Competence In Cognitive Therapy Research Articles

Use of cognitive techniques is associated with change in positive compensatory skills in the treatment of major depressive disorder in a community mental health setting

Objective: To examine the association between adherence and competence in cognitive therapy (CT) techniques and change in positive compensatory skills and depressive symptoms within a community mental health setting. Method: Adherence ratings were available for 97 individuals receiving CT for major depressive disorder. Assessments of adherence and competence were rated on one early session of CT. Compensatory skills were measured using the Ways of Responding Community Version at baseline and months 1, 2, and 5. Symptom severity was evaluated using the Hamilton Rating Scale for Depression at baseline and months 1, 2, 4, and 5. Results: In mixed effects models, adherence was significantly associated with linear change in positive compensatory skills from baseline to month 5 (F [1, 76] = 8.05, p=.006, r=.31). Competence was also significantly associated with change in positive compensatory skills from baseline to month 5 (F [1, 78] = 5.1, p=.027, r=.25). High adherence was associated with improvements in HAM-D scores from baseline to month 5 (F [1, 78] = 5.1, p=.027, r=.25). Conclusions: Results support the hypothesis that use of CT techniques is associated with change in compensatory skills in a community mental health setting.

Assessing panic disorder-specific competencies: evaluation of the Cognitive Therapy Competence Scale for panic disorder.

Evidence-based treatment for panic disorder consists of disorder-specific cognitive behavioural therapy (CBT) protocols. However, most measures of CBT competence are generic and there is a clear need for disorder-specific assessment measures. To fill this gap, we evaluated the psychometric properties of the Cognitive Therapy Competence Scale (CTCP) for panic disorder. CBT trainees (n = 60) submitted audio recordings of CBT for panic disorder that were scored on a generic competence measure, the Cognitive Therapy Scale - Revised (CTS-R), and the CTCP by markers with experience in CBT practice and evaluation. Trainees also provided pre- to post-treatment clinical outcomes on disorder-specific patient report measures for cases corresponding to their therapy recordings. The CTCP exhibited strong internal consistency (α = .79-.91) and inter-rater reliability (ICC = .70-.88). The measure demonstrated convergent validity with the CTS-R (r = .40-.54), although investigation into competence classification indicated that the CTCP may be more sensitive at detecting competence for panic disorder-specific CBT skills. Notably, the CTCP demonstrated the first indication of a relationship between therapist competence and clinical outcome for panic disorder (r = .29-.35); no relationship was found for the CTS-R. These findings provide initial support for the reliability and validity of the CTCP for assessing therapist competence in CBT for panic disorder and support the use of anxiety disorder-specific competence measures. Further investigation into the psychometric properties of the measure in other therapist cohorts and its relationship with clinical outcomes is recommended.

Revisiting How We Assess Therapist Competence in Cognitive Therapy

We report on two approaches to addressing the problem of low reliability in the assessment of therapist competence in cognitive therapy (CT). In Study 1, we utilized ratings of a session from each of six therapists and investigated how CT experts evaluate specific therapist behaviors in making ratings on the Cognitive Therapy Scale (CTS). Departures from the consensus on judgments of these therapist behaviors were associated with more discrepant competence ratings. We take these results to suggest that, at least among experts, providing greater clarity about which therapist behaviors are relevant to each CTS item may enhance reliability. In Study 2, we utilize a sample of 14 therapists and pilot test a standardized assessment of therapist competence. The standardized assessment exhibited an intra-class correlation coefficient of 0.89 for a single rater. Standardized assessments of competence were related to four measures of therapist experience and qualifications, whereas the CTS was only related to two of these measures. With these promising initial results, we encourage future research to examine the predictive validity of standardized competence assessments in CT.

Psychodynamic Therapy or Cognitive Therapy for Social Anxiety Disorder

Back to table of contents Previous article Next article Communications and UpdatesFull AccessPsychodynamic Therapy or Cognitive Therapy for Social Anxiety DisorderDavid M. Clark, D.Phil.David M. ClarkSearch for more papers by this author, D.Phil.Published Online:1 Nov 2013https://doi.org/10.1176/appi.ajp.2013.13060744AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: I read with interest the article by Leichsenring et al. (1) in the July issue of the Journal. Cognitive therapy was significantly more effective than psychodynamic therapy on four of five social anxiety measures, including all those mentioned in the trial registration document (ISRCTN53517394). As one of the developers of cognitive therapy, I was naturally delighted to see the trial extend the range of credible psychological therapies to which cognitive therapy has been shown to be superior (2). However, several design features suggest the trial is likely to have underestimated the benefit of cognitive therapy relative to psychodynamic therapy. Readers may wish to bear these in mind when considering the relatively small differences in outcome that are reported.First, to match psychodynamic therapy, the time over which cognitive therapy was delivered was extended from the usual 3–4 months to 8–9 months. There is good evidence that slowing down the delivery of cognitive-behavioral treatments for social anxiety disorder reduces their effectiveness (3).Second, “type of treatment” is confounded with “therapist experience.” On average, psychodynamic therapists were qualified and had 8.0 years of clinical experience, whereas cognitive therapists had only 1.7 years of clinical experience and many would still be trainees. In our clinic, cognitive therapy for social anxiety disorder achieves greater effects when delivered by fully trained therapists.Third, the average competency with which cognitive therapy was delivered seems to be low. Mean ratings of therapy videotapes on the cognitive therapy competence scale (unpublished 2013 paper of U. Stangier) suggest a substantial number of sessions fell below the “redline” minimum of 3.5 (out of 6.0). This is important because there is good evidence that competence predicts outcome in cognitive therapy for social anxiety disorder (4).Fourth, behavioral experiments in which therapists leave the office with patients to test their beliefs in real life are a central feature of cognitive therapy. To make such experiments feasible, the standard cognitive therapy protocol recommends 90-minute sessions. Almost all Leichsenring and colleagues’ sessions were 55 minutes, making it unlikely that such experiments were used regularly. Comparisons between previously published trials (2) show that cognitive therapy is associated with approximately 50% more improvement in social anxiety when sessions are 90 minutes compared with 55–60 minutes.In summary, Leichsenring and colleagues’ conclusion that cognitive therapy and psychodynamic therapy are both efficacious (superior to no treatment) is justified, as is the conclusion that cognitive therapy is superior to psychodynamic therapy. However, one might reasonably question their estimate of the relative effects of cognitive therapy and psychodynamic therapy. A further trial in which cognitive therapy is delivered as recommended and at an adequate level of competence would be required to clarify matters.Department of Experimental Psychology, University of Oxford, United Kingdom.The author reports no financial relationships with commercial interests.References1 Leichsenring F, Salzer S, Beutel ME, Herpertz S, Hiller W, Hoyer J, Huesing J, Joraschky P, Nolting B, Poehlmann K, Ritter V, Stangier U, Strauss B, Stuhldreher N, Tefikow S, Teismann T, Willutzki U, Wiltink J, Leibing E: Psychodynamic therapy and cognitive-behavioral therapy in social anxiety disorder: a multicenter randomized controlled trial. Am J Psychiatry 2013; 170:759–767Link, Google Scholar2 Stott R, Wild J, Grey N, Liness S, Warnock-Parkes E, Commins S, Readings J, Bremner G, Woodward E, Ehlers A, Clark DM: Internet-delivered cognitive therapy for social anxiety disorder: a development pilot series. Behav Cogn Psychother 2013; 41:383–397Crossref, Medline, Google Scholar3 Herbert JD, Rheingold AA, Gaudiano BA, Myers VH: Standard versus extended cognitive behavior therapy for social anxiety disorder: a randomized-controlled trial. Behav Cogn Psychother 2004; 32:131–147Crossref, Google Scholar4 Ginzburg DM, Bohn C, Höfling V, Weck F, Clark DM, Stangier U: Treatment-specific competence predicts outcome in cognitive therapy for social anxiety disorder. Behav Res Ther 2012; 50:747–752Crossref, Medline, Google Scholar FiguresReferencesCited byDetailsCited ByNone Volume 170Issue 11 November 2013Pages 1365-1365 Metrics PDF download History Accepted 1 September 2013 Published online 1 November 2013 Published in print 1 November 2013

Enhancing Self-Efficacy to Achieve Competence.

A primary goal of cognitive therapy supervision is to help the supervisee achieve greater competence in cognitive therapy. However, helping supervisees achieve competence rests in part on their judgments that they can use the skills they learned to help their clients feel and get better. Bandura referred to these judgments as self-efficacy, which he defined as an individual's perception that he is capable of accomplishing a certain level of performance (Bandura, 1977). Although it is understandable that most supervisees enter supervision with low self-efficacy, it can become an impediment to achieving competence if it persists. In this article, I define self-efficacy and describe four sources of information that influence self-efficacy: performance accomplishments, vicarious experiences, persuasion, and physiological states. I then describe how supervisors can use these sources to enhance the self-efficacy of supervisees to assist them in achieving actual competence.

Treatment specific competence predicts outcome in cognitive therapy for social anxiety disorder

Several studies have demonstrated a positive relationship between competence and outcome in CBT for depression but studies of CBT for anxiety disorders are lacking. The present study explores the relationship between competence and outcome in cognitive therapy (CT) for social anxiety disorder, using hierarchical linear modeling analyses (HLM). Data were drawn from a multicenter randomized controlled trial. Five trained raters evaluated videotapes of two therapy sessions per patient using the Cognitive Therapy Competence Scale for Social Phobia (CTCS-SP). Overall adherence to the treatment manual and patient difficulty were also assessed. Patient outcome was rated by other assessors using the Clinical Global Impression Improvement Scale (CGI-I) and the Liebowitz Social Anxiety Scale (LSAS). Results indicated that competence significantly predicted patient outcome on the CGI-I (β = .79) and LSAS (β = .59). Patient difficulty and adherence did not further improve prediction. The findings support the view that competence influences outcome and should be a focus of training programs. Further research is needed to compare different ways of assessing competence and to understand the complex relationships between competence and other therapy factors that are likely to influence outcome.

Assessing Therapeutic Competence in Cognitive Therapy for Social Phobia: Psychometric Properties of the Cognitive Therapy Competence Scale for Social Phobia (CTCS-SP)

There has been considerable acknowledgement in treatment outcome research that, although the assessment of treatment integrity is essential in many respects, it requires great effort as well as resources and is therefore often neglected. In order to fill this gap, the Cognitive Therapy Competence Scale for Social Phobia (CTCS-SP) was developed, based on the Cognitive Therapy Scale, to measure therapist competence in delivering cognitive therapy for social phobia. The aim of the present study was to investigate interrater reliability, internal consistency and retest reliability of the scale. Raters evaluated therapist competence from 161 videotaped sessions (98 patients) selected from 234 cognitive treatments within a multi-centre study. Interrater-reliability was found to be high for the overall score (ICC = .81) and moderate for individual items (ICC = .62-.92). Internal consistency and retest reliability were also found to be high (Cronbach's alpha = .89; (ICCretest = .86). The results indicate that the CTCS-SP is highly reliable. As even individual items yield satisfactory reliability, the scale can be used in various fields of research, including the measurement of changes in skill acquisition and the impact of competence on outcome criteria.

Assessment of adherence and competence in cognitive therapy: Comparing session segments with entire sessions

The aim of the study was to compare the reliability and validity of adherence and competence judgments of four raters, based on session segments on the one hand and on entire sessions on the other. The global adherence/competence judgments based on the middle section of 34 therapy sessions demonstrated satisfactory interrater reliability (ICC=.81/.71) and the highest correlations with therapy outcome (r=.55/.45). These results were comparable with judgments based on entire therapy sessions. However, the reliability of specific aspects of adherence and competence was higher when judgments were based on the entire session. The implications of these results are important in terms of reducing time and costs associated with the judgment process.

Therapist competence in cognitive therapy for depression: Predicting subsequent symptom change.

The efficacy of cognitive therapy (CT) for depression has been well established. Measures of the adequacy of therapists' delivery of treatment are critical to facilitating therapist training and treatment dissemination. While some studies have shown an association between CT competence and outcome, researchers have yet to address whether competence ratings predict subsequent outcomes. In a sample of 60 moderately to severely depressed outpatients from a clinical trial, we examined competence ratings (using the Cognitive Therapy Scale) as a predictor of subsequent symptom change. Competence ratings predicted session-to-session symptom change early in treatment. In analyses focused on prediction of symptom change following 4 early sessions through the end of 16 weeks of treatment, competence was shown to be a significant predictor of evaluator-rated end-of-treatment depressive symptom severity and was predictive of self-reported symptom severity at the level of a nonsignificant trend. To investigate whether competence is more important to clients with specific complicating features, we examined 4 patient characteristics as potential moderators of the competence-outcome relation. Competence was more highly related to subsequent outcome for patients with higher anxiety, an earlier age of onset, and (at a trend level) patients with a chronic form of depression (chronic depression or dysthymia) than for those patients without these characteristics. Competence ratings were not more predictive of subsequent outcomes among patients who met (vs. those who did not meet) criteria for a personality disorder (i.e., among personality disorders represented in the clinical trial). These findings provide support for the potential utility of CT competence ratings in applied settings.

Self-Evaluation of Cognitive Therapy Performance: Do Therapists Know How Competent They Are?

The quality control of therapy in routine clinical practice depends to a large degree on the ability of therapists to evaluate accurately their own performance in administering therapy. However, the literature in many fields casts doubt on the accuracy of people's self-evaluations. This study aimed to examine the accuracy of therapists' judgments about their own competence in cognitive therapy. Twenty-two therapists rated a tape of one of their cognitive therapy sessions from the middle of therapy using the Cognitive Therapy Scale (CTS) and provided information about their profession and their training in cognitive therapy. An independent expert rater, blind to all information about the therapist, also rated these tapes on the CTS. Therapists were coded as Competent or Less Competent on the basis of the observer-rated CTS score. Whilst there was a significant correlation between self-ratings and expert ratings of competence, therapists significantly over-rated their competence relative to the expert rater. Less competent therapists over-rated their own competence to a greater degree than therapists who met criteria for competence. The finding that therapists, especially less competent therapists, over-rate their competence in cognitive therapy has serious implications for ensuring effective practice of cognitive therapy in routine clinical situations.

The academy of cognitive therapy: Purpose, history, and future prospects

The Academy of Cognitive Therapy (ACT) was developed as a means to identify and credential mental health professionals who demonstrate competence in cognitive therapy. Its missions include certifying clinicians from all disciplines as competent cognitive therapists and educating the public about this empirically supported treatment. This article reviews the history of ACT, its current activities, and future prospects. It is argued that ACT fulfills several important roles and is a valuable resource for mental health professionals and consumers.

Impact of training on rating competence in cognitive therapy

This naturalistic study examines the impact of a training package on the inter-rater reliability scores of a scale devised to measure competence in cognitive therapy (CT). The study was conducted at the Newcastle Cognitive and Behavioural Therapies Centre, where trainees are routinely required to submit videotapes of their therapeutic work for marking independently by two supervisors. This process was used as vehicle for the present work, whereby the trainees’ videos were assessed in terms of their competence using a recently revised rating scale (CTS-R). The inter-rater reliability of the supervisors’ ratings was assessed both before and after the administration of a teaching package designed to improve the reliability in the use of the CTS-R. The results showed an improvement in the inter-rater agreement of five out of 12 items of the scale. The overall agreement also improved significantly following training.

The utility of the Revised Cognitive Therapy Scale (CTS-R) for assessing therapeutic competence when working with older people with depression and anxiety

The Revised Cognitive Therapy Scale (CTS-R) is a new scale for measuring therapist competence in Cognitive Therapy and is based on the original Cognitive Therapy Scales (CTS, Young & Beck, 1980, 1988). The CTS-R was developed jointly by clinicians and researchers at the Newcastle Cognitive and Behavioural Therapies Centre and the University of Newcastle-upon- Tyne (Blackburn, Milne & James, 1997). Early versions of the scale have been used in empirical studies to examine the development of therapeutic skills in therapists treating clients in adult outpatient settings (James, Blackburn, Milne & Reichelt, 2001). The present paper discusses aspects of therapy that require either emphasising, or adapting, when working with older people. Having reviewed these requirements, and then provided an overview of the scale, the paper concludes that the CTS-R needs little adaptation when used to assess the competence of therapy delivered to older people with affective disorders.

THE REVISED COGNITIVE THERAPY SCALE (CTS-R): PSYCHOMETRIC PROPERTIES

The existing scale for assessing competence in cognitive therapy (CTS) dates from 1988 and only the previous version of 1980 has been validated to any extent. A revised version, the CTS-R, was devised to improve on the CTS by: eliminating overlap between items, improving on the scaling system, and defining items more clearly. Kolb's well-known educational model was used as a guideline. In the new 14-item scale, three new items measure general therapeutic flair, the facilitation of emotional expression, and therapist's non-verbal behaviours (optional). We hypothesized that the CTS-R would prove more user friendly and demonstrate satisfactory reliability and validity. Twenty-one mental health professionals undergoing training in cognitive therapy provided 102 video-tapes of therapy with 34 patients, reflecting three stages of therapy. The tapes were rated by four expert raters, in a balanced design. The CTS-R showed high internal consistency and adequate average inter-rater reliability. Reliability for individual items varied widely among pairs of raters. Validity was demonstrated by improved ratings of competence for trainees who saw patients early and later during the course of training. Although raters found the CTS-R a more useful tool than the CTS and satisfactory reliability and validity were demonstrated, more refinement is needed in item definition. The study has led to modifications in the CTS-R, which are in the process of evaluation.

Moderators of trainee therapists' competence in cognitive therapy.

A revised version of the Cognitive Therapy Scale (CTS-R) was developed and used in an ecologically valid study designed to examine the acquisition of competence in cognitive therapy (CT). The relationship of therapist and patient variables to changes in competence was examined. Unlike most previous research, this study defines effectiveness of training in terms of therapist competence rather than patient outcome. A longitudinal design was employed within a naturalistic setting. Trainees' competence (the dependent variable) was sampled on three occasions during a training course. Twenty screened out-patients, who had been routinely referred to the Newcastle Cognitive Therapy Centre, were assigned to 20 postgraduate trainees receiving training in CT. Expert raters assessed trainees' competence at three points over the first 12 sessions of treatment using the CTS-R. The relationship of therapist and patient variables to changes in competence was examined. The patient measures used were the Beck Depression Inventory (BDI) and the Suitability for Short-Term Cognitive Therapy (SSCT). Three therapist factors were found to be related to competence: time (trainee therapists improving over the training period), previous experience with CT (those with most experience were most competent), and gender of the therapist (males improving at a greater rate than females). Therapist competence was also related to patients' suitability. These findings suggest that previous CT experience is an advantage prior to attending an advanced training course, and also that careful patient selection helps trainees to demonstrate therapeutic competence.

The Relationship Between Therapist Competency in Cognitive Therapy and General Therapy Skill

One recent trend in psychotherapy research involves the increased specification of the treatment variable through the use of therapy manuals and therapists who are trained to criteria. This study is an investigation of the relationship between ratings of therapist competence in one system of psychotherapy (cognitive therapy, CT) and ratings of therapist performance less dependent on modality-specific interventions (i.e., general therapy skills). Experts in cognitive therapy judged the quality with which a group of therapists implemented the CT protocol. The Matarazzo Checklist of Therapist Behaviour (MCTB), a scale less dependent on modality-specific interventions, was used by other, independent judges to rate the same therapy sessions. Results of correlational analyses indicated that subcategories of errors on the MCTB were differentially related to competence in cognitive therapy as measured by the Cognitive Therapy Scale. Highly competent performance was negatively related to errors in therapeutic focus, but was positively related to errors in communication. These data were interpreted to reflect the importance of tying judgments of therapy skill to the specific theoretical and technical model of the therapy system being examined.