You can't miss what you don't know. ⢠Attitude/ wrong ideas about scientific research. ⢠Naïve realism, Myths, Statistical complexity. ⢠Competence/skills (Waller ...
Implementation of CBT, Current State of Affairs and Future Directions Dr. Arno van Dam, clinical psychologist
Presentation • What do we implement if we implement CBT? • Does it work? • Who is to blame for failure and why? • What can we do?
What do we implement if we implement CBT?
Does it work? • CBT competence is low and overrated in/by therapists (Brosan, Reynolds, & Moore (2007)) • Experience, supervision, and accreditation are unrelated to competence (Brosan, Reynolds, & Moore (2007)). • Especially in complex cases (Thompson-Brenner & Westen, 2005) () • Post-qualification training in cognitive therapy improves levels of competence (Brosan, Reynolds, & Moore, (2007).
• Less experienced therapists are more easily trained to be competent in delivering CBT (Brown et al, 2013)
Does it work ? • Yes, in RCTs (F.E: Tummers, Knoop, van Dam, & Bleijenberg, 2012). • Yes, in emergencies (CATS Consortium, 2010).
• But in regular clinical practice ? • Many patients are not treated with a protocol (McHugh & Barlow, 2010; Shafran et al., 2009)
• The protocol is being delivered suboptimally (McHugh & Barlow, 2010; Shafran et al., 2009)
Does it work ?
How does it work? Who is involved and who is to blame ? DATA
Blame it on the therapist • Knowledge (Waller, 2009; Lilienfeld et al, 2013; Gallo & Barlow, 2012) •
You can't miss what you don't know
•
Attitude/ wrong ideas about scientific research
•
Naïve realism, Myths, Statistical complexity
• Competence/skills (Waller, 2009; Lilienfeld et al, 2013; Gallo & Barlow, 2012) •
Techniques
•
How to structure the session
•
Selling the technique
• Mental health of the therapist (Waller, 2009; Lilienfeld et al, 2013; Gallo & Barlow, 2012) •
Fear/ anxiety
•
Fatigue/ stress
Blame it on the manager • Training and supervision (Waller, 2009; Lilienfeld et al, 2013; Brown et al., 2013)) •
Enough training for enough therapists
•
Enough time to study
• Health of the therapist (Waller, 2009) •
Reduce work stress
• Organisational issues (van Dijk et al,, 21012; Hermens et al., 2011) • •
Availability of protocols Therapy pathways
•
Implementation plan
• Monitoring of results (Pincus et al., 2013; Waller, 2009; Lilienfeld et al, 2013; Gallo & Barlow, 2012) •
Therapy effectiveness
•
Competence
•
Adherence
Blame it on the patient • Knowledge (Waller, 2009; Lilienfeld et al, 2013; Gallo & Barlow, 2012; Prins et al., 2010) •
You can't miss what you don't know
•
Attitude/ wrong ideas about therapy
• Practical issues (Hermens et al., 2011) •
Not enough time
•
No transport
•
Other priorities
• Characteristics of the patient (Prins et al., 2010) •
Level of education
•
Severity of symptoms
Blame it on the scientist • Knowledge ((Shafran et al, 2009; Freiheit et al, 2004; Lilienfeld et al, 2013) •
Provide information about the research
•
provide manuals, supervision, courses etc
•
Provide information in accessible magazines.
• Communication (Waller, 2009; Lilienfeld et al, 2013; Gallo & Barlow, 2012) •
Talk to therapists on an equal level
•
Especially to critical therapists (“instead of preaching to the converted”)
• Expectations (Lilienfeld et al, 2013; Gallo & Barlow, 2012) •
Step by step
•
Implementation plan
•
Change is a slow process, one manual at a time.
A dysfunctional system ?
• How can they cooperate? • Is change possible?
Behaviour change
How to increase intrinsic motivation (Self Determination Theory, Deci & Ryan)
• Autonomy • Control (The Demand-Control Model: Karasek &. Theorell, 1990)
• Competence • Relatedness • Social Support (The Demand-Control Model: Karasek &. Theorell, 1990)
What about their basis needs ?
How to increase intrinsic motivation for CBT protocols (Self Determination Theory, Deci & Ryan)
• Autonomy • Active Participation in implementation • Allow local variations (to certain limtis)
• Competence • Feedback over succes
• Relatedness • Make implementation a joint effort
Key messages • Implementation of CBT in clinical practice is not easy • We can learn from motivation psychology • Implementation is not only a rational process • We all want to be valued, competent and happy
