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Factors that predict who takes advanced courses in cognitive therapy.


Training in Cognitive Therapy (CT) includes theoretical and didactic components combined with clinical supervision. An introductory course in CT might satisfy training needs in psychotherapy and help in the selection of those trainees who wish to continue to an advanced training level. Predictors of success at such an introductory course have been reported to be the abilities to learn and to relate successfully in group situation. Professional background as reflected on previous clinical and psychotherapeutic experience were not reported as significant predictors to take advanced course in CT.

Keywords: Cognitive Therapy, introductory course, prediction of competence.


The discipline of CT has a long history of standardizing methods of training, supervision, and assessment. Several courses in CT have been set up to train a variety of graduate mental health students and professionals seek training in CT and may benefit from training regardless of their original therapeutic orientation. These courses tend to vary in length and intensity (1-4). Training in CT is intended to enhance the competence of the therapist but it does not guarantee success in itself (5). Few studies have examined what are the most effective ways to reliably increase trainees' skills in CT (2,6). The literature on the effectiveness of CT training is limited and relatively unrefined, yet the available evidence supports the effectiveness of CT training in improving the competence of trainees. Furthermore, reports of the contents of such training programs indicate that theoretical and didactic components can be combined with clinical supervision to improve trainees' knowledge and skills, in line with the development of evidence-based practice (1). More refined research, designed to evaluate the training of competencies of CT and the contribution of such competencies to the outcome of therapy would provide valuable information to trainers and supervisors.

In the domain of training psychiatric residents in psychotherapy, educators must assure training methods that enable the acquisition of competence in certain kinds of psychotherapy (7, 8) and distinguish potentially hazardous practitioners from safe ones (9, 10). CT is one of the mandated competencies in psychotherapy in both Accreditation Council for Graduate Medical Education (ACGME) and European Board of Psychiatry (EBP) (11). In the USA the Residency review Committee (RRC) for psychiatry has mandated that training programs "must demonstrate that residents have achieved competency in at least the following forms of treatment: brief therapy, cognitive-behavioral therapy, combined psychotherapy and pharmacotherapy, psychodynamic therapy, and supportive therapy. The EBP requirements mention at least psychoanalytic and cognitive-behavioral psychotherapy should be included in the training curricula for 1 hour per week, or 120 hours in total.

Two major weaknesses have emerged namely: a) lack of resources and b) the assessment of competence in psychotherapy. Residency training programs are lacking the resources to provide adequate training in CT. In the USA a survey of the adult residency training programs directors demonstrated a lack of required training in cognitive-behavioral therapy, both in didactic and residency psychotherapy hours, in nearly half of the residency training programs whose directors responded in the survey (4). A survey conducted at Canada (12) reports that the vast majority of residents are highly interested and motivated to learn CT. Only a minority considered training requirements a motivation for seeking training. On the other hand the most commonly reported difficulty in gaining exposure to CT was supervisor availability.

The definitions of competence are not self-evident, and agreements as to how such competencies can be meaningfully assessed are not universally shared (9,10). The issue of measuring competence is addressed by placing ratings of "competent" midway on a continuum from "novice" to "expert" (13). It has been proposed that educators should be able to assure formative competencies in psychotherapy. Formative competency includes mastery of core knowledge of the psychotherapies, actual undertaking of these psychotherapies, and adequate performance in selected elements of these psychotherapies

CT training experience is an advantage prior to attending an advanced training course (1,14); therefore an introductory course in CT might be of value to satisfy training needs in psychotherapy (15) and help in the selection of those residents in psychiatry who wish to continue to an advanced training level. It might offer a better opportunity to observe and select those trainees that have the desired qualities necessary for the participation to a formal training program in CT that includes the treatment of patients under personal and group supervision.

A CT Training Program

A CT educational program in the department of Psychiatry at the Athens University, in collaboration with the University Mental Health Institute, has crystallized in its present form as two level training program,--an introductory and an advanced level--during the last ten years. This program gave us the opportunity to study the predictors of success in order for a trainee to be accepted at the advanced course.

Introductory Course

The primary purpose of this course is to familiarize the trainees with the basic tenets of CT, as well as its various interventions and indications. Entry to the introductory course is achieved through an open competition among mental health professionals. Main criterion for acceptance is the level and length of professional background, both clinical and psychotherapeutic. It consists of a course of 25 training sessions spread over one academic year (once weekly during a nine month period). Each training session consists of two hours of didactic presentations by university staff specialized in CT and two hours participation in one of three groups (8-12 trainees). These groups are coordinated by experienced cognitive therapists and aim at a more active participation of trainees through role-playing, modeling and group supervision of videotaped therapeutic sessions. Trainees are asked to complete thre written assignments. Approximately the top fourth of the total number of trainees is accepted to the advanced course. After the conclusion of the introductory course group coordinators rate trainees' suitability to continue further training to CT. This rating plays decisive role for the acceptance of a trainee into the advanced course. The rating of trainees' suitability to continue to the advanced course is related to the following factors:

Professional background, such as level of professional training, amount of experience estimated from the trainees' CV prior to entering the introductory course

Overall participation in the introductory course as evidenced by trainee's attendance and compliance to the written assignments.

The quality of the written assignments that reflect trainee's learning ability which was rated by a member of the staff and;

Coordinator's evaluations regarding the way trainees were interacting in group situation which is supposed to be associated with the way they relate with other people.

Advanced course

Aim of this course is a more specialized training to CT by undertaking 3-4 patients under both individual and group supervision.

Individual supervision: All trainees are assigned four cases of patients from the CT clinic. They are all psychiatric patients suffering mainly from depression (non psychotic and not bipolar) (16) and anxiety disorders. As a rule all patients are assessed by a coordinator of the program as for their suitability for brief CT. The maximum number of therapeutic sessions for each patient is 25. Each therapeutic session corresponds to one session of individual supervision. Treatment sessions start at the beginning of each academic year and are scheduled to be completed by the end of the academic year. If a patient drops out then immediately the trainee undertakes another patient from the available waiting list. In order of a case to be considered as completed the individual supervisor has to assess the successful implementation of CT in at least ten sessions leading to clinical improvement. We assume that prompt termination during an academic year reflects the successful performance at treating four cases of patients under individual supervision.

Group supervision: Consists of 25 two-hour sessions during the academic year lead by two experienced cognitive therapists. It aims at helping trainees to acquire the basic skills believed to be necessary and common for all psychotherapies such as abilities to manage boundaries, develop a therapeutic alliance, listen, deal with emotions and understand (13). Trainees choose either a representative session or relational problems that they wish to bring upon in the group. At the conclusion of the 25 sessions of group supervision, group supervisors rate, in consensus, each trainees' performance to the following items:

a) Theoretical knowledge,

b) Participation, that is both the number of absences and the extent of their involvement in the group processes,

c) Ability of relating in the group supervision situation,

d) Relational capacity with the patient as reflected in the discussion of the assigned cases in the group.

Predictors of Success at the Introductory Course

We studied trainees' characteristics prior to enter the advanced course and their performance at the introductory course as predictors for admission to the advanced course (15) In a standard linear regression we used as independent variables clinical experience, psychotherapeutic experience, number of attendances, number completed written assignments, quality of the written assignments and interaction inn group situation while competence to continue training was the dependent variable. The variables quality of written assignments and their interaction in group situation were the best predictors of the group coordinators' rating referring to the trainees' suitability to continue training in the advanced course. On the other hand previous clinical and psychotherapeutic experience were not critical in the prediction of the performance in the course.

These findings are consistent with previous findings that pre-existing theoretical orientations may not significantly affect learning of Cognitive-Behavioral techniques over a nine-month practicum (6). It is also consistent with the fact that the existing relationship between the amount of training and the acquisition of expertise is uncertain (17). Time in training or years of experience are used to define levels of professional "training" or "experience" but this temporal definition of professional experience and training is subject to misinterpretation because it does not attend to the critical issue of "what is trained."

A major limitation has to do with circular reasoning. The instructors of the introductory course are generating the evaluations that turn out to be most related to their decisions whether someone should continue to the advanced course. A study relating indexes of success in the advanced course to the introductory course evaluations is about to be published. Preliminary data show that performance at the introductory course is a significant predictor of performance in the advanced course.


We might need to reconsider our policy regarding trainees' admission to CT training programs. Having "objective", professional-background type criteria might be less important than having them enter an introductory course that offers a better opportunity to observe and select those trainees that have the desired qualities to continue to an advanced level.


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Author Contact Information:

Artemios Pehlivanidis, M.D.

Assistant Professor in Psychiatry

Athens University Medical School

Department of Psychiatry

Eginition Hospital

74, Vassilissis Sophias Avenue

11528 Athens, Greece

Phone: (3210) 7289249

Fax: (3210) 7242020

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Author:Pehlivanidis, Artemios
Publication:The International Journal of Behavioral Consultation and Therapy
Geographic Code:1USA
Date:Jun 22, 2007
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