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| British Journal of Psychiatry | Advances in Psychiatric Treatment | All RCPsych Journals |
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Department of Cognitive and Behavioural Psychotherapy, Mawson Lodge, 62-68 Valence Road, Leicester LE3 1AR, e-mail: Graeme.Whitfield{at}leicspart.nhs.uk
Gartnavel Royal Hospital, Glasgow
Lochgilphead Hospital, Argyll
Gartnavel Royal Hospital, Glasgow
M. Connolly is a co-director and supervisor on the South of Scotland certificate and diploma CBT course. All authors have themselves attended CBT certificate or diploma courses.
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Abstract |
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 Top Abstract IntroductionMethodResultsDiscussionReferences |
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Previous studies have suggested that despite the cost of attendance at postgraduate cognitive-behavioural therapy (CBT) courses, psychiatrists are unable to engage in CBT after qualification. A postal survey of psychiatrists with postgraduate CBT training currently practising in Scotland was performed to assess the levels of training and supervision that they provide, therapeutic CBT activity, and supervision and continued professional development that they receive.
RESULTS
Of the 58 psychiatrists, 51 replied to the survey (88%). Less than half of the respondents supervised other staff. Although 43 (84%) engaged in some therapeutic CBT activity, only 25 (49%) received supervision for their own practice. The main reasons given for not engaging in CBT therapeutic activity were that there was inadequate ‘protected time’and that CBT had not been included in‘job plans’.
CLINICAL IMPLICATIONS
Psychiatrists can help to disseminate CBT skills. To do this, they require personal supervision, and time for the development and maintenance of therapeutic skills as well as for the training and supervision of others. This survey builds on the results of others and indicates that these requirements are currently being inadequately met.
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Introduction |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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Training in CBT that is available to the psychiatrist ranges from local arrangements for senior house officers as part of basic specialist training, through to more formal postgraduate certificate or diploma courses typically costing £2500-£3500. Attendance can count towards gaining accreditation with the British Association for Behavioural and Cognitive Psychotherapies (BABCP) - the lead body for CBT in the UK (http://www.BABCP.com).
The training guidelines of the Royal College of Psychiatrists (2002) have fully endorsed training in CBT for all psychiatrists. A number of surveys have confirmed that it can prove difficult for practitioners to build upon the CBT skills they learn in postgraduate courses (Ashworth et al, 1999; Gournay et al, 2000; Hull & Swan, 2003). Le Fevre and Goldbeck (2001) surveyed all Scottish consultant psychiatrists and found that of the 268 respondents, 24 (9%) had received formal training from an accredited CBT course, and a total of 39 (15%) carried out formal CBT in their routine National Health Service practice. A recent UK-wide survey of BABCP-accredited psychiatrists (Swift et al, 2004) found that only 4 of 17 (24%) non-psychotherapy post holders were satisfied with the extent to which they used their CBT skills, compared with 12 of the 15 (80%) psychotherapy post-holders. In view of the lack of detailed information on the use of CBT skills by psychiatrists trained to certificate/diploma level in CBT, we conducted a survey of all such psychiatrists identified in Scotland.
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Method |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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We used an abbreviated version of a questionnaire used in a previous CBT course audit (Ashworth et al, 1999) and altered for a survey of UK-wide BABCP-accredited psychiatrists (Swift et al, 2004). The questionnaire asked the psychiatrist’s gender, professional grade and the year of attendance at the CBT certificate or diploma course. A yes/no question asked whether cognitive therapy was the ‘main focus’ of their current job description. We asked whether the psychiatrists ‘continued to use cognitive therapy as a technique with patients’ and for the reasons why they were not using CBT if this was the case. A 7-point Likert-type scale allowed the practitioners to subjectively rate their current skills in CBT relative to their skills at the end of the CBT course. A response of 1 equated to ‘a lot worse’, through to 7 which equated to ‘a lot better’. The remainder of the questionnaire assessed continuing professional development, supervision (both received and given) and BABCP membership status.
The participants were not asked to disclose their identity on the questionnaires. The questionnaire was given to 9 psychiatrists attending the South of Scotland CBT workshop in February 2003 and sent on one occasion only to a further 49 psychiatrists in June 2003. A self-addressed envelope for postage back to the authors was included but no further incentives were given. The results were analysed using the Statistical Package for the Social Sciences, version 11.5 for Windows.
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Results |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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Year of CBT certificate/diploma course
The consultants had completed their postgraduate courses a mean of 6.21
years (s.d.=3.64) prior to the survey, whereas the specialist registrars and
staff grades together as a group completed their training a mean of 3.67 years
(s.d.=1.83) previously.
Use of CBT since the course
When the psychiatrists were asked whether they ‘continued to use
cognitive therapy as a technique with patients’, 31 (61%) said they did
with ‘some of their case-load’, 12 (24%) said that cognitive
therapy was their ‘predominant therapeutic approach’, and 7 (14%,
all consultants) said ‘No, or only very occasionally’. One (2%)
did not respond. When asked if CBT was the ‘main focus’ of their
current job, 40 (78%) said that it was not, 9 (18%) responded that it was and
2 (4%) did not respond to this item. A greater proportion of the
non-consultant staff said that CBT was the main focus of their job (5 of 12,
42%) relative to the consultant group (4 of 37 or 11%, 
2=5.75,
d.f.=1, P=0.016).
Reason for not using CBT
Personal choice was clearly not the reason why most psychiatrists were not
practising CBT: 20 of the 22 (91%) respondents to this question specifically
answered ‘No’ to this with only two (9%) answering
‘Yes’ (Fig. 1).
Other reasons given were ‘too little protected time’, with 22 of
25 (88%) responding ‘yes’ to this item. Of 24 respondents, 18
(75%) stated that not having CBT in their ‘job plan’ was a
reason.
Supervision provided to others
Just under half of the responders (23, 45%) offered CBT supervision to
trainees, 26 (51%) did not and 2 (4%) did not respond; 16 of the 51 (31%) said
that they offered supervision to other team members, 27 (53%) did not and 8
(15.7%) failed to respond. Overall, 24 (47%) supervised either trainees or
other team members.
Skills attrition
Using the Likert-type scale for the subjective assessment of skills, the
consultant group (n=38, 1 missing response) rated their CBT skills as
having on average stayed the same since the CBT certificate or diploma course
(mean=4.08, s.d.=1.58). The non-consultant group (n=12) believed that
their CBT skills had improved (mean=5.25, s.d.=1.22). This mean difference in
subjective skill attrition between the two professional groups was
statistically significant (t=–2.35, d.f.=48, P=0.023). There
was no significant correlation between the years that had elapsed since course
attendance and the degree of skill attrition among the 50 respondents to this
item (Pearson correlation=–0.123, P=0.4).
Supervision received
About half of the psychiatrists (25, 49%) received CBT supervision for
their own practice, 24 (47%) said they did not and 2 (4%) did not respond to
this item. A significantly greater proportion of the non-consultants (10 of
12, 83%) were receiving supervision than the consultants (15 of 37
respondents, 41%, 2=6.64, d.f.=1, P=0.01). Eighteen
psychiatrists (16 of these consultants) continued to use CBT with at least
some patients, but were not receiving CBT supervision. Those who received
supervision for their own practice were more likely to provide supervision for
trainees (2=5.07, d.f.=1, P=0.024). Nevertheless, 6
psychiatrists (all consultants) supervised trainees but were not receiving
supervision themselves.
Continuing professional development
Eighteen psychiatrists (35%) had not attended any formal training in CBT in
the past year, 20 (39%) had attended 1 or 2 training days, and a further 11
(22%) had attended 3 or more. The majority (44, 86%) were interested in
further cognitive therapy training. Of the responding psychiatrists, 30 (59%)
were current members of the BABCP; 21 (41%) responded that they were not.
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Discussion |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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In common with the current survey, Ashworth et al (1999) noted that doctors saw only a small number of patients after completing the certificate/diploma course. The current study showed that this is likely to be owing to a lack of relevant job planning, supervision arrangements and protected time for CBT. Indeed, CBT has frequently been seen as the domain of psychologists or nurses in current UK mental health services. However, psychiatric consultants tend to have a wide experience of teaching, multiprofessional working, and managing and supporting teams. The psychiatrist therefore has the potential to integrate multiple factors within a cognitive-behavioural formulation and management plan for the purposes of teaching, and the management of patients.
It is worrying that 22 of the 37 responding consultants (59%) were not receiving supervision for their CBT practice, particularly as the majority of these continued to provide some CBT and (in 6 cases) provide supervision to juniors. These figures compare very unfavourably with a UK-wide study of cognitive-behavioural psychotherapists from all professional backgrounds, of whom 90% were being supervised (Townend et al, 2002). Supervision of CBT practice is an essential element of continuing professional development even in those therapists who do not need or wish to have formal accreditation with the BABCP (Townend et al, 2002). Likewise, over half of the psychiatrists in the current survey were not supervising others (trainees or other team members) in the CBT model. In view of the Royal College of Psychiatrists’ emphasis on training juniors in psychological approaches this was surprising.
There appears to be a real opportunity to assist in the provision of continuing professional development for psychiatrists with an interest in CBT. This could assist in the maintenance of morale in a group that frequently perceive their professional role and identity as having been excessively narrowed. The finding that having ‘too little protected time’ and ‘not having CBT in a personal job plan’ are the two most common blocks to engaging in CBT has important implications for consultant job planning.
In conclusion, our findings point to a population of CBT-trained Scottish psychiatrists who rarely use CBT, who are dissatisfied with this situation and who in the main neither provide supervision to others nor receive supervision for their own CBT practice. This situation represents a wasted resource. Planners should think carefully about how to harness and hold on to psychiatrists with these skills if future diversity in psychological skills training is to be assured.
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Acknowledgments |
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References |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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DEPARTMENT OF HEALTH (2001) Treatment Choice in Psychological Therapies and Counselling. London: Stationery Office.
GOURNAY, K., DENFORD, L., PARR, A., et al (2000) British nurses in behavioural psychotherapy: a 25 year follow-up. Journal of Advanced Nursing, 32, 343 -351.[Medline]
HULL, A. M. & SWAN, J. (2003) A survey of psychiatrists completing a cognitive behavioural psychotherapy diploma course. Behavioural and Cognitive Psychotherapy, 31, 467 -471.[CrossRef]
LE FEVRE, P. & GOLDBECK, R. (2001)
Cognitive-behavioural therapy: a survey of the training, practice and views of
Scottish consultant psychotherapists. Psychiatric
Bulletin, 25, 425
-428.
NATIONAL INSTITUTE FOR CLINICAL EXCELLENCE (2004a) Anxiety: Management of Anxiety (Panic Disorder, with or without Agoraphobia) and Generalised Anxiety Disorder in Adults in Primary, Secondary and Community Care. http://www.nice.org.uk/pdf/CG022NICEguideline.pdf
NATIONAL INSTITUTE FOR CLINICAL EXCELLENCE (2004b) Depression: Management of Depression in Primary and Secondary Care. http://www.nice.org.uk/pdf/CG023NICEguideline.pdf
ROYAL COLLEGE OF PSYCHIATRISTS (2002) Requirements for Psychotherapy Training as Part of Basic Specialist Training. http://www.rcpsych.ac.uk/traindev/postgrad/ptBasic.pdf
SWIFT, G., DURKIN, I. & BEUSTER, C. (2004)
Cognitive therapy training for psychiatrists: impact on individual clinical
practice. Psychiatric Bulletin,
28, 117
-119.
TOWNEND, M., IANNETTA, L. & FREESTON, M. H. (2002) Clinical supervision in practice; a survey of UK cognitive behavioural psychotherapists accredited by the BABCP. Behavioural and Cognitive Psychotherapy, 30, 485 -500.[CrossRef]
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
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