3/23/21 1 IAPT HI Top-Up Training in CT-PTSD Day 3 (Supervision) Oxford Centre for Anxiety Disorders and Trauma, Department of Experimental Psychology, University of Oxford, King’s College London & University of Exeter 1 Topics of Workshop Day 3 Please mute your microphones when not speaking! Please • Keep your camera on, unless you have broadband issues. • Stretch when you need. • Use the chat function to ask questions as soon as they pop into your mind. We’ll answer regularly • Select speaker view for PowerPoints, but you may want to switch to gallery view for discussions • You will need your smartphone for some exercises 1:00 pm Welcome and Overview Selection Training Cases and Treatment Decisions Break Supporting and Assessing competency in tCT Break 4:30 pm Attending to therapist appraisals in supervision Self-care Q & A 2
Transcript
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IAPT HI Top-Up Training in CT-PTSD Day 3 (Supervision)
Oxford Centre for Anxiety Disorders and Trauma, Department of Experimental Psychology, University of Oxford, King’s College London & University of Exeter
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Topics of Workshop Day 3
Please mute your microphones when not speaking!
Please• Keep your camera on, unless
you have broadband issues.• Stretch when you need. • Use the chat function to ask
questions as soon as they pop into your mind. We’ll answer regularly
• Select speaker view for PowerPoints, but you may want to switch to gallery view for discussions
• You will need your smartphone for some exercises
1:00 pm Welcome and OverviewSelection Training Cases and Treatment
Decisions
Break
Supporting and Assessing competency in tCT
Break
4:30 pm Attending to therapist appraisals in supervisionSelf-care
Our experiences in identifying and treating PTSD in IAPT
• Please share your thoughts about this on our Padlet throughout the day (wall you can post anonymous comments on)
• See link in zoom chat.• You can also use this QR code below (hold phone camera in front
of it as if taking photo and link should open)• We will discuss the comments and themes at end of day
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Supervising Trainee High Intensity Therapists in Trauma-Focused Cognitive Therapy
Oxford Centre for Anxiety Disorders and Trauma, Department of Experimental Psychology, University of Oxford, King’s College London & University of Exeter
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* Note: people are people not cases!
Selecting Useful“Training Cases*”
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Discuss for 6 minutes in groups of 3:• Regarding your experience of supervision on this
programme:• What kind of cases have best enabled you to develop tCT
skills & why?• What kind of cases have least well enabled you to focus
on the development of your tCT skills & why?• In each case, what has the experience been like a) for
you & b) for your client?• Please put your (brief) answers in the chat when we close
the breakout rooms
Group task
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• Meets PTSD diagnostic criteria• PTSD is the main problem• Limited co-morbidity & a clear client priority to work on PTSD• Low number of re-experienced traumatic events (1-3?)• Adult trauma• Ideally not cPTSD (interpersonal issues, emotional regulation,
pervasive & enduring negative view of self)• Low risk• Has a support network• Not too mild! E.g. recovers after psychoed.• Consents to recording and measures and can commit to
attend
A good training case:What your supervisors said…
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• Not PTSD/unclear• Not client priority• cPTSD• Repeated childhood traumas• Can’t commit to attending• Significant comorbidity• Heavy drug/alcohol use• Current litigation• Isolated with no social support• History of interpersonal conflict/rupture in therapy
&/attendance issues• History of serious risk
A poor training case:What your supervisor said…
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• Is PTSD the main presenting problem?• Is PTSD/Sx of PTSD the problem the client wants to
address?• Are traumatic memories limited to one or two main events?• Are the traumatic memories linked to events in adulthood?• Does the client have sufficient memory to carry out reliving?• Is the client sufficiently stable to focus on the PTSD (c.f.
earlier training on risk, coping, life circumstances etc)• Normal suitability for CBT criteria (e.g. Safran and Segal
scale)• Consider therapist factors (Emma will say more later re
therapist care)
Helpful Questions for Training Cases
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• Re-experiencing symptoms are the KEY feature of
PTSD
• Help diagnose & distinguish from other disorders that
you would treat differently
• BUT Re-experiencing Sx ≠ PTSD
A reminder from the previous workshop…
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Is it PTSD? Re-experiencing Sx
• Intrusions present in depression, agoraphobia, social anxiety, OCD, substance misuse, psychosis ….. Need all the other PTSD symptoms too for a diagnosis
• Check they are not talking about rumination (is it coming unbidden and feels more real/distressing/now than normal memory vs. choosing to think about and go back over something)
• Check they are not talking about normal remembering (as above)
Kerry Young CNWL
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• A guide to decision making in assessment when attempting to match presenting problems to a disorder-specific CBT model with an evidence-based intervention (Whittington, 2013)
Treatment Choice Decision Tree(Whittington, 2013)
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• Comorbid anxiety and depression very common: 57.5% (US) met both diagnostic criteria (Kessler et al., 2003)
• High correlation between depression & nine other conditions e.g. GAD, OCD, PTSD, panic disorder & phobias (McManus et al., 2009)
• Compared to those with depression alone:• more severe difficulties • increased risk of suicide• more likely to relapse
Why bother when training cases don’t represent “real” IAPT cases?
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• In any supervision context it is important to think about the developmental stage of the supervisee (Vygotsky’s “zone of proximal development”)
• For skills-based supervision when learning a new model of therapy, however experienced, it is helpful to be able to apply the model in a “standard” way before we “improvise”
• May be demoralizing (”I’m not doing it right”) or disillusioning (“the treatment doesn’t work”)
• May contribute to:• Therapist rigidity• Therapist drift• With poorer client (& therapist?) outcomes
Why bother continued…?
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• Natural when training to focus on technique and protocol.
• When things don’t seem to go well can redouble efforts but…
• Pushing harder on rigid technique in the face of alliance problems is linked to poorer outcomes (Castonguay et al., 1996)
• Planned flex in structure e.g. providing more sessions or “stressor” sessions can maintain good outcomes (Galovski et al., 2012).
Therapist rigidity
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• Alternatively the trainee may assume that the model simply does not apply
• May fall back on generic skills, “eclectic” or “integrative” approaches
• Drift away from pushing for behaviour change is common (Waller, 2009)
• Therapist switches away from core methods of CBT linked to poorer outcomes (Schulte and Eifert, 2002)
Therapist drift
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Examples:• Continuing to repeat reliving despite no emotional
change without exploring engagement / barriers to “connecting” emotionally such as panic anxieties, dissociation, or idiosyncratic fears
• Updating hotspots before identifying underlying meanings
• “Ticking off” techniques, e.g. stimulus discrimination even if no remaining triggers
What might rigid application of technique look like in PTSD?
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Examples:• Multiple sessions of “stabilisation” in complex cases• Abandoning memory reprocessing every time client
brings a current “crisis” or concern• Applying a generic CBT model with no tCT specific
elements• Avoiding reliving entirely because it might be too
upsetting• Doing timelines or “safe place” ‘ EMDR resourcing with
everyone
What might drift look like in PTSD?
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• For people presenting with PTSD & depression:
• Usually treat the PTSD first because the depression will often improve with successful PTSD treatment
• Treat the depression first if it might make psychological treatment of the PTSD difficult
Care for people with PTSD & Complex NeedsNICE 2018
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But how do we make decisions where there is complexity or even when not?
Sharing responsibility for session structure & content
ability to agree goals for the intervention
ability to plan and to review practice assignments (‘homework’)
using summaries and feedback to structure the session
ability to devise a maintenance cycle and use this to set targets
Guided discovery & Socratic questioning
ability to elicit key cognitions/images
ability to use thought records
ability to detect, examine and help client reality test automatic thoughts/images
ability to identify and help client modify assumptions, attitudes and rules
PTSD - Foa & Rothbaum PTSD - Resick PTSD – Ehlers
Behavioural Activation
ability to plan and conduct behavioural experiments
ability to develop formulation and use this to develop treatment plan /case conceptualisation
Panic Disorder (with or without agoraphobia ) - Clark Panic Disorder (with or without agoraphobia ) - Barlow
Metacompetences
ability to adhere to an agreed agenda
knowledge of common cognitive biases relevant to CBT
ability to identify and work with safety behaviours
ability to employ imagery techniques
ability to identify and help client modify core beliefs
capacity to implement CBT in a manner consonant with its underlying philosophy
capacity to manage obstacles to CBT therapy
capacity to use clinical judgment when implementing treatment models
knowledge of basic principles of CBT and rationale for treatment
ability to explain and demonstrate rationale for CBT to client
knowledge of the role of safety-seeking behaviours
Ability to structure sessions
ability to understand client’s inner world and response to therapy
Guided CBT self help
Depression – Low intensity interventions
Depression – High intensity interventions
capacity to adapt interventions in response to client feedback
capacity to formulate and to apply CBT models to the individual client
capacity to select and apply most appropriate BT & CBT method
CBT specific metacompentencies
capacity to structure sessions and maintain appropriate pacing
capacity to use and respond to humour
Generic metacompetences
ability to end therapy in a planned manner, and to plan for long-term maintenance of gains after treatment
ability to use measures and self monitoring to guide therapy and to monitor outcome
Ability to implement CBT using a collaborative approach
Generic therapeutic competences
knowledge and understanding of mental health problems
knowledge of, and ability to operate within, professional and ethical guidelines
knowledge of a model of therapy, and the ability to understand and employ the model in practice
ability to engage client
ability to foster and maintain a good therapeutic alliance, and to grasp the client’s perspective and ‘world view’
ability to deal with emotional content of sessions
ability to manage endings
ability to undertake generic assessment (relevant history and identifying suitability for intervention)
ability to make use of supervision
Metacompetences(Roth & Pilling, 2007)
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• Higher order competences that “focus on the ability to implement models in a manner that is flexible and tailored to the needs of the individual client” (pg.9)
• Procedural rules for applying therapy in a theoretically coherent but appropriately adapted way
Metacompetences(Roth & Pilling, 2007)
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Metacompetency and all that jazz!
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• Two key questions for supervision of tCT and indeed our own self-supervision / preparation
• WTF?• What’s The Formulation?• What’s The Function?
Applied to tCT
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• Formulation-based rather than formula-based therapy
• Keep coming back to the client’s presenting problems and how the tCT underpinning model makes sense of these
• Which of the key tCT targets are we working on?
• Nature of the Trauma Memory (& triggers)• Excessively Negative Appraisals• Strategies Intended to Control Threat
What is the (evidence-based) formulation?
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• Rather than rigidly applying techniques in “order”• Do the techniques I propose applying match the
formulation target – the particular presenting issues that we are working on at this stage in therapy?
• Does my / my supervisees application of them facilitate:
• Elaboration of the memory• Cognitive Reappraisal or• Reversing strategies intended to control threat that
prevent memory elaboration and cognitive reappraisal?
What is the technique function?
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• Formulating co-morbid depression that has occurred as a consequence of PTSD, incorporating elements of BA into reclaiming your life, but remaining focussed on memory work as key to enabling the remission of depression
• Formulating idiosyncratic fears re reliving and e.g. incorporating panic psychoeducation to enable reliving without abandoning key elements of the PTSD treatment…
• Updating a “quick win” hotspot early, where it is clear that the meaning has been identified and alternatives are believable to and fully articulated by the individual
• Using a site visit early in therapy to enhance reliving where there are significant gaps / perceptual distortions in the memory or emotional distancing
• Being brave enough to retrace your steps when it becomes clear that a piece of hotspot updating missed the mark in terms of the meaning….
Examples of metacompetent application of tCT
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• Nick Grey & Adrian Whittington• ‘How to become a more effective CBT therapist:
Mastering metacompetence in clinical practice’ (2014) • Highlight risks to effective practice• Suggest procedural rules for working with
comorbidity• Thanks to Nick and Adrian for use of their excellent
ideas, slides & pictures
Acknowledgements
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Assessing PTSD Competence
Dr Sheena Liness, School of Mental Health & Psychological Sciences, Institute of Psychiatry, King’s College London
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Therapist Competence (Roth & Pilling, 2007)
• Defining Terms:
• Adherence – is the intervention carried out as intended/prescribed
• Competence – is the intervention delivered skilfully
• Meta-competence – the right skill at the right time
• Treatment Integrity – best practice for patients
• Inter-rater reliability & confidence/clarity improves with training (Gordon, 2006; Reichelt et al., 2003; Loades & Armstrong, 2016; Kazantsis et al., 2018)
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Anxiety Disorder Specific Rating Scales• NICE Guidelines recommend disorder-specific rather than
generic CBT interventions for anxiety disorders• CTCS –SP for Social Anxiety (Clark et al., 2007; Von
Consbruch et al., 2012)• High inter-rater / test re-test reliability & internal
consistency
• CTCP for Panic Disorder (Clark et al., 2002)• High inter-rater reliability / internal consistency &
good face validity Significant difference competence classification CTCP vs CTS-R – CTCP more sensitive capture panic specific competence (Liness et al., 2020)
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Therapy Competence to Clinical Outcome
• Modest relationship significant in depression (CTS) (Webb, De Rubeis, & Barber, 2010; Zarafonitis-Muller et al., 2014)
• CBT Training (CTS-R):• No general relationship but trend reliable improvement
most competent (Branson et al., 2015/2017) • Small relationship in depression (Liness et al., 2019)
• Anxiety & Disorder Specific competence:• CTCS - Strong association SAD (Ginzburg et al., 2012)• CTCP -Association to panic beliefs and panic related
disability (Liness et al., 2020)
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CTCS-PTSD - PTSD Disorder Specific Rating Scale
• Psychometric validation in process
• PTSD training study - (Murray, 2017)• Sig more competent PTSD post training (self &
supervisor rated) maintained at follow up
• Used to assess PTSD trial therapists (OxCADAT)
• CTCS-PTSD vs CTS-R - IAPT trainees (underway)• High internal consistency, good inter-rater
reliability 40
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Conundrums
1. Skilfulness and competence are not static
• Develop over time• Develop across problems • Variation within and across sessions• Awareness of limits in self• Awareness of limits in therapy • Effects of organisational / service barriers
Garland, A 2008
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CTCS-PTSD – 16 Items
General Therapeutic Skills
Item 1: Setting the Scene/ Agenda Item 2: Quality of CommunicationItem 3: Pacing and Efficient Use of TimeItem 4: Interpersonal EffectivenessItem 5: Guided DiscoveryItem 6: Addressing Patient’s EmotionItem 7: Using Experiential Exercises to Facilitate Cognitive &
Emotional ChangeItem 8: Use of Feedback & SummariesItem 9: Homework
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CTCS-PTSD – 16 ItemsPTSD Specific Therapeutic Skills
Item 10: PTSD Conceptualisation Item 11: Reclaiming / Rebuilding your lifeItem 12: Education/normalisingItem 13: Working on the Trauma Memory/Triggers/IntrusionsItem 14: Modifying Negative AppraisalsItem 15: Working on Strategies that patient uses to control
threat or symptoms (cognitive and behavioural)Item 16: Focus on Appropriate Issues/Session targets and
selection of therapeutic strategies
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7-point Likert Scale: Poor to Excellent
• 0 Poor – Absent or failed to do• 1 Barely Adequate – Inappropriate or unhelpful• 2 Mediocre – An attempt but general/abstract major
problems & omissions• 3 Satisfactory – Generally competent some
inconsistencies• 4 Good – Plausible minor problems• 5 Very Good – Skilful appropriate effective • 6 Excellent – Facilitate cog & emotional change in face
• Overall summary: what went / did well and what might have done differently
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Kolb’s Learning Cycle
Concrete experienceHaving the experience
Reflective observationsReviewing the
experience
Active experimentation
Planning the next steps
Abstract Conceptualisation
Concluding from the experience
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Top Tips• Familiarise yourself with the scale – particularly part 2 • See as opportunity for self-reflection / feedback / learning• Don’t wait for the ‘perfect’ session • Most CBT PTSD sessions should tick enough of the items
but there will be N/A’s (you don’t have to tick every box)• When rating read key features & have item descriptors in
mind • Try to mark objectively related to key features• Submit an active PTSD session – i.e. active memory work /
updating / trigger discrimination/ experimenting• Beginning not an end – practice & discuss i.e. supervision
groups• Keep feedback succinct – what is key 47
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Rating the CTC-PTSD
• Role play observation
• Individual rating (put your rating into Pollev)• Group Discussion• Agree a group score and feedback :• Summarise
1. One thing liked / did well2. One thing could be improved
• One person put group rating into 2nd Pollev• One person put agreed feedback into Chat
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CBT Competence
• Therapist competence is dynamic not static• = Lifelong Learning• Remember ‘Therapist Drift’ (Waller, 2009; Waller &
Turner, 2016)
• Foster: • On-going self-reflection• On-going live review in supervision• On-going self-assessment• Anxiety disorder specificity
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Working with therapist cognitions & supporting therapists’ self care in CT-PTSD supervision
Oxford Centre for Anxiety Disorders and Trauma, Department of Experimental Psychology, University of Oxford & University of Exeter
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Creating a supportive space in supervision
• Agree in contract• Viewing video: focus on what going well• Supervisor/supervisees give feedback first on strengths • No such thing as a stupid question• Supervisor models imperfection, welcomes feedback • Neg cognitions normalized, explore collaboratively &
w/out judgement• Ask for feedback
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General techniques (mirror CT) • Get active!• Watch tape, evidence for/against, surveys, pie chart
etc. role-play, experiment• Get group involved – normalize, survey group, fish-
bowl role play• Some may need help spotting (keep diary or reading
e.g. Experiencing CBT from the inside out, Bennett-Levy et al., 2015)
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Survey pre-trainingTop 7 negative therapist cognitions about CT-PTSD (highest mean scores)
People with multiple traumas need a stabilization phase before they are ready to talk about the trauma
Traumas which occurred in childhood require a different treatment approach than those that occurred in adulthood
Working remotely is going to make it hard for the patient to engage or for the treatment to work When I go out with them, they may have an uncontrollable flashback
They will dissociate when we work on the trauma and I will not know what to do
Thinking or talking about the events will make the patient more suicidal
While we are working remotely, site visits cannot be done safely
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Cognition Potential impact/ signs to look for
Supervision strategy – (identify & normalize all thoughts first!)
Multiple traumas need stabilization phase
Delay memory work/not using CT-PTSD
Review learning from teaching, look back at training videos, ref to evidence, look at pros/cons, do survey of other therapists, look at fears re no stabilization, set up experiment
Childhood traumas need diff approach
As above As above
Working remotely hard to engage
Not using all CT-PTSD interventions remotely
Survey patients or other therapists, ref to evidence, role-play in remote supervision, look at training videos, experiment compare session using CT-PTSD interventions vs not.
When go out with them, flashbacks
Avoid out of office work Role play how to deal with flashbacks, look at videos of out of office work, survey other therapists, set up as experiment,
Dissociate when doing tf work
Avoid or delay tf work Role play dealing with dissociation, check dissociation measures-look at likelihood, training videos, set as experiment
Think/talk re memory increase suicidal
Avoid or delay tf work Look at evidence, survey therapists, experiment.
Site visits cannot be done safely remotely
Avoid site visit Try virtual site visit live in supervision, view training video, set up behavioural experiment to test cognitionsThen feedback next session & roleplay site visit on phone
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Look for overly positive thoughts tooPugh & Margetts (2020) Are you sitting (uncomfortably) Action based supervision and Supervisory drift. TCBT
• Overly played strengths, e.g. more confident with some techniques
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Video example – identify, formulate & address cognition
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Personal therapist beliefs (countertransference)
• Thoughts & feelings unrelated to patient (e.g. If all patients do not get better, I am a bad therapist) • Address if interfere CT-PTSD, strong emotional reactions for
therapist • Can detrimental to therapist self-care (e.g. not taking breaks)• Point to measures e.g. Leahy therapist schema
questionnaire (2001) or helpful books e.g. Experiencing CBT from the inside out (Bennett-Levy et al., 2015)
• Self disclosure can help normalize/ask group to share their experiences
• Draw on CT skills as needed (e.g. positive data log, responsibility pie chart, compassionate role play etc.)
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Keep a look out for supervisor cognitions• ‘Looking at therapist cognitions will be too upsetting’ • ‘Supervisees will find role-play too anxiety provoking’• ‘I don’t have sufficient expertise to supervise CT-PTSD’• Can lead to avoidance of active work in supervision • Self-reflection – record thoughts & work on them,
discuss in your own supervision and test out
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Reflection exercise• As a supervisee, what supervision strategies have you
found most useful in creating a safe space/ to addressing therapist cognitions?
• Write down a plan of one/two things you could try more of in your own supervision going forward?
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When trauma is personally upsetting for therapists or supervisors
• Therapists can ask not to see particular traumas if triggering • Discuss in supervision • Encourage use of Then vs Now and updating as needed • Identify emotions and thoughts during sessions and discuss
in supervision
• Be mindful of therapist’s emotional temperature in therapy (e.g. over/under engagement with trauma memories)
• All the same applies for supervision of personally upsetting cases
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Supporting therapist self-care in supervision
• Agree therapist self-care key to effective CT-PTSD
• Particularly important with remote working• Model in supervision – quick tea
break/encouraging stretching • Look out warning signs (e.g. no time lunch)• Help therapists to identify signs they are
struggling & any blocks to self-care (e.g. If I take a break people will think I’m not working hard at home)
• Use same metaphors we would in therapy
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Encourage therapists to…
• Move around and do something pleasurable after sessions
• Encourage speak to supervisor or colleague after challenging session
• Check on their ‘office’ space, can they change it at end of the day?
• Reasonable caseload, allowing space in working day? • Marking the end of the working day?• Using trigger discrimination if needed?• Be kind and self-compassion (e.g. “what would you say to
me/ another therapist in the group”? Write a compassionate letter to self)
• All the same applies to supervisors!
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Example
Dear Emma,
This last year has been incredibly difficult. Dealing with the uncertainty of a global pandemic, the worries of your friends and family, working full time alongside doing full-time childcare for so many months has been exhausting. You have been doing the best you can to be there for your patients, supervisees, team and children. Being online so much all day has been exhausting. Give yourself a break. You are doing your very best. My kindness plan: Tonight, pack your computer away at the end of the day. Run a bath once the kids are asleep and read a chapter of your book. Read this back if you need to.
Love, Emma
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Exercise – write compassionate message to self & include in there a plan for self-care
What would you write to another therapist who you heard was managing any of the below:• A global pandemic • Suddenly working at home• Away from usual work supports• Learning remote working/challenges tech• Lacking our usual friends/family for support• Unprecedented challenges in the home (caring for
others/stress on relationships/loneliness)• Managing the anxiety of COVID, our health, our loved ones• Difficult life experiences with less support than usual• Working with patients struggling more with these challenges
