The April BABCP Article of the Month is from Behavioural and Cognitive Psychotherapy and is entitled “Service support, work engagement and psychological wellbeing: validating an index of resource and infrastructure support for the delivery of CBT” by Ffion Evans, Helen Penny and Louise Waddington.

Therapists delivering CBT in routine practice do not generally enjoy the level of supervision and support available to therapists employed on research trials. Roth & Pilling, (2008) make the point that CBT competencies are not separable from the resources and infrastructure supporting practice: without these resources therapists cannot offer the best help. Lack of workplace support may be why pragmatic trials of CBT delivered in routine services have found reduced efficacy as compared with research trials. It is notable, for example, that pragmatic trials have offered additional training and supervision to participating therapists in order to demonstrate acceptable fidelity to the evidence-based model (Barkham et al. 2021; Bisson, (submitted for publication), Ehlers et al. 2013).

Lack of resources and support to offer effective CBT may also contribute to poor therapist wellbeing.  Some therapists in IAPT services have large caseloads and clinical complexity (Scott, 2015) and high levels of burnout have been identified (Westwood et al., 2017; NHS England & Health Education England, 2015). It is crucial to be able to assess the level of support therapists receive and to observe whether this relates to client outcomes.

We found no established measure of workplace support for CBT practice, but we were able to take an existing questionnaire developed by Groom and Delgadillo (2012: unpublished) as a starting point. Psychometric properties were established through expert review and pilot study resulting in a shorter index with good content validity, internal consistency (α=0.80) and temporal stability (r=0.74, p<.001). Construct validity was demonstrated through positive association between high scores on the index and measures of work engagement and practitioner wellbeing. The resulting 20-item index comprises six areas: access to recording equipment, suitability of the clinical environment, clinical supervision, time to offer flexible sessions and prepare, working outside the clinic, and continuous professional development.

The index is straightforward, and we invite others to use it. We hope it may shed some light on why CBT in routine practice may not match up to the outcomes observed in research trials and improve outcomes for therapists and clients.

Author biography:

Ffion Evans is a clinical psychologist working in child and adolescent mental health in the south west of England. This research was completed as part of doctoral training in clinical psychology at Cardiff University, under the supervision of Louise Waddington.

References

Barkham M, Saxon D, Hardy GE, Bradburn M, Galloway D, Wickramasekera N, Keetharuth AD, Bower P, King M, Elliott R, Gabriel L, Kellett S, Shaw S, Wilkinson T, Connell J, Harrison P, Ardern K, Bishop-Edwards L, Ashley K, Ohlsen S, Pilling S, Waller G, Brazier JE. (2021) Person-centred experiential therapy versus cognitive behavioural therapy delivered in the English Improving Access to Psychological Therapies service for the treatment of moderate or severe depression (PRaCTICED): a pragmatic, randomised, non-inferiority trial. Lancet Psychiatry 8(6):487-499

Ehlers, A., Grey, N., Wild, J., Stott, R., Liness, S., Deale, A., … & Clark, D. M. (2013) Implementation of cognitive therapy for PTSD in routine clinical care: effectiveness and moderators of outcome in a consecutive sample. Behaviour research and therapy, 51(11), 742-752.

NHS England (2015) Adult IAPT Workforce Census Report. Health Education England.

Roth, A. D., & Pilling, S. (2008) Using an evidence-based methodology to identify the competences required to deliver effective cognitive and behavioural therapy for depression and anxiety disorders. Behavioural and Cognitive Psychotherapy, 36(2), 129-147. 

Scott, C. (2018) An exploration of burnout in Improving Access to Psychological Therapy (IAPT) services : an interpretative phenomenological analysis.

Westwood, S., Morison, L., Allt, J., & Holmes, N. (2017) Predictors of emotional exhaustion, disengagement and burnout among improving access to psychological therapies (IAPT) practitioners. Journal of mental health, 26(2), 172-179.

From Paul Salkovskis, the Editor-in-Chief of BCP: Why I chose this article

This article is of particular importance as the results of high quality randomised controlled trials of CBT are rolled out in “the real world” at scale. The authors identify the fact that the implicit context of trials includes significant support infrastructure which has significant impact on fidelity. Not taking this into consideration can not only impair the effectiveness of interventions but also adversely impact on those delivering the treatments. This article addresses the crucial issue of a reliable and valid measure of workplace support. This measure, which is freely available, will not only assist in research on treatment fidelity in the broader context, but perhaps more importantly, also allow services and the individuals working within them to audit and improve the provision, providing a benchmark for the proper provision of CBT.