1. Dr Graham Sloan Cognitive Psychotherapist (BABCP & UKCP Accredited)
DCP Supervision Forum 2007 Cognitive Therapy Supervision: Using Structure to Guide Discovery
Dr Graham Sloan
Cognitive Psychotherapist
(BABCP & UKCP Accredited)

2. Acknowledgements Professor Craig White Sheelagh McCartney
Dr Janice Harper
Victor Henderson
Christine Padesky
Tania Yegdich
Jim Gibson
Derek Milne
Kevin Milton
John Heron
Dr Andrew Gumley
Dr Roslyn Law
Peter McCann
Carol Brough

3. Overview of Presentation
Describe Cognitive Therapy Supervision
Outline the supervision agreement and session agenda as the structure for supervision
Highlight the importance of experiential learning and relevance of self practice and self reflection in facilitating supervisee’ discovery
Provide an overview of the research on Cognitive Therapy Supervision
Consider the support necessary to sustain supervision in the organisation

4. Cognitive Therapy Supervision
Cognitive Therapy Supervision, as a framework for clinical supervision, was initially developed by Christine Padesky (1996) and Bruce Liese & Judith Beck (1997)
A small number of papers on this particular model of CT supervision have been published (see for example Sloan 1999, Todd & Freshwater 1999, Sloan et al 2000, Sloan & Watson 2002, Pretorius 2006, Sloan 2006)

5. CT Supervision: Some Guidelines
Build on supervisee’s strengths
Choose foci and modes that help develop next stage of competence
Build conceptualisation skills and self-reflection so that supervisee can help themselves
Use supervision worksheet to pinpoint the problem
Notice what is not discussed

6. Cognitive Therapy & Cognitive Therapy Supervision
Cognitive Therapy Supervision does not aim to provide therapy for the supervisee.
Nonetheless, the cognitive therapy model of supervision has close similarities with cognitive therapy process – it is focused, structured, educational and collaborative.

7. Cognitive Therapy Supervision
Focused: the development of the supervisee’s therapeutic competence
Structured: the supervisory relationship works towards achieving goals identified during the early stages of this relationship; individual sessions have a particular format
Educational: provides information, models skills, incorporates practice, provides positive and corrective feedback
Collaborative: supervisor and supervisee work as a team; supervisee is encouraged to be an active participant, formulate supervision questions and make a major contribution to the agenda for each session

8. Focus: What to talk about?
Padesky differentiates between the focus of supervision and the mode for supervision
Supervisor and supervisee have several options on what to focus:
cognitive therapy methods
case conceptualisation
client-therapist relationship
therapist reactions
supervisory processes

9. Focus: Therapist’s Reactions
Many cognitive therapy educationalists have emphasised the importance of therapists becoming aware of their cognitions, emotions and behaviour in their therapeutic work with clients.
Therapist/supervisee may have an underlying assumption about a client, the therapy process or the supervisor which is affecting their work or self-care in a negative way.
Exploring this in CS can increase awareness of how our own cognitions can influence the therapeutic endeavour and how we can use this to understand the process of therapy.

10. Focus: Therapist’s Reactions
Uncovering the supervisee's thoughts and feelings about their relationship with clients has, 'the added modelling effect of showing him or her how to work through similar emotions in the client' (Schmidt 1979 p 282).
In the example which follows the supervisory relationship had been longstanding and the issues discussed relate to the supervision agreement established at the outset of the relationship.

11. Focusing on Therapist’s Reactions
Foci: Conceptualisation, mastery of cognitive therapy techniques, therapist’s reaction
Modes: Case discussion and review of an audio recording of a therapy session
If I explore her sense of being incapable then I’ll make her feel worse
If my client becomes more distressed then it shows I’m a bad therapist
I should be able to make my client feel better

12. Focusing on Therapist’s Reactions
If I explore my client’s perspective then they will feel better understood
If my client becomes distressed then it highlights the significance of what is being discussed
If my client becomes distressed then I can provide a safe environment for them to express their feelings. I can ask for feedback on this aspect of the session and the session generally

13. Focusing on Therapist’s Reactions
Following some role-play to explore ways to facilitate expression of emotions, the supervisee proceeded to engage in a series of behavioural experiments to evaluate the usefulness of his new principles.

14. Structured: The Supervision Contract
When a detailed, co-constructed, rigorous contract is established, and renegotiated when necessary, the quality of the supervisory relationship is enhanced and deepened; both supervisor & supervisee report increased satisfaction with outcomes (Beinart 2004).
The supervision contract developed by Fiona Howard (1997) takes into consideration the issues that may contribute towards establishing an effective supervisory relationship

15. The Supervision Contract: Rationale
Supervision is an interpersonal process, the success of which owes much to the quality of the relationship between supervisor & supervisee; the supervision contract serves as a solid foundation for an effective supervisory relationship
Facilitates the sharing of desires & expectations of CS, and promotes agreement on the work to be undertaken
Ensures the style of working is structured & collaborative
Helps to minimise the potential for problems later in CS

16. The Supervision Contract
Purpose Confidentiality
Professional disclosure statement Documentation
Practical issues Dual relationships
Goals Problem resolution
Method/framework Accountability & responsibility
Evaluation Statement of agreement

17. Structured: Agenda Format
Personal update: How are things with you? What’s been happening?
Agenda setting: What do you want to focus on? What’s your supervision question? What is your goal for today’s session?
Link to last session: What was useful from our last session? How did you get on trying this with your clients?
Previously supervised case: How are things with client x?
Check on homework: You were going to arrange assessment interviews with family members, how did you get on?
Discussion of current issue: Role play interacting with critical parent
New homework: What does the research & theoretical literature suggest? From your experience, what have you found helpful?
Summary & feedback: What’s been useful or unhelpful today? Anything else we could have done to help?

18. Educational: Modes for CS
A supervision mode is the means by which supervisee learning and discovery occurs (Padesky 1996)
Supervision can include a variety of modes (methods):
case discussion
video/audio/live observation
role-play demonstrations
co-therapy (supervisor or peer)
Thus, a trainee attending supervision to learn about CBT for Obsessive Compulsive Disorder could learn through case discussion, review of an audio recording of supervisee-patient interaction, role-plays during supervision or doing some co-therapy with supervisor

19. Educational: Kolb’s Experiential Learning
David Kolb proposed a four-phase model of experiential learning
Concrete experience
Active experimentation
Reflective observation
Abstract conceptualisation

20. Kolb’s Learning Cycle Do Review Apply Learn Concrete experience
Experiment with ideas
Explore & predict
Trial & error
Active experimentation
Reflective observation
Review
Apply
Share & compare
Analyse & Interpret
Identify improvements
Implement improvements
Employ new ideas
Abstract conceptualisation
Learn
Reach conclusions
Absorb info
Develop new ideas

21. Kolb’s Learning Cycle
While we and our supervisees may have a preferred style, Kolb and others argue that to achieve effective learning we must work through the four stages
During a supervision session each stage of the cycle requires consideration.
It is therefore essential to pose questions which encourage reflection & conceptualisation
But also to identify ways to test out ideas (active experimentation & concrete experience)

22. Supervision Example Concrete experience: DO
Elicit negative automatic thoughts using the
three-column thought record
Reflective observation:
REVIEW
Active experimentation: APPLY
Reflect on experience -
What happened?Meaning?
Role play explaining completion
of thought record
Plan next intervention
Conceptualisation: LEARN
Work to understand how these experiences link with an evolving case formulation and theory

23. Educational: Learning CT from the Inside
James Bennett-Levy and others, advocate the use of Self-Practice and Self-Reflection as a means of learning about Cognitive Therapy from the inside (Bennett-Levy et al 2003, Beck 1995, Padesky 1996).
Self-Practice, refers to the actual practicing of the techniques on oneself (completing thought records, goal setting, behavioural experiments, positive data logs, cost/benefit analysis).

24. Educational: Learning CT from the Inside
Self-Reflection refers to the experience of reflecting on and evaluating self-practice.
There are sound reasons to suggest that SP/SR should be of value.
Experiential learning and self-reflection have a key role in the acquisition of new skills.
Professional artistry is best accessed by practitioner self reflection.
There are a broad range of models to guide self-reflection including, Johns’ Model of Reflection (Johns 2000), Atkins & Murphy’s Model of Reflection (Atkins & Murphy 1994), Schön’s Model of Reflection (Schön 1983).

25. Collaborative: Role of The Supervisee
Establishing a collaborative relationship
Sharing responsibility
Forthcoming in bringing work, including problems and insecurities/anxieties relating to their clinical work
Being open to feedback
Offering feedback to supervisor

26. Collaborative: Helpful supervisee questions
To help maintain focus Padesky advocates that supervisees are encouraged to come to supervision prepared with supervision questions:
How do I get my client to do their homework?
I’m not sure if my understanding of this client is complete, can we review my formulation?
I’m feeling anxious and uncertain about my abilities, feel as if I’m missing a lot of stuff, can we talk about this?
I find myself becoming increasingly annoyed with this client, can we explore my relationship with this client?

27. Evaluation of Cognitive Therapy Supervision

28. Benefits of CTS
The evidence base for the efficacy of CTS is very limited (Sloan et al 2000, Armstrong & Freeston 2006).
While there is an absence of evaluative research on this specific framework, CT supervision espouses many of the strategies regarded as ‘effective’ in the supervision literature
Providing the opportunity for the supervisee to observe his or her supervisor's clinical practice
Demonstrate and encourage the use of new skills using role-play
Providing relevant educational literature
Providing guidance with treatment and direction with therapeutic interventions
Having the relevant knowledge, clinical skills and teaching ability
Supportive

29. Benefits of CTS
In a review of cognitive-behavioural supervision (Milne & James 2000) the following strategies were regarded as effective supervisor strategies:
the close monitoring of the supervisee’s work
modelling competence
providing specific instructions
goal setting
providing verbal feedback on supervisee performance

30. Evaluation by Supervisee and Supervisor
What it brought to supervision
What is avoided
Discussions & reflection on therapy
Rating of therapy tapes
Supervisor
Contract
Supervisee’s satisfaction with CS
Beck’s Evaluation of Supervisors Form
Milne’s Process Evaluation of Teaching & Supervision

31. Keeping it Going?
Integrated within NHS Ayrshire and Arran’s implementation of psychosocial interventions project is a ‘support for clinical supervisors group’.
Furthermore, we promote and encourage time & space for supervision of supervision.
Encourage on-going CPD for clinical supervisors which would include supervision-related events.
Perhaps it is now time to develop a National network of supervisors, which could include the sharing of experiences, develop a formalised training for supervisors and identify relevant research questions.
Promote the accreditation of supervisors.

32. Conclusion
Cognitive Therapy Supervision has close similarities to Cognitive Therapy.
Structure is created through an overall supervision agreement and each session having its own agenda.
It is from this foundation that supervisors guide supervisee’ discovery.
A key focus is the acquisition and refinement of therapy skills so that clients receive effective delivery of evidence-based interventions.
The on-going development of supervisors can be nurtured in an organisational environment that supports this aspect of professional practice.

33. Thank You

34. Dr Graham Sloan January 2007
Accreditation as a Cognitive Behavioural Trainer and/or Clinical Supervisor
Dr Graham Sloan
January 2007

35. Agenda
Background to accreditation as a CBT Trainer and/or Clinical Supervisor
Members of working group
Criteria for accreditation as a CBT Trainer and/or Clinical Supervisor
Discussion

36. Background to Accreditation as a CBT Trainer and/or Clinical Supervisor
It is now more than 10 years since accreditation of practitioners was introduced by BABCP.
Widespread recognition of the need to develop criteria for accrediting CBT therapists who provide training and/or clinical supervision.
The process of accreditation aims to:
Recognise standards of practice in CBT training & supervision
Meet demand for recognised trainers & supervisors
Help organisations to identify specialists in CBT training and supervision
Work towards guidelines for the training of trainers & supervisors
Provide impetus to research and evaluation into the processes and outcomes of training, supervision, and clinical practice.

37. Group Membership Christine Barraclough (Psychology)
Mark Latham (Chair) (Nursing)
Charles McConnachie (Counselling)
Helen McDonald (Psychology)
Stirling Moorey (Medicine)
Ken Lewis (Counselling)
Howard Lomas (Social Work)
Jenny Riggs (Administrative Support)
Graham Sloan (Nursing)
Mary Wilson (Nursing)

38. Criteria for Accreditation as a CBT Trainer and/or Clinical Supervisor
To become accredited as a CBT trainer/supervisor,
applicants must fulfil the following criteria:
1. Be receiving regular clinical supervision from an expert/dedicated CBT supervisor and is receiving appropriate supervision/support for their CBT supervisory and/or training practice.
2. Be accredited or eligible for accreditation with BABCP as a CBT practitioner.

39. Criteria for Accreditation as a CBT Trainer and/or Clinical Supervisor
To become accredited as a CBT trainer/supervisor,
applicants must fulfil the following criteria:
3. Demonstrate a minimum of three years CBT practice since achieving eligibility for clinical practitioner accreditation.
4. Show evidence of ongoing continuing professional development in skills and theory in CBT which includes professional development as a trainer & clinical supervisor in CBT.

40. Criteria for Accreditation as a CB Trainer and/or Clinical Supervisor
To become accredited as a CB trainer/supervisor,
applicants must fulfil the following criteria:
5. Be a CBT practitioner.
6. Be providing regular specialist CBT training and/or clinical supervision.
7. Have treated a significant number of clients using CBT under regular CBT supervision from a spectrum of complexity and problem areas.

41. Criterion One
Must be receiving regular clinical supervision (minimum of one hour per month).
Details are required that you are and have been receiving ongoing supervision from a supervisor who is dedicated to, and has some expertise in, the CBT model.
Need to provide evidence of the supervisor’s competence to offer supervision for supervisory and training practice.

42. Criterion Two
You need to have been accredited with BABCP as a clinical practitioner for at least three years or show that you met criteria at least three years ago.
If not currently accredited as practitioner but can show that you met the criteria at least three years ago, you will need to complete clinical practitioner accreditation forms retrospectively.

43. Criterion Three, Five & Seven: Cognitive and/or Behavioural practice
Must provide details of last three years of CBT practice including how your CBT is divided in current employment:
100% of time on CBT
50% clinical, 30% supervision & 20% teaching
Summarise CBT work with clients since being accredited, providing information about setting and clinical supervisor (s)

44. Criterion Four
Provide information regarding attendance at workshops & courses, conducting research, writing publications, reading relevant articles and books to evidence your Continuing Professional Development in skills and theory of CBT.
In a separate section, you must enter details of CPD as a trainer and/or supervisor (on average: 6 hrs per year)

45. Criterion Six
If applying for accreditation as a trainer, you need to demonstrate that you have provided at least 40 hrs of training in the past two years.
Provide at least two evaluations of this training, which includes at least one external evaluation.
You should also submit a list of names and contact details of all people who can or have provided evidence of the quality and quantity of your training.

46. Criterion Six
If applying for accreditation as a supervisor, you need to demonstrate that you have provided at least 80 hrs of CS in the past two years.
You should obtain evaluations from one in five of your supervisees; there needs to be evaluations from at least two but not more than five supervisees.
You can also submit evaluation of your supervision from a course organiser/director.
Must submit list of the names and contact details of all supervisees.

47. References Two references are required
Referees will be someone who knows you and your clinical practice, and/or is the person to whom you turn for support/supervision in respect of your training and/or clinical supervision

48. Discussion What do you think about these criteria?
How close are you to meeting them?
If not, what do you need to do in order to fulfil criteria?
Any concerns?

49. Thank You