Education in cognitive-behavioural therapy for mental health professionals

Introduction

Improving mental health services in rural and remote areas of Australia is a high priority matter. Unfortunately, specialist mental health care is not available in many rural and remote settings, which means that patients have to travel long distances at their own expense or can only obtain emergency treatment when problems have escalated to crisis point. ¹ A major factor contributing to the lack of local services is the difficulty of attracting and retaining skilled mental health practitioners in rural areas. Professional isolation is a substantial problem that affects the retention of rural and remote practitioners. ² In addition, mental health practitioners often have high caseloads and are expected to provide a wide range of interventions for diverse clinical problems.

Importance of practitioner education

The provision of ongoing professional development in the form of regular educational programmes is an important approach to the above mentioned problems. First, educational programmes provide participants with the opportunity to ‘network’ with their peers and in doing so to receive much needed professional support and opportunities for debriefing. Second, educational programmes can improve participants' skills and confidence in the provision of interventions for clients. The advent of videoconferencing has allowed mental health practitioners situated in rural and remote communities to participate in professional development which might previously have been inaccessible. High rates of satisfaction with videoconferencing for education and training in various disciplines including mental health have been reported in studies in Japan, ³ the USA ⁴ and Australia. ⁵ This is probably because attending face-to-face education is expensive where it requires long-distance travel, accommodation and disruption from usual work hours. ⁶ Videoconferencing on the other hand enables mental health practitioners to participate in more regular education without the associated costs and disruption to the mental health service.

Training in cognitive-behavioural therapy

The Statewide Clinical and Service Enhancement Program (SCSEP) is a Western Australian programme to provide videoconferencing mental health services to rural and remote locations. The SCSEP programme delivers clinical services, clinical support, management, training and education to both patients and practitioners. The programme began in 1998. In 2001, we published preliminary findings on the outcomes of an initiative to increase practitioner knowledge and confidence in the use of cognitive-behavioural therapy (CBT). ⁷ There is considerable evidence about the value of CBT for treating a range of psychological problems. ⁸ Unlike previous published studies which had focused on measuring participant satisfaction, we measured practitioner knowledge of CBT, both before and after a training programme delivered by videoconference. Although the results were very positive, they were based on only 11 participants which limited the generalisability of the conclusions. Since then, other studies have emerged which have also attempted to measure outcomes beyond simply assessing participant satisfaction. For example, a study by Haythornthwaite in 2002⁹ compared a videoconferenced training programme to a face-to-face equivalent in the education of 26 rural and remote mental health practitioners who worked predominantly with youths at risk of suicide. The author found that videoconferencing produced similar improvements in knowledge and skill level to conventional face-to-face training. The finding that the quality of training and outcomes was not different between face-to-face and videoconferencing delivery has been replicated by studies that have looked specifically at provision of supervision to practitioners. ¹⁰

Thus, overall there seems to be increasing evidence that educational programmes delivered via videoconference can produce significant improvements in participants' knowledge levels. There is also evidence that the provision of such training is met with high levels of satisfaction among participants.

Videoconferenced CBT training in 2008

In view of the initial success of videoconferenced CBT training, we felt that it was important to evaluate the programme's effectiveness with a larger sample. As well as assessing knowledge levels before and after the training, we also wished to assess the clinical benefits of the training by asking participants about their use of CBT in day-to-day practice. To this end we collected pre- and post-training data from 48 participants who had completed the CBT training programme between 2001 and 2008. The participants (social workers, mental health nurses, psychologists, occupational therapists, youth workers and psychiatrists) came from 20 rural and remote regions in Western Australia (see Figure 1). As with our initial study, ⁷ we gave participants the Cognitive-Behavioural Therapy Knowledge Test (CBT-KT). The CBT-KT consists of a 50-item true/false measure of a participant's knowledge of basic CBT principles. ⁷ An example of an item is ‘Unhelpful thinking styles are statements not usually supported by evidence’. The CBT-KT scores can range from 0–50, with a high score indicating greater knowledge of CBT. The full CBT-KT is reproduced in the appendix. In addition to measuring knowledge acquisition we also included a measure of satisfaction which included an item asking about perceived professional isolation. The Videoconferencing Satisfaction Questionnaire (VSQ 7) consists of 25 questions requiring participants to respond on 5-point Likert scales. ⁷

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Figure 1

CBT training sites

The videoconferencing equipment was the same as that employed in the Rees & Gillam 2001 study. ⁷ The videoconferencing calls were made over ISDN connections at a bandwidth of 256 kbit/s. In order to connect multiple sites (videoconferencing units), a conference bridging device (MCU) was used so that all participants could see and hear each other. The presenter could control what appeared on the screen for all participants by using a web page link to the MCU. By using a scan converter the presenter could display images from a desktop computer to assist in teaching. When the computer images were being displayed the presenter could still be heard on audio.

The CBT-KT was completed initially one week before the course began and again immediately after the last session of the course along with the VSQ. A group of five people, who had completed the CBT training programme also participated in a short group interview. The interview lasted for 20 min and it was video-recorded to allow subsequent thematic analysis. The participants were asked the following questions in the group interview:

since completing the programme, have you used the CBT skills learnt with any of your clients?

Content of the CBT training programme

The CBT programme was developed specifically for delivery by videoconferencing and consisted of 10 weekly training sessions, each lasting 1.5 hours. Training programmes were conducted approximately every six months. The programme allowed for groups with a minimum of 6 and a maximum of 12 participants. The same trainer ran the training programmes between 2001 and 2008. A minimum of three sites were included for each training course with no more than two participants at any one site. The programme included reading material for the topics covered, workbooks and a programme timetable. Table 1 summarises the course content.

Knowledge and satisfaction following training

There was a significant difference between the pre-(median = 42; SE = 2) and post-training (median = 47; SE = 2) scores for the CBT knowledge test (P < 0.001). That is, the participants demonstrated a significant improvement in their CBT knowledge following the training course.

The majority of participants (95%) indicated that they had enjoyed the course and would recommend it to colleagues. Furthermore, nearly all (97%) of the participants indicated that they had an increased understanding of CBT following completion of the course and 96% indicated that they had greater confidence in using it as an intervention for their patients. The majority (83%) of participants reported that they felt less professionally isolated since participating in the course. Some participants (35%) indicated that CBT taught via videoconferencing delivery was less effective relative to face-to-face delivery. However, more of them (46%) indicated that CBT taught via videoconferencing was equally or more effective than other modes such as a group-setting or distance learning by telephone.

Transfer of knowledge into clinical practice

The first participant stated that he had used the CBT training for two of his patients suffering from bipolar disorder. The main aspect of the programme that this participant found useful was to ‘dispute some of the patients' negative self talk that they do during their depressive cycle’. The second participant indicated that she had used parts of the model and felt that it had informed the way that she worked. This participant stated that she had used her training for two of her patients suffering from anxiety. She stated that, ‘The training was useful for these patients as a way of changing their thinking related to their anxiety’. This participant also reported that the course was useful and effective for her work in general. The third participant reported that the training had led him to re-think where he had been going with his patients and had enabled him to provide them with more options about what could be helpful. In particular, this participant noted the importance of providing accurate formulations for patients. In addition, he expressed that he had previously been influenced by the medical model only but stated, ‘I now feel I have a different structure to move forwards with’. The fourth participant indicated that she was currently using CBT with ‘a 16-year-old girl who self harms and is anxious’. This participant indicated that she was using several thought diaries with the patient. The fifth participant stated that she was currently using the training with ‘two people with low self esteem, suffering from anxiety and depression as well as self harm and alcohol abuse’. This participant reported that she was using ‘thought diaries to get people to monitor their thoughts and feelings in different situations’. This participant indicated that the training had helped her to use more structure in her sessions as well as developing clear goals and aims for her patients.

The five participants indicated that the opportunity to practice CBT was the most useful aspect of the course. This was summed up by participant three: ‘the way that the lecturer had delivered the training allowing for lots of practice, getting everyone involved, and keeping everyone engaged had been very useful’. The most common response about how the course could be improved was the suggestion to include follow-up supervision in CBT.

Discussion

We have examined participant outcomes of videoconferenced CBT training over a seven-year period. Including participant data from several CBT training courses provides a more rigorous evaluation of the course because it includes many different participants and enables conclusions to be made as to the impact of the training. For example, if outcomes were only examined from a single course, it could be argued that the participants were not a representative sample of mental health practitioners or that they were somehow an especially motivated group. Our study included several different training groups made up of different mental health practitioners with varying levels of motivation and experience in mental health.

Providing CBT education via videoconference resulted in significant improvements in the participant's knowledge of the therapy and also resulted in a reduced sense of professional isolation. This is consistent with our earlier finding ⁷ and strengthens conclusions about the value of this approach to professional training. An increased knowledge of the cognitive behavioural model and knowledge of its application is considered to be a crucial first step in the provision of effective CBT to patients. However, simply possessing an increase in knowledge is not sufficient: it must be accompanied by the actual application of the therapy with patients. Interviews with a sample of participants indicated that all were applying the learning in their current practice. In addition, participants were utilising the therapy with a range of patients, from those with anxiety disorders to those with bipolar disorder, i.e. the training was applicable to professionals working at the more severe end of the disease spectrum.

Although this aspect of the study confirmed that participants were in fact applying the skills learnt during the course in their work, it gives no indication of the quality of their use of the therapy. The next phase of the development of the CBT training programme will be the inclusion of an intensive supervision component whereby the facilitator will observe participants providing CBT to clients.