Cognitive Behavioural Psychotherapy. Fionnula MacLiam, B.A., R.G.N.,R.M.N, P.G.Dip. Beh Psych, M.Sc. CBT, Lecturer, School of

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1 Cognitive Behavioural Psychotherapy Graduates in Ireland: A follow up survey of graduates from an Irish university Fionnula MacLiam, B.A., R.G.N.,R.M.N, P.G.Dip Beh Psych, M.Sc. CBT, Lecturer, School of Medicine, Trinity College Dublin, Correspondence: Fionnula MacLiam fionnulamac@gmail.com Submitted 29th June

2 Cognitive therapy graduates Ireland (running head) Abstract Training in Cognitive Behavioural Psychotherapy (CBT) is expensive both for the students and their funding bodies. It is important to know how graduates of CBT courses are putting their skills to use, and whether they are continuously updating those skills in order to achieve best practice. An internet survey, derived from previous postal questionnaires, was used to enquire into the practice, experience, and continuing professional development of graduates from the CBT courses at Trinity College Dublin. Keywords: CBT, cognitive behavioural psychotherapy, graduates, survey, training, supervision, Ireland 2

3 Learning Objectives: 1 To discover how graduates of a CBT course use their new skills 2 To discover whether graduates keep their skills updated 3 To discover the similarities and differences between CBT trainees in the UK and in the Republic of Ireland INTRODUCTION Behaviour therapy, and later cognitive behaviour therapy (CBT) have been in use in Ireland among mental health professionals since the 1970s. While learning theories have been taught to undergraduates in psychology, training courses in Clinical and Counselling Psychology have had different emphases. The first Behaviour Therapy course for psychiatric nurses in Ireland was in Since then, there have been several courses in Behaviour Therapy or CBT, which were recognised by An Bord Altranais (ABA - Irish Nurses Board), and more recently, university-based courses. As CBT increasingly becomes the treatment of choice for a range of conditions and is recommended as such by UK National Institute for Clinical Excellence (NICE), the demand for training courses is likely to rise. Consequently, CBT is in demand by both mental health professionals seeking training in CBT and clients seeking therapy. In Ireland, there are a number of 3

4 short introductory courses as well as longer ones lasting a year or more. At present however, few Irish courses are structured to fit the kind of training necessary for accreditation with the Irish Assoication for Behavioural and Cognitive Psychotherapies (IABCP) or the National Association for Cognitive and Behavioural Therapies (NACBT). Historically, courses (e.g those aimed at mental health nurses) tended to be occasional rather than regular and were accredited by professional bodies (e.g. ABA) rather than universities. A certificate course in BT for nurses did however run for 13 consecutive years at University College Cork (1). Other courses were often run and undertaken by nurses with little support, financial or otherwise. Though interprofessional post-graduate CBT courses are common place in the UK, this has not always been the case in Ireland and the present course at Trinity College Dublin (TCD) was the first in Ireland, starting in Previous follow-up studies Ashworth, Williams and Blackburn (2)(1999) found in their follow-up of CBT graduates from the Newcastle, England, course that past trainees continued to use their CBT skills, although the ways in which the skills were used seemed to be determined by the professional background. Their graduates comprised of psychiatrists, GPs, psychologists, nurses as well as other professions. Few of their graduates were employed as predominantly CBT specialists. Nurses qualifying in BT/CBT have been extensively studied more than any other profession (3-8). Gournay (2000) (3)reviewed 132 UK nurses who had 4

5 undergone BT/CBT training, found that the majority were employed as dedicated nurse therapists. In contrast, Ryan et al. s (2005) (1)review of 257 Irish nurses who had undertaken a Behaviour Therapy course between found that only 17% reported that behaviour therapy was the main focus of their work. A number of studies followed up psychiatrists who underwent CBT training (9-12). The main finding was that insufficient time affected psychiatrists ability to continue to provide cognitive behavioural therapy after qualifying. However many CBT-qualified psychiatrists stated that the training had impacted on their clinical work or on their occupational activities. Specialised CBT courses previously seemed to have been aimed at nurses, first by the Maudsley course and later ENB 650 (accredited by the English National Board for Nurses) in the UK and through various courses in Ireland run by UCC or in hospital nurse education settings. As CBT courses moved to universities, becoming recognised post graduate courses, the intakes comprised a mix of professions. However, professions other than nurses and psychiatrists do not seem to have been studied, although training courses regularly mention that their intakes also consist of psychiatric social workers, occupational therapists, GPs, psychologists and others. Why do a Follow Up survey? 5

6 There are a number of reasons for following up graduates. Mavis (2005 (13)) enumerates some reasons including (1) to justify funding for the course, (2) to find out to what extent the course is providing graduates with its expressed goals, and (3) to compare courses to monitor program outcomes and enhance program quality. Like other CBT courses (Ashworth (2) et al., 1999), the TCD course is expensive both financially for the funders and in terms of time committment. Most students attend through a day release agreement with their employers, and thus are absent from their posts on study days. The aims of this study are multiple but in line with Mavis s (2005) reasons, we aim to evaluate (1) whether learning on the course is carried over into the working life of the graduates, (2) whether the graduates continue to use CBT, if at all, (3) how they manage to integrate the CBT with their professional role, (4) whether they have become dedicated CBT therapists in the health service, (5) whether they have retained their interest in CBT by undertaking CPD, and (6) if the course had a positive impact on the students themselves. METHOD: An internet based voluntary and anonymous questionnaire survey was conducted between May and June The survey took approximately 15 minutes to complete. 6

7 Participants: All participants were graduates from the TCD CBT course, which has been running since Except for a 3 year gap when the course did not run and 2 years when an MSc was run, the course has been run at postgraduate diploma level. The last cohort of graduates surveyed was the group. Of 82 available records of trainees, 77 were contacted by and invited to participate. They were graduates of both the MSc (n=27, 37.7%) and the post-graduate diploma (n=53, 68.8%). Of the 5 missing graduates, 1 was deceased, 2 had retired and 2 were untraceable. Data Collection Data were collected through an internet based survey. This method was chosen because nowadays, most professional people use the internet on a regular basis, either at work or in their personal lives, or both. Response rates to internet-based surveys of health professionals range from 9% to 94% (14). Studies by Cook et al., (2000) and Couper (2000), quoted in Dillman (15) et al., (2009) found that response rates to internet-based surveys tended to be lower than to other modes. However, given that internet usage have increased exponentially in the last 10 years or so (from 8% in 1998 to 62.7% in 2008 (16)), and that there was a prior relationship with our graduates, we hoped for a larger response rate. In any case, most surveys require the use of reminders and the sending out of second batches is usual. Thus, s were sent to 77 graduates giving them a link to a survey on Surveymonkey. A 7

8 number of responses were obtained and the process was repeated 2 weeks later, sending the s with the link again, thanking those who had already responded. Thus, the responses were 14 to the first , 4 to the second and so on until a total of 43 (56%) responses were obtained through repeated reminders. Survey questions covered a number of different areas, mostly based on Ashworth et al. (2) (1999), with some based on Townend, Ianetta, & Freeston (2002) (17). The areas covered included: 1. Demographic information: age, gender, profession, year course completed, current work setting, etc. 2. Past and present work information: whether CBT had become a dominant therapeutic approach, whether the respondent had changed jobs, whether completion of the course had enhanced career prospects. 3. Experience of CBT course: a brief 7 point rating scale to summarise their experience, from very poor to excellent. 4. Professional Development. This covered whether the respondent received or provided formal or informal CBT supervision. 5. Continuous professional development: whether the respondent continued to read CBT journal articles or books, attended CBT workshops or 8

9 conferences, and membership of a CBT association. 6. General: usefulness of the CBT course personally, professionally, and clinically. RESULTS The average current age of respondents was 38, with a range from 30 to % (n=23) were female and 38% (n=14) were male - 6 respondents did not specify their gender. Respondents came from each year the course had run. Cohorts with the highest numer of responses were from years 2007 (n=6) and 2008 (n=11), with year 2009 having the lowest (n=4). Most respondents had completed the the course in the PGDiploma format (n=35) and the remainder in the MSc format (n=8). Forty three questionnaires were returned, giving a response rate of 56%. However, not all respondents answered each question and so percentages below are calculated from the numbers of responses received. 81% (35) respondents completed the questionnaire fully. Two respondents provided their responses in paper form. 37 (86%) respondents answered the question regarding the current area of employment. 26 were working in General Adult Mental Health; 3 in Child and 9

10 Adolescent Mental Health; 3 in Primary Care; 2 in Addictions; 1 in Rehabilitation; 1 in Psycho-Oncology; and 1 in Cardiology. Of 41 (95%) respondents who responded to the question regarding their work setting, 25 worked in the public health service; 5 in Voluntary Hospitals; 3 in a Private Hospital; 5 in Private Practice; 1 in a university counselling service. 2 respondents gave the responses hospital and private. Of 39 (90%) respondents answering the question regarding their core profession (Figure 1), mental health nurses were the most highly represented group (n=18; 46%), while dieticians and speech and language therapists were the least represented (n=1; 3%). Figure 1: Professions of Respondents Psychiatrist Nurse Social Worker Dietician Counsellor Speech & Language Therapist Occupational Therapist Psychologist 10

11 Participants were asked to state their grade at the commencement of their CBT training as well as after undertaking the course. Table 2 lists the responses to this question. Staff Nurse (n=9) and Clinical Nurse Specialist (CNS) (n=8) were the most frequently cited grades at the start of CBT training. Post training, clinical nurse specialist was the most frequently cited grade (n=14). Almost half (47%) of the respondents had changed their job since completing the course: 5 psychiatrists and 6 nurses, 1 psychologist and 1 occupational therapist. Dieticians, Speech and Language Therapists, Counsellors had remained at the same grade.) TABLE 1: Occupational Grade before and after course completion Number (before) Number (after) NURSES Clinical Nurse Specialist 8 14 Staff Nurse 9 3 PSYCHOLOGISTS Principal 1 2 Senior 1 0 Basic 1 1 OCCUPATIONAL THERAPISTS Basic 2 1 Senior 0 1 DIETICIAN Senior 1 1 SALT Counsellor 3 3 SALT Speech and Language Therapist Psychiatrists omitted as Registrar is a training grade. 11

12 Almost half (47%) of the respondents had changed their job since completing the course. The five Registrars had become Consultant Psychiatrists as part of their career progression. 6 nurses had become Clinical Nurse Specialists in CBT, one with an approved position as an Advanced Nurse Practitioner (ANP) but still awaiting funding. Other job changes were from the mental health domain to a university setting; from working with one particular population to another; or progression in the original profession (e.g. OTs). Completion of the CBT course was regarded as enhancing one s career by 70% (30) of the respondents. 9% (4) disagreed, and 20% (8) were uncertain that completion of the CBT course enhanced one s career. Prior to attending the course, the dominant therapeutic approach used by the 33 respondents to this question varied widely. 25% (8) said their approach was Person-centred (including the descriptions of Humanistic and Rogerian ), 16% (5) gave their orientation as medical or biological, 6% (2) as systemic and 6% (2) as biopsychosocial. Other descriptions given included interpersonal, integrative, eclectic, directive, didactic, supportive, strengthsbased, solution-focussed, collaborative, reality therapy and motivational interviewing. 34 (79%) respondents answered the question about the main current therapeutic approach. As expected 16 (47%) endorsed CBT as their main 12

13 approach. Other approaches were CBT-based or CBT plus medication or systems theory or biopsychosocial approach (n=7, 21%), collaborative (n=4, 12%), and integrative, biopsychosocial, psychosocial, psychotherapeutic, and structured (each with 2 or fewer endorsements). 17 (51%) of respondents reported that CBT was the main focus of their present job. Reasons given when CBT was not the main focus included lack of resources/funding (2), lack of time (3), other duties taking precedence (8), and a role which did not have a psychotherapeutic component (3). The majority of participants had high levels of clinical involvement, with 30 (91%) having between % of their time in clinical work. Supervision of others comprised less than 10% of work time for 15 (45%) of respondents, but 13

14 between 10-40% for 10 (23.3%) respondents. For 2 respondents, supervision comprised 40-60% of their work time. In total, 12 (39%) spent more than 10% of their worktime supervising others. 10 (23.3%) respondents taught (formally and informally) for 10-20% of their time, while 17 (51%) taught less than 10% of their work time. Other activities mentioned included journalism. 7 (37%) were spending more than 10% of their time participating in research activity. However, this question was only answered by 19 respondents. Interestingly, those with least client contact were more involved in supervision, teaching and research. Current CBT supervision Out of 32 respondents, 22 (69%) currently receive formal CBT supervision. 21 (66%) answered more detailed questions on the kind of supervision. 13 (59%) receive supervision on a one-to-one basis with an expert CBT therapist; 9 (41%) engage in peer group supervision; 1 has telephone supervision; and 4 (18%) have group supervision with an expert therapist. 5 respondents (23%) have access to more than one form of supervision. None of the psychiatrists receive CBT supervision, nor do 2 of the 3 psychologists, nor either of the 2 social workers, nor 1 each of the nurses and counsellors. 14

15 Table 2: Profession of Supervisor if different to your own. SUPERVISOR Therapist 1 Psychiatrist Mental Health Nurse 2 Psychiatrist Counsellor 3 Nurse OT 4 Psychiatrist Mental Health Nurse 5 Clinical Psychologist Mental Health Nurse 6 Psychiatrist Mental Health Nurse 7 Psychiatrist Counsellor 8 Clinical Psychologist Mental Health Nurse 9 Clinical Psychologist Mental Health Nurse 10 Clinical psychologist Dietician 11 Clinical Psychologist Mental Health Nurse 12 Nurse OT 13 Psychologist SALT As regards the profession of the supervisor, 10 (48%) of respondents have supervision from the same profession, and 11 (52%) from a different profession. 5 of the different profession are psychiatrists and 6 are psychologists; 2 are nurses. In both cases where a nurse is supervisor, the supervisee was an OT. Conversely, those supervised by a different profession are mostly nurses being supervised by psychiatrists or psychologists. These professions are also chosen by counsellors, dieticians, and SALTs who are unlikely to find same-profession CBT supervisors. 42% (n=6) of nurses were supervised by nurses; 28% (4) by psychologists; and 21% (3) by psychiatrists. 15

16 While 75% of supervisors are endorsed as having formal CBT training, the CBT qualifications of the supervisors are either unknown or lacking in the other 25%. Three-quarters (75%) of supervisors are reported to have formal training in supervision. 23% (n=7) of those who answered both questions, provide supervision but do not receive it. The majority (n=5, 71%) of these, however, state that the supervision they provide is informal and to their own profession. One however provides formal CBT supervision but does not receive it. Frequency of supervision is generally monthly (N=15, 63%), while 7 (30%) have weekly supervision. Almost 17% (4) report having supervision as necessary. The method most often used (n=22, 92%) in supervision is case discussion, followed by Formulation (n=18, 75%), audio/video recordings (n=11, 46%), role play (n=7, 29%), and Functional Analysis (n=6, 25%). Topics discussed (in order of frequency) are: interventions (n=23, 100%); therapeutic relationship (n=20, 87%); homework (n=18, 78%); ethical issues (n=16, 25%); risk assessment (n=13, 56%); and measurement (n=12, 52%). Other topics mentioned by individual respondents were process issues in therapy, literature, clinical and corporate governance issues. 16

17 Over half of respondents (n=11, 52%) had access to informal supervision, while 24% (n=5) had no access and 29% (n=6) had only occasional access to this. Most of the informal supervision (n=11, 85%) was accessed from a present colleague. We asked whether graduates had difficulty in accessing CBT supervision. 48% (n=10) had no difficulty, 48% (n=10) had difficulty, 1 (5%) of whom had problems with having time for supervision. 1 respondent did not try to access supervision. The majority of those having difficulty worked in the public health sectors: 7 (70%) in the Heath Services Executive (HSE), 1 (10%) in Rehabilitation and 1 (10%) in a Voluntary Hospital. On the other hand, half of those reporting no difficulty were working in the HSE. Several respondents suggested that the course provide support or supervision for graduates. 17

18 A large part of the respondents provided informal CBT supervision to their own profession (n=14, 44%) and almost a quarter (n=7, 22%) provided formal supervision to their own and other professions. However, one third (n=11, 34%) provided no supervision at all. Approximately two-thirds (n=20, 64%) had no training in providing supervision and the remaining 12 (37%) had undergone supervision training, although one stated that this training was not CBT-focussed. Eight (24%) respondents provided supervision, but did not recieve supervision: many of these stated that they provided informal CBT supervision to their own profession. The majority of those providing formal supervision (n=20, 87%) did so on a one-to-one basis; 43% (n=10) engaged in peer dyad or group supervision; and 13% (n=3) provided supervision as expert to a group. (As some respondents engage in more than one form of supervision, totals are more than 100%.) 18

19 Continuous professional development (CPD). The majority of respondents have attended CBT workshops (n=25, 75%), courses (n=9, 28%), conferences (n=15, 47%) and lectures (n=16, 47%), but 4 (15%) attended no CPD events at all. All respondents reported continued reading of CBT material, with 22 (69%) reading a lot and 10 (31%) reading a little. Membership of CBT Associattions 12 (36%) respondents are members of the Irish Association for Behavioural and Cognitive Psychotherapies (IABCP, a branch of the British Association for Behvioural and Cognitive Psychotherapies (BABCP), and 2 (6%) are members of the National Association for Cognitive and Behavioural Therapies (NACBT, which is the CBT section of the Irish Council for Psychotherapy). However, almost two thirds (n=20, 61%) are not members of either association. 22 (79%) have not pursued accreditation with either association, while the other fifth has done so. Asked whether they were aware of the BABCP jiscmail discussion forum, 6 (42%) of those who were BABCP members were aware of it and 2 (10% of the total, or a third of those aware) had made use of it. Continuous Professional Development (CPD) 19

20 It seems that membership of one of the CBT organisations is correlated with attendence at CPD events. Five respondents who were not members of either organisation did not attend any CBT CPD events. On average, those who were members of either or both IABCP or NACBT attended an average of 2.8 CPD-type of events (workshops, conference, lecture, course) while those who were not members of either organisation averaged 1.3 attendences. Four respondents who were not members of either CBT association had not attended any CPD events (one of these was on extended leave) but said they read CBT material. Experience of the CBT course. The majority (n=18, 55%) described their experience of the course as Excellent ; 33% (11) rated it as very good, 9% (3) as slightly good and 3% (1) as average. No ratings were received for the negative options of slightly poor, poor, or very poor. Comments on the course were in general complimentary of the teaching and organisation of the course, and of the value of the CBT approach. The reflective practice aspect of the course was favourably commented on by several respondents. However, two respondents gave generally negative views of the course: one felt it to be overly academic, and the other found it too focussed on diagnoses and individual pathology. Several mentioned a dearth of suitable supervision after the end of the course. Only one respondent mentioned the expense of the course. 20

21 Responses to the questions whether the course had been personally and professionally useful were unanimous at 100% each (n=32 and 33 respectively). In terms of clinical utility, 97% (32) felt the course had definately been useful, and 3% (1) that it was a little useful. There were no negative responses. Comments included: Self practice/self reflection made me look at life very differently. I became more conscious of what made me tick. It was scary but brilliant. The reflective practice approach and the skills learned from the course I feel has increased my confidence and helped me immensely in providing therapeutic interventions for my clients In a general hospital CBT (is) very useful Many of my patients have benefited from CBT and many more could if there was only more time and personnel. The current Psychiatric nurse training does not have enough emphasis on talk therapy which should be a given. I have a different approach to my patients which is definitely more collaborative I do a lot of snippets of CBT on the wards and in outpatients and direct all my patients to explore self-help material. 21

22 DISCUSSION The response rate was low compared to other university based CBT course follow-up surveys, most of which have taken place in the UK. There was generally a high response rate (c 80%) in UK surveys of CBT graduates (18) (5) (10) (9). The highest response rate of 94% was Swift et al. (2004 (10)), who targeted psychiatrists in the UK and sent out 1 batch and 1 reminder. Newell and Gournay (1994) (5) in the UK sent out 1 batch and obtained a response rate of 79.5%; Davidson (2004) (18) in Scotland sent out 2 batches and 1 reminder letter, obtaining a response rate of 81%, while Ryan et al. (2005) (1), in Ireland had a response rate of 53%, having sent out 1 batch of questionnaires. An unpublished survey of MSc CBT graduates from University College Cork (19) had a response rate of 43% from participants who had completed the course and graduated. In the current study, the initial response rate of 34% was boosted to the present 56% after 3 reminders. This may have been partly due to its format electronic rather than postal. Kaplowitz Hadlock and Levine (2004) (20) found that younger people ( 24 years) are much more likely to respond to a web survey than a postal survey. It is however interesting that the three Irish surveys had much lower response rates than the British ones. This raises the question of cultural attitudes to surveys affecting response rates. 22

23 The proportion of the various professions is in contrast to Ashworth et al. (1999) (2) study of CBT graduates in Newcastle, in which 33% were medical professionals, 27% were nurses, and 25% were psychologists. We had many more nurses, fewer medical professionals, and far fewer psychologists. Their survey had an almost close to gender balance, close to our female-male sample, and their mean age of 37 was also similar to ours. The course was highly rated by all and was percieved as enhancing one s career by 70% of the respondents. It is however, interesting that promotions seemed to have occured almost exclusively among the psychiatrist and the nurses. It is unclear if the promotions were due to undertaking the course, or for other reasons. It is likely that the psychiatrists were taking consultant posts in the normal progression of their careers. In nursing, the number of CNSs had increased from 8 to 15 after graduating from the course, with one in the process of becoming an Advanced Nurse Practitioner (ANP). It would thus seem that undertaking the course is associated with career advancement for nurses. However, the study would have benefitted from knowing whether the promotions/specialism were in CBT. In spite of the existance of a register of CNSs and ANPs in CBT (National Council for Nursing and Midwifery), which should make make tracking in easier, other studies too have failed to identify the use of CBT by CBT trained nurses (1). Overall, however our results support the findings of similar studies. Crowe s (2008) (19) study showed that 45% of participants believed that CBT training would enhance their promotion prospects. Another Irish study, focussing on Behaviour Therapy nurse 23

24 graduates (1) found that 70% believed that completion of the course altered their career prospects. Many of the repondents found that they did not have CBT as their main focus due to lack of time, resources or due to other duties. This again supports the findings of other studies (11) (9) (12) (10). This is interesting in light of the funding of courses by employers. Employers may support and fund CBT training but somehow not support its application post-qualification. This possible lack of employer support might also explain the low use of supervision and CPD. This would seem a waste of resources if indeed employers do not facilitate to optimum use of acquired skills. It is interesting that the respondents whose other duties took precedence, did try to incorporate CBT as much as possible into their work where appropriate. However, this reduced use of CBT skills post-qualification warrants further investigation. The responses to the question regarding CBT supervision supports those of other studies. Townend et al., (2002)(17) found that 57% of therapists made use of individual supervision (59% in the present study); group/expert 15% (18%); peer group 42% (41%) as well as using more than one form of supervision. The difficulty that was reported in accessing supervison seemed related to the workplace, in that no private hospital employees reported difficulty. This may well be due to the sizes of the relative institutions, as the public health service 24

25 covers the entire country and so CBT graduates may be quite isolated from other CBT practitioners. However, we did not ask graduates about their geographical location. The problem with lack of access to supervision does not bode well for the practice of CBT as lack of supervison results in therapist drift, a decline of skills and use of idiosyncratic practice (21, 22), which may reduce the effectiveness of the therapy being provided. Waller (2009)(21) states that supervision is essential to ensure that clinicians implement evidence based treatments. In future it may be interesting to review the outcomes of high versus low supervision therapists in Ireland. We did not ask whether those who provided supervision to others, received supervision for their supervision. It is perhaps perturbing that 23% of those who answered both questions, provide supervision but do not receive it. The majority of these, however, provide informal supervision to their own profession. Of the psychiatrists, none received CBT supervision, although one provided formal CBT supervision. In contrast, Whitfield et al (2006)(11) found that half of the CBT-qualified psychiatrists they surveyed received supervision for their own CBT practice. The paucity of CBT supervison for psychiatrists may reflect the amount of time they are able to devote to it, or the availability of supervision, and may deserve further study. It is interesting how few of the different professions providing supervision are nurses. Only 2 nurse respondents (14%) provide formal supervision to other professions, and only 3 (21%) provide formal supervision to other nurses. It is possible that nurses are percieved and percieve each other as lower status 25

26 supervisors resulting in seeking supervisors from other professional backgrounds. There may however be a number of other reasons for this eg geographical convenience, but this is beyond the present study. Of course, the more graduates complete the course each year, the more supervisors should be available, for both formal and informal. However, as only a third are members of the two CBT associations, supervisors may be difficult to find when more recent graduates seek supervision. As the graduates are spread widely in the public health service, apart from the Dublin area, it may be useful to emphasise that students need to maintain membership of the associations, and attend CPD events in order to network with their peers. The breakdown of how worktime was spent would have benefited from a 0% option; unfortunately the lowest posible answer was 0-10%, making it impossible to know whether the activity wasn t carried out at all. Clinical work rated the highest, with the majority of the respondents spending most of their worktime in clinical work. Supervision and teaching was undertaken by a considerable number, although whether this was CBT teaching was not clarified. We asked only yes/no questions about CPD, and so gained only basic information. More useful enquiries could have been made into the amount of CPD, and where the workshops were attended whether in Ireland or abroad. While it appears that association members attend more types of CPD events, 26

27 it may not in fact be the case that they actually have more CPD as we did not ask for CPD to be enumerated. It might also have been useful to enquire into what graduates read as CPD. A postal survey may have been more useful with this cohort of graduates, and may have led to a better response rate. It seems that further study of graduates of CBT courses in Ireland would merit examination, particularly as there seem to be notable differences to graduate surveys done in the UK. There has been little research with Irish CBT practitioners, and given the immediate differences between these findings and findings in the UK, it would appear that UK studies may not be generalisable to Ireland. ACKNOWLEDGEMENTS Katie Armstrong, for helping track down so many graduates. 1. Ryan D, Cullinan V, Quayle E. A survey of trainees' opinions and current clinical practice after behaviour therapy training. Journal of Psychiatric & Mental Health Nursing. 2005;12(2): Ashworth P, Williams C, Blackburn I-M. What becomes of cognitive therapy trainees? A survey of trainees opinions and current clinical practice after postgraduate cognitive therapy training.. Behavioural & Cognitive Psychotherapy,. 1999;27:

28 3. Gournay K. Nurses as Therapists ( ). Behavioural & Cognitive Psychotherapy 2000;28(4): Gournay K, Denford L, Parr A-M, Newell R. British nurses in behavioural psychotherapy: a 25 year follow up. Journal of Advanced Nursing. 2000;32: Newell R, Gournay K. British Nurses in behavioural psychotherapy: a 20- year follow-up.. Journal of Advanced Nursing. 1994;20: Marks I. Controlled trial of psychiatric nurse therapists in primary care. British Medical Journal (Clin Res Ed) 1985;290: Ginsberg G, Marks I. Costs and benefits of behavioural psychotherapy: a pilot study of neurotics treated by nurse-therapists.. Psychological Medicine 1977;28( ). 8. Marks I, Connolly J, Hallam R. Psychiatric Nurse as Therapist. British Medical Journal 1973;3: Hull AM, Swan J. A survey of psychiatrists completing a CBT diploma course. Behavioural & Cognitive Psychotherapy,. 2003;31: Swift G, Durkin I, Beuster C. Cognitive Therapy training for psychiatrists: impact on individual clinical practice. Psychiatric Bulletin 2004;28: Whitfield G, Connolly M, Davidson A, Williams C. Use of CBT skills among trained psychiatrists. Psychiatric Bulletin 2006;30: LeFevre PD, R G. CBT: a survey of the training, practice and views of Scottish consultant psychiatrists.. Psychiatric Bulletin 2001;25( ). 13. Mavis BE. Graduate Follow-up Surveys are a Good Idea [10th June 2010]; Available from: Braithwaite D, Emery J, de Lusignan S, Sutton S. Using the Internet to conduct surveys of health professionals: a valid alternative?. Family Practice. 2003;20(5): Dillman DA, Phelps G,., Tortora R,., Swift K, Kohrell J, Berck J, et al. Response rate and measurement differences in mixedmode surveys using mail, telephone, interactive voice response (IVR) and the Internet. Social Science Research. 2009;38: World B. World Development Indicators, Internet Users as a Proportion of the Population, Ireland. World Bank; 2010 [updated 7th May 2010; cited th June]; Available from: n+ireland. 17. Townend M, Iannetta L, Freeston MH. Clinical Supervision in practice: a survey of UK cognitive behavioural psychotherapists accredited by the BABCP. Behavioural and Cognitive Psychotherapy. 2002;30: Davidson K. Advanced CBT Training in Scotland: A NES Sponsored Study Crowe F. How effective is cognitive therapy training? A survey of particpants in a two year Masters course. [M.Sc thesis]. In press Kaplowitz MD, Hadlock TD, Levine R. A comparison of web and mail survey response rates. Public Opinion Quarterly. 2004;68(1): Waller G. Evidence-based treatment and therapist drift. Behaviour Research and Therapy. 2009;47(2):

29 22. Mannix KA, Blackburn IV, Garland A, Gracie J, Moorey S, Reid B, et al. Effectiveness of brief training in cognitive behaviour therapy techniques for palliative care practitioners. Palliative Medicine. 2006;20: