Cognitive behavioural therapy in Norway Egil W. Martinsen, M.D., Ph.D. President of the Norwegian Association for Cognitive Therapy The history Norwegian psychiatry and psychology has been and still is strongly influenced by psychodynamic thinking. In the training of residents in psychiatry, the theoretical basis is per definition psychodynamic. In addition to weekly clinical supervision, all residents have to complete a least two years of weekly supervision in psychodynamic psychotherapy. From 2005 a third year psychotherapy supervision is introduced. Here the candidates can choose among various forms of psychotherapy, and cognitive behavioural therapy (CBT) is one option. For psychologists there is no demand on theoretical orientation for supervisors. However, most supervisors have psychodynamic training, and there is a lack of supervisors trained in CBT both among medical doctors and psychologists. For others professions the situation is about the same. From this follows that the majority of training in CBT comes in addition to other forms of training during specialization, or has to take part after the residential training is completed. Behaviour therapy has always had a weak position in clinical psychiatry in Norway. The only field where it was in common use, to some extent, was in the health care for the mentally retarded. Here it came in discredit, however, due to unfortunate use of negative reinforcements, which received great attention in the media. The good side of this is that when cognitive therapy was introduced during the late 1980ies, there was no behavioural milieu to compete with. We therefore have not had the discussions and divergences, which have been so common in other European countries, and there have been no attempts to establish alternative associations. The strongest influences have come from USA and England. Arthur Freeman, Judith Beck and Jeffrey Young form the US gave seminars and workshops from the 1980ies, and among the British professionals David Clark, Paul Salkovskis and Adrian Wells have been among the most influential. This has been important for the development of a national milieu both for clinicians and for researchers. The Norwegian Association for Cognitive Therapy (NACT) The Norwegian Association was established in 1995, and it is the only CBT organisation in Norway. As part of the NACT we have established a National Institute for Cognitive Therapy (NICT), which is responsible for the national training programmes. NICT receives economical support from the Norwegian health authorities to the training programmes in CBT. The Norwegian Association became member of the EABCT in 2001, and the number of members is approaching 400. The administration of the Norwegian association is limited. The president earns a 20% position, and from 2002 an administrative secretary in 50% position has been employed. The address of the home page is www. kognitiv.no. The board of the NACT has five members. Every second year the association runs a national inspiration conference in CBT, with more that 200 participants. At this conference the biannual meeting of the association is arranged, and the president and board are elected for two-year periods. The Norwegian Journal of Cognitive Therapy Form the year 2000 the Norwegian Association has published a national journal. This has gone through a nice development. It is a highly appreciated publication among cognitive therapists in Norway, and there are four annual issues. Training programmes The Norwegian Institute has from the start run two different introduction courses for therapists; one for medical doctors and psychologists and one for nurses and social workers. The courses are arranged all around Norway. The policy has been to increase the availability by arranging courses close to where people work. There is also a training course in supervision. The question of personal therapy has never been a hot topic in Norway. During training in psychodynamic psychotherapy, psychoanalysis and group analysis, personal therapy is required. This is not a part of our training of CBT therapists or supervisors. One argument for this is that we do not have enough competent therapists. Second, the empirical base for requiring personal therapy is weak. We follow the thinking of the leading English professionals, stating that supervision based on videotaped therapies is a more effective way of improving therapist competence than what is personal psychotherapy. Introduction courses for medical doctors and psychologists This course lasts for two years. It consists of 160 hours teaching and 50 hours supervision, mostly in groups. The teaching covers the major areas of psychiatry. In the supervision four individual sessions are required, the rest may be in groups. The supervision is based on tapes from the therapy sessions of the candidates. The course has a written multiple choice examination. Those who complete teaching, supervision and examination get a diploma, stating that they have completed the introduction course. With this diploma follows the possibility to take part in supervisor training, and it gives credit in specialisation in psychology and psychiatry. Introduction courses for nurses, social workers and others professions at a bachelor level This course lasts for one year and consists of 50 hours teaching and 30 hours supervision in groups. This course aims at nurses and other health professionals on a bachelor level. The main focus of this programme is cognitive therapy for anxiety and depressive disorders. The teaching and training is in the group format. Each participant has to present a case and show a video from a session or a role play. The supervisor rates the tape according to the Cognitive Therapy Scale. The participant then must write a note, reflecting on the supervision. Those who pass the written examination, can take a private exam at a university. This gives credits for those who want to take a masters degree. Training programme for supervisors The Institute also arranges a 2-year training course for supervisors, consisting of 100 hours teaching and supervision. By 2004 there are 85 certified supervisors in CBT in Norway. There are supervisors from most health professions, the majority being psychologists and psychiatrists. The position of cognitive behavioural therapy in Norway During the last years the position of CBT in Norway has become gradually stronger. Many members have academic competence, and there are professors in psychiatry and/or psychology with cognitive orientation at all our four universities of Norway. The strongest milieu is at the University of Trondheim. There is an increasing activity among health professionals writing textbooks and popular books about CBT in Norwegian, and we now have a good variety of national literature. Themes of discussion The usefulness of having separate introduction courses for various health professions has been questioned. There is work in progress with a second year supplement to the 1-year introduction course for nurses and social workers. The interest for learning CBT among many groups of health professionals is increasing, and we are aiming at developing specialised courses for general practitioners, physiotherapists, and medical doctors in physical medicine and rehabilitation. There is also a need for more specialized, in-depth courses for those working in special areas, and a 1-year programme for treatment of substance abuse and dependence is developed. Future perspectives The aim of the Norwegian Association is to contribute to development and use of CBT in all areas of psychiatry and mental health among all professions. In addition to individual therapy we try to stimulate development of group and milieu therapy. We want to be a significant contributor in the training of health professionals in Norway, and we work hard to consolidate and develop teaching and supervision in CBT. We emphasize a broad orientation, where a majority may feel at home. We want to develop the field of cognitive behaviour therapy across the various professions, with high professional and ethical standards. CBT in Norway has a strong research basis, and there are several research milieus involved in high standard research on various diagnostic groups. We stimulate our members to continue writing books and take part in the scientific and public discussions. It is interesting and stimulating to be part in the development of CBT in Norway.
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