National Guidelines for Training in CBT

April 23, 2019

Preamble:

The CACBT-ACTCC is a multidisciplinary organization whose aim is to advance scientific knowledge and research in cognitive and behavioural therapies (CBT) and to promote and increase access to evidence-based assessment and intervention for health and mental health difficulties. The CACBT-ACTCC was formed in 2010 and with a mandate to promote awareness of the principles of evidence-based psychological treatments and that promotes knowledge of and access to cognitive-behavioural therapy. The CACBT-ACTCC does this by providing a platform for discussing CBT and evidence-based psychotherapy and seeks to educate and inform helping professionals as well as the public about matters pertaining to the science and practice of CBT. The activities of the CACBT-ACTCC include providing quality training in and dissemination of CBT through conferences, courses, workshops, public lectures, an email listserv, and a website (English site: www.cacbt.ca; French site: www.actcc.ca). The organization also promotes scientific research of CBT and the dissemination of these findings. Finally, CACBT-ACTCC has developed a formal certification process for CBT professionals to provide a benchmark for quality mental health services and an avenue for the public to locate qualified CBT professionals (through our online database).

The initiative for the current training guidelines arose for several reasons. One reason is global developments related to training standards for CBT.  This document relies on previous work in this area and is an effort to become part of the international movement to promote evidence-based therapies, such as CBT. Another factor is the current Canadian context, which is increasingly emphasizing evidence-based practice in mental health. We are also mindful of the introduction of provincial/territorial initiatives to enhance access to evidence-based mental health care.  Most directly, CACBT- ACTCC is committed to the enhancement of quality care and wishes to advance this goal through the development and promulgation of minimum guidelines for the content and competencies that should be included in training for CBT. 

An assumption of this document is that CBT training builds upon the core knowledge and competencies of regulated health professionals (and trainees) for whom psychotherapy is within their scope of practice.  These regulated professions may vary across provinces/territories, yet generally include psychologists, psychiatrists and other physicians, social workers, nurses, counsellors, and occupational therapists.

These guidelines provide recommendations for both the core knowledge and competencies that should be included in CBT training.  Within the scope of psychotherapy we recognize that there are both generic skills that apply across different models of CBT, as well as skills that are specific to particular populations, problems, and models of CBT.  It is expected that trainees will seek training specific to the populations, problems, and CBT models with which they work.

It is also noted that CBT training consistent with these guidelines is only one component of the requirements for CACBT-ACTCC certification.  Training is necessary but not sufficient for certification, which also requires clinical experience, letters of support, and work samples. More details on the certification process.

These guidelines were informed by and drew on the work of researchers and clinicians in the field of CBT training.  Although guidelines from various other agencies and professional organizations have been developed, there is a dearth of research on what constitutes adequate CBT training to ensure fidelity and enhance client outcome.  In line with the empirical underpinnings of CBT, more research should be conducted on CBT training.  As more research becomes available these guidelines should be regularly updated so as to reflect the current state of the science on CBT training.

We drew on published recommendations for training including those outlined by Muse and McManus (2013), Klepac et al. (2012), and Roth and Pilling (2007).  Additionally, we also reviewed established training programs including those developed by the British Association of Behavioural and Cognitive Psychotherapies (BABCP), the Improving Access to Psychological Therapies (IAPT) Program in the UK, and the Improving Access to Structured Psychotherapy (IASP) initiative in Ontario, as well as CBT certification recommendations developed by BABCP, the Academy of Cognitive Therapy (ACT), the Australian Association for Cognitive and Behaviour Therapy (AACBT), and of course the certification requirements of CACBT-ACTCC.  References for these documents are included at the end of these Guidelines. 

The process of developing these guidelines began in May 2018.  The Board of CACBT-ACTCC explored various ways that CACBT-ACTCC could be involved in the national and provincial dialogue for increasing access to mental health services and providing evidence-based treatment.  The Board concluded that the most effective way to broadly impact training across the country was to develop training guidelines that stakeholders could consult in developing CBT training initiatives.  The Board appointed a working group, the mandate of which was to develop a draft of the guidelines.  The working group, consisting of Andrea Ashbaugh (Chair of the working group and President-Elect), Jacquie Cohen (Certification Chair), and Keith Dobson (President), completed a draft of the Guidelines in February 2019. These Guidelines were then circulated to recognized Canadian experts in CBT, including CACBT-ACTCC Fellows and the Board, for feedback and recommendations.  The Guidelines will be revised and circulated among CACBT-ACTCC members and approval of the final version is anticipated to take place at the May 2019 Board meeting in Montreal, QC. 

Definitions:

Cognitive-behavioural therapy (CBT)–CBT is a general model of psychotherapy, within which several specific approaches can be identified, which vary in terms of the target problem(s) they address and specific intervention components. In general, however, CBT approaches use a combination of behavioural and cognitive principles and interventions. As defined here, CBT includes the entire scope of treatments within this general model, including those that are sometimes referred to as “third wave” CBT.  Given this broad focus, this document does not attempt to describe every approach or specific model within the broad framework of CBT but rather highlights training principles and competencies that are common across different approaches to CBT.

Guidelines– This document provides guidance about the content of training, minimum core knowledge, and clinical competencies that should be provided as part of CBT training.  It is not designed as a regulatory set of standards for CBT training.  We anticipate that these Guidelines will evolve as the field of CBT evolves.

Training–Training broadly encompasses activities that occur in the context of professional mental health programs, professional continuing education workshops, courses, certificate programs, supervision and consultation, and other delivery methods.  This training can occur in the context of an integrated program of study, a stand-alone course, or a combination of delivery methods. 

Knowledge– Knowledge refers to the understanding of human experience and human change processes based upon theory and scientific evidence. We recognize that knowledge will further accumulate over time as the field develops.

Competencies–Competencies are core sets of abilities, behaviors, or skills that a trainee should demonstrate by the end of training.  Competencies are predicated upon core knowledge and the experience to know when and how to apply that knowledge.  We recognize that competencies are not static but evolve over time as the field develops. Such competencies may be linked to certification or other forms of credentialing.

Core Knowledge

It is expected that trainees have already attained (or are in the process of attaining) foundational knowledgerelated to the practice of psychotherapy.  These include, but are not necessarily limited to knowledge and skills pertaining to:

• professional, regulatory, and ethical guidelines
• the importance of evidence-based practice in psychotherapy
• the role of context, diversity, and individual differences in psychotherapy, and the related role of treatment providers’ own individual characteristics and values
• client engagement and the development and maintenance of a therapeutic alliance
• evidence-based assessment approaches pertaining to treatment planning and ongoing assessment (e.g., outcome assessment) throughout treatment
• risk assessment and management
• case formulation and treatment planning
• the provision of individual, group, couple, and/or family treatment modalities as appropriate
• the coordination of a course of treatment, including beginning treatment, navigating treatment sessions, maintaining and modifying treatment as necessary, and ending treatment effectively
• the effective coordination of care, including the coordination of care among various professionals and the provision of appropriate referrals
• psychopathology and mental health problems
• models pertaining to the appropriate intensity and comprehensiveness of treatment (e.g., stepped care)
• the importance of ongoing education, consultation, and supervision

The following areas of core knowledge should be covered in the context of CBT training:

• development and history of CBT
• CBT within the context of the principles and practice of evidence-based care
• CBT models of the development and maintenance of clinical problems and psychopathology, the enhancement of functioning, and goal attainment
• suitability and contra-indications for CBT
• impact of stages of change and client engagement on CBT outcome
• assessment for CBT case conceptualization and treatment
• role of case monitoring and outcome assessment in CBT
• adapting CBT for various areas of diversity and individual differences (e.g., culture, age, sex and gender, client preferences)
• adapting CBT for co-occurring problems and complex presentations
• criteria for consultation with and/or referral to a specialist
• the nature and role of the therapeutic relationship in CBT, including collaborative empiricism
• the nature and role of structure in CBT, including structuring CBT sessions, setting an appropriate framework for treatment, and ending treatment in accordance with evidence-based and CBT principles
• core areas of intervention in CBT, such as cognitive therapy, exposure, contingency management, skills training, and other core CBT approaches
• the importance of generalizing principles, skills, and strategies to daily life
• the effective use of assignments and homework
• CBT models of maintaining change and relapse prevention
• common challenges in CBT

Core Competencies

This document recognizes that there are many competencies associated with different applications of CBT.  As such, we list here foundational competencies that are common across applications of CBT as well some competencies that are specific to certain populations and problems. 

It is expected that trainees have already attained (or in the case of trainees, in the process of attaining) general foundational competenciesrelated to the practice of psychotherapy and that these foundational competencies are observable within the context of CBT training. That is, trainees should demonstrate the application of the Foundational Knowledge outlined in Core Knowledge (above).

The following are general CBT core competenciesthat are common across applications of CBT and should be demonstrated by trainees by the end of CBT training. Specifically, trainees should demonstrate skills in the following areas:

Case conceptualization

• developing CBT conceptualizations and treatment plans for a range of client presentations
• evaluating and modifying CBT conceptualizations and treatment plans as needed
• collaboratively establishing treatment goals that are specific, measurable, achievable, relevant, and time-bound

Client Engagement and Collaboration

• determining when to work with a client and when to consult and/or refer
• effectively coordinating care, including coordinating care among various professionals and providing appropriate referrals
• applying theories related to the development and maintenance of a therapeutic alliance, and collaboration with clients
• effectively modelling principles and strategies (this might include appropriate self-disclosure)
• enhancing client motivation for change
• identifying and managing challenges in the application of CBT

Treatment structure

• collaboratively structuring a session, including setting and following an agenda
• appropriately directing and pacing sessions
• monitoring treatment progress and adapting interventions accordingly
• preparing for the end of therapy and developing a relapse prevention plan

Assessment and treatment approaches

• conducting an effective CBT assessment for a range of client presentations, including the selection, administration and interpretation of appropriate assessment tools
• explaining the rationale for CBT
• providing psychoeducation about CBT, as well as CBT models of specific problems
• conducting functional assessments of specific behaviours
• teaching, evaluating, and adapting self-monitoring and self-management skills
• teaching problem-solving concepts and skills
• identifying, exploring, and addressing problematic thoughts, attitudes, beliefs, and assumptions
• identifying and modifying problematic behaviours
• attending to and working with emotions, including helping clients understand and effectively manage their emotions
• incorporating self-help strategies
• collaboratively developing effective in- and between- session assignments
• collaboratively reviewing and modifying assignments
• adapting CBT for various areas of diversity and individual differences (e.g., culture, age, sex and gender, client preferences)
• adapting CBT for co-occurring problems and complex presentations
• consulting and using the scientific literature on assessment and treatment to update knowledge on a regular basis

The following specific CBT core assessment and treatment competenciesapply in some but not all applications of CBT. We recognize that some of these skills may be used only for specific populations or presenting problems.  Note that we have not listed the problem-specific protocols that have been developed in CBT; rather we list key methods or therapeutic strategies that are embedded within these protocols. When appropriate, they should be covered in the context of training and be demonstrated by trainees by the end of CBT training:

Examples of Primarily Behavioural Strategies

• Contingency management, including stimulus control and shaping of complex chains of behaviour
• Skills training in appropriate domains (e.g., self-management, interpersonal skills, emotion regulation)
• Exposure-based strategies including in vivo, interoceptive, and imaginal exposure. This includes identifying and targeting avoidance and safety behaviours.
• Behavioural activation
• Habit reversal
• Distress tolerance and arousal reduction strategies
  
  

Examples of Primarily Cognitive Strategies

• Identifying cognitive content and processes, including guided discovery and Socratic questioning
• Modifying cognitive content and processes, including evidence-based, alternative-based, and meaning-based strategies. Such strategies may include behavioural experiments, enhancing cognitive flexibility, and identifying alternative thinking patterns.
• Attentional retraining and cognitive bias modification
• Imagery rescripting
• Understanding and managing emotions
• Motivational enhancement strategies
• Mindfulness
• Acceptance- and compassion-based strategies
• Diffusion/distancing
• Values identification and other values-based work
• Interventions that emphasize the development and enhancement of resiliency and personal strengths

Training Strategies

CBT training must include both didactic and experiential components.  Training can occur through a variety of formats, including in person, online, and blended formats.  Experiential strategies involve learning by applying CBT principles and strategies. For effective training at least some experiential learning must involve using CBT principles with real clients. Although we recommend that didactic and experiential learning can take place in the same training, we recognize that they may also be taught separately.

Noting that there is limited research on what constitutes adequate training required to implement CBT, we consulted international CBT certification requirements (e.g., AACBT, ACT, BABCP, CACBT-ACTCC) to develop our recommendations.

In line with CACBT-ACTCC certification requirements, we recommend a minimum of 40 hours of CBT training, that is either didactic or both didactic and experiential.  In addition to these 40 hours of training, trainees should see at least 5 individual cases¹for a minimum of 8 sessions each under a supervision/consultation arrangement with a CACBT-ACTCC certified member (or equivalent)².  

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1. One group should be considered the equivalent of one case.
2. These cases seen under supervision may be counted towards the 12 cases required to document minimum CBT experience for CACBT-ACTCC certification.

The following table provides examples of didactic and experiential components.

Evaluation of Trainees

CBT training must involve evaluation of both the knowledge and competencies that have been outlined above.  Evaluation must be appropriate to the knowledge or competency being evaluated.

Evaluations of knowledge might include:

• Examinations and quizzes
• Essays
• Presentations
• Teaching
• Review of case reports

 Evaluations of competencies might include:

• Role-plays, both standardized and non-standardized
• Adherence evaluation of live or recorded sessions
• Competence evaluation of live or recorded sessions by using rating scales such as the Cognitive Therapy Scale (CTS; Young & Beck, 1980) or the Cognitive Therapy Scale Revised (CTS-R; Blackburn, James, Milne, Baker, Standart, Garland, & Reichelt, 2001)
• Case summaries and case discussion
• Case conceptualizations, both hypothetical and real clients

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Comments on these guidelines are welcome and can be submitted at:  info@cacbt.ca

References

Blackburn, I.-M., James, I.A., Milne, D.L., Baker, C., Standart, S., Garland, A., & Reichelt, K. (2001).  The Revised Cognitive Therapy Scale (CTS-R):  Psychometric Properties.  Behavioural and Cognitive Psychotherapy, 29, 431-446.

Hool, N. (2010) BABCP Core Curriculum Reference Document. BABCP. Available at:  http://www.babcp.com/documents

Klepac, R.K., Ronan, G.F., Andrasik, F., Arnold, K.D., Belar, C.D, Berry, S.L., Christoff, K.A.,…Strauman, T.J. (2012).  Guidelines for cognitive behavioral training within doctoral psychology progams in the United States:  Report of the inter-organizational task force on cognitive and behavioral psychology doctoral education.   Behavior Therapy, 43, 687-697.

DH Mental Health Programme.  (2008) Improving Access to Psychotherapies.  Implementation Plan:  Curriculum for high-intensity therapies workers. Available at:  https://www.babcp.com/files/Accreditation/Course/dh_083169.pdf

DH Mental Health Programme.  (2008). Improving Access to Psychotherapies. Implementation Plan; Curriculum for low-intensity therapies workers.  Available at: https://www.uea.ac.uk/documents/246046/11991919/implementation-plan-curriculum-for-low8208intensity-therapies-workers.pdf/eb770a57-e2e3-4da2-bf80-2d8b82f55812

Muse, K., & McManus, F. (2013).  A systematic review of methods for assessing competence in cognitive-behavioural therapy.  Clinical Psychology Review, 33, 484-499.

Ontario Structured Psychotherapy Program (2019).  CBT Training Program Overview. Toronto, Ontario.

Roth, A.D., & Pilling, S. (2007).  The competences required to deliver effective cognitive and behavioural therapy for people with depression and with anxiety disorders.  Behavioural and Cognitive Psychotherapy, 36, 129-147.

Young, J.E., & Beck, A.T. (1980).  Cognitive Therapy Scale:  Rating Manual. Unpublished manuscript, University of Pennsylvania, Philadelphia, PA.

Click below to download a copy of the National Guidlelines:

National Guidelines for Training in CBT (2019)   Lignes Directrices Nationales Relatives à la Formation en TCC

Approved May 2019