1. Simply Effective CBT Supervision For Low and High Intensity IAPT
Dr Michael J Scott Wednesday, September 10th 2014 For this presentation and notes me, if I have not replied in 48hrs send an appropriate reminder!

2. Resources
1. Simply Effective Cognitive Behaviour Therapy Supervision (2014) London: Routledge Michael J Scott 2. Collaborative Case Conceptualization (2009) New York: Guilford Press Willem Kuyken, Christine A. Padesky and Robert Dudley

3. Learning Objectives
To distil a viable model of supervision in which supervision is seen as a crucible for reflective thinking which reciprocally interacts with knowledge and skills
To appreciate the similarities and differences between traditional supervision and supervision for evidence based practise
Understand a framework for ensuring the EBP of Supervisees
Ensure Supervisees practice flexibility within fidelity
Appreciate that competence without adherence is meaningless – fidelity = adherence + competence
Distinguish competences: stage specific, diagnosis specific and generic
Appreciate that a failure in one competence sabotages the others

4. ‘I’m stuck with……….’
This is a reflection on a difficulty with a client that the supervisee feels they are unable to resolve
The supervisor determines whether there is a gap in the supervisees knowledge and/or skill in the matter
Collaboratively supervisor and supervisee determine how these gaps may be closed
This is the opening gambit of most supervisees in most supervision sessions

5. Thinking Back to Your Last Session as a Supervisor or as a Supervisee (if you haven’t yet Supervised):
Was a gap in knowledge identified?
Was a gap in skills identified?
How were the gaps closed?
If gaps in knowledge or skills were not identified and steps
taken, what therapist/supervisor learning has taken place?
Overall in your supervision sessions is there a balance of didactic and experiential learning?
Take 5 mins to recall your session and make notes on it then Discuss in groups of 4-6 for 15 mins whether there could have been better identification of gaps and better ways of closing gaps
Relective Thinking
Declarative knowledge
Procedural knowledge

6. Important Dimensions of The Supervisory Relationship – in the last session did my supervisor (or me) provide
Safe base e.g the supervisor was respectful of my views
Structure – sessions were structured
Commitment – did my supervisor pay attention to my anxieties feelings
Reflective education – did my supervisor encourage me to reflect on my practice
Role model – did I respect my supervisors skills
Formative feedback – was my supervisors feedback on my performance constructive
P161 The Supervisory Relationship Questionnaire. Spend a few mins reflecting on how you fare on these dimensions and make some notes. Anyone want to make a Confession? Any plans for moving forward?

7. Role Play Supervision re: Mark
Going to do a short role play of Supervision session, and then have plenary discussion of it
How do you think the Supervisor did in terms of the Supervisory relationship?
Will look at problems surrounding TFCBT in later clips, we will come back to Mark

8. Commonalities In Supervision Across Treatment Modalities
Identifying gaps in knowledge
Identifying gaps in skills
Bridging the gaps
Maintaining a good supervisory relationship
Balancing didactic and experiential learning

9. What Is Specific About Supervision In IAPT?
To answer this we have to ask, what is the ultimate rationale for supervision?

10. Defining The Primary Function of Supervision
What are we trying to build with supervision?

11. The Supervisor As A Conduit for EBT’s
Evidence-based treatment (EBT)
Supervisee
Supervisor

12. A Top Down Account of Evidence-Based Provision
Academic Clinicians
Randomised Controlled Trials
Scientist Practitioner Model
CBT Training Courses
Managers
Supervisors
Clinician Providers of CBT
Clients
The top down model assumes supervisors, managers and training courses are aware of the results of rct’s but is this the case?
Put up your hand if you currently supervise? Count the number x
Of the current supervisors how many routinely read Behaviour Research and Therapy or the Journal of Consulting and Clinical Psychology?
Where do you supervisors get your knowledge of rcts from?
How many are not current supervisors Count number
How many of current non-supervisors routinely read BRAT or Journal of Consulting and Clinical Psychology Count number
Where do you non-supervisors get your knowledge of rcts from?
How many Managers Count number
How many Managers read Brat or Journal of Consulting
Overall few managers supervisors are accessing materials on rcts

13. Question Time
How many studies show the superiority of behavioural activation to cognitive therapy or vice versa?
In what area/condition was a difference demonstrated?
What, if any, are the implications for routine practice?
How do you assess therapeutic competence in these modalities?
Plenary
Dimidjian et al (2006) Pandomised trial of behavioral activation , cognitive therapy and antidepressant medication in the acute treatment of adults with major depression. Journal of Consulting and Clinical Psychology, 74,
Only difference BA> CT for the severeley depressed but just one study
BA inrended to be simple no guided discovery CTRS therefore inappropriate

14. The Consequences of Not Appreciating The Strength of Evidence
Manager pressurising CBT therapist to provide a group for all comers
Inappropriate limiting of the number of sessions
Adoption of strategies based on eminence/convenience rather than evidence
Promotion of interventions that are new but have no demonstrated added value over a traditional CBT intervention

15. The Supervisor As Foreman
How do you ensure that the treatment your supervisee is providing is evidence-based?
If treatment is only as good as a reliable assessment, how do you ensure the latter?
How do you ensure that you don’t stop at the first disorder/major problem identified?
Multiple disorders are the norm, how do you help supervisees address this?
Spend 15 mins in groups discussing these, then plenary

16. The GAP Between Supervision in RCT’s and In Routine Practise
Frequency
Focus on fidelity (adherence plus competence)
Diagnosis specific protocols
Use of a manual
Supervision takes place in the context of ‘Gold standard assessments’, standardised semi-structured interviews such as the SCID
It isa myth that in rcts patients have only one disorder

17. To The Extent That Supervision In Routine Practise Departs From That In RCTs It Is Less Likely To Be Evidence Based
Discussion How could you close the gap?

18. ‘This Is Complex’
Imagine Mark visits the garage a few days after the accident the mechanic is peering under the bonnet of his car and proclaims ‘This is Complex’ His thoughts might be ‘is he/she working a fast one? Is this going to cost me an arm and a leg’?’
Departures from protocols are often justified on the basis that this case is ‘Complex’
I want to suggest that when someone decribes a case as ‘complex’ a warning bell should sound
The comment engenders scepticism, I think supervisors should be sceptical when supervisees use the term ‘complex’

19. Complexity Is Largely A ‘Fuzzy’
There is no evidence that it is not possible to interweave protocols for different disorders e.g Falsetti (2005) the treatment of panic attacks and PTSD Scott (2009) has given detailed examples of the interweaving of protocols There is no evidence that you have to treat one disorder e.g alcohol abuse before treating a co-existing disorder e.g PTSD, Gulliver (2010)

20. The CBT car called Fidelity!

22. For the CBT car to go need both a body to the car and an engine

23. The Competence Engine
Generic competence
Diagnosis Specific Competence
Stage Specific Competence
Use example of person checking more post trauma and therapist concludes got ocd, follows protocol faithfully but gets no where cause top cog not working not got ocd, even dong skillful therapy e.g good socratic getting nowhere, nothing turning

24. Competence in initial evaluation is crucial as most CBT treatments are diagnosis specific e.g Ehlers and Clark treatment of PTSD

25. Diagnosis Specific Competences
E.g
Treatment fidelity in depression
Adherence: How thoroughly were specific treatment targets and techniques addressed in the session?
Competence:
How skillfully was the target addressed using the particular techniques? Rate 1-7 where no competence 1 and 7 total competence
Not done Extensively
discussed
Treatment target
Technique
Score
Inactivity
Developing wide-ranging modest investments
Extract p94, table 8.1 explain
Treatment fidelity scales for depression and the anxiety disorders are on p’s

26. Generic Competence Can use one question
Competence is globally rated for each session with a single rating on a 7-point scale
Clearly Fair Good Excellent
Inadequate
A therapist is rated as excellent if she or he has warm, supportive, collaborative, Socratic Style and was able to articulate the concepts clearly, making them personally relevant to the client in the setting and review of homework.
Adapted from Huppert et al (2001)
p100

27. Generic Competence and the CTRS-R
It has only been found to relate to outcome in CBT for depression (Shaw et al 1999) and the effect was modest, accounting for 19% of variance in outcome on a clinician administered measure and no relation with self-report outcome measures
Aspects most associated with outcome were setting of agenda, assigning relevant homework and pacing the session. Guided discovery did not predict outcome
The CTRS-R is arguably a ‘silver standard’ and not a ‘gold-standard’
P53 CTRS-R

28. First Video Clip of Supervision Session re: Mark
In this clip the Supervisee has adhered to Foa’s treatment prolonged exposure, but hasn’t achieved the expected outcome. The Supervisor has updated the current understanding of the protocol and highlighted a new treatment target ‘buying’ into the model. In this way the Supervisor has bridged a knowledge gap but there is also a skills gap and the Supervisor has bridged this with a role play’ i.e has addressed both declarative knowledge and procedural knowledge as supervision should be both didactic and experiential.

29. References On Reduction of SUDS
Bluett et al (2014) Does change in distress matter? Mechanisms of change in prolonged exposure for PTSD. Behavior Therapy and Experimental Psychiatry,
Meuret at al (2012) Does fear reactivity during exposure predict panic symptom reduction? Journal of Consulting and Clinical Psychology,

30. Second Video Clip of Supervision Session Re: Mark
This clip highlights how things can go badly wrong because the initial evaluation was likely wrong, systematic enquiry had not been made about a wide range of disorders. The Supervisee had stopped at the first disorder suggested and had not reliably checked out whether this diagnosis was appropriate. Although she has faithfully adhered to Foa’s protocol the CBT car has stopped because of a poor initial evaluation, because the top cog has stopped rotating the others have ground to a halt

31. Reliable Initial Evaluation – a stage specific competence
Screen for a wide range of disorders
Enquire about each symptom of a DSM criteria, endorse a symptom as present only if it produces significant impairment e.g a person may report nightmares of a trauma but if currently it does not cause them to wake up, then wouldn’t endorse symptom as present now. See Scott (2008) Simply Effective Cognitive Behaviour Therapy Routledge: London
Expect that there will usually be more than one disorder present and to be targetted
My little old lady!

32. Depression Group Life Role Play
Use Depression Fidelity Scale to assess Therapist Competence
Also Use One Item Measure of Generic competence
Could also have used CTRS-R
There is a Group CBT Cognitive Therapy Rating Scale in Simply Effective Group Cognitive Behaviour Therapy (2009) Scott, as well as self-help manuals for depression and each of the anxiety disorders (these are available as free download from
Now do a group role play with me being the therapist 4 volunteers to be their last depressed case and use the Depression Fidelity Scale (slide 25) and the measure of Generic Competence to assess. Imagine it’s the 2nd therapy session and the first session has been about encouraging them to be more active and to read the depression Survival Manual that is a free download. Do role play 15 mins then discuss

33. Guided Self Help - Fidelity Checklist for Depression
Did the therapist focus on this and were applicable its’ implementation?
Yes (3), Yes, but insufficiently (2), No (1) 1.
Assess - using CBT Pocketbook, (beginning and end of contact) 2.
Psychoeducation – Section 1 How depression develops and keeps going 3.
Section 2 No investments, no return 4.
Section 3 On second thoughts 5.
Section 4 Just make a start 6.
Section 5 Expectation versus experience and recalling the positive 7.
Section 6 Negative spin or how to make yourself depressed without really trying
There are also checklists you can use in Low intensity Interventions

34. GSH Fidelity Scale for Depression contd.8.
Section 7 An attitude problem 9.
Section 8 My attitude to self, others and the future
10.
Section 9 Be critical of your reflex first thoughts not how you feel
11.
Section 10 Preventing Relapse
12.
Collaboratively plan homework
13.
Seek feedback on session
14.
Clarify if there are further questions
15.
Agree next appointment
16.
Review homework

35. The Supervisory Context and Organisational Mandates – some examples
Low intensity IAPT
Pain Management
Eating Disorders Unit
P55, the Supervisor may be subversive asin these examples, is your context problematic?

36. The CBT Therapist As Engineer May Challenge Received Wisdom
For example prolonged exposure for PTSD is an advocated EBT but few CBT therapists use it – Scott and Stradling (1997) found that only 57% of clients in routine practise complied with listening to a trauma tape. Therapists will not swallow wholesale the findings of EBT’s.
The Engineer is concerned at the sabotage of EBT by a) the use of surrogate outcome measures e.g self report measures used in IAPT studies and b) poorly specified populations e.g no semi-structured standardised interview to determine what the client is suffering from in IAPT studies
The Engineer is alarmed when a study of low intensity IAPT is described as ‘haemorrhaging clients’ Richards and Borglin (2011)

37. Scientist Practitioner Model Defunct?
CBT therapists are not an homogenous group, they consist of academic clinicians, involved in rct’s and Engineers delivering a service in routine practice. For effective dissemination and implementation communication must be bottom up as well as top down Engineers also likely to use a ’friends and family test’ would you recommend this treatment delivered by these practitioners to a friend or family member Engineers operate in a scientific paradigm, testing out the viability of interventions in different contexts

39. Supervision Is Mandatory

40. Does Supervision in IAPT, or indeed in CBT generally, make any difference to client outcome?
Is it proven, not proven or false?

41. The Facts Of The Matter
Bambling et al (2006) compared supervision v’s no supervision in problem solving therapy for depression:
The clients of therapists undergoing supervision did significantly better.
Dropout rates were 35% in those not supervised and 4.5% in those supervised.
P9-10 of book

42. The Facts Of The Matter contd.
2. Bradshaw et al (2007) compared the effects of a 2 day course for supervisors, to enable supervisee nurses delivering a family and CBT intervention to the care givers of patients with schizophrenia, with the same intervention delivered by nurses without any supervision. Those patients indirectly linked to supervision showed greater reduction in total psychotic symptoms.

43. The Facts Of The Matter contd. yet further
3. White and Winstanley (2010) trained supervisors via a 4 day course, and supervised nurses over the course of a year; the results were compared with patient outcomes where there was no supervision provided. The result was no difference in outcome.

44. Opinion Not a lot to go on
Just 2 studies involving CBT- questionable whether representative of normal supervision with supervisees with diverse clients
No study of the effectiveness of supervision for guided-self-help (GSH)
Is supervision evidence-based?
An evidence based intervention presumes the attainment of some target, what is the target in supervision?

45. Grading of Recommendations Assessment, Development and Evaluation (GRADE)
Code
Quality of Evidence
Definition A
High
Further research is very unlikely to change our confidence in the estimate of effect.
Several high-quality studies with consistent results
In special cases: one large, high-quality multi-centre trial B
Moderate
Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
One high-quality study
Several studies with some limitations C
Low
Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
One or more studies with severe limitations D
Very Low
Any estimate of effect is very uncertain.
Expert opinion
No direct research evidence
One or more studies with very severe limitations
From Grade Working Group based on ‘Grading quality of evidence and strength of recommendations’ BMJ, (2004)
NICE give similar gradings on evidence
As a rough rule thumb The treatments in High Intensity IAPT are A’s and B’s, whereas in low Intensity IAPT they are C’s and D’s, whatever the precise grading there is a transition from High evidence to Low evidence as you go from High intensity to Low Intensity IAPT.

46. ‘Individually tailored ICBT is an effective and cost-effective treatment for primary-care patients with anxiety disorders with or without comorbidities’ Nordgren et al (2014), 59, 1-11.
‘we did not administer the SCID – interview at post-treatment or at follow up, giving us no possibility to answer questions regarding remission or recovery from the initial diagnoses’
‘we rely on self-report measures’
The SCID was used initially to diagnose patients and to determine which protocol was used
Fuzzy outcome measures this was internet delivered cbt
We don’t use SCID in IAPT to diagnose and determine treatment so is this applicable, does IAPT assessment have to change

47. ‘All you need is a hot cross bun, a PHQ9 and a GAD7’

48. ‘ Evaluating Research Is Too Complex/Time Consuming Just Help Supervisee Make A Good Formulation’
Discuss

49. Cognitive Model
Cognitions
Emotion
Behaviour
Physiology

50. ‘How Reliable Is This Way of Proceeding
‘How Reliable Is This Way of Proceeding?’ As a Supervisor Would You Be Happy With This?
Discussion