4 Rinad S. Beidas, Matthew Ditty, Margaret Mary Downey, and Julie Edmunds Sburlati, Schniering, Lyneham, and Rapee (2011) have outlined a model of therapist competencies for the cognitive behavioral treatment (CBT) of pediatric anxiety and depressive disorders. CBT for these disorders is considered an evidence-based practice (EBP) given the significant empirical evidence it has garnered from randomized controlled trials. The authors have delineated three main categories of competencies: (i) generic therapeutic competencies (e.g., practicing professionally); (ii) CBT competencies (e.g., collaboratively conducting CBT sessions); and (iii) specific CBT techniques (e.g., changing maladaptive behaviors). These categories contribute to a deeper understanding of what competencies and techniques are necessary for appropriate delivery of CBT for pediatric anxiety and depressive disorders, which assists in closing the chasm between research and practice. This chapter describes generic therapeutic competencies related to professional practice that are relevant to CBT for pediatric anxiety and depressive disorders. The specific sub-competencies that fall under practicing professionally are outlined in Box 4.1. The first aspect to professional practice as delineated by Sburlati and colleagues (2011) includes open and positive attitudes toward EBPs and the ability to access, evaluate, and apply research to inform practice. The importance of therapists’ attitudes has long been recognized in the professional practice of evidence-based treatments. Early research identified the role of individual therapists’ attitudes in the dissemination and implementation of EBPs (Aarons 2004), and subsequently a number of studies surveyed therapist attitudes toward EBPs. One study found that therapists held favorable attitudes toward EBPs (Najavits, Weiss, Shaw, and Dierberger 2000) whereas another found that therapists held largely unfavorable attitudes toward EBPs (Addis and Krasnow 2000). One potential explanation for these conflicting results refers to therapist theoretical orientation. In the first study participants identified themselves as cognitive behavioral, the modality that has arguably received the greatest support in the EBP movement. In the second study a number of theoretical orientations were surveyed. Another potential explanation may be clinical experience. Therapists at an earlier stage in their careers may hold more favorable attitudes toward EBPs than therapists who are at a later stage (Aarons 2004). This may be due to increasing emphasis on training in EBP in graduate programs, or to more openness to varying viewpoints before identifying with a particular theoretical orientation. An early interest in therapist attitudes led to the development of the now widely used Evidence-Based Practice Attitude Scale (EBPAS), a 15-item psychometrically validated questionnaire that assesses participants’ attitudes toward the adoption and implementation of EBP via four subscales: appeal, requirements, openness, and divergence (Aarons 2004). Appeal refers to the extent to which a therapist will adopt a new practice if it is intuitively appealing. Requirements refer to the extent to which a therapist will adopt a new practice if it is required by his or her organization. Openness is the extent to which a therapist is generally receptive to using new interventions. Divergence is the extent to which a therapist perceives research-based treatments as lacking clinical utility. Given that positive attitudes toward EBPs predict the use of such practices (Nelson and Steele 2007), we recommend two ways supervisors can work to increase the likelihood that trainees will have more positive attitudes toward EBPs. First, we recommend that supervisors assess these attitudes regularly, in order to facilitate an open overall attitude toward psychotherapy research. In addition, the evidence suggests that training in EBPs may be associated with a greater appreciation of the value of evidence-based interventions (Beidas and Kendall 2010). It is likely that regularly monitoring openness and other attitudes toward EBPs, while providing feedback to trainees, will increase openness and diminish negative attitudes. Second, the delivery mode impacts the way EBP information is perceived by therapists. For example, providing a research summary of the most appropriate EBP alongside a case study increases the likelihood that a therapist will use an EBP rather than relying soley upon clinical experience (Stewart and Chambless 2007), so this could be a potential strategy used in supervision to modify attitudes and improve utilization of EBPs. Having an open attitude toward EBPs is likely necessary, but not sufficient for the successful implementation of EBPs. Another critical competency for therapists to master and for supervisors to foster is that of being “evidence consumers” (Spring 2007), which refers to the ability to identify, evaluate, and utilize research evidence to engage in evidence-based decision-making regarding treatment for individual clients. The process of being an evidence consumer is comprised of five steps, each of which is a separate skill necessary for evidence-based decision-making (Spring 2007). These steps are: ask the clinical question, acquire the evidence, appraise the evidence, apply the results, and assess the outcomes (Strauss, Richardson, Glasziou, and Haynes 2005). To develop as an evidence consumer, therapists must have the ability to identify, evaluate, and utilize resources so as to stay current with innovations and EBPs. Given the rapid proliferation of interest in EBPs, new resources are continuously being added that can guide therapists in the use of CBT for youth anxiety and depressive disorders. To keep abreast of the latest innovations for patient care, therapists can access websites such as http://www.nrepp.samhsa.gov/, http://www.effectivechildtherapy.com/, and http://www.iapt.nhs.uk/. Further, a number of online free training opportunities on how to provide EBPs are available (e.g., http://tfcbt.musc.edu/). These are just a few of many resources available on the internet. Therapists should learn how to find such resources, as new websites and resources constantly emerge and older material becomes outdated. To give an example of engaging in decision-making as an evidence consumer, imagine a therapist who meets with a new patient. She is a 12-year-old African American female with symptoms of anxiety in relation to an experienced trauma, as well as with some unrelated obsessions and compulsions. The first step, following evidence-based assessment, is to ask the clinical question, which in this case might be: “What interventions have empirical evidence supporting efficacy or effectiveness with African American youth with post-traumatic stress disorder (PTSD) and obsessive–compulsive disorder (OCD)?” The next step would be to acquire the evidence. One could visit a website such as http://www.effectivechildtherapy.com/ or PubMed, PsycInfo, or Google Scholar to search for treatment outcome trials. If a therapist searched for the terms “youth,” “PTSD,” and/or “OCD” together with the phrase “treatment outcome,” a number of studies documenting EBPs for these presenting difficulties would emerge (e.g., trauma focused-CBT; TF-CBT, exposure with response prevention). The therapist might also include the phrase “ethnic minority,” to check whether any studies have examined differential treatment outcome response based on ethnicity and/or race. After conducting this review, the therapist would need to appraise the evidence on the basis of the quality of the studies that were found. Typically, randomized controlled trials are considered the gold standard with regard to determining efficacy of interventions. In step 4, the therapist applies the results to the youth s/he is working with. In this case, the therapist would determine the primary disorder and begin there. For example, if the PTSD symptoms were primary, the therapist would start with TF-CBT and then move on to the OCD symptoms with exposure and response prevention. In the final step, the therapist would assess outcomes. In this case, administering self-report rating scales and tracking symptoms before, during, and after treatment would be important steps in the EBP process. In addition to having an open attitude and acting as an evidence consumer, professional competence involves awareness of other aspects of one’s own behavior, appearance, and communication style. Many of these attributes are not specified in CBT treatment manuals, yet they potentially impact the provision of effective care. Inappropriate self-disclosures, offensive language, messy office space, chronic lateness, inappropriate physical contact, or disrespectful attitudes toward colleagues could have similarly negative impact. Avoiding such behaviors requires introspection and judgment based on each client and context. For example, professional dress may differ greatly between agencies and according to the function of the worker. Appropriate boundaries can vary across cultural contexts. Not all behaviors pertinent to professionalism can be outlined here, yet consideration of them must not be ignored, given their potential impact on clinician effectiveness. Luckily, several attempts to outline succinct yet exhaustive lists of core generic professional competencies have been undertaken by organizations such as the American Psychological Association (APA), the Council on Social Work Education (CSWE), and the British Psychological Society (BPS). The “Competency Benchmarks Document” provides a particularly extensive resource for the APA (Fouad et al. 2009). The “Educational Policy 2.1” (Council on Social Work Education 2008) and the “Required Competencies Mapping Document for Doctoral Programmes in Clinical Psychology” (British Psychology Association, n.d.) similarly outline each organization’s behavioral expectations of professionals. While designed for academic use, such documents can be used as checklists for clinicians to consider the broad array of competencies necessary for professional practice, and each reference can easily be located with the help of an internet search. Further, supervisors can use these checklists to provide feedback to trainees about their professional practice. All three documents described above discuss ethics as a vital aspect of professional competence. Professional organizations such as the APA, the BPS, the Australian Psychological Society, the European Federation of Psychologists’ Associations, and the International Federation of Social Workers (IFSW) have formal ethical codes. Most include professionalism and evidence utilization in their definitions of ethical competence, while urging clinicians to respect and uphold human rights. Given the differences between nations and professions, all clinicians must be familiar with and abide by their respective professional organization’s ethics code. Professional competence also encompasses the ability to operate within legal parameters. Particularly relevant concerns for clinicians working with children are informed consent, privacy, and mandatory reporting. The specifics of these, such as the age at which a child can legally consent to treatment, what information a parent is entitled to, and the legal definition of abuse vary between countries and states. Clinicians must be aware of the laws to the best of their ability. However, knowing every local statute can be challenging, as laws are often difficult to locate and interpret, especially for clinicians lacking legal training. Therefore an important aspect of legal competence is connecting with helpful resources. Most of the professional organizations previously mentioned offer online guidelines and telephone assistance in legal matters for their members. Some clinical settings have their own attorney or knowledgeable individuals available for consultation. Supervisors can help guide clinicians to locate such resources as part of their training. A number of literature reviews (Beidas and Kendall 2010; Herschell, Kolko, Baumann, and Davis 2010; Rakovshik and McManus 2010) have suggested the importance of ongoing support in the form of supervision and/or consultation as a critical component in training therapists. We will use “consultation” as an umbrella term, to encompass the numerous others used for ongoing support – for instance supervision, coaching, and audit with feedback (Edmunds, Beidas, and Kendall 2013). Emerging empirical literature has demonstrated that the number of hours spent in consultation after training predicts therapist fidelity, above and beyond the type of training method (Beidas, Edmunds, Marcus, and Kendall 2012). Therapist fidelity involves adherence to an EBP – in other words, use of specified procedures – and competence in delivery – that is, skill (Perepletchikova, Treat, and Kazdin 2007). Thus a critical competency for therapists at all levels is to seek out and participate in regular consultation. This is required from trainees prior to licensure, but it is also a competency therapists of all levels must display, particularly when faced with a difficult case or a difficulty that presents itself outside of their competence area and where referrals are not possible (American Psychological Association 2002). Consultation’s mechanism of change is unknown, but it likely provides therapists with a venue for clarification and experiential practice with concepts, massed practice, case consultation, and problem solving of implementation barriers.
Professional Evidence-Based Practice with Children and Adolescents
Introduction
Key Features of Competencies
Attitudes and ability to utilize research
Attitudes
Evidence consumers
Operating within professional, ethical, and legal codes
Professional practice
Ethical practice
Legal practice
Supervision/consultation
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