Supervision of Cognitive Behavioural Therapy for Psychosis: A Hong Kong Experience

Introduction Cognitive behavioural therapy (CBT) for psychosis is now a recommended adjunct treatment for treatment-resistant psychotic patients in the United Kingdom's NICE (National Institute for Clinical Excellence) guidelines. (1) There is ample evidence to support the efficacy of CBT for the reduction of positive symptoms in medication-resistant psychosis. (2) There are case reports and uncontrolled trials in Asia that also support CBT for psychosis. (3) Tarrier (4) has highlighted some of the difficulties encountered with the dissemination of CBT in a daily clinical setting. One of the most prominent obstacles is that there is a lack of well-structured training programmes for novice therapists. Yet there is a dearth of data about what constitutes an effective training programme. The exact contribution of didactic and experiential training toward effective training in CBT for psychosis is not clear. If didactic learning is sufficient for acquiring essential skills in CBT for psychosis, it will potentially reduce the amount of training time needed. Teasing out the relative contribution of didactic and experiential training in a training programme is therefore of practical importance. Cognitive behavioural therapy supervision can be as complex and challenging as CBT itself. Thus it is surprising that so little has been written about CBT supervision. (5) A recent systematic review (6) and a local study in Hong Kong (7) have suggested that CBT supervision may lead to increased therapist competence and subsequent clinical improvement in patient symptom severity. Yet there are limited data about the impact of supervision on therapist competence in CBT for psychosis. Supervised training can be viewed as improving 2 different types of knowledge in the trainees, namely declarative knowledge and procedural knowledge. (8) Declarative knowledge refers to factual knowledge about the theories and practice of CBT (for example, current evidence of the efficacy of CBT for psychosis on first-episode psychotic patients). Declarative knowledge is typically learnt didactically through lectures and reading assignments. Such inert knowledge can only be transferred into practical skills through enactive training like role-plays, actual clinical practice and supervision. Procedural knowledge refers to the rules, plans, and procedures that lead to the direct application of skills. There is indirect evidence suggesting that imparting good declarative knowledge without transfer to procedural knowledge will affect the quality of therapy supervision. It has been found that 'traditional supervision' characterised by didactic teaching and direct feedback on therapy sessions is inferior to systematic training characterised by specific interpersonal skills training and actual implementation of skills in supervision. (9) Nonetheless, this important issue is far from being settled. The current study aimed to investigate the effect of a CBT training programme on the change in declarative and procedural knowledge in a group of mental health care workers in a non-governmental organisation (NGO) in Hong Kong. Methods Sample Trainee Therapists The sample was composed of 12 experienced care professionals who were working in a Hong Kong NGO providing a range of rehabilitation services for people suffering from serious psychiatric disorders (halfway houses, sheltered workshops, supported employment services and community outreach). They were recruited via recommendations from senior managers who selected the trainees based on their expressed interest in learning CBT and the nature of the trainees' work. Therefore, a trainee was only nominated for training if they expressed definite interest in learning CBT for psychosis and if they were taking care of psychotic patients on a regular basis. Patients for Cognitive Behavioural Therapy Each trainee was required to take up 1 patient suffering from medication-resistant psychosis for CBT for a period of not less than 6 months. …