Appendix A: Therapist Selection, Training, and Supervision
With appropriate training and supervision, a diverse range of therapists can implement CBT effectively. However, because this manual focuses on specific cognitive-behavioral techniques and does not cover basic clinical skills, certain minimal requirements are recommended.
- A master's degree or equivalent in psychology, counseling, social work, or a closely related field
- At least 3 years experience working with a substance-abusing population
- Some familiarity with and commitment to a cognitive-behavioral approach
Just as reading a textbook on surgery does not produce a qualified surgeon, mere review of this manual would be inadequate for the therapist to apply CBT strategies and techniques in clinical practice or research. Appropriate therapist training for CBT for cocaine dependence requires completion of a didactic seminar and at least two closely supervised training cases.
The didactic seminar usually lasts from 2 days to 1 week, depending on the experience level of the therapists. The seminar includes review of basic cognitive-behavioral theory and technique, topic-by-topic review of the manual, watching videotaped examples of therapists implementing the treatment, several role-play and practice exercises, discussion of case examples, and rehearsing strategies for difficult or challenging cases.
Supervised Training Cases
Supervised training cases offer an opportunity for therapists to try this approach and learn to adapt their usual approach to conform more closely to manual guidelines. The number of training cases varies according to the experience and skill level of the therapist. Generally, more experienced therapists require only one or two training cases to achieve high levels of competence. Less experienced therapists generally require two to four supervised cases.
Each session can be videotaped and forwarded to the supervisor. The supervisor should -
- Review each session.
- Complete a rating form to evaluate the therapist's adherence to CBT guidelines and competence in implementing the treatment that session.
- Provide 1 hour of individual supervision to the therapist. Supervision sessions are structured around ratings of adherence to CBT and competence in delivering the treatment, with the supervisor noting when the therapist delivered the treatment effectively as well as areas in need of improvement.
Rating of Therapists
To have a concrete basis on which to evaluate therapist implementation of CBT, therapists and supervisors should complete parallel adherence-rating forms (exhibit 13, CBT Therapist Checklist and exhibit 14, CBT Rating Scale) after each session conducted or viewed . (A copy of the rating manual and rater's guidelines that accompany these forms are available from Dr. Carroll.) They consist of Likert-type items that cover a range of key CBT interventions (e.g., review of homework, skills training).
The CBT Therapist Checklist asks therapists to rate the CBT strategies and interventions that were implemented in a given session and how much the intervention was used. The checklist has a variety of purposes -
- To remind the therapist, at each session, of the key active ingredients of CBT.
- To foster greater therapist adherence to the CBT sessions and topics through self-monitoring.
- To organize and provide the basis for supervision, since therapists can readily note and explore with the supervisor the strategies and interventions they have trouble implementing with a given patient.
- To generate a useful record of which interventions were or were not delivered to each patient in a given session. For example, one can construct a session-by-session map of the order and intensity of CBT interventions introduced to a range of different patient types.
The supervisor's version of the form, called the CBT Rating Scale, differs from the therapist's version by adding a skillfulness rating for each item. Thus, for each intervention, both quantity and quality are rated. The scale is an essential part of training.
- It provides structured feedback to the therapist and forms the basis of supervision.
- It provides a method of determining whether a therapist in training is ready to be certified to deliver the treatment.
- When used with ongoing supervision, it enables the supervisor to monitor and correct therapist "drift" in implementing the treatment.
- For therapists who have trouble adhering adequately to manual guidelines, but who maintain that they do follow it, pointing out discrepancies between the scale and the checklist is a useful strategy for enhancing adherence. Not all items on the rating forms are expected to be covered, or covered at a high level, during all sessions. However, items 3-11 reflect the essential CBT approach that should be present, at least to a moderate level, in the majority of sessions.
Certification of Therapists
Therapists are certified, or approved, to implement the treatment at lower levels of supervision when the supervisor determines that they have completed an adequate number of training cases successfully. More objective criteria would be an adherence score of a 3 or more on the key CBT items (items 3-11) for the most recent case and no skill rating below a 4 (adequate) on any item representing an aspect of CBT.
After certification, levels of therapist adherence to CBT guidelines are monitored closely using the CBT Rating Scale. When therapists stray from adequate adherence to the manual, supervisors increase the frequency of supervision until performance returns to an acceptable level.
The level and intensity of ongoing supervision reflects the experience and skill of the therapist as well as the time available for supervision. The minimum acceptable level of ongoing supervision for an experienced therapist is once a month; once-a-week supervision is recommended for less experienced therapists. Supervisors should also review and evaluate, using the CBT Rating Scale, one or two randomly selected sessions per patient.
Supervision sessions themselves should include a general review of the therapist's current cases, discussion of any problems in implementing CBT, and review of recent ratings from the supervisor. At least one of every two supervision sessions should include review of a session videotape with both the therapist and patient being present.
Supervision is most effective under the following circumstances.
- It is conducted at a consistent place, date, and time.
- The goals of the supervision are clear and both participants' roles are defined.
- The procedures that will be used for evaluation of the therapist are clear.
- Feedback to the therapist is focused and concrete.
"When you debriefed X's last slip, I thought you didn't get enough information for either of you to really understand what was going on. For example, it wasn't clear to me what was going on beforehand, how much she used, where she got the cocaine, and how the episode ended and she got back in control. I think you should be more thorough in doing functional analysis any time there is an episode of use."
Common Problems Encountered in Supervision
The structure of CBT sessions (and the 20/20/20 rule) is intended to integrate skills training with effective, supportive therapy that meets the needs of each patient as an individual. Novice therapists, particularly those with little experience in treating substance abusers or unaccustomed to a high level of structure in treatment, often let sessions become unfocused, without clear goals, and do not make the transitions needed to deliver skills training effectively. Such therapists often wait to introduce skills training until the last few minutes of the session. This results in rushing through important points, failing to use patient examples or get patient feedback, and neglecting review of the practice exercise - all of which gives the impression that skills training is not very important.
Other therapists allow themselves to become overwhelmed by the constant substance abuse-related crises presented by a patient and fail to focus on skills training or use it as an effective strategy to help the patient learn to avoid or manage crises. Falling into a crisis-driven approach tends to increase, rather than decrease, patient anxiety and to undermine self-efficacy. On the other hand, maintaining a relatively consistent session routine and balancing the patient-driven discussion of current concerns with a focus on skills and strategies is also a means by which the therapist can model effective coping and problem solving.
Conversely, some therapists become overly fixed and inflexible in their application of skills training and adherence to the manual. Anxious to get it right, they present the material in the manual more or less verbatim and fail to adapt it to the specific needs, coping style, and readiness of the particular patient.
For example, even though skills training requires considerable activity and commitment from the patient, some therapists launch into it with patients who are still highly ambivalent or even resistant to treatment. It is important to remind such therapists that the manual is not a script but rather is a blueprint or set of guidelines that provides a clear set of goals and overall structure for the treatment. This often requires considerable familiarity with the didactic material so that therapists can alter the material for each patient and present it in a way that sounds fresh and dynamic. Patients should never be aware that the therapist is following a manual.
Speeding Through Material
Many of the skills-training concepts, while seemingly straightforward and based on common sense, are quite complex, particularly for patients who have cognitive impairment, dual diagnoses, or low baseline levels of coping skills. A common error made by many therapists is to fail to check back with patients to make sure they understand the material and how it might be applied to their current concerns. When this occurs, it often takes the form of a lecture rather than a dialog between the patient and therapist. Ideally, for each concept presented, therapists should stop and ask patients to provide an example or to describe the idea in their own words.
Overwhelming The Patient
Some therapists try to present to each patient all of the coping strategies in the order given in the manual. For many patients, this is overwhelming. Learning and feeling comfortable with one or two coping strategies is preferable to having only a surface understanding of several strategies. Similarly, if too much material is presented, the time available for practice is limited.
A good general tactic is to start by presenting one of the coping strategies the patient already uses and is familiar with, and then to introduce one or two more that are consistent with the patient's coping style. Also, new coping strategies can be introduced over two sessions.
Therapists should attempt to teach general coping strategies using specific examples. However, some therapists use the coping strategies during the session but do not effectively communicate the basic underlying strategy. For example, they may effectively apply problem solving strategies to patients' problems but fail to make the problem solving steps explicit or assure that patients understand the concepts. It is essential that therapists use examples to teach the general, underlying strategy, but it is equally important that the general strategy be made clear.
No Specific Examples
Just as some therapists do not effectively communicate underlying priniciples, others fail to make the coping skills material alive by using specific examples, based on material provided by the patient, to illus-trate their points. Skillful therapists make the transition from the patient's report of current concerns to the skill-focused section of the session by using specific examples.
"Earlier, you talked about how hard it was to deal with Joe and his continuing to use, and today, I thought we would talk about some ways you might be able to effectively say no to him. How does that sound?"
Again, skills training should be presented as a dialog between the patient and therapist, with the therapist attempting to convey the message, "Here is something I think can help you with what you're struggling with right now."
Downplaying Practice Exercises
Although most patients do their practice exercises, and those who practice outside sessions have better cocaine outcomes, a number of therapists do not sufficiently attend to practice exercises. This takes the form of cursory review of completion of tasks in the beginning of sessions. It also leads to rushing through task assignments at the end of sessions, not being creative in task assignments, and letting practices slide if the patient does not do them. Often, this reflects a therapist's low expectations about the patient's attempting the exercise (and, often, low expectations about the patient's prognosis).
A review of the assignment provides some structure to the first part of the session and sends the message that outside practice is important. Generally, therapists who expect their patients to practice outside of sessions have patients who do so. Also, therapists and patients are by no means limited to the practice exercises suggested in the manual. In fact, it is preferable for patients to come up with their own extra-session tasks.
Abandoning The Manual With Difficult Patients
Many patients present with a range of complex and severe comorbid problems. Therapists may become overwhelmed by concurrent problems and drift from use of the manual in an attempt to address all the patient's problems. In such cases, therapists often take a less structured approach rather than the greater structure needed by the patient.
Generally, if the patient is sufficiently stable for outpatient therapy, the treatment described in the manual is adequate, even for fairly disturbed patients. CBT provides short-term therapy that includes the major attributes of an effective initial approach to cocaine abuse.
- A highly structured approach to treatment
- Prioritizing of concurrent problems
- Limited case management
- A primary focus on achieving abstinence