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Enhancing CBT Supervision Using Evidence-based Practices EBS ABCT Clinical Roundtable on Supervision November, 2008

Enhancing CBT Supervision Using Evidence-based Practices (EBS) ABCT Clinical Roundtable on Supervision November, 2008 . Robert Reiser, Ph.D. Director, Kurt and Barbara Gronowski Psychology Clinic, Pacific Graduate School of Psychology, Redwood City, CA. (rreiser@pgsp.edu)Derek Milne, Director, Doctorate Program in Clinical PsychologyNewcastle University, England. (d.l.milne@ncl.ac.uk)Rebecca Pittenger, PhD.,Pacific Graduate School of Psychology, Redwood City, CACOPIES OF PRESENTATION AVAILABLE AT ROBERTREISER.COM .

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Enhancing CBT Supervision Using Evidence-based Practices EBS ABCT Clinical Roundtable on Supervision November, 2008

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    1. Enhancing CBT Supervision Using Evidence-based Practices (EBS) ABCT Clinical Roundtable on Supervision November, 2008 Moderators Robert Reiser, Pacific Graduate School of Psychology Derek Milne, Newcastle University, England Lynn McFarr, Harbor UCLA Medical Center David Martin, Harbor UCLA Medical Center Panelists Caitlin Ferriter, Katherine Williams, Harbor UCLA Medical Center Rebecca Pittenger, Pacific Graduate School of Psychology 1 (c) Milne and Reiser, All Rights Reserved 2008

    2. Enhancing CBT Supervision Using Evidence-based Practices (EBS) ABCT Clinical Roundtable on Supervision November, 2008 Robert Reiser, Ph.D. Director, Kurt and Barbara Gronowski Psychology Clinic, Pacific Graduate School of Psychology, Redwood City, CA. (rreiser@pgsp.edu) Derek Milne, Director, Doctorate Program in Clinical Psychology Newcastle University, England. (d.l.milne@ncl.ac.uk) Rebecca Pittenger, PhD.,Pacific Graduate School of Psychology, Redwood City, CA COPIES OF PRESENTATION AVAILABLE AT ROBERTREISER.COM

    3. Background “We would never dream of turning untrained therapists loose on needy patients, so why would we turn untrained supervisors loose on untrained therapists who help those needy patients?” (p. 606) “If…supervision is really all that important, then why is training in how to supervise…so limited?... something does not compute.” (p. 604). Emphasis added (Handbook of Psychotherapy Supervision, 1997 (ed.) Watkins 3 (c) Milne and Reiser, All Rights Reserved 2008

    4. The Challenge of Supervision “…because the goal of supervision is to connect science and practice, supervision is among the most complex of all activities associated with (professional practice)”; (p30) Holloway, E.L., & Wolleat, P.L. (1994) ‘Supervision: The pragmatics of empowerment’ J. Educational & Psychological Consultation, 5, 23-43 4 (c) Milne and Reiser, All Rights Reserved 2008

    5. “We posit that the practice of supervision involves identifiable competencies, which can be learned and in turn promote the supervisee’s clinical competence…” (p4) Falender, C.A., & Shafranske, E.P. (2005) Clinical Supervision: a Competency-Based Approach Washington: APA 5 (c) Milne and Reiser, All Rights Reserved 2008

    6. BUT...What is our model to achieve competency in real world practice… “Cognitive therapy supervision parallels the therapy itself” (Padesky, 1996, p.289) Supervision training depends almost exclusively on the Reflexivity Model -Applying same principles and practices to ourselves as we apply with our patients… (See Liese and Beck’s 1997 comparison, in Table 8.4). 6 (c) Milne and Reiser, All Rights Reserved 2008

    7. What’s the problem here? This model underestimates the highly specialized aspects of supervision (e.g. educational theory). There has been little substantial progress in empirical investigations of supervision (e.g., no validated measure of competence in CBT supervision) CBT supervision does not actually appear to be implemented with adequate fidelity Major components of CBT supervision not significantly updated in past 10-15 years… 7 (c) Milne and Reiser, All Rights Reserved 2008

    8. An evidence-based supervision (EBS) model = a possible solution… 8 (c) Milne and Reiser, All Rights Reserved 2008

    9. Plan for Clinical Roundtable This clinical roundtable will discuss: Enhancements to standard CBT supervision based on an empirical review of best practices and evidence in the literature. Supervisee responses to the enhanced supervision process. The feasibility of providing EBS in real world settings. 9 (c) Milne and Reiser, All Rights Reserved 2008

    10. Standard versus Enhanced Supervision (EBS) Evidence-Based Supervision Greater use of iconic & enactive methods, within an experiential learning approach Higher levels of emotional experiencing during the session More challenging (guided experiential learning, challenging and disagreeing)-Potentially higher levels of anxiety or discomfort for trainee. Higher levels of emotional engagement reported by trainee and supervisor Standard (CBT) Supervision Higher level of reliance on case discussion –mainly verbal (symbolic) methods Lower levels of emotional experiencing in supervision More general support and passive listening-Lower levels of anxiety or discomfort in the trainee Lower levels of emotional engagement 10 (c) Milne and Reiser, All Rights Reserved 2008

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    13. Best evidence synthesis (BES): a novel approach to the systematic literature review BES “combines the meta-analytic approach of extracting quantitative information in a common standard format…with a systematic approach to the assessment of study quality and study relevance” (Petticrew &Roberts, 2006, p.181); Often used in education, to answer questions about what works; Careful selection of studies - Milne et. al. 2006: Nine inclusion criteria, incl.: ‘Clinical supervison (CS) manipulated; demonstrated effectiveness; in scientific journal’. 13 (c) Milne and Reiser, All Rights Reserved 2008

    14. Educational Pyramid, with BES sample (n=24). 14 (c) Milne and Reiser, All Rights Reserved 2008

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    25. Case study participants Consultant: Derek Milne, Ph.D., Director of a Doctorate in Clinical Psychology program, with over 25 years of supervison and training experience Supervisor: Robert Reiser, Ph.D., clinical psychologist with 20 years of clinical experience; training clinic director with over 5 years of experience in providing doctoral level training Supervisees:; Study II: Post-Doctoral student; Study I: Second year PhD Student 25 (c) Milne and Reiser, All Rights Reserved 2008

    26. Setting Kurt and Barbara Gronowski Psychology Clinic (internal training clinic for Pacific Graduate School of Psychology 2nd year PhD students and PGSP-Stanford Consortium PsyD students). Students are trained over a nine-month period in a closely monitored setting, which involves review of videotaped therapy sessions and weekly individual and group supervision. The clinic training model emphasizes the use of evidence-based practices. 26 (c) Milne and Reiser, All Rights Reserved 2008

    27. Study Design Independent variable: Provision of evidence-based supervision, enhanced by weekly (telephone) consultancy & written feedback, based on an EBS manual and guidelines. Dependent variables: SAGE rating scale- a standardized evaluation of supervision, assessing micro-processes & outcomes MyPETS questionnaire- a standardized feedback form to supervisor Structured interview with supervisee (ad hoc compilation) 27 (c) Milne and Reiser, All Rights Reserved 2008

    28. Study Design: Longitudinal N=1 ABA Design During the baseline period (SAU = supervision as usual): All sessions were audio-taped Supervision ‘as usual’ consisted of standard CBT supervision (Liese & Beck 1997; Padesky, 1996). The student provided feedback to supervisor (MyPets) after each session In the enhanced EBS supervision condition (EBS = intervention): Audio tapes of each supervision session were reviewed by consultant Each session was rated for competence, on SAGE; and, Consultant’s feedback was emailed to the supervisor, & then discussed in a weekly, 60-minute telephone call (“tele-consultancy”). As before, the student provided feedback (MyPets) after each session 28 (c) Milne and Reiser, All Rights Reserved 2008

    29. 29 (c) Milne and Reiser, All Rights Reserved 2008 Figure 2: CBT (baseline phases marked with blue background) versus CBT+ (intervention phases, green background) across phases for N=2 supervisees, indicating that CBT+ consultancy affects the supervisor’s competence scores (SAGE). Figure 2: CBT (baseline phases marked with blue background) versus CBT+ (intervention phases, green background) across phases for N=2 supervisees, indicating that CBT+ consultancy affects the supervisor’s competence scores (SAGE).

    30. Was Supervision manipulated effectively ? 30 (c) Milne and Reiser, All Rights Reserved 2008

    31. SAGE Correlational Data Supervision Cycle – Learning Cycle Correlation Coefficient Sig. (2-tailed)= .838 Spearman rho; N=51; total number of ratings (all clients rated)

    32. SAGE Correlational Data ”Experiencing” in Supervision Cycle– Learning Cycle Correlation Coefficient Sig. (2-tailed)= .793 Spearman rho; N=51; total number of ratings (all clients rated)

    33. SAGE Correlational Data ”Experimenting” in Supervision Cycle– Learning Cycle Correlation Coefficient Sig. (2-tailed)= .782 Spearman rho; N=51; total number of ratings (all clients rated)

    34. SAGE Correlational Data Common Factors – Learning Cycle Correlation Coefficient Sig. (2-tailed)= .817 Spearman rho; N=51; total number of ratings (all clients rated)

    35. Supervisee experiences What was the experience of EBS like? Experimenting - Never really done this before [in supervision]; challenging; increased directiveness with clients; not ‘possible’ without EBS. Challenging: Supervisee experienced significant increase in sense of being challenged. Experiencing- Increased emotional ‘arousal’. Reflecting on supervision– “unprecedented degree of exchange of experiences of supervision (two-way feedback). 35 (c) Milne and Reiser, All Rights Reserved 2008

    36. Supervisee experiences What was the experience of EBS like?

    37. Supervisee experiences What was the experience of EBS like?

    38. Conclusions Clinical supervision can be designed to “compute” Competence in EBS can be trained systematically (manual + guidelines) Competent EBS can be measured (SAGE + My PETS) EBS supervision can be effectively delivered in typical training settings EBS can be initially challenging but is an enriching process, for both supervisor and supervisee 38 (c) Milne and Reiser, All Rights Reserved 2008

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