Monthly Archives: March 2007

The “do as I do, not as I say” approach to therapy supervision

The other week I participated in a training workshop for supervision in cognitive behavioural therapy, which was well-attended by the psychologists in my Trust. It was a useful workshop – with some theory in the morning, going through the (albeit limited) evidence for CBT supervision, and then the afternoon spent doing roleplays of supervision issues (such as scenarios where the supervisee departs from the cognitive model unnecessarily, or feels hopeless about progress in therapy, or dislikes their client).

The workshop got me thinking about a paper I had read soon after qualifying in the mid 90’s, that described a behaviour analysis account to therapy supervision. The main argument of the paper written by William Follette & Greg Callaghan (see reference below and available here) was that it is difficult to train therapists to do therapy well if you only rely on direct instruction (verbal descriptions of how to behave, in written form or face to face supervision). This type of supervision has the potential to produce rigid therapist behaviour, where the trainee carefully follows the supervisor’s instructions regardless of the client’s presentation or description of new problems. Follette and Callaghan describe that this in-session therapist behaviour, that is not necessarily sensitive to changes in the therapeutic relationship, is not necessarily the fault of the trainee but perhaps an unintended consequence of the training method.The supervision setting can inadvertantly strengthen this process if the focus is based solely upon retrospective descriptions of the content of the therapy sessions.

Follette and Callaghan describe this as the unfortunate effect of rule-governed behaviour, where the trainee is reinforced for following the verbal instructions of the supervisor, rather than reinforced for effectively “tracking” contingencies in the therapy relationship. Rule governed behaviour is useful when you want behaviour to be fairly immune to situational contingencies; however, in the case of therapy you want to develop trainees who effectively attend to changes in the client’s in-session behaviour. Follette and Callaghan describe the mathematical and practical limitations of providing “rules” to trainees, as effective therapy cannot be reduced to simple formulae to be slavishly followed.

The authors describe an alternative/associated training technology: using direct feedback to the trainee within the therapy session by the supervisor, giving moment-by-moment feedback through the use of a computer monitor in the room. The monitor shows graphically the supervisor’s rating of the quality of the therapy provided by the trainee.The aim of this method is to direct the trainee to be sensitive to the emerging contigencies in the therapeutic context, as inflexible application of techniques and focus will result in low ratings by the supervisor. This is contingency-shaped behaviour, where the trainee is reinforced for effective tracking in the therapy session. The article is interesting in discussing the advantages of this method, although I did think about the anxiety of the trainee in the process of moment-by-moment therapy ratings!

This approach makes sense if you think about the complex social behaviour that is required when doing psychological therapy. Beginning (and experienced!) therapists can become focused on “doing CBT right”, which can result in paying less attention to the client’s behaviour within the session. There may be many opportunities to strengthen the influence of the therapeutic relationship that are missed when therapists become overly focused on technique. Creating the context for change would seem as important as the methods used to make the change.

This may seem to be at odds with the view of CBT as technique-focused enterprise, with the traditional criticism that in CBT there is less interest in the dynamics of the therapeutic relationship. In contrast, I think it is reasonable to say that a CBT approach considers the therapeutic relationship to be a necessary but not sufficient condition for change to occur. Effective CBT involves therapists who are attentive to the “moment” AND use evidence-based methods to assist the client to change.

Reference

Follette, W. C., & Callaghan, G. M. (1995). Do as I do, not as I say: A behavior- analytic approach to supervision. Professional Psychology Research and Practice, 26, 413–421.

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Filed under CBT, Clinical Psychology, cognitive behavioural therapy, Psychology

Anthropology and Counterinsurgency

Recently I read an article in the December 18 ’06 issue of the New Yorker by George Packer called “Knowing the Enemy“, about the involvement of anthropologists and other social scientists in developing strategic alternatives to counterinsurgency.

The article profiles the work of David Kilcullen, Australian anthropologist and Lieutenant Colonel in the Australian Army, who has been seconded to the US State Department as a strategist to develop counterinsurgency methods. Kilcullen’s ideas of how to approach counterinsurgency are based on his view that the “War on Terror” should be considered as an information war. This propaganda war is one that, unfortunately, the US and its allies are losing, while groups like Al Qaeda are much more savvy about setting the agenda for their message and making sure that it is heard.

Kilcullen asserts (while not directly criticising the Bush administration) that the current approach to counterinsurgency involves a number of mistakes being made, such as 1) aggregating all Jihad-inspired conflicts together so that local conflicts become part of a global problem (uniting disparate groups and not understanding the local grievances that might be causing conflict); 2) being clumsy in winning hearts and minds, due to not having enough cultural information about the populations involved in conflict; and 3) not understanding the modern sources of information to people in developing countries (ie., US Forces relying on broadcast media to provide information to local people, while insurgent groups will use text messaging, the internet etc.).

In March 2006 Kilcullen wrote the influential “Twenty Eight Articles: Fundamentals of Company-level Counterinsurgency”, a field guide aimed at company commanders whose units have been deployed in Iraq or Afghanistan. It is worth a look at for the type of approach he advocates. Whether this approach is one that the current US administration will follow is, of course, another story.

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The gentle art of Australian political invective: Paul Keating

One of the things that I miss about not living in Australia is the refreshing directness of language in parliamentary politics. A number of Australian politicians have exercised the extreme limits of parliamentary privilege when attacking the opposition, but the undisputed master in the art of political invective was (of course) former prime minister Paul Keating.

Watching Keating at work was genuinely entertaining, as he had a “take no prisoners” style when dealing with Opposition questions. One of my favourite occasions was when he was challenged by Coalition leader John Hewson to go to an early election, you can see Keating’s response courtesy of youtube:

Even Hewson laughed at that one.

If you enjoy such verbal rough-housing then you might like a trip down memory lane with the Paul Keating Insults Archive, showcasing some of his finest moments.

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The psychology of paranoia

Recent reports on the study of paranoid thinking have supported the view that suspiciousness and anxiety of harm from others are common experiences, with possibly up to a third of the population being regularly bothered by suspicious or paranoid thoughts.

Daniel Freeman, Jason Freeman, and Philippa Garety have written a self-help guide to “Overcoming Paranoid and Suspicious Thoughts”, published by Robinson (2006) . Considering how common these concerns are in the general population a self-help guide that addresses paranoia and suspiciousness per se, rather than talk about it just in the context of psychosis, seems a good idea.

It is a good read, describing a cognitive behavioural approach to understanding paranoid thinking and various ways of testing out suspicions to reduce their impact upon decision making and distress. Well-written for the general reader, the book also is useful for clinicians who want to discuss these concerns with clients, as it provides an example of describing paranoia and suspicion that is non-stigmatising and empathic in tone. Moreover the book’s contents represent the latest thinking in a cognitive behavioural approach to these concerns, with a number of exercises that can be used within therapy.

In the book the authors have detailed ways of coping with paranoid thoughts, which can be described in CBT terms as:

  • developing insight into the causes of suspicious thoughts (e.g., stress and major life changes, emotions, external and internal triggers, explanations for triggers, and reasoning);
  • becoming a detached observer of your fears;
  • practicing deliberately considering alternative explanations for suspicions and testing them out using behavioural experiments;
  • learning how to let go of suspicious thoughts when they come, and focus on what you are doing, not what you are thinking;
  • learning how to spend less time worrying about paranoid thoughts
  • deliberately thinking about positive aspects of your self

There is also a website, based upon the book, that is worth checking out.

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Filed under CBT, Clinical Psychology, cognitive behavioural therapy, Mental Health, Psychology