10 There is no easy answer to this question. Becoming a CBGT therapist requires a combination of two different skill sets: ability to implement CBT interventions for a range of disorders and ability to facilitate groups. Thorough knowledge of individual CBT is a logical and necessary prerequisite for being a lead therapist in CBGT, but the added complexity of the group format demands additional skills not necessarily offered in CBT training centers. While there are organizations offering certification, separately, in CBT and group therapy, the ones listed in this chapter do not offer formal certification in both, with a title of Certified CBGT Therapist. Ideal CBGT therapists are those who have had extensive, supervised CBT as part of their mental health education. Usually, this involves a minimum of at least 1 year, full-time supervised CBT training in the form of an internship in a formally approved hospital-based program or community mental health center. The majority of CBT internship programs in North America meet standards for approval by the American Psychological Association (APA) or the Canadian Psychological Association (CPA). Equivalent training is, however, also widely available to practicing and regulated health-care professionals who want to extend their scope of practice. They can seek this training through private training centers, such as the Beck Institute for Cognitive Behavioral Therapy and Research in Philadelphia, United States, or the Oxford Cognitive Therapy Centre, Oxford, United Kingdom. Clinicians are encouraged to check with their local CBT associations (some are listed at the end of this chapter) for training opportunities in their area. Admission to this type of training is usually restricted to mental health practitioners who already demonstrate strong foundational skills in the assessment and treatment of mental health problems. After completing formal internships or equivalent supervised training, CBT therapists can seek additional certification as a CBT therapist. In the United States, the Academy of Cognitive Therapy offers such certification, which is available to individuals who have demonstrated an advanced level of expertise in cognitive therapy. The academy’s certified membership includes social workers, psychiatrists, psychiatric nurses, psychologists, counselors, and other mental health professionals from around the world. This certification recognizes expert levels of, and leadership in, the field of cognitive therapy. Great Britain, Canada, and Australia also offer certification in CBT. Other countries in northern Europe—and China—are likely to follow suit as CBT is making significant inroads in those countries and is often even more accessible to the public compared to North America. Ideally, the expert CBT therapist would also have received certification in group therapy by a recognized training institute. The American Group Psychotherapy Association (AGPA), for example, offers the title of Certified Group Psychotherapist, which allows one to be recognized as a specialist in group psychotherapy as well as affirm commitment to a certain standard of practice for group psychotherapy. Group psychotherapy associations offer certifications for a wide range of therapy approaches, problems, and disorders. Thus, it is impossible—without inquiring—to know what kind of therapy a Certified Group Psychotherapist offers for what kind of client. However, clients can be confident that certified group therapists have a solid understanding of what makes therapy groups safe and helpful. Organizations such as the Canadian Group Psychotherapy Association (CGPA) and the AGPA offer training courses on the basics of group therapy covering issues such as developmental stages in a group’s life, group dynamics, processes, client selection and preparation, etc. CBGT therapists often find these courses helpful and inspiring. They offer CBGT therapists a broader appreciation for the potential healing capacity of the group process and how to best deliver the content of a CBT protocol in a group setting. CBGT would be a scarce resource if mental health centers required the top level of training sketched in the beginning of this chapter. At the same time, it is best to avoid the opposite extreme in which health professionals whose formal training did not include CBT, or any form of supervised psychotherapy, are asked to develop and run CBT groups. It does happen that such professionals are offered one or two CBT workshops in order to take on leadership of a CBT group. Although many professionals are fully capable of reading, understanding, and presenting any CBT manual, overreliance on any manual or guide, without prior supervised experience with a range of clients, can quickly undermine therapist confidence and be potentially harmful to group members. The unexpected always happens, and when therapists become unsure and anxious, group members immediately sense this and their anxiety about the group increases. A significant portion of CBT and CBGT involves presenting often complicated interventions, such as graded exposures. Even when these interventions progress well for most or all group members, deviations from any group manual are usually necessary. Group therapists are constantly faced with the challenge of accommodating individual group members’ symptom expressions and needs within the group context. The consequences of insufficient CBGT training can tarnish CBGT with a negative reputation. This is unfortunate when the problem is not CBGT per se. As with any craft or service, whether cabinet making, midwifery, or heart surgery, it is optimal to provide initial classroom teachings of basic knowledge followed by graduated, supervised training. Somewhere in the middle of these two training poles are rich opportunities for mental health practitioners from varied backgrounds to become responsible and competent CBGT therapists. In thriving, dedicated mental health CBGT programs across many countries, there is typically a CBT champion with significant CBT and group therapy training providing formal or informal leadership. One or two such leaders can, if given the necessary resources, train other mental health practitioners to become qualified and confident CBGT therapists. In what follows, I propose how CBGT can be incorporated into staff training. I then review issues pertaining to student training in CBGT and how to implement ongoing staff supervision, consultation, and professional development. A competent CBGT therapist will have had a combination of didactic learning and direct supervision. This combination can also be referred to as blending foundational or declarative knowledge, the kind gained through courses, workshops, and reading, with procedural knowledge, the kind obtained from ongoing and direct supervision (Newman, 2013). I elaborate on these two approaches in the following text. In any CBT group, it is critical that at least one of two group facilitators have had extensive CBT training for the particular type of group they are running. Since mental illness is a serious matter, similar to a physical illness such as heart disease, clients with mental health issues need effective treatment delivered by qualified practitioners. It is not professionally rewarding to be in charge of eight depressed group members if neither leader has had prior supervised experience with depression, including in a group setting. Compared to individual therapy, much more is at stake when an entire group breaks down, as it is not easy to transfer a whole group to another therapist. Individual clients are easier to transfer when therapists feel out of their depth or for other reasons do not believe they are the most qualified to offer treatment. In settings where one therapist has had formal training in mental health; at least 1 year of supervised CBT training, including CBGT; and an additional 2–3 years of ongoing CBT practice, this therapist can begin to train cofacilitators. A cofacilitator is often a mental health therapist who has a solid grasp of psychopathology, assessment, and mental health issues based on a formal education in psychiatric nursing, social work, counseling, psychology, or psychiatry. This clinician is familiar with diagnostic criteria for the various mental health disorders and all the personal and environmental variables influencing the functioning of people with mental illness. Such a cofacilitator knows how to engage in a client-centered manner, how to support the client in setting goals, and how to work collaboratively with the client in working toward improved well-being and symptom management. Many cofacilitators have had various group therapy experiences. These experiences may be supportive groups, psychoeducational groups, or interpersonal process groups. A cofacilitator who is being trained by the primary CBGT therapist will learn to add specific CBT skills to their already broad base of general knowledge about mental health. A cofacilitator will develop CBT skills—or declarative CBT knowledge—by taking courses and workshops and engaging in assigned readings and discussions. Mental health practitioners who already have a professional degree, including foundational skills in psychotherapy and are working independently within their scope of practice as they become cofacilitators, are obviously limited in how much additional declarative CBT knowledge they can add to their already busy workload, but if their goal is to become primary therapists in CBT groups, this didactic CBT training must be a priority. If they are comfortable with being cotherapists in a secondary role, they may not need the same amount of additional training outside of their work setting. The primary therapist will be able to offer recommendations for where gaps in knowledge need to be filled. Didactic training aimed at increasing declarative knowledge usually takes the form of a series of workshops on core CBT skills. For example, an introduction to CBT can, minimally, exist of five full-day (or 40 hours) workshops focusing on (a) introduction to CBT, (b) behavioral techniques, and (c) cognitive techniques. The introduction to CBT will cover its historical development, theoretical learning principles, the range of disorders and problems for which there is evidence to support CBT, appropriate client populations, characteristics of the therapist, and how to communicate the CBT model and treatment rationales. The coverage of behavioral techniques will include monitoring of symptoms, ongoing improvement, outcomes, hierarchy development in exposure therapy, and goal setting. The review of cognitive techniques will touch on dysfunctional assumptions and thinking (e.g., black-and-white thinking) and the use of Thought Records to challenge unhelpful thinking. In this kind of introductory course, some interventions are demonstrated by the workshop instructors, who also use the participants for role-play. Mental health professionals new to CBT who enroll in such a course enjoy having a better sense of the foundational CBT principles. Although the course is primarily a theoretical overview, it nevertheless offers a solid framework, which can be hard to get on one’s own. There may be initial education and training costs for programs that hire staff without prior CBT experience. However, this investment quickly pays off. When staff feel supported and confident in their CBT skills, they are more likely to enjoy a higher level of job satisfaction. The didactic part of CBT training is ideally done before entering into any CBT group as a trainee, but, if this is not possible, a concurrent approach is also workable. Following courses on CBT core skills, staff may seek more specialized knowledge on specific disorders depending on what groups they are involved in. For example, a program specializing in obsessive–compulsive disorder (OCD) would want their group facilitators to get as much specific knowledge about this disorder, especially given that CBT is the gold-standard intervention for OCD. And a program wishing to prioritize mixed diagnostic groups may want to send their staff to workshops on the new transdiagnostic protocols reviewed in Chapter 7. With some basic declarative knowledge of core CBT skills, the staff trainee will be able to add procedural knowledge, which is the process by which one implements acquired CBT skills to an actual group. This implementation follows a graded approach. A first helpful step would be to “silently” observe a CBT group. This could be done from behind a one-way mirror, which is ideal, but not always available in community centers (one-way mirrors are more common in academic psychotherapy training clinics). The group is told that there are trainees watching behind the mirror and that they participate in the postgroup therapist debriefing discussion. Group members may not easily be in a position to refuse this, if the program presents itself as also being a teaching site. It is, fortunately, a rare member who objects to having trainees involved. Groups are most often quite agreeable after having had an opportunity to discuss their concerns. In public settings, where clients appreciate getting high-quality therapy services for free, they are usually more than willing to offer “payment” in the form of going along with having trainees or students present. If a mirror is not connected to the group therapy room, the trainees can silently sit away from the group table so that it is clear they do not play an active role. It is important that the role of the trainees is explained during the first CBGT session. Therapists may tell clients to not worry about establishing eye contact or turning to the trainees when they talk. They can just ignore them. Such instructions are helpful. It is also best if the trainees do not mingle too much with clients during the break so as to minimize confusion about who is in or who is “out of” the group. It is a bit awkward and counter to the group spirit. It is one of the reasons why many supervisors prefer that trainees observe behind mirrors. Watching videotapes of groups in action is also helpful. But it is a less dynamic experience, since all group sessions have usually taken place by the time the video is presented to trainees. Trainees often have excellent questions, which the group facilitators take into account and may incorporate in their subsequent CBGT sessions. This kind of interaction is complicated to do if videos are used, but not impossible. With the appropriate equipment, each CBGT session could be reviewed by many trainees on a screen immediately after it took place, or simultaneously. This would allow the group facilitators to more actively work with issues that come up in the postgroup session debriefing and transfer it into the next group session. One could also imagine broadcasting videotapes of CBGT sessions with a wide trainee audience that teleconnects or Skypes from various sites and engages in a large debriefing discussion. With advances in technology, it is easier for therapists in more remote areas to access training and supervision. Before graduating to a real group, there is the possibility of conducting a mock group. This training approach has been described by Clarke (2010). Mock groups typically consist of several trainees preparing to lead independent groups taking turns being the leader with the remainder trainees role-playing clients in a particular group. In the Clarke example, the trainees role-played depressed adolescents. The trainee takes on a more active facilitation role after observing one or two groups—and perhaps running a mock group—and reading the CBT manual and any other relevant material assigned by the primary therapist. The trainee often does so as a third therapist in addition to two main cotherapists. The trainee therapist sits around the table and is expected to actively participate but not at the same level as the cotherapists. In the first CBGT session, the therapists carefully explain to the group who the main therapists are and who the trainees are. This frankness is critical so as to avoid any discomfort related to why one therapist barely speaks and seems nervous when they do. When introducing themselves, the trainee therapist will often say something like: I have just graduated as a social worker and am new to this program. I’m very excited about the opportunity for group therapy and although I did do one group during my training, it is my first time in a CBT depression group. Although I am mostly learning, I will from time to time take the lead on introducing new material. I may be a bit nervous, but hope you’ll forgive me. CBGT group members tend to react positively to this, and there may be some therapeutic value in how trainees model dealing with their own anxiety. The formal inclusion of the trainee provides ample opportunity for direct supervision and observational learning from more experienced therapists. Unlike individual therapy, where the trainee mostly hears about how well (!) their supervisor would have handled a certain challenge, in group therapy, the trainee gets to directly observe, something that can make even the most seasoned group therapist slightly nervous too. Sometimes, the senior therapist may not be “in the mood” for having a whole group plus one or two trainees hang at their every move and word. Senior group therapists—somewhat jokingly—occasionally express a longing for the private, individual therapy room. And even that can be intense. According to psychiatrist and Freud biographer, Anthony Storr (1989), Freud chose to sit behind his patients, who were on the couch, to facilitate free associations but also because he could not tolerate the self-consciousness he felt from having his patients stare at him hour after hour. Adequate time needs to be allocated to support the learning needs of the trainee. This usually involves having both a pregroup meeting and a postgroup debriefing. In the pregroup meeting, the two main therapists review the agenda with the trainee, the specific material to be covered, and any expectations and responsibilities from the trainee for a given session. For example, in a depression group, the trainee may be asked to introduce the SMART goal component of the group (reviewed in Chapter 4) and rehearse this with the facilitators before the group starts. The trainee may also be asked to take the lead on the homework go-round and review ways to prevent derailing in a time-consuming way by group members who have trouble limiting their turn to just their homework. The trainee will be reassured the main therapists will jump in whenever needed. It is also helpful to assuage trainees’ anxiety about saying the right thing when they have their moment in the group. Helpful words to that effect may be something like: You need to remind yourself of your basic good skills and clinical instincts; we are confident that nothing you say will be harmful, so just go for it. Even experienced therapists can often think of slightly better ways they could have explained something or offered feedback. That’s the good stuff we talk about in our postgroup debriefing. In the debriefing, the therapists along with the trainee review how the session went. This provides the opportunity to get comfortable with feedback. Feedback is essential for developing skills, and it is naturally also a salient aspect of any group therapy. Group therapists who are uncomfortable with receiving and offering their own feedback will likely have a tough time cofacilitating groups. The senior therapist emphasizes both corrective and confirming feedback and models his or her own ability to reflect on what they thought they handled well and not so well in the session. Scott’s General Group Therapeutic Skills Rating Scale (Scott, 2011) introduced in Chapter 2 is a helpful tool for this feedback process. The first item on Scott’s rating scale, for example, involves reviewing homework and setting the agenda. The lowest score of 0 would be given if the following description was true: Therapist did not set an agenda/did not review homework. The senior therapist may ask the trainee how he or she felt about their presentation of the agenda and their homework go-round management. The trainee may say that he felt he worked well with everyone’s homework and especially was able to support two members in solving problems related to their homework. The therapists and the trainee may also agree that they ensured all group members had roughly equivalent airtime. Thus, the therapists and the trainee may give themselves the highest score of 6 in the area referred to as Review of Homework/Agenda on Scott’s rating scale. The wording for a score of 6 is as follows: therapists set an agenda that was suitable for the available time. Established priorities and tracked the agenda. Difficulties with previous session’s homework were effectively problem solved. One therapist may praise his fellow therapist—or trainee—for effectively handling a particular problem in the homework review: I liked how you gently redirected Ben and brought him back to the topic. Or: I appreciated how you commented on Lara’s dosing off, as I had not really noticed, and it gave Lara an opportunity to give Brenda permission to poke her. I don’t think she felt scolded by you, and I liked how you just reflected on it being hard for her to stay alert. Learning from what did not go so well is perhaps the most productive part of the debriefing. This requires a sufficiently healthy cofacilitator dynamic in order to ensure that feedback is not perceived as criticism but rather as an opportunity for mutual learning. If it does not feel safe to offer feedback to one’s cotherapists, any steps to remedy this would be beneficial and in the best interests of the group members. It can be difficult to share a concern about one’s group therapist colleague. A concern could be about a didactic or process intervention. The following is an example of two group facilitators reviewing a missed opportunity for both of them. Using Scott’s rating scale, they realized they could have done better in Utilising Group Members as Role Models. In the postgroup discussion after a social anxiety group, one therapist shared this observation about how a particular situation could have been better handled. Therapist, Rosa, speaking to her cotherapist:
Who Is Qualified to Offer CBGT?
Standards for Training and Qualifications
How to Become a CBGT Therapist
Qualifications of the competent CBGT therapist
Declarative knowledge about core CBT competencies
Implementing declarative knowledge into real groups
Ongoing observational learning and supervision
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Who Is Qualified to Offer CBGT?
Henry, I liked how you referred to Kim when Hanna spoke about becoming more and more focused on what the woman she was talking to was thinking of her. Hanna said she became convinced that this woman found her “uninformed” and “silly.” Just before that Kim had also talked about self-preoccupation in terms of how he thinks others evaluate him. Kim mentioned that he had good success with trying some externalizing behaviors. Remember, Kim said he focused on the slight accent the person had, and the pattern of her shirt. Now, you only spoke about Kim having done well in his social interaction, but you did not point out that it was his externalizing behaviors that helped him. I just wonder if that may not have been important for Hanna to be reminded of. Kim was doing some good role modeling there.
