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Do they practice what we teach? Follow-up evaluation of a Schema Therapy training programme: A research update

21 Jul 2015 5:09 AM | Eshkol Rafaeli

Little is known regarding the effectiveness of clinical training or regarding training components which contribute to it. In this blog post, Deborah Kingston, Nima Moghaddam, and Kerry Beckley describe a study aimed to evaluate a Schema Therapy (ST) training programme. The programme consisted of a 3-day multicomponent approach workshop which included didactic, experiential, and reflective foci. The authors evaluated the nineteen trainees’ knowledge, confidence, and willingness to use ST at three time points: pre-training, post-training, and at a 3-month follow-up. Significant changes were observed from pre- to post-training in the knowledge and the confidence measures but not in the willingness one. Retention of learning was indicated, with no differences between post-training and follow-up assessments. Additional qualitative measures were collected and are discussed.




Dr Deborah Kingston

Offender Healthcare, Nottinghamshire Healthcare Trust



                                   Dr Nima Moghaddam

                                             Research Clinical Psychologist,
                                           University of Lincoln



Dr Kerry Beckley

Clinical Forensic Psychology Service,
Lincoln Partnership Foundation NHS Trust





Trainee clinical psychologists are taught to select and apply the ‘right’ evidence-based treatment approach for each client’s presenting problems.  However, clinical psychology training courses in the UK focus on developing competence in just two evidence-based approaches (Cognitive Behavioural Therapy plus one other) – leaving trainees with limited scope for selection/application according to individual client need. In our local region, trainees identified specific deficits in their ability to work with more complex presentations – particularly clients who present with personality difficulties or ’disorder’ – and consequently requested an opportunity to attend extra-curricular training in Schema Therapy (as an evidence-based approach for working with more complex presentations). Our study reports on the effectiveness of a Schema Therapy training programme that was designed to address trainee learning requirements.

There is a dearth of literature examining the effectiveness of training – or even whether training-related gains in knowledge and confidence are maintained and translated in to clinical practice – and ours was the first published study to evaluate a Schema Therapy (ST) training programme.

The model of training which informed the implemented training programme was one of experiential learning and reflection. In terms of underpinning theory, Kolb’s (1984) model was central to the training approach. The training delivery was further augmented through the process of didactic teaching and expert modeling. This multicomponent approach (including didactic, experiential, and reflective foci) was intended to encourage transfer of knowledge and techniques from the learning environment into clinical practice. The value of multicomponent training approaches has been supported empirically (Herschell, Kolko, Baumann & Davis, 2010) with evidence to suggest that different components have differential effectiveness (Bennett-Levy, McManus, Westling & Fennell, 2009). The training programme also mirrored the delivery of ST in clinical practice, in that participants were able to experience both client and therapist roles. Such techniques are core to the ST approach, their aim being to both activate the emotional content of schemas and also to provide corrective emotional experiences using experiential techniques such as imagery, re-scripting or chair work in the context of meeting unmet childhood needs. Table 1 provides an overview of the evaluated training programme.

This study aimed to evaluate the ST training programme by:

1)   Reviewing whether ST training increases knowledge, confidence and willingness to use ST and whether any gains were sustained at follow-up.

2)   Examining whether an increase in knowledge, confidence and willingness were associated with subsequent use of ST in clinical practice.

3)   Identifying facilitators/barriers to using ST in clinical practice.

The training was provided by a qualified Schema Therapist (the third author) who developed the training programme as a 3-day workshop, tailored to trainee learning needs (contents can be found in the journal article). Bespoke questionnaires were developed to capture knowledge, confidence, and willingness at three time-points: (1) start of training, (2) end of training, and (3) 3 months post-training (follow-up). The follow-up questionnaire included additional free-text boxes to capture barriers/facilitators to using ST in practice.

Nineteen participants enrolled on the training programme; most (18; 95%) were in their first or second year of their three-year doctoral training in clinical psychology. A series of one-way repeated ANOVAs were conducted comparing aggregated scores (in knowledge, confidence, and willingness to practice ST) across three time points. We further examined disaggregated (individual-level) changes by applying Reliable Change Index (RCI) computations (Jacobson & Truax, 1991). 

Analysis of group-level changes indicated that participants’ knowledge and confidence around the use of Schema Therapy increased from pre- to post-training, and that gains were sustained at 3-month follow-up. Explanatory content analysis of qualitative responses indicated that maintenance of gains was afforded by the opportunity to implement Schema Therapy in clinical practice. Reported willingness to use Schema Therapy also showed an increase from pre-training to follow-up. When exploring individual-level change (RCI), 9/17 (53%) of group participants reported statistically reliable improvements in knowledge from pre- to post- training. No individuals showed reliable change between post-training and follow-up – suggesting retention of learning. The proportion of individuals showing reliable change was higher in the confidence domain: wherein 11/17 (65%) of group participants reported reliable pre- to post-training increments in their confidence with Schema Therapy concepts and techniques. When exploring willingness to use ST, only 2/17 (12%) of group participants reported reliable change from pre- to post-training.  Limited change in this domain may be attributed to ceiling affects, as pre-training willingness was relatively high, which might have been expected in a sample of individuals seeking training. Qualitative analysis indicated that there were a number of facilitators and barriers to using ST in practice; factors moderating transfer into practice were: (1) type of placement, (2) supervision, (3) personal factors, and (4) training processes.

There are a number of limitations to this evaluation.  Principally, findings were subject to self-report biases. For example, participants may have been motivated to under-report pre-training knowledge and confidence and subsequently over-report training related gains. Similarly, reports of application in practice were not independently verified. Future evaluations would benefit from objective measures, such as behavioural observations or testing of knowledge and skills through case studies, role plays or written assessments.

This study contributes to the wider evidence-base supporting the effectiveness of workshop-style training and its potential transferability into clinical practice. From our analysis of factors that moderated transfer into practice, we believe that future training could be refined through attention to the theoretical principles outlined by Bennett-Levy (2006), who posited that therapists in training need to (1) reflect on declarative knowledge (knowing the theory; e.g., principles and concepts), (2) reflect on procedural knowledge (knowing what they do; e.g., two chair work, imagery), and (3) reflect on both declarative and procedural aspects (knowing what to do and when to do it).


References

Bennett-Levy, J., McManus, F., Westling, B. E., & Fennell, M. (2009). Acquiring and refining CBT skills and competencies: Which training methods are perceived to be most effective? Behavioural and Cognitive Psychotherapy, 37(5), 571-583.

Bennett-Levy, J. (2006). Therapist skills: A cognitive model of their acquisition and refinement. Behavioural and Cognitive Psychotherapy, 34(1), 57-78.

Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology59(1), 12-19.

Herschell, A. D., Kolko, D. J., Baumann, B. L., & Davis, A. C. (2010). The role of therapist training in the implementation of psychosocial treatments: A review and critique with recommendations. Clinical Psychology Review, 30(4), 448–466.

Kolb, D. A. (1984). Experiential learning: Experience as the source of learning and development. Englewood Cliffs: Prentice-Hall.





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Schema therapy has been extensively researched to effectively treat a wide variety of typically treatment resistant conditions, including Borderline Personality Disorder and Narcissistic Personality Disorder. Read our summary of the latest research comparing the dramatic results of schema therapy compared to other standard models of psychotherapy.

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