Psychology training and CBT: limitations and opportunities

Historically, training in psychology has tended to focus on course objectives for the acquisition of empirical knowledge and time spent (e.g. hours on clinical placement) in training as a proxy for competency (Kaslow et al., Reference Kaslow, Grus, Campbell, Fouad, Hatcher and Rodolfa2009; Pachana et al., Reference Pachana, Sofronoff, Scott and Helmes2011). The direct assessment of competencies, being the ability to integrate knowledge, procedures, skills, and to tailor these to a variety of individuals and contexts has tended to be overlooked (Kaslow et al., Reference Kaslow, Grus, Campbell, Fouad, Hatcher and Rodolfa2009; Pachana et al., Reference Pachana, Sofronoff, Scott and Helmes2011). As a result, a trainee may have declarative knowledge, but little skill in its application. This has been observed in research on competency in case formulations. Kuyken et al. (Reference Kuyken, Fothergill, Musa and Chadwick2005) found that only 44% of 115 early career professionals were able to develop ‘good enough’ formulations on a case study following specific training in the skill. In a similar study, Haarhoff et al. (Reference Haarhoff, Gibson and Flett2011) found that 61% of participants in a comparable program were able to achieve ‘good enough’ cognitive behavioural formulations following initial training in formulation.

Such difficulty with the translation of declarative knowledge to the development of competent skill in early training has been further suggested to then result in future difficulties with applying knowledge and skills that may be acquired later in a clinician’s career, reducing the capacity for evaluating the relevance and effectiveness of interventions to a given context and promoting over-reliance on information from ‘authorities’ (Stoltenberg and Pace, Reference Stoltenberg and Pace2007). Supporting this, a study assessing CBT competence by practising clinicians reported that both those that self-identified as CBT-oriented and those that did not performed to a ‘less than satisfactory’ standard with CBT-specific behaviours (Creed et al., Reference Creed, Wolk, Feinberg, Evans and Beck2016).

These findings can be explained by construal theory. In terms of construal theory, the development of concepts when learning can vary between a lower, more concrete construal and a higher, more abstract construal. Concrete construals involve more specific, idiosyncratic, and incidental information relating to a concept, while abstract construals provide more information about the general meaning and valence of a concept, promoting its integration with other existing knowledge (Trope and Liberman, Reference Trope and Liberman2010). In line with this theory, these results suggest that more didactic teaching and a focus on assessment of declarative knowledge may be insufficient in promoting the ability to develop a more abstract construal of psychological knowledge and skills, consequently resulting in a simpler, concrete construal of such knowledge and skills, and a subsequent rigidity to their application. The failure to develop a deeper, more abstract appreciation for cognitive behavioural theory has been suggested to result in a focus on technical eclecticism alone and to inhibit the ability to develop more complex case formulations (Trinidad, Reference Trinidad2007).

The failure to develop a higher construal with regard to cognitive behavioural theory and practice may subsequently promote cognitive biases that result in over-estimations in how individuals perceive their knowledge and competence (McManus et al., Reference McManus, Rakovshik, Kennerley, Fennell and Westbrook2012; Waltman et al., Reference Waltman, Frankel and Williston2016). In particular, it may promote the Dunning-Kruger effect in clinicians. This is a cognitive bias whereby people with limited knowledge or competence in an area over-estimate their knowledge and competence (Kruger and Dunning, Reference Kruger and Dunning1999). This is thought to be a result of the same lack of knowledge and competence, as this prohibits the meta-cognitive ability to assess their abilities as deficient, and they instead assume themselves to be competent. This is supported by research findings that those objectively rated as the least competent practitioners may demonstrate the greatest over-estimation, as they lack awareness of their own deficiencies (Brosan et al., Reference Brosan, Reynolds and Moore2008; Dunning et al., Reference Dunning, Johnson, Ehrlinger and Kruger2003). Consequently, this may result in the clinician failing to recognise a need for training or supervision to improve their practice, and the delivery of less effective or even harmful therapy to their clients (Beale et al., Reference Beale, Liness and Hirsch2020; Brosan et al., Reference Brosan, Reynolds and Moore2008; McManus et al., Reference McManus, Rakovshik, Kennerley, Fennell and Westbrook2012). For less experienced trainees the self-assessment of competency has been more variable. Studies have suggested that this group can demonstrate both over-confidence in their abilities (Rozek et al., Reference Rozek, Serrano, Marriott, Scott, Hickman, Brothers and Simons2018) and an under-estimation of their competence, potentially reflecting issues with self-confidence (McManus et al., Reference McManus, Rakovshik, Kennerley, Fennell and Westbrook2012). Complicating this may be the nature of the training provided, with self-assessments having been found to be more accurate when comparative feedback by expert evaluators is provided in training programs (Kaslow et al., Reference Kaslow, Grus, Campbell, Fouad, Hatcher and Rodolfa2009; Waltman et al., Reference Waltman, Frankel and Williston2016).

A method of teaching that can help to resolve these issues is problem-based learning (PBL). While conventional teaching methods are generally associated with better knowledge retention in the short term, PBL has been demonstrated to have longer-term benefits that include greater knowledge retention and improved application of knowledge to practice (Kaslow et al., Reference Kaslow, Grus, Campbell, Fouad, Hatcher and Rodolfa2009; Wiggins et al., Reference Wiggins, Chiriac, Abbad, Pauli and Worrell2016). PBL aims to cultivate an investigative approach to learning while also promoting a sense of responsibility for one’s own learning. It involves self-directed learning to solve problems, often utilising group exercises (Wiggins et al., Reference Wiggins, Chiriac, Abbad, Pauli and Worrell2016). As a result, PBL has been suggested to provide for improved outcomes in problem-solving, in the ability to tolerate uncertainty, to increase flexibility in the ability to adapt theory to practice, and to increase skills for collaboration, while at the same time cultivating intrinsic motivation and autonomy for learning (Dunsmuir et al., Reference Dunsmuir, Frederickson and Lang2017; Wiggins et al., Reference Wiggins, Chiriac, Abbad, Pauli and Worrell2016). Understandably, such training methods could therefore translate into enhanced outcomes for the development, and maintenance, of clinical competence.

In summary, psychological training methods focused primarily on the development of declarative learning is limited in the ability to promote a deeper level of understanding of the material covered and competency with skills. This tends to result in difficulties with adapting such knowledge and skills to new contexts and can potentially contribute to biases and over-confidence. A potential solution to this is the application of PBL strategies to training in psychological therapy. Incorporating such learning approaches into training programs would provide learning opportunities that promote a deeper construal of knowledge and skills covered, which results in a more nuanced understanding of the targeted knowledge and greater flexibility in the application of skills learnt through such methods.

Issues with existing measures of competence

The SP/SR training framework

Personal practice has long been considered an important form of experiential learning for those seeking to acquire clinical knowledge and skills. For a number of decades, personal practice activities have been recommended as an important method for learning the intricacies of cognitive behavioural therapy (Beck, Reference Beck1995; Padesky, Reference Padesky and Salkovskis1996). It has only been since the turn of the century, however, that such training methods have received attention, in terms of developing structured approaches and research on its training outcomes (Bennett-Levy et al., Reference Bennett-Levy, Thwaites, Haarhoff and Perry2015; Chigwedere et al., Reference Chigwedere, Thwaites, Fitzmaurice and Donohoe2019; McGillivray et al., Reference McGillivray, Gurtman, Boganin and Sheen2015). A prominent strategy to emerge from this literature has been the self-practice/self-reflection (SP/SR) framework developed by Bennett-Levy and his colleagues (Bennett-Levy et al., Reference Bennett-Levy, Thwaites, Haarhoff and Perry2015). This model was developed to help transition declarative learning into skill development (Bennett-Levy, Reference Bennett-Levy2006; Bennett-Levy et al., Reference Bennett-Levy, Turner, Beaty, Smith, Paterson and Farmer2001).

The SP/SR models provides a structured training framework that pairs the application and practice of cognitive behavioural theory and interventions to the self with reflective exercises (Thwaites et al., Reference Thwaites, Bennett-Levy, Davis, Chaddock, Whittington and Grey2014). It has three core elements: (1) the identification of a challenging problem, (2) self-practice, and (3) self-reflection (Bennett-Levy, Reference Bennett-Levy2019). The challenging problems can be either of a personal or professional nature, and it is suggested that these be of mild to moderate difficulty (i.e. not a major difficulty). These problems may then be used within the context of either individual or group exercises, in which the trainees gain self-practice as both a therapist and as a client, with self-reflection emphasised for experiences in both roles (Bennett-Levy et al., Reference Bennett-Levy, Thwaites, Haarhoff and Perry2015). The self-reflection focuses on their experiences both from a personal perspective and from a professional perspective, with guided questions. These reflective questions also include ‘bridging’ questions that are suggested to promote the translation of the trainees personal learning into professional learning, with regard to related theory, strategies, and interpersonal skills for clinical work (Bennett-Levy, Reference Bennett-Levy2019). The SR component is further highlighted as providing training in a meta-competence that promotes ongoing learning from experience that can help with the refinement of clinical skills (Bennett-Levy et al., Reference Bennett-Levy, Thwaites, Chaddock and Davis2009). Based on these descriptions, the framework can be considered to be a form of problem-based learning.

The research to date on the use of SP/SR as a training technique suggests that it is an effective training method, with studies supporting its use with novice therapists through to more experienced practitioners (Bennett-Levy and Lee, Reference Bennett-Levy and Lee2014; Bennett-Levy et al., Reference Bennett-Levy, Turner, Beaty, Smith, Paterson and Farmer2001; Chigwedere et al., Reference Chigwedere, Thwaites, Fitzmaurice and Donohoe2019; Collard and Clarke, Reference Collard and Clarke2020; Davis et al., Reference Davis, Thwaites, Freeston and Bennett-Levy2015; Thwaites et al., Reference Thwaites, Bennett-Levy, Davis, Chaddock, Whittington and Grey2014). Participants have typically reported a range of promising outcomes from this form of training. Amongst the benefits reported have been an enhanced confidence with, and understanding of cognitive behavioural theory, an increased appreciation for cognitive behavioural strategies, and greater skill in the application of techniques, including greater flexibility and nuance in their application (Bennett-Levy, Reference Bennett-Levy2019; Chigwedere et al., Reference Chigwedere, Thwaites, Fitzmaurice and Donohoe2019; Collard and Clarke, Reference Collard and Clarke2020; Collard and Clarke, Reference Collard and Clarke2022; Davis et al., Reference Davis, Thwaites, Freeston and Bennett-Levy2015; McGillivray et al., Reference McGillivray, Gurtman, Boganin and Sheen2015; Scott et al., Reference Scott, Yap, Bunch, Haarhoff, Perry and Bennett-Levy2021). Participants also tend to report improved interpersonal skills, allowing for a greater attunement with clients and increased empathy for their presenting difficulties (Bennett-Levy et al., Reference Bennett-Levy, Thwaites, Haarhoff and Perry2015; Chigwedere et al., Reference Chigwedere, Thwaites, Fitzmaurice and Donohoe2019; McGillivray et al., Reference McGillivray, Gurtman, Boganin and Sheen2015; Thwaites et al., Reference Thwaites, Bennett-Levy, Davis, Chaddock, Whittington and Grey2014). More generally, participants typically noted that such training programs also result in an enhanced self-reflective capacity, greater self-awareness, and improved wellbeing (Bennett-Levy, Reference Bennett-Levy2019; Bennett-Levy and Lee, Reference Bennett-Levy and Lee2014; Gale and Schröder, Reference Gale and Schröder2014). Unsurprisingly, these findings are also consistent with the literature on ‘real-plays’ (vs role-plays), which also utilises self-practice, and claims to better promote skill development and empathy (Lertora et al., Reference Lertora, Croffie, Dorn-Medeiros and Christensen2020; Nemec et al., Reference Nemec, Swarbrick and Legere2015).

It is important to note that while training through SP/SR programs can be considered an engaging form of training, it can also be considered more challenging. Balancing the level of challenge provided in such programs is crucial for maximising learning outcomes for trainees, as excessive challenge can reduce engagement with it, which subsequently affects a trainee’s ability to achieve positive learning outcomes (Bennett-Levy and Lee, Reference Bennett-Levy and Lee2014). A key factor that can negatively influence level of engagement with SP/SR training methods is anxiety, particularly in relation to worries about loss of control and social judgement (Bennett-Levy and Lee, Reference Bennett-Levy and Lee2014; Spendelow and Butler, Reference Spendelow and Butler2016). Offsetting this are factors that promote positivity towards the model and help to reduce anxiety. These include expectations of benefit from the experience, structure, positive group dynamics, links to course outcomes, and a positive perceptions of coping resources (Bennett-Levy and Lee, Reference Bennett-Levy and Lee2014). A sense of control over the experience can also reduce anxiety, which can be encouraged by self-selection, control over the content of exercises, and control over the level of sharing about experiences (Bennett-Levy and Lee, Reference Bennett-Levy and Lee2014).

SP/SR as a form of competency-based training and assessment

While promising, the findings on SP/SR training programs are limited in terms of the assessment of actual improvements to competency levels, as they are predominantly based on self-report (McGillivray et al., Reference McGillivray, Gurtman, Boganin and Sheen2015). Despite this, the framework would appear to offer a potential method for developing and assessing clinical competency in a way that can address the concerns with self-reflection, with regard to the scaffolding of competency development and assessment, and in a context that does not provide risk to the public. In line with this, we propose a new extension to the SP/SR framework to enable its use as a form of competency-based training and assessment.

As noted above, self-assessment of competency allows for the influence of self-report biases, like the Dunning-Kruger effect (Dunning et al., Reference Dunning, Johnson, Ehrlinger and Kruger2003; Kaslow et al., Reference Kaslow, Grus, Campbell, Fouad, Hatcher and Rodolfa2009). To remedy this Pachana et al. (Reference Pachana, Sofronoff, Scott and Helmes2011; p. 68) recommend that for the development of competency in clinical skills ‘practice should be deliberate and guided by feedback regarding performance and how it compares with optimal performance’. This has been supported by research demonstrating that when paired with feedback from an expert supervisor, self-reflections become more accurate, with student and supervisor ratings converging over time (Beale et al., Reference Beale, Liness and Hirsch2020; Brosan et al., Reference Brosan, Reynolds and Moore2008; Kaslow et al., Reference Kaslow, Grus, Campbell, Fouad, Hatcher and Rodolfa2009). The SP/SR framework allows for this, as it provides training in the practice of skills in a supportive framework that can provide feedback and guidance regarding the application of knowledge and skills (Bennett-Levy et al., Reference Bennett-Levy, Thwaites, Haarhoff and Perry2015).

A further suggested benefit of the SP/SR training model is that the pairing of guided feedback with self-reflections also helps to build competency in the use of self-reflection itself. The development of a capacity for self-reflective practice is considered to subsequently provide a lifelong competency, helping to develop and improve clinical skills into the future as well (Bennett-Levy et al., Reference Bennett-Levy, Thwaites, Chaddock and Davis2009; Kaslow et al., Reference Kaslow, Grus, Campbell, Fouad, Hatcher and Rodolfa2009). Within the SP/SR framework, guided feedback could act as a mechanism for helping trainees to assess their competency with both clinical skills and with self-reflection skills, as the expert ratings and feedback can help to provide assessment against established clinical standards. Ultimately, this could help to improve the trainee’s ability to be more accurate in recognising their own competency levels and to enhance their confidence in their abilities (Scott et al., Reference Scott, Yap, Bunch, Haarhoff, Perry and Bennett-Levy2021).

In terms of providing learning and assessment of competencies in a scaffolded manner, the SP/SR framework provides an avenue for trainees to practise and develop competency with specific skills outside the context of an overall therapy session. With the self-practice aspect of the SP/SR framework, trainees are required to practise formulation skills in relation to their own problems, to develop and apply interventions to these, and to then reflect upon what is learnt from these (Bennett-Levy et al., Reference Bennett-Levy, Thwaites, Haarhoff and Perry2015). While much of the SP/SR research has looked at outcomes from overall training programs, there have been a few studies that have focused on the learning outcomes from some specific exercises, including thought diaries, exposure tasks, and behavioural experiments (Bennett-Levy, Reference Bennett-Levy2003; Collard and Clarke, Reference Collard and Clarke2020; Collard and Clarke, Reference Collard and Clarke2022). These have shown that the SP/SR exercises can be used to target specific skills around formulation, intervention planning, and for reviewing intervention outcomes. For instance, in the study by Collard and Clarke (Reference Collard and Clarke2020), participant trainees were asked to develop an exposure intervention for their own social anxiety and to present a situational formulation of their anxiety reaction. Efforts were also made to provide a supportive environment for the exercise, with detailed guidance, an extended time period for completion, and opportunities for trainees to gain additional support if required. Not only did this task allow for an external evaluation of the trainees’ formulation skills (which had previously been practised in isolation), it also gave an opportunity to assess their competency in designing and reviewing a behavioural experiment or exposure intervention. The students had previously been informed of the focus on these skills through the provision of learning outcomes and a rubric that highlighted the skills for which they were being assessed, and the related clinical standards required for demonstrating their level of competence with such skills.

Furthermore, from the general reflection prompt on the task it was noted that the task helped the trainees to better appreciate the role of their cognitions in the associated anxiety (formulation skills), to better appreciate the challenge of facing their anxiety during the task (empathy/interpersonal skills), to appreciate the benefits and limitations of applying coping strategies in the context of such an exercise (intervention skills), and to better appreciate the learning that behavioural challenges can provide (evaluation skills; Collard and Clarke, Reference Collard and Clarke2020).

Pairing such exercises with guided reflection, to prompt consideration of related theory and strategies, could then be used to further develop competency in skills related to SP/SR exercise (see Table 1 for examples of questions that could be used in relation to formulation skills, cognitive restructuring exercises, and exposure interventions).

Table 1. Guided questions for competency self-reflection

In a training program these could then also be translated into further SP/SR exercises for the trainee, providing an avenue for ongoing observation on the development of such knowledge and skills (e.g. development of competency across a series of exposure interventions with a variety of degrees of challenge, for reinforcement of learning from the exposure exercises, and for generalisation of adaptive learning). Thus, SP/SR can grant the opportunity to work on the development of competency with skills in a scaffolded manner, rather than under complex scenarios that risk overloading trainees (van Merriënboer and Sluijsmans, Reference van Merriënboer and Sluijsmans2009).

Such scaffolding of tasks within SP/SR training programs would also allow for a more discrete focus, both in terms of the scenarios under consideration and the area of skill development, reducing the time commitments for trainers/supervisors. As suggest by the research by Schmidt et al. (Reference Schmidt, Strunk, Derubeis, Conklin and Braun2018), this may provide for a more accurate assessment of competency over more complex training tasks.

Finally, with the focus on self-practice, rather than client practice, the SP/SR framework provides several mechanisms that promote better outcomes for clients. To date, many existing methods for competency assessment in psychology training programs rely on observation of direct client work (Humphreys et al., Reference Humphreys, Crino, Wilson and Hannan2017b). Using a SP/SR approach to training allows for the assessment of a base level of competency prior to engaging with real clients, reducing the potential for trainees delivering ineffective or harmful therapy.

Importantly, training within a SP/SR framework is also suggested to promote outcomes that may also help to address factors in addition to clinical knowledge and technical skill that can negatively impact upon clinical competency. For instance, engagement in SP/SR training has been shown to address factors that may influence a trainee’s willingness to implement strategies with a client. This includes the development of confidence in applying specific techniques (Bennett-Levy, Reference Bennett-Levy2019; Gale and Schröder, Reference Gale and Schröder2014), where a low level of confidence in one’s ability may result in avoidance of effective strategies for client problems (Odyniec et al., Reference Odyniec, Probst, Margraf and Willutzki2019). It can also address unhelpful attitudes and beliefs about techniques. For instance, negative attitudes about CBT in general or about specific techniques, such as exposure interventions, can reduce the willingness of therapists to apply cognitive behavioural techniques, or at least to apply them in an effective manner (Deacon and Farrell, Reference Deacon and Farrell2013; Rameswari et al., Reference Rameswari, Hayes and Perera-Delcourt2021). Research on SP/SR training strategies has been shown to have the potential to address such negative beliefs, with participants being more willing and enthusiastic about using the techniques they have practised themselves with their future clients (Bennett-Levy et al., Reference Bennett-Levy, Lee, Andrews, Pohlman, Hamernik, Travers and Hamernik2003; Collard and Clarke, Reference Collard and Clarke2022; Gale and Schröder, Reference Gale and Schröder2014).

SP/SR has also been reported to enhance trainees’ emotional regulation skills, a competency that has been shown to directly and indirectly influence competence with other skills. For instance, it has been found that trainees undergoing such training generally develop an increased level of self-awareness (Bennett-Levy, Reference Bennett-Levy2019; Bennett-Levy and Finlay-Jones, Reference Bennett-Levy and Finlay-Jones2018). The awareness of personal processes, including one’s worldview, biases, coping strategies, and potential conflicts, is generally considered an important precursor for the ability to provide effective psychological therapy (Pieterse et al., Reference Pieterse, Lee, Ritmeester and Collins2013). Increased self-awareness has also been linked to increased acceptance of one’s present level of clinical skill (Haarhoff et al., Reference Haarhoff, Gibson and Flett2011), for enhancing capacity for self-reflective learning (Bennett-Levy et al., Reference Bennett-Levy, Lee, Andrews, Pohlman, Hamernik, Travers and Hamernik2003), and for preventing burnout (Scott et al., Reference Scott, Yap, Bunch, Haarhoff, Perry and Bennett-Levy2021).

Potentially following from this, SP/SR programs are also typically linked to personal development and wellbeing. It has been reported by trainees that it helps with the development of more adaptive beliefs and coping strategies, and with reduced psychological distress (Bennett-Levy, Reference Bennett-Levy2019; Gale and Schröder, Reference Gale and Schröder2014; McGillivray et al., Reference McGillivray, Gurtman, Boganin and Sheen2015; Thwaites et al., Reference Thwaites, Bennett-Levy, Davis, Chaddock, Whittington and Grey2014). The importance of such outcomes is highlighted by research showing that conscientiousness is positively linked to the development of clinical competence while the experience of emotional distress, particularly depression, has been negatively linked to the development of competencies (Humphreys et al., Reference Humphreys, Crino and Wilson2017a) and that maladaptive emotion regulation strategies have been linked to compassion fatigue and burnout (Chang and Shin, Reference Chang and Shin2021). Furthermore, SP/SR is suggested to be a method for developing distress tolerance in trainees, a skill required for psychologists, especially when dealing with challenging presentations that may include personality pathology, suicidal or self-injurious behaviour, trauma processing, or exposure interventions (Waltman et al., Reference Waltman, Frankel and Williston2016). Distress tolerance has also been suggested to encourage a willingness to be vulnerable and not perfectionistic and to promote ethical practice, in line with providing the highest quality of client care and an accurate representation of competence (Waltman et al., Reference Waltman, Frankel and Williston2016). Finally, these factors, along with enhanced empathy, may contribute to improved interpersonal skills. This is a commonly reported outcome from SP/SR training, with trainees reporting increased competency in their ability to utilise active listening skills, to explain concepts, to work collaboratively, and to resolve therapeutic rifts that may arise (Bennett-Levy, Reference Bennett-Levy2019; Gale and Schröder, Reference Gale and Schröder2014; McGillivray et al., Reference McGillivray, Gurtman, Boganin and Sheen2015).

Taken together, these outcomes suggest that when trainees that progress through a SP/SR program move on to direct client work they have greater self-awareness, are more resilient, and will be equipped with better coping and interpersonal skills. This would subsequently result in better clinical decision making, and thereby improved competency. Again, observation of the development of such competencies could be taken from practices done in a class environment, from recordings, and from written summaries and reflections presented by the trainees, allowing comparison of their skill against established criteria.