With the growing emphasis on Evidence-Based Psychotherapies (EBPs) it is important to take notice that in the community there are generally no assurances of fidelity to a treatment methodology. Consider the following scenario: A young man experiencing symptoms of Panic Disorder is advised by a savvy primary care physician to seek psychotherapy. This gentleman does some research online and finds that Cognitive Behavioral Therapy (CBT) with Interoceptive Exposure is generally accepted to have the most empirical support for treating Panic Disorder. He calls a local psychotherapist, whose website describes the clinician’s orientation as “CBT.” If that young man obtains psychotherapeutic services from that therapist, would he actually receive CBT similar to that described in the research that he read about online?
According to a recent study by the Aaron T. Beck Psychopathology Research Center published in Administration and Policy in Mental Health and Mental Health Services Research, we do not actually know what type of services might be provided (see Creed, Wolk, Feinberg, Evans, & Beck, 2014), as a therapist’s self-identified theoretical orientation might not be a valid predictor of what is actually done in session (see McKay, 2014).
In the referenced article, Creed et al. (2014) state that their purpose was to look at the relationship between clinician self-report of theoretical orientation and competency in that method as measured by ratings of audio recordings of work samples. The researchers were focused on competency in CBT, but the implications of this research will be discussed broadly. With a sample of 321 community clinicians, they found that the ratings of fidelity to the CBT model for the audiotapes of the therapists who identified as CBT-therapists were scored as roughly equivalent to those of their non-CBT counterparts. In other words, clinicians who reported using CBT in session would not be considered to be doing so when adhering to objective standards of competence and fidelity. In fact, the average CBT competency ratings were indistinguishable between CBT and non-CBT self-identified community clinicians.
Upon closer examination, both groups were in the “good” range for items relating to empathy, warmth, and collaboration; however, both groups were in the less than “satisfactory” range for the CBT-specific items. Notably, the majority of these clinicians were later trained to competency in CBT per the Cognitive Therapy Rating Scale (CTRS; Young & Beck, 1980). Creed and colleagues recognized that people seeking psychotherapeutic services may be in a precarious situation, as their findings indicated that how psychotherapists represent themselves may not reflect the quality or content of what they actually do in session. They state that the public may need to rely on specialty certifications such as those available through the Academy of Cognitive Therapy and the American Board of Professional Psychology.
Implications for Psychotherapists
While Creed and her colleagues looked at CBT specifically, these findings are relevant to the field of psychotherapy in general. The potential negative outcomes for clients—who may not be receiving the services they seek—are clear and should be cause for concern. The results of the study should provide clinicians with an opportunity for reflection as well. We assume that the therapists in the study were not being deliberately deceitful, but the findings do raise questions about professional self-awareness and perhaps therapist training. An important concept to review is the better-than-average effect (Hilbert, 2012; Hoorens, 1993)—a finding that most people deem themselves better than average. This natural overconfidence is dangerous to our clinical work, and a way to address this cognitive bias is through practicing vulnerability (Brown, 2012).
Audio-Recording Therapy Sessions
The topic of audio-recording psychotherapy sessions has been a hot-button topic in the literature (Aveline, 1992). A regularly reported concern is a fear that audio recordings will inhibit client self-disclosure (Gelso, 1973); however, it has been found that as the session progresses both the client and the therapist often forget about the recording device, and clients do not report feeling inhibited by the recording process (Brown, Moller, & Ramsey-Wade, 2013). Shepherd, Salkovskis, and Morris (2009) explored the utility of audio-recording sessions and found that the majority of clients are open to having sessions audio recorded for the purposes of therapist peer-supervision. Further, it was found that clients liked having copies of these recordings to review the session content in between sessions. Thus, not only are clients open to therapists recording sessions for the purposes of peer supervision, but allowing the client to have a copy of these recordings may accrue additive benefits to the services being provided. Shepherd and her colleagues found that clients rated this practice as being both highly acceptable and highly useful. This is certainly consistent with our anecdotal experience.
The review of audio-recordings of sessions has long been suggested as a core component of both CBT and psychodynamic supervision (Aveline, 1992; Pretorius, 2006). Interestingly, Shepherd and her colleagues (2009) found that psychotherapists were more likely than their clients to express concern about recording sessions. A possible reason for this hesitancy might be that professional psychotherapists might associate audio-recording their sessions with being in the trainee role and this may invoke feelings of unease, anger, or shame. There is a wealth of literature showing that a common reaction to all of these feelings is avoidance (see Brown, 2012; Linehan, 1993), and, as the adage goes, the only way out is through.
Revisiting the Concept of Peer-Supervision
Peer-supervision is ideally a practice in vulnerability, where therapists choose to tolerate feelings of unease in order to refine their skills and deliver better client care. A core-component of peer-supervision should be work-sample review. The literature on the use of audio recordings in traditional supervision has demonstrated that clinician memory may not be completely reliable and that the nuances of a case are more easily understood when listened to than explained (see Aveline, 1992; Brown et al., 2013; Shepherd et al., 2009). In our experience, having a flexible schedule of who will be presenting works well. It allows for clinicians to come prepared to share and for the addressing of any pressing needs that develop in between peer-supervision sessions.
One could think of peer-supervision as having three goals: (1) Providing emotional and practical support for the therapist, (2) Refining the therapist’s clinical skills/acumen, and (3) Ensuring better client care. To facilitate these goals a peer-supervision group would need to establish an emotionally-safe environment and have competent clinicians within the group. We’ll first discuss establishing a safe space and then measuring clinician competency.
A useful model to consider is that presented by Linehan (1993), in which clinicians come to peer-supervision with specific consultation questions, are reminded to practice a nonjudgmental stance, receive validation and support from the team, and have a fallibility clause stating that clinicians are fallible and that’s okay. Typically, we find that practicing vulnerability through embracing our imperfect human nature and owning up to mistakes needs to be modeled by more senior clinicians to reassure newer clinicians that peer-supervision is a safe space. The words of John Steinbeck from East of Eden (1952) illustrate the usefulness of the fallibility agreement: “And now that you don't have to be perfect, you can be good.”
To aid in the assessment of clinician competence we recommend the use of competency rating scales. In order to receive a valid score on these measures you often need to be calibrated to the measures; nevertheless, the content of these freely available tools can be useful when reviewing your own or a peer’s session audio. The most widely used measure of CBT competencies is the CTRS (Young & Beck, 1980). For clinicians who do not identify as CBT practitioners, a number of useful non-CBT competency measures have been developed. For example, the Yale Adherence and Competence Scale (YACS; Carroll et al., 2000) measures competency of addiction counselors and the Common Factor Therapist Competence Scale for Youth Psychotherapy (Brown, 2011) was recently developed for therapists who espouse an eclectic orientation.
Specialty Competency-Based Certifications
The following question has been raised: How do we protect the public from those who unknowingly or inadvertently misrepresent their services? Returning to the gentleman we previously discussed, how do we ensure that he actually receives the services he researched? Currently, the best bet is through specialty competency-based certifications such as those available through the Academy of Cognitive Therapy and the American Board of Professional Psychology (McKay, 2014). What distinguishes competency-based certifications from other existing options is the use of practice sample review and objective standards of competency. For example, when a clinician applies for certification through the Academy of Cognitive Therapy the review process involves verifying training and licensure, having supervised experience in CBT, having been practicing CBT for a number of years with a number of clients, having read the essential treatment manuals and textbooks, letters of recommendation, and a work sample review consisting of submitting a thorough treatment summary and audio sample which is rated on the CTRS. Thus, it is clear that when we say that these specialty certifications protect the public it is because they thoroughly assess the competency and qualifications of a psychotherapist. If we were to refer the gentleman we previously discussed for therapy and we wanted to ensure he received high-quality CBT, we would first look for a therapist who was certified by a body such as the Academy of Cognitive Therapy. For those of you reading this article who do not practice CBT, we’d encourage you to seek high-quality training, supervision, consultation, and certification in the therapeutic orientation in which you provide services. For example, the American Board of Professional Psychology also provides certification in psychoanalysis. Additionally, many other specialty certifications exist; interested parties should be wary of vanity certifications and should seek consultation with reputable professional bodies regarding the merit of these credentials.
Summary and Conclusions
In summary, we reviewed a recent troubling finding that a discrepancy exists between how therapists describe their theoretical orientations and their competence in those orientations. We highlighted barriers such as the better-than-average bias and avoidance that may prevent professional clinicians from seeking peer supervision. We reviewed the utility of peer supervision, audio recording sessions, competency measures, and specialty certifications. Overall, the goal is to do whatever you do really well, and to recognize that in order to grow as a clinician you may need to practice some vulnerability.
Cite This Article
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