James Bennett-Levy

Acquiring and Refining CBT Skills and Competencies: Which Training Methods are Perceived to be Most Effective?

BACKGROUND A theoretical and empirical base for CBT training and supervision has started to emerge. Increasingly sophisticated maps of CBT therapist competencies have recently been developed, and there is evidence that CBT training and supervision can produce enhancement of CBT skills. However, the evidence base suggesting which specific training techniques are most effective for the development of CBT competencies is lacking. AIMS This paper addresses the question: What training or supervision methods are perceived by experienced therapists to be most effective for training CBT competencies? METHOD 120 experienced CBT therapists rated which training or supervision methods in their experience had been most effective in enhancing different types of therapy-relevant knowledge or skills. RESULTS In line with the main prediction, it was found that different training methods were perceived to be differentially effective. For instance, reading, lectures/talks and modelling were perceived to be most useful for the acquisition of declarative knowledge, while enactive learning strategies (role-play, self-experiential work), together with modelling and reflective practice, were perceived to be most effective in enhancing procedural skills. Self-experiential work and reflective practice were seen as particularly helpful in improving reflective capability and interpersonal skills. CONCLUSIONS The study provides a framework for thinking about the acquisition and refinement of therapist skills that may help trainers, supervisors and clinicians target their learning objectives with the most effective training strategies.

MindSpot Clinic: An Accessible, Efficient, and Effective Online Treatment Service for Anxiety and Depression

OBJECTIVE The main objective of this study was to report the feasibility of delivering online cognitive-behavioral therapy (iCBT) treatments for anxiety and depression in a national public mental health service. METHODS A prospective noncontrolled cohort study was conducted of all patients who began assessment or treatment at the MindSpot Clinic from January through December 2013. Clinic services were used by a representative cross-section of the Australian population. Mean age at assessment was 36.4±13.0 years, and age range was 18-86 years. Patients completed one of four online courses over eight weeks, during which they received weekly support from a therapist via telephone or secure e-mail. Primary outcome measures were the nine-item Patient Health Questionnaire (PHQ-9) and the seven-item Generalized Anxiety Disorder scale (GAD-7) administered at posttreatment and three months posttreatment. RESULTS A total of 10,293 adults who self-identified as having problems with anxiety or depression commenced assessment, and 7,172 completed the assessment and were eligible for analysis. Of these, 2,049 enrolled in a course and 1,471 completed the course, for a course completion rate of 71.8%. Moderate to large noncontrolled effect sizes (Cohens d=.67-1.66, 95% confidence interval=.08-2.07) were found from assessment to three-month follow-up. At posttreatment and follow-up, reliable recovery ranged from 46.7% to 51.1%, and deterioration ranged from 1.9% to 3.8%. Mean total therapist time per patient was 111.8±61.6 minutes. CONCLUSIONS The MindSpot Clinic produced treatment outcomes that were comparable to results from published clinical trials of iCBT. This model of service delivery represents an innovative method of providing accessible, low-cost, effective, and acceptable mental health services to many people who currently are not receiving care.

The promise of online cognitive behavioural therapy training for rural and remote mental health professionals

Objective: The aim of this paper is to indicate how online cognitive behavioural therapy (CBT) training for rural and remote health professionals can enhance access to evidence-based treatments in rural communities and address psychotherapy training shortfalls for rural practitioners treating Australians with high prevalence psychological disorders. Conclusions: Issues of cost, distance and disruption to services have meant that, until now, it has been very difficult to provide really effective training in evidence-based therapies (in the main, CBT) for Australian rural and remote health professionals. The recent development of online CBT training provides new opportunities. Online training, supplemented by regular supervision, can fulfil many of the functions of face-to-face training at significantly reduced cost. While face-to-face residential workshops will still be necessary to embed new skills, we estimate that online training can reduce the face-to-face time required by at least 50%.

A Measurable Impact of a Self-Practice/Self-Reflection Programme on the Therapeutic Skills of Experienced Cognitive-Behavioural Therapists

The need for effective training methods for enhancing cognitive-behavioural therapist competency is not only relevant to new therapists but also to experienced therapists looking to retain and further enhance their skills. Self-practice/self-reflection (SP/SR) is a self-experiential cognitive-behavioural therapy (CBT) training programme, which combines the experience of practicing CBT methods on oneself with structured reflection on the implications of the experience for clinical practice. In order to build on previous qualitative studies of SP/SR, which have mainly focused on trainee CBT therapists, the aim of the current study was to quantify the impact of SP/SR on the therapeutic skills of an experienced cohort of CBT therapists. Fourteen CBT therapists were recruited to participate in an SP/SR programme specifically adapted for experienced therapists. In the context of a quasi-experimental design including multiple baselines within a single-case methodology, therapists provided self-ratings of technical cognitive therapy skill and interpersonal empathic skill at four critical time points: baseline, pre-SP/SR and post-SP/SR and follow-up. Analysis of programme completers (n = 7) indicated that SP/SR enhances both technical skill and interpersonal therapeutic skill. Further intention-to-treat group (n = 14) analyses including both those who left the programme early (n = 3) and those who partially completed the programme (n = 4) added to the robustness of findings with respect to technical cognitive therapy skills but not interpersonal empathic skills. It was concluded that SP/SR, as a training and development programme, could offer an avenue to further therapeutic skill enhancement in already experienced CBT therapists.

The first 30 months of the MindSpot Clinic: Evaluation of a national e-mental health service against project objectives

Objective: The MindSpot Clinic provides online mental health services to Australian adults with anxiety and depression. This paper describes users of MindSpot between January 2013 and June 2015. Outcomes are considered against three key objectives: improving access to mental health services, improving public awareness of how to access services and providing evidence-based treatments. Method: Website traffic data were examined to determine patterns of use. Demographic characteristics, past service utilisation and reasons for contacting MindSpot were analysed. Outcomes for patients enrolled in a MindSpot treatment course were also analysed. Primary outcomes were scores on the 9-Item Patient Health Questionnaire, Generalised Anxiety Disorder 7-Item, Yale–Brown Obsessive Compulsive Scale and Post-Traumatic Stress Disorder Checklist–Civilian Version, administered at assessment, post-treatment and 3-month follow-up. Results: The website was visited by almost 500,000 Australians, of which 33,990 adults started assessments, and 25,469 people completed assessment and were eligible for analysis. Mean age was 36.4 years (standard deviation = 13.3 years; range = 18–94 years), and 72% were female. The proportion living in rural or remote regions and who identified as Aboriginal and Torres Strait Islander closely matched national statistics. The majority (82%) reported that they were not currently in contact with mental health services. Most patients sought an assessment, information about treatment options, or referral to another service, and only 24% of those completing an assessment commenced a MindSpot treatment course. Of these, large clinical effects (d: 0.7–2.4; average symptom reductions: 25.5% to 61.6%) were found from assessment to follow-up on all outcome measures. Deterioration ranged from 1.0% to 4.3%. Conclusion: Based on the number of website visits, completed assessments and treatment outcomes, MindSpot achieved its three programme objectives. This model of service provision has considerable value as a complement to existing services, and is proving particularly important for improving access for people not using existing services.

Understanding individual differences in response to Self-Practice and Self-Reflection (SP/SR) during CBT training

Self-Practice/Self-Reflection (SP/SR) has been developed as a self-experiential training strategy to enhance CBT therapists’ skills. SP/SR gives therapists an experience of CBT through practising CBT techniques on themselves, and reflecting on the experience and its implications for clinical practice. Many practitioners report significant professional and personal gains from SP/SR; however, there is considerable individual variation. This study examined individual experiences of SP/SR in order to develop a better understanding of idiosyncratic variations in participants’ approaches to SP/SR, and to inform the design and implementation of future SP/SR programmes. A single-case design was employed to examine the experiences of four trainee cognitive-behaviour therapists who were undertaking SP/SR as part of their professional training in CBT. Quantitative data from self-ratings of skill, and qualitative data from participants’ reflections and attributions following completion of SP/SR were examined. Both the participants, and two additional reviewers were consulted in the interpretation of the results. The impact of SP/SR appeared specific to each participant, reflecting different ways that participants engaged with SP/SR materials. The study suggests that for optimal development, engagement of the personal self and therapist self may be required.

The role of personal practice in therapist skill development: a model to guide therapists, educators, supervisors and researchers

Abstract Prior to 2000, personal practice (PP) for therapists mostly meant personal therapy. Recently a new landscape of PPs has emerged, with meditation-based programs and therapy self-practice/self-reflection (SP/SR) programs playing an increasing role in training and personal/professional development. The challenge now for practitioners and researchers is to refocus on the role of PPs in training and professional development. Are PPs of value - or not? Do they have a role in therapist development? How might PPs enhance therapist skilfulness? Do different PPs act in similar or different ways? Currently, the PP literature lacks a theoretical framework to guide practitioners in their choice of PPs or researchers in their choice of research questions and measures. The purpose of this article is to provide such a framework, the Personal Practice (PP) model. The PP model proposes primary impacts of PPs in four domains: personal development/wellbeing, self-awareness, interpersonal beliefs/attitudes/skills and reflective skills. The model also suggests a secondary impact on therapists’ conceptual/technical skills when therapists use reflection to consider the implications of their PP for their “therapist self”. We offer some suggestions to enhance the quality of future research, and conclude that PPs may play an important and perhaps unique role in therapist training.

Translating E-Mental Health Into Practice: What Are the Barriers and Enablers to E-Mental Health Implementation by Aboriginal and Torres Strait Islander Health Professionals?

Background With increasing evidence for the effectiveness of e-mental health interventions for enhancing mental health and well-being, a growing challenge is how to translate promising research findings into service delivery contexts. A 2012 e-mental health initiative by the Australian Federal Government (eMHPrac) has sought to address the issue through several strategies, one of which has been to train different health professional workforces in e-mental health (e-MH). Objective The aim of the study was to report on the barriers and enablers of e-MH uptake in a cohort of predominantly Aboriginal and Torres Strait Islander health professionals (21 Indigenous, 5 non-Indigenous) who occupied mainly support or case management roles within their organizations. Methods A 3- or 2-day e-MH training program was followed by up to 5 consultation sessions (mean 2.4 sessions) provided by the 2 trainers. The trainer-consultants provided written reports on each of the 30 consultation sessions for 7 consultation groups. They were also interviewed as part of the study. The written reports and interview data were thematically analyzed by 2 members of the research team. Results Uptake of e-MH among the consultation group was moderate (22%-30% of participants). There were significant organizational barriers to uptake resulting from procedural and administrative problems, demanding workloads, prohibitive policies, and a lack of fit between the organizational culture and the introduction of new technologies. Personal barriers included participant beliefs about the applicability of e-MH to certain populations, and workers’ lack of confidence and skills. However, enthusiastic managers and tech-savvy champions could provide a counter-balance as organizational enablers of e-MH; and the consultation sessions themselves appear to have enhanced skills and confidence, shifted attitudes to new technologies, and seeded a perception that e-MH could be a valuable health education resource. Conclusions A conclusion from the program was that it was important to match e-MH training and resources to work roles. In the latter stages of the consultation sessions, the Aboriginal and Torres Strait Islander health professionals responded very positively to YouTube video clips and apps with a health education dimension. Therapy-oriented apps and programs may fit less well within the scope of practice of some workforces, including this one. We suggest that researchers broaden their focus and definitions of e-MH and give rather more weight to e-MH’s health education possibilities. Developing criteria for evaluating apps and YouTube videos may empower a rather greater section of health workforce to use e-MH with their clients.

“You didn’t just consult community, you involved us”: transformation of a ‘top-down’ Aboriginal mental health project into a ‘bottom-up’ community-driven process

Objective: Recently, there has been a consistent call for Indigenous health research to be community-driven. However, for a variety of reasons, many projects, such as the one featured here, start as ‘top-down’. Using ten accepted principles for Aboriginal health research, the present article illustrates how a top-down project can be transformed into a ‘bottom-up’ community-driven project. Method: A table of examples is provided to show how the ten principles were translated into practice to create a bottom-up process. Results: We suggest that key elements for creating a bottom-up process are iterative conversations and community involvement that goes beyond notional engagement. A feature of community involvement is generating and sustaining ongoing conversations with multiple levels of community (organisations, health professionals, Elders, community members, project-specific groups) in a variety of different forums across the entire duration of a project. Local research teams, a commitment to building capacity in the local Indigenous workforce, and adequate timelines and funding are other factors that we hypothesise may contribute to successful outcomes. Conclusion: The article contributes to a much-needed evidence base demonstrating how appropriate structures and strategies may create bottom-up processes leading to successful outcomes.

Aboriginal and Torres Strait Islander Mental Health Practitioners Propose Alternative Clinical Supervision Models

Abstract The purpose of this article is to identify issues affecting the clinical supervision of the Aboriginal and Torres Strait Islander mental healthcare workforce, and propose alternative supervision models. Participatory Action Research (PAR) was the primary methodology used to elicit and analyze the reflections of five Aboriginal counselors. The data highlighted a number of inadequacies with current practices that typically lead to high levels of stress and burnout. We recommend the implementation of alternative supervision models including the use of cultural supervisors, and dual supervisors; and accessibility to consultation, supervision, and communities of practice for remote workers through modern technologies.