Before you can be referred clients from Talking Therapies you need to complete one of these forms which constitutes a contract between us.

Please complete the details, and indicate at the bottom that you have understood it’s contents.

Because you are a talking therapies practitioner, we anticipate that you will be keen to use theoretical approaches, perhaps beyond your primary training, working in a genuinely flexible and open way.

Whilst the competences currently favour CBT, as it is most developed in its evidence base, we are populating the Talking Therapies service with the range of practitioners, over a wide geographical area, starting in Brighton, Sussex, Surrey, Kent and London.

We will expect that you are willing to work with the competences relevant to your theoretical approach, and that of other approaches, making yourself conversant with the finer points of these key skills, being sufficiently flexible and open with clients to undertake these more transparent forms of formulation and ‘treatment’.

As a commitment to this approach from you, we will pay for your supervision with an appropriate supervisor who will help with the implementation of your therapy, perhaps in a different theoretical orientation that you are used to, to refine your therapeutic approach. For every 20 sessions you provide for us, we will pay for a supervision session (unless your supervisor is very expensive, when we can change that ratio !), up to a maximum of one session a week.

There is a balance to the approach of the Talking Therapies organisation being overly prescriptive and inflexible, saying that you must do this and only this with this diagnosis, and the liberal view of allowing therapy to wallow in an iterative self-fulfilling directionless state driven by theory alone. We need to offer the clients the very best service, and we ask from you an approach that forms good therapeutic relationships, does not hide behind theory and are willing and able to openly work in the elements of therapy that have been shown to be effective within a transparent formulation.

We hope that you enjoy working with us and will play an open hand with clients, working with clients in a non-pathologising manner, showing your working in the margin, as you are able to explain how your work is the most appropriate approach, based on the best evidence that the psychotherapy community can provide.

Thank you, and I hope that this will be the beginning of a fruitul working relationship between us all as you join the Talking Therapies network.

Jeremy Christey
TT Director

Each session undertaken, practitioners are paid £50.

VAT is not currently charged on sessions, and we will always aim to charge 10% less than equivalent local CBT services.

Of the money paid to Talking Therapies, money goes towards supervision and to run the referral network.

Every 20 sessions paid in to the Talking Therapies account, one supervision session is paid, directly to the supervisor that is either approved of, or provided by, Talking Therapies where these costs are incurred by the practitioner. Up to one supervision a week will be provided by Talking Therapies.

We anticipate that you will be able to undertake at least 10 sessions a month for the TT network, and you are responsible for the usual professional costs, practice insurance, room rental etc.

This and other aspects of this policy may change in the future, and we will prompt you by email to check here when they do.

If they are paying by bank transfer, please indicate this on your return and can you ask them, as their bank reference with their payment, to put their initials and the dates of the sessions which the money pertains to.

Any money cleared into the TT account by the end of the third week of the month, will be paid back to the therapist by the end of the month, directly into your account. We’ll need your bank details, so email them to
j.christey@talking-therapies.com or call him with them.

The Talking therapies account for money transfers in;
Talking Therapies Ltd
Sort code; 60 16 41
Account Number; 83020683

Let us know your account details for transfer of money back out.

Currently we do not charge VAT on our services, but this and other aspects of this money policy may change and we will prompt you to by email to check here when they do.

Monies for all sessions for clients referred to you through the Talking Therapies network need to be paid into our account account, (including follow up sessions at a later date) and Talking Therapies will pay you the relevant amount back.

Any deviation from this will result in instant dismissal from the Talking Therapies network, and losses to Talking Therapies will be pursued.

Can you return it by the third week of the the following calendar month, having entered information about the previous month.

It also has some other information about important you as a practitioner, which is a standing item on the form.

Talking-Therapies-practitioner-monthly-return

This will either appear in your downloads box, or on your desktop under the name of Talking Therapies Practitioner Monthly Return. You can use the same blank form to complete each month, but please date them individually for each month. Make a note of relevant data throughout the month to complete the form.

Please return it attaching it to an email, using your talking-therapies email account and send it to
monthlyreturns@talking-therapies.com

They are not a ‘stand-alone’ description of competences, and should be
read as part of the CBT competence framework.

Effective delivery of problem-specific competences depends on their
integration with the knowledge and skills set out in the other domains of
the CBT competence framework.

Panic Control Therapy (PCT)1
Barlow

Source:
Craske M.G. and Barlow D.H. (2007) Mastery of your anxiety and panic (Therapist guide) 4th
edition) Oxford: Oxford University Press

Problem specific competencies

Knowledge
An ability to make use of knowledge of the model underpinning PCT (which
assumes that panic arises from a vicious cycle arising from catastrophic
misattribution of bodily sensations mediated by interoceptive conditioning (a
learned association between internal or external cues and unexpected panics)
and maintained by avoidance behaviours).
An ability to make use of knowledge of the DSM criteria for panic disorder,
and of organic conditions which may produce panic symptoms

Capacity to undertake assessment and derive a case formulation
An ability to conduct an assessment that aims to identify and appraise
presenting problems in the domains of:
- behaviours (e.g. avoidance, or other coping behaviours)
- cognitions (e.g. perception of intensity of the symptoms and perceived
consequences of symptoms)
- somatic reactions (e.g. increased heart rate etc)
An ability to derive a detailed description of each clients idiosyncratic patterns
of behavioural, cognitive and somatic reactions, and which also describes the
social context in which these patterns present
An ability to establish that panic disorder is the primary presentation (i.e. to
identify panic that arises in the context of other anxiety disorders (such as
specific phobia or social phobia), and to exclude the possibility that other
(particularly more serious problems) are more relevant
A capacity to apply the basic treatment model in order to construct an

1
Earlier versions of PCT included progressive muscle relaxation as a component of the
intervention. As current versions of PCT do not include this, relaxation is not described in this
competence list.

individual case formulation
An ability to make use of a ‘graduated funnel’ approach to obtain information
(moving from global to more detailed questions)
An ability to determine functional relationships between a) avoidance
behaviours, cognitions and panic, and b) internal/ external cues and panic.
An ability to assess both the range and the degree of reliance on safety
signals which contribute directly to the maintenance of panic
An ability to instruct clients in the use of structured recording (e.g. Weekly
Record and the Panic Attack Record)

Explaining the rationale for intervention
An ability to help the client understand their own experience of panic by giving
them information regarding the somatic features and psychological responses
which contribute to its maintenance (the vicious cycle of panic and the
relationship between physiological arousal, cognitions and behaviour)
An ability to help clients understand the relevance of this model to themselves
and to the intervention.
An ability to help clients understand the relevance of the three components of
the intervention (breathing skills training, cognitive techniques and exposure
therapy) and the rationale for their use

Intervention

Across all components of the intervention, and ability to work with the client to
agree and regularly to review homework assignments, and to encourage self-
monitoring using appropriate record forms

Cognitive treatment component
An ability to help clients to learn to monitor their cognitions, with a view to
identifying the kinds of predictions, interpretations and self-statements they
make in anxiety-provoking situations.
An ability to help clients to explore alternative explanations for anxiety-
provoking cognitions
An ability to help clients to learn to treat their cognitions as hypotheses rather
than facts, and to detect common information processing errors (such as
overgeneralisation, all or nothing thinking etc)
An ability to help clients learn techniques for decatastrophising cognitions,
especially those relating to the anticipated consequences of feared events
An ability to help clients worrying over specific events to identify which
aspects of the situation they have control over, and which they do not, with
the aim of reducing worry regarding events over which they have no control
An ability to construct behavioural experiments which help clients learn how to
use behavioural experiments to test-out their beliefs regarding anxiety
An ability to help clients learn to use coping self-statements to help them
manage fear and anxiety-provoking situations
An ability to help clients generalise cognitive coping skills to a range of
situations

Breathing skills
An ability to help the client understand the physiological consequences of
overbreathing and the way in which misconstrual of these effects can
contribute to panic
An ability to help the client learn diaphragmatic breathing, with the primary
aim of helping clients to employ this approach during exposure (helping them
to break the panic cycle and hence engage with, and gain a sense of mastery
in, anxiety-provoking situations)
An ability to help the client learn diaphragmatic breathing both in a relaxing
environment and to generalise this skill to more anxiety-provoking situations

Exposure treatment component
An ability to explain the rationale for exposure therapy, in particular its use as
a way of helping clients re-evaluate anticipated consequences and to learn to
tolerate (rather than rigidly to avoid) fear and anxiety cued by both situational
and interoceptive (somatic) stimuli
An ability to introduce the concept of hierarchical exposure and to help clients
to construct a hierarchy of feared situations for both situational and
interoceptive items, and their combination
An ability to work with the client to implement exposure in a manner which
maximises the probability of benefit, in terms of its structure (e.g. number of
situations faced, duration and pacing), as well as helping the client identify
and circumvent any covert avoidance or the use of safety behaviours
An ability to identify, plan and implement interoceptive ,in vitro and in vivo
exposure to help clients learn that some physiological sensations can by
induced behaviourally and / or cognitively
An ability to identify when it would be helpful to involve significant others in
exposure, and to plan and implement this
An ability to help the client follow-up any therapist-directed exposure with self-
directed exposure
An ability to help the client review exposure experiences
An ability to help clients draw upon skills learnt within the cognitive and
relaxation components of the intervention to help them to manage anxiety
when undergoing graded exposure tasks

Termination and relapse prevention
An ability to work with the client to reduce likelihood of relapse (e.g. by helping
them identify the procedures they have learned for self-management, and by
planning options for managing stress)

Metacompetences

An ability to introduce and implement the components of the programme in a
manner which is flexible and which is responsive to the issues the client
raises, but which also ensures that all relevant components are included

Appendix A

Earlier versions of PCT (and hence contributing to evidence for efficacy of this
approach) included a comprehensive package of relaxation training.

Current versions of PCT no longer employ these techniques, though training
in diaphragmatic breathing has been retained. For reference the competences
associated with relaxation in earlier versions were:

Relaxation treatment component
An ability to train clients in the techniques of relaxation (including progressive
relaxation, discrimination training, and cue-controlled relaxation)
An ability to teach clients diaphragmatic breathing

Back to Competences Map

Assessment
An ability to assess the detailed pattern of panic attacks, and to identify whether panic disorder is the main problem, or whether the pattern of panic is better accounted for by another diagnosis
An ability to gain a detailed description of panics, particularly, their frequency and severity, associated somatic sensations, fearful thoughts and safety seeking behaviours.
An ability to maintain a focus on examples of recent and severe panics in order to identify details of relevant negative thoughts, images and somatic reactions
An ability to draw links between specific somatic sensations and specific thoughts
An ability to identify safety seeking behaviours aimed at preventing or minimising catastrophic fears
An ability to identify the situations and activities associated with the occurrence of panics
An ability to identify patterns of avoidance (e.g. situations and activities, active and passive avoidance)
An ability to identify factors which influence the severity of panics (i.e. make them more or less manageable, better or worse)
An ability to appraise the client’s own beliefs about the problem, and the likely implications of these on motivation for treatment
An ability to assess the attitudes/beliefs and responses of significant others to the problem

Formulating an individualised version of the cognitive model
An ability to conclude the assessment phase by working with the client to construct an individualised version of the cognitive model, which shows how their particular thoughts, sensations and behaviours contribute to the vicious circle of panic

Intervention

Establishing the session structure
An ability to use appropriate monitoring procedures, including questionnaires, panic diaries and in-session ratings of beliefs
An ability to negotiate an initial focus on catastrophic misinterpretations (rather than on controlling feared sensations)
An ability to interweave discussion techniques and behavioural experiments in response to client need and client progress

Using a range of techniques help clients identify panic-related negative automatic thoughts and images

Discussion techniques
An ability to discuss the observations that the client uses as evidence for their panic-related beliefs.
An ability to engage in psychoeducation focused on the specific beliefs the client holds regarding somatic sensations occurring before and during panics, tailoring this education to the specific concerns of the client
An ability to help the client identify any examples where panic intensity has been moderated by events that contradict their beliefs, and to help them recognise the significance of these
An ability to help clients modify images representing feared outcomes using image restructuring (through agreement regarding how realistic the image is, eliciting and reworking imagery in a graduated manner, and encouraging homework practice)

Behavioural experiments
An ability to devise and to conduct behavioural experiments aimed at modifying catastrophic misinterpretation of introceptive cues, ensuring that experiments are relevant to the client, and that the outcomes from experiments are used to help the client see how these challenge their beliefs.
An ability to carry out a ‘paired associates’ behavioural experiment in order to help the client discover the operation of the vicious cycle of panic
An ability to conduct a behavioural experiment utilising hyperventilation in order to help the client discover operation of the vicious cycle of panic
An ability to conduct behavioural experiments involving redirected of attention from an internal to an external focus in order to help the client discover the operation of the vicious cycle of panic
An ability to conduct a “chest pain” behavioural experiment in order to help the client discover the operation of the vicious cycle of panic
An ability to use behavioural experiments to in order to help the client discover that some safety seeking behaviours induce panic related sensations
An ability to prepare clients for behavioural experiments in which the client is asked to evoke feared sensations without attempts to prevent anticipated catastrophes, and to ensure that these are introduced only when the client is ready to undertake them

Adapting behavioural experiments to manage avoidance behaviour
A capacity to encourage clients to expose themselves to feared situations or activities, in particular focussing on the ways in which this enables the client to test specific beliefs
An ability for the therapist to model (role play) the social consequences of panic attacks which the client fears (such as fainting) with the aim of helping them discover that reactions to these events are less extreme than predicted

Relapse prevention
An ability to plan for relapse prevention by encouraging the client to anticipate strategies for the management of potential setbacks
An ability (towards the end of therapy) to review whether any remaining panic-related beliefs are considered credible, and to work on these residual beliefs prior to termination

Source:
Clark, D.M. and Salkovskis P.M. (in press) Panic Disorder in Hawton, K., Salkovskis, P.M.,
Kirk, J. & Clark, D.M. (Eds). Cognitive Behaviour Therapy: A Practical Guide (2nd Edition).
Oxford: Oxford University Press.

Problem specific competencies

Knowledge
Knowledge of the cognitive model of social phobia, including a clear understanding of the maintaining factors specified in the model (self-focused attention, processing of the self as a social object and safety behaviours).

Establishing a working relationship
A capacity to recognise the problems associated with social phobia that could adversely influence or inhibit the development of a therapeutic relationship
A capacity to adapt therapeutic style to manage client’s interpersonal difficulties and excessive self-consciousness (e.g. using strategies such as reducing eye gaze, modulating social distance etc)

Assessment
An ability to clarify the primacy of social phobia to other co-existing problems or psychological disorders, and to determine appropriate intervention plans in relation to comorbidity.
An ability to identify details of the client’s current social network
An ability to identify current psychotropic medication and recreational drug use and its impact on the social phobia
An ability to administer and review standardised questionnaires relating to social anxiety
An ability to integrate information from these questionnaires into the assessment interview, where appropriate using responses to guide questioning
An ability to gain detailed information about the social situations in which anxiety is manifested, or which are avoided because of fear
An ability to identify patients’ specific negative automatic thoughts and fearful predictions about social interactions
An ability to identify the anxiety symptoms triggered by negative automatic thoughts
An ability to identify the specific ways in which increase self-focussed attention and self-monitoring are manifested in anxiety-provoking situations
An ability to elicit the images or impressions that form client’s self-image in social situations (i.e. how they think they appear to others)
An ability to identify socially traumatic early experiences associated with the initial development of the client’s negative self-image/impression.
An ability to identify the safety behaviours that arise in the context of negative automatic thoughts
An ability to identify the anticipatory negative thoughts and images which the client experiences prior to a social situation
An ability to identify ‘post-mortem’ negative thoughts and images which the client uses to review/appraise social experiences
An ability to identify any problematic social beliefs held by clients (such as excessively high standards, conditional beliefs and unconditional beliefs)
An ability to assess beliefs about what can be changed

Case formulation
An ability to construct an individualised cognitive model of social phobia (which links the main negative automatic thoughts, safety behaviours, anxiety symptoms and the contents of self-focussed attention (self-consciousness)
An ability to use an individualised cognitive model of social phobia to guide treatment, working with the client to build the model collaboratively

Intervention

Socialisation to the model
An ability to help the client understand the relevance of the cognitive model of social phobia to their difficulties using guided discovery rather than a didactic approach
An ability to clarify and agree with the client specific and realistic goals for the intervention

Manipulation of self-focused attention and safety behaviours
An ability to set up an experiental exercise in which clients vary their self- focused attention and safety behaviours (by role-playing a feared interaction, in one condition focusing attention on themselves and employing safety behaviours, in the other dropping safety behaviours and focusing on the other person)
An ability to use the experiential exercise to help clients become aware of the way in which self-focussed attention and safety behaviours increase (rather than decrease) their social anxiety (by increasing their negative views of their performance and interfering with the social interaction).

Helping clients to use feedback
An ability to make use of feedback to help clients obtain realistic information about how they appear in social situations, using feedback based on video, audio and still photographs, and eliciting and skilfully using feedback from other people in the interaction
An ability to help clients prepare for watching/listening to tapes by using cognitive preparation (such as describing and operationalising how they think they will appear prior to viewing tapes, and using this to contrast to actual behaviour)
When clients remain concerned about their social performance after reviewing tapes, an ability a) to engage in discussion of these concerns, and b) to identify instances where engaging in safety behaviours produces the behaviours which the client is concerned about.

Attention training
An ability to explain the rationale for training clients in non-evaluative, externally-focussed attention.
An ability to help clients develop the skill of being externally focussed in a non-evaluative manner in social situations, using a systematic programme of exercises that develop this skill in non-social and social situations.
An ability to set and review attention training homework.

Behavioural experiments
An ability to work with clients to develop behavioural experiments that can test their negative beliefs about how they appear to other people, as well as their beliefs about what will happen if they confront feared and avoided social events and tasks.
An ability to work with clients to devise behavioural experiments across a range of contexts (in-office tasks, out of the office but therapist accompanied tasks and homework tasks)
An ability to devise behavioural experiments which can correct overestimates of both the probability and the cost of feared outcomes
An ability to help patients to obtain the maximum amount of corrective information during behavioural experiments by dropping their safety behaviours and configuring their attention appropriately
An ability to structure behavioural experiments using a record sheet which identifies client’s predictions about the social event, the ‘experiment’ used to test this prediction, the actual outcome and the learning which ensues.
Where clients have rigid rules about acceptable and unacceptable social behaviours an ability to construct behavioural experiments aimed at testing out the realism of these rules and increasing social flexibility
An ability to conduct and use surveys of other people’s views to help clients change their negative beliefs.
An ability to use discussion and behavioural experiments (including positive data logs) to challenge the client’s unconditional assumptions their social self (e.g. “I am unlikeable).

Managing anticipatory and post-event processing
An ability to help clients identify the ways in which they think and behave before social events
An ability to help the client weigh the pros and particularly the cons of anticipatory thoughts and behaviours
An ability to help the client to stop employing anticipatory thoughts and behaviours using behavioural experiments to test their (lack of) utility
An ability to help clients desist from using “post-mortem” analysis

Managing assumptions and negative automatic thoughts
An ability to help clients reappraise excessively high or rigid standards of social behaviour using behavioural experiments designed to test the realism of these standards
For clients who hold particularly strong negative self-beliefs, the ability to help clients operationalise and appraise these beliefs
For clients who are prone to discount information which contradicts negative self beliefs, an ability to facilitate client’s use of a positive data log
An ability to work collaboratively to challenge negative automatic thoughts by examining their validity, reframing in more realistic terms and considering strategies for managing realistic appraisals
An ability to help the client use discrete positive self statements (which they themselves have generated) to counter negative automatic thoughts or ‘self-processing’

Rescripting early memories linked to current, intrusive and negative self-images.
An ability to help client’s to identify links between memories of early socially traumatic events and their current negative, intrusive self-images in social situations
An ability to identify an “encapsulated belief” that summarizes the meaning of both the early memory and the intrusive self-image
An ability to use cognitive restructuring to help the client to reappraise the encapsulated belief and develop an alternative more realist perspective
An ability to incorporate the new perspective into the social trauma memory through a three stage imagery rescripting procedure, using changes in affect as the index of success

Metacompetencies

An ability to introduce and implement the components of the programme in a manner which is flexible and which is responsive to the issues the client raises, but which also ensures that all relevant components are included

Clark, D.M. (2005) A cognitive Perspective on Social Phobia in W. Ray Crozicr W.R.and
Alden, L.L .The Essential Handbook of Social Anxiety for Clinicians Chichester: John Wiley &
Sons Ltd.
Wells, A. (1997). Cognitive therapy of anxiety disorders: A practice manual and conceptual
guide. Chichester, United Kingdom: Wiley.
Clark D.M. (2009?) Cognitive therapy for social phobia

Engagement and assessment

Establishing a working relationship
A capacity to recognise the problems associated with social anxiety that could adversely influence or inhibit the development of a therapeutic relationship
A capacity to adapt therapeutic style to manage client’s interpersonal difficulties and excessive self-consciousness (e.g. using strategies such as reducing eye gaze, modulating social distance etc)

Assessment of social anxiety
An ability to conduct a thorough assessment of the client’s difficulties, combining information from interview and relevant instruments in order to confirm a diagnosis of social anxiety
An ability to clarify the primacy of social phobia to other co-existing problems or psychological disorders, and to determine appropriate intervention plans in relation to comorbidity.
An ability to use measures to aid evaluation of the full clinical picture and to gain a pre-treatment baseline
Awareness of the potential impact of shame and anxiety on information given in the initial assessment, and an ability to supplement information from the interview with measures
An ability to devise and carry out a pre-treatment behaviour test as part of the assessment

Intervention

General considerations
An ability to be comfortable with, and to manage, manifestations of high levels of anxiety (including anger in response to perceived threat)
An ability to identify when clients are struggling with aspects of the intervention, to address the problem and if appropriate to adapt the intervention appropriately to meet the client’s needs
An ability to integrate the main elements of the intervention (exposure and cognitive restructuring), and to implement treatment in a manner which is structured but responsive to the needs of the individual client

Psychoeducation
An ability to help the client conceptualise their own social anxiety in the context of the CBT model (the primacy of cognition, negative consequences of avoidance and habituation)
An ability to provide an overview of the treatment model, particularly its emphasis on the active role of the client in applying their coping skills through homework tasks
An ability to help the client conceptualise their difficulties in the context of the treatment model, but also to acknowledge ways in which the client’s perspective differs from this model
An ability to present a biopsychosocial model of aetiology which acknowledges the role of genetics and early experience, but which emphasises the role of information processing biases in generating social anxiety and avoidance
An ability to link the model to the major components of treatment (exposure, cognitive restructuring and homework tasks)
An ability to assess the client’s perception of the credibility of therapy, and to discuss these if there is an indication that the clients’ perceptions are likely to impact on engagement (e.g. if the therapy is viewed sceptically or over-enthusiastically)

Establishing a hierarchy of feared situations
An ability to help the client construct a hierarchy of feared and avoided social situations by working with the client to: “brainstorm” a list of feared and avoided social situations in order to ensure that all potentially relevant situations are included identify a shortlist of approximately 10 situations that are representative of the client’s current difficulties, and which range from mildly to more severely anxiety provoking rank order the situations identify the dimensions that make the situations easier or harder to manage (e.g. characteristics of other persons present, or the nature of the situation) rate the degree of fear and avoidance for each situation using SUDS (Subjective Units of Discomfort Scale)

Self-monitoring
An ability to help clients begin self-monitoring of their social anxiety and mood, using in-session practice to check that the client understands the procedure, that they understand the rationale for monitoring, and to identify and ‘troubleshoot’ any potential barriers to monitoring
An ability consistently to review the self-monitoring across and within all sessions
Where the client has difficulty in self-monitoring, an ability to help them identify and resolve any issues which make self-monitoring problematic

Cognitive Restructuring
An ability to explain the concept of automatic thoughts and to offer appropriate illustrative examples, with the aim of helping the client identify that it is not the event itself which creates anxiety, but their interpretation of that event
An ability to discuss the concept of cognitive restructuring with the client, with the aim of helping the client to understand this as an opportunity to appraise the validity of their thoughts, rather than to see these thoughts as ‘wrong’
An ability to help clients identify and self-monitor automatic thoughts, and to make links between these and the emotions, behavioural and physiological reactions they give rise to
An ability to help clients who find it difficult to access automatic thoughts, using strategies such as review of specific situations, or helping them to translate of images of situations into verbal statements
An ability to help clients challenge automatic thoughts by: explaining the concept of information processing biases and offering illustrative examples helping the client to consider these biases in relation to their own automatic thoughts making systematic use of “Disputing Questions (e.g. what evidence do I have that…, do I know for certain that … etc) to appraise the validity of their automatic thoughts generating phrases or statements that summarise the most important points made when challenging specific automatic thoughts (‘rational responses’)

Exposure
An ability to conduct an initial in-session exposure by working with the client to: choose an appropriate situation, fixing an appropriate duration for the exposure and ensuring that the exposure is carried out identify and agree achievable behaviour goals for the role play identify automatic thoughts and using cognitive restructuring make ratings of SUDS during and after the exposure
An ability to debrief after exposure, ensuring that the client’s perceptions are thoroughly explored
An ability to provide feedback on the exposure task in a constructive manner which is both accurate and honest, and which focuses on contrasting the client’s actual performance with their prior beliefs
An ability to help the client summarise what they have learnt from the exposure that can be applied to future situations
An ability to plan appropriate in-session exposures
An ability (where appropriate) to make use of external role players (which will
involve briefing the client and giving guidance to role-players regarding their feedback to the client)
With clients who refuse or avoid exposure, an ability to explore their concerns and to develop a plan for proceeding which accommodates these
Where clients react catastrophically to a completed exposure exercise, an ability to help them appraise their perceptions of the experience
An ability to agree and to assign self-exposure homework which explicitly includes the three elements of exposure, self- monitoring and cognitive restructuring
An ability to work with the client to design effective exposure tasks for specific manifestations of social anxiety (e.g. signing name in public, eating or drinking in public, fear of using public toilets), incorporating the feared outcome where a loss of control or fear of humiliation is a significant part of the anxiety
An ability to help the client focus on automatic thoughts prior to exposure in a graduated manner (usually starting with situationally-based performance-related thoughts, at later stages considering thoughts related to negative self-evaluation)
An ability to review homework tasks, and to explore and resolve any difficulties the client has in completing these tasks

Addressing core beliefs
An ability, usually at later stages of therapy, to identify core beliefs and to
discuss with the client the ways in which these beliefs may generate and/or maintain their social anxiety
An ability to help the client ‘unpack’ the meaning of emotionally loaded words (such as ‘perfect’ ‘right’ ‘best’) in order to identify core beliefs
An ability to challenge core beliefs using cognitive restructuring and exposure

Ending therapy and planning for relapse prevention
An ability to assess overall progress, and to make decisions about further treatment based on measures and client self-monitoring forms
An ability explicitly to discuss the issue of relapse, and to help clients consider how they can employ the skills they have learned after treatment ends
An ability to acknowledge client’s feelings about losing therapist contact

Sources:
Hope, D.A , Heimberg, R.G, & Turk, Cynthia, L. (2006) Managing social anxiety: A cognitive-
behavioural approach. Oxford: OUP
Hemiberg R.G. and Becker, R.E. (2002 ) Cognitive-behavioral group therapy for social phobia
New York: Guilford Press

Assessment
An ability to determine the precise nature of the phobia (in terms of specific symptoms, severity and its impact on daily living)
An ability to help the client identify the specific thoughts, feelings and behaviours associated with the phobia (including an ability to help the client
identify these by exposure to feared situations, either behaviourally or in imagination)
An ability to identify patterns of avoidance and/or safety behaviours associated with the phobia
An ability to identify both adaptive and maladaptive coping skills employed by the client to manage their phobia
An ability to work with the client to develop a list of phobic objects and situations and to develop a graded hierarchy which can be used to guide exposure

An ability to identify the presence of other anxiety disorders and to evaluate
whether they or the specific phobia represent the primary problem for intervention
An ability to assess the significance of coexisting problems which may make treatment less easy or more protracted (such as severe depression, substance misuse or severe personality disorder)

Explaining the rationale for intervention
An ability to help the client understand the nature of their phobic reaction(s)
An ability to convey to the client the rationale for a cognitive behavioural intervention, with its focus on behavioural and cognitive factors which maintain the phobic reaction
An ability to help the client define realistic goals for treatment

An ability to help the client to complete relevant self-monitoring records for
use throughout the intervention

Intervention

An ability to help the client use self-monitoring to foster the development of a more objective sense of their reactions to phobic situations, and hence foster a greater sense of mastery and control

Cognitive restructuring
An ability to help the client understand the role of cognitions in maintaining
phobias (e.g. misperception of risk associated with phobic situations, or misinterpretation of interoceptive cues related to overbreathing)
An ability to help the client understanding how fear of their physical reactions to phobic situations may contribute to maintenance (‘fear of fear’)
An ability to help the client identify thoughts and assumptions which are associated with anxiety, and to use guided discovery to generate alternative cognitions
An ability to help the client generate behavioural experiments (usually as part of the exposure component) to test the validity of cognitions and assumptions

Exposure component
An ability to convey the rationale for exposure – both to explain the behavioural model of phobic anxiety (using examples to explain how avoidance can maintain symptoms), and to convey the sense that exposure is an opportunity to test the validity of relevant cognitions and assumptions
An ability to work with the client to draw up a graduated list (or lists) of practice and homework tasks
An ability to work with the client to ensure that exposure is graduated, repeated and prolonged, and to identify any problems in the application of exposure
An ability to implement imaginal exposure where practical problems make it hard to implement in-vivo exposure
An ability to implement interoceptive exposure for clients who are fearful of bodily sensations in the phobic situation
An ability to help the client identify and circumvent any covert avoidance or the use of safety behaviours
An ability to help clients with blood and injury phobia learn applied tension techniques
An ability to help the client identify pertinent homework tasks (usually in-vivo exposure), to review progress and to plan further homework
An ability to make use of role playing and rehearsal
An ability to model non-phobic behaviour (e.g. approaching the phobic object)

Maintenance of gains
An ability to discuss strategies for the maintenance of gains and for managing setbacks and relapse

An ability to use clinical judgment in order to balance adherence to a model against the need to attend to any relational issues which present themselves

An ability to maintain adherence to a therapy without inappropriate switching between modalities in response to minor difficulties (i.e. difficulties which can be readily accommodated by the model being applied)

An ability to terminate therapy in a manner which is planned, and to signal plans for termination at appropriate points throughout therapy

An ability to plan for maintenance of therapy gains after the end of treatment:

An ability to help clients identify and elaborate their concerns about termination (e.g. worry that that they need support to manage on their own, or that they will relapse)

An ability to help clients who have recovered identify problematic events which have led them to become depressed or anxious in the past

An ability explicitly to plan ways in which relevant coping strategies could be implemented to manage these events if they recurred in the future

An ability to explain the rationale for problem-solving to the client

An ability to help the client to select problems, usually on the basis that problems are relevant for the client and are ones for which achievable goals can be set

An ability to help the client specify the problem(s), and to break down larger problems into smaller (more manageable) parts

An ability to identify achievable goals with the client, bearing in mind the client’s resources and likely obstacles

An ability to help the client generate (“brainstorm”) possible solutions

An ability to help the client select a preferred solution

An ability to help the client plan and implement preferred solutions

An ability to help the client evaluate the outcome of implementation, whether positive or negative

An ability to help clients test beliefs/assumptions which impede problem solving

An ability to work with the client in order to develop hypotheses about how their thoughts, physical symptoms, behaviours and emotions inter-relate and feedback on themselves in a way which maintains the client’s problems

An ability explicitly to discuss initial hypotheses about the maintenance cycle with the client, checking that the client understands the concept of the cycle and sees its potential relevance to their problems

An ability to work with the client to develop and (if relevant) modify hypotheses, and to arrive at a jointly-shared conceptualisation of the maintenance cycle.

An ability to use the maintenance cycle to identify appropriate targets for intervention

Knowledge of measures

An ability to draw on knowledge of commonly used questionnaires and rating scales, and to select measures relevant to the client’s presentation

Ability to interpret measures

An ability to draw on knowledge regarding the interpretation of measures (e.g. basic principles of test construction, norms and clinical cut-offs, reliability, validity, factors which could influence (and potentially invalidate) test results)

An ability to be aware of the ways in which the reactivity of measures and self-monitoring procedures can bias client report

Knowledge of self-monitoring

An ability to draw on knowledge of self-monitoring forms developed for use in specific interventions (as published in articles, textbooks and manuals)

Knowledge of the advantages of using self-monitoring (to gain a more accurate concurrent description of behaviours (rather than relying on recall), to help adapt the intervention in relation to client progress, and to provide the client with feedback about their progress)

Knowledge of the role of self-monitoring in CBT (a means of helping the client to become an active, collaborative participant in their own therapy by identifying and appraising how they react to events (in terms of their own physiological reactions, behaviours, feelings and cognitions))

An ability to draw on knowledge of measurement to ensure that procedures for self-monitoring are relevant (i.e. related to the question being asked), valid (measuring what is intended to be measured) and reliable (i.e. reasonably consistent with how things actually are)

Ability to integrate measures into the intervention

An ability to use and to interpret relevant measures at appropriate points throughout the intervention, with the aim of establishing both a baseline and indications of progress

An ability to share information gleaned from measures with the client, with the aim of giving them feedback about progress

An ability to establish an appropriate schedule for the administration of measures, avoiding over-testing, but also aiming to collect data at more than one timepoint

Ability to help clients use self-monitoring procedures

An ability to construct individualised self-monitoring forms, or to adapt ‘standard’ self-monitoring forms, in order to ensure that monitoring is relevant to the client

An ability to work with the client to ensure that measures of the targeted problem are meaningful to the client (i.e. are chosen to reflect the client’s perceptions of the problem or issue)

An ability to ensure that self-monitoring includes targets which are clearly defined and detailed, in order that they can be monitored/recorded reliably

An ability to ensure that the client understands how to use self-monitoring forms (usually by going through a worked example during the session)

Ability to integrate self-monitoring into the intervention

An ability to ensure that self-monitoring is integrated into the therapy, both in the session and as part of practice assignments (or “homework”), ensuring that the agenda for the session includes regular and consistent review of self-monitoring forms

An ability to guide and to adapt the therapy in the light of information from self-monitoring

Reviewing practice assignments
An ability to ensure that homework that the client has undertaken is carefully
discussed and reviewed with them in the next session, with the aim of helping
them identify what they have learned from their experiences
An ability to help clients appraise the outcomes of homework:
when outcomes are in line with the prior expectations of the therapist
and client
when there is a different outcome from that which has been predicted
An ability to integrate learning from homework into the session, and to build
on this learning in identifying further homework assignments

Pacing and efficient use of time
An ability to ‘time manage’ the session in relation to the agenda
An ability to pace the session in relation to the client’s needs and learning
speed

Key Skills:

Share responsibility for session structure & content
Agree and adhere to an agreed agenda
Plan and review “practice assignments” (or “homework”)
Use summaries and feedback to structure the session

An ability to be explicit about expectations regarding the sharing of responsibility for the sessions

An ability to be appropriately structured (especially in the initial stages of the intervention), but also to avoid becoming inappropriately didactic

An ability to invite shared responsibility by explicitly asking the client to take more responsibility for the agenda, or to provide their own capsule summaries

An ability to identify and discuss difficulties clients have regarding sharing responsibility (especially when these directly reflect aspects of the client’s problems), and to work with these in a manner which is congruent with the CBT model

An ability for the therapist to reflect on their practice in order to detect when their actions may make it harder for the client to share or to take responsibility (e.g. by being too didactic, by over-structuring sessions, or by taking decisions for the client)

An ability to structure the therapy session by regularly giving feedback to the client, and by eliciting regular feedback from the client

An ability to elicit and respond both to verbal and non-verbal feedback from the client throughout the session (i.e. to take into account explicit statements made by the client, their in-session emotional reactions, and the therapy process as a whole)

An ability to give verbal feedback to the client throughout the session, by offering ‘capsule’ summaries and by ‘chunking’ important (salient) information and/or topics

An ability to invite summaries from the client (to check that the therapist understands the client’s problems and that the client understands what the therapist is saying)

An ability to offer summaries at the start of sessions (e.g. a review of prior sessions) and at the end of the session (covering the main points of the session)

An ability to help the client generate their own goals for the intervention, and to reach a shared agreement about these, by helping them:

…Translate vague/abstract goals into concrete goals
…Identify goals which will be subjectively and objectively observable and potentially measurable (i.e. to ensure that if change takes place it will be noticeable to the client and to others)
…Work with the client to ensure that goals reflect the issues/problems with which they present
…Work with the client to ensure that goals are realistic and achievable

A good therapeutic relationship is the foundation of CBT, as it is in other therapies, although this can be less emphasised in CBT.

Key skills;
An ability to explain the rationale for a focus on behaviours and cognitions, including the association between the cognitive triad (the link between how the person thinks about themselves, their environment and their future) and feelings, motivation and behaviour

An ability to explain the rationale for a focus on behaviours (e.g. because in vivo experience is more powerful and immediate than discussion, because the experience itself can provide immediate feedback regarding the client’s expectations and assumptions, and because the experience can help the
client become more aware of their perceptions and assumptions (because it taps into experiential/emotional processing)

An ability to present the cognitive model in terms of a focus on information processing that leads to unhelpful conclusions

An ability to ensure that the cognitive model is described in a way which implies that client is thinking unhelpfully rather than ‘irrationally’

Demonstrating the rationale
An ability to help the client see the potential relevance of the CBT model to their own difficulties (e.g. by working in a collaborative (rather than a didactic manner) to demonstrate the potential utility of the model by applying it to a specific example of the problems that the client has identified)

Knowledge of the role of safety-seeking behaviours:

The ways in which safety-seeking behaviours give the client a sense of coping in the short term

The ways in which safety-seeking behaviours reduce the opportunity for learning different and potentially more adaptive ways of coping with problems (e.g. because they prevent clients from learning that their worst fears won’t happen)

The importance of aiming to help the client desist from safety-seeking behaviours by the end of treatment the potential role of “residual” safety-seeking behaviours in relapse

An ability to draw on knowledge of safety-seeking behaviours in order to identify both overt and covert safety behaviours, and hence their impact in the development and maintenance of the client’s problems

http://www.youtube.com/watch?v=jnf8To59EZg

• All or nothing thinking – viewing a situation in only two categories rather than on a continuum (e.g. oversimplifying events or beliefs as good/ bad or as right/wrong)
• Catastrophising – predicting the future negatively without considering alternative outcomes
• Disqualifying or discounting the positive – telling yourself that positive experiences/ qualities do not count
• Emotional reasoning – reasoning from how you feel rather than from any evidence
• Labelling – putting a fixed, global label on self or others without considering evidence that would lead to a less disastrous conclusion
• Magnification/ minimisation – exaggerating the negative and minimising the positive (blowing things out of proportion or shrinking their importance)
• Selective abstraction – paying undue attention to negative detail rather than seeing the whole picture
• ‘Mind-reading’ – making (negative) assumptions about the way in which others think about you when there is no evidence for this
• Overgeneralisation – drawing a sweeping conclusions from a single incident and applying it to related and to unrelated situations
• Personalisation – relating external events to yourself when there is no basis for making such a connection
• Making ‘should’ and ‘must’ statements (“imperatives”) – having an over- precise idea of how you and others should behave, and overestimating the consequences of how bad it would be not to meet these expectations
• Tunnel-vision – only seeing the negative aspects of a situation

Knowledge of the role of processing biases in the development and maintenance of problems.

Source: Beck, J. (1995) Cognitive therapy: Basics and beyond New York: Guilford press

An ability to introduce the concept of hierarchical exposure and to help clients to construct a hierarchy of feared situations for both situational and interoceptive items, and their combination.

An ability to work with the client to implement exposure in a manner which maximises the probability of benefit, in terms of its structure (e.g. number of situations faced, duration and pacing), as well as helping the client identify and circumvent any covert avoidance or the use of safety behaviours.

An ability to identify, plan and implement interoceptive ,in vitro and in vivo exposure to help clients learn that some physiological sensations can be induced behaviourally and / or cognitively.

An ability to identify when it would be helpful to involve significant others in exposure, and to plan and implement this.

An ability to help the client follow-up any therapist-directed exposure with self-directed exposure.

An ability to help the client review exposure experiences.

An ability to help clients draw upon skills learnt within the cognitive and relaxation components of the intervention to help them to manage anxiety when undergoing graded exposure tasks.

Knowledge of the cognitive component in CBT – the way people think and create meaning about events in their lives, and how this links to the ways in which they develop beliefs about themselves, others and the world in which they live.

An ability to draw on knowledge of the basic principles that underpin the rationale for CBT:

• the inter-relationship between thoughts and images, feelings and behaviours
• the aim of helping clients to become more aware of the how they reason and ascribe meaning, to develop alternative viewpoints and explanations for their difficulties and to use behavioural experiments to test-out the accuracy of these alternatives
• the aim of helping the person feel safe in order to test out their assumptions and fears and to change their behaviour

An ability to draw on knowledge of the importance of working collaboratively with the client:

• a consistent philosophical and practical commitment to the notion that the client and the therapist work together to do the work
• awareness that the aim of therapy is to help clients tackle their problems by harnessing their own resources

An ability to draw on knowledge and awareness of the importance of the client putting what has been learned into practice between sessions (practice assignments, or “homework”)

An ability to draw on knowledge of the factors associated with the development and maintenance of mental health problems.

An ability to draw on knowledge of the usual pattern of symptoms associated with mental health problems.

An ability to draw on knowledge of the ways in which mental health problems can impact on functioning (e.g. maintaining intimate, family and social relationships, or the capacity to maintain employment and study).

An ability to draw on knowledge of the impact of impairments in functioning on mental health.

An ability to draw on knowledge of mental health problems to avoid escalating or compounding the client’s condition when their behaviour leads to interpersonal difficulties which are directly attributable to their mental health problem.