Seeking to improve cognitive behavioural therapy delivery in the NHS through the practical application of outcome predictors and therapist development

The PhD in Professional Practice (Canterbury Christ Church University, 2014) is a service focused research programme, designed to investigate how psychological and research principles can be applied to a practical setting. The programme differs from a traditional PhD programme in that it requires that multiple approaches are taken to research on a common theme, each applying a different theoretical approach or addressing a different aspect of the subject. Within this context, the purpose of this thesis is to investigate the delivery of Cognitive Behavioural Therapy (CBT), within a large National Health Service Mental Health Foundation Trust in the United Kingdom, with a focus on possible ways of making that delivery more effective. Drawing on the author’s experience as a therapist, trainer and leader in CBT services in the aforementioned Trust the thesis focuses primarily (though not exclusively) on the implementation of CBT in the Improving Access to Psychotherapies (IAPT) service that the author came to lead over the course of the PhD programme.

The thesis is divided into two distinct sections. Section 1 (Chapters 2 and 3) focuses on the prediction of therapy outcomes for CBT treatment of common anxiety and depressive disorders as may be applied to an IAPT service, and the possible practical applications of these. Chapter 2 is a
critical review of the existing literature relating to clients’ nonclinical pre-treatment psychological profiles and attitudes towards individual face to face CBT. It identified five factors that may predict outcomes; client personality traits, expectancy for/credibility of therapy, clients’ interpersonal style, beliefs about illness, and preference for treatment. Evidence for each of these factors was mixed, with only client personality consistently predicting outcomes in all studies that it was investigated. Client motivation and dysfunctional attitudes were also identified as having good evidence for prediction based on previous reviews of the subjects. The review also explored CBT specific factors, such as an ability to recognise unbidden thinking (negative automatic thoughts (Beck et al., 1979) or differentiate between emotional states, through an investigation of multifactor tools for predicting client suitability for CBT. Only the Suitability for Short Term Cognitive Therapy Scale (SSCT) (Safran et al. 1993) showed consistent predictive validity for client outcomes over a number of studies, although which aspects of the SSCT are predictive remains unclear (Mhyr et al., 2007, Renaud et al., 2014). Chapter 3 consists of an examination of the predictive validity and factor structure of an existing pre-treatment self-report questionnaire that makes use of some of the above factors, to attempt to predict who would benefit most from receiving CBT. The Suitability for Cognitive Behaviour Therapy Scale (CBT-Suits) (McLellan et al., 2016), had previously demonstrated a good factor structure in existing literature and shows promise as a cost effective easy to use tool for aiding in clinical assessments of need in CBT (McLellan et al., 2016; McLellan et al., 2019). The factorstructure and predictive validity of the CBT-Suits were investigated using data from participants attending the participating IAPT service for CBT for anxiety and depressive disorders. The CBT-Suits demonstrated good factor structure in confirmatory factor analysis but did not demonstrate any predictive validity for outcomes over and above that provided by initial symptom severity. Implications of this are discussed.

The client is not the only participant in therapy however and the quality of the therapy provided can also correlate significantly with client outcomes (Simons et al., 2000; Westbrook et al., 2008). In addition to the critical review of literature and investigative research projects, the PhD in Professional Practice requires the completion of two other studies, a smaller scale service related project, designed to improve the quality of services in the author’s field of work, and a more personal study based on their own practice.

Section 2 (Chapters 4 and 5) of this thesis incorporates both the service related project and the report of professional practice for this PhD programme. As Section 1 focused on how client predictors f therapy outcome might be utilised to improve the quality of CBT provision, Section 2 addresses the
subject of therapist competence, focusing on both the evaluation, and practical challenges of providing therapist training and development in a clinical NHS setting. Chapter 3 evaluates a CBT training and supervision programme for junior doctors undergoing Core Psychiatry training with the Royal College of Psychiatry (Royal College of Psychiatrists, 2015). This training and supervision programme was required to teach doctors with little to no previous experience of CBT to adequately provide a course of CBT treatment to a member of the public with clinical symptoms of anxiety and/or . It explores the issues faced and successes achieved by the group as they undertake their first clinical CBT case and evaluates the support and training that they were offered. Evaluations of the programme revealed that it was universally well liked and regarded by the trainees as adding significantly to their competence. Amendments to the programme based on the feedback are discussed. The final substantive chapter of the portfolio (Chapter 5) approaches the subject of therapist development from the opposite end of the spectrum by exploring the experiences of a skilled CBT therapist and trainer (the author) when undertaking an evidence based Continuing Practice and Development (CPD) programme for CBT therapists known as Self Practice and Self Reflection (SPSR) (Bennett-Levy et al., 2001). As with Chapter 3, the primary aim of this chapter is not to evaluate any direct relationship between undertaking the programme and clinical outcomes, but rather to investigate its applicability in a busy clinical setting, exploring not only the perceived benefits of undertaking such a programme, but also the struggles and stresses placed on both services and the individual engaging in it. The SPSR programme was broadly helpful in enabling the therapist to address their concerns about their CBT practice, and highlight and address areas of therapist drift (Waller, 2009), in which their competence as a therapist had deviated from the evidence based best practice. However, the programme was challenging and the therapist found it difficult to prioritise CPD completion alongside their clinical practice, particularly in the context of the Covid-19pandemic. Reflections are made on the balance between a focus on competence development at the possible cost to service delivery for therapists who already meet the required competences to provide effective therapy.

Taken as a whole this thesis addresses the question of how can what we know about the people attending for CBT, and those providing CBT be utilised practically to improve the quality of therapy provided by NHS services. Section 1 asks the question “what do we know about who is likely to benefit from CBT and can we use this to improve the therapy they receive?”, and Section 2 asks “How can we improve the competence of therapists, in the most effective way, without detracting from the service provided?", and “how do we balance the conflicting demands of therapist development and service delivery?”. Taken together it is hoped that this knowledge can be applied to the delivery of CBT services, in order to provide the most clinically effective treatments in the most efficient manner.