Reflection in CBT

Beverly Haarhoff, Richard Thwaites, Author

• Publisher: SAGE Publications Ltd
• Year: 2015
• Print ISBN: 9781446258897, 9781446258880
• eBook ISBN: 9781473943070
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

Developing skills and competency in CBT is a complex process of which self-observation and self-reflection are an essential part. In this new book, leading figures Beverly Haarhoff and Richard Thwaites outline the rationale for a focus on self-reflective practice in CBT, before offering practical and accessible guidelines demonstrating how this can be achieved in training and practice.

Highlighting relevant research throughout and using case studies to illustrate theory in practice, ten chapters consider:

-       reflection in training and in supervision and self-supervision,

-       reflecting on the therapeutic relationship, on our sociocultural perceptions and biases and on client feedback

-       how reflection is vital to self-care and to becoming a better therapist, supervisor and trainer.

This is an essential read for trainees in both high and low intensity CBT programmes, those on broader CBT courses, and for qualified practitioners working independently to enhance their self-reflective capacity.

1 Reflection in CBT: Becoming Better Therapists, Supervisors and Trainers

Beverly Haarhoff

and Richard Thwaites

Learning aims

• To introduce the Declarative Procedural Reflective (DPR) model of therapist skill development as the theoretical spine of the book
• To highlight the importance of reflection for the training, ongoing professional development and professional lives of all CBT therapists

Introduction

When at work, with my clients, supervisor or colleagues, I can sometimes feel bored, angry, sad, anxious, guilty, scared, hopeless, uncertain, or out of control. Why is this? Is it them or is it me? What should I do next? Have I made the right decision? How is it that my intervention didn’t work? Why did I fall into that old pattern of reacting? How will I cope? What should I do next? What if the client gets worse? I can’t stand working with depressed/angry/anxious/older/younger/suicidal clients. Am I a good enough therapist? Why did my client suddenly drop out of therapy? Could I have done something different? How can I improve as a therapist?

These are all familiar questions that occur from time-to-time for therapists (and other professionals) dealing with complexity, ambiguity, multiple sources of information, risk, and evaluation on a daily basis. Ever since the publication of Donald Schön’s ground-breaking book The Reflective Practitioner in 1983, reflection and reflective practice have been recognised as important processes which can be helpful in unpacking, managing and responding to these questions, and to the situations that generate them (Schön, 1983). In addition, Schön also identified reflection as playing an important role in education and professional development. In a nutshell, he challenged the accepted notion that there was a body of empirical knowledge that professionals from various disciplines could learn at university and then apply with confidence, once qualified, to guide problem-solving and decision-making. He observed that the day-to-day nature of professional responsibility frequently entails the ability to cope with complexity, uncertainty, ambiguity, conflicts of values, and ethical and moral dilemmas. Being professionally effective, he insisted, requires not only the mastery of the theoretical principles and knowledge base connected to the profession, but being able to apply this knowledge in flexible, adaptive and creative ways. He identified reflection on experience as the primary key to unlocking what he describes as “professional artistry”, the ability to skilfully unite theory and scientific facts with practical experience. To do this the professional practitioner needs to be able to reflect on what they are doing as they do it (reflection-in-action) and also reflect on what they have done (reflection-on-action) and plan to do in the future. Reflection is now considered a core competency by many professional bodies, and practitioners from different professions are often required to demonstrate their reflective ability in the form of written reflective accounts of their practice in order to maintain their professional registration. This is particularly prevalent in the “helping” professions, such as nursing, social work and psychotherapy. Numerous academic courses also have a reflective component as part of course work, which is often assessed and evaluated.

Reflection in CBT

Historically, CBT is firmly rooted in the empiricist tradition, evolving as it did from the behavioural therapies developed by academic psychologists in opposition to the powerful psychoanalytic models of human development and psychopathology (Watson & Rayner, 1920; Wolpe & Lazarus, 1966). CBT is now widely recognised as the foremost evidence-based psychotherapy, with a proven track record of effectiveness with an ever-increasing range of diagnostic presentations (Butler, Chapman, Forman & Beck, 2006). CBT practitioners are expected to consistently deliver evidence-based interventions tailored to the client’s diagnostic presentation and there is considerable evidence to suggest that the closer CBT practitioners stick to the evidence-based protocols, the more successful the therapy is likely to be (Schulte & Eifert, 2002). To some degree this history has engendered a misperception that CBT therapists are technically-focused practitioners applying proven interventions in a “cookbook” manner, not recognising or utilising reflection as an important element of training and professional development (Bennett-Levy, Thwaites, Chaddock & Davis, 2009). Although reflection and reflective practice has not, traditionally, been explicitly integrated into CBT training and professional development programmes in the same way as it has been in professions such as nursing and social work, this perception is not accurate and reflection has always been tacitly incorporated in CBT, as shown in the following examples:

• Socratic enquiry (“What do you make of that?” “How do you make sense of what happened given your belief about this?”)
• Reflecting on the outcome of behavioural experiments
• Supervision models
• The use of informal self-practice and self-reflection in training programmes (“How did you experience keeping an activity diary?”)
• The emphasis on collecting and responding to feedback from clients and supervisors

In addition, since 2000, Self-Practice/Self-Reflection (SP/SR), as an experiential adjunct to CBT training, has become integrated into a growing number of training programmes and professional development opportunities (Bennett-Levy et al., 2001; Haarhoff et al., 2011). Furthermore, since CBT has expanded to provide therapy for more severe and complex presentations, such as clients diagnosed with a personality disorder, CBT therapists have been advised to reflect on the interaction between therapist and client assumptions, beliefs and compensatory behaviours (Beck, 2011; Laydon, Newman, Freeman & Morse, 1993; Leahy, 2001; Young, Klosko & Weishaar, 2003). Reflection on the therapist’s own beliefs, feelings and actions is now seen as essential in the development and maintenance of therapeutic relationships, particularly when addressing alliance ruptures (Safran & Segal, 1990). Personal therapy, the therapist’s therapy, is the form reflection often takes in many psychotherapeutic modalities (Laireiter & Willutski, 2003), and although personal therapy is not generally a compulsory part of CBT training in most English-speaking countries, many CBT therapists independently seek out personal therapy as a self-reflective forum (Orlinsky, Norcross, Rønnestad & Wiseman, 2005).

In this book we build on and extend the wide-ranging reflective practice already inherent in the principles of CBT. Our overall aim is to show how reflection and reflective practice can, and should, play a key role in the training, professional development and the ongoing daily professional life of all CBT therapists (whether novice or expert), supervisors and trainers, in many different contexts and formats. Our goal is to clearly identify the different forums of reflection in CBT and provide clear structured procedural guidelines for practice in each.

In this introductory chapter we clarify the ways in which we will be describing the various components of reflection, namely reflective practice, skill and process. We also introduce the Declarative Procedural Reflective (DPR) model of therapist skill acquisition (Bennett-Levy, 2006) as our guiding theoretical model and highlight reflection as a metacompetency underpinning all other therapeutic competencies. Remaining true to our empirical roots, we summarise the evidence collected over the past decade that consistently suggests that certain forms of reflection are useful in specific CBT skill acquisition, conceptual understanding and more skilful management of the interpersonal dimensions of therapy.

CBT practitioners can often have very different reactions to the requirements and expectations around reflection. Some will embrace and delight in the activity, others may feel somewhat unnerved or confused, possibly worried that they have no idea how to go about engaging in such activities, especially if during training this involves meeting institutional expectations. Each chapter therefore concludes with some suggestions regarding the ways that reflection can be taken forward and implemented by the CBT therapist. This introductory chapter will conclude with some guidelines concerning how best to use this book.

Understanding and defining reflection in CBT

There are many definitions of reflection. From a common-sense perspective, however, reflection is: “thinking about something that has happened [usually in a complex, difficult or ambiguous situation] and considering the implications in more detail” (Moon, 1999, our italics). While this makes sense, it has been noted that the language of reflection in the context of psychotherapy could benefit from clarification as the term covers a number of different and discrete aspects of reflection (Bennett-Levy, Thwaites, et al. 2009). These authors distinguish four usages of the term, which are described below:

Reflective practice refers to reflecting on clinical experience that includes the personal reactions of the therapist. This may happen in supervision, self-supervision, through reflective journals and Self-Practice/Self-Reflection. Reflective practice can also involve reviewing therapy tapes, attending to client or supervisor feedback and reviewing client progress measures.

Reflective skill encompasses general reflective skills (the ability to reconstruct and explore events) and self-reflective skills (the observation and exploration of self, for example the therapist’s own thoughts, emotions and behaviours).

The reflective system is part of the Declarative Procedural Reflective (DPR) model of therapist skill acquisition developed by Bennett-Levy and colleagues (Bennett-Levy, 2006; Bennett-Levy & Thwaites, 2007). This model will be discussed in greater detail below. Briefly, however, declarative knowledge refers to theoretical and practical knowledge gained through traditional pedagogical channels, such as reading and attending lectures – technical knowledge in Schön’s terms (Schön, 1983). Declarative knowledge is abstract knowledge. For example, knowledge about the therapeutic relationship can exist without actually ever having been part of a therapeutic relationship (e.g. “It is a good thing to foster collaboration in CBT”). Procedural knowledge and skills we build up over time in a more complex manner and this relies on the ability to utilise experience in a meaningful manner, detecting patterns and processes. In the therapeutic context, procedural knowledge and skills are often observed to differentiate experienced from novice clinicians. Experience allows the clinician to build up a series of implicit rules, for example, “When this happens, then I do x, y or z”. The reflective system is characterised as being at the centre of therapist knowledge and skills, containing no permanent knowledge but functioning as an “engine” which drives the other two systems, integrating knowledge from both declarative and procedural systems, helping the therapist obtain answers to questions such as “How does this theory or practical intervention work out with this particular client?” In therapy, an effective reflective system should focus and integrate information derived from what is happening in therapy with the client, and what is happening in the therapist’s head, with appropriate evidence-based declarative and procedural knowledge. For example, if a client is struggling to complete an intervention such as a thought diary, the therapist can bring to mind other similar experiences to shed potential light on how to manage the current difficulty (for example, some clients find writing and spelling difficult and need reassurance that this is not important, some clients have a belief that writing thoughts down makes them more likely to occur). Strengthening the reflective system has particular relevance for the development of interpersonal skills which are essential in the delivery of sensitive and flexible interventions and which can reduce the likelihood of client disengagement and aid the therapist in addressing inevitable therapeutic alliance ruptures (Bennett-Levy & Thwaites, 2007).

Reflection as a process is seen as having three parts:

• Focused attention on a problem. This can be stimulated by a rupture in therapy, an unexpected or overfamiliar emotional reaction, curiosity, or a mismatch between client and therapist goals and expectations;
• The ability to reconstruct and observe the event. Reconstruction can rely on imagery, role-play or mindful observation; and finally,
• The event is conceptualised and synthesised by a process of self-questioning, logical analysis and problem-solving strategies.

To summarise, our understanding of the scope of reflection includes the practice of reflection together with the general and self-focused reflective skills involved. We also consider the reflective system as the key element or engine driving the Declarative Procedural Reflective model of therapeutic skill acquisition. Finally, the process of reflection entails attention, reconstruction and conceptualisation, which ideally can be used by the CBT therapist in ways that extend understanding and ideally also change emotional reactions and behaviours.

The DPR model of therapist skill acquisition

In the original representation of the DPR model (Bennett-Levy, 2006), each of the systems was depicted as of equal size. Subsequently, however, the model was redrawn to centralise and privilege the contribution of the reflective system now described as the “engine” driving lifelong learning, demonstrating the role of reflection as a regular process within iterative learning cycles (Bennett-Levy, Thwaites et al., 2009) (see Figure 1.1). In addition, in the model adapted for this chapter, the relationships between the reflective system and declarative knowledge and procedural skills are clearly marked as a two-way process. For more experienced CBT therapists, their knowledge and skills will be both an input and an output to the ongoing process of reflection in the development of expertise (Bennett-Levy, 2006). This is to be contrasted with the novice therapist who will possess more limited therapy-related declarative knowledge and potentially even less procedural skills. For such an individual there is likely to be a greater role for the reflective system producing therapy-specific knowledge and skills and a lesser role for knowledge and skills feeding into the process of reflection.

Figure 1.1 A perspective on the DPR model highlighting the central role of reflection on therapist skill development (adapted from Bennett-Levy, Thwaites, Chad...

Table of contents

• Cover
• Half Title
• Publisher Note
• Title Page
• Copyright Page
• Contents
• About The Authors And Contributors
• Foreword
• Acknowledgements
• Introduction
• 1 Reflection in CBT: Becoming Better Therapists, Supervisors and Trainers
• 2 Bringing CBT supervision alive: Maximising the Role of Supervisor and Supervisee Reflection
• 3 Developing your self-supervision practice: Using Reflection to Increase Therapeutic Effectiveness and Enhance Cbt Skill Development
• 4 Reflecting on the therapeutic relationship in CBT
• 5 Reflecting on our socio-cultural background: Becoming More Culturally Sensitive and Effective Cbt Therapists
• 6 Client feedback: An Essential Input to Therapist Reflection
• 7 Reflection in CBT training
• 8 Experiencing CBT for yourself: Using Self-Practice and Self-Reflection (Sp/Sr) to Develop Therapeutic Competence and Metacompetence
• 9 Reflection in low intensity CBT: Challenges and Practice-Based Innovations
• 10 Using self-reflection to promote CBT therapist self-care
• References
• Index