Core Competencies in Cognitive-Behavioral Therapy

Becoming a Highly Effective and Competent Cognitive-Behavioral Therapist

Cory F. Newman

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781136261978
• Edition: 1
• Topic: Psychology
• Subtopic: Cognitive Psychology & Cognition
• Index: Psychology

This volume is a concise, convenient, and clearly written book for those who wish to study, master, and teach the core competencies of cognitive-behavioral therapy. Relevant for novice therapists as well as experienced clinicians and supervisors, this text also goes "between the lines" of evidence-based practices to highlight those methods which maximize the motivational and inspirational power of this therapy. Dr. Newman focuses on ways in which therapists can make treatment memorable for clients, thus enhancing maintenance and self-efficacy. He also highlights the value system that is inherent in best practices of cognitive-behavioral therapies, such as clinicians' commitment to earn the trust and collaboration of clients, to be humble students of the field for their entire careers, and to seek to combine the best of empirical thinking with warmth and creativity. Notably, this handbook also emphasizes the importance of therapists applying cognitive-behavioral principles to themselves in the form of self-reflective skills, good problem-solving, being role models of self-care, and being able to use techniques thoughtfully in the service of repairing strains in the therapeutic relationship. Newman's book provides many enlightening clinical examples, including those practices that otherwise eager therapists should not do (such as "micro-managing" the client's thoughts), as well as a plethora of transcript material that describes best supervisory practices. It does all this with a tone that is engaging, respectful of the reader, caring towards the clients, and optimistic about the positive impact cognitive-behavioral therapies—when learned and used well—can have on the lives of so many, clients and clinicians alike.

1

Introducing the Clinical Competencies of Cognitive-Behavioral Therapy

“To show our simple skill, that is the true beginning of our end.”

William Shakespeare (Midsummer Night’s Dream)

To the “naked eye,” the conducting of CBT in a competent manner often looks very straightforward and uncomplicated. However, it is actually not so easy to deliver CBT in the manner in which it was intended—that is to say, with accurate empathy, warmth, good listening skills, and clarity of communication as a starting point, combined with the organizational, conceptual, and technical skills that are well-tied to CBT theory and principles. Adding to the challenge, these methods are to be practiced with a considerable level of energy, as CBT therapists generally do not sit back passively, but rather actively direct the course of treatment while enthusiastically collaborating with clients in setting and pursuing therapeutic goals (Beck, Rush, Shaw, & Emery, 1979). Further, the competent practice of CBT requires clinicians to be knowledgeable about cross-cultural and ethical issues, and to be highly motivated to use this knowledge to provide clients with the most appropriate care.

TOWARD AN UNDERSTANDING OF “CORE COMPETENCIES”

What comprises the knowledge base, the practice skills, and the attitudes (or value system) that are necessary for therapists to demonstrate “competency”? This chapter will provide an overview of several models of competency that are highly instructive in their own ways, yet show a natural overlap that indicates concurrent validity. Extending from this, the chapter will briefly describe the rating items of the Cognitive Therapy Scale (Young & Beck, 1980) as exemplars of what constitute competency from a CBT perspective per se. This will be followed by an explication of some of the most important attitudes or values that competent CBT practitioners maintain to maximize the use of their fund of knowledge, their technical know-how, and their capacity for collaborating positively with their clients.

The Core Competencies in Counseling and Psychotherapy (the Sperry model)

Sperry (2010) explains that the route to becoming a highly competent and effective therapist involves significantly more than just learning and practicing a set of technical skills. He argues that the term competency connotes an integration of knowledge, skills, and attitudes such that there is authenticity and congruency between the therapist’s behaviors and intentions. Taking this position a step further, the author states that successfully combining these important factors allows therapists to meet professional standards, to advance the well-being of others (e.g., clients, clinical trainees), to develop greater levels of expertise and capability, and to utilize self-reflection skills that will result in an enhancement of all of the above.

Sperry (2010) identifies six core competencies comprised of 20 subcategories that he describes as essential competencies that cut across many different mental health professions and theoretical orientations. The current volume will follow Sperry’s organizational model closely, with many of the upcoming chapter titles reflecting these core competencies, and the chapter subheadings approximating the essential competencies. The following serves as a template for the way in which the Sperry model is reviewed in the present text:

1.	Conceptual foundation. This refers to applying a conceptual “road-map” to understand client functioning and dysfunction, and to direct the process of therapy. The current text will describe the conceptual foundations of CBT in Chapter 2.
2.	Relationship building and maintenance. Covered in Chapters 3 and 4, this core competency includes establishing a positive alliance with clients; assessing their readiness for change and fostering treatment-promoting factors; recognizing and dealing effectively with resistance; noticing and repairing alliance strains; and managing the problems traditionally described by the descriptors “transference” and “countertransference,” in cognitive-behavioral terms.
3.	Intervention planning. Described in Chapters 5 and 6, this core competency entails performing an integrative, initial assessment; specifying a DSM-based diagnosis; formulating a cognitive-behavioral case conceptualization; devising a well-directed cognitive-behavioral treatment plan; and writing a thorough report that covers the above.
4.	Intervention implementation. Largely presented in Chapter 7, this core competency involves establishing and maintaining a treatment focus across sessions; applying CBT procedures and related homework assignments; and dealing effectively with factors that would otherwise interfere with the successful delivery of CBT.
5.	Intervention evaluation and termination. Reviewed in Chapters 8 and 9, this core competency is exemplified by monitoring client progress and modifying treatment accordingly (including the utilization of supervision for this purpose); helping clients maintain their treatment gains; and preparing clients for a positive end to treatment.
6.	Culturally and ethically sensitive practice. Addressed in Chapter 10, this core competency is reflected by the development of effective, cultural case formulations; planning, tailoring, and delivering culturally sensitive interventions; and making ethically sound and sensitive decisions.

The final chapter of this text (Chapter 11) does not explicate a core competency per se, but rather presents the factors that help CBT practitioners to attain (and retain) competency and expertise over time, as therapists and as supervisors.

The “Cube Model”

A useful heuristic called the “cube model” (Rodolfa et al., 2005) illustrates three hypothesized dimensions on which to gauge the degree to which therapists are meeting the standards of the profession. The first of these dimensions has been labeled the foundational competencies, representing the overarching qualities to which all therapists should aspire, irrespective of their theoretical orientation. These include a healthy awareness of and respect for ethical standards; the ability to relate to others in a sincere, caring manner; possessing good communication and interviewing skills; being sensitive to cultural issues in conducting therapy and supervision; having the ability to engage in self-reflection and self-correction; possessing a working knowledge of models of psychological dysfunction and wellness; and collaborating effectively with practitioners across related disciplines. The clinician who demonstrates foundational competencies is already well positioned to become a competent CBT practitioner even before starting CBT training per se.

The second dimension is known as the functional competencies, which are comprised of a more specific knowledge base and practice skill set. From the vantage point of CBT, the list of functional competencies would include the ability to convert raw, clinical data into a cognitive-behavioral case formulation; facility in conducting well-paced, well-organized, goal-directed therapy sessions; knowing how to engage clients in an active, collaborative process; possessing a wide repertoire of cognitive-behavioral techniques; being adept at teaching those techniques to clients and using homework to solidify the clients’ learning; and conducting CBT supervision in a way that promotes the trainees’ development as CBT clinicians while simultaneously attending to the proper care of their clients, and others.

The third dimension of the “cube” is the developmental axis, which takes into account the therapist’s stage of training and experience in assessing his or her level of competency. As skill acquisition is a process, and as learning for one’s entire career (and life) is an important value (see below), it makes sense to assess a CBT practitioner’s level of effectiveness at different junctures, from the early days of being a practicum extern in graduate school to the later years of being a seasoned therapist, supervisor, and perhaps a training director. This text will describe core elements of competency that apply across the span of one’s career, though some skills will be identified as basic, whereas others will be highlighted as being more advanced.

The DPR Model

The “declarative–procedural–reflective (DPR)” model (Bennett-Levy, 2006) represents another heuristic through which to understand how therapists acquire competencies. Declarative knowledge has to do with the verbal propositional knowledge base for conducting CBT. This is comprised of information gleaned from readings and lectures in order to reach an abstract understanding of CBT theory and how CBT treatments may be delivered. This information may be interpersonal (e.g., having to do with the therapeutic relationship), conceptual (e.g., how psychopathology develops and is maintained), and/or technical (e.g., descriptions of therapeutic techniques such as guided discovery, activity scheduling, and rational responding). Declarative knowledge is acquired throughout one’s career, but there is significant “front-loading” of this information early in one’s graduate training, as a prelude and later as a companion to practicum experiences in which early-career therapists begin to learn procedural knowledge, which has to do with the practice of therapeutic methods, either in classroom workshops or more naturalistically with clients. Procedural knowledge is obtained, honed, and grown through actual enactments of the methods of therapy, based originally on declarative knowledge, but enhanced and developed through personal, hands-on experience. Over time, as therapists practice CBT with a greater number and variety of clients, they develop implicit rules and procedures that guide their actions in session, helping them to “decide with which client, at which point in time in therapy, with which kind of problem, it is most appropriate to use what kind of intervention, under what circumstances” (Bennett-Levy & Thwaites, 2007, p. 258).

The reflective system of learning pertains to the therapist’s moment-by-moment awareness and evaluation of what is happening in the session, including the therapist’s own thoughts, feelings, and actions. This area of learning comprises immediate awareness of a problem (e.g., the client’s anger about a homework assignment), assessment of this problem (e.g., the homework assignment is triggering the client’s beliefs and feelings of mistrust and vulnerability), and hypotheses and ideas about how to deal with the problem (e.g., to express concern for the client’s feelings and communicate a desire to understand his or her thoughts rather than simply try to convince the client to do the homework). Being “reflective” means that therapists are attuned to their own experiences, the client’s perceptions, and their interactions. The development of these skills, “can help to move therapists from being aver...