Introduction
The aim of this book is to help you understand the philosophies, principles, methods and techniques that can inform the effective assessment and case formulation of your clientsâ needs and, in doing so, assist the development of your mastery of cognitive behavioural therapy (CBT).
Assessment and case formulation, within the context of a co-constructed therapeutic relationship, lie at the heart of effective CBT. Conducting a thorough, theoretically and relationally informed assessment and using the information obtained to devise a case formulation that can assist intervention planning are clinical activities that have been consistently identified as forming the backbone of CBT (Grant and Townend, 2008; Corrie and Lane, 2010). However, knowledge of the optimal ways of carrying out these activities remains lacking. Despite some laudable attempts to provide clearer guidance (see for example, Butler, 1998; Kuyken et al., 2009; Corrie and Lane, 2010), the lack of consensus about how to assess and formulate clientsâ needs disadvantages those practitioners who seek to develop a rigorous and systematic approach that can take account of developments in the field, respond to the demands of different service contexts and remain attentive to the unique characteristics of the individual client.
The lack of definitive guidelines on how best to assess and formulate clientsâ needs is perhaps not surprising when we consider the terrain that must be navigated. Contemporary CBT is a broad, emerging therapeutic landscape that encompasses a range of concepts, theories, models and styles of working, rather than a single, unified discipline (Gilbert, 2008; Grant et al., 2008; Westbrook et al., 2011). What constitutes effective assessment and case formulation within one âschoolâ of CBT may, therefore, look somewhat different in another and may also alter with the passage of time as advances in the field occur.
Although certain fundamental assumptions may be shared (for example that cognition plays an important role in distress and is amenable to intervention) the range of problem-specific formulation models and disorder-specific constructs guiding assessment and intervention planning has increased exponentially. As noted by Grant and Townend (2008), the amount of content that needs to be absorbed can feel overwhelming until the theoretical assumptions shared across models become clear.
Experienced practitioners who are confident that their knowledge of models and protocols remains current will also encounter challenges at least some of the time. Indeed, navigating a constantly changing theoretical and empirical landscape whilst holding in mind our clientsâ self-told stories arguably should be a challenge. Clients do not always present with neatly packaged difficulties that can be swiftly or easily categorized according to therapistsâ preferred classification schemes. Even where clients appear to have relatively uncomplicated needs or clearly do meet diagnostic criteria for a particular disorder, the way in which therapy unfolds will depend on a wide variety of factors including the skillfulness of the therapist in engaging, understanding, conceptualizing and responding to emergent issues on a moment-by-moment and session-by-session basis. As Padesky (1996a) observes, competence requires both knowledge of cognitive and behavioural theory and an ability to apply this knowledge in a systematic fashion to the material encountered in the consulting room. This was echoed more recently by the Improving Access to Psychological Therapies (IAPT) initiative (see www.iapt.nhs.uk/about-iapt/website-archive/competencies-and-national-occupational-standards/cognitive-behavioural-therapy-competences-framework) where it is noted that although a structured therapy, CBT:
...works best if therapists consistently maintain a sense that clients need to understand themselves through a process of âguided-discoveryâ, so that they find out about themselves for themselves... CBT should help clients learn skills which enable them to cope with future adversity in a more effective way.
Individuals with the same diagnosis or problem of living are not a homogeneous group and when working with clients, therapists face an unending series of choices about which direction to take. Therapy will always need to be tailored to the individual client even where what is being offered is a manualized intervention.
Contextual factors shaping the delivery of CBT
At the same time as having to negotiate an evolving scholastic and clinical terrain, CBT practitioners also need to embrace the shifting demands and expectations of their services. In the past 50 years or so, the ways in which psychological therapies are mandated, organized and practised have changed radically (Lunt, 2006). The development and delivery of CBT is couched within a broader political, social and economic climate characterized by unprecedented levels of unpredictability, complexity and volatility. This evolving and uncertain climate has a number of implications for the knowledge and skills that CBT therapists are expected to acquire, the clinical problems with which they need to be equipped to work and the training routes available to facilitate the development of their competence.
A first implication of this rapidly changing professional climate is that in recent years the professions themselves have come under greater scrutiny and control (see Lo, 2005; Lane and Corrie, 2006, for a review of these debates). This has contributed to the increasing professionalization and regulation of the psychological therapies including CBT, as well as the need for more objective standards to guide policy. Both the demonstrated efficacy of cognitive and behavioural therapies for a diverse range of mental health problems and the commitment to ongoing refinement through the accumulation of a robust evidence-base have enabled CBT to secure an advantageous position with government and other funding bodies who seek evidence of efficacy as a basis for commissioning (McHugh and Barlow, 2010). In the context of a health care climate organized around empirically-supported interventions, CBT is likely to remain a desirable commissioning choice.
A second major, and related, development has been the advent of the UK governmentâs initiative for England, Improving Access to Psychological Therapies (IAPT; Department of Health, 2008a), funded and developed to improve the psychological well-being of the population through more rapid and consistent access to evidence-based therapies. IAPT has resulted in the emergence of a new CBT workforce to deliver routine and first-line stepped care interventions â a workforce created to support Primary Care Trusts in implementing National Institute for Health and Clinical Excellence (NICE) guidelines for people suffering from depression and anxiety disorders. The ability of this workforce to deliver on the targets specified requires skill in the implementation of empirically-supported interventions which in turn depend upon well-honed knowledge of how to assess and formulate clientsâ needs within the context of protocol-guided practice. Thus, through IAPT, CBT has become uniquely placed within the governmentâs mandate to increase the availability of psychological therapies.
A third implication is that there are now in the UK established pathways through which individuals can become formally âaccreditedâ as CBT practitioners, based on their ability to evidence sufficient levels of clinical experience, knowledge, skill and professionalism. As the lead organization for CBT in the UK, the British Association for Behavioural & Cognitive Psychotherapies (BABCP, 2012) specifies the âMinimum Training Standardsâ for eligibility for accreditation. These standards outline the number of CBT cases which must be completed, the number of clinical practice hours to be accrued and the amount and type of supervision that must be received to support this practice. Additionally, written submissions are required demonstrating both theoretical and clinical understanding of a spectrum of client presentations. IAPT therapists in particular are offered employment contracts on the basis of completing a rigorous training that maps on to these requirements and follows a specific curriculum.
As protocols are developed to target the unique cognitive and behavioural profiles of specific disorders, issues of adherence (i.e. whether the therapy is delivered according to the protocol) and competence (whether the therapy is delivered with sufficient skill) become vital to ascertain. However, this gives rise to questions about the nature of competence itself â in particular, what does âcompetentâ CBT look like, what is the knowledge and skill-base that needs to be acquired and how can competence be reliably and accurately measured?
Muse and McManus (2013: 485) have defined competence in CBT as, ââŚthe degree to which a therapist demonstrates the general therapeutic and treatment-specific knowledge and skills required to appropriately deliver CBT interventions which reflect the current evidence base for treatment of the patientâs presenting problemâ. In their work aimed at identifying the activities that typify proficient CBT for clients with depression and anxiety disorders, Roth and Pilling (2007) have devised a map of competences which provides important clarification of the knowledge, skills and attitudes required. Through reviewing the efficacy of therapeutic approaches demonstrated in controlled trials, and studying the associated treatment manuals, Roth and Pilling have identified over 50 competences that appear central to the delivery of effective CBT for depression and anxiety disorders. The authors note that given the number and levels of competences outlined, the framework should not be used in a prescriptive way but rather seen as an aid to decision-making, competence development and assessment of therapist skill.
The identified competences have been organized into five domains each of which comprises a range of activities which in turn consist of a set of specific skills. These are as follows (see also www.ucl.ac.uk/CORE):
- Generic (the so-called âcommon factorsâ of effective therapy such as knowledge of mental health problems and the ability to form positive working alliances with clients).
- Basic CBT competences (such as a working knowledge of common cognitive distortions, the ability to structure therapy and how to explain to clients the rationale for homework).
- Specific behavioural and cognitive techniques (e.g. the principal methods and techniques that are employed in most CBT interventions such as exposure and response prevention and guided discovery).
- Problem-specific competences (those CBT interventions and procedures adapted to specific disorders. The competence framework details these for specific phobias, social phobia, panic disorder, obsessive-compulsive disorder, generalized anxiety disorder, post-traumatic stress disorder and depression).
- Metacompetences (those âhigher orderâ skills of thinking and procedural knowledge that enable a therapist to implement and adapt, pace and time specific interventions in response to client need).
Assuming that competence can be defined, described and identified in practice, how do we assess our own and othersâ progress towards it? In their review of the methods currently available for assessing proficiency in CBT, Muse and McManus (2013) identify examples of both transdiagnostic CBT rating scales (that is, those assessing the general CBT competences demonstrated in a particular session) and disorder-specific measures (i.e. assessing the competences required to deliver a particular treatment protocol for a given disorder). An example of the former would be the Cognitive Therapy Scale â Revised (Blackburn et al., 2001), whereas an example of the latter would be Cognitive Therapy Scale â Psychosis (Haddock et al., 2001). There can be challenges with implementing disorder-specific measures of assessment in routine clinical services (Muse and McManus, 2013). Nonetheless, competence frameworks, generic and disorder-specific measures of therapist competence and the available evidence-base all point to an emerging clarification of what proficient CBT comprises, the knowledge, attitudes and skills to which novice CBT therapists need to aspire, and the abilities that supervisors and trainers should inculcate in their students.
The above factors represent just some of the enabling and constraining factors which CBT therapists must understand and negotiate in order to provide an optimally effective service to their clients. What is also evident is that within these rapidly evolving professional contexts, practitioners are increasingly required to take responsibility for their professional development, to be able to synthesize insights from theory, research and practice to inform their work with clients, and to see themselves as lifelong learners so that their knowledge and skills remain fit for purpose (we address this in more detail in Chapter 17). Indeed, there is an argument that professional âsurvivalâ is tied to our commitment to remain informed and justify our practice (Guest, 2000). This book speaks to this agenda and in the chapters that follow we have attempted to provide information, offer guidance and acquaint you with the necessary skills that can serve to enhance the quality of your CBT practice and aid your endeavours as lifelong learners.
The second edition of this book: the vision behind the content
Knowledge of clinical presentations is never static and since the first edition, scholarly activity, professional expertise and changes in diagnostic classification have taken collective understanding of clientsâ difficulties and needs in new directions, a process that will undoubtedly continue. In this second edition we have sought to retain the essence of what made the first edition so influential and popular, whilst also remaining abreast of developments in the field as well as standards in professional practice and the diverse contexts in which CBT therapists now deliver their services.
We have sought to capture some of the many ways in which CBT is practised by including a series of case studies describing the adaption of CBT assessment and case formulation for different clinical presentations. As noted previously, there is no single model of therapy that is âCBTâ and it will become evident from reading the different chapters that our contributors (and indeed ourselves as the authors of this text) do not adhere to identical understandings of what precisely CBT is or how it is optimally delivered. This diversity is intentional as we believe that any text seeking to do justice to such a rich discipline needs to reflect at least some of the perspectives that now characterize the field.
As Clark (2014: xv) asserts, the task for therapists is always one of needing to ââŚtailor CBT methods whilst remaining true to the core principlesâ. Our contributors have, we believe, achieved this admirably, demonstrating how they have adapted their approach to engage and work effectively with their clients while remaining committed to the core principles that define the field. What our contributors share is (1) a commitment to empirically underpinned and theoretically informed approaches to the therapeutic relationship and to assessment and formulation; (2) an ability to provide a contemporary perspective on their area of expertise; and (3) a first-hand knowledge of how rewarding (but at times challenging and even bewildering) therapeutic practice can be.
The brief we gave our contributors was to hold in mind information and guidance that would support CBT practitioners in working towards mastery of a particular application of CBT assessment and formulation, as well as reflective exercises to support readersâ further engagement with the topic. Additionally, we wanted to avoid the âpolishedâ case studies that can sometimes attract criticism from (especially novice) readers that they are too remote to feel entirely accessible. In practice, there is often a need to balance ...
