Supervision in Cognitive Behavioral Therapy: Tracing other Ways Besides the School Service
Supervision in Cognitive-Conductual Therapies: Using Other Ways to School Services
Summary
The objective of this study is to describe a supervision model that prepares psychologists to develop actions focused on prevention, promotion, protection, and rehabilitation in health. The theoretical orientation of this article is the cognitive-behavioral approach, engaging with the notions of comprehensive care and interprofessional teamwork. Studies on this articulation are scarce, hindering the sharing of these training practices. The opportunity to describe this expanded model for the training of cognitive-behavioral therapists points to one of the various possibilities for preparing students in the Psychology course and indicates the need for systematic research in the area.
Keywords:
clinical supervision; university students; psychology; cognitive-behavioral therapy
Abstract
The objective of this study is to describe a supervision model that prepares psychologists to promote actions at prevention, promotion, protection and health rehabilitation. The theoretical orientation of this article is the cognitive-behavioral approach that considers the concepts of comprehensive care and work in inter-professional teams. Studies on this topic are scarce, making it difficult to share these training practices. The opportunity to describe this model of cognitive-behavioral therapist’s formation shows the various possibilities of preparation of student of psychology and indicates the need for systematic research in the area.
Keywords:
clinical supervision; college students; psychology; cognitive behavioral therapy
Summary
The objective of this study is to describe a supervision model that prepares psychologists to develop actions aimed at preventing, promoting, protecting and rehabilitating health. The theoretical orientation of the article is the cognitive-conductual approach that dialogues with the notions of integral care and work in an interprofessional team. Studies on this topic are scarce, which is why it is difficult to share these training practices. The opportunity to describe this expanded model of training for cognitive-conductual therapists demonstrates the different possibilities for preparing psychology students and indicates the need for systematic investigations in the area.
Keywords:
clinical supervision; university students (psychology); cognitive behavioral therapy
The change in the concept of health, marked in the 1988 Constitution, demanded a reformulation of the actions and training of psychologists. As a health professional, as defined by the National Health Council (CNS resolution nº 218/97), the psychologist must develop competencies for actions aimed at prevention, promotion, protection and rehabilitation in health (Carvalho, Freire & Bosi, 2009The National Curriculum Guidelines for the Psychology Course highlight the need to develop resources for working in multidisciplinary teams, in different contexts, from the perspective of comprehensive care (Brazil, 2002Therefore, the training of psychologists assumes a commitment to changes in the field of health, which involves questioning the traditional clinical model. Beyond legal frameworks, the renewal of the traditional clinical model requires experimentation with new teaching and learning methods, as well as overcoming the clinical model centered on individual care and private practice.Luiz Ribeiro & Amélia Luzio, 2008).
The objective of this theoretical article is to describe a model of clinical supervision within the cognitive-behavioral approach. The proposal, following the recommendations of the Brazilian Ministry of Education (MEC), the National Health Council (CNS), and the university’s own Political Pedagogical Project (PPP), is that the teaching-learning process of Cognitive-Behavioral Therapy (CBT) be accompanied by resources that strengthen interprofessional actions from the perspective of comprehensive care. CBT, like other theoretical approaches, can be an instrument for individual and collective transformations; for this potential to be realized, it is necessary to pay attention to the new demands in the training of future therapists.
There are several ways to develop the skills to become a therapist, but as pointed out byBarletta, Fonseca and Delabrida (2012)Studies on the subject are scarce, making it difficult to share these training practices. Supervisors, regardless of their theoretical orientation, need to be aware of the transformations in the concept of Clinical Psychology and internship fields. The insertion into new contexts, such as the Unified Health System (SUS), has required the adaptation of the development of specific skills and abilities to address human suffering, wherever it may appear, including outside of consulting rooms (Dutra, 2004).
The development of clinical skills is a constant requirement, as, according to data from the Federal Council of Psychology made available by…Regional Council of Psychology – SP (2013)In 2009, approximately 80% of Brazilian psychologists practiced Clinical Psychology. The Federal Council of Psychology (CFP) – the body responsible for regulating, guiding, and overseeing the professional practice – defined through CFP Resolution No. 013/2007 that a specialist in Clinical Psychology is one who:
It operates in the specific area of health, in different contexts, through interventions aimed at reducing human suffering, taking into account the complexity of the human being and their subjectivity. These interventions can occur at the individual, group, social or institutional level and involve a wide range of clinical devices, already established or to be developed, from a preventive, diagnostic or curative perspective. CFP, 2007 , p. 24).
However, it must also be admitted that there is no consensus among professionals on the concept of a clinic, as pointed out byLohr and Silvares (2006)Some argue that the clinical method relates to the ability to problematize phenomena and raise the psychological aspects involved in them, regardless of the context; on the other hand, there are those who consider that the clinical method is linked to an individualistic model.
The coexistence of these models of clinical practice points to a movement of change in Psychology that occurred in the 1980s, when clinical practice ceased to be focused solely on private practices and expanded to primary and secondary care. During this period, new theoretical frameworks emerged that also expanded to include the “social insertion of the subject” (Brasileiro & Souza, 2010Some theoretical frameworks explain subjectivity as a product of social and historical construction, in opposition to individualistic clinical practices.
Contributing to the transformation of the clinical model, the National Curriculum Guidelines (2004) for the field of Psychology break with the theory-practice dichotomy. In this direction,Abdalla, Batista and Batista (2008)They point out that the shift in curricular guidelines, from discipline-based to competency-based, professional skills-based, required faculty to restructure academic activities, including clinical supervision. The development of competencies for clinical practice, from a cognitive therapy perspective, depends heavily on clinical supervision (Barletta et al., 2012Study conducted byRangé, Falcone and Sardinha (2007)It also points to training in teaching clinics as a fundamental tool for developing basic skills for the practice of CBT.
Preparation to become a cognitive-behavioral therapist can occur through different didactic approaches, which may be more or less aligned with the traditional clinical model. When CBTs emerged in Brazil, predominantly in Rio de Janeiro and São Paulo in the late 1980s, the model of practice was centered on the individual. In the 1990s, due to various scientific evidence of its effectiveness, the model spread throughout the country. In addition to regional expansion, there was an expansion of professional settings in the public health network. The new paths taken required the development of new therapeutic skills in CBT. In universities, future psychotherapists receive generalist training, of a merely introductory nature to psychotherapy, although, strictly speaking, the intern, upon completing the course, can work with psychotherapy without being a specialist (Quayle, 2010Therefore, the undergraduate program does not aim to train specialists in final course projects; however, it is expected that basic and specific skills and competencies will be developed throughout the course.
The Learning Process of Specific CBT Skills
According toFederal Council of Psychology (2013)The internship represents the shared area between academic activities and professional training. The teaching practice is integrated into the Political Pedagogical Project (PPP) of each Psychology course. The PPP establishes, as a general objective, the preparation of psychologists capable of working in an interprofessional team from the perspective of comprehensive care.Federal University of São Paulo, 2013It is evident that there is a need to train professionals capable of acting critically in different contexts connected to social reality (CFP, 2002Despite this demand, there are still few Psychology courses that include content directly addressing topics related to the Brazilian Unified Health System (SUS) and public health policies.Souto, Batista, & Alves Batista, 2014;Luiz Ribeiro & Amélia Luzio, 2008Theoretical change must be accompanied by a critical attitude, and to achieve this, it is necessary to consider new ways of providing supervision.
The inclusion of internships outside of teaching clinics represents a break from traditional training. The description of a clinical model, from the perspective of CBT (Cognitive Behavioral Therapy), articulated with the proposal of comprehensive care and interprofessional teamwork, represents a contribution to the preparation of new therapists who possess skills for working in the Brazilian Unified Health System (SUS), without disregarding the specificities of CBT. The perspective of comprehensiveness should contribute to the understanding of the complex constitution of subjectivity, as well as to the planning of interventions in order to reduce the suffering of the individual.
Cognitive-behavioral therapists implement interventions to reduce suffering by understanding human subjectivity, understood as a reciprocal interaction between beliefs, emotions, behaviors, physiology, and environment. Recognizing and questioning one’s own set of beliefs plays a central role in managing suffering. Therefore, students should be trained to understand the relationship between beliefs, emotions, behaviors, physiology, environment, and the problems presented by the patient; that is, to develop the ability to conceptualize patients seen in teaching clinics or any other field of internship.
Conceptualization can be considered the most important resource for planning and conducting an appropriate intervention. It can be referred to by various names, such as conceptualization, formulation, or cognitive framing of the case, always referring to the cognitive understanding of the patient (Neufeld & Cavenage, 2010). Developing conceptualization skills reduces the likelihood of non-critical interventions, such as applying cognitive and/or behavioral techniques in a way that is disconnected from understanding the patient’s dysfunctional beliefs and how they relate to problems and ways of coping with them (Neufeld & Cavenage, 2010;Kuyken, Beck, & Dudley, 2010The development of conceptualization skills also helps the beginning therapist identify the interference of their own beliefs, generating an urgency to demonstrate their competence through the use of one technique or another as an indication of “knowing how to do it.” Throughout supervision, it is necessary to make it clear that the suitability of a technique is completely related to an appropriate understanding of the relationship between beliefs, emotions, behaviors, physiology, the environment (their social reality), and the problems presented by the patient. The use of techniques must be preceded by the ability to describe and understand the patient’s difficulties without separating the psychological aspects from the social context in which they find themselves. If this broader understanding is lacking, there is a risk of a technical approach that is uncommitted to the comprehensiveness of care.
Comprehensive care must be based on a broad understanding of the human being, that is, on a conceptualization that allows for the recognition of the subject’s active role in reducing their suffering. Kuyken, Beck, and Dudley (2010) proposed a new model of cognitive conceptualization, based on the traditional model developed by Beck, in which the synthesis of the patient’s individual experience with the theory and research of CBT occurs. The difference in this proposed model is the emphasis on three guiding principles of this practice: collaborative empiricism, the incorporation of the client’s strengths, and the development of levels of conceptualization. The emphasis on the patient’s participation in understanding their problems, as well as their strengths, aligns with the way of understanding health proposed in the university’s Pedagogical Project, by the Ministry of Education, and by the National Health Council.
Based on this model proposed byKuyken et al. (2010)The text describes supervisory practices that utilize collaborative empiricism, incorporate client strengths, and develop levels of conceptualization to guide the therapist training process.
Collaborative Empiricism
In order to formulate an understanding of the patient’s problems, one can resort to collaborative empiricism or to the unilateral explanatory model, typical of traditional clinical models. Working collaboratively with the patient favors adherence to treatment, as well as fostering autonomy. Therapists have theories and research in CBT to describe and explain the client’s problems, but it is the sufferer who offers fundamental data and feedback that ratify or not the conceptualization. The shared formulation of the case is fundamental in choosing the therapeutic goals and interventions to be carried out.Beck, 1997;Knapp & Beck, 2008;Neufeld & Cavenage, 2010).
Conceptualizing without the real participation of the patient is common among those beginning clinical practice, because, despite the existence of a new conception of health centered on the individual, the tendency to focus on the disease is still strong.Guareschi, Reis, Ecker, & Machry, 2014Another mistake is not valuing how the patient explains their problems. Disagreement – explicit or veiled – regarding the description and explanation of the complaints compromises adherence to treatment. Therefore, it is not enough to communicate the case formulation to the patient; it is necessary to discuss it and even revise it until it makes sense to both parties. Another challenge for some beginners is the integration between the explanations for each of the complaints presented; its absence also points to difficulties in case formulation and makes the patient’s acceptance of the formulation less likely.Kuyken et al., 2010).
Even during supervision, it is necessary to be attentive to the art of teaching collaborative conceptualization. Time constraints, students’ fragile mastery of the cognitive model, and the tendency towards listening developed throughout their school life hinder collaborative work between supervisors and trainees. It is known that learning through modeling is very important. It is possible to draw an analogy between the supervisor/trainee relationship and that of the trainee with their patient. The supervisor has greater mastery of theories, research, and clinical practice in CBT, but it is the student who provides the care and is better able to offer data for understanding the case. When the trainee participates more collaboratively in conceptualization, they tend to reflect more critically on the description and explanation of the patient’s problems, becoming more likely to identify and correct possible flaws in the process – which contributes to the development of the reflective learning process.Kuyken et al., 2010;Padesky 2004).
Incorporating Strengths
Another critical point is teaching about incorporating strengths, that is, identifying the client’s current resources that can be used to overcome adversity (Neufeld & Cavenage, 2010Beginning therapists may focus solely on complaints, neglecting internal and external resources. This principle becomes even more important when working in a public health institution. An example is the case of adolescents treated by interns in a public health facility. Many adolescents from dysfunctional families face daily situations of violence and attend a school that produces more exclusion than inclusion. Despite these adversities, only a portion present mental disorders. Research developed byRozemberg, Avanci, Schenkere and Pires (2014)It also points to the lack of correlation between coping mechanisms and socioeconomic status and other variables, such as sex and race/ethnicity. Young people’s coping mechanisms are not innate, but rather a characteristic that develops from a person’s interaction with their environment. Therefore, the way of dealing with adversity is not a static condition and can be strengthened by health and education professionals, families, or any social group or institution.Assis, Pesce, Avanci, & Njaine, 2005In this context, strengthening these coping resources reflects the commitment of cognitive therapists to the needs of this more vulnerable population.
Levels of Conceptualization
SecondKuyken et al.(2010)Conceptualization evolves throughout therapy from a descriptive to an explanatory level. Initially, it is necessary to help the trainee translate the patient’s complaints into terms of thoughts, feelings, and behaviors. This task requires the student to use the lens provided by the cognitive model to understand the patient’s problems (descriptive conceptualization). Next, it is necessary to identify triggering and maintaining factors of the current problems (cross-sectional conceptualization) and, finally, to recognize predisposing and protective factors (longitudinal conceptualization). Progressively, conceptualization becomes more complex as more elements are integrated (Neufeld & Cavenage, 2010).
Developing the ability to perform the three levels of conceptualization requires systematic learning of CBT. There are several explanatory models that allow for discussion of the development of specific CBT competencies and skills. In the format proposed byKuyken et al. (2010)there is an adaptation of the model proposed byBennett-Levy (2006)which describes three interconnected learning processes: declarative (when the student acquires fundamental knowledge, such as CBT theories or treatment protocols, i.e., “knowing that”), procedural (skills to know how to conduct CBT, including interpersonal and technical skills, i.e., “knowing how”) and reflective (involving the ability to observe, analyze, evaluate and reflect on one’s own therapeutic actions).
The declarative process is the means by which the student accesses information about theories, techniques, and protocols, as well as social skills relevant to the therapeutic relationship. This learning process occurs in the curricular units of the Final Course Project (TCC), through participation in courses and congresses, and through specialized readings. However, the translation of this knowledge into competence or skill (processual aspect) does not occur passively; practical activities in clinical or supervisory contexts are necessary.Bennett-Levy, 2006).
Kuyken et al(2010)They also highlight that the procedural dimension allows for the development of “how” to conduct CBT and encompasses: technical skills (for example, socializing the client to the cognitive model or conducting Socratic questioning); interpersonal skills (for example, establishing the therapeutic bond) and nonverbal skills (such as perceiving significant changes in tone of voice).
The reflective process involves the therapist’s ability to distance themselves from their own practice and reflect critically upon it. It requires skills in observation, analysis, and evaluation of the declarative and procedural knowledge employed in each case.Bennett-Levy (2006)They suggest that, in order to develop this critical sense, strategies such as personal therapy, the use of the Socratic style of supervision, and problem-based learning should be encouraged.
The progression from a declarative to a procedural and finally to a reflective process is one of the great challenges in clinical training, representing the integration between academic knowledge and the development of professional skills and abilities.
The Structure of the Internship
Adopting as a reference the teaching and learning model proposed byKuyken et al. (2010)This document presents strategies for developing the skills of CBT therapists, aiming to prepare future Brazilian therapists to use CBT to promote actions focused on prevention, promotion, protection, and rehabilitation in health.
The undergraduate thesis internship at this university is annual and takes place in two settings: (a) a public institution focused on serving adolescents and (b) a Psychology Teaching Clinic. This format creates a unique opportunity for students, as they can practice their skills in both institutional and private practice settings. This dual setting enriches their training, fostering not only the development of specific CBT skills but also enabling them to learn interprofessional teamwork.
Evolving from “Knowing that” to “Knowing how”
The teaching-learning process evolves gradually, from theoretical knowledge to critical practice.Kuyken et al. 2010;Neufeld & Cavenage, 2010;Padesky, 2004At the beginning of the internship, it is necessary to strengthen the declarative process through complementary technical readings, in addition to those already carried out in the Cognitive-Behavioral Therapy (CBT) module. Interns receive theoretical training in various approaches, and sometimes have difficulty recognizing the specific lens of CBT, which focuses on cognitive processes, pointing out how a person’s own beliefs contribute to the cause and/or maintenance of their psychological problems. Even when living conditions are objectively unfavorable, CBT can contribute to a more accurate assessment of the situation and to the development of problem-solving skills.Moorey, 2004This caveat is important because a large part of the population served by public facilities lives in adverse and socially vulnerable conditions. In order to make professional practice more efficient in these contexts, it is necessary to articulate notions such as: comprehensive care and interprofessional work with the concepts of clinical practice from the perspective of CBT (Cognitive Behavioral Therapy).
Seeking to broaden the students’ experience in the proposed model, case discussions and role-playing were conducted to develop procedural knowledge. Automatic thoughts related to “disapproval from supervisors and peers” may have affected the students’ performance. Difficulty in accepting their own mistakes or a lack of familiarity with the process of enacting practices may have inhibited participation in the initial role-playing activities . This activity allowed students to critically reflect on their performance (although the process of reflective learning was still incipient).
Following the fieldwork, the interns gave verbal reports on their experiences at the municipal health facility. Discussions focused on possible ways to understand the problems, as well as interventions made by other professionals, based on the Theory of Cognitive Behavioral Therapy (TCC). Finally, proposals were made for new ways to intervene in the situation when it was still possible to return the following week. The procedural process was consolidated through fieldwork.
Internship in Public Facilities Focused on Serving Adolescents
One of the internship sites is a mental health facility that serves adolescents through both spontaneous and referred requests. The problems presented by the adolescents include mental disorders, school-related issues, family conflicts, and drug use. The interdisciplinary team works with a proposal for comprehensive and humanized care for the adolescent.
The interns’ actions aligned with the commitments to social transformation undertaken by Psychology in recent years (CFP, 2002) and the TCC proposal to promote client autonomy (Cottraux & Matos, 2007The interventions aimed primarily to strengthen the subjective resources of adolescents and their families so that they could cope with the situation of social vulnerability in which they were immersed. The construction of new meanings by young people is a resource that can help them perceive themselves as agents of their own lives, capable of overcoming biological and/or social vulnerabilities.
Clinical interventions should aim to foster the personal and social growth of individuals, taking into account all the fundamental social structures necessary to address the problem.Cottraux & Matos, 2007Therefore, it is necessary to recognize that the socioeconomic and cultural reality of the population served by the aforementioned public facility is concerning. Cognitive therapists know that cognitive, emotional, behavioral, and physiological symptoms do not occur in a vacuum, but depend on the interpersonal context/environment (Friedberg & McClure, 2001).
The referral of adolescents with school problems, for example, is part of a social reality that needs to be considered for a more accurate understanding. Adolescents with problems at school are routinely referred by schools to this public service. The referrals are accompanied by requests for specific services that disregard the processes of tension and devaluation that adolescents suffer in schools. The implications of the disillusionment experienced in schools, stemming from the frustrations of the adolescents’ and their families’ aspirations for social advancement, are not recognized. Disregarding this context can lead to the exclusive blaming of the adolescent for the problems of adaptation to the school environment (Rocha, 2008Recognizing the contribution of the school environment to learning and behavioral problems requires a broader conceptualization of these problems, favoring the development of new resources and strengthening the adolescent’s strengths to cope with challenges.
The adolescents’ “school complaints” provided the interns with an opportunity to advance in the procedural learning process. The practice of these skills was consolidated in a group intervention conducted with six adolescents who had been referred to the facility due to “school problems.” Initially, individual interviews were conducted with each adolescent and their guardian. This provided an opportunity to develop a conceptualization of each case. Some of the difficulties encountered by the interns were: (a) employing the cognitive model as a lens to understand the accounts, (b) asking relevant questions to understand cognitive functioning, (c) developing a bond that favored the young person’s self-disclosure, and (d) establishing a relationship between the different problems presented.
The next step was planning the intervention with the group of adolescents. The therapeutic goal was to help participants “think about their thinking,” that is, to identify distorted ways of thinking and broaden their ability to attribute meaning to events. Identifying one’s own way of thinking allows one to understand the reasons for current problems and to modify coping strategies.Caminha & Caminha, 2008;Stallard, 2004A weekly plan was created, although one of the interns did not understand the advantage of prior planning, valuing the spontaneity of the interventions. This observation led to a discussion about the structuring of therapeutic interventions and sessions. Beliefs about structuring the psychologist’s actions were raised, and the advantages and disadvantages were listed, broadening the conception and understanding of prior planning in CBT. This was a central point in the supervision process, as it was worked on from the perspective of the student’s active and critical thinking.
The intervention also included guidance for caregivers, as it is crucial to be attentive to the bond established with the adolescent and their parents/guardians. Furthermore, family relationships can compromise mental health or represent opportunities for overcoming problems; therefore, it is necessary to consider the adolescent/family dynamic.Rocha (2002)It highlights that families, particularly those from less privileged backgrounds, have few resources and little information, in addition to being overburdened with work and lacking time to educate their children, but that this situation can be managed by healthcare professionals.
When working with families, psychologists cannot lose sight of their living conditions, lest they simply reproduce the pattern of blaming them for the adolescents’ problems. Cognitive therapists know that it is not the facts or people that produce suffering, but the way they interpret situations; this meaning is greatly influenced by the social environment in which each individual is embedded.Beck, 1997;Knapp & Beck, 2008Recognizing this context of social vulnerability, guidance on positive parenting practices was offered, and caregivers were encouraged to use the behavioral and technical skills learned in the group to help overcome the adolescents’ problems.
The interventions with adolescents and their families were carried out in groups, based on research indicating the effectiveness of group CBT for the development of social and behavioral skills.Caballo, 1999The group interventions, with the participation of a pair of interns, facilitated the learning process of “knowing how to do,” as it provided an opportunity for feedback to occur among the students themselves.
One obstacle encountered in advancing procedural knowledge was developing the ability to socialize adolescents and their families to the cognitive model. It was observed that the interns tended to explain the cognitive model in an excessively didactic way, making little use of the examples that arose during the socialization process. This situation compromises the development of the user’s autonomy, who needs to learn to understand their problems from the perspective of the cognitive model. Another specific skill developed in the group was the use of cognitive techniques to help adolescents identify, question, and restructure their belief system.
Behavioral techniques were also employed, as changing behavior creates opportunities to obtain factual evidence to test the validity of thoughts, as well as potentially generating important contingent changes (Caminha & Caminha, 2008The handling of these techniques was difficult for the trainees who, in addition to having little mastery of them, needed to adapt them to the language of adolescents. Finally, the third stage of the training, the reflective learning process, was developed as some interventions did not have the expected effect or as the trainees realized their own limitations in knowing “how”.
Weekly participation in team meetings provided an opportunity to reflect on the importance of teamwork, as these meetings addressed the problems of adolescents from the perspective of comprehensive and interprofessional care. An important point in the training was the guidance that ethical evaluation focused on interventions, not on the professionals working in the facility.
Psychology School Service (SEP)
In a more traditional setting, the SEP (Specialized Psychological Intervention) process of evolving from “knowing that” to “knowing how” enabled the development of specific skills. The procedural learning process in relation to individual care involved understanding that cognitive conceptualization is different from diagnosis. Diagnosis refers to a set of symptoms that generally describe the patient’s problems and is atheoretical. Cognitive conceptualization is a set of personalized hypotheses about the person’s problems and is supported by the cognitive model (Friedberg & McClure, 2007). It is necessary to understand what and why the problem is for the patient, as well as to recognize strengths that can be used to promote autonomy. In the SEP, the proposed individual intervention took on a character not only of treating the person’s symptoms, but also of developing the capacity for managing one’s own life, as proposed by…Cottraux and Matos (2007).
The evolution from a declarative to a procedural process has not always been fluid. In supervision, it was observed that trainees had difficulty describing patient complaints in terms of the relationship between thoughts, emotions, behaviors, physiology, and environment. This difficulty in descriptive conceptualization produced undesirable effects during the socialization to the cognitive model, hindering learning and adherence to the proposed techniques.
Another obstacle to overcome was the difficulty in distinguishing between questioning Socratically and convincing the patient that they are thinking in a distorted way. Lack of experience and the belief that therapeutic changes should happen immediately may have contributed to this misunderstanding. On the other hand, role -playing , gathering evidence confirming or contradicting automatic thoughts during supervision, recognizing the interference of one’s own beliefs in conducting the technique, and other resources were used to minimize this lack of experience on the part of the intern and broaden their understanding of the application of the cognitive-behavioral model.
Another central point in the process of learning therapeutic skills was the structuring of the session, an aspect discussed in the technical manual for clinicians in training in cognitive therapy proposed byBeck (1997)Establishing an agenda requires technical expertise and interpersonal skills, including assertiveness. A lack of familiarity with time and activity management may have contributed to difficulties in structuring the session. The interns were advised to question their own automatic thoughts that occurred during the session in order to manage this difficulty.
Conclusions
The presentation of this clinical internship supervision model contributes to the discussion on the training of new professionals, including the demands arising from the inclusion of therapists who use CBT in the Brazilian Unified Health System (SUS). The transition from the process of “knowing that” to “knowing how” needs to be built collaboratively between interns and supervisors. The development of the reflective process should include the observation, analysis, and evaluation of declarative and procedural knowledge, as well as the individual and collective implications of using this knowledge for health promotion. By moving beyond the walls of teaching clinics, the training of new CBT professionals takes on innovative contours. Supervisors and interns assume a commitment to transforming the health network through the provision of qualified and contextualized interventions. The opportunity to reflect on and question the teaching-learning model proposed in this article allows for a broader discussion on this important stage in the training of psychology students and points to the need for greater investment in systematic research in the area. It is necessary to identify which training programs can be most beneficial for the development of cognitive-behavioral therapists committed to holistic care and interprofessional work.
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Publication Dates
- Published in this collection
Sep-Dec 2015
History
- Received
March 17, 2014 - Revised
November 20, 2014 - Accepted
December 22, 2014
