Processes and relationships involved in homework use are just some of many possible mechanisms of change within psychotherapy. With a propensity towards
enormous variation in how a particular form of therapy in delivered, increasingly manual-based treatment protocols have been proposed as a means to standardize treatment delivery and methodology. Such manuals might instruct on how treatment variables, techniques or strategies should be integrated into therapy (e.g., such as CC processes and the use of homework) or alternatively be used to fix particular variables that might fluctuate in therapy to manipulate variables otherwise fixed in the
treatment manual or to compare with alternatives to the treatment manual. The use of manual-based treatment protocols has facilitated the assessment of treatment integrity and enabled the establishment of empirically supported treatments (EST; Chambless & Hollon, 1998; Wilson, 1996). Although manual-based treatment protocols are standardized and provide structure to therapy sessions, a certain degree of therapist
flexibility in implementing treatment is emphasized in contemporary literature (Beutler et al., 2006; Connolly Gibbons et al., 2003; Mumma, 1998; Persons, 2006; Sanderson, 2006). Such emphasis may serve as a reminder to therapists about the importance of flexibility where, for example, in the practice of CBT, flexibility is crucial in order for the therapist to remain consistent with fundamental theory (A. T. Beck, 1979). Similarly, the National Institute for Health and Clinical Excellence (NICE; 2009) present guidelines for the treatment of depression and are widely considered to be among the leading independent organizations regarding best practice in the treatment of depression. NICE guidelines recommend “person centered” care and advocate a flexible approach to the treatment of depression:
Treatment and care should take into account patients’ needs and preferences. People with depression should have the opportunity to make informed decisions about their care and treatment, in partnership with their
practitioners...Good communication between practitioners and patients is essential. It should be supported by evidence-based written information tailored to the patient’s needs. (p.7).
While the integrity of protocols as a whole has received empirical support (A. T. Beck et al., 1979), there has been a shift towards investigation of individual
components of protocols as exemplified by contemporary literature examining the use of homework in psychotherapy (Addis & Jacobson, 2000). It has been argued that standard manual-based approaches need to be adapted to the individual and in practice are somewhat tailored to the individual. For example, in the case of idiosyncratic CCs formulated to help inform individualized treatment plans utilized to meet the needs and specific goals of the individual patient (Bond, 1998; Persons, 2006; Rogers, Reinecke & Curry, 2005). This is seen, for example, in the therapist’s choice of techniques or homework tasks and treatment interventions for individual patients (A. T. Beck et al., 1979; Gibbons, Crits-Christoph, Levinson, & Barber, 2003; Nezu, Nezu, & Lombardo, 2004). Optimizing the process by which a CC is constructed has been suggested as a means to further systematize or structure the process of making ‘clinical judgments’ more accurate (Persons, 1989). In contrast, a less structured approach even within a manual-based treatment protocol may result in ‘gaps’ or shortcomings in the testing of hypotheses about a patient’s presentations. For, example, a therapist who tests hypotheses by intuition, and does not keep a record of the data that has and has not been gathered might have a tendency to explore emotion but neglect behaviours that maintain the specified emotion. Alternatively, a therapist might have concluded that a hypothesis about a patient has been confirmed without
systematic reference to situations that challenge the hypothesis having not recorded previous important situations for future reference.
It follows that while standard manualized protocol for psychotherapy provide guidelines for practice in keeping with the particular manual, the practical
performance of the therapist is not measured. Thus, standard manualized treatment protocols provide a means of reducing the variance or controlling therapist variables that might account for key therapy outcomes (e.g., reduction in depressive symptoms) but are not independently sufficient to ensure treatment fidelity. Moreover, therapist competence in different areas related to the treatment protocol (i.e., CC and
homework use) is also likely to influence key therapy outcomes. In sum, the use of a manual-based standardized CBT protocol adapted to incorporate a standardized approach to a therapist’s homework adherence and competence, combined with a structured format for therapist’s use of CC with CBT Homework Project facilitates the investigation of the relationship of CC and homework processes in CBT for
depression (See Chapter VII).
4.6 Summary
This chapter has provided a brief introduction to the empirically supported theory and practice of CBT for depression. Homework has been identified as a central feature in facilitating mechanisms of change which has been demonstrated in recent burgeoning research to influence the process and outcome of CBT. Lastly, a
discussion of the utility of standard treatment protocols such as A. T Beck’s treatment manual for the CBT of depression (A.T. Beck et al., 1979) serves to further reinforce the need to research in areas of therapist competence that serve to guide the use of standard manualized treatment protocols.
The present thesis aims largely to investigate the process by which therapists gather, record, and utilize conceptual data pertinent to patient presentations to provide clarity and support for existing theory. It must also be recognized that the focus of the present thesis was not to investigate specific homework tasks as they might relate to CC or therapeutic benefit. Instead, the competence of the therapist in using any number of individualized homework tasks was investigated, with the recognition also that some tasks in particular were likely to be used routinely with all patients
consistent with a standard approach to CBT for depression (e.g., thought records and monitoring of thoughts and moods, or specific behavioural experiments). More specifically, the present thesis aims to design a new measure of therapist competence of CC in CBT for depression. It is intended that this new measure will facilitate reaching additional aims to investigate how therapist CC change over the course of therapy and investigate the relationship between therapist CC, use of homework, and outcome.
The next chapter provides a discussion of therapist competence in the context of CBT for depression and in relation to CC and broader therapy outcomes. The rationale for a new measure of therapist competence specifically assessing CC is expanded further.
CHAPTER V
Therapist Competence in CBT for Depression