Skill development in Cognitive Behavioural Therapy : a review of self-practice/self-reflection and a comparative analysis of therapy session reflections

Abstract

This research area this work addresses is skill development in cognitive behavioural therapy (CBT). Understanding how knowledge and skills develop and accurate measurement of these allows specific targeting of learning needs in trainees and experienced therapists (Davis et al., 2015; Muse & McManus, 2013). The literature review addresses a training method, self-practice/self-reflection (SP/SR), which is purported to enhance CBT skill development (Thwaites et al., 2014). SP/SR was first conceptualised approximately 25 years ago. Gradual development of the evidence base has led proponents to call for research which moves from addressing whether it works to enhance CBT skills, to how it works to enhance CBT skills (Thwaites, Bennett-Levy & Haarhoff, 2015). As such, this work asked what has been learned since the last review in 2015 about how SP/SR impacts the development of conceptual knowledge and technical skills in CBT. Ten studies were systematically reviewed, critically appraised and synthesised using thematic synthesis. Four themes were constructed which may be suggestive of potential learning processes, such as SP/SR supporting the development of a personal experiential understanding of CBT and facilitating meta-competence. It was acknowledged that a major limitation to this evidence base which prevented the research question in this review being answered fully is the complexity of measuring skill development (Bennett-Levy, 2019). This has led to the lack of a reliable measure of meta-competences, particularly reflective skill. The empirical paper forms part of broader programmatic research aiming to develop a reliable measure of meta-competences which may address the lack of such a measure noted Iin the literature review. Research on meta-competences in CBT is in its early stages. The empirical paper reports an exploratory study analysing differences between trainee and qualified CBT therapists in reflective functioning by examining their reflections about a recent therapy session. This primary aim of this work was to replicate Campbell et al. (2024) that experienced CBT therapists make more III reflective statements than trainees. That study addressed practitioner reflections on hypothetical clinical scenarios, whilst this project examined practitioners’ reflections on a session with a current client. Forty-one trainees and qualified CBT therapists were interviewed using a newly developed measure delivered in a semi-structured interview format. Therapists’ reflections were coded using a schema that classified therapist statements into nine types based on two dimensions at three levels: knowledge type (declarative, procedural, reflective) and interpersonal focus (client, therapist, dyad). Qualified therapists made more statements overall, but this may be related to using more words during the semi-structured interview. No significant between-group differences were observed in the knowledge type or interpersonal focus of statements. Although there were no between-group differences with respect to knowledge type and interpersonal focus, these factors interacted significantly. The measure may be a useful formative tool to support therapists’ reflections about their sessions. Further replication is advised.