Many white psychotherapists may lack the skills required to work effectively with service users from minoritised ethnicities. This article proposes that the nature of this skills deficit can be understood through applying the Declarative-Procedural-Reflective (DPR) model of therapist skill development. The DPR model has been used in a range of psychotherapeutic contexts, and it provides a systematic account of how therapists from all modalities develop and can improve their skills. Adapting this model to white therapists’ skills in working with service users from minoritised ethnicities allows the identification of specific areas of skills deficit, and therefore clear recommendations as to how to address those deficits. The application of the DPR model to this context suggests that there are clear areas of skills deficit in terms of knowledge base, the practical skills of carrying out therapy, and the ability of therapists to reflect on their work with service users from minoritised ethnicities. I conclude by making a number of suggestions as to how those deficits could be addressed, both by individual therapists and at a systemic level.

Hearing voices is a distressing and trans-diagnostic experience. Cognitive behavioural therapy (CBT) is an effective psychological treatment for distressing voices, but is offered to only a minority of patients. Limited resources are a barrier to accessing CBT. Evaluations of brief forms of CBT for voices have offered encouraging findings, but the ability of briefly-trained therapists to deliver these brief therapies has yet to be explored. We evaluated the outcomes of a brief form of CBT (Coping Strategy Enhancement, CSE) for voices when delivered by highly-trained and briefly-trained therapists. This was a service evaluation comparing pre–post outcomes in patients who had completed brief CSE over four sessions, within NHS Mental Health Services, delivered by highly-trained and briefly-trained therapists. The primary outcome was the negative impact scale of the Hamilton Program for Schizophrenia Voices Questionnaire. Data were available from 92 patients who completed a course of brief CSE – nearly half of whom received therapy from a briefly-trained therapist. Modest benefits across the sample were consistent with previous evaluations and did not seem to be influenced by the training of the therapist. This service evaluation offers further evidence that brief CSE can begin a therapeutic conversation about distressing voices within routine clinical practice. The usefulness of this initial conversation does not seem to be reliant upon the extent of therapist training, suggesting that briefly-trained therapists may play a role in increasing access to these conversations for patients distressed by hearing voices.

Although training in psychotherapy is an integral part of psychiatry training, standards in psychotherapy training have wide variation across and within countries. Post-graduate psychiatry training has been conducted in Nepal for over two decades, but little is known about its psychotherapy training provisions. An online survey was conducted with early career psychiatrists in Nepal. The findings show that the majority recognised psychotherapy training as important and were eager to pursue further training. However, two-thirds had no access to psychotherapy training opportunities. These results highlight the need to improve access to training in different psychotherapy modalities in Nepal.

Self-Practice/Self-Reflection (SP/SR) has been proposed both as an adjunct to therapy training programmes, and also as a means for therapist development among experienced therapists. Research suggests it develops aspects of knowledge and skill that may not be addressed through other training methods. With increasing interest in SP/SR, a growing evidence base regarding both participant benefits and potential risks from SP/SR, and the development of SP/SR programmes across a range of therapeutic modalities, we argue it is timely to identify a set of principles that can guide the design, adaptation and implementation of SP/SR programmes. At this stage, there is little empirical evidence to guide trainers wishing to implement SP/SR in different contexts. Accordingly, these principles have been derived from reflection on developing, testing and implementing SP/SR programmes as well as on other training and supervisory experience. The first set of principles detailed in Section 1 draw on various theories of learning and development and frame the processes involved, the next principles speak to the content of SP/SR programmes, and the final principles address structure. Within Section 2, the principles are then considered for their practical implications. In Section 3, the sharing of what are initially private self-reflections is then considered together with some implications for SP/SR programmes, especially when there is assessment involved. We argue that SP/SR will continue to progress with well-designed standard programmes, careful implementation, thoughtful adaptation, ongoing innovation, and especially more evaluation.

Over the last decade, there has been increasing interest in the use of metaphor in cognitive behaviour therapy. However, to date, there has been only very limited research on the use of metaphor in CBT sessions, and no studies which have examined how to train therapists in this skill. The present study is the first in the literature to explore how we might train therapists in metaphor-enhanced CBT. Twelve therapists attended two half-day training workshops, 2 weeks apart. Details of the content of the training workshop are provided. The therapists rated the workshop quality and provided structured self-report ratings and reflections on their ongoing application of learning over a 3-month period which were compared with pre-training ratings. Therapists reported significantly increased awareness of metaphors, with increased confidence in responding intentionally to client metaphors and bringing them into shared conceptualizations. In addition, there were significant increases in reported time spent elaborating on client metaphors, and use of metaphors when conceptualizing with clients. Barriers and solutions to application of learning are discussed.

Background: There is limited research into the effect of supervision in cognitive behavioural therapy (CBT) from the supervisees’ perspective. Aims: The aim of the study was to acquire knowledge from the supervisees’ perspective as to what in particular in the supervision process contributes to the therapy process. Method: Fourteen supervisees on a foundation course participated in the study. A qualitative approach was used with thematic analysis of the participants’ written diaries after supervision and therapy sessions. Results: Analyses of supervisees’ experiences suggested that a variety of therapeutic interventions were easier to implement if one had the supervisor's support and felt free to decide if and when the suggested interventions could best be implemented. Evaluation in the form of positive feedback from the supervisor indicating that the supervisee was ‘doing the right thing’ was perceived to be important. A unifying theme when supervisees felt they were not getting anything out of the supervision was that the supervisees did not have a supervision question. Conclusions: The results of this research suggest that the supervisor's support during training is perceived to be important for the supervisee. Receiving positive feedback from one's supervisor in an evaluation is perceived to have a great impact on whether the therapist implements the suggested therapeutic interventions discussed in the previous supervision.

Clinical supervision is regarded as one of the most important components of psychotherapy training. In clinical practice, it has been found that the implementation of clinical supervision varies substantially and often differs from the recommendations made in the literature. The objective of the current study was to investigate the frequency of topics (e.g. ethical issues) and techniques (e.g. role play) in the clinical supervision of psychotherapy trainees in Germany. To this end, we considered supervisions in cognitive behavioural therapy (CBT) and psychodynamic therapy (PT). A total of 791 psychotherapy trainees (533 CBT and 242 PT) were asked via the internet to provide information about their current supervision sessions. We found that clinical supervision in psychotherapy training addressed topics that are central for the effective treatment of supervised patients (i.e. therapeutic interventions, therapeutic alliance, maintaining factors, and therapeutic goals). However, the most frequently used intervention in clinical supervision in psychotherapy training was case discussion. Rarely were techniques used that allowed the supervisor to give the supervisee feedback based on the supervisee's demonstrated competencies. For example, 46% of the supervisors never used audiotapes or videotapes in the supervision. Differences between CBT and PT were rather small. Current practice regarding the techniques used in clinical supervision for psychotherapy trainees contradicts recommendations for active and feedback-oriented clinical supervision. Thus the potential of clinical supervision might not be fully used in clinical practice.

Accurately evaluating how competently one is performing can be a precursor to seeking training and supervision, therefore contributing to safe, effective practice. Little is known about what predicts accurate self-evaluation. Prior research findings are inconsistent, with overestimation of self-rated competence in some studies and underestimation in others. We aimed to explore the relationship between therapists' reflective ability and the level of agreement between self-rated competence and competence rated by an experienced CBT assessor. Thirteen trainees undertaking a postgraduate CBT diploma submitted a series of recordings accompanied by self-ratings using the Cognitive Therapy Scale – Revised (CTS-R) and related written reflective analyses. Independent assessors marked the written analyses using a standardized marking scheme and rated the therapy sessions using the CTS-R. Trainees tended to overestimate or underestimate their competence in comparison to the independent assessors. The level of agreement between the assessors' ratings and self-evaluation of competence tended to improve during training, while reflective ability did not. Reflective ability was significantly related to level of agreement between self-rated and assessor-rated competence. Trainees do not consistently demonstrate the bias for overestimating their competence previously found in qualified therapists. During training, the tendency of an individual to over- or underestimate their competence may not remain stable, but tends to become more consistent with ratings undertaken by an experienced CBT assessor. Trainees who were rated as more reflective, tended to agree more closely with independent assessors on evaluation of competence. Therefore, enhancing reflective ability may help therapists to more accurately self-evaluate their competence.

The feasibility and effectiveness of trainee psychiatrists providing CBT in primary care was assessed by a triangulated procedure of service overview, trainee feedback and assessment of clinical measures. Hitherto trainees sought ‘suitable’ cases by individual request. In the primary-care setting: 82% of 11 trainees (50% previously) completed a ‘short case’ treatment within a 6-month attachment; 86% of trainees found the level of supervision ‘about right’; depression and anxiety scores for patients (n = 16) achieved statistically significant gains and showed moderate to large effect sizes. Although there was no comparator group, findings were just above the IAPT aim of a 50% recovery. Conclusions are that completion of their ‘short case’ experience within a 6-month attachment is feasible in a primary-care setting. Evidence that patients and the service also benefited demonstrates this to be good and ethical ‘business’ for the service provider. Integrating these skills into routine medical psychiatric practice may remain a later supervision need. Other training experiences including psychological treatments could initially be best met in less testing clinical encounters than those experienced in secondary care. Locally agreed formal arrangements would facilitate this and there is potential for the development of greater cross-service understanding in the longer term.

Background: A large body of research has identified that many therapists do not use research to inform their practice, but few studies investigate the reasons behind this. Aims: The current study seeks to understand what sources therapists use to inform their practice and why they are chosen. Method: Thirty-three interviews with psychological therapists in the UK were undertaken. These were transcribed and analysed using Interpretative Phenomenological Analysis. Results: Two superordinate themes emerged. The former focused on the nature of evidence and the latter described why certain sources were used to make clinical decisions. When discussing evidence, participants felt that research studies, specifically Randomized Controlled Trials (RCTs), used unrepresentative samples. Therapists felt that research other than RCTs, particularly qualitative research, was important. Therapist specific factors were felt to be as, or more, important than the technique used to treat patients. When discussing the sources they used, therapists preferred to use their clinical experience or their patients’ experience to make clinical decisions. Theoretical or practical information was preferred to empirical research. The presentation of information was felt to be important to encourage the implementation of research, and therapists also felt tools such as outcome measures and manuals were too rigid to be useful. Finally, patients’ choice of treatment was felt to be important in treatment decisions. Conclusions: The views of therapists were heterogeneous, but this study highlighted some of the barriers to closing the gap between science and practice. This knowledge can be used to increase the translation of science into practice.

Background: The Improving Access to Psychological Therapies (IAPT) initiative has depended on the training of a new NHS mental health workforce. At step 3 of the stepped care model, capacity building has required the recruitment of a wide range of mental health professionals into high intensity therapists training posts. This shift naturally entails role transition on the part of trainees into delivering cognitive behavioural psychotherapy (CBP), but no previous research has examined the experience of such transitions. Aim: To describe the lived experience of transition from mental health nurse to IAPT high intensity therapist and to identify possible factors which moderate effective role conversions. Method: Six qualified high intensity therapists were interviewed using a semi-structured interview and the subsequent interviews transcribed. Thematic content analysis (TCA) was used to analyze personal accounts of role transition. All participants had previously been mental health nurses and attended the same IAPT high intensity therapist (HIT) training programme. Results: Six key themes were apparent from the TCA. Three interconnected themes concerning supervision (style, impact of approach and historical context) and three additional themes of the challenge of learning a new clinical approach, high need for support, and forming a new psychotherapist identity. Conclusions: Findings suggest supervision is the most important factor in supporting complex psychotherapy role transitions. Clinical supervisors may need to incorporate dedicated time on role and identity shift during CBP training to ensure effective assimilation and transition. Methodological short-comings are identified and discussed.

Background: It is recommended that Mindfulness-Based Cognitive Therapy (MBCT) instructors should undertake MBCT themselves before teaching others. Aim: To investigate the impact of MBCT (modified for stress not depression) on trainee clinical psychologists. Method: Twenty trainees completed questionnaires pre- and post-MBCT. Results: There was a significant decrease in rumination, and increases in self-compassion and mindfulness. More frequent home practice was associated with larger decreases in stress, anxiety and rumination, and larger increases in empathic concern. Only first-year trainees showed a significant decrease in stress. Content analysis of written responses indicated that the most commonly reported effects were increased acceptance of thoughts/feelings (70%), increased understanding of what it is like to be a client (60%), greater awareness of thoughts/feelings/behaviours/bodily sensations (55%) and increased understanding of oneself and one's patterns of responding (55%). Participants reported increased metacognitive awareness and decentring in relation to negative thoughts. Eighty-five percent reported an impact on their clinical work by the end of the course. Conclusions: Trainee psychologists undergoing MBCT experienced many of the psychological processes/effects that they may eventually be helping to cultivate in clients using mindfulness interventions, and also benefits in their general clinical work.

The Oracle of Delphi's admonition to ‘know thyself’ may be more difficult than it seems, when it comes to self-assessment of competence in cognitive behaviour therapy (CBT). This paper investigates the accuracy of self-rating of competence in relation to other measures such as ‘direct’ assessment of videotaped sessions or supervisor ratings. Self-assessment of competence is something most of us do and arguably has an important role in professional development, but it may also be biased and unreliable. Two measures were developed, based on the Cognitive Therapy Scale – Revised, to assess student and supervisor assessments of competence at the start and end of a CBT training course. Competence data across a range of measures from a 5-year audit of a postgraduate CBT course is presented and the relationship between self-rated and other-rated measures explored. Results are discussed and it is suggested that trainee self-assessment, while not found in this study to be correlated with other measure of competence, may provide important information about confidence development, and areas where a trainee perceives they have strengths and weaknesses.

Evidence indicates that workshop training, personalized feedback, and individual consultation can increase competence in motivational interviewing (MI) among highly motivated and skilled substance abuse counselors. Little is known, however, about the translational value of these training strategies for counselors with fewer counseling skills and less stated motivation to learn MI. This study presents evidence from a randomized, controlled trial of 129 behavioral health providers assigned to receive workshop training and enrichments to learn MI. A diverse group of Air Force behavioral health providers working in substance abuse treatment programs were trained in MI and subsequently observed in clinical sessions at 4, 8 and 12 months after training. Results indicate that training was effective in increasing the skill level of these clinicians; however, these gains had decreased by the 4-month follow-up point. Training enrichments in the form of personalized feedback and consultation phone calls did not have an expected, additive effect on clinician skill level. The results of this study lend support to the hypothesis that a greater investment of resources and incentives may be necessary to achieve gains in MI skills for counselors with relatively lower baseline skills than those commonly participating in research studies.