Читать книгу A Clinician's Guide to CBT for Children to Young Adults - Paul Stallard - Страница 21

The absence of a psychometrically robust scale developed specifically to assess general CBT competence with children and young people led to the development of the Cognitive Behaviour Therapy Scale for Children and Young People (CBTS‐CYP) (Stallard, Myles, et al. 2014). The aim was to develop a scale to assess the overall quality of CBT, not to assess in detail the way that specific techniques like exposure are conducted.

In terms of development, it was firstly decided to build upon the CTS‐R. The CTS‐R is widely used and considered to provide a comprehensive overview of the generic skills required to competently practise CBT with adults (Fairburn & Cooper 2011; Kazantzis 2003; Keen & Freeston 2008). Secondly, the CTS‐R assesses the specific use of CBT methods as well as general skills that facilitate their effective delivery. It was therefore decided that the CBTS‐CYP would contain items that assessed competence both in the application of specific methods and in the process of using CBT with children and young people. Thirdly, upon reviewing the CTS‐R, it was decided that all items should be included in the CBTS‐CYP, modified as appropriate to reflect the use of CBT with children and young people. Similarly, the framework for defining competence proposed by Dreyfus (1986) and adapted into a seven‐point Likert scale on the CTS‐R was adopted for use in the CBTS‐CYP. Fourthly, the CTS‐R is widely used by CBT training courses to assess competence. In order to maintain consistency with the CTS‐R, it was decided to adopt the same thresholds for assessing competency, that is, score 2 or more on each item and a total score of 50% or more. Finally, it was decided that the scale would be developed to assess both verbal and non‐verbal behaviours and so could be used like the CTS‐R to assess both audio and video recordings of clinical sessions. It was anticipated that specific items would not necessarily be mutually exclusive. For example, a formulation requires the development of a shared conceptualisation in which important cognitions, emotions, and behaviours are bound together within the CBT model. The elicitation and identification of key cognitions and processes would therefore be expected to be associated with the formulation. Similarly, CBT typically involves developing an understanding of the links between cognitions, emotions, and behaviours and as such there will inevitably be overlap between these different aspects of the cognitive behavioural model.

In addition to competencies in the application of core methods, the use of CBT with young people also requires competencies in the way that CBT is provided. CBT is predicated on a process of collaborative empiricism, a process which requires greater attention when working with children, adolescents, and young adults. These competences relating to the therapeutic process have been defined by the acronym PRECISE (Stallard 2005).

 P: The therapeutic process involves the young person and their family working in a partnership with the clinician. The partnership is based upon collaborative empiricism and highlights the active roles of the young person and their parents/carers in securing change.

 R: The intervention is pitched at the right developmental level to ensure that it is consistent with the young person’s cognitive, linguistic, memory, and perspective‐taking abilities.

 E: A warm, caring, respectful, and empathic relationship is established.

 C: The concepts of CBT are creatively and flexibly conveyed in a way that matches the young person’s interests and understanding.

 I: Investigation and self‐discovery are encouraged through the adoption of a curious and reflective approach.

 S: Self‐efficacy is promoted as the young person is helped to discover and build upon their strengths, skills, and ideas.

 E: Sessions are enjoyable and engaging in order to maintain the young person’s motivation and commitment to change.

The CBTS‐CYP assesses the above seven PRECISE process items and the following eight method items, referred to as the ABCs of CBT.

 A: Assessment , and the ability to establish clear goals and to appropriately use diaries, questionnaires, and rating scales for assessment.

 B: Use of behavioural techniques such as graded exposure, behavioural activation, and activity scheduling to facilitate therapeutic change.

 C: Use of cognitive techniques to identify cognitions, to promote cognitive awareness, to challenge, to reframe, or to develop mindfulness, acceptance, and compassion.

 D: Facilitating discovery using techniques such as the Socratic dialogue, behavioural experiments, and prediction testing.

 E: Use of emotional techniques to identify and manage strong, unpleasant emotions.

 F: Ability to construct a case formulation which highlights the relationships between events, cognitions, emotions, physiological responses, and behaviour.

 G: General skills to effectively manage sessions such as agenda setting, session planning, and managing challenging behaviour

 H: Appropriate use of home assignments with clear goals and purpose.

The first version of the CBTS‐CYP consisted of 14 items, with home assignments initially being subsumed within the discovery competence. Following review, these were separated, with the current iteration, like the CTS‐R, having home assignments as a separate and discrete set of competencies. Table 1.1 summarises how the CTS‐R items map on to the 15 items of the CBTS‐CYP.

In an initial evaluation of the CBTS‐CYP, video clips of clinicians undertaking CBT were assessed by independent raters (Stallard, Myles, et al. 2014). Face validity and internal reliability were high, and convergent validity with the CTS‐R was good. It compared well with the CTS‐R in discriminative ability and demonstrated an increase in skills through a course of CBT training.

The CBTS‐CYP can be used for clinical reflection and self‐assessment. It should be completed in an open and honest way so that strengths, weaknesses, and development needs can be identified. These competencies can then be self‐monitored and reflected upon after clinical sessions as a way of developing practice.

A copy of the CBTS‐CYP is included in Chapter 12. The subsequent chapters will explore each competence in detail and provide specific examples.

Table 1.1 Comparison of items on the CBTS‐CYP and CTS‐R.

CBTS‐CYP process item	Equivalent CTS‐R item
Partnership working (P) Establishes a collaborative partnership with the child/young person (and, as appropriate, their carers) in which they are actively engaged in working together towards a set of joint goals and targets	Collaboration
Right developmental level (R) Engages with the child/young person and family at a level and in a manner that is consistent with their developmental level and understanding	None
Empathy (E) Empathises with the child/young person and their carers/family through the development of a genuine, warm, and respectful relationship	Interpersonal effectiveness
Creative (C) Adapts the ideas and concepts of CBT to facilitate the understanding of and engagement in therapy of the child/young person and their parents/carers	None
Investigation (I) Adopts an open and curious stance that facilitates guided discovery and reflection	Feedback
Self‐efficacy (S) Adopts an empowering and enabling approach in which self‐efficacy and positive attempts at change are promoted	None
Enjoyable and engaging (E) Makes therapy sessions appropriately interesting and engaging	None
CBTS‐CYP methods item
Assessment and goals (A) Establishes clear goals for the intervention and appropriately uses diaries, questionnaires, and rating scales for assessment	None
Behavioural techniques (B) Demonstrates appropriate use of a variety of behavioural techniques to facilitate therapeutic change	Eliciting behaviours Application of change methods
Cognitive techniques (C) Demonstrates appropriate use of a variety of cognitive techniques to facilitate therapeutic change	Eliciting key cognitions Application of change methods
Discovery (D) Appropriately uses a variety of methods to facilitate self‐discovery and understanding	Guided discovery
Emotional (E) Appropriately uses a variety of emotional techniques to facilitate therapeutic change	Eliciting appropriate emotional expression Application of change methods
Formulation (F) Facilitates the development of a coherent understanding which highlights the relationships between events, cognitions, emotions, physiological responses, and behaviours	Conceptual integration
General skills (G) Sessions are well prepared and conducted in a calm and organised way	Agenda setting and adherence Pacing and efficient use of time
Home assignments (H) Uses home assignments to gather data and transfer skills between clinical sessions and everyday life	Homework setting