Introduction The purpose ofthis account is to reflect on my performance in the simulated competency assessmentwith a mock patient using the video recording that has been provided. Reflectioncan be defined as the act of examining and evaluating one’s own thoughts,feelings and actions through introspection and observation. Reflection orreflective practice in a healthcare setting is essential to the development ofa clinical practitioner. It is a way of scrutinizing your own experiences againsttheoretic principles to help facilitate continuous learning and ultimately leadto a higher standard of care being delivered to patients.
Methods forreflection in CBT can include reflective writing (Bolton 2001). Schon (1983) advocated2 sorts of reflective practice; reflection-in-action and reflection-on-action.Reflection-in-action is to reflect on actions as you are doing them. Forexample during the simulation I would have used my knowledge of the key PWPskills to guide my decision-making process. Reflection-on-action on the otherhand involves reflecting retrospectively on the actions you have already taken.
This evidently is the approach utilized in this account. The model I willemploy to aid in structuring my reflection will be Gibbs’ reflective cycle(GIbbs 1988). The stages of this cycle begins with describing what happenedduring the experience including my own feelings and thoughts, then evaluatingwhat went well and what didn’t, followed by analyzing what sense can be made ofthe experience as well as what could be done differently and finally generatingan action plan of what I would do differently to improve for next time includingwhat steps I would need to take to achieve this.
It is important that I try torefer to LI CBT literature as a rationale for my actions where appropriate andincorporate competing evidence for good practice. In terms of action planning Ishould try and consider how my actions might affect a wider historical, socialand political context. I will organize this account by reflecting on all sixaspects of the Assessment Competency Scale separately by using headings. Introduction toAssessment Session I began theintroduction segment by introducing my self by name. I then clarified my roleas a tPWP, elicited the patient’s full name and DOB and checked if she had apreferred name. Following that I outlined the purpose of the assessment, setthe agenda including the methods used, defined the time scale of forty-fiveminutes and explained my service confidentiality policy.
I was conscious of timeduring this section and wanted to complete it as quickly as possible due to itbeing a timed assessment to simulate typical service targets. This real world constrainthighlights the importance of pacing and efficient use of time in a therapysession (Young & Beck 1980 & 1988) (Blackburn et al 2001). On the otherhand I wanted to remain clear in my explanations, seeing as a clear introductionhas been identified as one of the key factors in establishing a goodtherapeutic relationship (Richards and Whyte 2011), which is crucial forsuccessful outcome (Myles and Rushforth, 2007). I believe I made good use of time and I managed to cover all aspectsof the competency scale in less than two minutes.
However, it did appear rushedin parts particularly when explaining the limits of confidentiality and althoughI asked the patient if she was happy to continue with the assessment on thebasis of our service policy, I did not ask her understanding of it. Papworth etal (2013) noted that it is vital the client is fully aware of the limits ofconfidentiality before they start to recount their problem as patients cansometimes attend with the assumption that what they say will not be revealed toanyone under any circumstances. I think if I had asked her to verbalize herunderstanding of confidentiality this would have emphasized to the patient the importanceof its limits and should help to prevent any misunderstanding in future thatcould damage the therapeutic alliance. It would also mean the patient is makinga fully informed decision on whether to continue with the session. I will trythis approach at future assessments. I will also ensure that during my nextobservation of a qualified colleague, I make note of how they explain confidentialityin the context of a time-limited assessment and ask their advice on bestpractice based on their knowledge and experience. This should help increase myconfidence as a practitioner and find a better balance between efficient use oftime and a clear and detailed introduction.
Establishing andMaintaining Engagement As referenced above, the therapeutic relationship hasbeen shown to be critical in determining good outcomes for patients. It hasbeen said that common factors play a key role in the therapeutic relationshipand the more a practitioner invests in common factors skills the bettertheir therapeutic relationship will be with patients (Cahill et al 2008). They can account for a significant amount of clientimprovement (Lambert & Barley, 2002) with some suggesting as much as 30% ofthe outcome (Lambert 1992). Examples of commonfactors include a clear introduction, the establishment of relevantexpertise, 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 psychotherapycould point to notable successes. He concluded that these successes could beexplained by implicit common factors that exist across the seemingly diverseapproaches, which are perhaps more important than the specific factors. To thecontrary, specific factors are defined as being unique to the particulartherapy (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 commonfactors 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 asfollows; maintaining a collaborative approach, the use of complex & simplereflections as well as capsule & major summaries and having a balancedratio of questions to feedback. During the simulation it felt as though I hadto demonstrate these skills at any given opportunity due to the significanceplaced on them throughout the training thus far. I believe as a result there isevidence of all them throughout the assessment. That said, I wonder whetherbecause of my eagerness I overused certain elements to the detriment of others.One example being simple reflections over complex, seeing as the former weremuch simpler to demonstrate. The reflection of feelings through the use ofcomplex reflections can help the interviewee uncover blind spots in their perceptionsand assessment of a situation and assists both the interviewer and intervieweein coming to a shared understanding of what’s going on for that person (Egan2001).
For that reason it would be reasonable to assume there is a benefit to applyingthe full range of common factor skills proportionally. In future, I plan to practiceusing complex reflections in role-play with fellow trainees and team members withthe aim of becoming more comfortable and fluent in using them. This will helpme to translate them into interviews with real life patients, which shouldimprove my therapeutic alliance, leading to better outcomes and recovery ratesfor my service and me. In spite of that I must be mindful that I do notprioritize the application and practice of common factors skills over specificCBT processes, as both have been shown to be vital in determining positiveoutcomes. Interpersonal SkillsCommon factors also comprise of Interpersonal skillssuch as displaying empathy through verbal communication, normalizing,maintaining a non-judgmental stance, showing warmth & compassion anddemonstrating good non-verbal skills in communication e.g.
eye contact and bodylanguage. Upon review of the recording I felt I had goodinterpersonal skills, particularly in warmth which can be described as “a typeof softness and gentleness that conveys caring concern” (Gilbert 2007) as wellas maintaining a non-judgmental stance which has been identified as acharacteristic of a good listener (Myles & Rushforth 2007). Unfortunately,in regards to normalization and empathy through verbal communication I felt asthough there were some missed opportunities and I appeared to be repeating thesame statements for each e.g. “It can be quite common for people…” & “thatmust be quite difficult…” Carlat (2005) advises that normalization is the mostuseful technique for eliciting sensitive or embarrassing material. Likewise ithas been proposed that empathic communication; one of the key elements indevelopment of therapeutic empathy fulfills a variety of functions within CBT(Thwaites & Bennett-Levy 2007). This would suggest that to use them inconsistentlyand in an inauthentic manner might be disadvantageous. Be that as it may, it ispossible I may be biased in my perception and this might not be congruous withthe patient experience.
So, to test this in future I will ask patients whilstcompleting their patient experience feedback form whether they felt as though Iunderstood their situation as a measure of empathy (Papworth et al 2013) andwhether they felt they weren’t alone in their problem as a measure ofnormalization. I can use these findings as a metric of competency in deliveringthe above skills and reflect on them in clinical case management. Information Gathering: Problem FocusedI began my information gathering by asking about thefour W’s (Myles & Rushforth 2007) to ascertain the main problem that led tothe patient seeking help. I managed to gather all of this information thoughnot in sequence seeing as the initial feedback responses contained detail aroundthe events or situations that provoked the onset of the main problem.
I couldhave perhaps been more rigid in the delivery of my script/ template but I amaware of the need to be flexible in adapting to the needs of the patient andsharing the power and responsibility (Mead & Bower 2002). The onset of apatient’s problem can be referred to as a one of the precipitating factors orcritical incidents, which is sometimes confused with triggers. The differencebeing that precipitants happened in the past and typically on one occasion whilsttriggers continue to operate in the present (Westbrook & Kennerley 2011).Although I asked questions about both of these I could have done a better jobemphasizing the distinction between them e.g.
by not using the word ‘trigger’when asking about past events. The consequence of this could mean confusion aboutwhat was a problem in the past and what is still a problem in the present. Thisdraws attention to the influence that language and semantics can have on comingto a shared understanding of something.
I will try and be more mindful of thisat future assessments and ask about ways of overcoming this issue at my nextCPD 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). Theaim of this model is to help illustrate that what we think affects what we feelemotionally and physically and alters what we do.
It also enables us toidentify clear targets for intervention (Williams & Garland 2002). The fiveareas comprises of the situation/ environmental factors, thoughts/cognitions,emotions/mood, biology/ physical symptoms and behavior (Padesky Mooney 1990). Ichose not to explain to the patient why I was asking these questions as I feltthis was best done at the information giving stage. This is because patientsmay not be receptive to information whilst recounting their problem.
Other areas that are helpful to ask around include; pasttreatment, current medication and attitude to this, alcohol & drug use, andwhy they want help now (Richards and Whyte 2011). I had covered all of these bythis stage in the interview. It is worth considering that I gathered thisinformation prior to asking questions around risk and reflecting on the outcomemeasure questionnaires or minimum data set (MDS).
Seeing as risk and MDS are apriority, it might be advisable to enquire about other relevant informationafter this has been captured. I will bring this to clinical skills to see howmy more experienced colleagues structure their assessment.I then integrated the MDS into the assessmentincluding the PHQ-9 & GAD-7. Whilst delivering this section and in theinterest of being collaborative I informed the patient of the severity ratinge.g. mild, moderate… represented by herscores on each. The purpose of this being to check with her whether it was afair reflection of how she felt.
On review I think this went well. MDS asstated above, is an essential tool within IAPT services because they help toinform treatment planning and effectiveness and are reported at a nationallevel to form part of the services’ key performance indicators. The PHQ-9 hasbeen shown to be a reliable and valid measure of depression severity Kroenke etal 2001) and the GAD-7 shown to be a valid and efficient tool in screening for generalizedanxiety disorder (Spitzer et al 2006). Unfortunately, routine use can causepractitioners to be over-reliant on and excessively influenced by them(Papworth et al 2013). It can also cause problems in making the wrong treatmentdecisions in the presence of co-morbidity seeing as it is more common forpeople 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 potentialbias when assessing patients and when discussing them in clinical casemanagement. This will help to minimize any errors in judgment, which shouldagain lead to better outcomes.I then introduced the risk assessment immediatelyfollowing the outcome measures, using the PHQ-9 Q9 as the prompt.
It is recommendedthat this follows a format which has been termed as a hierarchal questioningstyle (Bryan & Rudd 2006). Hierarchal questioning refers to a gradualincrease in the intensity and sensitivity of the questioning e.g. thoughtsbefore past behaviors and is likely to increase client engagement anddisclosure within the process (Papworth et al 2013). On review I think I keptto this format. In addition, I believe I made an effort to draw distinctionbetween self-harm and suicide at this point.
The reason being that self-harm mayhave an alternative purpose to suicide e.g. to gain a sense of relief frompsychological and emotional pain or as a means of self-punishment (Kutcher& Chehil 2007). It is therefore crucial to make this distinction whenconducting a risk assessment to help make an accurate judgment on the severityof risk. This also highlights the need to assess subjective intent vs.objective intent (Beck & Lester 1976). Subjective intent is what the patientstates during the interview whereas objective intent is based upon the patient’scurrent presentation and past behaviors (Bryan & Rudd 2006). Objectiveintent may or may not coincide with their subjective intent so if there is adiscrepancy this should be explored further (Papworth et al 2013).
I had notconsidered this relationship during the assessment and although there was nodiscrepancy on reflection it is something I need to think about in future sothat I can challenge when required. Information Giving: Suitable to the ProblemThe next phase involved providing the patient withinformation about their problem based on our shared understanding. I firstly explainedthe basics of what is meant by CBT and I then conceptualized her problem intothe five areas. I was pleased to see that I checked the patient’s understandingof CBT and the 5 areas so as to emphasize the importance of the model and makesure that I had explained it in a way that could be understood. Succeeding thiswe then collaborated in creating a problem statement which aims to summarise key elements of theassessment providing the patient with a simple and comprehensive account oftheir main difficulties which can be used as a reference point throughouttreatment to monitor any changes (Richards and Whyte). I was conscious thattime was running out during this so I felt anxious to get through it quickly whichmeant I did not give this as much due care and attention as was needed.
We havealready established that it is important to be time efficient so in terms oflearning it might be helpful to have more of a guide as to how long I amspending on each segment so as to aid in pacing e.g. 5min intro, 15min infogathering, 10min risk assessment etc.Shared Planning and Decision MakingThis was the final section of the assessment in whichI first asked the patient about goals for treatment. As is common with initialresponses to this question the answers were vague and her targets difficult tomeasure e.g. “I want to be back to me” etc.
Therefore, I followed this up witha more specific question around behavioral goals in keeping with SMART principlese.g. specific and measurable (Doran 1981).
One of the reasons we set goals isto 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 focusingon the future can be helpful it is important that due to the time limitednature of CBT at step 2 and 3 the goals need to be more medium term e.
g. a fewmonths / by the end of treatment. On reflection I could have been clearer inexplaining this. We also devised some short term between session goals to readthrough the treatment options and some depression self-help material. Both themedium and the shorter-term goals were in accordance with SMART principles ofachievable, relevant and time-specific. I felt I covered everything on thecompetency but as with the latter part of the information giving stage I felt Irushed 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 oftime for each section so as the latter parts of the assessment are notneglected.ConclusionThrough completingthis exercise I can conclude that finding the right balance between all of thefeatures of the CBT assessment is the key to being able to deliver itcompetently.
For example the degree to which emphasis is placed on commonfactors vs. specific, quantitative data collection vs. qualitative, timeefficiency vs.
patient centered interviewing, subjective symptoms vs. objectivesigns. The evidence suggests they all serve their function but too muchattention paid in one aspect can be at the detriment to another. With more clinicalexperience and through the use of clinical case management, clinicalsupervision alongside routine reflective practice I am confident that it willbecome easier to discover this balance. However in view of the fact that everyperson is unique I must be flexible in being able to adjust and adapt to suitthe specific needs of the presenting patient.
I’m pleased that I passed thecompetency assessment and I look forward to receiving my qualitative feedbackand I will take this experience as a valuable learning tool in becoming a moreproficient practitioner.