This reflective essay is based on my experience of having undertaken the Treatment Objective Structured Clinical Examination (OSCE) where I was assessed on clinical skills testing my competence and knowledge on delivering low intensity cognitive behavioural interventions using the guided self-help approach (GSH). My aim is to explore and reflective the use of cognitive behavioural interventions and interpersonal skills in clinical practice.
To assists me in the process of this reflection I will be using Gibbs (1988) reflective model to reflect on the essential skills necessary to deliver a fully competent therapy session as assessed by the low intensity cognitive behavioural competency scale (Kellett et al. , 2005). Introduction (89) The client Pat; presented symptoms of anxiety and panic – a tight feeling in her chest, followed by tingly sensations in fingers and feeling dizzy, avoids situations where she felt panicky before, carries a bottle of water in case she starts to feel faint again etc. (DSM-5 & ICD10).
It was her fourth session of guided self-help, we continued working on Exposure Therapy* (NICE). Information Gathering Please refer to Appendix A Agenda setting – An essential characteristic of GSH sessions is ensuring therapists and clients work collaboratively, ensuring a shared responsibility for the session (RESOURCE). The guidelines suggest the agenda involves reviewing items from the previous session and items to cover in the present session (RESOURCE). Following the agenda setting, a mood check helps bridge the session with the previous session (RESOURCE).
Adhering to the agenda is important, therefore, involves collaboratively setting discrete and realistic targets for the session (RESOURCE). I felt confident in setting the agenda and adhering to it. However, the pacing felt a bit rushed towards the end. Thus, for future sessions, I will ensure that the agenda includes a rough duration spent on each item. Furthermore, it would be beneficial to work on making the items more concrete and specific; which will result in more focused sessions.
Information gathering – There is considerable value in gathering information on mood hanges, reviewing goals, risk reviews, medication reviews and homework reviews; this helps guide sessions as it indicates what has been covered, learnt and understood as well as any benefits and challenges so far (RESOURCE). The therapist’s understanding of the client’s progress and current situation is vital in deciding what change method intervention to offer, I felt extremely anxious as I did not want to miss any important information and also wanted to come across as empathetic. After watching the tape, I feel satisfied with my information gathering skills.
I understood Pat’s current situation, her progress towards achieving her goals, I got a full risk assessment done, reviewed her medication and homework; this was done by the use of effective summaries and providing and elicit feedback. An example of this was when we reviewed the homework. Evidence shows that reviewing homework makes it more likely that clients will carry it out (RESOURCE). Thus, I started the discussion by asking Pat to summarise her understanding of the homework and why she did it (TIME). Eliciting such feedback ensured me that she had understood the interventions, formulations and lines of reasoning for the homework.
Research shows that the clients understanding and motivation to complete homework plays a key role in the outcome of it (COM-B). Using ‘feedback’ helped both Pat and me to focus on the main therapeutic issues and reduce amorphous issues (RESOURCE). It also helped determine if we had a shared understanding of the problems and concerns discussed (RESOURCE). Moreover, as part of the PWP curricula, practitioners should make use of systematic ways of recording progress and mood changes by using the PHQ-9 and GAD-7 questionnaires (RESOURCE).
In this case, the client presented with symptoms of anxiety. Therefore, the GAD-7 was completed (RESOURCE). Using this questionnaire led us to discuss her progress in therapy and enabled me to demonstration my skills in being empathic and normalising her difficulties. Regardless of being able to elicit Pat’s understanding and gather sufficient information to make clinical decisions in guiding the session, there were moments during the process where I came across as leading.
This might have been because I was anxious about making the right judgement on how to structure the change method section. Thereby, there were times where I failed to funnel and ask specific questions (when, where, what, etc. ) which would have made it more client-centred. I believe that such improvements will come with practice and confidence. Reflecting on these strengths and challenges has enlightened me to think about clinical skills to bring to future supervisions. Change Method Please refer to Appendix B
For this part of the session, my aim was to derive informal formulations (Exposure Therapy, Habituation, Fight and Flight Response etc. ) and make use of previous formulations that we had worked on (5 AREAS, TIME) which would account for the development and maintenance of the client’s problems to help create a framework for the application of the exposure therapy. Having this formulation helped bridge theory and the practice which we would plan in the next section (i. e. homework). It also helped to ensure that the session was mapped to Pat’s individual needs.
Since the formulations were shared with the client, it gave her the chance to conceptualise her own difficulties and to appraise the degree of fit between the formulation and her own experiences. Previous formulations and theories (habituation and fight and flight response) were reviewed, discussed and built upon during this session. I felt quite excited while working on these formulations, as it allowed me to demonstrated and share my understanding of the intervention and allowed me to tailor it to the patient’s difficulties, progress, understanding and needs (TIME).
I have previously found it difficult to do this in a collaborative way but feel like I managed it well this time. Yet again, the use of feedbacks made it a lot easier to share the responsibility of its effectiveness. Research shows that this process is critical because there is usually a close link between the treatment plan and the formulation; if it makes sense to the client, they are more likely to engage with the therapy (RESOURCE). I feel like I was successful in tying those links with my clinical skills and questioning style.
Furthermore, the rationale for employing the tasks was carefully explored and clear goals were established (TIME). Evidence, however, suggests that the potency of the clinical techniques depends upon whether they are applied at the appropriate stage in therapy; upon reflection I feel like this section felt a bit repetitive, I could have saved some time on clarifying the new skills rather than spending so long on checking understanding of the learnt skills (RESOURCE).
Demonstrating such feature goes beyond mere adherence (i. e. he preciseness with which a technique is applied), in the future I would like to focus on being more articulate, comprehensible, sensitive and systematic when discussing and implementing the technique. One specific missed opportunity to demonstrate such skills was when explaining the Exercise Rating Sheet (TIME). It is no surprise that behavioural tasks play a key role with respect to the reinforcement of new learning, and are also useful mythologies to employ prior to asking the patient to use the activity in a homework task (RESOURCE).
A good way to demonstrate this in future sessions would be to collaboratively work with the patient to start the monitoring sheets within sessions in order to ensure that the task is understood correctly. Thus, behavioural methodologies work as important feedback and reinforcement activities. During this session, Pat’s understanding of the tasks was solely verbally confirmed (TIME). Nevertheless, we managed to collaboratively be creative and resourceful with the homework setting using the skills we covered in this section.
Part Three: Shared Decision Making Please refer to Appendix C Bridging therapy and the real world is an essential element to GSH, which is often done by ‘homework setting’ (REFERENCE). Evidence shows that better therapeutic outcome is more likely to occur when patients are able to apply the concepts learned in therapy to their day-to-day lives (REFERENCE). The effectiveness of the homework is based on how the therapist explains the rationale for the perspective assignment and eliciting reactions to the homework (RESOURCE).
At this point of the session, I was scared that I was going to run out of time, but tried to stay rationale and not come across as leading. Thereby, I let the client lead by asking her ‘What do you believe would be best for you to do between sessions to strengthen what we have learnt today’ (TIME). Since the homework she set was derived from the material discussed in the session; I got the impression that she had understood the task. To make the homework more achievable, I guided her in making the tasks more specific and structured.
This was done by asking questions around the where, what, when and how of the behavioural steps (TIME). Research suggests that it is valuable to get client’ feedback on the assignment, this was demonstrated when I asked her ‘Does that sound useful’ and ‘Does it seem manageable’ (TIME) (RESOURCE). These questions helped to determine if she was clear about the homework and evaluate her understanding of the cognitive rationale underpinning it (REFERENCE). Even though this helped to explore possible difficulties and how these might be overcome (EXAMPLES, TIME), I feel like the homework setting was a bit rushed.
For future sessions, I definitely plan to dedicate sufficient time to explain the specific details of the homework more clearly (i. e. discuss the relevance of task, predict obstacles, etc. ). I would also elicit more feedback on the set homework; ‘What will you learn from completing/not completing this homework’ as well as questions around her cognitions, affective and physiological states and behavioural repertoire; which will set client’s to reflect on their exercises as well as bring more meaning and value to it.
Conclusion In conclusion, I am content with my performance. I have found this reflective commentary helpful in identifying clinical skills requiring further practice. I intend to practice such skills during supervision and clinical hours at work. I am confident that the action plans put in place from this reflective commentary will help me to improve my overall clinical practice. I look forward to seeing such change and improvements in myself.
