1. Evaluating child psychiatric fellows’ competence in CBT: Gold and lead standards
Micaela Thordarson, M.S.
Marisa Keller, M.S.
Robert D. Friedberg, Ph.D., ABPP

2. Statement of Potential Conflicts of Interest
Evaluating child psychiatric fellows’ competence in CBT: Gold and lead standards
Relating to this presentation, the following relationships could be perceived as potential conflict of interests:
Robert Friedberg, Ph.D., ABPP: Guilford Publications, Routledge,
John Wiley, & Professional Resource Press
Relating to this presentation, there are no relationships that
could be perceived as potential conflict of interests:
Marisa Keller, M.S.
Micaela Thordarson, M.S.

3. Agenda Review of models of competence in CBT
Current measures of competence in use
CTRS-CA

4. Newman (2010): Cube Model Developmental Functional Foundational
Declarative knowledge forms the foundation of competence
Procedural proficiency marks a clinician’s skill in applying declarative knowledge
Without procedural skill, declarative knowledge remains inert
Developmental skill reflects the clinician’s ability to generalize skills to novel and increasingly complex situations; this ability distinguishes expert clinicians from novices
Competence assessments must therefore attend to both procedural and self-reflective knowledge.

5. Definition of Competencies: The “Cube” Model
Foundational Competencies
Applies to all psychotherapeutic modalities
Overall professionalism
Adherence to ethical standards
Ability to self-reflect and self-correct
Cultural awareness and sensitivity
Collaboration with other professionals
Functional Competencies
Developmental

6. Definition of Competencies: The “Cube” Model
Foundational Competencies
Functional Competencies
Specific knowledge and skills
Assessment and diagnosis
Structuring sessions
Teaching specific skills
Case conceptualization
Assigning and reviewing homework
Developmental

7. Definition of Competencies: The “Cube” Model
Foundational Competencies
Functional Competencies
Developmental
Therapist’s stage of training and experience
Competence should not be measured at a single point in time

8. Definition of Competencies: Specific for CBT with Youth
Sburlati and colleagues (2011) model of therapist competence for evidence-based treatment of child anxiety and depression
General therapeutic competencies
CBT competencies
Specific CBT techniques
General therapeutic competencies can be thought of as analogous to the foundational competencies described in the “Cube” model.
CBT competencies and specific CBT techniques fall into the functional competency category and can be described in a broad way that applies to many populations and target problems, or specified as Sburlati et al did for EBTs for child anxiety/depression.

9. Definition of Competencies: The Example of Child Anxiety
General therapeutic competencies
Knowledge of relevant child and adolescent characteristics
In addition to general competencies required for working with any population (e.g., professionalism – foundational competencies), child practitioners need competency in developmental knowledge

10. Definition of Competencies: The Example of Child Anxiety
Specific CBT techniques
Managing negative thoughts
E.g.: Cognitive restructuring
Positive imagery
Thought stopping/interruption
Changing maladaptive behaviors
Interoceptive exposure
Response prevention
Behavioral activation
Managing maladaptive mood and arousal
Emotion identification, expression and regulation
Progressive muscle relaxation
Broad CBT competencies remain similar for any population, but specific CBT techniques are needed depending on the population and target problem.

11. Definition of Competencies: The Example of Child Anxiety
Specific CBT techniques
General skills training
Problem solving skills
Friendship skills
Communication and negotiation skills
Modifying the family environment
Family communication and conflict resolution
Parental expectations management
Parent contingency management

12. Definition of Competencies: Methods for Evaluation
Clinical Skills Hierarchy (Muse & McManus, 2013)
Level 1: Knows
Level 2: Knows how
Level 3: Shows how
Level 4: Does
Muse & McManus added to the literature on clinician competency by outline the various assessment strategies that can be used to measure different types of clinician skill.
They describe four levels of clinician skill that are arranged hierarchically – one must attain competence in Level 1 to have competence in Level 2 and so on.

13. Definition of Competencies: Methods for Evaluation
Clinical Skills Hierarchy (Muse & McManus, 2013)
Level 1: Knows
Does the therapist have the relevant knowledge?
Assessments of knowledge
Multiple choice questions
Essays
Level 2: Knows how
Level 3: Shows how
Level 4: Does
These are the types of measurements used in academic settings. Graduate schools test students on the knowledge acquired that is ideally relevant to future clinical practice.

14. Definition of Competencies: Methods for Evaluation
Clinical Skills Hierarchy (Muse & McManus, 2013)
Level 1: Knows
Level 2: Knows how
Does the therapist know how to apply the knowledge?
Assessments of practical knowledge
Short-answer clinical vignettes
Case reports
Multiple choice questions
Essays
Level 3: Shows how
Level 4: Does
Level 2 moves from static knowledge into application. Requires the ability to take Level 1 knowledge and understand how and when to apply it to case examples.

15. Definition of Competencies: Methods for Evaluation
Clinical Skills Hierarchy
Level 1: Knows
Level 2: Knows how
Level 3: Shows how
Can the therapist demonstrate the skill?
Assessments of practical application of knowledge (skill)
Standardized role plays
Level 4: Does
Level 3 emphasizes practical skill. This is the ability to demonstrate a specific skill, such as through role plays.

16. Definition of Competencies: Methods for Evaluation
Clinical Skills Hierarchy
Level 1: Knows
Level 2: Knows how
Level 3: Shows how
Level 4: Does
Can the therapist use skill in practice?
Assessment of clinical practice
Ratings of treatment sessions (self or observer)
Supervisory assessments
Patient surveys or outcomes
Level 4 is the ultimate goal – the competence use of skills in practice. It is this area of competence evaluation that is most critical to ensuring standard of care and accountability in the changing healthcare landscape.

17. Current Measures of CBT Competence
Cognitive Therapy Rating Scale (Young & Beck, 1980, 1988)
Gold standard evaluation of competence for CBT
Items score on 7-pt Likert scale
Explicitly assesses functional competencies
Developed for and normed on adult population
Cognitive Therapy Rating Scale – Revised (Blackburn et al., 2001)
Revision of original CTRS
Aims to improve on prior measure by eliminating redundant items, clarifying item anchors, and adding items to address adherence
Developed for adult patients
CTRS – excellent for use in CBT with adults
neglects skill integral to effective care of youth
CTS-R – not a distinct improvement from original

18. Current Measures of CBT Competence
Cognitive Therapy Supervision Rating Scale (Sudak et al., 2001)
Assesses skill in CBT based on AADPRT standards
Items score on 3-pt scale
Not specific to child patients
Cognitive Therapy Adherence and Competence Scale (Barber, Liese, & Abrams, 2003)
Aims to measure adherence and competence in CBT
Separate scores for adherence vs. competence
7-pt Likert scale
CTSRS – developed specifically for psychiatry
not for practice with youth
limited variability in scoring does not allow for nuanced feedback or clear reflection of progress
CTACS – FIND OUT MORE ABOUT THIS MEASURE
Each of these measures of competence demonstrates good - moderate psychometric properties, is to be completed by an observer, and applies transdiagnostically
However, not one is developed for young patients and none account for the different clinical skills needed to work with children and adolescents.

19. Current Measures of CBT Competence
Latest measures
Assessment of Core CBT Skills (Muse, McManus, Rokovshik, & Kennerley, 2014)
Draws from CTRS, CTS-R
High specificity of skill assessment
Not specific to treatment of youth
Cognitive Behavior Therapy Scale for Children and Young People (Stallard, Myles, & Branson, 2014)
Draws from CTS-R
Process and Method domains
Addresses particular competencies for work with youth
ACCS – increased specificity of skill assessment but the drastic increase in the number of items does not attend to the criticisms of competence assessments as time/resource consuming
CBTS-CYP – though this measure attends to the fact that tx of youth is different from work with adults, some of the items are non-specific or leave room for subjective understanding (not clearly operationalized); also has more items, creating a bulky measure

20. CTRS-CA (Friedberg & Thordarson, 2013)
14 items
Likert scale 0-6
Developed from other measures, clinical child therapy literature, and CBT research
Refined using Delphi technique
Completed after direct observation by an observer
3 domains:
General Clinical Stance Variables
Session Structure
Strategies for Change
Current studies under way assessing psychometric properties

21. CTRS-CA General Clinical Stance Variables Collaboration
Essential ingredient for CBT
Informality
Creates a relaxed and open atmosphere
Playfulness
Engages youth in therapy
Credibility
Ability to communicate effectively with youth and parents
Pacing & pushing
Efficient use of session time
Interpersonal effectiveness & empathic communication
Fundamental micro-counseling skills
Skills are dialectical – ability to strike balance between the ends of the spectrum

22. CTRS-CA Session Structure Agenda
Collaborative and realistic outline of session tasks
Feedback
Elicitation of patient and parent input throughout session
Homework
Design of tasks outside of session to generalize skills

23. CTRS-CA Strategies for Change Guided discovery
Thoughtful use of questions to direct therapy
Focusing on key cognitions and/or behaviors
Identification of thoughts/behaviors indicative of core beliefs
Strategy for change & case conceptualization
Use of techniques following a cohesive formulation of patient’s distress
Application of cognitive-behavioral techniques
Skill observed in use of interventions

24. CTRS-CA Retains the strengths of the CTRS for adult patients
Attends to specific skillset needed to effectively care for youth.
Clearly operationalizes each proficiency and illustrates levels of competence across the spectrum.
Directs training and practice to distinguish between young patients and adults.
Provides clear, specific guide for improvements in delivery of care.

25. Summary
Clinician competence is a critical aspect to care that requires active attention.
Multiple measures available to assess.
However, very few for child populations.
New measures in stages of development/validation create opportunities to enhance training and delivery of care.
Use of child-specific CBT competence measures ensure continuation of the field.

26. References
Friedberg, R. D., & Thordarson, M. A. (2013). Cognitive therapy rating scale for children and adolescents. Los Altos: Center for the Study and Treatment of Anxious Youth.
Muse, K., & McManus, F. (2013). A systematic review of methods for assessing competence in cognitive-behavioural therapy. Clinical Psychology Review, 33(3), 484–99.
Newman, C. F. (2010). Competency in conducting cognitive-behavioral therapy: Foundational, functional, and supervisory aspects. Psychotherapy Theory, Research, Practice, Training, 47, 1,
Sburlati, E. S., Schniering, C. A., Lyneham, H. J., & Rapee, R. M. (2011). A model of therapist competencies for the empirically supported cognitive behavioral treatment of child and adolescent anxiety and depressive disorders. Clinical Child and Family Psychology Review,14(1), 89–109.
Young, J., & Beck, A. T. (1980). Cognitive Therapy Rating Scale (CTRS). Bala Cynwyd, PA: Beck Institute for Cognitive Behavior Therapy.