One of the ways in which psychotherapies are adopted in the NHS is through the publication of competence frameworks. These are formal documents, available online, which set out in clear, lay language what practitioners need to know and what skills they must acquire to practise a particular therapy. The reason it’s in lay language is because it is not primarily for the adherents of the method but for the outsiders: the service commissioners, managers, funders, service users and the interested general public.
The adoption of CBT into IAPT was accompanied by such a competence framework, commissioned from University College London by the IAPT programme, and others followed. CAT has its own framework alongside CBT, psychoanalytic and psychodynamic therapy, systemic therapy, humanistic therapy, interpersonal psychotherapy, dynamic interpersonal therapy, and counselling for depression.
The CAT framework was produced by an expert reference group (ERG) Glenys Parry, Steve Kellett, Jason Hepple, Ian Kerr and Liz Fawkes, led by Dawn Bennett with the help of Professor Tony Roth (of Roth and Fonagy fame) who co-lead the programme at UCL.
Please find a summary of this work below and how you may use it. The framework and competences are designed to be viewed online at http://www.ucl.ac.uk/core/competence-frameworks/
Dawn Bennett & Glenys Parry
How did we do this? The framework was developed using the evidence-based method developed by Roth & Pilling (2008). A review of the CAT outcome literature identified where CAT interventions had evidence of efficacy, giving reason to believe that the competences it sets out are likely to make a difference to outcome. This process was supported by the expert reference group (ERG) who provided professional advice on areas where the evidence base was lacking, but where CAT interventions were commonly used by therapists trained in the model. The role of expert professional opinion is important in supplementing or interpreting this evidence.
What does it look like? The framework was produced and structured in terms of core knowledge, core skills and meta-competences (the ‘overarching’ competences of CAT therapists that are relevant across a wide range of clinical settings that require therapeutic judgement rather than simple adherence to a treatment protocol). Whilst generic competences are important (and these are listed in the competence framework for all the therapeutic modalities), there are five CAT-specific domains of competence.
The CAT-specific competences reflect the three-phase structure of the therapy: reformulation, recognition and revision:
1. Knowledge of the basic principles of CAT and rationale for therapy
2. Reformulation and Engagement Phase:
a. Knowledge of reformulation in CAT
b. Engaging the client to reach a shared reformulation
3. Recognition and Revision Phases:
a. Knowledge of working at change in CAT
b. Facilitating change in CAT
c. Working with the time-limited nature of CAT
4. CAT-specific meta-competences
A list of competences is hard for the reader to structure. For this reason, the method sets out a ‘map’ of competence headings which identifies all the areas of knowledge and skill, organises them into a series of domains and helps to show the ways that the different sets of competences inter-relate, particularly over the course of a therapy. The map is intended to be viewed online in an interactive format, so that each heading in each domain can be linked to a full account of the competences. In addition to the ‘map’ and list of competences there is a clinicians’ guide describing each of the domains and a description of CAT for service users. All four documents can be viewed at http://www.ucl.ac.uk/core/competence-frameworks/
Do we have to do all of this? Although these competences are thought to describe best practice on the basis of current evidence, it is impossible to claim that they are all essential to good outcome.
How do we guide against manualisation? The value of such a framework in de-mystifying CAT and laying out its key features must be balanced against the risk of it being seen as a series of technical steps. CAT (in common with many forms of psychological therapy) cannot be reduced to a series of technical competences, not least because of the need to make moment-by-moment judgements and adjustments within a complex collaborative relationship. Indeed this statement is in the CAT Framework. Competency frameworks are indicative rather than prescriptive – they are a support tool and a guide to best practice, not a substitute for clinical judgement nor an ‘instruction manual’ for how the therapist must or should relate to the client. This is particularly important for a therapy such as CAT, which whilst theoretically driven and structured around a clear set of therapy tasks, does not follow a set protocol.
How will it be used? The framework enables trainees, service users, service managers and commissioners to better understand the core features of CAT and what is necessary for CAT to be skilfully delivered in practice. CAT practitioner training courses internationally can now audit their course content against the competences map to ensure that their curricula are covering the necessary competences.
What do people think of the framework? Initial feedback from CAT practitioners, trainees, trainers and supervisors and service managers is that the framework is clear, helpful, applicable and theory-driven. We welcome feedback on the framework and accompanying papers and also on the document for service users.
Limitations of the framework. The focus is the practice of formal cognitive analytic therapy, rather than applications of cognitive analytic principles in health care, of which there are many. Applications that are beyond the scope of the current framework include using CAT concepts when consulting to teams, contextual reformulations, supporting CAT-informed case management and the use of CAT in groups.
Summary It is possible to define the core competences of CAT. The competence map summarises the skills necessary for safe and effective delivery of CAT and enables this complex relational model to be understood in terms of more pragmatic individual competence items that also usefully reflect the three-phase structure of the approach.
Parry, G., Bennett, D., Roth, A.D., & Kellett, S. (submitted). Developing a competence framework for cognitive analytic therapy. Psychology and Psychotherapy: Theory, Research and Practice.
Roth, A. D., & Pilling, S. (2008). Using an evidence-based methodology to identify the competences required to deliver effective cognitive and behavioural therapy for depression and anxiety disorders. Behavioural and Cognitive Psychotherapy, 36(2), 129-147.
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