Background
Psychiatric training, alongside other professional education, is undergoing rapid evolution and has moved to a competency-based curriculum. This aims to facilitate learning by focusing learning activity on what is required to successfully fulfil the role for which learning is required and providing standards by which learning progress can be assessed. Publication of the curriculum and the latest iteration in psychotherapy requirements has helped clarify the College's view on the aims of psychotherapy training as a whole [Royal College of Psychiatrists (RCPsych), 2009, 2010]:
• Knowledge. Apply contemporary knowledge and principles in psychological therapies.
• Skills. (1) Foster a therapeutic alliance with patients; (2) with appropriate supervision, commence and monitor therapeutic treatment in patients, based on a good understanding of the mechanisms of their actions; (3) demonstrate the capacity to deliver basic psychological treatments in at least two modalities of therapy and over both longer and shorter durations. (‘Shorter’ or ‘brief’ has traditionally been defined as 12–16 sessions.)
The superordinate Intended Learning Outcome demonstrates a clear expectation ‘to integrate these psychotherapies into everyday treatment’. While the ability to translate skills learned in one situation (formal therapy) into another (everyday practice) and then seamlessly integrate them is a highly desirable additional meta-skill, there is: (i) a lack of clarity about how such integration of CBT skills would appear in practice and therefore how to measure it; (ii) lack of evidence concerning the effectiveness of this on patient outcome, and (iii) no recognition of the potentially shifting nature of the therapeutic relationship required to achieve such integration. These challenge the principles of competency-based learning as, respectively: (i) the competency required for the role in which clinicians will work is ill-defined; (ii) it is uncertain that this will improve patient care (necessary to fulfil the role), and (iii) this specific competency is not identified.
This paper reports the outcomes of a workshop held at the 2008 Spring Meeting of the Northern and Yorkshire Division of the RCPsych and discusses the implications. The workshop led to proposal of competencies that do not relate to delivery of CBT, but rather CBT-related competencies that would be helpful in non-specialist practice. Its aim is to engage in the debate about what is the role of CBT training in core psychiatric education (years 1–3). It should help those involved in CBT training of psychiatrists better understand the background upon which this training is occurring and reflect upon the desired outcomes. Other professionals, teaching CBT to colleagues who are not engaged in specialist CBT practice, may be interested in the potential benefit of careful and specific linking of training experience with desired outcomes that is proposed in this paper.
Workshop presentation
There were 89 psychiatrists (including 34 trainees) in attendance. The presentation introduced the following assessment frameworks/configurations of training:
• Experience only: the situation that prevailed until publication of updated requirements in November 2008 and the new curriculum in 2009 (RCPsych, 2009, 2010). Trainees were requited to complete three brief (12–16 sessions) cases in different psychotherapy modalities and one long case. There was no requirement for trainees to gain anything other than the experience. At the time of the workshop, it was in the process of being phased out and this is now complete.
• Cognitive Therapy Scale – Revised (CTS-R; Blackburn et al. Reference Blackburn, James, Milne, Baker, Standart, Garland and Reichelt2001). The CTS-R represents an established view of best practice for delivery of CBT. It is used to evaluate the skills of therapists in training, as well as fidelity to the model in trials. It consists of 12 items (14 in its original publication), rated 0–6, where a score of ≥3 (with no individual item scoring <2) is considered competent. The items are grouped under procedural items, interpersonal items and items concerning the delivery of specific techniques. It has satisfactory inter-rater reliability and validity. An extensive review of competence measured by this and similar tools (Rakovshik & McManus, Reference Rakovshik and McManus2010) concluded that there was an overall positive relationship between therapist competence and patient outcome reported in multiple clinical settings, including research trials.
• The CBT Basic Competencies map (Roth & Pilling, Reference Roth and Pilling2007). This was developed to facilitate the implementation of the Improving Access to Psychological Therapies (IAPT) initiative in a collaborative effort between the British Association of Behavioural and Cognitive Psychotherapists (BABCP), the British Psychological Society, the British Association of Counselling Psychotherapists and the Department of Health. It has achieved widely consensual approval within the CBT community.
• An extract of the old RCPsych curriculum, published online and which focused on aspects that might be learned within a psychotherapy training experience (Denman, Reference Denman2008). There had been a lack of competencies specific to psychotherapy within the curriculum and this had caused concern in the medical psychotherapy community. There is now a requirement to meet locally (at deanery level) agreed competency progression standards, the tools provided for the assessment of which closely accord with proposals in a document that was published online (Denman, Reference Denman2008) at the time of the workshop (see introduction to SAPE below). An extract is shown in Table 1.
• A group of psychotherapy competencies that were CBT-specific and that were under consideration by the RCPsych Adult Speciality Curriculum Committee at the time. They have not since appeared in the curriculum.
• The Structured Assessment of Psychotherapy Expertise (SAPE). This assessment tool was developed within the RCPsych Psychotherapy Faculty for evaluating trainees completing a psychotherapy case. Its items were presented as competencies with clarification of the nature of each competency made by citing the upper anchor points. For example, item 1 refers to attitude towards the patient and the upper two anchor points clarify this as ‘respectful, non-judgemental’ (satisfactory) and ‘informed by realistic but positive view of patient's potential’ (accomplished). The items are shown in Table 2. The table also demonstrates how SAPE items may relate to the CBT competencies framework. Essentially, the majority of SAPE covers competencies considered to be generic in the CBT framework.
Table 1. Extract of views expressed in psychotherapy faculty concerning psychotherapy-related competency components of core and general curriculum
Table 2. Relationship between SAPE and CBT competencies
The question was posed to the workshop, ‘Should all new consultants have specific CBT skills/competencies in addition to the “generic” and those covered in SAPE?’
Workshop discussion
Feedback from the five discussion groups was almost unanimous. For the purposes of becoming a psychiatrist, all should have generic psychotherapy competencies, as evaluated by SAPE. It was useful to have clarified the components in this measure that do relate to competencies identified in a CBT context. However, knowledge and attitude competencies were considered to be sufficient in relation to CBT specifically as most psychiatrists would not have the opportunity to implement CBT skills competencies beyond this.
The workshop concluded that, attitudinally, psychiatrists should value the contribution of CBT and the skills of those delivering it in patients’ treatment. Psychiatrists should understand the nature of the therapy so that they can:
Make a reasonable attempt to identify suitable patients, discuss the therapy with patients and patients’ progress with therapists and be able to make informed decisions about future career paths that might involve becoming a Consultant in CBT.
One group of trainee psychiatrists thought that the CBT competencies framework should wholly be the vehicle for influencing development of psychiatrists with respect to CBT competencies and that generic psychotherapy skills could be evaluated within this. There was strong support for a new suggestion from one group that a skills competence be included referring to the ability to provide a rationale for treatment, integrating pharmacological and psychological approaches.
Discussion
Summary of workshop findings and relationship with goals of psychotherapy training as part of core training for psychiatrists in years 1–3
The findings from this workshop are broadly in keeping with the view of the RCPsych: knowledge competencies in relation to CBT should accrue from this training, while non-specific psychotherapy skills are developed.
New skill competencies were proposed: (1) ability to recognize match between patients and a CBT approach (so that clinicians could appropriately refer patients and engage in informed discussion with CBT therapists) and (2) to be able to provide a rationale for treatment, integrating pharmacological and psychological approaches. In fact the CBT ‘five areas’ formulation (Williams, Reference Williams2001) (which includes components of ‘situation’ as well as ‘thoughts’, ‘emotions’, ‘behaviour’ and ‘physical changes’) provides a framework to personalize and specify the relatively generic ‘bio-psycho-social’ framework espoused for assessment, formulation and treatment in psychiatric practice. In this case the area of ‘physical changes’ may helpfully include neurochemical changes/pharmacotherapeutic intervention.
An additional aim for the training identified was professional development that sits outside a competencies’ curriculum: to experience the delivery of the therapy in order to make informed decisions concerning career path (for trainees to decide whether or not to pursue a CBT career or develop an interest in the therapy). The workshop did not support the learning of CBT-specific skills and therefore precluded their integration into generic practice, the over-arching or contextual competence specified in the curriculum.
CBT-specific skills and their integration into clinical practice: authors’ discussion
In formal CBT, therapists do much more than inform patients of very understandable CBT principles and show them how to implement these; in other words, they apply CBT-specific skills. A recent review of training and outcomes provides evidence that dose of training is associated with better therapist competence and clinical outcomes for patients (Rakovshik & McManus, Reference Rakovshik and McManus2010). It is interesting that a group of training psychiatrists would have wanted to develop more CBT competencies. However, the dose of training currently received by trainee psychiatrists would equate to ‘brief’ training in this review and this is not associated with significant effects for therapist competence or patient outcome compared to either the pre-intervention baseline, treatment as usual (TAU), or a control group. In other words, this level of training does not seem to improve patient outcome when subsequently attempting psychological treatment.
There is little evidence that clinicians can integrate skills learned in one context (CBT training) into another (generic psychiatric practice) without supervision focused upon this. This is likely to be particularly difficult when the nature of the therapeutic relationship, the vehicle for implementing those skills, is fundamentally different in an outpatient clinic context (15-min review sessions; focus on symptoms not function; patient and doctor expectation for advice to be offered; traditionally (although changing) paternalistic relationship). Furthermore, the evidence base supporting CBT is focused on competent CBT as defined in several assessment tools. If competence so-defined following ‘brief’ training is poor for formal therapy, it is much less likely that patients will benefit from practice that is ‘integrated’ and compressed from brief training. There is risk, then, that patients in clinicians’ generic practice could be offered an intervention that has no evidence base and, worse, a concomitant danger that patients who fail to respond could be blamed or considered unsuitable.
If ‘the main aim of CBT training is to improve patient outcomes by enhancing therapists’ competence in CBT’ and ‘competence is defined as the ability to appropriately apply CBT interventions that reflect the contemporaneous evidence base for the treatment of that patient's presenting problem’ (Rakovshik & McManus, Reference Rakovshik and McManus2010), current training for psychiatrists is neither structured to achieve this, nor desired to be so by most psychiatrists in this sample or indeed by the published curriculum. Thus, a training that is based on models established to train therapists in CBT (introductory workshops and supervised practice) may not be appropriate.
However, it would be wrong for such a large and influential body of mental health professionals to be unfamiliar with the psychological treatment most often recommended by the National Institute for Clinical Excellence. Furthermore, it would be unethical for them not to be informed enough to be able to develop a basic understanding of a patient's problems within a CBT framework and to be able to suggest self-help materials or even briefly engage in some guided discovery when the opportunity arose. Thus a more complicated question is how ‘competent’ would appear to an observing assessor in this context in relation to such activities and what kind of training and supervision would enable such integration.
Alternative approaches to training psychiatrists – a proposal
A recent email discussion among consultant psychiatrists, in the medical special interest group on the BABCP jiscmail system and involved in training junior psychiatrists, revealed a wide variety of models of training. This included training that adhered closely to college requirements for delivery of one therapy of 12–16 sessions; delivery of one or more therapies of any length depending on trainee interest; delivery of one or multiple ultra-brief (1–2 sessions); and delivery of therapy within an IAPT framework. This may reflect the lack of clarity about what to prioritize from the curriculum: the integration in practice or the experience of therapy delivery, while recognizing achievement of both to be unrealistic within resource and trainee time constraints.
An ideal solution would have trainees completing several cases under supervision and extended supervision focused on integration of specific knowledge skills and attitudes through video-recording clinical encounters. Trainee time and training resource constraints make this unfeasible. Engaging our trainee psychiatrists in psychological well-being practitioner training would provide a structure of training, access to cases and integrate their work within a stepped care CBT pathway. Stepped care is not addressed by the current curriculum for years 1–3. However, the training for people who already possess a mental health professional background is 15 days at university and 10 days of university-directed learning (National IAPT Programme, 2010). This would be difficult for trainee psychiatrists to achieve. It would also replicate the mistake of taking trainees out of their normal work environment and teaching them to do something in a context within which they will not continue to practice. The separation of the curriculum into knowledge, skills and attitudes-demonstrated-by-behaviour domains and clarification that specific CBT specialist-skill competencies are not required suggests it may also be worthwhile considering other training models at this time.
Taking the lead from practising psychiatrists at this workshop and developing the ideas slightly, this paper proposes competencies that facilitate integrating CBT models into clinical practice (not CBT-specific skills): (1) ability to provide a rationale for treatment, integrating pharmacological and psychological approaches; (2) ability to facilitate patients’ reflection on the relationship between their problems and the model; (3) ability to enable patients to use this understanding to solve problems associated with their condition (this could include some basic behaviour therapy or guided discovery); (4) ability to explore with patients how an assessment for CBT would be experienced and decide whether to pursue this at this time, and (5) ability to use an integrated treatment rationale to support patients engaging CBT with a therapist.
Competencies (1), (2), (4) and (5) are developed directly from the workshop. Competency (3) represents opportunistic use of adapted CBT as aspired to in the current curriculum. These would be of greatest ecological validity if developed and assessed in practice that was not CBT-specialist in nature. Thus, many clinical encounters would be amenable to implementing these and receiving supervision. This may help overcome the challenge facing the provision of psychotherapy training provided by the difficulty in finding so-called ‘training cases’ in psychiatric practice and any local shortage of supervisors. Implementation could be assessed by video recording of outpatient or in-patient consultations. These may satisfy better the aspirations of training psychiatrists and research into this would be helpful. Furthermore, the opinions of the service user stakeholder body could be helpfully elicited to determine their expectations of their psychiatrists.
A form of training well established in the Family Therapy setting is observation and discussion of therapy that is delivered by a trainer or on video. In this case, knowledge and attitudinal competencies may be developed and assessed in a different format. A discussion of patient/therapy match, for example, could occur in this setting and development of competency (4) subsequently assessed and supervised by video.
More generic psychotherapy skills (such as attitude towards patient; developing empathic and responsive relationship; establishing frame for treatment; managing endings) may resemble aspects of communication skills developed and taught so effectively within GP training programmes (Simpson et al. Reference Simpson, Buckman, Stewart, Maguire, Lipkin, Novack and Till1991). These may be taught by trainers providing supervision in the workplace environment in which most trainees will proceed to work or creatively synchronized with GP trainees.
The teaching and assessment of these are amenable to models of distance learning for locations where local expertise is sparse. From the point of view of the RCPsych where international development is highly valued, this aspect of these proposals would be very encouraging. This could allow the College to continue to insist on mandatory requirements of specific skills, but allow for more influence of local culture and skill availability.
These competencies would facilitate the use of self-help materials which have been shown to helpfully supplement therapist interventions and reduce face-to-face contact time. This specification of these competencies would allow their impact on patient outcome to be helpfully researched. In practice, curriculum competencies relating to history-taking and diagnosis-forming could impede the ability to implement more traditional CBT competencies as the former set the doctor–patient relationship on a trajectory of relating that implies, ‘how can I help you?’ rather than, ‘what would you like to work on?’ Competency (1) could potentially be the vehicle by which a movement in this relationship is facilitated.
A CBT career for psychiatrists?
The College requirement is for the experience under discussion here to be part of Core Training (years 1–3). The workshop wanted psychiatrists to gain enough experience to be able to decide upon potential future career pathways that could include becoming a Consultant Psychiatrist in Psychotherapy (CPP). The training goals proposed would not provide enough experience to allow psychiatrists to make informed decisions about this. A trainee would be hard pressed to find additional time for this in years 1–3 given other demands and arguably one brief case is inadequate experience on which to make such a decision. Interested trainees would need to find other ways to achieve adequate experience for this. The role of CPPs in this training might best be to assure its quality and to support Diploma-trained but non-CBT-specialist clinicians. Such clinicians who have brought CBT into their own practice would be well-placed to help trainees bring these CBT-related competencies into their practice if these proposals were adopted.
Summary of main points
• Broad support exists for CBT knowledge and attitudinal competencies being taught to psychiatric trainees to a level that would allow this to inform day-to-day practice, within a generic psychotherapeutic framework.
• The suggestion of generational difference is intriguing and the College may wish to engage more actively with psychiatrists in training to understand better their aspirations regarding competencies they wish to acquire.
• New competencies were proposed by the workshop that were considered meaningful in psychiatric practice. These are elaborated and specified in this paper. A further competence is proposed. Together these specify a meaning of (CBT) ‘informing day to day practice’ and ‘integrating (CBT) into every day treatment’.
• The separation of these competencies into knowledge, attitude and skill domains leads to other possible models of training and assessment that may be more effective and there may be opportunities to be more creative in training programmes by linking specific competencies with specific training experience. Some of these are amenable to distance learning.
• Consultant psychiatrists in CBT are well placed to provide this training but could focus on an overseeing role.
• Research to validate CBT competencies in non-CBT specialist practice is needed, as is research to identify both aspirations of training psychiatrists and service users’ expectations of their psychiatrists.
Acknowledgements
Thanks to the participants of the workshop for openly and constructively engaging in this work and to Dr Kevin Meares for comments on manuscript construction.
Declaration of Interest
None.
Learning objectives
(1) Improved understanding of the current state of play regarding learning objectives for CBT training in a psychiatric training programme and their debate.
(2) Improved understanding of the relationship between psychiatric learning objectives, required learning assessment tools and the CBT competencies framework.
(3) Understanding of potential benefits of considering learning objectives in domains of knowledge, skills and attitudes for developing training experiences within training programmes.
(4) Improved understanding of what psychiatrists themselves wish to gain from CBT training and what CBT learning other mental health professionals may expect psychiatrists to have.
(5) To have considered aspects of CBT learning that may be applicable in daily non-specialist practice.
Comments
No Comments have been published for this article.