Evaluation of CBT Training of Clinicians in Routine Clinical Practice
There is a consensus that cognitive-behavioral therapy (CBT) constitutes an effective and evidenced-based psychological treatment. Clinical practice guidelines consistently recommend CBT as an adjunctive intervention for schizophrenia and other psychiatric disorders, but mental health services often do not provide CBT to most of their consumers. Barriers to service provision often include a lack of suitably qualified practitioners to provide training, insufficient training programs, a lack of support from managers to implement training programs, financial constraints, limited time availability for training, and even a change-averse culture.
Peninsula Health Psychiatric Service (in Australia) has over the past three years implemented a 40-session, one-hour weekly CBT training program, which is available to all inpatient and community mental health clinicians in its service. Participants have included psychiatric nurses, occupational therapists, psychiatric trainees, and social workers. The training consists of a combination of didactic lectures, experiential training, and group supervision. Formal CBT is taught throughout the course and includes CBT for psychosis as well as depression and anxiety, which are often highly comorbid with psychotic disorders.
To address potential barriers, the facilitators, both experienced in teaching CBT, advocated for the implementation of the training program. Ongoing consultation occurred with management and other stakeholders, and although no additional funds were required for the program, management committed to invest in the training and ongoing supervision through allocation of resources. Information related to the need for change was disseminated throughout the service and included reviews of evidence-based practice and professional development discussion groups. Interviews conducted with participants before the training began indicated a genuine desire to provide a more effective treatment to their consumers.
The initial results indicated that the training program was effective in bringing about a relative change in practice for most of the participants. The immediate effectiveness of the training was assessed with a set of eight questions administered before and after the course to all participants. The results indicated that the course was successful in increasing participant's knowledge and confidence in implementing CBT for symptoms of psychosis, depression, and anxiety. In addition, participants reported an average increase of approximately 40% in the number of sessions spent using CBT. Audits were conducted 12 months and 24 months later on the files of the first two years of CBT-trained clinicians, and 88% had documented evidence of using CBT. Of these, 38% had implemented structured CBT interventions that showed progressive change for the consumer, and 50% showed evidence of teaching clients brief CBT strategies in a more opportunistic but effective manner. In addition, informal interviews were conducted with the clinicians to obtain qualitative data regarding the effectiveness of the training and the change in treatment approach.
Many clinicians highlighted the importance of ongoing supervision and periodic education sessions to the success of the training program. Further, some clinicians reported difficulty with providing a more psychotherapeutic approach within a case management model of care. As a result of the evaluation, a greater commitment from managers and administrators of the service has been given to imbed the training and supervision program within a broader strategic service plan. This has resulted in the development of clinical pathways to ensure that consumers have greater access to evidence-based psychological treatment as part of the service. Further study is required to more formally evaluate adherence to treatment models by clinicians who are trained in CBT and the effect of the interventions on the consumers.
To conclude, this training initiative indicates that a change to more evidence-based practice can be relatively easily implemented through the identification of specific individuals who will diligently advocate for change, identify and address barriers, promote a commitment from service administrators, ensure appropriate training, and assist with incorporating the change into routine practice within the context of broader strategic service planning. The result is better access to evidence-based therapy, which increases the ability of the service to address the charges of clinical governance: that the service meets the relevant needs of the population with a range of safe and effective therapies that reflect best practices for psychiatry.
