors changing existing dynamic interpersonal learn therapy). to models

Pathways of change through the stages:

Psychological therapy is often described as being predicated on change (Horowitz, 2005) and training for psychological therapy assumes changes in the trainees' behaviours, though and some will always resist change. Change and attitudes frequently in interviews. to Looking at Figure the change are mentioned resistance 6.2, we can see evidence for both. There are some changes in colour from pre to post training stages,yet many trainees retain their original allegiances. Looking at the trainees who report having changed, one is reminded of the `swing voters' who frequently seem to decide elections (Dalton, 2006). In this `election', where after all had all the campaign expenses and a favourable position that outweighed all one party floating has CBT (346,349,351,356,468,355, the towards most of vote gone others, 347,472,480 and 357) but there are also some pleasingly `local' results: 477 changed from PCT to Integrative, 361 from Psychodynamic to Integrative, and, finally, 471 from CBT Integrative. The allegiance change of 361 indicates that all to changed psychodynamic-oriented trainees did actually change allegiance in some way. This is because the well known and well rehearsed differences between the two perhaps models would mean that anyone contemplating training in the other model was certainly contemplating change.

219

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Chapter 7: Conclusions

7.1: Introduction

background It by begins the the continues of context and study. This chapter restating how brief then the author was by offering a shows summaryof previous studiesand in The this that to these identify the studies study sought address. chapter gap to able followed by brief the the results of of main study, consideration resume then offers a in the limitations the study. used methods of the of The chapterthen considersthe implications of this work for further researchand data involves by This the the the and validity reliability of examining collected policy. be the to the to the study results of might generalised which extent other and study
by The chapter concludes offering some reflections on the populations and contexts. implications of the study for training in CBT.

7.2: The Context of the Present Study: This was a longitudinal study of 3 successive annual cohorts of trainees who enrolled basis in behaviour to training therapy (CBT). CBT undertake cognitive voluntary on a is one of the four main broad schools of psychological therapy available in the UK It by countries. was preceded psychodynamic therapy, coming from the and other Freudian tradition, and by person-centred therapy (PCT) from the humanistic tradition. Integrative/Eclectic therapy attempts various combinations of these other traditions and emerged about the same time as CBT. The four broad schools share ideas and methods but also have distinct points of difference. There has been a some history of competition and co-operation between these four broad schools. Conflicts between them have ebbed and flowed over the years. A degree of conflict between CBT and the other traditions has occurred in recent years as CBT has been accorded increased status as the UK medical profession has promoted claims for the efficacy of CBT - claims that other approaches have found hard to match.

The currentpolicy proposals,initiated by Lord Layard, to increasethe UK provision of psychologicaltherapyin generaland CBT in particular (Linklater, 2005) have been resistedby the other approaches, naturally though it has beendifficult for them

221

from to gains to formulate a policy as they themselvesmay stand make some

expansion of services.
by fact been has the that they tend different exacerbated between division The schools though there training are also organisations, have and to separateprofessional Psychotherapy for Counselling Association British and organisations, such as (BACP), the British Psychological Society (BPS) and the United Kingdom Council

(IJKCP) that try to unify nationalstandards. for Psychotherapy

Training in psychological therapy may become one of the arenasin which the differences between models may make themselvesfelt. Trainees have first to decide is be best for kind training them training then will such and whether of what is based Sometimes find trainees that training on will a course conveniently available. differences different ideas These familiar to those that they with. are already a set of in ideas and methods may lead to complications in training. Usually, however, trainees are quite well aware of these differences and will select themselves out of for differences ideas in they that may prove problematic estimate situations where their progress. Sometimes, however, other factors, such as locality, cost or convenience,may not allow them to select their ideal course.

Anotherthrust in recentgovernment policy, actually a forerunnerof the Layard

initiative already mentioned, has been the promotion of evidence based practice in in but these to psychological concerns, most germane many professional activities, based is 1996). The & Richardson, that thrust (Parry practice of evidence therapy practitioners should be aware of what the current evidence says about various least best implement to the treatment to at refer or treatment options and should seek for the most suitable patients. This is by no means as simple as it sounds. Keeping up for the busy findings is task, practitioner with especially a arduous an with research known fields in to keeping load. are Professionals struggle many with everyday work have been therapists fields in date psychological their and no with research up to hard interpret findings to Research often are and may be exception (Persons, 1995). for indicated An referral source interpretations. an different appropriate open to for features CBT find. treatment, example, be hard strongly in the to treatment may from in suffers is and uneven but geographical supply literature short efficacy

222

distribution (Shapiroet al. 2003)'. For an individual practitioner, it would be difficult be that the might methods to spanall neededto provide an effective service according Finally, from therapists the different traditions often do not acceptthe these to criteria. for base traditions other and may want to rewrite the rules about what sort of evidence Some have truer `evidence-based the that picture. even argued gives research practice' by `practice-based (Mellor-Clark, be 2004). evidence' replaced should Theseprofessionalpolitics do impact on the choicesthat traineeshave to make when interviews for In the this study to training conducted pursue. consideringwhat sort of traineesoften referredto a perceptionthat CBT was the `coming thing' and that
CBT in NHS, taking the on as a treatment of were government services, especially CBT For leaned in theory and practice, towards trainees, some choice. who any case this seemedvery serendipitous, especially when they had access to a training course homes 15-20 in to their there this the time the were only study, near cohorts of - at directions, in leant in For trainees the a those other who such course centres country. local course in CBT might have still seemed quite serendipitous, in that it might allow CBT to be attached to the trainee's portfolio and lead to a higher degree into the bargain. In making a calculation about whether to sign up for such training, a trainee neededto make an assessmentof likely gain as against likely loss.

There is a discourse within psychotherapy outcome research that argues that there are differences in outcome between psychotherapy models - the `Dodo bird significant no (Luborsky et al, 2002). Not all agree with this line of argument (Hunsley & verdict' Di Giulio, 2002), especially advocates of CBT (Chambless, 2002). The argument that the main models of psychotherapy have equivalent effects is an influential one in the therapy world and might encourage trainees to disregard, or at least make light of any differences they might have with the therapeutic paradigm that they might be in to absorb a particular type of training. In a nutshell, this discourse expected declares that therapeutic outcome is most influenced by `common factors' mainly connected to the therapeutic relationship. It is further argued that therapeutic technique is not important, does not contribute much to outcome difference, and that therefore all therapies are equally effective. In a conclusion that conveniently
Shapiro et al (2003) report that there were 602 accredited CB therapists in England & Wales in 2003.

223

downplays inter-professional rivalry, this discourse ends by suggesting that `Everyone has won and all must have prizes' (Luborsky et al, 1975). Thus trainees may have hoped that CBT techniques could be added to their current repertoire of skills in some form of integrative practice, either of an eclectic type or by combining particular far How CBT. Psychodynamic CBT, trainees PCT with or with as models, such depend CBT therapeutic `live on exactly what might they practice thought with' could held Many in how held them. trainees they this they strongly and currently attitudes CBT but did hold that therapy variance at with principles were about attitudes study because Others low that into CBT any was not wide. gap risk as saw the move

do CBT to too the about choosing that and agonised wide prove might gap worried decided in this that the risk was Self-evidently trainees the training. studyeventually
for decision for One than it some taking though others. closer was a might worth holding training however, type that whilst of reservations might undertaking a expect,

in learning adversely. someway, perhaps affect

7.3: Previous studies:

Therehasbeena gooddealof literatureandstudieson the role of orientation in

1999; Goldfried, but 2000) & Mytton, (Dryden therapy not much of it psychological has centred on training. Most of the studies of training have been of comparatively:. CBT Mackay In training, training about not study, et al (2001)2 one recent origin. `change how tried to person-centred counsellors of a group models' by examined learning Interpersonal dynamic therapy. This study focused on the difficulties do by Although to they this. the study was trainees as attempted experienced concernedwith a different set of attitude changesthan the one in this study, the traineesreported some of the same senseof difficulty in changing attitudes. Some also hard' difficulty `trying too to take on the new model and thereby the of mentioned blocking the development of actual learning.

Personset al (1996) described the reservationsabout CBT reported by trainees wit

psychodynamic background as they undertook CBT training. This was a qualitative describing focused theoretical and practical reservations that on report mainly about .., CBT. For example, a major reservation was that attempts by CBT to alleviate
2 SeeChapters 3&6.

224

`work to try therapists than uncover and might as psychodynamic symptoms, rather like that deeper a sticking over a wound putting plaster was conflicts, through' CBT (1996) that these Persons also suggest reservations about al et required surgery. for doing during they training be and suggest a mechanism so overcome can discuss their to then by them trainees reservations, surface and encouraging namely, The in CBT and experimental way. a gradual process of surfacing and methods to try likened be to the way problems of cognitive dissonance discussing reservations may One dissonant 1999). is (Atherton, in training dealt way of resolving attitudes with are (1986) `elaboration likelihood' Cacioppo & by Petty as an described process, and is in lasting likely Petty & Cacioppo to shifts promote attitudes. a process advanced as be by changed persuasion whereas centrally (1986) argue that peripheral attitudes can important attitudes can only usually be changed by an attitude elaboration likelihood have argued that these processes are well (1996) & Mejia-Millan Heersacker process. in but has therapy the to change psychological client analysis explain not yet placed been applied to training in psychological therapy, as far as I have been able to imply in (1996) Persons do the that trainees their many of al et study ascertain. but CBT do describe they how towards their they ambiguous attitudes not resolve derived their data about this and they do not describe any outcomes of this training in knowledge or acquisition. terms of skill

Knowledge acquisition during CBT training was described in the study by Freiheit & Overholser (1997). They studied the responsesof 3 annual cohorts of US clinical from trainees coming a variety of model preference positions to training psychology in CBT. They measured their therapeutic attitudes and their knowledge levels pre and They found from different training. that trainees post model perspectives learned the in model similar ways and reported roughly similar changes in their practice. Freiheit & Overholser (1997) did not, however, include any assessmentof CBT skill in acquisition their study. They commented that future studies should include analysis of skill acquisition.

Morgenstern et al (2001) studiedhow a group of drug counsellors,mainly following the AA twelve stepmodel, responded to CBT training. They found that traineeswere their previousmodel basesufficiently to be able to learn mainly ableto transcend CBT concepts and skills. Thesefindings were, however, 225 quite specific to the context

drug than the drug measure rather specific the work a used study counselling and of Cognitive Therapy in CBT the training, usual and standardisedskills measureused Scale (Young & Beck, 1980,1988; Milne et al, 2001).

The study described in this thesis therefore built on these preceding studies and included all their major elements,overcoming the limitations of previous studies in included. been It had 3 the explored attitudes not of another which one element or from CBT trainees, a variety of practice settings and model perspectives, cohorts of by administering questionnairesand by conducting semi-structured interviews with how had been focused they trainee Interviews successful of perceptions them. on also in overcoming their reservations during training. The CBTTQ questionnaire contained Inventory (CBPI) Principles found Behavioural that Cognitive inventory, the was an development the internal have allowed of therapeutic and to consistency strong -from be to followtracked one to year post-training pre-training trainees attitudes of development CBT their the The acquisition of of skills, using up. study also measured Milne 2001) (CTS-R: Scale-Revised Therapy Cognitive et al, at pre, mid and end the in described the The preceding chapters were study, as methods of of training. by data these methods allowed examination of The collected transparentand clear. development describing therapeutic focused the of on attitudes, researchquestions CBT skills and the interaction between these two factors. Interviews also allowed traineesto reflect on the training process,including on factors that seemedto help hinder them in attaining their various goals.

or

In summary, previous studies on CBT training with trainees with non-CBT therapeutic attitudes stressedthat attitude differences could be overcome by the, training process,though they have sometimes made light of the differences and have tended not to describe how trainees resolved difficulties that might arise from them. Personset al (1996) described psychodynamic reservations that are founded in deeply held attitudes. Personset al (1996) implied that such reservations maybe overcome but doesnot say how. In contrast, discussion in this study has focused more on the because counsellors, mainly of person-centred reservations of their predominance in the counselling field. It also describestheir reservations about CBT in depth. Additionally, the interviews offered the trainees an opportunity to describe the extent to which they had resolved their reservations and how they had achieved this. The

226

findings has Mackay (2001) in to the to similarities of et al that relation emerges story interpersonal in Additionally, therapy. this study psychodynamic training counsellors has focused on CBT competence development. Only one other study, Morgernstern et they included to (2001) ratings, and used a measure specific working competence al (2001) did focused Morgernstern et al not make precise and with alcohol problems. development. In contrast, this study makes between competence links attitude and between links therapeutic the attitudes and certain execution of specific skills specific how identify tutors to is about therefore make recommendations can and able and delay for that competence task-interfering may acquisition attitudes work with trainees in CBT.

7.4: A resume of the main results of the study The datain this study was collectedto answerfour researchquestions: 0 What attitudesdo traineesenteringa CBT training coursehold towards
CBT practice principles and how do these attitudes develop during

training and in the year following the end of training?

0 With what level of pre-existing competence in performing the skills

do CBT CBT trainees training and how practice enter associated with do theseCBT skills developduring training? 0 What kind of associationand influence do model preferences and the
attitudes towards CBT principles held before and during training have in the development of competence in skills associated with CBT practice. What characteristics of CBT training and development do CBT trainees report as being most likely to lead to the resolution of difficulties in learning CBT during training?

It was hypothesised that traineeswould hold different setsof therapeuticattitudes, someof which would be likely to be difficult to squarewith CBT attitudes.It was also hypothesised that CBT- incongruentattitudeswould causesomedifficulties in learningCBT skills. Finally, it was hypothesised that, as adult learners,traineeswould to someaspects of experientialand self-directedlearning, combinedwith respond learning of skills and techniques. structured

227

The CBTTQ data showed that the trainees in this study began with a variety of model began 14%, trainees the with a of preferencesand that only a small minority, largest half the Almost for CBT. the trainees model preference subpreference largest (PCT). The Person-centred therapy sub-group was that next group, preferred Only 12% Integrative/Eclectic 26% model. trainees an who preferred of the of interviews In the Psychodynamic the questionnaire and many the of model. preferred PCT and Psychodynamic trainees showed that they began training with significant to the CBT theory connected structure especially practice and reservationsabout focused behaviourally CB CBT fact therapy in CBT, that goals and the promoted used

interventions. in time circumscribed aimedto achievethesegoals relatively

Although most of these PCT and psychodynamic trainees modified these reservations time the trainees, CBT scale as same other much over a competence and attained found initial PCT the transition trainees preference, with of more minority, especially in to some casesrequiring extra periods difficult and were slower attain competencefollowing Trainees in began the academic year. to who modules of assessment retake by preferring CBT showed strong and growing agreementwith CBT principles over the period of training and were the model preference group that proceeded to Integrated/Eclectic Psychodynamic trainees took and most quickly. competence intermediate positions between the CBT and PCT groups in both growing agreement CBT the CBT competencies. acquisition of principles and with Analysis of the acquisition of the skills of CBT identified by the CTS-R (Milne et al, 2001) showed that trainees in this study generally moved quite quickly towards Thirty-two 55 58% the trainees, competence. of of them, demonstrated overall overall competenceat the first opportunity. A further 11 of them, 31%, achieved competence by resubmitting for further assessments. The remaining 6 trainees could retake by following in the academic year. All 6 trainees were able to do, modules enrolling this successfullybut this meant that they had taken twice as long to achieve had 32 demonstratedoverall competence in trainees than those who competence CBT skills at the first opportunity. Five of these 6 trainees began training with a PCT preferenceand one with a psychodynamic preference.The mean training completion times for PCT trainees, 11.54 months, and Psychodynamic and Integrative/Eclectic _

228

longer for traineeswith CBT model preference, 10.71 than were months, preferences, differences these though were not statistically significant. 9.38 months,
defined it by CTS-R, CBT individual the that skills, as showed was more Analysis of in for to trainees competence some skills than others. Pre-training difficult acquire did training to that trainees arrive at already able showed skills of analysis demonstrate competence in some of the skills associated with CBT. The CTS-R distinguishes between `General Therapy' and `Specific CBT' skills. In general, developed This therapy general skills. training was not more with trainees arrived at for basic to in skills was a that requirement entry counselling of a mastery surprising Agenda-setting Some therapy in the skills, such as and the general of study. the course Pacing, are, however, less associated with the humanistic models of counselling to been Trainees had trainees the exposed. showed particular previously which many of difficulty with agenda setting and this constituted the most persistently failed item of beginning in Although the CTS-R this of training trainees showed at study. the difficulties these to they resolve were able more quickly than problems with pacing, they were with the problems associatedwith agenda-setting. Larger numbers were items Guided CBT discovery, lacking Formulation such as skills, as specific assessed behavioural Applying methods, at pre-training, though these skills cognitive and and Although, learned training. towards trainees were more able to the of end rapidly were Eliciting Eliciting less the they and emotions, skills of cognitions were perform Eliciting behaviours. be blind There to with appeared a spot to behavioural successful work even among these trainees in CBT. The skill of setting homework was demonstrated by a surprisingly high number of trainees at pre-training and was not later for the other trainees. to master problematic

The difference between the competency acquisition rates for agenda-setting and homework is particularly interesting. Both are concerned with structuring the setting therapy, the former is a device for opening the structured therapy session and the latter a device for closing it. Amongst the individual CBT principles of the CBPI, agreementwith the principle of structuring therapy was the weakest recorded agreementlevel for any principle. Reservations about structuring were particularly by stressed trainees who began training by preferring the PCT and Psychodynamic low This level models. of agreement was evident in both responses to the CBPI and in

229

interviews. frequently Trainees described during the semi-structured commentsmade CBT. They the of also referred to strategies structuring requirements a struggle with Although these to agreementwith the structuring principle was struggles. used resolve it for PCT lower Psychodynamic trainees than trainees, was amongst even Psychodynamictrainees mentioned the issue less in the interviews and gave the impression of a more pragmatic adaptation to this requirement. PCT trainees really in in the interviews to competence agenda-setting achieving and seemed struggle with directive by fears to their with clients of appearing overly setting an agenda referred interventions. directive CBT Non-directiveness has been and undertaking other more (Rogers, 1942,1980). In PCT the approach contrast trainees had a prime principle of few reservations about setting homework, which was widely seenby trainees from all for It the possibility of change clients. as enhancing might also be preferences model that more skill disruption is causedby the agenda setting requirement because it = before has had the therapist the time to settle in with the session of start comes right at the client. In effect, it requires that the therapist takes some degree of control of the having from the yet a senseof mandate to do so. In without very start, sessionright homework, has had the trainee therapist to more contrast, with regard setting

land' likely to `lay the interpersonal the the to and ascertain client's of get opportunity do homework. being to to asked response
A number of important issuesare suggestedby this comparison of requiring trainees to set agendasand homework. Firstly, it seemspossible that various skilled behaviours are influenced by specific task-interfering attitudes and cognitions, hypothesis' `cognitive links, for the specificity as example, `depressogenic' cognitions with the emotions and behaviours of depression (Beck, 1976). In this case, specific attitudes doubting the desirability of structure in therapy will Particularly, interfere with skilled behaviours focused on implementing structure. Secondly, the extent of disruption of skilled behaviour may be affected by contextual factors such as the sequenceof expectedbehaviours. In this case,behaviours expected to be demonstratedat the start of the sequenceof CBT behaviours, e.g., Agenda setting, may be more easily disrupted than behaviours that are expected to be demonstrated at the end of the sequence- e.g., Homework setting. Thirdly, attitudes that are highly salient for traineesmay be particularly hard to suspendwhilst trying out a new skill.,

rather

. PCTtrainees frequent `person-centred to reference made values' during the intervie, `,S 230

by having that these threatened to showed values often seemed these references and These CBT comments often showed a sense of threat and approach. implement a described almost frantic attempts to resolve the sense of crisis that came in wake of discomfort be dissonance. the Such understood as of cognitive crises may threat. Atherton (1999) has described how trainees may feel more threatened by new learning i. designed ideas behaviours be `supplantive' to to e., replace current or that appears ideas behaviours. designed to `additive' existing operate alongside or than Processesof resolving contradictory ideas may be facilitated by Socratic dialogue, in in 1998) (Nehemas, discourse and therapy (Beck et al, 1979). It may also both general be that experiences of resolution are facilitated by understanding changes in attitudes (Petty & Cacioppo, 1986). In likelihood the process contrast to elaboration through by described interviewees trainees, the one of psychodynamic some the senseof crisis `change language her to to take advice your supervisor's on and suspend seemedable disbelief' (361/A5) - an altogether more pragmatic approach which in effect accepted dealt be by less trainee with might requirements central cognitive process. that certain

The interview data showed that trainees approached training in CBT with differing degreesof idealism and pragmatism about how far they would absorb CBT principles The held trainees methods. majority of some reservations about CBT and and practice these were likely to raise a degree of cognitive dissonance in the learning process. Some did regard the training as more additive' and some as more supplantive (Atherton, 1999). An additive perspective was that CBT concepts and methods might be integrated with current methods to evolve an eclectic form of practice or that they integrated be by combination with another model. A supplantive perspective might CBT that methods would be implemented in a more complete way that may accepted well eclipse certain previous elements of practice. A trainee who perceived the training requirement in this way could therefore fear that previous competencies

could

be lost and a number of interviewees made this observation (for example, Interviewee 472 answering question A7).

The imperative to learn CBT in a through way sometimes challenged the additive perspective, precipitating a senseof crisis in some trainees. Sometimes trainees by `trying hard too to be CBT' (see response of 349 in Chart 6a) responded and becamebecalmed by anxiety and over-rigid attempts `to do the tutors as said'.

231

it finding described by dilemma described their Trainees this way out of also who
This back them to training. the towards allowed step adopting a more relaxed attitude from trying too hard and then allowed them to `play with' the CBT model and find it least Such implement their a point. as stating own version of -at ways to better increased lead to skill performance. to and confidence manoeuvresseemed Trainees often seemedto find these processesof attitude shifts for themselves. Occasionally an attitude shift was aided by comments from tutors and other trainees,

formal by training processes. than rather to reflect on their experience The interview also allowedtrainees of implementing
CBT after training. Many reported permanent changesto their practice and on-going Others the CBT professional association. via the community engagementwith little CBT the in with wider engagement and reported partial changes practice herself Christian, `convert' to referred One as trainee, to a committed community. is it instructive few to reflect on this perhaps expression, CBT. Though others used (2006, 89): by Blomberg `A `conversion' definition p. radical suggested of the -

behaviour, belief of group affiliation of conductand, reorientationof convictionand in did ' Though trainees belonging. these show changes all most not areas,most and in someof them: including the degree to which they practiced', did refer to changes in work patterns, CBT, changes andpersonalengagement andprofessional with the CBT community.The degree to which they followed thesedirectionsoften related had further in backto their pre-trainingpreference CBT they the direction gone a further they went on now. the previously,

The study also collected data on employment factors, particularly on the degree to which employers had encouragedtrainees to get training specifically in CBT as a form of `evidence-based practice.' There was little evidence of such employer influence, especially in the first cohort, 2000-2001. Employer influence was somewhatmore evident in the final cohort, 2002-2003, and also in the interviews, when a number of trainees reported professional progress after training through achieving CBT accreditation and/ or new employment that was more CBT-related, 7.5: Implications of the study for further research

232

in training psychological therapy - that as yet has not This study exploredan areabe It that as the current emphasison questionsabout may beenwidely researched. is increasingly therapy to consensual so more attention can psychological effective best development into training to the types the of suited support of turn to research Such implement therapy. researchwill needto consider effective therapistswho can Future be helping to trainees change models. some will researchers able the reality of lines it but before is build this suggestions about making of such research, study to on to reflect on the validity and reliability of the data of this study and first necessary during have issues this that arisen research. methodological someof The work on establishingthe validity and reliability of the CTS-R competence in Chapters described 3 4. been has referenced and and extensively measure
The concepts of validity and reliability are used somewhat differently in quantitative but have (Ritchie & Lewis, the same underlying meaning research and qualitative 2003). Validity refers to the extent to which the concepts being targeted are being be held There to three types of validity: criterion are commonly truly represented. (de Vaus, 2001). Criterion validity content validity and construct validity, validity how in to the responses measure question match with existing measures examines known to be valid. Content validity examines the extent to which a measure relates to Construct in the review. of under concept validity refers to the a wide range meanings extent to which the measure conforms to theoretical expectations.

The CBTTQ questionnaire and its accompanyinginventory, the CBPI, were new devised by The the the study. contentof the CBPI was basedon a measures author of for CBT that havebeendevelopedby Beck and his associates principles setof over forty years(Beck, 1967;Beck, 1976;Beck et al, 1979;Beck & Emery, 1985; nearly Beck, 1991 a; Beck, 1995;Beck, 2004). Somelimitations of the CBPI have already but nevertheless, beenacknowledged the measuredid conform to theoretical in discerningclear and significant differencesin the expectations way trainees to the inventory before and after training. All accounts CBT responded of stressthat it is a fusion of generaltherapyskills, including interpersonal effectivenessand the capacityto form therapeuticrelationships,and more specifically cognitive behavioural technical skills. Both the CBPI and the CTS-R containeditems relatedto 233

both generaltherapy and technical skills and the analysis of this study and elsewhere (Blackburn et al, 2001b) showed that respondentsgave consistent responses within in For different these example, this study the same respondents often areas. highlighted difficulties in agreeingwith the structured aspect of CBT in the CBPI, in in interviews in CBTTQ, the assessmentof their the the and the open questions of involved items the therapy. CBT that structuring skill performance on Ritchie and Lewis (2003) distinguish between ways of establishing the internal and be by data. Internal taking may clarified validity steps qualitative external validity of from In fit the that this study, analysis. emerge to check the goodnessof of categories

interrogated discussion initial via with a group of was the author's useof categories interview to the transcriptsand ,= `critical friend' colleagues who were given access
External to them. discussion seemed relevant categories to what about contributed by for be data triangulation by interview enhanced example the may validation of This bear had data the to different same phenomena. study the on types of use of data interview that reflected on the views both having benefit of questionnaire and developing in therapy to trainees a orientation, evolving relation and experiencesof Consistent for therapy. training responseswere clearly therapy skill competenceand data. interview For PCT for both trainees the example, and questionnaire evident CBT in fears the of pre-training questionnaires nature over-structured about reported and in interviews conducted one year the end of training.

is established by showingthat it has internal consistencyin Reliability of a measure

the way it measuresitems. The reliability of the CBPI was established by subjecting - ,` the measureto analysis using Cronbach's alpha. The usual minimum reliability level is suggestedto be 0.75 (Hinton et al, 2004). All the analysesof different sections of the CBPI data using Cronbach's alpha exceededthis level, as did the supplementary analysis of other reliability tests such as Spearman-Brown. The reliability of the measurewould, however, have been further enhancedby using a test-retest procedure,, before its initial administration so that as this was not carried out, it must be acknowledgedas an omission.

Ritchie & Lewis (2003) argue that the reliability of qualitative data is primarily' by the researcherbeing as transparentas possible about the addressed procedures that

234

have fully data been In followed. this been collection study proceduresof have
interview data have been the the presented, along described and steps of analysis of

interviews. the full transcripts of with

fact data limited by that the the findings the was gathered within a The study are of data The therefore that may reflect some aspects of particular centre. course single in involved The tutor this this a course as course was centre and author centre. course desirability' for `social difficulties the trainees with connected potential some raised hear (de Vaus, 2001) by to tutor the thought they want might and a to report what Efforts in by held to trainees. to the were made author relation of power position by limitations that trainees these should only participate emphasising potential reduce in the study in a voluntary capacity and could withdraw from the study at any time. The degree of confidentiality was maximised by anonymising data collection until the had The their the training trainees studies at completed all centre. when point in however, have been trainee retrospect, consent would, of made clearer principle had the trainees been asked to give written consent to be in the study. It would also have been helpful for the study to pass through a formal ethical approval process, had one existed at the time of the start of the study.

The potential for improving other aspects of the design of the questionnaire became for the study as progressed: example, supplying a definition of the model evident labels for example,'CBT' and 'Person-centred therapy' would have resulted in respondentsmaking more informed choices between them. Attitude questions could have profitably contained more items, including some with reverse scoring. The scoring of some of the measures might have revealed richer data if they had been designed differently: for example, offering a neutral score for the principle statements in the CBPI. Using the full scoring range of the CTS-R might have revealed more aspectsof skill performance. The CTS-R assessmentsin the study were based on a small number of tapes submitted by each trainee and thus probably only showed that trainees were capable of performing competently on those occasions. A fuller and wider knowledge of the trainees' everyday practice would have given a fuller picture of their competence. It should be noted however that tape and practice assessmentis very time consuming work and would probably require a large team of assessorsable to devote considerable time to the task, also assuming that problems of access to on-

235

from therapy clients and agencies could be sessions and permissions needed going have been Finally, comparisons of skill performance would enhanced by surmounted. items full assessment CTS-R the skills at all stages. of all

Some of limitations were evident to the researcherduring the course of the study itself but to have changedthem would have limited the degreeto which data already data by be collected with amended research methods. One compared collected could design longitudinal is limitations that, though it is the and measures repeated of of identifying development limitation trainees time, the to track of over a rewarding may well face the researcherwith the stark choice of starting again or living with the

limitation.

7.6: Suggestions for further research: The scopeof this kind of study could be enhancedby focussing on the widest possible levels demonstrating their instances trainees of competence via submitting, of range of knowledge if larger it was able to A would enrich our current tapes. scale study audio longer trainee to skill performance of over gain access a wider sample periods both during and after training. Alternatively a smaller scale study could perhaps pursue this by following a small number of trainees as case studies. sameobjective

BecausePCT trainees were so prominent on this course, the study has been able to interesting connectionsbetween specific ways of holding PCT attitudes show some and the performance of specific skills. The study found out less about other specific attitude affects connectedto the other therapeutic modalities. Persons et al (1996), for example, made a convincing analysis of psychodynamic reservations about CBT but did not offer any analysis on whether these reservations did have any effects on skill acquisition. Generally, work that focused on specific interaction effects between various attitudes and the acquisition of competencewould help trainers to respond more effectively to trainees undergoing these struggles. Although this study has been of CBT training, it is likely that there are parallel effects in other types of training. ; Trainers would benefit from knowledge of a wide range of training situations, as this study benefited from the findings of Mackay et al (2001) on how counsellors tried to `changemodels' into interpersonal dynamic therapy.

236

`non-directiveness' towards in were shown to play an this attitudes Finally, study, CBT Attitudes towards this in to training. trainees the responded influential part way if PCT CBT 'hands-off' polarised, rather as was entirely nd principle often seemed be interesting for It `hands to would researchers get a clearer picture on. was entirely in indeed how in do directing how and clients worked out practice clients actually of fact react to various directive interventions. One respondent in this study remarked in hobnail boots in did `went (See 351 directive that being one with not mean on' that 6.1.2). Fuller behavioural descriptions of CBT with and without what respondents help boots' `hob-nail their trainers to promote or would equivalents thought of as interesting know be how far It CBT to clients might practice. would also sensitive discern such behaviours. We might then be more able to discuss whether such `directive' behaviour was best seen as hidden control or humane concern. Rogers himself (in Kirchenbaum & Henderson, 1990) defines `directive' and non-directive' discussed being they though are often as if they were therapy as on a continuum, mutually exclusive.

7.7: Generalisation of findings to wider populations Researchersfrom such diverse traditions as Cronbach (1975) and Lincoln & Guba (1985) agree that there will always be factors that make a particular setting unique. Lincoln and Guba (1985) argue that any generalisation from one research context to between depends level `sending (i. the on some of comparison context' e., the another (the `receiving the the context' of research study) and setting to which any setting The to aims relate). reader who wishes to estimate the degree to which generalisation is transfer valid will need sufficient detail about the two contexts ('thick such description' in Lincoln & Guba's terminology) in order to decide this.

In this study, there were some features of the `sending context' which may not always be found in other contexts. Firstly, the training course was based in South Wales, a in the country of which CBT services have been underdeveloped and this fact part may partly explain why trainees saw their employers as not giving priority to CBT training. Secondly, the context of the training was in a University college that had a programme of counselling training that culminated in a Masters Degree award. At the time of the study, the Masters arm of the programme contained the CBT training Masters dissertation. The incentive of the Masters and a modules award may have led

237

have done trainees, some so, to undertake CBT training. who otherwise would not Some trainees in the interviews alluded to the fact that, though they had found CBT training valuable, having a Masters degreemeant more to them and their career development. Finally, although the course did include a small number of had the workers, participants and social most often emerged psychologists, nurses from previous counselling training and often described their work as 'counselling', ' a influenced by has been the person-centred, Rogerian that particularly context tradition. Sheldon (1995) has, however, reported how social worker trainees often behavioural in to and methods ways very similar to how the cognitive seemresistant trainees in this study report themselvesto be. Kazantzis et al (2004) reported similar homework CBT directive the nature of setting amongst clinical reservationsabout CBT in New Zealand. training courses elsewhere may, however, trainees psychology diversity. initial Other less model preference and occupational courses may be show health from by dominated the trainees services or other psychiatric settings and more in bring them methods more widely practiced in those experience more with may settings. Other features of the sending context, however, may seem more likely to encourage literature, for degree The example, shows that trainees have of generalisation. some in diverse CBT training to with paradigms other contexts, for example in the come context of Americans training for clinical psychologists (Personset al, 1996; Freiheit & Overholser) and in the contexts of British and American (Morgenstern et al, 2001) training for counsellors. The broad findings of these studies are in line with the main conclusions of this study: that generally attitude differences connected to therapy, be models can resolved during training. The resolution of difficulties in `changing is models' not however always entirely smooth. Resolution seemsto be enhanced by certain types of sensitive responsesfrom trainers. Even given sound training practices,, however, there does seemto be a minority of trainees who continue to struggle and thus may drop out or be delayed or never achieve practice competence. 7.8: Implications for CBT training policy: New Labour social policy has had two particular elementsthat have assisted the promotion of cognitive behaviour therapy in the last decade:the development of evidencebasedeffective public services and service development to counter social

238

isolation (Giddens, 2007). The initial impetus for a definite plan to develop CBT for Sainsbury Mental Health Centre by Lord Layard the from written a report came (Linklater, 2006). Layard proposed a large increase in funding for improving access to by justified from benefit the from therapy, savings provision resulting psychological depression to treated anxiety and return work more quickly. successfully with people We have already reviewed some of the evidence regarding the efficacy of CBT and Lord Layard, as part of his intense political lobbying, added to this rationale the idea that a schemeto improve accessto therapy would also tackle deprivation - `psychic deprivation' (Hodson & Browne, 2008, p. 4).

Layard's lobbying resulted in Alan Johnson's, Health Secretary, announcing in December 2007 the provision of 173 million for developing therapy, largely CBT, training and provision (CBT Today, December, 2007). Layard explained the emphasis by by justified fact CBT the the that the greatest shortage and as efficacy evidence on lies in the number of available CB therapists. He also clarifies that the required for CBT be training will wide: recruitment
Some of the trainees will be clinical psychologists but the majority will be drawn from other mental health professions, for example, nurses, social workers and counsellors taking one year training in CBT (CBT Today, December, 2007, p. 4).

Given the reservations of other therapeuticmodalities about CBT, theseproposals from them. Theseobjections have havepredictablyraisedprotestand reservations from branch root and of the model: ranged
CBT... was originally designed using animal experimentation It is well known ... that cognitive'techniques were usedto try to makepeople conform to society's view of normality, for examplein the 1950s,and that CBT was widely usedin China in the Cultural revolution... Thesetherapiesdeny the input of the therapist... (Pointon, 2008, p. 21). To more practical objections for example, some therapists have asked whether one year trained CBT therapists be regarded as senior to psychodynamic therapists who trained for 5 years (Hodson & Browne, 2008, p. 6).

It is likely thereforethat the issueof traineeschanging models

as they come into CBT

training will ariseas the new training attitudesinteract with previously held attitudes. 239

It is also clear that the implementation process,just beginning as I write (March, ' 2008) will be rapid and, as with many recent initiatives, the detail is not clear even as the processbegins. A major fact of the likely relevant detail arises in the nature of the `steppedcare' concept built into the Layard proposals. Stepped care involves different levels of psychological treatment from the `high volume, low intensity' interventions intensity' interventions' high Step 5 (White, `low 2008). It Step 1 to the of volume, of is assumedthat different professions will gravitate to different steps, clinical lower higher towards the the towards steps and others ones (CBT psychologists -

Today, December, 2007, p.2). So whilst Layard is right that many professions are likely to be involved in the Improving Access to Psychological Therapy (IAPT) project, how they will be involved and what training and opportunities are open to them is not yet clear. Some have referred to people working on steps 1 to 4 as `technicians' and step 5 as `therapists' (CBT Today, December, 2007, p. 2) - an approachlikely to exacerbate the paradigmatic and attitudinal training conflicts, discussedearlier. This study does, however, suggestways in which such training difficulties can be tackled - ways that bear comparison to CBT itself. It shows that certain attitudes held in particular ways do interfere with the acquisition of CBT competence, sometimes jr highly specific ways. These attitudes may, as in this study, be connected to theoretical differences between but that the different arise similar attitude orientation `Layard to the get on score board'. The study also occupational groups struggling be by difficulties these that overcome can a training process that provides suggests supportive environment in which attitudinal differences can be surfaced, explored and, mostly, resolved. Such a supportive environment may, however, need to take, care that all professional groups are respectedand that professional politics arising in other contexts are minimised in this one.

7.9: Implications for CBT training methods: In view of the large scale nature of the Layard training plan, it seemslikely that more people from diverse ranges of previous experience and points of view will present themselvesfor CBT training in the coming years. It is therefore important to understandhow these previous experiencesand previously held attitudes may influence responseto CBT training, especially in the way that they develop

240

Speedy (1998) has noted the clash between the in their of model. practice competence 'non-judgemental' counselling courses and university assessment of the ethos be added the clash between the ideals of self-directed learning To this can processes. based have As for drive the skill and education. we examined the vocational and have however noted that concepts often act as polarities and issues we educational from both for things polarities: example, externally validated that trainees may want least learning that them gives experience experience of at some a qualifications and have argued that something like Socratic Many learning. authors self-directed dialogue and negotiation can lead to creative compromise and resolution between has differences This 1998). that (Speedy, these also shown resolving study can them involve considerable dissonance and stress for trainees.

that: This study suggests helping Training processes traineesto capable of are mostly
in their attitudes such a way they are able to attain existing reformulate competence.

"

Considering processesto facilitate attitude change by using Socratic discussion based on models such as elaboration likelihood (Petty & Cacioppo, 1986) is helpful for trainers seeking to find the balance between facilitating trainees' development and persuading them of the benefits of new learning. The model is also helpful to trainees: they

canuse it identify any reservationsabout learning the therapy and what ways of resolving suchreservations may be opento them. Someof the dissonance felt by traineesmay be hard for them to declarewithout seemingto be out of kilter with the training. Some of the stressmay thereforebe kept hidden from trainers. Training that could make it safefor traineesto surfacetheir processes reservations would be helpful. It may also be helpful to have an agreed way for traineesto decidethat the training is not for them so that they can effectively give themselvesan `honourabledischarge' from

241

do trainees this lack The can only mean may option an such of courses.

to `fail'. As trainersthemselves in rathermessywaysby appearing be impasses how they become resolved, could will such of moreaware
be able to be more helpful to trainees at this point. During the processesof Socratic dialogue and elaboration likelihood designedto facilitate attitude change, it will be helpful if trainee and impact the on the may way attitudes trainers are more aware of

be This there that may suggests study acquisitionof competence. For aboutthe principle example,reservations effects. specific attitude finding it lead difficult is to trainees to {therapy that may structured
because More the structuring the still, specifically session. structure has be to undertaken quite near to the start agenda an activity of setting be to the meaningful, any procrastination about carrying out session of the activity may be fatal for successful assessmentof the skill. The demonstrating include for the skill of agenda setting the specifications fact that it should be done in a relevant way - delay in setting an irrelevance in its immediate lead delay that to the agendamay may leave insufficient time for topics to be covered. It was interesting that failed item in the this study. assessment most of was setting agenda Other structuring activities such as pacing the session were not so

them more quickly. Homework time-boundandtrainees mastered and gives the therapist more settingcomestowardsthe endof a session time to settleinto a goodinterpersonal style with the client.
The processof reviewing and modifying attitudes may be helpfully by supplemented a processof reflection and practice (Bennett-Levy & Thwaites, 2006) during which a trainee can be encouraged to `play it lightly the more model, wear and to implement aspects of it with' at her own pace as it becomesmore comfortable to her. These methods in be can used an educational practice which utilises the principles of reflective practice, self-directed and experiential learning as well as focusing on structured professional learning.

242

7.10: Conclusions This study hasbeenable to identify somecommonly assumedfacets of training during develop behaviours in trainees training of and after practice attitudesand has been development It to the that also able show ways. of preciseand concrete development behaviours. The linked is to the practice of skilled effect of attitudes behaviours lessened the at was most evident pre-training stage, on practice attitudes during the early stages of training and was largely neutralisedby the end of training. that it is helpful to target specific attitudesand the way they The study hassuggested behaviours. Precise link to skill practice understandingof the context specific might important difficulty that trainees the aspects of can clarify each skill of may use of in implementing Interviews them. conductedafter the end of training experience during had been largely training that attitudechange maintainedat one year suggest follow-up. It was not possibleto measure whether skill acquisition had beenretained during the post-trainingperiod, though intervieweesfrequently reportedthe intention to maintain and increase commitmentand engagement with the skilled delivery of CBT. Traineesalso reportedthe kinds of personaland occupationalchangethat were for CBT likely to sustaindevelopment of example,moving into more practicepostsand engagingwith professionalassociations specialised and activities linked with CBT practice. The studymay also prove helpful to trainersand traineesby identifying the possibility that specific attitudestowardstherapymay be linked with specific aspectsof skill has It basedon an performance. also identified elementsof the kind of processes, of how Socraticexchange understanding andthe influencing processmay facilitate facilitate attitudechange.Suchattitude changes may skill development.The linkage of cognitive processes and behaviouralchangehas a satisfying congruencewith the

CBTmodelitself.
With CBT training set to expandin the UK following the Layard plan, understanding suchtraining processes shouldhelp to ensurethat training is carried out in effective ways.

243

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APPENDICES

267

APPENDIX

1: Letter to trainees and CBTTQ:

School of Ilealth and Social Care, University of Wales Newport, PO Box 180, NEWPORT, South Wales, NP20 5XR. 16 September 2000. Dear Student, CNT Training research study: Further to our discussion at the pre-course meeting earlier this week, I am pleased to send you the first of the 3 questionnaires that I told you about. It has come to you via Mike Simmons who is co-ordinating data collection for me. We are using this system to ensure that your responses are confidential. You will see that there is a number written on your questionnaire. All data will be kept under this number, not by name. This study number will remain the same for you throughout the study. In the unlikely event of you being sent a future has been different there that this means an error. In this event, number, questionnaire with a has lie let know Mike to sort out what gone wrong. endeavour and will please As I told you at the pre-course meeting, it is important for you to know you are fully entitled not to take part in the study and also that you may withdraw from it at any time, with no adverse consequences for yourself. Your responses will stay fully anonymous until after you have finished your training and education at UWN. After that I may need to identify your individual responses to match them up with other data regarding your training here. Any be by however, your anonymous study number. If you have any will, reporting of results concerns about this situation, please contact Mike Simmons, on 01633-432520, for further

discussion and/or clarification. The questionnaire has been designed to be comprehensivewithout being too burdensome. I
am aware of the demand for questionnaire completion these days and want to thank you in advance for your forbearance. Please feel free to add any views you have about CET training. I have left some spaces quite small to avoid making the questionnaire too long and unwieldy, so you might want to add more on an additional sheet of paper as an addendum. May I also take this opportunity to remind you that all respondents returning questionnaire will be put into a prize draw. The draw will be made by Mike and the prize will be a 30 book token.

Thanks in advanceonce again for agreeing to help. Frank Wills

268

COGNITIVE

BEHAVIOUR

THERAPY TRAINING PRE-TRAINING

QUESTIONNAIRE

(('RT'I'Q):

Copyright: Frank Wills, 2000: This questionnaire may not be used without the written permission oJ' the author.

A) Background Information
Phase FU Date Gender n/a Age n/a

Study number Present job/occupation

Time in post Previous job/occupation Education/Training: (no response needed) GCSE/O-levels (Please circle all relevant responses) Professional Qualifications n/a A-levels Degree Postgraduate

Other

i)

Does your employer support * Giving time off to attend

your CBT training

by:

* Paying part or all course fees * Paying a book allowance * Arranging appropriate supervision * Other (Please tick all relevant responses) ii) Does your employer regard CBT training as: very high priority (Please circle) quite high priority quite low priority low priority

iii) How strongly would you rate your employer's support

very strong quite strong quite weak in CBT very weak (please circle)

iv) Will having a qualification

prove to be an advantage

in relation to things like promotion in your workplace? YES NO NOT SURE (please circle)

Why/Why not? V) What do you expect to be doing 2 years after the completion of the course?

269

C) Attitude

to principles

of CBT

i) Thinking of your practice now, rank orders the following models that influenced your practice. (NB The rank order I= the model that exercises most influence, 2= the next most influential etc. ) Person-centred therapy Behaviour therapy Other (Name Eclectic/Integrated CBT Psychodynamic therapy

ii) How strongly does your practice show adherence to the model given rank I above? very strong quite strong quite weak very weak

iii) Rate the following principles of CBT in terms of how much you agree with them
as key principles for a model of psychotherapy to follow. It may be difficult to assess each principle in an abstract context, but try to consider them in relation to work with your most typical clients. Tick the appropriate rating and add any comments you would like to below each principle.

Therapy should be based on an ever-evolving conceptualisation of the client and his/her a) problems in cognitive terms.
Strongly disagree Disagree Agree strongly agree

b) A sound therapeutic Strongly disagree

relationship

is necessary but not sufficient agree

for effective therapy strongly agree

disagree

c) Therapy should emphasise collaboration and active participation

Strongly disagree disagree agree strongly agree

d) Therapy

should he goal-orientated disagree

and problem-focused. agree strongly agree

Strongly disagree

e) Therapy

initially

emphasise the present rather than the past

Strongly disagree

disagree

agree

strongly agree

270

Thanks for filling this out. Please now use the stamped addressed envelope to send it back to the author's agent by

272

COGNITIVE

BEHAVIOUR THERAPY TRAINING QUESTIONNAIRE END & FOLLOW-UP VERSION

(CBTTQ)

Copyright: Frank Wills, 2000: This questionnaire may not be used without the written permission of the author.

Phase

FU

Date Gender n/a Age n/a

Study number Present job/occupation Time in post

Previous job/occupation Education/Training: (no response needed) GCSE/O-levels (Please circle all relevant responses)
Professional n/a Qualifications

A-levels

Degree

Postgraduate

Other

i)

Did your employer support your CBT training * Giving time off to attend

by:

* Paying part or all course fees * Paying a book allowance * Arranging appropriate supervision * Other (Please tick all relevant responses) ii) Did your employer regard CBT training as: very high priority (Please circle)
iii) How strongly

quite high priority

quite low priority

low priority

would you rate your employer's

support

very strong

quite strong

quite weak

very weak

(please circle)

iv) Will having a qualification

in relation YES NO

to things like promotion NOT SURE

in CBT prove to be an advantage

in your workplace?

(please circle)

Why/Why not? V) What do you expect to be doing 2 years after the completion of the course? n/a

273

C) Attitude to nriocinles of CBT

i) Thinking of your practice now, rank orders the following models that influenced your practice. (NB The rank order I= the model that exercises most influence, 2= the next most influential etc. ) Person-centred therapy Behaviour therapy Other (Name CBT Eclectic/Integrated Psychodynamic therapy

ii) How strongly does your practice show adherence to the model given rank I above? very strong quite strong quite weak very weak

iii) Rate the following principles of CBT in terms of how much you agree with them
follow. It be difficult for to assess each key to of psychotherapy may principles a model as principle in an abstract context, but try to consider them in relation to work with your most typical clients. Tick the appropriate rating and add any comments you would like to below each principle. b) Therapy should be based on an ever-evolving problems in cognitive terms. Strongly disagree Disagree conceptualisation of the client and his/her

Agree

strongly

agree

b) A sound therapeutic Strongly disagree

relationship

is necessary but not sufficient agree

for effective therapy strongly agree

disagree

c) Therapy should emphasise collaboration and active participation

Strongly disagree disagree agree strongly agree

d) Therapy

should be goal-orientated disagree

and problem-focused. agree strongly agree

Strongly disagree

e) Therapy

initially

emphasise the present rather than the past

Strongly disagree

disagree

agree

strongly agree

274

275

Thanks for filling this out. Please now use the stamped addressed envelope to send it back to the author's agent by

276
L

APPENDIX 2: TRAINING IN COGNITIVE BEHAVIOUR THERAPY Semi-structured Interview Schedule

INTERVIEW WIT1I CU"1''l'RAINF

Study number

Course Cohort

Date of interview

//

Place of interview

INTRODUCING THE INTERVIEW

Thanks for agreeing to be interviewed about your experiences learning Cognitive Behaviour Therapy. The interview is designed to last between

50 and 60 minutes. It will be divided into three sections your before, during experiences and after the training course. I will ask you but free feel to expand or add points, as they seem some questions please relevant to you.

277

A. BEFORE THE CB TRAINING COURSE

Al. How did your interest in Cognitive Behaviour Therapy begin?

A2. When did your interest in Cognitive Behaviour Therapy begin?

278

279

A6. What factors finally led you to decide to do CBT training?

280

a a. MN C .: ,. _.. _ ..

A8.
Are you employed or self-employed? Part-time or full time?

If employed, what was your employer's attitude towards you doing a CBT course?

281

B. DURING CB TRAINING: B9.

How were you feeling about the training course at around the halfway point? (Prompt -'As you handed in your first assessed tape')

B10. What aspects of CBT training gain most from? did you

(Prompt - If more than one, rank order)

282

B!!. What aspects of CBT training were difficult? most

(Prompt order)

If than one, rank more -

If answered SELF-EMPLOYED to Question A8, move to Question C 15. B14.

How has your completion of CBT training been recognised and/or rewarded by the your employer/s?

284

C. AFTER CB TRAINING: C15.

Would you now describe yourself Cognitive Behaviour Therapist? as a

If NO or OTHER, what term do you use to describe yourself as a practitioner?

285

C17. Looking back at how you saw CBT at the start of the training course, would you say that you see CBT differently now? (If YES, In what ways? )

(Prompt #1- refer back to answer for Question A7)

(Prompt #2 - Big shift, small shift, mixed bag? )

C18. What role do you expect CBT will play in your practice in the future?

286
k

287

inal f there fear J pints these any re 1.7nullt', thanks ve'rt' much que.stionss.. -I answering
that von wouuldlliheto nmld?

inter'ic'''roc'c'. fielt /to'. the ss' Way I ulcn cl. t'oli crhout c% 1'011

I)n nu think I. Wervi. over?

! lrrr! 'r, rr rrriglrr answered the questions

dif

I would /i/c' to send }'ou a draft of in*v t'rilc'-up of this interview to ensure that I have recorder! vhat you have said accurately. Is that okay R'ith t ou? .

final hrie'f flit dif 1(1111 to V of a report up write uh going Iltis brief report? %entlyoU u cu/)t, of .

s. Would VOll like rit' to

288

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