Introduction on my performance in the simulated competency assessment



The purpose of
this account is to reflect on my performance in the simulated competency assessment
with a mock patient using the video recording that has been provided. Reflection
can be defined as the act of examining and evaluating one’s own thoughts,
feelings and actions through introspection and observation. Reflection or
reflective practice in a healthcare setting is essential to the development of
a clinical practitioner. It is a way of scrutinizing your own experiences against
theoretic principles to help facilitate continuous learning and ultimately lead
to a higher standard of care being delivered to patients. Methods for
reflection in CBT can include reflective writing (Bolton 2001).

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Schon (1983) advocated
2 sorts of reflective practice; reflection-in-action and reflection-on-action.
Reflection-in-action is to reflect on actions as you are doing them. For
example during the simulation I would have used my knowledge of the key PWP
skills to guide my decision-making process. Reflection-on-action on the other
hand involves reflecting retrospectively on the actions you have already taken.
This evidently is the approach utilized in this account.


The model I will
employ to aid in structuring my reflection will be Gibbs’ reflective cycle
(GIbbs 1988). The stages of this cycle begins with describing what happened
during the experience including my own feelings and thoughts, then evaluating
what went well and what didn’t, followed by analyzing what sense can be made of
the experience as well as what could be done differently and finally generating
an action plan of what I would do differently to improve for next time including
what steps I would need to take to achieve this. It is important that I try to
refer to LI CBT literature as a rationale for my actions where appropriate and
incorporate competing evidence for good practice. In terms of action planning I
should try and consider how my actions might affect a wider historical, social
and political context. I will organize this account by reflecting on all six
aspects of the Assessment Competency Scale separately by using headings.


Introduction to
Assessment Session


I began the
introduction segment by introducing my self by name. I then clarified my role
as a tPWP, elicited the patient’s full name and DOB and checked if she had a
preferred name. Following that I outlined the purpose of the assessment, set
the agenda including the methods used, defined the time scale of forty-five
minutes and explained my service confidentiality policy. I was conscious of time
during this section and wanted to complete it as quickly as possible due to it
being a timed assessment to simulate typical service targets. This real world constraint
highlights the importance of pacing and efficient use of time in a therapy
session (Young & Beck 1980 & 1988) (Blackburn et al 2001). On the other
hand I wanted to remain clear in my explanations, seeing as a clear introduction
has been identified as one of the key factors in establishing a good
therapeutic relationship (Richards and Whyte 2011), which is crucial for
successful outcome (Myles and Rushforth, 2007). I believe I made good use of time and I managed to cover all aspects
of the competency scale in less than two minutes. However, it did appear rushed
in parts particularly when explaining the limits of confidentiality and although
I asked the patient if she was happy to continue with the assessment on the
basis of our service policy, I did not ask her understanding of it. Papworth et
al (2013) noted that it is vital the client is fully aware of the limits of
confidentiality before they start to recount their problem as patients can
sometimes attend with the assumption that what they say will not be revealed to
anyone under any circumstances. I think if I had asked her to verbalize her
understanding of confidentiality this would have emphasized to the patient the importance
of its limits and should help to prevent any misunderstanding in future that
could damage the therapeutic alliance. It would also mean the patient is making
a fully informed decision on whether to continue with the session. I will try
this approach at future assessments. I will also ensure that during my next
observation of a qualified colleague, I make note of how they explain confidentiality
in the context of a time-limited assessment and ask their advice on best
practice based on their knowledge and experience. This should help increase my
confidence as a practitioner and find a better balance between efficient use of
time and a clear and detailed introduction.


Establishing and
Maintaining Engagement


As referenced above, the therapeutic relationship has
been shown to be critical in determining good outcomes for patients. It has
been said that common factors play a key role in the therapeutic relationship
and the more a practitioner invests in common factors skills the better
their therapeutic relationship will be with patients (Cahill et al 2008). They can account for a significant amount of client
improvement (Lambert & Barley, 2002) with some suggesting as much as 30% of
the outcome (Lambert 1992). Examples of common
factors include a clear introduction, the establishment of relevant
expertise, displaying a positive non-judgmental attitude and demonstrating verbal
& non-verbal competencies (Richards and Whyte 2011).

Rosenzweig (1936)
first proposed the concept of common factors. He observed that all forms of psychotherapy
could point to notable successes. He concluded that these successes could be
explained by implicit common factors that exist across the seemingly diverse
approaches, which are perhaps more important than the specific factors. To the
contrary, specific factors are defined as being unique to the particular
therapy (Katzow & Safran 2007) e.g. problem statement or 5 areas conceptualization in CBT,
and there is some evidence that they have a greater effect compared to common
factors on treatment outcomes (Blow et al 2007).

In terms of establishing and maintaining engagement,
the common factors skills specified in the assessment competency scale were as
follows; maintaining a collaborative approach, the use of complex & simple
reflections as well as capsule & major summaries and having a balanced
ratio of questions to feedback. During the simulation it felt as though I had
to demonstrate these skills at any given opportunity due to the significance
placed on them throughout the training thus far. I believe as a result there is
evidence of all them throughout the assessment. That said, I wonder whether
because of my eagerness I overused certain elements to the detriment of others.
One example being simple reflections over complex, seeing as the former were
much simpler to demonstrate. The reflection of feelings through the use of
complex reflections can help the interviewee uncover blind spots in their perceptions
and assessment of a situation and assists both the interviewer and interviewee
in coming to a shared understanding of what’s going on for that person (Egan
2001). For that reason it would be reasonable to assume there is a benefit to applying
the full range of common factor skills proportionally. In future, I plan to practice
using complex reflections in role-play with fellow trainees and team members with
the aim of becoming more comfortable and fluent in using them. This will help
me to translate them into interviews with real life patients, which should
improve my therapeutic alliance, leading to better outcomes and recovery rates
for my service and me. In spite of that I must be mindful that I do not
prioritize the application and practice of common factors skills over specific
CBT processes, as both have been shown to be vital in determining positive

Interpersonal Skills

Common factors also comprise of Interpersonal skills
such as displaying empathy through verbal communication, normalizing,
maintaining a non-judgmental stance, showing warmth & compassion and
demonstrating good non-verbal skills in communication e.g. eye contact and body

Upon review of the recording I felt I had good
interpersonal skills, particularly in warmth which can be described as “a type
of softness and gentleness that conveys caring concern” (Gilbert 2007) as well
as maintaining a non-judgmental stance which has been identified as a
characteristic of a good listener (Myles & Rushforth 2007). Unfortunately,
in regards to normalization and empathy through verbal communication I felt as
though there were some missed opportunities and I appeared to be repeating the
same statements for each e.g. “It can be quite common for people…” & “that
must be quite difficult…” Carlat (2005) advises that normalization is the most
useful technique for eliciting sensitive or embarrassing material. Likewise it
has been proposed that empathic communication; one of the key elements in
development of therapeutic empathy fulfills a variety of functions within CBT
(Thwaites & Bennett-Levy 2007). This would suggest that to use them inconsistently
and in an inauthentic manner might be disadvantageous. Be that as it may, it is
possible I may be biased in my perception and this might not be congruous with
the patient experience. So, to test this in future I will ask patients whilst
completing their patient experience feedback form whether they felt as though I
understood their situation as a measure of empathy (Papworth et al 2013) and
whether they felt they weren’t alone in their problem as a measure of
normalization. I can use these findings as a metric of competency in delivering
the above skills and reflect on them in clinical case management.


Information Gathering: Problem Focused

I began my information gathering by asking about the
four W’s (Myles & Rushforth 2007) to ascertain the main problem that led to
the patient seeking help. I managed to gather all of this information though
not in sequence seeing as the initial feedback responses contained detail around
the events or situations that provoked the onset of the main problem. I could
have perhaps been more rigid in the delivery of my script/ template but I am
aware of the need to be flexible in adapting to the needs of the patient and
sharing the power and responsibility (Mead & Bower 2002). The onset of a
patient’s problem can be referred to as a one of the precipitating factors or
critical incidents, which is sometimes confused with triggers. The difference
being that precipitants happened in the past and typically on one occasion whilst
triggers continue to operate in the present (Westbrook & Kennerley 2011).
Although I asked questions about both of these I could have done a better job
emphasizing the distinction between them e.g. by not using the word ‘trigger’
when asking about past events. The consequence of this could mean confusion about
what was a problem in the past and what is still a problem in the present. This
draws attention to the influence that language and semantics can have on coming
to a shared understanding of something. I will try and be more mindful of this
at future assessments and ask about ways of overcoming this issue at my next
CPD training session seeing as it is a theme that has come up previously.

I then went onto elicit information around the five areas,
which is the fundamental principle of cognitive behavioral therapy (CBT). The
aim of this model is to help illustrate that what we think affects what we feel
emotionally and physically and alters what we do. It also enables us to
identify clear targets for intervention (Williams & Garland 2002). The five
areas comprises of the situation/ environmental factors, thoughts/cognitions,
emotions/mood, biology/ physical symptoms and behavior (Padesky Mooney 1990). I
chose not to explain to the patient why I was asking these questions as I felt
this was best done at the information giving stage. This is because patients
may not be receptive to information whilst recounting their problem.

Other areas that are helpful to ask around include; past
treatment, current medication and attitude to this, alcohol & drug use, and
why they want help now (Richards and Whyte 2011). I had covered all of these by
this stage in the interview. It is worth considering that I gathered this
information prior to asking questions around risk and reflecting on the outcome
measure questionnaires or minimum data set (MDS). Seeing as risk and MDS are a
priority, it might be advisable to enquire about other relevant information
after this has been captured. I will bring this to clinical skills to see how
my more experienced colleagues structure their assessment.

I then integrated the MDS into the assessment
including the PHQ-9 & GAD-7. Whilst delivering this section and in the
interest of being collaborative I informed the patient of the severity rating
e.g. mild, moderate…  represented by her
scores on each. The purpose of this being to check with her whether it was a
fair reflection of how she felt. On review I think this went well. MDS as
stated above, is an essential tool within IAPT services because they help to
inform treatment planning and effectiveness and are reported at a national
level to form part of the services’ key performance indicators. The PHQ-9 has
been shown to be a reliable and valid measure of depression severity Kroenke et
al 2001) and the GAD-7 shown to be a valid and efficient tool in screening for generalized
anxiety disorder (Spitzer et al 2006). Unfortunately, routine use can cause
practitioners to be over-reliant on and excessively influenced by them
(Papworth et al 2013). It can also cause problems in making the wrong treatment
decisions in the presence of co-morbidity seeing as it is more common for
people to have features of both depression and anxiety than just one of them
(Kaufman & Charney 2000). It is crucial that I am aware of this potential
bias when assessing patients and when discussing them in clinical case
management. This will help to minimize any errors in judgment, which should
again lead to better outcomes.

I then introduced the risk assessment immediately
following the outcome measures, using the PHQ-9 Q9 as the prompt. It is recommended
that this follows a format which has been termed as a hierarchal questioning
style (Bryan & Rudd 2006). Hierarchal questioning refers to a gradual
increase in the intensity and sensitivity of the questioning e.g. thoughts
before past behaviors and is likely to increase client engagement and
disclosure within the process (Papworth et al 2013). On review I think I kept
to this format. In addition, I believe I made an effort to draw distinction
between self-harm and suicide at this point. The reason being that self-harm may
have an alternative purpose to suicide e.g. to gain a sense of relief from
psychological and emotional pain or as a means of self-punishment (Kutcher
& Chehil 2007). It is therefore crucial to make this distinction when
conducting a risk assessment to help make an accurate judgment on the severity
of risk. This also highlights the need to assess subjective intent vs.
objective intent (Beck & Lester 1976). Subjective intent is what the patient
states during the interview whereas objective intent is based upon the patient’s
current presentation and past behaviors (Bryan & Rudd 2006). Objective
intent may or may not coincide with their subjective intent so if there is a
discrepancy this should be explored further (Papworth et al 2013). I had not
considered this relationship during the assessment and although there was no
discrepancy on reflection it is something I need to think about in future so
that I can challenge when required.

Information Giving: Suitable to the Problem

The next phase involved providing the patient with
information about their problem based on our shared understanding. I firstly explained
the basics of what is meant by CBT and I then conceptualized her problem into
the five areas. I was pleased to see that I checked the patient’s understanding
of CBT and the 5 areas so as to emphasize the importance of the model and make
sure that I had explained it in a way that could be understood. Succeeding this
we then collaborated in creating a problem statement which aims to summarise key elements of the
assessment providing the patient with a simple and comprehensive account of
their main difficulties which can be used as a reference point throughout
treatment to monitor any changes (Richards and Whyte). I was conscious that
time was running out during this so I felt anxious to get through it quickly which
meant I did not give this as much due care and attention as was needed. We have
already established that it is important to be time efficient so in terms of
learning it might be helpful to have more of a guide as to how long I am
spending on each segment so as to aid in pacing e.g. 5min intro, 15min info
gathering, 10min risk assessment etc.

Shared Planning and Decision Making

This was the final section of the assessment in which
I first asked the patient about goals for treatment. As is common with initial
responses to this question the answers were vague and her targets difficult to
measure e.g. “I want to be back to me” etc. Therefore, I followed this up with
a more specific question around behavioral goals in keeping with SMART principles
e.g. specific and measurable (Doran 1981). One of the reasons we set goals is
to help the patient focus on the future rather than their current difficulties
(Westbrook et al 2011). They also aid in guiding treatment e.g. signposting,
and evaluating progress throughout treatment. Nevertheless, although focusing
on the future can be helpful it is important that due to the time limited
nature of CBT at step 2 and 3 the goals need to be more medium term e.g. a few
months / by the end of treatment. On reflection I could have been clearer in
explaining this. We also devised some short term between session goals to read
through the treatment options and some depression self-help material. Both the
medium and the shorter-term goals were in accordance with SMART principles of
achievable, relevant and time-specific. I felt I covered everything on the
competency but as with the latter part of the information giving stage I felt I
rushed this section in order to keep within the forty-five minute time limit.
As mentioned above I would likely benefit from allocating a rough amount of
time for each section so as the latter parts of the assessment are not


Through completing
this exercise I can conclude that finding the right balance between all of the
features of the CBT assessment is the key to being able to deliver it
competently. For example the degree to which emphasis is placed on common
factors vs. specific, quantitative data collection vs. qualitative, time
efficiency vs. patient centered interviewing, subjective symptoms vs. objective
signs. The evidence suggests they all serve their function but too much
attention paid in one aspect can be at the detriment to another.


With more clinical
experience and through the use of clinical case management, clinical
supervision alongside routine reflective practice I am confident that it will
become easier to discover this balance. However in view of the fact that every
person is unique I must be flexible in being able to adjust and adapt to suit
the specific needs of the presenting patient. I’m pleased that I passed the
competency assessment and I look forward to receiving my qualitative feedback
and I will take this experience as a valuable learning tool in becoming a more
proficient practitioner.