Introduction

Outcomes for cognitive behavioral therapy (CBT) and other evidence-based psychotherapies have been evaluated extensively, but the research literature on methods of training in these therapies and on disseminating them is relatively sparse. Recent changes in the mandates of governments, mental health agencies, and research associations have, however, sharpened the focus on knowledge translation and evidence-based practices. Therefore research has started to examine what constitutes effective training for CBT and how to best help trainees implement CBT in real-world conditions of practice when working with clients of various ages who suffer from internalizing disorders. This chapter examines training methods generally, then more specifically in relation to the treatment of anxiety disorders, depression, children and adolescents. It concludes with a review of obstacles to effective training.

Key Features of Training: Presenting Training Material Using Effective Strategies

Effective strategies for presenting training material have been derived from learning models. Three different but complementary models are reviewed and then linked to specific training methods. Beidas and Kendall (2010) seek to understand how training models affect the translation of evidence-based practices (EBP) through a systems-contextual perspective. Theirs is considered a broad, holistic approach that emphasizes that an individual works within a system and thus quality of training, organizational supports, therapist variables, and client variables interact to effectively translate EBP. Provisional evidence from Beidas and Kendall’s (2010) literature review suggests that, when all levels of the systems-contextual model are addressed, therapists reach proficiency levels in competence, adherence, and skill that facilitate effective client change.

Bennett-Levy (2006) presents a cognitive model for training therapists that emphasizes changes in therapists’ information processing and reflection. In Bennett-Levy’s model there are three principal systems at work: declarative, procedural, and reflective (DPR). The declarative system consists of factual information typically learned through didactic teaching, observed learning, supervision, and reading assignments. The procedural system consists of applied skills; and the reflective system consists of metacognitive skills that include observations, interpretations, and evaluations of one’s self in the past, present, and future. Bennett-Levy demonstrates how this model accounts for a new therapist’s progressive learning until he or she becomes an expert. The new therapist begins by relying on the declarative system using didactic learning, modeling, practice, and feedback but further develops clinical expertise through the procedural system. Finally, he or she moves to the stage of clinician, as a teacher or expert, through the reflective system. The transition to becoming an expert happens when the therapist goes from reflection-on-action (retrospective review of therapeutic interventions) to reflection-in-action (reflection that occurs during therapy sessions).

Other theoretical reviews – such as Milne, Aylott, Fitzpatrick, and Ellis (2008) and Rakovshik and McManus (2010) – emphasize the relationship between trainee changes and methods of instruction. Here it is found that trainees in CBT need supervision that provides not only didactic teaching but also experiential learning methods such as role-play, cotherapy, and modeling. Further, Rakovshik and McManus (2010) provide evidence to suggest that, if supervision is removed prior to consolidation, then the learned skills can deteriorate over time.

On the basis of these learning models, many types of training have emerged. Bennett-Levy, McManus, Westling, and Fennell (2009) examine which training methods are most effective, testing the didactic versus experiential distinction described above. Although their study relies on therapists’ perceptions, it does allow for predictions to be made about the effect of training methods on CBT skills and competence. In this study, 120 therapists were surveyed regarding the effectiveness of 6 popular training methods and 11 different CBT skills. Bennett-Levy and colleagues found that different methods of learning were perceived to be effective across different CBT skills. Passive training strategies such as reading manuals and books, attending lectures and workshops, and completing non-interactive online training increased declarative knowledge and some conceptual and technical skills. Active training strategies such as role-play, reflective practice, self-experiential work, graded training and supervision were found to increase the therapist–client exchange and the level of technical, interpersonal, procedural, and reflective skills.

Herschell, Kolko, Baumann, and Davis (2010) reviewed 55 different studies on training therapists in psychosocial treatments. Their review found that passive training – such as reading and workshops – develops knowledge but is not sufficient for achieving competence, as skills learnt through these methods do not reliably persist over time. The addition of skill feedback and short-term consultation or supervision after a workshop was shown to increase both knowledge and skills. In particular, clinical supervision and consultation with field experts consistently produced superior training outcomes, despite difficulties that may arise with cost and availability. Overall, Herschell and colleagues concluded that multi-component training programs are superior to other (single-component) training methods.

With the advent of online training, new hybrid training methods that incorporate both passive and active learning methods have become popular (Dimeff et al. 2009; Granpeesheh et al. 2010; Sholomskas and Carroll 2006; Sholomskas et al. 2005; Weingardt 2004; Weingardt, Cucciare, Bellotti, and Lai 2009). For example, Dimeff et al. (2009) investigated the efficacy of three different training methods for dialectical behavior therapy (DBT): (i) a 20-hour interactive online training (OLT) session; (ii) a two-day instructor-led training (ILT) session; and (iii) reading two treatment manuals. These researchers made sure the OLT was interactive and sophisticated, as they felt that variable results in other studies might be due to OLT’s being presented like a book on a screen. Specifically, the OLT included audio and visual presentation as well as a fictional DBT skills group for participants to observe and learn from, expert insights, practical exercises, and knowledge quizzes. Participants were evaluated before and after training, and also in a 90-day follow-up, regarding their knowledge of DBT, satisfaction with training, referencing of materials, and clinical performance in role-play. Dimeff and colleagues found that OLT significantly out-performed both the ILT method and the method of training through manuals.

The duration of training is, potentially, a factor to be considered when investigating effective training methods. However, conclusions on duration are difficult to draw, as the majority of studies do not address this topic. Those studies that do mention training duration only give broad temporal descriptions and vary widely in approach, which makes them difficult to compare. In Rakovshik and McManus (2010), 37 different training programs are compared; but researchers point to a lack of agreement on the terminology that describes the training. For example, they argue that a comparison between a “workshop” that was didactic and interactive and contained role-play and case discussions and a “workshop” that was strictly didactic would be imprecise. Finally, specifying the nature of competence and its measurement presents its own challenges (see below). Therefore further research is needed on measuring competence and on the optimal duration of training. Nevertheless, most training studies reviewed above support multi-component programs that include active learning methods as well as didactic teaching.