3 Elizabeth S. Sburlati and James Bennett-Levy The gold standard for ensuring therapists have an acceptable and sustainable level of competence is generally achieved through objective measurement of a therapist’s competency by an experienced assessor, clinical supervision, continued targeted professional development, and positive outcomes with clients. However, in routine clinical practice, the most usual and most readily available method of quality control on a daily basis is self-assessment. Research has shown that therapists are often inaccurate in their estimations of their level of competence. Less competent therapists have been reported to overrate their level of competence when their own ratings were compared to ratings made by objective observers (Brosan, Reynolds, and Moore 2008). One of the reasons, it is suggested, is that less competent therapists often “don’t know what they don’t know” (Bennett-Levy and Beedie 2007; McManus, Rakovshik, Kennerley, Fennell, and Westbrook 2012, p. 301). On rare occasions it has been found that more competent therapists underestimate their abilities by comparison with supervisor ratings (McManus et al. 2012). Generally, however, therapists tend to have an overly positive view of their own abilities (Walfish, McAlister, O’Donnell, and Lambert 2012), which may compromise the standard of practice among the therapist workforce (Brosan et al. 2008). Since research shows problems with therapists’ self-assessment, the purpose of this chapter is to assist with improving self-assessment, both in general and in the specific area of the treatment of child and adolescent anxiety and depressive disorders. In order to do this, the chapter includes four sections, which cover (i) suggested methods for competent self-assessment of therapeutic knowledge and skills; (ii) self-assessment in relation to working with anxiety and depressive disorders; (iii) self-assessment in relation to working with children and adolescents; and (iv) common obstacles to self-assessment and methods to overcome them. We should make it clear from the outset that, although self-assessment may be commonly used, it is a far from perfect method of assessing therapist competence. While in this chapter we suggest some ways to assist therapists in assessing themselves, it is important to note that far more research is required in this area. Self-assessment is probably best used in combination with other methods of therapist competence assessment, such as objective competence assessment, client process and outcome data, 360-degree evaluations, pen-and-paper tests, and oral examinations (Kaslow et al. 2009). Self-assessment of competence is the practice of validly assessing one’s professional competencies in an area of practice, with the purpose of determining competency strengths and weaknesses (Kaslow et al. 2007; Kaslow et al. 2009). Following self-assessment, therapists should identify their competency limitations, make plans to improve these competencies by engaging in appropriate professional development study, supervision/consultation, and deliberate practice (Ericsson, 2009), and monitor progress toward their competency goals (Belar et al. 2001; Caverzagie, Shea, and Kogan 2008; Kaslow et al. 2007; Kaslow et al. 2009). We recommend the following methods of self-assessment: measurement of client outcomes and process; use of a guiding model of therapist competencies; use of valid and reliable assessment tools; active review and reflection on audio or video recording of therapy sessions; engagement in reflective practice; and active participation in clinical supervision and professional development, so as to increase one’s knowledge and refine self-assessment skills. These six methods are described below. A useful metric of therapist performance is whether clients are improving in line with expectations, or whether they are failing to improve. Research shows that therapists tend to be poor judges of client progress and outcomes and have an overly optimistic perspective and a biased appraisal of their own skill level (Newnham and Page 2010; Walfish et al. 2012). These biases suggest the need for accurate feedback on client progress. The adult psychotherapy literature indicates that the best way to judge client progress accurately is to measure outcomes on a routine basis (e.g., every session) and compare the results against population benchmarks and expected outcomes (Lambert 2010). An additional refinement is to get direct feedback from clients about the process of therapy: Are the client’s needs (therapeutic bond, tasks, and goals) being adequately met? Routine monitoring of the client’s experience of therapy, with a particular emphasis on elements with which the client is dissatisfied, has been shown to enhance therapy outcomes (Lambert 2010). The conclusion from the adult psychotherapy literature is that the assessment of client outcomes and therapeutic process provides an important foundation for making both positive adjustments to the therapeutic intervention (where these are necessary) and accurate self-assessment. In order to assess the therapeutic process and its outcomes, clinicians working with children and adolescents can use a range of available measures. Chapter 7 provides information on a number of evidence-based measures for assessing anxiety and depression that allow for an evaluation of client outcomes in terms of return to nonclinical range. Chapter 6 provides information on process-oriented measures that can be used to identify whether changes may be needed in the therapeutic process in order to enhance the likelihood of positive gains. Unlike the adult literature, however, the child and adolescent literature does not yet have client outcome benchmarks against which a therapist can compare his or her client’s progress during therapy. In consequence, a therapist can only determine whether all his or her clients’ outcome scores are improving or not, but cannot determine whether the degree of improvement of an individual client is at the expected level during therapy. In the absence of appropriate benchmarks, data concerning the outcomes of a number of clients treated by a therapist could be compared with the expected outcomes that are based on meta-analyses. In anxiety disorders, for all clients who begin treatment, the response rate expected immediately after treatment would be about 59 percent – assuming that, if there are drop-outs, these did not improve (James, James, Cowdrey, Soler, and Choke 2013). Comparisons for depression are only available on the basis of effect sizes; however, response rates for the larger treatment trials would indicate an expected response of between 43 and 65 percent at the 12–18 week mark (March et al. 2007). Although this is a crude comparison, it will provide useful evidence for a therapist’s self-reflection, until such time as research yields appropriate benchmarks for children and adolescents. Without clear competency guidelines, therapists are unlikely to have a good understanding of the competencies required to implement a particular therapy with a given population. Further, the evidence suggests that, when left to their own devices, therapists prefer to focus on self-assessing and improving conceptual knowledge and technical skills rather than interpersonal skills (Niemi and Tiuraniemi 2010). One way of ensuring that therapists are aware of the depth and breadth of the required competencies is to develop therapist competencies guidelines that list and describe in detail the competencies required when one is using a particular therapeutic orientation with a specific population. For example, there are guidelines in the form of therapist competencies models for treating anxiety and depression using CBT in adults (Roth and Pilling 2008) and in children and adolescents (Sburlati, Schniering, Lyneham, and Rapee 2011). Such models should be made readily available for those therapists who are attempting to learn the competencies required for a given therapy and population. Self-assessment practices tend to be non-standardized. One way to make self-assessment more standardized would be to use reliable and valid therapist competence assessment tools. This has been done in a number of research trials (e.g., Bennett-Levy and Beedie 2007; McManus et al. 2012). These assessment tools include a number of items that correspond to necessary competencies in a given area of practice, and also a Likert scale of competency-related anchor points (e.g., incompetent, novice, advanced beginner, competent, proficient, expert) for each item (see Blackburn, James, Milne, and Reichelt 2001). An overall label is given for each competency item and more detailed descriptions are provided for how that competency might look at each level of competence. While the vast majority of these tools are observer-rated – that is, a supervisor or some other observer rates the competence of a therapist, either in vivo or from a recording – the self-assessing therapist can record selected therapy sessions and simply change any reference to “the therapist” in the assessment measure to “I.” The validity of therapist self-assessment ratings might be increased when these ratings are made in conjunction with observer ratings on the same therapy sessions (Bennett-Levy and Beedie 2007). Two examples of observer-rated CBT competency measures that have been psychometrically validated are the following: A problem is that the above competency tools are measures of CBT in treating adults. Measures of competencies in treating children and adolescents with anxiety and depressive disorders are required. A measure based on the Sburlati and colleagues (2011) model is currently under development. Neither self-assessment nor objective assessment of competencies can take place in a systematic manner without sessions being audio- or video-recorded. Competency measures typically have a number of dimensions (e.g., conceptual, technical, interpersonal), and assess specific skills (e.g., identification of negative automatic thoughts, case formulation). Recording one’s sessions enables therapists to review their microskills at a level of detail that is simply impossible when conducting a session in vivo (Brown, Moller, and Ramsey-Wade 2013).
Self-Assessment of Our Competence as Therapists
Introduction
Key Features of Self-Assessment and Professional Development Competencies
Definition of self-assessment
Methods of self-assessment
Measurement of client outcomes and process
Having a model of therapist competencies as a guide
Use of reliable, valid, objectively rated assessment tools
Audio or video recording of therapy sessions
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